Who will I see about my Ear and Hearing?

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 (ENTphysician) 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 theirENT 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

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

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.

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.

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:

http://vestibular.org/understanding-vestibular-disorder/treatment.

What is Tinnitus?

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

A Discussion of Eustachian Tube

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

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

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.

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

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

A discussion of acoustic neuromas

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.

Preparation for Balance Testing

PREPARATION FOR BALANCE TESTING

Your physician has recommended that testing be performed on your balance system. Please read and follow the guidelines in preparation for your testing.

Your appointment is scheduled on _____________________________ at _________________.

Women are asked to wear pants or shorts for testing. Gentlemen are asked to wear loose fitting clothes for comfort during testing.

Please refrain from wearing any skin lotions, moisturizing creams, makeup, mascara etc., on your face the day of the testing.

Certain substances influence the body’s response to the tests, therefore, for the 48 HOURS PRIOR TO TESTING REFRAIN FROM THE FOLLOWING:MEDICATIONS FOR THE CONTROL OF NAUSEA OR DIZZINESS, ALCOHOL,TRANQUILIZERS, SLEEPING PILLS, COLD REMEDIES, ASPIRIN, TYLENOL,ETC. PLEASE REFER TO THE ATTACHED SHEET FOR SPECIFICMEDICATIONS. If you are taking a medication that is not on this list and have any question, please call our office.

BALANCE TEST PROCEDURES INCLUDE SOME OR ALL OF THEFOLLOWING:

A) Visual observation of various stationary or moving lights or stripes.

B) Placement of the patient in various head and body positions to determine if such maneuvers create dizziness.

C) Stimulating the balance system of the inner ears by with cool and warm air.

A variety of eye, head, and body movements are recorded during these procedures. The devices used to measure these movements (surface skin electrodes, etc.) are neither dangerous nor painful.

MOST COMMONLY ASKED QUESTIONS REGARDING BALANCE TESTING

1. What does this testing look at?

Balance testing evaluates parts of the body that help maintain balance, including the brain, central nervous system, visual input, proprioception and the inner ear function.

2. Will the test hurt? Will it make me dizzy?

Your balance testing will not be painful. Since we are evaluating the balance system, portions of the testing may cause you to experience dizziness. Dizziness produced during balance testing is usually not severe and does not usually last an extended period of time.

3. Will I be able to drive after I am finished with my testing?

Patients usually have no difficulty driving after testing. If you are extremely dizzy, or question your ability to drive, please have someone come with you who will be able to drive in the event you are unable.

4. Why must I stay off certain medications prior to my testing?

Certain medications may affect the results of the testing and should therefore be avoided for at least 48 hours prior to your testing. All forms of alcohol should be avoided for the same period of time. Under certain conditions, the doctor may allow certain medicines up to 24 hours prior to testing, but this may compromise the results.

5. Why am I having several different tests run on my balance system?

Each test performed provides a piece to a puzzle. There are several different portions to the balance system. Some portions test the inner ear/eye reflexes and others test the inner ear/spinal reflexes. Usually, several tests are necessary to correctly diagnose a problem.

6. How long will the testing take?

The length of your testing will depend on which examination the doctor is requesting you have run. Testing can take anywhere from 30 minutes to 1? hours total.

7. What are the results of my balance testing?

Your test results will diagnosis the cause of your dizziness and/or balance problems.

8. May family members be present during my testing?

Family members are not allowed in testing rooms while patients are being tested. The only exception to this will be one parent present while a child is being tested. Your cooperation is appreciated.

If you have any questions regarding your testing, please contact our office. We will be happy to help you.

The following is a guideline for taking medications prior to vestibular (balance) testing. It is necessary to avoid certain medications 48 hours prior to testing to produce accurate test results.

DON’T TAKE

Sleeping pills

Aspirin, Tylenol

Antihistamines

Cough medicine

Alcoholic beverages

Pain medication

Muscle relaxers

DO TAKE

Heart medicine

Diabetes medicine

Thyroid medicine

Blood pressure medicine

Seizure medicine

Birth control pills

Any antibiotic

Vitamins

Diuretics

COMMON MEDICATIONS TO AVOID

Antivert Hismanal

Bonine Meclizine

Dalmane Midrin

Diazepam Pamelor

Dramamine Phenergan

Elavil Prozac

Entex Seldane

Entex LA Transderm Scop (patch)

Feldene Valium

Entex LA Transderm Scop (patch)

Fiorinal Xanax

Entex LA Vontrol

Halcion

*You are allowed to eat prior to the test, but we suggest you eat light.