Among my friends, colleagues and trade association, I am raising awareness of the risks of microsuction.
Microsuction is a highly effective method of ear wax removal, but it has associated risks. These risks are magnified when the procedure is carried out by someone who is unaware of them, and there are many people in the field who are unaware. Sadly there are even many audiologists and ENT surgeons who are unaware of the immediate and cumulative risks..
My motivation is not to stop people from having microsuction, simply to raise awareness that there are clear risks as well as benefits. No procedure of wax removal is risk free, with the possible exception of olive oil*. The problem with olive oil is that it's messy, clogs hearing aids and doesn't work particularly well!
Microsuction machines vacuum out ear wax using suction. The suction causes noise, and the noise level is often above "safe" levels. Sound recorded at the eardrum range between 75 and 150 decibels (dBA scale), and the louder the sound the more damage is caused.
Factors that affect the sound level at the eardrum include:
Machine used
Calibre (bore size) of the nozzle
Amount of water or liquid in the ear canal
Volume of ear canal
How close the nozzle is to the eardrum
Factors that increase the risk of damage to hearing include:
Noise level
Exposure time
Microsuction is therefore less risky when it is swift, skilled (because it is quicker) and carried out by a small calibre nozzle, from a quiet machine, in a dry ear canal.
There is absolutely no doubt, no matter what research paper someone chooses to cite, that loud sound damages hearing and causes or exacerbates tinnitus. This is not up for debate at this stage of our knowledge.
We have known for decades that loud noise causes a Temporary Threshold Shift (temporary hearing loss) or TTS. Some audiologists know, but an alarming level don't, that a TTS is not temporary damage. It is a very obvious sign of damage, and it leads to inner ear hearing problems. Not just hearing damage that shows up on a hearing test, but also cochlear synaptopathy (AKA Hidden Hearing Loss, see previous blog article for more details). Noise induced hearing loss is bad enough on its own, but synaptopathy ruins your ability to hear speech in noise. It is also difficult to prove and measure, and it can happen very quickly.
There are no end of studies on noise levels during microsuction. Small studies are sometimes inconclusive because of the sheer number of factors involved. It is not in doubt though that microsuction equipment has the ability to cause unsafe levels of sound, right next to your eardrum where the worst damage occurs. The ear canal itself resonates at 4kHz (a high pitch sound), which amplifies this frequency beyond the actual noise level of the machine. The only way to measure the sound level at your eardrum is to use a probe during the procedure. All of this information is known, and not up for debate.
What I want to do is raise awareness that we should be training those who carry out microsuction. We should be training the trainers who teach the suction workers. We should be getting patients' informed consent before carrying out the procedure, every time. Patients should know that there are inherent risks, so they can assess for themselves if irrigation (syringing water) and/or preventative measures are more suitable for them.
It is not good enough to say "well the wax has to come out" or "microsuction is a safe procedure".
I am quite sure that as research on Hidden Hearing Loss progresses that we will find safe levels of sound and exposure time are lower than we currently think. If you take cochlear synaptopathy into account, it is my opinion that some people's individual risk factors mean that even the standard microsuction procedure is unsafe for them.
As a patient, you have limited options while we wait for research to catch up with the industry. However I strongly suggest that you:
Use microsuction as a last resort method, and only when necessary (when wax is preventing you from hearing/using hearing aids
See a well-trained operator (preferably an audiologist or ENT) for the procedure and ask them about the risk before accepting treatment. If they give you a woolly answer, steer well clear. Do not allow "white coat syndrome" to stop you from rejecting a procedure
Weigh up the risk. If you have hearing problems, noise damage or tinnitus already, perhaps you do not want to take this additional risk?
Weigh up the benefit. If you have been told you have wax in your ears, does it actually need to be removed or can you wait for it to come out on its own?
A Temporary Threshold Shift - which you will experience as dull hearing with/without tinnitus - is a cast iron sign that damage has occurred, do not revisit a practitioner who has caused this in the past. It may have been necessary to do this damage to carry out the procedure but in the absence of other markers to prove damage, this is the best we can get. Be aware that if you have hearing loss and tinnitus already, you may have damage but no signs.
Be aware there is damage such as not being able to hear speech clearly in noise which does not show up on a hearing test. If you believe this has happened to you already, please avoid future microsuction unless absolutely necessary. Cochlear synaptopathy is (currently) irreversible, and it is very hard to treat.
Choose wisely and make sure your practitioner is someone who is well aware of the risk. Ask them questions, such as "how do you protect me against noise damage during this procedure ?" Ask them, "is this procedure absolutely necessary for me and why?" and see how they respond. Avoid practitioners who give you a feeble response. The only realistic true response is "This procedure has risks with regard to hearing and tinnitus and I do X, Y and Z to mitigate them".
Be aware that if you have some hearing loss already, you will not be experiencing the sound of the nozzle as loud as it is in reality. A practitioner may be going on visible discomfort levels to work out if you are experiencing sound that is unsafe, but you are not going to be uncomfortable with 120dBA sound if you have a 50dB HL sensorineural hearing loss. You are at the mercy of the practitioner to ensure they are practicing as safely as possible.
Comment below if you have had any negative experiences with microsuction, as I am interested to understand the scale of this issue. If you prefer to be anonymous you can email me at sally@hearingandtinnitus.co.uk.
If you are in my local area, I can recommend Ralph Leach at Pennine Ear Care for microsuction, or Ramzy's Pharmacy for irrigation wax removal. I do not perform wax removal as a standalone treatment currently. I only use the curette method on existing patients. If you are prone to wax buildup, I also recommend using a few drops of sterile/clean olive oil* in the ear canals once a week, to avoid buildup of earwax**.
Sally Jackson, BSc Healthcare Science (Audiology). RHAD, MSHAA
*Do not use olive oil if you have perforated eardrums or other damage to your ears. Ask an audiologist to examine your ears if you are in any doubt. Be sure to do it last thing at night and avoid using your hearing aids until the olive oil has come out.
** Olive oil binds to wax, softens it and encourages wax out of the ears where it can safely be wiped away. Cheap and (moderately) effective, if it's clean/fresh and you're in good health, you can use the stuff from your cupboard. Alternatively you can purchase it in the form of "Otex" or medical grade "olive oil BP" from a pharmacy.