Cerumen Management — One of Hearing Healthcare’s Neglected Services
In February 2021, the World Health Organization (WHO) released the World Report on Hearing. This long-awaited report “envisions a world in which no individual experiences hearing loss due to preventable causes…”.1 One of the stated goals in the report’s introduction is to draw attention to existing solutions to prevent and rehabilitate hearing loss and the challenges in their delivery and access.
According to the World Report on Hearing, cerumen impaction affects a significant number of people globally. The reported prevalence of wax impaction varies across age groups, with the prevalence being higher in older adults. Some 10% of children and 5% of adults have impacted cerumen. Over 50% of older adults may be affected. This constitutes an alarming number of people living with preventable hearing loss.
Cerumen management is an often neglected area of hearing healthcare. Individuals with significant cerumen impactions often go undiagnosed and untreated for prolonged periods. When individuals seek treatment, they often face difficulties finding a healthcare provider with the necessary knowledge and skills willing to address their needs. The lack of providers can result in significant delays in treatment. Individuals who go untreated run the risk of developing other serious health conditions associated with cerumen impaction, such as otitis externa or cholesteatoma.
Currently, there is no universal standard of care for cerumen management. Although included in the scope of practice of several healthcare providers (i.e., doctors, audiologists, nurses, hearing instrument practitioners), these individuals are often not adequately trained. Their knowledge of cerumen management protocols is often deficient due to a lack of comprehensive training. In a survey of Doctors of Audiology, who had completed residential AuD programs, Johnson et al. report that almost half (48%) of the respondents believed their training programs inadequately prepared them to perform cerumen management.2 In Canada, several training programs for both Audiologists and Hearing Instrument Practitioners do not have any formalized training for cerumen management in their curriculums. A review of two other Audiology training programs, one in Australia and one in South Africa, revealed the same lack of comprehensive training in their curriculums.
Proper regulations and requirements for the safe and efficient provision of services are not in existence in many regions. This lack of rigor leads to confusion by the public seeking help and often leads to these individuals looking for assistance from facilities that should not be relied upon for the routine provision of cerumen management. An example can be found in the USA where emergency rooms see many individuals seeking relief from cerumen impaction. Yang et al. reported that some 310,000 Americans, over three years, attended hospital emergency rooms seeking cerumen impaction treatment.3 In addition, Yang reported that 75% of cerumen extraction billings to Medicare during this same period were by otolaryngologists. This would appear to be an inappropriate use of facilities, expertise, and funding.3 Cerumen management should not have to occur in an emergency room or be conducted by a surgeon, except in exceptional cases.
I believe that the current provision of cerumen management services globally is not meeting the needs of the public at large. Individuals with hearing loss or those seeking audiologic rehabilitation services are significantly underserved by the very hearing healthcare providers who are charged with providing diagnostic and rehabilitative services. Given the number of healthcare providers who have cerumen management in their scope of practice, there is no reasonable explanation for this situation to continue.
Hearing healthcare issues caused by cerumen impaction are preventable and should be addressed before further complications arise. However, timely and appropriate access to cerumen management services is often lacking, even in developed countries. Unnecessary delays and even injuries can and do occur due to a lack of adequately trained providers. Regulatory bodies, training institutions, and allied health professionals need to address this issue. The knowledge, protocols, and tools exist to develop comprehensive cerumen management services for the entire population.
References
- World Report on Hearing. Geneva: World Health Organization. Licence: CC BY-NC-SA 3.0 IGO. 2021. Available at: https://www.who.int/publications/i/item/world-report-on-hearing
- Johnson CE, Danhauer JL, Rice EN, and Fisher SK. Survey of audiologists and cerumen management. Am J Audiol 2013;22(1):2–13. https://doi.org/10.1044/1059-0889(2012/12-0032)
- Yang EL, Macy TM, Wang KH, Durr ML. Economic and demographic characteristics of cerumen extraction claims to Medicare. JAMA Otolaryngol Head Neck Surg 2016;142(2):157–61. doi:10.1001/jamaoto.2015.3129