Hearing anatomy and types of hearing loss. How to detect hearing loss in your patients How to interpret audiograms

Transcription

1 Outline for today Hearing system refresher Hearing anatomy and types of hearing loss Hearing loss in General Practice How to detect hearing loss in your patients How to interpret audiograms When to refer to us including red flags Vertigo Tinnitus Resources and new advances Rehabilitation and new advances

2 HEARING SYSTEM REFRESHER

3 The Hearing System Overview jgfdjdj

4 Hearing Loss jgfdjdj

5 Main types of Sensorineural Loss 1. Presbyacusis Age Related Wear & Tear Hair Cell Damage Bilateral Affects Clarity, rather than Volume & Speech intelligibility People with hearing loss.. Over 60-1 in every 2 (55%) Over 80-9 out of 10 (93%)

6 Main types of Sensorineural Loss 2. Noise Induced Hearing Loss (NIHL) High Frequencies mainly & Bilateral Historically difficult to correct Now well suited to open fitting aids Clarity, not Volume Speech intelligibility ACC Funding GP needs to start claim form ACC arranges HT and ENT appointment If approved, hearing aids partially funded

7 HEARING LOSS IN GENERAL PRACTICE

8 How can you detect hearing loss in your patients? The Bay AudioCHEK Pro A simple, 40-second screening device which tests both ears an objective measure in detecting hearing problems even in the early stages Should hear four tones in each ear (lights up to indicate when presented) Refer for diagnostic HT if not hearing all four tones New version upgraded according to feedback from a survey of 345 NZ GPs. Now with longer battery life, low battery indication, improved acoustic shielding, now accurate output to within 1.5 db. If faulty, marketing@bayaudiology.co.nz to be sent a new one

9 How can you detect hearing loss in your patients? Tuning fork tests The lengthy road to better hearing Ignorance & Denial Accommodation & Avoidance Isolation & Depression External events prompt action Comment from a friend or family member Embarrassment Advertisement Any reported difficulty hearing at home or work. Often first signs are difficulty in crowds or background noise, or has the TV turned up too loud for others For referral pads and $20 discount vouchers, marketing@bayaudiology.co.nz

10 Interpreting Audiograms Hearing Levels Shaded region at top is normal hearing. Symbols further down the page indicate a mild, moderate, severe, profound hearing loss respectively

11 Interpreting Audiograms Speech Audiometry Looking for better speech discrimination as volume is increased Can indicate if hearing devices are appropriate

12 Interpreting Audiograms Tympanometry Type A: normal Type B: no TM movement Low volume most likely middle ear effusion High volume most likely perforation Type C: negative pressure - Eustachian tube dysfunction

13 When to refer to an Audiologist Age related losses / or if unsure about hearing levels Tinnitus assessment Unilateral HL or tinnitus - then we d refer to ENT Most Audiology clinics can test children 4 yrs and older Some can also test younger (Bay Audiology Takapuna) Hearing Aid funding advice Hearing aid assessment

14 Red Flag: Sudden hearing loss Could be Sudden Sensorineural Hearing Loss (SSHL) 30dB drop in hearing in 3 sequential frequencies over 1-3 days Often accompanied by tinnitus (~80%) and aural fullness (~80%) Usually unilateral, usually idiopathic Could be: Bacterial/viral infection of cochlea Vascular Auto immune A short course of oral corticosteroids is commonly prescribed Also could be: Acute Otitis Media Occluding wax (impacted by cotton buds!)

15 Vertigo The feeling that you or your environment is moving or spinning Classification Peripheral: caused by problems with inner ear Central: caused by injury to the CNS

16 Vertigo Sensation that everything is moving/spinning & also may include: Loss of balance Nausea/Vomiting Abnormal eye movements (nystagmus) Hearing Loss Tinnitus Blurred Vision Earache

17 The Inner Ear Taken from

18 Causes of Vertigo Common Causes of Vertigo Peripheral Vertigo Central Vertigo Other Vestibular Neuritis Benign Paroxysmal Positional Vertigo (BPPV) Meniere s Disease Vestibular Migraine Psychogenic Vertigo Rare Causes of Vertigo Peripheral Vertigo Central Vertigo Other Cholesteatoma Herpes Zosta Oticus Labyrinthitis Cerebellopontine Angle Tumour (Acoustic Neuroma) Transient Ischemic Attack (Brainstem or Cerebellum) Multiple Sclerosis Medicines Adapted from ://

19 Red Flags in Vertigo Diagnosis Vertigo lasting several days Nystagmus that is down-beating & continuous Continuous headache and nausea Ataxia/other cerebellar signs eg poor balance, gait, coordination Progressive hearing loss

20 What is the cause? The duration of each episode is an important indicator of the likely aetiology: Seconds - likely to be psychogenic Less than a minute likely BPPV Minutes likely to be vascular/ischemic Hours likely to be Meniere s or vestibular migraine Hours to Days likely to be vestibular neuritis or a central cause Recurrent with headaches, photophobia & phonophobia likely to be vestibular migraine

21 Further questions to ask Is it triggered by lying down? Rising? Turning over in bed? Looking up? Stooping? Does it start when they are upright and still? Have they had a recent head injury? Are they taking any new medication? Are there other symptoms they are experiencing such as tinnitus, hearing loss or pressure in one ear? Are the episodes accompanied by a headache?

22 Examination to confirm cause Cardiovascular heart rate & rhythm, BP Otoscopy inflammation, infection, secretion, odour, cholesteatoma or herpes Neurologic Examination eyes, gait, balance & coordination. *If vertigo is peripheral, no abnormal neurological signs other than nystagmus (and possibly hearing loss) Basic Hearing Test a pure-tone audiogram Specific Positional Testing Head Impulse Test for VOR, Dix Hallpike Test

23 Head Impulse Test for VOR Taken from 6

24 Dix-Hallpike Test Taken from

25 Management & Treatment Cause Benign Vertigo Central Disorder BPPV Meniere s Disease Vestibular Neuritis Labyrinthitis Vestibular Migraine Medicine-related vertigo Treatment Symptomatic Treatment Referral Hospital Epley Manoeuver Referral Audio & ENT Symptomatic Treatment Referral Hospital Treat as for migraine Trial cessation of expected medicine if appropriate

26 Epley Manoeuver Taken from

27 Follow Up Essential for all people with vertigo Continuing/worsening symptoms may indicate incorrect initial diagnosis Vestibular rehabilitation may be beneficial for persistent non-fluctuating peripheral vertigo Patients with Meniere s Disease will need ongoing monitoring of their hearing loss

28 Tinnitus Objective tinnitus - an actual internal sound perceived Clicks or crackling due to muscle spasms around the middle ear Pulsatile tinnitus - altered blood flow or increased blood turbulence near the ear atherosclerosis or venous hum carotid artery aneurysm/dissection. Vasculitis idiopathic intracranial hypertension Subjective tinnitus sound perceived with no physical sound stimuli present. Most commonly a result of hearing loss Several subtypes of subjective tinnitus although not fully understood. Otologic: Conductive hearing loss (otitis media, earwax, etc.) Sensorineural hearing loss (age/noise related, Meniere's, ototoxic medications, acoustic neuroma, etc.) Neurological: M.S, head injury, whiplash, TMJ dysfunction, etc. Metabolic: Thyroid disease, etc. Psychiatric: Depression, anxiety, etc. Complex neural networks can maintain/exacerbate tinnitus

29 Flowchart for the Diagnostic & Therapeutic Management of Tinnitus Tinnitus can be a symptom of a wide range of different underlying pathologies and can be accompanied by many different comorbidities. To help facilitate multidisciplinary diagnostic assessment, the Tinnitus Research Initiative (TRI) Clinical Network developed a comprehensive interactive flowchart Can download pdf from TRI website

30 Red Flags: Tinnitus Sudden onset tinnitus Accompanying hearing loss? Vertigo or aural fullness? Unilateral tinnitus Asymmetrical hearing loss? Middle ear pathology? Retro-cochlear pathology? Pulsatile tinnitus Vascular? Carotid bruit? Middle ear pathology? Hyperacusis: Don t forget to ask if there is any sensitivity to sounds!

31 Advances in Tinnitus Treatment Understood that different tinnitus subtypes need different management. For bothersome subjective tinnitus, a combination of directive counseling and sound therapy is the current gold standard. Sound therapy features an option now included in many brands of hearing aids. Random fractal (no pattern) tones Adjustable pitch, volume, and type of sound to optimise masking Automatically modulate volume depending on environment Potential future therapies on the horizon: New pharmacology options ie long acting benzodiazepines Trans-cranial magnetic stimulation Game therapies to retrain the brain Combinations of therapies better targeted at different tinnitus subtypes

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33 Hearing aids and assistive devices

34 Assistive devices to help your patients Amplified telephones Good for people both with and without hearing aids. Boost button to increase volume, telecoil to wirelessly transmit sound to hearing aids. Can slow speed of answering machine message Wireless headphones for TV Simple and easy to use Good for volume boost Integrated home systems Links doorbell, telephone, and smoke alarm with hearing aids

35 Advances in Hearing Aid Technology Wireless, connect to mobile phones or to TV Better water and dust resistance Better performance in crowds and background noise IIC hearing aids (invisible in the canal) CROS and BiCROS systems

36 Funding available to help your patients Ministry of Health funding managed by Accessable: Hearing Aid Subsidy Scheme Available for ALL NZ citizens and permanent residents $511 per aid ($1022 for pair), eligible again 6 yrs later Hearing Aid Funding Scheme NZ citizens and permanent residents that fit one of the criteria for extra assistance: 1. Have had a significant hearing loss from childhood 2. Have hearing loss and a significant visual impairment, intellectual disability or a physical disability that limits their ability to communicate safely and effectively 3. have a Community Services Card and are: in paid employment for 30 hours per week or more, or a registered job seeker seeking paid employment, or doing voluntary work (more than 20 hours per week), or studying full time, or caring full time for a dependent person. Hearing aid fully funded, patient pays a fixed clinical management fee ($1200-$1500) Order some hardcopy booklets to have in your clinic:

37 Funding available to help your patients ACC Look for pattern of NIHL & history of work GP to start claim process ACC allocates lump sum based on % loss work related, Band 1 ($1403) up to Band 10 ($4830) Client often tops up, but at our clinics there are options even for those that can t afford to top up anything. War Pensions Eligible if have served overseas in a recognised conflict and had hearing loss recognised as a result of their service Audiologist completes and sends application to Veterans Affairs Fully funded hearing aids and repairs, receive pension for batteries Work & Income WINZ often provide an advance, patient pays back small amount each week from their benefit. Maximum limit is on on a case by case basis but $1500 is typical

38 MedTech For those of you that use MedTech, you can now refer patients to Bay Audiology! To access the MedTech referral form you need a patient on the palette (F2, type in patient name) When the patient is on the palette, then go to ConnectedCare Menu Audiology Referrals Refer to Bay Audiology *For those without MedTech we have some referral cards

39 Thank you for your time! ANY QUESTIONS? Feel free to contact us for a copy of the presentation or for any audiology enquiries: ryan.hunt@bayaudiology.co.nz libby.sanderson@bayaudiology.co.nz

40 References and Resources Anderson, P. (n.d.). Sudden Sensorineural Hearing Loss Needs Urgent Referral. Medscape Today. Retrieved from Schreiber, B. E., Agrup, C., Haskard, D. O., & Luxon, L. M. (3). Sudden sensorineural hearing loss. The Lancet, 375(9721), doi: /s (09) Hoare, D. J., & Hearing, N. N. (2013). Managing tinnitus in primary care. Nursing in Practice, 61. El-Shunnar, S. K., Hoare, D. J., Smith, S., Gander, P. E., Kang, S., Fackrell, K., & Hall, D. A. (2011). Primary care for tinnitus: practice and opinion among GPs in England. Journal of evaluation in clinical practice, 17(4), ANY QUESTIONS?