1. HEARING LOSS AND TINNITUS Charles Stewart

2. 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

3. 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

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

5. 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

6. 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

7. 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; dynes/cm2
HL: Hearing level; 0 dB HL on audiometer
SL: Sensation level
Hearing range: ,000 cps; Intensity range 0-120

8. HEARING IMPAIRED: anyone with hearing loss
DEAF: anyone with profound SNHL
Categorizing hearing loss:
normal: dB
mild H.L.: dB
Mod.H.L.: dB
Severe H.L.: dB
Profound H.L.: >90 dB

9. 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

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

11. 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

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

13. 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

14. 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

15. 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

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

17. BAHA

18. COCHLEAR IMPLANTS

19. COCHLEAR IMPLANTS

20. COCHLEAR IMPLANTS

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

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

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

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

31. 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 Hz , high shrill of a dog whistle, many can’t hear. Human speech is 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

32. 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

33. 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?

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

35. 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 hrs. after exposure.
3. Noise exposure for unprotected ear is 115 dB for 15 min/day (rock concert dB)
4. Noise above 140 dB is not permitted unprotected

36. 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

37. TINNITUS & HEARING LOSS
How effective are hearing protectors?
Earplugs & earmuffs: are about equally effective, reduce noise dB. Earplugs are better for low frequency sounds, earmuffs for high frequency sounds
Combined use of earplugs & earmuffs: adds 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

38. 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

39. 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

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

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