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Play it by ear

The benefits of regular visits to the optician and dentist are well understood but less attention is paid to our ears – yet hearing loss has been linked with cognitive decline and other problems. Tackling it as soon as possible is crucial.

Learning objectives

After reading this feature you should be able to:

  • Identify those customers who may have a hearing problem
  • Recommend self-care measures to manage minor ear conditions
  • Explain the link between hearing loss and cognitive decline.

Pharmacy teams are well placed to promote good ear health and advise patients when to seek further help. So let’s start by looking at some of the more common issues that may be encountered, beginning with earwax.

“Earwax is a normal substance that helps protect the outer ear,” says Franki Oliver, audiology manager at RNID, the national hearing loss charity. “For most people, it moves out of the ear naturally over time. However, 2.3 million people a year in the UK require their earwax to be removed by a professional. If left untreated, earwax build-up can lead to temporary hearing loss, earache, a greater risk of infections, social isolation and even depression.” 

Previously, most people could access earwax removal services on the NHS – often through a practice nurse – but many now have to pay privately, sometimes through community pharmacies, or remove earwax themselves using OTC preparations, continues Oliver. 

“Seventy-one per cent of people we surveyed in 2022 with earwax build-up had resorted to removing it themselves, although two-thirds said they did not feel confident doing this. Many of the self-removal methods were dangerous, including using hair clips, paper clips, toothpicks, cotton buds and Hopi ear candles. We strongly advise against any of these methods as they could cause permanent hearing damage,” she says. 

“The NHS recommends using medical grade olive oil ear drops three to four times a day for three to five days. Wax should then fall out of the ear during the next two weeks or so. These ear drops can also be used to soften earwax prior to professional removal. If the problem continues, people should visit their GP to find out more about getting earwax professionally removed.”

Ear drops should not be recommended if the patient is suspected of having a perforated tympanic membrane, dermatitis, or infection of the ear canal. RNID is campaigning for earwax removal services to be brought back into primary care. 

Other conditions you may encounter

Otitis externa is inflammation of the external ear canal. Also known as swimmer’s ear (since it is often brought on by trapped water), symptoms include itching, redness, ear pain, liquid discharge or muffled hearing. 

Acidic eardrops can help stop bacteria or fungus spreading. Advice can also be given on appropriate painkillers, as well as preventive measures (e.g. wearing a well-fitting cap when swimming; not sticking cotton buds in the ears).

A middle ear infection (behind the eardrum), otitis media can be caused by both viruses and bacteria, and symptoms may include earache, fever and dulled hearing. Anyone can be affected, but it is more common in young children, who might tug at their ears. Otitis media often clears up within a few days (although some cases may need an antibiotic prescription), but pharmacy teams can help by advising on suitable pain relief if required. 

 Commonly known as glue ear, otitis media with effusion occurs when the middle ear fills up with sticky fluid. Symptoms can include temporary hearing loss, earache or tinnitus. 

Glue ear often clears up by itself within three months. In some cases, treatment might include antibiotics (if it causes an infection), a procedure called autoinflation, or surgery to insert grommets.

Often the first time people notice a problem with their ears is when they experience some degree of hearing loss. This may be caused by one of the infections mentioned previously but in other cases it can be the result of cumulative damage.

According to RNID, noise exposure is the second most common cause of hearing loss after ageing, but also is the most preventable. 

“Situations that could put hearing at risk include listening to loud music, either live or through headphones, a noisy workplace, or loud bursts of sound such as explosions,” says Franki Oliver.

“There are two factors that increase the risk of noise-induced hearing loss or tinnitus: how loud the sound is and how long you are exposed to it. Long exposure to sounds over 80dB can damage your ears. In a real-life situation, you should be able to talk to someone who is two metres away without having to shout over background noise ­– if you can’t, it is likely you are somewhere that is dangerously loud.”

When listening to music through headphones, it is really important not to exceed the safe volume limit on the device, says Oliver. “It is also a good idea to take regular breaks – for example, have five minutes off for every hour of listening. If you go somewhere where the sound level hurts your ears, you should leave.”

Time for a test?

If patients feel that their hearing is getting worse, they should be advised to see their GP, who may refer them to a specialist. Private hearing tests are also available. 

Yaksha Makan, an audiologist/speech and language therapist, and founder of InspirEar: Professional Ear Health, says that a typical consultation will include:

  • A case history of the patient
  • Conducting an examination of the head, neck and outer ear
  • Middle ear testing
  • A diagnostic hearing test, which provides a clinical picture of the entire auditory system (the type of test is dependent on the age and abilities of the patient)
  • Feedback and recommendations for treatment depending on the likely aetiology and type of hearing loss diagnosed (e.g. recommending a hearing aid or onward medical referral).

NHS hearing aids are good quality and treatment is free of charge but people will have more choice and wait a shorter time if they go privately, says Franki Oliver. “Hearing aid technology has advanced significantly, so there should be a device that will suit everyone,” she says. The average cost of a pair of hearing aids obtained privately is £2,700.

“Hearing aids range in style and size, from those that sit behind the ear to those that sit in the ear,” says Yaksha Makan. “Some hearing aids are surgically implanted if there is a medical need to do so. 

“The type and style of hearing aid are ideally chosen according to the type of hearing loss, age and dexterity of the patient. The price of hearing aids varies according to supplier, the level of technology capabilities, and sometimes the service plans of the provider as well.”

“If you listen to music through headphones, it is really important not to exceed the safe volume limit”

A supportive ear...

Community pharmacy teams may encounter some patients who are hesitant about getting their hearing tested or using a hearing aid. 

“Education and awareness are key to a positive hearing aid journey,” says Yaksha Makan, adding that pharmacists can promote hearing aid use by:

  • Educating patients about the beneficial consequences of using a hearing aid
  • Informing patients that advancements in hearing aid technology provide users with options for the device to become adaptable and customised to their lifestyle
  • Alerting patients that most hearing aid providers may allow a trial period of use
  • Signposting patients to audiologists and hearing aid dispensers specialised in hearing loss
  • Highlighting support services/groups available for people with hearing loss. 

“If someone is reluctant to get their hearing tested, encourage them to take RNID’s free online hearing test,” says Franki Oliver. “It takes three minutes and can be done in the comfort of their own home.”

Cognitive connections

A growing body of research is linking hearing loss and cognitive decline.

One study by a team at Johns Hopkins in the US, which involved nearly 2,000 participants, reported that “volunteers with hearing loss, undergoing repeated cognition tests over six years, had cognitive abilities that declined some 30-40 per cent faster than in those whose hearing was normal”. 

Another study published in The Lancet Public Health journal suggests that people experiencing hearing loss who are not using a hearing aid may have a higher risk of dementia than people without hearing loss.

“The evidence is building that hearing loss may be the most impactful modifiable risk factor for dementia in mid-life, but the effectiveness of hearing aid use on reducing the risk of dementia in the real world has remained unclear,” says Professor Dongshan Zhu of Shandong University in China. “Our study provides the best evidence to date to suggest that hearing aids could be a minimally invasive, cost-effective treatment to mitigate the potential impact of hearing loss on dementia.”

The researchers looked at data from 437,704 people who were part of the UK Biobank database. Information on the presence of hearing loss and use of hearing aids was collected via self-reported questionnaires, and dementia diagnoses were determined using hospital records and death register data. The average age of study participants at recruitment was 56 years, and the average follow-up time was 12 years.

The study suggests that, compared to participants with normal hearing, people with hearing loss not using hearing aids had a 42 per cent higher risk of all-cause dementia. No increased risk was found in people with hearing loss who used hearing aids.

Background noise

Meanwhile, a study of more than 82,000 people – led by University of Oxford researchers and published in Alzheimer’s & Dementia: The Journal of the Alzheimer’s Association in 2021 – found that difficulty hearing speech in noisy environments is associated with up to 91 per cent increased risk of developing dementia.

Finally, a 2022 study of more than 4,000 participants, by Ulster University, Dementias Platform UK and others, found that hearing aid users had more than 50 per cent lower risk of mild cognitive impairment. And a meta-analysis of 31 studies, published in JAMA Neurology in December, found that the use of hearing restorative devices (hearing aids and cochlear implants) was linked “with a 19 per cent decrease in hazards of long-term cognitive decline”.

“Hearing aids have positive effects on a person’s physical, social, emotional and mental wellbeing, and are significantly associated with lower odds of depression for adults with hearing loss,” says Franki Oliver of RNID.

“While there is no sure-fire way to prevent dementia, we know there are steps we can take that could reduce our risk,” says Dr Susan Mitchell, head of policy at Alzheimer’s Research UK. “This includes getting our hearing checked. Research has shown that people with unaddressed hearing loss are five times more likely to develop dementia than those without hearing loss.

“It is essential that any perceived barriers to getting a hearing check are minimised, ensuring that people can access one at every opportunity,” Dr Mitchell says. “We believe that integrating a hearing check within the NHS Health Check, freely available for the over-40s in England, is one potential way to do this.”

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