Singapore-based startup NousQ is about to drastically simplify the treatment protocol for Otitis Media with Effusion. The condition, commonly known as glue ear, occurs when fluid accumulates in the middle ear, and is globally the top reason for children’s hospital visits, antibiotic usage, and hearing loss.
Surgical intervention for glue ear involves implanting a tiny ventilation tube on the eardrum to drain the trapped fluid, and is currently performed in the operating theatre under general anaesthesia. This translates to cost and access issues though. As a result, glue ear surgery has low take-up rates, even in developed countries, despite the condition’s impacts on a child’s hearing, as well as learning and development.
NousQ’s solution is CLiKX, a robotic handheld tube applicator that mimics the same surgical procedure, but does so in just 1 second instead of 10 to 20 minutes – while offering repeatability and greater precision to boot. What is arguably the device’s greatest advantage is how glue ear surgery can now be an outpatient procedure that’s done in the clinic with just local anaesthetic. This improved accessibility will, in turn, benefit tens of millions of children worldwide.
CLiKX is the brainchild of Dr Lynne Lim, the founder and CEO of NousQ, who has spent the better part of the past decade on the project. She shares more about its genesis and development in this interview.
How did CLiKX come about?
I was on a mission trip to Cambodia several years ago, and on one of the days I helped to perform various surgeries for children. The next day, literally hundreds more children showed up seeking help, many of them with glue ear. It hit me then that while I could perform larger, more complex surgeries like removing neck lumps using just local anaesthetic, glue ear surgery was impossible because there was no operating theatre and general anaesthetic in such settings.
Some time later, I saw my daughter getting ear piercings. She was quite young then, but I noticed that even after the first piercing, she could stay still for the second one. At that moment, I realised that speed is crucial – if you can perform the procedure of inserting an ear tube quickly, then it’s actually going to be doable.
How did you go from this eureka moment to CLiKX?
It took many, many iterations. I think we must have had at least 5 major revisions and 15 minor ones? We started off as a project that was supported by an A*STAR grant, which provided proof-of-concept funding, then got another grant from A*STAR to show proof of value. The challenge came after, because I was in private practice then, and there were very few sources of support for research work carried out by doctors in private practice. Eventually, we managed to convince [Singapore's] National Research Foundation to support us. Following this, we established NousQ to continue this work, partly because it was difficult to secure additional funding.
It sounds like there’s a funding gap here for doctors in private practice who wish to carry out research work.
It’s a common belief that doctors in private practice are largely driven by money, but people leave the public healthcare system for various reasons, and some of them really want to conduct research for the greater good. In my experience, I actually had more time to engage in research work in private practice because I had greater control over my schedule. I do wish there were more opportunities and avenues to fund our research and development at that point in time.
Unlike its competitors, CLiKX uses existing ear tubes that are already on the market, which lowers both the barriers for regulatory approval and the psychological barriers that doctors may have. Was this planned as a feature right from the start?
Right at the beginning, I told Chee Wee [Gan, co-founder and CTO of NousQ] that the device needed two things. One: the procedure must be done in 1 second. (laughs) That was very tough, and it was honestly a bit of a stretch at the start. The second thing, which also made it really difficult, was that our device had to fit existing ear tubes on the market.
There were other considerations, of course. As an ENT surgeon, it was also important to me that any trauma to the eardrum was minimised, so the incision itself had to be as small and as precise as possible. Other features, like having a minimal touch on the eardrum, were to reduce any pain and discomfort. Then there was automation, to make the procedure replicable. These were all intentional decisions aimed at moving the procedure away from general anaesthesia and out of the operating theatre.
Making this an outpatient procedure will really improve healthcare equity for glue ear.
That’s right, and we are not just solving this issue for developing countries. In developed countries like the US, Australia, and the UK, glue ear surgery has low take-up rates as well. The reasons are often related to the requirements for an operating theatre and general anaesthesia. Maybe the wait times are too long, or it’s too troublesome to travel for the surgery, or there are concerns over GA’s effects on a child’s brain development.
These issues are less prevalent in Singapore, but access isn’t perfect either. One of the largest private hospitals in Singapore, for example, only has two surgical microscopes because of how expensive they are, so surgeries are scheduled around their availability. With CLiKX, access is fundamentally improved because the same procedure can be performed in the clinic under local anaesthesia with just a headlight and magnifier. This can address a huge unmet need in both developed and developing countries worldwide.
What’s the next milestone for NousQ?
Our next big step will be clinical trials, which will start at the end of this year. We are quite confident about it, because we’ve just done our pre-submissions to the FDA and things look good there. After clinical trials, we will be looking forward to FDA approval by the end of 2024. From there, we will weigh our options. Strategic acquisition is a possibility, but so is continuing on with further development and additional product lines, or maybe even a combination of these options. We’ll see what happens.
What will you say to investors who are interested in NousQ?
We see the possibility of an early exit at the end of 2024 – after FDA approval – via an acquisition by a strategic investor. That’s with an investment return of around 10x if you peg estimates to past acquisitions related to handheld applicators for ear surgery. We also have the opportunity to continue towards IPO as we already have additional product pipelines.
But I think the big picture here is this: they’ll be joining a company that isn’t just focused on returns. Yes, we believe investment returns will come. Beyond that, however, we are really going for impact here – we want to focus on areas where there are huge unmet needs, instead of just going for the low-hanging fruits to make money.