HEARING LOSSAND

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

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 LOSSAcoustics

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 LOSSAcoustics

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)

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

TINNITUSDIFFERENTIAL DIAGNOSIS

Two types:

1. Objective tinnitus -others hear it too

2. Subjective tinnitus -patient only hears it

OBJECTIVE TINNITUS

l. Patulous eustachian tube:

2.Muscular:

1. Stapedius spasm: myoclonus of the stapedius causes contractions of the TM seen with impedance bridge or otoscope

2. Palatal myoclonus: myoclonus of the palate

3. TMJ: 28% of those with TMJ syndrome have tinnitus

TINNITUSOBJECTIVE

3.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 arteryVenous hum:

HBP; Hyper/hypothyroidism; high jugular bulb

TINNITUSTESTS

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

TINNITUSTREATMENT

Tinnitus may be eliminated if a specific cause is found:

l. Tumors: glomus, AN,

2. Infections, wax

3. Meniere’s disease:

4. TMJ disorder

5. Otosclerosis

6. Vascular malformations

7. Medications

TINNITUSTREATMENT

Medications:

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

2.Drugs:

ASA

NSAIDS

Aminoglycosides

Antidepressants

Heavy metal

3. Metabolic

Vitamin A/B deficiency

Hyperlipidemia

SUBJECTIVE TINNITUS

4. Neurologic:Head trauma

MS

Meningitis

Acoustic neuroma

Temporal lobe tumour

5. PsychologicAnxiety

Depression

TINNITUS & HEARING LOSSCOMMON 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?

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

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 LOSSHEARING 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

TINNITUS & HEARING LOSSHow 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

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

TINNITUSTREATMENT

Miscellaneus approaches:

l. Hearing aids:

2. Maskers

3. Psychological help:

4. Self help

5. TRT (Tinnitus Retraining Therapy):

TINNITUSTREATMENT

Non-drug treatments: dubious

l. Acupuncture:

2. Electrical stimulation:

3. Electromagnetic stimulation

4. Magnetic stimulation:

5. Ultrasound

6. Surgery