SWC September 2008 Newsletter

Question: What is the connection between gradual sensorineural hearing loss, tinnitus and vertigo? These symptoms appear to be concurrent in some cases.

Michael: These three symptoms can occur concurrently or independent from one another. Some of the underlying pathophysiology resulting in hearing loss can additionally cause tinnitus or vertigo, although each can occur without presence of the other.

While what we call sensorineural hearing loss can occur due to pathology of a number of different structures, most commonly atrophy or death of regions of the cochlea of the inner ear, specifically pathological changes to the outer and/or inner hair cells, can result in sensorineural hearing loss.

While less is known about tinnitus, there are a number of theories posed to explain this. One such theory describes the relationship between the inner hair cells, the outer hair cells and the brain, in which damage to these neurons may result in difficulty of the brain to regulate gain of the sound, resulting in ear noise. Vertigo, too, can occur for various reasons. One disorder, Meniere’s Disease, is believed to result from difficulty of the vestibular (balance) system (located in the ear) to absorb endolymph, which is a fluid located within the ear’s balance and hearing portions. The impact often results in all three symptoms. However, one can have pathology of the ear that results in vertigo alone. That pathology may be more transient (as in an inner-ear inflammation), or it may be more significant (as in a vestibular schwannoma, an inner-ear tumor).

So, to answer this question, while it is possible that a pathological agent or disturbance may elicit all three of these symptoms, the specific site of any injury may limit the symptomatology to any combination of sensorineural hearing loss, tinnitus and/or vertigo.

Question: At what point in your hearing loss are you a candidate for a CI? Is it different for each person? Say, someone who has less than 20% comprehension is considered for a CI over another person in the same boat, only because that person doesn't function as well with a hearing aid?

Michael: While in the early days of CI, candidacy was more commonly limited to those with profound hearing loss, this is no longer the case. As you note, it is important to determine benefit from hearing aids so that it can be established that prognosis with a CI will exceed prognosis with a hearing aid. Criteria can vary across centers, and a number of factors are considered, including degree of hearing loss, health, vision, intelligence, ability/motivation to obtain audiologic rehabilitation, as well as ability to recognize speech and other sounds. While it is not necessarily a “deal-breaker,” having superior functionality with a hearing aid may limit one’s candidacy. CI is still an invasive surgical procedure (and, as any such surgical procedure, has inherent risk) that should not be conducted unless there is reasonable expectation that the person will be able to communicate better than s/he currently does.

Question: I would like to know more about tinnitus. I am starting to really suffer from it. My ears ring in multiple tones at once, and I hear chirping or the sound of jets going overhead. It's sometimes so loud it keeps me up at night. Is there anything I can do to stop it at least during the night so I can sleep?

Michael: While many people exhibit tinnitus at one point or another, and while it can take many different forms, can vary in duration, can occur in one ear or both, etc., a smaller subset of people exhibit symptoms to such degree as to feel it is problematic and impacting their lives. A significant number of people with these pathologic forms of tinnitus report that the sound(s) are most disturbing at bedtime; mainly this is so because the environment tends to be quietest when preparing for sleep. Not surprisingly, a top complaint is that tinnitus results in insomnia.

There are different ways to combat the symptom. Intervention obviously varies by the specific patient, but it is not uncommon to begin with a least-restrictive protocol. The effects of tinnitus are often (note, not ALWAYS, but often) limited by keeping the individual out of quiet. How can someone do this yet maintain a setting conducive to sleep? Well, a solution that is sometimes effective involves use of a “sound conditioner." There are products such as this, sometimes in the form of alarm clocks, that play sounds considered by many to be “soothing,” i.e., birds chirping, waves rolling, wind blowing, etc. For those who sleep in the same room as others, who may find the sound disturbing, these solutions can often be used under headphones. I had a patient who actually made his own “sound conditioner” by downloading an MP3 of rushing water which he played in an endless loop on his iPod. Still others choose to use music or the TV on a sleep timer. It may seem ironic that one way to limit the effects of noisy tinnitus is to use another noise, but it is quite often effective!

Obviously, this solution will not help everyone. For those who find sound conditioners to be unhelpful, management of tinnitus may take the form of dietary control (for example, excessive sodium in diets has been linked to tinnitus, as has high dosages of aspirin). Some have achieved success in managing it psychologically in ways similar to how pain might be managed. For those finding little relief, it is important to note a couple things: 1) there is NO research to indicate that any particular medication or vitamin can reduce tinnitus (avoid the snake-oil!) and 2) there are programs in existence that involve therapeutic intervention which some swear by; your audiologist should be able to lead you to more information. A good resource is the American Tinnitus Association, which can be found at ata.org.

Question: I have always wondered: Why does hearing impairment cause some people's voices to become very nasal, while others sound more normal? I have a bilateral sensorineural hearing loss with a rather nasal tone of voice to go along with it. While I have always heard references to my hearing loss being the reason for my voice nasal-sounding voice, nobody has ever really given me a clear explanation of why.

Michael: As you might imagine, people (especially children during critical stages of speech and language acquisition in the first few years of life) will learn to produce sounds the way they perceive it. The specific impact on articulation and phonological development is affected by the type, configuration and magnitude of hearing loss. Thus, sensorineural vs. conductive losses can make a difference, as can a low- vs. high-frequency loss, as can a mild vs. profound loss.

While it has been shown that certain configurations of hearing loss can impact tonality, prosody (rate), place and manner of articulation, a more common result of a high-frequency sensorineural hearing loss would be omissions or substitutions of voiceless consonant sounds of high-frequency emphasis. Thus, missing “s” sounds, “p” sounds, “t” and “k” sounds would be typical of the speech production. Additionally, resonance disorders such as hyper-(excessive) or hypo-(reduced) nasality can occur with various types of hearing loss. Consider, too, that sometimes people develop pathological processes of the speech mechanism that actually have little or nothing to do with hearing loss (as people who exhibit NO hearing loss sometimes exhibit hyper- or hyponasality). It is not possible to determine the likelihood of these things in your specific case with such limited information, but alas it IS possible to have a variety of effects on one’s speech patterns resulting from hearing loss. With appropriate amplification and a visit to a speech-language pathologist who specializes in voice disorders, steps can be made towards reducing the resonance difficulty.

Question: My hearing loss is from cholesteatoma. I have had numerous surgeries on both ears. My eardrum in my bad ear was reconstructed. Hearing bones were chiseled because they were fused together. A year after reconstruction I had a laser stapedectomy. This prosthesis lasted approximately 7 years and then was rejected. The prosthesis punctured my reconstructed eardrum and then I had to have another surgery to remove it. I now have terrible tinnitus in my reconstructed ear due to all the surgeries. My question now is would a hearing aid help in this ear if I do not have any functional hearing bones? I believe I have an 85/90 dB loss is that ear. My better ear has a 35/40 dB loss. This ear still has a hole in the eardrum even though I had surgery twice on that ear to correct the hole. How would an aid help if there is still a hole in the eardrum?

Michael: Yes, amplification would be expected to help. There are a few “buts,” though. Firstly, considering the surgical nature of your ear, one would need to medically determine that it would be safe for you to wear a traditional hearing aid. In other words, some ears are medically advised to remain unobstructed, for ventilation purposes. However, even in that case, there are often solutions. Secondly, the prognosis will vary by the degree of the sensorineural component of the hearing loss (i.e., the assumption is that you currently have a mixed hearing loss). The greater the component of the hearing loss that is conductive, the less that it is sensorineural, generally the better the prognosis in this case. But, even with a large sensorineural component, benefit would be expected.

Question: What are frequency transposition aids? What are the differences between the digital aids on the market vs. the transposition aids? What type of hearing loss would benefit from this type of aid?

Michael: Frequency transposition aids have been around for at least 10 years. They are specifically for those with a "corner audiogram," which is the type of hearing loss someone has when there is usable, aidable hearing ability in the low frequencies, and profound hearing loss in the high frequencies. I believe one of the manufacturers that made these changed the name to "frequency compression" hearing aids. Basically what they do is move sound in the frequency range that is not functioning to the frequency range that is functioning. So the sound is not quite like sound that one might be used to or that we know sound to be. I've not dispensed them, but I've heard of colleagues who've had success when combined with a rehab program not unlike what one might conduct in conjunction with CI implantation.

Michael Bergen is the Director of Brooklyn College's Speech and Hearing Center and is on the faculty of the Doctor of Audiology (AuD) Program at the CUNY Graduate Center. Michael is a NYS licensed, ASHA certified audiologist. As Director, Michael oversees daily operations, supervising clinical sessions and teaching doctoral, masters and undergraduate students. He was recently honored with the "Distinquished Service Award 2008" by NYSSLHA and named Favorite Teacher" of the Dept. of Speech & Communication Arts & Sciences by Brooklyn College for 2007 and 2008.

Michael was elected NYSSLHA VP of Audiology 2006-07, 2008-09 and has chaired or
served on committees at the university, local, state and national levels, including for NYSSLHA, ASHA, AAA, CAPCSD and the Metro Council.