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The importance of word testing.

There is a conventional battery of tests, with a few variations, that give an audiologist diagnostic information about a patient’s ear health and hearing capabilities. Otoscopy allows the examiner to visualize the outer ear, including the external ear canal all the way to the tympanic membrane (eardrum) for malformations, blockages or signs of trauma or disease. Pure tone audiometry assesses the intensity level necessary for a patient to barely detect various frequencies of sound within the spectrum of human hearing. Bone conduction determines the degree to which the outer and middle ear may reduce the amount of sound energy that reaches the inner ear by quantifying any “conductive loss”. Tympanometry, acoustic reflexes and otoacoustic emissions are objective tests of ear function (not hearing per se), and have been described in earlier blog entries. Another vital area of diagnosis is word testing.

There are several reasons audiologists test with words native to the test subject. Verbal communication is obviously the most important reason we have a hearing system, along with safety. Helen Keller famously observed that loss of vision “separates us from objects”, but hearing loss “separates us from people”. This is truer of people who have lost hearing than of people born deaf, but the fact remains that verbal communication is of immeasurable importance for most of us and is the deficit hearing impaired patients complain most bitterly about.

A second reason word testing is necessary is that certain patterns of errors that can ONLY be revealed by careful test administration can act as “red flags” for conditions that require referrals to other specialists, such as otolaryngologists, and additional testing, such as MRI. A competent tester must be familiar with these signs and the proper procedures.

Thirdly, for the many patients who require amplification, a good hearing aid dispenser must understand not only the diagnostic implications of word testing, but also be able use the data to guide selection of the most appropriate instruments. Patterns of word errors are typically consistent with patterns of hearing loss and the frequencies of the sounds patients are missing. Often these are high-frequency consonant sounds, such as /s/, /f/ or /th/. Patients must be given expectations for improvement that are high yet realistic. Word testing is a large component of these expectations.

All hearing testing, especially word testing, must be done in a sound-shielded booth through headphones. An approved word list should be used. Words are not randomly chosen, and the intensity level of the presented words must be appropriate.  An old-fashioned “whisper test”, where an examiner stands behind the subject and whispers words to be repeated, is virtually useless.

Always be sure to choose a hearing center that tests thoroughly and explains all results and their implications for you as a patient.

• Tinnitus is defined as “phantom noise perception” – a real perception of sound that did not originate outside your body.
• Tinnitus was regarded by the ancient Egyptians as private messages directly from the gods! The ancient Greeks recognized tinnitus, but did not have such a positive attitude toward it. They thought you could “chase it away” with sound.
• Tinnitus is perceived by at least 50,000,000 Americans alone. One third of citizens over 65 hear persistent buzzing, ringing, humming or other noises. In a completely soundproof room almost everybody will hear tinnitus.
• To date, no medications or supplements have been found to reduce or eliminate tinnitus without significant side effects, including dependency. Drugs are not recommended and not necessary. Our tinnitus therapy has no side effects.
• Tinnitus very RARELY signals a pathological medical condition.
• Tinnitus is a symptom and not a disease, and it is typically the result of increased nerve activity triggered by damage along the pathways of hearing, often very minor damage.
• Tinnitus is only a problem to the extent that it bothers you.
• Bothersome tinnitus is not a problem of noise perception, but of hypermonitoring the noise.
• Tinnitus does not cause hearing loss, nor does it mask hearing, although it may compete for your attention.
• A majority of tinnitus patients have measurable hearing loss, although not all require hearing aids.
• Habituation, the process that allows us to ignore unpleasant odors or the feeling of our clothes on our skin over time, has been found to be VERY successful with tinnitus patients, if basic protocols of Tinnitus Retraining Therapy (TRT) are followed. Ear-worn sound generating devices, including the Serenade® device by SoundCure™, have been found to significantly increase the habituation process in many patients.
• Patients often compare their tinnitus to crickets or “white noise”, yet people rarely tend to be bothered by real crickets or white noise. It’s the significance attached to the sound, and not the sound itself, that is an annoyance. It is a learned behavior we can “unlearn”!

Beware of hearing aid claims in marketing!

Advertisements for hearing aids are found in many places, from print ads in the popular press to internet marketing to television ads. Many of the marketing pieces on hearing aids are completely legitimate and truthful and guide patients ethically towards a particular practice.

Several marketing devices seen lately, however, have been using information that makes a particular brand or style of hearing instrument appear more unique, new or high-tech than it may be in reality. A well-known retailer of hearing aids was taken to task years ago for unrealistic claims of eliminating background noise, for example, demonstrating that consumers must pay attention to claims being made. While good digital technology typically features directional microphones and “noise management”, it is simply impossible for a hearing aid’s circuits to distinguish signal from noise with 100% accuracy, and environmental noise is still an integral part of hearing.

One retail-model center has made recent claims about an extended frequency range their hearing aids reach (5000 Hz) and patients have been told other hearing aids cannot match this feature. The truth is that many current brands of hearing aids regularly extend to at least 6000 Hz, and most hearing impaired patients would not be able to utilize extremely high-frequency amplification in a meaningful way. This is reminiscent of high-end stereo equipment that extends to 20,000 Hz, even though the average adult listener cannot detect such high frequencies, nor would they know if they were missing. Many hearing-impaired patients have very limited residual hearing at 8000 Hz, and when a sound is loud enough to be detected at that frequency, it may actually be too loud for their comfort. What looks good on paper does not necessarily translate to improved performance for a typical user, although these claims often make for good “selling points”.

All modern digital hearing instruments can be custom-programmed to match a patient’s hearing loss. If a hearing aid is said to cover a “full frequency spectrum”, including 6-8000 Hz, this may not match the patient’s full spectrum of available hearing. Features such as dynamic range compression, output limiting, multiple-band gain control, feedback suppression, background noise management, microphone polar plots, remote controls and “speech optimization” may be useful for audiologists and dispensers only if they know how to use them in an appropriate manner for a specific patient. Otherwise, they are nothing more than impressive sounding words. And most digital hearing aids have these features regardless of brand.

Given the similarity of technology and features across brands of hearing aids, the most important aspects of the process are appropriate selection of style and level of technology, as well as the experience, knowledge and competence of the professional programming the devices. As we’ve stated before, trust your ears only to a qualified expert (with a local phone number), not a “consultant”.

 Why are audiologists necessary?

A new patient recently informed us that another hearing center told her that an audiologist was not necessary for examining her ears and fitting hearing aids. The person she spoke to on the phone also said their hearing testing was always free. This patient eventually came to our office, where we took care of her and allowed her to experience, first hand, the value of having a thorough diagnostic evaluation, an in-depth discussion of any medical, social, lifestyle and psychological factors, and a review of any and all options for management of her problem. This woman, in fact, was in need of medical intervention for middle ear pathology before we could proceed with any amplification options. Referrals were made, the ear was treated, and we eventually proceeded with an appropriate course of action.

The business the lady had spoken with is a retail-model center for hearing aids. No audiologists are employed. While this does not prohibit them from dispensing hearing aids, the center did this woman a disservice by suggesting there would be no value in seeing an audiologist, a professional trained not only in hearing diagnostics, but also in recognizing clinical signs and “red flags” signaling the need for further intervention. The intervention may have been medical, surgical, or neurological in nature. The “free testing” they promote is more correctly referred to as a screening. This screening is only sufficient to gauge hearing aid candidacy solely on the basis of hearing levels. It is not diagnostic of the type of hearing loss, the “site of lesion” or part of the hearing system responsible for the problem, the state of the middle ear and Eustachian tube or the ability to understand speech.

Having the diagnostic information NOT provided by quick free screenings is precisely what allows us to make the most APPROPRIATE recommendations for treatment. We do much more than fit hearing aids with our test results and clinical experience. Our diagnostic test battery has provided physicians and surgeons information that guided further action, such as MRI, middle ear surgery, medical management of external ear canal infections, ventilation tubes, and even cochlear implants for some of our more severe to profound hearing loss patients.  Additionally, when hearing aid options are considered, any and all audiometric data is HEAVILY taken into account. With seemingly infinite choices for hearing aid models, a good dispenser will know exactly how to incorporate diagnostic information into the best fit for the INDIVIDUAL patient.

Your ears, communication and hearing are too important to not trust them to qualified professionals. Always find a center you are comfortable with where you will be examined and treated respectfully as a patient, not as a customer.

How do we assess dizziness?

How is it that audiology/hearing based practices would find themselves assessing and often treating disorders of balance and dizziness?

Few people are aware that the ear is primarily an organ of balance. Its main function, even before hearing our world, is to keep our heads safe atop our bodies and our eyes focused on the environment while we move about. There are organs of balance in the inner ears, some which are sensitive to “linear velocity” or movement forwards, backwards, upwards or downwards. Others are sensitive to changes in “angular velocity” or movement at an angle, such as head tilts. At any given moment the inner ear balance organs are sending nerve impulses to the brain about the position and movement of the head.

It stands to reason, therefore, that disorders of balance are highly likely to originate in the ears. Unfortunately, the inner ear is housed within the temporal bone of the skull, and it is impossible to observe these organs directly. What the study of our physiology has revealed for us, however, is that the nerve projections from the inner ear to the extraocular muscles (which move the eyes) and to the spine can provide us with insight as to the state of the inner ear. It is said that the eyes are the window to the soul. The eyes, we find, are absolutely a window to the inner ear.

A major part of our diagnostic test battery includes videonystagmography (VNG) testing, which exploits the connection between the inner ear balance centers and the eyes. Patients perform various tasks involving eye movements, gazing at targets, and changing head and body positions as fiber-optic camera-mounted goggles track eye movements. In this manner patterns in eye movements can be observed and measured, enabling us to determine the likelihood of an inner ear disorder, central nervous system involvement, or a combination of factors. The results guide treatment.  Occasionally a patient will produce normal results on all tests, necessitating the involvement of other professionals who can evaluate other systems which may produce these symptoms.

The balance centers of our inner ears are intended to work as partners, sending constant streams of information to the brain about the position or movement of the head. Often one side will sustain damage, due to infection, injury, interruption in blood supply, nerve damage, etc. The ears are no longer equal partners, as one side will then send stronger information then the other. This induces dizziness episodes and imbalance. Once identified, however, this condition can often be treated with activities designed to promote a “recalibration” to the asymmetric nerve output and decrease the symptoms over time through repetition and what is known as “central compensation”.

Another disorder commonly diagnosed is Benign Paroxysmal Positional Vertigo (BPPV). This is very easily treatable and will be the topic of a future blog article. Watch this space!

Balance and dizziness disorders are often highly treatable with timely accurate diagnosis and follow-through. Do not suffer needlessly!  Help is available.

Otoacoustic emissions testing

When an audiologist tests a patient's hearing, there is an important reality that must be addressed. Conventional audiometry is based on threshold estimation: the tester is seeking the subject's limits of detection of weak signals, typically tones, in order to determine the intensity at which the subject begins to hear sounds. It is necessarily a behavioral test. Since hearing is a perception and not merely a detection, the tester must necessarily rely on the subject to report the perception. Typically a test subject raises his hand, clicks a hand-held device or signals verbally ("yes", for example) when a sound is perceived. This requires several trials of manipulation of the intensity of the sound followed by patient responses. The process is necessarily a STATISTICAL ESTIMATE of function.

There are methods of estimating the reliability of these patient responses, such as agreement between different tasks and the reliability of the subject's responses (was the subject guessing or responding inconsistently?), however, a pure-tone audiogram is still an estimate regardless of the quality of the equipment used, the experience of the tester and the reliability of the responder. It is important to support this data with objective measurements whenever possible. The inner ear in inaccessible to direct observation. We cannot see the damage along the hearing pathways, even by way of imaging studies, other than tumors that can grow along the hearing nerve. The term "sensorineural loss" implies the damage is either sensory (inner ear organ of corti) or neural (along the auditory nerve), but how can we know where the problem really lies?

Otoscopy and ear microscopy can allow us to view the external ear and canal and inspect for signs of malformations that might interfere with hearing. Tympanometry allows us to rule out middle ear fluid, discontinuity of the ossicles (the tiny bones behind the ear drum) or other signs of "conductive loss". There is one test, however, that allows us to test the integrity of the inner ear "outer hair cells" directly, known as Otoacoustic Emissions (OAE).

This approach was originally demonstrated by a geologist named David Kemp, who had used sonar to determine rock stata. Building upon earlier work suggesting amplification of signals was occurring in the inner ear, the idea emerged from the suggestion that the ear can make its own noise or could reflect external noise which may be measured. Given that sound can be measured in mathematical terms (the frequency and wavelength that determines pitch and the sound pressure that determines intensity are measurable, physical properties that can be described mathematically), specific sounds can be delivered into the ear via a probe, eliciting reflected sound energy that is measurable by the same probe. The resulting sound measured is mathematically related to the stimulus tones delivered to the ear, often the "cubic difference tone". These emissions can be measured for different frequencies of stimulus tones. No response from the subject is needed.

Is has been found that a healthy set of hair cells will generate much stronger emissions than an impaired inner ear. This makes the test valuable for "site of lesion" determination, when we wish to differentiate between "sensory" and "neural". This is important in patients who show clinical signs of acoustic neuromas or other "retrocochlear disease" (growths along the hearing and balance nerve. It enables evaluation of patients who are difficult to test, such as infants, young children, patients with physical or mental limitations, etc. OAE is also sensitive to early hair cell damage, often prior to changes in hearing, making it a useful gauge of drug toxicity or early noise damage. The test requires a well-functioning middle ear, therefore, it can gauge middle ear function if tympanometry is not available or cannot not be tested.

Otoacoustic emissions are a quick, non-invasive, objective, and highly useful method of assessing inner ear function. They are another excellent tool for evaluating the health of patients' ear.

Several patients who are tech-savvy and/or very current on audio have noticed the recent popularity of noise-cancelling headphones. These are very popular, not only for travellers, but anyone who seeks to hear music or recorded books or movies with less intrusive background noise. A patient recently asked if this concept could be used to modify or reduce tinnitus, the phantom noise many patients hear.

The underlying idea behind noise-cancelling technology is that sound is comprised of "condensations and rarefactions" of matter (usually air) in a wave pattern radiating outward from the source. The source may be vocal cords, a stereo speaker, a guitar string or any collision of matter vigorous enough to produce such a disturbance and wave propagation. Sounds are comprised of "sine waves" in various combinations. Waves have the properties of amplitude, which contributes to the strength or intensity of the sound, frequency, which relates to the pitch of the sound (say bass vs. treble), and phase, which describes the pattern of peaks and valleys of any wave. Phase cancellation is a process of generating a sound of identical frequency and amplitude of the incoming sound, but with opposite phase, which is to say, a peak in the incoming sound would be matched in time by a valley in the generated sound. Simultaneous peaks and valleys "cancel out", leaving very little amplitude (strength) of the wave in question.

While it would be adventageous to be able to apply this idea to tinnitus, we must remember that tinnitus is not an acoustic signal. This phantom perception of a sound is generated along the nerve itself. Nerves carry impulses, also known as spikes towards the brain for recognition, but the signals do not have "phase" in the acoustical sense. Phase cancellation simply would not be effective on the strength of a tinnitus signal travelling towards the auditory portion of the brain.

We would love to explain strategies, based similarly in science, technology and physiology, which HAVE been found to be effective in treating tinnitus. Let us put you on a Clear path to good hearing and health.

Otitis media in adults: Title: Managing “fluid in your ears”

Most people are aware that middle ear infections are very common in young children. Many pediatrician visits result in treatment for otitis media, which, in children, often presents as “glue ear” and may be accompanied by pain, fever and reduced hearing. Children are known to be more prone to this condition due to their more horizontal Eustachian tubes and propensity for harvesting infections in general. Pain may increase until the eardrum ruptures from fluid pressure. Over 5 million cases of acute Otitis Media are reported annually in the US.

Adults can find themselves with middle ear fluid as well. Patients often report their primary physician suspected “fluid in the ears”. Often the fluid trapped behind adults’ eardrums is serous and is typically painless. This may be the result of Eustachian tube dysfunction, in which the middle ear space cannot drain to the throat adequately, often due to congestion in the tube itself. The tympanic membrane (eardrum) is drawn backwards from negative pressure, and yellow watery fluid can be drawn from the tissues lining the middle ear cavity.

Symptoms most seen in adults include drainage, ear pain, recent decrease in hearing, ear fullness sensations, recent dizziness or balance difficulty, fever (if there is an infection).

Adult risk factors for this condition include GE reflux, smoking, allergies, upper respiratory infections, immune system suppression (as with diabetes, chemotherapy, HIV/AIDS), sinusitis, enlarged tonsils/adenoids, ruptured eardrum and family history.

If you suspect fluid and/or an infection in your ear(s), they should be examined medically.  Ideally an otoscopic/microscopic examination of the canals and eardrums, tympanograms and pure tone audiogram (hearing test) can verify or rule out fluid, therefore a visit to an audiologist prior to a medical exam can aid the physician in the diagnosis. Medical or surgical management of the ear is best treated by an otologist or otolaryngologist, or “Ear, Nose and Throat” physician.

Treatment options include antibiotics, analgesics, antipyretics, as well as supplements such as Vitamin C, Zinc and Echinacea. Chronic, recurrent Otitis Media may be treated by means of myringotomy and insertion of tympanostomy tubes (through the tympanic membrane) for drainage and pressure equalization.

Do not wait if you or your physician suspect fluid in your middle ears. A thorough diagnostic ear exam is the first step toward appropriate treatment and relief.

At our practice we see many patients with tinnitus, which is described as phantom noise perception.  It is typically generated along the hearing nerve pathways that ascend towards the brain from the inner ear.  Much has been written, here and elsewhere, about typical "ringing", "buzzing", "chirping", "humming", or "hissing" sounds people commonly complain of (see our tinnitus page).  "Roaring" or "rushing" noises can be indicative of conditions such as Meniere's Disease or growths along the hearing nerve, and should always be evaluated audiologically and medically.

Pulsing noises, however, are a different class of head sound entirely, and can be considered a "somatosound" or bodily noise.  These noises are typically synchronized with one's cardiac pulse, which can be easily confirmed by most patients.  "Pulsatile tinnitus" is typically vascular in nature.  You are literally hearing your pulse to an abnormal degree.  Although many cases are not serious at all, this symptom should not be ignored.  A thorough diagnostic audiological/middle ear evaluation is an appropriate first step.  Your audiologist will then likely refer you to your primary physician, an otolaryngologist or a neurologist, depending on your history and his or her findings. 

Causes of pulsing noises include: intracraninal hypertension (high blood pressure inside the head), conductive hearing loss, middle ear fluid (trapped behind the ear drum), arterial or venous abnormalities, anemia, aneurism, thyrotoxicosis, or even pregnancy.  Obviously none of these conditions should be ignored, so please have your ears checked if you notice a pulsing noise not coming from your environment.  Let us help keep you on a clear path to good hearing and ear health!

Those of us who work in the hearing care field have taken on the responsibility of providing the best possible care of our patient's ears, hearing and/or balance, through training, education, listening and applying the best available information and technology to the specific problems our patients present with.  Ultimately, however, your ears are your responsibility.  You will always get the most out of your relationship with your professionals and your hearing aids (or hearing protection devices) when you comply with the practices that have been recommended to you during counseling. 

Another way to maintain responsibility for your ears is to practice good "aural hygiene" (aural means "ear-related").  What does this mean? 

Firstly, refrain from inserting any object other than a recommended hearing device into your ear canal.  Be sure every audiologist, hearing aid dispenser, otolaryngologist or primary physician inspects the ear canals for wax and abnormalities regularly.  Wax can be removed by an otolaryngologist, primary physician, audiologist or nurse.  Avoid do-it-yourself wax removal products using suction or violent sprays.  Wax drops, such as DeBrox or Miracel are fine if used sparingly and gently.  They are good for pre-softening wax for professional removal.  Straight hydrogen peroxide can be harsh, and cleaning one's ears too aggressively can remove too much of the protective qualities we rely on earwax for, such as lubrication and protection from viruses, bacteria, fungi and insects.

Protecting ears from excessive noise seems obvious, however, the number of noise-related hearing losses we see suggests otherwise.  Industry is compelled to follow OSHA regulations regarding workplace noise exposure (which factor in intensity level and exposure time), and there is no shortage of excellent hearing protection devices for hunting, shooting, music performance and listening, power tool use or industrial work.  But they must be used diligently and properly.  Strategies for musicians will be an excellent topic for a future blog (stay tuned!).  We say "the best ear plugs in the world are the ones that actually get used". 

Finally, be tuned to your ears for sudden changes in physical sensation (such as pain, fullness or pressure), changes in hearing, rapid-onset tinnitus or dizziness, drainage or bleeding.  These abrupt developments need to be evaluated immediately by an audiologist, otolaryngologist or primary physician.  Often fast intervention can be worth the effort.  Do not "wait and see" for these symptoms!

At Clear Choice our most successful patients have taken responsibility for their ears and their hearing.  They put their trust in us for their care, and we always strive to put you on a Clear Path to better hearing and health.

There has been some confusion lately about terminology regarding the testing of hearing. There are often retail-model hearing aid centers, often corporate chains with headquarters outside the state, who will offer "free hearing tests" to hearing aid candidates. Be advised that these tests are strictly screenings to determine candidacy for amplification. Typically hearing levels to tones are tested, often without word-recognition testing. "Customers" are then shown hearing aid options. The term "precision screening" is a contradiction, but has been used in marketing materials.

The aforementioned practice is not to be confused with full-scale diagnostic testing by a Doctor of Audiology, such as patients would encounter at Clear Choice Hearing and Balance, as well as several other practices regionally. Typically, Doctors of Audiology have credentials to work with insurance companies and provide evaluations that examine the outer ear, middle ear function, often inner ear hair cell function, as well as air conduction and bone conduction testing and tests of word understanding. One of the less obvious benefits of this type of center is the ability to detect "red flags" for referrals to other medical professionals. Is earwax, an active outer or middle ear infection, or the fluctuations inherent to conditions such as Meniere's Disease contributing to today's results? Does a referral need to be made to a specialist who can diagnose and treat diseases of the ear? And how might conductive vs. sensory losses of hearing affect hearing aid fittings? These are questions we deal with on a daily basis.

Please choose wisely when considering diagnostic centers for problems of the ears and hearing. You only get one set of ears! We hope to put you on a clear path to good hearing and health!

Most people who complain of tinnitus have steady noises, often sounding like ringing, hissing, buzzing or humming that may wax and wane but drone on when heard. This is typical neurologic tinnitus often caused by inner ear damage or nerve dysfunction or hyperactivity. Some people hear a pulsing noise in one or both ears. What causes this?

This "pulsatile tinnitus" is often considered a "somatosound" or noise that is generated by some physical movement within the body. Clicks can be due to middle ear muscle spasms, TMJ dysfunction can produce clicking or grinding noises, and damaged spinal vertebrae can produce noise as well. However, if the sound is a "whooshing" that is timed with one's heart pulse, the cause is typically vascular, or blood vessel related. Intracranial hypertension, or high blood pressure in the head, can cause one to hear the pulse in the eardrum. Also, conditions such as glomus tumor or glomus jugulare are abnormal blood vessel configurations that can pulsate, also timed to the heartbeat.

If anyone you know complains of this phenomenon, an audiological/middle ear evaluation is a good starting point. It is important to determine the state of the middle ear, as well as hearing in both ears. Often an otolaryngologist can use this information to differentiate between potential causes. Imaging studies may be helpful, as well. There may not be a serious health risk, but the sensation may be a warning sign to the patient to have the ears examined.

Please call for any additional information that might be helpful, and let us put you on a Clear path to healthy ears and hearing.