Dear Ms Knachel and Members of the Board of Audiology and Speech Language Pathology, 

As a nationally recognized authority in cerumen management training, it is with great interest and respect that I comment on the Virginia Title 18 Professional and Occupational Licensing Board Audiology Speech-Language Pathology Emergency Regulation performed by audiologists. Cerumen Management is considered part of the customary procedures of audiologists by national audiology professional organizations, as well as most of the state audiology license boards.

I, and others, have taught audiologists cerumen management workshops, distance learning courses for doctoral candidates, and classes for residential doctoral candidates since 1995.  The onsite classes are usually 6-10 hours depending on the needs of the institution.  Because audiologists are already trained in such areas as anatomy, physiology, and conditions of the ear and hearing, these areas are reviewed in the courses. The emphasis is on the methods of cerumen management including proper lighting and equipment.  The participants spend at least 2 hours practicing with actual instruments and equipment during the course. Depending on the setting, the participants will either have supervised practice among themselves, and/or actual volunteers are solicited from the community, who may have earwax.

It should be remembered that audiologists are already injecting and inserting foreign objects and materials (otoblocks, impression material, probe microphone tubes, transtympanic membrane electrodes, extended wear hearing aids, etc.) deep into the ear canal, oftentimes beyond the isthmus and second bend. Audiologists have had more than enough training by virtue of their university requirements and practical clinical experience to work in the outer ear, which, as you are aware, includes the ear canal up to and including the tympanic membrane.   Although it might be a hardship for a clinician in the rural areas of Virginia to obtain additional supervision in removal after such training, I am, in general, supportive of the training requirements specified in your guidelines.  Perhaps the requirement that demonstration after observation of each method could be required during a course.

Great emphasis, during these courses, is placed on contraindications for audiological management of cerumen.  A particular point is made that the clinician should only attempt to perform techniques within their comfort level. However, responding separately to each of the recommendations in section C of the emergency regulations let me note as follows:

C. An audiologist shall not perform cerumen management on a patient who is younger than 12 years of age or on a patient who has any of the following pre-existing contraindications:

1. Hearing in only one ear;

Understandably, an unqualified clinician might abuse the outer ear causing damage such that there is then a decrease of hearing binaurally. However, this would be the same concern for making an ear impression (such as for custom ear protection) which is not prohibited. At the very least, instrumentation should be permitted for a unilateral hearing loss.

2. A perforated tympanic membrane;

Only irrigation is contraindicated and, perhaps, aural suction. Once again, depending on the circumstance, at least instrumentation would be appropriate.

3. Inflammation, tenderness, or open wounds or traces of blood in the external ear canal;

I agree that these patients should be referred to a medical doctor.

4. Drainage from the external ear canal or middle ear;

I agree that these patients should be referred to medical doctor.

5. Current tympanostomy tubes;

Depending on the location of the cerumen, instrumentation is appropriate.

6. History of ear surgery, excluding past tympanostomy tubes or simple tympanoplasty;

Depending on the location of the cerumen, and the timing of the surgery, instrumentation is at least appropriate.

7. Diabetes mellitus, HIV infection or bleeding disorders;

There is no reason that these patients not be treated by an audiologist, provided use of universal infection control procedures and additional care to not be too aggressive in removing the cerumen.

8. Actual or suspected foreign body in the ear;

There is no reason that an audiologist, within their comfort level, be prohibited from removing hearing aid domes, wax guards, cotton blocks, bugs, dirt, etc. from the ear canal.  Once again, if placing and injecting foreign material (an otoblock, impression material) into the ear canal, at or beyond the second bend, and then removing it, is acceptable, then removing wax and foreign objects should also be included.

9. Stenosis or bony exostosis of the ear canal;

This, again, should be left to the comfort level of the audiologist, based on the degree of the impairment and the location of the ear wax.

10. Cerumen impaction that totally occludes the ear canal; or

Audiologists are taught how to soften the wax, treat it so that a tympanogram can be taken, and safely remove the wax. This should not be prohibited and proper training will teach the correct method(s) to use.

11. Inability to see at least 25% of the tympanic membrane.

Audiologists are taught how to soften the wax, treat it so that a tympanogram can be taken, and safely remove the wax. This should not be prohibited and proper training will teach the correct method(s) to use.
 

Another concern about restricting the scope of practice of audiologists removing cerumen is the time, stress, and cost imposed on a patient by having to see an additional health care provider.  Removal of cerumen may take as little at 5 minutes or, perhaps longer.  By requiring a patient to have this procedure performed by a different practitioner, this overbroad regulation would  unnecessarily increase the time the patient (and family member who transports the patient) must take off from work, create unwarranted stress from  needing to make yet another appointment, and incur  the burdensome cost of getting to the appointment and paying for it. All this is cast upon the patient when the treatment could have been done at the time the patient was with the audiologist, who is qualified, and in most other states permitted, to take care of the problem. 

Similarly, it could very well require a return to the audiologist for a hearing evaluation, hearing aid fitting, ear mold impression, etc. when it could all have been taken care of at the one visit to the audiologist. This type of duplication of services is a major contributor to the skyrocketing healthcare costs our nation has been crippled with over the last 10 years. Hopefully, the State of Virginia will take steps to help curb those unnecessary expenditures in at least this one area.

As a practicing audiologist for over 40 years, a clinical provider of cerumen removal for over 20 years, and a national instructor of audiologists in the procedures for safe cerumen management, I urge you to reconsider the restrictions you have placed on this essential audiology practice. Please don’t hesitate to contact me  if you have any questions or require additional information.

Respectfully,

Rita R. Chaiken, Au.D.

Doctor of Audiology