Cerumen removal is taking off in Australia with audiology at the forefront. As more practitioners train in ear wax removal and clinics offer the service, it’s not only providing a short-term revenue boost, but is another way of spreading key health messages and seeing more clients for future hearing needs.
Perth audiologist Mr Sam Mitchell took a risk to open a full-time cerumen removal business. He now runs two clinics which are open seven days a week to cater for demand.
Mitchell opened Clear Ears Perth in 2022 after seeing patients in hospitals who had waited years for an ear wax clean from overworked ENT surgeons.
Previously, for seven years he worked in independent audiology clinics mainly focusing on adult rehabilitation. That was until 2020 when he began working in major public hospitals in Perth, gaining experience in hearing implants and conducting assessments for ENT clinics.
“I had some experience with micro-suction but I routinely used curettage in adult rehabilitation. It was a skill I was confident I could do and felt there was limited access to this service in Perth,” he says.
“I noticed patients who had been waiting several years to be seen by an ENT and who would have benefitted from simple cerumen removal in a community setting, while helping to relieve some pressure on ENT clinics. I started cerumen removal as a side hustle and was surprised by the demand and overwhelmed by the appreciation for the service being available.
“It was difficult to leave my hospital job as I enjoyed the hearing implant work and had worked hard to secure a full-time contract. I had to choose between a secure public service job and pursuing Clear Ears Perth full time. It was a risk and also scary at the time as my wife had just given birth to our third daughter.”
Mitchell started seeing patients after hours and on weekends at one of his clinics in Balcatta and did home visits. He hired staff and was managing the clinic while still working at the hospitals. “Once I found a suitable space I opened the second clinic in a suburb that people south of the river could access easier as patients were travelling a long way to Balcatta in the north so it made sense,” he recalls.
He realised there was demand for weekend treatments from people working during the week and had staff who were studying or working in other jobs who wanted weekend work. He now employs six audiologists across both clinics.
“When your ear is blocked with ear wax, it’s distressing and you want it resolved ASAP,” MItchell says. “This can happen over the weekend but having the service accessible every day can prevent blocked ears becoming infected and avoids these patients going to the emergency department.”
Microsuction the ‘gold standard’
Equipment includes a converged binocular optical system which is like looking through a microscope. However, it’s worn on the head, allowing depth perception and both eyes to clearly see deep into the ear. Being head-worn allows the audiologist to be mobile, instead of having to constantly adjust the position of a microscope.
“Micro-suction is more comfortable for the patient compared to curette, forceps or ear hook. The ear canal is very sensitive, especially the deeper you get and micro-suction can be used without having to touch the canal wall,” Mitchell explains.
“Each case is different but generally micro-suction is safer and the best tolerated method; manual cerumen removal using micro-suction is the gold standard compared to ear irrigation which carries more risks.”
The business extended to paediatrics due to demand from parents asking about the safest way to remove ear wax for their children.
“We had limited the age to eight years and over but are now seeing four-year-olds. There was demand and as all clinicians are highly experienced in the procedure, we thought it was our duty of care to offer the service,” Mitchell says.
“Like any other skill, the more exposure to different cases and the more you carry out the procedure, the better you will get at it. It’s important you’re not complacent when doing cerumen removal as consequences of it being done incorrectly are much greater than when doing a hearing test or hearing aid fitting. Always err on the side of caution.”
Mitchell says GPs are offering micro-suction but irrigation is still commonplace. “The UK and New Zealand are ahead of Australia in this space and ear irrigation hasn’t been used for several years.
“I think most audiologists who are doing cerumen removal are mainly using it as a complementary service alongside fitting hearing aids,” he says.
“Along with ENTs, audiologists are best suited to this work and that’s why I decided to only hire audiologists. However, in my experience there have been many audiologists who realise they are not suited to the role as it requires dexterity and patience to become proficient in the skill and it’s not easy for everyone to pick up.”
Between them, his staff have done every course on cerumen removal offered through CPD and are looking at overseas training to continue to improve services and knowledge. “There needs to be a more advanced course on cerumen removal in Australia as some of the current courses I feel are substandard and only provide the basics,” he adds.
Blogs on his website educate the public. “We have a duty of care to provide this information which can prevent people from doing things that could damage their ear health. They shouldn’t need to pay for this advice,” he says.
Elsewhere, in Adelaide, audiologist Ms Alicia Littledyke from Hearing SA achieved cerumen removal certification while working at Bloom Hearing and is now offering the service at Hearing SA.
“It’s maybe 30% of our business at two Hearing SA clinics. On my busiest day I treated seven people for ear wax,” she says.
“Wax removals are straightforward, simple and with the right maintenance, can be done without a lot of follow-up. Removing wax that was impacting hearing aids and offering the service to people outside our client base is popular and allows us to build another side of the business.
“Cerumen removal wasn’t something that was taught in the standard audiology course. When I went to university 12 years ago, we were told audiologists don’t touch ear wax – that’s something you leave for GPs and ENTs – so it’s changed over the past 10 years.
“Not only has there been more demand – I think more people understand wax and the impact it can have.”
Littledyke says GPs have been confident to perform cerumen removal, but she’s been told by many that syringing or water flushing – which can lead to burst ear-drums or infection – was one of the biggest causes of malpractice complaints. Many have stopped for insurance purposes, she adds.
“Trying to get into an ENT is difficult in terms of waiting times, more steps, referrals and costs,” she says. “Audiologists are saying to GPs and ENTs we’re here to bridge the gap and we are specialists in ears. We look at them all day, every day, can be trained and have the right equipment to offer that service and take pressure off doctors and surgeons.”
Increased air travel
Littledyke is increasingly seeing younger people coming in for cerumen removal and more musicians. While wearing earbuds, in-ear monitors and headphones can compact ear wax, she believes extra demand relates more to increased understanding. But she also believes a big factor is more air travel which can make pressure in the ears uncomfortable.
“Especially if going overseas or on longer flights, having a big build-up of wax with additional air pressure can cause a lot of discomfort,” she adds.
“Swimming is another factor as swimming softens wax. Wax might have been building up for ages but then instantaneously something happens and being able to offer a service where people can be seen within a short period and receive instant relief is great.”
Dry vacuum micro-suction has been passed down from ENTs, and learning to perform wax removal with this is a big part of training programs, she adds.
“It’s generally very safe and effective with minimal risks because it’s a dry procedure. We’re not putting any water in the ear so if they’re at risk of infections or they’ve had previous damage, we’re not putting them at further risk. It’s gentle and is done within 30 minutes.”
Micro-suction machines cost about $2,000 to $2,500, and other accessories include probes to get into ear canals of different shapes and sizes, she adds.
Several universities and companies offer training courses including theory and practical components. Audiology associations sometimes offer cerumen workshops at conferences which she says are always popular.
“It’s an evolving skill that many clients can benefit from and audiologists can add to their scope-of-practice, starting with removing wax for patients with hearing aids to ensure they have maximum hearing, and then adding it as a service for any patient,” she says.
Hearing SA sees both types from age 16 up. “We have a mix of regular hearing aid clients who we’re managing wax for, but the biggest proportion are people of all ages who don’t have hearing aids.
“It’s good from a business viewpoint as it can bring clients in who may not normally have walked in the door. Wax removal sometimes fixes their hearing concerns but if wax comes out and hearing doesn’t change, it’s an opportunity to discuss ear health or hearing concerns, educate them and potentially get them back for a hearing test,” she says.
“You can build that relationship from a gentle approach of looking at wax and it can be a great gateway.”
Social media including video posts of ear wax removal have also contributed to increased awareness and growth in demand. Many clients like to look through a visual otoscope to see what is being removed which is helpful for education particularly if there’s a fungal infection or redness. This educates on preventing re-infection.
A new portable magnified vision system used overseas enables wider scope and videos what is happening during the procedure, enabling patients to watch on a live monitor. It also enlarges the view for audiologists.
Littledyke discusses management options with patients including softening options from pharmacies, and stocks several sprays. Some need regular maintenance treatments every six to 12 months. She sets them up to use a spray weekly or monthly to soften wax and move it down the ear canal, instead of allowing it to dry out and build up, leading to blocked ears.
She encourages other practices to initiate cerumen removal but recommends a certification course.
“When you first start it can be quite scary to work the equipment, making sure you’re doing it in a safe and pain-free way and avoiding risk,” she says. “Do practise sessions on staff or relatives to build skills. Be informed of options and share the word with GPs and pharmacists so they can refer patients to you.
“We are in a shopping centre and have a good relationship with our pharmacists; we send them people and they send us people. If GPs know it’s for an ear health problem, and they’re booked out, they send the patient to us. We have a sign out the front about wax removal and on quiet days advertise walk-ins; it’s an easy way to fill gaps.”
From a work satisfaction perspective, cerumen removal breaks up the day by providing a change to hearing testing and hearing aid fitting.
“If you’ve had a few long in-depth, complex appointments, this is quite a light session, a nice appointment where you get a nice win resolved quickly,” Littledyke adds.
Complex or risky case are, of course, referred to an ENT surgeon.
She says the next step is more portable equipment to serve patients who cannot travel to a clinic. “There needs to be more services though, more audiologists offering it,” Littledyke adds.
Knox Audiology also expanding
As chief operating officer of Knox Audiology – with four Melbourne clinics – Ms Jane Louey says cerumen removal is performed by a single audiologist at its Wantirna clinic, comprising 3% of appointments this year.
In July the rest of the team received training including audiologist Ms Vanessa Zhang, and the business started advertising the service more. It uses micro-suction and curettage and is receiving referrals from GPs.
“I recommend wax removal because it can affect hearing test results. If a person comes in with hearing loss but they have an ear full of wax we can fix the issue almost immediately if it’s a wax issue,” Zhang says. “I’ve seen audiologists who haven’t done a cerumen course refer to another audiologist or GP so that’s another reason audiologists should train in wax removal as they can then do a hearing test straight away.
“Wax naturally migrates out of the ear by itself but when there’s obstacles like a hearing aid, it can stop halfway as hearing aids can make it harder for wax to naturally come out. Genetics and some foods may affect wax, so promoting a heathy, well-balanced diet can help maintain appropriate ear wax production.”
The Global Ear Clean Spray Sales Market Report 2024 says the market is witnessing significant growth, driven by rising awareness of ear hygiene and increasing incidence of ear-related conditions. Cerumen removal services will only grow in Australia and audiologists are the ideal profession to seize the opportunity.
Audiologists call for Medicare and health insurance rebates for cerumen removal
Several audiologists who practise cerumen removal believe Medicare and health insurance rebates should apply for patients who seek ear wax removal from audiologists.
Audiology Australia (AudA) has advocated actively in this space and continues to push for audiologists to have rebates for cerumen removal. “It is something we support and will continue to raise with government as appropriate,” AudA says.
Audiologist Mr Sam Mitchell, owner of Clear Ears Perth, said he believed the government should extend the Medicare rebate from GPs to audiologists and health insurance should come to the party and allow members to claim.
“It’s disappointing the government is not acknowledging the positive impact community-based cerumen removal can have on people’s ear health,” he says. “With a Medicare rebate it would allow wax removal to be more affordable and increase accessibility.”
One of Australia’s first adopters of microsuction, Mr Keith Chittleborough from Melbourne’s Earman Audiology, told HPA: “Given that cerumen removal is not a patient priority for ENTs, shifting the burden of expert wax removal from ENTs to specialist audiologists through a change in Medicare funding pathways could be advantageous to ENTs, audiologists, and patients.”
Mitchell also believes the Medicare rebate should extend to nurses and further extend for GPs. In 2020, Medicare removed the rebate for GPs for removal of uncomplicated wax in the absence of other ear disorders, only allowing it if a GP considered it medically necessary.
“It’s gone backwards as the MBS rebate only applies to GPs if there’s pathology that requires them to use an operating microscope and not for simple cerumen removal,” Mitchell says. “They’re now forced to use their consultation rebate which doesn’t encourage GPs to offer this time-consuming service.”
However, he believes GPs should refer to audiologists. “Audiologists need to provide more services beyond hearing aid fittings and sales to change the perception of audiology with other professions and the wider community,” he adds.
Chief operating officer of Knox Audiology in Melbourne, audiologist Ms Jane Louey says: “The first question often asked by patients when enquiring about wax removal is, ‘Do I get anything back from Medicare? Medicare rebates would make the service more accessible and could make it more appealing for GPs to refer to audiologists, especially GPs who would prefer not to do cerumen removal given the option.”
Hearing SA senior audiologist, Ms Alicia Littledyke, also backs Medicare rebates and adds: “Some private health insurance companies offer rebates for an audio consult. Our clinic is working with funds to determine if educating clients, checking their ear health and doing wax removal qualifies as an audio consult.”
Chittleborough, a trainer for Ear Health Courses and contractor to ENT practices, recommends a high gold-standard of medical microscope and an ENT chair, digital otoscopy shared with the patient pre- and post-service, wax removal via all methods (microsuction, curette and, when indicated, indirect water) and the audiologist having thorough knowledge of complicating pathologies.
He suggests 30 minutes dedicated time and a $150 charge. “As audiologists we should not underestimate the value of our expertise,” he says. “An ENT may have a set $230 consult fee ($85 Medicare rebate) plus ear toilet $145 (with $106 rebate using item 41647 when cerumen removal with operating microscope or endoscope is clinically necessary) leaving the patient a minimum $185 out of pocket plus long wait times.”
Chittleborough said, in an AudA blog, earlier this year: “I don’t go six months without treating a patient whose sudden sensorineural hearing loss was sat on by a GP, who gave drops for ear wax or a nasal spray, and who didn’t see an audiologist for weeks or months later when the theorised critical window for treatment via oral corticosteroids, or trans-tympanic membrane injection, was lost.
“Ten years ago, virtually no audiology practice was doing microsuction earwax removal. I’d like to see the word ‘audiologist’ become synonymous with ear expertise; all performing wax removal and first point-of-call when a patient thinks ‘what’s up with my ears?’
“I’d like to see a referral funding pathway shakeup, with tweaks like the capacity for audiologists to refer directly to ENTs and Medicare rebates for diagnostic audiology without the redundant GP referral.”
Chittleborough said in the blog that nurses were creating businesses for ear cleaning. “Shouldn’t this be the domain of audiologists? What’s the point of our expensive Masters degree with pathology modules if we refer patients to others, sometimes risking potential dangers of syringing, to manage the inevitability of cerumen?”
Mitchell says: “Along with ENTs, audiologists are best suited to this work and that’s why I decided to only hire audiologists at our clinics,” adding there needs to be a more advanced course in Australia.