Now let's introduce our final speaker, Daniel Pacioretty. A graduate from San Francisco State University with a master's degree in communication disorders, Daniel Pacioretty has more than 40 years of experience as an audiologist, educator, administrator, and researcher. He has worked in hospitals, public health clinics, education, and the hearing aid manufacturing industry. Dan has provided hearing healthcare services and developed related programs for deaf and hard of hearing individuals of all ages with a special focus on school-aged children and older adults. He has conducted and published research, recently acting as a research audiologist for a study looking at older adults' ability to benefit from advanced hearing technology in noisy environments. Dan participated in the development of the World Health Organization's Assistive Product Specifications and How to Use Them guide that was published in 2021 with contributions to the sections on hearing aids and FM systems. During the past decade, Dan has provided mentorships for audiologists and hearing instrument practitioners in British Columbia towards certification in cerumen management. He has conducted workshops that provide hands-on training in cerumen removal techniques. Along with colleagues from the Pacific Audiology Group, Dan co-authored the development of a comprehensive cerumen management online course. Dan is an active member of Speech and Hearing BC and Speech and Audiology Canada and holds SAC certification in audiology. And now for our final session, Dan. Great, thank you, Sierra, for the introduction. And I just need to bring up my share screen here for everyone. And we'll get this last session started. There we go. Okay, great to be able to speak to my fellow Canadians this afternoon about an area that I feel quite patient about because I feel it's something that's really underserved in our hearing healthcare sector. Back in 2021, for the Canadian Audiologist Online Journal, I wrote an article about cerumen management as being one of hearing healthcare's neglected services. And it's nice to also hear today that there are a couple of other topics, tinnitus and oral rehabilitation, which I also feel are a bit neglected by our field in areas where I think we can really increase our presence, our participation in hearing healthcare and keep our relevance in this field of hearing services. So in this talk, full disclosure here, I did help build a online cerumen management course. And it is something I will talk to a little bit about in this presentation. And so if you were to choose to purchase that online course, I will benefit financially from that purchase. You will be making a contribution to the Dan Pacioretty Retirement Travel Fund. I have retired from being an audiologist as far as clinical, no longer hold the license in British Columbia to provide clinical services, but I still feel that I have an opportunity to share knowledge, experience, and can do some consulting. Well, let's go ahead here and get to our first slide. Got a lot of topics to cover off in this short session, this short amount of time that I have with you, but I will do my best to comment and talk about each of these areas because I think it's important for us first to realize the need for cerumen management services within the general population and our unique opportunity to be positioned to provide that service to individuals who are seeking good, competent cerumen management services and how this can really benefit our clinical business, our patient flow, and also our relationships within the hearing healthcare sector. So let's go ahead and get started here with this first slide about the World Health Organization. Don't know if you're familiar with this report on hearing that was released in 2021. It's available on their website, free of charge to download. And in this document that the World Health Organization released, they were basically wanting to provide an outline. So they were using this acronym HEARING to outline a package of recommended key public health initiatives to address hearing loss across the lifespan, focusing on prevention and early intervention. And so we're not gonna be able to talk about each of these different sections. I'm gonna just focus in on the one that you see highlighted there, the E for ear disease prevention and management. So the goal within this heading on this World Health Organization report is through this ear disease prevention and management is to prevent and treat ear diseases at the earliest possible stage to avoid associated hearing loss and other complications. And then they give you some additional information under this objective as to what this includes. So they're wanting to address common ear diseases through prevention. So having good ear hearing care practices, early identification at a community level, primary level through a trained workforce, and also to take intervention, medical, surgical is what they're talking about here at a primary, secondary, and tertiary level. And the example that they're talking about is chronic otitis media. But I see that cerumen management services would absolutely fit within this category on this World Health Organization chart. So when we're looking at this WHO report on hearing, on page 19 is the one and only time that you see the word cerumen mentioned. But they do mention it as being a factor that does impact individuals across the lifespan. And then under this category of cerumen, they talk about its influence on hearing. I don't think they go quite far enough because all they talk about here is influence on hearing is that it may lead to a five to 10 dB conductive hearing loss for complete impaction. And of course, we know from our knowledge and experiences that cerumen can have other impacts on an individual's health as well as their cognitive abilities. So when you have impacted cerumen, you are running a higher risk of infection of the ear. You can also have issues with pain, discomfort from the cerumen impaction, as well as impacts on your balance. And we've heard earlier today, it can impact and cause tinnitus. So the influence on hearing is more than just a conductive hearing loss. And of course, as hearing instrument practitioners, you know, cerumen can really mess up a lot of the things that you're trying to do. And especially when we're fitting hearing aids, that's the number one reason hearing aids go in for repair is because of cerumen that's gotten into the receivers, gotten into the custom product that you may have fit. Under important considerations, they just talk about the fact that cerumen can be, impaction can be made worse by using Q-tips, no argument there. But what's more important about this category is where the World Health Organization gives us some statistics on what is the prevalence of cerumen impaction in the general population. And you're going to see there on the slide is that the prevalence of impaction is anywhere from seven to 35% across the lifespan with the highest percentage of prevalence in the older adult population. So young children, they can have problems with cerumen. Younger adults generally don't have as much of an issue with cerumen, but as we age, that's where we'll see more and more impactions occurring. And there's many reasons for that. We don't have time to go into those, that's all covered in our course. But that one number there, that 57% of older adults, I know that comes from a study where they were looking at the number of older adults who live in residence, who live in seniors care facilities, intermediate care facilities, and that's where they found that over 50% of those individuals had cerumen impaction. And of course, that can have some really negative effects on the individuals if it's not first identified and then remedied. Now, when we talk about cerumen impaction, we're not always talking about a complete impaction, which it seems to be what the World Health Organization is talking about in their report. I like the definition that is used by the American Academy of Otolaryngology, where cerumen impaction can be an accumulation of cerumen that causes some form of a symptom, but also prevents assessment of the ear or a combination. So something that's a little bit more broad, something that isn't saying that it has to be a complete occlusion, that it can be a partial occlusion, but it will still cause symptoms or cause issues with examination and treatment. Unfortunately, when people do have cerumen impaction and they go out into the community looking for services to address it, this is where they usually run into some issues in trying to access proper cerumen management. By proper, I mean by a professional who's knowledgeable and well-trained in how to address cerumen impactions. So this lack of services that are available in our communities, and this is global, this is not just something that's occurring in the developing world, but also in the first world, this increases wait times for services. So people are often having to run around town looking for somebody who will look after their cerumen or waiting for that referral to an ENT to get the cerumen addressed. So we see real increased wait times in services. This will also increase incidence of hearing loss. So this goes back to the World Health Organization's call to reduce the impact of hearing loss. And so this is something that if individuals do have complete impaction, they will have that conductive hearing loss that is not being addressed or being addressed in a timely fashion. Increased incidence of hearing aid malfunction, I already touched on that. Increased incidence of false hearing test results. This can really play havoc on the accuracy of your hearing tests that you're doing in your clinics. Increased incidence of misdiagnosis of cognitive ability. I think Doug touched on this earlier today where if individuals have hearing loss and it's not known that they have hearing issues, they may be judged to have cognitive impairment that really maybe isn't there or isn't as severe as it might be manifesting itself. So incidence also increase of injury due to lack of training. So this is where individuals will go find somebody who says they'll take care of their cerumen but that individual really doesn't have all the proper tools or knowledge and can actually cause a significant injury. I've got a case study I'll share with you. And then we also have the incidence where people have gone to a drugstore and gotten one of those cerumen management kits off the shelf as a recommendation by the pharmacist. They take it home, they don't use it properly, and they can cause injury to themselves. And we'll see some actual stats that are now available on that from the UK. Now, in the United Kingdom, they have the National Health Service. And up to just about a year ago, the National Health Service provided cerumen management services where they would pay for those services. So individuals could go to their family physician, health clinic, get cerumen management taken care of, whatever their issue was, and that was paid for by the National Health Service. Well, they were looking for cost savings, so they thought this is probably an area that made sense to reduce their costs. So they eliminated paying for cerumen management services through the National Health Service. And so this meant people now had to find their own way to look for an individual or a person who could help them with their hearing problem brought on by the cerumen. So the University of Manchester undertook a survey, a research survey, and they just published this in 2022, it was in November. And they were looking at individuals who had accessed the NHS's cerumen management program or funding to find out what this impact was on them having this service now removed. So one of the areas that they wanted to look at, well, why did you feel you needed to go to NHS to have the cerumen removed? And on the 500 individuals that they surveyed, 90% of the individuals reported that they were having at least a moderately bothersome problem hearing. And so this is, again, coming back to the World Health Organization, we're trying to eliminate that and prevent that from occurring. Here now is a situation brought on by this lack of funding where these individuals have been going for services now no longer able to, 90% have reported that they had less, they were, excuse me, difficulty hearing at least at a moderate level. 60% of those individuals reported that it was an extremely bothersome issue, and that's why they were wanting to go and have the service performed. Of these individuals, 80% reported immediate improvement after cerumen removal. So Manchester's survey that they were trying to show the NHS was that you have cut a very valuable service, and one that people really appreciated, and one that people got immediate improvement from when they could access the funding. They also showed that there were some other side effects that people were having because of the lack of the ability to hear, which was causing problems with their enjoyment of TV, their ability to monitor environmental sounds, and that there were those reported additional symptoms that we know can occur where people were having discomfort and people were experiencing increases in tinnitus. So this lack of services, we know that the demand from the numbers from the World Health Organization on the prevalence lag, the services lag, the demand. Primarily, physicians and nurses are doing most of the cerumen management in North America, although their training is very limited. They're often not trained in best practices for cerumen management. Typically, it's irrigation for everything. When you go to see the doctor, and we know that irrigation is not appropriate for many people who have cerumen impaction, and that also we're seeing this erosion of the ability for people to go and have, if they have universal healthcare, to have cerumen covered under their plans. And we know this is just something that happened in Ontario in the last couple of years, where cerumen has been delisted or the funding cut significantly so that if individuals went to their primary care physician that if a physician did cerumen management, they were not going to get paid for from the health system. Only if you went to see an ENT was it going to be covered. Also, we know that in some of the areas we have that the scope of practice for cerumen management is not included for all hearing instrument practitioners. Across Canada, that's changing. I think we've got it in almost all the provinces now where cerumen management is in the scope of practice. The one province that I believe it's not is Manitoba. At least that's the last time I checked, and hopefully that's something that will change. Well, here's the issue that we also have, is that we have this cerumen management in the scope of practice across Canada for audiologists and for most hearing instrument practitioners. And yet there's very little training available or training that's done for us to be able to acquire the knowledge and the skills to be able to provide cerumen management. So I know that in Canada, there isn't any of the hearing instrument practitioner programs that provide cerumen management. In fact, most of the university programs in Canada for audiologists do not include cerumen management as part of their curriculum or provide any training. So we have this real lack of training for something that is in our scope that we should be able to do. And so often clinicians are having to seek this training and supervision for training or practicums in cerumen management after they have graduated and entered the field and now are busy in their clinics trying to meet the demands of their schedule. If we look at the training of other healthcare providers, we can see that nurses, again, or nurses and doctors are the ones who do most of it, and yet they receive little or no formal training in cerumen management. We've talked to a number of nursing programs, administrators, and they say, no, we don't teach cerumen management in our courses. We know that the doctors will show the nurses how to do it if they want them to do it in their offices. We talked to the doctors and the doctors tell us that they've received little or no training, formal training on cerumen management. In fact, what they were told is you just make sure when you use the irrigator that you direct the stream of water up to the ear canal, wall and not down the ear onto the eardrum because you might hurt the person. And that's about the extent of their training. So irrigation is what they use almost universally. ENTs, of course, we know they've got a lot of knowledge and training in cerumen removal, cerumen management. But these guys are spending nine years minimum to acquire surgical skills to do very micro surgeries. And yet this is what we're finding that ENTs are being flooded with people needing cerumen management, where it could have been taken care of much, much earlier and didn't need to involve their level of skill and knowledge. Here's a case study I'll share with you that happened just in the last year. I was at the time licensed in BC and was providing mentorship to an audiologist who was working towards certification for cerumen management. In BC, you have to hold an advanced certification before you can do any kind of cerumen management as an audiologist or as a hearing instrument practitioner. So I was in this clinic working with this audiologist and we had a whole day lined up of individuals to come in so that I could do some demonstrations, I could do the mentorship and do the supervision of them doing extractions to meet the requirements for the certification. And we had a couple of people who no-showed and during this time when we were sitting there waiting, another audiologist in the clinic who was not certified yet for cerumen popped their head and they said, ah, I've got a lady that just come in for a hearing test, she's got occlusion of wax in her left ear, would you be able to see her? And we said, well, absolutely, have her come in. So she comes in, sits down, we do our case history, we do our informed consent and we learned that she's had an ongoing issue with her left ear, not the right ear, the left ear, where she's constantly building up wax and having to have it removed. And she had always gone to a medical clinic, a walk-in clinic where they would syringe her ears and clear out the wax. And she told us that the last time she did this, she hadn't gone back to have the wax removed for well over a year. Why? Because the last time she had the irrigation done, it was so very painful. And so right immediately there was a red flag for me, so very painful. Okay, what happened? So we look in her ear and sure enough, it's occluded. This is not her ear, but it looked very much like this. And so we know that we are gonna need to do something to get that wax out. We cannot use irrigation because we do not know the status of the tympanic membrane behind that full occlusion. And so we were using microsuction and so that was no problem. The audiologist went in with the suction tip, went to the block and realized that it was fairly soft and looked like it was moving as the one cohesive piece. And so they were going to be able to extract that cerumen relatively easy. So with a little bit of rocking movement of the cerumen plug, sure enough, it started to break free and come out as one large piece of wax. And as that was brought out, the individual immediately noticed an improvement in her hearing. But the main thing she wanted to let the audiologist know was to turn and listen, that didn't hurt at all. So of course, as good practice is, once you've removed the cerumen, you're going to get your otoscope, you're gonna go back in and examine the ear, look at the eardrum, make sure everything's clear. And when the audiologist did this, there was this little bit of a pause. And I thought, okay, they're seeing something in there. And it turned to me, Dan, would you like to take a look in this ear as well? Absolutely. I look in the ear and there is this huge perforation of the tympanic membrane. Whoever did her irrigation that over a year ago, did it improperly, versed the eardrum, didn't even look to see what had happened. And so this woman was living with this perforation and this accumulating wax until she came in to see us. Well, of course, this is now a medical referral. Off she goes to see an ENT because she's got a perforation. Probably is gonna need some form of a tympanic membrane patch because it obviously had not healed on its own. Okay. So we've got this real lack of training and skill out there that we need to address. And so this is where we're wanting to look at training. And this is where there are course that we developed addresses as a comprehensive cerumen management course, but it is just the knowledge. You still are gonna have to acquire some form of skill or practicum I recommend for individuals. And we'll talk a little bit more about that later. But there is a burden, not just to the client, but there is a burden to our primary healthcare system. So these numbers are out of the US. And so in the US, some recent articles that were published, they looked back and they saw that the number of individuals who were going to emergency rooms for cerumen impaction was huge. In 2009 and 2011, over 310,000 individuals went to emergency rooms for cerumen impactions. In 2012, ENTs billing Medicare, billed Medicare for 1.3 million impactions at a cost of $46.8 million. So this is something that can be a huge burden on the healthcare system. And also where individuals are going to, are accessing our emergency rooms or accessing ENTs at a very high level, when most of that cerumen impaction probably could have been better addressed or addressed earlier through having other healthcare providers skilled and knowledgeable in doing removals. We have the same situation in Canada. We don't have numbers like we have from the US, but in talking to GPs and talking to ER doctors, we know that the story is pretty much the same in Canada as it is in the US. So now this slide here pertains to the burden to the hearing healthcare professional, hearing instrument practitioners, audiologists. If you are providing cerumen management services in your clinic, this slide really does not apply to you. But if you are not, then I feel that the points on this slide do apply to you. First of all, for the majority of us, it is in our scope of practice. And if you're not knowledgeable and trained, then you're unable to perform a skill that is within your scope of practice. This also then means that you're unable to meet all the patient's needs, that you're going to need to refer people out of your clinic to get the cerumen removed before you can complete a hearing test, before you can do that hearing aid fitting. And this really does risk you losing that patient to another provider or just losing that individual to follow up. They never come back. This does impact your clinic schedules. You're going to have to do rescheduling of these individuals, maybe more than one time, because the wax wasn't removed properly wherever they went. And this is going to cause a lot of delays also in your treatments. It can impact your testing results if you're saying, well, you know, I was taught that if there's some cerumen, but there's a hole in that cerumen in there, I could see that there's a way for sounds to get into the eardrum. That person can still hear. And so I probably can still do my hearing test. Well, back in 1964, there was research that showed that when you have large amounts of cerumen in the ear canal, you're changing the acoustics of the ear canal. And therefore you will have unreliable air conduction, bone conduction test results as a result of that cerumen. So we really want to have it out. We want that ear as clear as possible when we're going to be doing a hearing test. We already talked about high rates of hearing aid repairs. If you're not addressing people's cerumen buildup, they're going to be coming in on a regular basis because their hearing aid is now blocked, clogged, needs to be cleaned. If you can't clean it, you're going to have to send it to the manufacturer. You tell the person, you know, you really need to get that wax taken out of the ear. Yeah, yeah, I tried to find somebody, but I can't find anywhere to go. So I'm doing the best that I can, but here they come in again to your clinic time and time again with their hearing aid needing repairs because of the cerumen. And also if you're not doing cerumen management, you are losing the ability to have lead generation and create additional revenue for your clinic. Okay. The other thing that happens when you don't provide cerumen services and it's in your scope and you are a hearing healthcare provider is that it reduces your standing in the medical community. So this was a little email that was shared to us, Pacific Audiology Group, by a clinician who was on the fence about getting certified in BC to provide cerumen services. They were waffling. Yeah, I should do it, but I just don't have the time. It's really difficult to get it. It takes a lot of effort. I should do it, but I just haven't got around to it. Well, they got this really terse note back from a physician when they sent a report about the hearing test that they had completed on this individual. And they had mentioned in the report that the individual had occluding cerumen. And so this physician wrote back, am I to understand you don't remove cerumen? Probably should learn how. It's pretty simple. There's a pump bottle that does it safely through medical supply places like BC Stevens. At Townsite, I had my secretaries doing it. It was so safe and easy. Okay, that's scary right there. This doctor would have their secretaries doing cerumen management. Anyway, at Wallace, we now have a nurse who can. You can advise a patient to call or book an appointment with the nurse to have that done if you're not able, willing. Okay, so when we are having these lack of services and access points for people to get cerumen taken care of, we've created a dangerous situation. In Ontario, we know OHIP reduced cerumen removal. So now where do people go to get that done? In the UK, the National Health Service cut it. Where do people go to get their cerumen done? Well, the National Institute, Royal, sorry, Royal Institute for Deaf People in the UK did a survey after the money was cut from NHS. And they asked these individuals, 1,400 individuals, now that you can no longer access NHS for cerumen, what are you doing? Well, most people were doing self-removal. And so they found from their survey that the methods described for self-removal were, and this should really scare you, so it did me when I read this report, that they were using hair clips, paper clips, toothpicks, cotton buds, and ear candles to remove the cerumen. How good were they doing self-removal? Well, 20% said that their problems went away when they did their self-removal. 55% said they noticed no change, so nothing really improved in their condition. And 10% said that their symptoms actually got worse or they caused themselves injury, which required medical attention. So NHS, you thought you were saving money? You weren't. These people now need a much greater intervention medically than having a little bit of cerumen taken out of their ear. What are the benefits for offering cerumen services? Well, there's benefits to the client. And that just means that they're not going to have as much risk in getting the removal if it's done safely and by somebody who's competent. It's going to address some of those World Health Organization calls to reduce the impairment or the potential impairment of neglecting services for people with hearing loss. And so we know it's going to reduce infections, impaired hearing, it's going to reduce the repair rates for hearing aids. So there is great benefit for the individuals that we serve to have a place to go for cerumen management services. For the professional, there is, again, going back to that slide where we showed that if you're doing cerumen management services as part of your clinical services, you don't need to have people referred out to have this done. You're going to be able to take care of the vast majority of individuals yourself. There will be an occasional person that needs a higher level of medical intervention, that needs an ENT skills, but the vast majority, you will be able to address successfully. You will create additional revenue or the opportunity to. You're going to be able to provide more timely care, better continuation of care. You're going to be working to your full scope of practice. And this will, I feel, increase your reputation within the hearing healthcare community because you are now providing an additional service that a lot of doctors and nurses don't want to be doing. And as I already said earlier, don't really have the knowledge and skills to do best practice. For the healthcare system, yes, we can reduce the number of people going to GPs, ENTs, and ERs for cerumen. We're going to be giving people more places they can access good cerumen services. So what do you need to do to get started? How to get started in cerumen management services? Well, first of all, you do have to complete a training course. And we recommend mentorship or supervision if it's available to you. You've already got a lot of, you got a good skill set for working in the ear canal. You're already doing a lot of things within the ear canal. You know about the ear canal sensitivity, all the bends. So you've already well on your way to being able to provide good quality cerumen management services. But it's still, I think, beneficial to be able to watch somebody do it or have somebody mentor you, if that's possible, if you've got that availability. You're going to need to look at what kind of equipment you need to purchase. And this is going to be based on what methods you decide to use in your clinic. I don't think you can get away with just using one form of cerumen management. Usually you need two. One form of cerumen management will not always address all the people's needs. And so you maybe have to look at equipment for irrigation, manual removal, or suction. All three would be great, but sometimes the budget won't allow, but at least have two forms of cerumen removal at your disposal. You're going to have to develop some clinical protocols. So you will need to develop an informed consent form that addresses cerumen extraction. And you also have to do a little bit of additional updating for your infection control. Both of these are covered in our course. We don't have time to go into those today. You also need to decide how you're going to promote your management services. Are you going to promote directly to just your clients, or do you want to promote this out to the general public? Something that I would encourage because it's a way to really bring people to your clinic who otherwise would not come across your threshold. And when you do this, you are going to be able to then offer them additional services past the cerumen management, or at least for them to learn that you have other services that they could access or their friends could. If you're going to intermediate care facilities where seniors live, we know that's the greatest percentage of people with cerumen impaction. There's an opportunity to meet with the directors of care and see if there's the possibility of providing cerumen management services in their facilities, something that you can charge for, but also use as, again, lead generation. You definitely want to make sure that local physicians know that you have the ability to do cerumen management. They will refer. They don't want to do this by and large. They would rather someone else looks after it because they don't have the skills or knowledge. They don't have anything really in their clinics other than irrigation typically to address this. You might want to let other clinics know that you're doing cerumen that don't offer it. Can't imagine you're going to get many referrals from your competitors because they know that the person's probably not going to come back to them after the cerumen has been removed. What are the costs of getting started? So, well, you do have to budget some funds here. So you're going to have to budget for training and certification, additional insurance maybe. This is something you need to check with your insurance provider to make sure that you are covered for malpractice when doing cerumen removals. I checked with my provider when I was doing clinical work and they asked me a few questions. Is it in your scope of practice? Yes, it is. Are you trained to do cerumen? Yes, I am. I'm actually certified in BC to do advanced, I have the advanced certification in BC for cerumen removal. You're covered by your malpractice insurance, but you need to check that. You have to check for yourself what your coverage is. In Ontario, AHIP has a certification program for individuals and at the completion of the certification program for AHIP, they have an insurance program that you can access for malpractice coverage for cerumen removal. So they're looking after it for you. You're going to have some one-time costs. If you're going to look at a suction pump, you'll need to purchase that. It has to be a class two in Canada. And so there's only a couple of places, Walton Medical and Diatek, that I know have pumps that meet the class two for Health Canada. You'll need a really good headlight with magnification because you need to have very good view down the ear canal because you're in there with some implements, potentially working at pulling cerumen out gently, but with some force. And so you really need to have good lighting and magnification. So there could be additional costs there. If you're going to be doing stainless steel, you're going to be reusable curettes for manual extraction. There's a cost in that. Irrigation, if irrigation is the way you want to go, there are very simple hand pumps available, but there are also some new enclosed irrigation systems that I'll hopefully have time to highlight here in just a few minutes. You will need some furniture that you have to look at. Being able to adjust either the patient, the client or yourself so that you have eye, ear level focus, because that is critical if you're gonna be doing cerumen removals. Ongoing costs, if you go by our recommended way, which is disposable, because it just addresses a lot of the infection issues, you will have to look at the ongoing costs of buying the curettes, the irrigation tips. Softening agents is something you might wanna consider, purchasing and then selling in your clinic, rather than people going to the drugstore and seeing whatever's on the shelf. You offer a cerumen softening agent that you know works really well. Audiologist's Choice is one that's available here in Canada. You will probably have some increased costs in your infection control. So what are you going to do for funding this? What are your fees for service? Are you going to charge? I have some people say, well, no, I just do cerumen management for the people I'm fitting hearing aids, and it's all included in the fitting of the hearing aids. So, okay, that's interesting, but what happens when they come back a second time and the cerumen has built back up? Are you going to do cerumen management again at no charge? I think, really, this is a service that needs to have a fee attached to it for most situations. It is, again, as we talked earlier, a potential revenue-generating activity for you. You need to establish a fee schedule for cerumen services. You've invested a lot of time in training, in getting certified. You've purchased cerumen-specific equipment. And so clients will see this as a valued service. They won't really have a major issue with the fact that they're having to pay for this service because it's being done in a professional and a safe manner. We actually now have clinicians in Canada who are looking at developing this as their business, that they're providing cerumen services, and that's all they do is provide cerumen services. We've seen it in the UK, and we're seeing it in Canada, and I'm having a lot of people approach me about, do you think this is viable? Do you think I could build a business just removing cerumen? Based on the prevalence and the number of people needing services, absolutely, it is possible. It is something that could be done. Regulatory requirements here in Canada. Yeah, so this is all done provincially, and so you need to check with your regulators to see what the requirements are in order to provide cerumen management services. In the States, if we have anybody who's listening in from the US today, there's only about 12 states that allow hearing instrument practitioners to do cerumen management. I hope it's changing. It needs to change. We need to have more people skilled and knowledgeable or places for people to go to get cerumen managed, and so in Canada, the only place, again, as I said that I'm aware of, that it seems that hearing instrument practitioners are not allowed to do cerumen management is Manitoba. Could be wrong on that, and hopefully, if I'm correct, that that will change very soon, but you always have to look at who is your regulator, what are their requirements for you to be able to provide cerumen management services? As I said, Pacific Audiology has a cerumen management training course. It's self-paced, about four or five hours in duration. It is something that is accepted by a number of professional organizations. It's meeting the requirements for training and knowledge, and so at the end of the course, which you have access for one full year to complete it, one full year, and you can go back as many times as you want, you will get a certificate of completion that you can then present to whoever your regulator is to show that you have taken a comprehensive advanced cerumen course, and there's the web address for that, and it is IHS approved, so you can get continuing education, and if you do go and do that purchase of our course, online course, and you enter in the code IHS, you'll receive a 20% discount on the cost. Now, I see we're running a little bit over, so I'm not gonna go into the emerging technologies other than to let you know that cerumen is changing and that the tools that we had in the past, which made it rather difficult and not always satisfactory to provide cerumen services has changed greatly. We're seeing that people are realizing more needs to be done in cerumen, and so we're seeing a real influx of new technologies and new methods in order to extract cerumen from people's ears. Very quickly, these are things like the Ear-A-Way Pro. You can look them up on the internet. This is a disposable device. It's basically a little bit of an ear screw that you gently twist into the ear canal to grab ahold of the cerumen and pull out the cerumen in one chunk. This can greatly reduce the time you spend doing cerumen management. You can get it done as quickly as 30 seconds to have a complete extraction of the cerumen. New tools that are lighted for illumination down the ear canal and articulated so that you have a good, clear view of the cerumen that you might be working on manually. This is from Bionics. You can go to their website. They've got a long list of different cerumen management equipment that they've developed. This is one of those new irrigation systems. This is FDA-approved, not approved by Health Canada yet. Hopefully that'll change soon, but this is a closed system. These headphones are put on the individual's ear and the water is held in an upper chamber and it's injected into the ear to start to flush out the cerumen. And in the bottom portion, there's a little suction device that suctions all the water and cerumen back out into the lower chamber. I only had a chance to play with this once, very short period of time. Was impressed by its design and its functionality, but didn't have a chance to see how well it works in a clinic on a day-to-day basis. I've heard good things about it though. And the last slide here is, this is coming hopefully to Canada soon. This is the ability to have endoscopic cerumen management. These are both from the UK. They're the only places I've seen this, but really they have the ability now to put a little endoscopic camera with a bright light down the ear canal and then using an external monitor, a watch as they go in with a suction tip or with a curette to extract the cerumen. There's a fellow called the Ear Wax Whisperer, Neil Rattatar, and he's got a lot of YouTube videos that are fantastic to watch if you're into cerumen removal as I am. And you can watch all the different cases and all the ways that he addresses removal using that ClearWax Ear Scope. Okay, and with that, I'm out of time and I need to see if there's any questions for me. Dan, thank you so much for your wonderful presentation. We do have a few questions coming through already, so we'll jump right in. As a reminder to our attendees, you can enter your questions into the Q&A box on the bottom of your screen. We'll go ahead and take as many questions as we can in the time remaining. So Dan, our first question here is from Mary, and she's wondering if you know why the Hearing Instrument Practitioner Programs in Canada don't teach cerumen. Have you possibly had any conversations with them about that or have any awareness about why they don't teach it or if they might teach it in the future? Yeah, I think it's that cerumen was looked at as something that was not a primary focus for these programs. There's limited time that they have to teach individuals. We've reached out to all the programs, the university as well as the Hearing Instrument Practitioner Programs to ask about this, and they've just said, well, it was never built into the curriculum when they originally set up their programs, and to make any changes in their curriculum is very difficult to do. They're talking about it, but I haven't seen anybody move to actually putting it in the curriculum so that when you graduate, you are recognized as having knowledge and skills and ability to do cerumen removal. The University of British Columbia, we got an opportunity a couple of years ago to go in and actually do the very first training of the graduating class on cerumen management. We haven't been able to go back since, and so there's a program for Western Canada training audiologists. Unless the audiologist lands in a clinic where there is a clinician already providing cerumen, they're getting no exposure to getting no knowledge or experience, and for hearing instrument practitioners, it's pretty much the same thing. If you happen to land somewhere where somebody's doing it, wonderful, you're gonna get an opportunity to see it, maybe even try it under supervision, but there is no formal training going on, and it's something I think that really needs to change. Thank you very much. The next question here is from an anonymous attendee, and they state that time management with cerumen removal can become an issue since it takes 15 to 30 minutes to soften the wax, 15 minutes to take it out. Then maybe there isn't time to do the actual hearing evaluation, or they need to be rescheduled. Can you speak to, in the clinic environment on a day-to-day, how you would recommend somebody fit this into their schedule? And then the follow-up question there as well is, what, in your opinion, are the best wax softeners in the Canadian market that maybe would help alleviate some of that burden of time? Okay, that's a lot to talk about here, okay. Yeah, I think you have to build this into your clinic schedule, that you have dedicated time slots for cerumen management. So if somebody comes to your clinic and they have cerumen that can easily be removed, you could just take care of it right away. But if it is going to be more complex, where you're going to need them to go home and do a little bit of softening of the wax for you, and then have a scheduled time to come back to your clinic, then you're going to be able to get that done in a relatively quick period of time. I would think that a 15-minute block should be what's required. If you want to extend it further, you could, but working with clinics doing their mentorship and supervision, we were blocking 15 minutes to get the cerumen extraction done. What I had the clinicians do was to check, to prepare the individuals for that 15 minutes. So they had seen that the individual needed wax removed, they had scheduled them to come into the clinic for this wax day, and they had them do the softening. And doing the softening often would mean that we were getting that wax out very quickly and efficiently within that 15 minutes. Rarely did we have to extend over that. And if you've got the right tools, if you've got suction, you've got some good, like the Airway Pro system, you can get the wax out in minutes, just very quickly. Doesn't have to take a long time. Softeners, Audiologist's Choice is the one that I know that's available commercially. It's Health Canada approved. It's the one that I would recommend. Muricel is another one that often is used for this purpose. Individuals can use mineral oil. They can use olive oil. These are often recommended by ENTs for people to soften the wax. So any liquid you put into the ear will cause softening of the cerumen. Some are better than others. Some react quicker than others. There is a product out of the States called Earwax MD. It's not Health Canada approved, to my knowledge. People can purchase it over the internet, online, but it actually causes a disintegration of the cerumen. It actually dissolves it. The cerumen is still there, but it dissolves it so quickly that within 10, 15 minutes, you can go in and extract even a really solid block of cerumen. So it's the one I like the best, but unfortunately I don't see that it's got Health Canada approval. So whether you should be using it in the clinic, it's very questionable, but- Yeah, that's great. Thank you for your nuanced expertise on that, Dan. That was really helpful. The next question here is from Cheryl, who would like to know if you have any thoughts on how they can let other providers know that they're doing this cerumen removal to then increase those referrals to their clinic. When I was working for Phonak, Phonak was always trying to come up with tools and things to give clinicians so that they could go knock on the doctor's doors in their community. Hearing screeners, hearing lights and everything, anything to try to get some time with the physician. Well, I can tell you that my experience is if you have the ability to go to see your local doctors, knock on their doors, to tell them about your cerumen management services, I think it's highly likely that you're going to get some of their time, or at least their administrator's time to know that when people come into their clinic who have cerumen issues, there's some place where they can refer them. And that once you've received one of their individuals, make sure you send a report back on how things went. If you have a video otoscope, it's a perfect use of your video scope pre and post, and very impressive to the doctor to say, well, look at all that wax and it is gone. Well, this person really knows what they're doing. And my patient was happy with the experience because it was done professionally and using best practice. And so there was no pain. There was no damage. That's rare. It is a risk. We know it can happen, but it is rare. Never punctured an eardrum in my 40 plus years. I've caused a few little hematomas, few little tiny lacerations, but I've always felt confident doing cerumen and that confidence and my skills, I didn't cause any real significant injuries. So knock on doctor's doors. They'll be happy to know there's a place that's doing cerumen. Great, thank you. The next question here is from Trina, and this is specifically about British Columbia. She said she's been wanting to get her cerumen management certification in BC, but as you said, it is time consuming and can be difficult to arrange. To your knowledge, Dan, is there a program that satisfies all the requirements of the College of Speech and Hearing of BC, including the supervised hours? Yeah, no, there is not. Our course is recognized as satisfying the educational component, but you still have to seek somebody who has the certification, who holds certification, who will then provide you with access to observe them doing five extractions of cerumen, and then will actually supervise you for 10 extractions, and then supervise you for another five general supervision of extractions where you're reporting back to them how I just did a cerumen removal, and it went really well, no complications. And so there's quite a lengthy process, but you do have to find an individual who is willing to do that for you. I used to do that when I was licensed, but I think it's becoming the real bottleneck or the real roadblock for people in BC is that they just can't find somebody who's willing to provide them that mentorship, because the person who does that mentorship has to do it at no charge. They have to do it for free. And so it's one of those things where I think the college has created a situation they're gonna have to address. They're gonna have to address this and figure out how can we get people certified? It's the only province in BC that requires that level of supervision. Although I know Ontario AHIP has their certification program also now requires some form of mentorship. And so I don't know how they're working that as far as finding enough people willing to provide the mentorship for people in Ontario. That's really interesting, thank you. Yeah, while you were talking about the requirements, I was thinking, well, an audiologist should offer that as a paid service. You can pay me and I'll do your supervision. And then you said that they can't do that. So I can see where that would create quite a problem. Yeah, I would say that's something that I was doing, but then as I was deciding whether I should renew my license or not this year, I understood the college had said, oh, you're not allowed to charge for this because that creates a conflict of interest. And therefore you have to do it for free. And I thought, good luck with that. I know the amount of time I put into this and I'm not in a clinic working with a full schedule. I don't know how they're going to find people to do the mentorship. So in BC, good luck with this is a conversation to continue to have with the college where they need to go through whatever the process is in order to try to get some kind of a modification for that requirement. Definitely, thank you for that. What I'm interested if I could Dan and hearing from you about is your, these emerging technologies, you shared a little bit about them. What are you most excited about in terms of those emerging technologies? And what do you think might be coming even further down the pike in cerumen removal? Yeah, well, the one that had me really get excited was the endoscopic. And unfortunately I'm not going to be able to get to do it because I've retired. I'm no longer allowed to do any kind of clinical services, but that ability, if you've watched some of the new editors, YouTube videos, you just see it's incredible to go down and use his system to just even examine the air canal much as an ENT might with a really high magnification illumination system that they have. The views that you get, the amount of information you can gain, but then also to be able to go in with your implements and see the extraction and see where the wax is with incredible fidelity. To me, it's very exciting. It's very exciting. I do like the other tools that we're seeing where we've got the EarWave Pro because that has greatly reduced the time it takes to remove cerumen for a significant number of people. I'm also aware, not really maybe to talk too much about it, but I'm aware that there are some people looking at developing truly portable suction systems because most of the suction machines, they call them portable, aren't going out of the clinic. They're too bulky. But I do know that there are some people working on, can they develop a suction that truly is something you could carry in your bag, go into an intermediate care facility for seniors and do some micro suctioning of cerumen? That's exciting. That sounds really cool. Well, thank you so much for sharing your perspective on that. We have answered all of our attendee questions. So again, thank you so much, Dan, and to all of our speakers today, what a great session and such a fantastic day we've had. We hope that you all enjoyed today's sessions as much as we did. And I also want to thank again, our sponsor Starkey Widex Insignia of the event today.

Daniel Pacioretty

San Francisco State University

communication disorders

audiologist

hearing healthcare

cerumen management

World Health Organization

assistive products

SAC certification

emerging technologies