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Dr. Salgo:
Welcome to Second Opinion where each week our healthcare team solves a real medical mystery. When we close this file a half-an-hour from now you'll not only know the outcome of this week's case but you'll be better able to take charge of your own healthcare. And doctors will be able to listen to patients more effectively. I'm your host, Dr. Peter Salgo, and you've already met our special guests who are joining our primary care physician, Dr. Lou Papa. Lou welcome again.
Dr. Papa:
Okay. And how are you?
Dr. Salgo:
I've got to tell you that nobody on this panel knows this case. We're going to get right to work as we roll it out. Let me tell you a little bit about Jeff. Jeff is a sixty-one year old lawyer. He has been in the same law practice, Lou, his whole life. He's married, three grown children. He's in fairly good health, according to Jeff. He works out in his company's gym. Feels that he eats well, doesn't drink much. He just has one gin and tonic each night, just one. He's in his primary care doctor's office for his annual physical. I've got some data for you about him, would you like it?
Dr. Papa:
Sure.
Dr. Salgo:
He's 5'11", 201pounds. He's on Metoprolol XL 50 mg. His blood pressure is 116 over 76. He's taking ten of Lipitor and his total cholesterol is 122. His LDL is 72.
Dr. Papa:
Okay.
Dr. Salgo:
That's all the lab results I got in the chart here. Would you do a hearing test and an eye test routinely on someone who walks into your office?
Dr. Papa: Typically, usually not the hearing test. Usually it's complaint specific.
Dr. Salgo:
Well in this case, Jeff says he has no problem hearing things at work but, he says, his wife always complains that he can't hear her. Insert joke here. I can't even think of one for this.
Dr. Papa:
Yeah.
Dr. Salgo:
I mean if you did a hearing test on every man who came in and said that you'd be checking everybody. Does this raise any red flags, however, for you?
Dr. Papa:
It can. Very often when I hear about hearing complaints about a patient it's usually not from the patient it's usually from the spouse or from family members. And it's usually in a setting like that that they describe the hearing problems.
Dr. Salgo:
So if you're talking about a guy who's going to work every day. He's hearing well at work. And yet his wife says he can't hear anything. How can this be?
Dr. Chandrasekhar:
To me that means that in a contained environment where he's very comfortable at work perhaps. He's a lawyer at sixty-one, he's in charge. So he's not acquiring that much new verbal information at work and he's probably leading teams and leading groups. At home, his wife, possibly, has a more high frequency voice.
Dr. Salgo:
Is this selective hearing loss?
Dr. Frisina:
No I think it.
Dr. Salgo:
He's deaf to his wife?
Dr. Frisina:
It can be a selective hearing situation. And I think it's helpful for the primary care physician to say, initially ask more questions. What are the other environments where you're having problems in and is background noise an issue because that is a very common problem even if you can hear in quiet pretty well.
Kathy Kastan:
Well isn't it true, though, if he's at work it's probably less likely that a cohort or even somebody that's working for him is going to say to him, you know, we're having trouble, you know, talking to you and you listening to us. And I mean.
Dr. Chandrasekhar:
Yes. You're right. If you ask another question, is it just your wife. Well you know I'm not going to so many cocktail parties any longer because I just seem to smile and nod a lot. Or I just don't. I don't like the way they're filming movies these days. It seems to me that the conversation is shot at a softer volume than the background noise. These are all telltale signs of what you're referring to, we think, is high frequency hearing loss, which comes with age, called presbycusis.
Dr. Salgo:
Now Kathy, you've had hearing loss but you experienced it not at home but at work. Tell us a little bit about that.
Kathy Peck:
Right. Well I'm a bass player and I was in the Contractions, an all girl band in the eighties. And when I experienced, it was a huge experience. We just did our first album and we were opening up for Duran, Duran. And it was the screaming little girls and throwing the teddy bears with mash notes in it. I mean it was just deafening. And after that show I experienced tinnitus or tinnitus, ringing in the ears. But this was actually a different sound. It was more like drumming in my ears. And I actually felt like my hearing was dropping. At one point, I could see people's lips move and not hear conversation. And that's when it was really terrifying.
Dr. Salgo:
Does this. Does this sound like a story that you guys have heard before?
Dr. Frisina:
This is a very common thing for people who have jobs or occupations, musicians, factory workers, sports, hunting, military. This is a very common complaint.
Dr. Salgo:
How come? What are the numbers here? How often? How many people?
Dr. Frisina:
The numbers are. The prevalence is very high. In the U.S. about ten percent of the population has a significant hearing loss. That's about thirty million people.
Dr. Salgo:
Point one times three hundred is thirty million.
Dr. Frisina:
Yeah.
Dr. Salgo:
Before we go any further can you just give me some of the anatomy and physiology here. How do we hear?
Dr. Frisina:
Well sound enters the part of the ear you can see. Then it goes into a small fluid filled cavity in the bone, the skull behind the ear. And in that fluid filled cavity there are tiny cells, which convert sound into the code of the nervous system. Then there are nerve fibers, which carry that information from that inner ear up to the parts of the brain that are used for hearing. And that gets processed further and then you can hear speech, music, localized sounds and all the aspects of hearing.
Dr. Salgo:
Now we mentioned the phrase hearing loss. I don't want to go on without defining that. Can you define hearing loss in terms of what he was just talking about?
Dr. Chandrasekhar:
Hearing loss is the inability to perceive sounds within what we have determined to be a normal range. So somewhere in the sixties a bunch of college students were tested and normative data was obtained. And so we start hearing tests at the softest perceivable whisper, which is called zero decibels. And hearing should be between that and twenty-five decibels. Which is very soft speech. Very, very soft speech. Normal conversation is at about forty decibels and for example, common things that you are perhaps exposed to. A vacuum cleaner is at about seventy decibels. The A train at Columbus Circle in New York City is about ninety decibels. A rocket ship at launch pad is at about a hundred and twenty decibels. So things get expedientally louder when they, as we measure them in decibels. When I'm confronted with somebody with hearing loss I want to determine whether it's a mechanical problem, which is something that is preventing sound from the environment, from getting into my ear and traversing the ear canal, the ear drum, the bones of hearing to get to the cochlear, which is the fluid filled space, or something that's nerve or sensory neural, which is from the cochlear inner ear to and including the brain. Or whether it's mixed. Whether this is. Whether you had suddenly fluid in your middle ear that caused a bit of a hearing loss and you had noise induced nerve type of hearing loss.
Dr. Salgo:
Now Lou, he's still in your office or the primary care physician's office.
Dr. Papa:
Correct.
Dr. Salgo:
Let's for the moment assume it is you.
Dr. Papa:
Right.
Dr. Salgo:
You going to send him onto a specialist Lou?
Dr. Papa:
Well usually if there's, it's interesting. It depends on how much of an issue it is for the patient. But usually at that point, if hearing is brought up as an issue and I don't find anything at that point, I would usually do an audiometry, where I do a hearing test.
Dr. Salgo:
You do that in your office or do you send them off?
Dr. Papa:
I'd send them off for that. I don't have that in my office.
Dr. Salgo:
What's involved in an audiometry test, can you tell me that?
Dr. Frisina:
Generally the audiologist will do the pure tone test that we've all taken.
Dr. Salgo:
Well some of us have. What is a pure tone test?
Dr. Frisina:
A pure tone is a simple sound, low pitch, medium pitch, high pitch, can you hear it. They do left ear, right ear. And then based on that I would say he would likely have some sort of high pitch hearing loss at his age. And then a good audiologist will do more extensive speech testing.
Dr. Salgo:
Well let me tell you. Jeff goes to an audiologist. And I happen to have in the chart the results of his audiometry. I have a set of numbers. I can tell you that his right and left ear are symmetric through five hundred cycles per second. One thousand or hertz if you will. Two thousand, his right threshold is thirty-five; his left is twenty-five. At three thousand, his right threshold is fifty, his left is forty. At five thousand, his threshold in his right ear is seventy-five and his left ear is sixty. And then at eight thousand, its thirty-five and thirty. You want to parse this out for me. Does that help?
Dr. Frisina:
That's very helpful. The fact that it comes up at 8K, eight thousand hertz, suggests that he's had some noise damage over his life time, the fact that it comes up again. In the classic age related hearing loss it would have just kept going down at those higher pitches. He's got a significant hearing loss that's going to probably interfere with his communication.
Dr. Salgo:
You going to tell him this, Lou? You going to say you got some hearing loss.
Dr. Papa:
Oh yeah. I mean absolutely. It's we've done the test. It doesn't make much sense to do the test and not discuss the results. So absolutely.
Dr. Salgo: Eric, when he hears this, what's he going to think?
Dr. Caine:
A lot of people get very distressed that they aren't what they used to be and that is just one of the most common problems and some people bear up and they start to figure out what life will hold for them in the years ahead. And others seem to fall in the face of that. And we don't know about this fellow yet but this is certainly the kind of thing that you have to be very, very careful about.
Dr. Chandrasekhar:
Well and in this particular case he actually has an A symmetric hearing loss. So his right ear didn't get older faster than his left ear. So we actually have to look into that. And noise hearing loss that affects one ear more than the other is really, if this fellow gives you a history of I have worked in a printer shop for the last fifty years and the noisy machines are always on my right. So my left ear is protected by the shadow. Or I was a rifle. I was a marksman in the army and I'm right handed. Well then my left ear gets the brunt of the noise before my right ear does. So that head shadow affect is there if you can get that history.
Dr. Salgo:
You were very quick to say that this is noise related. Now you pointed out that hearing is a whole chain of events with sound going to the ear drum. Being, if you will, transmuted into neural signals after a whole sequence of physical changes, then onto the brain. So where did this break down. Can it break at any point and if this noise related where does that break?
Dr. Frisina:
The noise, the permanent noise damage is usually in that inner ear. And what happens in almost every permanent case of hearing loss those tiny cells in the inner ear are lost or damaged. And the problem is they don't grow back.
Dr. Caine:
But if this is noise related, why now? Why wasn't it ten years ago or fifteen years ago or twenty years ago? When he was exposed, presumably. I don't think the law firm is using, you know, pneumatic drills on the floor every day.
Kathy Peck:
It's insidious.
Dr. Chandrasekhar:
Yes.
Kathy Peck:
Hearing loss is insidious. You don't know you have it until it's gone. It's a hidden disability. It's the number one hidden disability.
Dr. Chandrasekhar:
It's hidden and his coping mechanism for it, which he didn't even know he was doing, is aging as well.
Dr. Salgo:
I just want to be very clear about that. Something in that chain of events is wrong. Do you need every chain to work to hear or can you break the link somewhere and work around it?
Dr. Chandrasekhar:
There's a lot of redundancy within the inner ear, so from the outside world to the inner ear you need everything to work. It doesn't have to work maybe a hundred percent but you need everything to be intact. You need the canal to be clear, the drum to be intake, the three little bones to work, the third bone to move in and out of the inner ear. From the inner ear, we have some redundancy built into the system in a beautiful organizational way where the basal turn of the inner ear responds to high frequency sounds, the apical turn or the narrow portion of the inner ear responds to low frequency sounds.
Dr. Salgo:
You're talking about curly cues in the anatomy?
Dr. Chandrasekhar:
Right. It's this snail in your ear. And then the nerves keep that orientation as they go to the brain.
Dr. Salgo:
All right. Let me pause here for a moment and let's sum up what we've been talking about. Normal hearing requires all the components of the physical hearing chain to be functioning properly. Any breakdown or impairment in that chain may result in a loss of hearing acuity. Straight forward you need the chain to work? Let me tell you a little bit more. You've heard Jeff's test results now. What's your diagnosis here? What would you say about Jeff?
Dr. Chandrasekhar:
He has A symmetric high frequency sensory neural hearing loss.
Dr. Frisina:
Which is probably a combination of aging and noise, previous noise exposure.
Dr. Salgo:
All right. Let me put it to you far more simply. If Jeff deaf?
Dr. Chandrasekhar:
No.
Dr. Frisina:
No he's not deaf. He's hearing impaired.
Dr. Salgo:
Okay. He's diagnosed with high frequency hearing loss. That's what it says here in the chart. How bad is it from these numbers?
Dr. Frisina:
It's pretty significant for communication. We talked about consonants, high pitches. He's losing a lot of consonant information and he's going to confuse a lot, the meaning of a lot of words.
Dr. Salgo:
Do you have a differential, Lou that you ask your patients?
Dr. Papa:
A good audiologist will have in the report a contact and say this was not what we expected to see. This is a little bit more concerned to us. And for me, if I see that pattern is deviated. If there's A symmetry or it's not a pattern expecting I send them to an ENT doc.
Dr. Salgo:
What other things might you get from a history or a questioning of this patient that might rule in or rule out other causes of progressive hearing loss? I guess what I'm asking is what are the other causes?
Dr. Chandrasekhar:
I would like to know if he's served in the armed forces or?
Dr. Salgo:
No, he did not.
Dr. Chandrasekhar:
If he had noise exposure during his life?
Dr. Salgo:
Yes. He played in a rock band. A garage band when he was younger, for quite some time. So there's that in the history. He is an intelligent lawyer. Since he was sent for his audiometry test he's been on the web and the next thing you know he's asking about the gin and tonic. Why on earth would he ask about the tonic water?
Dr. Chandrasekhar:
Oh.
Dr. Papa:
Quinine.
Dr. Salgo:
Quinine. What is quinine having, doing over there?
Dr. Chandrasekhar:
Quinine. High doses of quinine cause ototoxicity. He has one gin and tonic a night. (laugh) I mean unless he's a.
Dr. Frisina:
It's the rock band. Yeah.
Dr. Chandrasekhar:
Putting special levels of quinine. If he's taking it with Larium or he's taking it with an antimylarial. It's a very.
Dr. Salgo:
He's also taking an aspirin.
Dr. Chandrasekhar:
It's a very low though. One or two aspirins a day. One gin and tonic a day. One lasiks a day are not going to cause you hearing loss.
Dr. Salgo:
He also tells you by the way, I've had no injury to my head. Is injury a common cause of hearing loss?
Dr. Chandrasekhar:
You can. It has to be a pretty significant injury to have what we call a cochlear concussion. You have to bang your head pretty badly and it has to be repeated trauma to the head. I mean significant repeated.
Dr. Frisina:
It would go along with other neural problems of head injury.
Dr. Salgo:
Kathy when you finally got seen for your hearing loss, after all was said and done, what did they say was your diagnosis? What caused it?
Kathy:
Well this is. I had a combination of loss. And then I was able at some point to have an operation, which brought my hearing up to where it is now. I still have noise damage from music but at least I'm hearing person.
Dr. Salgo: We haven't asked about something here, which is genetics. Does hearing loss run in families? Is that something that we need to worry about.
Kathy: My identical twin has hearing loss. I just found out.
Dr. Chandrasekhar: Does she has Otosclerosis?
Kathy: Yeah.
Dr. Salgo: Is that right?
Dr. Chandrasekhar: Because Otosclerosis is familial.
Dr. Frisina: She wasn't in a rock band.
Dr. Chandrasekhar:
In over fifty percent of cases.
Dr. Salgo:
Of all hearing loss? All comers. Genetics, the most common, the least common?
Dr. Frisina:
In age related hearing loss.
Dr. Salgo:
Right.
Dr. Frisina:
It's been pretty well shown that there is a strong familial component, meaning there is a genetic component.
Dr. Salgo:
Now we are the first generation to be exposed to what, the hair dryers, the loud rock concerts, weedwackers. All this stuff. You walk down the street and all of the loud machinery. Are we going to be a generation of deaf people?
Dr. Chandrasekhar:
We're not going to be deaf. Are we all going to have a higher incidence of hearing loss or hearing impairment given our noise exposure, yes. The Bain of the industrial age is noise related hearing loss both from industry and from life.
Dr. Caine:
I think, you know, the question, obviously is the one when you put the ear buds in your ears and you turn up the blaster and in the elevator or nearby you can hear the music almost as clearly as the person's hearing it there. That's going to be an issue. And we certainly see that in a lot of patients who get admitted to the hospital now. You know, they're not hearing as well. I mean and I talk about, I'm coming into the psych service but, you know, wherever.
Dr. Salgo:
Well let me ask you this. I mean can we prevent some of this by some simple techniques. And he brings up the I-Pod. Is there a way to keep from losing your hearing?
Dr. Chandrasekhar:
Yes.
Dr. Salgo:
You can't pick your parents. Your genetics are what they are.
Dr. Chandrasekhar:
Right.
Dr. Salgo:
What can you do to protect your hearing and save it for later in life?
Dr. Chandrasekhar:
So what you can do is if you have to listen to a personal listening device you can either. I know I-Pod sells headphones that cannot go beyond I think its seventy decibels. Even if you wore your I-Pod all day long, antioxidants. We are looking into very much for prevention and treatment of drug induced hearing loss and noise induced hearing loss. So eat some leafy green vegetables, have some fresh tomatoes. A general healthy lifestyle we know. Caffeine and nicotine are very bad for hearing.
Dr. Salgo:
All right. And with that, let me sum up where we are. Some types of hearing loss are preventable. They are avoidable. Avoidable hearing loss can be due to noise, sometimes to toxins. Sometimes to injury so don't get hit on the head very hard. But mostly I hear that its noise. Noise is the big offender. I'm assuming that if you go to a rock concert you want to wear earplugs. Huh?
Dr. Chandrasekhar:
If you go to rock concerts now, all of the roadies, all of the humans who work there are wearing earplugs and at least half of the audience is wearing earplugs.
Dr. Salgo:
All right. We.
Female Voice2:
Are you still hearing with the earplugs in?
Dr. Chandrasekhar:
Yeah. It sounds great because you don't get the obnoxious noise level that hurts. You actually get the music.
Dr. Salgo:
Remember Jeff? The guy, the lawyer.
Female Voice2:
Jeff. Yeah.
Dr. Salgo: Let's talk about hearing aids for a minute. Does he need hearing aids now do you think?
Dr. Chandrasekhar:
He'd benefit.
Dr. Salgo:
She says yes.
Dr. Chandrasekhar:
The hearing aids would do wonders for this man.
Male Voice: But its amazing how, and being from, it's easier for me to get people to wear oxygen than to get them to wear hearing aids. It's like, you know, what? This is a quality of life thing for me. And right now my quality of life is worse wearing this hearing aid because I don't like the way it looks. I don't like how expensive it is. I can hear the birds chirping across the street. I'm taking it off.
Dr. Salgo:
Let's get it straight. What do hearing aids do? Are they just amplifiers? Everything comes in louder? You just told me that loud sound is bad.
Dr. Frisina:
Hearing aids ideally will limit sounds and amplify sounds. So the idea is to get the sound right in the correct region for the best perception. The problem with hearing aids is they're not correcting the biological problem.
Dr. Salgo:
Kathy, what did the doctors do for you? With your diagnosis, what happened to you sequentially?
Kathy:
Well I, you know, went through lip reading. I had hearing aids, two hearing aids. And I had them for several years.
Dr. Salgo:
What was that like? Did you like them?
Kathy:
It helped me to hear again but it was like ahhh, you know. As a musician I couldn't use them when I was performing, wear earplugs.
Dr. Salgo:
You said you used to use hearing aids. You're not using them now?
Kathy:
Well no because I had that operation.
Dr. Salgo:
What operation did you have?
Kathy:
I had the stapedectomy. But that's not for noise. That's not for a nerve loss. That's for the conductive loss.
Dr. Salgo:
That's the other part of the chain, right?
Dr. Chandrasekhar:
Right.
Kathy:
Yeah. So I had another chance.
Dr. Salgo:
If you had the surgery and you hear better now, you don't need the hearing aids. Yet you still have noise related hearing loss.
Kathy:
I have borderline mild; I have more of a mild loss. But if it keeps worsening, I will get hearing aids.
Dr. Salgo:
Let's talk about Jeff. His doctor says, look, let's cut to the chase. What you need is hearing aids. And Jeff says, no. And the reasons he gives are what we already discussed. He doesn't want the stigma. He doesn't want to look old. That's just what he says. If he does nothing what's going to happen?
Dr. Frisina:
His hearing will get progressively worse. He'll start losing his communication
abilities at home, with his family.
Kathy Kastan:
He'll frustrate his family.
Dr. Frisina:
His wife will be calling the primary care. He'll lose, if he has grandchildren he'll lose communication with the grandchildren because they won't be patient and repeat everything for him. And it will start to interfere at work. In a meeting situation like this where there are multiple talkers. It will hurt him at work.
Dr. Papa:
This is a good point when you're in primary care to bring in the family. To bring in the wife and sit down, because the reality is, is he's going to do what he wants to do. It's a lifestyle thing. All right. It's like walking with a cane. It's like, you know, wearing your glasses but it's affecting other family members.
Dr. Salgo:
Jeff finally does agree to wear hearing aids and he choices his hearing aid purely on the basis of cost. He buys a cheap one. Is that the right decision? How expensive can hearing aids be? Do cheap ones work just as well as expensive ones?
Dr. Papa:
Some of them are really expensive.
Dr. Frisina:
Some of them get, if you buy two of them can be five, six thousand dollars.
Dr. Salgo:
Really.
Dr. Frisina:
And generally most of the cost of the hearing aid itself is not covered by insurance, so that's a big issue in the U.S. There are many different hearing aids. Given his position you would think he would want to try a pretty expensive one and given the importance of hearing to him.
Kathy Kastan: Well do you mean two or one? Because I know.
Dr. Chandrasekhar: He would need two.
Dr. Frisina: There's a lot of evidence suggesting that two are better than one.
Dr. Salgo: All right. Let me pause here for a moment and let's sum up what we've been talking about. There are personal and societal implications to hearing loss however there are good treatments available including hearing aids, surgery for some people but not early in the case. Technology is constantly improving. They come in lots of different flavors, do the hearing aids. When last we left Jeff he'd bought some cheap hearing aids. He's frustrated with them. They squeal. He sometimes hears background noises very loudly. Is this experience unique?
Dr. Papa:
You get what you pay for.
Dr. Chandrasekhar:
Yeah. This is a problem. You can have difficulty with even the best hearing aids and that's why you go to a good hearing aid dispenser. The mould has to be correct to fit in your ear. If you got an ill fitting mould or you bought, you know, size medium from the small, medium, and large store, that's going to give you feedback. It's going to feel like a plug. It's going to. You should not feel your hearing aid when it's on your ear except to know that you are suddenly hearing everything you're supposed to be hearing.
Dr. Salgo:
You've taken this event that happened to you, your hearing loss, and you've worked with it and done something constructive with it. Can you talk about that a bit?
Kathy:
Well yes. Well HEAR, Hearing Education Awareness for Rockers, it's my twentieth anniversary.
Dr. Salgo:
Congratulations.
Kathy:
Thank you. Typically hearing does not get the big funding bucks for research. And especially awareness programs. So you know, prevention is really important because a little bit of prevention goes a long way. And we were just honored by NAMM, the National Association of Music Manufacturers with, acknowledging our work. So we are working with the music manufacturers and many of them are really pro hearing. Hearing awareness. And there's more, there's more, always more work to be done.
Dr. Salgo:
I want to thank you for being here. Thank all of you for being here. A great discussion. We've covered a lot of ground today. Let's sum up the key things to remember. Normal hearing requires all components of the physical hearing chain to be functioning properly. Any breakdown or impairment in that chain may result in a loss of hearing acuity. Some types of hearing loss are preventable. Avoiding hearing loss can be, avoidable hearing loss, by the way, can be due to noise, toxins or even injury. There are personal and societal implications to hearing loss, however there are good treatments available including hearing aids and surgery. Technology is constantly improving. And our final message is this, taking charge of your health means informed health care. Being informed and having quality communication with your doctor. I'm Dr. Peter Salgo, and I'll see you next time for another Second Opinion.
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