It is appropriate for patients to insert which of the following into their ear canals?

Some ear canals have a very sharp first bend. A hearing aid or earmold made for these ears can act like a fishhook if the patient tries to remove it from the ear by lifting it out from the back. Occasionally, patients are unable to remove the hearing aid at all. Other times, they injure their ear tissue by pulling the device out too forcibly.

In fact, ears with sharp bends—“fishhooks”—need not be disasters. We can avoid the problem by ordering modified products, teaching our patients how to avoid the “hook” problem, and using lubricants.

Figure 1 shows an ear impression with a sharp curve in the first bend. It is difficult to remove the impression—much less the earmold or hearing aid—from ears with bends and other irregular shapes.

Figure 1

Figures 2 and 3 are made from the photograph in Figure 1; the sharp bends and first curve are obvious. Figure 3 shows a fishhook superimposed on an illustration of an ear. Notice how the hook shape closely matches the shape of the ear canal created by the sharp curve in the first bend in the impression.

Figure

Figure 4 shows how the end of the hook gets pushed (driven) into the ear tissue if you attempt to pull it out using the conventional removal technique, i.e., lifting it out from the back. You do not want to remove instruments shaped like this by putting your finger behind them to pull them out. More about this later.

SOLVING THE PROBLEM

The solution to this problem has three parts. All are critical and should be employed until the patient gains the knowledge and confidence to insert and remove the earmold or hearing aid properly. The three keys are:

• Modify the canal length and shape.
• Teach the patient how to remove the aid by lifting it out from the bottom.
• Use Otoease, baby oil, or some other lubricant.

If the patient is a new user, I recommend you err on the side of caution. Novices tend to panic when they cannot easily remove their hearing aids. I also recommend that you always have patients insert and remove their hearing aids or earmolds several times when you first fit them. If a patient has problems in the office, don't let the person take the hearing aids home. A minor problem in the office quickly turns into big trouble at home.

Even with an experienced hearing aid user, the fishhook problem can be serious if you are not very careful. When we order new hearing aids for an existing user, we tend to order longer canals. Increasing the canal length on the new hearing aids markedly increases the hook effect. This is especially true if the end of the canal has an edge.

Now let's examine the three key rules.

Modify the canal length and shape

The canal should be as short as possible. I almost always order short canals for patients with fishhook-shaped canals. A couple of times I've had to remake a short-canal hearing aid into a no-canal hearing aid to avoid the hook problem.

Some labs initially trim impressions with scissors. This creates a sharp edge at the end of the impression. It is important that the edge be removed completely during the manufacturing process; and the end of the canal needs to be blunted so it is hotdog- or finger-shaped. The inside edge must be rounded off totally.

Teach the patient

The fishhook shape is most problematic when patients try using the conventional technique to remove the hearing aid. People instinctively try to put their fingers under the hearing aid from the back of the aid. This movement, illustrated in Figure 4, drives the fishhook into the canal wall.

When patients try this technique, they create an almost impossible situation. The end of the hearing aid or earmold “hooks” or locks into the tissue. The harder they pull, the harder the end of the canal is pushed into the tissue. Hematomas and bruising can result if a hooked-shaped instrument is pulled out of the ear incorrectly.

This hooking action can be avoided in most ears if you instruct patients to put their thumb under the hearing aid in the center of the earlobe, exactly where a conventional earring would be located. Have the patient put a thumb on the

“earring spot” and then push upward and inward toward the middle of the

head and under the hearing aid. This action lifts the hearing aid up and out. Most patients find this technique quite easy to use.

If the patient has a memory problem, I send a note home saying, “Always remove the hearing aid from the bottom.”

Before I teach a patient this procedure—removing the aid from the bottom—I do it myself several times, making sure it works easily on this patient's ear. The technique is usually successful because there is no rotation of the end of the canal toward the ear tissue. The aid is simply “popped out” from the bottom.

Using baby oil and Otoease

Lubricants such as baby oil and Otoease help many patients. In the case of fishhooks, they are critically important. But be careful. Sometimes lubricants work so well you might incorrectly believe you do not need to modify the fitting. Several times I have put too much faith in a lubricant, only to have the patient return because of difficulties removing the hearing aid.

My test for fishhook-shaped hearing aids or earmolds is simple. If I have difficulty putting them in the patient's ear without lubrication, then the hook problem probably needs to be resolved at the factory.

CONCLUSION

You need experience in this profession. There is no substitute. You cannot compare the level of expertise between a hearing aid dispenser with fewer than 100 fittings and one who has fitted thousands of patients. All professionals develop special techniques to deal with difficult and potentially dangerous situations. We must do likewise by eliminating potential problems like fishhooks before they happen.

Acknowledgment

I want to thank Don Calvert and his art staff at Westone for the use of photographs and illustrations in this article. Their contribution was invaluable.