Sounding It Out

This is the final part of a 4 part mini-series about the UK’s earwax crisis.

Throughout the series industry experts have been talking about the innovative ways their clinics have for addressing the earwax problem.

In this episode, we’re finding out first hand what it’s like using the Earways Pro tool. It’s been put into practice at the Southeastern Health and Social Care Trust. Nora McDonald is the Acting Adult Lead Audiologist at the trust and is Julia’s guest.

For more information about Earways Pro head to their website

Contact Nora at [email protected]

Got a topic you think we should be talking about? Get in touch here: [email protected]

For more information about Signia UK and Ireland, visit their website

Sounding it Out by Signia, is produced by Annie Day from Fresh Air Production.

FULL TRANSCRIPT

[00:00:00] Julia: Hello and welcome back to Sounding It Out, the podcast dedicated to audiology, brought to you by Signia UK and Ireland. I'm Julia van Huyssteen, your host and Head of Audiology at Signa. This is the fourth and final episode of the miniseries about the wax management crisis we are facing here in the UK. All the guests in this mini- series have found new and inventive ways of tackling the issue in their trusts, and are sharing their experiences and expertise with you.

Last time we heard from Nicola Phillips, who is the Principal Clinical Scientist and Head of Primary Care Audiology at Swansea Bay University Health Board. Nicola talked to us about how her trust implemented an audiology led primary care earwax removal service.

[00:00:52] Nicola: All our patients access primary care audiology through their GP surgeries. In some practices, patients get triaged by the receptionist and book directly into audiology slots, or the wax removal slots. In other practices GPs will triage over the phone and then book them directly into clinics using a shared booking system.

[00:01:10] Julia: If you've missed the first three episodes, you can go back and download them for free wherever you get your podcasts.

Today, let me introduce you to Nora McDonald, who is the Acting Adult Lead Audiologist at the Southeastern Health and Social Care Trust. She is going to be sharing her experiences of using the Earways Pro Tool. Hello Nora.

[00:01:34] Nora: Hi, good morning Julia, thanks for having me.

[00:01:38] Julia: Nora, thank you for joining us as guest speaker.

Although you've only recently started using the Earways Pro tool, you have some great experiences you can share with us today. Before we start getting into the nitty gritty, where did you first hear about the Ear Earways Pro tool and what about it made you pay attention?

[00:01:55] Nora: Our Audiology and ENT manager, Barbara Greg, had noticed it at the 2021 BA conference. We had long ENT waiting lists after covid and more and more patients were presenting to the audiology appointments with obstructive wax. Of course, we're always interested in exploring any wax management options including alternatives for microsuction.

[00:02:20] Julia: So it sounds to me like the impact was both on ENT and audiology. Of course that would be something that makes you pay attention to an alternative method that could actually ease the service. Now, what did the ear removal service exactly look like in your trust before introducing the Earways Pro tool?

[00:02:39] Nora: So the ENT specialist nurses manage the wax removal service. They manage their own waiting lists, reviewing patients as and when required, and accepting new referrals from audiology or ENT as indicated. The audiology service in our trust works across four individual sites and we don't always run alongside the ENT microsuction nurse. So if we were faced with obstructive wax within an audiology appointment and didn't have access to a nurse to remove it, the majority of patients would've been advised to contact their GP for wax removal locally, provided obviously that they had no contraindications for local management. We tried to limit referrals to the nurse-led microsuction clinics to those who warranted that specialist ENT attention. For example, the atypical ears perforations, mastoid cavities, history of otitis, surgery, collapsing ear canals, et cetera. But obviously due to a combination of the Covid pandemic and the withdrawal of many local GP wax removal services, our ENT waiting list for microsuction was just... grew longer and longer, so it became quite a big problem that we needed to address.

[00:03:57] Julia: Wow. I can really see the impact of limited wax removal opportunities across the four sites too. And of course you also limited wax removal opportunities within primary care, so going back to primary care then, what was the GPs and your trusts response together, I guess, to this problem previously? What did you do, was private wax removal and option, and what was the feedback from the patients around these waiting times or potential wax removal at a cost?

[00:04:26] Nora: I can't speak too much on behalf of the GPs, but as far as our department is concerned we added as many additional ENT microsuction clinics as possible in an attempt to tackle the waiting list. But of course, we have all the usual staffing and equipment demands. Patients were obviously understandably disappointed to learn of the long waiting list for microsuction within the trust and would explore options on the high street for a quicker alternative. This is obviously not always an accessible option for patients due to the associated costs, and it obviously doesn't sit well with us as NHS audiologists to suggest this as an option. Our department is always re-evaluating and exploring all options, including further wax removal training and equipment for audiologists and we are hopeful that the use of the Earways Pro tool in audiology appointments will reduce the referral rate and lift that pressure of the ENT microsuction waiting lists.

[00:05:25] Julia: Understandably yes. And actually, I mean you talk about the waiting lists, but what about any data around, for want of a better word, wasted appointments due to patients presenting with wax? You mentioned earlier, I think in the first answer, that often you were presented with patients with wax and you didn't have access to ENT wax removal. Many of those appointments would of course not be able to be completed. Can you share with us any figures at all?

[00:05:53] Nora: Yeah, unfortunately not on that specific area of wasted appointments, I suppose it isn't something we've been able to reliably audit because now that we have the Earways Pro tool, that would involve a huge retrospective study to investigate all the appointments where wax contraindicated a procedure so that's not something we've managed to to reliably assess.

[00:06:18] Julia: That makes sense. But I think from the conversation so far, what I hear is that from both the trust perspective the audiology and ENT and from the patient's perspective, it pretty much wasn't everybody's interest to think outside of the box and look at alternative methods, so good on you, really. So at this point, I just think it's important for us to highlight to our listeners that the Earways Pro tool is regulatory approved. It's a medical device and it's for used by trained professionals. Just emphasizing trained professionals. For our listeners benefit at this point, for those who have not seen the tool before or hasn't got any experience with it, shall we attempt to describe more or less what it looks like and how it functions?

[00:07:06] Nora: The tool is a slim, handheld single-use device with a small grip handle and a flexible helical head. They come in small, medium, and large. In terms of the circumference of the spiralled head, patients often comment actually when shown it that they've seen similar online to buy. But I do point out, as you've just said, that the Earways Pro tool is medically approved device only to be used by trained professionals and shouldn't be available to purchase online.

I tend to highlight the main difference between the Earways Pro tool and similar commonly advertised to purchases that the helical head at the top is a completely open spiral, so that prevents impacting the wax further the same way a cotton bud would.

[00:07:54] Julia: Yeah. So with that spiral head the Earways Pro is designed to spiral around the wax and engulf it. And you've mentioned that open-ended tip and then because it's spiralling around the wax, we are not pushing it further into the canal. We're just simply pulling it straight after the ear. So it is very cleverly designed to be safe to use. Now my next question considering that ENT was previously pretty much solely responsible, whether nurses or surgeons or doctors for the wax removal, what was their view or what is their view actually on the Ear Earways Pro? Did they have any training from you or anybody else? Have they actually made an effort to observe you using the tool, considering that they are ENT specialists? Were they positive or were they negative? And have they actually mentioned any impact in their own clinics in terms of waiting times in people coming for wax removal?

[00:08:53] Nora: Yeah, so it's our ENT nurses that lead the microsuction waiting lists as opposed to ENT in general. The nurses were very intrigued and supportive. They recognize that the Earways Pro will hopefully enable us to help those more typical layers within an appointment that the patient's already attending and allow them, the EENT nurses, to concentrate back on those patients with the more complex presentations who require their specialist attention or the microsuction procedure. In terms of any impact on their clinics yet? It's still early days. We are definitely seeing it, but I think at this stage, they're just ticking over, absolutely swamped. So at the moment we haven't quite audited.

[00:09:40] Julia: So perhaps a follow up session on that for another series, hey.

[00:09:45] Nora: Absolutely, yeah.

[00:09:46] Julia: So earlier we stressed that the Earways Pro Tool, both yourself and myself, is a regulatory medical device for used by trained professionals. I wonder if you can please talk us through the training that you and your colleagues have had prior to using the Earways Pro tool. What did that training package look?

[00:10:06] Nora: So when we were first interested in the Earways Pro Tool, we contacted the distributor, Signia, and they put us in touch with one of their accredited trainers, Chris Cartwright, the Director of Audiology at the Audiology Academy. He kindly visited us in the department in Belfast and did a half day of theoretical training with our audiology team on wax management options and introduced the Earways Pro tool. Because we were new to the device we weren't sure how useful it would prove to be. We had arranged four audiologists to continue onto the hands-on practical training into the afternoon. We had booked a wax removal clinic full of about 16 from our ENT microsuction waiting lists. We used the Airway Pro tool on these patients under Chris's guidance and supervision and he signed us off. And then those four trained audiologists then continued onto the use of the tool within audiology appointments when indicated. And then we ordered them.

[00:11:15] Julia: Wow, that is very comprehensive. So what I'm hearing is that you had half a day off of theory really going back to Otoscopy Anatomy and what to look out for when you do wax removal. And then of course you had the follow up in the afternoon with the practical session where you all got to practice. That's great to hear, and goes back to the fact that we talked about, the Earways medical tool is for used by trained professionals. I've heard that there is a learning curve for getting proficient using the Earways Pro tool, even if you are very experienced at looking in ears and taking impressions, and even if you've got experience with wax removal. We hear this about this learning curve. Have you and your team observed this? And how many years would you say it takes for building up confidence and how many years does it take to practice before you feel that you've got the confidence to select the right size, the right type of wax, the right ear, and all of those things?

[00:12:11] Nora: Yeah, so there was quite a steep learning curve initially going from theory to real ears in one day. But ears are our bread and butter, and we are well used to spotting contraindications and performing procedures on them whilst employing all the appropriate safety techniques with regards to positioning, bracing, et cetera. As with any of our procedures in audiology, even six months on our learning with the Earways Pro tool hasn't plateaued. No two ears are ever the same and of course, wax can present in many different forms, even in the same patient, on the same ear. We're still learning every time we use it, both in a practical sense of how to manipulate the device, but also by auditing our outcomes in particular, when it tends to be successful and when maybe less so. I couldn't really place a number of ears as per se on it, but our confidence continues to grow with it each time we use it.

[00:13:11] Julia: And I think that's the key here, is that each time you use it, your confidence is growing. So with practice doesn't come necessarily perfection as we've just we should have heard from yourself, but it certainly means that your confidence is growing. From your experience so far, you mentioned six months in or so how long does the procedure take, especially when we compare it to alternative wax removal services like microsuction, for example.

[00:13:38] Nora: In my experience, the procedure itself, excluding case history only takes a few minutes or so. There have been times where the wax has come out in one solid, lovely plug within a few seconds and others where a lot's come out. And then reviewing the ear after there's even more behind. So we repeat the procedure again with a new tool. Looking at our outcomes so far 50% of procedures took one to two minutes, 38% took over two minutes. And of note, many of those were those that were unsuccessful, so probably involved maybe a repeat attempt or changing the tool size and 12% took under a minute so around a few minutes really.

[00:14:25] Julia: Wow. So that really shows us that this is a tool that can be implemented very quickly in an appointment like you mentioned at the start, where you can have a patient that presents with wax, for example, at a direct referral appointment and rather, have to book a separate session with a nurse or asked a nurse to help.

You could potentially use the Earways Pro tool for, let's say, two minutes or so which doesn't take that much more because you'd have to take the case history anyways. And then within that same appointment you'd be able to still fit in the rest of the appointment because the Earways Pro only took let's say a couple of minutes or so. So that's really quite impressive.

[00:15:04] Nora: Yeah, I think it very often does just take that amount of time and actually when, because some of our staff aren't trained yet, we have some of them if they have too much wax that it's preventing a procedure and they aren't trained on the Earways Pro. I did ask them to book in with one of the people who are trained to give it a go if the patient was interested in giving a go. And actually at the beginning people were booking in a half hour, it was much too long. It was a waste of time. 15 minutes did it. So we changed 15 minutes because in a couple of minutes you know if it's going to work or not. So I think that gives you an idea of how much time it takes.

[00:15:47] Julia: Yeah, definitely. So you've mentioned there that some of the staff isn't trained at the moment, but at the BAA you mentioned that actually they are really quite keen to also get trained because they have already started to see the benefit of the Earways Pro tool. Do you have any plans for rolling the training out to the rest of the department too?

[00:16:06] Nora: Yeah, so the feedback from the trained staff is really positive. They are relieved to have something in their toolbox to at least reach forward to try to remove obstructive wax, which may be preventing their management rather than just giving their apology to the patient and wasting a patient visit and appointment time.

It's often successful, the use of the Earways Pro, so within a few minutes we're able to identify the wax, remove it, and move on with our appointment without any need for a return visit or onward referral. It's been used successfully in domiciliary. With bed bound and dementia patients where alternative wax removal options aren't always accessible, it's made it possible to obtain reliable objective testing and take impressions within the same visit and move things along quickly without delay. Which is obviously particularly important for that patient group. So it's been a real positive difference to the department. And we recently asked the team if anyone else was interested in being trained on the Earways proto and everyone volunteered. So that's the plan over the coming months. No one wants to be the one who can't do anything about the wax when faced with obstructive wax.

[00:17:23] Julia: Fear of missing out, right, is what it sounds like to me. And you mentioned domiciliary visits and I've heard other trusts also mention going to care homes, with it being very convenient for that and also repair clinics, if somebody comes in for a hearing aid repair and the main problem is that they've got obstructive wax .Due to the time that you've just described two minutes, you could actually fit it into a repair clinic, whereas previously you'd have to send the patient away to use olive oil for a couple of weeks, then book them in with the ENT nurse so you can start to see the applications and the relevance of this tool in an audiology department more and more so as you gain experience using it in different ways. Earways Pro themselves have some data from the US and Canada, the UK and Australia where they included 43 clinicians who did the Earways Pro procedure on 330 ears. And amongst other things, these clinicians have rated the Ear Earways Pro Tool 4.2 out of five for safety. Now, I know that you are relatively new to the tool, but from your experience has there been any incidents that made you worry about its safety at all?

[00:18:38] Nora: So we paid particular attention to the case history before the procedure to ensure there's no contraindications. We don't use the Earways pro tool on patients who have any type of otitis, have history of ear surgery including grommets or hearing. We don't use it with patients who have any abnormalities of the pinna or ear canals or malignancies of the ear or temporal bone or patients who have had any radio radiation therapy for the head and neck and we also exercise caution with those on anticoagulants because obviously they have a higher risk of hemorrhage and hematomas. And as with otoscopy and impression taking, we are well used to employing appropriate positioning and brace technique, which is obviously crucial and of course, oscopy is essential before the procedure to note any contraindications and to document the condition of the air canal, after the procedure. Our audits to date indicates that in five ears out of 77, there was a slight redness of the ear canal observed after the procedure. But in the majority cases, there has been no change in otoscopy findings of the ear canal walls after the procedure. We do tend to advise patients to keep their ears dry for a subsequent 48 hours after the use of the tool, just as a precaution to reduce any risk of infection of the newly exposed, potentially vulnerable ear canal skin.

And we've not had any reports of post-procedural Otitis to date or anything from my personal experience. The wax usually slides out really easily. But I have had one occasion where when I've gone to remove the tool, I've had a slight kind of friction or almost pull back, which indicated to me that the wax was too stuck.

So I just rotated the tool back in the opposite direction and removed it from the ear and advised olive oil and left it at that. So I have just been aware of that feeling what you're doing and being mindful that obviously it shouldn't require any force on your part. It should just slide out once it's been gripped.

[00:20:52] Julia: So what I'm hearing from that is that you mentioned five patients, I think, did you say, was it out to 70 or so? 77, yeah, 77 that had slight redness. And I guess you can compare it to any other wax removal technique. Or even impression taking where there will always be a few people that show some slight redness afterwards but as you say, there's been no real complications post-procedure that you are aware of either, that sounds great. So basically the conclusion is here be a good audiologist

[00:21:23] Nora: Exactly, it's remembering all the usual safety procedures and precautions that you do anyway in your day-to-day.

[00:21:33] Julia: Yes. Exactly. Now you mentioned there that you can tell when the Earways Pro isn't the appropriate tool to do. But what about the patient and in terms of talking to them about using this new way of tackling Earways. I guess it's something quite new to them too. When you look at the tool itself, it is something that you tell them that will be going into the ear. They may feel a little bit worried about this new procedure. I guess counselling is really quite important in terms of making them feel safe and happy for you to go ahead. What are the type of things that you would say to the patient to a, talk them through the procedure and b, put them at rest that that it's okay to do this procedure.

[00:22:18] Nora: Yep, so I've obviously mentioned that we've been collecting outcomes on every time we use the Earways Pro, regardless of whether it's successful or not. And one of the things we are obviously very keen to record is comfort. 50% of instances reported no discomfort at all during the procedure.

While 50% reported a slight discomfort of which hundred percent characterized the slight discomfort as only momentary, so no one reported discomfort that continued after the procedure, and no patients reported that they had some discomfort rather than slight, was uncomfortable or was painful in our comfort scale. And in the early days, one patient did comment that they weren't physically uncomfortable during the procedure, but they just felt nervous, which is what you were saying there. So I think it is important to be mindful that it can be nerve wracking having someone effectively poke a device into your very sensitive ear. And I personally explain a few things before the procedure. I tend to explain that it's a medically approved tool that I can use to try to remove the wax. And sometimes it works and sometimes it doesn't. Just to give them realistic expectations. I obviously show them the tool and I explain that it may feel deep, often deeper than it actually is. And I explain that we have a strong protective reflex in our ear canals that will make them want to cough. And I sometimes suggest that they keep swallowing repeatedly through that sensation where possible that kind of can sometimes ease that feeling. And I explained that it may feel intrusive and not particularly comfortable, but it should not be painful.

And any pain, obviously raise your hand and obviously I check that they're happy to proceed and gain consent, because of course, if they're more comfortable trying an alternative method, that's entirely up to them. So I guess just reassurance. Often, also while doing the procedure so whenever you're rotating the tool, obviously through the air of the ear canal before you hit the wax, you can feel when you do a very slight change in the friction when the tool reaches the wax and you're spiralling into it. So I tend to, at that point, reassure the patient that, okay I've reached the wax now and I just need to get a good grip of it and then we'll just slowly remove it. So just so that they are aware of if they have a change in sensation that I'm explaining why at that point.

But they're obviously delighted by the end if it's successful. Oh my goodness. They love to look at it and study it and see what it was. I can't believe I had one patient who asked to take it home. Another patient said she wanted to jump on the weighing scales cause she felt like she'd lost five pounds. So yeah, lots of photos taken of it after it of the patient to show their families.

[00:25:24] Julia: Oh, that's so funny actually and you don't tend to get that really with other wax removal techniques. So I guess this is a unique one. In terms of the counselling, what I'm hearing is that it's really important to describe the procedure before, describe the tool to the patient and pretty much the safety mechanisms of the tool, and then describe to them what they may expect in terms of feeling. And then as you're doing it, talking them through the procedures to keep them informed all the way through. And of course the last piece is if there is discomfort, let me know. And then I've heard people say, or check in with the patient, do you mean by discomfort that it's painful or that you feel pressure or that it feels a little bit strange? Or as you said, it may feel a little bit deep. And often when you talk about what this discomfort is that they initially say, "oh, this is uncomfortable". It isn't necessarily pain, it may be one of these other sensations that they weren't expecting.

[00:26:18] Nora: Yeah, and also as we do with any procedure is observing the patient. You can see if they scrunch their eyes a little bit, then obviously that's your cue to check in with them because they might not be the most vocal and they might not want to interrupt or complain of course, so it's just reading their cues as well, and constant communication and take it from there. .

[00:26:41] Julia: Okay, great. Do you have any data for us? I know you said that retrospective data's quite hard for you to get because obviously you'd have to go back and do a really big study in terms of who you weren't able to see and you had to refer back to the nurses or to the GP. But do you have actually any data for us since you started using Earways on referrals that you managed to avoid because now you've got the Earways Pro tool?

[00:27:04] Nora: Yeah so from a total of 77 years, 32% were unsuccessful, 58% were either partially or fully cleared, requiring no onward referral. So out of the documented instances where an odd logical procedure was inhibited by wax, 40% of these instances were preventing PTA or speech testing or some assessment of their audiological hearing threshold. But Earways Pro use enabled continuation of the assessment in 83% of those cases 50% of delayed procedures were, was impression taking. And 66% of those were able to be continued after the Earways Pro tool use.

So that hopefully gives you a bit of an idea on the benefit and the ability to continue our procedures because of just being able to reach for this tool prior to impressions or prior to PTA

[00:28:07] Julia Those are really crazy numbers and I hope that our listeners will take that on board in terms of how successful this tool has been for your patient pathway and allowing you to carry on with audiological procedures that you would not normally be able to carry on with at all. Staggering numbers, really. What is the perfect patient and the perfect type of wax for the tool to be most effective? I know you've talked about contraindications before, but is there certain things that you look out for when a patient arrives in clinic just in a standard case history that makes you think "I'm gonna try..", or looking into the ear in terms of the ear canal shape and size, looking at the wax, cause we know that Earsways Pro is more effective for certain individuals and wax types.

[00:28:50] Nora: So in 56% of the unsuccessful instances, the audiologist felt that the reason was because the wax was too deep. So I think that might be an indication that we need to scream even louder about the impact of cotton bud use. 28% was because it was too soft and it was attributed to it being stuck to the canal wall with another, 8% the reason being unknown. Of the fully cleared wax instances, the texture of the wax was described as firm, in the majority, 63% of cases, the colour was described as a darker brown in 52%, and brown in 26, and a light brown in 21 of the fully cleared instances. In my personal experience, wax would ideally be firm but not dry. And by firm I mean that it isn't too moist or drowning in olive oil as the tool can slip right through that, but also not dry and flaky as it needs to obviously grip onto something and not break apart. I usually get excited when I see a thick smooth, completely occluding plug of darker brown wax that almost hits you in the face when you do otoscopy

[00:30:10] Julia: Oh man. You're describing a wax that is usually for us as audiologists, the biggest challenge and to hear you say that you get excited about that is something that I think a lot of listeners wouldn't expect, but you're right. That is exactly the type. But you look into the ear and like you say, you almost can't get the otoscope in because it's that occluded? And you think this is perfect. And then the other flip side to that is we've not really talked about that, but how rewarding it is for us as audiologists to be able to see that wax, and you think, oh, I've got the right size tool here. And you go through the procedure and that plug of wax that jumped out at you physically gets out of the ear in one go. Very rewarding.

[00:30:47] Nora: I'm not gonna lie, obviously, I'd rather look in and see a pristine ear, but if I'm going to see wax rather than Oh, the dread, oh my goodness, what am I gonna do? And you're already trying to work through how you're going to break it or break the news or explain the options, which are quite poor that they have or to get the wax removed.

It's it great when you see that type of wax that really is obstructing the ear and nice and close and yes, it's very empowering to be able to say, oh, we actually have this tool that we could try and when it's successful, oh it's really is fantastic. And then just being able to move on rather than having to explain options of things that they might have to try and think about doing or consider doing. And it just makes it a lot cleaner and a lot nicer and a much more enjoyable experience for us as audiologists.

[00:31:45] Julia: and I've heard other audiologists also say that if they do have other wax removal options available to them, whether that's through ENT or audiologists having microsuction training, they all say that this has got a fantastic place in the toolbox because when you see the right person, the right ear canal, the right ear wax it is a great tool to have in the box to be able to do something about that wax quickly, to be able to move on.

So many thanks to you, Nora. It was great to hear about the success you have had with Earways Pro in your trust and there was lots of really rich content for our listeners to process.

[00:32:22] Nora: Thanks very much for having me, Julia.

[00:32:33] Julia: Many thanks also to my other guests in this series, Frankie Oliver, Mark Newman and Nicola Phillips for sharing their insights. All those episodes are available to you to download from wherever you get your podcasts. If you want to talk to Nora about her experiences, you can find her email on the episode page.

I'll end by reminding our listeners of the RNID or Royal National Institute for Deaf People's Campaign priorities. And that is firstly for earwax removal services to be brought back into primary care or community setting. Secondly for the Department of Health and Social Care, NHS England and local health bodies to explore new models for delivering ear wax removal services to make sure people can access timely and appropriate treatment. And thirdly, for the NHS to publish clear information on how people can manage ear wax build up themselves at home.

If you found any of what you've heard in these episodes helpful, please tell your colleagues so as many people as possible can share the knowledge. And if there's a topic you think we should be covering, drop us an email to the address on the show page and remember to follow wherever you get your podcasts so you don't miss an episode.

This is a Fresh Air production for Signia UK and Ireland, until next time, goodbye.

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