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February 2012MIAMI BEACH — More and more options are emerging to help patients improve their hearing, a group of aural rehabilitation panelists said here on Jan. 27 at the Triological Society Combined Sections Meeting.
Hearing loss is the third most common chronic health care issue in the U.S., a fact that is “just amazing to me,” said moderator Jennifer Derebery, MD, clinical professor of otolaryngology at the University of Southern California School of Medicine and a neurotologist associate at House Ear Clinic in Los Angeles.
“We all know that the workhorse treatment of hearing loss is the hearing aid, and yet the prevalence of individuals who need hearing aids and actually obtain them has been flat for decades,” she said.
Six million people over 55—just a fraction of those who could benefit from one—have a hearing aid, with just 5 million of them actually using it. Of those, 2.5 million patients are unhappy with their hearing aids, Dr. Derebery noted during her presentation.
Improvements
Samuel Selesnick, MD, FACS, professor and vice chairman of otolaryngology-head and neck surgery at Weill Cornell Medical College in New York City, said hearing aids are improving.
The “open fit slim tube” found in some hearing aids reduces the occluding of the canal, making them comfortable and more cosmetically appealing. There are models that reduce feedback, allowing for improved hearing of speech in noisy settings, directional microphones that allow the listener to direct the device; for example, in front of them where the person talking is likely to be; and devices allowing listeners to better determine the origin of sounds.
Cell phones have come into the mix as well, acting as a hearing aid remote control with volume and channel control and even acting as a remote microphone with bluetooth technology, able to be placed, for instance, in the middle of a table during a meeting.
But Dr. Selesnick said a focus on technology might not be what’s best for patients. “One might argue that the entire high-tech issue is really of relatively minor importance when compared to the counseling and rehabilitative aspect,” he said. “Instead of the center of the model being technology it really should be a person-centered model, with technology being one important part.”
He said this is made difficult by lack of compensation to providers to spend more time with patients and a limited availability of qualified providers with the right “passion and skill set.”
Implantable Devices
Herman Jenkins, MD, professor and chair of otolaryngology at the University of Colorado School of Medicine in Denver, said that while implantable devices for the middle ear are promising, challenges remain, particularly with creating a battery that is compact and has a long life span.
“You’re putting a translating system into a biological system and expecting it to last many, many years and that is technically a very difficult thing to accomplish,” he said.
Dr. Jenkins said the FDA-approved Envoy Esteem has a great microphone system but involves an extensive operation involving removal of 3 mm of the incus to prevent feedback problems.
For patients with an Eustachian tube problem, he added, the microphone system becomes “fairly ineffective.” The implantable devices might have a place in helping certain patients, but not all patients need to go that far, he said.
“Remember, hearing aids are really quite good,” he said. “If the patients will use it, they’ll do well with it. The problem is… how many people actually use it.”
Unilateral vs. Bilateral Implants
David Haynes, MD, associate professor at the Vanderbilt Bill Wilkerson Center for Otolaryngology and Communication Sciences in Nashville, talked about the benefits of cochlear implantation. He said that since it is difficult to determine through tests which ear will perform better with the cochlear implant, the only way to be sure you’re implanting the ear best for the implant is to implant both ears.
That has to be balanced against the added risk, more difficult preparation, the time commitment, and increased incidence of vertigo, as well as “using up the ear before future technologies” emerge, Dr. Haynes said.
He pointed out that unilateral hearing loss is underappreciated, with 35 percent of children with hearing loss on one side failing one or more grades. There is now more of an inclination, therefore, to treat unilateral hearing loss, he said.
He pointed to a European analysis of a bone-anchored hearing aid (BAHA) database that found that 109 of 166 patients (66 percent) declined a BAHA after trying it pre-operatively (Eur Arch Otorhinolaryngol. 2011. [published online ahead of print August 11, 2011]).
The main reasons were not enough improvement in their hearing or tinnitus, both of which have been shown to improve with cochlear implants, Dr. Haynes said.
Therapy
Auditory verbal therapy can be particularly fruitful for children getting cochlear implants, said Thomas Balkany, MD, director of the University of Miami Ear Institute. Auditory verbal therapists (AVT) generally have master’s degrees in audiology, speech pathology and deaf education and work with a mentor for three years, a period that includes 900 hours of therapy.
In AVT, parents are taught to teach their children to listen, with listening strategies integrated into daily routines. No sign language, total communication, or lip reading is involved. In studies comparing profoundly deaf children given AVT therapy compared to those using total communication, which involves using hand gestures and other means, the AVT group has fared significantly better on a slate of speech perception tests, Dr. Balkany said (Otolaryngol Head Neck Surg 1999;121:31-34).
“Auditory verbal therapy is an effective method of habilitation,” he said. “I think this method could be modified in the future according to our new understanding of brain function and also in consideration of the wonderful technology we now have.”
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