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Loud and clear

With more and more pharmacies offering extensive ear care services, it’s important for the whole team to be up to speed on common ear conditions

In the UK around 12 million adults have some level of hearing loss, which is thought to increase dementia risk by up to five times, according to the Royal National Institute for Deaf People (RNID). 

“There’s a growing body of evidence demonstrating the benefits of acting on hearing loss as early as possible, to reduce the risk of social isolation, mental health problems and dementia,” says Franki Oliver, audiology advisor at the RNID. “And yet we know people don’t take action soon enough.” 

Yet, hearing loss is not the only ear problem faced by the public. There are over seven million adults living with tinnitus, while an ear infection is one of the most common reasons individuals seek a GP appointment. 

Other ear complaints pharmacy teams may come across include balance problems, outer ear infection and impacted earwax. In fact, a survey conducted by manufacturer Earex found that two in five adults have suffered from earache with a third of these cases being due to impacted earwax. 

“There is a lack of knowledge among consumers on how to manage earwax,” says Clare Campbell, brand manager at Earex. “Over half of those surveyed believed they neglect their ear health. Consumers tend to only seek help when things go wrong.”

As the first point of contact, pharmacy staff are well placed to help customers suffering from a variety of ear problems. Here we examine the most common conditions and the treatment options available. 

Stuck in the middle

Otitis media, or middle ear infection, can often be caused by both a virus and bacteria. It is most common in children under four-years-old with symptoms including ear pain, dulled hearing and fever. Children may also be sick and feel generally unwell, while babies may be hot, irritable and unable to feed properly.

In many cases, middle ear infection will resolve itself within a few days, and pharmacy teams can recommend paracetamol or ibuprofen to relieve pain and fever. Most infections will not need antibiotics.

However, some customers should be referred to their GP, these include:

  • Babies under three months with a fever over 38°C
  • Babies aged three to six months with a fever over 39°C
  • Anyone who is very unwell with the infection
  • Children with recurrent ear infections as this can be a sign of glue ear, a condition where fluid builds up in the middle ear, eventually causing hearing loss.

Better than the build up

Earwax cleans, lubricates and protects the lining of the ear canal, trapping dirt and repelling water. Normally earwax clears naturally from the ears, but sometimes a build-up remains and can become impacted, causing impaired hearing and tinnitus.

Impacted earwax can be triggered by an over production of wax or drier ear wax. Those most affected are:

  • Over 50s
  • Under-fives, with 10 per cent affected
  • People with narrow ear canals
  • People with Down’s syndrome
  • Anyone with a dry skin condition
  • People who use cotton buds to clean their ears.

Some 2.3 million people a year have problem earwax that needs intervention. According to NICE guidance, earwax should be removed if:

  • It is contributing to hearing loss or other symptoms
  • The tympanic membrane is obscured but needs to be examined
  • An impression needs to be taken of the ear canal.

While the National Institute for Health and Care Excellence (NICE) recommends removal of wax in these circumstances, it is no longer one of the core services GPs have to provide for their patients. The service is increasingly being offered by hearing care centres and community pharmacies.

“Pharmacists are often a source of advice for patients on how to manage wax,” says Franki Oliver, audiology advisor at the Royal National Institute for Deaf People (RNID). “If pharmacies are interested in providing earwax removal services, we would advise them to ensure any training they undertake meets the minimum guidelines set out by the British Society of Audiology.”

Off-balance

Ménière’s disease is a long-term condition caused by a fluid build-up in the labyrinth, part of the inner ear responsible for controlling balance and hearing. It may be triggered by a variety of causes including autoimmunity, a genetic susceptibility, an imbalance of salt and potassium in inner ear fluid or a viral infection. 

The condition can have a significant effect on an individual’s balance and hearing. Around one in 1,000 are affected and it’s most common in those aged 30-60. The main signs include unpredictable attacks of vertigo with nausea and vomiting, according to charity the Ménière’s Society.

Other common signs are tinnitus, hearing loss and a feeling of fullness in the affected ear. Attacks often last a few hours and can occur in clusters over several weeks. Although incurable, it is important to keep an eye on the condition as it can lead to falls and have negative psychological effects including provoking feelings of anxiety and depression.

A short course of prochlorperazine or an antihistamine can help relieve nausea during an attack. In severe cases, patients may need an intravenous injection of anti-nausea medication. Betahistine can also be prescribed to those 18 and over to reduce frequency and severity of attacks.

Keeping medication close to hand in case of sudden attacks should be advised. The Driver and Vehicle Licensing Agency (DVLA) should also be informed about the person’s condition, and they should stop driving when they are dizzy or if they experience a sudden bout of vertigo.

Lost in the labyrinth

Labyrinthitis is an inflammation of the labyrinth, usually affecting one ear. Mostly triggered by a viral infection, it causes dizziness, imbalance and hearing loss. The condition can affect all ages but is rare in children. 

Customers with possible signs should see their GP for diagnosis. Anti-vertiginous medicines, antihistamines and rest are advised for a viral infection – acute episodes are usually improved after two weeks. Bacterial labyrinthitis is treated with antibiotics.

Those with the inflammation are advised to rest in a dark room when feeling dizzy, avoid noise and bright lights, get plenty of sleep and keep the eyes focused on a fixed object when walking.

Case study

Pharmacist Amish Patel set up a successful earwax removal service at Hodgson Pharmacy in Longfield Kent. Here he tells TM about the training involved, how the process works for customers and the positive feedback he’s received. 

“We set up our earwax removal service in 2020. It’s something I was looking into doing for a few years but couldn’t find any training providers,” he explains. “I saw a gap in the market and thought, this is definitely a service that community pharmacies could get involved with. Now there are lots of training providers, and as it’s no longer a core GP service, an increasing number of pharmacies are starting to offer it.”

Amish’s training day at Rotherham Hospital involved observing 20 treatments before he was able to start offering it to his customers. “The total set up costs, including training, were around £2,000,” he adds.

Now, customers can call in or book an appointment on the pharmacy’s website. “We ask for a £20 deposit, which is deducted from the total fee,” says Amish. “We charge £50 for one ear or £80 for both. First, we do a medical questionnaire with the customers to find out if they will be suitable for the procedure and if there are any contraindications or concerns we need to be aware of. We examine their ears and show them on a screen where the wax has built up. We use a microsuction device, and it all takes around 15 minutes.”

The service has become very popular, with appointments usually being booked up to two weeks in advance. “At the moment I’m the only one trained to carry it out, but I would like to get another pharmacist trained,” he explains. “Customers are very grateful for the service and pleased with the results. We get lots of word of mouth recommendations and customers travel from far afield to access it.”

Ringing out

Tinnitus is the sensation of hearing a sound without any external source. It can be perceived as ringing, hissing, buzzing, whooshing, whistling, or humming. It can be in one or both ears, either constant or intermittent. 

Around 30 per cent of the population will experience it at some time, while 13 per cent live with the condition constantly, with those who suffer from hearing loss and other ear problems being particularly susceptible. 

“It’s hard to pinpoint the exact cause, but it’s generally agreed that it results from some type of change to the person’s wellbeing. Common causes include hearing loss, exposure to loud noise, stress and anxiety, ear infections, wax build up, glue ear and Covid-19 infection,” says Nic Wray at the British Tinnitus Association (BTA). “Customers should be reassured that tinnitus is common and may resolve by itself and that there are a number of management options. An ear examination by a GP should be suggested to identify and treat any external ear problems. They can also make a referral to audiology services for further assessment.”

Nic explains that after initial assessment and tests, key management tactics include “treating any underlying condition, managing the hearing loss, using sound therapy and trying talking therapy, such as CBT”. In addition, “if a hearing aid has been prescribed, this should be worn as directed”.

For further support the BTA has a free e-learning programme called Take on Tinnitus which covers using hearing aids, sleep, relaxation and sound therapy. See: takeontinnitus.co.uk for more information. The BTA website also has a support team who can answer queries by phone (0800 018 0527), email, text or webchat. Posters and leaflets are available for pharmacy staff.

Sink or swim

Otitis externa (swimmer’s ear) is an inflammation of the external ear canal. The condition is classed as acute if it lasts less than six weeks and chronic if longer than three months – acute is usually due to a bacterial infection and chronic, a fungal infection.

Symptoms include itching in the ear canal, ear pain, discharge and sometimes hearing loss. There is often a lack of earwax in the ear canal and dry, scaly skin.

Swimming can make the ear canal more prone to infection, but other causes include dry skin conditions, otitis media and trauma to the ear canal from cleaning, syringing, ear plugs or hearing aids.

There are a variety of treatment options available for customers suffering from swimmer’s ear, including: 

  • Acetic acid 2% drops or spray for a maximum of seven days
  • Analgesics to manage pain
  • Topical antibiotics can be prescribed, along with a topical corticosteroid
  • For chronic infection caused by fungal infection, a topical antifungal such as clotrimazole can be prescribed.

Self care tips to share with customers include keeping the ears clean and dry; avoiding swimming for at least seven to 10 days during treatment; wearing ear plugs and/or a tight swimming cap; and keeping shampoo, soap and water out of ears when showering. Using a hair dryer to dry ear canal after hair washing, showering or swimming can also help.

“In the UK around 12 million adults have some level of hearing loss”

Keep the door open

Aside from offering treatment advice for ear conditions, pharmacy teams can also work on making the pharmacy more accessible, particularly for those suffering from hearing loss. Though this may seem like a difficut task, there are plenty of simple ways to make a difference.

“Make sure you have accessible contact methods, so that deaf customers or those with hearing loss can contact you. This includes offering an email or text option on your website for people to contact you through Relay UK or video relay services for BSL users,” says Franki. “If you wear face coverings, be aware that someone with hearing loss won’t be able to lipread you. Consider taking your face covering down or using one with a clear panel.” 

Hearing loss

Over 70 per cent of over 70s, and 40 per cent of those aged 50 and over, have hearing loss. “Hearing loss can be slow to spot, and additional factors like feelings of fear and embarrassment about getting old can cause people to wait 10 years on average before seeking help,” says Franki Oliver, audiology advisor at the Royal National Institute for Deaf People (RNID).

Hearing loss is strongly linked with increased dementia risk but wearing hearing aids can reduce this. “Some people may have misconceptions about hearing aids, that they won’t work or will make them look old, but this isn’t the case,” adds Franki. “All hearing aids available on the NHS, or privately, are digital, with advanced speech processing technology.” Signs of age-related hearing loss include:

  • Thinking people are mumbling and asking them to repeat things
  • Having difficulty following conversation in noisy places
  • Finding it hard to follow in group conversations
  • Getting tired from having to concentrate so hard on what’s being said
  • Having trouble hearing on the phone.

The RNID has an online hearing check to give an indication of whether there is any hearing loss. 

If a hearing test indicates a need for hearing aids, customers can go to their GP for referral to an NHS clinic or buy them privately.

For further support, customers can also call the RNID on: 0808 808 0123 or email or webchat.

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