43 Excess Cerumen : Failure Rate of Black and Indian Preschool Children from Durban on the Middle Ear Screening Protocol (MESP) Daksha Bhoola and Rene Hugo Department of Communication Pathology University of Pretoria ABSTRACT The aim of the study was to examine the failure rate of Black and Indian subjects within the excessive cerumen category of the Middle Ear Screening Protocol (MESP). The subjects included four to five year old Black and Indian children attending pre-schools in the Durban Central Region. Thus, a sample of 728 subjects (average age = 4.6 years), 312 Black (135 male and 180 female) and 413 Indian (223 male and 190 female) was screened using referral criteria based on a Middle Ear Screening Protocol (MESP). The results of the study indicated that a significant percentage of Black (38,4%) and Indian (49,9%) subjects failed, due to excessive cerumen. These results are discussed with reference to the literature. A cerumen management program has been outlined and recommended to be implemented in preschools in South Africa. OPSOMMING Die doel van die studie was om ondersoek in te stel na die invloed van oormatige was op die faalkategoriee van 'n middeloorsiftingsprotokol. Die proefpersone het bestaan uit vier- en vyfjarige Swart- en Indierkinders verbonde aan pre- primere skole in die Durban Sentraalstreek. 'n Totalegroep van 728proefpersone (gemiddelde ouderdom = 4.6jaar), waarvan 312 Swart (135 manlik en 180 vroulik) en 413 Indier (223 manlik en 190 vroulik) kleuters was, het 'n Middeloorsiftingsprotokol ondergaan. Die resultate van die studie dui daarop dat 'n betekenisvolle groot groep van die proefpersone -38.4% Swart en 49.9% Indier - die siftinggefaal het as gevolg van oormatige was. Hierdie resultate is bespreek aan die hand van relevante literatuur en opgevolg deur 'n voorgestelde was-hanteringsprogram wat moontlik sinvol in Suid-Afrikaanse kleuterskole geimplementeer kan word. KEY WORDS: Black and Indian children, 4-5 years, Cerumen Management program, excessive cerumen, Middle Ear Screening Protocol. INTRODUCTION The SANCD (1990) classifies auditory dysfunction that occurs when the site is the external ear or middle ear, as conductive hearing loss. One of the commonest causes of conductive hearing impairment is the accumulation of cerumen in the External Auditory Meatus (EAM) (North- ern & Downs, 1984; Martin, 1981; Newby, 1979). Total occlusion of the EAM due to excessive or impacted cerumen is said to cause a threshold shift of about 45 - 70 dB (Chandler, 1964). In fact, Bricco (1985) pointed out that impacted cerumen is regarded as an ear disease - it can cause otitis externa, hearing loss, pain, itching and tinni- tus (Bullachanda & Pears, 1992; Roeser & Crandell, 1991). Furthermore, Bricco (1985) stated that if cerumen im- pinges on the eardrum, a chronic cough may be triggered and persist until the cerumen is removed. Myers and Fueschel (1987) even related impacted cerumen to major psychiatric changes. Bricco's (1985:241) investigation sug- gested "an association between the presence of impacted ear wax (cerumen) and subsequent middle ear or hearing problems, but a causal relationship is not inferred from the study". However, Garber (1986) found that in some 30% of children, accurate diagnosis of acute otitis media (AOM) requires cerumen removal. He stated that "you cannot assume that the heat of the middle ear infection will melt earwax : Ceruminosis and acute otitis media can coexist". (Garber 1986:151). The reasons for cerumen impaction are many. It may be due to increased secretory function of ceruminous glands, leading to more than normal production (Mandour, El-Ghazzawi, Toppozoda & Malaty, 1974) or failure of keratinocyte separation that occurs normally in the ear- canal (Robinson & Hawke, 1990). Anatomical abnormali- ties of the ear-canal, the improper use of cotton swabs, hearing aids, or a collapsed ear-canal have also been re- ported to obstruct extrusion of cerumen from the canal (Ballachanda & Peers, 1992). Furthermore, the aggressive cleaning of soft wax by well-meaning parents can result in the wax becoming im- pacted against the tympanic membrane (Bricco, 1985; Newby, 1979; Martin, 1981). In addition, Ballachanda and Peers (1992) stated that cerumen enlarges when it becomes soaked with water (e.g., after bathing, swimming) and can completely occlude the EAM. Thus, even the presence of excessive amounts of soft cerumen, poses a significant audiological problem since it can result in a mild conduc- tive loss. Die Suid-Afrikaanse Tydskrif vir Kommunikasieafwykings, Vol. 44, 1997 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) 44 It has been proven in studies on recurrent otitis media that mild and fluctuating conductive losses have negative effects on language and auditory function and on later educational achievements (Gravel & Wallace, 1992; Boothroyd, 1982; Northern & Downs, 1984). This is equally true of excess cerumen and the negative consequences can be prevented through routine otoscopic examination of preschool children. In fact, the American Food and Drug Administration (1977), cited by Alpiner and McCarthy (1987), as well as ASHA (1990), identified excessive accu- mulation of cerumen as a condition that needed medical intervention. Furthermore, American physicians are said to perform cerumen extraction on approximately 44 000 ears per year (Sharp, Wilson, Ross & Barr-Hamilton 1990). According to Burgess (1977), wax removal is done more than 40 000 times a week in the United Kingdom. Thus, otoscopic examination can "improve the timeliness of medi- cal management for those in most urgent need." (Roush 1990:367). The research design of the present study used a modi- fied version of the revised ASHA (1990) protocol, referred to as the Middle Ear Screening Protocol (MESP). Disor- ders of the outer and middle ear contribute to the conduc- tive component of a hearing loss, which in many cases can be remediated with medical attention. It is possible that disease in the outer ear may spread to the middle ear and vice-versa (Martin, 1981). Therefore it is logical to include examination of the outer ear when considering middle ear disorders. It is for the above reasons, that the protocol used in this study, although being a middle ear screening pro- tocol, is included in the examination of the outer ear. The MESP consists of three components; history, visual inspec- tion and tympanometry. (Refer to Appendix A, Table 1.) Excess cerumen was identified using this protocol. Martin (1991) stated that the problem of ear wax is a complex one and that no one wants to take the responsi- bility for the managing of it. In this regard two important questions needed to be answered: (i) "Why haven't audiologists assumed the responsibil- ity for cerumen management?" According to Roeser and Crandell (1991:52) a likely reason is that audi- ology's roots are in nonmedical institutions of higher education, where the philosophy is to avoid procedures that might be interpreted as "medical". Moreover, in the early years of the profession, routine audiological protocols did not require placing objects in the ear- canal. In fact, otoscopy was not performed or encour- aged routinely. However, standard audiology protocols now require placing objects in the ear-canal and au- diologists are familiar with the proper protocols to follow, as well as the possible contra-indications. The ear-canal is irrigated similarly to that of cerumen re- moval for caloric testing during electronystag- mography. In addition, otoscopy is a mandatory pre- requisite for proper audiological screening, evaluation and management. Visual inspection of the ear-canal (otoscopy) is required in the ASHA screening guide- lines (ASHA, 1989); moreover, the Standard Proce- dures in Audiology manual developed by the Veter- ans Health Services and Research Administration (VHSRA, 1990) includes visual inspection of the ear as an audiological procedure. It is apparent that the above reasons are valid and that cerumen manage- ment should be the responsibility of the audiologist Daksha Bhoola & Rene Hugo in view of the new standard audiology protocols and the high frequency of occurrence in the population under study. (ii) Should cerumen management be a part of audiology practice? ASHA (1990) defined the scope of practice in audiology to include : facilitating and conservation of auditory system function; preventing auditory sys- tem dysfunction; and selecting, fitting and dispens- ing amplification. In addition, ASHA (1996) included the following in the audiologist's scope of practice "Oto- scopic examination and external ear canal manage- ment for removal of cerumen in order to evaluate hearing or balance, make ear impressions, fit hearing protection or prosthetic devices, and monitor the con- tinuous use of hearing aids". (ASHA, 1996:14). Fur- thermore, the American Academy of Audiology (AAA) (1989:1), adopted a scope of practice statement that defines an audiologist as "a person who, by virtue of academic and clinical training and appropriate certi- fication and/or licensure, is uniquely qualified to pro- vide a comprehensive array of professional services related to the prevention, assessment and rehabilita- tion of auditory and vestibular impairments". In ad- dition, "the audiologist is an independent practitioner, and may practice in a hospital, clinic, school, private practice or any other setting in which audiological services are relevant". In view of the limitations in providing comprehensive audiological services when excessive/impacted cerumen is present, both ASHA and AAA scope of practice statements give strong support and rationale for audiologists to en- gage in cerumen management. Furthermore, considering the results of the present study on excessive cerumen in both race groups, it is time to recognize that audiologists can and should manage cerumen. It is evident from the results of the present study and the literature review presented above on the problem of excessive cerumen, that this is a serious problem in many countries, including South Africa, and which needs urgent attention. The writer, therefore recommends a cerumen management programme which could be implemented in pre-schools and primary schools in South Africa. 1 METHOD RESEARCH DESIGN I In order to realise the aim of the study, the methodol- ogy of research design used was the analytical (quantita- tive) survey method (Leedy, 1989). AIM The aim of the study was to examine the failure of Black and Indian preschool children within each category of the Middle Ear Screening Protocol (MESP). SUBJECTS A total of 728 randomly selected subjects (mean age 4,6 years), comprising 315 Blacks (135 males, 180 females) and 413 Indians (223 males, 190 females) contributed rel- evant data for the purpose of this study. Available litera- ture has indicated a paucity of information of middle ear The South African Journal of Communication Disorders, Vol. 44, 1997 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) Excess Cerumen: Failure Rate of Black and Indian Preschool Children from Durban on the Middle Ear Screening Protocol (MESP) disorders within the Indian and Black ethnic groups in South Africa, which motivated the criterion of race. All subjects attended preschools located in the magisterial district of Durban Central. According to Bess and Humes (1990), children who reside in the inner city and attend day care centres are prone to suffer from outer and mid- dle ear disorders. Table 1 presents the subject character- istics of this study. All subjects were required to fall within the age range of 48-60 months inclusive (4-5 years) as a literature review has shown an increased prevalence of middle ear infection in this age range worldwide (Davidson et al., 1988). 45 TABLE 1 : Subject Characteristics N% Mean age in years Mean age in years Black Males Females 315 (43) 135 (43 180 (57) 4,7 4,6 4.0-4,9 4.1-4,9 Indian Males Females 413 (57) 223 (54) 190 (46) 4,6 4,6 4,2-5,0 4,0-4,8 Total 728 DATA COLLECTION PROCEDURE screening. * Immediate medical referral was made in cases of ab- normally large canal volume (>1.0ml) estimates accom- panied by low static admittance (<0.2ml) (when there was a reason to suspect a perforation of the tympanic membrane) (ASHA, 1990). * When tympanometric results were abnormal, (low static admittance (<0.2ml) and abnormal tympanometric peak pressure (< -200daPa)) rescreening was scheduled in 4-6 weeks from the date of the first screening. If the results were again abnormal, a medical referral was made. * Normative data (Table 2 of Appendix A) based on the work of Margolis and Heller (1987) and ASHA (1978) were used for analysis of results in the procedures above. The pass-fail criteria are indicated in Appendix A. * When a subject failed the first or second screening, the parents and school officials were informed by letter/re- port, of the test results and informed of a need for fur- ther evaluation. When medical review was indicated, parents were advised to consult with a general practi- tioner or their family doctor. A medical follow-up was requested from the attending doctor specifying his/her findings and treatment procedures for school records. DATA ANALYSIS PROCEDURES Failure rate was computed in terms of percentages and numbers, and reflected in tables and graphs. The specific criteria for evaluation were as follows: All procedures for middle ear screening were completed on the same day, i.e., history, visual inspection and tympanometry for each subject. The screening was con- ducted on the school premises during school hours (08h00- 12h30). Screening was scheduled for Fall, i.e., between February and April 1992, to control for seasonal varia- tions, since otitis media has its highest prevalence during the winter months (Roust, 1990; Sorensen, 1981). All sub- jects who met the subject1 selection criteria were included. The criteria included: race (Black and Indian), age (4-5 years old), and area of school (Durban Central Region). * The teacher provided the biographical details as well as information pertaining to observable history of pain and ear drainage, wliich was recorded on the record form (Appendix B). ; * Following the collection of the above information, a visual inspection of the ear, head and neck was per- formed, using a Welch-Allen battery operated otoscope. Otoscopic examination of each ear was conducted to identify, earcanal abnormalities, blood effusion, occlu- sion, inflammation, excessive cerumen, tumour or for- eign material. Each ear was then examined for eardrum abnormalities, and specifically for obvious inflamma- tions, and severe retractions. * After visual inspection, typanometry was performed except when the earcanal was occluded with cerumen, or any other foreign material which prevented visual inspection of the tympanic membrane. According to ASHA (1990), excess cerumen is classified as soft or hard cerumen that totally occludes the ear canal and impacted wax. Tympanometric measures were obtained using the Grason-Stadler 28A (Grason-Stadler, 1990), which was calibrated in January 1992, i.e., prior to (i) Middle Ear Screening Protocol (MESP) included his- tory, visual inspection and tympanometry. The MESP consisted of two elements: - Outer ear tests and Middle ear tests. (ii) Failure on Outer ear tests included: - structural defects of the ear, head and neck - ear-canal abnormalities, (i.e., BL to B9, refer to Ap- pendix B). (iii) Failure on Middle ear tests included: - eardrum abnormalities - tympanometry (iv) Failure of a subject on any one of the categories, un- der outer ear and middle ear tests independently, was regarded as a fail. (v) Failure of a subject on either ear on each category independently was regarded as a fail. (vi) Both ears of a subject had to pass the three screening procedures in order for that subject to be regarded as a pass. The data were analysed in terms of failure rate of Black and Indian subjects within each category of the MESP. Results were calculated using one subject as the statisti- cal unit and classifying each subject according to the poor- est result obtained in either ear. RESULTS The failure rate of Black and Indian subjects was com- puted within each category of the Middle Ear Screening Protocol. Results in Table 2 and Figure 1 reflect the following failure rates for Black, and Indian subjects, within each category of the Middle'Ear Screening Protocol (MESP). Die Suid-Afrikaanse Tydskrif vir Kommunikasieafwykings, Vol. 44, 1997 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) 46 Daksha Bhoola & Rene Hugo (i) History On history 0,3% (1) Black and 0,5% (2) Indian failed on otalgia, whereas 0,3% (1) Black and 0,2% (1) In- dian failed on otorrhea. (ii) Visual Inspection Visual inspection is divided into three subcategories, i.e., structural defects, earcanal abnormalities (ECA) and eardrum abnormalities (EDA). The results are as follows: * Structural Defects Only one Black (0,3%) failed on structural defects of the head. There were no failures in the Indian group. * Earcanal Abnormalities (ECA) There were no Black or Indian failures on occlusion Bg categories. In the blood effusion category, 0,3% (1) Blacks failed whereas no Indians failed (B4). Four point eight percent (15) Blacks 2,2% (9) Indians failed to inflammation (B6). Of the 103 Blacks, 32,7% and of the 188 Indians, 45,5% failed due to excessive cerumen (B7) and 1,0% (3) Blacks and 2,2% (9) Indians failed to foreign ma- terial (B9). It is evident that a large percentage of Indians (45,5%) and Blacks (32,7%) failed due to excessive cerumen as compared to failure on any other category of earcanal abnormalities. Furthermore, more Indi- ans (45,5) failed than Blacks (32,7%) on excessive ceru- men only. '' Eardrum Abnormalities (EDA) There were no Black or Indian subjects failing due to severe retractions(B12). However, 1,0% (3) Blacks and 0,5% (2) Indians failed due to obvious perforations (B ) and 1,6% (5) Blacks and 1,0% (4) Indians failed due to obvious inflammation (B ). (iii) Tympanometry On tympanometry measures, 1,0% (3) Blacks and 0,5% (2) Indians failed due to flat tympanogram (C ) and equivalent earcanal volume outside normal range (C ) ie. > 1,0cm3; 5,4% (17) Blacks and 4,8% (20) Indians failed due to low static admittance (C3), ie. <0,2cm3 and 8,3% (26) Blacks and 10,4% (43) Indians failed tympanometric peak pressure (C4) ie. <-200 daPa. Failure Rat· (%) 1 1 Xj <5 118 Bv j||\· H - i ? J p A I A 2 B I B 2 S ! D * B S 5 e B - Π B L A C K Ββ B1 Β» Btl Β12 CHCZ CI C4 ^ INDIAN FIGURE 1 : Failure rate (percentage) of Black and Indian subjects within each category of the MESP TABLE 2 : Failure rate (percentage and numbers) of Black and Indian subjects within each category of the Middle Ear Screening Protocol (MESP) Middle Ear Screening Protocol (MESP) Outer Ear Tests Middle Ear Tests Subject History Visual Inspection Subject Structural Defects Ear-Canal Abnormalities Ear-Drum Abnormalities Tympanometry I a 2 B, B2 B3 b4 B5 B6 b7 b8 B9 B10 B u b12 c / c 2 c 3 et Black 0,3 (1) 0,3 (1) 0 0,3 (1) 0 0.3 (1) 0 4.8 (15) 32.7 (0.3) 0 1.0 (3) 1.0 (3) 1.6 (5) 0 1.0 (3) 5.4 (17) 8.3 1 Indian 0,5 (2) 0,2 (1) 0 0 0 0 0 2.2 (9) 45.5 (188) 0 2.2 (9) 0.5 (2) 1.0 (4) 0 0.5 (2) 4.8 (20) 10.4 (13) NOTE: Figures in parenthesis denote number of subjects failed. Key for Table 2 and Figure 1 Aj - Otalgia Β j - Structural Defect of the Ear B3 - Structural Defect of the Neck B5 - Occlusion B7 - Excessive Cerumen B9 - Foreign Material B u - Obvious Inflammation Cj - Flat Tympanogram (Type B) Cg - Static Admittance (<0.2cm3) V B 2 " B 4 - Bs- B„ - Β c 2 - Ottorrhea Structural Defect of the Head Blood Effusion Inflammation Tumor . - Obvious Perforation - Severe Retraction Equivalent Ear-Canal Volume (> 1.0 cm3) Tympanometric Peak pressure (<-200 daPa) The South African Journal of Communication Disorders, Vol. 44, 1997 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) Excess Cerumen: Failure Rate of Black and Indian F Middle Ear Screening Protocol (MESP) DISCUSSION With reference to Table 2 and Figure 1, it is evident that a large percentage of both Indians (45,5%) and Blacks (32,7%) failed due to excessive cerumen as compared to failure on any other category of earcanal abnormalities. Furthermore, more Indians (45,5%) than Blacks (32,7%) failed on excessive cerumen. Ruben and Fishman (1981) also found that the problem of impacted cerumen was com- mon in their study of American infants. Six of the 21 hear- ing impaired infants examined, presented with cerumen, this being a significant finding (Rubin & Fishman, 1981). Bricco (1985), in her study of children younger than 7 years of age, found that 10 percent (35) of the subjects failed the screening because of impacted cerumen. However, 4,63% of the school children screened by audiologists Watkins, Moore and Phillips (1984) failed their screening because of excessive cerumen in the EAM. Roeser and Crandell (1991) emphasised that the incidence of excessive or im- pacted cerumen in children aged 6-17 years, is approxi- mately 10%. In a pilot study conducted on Indian children, (House of Delegates, 1990) 87,8% of the subjects failed the hearing and immittance screening protocol. They con- cluded that "the majority of pupils failed one or all three subtests due to the presence of impacted wax unilaterally or bilaterally (House of Delegates, 1990:3)". Comparisons between the results of this study and the studies cited above must be drawn with caution due to the differences in age range of subjects in each study. How- ever, in a study conducted by Mandour, El-Ghazzawi, Toppozada and Malaty (1974) on histological and histo- chemical study of the activity of ceruminous glands in normal and excessive wax accumulation in subjects aged one to thirty years, they showed no difference in the nor- mal control groups either in the two sexes or at different ages. There appears to be no available information on the relationship between race and excessive accumulation of cerumen. Comparatively, results on all other categories of the MESP was found to be nojt significant for both Black and Indian subjects. The striking results on the excessive ceru- men category therefore indicate an urgent need for ceru- men management. CONCLUSION AND RECOMMENDATIONS The study revealed a high prevalence of excessive ceru- men in both race groups. Several studies in the literature have noted a high prevalence. As discussed in the Intro- duction, excessive cerumen can cause a mild to moderate (fluctuating) conductive hearing loss. Furthermore, medi- cal consequences of impacted cerumen include tinnitus, pain, fullness in the ear and loss of hearing. The implication of this result is that there is an urgent need for cerumen management programs to be imple- mented and established with preschool children. The de- sired result of any screening program is the proper refer- ral and care of individuals with identified problems. Fur- thermore, universities can actively promote training and participation by students in cerumen extraction processes as part of their course requirements. Unless audiologists manage cerumen they will be unable to provide compre- hensive services to as many as 25-30% of certain populations (ASHA, 1990). A strong case is put forward for the audiologist's responsibility in cerumen manage- ihool Children from Durban on the 47 ment. Further research in this respect is suggested. It is further suggested that teacher-parent education and general public awareness on the harmful effects of excessive cerumen, prevention and treatment of cerumen through organized programs need to be developed. Although audiologists currently receive some theoreti- cal training and clinical experience that qualifies them to manage cerumen, specific training in cerumen removal should be conducted before they engage in this activity (Roeser & Crandell, 1991). According to ASHA(1991), each audiologist who intends to perform cerumen removal pro- cedures must ensure that he/she has acquired the knowl- edge and skills necessary to do each task necessary to the procedure. ASHA (1991) has outlined the tasks to be per- formed, the necessary proficiencies and the knowledge and skills necessary to do each task are summarised in Ap- pendix C. ASHA (1991) also stressed that the training should take place through direct supervision by a qualified professional in a setting allowing the trainee adequate clinical experi- ence. The writer is in agreement with ASHA (1991) and recommends that ASHA's suggestions be followed in the South African pre-schools. However, each practitioner should consider the following precautions or circumstances prior to undertaking these procedures: (a) Obtain a ruling from the appropriate professional board(s) to determine whether there are any limita- tions on the scope of audiology practice which restrict the performance of these procedures. (b) Check professional liability insurance to ensure that there is no exclusion applicable to cerumen manage- ment. (c) Check medical policy, institution insurance coverage and delineation of practice privileges for the specific institution to ensure that there are no restrictions ap- plicable to an audiologist performing these procedures. (d) Know whom to contact if emergency medical assist- ance is needed. (e) Obtain informed consent from parents/guardian/ caregiver to proceed with cerumen management and maintain complete and adequate documentation. The program that follows, is extracted and modified from the Dallas (Texas) Independent School District Pro- gram (DISD) (Roeser, Adam & Watkins, 1991). The pro- gram has been modified to suit the preschools in the South African context. PROGRAM PROCEDURES Figure 2 presents a flow chart outlining the program. Otoscopy should be performed by an audiologist prior to audiometric screening. Audiometric screening should only be performed if both earcanals are unoccluded. If either or both canals are occluded, written permission from the parents/guardian is obtained for earcanal irrigation. If the child has no previous otologic history and permission is obtained, the audiologist must then instill wax softening agents into the earcanal twice daily for four to five days and the ears must be checked otoscopically. If cerumen is removed by the wax softening agent, audiometric and immittances screenings should be done. Ears that remain occluded, must be irrigated until clean by the audiologist with a Water Pik using lukewarm wa- Die Suid-Afrikaanse Tydskrif vir Kommunikasieafwykings, Vol. 44, 1997 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) 48 Daksha Bhoola & Rene Hugo Yes 1 Proceed withAudiometry No FIGURE 2: Flow chart of procedures for Cerumen Management Preschool Program Reference: Roeser, Adam & Watkins (1991: 47) ter (35 -39°C, 96 -100°F). Care must be taken to avoid ex- treme temperatures which may cause nausea and vomit- ing. A low pressure setting, no higher than 2 on a scale of 0-10 on the Water Pik, should be used to dislodge the ceru- men. Audiometric and immittance screening should be performed once the ears are clear. These procedures are in accordance with Roeser, Adam and Watkins, (1991). The audiologist must consider the contraindication of irrigation when implementing the programme. Garber (1986) suggested that irrigation is contraindicated: (a) in young children or infants, because perforations are more likely in this age group; (b) in patients with tympanostomy tubes; (c) when tympanic membrane is perforated; (d) when surgery of middle ear has been recent. The program offers several significant advantages: (a) Each child with impacted cerumen receives treatment necessary to ameliorate the problem. At present, pa- tients with impacted cerumen are referred to ENT spe- cialists or doctors. Often, these referrals are not com- pleted and audiometric status remains unchanged, which may affect academic, psychoeducational and psy- chosocial development (Roeser et al., 1991). '(b) The program will represent a time and monetary sav- ing for parents because completing a referral often means half a day out of class for the child, medical expenses, the loss of parents'working time and salary. (c) Reduced case load for ENT specialists and doctors. (d)Cerumen management will increase accessibility of the public to audiological practices and widen the use of our services. The procedure does have some inherent risks. Injury and infection to the external auditory canal, perforation of the tympanic membrane, exacerbation of chronic mid die ear disease and damage to the ossicular chain can re- sult (Brooks, 1980). However, if procedures are performed by trained staff and applied judiciously, these risks are minimal to nonexistent (Roeser et al., 1991). The program represents a modest investment of finan- cial resources by the school system and time of the health care staff. Roeser et al. (1991) reported data on more than 2000 ears that were irrigated without complications. The benefits to patient care and increased professional inde- pendence far outweigh the potential risks (Roeser & Crandell, 1991). It must be stressed that the proposed program is only a guideline and not a protocol that needs strict adherence. The validity and reliability of the program need to be de- termined. ACKNOWLEDGEMENT This article is based on Master in Logopaedics by the first author and she wishes to thank Professor Rene Hugo and Cyril Govender for their support and assistance in the supervision of this study. REFERENCES Alpiner, J.G. & McCarthy, P.A. (1987). Rehabilitative audiology : children and adults. Baltimore : Williams & Wilkins. American Academy of Audiology. (1989). Scope of practice - working draft. American Food and Drug Administration. 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American Journal of Nursing, 84:1107.0 A P P E N D I X A T A B L E 1 rReferral Criteria : M i d d l e E a r S c r e e n i n g P r o t o c o l ( M E S P ) I H i s t o r y (a) Otalgia (b) O t o r r h e a II V i s u a l I n s p e c t i o n of the E a r (a) Structural dejfect of the ear, h e a d or n e c k (b) E a r c a n a l abnormalities B l o o d or effusion O c c l u s i o n I n f l a m m a t i o n E x c e s s i v e c e r u m e n , tumour, foreign material (c) E a r d r u m abnormalities O b v i o u s perforation O b v i o u s i n f l a m m a t i o n Severe retraction III T y m p a n o m e t r y (a) Flat t y m p a n o g r a m and equivalent earcanal volume ( V c ) outside normal range, o c c u r r e n c e s in a 4 - 6 w e e k interval. Modified from : A S H A (1990) a n d A S H A (1978) Die Suid-Afrikaanse Tydskrif vir Kommunikasieafwykings, Vol. 44, 1997 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) 50 Daksha Bhoola & Rene Hug TABLE 2 : Interim Norms (Means and 90% Ranges) for Static Admittance (Peak Y), Equivalent Earcanal Volume (Vcc) and Tympanometric Peak Pressure (TPP) PeakY cm3/ml* v EC cm'/ml* TPP daPa Means 90% Range Means 90% Range Means 90% Range Children 0.05 0.2-0.9 0.7 0.4-1.0 100 -200 - +100 The values were extracted from Margolis & Heller (1987) who employed an acoustic immittance screening instrument (226-Hz) probe tone; pump speed -200 daPa/s that automatically compensated for earcanal volume by subtracting the admittance at 200 daPa from all values. Normative values for children were obtained from preschool-aged children (3-5 years). *cm3 and ml are equivalent units (ASHA, 1990). Modified : Roush (1990) From ASHA (1978) APPENDIX Β Pupil Record Form PERSONAL DETAILS Reference No: Name: Sex: School D.O.B Date of Test: Age: Date of Retest: Race :, Audiologist: Daksha Bhoola KEY: Red = Right Ear; Blue = Left Ear A. HISTORY First Screen Second Screen A.l OTOLGIA YES NO YES NO OTORRHEA YES NO YES NO B. VISUAL INSPECTION STRUCTURAL INSPECTION OF THE B.l EAR YES NO YES NO ' B.2 HEAD YES NO YES NO I B.3 NECK YES NO YES NO ' EAR CANAL ABNORMALITIES B.4 BLOOD EFFUSION YES NO YES NO B.5 OCCLUSION YES NO YES NO B.6 INFLAMMATION YES NO YES NO. B.7 EXCESSIVE CERUMEN YES NO YES NO B.8 TUMOR YES NO YES NO B.9 FOREIGN MATERIAL YES NO YES NO EARDRUM ABNORMALITIES B.10 OBVIOUS PERFORATION YES NO YES NO B . l l OBVIOUS INFLAMMATIONS YES NO YES NO B.12 SEVERE RETRACTIONS YES NO YES NO The South African Journal of Communication Disorders, Vol. 44, 1997 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) Excess Cerumen: Failure Rate of Black and Indian Preschool Children from Durban on the Middle Ear Screening Protocol (MESP) 51 FIRST SCREEN C. TYMPANOMETRY c 1 TYMPANOGRAM C 2 STATIC ADMITTANCE C.3 EARCANAL VOLUME C.4 TYMPANOMETRIC PEAK PRESSURE D. SUMMARY D.l HISTORY D.2 VISUAL INSPECTION D.3 TYMPANOMETRY D.4 SEND LETTER TO PARENT D.5 SEND LETTER TO ENT D.6 RETEST A <0,2 <0,4 <-200daPa As Β 0,2-0,9 0,4-1,0 -200-+100daPa FAIL FAIL FAIL YES YES YES C Ad >0.9 >1,0 +lOOdaPa Actual Value R L PASS PASS PASS NO NO NO SECOND SCREEN C. TYMPANOMETRY c . l TYMPANOGRAM C.2 STATIC ADMITTANCE C.3 EARCANAL VOLUME C.4 TYMPANOMETRIC PEAK PRESSURE A <0,2 <0,4 200daPa As Β 0,2-0,9 0,4-1,0 -200-+100daPa C Ad >0.9 >1,0 +lOOdaPa Actual Value R L D. SUMMARY D.l HISTORY D.2 VISUAL INSPECTION D 3 TYMPANOMETRY D.4 SEND LETTER TO PARENT D.5 SEND LETTER TO ENT D.6 RETEST FAIL FAIL FAIL YES YES YES PASS PASS PASS NO NO NO APPENDIX C Summary of Tasks, i^roiiciency, iuiuwi TASK ! BUgc auu ——1 — PROFICIENCY KNOWLEDGE/SKILLS NEEDED Inspect visually via hand-held otoscope or head-light (mirror)! and speculum the EAC and TM for presence'of obstructing material, evidence of lesions or ongoing infectious process, evidence of anato- mical anomalies that may affect the accuracy of immittance or caloric irrigations. Visual inspection of the EAC and TM. 1. Knowledge of anatomy, physiology and pathophysiology of the EAC and TM. 2. Knowledge of common medical or post-surgical conditions of the EAC, TM or middle ear that alter the appearance and/or function of the EAC and/or TM. . 3. Skill in the use of otoscopy. 4. Skill in the interpretation of visual inspection of the EAC and TM Inspect the EAC and TM visually via hand-held pneumatic otoscope or head light (mirror) and Seigel scope for determining the mobility of the TM. Determination of appropriate- ness of TM mobility. 1. Knowledge of anatomy, physiology and pathophysiology of the EAC and TM. 2. Knowledge of common medical or postsurgical conditions of the EAC, TM or middle ear that alter the appearance and/or function of the EAC and/or TM. Die Suid-Afrikaanse Tydskrif vir Kommunikasieafwykings, Vol. 44, 1997 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) 52 Daksha Bhoola & Rene Hug 3. Skill in the use of otoscopy and pneumatic otoscopy. 4. Skill in the interpretation of visual inspection of the EAC and TM. Inspect the EAC and TM visually prior to and following caloric irrigation, immittance, ear mould impression, real ear acoustic measurements or non- invasive electrocochlegraphy for purpose of documenting status of the EAC and TM after one of these proce- dures is performed. Visual inspection of the EAC and TM 1. Knowledge of common medical or post surgical conditions of the EAC, TM or middle ear that alter the appearance and/or function of the EAC and/or TM. 2. Skill in the use of otoscopy and pneumatic otoscopy. 3. Skill in the interpretation of visual inspection of the EAC and TM. Determine if occluding material visualized in the EAC is cerumen and if it can be removed comfortably and safely without the use of an operating microscope. Recognizing cerumen versus other occluding versus other occluding materials, and determining its need for removal and the most effective method of removal 1. Skill in the use of otoscopy and pneumatic otoscopy. 2. Skill in the interpretation of visual inspection of the EAC and TM. 3. Skill in cerumen removal by a variety of techniques and equipment. Determine if the procedure to be performed should be deferred, based on EAC and TM inspection, and if referral to an otolaryngologist is indicated. Determining the status of the EAC and TM relative to the needs of the procedure to be performed. 1. Knowledge of anatomy, physiology and pathophysiology of the EAC and TM. 2. Knowledge of common medical or postsurgical conditions of the EAC or TM or middle ear that alter the appearance and/or function of the EAC and/or TM. 3. Skill in the use of otoscopy and pneumatic otoscopy. 4. Skill in the interpretation of visual inspection of the EAC and TM. 5. Skill in cerumen removal by, e.g., use of cerumen loop and hand-held otoscopic device; use of cerumen loop, head mirror and hand-held speculum; use of material for softening and gentle water irriga- tion or a combination of these methods. Establish appropriate protocol with medical personnel to handle EAC abrasion or laceration that could result from cerumen removal. Determining need for other medical service involvement in the care of the EAC and TM. 1. Knowledge of anatomy, physiology and pathophysiology of the EAC and TM. 2. Knowledge of common medical or t postsurgical conditions of the EAC; TM or middle ear that alter the j appearance and/or function of the EAC and/or TM. Select appropriate method and remove occluding cerumen or refer to an otolaryngolist for removal once determining that: a. use of a microscope may be required; b. the cerumen is too close to the TM; c..the occluding material is not cerumen; d. the comfort or safety of the patient may be comprised Determining if occluding material is cerumen and, if it is cerumen, determining if it can be removed safely and comfortably without the use of an oprating microscope. 1. Knowledge of anatomy, physiology, and pathophysiology of the EAC and TM. 2. Skill in cerumen removal by a variety of techniques and equipment Key : EAC - External auditory Canal, tympanic membrane Reference : ASHA (1991:66) The South African Journal of Communication Disorders, Vol. 44, 1997 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2)