We’re using social isolation to combat the novel coronavirus, which is good; however, social isolation for a hard-of-hearing patient is horrible. —Jed Grisel, MD
Explore This IssueOctober 2020
Other otolaryngology settings, however, have open in-person appointment slots that are going unfilled. A growing body of medical literature suggests that patients with a variety of medical problems are putting off their care during the pandemic, and this may apply to patients with hearing loss even more strongly for several reasons, including older patient age or a lack of understanding of hearing loss effects on younger patients.
Many elderly patients may be nervous about coming to the office to have their hearing checked, Dr. Grisel explained. “I think people are saying, ‘Hearing loss won’t kill me, so I’ll wait until this all passes,’” he said. “Some patients are certainly delaying treatment, which exacerbates hearing loss.”
Dr. Preciado expressed concern that children with hearing loss issues may not get care as promptly as needed, given parents’ fears about COVID-19 exposure and a lack of understanding about the importance of early intervention. He also noted that the current crisis highlights existing problems of care coordination. Interventions for childhood hearing loss typically involve multiple medical appointments for a full evaluation, which may be a real challenge in the current environment.
It’s important to not make assumptions about how well a patient hears. A person with an assistive listening device still may not understand everything that’s said during an appointment.
Practitioners need to keep in mind the particulars of their environment, said Dr. Lee. He emphasized how important it is to speak clearly and loudly while maintaining good eye contact. “The din of a perioperative patient bay or operating room is far greater than that of a clinical office space, making communication more challenging.”
If possible, patients can bring a family member to help ensure clear communication. Early in the pandemic, visitors were limited or disallowed in healthcare settings, but some otolaryngology practices are now allowing another person to attend the appointment.
Traditionally, surgical staff have resorted to writing on a physical white board to communicate with patients who have significant hearing loss. This approach, though sometimes effective, can be cumbersome and time consuming, and doesn’t allow for a spontaneous or detailed discussion. Clinicians can use the word processor function on their computers or tablets to communicate with patients, increasing the font size for patients who have poor vision.
Dr. Lee sees the recent pandemic as an opportunity to use existing technology to enhance communication with hard-of-hearing patients in challenging listening environments. “In your pocket you have an amazing transcriber and translator—your smartphone,” he said. “You have access to a tremendous and powerful database that allows for live speech recognition as well as foreign language translation.”
The pandemic has opened up new opportunities via telehealth that weren’t previously a part of many otolaryngology practices due to barriers like insurance coverage. Some of these obstacles have now been ameliorated, at least for now, and otolaryngology practices see telemedicine visits as opportunities to help keep some hard-of-hearing patients safe.
“Virtual visits are a really good development,” said Dr. Francis. “With the right equipment, it allows patients to visualize mouth movements, alter the volume, and manage background noise.” Live captioning, separate video feeds for communication through sign language, and separate audio feeds for patients who speak a different language are also available on some platforms.
Telehealth is a good option for some complaints, such as looking at an incision following a surgery or for dizziness screening. Dr. Francis noted that in some cases it’s possible to have a hearing aid adjusted remotely, though not every facility has this ability. “We can often remotely establish a preliminary differential diagnosis and potentially initiate empiric therapy with a plan for continuing care, then schedule an in-person visit for a formal examination and confirmatory testing. Subsequent in-person visits have been very productive and relatively faster when preceded by a remote visit.”
Not everything can be done remotely, however, especially when examining particular areas, such as the back of the throat or inside of the ear, that require specific equipment (microscopes, audiometers). Dr. Babu emphasized the need to stratify patients to make sure that the appropriate patients can be seen in person when necessary.
Dr. Preciado said that full audiology testing is challenging to do remotely because of the specialized equipment and environment needed and the interactive aspect of the exam; it can be even more so in audiology testing for children. “Getting hearing aids, being tested in a sound booth, following up on how a child is doing with hearing aids—often these are best done in person.”
Dr. Grisel noted that it may be especially important to perform proper COVID-19 screening and sanitization protocols for patients who will be sitting in small, confined areas for hearing tests. “If you did have a patient who was actively shedding virus, the hearing booth would be a high-risk scenario,” he explained. However, unlike some other evaluations that carry a high aerosolization risk, audiology tests are generally non-aerosolizing.
It’s critical that otolaryngologists are sensitive to the challenges faced by their hard-of-hearing patients and continue to assess the impacts of the pandemic on this group.
“I think it’s important for practices to set sound safety policies and remove as many barriers as possible for this group of patients,” said Dr. Grisel. “We want patients to continue coming in to get the care they need.”