Robert L. Martin, PhD, has been a Dispensing Audiologist in private practice in the San Diego year for 30 years and been writing Nuts & Bolts since 1989. Correspondence to Dr. Martin at 7750 University Avenue, La Mesa, CA 91941.
Fiber-optic otoscopes are an indispensable professional tool that can be used to inspect microphone ports, check for debris in receivers and receiver tubing, and read worn-out serial numbers, as well as for their primary intended use of inspecting ears. Back in June 1992 when I first wrote about otoscopes, I said, “I strongly believe that everyone who fits any type of hearing instrument should examine the external ear canal with a fiber-optic otoscope.” I would now go so far as to say we are acting incompetently if we do not do so.
To understand why this is so important, let's consider three examples: an ear plugged with wax, a hearing aid plugged with wax, and a microphone plugged with debris.
David came to my office with a copy of a 2-day-old hearing test. His right ear was completely plugged with cerumen, which was obvious when you looked in the ear canal with the otoscope. Yet the audiogram did not indicate a significant air-bone gap on that side. I removed the large wax plug from his ear and repeated the hearing test. The audiologist had not bothered to look in David's ears before testing his hearing. Instead, he had looked at an old hearing test and told David, “Your hearing has not changed.”
Judy came to me with a pair of 2-1/2-year-old hearing aids. The right one was “dead,” and she had been told she needed a new pair. I quickly and easily removed a small wax plug from the sound tube and the aids worked fine.
Mike arrived at my office unhappy and nervous because his hearing aid was not working. The microphone opening was occluded with debris. I had Mike look through the otoscope at his hearing aid before I removed the debris. Once the debris was removed the aid worked well.
WHY SUCH ERRORS OCCUR
In the first example, I believe the audiologist was strongly influenced by David's old hearing test. As a result, he did a poor job, an incompetent job, in administering the new hearing test. Had the audiologist used an otoscope and seen that the ear was blocked with wax, I am sure the results of the hearing test would have been different.
A lot of audiologists work in hospital settings or busy clinics where the ENT physician looks in the ears and asks for a hearing test. Many of these audiologists do hearing tests without looking in the ears. That is a serious mistake, for which there is no excuse in even the busiest clinic. It takes me less than a minute to examine a patient's ears. And doing so often enables me to detect perforations, surgical tubes, or sclerotic eardrum, all of which impact the hearing and otoadmittance tests.
In Judy's case, I believe the hearing aid specialists were simply trying to sell her another set of hearing aids without fulfilling their responsibility to maintain her current instruments. When patients are treated improperly, we all suffer because patients talk to one another and stories like this get repeated many times.
Mike is someone who needs to take more responsibility for the care of his own hearing aid. He was asked to come back to the office 6 months after he purchased the hearing aid to have it cleaned. He did not. When the aid stopped working, he blamed the manufacturer rather than accepting responsibility himself.
SCOPES ARE MORE IMPORTANT THAN EVER
As I get older my eyes get weaker, but my need to see well is as critical as ever to the success my practice. It's increasingly difficult for me to read the serial numbers on small hearing aids and to find small perforations in the eardrum. This is another reason that the hand-held fiber-optic otoscope is one of my most important tools. I find myself using one on every patient.
Even if you don't clean ears, you must be able to see and inspect all the tissue in the ear. When a flake of dead skin occludes the ear canal, it interferes with the sound transmission from the hearing aid, causing feedback. We need to spot flakes of dead skin, and we also have to see and inspect pressure points created by hearing aids.
I am constantly learning about new treatments and medications that can be used to keep ears healthy and free of itch and other irritations. But no treatment or recommendation can be made until the hearing professional has carefully examined the patient's ears with a good fiber-optic otoscope.
It may sound as if I'm working for one of the otoscope manufacturers, but I'm not. None of them has even bought me a beer!
It's just that I believe very deeply that we provide patients with a much higher standard of hearing healthcare when we use fiber-optic otoscopes to improve our vision. Cerumen management, feedback control, and dealing with problems like itchy ear, pain in the ears, pressure sores created by hearing aids, and the patient's sensation of a plugged ear all require the use of a good otoscope. And, I believe it is just plain foolish to do hearing and impedance testing without first studying the ears with a fiber-optic otoscope.