Decreased Hearing

Introduction:

Decreased hearing is one of the most common physical disabilities; over 10% of all of people suffer from this condition. Although hearing loss affects people of all ages, it is most common in older patient populations. Indeed, over one third of individuals over the age of 65 have some degree of hearing loss. In the United States, as our baby boomer population ages, the number of people with hearing loss is expected to double within the next 20 years. Certainly, if we live long enough, we will all likely experience some degree of hearing loss.

The effects of hearing loss can be significant. The obvious inconveniences of missing conversations, not always understanding what is being said, or making embarrassing interpretations, can lead to social isolation. Patients can become depressed because they can no longer communicate with others or participate in their formerly normal lifestyle. Children with hearing loss may be excluded from certain activities such as sports or social endeavors. The depression and social isolation can then lead to high blood pressure due to frustration and conceivably even hypercholesterolemia and weight gain.

However, this need not be the case for most patients who suffer decreased hearing. Proper examination and diagnosis of the condition causing the hearing loss can lead to appropriate treatment and restoration of some or most hearing, in most cases. An otolaryngologist or ENT (ears, nose and throat) physician is the doctor best trained to evaluate, diagnose and treat patients with hearing loss. He/She will usually have an audiologist, audiology technician or themselves perform a hearing test or audiogram. Typically, the audiologist is the person who will fit the patient with hearing aids if that is what is recommended by the physician. Audiologists may have a masters or doctorate degree in audiology, in addition there are hearing aid technicians who also sell/fit hearing aids. Unfortunately, many patients do not seek out diagnosis and treatment because they feel that they would be prescribed a hearing aid. A hearing aid for many patients is a stereotype of someone who is either old, unintelligent, or incompetent. In fact, only about 20% of all patients with hearing loss that could benefit from hearing aids actually wear them, often due to concerns of the aforementioned stigma. However, as we will discuss further, many advances in hearing aid technology have occurred, such that they are less conspicuous and provide much better sound quality than in the past.

Anatomy of Hearing:

The ear is the hearing organ. We have two ears for several reasons. It allows us to be able to localize sound because of the time difference it takes to be heard in one ear versus the other, it allows us to hear sounds from both sides without having to turn our heads, and allows us to better concentrate on conversations when there is background noise.

The ear itself can be divided into three separate sections. There is an outer ear, a middle ear, and an inner ear. FIG 1 delineates this quite nicely. The outer ear is really the auricle, the portion that you see, and the ear canal. The ear itself can act like a funnel, pulling in the sound waves and directing them down the ear canal. The middle ear is comprised of the ear drum, the three little bones of hearing (ossicles), and the air space behind the ear drum, to the floor of the ear. Sound enters and vibrates against the eardrum, which in turn vibrates the ossicles. The last ossicle, stapes, acts as a piston, and moves up and down. The inner ear, the cochlea, looks like a snail. It is a chamber that is filled with fluid and nerve endings that look like little fingers or hairs. The piston or stapes, pushes the fluid in and creates a fluid wave in the inner ear. The peaks and troughs of this wave bend the nerve endings; which nerve endings are bent, for how long, and in what direction is critical information that is relayed to the brain interpreted as sound and loudness, pitch, and speech. In addition to hearing, the cochlea is also connected to the balance portion of the inner ear. Thus, occasionally, someone may have a problem with hearing loss and dizziness or balance problems that are related.

Types of Hearing Loss

There are basically three types of hearing loss. One is conductive, one is sensorineural, and the other is a combination of the two, or mixed.

Conductive hearing loss: Conductive hearing loss occurs when the sound cannot get to the inner ear properly. Thus, a conductive hearing loss usually is due to some problem with either the outer ear or the middle ear, or both. Thus, anything as simple from wax build up in the ear canal, a hole in the eardrum, fluid build up in the middle ear, or abnormal bony growths, can all lead to conductive hearing losses. The good news about the causes of conductive hearing loss are that they are usually treatable with either medicine or surgery.

Sensorineural hearing loss: Sensorineural or nerve hearing loss actually occurs because the nerve endings or hair cells within the inner ear no longer function properly or have died. This is by far the most common cause for sensorineural hearing loss and may be caused by infections, noise exposure, or the aging process. Occasionally, the inner ear may not form completely in children and this can also lead to nerve hearing loss. Thankfully, sensorineural hearing loss can be treated with hearing amplification, in most cases, and if it is severe to profound, can now be treated with cochlear implants.

Mixed hearing loss: Mixed hearing loss simply refers to a combination of both sensorineural and conductive hearing loss in the same ear. Usually this is due to a combination of factors. Again, just as in conductive alone or sensorineural alone, these can be treated.

REASONS FOR HEARING LOSS

Conductive hearing loss – ear canal

Cerumen: Cerumen (wax) impaction of the ear canal can cause conductive hearing loss. More often, even though it may not be measured on a hearing test, the fullness or plugged feeling that it produces definitely decreases one's ability to hear. Fortunately, this is easily managed in an office setting, where the ENT physician can remove the cerumen, often under microscopic visualization. Typically the patient will be examined using a microscope. While looking through the microscope the physician will remove the wax using small tools and/or suction. This is the safest and least painful way to remove wax. If there is just a small amount of wax this can sometimes be removed using a handheld otoscope (tool used to look at the ear) and a small tool or suction just like those used under the microscope. This avoids the mess and possible trauma (infection or eardrum perforation) associated with trying to irrigate cerumen out of the ear canal with a water pick or other water flushing methods, which is not recommended.

Swimmers ear or otitis externa: An infection of the ear canal causes swelling and severe pain. As the swelling of the ear canal increases, it can block the ability of sound waves to reach the eardrum and cause a conductive hearing loss. The treatment is usually accomplished with antibiotic or medicated ear drops and occasionally oral antibiotics.

Absence of ear canal: Some children are born without an ear canal or an ear canal that is very small or stenotic. Although these children tend to have a maximal conductive hearing loss, if they have normal nerve hearing the resulting loss is an approximately 60% deficit. In children, depending on parent’s wishes, there are many treatment options available. The patient could wear a bone conductive hearing aid, they may be a candidate for a bone anchored hearing implant, or they may be a candidate for surgical correction of the ear canal. In addition, the patient may have an abnormal ear on the outside, as well as an absent or stenotic ear canal. That is usually treated with either a prosthetic ear or a surgically made ear when the child is 4-6 years of age. Fig 2

Conductive Hearing Loss - middle ear

Eardrum perforations: Although a small hole in the eardrum would typically not result in significant conductive hearing loss, it can, on occasion, be related to hearing loss, especially if it is located over the ossicles. Larger perforations (due to infections, trauma, drum not healing after tube is removed, Eustachian tube dysfunction and others) certainly are a source of conductive hearing loss, as the eardrum no longer moves efficiently, such that the mechanical forces of the sound waves cannot be transmitted through the ossicular chain to the cochlea. Fortunately, this condition can be treated surgically, where the eardrum is rebuilt by the ENT physician, or hearing aids may be utilized. Fig 3

Scarring of the eardrum: Occasionally, the eardrum can become thickened due to recurrent infections or previous surgery. At times, the drum may just be very thick, like scar tissue, or it may actually form hard calcium deposits, like bone, again limiting its ability to vibrate or move efficiently and thus causing conductive hearing loss. Depending on the degree of hearing loss and status of the drum, this may be treated surgically or with hearing aids.

Infection: With an eardrum that is intact, if there is fluid that fills the middle ear space, it will not allow the eardrum to move and thus causes a conductive hearing loss. This fluid can be acutely infected and consist of pus, which causes a very red and painful eardrum. At times, the eardrum may even burst and drain. The fluid may be thin and watery or it may be very thick, like glue. Normally, fluid after an acute infection will go away on its own in about three months in most patients. Acute infections are usually treated with antibiotics. If the fluid does not dissipate after three months, and depending on the patient's age and level of hearing, they may be a candidate for evacuation of the fluid from behind the eardrum. In most children this is typically done in the operating room where a small hole is made in the eardrum, the fluid suctioned out, and a tube may or may not be placed. In an adult, this is a procedure that can usually be performed in the office setting. At times, adults may opt just for a myringotomy (small incision of the eardrum) with drainage of the fluid, to allow them to hear again. Indeed, most adult patients find it extremely difficult to go more than a few weeks without having the fluid drained. However, in children, we recommend that they wait longer – up to 3-6 months. This is done to avoid general anesthesia if possible. However if the child has pre-existing sensorineural hearing loss too then we may not wait as long so as not to subject them to even further hearing loss. During this time, and in the short term, it will affect their ability to hear and if they are still developing speech and language skills, there may be developmental delays. However, studies seem to indicate that these effects are short term and that five or more years down the road, any delay will likely have been overcome.

Cholesteatoma: Cholesteatoma is nothing more than a benign growth of dead skin in the middle ear. This can occur for many reasons, but essentially dead skin gets trapped in the middle ear and cannot get out. When this happens, the dead skin that forms continues to grow bigger and bigger, like an onion, as the skin cells continue to die and new cells take their place. As the cholesteatoma enlarges, it will frequently erode bone, such as the little bones of hearing, or cause significant infection and drainage, both of which can alter hearing and produce a conductive hearing loss. Cholesteatoma is a surgically treated disease, as with any other tumors or growths of the middle ear or ear canal.

Otosclerosis: Otosclerosis is a condition in which the stapes, or last bone of hearing, becomes fixed and is no longer able to move up and down in its normal piston-like motion. Indeed, there is a small amount of bony overgrowth or even larger bony overgrowth over the end of the stapes, such that it fixes it from moving. Basically, all it can do is vibrate back and forth, which will produce a conductive hearing loss. This disease can run in families or may be related to a virus. The treatment for otosclerosis is either hearing aids or a surgical procedure, called a stapedectomy, where the last little bone of hearing is removed and replaced by an artificial piston. This usually has very good results for restoring hearing.

Retracted eardrum: The retracted eardrum is usually caused by the eustachian tube not functioning properly. The eustachian tube is a small, muscular tube that connects the back of the nose to the middle ear space. If for any reason the eustachian tube does not function or is blocked, for instance, from sinus infections or allergies, the result can be a negative pressure or vacuum effect in the middle ear. This pulls the eardrum down into the middle ear space, onto the floor of the middle ear. When this happens, the eardrum can no longer vibrate in a normal fashion, which causes the hearing loss. The treatment is varied and may consist of medical or surgical options.

Sensorineural or Nerve Hearing Loss

Congenital or Pediatric: Congenital hearing loss occurs in about .1-.2% of children that are born. Most of the time, it will be genetic in nature, however can also be due to abnormal development of the inner ear structures, infections, syndromes or truama. Typically an infant or child suspected of hearing loss is evaluated by an ENT physician or otolaryngologist. Often times, these patients are referred to an ENT who just specializes in ear disease (an otologist/neurotologist) or and ENT who specializes in pediatrics. These doctors will most likely perform and recommend further evaluation with other tests and other physicians. Sometimes blood may be evaluated for thyroid disease, diabetes, blood counts, syphilis, or autoimmune function. In addition, some physicians may test for gene defects with blood tests. The most common gene defect is that of connexin 26 another is connexin 30. The difficulty with these tests is that we know the gene defect responsible for the hearing loss but we do not know what this means. For instance, we do not know if future children of the parents have a higher risk for hearing loss or if the child with hearing loss will have a higher risk for having children with hearing loss. Congenital hearing loss may also occur with other syndromes and children who are identifed with these require further evaluation by other physicians to insure that the heart (Jervell-Lange-Nielson syndrome), eyes (Ushers syndrome or just decreased vision), kidneys (Alports syndrome), and thyroid (Pendred’s syndrome) are functioning normally. Alternatively, a child may be born with a malformed cochlea/inner ear or an enlarged vestibular aqueduct (EVA), these are diagnosed with a CT scan. Some physicians will get this before testing for connexin defects because of the cost of connexin studies which are not routinely a covered expense.. An EVA results from abnormal communication between the fluid that surrounds the brain (CSF) and the inner ear. This communication creates increased pressure in the inner ear system, resulting in trauma to the nerve endings and hearing loss. Finally, there are some in utero infections that can occur which can also cause hearing loss in newborns.

Depending on the degree of hearing loss, hearing aids or cochlear implants can restore hearing to these children regardless of the etiology of their hearing loss.. It is important to identify a child with hearing loss early, so that they can get the proper treatment. For those children with profound hearing loss who would benefit from cochlear implantation – having this surgery between 12-24 months allows for the best hearing results. In those children whose hearing loss is not profound hearing aids should be fitted in the first few months, again to maximize speech and language development.

Age related hearing loss or presbycusis: Presbycusis is the most common hearing loss in adults. The normal wear and tear on the tiny nerve endings or hairs as well as a life time of exposure to noises of all types, and particularly loud noises, causes them to die. The fact that many people also have problems with their arteries supplying blood to various organs, can also have an affect on hearing. The blood supply to the inner ear consists of small vessels and patients with peripheral artery disease can experience hearing loss as well. Presbycusis most commonly starts in the very high frequencies and then will gradually involve the middle and then lower frequencies. At first, the patient will usually experience decreased ability to hear when there is background noise, such as at a restaurant or party. They will also have difficulty with some consonant sounds, like "ch," "sh," and "s," which can sometimes cause embarrassing misinterpretations of what is said. The patient may also experience tinnitus, for some it is high pitched ringing for others it may sound like crickets, a car engine, a seashell or just about any unwanted sound. This typically starts in the age range of 55-65 years. Everybody loses the hearing at different rates, and different frequencies can be affected. However, this type of hearing loss can be treated with amplification. The various types of amplification will be discussed below. If hearing aids cannot provide improved hearing then the patient should be evaluated for a cochlear implant. Even healthy 80 and 90 year olds have been successfully implanted.

Noise

It is well known that exposure to loud sounds can cause both temporary hearing loss and permanent hearing loss. Many of us know that when we leave work, if it is a very noisy area, or a concert, or some other loud venue, that for a while we feel that we cannot hear very well, but this sensation gradually gets better. This occurs because the little nerve endings are put under stress and are unable to function until they are able to repair themselves. However, in the scenario ofrepeated exposure, there comes a time when the nerve endings can no longer repair themselves and the damage becomes permanent. Alternatively, we can also experience immediate loss of hearing due to very short loud sounds, such as: gunshots, noises that are over about 130 decibels, airplane engines, and firecrackers. Because of this, the Occupational Safety and Health Authority (OSHA) has set standards for noise exposure (osha.gov). Any work place where the noise is over 85 decibels, requires hearing protection programs. Workers need to wear some type of hearing protection in these environments. They need to be tested annually. Again, this type of hearing loss can be helped with hearing amplification. Research is being done on certain medications that in the future may allow hair cells to repair themselves or may make them more resistant to damage from noise.

Tinnitus can be associated with any type of nerve hearing loss. Simply stated, this is akin to a patient who has lost an arm or leg who continues to feel pain, burning, or itching in the phantom limb. With tinnutis, the brain no longer gets the sounds it is accustomed to receiving, but makes up sounds of its own. We believe that in most instances, it is a central occurring phenomena, arising from the brain. There are many different treatments for tinnitus, some are better than others but there is no known cure for it. The treatment for tinnitus will be discussed below.

Noise induced hearing loss is one of the fastest growing causes of hearing loss in America. The exposure to loud noises is starting at a much younger age. Music players and other devices, played directly to the ear, often set at high volumes, can lead to earlier and earlier signs of noise-induced hearing loss. That is why it is important to keep the volume of such devices at a low level. If one wears a hearing aid, one should also remove the hearing aid prior to any exposure to loud noise.



Medications: There are many medicines that can be ototoxic. The more common ones are those used to treat severe infections, such as Gentamicin, Streptomycin, and other aminoglycoside antibiotics. There are some chemotherapeutic agents that are known also to have a propensity to cause hearing loss, as well as high doses of aspirin, nicotine, and some diuretics may also be a common cause for hearing loss. At times these medications are unavoidable but ask your doctor to follow your hearing with audiograms,while on these medications and adjust the dosage if possible. These ototoxic medications can also affect the vestibular system and make one dizzy.

Infections:

Infections can cause damage to the inner ear system from bacterial and viral toxins. Otitis media, bacterial in nature, could lead to sensorineural hearing loss, as can a viral infection, such as the flu, chicken pox, or meningitis. One of the more common causes of an infection may be due to a herpes virus, which usually results in a sudden hearing loss. Fortunately, this sudden hearing loss is usually just unilateral. Because the vast majority of infections that cause hearing loss are viral in nature, they are difficult to treat or arrest before the hearing loss occurs. However, for sudden sensorineural hearing loss, many ENTs will treat with either intratympanic steroids ( a series of 3 weekly injections) or high dose (60 – 80mg of predisone)oral steroids or both, along with an antiviral medication that is in the acyclovir family such as Valtrex (1 gram three times a day) or Famvir.

Trauma:

Trauma itself can cause sensorineural hearing loss. The trauma could be blunt or penetrating. It can be as simple as someone inserting a Q-Tip too far into the ear canal, pushing the stapes into the inner ear or causing perforation of the ear. A fracture of the temporal bone from blunt trauma can also cause a sensorineural hearing loss if it extends into the vestibular system or inner ear. Indeed, each one of these could also cause a conductive hearing loss as well, thus producing a mixed hearing loss picture. These may or may not be treatable with amplification or surgery.

Tumors:

Tumors of the inner ear or on the hearing nerve in the internal auditory canal are often associated with a unilateral nerve hearing loss. Anybody who has unilateral symptoms of hearing loss and/or tinnitus, or ear fullness, should have an MRI with gadolinium to evaluate for these growths. Fortunately, the overwhelming majority of these are going to be benign growths, such as acoustic neuromas or meningiomas. The treatment options for these include surgical excision, stereotactic radiation surgery, or even observation, depending on the symptoms and size.

Prevention of Hearing Loss:

There are many things that can be done to help avoid the result of hearing loss. When it comes to trauma, people should know not to use Q-Tips, car keys, bobby pins, or other devices to clean their ears. The most common results are a scratch in the ear canal, followed by an infection of the ear canal, or compression of the wax further into the ear canal, creating more of a plug or damage to the eardrum itself. That is why it is important to allow the physician to inspect the ear and remove the wax as needed. He may have you use some type of acetic acid ear drops, such as a 50:50 mixture of rubbing alcohol and vinegar, to help remove the wax.

Noise exposure prevention is essential, thus, the use of noise protectors, volume control in-ear headphones or earbuds are a good way to help prevent noise-induced hearing loss. To prevent sensorineural hearing loss from trauma the use of helmets when participating in activities, such as bicycling, skiing, roller blading, and others, are very beneficial.

Transient hearing loss sometimes accompanies flying or scuba diving. This is especially true if a patient has a cold or sinus infection at the time. If the patient can tolerate it, we recommend the use of over-the-counter nasal decongestants, such as Afrin or Neo-Synephrine, a couple puffs in each nostril, as boarding the plane and in long plane flights, repeating the regimen on descent. The use of an oral decongestant prior to boarding a plane may also be beneficial. This helps one to be able to clear the ears more easily and thus avoid that plugged feeling and decreased hearing loss.

Symptoms:

Patients with decreased hearing may:

• Be unable to hear well when there is background noise, such as at a party or a restaurant
• Complain that people are mumbling
• Continually have to ask people to repeat themselves
• Need to have the television, radio, or other devices louder than others may appreciate.
• Have trouble hearing at the movies or theater or church.
• Find that they sometimes will have difficulty understanding what people are saying, especially if they cannot see their faces, to help read their lips.
• Become impatient and frustrated, irritable, or withdrawn.
• Sometimes feign agreement, or appear to be hearing when, in fact, they are not, in order to give the illusion that they are fitting in.
• Experience problems with tinnitus, which can take the form of multiple different types of noise. For some, this noise can be debilitating and for others it is just a mild annoyance.
• Become depressed
• Cause the patient to stop socializing
• Lead to other medical problems, such as overeating, overweight, hypercholesterolemia, and hypertension.

Evaluation or Tests:

Most people are familiar with the audiogram or hearing test. For a hearing test, the patient is normally brought into the sound proof booth, the audiologist, ENT physician, or other hearing health care professional conducts a test to determine at what level the patient hears, or ceases to hear, at a number of different frequencies, from low to high. In addition, the audiologist will induce noise into the ear that is not being tested to insure that only the ear that they are testing is giving correct information and that the patient is not hearing the test sound in the opposite ear. They will also place a bone oscillator on the skull during the hearing test to determine the bone conduction hearing level. The bone conduction hearing level and the air conduction hearing level should be the same. If they are not, this is a way to test for a conductive hearing loss. In addition, they will assess the ability to recognize spoken words by asking the patient to repeat them back. This gives some indication of how well a patient may perform with a device, such as a hearing aid. Of course, these tests are performed on patients who can cooperate, which includes most adults, most adolescents, and older children. Anybody who feels that they have a hearing loss should be evaluated with this type of exam. In addition, a full ear exam and medical evaluation and history should be taken by the physician, usually an ENT physician.

Recommendations by the American Speech and Language Hearing Association states that adults should have their hearing checked every 10 years through the age of 50 and then probably every three years thereafter. Of course, this changes if there are complaints of hearing loss.

Children: It is often thought that infants and small children cannot have their hearing tested but this is certainly not the case. Even babies can be assessed for hearing loss and the earlier this is detected, the better. Infants can be tested in several ways. Otoacoustic emissions are usually administered to newborns prior to discharge from the hospital.This is a test that a nurse or audiologist does by placing sound into the ear and measuring sound sent back while the baby sleeps. If there is any question than a more sophisticated test, an auditory brainstem response (ABR) is performed. This test is usually done while the child sleeps or in the operating room. Sound is presented to the ear and then noninvasive electrodes measure how long it takes the sound to get from the ear to the brain and if it does. Both of these tests can be done on any patient of any age too. As the children get a little older, they can be tested with visually reinforced audiometry tests or play audiometry, where the tester discerns when the child is hearing due to the child’s responses to auditory and visual stimuli. Indeed, these tests and many others, allow us to really assess the hearing level in children of all ages, including infants, so that proper treatment and referrals can be made in a timely fashion. Finally, these tests can be done on adults too. The ABR and otoacoustic emissions can be used on those adults who cannot/will not cooperate with a normal audiogram, to ascertain their hearing level.

Treatment:

We have already discussed some of the treatment options available for patients with conductive hearing losses, based upon the etiology of the loss. However, the treatment for sensorineural hearing loss is different. Patients with sensorineural loss and some conductive hearing losses as well or mixed hearing losses benefit most from hearing amplification or hearing aid. Unfortunately, most people go many years before starting to wear a hearing aid. Some of these may be due to the cost of the hearing aid (typically these can cost anywhere from 1500 dollars for the open air aids or analog aids up to 4-5 thousand for the best digital aids), it may be due to a perception of stigma, that some patients feel a hearing aid comes with, in others it may be lack of information concerning hearing aids or knowing a friend or relative who has had a negative experience with a hearing aid.



In counseling patients about hearing aids, it is important that they understand that a hearing aid will not cure the sensorineural hearing loss. The hearing aid is an amplifier that will make sounds louder. Because of this, sometimes it is difficult for patients to distinguish between sounds that they want to hear and those that they do not want to hear. However, improved technology has allowed patients to better control what they want to hear and what they do not. There are many different types of hearing aids available now. There are also many manufacturers of hearing aids. Hearing aids can range from those that are tiny and fit inside the ear canal and cannot be seen to those that cover part of the outside of the auricle and can be seen, to those that are a little bit larger and fit behind the ear with a mold in the ear canal, to the newest type of hearing aid, called an open air hearing aid. This hearing aid is very small and fits behind the ear, with a very thin silastic tube that then sits in the ear canal. It was originally designed for patients with high frequency sensorineural hearing loss, because this was the most difficult hearing loss pattern to treat with conventional hearing aids but is now used for other types of hearing loss. It seems to provide good clarity and eliminates the occlusive effects that patients had complained, about as well as whistling and other problems that some of the other types of hearing aids have. However, for those patients who have significant hearing losses, it may not have enough power.

In order to obtain a hearing aid, one needs to be evaluated and diagnosed by a physician, most commonly this will be the ENT physician. When the patient is referred for the hearing aid evaluation, the audiologist (most often) or ENT physician will usually spend about an hour or longer with the patient, going over the different types of hearing aids. Depending on the hearing aid chosen, ear mold impressions may be taken at that time, and then the specific aid will be ordered. Once the hearing aid arrives, it will need to be fitted and it will sometimes take several visits to get the hearing aid to be fitted just perfectly. Most reputable physicians and audiologists will allow the patient to use the hearing aid on a trial basis, usually one month, to see if it works for them. If it does not, it may be returned for a refund. It should be noted, however, that one should not always give up if the first hearing aid did not work out. Many patients have to try several different types or even brands of hearing aids in order to find one that actually works for them. It should also be remembered that hearing aids take time to get used to and that is why the trial period is given.

Cochlear implants: Any patient who has a severe hearing loss or does not benefit to the level they would like from the use of conventional hearing aids should be evaluated for the possibility of cochlear implantation. A cochlear implant is a device that replaces the inner ear nerve endings. An electrode array is inserted into the cochlea to stimulate the nerve directly by passing the nerve endings. The internal device is placed under the skin and muscle of the scalp, during a surgical procedure. The processor is worn behind the ear and is attached with a magnet to the internal device. Sound is picked up from a microphone; the soundwaves are changed in the processor by various computer programs into electrical magnetic energy, which is then transmitted to the internal device, down the electrode array, and into the cochlea. This in turn stimulates the nerve which transmits this sound to the brain. A cochlear implant can be used in children 12 months of age or older to elderly adults. Sometimes children who are less than 12 months of age are implanted, if the hearing loss was caused by meningitis and there is concern over the cochlea ossifying or turning to bone. Typically, patients need to have severe to profound hearing loss in both ears and the implant can be implanted in one ear or in both ears. It can be implanted bilaterally at the same time or in two separate surgical procedures. Although one can never predict how well each particular patient is going to perform with the cochlear implant, as there are many variables associated with this, the expectations are that most children will be able to be mainstreamed in school and that most adults that are post-lingual, meaning that they already have speech and language skills, should be able to hear and understand speech. As the speech processing techniques improve, this ability becomes greater and greater for more patients and the horizon is such that the ability to appreciate music is getting better and better as well.

BAHA implant:

 The bone anchored hearing implant is a device which is used for patients with a unilateral total or profound hearing loss, or in patients with a conductive loss, who either cannot or do not want to wear a hearing aid. The BAHA device is an osteointegrated screw that is implanted into the temporal bone. Once the screw integrates into the bone and is solid with the bone, usually after three months, the sound processor device is able to be used. The small processor snaps onto a small abutment of the screw that sticks slightly out of the skin. This device is worn like a hearing aid, it comes on and off, just like a hearing aid would do. It works a little bit differently, in that it sends the sound waves through the actual boney skull to the inner ear and generates the fluid wave within the cochlea through bone conduction rather than through the air. The sound quality is usually better than they received with a hearing aid if there loss was conductive and for those with total unilateral hearing loss it appears to be the choice of amplification over a CROS hearing aid for patients due to the sound quality.

Hearing aid terms:

Hearing aids are either digital or analog. The old hearing aids are all analog, they are also the cheapest and basically all they do is use an electrical signal to amplify sounds. The digital hearing aid uses a computer chip to amplify sounds and can enhance speech understanding by suppressing some ambient noise. These are more expensive then the analogs. There is also a programmable hearing aid, which can be set for a variety of different noise environments and types of hearing loss.

CROS or BI-CROS Hearing Aids: We talked about behind the ear style, in the ear, and in the canal styles and the open air hearing aids. There is another hearing aid, called the CROS hearing aid or BI CROS hearing aid. This type of hearing aid is used when a patient has a unilateral deafness, where the microphone will pick up the sound on the ear that does not hear and transfer it to the good ear, either with a wire or wireless lead.

What YOU Can do to Help with Your Hearing Loss

Be assertive. Don't be afraid to let others know that you have a hearing loss. Tell them when you don't understand something, make sure that you look at them when they are speaking; ask people to communicate clearly with you, and thank them when they do.

Lip read: Although it can be difficult to learn, it is extremely helpful to develop the ability to read lips, and combine this with hearing.

Change the environment. Try to rearrange rooms, so that you are closer to, and have better access to TVs, radio, and computers. Also, you can change furniture configuration so that guests are closer and facing you.

Pocket Talkers or TV adapters. For patients that do not or cannot obtain a hearing aid, a device such as the head phone set that could be plugged into a TV or radio may increase quality of life. Another useful aid is a pocket talker, a set-up that includes a head set worn by the patient, and a microphone that people can speak into. Some telephones can also be amplified or hooked into a hearing aid

Hearing dogs. Just as there are seeing eye dogs, there are dogs that can be trained to alert people who have profound hearing loss to noises, such as smoke alarms, oven timers, telephones, or door bells.

Hearing Loss Tips for Friends and Family.

Attention. Make sure that the listener with hearing loss is looking at you and making eye contact, as this will allow the patient to know that you want to speak to them. Maintain your eye contact with the patient. Facial expressions and body language give vital information about what you are trying to say or communicate.

Speak naturally. One does not need to yell or shout. Indeed, that can sometimes only distort words and make it sound like you are mumbling. Try to speak distinctly. Use pauses rather than slow speech.

Rephrase. If a listener has difficulty understanding what you are saying, try to think of a different way of saying it, rather than repeating the same words.

Reduce background noise. If the listener has not done this, turn off any background noise, such as a radio or a TV in order to enhance the listener's ability to hear.

Keep Face Free. Keep things away from your face while you are speaking. In other words, no cigarettes in the mouth, no food in the mouth, no hands on the face; this allows the listener to have a clear view of your face and lips in order to enhance their listening ability.