Communication with hard-of-hearing patients, particularly those who are older, is a longstanding challenge for all physicians. Otolaryngologists, especially those specializing in otology, are even more likely to see patients for whom hearing loss is the primary medical complaint or a secondary issue that deserves major consideration.
During the COVID-19 pandemic, however, hard-of-hearing patients have faced additional challenges, including worsened communication and difficulties accessing healthcare. Through awareness and planning, otolaryngologists can help their patients better navigate these issues to get the help they need.
Whether resulting from increased cognitive load, social isolation, or other degenerative factors, researchers have found independent associations of hearing loss with dementia, poor health outcomes, and overall mortality. Unfortunately, the COVID-19 pandemic may exacerbate these existing problems. Neurotologist and otologist Howard W. Francis, MD, MBA, the Richard Hall Chaney Sr. Distinguished Professor of Otolaryngology at Duke University in Durham, N.C., noted that patients with hearing loss tend to report poorer communication with their physician and worse perceptions of their overall healthcare quality (J Am Geriatr Soc. 2014;62:2207-2209).
“We’re using social isolation to combat the novel coronavirus, which is good; however, social isolation for a hard-of-hearing patient is horrible,” said Jed Grisel, MD, an otolaryngologist practicing in Wichita Falls, Texas. “The public policy that’s being used to address COVID-19 could actually be exacerbating some of the effects of hearing loss.”
In addition, hard-of-hearing patients who are older face an increased risk of suffering severe complications from COVID-19 due to pre-existing health conditions, said Dr. Grisel. “Unfortunately, the group of patients with hearing loss who are at greater risk of social isolation and dementia are the exact same group of patients who are at greater risk of complications from the coronavirus.”
The Mask Situation
Communication with hard-of-hearing patients is a challenge under normal circumstances, but the widespread use of face masks to decrease COVID-19 spread has only exacerbated this challenge.
Face masks disrupt the visual input that many hard-of-hearing individuals depend on. These visual clues are especially important for people with more profound hearing loss, who may rely heavily on lip reading. Additionally, masks muffle voices and decrease the quality of sound received. With more brain resources working to process degraded speech, hard-of-hearing patients may be less able to engage in other cognitive operations, leading to mental fatigue and avoidance behaviors (Ear Hear. 2018;39:204-214).
“What’s most interesting to me is how significantly transmission of higher frequency sounds—1,000 hertz and higher—is negatively affected by masks, therefore obscuring consonant sounds,” said Dr. Francis, remarking on a study that examined the reduced transmission of speech through face coverings (arXiv ePrint archive. August 11, 2020. Available here). “Masks affect the worst possible frequency range for effective communication. Unfortunately, that’s where most of the hearing loss already is, particularly for older patients.”
In your pocket you have an amazing transcriber and translator—your smartphone. You have access to a tremendous and powerful database that allows for live speech recognition as well as foreign language translation. —Daniel J. Lee, MD
Seilesh C. Babu, MD, a neurotologist in Farmington Hills, Mich., has noticed that mask use often changes patients’ perceptions of their own hearing loss. Many of his patients who didn’t think they had much of a problem suddenly recognize that their hearing isn’t as good as they thought it was and that they were previously lip reading without realizing it.
Some otolaryngologists use clear masks to help facilitate communication, with the obvious advantage of providing additional visual clues to patients who rely on lip reading. Transparent masks can be difficult to obtain due to high demand, however, and do have drawbacks. The arXiv study referenced above found that sound transmission was more heavily impaired when traveling through plastic than through cloth.
Daniel J. Lee, MD, associate professor of otolaryngology–head and neck surgery at Harvard Medical School and director of pediatric otology and neurotology at Massachusetts Eye and Ear Infirmary in Boston, said that transparent masks are prone to fogging up from condensation, obviating the advantage of having a transparent screen in the first place.
Safety is another concern for transparent masks. Such masks are more open on the sides and are therefore not very protective against airborne aerosols. Mask side closure can better seal off the aerodigestive tract, but this worsens condensation issues. No transparent mask is approved for COVID-19 inpatient services, and none currently available are N95 rated (JAMA Otolaryngol Head Neck Surg. 2020;10.1001/jamaoto.2020.1705).
Dr. Francis and his colleagues are currently working on their own study to characterize the added impact of face masks on hard-of-hearing patients age 60 or older. The project will include 40 patients who received care from a provider wearing a clear mask and another 40 who received care from a provider wearing a nonclear mask. Dr. Francis hopes to analyze data next spring to identify potential risk factors and evaluate patients’ ease of communication, listening effort, and mental fatigue.
Healthcare Access Issues
The COVID-19 pandemic also poses problems of medical access for some hard-of-hearing patients. Diego A. Preciado, MD, PhD, vice chief of pediatric otolaryngology at Children’s National Hospital in Washington, D.C., explained that underinsured or publicly insured hard-of-hearing patients tend to be delayed in all aspects of their hearing care. “It’s always been an issue for these patients, but it’s magnified now,” he said. “A global recession may make that worse.”
Dr. Grisel noted that the average price for a single hearing aid can be as much as $4,500, a cost that isn’t covered by Medicare. Even when insurance partly helps with this cost, recurring expenses like batteries and, ultimately, replacement can add up.
“If people are scared about finances, hearing healthcare is one thing they’ll eliminate or put off,” said Dr. Grisel. “Everyone’s nervous and there’s a lot of insecurity about what’s going on with the economy, which influences purchasing decisions of all kinds.”
The pandemic has limited healthcare access in other ways. Dr. Preciado noted that COVID-19 has negatively impacted access to medical providers, at least in some tertiary centers. Due to physical distancing measures, some institutions have placed restrictions on the number of patients who can be in ambulatory clinics, with fewer slots available for in-person visits.
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
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.”
Ruth Jessen Hickman, MD, is a graduate of the Indiana University School of Medicine. She is a freelance medical writer living in Bloomington, Ind.