Week 6, Spring 2008

Today, I saw a 25 year old male who had a history of noise exposure. He noted going to many concerts and drag racing as teenager. He also had a history of hunting and shooting. Hearing protection was not used during any of these activities.

Otoscopy revealed normal, intact TMs bilaterally. Type A tympanograms were also found bilaterally. ART testing was not performed due to time constraints.

Pure tone AC thresholds were normal bilaterally, but were slightly worse (5-10 dB HL) in the left ear. This may have been due to right-handed shooting.

The following article Hearing Loss and Hearing Handicap in Users of Recreational Firearms, by Michael Stewart, Rebecca Pankiw, Mark E. Lehman, and Thomas H. Simpson, evaluated a total of 232 shooters ranging in age from 13 to 77 years with a mean age of 40 years. There were 187 males and 45 females, all subjects reported using firearms during the previous year. The hearing acuity of the subjects ranged from bilaterally normal across the frequency range to a severe to profound high-frequency hearing loss bilaterally. All subjects had normal ME systems.

http://web.ebscohost.com.www.libproxy.wvu.edu/ehost/pdf?vid=3&hid=113&sid=9da9fc7b-df51-43f3-8378-8d188e7a3ab6%40sessionmgr109

http://web.ebscohost.com.www.libproxy.wvu.edu/ehost/detail?vid=5&hid=106&sid=55fb21cd-5a39-4c5b-b0a2-4842d09d2093%40sessionmgr108

http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=6717781&site=ehost-live

(These were the only links available. If they don't work for you, I provided the reference as well.)

I don't know about you, but I've never known quite the right way to explain why shooters have worse hearing on the side contralateral to gun. Here is how the authors explained it: "Because the ear contralateral to the shoulder supporting a rifle in a firing position is closer to the source of the sound (gun bore), and the ipsilateral ear is slightly protected by head shadow, asymmetry in high-frequency hearing may occur, with the contralateral ear being worse. Also, the directionality of the noise causes the level of the impulse noise to be reduced to the ipsilateral ear." In layman's terms, when you're shooting, your ear nearly rests against the shoulder that the gun rests on. This blocks some of the sound from damaging that ear. However, the other ear is closer to the source of the sound receives no protection, so it often becomes more damaged by the noise from the gun.

All participatnts completed a questionnaire related to demographic information, knowledge and use of hearing protection, firearm safety training, and shooting habits. Otoscopy and pure tone audiometry were performed. PT thresholds were obtained at .5, 1, 2, 3, 4, and 6 kHz bilaterally. A screening version of the Hearing Handicap Inventory for Adults (HHIA-S) was administered to any individuals whose thresholds were equal to or worse than 25 dB HL at any test frequency in either ear.

The results of this study revealed that many of the subjects who reported shooting
firearms for sport purposes exhibited varying degrees of high-frequency hearing loss and associated self-reported hearing handicap. Certain demographic groups of the recreational firearm users, including males, older individuals, and blue collar workers, exhibited more high-frequency hearing loss and reported more hearing handicap than others.

Males and blue collar workers also tended to shoot more powerful guns than their demographic counterparts. Hearing loss in blue collar workers may also be attributed to industrial noise.

Individuals with more significant high-frequency hearing loss tended to report more hearing handicap. Based on these results, it appears that the HHIA-S may be useful as a screening tool in populations in which NIHL is prevalent, such as shooters and industrial workers. It may also be useful as an aid to counseling individuals with
high-frequency hearing loss and to assess the benefits of intervention strategies by comparing pre- and post-intervention scores.

Different formulae were used to identify those who may be handicapped by HL. However, high-frequency pure-tone average formulae, used to identify patients who may be hearing handicapped, were more likely to identify populations with high-frequency hearing loss than those using formulae that employ 500 Hz.

Thus, in the future, it may be helpful to administer a scale like the HHIA-S with those who are prone to NIHL. It may also be benefical to report a high-frequency PTA as well as a standard PTA of .5, 1, & 2 kHz.

Week 5, Spring 2008

This week in clinic I saw an older gentleman who was having obvious difficuly understanding normal conversational speech during the case history interview. I found myself raising my voice substantially and repeating myself often in order to communicate with him. Direct view of my face was also needed for him to understand what I was saying.

The client had normal EACs and normal tympanograms. Acoustic reflex testing revealed elevated ipsilateral and bilateral ARTs. The client had sloping mild to moderately-severe sensorineural hearing loss bilaterally. His PTA and SRT were in good agreement for both ears, and his WR scores were fair (82% in the right ear and 78% in the left ear).

Significantly, the client noted that he and his wife had been fighting about his inability to hear lately. He said that she was constantly "nagging" him about not listening, and it was becoming an issue in their marriage. He also stated that he was no longer able to talk on the phone because of his hearing loss. According to the gentlemen, the purpose of his visit was mostly to appease his wife.

The following article titled "Effect of Hearing Aids on Hearing Disability and Quality of Life in the Elderly" describes a study that measured perceived benefits on social and emotional wellbeing following a hearing aid fitting. A total of 98 participants, who were first-time hearing aid users, were fit monaurally with a hearing aid. At the beginning of the study, prior to the fitting, the participants were given the Hearing Handicap Inventory for the Elderly short version (HHIE-S) and other questionnaires. All inventories were given again six months after the intial fitting. Most hearing aids used were BTEs, but ITEs were used as well. Some were digital and some were analog hearing aids.

Prior to the fitting, the HHIE-S revealed that almost 70% of the participants felt that their HL was handicapping, and over 50% noted that it limited their lives. The mean HHIE-S score was 28.7 prior to the fitting and 12.7 six months post-fitting. Lower scores in indicate lessening of a perceived handicap, which presented in 40-60% of the participants post-fit. Thus, being fit with hearing aids made most individuals feel substantially less handicapped.

Hopefully, being fit with hearing aids will also increase my patient's perceived quality of life. However, careful counseling will be needed to ensure that he has appropriate expectations.

http://web.ebscohost.com/ehost/pdf?vid=3&hid=114&sid=b45b12c1-d016-427f-aba0-46dfc4f04186%40sessionmgr109

Week 4, Spring 2008

This week, I saw a grumpy man with a history of noise exposure. Throughout the case history interview, he offered short, vague answers, and he acted as though he would rather be somewhere else. He was a bit impatient during immittance testing, but he had normal tympanograms bilaterally.

During pure tone testing, he was directed toward the right speaker; however, he didn't make any attempts to look my way. In fact, he kept his head down during testing. I tried to be as cheery as possible during our interactions in order to make him feel more at ease, but the client never seemed to warm up. I just assumed that he was a grumpy man who didn't want to be there, but was required to come for an annual evaluation.

Pure tone testing revealed a slight to moderate sensorineural hearing loss in his right ear and a slight to moderately-severe hearing loss in his left ear. My supervisor and I reviewed his audiogram prior to discussing results with the patient. We observed that his hearing had worsened 10-15 dB HL since last year. He had been coming to our clinic for several years for annual evaluations, and I expected that explaining results wouldn't be particularly eventful. Still, we asked the client to come into the hearing aid room so that we could explain results and discuss amplification.

What I didn't anticipate was ... the patient's reaction to the results.

While I explained how to interpret the audiogram, the client was very quiet. I talked about pitch and loudness and sounds that those with normal hearing perceive at various frequencies. I then described the amount of hearing loss that was displayed on his audiogram. We talked about what sounds might be difficult for him to hear, and we used the speech banana as a visual aid. Throughout the explanation, the client remained silent.

Then, when my supervisor and I talked with him about the change in his hearing from last year and the possibility of amplification, the client became visibly upset. At that point, he began to open up about the increased difficulty with communication that he has been facing and the mounting tension between he and his wife. In part, he seemed relieved that he could tell his wife that he actually had a hearing loss. He even asked for a copy of his audiogram so that he could explain it to her. Conversely, he also seemed deeply saddened that his hearing had deteriorated.

My supervisor and I spent some extra time talking with him and counseling him about amplification options. However, he just didn't seem ready to pursue amplification at that time. I talked with him about making an appointment for a later date if he ever decided that he would like to try amplification.

The most important thing that I learned from this experience was ... Sometimes, irritability masks a more profound problem. In this case, I think he was afraid to learn the outcome of our test results. This was a great learning experience that emphasized the importance of being kind and patient with all clients ... especially the crabby ones!

In the article "How Personality Types Correlate with Hearing Aid Outcome Measures," the authors sampled 21 adults ages 60-80. All individuals had mild to moderate bilateral, symmetric SNHL and were first-time hearing aid users. Subjects underwent a HE and a HAE and also completed the COSI and the Myers-Briggs Type Indicator (MBTI). From the MBTI, 16 possible personality types could emerge from combinations of 4 personality dimensions: 1)extroversion vs. introversion; 2)sensing vs. intuition; 3)thinking vs. feeling; 4)judging vs. perceiving. After 4 and 8 weeks of hearing aid use, participants were asked to rate the degree of change resulting from hearing aid use, and the COSI was re-administered in order to monitor perceived benefit. These results were compared to established personality types in a correlational analysis.

The authors found several trends. A moderate negative correlation was found between perceived hearing aid benefit and the thinking and judging personality types. On the other hand, a strong positive correlation was found between perceptive individuals and their perceived benefit from amplification. Using this information, clinicians could informally assess patients personality preferences and use results to tailor appropriate informational counseling. In particular, it may be necessary to spend more time counseling "thinkers" and "judgers" about realistic expectations.


http://www.audiologyonline.com/theHearingJournal/pdfs/HJ2005_07_pg28-34.pdf

Week 3, Spring 2008

Today, I saw client with an interesting case history and pattern of test results. Also, first and foremost, she was a very sweet lady.

The client had previously visited our clinic due to auditory fullness and ear pain related to middle ear infections approximately one year ago. She was advised to seek medical attention at that time.

At the current visit, the patient described medical conditions including hypertension and rheumatoid arthritis. Medications used to lower blood pressure and used to manage inflammation and pain, secondary to rheumatoid arthritis, were taken regularly. The patient also reported “a cotton ball feeling” in her left ear and intermittent high frequency tinnitus lasting less than one minute. Her tinnitus was described as alternating between her ears. Head trauma from a car accident occurred in the 1980s. CAT scan results following the accident were normal, according to the client’s account.

Two episodes of true vertigo were reported. The first episode was approximately five to ten years ago and lasted at least two hours. The patient fell unconscious for a few minutes at work and was hospitalized. No conditions seemed to initiate or worsen the attacks. Meclizine was prescribed by the patient’s physician in order to manage future attacks, if needed. The second episode was also five to ten years ago and occurred at home. The patient reported a sensation, which she characterized as “spinning in bed and moving down a tunnel,” that lasted for approximately four to five hours. When she was hospitalized for the second episode, her physician reported that her blood pressure was extremely elevated. Continued use of Meclizine during attacks was the recommended course of treatment at that time.

Recent bouts of shingles, within the past few years, were noted as well. The first outbreak occurred eight or nine years ago. Symptoms included sores on the thoracic region up to the left side of the neck and head, including a sore on the left ear. A vision specialist was consulted, at that time, due to concerns about viral attacks on the optic nerve. A hearing evaluation was completed by the client’s ENT specialist following episodes of shingles; however, the client was not able to remember the exact results of that evaluation.

Residual numbness along the jawline has not remitted since the onset of shingles outbreaks. The client is currently undergoing evaluation for subcutaneous growths of unknown pathology around the shoulders and neck on her left side and will soon have an MRI.

Otoscopy revealed a subcutaneous node behind the left ear. Normal ear canals and clear, intact tympanic membranes were observed bilaterally. A normal (Type As) tympanogram from the right ear and a normal (Type A) tympanogram from the left ear were observed. Acoustic reflexes were tested ipsilaterally and contralaterally at 500, 1000, and 2000 Hz bilaterally. Normal ARTs were found with right ipsilateral and left contralateral stimulation. Absent ARTs were observed with left ipsilateral and right contralateral stimulation. Stimulation beyond 105 dB HL was not attempted due to tolerance problems and reports of associated nausea. Reflex decay did not occur in the left ear at 1000 Hz with contralateral stimulation. Right contralateral reflex decay could not be tested due to absent ARTs.

Normal hearing sensitivity in the right ear was observed. A unilateral, mild sloping to moderately-severe, high-frequency sensorineural hearing loss was documented in the left ear, beginning at 4000 Hz. Asymmetry of 10-35 dB HL between ears was found at all test frequencies with the most pronounced difference, of 35 dB HL, occurring at 6000 Hz. Significant asymmetries, of greater than 10 dB HL, were observed from 4000 to 8000 Hz.

Speech recognition thresholds were normal and in good agreement with pure tone averages bilaterally. However, a pronounced difference, of 15 dB HL, in SRT was noticed between ears, with the right SRT at 10 dB HL and the left SRT at 25 dB HL. Word recognition scores were excellent bilaterally with no outstanding ear differences.

The client had normal hearing sensitivity in her right ear, and a mild to moderately-severe high-frequency sensorineural hearing loss in her left ear. Significant asymmetries, of greater than 10 dB HL, were observed from 4000 to 8000 Hz. Case history information, including multiple bouts of shingles and an immunocompromised system, is highly suggestive of viral etiology. A viral insult on the vestibular branch of the VIII nerve also is suspected due to complaints of true vertigo. Reports of left-sided facial numbness and absent acoustic reflex thresholds on the probe side, ipsilateral to the shingles-effected side, were consistent with potential VII nerve involvement.

Results were discussed with the client, and a release of medical information was signed. Following client contact with her primary care physician, findings from the hearing evaluation performed at our clinic will be faxed to the appropriate medical facilities. The client was strongly encouraged to request an ENT consultation during or following a previously-scheduled MRI, which was intended to evaluate the nodes on her shoulder. Following neurootologic evaluation by a physician, the client was asked to return to our clinic every six months for follow-up hearing evaluations. In addition, a formal vestibular evaluation may also be warranted. Lastly, the client was advised to consult an ENT specialist immediately if sudden changes in her sensory perception occurred.

Because I am not a medical doctor, I couldn't make a specific conjecture about the origin of the patient's symptoms in my report in or in my discussions with her. However, in my blog, I will!

I think that this patient has Ramsay Hunt Syndrome (RHS). Varicella-zoster virus (VZV) reactivation causes zoster lesions in the auricle or oropharyngeal epithelium, as well as facial paralysis (FP) in patients with Ramsay Hunt syndrome(RHS). RHS is frequently complicated by disorders of the auditory nerve, such as hearing loss, tinnitus, and vertigo.

This article, Varicella-Zoster Virus Load and Cochleovestibular Symptoms in
Ramsay Hunt Syndrome by Fumio Ohtani, MD; Yasushi Furuta, MD; Hiroshi Aizawa, MD; Satoshi Fukuda, MD, compared two sets of patients with RHS.

Twenty-nine patients exhibited acute facial paralysis (FP) along with cochleovestibular symptoms (CVSs) and were categorized as group 1. Twenty-four of these patients also had zoster lesions on the skin or the oropharyngeal epithelium, and the remaining 5 patients did not have zoster lesions. In group 2, comprised of 27patients, cochleovestibular symptoms were absent. Those 27 patients also had acute FP and zoster lesions on the skin or oropharyngeal epithelium.

The study aimed to examine the association between varicella-zoster virus (VZV)reactivation and the onset of CVCs. They performed this analysis by analyzing saliva and blood samples. Results were somewhat inconclusive, but they did make some conjectures based on their findings.

They suspected that CVSs in RHS might be caused not only by the spread of inflammation to the cochleovestibular system through VZV reactivation in the geniculate ganglion, but also by reactivation of VZV in the spiral and/or vestibular ganglia themselves.

Importantly, prompt monitoring and treatment of clients with RHS is essential to appropriate care, as are necessary referrals.

http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=20255771&site=ehost-live

http://web.ebscohost.com.www.libproxy.wvu.edu/ehost/pdf?vid=39&hid=116&sid=5b7088be-e3c7-45f7-9df3-20ac14811b59%40sessionmgr108

Week 2, Spring 2008

This week, I saw a 20 year old college student who indicated that he has had difficulty processing auditory information in the classroom since enrolling in college. He reported a history of reading problems as a child. A neck surgery, due to an infection in the muscle, was noted, but no other outstanding medical history was provided.

Ear canals were clear, and tympanic membranes were visible and intact bilaterally. Tympanometry revealed normal, Type A, results bilaterally; however, the left TPP was slightly negative. Acoustic reflexes were normal for both ipsilateral and contralateral stimulations bilaterally.

Pure tone audiometry revealed normal thresholds at all test frequencies. Speech recognition thresholds were 15 dB HL bilaterally and were in good agreement with pure tone averages. When performed at 30 dB SL, word recognition scores were excellent, at 100%, bilaterally.

For the APD evaluation, the SCAN-A, the Auditory Fusion Test-Revised (AFT-R), and Staggered Spondaic Word Test (SSW) were administered. The SCAN-A is a screening measure that taps into many different types of processing. The AFT-R is a temporal processing test, and the SSW is a dichotic listening test that requires binaural integration. The client was normal on all test measures and did not exhibit any patterns on the chosen tests that suggested an APD. However, the client still reported difficulty understanding orally-presented information, particularly when background noise was present. These complaints occurred with normal hearing and no obvious APD.

Strange you say?!???!

That's what I thought too ... I found an article that represented a syndrome that causes problems that are similar to my client's complaints. The following article, Distortion Product Otoacoustic Emissions in Patients with King-Kopetzky Syndrome, by Fei Zhao and Dafydd Stephens details a comparison of a control group and a group with suspected King-Kopetzky syndrome.

http://web.ebscohost.com/ehost/pdf?vid=7&hid=107&sid=57c0ad2a-5431-4a2d-bd6d-82ab981bccc1%40sessionmgr102

http://web.ebscohost.com.www.libproxy.wvu.edu/ehost/pdf?vid=4&hid=106&sid=55fb21cd-5a39-4c5b-b0a2-4842d09d2093%40sessionmgr108

King-Kopetzky syndrome (KKS) is thought to be a multifactorial disorder with possible autosomal dominant inheritance. The chief complaint of those with KKS is hearing difficulties, particularly in noise, in the presence of normal pure tone thresholds. Although those with KKS have "normal" hearing, the test group in this study have thresholds averaged over 0.5 - 4 kHz that are significantly worse than age/sex-matched normals. Psychological factors, such as anxiety and depression, psychoacoustical factors, such as peripheral or central HL, and hereditary factors, such as family history and late-onset, dominant genetic inheritance may all contribute to KKS. The authors noted that KKS is present in 1% of ENT clinic patients complaining of problems with their ears or hearing and in 5-10% of those reporting hearing problems at audiology clinics.

This study used 35 males and 35 females ages 16-50 with one person per gender for each calendar year. All subjects had normal hearing, defined as thresholds better than or equal to 20 dB HL between 250 and 4000 Hz in the poorer ear. No threshold between 250 & 8000 Hz could be poorer than 30 dB HL. No other obvious signs of difficulty or signs of conductive pathology could be present. The control group had no recent hearing problems, and the KKS group had recently sought help for hearing difficulties, particularly understanding speech in noise.

TEOAE, DPOAE, and SOAE testing was performed. For TEOAEs, BB nonlinear clicks of 77 dB SPL (+/- 3 dB) were used. Clicks were presented for 80 usec at a rate of 50 clicks/sec. Responses were found when 260 sweeps were averaged with 50% or better reproducibility. A 0.5-6 kHz pass-band was used, and responses greater than or equal to 3 dB above the noise floor were considered "passes." When a statistical significance level of 0.05 was used, a significant difference was found when the normal responses of the control group (96%) and the KKS group (77%) were compared.

For DPOAEs, an f2/f1 ratio of 1.22 was used, and L1 = L2 = 70 dB SPL. Higher intensity levels were used because TOAEs were absent for many of the subjects in the KKS group. The response at 2f1 - f2 was analyzed. The global mean levels of the DPOAEs were significantly lower in the KKS group, and mid-frequencies (1.398-5.582 kHz) were most negatively affected.

Lastly, SOAE testing was performed, and fewer SOAEs were found in the KKS group.

This study indicated that a decrease in DPOAEs in the KKS groups from ~1-6 kHz (with the exception of 4 kHz) may indicate an area of minor dysfunction of the OHCs. Consideration of DPOAEs, case history, and probable subcategories of KKS may guide rehabilitation. (The subcategories are as follows: 1)ME dysfunction, 2)mild cochlear pathology, 3)central/medial olivocochlear efferent system auditory dysfunction, 4)purely psychological problems, 5)muliple auditory pathologies, 6)combined auditory dysfunction & psychological problems, 7)unknown.) Finally, additional testing, medical, &/or psychiatri referrals may be needed if patients seemingly have normal peripheral and central hearing, but persistently claim to have difficulty with speech in noise.

Although I did not do DPOAE testing with my client, that may be warranted in the future. However, when I saw him, I recommended compensatory classroom strategies, such as moving to the front of the room and asking for handouts of orally-presented material, to address his difficulties. I also recommeneded that he should seek additional disability services in our University's Disability Services Office.