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Cerumen impaction, ear hygiene practices, and hearing acuity
Cerum n Impaction, Ear Hygiene Practic s, and Hearing Acuity Nurses should playa more active role in identifying cerumen impactions and other causes of hearing loss. By
DiANA
F.
NRY
AUIIC"'"
common but reversible cause of conductive hearing loss is impacted cerumen (ear wax) in the external auditory canal. 1 Cerumen is produced by sebaceous and apocrine glands in the outer portion of the external auditory canal and serves to lubricate and protect the canal (Figure 1).2 Normally produced in small amounts, cerumen is gradually propelled out of the ear by the action of the cilia and the movements of chewing and talking. While some individuals will form only scanty amounts of cerumen, other people tend to form excessive amounts, which may accumulate and obstruct the ear canal. The obstruction (or impaction) may interfere with the passage of sound vibrations through the external auditory canal to the middle and inner ear and affect a person's ability to hear and communicate. This study sought to elicit information about cerumen impaction, ear hygiene practices, and hearing acuity among three groups of older adults residing in a rural area.
A
Review of the Literature With increasing age, changes occur in the external auditory canal that may affect the production and movement of cerumen. For instance, older men often develop stiff, coarse terminal hairs that interfere with the normal extrusion of cerumen.I and loss of elasticity of the cartilage may result in a tortuous or abnormally narrow canal, which makes cerumen extrusion difficult." Mahoney! studied the incidence of cerumen impaction among older adults attending a community-based ambulatory health center and found an occurrence rate of 34%. Janken and
DIANA F. NEV, RN, PhD, CRNP, is an associate professor of nursing at Slippery Rock University, in Slippery Rock, Pa. Copyright e 1993 by Mosby-Year Book, Inc. ISSN 0197-4572/93/$1.00 + .to 34/1/44273
70 Geriatric Nursing Marchi April 1993
...
tl'tUllIL
CAUL
FIGURE 1. Cross section of ear.
Cullinan'' studied cerumen impaction among hospitalized elderly patients and found a similar incidence. It is estimated that 25% to 40% of people over 65 years of age are hearing impaired, with more than 90% of people in their ninth decade of life demonstrating a hearing handicap." Characteristically, the hearing loss is a slowly developing, bilateral high-frequency sensorineural impairment with a lack of ability to hear and understand conversational speech. A small percentage of older adult hearing impairment may be attributed purely to a conduction defect, and a conduction defect may compound and complicate an existing sensorineural hearing defect. If the defect is a cerumen impaction, identification and removal of the impaction may restore hearing acuity and relieve symptoms associated with impactions. Janken and Cullinan found that removal of cerumen significantly improved hearing ability. Individuals with cerumen buildup may experience a feeling of fullness, itching, or tinnitus. These individuals
Ney
BOX 1. PROTOCOL FOR CERUMEN REMOVAL Assess for ear pain, traumas, abnormal ities, drainage, surgeries or perforations. These or any other unusual findings sho uld be referred to an otolaryngologist. When aural exam ination revea ls cerumen impaction with no other abnormalities, the nurse may irrigate lor cerumen removal using the following techniques: • Carefully clip and remove ha irs in ear canal. • Instill a soh ening agent, such as slightly worm mineral oil, !h to 1 ml twice daily lor several days until wax becomes softened. • Protect clothing and linens from drainage of oil or wax by placing a small cotton ball in each external ear canal. • When irrigating the ear, use hand-held bulb syringe, a 2 to 4 ounce plastic syringe or Water Pik with emesis basin under ear to catch droinage; tip head to side being drained. • Use solution of 3 ounces 3% hyd rogen peroxide in quart of wa· ter warmed to 98 to 100° F; if client is sensitive to hydrogen peroxide, use sterile normal saline solution. • Place towels around neck, empty emesis basin frequently, observing for resid ue from ear; keep client dry and comfortable; do not inject ai r into client' s ear or use high pressure when inieding fluid . • If the cerumen is not successfully washed out , begin the process again of instilling a softening agent for several days. Adapted (rom Webber-Jones J. Am J Nuts 199211,37·40.
FIGURE 2. Audioscope's settings . (Co u rte sy of Welch Allyn , Skaneateles Falls, N. Y.J
are also at greater risk for ca nal macera tion and secondary infection.f Recommended a ura l hygiene involves the gentle jects were aged 60 yea rs or older, able to give informed cleansing of the auricles (outside ears) during the bath." consent, and not under the care of a physician for an car A sudden onset of deafness may occur following washing disorder. A convenience sa mple of 240 volunteers was obor showering when water, entering a partially impacted tained . After the purpose of the study was explained and ear canal, causes the ceru men to swell and completely the consent to participate was obtain ed, the subjects were block the canal." The use of cotton-tipped applicators to asked to describe their current ear hygiene practice. The cleanse the external canal is discouraged because the de- ac tual visualization of the external canal and the screenvices may push the cerumen deeper into the canal and ing of hearing with the audioscope took place in a private, thus increase the risk of compaction, as well as trauma- quiet room. Registered nurses, specially trained in the use of the a ud ioscope, perform ed the visualization and tization of the canal walls and tympanic membrane. I I The physician is usually responsible for the removal or screening. impacted cerumen, which is accomplished through use or A valid, reliable, and convenient instrument to use in irrigation techniques or a curette under direct vision.'? screening for hearing loss is a hand-held audioscope.l ' Nurses may remove cerumen using a specific protocol This instrument is a combination otoscope (allow ing for (Box I). Impaction removal is made easier by the instil- visualization of the tympanic membrane) and screening lation of a wax softener such as mineral oil or carbamid e aud iometer that deliver s a 20,25 , or 40 dB tone at Irequencies of 500, 1000,2000, and 4000 Hz ( Figure 2). peroxide.' ? The primar y purpose of this study was to explore the T he 40 dO HL level is recommended for use with an eldprevalence of cerumen impaction among three groups of erly populat ion." To use the audioscope the nurse selected the largest ca r older adults residing in u rural area. The groups included older adults living independen tly in the community and speculum required to ensure a sea l within the extern al aupart icipating in senior citizen center activities, in per- ditory canal. The subject was instru cted to raise and then sonal care homes, and in nursing homes. The stud y also lower a finger each time he or she heard a tone. After reexamined the ear hygiene practices and hearing acuity of tr acting the pinna, the nurse inserted the audioscope into the entrance of the ear and visualized the canal and the the three groups . tympanic membrane. If the canal was obstructed by cerumen and the tympan ic membrane was not visible, the cur Methods was described as having an impaction. If only half of the Subjects were recruited from senior citizen centers, tympanic membrane was visible, it was described as havpersonal care homes, and nursing homes in a rural West- ing a partial impaction. The presence of lesser amounts or ern Pennsylvania area. To be included in the study, sub- ce rumen in the canal was described as a small amount.
Geriatric Nursing Volume 14, Number 2 71
TABLE 1. SUBJECTS A CCO RDING TO GROUP
AND SEX Women
Group I sen ior citizen centers Group II personal co re homes Group III nursing homes
Tota l
Men
No.
%
No.
010
No.
%
90
37.5
29
12.1
119
49.6
35
14.6
21
8.75
56
23.3
44
18.3
21
8.75
65
27.1
-
-71
-240
-100-.0%
-169
70.4
29 .6
With th e uudioscope poin ted toward the tympa nic membrane, the start button was depressed and the tone seq uence initiated . Th e seq uence began with a 1000 Hz pretone, presented a t 20 dB H L a bove the screeni ng level of 40 dBHL to provide the subject with an opportunity to practice "listening" before the ac tual screening began. Th en the ton es were delivered a t frequencies of 1000, 2000, 4000, a nd 500 H z. Both ears were screened. Forty dB adj usts for normal hearing loss associa ted with ag ing. Subjects failing to hear frequen cies of 2000 Hz or less were rescre ened, and results of the second screening were used for du ia analysis . The nurse recorded either a pass or a fail response for each frequenc y for each ear. For the purpose of data analysis, the highest tone heard by the subject (in either ear) was used as an indication of hearing acuity. At the conclusion of the visual examinatio n and screening, the nurse gave the subje ct a written copy of the results and discussed the findings. It was suggested that individua ls with excess ear wax or a n inab ility to hear tones at 500, 1000, or 2000 Hz consult their physicians for further examin ation and evaluation . Descriptive statistic s were used to a na lyze the demographic da ta, ear hygiene practices, incidence of cerumen impactions, and hearin g ac uity findings. The chi squa re lest was used to identify significa nt frequencies and differences. Findings
A total of 240 older ad ults from senior citize n centers, persona l car e homes, and nu rsing homes participated in the study . The subj ects ran ged in age from 60 to 10\ years, with a mean age of 76.5 yea rs. A majority of the subjects (70%) were women (Tabl e I). Taken as a group , the senior citizen subj ects were younger (mean age of 73 yea rs) when compared with personal care home residents (mean age of 82 years) and nursing home residents (mean age of 85 year s).
72 Ger ia t ric Nursing March/ April
[ 1)1). 1
Most or the subjects described t he clea nsing of their ears as a part of their daily hygiene, which consisted of the use of soap and water on the race and outer ea rs. Man y subjec ts (32%) described the use or a var iety of commo n objec ts to " clean " their ea rs-incl uding hair pins, bobby pins, mat chsticks, paper clips, car keys, and, in one case. a nail (us ed by a retired carpenter)-on an occas iona l or regular basis. The objec t used most often to "clean" the ears was the colton-tipped a pplica tor (38%). Applicato rs were used significant ly more often amon g subjects in the senior citizens' group (p = 0.005) . This finding probably refl ected a greater accessibility to the applicators and a higher level of self-care activity. When caut ioned about the potentia l risks or cottontipped applicator use, the usual response was that the 01[1plicator was used carefully. The investigator felt that the actual use of applicators to clean the external ear canal was even greater than that stated but that some subjects were reluctant to admit to their lise. Twelve subjects (5%) said they instilled a few drops of alcohol or hydrogen peroxide in the ea r can al to help soften or prevent the build-up or cerumen. Only one subject stated that he used an over-the-counter dru g developed specifically to soft en ear wax.
Sublecte were pleased that someone ro@k time to examine their ears,
OJ
procedure apparently
seldom done during routine health visits. The amount of cerumen seen dur ing the inspection or 480 ears (240 subjects) ranged from none to an excessive amount that completely obscured the tym panic membrane . Taken as a group, II % of the subjects demonstrated a cerumen impact ion or one or both ears. When the impaction involved one ear only, the impaction s occurred equally between the right and left ea rs. Su bjects from the senior citizen centers had signifi cantly fewer impact ions tha n did the personal ca re or nursing home subjects (p = 0.038) . There was a gender difference in the incidence of impactions. Th e male subjects had signifi cantly more impactions in one or both ear s tha n did the female subj ects (p = .00 I). A common comment made by the subjects, especially those from the senior citizen centers, was that they were "pleased" that "s omeone" took time to exa mine their ears, a procedure a pparently seldom done during routine health visits, yet of voiced importan ce to the subje cts. Heari ng acuity ra nged lrom those individua ls who heard all of the tones in both ems to those individuals who wert: a ble to hear tones in only one ea r to those individuals who were unable to hear any tones in either car. A third or the subjects could hear at the highest frequency (4000 Hz). But 18% of the total populat ion were severely
Ncy
hearing impaired (unable to hear high-, middle-, or lowfrequency tones). Thirty-nine percent of the nursing home subjects were severely hearing impaired, compared with personal care home subjects (16%) and senior citizen center subjects (8%). All but three of the subjects demonstrating cerumen impactions were severely or moderately hearing impaired. Some (35%) of the severely hearing impaired used hearing aids. Others said they had hearing aids but they "didn't like them" and thus did not use them. Many complaints about hearing aids were voiced by both the aid wearers and non-wearers.
among older adults. The presence of cerumen impactions may have inflated the impairment figures for obstruction of the external auditory canal may interfere with the passage of sound vibrations. The findings of the study support the premise that nurses can playa more active role in health promotion involving older adults and their ears and hearing, Not only can they identify (through hearing screening) older adults with hearing problems and refer them for evaluation and management, but they can detect (through visual examination) cerumen impactions and assist with their removal. III
Discussion This descriptive study presents data on the incidence of cerumen impaction among three groups of older adults living in a rural area. Eleven percent of the subjects demonstrated an impaction of one or both ears. This is less than the 34% and 35% reported in previous studies.S 6 The senior citizen center group (75% of whom were women) had significantly fewer impactions than did the personal care home or nursing home residents. This may be a reflection of subject selection, a gender difference, a higher level of physical activity with greater opportunity for extrusion of cerumen, or, possibly, greater use of ear hygiene activities. This group was the largest user of the cotton-tipped applicators. This study has also shown that almost a third of the subjects (32%) introduced an object into their ears on a regular or occasional basis, for the purpose of cleaning wax from the external canal. The object used most often was the ubiquitous cotton-tipped applicator. This finding suggests that efforts should be directed toward the evaluation of current aural hygiene and self-care practices with exploration of alternative approaches. Since many older adults are quite capable of a high level of self-care, those with a continuing cerumen problem could be taught safe self-care practices to prevent a cerumen buildup and impaction. The finding that two thirds of the subjects heard less than the highest frequency (4000 Hz) on the audioscopic screening, with 18% of the total population unable to hear any tone, highlights the problem of hearing impairment
This study was supported, in part, by a grant from Marion Laboratories, I thank registered nurses enrolled in the Slippery Rock University Bachelor of Science in Nursing Program for their assistance in the collection of data for the study. REFERENCES I. HilgerP, PaparellaM, Anderson R, Conductive hearing loss, In: Meyerhoff W, ed, Diagnosis and management of hearing loss. Philadelphia: WD Saunders, \984:41. 2. DeWeis D, SaundersW, SchullerD, Schlewning A. Otolaryngology-head and neck surgery. St. Louis: CV Mosby, 1988:395. 3. Selmanowitz VJ, Rizer RL, Orentreich N. Agingof the skin and appendage, In: Finch C, Hayflick L, eds, Handbook of the biology of aging.New York: Van Nostrand, 1977:310, 4. SoucekS, Michaels L, Hearing loss in the elderly. London: Springer-Verlag 1990:26. 5. Mahoney D, One simple solution to hearing impairment, GURIATR NURs 1987;242-5, 6, Janken J, Cullinan C. Effectof cerumenremoval ou thehearingability ofge. riatric patients, J Adv Nurs 1990:15:597. 7, Lichtenstein M,BessF, LoganS. Validation of screening toolsforidentifying hearing-impaired elderly in primarycare, JAMA 1988;259:2878. 8. Ballinger J. Diseases of the nose, throat, ear, head, and neck, Philadelphia: Lea & Febiger, 1985:1088, 9. Craven R, Hirnle C. Fundamentals of nursing. Philadelphia: Lippincott, 1992:676. . 10. Dinell JF, ed, LoganTurner's diseases of the nose, throat, and ear. London: Wright, 1982:333. 1J. Caruso V, Meyerhoff W, Trauma and infections of the externalear. In: PaparellaM, Shumrick D, eds, Otolaryngology: Vol II. The ear. Philadelphia: WB Saunders, 1980:1345. 12. Amundson L. Disorders of the external ear. In: Vogt H, ed, Primary care. 1990;17:220-1. 13. Mulrow C. Screening for hearing impairment in the elderly, Hasp Pract 1991;26:2A. 14. Frank T, Peterson D, Accuracy of a 40 dB HL audioscope and audiometer screening for adults. Ear Hear 1987;8:180.
GERIATRIC NURSING welcomes unsolicited manuscripts related to and aspects of care for the elderly. See the "Information for Authors" for details about the JOURNAL'S editorial policies and manuscript preparation.
Ney
Geriatric Nursing Volume 14, Number 2 73
DiANA
F.
NRY
AUIIC"'"
common but reversible cause of conductive hearing loss is impacted cerumen (ear wax) in the external auditory canal. 1 Cerumen is produced by sebaceous and apocrine glands in the outer portion of the external auditory canal and serves to lubricate and protect the canal (Figure 1).2 Normally produced in small amounts, cerumen is gradually propelled out of the ear by the action of the cilia and the movements of chewing and talking. While some individuals will form only scanty amounts of cerumen, other people tend to form excessive amounts, which may accumulate and obstruct the ear canal. The obstruction (or impaction) may interfere with the passage of sound vibrations through the external auditory canal to the middle and inner ear and affect a person's ability to hear and communicate. This study sought to elicit information about cerumen impaction, ear hygiene practices, and hearing acuity among three groups of older adults residing in a rural area.
A
Review of the Literature With increasing age, changes occur in the external auditory canal that may affect the production and movement of cerumen. For instance, older men often develop stiff, coarse terminal hairs that interfere with the normal extrusion of cerumen.I and loss of elasticity of the cartilage may result in a tortuous or abnormally narrow canal, which makes cerumen extrusion difficult." Mahoney! studied the incidence of cerumen impaction among older adults attending a community-based ambulatory health center and found an occurrence rate of 34%. Janken and
DIANA F. NEV, RN, PhD, CRNP, is an associate professor of nursing at Slippery Rock University, in Slippery Rock, Pa. Copyright e 1993 by Mosby-Year Book, Inc. ISSN 0197-4572/93/$1.00 + .to 34/1/44273
70 Geriatric Nursing Marchi April 1993
...
tl'tUllIL
CAUL
FIGURE 1. Cross section of ear.
Cullinan'' studied cerumen impaction among hospitalized elderly patients and found a similar incidence. It is estimated that 25% to 40% of people over 65 years of age are hearing impaired, with more than 90% of people in their ninth decade of life demonstrating a hearing handicap." Characteristically, the hearing loss is a slowly developing, bilateral high-frequency sensorineural impairment with a lack of ability to hear and understand conversational speech. A small percentage of older adult hearing impairment may be attributed purely to a conduction defect, and a conduction defect may compound and complicate an existing sensorineural hearing defect. If the defect is a cerumen impaction, identification and removal of the impaction may restore hearing acuity and relieve symptoms associated with impactions. Janken and Cullinan found that removal of cerumen significantly improved hearing ability. Individuals with cerumen buildup may experience a feeling of fullness, itching, or tinnitus. These individuals
Ney
BOX 1. PROTOCOL FOR CERUMEN REMOVAL Assess for ear pain, traumas, abnormal ities, drainage, surgeries or perforations. These or any other unusual findings sho uld be referred to an otolaryngologist. When aural exam ination revea ls cerumen impaction with no other abnormalities, the nurse may irrigate lor cerumen removal using the following techniques: • Carefully clip and remove ha irs in ear canal. • Instill a soh ening agent, such as slightly worm mineral oil, !h to 1 ml twice daily lor several days until wax becomes softened. • Protect clothing and linens from drainage of oil or wax by placing a small cotton ball in each external ear canal. • When irrigating the ear, use hand-held bulb syringe, a 2 to 4 ounce plastic syringe or Water Pik with emesis basin under ear to catch droinage; tip head to side being drained. • Use solution of 3 ounces 3% hyd rogen peroxide in quart of wa· ter warmed to 98 to 100° F; if client is sensitive to hydrogen peroxide, use sterile normal saline solution. • Place towels around neck, empty emesis basin frequently, observing for resid ue from ear; keep client dry and comfortable; do not inject ai r into client' s ear or use high pressure when inieding fluid . • If the cerumen is not successfully washed out , begin the process again of instilling a softening agent for several days. Adapted (rom Webber-Jones J. Am J Nuts 199211,37·40.
FIGURE 2. Audioscope's settings . (Co u rte sy of Welch Allyn , Skaneateles Falls, N. Y.J
are also at greater risk for ca nal macera tion and secondary infection.f Recommended a ura l hygiene involves the gentle jects were aged 60 yea rs or older, able to give informed cleansing of the auricles (outside ears) during the bath." consent, and not under the care of a physician for an car A sudden onset of deafness may occur following washing disorder. A convenience sa mple of 240 volunteers was obor showering when water, entering a partially impacted tained . After the purpose of the study was explained and ear canal, causes the ceru men to swell and completely the consent to participate was obtain ed, the subjects were block the canal." The use of cotton-tipped applicators to asked to describe their current ear hygiene practice. The cleanse the external canal is discouraged because the de- ac tual visualization of the external canal and the screenvices may push the cerumen deeper into the canal and ing of hearing with the audioscope took place in a private, thus increase the risk of compaction, as well as trauma- quiet room. Registered nurses, specially trained in the use of the a ud ioscope, perform ed the visualization and tization of the canal walls and tympanic membrane. I I The physician is usually responsible for the removal or screening. impacted cerumen, which is accomplished through use or A valid, reliable, and convenient instrument to use in irrigation techniques or a curette under direct vision.'? screening for hearing loss is a hand-held audioscope.l ' Nurses may remove cerumen using a specific protocol This instrument is a combination otoscope (allow ing for (Box I). Impaction removal is made easier by the instil- visualization of the tympanic membrane) and screening lation of a wax softener such as mineral oil or carbamid e aud iometer that deliver s a 20,25 , or 40 dB tone at Irequencies of 500, 1000,2000, and 4000 Hz ( Figure 2). peroxide.' ? The primar y purpose of this study was to explore the T he 40 dO HL level is recommended for use with an eldprevalence of cerumen impaction among three groups of erly populat ion." To use the audioscope the nurse selected the largest ca r older adults residing in u rural area. The groups included older adults living independen tly in the community and speculum required to ensure a sea l within the extern al aupart icipating in senior citizen center activities, in per- ditory canal. The subject was instru cted to raise and then sonal care homes, and in nursing homes. The stud y also lower a finger each time he or she heard a tone. After reexamined the ear hygiene practices and hearing acuity of tr acting the pinna, the nurse inserted the audioscope into the entrance of the ear and visualized the canal and the the three groups . tympanic membrane. If the canal was obstructed by cerumen and the tympan ic membrane was not visible, the cur Methods was described as having an impaction. If only half of the Subjects were recruited from senior citizen centers, tympanic membrane was visible, it was described as havpersonal care homes, and nursing homes in a rural West- ing a partial impaction. The presence of lesser amounts or ern Pennsylvania area. To be included in the study, sub- ce rumen in the canal was described as a small amount.
Geriatric Nursing Volume 14, Number 2 71
TABLE 1. SUBJECTS A CCO RDING TO GROUP
AND SEX Women
Group I sen ior citizen centers Group II personal co re homes Group III nursing homes
Tota l
Men
No.
%
No.
010
No.
%
90
37.5
29
12.1
119
49.6
35
14.6
21
8.75
56
23.3
44
18.3
21
8.75
65
27.1
-
-71
-240
-100-.0%
-169
70.4
29 .6
With th e uudioscope poin ted toward the tympa nic membrane, the start button was depressed and the tone seq uence initiated . Th e seq uence began with a 1000 Hz pretone, presented a t 20 dB H L a bove the screeni ng level of 40 dBHL to provide the subject with an opportunity to practice "listening" before the ac tual screening began. Th en the ton es were delivered a t frequencies of 1000, 2000, 4000, a nd 500 H z. Both ears were screened. Forty dB adj usts for normal hearing loss associa ted with ag ing. Subjects failing to hear frequen cies of 2000 Hz or less were rescre ened, and results of the second screening were used for du ia analysis . The nurse recorded either a pass or a fail response for each frequenc y for each ear. For the purpose of data analysis, the highest tone heard by the subject (in either ear) was used as an indication of hearing acuity. At the conclusion of the visual examinatio n and screening, the nurse gave the subje ct a written copy of the results and discussed the findings. It was suggested that individua ls with excess ear wax or a n inab ility to hear tones at 500, 1000, or 2000 Hz consult their physicians for further examin ation and evaluation . Descriptive statistic s were used to a na lyze the demographic da ta, ear hygiene practices, incidence of cerumen impactions, and hearin g ac uity findings. The chi squa re lest was used to identify significa nt frequencies and differences. Findings
A total of 240 older ad ults from senior citize n centers, persona l car e homes, and nu rsing homes participated in the study . The subj ects ran ged in age from 60 to 10\ years, with a mean age of 76.5 yea rs. A majority of the subjects (70%) were women (Tabl e I). Taken as a group , the senior citizen subj ects were younger (mean age of 73 yea rs) when compared with personal care home residents (mean age of 82 years) and nursing home residents (mean age of 85 year s).
72 Ger ia t ric Nursing March/ April
[ 1)1). 1
Most or the subjects described t he clea nsing of their ears as a part of their daily hygiene, which consisted of the use of soap and water on the race and outer ea rs. Man y subjec ts (32%) described the use or a var iety of commo n objec ts to " clean " their ea rs-incl uding hair pins, bobby pins, mat chsticks, paper clips, car keys, and, in one case. a nail (us ed by a retired carpenter)-on an occas iona l or regular basis. The objec t used most often to "clean" the ears was the colton-tipped a pplica tor (38%). Applicato rs were used significant ly more often amon g subjects in the senior citizens' group (p = 0.005) . This finding probably refl ected a greater accessibility to the applicators and a higher level of self-care activity. When caut ioned about the potentia l risks or cottontipped applicator use, the usual response was that the 01[1plicator was used carefully. The investigator felt that the actual use of applicators to clean the external ear canal was even greater than that stated but that some subjects were reluctant to admit to their lise. Twelve subjects (5%) said they instilled a few drops of alcohol or hydrogen peroxide in the ea r can al to help soften or prevent the build-up or cerumen. Only one subject stated that he used an over-the-counter dru g developed specifically to soft en ear wax.
Sublecte were pleased that someone ro@k time to examine their ears,
OJ
procedure apparently
seldom done during routine health visits. The amount of cerumen seen dur ing the inspection or 480 ears (240 subjects) ranged from none to an excessive amount that completely obscured the tym panic membrane . Taken as a group, II % of the subjects demonstrated a cerumen impact ion or one or both ears. When the impaction involved one ear only, the impaction s occurred equally between the right and left ea rs. Su bjects from the senior citizen centers had signifi cantly fewer impact ions tha n did the personal ca re or nursing home subjects (p = 0.038) . There was a gender difference in the incidence of impactions. Th e male subjects had signifi cantly more impactions in one or both ear s tha n did the female subj ects (p = .00 I). A common comment made by the subjects, especially those from the senior citizen centers, was that they were "pleased" that "s omeone" took time to exa mine their ears, a procedure a pparently seldom done during routine health visits, yet of voiced importan ce to the subje cts. Heari ng acuity ra nged lrom those individua ls who heard all of the tones in both ems to those individuals who wert: a ble to hear tones in only one ea r to those individuals who were unable to hear any tones in either car. A third or the subjects could hear at the highest frequency (4000 Hz). But 18% of the total populat ion were severely
Ncy
hearing impaired (unable to hear high-, middle-, or lowfrequency tones). Thirty-nine percent of the nursing home subjects were severely hearing impaired, compared with personal care home subjects (16%) and senior citizen center subjects (8%). All but three of the subjects demonstrating cerumen impactions were severely or moderately hearing impaired. Some (35%) of the severely hearing impaired used hearing aids. Others said they had hearing aids but they "didn't like them" and thus did not use them. Many complaints about hearing aids were voiced by both the aid wearers and non-wearers.
among older adults. The presence of cerumen impactions may have inflated the impairment figures for obstruction of the external auditory canal may interfere with the passage of sound vibrations. The findings of the study support the premise that nurses can playa more active role in health promotion involving older adults and their ears and hearing, Not only can they identify (through hearing screening) older adults with hearing problems and refer them for evaluation and management, but they can detect (through visual examination) cerumen impactions and assist with their removal. III
Discussion This descriptive study presents data on the incidence of cerumen impaction among three groups of older adults living in a rural area. Eleven percent of the subjects demonstrated an impaction of one or both ears. This is less than the 34% and 35% reported in previous studies.S 6 The senior citizen center group (75% of whom were women) had significantly fewer impactions than did the personal care home or nursing home residents. This may be a reflection of subject selection, a gender difference, a higher level of physical activity with greater opportunity for extrusion of cerumen, or, possibly, greater use of ear hygiene activities. This group was the largest user of the cotton-tipped applicators. This study has also shown that almost a third of the subjects (32%) introduced an object into their ears on a regular or occasional basis, for the purpose of cleaning wax from the external canal. The object used most often was the ubiquitous cotton-tipped applicator. This finding suggests that efforts should be directed toward the evaluation of current aural hygiene and self-care practices with exploration of alternative approaches. Since many older adults are quite capable of a high level of self-care, those with a continuing cerumen problem could be taught safe self-care practices to prevent a cerumen buildup and impaction. The finding that two thirds of the subjects heard less than the highest frequency (4000 Hz) on the audioscopic screening, with 18% of the total population unable to hear any tone, highlights the problem of hearing impairment
This study was supported, in part, by a grant from Marion Laboratories, I thank registered nurses enrolled in the Slippery Rock University Bachelor of Science in Nursing Program for their assistance in the collection of data for the study. REFERENCES I. HilgerP, PaparellaM, Anderson R, Conductive hearing loss, In: Meyerhoff W, ed, Diagnosis and management of hearing loss. Philadelphia: WD Saunders, \984:41. 2. DeWeis D, SaundersW, SchullerD, Schlewning A. Otolaryngology-head and neck surgery. St. Louis: CV Mosby, 1988:395. 3. Selmanowitz VJ, Rizer RL, Orentreich N. Agingof the skin and appendage, In: Finch C, Hayflick L, eds, Handbook of the biology of aging.New York: Van Nostrand, 1977:310, 4. SoucekS, Michaels L, Hearing loss in the elderly. London: Springer-Verlag 1990:26. 5. Mahoney D, One simple solution to hearing impairment, GURIATR NURs 1987;242-5, 6, Janken J, Cullinan C. Effectof cerumenremoval ou thehearingability ofge. riatric patients, J Adv Nurs 1990:15:597. 7, Lichtenstein M,BessF, LoganS. Validation of screening toolsforidentifying hearing-impaired elderly in primarycare, JAMA 1988;259:2878. 8. Ballinger J. Diseases of the nose, throat, ear, head, and neck, Philadelphia: Lea & Febiger, 1985:1088, 9. Craven R, Hirnle C. Fundamentals of nursing. Philadelphia: Lippincott, 1992:676. . 10. Dinell JF, ed, LoganTurner's diseases of the nose, throat, and ear. London: Wright, 1982:333. 1J. Caruso V, Meyerhoff W, Trauma and infections of the externalear. In: PaparellaM, Shumrick D, eds, Otolaryngology: Vol II. The ear. Philadelphia: WB Saunders, 1980:1345. 12. Amundson L. Disorders of the external ear. In: Vogt H, ed, Primary care. 1990;17:220-1. 13. Mulrow C. Screening for hearing impairment in the elderly, Hasp Pract 1991;26:2A. 14. Frank T, Peterson D, Accuracy of a 40 dB HL audioscope and audiometer screening for adults. Ear Hear 1987;8:180.
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