Theme 1: Perceptions of the nasal balloon
Coherence and acceptability
Nasal balloon autoinflation was described by most parents as a natural, holistic treatment that offers a practical solution to glue ear and is appealing to children:
‘Anything holistic that doesn’t involve sort of medicine or drugs, I think, is brilliant. So that’s what attracted me to the study, because it’s very practical, and a physical, practical solution.’
(Parent 3)
GPs with previous experience of the nasal balloon method described it as easy to understand and explain to families, having a logical mode of action similar to methods of middle-ear inflation that were currently being recommended in some GP practices; for example, the Valsalva manoeuvre, mouth inflation of party balloons:
‘I think that would be something really easy and something that you could show to parents actually in the appointment.’
(GP 19)
GPs and practice nurses described nasal balloon autoinflation as a low-harm, low-cost intervention appropriate for primary school age children, which could promote self-management and enhance the watchful waiting process:
‘I think while they are waiting for the audiological review is a good starting point, because if it’s already improving by then, it reinforces the concept of watchful waiting.’
(GP 13)
‘I think with the balloon, I would assume it’s relatively inexpensive. It has to be a good process of elimination for glue ear and grommets, and I think a lot of referrals to consultants at, you know, secondary care, could be avoided by 3 months of trialling the balloon.’
(Nurse 1)
Credibility
Some GPs, particularly those who were unfamiliar with the nasal balloon before this study, raised concerns about the credibility of prescribing or recommending such a treatment, describing the nasal balloon as possibly a ‘gimmick’, or ‘purely a placebo’:
‘When you look at it, it’s just a load of balloons and a plastic device, and they will probably think, well, “what’s the doctor telling me?” It might look a bit strange.’
(GP 12)
However, parents who participated in AIRS did not identify problems with credibility, and generally described the treatment as a practical and holistic treatment for glue ear:
‘I was really keen to see whether this would work, because this is a very non-invasive way of dealing with glue ear, I thought.’
(Parent 7)
Safety
Parents and healthcare professionals expressed some uncertainties about potential harms associated with inflating the nasal balloon. Parents noticed that some children turned red in the face, whereas others reported children experiencing some mild pain, popping, and clicking when using the balloon:
‘Sometimes, I did kind of wonder, thinking, you know, it puts a lot, it’s what the pressure of it will be doing in your head, you know. His face would go quite red.’
(Parent 9)
However, most GPs described the balloon as a low-harm treatment option, and nurses did not report any particular safety concerns in this study:
‘It’s easy to use. Physiologically, you can see how it could be helpful … and the likelihood of it doing any harm is very, very low.’
(GP 1)
Theme 2: Implementing in primary care
Suitability and relevance
A common concern raised by GPs, especially those who did not have personal experience with the balloon, was how to select children for nasal balloon treatment. There was a general perception that the treatment would be suitable for older children (5–7 years), as the technique was thought to require a level of dexterity and cooperation:
‘You wonder what age onwards the child would be able to do that, but you would have thought from about 5 onwards, maybe; I would have thought a child under 5 might struggle.’
(GP 16)
However, nurses and GPs with previous experience of the nasal balloon found that children aged ≥4 years were generally capable of successfully inflating the balloon with some training.
Some GPs suggested potential barriers to uptake of the nasal balloon in diverse cultural populations and areas of increased social deprivation:
‘We are in an urban practice, with lots of different migrants registered at our practice, so language is one barrier; cultural expectation is another barrier.’
(GP 28)
Engaging families
GPs described the perceived need for a high level of parental motivation to ensure good uptake with the nasal balloon:
‘The other barrier would be patient acceptance; do they want to take it up? And they might go “oh, I can’t be bothered with this sort of thing, it’s too much of a faff”.’
(GP 7)
Nurses described the need for children to be willing to cooperate, as the technique requires active participation:
‘It’s not like taking a tablet, is it? It’s something that they’ve got to do, and I think that’s always hard for a parent, isn’t it, getting a child to do something, rather than just, you know, take something?’
(Nurse 12)
Although some GPs proposed that a lack of parental commitment and child cooperation could be a barrier to engagement, the vast majority of parents in the study were happy to try the nasal balloon as part of AIRS, and readily committed to the treatment regimen. Additionally, children were engaged with the treatment, especially in the first few weeks, if it was made fun or part of a game:
‘The girls thought that was great fun; anything to do with balloons, isn’t it? They think it’s great.’
(Parent 5)
Training and demonstration
GPs proposed that a good demonstration would be required to ensure children mastered the nasal balloon technique and engage with the intervention:
‘Demonstrations are always really important. It’s all about technique. All these things are about technique.’
(GP 30)
Nurses agreed that either demonstrating the technique personally, or asking parents to demonstrate, was an effective way of encouraging and engaging the child:
‘I demonstrated, and they would then have a go and they, obviously, weren’t particularly good at it. So I said to the mum, “oh, you have a go and if you can do it, that helps the child”.’
(Nurse 12)
Parents also described the importance of a good demonstration to help them understand exactly what their child needed to do:
‘It was very easy. The instructions were straightforward; the nurse gave us great demonstrations and a great explanation about how to use it.’
(Parent 11)
However, although some GPs proposed that a personal demonstration would add credibility to the treatment and improve the technique, others either did not see demonstrating the nasal balloon as their role, or did not consider it feasible during a routine consultation:
‘I honestly think I would struggle to teach it within a busy consultation, because there are often other problems being brought, or other kids running round the room, and I don’t think I would be the best person to teach it.’
(GP 31)
Some GPs suggested that an online training video ought to be sufficient to train families in the use of the nasal balloon:
‘I wouldn’t necessarily feel the need to have to demonstrate it, because these days I think you should get a video or YouTube, or whatever, to show it, I’d have thought.’
(GP 5)
Others suggested that pharmacists could demonstrate the balloon as part of their dispensing procedure, although there were uncertainties about whether they would be happy to fulfil this role:
‘I find this with inhalers, that I’m very keen to get the pharmacist involved. So, if the pharmacist could actually demonstrate it, they’ve got a bit more time.’
(GP 15)
Mastering the technique
Parents reported that some children have initial difficulties with inflating the nasal balloon. Nurses agreed that first inflations could be difficult for children due to the balloon tension, and some children are reported as having difficulties blowing through their nose. Inflations were reported as becoming easier if the balloon is pre-stretched by hand or mouth beforehand:
‘I think they all found it a little bit difficult at the start, because the balloon was, and it is quite hard to blow up initially.’
(Nurse 4)
Nurses described the importance of involving the children early on in the consultation process and giving lots of encouragement to achieve successful inflation:
‘Even if they blew it up a bit, then we sort of said: “Oh, that’s brilliant.” And then, of course, the next time you saw them they’d be blowing it up to the size of an orange.’
(Nurse 2)
Parents and nurses both reported that in most cases children either mastered the technique quickly or got better with practice:
‘She struggled a little bit at the beginning. But we then took it home and practised. Well, once she got the hang of it everybody who came in the door had to have it demonstrated.’
(Parent 2)
Theme 3: Continuing and monitoring
Remembering and persevering
Treatment with the nasal balloon is ideally 3 months — a reasonable watchful waiting period — and thus requires an element of remembering to use it and persevering with treatment. GPs stated that this might cause problems for some families:
‘There is always some element of complex family dynamics, and not everybody’s on board with certain treatments that have to be repeated day in, day out.’
(GP 19)
Parents, however, reported that making the nasal balloon part of a child’s daily routine helped with adherence to the treatment regimen:
‘In the morning, whatever we were doing, and then at bedtime. So, it was just like cleaning your teeth, just brought it in as an extra thing to do as part of the routine.’
(Parent 6)
Parents and nurses reported that the use of incentives, such as sticker reward charts, improved compliance, and motivated children to use the nasal balloon:
‘I think, in general, the children love stickers of any sort, don’t they? And if they can put a “well done” at the end of the day, because they’ve done it and inflated it, and it does give them a boost.’
(Nurse 7)
Although many children managed and persevered in the AIRS trial, some nurses reported that children could lose interest over time:
‘The first 2 or 3 weeks were fairly good, but once the children started getting bored with it, then it was a little bit hit-and-miss.’
(Nurse 13)
Additionally, a number of parents reported that children were less likely to comply with treatment if they found the technique difficult or uncomfortable, or if they were unwell:
‘It got trickier as the trial went on, because she got fed up with it; and she did get quite poorly a couple of times, with really bad colds and blocked up nose, and she just point blank refused.’
(Parent 5)
Monitoring
GPs described relying on parents to monitor their child’s hearing and to return to the GP if things had not improved. However, some parents remained unclear about how long to continue treatment, how quickly they should expect to see results, and if or when to return to the GP for further advice:
‘So, how long do you persist with this before you think: “OK, I need to take it to the next level?” That isn’t clear to me.’
(Parent 8)
GPs without previous exposure to the nasal balloon described needing to build up personal experience with it in their own patient population:
‘I think, if it didn’t seem to, you know, if the vast majority were coming back with it not making any difference, it would probably fall out of favour for me, to be honest.’
(GP 19)
