To Ear Plug or Not to Ear Plug

Seems like a fairly simple question... but oh what controversy it stirs up when regarding a patient with ear tubes who wants to go swimming.

There are two schools of thought...

1) Based on evidence and research, no need to wear ear plugs... ever.

The argument... Well, here's the research:

• A meta-analysis of swimming and water precautions.
• Water precautions and tympanostomy tubes: a randomized, controlled trial.
• A meta-analysis of swimming and water precautions.
• The effect of water exposure after tympanostomy tube insertion. 

 2) Based on personal experience, ear plugs should be worn.

The argument:

When there's a tube present through the eardrum, any water that gets into the ear canal can potentially go through the tube and into the middle ear space and cause an infection (otitis media). The middle ear space should remain sterile, but if the water is contaminated with germs, this sterile space becomes violated.

Remember, germs found in swimming pools, lakes, rivers, and oceans can be quite funky to say the least. Think of all the birds and animals that go potty in such bodies of water (let alone humans).

Furthermore, there is a type of ear infection called Swimmer's Ear (otitis externa) which is an infection of the skin lining the ear canal. If swimming can cause Swimmer's Ear, than by golly, it certainly can cause middle ear infections as well.

Also, if swimming can cause life-threatening brain eating amoebic infections (amoeba travels into the nose and up into the brain), than by golly, such water getting into the ear can certainly cause ear infections.

Though research does not necessarily bear this argument out, many ENTs have noted from personal experience that it is not uncommon that a patient with ear tubes presents with a draining ear infection within a few days of swimming.

Given water precautions take minimal effort and costs little ($10 ear plugs or swim cap or ear bands... see below), it seems worth it to play it on safe side.

Conclusion?

What do I typically recommend? Ear plugs when swimming, but not necessary when taking a bath (given tap water is theoretically clean).

Many will disagree depending on who you ask, but that's my personal opinion.

Noise Hyper-Sensitivity in Kids

Although we mainly see kids for hearing loss due to fluid in the ears, chronic ear infections, or eustachian tube dysfunction, every so often, a child will show up with the exact opposite problem.

The child hears just fine, but suffers from noise hypersensitivity, also known as auditory hypersensitivity. Such children are overwhelmed from everyday noises whether doorbells, sirens, key clanking, etc; typically high-pitched sounds. The hands will go over the ears in an attempt to dampen the sound and may even become tearful.

This phenomenon is not uncommon in kids with developmental delays, autism, central auditory processing disorders (CAPD), Down's syndrome, etc. But "normal" kids may suffer from this condition as well.

Before going into treatment, one first needs to understand how sound is perceived first.

Human hearing is a complex listening device composed of not just the ability to "hear" the sound, but also to "comprehend" the sound. Disorders like CAPD is analogous to dyslexia where the patient can "hear" sounds perfectly normally, but has trouble understanding what they hear.

As a child develops, the auditory neural pathways in the brain that govern the comprehension of sounds are either reinforced or dampened down with time. For example, auditory neural pathways that allow for speech comprehension are reinforced whereas neural pathways perceiving background noises and other random sounds are dampened with time.

In auditory hypersensitivity, for whatever reason, the auditory neural pathways governing the perception of certain miscellaneous noise like sirens or doorbell are reinforced causing the perception of the sound to be more significant and tremendous than it should be. In a normal child without sensitivity, such pathways are suppressed.

To use an analogy, consider the auditory neural pathway like the road system in the United States. Over time, certain roads like the interstate highway is "reinforced" leading to more drivers using such streets to get from point A to point B far more quickly than if they used local roads. Problems occur if for some reason, cars avoid the highways and local roads are taken preferentially leading to traffic jams and irate drivers.

Auditory hypersensitivity is kind of like that... local roads being "reinforced" when it should be suppressed.

So what can be done to treat this frustrating condition?

In essence, therapy is geared towards reinforcing good auditory neural pathways and suppressing the bad ones that lead to noise hypersensitivity.

Such therapy programs include listening to special music and ear training exercises. One such program is "The Listening Program".

But one thing is clear... keeping someone with noise sensitivity in silence is the worst thing that can be done. It just reinforces the bad pathways!

Of course, there are other causes of noise sensitivity:

1) Migraines (children may not exhibit the class head pain, but they still can suffer from noise sensitivity)
2) Cochlear hydrops (if associated with hearing loss, tinnitus, sound distortion)

Actress Kristin Chenoweth Suffers from Meniere's Disease

Kristin Chenoweth is an accomplished actress both on TV and live on Broadway having performed in Wicked as Glinda as well as appearances in TV shows Glee and Pushing Daisies.

She also suffers from Meniere's Disease which was diagnosed in 2007.

As such, she is prone to dizzy attacks which may have contributed to well-known falls during performances over the years.

• 2003: Fell off the stage during rehearsals for Wicked
• 2006: Fell off the stage during Broadway revival of The Apple Tree
• 2011: Fell down the stairs during injuring her back on the set of Glee.

And those are just the falls we know about.

Meniere's disease is a disorder of the inner ear which leads to spinning dizzy attacks without any specific trigger. The dizzy spinning typically lasts several hours and is often preceded by tinnitus, aural pressure, and a hearing decrease on just the affected ear.

Fluctuating hearing loss is not uncommon as well.

Diagnosis is not straightforward and is usually obtained by history alone, but supporting tests include ENG (electronystagmography), VEMP (vestibular evoked myogenic potentials), ECoG (electrocochleography), ABR (auditory brainstem response), MRI scan, etc.

Once diagnosis of Meniere's disease is made, treatment occurs in stages:

Stage 1: Eliminate all salt (less than 1000mg of sodium per day), caffeine (no coffee, tea, decaffeinated, sodas, chocolate, etc), and alcohol from the diet.

Stage 2: If stage 1 does not help, addition of a diuretic pill like maxzide.

Stage 3: Invasive procedures which include endolymphatic shunt operation or vestibulectomy using intratympanic gentamyin injection into the ear or surgical lysis.

Flare-ups are treated symptomatically with phenergan and if needed, steroids whether oral or injection into the ear.

What is Asymmetric Nerve Hearing Loss

Given my last blog article regarding an ENT who got sued for not doing an MRI after audiogram showing an asymmetric hearing loss, the question that should be on everybody's mind is what IS asymmetric nerve hearing loss on a hearing test?

I am sad to report that there is no clear consensus on what is asymmetric nerve hearing loss.

First of all, at its most basic definition, asymmetric nerve hearing loss is when hearing is worse in one ear when compared with the opposite ear due to nerve damage.

Technically, hearing should decrease equally on both sides over time, but when one side gets worse faster than the other, it can cause concern because:

1) A tumor can be pressing against the nerve causing it to slowly fail faster than the other ear's nerve which is not compressed.
2) There is a loud noise history with asymmetric exposure to the ears. One example is hunting with a rifle where the left ear would repetitively get noise-induced damage from the gunshot in a right-handed shooter.
3) Bad luck

The conflict is at what point is an asymmetry considered significant enough to warrant a workup which may include an MRI scan of the head and/or auditory brainstem response (ABR)? Also, for a given patient history, a physician/patient may elect to recheck hearing bi-annually to monitor for asymmetric progression rather than pursue workup immediately (further studies being pursued only if asymmetry progresses over time).

Is asymmetry defined as 1 decibel difference between ears? Is it 50 decibel difference?

Even if the decibel difference is agreed upon, than over what frequencies? All of them or just a few of the frequencies?

So for the purposes of a "medically" significant asymmetric nerve hearing loss, the definition must define not only HOW big the difference in hearing loss is present between ears but also at what frequencies.

In one paper, it is 15 decibels at just 3000 Hz.

In another paper, it is 20 decibels at any two adjoining frequencies (or 15 decibels at two adjoining frequencies between 2000 and 8000 Hz).

Get this... even when criteria is defined, one study found substantial disagreement among five expert judges on what hearing tests they considered showed asymmetry.

Even insurance companies are jumping into the fray in what they considered significant enough to warrant covering the MRI scan. At one point when I ordered an MRI scan of the head for what I thought was a significant asymmetry found in one patient's hearing test, the insurance company denied the test citing "that there needed to be other neurological deficits PLUS the asymmetry seen on hearing test before MRI scan would be authorized".

I personally pursue further workup using the 20 decibel difference at two adjoining frequencies OR 30 decibel at one frequency.

Assuming medically significant asymmetric hearing loss has been defined and is present...

What are the chances of something bad going on (i.e., tumor) when an MRI scan of the head is ordered for asymmetry found on hearing test?

Less than 10% (depending on study, can be as low as 1-4%).

Given such a low positive yield on testing, why even pursue a MRI scan?

Because of defensive medicine to avoid being named in a lawsuit if the affected patient just happens to be within that 10% found to have an acoustic neuroma.

Indeed, in one study, 40% of ENTs stated medico-legal concerns factored into their decision to get an MRI scan of the head.

ENT Sued for Malpractice for Hearing Loss Due to Acoustic Neuroma

A patient has sued an ENT for failing to workup an asymmetric sensorineural hearing loss (nerve hearing loss greater in one ear compared to the opposite ear) that allegedly deviated from standard of care that ultimately led to permanent hearing damage and facial paralysis.

Since January 2008, the plaintiff saw the defendant ENT who performed 3 audiograms that revealed an asymmetric sensorineural hearing loss. In 2010, the plaintiff suffered a sudden sensorineural hearing loss at which time an MRI scan of the head was performed revealing a "large" acoustic neuroma (benign tumor of the hearing nerve).

Resection of this tumor resulted in a visible facial droop, permanent hearing loss, and cognitive deficits due to partial removal of brain tissue.

According to plaintiff, had the ENT performed MRI scan when asymmetric sensorineural hearing loss was first detected (presumably back in 2008), he never would have suffered from these defects.

Read about the case here.

Normally, if and when asymmetric sensorineural hearing loss is first detected, some type of workup is typically performed (auditory brainstem response and/or MRI scan of the head) unless there are extenuating factors present in the history. Such extenuating factors include old age and/or significant loud noise history that may lead to asymmetric hearing loss such as shooting (which often causes left greater than right nerve damaged hearing loss in right-handed shooters).

Apparently THREE audiograms were performed over time. If there was progressive worsening of the asymmetric sensorineural hearing loss, than MRI should have been performed and/or at the very least an auditory brainstem response testing (ABR). IF the audiograms showed stable asymmetry over time, it can be argued that absolutely no further workup is needed.

The key question in this case is had the defendant ENT obtained an MRI in 2008 when asymmetric sensorineural hearing loss was first detected, the acoustic neuroma would have been discovered earlier thereby preventing the permanent hearing loss he later suffered in 2010 along with facial paralysis and cognitive defects that occurred after surgical resection.

A couple problems with this line of reasoning:

1) Acoustic neuromas grow at a rate of 1mm per year on average. As such, if the acoustic neuroma was large in 2010... it most certainly was large in 2008 being only 2mm smaller.
2) As such, surgical resection of the "large" acoustic neuroma had it been performed in 2008 probably would have resulted in the same outcome of permanent hearing loss, facial paralysis, and cognitive defects.

Furthermore, had the MRI been performed back in 2008 revealing the tumor, the options that would have been presented to the defendant patient would be:

1) Surgery
2) Radiation
3) Observe

Given it is established that the acoustic neuroma was large even in 2008, any type of intervention whether surgery or radiation, most certainly would put at risk the facial nerve which runs alongside the acoustic neuroma. Permanent facial paralysis and hearing loss most certainly is not an uncommon outcome after intervention.

One could even argue that in all likelihood, ALL the defendants current complaints would have occurred 2 years more quickly had the MRI scan of the head and subsequent intervention been performed.

Observation would have only lead to the current sequence of events.

As such, did malpractice occur?

I don't think so.

Should the defendant ENT have ordered the MRI scan of the head back in 2008 when an audiogram he obtained showed the asymmetric sensorineural hearing loss?

Probably though this might be debatable depending on patient's prior noise history and exact audiogram findings. Most definitely if the audiograms revealed a progressive worsening of the asymmetry over time. Most likely not if the audiograms remained the same over time.

Would knowing there was an acoustic neuroma present in 2008 have changed the patient's ultimate outcome?

Probably not.

Source:
Couple sues physician for medical malpractice. The West Virginia Record 7/10/12