How do I make a referral for a hearing test?
- Medicare may pay for hearing tests for new patients or patients that are experiencing changes in their hearing.
- In order to make a referral, please write on a prescription pad “Hearing Evaluation”, and fax it to the number 765-448-9416.
Hearing Loss Information
Ototoxicity and the Risk of Chemical Exposure Related to Hearing Loss
While noise is the single greatest cause of occupational hearing loss, other components that can affect healthy hearing often fly under the radar of unsuspecting employees and, in some cases, business owners who aren’t fully aware of the dangers that some toxins represent to workers. Chemicals, metals, solvents, asphyxiants, and heat may play a larger role in hearing loss than some industries care to admit, and often these dangers are exacerbated by the presence of consistently loud noise. Chemicals and other drugs that are known to cause hearing loss are referred to as ototoxic.
Chemical-induced hearing loss (CIHL) is not commonly identified as a cause of significant hearing threshold shift, and in many cases, individuals who experience this type of hearing loss do not know or remember the name of the chemical that they’ve been exposed to — and with more than 750 different groups of chemicals labeled as potentially toxic to hearing, odds are slim that healthcare providers would be able to identify the ototoxic product. Few chemicals have been studied indepth, but characteristics of hearing loss via ototoxic exposure are common among relative diagnoses: irreversible hearing loss affecting specific frequencies (3,000 to 6,000 Hz) and some damage to the cochlea occurring bilaterally.
Both animal experiments and human studies suggest that exposure to specific chemicals causes damage to the hearing and balance functions of the ear. Ototoxins can cause mild to severe hearing loss, tinnitus, or total deafness once absorbed by the body. They can be ingested, inhaled, or absorbed through the skin and can damage the auditory nerve or hair cells in the cochlea (similar to how noise-induced hearing loss damages hair cells); can create lesions in auditory pathways; and can lead to sensorineural hearing loss. Organic solvents are the most commonly identified ototoxic chemicals, but the hearing frequencies affected by exposure to these chemicals are different from those that are affected by noise.
However, some solvents may interact with noise, and when not at permissible exposure levels, that impact can have greater effects than exposure to either chemicals or noise alone. Noise elevates blood flow in the inner ear, which appears in some cases to act as a vehicle for introduction of chemicals into all structures of the ear. And the list of chemical agents in the form of gases, paints, metals, and pesticides is impressive. High-priority ototoxins present immediate danger in certain elemental forms; toluene, xylene, styrene, n-hexane, trichloroethylene, carbon monoxide, and alcohols are all considered high priority, and workers should avoid exposure to any and all relative products.
Other chemicals associated with hearing loss are benzene, carbon disulfide, ethylbenzene, hydrogen cyanide, lead, and mercury; some of these are found in organic solvents that are widely used for a variety of projects. Many of the following are used in projects that present simultaneous noise and chemical hazards:
- Automotive and aviation fuels
- Paint thinners
- Fabric and paper coatings
- Printing inks
- Spray surface coatings
- Insect repellents
Boat building, various construction projects, firefighting, fueling vehicles/aircraft, furniture making, manufacturing of metals/leathers/petroleum products, painting, printing, and firing weapons can all present dangerous situations in which chemicals are absorbed by the body while the ears are exposed to dangerous levels of noise. The initial effects of ototoxicity are tinnitus and balance problems that become more prevalent — particularly if no balance issues existed before — as well as general dizziness. Some of the ototoxic effects of chemicals can be difficult to determine in workers, as exposure sometimes occurs without noticing the exact solvent being used. Exposure can also involve a mixture of compositions and concentrations, which makes isolating exact chemicals more difficult.
Pregnant women are also at great risk of exposing their child to harmful chemicals. During pregnancy, drugs such as Accutane, Dilantin, alcohol, and those used in chemotherapy can affect the fetus ototoxically. After birth, a child exposed to aminoglycoside antibiotics, diuretics, cisplatin, and others can experience the effects of ototoxicity.
Current occupational exposure limits and hearing conservation programs may not be adequate for chemical-exposed workers, as there are currently no workplace regulations regarding interaction between noise and ototoxins. Protecting workers from both CIHL and NIHL — and combinations of the two — should be a priority of labor unions and management, but employees can also take steps to ensure their safety by conducting a hearing loss and chemical exposure hazard assessment. Safety and hearing health should be a priority, and that can be achieved through:
- Removing hazardous substances or noises from the workplace
- Use of less hazardous chemicals to perform duties
- Initiating steps to minimize exposure through inhalation, ingestion, skin absorption, and sound
- Adding ventilation, as well as skin, respiratory, and hearing protection
- Creating a hearing conservation program that considers and monitors the combined effects of exposure to solvents and noise
It is everyone’s duty to ensure the safety and hearing health of the local community. Some treatment methods can be limited in scope and effectiveness once too much damage has been done. Preservation and prevention is the best way to ensure healthy hearing.
Understanding Genetic and Progressive Hearing Loss
In adults and children, loss of hearing can sometimes progressively worsen at a much faster rate than noise-induced or age-related hearing impairment. These symptoms usually indicate a specific type of hearing loss, referred to as progressive hearing loss, which can stem from a variety of both detectable and unknown diseases. In about 50 percent of all children and adolescents suffering from a hearing loss, the cause has been present since birth.
About one in 500 infants are born with or develop a hearing loss throughout early childhood. When children are born with a hearing impairment, this is considered “congenital,” while the development of an impairment after birth is referred to as “acquired.” There are many potential causes; for example, German measles, syphilis, and diabetes present a high risk to unborn children. But the most prominent causes are:
- A genetic disease passed down from parents
- An infection that affected the fetus during gestation or shortly after birth
- Exposure to an ototoxin as a fetus or infant
For some children, a cause may never be identified. A child can have normal hearing as an infant and may proceed to lose their hearing after one or two years of life; this type of “delayed onset” hearing loss usually happens when a child is born with a virus that no one is aware of until later. A child may also develop hearing loss from an ototoxic medicine used when the child is sick, and it may continue to worsen even after the child stops taking the identified medication.
Risk factors for a genetic or progressive hearing disorder include:
- A family history of hearing loss
- Premature birth, which is sometimes responsible for underdeveloped lungs that necessitate the use of a ventilator; excessive ventilator use is associated with lung infections that can spread to the ear canal
- Physical malformations of the head or ears
- Infections during pregnancy or birth
A newborn with known risk factors for progressive hearing loss should have their hearing tested prior to age 3, in case a previously undetectable hearing loss may have emerged since birth. Children born with the cytomegalovirus (CMV), for example, face a significantly higher risk of developing progressive hearing loss. Urine samples testing for CMV can serve as a warning sign to parents and caregivers. If the child doesn’t seem to respond to the noises they used to, or if their speech patterns change, they may be experiencing a progressive hearing loss.
Over the course of several months, a bilateral progressive hearing loss can occur and can be diagnosed as autoimmune inner-ear disease, which happens when the body’s immune system misdirects its defenses against the inner-ear structures to cause damage to this part of the body. This disease is typically managed with long-term corticosteroids and other drug therapy. Other illness, like meningitis, makes a present hearing loss more likely to get worse over time.
There are two developmental conditions, genetic in nature, that may cause a wide range of hearing impairment:
- Waardenburg syndrome is associated with hearing loss that ranges anywhere from mild to total deafness, and is characterized by a wide spacing between the eyes, a broad nose and bridge, and connecting eyebrows. This hearing loss is present from birth.
- Crouzon syndrome causes the plates of the skull to fuse together, preventing the brain from growing. Facial deformities, particularly of the inner ear, are common and may result in no ear canal whatsoever.
On occasion, progressive hearing loss is correctable through surgery. Cholesteatoma and otosclerosis are two causes of progressive hearing loss in which patients can see a total or near-total recovery of their hearing.
- Cholesteatoma is a disease of the ear in which a noncancerous skin cyst grows into the middle ear and the mastoid, eroding tissue and causing destruction of the ear. This could be caused by improper function of the Eustachian tube. Cholesteatomas can take years to form and are common in individuals with a history of middle-ear fluid and infections.
- Otosclerosis is a disorder of the stapes, a tiny bone in the middle ear that helps conduct sound to the inner ear. This is a genetic development problem, with about 50 percent of all patients showing a family history of otosclerosis. During surgery, the stapes is removed and replaced by a prosthesis to restore function.
For most other forms of progressive hearing loss, hearing aids are a viable option. If the patient’s loss reaches a level where use of hearing aids no longer helps, a cochlear implant or a direct bone-conduction system are two advanced hearing solutions that should be considered to help patients hear their best.
Hearing loss is associated with twice as many visits to the emergency room, a tenfold increase in the risk of being held back at least one grade in school, and reduced earning potential as an adult. Many forms of progressive hearing loss cannot be reversed, but they can be treated through use of medication, surgery, and advanced better-hearing technology. By creating solutions, healthcare providers and hearing specialists can partner to create a healthier local community for hearing loss sufferers of all ages.
– Centers for Disease Control and Prevention. A Parent’s Guide to Genetics & Hearing Loss. U.S. Department of Health and Human Services.
– Holt, J. Cholesteatoma and Otosclerosis: Two Slowly Progressive Causes of Hearing Loss Treatable Through Corrective Surgery. Clinical Medicine and Research. April 2003.
Sound of Silence: The Causes and Cures of Sudden Hearing Loss
Though sometimes no cause for alarm, ear infections do have the potential to cause a temporary or reversible hearing loss. This usually occurs because these infections block sound from passing through some part of the ear — better known as conductive hearing loss — making sounds that are normally easy to hear temporarily muffled or quiet. Occasionally, more serious conditions can cause a sudden sensorineural hearing loss (SSHL), or sudden deafness. Although tests can usually properly diagnose the difference, it is particularly important for the individual to act quickly to prevent permanent damage from this medical emergency.
Ear infections vary in intensity and scope, and they can occur in any of the three parts of the ear: outer ear, middle ear, or inner ear.
- Outer-ear infections: The ear canal becomes inflamed or infected due to bacteria. Blockage may occur, preventing sound from moving through the ear canal, but hearing usually returns after the infection is gone.
- Middle-ear infections: Swelling or pus forms in the middle ear, blocking sound from moving to the inner ear. Hearing usually returns after the infection goes away, but untreated middle-ear infections can cause damage that results in permanent hearing loss. Most infections resolve on their own, but an antibiotic regimen can expedite the healing process.
- Inner-ear infections: Also known as labyrinthitis, inner-ear infections typically have an immediate onset of severe vertigo, nausea/vomiting from imbalance, and loss of hearing in higher frequency ranges. A virus or bacteria is the primary cause, and recovery may take several weeks or months. Most patients will make a complete recovery.
Another less common infection, mastoiditis, can cause persistent conductive hearing loss. Mastoiditis is a bacterial infection of the mastoid bone, which consists of air pockets that help drain the middle ear. Mastoid cells become infected or inflamed as a result of an unresolved middle-ear infection, and if the infection spreads, the resulting health complications can be severe. Chronic mastoiditis sufferers face an ongoing infection of the middle ear and mastoid, which causes persistent drainage from the ear. The disease is usually resolved via oral antibiotics, eardrops, regular ear cleanings, or surgery, if necessary.
Mastoiditis displays two symptoms that make it fairly easy to identify: a swelling of the earlobe and redness/tenderness behind the ear. In some cases, there may be a bulging or drooping of the ear. Fever, irritability, and lethargy are other symptoms. Left untreated, mastoiditis can cause hearing loss, a blood clot, meningitis, or a brain abscess. However, early treatment usually means a full recovery.
These diseases usually don’t cause sudden hearing loss, but they should often be treated as a medical emergency because of how dangerous relative infections can be. The approximately 4,000 new cases of SSHL each year in the U.S. can affect anyone but happen most often to individuals between the ages of 30 and 60. There are more than 100 possible causes, including head trauma, abnormal tissue growth, immunologic diseases like Cogan’s syndrome, toxic causes, ototoxic drugs, circulatory problems, neurologic causes, and Ménière’s disease. But one that has gained traction among medical professionals is the idea of a viral infection that affects the cochlea and causes sudden hearing loss. In these cases, hearing may completely return, may partially return, or may not return at all.
Sudden deafness can occur all at once or over a period of up to three days. A doctor can determine SSHL with a normal hearing test; a loss of at least 30 decibels in three connected frequencies equates to a diagnosis of SSHL. Nine in 10 people who experience SSHL are affected in only one ear, and many people notice it when they wake up in the morning or try to use the deafened ear and realize it’s not working. Others notice a loud “pop” just before their hearing disappears, and they often experience dizziness, tinnitus, or both after SSHL occurs.
It is important that a medical specialist is seen within the first 48 hours of experiencing SSHL to ensure a complete recovery. Some patients recover completely without medical intervention within the first three days (referred to as a spontaneous recovery), while others recover over a one- or two-week period. In most cases, a good to excellent recovery is likely, but 15 percent of those who experience SSHL note that their hearing loss gets worse over time.
Two factors that help hearing function properly are good airflow and blood flow inside the ear; research now indicates that SSHL occasionally occurs when important parts of the inner ear do not receive enough oxygen. A treatment of carbogen — a mixture of carbon dioxide and oxygen — seems to help air and blood flow in the ears of some patients when inhaled. But the most common treatment for SSHL in which there is no known cause is steroids, which reduce inflammation and help the body fight whatever illness is causing the SSHL. Steroids are particularly effective in those with SSHL who also have conditions that affect the immune system.
Hearing can evaporate quickly over the course of only a few days and never return. Stressing a prompt examination with treatment by medical specialists can prevent this permanent hearing loss, and can keep our local community happy and healthy.
– National Institute on Deafness and Other Communication Disorders. Sudden Deafness. U.S. Department of Health and Human Services
– Hain, T. Sudden Hearing Loss. American Hearing Research Foundation. Oct 2012.
– Massachusetts Eye and Ear. Sudden Deafness.
Healthy Hearing Can Prevent Brain Atrophy
The litany of hearing loss research making headlines over the past few years is staggering, and the findings have given healthcare providers reason to suggest to patients that they seek out better-hearing solutions. But the latest revelation by Johns Hopkins researchers may be the most compelling reason yet: Brain volume shrinkage is accelerated in older adults with hearing loss.
Although the brain becomes smaller with age regardless of hearing ability, findings indicate that shrinkage occurs at a greater rate for those suffering from a hearing loss of at least 25 decibels (considered a “mild” hearing loss). Researchers found that brain tissue atrophy was greater by an additional cubic centimeter per year in those with compromised hearing. Much of this shrinkage occurred in regions of the brain that are associated with processing sound and speech, as an apparent consequence of starving the auditory cortex of stimulation. The study was performed over 10 years, and participants underwent yearly MRIs to track brain changes.
“Our results suggest that hearing loss could be another ‘hit’ on the brain in many ways,” says Dr. Frank Lin, a Johns Hopkins researcher and assistant professor at the University’s schools of medicine and public health.
The Johns Hopkins study is congruent with other research that indicates brain structures are smaller in people and animals with a measurable hearing loss — but it’s not completely clear whether these structural changes occurred as a result of hearing loss or were a reason for the hearing loss. Still, it is important to treat hearing loss before any potential structural changes take place and worsen overall health.
“If you want to address hearing loss well, you want to do it sooner rather than later,” says Dr. Lin. “If hearing loss is potentially contributing to these differences we’re seeing on MRI, you want to treat it before these brain structural changes take place.”
The findings represent yet another addition to the already troubling list of consequences associated with hearing loss, including dementia, increased instances of falling, and diminished overall physical and mental health. And it’s important to note that the same areas of the brain that suffered atrophy also play a role in memory and sensory integration, and are involved in early stages of mild cognitive impairment and Alzheimer’s disease.
Methods to reduce the risk of health problems through early hearing loss treatment will be developed over the next several years. Already studies have indicated that those who suffer from a hearing loss of only 25 decibels are three times more likely to have a history of falling. Each additional 10-decibel loss in hearing represents an increase in the chances of falling by 1.4-fold — and these findings held true when accounting for other factors linked with falling, such as age, sex, race, cardiovascular disease, and vestibular function. And perhaps most troubling: Excluding patients suffering from moderate to severe hearing loss did not change the results of the analysis. Patients who have trouble with their balance may be experiencing at least a mild hearing loss and may not be completely aware of it.
The injuries that result from these falls generate billions in healthcare costs. Though the falls cannot be attributed entirely to hearing loss, the statistics are too profound to ignore. Many people who suffer from balance issues also suffer from some form of hearing loss, for which one possible explanation is that those who can’t hear very well simply might not have a good awareness of their environment. Localization, a term that explains our auditory ability to determine where sounds come from, dissipates as hearing loss becomes more prominent. Although we don’t realize it, background noises often help our brain dictate where objects are based on how sounds are reflected off other objects. Missing out on those sounds affects our balance in ways that we might not have previously realized.
Another possible explanation for injuries is that the brain becomes overwhelmed with demands on its limited resources, which become further limited as brain shrinkage occurs. Regardless of the reason, research shows that men and women with hearing loss who are 70 and older are 32 percent more likely to have been admitted to a hospital in the previous four years than those with normal hearing. Prolonged injuries were worse too, as those elderly patients were also 36 percent more likely to have prolonged stretches of illness or injury (lasting more than 10 days), and a startling 57 percent were more likely to have deep episodes of stress, depression, or bad moods for long periods.
As new data is brought to light regarding hearing loss, the need for specialized, unique, individual care is further emphasized. Hearing loss does not affect any two people in the same manner, so a one-size-fits-all solution is not the answer. An experienced hearing health professional who emphasizes patient relationships and creates a hearing loss solution that suits individual needs will do wonders for your patients who are hard of hearing. Our practice would love to connect with yours and discuss a partnership that benefits both of us — and vastly improves the life of every patient we meet.
– Lin, F. et al. Hearing Loss Linked to Accelerated Brain Tissue Loss. Johns Hopkins Medicine. January 2014.
– Lin F. et al. Hearing Loss in Older Adults Tied to More Hospitalizations and Poorer Physical and Mental Health. Johns Hopkins Medicine. June 2013.
– Lin, F. et al. Hearing Loss Linked to Three-Fold Risk of Falling. Johns Hopkins Medicine. February 2012.
All Aspects of Life – Not Just Hearing – Are Greatly Affected by Hearing Loss
Because hearing loss occurs gradually in most individuals, few realize the damage it can inflict on all aspects of health and overall quality of life. Research over the past 15 years has only begun to emphasize the importance of seeking treatment when hearing loss becomes a factor in daily life, and only one in five people actually take advantage of all that hearing aids can offer after learning they aren’t hearing their best. Those four in five Americans who don’t use hearing aids can sometimes delay treatment for so long that communication — even in the most optimal situations — becomes problematic.
With the advancement of medical technology comes increased life expectancy. Data shows hearing loss has been steadily increasing over the last two decades, and with an aging boomer population, instances of hearing impairment are likely to reach heights never before seen.
Some effects of hearing loss on quality of life are more obvious than others: Understanding conversation becomes more difficult, and communicating with friends and loved ones becomes an exhausting exercise and can be very frustrating. But then there are the darker aspects that few see. In a 1999 survey by the National Council on Aging, results from 4,000 adults with hearing loss and their significant others showed significantly higher rates of depression, anxiety, and other psychosocial disorders in individuals who were not wearing hearing aids. These findings were consistent with another large, randomized study in which hearing loss was associated with decreased social interaction and more instances of cognitive dysfunction for those who did not use hearing aids compared to those who did. After being fit for hearing aids, those who experienced depression and decreased social interaction saw their conditions improve.
Unfortunately, hearing loss is often ignored during diagnosis and treatment of cognitive memory disorders, with elderly patients in particular. Understanding this link, and the wealth of research linking hearing loss with other disorders, will help with more appropriate diagnosis and better outcomes from treatment in the future.
But quality of life is not based entirely on mental condition, and many with hearing loss also rate total income and overall wellness as unsatisfactory. Consider:
- People with hearing loss are less satisfied with “life as a whole” than those without hearing loss. Individuals with some level of hearing loss report greater dissatisfaction with their friendships, family life, health, and financial situation than individuals without hearing loss. Dissatisfaction with their finances may be related to the fact that those with hearing loss are, in general, less well off than those without; the median net worth of those with hearing loss, ages 51 to 61, is nearly $40,000 less than those without a hearing loss.
- Fewer working-age individuals (18- to 64-year-olds) with hearing loss are employed than those without hearing loss. About 13 percent of workers ages 51 to 61 with hearing loss report that being hard of hearing limits their work, either in type or amount.
- Loss of independence is another reason for dissatisfaction with some aspects of life. The unwillingness to engage in social activities is one factor. People of all ages with hearing loss are also more likely to require assistance to perform regular daily activities, such as preparing meals, shopping, and handling money. Individuals with hearing loss over the age of 70 are about one-third more likely to need help with shopping compared to those without hearing loss.
- Depression symptoms in individuals 70 or older are more prevalent. About 26 percent of those with hearing loss reported that they had experienced at least four symptoms of depression in the prior week, while less than 15 percent of those without hearing loss reported the same.
- Only 39 percent of those with hearing loss consider themselves in excellent or very good physical health, while 68 percent of well-hearing individuals say the same. Those with hearing loss are more than three times as likely to report being in fair or poor health than those without hearing loss.
- Poor health appears to be a large factor in the decision to retire among those with hearing loss. About 70 percent of retired people with hearing loss reported their health was an important factor in their decision to retire; of those without hearing loss, 44 percent cited health as a factor in their decision.
- Among those retired, overall satisfaction with their retirement shows stark differences. Only 29 percent of people with hearing loss are very satisfied with their retirement, compared to 42 percent without hearing loss.
Among the reasons why individuals delay seeking treatment for their hearing loss is the stigma associated with wearing hearing aids. Individuals with hearing loss often choose not to partake in social activities because they’re unable to hear well enough to participate — or because they don’t want to lose face by admitting they must wear hearing aids in order to engage with their friends and family.
In one survey, one-third of respondents stated they do not use assistive technology because they believe that hearing aids would “not help with my specific problem.” Our office offers better-hearing solutions to individuals suffering from all forms of hearing loss, and we’re working to improve the health of the local community — just like you.
– National Academy on an Aging Society. Hearing Loss: A Growing Problem that Affects Quality of Life. December 1999.
– Better Hearing Institute. Facts About Hearing Disorders. 1999.
– Ries, Peter W. (1994). Prevalence and Characteristics of Persons with Hearing Trouble: United States, 1990–91. National Center for Health Statistics, Vital and Health Statistics, Series 10, No. 188.
– M.I. Wallhagen, W.J. Strawbridge, R.D. Cohen, and G.A. Kaplan. “An Increasing Prevalence of Hearing Impairment and Associated Risk Factors Over Three Decades of the Alameda County Study.” American Journal of Public Health (1997); 87(3): 440–442.
– The National Council on the Aging. The Consequences of Untreated Hearing Loss in Older Persons. Washington, D.C. (1999).
– Data from the Hearing Industries Association as explained by Sergei Kochkin, M.D. (personal communication, June 1999).
Making Sense of Sensory Processing Disorders and Hearing Loss
Our bodies and brains act as filtering systems for things that are happening around us — the information picked up by our senses — so we don’t become overloaded by attempting to process too much at once. If we were totally aware of every single bit of information our senses gave us, processing everything would be nearly impossible due to the finite resources our brains offers us. Yet for some individuals, this is their reality. It’s called sensory processing disorder (SPD), and it results in an overload of sensory data that their minds are unable to interpret correctly.
Sensory processing disorders affect both children and adults, causing a misinterpretation of everyday sensory information that others take for granted, including senses related to movement and positioning. Though the disorder can affect any number of senses — or all of them at once — it can be particularly daunting when it affects the auditory region of the brain in individuals who already suffer from hearing loss. The severity and nature of the disorder is based on the unique effects it has on the individual; no two people experience the same exact symptoms.
When a sensory processing disorder affects the auditory region of the brain, it is referred to as auditory processing disorder (APD). When affected by this, individuals have difficulty catching subtle differences between sounds and words. Confusing one word for another usually results in a misunderstanding between the speaker and the listener, regardless of which is the affected individual. Listening to complex information or listening in a noisy environment will usually lead to misinterpretation during conversation. Sometimes all sounds are perceived as equal, creating a different kind of difficulty communicating and responding to verbal instruction; this typically means an acute sensitivity to background noises.
Generally speaking, there are two forms of APD: hypersensitivity and hyposensitivity. Hearing is considered hypersensitive when the individual is too sensitive to noise, and it’s considered hyposensitive when the individual’s hearing is dampened. Suffering from hypersensitivity, also referred to as auditory defensiveness, can result in:
- Distraction by sounds that others do not notice
- Fear of or sensitivity to loud noises, like a flushing toilet, a vacuum, a hair dryer, or a barking dog
- Being startled or distracted by unexpected sounds and background noises
- Frequently asking for quiet
- Basing feelings about a person on the way their voice sounds
Conversely, suffering from hyposensitivity, also referred to as under-registering sounds, can result in:
- No response to verbal cues or to the person’s name being called
- Listening to excessively loud music or TV
- Making noise for the sake of hearing noises
- Difficulty understanding or remembering what is said
- Being oblivious to some sounds
- Confusion about where sounds are coming from
- Talking through tasks and instructions as they perform them
- Repeating directions
Usually, the brain consciously processes about 30 percent of sounds and filters out the remaining noises. In the case of APD, processing is thrown off by a wider margin, either increasing or decreasing in an amount that makes it difficult to combine activities (such as walking and talking, or talking when there’s background noise) or to constantly shift from one activity to the next. In children APD can create emotional disorders that continue to affect them as adults, stemming from an inability to make sense of the world. Social skills tend to develop more slowly, as making friends is more difficult due to an individual’s seemingly strange behavior.
Prevalence of the disease is unknown, but males are thought to be twice as likely to be affected by the disorder as females. APD may result from ear infections, head injuries, or neurodevelopment delays that affect the way the brain processes information. Because the cause of the disease can be difficult to detect, it can be particularly difficult to diagnose the disorder. Children with symptoms of APD typically show no signs of neurological disease; the diagnosis is made on the basis of the child’s performance during auditory tests.
There is no surefire cure for APD, but there are a variety of treatment methods that can greatly alleviate symptoms and help the sufferer to lead a normal life. Treatment is typically individualized and specific to the unique problems the patient faces. It is easier to manage for adults who experienced its onset early in life, and who learned coping strategies in childhood. No single therapy is effective for any two children, so appropriate treatment should be provided after a careful diagnosis by an audiologist. The focus lies in three primary areas:
- Changing the learning or communication environment
- Using new skills to compensate for the disorder
- Attempting to identify and, if possible, solve the auditory deficit itself
Initially, environmental changes are important because they allow the child to focus his or her attention on the message. Some strategies consist of strengthening the central resources they can use to overcome the auditory disorder, and teaching children with APD to take responsibility for their listening success or failure by being an active participant and using problem-solving techniques. With early intervention, children with APD can learn to become involved in their listening and communication success — rather than remain victims of their own unfortunate impairment.
– Bellis, T. Understanding Auditory Processing Disorders in Children. American Speech-Language-Hearing Association.
Relationships, Self-Image, and Social Life Greatly Improve with Hearing Loss Treatment
Of the American population affected by some type of hearing loss, more than 19 million are ages 45 and up — but three out of five older Americans (65+) and six out of seven middle-age Americans with hearing loss do not use hearing aids, creating a gap in communication and social activities that affects many individuals at a deeper level than their loved ones may understand. Many with hearing loss choose not to engage in social activities because the stigma associated with it is embarrassing; the belief that they are “weak,” “old,” or are in need of help because they have hearing loss can be difficult to reconcile, despite the fact that treatment is likely to improve their social lives.
Individuals who cannot understand or hear what others are saying sometimes choose to avoid social situations entirely, rather than ask others to repeat themselves — especially in situations where background noise is significant. Avoiding social outings with friends and family begins the process of social isolation that contributes to loneliness and depression, two factors that have become more common in those with hearing loss.
Over the past 15 years in particular, research on the subject has become prominent. Dr. Frank Lin, an assistant professor and researcher for Johns Hopkins University, examined data spanning from 1999 to 2006 to determine a cross-sectional association between social isolation and hearing loss. Social isolation scores were based on the presence or absence of emotional support, financial support, close friends, spouse, or partner; hearing level scores were defined as pure-tone average in the better-hearing ear. Results showed that social isolation and hearing loss were found to be especially significant in women ages 60 to 69, when cognitive impairment occurred faster by an estimated three years.
Another survey of 2,300 adults 50 and older, performed by the National Council on Aging (NCOA), found that those with untreated hearing loss were more likely to report depression, anxiety, and paranoia, and were less likely to participate in organized social activities compared to those who wear hearing aids. Seniors who did not wear hearing aids reported feelings of sadness or depression that lasted two or more weeks in the previous years, and the perception that other people got angry with them for no reason — an indicator of paranoia — was increased. Among those with severe hearing loss, the difference was even greater.
This survey, much like Dr. Lin’s research, also examined social behavior and found that people who don’t use hearing aids were much less likely to participate in social activities. Some effects of hearing loss on the quality of social life — on the part of all individuals in conversation — are more obvious than others. Understanding trivial elements of conversation becomes more difficult. Individuals focus more energy on what a person is saying, and on watching the speaker’s face and body language for cues; so much energy is spent focusing on what is being said that less energy can be spent thinking of a reply. Those with hearing loss usually sit closer to the speaker in order to hear key elements. Communicating with friends and loved ones becomes an exhausting, frustrating exercise, and avoiding them altogether seems a better option for some.
Another significant component of the NCOA study was that 2,090 close family members or friends of the hearing impaired were asked a parallel set of questions, both before treatment and after treatment. Benefits of treatment with hearing aids were significant, offering improvements in many areas of life, ranging from relationships and social life to sense of independence:
- Relations at home improved by 56 percent according to the hearing aid user, 66 percent according to family and friends.
- Self-image improved by 50 percent according to the user, 60 percent according to family and friends.
- Life overall improved by 48 percent according to the user, 62 percent according to family and friends.
- Relations with children and grandchildren improved by 40 percent according to the user, 52 percent according to family and friends.
- Mental health improved by 36 percent according to the user, 39 percent according to family and friends.
- Self-confidence improved by 39 percent according to the user, 46 percent according to family and friends.
- Sense of safety improved by 34 percent according to the user, 37 percent according to family and friends.
- Social life improved by 34 percent according to the user, 41 percent according to family and friends.
- Relations at work improved by 26 percent according to the user, 43 percent according to family and friends.
Despite these results, refusal to wear hearing aids remains the primary obstacle to a better life through better hearing. Among the reasons stated for refusal were cost, the feeling that respondents’ hearing was not bad enough to need a hearing device, and that they could “get along” fine without them. One in five stated, “It would make me feel old” or “I’m too embarrassed to wear one.”
Statistics show that almost two-thirds of men with hearing loss began to lose their hearing before age 44, meaning many of the more than 19 million middle-age or older adults with hearing loss are likely to face far worse hearing in later years than they had when they were younger. Data shows quality of life is much worse before hearing aids and much better after. Once hearing aids are fit, and the brain rewires itself to adjust to the sounds that have been missing, the only reason to turn back is social stigma. Through continuing education and specialized treatment, better hearing can help to eliminate social isolation — and our community can be happier and healthier than ever before.
– Lin, F., Mick, P. Social Isolation and Hearing Loss in the Elderly. Otolaryngology—Head and Neck Surgery. September 2013.
– Lin, F. et al. Hearing Loss and Cognitive Decline in Older Adults. JAMA Internal Medicine. February 2013.
– Holmes, C. et al. Untreated Hearing Loss Linked to Depression, Social Isolation in Seniors. Seniors Research Group, The National Council on the Aging. Audiology Today. May 1999.
Hearing Aids May Help Keep Your Brain Sharp
A new 20-year cognitive analysis published in the April 2015 issue of the American Journal of Epidemiology further explores the link between hearing loss and decline in memory and overall cognitive function. The results find that participants with moderate to severe hearing loss consistently scored worse than those with mild or no hearing loss, and estimated declines were greatest in individuals who did not wear a hearing aid.
Conversely, participants who wore hearing aids scored only slightly worse after two decades of testing than those without a hearing loss.
“This study is important because it focuses on a risk factor that is amenable to intervention in later life and could potentially postpone cognitive decline,” said Jennifer Deal, the study’s lead author.
This pilot research was performed as part of the Atherosclerosis Risk in Communities (ARIC) Study, a population-based research study that includes 15,792 men and women age 45–64 years—ages that are concurrent with the Baby Boomer population.
While many prior studies have focused on finding a link between hearing loss and cognitive decline, this study sought to discover whether hearing aid use might provide patients some protection against future cognitive trouble. After correcting for known variables that interact with hearing health — including cigarette smoking, hypertension, diabetes, and depression — the data revealed that individuals who did not wear hearing aids during the study tested worse than those who did, and that hearing aid use might reduce the risk of cognitive decline.
Previous studies have associated hearing loss with cognitive difficulties, including increased rates of incident dementia, accelerated rates of cognitive decline and brain volume atrophy, an increased risk of falls and injury, and increases in an assortment of mental and emotional illnesses ranging from anxiety to depression.
The average age of study participants was 76.9 years, and 58.9% of participants had a high school education or less. On average, study participants with moderate to severe hearing loss were older, more likely to be male, and more likely to have hypertension than participants with mild or no hearing loss — majority statistics that also fall in line with prior hearing loss demographic assessments.
– Deal J, et al. Hearing impairment and cognitive decline: a pilot study conducted within the Atherosclerosis Risk in Communities Neurocognitive Study. Am J Epidemiol. 2015;181(9):680–690.
Healthy Diets Support Hearing Health
Treatment for hearing loss comes in many forms, including the well-known use of hearing aids. Now a wealth of information from recent studies has suggested that adding specific vitamins, minerals, and nutrients to patients’ diets may head off the need for such devices later in life. Folic acid, a water-soluble B vitamin that aids in DNA synthesis and formation of healthy red blood cells, is one such vitamin that may also play an important role in preserving hearing health later in life.
According to a 2007 study published in the Annals of Internal Medicine, folic acid supplementation may slow age-related hearing loss in older adults. Scientists from Wageningen University conducted a double-blind, placebo-controlled study on 728 men and women between the ages of 50 and 70 living in the Netherlands. At the initial screening, all participants had either healthy hearing or hearing loss solely related to age, and they presented with low levels of folic acid (approximately 50 percent lower than those found in the U.S. due to the Netherlands’ prohibition of the folate fortification of food). Participants also had high homocysteine levels, which are directly affected by folic acid and can be reduced with folate supplementation.
Over the course of the three-year study, half of the participants took a folic acid supplement of 800 micrograms per day, while the other half received a placebo. At the end of the three-year trial, the participants who had received folic acid had less low-frequency hearing loss than those who had received the placebo, suggesting that folate may play a role in slowing the progression of hearing loss.
This hypothesis is supported by additional studies, including research from 1999 by the American Journal of Clinical Nutrition. The study was conducted on 55 healthy Caucasian females between the ages of 60 and 71. The results found that women with presbycusis had significantly lower levels of vitamin B12 and folate than women with normal hearing, indicating that along with folic acid, vitamin B12 may play an important role in auditory health.
With no single known cause for the pervasiveness of hearing loss in older adults, and no known cure, hearing loss prevention is crucial. Educating patients on which nutrients aid in the deterrence of presbycusis, where to find them, and how to integrate them into their daily dietary intake is one simple approach.
Folic acid and vitamin B12 can be taken in the form of a supplement or increased naturally through basic dietary changes. Foods that naturally contain folic acid include leafy green vegetables, citrus fruits, and legumes. Since 1998 folic acid has also been added to an array of foods such as breakfast cereals, breads, flours, and pastas, which are labeled “enriched.”
Along with having the potential to preserve hearing health, vitamin B12 plays an essential role in protecting the brain and central nervous system. It is found in fortified foods like breakfast cereal and soy products, and it occurs naturally in fish, milk, and eggs.
Folic acid and vitamin B12 aren’t the only nutrients that have been found to help thwart hearing loss. While using protective devices such as earplugs is the only proven method of preventing noise-induced hearing loss (NIHL), studies haveshown that taking a mixture of vitamins C, E, A, and magnesium can reduce the damage caused by excessive noise. According to a study published in 2007 by Free Radical Biology & Medicine, taking the vitamin mixture both prior to and after exposure to high levels of noise may significantly minimize the effects. It is believed that the mixture’s success is derived from the fact that the vitamins are antioxidants with the ability to fight free radicals. Free radicals (destructive molecules that begin to form in the ear before and after exposure to excessive noise) are thought to destroy the inner-ear hairs or sensory cells, damaging the inner ear and, thus, hearing.
Vitamins C, E, A, and magnesium can be taken in supplemental form or found naturally occurring in the following foods:t• Vitamin C: oranges, chili peppers, and broccoli.
- Vitamin A: carrots, sweet potatoes, and mangos
- Vitamin E: almonds, Swiss chard, and kale
- Magnesium: bananas, cashews, and edamame
Many of the aforementioned vitamins and minerals are found in the same and complementary foods and can easily be worked into a balanced diet supported by daily supplements. By integrating healthy food choices and well-balanced meal planning into patients’ daily lives, hearing health will be supported and protected while overall health is improved.
– Le Prell, C.G., Hughes, L.F., and Miller, J.M. Free radical scavengers, vitamins A, C, and E, plus magnesium reduces noise trauma. Free Radical Biology & Medicine 2007 May 1; 42(9): 1454-1463.
– Durga, J., Verhoef, P., Anteunis L.J., Schouten, E. & Kok, F.J. Effects of folic acid supplementation on hearing in older adults: a randomized, controlled trial. Annals of Internal Medicine 2007; 146: 1-9.
– Houston, D., Johnson, M.A., Nozza, R.J., Gunter, E.W., Shea, K.J., Cutler, G.M. & Edmonds, J.T. Age-related hearing loss, vitamin B-12, and folate in elderly women. American Journal of Clinical Nutrition March 1999 vol. 69 no. 3; 564-571.
How Better Heart Health Can Prevent Hearing Loss
According to the American Heart Association, 60 to 70 percent of Americans, including children between the ages of 2 and 19, are either overweight or obese. These alarming numbers have prompted many to label obesity an epidemic, and with links to cardiovascular health problems and type 2 diabetes, obesity presents a significant health threat. Now, according to mounting evidence from multiple studies, obesity may also present a risk to hearing health.
The results of a 20-year Harvard Nurses’ Health Study published by the American Journal of Medicine in 2013 indicate that obesity, or having a body mass index (BMI) of 30 or higher with extra weight around the midsection, may put individuals at a higher risk for hearing loss. Beginning in 1989, 68,000 women between the ages of 25 and 42 had their BMI measured at the beginning of the study, then assessed biennially on a questionnaire that detailed overall health and daily living habits. Participants submitted waist measurements in 1993 and again in 2005; then, during the final year of the study (2009), they were asked if they had experienced hearing loss. There were a total of 11,286 reports of hearing loss — one out of every six involved in the study.
Obese participants were 17 to 22 percent more likely to report hearing loss than those in the normal BMI range, and severely obese individuals had a 25 percent higher risk. Similarly, participants with a waist measurement larger than 34 inches were 27 percent more likely to report hearing loss than those with waists measuring fewer than 28 inches.
Data also revealed that exercise impacted hearing health: Among participants who engaged in four or more hours of physical activity per week, the risk of hearing loss decreased by 15 percent. These findings suggest that modifiable lifestyle factors such as weight and activity level can reduce the risk of hearing loss while improving cardiovascular health overall. But the connection between hearing and cardiovascular health doesn’t end there.
In his article “The Ear Is a Window to the Heart: A Modest Argument for a Closer Integration of Medical Disciplines,” Charles E. Bishop, Au.D., asserts, “What we can say with confidence is that states of disease, whether cardiovascular or cardiometabolic in nature — which result from patterns of behavior generally linked to poor nutrition, lack of exercise, stress, and smoking — are clearly related to loss of hearing acuity in older adults.” Additional studies support this idea; some suggest that the correlation could play a key role in the early detection of cardiovascular disease.
The results of a 2009 study published by Dr. David R. Friedland and his associates indicate that low-frequency presbycusis could act as a predictor of cardiovascular disease. Friedland even suggests that audiogram patterns might serve as a screening test. He explains, “The inner ear is so sensitive to blood flow that it is possible that abnormalities in the cardiovascular system could be noted here earlier than in other less sensitive parts of the body.” And while there is no proof that mitigating cardiovascular damage through weight loss and physical activity will reverse hearing loss, physicians across multiple specialty areas (cardiology, endocrinology, and audiology) should feel encouraged to recommend these lifestyle improvements to their patients as a preventive measure against cardiovascular disease, type 2 diabetes, and hearing loss.
The correlation between obesity, cardiovascular health, and hearing — and the suggestion that they each may play a role in the predictability of the other — supports Bishop’s belief that collaboration between medical disciplines is beneficial to patients. He says, “There is simply too much evidence that hearing loss is related to cardiovascular disease and other health conditions. It’s time we maximized the information we have in order to benefit the individual’s overall well-being.”
Maintaining a normal BMI through healthy diet and regular exercise is key in preventing cardiovascular disease, type 2 diabetes, and hearing loss. Additional factors that influence weight control and contribute to reduce obesity include limiting screen time, getting a minimum of eight hours of sleep at night, and minimizing stress. Through collaboration across specialty fields, the utilization of hearing measurements as an indicator for cardiovascular disease, and the promotion of healthy lifestyle modifications, physicians can support the health of the whole patient to avoid serious health conditions.
– Bishop, C.E. The Ear Is a Window to the Heart: A Modest Argument for a Closer Integration of Medical Disciplines. Otolaryngology. 2012.
– Friedland, D.R., Cederberg, C., and Tarima, S. Audiometric Pattern as a Predictor of Cardiovascular Status: Development of a Model for Assessment of Risk. The Laryngoscope. 2009; 119: 473–486.
– Curhan, S.G., Eavey, R., Wang, M., Stampfer, M. J., Curhan, G.C., Body Mass Index, Waist Circumference, Physical Activity, and Risk of Hearing Loss in Women. The American Journal of Medicine. December 2013; volume 126, issue 12, pages 1142.e1-1142.e8.
Tinnitus: Common, Constant – but Very Manageable
Tinnitus is a fairly common medical malady that afflicts many people in mild forms, although they may not always be aware of it. As many as 50 to 60 million people are affected by a phantom ringing, whistling, or buzzing noise that is usually only perceived by them. A much smaller percentage (usually 1 to 2 percent) describes the condition as debilitating and, although there is no cure, must seek treatment to see a significant impact on their condition and to live a normal life.
Most of the time, the cause of tinnitus is unclear. In the absence of damage to the auditory system (such as head or neck trauma), things like jaw-joint dysfunction (TMJ), chronic neck-muscle strain, and excessive noise exposure have been suggested as causes. Certain medications can also cause tinnitus, which, in this case, can either disappear again after usage of the medication ends or can cause irreparable damage that results in permanent tinnitus. Other causes may be wax buildup, cardiovascular disease, or a tumor that creates a strain on the arteries in the neck and head. These tumors are usually benign.
When noise is properly filtered, the ears and brain ignore some sounds; people with normal hearing typically perceive about 30 percent of external sounds consciously, while the rest unconsciously fades away. Tinnitus sufferers often find that undesired sounds can become amplified. Intense stimulation of the auditory nerve over a long period of time can result in residual sensory perception — a sound or tone that continues even after the stimulating factor is gone. These sounds can manifest in a number of ways:
- Subjective tinnitus: The most common form of tinnitus. Symptoms can only be heard by the affected individual and are usually caused by exposure to excessive noise. Subjective tinnitus can appear and disappear suddenly, and may last three to 12 months at a time. In some severe cases, it may never stop.
- Neurological tinnitus: Usually caused by a disorder such as Ménière’s disease that primarily affects the brain’s auditory functions.
- Somatic tinnitus: Related to the sensory system. This form is caused, worsened, or otherwise related to the sensory system.
- Musical tinnitus: Also called musical hallucinations or auditory imagery, this type is less common. Simple tones or layers of tones come together to recreate a melody or composition. Musical tinnitus tends to occur in people who have had hearing loss and tinnitus for some time, though people with normal hearing or increased sensitivity to sound can also have musical hallucinations.
- Pulsatile tinnitus: A rhythmic tinnitus that aligns with the beat of the heart, and usually means a change of blood flow to the vessels near the ear, or an increase in awareness of the blood flow to the ear.
- Low-frequency tinnitus: Perhaps the most confusing type of tinnitus because sufferers aren’t sure whether the sound is being produced internally or externally. Often the tones correspond to the two lowest octaves on a piano and are described as a humming, murmuring, rumbling, or deep droning. This type of noise seems to affect people most strongly.
- Objective tinnitus: A rare form of tinnitus that may be caused by involuntary muscle contraction or vascular deformities. When the cause is treated, the tinnitus usually stops entirely. This is the only form of tinnitus that can be heard by an outside observer, and the only type that has the possibility of a permanent fix.
Tinnitus can be managed through strategies that make it less bothersome. No single approach works for everyone, and there is no FDA-approved drug treatment, supplement, or herb proven to be any more effective than a placebo. Behavioral strategies and sound-generating devices often offer the best treatment results; this is partially why distracting the individual’s attention from these sounds can prevent a chronic manifestation. Some of the most effective methods are:
- Cognitive behavioral therapy (CBT): Uses techniques to relax and restructure the way patients think about and respond to tinnitus. Sessions are usually short term and occur weekly for two to six months. CBT usually results in sounds that are less loud and significantly less bothersome, with overall quality of life improved.
- Tinnitus retraining therapy: Effective based on the assumption that the tinnitus results from abnormal neuronal activity. This therapy habituates the auditory system to the tinnitus signals, making them less noticeable or bothersome. Counseling and sound therapy are the main components, with a device that generates low-level noise that matches the pitch and volume of the tinnitus. Depending on severity of the tinnitus, treatment may last one to two years.
- Masking: Use of devices generating low-level white noise that can reduce the perception of tinnitus and what’s known as residual inhibition. Tinnitus is less noticeable for a period of time after the masker is turned off. A radio, television, fan, or other sound-producing machine can also act as a masker.
- Biofeedback: A relaxation technique that helps control stress by changing bodily responses to tinnitus. A patient’s physiological processes are mapped into a computer, and the individual learns how to alter these processes and reduce the body’s stress response by changing their thoughts and feelings.
Treatment options are legion but vary in effectiveness depending upon type of tinnitus. Research shows more than 50 percent of tinnitus sufferers also have inner-ear hearing impairment. While hearing aids act as an effective relief method for those with tinnitus by amplifying external sounds to make internal sounds less prevalent, they are not the only method. Careful diagnosis by a professional with years of experience creating solutions for tinnitus sufferers is essential.