Martin, Robert L. PhD
According to the Thinkmap Visual Thesaurus, a bugaboo is a type of headache, concern, vexation, or worry, “something or someone that causes anxiety, a source of unhappiness.” Sounds like the problems created by earwax, doesn't it?
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Many patients are concerned about earwax, and despite improvements in preventive measures, manufacturers continue to report a large number of hearing aid repairs related to earwax. The excessive accumulation of dry skin in the ear canal also plugs up hearing aid receivers, causing hearing aids to go into feedback and preventing people from hearing well. Earwax and dry skin flakes mix together and make highly effective sound barriers in the ear canal, a primary cause of feedback.
Most hearing aid textbooks mention wax-prevention devices: filters, domes, and adhesive strips, but these books have little information on how to clean ears and keep them clean. That is my objective, solving the problem at the root level. It starts by developing a simple, effective program to help your patients keep their ears clean. If your state license allows you to clean ears, then you will be doing most of the work. If it does not, then you need to coordinate with a medical doctor so they can do the actual cleaning. Regardless, you need to supervise the program and make sure patients keep their appointments.
HOW OFTEN SHOULD YOU SEE THE PATIENT?
Create a column in your database, and index all patients according to wax production. This step is critical! Send patients follow-up letters for office visits for cleaning. Every time you see a patient, you should use a fiberoptic otoscope to inspect his ears and hearing aid sound tubes.
I suggest you divide your patients into five groups according to their tendency to generate earwax: massive, excessive, typical, minimal, and little or no wax production. You should see these people for cleaning every one to two months, three to four months, six to 12 months, 12 to 24 months, or as needed, respectively.
When you see people for the first time, assign them into a group by looking in their ears and asking them about their tendency to make wax. If in doubt, I assign people to the typical group, and adjust the category as I learn more about the patient. As you see patients month-by-month and year-by-year, you learn a lot about their wax proclivity.
You may question the importance of categorizing patients based on their tendency to generate wax, but a patient named David will illustrate its significance. You have had many patients like him. David thought BTE hearing aids were ugly so he selected the mini-ear canal style instruments. Over the next five years, he had more than a dozen repairs. David was unhappy and complained to everyone who would listen. When I finally convinced him he had excessive earwax production and he would have been better off with BTE hearing aids, he said; “Then you should never have sold me canal hearing aids. You're the doctor. If it was stupid for me to purchase canal aids, you should not have allowed me to buy them.”
Patients do not care why hearing aids stop working. If the instruments go dead for any reason, the patient's point of view is that the hearing aids must not be any good and the doctor who sold them to him was not doing a good job.
I made several major mistakes with David. First, I should have recognized sooner that he generated a lot of wax. I should have explained the consequences of excessive wax. I give all of my patients a checkbook-style calendar, and I should have marked all of his upcoming office visits on it. Once I realized he was needing too many repairs, I should have immediately switched to a different aid style.
Unless we transfer much of the responsibility to our patients, they will hold us totally accountable for everything that goes wrong with the fitting. After categorizing all patients according to their tendency to generate wax, they need to be educated on the need to keep their ears clean. Remember, properly educated patients come back to the office, and say, “I am a few months late for my cleaning, and I think my hearing aid is dead. I am so sorry.” Poorly educated patients come back to the office and say, “These hearing aids you sold me are a pile of junk, and I should get my money back. They go dead every few months, and I always have to come in to have them repaired.”
Patients who generate significant wax need to be given a small slip of paper with a warning message similar to those posted on cigarette packages. The language needs to be direct and honest: “Your ears generate a lot of wax. We need to see you every three months to clean your ears. Failure to keep the wax out of your ears will result in problems with your hearing aids.”
Some physicians, especially pediatricians, tell their patients to use hydrogen peroxide to soften and remove earwax. Hydrogen peroxide is helpful if the ear canal is small and a highly viscous liquid is needed. Most adults with large ear canals do better using carbamide peroxide, a thick cousin to hydrogen peroxide. One otolaryngologist I know has his patients put drops of baby oil in their ears before coming to the office to have their ears cleaned. The oil softens the wax and facilitates wax removal. But before you tell patients to use any type of drops in their ears, be sure you have studied their ears otoscopically and ruled out perforations, drainage, or any type of ear problem. Also, make sure they stop wearing their hearing aids after they use the drops, otherwise the debris will end up in the sound tube.
Local drug stores have five to 10 different ear cleaning solutions for sale, but they all contain carbamide peroxide. To my knowledge, this is the only substance the FDA has approved for cleaning ears.
In theory, people could put a few drops of this solution in their ear, wait a few minutes, and then gently wash the ear to remove the solution and the debris. Unfortunately, the liquid is thick like honey and difficult to get into the ear canal. Many people fail to get the solution deep enough to make contact with wax. The aperture to the ear canal for many people is small and the surface tension of the liquid often prevents it from going into the ear. The directions on the solutions are not very helpful either, and it is difficult to put this liquid into one's own ear. I often provide patients with supplemental instructions to maintain their own ear cleaning regimen. (See sidebar.)
When you clean ears and teach patients how to clean their own ears, you greatly simplify your hearing aid practice. The other day, for example, I fixed three different hearing aids that were plugged with wax, and I cleaned seven to eight ears, but none of these patients were unhappy with me or their aids. By talking to patients constantly about earwax, and the need for continuous cleaning, the patient understands and accepts the responsibility of keeping his own ears clean.
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