HEARING LOSS AND TINNITUS Charles Stewart

HEARING LOSS Hearing loss to many is an insignificant disability Why is this? It is invisible usually painless It is a hurt that does not show To the profoundly deaf, they live in a world of silence, the emotional pain is devastating You enter a room where a conversation is going on. On one side is a deaf person. On the other a blind person. Introduction: The blind is looking back and forth as the conversation goes on, he acts normal. The deaf person acts dumb. Hense the phrase deaf and dumb Just think if you were a father, your kids ingnor you, to much trouble to communicate

HEARING LOSS Hearing loss is important! 1 in 10 in the U.S. have some H.L. 1 in 100 has extreme difficulty with understanding speech The cost to society is in the billions per year

WE NEED TO BE MORE AWARE, MORE SYMPOTHETIC, MORE HELPFUL TO THOSE WITH HEARING LOSS

HEARING LOSS Types of hearing loss: Conductive hearing loss Sensorineural hearing loss Sensory (cochlea) Neural (8th nerve) Mixed hearing loss Functional hearing loss: non-organic

HEARING LOSS Acoustics Intensity of sound: loudness, measured in dB Frequency of sound: Pitch, measured in Hz or cps Pure tone: single frequency sound, as audiogram, rare in nature Complex sound: more than one frequency; noise is a complex sound

HEARING LOSS Acoustics Decibel scale (db): logarithmic scale, to measure intensity of sound; dB=log of a ratio of two sounds: reference sound & sound being described Stimulus levels are stated with reference levels: SPL: sound pressure level; .0002 dynes/cm2 HL: Hearing level; 0 dB HL on audiometer SL: Sensation level Hearing range: 10-20,000 cps; Intensity range 0-120

HEARING IMPAIRED: anyone with hearing loss DEAF: anyone with profound SNHL Categorizing hearing loss: normal: 0-25 dB mild H.L.: 26-45 dB Mod.H.L.: 46-70 dB Severe H.L.: 71-90 dB Profound H.L.: >90 dB

PURE TONE AUDIOMETRY Air conduction: actual hearing level: outer, middle, inner ear Bone conduction: Potential hearing level, inner ear function Conductive hearing loss: Difference between air & bone conduction threshold, the ABG

AUDIOGRAM Screening audiogram should include: l. Pure-tone evaluation: bone/ air threshold 2. Speech receptive threshold: (SRT) 3. Speech discrimination score (SDS)

THE MAJOR CAUSE OF SENSORINEURAL HEARING LOSS IS NOISE EXPOSURE The cause of the hearing loss is : l. Acoustic trauma: single high intensity sound, causing a conductive &/or SNHL 2. Noise induced hearing loss: gradual loss from prolonged or repetitious noise exposure

EFFECTS OF NOISE EXPOSURE Hair cell swelling (temporary threshold shift) Hair cell destruction (permanent threshold shift)

CONTROL OF NOISE EXPOSURE Environmental control: reduce noise Personal protection: ear protection (ear plugs) job rotation job reassignment test hearing periodically (annually) ANY HEARONG LOSS > 10 IN ONE YEAR REQUIES YEARLY TESTING AND JOB ROTATION ETC

TYPES OF HEARING LOSS THAT RAISE AN INDEX OF SUSPICION Sudden hearing loss in healthy individuals Gradual hearing loss Fluctuating hearing loss Pronounced buzzing or roaring tinnitus

What suggestive clues or symptoms does a person undergoing noise induced hearing loss have? Difficulty communicating at work Head noise at work Temporary loss of hearing

WHAT IS NEW FOR THE TREATMENT OF HEARING LOSS? BAHA COCHLEAR IMPLANTS

BAHA

COCHLEAR IMPLANTS

COCHLEAR IMPLANTS

COCHLEAR IMPLANTS

TINNITUS Definition: perception of noise in the absence of acoustic stimulus phantom auditory perception Incidence: 40 million Americans have it 75% are not bothered by it 25% it interferes with their daily life

TINNITUS DIFFERENTIAL DIAGNOSIS Two types: 1. Objective tinnitus -others hear it too 2. Subjective tinnitus -patient only hears it If someone hears voices that no one else does, that is AUDITORY HALLUCINATIONS

OBJECTIVE TINNITUS Patulous eustachian tube: Muscular: Stapedius spasm: myoclonus of the stapedius causes contractions of the TM seen with impedance bridge or otoscope Palatal myoclonus: myoclonus of the palate TMJ: 28% of those with TMJ syndrome have tinnitus

TINNITUS OBJECTIVE Vascular AV shunts: Glomus tympanicum/jugulare tumour Pulsating tinnitus, hearing loss Bluish mass behind ear drum Arteriovenous malformation: Dxn. with MRI, MRA, Angiogram; Tmt. Embolization Arterial bruits: Aberrant carotid artery Persistent stapedial artery Papilloedema has increased intracranial pressure, will have tinnitus Venous hum: HBP; Hyper/hypothyroidism; high jugular bulb

TINNITUS TESTS Audiogram, tympanogram: ENG & posturography not usually necessary Lumbar puncture: after CT, those with papillodema BAER, ECOG: MRI, MRA, CT Blood tests: ANA,B12,FTA,ESR,SMA-24 Glucose,TSH,antimicrosomal antibodies

TINNITUS TREATMENT Tinnitus may be eliminated if a specific cause is found: l. Tumors: glomus, AN, 2. Infections, wax Meniere’s disease: TMJ disorder Otosclerosis Vascular malformations Medications

TINNITUS TREATMENT Medications: ASA & other salicylates NSAIDS (motrin, naproxen, relafen, etc) ASA & other salicylates Lasix & other “loop” diuretics “mycin” antibiotics such as vancomycin( rarely macrolides as azithromycin) Quinine Chemotherapy drugs as cis-platin Rarely, SSRI antidepressants as Paxil

SUBJECTIVE TINNITUS l. Otologic: Noise induced hearing loss Presbycusis Otitis media with effusion Otosclerosis Meniere’s disease Cerumen Foreign body against tympanic membrane

SUBJECTIVE TINNITUS Drugs: 3. Metabolic ASA NSAIDS Aminoglycosides Antidepressants Heavy metal 3. Metabolic Vitamin A/B deficiency Hyperlipidemia

SUBJECTIVE TINNITUS 4. Neurologic: 5. Psychologic Head trauma MS Meningitis Acoustic neuroma Temporal lobe tumour 5. Psychologic Anxiety Depression

TINNITUS & HEARING LOSS COMMON QUESTIONS 90% of those with tinnitus have some hearing loss. Noise exposure is the most common cause of hearing loss & of tinnitus Is ringing in my ear normal? Is it possible for others to hear my tinnitus? Can I “Toughen Up” My Ears? How can I tell if Noise is Dangerous? How is sound measured, and how does Frequency of sound and Intensity of sound affect hearing loss? What is a Decibel? 36-40 million americans have it, 17% of population, 25% are bothered by it , it affects their sleep work, play 7 million are so affected they can’t live normal lives Objective tinnitus caused by blood vessels or tumor in or around te ear, or muscle spasms in the ME or palate or TMJ Can’t toughen the ears, once the inner ear is damaged SNHL it’s gone forever. Some have steal ear, some fragile ex. Jack hammer No way to restore life to dead nerve endings, damage is permanent. Noise is dangerous if l. Ears ring or hurt after noise exposure 2. you have to shout over background noise to be heard 3. you have difficulty hearing for hours after noise exposure Sound is measured by 2 ways: Intensity, or loudness of sound, measured in decibels, and Pitch is measured in frequency of sound vibrations per second. Low pitch has few vibration, high more fibrations. Frequency is measured in cycles per secon or Hertz. Higher the pitch, the higher the frequency. Young kids hear sounds from 20 Hz, lowest note on a large pipe organ to 20000 Hz , high shrill of a dog whistle, many can’t hear. Human speech is 250-4000 Hz. When hearing impairment starts, high frequency goes lst, so people have difficulty hearing women and children lst.. Then the discrimination starts to go, words sound alike, that contain S,F, SH, CH, H or soft C sounds, because these consonants are in a higher frequency, than vowels and other consonants A decibels is used to describe the intensity of sound. The faintest sound the human ear can hear is labeled as 0 dB to over 180 dB noise from a rocket pad. dB are measured logarithmaically. A decibel intensity increases by units of 10, each increase is 10 times the lower figure. 20 dBs is 10 times louder than 10 dBs, and 30dB is 100 times as intense as 10 dB

NOISE EXPOSURE & HEARING LOSS How does noise cause hearing loss? Is it permanent? What is loud? 0 dB faintest sound heard by human ear 30 Whisper, quiet library 40 Refrigerator hum 50 Rainfall 60 Normal conversation, typewriter, sewing machine, truck traffic 70 Washing machine 85 average traffic 95 MRI 100 Blow dryer, subway train,chainsaw, snowmobile 115 Sandblasting, rock concert, auto horn, screaming child 130 Jack hammer, jet engine plane 140 Shotgun blast, airbag deployment, firecracker, pain is experienced in unprotected ears Noise induced hearing loss can be caused by l. One-time exposure to noise causiing a permanent SNHL,even one blast can cause total hearing loss or 2. repeated exposure to sounds over an extended period of time. You cannot toughen your ears up contrary to popular opinion. With loud noises one can see usually a temporary threshold shift, occasionally a permanent shift, which usually is after repeated exposure Some have steel ears, some fragile. Ex run a jack hammer all day long no loss, another for 5 min. total loss Loud noise can cause vasoconstriction in the stria vascularis, hypoxia, swelling of the hairs, eventually death

TINNITUS & HEARING LOSS Why has hearing loss increased significantly in young people? Loud rock music along with the use of earphones with portable radios Can noise affect more than my hearing? Tinnitus commonly occurs after noise exposure, and may be permanent Who should wear hearing protectors? What are the laws for on the job?

TINNITUS & HEARING LOSS OSHA (Occupational Safety & Health Administration) Guidelines What is permissible Noise Level Exposure? Hours per day Sound level 8 90 dB 4 95 dB 2 100 dB 1 105 dB .5 110 dB 85 dB or higher more than 8 hrs. requires hearing conservation programs to protect workers.

TINNITUS & HEARING LOSS What does OSHA recommend for Hearing Conservation? l. Hearing protection devices: 2. Education: Sound less than 80 dB is unlikely to cause hearing loss. Over 85 dB a One time exposure or continuous noise may cause temporary threshold shift, usually disappears in 16- 48 hrs. after exposure. 3. Noise exposure for unprotected ear is 115 dB for 15 min/day (rock concert 115-120 dB) 4. Noise above 140 dB is not permitted unprotected

TINNITUS & HEARING LOSS HEARING CONSERVATION TIPS Be conscious of environmental noise: 3 foot rule Wear earplugs at the movies, ask the manager to turn the volume down Wear earplugs at amusement parks, concerts Wear earplugs or earmuffs using power lawn mower, vacuum, power tools Read labels on appliances, toys that generate sounds If can’t hear a person 3 feet from him noise is probably damaging to you

TINNITUS & HEARING LOSS How effective are hearing protectors? Earplugs & earmuffs: are about equally effective, reduce noise 15-30 dB. Earplugs are better for low frequency sounds, earmuffs for high frequency sounds Combined use of earplugs & earmuffs: adds 10-15 dB more protection, should be used if noise is above 105 dB Can I get protection stuffing my ears with cotton? Cotton reduces noise by 7dB Common problems of Hearing Protectors: ½ of workers, get ½ the needed protection because they are not worn continuously & are poorly fit. 7 hrs. of protection is only 9 dB of protection How do I know I’m getting protection? Your own voice is louder & deeper Hearing protectors decrease the intensity of the sound that reaches the inner ear During the l hour with unprotected ears, the worker is exposed to 1000 times more sound energy because of 10 fold increse in noise energy for each 10 dB increase. 10db increase 10x, 20 db increase 100 x, 30 db increase 1000x

TINNITUS & HEARING LOSS Can I understand other people & hear machinery well enough with hearing protectors? They enhance speech discrimination in very noisy places. Those with SNHL may have reduced ability to understand normal conversation. Workers adjust to the lower level of noise of machinery & still can detect problems. How can I tell if my hearing is already damaged? People seem to mumble, difficulty understanding, need people to repeat frequently, & tinnitus is present Hearing loss is painless, invisible & comes on slowly Only sure way to tell is by a hearing test

TINNITUS TREATMENT As of 4/2002 the National Library of Medicine’s search engine revealed 3900 research articles on tinnitus since 1966 What do you do if you have tinnitus & no specific cause? l. Avoid noise exposure 2. Avoid stimulants, coffee, tea, coke, nicotine 3. Decrease salt intake (hydrops) 4. Avoid fatique, get adequate rest, daily exercise 5. Avoid ototoxic drugs, as ASA, non-steroidals, quinine preparations 6. Balanced diet, normal amts. Of fruits & vegetables

TINNITUS TREATMENT Miscellaneus approaches: l. Hearing aids: 2. Maskers 3. Psychological help: 4. Self help 5. TRT (Tinnitus Retraining Therapy):

TINNITUS TREATMENT Non-drug treatments: dubious l. Acupuncture: 2. Electrical stimulation: 3. Electromagnetic stimulation 4. Magnetic stimulation: 5. Ultrasound 6. Surgery