In the not so distant past, a patient presenting to a doctor with hearing damage might reasonably be assumed to have spent time in a noisy factory, a heavy industrial environment, or even at war. Nowadays, they might simply be too attached to their AirPods.
“There is one thing that kills ears – and that’s noise,” says Michael Wareing, a highly regarded London-based Consultant Ear, Nose and Throat (ENT) surgeon. “Noise kills ears. It’s all related to the dose, which is intensity and time; the longer the time [of exposure] and the higher the intensity, the worse it is.”
Hearing damage from industrial noise even has a name, Boilermaker’s Notch, because so many workers who made steam boilers during the Industrial Revolution developed hearing loss. In the 20th century, the artillery of two World Wars took its toll on hearing.
“Now we’ve got much better occupational protection against noise exposure, the commonest cause [of noise exposure] is recreational,” says Michael. “The noisiest ones are concerts and music events; plus if people overuse AirPods or headphones, they can damage their ears.”
He is seeing outer ear infections – more commonly linked with swimming – increasingly associated with headphone usage. “I’ve had people coming in to talk to me about their ear infection, while wearing their AirPods – and not, apparently, putting two and two together,” he says.
The vast majority of people use headphones with no ill-effects, of course, but it does illustrate the constantly changing nature of the clinical specialty of ENT. Michael studied at St Bartholomew’s Medical School in London in the 1980s and knew from an early stage of his studies that he wanted to do ENT. An internal elective in the area sealed the deal.
“To be honest, all the ENT registrars I met seemed to have their lives relatively well sorted out,” he says, laughing. “More seriously, the ear always really fascinated me. Trying to understand the anatomy [of the ear] is quite a challenge, it’s quite difficult reading from textbooks. Every ear is sort of the same but they are all slightly different, the angles are a bit different. So sometimes it presents difficult surgical challenges.”
The nerve supply to the facial muscles runs through the ear, making ear surgery a delicate operation, explains Michael, who has supra-specialist knowledge in ear and skull base surgery. Further in lie the nerves of sensation to the face; the jugular veins, which carry blood from the brain back towards the heart; and the internal carotid artery, which goes up to supply the brain with blood.
“The main bit of skull base surgery is something called Acoustic Neuroma or Vestibular Schwannoma, which are benign tumours,” he says. “The problem is that they’re in a relatively inaccessible area in the head. There are various ways you can get to them and a couple of those involve going through ear.”
Ear, nose and throat are grouped together medically because they are all functionally inter-interrelated, particularly the ear and the back of the nose. Illness in any of the three areas can seriously affect a person’s quality of life; on the flipside, successful treatment of ENT conditions improves people’s quality and enjoyment of life, says Michael.
“It’s all quite close to your head,” he says. “There’s quite a lot of cortical imprint related to ENT.”
Earlier in his career, Michael’s work was a mixture of paediatric and adult ENT but he now solely concentrates on adult ENT. He has a hectic schedule, consulting privately at the London Clinic on Mondays, Tuesdays and Thursdays.
His Wednesdays are spent with the NHS, at the Royal London Hospital at Whitechapel, where he either does clinic or operates. On Fridays, he operates privately on alternate weeks. He also does case-by-case work with neurosurgeons, which is slotted into his calendar. On average, he does three or four ENT procedures a week.
“There is a saying: a junior surgeon knows how to operate, a good surgeon knows when to operate, and an excellent surgeon knows when not to operate,” he says.
“You see quite a lot of patients who have ENT symptoms but may not clearly have ENT disease. I’m seeing quite a lot of patients who have headaches and facial pain that is thought to be their sinuses, but it may be more of a headache problem.”
Tinnitus is a common complaint and he also sees quite a few patients with Meniere’s disease, which can cause vertigo and hearing loss. One of his recent procedures involved surgery on a patient who had a cholesteatoma – where the eardrum is retracted and skin has built up – which led to a brain abscess.
He started his private ENT practice in 2000, taking over from a colleague who was retiring.
“I got filing cabinets full of paper notes,” he recalls. “The accounts were done on an index card system so, fairly early on, we bought a billing system.”
He started using practice management software from DGL, part of Clanwilliam, more than 15 years ago. Patient notes, scans and correspondence are scanned and stored, fully accessible anywhere he has an internet connection. Just as importantly, his secretary is a fan of the DGL system, he says.
“Every patient’s medical notes – things like hearing tests, scans and imaging, operation notes – are all in DGL,” says Michael. “I’ve bought a system that takes endoscopic pictures of ears and we can save those to the record as well. It produces a pretty integrated record and I can access my private patients even on the iPhone.”
His NHS practice is based at St Bartholomew’s and the Royal London Hospitals, where he was head of the ENT department for two separate periods, from 2003 to 2009 and 2012 to 2014.Training and education are important for Michael, who set up a Temporal Bone Course in 2002, allowing trainees to learn to drill temporal bones on donated post-mortem samples.
“You can use simulators but it’s probably not quite as good as the real thing,” he says. “The anatomy is so complex, you need to be able to see what you’re doing.
The pandemic period had ENT implications, as smell loss was identified as an important symptom of Covid-19. “Interestingly, the sense of smell can come back after a long time, even two years or longer. So it’s sort of important for people not to give up hope,” he says.
Unlike many other areas of medicine, telemedicine isn’t ideal for people with ear complaints, particularly for a first consultation, he says. “Often you need to examine a patient and look in their ear. If you’ve already seen a patient once and know what you’re dealing with, remote consultations work quite well for follow-up.”
Away from the clinic and hospital, he is a “reasonable” golfer and has a hardcore cycling habit that started after he had a minor motorbike accident in 2009. “I didn’t hurt myself but I have never ridden a motorbike since,” he says. “I started commuting by bicycle after that. I was living in north-west London so it was about 15 or 16 miles into town.”
He “built up gradually” from there and cycled the 1,400km (870 mile) length of Britain from Land’s End to John o’ Groats with a friend in 2012, raising £25,000 for Deafness Research UK and Help for Heroes. He is also a regular participant in the annual L’Etape du Tour de France, where amateur cyclists race a stage of the Tour de France.
“They’re quite good fun. It’s just one stage but it’s usually the most hilly stage,” he says. He has a place in this year’s L’Etape, between Nice and the Col de la Couillole in the southern end of the Alps, on July 7th. Billed as one of the most demanding to date, the 138km route includes 4,600 metres of ascent. “Yeah, I’m not sure about L’Etape this year,” he says, on reflection. “Going up those hills is a killer.”
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