What is it & why is it there?
Cerumen – commonly known as earwax – is present in everyone’s ear to a greater or lesser degree. Indeed, it is a very useful natural component of the outer portion of the meatus [ear canal]. It protects physically against damage to the delicate skin lining and trapping dirt plus chemically protecting against infections.

It occurs through the mixing of discarded skin cells and glandular secretions and will only be found in the outer “fleshy” portion of the ear canal unless … you [or some outside force] have pushed it further down the canal to the “bony” portion. Ironically, if left alone it usually migrates out of its own accord, though as the body ages and the skin dries out, the wax can then stick to the surface more easily; similarly if a hearing aid is worn.

How’s it made?
Not only does the ear contain the smallest bones in the body [ossicular chain – malleus, incus & stapes] but it also has a pretty marvellous and mysterious technique whereby the superficial keratin squames [surplus dead skin cells], which owing to the shape and positioning of the ear canal cannot, through friction, dispose of this waste, circumvents the problem through epithelial migration. The outer layer [skin] of the three-layered TM [Tympanic Membrane – ear-drum] moves in a radial motion until reaching the walls of the canal. It then moves laterally until it encounters resistance in the “hairy” part of the canal in the cartilaginous zone [the outer third]. This where it becomes “earwax” as it mixes with the secretions of the cerumen glands [plus associated debris blown in from the outside world]. Talking, laughing, yawning and chewing automatically helps dislodge this wax to drop out of your ear.

Does it make you deaf?
That would depend largely on your definition of “deaf”. My dictionary defines it as partially or totally unable to hear; it doesn’t debate any permanence. So, it does affect your hearing and, therefore under that description, earwax can make you deaf. But it is not a permanent situation; the wax blockage can be removed and, virtually in an instant, your residual hearing is restored. This situation is usually only caused by complete blockage of the auditory meatus [ear canal]. Cerumen can be over-produced in response to infections or loud noises. Some people with abnormally shaped ear canals might encounter build-up. Impacted wax usually causes some degree of loss.

What problems does it cause?
Apart from the afore-mentioned hearing problems, there is a slightly different situation when one has impacted wax. This generally only affects a small percentage of the population and can be caused by a variety of means – constant, inappropriate use of “cotton buds” ramming the wax back into the meatus a bit like the old fusiliers with their muskets. A number of symptoms might be experienced from impacted wax including: tinnitus [ringing in the ear], pain, vertigo [balance problems] itching and/or even a cough.

Another major problem for millions is the effect wax build-up has on them wearing hearing aids. When a custom made aid [or ear-mould] is inserted into a waxy ear it can push the wax further in and thus contributes to the condition previously discussed – impacted wax. More importantly, despite a whole host of ingenious ideas from leading manufacturers on the principle that prevention is better than cure [particularly under warranty repair in their laboratories], it can so easily get inside the sound outlet and, often immediately, stop the aid from working. Very few people using hearing aids, despite the best advice from whomever fitted the aid, actually go through the recommended process for their particular hearing aid to keep it virtually clear of earwax. And, because many of them are so small, which in turn makes the sound outlet extremely tiny; it’s almost impossible with the naked eye to see the slowly encroaching build-up of wax within the hearing aid. Consequently, audiologists are frequently regaled by tales from unhappy users that their hearing aid is broken!

Should I remove it & how?
The simple [yet confusing] answer is Yes and No! “Yes” excess earwax should be removed and “No” you shouldn’t try doing it yourself – at least not with manual insertions of any objects. Let me say here and now do not push cotton buds into your ear canals. As someone once asked me, in response to my last statement, “So why do they make them then?” – my response: they make sharp knives but one does not have to push them into one’s orifices.

It is better to keep one’s ears clear of wax build-up as explained above and, once clear, a weekly spray of clinical olive oil from a product such as Earol will have beneficial preventative assistance in aiding the natural epithelial migration. The ears will retain more elasticity and keep supple with the surface of the skin being smoother allowing easier migration.

There are many products commercially available to assist in removing wax build-up and it is usually a case of “different strokes for different folks” as to which suits whom. Many practice nurses, in preparation for syringing a patient’s ears, will advise using a few drops of oil [Olive or Almond] each day for up to seven days prior to the visit. Unfortunately, they often don’t explain that for this to have a truly beneficial effect it needs to be done one ear at a time; keep the head in a horizontal position with the oiled ear uppermost for at least ten minutes. Otherwise the oil will not have time to penetrate the hard wax and will instead just fill the piece of cotton wool placed in the ear to prevent the oil from escaping.

An E.N.T. consultant surgeon can remove wax in many ways including suction as they have operating microscopes allowing greater insight. One ENT that I know and refer to frequently has issued a list of helpful hints, which includes immersing one’s head in the bath [assuming the water still to be clean and no known under-lying pathology affecting the ear canal and/or middle ear].

Unfortunately, owing to the increasingly litigious society in which we live, it is becoming ever more difficult to find GPs’ practices who are willing to allow syringing. Naturally, this has serious knock-on potential consequences for hearing aid users: poor hearing > get hearing aid > better hearing > produce more wax > poor hearing > no removal > virtually no hearing. Although those fortunate enough [in the UK] to have effective private medical insurance to pay ENT consultants to remove the offending earwax build-up, it could be very costly for others.

So, finally
Earwax is a natural product that we need but don’t want too much of. Please try to keep it under control, especially if you wear hearing aids. And, as Granny said: “Just use your elbow in your ear!”

If you have jumped down to here without reading, you can meet Dr Bill, click on this link http://www.youtube.com/watch?v=3UWq0gZhn_k
and watch and listen instead.
If have already read it, then you’ll have a more in-depth knowledge when you check out the link!

For ENT contacts; Earol; more ear toilet advice; tinnitus advice; hearing aids and protection:
http://www.easi-ear.com

Is it because of what they look like? 

Hearing aids look like hearing aids because they ARE hearing aids.  Unfortunately, despite some very novel designs – some have even won design awards – they still don’t have the cachet of “designer” glasses.  I know.  One venue I visit – an optical outlet – was ram-raided and the thieves took all the designer sunglasses but completely ignored the digital hearing aids on view, which were actually worth a lot more than the specs.

In fact, many hearing aids today DON’T look like hearing aids [at least not the traditional NHS behind the ear type] but still don’t make people want to whip them out of their ear and say “Take a butchers’* at that!”   Yet they are technologically far more advanced than many consumer items (generally considered prized possessions to be paraded) and frequently more costly.

Is it because of the colour?

As in “we don’t like flesh colour”? Well, I say flesh colour but if you encountered anyone looking the same colour you’d either flee screaming or summon an emergency paramedic from the tropical disease hospitals.  And that is also making a mighty big presumption that everyone in the world has identical flesh colour, which the last time I looked ….

Mind, there are still some who manufacture hearing aids who aren’t too sure of what flesh colour does mean.  A few years ago I was trying to find a custom-fit tiny aid for a lady who had quite a big loss in quite a small ear – she also had very dark skin.  They came back from the chosen supplier [no names I’m afraid] with a beautifully snug fit in a wonderfully tiny aid enabling her to hear really well and a really superb matching “plain chocolate” faceplate [the bit you can see in the ear].  So what was the problem with this high-tech digital hearing aid?  It still had a conventional “flesh” colour body. This meant that when viewed in the ear it had a kind of halo effect around it and, “angelic” though that woman might have been, she did not want it attracting the attention of her toddler – the whole reason for getting them in the first place.  There is another, humourous, aspect to this particular experience, which I might recount at a later date.

Is it because of what they feel like?

Well, naturally, some people don’t like the feel of “plastic” things and a few unfortunate souls actually suffer extreme sensitivity in their ear canals.  Then there are those whose ears are “too close to their head” and really don’t have room for a traditional hearing aid fitting, especially if they also need to wear specs.  And there will always be some who just don’t like having anything in their ear at all – not even “sweet nothings”.  But for the vast majority they are no worse than a pair of glasses perched on the bridge of the nose – and for those who would prefer the little luxury of paying for custom made items to fit discreetly into the ear canal, it is really no different from the contact lens wearer sticking their fingers in their eyes once a day.

Or is it because of what they suggest?

This is, in my humble[?] opinion, the clincher.  Hearing aids = deaf.  And deaf = daft … and old!  This, I hasten to add, is not my opinion but that of many people conveniently unaffected by hearing loss and unfortunately thus, by osmosis,  the [often] sub-conscious opinion of many who do need to wear hearing aids.

But, hold on there, have they got a point? Well, in reverse order, let’s have a quick peek at the argument: OLD?  Well, although it is a fact that as we age the incidence of some measurable hearing loss does indeed increase, it also remains that 50% of people with hearing loss in the UK are actually under the age of 55.  DAFT?  Well, most certainly not, if one encounters some of the wonderful people who have varying degrees of hearing loss [and use a variety of methods to combat their particular malfunction] that I have had the pleasure and honour of meeting.  But, could this particular soubriquet be awarded to the millions [estimated by many, including the RNID,] out there.  In the UK alone, it is thought there are up to 6,000,000 [yep SIX MILLION] who are thought to have a measurable hearing loss y e t   d o   n o t h I n g   a b o u t   i t. 

Please, if you know [or indeed are] one of these people, all that anyone in my field [NHS or Private audiologists; ENT consultants & charities] would request – please ask us the following:

“Tell, show & demonstrate the options available to me” and then, maybe, some of the 5-6 million UK residents currently with hearing loss but without hearing help would benefit.

• Butchers = butchers’ hook = look =Rhyming slang from England for our overseas visitors.

Purpose

The purpose of audiological assessment is to quantify and qualify hearing in terms of the degree of hearing loss, the type of hearing loss and the configuration of the hearing loss.

With regard to degree of hearing loss, the audiologist is looking for quantitative information. Hearing levels are expressed in decibels (dB) based on the pure tone average for the frequencies 500 to 4000 Hz and discussed using descriptors related to severity: normal hearing (0 to 20 dB HL), mild hearing loss (20–40 dB HL), moderate hearing loss (40–60 dB HL), severe (60–80 dB HL) and profound hearing loss (80 dB HL or greater).

With regard to the type of hearing loss, the audiologist is looking for information that suggests the point in the auditory system where the loss is occurring. The loss may be conductive (a temporary or permanent hearing loss typically due to abnormal conditions of the outer and/or middle ear), sensorineural (typically a permanent hearing loss due to disease, trauma, or inherited conditions affecting the nerve cells in the cochlea, the inner ear, or the eighth cranial nerve), mixed (a combination of conductive and sensorineural components), or a central auditory processing disorder (a condition where the brain has difficulty processing auditory signals that are heard).

With regard to the configuration of the hearing loss, the audiologist is looking at qualitative attributes such as bilateral versus unilateral hearing loss; symmetrical versus asymmetrical hearing loss; high-frequency versus low frequency hearing loss; flat versus sloping versus precipitous hearing loss; progressive versus sudden hearing loss; and stable versus fluctuating hearing loss.

Audiological evaluation is also carried out for purposes of monitoring an already identified hearing loss. Once a particular hearing loss has been identified, a treatment and management plan is put into place. The plan may include medical or surgical intervention, prescription of personal hearing aids, prescription/provision of assistive listening devices, skills development through aural (audiologic) habilitation/rehabilitation, or simply monitoring of the condition through periodic assessment.

Once a treatment and management plan is in place, it is still important for an individual’s hearing loss to be checked periodically to determine its stability. Is it fluctuating? Has it improved as a result of medical intervention? Is it progressing? Have new conditions come into play that have affected the original condition?

It is also important that a person’s ability to hear using amplification (e.g., personal hearing aids and any assistive listening devices that are used in place of, or in conjunction with, personal amplification) be monitored and documented. This monitoring would include functional gain assessment, real ear measurement, electroacoustic analysis, listening check, and even informal “functional” assessment in the person’s typical listening environment (e.g., the classroom, the workplace, the home).

The Assessment Itself

An audiologic evaluation is sometimes thought of as “just a hearing test,” but more than “just” the ability to hear sounds is involved. The audiologic evaluation consists of a battery of tests each providing specific standalone information. Yet, the tests complement one another. The audiologic evaluation consists of several different components.

Case History

The audiologist will ask several questions during the case history. For example:

• What brought you here today?
• Have you noticed difficulty with your hearing? What have you noticed? For how long? When do you think the hearing loss began?
• Does your hearing problem affect both ears or just one ear?
• Has your difficulty with hearing been gradual or sudden?
• Do you have ringing (tinnitus) in your ears?
• Do you have a history of ear infection?
• Have you noticed any pain in your ears or any discharge from your ears?
• Do you experience dizziness?
• Is there a family history of hearing loss?
• Do you have greater difficulty hearing women’s, men’s, or children’s voices?
• Do people comment on the volume setting of your television?
• Has someone said that you speak too loudly in conversation?
• Do you frequently have to ask people to repeat?
• Do you hear people speaking, but can’t understand what is being said?
• Do you have any history of exposure to noise in recreational activities, at work, or in the military?
• Are there situations where it is particularly difficult for you to follow conversation? Noisy restaurant? Theater? Car? Large groups?

For children, questions will also be asked regarding:

• speech and language development
• health history
• recognition of and response to familiar sounds
• the startle response to loud, unexpected sounds
• the presence of other disabilities
• any previous hearing screening or testing results

Physical Examination

The audiologist will look at the outer ear (the pinna) checking for any malformation. The audiologist will use an otoscope, an instrument that contains a light and a magnifying lens, to examine the ear canal and eardrum. The ear canal is examined for the presence of excessive wax (cerumen), or foreign objects (food, toys, pieces of cotton swabs, etc.). The eardrum (tympanic membrane) is examined for any perforation and signs of fluid or infection. The audiologist will look for any indicators suggesting the need for referral for a medical evaluation and/or treatment.

Tests of Hearing and Listening

The audiologist will conduct tests of hearing tones. This is called pure-tone audiometry. The results are recorded on a graph called an audiogram. The audiologist will also determine speech reception threshold or the faintest speech that can be heard half the time. Then the audiologist will determine word recognition or ability to recognize words at a comfortable loudness level.

Tests of Middle Ear Function

The audiologist may also take measurements that will provide information about the status of the outer and middle ear. These are called acoustic immittance measures. Tympanometry, one aspect of immittance testing, can assist in the detection of fluid in the middle ear, perforation of the eardrum, or wax blocking the ear canal. Acoustic reflex measurement, another aspect of immittance testing, can add diagnostic information about middle ear function and hearing loss.

After the test battery is completed, the audiologist will review each component of the audiologic evaluation to obtain a profile of hearing abilities and needs. Additional specialized testing may be indicated and recommended on the initial test results. Audiological evaluation may result in recommendations for further follow-up such as medical referral, educational referral, hearing aid/sensory aid assessment, assessment for assistive listening devices, audiologic rehabilitation assessment, speech and language assessment, and/or counseling.

As you can see, an audiologic evaluation is much more than “just a hearing test!”

Pure-tone Audiometry

Pure-tone audiometry is completed in a soundproof booth—a room with special treatment to the walls, ceiling, and floor to ensure that background noise does not affect test results. Only those sounds that the audiologist introduces into the room, either through earphones or through speakers located in the room, will be heard. Sounds may also be sent through a special headset “vibrator” that has been placed just behind the ear or on the forehead.

In testing hearing for tones, a pure tone air conduction hearing test is given to find out the faintest tones a person can hear at selected pitches (frequencies) from low to high. During this test, earphones are worn and the sound travels through the air in the ear canal to stimulate the eardrum and then the auditory nerve. The person taking the test is instructed to give some type of response such as raising a finger or hand, pressing a button, pointing to the ear where the sound was received, or saying “yes” to indicate that the sound was heard.

Sometimes children are given a more play-like activity (conditioned play audiometry) to indicate response. They may be instructed to string a peg, drop a block in a bucket, or place a ring on a stick in response to hearing the sound. Infants and toddlers are observed for changes in their behavior such as sucking a pacifier, quieting, or searching for the sound and are rewarded for the correct response by getting to watch an animated toy (visual reinforcement audiometry).

The audiologist uses a calibrated machine called an audiometer to present tones at different frequencies (pitches) and at different intensity (loudness) levels. A signal of a particular frequency (something like a piano note) is presented to one ear, and its intensity is raised and lowered until the person no longer responds consistently. Then another signal of a different frequency is presented to the same ear, and its intensity is varied until there is no consistent response. This procedure is done for at least six frequencies. Then the other ear is tested in the same way.

The frequency or pitch of the sound is referred to in Hertz (Hz). The intensity or loudness of the sound is measured in decibels (dB). The responses are recorded on a chart called an audiogram that provides a graph of intensity levels for each frequency tested.

In some cases, it is necessary to give a pure tone bone conduction hearing test. In this test, the tone is introduced through a small vibrator placed on the temporal bone behind the ear (or on the forehead). This method “bypasses” blockage, such as wax or fluid, in the outer or middle ears and reaches the auditory nerve through vibration of skull bones. This testing can measure functionality of the inner ear independently of the functionality of the outer and middle ears.

Air conduction test results indicate hearing losses that are either conductive or sensorineural. Bone conduction test results reflect only the sensorineural component. By comparing air conduction and bone conduction test results, the audiologist can determine whether there is a hearing loss due to a problem in the outer or middle ear. If air and bone conduction thresholds are the same, the loss is sensorineural. If there is a difference between air and bone thresholds (an air-bone gap), the loss is conductive or mixed.

Speech Audiometry

Speech audiometry includes determining speech reception threshold (SRT) and testing of word recognition. Speech reception threshold testing determines the faintest level at which a person can hear and correctly repeat easy-to-distinguish two-syllable (spondaic) words. Examples of spondaic words are “baseball,” “ice cream,” “hot dog,” “outside,” and “airplane.” Spondaic words have equal stress on each syllable. The individual repeats words (or points to pictures) as the audiologist’s voice gets softer and softer. The faintest level, in decibels, at which 50% of the two-syllable words are correctly identified, is recorded as the Speech Reception Threshold (SRT). A separate SRT is determined for each ear.

Tests of word recognition attempt to evaluate how well a person can distinguish words at a comfortable loudness level. It relates to how clearly one can hear single-syllable (monosyllabic) words when speech is comfortably loud. Examples of words used in this test are “come,” “high,” “knees,” and ”chew.” In this test, the audiologist’s voice (or a recording) stays at the same loudness level throughout. The individual being tested repeats words (or points to pictures). The percentage of words correctly repeated is recorded for each ear.

Thus, a score of 100% would indicate that every word was repeated correctly. A score of 0% would suggest no understanding.

Word recognition is typically measured in quiet. For specific purposes, word recognition may also be measured in the presence of recorded background noise that can also be delivered through the audiometer.

How to Interpret an Audiogram

The audiogram is a graph showing the results of the pure-tone hearing tests.

Pitch or frequency

Each line from left to right represents a pitch or frequency in Hertz (Hz) starting with the lowest pitches on the left side to the very highest frequencies tested on the right side. The range of frequencies tested by the audiologist are 125 Hz, 250 Hz, 500 Hz, 1000 Hz, 2000 Hz, 4000 Hz and 8000 Hz. If you are familiar with a piano keyboard with the low notes at the left end and the high notes at the right end, the audiogram is similar. On the audiogram, 250 Hz is the same as the “middle C” key on the piano.

Examples of sounds in everyday life that would be considered “low frequency” are: bass drum, tuba, and vowel sounds such as “oo” in “who.”

Examples of sounds in everyday life that would be considered “high frequency” are: bird chirping, triangle playing, and consonant sounds such as “s” in “sun.”

If we were to compare a flute playing and a tuba playing, we’d say the flute was primarily high frequency (high pitches) and the tuba was primarily low frequency (low pitches).

If we were to compare the sound of “f” as in “fly” to the sound of “m” as in “moon,” we’d say the “f” was primarily high frequency (high pitch) and the “m” was primarily low frequency (low pitch).

Loudness or intensity

Each line on the audiogram from top to bottom represents loudness or intensity in units of decibels (dB). Lines at the top of the chart (small numbers starting at minus 10 dB and 0 dB) represent soft sounds. Lines at the bottom of the chart represent very loud sounds.

Examples of sounds in everyday life that would be considered “soft” are: clock ticking, whispering, and the consonant sound “t” in the word “too.”

Examples of sounds in everyday life that would be considered “loud” are: lawnmower, car horn, and the vowel sound “o” as in the word “poke.”

If we were to compare the sound of a jackhammer to the sound of a vacuum cleaner, we’d say the jackhammer was “loud” and the vacuum cleaner was “soft.”

If we were to compare the sound of “s” as in “spot” to the sound of “ah” as in “spot”, we’d say the “s” was “soft” in comparison to the vowel “ah.”

If we were to compare “normal conversational loudness level” (typically 60 dB) to “whispering” (typically 30 dB), we’d say that whispering was soft and conversation was loud.

Some audiograms are also divided into sections showing the severity of hearing loss.

As the audiologist tests your hearing, the results are recorded on the graph. At each frequency tested, the “O” represents the softest tone you can hear in your right ear and the “X” represents the softest tone you can hear in your left ear.

If the “X’s” and “O’s” all fall in the -10 dB to 15 dB range, your hearing lies in the normal range. If the “X’s” and “O’s” all fall in the 16 dB to 25 dB range, you have a slight/minimal loss. If the “X’s” and “O’s” all fall in the 31dB to 51dB range, you have a moderate loss. If the “X’s” and “O’s” all fall in the 91 dB and above range, you have a profound loss.

The audiogram configuration may be flat; sloping down, showing better hearing in the low frequencies; or rising, showing better hearing in the high frequencies. The configuration may be symmetrical, showing the same hearing loss for both ears; or asymmetrical, showing a different hearing loss configuration for each ear.

Once the audiogram is completed, the audiologist computes the pure tone average for each ear. It is the average of hearing thresholds at 500, 1000, and 2000 Hz, which are considered to be the major frequencies for speech. The pure-tone average represents the degree of hearing loss in decibels. It is not a percentage.