Otology: Cerumen Impaction and Aural Foreign Bodies.

Cerumen lubricates and protects the external auditory canal, but excess accumulation can lead to ear fullness, itching, otalgia, discharge, hearing loss, and tinnitus. Cerumen should be treated whenever symptoms are present or if it limits diagnosis by preventing a needed otoscopic examination. Clinicians should evaluate for cerumen impaction in those using hearing aids and patients with intellectual disability. Cerumen impaction can be treated with cerumenolytics, ear irrigation, and manual removal with instrumentation. Aural foreign bodies can cause ear fullness, otalgia, discharge, and hearing loss. They are more common in children than adults. The most common type of aural foreign bodies in children is jewelry, followed by paper products, parts of pens or pencils, desk supplies (eg, erasers), BBs or pellets, and earplugs or earphones. In adults, the most common aural foreign bodies are cotton swabs or cotton, followed by hearing aid parts and jewelry or ear accessories. Patients should avoid using cotton tip applicators in the external auditory canal. Alligator forceps, small right angle hooks, and ear irrigation commonly are used to remove aural foreign bodies in an outpatient clinic setting, but the choice depends on the type of foreign body. Soft and irregularly shaped objects can be removed without referral to an otolaryngologist. Patients with hard, spherical, or cylindrical objects should be referred to an otolaryngologist if previous removal attempts have failed or if there is ear trauma to avoid worsening its position in the ear canal.

Prevalence and clinical findings of feline otitis externa in Midwest Brazil.

This study was conducted to evaluate the prevalence of otitis externa (OE) in cats using cytology, direct otoscopic examination, and parasitological examination through swabs and curettage, and to compare the accuracy between collection methods for parasitological examination. Direct otoscopic evaluation of the external auditory canal (right and left), swabs for cytological examination of the external auditory canal, and collection of cerumen for parasitological examination through swabs and curettage of 137 cats from a veterinary hospital care were conducted between March 2021 and March 2022. The influences of age, sex, habitat, street access, and the presence of fleas on OE were evaluated. Cytological evidence of OE was observed in 25.5 % of cats and was statistically associated with flea and mite parasitism. Otodectes cynotis was found in 13.9 % of the cats. Cocci and Bacilli were the secondary factors in 34.3 % and 22.9 % of cats with OE, respectively. The Malassezia genus was a secundary factor in 57.1 % of the cats with OE. The frequency of OE was high in cats receiving hospital care. O. cynotis was a frequent primary cause of OE in cats. The curette sampling method is a great option for diagnosing O. cynotis infestation due to its ease of use.

Simultaneous determination of tramadol in earwax and urine samples: effects of age, duration time and sex.

Background: This study aims to determine the concentrations of tramadol in earwax (µg/g) and urine (µg/ml) samples taken from postoperative patients, to evaluate the sensitivity of earwax (cerumen) as an alternative analyte and compare it with the findings in urine samples. Results: The results indicated that tramadol concentrations in earwax samples were averaged 45.08 µg/g (range: 13.5-107.7 µg/g), whereas tramadol concentrations in urine samples were averaged 4.97 µg/ml (range: 1.57-10.11 µg/ml). There were significant differences when comparing age groups, duration and sex between earwax and urine samples (p < 0.05). Conclusion: Despite the significant differences between earwax and urine samples, earwax can be used as a bioindicator of tramadol detection.

Cancer evaluation in dogs using cerumen as a source for volatile biomarker prospection.

Cancer is one of the deadliest diseases in humans and dogs. Nevertheless, most tumor types spread faster in canines, and early cancer detection methods are necessary to enhance animal survival. Here, cerumen (earwax) was tested as a source of potential biomarkers for cancer evaluation in dogs. Earwax samples from dogs were collected from tumor-bearing and clinically healthy dogs, followed by Headspace/Gas Chromatography-Mass Spectrometry (HS/GC-MS) analyses and multivariate statistical workflow. An evolutionary-based multivariate algorithm selected 18 out of 128 volatile metabolites as a potential cancer biomarker panel in dogs. The candidate biomarkers showed a full discrimination pattern between tumor-bearing dogs and cancer-free canines with high accuracy in the test dataset: an accuracy of 95.0% (75.1-99.9), and sensitivity and specificity of 100.0% and 92.9%, respectively. In summary, this work raises a new perspective on cancer diagnosis in dogs, being carried out painlessly and non-invasive, facilitating sample collection and periodic application in a veterinary routine.

A veterinary cerumenomic assay for bovine laminitis identification.

Bovine laminitis disorder results in animal welfare and economic concerns in dairy and beef farms worldwide. However, the affected metabolic pathways, pathophysiologic characteristics, and inflammatory mechanisms remain unclear, hampering the development of new diagnostics. Using cerumen (earwax) as a source of volatile metabolites (cerumenomic) that carry valuable biological information has interesting implications for veterinary medicine. Nonetheless, up to now, no applications of veterinary cerumenomic assays have been made to identify bovine laminitis. This work aims to develop a veterinary cerumenomic assay for bovine laminitis identification that is non-invasive, robust, accurate, and sensitive to detecting the metabolic disturbances in bovine volatile metabolome. Twenty earwax samples (10 from healthy/control calves and 10 from laminitis calves) were collected from Nellore cattle, followed by Headspace/Gas Chromatography-Mass Spectrometry (HS/GC-MS) analysis and biomarker selection in two multivariate approaches: semiquantitative (intensity data) and semiqualitative (binary data). Following the analysis, cerumen volatile metabolites were indicated as candidate biomarkers for identifying bovine laminitis by monitoring their intensity or occurrence. In the semiquantitative strategy, the p-cresol presented the highest diagnostic figures of merit (area under the curve: 0.845, sensitivity: 0.700, and specificity: 0.900). Regarding the binary approach, a panel combining eight variables/volatiles, with formamide being the most prominent one, showed an area under the curve, sensitivity, and specificity of 0.97, 0.81, and 0.90, respectively. In summary, this work describes the first veterinary cerumenomic assay for bovine laminitis that indicates new metabolites altered during the inflammatory condition, paving the way for developing laminitis early diagnosis by monitoring the cerumen metabolites.

A prototype 3D printed suction port adapter for a wireless otoendoscope

Background and Objective@#To design and fabricate a suction port adapter to use various sizes of suction cannulas with a wireless otoendoscope enabling ear cleaning under endoscopic guidance demonstrated using an ear examination simulator.@*Methods@#Design: Instrument Innovation. Setting: Tertiary Private Training Hospital. Patient: Ear Examination Simulator.@*Results@#The fabricated suction port adapters were able to hold the wireless otoendoscope and suction cannulas together, allowing simultaneous inspection of the ear canal and suctioning of ear canal debris using the Ear Examination Simulator.@*Conclusion@#Our prototype 3D-printed suction port adapters for a wireless otoendoscope may improve ear cleaning by enhancing the accuracy of suctioning debris and decreasing duration since they hold the suction cannulas in place under endoscopic guidance. They may aid ENT physicians in easier visualization and simultaneous ear cleaning of patients and improve ear cleaning techniques and times, especially among less experienced physicians, but actual clinical trials are needed to confirm this.

Molecular strategy for the direct detection and identification of the most common fungal community in cerumen specimens by multiplex PCR.

Introduction. Otomycosis is a superficial fungal infection that is responsible for approximately 9-27 % of otitis externa. However, fungal communities in otomycosis are varied, but Aspergillus spp. and Candida spp. are the most common causes of this infection.Hypothesis Statement. The multiplex PCR assay is postulated to be able to directly detect more than one fungal genus in cerumen specimens.Aim. This study aimed to develop and evaluate the role of the multiplex PCR assay in detecting the most common genus of fungi that cause otomycosis directly from the cerumen specimens.Methodology. To detect Candida and Aspergillus/Penicillium genera, three pairs of primers, including pan-fungal, pan-Candida, and pan-Aspergillus/Penicillium, were used in a multiplex PCR. In order to evaluate the performance and reproducibility of the multiplex PCR. the cerumen of 140 patients suspected of otomycosis were investigated.Results. Pan-Candida and pan-Aspergillus/Penicillium primers were designed to amplify the ITS1-5.8S-ITS2 region and the ß-tubulin gene, respectively. In the multiplex PCR assay, 64 (47.40 %) and 118 (87.40 %) specimens were positive with pan-Candida and pan-Aspergillus/Penicillium primers, respectively. Double amplicon bands of Candida and Aspergillus were obtained in 51 (37.77 %) specimens. In the culture method, yeast (n=18, 13.33 %) and mould (n=117, 86.66 %) were isolated from 135 cerumen specimens. The sensitivity, specificity, and positive and negative predictive values of the multiplex PCR assays using culture method results as the gold standard were determined to be 94, 33, 97, and 22 %, respectively.Conclusion. In our study, multiplex PCR assays enabled simultaneous detection of two common genera of the causative agent of otomycosis in a cerumen specimen. Regarding the high sensitivity of the first step of the multiplex PCR assay, this assay may be used for the direct detection of Candida and Aspergillus genera in other clinical specimens.

"Do-It-Yourself" Ear Canal Care.

There are a large variety of over-the-counter home remedies and devices for cerumen impaction available in the United States. It is a challenge for clinicians to maintain awareness of the safety and efficacy of these tools, as they are not considered "medical devices" and frequently have no requirement for demonstrating safety or efficacy. This article provides a broad overview of the products being advertised to patients and discusses considerations when recommending home cerumen maintenance.

Follow the Wax: The Natural Protection of the Ear Canal and Its Biome.

The external canal is a unique environment that has an elaborate mechanism for self-cleaning and protection. The fundamental basis of this is the epithelial migration of the desquamating layers of the keratinizing epithelium that lines the entire canal and ear drum. This migratory movement results in a "conveyor belt" effect where the dead skin is moved out of the bony ear canal to the cartilaginous portion, where it is lifted off with the help of glandular skin secretions and the hairs of the canal to form what we call "ear wax." The ear wax has numerous protective properties and is essential to the health of the external ear. The protective properties are due to chemical properties of the wax, in addition to intrinsic chemical secretions by the sebaceous and cerumen apocrine glands. The protection also comes from a diverse population of organisms that exist in the external ear that are usually saprophytic, commensal, and symbiotic, but in some cases, they can become parasitic and pathologic. Detection and quantification of the members of this biome has been difficult, and their overall role in the normal biome of the ear and their transition into pathogens remain an area of active research and investigation.

Determination of cannabinoids in human cerumen samples by use of UPLC-MS/MS as a potential biomarker for drug use.

A quantitative analytical procedure was developed and validated by the use of Ultra- Performance Liquid Chromatography tandem Mass Spectrometry (UPLC-MS/MS) for the determination of Cannabidiol (CBD), Cannabinol (CBN), Δ9-Tetrahydrocannabinol (Δ9-THC), Cannabichromene (CBC), Cannabigerol (CBG) and 11-Nor- 9- Carboxy- Tetrahydrocannabinol (THC-COOH) in an unconventional biological matrix, cerumen. All the investigated calibration curves were characterized by high correlation values (R2 ≥ 0.9965). The LODs and LOQs ranged from 0.004 to 0.009 µg g-1 and 0.012-0.029 µg g-1, respectively. Intra-assay and inter-assay precision were found to be 0.6-2.5%, and 0.8-2.2%, respectively. All recovery values of cannabinoids, with the use of the optimum cotton swab, at low (0.008 µg g-1 of cerumen), medium (0.037 µg g-1of cerumen) and high (0.16 µg g-1 of cerumen) control levels, were estimated to be above 86%. The method developed here permitted the analysis of real cerumen samples obtained from fourteen cannabis users. In twelve out of fourteen cases, Δ9-THC was found to be positive, while in six cases, three major cannabinoids, CBN, CBG and Δ9-THC were quantified at concentrations 0.02-0.21 µg g-1, 0.01-0.24 µg g-1 and 0.01-4.86 µg g-1, respectively. Subject #8 has the highest amount of the detected substances in both left and right ear, with Δ9-THC at a concentration of 1.85 and 4.86 µg g-1, CBG 0.06 and 0.24 µg g-1, CBN 0.10 and 0.21 µg g-1, respectively. In addition, a detection window for the substances Δ9-Tetrahydrocannabinol, Cannabinol and Cannabigerol, in cerumen, was defined with success. In this case, Δ9-THC reached a maximum detection frame of up to fifteen days after smoking 0.5 g of marijuana cigarette. ANOVA-one-way analysis also indicated that the average earwax production of non-cannabis users differs significantly from the one of cannabis users (p = 0.048, <0.05). On the other hand, no significant difference was noticed between male and female users as the p value exceeded 0.05. In addition, no significant effect was observed on earwax production in regard to age, frequency and the last time of use (p > 0.05). These last three factors proved to have a significant impact on cannabinoids concentrations, since p values were less than 0.05.

Development and validation of an ultra-performance liquid chromatography-tandem mass spectrometric method for the determination of 25 psychoactive drugs in cerumen and its application to real postmortem samples.

PURPOSE: In the present study, a method for the detection of 25 psychoactive substances in cerumen was developed and validated. This method targets opiates, cocaine, antidepressants, benzodiazepines, antipsychotics and antiparkinsons. METHODS: Analysis was performed on a SCIEX Triple Quad 6500+ system after liquid-liquid extraction. Methanol with 1% acetic acid was chosen as the extraction solvent. After the addition of the solvent, samples were vortexed, sonicated, centrifuged and directly injected into the liquid chromatography-tandem mass spectrometry system. RESULTS: The method was found to be selective and sensitive (limit of detection: 0.017 ng-0.33 ng/mg), the assay was linear for all analytes with linear regression coefficient ranging 0.9911-1.00. The values for intra-assay precision was between 4.34 and 14.6% and inter-assay precision between 5.81 and 17.7%, with accuracy within the acceptable criteria for all analytes. All analytes in cerumen specimens were stable for 48 h at 4 °C and 72 h at - 20 °C, whilst no significant matrix effect or carryover was observed. Applicability was proven by analyzing cerumen samples from 25 deceased with a history of drug abuse. All analytes were detected in real samples, thus confirming the sensitivity of the developed method. CONCLUSIONS: According to our knowledge, it is the first time that a method for the simultaneous detection of 25 psychoactive drugs in cerumen was developed, fully validated and finally applied to 25 postmortem samples.

Trends in Billing and Medicare Reimbursement for In-Office Cerumen Removal by Otolaryngologists and Other Providers.

OBJECTIVES: To analyze trends in billing patterns, Medicare reimbursement, and practice-setting for otolaryngologists (ORLs) and other provider types performing in-office cerumen removal. METHODS: This retrospective study included data on Medicare-billing providers from the Medicare Part B: Provider Utilization and Payment Datafiles (2012-2018). Number of providers performing in-office cerumen removal, total sums and medians for Medicare reimbursements and services, and services per patient were gathered along with geographic distributions. RESULTS: There have been near linear declines in number of general physicians and other provider types performing cerumen extractions with 42.6% and 40.7% declines, respectively, and near linear growth in number of ORLs and advanced practice providers (APPs) with 9.7% and 51.1% growth, respectively. At the median, general physicians, APPs, and other provider types have been billing for a similar and constant number of cerumen extractions per provider, while ORLs have seen a 10.6% increase. Total Medicare reimbursement to general physicians and other provider types has fallen 45.0% and 32.5%, respectively, and to ORLs and APPs has grown 16.9% and 103.4%, respectively. Compared to non-ORLs, ORLs tend to bill for cerumen extraction out of an urban setting rather than a rural setting (P < .001). CONCLUSIONS: General physicians and other provider types are increasingly referring cerumen disimpaction patients to ORL physicians and allowing APPs to perform these procedures, indicating a change in landscape of medical practice among these providers. General physicians may be filling a need in the rural setting, where there are fewer ORLs practicing.

Determination of fentanyl and norfentanyl in cerumen in the setting of postmortem investigation.

Cerumen is an emerging alternative biological matrix in the field of forensic toxicology. An ultra-high-pressure liquid chromatography-mass spectrometry/mass spectrometry [UHPLC-MS/MS] method for the determination of fentanyl and norfentanyl in cerumen was developed and applied in a mixed drug toxicity fatal case. The method was found to be selective and sensitive (LOQ: 0.05 ng/mg for fentanyl and 0.02 ng/mg for norfentanyl), while validation included recovery, carryover, short-term stability, matrix effect, accuracy, and precision (RSD%). Accuracy ranged from 83.1% to 103.5%, while intra- and inter-day precision ranged from 8.6% to 13.1% and from 8.3% to 15.8%, respectively. Matrix effect experiments showed that matrix did not significantly affect signal intensity (82.3%-96.8%). Short-term stability concerning sample extracts was found satisfactory. Fentanyl and norfentanyl were detected in cerumen at a concentration of 1.17 and 0.36 ng/mg respectively. The findings in cerumen corroborate the cause of death and suggest that cerumen is a potential specimen for detecting drugs of abuse in forensic cases.

The Outcome of Cerumen Removal in the Pediatric Emergency Department.

OBJECTIVE: Cerumen obstructs the visualization of the tympanic membrane (TM) in up to 40% of children, sometimes posing a challenge to rule out the diagnosis of acute otitis media (AOM) as the source of otalgia (for verbal children), irritability, fever, and febrile seizures. We aim to determine the rate at which removing the cerumen from blocking the view of the TM could change the management of these patients in the pediatric emergency department (PED). METHODS: We retrospectively investigated all medical records of patients who underwent cerumen removal in the PED at a tertiary children's hospital from 2018 to 2019. We analyzed the effect of the procedure on the subsequent workup during their PED visit. RESULTS: Of 482 children who presented to the PED with otalgia, irritability, fever, and/or febrile seizures and who were referred to an otolaryngologist for subsequent treatment after preliminary evaluation in the PED, 176 were included in the study group after having the cerumen removed from one or both ears. Seventy-three of them were given a diagnosis of AOM, 93 had a normal-appearing TM, and 10 had external otitis. Twenty-one percent of those with AOM and 46% of those with a normal TM ( P = 0.008) had blood drawn as part of their workup in their PED visit. The rate of chest x-rays was also significantly less for the AOM group (16% vs 30%, P = 0.03), and they also underwent fewer urine tests ( P = NS). CONCLUSION: Cerumen removal changes the management of children in the PED who present with a possible diagnosis of an ear infection. Cerumen removal could avoid unnecessary laboratory and imaging studies, which could save time, costs, and suffering.

Quality Improvement in Otolaryngology-Head and Neck Surgery: Developing Registry-Enabled Quality Measures From Guidelines for Cerumen Impaction and Allergic Rhinitis Through a Transparent and Systematic Process.

BACKGROUND AND SIGNIFICANCE: Quality measurement can drive improvement in clinical care and allow for easy reporting of quality care by clinicians, but creating quality measures is a time-consuming and costly process. ECRI (formerly Emergency Care Research Institute) has pioneered a process to support systematic translation of clinical practice guidelines into electronic quality measures using a transparent and reproducible pathway. This process could be used to augment or support the development of electronic quality measures of the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) and others as the Centers for Medicare and Medicaid Services transitions from the Merit-Based Incentive Payment System (MIPS) to the MIPS Value Pathways for quality reporting. METHODS: We used a transparent and reproducible process to create electronic quality measures based on recommendations from 2 AAO-HNSF clinical practice guidelines (cerumen impaction and allergic rhinitis). Steps of this process include source material review, electronic content extraction, logic development, implementation barrier analysis, content encoding and structuring, and measure formalization. Proposed measures then go through the standard publication process for AAO-HNSF measures. RESULTS: The 2 guidelines contained 29 recommendation statements, of which 7 were translated into electronic quality measures and published. Intermediate products of the guideline conversion process facilitated development and were retained to support review, updating, and transparency. Of the 7 initially published quality measures, 6 were approved as 2018 MIPS measures, and 2 continued to demonstrate a gap in care after a year of data collection. CONCLUSION: Developing high-quality, registry-enabled measures from guidelines via a rigorous reproducible process is feasible. The streamlined process was effective in producing quality measures for publication in a timely fashion. Efforts to better identify gaps in care and more quickly recognize recommendations that would not translate well into quality measures could further streamline this process.