Hearing Library 2016-12-21T17:24:10-05:00
What is Tinnitus? 2014-10-08T09:39:33-05:00

Tinnitus is an abnormal perception of a sound reported by a patient. This “head noise” is unrelated to an external source of stimulation. Tinnitus is a common disorder affecting over 50 million people in the United States. It may be intermittent, constant, or fluctuant, mild or severe, and tinnitus may vary from a low roaring sensation to a high-pitched type of sound. The location of the tinnitus may be in one or both ears, or it could also involve the head.

Classifications of Tinnitus
Tinnitus may or may not be associated with a hearing loss. It is classified as:
-Subjective tinnitus – A noise perceived by the patient alone, which is quite common. With this type of tinnitus, the patient has problems with the auditory (hearing) nerves or a deficit in the auditory pathway, which is the part of the brain that interprets nerve signals as sounds
-Objective tinnitus – A noise perceived by the patient as well as by another listener, which is relatively uncommon. With this form of tinnitus, the patient and the doctor can hear the head noise. This is usually due to a vascular issue, a muscle contraction, or an inner ear condition.

Symptoms of Tinnitus
The bothersome sound of tinnitus is described differently by different patients. The head noise may be of a low pitch to a high squeal, and it can affect one or both ears. Typical symptoms of these phantom noises are described as:
-Buzzing
-Ringing
-Roaring
-Ocean waves
-Hissing
-Clicking

Causes of Tinnitus
Tinnitus is the term for the perception of noise when no external sound is present. It is often referred to as “ringing in the ears,” although some people hear hissing, roaring, whistling, chirping, or clicking. Tinnitus (often called head noise) is not a disease, but a symptom of another underlying condition – of the ear, the auditory nerve, or elsewhere. Tinnitus can be intermittent or constant, with single or multiple tones. Its perceived volume can range from very soft to extremely loud.

Factors that Contribute to Tinnitus
The exact cause (or causes) of tinnitus is not known in every case. There are, however, several likely factors which may cause tinnitus or make existing head noise worse. These include:
-Noise-induced hearing loss
-Wax build-up in the ear canal
-Certain medications
-Ear or sinus infections
-Age-related hearing loss
-Ear diseases and disorders
-Jaw misalignment
-Cardiovascular disease
-Certain types of tumors
-Thyroid disorders
-Head and neck trauma

Of the many factors that contribute to tinnitus, exposure to loud noises and hearing loss are the most common causes of tinnitus. Treating a hearing loss, either by medical management or with hearing aids can help. Modern digital hearing aids also provide tuned noise maskers, which may alleviate the tinnitus. Other new and effective tinnitus treatments are also available. If you have tinnitus, a comprehensive hearing evaluation by an audiologist and a medical evaluation by an otologist are recommended.

Tinnitus Treatment and Management
Tinnitus will not cause you to go deaf. Statistically, 50 percent of patients may express that their tinnitus decreases with time or is hardly perceptible. Generally, most patients will not need any medical treatment for tinnitus. There are several treatments and measures to help with the management of tinnitus.
Listening to a Fan or Radio
The external noise will mask some of the head noise. In addition, other sound source generators can be obtained and be adjusted to sound like environmental noises, and this is also effective in masking tinnitus. Generally, this is more advantageous if one is attempting to go to sleep.
Tinnitus Masker Device
A tinnitus masker is utilized for some patients. It is a small electronic instrument built into a hearing aid case. This device generates a sound which prevents the wearer from hearing his own head noise. The technology of a tinnitus masker is based on the principle that most individuals with tinnitus can better tolerate outside noise than they can their own inner head noise.
Biofeedback Training
This is effective in reducing the tinnitus in some patients. Biofeedback training consists of exercises in which the patient learns to control various parts of the body and relax the muscles. When a patient is able to accomplish this type of relaxation, tinnitus generally subsides. Most patients have expressed that the biofeedback offers them better coping skills.
Avoidance Measures
Other measures to control tinnitus include making every attempt to avoid anxiety, as anxiety will increase tinnitus. You should attempt to obtain adequate rest and avoid over-fatigue as patients who are tired seem to notice their tinnitus more. The use of nerve stimulants is to be avoided, as are excessive amounts of caffeine and smoking. Stimulating agents tend to make tinnitus worse.
Avoiding Certain Medications
There are some drugs which will also cause tinnitus. If you have tinnitus and are on medication, you should discuss the symptom of tinnitus with your physician. In many instances, once the drug is discontinued, the tinnitus will no longer be present. These medications include:
-Certain antibiotics (gentamicin, neomycin, and streptomycin)
-Antidepressants (amitriptyline and nortriptyline)
-Anti-inflammatory drugs (aspirin, ibuprofen, and naproxen)
-Antihypertensives (captoprin and ramipril)
-Heart medicines (propranolol and verapamil)
-Parkinson’s drugs (levadopa)
-Diuretics (furosemide and bumetanide)
-Supplements (vitamin A and niacin)

Medications
There are several medications which have been utilized to suppress tinnitus. Some patients benefit with these drugs and others do not. Each patient has an individual response to medication, and what works for one patient may not work for another. Some of these medications have been proven, however, to decrease the intensity of the tinnitus and make it much less noticeable. There is, however, no drug anywhere which will eliminate tinnitus completely and forever.
For tinnitus management, visit the American Tinnitus Association website for more information, ideas, and strategies at www.ata.org

Cause of Tinnitus 2014-10-06T21:26:12-05:00

Tinnitus is the term for the perception of sound when no external sound is present. It is often referred to as “ringing in the ears,” although some people hear hissing, roaring, whistling, chirping, or clicking. Tinnitus is not a disease but a symptom of another underlying condition – of the ear, the auditory nerve, or elsewhere. Tinnitus can be intermittent or constant, with single or multiple tones. Its perceived volume can range from very soft to extremely loud. 50 million Americans experience tinnitus to some degree. Of these, about 12 million have tinnitus which is severe enough to seek medical attention. Of those, about two million patients are so seriously debilitated by their tinnitus, that their day to day functioning is affected.

The exact cause (or causes) of tinnitus is not known in every case. There are, however, several likely factors which may cause tinnitus or make existing tinnitus worse: noise-induced hearing loss, wax build-up in the ear canal, certain medications, ear or sinus infections, age-related hearing loss, ear diseases and disorders, jaw misalignment, cardiovascular disease, certain types of tumors, thyroid disorders, head and neck trauma and many others. Of these factors, exposure to loud noises and hearing loss are the most common causes of tinnitus. Treating a hearing loss, either by medical management, if indicated, or with hearing aids, may offer relief of tinnitus. Modern digital hearing aids also provide tuned noise maskers which may alleviate the tinnitus Other new and effective tinnitus treatments are also available. If you have tinnitus, a comprehensive hearing evaluation by an audiologist, and a medical evaluation by an otologist is recommended.

The Prevalence of Tinnitus 2014-10-06T21:25:32-05:00

What is Tinnitus and How Many People Have It?

Tinnitus is the term for the perception of sound when no external sound is present. It is often referred to as “ringing in the ears,” although some people hear hissing, roaring, whistling, chirping, or clicking. Tinnitus can be intermittent or constant, with single or multiple tones. Its’ perceived volume can range from very soft to extremely loud.

HOW MANY PEOPLE HAVE TINNITUS?

50 million Americans experience tinnitus to some degree. Of these, about 12 million have tinnitus which is severe enough to seek medical attention. Of those, about two million patients are so seriously debilitated by their tinnitus, they cannot function on a “normal,” day-to-day basis.

Tinnitus Treatment and Management 2014-10-06T21:27:19-05:00

Generally, most patients will not need any medical treatment for their tinnitus. For patients who are greatly bothered by tinnitus, they may use some masking techniques such as listening to a fan or radio which would mask some of their tinnitus. In addition, other sound source generators can be obtained and be adjusted to sound-like environmental sounds and this is also effective in masking tinnitus. This generally is more advantageous if one is attempting to go to sleep. A tinnitus masker is utilized in some patients. It is a small electronic instrument built into a hearing aid case. It generates a noise which prevents the wearer from hearing his own head noise. It is based on the principle that most individuals with tinnitus can better tolerate outside noise than they can their own inner head noise.

Biofeedback training is effective in reducing the tinnitus in some patients. It consists of exercises in which the patient learns to control the various parts of the body and relax the muscles. When a patient is able to accomplish this type of relaxation, tinnitus generally subsides. Most patients have expressed that the biofeedback offers them better coping skills.

Other measures to control tinnitus include making every attempt to avoid anxiety, as this will increase your tinnitus. You should attempt to obtain adequate rest and avoid overfatigue because generally patients who are tired seem to notice their tinnitus more. The use of nerve stimulants is to be avoided. Therefore, excessive amounts of caffeine and smoking should be avoided. Tinnitus will not cause you to go deaf and statistically, 50 percent of patients may express that their tinnitus with time decreases or is hardly perceptible.

There are other medications which have been utilized to suppress tinnitus. Some patients benefit with these drugs and others do not. Each patient has an individual response to medication, and what may work for one patient may not work for another. Some of these medications have been proven, however, to decrease the intensity of the tinnitus and make it much less noticeable to the patient. There is, however, no drug anywhere which will remove tinnitus completely and forever. There are some drugs which will also cause tinnitus. If you have tinnitus and are on medication, you should discuss the symptom of tinnitus with your physician. In many instances, once the drug is discontinued the tinnitus will no longer be present.

Visit the American Tinnitus Association website for more information, ideas and strategies at www.ata.org

A Patient’s Guide to Tinnitus 2014-10-06T22:15:42-05:00

What is tinnitus?

Tinnitus, often described as ringing, buzzing or hissing sounds in the ears, is a symptom that can be related to almost every known hearing problem. Tinnitus can be temporary (acute) or permanent (chronic). It can also be constant or intermittent. Temporary tinnitus can be caused by exposure to loud sounds, middle or inner ear infections, and even wax on the eardrum. Because tinnitus can sometimes be treated medically, all patients who develop the symptom should first consult with an ear, nose and throat physician (otolaryngologist).

Tinnitus and hearing loss

Chronic tinnitus is usually associated with some degree of hearing loss. 90% of the patients who come to our Tinnitus Clinic have at least some hearing loss. Below are questions commonly asked by tinnitus patients:

Q: Does tinnitus cause hearing loss?
A: No. In fact, the reverse is true: whatever caused a person to have hearing loss (including noise exposure, infections, aging or genetic factors) is also responsible for the generation of tinnitus.

Q: Does tinnitus interfere with hearing?
A: No, tinnitus does not interfere with hearing, although it may affect ones attention span and concentration. On the other hand, tinnitus might seem louder if hearing loss increases (or if you wear ear plugs or ear muffs) because outside sounds will no longer reduce the perception of tinnitus.

Q: Does cutting the hearing nerve cure tinnitus?
A: Unfortunately, cutting the nerve does not relieve tinnitus often enough to recommend it as a treatment. It does, however, produce total deafness in the operated ear, may cause balance problems, and in some cases can make tinnitus worse.

How many people have chronic tinnitus?

According to Seidman & Jacobson,1 Approximately 40 million Americans have chronic tinnitus. For 10 million of these people, tinnitus can be a severely debilitating condition. However, for 30 million Americans with tinnitus, it is not bothersome. Tinnitus does not interfere with the enjoyment of life for the majority of people who experience it.

What can be done to help people who are bothered by chronic tinnitus?

I agree with Duckro et al2 who wrote: “As with chronic pain, the treatment of chronic tinnitus is more accurately described in terms of management rather than cure.” The goal of tinnitus management is not necessarily to mask or remove the patients physical perception of tinnitus sounds. Instead, we help patients learn to pay less attention to their tinnitus so that it bothers them less of the time. The realistic goal of an effective tinnitus management program is to help patients understand and gain control over their tinnitus, rather than it having control over them. Ultimately we hope to help patients progress to the point where tinnitus is no longer a negative factor in their lives. We want them to move from the “severely debilitated” group of tinnitus sufferers to the “not bothered by tinnitus” group and to enjoy their lives as much as possible.

There is usually no cure for chronic tinnitus that has been present for a year or more. One day, medical science will probably develop a way to eliminate the symptom. In the meantime, there are several effective management strategies that provide relief for most tinnitus patients.

Elements of an effective tinnitus management program

It is preferable for the program to have a Tinnitus Management Team rather than just one clinician. Depending on the clinical expertise required to help a particular patient, a Tinnitus Management Team could be composed of an otolaryngologist, an audiologist, a neurologist, a psychologist, a psychiatrist, and sleep or pain specialists.

The Tinnitus Management Team members should be willing and able to spend a substantial amount of time with each patient.

As much information as possible should be gathered about each patients medical, hearing, tinnitus, and psychosocial histories and conditions. Because each tinnitus patient is unique, therapeutic interventions should be individualized. The most successful treatment programs employ multimodal strategies that are designed to address the specific needs of each patient.

Patients should meet with Tinnitus Management Team members for an in-depth interview and review of their histories and conditions.

Patients should receive education about possible causes of tinnitus as well as reassurance and counseling regarding factors that could exacerbate or improve their condition.

Patients should receive the following:

  • Thorough otolaryngological and neurological examinations.
  • Comprehensive audiological evaluations.
  • Tinnitus evaluations that include matching tinnitus to sounds played through headphones.

Evaluations of acoustic therapies: based on the patients audiological evaluations, various devices should be described and demonstrated. These could include hearing aids, in-the-ear sound generators, tinnitus instruments (combinations of hearing aids + sound generators), tabletop sound generation machines, Sound Pillows, tapes or CDs.

For patients with significant hearing loss, hearing aids will not only improve their hearing ability, the devices will also reduce their perception of tinnitus. For patients with normal hearing, in-the-ear sound generators usually provide relief from tinnitus.

The Tinnitus Management Team should review the results of evaluations and explain them to the patient.

Recommendations can then be formulated and explained to the patient. Referral and contact information regarding physical or psychiatric evaluations, psychological counseling, and other recommended services or products should be provided.

Follow-up: patients should be encouraged contact the clinic anytime if they have questions and also to inform clinicians of their progressSome tinnitus patients also experience insomnia,3 anxiety4 or depression.5 These symptoms can form a vicious circle and exacerbate each other as illustrated in the diagram below:

Tinnitus does not always start this cycle. Some patients experienced depression, insomnia, or anxiety before their tinnitus began. Tinnitus can, however, make each of these problems seem worse. Also, patients who continue to experience depression, insomnia, or anxiety report that these factors can cause their tinnitus to seem more severe. In these cases, effective treatment of depression, insomnia, and anxiety is necessary. A combination of medication and/or psychotherapy should reduce the severity of all of these conditions including tinnitus.

Things to Avoid

  1. Harmful Sounds — Wear ear plugs or ear muffs as protection against loud sounds such as gunfire, gas lawn mowers, leaf blowers, chain saws, circular saws, other power tools and heavy machinery. Exposure to loud sounds can make tinnitus worse and can also cause additional hearing loss.
  2. Excessive use of alcohol, caffeine, or aspirin — However, moderate use of these products is usually O.K.
  3. False claims about tinnitus “cures” or herbal “remedies.” These do not exist for most cases of chronic tinnitus.

Even though a true “cure” for most cases of chronic tinnitus is not yet available, patients can obtain relief from the symptom with assistance from qualified and experienced clinicians.

References

1. Seidman MD, Jacobson GP. Update on tinnitus. Otolaryngol Clin North Am 1996 Jun;29(3):455-465.
https://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8743344&dopt=Abstract

2. Duckro PN, Pollard CA, Bray HD, Scheiter L. Comprehensive behavioral management of complex tinnitus: a case illustration. Biofeedback Self Regul 1984 Dec;9(4):459-469.
https://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=6399462&dopt=Abstract

3. Folmer RL, Griest SE, Martin WH. Chronic tinnitus as phantom auditory pain. Otolaryngol Head Neck Surg 2001 Apr;124(4):394-400.
https://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11283496&dopt=Abstract

4. Folmer RL, Griest SE. Tinnitus and insomnia. Am J Otolaryngol 2000 Sept-Oct;21(5):287-93.
https://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11032291&dopt=Abstract

5. Folmer RL, Griest SE, Meikle MB, Martin WH. Tinnitus severity, loudness, and depression. Otolaryngol Head Neck Surg 1999 Jul;121(1):48-51.
https://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db=PubMed&ist_uids=10388877&dopt=Abstract

For More Information

American Tinnitus Association
P.O. Box 5
Portland, OR 97207-0005
telephone: (800) 634-8978
email: tinnitus@ata.org
web: www.ata.org

OHSU Tinnitus Clinic
Mail Code NRC04
Oregon Health & Science University
3181 SW Sam Jackson Park Road
Portland, OR 97201-3098
telephone: (503) 494-7954
email: ohrc@ohsu.edu
web: https://www.ohsu.edu/ohrc/tinnitusclinic.

Author: Robert L. Folmer, Ph.D. This article was originally published on Healthy Hearing (www.healthyhearing.com) on 1/14/02 and is reprinted here, based on popular request.

Tinnitus: It Has a Certain Ring to It 2014-10-06T22:17:08-05:00

Tinnitus: It Has a Certain Ring to It.

Robert E. Sandlin, Ph. D., Adjunct Professor of Audiology, Private Practice, San Diego, CA & Robert J. Olsson, M. A.

Robert E. Sandlin, Ph.D.
Adjunct Professor of Audiology
San Diego State University
San Diego, California

and

Robert J. Olsson, M.A.
Clinical Director
California Tinnitus & Hyperacusis Therapy Center
San Diego, California

Introduction:

Fifty million Americans experience some form of tinnitus. Twelve million have sought professional intervention. Tinnitus is a significant and common problem across the USA. For individuals with tinnitus, something is occurring within the auditory system, or elsewhere in the neural pathways, which gives rise to the perception of an acoustic-like sensation, for which there is no known external cause. There are two types of tinnitus; objective tinnitus, wherein the patient and the practitioner can hear the ongoing tinnitus, and, subjective tinnitus, heard only by the patient. By far, the most prevalent of the two is subjective tinnitus. Some estimates indicate that 95 percent of all tinnitus is subjective.

Since the audiologist has interest in conditions and anomalies that affect the auditory system, and since tinnitus is such a condition, it seems logical that our scope of training should provide differential diagnostic and therapeutic intervention management for tinnitus. However, many audiologists do not have an extensive background in the clinical management of tinnitus. This is not an indictment of audiologists as a professional body. Audiologists have strong clinical backgrounds in the assessment of hearing loss with regards to the type and degree of hearing loss, diagnostic testing and interpretation, prevention of hearing loss and in the provision of rehabilitative practices and devices for the hearing impaired. Tinnitus management is a relatively new arena for the audiologist and therefore, this paper serves to explore some of the issues associated with tinnitus management by the audiologist. Based on a thorough understanding of tinnitus, a definitive and defensible audiologic diagnosis can be made and a plan of rehabilitation formulated. It is not the purpose of this article to encourage audiologists to consider clinical involvement with tinnitus patients. Rather, our purpose is to offer an overview of major therapeutic approaches used in the treatment of this disorder.

At this time, there is no single therapeutic approach to the treatment of tinnitus that is sufficiently compelling to warrant its exclusive use above all others. There are no test batteries for tinnitus that provide reliable, clinical predictors of cause or treatment. Perhaps this uncertainty keeps many audiologists from being involved in treating the tinnitus patient. For others, the obstacle may be the depth of the psychic involvement of tinnitus sufferers with their condition, for tinnitus is as much an emotional issue as it is a ‘hearing’ issue.

Three Realities in Tinnitus Treatment:

There are three realities that one must be aware of in the treatment of tinnitus. First, there is no consensus as to what causes the problem. This is not to suggest that a rational answer for the mechanisms of tinnitus is not of interest, but rather that is not germane to our discussion of tinnitus treatment. Second, there is no known cure. Third, all present forms of therapeutic intervention treat the symptoms of the disorder, not the cause of the disorder.

Given these clinical limitations, what are the current therapeutic practices used by those who treat the tinnitus patient? Rather than offering an exhaustive analysis of each modality, we will discuss specific approaches related to both medical and non-medical intervention processes. Parenthetically, it has been our observation that the therapeutic modality chosen is most often determined by the professional and clinical backgrounds of the practitioner. Medical models seem to be supported by physicians. Non-medical models appear to be supported by other non-physician professionals. For example, psychologists rely on counseling, whereas audiologists generally employ some form of sound/auditory therapy.

Medical Management:

Medical models typically include the use of drugs to attempt to control the subjective loudness of the ongoing tinnitus, or (more commonly) to reduce the intensity of the patient’s response to it. For the most part, specific drugs seem to be the medical treatment of choice. Anti-anxiety and anti-depression medications reduce negative behaviors brought on by the presence of tinnitus. Other drugs used in the treatment process may include lidocaine, tocanide (oral cognate of lidocaine), Lasix, Misolene, Tegratol and others. Sandlin and Olsson (1999) reviewed the value of drug use and the risks assumed by the patient.

To date, there is no large body of evidence that warrants adapting one particular form of drug therapy. Each of the drugs mentioned above has proven beneficial to some. The general wisdom suggests that drugs constitute an ongoing process that permit the patient to derive some prolonged benefit. Brummet (1997) cautions the practitioner about possible consequences of drug use to control tinnitus. Most patients are treated with non-medical approaches.

Surgical Management:

Some, but very few, physicians have previously elected to perform surgery to eliminate or reduce or control tinnitus. Surgical management of tinnitus has not produced consistent, acceptable results. Surgically sectioning the auditory nerve of the offending ear, more often than not, does not solve the problem. For some, the subjective loudness of the tinnitus, as perceived in the post-operative period, is the same. For others, the tinnitus is exacerbated. Another form of surgical control of tinnitus involves microvascular surgery to eliminate or reduce vascular compression (i.e.‘vascular loops’) in the area of the VIII cranial nerve, theorized by some to be a frequent cause of tinnitus (Vernon, 1998). Another surgical approach involves direct electrical stimulation of structures deep in the brain (Shi & Martin, 1999).

Non-Medical Management:

Although there are many non-medical treatment modalities, only a few have received widespread acceptance The three most common, and most promising, non-medical methods of treatment are masking, tinnitus retraining therapy (also known as habituation therapy) and cognitive therapy. Alternative non-medical treatements include; biofeedback, psychological counseling, nutritional controls, acupuncture, gingko biloba, and Vitamin B 12. For an overview and comprehensive listing of herbs and vitamins purported to assist in the management of tinnitus, the reader is referred to the March 2000 issue of Tinnitus Today, published by the American Tinnitus Association (ATA). It should be noted that gingko biloba, despite its enthusiastic cohort of supporters, has been rather clearly shown to have no more benefit than a placebo (Drew & Davies, 1999). For a more comprehensive overview of treatment, the reader is referred to the book by Vernon (1998), Tinnitus – Treatment and Relief, available from the ATA (published by Allyn and Bacon).

Maskers and Combination Devices:

Masker use, as described by Dr. Jack Vernon, (1977, 1978, 1979, 1981) has proven to be effective for some, but not for all. Masking involves using an external signal (i.e., masking noise) sufficient to mask or ‘cover’ the ongoing tinnitus. The rationale is that an external acoustic stimulus is easier for the patient to ignore than the constant, ongoing tinnitus. Johnson (1998) reported the use of masker devices was effective about 35 to 40% of the time for those who investigated their use. Although not an impressive number in isolation, tinnitus sufferers who were in the 35 to 40% group find masker devices to be a godsend.

A combination device, an instrument containing both a hearing aid and a noise generating circuit, increased success rates to about 70%. That is, for those tinnitus patients having tinnitus and hearing loss sufficient to interfere with speech understanding, the combination device provided more relief than a masker device alone. The combination device also provided more relief than a hearing aid alone.

Maskers and combination devices continue to be used by tinnitus patients, suggesting that these instruments continue to be a valuable therapeutic modality, which provides relief and reduces the high stress level often associated with tinnitus.

Tinnitus Retraining Therapy

Dr. Pawel Jastreboff (www.tinnitus-pjj.com/) is recognized as the person who conceived and popularized the use of Tinnitus Retraining Therapy. In essence, Dr. Jastreboff postulated that acoustic, or acoustic-like perceptions, could be habituated to if they were not considered to be a harbinger of disease, danger or mental stress. For example, grandfather clocks ticks day in and day out. Yet those who live in a house with a grandfather clock have habituated to its ticking. Literally, they do not perceive it. Similarly, the refrigerator motor goes on and off many times during the day, yet one is not consciously aware of it. If you are sitting in front of a computer as you read this, you are probably not aware of its cooling fan. This ability to habituate to a number of sensory experiences is an integral part of human behavior.

Jastreboff’s (1987, 1994a, 1994b, 1990) account of the model goes something like this:
First, there is the perception of the stimulus. At the cortical level, a decision is made as to whether overt action of any kind is mandatory. If the conscious brain deems the stimulus does not demand some purposeful behavior, it can be habituated to (i.e., dismissed) if there are frequent occurrences of the same stimulus. Suppose, however, that tinnitus serves as the stimulus? The conscious brain attempts to make some rational decision. ‘Have I heard this before? What causes it? Is it some sort of precursor indicating I am going deaf? Do I have a serious disease? I haven’t heard this sound before and I must attend to it until I understand its cause.’ The cortex, failing to find an answer for the tinnitus’ presence, labels the sound a threat. The limbic system (the brain’s emotional control system) is thus alerted and activated to the tinnitus, and the tinnitus becomes a more significant problem for the patient.

Emotional involvement with tinnitus can produce psychological and physiological behaviors. Sleep disturbance, irritability, anger, loss of concentration and anti-social consequences are often reported. If these negative behaviors produced by the limbic system persist over time, then the autonomic nervous system may also become involved.

A self-perpetuating cycle of events takes place in the brain. The subconscious brain continues to maintain the conscious brain’s awareness of the tinnitus. The conscious brain continues to involve the subconscious brain, including the limbic and autonomic nervous systems, as it seeks a resolution that is not forthcoming. This cycle, in turn, serves to increase the subjective loudness and importance of the perceived sound.

Jastreboff suggests two things that are important in the control of the tinnitus:

1- The patient must habituate to the tinnitus itself, and
2- The patient must habituate to the emotional consequences of the tinnitus.

To habituate to the tinnitus, it is necessary to reduce the contrast between the ambient noise level and the subjective level of the ongoing tinnitus. To accomplish this task, bilateral noise generators are used These are acoustically similar to, but much quieter than, tinnitus maskers. Depending on the individual patient requirements and categorization, the level of the noise produced by the generators may be increased equal to the loudness of the tinnitus. This makes it more difficult for the conscious brain to concentrate on the ongoing tinnitus.

To habituate to the emotional consequences, directive counseling is used. The essence of this directive counseling, according to Jastreboff, is to make certain the patient understands what tinnitus is, demystifies it as much as possible, and realizes that it not an indicator of a serious physical or psychological problem. To achieve this change of thinking, it is necessary to reinforce one’s understanding of the disorder. To do so, the patient must be adequately counseled. This is accomplished through a prearranged and individually scheduled series of follow-up appointments wherein the clinician and the patient review the patient’s current status.

Jastreboff maintains that the Tinnitus Retraining Program treatment program typically achieves its greatest success within 18 to 24 months. Importantly, this does not mean that nothing positive happens until then. Rather, it indicates that it probably will take 18 to 24 months to achieve maximal results.

Clinics throughout the world, our own included, report success rates in the 80-90% range with tinnitus retraining therapy. Success is determined by the following criteria:

1. Tinnitus awareness is reduced by 20%.
2. The impact of tinnitus on the quality of life is reduced 20%.
3. Tinnitus annoyance is decreased by 20%.

The success criteria listed above represent minimal levels of improvement. The majority of patients exceed the 20% level of change.

Cognitive Therapy

One of the common threads found in therapeutic approaches to tinnitus treatment is the effective use of counseling intervention. One such counseling intervention process is Cognitive Therapy. ‘Cognition’ refers to thought processes. ‘Therapy’ refers to some form of management intended to create change in the thinking process. Therefore, the purpose of cognitive therapy is to alter the negative thinking of the patient and bring about a more realistic assessment and understanding of the problem. Sweetow (1986) reports on management of the tinnitus patient using cognitive therapy as a therapeutic base.

Dr. David Burns (1980) is to be given much of the credit in the development of Cognitive Therapy. Cognitive Therapy is a form of behavioral modification. The practitioner attempts to modify the ways in which the patient may react to his or her tinnitus. Dr. Burns coined the phrase ‘cognitive distortions.’ These distortions are defined in the following ways:

1. All or nothing thinking: If performance falls short of perfect, you see yourself as a total failure.
2. Overgeneralization: You see a single negative event as a never-ending pattern of defeat.
3. Mental Filter: You see a single negative detail and dwell on it exclusively.
4. Disqualifying the positive: You reject positive experiences by insisting that for some reason or another, they don’t count.
5. Jumping to conclusions: You make a negative interpretation of a particular event,although there is no evidence to support the negative conclusion.
6. Magnification: You exaggerate the importance of things or events.
7. Emotional reasoning: You think your negative emotions reflect the way things really are.
8. Should statements: You try to motivate yourself with should or shouldn’t statements.
The emotional consequence is guilt.
9. Labeling and mislabeling: Instead of describing your action as an error, you attach a negative label, such as ‘I’m no good,’ to yourself
10. Personalization: You see yourself as the cause of some negative event, even though you were not.

It is evident that these distortions of thinking tend to perpetuate the patient’s negative behaviors. Failure to modify cognitive distortions can have undesirable consequences and lead to destructive behaviors. Although Cognitive Therapy was not intended primarily for tinnitus patients, it has been useful in their counseling process.

Whether, and to what extent, audiologists should be involved in cognitive therapy with tinnitus patients is a controversial topic. There are strong arguments both for and against. On the one hand, audiologists, more than anyone else, understand the auditory system, and provide hearing system rehabilitation. Furthermore, audiologists engage in counseling routinely. All aural rehabilitation beyond the provision of hearing aids is by definition counseling. The hearing aid fitting process itself involves counseling. On the other hand, audiologists generally do not have explicit training in emotionally centered counseling, and need to work within their scope of practice and licensure.

Summary

The incidence of tinnitus is rather high. Early on, there was little interest in the clinical management of this disorder. That is changing. Increased awareness and interest, spurred on by the American Tinnitus Association, have contributed greatly to the number of clinicians, audiologists included, providing therapeutic programs.

Although the cause, or causes, of tinnitus is unknown, treating the symptoms of the disorder has been beneficial. Even though there is no one absolute therapeutic approach or treatment modality, there are medical and non-medical intervention programs, which have proven to be of significant value. It is no longer defensible to tell a patient to ‘go home and learn to live with it.’

We are convinced that audiologists will find clinical and research challenges in working with the tinnitus patient. However, if the audiologist is to diagnose and manage those with tinnitus, we strongly recommend that he or she seek sufficient academic and clinical training prior to the provision of service. Reading a few articles is a wholly inadequate preparation. In particular, attempting to implement tinnitus retraining therapy without proper instruction can leave the patient in a worse condition.

We feel that at some future date a cure will be found for tinnitus. It is quite possible that the cure will come in the form of specific drugs, which are effective in altering neurochemical behaviors that reduce or eliminate the onset or awareness of tinnitus without the serious side effects of the medications now sometimes employed. We also believe that a compelling therapeutic approach will emerge.

Regardless of what the future holds, there is a current need to provide treatment for those who suffer from this disorder and seek relief. As individuals who have worked with the tinnitus patient for
several decades, the authors can say without fear of contradiction that providing tinnitus management therapy is a demanding challenge that can stimulate your clinical and intellectual abilities and can greatly impact and improve the quality of life of your patients.

Direct correspondence or inquiries to:

Robert J. Olsson, M.S. Ed., M. A., Au.D. Candidate, FAAA
California Tinnitus & Hyperacusis Therapy Center
6505 Alvarado Road, Suite 103
San Diego, California 92120
(619) 583 6612

REFERENCES

Brummelt, R.E. (1997). Are there safe and effective drugs available to treat mv tinnitus? In J. Vernon (Ed). Tinnitus: Treatment and Relief Allyn & Bacon, Needham Heights, MA. Pp, 34-42.

Burns, D. (1980). Feeling Good: The new mood therapy. Avon Books, New York pp.4243.

Drew, S.J. Davies, W.E. (1999). Gingko biloba in the treatment of timutus. Preliminar,~ results of a matched pair. double blinded placebo controlled trial involnug 1115. In the proceedings of the 6~internateional tinnitus seminasr. CD ROM. Tinnitus & Hyperacusis Centre, London

Johnson, R. (1998), The masking of tinnitus. In J~ Vernon (Ed). Tinnitus: Treatment and relief Allyn & Bacon, Needham Heigths, MA. Pp.164-173

Jastreboff, P.J.., Brennan, F.F., Sasaki, C.T. (1987). Behavioral and electrophhysiological animal model of tinnitus. In H. Feldman ~d). Proceedings of the III International Tinnitus Seminar, Muenster, Karlsruhe, Karsch Verllag. Pp.95-99

Jastreboff, P.J., (1990). Phantom limbs: Scientific American 266, pp: 120-126

Jastreboff P.J., Sasaki, C.T. (1 994a). An animal model of tinnitus: a decade of development. Am J Cto: 15:19: pp 19-27

Jastreboff, P.J., Hazell, J.P.W., Graham R.L.(1994 b). Neurophysiological model of tinnitus: Dependence of the minnimal masking level on treatment outcome. Hear Res: 80: pp.216-232

Sandilin, R.E., Olsson, R. J. (1999). Evaluation and selection of maskers and other devices used in Treatment of Tinnitus and Hyperacusis. Trends in Amplifiction, 4(1).

Shiy, Y.B., Martin, W.H. (1999). Deep brain stimulation – a new treatment of tnniitus? In proceedings of the 6~ international tinnitus seminar. CD ROM, Tinnitus & H,~peracusis Centre, London.

Sweetow, R. (1986). Cognitive aspects of tinnitus patient management. Ear Hear 7(6): 390-396. Sweetow, R. (1989). Adjunctive approches to tinnitus-patient management. Ear Hear. 42:11; pp.3843

Vernon, J. (1979). The use of masking in relief of tinnitus. In H. Silverstein, H Norell (Eds). Neurological Surgery of the Ear. Birinnigham, AL: Aesculapius.

Vernon, J. (1981). The history of masking as applied to tinnitus, In Tinnitus Proceedings of the First International Tinnitus Seminr. New York. The Jour Laryn and Cto, Ashford, Kent, UK: Invicta Press: Suppl 4, pp 76-79)

Vernon, J. (1982). Relief of tinnitus by masking treatment. In G.M. English ~d). Ctola~ngology. Philadelphia: Harper & Rowe: pp.1-21.

Vernon, J.( 1998). Tinnitus: Treatment and relief Allyn & Bacon, Needham Heights. MA.

Managing Chronic Tinnitus As Phantom Auditory Pain 2014-10-06T22:16:25-05:00

Managing Chronic Tinnitus As Phantom Auditory Pain

Robert L. Folmer, Ph. D., Assistant Professor of Otolaryngology, Oregon Health Sciences University, Portland, OR

Robert L. Folmer Ph.D.
Tinnitus Clinic, Oregon Hearing Research Center, Department of Otolaryngology, Oregon Health Sciences University, Portland

Correspondence to:
Robert L. Folmer, Ph.D.
Oregon Hearing Research Center
Mail Code NRC04
3181 SW Sam Jackson Park Road
Portland, OR 97201-3098

Telephone: (503) 494-8032
Fax: (503) 494-5656
email: folmerr@ohsu.edu
Web address: www.ohsu.edu/ohrc/tinnitusclinic

ABSTRACT:
Patients experiencing severe chronic tinnitus have many characteristics in common with chronic pain patients. This study explored these similarities in order to formulate treatment strategies that are likely to be effective for patients experiencing phantom auditory pain. Answers to questionnaires filled out by 160 patients who visited our Tinnitus Clinic were analyzed. Patients rated the severity and loudness of their tinnitus; completed the State-Trait Anxiety Inventory (STAI) and an abbreviated version of the Beck Depression Inventory (aBDI). Patients received counseling, audiometric testing, and matched the loudness of their tinnitus to sounds played through headphones. Tinnitus severity was highly correlated with patients degree of sleep disturbance, STAI and aBDI scores. The reported (on a 1-to-10 scale) — but not the matched — loudness of tinnitus was correlated with tinnitus severity, sleep disturbance, STAI, and aBDI scores. Treatment recommendations are discussed in reference to these results.

INTRODUCTION:
Tinnitus is the sensation of sound without external stimulation. Jastreboff1 referred to tinnitus as phantom auditory perception. Outside of the auditory system, the most infamous example of phantom perception is reported by some patients who have lost a finger, hand, arm, toe, foot or leg. These patients continue to perceive the presence of — and sometimes pain from — appendages that have been amputated. Missing appendages that continue to generate sensations are known as phantom limbs; painful sensations attributed to them are referred to as phantom limb pains.

Similarities between the perception of chronic tinnitus and the perception of chronic pain were listed by Tonndorf2: both tinnitus and pain are subjective sensations; both are continuous events that may change in quality and/or character over time; both have the potential to be masked/reduced by appropriate sensory stimulation or medications; both the auditory and somatosensory systems possess a well-developed network of efferent fibers that appear to exercise some control over afferent activity; de-afferentation (that is, a disruption in the balance between afferent and efferent activity) might explain both perceptions; both perceptions are under the control of the central nervous system; efforts to treat both sensations peripherally have met with limited success.

To this list of similarities Moller3 added: chronic pain and some forms of tinnitus are characterized by hypersensitivity to sensory stimulation; the anatomic locations of the neural structure(s) generating the sensations of chronic pain or tinnitus are different from the locations of the structures to which these symptoms are referred (the ears for tinnitus or the peripheral location of injury for pain); the strong psychological component that often accompanies chronic pain or tinnitus supports the hypothesis that brain areas (limbic/sympathetic) other than those responsible for sensory perception are involved; pain and tinnitus are both heterogenous, multimodal disorders that can have different causes and pathophysiologies; consequently, multimodal approaches should be used to treat these disorders.

Muhlnickel et al4 used magnetoencephalography to compare the organization of auditory cortex in 10 chronic tinnitus patients with that of 15 non-tinnitus control subjects. Results of their study demonstrated that the organization of auditory cortex in tinnitus patients was significantly different from the control subjects, especially in brain areas corresponding to perceived tinnitus frequencies. Muhlnickel et al4 concluded that similarities between these data and the previous demonstrations that phantom limb pain is highly correlated with cortical reorganization suggest that tinnitus may be an auditory phantom phenomenon.

Jeanmonod et al5 hypothesized that positive neurological symptoms (including neurogenic pain and tinnitus) might be attributable to abnormal neuronal activity in the thalamus (specifically, low threshold calcium spike bursts that are related to thalamic cell hyperpolarization). A subsequent magnetoencephalographic study by Llinas et al6 demonstrated that neurogenic pain and tinnitus are both characterized by thalamocortical dysrhythmia resulting from inhibitory asymmetry between high- and low-frequency thalamocortical modules at the cortical level. These findings support the assertions of Jastreboff1, Tonndorf2, Moller3 and others who contend that abnormal asymmetries of neuronal activity are responsible for tinnitus generation.

It is clear that the perception of chronic tinnitus has many physiological characteristics in common with the perception of chronic pain. In his behavioral nosology, Briner7 used the phrase phantom auditory pain to describe severe chronic tinnitus. The present study will explore similarities in psychological characteristics, reactions, and coincidental disturbances exhibited by patients who experience chronic tinnitus or pain. The goal is to contribute to the development of treatment strategies that are likely to be effective for patients experiencing phantom auditory pain.

METHODS:
Detailed questionnaires were mailed to patients prior to their initial appointment at the Oregon Health Sciences University Tinnitus Clinic. These questionnaires requested information about patients medical, hearing, and tinnitus histories. Appendix 1 contains twelve questions that constitute the Tinnitus Severity Index8 which is an efficient indicator of the negative impacts of tinnitus upon patients. The State-Trait Anxiety Inventory (STAI)9 and an abbreviated version of the Beck Depression Inventory (aBDI)10 were also included.

Data relating to patient demographics, audiometric thresholds, matched and reported (according to the 1-to-10 scale in Appendix 1) tinnitus loudness, tinnitus severity, sleep difficulties, aBDI and STAI scores were analyzed.

RESULTS: Data from the last 160 patients (112 males, 48 females; mean age 50.912.8 years; age range 17-87 years) who visited our clinic were analyzed. Table 1 contains the grand averaged pure tone air conduction thresholds for these patients. This pattern of high-frequency sensorineural hearing loss is typical for our patient population.

Table 2 contains mean STAI, aBDI, tinnitus severity scores, matched and reported tinnitus loudness values for three groups of patients based on their response to question 12: Does your tinnitus interfere with sleep? Note that mean values for all of these measures tend to increase with greater sleep interference. Statistically significant differences exist between the No and Often sleep interference groups on all measures except the matched loudness of tinnitus. Statistically significant differences exist between the Sometimes and Often sleep interference groups on all measures except the matched and reported loudness of tinnitus. Statistically significant differences exist between the No and Sometimes sleep interference groups on two measures: severity and reported loudness of tinnitus.

Table 3 contains mean STAI, aBDI, tinnitus severity scores, matched and reported tinnitus loudness values for all of the patients in the study. Because there were no significant differences between male and female patients in any of these measures, correlation analyses were performed on mean values derived from the group as a whole. Fifty patients (31%; 30 males, 20 females) reported that they had current depression. Fifty nine patients (37%; 35 males, 24 females) reported a history of depression. Scores on the aBDI ranged from 0 to 28 (maximum possible score = 39). Thirty four patients (21%) scored 8 or higher on the aBDI which, according to Dobie & Sullivan,10 can indicate that a patient is experiencing major depression.

Table 4 contains Pearson Correlation coefficients and 2-tailed p values that resulted from statistical analyses of these measures. Note that tinnitus severity is highly correlated with STAI and aBDI scores. The reported — but not the matched — loudness of tinnitus is correlated with tinnitus severity, STAI, and aBDI. Both anxiety indices were highly correlated with each other and also with the aBDI.


DISCUSSION:
Results from this and other studies demonstrated that the severity of chronic tinnitus is often correlated with insomnia11, anxiety12, and depression.13 As illustrated in Figure 1, these symptoms can form a vicious circle and exacerbate each other. Insomnia, anxiety, and depression are also common co-symptoms for patients with chronic pain. In fact, the word pain can be substituted for the word tinnitus in Figure 1 and the relationships among these symptoms will remain the same.

What other characteristics do pain patients have in common with tinnitus patients? Numerous studies contributed to the following list: hypochondriasis; obsessive-compulsive tendencies; high degrees of self-focus/attention; perceived lack of control over symptoms/life events; catastrophic thinking; focusing/dwelling on symptoms; maladaptive coping strategies; reluctance to admit to problems other than immediate physical symptoms; the patients perceived severity of their condition is not necessarily related to objective measures of stimulus intensity; severity of symptoms can be related to patients perceptions of attitudes or reactions of others to their condition. Of course, every patient does not necessarily possess any or all of these characteristics. However, these traits are more likely to occur in pain or tinnitus patients who perceive their symptoms to be severe or debilitating.

Did the onset of chronic tinnitus cause these behaviors or co-symptoms to occur? Dobie & Sullivan10 reported that approximately 50% of their tinnitus patients with depression had at least one bout of major depression before the onset of their tinnitus. Rizzardo et al14 reported that 50% of their patients exhibited psychological symptoms before the onset of tinnitus; 71% of these patients experienced greater than normal levels of depression, anxiety, hypochondriasis, and/or neuroticism after tinnitus began.

Rizzardo et al14 stated that there appears to be a link between psychological distress and tinnitus in a potential somatopsychological and psychosomatic vicious circle (a psychological predisposition to react emotionally to events, tinnitus as a source of distress that reinforces the symptom, accentuating hypochondriac fears). Dobie & Sullivan10 agree that some people are more predisposed to depression than others and that tinnitus is one of many internal and external triggers that can precipitate major depression in susceptible individuals. Perhaps the most logical conclusion was stated by Halford & Anderson12: It is considered that the causal relationship between these psychological variables and tinnitus severity is likely to be bi-directional.

How can this information be used to help patients with severe chronic tinnitus? Because tinnitus patients share many similarities with chronic pain patients, otolaryngology clinicians can use some of the same techniques and strategies in tinnitus treatment that are employed in pain management. These include the following15:
1. Treatment of depression using medications and/or psychotherapy. Sullivan et al16 demonstrated that successful treatment of depression can reduce the severity of tinnitus for patients experiencing both maladies. Some antidepressant medications will also improve sleep patterns and reduce anxiety. Identification of tinnitus patients who are also experiencing depression can be accomplished by using the complete Beck Depression Inventory17 or other appropriate instruments (such as the aBDI10).
2. Treatment of insomnia using medications, relaxation therapy, and/or acoustic therapy (this includes pleasant sounds generated in the bedroom by tabletop devices, tapes, CDs, pillow speakers, fans, or small fountains).
3. Treatment of anxiety using medications, relaxation therapy, psychotherapy, biofeedback, hypnosis, massage, or any other appropriate stress management techniques.
4. Any neuroses, psychoses, or other maladaptive behaviors need to be assessed and addressed during a series of psychotherapy/counseling sessions. Many experts agree with House18 who wrote that most tinnitus patients can often be helped by psychological intervention. If the physician, nurse, or audiologist does not feel that they have the time or training to provide the counseling personally, the clinician should refer the patient to an appropriate mental health professional.

Acoustic therapy is one way to give patients some control over — and relief from — their tinnitus. This can include the devices mentioned above as well as in-the-ear sound generators, hearing aids, or combination instruments (hearing aids + sound generators).

Because patients with severe tinnitus often have negative affectivity (characterized by tendencies to be distressed, worried, anxious, and self-critical), their counseling should be as positive and productive as possible. Jakes et al19 admonished clinicians: instead of advising patients that they must learn to live with it with no advice as to how this is to be achieved, one could rather advise them that distress about tinnitus is not determined by having tinnitus, and that an intrusive, subjectively loud tinnitus will not necessarily produce a strong effect on the patient’s social, domestic, or economic functioning. After appropriate tests have ruled out acoustic neuroma or other retrocochlear etiologies for a patient’s tinnitus, clinicians should reassure the patient that tinnitus is usually related to hearing loss20 and that it is a harmless perception of sound generated by the auditory system. Tinnitus will not necessarily become worse with time and it does not portend additional hearing loss nor the manifestation or exacerbation of any other medical condition.

Because each tinnitus patient has a unique medical, psychological and social history, therapeutic interventions should be individualized. In fact, the most successful treatment programs employ multimodal strategies that are designed to address the specific needs of each patient. Hawthorne et al21 concluded that psychiatric intervention significantly reduced the emotional distress in a population of tinnitus patients. This was achieved by not only dealing with the somatic disease but also by psychiatric management of the coincidental mental distress. This was very time-consuming. Many of the patients had complex difficulties; although they all had tinnitus and most had mood disturbance, no history was typical. The problems were protean and the psychotherapeutic interventions had to be tailored for each person.

How effective are individualized, multimodal treatment programs at reducing the severity of chronic tinnitus? We conducted a long-term follow-up study of 174 patients (130 males, 44 females; mean age 55.9 years) who were evaluated and treated in our clinic between 1994-1997. 22 One to four years after their initial clinic appointment (mean = 2.3 years), these patients reported no significant change in self-rated loudness of tinnitus. However, there was statistically significant improvement in nine of the twelve measures of tinnitus severity (including feeling irritable or nervous; feeling tired or stressed; difficulty relaxing; difficulty concentrating; interference with their required activities; interference with their overall enjoyment of life; interference with sleep; the amount of effort to ignore tinnitus; and the amount of discomfort usually experienced when tinnitus is present) for the entire patient population. A subset of 40 patients who purchased and used in-the-ear devices (hearing aids, maskers, or combination instruments) reported significant improvement in all twelve measures of tinnitus severity.

If a clinician has assessed and treated every reasonable medical cause for a patient’s tinnitus, and the patient reports little improvement in tinnitus severity, the clinician should do one of two things: 1) spend the time necessary to effectively treat the patient according to procedures described here and elsewhere23; or 2) refer the patient to a comprehensive treatment center with experienced personnel who are willing and able to spend a substantial amount of time with each patient. For a certain number of patients with phantom auditory pain, only a specialized treatment program of this type can help them to improve their condition. Telling patients that since nothing can be done for tinnitus they just have to learn to live with it is both erroneous and counterproductive.


REFERENCES:
1. Jastreboff PJ. Phantom auditory perception (tinnitus): mechanisms of generation and perception. Neurosci Res 1990;8:221-254.
2. Tonndorf J. The analogy between tinnitus and pain: a suggestion for a physiological basis of chronic tinnitus. Hear Res 1987;28:271-275.
3. Moller AR. Similarities between chronic pain and tinnitus. Am J Otol 1997;18:577-585.
4. Muhlnickel W, Elbert T, Taub E, Flor H. Reorganization of auditory cortex in tinnitus. PNAS 1998;95:10340-10343.
5. Jeanmonod D, Magnin M, Morel A. Low-threshold calcium spike bursts in the human thalamus: common physiopathology for sensory, motor and limbic positive symptoms. Brain 1996;119:363-375.
6. Llinas RR, Ribary U, Jeanmonod D, et al. Thalamocortical dysrhythmia: a neurological and neuropsychiatric syndrome characterized by magnetoencephalography. PNAS 1999;96(26):15222-15227.
7. Briner W. A behavioral nosology for tinnitus. Psychol Rep 1995;77:27-34.
8. Meikle MB. Methods for evaluation of tinnitus relief procedures. In: Aran JM, Dauman R, editors. Tinnitus 91: proceedings of the fourth international tinnitus seminar. Amsterdam: Kugler Publications;1992. p. 555-562.
9. Spielberger CD. State-Trait Anxiety Inventory for adults (Form Y). Palo Alto, California: Mind Garden, 1998.
10. Dobie RA, Sullivan MD. Antidepressant drugs and tinnitus. In: Vernon JA, editor. Tinnitus treatment and relief. Boston: Allyn and Bacon;1998. p. 43-51.
11. Folmer RL, Griest SE. Tinnitus and insomnia. Am J of Otolaryngology 2000;21(5):287-293.
12. Halford JBS, Anderson SD. Anxiety and depression in tinnitus sufferers. J Psychosomatic Res 1991;35:383-390.
13. Folmer RL, Griest SE, Meikle MB, Martin WH. Tinnitus severity, loudness and depression. Otolaryngology – Head and Neck Surgery 1999; 121:48-51.
14. Rizzardo R, Savastano M, Bona Maron M, et al. Psychological distress in patients with tinnitus. J Otolaryngol 1998;27(1):21-25.
15. Irving GA, Wallace MS. Pain management for the practicing physician. New York: Churchill Livingstone; 1997.
16. Sullivan M, Katon W, Russo J, et al. A randomized trial of nortriptyline for severe chronic tinnitus. Arch Intern Med 1993;153:2251-2259.
17. Beck AT, Steer RA. Beck Depression Inventory manual. San Antonio Texas: Psychological Corp.;1987.
18. House PR. Personality of the tinnitus patient. J Laryngol Otol 1984; Suppl 9:233.
19. Jakes SC, Hallam RS, Chambers C, Hinchcliffe R. A factor analytical study of tinnitus complaint behavior. Audiol 1985;24:195-206.
20. Schleuning A. Medical aspects of tinnitus. In: Vernon JA, editor. Tinnitus treatment and relief. Boston: Allyn and Bacon;1998. p. 20-27.
21. Hawthorne MR, Britten SR, OConnor S, Webber P. The management of a population of tinnitus sufferers in a specialized clinic: Part III. The evaluation of psychiatric intervention. J Laryngol Otol 1987;101:795-799.
22. Folmer RL, Griest SE. Improvements in tinnitus severity: a follow-up study. In Hazell J (ed): Proceedings of the Sixth International Tinnitus Seminar. London: The Tinnitus and Hyperacusis Centre, 1999;546-549.
23. Jastreboff PJ, Jastreboff MM. Tinnitus Retraining Therapy (TRT) as a method for treatment of tinnitus and hyperacusis patients. J Am Acad Audiol 2000;11(3):162-177.

There IS something you can do about tinnitus! 2014-10-06T22:13:58-05:00

Barbara Tabachnick Sanders, American Tinnitus Association (ATA), Director of Education

INTRODUCTION

Nearly 50 million people in the U.S.A. have tinnitus. Tinnitus may be described as a ringing, hissing or other noise heard in the ears or head when there is no outside source for the sound. Tinnitus is not a disease but a symptom of an underlying condition in some part of the body – the ear, the auditory nerve, the brain, or elsewhere.

Fortunately, the majority of people who experience tinnitus are able to ignore or dismiss the internal noise they hear as nothing more than a nuisance. But for about 12 million Americans, the noises are unrelenting and distressing. When tinnitus is that severe, it can interfere with one’s ability to sleep, concentrate, hold a job, and interact socially.

Since 1979, the American Tinnitus Association (ATA) has been an advocate and resource for millions of people who have troubling tinnitus and who need answers. ATA is a donation-supported organization that leads the nation in funding tinnitus research. ATA educates patients, adults and children alike;  their families, doctors, and all hearing health professionals regarding the causes of tinnitus and the many ways to relieve it. ATA produces clear and helpful informational brochures for tinnitus patients on coping strategies, treatments, the effects of loud noise on hearing, and the first steps to take.

ATA’s Web site (www.ata.org) is a current and ready resource for anyone seeking tinnitus answers and information today. ATA provides local self-help group and professional resource lists, elementary school hearing conservation programs, the quarterly journal Tinnitus Today, and, perhaps most importantly, hope to thousands of Americans with tinnitus.

CAUSES of TINNITUS

 For millions of people, the cause (or etiology) of their tinnitus is unknown. The most common known cause of tinnitus is exposure to loud noise — usually either a single intense blast (like from a shotgun blast) or a long-term noise exposure (such as from working in a factory for many years).

Tinnitus can also be caused by:

  • ear infections
  •  

  • ear wax (cerumen) buildup
  •  

  • use of aspirin, quinine, alcohol, certain antibiotics, and other drugs
  •  

  • underactive thyroid gland
  •  

  • allergies
  •  

  • middle ear disorders (such as otosclerosis)
  •  

  • Meniere’s disease
  •  

  • disorders of the temporomandibular joint (TMJ)
  •  

  • injury involving the neck or head, like whiplash
  •  

  • acoustic neuroma, a tumor on the auditory nerve

  • Certain prescription drugs (such as “mycin” antibiotics) and non-prescription drugs (such as aspirin) can cause tinnitus in susceptible people. Tinnitus-causing drugs might also make existing tinnitus louder. Ask your doctor or pharmacist, or look on the PDR side effects list for tinnitus-causing drugs. If you are prescribed one of those drugs, ask about a substitute medication.

    DIAGNOSIS of TINNITUS

    Many people ask, “Do I have tinnitus?” The simple answer is, “If you hear it, you have it.” The not-so-simple answer is, “Tinnitus is a symptom of something that has gone wrong somewhere in the body – maybe in the ear, or along the auditory pathway to the brain, or in the brain, or elsewhere.” In the majority of cases, the source of the tinnitus is idiopathic – that is, without a known source. Nevertheless, many physical disorders do include tinnitus as a primary or secondary symptom, and these physical disorders can only be addressed and “ruled out” by professionals.

     

    If you have tinnitus, get a thorough medical and audiological examination. These examinations may uncover a treatable cause and point you to the most appropriate treatment. ATA can give you the names and phone numbers of ENT physicians, audiologists, and other health professionals in your area who are versed in tinnitus management.

    TREATMENT of TINNITUS
    There are many treatments that help people manage their tinnitus. Some common treatment protocols are outlined below:

    Masking is the introduction of an external, pleasant, low-volume sound that reduces the perception of the tinnitus. Maskers (or sound generators) are as small as hearing aids and can be worn the same way. New digital and programmable masking devices are available. These are specialty devices manufactured by hearing aid manufacturers, and can be “tuned” to help mask the sounds of your tinnitus. Masking can also be achieved with environmental tabletop sound machines and special tinnitus masking recordings. Some patients use creative homemade maskers, such as fans, or radios “de-tuned” between stations, or soft music, or even CDs (or cassettes), which play the sounds of a rain forest or a waterfall.

    “Tinnitus retraining therapy (TRT) is a treatment that combines the introduction of sound (usually with masker-like sound generators set to a non-masking level) with specialized and highly beneficial patient education and directive counseling. The goal of TRT is to reduce the patient’s awareness of his or her tinnitus. TRT is available through many audiology offices.”


    Amplification
    with hearing aids helps to bring back environmental sounds that can naturally mask tinnitus. Since many people with tinnitus have hearing loss, there is often a double benefit for those patients. For example, patients with hearing loss and tinnitus may discover hearing aids help them hear more easily, which can — in and of itself — reduce stress and make the tinnitus more tolerable. In some cases, the amplified sounds heard through hearing aids mask the tinnitus.

    Several medications have shown limited, but positive effects on tinnitus. Xanax, Neurontin, Pamelor, Klonopin, and dozens of other prescription drugs are helping people cope more effectively with their tinnitus. All medications have the potential for unwanted side effects. These side effects need to be weighed against the possible benefit they might deliver. Of course, all medical options should be reviewed with your physician.

    Some herbs have been reported to help manage or reduce tinnitus. While there is little scientific evidence of these successes, there are many anecdotal and individual reports of success. Herbs can behave like medicines in the body and interact with other medicines being taken. As a precaution, always talk with your doctor before trying herbal preparations.

    Acupuncture, biofeedback, and hypnosis have also been used with anecdotal success. Relaxation and stress-reduction exercises (such as progressive relaxation) can help make tinnitus more tolerable. It is well known by professionals that stress and anxiety can exacerbate (or worsen) tinnitus.

    Although not exactly a tinnitus treatment, the use of hearing protection is an important part of any tinnitus treatment plan. Existing tinnitus is often made worse by exposure to loud noise. The ATA suggests that earplugs, protective earmuffs, or a combination of the two be worn in very noisy situations. Foam earplugs are relatively inexpensive (less than two dollars a pair at most pharmacies) and, if properly situated in the ear, can cut out 15 to 20 decibels of sound. “Musicians’s Earplugs” are customized earplugs that can cut out 15 decibels across all frequencies, which enables the wearer to hear music and conversations, just at a quieter level. Customized earplugs are more expensive, but they are made to comfortably and exactly fit the wearer’s ears. .

    Since a combination of treatments is often what a patient needs to obtain relief, it usually takes persistence and patience to find the right tinnitus management therapy for each individual.

    Tinnitus Research

    There are dozens of tinnitus-specific research studies in progress around the world. The American Tinnitus Association, the Tinnitus Research Consortium, the National Institute of Deafness and Other Communication Disorders, and various universities have funded these studies. Some of the research projects are examining the benefits of cochlear implants, electrical stimulation, and experimental drug therapies for tinnitus patients, and at brain scanning to see which parts of the brain “light up” when tinnitus is present.

    Education and Support for Patients

    While the search for a cure continues, ATA’s educational programs and support networks help fill in the gaps for tinnitus patients. ATA sponsors a national network of health professionals – ENTs, audiologists, mental health professionals, and hearing aid specialists- all who treat tinnitus patients. ATA also sponsors a national self-help network. Lists of local support groups and tinnitus health professionals are available from ATA. Many audiologists assist or become tinnitus support group leaders.

    ATA reaches out to children with our Hear for a Lifetime program. Hear for a Lifetime helps 1st through 3rd graders understand that they can walk away from loud noise, turn it down, or cover their ears to conserve their good hearing.

    Educating Health Professionals about Tinnitus

    Tinnitus sufferers usually seek medical attention when their tinnitus first appears. Unfortunately, the majority of patients are told by their doctors that “nothing can be done” and that they need to “learn to live with it.” But most are not told how to live with it, or about the many treatment options available (see above).

    The impact that unremitting tinnitus has cannot always be measured or understood. Consequently, many doctors dismiss tinnitus, to the great (and sometimes tragic) dismay of the patient. ATA is committed to educating health professionals about current tinnitus treatments, the value of one-on-one support, the benefits of counseling and the unnecessary havoc created when they tell patients to live with it.

    Today, more professionals than ever are taking the time to explore the myriad of tinnitus treatment options with their patients. Many understand that the solution to a particular patient’s tinnitus might lie outside their professional domain. And importantly, more are willing to work in concert with other health professionals for the benefit of the patient.

    When healthcare professionals, family members, and patients learn about tinnitus – its treatments, causes, and breakthroughs in research, ATA accomplishes the best part of its mission: to help tinnitus patients find the answers and help they seek.

    Frequently Asked Questions about Tinnitus

    What is tinnitus?

     Tinnitus is the perception of sound when no external sound is present. The noise can be ringing, screeching, hissing, humming, clicking, chirping, buzzing, even music; constant or intermittent; subtle or perceived as incredibly loud.

    Now that I have tinnitus, what is the first thing I should do?

    See an ear, nose, and throat doctor (otolaryngologist) and an audiologist to rule out any serious medical problem. Next, learn about your options and get involved in choosing your treatments. Use earplugs or other hearing protection in noisy environments to possibly avoid worsening the tinnitus. Join the American Tinnitus Association to keep current on new tinnitus treatments and to support research.

    Can tinnitus be prevented?

    Yes, some tinnitus can be prevented. Protect your ears with earplugs and/or protective earmuffs in all loud environments! Since many drugs can cause tinnitus, ask your doctor or pharmacist about the possible side effects of medications (and herbs) before you take them.

    Does having tinnitus meant I am going deaf?

    No. While an estimated 80% of people with tinnitus have some hearing loss, a significant number of people with tinnitus have normal hearing. Hearing loss may often help reveal or worsen existing tinnitus since the background sounds that had previously been heard, and were helping to “mask” the tinnitus, are no longer being heard.

    Is there a nutritional approach to treating tinnitus?

     There is no research on this subject. However, some patients report anecdotally that their tinnitus is made worse by consuming certain foods, such as cheese, salt, caffeinated foods (coffee, tea, chocolate), red wine, and aspartame (Nutrasweet).

    How can I join the American Tinnitus Association?

    You can write, call, or go online to join ATA.
    American Tinnitus Association
    P.O. Box 5
    Portland, OR 97207-0005
    503-248-9985
    800-634-8978
    www.ata.org
    tinnitus@ata.org
    Annual membership is $25 in the U.S., $40 outside of the U.S.

    All ATA members receive the quarterly journal, Tinnitus Today, featuring research updates, Jack Vernon’s Q & A column and articles of special interest to tinnitus patients and their families. Members also receive six educational brochures on treatments, coping, noise, and more; lists of local tinnitus support groups and health care providers; discounts on tinnitus-related books and videos; and access to the Member’s Only section on ATA’s Web site (www.ata.org).

    FINAL THOUGHTS

    Tinnitus can be a debilitating problem. But fortunately there are many successful treatment programs. If you have tinnitus, see an audiologist and a physician for a complete examination before starting a treatment plan. It might take a combination of treatments (for example, TRT and medication, or masking and biofeedback) and possibly some lifestyle changes (avoiding certain foods, alcohol, caffeine, or tobacco) to best manage your tinnitus.

    Additionally, if a health care professional has told you to “go home and learn to live with it” without telling you HOW to live with it, seek other professional advice. And please, visit ATA?s Web site (www.ata.org) or call 800-634-8978 for the latest tinnitus information and self-help resources.

    The American Tinnitus Association: A Resource for Enhancing Tinnitus Patient 2014-10-06T22:22:37-05:00

    The American Tinnitus Association: A Resource for Enhancing Tinnitus Patient Services

    Cheryl McGinnis, MBA, Executive Director of the American Tinnitus Association.


    Introduction and History:

    The American Tinnitus Association (ATA) assists healthcare providers in serving patients who have, or are learning to cope with, tinnitus. An estimated 40-50 million people in the United States experience tinnitus, 10-12 million of these individuals have sought help for their tinnitus and 2.5 million people report their tinnitus is debilitating (AAA, 2001).

    Hearing healthcare services in general, and audiologic services in particular, are in demand as these patients seek answers and relief from the ringing, hissing, roaring, or other sounds that are perceived, but cannot be attributed to an external sound source.

    Charles Unice, MD, and Jack Vernon, PhD, founded the American Tinnitus Association (ATA) in 1971 for the purpose of providing financial support for tinnitus research. During the early years, the University of Oregon Medical School (now known as the Oregon Health Sciences University) sponsored ATA as an affiliate nonprofit association. Advisors to the ATA were scientists, academicians, clinicians, businessmen, and public officials. Volunteers completed all activities of the association until 1979 when a small full-time staff was hired and the ATA was incorporated as a 501©(3) organization. Robert Hocks, a Portland businessman, was the first Board of Directors Chairman and Gloria Reich, PhD, was the first Executive Director.

    The ATA currently has a 13 member Board of Directors and a 22 member Scientific Advisory Committee (SAC). The Board of Directors is responsible for the governance issues of the association including setting policies. The Scientific Advisory Committee members are physicians, audiologists, and other researchers who review research grant applications and advise the Board and staff on scientific matters.

    ATA’s research grant program funds tinnitus research projects at the nation’s top institutions. Many ATA funded projects have gone on to receive support from the National Institutes of Health. Please visit our Web site (www.ata.org) for a listing of research projects funded. To date, ATA’s support for tinnitus research exceeds $1.3 million. Our goal is to fund $500,000 in research projects for each of the next three years. Musicians including Styx and Barbara Streisand, as well as others, have donated money for tinnitus research.

    Importantly, funding research was not (and is not) the only function of the ATA. People with tinnitus and tinnitus treatment specialists requested many things of the ATA. Callers asked for information about the condition and for techniques that would provide relief. In 1978, ATA initiated workshops, regional meetings, and seminars for professionals and patients to learn about tinnitus.

    Public Service Announcements (PSAs) to raise public awareness featured such celebrities as Lou Ferrigno (actor in Incredible Hulk TV series), William Christopher (actor in M*A*S*H series), Tony Randall (actor in Odd Couple series), and Al Unser (auto racing driver).

    Tinnitus Diagnosis and Management:

    The diagnosis and management of tinnitus has become highly specialized. The long wait to obtain appointments in tinnitus clinics across the U.S. gives testimony to the need for this focused, specialized care. A person troubled by tinnitus will usually seek services from a family physician, an ENT, or an audiologist. This is where appropriate diagnosis must begin. ATA staff encourage tinnitus patients to seek diagnosis and treatment from physicians and audiologists. A multidisciplinary team approach is recommended (AAA, 2001). Interestingly, hearing loss is a co-existing condition for 90% of individuals who have tinnitus.

    The most common cause of tinnitus is exposure to excessively loud noise – either a single intense event (acoustic trauma), or long-term noise exposure. Other causes of tinnitus might include; physical trauma to the head or neck, acoustic trauma, conditions such as hypertension, acoustic neuroma, ear infection, impacted cerumen, ototoxic drugs, thyroid disease, vascular disorders, TMJ disorder, nutritional deficiency, aneurysm, multiple sclerosis, and many others. Prescription and over-the-counter drugs can exacerbate tinnitus. In some cases, tinnitus will lessen or completely disappear when the offending drug is discontinued.

    The physician’s role in tinnitus diagnosis and treatment is typically to rule out, counsel or treat physical or medical causes of tinnitus. In some cases, successful treatment of a medical condition can relieve tinnitus. Most patients who seek medical help for their tinnitus learn there is no serious medical problem causing their condition. This knowledge is sometimes enough to allow some patients to adapt to their tinnitus. Other people, however, experience tinnitus as disruptive and stress inducing, and need help learning how to cope with and manage the sounds.

    The audiologist’s role is multifaceted and relates to comprehensive testing (including; diagnostic audiometric evaluations, loudness discomfort levels, tinnitus pitch and loudness matching, minimal masking level, questionnaire administration and interpretation), hearing protection, hearing aids, tinnitus maskers, assistive listening devices, tinnitus management therapies, counseling and tinnitus support group participation and facilitation.

    Sometimes referral to a professional counselor or other specialists experienced in managing tinnitus patients, is particularly beneficial when stress, depression or obsession with tinnitus is noted by the audiologist or the physician.

    Tinnitus Treatment Strategies:

    Among the vast treatments for tinnitus, the most common treatments include:

    *Hearing aids are often used to help ‘cover-up’ tinnitus by increasing the sounds of the environment. Multiple memory (multiple program) hearing aids are sometimes useful as they provide alternative sounds to listen to, depending on the tinnitus and the acoustic environment.

    *Specialized tinnitus maskers which produce low-level sound to reduce or eliminate the perception of tinnitus. Masking can cause ‘residual inhibition,’ the reduction or elimination of tinnitus that continues for a short time after the masker is removed.

    *Combined hearing aid/tinnitus maskers, in one unit. These units allow the patient to select which circuit to listen to, either the masker or the traditional hearing aid circuit.

    *Tinnitus retraining therapy (often referred to as TRT) involves directive counseling to de-mystify tinnitus. Tinnitus retraining therapy also uses maskers to help a person learn to be less aware of, or to habituate to, the sounds of their tinnitus.

    *Biofeedback is essentially a method of relaxation, sought as a stress-reduction technique to help control heart rate, blood pressure, breathing, and muscle tension.

    • Drugs can help ease stress, depression, and sleep difficulties. Many of these drugs are available by prescription only, and most have met with minimal, although highly variable success.

    *Counseling services can assist with stress, depression or anxiety that may accompany tinnitus. Cognitive therapy helps patients alter the way they react to tinnitus by identifying and eliminating negative thought and behavior patterns.

    *Alternative treatments sought include naturopathy, hypnosis, massage therapy, and acupuncture.

    Professional advice is beneficial to best match the patient with an appropriate treatment strategy. Referring patients to the ATA will further enhance the services provided directly. For people seeking tinnitus information, often the local healthcare professionals are the best first step. Secondarily, ATA can provide additional patient support though our education, advocacy, research and support services.

    ATA Services and Resources:

    The American Tinnitus Association’s many programs are organized under the acronym E.A.R.S. – Education, Advocacy, Research, and Support.

    The education program includes ‘Hear For a Lifetime,’ which teaches 1st through 3rd grade students how to avoid tinnitus. Additionally, we offer outreach programs to doctors, audiologists, and hearing aid specialists regarding tinnitus and treatment as part of our education program.

    Our two most visible and popular means of providing information are through our quarterly journal, Tinnitus Today, which is sent to all ATA members, and the ATA Web site www.ata.org.

    ATA offers books, videos, audiotapes, informational brochures, and posters. Our bibliography service includes over 4,000 article titles related to tinnitus. ATA’s six educational brochures answer the most common questions about tinnitus and are available in English and in Spanish.

    Brochures are sold for 25 cents each to members and $1.00 each to non-members. Information covered is described by the titles:

     

  • Coping with the Stress of Tinnitus; Information about Tinnitus;
  •  

  • Noise and Its Effects on Hearing and Tinnitus;
  •  

  • If You Have Tinnitus: the First Steps to Take;
  •  

  • Tinnitus Treatments: What’s New, What Works; and
  •  

  • Understanding Tinnitus: Advice for Family and Friends.
  •  

    ATA sponsors several public forums around the U.S. annually. Our public forums feature panels of audiologists, physicians, and researchers with expertise in tinnitus. Equal time is given for attendees to ask questions of the experts.

    Our advocacy department researches public policy issues, supports hearing conservation activities, and provides resources for people needing specific assistance on such things as pursuing insurance claims. Our national media campaign aims to raise awareness, generate support for research, and educate people on ways to prevent tinnitus.

    The support program includes self-help groups, help network volunteers, and provider listings – all resources to help people cope with tinnitus. Self-help groups meet regularly to share coping strategies, offer a supportive environment, and emphasize positive change. ATA has a network of 50 self-help groups. Group leaders receive information and organizational support from the ATA. Frequently, leaders schedule guest speakers – audiologists, biofeedback specialists, medical doctors, psychologists, and others who actively treat tinnitus patients.

    Help Network Volunteers are friendly telephone, e-mail, and letter contacts that listen and respond to callers needing understanding, comfort, and information. In this way, support and comfort is given while engaging in a healthy dialogue about ways to successfully manage tinnitus.

    Our Tinnitus Provider Listing includes the names and contact information of physicians, audiologists, and other healthcare providers who have an active interest in treating tinnitus. The listed professionals self-report their specialties and services and are listed by region for distribution to interested patients.

    Tinnitus is often as frustrating for the clinician to treat as it is for the patient to resolve. The ATA is a resource available to tinnitus patients and healthcare professionals. We invite you to become involved in the ATA as a member yourself.

    You can contact us by calling (800) 634-8978, writing to us at PO Box 5, Portland, OR 97207, or e-mailing tinnitus@ata.org.

    Recommended Resources and References:

    AAA (2001). American Academy of Audiology Position Statement on ‘Audiologic Guidelines for the Diagnosis and Management of Tinnitus Patients.’ Audiology Today, Vol 13, No 2, March/April 2001.

    Tyler, R. S., (Ed.). (2000). Tinnitus Handbook. San Diego, CA: Singular Thomson Learning.

    Vernon, J. A. & Tabachnick Sanders, B. (2001). Tinnitus questions and answers. Needham Heights, MA: Allyn & Bacon.

    To view all Healthy Hearing Articles on Tinnitus, please click here.

    Why Arent Hearing Conservation Practices Taught in Schools? 2014-10-06T22:12:26-05:00

    Robert L. Folmer, Ph.D., Oregon Hearing Research Center, Oregon Health & Science University, Portland, OR
    Robert L. Folmer, Ph.D.
    Oregon Hearing Research Center
    Mail Code NRC04
    Oregon Health & Science University
    3181 SW Sam Jackson Park Road
    Portland, OR 97201-3098

    Telephone: (503) 494-8032
    Fax: (503) 494-5656
    email: folmerr@ohsu.edu
    web: www.dangerousdecibels.org

    According to the OSHA’s Occupational Noise Exposure Standard and Hearing Conservation Amendment (published in the Federal Register on March 8, 1983), if workers are exposed to excessive sound levels, “the employer shall administer a continuing, effective hearing conservation program.”

    Children are often exposed to excessive levels of sound

    At some time in their young lives, 97% of 273 third graders surveyed by Blair et al (1996) had been exposed to hazardous sound levels. Chermak & Peters-McCarthy (1991) reported that 43% of the elementary school students in their study routinely listened to a personal stereo system or television at a loud volume. Thirty percent of the students said they sometimes participated in other noisy activities (such as shooting firearms or attending auto races); however, only 5.5% of the students ever used hearing protection while engaged in these activities. Sources of excessive sound exposure for children include loud music (Lipscomb, 1972; Meyer-Bisch, 1996), real or toy firearms (Woodford, 1973; Lipscomb, 1974), power tools (Roeser, 1980; Plakke, 1985), fireworks (Ward & Glorig, 1961; Gupta & Vishwakarma, 1989), loud toys (Axelsson & Jerson, 1985; Hellstrom et al, 1992); snowmobiles or other loud engines such as jet skis or motorcycles (Bess & Poynor, 1972).

    Noise-Induced Hearing Loss (NIHL) in children

    When humans of any age are repeatedly exposed to hazardous sound levels without using adequate hearing protection, the common result is noise-induced hearing loss (NIHL). Several studies have demonstrated that the prevalence of NIHL among children is increasing (Woodford & O’Farrell, 1983; Chermak & Peters-McCarthy, 1991; Montgomery & Fujikawa, 1992). Anderson (1967) reported a surprisingly high prevalence of NIHL in school-aged children more than 30 years ago. Blair et al (1996) claimed that 1% of the school age population has some degree of NIHL. Niskar et al (2001) estimated that 12.5% of all children in the United States aged 6 to 19 years have noise-induced hearing threshold shifts (NITS) in one or both ears. Studies by Weber et al (1967), Cozad et al (1974) and Hull et al (1975) all found relatively large numbers of school boys who failed hearing screenings at 4000 Hz — an indicator of NIHL. Evidence of NIHL was also observed in Swedish (Costa et al, 1988), Chinese (Morioka et al, 1996) and French (Meyer-Bisch, 1996) children.

    What are the consequences of NIHL in children?

    Even though the degree of high frequency hearing loss detected in these studies was generally mild and usually not even noticed by the children involved, Lass et al (1986) warned: “the significance of the problem lies in the insidious nature of noise-induced hearing loss (NIHL) as well as the cumulative interaction between this type of loss and sociocusis. It follows then that a mild high-frequency hearing loss in a 16-year-old high school student may well deteriorate to a debilitating degree in later life. Additionally, there is another factor that could indicate that damage to the auditory system in this population is more prevalent and/or significant than might be believed from results of hearing tests.” Prasher (1998) reiterated the assertion that audiometric thresholds may be normal despite substantial loss of outer and inner hair cells.

    Children with high frequency hearing loss in Anderson’s (1967) study had more learning difficulties and behavioral problems than their classmates who had normal hearing. Bess et al (1998) reported that, compared to their classmates with normal hearing, children with minimal sensorineural hearing loss (MSHL) scored significantly lower on the Comprehensive Test of Basic Skills; they also exhibited more behavioral problems and lower self-esteem. Thirty-seven percent of children in the study with MSHL failed at least one grade compared to the school district average of eight percent or less.

    What should be done?

    In response to this trend of increasing NIHL among children, numerous experts have recommended the implementation of hearing conservation education programs in schools:

    “Educating students to the possible consequences of future vocational and avocational noise exposure, as well as instructing them in how to protect their hearing when exposed to noxious noise levels, may prevent further hearing loss and perhaps extensive communication problems later in life.” (Cozad et al, 1974)

    “The findings from this survey certainly suggest the need for some form of hearing conservation program at the high school level.” (Roeser, 1980)

    “Hearing-conservation programs are needed to provide students with the proper information about hearing and hearing loss, and about the protective measures to prevent hearing loss at home, in school (e.g., in industrial art classes), and at social/recreational events.” (Lass et al, 1987a)

    “Education on the hazards of noise is needed at all levels, and early education is particularly important.” (Florentine, 1990)

    “Strategies to prevent damage from sound exposure should include the use of individual hearing protection devices, education programs beginning with school-age children, consumer guidance, increased product noise labeling, and hearing conservation programs for occupational settings.” (National Institutes of Health Consensus Development Conference Statement, 1990)

    “Due to the rising numbers of children acquiring noise-induced hearing loss (increasingly in the elementary school years), education about the impact of excessive noise on hearing would be a worthwhile addition to the health curriculum of any school district. It is only through early and repeated education that we may reach these young people so that they may responsibly prevent permanent hearing loss.” (Anderson, 1991)

    “Hearing conservation programming should begin no later than third or fourth grade in order to prevent noise-induced hearing loss.” (Chermak & Peters-McCarthy, 1991)

    “Education regarding the potential dangers of high decibel levels for students should begin in the elementary grades.” (Montgomery & Fujikawa, 1992)

    “Comprehensive, age-appropriate educational programs must be developed for elementary and secondary students and their parents to acquaint them with potentially hazardous noise sources in their environment.” (Brookhouser et al, 1992)

    “Otolaryngologists should support efforts to provide information about NIHL as part of health education in our schools.” (Dobie, 1995)

    “The percentage of high-frequency hearing losses is greater in the upper grades, suggesting that hearing conservation programs should be introduced in the elementary grades.” (Blair et al, 1996)

    “Educate the public and especially children to practice lifetime hearing health with regular audiograms and ear protection against toxic noise.” (Wheeler, 2000)

    Even though children are often exposed to excessive sound levels, there are no policies requiring hearing conservation practices to be taught in our nation’s classrooms. In spite of mounting evidence that the prevalence of NIHL is increasing among children — and contrary to the recommendations of countless audiologists and other experts in the field — basic hearing conservation information (that could prevent many cases of NIHL) remains conspicuously absent from most school curricula.

    Why aren’t hearing conservation practices taught in most schools?

    • Lack of public awareness about how excessive sound exposure damages hearing and the consequences of hearing loss. In general, people tend to take hearing for granted until their own hearing loss becomes so severe that it interferes with communication. Because most teachers, school administrators, and parents are not aware of the problem, hearing conservation and the preventability of NIHL are given a low priority if they are considered at all.
    • Lack of effective dissemination of existing hearing conservation programs, curricula, and materials.

    Berger & Royster (1987) made the following statement about occupational hearing conservation programs: “In large part, what is needed is not the development of new solutions, but rather the broad dissemination of existing techniques plus the education and motivation of management and labor alike to speed the implementation of effective programs.” If we substitute the words “administrators, teachers, parents, and students” for “management and labor,” this statement would also apply to school hearing conservation programs.

    The problem is not a lack of hearing conservation education materials and resources. The problem is not a lack of agreement among experts about what should be done. Given the paucity of hearing conservation instruction that is offered in our nation’s schools, the problem is a lack of dissemination of this important information to our children.

    • Lack of perpetuation of hearing conservation instruction. A relatively small number of teachers, audiologists, nurses, or trained volunteers have presented hearing conservation curricula in selected classrooms across the country. However, if the person who implemented the program retires, moves, or stops making such efforts for other reasons, hearing conservation education in those schools usually diminishes or ceases completely.

    What can be done to address these problems?

    • Raise public awareness about hearing; how hearing can be damaged by excessive sound exposure; the consequences and permanent nature of sensorineural hearing loss; how NIHL can and should be prevented.
    • Inform teachers and school administrators about existing hearing conservation programs, curricula, and materials that can be used in classrooms.
    • Persuade teachers and school administrators to integrate hearing conservation messages into existing lesson plans on hearing, sound, music, science, math, and health.
    • Seek a mandate from state and local school boards, and state or federal legislatures to implement and perpetuate hearing conservation instruction to each new 1st, 4th, 7th, and 10th grade class of students in all of the nation’s schools on a continuing basis.

    What elements should be included in a hearing conservation education program for children?

    Lass et al (1987a) recommended the following: Instruction about 1) normal auditory mechanisms; 2) types of hearing loss and their causes; 3) noise and its effect on hearing; 4) warning signs of noise-induced hearing loss; and 5) specific recommendations for preventing noise-induced hearing loss. Anderson (1991) added the following topics to the list: Instruction about consequences of hearing loss and how it can affect life quality; what kinds of noises or noisy activities are most dangerous to hearing?

    It is not necessary to spend exorbitant amounts of class time to cover the basics of hearing, hearing loss and hearing conservation. Teachers should be encouraged to integrate the information into existing lesson plans on hearing, sound, music, science, math, and health.

    Chermak et al (1996) reported that students who received the hearing conservation message through an interactive style of instruction exhibited greater improvement on post-instruction tests than students who heard it in a more traditional lecture format. Results from a study by Bennett & English (1999) agree with this conclusion. Therefore, a hearing conservation program for children should be as interactive as possible and utilize a variety of media and activities.

    What resources are available to facilitate hearing conservation instruction in classrooms?

    Table 1 lists twelve organizations that produce or use a variety of materials in a comprehensive hearing conservation curriculum for school-age children.

    To view Table 1 please Click Here. (Requires Adobe Acrobat)

    The Crank It Down! curriculum includes construction of a sound thermometer, spaghetti and Play-doh model of stereocilia, and demonstrations of proper usage of hearing protection. The “Know Noise” video and “Unfair Hearing Test” audiocassette — a list of 10 common words with high frequencies filtered out to simulate hearing loss — (both available from the Sight and Hearing Association) also are used. Crank It Down! has been presented by trained guest speakers to students in second, third, fourth, and fifth grades. Presentations to students in second and third grades can be shortened and simplified by leaving out the sound thermometer and “Unfair Hearing Test” activities. Crank It Down! materials are available from the National Hearing Conservation Association.

    Dangerous DecibelsTM is a hearing health education program being developed by the Oregon Hearing Research Center and the Oregon Museum of Science and Industry. Program goals are to raise public awareness about mechanisms of hearing and hearing loss, and to educate people about sources of, effects of, and how to protect themselves from hazardous levels of sound. When completed, the program will include 11 permanent museum exhibits; classroom curricula and activities for all school-age children; training and materials for teachers; epidemiological and educational research components.

    HIP Talk was developed by the House Ear Institute in Los Angeles. The curriculum, originally designed for fifth- and sixth-graders, includes information about ear anatomy (illustrations are provided), environmental noise, hazardous sounds, and ways to protect hearing. Also included are separate quizzes for elementary, middle school, and high school students; the “HIP Talk” video (produced in 1992, 34 minutes); 400 pairs of foam ear plugs to distribute to students; and a form that solicits comments about the curriculum from teachers. The video is a significant component of the curriculum. Because much of the video consists of a panel discussion among musicians and a moderator, it will not hold the attention of most students. However, a brief segment of the video contains an effective simulation of hearing loss: the audio portion of a Flintstones cartoon is filtered to demonstrate mild, moderate, and severe high frequency hearing loss.

    Know Noise is distributed by the Sight and Hearing Association of St. Paul, Minn. The Know Noise program includes lesson plans, activities, illustrations, and transparencies for grades three through six. Also included are the “Know Noise” video (produced in 1993, 14 minutes), the “Unfair Hearing Test” audiocassette, supplemental articles, and teacher comment forms. The main weakness of this program is the video. Although it conveys some useful information, the “Know Noise” video, like many hearing conservation videos, is dated. This problem is recognized by producers of educational materials: videos are expensive to make and they tend to go out of date quickly. If the fashions, music, and dialogue seem antiquated or “corny” to an audience of children (especially older children), these distractions tend to dilute any educational message contained in the video. However, carefully selected portions of videos that are less susceptible to this aging process (and still convey pertinent information) may be used indefinitely.

    Wise Ears, one of the most complete hearing conservation curricula for children available on the Internet, is provided by the National Institute on Deafness and Other Communicative Disorders (NIDCD). Their web site includes lesson plans and activities for grades three through six, questions and answers about hearing, an interactive sound ruler, and three videos. NIDCD also distributes the video “I Love What I Hear” (produced in 1992, 8 minutes) to be used in the classroom.

    Table 2 lists seventeen organizations that produce one or a few types of material (e.g., a video or printed material) designed for children or which could be adapted for use in a classroom.

    To view Table 2 please Click Here. (Requires Adobe Acrobat)

    Perry Hanavan’s “Virtual Tour of the Ear” web site provides a comprehensive list of links to dozens of web sites that contain a variety of illustrations, photographs, micrographs, and animations of the outer, middle, and inner ear as well as auditory structures in the brain.

    To encourage people to protect their ears from hazardous noise, most hearing conservation programs include some information about how the ear works and how excessive sound exposure causes permanent damage to inner ear structures. One of the fastest and most entertaining ways to convey this information is to use animations such as those in “The Hearing Video” produced by the Workers’ Compensation Board of British Columbia, Canada. Portions of this fast-paced, informative, and entertaining video can be used with students of all ages. One negative aspect of “The Hearing Video” is its relatively high purchase price. A less expensive video that illustrates auditory system function and damage is “Quieting the Skies” (available from N.A.S.A. Central Operation of Resources for Educators). A much more technical, anatomically accurate and expensive video series, “Human Hearing,” is being produced in four volumes by Caldwell Publishing Co., in Redmond, Wash.

    Most of the other resources listed in Table 2 provide basic information (booklets, pamphlets, posters, or web sites) about hearing and the consequences of excessive sound exposure. For example, Howard Leight Industries produces posters and leaflets with photomicrographs of a normal cochlea with the caption “This is your inner ear,” and a cochlea damaged by excessive sound exposure with the caption “This is your inner ear without plugs. Any questions?”

    How effective are hearing conservation programs for children?

    Numerous studies evaluated the effectiveness of hearing conservation programs administered in elementary schools (Chermak & Peters-McCarthy, 1991; Blair et al, 1996; Chermak et al, 1996; Bennett & English, 1999), middle schools (Lass et al, 1987b; Knobloch & Broste, 1998), and high schools (Lewis, 1989; Lerman et al, 1998; Lukes & Johnson, 1998). All these studies concluded that, compared to preinstruction responses, students’ performance on hearing knowledge and noise awareness questionnaires improved significantly after they participated in hearing conservation programs.

    It is much more difficult to assess potential changes in behavior that might occur as results of these programs. Knobloch and Broste (1998) reported that 87.5% of students who received hearing conservation instruction used hearing protection devices in noisy environments at least some of the time. Only 45% of students in control groups who did not receive such training reported using hearing protection in similarly noisy conditions. Studies by Lass et al (1987b), Lewis (1989), and Chermak et al (1996) all reported postinstruction increases, compared to preinstruction responses, in student intentions to protect their ears from excessive sounds.

    The ultimate goal of hearing conservation education programs is to reduce the prevalence of noise-induced hearing loss among children and adults. Even if hearing conservation instruction began immediately in all of the nation’s classrooms, it would take years to determine if such instruction had any effect on the prevalence of NIHL in the United States. However, every person who can be spared the debilitating consequences of NIHL (including communication difficulties, isolation, frustration, depression, or chronic tinnitus) is worth the effort.

    Conclusion

    Hearing conservation should receive attention and resources similar to those allocated for anti-smoking, anti-drug, teen pregnancy, and sexually transmitted disease education programs that are now presented routinely in public schools. The time is now to wage a public health campaign against NIHL, a potentially debilitating condition that, according to Dobie (1995), “is almost entirely preventable.”
    ___________________________________________________________________

    This article was adapted from Folmer RL, Griest SE, Martin WH. Hearing conservation education programs for children: a review. Journal of School Health 2002;72(2):51-57.

    References

    Anderson KL. Hearing conservation in the public schools revisited. Seminars in Hearing 1991;12(4):340-364.

    Anderson UM. The incidence and significance of high-frequency deafness in children. Am J Dis Child 1967;113:560-565.

    Axelsson A, Jerson T. Noisy toys: a possible source of sensorineural hearing loss. Pediatrics 1985;76(4):574-578.

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    Hearing Aids: Reasonable Expectations for the Consumer 2014-10-06T22:11:41-05:00

    Rose L. Allen, Ph.D., CCC-SLP/A, Assistant Professor of Audiology, East Carolina University, Dept. of Communication Sciences & Disorders

    Editor’s Note: This article was the winning submission for the Audiology Online (www.audiologyonline.com) contest sponsored by Rayovac Ultra Pro Line, for the best new article written for consumers and patients, titled “Hearing Aids: Reasonable Expectations for the Consumer.” We offer Dr. Allen our congratulations for her excellent work, and we invite the readers to download (in its entirety) and distribute this article to their patients for educational purposes. —-Editor

    INTRODUCTION:

    Since you are considering the purchase of hearing aids, it’s important for you to establish reasonable expectations from these highly sophisticated, miniature devices. Acquiring hearing aids is not merely a simple act of going to a store and purchasing a product.

    Rather, it is a complex process – one that evolves over time and begins with the hearing-impaired individual accepting the realization that hearing impairment has detrimental effects on interpersonal relationships and safety. The hearing impaired person’s motivation to hear well is the single most important factor in determining the success of the hearing aid fitting. It is important to realize that you will not experience the exact same benefits from your hearing aids as your neighbor does. This individuality is a critical component, and I want to emphasize that your expectations should be based on you, your type and degree of hearing loss, your past experiences, and the improvements you personally receive from amplification.

    The title of this article implies there are “reasonable expectations” for the consumer. Therefore, there must also be “unreasonable expectations”. For the most part, there is only one totally unreasonable expectation – do not expect normal or perfect hearing.

    It is my hope that this point-by-point tutorial will help guide you in establishing realistic and reasonable expectations from hearing aids, from the professionals you interact with, through the process of acquiring hearing aids, using them effectively, maintaining them, and living the fullest life possible.

    1. Expect others to notice your hearing loss before you do! A common complaint of hearing-impaired individuals is that other people mumble – and if they would just speak up, it would be easier to hear them! This is placing the “blame” externally, rather than accepting the reality that your ears are not as good as they used to be. Realize that it is your hearing. Take that step to have your hearing tested before you blast your loving spouse out of the den with the blaring sound of the TV set. Seek the advice of your local hearing instrument specialist (HIS), who you will find listed in the yellow pages under “hearing  aid specialist” or “hearing aids”. Of course, another option is to go to the Healthy Hearing website (www.healthyhearing.com), and if you enter your city and state, or just your zip code, a list of professionals will be created for you.

    2. Expect your Hearing Instrument Specialist (HIS) to be knowledgeable, courteous, and accommodating. Your HIS will take a thorough case history. He/She is searching for information about your hearing loss, it’s probable cause, and whether your offspring may be affected. It is important to establish the presence of any medical condition associated with your hearing loss as this will trigger a medical referral. Comprehensive hearing and hearing aid evaluations will be conducted. These evaluations will provide information about the degree and nature of your hearing loss, as well as your ability to process and discriminate the fine sounds of speech. Comfortable listening levels will be defined, as well as a determination about how well you tolerate loud, intense speech and other sounds. These findings are very important as they allow the professional to pre-set some of the characteristics of the hearing aid’s circuitry. You will have time to talk with the HIS about the differing styles of hearing aids (in-the-ear, in-the-canal, completely-in-the-canal, behind-the-ear), the advantages and disadvantages of each style, and maintenance issues and costs involved. Approximately 80% of all hearing aids sold fit in the ear1. After you and your hearing professional determine the best style of hearing aid for your needs, an ear impression will be obtained. The ear impression is a plastic cast of your ear which reveals the exact shape of your ear, so the laboratory can place circuitry in a hearing aid shell that will fit your ear(s) only.

    3. Expect differing opinions. If you choose to seek the advice of two or more HISs, you may get differing opinions about the “best aid” for you. Everyone in the hearing aid industry acknowledges the fact that there is not a single “best” hearing aid. Rather, there are many excellent hearing aid brands available, and there are many different types of circuitry that may benefit you. Your HIS uses the case history information and the evaluation results to make the best recommendation for you and your lifestyle. Expect a recommendation to purchase two hearing aids if both of your ears are hearing impaired and are “aidable.” There are many benefits to binaural (two ear) hearing, including being better able to understand speech in noise, and being better able to localize sound. Your HIS will explain the advantages of a binaural fitting versus a monaural fitting in more detail2. Nonetheless, it is very important to understand that if you have two ears with hearing loss, and you only wear a hearing aid on one ear, you will still have significant hearing problems, even under the best of circumstances. A reasonably good analogy is to consider wearing a single eye glass (monocle) for a two-eye vision problem, such as being near-sighted or far-sighted ? it simply will not work well for very long!

    4. Expect your Hearing Instrument Specialist (HIS) to assess your hearing difficulties in several environments and define individual goals for you. Although there are many self-assessment scales available, a popular one is the Abbreviated Profile of Hearing Aid Benefit (APHAB) developed by Cox and Alexander3. It may be administered to you prior to and following the hearing aid fitting to identify the benefits you receive from the hearing aids and to measure the reduction of any disabling effects of your hearing loss. The COSI (pronounced “cozy”) is the Client Oriented Scale of Improvement which was developed by Dr. Dillon and colleagues at the National Acoustics Laboratory in Australia 4. As you will remember from my earlier comments, I emphasized that benefits from hearing aids are highly individualized. The COSI allows the HIS to determine, based on your input, five major goals or changes you want to occur as a result of wearing hearing aids. These goals may include hearing your spouse better in the car, hearing your friends better on the phone, or any others that relate to you and your hearing difficulties. These assessments are not like the hearing evaluation given by the HIS. These are tools that allow us to measure your self-perception of how your hearing loss affects your activities of daily living and how amplification can improve your quality of life.

    5. Expect to be offered a 30 day trial period. Although not always required by law, many audiologists/HISs offer a trial or rental period of 30 days for you to adapt to amplification. You may be asked to pay a non-returnable fee during this time. Ask about this trial period, and if not offered, seek a second opinion. Use this 30 day period to test the hearing aids in the environments that are typical of your lifestyle – not only at home, but also at your friends and relatives homes, your favorite restaurant, shopping center, grocery store, or place of worship.

    6. Expect a referral to a physician to rule out any medical condition that may contribute to your hearing loss. All hearing aids are medical devices and, as such, are governed by regulations of the Food and Drug Administration (FDA). The FDA requires that all users of hearing aids be examined by a physician, preferably one who specializes in diseases of the ear. If you are over the age of 18 years, you may be given the opportunity to sign a medical evaluation waiver that will allow the HIS to proceed with your hearing aid fitting. It is in your best interest to be evaluated by a physician prior to the hearing aid fitting, but particularly so if you have a history of ear problems or hearing loss of unknown origin.

    7. Expect the hearing aids to cost more than you think they should. There are three categories of hearing aid technology – analog, digitally programmable, and digital. Analog technology has been around for many years. Aids utilizing this technology are also called “conventional” hearing aids and they are the least expensive. According to the most recent dispenser survey published in the Hearing Review in June of 2001, the average price of a hearing aid with analog technology will cost approximately $900 to $1500 per aid, depending on the size of the aid – the smaller the aid, the larger the price1. Digital hearing aids use digital signal processing – the newest form of technology on the market. Digital hearing aids are indeed complete computers, similar to the PC on your desktop, but they are the size of a pencil eraser! These aids cost approximately $2500 per aid, similar to your PC. Digitally programmable hearing aids will probably cost somewhere between the conventional price and the digital price. You may benefit from any of the three types of technology. Speak with your HIS about the types of circuitry and which would be best for you. Importantly, in 2002, some basic digital hearing aids are available at a lower price than in previous years. Many of the manufacturers have switched the focus of their product lines to completely digital offerings, as digital products are more efficient and have broader application. Consequently, as the demand and sales have increased, the price has gone down a little. The bottom line is that there are many more digital hearing aids on the market in 2002 than there was in 1999, and the prices vary tremendously, as do the products.

    8. Expect an initial orientation session with your Hearing Aid Specialist (HIS) in which you will learn how to handle and care for your new aids. You should invite your spouse or significant other to attend this first critical session in getting oriented to your new aids. During this session, you will be taught how to operate the hearing aids, how to clean them, and how to change the batteries. You will receive written information about your aids – a booklet called a “User Instructional Brochure” which is a requirement of the FDA. Please note, batteries are particularly important. Please be sure to store them and use them exactly as your hearing healthcare professional advises. Please be sure to keep all batteries way from pets and children. It may be difficult for you to remember all the things the HIS tells you during this first session, so don’t leave the office without your instructional brochure! It will be very valuable to you, particularly during the first weeks of owning your new hearing aids.

    9. Expect a period of adjustment. Remember the 30-day trial or rental period mentioned earlier (see point 5 above)- Once you get your new hearing aids, expect an adjustment period of several days to many weeks to get used to the daily care and maintenance of the hearing aids.

    You?ll need time to learn how to; insert and remove the hearing aids from your ears, learn to adjust the volume control (some hearing aids have volume controls, other are automatic), learn how to clean them, learn how to open and close the battery door, learn to change the battery, get accustomed to placing the hearing aids in a dry-aid kit for the times when they are not in your ears. As you can see, there is a lot to learn, and people learn at different speeds. I recommend that you go slowly, learn one thing at a time, practice, and stay in contact with your hearing healthcare professional.

    Many times, a spouse (or significant other) is very useful in helping you adjust to the new responsibilities of ownership of hearing aids. The largest adjustment you will go through is, of course, listening with your new hearing aids. You will hear sounds that you have not heard for a long, long time. Some of these will be “good sounds”, like the songs of the birds or high-pitched voices of children. Other sounds, the “obnoxious ones”, are sounds we need to hear for our safety and/or general knowledge of what is happening around us. These are sounds like the refrigerator or air conditioning units humming and buzzing, the sound of our footsteps, or a “knock” in the sound of the car engine. Research in this area has shown that this adaptation or adjustment period may last a few months. It takes time for the brain to re-learn all these sounds. Be patient!

    10. Expect your voice to sound different. For many reasons, your voice will sound strange to you at first – like being in a barrel. This is a normal early perception and it is often called the “occlusion effect”. If you don’t adjust to this after a few days, discuss this with your HIS. Many times, this feeling can be alleviated through changing the vent size in your hearing aids or changing the amount of amplification you are getting for low-pitched tones. Your HIS deals with this issue regularly, and they will be able to solve this with you, over a short period of time.

    11. Expect a good, comfortable fit. Initially, it will take a while to get used to having the hearing aids in your ears. You may experience a little soreness or irritation at first, but after a few days or a week or so, you should be able to wear the aids for several hours per day without any pain or discomfort. I always find it reassuring when patients tell me they often forget that they are wearing their aids. Remember – even though the HIS will make your ear impressions so your hearing aids will be custom fit, many things can happen in the manufacturing process and any discomfort should be reported to your HIS immediately. If your aids are not comfortable, you will not get the maximum benefit from them, and you should not wear them. Report all discomfort or irritations to your hearing healthcare professional, and do not wear the hearing aids until he/she advises you as to how to best address the problem.

    12. Expect multiple follow-up appointments. The greatest advantage of digital hearing aid technology is the flexibility in programming the sound quality, as well as many other electro-acoustic characteristics of your hearing aids. These hearing aids are highly sophisticated instruments with many features. The computer software that is used to program your hearing aids allows the HIS to make a multitude of adjustments while the aids are in your ears. You can actually hear many of the changes as the HIS is adjusting different features or characteristics. Other features will only be noticeable in other environments. So, be sure to tell your HIS as much as you can about your listening experiences in many environments. If you are a new user, you may get an initial setting of about two-thirds of the amplification that will be ideal for you. As you get used to your aids, the HIS will increase the amount amplification over several visits. This will help in your adjustment period and lessen the chances of rejection due to over-amplification.

    13. Expect your audiologist/HIS to evaluate the benefits provided by your hearing aids. This is normally done in at least two ways. First, electronic measurements of “real ear” performance give the HIS an idea of how the aids are functioning when the hearing aids are in your ears. Your HIS may make measurements in which a small microphone is placed in your ear to measure what is happening in your ear canal with and without the hearing aids in place. This is an objective measure and a starting point for successive changes in the performance of your aids. Secondly, the APHAB, COSI, or other assessment scales may be repeated so the HIS can help you evaluate pre- and post-fitting hearing difficulties. These two evaluation methods are important in establishing the benefits you personally receive from amplification. If there are no significant changes in these measures, your HIS will need to make additional changes in your hearing aid fitting.

    14. Expect to be able to hear well, but not perfectly, in quiet one-to-one situations and most small group settings. In order for you to hear well, we must make sound audible, then comfortably loud. Your hearing aids will amplify sound so speech will become comfortably loud. You should be able to hear most of what is said without having to watch a person’s lips all the time. However, even people with normal hearing watch the person speaking in order to gain more information! Even when wearing the hearing aids, you should combine your vision and your hearing to maximize your benefits from the hearing aids. When sound is comfortably loud, it will be easier for you to listen and the stress of straining to hear rapidly diminishes. Therefore, listening in social situations becomes pleasurable again. If everyday sounds are uncomfortably loud, report this to your a HIS immediately.

    15. Expect an optimal “distance for hearing”. The best distance for hearing with your aids will be dependent on the type of microphones in your hearing aids, and other factors. The hearing aids may be directional or omni-directional. Find out from your audiologist/HIS which type of microphones you have, and the effective listening range or effective “distance for hearing”. People within this distance will be the most audible to you. Once you increase the distance from the source you want to listen to, it will get increasingly difficult to hear – just like without the hearing aids.

    16. Expect to have difficulty hearing in noisy situations. You may say that you can hear fine in quiet and that the noisy situations are the ones in which you need the most help. This is a common statement made by individuals who have presbycusis (hearing loss due to aging), noise-induced hearing loss, or any hearing loss where the
    high-pitched tones are affected the most. Eventually though, as your hearing loss progresses, your ability to hear in quiet settings is also affected. Background noise is a nuisance for everyone, even normal hearing individuals. As sophisticated as today’s technology is, hearing aids still cannot eliminate background noise for you. Some of the more sophisticated digital circuitry can effectively reduce (although not eliminate) background noise. If you are in a lot of noisy environments, it is important to discuss this with your audiologist/HIS when discussing your case history and setting your goals for improvement.

    17. Your hearing aids may squeal (also called “whistle,” or “feedback”) under some circumstances. If a hearing aid is somewhat functioning and has a good battery in it, this squeal (acoustic feedback) will occur when the hearing aid is cupped in the hand. Most users find that this helps determine the status of the battery and it is a good sign! However, you should be able to wear your hearing aids at a comfortable loudness level and not experience this squeal. If you do not have a volume control on your aids, they will squeal when you place them in your ears – until you get them placed comfortably. Sometimes, your aids will squeal if you press the phone too tightly to your ear. Report these events to your audiologist/HIS and determine what is normal, what is abnormal, and what can be done to reduce unnecessary acoustic feedback.

    18. Expect repairs. You should realize that hearing aids are incredibly sophisticated devices being inserted in the ear canal where moisture and cerumen (ear wax) is waiting to attack any foreign object! Hearing aids are also prone to being dropped if our fine motor dexterity is a little compromised. Microscopic solder joints that connect the tiny wires of the microphone and receiver to the computer chip in the hearing aid can be jarred loose. All repairs cannot be avoided, but the majority of repairs can be avoided with regular and careful maintenance! Being careful and establishing and maintaining a good preventive maintenance schedule, at home and at your audiologist?s/HIS?s office, can significantly reduce the number of repairs on hearing aids. Your aids will probably come with a standard one year warranty, and after that, you can purchase hearing aid insurance from a number of companies. Talk to your HIS about additional warranty options when you purchase the aids.

    19. Expect to buy batteries. Hearing aid batteries will probably last a week or two in the hearing aid. Hearing aid battery service life varies based on the hearing aid circuit and the quality and type of battery and is also dependent on environmental conditions (temperature, humidity etc.). Some people ask why hearing aid batteries don’t last as long as watch batteries. The answer is the hearing aid battery accomplishes a great deal more work and requires much more electrical energy than does a watch battery. The information you receive during the hearing aid orientation session will define a reasonable length of time for your batteries. When your hearing aids are new, you might want to keep a calendar indicating the days you change batteries. Report any significant changes in battery usage to your audiologist/HIS. Many professional offices offer battery promotions or special programs for their patients. Ask your hearing healthcare professional about this.

    20. There are two “NEVERs” with batteries. NEVER keep batteries with your medicines, as you might accidentally ingest one. NEVER allow young children to handle batteries, as they might ingest them. All hearing aid batteries are toxic if swallowed. Keep them in a safe place and be sure to recycle your batteries properly.

    21. Expect to purchase new hearing aids every 5 years. This may come as a surprise, particularly if you just purchased a set of digital hearing aids! However, hearing aid technology changes rapidly, just like computers, and new technology may benefit you greatly. Some people may keep the same pair of hearing aids for 10 to 12 years, particularly if their hearing loss remains stable over time and if they do a great job with maintenance, but the average life expectancy is about five years.

    22. Most importantly, expect to enjoy the sounds of life again! Your hearing aids are a key ingredient to staying active and improving the quality of your life. You will once again enjoy social events, leisure activities, and conversations with your family, friends, and co-workers. Your hearing aids will also help you hear sounds to keep you safe and well.

    References

    1. Strom, K. E. (2001). The HR 2000 dispenser survey. The Hearing Review, 7 (6), 20-42.

    2. Staab, W. J. (2000). Hearing aid selection: An overview. In Sandlin, R. E. (Ed.), Textbook of Hearing Aid Amplification: Technical and Clinical Considerations (pp 63-64). San Diego, CA: Singular Thomson Learning Publishing Group.

    3. Cox, R. M. and Alexander, G. C. (1995). The abbreviated profile of hearing aid benefit. Ear & Hearing, 16 (2), 176 – 186.

    4. Dillon, H., James, A. and Ginis, J. (1997). Client Oriented Scale of Improvement (COSI) and its relationship to several other measures of benefit and satisfaction provided by hearing aids. Journal of the American Academy of Audiology, 8 (1), 27-43.

    For more information please click here.

    Aural Rehabilitation: Some Personal and Professional Reflections 2014-10-06T22:10:35-05:00

    Editor’s Note – The original article (as published in the Hearing Review, see above) was a podium presentation for a professional audience. Due to the importance and depth of this fine presentation, we have minimally re-edited this article for the non-professional audience, to help transfer the knowledge and concepts in a non-technical manner. We appreciate permission from Dr. Mark Ross and Mr. Karl Strom, Editor-In-Chief of the Hearing Review, for allowing us to republish this important work.

    INTRODUCTION:

    When Geoff Plant asked me to give this keynote presentation, he said to be sure that I included some of my personal experiences as a hard of hearing person. Actually, I wasn’t sure if I could or should do this, since I don’t feel all that comfortable talking about myself. On reflection, however, it really may be a good way to introduce a conference on Aural Rehabilitation (AR), since I believe there are lessons we can draw for the present day from my personal experiences a half-century ago

    My hearing loss was detected in l951 while I was in the Air Force. I think its onset occurred during an earlier period of military service. Of course, like just anybody else with hearing loss, I knew I had some hearing difficulties and, like many other people in the same predicament, I simply tried to ignore its presence, getting along as best I could. At the time, the only help I would have considered would have been medical or surgical — some way to “cure” or “fix” my hearing loss. Fortunately for me, I was not given a choice.

    After I was given an audiometric test, which clearly revealed the presence of hearing loss, the next thing I knew I was transferred to Walter Reed Hospital, as an involuntary participant in their AR program. But not before the examining otolaryngologist told me that I had “progressive hearing loss” and that I would soon be going “deaf!”

    It was only many years later that I realized the doctor’s definition of “deaf” and my definition of “deaf” were quite different. Without hearing aids, I would indeed be “deaf”, but certainly not with them. From my perspective, the only definition of “deaf” that counted was my ability to use audition as my primary communication mode. The fact that I can still do this, even with a bilateral 90 dB hearing loss, tells me that I am not functionally “deaf”. That doctor did me, and I’m sure many other patients, a great disservice when he employed a term in one way that most people would understand in a different way. Simply said, his comment scared the hell out of me and this fear stayed with me for many years, until I learned better.

    In any event, the Air Force gave me no opportunity to object to the transfer, or to engage in the usual and agonizing self-defeating exercise of denial. Ironically, it now appears that one of the merits of this entire process may have been the fact that I did not have a choice: being in the military, I was simply ordered to go and I did. In my case, there was not the usual seven-year delay between the symptoms of a hearing loss becoming apparent and the acquisition of hearing aids. Clearly, the military model is not a model we can follow in civilian life, however we might sometimes wish it.

    The Walter Reed AR program lasted for two months, during which time the participants were all boarded together in a separate facility. All day every day we went to various classes, ranging from general information about hearing loss to speechreading and auditory training. At the beginning of the program we were issued hearing aids selected for us by the traditional Carhart procedure (an early hearing aid selection protocol). We were each tested with about four to six aids, trying to determine which one was “best” for us. The measures included unaided and aided speech discrimination tests in quiet and in noise, comfort and uncomfortable determinations, and both use and full gain aided speech reception threshold (SRT) tests. “Best” was defined in terms of higher speech discrimination scores, wider dynamic range, lower aided SRTs, and subjective preferences. Cosmetic preferences, as can be imagined, never came up.

    This test battery would take almost a complete morning or afternoon. Even so – that was not the end of the process. About once a week, I returned for follow-up testing and such “fine-tuning” as could be done in those days. Complaints and problems with the hearing aids and earmolds were handled almost immediately. However, it is important to note that unlike today, where the provision of hearing aids is often considered the end point, in my AR program, the hearing aid was just one component of a comprehensive AR program.

    The formal program was supplemented by many “bull-sessions” and informal exchanges between and among clients that took place during, in-between, and after classes. Although we did not use the term “coping and communication strategies”, that was in essence, what was going on. We shared our hearing experiences, some of our feelings (being “macho” young men we didn’t delve too deeply into ourselves) and examples of what kind of communication tactics worked and did not work. Actually, in retrospect, these experiences were probably the most valuable aspect of the program. The group interactions provided the kind of emotional support impossible to replicate in individual counseling sessions. This is definitely a lesson that we can take to heart even now.

    Although we thought we were learning to lip-read and how to make better use of our residual hearing, and some of us undoubtedly were, what was also happening was that we were learning how to accept the hearing loss and accept ourselves. We would joke with one another about “being on the air” when we put our hearing aids on and, by example, encourage those who were reluctant to wear them. Unlike the pressures new hearing aid users often feel that can lead to them to discard their hearing aids feeling “different”, stigmatized and a bit ashamed – the social climate in the AR program was exactly the opposite. It was expected that everybody would “conform” to the accepted practice by regularly wearing his hearing aids. The fact that the program lasted for two months made it easier to continue our good hearing aid habits after we left.

    The hearing aids we were issued were monopack vacuum tube hearing aids, requiring an “A” battery that had to be changed every two or three days and a “B” battery that would last a week or two. We felt very lucky to be the recipients of these “small” convenient instruments, particularly since the groups who preceded us were issued duo-pack hearing aids; those required a battery pack physically separate from microphone and amplifier. Besides, being in the service, we could hardly insist on receiving more “cosmetically acceptable” devices. First, because this kind of demand was simply unheard of in those days, and second, cosmetic concerns, even if we could conceive of how far down the ear canal it has taken us nowadays, was simply not an issue. We wore what we were ordered to wear, based on professional judgment regarding what was considered “best” for us. Nowadays, unfortunately, professional judgment regarding performance often takes a distant back seat to a patient’s expressed cosmetic concerns.

    After the AR program, I spent three years in the Air Force, spending much of that time in North Africa where, I believe, I may have been the only person wearing hearing aids, if not on the entire continent, at least in the immediate region. There’s another, very important lesson, here for the present day: Because I accepted the fact that I had to wear hearing aids, and accepted myself on this basis, I truly believe the presence of my hearing aids was completely irrelevant as far as my work and social activities were concerned. I didn’t make a big deal about the fact that I wore hearings aid and consequently, neither did anyone else. If somebody asked about it, I simply said it helped me hear like eyeglasses help someone see. I can’t think of a time when this explanation did not suffice. I’ve never accepted the notion that wearing a visible hearing aid is associated with a negative personal appraisal, some kind of social stigma invoked by society on hearing aid users, or what has been termed the “hearing aid effect”. Of course, I do know that some people in our society may initially judge hearing aid users as less competent and less desirable, etc. But, I’m convinced that, given self-acceptance, their attitudes will soon either be irrelevant or changed. Instead of confronting this presumed “stigma”, however, we pander to it by focusing on cosmetics rather than performance and need.

    I should point out, however, that even with the exemplary Walter Reed program, I must have still felt a great deal of uncertainty about how the hearing loss was going to affect my life. Given the initial diagnosis of “progressive hearing loss”, I was understandably insecure about the future. When I returned to the U.S. from North Africa, I asked to be transferred to Walter Reed hospital so that I could take the AR program once again. To its credit and to my benefit, the Air Force agreed to my request.

    In a sense, what I was asking for was an AR “booster” shot. Even more than my first experience, I believe it was at that time that I truly came to terms with the fact that I had permanent hearing loss. It was at that time that I accepted the notion that while its presence was clearly going to produce some difficulties in my life, the fact that I was hearing-impaired need not restrict the course of my life in any fundamental way.

    There are lessons we can draw from this for the present day. Just because we have, or think we have, provided what we believe to be an appropriate AR program to our patients, that does not mean that they will thereafter be “cured” and never darken our doors again. As we well know, it doesn’t work that way. We know that people’s hearing loss and their communication needs change over time. We know that much of what we covered and what we thought we had resolved initially may have been forgotten. And we know that new devices and techniques are constantly being introduced, which may offer benefits previously unavailable.

    Our clients often need a “booster” shot from us, a provision that should necessitate a routine follow-up program.

    The “Stigma” of Wearing Hearing Aids

    Majoring in “Speech and Hearing” when I left the service brought about a whole new set of lessons that have stayed with me. Actually, the primary reason I started college was to learn enough about audition and hearing aids to be a knowledgeable hearing aid salesman. So for the first year I was at college I sold hearing aids part time. In all that time, I sold just one aid, and only because one of my brothers arranged the sale! I worked by knocking on the doors of people who had made some sort of inquiry in the past. Their responses really exposed me to some of the attitudes about hearing loss that pervaded our society then and, to a large extent, now. People would deny they had hearing loss while I had to shout at them to be heard! Or they would be very upset that I somehow knew about this terrible secret of theirs. After all, they were promised when they responded to an advertisement that they would be sent material in a plain brown envelope, so nobody would know they inquired, and that no salesman would come knocking at their door. And here I was exposing their shame and stigma for all the world to see!

    Salesmen were advised to stress how small and invisible the hearing aids were. These, we should note, were body aids! All kinds of tricks were played to minimize visibility, from transparent tubing that ran from the earmold to the receiver pinned under the collar, to beret style aids that were placed in the hair. Fifty years later, we’re still doing the same thing. It doesn’t matter how technically advanced hearing aids have become, or how tiny these really sophisticated devices are; they’re still not sufficiently invisible for many people. And for some, they will never be small enough.

    It’s clear that the problem is not the visibility of the hearing aids, but rather the acceptance of the hearing loss. In the fifty years that I’ve been involved with this field, we are still communicating mixed messages. On one hand, we justifiably stress the technical advances incorporated in modern hearing aids. At the same time, however, we emphasize how tiny they are, how they can fit all the way down in the ear canal and that nobody “need know they’re wearing hearing aids.”

    What is happening is that we are reinforcing the very denial attitudes we are trying to overcome. By stressing invisibility, we convey the message that there is something shameful about hearing loss, that it is a stigmatizing condition that people must disguise as well as they can. I’m convinced that more potential hearing aid candidates are discouraged from trying needed amplification by this type of appeal than are motivated to try them by the cosmetic arguments. People don’t “hear” the cosmetic appeal as loudly as they do the underlying shame and stigma message. If we can’t get people to acknowledge that they have hearing loss, there is nothing we can do to help them. Clearly, they are not ready to help themselves. One measure of our success in this endeavor would be the percentage of people who can potentially benefit from amplification who actually wear hearing aids. In this country, that figure is usually considered to be about twenty percent – not a very impressive record.

    Taking Hearing Loss Seriously

    In order for this percentage to increase, there has to be more awareness
    regarding the potential consequences of hearing loss, that it can, and often does, impact on every aspect of a person’s life. However, instead of some measure of empathy, what we often get are insensitive comments like “she can hear if she only pays attention”.

    If society underestimates, mocks or trivializes the total impact of hearing loss then it is unlikely that any type of AR program will be supported or encouraged. The condition would not be considered a severe enough public health problem to warrant public resources allocated to its remediation.

    At a time of limited resources and rising expectations, such an understanding is crucial if AR is to receive its justified portion of the health-care pie.

    If we only had to convince the general public and policy makers regarding the potential implications of a hearing loss, and the need for AR services for most people with hearing loss, then our challenge would be straightforward, if not easy.

    Unfortunately, it seems to me that before we educate others, we need to start by educating ourselves.

    The hearing aid selection and dispensing model most often employed by hearing aid dispensers focuses on the instrument – the hearing aid itself, rather than the person with hearing loss. In the ordinary sequence, a client first receives an audiological evaluation, then the hearing aid is selected and several follow-up appointments are scheduled.

    In the current hearing aid dispensing model, the average total time devoted to all of the activities associated with the hearing aid acquisition, from the initial testing and personal interview to the actual selection, fitting, follow-up and counseling is little more than two hours (Stika and Ross, 2001). Less than an hour is spent on the counseling component (Kochkin, l999). Perhaps the current model provides sufficient time for these activities. But there certainly will not be time to deal with other personal and social issues arising from hearing loss. The current hearing aid dispensing model implies that all hearing-impaired people need to correct their problem is an auditory prosthesis, i.e., a hearing aid. This is clearly not the case.

    The fact that people want and need more information can be seen in the marketing survey prepared for the AAA (Audiology Today, l998). Almost half the hearing-impaired people who responded to the survey reported they would have liked more information on how to select, wear, and care for hearing aids. About forty percent of them wanted to learn more about the causes and treatment options for hearing impairments. Even this relatively high number probably underestimates the number of people who could use and benefit from such information.

    It is not as if there is any real dispute among professional audiologists regarding the consequences of hearing loss. Indeed, there is also an enormous body of literature on this topic, much too much to review in any detail here. For example, Carren Stika reported the results of the many focus groups she conducted with hard of hearing people and their significant others (Stika, 1997a;l997b). The fact that hearing loss can have a pervasive and profound effect upon the affected person and his/her family was clearly demonstrated in this project.

    Implicit in the current hearing aid dispensing models is the assumption that the provision of hearing aids are both a necessary and sufficient response to the hearing loss condition. This model implies that hearing aids can functionally “cure” the hearing loss and that further services are either unnecessary or not cost effective. We would all agree that hearing aids are an absolutely necessary measure to take in most instances of hearing loss. However, I would hold that for most people, hearing aids alone are insufficient.

    Of course hearing aids help, and of course most people, comparing their ability to function with and without hearing aids, do better with them than without them (Kochkin & Rogin, 2000). No doubt, many people would believe, at least initially, their hearing problems have been “solved” or at least rendered functionally irrelevant by the hearing aids. Not knowing any better, they accept less than is possible and live with the resulting limitations and problems while enjoying the benefits. This is not good enough. We can do better.

    For example, about 16% of people eventually stop wearing their hearing aids, and a similar number rate their hearing aid usage as unsatisfactory (Kochkin, 2000). Satisfaction percentages seem to hover somewhere between 60 and 70 percent. Importantly, we know that additional counseling and follow-up programs can reduce the number of returns and increase benefits, use, and satisfaction rates (reviewed in Ross, 1999; Kochkin, 1999). Indeed, a number of papers explicitly address the organization, advantages, and cost effectiveness of AR procedures that go beyond merely providing hearing aids or cochlear implants.

    Services and Information Needed by Hearing Aid Wearers

    Let’s consider the services that hearing-impaired people require when they finally arrive at a hearing center. It is important to keep in mind that we would not be seeing these people if their hearing problems had not, somehow, become personally intolerable or if they had not finally succumbed to repeated nagging from some significant other.

    What, then, are our professional obligations to them? The ostensible reason they come to us is for professional advice regarding hearing aids. And, of course, the proper selection and instruction in the use of hearing aids still has to be a paramount consideration. The implicit reason they see us, however, is not for hearing aids per se, but because they want help in minimizing the hearing-related problems they are experiencing. Well-selected hearing aids are just one tool, albeit the major one, that addresses this issue. There are other services and information we can provide that will help people reduce the total impact of hearing loss on their lives. The clients may not be aware of these other services, but shouldn’t it be a professional responsibility to make these services known to them? What I am suggesting is a focus not on a product, but on the rehabilitative process. It is when patients show up at our door asking for help with hearing aids that we have the best opportunity to address the totality of their hearing-related problems. So what services am I talking about?

    • All prospective hearing aid users require a comprehensive audiologic evaluation. This may sound self-evident, but what with hearing aids being sold through mail order and the internet, it cannot be considered a given. A component of this evaluation should be devoted to an extensive personal interview.
    • Either preceding or immediately following the personal interview and audiologic evaluation, the client should have an opportunity to complete some type of standardized self-assessment scale. The same scale should be administered after the person has worn hearing aids for some time. In a recent chapter, Abrams & Hnath-Chisolm (2000) provide a comprehensive discussion of outcome measures, with examples of the different types that can be used for different purposes. Their rationale extends beyond providing data regarding therapeutic effectiveness and institutional accountability. Responses to self-assessment scales can help guide the nature of the therapeutic process. 
    • Many, perhaps most, people with hearing loss can benefit from a group hearing aid follow-up program. The follow-up program is to supplement, not supplant, individual counseling. This gives clients an opportunity to review and share their listening experiences with other people with hearing loss. The mutual support people give each other transcends that which professionals can provide. Some topics, such as advantages of binaural hearing aids, can be covered more convincingly when someone else in the group relates personal experiences, rather than when the recommendation appears to be tied to a dispenser’s self interest. Reluctant hearing aid users, or those who feel that “it is just too much” trouble can be encouraged appropriately by their peers and colleagues.
    • People need general information regarding the cause of hearing loss and treatment options. People deal with problems more effectively when they have a greater understanding of its nature. Many people come to clinics wanting and expecting to be “fixed” medically or surgically. They have to understand why some types of hearing loss are not amenable to such treatment and that the best single “treatment” is often a well-functioning hearing aid.
    • People need information about the listening implications of their own audiometric results (for example, why so many people seem to be “mumbling”, and why they can often “hear” but not “understand”). This is the kind of topic that dispensers tend to gloss over after the 1000th time they explain it to clients. It is difficult, but necessary to provide such information each time, as if it were the first time.
    • The “significant others” in each person’s life should understand the communication implications of their loved one’s hearing loss. By listening to others make complaints similar to their loved ones, they can more fully appreciate the problems. One useful technique is to play a tape of filtered speech to the normally hearing significant others.
    • People need information regarding how to care for their hearing aids and earmolds. They need to know why one type of hearing aid was selected rather than another. This leads to a discussion of the particular features of their own hearing aids, what they do, and why they were included (e.g. directional microphones, T-coils, presence or absence of volume controls, personal FM capability, direct audio input, multi-bands, multi-memories and so on). This kind of information takes time to convey and group presentations can supplement individual instruction.
    • A group setting lends itself to help people develop realistic expectations of what hearing aids can and can’t do. Some people’s expectations may be unrealistically high, while others set theirs too low. People have to understand what hearing aids can and can’t do. This discussion leads naturally to the topic of other types of hearing assistive devices. 
    • The evaluation and dispensing of other types of assistive listening devices (ALDs) is, in my estimation, one of the biggest weaknesses in present hearing aid dispensing practices. For some people, specific ALD devices can significantly improve their quality of life as well as directly impact upon job performance. Virtually everybody in our society is required to use a telephone and importantly, telephone communication can be improved for almost every person with hearing loss. Virtually everybody watches TV, goes to the movies, attends lectures or concerts, or visits houses of worship. In each of these venues, it is possible to improve listening comprehension with an assistive listening device. Some people will function better on the job if they can use a personal FM, a conference microphone, an amplified telephone, or a vibrating pager. The need for such devices may not be immediately apparent; it requires an explicit evaluation to make this determination.
    • People with hearing loss can benefit from information about various kinds of communication and repair strategies that can be used to enhance interpersonal communication. This should include a presentation and discussion of the basic principles of speech reading. With a little practice and focus on the lips and face, hearing-impaired people can improve their comprehension of the spoken word. They should know about the concept of assertiveness, when and where it would be appropriate, and encouraged (via “homework”) to practice it in their everyday lives.
    • Finally, even after receiving the services specified above, many people with hearing loss still need the continuing support of others in similar circumstances. The astute audiologist will keep an open channel to a local chapter of Self Help for Hard of Hearing People, Inc. (SHHH) and make his/her clients aware of the potential contribution of this consumer support group.

    Does everybody with hearing loss require all of the above? Probably not. But we should begin, with the clinical assumption that anybody who needs hearing aids to improve communication functioning can benefit from most of them.

    The record in this regard is mixed (Stika & Ross, 2001). The key limitation is time -and how to find it. It takes time to listen to our clients and to deal with communicative, as well as the psychosocial implications of hearing loss. It takes time to conduct a group hearing aid orientation program. It takes time to evaluate the need for and to provide assistive listening devices. And it takes time, particularly for older people, to work through hearing aid fitting procedures until they reach the point that they are receiving the full benefits of hearing aid amplification. As we keep hear over and over again, “Time is Money,” and importantly, where do we do find the money to pay for the time?

    Redefining the Hearing Aid Selection Procedure

    The first thing we have to do, I believe, is change the way we think about the hearing aid dispensing process. We can’t rediscover Camelot, the AR program that I experienced fifty years ago is gone. Like the original Camelot, it has faded in the mists of time; an idealistic dream of perfection that we know can never be recalled. Still, as much as I personally enjoyed and benefited from the program, I do think much of it was overkill. When all this began during WW II, there must have been a great deal of insecurity about what newly deafened servicemen needed. The decision must have been to give them everything, growing out of a concern that otherwise some vital element would be omitted.

    We can’t do “everything” nowadays; choices have to be made. I believe we can do a credible job within the present system if we incorporate some of the lessons from the past.

    The most important of these lessons is that we must conceptualize the selection and dispensing of hearing aids within a larger framework. While it may sound like a cliche, we do have to keep in mind that we are not working with a pair of ears but with the person to whom the ears are attached. We should view the hearing aid fitting as an opportunity to explore a number of hearing-related issues and to help the hearing-impaired person deal with them. We must, in brief, redefine the hearing aid selection process in a way that it routinely incorporates a multi-session group hearing aid orientation, or short-term AR, program (Ross, 1999). I hasten to point out that this is not an original concept by me; it has been recommended, written about, and practiced by many of our colleagues, many of whom are now attending this conference.

    I do believe that such a program should not be optional, but simply be included as a routine component of the hearing aid dispensing process. For the same reason we would not think of fitting someone with a hearing aid unless a prior audiological evaluation was conducted, we should not fit hearing aids without an organized follow-up program. This is based on my assumption that the overwhelming majority of people acquiring hearing aids for the first time need the kind of services and information outlined above. By separating these services from the hearing aid itself, by referring only some of our hearing aid clients to an organized follow-up program, we send a message that only exceptional hearing aid users require and can benefit from such a program.

    On the contrary, I believe we should send the opposite message, that a hearing aid, while certainly the centerpiece of the aural remediation effort, is only one of the tools used to reduce the communicative and handicap impact of hearing loss. What this implies is that the expenses of the short-term AR program be included in the cost of the hearing aids (Ross and Beck, 2001).

    In summary, our current management model tends to minimize the total impact of hearing loss. Most people can use and benefit from the additional services a short-term aural rehabilitation program can provide. Such a program can be most efficiently and conveniently included in association with the acquisition of hearing aids. In this respect, the lessons from the past are very clear. If only we “listen” to them.

    This article is reprinted with permission from The Hearing Review and MWC/Allied Healthcare Group, Los Angeles, Sept 2001 (v. 8, no. 9), pgs. 62-67. All rights reserved.


    References:

    Abrams, H. B. & Hnath-Chisolm, R. (2000). Outcome measures: The audiologic difference, in Audiology: Practice Management, Hosford-Dunn, Roseser &
    Valente (Eds.) 69-94, Thieme Medical Publishers Inc.: New York

    Abrahamson, J (l997). Patient education & peer interaction to facilitate hearing aid adjustment. Hearing Review Supplement, 19-22.

    American Academy of Audiology, 97 AAA Marketing Study, Audiology — Today, 10(1), 10-14.

    Kochkin, S. (1999) Paper delivered at the World of Hearing Conference, May 29, Brussels, Belgium.

    Kochkin, S. (2000). MarkeTrak V: “Why my hearing aids are in the drawer”: The consumer perspective”, The Hearing Journal, 53(2) 34-42.

    Kochkin, S. & Rogin, C. (2000) Quantifying the obvious: The impact of hearing instruments on quality of life. The Hearing Review, 7(1), 6-35.

    Ross, M. (1999) Redefining the hearing aid selection process. Aural Rehabilitation and its instrumentation, Special Interest Division #7, American Speech-Language Hearing Association, 7(1), 3-7.

    Ross, M. & Beck, D. (2001).Expensive Hearing Aids: Investing in technology and the audiologist’s time, article in Audiology Online, www.audiologyonline.com April 26.

    Stika, C. (l997a). Living with hearing loss—Focus group results: Part I: Family relationships and social interaction. Hearing Loss, 18(5) 22-28.

    Stika, C. (l997b). Living with hearing loss- Focus group results: Part II: Career developments and work experiences. Hearing Loss, 18(6), 29-32.

    Stika, C. (2001). Results of a hearing aid services and satisfaction questionnaire, First International Aural Rehabilitation Conference, Portland, Maine.

    Strom, K. E. (2001). An Industry in transformation: Technology & consolidation lead the field into a new millennium. The Hearing Review, 8(3), 28-44, 87.

    Hearing, Hearing Loss and Hearing Aids: Issues and Answers 2014-10-06T22:09:24-05:00

    Hearing, Hearing Loss and Hearing Aids: Issues and Answers
    Dr. Douglas L. Beck , Audiologist, Editor-In-Chief, Healthy Hearing Website

    Hearing loss occurs to most people as they age. Hearing loss can be due to the aging process, exposure to loud noise, certain medications, infections, head or ear trauma, congenital (birth or prenatal) or hereditary factors, diseases, as well as a number of other causes. In the year 2001, there are some 28 million people in the USA with hearing loss. Hearing loss is the single most common birth “defect” in America. Hearing loss in adults, particularly in seniors, is common.

    HOW DO I KNOW IF I HAVE HEARING LOSS?

    You may have hearing loss if –
    -You hear people speaking but you have to strain to understand their words.

    -You frequently ask people to repeat what they said.

    -You don’t laugh at jokes because you miss too much of the story or the punch line.

    -You frequently complain that people mumble.

    -You need to ask others about the details of a meeting you just attended.

    -You play the TV or radio louder than your friends, spouse and relatives.

    -You cannot hear the doorbell or the telephone.

    -You find that looking at people when they speak to you makes it easier to understand.

    If you have any of these symptoms, you should see an audiologist to get an “audiometric evaluation.” An audiometric evaluation (AE) is the term used to describe a diagnostic hearing test, performed by a licensed audiologist. An AE is not just pressing the button when you hear a “beep.” Rather, an audiometric evaluation allows the audiologist to determine the type and degree of your hearing loss, and it tells the audiologist how well or how poorly you understand speech. After all, speech is the single most important sound, and the ability to understand speech is extremely important. The AE also includes a thorough case history (interview) as well as visual inspection of the ear canals and eardrum. The results of the AE are useful to the physician should the audiologist conclude that your hearing problem may be treated with medical or surgical alternatives.

    Written hearing tests, “dial a hearing test” and other online hearing tests are not particularly accurate and are certainly not diagnostic tests, but may be utilized as screening tools. These screenings are usually free and can be scored within a few seconds. Written hearing screenings may point the patient (or consumer) in a particular direction and may help validate that a hearing problem may indeed exist.

    Therefore, we have designed a written hearing screening to provide you with some general guidelines about your hearing ability. It is free and it may offer you insight regarding the likelihood that a hearing loss is present. If you would like to take the written hearing screening, Click here.

    AUDIOLOGIST:
    An audiologist is a person who has a masters or doctoral degree in audiology. Audiology is the science of hearing. In addition, the audiologist must be licensed or registered by their state (in 47 states) to practice audiology.
    In the field of audiology, the master’s degree has been the accepted “clinical” degree for almost 50 years. However, the profession is undergoing a transition to a doctorate level degree as the entry-level requirement to practice audiology. In a few years, there will be very few colleges and universities offering a master’s program in audiology. The Au.D. (Doctor of Audiology) is the clinical doctorate degree and is issued exclusively by regionally accredited universities and colleges. There are other doctoral degrees that have been earned and utilized by audiologists to date, such as the Ph.D. (still highly sought today by researchers and academicians), the Sc.D. and the Ed.D.

    Audiologists work in a variety of settings including hospitals, schools, clinics, universities, rehabilitation facilities, cochlear implant centers, speech and hearing centers, private audiology practices, hearing aid dispensing offices, hearing aid manufacturing facilities, medical centers, as well as otolaryngology (ENT physician) offices. Although the vast majority of hearing problems do not require medical or surgical intervention, audiologists are clinically and academically trained to determine those that do need medical referral. As a licensed healthcare provider, the audiologist appropriately refers patients to physicians when the history, the physical presentation, or the results of the audiometric evaluation (AE) indicate the possibility of a medical or surgical problem. Many audiologists also dispense (sell and service) hearing aids and related assistive listening devices for the telephone, TV and special listeningsituations.

    PHYSICIANS:

    Otolaryngologists (also called ear-nose-and-throat, or ENT, doctors) are physicians who have advanced training in disorders of the ear, nose, throat and head and neck. Otologists or neurotologists are physicians who in addition to their ENT requirements continue their specialized training for an additional year or more in the diagnosis and treatment of disorders of the ear. Otolaryngologists, neurotologists and otologists are the physicians who typically treat disorders of the ear (or hearing mechanisms) requiring medical or surgical solutions.

    HEARING AID SPECIALISTS:

    The hearing aid specialist has training in the assessment of patients who specifically seek rehabilitation for hearing loss. The hearing aid specialist is licensed or registered to perform basic hearing tests and can sell and service hearing aids and related products.

    DEGREE of HEARING LOSS:
    Results of the audiometric evaluation are plotted on a chart called an audiogram. Loudness is plotted from top to bottom. Frequency, from low to high, is plotted from left to right. Hearing loss (HL) is measured in decibels (dB) and is described in general categories. Hearing loss is not measured in percentages. The general hearing loss categories used by most hearing professionals are as follows:
    _____Normal hearing (0 to 25 dB HL)
    _____Mild hearing loss (26 to 40 dB HL)
    _____Moderate hearing loss (41 to 70 dB HL)
    _____Severe hearing loss (71 to 90 dB HL)
    _____Profound hearing loss (greater than 91 dB HL)

    TYPES OF HEARING LOSS:
    The external and the middle ear conduct and transform sound; the inner ear receives it. When there is a problem in the external or middle ear, a conductive hearing impairment occurs. When the problem is in the inner ear, a sensorineural or hair cell loss is the result. Difficulty in both the middle and inner ear results in a mixed hearing impairment (i.e. conductive and a sensorineural impairment). Central hearing loss has more to do with the brain than the ear, and will be discussed only briefly.
    ______Conductive hearing loss occurs when sound is not conducted efficiently through the ear canal, eardrum, or tiny bones of the middle ear, resulting in a reduction of the loudness of sound that is heard. Conductive losses may result from earwax blocking the ear canal, fluid in the middle ear, middle ear infection, obstructions in the ear canal, perforations (hole) in the eardrum membrane, or disease of any of the three middle ear bones.
    A person with a conductive hearing loss may notice that their ears may seem to be full or plugged. This person may speak softly because they hear their own voice quite loudly. Crunchy foods, such as celery or carrots, sound very loud and this person may have to stop chewing to hear what is being said. All conductive hearing losses should be evaluated by an audiologist and a physician to explore medical and surgical options.
    ______Sensorineural hearing loss is the most common type of hearing loss. More than 90 percent of all hearing aid wearers have sensorineural hearing loss. The most common causes of sensorineural hearing loss are age related changes and noise exposure. A sensorineural hearing loss may also result from disturbance of inner ear circulation, increased inner fluid pressure or from disturbances of nerve transmission. Sensorineural hearing loss is also called “cochlear loss,” an “inner ear loss” and is also commonly called “nerve loss.” Years ago, many professionals said there was nothing that could be done for sensorineural hearing loss that is totally incorrect today. There are many excellent options for the patient with sensorineural hearing loss.
    A person with a sensorineural hearing loss may report that they can hear people talking, but they can’t understand what they are saying. An increase in the loudness of speech may only add to their confusion. This person will usually hear better in quiet places and may have difficulty understanding what is said over the telephone.
    ______Central hearing impairment occurs when auditory centers of the brain are affected by injury, disease, tumor, hereditary, or unknown causes. Loudness of sound is not necessarily affected, although understanding of speech, also thought of as the “clarity” of speech may be affected. Certainly both loudness and clarity may be affected too.

    HEARING AID STYLES:

    There are many styles of hearing aids. The degree of the hearing loss, power and options requirements, manual dexterity abilities, cost factors, and cosmetic concerns are some of the factors that will determine the style the patient will use. The most common styles are listed below:
    ITE: In-The-Ear units are probably the most comfortable, the least expensive and the easiest to operate. They are also the largest of the custom made styles.
    ITC: In-The-Canal units are a little more expensive than ITEs. They require good dexterity to control the volume wheels and other controls on the faceplate, and they are smaller than ITEs.
    MC: Mini-Canals are the size between ITC and CIC. A mini canal is a good choice when you desire the smallest possible hearing aid while still having manual control over the volume wheel and possibly other controls.
    CIC: Completely-In-the-Canal units are the tiniest hearing aids made. They usually require a “removal string” due to their small size and the fact that they fit so deeply into the canal. CICs can be difficult to remove without the pull string. CICs do not usually have manual controls attached to them because they are too small.
    BTEs: Behind-The-Ear hearing aids are the largest hearing aids and they are very reliable. BTEs have the most circuit options and they can typically have much more power than any of the custom made in the ear units. BTEs are the units that “sit” on the back of your ear. They are connected to the ear canal via custom-made plastic tubing. The tubing is part of the earmold. The earmold is custom made from an ear impression to perfectly replicate the size and shape of your ear.

    EAR IMPRESSIONS:
    All custom made hearing aids and earmolds are made from a “cast” of the ear. The cast is referred to as an ear impression. The audiologist or hearing aid dispenser makes the ear impression in the office. It takes about 10 to 15 minutes. The audiologist places a special cotton or foam dam in the ear canal to protect the eardrum, and then a waxy material is placed in the ear canal. When the material hardens (about 5 to 10 minutes later) the wax cast, along with the dam are removed from the ear canal. Often, the ear canal will be “oily” after the impression is removed. This is normal. The oil comes from the wax material and prevents the wax material from sticking to the skin.
    Tell the audiologist before the ear impression is obtained if you are allergic to plastic or dyes!

    REALISTIC EXPECTATIONS:
    Hearing aids work very well when fit and adjusted appropriately. They amplify sound! You might find that you like one hearing aid better than the other. The left and right hearing aids will probably not fit exactly the same and they probably won’t sound exactly the same. Nonetheless, hearing aids should be comfortable with respect to the physical fit and sound quality. Hearing aids do not restore normal hearing and are not as good as normal hearing. You will be aware of the hearing aids in your ears. Until you get used to it, your voice will sound “funny” when you wear hearing aids. Hearing aids should not to be worn in extremely noisy environments. Some hearing aids have features that make noisy environments more tolerable, however, hearing aids cannot eliminate background noise.

    THREE LEVELS OF HEARING AID TECHNOLOGY:
    There are essentially three levels of hearing aid technology. We refer to these as analog, digitally programmable, and digital.
    ANALOG technology is the technology that has been around for many decades. Analog technology is basic technology and offers limited adjustment capability. It is the LEAST expensive.

    DIGITALLY PROGRAMMABLE technology is the “middle grade” technology. Digitally programmable units are analog units digitally controlled by the computer in the office to adjust the sounds of the hearing aid.

    DIGITAL technology is the most sophisticated hearing aid technology. Digital technology gives the audiologist maximum control over sound quality and sound processing characteristics. There are qualitative indications that digital instruments do outperform digitally programmable and analog hearing aids. Digitals are not perfect, but they are very good. Digital hearing aids have been widely available since 1996.

    DIGITAL HEARING AIDS:

    The term DIGITAL is used so often today, it can be confusing. When the term “digital” is used while referring to hearing aids, it generally means the hearing aid is 100% digital. In other words, the hearing aid is indeed a “complete computer”. 100% digital hearing aids have been commercially available since 1996 and are wonders of modern technology. 100% digital hearing aids can process sound using incredibly fast speeds such as 100 to 200 million calculations per second. Interestingly, most 100% digital hearing aids have analog components, such as the microphone and the receiver. 100% digital hearing aids transform analog information into a digital signal and process the sound to maximize the speech information you want to hear, while minimizing the amplification of sounds you do not want to hear.
    Digital technology is tremendous and it allows the audiologist maximal control over the sound quality and loudness of the hearing aid. Importantly, digital technology allows the audiologist to tailor or customize the sound of your hearing aids to what you need and want to hear. In summary, if you want the best technology— get 100% digital hearing aids.

    YOUR OWN VOICE:

    When you wear hearing aids for the first time, you will probably notice your voice sounds funny! You will hear your voice amplified through the hearing aid. You may describe this sensation as feeling “plugged up” or hearing your voice echoing. This is normal and will usually go away in a few days after you have given yourself a chance to get accustomed to your new hearing aids and learned to adjust the volume control. There are adjustments that the audiologist can do to relieve these symptoms, should these persist beyond the first few days of wearing your new aids.

    GETTING USED TO HEARING AIDS:
    People learn at different rates. Some people need a day or two to learn about and adjust to their hearing aids, most need a few weeks and some may need a few months. There is no perfect way to learn about hearing aids. I usually recommend you wear the hearing aids for a few hours the first day, and add about an hour a day for each day that follows. Do not try to set an endurance record. Over a period of time you will lengthen the amount of time that you wear the aid. Eventually you will wear the hearing aids most of your waking hours. It is recommended that you interact with those people you are most familiar with during your first few days. Start off listening with your hearing aids in a favorable listening environment and work towards more difficult listening situations. Let your friends and family know that you are using your new hearing aids.
    Helpful Steps to Learning to Use a Hearing Aid:
    Use the aid at first in your own home environment.

    -Wear the aid only as long as you are comfortable with it.

    -Accustom yourself to the use of the aid by listening to just one other person – husband or wife, neighbor or friend.

    -Do not strain to catch every word.

    -Do not be discouraged by the interference of background noises.

    -Practice locating the source of the sound by listening only.

    -Increase your tolerance for loud sounds.

    -Practice learning to discriminate different speech sounds.

    -Listen to something read aloud.

    -Gradually extend the number of persons with whom you talk, still within your own home environment.

    -Gradually increase the number of situations in which you use your hearing aid.

    -Take part in an organized course of aural rehabilitation, see your audiologist to learn about these courses.

    HEARING and VISION and COMMUNICATION:

    To maximally communicate, you need to use hearing from both ears (binaural hearing) and you need to use your eyes and ears together. You will not communicate well using your hearing aids alone. To facilitate optimal communication, you will need to pay attention to the speaker’s gestures and facial expressions! To maximize communication remember to watch the person speaking, reduce the distance between the speaker and the listener, reduce or eliminate background noises from the listening environment and use good lighting. If someone is speaking to you from across the room, while the TV is on, while doing the dishes, it will be very difficult to adequately communicate, despite fantastic hearing aids!

    BINAURAL HEARING: DO I NEED TWO HEARING AIDS?
    Basically, if you have two ears with hearing loss that could benefit from hearing aids, you need two hearing aids. It is important to realize there are no “normal” animals born with only one ear. Simply stated, you have two ears because you need two ears. If we try to amplify sound in only one ear, you cannot expect to do very well. Even the best hearing aid will sound “flat” or “dull” when worn in only one ear.
    Assuming you have two ears that hear about the same, you can do a little experiment at home to better understand how important binaural hearing is:
    First, gently close just one ear, by simply pressing the little fleshy part in the front of your ear canal (the tragus) into your ear canal — a little. Do not apply pressure, do not hurt yourself. Just close the ear canal to eliminate sound from entering the ear. The idea is to close that ear for about ten minutes while you watch TV or listen to the radio, or speak with your spouse. Then, after a full ten minutes, remove your finger. What an amazing difference!
    There are many advantages associated with binaural (two ear) listening and importantly, there are problems associated with wearing only one hearing aid — if you are indeed a candidate for binaural amplification.
    Localization (knowing where the sound came from) is only possible with two ears, and just about impossible with one ear. Localization is not just a sound quality issue; it may also be a safety issue. Think about how important it is to know where warning and safety sounds (sirens, screams, babies crying, etc) are coming from. Using both ears together also impacts how well you hear in noise because binaural hearing permits you to selectively attend to the desired signal, while “squelching” or paying less attention to undesired sounds such as background noise.
    Binaural hearing allows a quality of “spaciousness” or “high fidelity” to sounds, which cannot occur with monaural (one ear) listening. Understanding speech clearly, particularly in challenging and noisy situations, is easier while using both ears. Additionally, using two hearing aids allows people to speak with you from either side of your head not just your “good” side!

    People cannot hear well using only one ear. There are studies in the research literature that show that children with one normal ear and one “deaf” ear are ten times more likely to repeat a grade as compared to children with two normally hearing ears. Additionally, we know that if you have two ears with hearing impairment, and you wear only one hearing aid, the unaided ear is likely to lose word recognition ability more quickly than the ear wearing the hearing aid.

    PHYSICAL FIT:
    One concern with all new hearing aids is the physical fit. Hearing aids need to be comfortable, not too tight and not too loose, they should fit just right. Do not wear the hearing aids if they cause any discomfort or irritations. Do call your audiologist to schedule an appointment time to remedy the problem as soon as possible. Do not wear them if they are uncomfortable.

    BACKGROUND NOISE:
    Virtually all patients wearing hearing aids complain about background noise at one time or another. There is no way to completely eliminate background noise.
    Remember, when you had normal hearing there were still times when background noise was a problem. It is no different now, even with properly fit hearing aids! The good news is there are circuits and features that help to reduce (or minimize) background noise and other unwanted sounds. In fact, there are research findings that demonstrate digital hearing aids with particular circuit and microphone options can effectively reduce background noises. Please speak with your audiologist about this.
    Many early digitally programmable (and even some digital) circuits, which claimed to reduce or eliminate background noise, actually filtered out low frequency sounds. This indeed made the sounds appear quieter, however, not only was the background noise made quieter, but so too, was the signal (the speech sound).
    Newer ways to reduce background noise are based on timing and amplitude cues and other noise processing strategies, which 100% digital hearing aids can incorporate. These methods work, but are not perfect. Directional microphones are available and are useful as they help to focus the amplification in front of you, or towards the origin of the sound source. Directional hearing aids can offer a better signal-to-noise ratio in difficult listening situations by reducing a little bit of the noise from the sides or behind you. In most 100% digital hearing aids, the noise control features help make noise more tolerable, but do not completely eliminate the noise.
    The best and most efficient way to eliminate or reduce background noise is through the use of FM technology. Please speak with your audiologist about this.

    MAINTENANCE:
    More than 75 percent of all hearing aid repairs are due to moisture and earwax accumulating in the hearing aid. The vast majority of these repairs are 100 percent preventable. It is extremely important to clean the entire hearing aid every time it is removed from your ear by wiping and brushing it. To better protect your investment, use a DRY-AID kit every night! Electronic dry-aid kits are the best. They include a germicidal light that kills most bacteria and other germs. They also have desiccants to absorb moisture and fans to circulate air around the internal components of the hearing aid. Get in the habit of cleaning the hearing aid after each use and keeping the hearing aid in the dry-aid kit at night. The hearing aid is electronic and moisture is the enemy! Preventive maintenance is the key to trouble free, long life from a hearing aid. A well maintained hearing aid can easily last 5 to 7 years, maybe longer.
    For more information on hearing aids please visit the following:
    Siemens_Hearing_Instruments
    Oticon
    Sonic_Innovations
    GN_ReSound
    Starkey
    Phonak
    Beltone

    HEARNG AID BATTERIES:

    All batteries are toxic and dangerous if swallowed. Keep all batteries (and hearing aids) away from children and pets. If anyone swallows a battery it is a medical emergency and the individual needs to see a physician immediately.
    One question often asked is “How long does the battery last?” Typically they last 7-14 days based on a 16 hour per day use cycle. Batteries are very inexpensive, costing less than a dollar each. Generally, the smaller the battery size, the shorter the battery life. The sizes of hearing aid batteries are listed below along with their standard number and color codes.

    Size 5: RED

    Size 10 (or 230): YELLOW

    Size 13: ORANGE

    Size 312: BROWN

    Size 675: BLUE

    Today’s hearing aid batteries are “zinc-air.” Because the batteries are air-activated, a factory-sealed sticker keeps them “inactive” until you remove the sticker. Once the sticker is removed from the back of the battery, oxygen in the air contacts the zinc within the battery, and the battery is “turned-on”. Placing the sticker back on the battery will not prolong its life. Since many of today’s automatic hearing aids do no have “off” switches, removing the battery at night assures that the device is turned off. Zinc-air batteries have a “shelf life” of up to three years when stored in a cool, dry environment. Storing zinc-air hearing aids in the refrigerator has no beneficial effect on their shelf life, in fact, quite the opposite may happen. The cold air may actually form little water particles under the sticker. Water is made of oxygen and hydrogen. If the water vapor creeps under the sticker, the oxygen may contact the zinc, and the battery could be totally discharged by the time you peel off the sticker! Therefore, the best place to store batteries is in a cool dry place, like the back of your sock drawer, not the fridge!

    For More Information on Hearing Aid Batteries CLICK HERE.

    WHAT ARE ASSISTIVE LITSENING DEVICES (ALDs)?

    You may have certain communication needs that cannot be solved by the use of hearing aids alone. These situations may involve the use of the telephone, radio, television, and the inability to hear the door chime, telephone bell, and alarm clock. Special devices have been developed to solve these problems. Like hearing aids, assistive listening devices make sounds louder. Typically, a hearing aid makes all sounds in the environment louder. Assistive listening devices can increase the loudness of a desired sound (a radio or television, a public speaker, an actor, someone talking in a noisy place) without increasing the loudness of the background noises. This is because the microphone of the assistive listening device is placed close to the speaker, while the microphone of the hearing aid is always close to the listener.

    ARE ALDs ONLY FOR PEOPLE USING HEARING AIDS?

    No. People with all degrees and types of hearing loss — even people with normal hearing can benefit from assistive listening devices. Some assistive listening devices are used with hearing aids; some are used without hearing aids.

    WHAT TYPES OF ALDs EXIST?

    There are many assistive listening devices available today, from sophisticated systems used in theaters and auditoriums to small personal systems.
    Various kinds of assistive listening devices are listed below:
    Personal Listening Systems: There are several types of personal listening systems available. All are designed to carry sound from the speaker (or other source) directly to the listener and to minimize or eliminate environmental noises. Some of these systems, such as auditory trainers, are designed for classroom or small group use. Others, such as personal FM systems and personal amplifiers, are especially helpful for one-to-one conversations in places such as automobiles, meeting rooms, and restaurants.
    TV Listening Systems: These are designed for listening to TV, radio, or stereos without interference from surrounding noise or the need to use very high volume. Models are available for use with or without hearing aids. TV listening systems allow the family to set the volume of the TV, while the user adjusts only the volume of his or her own listening system.
    Direct Audio Input Hearing Aids: These are hearing aids with direct audio input connections (usually wires) which can be connected to the TV, stereo, tape, and/or radio as well as to microphones, auditory trainers, personal FM systems and other assistive devices.

    Telephone Amplifying Devices: Most, but not all, standard telephone receivers are useful with hearing aids. These phones are called “ hearing aid compatible.” The option on the hearing aid is called the T-Coil. The T-coil is automatically activated on some hearing aids and manually activated on others. Basically, the telephone and the hearing aids T-coil communicate with each other electromagnetically, allowing the hearing aid to be used at a comfortable volume without feedback and with minimal background noise. You should be able to get hearing-aid-compatible phones from your telephone company or almost any retail store that sells telephones. Not all hearing aids have a “T” switch. Make sure your hearing aids have a T switch before purchasing a new hearing aid compatible phone! There are literally dozens of T-coil and telephone coupling systems. Speak with your audiologist to get the most appropriate system for your needs.

    Cell Phones: Most hearing aids can be used with most cell phones. Importantly, digital hearing aids and digital phones may create constant noise or distortion. There may be significant problems for some hearing aids when used with particular cell phones! The best person to address this problem is your audiologist speak with your audiologist BEFORE you buy a cell phone or hearing aids!!!!
    Regarding “hands free” systems, there are many to choose from and hearing impaired users usually benefit maximally by using binaural hands free systems.
    WHAT IS TINNITUS?

    Tinnitus is the term for the perception of sound when no external sound is present. It is often referred to as “ringing in the ears,” although some people hear hissing, roaring, whistling, chirping, or clicking. Tinnitus can be intermittent or constant, with single or multiple tones. Its’ perceived volume can range from very soft to extremely loud.

    HOW MANY PEOPLE HAVE TINNITUS?

    50 million Americans experience tinnitus to some degree. Of these, about 12 million have tinnitus which is severe enough to seek medical attention. Of those, about two million patients are so seriously debilitated by their tinnitus, they cannot function on a “normal,” day-to-day basis.

    WHAT CAUSES TINNITUS?

    The exact cause (or causes) of tinnitus is not known in every case. There are, however, several likely factors which may cause tinnitus or make existing tinnitus worse: noise-induced hearing loss, wax build-up in the ear canal, certain medications, ear or sinus infections, age-related hearing loss, ear diseases and disorders, jaw misalignment, cardiovascular disease, certain types of tumors, thyroid disorders, head and neck trauma and many others. Of these factors, exposure to loud noises and hearing loss are the most probable causes of tinnitus. I strongly recommend that an audiologist and a physician should evaluate all presentations of tinnitus.
    TINNITUS MANAGEMENT and TREATMENT?

    There are many options for people who experience tinnitus. Some wear hearing aids to help cover up their tinnitus, some wear tinnitus maskers. Additionally, there are combined tinnitus maskers and hearing aids all in one unit! Some patients require counseling to help them develop strategies to manage their tinnitus. If you’ve been told “learn to live with it,” there are many additional options to explore. Your audiologist is an excellent resource for issues and answers related to tinnitus. Additionally, I recommend that all people with tinnitus visit the American Tinnitus Association website for more information, ideas and strategies concerning tinnitus. https://www.ata.org/

    MIDDLE EAR IMPLANTS:
    Middle ear implants are surgically implanted devices. The FDA has approved specific middle ear implants and the FDA is still reviewing others. The middle ear implant is a useful hearing instrument and is quite different from traditional hearing aids. Generally speaking, hearing aids reproduce sounds and make them louder than the original sound. When a hearing aid is placed in the ear canal, the loud sound is perceived by the hearing impaired ear. Middle ear implants work by vibrating the middle ear bones, rather than by producing audible sound.
    Therefore, middle ear implants are less likely to produce feedback, and they do not occlude, or “plug up” the ear canal. Additionally, for most people wearing middle ear implants, their hair tends to cover up the external device.
    In summary, the reported benefits of middle ear implants are elimination of the occlusion effect, elimination/reduction of feedback, reduction in distortion, improved clarity, as well as some cosmetic advantages.
    Middle ear implants are an excellent alternative for people with moderate to severe sensorineural hearing loss, after they have tried traditional hearing aids for a few months and after they have determined that traditional hearing aids are not able to provide the desired benefit.
    If you are considering a middle ear implant, speak with your audiologist. Your audiologist can direct you to an otolaryngologist, otologist or neurotologist with experience and expertise in implanting these devices.
    Not all patients are surgical candidates, and each candidate does not receive the same benefit. Nonetheless, middle ear implants are an option, and are worthy of further consideration for appropriate patients. Again, the best source for initial information on this topic is your audiologist.

    For more information on middle ear implants, CLICK HERE.

    COCHLEAR IMPLANTS:
    Generally speaking, cochlear implants are for patients with severe-to-profound, sensorineural hearing loss. There are approximately 500,000 patients in the USA with severe-to-profound hearing loss. Cochlear implants are only recommended after the patient has tried the most powerful and most appropriately fit hearing aids, and has not shown sufficient benefit from hearing aids. Cochlear implants are devices that are “permanently” surgically implanted into the inner ear.
    Cochlear implantation is a surgical procedure performed by otolaryngology surgeons. Cochlear implants have been FDA approved for almost two decades and the advances and improvements in the technology have been amazing. The Food and Drug Association (FDA) and the American Medical Association (AMA) recognize cochlear implants as safe and effective treatment for severe-to-profound sensorineural hearing loss. Most insurance programs pay (at least partly) for cochlear implantation. Your audiologist, your otolaryngology surgeon and their appropriate office staff are experienced at managing insurance issues.
    Appropriately identified adults as well as profoundly deaf children (starting at age 12 months) can be implanted. Research demonstrates that the earlier a deaf child is implanted, the better the long term result will be with respect to speech and language development. Following surgery, rehabilitation is necessary, as the child must learn to associate the sound signals with normal sounds. Regarding deaf adults, research suggests that adults who receive cochlear implants are less lonely, have less social anxiety, are more independent, have increased social and interpersonal skills, and of course, they hear better with the cochlear implant!

    Cochlear implants are utilized in the patient who cannot benefit from hearing aids. The cochlear implant is a device used to bypass the nonfunctional inner ear and converts sound into electrical impulses that directly stimulate the cochlear nerve. The implant consists of an external portion comprised of a microphone, sound processor, and external coil and an internal portion that must be surgically implanted. The surgical procedure involves the placement of an internal receiver beneath the skin behind the ear, and stimulating electrode array, which is inserted into the cochlea or inner ear. The electrical signals are manipulated and controlled by the audiologist to maximize speech perception. The brain interprets these electrical impulses as sound. Again, not all patients are surgical candidates, and not all cochlear implant recipients receive the same benefit.
    It is important to remember that the vast majority of the patients who receive cochlear implants are actually “deaf” prior to implantation, and they have not been successful with traditional hearing aids. Your audiologist is a very knowledgeable resource in regards to cochlear implants and will be happy to discuss them with you.

    For more information on cochlear implants please visit the following:
    Advanced Bionics
    MED EL and
    Cochlear.

    RECOMMENDTAIONS and WARNINGS:
    Please review this information with your spouse or loved ones and please feel free to discuss all of these issues with your audiologist and/or your physician.
    Federal regulation prohibits any hearing aid sale unless the buyer has first received a medical evaluation from a licensed physician. However, if you are at least 18 years old, you can sign a form (waiver) that says you are fully aware of your rights but choose not to have the medical evaluation. Then, you can purchase hearing aids without seeing a physician. For people under 18 years of age, waiver of the medical evaluation is not permitted. These rules and regulations may vary state-by-state and you certainly need to check with your state rules, regulations and laws. I do not recommend using waivers.
    I believe your best health interest is served by seeing a licensed audiologist for a complete audiometric evaluation and seeing an otolaryngologist for the medical and/or surgical diagnosis and treatment of all ear and hearing disorders and diseases.
    The opinions throughout this article are those of the author. Other audiologists and otolaryngologists may have different opinions and recommendations. Additionally, each patient and each hearing problem is unique. “Self-diagnosis” and treatment is unwise, is not recommended and may indeed lead to a worsening situation.
    Some state associations, national associations and indeed many state and federal rules and regulations vary from location-to-location and they change over time. Therefore, it is very important for you to check with your local licensed health care professionals to verify and confirm the information in this pamphlet, and to best determine how it applies to you and your situation, if at all.
    This article may be downloaded and photocopied in its entirety (only) for personal and educational purposes.
    If you have questions, or would like to contact the author, you can contact Dr. Beck at email address: audsx2@aol.com.

    ACKNOWLEDGEMENT:

    Dr. Beck wishes to thank: Aimee LaCalle Au.D., at HearLab Inc. in San Antonio, Texas, and Barbara Beck, Au.D Candidate, from Audiology Online in San Antonio, Texas for their kind, thoughtful and helpful review of this manuscript.

    Who will I see about my Ear and Hearing Problems? 2014-10-06T21:59:02-05:00

    Audiologist

    An audiologist is a person who has a masters or doctoral degree in audiology. Audiology is the science of hearing. In addition, the audiologist must be licensed or registered by their state (in 47 states) to practice audiology.
    In the field of audiology, the master’s degree has been the accepted “clinical” degree for almost 50 years. However, the profession is undergoing a transition to a doctorate level degree as the entry-level requirement to practice audiology. In a few years, there will be very few colleges and universities offering a master’s program in audiology. The Au.D. (Doctor of Audiology) is the clinical doctorate degree and is issued exclusively by regionally accredited universities and colleges. There are other doctoral degrees that have been earned and utilized by audiologists to date, such as the Ph.D. (still highly sought today by researchers and academicians), the Sc.D. and the Ed.D.
    Audiologists work in a variety of settings including hospitals, schools, clinics, universities, rehabilitation facilities, cochlear implant centers, speech and hearing centers, private audiology practices, hearing aid dispensing offices, hearing aid manufacturing facilities, medical centers, as well as otolaryngology (ENT physician) offices. Although the vast majority of hearing problems do not require medical or surgical intervention, audiologists are clinically and academically trained to determine those that do need medical referral. As a licensed healthcare provider, the audiologist appropriately refers patients to physicians when the history, the physical presentation, or the results of the audiometric evaluation (AE) indicate the possibility of a medical or surgical problem. Many audiologists also dispense (sell and service) hearing aids and related assistive listening devices for the telephone, TV and special listening situations.

    PHYSICIANS:
    Otolaryngologists (also called ear-nose-and-throat, or ENT, doctors) are physicians who have advanced training in disorders of the ear, nose, throat and head and neck. Otologists or neurotologists are physicians who in addition to their ENT requirements continue their specialized training for an additional year or more in the diagnosis and treatment of disorders of the ear. Otolaryngologists, neurotologists and otologists are the physicians who typically treat disorders of the ear (or hearing mechanisms) requiring medical or surgical solutions.

    A Discussion of Chronic Ear Infections 2014-10-06T21:58:10-05:00

    CHRONIC EAR INFECTION
    Chronic ear infection is the result of an ear infection that has left a residual injury to the ear. This type of infection has been established as the cause of your ear problem. Chronic ear infection (the technical diagnosis is chronic otitis media) symptoms depend upon whether or not there is involvement of the mastoid bone and whether there is a hole in the eardrum. In addition, the hearing level depends on whether or not there has been injury to the middle ear bones as well as the eardrum. There may be drainage, hearing impairment, tinnitus (head noise), dizziness, pain, or rarely, weakness of the face. Most often there is simply hearing loss, an uncomfortable feeling and occasionally some discharge.

    FUNCTION OF THE NORMAL EAR
    The ear is divided into three parts the external ear, the middle ear, and the inner ear. Each part performs an important function in the process of hearing.
    Sound waves pass through the canal of the external ear and vibrate the eardrum, which separate the external ear from the middle ear. The three small; bones in the middle ear (hammer or malleus, anvil or incus, and stirrup or stapes) act as a transformer to transmit energy of the sound vibrations to the fluids of the inner ear. Vibrations in this fluid stimulate the delicate nerve fibers. The hearing nerve then transmits impulses to the brain where they are interpreted as understandable sound.

    TYPES OF HEARING IMPAIRMENT
    The external ear and the middle ear conduct sound; the inner ear receives it. If there is some difficulty in the external or middle ear, a conductive hearing loss occurs. If the trouble lies in the inner ear, a sensorineural or hair cell loss is the result. When there is difficulty in both the middle and inner ear, a combination of conductive and sensorineural impairment exists.

    THE DISEASED MIDDLE EAR
    Any disease affecting the eardrum or the three small ear bones may cause a conductive hearing loss by interfering with the transmission of sound to the inner ear. Such a hearing impairment may be due to a perforation (hole) in the eardrum, partial or total destruction of one or all of the three little ear bones, or scar tissue.
    When an acute infection develops in the middle ear (an abscessed ear), the eardrum may rupture, resulting in a perforation. This perforation usually heals. If it fails to do so a hearing loss occurs, often associated with head noise (tinnitus) and intermittent or constant ear drainage.
    Occasionally after an infection in the healing process, skin from the ear canal may be stimulated to grow through a perforated eardrum, into the middle ear and into the mastoid. When this occurs, a skin-lined cyst known as a cholesteatoma is formed. This cyst will continue to expand over a period of time and progressively destroy the surrounding bone. It usually destroys the middle ear bones first, followed by the mastoid. Cholesteatoma presents a grave danger to the inner ear and event to the brain as meningitis may result. If a cholesteatoma is present, drainage tends to be more constant and frequently has a foul odor.

    TREATMENT OF CHRONIC OTITIS MEDIA
    Home Care of the Ear
    If a perforation is present, you should not allow water to get into the ear canal. This may be avoided when showering or washing by placing cotton in the external ear canal and covering it with a layer of Vaseline. If you desire to swim, a custom made mold is helpful in keeping water out of the ear canal.
    Avoid blowing your nose repeatedly in order to keep infection in the nose from spreading to the ear through the eustachian tube. If it is necessary to blow your nose, do not occlude or compress one nostril while blowing the other.
    In the event of ear drainage, keep the ear clean by using a small cotton tipped applicator at the very outer portion of the canal. Medication should be used if discharge is present or when discharge occurs. Cotton may be placed in the outer ear canal to catch discharge, but should not be allowed to completely block the canal.

    Medical Treatment
    Medical treatment, including oral medications and ear drops, will frequently stop the ear drainage. In addition, careful cleaning of the canal and at times the application of antibiotic powder may be necessary.
    Different antibiotics by mouth may be necessary in some cases.
    If the ear is safe, that is, if there is not continuing destruction of the ear by scarring, infection, or by cholesteatoma, and there is minimal hearing loss, medical treatment may be all that is necessary for chronic otitis media. Otherwise, surgery will be necessary.

    SURGICAL TREATMENT
    For many years surgical treatment was instituted in chronic otitis media primarily to control infection and prevent serious complications, that is, to make the ear safe and dry. In recent years, it has often been possible with advances in surgical techniques to reconstruct the diseased hearing mechanism.
    Various tissue grafts may be used to repair the eardrum. These include the covering of the muscle (fascia), vein, or the covering of cartilage (perichondrium).
    A diseased ear bone may be replaced by a synthetic prosthesis and cartilage. Silastic may be used in the middle ear, behind the eardrum to prevent scar tissue from forming, to promote normal function of the ear and motion of the eardrum. When the ear is filled with scar tissue or cholesteatoma or when all the ear bones have been destroyed, it is usually necessary to perform the operation in two stages. In the first stage, the cholesteatoma is removed and silastic may be inserted to allow more normal healing without scar tissue. In the second operation, the silastic is removed and hearing may be reconstructed. In addition, at this time total cholesteatoma removal is assured. If it is not, it is removed at this time. Hearing improvement is rarely noted at or immediately following surgery.
    For further information, contact the American Academy of Otoloaryingology at:
    www.entlink.org/healthinformation/ears.cfm

    A Discussion of Dizziness 2014-10-06T21:55:21-05:00

    Dizziness is a symptom, not a disease. It may be defined as a sensation of unsteadiness, imbalance, or disorientation in relation to an individual’s surroundings. The symptom of dizziness may vary widely from person to person and be caused by many difference diseases. Dizziness may or may not be accompanied by a hearing impairment.
    Movement of fluid in the balance chambers (vestibule and three semicircular canals) also stimulates nerve endings, resulting in electrical impulses to the brain, where they are interpreted as motion.

    MAINTENANCE OF BALANCE
    The inner ear balance mechanism has two main parts: the three semicircular canals and the vestibule. Together they are called the vestibular labyrinth and are filled with fluid. When the head moves, fluid within the labyrinth moves and stimulates nerve endings that send impulses along the balance nerve to the brain. Those impulses are sent to the brain in equal amounts from both the right and left inner ear. Nerve impulses may be started by the semicircular canals when turning suddenly, or the impulses may come from the vestibule, which responds to changes of position, such as lying down, turning over or getting out of bed.
    When one inner ear is not functioning correctly the brain receives nerve impulses that are no longer equal, causing it to perceive this information as distorted or off balance. The brain sends messages to the eyes, causing them to move back and forth, making the surroundings appear to spin. It is this eye movement (called nystagmus) that creates a sensation of things spinning.

    TYPES OF DIZZINESS
    Ear Dizziness
    Ear dizziness, one of the most common types of dizziness, results from disturbances in the blood circulation or fluid pressure in the inner ear chambers, from direct pressure on the balance nerve, or physiologic changes involving the balance nerve. Inflammation or infection of the inner ear or balance nerve is also a major cause of ear dizziness.
    The inner ear mechanism is about the size of a pea, and is extremely sensitive. There are two inner ear chambers: One for hearing (cochlea), and one for balance (vestibule and semicircular canals). These chambers contain a fluid which bathes the delicate nerve endings. These nerve endings are stimulated when there is movement of the fluid. Nerve impulses are then transmitted to the brain by the hearing and balance nerves. The nerves pass through a small bony canal (internal auditory canal), accompanied by the facial nerve.
    Any disturbance in pressure, consistency or circulation of the inner ear fluids may result in acute, chronic, or recurrent dizziness, with or without hearing loss and head noise. Likewise, any disturbance in the blood circulation to this area or infection of the region may result in similar symptoms. Dizziness may also be produced by over stimulation of the inner ear fluids, such as one encounters when he spins very fast and then stops suddenly.
    unsteadiness experienced when one tries to walk on a leg that has “gone to sleep.”
    This nystagmus is common during severe dizziness.

    WARNING
    Persons subject to dizziness should exercise caution when swimming. Buoyancy of the water results in an essentially weightless condition, and visual orientation is greatly impaired if one’s head is under water. As a result, orientation depends almost entirely on the inner ear balance canals. An attack of dizziness at this time could be very dangerous. Similarly, individuals who have lost both inner ear balance canals should avoid underwater swimming.

    EAR DIZZINESS: SYMPTOMS
    Ear dizziness may appear as a whirling or spinning sensation (vertigo), unsteadiness, or giddiness and lightheadedness. It may be constant, but is more often intermittent, and is frequently aggravated by head motion or sudden positional changes, nausea and vomiting may occur, but one does not lose consciousness as a result of inner ear dizziness.

    DIAGNOSING THE CAUSE OF DIZZINESS
    Dizziness may be caused by any disturbance in the inner ear, the balance nerve or its central connections. This can be due to a disturbance in circulation, fluid pressure or metabolism, infections, neuritis, drugs, injury, or growths.
    an extensive evaluation is required to determine the cause of dizziness. The tests necessary are determined at the time of examination and may include detailed hearing and balance tests, x-rays, and blood tests. A general physical examination and neurological tests may be advised.

    Occlusion
    As one gets older, blood vessel walls tend to thicken due to an aging process known as arteriosclerosis. This thickening results in partial occlusion, with a gradual decrease of blood flow to the inner ear structures. The balance mechanism usually adjusts to this, but at times persistent unsteadiness develops. This may be aggravated by sudden position changes such as that encountered when one gets up quickly or turns suddenly.

    Treatment
    Treatment of dizziness due to changes in circulation consists of anti-dizziness medications to suppress the symptoms. They also stimulate the circulation and enhance the effectiveness of the brain centers in controlling the symptoms. An individual with this type of dizziness should avoid drugs that constrict the blood vessels, such as caffeine (coffee) and nicotine (tobacco). Emotional stress, anxiety and excessive fatigue should be avoided as much as possible. Often, increased exercise will aid in the suppression of dizziness in many patients by stimulating the remaining function to be more effective.

    BENIGN POSITIONAL VERTIGO
    Postural or Positional Dizziness
    Postural or positional dizziness is a common form of balance disturbance due to circulatory changes or to loose calcium deposits in the inner ear. It is characterized by sudden, brief episodes of imbalance when moving or changing head position. Commonly it is noticed when lying down or arising or when turning over in bed. This type of dizziness is rarely progressive and usually responds to treatment, but it may recur. Treatment usually consists of exercises designed to provoke the dizziness until it fatigues. This type of exercise may be recommended by your physician to cause the positional dizziness to run its course more quickly. Occasionally, postural dizziness may be permanent and surgery may be required.

    IMBALANCE RELATED TO AGING
    Some individuals develop imbalance as a result of the aging process. In many cases this is due to circulatory changes in the very small blood vessels supplying the inner ear and balance nerve mechanism. Fortunately, these disturbances, although they may persist, rarely become worse.
    Postural or positional vertigo (see above) is the most common balance disturbance of aging. This may develop in younger individuals as a result of head injuries or circulatory disturbances. Dizziness on change of head position is a distressing symptom, which is often helped by vestibular exercises.
    Temporary unsteadiness upon arising from bed in the morning is not uncommon in older individuals. At times this feeling of imbalance may persist for an hour or two. Arising from bed slowly usually minimized the disturbance. Unsteadiness when walking, particularly on stepping up or down, or walking on uneven surfaces, develops in some individuals as they progress in age. Using a cane and learning to use the eyes to help the balance is often helpful.
    thyroid hormone. Abnormalities in the blood sugar are diagnosed, again by blood studies, and treatment usually consists of diet control and/or drug therapy. Fat metabolism problems and diagnosed by studies of the fatty acids and cholesterol in the blood. Treatment of these may consist of diet control with or without drug therapy.

    ALLERGIES
    Rarely, allergies may cause dizziness and/or vertigo. Allergies are usually diagnosed by obtaining a careful history and occasionally performing a series of skin tests with inhalants and food, and/or blood tests. Treatment usually consists of elimination of the offending agents when possible, or, if this is not possible, by allergy shots to stimulate immunity.

    INJURY
    Injury to the head occasionally results in dizziness of long-standing origin. If the trauma is severe, it is usually due to the combined damage to the inner ear, balance nerve, and central nervous system. Lesser injury may damage any one, or a combination of these components. The unsteadiness is at times prolonged, and may or may not be associated with hearing loss and head noise as well as other symptoms.

    LABYRINTHINE DYSFUNCTION
    Labyrinthine dysfunction describes one of the non-specific conditions where the inner ear is not functioning properly. Although the cause is often unknown, viral illnesses, medication, and trauma are known at times to cause this condition. In order to reach this diagnosis definitively, hearing and balance testing must be done.
    Symptoms may be highly variable. They can range from occasional unsteadiness to episodic vertigo or constant unsteadiness. Hearing loss is occasionally present.
    Initially, treatment is medical and a wide variety of medications may be used. Occasionally, vertigo exercises are helpful. When vertigo cannot be controlled with medication or exercises, surgery is sometimes indicated.

    ENDOLYMPHATIC HYDROPS
    Endolymphatic hydrops is a term which describes increased fluid pressure in the inner ear. In this respect it is similar but not related to glaucoma of the eye fluids. A special clinical form of endolymphatic hydrops is called Meniere’s disease, described elsewhere in this book. All patients with Meniere’s disease have endolymphatic hydrops, but not all patients with hydrops have Meniere’s disease.
    There may be many causes of endolymphatic hydrops. It occurs widely in people of European decent and rarely in oriental or black people. It may be caused or aggravated by excessive salt intake or certain mediations. The symptoms are highly variable. The patient may have one symptom or a combination. Often there is a combination of hearing changes, disequilibrium, motion intolerance, or short dizzy episodes. There may be tinnitus and/or a pressure feeling in the head or ears. The patient does not have the well defined attacks of Meniere’s disease (fluctuating hearing loss, tinnitus and episodes of spinning lasting minutes to hours). Often the division between the two diagnoses may be blurred and difficult to separate, even for the patient. Endolymphatic hydrops may progress to Meniere’s disease in some patients.
    The treatment of endolymphatic hydrops is similar to that for Meniere’s disease. Medications are first used. Diuretics (water pills) are almost always used. Their purpose is to decrease the fluid pressure in the inner ear. In addition to diuretics, other medications may be indicated, depending on the cause of symptoms in each patient’s case. If these fail, surgery is sometimes indicated. (See Surgery for vertigo elsewhere in this document).

    MENIERE’S DISEASE
    Meniere’s disease is a common cause of repeated attacks of dizziness, and is thought to be due (in most cases) to increased pressure of the inner ear fluids due to impaired metabolism of the inner ear. Fluids in the inner ear chamber are constantly being produced and absorbed by the circulatory system. Any disturbance of this delicate relationship results in overproduction of underabsorption of the fluid. This leads to an increase in the fluid pressure (hydrops) that may, in turn, produce dizziness which may or may not be associated with fluctuating hearing loss and tinnitus.
    A thorough evaluation is necessary to determine the cause of Meniere’s disease, if possible. Circulatory, metabolic, toxic and allergic factors may play a part in any individual. Emotional stress, while making the disease worse, does not cause it.

    Symptoms
    Meniere’s disease is usually characterized by attacks consisting of vertigo (spinning) that varies in duration from a few minutes to several hours. Hearing loss and head noise, usually accompanying the attacks, may occur suddenly. Violent spinning, whirling, and falling associated with nausea and vomiting are common symptoms. Sensations of pressure and fullness in the ear or head are usually present during the attacks. The individual may be very tired for several hours after the overt spinning stops.

    Treatment of Meniere’s Disease
    Treatment of cochlear and vestibular hydrops is the same as for classic Meniere’s disease. The treatment of Meniere’s disease may be medical or surgical, depending upon the patient’s stage of the disease, life circumstances, and the condition of the ears. The purpose of the treatment is to prevent the hearing loss, and stop the vertigo (spinning).
    It is aimed at improving the inner ear circulation and controlling the fluid pressure changes of the inner ear chambers. Treatment may consist of medication to decrease the inner ear fluid pressure or prevent inner ear allergic reactions. Various drugs are used as anti-dizziness medication. Vasoconstricting substances have an opposite effect and, therefore, should be avoided. Such substances are caffeine (coffee) and nicotine (cigarettes).
    Diuretics (“water pills”) may be prescribed to decrease the inner ear fluid pressure.
    Meniere’s disease may be caused or aggravated by metabolic or allergic disorders. Special diets or drug therapy are indicated at times to control these problems.
    On rare occasions we may use gentamycin injections which selectively destroy balance function. This treatment is reserved for patients with Meniere’s disease in their only hearing ear or with Meniere’s disease in both ears.
    Surgery is most successful in relieving acute attacks of dizziness in the majority of patients. Some unsteadiness may persist over a period of several months until the opposite ear and the central nervous system are able to compensate and stabilize the balance system.

    DIZZINESS: NONSURGICAL TREATMENT
    Vestibular Rehabilitation
    Current retrospective studies indicate that 85% of patients with chronic vestibular dysfunction gain at least partial relief of their symptoms after undergoing vestibular rehabilitation.. One of the most difficult things for patients with vestibular disorders to do is walk and move the head. Different combinations of head and neck movements are performed during gait to provoke symptoms.
    Following the evaluation, a treatment plan is developed. The treatment consists of habitual exercises, balance retraining exercise, and usually a general conditioning program. Balance retraining exercises are also given when appropriate and consist of activities directed towards improving the patient’s balance. Exercises are chosen according to the problem areas discovered in the evaluation and often involve interaction among the three sensory inputs involved in balance: vision, somatosensory cues and vestibular inputs.

    SUMMARY
    There are many causes of dizziness. This dizziness may or may not be associated with hearing loss. In most instances the distressing symptoms of dizziness can be greatly benefited or eliminated by medical, surgical, or rehabilitative treatments.
    For further information, contact the Vistibular Disorders Association at:
    https://vestibular.org/understanding-vestibular-disorder/treatment.

    A Discussion of Eustachian Tube and Middle Ear Problems 2014-10-06T22:19:50-05:00

    First, in order to understand possible problems of the middle ear and eustachian tube, a brief review of ear anatomy & physiology is in order.

    MECHANISM OF HEARING
    The ear is comprised of three portions: an outer ear (external), a middle ear and inner ear. The outer (external) ear consists of an auricle and ear canal. These structures gather the sound and direct it toward the ear drum (tympanic membrane).
    The middle ear chamber lies between the external and inner ear. This chamber is connected to the back of the throat (pharynx) by the eustachian tube which serves as a pressure equalizing valve. The middle ear consists of an eardrum and three small ear bones (ossicles): malleus (hammer), incus (anvil) and stapes (stirrup). These structures transmit sound vibrations to the inner ear. A disturbance of the eustachian tube, eardrum or the ear bones may result in a conductive hearing impairment. This type of impairment is usually corrected medically or surgically.

    FUNCTION OF THE EUSTACHIAN TUBE
    The eustachian tube is a narrow channel which connects the middle ear with the nasopharynx (the upper throat area just above the palate, in back of the nose). The Eustachian tube is approximately 1 1/2 inches in length. The narrowest portion is that area near the middle ear space.
    The eustachian tube functions as a pressure equalizing valve of the middle ear, which is normally filled with air. Under normal circumstances the eustachian tube opens for a fraction of a second in response to swallowing or yawning. In so doing it allows air into the middle ear to replace air that has been absorbed by the middle ear lining (mucous membrane) or to equalize pressure changes occurring with altitude changes. Anything that interferes with this periodic opening and closing of the eustachian tube may result in a hearing impairment or other ear symptoms.
    Obstruction or blockage of the eustachian tube results in a negative middle ear pressure, with restraction (sucking in) of the eardrum (tympanic membrane). In an adult this is usually accompanied by some discomfort, such as a fullness or pressure feeling, and may result in a mild hearing impairment and head noise (tinnitus). In children there may be no symptoms. If the obstruction is prolonged, the fluid may be sucked in from the mucous membrane in the middle ear creating a condition called serous otitis media (fluid in the middle ear). This occurs frequently in children in connection with an upper respiratory infection or allergies and accounts for the hearing impairment associated with this condition.
    On occasion just the opposite from blockage occurs; the tube remains open for a prolonged period. This is called abnormal patency of the eustachian tube (patalous eustachian tube). This is less common than serous otitis media and occurs primarily in adults. Because the tube is constantly open the patient may hear himself breathe and hears his voice reverberate in the affected ear. Fullness and a blocked feeling are not uncommon sensations experienced by the patient. Abnormal patency of the eustachian tube is annoying but does not produce a hearing impairment.

    EUSTACHIAN TUBE PROBLEMS RELATED TO FLYING
    Individuals with a eustachian tube problem may experience difficulty equalizing middle ear pressure when flying. When an aircraft ascends, the atmospheric pressure decreases, resulting in a relative increase in the middle ear air pressure. When the aircraft descends, just the opposite occurs; atmospheric pressure increases in the cabin of the aircraft and there is a relative decrease in the middle ear pressure. Either situation may result in discomfort in the ear due to abnormal middle ear pressure compared to the cabin pressure, if the eustachian tube is not functioning properly. Usually, this discomfort is experienced upon descent of the aircraft.
    To avoid middle ear problems associated with flying you should not fly if you have an acute upper respiratory problem such as a common cold, allergy attack or sinus nfection. Should you have such a problem and must fly, or should have a chronic eustachian tube problem, consult with your Physician and he/she may recommend one or more of the following:
    1. Sudafed tablets and a plastic squeeze bottle of 1/4 percent NeoSynephrine or Afrin nasal spray.
    2. Should your ears “plug up” upon ascent, hold your nose and swallow while attempting to force air up to the back of the throat. This will help suck excess air pressure out of the middle ear.
    3. Chew gum to stimulate swallowing. Should your ear “plug up” despite this, hold your nose and blow gently toward the back of the throat while swallowing. This will blow air up the eustachian tube into the middle ear (Valsalva Maneuver).

    SEROUS OTITIS MEDIA
    Serous otitis media is a term which is used to describe a collection of fluid in the middle ear. This may be a recent onset (acute) or may be long standing (chronic).
    Serous otitis media is the most common cause of hearing loss in children. Fortunately, the hearing loss associated with this condition usually is not permanent. However, serous otitis media may be present without recurrent ear infections and a mild hearing loss may be the only sign of its presence. Prompt Audiological identification of the hearing loss and Medical intervention, usually restore hearing to normal or near normal levels.
    Serous Otitis Media is quite common in young children. Although the hearing involvement that ocurrs as a consequence is rarely severe, left over a long period of time, has been known to cause or exacerbate speech and language delays. Again prompt identification and intervention are advised.
    Acute serous otitis media is usually the result of blockage of the eustachian tube from an upper respiratory infection or an attack of nasal allergy. In the presence of bacteria this fluid may become infected leading to an acute suppurative otitis media (infected or abscessed middle ear).This chronic condition is usually associated with a hearing impairment. There may be recurrent ear pain, especially when the individual catches a cold.
    Serous otitis may persist for many years without producing any permanent damage to the middle ear mechanism. Presence of fluid in the middle ear, however, makes it very susceptible to recurrent acute infections. These recurrent infections may result in middle ear damage.

    CAUSE OF SEROUS OTITIS MEDIA
    Serous otitis media may result from any condition that interferes with the periodic opening and closing of the eustachian tube. The causes may be congenital (present at birth), may be due to infection or allergy, or may be due to mechanical blockage of the tube.

    The Immature Eustachian Tube
    The size and shape of the eustachian tube is different in children than in adults. This accounts for the fact that serous otitis media is more common in very young children. Some children inherit a small eustachian tube from their parents; this accounts in part for the familial tendency to middle ear infection. As the child matures, the eustachian tube usually assumes a more adult shape

    Infection
    The lining membrane (mucous membrane) of the middle ear and eustachian tube is connected with, and is the same as, the membrane of the nose, sinuses and throat. Infection of these areas results in the mucous membrane swelling, which in turn may result in eustachian tube obstruction.

    Allergy
    Allergic reaction in the nose and throat result in swelling of the mucous membranes and this swelling may also affect the eustachian tube. This reaction may be acute or chronic.

    ACUTE SEROUS OTITIS MEDIA
    Treatment of acute serous otitis media is medical, and is directed towards treatment of the upper respiratory infection or allergy attacks. This may include antibiotics, antihistamines (anti-allergy drugs), decongestants (drugs to decrease mucous membrane swelling) and nasal sprays.

    ACUTE SUPPURATIVE OTITIS MEDIA
    In the presence of an upper respiratory infection, such as a cold, tonsillitis, or pharyngitis, fluid in the middle ear may become infected. This results in what is commonly called an abscessed ear or an infected middle ear.
    This infected fluid (pus) in the middle ear may cause severe pain. If the audiological and medical evaluations reveal there is considerable ear pressure, a myringotomy (incision of the eardrum membrane) may be necessary to relieve the pressue, drainage, and the pain. In many instances antibiotic treatment will suffice. The pressure equalization tube inserted usually stays in and open for 4-6 months and then is naturally pushed out be healing processes in the ear.

    CHRONIC SEROUS OTITIS MEDIA
    Treatment of chronic serous otitis media may either be medical or surgical.

    Medical Treatment
    As the acute upper respiratory infection subsides, it may leave the patient with a persistent eustachian tube blockage. Antibiotic treatment may be indicated.

    Allergy is often a major factor in the development or persistence of serous otitis media. Mild cases can be treated with antihistaminic drugs. Again, the insertion of a ventilation tube is indicated when the ears are not responsive to pharmacological treatment.

    The ventilation tube temporarily takes the place of the eustachian tube in equalizing middle ear pressure. Usually the chonic condition resolves while the tube is in place, not requiring the re-insertion of an additional tube.
    In adults, a myringotomy and insertion of a ventilation tube is usually performed in the office under local anesthesia, with the use of a topical solution placed on top of the tympanic membrane. In children, general anesthesia is required.
    When a ventilation tube is in place, a patient may carry on normal activities with the exception that no water must enter the ear canal. Often this can be prevented with vaseline on a cotton ball or a silicone ear plug. In addition, a custom made earmold, made by the Audiologist, will often prevent water from entering the ear canal.

    The Role of the Audiologist in the Diagnosis of Eustachian Tube and Middle Ear Disorders.
    Although the discomfort which often accompanies middle ear and Eustachian Tube maladies often will bring an adult straight to a Physician, sometimes, especially with children, ther is no discomfort. With them, often, the only way to know of a middle ear or Eustachian Tube discorder is from a louder T.V. Or a report home from school that there are more “whats” or “huhs” in the classroom, as a consequence from the ensuing hearing involvement. Hearing screening in the schools, Pediatricians’ offices, or audiologic follow-up by the Audiologist, may be the first line of identification of these disorders.

    Even before a hearing loss presents itself, tympanometry may be the most sensitive diagnostic test for middle ear and Eustachian Tube disorders. With tympanometry (see Services section for more details) the Audiologist inserts a small probe to the outside of the ear canal for 5 seconds. The probe “reads” how much sound energy is transferred in to the inner ear. If too much sound energy is reflected back to the probe, fluid in the middle ear cavity, due to one of the above reasons, is suspected. Also, tymanometry can read whether the ear drum is drawn in due to negative middle ear pressure, an often times precursor to middle ear fluid.
    Even after ventilation tubes (P.E. Tubes) are inserted, hearing tests are important to monitor and substantiate the improved hearing. Moreover, the tympanometry can verify that the P.E. Tubes are still functional.

    A Discussion of Facial Nerve Problems 2014-10-06T21:46:11-05:00

    Spasm, weakness or paralysis of the face is a symptom of some disorder involving the facial nerve. It is not a disease in itself. The disorder may be caused by many different diseases, including circulatory disturbances, infection, or tumor.

    FUNCTION OF THE FACIAL NERVE
    The facial nerve resembles a telephone cable and contains hundreds of individual nerve fibers. Each fiber carries electrical impulses from the brain to a specific facial muscle. Acting as a unit, this nerve allows us to laugh, cry, smile or frown, hence the name, “the nerve of facial expression.” The facial nerve not only carries nerve impulses to the muscles of one side of the face; but also carries nerve impulses to the tear glands, saliva glands, to the muscle of a small middle ear bone (stapes), and transmits taste fibers from the front of the tongue and pain fibers from the ear canal. As such, a disorder of the facial nerve may result in spasm, weakness or paralysis of the face, dryness of the eye or mouth, loss of taste and, occasionally, increased sensitivity to loud sound and pain in the ear.
    An ear specialist is often called upon to manage facial nerve problems because of the close association of this nerve with the ear structures. After leaving the brain, the facial nerve enters the temporal bone (ear bone) through a small bony tube (the internal auditory canal) in very close association with the hearing and balance nerves. Along its inch and a half course through a small bony canal in the temporal bone, the facial nerve travels near the three middle ear bones, in back of the ear drum, and then through the mastoid to exit below the ear. Here it divides into many branches to supply the facial muscles. During its course through the temporal bone the facial nerve gives off several branches: to the tear gland, to the stapes muscle, to the tongue and saliva glands and to the ear canal. The facial nerve does not supply the muscle used in chewing.

    CAUSES OF FACIAL NERVE DISORDERS
    Bell’s palsy
    The most common condition resulting in facial nerve weakness or paralysis is Bell’s palsy, named after Sir Charles Bell, who first described the condition. The underlying cause of Bell’s palsy is felt to be due to a viral infection of the nerve or inflammation of the nerve. We know that the nerve swells in its tight bony canal. This swelling results in pressure on the nerve fibers and their blood vessels. Treatment is directed at decreasing the swelling and restoring the circulation, so that the nerve fibers may again function normally.

    Herpes Zoster Oticus
    A condition similar to Bell’s palsy is herpes zoster oticus or “shingles” of the facial nerve. In this condition, there is not only facial weakness but often hearing loss, unsteadiness, and painful ear blisters. These additional symptoms usually subside spontaneously but some hearing loss or unsteadiness may remain.
    Injuries of the Facial Nerve
    The most common cause of facial nerve injury is due to a skull fracture. This injury may occur immediately or may develop some days later due to nerve swelling.
    Injury to the facial nerve may occur in the course of operations on the ear. This complication, fortunately, is very uncommon. It may occur, however, when the nerve is not in its normal anatomical position (congenital abnormality) or when the nerve is so distorted by mastoid or middle ear disease that it is not identifiable. In rare cases, it may be necessary to remove a portion of the nerve in order to eradicate the disease. In more complicated ear problems, such as tumors of the hearing and balance nerve, the facial nerve may be injured and at times, the nerve must be severed to allow complete removal of a tumor.
    Delayed weakness or paralysis of the face following reconstructive middle ear surgery (myringoplasty, tympanoplasty, stapedectomy) is uncommon, but occurs at times due to swelling of the nerve during the healing period. Fortunately, this type of facial nerve weakness usually subsides spontaneously in several weeks and rarely requires further surgery.

    Tumors
    Acoustic Tumors: The most common tumor to involve the facial nerve is a nonmalignant tumor to the hearing and balance nerve called an acoustic neuroma (vestibular schwannoma). Although there is rarely any weakness of the face before surgery, tumor removal sometimes results in weakness or paralysis due to the close proximity of the facial nerve. This weakness usually subsides in several months without treatment.
    It may be necessary to remove a portion of the facial nerve in order to remove the acoustic tumor. In that case, the face is totally paralyzed until the nerve is repaired and has had a chance to regrow. It may be possible to sew the nerve ends together at the time of surgery or to insert a nerve graft. At times, a nerve anastomosis procedure is necessary, connecting a tongue or shoulder nerve to the facial nerve.

    Facial Nerve Neuroma: A nonmalignant growth may grow in the facial nerve itself, producing a gradually progressive facial nerve paralysis.
    It may be necessary to severe or remove a portion of the facial nerve in order to remove a facial nerve neuroma. An attempt is made to sew the nerve ends together at the time of surgery or to insert a nerve graft. The nerve used in grafting is taken from a skin sensation nerve in the neck. Total paralysis will be present until the nerve regrows through the graft, usually a period of 6 to 24 months. At times, a nerve procedure is necessary later, connecting a tongue nerve to the facial nerve (hypoglassal-facial anastomosis). In all of these situations there will be some permanent facial weakness.
    Removal of a facial nerve neuroma may necessitate removal of the inner ear structures. If this is necessary, it results in a total loss of hearing in the operated ear and temporary severe dizziness. Persistent unsteadiness is uncommon.

    Infection
    Acute or chronic middle ear or mastoid ear infections occasionally cause a weakness of the face due to swelling or direct pressure on the nerve. In acute infections the weakness usually subsides as the infection is controlled and the swelling around the nerve subsides.
    Facial nerve weakness occurring in chronically infected ears is usually due to pressure from a cholesteatoma (skin cyst). Mastoid surgery is performed to eradicate the infection and relieve nerve pressure. Some permanent facial weakness may remain.

    Brain Disease
    Tumors and circulatory disturbances of the nervous system may cause facial nerve paralysis. The most common example of this is a stroke.
    As opposed to other conditions listed in this booklet, in brain diseases there are usually many other symptoms which indicate the cause of the problem. Treatment is managed by the neurotologist in conjunction with an internist, neurologist, or neurosurgeon.

    Hemifacial Spasm
    Hemifacial spasm is an uncommon disease which results in spasmotic contractions of one side of the face. Extensive investigation is necessary at times to establish the diagnosis correctly. In some cases, a hemifacial spasm is caused by an irritation of the facial nerve by a blood vessel near the brain. Examination of the nerve and correction of the irritation, if present, is possible by a surgical approach.

    DIAGNOSIS OF FACIAL NERVE DISORDERS
    An extensive evaluation is often necessary to determine the cause of the disorder and localize the area of nerve involvement.
    Hearing Test
    Tests of the hearing are done to determine if the nerve disorder has involved the delicate hearing mechanism. Facial nerve disorders are accompanied at times by a hearing impairment. When the face is totally paralyzed, a special hearing test (stapedius reflex) helps to localize the problem area.
    ABR (auditory Brainstem response) testing is a sophisticated computerized hearing test which evaluates the neural pathways of hearing through the Brainstem. These are pathways closely related to those of facial function. Abnormalities here help to further define the nature of the facial nerve disorder.
    Hearing is measured in decibels (dB). A hearing level of 0 to 25 dB is considered serviceable hearing for conversational purposes.
    Balance Tests
    Special testing of the balance portion of the inner ear may be necessary in some cases to clarify the cause or location of the facial nerve disorder. Conventional balance testing involves measuring the eye movements relative to stimulation of the ear in a test called electronystagmography (ENG).

    Imaging (X-rays)
    MRI (magnetic resonance imaging) and CT (computer tomography) are both head scans highly capable of determining if the facial nerve disorder is due to tumor, infection, bone fracture or vascular conditions such as stroke. In some cases, it may be necessary to obtain special x-ray studies of the blood vessels (angiography) in the area of the brain or ear.
    Nerve Stimulation Tests
    Facial nerve stimulation or nerve excitability tests help to determine the magnitude of nerve fiber damage in cases of facial paralysis. It is an estimation of the health of the nerve and may be useful in helping to predict ultimate functional recovery of the paralysis. Despite the presence of obvious facial paralysis, these tests are capable of indicting the degree of damage which is occurring. These tests may be repeated regularly, perhaps daily; so as to detect any change, for better or worse, in the overall process of paralysis.
    Nerve excitability testing includes maximum stimulation tests (MST) and the more sophisticated electroneurongraphy (ENOG) or evoked electromyography (EEMG).
    In cases of long-standing facial paralysis, an EMG (electromygraph) may be requested. This test helps determine the status of nerve and facial muscles in the recovery process.

    MANAGEMENT
    Treatment of facial nerve weakness or paralysis may be supportive, medical, eye care, surgical, or a combination of all four.

    Medical Treatment
    Medical treatment is instituted to decrease the swelling. It often involves the use of steroids. This treatment may be continued until the nerve shows sign of recovery.

    Eye Care
    The most serious complications that may develop as the result of total facial nerve paralysis are an ulcer of the cornea of the eye. It is most important that the eye on the involved side be protected from this complication.
    Closing the eye with the finger is an effective way of keeping the eye moist. One should use the back of the finger rather than the tip in doing this to insure that the eye is not injured.
    Glasses should be worn whenever you are outside. This will help prevent
    particles of dust from becoming lodged in the eye. Contact lenses should
    not be worn in this situation. The advice of your eye doctor should be sought.
    If the eye is dry, you may be advised to use eye drops. The drops should be used as often as necessary to keep the eye moist. Ointment may be prescribed for use at bedtime.
    The best protection for night/sleep hours is to place a clear eye guard over the eye. This can be secured in place with tape. Eye care must be compulsive! Any eye problems or irritation which does not quickly pass should warrant consultation with your eye doctor as soon as possible.
    If facial weakness is anticipated following surgery, a silk thread is sometimes placed in the lid to help close it. When lid closure is adequate this easily removed.
    In some cases of long-standing paralysis, it may be necessary to insert a weight into the eyelid to close the eye or perform some other procedure to help the eyelid close (i.e. tarsorrhaphy).

    Surgical Treatment
    Surgical treatment for facial paralysis is very controversial. Surgery to decompress the swelling facial nerve is indicated in very special and well defined circumstances. Surgical facial nerve treatment is not applicable to everyone.
    The degree and rapidity of recovery of facial nerve function depends upon the amount of damage present in the nerve at the time of surgery. Recovery may take from 3 to 18 months and may not ever be complete.
    Fortunately, it is unusual to develop a hearing impairment following
    surgery but this depends on the extent of surgery needed in the individual case.
    Mastoid decompression of the facial nerve. Surgical decompression of the facial nerve is indicated in cases of paralysis when the electrical tests show that the nerve function is deteriorating or a fracture is present. This operation is performed under general anesthesia and requires hospitalization for 1 to 2 days. Through an incision behind the ear the mastoid bone around the nerve is removed, allowing repair of a nerve or relieving pressure so that the circulation may be restored.
    Middle fossa facial nerve decompression. This procedure involves making an incision above the ear, and making a small opening in the skull. This procedure allows pressure to be relieved from the nerve or repair of a nerve, if injured.
    Retrosigmoid facial nerve decompression. In certain conditions such a hemifacial spasm or facial nerve tumors, the facial nerve may need to be investigated where it enters the brain. This is performed through an incision behind the ear and removal of either the mastoid bone or a portion of the skull just behind the mastoid. This exposes the area between the brain and the inner ear to allow appropriate treatment.
    Translabyrinthine facial nerve decompression and repair. In certain situations, the hearing and balance function of the inner ear is destroyed by the same process causing the facial paralysis. Usually this is trauma or a tumor. In this instance, the inner ear structures for balance and hearing may be removed to give greater access to repair the facial nerve.

    Facial nerve graft. A facial nerve graft is necessary at times if facial nerve damage is extensive. A skin sensation nerve is removed from the neck and transplanted into the ear bone to replace the diseased portion of the facial nerve. Total paralysis will be present until the nerve regrows through the graft. This usually takes 6 to 15 months. Some facial weakness is permanent.
    Hypoglossal-facial nerve anastomosis. When it is not possible for a facial nerve connection by other means, the nerve to the muscles of one side of the tongue is connected to the facial nerve. Usually, this occurs when the facial nerve is severed during tumor surgery or trauma and may be performed immediately or up to several years after the injury. Surgery is performed under general anesthesia. The previous incision behind the ear is opened and extended into the neck. The nerve to the tongue (hypoglossal nerve) is cut and then connected to the facial nerve. In 6 to 12 months, when the tongue nerve grows into the facial nerve, a variable degree of facial motion returns. Facial appearance may be nearly normal at rest. There will be some persistent weakness of the face. On moving the face, all of the muscles tend to contract at once, and some face motion may occur when speaking. Weakness and wasting of one half of the tongue develops following cutting of the hypoglossal nerve. This results in some difficulty in speaking, chewing and swallowing. Although the tongue weakness is permanent, it is rare for a severe disability to persist.

    RISKS AND COMPLICATIONS OF FACIAL NERVE SURGERY
    The surgeon carefully weighs the risks and complications of each procedure for the individual patient. Surgery is not recommended unless the benefits derived from surgery to optimize the return of facial nerve function far outweigh the risks and complications of surgery. Patients are required to carefully study the risks and complications of surgery so they may make a thoughtful, informed consent if surgery is decided upon by the patient and the surgeon. Patient questions are encouraged so the patient has a clear understanding of the facial nerve problem and the options available for management.

    Hearing Loss
    All patients notice some hearing impairment in the operated ear immediately following surgery. This is due to swelling and fluid collection in the mastoid and middle ear. This swelling usually subsides within 2-4 weeks and the hearing returns to its preoperative level. In an occasional case scar tissue forms and results in a permanent hearing impairment. It is rare to develop a severe impairment, unless a translabyrinthine approach was utilized.

    Dizziness
    Dizziness is common immediately following surgery due to swelling in the mastoid and unsteadiness may persist for a few days postoperatively. On rare occasions dizziness is prolonged.

    Other Complications
    A hematoma (collection of blood under the skin incision) develops in a small percentage of cases, prolonging hospitalization and healing. Re-operation may be necessary to remove the blood.
    A cerebral spinal fluid leak (leak of fluid surrounding the brain) develops in an occasional case. Re-operation may be necessary to stop the leak.
    Infection is a rare occurrence following facial nerve surgery. Should it develop, however, after an intracranial procedure, it could lead to meningitis (infection in the fluid surrounding the brain). Fortunately, this complication is very rare.
    Brain injury or stroke, which may lead to paralysis or other neurologic disability, has occurred following intracranial operations for facial nerve repair. This complication is, however, extremely rare.

    Related to Intracranial Surgery
    The middle fossa, retrolabyrinthine/retrosigmoid, and translabyrinthine approaches to the facial nerve, absolutely necessary in some cases, are more serious operations. Hearing and balance disturbances are more likely following this surgery.
    Related to Anesthesia
    Operations on the facial nerve usually are performed under general anesthesia. There are risks involved with any anesthesia and you may discuss this with the anesthesiologist if desired.

    GENERAL COMMENTS
    During the period of recovery of facial function, exercises may be recommended. Exercising the muscles by wrinkling the forehead, closing the eyes tightly, and smiling forcefully may be beneficial.
    Electrical stimulation of the facial muscles is usually not recommended. Electromyographic biofeedback may be used during rehabilitation of the facial nerve injury to educate and instruct patients in facial muscle contraction.
    Should any questions arise regarding your problem, feel free to call, write, or email our office.

    A Discussion of Hearing Problems in Children 2014-10-06T21:43:53-05:00

    Five thousand children are born profoundly deaf each year in the United States alone. Another 10 to 15 percent of newborns have a partial hearing loss.

    SENSORINEURAL IMPAIRMENT
    A sensorineural hearing loss is used to describe hearing impairments which result from a disruption of the conversion of mechanical viabrations in the inner ear to nerve signals, which go up to the brain. These impairments may be congenital (i.e. present at birth), hereditary, developmental, or a combination of these. In addition, these impairments may result from infections, injuries, ototoxic drug therapy, or lack of oxygen.

    Hearing loss may be divided further due to the cause of the hearing handicap.
    A. Congenital hearing loss
    1. Genetic – In the genetic type there is an actual defect in your child’s genes which results in an abnormal development of the ear.
    2. Non-genetic – This is a hearing loss which is due to some problem which occurred during the fetal development or the immediate birth period.
    B. Acquired hearing loss – This is a hearing impairment which occurs sometime after birth and is not transmitted to future children.

    CONGENITAL FACTORS
    Several viral infections, including CMV and German measles contracted by the mother during the first three months of pregnancy, may interfere with inner ear development in the fetus. Occasionally, the origin is other viruses, such as the viruses of measles and mumps. Fortunately, due to better immunization prevelance, these diseases are not as common as they once were.

    PROBLEMS AT BIRTH
    A very difficult and complicated labor or premature birth may also result in an inner ear hearing impairment on occasion. This may be due to lack of oxygen. These are many syndromes which can also result in a hearing impairment at birth. One can have a hearing loss at birth without any hereditary relationship.
    Jaundice occurring at or shortly after birth is capable of damaging the inner ear. This is most often due to Rh incompatibility between the mother’s and the child’s blood. Fortunately, this is not a common occurrence.

    HEREDITARY IMPAIRMENT
    The development and function of the ear is dependent upon hundreds or even thousands of genes, interacting with each other and with the inter-and extrauterine environment. A major cause of late-onset hearing loss for children is genetic in origin. Most cases of hereditary-based childhood deafness are sensorineural rather than conductive in nature. frequencies.
    Hereditary sensorineural hearing loss may be present at birth, or may develop later in life. This may be due to inner ear malformations or to other associated syndromes which have an associated inner ear hearing loss. One may see a genetic sensorineural hearing loss with or without associated abnormalities.

    INFECTIONS
    The most common type of acquired sensorineural loss is meningitis. Frequently this may affect both ears, but can involve one ear. Other types of infections would include viral diseases, such as mumps, rubella and otitis media.

    HEARING IMPAIRMENT IN ONE EAR
    A hearing impairment that is confined to one ear deprives a person of the ability to distinguish the direction of sound. He will also have difficulty hearing from the involved side in a noisy background. These are minor problems to a young child. When this hearing impairment in one ear is conductive, surgery will usually be able to restore the hearing, giving a better balance to the hearing hearing. When the unilateral impairment is sensorineural, either amplification in the poorer ear, or use of a CROS hearing aid is indicated. A CROS hearing aid (Contralateral Routing of Signal) is utilized when the hearing in the poorer ear is too poor to be aided directly. With a CROS aid, a microphone is placed on the poor hearing side and a signal is transmitted to the better hearing side.

    TREATMENT
    There is no known medical or surgical treatment that will totally restore normal hearing in patients with sesorineural hearing impairments. We therefore, rely on rehabilitation through the use of a hearing aid, a cochlear implant and/or special training. Fortunately, many children with this type of hearing impairment will not show progression of the impairment as they get older.

    THE HARD-OF-HEARING CHILD
    If your child’s hearing impairment is in the range of 35-70 dB HL, he or she should do well with a properly fitted hearing aid. He or she will probably be able to attend school with normal hearing children. He or she will need preschool speech therapy and auditory training in order that communication abilities will be at the optimal level when regular school starts.

    HEARING AID EVALUATION
    The techniques involved in assessing the hearing of young children have improved over recent years. Electrophysiologic techniques such as A.B.R. and O.A.E. Testing have improved the accuracy of test results at progressively earlier ages. It is important to determine an accurate measurement of both the type and the degree of hearing impairment in order to select the proper hearing aid. Care must be taken to prescribe the correct amount of sound amplification or gain for the aided infant/toddler/child. Too much powerful and the child might reject the aid. If the aid is not strong enough, a child may receive little or no benefit from it and therefore object to wearing it. Fortunately, there are also objective measures through real-ear probe-tube microphone measurements which can both accurately prescribe as well as validate/measure the actual amount of amplification being delivered to the child.

    SPEECH READING (LIP READING)
    Speech reading is very important whatever the type of degree of impairment. This skill enables a person with impaired hearing to understand conversation by attentively observing the speaker. All of us, whether we have a hearing loss or not, employ the sense of sight as well as the sense of hearing in ordinary conversation. We find it easier to comprehend if we can watch the speaker’s facial expressions, lip movements and gestures. .It is important to tell other family members and friends to get the child’s attention before speaking. The child with a hearing impairment must recognize characteristics of the English language. Many sounds and many words look the same on the lips. The hearing impaired child will find it impossible to see certain words on the lips and therefore needs to continuously fill in the “gaps” of words and sentences. The child, who is learning to speech read, learning to use a hearing aid, or both, should have help from a professional person trained to teach these skills.

    PROFOUND SENSORINEURAL HEARING IMPAIRMENT
    With the increasing implementation of Cochlear Implants, even children with profound hearing losses will likely be able to hear sound to some degree. However, the sound will not have the same tonal quality as it does for a normally hearing person. They still may need what is called a manual form of communication and intensive auditory trainging. American Sign Language is still used, though it is not as common for younger profoundly impaired children as it is for older adults. Whether the child communicates orally, with A.S.L., or in a “total communication” invironment, they will most likely need intesive interventional help to mainstream to regular society.

    REHABILITATIVE MEASURES
    There are two very important factors to be determined upon examining the child with a suspected hearing impairment. First, determination should be made regarding the presence of a hearing loss and the type (i.e., conductive or sensorineural). Secondly, once a hearing loss is found to be present, it should be determined if this loss is progressive or stable. Therefore, your child may require periodic audiograms to be sure that the hearing loss is going to remain stable.
    Complete Audiologic and Otologic examinations are recommended to determine what type of hearing impairment is present, its probable cause, and its treatment. The Otologist (ENT) may recommend special x-rays of the inner ear (CT,MRI, etc), a balance test or other laboratory tests to make this decision.
    A well-rounded program of rehabilitation for children with hearing loss may include speech reading, auditory training, speech therapy and instruction in the use of a hearing aid. One may also consider other adjuvants to assist with their communication skills such as cued speech or other manual techniques. All aspects of the program do not necessarily apply to each child with an impairment, but each individual may be helped through some of these methods. One cannot stress the importance of early indentification of hearing loss and early intervention. Critical speech and language development starts within the first three to four months of life.

    THE COCHLEAR IMPLANT
    The cochlear implant is an electronic device that is implanted into the inner ear of a severe to profoundly hearing impaired child. This device is only utilized in the child who can benefit more from an implant than from a hearing aid. It is a device which is used to bypass the diseased or nonfunctional hair cells and converts sounds to electrical impulses which directly stimulate the cochlear nerve. The implant consists of an external portion comprised of a microphone, sound processor, and external coil and an internal portion that must be surgically implanted. The surgical procedure involves the placement of an internal coil beneath the skin behind the ear and a stimulating electrode which is inserted into the cochlea or inner ear.
    To determine suitability for this device in the severe to profoundly hearing impaired child, a careful examination is required. The evaluation is performed to determine whether or not the child can receive adequate information from a powerful hearing aid, or whether or not the implantation procedure can be performed and give the expected improvement.
    Currently there are several multiple stimulating channel devices used. This is related to the number of stimulating electrodes within the cochlea.
    For further information, contact: www.agbell.org

    Practical Suggestions for Persons with a Hearing Impairment 2014-10-06T23:00:23-05:00

    FUNCTION OF THE NORMAL EAR

    The ear is divided into three parts: an external ear, a middle ear and an inner ear. Each part performs an important function in the process of hearing.

    The external ear consists of the auricle (pinna) and ear canal. These structures gather the sound and direct it down the ear canal, towards the ear drum membrane.

    The middle ear chamber lies between the external and the inner ear and consists of an ear drum membrane and three small ear bones (ossicles): malleus (hammer), incus (anvil) and stapes (stirrup). These structures transmit the sound vibration to the inner ear. In so doing they act as a transformer, converting the sound vibrations in the external ear canal into fluid waves in the inner ear.

    The inner ear chamber contains the microscopic hearing and balance nerve endings (hair cells) bathed in fluid. Fluid waves initiated by movement of the stapes bone stimulate the delicate hearing nerve endings, which in turn transmit an electric impulse to the brain where it is interpreted as sound.

    TYPES OF HEARING IMPAIRMENT

    The external ear and the middle ear conduct and transform sound; the inner ear receives it. When there is some problem in the external or middle ear, a conductive hearing impairment occurs. When the trouble lies in the inner ear, a sensori-neural or hair cell loss is the result. Difficulty in both the middle and inner ear results in a mixed hearing loss (i.e. conductive and a sensori-neural impairment).

    CONDUCTIVE IMPAIRMENT

    A conductive type of hearing impairment occurs when sound is not conducted efficiently through the ear canal, ear drum, or tiny bones of the middle ear. Conductive losses reduce the loudness of sound that is heard. A conductive impairment may result from blockage of the external ear canal, from a perforation (hole) in the ear drum membrane, from middle ear infection or from disease any of the three middle ear bones. This type of hearing impairment is usually correctable.

    A person with a conductive hearing loss may notice that his ears may seem to be full or plugged. He usually speaks softly, with a well modulated voice, because he
    hears his own voice quite loudly. In general, he hears better in noise than in quiet. Crunchy foods, such as celery, sound very loud and he may have to stop chewing to be able to hear what is being said. With this type of impairment one hears quite well over the telephone.

    Fortunately, the patient with a conductive hearing impairment will never go deaf. He will always be able to hear, with reconstructive ear surgery or by use of a properly fitted hearing aid.

    SENSORI-NEURAL IMPAIRMENT

    A sensori-neural hearing impairment may result from disturbance of inner ear circulation, increased inner fluid pressure or from disturbances of nerve transmission. The most common cause of sensori-neural impairment is an aging change in the nerve endings (hair cells in the cochlea). This type of impairment is not able to be corrected by surgery, but rarely leads to deafness.

    The person with a sensori-neural impairment may state that he can hear people talking, but he cannot understand what they are saying. An increase in the loudness of speech may only add to his confusion. Speech is audible, but not often understandable. He usually hears better in quiet places and he may have difficulty understanding what is being said over the telephone. He will probably hear low tones better than high tones and, therefore, may find a man’s voice more understandable than a woman’s higher pitched voice. Often the patient with this type of hearing impairment may not hear a door bell or the telephone ringing in another room.

    CENTRAL IMPAIRMENT

    A central type of hearing impairment occurs when auditory centers of the brain are affected by injury, disease, tumor, heredity, or unknown causes. Loudness of sound is not affected necessarily, but understanding speech is.

    HEARING IMPAIRMENT IN ONE EAR

    A hearing impairment that is confined to one ear prevents a person from distinguishing the direction of sound. He will also have difficulty hearing from the involved side and may find it difficult to understand words in a noisy background or where the acoustics are poor.

    When this impairment is secondary to a middle ear problem (i.e. conductive), surgery will usually be possible to restore the hearing, giving a better auditory balance. When the impairment is sensori-neural (i.e. hair cell loss), it is often possible to restore some of this hearing balance through the use of a hearing aid.

    REHABILITATIVE MEASURES

    A complete audiologic/otologic examination by a competent ear specialist is necessary to determine what type of hearing impairment is present, its probable cause and its treatment.

    The treatment of choice may be remedial, preventive, medical, surgical or a combination of these. Each person with impaired hearing should have the benefit of adequate auditory rehabilitation.

    A well rounded program of rehabilitation for persons with a hearing loss may include speech reading, auditory training, speech strategy techniques, instruction in the use of a hearing aid and guidance in social adjustment. All aspects of the program do not necessarily apply to each individual with impairment, but each individual may be helped through some of these methods.

    HINTS FOR FRIENDS AND RELATIVES OF THE HARD OF HEARING

    The individual with a hearing impairment must stop, look and listen in order to understand speech.

    There are a number of factors that can significantly influence the communicating ability of the hearing handicapped. An understanding of some of these factors will prepare you to communicate more effectively with such persons.

    Persons with a mild hearing loss may have trouble hearing only certain sounds such as f, s, and t, h, or hearing in certain situations. Hearing problems may also occur when the sound source is far away or when there is a lot of background noise. Persons with moderate or severe hearing losses have trouble in many situations, and persons with profound hearing loss hear little or nothing around them.

    Speech Reading (lip reading). It is not uncommon for the person with impaired hearing to say, “I can’t hear a thing without my glasses.” This expression is a sure indication that he relies heavily on speech reading (lip reading). Many use speech reading without being aware that they have developed the skill. Over the years, the listener unconsciously compensates for his auditory impairment by obtaining visual clues of speech from the lips and facial expressions of the speaker.

    Many take formal training from tutors who are especially prepared in this area. Whatever the means of acquiring the skill, it is helpful to all hearing handicapped to be able to view the face of the speaker. The speaker who absentmindedly covers his mouth, chews gum, or does not face the patient with a hearing loss during a conversation deprives the handicapped listener of valuable visual information that could enhance this understanding. Poor speech habits not only limit the lip reading skill of the listener, but also introduce distorted speech sounds. On the other hand, overly precise lip movements are to be avoided because exaggerated mouthings also result in speech distortion. Lip readers have learned to interpret normal speech movement.

    Attention. Relatives of the hard of hearing have been heard to say, “Oh, he hears what he wants to hear.” Sometimes a person is able to hear and understand without apparent difficulty. However, his “good hearing” is often the result of an ideal listening situation in which he was communicating at a short distance, with an articulate speaker, in the absence of noise. Attempts to communicate in noise or with poor articulation or from another room in the house will often end in failure. The hearing handicapped expend an enormous amount of energy in an effort to determine the important clues of speech. Their attention to the task of hearing requires concentration.

    Modulated Voice. A very loud voice that is further amplified by a hearing aid becomes distressing and sometimes painful to the hearing aid user. If a person seems to hear but not understand, shouting will not benefit the listener. It is also wise to remember not to drop the loudness of your voice at the end of a sentence.

    Speaking clearly. One must speak with care while at the same time not exaggerating the words. Overdoing one’s enunciation also leads to distorted speech. Remember that the listener will not understand all the sounds even when they are properly articulated. Faulty enunciation will further reduce his understanding.

    Rate. Rapid speech is very difficult for the hard of hearing to understand. Spoken words last only a fraction of a moment. The brain must quickly identify each group of sounds in a word and assign a meaning. If groups of sounds (words) are run together or any single word is distorted or omitted by fast speaking, then the listener’s understanding is affected. Because spoken language is so brief, the listener only has a short time to identify each word. Frequently, the hard of hearing give the wrong answer to a question, not because they don’t know the answer, but because they have misinterpreted the question.

    Speech Clues. Poor speech discrimination (inability to understand words) is the major handicapping aspect of a hearing impairment. Because the meaning of many words is lost or misinterpreted by the hearing impaired patient, the speaker can help by offering as many clues as possible to establish the meaning of conversation. By using several different words to express the same thought, the hard-of-hearing listener is provided with additional clues as to the context of the speech. For example, instead of saying, “Would you like to see the paper?” you might say, “The Gazette; would you like to read the newspaper?” You will notice that the loss of some of the more important words is less critical when there are others to indicate the same idea. However, the misinterpretation of the single work, “paper” in the first sentence results in a complete breakdown of communicating that particular idea.

    Hearing impairment is a complex handicap. The task of adjusting to one’s handicap can be eased by remembering a few simple rules. Get the hard of hearing person’s attention, enunciated clearly and speak loudly enough. Don’t speak rapidly. Above all, be patient.

    SPEECH READING

    Speech reading is a skill that enables a person with impaired hearing to better understand conversation by attentively observing the speaker.

    All of us, whether we have hearing impairment or not, employ the sense of sight as well as the sense of hearing in ordinary conversation. We find it easier to comprehend if we can watch the speaker’s facial expression, lip movements and gestures. A study of the fundamentals of speech reading will make conversation less of an effort and therefore more pleasant for both the speaker and the listener.

    It is important that the person who has a hearing loss inform his family, close friends, and associates with his problem so that they may avoid needlessly increasing the difficulty of speech reading. He speech reader must, so to speak, “stop, look and listen”, in order to understand what he hears. It is helpful to point this out to family and associates so that they will get the patient’s attention before speaking.

    The patient with the hearing impairment must recognize characteristics of the English language. Many sounds and many words look the same on the lips. Look into your mirror and say the following pairs of groups of sounds and works: f, v, p, b, m; beet, meet, meat, shoe, chew; few, view. Each pair or group of letters and words looks the same on the lips.

    The speech reader must determine from the context of the sentence which word is being used, just as the normal hearing person must depend upon the context to tell which of two or more words that sound the same are being used.

    The hard-of-hearing person should be aware that it is impossible to see certain words on the lips and therefore he will continuously need to fill in “gaps” in words and in sentences. Look in the mirror again and say the following sounds: k, g, n, l, and t. It is impossible to see these sounds on the lips because they are formed in the throat and in back of the mouth. Two-thirds of all sounds in the English language are not visible on the lips. Because of the difficulties presented by sounds, the speech reader is encouraged to follow the context or thought of what is being said, rather than to try to lip read each word.

    The hard-of-hearing person can also help himself by being keenly aware of the rhythm of conversation. A change in the rhythm is a definite aid to understanding what is being said. Pauses between words and sentences, stress and inflection, all effect what the speech reader sees and should convey different meanings to him.

    To master speech reading, one must acquaint himself with the “setting” of a given situation. For instances, if the hard-of-hearing person is invited to a gathering, he should find out as much as possible about the occasion to give himself a background for speech reading. Who will be present? What are the names of some of the persons who are likely to attend? What are the interests of this particular group? What are they most likely to discuss as a group or individually?

    The person, who is learning to speech read, learning to use a hearing aid, or both, should have the help of a professional person trained to teach these skills. There are many books on the subject of speech reading. Recognizing spoken words by watching the speaker’s lips, face and gestures is a daily challenge for all deaf persons. Speech reading is the least consistently visible of all the communication choices available to deaf people; only about 30 percent of English sounds are visible on the lips and 50 percent are homophonous, that is, they look like something else.

    HEARING AIDS

    If the hearing level has dropped below the point of serviceable hearing, perhaps the greatest assistance to effective speech reading is a carefully selected hearing aid. Much of the strain, fatigue and tension accompanying speech reading can be reduced, and perception and understanding can be enhanced, by a properly fitted hearing instrument. It is most important for the person with impaired hearing to avail himself of this opportunity for maximum understanding. It can mean the difference between constantly straining to “get” what is being said and understanding conversation with relative ease and comfort.

    Hearing aids may be worn as ear level instruments or as body type aids. Ear level aids may be placed deep in the ear canal, in the outer ear opening, or may be worn in back of the ear. Body worn hearings aids as a general rule have a greater amplifying potential and are used in severe or profound hearing impairment.

    The CROS hearing aid is available for persons with a one-sided hearing loss. This aid picks up sounds which originate on the poor hearing side and routes the sound to the better ear. A CROS hearing aid may be worn behind the ear or in the ear.

    In using a hearing aid, remember that hearing loss involves two factors: volume and clarity. A hearing aid amplifies speech to help you hear what people say. It also amplified most of the sounds around you. However, the amplification of other sounds, such as clattering dinnerware or a plane flying overhead may be distracting. For this reason, it often takes several weeks to become accustomed to wearing a hearing aid.

    Some hearing aids have a “T” switch which enables them to hear on the telephone. In addition to acting as an amplifier, the “T” switch helps to eliminate background noises.

    If you have a hearing loss but you do not want a hearing aid, you might still benefit from an amplifier for your telephone. Several kinds are available. One type comes built into the receiver and is available from phone companies. Another type is portable, can be attached to any telephone, and is small enough to be carried in a purse or a pocket. There are numerous different styles of hearing aids: all in the ear, behind the ear, body aid, canal aid, and deep insert canal aid.

    THE USE OF A HEARING AID

    Individuals react differently to the use of a hearing aid. One’s age, the severity of the hearing impairment, and the acceptance of the need for the aid may strongly influence one’s reaction to supplementing his own hearing with amplified sound. The type and degree of hearing impairment may limit the benefit to be gained from a hearing aid. Generally speaking, the hearing impaired patient has a dual problem. He experiences a reduction in the intensity of sound in which every day environmental noises, including speech, are not perceived in their normal loudness. In addition, there is often an accompanied reduction in what is called discrimination. An impairment of one’s ability to distinguish among the sounds of speech leads to a reduction of understanding.

    If a person has an impairment of a conductive type, he can expect maximum benefits from a hearing aid because discrimination ability is not greatly affected. Most persons with this type of impairment become adjusted to using a hearing aid with very little difficulty.

    If the hearing impairment is of the sensorineural or sensory type (loss of hair cells), the difficulty of adjusting satisfactorily to a hearing aid may be greatly increased. Very often, persons who have this type of loss can hear speech sounds if they are loud enough, but cannot always understand what is being said. It is true that the speech must be loud enough to permit the listener to understand to his full capability. But making speech increasingly louder will not necessarily lead to a correspondent improvement in discrimination because the hair cells have become less sensitive to the acoustic differences of speech sounds. A hearing impaired person will often say, “I hear but I cannot always understand what I hear.” Because the prime function of an aid is to amplify sounds, many users of these instruments continue to experience difficulty in understanding. Although the hearing aid does not correct the discrimination impairment through amplification, many sounds of speech can be heard and understood with greater ease. A hearing aid offers the user hearing that is short of normal acuity but more satisfactory than the uncompensated impairment. The major problem for a new hearing aid user is to adjust the hearing aid in noise. There have been many innovations in hearing aid fitting that have helped new users to learn to live with noise. Changes in circuitry of the hearing aid have greatly eased the initial learning process for many patients.

    STEPS IN LEARNING TO USE A HEARING AID

    Whatever the type of hearing impairment, it is important to follow a planned program of “learning to use the hearing aid.” The ease or difficulty of hearing will vary depending on the loudness of background noises, the distance of the listener from the source of the sounds, the clarity of speech or of music, and the lighting (which may enhance or may interfere with lipreading). Practice exercises will help to prepare the wearer to use his hearing aid in a variety of
    different situations. Recommendations for learning to use a hearing aid for maximum benefit are described in the following paragraphs.

    1. Use the Aid at First in Your Own Home Environment.

    Your hearing aid amplifies noise as well as it amplifies music or speech and you may be disturbed temporarily by background noise. Concentrate on listening for all of the normal household sounds and try to identify each sound that you hear. Once you identify background noises, such as the hum of the refrigerator, the roar of an electric fan, the clinking of dishes, or the slamming of doors, these noises will tend to be less annoying and distracting to you.

    2. Wear the Aid Only as Long as You Are Comfortable With It.

    Do no attempt to set an endurance record or to wear the aid at first during all of your waking hours. If you are tired and fatigued after using the aid for an hour or two, take it off. Let the way you feel be your guide. You can, over a period of several weeks, gradually lengthen the amount of time that you wear the aid.

    3. Accustom Yourself to the Use of the Aid by Listening to Just One Other
    Person – husband or wife, neighbor or friend.

    Talk about familiar topics; use common expressions, names, or a series of numbers for practical purposes. After a few day of practice with one person in a quiet environment try a different listening exercise. Turn on the radio or television and with this auditory distraction try to understand your companion’s speech.

    4. Do Not Strain to Catch Every Word

    The importance of listening carefully and of concentrating on what is being said cannot be overemphasized, but do not worry if you miss an occasional word. Normal hearing persons miss individual words or parts of sentences and unconsciously “fill in” with the thought expressed. (Keep your eyes on the face of the speaker. Speech reading is a very great help as a supplement to the hearing aid.)

    5. Do Not Be Discouraged by the Interference of Background
    Noises.

    If your initial experience with the aid is unsatisfactory, remember that you are learning new habits, or rather, relearning old habits in a new setting. Normal hearing persons are aware of background noises too, but have learned to push them out of conscious awareness. As you learn to discriminate between noise and speech and to identify various background sounds, you will also be able to ignore extraneous noises just as persons with normal hearing do.

    6. Practice Locating the Source of Sound by Listening Only.

    Localization of sound (the determination of the direction from which the sound comes) often presents a special problem to wearers of hearing aids. One exercise that helps to develop directional perception is to relax in a chair, keep your eyes closed, and have someone speak to you from different places in the room. Each time your helper changes his position, attempt to locate him through the sound of his voice alone.

    7. Increase Your Tolerance for Loud Sounds.

    At first, hearing aid users tend to set the volume control at a level too low for efficient listening. Louder sounds need not cause discomfort. By a very simple procedure you may, over a period of time, increase your tolerance for sound. While you are listening to one speaker or to your radio or television in your home, gradually turn up the volume control of your hearing aid until the sound is very loud. When the loudness is uncomfortable, very slowly turn the volume down to a more comfortable level. After a period of practice you will find that your comfort level has increased considerably.

    8. Practice Learning to Discriminate Different Speech Sounds.

    Prepare a list of words which differ in one sound only. For example:

    Food-mood ball-all

    see-she feel-peel

    could-good gown-down

    Have your helper pronounce these words slowly and distinctly. Watch the lip movements closely while you carefully listen for the differences in similar pairs of words. Then try to discriminate the words by listening alone.

    9. Listen to Something Read Aloud.

    A good exercise in listening is to have your companion read aloud from a magazine or a newspaper while you follow along with your own copy of the reading material. At irregular intervals your reader should stop and have you repeat the last word read.

    10. Gradually Extend the Number of Persons with Whom You Talk, Still Within Your own Home Environment.

    You will find that it is more difficult to carry on a conversation with three or four persons than it is to talk to one. Concentrate mainly on the individual who is talking the most.

    11. Gradually Increase the Number of Situations in which you use Your Hearing Aid.

    After you have adjusted fairly well in your own home to background noise and to conversation with several people at once, you will be ready to extend the use of your aid to the supermarket, church, theater, and other public places. Turn the volume low to reduce the impact of unfamiliar background noise; do not sit under balconies; move about in different areas of the auditorium or theater until you find a section or a seat where you can hear well. Dining out may present special problems to the hearing aid user, so eat your first meals in public in a quiet restaurant with carpeted floors and draped windows. Avoid noisy cafeterias. Sit away from the kitchen area. As your tolerance for noise increases, you will find it easier to experiment with increasingly noisy environments.

    12. Take Part in an Organized Course in Lipreading.

    Lipreading will help you in general communication with others; consider it an important supplement to the use of the hearing aid. Although lipreading has many limitations, some words cannot be seen on the lips and some words cannot be distinguished from each other, lipreading combined with a hearing aid is often more satisfactory than is either alone.

    13. The Telephone and the Hearing Aid.

    If your hearing loss is not especially severe, you will probably be able, with a little practice, to use your hearing aid with the telephone. Place the receiver end of the telephone next to the microphone of the hearing aid. In some hearing aids an induction coil is an integral part of the aid, and the cordless portion of the telephone is placed in contact with the case of the aid. Getting used to the placement of the telephone and getting used to listening in this manner requires practice. It is suggested that you arrange to have a friend telephone you at a certain time each day for several days to help you become accustomed to the telephone procedure with the hearing aid.

    The prime objective in wearing a hearing aid is to give you more normal communications in every day life. For maximum benefits, lipreading rehabilitation should accompany the practice training in using the hearing aid.

    SPECIAL DEVICES

    You may have certain communications that cannot be solved by the use of a hearing aid or by speech reading. These problems may involve the use of the telephone, radio, and television, and the inability to hear the door chime, telephone bell, and alarm clock.

    Special instruments have been developed to solve these problems. They are listed in journals such as Shhh and Voice.

    TELEPHONE COMMUNICATION

    The telephone represents an important avenue of communication and one that offers the hearing handicapped considerable difficulty.

    Many hearing aids provide a telephone switch. Moving the switch turns off the aid’s microphone and activates what is called an “induction coil.” The telephone receiver is placed in contact with the case of the hearing aid to amplify the conversation without picking up distracting noises.

    Volume control handset. This telephone handset is equipped with a thumb-operated wheel with which to adjust the loudness of an incoming message.

    Telephone amplifier. This unit is a pocket size battery operated amplifier that is useful to the hearing impaired person who uses different telephones. It can be carried in a purse or pocket and simply clips on to most telephone receivers.

    Auxiliary receiver. Many severely handicapped people rarely rely solely on speech reading which, of course, cannot be used on the telephone. A procedure using the assistance of a third person is helpful. The “third person’ listens to the incoming message through the auxiliary receiver attached to a conventional telephone. He repeats the message so that the hard-of-hearing “listener” can lip read and speak his answer directly into the telephone. In this way, the profoundly handicapped can actively participate in the telephone conversation.

    Code-Com telephone set. This telephone instrument converts incoming sounds into light and vibratory signals. By using a prearranged code of dots and dashes, the profoundly deaf can enjoy telephone communication by watching the flashing light —TDD/TTY (Telephone Device for the Deaf) systems.

    Teletypewriters. The telephone-teletype system is another method of communication for the profoundly deaf that permits the two-way transmission of typewritten messages over telephone lines. The deaf person who wishes to make a telephone call to someone with similar teletype equipment places the handset in a special cradle and dials the number. A monitor light flashes to signal when the phone at the other end is busy, ringing, or when someone answers. After contact is made, a conversation can be typed back and forth between the two parties, offering a printed record of the messages. A large national telephone-teletype network for the deaf has been made possible, in part, by the generosity of organizations that donate repairable teletype machines to the deaf. A number of these different devices can be seen in the Hearing Journal.

    Dataphone data set. Dataphone service can link telephone facilities to teletypewriters, facsimile and telewriting devices, and other equipment used by persons with physical impairments.

    Graphic Communicator. The telephone can also be used to transmit and receive written messages. Messages and diagrams written on the paper surface of the unit are reproduced simultaneously at any phone location that is equipped with a similar apparatus. Either written or oral material can be seen over the same telephone so that the hearing members of the family can use the same handset.

    Switchboard amplifier. The telephone operator who has a hearing impairment will encounter difficulty. However, the requirements of her job may be satisfied through the use of a small transistorized amplifier which has a volume control. The operator simply adjusts the loudness of the incoming calls to suit her needs.

    SIGNAL DETECTION

    Signal bells. Some hard-of-hearing persons have difficulty hearing the door chime or the telephone bell. The problem of hearing a particular signal may be solved by either amplifying the signal or by substituting it with another sound that can be easily heard. For example, one may find help by substituting a lower pitched buzzer for the door bell. Similarly, the local telephone company supplies eight signal bells with different pitch characteristics ranging for 800 to 4000 Hz. You may request to listen to the different telephone bells in order to select the one you hear most easily. Generally, an “800 Hz bell” is the most rewarding.

    Tone ringer. The telephone ringer concentrates the acoustic signal within a range (580-1500 Hz) easily heard by many of the hard-of-hearing patients.

    Buzzer. This telephone signal substitutes a buzzer-like sound for the usual ringer. It is preferred by many hearing impaired persons who have adequate hearing acuity for low frequencies.

    Extra strength signals. In addition to bells of different pitch, are alarms of extra-loudness, such as gongs, bells, and horns to signal the ringing of the telephone.

    Auxiliary control device (Signalman). This unit signals the ringing telephone by activating a flashing lamp. Substituting a visual clue for the auditory signal is particularly helpful to the severely hearing impaired.

    Electronic switch. The inability to hear a sound originating in another part of one’s home poses another problem for the hearing impaired. One can solve his reception of a specific sound such as a door chime or the cry of a baby by installing this special switch. The switch converts sound into either visual or vibratory impulses. Lamps or vibrators are wired from the sound sensing apparatus to various rooms throughout the house.

    Automatic waking devices. This device consists of an electric clock into which is build or plugged into a bedside lamp, buzzer, or vibrator, depending on the preference of the user. The buzzer can be placed under the pillow while the vibrator is attached to the bed frame. At a preset time, the clock activates the alarm signal. It is the light and the vibrations that awaken the sleeper.

    Electronic stethoscope. This instrument consists of a standard stethoscope to which a modified hearing aid amplifier is attached. The user adjusts the volume control and frequency response to his requirements. In this way, the hard-of-hearing physician and nurse can hear faint body signals that otherwise would go undetected.

    RADIO AND TELEVISION LISTENING

    Amplified earphone. This device permits the whole family to enjoy radio and television. Remote headsets allow the hearing impaired patient to adjust volume while situated at his chair.

    Loudspeaker. This unit is also connected to the television and the speaker placed conveniently next to the hearing impaired listener’s chair. Your radio and television repairman can provide and install a suitable amplifier and when coupled to a loudspeaker or headset will provide adequate amplification.

    Desk model amplifier. Some persons prefer to use a small transistorized auditory trainer that is equipped with earphones. This type of amplifier offers greater fidelity than the average hearing aid. These devices permit other household members to listen in comfort while the sound is amplified for the hearing impaired listener.

    Induction coil apparatus. Frequently, the hearing impaired person complains that he is distracted from radio and television listening by household sounds amplified by the hearing aid. If the aid is equipped with a telephone switch, he can use an inexpensive induction coil that is connected to the loudspeaker of the television. This coil creates a magnetic field from which the hearing aid picks up and amplifies the radio and television signals. The television sound is placed on a plate containing the special coil. A small induction coil plate is also available that can be used with an ear-level aid.

    Induction loop system. This is a variation of the coil apparatus in which a magnetic field is produced by a wire loop running from the television set around the baseboard of the viewing room. A switching device permits the user to receive the sound through his hearing aid from either or both the television loudspeaker and the induction loop system. In this way, hearing impaired and normal hearing viewers can enjoy a television program together.

    Hearing Ear Dog. A new program for the profoundly hard-of-hearing and totally deaf individual is the use of dogs to hear for their masters. A group in Denver, Colorado, has pioneered the first hearing ear dogs to aid deaf persons. Similar to the Seeing Eye program, these dogs are trained to look out for their masters by using their ears. For example, if the deaf individual’s house catches on fire, the hearing ear dog is trained to awaken his master in order that he may save himself. In a similar manner, the hearing dog alerts his master to the doorbell, telephone, etc. The Ear Foundation can help answer your questions about this program.

    Vibrotactile devices. This is composed of an electronic case which can be carried in the pocket and the vibrator is worn on the chest or with a wrist harness. Many users find the tactile aid of significant help in speech reading as a safety device for being aware of traffic and other warning sounds and generally as a help in feeling more “contacted”.

    Closed captioning. This is a process by which the audio portion of a television program is translated into captions (sub-titles) that appear on the TV screen. Hearing impaired viewers can then read what they cannot hear. Closed captions can be seen when a telecaption adapter is connected to a television set.

    Computers. Computers (Personal computers) can offer a significant advantage to the hearing impaired child to reach the same level of scholastic development that is achieved by hearing children

    Concerts and Auditoriums. Many public facilities such as churches, theaters, and concert halls have special facilities for hearing impaired attendees. These FM or infrared systems are headsets which allow for control of background noise as well as amplification of the “main event.” Contact facilities you are interested in attending to determine whether such assistance is available and if advance reservation is required.

    Special surgical devices-cochlear implants. Cochlear implants are surgically implanted devices which enable the deaf or profoundly hearing impaired to hear by electrically stimulating the inner ear or cochlea. Components of the system include a microphone, signal processor, external transmitter, and implanted receiver.

    SUMMARY

  • A complete audiologic/otologic examination is necessary to determine what type of hearing impairment is present, its probable cause and recommended treatment.
  • Hearing is a natural and a normal way to understand speech. If your hearing can be improved by medical or by surgical means, or through the use of a hearing aid, this should be done.
  • Whatever the type of treatment carried out, rehabilitation is essential if you are to gain maximum benefits from treatment.
  • Be determined to master speech reading – make a hobby of it. It will help in every conversation.
  • Make every effort to relax. Do not strain either to hear or to see speech. Strain causes tension and makes lip reading much more difficult. A combination of seeing and hearing, under relaxed conditions, enables persons with impaired hearing to hear most speakers quite well.
  • Do not expect to understand every word in a conversation, but follow along with the speaker. As you become familiar with the speech, key words will emerge and you will be able to understand the complete thought.
  • Try to stage-manage the situation to your advantage. Lighting is important. Avoid facing a bright light and avoid having a shadow on the speaker’s face. Six feet is an ideal separation from the speaker; from this distance his lip movements, facial expressions and gestures can be readily observed.
  • Maintain an active interest in people and events. Keep abreast of national affairs and events in your community and intimate social circles. You will be able to follow discussions more easily.
  • Remember that conversation is a two-way affair. Do not monopolize the conversation in an attempt to direct and control it. On the other hand, do not let it pass by without participating. Take an active and interested part whenever possible.
  • Be particular about your speech. A hearing impairment of long duration may bring changes in volume as well as in articulation and voice quality. These changes must be prevented when possible and corrected where indicated. A pleasant, well-modulated voice is a great asset.
  • A friendly, sympathetic interest in other people and in their problems can do much to smooth one’s own path.
  • The education of the public is your responsibility and ours alike. You cannot help others to understand your problem if you conceal it from them. Do not hide the fact that you wear a hearing aid, or that you depend on speech reading to understand conversation. By letting others know about your problem, you can make communications easier for you. It is only through mutual acceptance and understanding of the problems of persons with impaired hearing that the “outsider” can be expected to adjust to needs of the speech reader. Without this understanding the “outsider” may unintentionally add to the problems of the speech reader.
  • Always keep in mind that the success of your auditory rehabilitation is largely dependent on you, your attitude and your acceptance of the problem.
  • Try to find a quiet place to talk. Cutting down on background noise will make it easier to understand the speaker.
  • Ask people to repeat or rephrase things that are not clear. Pretending to understand when you do not will only cause problems later.
  • A Discussion of Acoustic Neuroma 2014-10-06T21:37:13-05:00

    GENERAL COMMENTS
    Acoustic tumors are fibrous growths originating from the auditory or balance nerves and are usually not malignant. They do not spread to other parts of the brain, other than by direct extension. They constitute approximately 10% of all brain tumors. They are located between the brain stem and the inner ear, adjacent to vital brain centers. As they grow, they cause additional involvement by pressing on surrounding nerves. If they are allowed to grow over a long period time, they can press on vital brain centers, and thereby could be fatal. In most cases, these tumors grow slowly. The cause of most acoustic neuromas is unknown. There is a small group of patients who have acoustic tumors as a result of having neurofibromatosis Type II, which is a genetically-based disease.
    Acoustic tumors usually displace normal tissue as they grow, yet remain within their lining (encapsulated). An acoustic neuroma first distorts the eighth nerve, and then presses on the seventh (facial) nerve. The slowly enlarging tumor protrudes from the internal auditory canal and as mentioned will ultimately press into the brainstem. The tumor also may press on adjacent nerves, such as the fifth, or trigeminal nerve, which is the nerve providing facial sensation

    Many diagnostic procedures are used to be as certain as possible of an accurate diagnosis, and to determine the extent of the tumor growth. When the tumors are small, the mortality rate (i.e., loss of life) is less than 1%. When they are middle or large sized, the mortality rate is approximately 3%. The second objective of surgery is to preserve as many vital structures as possible. In many cases, a completely normal life results following surgery and in others, which are larger and more involved, some permanent handicap may result.
    The first symptom from the tumor is usually some disturbance in hearing. This is due to pressure on the cochlear portion of the eighth nerve but also due to involvement of the blood supply to the hearing structure. The cochlear nerve is more sensitive to pressure than most other cranial nerves. The ability to hear requires not only an intact nerve but adequate blood supply to the hearing structure (cochlea). The blood supply to the cochlear nerve and to the hair cells in the cochlea comes from the internal auditory artery.

    DIAGNOSIS OF ACOUSTIC NEUROMA
    The diagnosis of an acoustic neuroma begins with a complete history, physical examination, and conventional audiologic evaluation. Following this, if there are any indications of tumor, an auditory brainstem response (ABR) test, is usually perfomred by the audiologist. This uses a sophisticated computerized audiometer to analyze the electrical activity of the hearing nerves on both sides to determine if there is a normal conduction of neural signals to the brain. If the conduction is slowed down on one side, this may indicate a tumor. CAT scanning or Magnetic Resonance Imaging (MRI) scans are sophisticated imaging methods used to determine (by picture) the cerebellopontine angle region of the brain to determine if there is an acoustic neuroma present. At times, an electronystagmagram (test of the balance system) may be used to determine the involvement of the tumor with the balance nerves.

    TREATMENT
    At this time, the primary treatment used to cure a patient with an acoustic neuroma is surgical removal. With the use of an operating microscope and lasers, the Neurotologist and Neurosurgeon are able to remove the tumor with some preservation of hearing in most cases. The size of the tumor, hearing status, patient’s age, and health determine which surgical approach is utilized.
    Another form of treatment which has recently developed is the use of stereotactic radiation therapy (i.e., gamma knife). Stereotactic radiation therapy is a technique based upon the principle that a single high dose of radiation delivered precisely to a small area of tumor could arrest the growth of the tumor and not damage surrounding brain tissue and/or function. There is no incision. Almost all patients are discharged from the hospital the same day or the following day. Life long follow up with MRI scans is currently recommended. Unlike microsurgery which would remove the tumor, stereotactic radiation therapy “controls” the tumor growth. The tumor does not disappear but persists, allegedly, in a “harmless” state. With a greater degree of facial nerve preservation. Radiation therapy represents an alternative for patients who are elderly, or have medical problems such as cardiac or pulmonary disease and are at high risk for surgical removal.

    Hearing Loss
    Increasingly with improved surgical techniques and with small tumors, it is possible to remove the tumor and preserve hearing. Even if hearing cannot be maintained in that ear, CROS hearing aids have allowed the transfer of sound from the operated ear side to the functional ear, so that one may “hear” from both sides.
    The earlier tumors are diagnosed and removed, or progress slowed, the less likely the possibility of serious complications.
    For further information, contact the Acoustic Neuroma Association at:
    www.anausa.org

    A Discussion of Meniere’s Disease 2014-10-06T21:34:28-05:00

    Inner Ear Anatomy and Function

    The inner ear is a delicate membraneous sense organ, which is encased in a bony shell. It is suspended within a latice-like bony framework, called the mastoid bone, which is located behind the outer ear. The delicate inner ear membranes are surrounded by a fluid called perilymph, which is rich in sodium, and lies between the outer bony layer and the inner membraneous layer. Within the membraneous layer circulates a second fluid rich in potassium, called endolymph. The electrical potential created by the separation of these two fluids is the driving force of the inner ear.

    The organ of hearing is called the cochlea, which resembles a snail with its 2 ? turns; it is divided into three chambers or scala. The scala media is separated from the scala tympani by the basilar membrane and from the scala vestibuli by Reissner’s membrane. Only the scala media contains endolymph, whereas the other two contain perilymph. The organ of Corti is housed within the scala media, and rests on the basilar membrane. Special cells with hair-like projections are attached to the tectorial membrane, and project to the hearing nerve (cochlear nerve). The nerve travels through the temporal bone (the bone surrounding the outer, middle and inner ear) to the brainstem. During it’s course through the temporal bone, it is joined by the two balance nerves (vestibular nerves) and the facial nerve. All four travel together to the brainstem. Upon entering the brainstem, the cochlear nerve relay’s its message to nerves that will travel to that particular region of the brain responsible for decoding the message (temporal lobe).

    The Mechanics of Hearing

    Hearing occurs as sound enters the outer ear canal and causes vibration of the tympanic membrane (eardrum) and subsequently the movement of the middle ear bones. The piston-like action of the stapes bone (stirrup) initiates a fluid wave within the perilymph of the scala vestibuli. This “traveling wave” in turn activates the hair cells of the organ of Corti, causing the nerve to discharge. The hair cells are responsible for converting the mechanical energy of the fluid wave into an electrical signal, which will be processed by the brain. There are actually two different types of hair cells in the cochlea: inner and outer hair cells. Inner hair cells are the special sensory receptors that receive the traveling wave information and relay it to the brainstem. The outer hair cells are responsible for amplifying the traveling wave signal, and “fine tuning” the signal to a frequency specific region of the cochlea.

    Hearing loss may arise from the outer, middle and inner ear, as well as from the cochlear nerve, brainstem or temporal lobe. A loss that arises as a result of a blockage of sound energy from reaching the inner ear is referred to as conductive; whereas, a loss that results from injury to the inner ear or central structures is called sensori-neural. Although a clinical exam will often identify the type of hearing loss, an audiogram (hearing evaluation) is usually necessary to pinpoint the location, as well as the severity. Specialized hearing evaluations, and (uncommonly) imaging studies are sometimes performed if the cause of the loss is still unknown.

    The Mechanics of Balance

    The balance portion of the inner ear is made up of three semicircular, fluid filled canals which join a larger, globular structure called the vestibule. Similar to the cochlea, the semicircular canals are tubular structures filled with endolymph and surrounded by perilymph. The hardest bone in the body, the labyrinthine bone, surrounds the entire structure. Each semicircular canal is oriented at right angles to the others, comprising vertical, horizontal and posterior (behind) canals. The right and left semicircular canals are mirror images of each other, so that each and every direction of angular head motion is represented by both ears. At the junction of each semicircular canal and vestibule is a special receptor for angular rotational movements of the head, referred to as the crista. The crista contain hair cells embedded in a gelatinous matrix, with accompanying nerve fibers. As the head turns in a particular direction, the fluid within that semicircular canal turns in the opposite direction bending the hair cells and inducing a neural discharge. That signal is sent through the vestibular (balance) nerve to the brain where it is interpreted, and adjustments are made in eye movements and postural control. This ensures that the eyes remain on a given target, and that the arms and legs remain in a good position for maintaining stable posture. Within the vestibule are hair cells that respond to changes in head and body movements in the horizontal and vertical planes. These “otolithic” hair cells are embedded in a layer of calcium carbonate, making them top heavy and therefore motion sensitive for both linear acceleration and gravitational forces.

    Nerve fibers from the crista and the otolithic organs form two large balance nerves, the superior and inferior vestibular nerves. They travel from the inner ear to the brainstem along with the cochlear and facial nerves. Within the brainstem they form an extensive neural network involving nerves from the eyes, ears, the cerebellum, and positional receptors “proprioceptors” located in the arms, legs and neck. The brain interprets this information, and makes modifications in eye, head and body position to maintain a fixed eye position, and erect posture. Unfortunately, there are also connections to the thalamic region of the brain, which is responsible for the nausea and vomiting which accompanies most disturbances within the vestibular system. A sensation of dysequilibrium may accompany any imbalance or dysfunction within this neural network. Therefore, similar symptoms of imbalance or “dizziness” may be experienced by injury to the eye, ear, brain, and proprioceptors from the extremities. Therefore it is often difficult to determine the site of injury based on symptoms alone, and diagnostic testing is necessary.

    Meniere’s Disease

    Prosper Meniere was a French physician who described a new disease process in the mid-1800’s. The disease he identified consisted of four symptoms: attacks of vertigo, ear fullness or pressure, low-pitched tinnitus (ringing), and fluctuations in hearing. At the time, the cause of the ailment was unknown, but Meniere believed that it originated within the ear. Since that time much has been learned about the disease and its treatment; interestingly however, we still do not know the cause of the disease Meniere described. There are now known to be multiple variants of this disease process, with similar pathologic consequences (abnormal tissue changes). Some forms affect only hearing, others only balance and still others have a few, but not all of the classic four symptoms.

    Histopathology

    It has been well characterized since the 1930’s, that all forms of Meniere’s disease involve dilation of the scala media, with subsequent bulging of Reissner’s membrane into the scala vestibuli. Eventually the membrane ruptures with mixing of endolymph and perilymph, causing injury to the hair cells, producing the characteristic symptoms. This process is called “endolymphatic hydrops”, meaning too much endolymph. Only the disease process described by Meniere himself is should be referred to as Meniere’s disease, whereas all the others are more properly termed hydrops, or endolymphatic hydrops. The precise cause of the excessive fluid is unknown, whether due to an overproduction of endolymph or from an under-resorption is hotly debated. Either way, the net result is too much endolymph with distressing symptoms. Although the etiology (cause) of “Meniere’s disease” is unknown, there are many known causes of endolymphatic hydrops. These include allergy, immune mediated, metabolic disorders, infections (syphilis), congenital malformations of the ear and trauma. The known causes occur infrequently compared to the idiopathic form (unknown cause), but a search is often undertaken.

    Diagnosis

    The discussion you have with your physician is the most important aspect of making the diagnosis. The vertigo spells are always episodic, never occurring more than once a day, and often separated by days, weeks or even years. Vertigo (sensation of motion) in hydropic attacks can occasionally be heralded by ear fullness, an increase in ringing (tinnitus) or a sudden drop in hearing. Rarely, an improvement in hearing precedes the attack (Lermoyez syndrome). The attack typically lasts anywhere from 20 minutes to an entire day, depending on how long it takes for Reissner’s membrane to repair itself. The vertigo is typically described as a spinning sensation (either the environment or the individual spins), which is quite disabling, and often associated with severe nausea and vomiting, sweating and occasionally loss of bowel and/or bladder control. They are not associated with severe headaches. The Tumarkin variant of hydrops has sudden loss of postural control rather than vertigo, thought to be due to involvement of the otolithic component of the inner ear. After an attack of vertigo, one may experience a period of unsteadiness lasting from hours to weeks (occasionally years) as the brain compensates for the loss of balance function.

    Hearing loss in hydrops is quite variable, ranging from a sudden, severe loss without return of function, to a gradual decline over months to years. The most typical pattern is that of hearing fluctuations, with periods of good and poor hearing, associated with a gradual decline in word recognition. The classic form of Meniere’s disease consists of a low frequency loss during an attack that may (or may not) return to normal afterwards. Essentially, any pattern of hearing loss may be associated with hydrops; therefore, the audiometric pattern can not be relied upon to make the diagnosis. A demonstrable fluctuation in hearing in one ear or the other helps to make the diagnosis of hydrops.

    Classically, low-pitched roaring sound is heard in the affected ear prior to, or during an attack of vertigo. This too is highly variable, and some individuals may experience constant ringing in the ear (tinnitus). The precise etiology of tinnitus is poorly understood, but thought to arise from a loss of the usual spontaneous activity of the cochlear hair cells. A sensation of fullness or pressure in the ear may accompany the vertigo attack as well. This is thought to arise from over-distension of the endolymphatic compartment with injury to the hair cells.

    Not unusually, patients with hydrops are quite sensitive to changes in barometric pressure, and may experience more attacks in the spring and fall. Hormonal changes that occur during menses and pregnancy may trigger an attack. Tension, stress, anxiety, allergy and exhaustion are also known triggers of an attack.

    Testing

    A long list of disease processes must be excluded prior to making the diagnosis of hydrops or Meniere’s disease. Tests of hearing, balance, blood count and chemistry and occasionally imaging, are often performed. Pure tone and speech audiometry, as well as electrocochleography (ECoG), are routinely performed. The former is a standardized hearing evaluation, while the latter is a more specific test of inner ear fluid balance. Balance testing is performed if the diagnosis is in doubt, or persistent dysequilibrium is present. When the diagnosis of hydrops is entertained, an MRI or CT scan (imaging studies) is performed to ensure that the symptoms are not being caused by a tumor. It has been shown that nearly 1 patient in 10 with a tumor on the balance nerve will demonstrate “classic Meniere’s symptoms”. This does not mean that 1 out of 10 people with hydrops has a tumor, as these tumors are exceptionally rare, yet it remains an integral part of the diagnostic workup.

    Treatment

    Each and every therapeutic endeavor employed is aimed at eliminated vertigo. Hearing loss, fullness, pressure and tinnitus that occur with hydrops often defy known treatment, although a few options are available. With any given treatment, some patients will have improvement in these symptoms, while others will have no change, and still others may have aggravation of these symptoms. This likely represents the natural history of the disease process. The mainstay of treatment for all forms of hydrops is a low sodium diet and a diuretic. We encourage our patients to maintain a very low sodium diet, less than 1800 mg of sodium each day. A pamphlet will be provided to assist you with this. Additionally, a diuretic is often used to eliminate extra fluid. Both of these maneuvers are employed to help maintain fluid balance within the inner ear. As many as 85% of patients will benefit from this treatment, either with complete cessation of vertigo, or (at least) substantially reduced attack severity. Some individuals are extremely salt sensitive, having a vertigo attack within hours of sodium indiscretion (hamburger and fries for example). Occasionally, a sudden drop in hearing will respond to a steroid burst over 7-10 days. With progression of the disease, this often becomes ineffective. Hundreds of other forms of medical therapy have been tried and shown to be no better than placebo (sugar pill). A vertiginous attack may be controlled through a variety of vestibular suppressants, depending on the age and health status of the individual.

    For those patients who do not respond to medical therapy alone (approximately 15%), surgical treatment is necessary to control the vertigo. Four surgical options are available to everyone, although those with good hearing are advised to consider only those options which attempt to preserve normal hearing.

    Endolymphatic Shunt Surgery

    This minimally invasive procedure has been hotly debated for many years. It involves an incision behind the ear and a mastoidectomy (removing the bone behind the ear). The endolymphatic sac is then identified within the mastoid bone, which is connected to the inner ear endolymphatic compartment. The sac is opened and a piece of surgical grade plastic is inserted inside. The theoretical purpose of this operation is to “shunt” excessive endolymph away from the inner ear. In reality, no one knows why the operation is so successful. Perhaps it has to do with altering the vascularity or immune function of the sac, but it is doubtful that it has anything to do with “shunting” fluid. It has been shown countless times that this operation is successful in controlling vertigo in 75% of those with hydrops. The surgery has relatively few risks, and can be performed as an outpatient.

    Vestibular nerve section

    Attacks of vertigo can be eliminated by cutting the balance nerves on the affected side. The operation can be performed either from above the ear, or behind the ear. It requires a craniotomy (opening through the skull) to access the balance nerves as they exit the inner ear. The vestibular nerves are separated from the cochlear and facial nerves, and then divided. Because of the intracranial nature of this operation, the patient is observed in the intensive care unit overnight, and remains in the hospital from 3 to 5 days. The risks of the operation are higher than for an endolymphatic shunt, however there is a much higher rate of vertigo control, up to 97%.

    Labyrinthectomy

    For an individual with very poor hearing, this is the procedure of choice. The operation begins with a mastoidectomy, but then continues deeper to remove the inner ear semicircular canals and vestibule. Some surgeons also cut the balance nerves at the same time. Vertigo is controlled up to 99% of the time with minimal risks, unfortunately hearing on the side of the surgery is eliminated.

    Intratympanic gentamycin

    Gentamycin is an antibiotic which has as a side effect, injury to the balance organs. This can be utilized to eliminate vertigo in many individuals with hydrops. The eardrum on the side of the disease is anesthetized (local anesthesia), and a tiny needle is passed into the middle ear space. A small amount of this antibiotic in injected into the middle ear, and the patient remains in a recumbent position for 20-30 minutes. Anywhere from 2-5 injections over the course of a month are often necessary to affect vertigo control. Between injections hearing and balance function are monitored. At the first sign of either hearing loss or balance dysfunction, the treatments are discontinued. Studies have shown that control of vertigo can be accomplished in up to 80% of patients, however hearing loss occurs in as many as 20% as well. For many elderly and medically infirm patients, this is an excellent option.

    Prognosis

    Hydrops is a chronic disease, like diabetes or hypertension. It needs to be treated medically (low sodium diet and diuretic) like other disease processes for many years. Like other disease states, it can be well controlled with therapy. Certain individuals with hydrops will develop the disease in the opposite ear. This occurs in 4-10% of patients with hydrops. This fact needs to be taken into account when surgical options are entertained.

    What is a Central Auditory Processing Disorder (CAPD)? 2014-10-06T21:31:55-05:00

    Auditory Processing (also called Central Auditory Processing) refers to the means by which we make sense of what we hear. “Auditory Processing Disorders” refers to the abnormal interaction of hearing, neural transmission and the brain’s ability to make sense of sound. People with auditory processing disorders may indeed have normal hearing, but they have difficulty understanding auditory information. This may be apparent by difficulty understanding speech in the presence of noise, problems following multi-step directions, and difficulty with phonics or reading comprehension, among other things. Parents, educators, physicians, speech-language pathologists and others realize the role that auditory processing plays in a child’s ability to learn, leading to an increase in referrals to audiologists with expertise in this area. Proper diagnosis can be made only after the completion of a battery of audiometric tests, administered by an audiologist. Individualized remediation programs are available to help strengthen auditory processing skills in diagnosed children and adults.

    What is an Auditory Processing Disorder (APD)? 2014-10-06T21:31:31-05:00

    Auditory Processing (also called Central Auditory Processing) refers to the means by which we make sense of what we hear. Auditory Processing Disorder (APD) refers to the abnormal interaction of hearing, neural transmission and the brain’s ability to make sense of sound. People with APD have normal hearing sensitivity, however, they have difficulty processing the information they hear. Individuals may experience difficulty understanding speech in the presence in noise, problems following multi-step directions, and difficulty with phonics or reading comprehension.

    Parents, educators, physicians, speech-language pathologists and psychologists realize the role that auditory processing plays in a child’s ability to learn, leading to an increase in referrals to audiologists with expertise in this area. Proper diagnosis can be made only after the completion of a battery of special tests, administered and interpreted by an audiologist. There may be other neurological factors contributing to the symptoms of APD as well, which should be examined by a physician. Individualized treatment programs, possibly including assistive listening devices, are available to help strengthen auditory processing skills in children and adults diagnosed with APD.

    Different Types of Ear Physician Specialists 2014-10-06T21:30:21-05:00

    There are many different types of physicians who specialize in disorders of the ear. It is not uncommon for patients to ask “What is the difference between an Otoloaryngologist, Neurotologist and Otologist?”

    Otolaryngologist (ENT)
    According to the American Academy of Otolaryngology – Head and Neck Surgery, Otolaryngologists are physicians trained in the medical and surgical management and treatment of patients with diseases and disorders of the ear, nose, throat (ENT), and related structures of the head and neck. They are commonly referred to as ENT physicians.
    Otologists or neurotologists
    Otologists or neurotologists are physicians who in addition to their ENT requirements continue their specialized training for an additional year or more in diseases of the ear, including trauma (injury), cancer, and nerve pathway disorders, which affect hearing and balance.

    What is a Neurotologist? 2014-10-06T21:29:33-05:00

    What is a Neurotologist?

    Otolaryngologists (also called ear-nose-and-throat, or ENT, doctors) are physicians who have advanced training in disorders of the ear, nose, throat and head and neck. Otologists or neurotologists are physicians who in addition to their ENT requirements continue their specialized training for an additional year or more in the diagnosis and treatment of disorders of the ear.
    Otolaryngologists, neurotologists and otologists are the physicians who typically treat disorders of the ear (or hearing mechanisms) requiring medical or surgical solutions.

    Cochlear Implants 2014-10-06T21:29:05-05:00

    Generally speaking, cochlear implants are a means of surgical amplification for patients with severe-to-profound sensorineural hearing loss. There are approximately 500,000 patients in the United States with severe-to-profound hearing loss. Cochlear implants are only recommended after the individual has tried the most powerful and appropriately fit hearing aids with no sufficient listening benefit. Cochlear implants are devices that are permanently implanted into the inner ear.

    Cochlear implantation is a surgical procedure performed by ear surgeons, or otologists. Cochlear implants have been approved by the Food and Drug Administration (FDA) since the early 1980s, and the advances and improvements in the technology have been amazing. The FDA and the American Medical Association (AMA) recognize cochlear implants as safe and effective treatment for severe-to-profound sensorineural hearing loss. Most insurance programs pay (at least partly) for cochlear implantation. Your audiologist, cochlear implant surgeon and their appropriate office staff are experienced at managing insurance issues.

    Appropriately-identified adults as well as children with severe to profound hearing loss (starting at age 12 months) can be implanted. Research demonstrates that the earlier a child is implanted, the better the long-term results will be with respect to speech and language development. After surgery, ongoing rehabilitation is necessary, as the child must learn to associate the sound signals with everyday sounds.

    Regarding adults with profound hearing loss, research suggests that adults who receive cochlear implants are less lonely, have less social anxiety, are more independent, have increased social and interpersonal skills, and of course, they hear better with the cochlear implant.

    Cochlear implants are used in the patient who cannot benefit from hearing aids. The cochlear implant is a device used to bypass the damaged organ of hearing and convert sound into electrical impulses that can directly stimulate the hearing nerve. The implant has of an external portion worn on the ear like a hearing aid or on the body. This device, called the sound processor, is comprised of a microphone, power compartment and external coil. The internal portion, which is typically made of ceramic or silicone, consists of an electrode array and must be surgically implanted. The surgical procedure involves the placement of an internal receiver beneath the skin behind the ear, and the electrode array, which is inserted into the organ of hearing, or the cochlea. The electrical signals are programmed by the audiologist to maximize speech perception and are controlled by the speech processor. The brain interprets these electrical impulses as sound. Again, not all patients are surgical candidates, and not all cochlear implant recipients receive the same benefit.

    For more information, visit:
    American Speech-Language-Hearing Association

    U.S. Food and Drug Administration

    Types of ALDs 2014-10-06T21:24:49-05:00

    What Types of ALDs Exist?
    There are many assistive listening devices available today, from sophisticated systems used in theaters and auditoriums to small personal systems.

    Various kinds of assistive listening devices are listed below:

    Personal Listening Systems: There are several types of personal listening systems available. All are designed to carry sound from the speaker (or other source) directly to the listener and to minimize or eliminate environmental noises. Some of these systems, such as auditory trainers, are designed for classroom or small group use. Others, such as personal FM systems and personal amplifiers, are especially helpful for one-to-one conversations in places such as automobiles, meeting rooms, and restaurants.

    TV Listening Systems:These are designed for listening to TV, radio, or stereos without interference from surrounding noise or the need to use very high volume. Models are available for use with or without hearing aids. TV listening systems allow the family to set the volume of the TV, while the user adjusts only the volume of his or her own listening system.

    Direct Audio Input Hearing Aids: These are hearing aids with direct audio input connections (usually wires) which can be connected to the TV, stereo, tape, and/or radio as well as to microphones, auditory trainers, personal FM systems and other assistive devices.

    Telephone Amplifying Devices: Most, but not all, standard telephone receivers are useful with hearing aids. These phones are called “ hearing aid compatible.” The option on the hearing aid is called the T-Coil. The T-coil is automatically activated on some hearing aids and manually activated on others. Basically, the telephone and the hearing aid’s T-coil communicate with each other electromagnetically, allowing the hearing aid to be used at a comfortable volume without feedback and with minimal background noise. You should be able to get hearing-aid-compatible phones from your telephone company or almost any retail store that sells telephones. Not all hearing aids have a “T” switch. Make sure your hearing aids have a T switch before purchasing a new hearing aid compatible phone! There are literally dozens of T-coil and telephone coupling systems. Speak with your Hearing Health Care Provider to get the most appropriate system for your needs.

    Cell Phones: Most hearing aids can be used with most cell phones. Importantly, digital hearing aids and digital phones may create constant noise or distortion. There may be significant problems for some hearing aids when used with particular cell phones! The best person to address this problem is your audiologist – speak with your audiologist BEFORE you buy a cell phone or hearing aids!!!!
    Regarding “hands free” systems, there are many to choose from and hearing impaired users usually benefit maximally by using binaural hands free systems.

    Candidates for ALDs 2014-10-06T21:22:59-05:00

    Are ALDs Only for People Using Hearing Aids?

    No. People with all degrees and types of hearing loss — even people with normal hearing can benefit from assistive listening devices. Some assistive listening devices are used with hearing aids; some are used without hearing aids.

    Types of Hearing Aids 2014-10-06T21:21:36-05:00

    There are many types of hearing aids today, and the style or device is dependent upon the user’s individual needs. There are in-the-ear styles as well as behind-the-ear styles. Also, hearing aid technology has advanced, with many new and improved options to choose from.

    Styles of Hearing Aids

    Hearing aids are available in many different sizes and styles, thanks to advancements in digital technology and miniaturization of the internal components. Many of today’s hearing aids are considered sleek, compact, and innovative – offering solutions to a wide range of hearing aid users. When selecting a style of hearing aid, you should consider:
    -The degree of the hearing loss
    -Power requirements
    -Manual dexterity and visual abilities
    -Patient budget
    -Cosmetics and aesthetics
    -Skin sensitivities
    -Anatomical and medical considerations

    In-the-Ear Styles
    Invisible-in-The-Canal (IIC) – This style is the newest and smallest custom hearing aid available. These devices fit deep inside of the ear canal to take advantage of the natural acoustics of the ear.

    Completely-in-the-Canal (CIC) – These extremely small custom devices sit deep and entirely inside the ear canal. They usually require a “removal string” due to their small size and the fact that they fit so deeply into the canal. These hearing aids work well for someone with a mild to moderate hearing loss and offer high cosmetic appeal, but are difficult for people who have limited dexterity with their fingers.

    In-the-Canal (ITC) – These hearing aids sit in the lower portion of the outer ear’s bowl and are slightly larger than a CIC device. Because of their slightly larger size, ITCs often have a longer battery life than CICs, and they come available with more user options, depending upon the size of ear. These devices suit people with mild to moderate hearing losses.
    Half-Shell – The half shell model fills half of the bowl of the outer ear, and like ITC hearing aids, they allow more options and longer battery life due to the larger size. These devices are ideal for persons seeking a smaller hearing aid and those who may have potential dexterity concerns.

    Full Shell or In-the-Ear (ITE) – The largest of custom hearing aids available, full shell hearing aids fill up the entire bowl of the outer ear. Their size allows the maximum number of controls and features, and they are able to accommodate mild to severe hearing losses.

    Behind-the-Ear (BTE) Styles
    Mini-BTE with slim tubes – This type of BTE is often referred to as an “open fit” hearing aid. The small miniature hearing aid sits behind the ear and transmits sound into the ear canal via a thin plastic tube. The tubing connects to a soft tip that sits in the ear canal but doesn’t occlude it. The result is a natural, open feeling as air and sound enter the ear naturally around the tip, while amplified sound enters through the tip. This style of BTE is recommended for mild to moderate high-frequency hearing loss and offers cosmetic appeal due to the small size of the hearing aid.

    Receiver-in-the-Ear (RITE) – RITE hearing aids are similar to the mini BTE. However, with the RITE, the speaker of the hearing aid sits inside the ear canal close to the eardrum versus the main body of the hearing aid going behind the ear. Although it looks like a mini BTE when worn on the ear, the RITE style fits a higher degree of hearing loss (mild to severe), while still providing the “open” fitting.

    Behind-the-Ear (BTE) with custom ear mold – These devices suit people with a wide range of hearing loss, which can be from mild to profound. They are slightly longer in shape and are contoured to sit nicely behind the ear for a sleek, compact look. This style of hearing aid typically offers a wide array of features and options, as well as more control and power than custom models. Additionally, they are connected to the ear canal via custom-made plastic tubing and an ear mold. The ear mold color and style, as well as the wearer’s hairstyle, will determine how this style looks on each person.

    Hearing Aid Technology
    A wide range of technology and a host of features are available in each hearing aid device. The cost of hearing aids generally depends on the technology and the number of features. Today’s digital hearing aids are typically offered in various levels, such as basic or entry-level to advanced or premium-level. Within each level, different technology and features are available.

    Basic digital hearing aids generally require the wearer to make some manual adjustments in certain listening environments, such as turning a volume control up or down, or pushing a button to change listening programs. In contrast, a premium or more advanced hearing aid responds automatically to changes in the listener’s environment, making adjustments based on the signals detected by the hearing aid. However, the hearing aid wearer is not required to make any manual changes.

    As the level of the technology increases in hearing aids, so does the availability of advanced features. Examples of some of the advanced features found in today’s digital hearing aids include:
    -Directional Microphones – This applies preference to sounds in front of the wearer and reduces sound from behind the wearer. This technology has been proven in studies to improve speech understanding in background noise.
    -Noise Reduction – This feature determines if a signal contains unwanted background noise and reduces the level of background sound, if present. Because of this feature, background noise is less annoying, and the hearing aid wearer’s listening comfort is improved in noisy situations.
    -Feedback Management – Reducing or eliminating bothersome whistling that may occur with hearing aid use, this feature is optimal for many people with hearing loss. Because of this feature, the hearing aid wearer’s comfort is improved.
    -Wind Noise Reduction – This feature reduces the noise created from wind blowing across the hearing aid’s microphone(s). This is designed to improve comfort for people who spend a lot of time outdoors.
    -Data Logging/Learning – This is the ability of the hearing aid to track and learn the hearing aid wearer’s preferences in various listening environments. This information can assist the hearing professional in making future programming adjustments and allows the hearing aid to adapt to the wearer’s preferences.
    -Telecoil/Auto-Telecoil – This feature picks up a signal from a compatible telephone, allowing hearing aid wearers to listen to the telephone without whistling (feedback). Some hearing aids require a push of a button to activate the feature; other manufacturers offer an auto-telecoil, where the hearing aid switches automatically when a telephone signal is detected.
    -Bluetooth Interface – This technology establishes a wireless connection between hearing aids and Bluetooth-compatible devices. It is designed to improve wearer convenience and use with devices, such as television, telephones, MP3 players, and computers.

    Medical Science Shows Insight into Noisy Eyeballs and Tinnitus 2014-10-06T21:18:18-05:00

    Recently an article was published in Scientific American on noisy eyeballs. Yes you read correctly, noisy eyeballs.

    Often times happy accidents happen in medicine or shall you serendipity in science.

    You see R. Douglas Fields, developed noisy eyeballs. Each time he moved his eyeballs he heard a grating sound. As luck would have it, R. Douglas happened to meet Josef Rauschecker, a professor of physiology and biophysics at Georgetown. Fields started discussing his noisy eyeballs and Rauschecker, an expert on the brain’s auditory cortex, suggests Fields have his serotonin levels checked.

    Serotonin is a neurotransmitter in the brain – a chemical responsible for the movement of signals from point A to point B in the brain. Coincidentally the noisy eyeball expert had also been conducting tests on subjects who experienced tinnitus – ringing in the ears. Dr. Rauschecker felt the two phantom sounds were related to low serotonin levels.

    Dr. Rauschecker had discovered that brain scans of patients with ringing in the ears showed that these men and women had a smaller nucleus accumbens. This nut-sized section of the brain is the valve that controls the amount of serotonin released by the brain.
    This enables us to block out sounds and prevent sensory overload. It’s Dr. Rauschecker’s belief that tinnitus, at least in some cases, isn’t always an ear problem. It’s a problem of serotonin levels in the brain. The cure? Selective serotonin reuptake inhibitors, or SSRI drugs.

    Now, these drugs are currently prescribed to treat depression, anxiety and other stress disorders. Though not available for use in treating tinnitus just yet, someday, based on the ongoing research results, doctors may be prescribing drugs used to treat depression to people who experience tinnitus.

    Currently there is no the cure for tinnitus, though 50 million Americans (1 out of 6) experience ringing in the ears. Over 12 million of us have sought medical attention to address the symptoms of tinnitus. Not to mention tinnitus is one of the leading medical disabilities military veterans are experiencing.

    The luck of science may in fact lead to the discovery of a medication to ease or even eliminate tinnitus in some people. That would be nice.

    Or shall we say serendipity science.

    Three Levels of Hearing Aid Technology 2014-10-06T21:15:19-05:00

    There are essentially three levels of hearing aid technology. We refer to these as analog, digitally programmable, and digital.

    Hearing Aid Battery Information 2014-10-06T21:14:36-05:00

    All batteries are toxic and dangerous if swallowed. Keep all batteries (and hearing aids) away from children and pets. If anyone swallows a battery it is a medical emergency and the individual needs to see a physician immediately. If a battery is swallowed, immediately call the 24-hour National Battery Ingestion Hotline at 202-625-3333 (call collect if necessary) or call your poison center at 1-800-222-1222.

    The sizes of hearing aid batteries are listed below along with their standard number and color codes.
    Size 10 YELLOW
    Size 13 ORANGE
    Size 312 BROWN
    Size 675 BLUE
    Today’s hearing aid batteries are “zinc-air.” Because the batteries are air-activated, a factory-sealed sticker keeps them “inactive” until you remove the sticker. Once the sticker is removed from the back of the battery, it is active.

    Do Not store zinc air batteries in the refrigerator. Water particles will form under the sticker and oxygen will reach the battery. Batteries should be stored in a cool location.

    Battery Safety Warning
    There was an incident where a used Zinc Air Cell Battery was stored for disposal jointly with other batteries in a film box and burst with a loud bang. If battery cells which are totally discharged come into electrical contact with one another, an unintentional charging, and in exceptional cases, bursting of the cell is possible. Batteries should be recycled. Do not dispose of in fire, recharge, reverse polarity, or allow batteries to inadvertently contact metal objects or other batteries – – they may leak or explode and cause injury.

    Taking an Impression of the Ear 2014-10-06T22:55:33-05:00

    All custom made hearing aids, ear molds and some hearing protectors are made from a “cast” of the ear. The cast is referred to as an ear impression. The hearing specialist makes the ear impression in the office. It takes about 10 to 15 minutes. A special cotton or foam dam is placed in the ear canal to protect the eardrum, and then a silicone material is placed in the ear canal using a syringe. When the material hardens (about 5 to 10 minutes later) the cast, along with the dam are removed from the ear canal. Often, the ear canal will be “oily” after the impression is removed. This is normal. The oil comes from the material and prevents the material from sticking to the skin.
    Tell the hearing specialist before the ear impression is obtained if you are allergic to plastic, dyes or have any ongoing problems such as chronic perforation on the ear drum. It is dangerous to attempt this procedure yourself. It takes a trained specialist to visualize a normal eardrum and then appropriately place the block.

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    What is Digital Technology? 2014-10-06T21:16:52-05:00

    The term digital is used for most of today’s current technology, from televisions to cell phones. Hearing aids today are digital, which means incoming sound is converted into a series of numbers which are then processed using mathematical equations. Digital processing enables very complex manipulation of sound, for example, to separate speech from noise. A few digital instruments are capable of 1.8 million calculations per second.

    The digital technology within hearing aids allows sounds to be separated into different frequency regions, or bands, and amplify each region selectively, depending on the hearing aid user’s hearing loss. In addition, the advanced digital processing within the hearing aid enables different amounts of amplification for soft, moderate, and loud sounds, so that soft sounds are audible, but loud sounds are not uncomfortable or over amplified. Digital signal processing allows amplification to occur with minimal distortion, resulting in a more natural sound quality.

    Digital hearing aids are programmable, meaning the hearing aid settings can be precisely fine-tuned, and special features can be adjusted for each wearer by the Audiologist, using special hearing aid software on a computer. Hearing aids are programmed and customized for both the hearing loss, the preferences, and the lifestyles of the person who wears them.

    ADVANCED TECHNOLOGY
    In addition to basic the basic digital signal processing discussed above, many hearing aid manufacturers offer different hearing aid models, based upon the sophistication of audio processing technology. The more sophisicatied and advanced digital hearing aids tend to be more automatic in that they better adapt the audio processing profile to the specific environment encountered. The more sophisticated hearing aids are best suited for individuals who often find themselves trying to listen in challenging audio environments. Examples of some of these advanced features, what they do and how they benefit the hearing aid wearer are:
    Directional Microphones – Two microphones on the hearing aids work together to give preference to sounds in front of the wearer and reduces sound, especially noise, from behind the wearer. This technology has been proven in research to improve speech understanding in background noise. In some more sophisticated digital hearing aids, the focus point for speech can be configured to be to the right, left or behind the person. This enhances listening benefit in difficult situations, such as the car.

    Noise Reduction – Determines if signal contains unwanted background noise and reduces the level of background noise if present. This noise reduction circuitry is most effective in squelching a steady-state noise which has a diffrent acoustical envelope or “signature” than speech, such as road noise or a fan. The outcome of this specialized noise reduction circuitry is that the background noise is less annoying, and the user’s listening comfort is improved in noisy situations.

    Feedback Management – Reduces or eliminates whistling that can occur with hearing aid use. The advanced digital technology eliminates any whistling from the hearing aid without compromising volume or sound quality.

    Wind Noise Reduction – Reduces the noise created from wind blowing across the hearing aid’s microphone(s). This is designed to improve comfort for people who spend a lot of time outdoors.

    Data Logging/Learning – The ability of the hearing aid to track and learn the hearing aid user’s preferences in various listening environments. This information can assist the Audiologist in making future programming adjustments and allows the hearing aid to adapt to the user’s preferences.

    Bluetooth Interface – Establishes a wireless connection between hearing aids and Bluetooth compatible devices such as cell phones, computers, televisions, remote microphones, etc.

    Hearing Aids in the Presence of Background Noise 2014-10-06T21:10:30-05:00

    Virtually all patients wearing hearing aids complain about background noise at one time or another. There is no way to completely eliminate background noise. Background noise exists and is important to hear in order for the hearing aid user to be involved in their environment. There is no way to completely eliminate background noise, however, technology exists today to reduce distracting noise and allow you to focus better on the person you want to hear.

    Remember, when you had normal hearing there were still times when background noise was a problem. It is no different now, even with properly fit hearing aids! The good news is there are circuits and features that help to reduce (or minimize) background noise and other unwanted sounds. In fact, there are research findings that demonstrate digital hearing aids with particular circuit and microphone options can effectively reduce background noises.

    Many early digitally programmable (and even some digital) circuits, which claimed to reduce or eliminate background noise, actually filtered out low frequency sounds. This indeed made the sounds appear quieter, however, not only was the background noise made quieter, but so too, was the signal (the speech sound).

    Newer ways to reduce background noise are based on timing and amplitude cues and other noise processing strategies, which 100% digital hearing aids can incorporate. These methods work, but are not perfect. Directional microphones are available and are useful as they help to focus the amplification in front of you, or towards the origin of the sound source. Directional hearing aids can offer a better signal-to-noise ratio in difficult listening situations by reducing a little bit of the noise from the sides or behind you. In most 100% digital hearing aids, the noise control features help make noise more tolerable, but do not completely eliminate the noise.
    The best and most efficient way to eliminate or reduce background noise is through the use of FM technology.

    Realistic Expectations for the Hearing Aid User 2014-10-06T23:01:47-05:00

    Hearing aids work very well when they are fit and adjusted appropriately to the user’s prescription. Most people do not know that there is an adjustment period for your ears and your brain to reconfigure to incorporate hearing aids (or new hearing aids) into your life. In the beginning this will sound different. Nonetheless, they should be comfortable with respect to the physical fit and the sound quality. They will not restore your ears back to exactly what you may remember from years ago and they are not as good as normal hearing. You may be aware of the hearing aids in your ears. Until you get used to it, your voice may sound “funny.” Some hearing aids have features that make noisy environments more tolerable; however, hearing aids cannot completely eliminate background noise. It is important to have realistic expectation and know what your hearing aids can and cannot do.

    Your Own Voice
    When trying hearing aids for the first time or when you are fit with new hearing aids you will probably notice your own voice sounds different or funny. Don’t worry- this is very common and should go away. You will hear your voice amplified through the hearing aid and may describe this sensation as sounding “hollow” or feeling “plugged up.” Again, this is normal and will usually go away in a few days after you have given yourself a chance to get accustomed to your new hearing aids. There are adjustments that the hearing specialist can do to relieve these symptoms, should these persist beyond the first few weeks.

    Adapting to New Hearing
    People learn at different rates. Some people need a day or two to learn about and adjust to their hearing aids, most need a few weeks and some may need a few months. There is no perfect way to learn about hearing aids. If you notice that you are struggling on the first day, it is recommended you wear the hearing aids for a few hours then take them out. After that you should add about an hour a day for each day that follows until you are wearing it full-time during your waking hours. Do not try to set an endurance record. Over a period of time you will lengthen the amount of time that you wear the aids. It is recommended that you interact with those people you are most familiar with during your first few days. Start off listening with your hearing aids in a favorable listening environment and work towards more difficult listening situations. Let your friends and family know that you are using your new hearing aids.

    Physical Fit
    Hearing aids need to be comfortable, not too tight and not too loose, they should fit just right. Do not wear the hearing aids if they cause any discomfort or irritations. Do call your hearing specialist to schedule an appointment to remedy the problem as soon as possible. Do not wear them if they are uncomfortable.

    Helpful Steps to Learning to Use a Hearing Aid:
    -Use the aid at first in your own home environment.
    -Wear the aid only as long as you are physically comfortable with it.
    -Accustom yourself to the use of the aid by listening to just one other person – husband or wife, neighbor or friend.
    -Do not strain to catch every word.
    -Do not be discouraged by the interference of background noises.
    -Practice locating the source of the sound by listening only.
    -When you hear a sound that you are unfamiliar with acknowledge it. This will increase your tolerance for sounds.
    -Practice learning to discriminate different speech sounds.
    -Listen to something read aloud.
    -Gradually extend the number of persons with whom you talk, still within your own home environment.
    -Gradually increase the number of situations in which you use your hearing aid.
    -Consider using a computer aided program such as LACE to increase you success and benefit with hearing devices.

    How do I know if I have Hearing Loss? 2014-10-06T21:08:12-05:00

    Hearing loss can be due to the aging process, exposure to loud noise, certain medications, infections, head or ear trauma, congenital (at birth) or genetic factors, diseases, as well as a number of other causes. Recent data suggests there are over 34 million Americans with some degree of hearing loss. Hearing loss often occurs gradually throughout a lifetime. People with hearing loss compensate often without knowing they have hearing loss.

    You may have a hearing loss if:
    -You hear people speaking but you have to strain to understand their words.
    -You frequently ask people to repeat what they said.
    -You don’t laugh at jokes because you miss too much of the story or the punch line.
    -You frequently complain that people mumble.
    -You need to ask others about the details of a meeting you just attended.
    -You play the TV or radio louder than your friends, spouse and relatives.
    -You cannot hear the doorbell or the telephone.
    -You find that looking at people when they speak to you makes it easier to understand.
    -You miss environmental sounds such as birds or leaves blowing.
    -You find yourself avoiding certain restaurants because they are too noisy, or certain people, because you cannot understand them.

    If you have any of these symptoms, you should see a Licensed Hearing Healthcare Professional to have a formal hearing evaluation. This hearing test, or audiologic evaluation, is diagnostic in nature. A diagnostic audiologic evaluation is more than just pressing a button when you hear a beep! Rather, an audiologic evaluation allows the Hearing Healthcare Professional to determine the type, nature and degree of your hearing loss. In addition, your sensitivity, acuity and accuracy to speech understanding will be assessed. In addition, the Hearing Healthcare Professional may test for speech understanding at different volume levels and in different simulated environments. This additional testing may be performed in order to provide the Hearing Healthcare Professional with an indication as to how successful of a candidate you might be for amplification.

    The hearing evaluation should also include a thorough case history (interview) as well as a visual inspection of the ear canal and eardrum. Additional tests of the middle ear function may also be performed. The results of the evaluation can useful to a physician, if the Hearing Healthcare Professional believes your hearing loss may benefit from medical intervention. Results of the hearing evaluation are plotted on a graph called an audiogram. The audiogram provides a visual view of your hearing test results across various pitches or frequencies, especially the ones necessary for understanding speech (250-8000 Hz).

    The audiogram and results from your speech understanding tests are used to create a prescription and program the hearing aids, when so indicated.

    What is an Audiologist? 2014-10-06T21:06:52-05:00

    Audiologists are health-care professionals who evaluate, diagnose, treat, and manage hearing loss, as well as other conditions like tinnitus and balance disorders. An audiologist is a person who holds a minimum of a Master’s degree in Audiology; professionals seeking education in Audiology who do not currently hold a Master’s degree must now pursue a Doctoral degree in Audiology (Au.D). Additionally, audiologists must be licensed in the state where they practice, and these hearing professionals are regulated by the Division of Consumer Affairs.

    An audiologist may be awarded the Certificate of Clinical Competence in Audiology by the American Speech-Language-Hearing Association (ASHA), otherwise known as the CCC-A. With additional training and expertise, the audiologist may receive the honor of Fellow, which is bestowed by the American Academy of Audiology (AAA).

    Audiology Diagnostic Tests and Treatments

    Some typical occupational duties provided by an audiologist include:

    -Performing technical diagnostic hearing tests.
    -Prescribing and fitting hearing aids (when additionally licensed to do so).
    -Billing insurance for medically necessary diagnostic testing and hearing aids, when patients have policies that cover these benefits.
    -Assisting in cochlear implant programs.
    -Performing ear- or hearing-related surgical monitoring in hospital settings.
    -Clinically coordinating, monitoring, and supervising newborn hearing loss detection programs.
    -Designing and implementing hearing conservation programs.
    -Providing hearing rehabilitation auditory training.
    -Assisting with speech-reading training.
    -Offering listening skills training

    For further information about audiologists, contact the American Academy of Audiology (www.audiology.org) or the American Speech-Language-Hearing-Association (www.asha.org)