NL0313A Hearing Loss – Introduction and Overview Printed with Permission from Better Hearing Institute

NL0313A Hearing Loss – Introduction and Overview Printed with Permission from Better Hearing Institute http://www.betterhearing.org

The Better Hearing Institute (BHI) is a not-for-profit corporation that educates the public about the neglected problem of hearing loss and what can be done about it. Founded in 1973, we are working to:

 Erase the stigma and end the embarrassment that prevents millions of people from seeking help for hearing loss.  Show the negative consequences of untreated hearing loss for millions of Americans.  Promote treatment and demonstrate that this is a national problem that can be solved.

1. HOW WE HEAR

Patricia E. Connelly, PhD, CCC-A, FAAA, New Jersey Medical School, NEWARK, NJ

The Hearing System

The anatomy of the hearing system can be divided into four components for our convenience in remembering the parts and associating these parts with their function. These divisions are the:

1. outer ear 2. middle ear 3. inner ear 4. central auditory pathways

The Outer Ear (1)

Several structures comprise the outer ear. The most readily seen is the pinna, also called the auricle. The pinna is made up of a frame of cartilage that is covered with skin. The pinna has obvious folds, elevations, depressions and a prominent bowl - all of which vary somewhat from person to person but a basic pattern in these features is fairly universal among all people. The pinna acts as a funnel to collect and direct sound down the ear canal. It also serves to enhance some sounds through its resonance characteristics. Finally, it helps us to appreciate front-back sound localization.

The other structure of the outer ear is the external ear canal. The outer two-thirds of this canal has a cartilaginous framework, and the inner one-third is bony. The skin of the external ear canal is continuous with the skin of the pinna. The ear canal is curved, almost "S" shaped and averages about 1 inch in length in adults. The skin of ear canal has hairs (more prominent in some people) and glands that produce wax called cerumen (also more prominent in some individuals than in others). This hair and cerumen serve a protective function for the ear canal. In addition, cerumen helps to lubricate the skin and keep it moist.

The Middle Ear (2)

The middle ear begins at the inner end of the external auditory canal, specifically at the eardrum. Also called the tympanic membrane, the eardrum is a thin and delicate membrane stretched across the entire inner end of the ear canal separating the environment from the middle ear. Despite the delicacy of its structure, the tympanic membrane never stops working to transform fluctuations in air pressure known as sound into exact copies in the mechanical domain as vibrations.

On that inner side of the tympanic membrane is an air-filled space called the middle ear cavity. It contains the bones of hearing, two muscles, a number of ligaments, a small branch of the nerve of taste, and the opening of the Eustachian tube. The vibratory motions of the tympanic membrane are transmitted to the bones of hearing, also known as the ossicles or the ossicular chain. This ossicular chain articulates with the tympanic membrane through the lateral most bone called the malleus (hammer). The malleus then sends the mechanical vibrations to the incus (anvil), which in turn communicates with the inner most ossicle called the stapes (stirrup). These are the three smallest bones in the body, and, like the tympanic membrane, they never stop moving because they are constantly bombarded with sound, even while we're sleeping! Functionally, the tympanic membrane converts the acoustical energy of sound into an exact copy in the mechanical domain. The ossicles then convey this mechanical energy to the inner ear at the oval window where the footplate of the stapes sits. It is at this location where the mechanical energy is then transformed into the hydraulic energy that the inner ear processes.

The ossicles are suspended from the roof of the middle ear cavity by tiny ligaments, and the malleus is connected to the tympanic membrane by a ligament, as well. In addition, there are two muscles located in the middle ear space. One is called the stapedius. It is attached to the stapes and contracts when very loud sounds are detected.

The opening for the Eustachian tube is located at the front wall of the middle ear cavity, and the other end opens in the upper, back part of the throat. The Eustachian tube is a muscular tunnel that opens and closes to provide fresh air to and drain debris from the middle ear space and to equalize the pressure between the environment and the middle ear space. It's what we try to "pop" when we're in an airplane, or an elevator, or in the mountains. Its functions are very important to maintaining the health of the middle ear space.

The Inner Ear (3)

The inner ear has two divisions: one for hearing, the other for balance. The division for hearing consists of the cochlea and the nerve of hearing. The cochlea is snail-shaped, bony structure that contains three fluid-filled compartments that run the cochlea's entire length. One compartment is sandwiched between the other two, and it contains the sensory organ for hearing called the organ of Corti. The organ of Corti responds when the hydraulic energy of the cochlear fluid activates its tiny hair cells to release chemical messengers. These messengers then stimulate the nerves of hearing which carry sound stimuli to the brain. The pitch and loudness of the original acoustic signal in the ear canal determine the exact location and the number of hair cells activated on the organ of Corti.

The balance mechanism is also called the vestibular system. It too is made up of a series of fluid-filled compartments (three semi-circular canals and two larger divisions) that contain the sense organs for balance and movement. The vestibular sensors detect angular movements, direction and velocity of the head. This information about equilibrium is sent to the brain by the vestibular nerves, a functionally separate division of the auditory vestibular nerve, the VIIIth cranial nerve.

Central Auditory Pathways (4)

"Inner ear" is a collective term that encompasses the separate structures for hearing and balance. Once the auditory vestibular nerve reaches the brainstem, the balance system sends its information to brain structures responsible for processing this type of sensory information, whereas the hearing system sends its information to different parts of the brain specifically to extract the sound cues out of the electrical message brought by the nerves of hearing.

We can think of the central auditory pathways as being organized like circuits. There are short and long segments, all of which work together as the central auditory pathways or the central auditory nervous system. This system begins as the nerve of hearing enters the brainstem. From here, the neural pathway makes its way up to the cerebral cortex at the temporal lobe of the brain along the way switching back and forth from each side of the brainstem with neurons multiplying in number at each relay station along the circuit. Right ear information is directed to the left temporal lobe, and left ear information goes to the right temporal lobe. In addition, there is a transfer of information from one side of the brain to the other. In most people, the left side of the brain processes speech and other complex language functions, whereas tonal stimuli and music are deciphered by the right side of the brain.

2. THE PROCESS OF "HEARING"

Our ears work to transform the acoustic stimulus that travels down our ear canals into the type of neural code that our brains can recognize, process and understand. It all starts at the tympanic membrane where the physical attributes of the sound are transformed into a mechanical stimulus. This mechanical code is transmitted through the ossicular chain to the stapes footplate where the code is again transformed this time into hydraulic energy for transmission through the fluid-filled cochlea. Finally, when the cochlea's hair cells are stimulated by the fluid waves a neurochemical event takes place which excites the nerves of hearing. The physical characteristics of the original acoustic signal are preserved at every energy change along the way until this code becomes one that the central auditory pathways can direct to the temporal lobe of the brain for recognition and processing.

The brain and the relay stations along the central auditory pathways can extract not only the pitch and loudness features but also as other critical attributes such as temporal features (timing) and different cues from each ear. Features of the sound stimulus can be extracted, enhanced, and modulated and this information can be compared separately from each ear or combined into a single perception. These features can be compared to other acoustic patterns that are stored in the brain, perhaps for the recognition of the voice of a family member or friend, or they can be the initial experience with a new sound or a new voice.

Our hearing systems anchor us to the soundscape of our environment with an incredible ability to detect and differentiate infinitesimally small acoustic cues. Our brains store the neural equivalents of acoustic patterns - voices, music, environmental sounds, danger signals - that make it easier to process and recognize both familiar and unfamiliar signals. Hearing loss misleads our brain with a loss of audibility (sounds are softer, not as loud) as well as a distortion of the information that reaches the brain. Changes in the effectiveness of the brain to process stimuli, through head trauma, neurologic disease or disorder, or the naturally occurring process of aging, can result in symptoms that mimic hearing loss - inattention, inappropriate responses, confusion, a disconnect from the those around us, for example. The ears and the brain combine in a truly remarkable way to process neural events into the sense of hearing and all that it encompasses. Perhaps it's fair to say that we "hear" with our brain, not with our ears!

Consequences of Hearing Loss

"Sound is not only a guide to the practicalities of living….it is also an aesthetic pleasure." (Farewell to Fear) Tomi Keitlen

Many people are aware that their hearing has deteriorated but are reluctant to seek help. Perhaps they don't want to acknowledge the problem, are embarrassed by what they see as a weakness, or believe that they can "get by" without using a hearing aid. And, unfortunately, too many wait years, even decades, before getting treatment.

But time and again, research demonstrates the considerable negative social, psychological, cognitive and health effects of untreated hearing loss . . . with far-reaching implications that go well beyond hearing alone. In fact, those who have difficulty hearing can experience such distorted and incomplete communication that it seriously impacts their professional and personal lives, at times leading to isolation and withdrawal.

Studies have linked untreated hearing loss to:

 irritability, negativism and anger  fatigue, tension, stress and depression  avoidance or withdrawal from social situations  social rejection and loneliness  reduced alertness and increased risk to personal safety  impaired memory and ability to learn new tasks  reduced job performance and earning power  diminished psychological and overall health

Hearing loss is not just an ailment of old age. It can strike at any time and any age, even childhood. For the young, even a mild or moderate case of hearing loss could bring difficulty learning, developing speech and building the important interpersonal skills necessary to foster self-esteem and succeed in school and life.

At the Better Hearing Institute, our mission is to help educate the public about hearing loss and promote the importance of prevention and treatment. On this website, you will find basic information about hearing loss, including advances in diagnosis and treatment, a review of different hearing aids, and resources for medical care and financial assistance. If you think you or a loved one suffers from hearing loss, don't delay another day. Visit a hearing healthcare professional and take the first step toward a world of better hearing.

Sergei Kochkin, Ph.D. Executive Director Better Hearing Institute

Prevalence of Hearing Loss

Sergei Kochkin, Ph.D. Better Hearing Institute, Washington, DC

In order to gauge the number of people with hearing loss in the United States, 80,000 members of the National Family Opinion (NFO) panel were surveyed. This survey, which has been funded by a sponsor of BHI since 1989, is published under the name "MarkeTrak". The NFO panel is representative of U.S. households.

People with hearing loss are often embarrassed because they think that they are different or that they have a rare condition. The last MarkeTrak survey (2004) estimated that 31.5 million people report a hearing difficulty; that is around 10% of the U.S. population. So if you have a hearing loss, understand that you are not alone. The number of people with hearing loss by age is provided in the graph above.

Here are some general guidelines regarding the incidence of hearing loss:

 3 in 10 people over age 60 have hearing loss;  1 in 6 baby boomers (ages 41-59), or 14.6%, have a hearing problem;  1 in 14 Generation Xers (ages 29-40), or 7.4%, already have hearing loss;  At least 1.4 million children (18 or younger) have hearing problems;  It is estimated that 3 in 1,000 infants are born with serious to profound hearing loss.

Common Myths

Hearing loss affects only "old people" and is merely a sign of aging. Actually it is the reverse of what most people think. The majority (65%) of people with hearing loss are younger than age 65. There are more than six million people in the U.S. between the ages of 18 and 44 with hearing loss, and nearly one and a half million are school age. Hearing loss affects all age groups.

If I had a hearing loss, my family doctor would have told me. Not true! Only 13% of physicians routinely screen for hearing loss during a physical. Since most people with hearing impairments hear well in a quiet environment like a doctor's office, it can be virtually impossible for your physician to recognize the extent of your problem. Without special training, and an understanding of the nature of hearing loss, it may be difficult for your doctor to even realize that you have a hearing problem.

Signs of Hearing Loss

Patricia E. Connelly, PhD, CCC-A, FAAA, New Jersey Medical School, NEWARK, NJ

THE SIGNS OF HEARING LOSS CAN BE SUBTLE AND EMERGE SLOWLY, OR THEY CAN BE SIGNIFICANT AND COME ON SUDDENLY. EITHER WAY, THERE ARE COMMON INDICATIONS. YOU SHOULD SUSPECT HEARING LOSS IF YOU EXPERIENCE ANY OF THE SIGNS BELOW. You might have hearing loss if you . . .

Socially:

 require frequent repetition.  have difficulty following conversations involving more than 2 people.  think that other people sound muffled or like they're mumbling.  have difficulty hearing in noisy situations, like conferences, restaurants, malls, or crowded meeting rooms.  have trouble hearing children and women.  have your TV or radio turned up to a high volume.  answer or respond inappropriately in conversations.  have ringing in your ears.  read lips or more intently watch people's faces when they speak with you.

Emotionally:

 feel stressed out from straining to hear what others are saying.  feel annoyed at other people because you can't hear or understand them.  feel embarrassed to meet new people or from misunderstanding what others are saying.  feel nervous about trying to hear and understand.  withdraw from social situations that you once enjoyed because of difficulty hearing.

Medically:

 have a family history of hearing loss.  take medications that can harm the hearing system (ototoxic drugs).  have diabetes, heart, circulation or thyroid problems.  have been exposed to very loud sounds over a long period or single exposure to explosive noise.

Types of Hearing Loss Detail

Patricia E. Connelly, PhD, CCC-A, FAAA, New Jersey Medical School, NEWARK, NJ

A comprehensive audiologic evaluation must be completed in order to determine the type and severity of hearing loss and to make appropriate recommendations for each patient. Pure tone and speech audiometry as well as the immittance test battery must be completed, in addition to any additional assessments necessary for an exhaustive profile of the hearing system. A balance test called electronystagmography (ENG) might also be needed if dizziness or imbalance is also a complaint. Some patients who are bothered by tinnitus only might have a complete tinnitus evaluation. Finally, the audiologic data provide the clinical foundation for recommendations regarding hearing aids and other assistive devices.

In general terms, there are two types of hearing loss, conductive and sensorineural. A combination of both is also seen as a mixed hearing loss. Each is discussed below.

Conductive Hearing Loss

Conductive hearing loss is caused by any condition or disease that impedes the conveyance of sound in its mechanical form through the middle ear cavity to the inner ear. A conductive hearing loss can be the result of a blockage in the external ear canal or can be caused by any disorder that unfavorably effects the middle ear's ability to transmit the mechanical energy to the stapes footplate. This results in the reduction of one of the physical attributes of sound called intensity (loudness), so the energy reaching the inner ear is lower or less intense than that in the original stimulus. Therefore, more energy is needed for the individual with a conductive hearing loss to hear sound, but once it's loud enough and the mechanical impediment is overcome, that ear works in a normal way. Generally, the cause of conductive hearing loss can be identified and treated resulting in a complete or partial improvement in hearing. Following the completion of medical treatment for cause of the conductive hearing loss, hearing aids are effective in correcting the remaining hearing loss.

The audiometric profile that indicates a conductive hearing loss is the presence of air-bone gaps (better hearing by bone conduction than by air conduction), excellent word recognition at a comfortable listening level, and evidence of a middle ear dysfunction on immittance. For situations where a blockage is noted in the external ear canal, hearing testing is deferred until the canal is cleared.

Sensorineural Hearing Loss

The second type of hearing loss is called sensorineural hearing loss. This word can be divided into its two components - sensory and neural - to allow us more clarity in specifying the type of hearing loss. The comprehensive audiometric assessment and supplemental tests can yield the information needed to differentiate between a sensory and a neural hearing loss, although they can co-exist in the same ear. Neural hearing loss is another name for retrocochlear hearing loss.

Sensorineural hearing loss results from inner ear or auditory nerve dysfunction. The sensory component may be from damage to the organ of Corti or an inability of the hair cells to stimulate the nerves of hearing or a metabolic problem in the fluids of the inner ear. The neural or retrocochlear component can be the result of severe damage to the organ of Corti that causes the nerves of hearing to degenerate or it can be an inability of the hearing nerves themselves to convey neurochemical information through the central auditory pathways.

Mixed Hearing Loss

A mixed hearing loss can be thought of as a sensorineural hearing loss with a conductive component overlaying all or part of the audiometric range tested. So, in addition to some irreversible hearing loss caused by an inner ear or auditory nerve disorder, there is also a dysfunction of the middle ear mechanism that makes the hearing worse than the sensorineural loss alone. The conductive component may be amenable to medical treatment and reversal of the associated hearing loss, but the sensorineural component will most likely be permanent. Hearing aids can be beneficial for persons with a mixed hearing loss, but caution must be exercised by the hearing care professional and patient if the conductive component is due to an active ear infection.

Causes of Hearing Loss

Patricia E. Connelly, PhD, CCC-A, FAAA, New Jersey Medical School, NEWARK, NJ

The causes of hearing loss are varied and their impact on hearing is variable. Sometimes the cause or etiology is readily apparent, such as a wax build-up in the external ear canal or an ear infection. At other times, the causes of hearing loss are presumed or indefinite given current levels of technology and the information they provide, such as in cases of sudden onset or non-syndromic sensorineural hearing loss.

The main causes of hearing loss are as follows:

 Excessive noise (i.e. construction, rock music, gun shot, etc)  Aging (presbycusis)  Infections (otitis media)  Injury to the head or ear  Birth defects or genetics  Ototoxic reaction to drugs or cancer treatment (i.e. antibiotics, chemotherapy, radiation)

Hearing Health Medical Issues Explained

 Autoimmune Inner Ear Disease Autoimmune inner ear disease (AIED) is an inflammatory condition of the inner ear. It occurs when the body's immune system attacks cells in the inner ear that are mistaken for a virus or bacteria.

 Cholesteatoma A cholesteatoma is a skin growth that occurs in an abnormal location, the middle ear behind the eardrum. It is usually due to repeated infection, which causes an in growth of the skin of the eardrum.  Cochlear Implants A cochlear implant is an electronic device that restores partial hearing to the deaf. It is surgically implanted in the inner ear and activated by a device worn outside the ear.

 Ear Tubes Explained Sometimes ear infections and/or fluid in the middle ear may become a chronic problem and insertion of an ear tube by an otolaryngologist (ear, nose, and throat surgeon) may be considered.

 Ear Infections and Earache Otitis media means inflammation of the middle ear. The inflammation occurs as a result of a middle ear infection, and can occur in one or both ears. Otitis media is the most frequent diagnosis recorded for children who visit physicians for illness.

 Ears and Altitude Ear problems are the most common medical complaint of airplane travelers, and while they are usually simple, minor annoyances, they occasionally result in temporary pain and hearing loss.

 Earwax Ear doctors would say "never put anything smaller than your elbow in your ear! Cotton swabs are for cleaning bellybuttons-not ears."…find out why.

 Genes and Hearing Loss Learn more about how the genes you inherit from your parents can contribute to hearing loss in you or your children.

 Hyperacusis - An increased sensitivity to everyday sounds Hyperacusis is a condition that arises from a problem in the way the brain's central auditory processing center perceives noise. It can often lead to pain and discomfort.

 Meniere's Disease Meniere's Disease is a disorder of the inner ear. Learn more about its symptoms, diagnosis, and treatment.

 Otosclerosis Find out more about otosclerosis, a hardening of the bones in the middle ear.

 Ototoxic Drugs Some common drugs such as antibiotics, aspirin, diuretics and chemotherapy can cause hearing loss. In fact BHI spokesperson Shelley Beattie developed hearing loss as a child due to an overdose of aspirin. See below for reputable websites on the link between drugs and hearing loss.

American Speech Hearing Association (ASHA)

Merck Drug Company

National Institute of Health (NIH)

Otoneurology Education Tutorial: Comprehensive write-up by Dr. Timothy C. Hain

The Royal National Institute of Deafness (RNID)

 Perforated Eardrum A perforated eardrum is a hole or rupture in the eardrum, a thin membrane that separates the ear canal and the middle ear. The medical term for eardrum is tympanic membrane.

 Plastic Surgery of the Ear Protruding and drooping ears or torn earlobes can be surgically corrected. These procedures do not alter the patient's hearing, but they may improve appearance and self-confidence.

 Swimmer's Ear If you already have an ear infection, or if you have ever had a perforated or otherwise injured eardrum, or ear surgery, you should consult an ear, nose, and throat specialist before you go swimming and before you use any type of ear drops. o

Causes of Hearing Loss – Conductive

Conductive Hearing Loss

 External Ear o congenital malformation where pinna and ear canal fail to form o blockage in ear canal - foreign body or accumulated cerumen (ear wax)  Middle ear o perforation in tympanic membrane (ear drum) from trauma or disease o otitis media (ear infection) o broken ossicular chain due to head trauma or trauma to the ear

Causes of Hearing Loss – Sensorineural:

Sensorineural Hearing Loss

Sensorineural hearing loss can be divided into its two components - sensory and neural - to allow us more clarity in specifying the type of hearing loss. The comprehensive audiometric assessment and supplemental tests can yield the information needed to differentiate between a sensory and a neural hearing loss, although they can co-exist in the same ear. Neural hearing loss is another name for retrocochlear hearing loss.

The reason for sensorineural hearing loss sometimes cannot be determined, it does not typically respond favorably to medical treatment, and it is typically described as an irreversible, permanent condition. Like conductive hearing loss, sensorineural hearing loss reduces the intensity of sound, but it might also introduce an element of distortion into what is heard resulting in sounds being unclear even when they are loud enough. Once any medically treatable conditions have been ruled out, the treatment for sensorineural hearing loss is amplification through hearing aids.  Sensory o neonatal risk indicators o genetic disorders causing non-syndromic sensorineural hearing loss o presbycusis - hearing loss from aging o ototoxic drugs such as some antibiotics o cancer treatments - chemotherapy and radiation therapy o head trauma - fractured temporal bone o excessive noise expose o diseases of the vascular system such as sickle cell anemia o kidney disease o Meniere's syndrome o congenital infections such as toxoplasmosis, rubella, CMV, herpes, other bacterial infections like syphilis o acquired infections such as influenza, meningitis, labyrinthitis, mumps, syphilis  Neural o acoustic neuroma or other tumor of or near the nerve of hearing and balance

Prevention of Hearing Loss from Noise Exposure

Brian J. Fligor, Sc.D., Children’s Hospital Boston, Harvard Medical School, Boston, MA

Introduction

Noise is one of the most common causes of hearing loss, and one of the most common occupational illnesses in the United States. A single shot from a large caliber firearm, experienced at close range, may permanently damage your hearing in an instant. Repeated exposures to loud machinery may, over an extended period of time, present serious risks to human hearing. According to the National Institute on Deafness and Other Communication Disorders (NIDCD):

 10 million Americans have already suffered irreversible hearing damage from noise  30 to 50 million more are exposed to dangerous noise levels each day.

Why has this problem become so widespread? Unfortunately, the effects of noise are often underestimated because the damage takes place so gradually, loud noises have become so common in our culture, and (although traumatizing to the parts of the body responsible for hearing) there are no externally-visible physical changes (like bleeding). As a result, people have traditionally not appreciated the serious impact of noise-induced hearing loss (NIHL) on their daily living until they’re frustrated by a permanent communication problem or ongoing ringing in their ears. Perhaps a bit too late, they then become passionate about “hearing conservation” in order to save the hearing they still possess. Doesn’t it make more sense, though, to emphasize “HEARING LOSS PREVENTION”, while you still have good hearing sensitivity? This document will summarize how excessive noise can damage the hearing system, factors that influence this damage, and actions that you can take to prevent hearing loss.

Noise-induced hearing loss

Every day, we enjoy sounds: from nature sounds, to music, to a good conversation with a friend or loved one. Stop for a moment and think of your favorite sound. Is it the rain, or ocean waves, or a child’s laughter? Now, imagine permanently losing the ability to hear your favorite sound… slowly. That would be tragic. When an individual is exposed at work or at home to harmful sounds – sounds that are too loud for too long a time - sensitive structures of the inner ear can be damaged, causing noise-induced hearing loss (NIHL). NIHL is a hearing disorder characterized by a gradual, progressive loss of high frequency hearing sensitivity over time, as a result of exposure to excessive noise levels. The Figure below illustrates this typical progression, in which the pattern of NIHL usually shows a “notch” that is most often seen at or near 4000 Hz. In later stages, the hearing loss may spread to frequencies that are more critical to understanding human speech (in the range of 500-3000 Hz). NIHL usually occurs in both ears. However, the hearing loss may not necessarily occur equally between the left and right ears when the exposure conditions favor one side of the head. A common example of “asymmetric” NIHL is from shooting a rifle or shotgun (a right-handed shooter often has poorer hearing in the left ear, which is closer to the muzzle than the right ear). It is even possible to see a hearing loss in only one ear, as can happen in acoustic trauma, when a loud blast affects the ear nearest the explosion.

Progression of hearing loss following exposure to loud noise (95 dBA, averaged across the work day. Data show hearing loss for white males at ages 20, 30, 40, 50 and 60 years with 0 - 40 years of exposure, respectively). (ANSI 3.44-1996)

Tinnitus and noise exposure

Another condition that is often part of NIHL is tinnitus (pronounced “TIN-i-tus” or “tin-EYE-tus”). This is a condition described as the perception of sound (often buzzing, ringing, or hissing) in the absence of any external stimulus (that is, there is no sound others hear but the tinnitus sufferer does). This essentially takes away the opportunity for the person to experience quiet, and can be very distressing.

Some 30 million adults suffer from persistent tinnitus (it can also affect children). For some people the problem is severe enough that it impacts their everyday life. Tinnitus affects people differently. The most common areas in which tinnitus has a direct influence are:

 Thoughts and emotions. Some are annoyed, bothered, depressed, anxious or angry about their tinnitus. They think and focus on their tinnitus often.  Hearing. In some, the sound of the tinnitus competes with or masks speech or environmental sound perception.  Sleep. Many tinnitus sufferers report that their tinnitus interferes with them getting to sleep. It can also make it more difficult to get back to sleep when they wake up in the middle of the night.  Concentration. Some tinnitus sufferers report that they have difficulty focusing on a task because of their tinnitus. This might include reading a book or the newspaper.

For more information on tinnitus and treatment:

 See the Better Hearing Institute's Your Guide to Tinnitus  Visit the American Tinnitus Association website at www.ata.org.

How do we hear and the impact of noise?

While earlier we have explained the mechanisms of hearing, it would be useful to review these principles in terms of how noise can lead to permanent hearing damage. Our hearing system is designed to detect and process sounds over a remarkably wide range of levels. One can appreciate that early humans with better hearing could hear a predator or enemy trying to sneak up on them and “get the jump on them” and so have the greatest opportunity to survive and have offspring with good hearing. Modern industrialization, with combustion engines, pneumatic pumps, and repetitive loud machine noise wouldn’t have existed early in human development, and so the ear would not have been tuned to develop to be able to tolerate these very recent high sound levels.

Acoustic signals enter the auditory system through the outer ear, funneled by the pinna (the external part of the ear that we can see) and external ear canal. This funneling causes a “resonance” (like that created when you blow across the top of a glass bottle) which boosts energy in high frequencies, about 2000 Hertz (heard as a high pitch). The energy then reaches the eardrum and is transmitted through the middle ear by vibrating three tiny bones, called the ossicles. The eardrum and ossicles amplify the vibrations and carry them to the inner ear (specifically, the “cochlea”), which is a fluid-filled chamber locked inside the skull. These vibrations through the middle ear can be dampened when loud sounds cause a contraction of two tiny muscles attached to the middle ear bones, but this action is not fast enough to offer protection from sudden bangs and cannot be sustained during long exposures.

Inside the cochlea are very specialized sensory cells, called “hair cells” which are responsible for our remarkable ability to detect very soft sound and tolerate reasonably loud sound. We are born with a full complement of cells (about 17,000); if these cells are damaged, they are not replaced with new cells. So, when a hair cell dies, it is gone for good. Vibration from the middle ear to the inner ear causes motion in the inner ear fluid. This motion stimulates the top portion of the hair cells, which results in chemical changes that produce nerve impulses. These nerve impulses are carried along the hearing nerve to the brain, where they are interpreted as sound. The brain uses the incoming nerve impulses in an elegant interpretation of which, when and how many hair cells are stimulated. The hearing sensitivity of young children, with no hearing damage, allows them to detect very soft sounds across a range of approximately 8-9 octaves.

Noise "ages" hearing

Noise damages hearing in a manner not dissimilar to the effects of aging. In some ways, age-related hearing loss (presbycusis) is “lifetime wear and tear” on hearing. Noise serves to speed up the “wear and tear” process. When the hearing system is exposed to excessive noise, mechanical and metabolic changes can occur from this stress. Scientific research, based on studies of industrial workers, as well as lab studies of humans and animals, have investigated the effects of noise on hearing. This work has determined that, after excessive noise has stimulated cells in the inner ear, chemical processes occur that can exceed the cells’ tolerance, damaging their structure and function.

When sound is sufficient to cause hearing loss, most often there is a temporary loss of hearing sensitivity, known as temporary threshold shift (TTS). You likely have experienced this after attending a loud concert or working with loud tools or machinery. If the ear is given time to rest (typically 16 to 48 hours of relative quiet) the TTS recovers back to baseline hearing. With repeated occurrence, this TTS does not recover, and instead becomes a permanent threshold shift. How quickly this happens varies from one person to the next, and depends on how high was the offending sound exposure.

While earlier we have explained the mechanisms of hearing, it would be useful to review these principles in terms of how noise can lead to permanent hearing loss damage. Our hearing system is designed to detect and process sounds over a wide range of levels, but probably not for the extremely loud noises that occur in our modern world. Acoustic signals enter through the outer ear, funneled by the pinna (the external part of the ear that we can see) and external ear canal. This funneling causes a "resonance" (like that created when you blow across the top of a glass bottle) which boosts energy in high frequencies, about 2000 Hertz (heard as a high pitch). The energy then reaches the middle ear where it causes the eardrum to vibrate three tiny bones, called the ossicles, in the middle ear. The eardrum and ossicles amplify the vibrations and carry them to the inner ear or cochlea, which is a fluid-filled chamber locked inside the inner ear. These vibrations can be dampened when loud sounds cause a contraction of two tiny muscles attached to the middle ear bones, but this action is not fast enough to offer protection from sudden bangs and cannot be sustained during long exposures. The vibrations move through the fluid in the cochlea, which contains about 20,000 sense cells of hearing, called the hair cells. Movements in the fluid stimulate the top portion of the hair cells, which causes chemical changes that produce nerve impulses. These nerve impulses are carried along the hearing nerve to the brain, where they are interpreted as sound. The brain uses the incoming nerve impulses in an elegant interpretation of which, when and how many hair cells are stimulated. The hearing sensitivity of young children, with no hearing damage, allows them to detect very soft sounds across a range of approximately 8-9 octaves.

Loud explosions (that peak for a few milliseconds at levels greater than 130-140 dB) may cause immediate hearing loss (this is called “acoustic trauma”). More often, however, hearing loss is caused by repeated exposure to noise above 85 dBA over long periods. The risk of noise-induced hearing loss depends on both the intensity and duration of the exposure. As intensity increases, the length of time for which the exposure is “safe” decreases. As a result, someone exposed to 85dBA (often produced by gas-engine lawn mowers) for 8 hours may be equally at risk for noise exposure after using a chain saw (producing 110dBA) for only a few minutes.

For typical long term exposure to high level sound that results in permanent hearing loss, a cascade of chemical events occurs when the cell is metabolically “overloaded” and the cell undergoes a process known as “apoptosis.” The cell that is damaged beyond its ability to recover literally fragments and the pieces of the cell are ejected into the fluid of the cochlea. Cells around the now missing hair cell serve as “scar tissue” to maintain the structural integrity of the system, but these supporting cells do not contribute to the active process of hearing. This damage results in sensorineural hearing loss and, often, tinnitus.

What are the symptoms of NIHL?

NIHL develops gradually so that people may lose a significant amount of hearing before becoming aware of its presence. During the early stages, sufferers often report having to turn up the volume on the TV or have difficulty understanding speech in groups or in the presence of background noise. As the hearing loss worsens, it becomes difficult to understand normal conversation even in quiet, one-on-one situations. The individual may not be aware of the high frequency hearing loss, but it can be detected with a hearing test. In fact, early identification is important in order to recognize the presence of NIHL and then take steps to prevent further hearing loss.

Some of the warning signs of the presence of, or exposure to, hazardous levels of noise are as follows:

 You can’t hear someone talking three feet away  You have a feeling of “fullness” in your ears after leaving a noisy area  You hear ringing or buzzing (tinnitus) in your ears immediately after exposure to noise  You suddenly have difficulty understanding speech after exposure to noise; you can hear people talking but you have difficulty understanding them.

Preventing noise-induced hearing loss

NIHL is almost entirely preventable. Although hearing normally declines with age, the average, healthy, non-noise- exposed person can have essentially normal hearing at least up to age 60. Individuals vary in their susceptibility to hearing loss. While research has shown some trends, there currently is no reliable way to identify which particular individuals may be most susceptible to NIHL. To protect themselves when exposed to hazardous noise, everyone should take these precautions:

 Know which noises can cause damage (those above 85 decibels), including jet engines, lawn mowers, motorcycles, chainsaws, powerboats, and personal listening devices (like MP3 players). If you have to raise your voice to shout over the noise to be heard by someone within an arm’s length away, the noise is probably in this range. More formal noise measurements can be made (and are required in most industries), to determine risks from noise exposures. The noise thermometer below shows you the relative risk associated with certain noisy environments.  If possible, try to reduce noise at the source. Sometimes, replacing mufflers, keeping equipment in good maintenance, or placing the machine inside an enclosure can shield a person from the risks of NIHL. When purchasing new tools and yard equipment, consider their noise outputs before buying units with ineffective mufflers.  Personal listening devices (like MP3 players with earphones) can also present risks to hearing if used at too high a volume for too long. Consider using earphones that block out background noise to help you moderate your listening level, and give yourself listening breaks if you do choose to listen loud. Some devices exist on the market which limit the volume that can be output by the MP3 player, virtually making them kid-proof.  Wear hearing protection devices (HPDs) such as earplugs or earmuffs, when involved in loud activities (at work or when involved in noisy recreational activities). When properly selected and used, HPDs can be powerful tools for preventing NIHL. HPDs are required by law to be labeled with a Noise Reduction Rating (NRR) that is based on performance obtained under ideal laboratory conditions. Usually, people obtain far less protection than the labeled rating because they don’t wear the devices correctly or neglect to wear them during the entire period of the noise exposure. It must be emphasized that the best hearing protector is not the one with the highest NRR, but the one that people will consistently wear whenever exposed to loud noise. There is no single protector that will fit everyone, be universally comfortable, and be appropriate in every environment. What follows are some typical HPD options, as well as some special-purpose options, that you may consider.

click on noise thermometer to enlarge

Disposable plugs are placed inside the ear canal to block out noise. They are commonly made of expandable foam. One size fits most everyone. They roll up into a thin cylinder for insertion. Once they're inside your ear canal, they expand to form a good seal. Keep the plugs as clean as possible by inserting them with clean hands. Always inspect them before reinsertion. If they are damaged or dirty, throw them away.

Sound isolating earphones with universal-fit ear tips. These earphones provide considerable sound isolation to most people, therefore the volume on MP3 players may be set lower. Noise cancelling headphones are also available which do a great job of cancelling steady state noise such as on an airplane. These devices require little maintenance. The ear tips may be cleaned as needed; if they become brittle simply replace.

Reusable plugs are preformed to fit the ear. They are usually made of a flexible rubber or silicon. They may be flanged or cone-shaped and are often joined by a cord so that they're not easily lost. Reusable plugs can be worn safely for months, depending on the type. They should be replaced as soon as they become hard, torn, or deformed. Inspect and clean them often with warm soapy water. Rinse well. Store them in the case supplied by the manufacturer.

Earmuff stereo headphones. The soft plastic cushions, filled with foam or liquid, should form a good seal against noise. If you wear glasses with wide temples, you may want to choose another type of protector. If you're exposed to very loud noise, you can wear earmuffs and plugs together. Wipe the cushions clean with a damp rag when they become soiled. Check the cushions often, and replace them if they're stiff, worn, cut, or torn. Do not modify your muffs in any way.

Special purpose headsets. When communication is required with hearing protection, special-purpose earmuffs may help you understand speech from co-workers or those transmitting signals to you by radio. Advances in active noise reduction may be effective in reducing low frequency noises that can interfere with speech. Care of special-purpose earmuffs also requires that the internal electronics are maintained.

Musicians Earplugs™ are sleeves that fit in the ear canal and a removable filter to change between different levels of attenuation: 9 dB, 15 dB, or 25 dB. Musicians and music enthusiasts may prefer to use a type of earplug that is designed to match the ear’s natural response, making sound quieter but not distorted. Filters in these Musicians EarplugsTM use a diaphragm that reduces noise levels relatively equally across all frequencies. These filters can be placed in pre-formed or custom-made earplugs. While these earplugs may be washed with water and mild soap, the filter should never be exposed to water. Remove the filter before such washing. Molds should be replaced when discolored, cracked, or obviously hardened. Never use alcohol or solvents to clean the sleeves.

Custom in-ear monitor, made of a silicone material. The benefit is a consistently comfortable fit and excellent sound isolation. Musicians can also use custom in-ear monitors to hear themselves rather than through the floor "wedge" loudspeaker monitors. This results in lower levels on stage and if the earpiece is tightly sealed to the ear without venting, it can serve as a hearing protection device. Used inappropriately, however, it can be turned up to dangerous levels. A variation for the normal consumer can be obtained from hearing health professionals for simply listening to MP3

players; the devices can be made of silicone or acrylic (although silicone seals in the ear better and most often provides better sound isolation). Keep the sound ports that fit in the ear canal clear of earwax and use a “wax loop” tool to remove wax. Do not get these wet and do not use alcohol or solvents to clean the earpieces. Wipe them with a tissue and store them in a cool, dry place between use. Consider using a desiccant (moisture absorber) container if you sweat a lot during performance.

Preventing noise-induced hearing loss

 If you’re exposed to hazardous noise on the job, your employer may already be providing annual hearing tests to identify any change in hearing that might indicate under-protection from the noise. Occupations particularly at risk for hearing loss due to exposure to noise are as follows: o Firefighters o Police officers o Factory workers o Miners o Farmers o Construction workers o Military personnel o Heavy industry workers o Musicians o Entertainment industry professionals o Office staff in crowded buildings

Conclusions

 If you are aware of some of the symptoms of NIHL (like ringing ears or muffled speech), seek a hearing test from a qualified hearing health professional. Although noise exposures are hazardous, other medical causes for hearing loss should be ruled out by a qualified health care provider, using data from your hearing test and your history.  Be alert to hazardous noise. Since prevention is so critical, make sure that your family (especially children), friends, and colleagues are aware of the hazards of noise. Although animal research with drug therapies and the physiology of the hearing system may eventually lead to the development of treatment strategies to reduce NIHL, the most fundamental recommendation is the best. One-third of permanent hearing loss is preventable with proper hearing loss prevention strategies.

PROTECT THE HEARING THAT YOU HAVE NOW!

REFERENCES

ANSI (1996). American National Standard: Determination of occupational noise exposure and estimation of noise- induced hearing impairment. New York: American National Standards Institute, Inc., ANSI S3.44-1996.

National Institutes of Health (1990). Noise and Hearing Loss. NIH Consensus Development Conference Consensus Statement 1990, Jan 22-24; 8 (1).

National Institute for Occupational Safety and Health (1998). Revised Criteria for a recommended standard - Occupational noise exposure, U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication 98- 126.

National Institute on Deafness and Other Communication Disorders (1999). Noise-Induced Hearing Loss. NIH Pub. No. 97-4233.

Occupational Safety and Health Administration (1983). Occupational Noise Exposure Standard. 29 CFR Chapter XVII, Part 1910.95.

NIDCD, Statistics and Epidemiology of Hearing Loss. http://www.nidcd.nih.gov/health/statistics/quick.htm accessed December 1, 2009.

Kopke RD, Jackson RL, Coleman JK, Liu J, Bielefeld EC, and Balough BJ. (2007) NAC for noise: from bench top to the clinic. Hearing Research 226(1-2): 114-25.

Yost W. (1994) Fundamentals of Hearing: An Introduction (3rd ed.). San Diego: Academic Press, Inc.

Photos courtesy of, and used with permission:

Sight and hearing www.soundandhearing.org: Noise Thermometer

Etymotic Research: Musician ear plugs, noise canceling earbuds

Sensaphonics: in-ear monitor

Tinnitus photo: Auricle Ink Publishers, Inc, Sedona, AZ.

The Impact of Treated Hearing Loss on Quality of Life

Sergei Kochkin, Ph.D. - Better Hearing Institute, Washington, DC

Click here to download "The Impact of Treated Hearing Loss on Quality of Life"

The number one reason why people purchase their first hearing aids is they recognize their hearing has worsened. The second reason is pressure from family members who are negatively impacted by the individuals hearing loss. As you know by now, hearing loss occurs gradually. By the time you recognize a need for hearing aids, your quality of life may have deteriorated unnecessarily. The average age of first-time hearing aid wearers is close to 70 years of age, despite the fact that the majority (65 percent) of people with hearing loss are below the age of 65; and nearly half of all people with hearing loss are below the age of 55.

For the vast majority of individuals who have decided to wait to purchase hearing aids (78 percent of all people who admit to hearing loss), although they may be aware their hearing loss has deteriorated, they delay hearing aid purchases under the excuses: "My hearing loss is not bad enough yet; I can get by without them; my hearing loss is mild." A large number of people wait 15 years or more from the point when they first recognize they have a hearing loss to when they purchase their first hearing aids. This is a tragedy since they might not be aware of the impact this delayed decision has had on their life, and the lives of their family and associates. The literature presents a compelling story for the social, psychological, cognitive and health effects of hearing loss. Impaired hearing results in distorted or incomplete communication leading to greater isolation and withdrawal and therefore lower sensory input. In turn the individual's life space and social life becomes restricted. One could logically think that a constricted lifestyle would negatively impact the psychosocial well-being of people with hearing loss.

Research indicates that hearing loss is associated with: embarrassment, fatigue, irritability, tension and stress, anger, avoidance of social activities, withdrawal from social situations, depression, negativism, danger to personal safety, rejection by others, reduced general health, loneliness, social isolation, less alertness to the environment, impaired memory, less adaptability to learning new tasks, paranoia, reduced coping skills, and reduced overall psychological health. For those who are still in the workforce, uncorrected hearing loss has a negative impact on overall job effectiveness, opportunity for promotion and perhaps lifelong earning power. Few would disagree that uncorrected hearing loss is a serious issue.

Prior Experimental Evidence that Hearing aids Improve Quality of Life

An effective human being is an effective communicator; optimized hearing is critical to effective communication. Modern hearing aids improve speech intelligibility and therefore communication. The benefits of hearing aids (audiologically defined as improved speech intelligibility) have been demonstrated in rigorous scientific research. It would seem that if one could improve speech intelligibility by correcting for impaired hearing, that one should observe improvements in the social, emotional, psychological and physical functioning of the person with the hearing loss. There have only been a few studies to date comparing hearing aid owners and non-owners with known hearing loss. The majority of studies had small sample sizes and in general tended to confine themselves to U.S. male veterans. The results of these studies, as well as the exciting findings of a very large U.S. study conducted in collaboration with the National Council on the Aging in 1999 (with publication in January 2000), are described below.

Harless and McConnell demonstrated that 68 hearing aid wearers had significantly higher self-concepts compared to a matched group of individuals who did not wear hearing aids. Dye and Peak studied 58 male veterans pre- and post- hearing aid fitting and found significant improvement on memory tests. In the most rigorous controlled study to date, Mulrow, Aguilar and Endicott studied 122 male veterans and 72 patients from primary care clinics. Half were randomly chosen and fit with hearing aids while the other half were not. After four months compared to the control group, the researchers found significant improvements in the hearing aid wearers on emotional and social effects of hearing handicap, perceived communication difficulties, cognitive functioning, and depression.

In addition, the same researchers in a follow-up study published in 1992 demonstrated that the quality of life changes were sustainable over at least a year. Bridges and Bentler determined in a study of 251 subjects comprised of normal hearing elderly individuals with hearing aids, and individuals with unaided hearing loss that hearing aid wearers had less depression and higher quality of life scores compared to their unaided counterparts.

Finally, in a pre-post study (that is the person was studied before and after a hearing aid fitting) with 20 subjects, Crandall demonstrated after three months of hearing aid use that functional health status improved significantly for hearing aid wearers.

Research on the Positive Impact of Hearing aids on Quality of Life

Following are the results of the largest study in the world conducted on the impact of hearing aids on quality of life. After reading this, we hope you agree that hearing aids when successfully fit to your unique audiological needs, have the potential to literally transform your life.

Utilizing the famous National Family Opinion Panel (NFO) in 1997, a short screening survey was mailed to 80,000 panel members to find a representative sample of people with hearing loss in the United States. This short survey helped identify nearly 15,000 people with self-admitted hearing loss. The response rate to the screening survey was 65 percent. Since 1989, research has been conducted in this manner on more than 25,000 people with hearing loss and the findings have been under the generic name "MarkeTrak." Working with the National Council on the Aging, a sample of 3,000 individuals with hearing loss ages 50 and over were randomly drawn from the MarkeTrak hearing loss panel. Equal samples of 1,500 hearing aid owners and non-owners were drawn from the panel. What is unique about this study is that people with hearing loss, as well as their significant other (usually the spouse), were studied.

Extensive questionnaires were sent to both the person with the hearing loss and the spouse or family member. The number of questions was 300 and 150 respectively. The comprehensive survey covered a myriad of topics including: self and family assessment of hearing loss, psychological well-being, social impact of hearing loss, quality of relationships, life satisfaction, general health, self and family perceptions of benefit of hearing aids (wearers only) , reasons for purchasing hearing aids (wearers only), reasons for not purchasing hearing aids (non-wearers only) , and attitudes toward hearing health and hearing aids. In addition, a number of personality scales, which were deemed relevant to this study, were included in the survey.

After analyzing the returned surveys for usability (e.g. minimal missing information, hearing aid owners who wear their hearing aids) the final sample sizes for respondents with hearing loss and family members were reduced to 2,069 and 1,710 respectively. Thus, this study involved nearly 4,000 people.

The goal of the study was to determine if hearing aids had an impact on hearing loss independent of hearing loss. In other words, do people with mild hearing loss derive as much benefit as individuals with more serious hearing losses? As part of the research design, in addition to quality of life items, a paper and pencil assessment of hearing loss was administered with the anticipation that the results of this assessment would be used to control for hearing loss when comparing the quality of life of hearing aid wearers and non-wearers.

The key hearing assessment tool used was the Five Minute Hearing Test (FMHT) by the American Academy of Otolaryngology-Head and Neck Surgery. The FMHT is a fifteen-question test measuring self-perceived hearing difficulty in a number of listening situations (e.g. telephone, multiple speakers, television, noisy situations, reverberant rooms), as well as self-assessments of some signs of hearing loss (e.g. people mumble, inappropriate responses, strain to hear, avoid social situations). Previous research has determined that the FMHT is significantly correlated with objective audiological hearing loss measures.

Based on hearing difficulty scores, all subjects in this study were grouped into five equal size groups (20 percent each-called quintiles). These ranged from quintile 1 (the 20 percent of respondents with the mildest hearing loss as measured by the FMHT) to quintile 5 (the 20 percent with the greatest hearing loss). The quintile system was utilized for all analysis as a means of controlling for differences in hearing loss between the hearing aid wearer and non- wearer samples. The use of these quintiles allowed the researchers to achieve more valid comparisons between samples of hearing aid wearer and non-wearers.

If the responses of all hearing aid wearers with those of all non-wearers were compared without regard to degree of hearing loss, the findings would have been misleading, and even erroneous. For example, it is widely known that incidence and degree of depression have been found to increase with severity of hearing loss. Thus, even if people with severely hearing loss experience reduced depression after getting hearing aids, they might still report more depression than non-wearers overall, since hearing aid wearers tend to have more severe hearing loss. However, when hearing aid wearers are matched with non-wearers in the same quintile (non-wearers having a fairly similar degree of hearing loss), the differences between them better reflect the potential impact of the hearing aids rather than the effect of their degree of hearing loss.

While there is no audiological basis for labeling hearing loss associated with each quintile group, the researchers did find an excellent correlation between self-perceived loss (e.g. mild to profound hearing loss) and the FMHT test. As we discuss the findings of this study with respect to the five hearing loss groups, it's appropriate to consider people in quintile hearing loss groups 1, 3 and 5 as having respectively a "mild," "moderate," and "severe /profound" hearing loss; group 2 is between mild and moderate hearing loss while group 4 should be viewed as between moderate and severe hearing loss.

Research Findings

Following is a systematic evaluation of the impact that hearing aids have on quality of life. This will be done by comparing the responses of hearing aid wearers and non-wearers while controlling for hearing loss. As you evaluate the impressive findings below keep in mind the following:

 the devastating impact of hearing loss on quality of life is well- documented;  quality of life is primarily impacted by the fact that uncorrected hearing loss results in reduced speech intelligibility;  hearing aids when fitted correctly improve speech intelligibility and therefore can restore your ability to function more effectively in life.

Demographics & Household Income.

It should be recognized that in most respects the five hearing loss groups were well matched on key demographics: gender, marital status, employment status, and age. A striking trend was discovered when evaluating household income by level of hearing loss. Income is significantly related to both hearing loss and hearing aid usage. Figure 1 shows there was close to an $8,000 difference between those with mild hearing loss (quintile 1) and those with profound hearing loss (quintile 5). Note that income drops significantly only for severe to profound hearing loss groups (4 and 5-the top 40 percent of individuals with hearing loss).

Compared to non-wearers, there was a $13,000 a year difference between the mild and profound hearing loss groups. The differential for hearing aid wearers was much less severe ($7,000). Hearing aids appeared to have a positive impact on household income, but only for individuals whose hearing loss was in the higher 60 percent (moderate- profound). People with a moderate to profound hearing loss, who did not use hearing aids, on average, experienced household incomes $5000-$6000 less than their counterparts who did use hearing aids. This is despite the fact that the higher hearing loss non-wearer groups tended to be employed slightly more often.

Hearing aid wearers also reported that they have plenty of discretionary income more often than non-wearers. For example, 22 percent of group 5 (profound hearing loss) hearing aid wearers reported they had plenty of discretionary income compared to only 8 percent of non-wearers. The discretionary income differential for samples with more severe hearing loss was a likely cause of the lower earning power. Because of higher hearing disability levels, communication is probably impacted, resulting in lower income and therefore less earning power. Finding a solution to their hearing loss is exacerbated for these groups, in that lower earning power means that the respondent was less likely to be able to afford a hearing aid to correct the hearing loss.

Activity level

Respondents were asked to indicate the extent (times per month) to which they engaged in thirteen activities in a typical month. Six of the activities were solitary in nature while seven involved other people. Total solitary and social activity scores were calculated. Hearing aid wearers were shown to have the same level of solitary activity as non-wearers. However, hearing aid wearers were more likely to engage in activities involving other people. They were shown to have significantly higher participation in three to four of the seven activities measured. Four out of five quintile hearing aid wearer groups indicated they participated more in organized social activities while three out of five of the hearing loss groups reported they were more likely to attend senior centers if they were hearing aid wearers. The most serious hearing loss group (quintile 5) reported greater participation in four out of the seven activities if they were hearing aid wearers.

Interpersonal relations

The survey asked 12 questions concerning the respondents' quality of interpersonal relationships with their family using a four-point scale. Twelve questions concerned negativity (e.g. arguments, tenseness, criticism) in the relationship. We found that interpersonal warmth in relationships significantly declined as hearing loss worsened. Hearing aid wearers in quintiles 1-3 (mild to moderate) were shown to have significantly greater interpersonal warmth in their relationships than their non-wearer counterparts. Also, significant reductions in negativity in family relationships appeared to be associated with hearing aid usage in quintiles 1 and 2-the hearing loss groups with the mildest hearing disability.

Social Effects

Forty-seven items in the survey assessed the social impact of hearing loss and hearing aid usage. The majority of the items were scored on a five-point scale taking the values "strongly agree" to "strongly disagree." Average monthly contact with family and friends by phone and in person was also assessed.

The stigma of hearing loss was shown to increase as hearing loss increased. All five non-wearer groups reported they would be embarrassed or self-conscious if they wore hearing aids, while all five wearer groups reported lower stigmatization with hearing aids. The conclusion is not, of course, that usage of hearing aids would lead to reduced stigma; most likely hearing aid wearers have resolved their concerns about the stigma associated with hearing aid usage more so than their non-wearer counterparts.

As hearing loss increased, respondents were more likely to overcompensate for hearing loss by pretending that they heard what people said, by avoiding telling people to repeat themselves, by avoiding asking other people to help them with their hearing problem, by engaging in compensatory activities such as speech reading, or by defensively talking too much to cover up the fact that they could not hear well.

All five hearing aid wearer groups reported significantly lower overcompensation scores. The greater the hearing loss, the greater was the likelihood that respondents reported they were the target of discrimination. The greater the hearing loss, the greater the likelihood that respondents with more serious hearing losses were accused of hearing only what they wanted to hear, found themselves the subject of conversation behind their backs, were told to "forget it" when frustrated family members were not heard the first time, and so on. All hearing loss groups except quintile 1 (the mildest hearing loss) reported significant reductions in discriminatory behaviors, if they were hearing aid wearers.

A strong relationship between hearing loss and family member concerns of safety (e.g. cannot hear warning signs, instructions from doctor, made a serious mistake, not safe to be alone) was found, as well as significant differences between hearing aid wearers and non-wearers. Respondents also agreed that safety concerns increased as hearing loss increased.

The data however, indicated that safety concerns were significantly higher among hearing aid wearers than non- wearers in quintiles 1-3. Perhaps the realization that mistakes were being made or that unaided hearing loss could result in possible injury, motivated the current hearing aid owner to purchase hearing aids. This explanation is consistent with the findings from previous MarkeTrak research, which indicated that the number one motivation to purchase hearing aids was "the realization that their hearing loss was getting worse."

There were a number of social effects that were correlated with hearing loss but were not impacted by hearing aid usage. These were negative effects on the family (e.g., "I find it exhausting to cope with their needs"), family accommodations to the individual with hearing loss (e.g., "I have to use signs and gestures a lot of the time"), rejection of the person with hearing loss (e.g., "They tend to get left out of social activities because of their hearing loss"), and withdrawal (e.g., "They tend to withdraw from social activities where communication is difficult"). In addition, hearing aid usage was not associated with increased phone or in-person contact with family or friends.

The Emotional Effects

Eighty items in the survey dealt with the emotional aspects of hearing loss. All five hearing aid wearer groups scored significantly lower in their self-ratings of emotional instability. In agreement with their family members, they were less likely to be tense, insecure, unstable, nervous, discontent, temperamental, and less likely to display negative emotions or traits. Four of the five hearing aid wearer groups reported significantly reduced tendencies to exhibit anger (e.g., "I sometimes get angry when I think about my hearing") and frustration (e.g., "I get discouraged because of my hearing loss"). In agreement, family members observed significantly less anger and frustration in all five hearing aid wearer groups.

The average reduction in depression associated with hearing aid usage across all five groups was 36 percent. All five hearing aid wearer groups reported significantly lower depressive symptoms (e.g., tired, insomniac, thinking of death) while four of the five hearing aid wearer groups (quintiles 1-4) reported a significantly lower incidence of depression within the last 12 months compared to their non-wearer counterparts.

Hearing aid wearers in quintiles 2-4 reported significantly lower paranoid feelings (e.g., "I am often blamed for things that are just not my fault"). Not surprisingly, in agreement with family members, all five non-wearer groups scored higher on denial when compared to hearing aid wearers (e.g., "I don't think my hearing loss is as bad as people have told me").

Family members and respondents were asked to indicate if the person with the hearing loss exhibited anxiety, tenseness or if they worried for a continuous period of four weeks in the previous year. In addition, they were asked to indicate if they experienced anxiety symptoms (e.g., keyed up or on edge, heart pounding or racing, easily tired, trouble falling asleep). Three of the five non-wearer groups (1, 3, 5) exhibited higher anxiety symptoms. In addition, three of the five non-wearer groups (1, 2, 5) exhibited more social phobias than non-wearers of hearing aids. Reduction in phobia and anxiety associated with hearing aid usage would appear to be more pronounced in individuals with serious to profound hearing losses (Quintile 5).

Factors not appreciably impacted by hearing aid usage in this study were: sense of independence (e.g., burden on family, answering for the person with hearing loss) and overall satisfaction with life. Although not as conclusive as some of the previous factors, non-wearers reported that they were more self-critical (e.g., "I dwell on my mistakes more than I should") and had lower self-esteem (e.g., "All in all, I'm inclined to feel that I am a failure"). Hearing loss was found to be highly correlated with self-criticism. There is also some evidence, though not as strong as other correlates of hearing aid use, that non-wearers were more critical of themselves (Quintiles 1, 3, 5).

Personality Assessment

Seventy-nine items were devoted to miscellaneous personality scales in addition to the personality measures under emotional and social effects. All of the personality scales used in this study are published scales. Family members indicated that the respondents' cognitive/mental state (e.g., they appear confused, disoriented or unable to concentrate) was affected by their hearing loss, primarily if the hearing loss was "severe" to "profound" (groups 4 and 5). In this study, impressive improvements in family perceptions of the persons' mental and intellectual state were observed if the individual had a severe to profound hearing loss (groups 4 and 5 only). Non-wearers were more likely to be viewed as being confused, disoriented, non-caring, arrogant, inattentive, and virtually "living in a world of their own."

Previously we indicated that there were no significant differences in measures of "withdrawal" between aided and unaided subjects. This finding is contrary to the literature. However, family members did report that non-wearers in three of five groups (1,4, 5) were more introverted as evidenced by greater likelihood of being private, passive, shy, quiet, easily embarrassed, etc. Moderate to severe hearing loss non-wearers (quintiles 3-5) were shown to score higher on a personality variable called "external locus of control." This means they were more likely to believe that events external to them control their lives. In other words, they felt less in control of their own lives. On the other hand, hearing aid wearers felt they were more in control of their lives and less a victim of fate.

Health Impact

The survey asked six generic questions on self-perceptions of health, prevalence of pain and the extent to which the respondent believed that hearing loss impacted their general health. In addition, from a list of 28 health problems, respondents indicated whether they experienced that health problem and the extent to which the problem interfered with their activities.

Overall assessment of health (including absence of pain) appeared to decline as a function of hearing loss with further deterioration of heath associated with non- usage of hearing aids for the three most serious hearing loss groups (quintiles 3-5). Three of the five hearing aid wearer groups (quintiles 1, 3, 5) reported significantly better health compared to their non- wearer counterparts. The lowest self-rating of overall health was the non-wearer group in quintile 5 (profound hearing loss). Nonetheless, our research determined there was no consistent evidence that hearing aid usage is associated with reductions in arthritis, high blood pressure, heart problems or other serious disease states.

Perceived Benefit of Hearing aids

As a validation check on comparisons of hearing aid wearers and non-wearers, both respondents and their family members were asked to rate changes they observed in 16 areas of their life that they believed were due to the respondent using hearing aids. Total findings are shown in Figure 2. In general, for nearly all quality of life areas assessed, the observed improvements were positively related to degree of hearing loss. Family members in nearly every comparison observed greater improvements in the respondent.

The top three areas of observed improvement for both respondents and family members were "relationships at home," "feelings about self," and "life overall." The most impressive improvements were observed in quintile 5 (profound hearing loss) in that 11 of 16 lifestyle areas were rated as improved by at least 50 percent of the respondents or family members.

Conclusions and Discussion

The results for this study are impressive. Hearing aids clearly are associated with impressive improvements in the social, emotional, psychological, and physical well-being of people with hearing loss in all hearing loss categories from mild to severe. As such, these findings clearly provide strong evidence for the value of hearing aids in improving the quality of life of people with hearing loss. Specifically, hearing aid usage is positively related to the following quality of life issues:

 greater earning power (especially the top 60% of hearing losses)  improved interpersonal relationships (especially for mild-moderate losses) including greater intimacy and lessening of negative dysfunctional communication  reduction in discrimination toward the person with the hearing loss  reduction in difficulty associated with communication (primarily severe to profound hearing losses)  reduction in hearing loss compensation behaviors  reduction in anger and frustration  reduction in the incidence of depression and depressive symptoms  enhanced emotional stability  reduction in paranoid feelings  reduced anxiety symptoms  reduced social phobias (primarily severely impaired subjects)  improved belief that the subject is in control of their lives  reduced self-criticism  improved cognitive functioning (primarily severe to profound hearing loss)  improved health status and less incidence of pain  enhanced group social activity

In this study, both respondents and their family members were asked to independently rate the extent to which they believed their life was specifically improved due to hearing aids. All hearing loss groups from mild to profound reported significant improvements in nearly every area measured:

 relationships at home and with family  feelings about self  life overall  mental health  social life  emotional health  physical health

Short of stating definite causality, the evidence is quite compelling and perhaps suggestive of causality for the following reasons:

 The sample, the largest of its kind, is nationally representative of hearing loss subjects ages 50 and over. Thus, we need not be concerned with spurious findings due to sampling methodology.  Many of the findings held up across all hearing loss quintiles from mild to profound.  The specific findings were corroborated within the study. That is, significant differences between wearers and non-wearers were noted. Also, at the end of the survey respondents and their family members were asked to specifically indicate if their life was improved as a result of wearing hearing aids in 16 quality of life areas. Both respondents and their family members indicated significant benefit due to hearing aids in most areas measured.  The differential efficacy between the 16 quality of life parameters noted by respondents and their family members (from a low of 4 percent to high of 74 percent improvements) indicates that a positive halo or acquiescence did not exist in this sample of respondents.  The survey findings are consistent with other correlational and especially the randomized control studies and pre-post hearing aid fitting studies among smaller, more narrowly defined samples.  The findings are consistent with the literature on factors impacting hearing loss; that is, the theoretical improvements that should occur if hearing loss is alleviated.  The findings are consistent with the observations of clinicians and dispensers of hearing aids. A Call to Action

Dr. Firman of the National Council on the Aging stated in his speech to the media in the summer of 1999, "This study debunks the myth that untreated hearing loss.is a harmless condition."

In focus groups conducted with physicians, the prevalent view is that hearing loss is "only" a quality of life issue. If, quality of life is defined as "greater enjoyment of music," then one might agree. But the literature and this study clearly demonstrate that hearing loss is associated with physical, emotional, mental, and social well-being. Depression, anxiety, emotional instability, phobias, withdrawal, isolation, lessened health status, lower self-esteem, and so forth, are not "just quality of life issues." For some people, uncorrected hearing loss is a "life and death issue."

This study challenges every segment of society to comprehend the devastating impact of hearing loss on individuals and their families, as well as the positive possibilities associated with hearing aid usage. We need to help physicians recognize hearing loss for the important health issue that it is. We need to help those with hearing loss who are currently in denial about their impairment, to understand the impact their hearing has on their life as well as that of their loved ones. We need to assure that hearing aids are recognized in society not just for their treatment of hearing loss, but also as a potential contributing factor to the successful resolution of other medical, emotional, social and psychological conditions.

This study also demonstrates for the first time that individuals with even a mild hearing loss can experience dramatic improvements in their quality of life. This finding is significant because the challenge is to demonstrate to "baby- boomers" (ages 45-59) with emerging hearing losses that hearing aids offer something to them of value early-on in their lives, and that they do not need to wait until retirement to receive the benefits of enhanced hearing.

If you are one of those people with a mild, moderate or severe hearing loss, who is sitting on the fence, consider all the benefits of hearing aids described above. Hearing aids hold such great potential to positively change so many lives.

Common Myths

The consequences of hiding hearing loss are better than wearing hearing aids.

What price are you paying for vanity? Untreated hearing loss is far more noticeable than hearing aids. If you miss a punch line to a joke, or respond inappropriately in conversation, people may have concerns about your mental acuity, your attention span or your ability to communicate effectively. The personal consequences of vanity can be life altering. At a simplistic level, untreated hearing loss means giving up some of the pleasant sounds you used to enjoy. At a deeper level, vanity could severely reduce the quality of your life.

Only people with serious hearing loss need hearing aids.

The need for hearing amplification is dependent on your lifestyle, your need for refined hearing, and the degree of your hearing loss. If you are a lawyer, teacher or a group psychotherapist, where very refined hearing is necessary to discern the nuances of human communication, then even a mild hearing loss can be intolerable. If you live in a rural area by yourself and seldom socialize, then perhaps you are someone who is tolerant of even moderate hearing losses.

Hearing Loss Treatment Sergei Kochkin, Ph.D. - Better Hearing Institute, Washington, DC

It would seem that hearing is a second-rate sense when compared to vision in our visually oriented modern society. People with hearing loss delay hearing loss treatment because they are unaware of the fact that receiving early treatment for hearing loss has the potential to literally transform their lives.

A.Hearing Aids

Gus Mueller, Ph.D. Vanderbilt University, Nashville, Tennessee Ruth Bentler, Ph.D. University of Iowa, Iowa City, Iowa

How Hearing Aids Work

While the processing of modern hearing aids is complex, and computer programming is required to make some of the adjustments, the basic components that make them work has not changed. The basic function of a hearing aid is as follows:

 Sound waves enter through the microphone, which converts acoustic signals into electrical signals.  The amplifier increases the strength of the electrical signal.  From the amplifier, the signal is then transformed back to an acoustic signal by the receiver (a miniature loud speaker).  From the receiver the signal is channeled intro the ear canal, either through a small tube or through an ear mold.  A battery is required to power the hearing aid and enable the amplification process.

Many hearing aids also have user controls (e.g. toggle switch, volume control wheel, push button, or remote control) that enable the wearer to adjust a variety of hearing aid parameters, including:

 Turning the hearing aid "on" or "off"  Changing the volume  Switching to the telecoil  Switching between omni- and directional-microphone settings  Switching to a different pre-programmed memory

Styles of Hearing Aids

Hearing aids have been available in four styles: body, eyeglass, behind-the-ear (BTE), and in-the-ear (ITE). Included in the category of ITE hearing aids are in-the-canal (ITC) and completely-in-the-canal (CIC) styles (all shown in the figures below). While body and eyeglass style hearing aids were regularly used 40-50 years ago, they comprise only about 1% of all hearing aids marketed today. Instead, most individuals choose ITE (approximately 80%) or BTE (approximately 20%) style hearing aids. This transition in style, use, and preference is occurring for a number of reasons, including the reduction in the size of the components, durability, and cosmetic concerns on the part of the consumer.

The ITE style hearing aid fits directly into the external ear. The circuitry is housed primarily in the concha (external) portion of the ear. Due to the miniaturization of the component parts (including the microphone, receiver and battery), it is possible to make hearing aids small enough to fill only a portion of the concha (ITC) or fit deeply into the ear canal (CIC). All three of these styles have typically been considered to be more modern and cosmetically appealing. However, modern BTE hearing aids have become smaller and at times are less noticeable than some ITC hearing aids. Other features of in- the-ear instruments are as follows:

 More secure fit, and easier insertion and removal than with BTEs.  Improved cosmetic benefits with smaller styles (CIC, ITC).  Less wind noise in the smaller styles than with BTEs.  Directional microphone technology available for most styles, excluding CICs.  Deep microphone and receiver placement with CICs may result in increased battery life and high frequency amplification compared with other styles.  All components are integrated into a one-piece shell, which may be easier to handle and operate than for BTE styles.

The BTE style hearing aid is housed in a small curved case which fits behind the ear and is attached to a custom earpiece molded to the shape of your outer ear. Some BTE models do not use a custom earpiece; instead the rubber tubing is inserted directly into the ear. The case is typically flesh colored, but can be obtained in many colors and/or patterns. Other features include:

 BTEs may be the most appropriate choice for young children, as only the earmold needs to be replaced periodically as the child grows and the ear changes in dimension.  Typically, BTEs are the most powerful hearing aid style available, and may be the best option for persons with severe-to-profound hearing loss.  FM and direct auditory input is routinely available as an optional or standard feature.  Telecoil circuitry is often more powerful than with ITEs.  Non-occluding earmolds may be used with BTE hearing aids, if a medical

condition exists or if the patient reports a “plugged” sensation when wearing other hearing aid styles.  Directional microphone technology available with most BTE styles and models.  Larger battery sizes used in BTEs may be easier to handle than smaller styles for those with limited manual dexterity or vision deficits.

B. Assistive Listening Devices

Cynthia Compton-Conley, Ph.D. - Gallaudet University, Washington, DC

Due to technological advancements in recent years, today's hearing aids do an excellent job of helping people meet many of their communication needs. However, sometimes there are situations where additional technologies may be needed. For example, some hearing aid users may continue to experience difficulty understanding speech in noisy environments, from a distance, as when watching TV or attending a movie or play, or while listening on the telephone. At bedtime, a person with even a mild to moderate hearing loss may not hear the smoke alarm located down the hall. This same person might miss a doorbell chime while listening to the TV a room away. Further, a child with normal hearing, who suffers from recurrent middle ear infections or who has a central auditory processing disorder, is at a definite educational disadvantage when seated in a typical classroom with poor room acoustics and excessive noise.

How Assistive Technology Can Help

Many auditory and non-auditory devices — collectively known as Assistive Technology, Assistive Listening Devices (ALDs), or Hearing Assistance Technology (HAT) — are available to help people with all degrees of hearing loss. These devices can help facilitate improved face-to-face communication, reception of electronic media, telephone reception, and reception of important warning sounds and situations.

Devices to Facilitate Face-to-Face Communication and the Reception of Electronic Media

Auditory assistive listening devices can be thought of (roughly) as "binoculars for the ears." By placing a remote microphone next to the talker (or loudspeaker) or by connecting directly into the sound source (TV, VCR, MP3 player, etc.), these devices bring the desired sound closer to one's ear(s) before it has a chance of being mixed with noise and reverberation. The "captured" sound is then sent to the listener via a "hardwired" or "wireless" link. Three wireless systems can be used: FM (see below), infrared or inductive (audio loop). In order to use these systems, the hearing aid must be equipped with either a "telecoil" or a feature called "direct audio input (DAI)." DAI allows very tiny FM receivers to be plugged into the bottom of the hearing aid. DAI or a telecoil also allow body worn FM and infrared receivers to be used with more styles of hearing aids. Finally, a telecoil allows the hearing aid itself to function as the receiver when listening to a room-sized inductor (room loop) installed in a building (e.g. church, movie house). For greatest listening flexibility ask for hearing aids with telecoils built into them. And, if you want to have the opportunity to use the latest tiny FM receivers, think about purchasing behind-the-ear (BTE) hearing aids equipped with DAI.

Two types of visual systems are available to help people understand speech at a meeting or other live event: Computer-Assisted Note taking (CAN) and Communication Access Real Time Translation (CART), also known as Real Time Captioning.

Devices to Facilitate Telephone Reception

Special telephone amplifiers are available that replace the telephone handset, attach to the phone between the handset and the phone (in-line amplifiers) or attach to the handset and are powered by a battery (portable amplifiers). Each of these amplifiers can be used with or without a hearing aid. These standard telephone amplifiers can be coupled to a hearing aid either acoustically or inductively. With acoustic coupling, the amplifier is held up to the hearing aid's microphone. While this tends to work well with a CIC hearing aid, it may result in an annoying whistling sound (feedback) with the larger hearing aid models. However, if the larger models are equipped with a telecoil, then the hearing aid can be set to "T" and held next to the amplifier, with no feedback.

Special telephones with built-in amplification are also available in both standard and wireless handset models. Also available are devices that enable you to use your hearing aid(s) with a digital cell phone for distortion-and noise-free reception. For those who cannot understand over the voice telephone, even with amplification, there are other options such as the Voice Carry Over (VCO) or "read and talk" telephone. Used with the telephone relay service, VCO allows you to talk directly to the other party while an operator translates what the other party says to you into print that is displayed on a small LCD screen

Alerting Devices

Alerting devices allow hard of hearing and deaf people to be aware of many environmental sounds and situations in the home, in school or in the workplace, as well as for travel and recreation. Such systems use either microphones or electrical connections to pick up the desired signal and hardwired or wireless transmission to send the signal to you in a form to which you can respond. For example, when someone presses the doorbell button, when the phone rings or the fire alarm is activated, these events can trigger a flashing incandescent or fluorescent light, a loud horn, a vibrational device (pager, bed shaker), or a fan.

WHICH SYSTEM IS BEST?

A broad assortment of auditory and non-auditory technology is available to assist in removing the communication barriers of everyday life. Your hearing healthcare professional should be able to help you select the best system, or combination of systems, based on your own unique communication needs and lifestyle.

Audiological Advances for Hearing Loss Treatment

Patricia McCarthy, Ph.D., Rush University Medical Center, Chicago, IL Ross J. Roeser, Ph.D., University of Texas-Dallas/Callier Center for Communication Disorders, Dallas, TX

New information about how we hear, as well as the explosion of new technology has made help available for almost everyone with hearing loss.

Improved Identification of Hearing Loss

With recent advancements, it is now possible to perform comprehensive testing to determine:

 If hearing loss exists, even for the youngest populations  The amount and nature of the hearing loss  The benefits that are possible through available treatments

Breakthroughs in identification techniques include:

 Universal neonatal hearing screening — to test the hearing of babies within the first 48 hours of life; now required by law in most States. Such tests identify hearing loss in infants so that treatments can begin as soon as possible.  Auditory brainstem response (ABR) testing — for use with difficult-to-test populations and for medical diagnosis of auditory disorders. The ABR test can be performed on individuals of any age, even the youngest infant. There is no longer any reason to delay referral of infants for hearing evaluation because they are "too young to test."  Immitance testing — for objective and complete evaluation of middle ear function and assessments of the nerve function of the ear.  Otoacoustic emissions testing — that provide information regarding the hearing nerve in the inner ear and help identify the cause of hearing loss.  Special auditory tests — for identification of the exact location of the auditory impairment.

Improved Rehabilitation

Auditory rehabilitation is now available for individuals of all ages who have hearing loss. New and modernized techniques include:

 specialized educational programs for children with hearing loss  individually tailored and computerized training in speech reading (lip reading), auditory training, and counseling  assistance in everyday listening through custom-designed personal hearing aids  assistance in specific listening situations (telephone, television, and group listening devices) through the use of assistive listening devices  help for those with profound deafness through the use of cochlear implants, tactile hearing aids, and alerting devices  benefit to those who suffer from tinnitus (ringing in the ears) through counseling and the use of specially designed tinnitus maskers

Help is now available for almost everyone with a hearing loss.

 If you THINK you have a hearing loss, diagnostic testing is available  If you KNOW you have a hearing loss, rehabilitation is available

Hearing Loss Counseling (Auditory Rehabilitation)

Patricia McCarthy, Ph.D. Professor, Rush University Medical Center, Chicago, IL. Ross J. Roeser, Ph.D. Professor and Executive Director

Once your hearing loss has been identified, it is essential that you become informed of all of the options available to help improve your communication. There is a common misconception that hearing aids are the "cure all" for hearing loss. In reality, improving communication involves a long term rehabilitative process in which the hearing aid is only part. As such, you should enter into this rehabilitative process with realistic goals and knowing what to expect from the hearing aid and your hearing health provider. If you are to be successful in improving communication with amplification, you must be committed, motivated and educated about your role in this process. You should be sure that each of the following facets of the rehabilitation process are offered by your hearing health provider before proceeding.

Education

The first step in the rehabilitative process is insuring that you are an informed consumer. All aspects of your hearing loss should be explained to you in detail including type and degree of hearing loss, implications for communication, preventative and rehabilitative recommendations and need for referrals to other professionals including physicians. Being knowledgeable about your hearing loss will assist you in making rehabilitative decisions.

If amplification is recommended, your hearing health provider should provide you with written information and should give you a step-by-step explanation of the hearing aid fitting and rehabilitation process. Before engaging in this process, you must be knowledgeable of hearing aid options, the adjustment process, and the use of communication repair strategies necessary for success with amplification. You should be made aware of all your amplification options as well as the level of support that you will be provided after being fit with hearing aids.

Including family members or significant others in this discussion is highly recommended. It will allow your communications partners to understand better the hearing difficulties you are encountering and the rehabilitative options that are available to you.

Expectations and Goals

Successful use of amplification is predicated on realistic expectations. Everyone's expectations for amplification are different so it is important that your hearing health provider assess your unique expectations about amplification. There is a fine line between expecting too much out of your hearing aids and having appropriate expectations. For example, expecting that your hearing will return to "normal" is not a realistic expectation for any hearing aids, but expecting to have increased ease of communication with hearing aids is realistic. Unrealistic expectations often lead to frustration, disappointment and often failure. Including your family and/or significant others in your discussion of goals and expectations also will contribute to successful use of amplification and improved communication.

Establishing your goals for improving your communication will assist you and the hearing health provider in choosing the best rehabilitative option for you. For example, if telephone communication is problematic, you should be provided information about telecoils and other options to improve your ability to use the telephone effectively. Your occupation, your social life and your pastimes will help in the decision making process regarding hearing aid features.

Some hearing health providers will have you complete questionnaires to assist them in determining your needs and expectations. These questionnaires often ask about how the hearing loss has influenced various aspects of your life and can be helpful in determining rehabilitative options. Be sure your hearing health provider takes the times to assess your individual needs, goals and expectations so that they are achievable given your hearing loss.

Hearing aid Follow-Up

Once you have been fit with hearing aids, the rehabilitation process begins. Because the audiologic rehabilitation process involves more than just purchasing hearing aids, it is imperative that you be provided with post-fitting orientation, counseling and rehabilitation. You should be offered several sessions that include verification of the hearing aid fitting, adjustment counseling and communication training. Verification of the hearing aid fitting can be done in several ways. Your hearing health provider will conduct objective tests to verify that the hearing aids are working optimally while at the same providing you comfortable, effective amplification. In addition to this objective testing, your provider should be assessing your subjective benefit from hearing aids. You may be asked to complete questionnaires that assess the level of benefit you receive in various listening environments. Or you might be asked about your level of satisfaction with the hearing aid fitting process. All of this information helps the hearing health provider to make adjustments in the rehabilitative plan to insure that you are successful.

Adjustment Counseling

Adjustment to amplification and learning to hear again can be challenging. People are often surprised when they first hear foot steps, refrigerator noise and distant laughter that they had not heard in years. Because the brain has not received this type of stimulation for the duration of your hearing loss, it may take a while for you to adjust to the new sounds you are hearing. Different listening environments present different challenges.

Initially, your new ability to hear may be overwhelming to you. But as your brain relearns to hear, particularly in noisy situations, you will find communication will become increasingly easier. Adjusting to amplification is an individual issue. Some people adjust immediately while others take weeks or months to adjust to their new world of sound. Your hearing health provider should be willing to counsel you through this period in addition to making adjustments to your hearing aids.

Communication Strategies

Hearing aids are powerful, effective tools for increasing your ability to hear. But hearing aids will not automatically make you a better listener. That takes work! Listening requires attention, concentration and interest. Often times, people with hearing losses develop poor listening skills. This occurs because hearing becomes so difficult that they give up and just "turn off" the speaker. Once you are fit with hearing aids, it is imperative that your listening skills be resharpened. Your hearing health provider should work with you to improve these skills.

Just because you get hearing aids does not mean that you no longer need to rely on your vision. Using visual cues while communicating is essential. People often will say, "I can't lipread" but, in truth, we all lipread to some degree. The eyes are powerful in taking in visual speech information. The brain then masterfully combines the visual speech cues with the hearing cues so that your understanding of the speaker increases dramatically. While very few hearing health providers will offer lipreading lessons per se, they should be able to provide you tips on how to improve your use of visual cues in communication in combination with your hearing aids.

Communication also can be improved with the use of communication strategies such as environmental manipulation and repair strategies. Learning where to position in different listening situations (i.e. at a party, in a restaurant, in a place of worship) can enhance your ability to benefit from your hearing aids. Learning how to keep the conversation alive in a noisy environment by using communication strategies is another rehabilitative strategy. Your hearing health professional can provide you with a wealth of information on how to incorporate these strategies into your everyday communication patterns.

Group Hearing aid Orientation

Many hearing health providers are beginning to recognize the benefits of offering group hearing aid orientation sessions. Rather than providing education and rehabilitative services on an individual basis, these sessions are open to groups of individuals recently fit with hearing aids and their family and/or significant others.

Hearing aid groups vary from setting to setting. Some hearing aid providers will offer a specific number of sessions following the hearing aid fitting while others allow people to attend as many sessions as they need. The focus of these sessions is typically on use, care and repair of the hearing aids, adjusting to amplification, listening and communication strategies. Many people find that the primary advantage of the group environment is that it can provide peer support for adjusting to amplification.

The Role of Your Family

As mentioned previously, including family members and/or significant others throughout the rehabilitation process is strongly advised. In addition to learning about your hearing problems and how they can be remediated, family members can learn how to improve their communication skills to facilitate easier communication. It is important that family members understand their roles in communication breakdowns and how they help avoid and/or repair these breakdowns.

One example of a rehabilitative strategy taught to family members is the use of Clear Speech. With this method, family members are taught to use an appropriate rate (speed) and volume of speech to improve communication with people with hearing loss. Clear Speech is easily taught and quite effective. Family members also can be taught how to use communication repair strategies to facilitate smoother conversations without constantly hearing "huh?". Family members can be taught good communication practices such as limiting background noise when conversing, getting the attention of the listener and not communicating from room to room.

Summary

When choosing a hearing health provider, be sure to determine if he/she will be able to offer you the variety of services discussed above. Simply purchasing hearing aids will not insure improved communication. It is important to remember: hearing aids are not a quick-fix purchase. They are simply the tools that provide the amplification you need to become a better listener and communicator. If you are motivated to improve your communication by obtaining amplification, relearning to listen and engaging in an active rehabilitation process, then your chances for improved communication are excellent.

Aural Education and Counseling

Patricia McCarthy, Ph.D. Professor, Rush University Medical Center, Chicago, IL. Ross J. Roeser, Ph.D. Professor and Executive Director

Education

Expectations and Goals

Hearing aid Follow-Up

Verification of the hearing aid fitting can be done in several ways. Your hearing health provider will conduct objective tests to verify that the hearing aids are working optimally while at the same providing you comfortable, effective amplification. In addition to this objective testing, your provider should be assessing your subjective benefit from hearing aids. You may be asked to complete questionnaires that assess the level of benefit you receive in various listening environments. Or you might be asked about your level of satisfaction with the hearing aid fitting process. All of this information helps the hearing health provider to make adjustments in the rehabilitative plan to insure that you are successful.

Adjustment Counseling

Communication Strategies

Just because you get hearing aids does not mean that you no longer need to rely on your vision. Using visual cues while communicating is essential. People often will say, "I can't lip read" but, in truth, we all lip read to some degree. The eyes are powerful in taking in visual speech information. The brain then masterfully combines the visual speech cues with the hearing cues so that your understanding of the speaker increases dramatically. While very few hearing health providers will offer lipreading lessons per se, they should be able to provide you tips on how to improve your use of visual cues in communication in combination with your hearing aids.

Group Hearing aid Orientation

The Role of Your Family

Summary

Employment and Hearing Loss

Sam Diehl, J.D. - Attorney, Gray Plant Mooty, Minneapolis, MN

A. Employment: The ADA and Reasonable Accommodations

Employment is one of the most important areas of legal rights for people with hearing loss. The ADA is the primary federal law relating to employment of people with disabilities. The law requires employers with 15 or more employees to provide qualified individuals with disabilities equal access to the employment opportunities available to others. The ADA prohibits discrimination in recruitment, hiring, promotions, training, pay, social activities, and other terms and conditions of employment. It restricts questioning about an applicant's disability before a job offer is made, and it requires that employers make reasonable accommodation to the known physical or mental limitations of otherwise qualified individuals with disabilities, unless the accommodation would create an undue hardship for the employer. The larger the employer, the less likely they can successfully claim "undue hardship."

The Accommodation Process

For employees with hearing loss, it is important to know how to request reasonable accommodations in employment and what "reasonable" means. ADA accommodations may be relevant both in the initial application or interview process as well as in the day-to-day activities of the position. It is important to remember that employers do not need to provide accommodations if they are not aware of the individual's need. However, they cannot ignore the situation if the employer "knows or has reason to know" that the employee is experiencing workplace problems because of the disability, particularly if the disability may prevent them from asking for an accommodation. (see http://www.gtlaw.com/pub/alerts/1999/eeoc99.htm). For instance, someone with hearing loss may not be aware that they do not correctly understand communications. In these instances, the employer should inquire if reasonable accommodations are needed.

Requests for accommodations do not have to be in writing, but it is a good idea to make a written request in the event that there is a dispute about whether or when you requested accommodation. You may want to include the following information in your request:

 Identify yourself as a person with a disability;  State that you are requesting accommodations under the ADA (and any relevant state law or the Rehabilitation Act if you are a federal employee);  Identify your specific problematic job tasks;  Identify your accommodation ideas;  Request your employer's accommodation ideas;  Refer to any attached medical documentation if appropriate; and  Ask that your employer respond to your request in a reasonable amount of time.

Once you have made a request, your employer is obligated under the ADA to engage in an informal, interactive process with you. This process focuses on whether you have a disability under the ADA and why your requested accommodation is needed. In many instances, a simple conversation will suffice to resolve these issues but if it does not, the employer may ask for additional information. The employer may request reasonable documentation from an appropriate health care or vocational rehabilitation professional about your disability and functional limitations. If you do not use the "proper" language it does not excuse the employer from identifying and providing accommodations you need.

There are three categories of "reasonable accommodations":

1. changes to a job application process; 2. changes to the work environment, or to the way a job is usually done; and 3. changes that enable an employee with a disability to enjoy equal benefits and privileges of employment (such as access to training).

While employers are required to consider reasonable accommodations, they do not have to provide a reasonable accommodation that causes "undue hardship." Undue hardship may include accommodations that are too expensive, unduly extensive or disruptive, or those that would fundamentally alter the nature or operation of the business.

Once the employer and employee have engaged in this process, the employer may choose among reasonable accommodations as long as the chosen accommodation is effective. It is important to remember that reasonable accommodations are unique to each individual and their employer. Important factors may include the nature and requirements of the business and job at issue, the financial and other resources of the employer, and the nature and extent of the employee's disability.

Examples of Reasonable Accommodations

Reasonable accommodations may include everything from simple paper notepads to employer-paid sign language interpreters or stenographers. Employers, however, do not have to provide "personal use" items, such as eyeglasses, hearing aids, or similar devices. Examples of accommodations that may be reasonable for individuals with hearing loss include:  Substituting computer technologies such as email, instant messaging, or chat or voice recognition software for audible communication;  Providing assistive listening devices that enable an individual to focus directly on the sound source, reducing distractions from background noise;  Providing sign language interpreters or stenographers;  Training coworkers in basic sign language;  Providing phone amplification technology, headsets, or TTY; and  Considering environmental factors in meetings or other communications such as background noise, seating and positioning. ADA Enforcement

Enforcement of the ADA is carried out by the U.S. Equal Employment Opportunity Commission (EEOC) or state and local agencies that work with the EEOC. Complaints under the ADA generally must be filed within 180 days of the discrimination or within 300 days if filing with state or local agencies. Some state laws have different time limits and procedural requirements. Individuals may file their own lawsuit in federal court only after they receive a "right-to-sue" letter from a designated government agency.

B. Assisting Employees with Hearing Loss

By Sergei Kochkin, Ph.D.

Question: What can organizations do to plan for and address the impact of employee hearing loss?

Answer: Employers can take a number of simple steps to educate employees about hearing loss and to facilitate the use of hearing aids, where needed.

In a 2009 survey of 46,000 U.S. households, the Better Hearing Institute (BHI) determined that over the past generation hearing loss grew at 160 percent of the U.S. population growth— primarily attributable to the aging of the American population. Yet the study found that 60 percent of people with hearing loss are below retirement age, meaning that 16.3 million people with hearing loss were in the U.S. workforce in 2010.

Previous research at BHI has shown that 50 percent of people with untreated hearing loss have never had their hearing checked by a professional and lack sufficient information to know whether they need to take action to correct it. Human resource professionals can help employees understand if they need treatment by:

 Educating employees on the impact of untreated hearing loss on quality of life.  Encouraging employees to take valid online hearing tests such as the five-minute hearing evaluation offered by BHI.  Encouraging local hearing health professionals to conduct on-site hearing screenings.

In many cases hearing aids can help protect employees from being at a competitive disadvantage with peers. Organizations can encourage the use of hearing aids, when needed, by ensuring that health insurance covers such devices and by recommending that employees purchase hearing aids using pretax medical flexible spending account funds.

In addition, employers can: Create a corporate climate where hearing loss is recognized so those with hidden hearing loss feel more comfortable.

 Avoid noisy restaurants as meeting locations.  Summarize meeting minutes in writing to be sure that those with hearing issues are clear on the outcome of the meeting.  Provide easy accommodations, such as moving an employee's desk away from noisy hallways, machines, or air conditioning and heating vents, or installing a phone that amplifies high frequencies.  Build work environments that facilitate better hearing by choosing cubicles with noise-absorbent materials and equipping meeting rooms with an inductive loop that creates a wireless zone for hearing aids with telecoils, headsets or microphones.

By encouraging employees to treat hidden hearing loss rather than hide it, an employer creates a win-win situation by ensuring that the loss of hearing does not interfere with job performance, productivity, safety, or the employee’s career or quality of life on or off the job.

Public Accommodation and Transportation for Hearing Loss Sam Diehl, J.D. - Attorney, Gray Plant Mooty, Minneapolis, MN

Public Services, Public Accommodations and Transportation

The ADA also has important protections relating to state and local government, public accommodations and transportation. The law requires state and local governments to give people with disabilities equal access to programs, services, and activities. This encompasses such areas as public education, transportation, recreation, health care, social services, courts, voting, and town meetings.

The ADA also prohibits exclusion, segregation, and unequal treatment by "public accommodations" and transportation providers, such as buses, trains, restaurants, retail stores, hotels, movie theaters, private schools, doctors' offices, day care centers, recreation facilities, and other places open to the public. Reports of violations can be filed with the U.S. Department of Justice, Civil Rights Division and related state agencies. As with employment, state and local laws may differ from the ADA about public accommodations and transportation. Private schools, recreational organizations, daycare centers, museums and institutions are public accommodations covered by the ADA and, as such, must provide auxiliary aids and services when necessary to provide equal access to people with disabilities. The costs for such aids may not be imposed upon the individual with disabilities.

Education

Public schools, colleges, and universities that receive federal assistance (which includes virtually all such institutions) are required to provide interpreters or other auxiliary aids to people with disabilities when necessary. The ADA also requires access for people with disabilities in all state and local government programs, including public schools, colleges, and universities, regardless of whether or not the programs get federal assistance.

In addition, the Individuals with Disabilities Education Act (IDEA) requires public school systems to provide a "free, appropriate public education" to children who need specialized services because of a disability. It establishes a procedure for developing an individual education program (IEP) and identifying needed support services for individual children.

Communication

The ADA requires telephone and television access for people with hearing and speech disabilities. It requires telephone companies to establish interstate and intrastate telecommunications relay services (TRS) 24 hours a day, 7 days a week. The law also requires closed captioning of federally funded public service announcements. The Federal Communications Commission (FCC) enforces these provisions and also works with broadcast providers to encourage additional captioning.

The FCC has additional captioning requirements as well. As of January 1, 2006, all new English-language programming must be captioned and 75% of previously uncaptioned materials must be captioned by the first quarter of 2008. Spanish-language programming must also be captioned as of 2010 and 2012.

Perhaps most importantly, the FCC mandated that emergency situations be captioned. Should you become aware that your local broadcasters are not in compliance, you can file a complaint by contacting the relevant station and also the FCC. You can contact the FCC by any reasonable means, including its on-line complaint form, e-mail, fax, or U.S. mail. You can also submit your complaint in an alternate format audio-cassette recording, or by phone at: 1-888-CALL-FCC (1-888-225-5322) voice or 1-888-TELL-FCC (1-888-835-5322) TTY. Your complaint should include as much information as possible such as the name of the video programming distributor, the TV channel name and number, the date and time of the omission of captioning of emergency information, the type of emergency, and your contact information.

Another federal law, the Telecommunications Act, requires manufacturers of telecommunications equipment and providers of telecommunications services to ensure that such equipment and services are accessible to and usable by persons with disabilities. This law helps ensure that people with disabilities have access to telecommunications devices, including telephones, cell phones, pagers, call-waiting, and operator services. All electronic and information technology developed, maintained, procured, or used by the federal government must be accessible to people with disabilities, including both federal employees and members of the public.

Other Areas

Other areas are covered by disability laws. For example, the Fair Housing Act and similar state and local laws prohibit landlords, real estate sellers, management companies and homeowners' associations from discrimination based on disability. The Voting Accessibility for the Elderly and Handicapped Act of 1984 requires polling places across the United States to be physically accessible to people with disabilities for federal elections.

It is important that you familiarize yourself with these laws and assert your rights when necessary. There is no reason that your hearing loss should be counted against you or hold you back from life's opportunities. Fortunately, the law is usually on your side in this effort.

*Sam Diehl is an attorney with the law firm of Gray Plant Mooty in Minneapolis, MN. He represents and advises employers in all areas of employment law and litigation.