ATT0691_Audiology-Reference-Guide_16pp_A4_v7 by Travis Naughton

Audiology Reference Guide For Medical Practitioners

Version Three Attuneâ&#x201E;˘ is Government accredited to provide fully subsidised hearing aids, hearing devices and other private hearing services for eligible Pensioners and Veterans. AttuneTM is a registered trademark of Attune Hearing Pty Ltd. Founded in 1986, AttuneTM delivers the most accurate hearing evaluations, and the most appropriate treatments making us the preferred choice for Ear, Nose and Throat Specialists in Australia. AttuneTMâ&#x20AC;&#x2122;s Audiologists are supervised and supported by local Ear, Nose and Throat Specialists. AttuneTM is the trusted name in hearing healthcare.

Contents

Anatomy of the Ear 1 What test(s) will your patient need? 2 Audiological Services Summary 3 What to expect from Attuneâ&#x20AC;&#x2122;s Audiological Report 4 Types of Hearing Loss 5 When to refer your patient for a Hearing Aid assessment 6 Office of Hearing Services (OHS) Program 7 Help for Dizzy Patients

Help for Children with Hearing, Speech or Learning Difficulties 9 Help for Tinnitus Patients 10 Cochlear Implant 12 Middle Ear Implants 13 Eustachian Tube Dysfunction Glue Ear

14 16

Dementia and Hearing Loss

Meniereâ&#x20AC;&#x2122;s Disease

Otology Photographs (dirty pictures)

Attune is an Accredited Activity Provider for RACGP - 2011-2013 triennium. Attune would be happy to provide educational activities for your practice. Further information regarding these opportunities please contact your audiologist at your local Attune Clinic.

Anatomy of the Ear

Brain Incus (anvil) Stapes (stirrup)

MIDDLE EAR

Helicotrema

INNER EAR Auditory Nerve

OUTER EAR

Helix

Malleus (hammer)

Mastoid process

4 3 1

Vestibular Organ

Cochlea

Oval Window

Cartilage

Eustachian Tube

1 Ear Canal

Sound moves through the ear canal and strikes the eardrum.

2 Eardrum and bones

Sound waves cause the eardrum to vibrate, sending the bones in the middle ear into motion.

3 Inner ear

This motion causes the fluid inside the inner ear (cochlea) to move the hair cells.

4 Hearing nerve

Hair cells change the movement into electric impulses, which are sent from the hearing nerve into the brain; you hear sound.

CLINICS

Please see www.attune.com.au or call 1800 195 155 for current Attune clinic locations. AttuneTM is supported and supervised by local Ear, Nose and Throat (ENT) specialists.

What test(s) will your patient need?

Symptom

Details

Ringing in the Ear

Bilateral

PTA

Unilateral

PTA + ABR

Pulsatile (heart beat)

PTA

Dizziness & Vertigo

Imbalance

PTA + VNG/ENG & Caloric (see Help for the Dizzy Patient page)

Hearing Loss

Bilateral

PTA

Unilateral

PTA + ABR PTA (urgent request) Must have hearing test within 12 hours

Sudden

Blocked Ears

Bilateral

PTA

Unilateral

PTA ENT Referral - see ENT Directory on the Attune website: www.attune.com.au

Discharge

Difficulty Hearing in Noise

Test Required

Adults

PTA

Children (over 7 years)

PTA + (C)AP

Children (under 7 years)

PTA ENT Referral - see ENT Directory on the Attune website: www.attune.com.au

Foreign Objects in the Ear

PTA

Pure Tone Audiogram (PTA) - Hearing Test + Immittance + Speech Discrimination

PTA + VNG/ENG & Caloric

Balance Tests (VNG/ENG & Caloric) + Hearing Test (PTA) + Immittance + Speech Discrimination

PTA + ABR

Auditory Brainstem Evoked Response (ABR) + Hearing Test (PTA) + Immittance + Speech Discrimination

PTA + CAP

(Central) Auditory Processing Test (C)AP + Hearing Test (PTA) + Immittance + Speech Discrimination

Call 1800 195 155 for referral information or to discuss what test your patient needs. Information for GPs ENT Surgeons, working in collaboration with Attune audiologists, support and review all clinical aspects of your patientâ&#x20AC;&#x2122;s hearing test and rehabilitation â&#x20AC;&#x201C; ensuring patient care is based on the highest medical and scientific standards. This unique collaboration differentiates Attune from other hearing screening centres.

CLINICS

Please see www.attune.com.au or call 1800 195 155 for current Attune clinic locations.

AttuneTM is supported and supervised by local Ear, Nose and Throat (ENT) specialists.

What Test to Refer Attune Services

Audiological Services Summary Attune is supported by ENT Surgeons who review all aspects of your patient’s audiological management.

Attune offers the following audiological services: Diagnostic Test/Management

Recommended Age

What Happens

Pure Tone Audiogram (PTA) (Hearing Test)

Children 3.5 years+ and adults

Tests hearing sensitivity of each ear individually, includes a range of frequencies. Measures the ability to understand speech. Evaluates middle ear status

Hearing Test for Infants

6 to 13 months

Visual Reinforcement Orientation Audiometry (puppet show as a visual reward) Play Audiometry (child is asked to respond to a sound using toys in a game).

Hearing Test for Young Children

13 months to 4 years

Objective Assessments: Otoacoustic Emissions (assessment of middle ear and cochlear status). Immittance or Auditory Brainstem Response to help determine hearing status.

(Central) Auditory Processing (C)AP

7 years + and adults

Evaluates auditory processing function when a child’s hearing is normal but has difficulty understanding speech in challenging listening environments or shows poor achievements in the classroom.

Auditory Brainstem Evoked Response [ABR]

Adults, children and infants

Test used for diagnostic purposes and/or to determine hearing thresholds. Suitable for patients with asymmetrical hearing or suspicious unilateral symptoms eg tinnitus and/or dizziness. Investigates different areas of the hearing system, determining the site of hearing disorder. Includes tests sensitive to retrocochlear or brainstem lesions.

Hearing Aid Assessment, Fitting and Rehabilitation (FREE for pensioners and veterans)

Adults

Assessment and advice on amplification based on which part of the hearing system has been affected and what type of hearing aid management is most suitable for the patient’s hearing loss and lifestyle needs.

Balance and Dizziness (VNG/ENG and/or Caloric)

Adults

Tests the vestibular system following the onset of dizziness, disequilibrium or imbalance. Test instructions: NO medications for dizziness or nausea 2 days prior to the test. NO alcohol or smoking for at least 48 hours and only have a light meal before the test. NO driving immediately after the test.

Tinnitus Consultation

Adults

Counselling and tinnitus coping strategies (Tinnitus Retraining Therapy (TRT), Neuromonics).

Pre-Employment (Hearing Test)

Adults

Test is required as part of Workplace Health and Safety.

Medico Legal Report

Any age

Audiological assessment and comment of these results for legal purposes.

Specialised Diagnostic Tests (Normally ordered by specialists)

Your patient is eligible for Medicare rebate for most diagnostic assessments. To receive a rebate patients must have a referral from a Medical Practioner.

Implant Assessment ‘Bionic Ear’ ( Cochlear, MED-EL) Bone Anchored Hearing Aids (BAHA) VIBRANT Soundbridge (VSB) Fistula Test ECoG - Electrocochleography Eustachian Tube Dysfunction Test with Audiogram VEMP - Saccule Function Test

CLINICS

Please see www.attune.com.au or call 1800 195 155 for current Attune clinic locations. AttuneTM is supported and supervised by local Ear, Nose and Throat (ENT) specialists.

What to expect from Attune’s Audiological Report

Attune’s audiological evaluation will:

Recommend hearing aid fitting if necessary and/or other audiological management.

Determine the degree and type of hearing loss. Identify the location of the lesion within the auditory system producing the problem.

Help establish the cause of the hearing loss. SERVICES Time:

Date:

Diagnostic Tests Estimate the extent of the communication impairment. (Adult and Paediatric)

Audiology Report

Pure Tone Pure ToneAudiometry Audiometry 250

500

Normal

12.5k

Type

Immittance

125

Hearing Aid Assessment and Fitting

Frequency Hz

R L

Mild

Freq

Moderate

50 60

Probe R

Probe L

Severe

Acoustic Reflex

dBHL

Middle Ear

Cochlear Implant

Ear Canal

Degree of Hearing Loss

20 30

Static

Program This part of the assessment determines hearing ability of each ear Compliance Pressure Volume Tinnitus Management at different frequencies (pitch of sounds measured in hertz) and Accessories intensity levels (loudness of sounds measured in decibels)

R Ipsi

Loudness Level (dBHL) WBN

Normal 0-20 Mild 21-40

Dr J Agnew

L Contra

Moderate 41-70

L Ipsi

Severe 71-90

Dr D Bell-Allen

Profound >90

Dr D Bennett

R Contra

Dr L Allen Dr J Askew

Dr R Bird

x no response at maximum level

–– frequency was not tested

(see next page for types of hearing loss)

ENT SPECIALISTS

Dr B Black

Profound

110 120 R

Immittance (Tympanometry) Air Condution Unmasked X ͦ

Unspecified

•

Air Conduction Masked

Type

Bone Conduction Unmasked

Static > Compliance

Middle Ear Pressure

Bone Conduction Masked

Air Conduction Aided







□

Air Conduction-Sound Field

No Response

Otoscopy:

 Clear

Probe R

Dr W Earnshaw

This part of the assessment provides an objective measure of middle ear function Dr K Feely

Ear

Type Interpretation

Level dBHL % Score

Compliance (ml)

A As Ad

Normal 0.3-1.6ml Hypocompliance <0.3ml Hypermobility >1.6ml

Middle Ear Pathology

R L

No Compliance

Eustachian Tube Normal Ranges Cochlear Implant Assessment Recommended: C

R Ipsi L Contra

L Ipsi Probe L R Contra

Ear Canal Volume (ECV)

Dr B Moore Dr S Nasser -99 to +50daPa Dr M Stevens -99 to +50daPa

Adult: 0.65-1.75cc Children: 0.5-1.0cc

Dr F Szallasi

Test

Dysfunction

Dr A Lomas Middle Ear Pressure Dr D McIntosh (daPa)

No Pressure

Large ECV = patent grommet = perforation Middle Ear Pathology: normal ECV

-100 or below

Normal ECV Ranges

Hearing Aid Recommended:

 Wax

Acoustic Reflex Freq

Dr C Bond List

Ear Canal Volume

∏

Other Tests

Modality/Ear

Speech Audiometry

Dr R Black

100

WBN

Assesses the stapedius muscle reflex pathway Confirm PTA Threshold Assists in identifying Retrocochlear Pathology Assists in identifying functional hearing loss

Speech Audiometry List Ear Level dBHL % Score

Objective measure of how well speech is understood when amplified Confirm PTA Threshold Determine Hearing Aid appropriateness and benefit Identify Retrocochlear Pathology Assists in identifying functional hearing loss

CLINICS

Please see www.attune.com.au or call 1800 195 155 for current Attune clinic locations.

AttuneTM is supported and supervised by local Ear, Nose and Throat (ENT) specialists.

Audiology Report Types of Hearing Loss

Types of Hearing Loss

<> <> <> <> <> <> Frequency Hz 250

X X X X X X

0 10

12.5k

Mild

20 30

Moderate

40 50 60 70 Severe

Hearing Levels in Decibels (dB)

500

Normal

125

Conductive Due to problems with middle ear system (ear drum, ossicles). An ‘air-bone gap’, a gap between air-conduction (O,X) and bone-conduction ( ) levels is evident. Note the bone-conduction levels ( ) are within normal limits (less than 20dB).

90 Profound

100 110 120

Frequency Hz 125

250

500

Normal

0 10

<X> <X>

40 50 60

<X>

Due to problems with cochlea (hearing organ in inner ear) and/or hearing nerve. No significant ‘air-bone gap’ is evident.

Moderate

Mild

Sensorineural

<X>

Profound

100

Severe

Hearing Levels in Decibels (dB)

12.5k

110 120

Frequency Hz 500

Mixed

Due to problems with both middle ear system and cochlear and/or hearing nerve.

’Air-bone gap’ is evident. Bone-conduction [<,>] levels are outside normal limits (greater than 20dB).

Normal

0 10

<> <>

70 80

X X

90 100 110 120

<> <> <> X

<> X

Modality/Ear

Air Conduction Unmasked

Air Conduction Masked

•

Bone Conduction Unmasked





Unspecified

Bone Conduction Masked Air Conduction Aided Air Conduction-Sound Field

Severe

Symbol Key

No Response

 

Profound

Hearing Levels in Decibels (dB)

12.5k

Mild

250

Moderate

125

CLINICS

Please see www.attune.com.au or call 1800 195 155 for current Attune clinic locations. AttuneTM is supported and supervised by local Ear, Nose and Throat (ENT) specialists.

When to refer your patient for a Hearing Aid assessment

Refer for a Hearing Aid assessment if your patient has any degree of hearing loss or communication difficulty. Consider referring your patient for a hearing aid assessment if they complain of any of the following: Not hearing well in background noise

Sounds like people are mumbling

Ringing in the ear(s)

Constantly having to turn up the TV and radio

Friends and family are having to repeat themselves A Hearing Aid style to suit every hearing loss and lifestyle Behind The Ear (BTE)

MicroBehind The Ear (BTE)

In The Ear/ In The Canal (ITE/ ITC)

Good durability.

Very discreet and cosmetically appealing.

Good degree of amplification.

Flexible if hearing changes or deteriorates.

No ‘blocked up’ feeling in the ear.

Flexible if hearing is different between ears.

Completely in Canal (CIC)

Lyric (like a contact lense for the ear)

Very discreet and cosmetically appealing.

No daily insertion or removal

How have hearing aids changed over the past decade? No longer occlude the ear so patients don’t experience a ‘blocked up’ feeling. Cosmetically appealing.

Easy to manage.

Completely invisible from the outside No batteries, no daily maintenance Shower and Swim

Natural sound quality. No whistling. Automatically adjusts for different listening environments. Reliable in humid climates.

Did you know Attune is accredited to provide FREE hearing aids and services for eligible pensioners and DVA patients? Please see the ‘Office of Hearing Services (OHS) Scheme’ page for information regarding the free services available for your eligible patients. Attune Hearing, supervised and supported by local ENT surgeons, offers comprehensive audiology services including Hearing Aids, Diagnostic Testing, Tinnitus Treatment and a Cochlear Implant Program. The unique collaboration between audiologist & ENT surgeon differentiates Attune from other hearing service providers.

CLINICS

Please see www.attune.com.au or call 1800 195 155 for current Attune clinic locations.

AttuneTM is supported and supervised by local Ear, Nose and Throat (ENT) specialists.

Hearing Aids Office of Hearing Services

Office of Hearing Services (OHS) Program

Attune Hearing is accredited to provide free hearing services including free hearing aids to eligible pensioners and veterans (DVA) under the Australian Government Hearing Services Program. Attune participates in the Hearing Services Program which means patients are able to access Attune’s private services with no out of pocket expense.

How To Apply For A Hearing Services Voucher Obtain a ‘New Clients Application for Hearing Services Voucher’. You can obtain this form from your doctor or Attune Hearing on 1800 195 155 or www.attune.com.au

Who is Eligible? A Medical Practitioner must sign and complete the ‘Referral Details’ section of the Application Form in Part B.

You are eligible to apply for a hearing services Voucher if you are an Australian Citizen or permanent resident 26 years or older and you are: A Pensioner Concession Card Holder Receiving Sickness Allowance from Centrelink The holder of a Gold Repatriation Health Card issued for all conditions The holder of a White Repatriation Health Card issued for conditions that include hearing loss

Post the completed Application Form to Canberra (address details are included on the voucher form)

A dependant of a person in one of the above categories A member of the Australian Defence Force Undergoing an Australian Government funded vocational rehabilitation service and you are referred by your service provider

The Patient will receive a Voucher confirming eligibility within 6 weeks.

You are eligible to receive other declared hearing services if you are an Australian Citizen or permanent resident and you are: Younger than 26 years An Aboriginal person or Torres Strait Islander who is over 50 years, or a participant in a Community Development Employment Projects Program. Attune’s Services for Eligible Patients Attune is accredited to provide the following hearing services to eligible persons: Free Hearing Test to identify the type and degree of hearing loss and communication disability. Free Hearing Aids and other devices to assist and improve communication and hearing ability. Comprehensive Audiology Report including interpretation of results and recommendations forwarded to the patients Medical Practitioner. Free Counselling to help the patient understand the impact of hearing loss on communication and quality of life. A Rehabilitation Program to help maximise communication potential for the client. Maintenance and Batteries supplied. (conditions apply).

Call Attune Hearing on 1800 195 155 once Voucher is received to make an appointment for a free hearing assessment at their nearest clinic.

‘Top-Up’ arrangements The Australian Government Hearing Services Program allows for Top-Up arrangements where the patient may choose to be fitted with a hearing aid with additional features beyond those necessary to achieve a satisfactory rehabilitation outcome. Conditions apply to clients under the Commonwealth Hearing Services Voucher System. Important Notes If the patient is currently an Attune client in the Australian Government Hearing Services Program they will be issued a Return Voucher every three years which will entitle the patient to a full review of their hearing. Attune staff can advise on the Hearing Services Program and welcome contact from any patient who may need advice or assistance in obtaining a Voucher. Please phone 1800 195 155 for your local clinic. Information on the Program is also available from the Office of Hearing Services on 1800 500 726 (or 1800 500 496 for users of TTY equipment).

CLINICS

Please see www.attune.com.au or call 1800 195 155 for current Attune clinic locations. AttuneTM is supported and supervised by local Ear, Nose and Throat (ENT) specialists.

Help for Dizzy Patients

Vertigo Assessment and Investigation Guide

events. A delay in diagnosing a vestibular cause of vertigo is usually of little consequence, while a delay in diagnosing a cardiac or neurological cause can result in a catastrophic event. Posterior fossa ischaemia can be difficult to detect and relatively clinically silent.

Vertigo, the subjective sensation of movement, is a symptom that patients are usually quite poor at describing. Dizziness, imbalance, spinning and vertigo are common complaints and assessing who should be investigated and in what manner is determined predominantly by history. Balance homeostasis is co-ordinated by the brain with major inputs from the ears, eyes and lesser input from, particularly cervical, proprioception. Upsets in any of these areas can result in balance symptoms.

The common ENT diagnoses are labyrinthitis and benign paroxysmal positional. Meniere’s disease is less common and often the more common vestibular migraine is misdiagnosed as Meniere’s disease. Neuro-otological examination should include assessment of cerebellar function, ocular movements and vestibular function. It should include head impulse tests, Rhomberg’s tests, Unterberger’s tests and Dix Hallpike tests. Full cranial nerve and long tract assessments should be done.

The history should include questions regarding the frequency, duration, severity, aggravating factors, relieving factors and nature of the balance symptoms and also questioning regarding accompanying symptoms. Associated symptoms that should be enquired about include headache, cardiac symptoms, visual symptoms, major neurological symptoms, neck symptoms and otological symptoms. Past medical history, particularly cardiovascular risk factors, headache and travel sickness history and family history of cardiovascular and migraine should be included. Current drug history is obviously important. Past ototoxic history may be important.

Tests of hearing and balance can be performed by Attune to aid in diagnosis when needed. An audiogram is a good screen for cochlear disease. Electronystagmography (ENG) including video-oculography (VNG) and calorics can give information on central and peripheral causes of vertigo. ECoG is only occassionally useful in Meniere’s patients. Imaging should be ordered in patients who historically are at risk of posterior fossa ischaemia. Non-contrasted CT scans of the head can miss posterior circulation problems. A guide to when to consider referral for investigation is below.

The major aim is to identify rapidly patients who have vertigo due to brain hypo-perfusion, be it due to cardiac problems or ischaemic

When to refer for a Dizzy Assessment Symptoms Vertigo Subjective sensation of rotation in space - Patient reports spinning

Possible Causes

Tests Required

episodic > 5mins + hearing loss + fullness + tinnitus + drop attacks +/- nausea +/- vomiting

Hydrops Vestibular neuritis

Brainstem Meniere’s

PTA VNG/ENG and Caloric ECoG

Positional <30secs Clusters< 6weeks

BPPV

Other

Vascular Infective

Perilymph fistula Barotrauma

PTA Fistula test ABR

Lightheaded - Patient reports about to pass out

Episodic – short Postural

Not otologic Vascular Hypotension Epilepsy

Arrhythmia Hyperventilation Panic attack

PTA VNG/ENG and Caloric Fistula test Medical assessment

Unsteadiness - Patient reports constant dizzy feeling

Not ataxic No hearing loss Not disabled Clinically normal

Functional

Ataxic Bilateral weakness

Cerebellar Brainstem Other neurological

PTA VNG/ENG and Caloric

Autoimmune Metabolic

PTA ABR VNG/ENG and Caloric EEG MRI

CLINICS

Please see www.attune.com.au or call 1800 195 155 for current Attune clinic locations.

AttuneTM is supported and supervised by local Ear, Nose and Throat (ENT) specialists.

When to refer for a Paediatric Hearing Test Speaks loudly or whispers. Speech development stops or slows. Little or no babbling. Appears inattentive, restless or expresses some behavioural problems. Doesn’t respond to speech from behind or soft speech.

Help for Dizzy Patients Help for Children

Help for Children with Hearing, Speech or Learning Difficulties

When to refer for a (Central) Auditory Processing Assessment (C)AP Has trouble paying attention and remembering information presented orally. Has low academic performance particularly in reading and spelling. Has difficulties understanding speech in the presence of any background noise.

Learning difficulties. with Hearing, Speech or Learning Difficulties Help for Children Has problems carrying out multi-step directions. Pulls at their ears (may be a sign of ear infection). What test to refer Hearing Test for infants (birth to 13 months) or Hearing Test for young children (13 months to 4 years). Management Attune recommends intervention for children over 3 months with middle ear problems that persist. This can be determined by clinical assessment. Attune will repeat the audiometry if required. If there is a possible sensorineural hearing loss (permanent) referral to Attune for diagnostic audiometry and to ENT for medical investigation is recommended.

Seems to hear but not understand what people say. Needs more time to process information. Has difficulty with sound direction and localisation. Central Auditory Processing (C)AP Assessment The (C)AP assessment will assess the various auditory skills in the (C)AP system including: Auditory closure skills. Auditory integration skills. Auditory separation skills. Temporal aspects of processing information. Auditory interaction skills. Management Ideally the management of (C)APD involves a team of professionals (eg speech pathologists, educational psychologists, learning support teachers, paediatricians, occupational therapists), with the amount of each member’s involvement dependent on the specific needs of the child. The management of the (C)APD focuses largely on the implementation of various strategies to maximise existing listening skills, and to encourage the development of new skills.

CLINICS

Please see www.attune.com.au or call 1800 195 155 for current Attune clinic locations. AttuneTM is supported and supervised by local Ear, Nose and Throat (ENT) specialists.

Help for Tinnitus Patients

How Tinnitus Treatment Works Tinnitus is very common and affects millions of people around the world. Tinnitus is a phantom auditory perception and this auditory sensation is not related to an external sound.

not exclusively an auditory problem. As tinnitus is a cycle of audiological, neurological and psychological factors, a multifaceted approach is required to manage and treat tinnitus awareness and disturbance. The Attune program targets all aspects of the patients tinnitus and the impact on their quality of life.

Although there is no cure for tinnitus patients can successfully learn to manage their tinnitus thus limiting emotional effects.

If your patient have one or more of the following they may be suitable for Tinnitus Treatment:

Because each person’s hearing thresholds and tinnitus characteristics are different they require a tinnitus assessment and hearing test to help in the identification of the auditory, limbic and neural pathways which may contribute to the problems with their tinnitus.

Tinnitus with or without associated hearing loss.

After assessment the most appropriate tinnitus treatment strategy and management is recommended and if the patient agrees to proceed, the treatment techniques used are designed to interact, interrupt and desensitise their tinnitus and give long term relief.

They feel their tinnitus is interfering with their ability to hear.

The clinical goal is to have the patient feel more relaxed and reduce the impact of tinnitus on their lives.

What are the treatment steps?

Tinnitus Treatment and Management

Step 1. Tinnitus and hearing assessment by Attune specialist audiologist.

Targets the neurological, audiological and psychological aspects of the patients tinnitus. Management is customised to the patients individual tinnitus and hearing profile.

Experiencing sleep disturbance due to tinnitus. Finding it hard to relax due to tinnitus. They feel their tinnitus is out of control. Sensitive to moderate or loud sounds. Tinnitus is still disturbing after hearing aid fitting.

Step 2. Explanation of the auditory and neurological pathways relevant in understanding tinnitus. Step 3. Appropriate Tinnitus Management model recommended.

Treatment is comprehensive and non–invasive.

Recruitment? Hyperacusis ? Phonophoba?

Treatment is aimed at retraining or reversing the connections between the auditory, limbic and autonomic nervous system to achieve change.

Should your patient at any time report the following a diagnostic hearing test ( PTA) should be performed.

Management is monitored by Attune specialist audiologists. Even when tinnitus is no longer an issue for a patient, they will generally report being aware of tinnitus a small percentage of the time. However they will also report that tinnitus is no longer a major disturbance in their life.

Possible Causes for Tinnitus There are many potential causes of tinnitus making each individual case unique. An undiagnosed medical problem, exposure to loud noise, ear problems, viral infections, some drugs and hearing loss may contribute to the patients tinnitus.

At times the following are associated with tinnitus. Pure Tone Audiometry (PTA) is recommended. Recruitment is when a patient with a hearing loss perceives sounds as “getting too loud too fast” or being louder than they really are to the point of discomfort. Recruitment is always a consequence of a sensorineural hearing loss. Hyperacusis is the super-sensitivity to normal sounds and may be associated with a hearing loss. Often found in children. Phonophobia is the fear of normal sounds resulting in super-sensitivity to them.

While tinnitus typically begins with a hearing loss (59 to 86% of tinnitus suffers also experience some form of hearing loss (Jastreboff 2004), it is

CLINICS

Please see www.attune.com.au or call 1800 195 155 for current Attune clinic locations.

AttuneTM is supported and supervised by local Ear, Nose and Throat (ENT) specialists.

Help for Tinnitus Patients

Allow your patient to take control of their tinnitus Most people have experienced a form of tinnitus - a sensation in the ears of buzzing, hissing, ringing or crickets chirping. Often the sensation occurs after hearing a loud noise but it is usually temporary.

For people with chronic tinnitus, life becomes difficult, even traumatic. Constant awareness of this ‘noise’ affects their ability to sleep, work, relax, socialise, and function normally. The resulting stress and anxiety can dominate their life and rob them of simple daily pleasures.

Many have tried everything from acupuncture to drug therapy to make the persistant noises they hear stop. Tinnitus Treatment helps to relieve these symptoms and allows your patient to reclaim their lives.

Types of Tinnitus Treatment Neuromonics® Tinnitus Treatment

Tinnitus Retraining Therapy

Cognitive Behaviour Therapy

Hearing Aids

Maskers

Noise/Sound Generators

Drug Treatment

Treats symptoms — (emotional, mental, quality of life, etc.) Treats cause Potential for immediate relief Potential for long-term relief after treatment Convenient/non-invasive during treatment Proven effective

Tinnitus is common Tinnitus affects 20% of the general population Over the age of 55 the incidence of tinnitus increases to over 30% 1 -2 % of people are severely affected

Attune audiologists will help your patient choose the most appropriate treatment for their tinnitus

CLINICS

Please see www.attune.com.au or call 1800 195 155 for current Attune clinic locations. AttuneTM is supported and supervised by local Ear, Nose and Throat (ENT) specialists.

Cochlear Implant How the ear hears with a Cochlear Implant System.

At least a bilateral moderately severe-to-profound hearing loss – relying more on lip-reading than on hearing aids. When hearing aids have failed to restore communication function. Find one to one conversation very difficult, even with hearing aids. Unable to participate in group discussions. Feel increasingly isolated. Stopped using the telephone due to poor speech understanding. Find their social life increasingly restricted. Job in jeopardy due to hearing loss. No upper age limit for referrals. If referring a patient to The Attune™ Cochlear Implant Program you will first need to refer your patient to our Cochlear Implant Surgeons for medical suitability. For more information please see the Attune website: www.attune.com.au. The Attune™ Cochlear Implant Centre is a member of The Hearing CRC (Cooperative Research Centre)

Investigation & Assessment The CI assessment will assess patient suitability from a surgical, audiological and psychological perspective including: CT scan / MRI of cochlea. History of the onset and progression of hearing loss.

Cochlear Implant Cochlear Implant

Plea The

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1 Speech processor: The external speech processor captures sound and 1 4 converts

it into digital signals. 1

2 Digital signals: The processor sends the digital signals to an internal implant. 3 3 Electrode array: The internal implant converts the signals into electrical energy,150 3 then sends the energy to an electrode array inside the cochlea.

Audiogram and vestibular assessment.

4 Hearing nerve: Electrodes stimulate the hearing nerve, bypassing damaged

Cognitive and mental health status. Management Post implant care involves the CI team of professionals (ENT surgeons, audiologists, psychologist) and includes: Periodic checks of the implant site. Regular programming of electrical stimulation levels. Auditory and communication training.

hair cells, and the brain perceives the signals as sound. Speech processor: The external speech processor captures sound and converts Figure 11 How the ear hears with a Cochlear Implant System it into digital signals. Image used with permission of Cochlear™ Limited. 2 Digital signals: The processor sends the digital signals to an internal implant.

Hearing Threshold dBHL

Motivation and expectations.

SERVICES

then sends the energy to an electrode array inside the cochlea. it into digital signals.

100

hair cells, and the brain perceives the signals as sound. it into digital signals.

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2 Figu

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2 4

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8 3 Electrode array: The internal implant converts the signals into electrical energy, 2 Digital signals: sends the digital Figure 1 HowThe the processor ear hears with a Cochlear Implantsignals System to an internal implant. Figure 1 Cochle

thenImage sends energyoftoCochlear™ an electrode used the with permission Limited. array inside the cochlea.

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3 Electrode array: The internal implant converts the signals into electrical energy, 4 Hearing nerve: Electrodes stimulate the hearing nerve, bypassing damaged

then sends the energy to an electrode array inside the cochlea. hair cells, and the brain perceives the signals as sound.

4 Hearing nerve: Electrodes stimulate the hearing nerve, bypassing damaged

10 12

Figure Howand thethe earbrain hearsperceives with a Cochlear Implant System hair 1cells, the signals as sound.

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Figure 1 How the ear hears with a Cochlear Implant System

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Image used with permission of Cochlear™ Limited.

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Please see www.attune.com.au or call 1800 195 155 for current Attune clinic locations. AttuneTM is supported and supervised by local Ear, Nose and Throat (ENT) specialists.

12 40

1 Speech processor: The external speech captures sound and converts 4 Hearing Electrodes stimulate theprocessor hearing nerve, bypassing damaged 2 Digital signals:nerve: The processor sends the digital signals to an internal implant.

CLINICS

1 Speech processor: The speechconverts processor captures sound and converts80 3 Electrode array: Theexternal internal implant the signals into electrical energy,

Image used with permission of Cochlear™ Limited.

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Pattern of hearing aid use. Speech perception with the hearing aids.

Hearing Threshold dBHL

Please use the following guidelines to make appropriate referrals to The Attune™ Cochlear Implant Program:

Whe

A cochlear implant is a routine medical option designed to help someone with a moderately severe-to-profound hearing loss to communicate more easily. It is an option when attempts to improve hearing ability, with powerful How Information and support recipient and family. the ear hears with acounselling Cochlear of Implant System. hearing aids, no longer provide assistance. Unlike hearing aids, which amplify sound, Device management, care and maintenance. a cochlear implant damaged hair System. cells in the inner ear or How the ear hears withbypasses a Cochlear Implant cochlea Telephone training. the hearing nerve directly. and stimulates Trial of other assistive devices. How Cochlear Implant works How the ear hears with a Cochlear Implant System. Most recipients are independent with the device by 3 months and after the first year, an annual check is sufficient. What is a Cochlear Implant?

HearingHearing Threshold Threshold dBHL dBHL

When to refer a patient for a cochlear implant assessment

What is a Cochlear Implant?

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Cochlear Implant Middle Ear Implants

Middle Ear Implants How middle ear implants help restore communication

What is a middle ear implant?

Management

Middle ear implants are an alternative semi-implantable device for when conventional hearing aids are medically contraindicated. They are used in mild to severe hearing loss (conductive, mixed, or sensorineural) in those who cannot benefit from conventional amplification.

Post implant care involves the implant team of professionals (ENT surgeons, audiologists) and includes:

With middle ear implants, the external ear and tympanic membrane are by-passed. Two types of middle ear implants are fitted at Attune: the Bone Anchored Hearing Aid (BAHA) uses bone conduction - sounds are transmitted directly to the cochlear by vibration of the skull. The Vibrant Soundbridge (VSB) uses an implanted transducer to directly drive the ossicular chain.

Periodic checks of the implant site Periodic reviews of hearing levels Regular programming of the external sound processor Instruction, information and support counseling Device management, care and maintenance Most recipients are independent with the device in 1-2 months and after the first year an annual check is sufficient.

When to refer a patient for a middle ear implant assessment

How a BAHA works

Patients with the following contraindications to hearing aids can be assessed for middle ear implants:

A titanium implant is surgically implanted behind the ear where it integrates with the bone through the process of ‘osseointegration’

Chronic external otitis, otitis media or myringitis Atresia, microtia or stenosis of the external ear canal Severe exostoses Obliterative adhesions of the middle ear Previous middle ear surgery e.g. radical mastoidectomy Irregular pinna that will not support an aid e.g. due to injury, cancer Allergy to ear mould materials

The sound processor behind the ear picks up and amplifies the sound A connecting abutment transfers the sound from the processor to the implant The implant transfers the sound vibrations, via the skull, directly to the cochlear

Single sided deafness How a VSB works

If referring a patient to Attune Implant Program you will first need to refer your patient to our middle ear implant surgeons for medical suitability. For more information please see the Attune website.

T he external audio processor, magnetically attached to the head, collects sounds

Investigation and assessment

T he processor converts the sound to electrical signals

The middle ear implant candidacy assessment will assess patient suitability from a surgical and audiological perspective including:

T he signal is transmitted across the skin to the implant by radio frequency

History of previous middle ear surgery

conductor link cable relays the signal A from the implant to a transducer attached to the ossicles and cause it to vibrate

CT Scan of middle ear Audiogram and speech perception assessment History of previous issues with hearing aids

T hese vibrations conduct the sound to the inner ear

Motivation and expectations Dexterity and personal hygiene

Summary

A period of around 8 weeks healing time is required between surgery and external device fitting.

If your patient cannot tolerate a conventional hearing aid, or aid use is limited by medical issues, a middle ear implant may provide an alternative solution. Which device provides the best solution can depend on factors such as type of pathology and hearing loss, lifestyle (sport), skin condition, general health, cognition, environment and patient preferences.

CLINICS

Please see www.attune.com.au or call 1800 195 155 for current Attune clinic locations. AttuneTM is supported and supervised by local Ear, Nose and Throat (ENT) specialists.

Eustachian Tube Dysfunction

The ear is divided into three parts: the external ear includes the pinna and the ear canal; the middle ear is the air-filled space behind the eardrum that contains the ossicles; and the inner ear contains the sensory organs of hearing (cochlea) and balance (semicircular canals). The Eustachian tube is a narrow tube that connects the middle ear to the back of the nasopharynx. The eustachian tube is approximately 35 mm long. It runs inferior, anterior and medial from the anterior middle ear space into the nasopharynx. The proximal 1/3 is boney and the distal 2/3rds is cartilaginous. Normally, the Eustachian tube opens with every swallow or yawn to act as a pressure-equalizing valve for the middle ear. It also serves to drain the mucus produced by the lining of the middle ear.

Blockage of the Eustachian tube isolates the middle ear space from the outside environment. The lining of the middle ear absorbs the trapped air and creates a negative pressure that pulls the eardrum inward. The eardrum is made of three layers and is densely innervated. When it becomes stretched inward, patients often experience pain, pressure, and hearing loss. Long-term blockage of the Eustachian tube leads to the accumulation of fluid in the middle ear space that further increases the pressure and hearing loss. This is called otitis media with effusion (OME). The fluid can be thin (serous) or if the negative middle ear pressure is chronic then a thick effusion develops (mucoid- GLUE ear). Should bacteria contaminate this fluid, a middle ear infection may result, called acute otitis media.

Tectorial Membrane

Outer Ear Fossa triangularis

Middle Ear

Inner Ear

Outer Hairs cells

Inner Hair cells

Organ of Corti

Helix Semi Circular Canals Malleus Incus

Nerve

Cochlear nerve

Stapes

Vestibular nerve

Facial Nerve

Basilar Membrane

Ductus cochlearis

Inner Ear Canal Scala vestibuli

Scapha

Cymba conchaea

Nerve

Eardrum

Cavum conchae Anthelix

Modiolus

Scala tympani

Ear canal

Bony Canal

Petrous Bone

Cochlea

Cochlea cross section

Cartilagenous Canal Lobulus auriculae Eustachian tube

Eustachian tube dysfunction can occur when the lining of the nose becomes irritated, inflamed or infected narrowing the Eustachian tube opening or its passageway. Illnesses like the common cold or influenza are often to blame. Allergic rhinitis is a very common problem and often associated with ETD. Pollution and cigarette smoke can also cause ETD. Obesity can also predispose a patient to Eustachian tube dysfunction because of excess fatty deposits around the passageway of the Eustachian tube. Sudden changes in pressure (barotrauma-flying,scuba diving ) may result in ETD. Rarely, Eustachian tube blockage may be the sign of a more serious problem such as nasal polyps, a cleft palate, or a skull base tumor. If an adult has an unexplained OME then the nasopharynx must be examined to exclude a tumour. Young children (especially ages 1 to 6 years) are at particular risk for Eustachian tube dysfunction, serous otitis media, and acute otitis media because they have very narrow Eustachian tubes. Also, they may have

adenoid enlargement that can functionally block the opening of the Eustachian tube or act as a reservoir of infection (adenoiditis ). Since children in daycare are highly prone to getting upper respiratory tract infections, they tend to get more ear infections compared to children that are cared for at home. The Eustachian tube in infants and young children is runs horizontally, rather than sloping downward from the middle ear. The horizontal course of the Eustachian tube also permits easy transfer of bacteria from the nose to the middle ear space. This is another reason that children are so prone to middle ear infections. Most children older than 6 years have outgrown this problem and their frequency of ear infections should drop substantially. The adenoids tend to atrophy and disappear in the teenage years. The Eustachian tube in adults lengthens and becomes more vertical making reflux of infected nasopharyngeal contents into the middle ear more difficult.

CLINICS

Please see www.attune.com.au or call 1800 195 155 for current Attune clinic locations.

AttuneTM is supported and supervised by local Ear, Nose and Throat (ENT) specialists.

Eustachian Tube Dysfunction

Symptoms of Eustachian Tube Dysfunction PAIN - due to stretching of the TM which is highly innervated. DISCHARGE – generally would indicate a ruptured TM secondary to AOM. DEAFNESS – mild to moderate TINNITIS – often pulsatile VERTIGO – kids often seem more clumsy/unsteady

A type B tympanogram (and normal canal volume) indicates a middle ear effusion. Nasal Endoscopy.- adults with OME should have the nasopharynx directly examined to exclude pathology including neoplasia. Radiology.- CT SCAN of sinuses if suspect sinus disease exists.(Generally adults, rarely in children)

Investigations. Pure Tone Audiometry (PTA) including Tympanometry.- often a mild conductive hearing loss is noted. A type C tympanogram indicates Eustachian Tube Dysfunction.

Medical Treatment Allergy Treatment and Nasal Decongestion Valsalva Surgical Treatment /options: Myringotomy, Adenoidectomy, Pressure Equalization Tubes/Grommets

WARNING: A blocked ear may NOT be Eustachian Tube Dysfunction. Other causes of a blocked ear includeSUDDEN SENSORINEURAL HEARING LOSS: Needs urgent ENT referral. There will be a history of blocked ear and hearing loss and often tinnitus but no pain, no obvious cause and a normal looking ear drum. TEMPOROMANDIBULAR JOINT (TMJ) problems: Seek dental or maxillo-facial surgeon review. A blocked ear usually associated with otalgia but normal looking ear drum and no hearing loss or tinnitus.

Chronic ETD resulting in gross posterior TM retraction onto the incudo-stapes joint. Note also ATTIC retraction superiorly. (RIGHT EAR)

GROMMET in anterior segment left tympanic membrane.

Reference: Alford, B. Eustachian Tube Dysfunction. Department of Otolaryngology-Head and Neck Surgery 2007 March; http://www.bcm.edu/oto/jsolab/eust_tub.htm. Dr David Bell Allen :Attune Supervising Otologist

CLINICS

Please see www.attune.com.au or call 1800 195 155 for current Attune clinic locations. AttuneTM is supported and supervised by local Ear, Nose and Throat (ENT) specialists.

Glue Glue EarEar Glue Ear Otitis Otitis Media Media with Effusion Effusion – OME – OME Glue Glue Ear Earwith Otitis Media with Effusion – OME Glue Ear Otitis Otitis Media Media with with Effusion Effusion – OME –– OME Otitis Media with Effusion OME Otitis Media with Effusion – OME

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Ityounger ear. canItaffect canthan affect adults, adults, although is primarily it is primarily aiscondition a condition Hearing Hearing difficulties difficulties (may (may affect affect speech speech development, development, reading reading and spelling) and spelling) that occurs in 7 years of although age.itPresentation usually Otalgia Hearing difficulties (may speech development, reading Otalgia (pain (pain or effects pressure or pressure inaffect theinear) the –ear) frequently – frequently severesevere and ofand of Symptoms and Glue ear (or Otitis Media with Effusion – OME) is an accumulation of fluid brief duration that occurs that occurs in children in children younger younger than 7 than years 7 years of age. of Presentation age. Presentation is usually is usually FeverFever (sometimes (sometimes with febrile with febrile convulsions) convulsions) during winter and spring. brief duration duration (may affect speech development, reading and spelling) withinWhat the middle ear. It can affect adults, although it is primarily a condition andbrief spelling) What happens? happens? Hearing difficulties What duringduring winterhappens? winter and spring. and spring. Otalgia (pain or pressure in the ear) –and frequently severe and of Unusual Unusual irritability, irritability, difficulty difficulty sleeping sleeping decreased and decreased appetite appetite Hearing Hearing difficulties difficulties (may (may affect speech speech development, development, reading reading and spelling) and spelling) thateffusion occurs in children younger than 7 years of age. Presentation is usually Fever (sometimes with convulsions) An An effusion frequently frequently begins begins with an with upper an upper respiratory respiratory infection. infection. The middle The middle Nasal Fever (sometimes withfebrile febrileaffect convulsions) effusion frequently begins with an upper respiratory infection. brief duration Nasal congestion congestion WhatAnhappens? Fever Fever (sometimes (sometimes with febrile with febrile convulsions) convulsions) during winter and spring. Unusual irritability, difficulty sleeping and decreased appetite ear is ear normally is normally air-filled, air-filled, the air the begins air begins to pass to to pass the to ear the from ear from the nose the nose by the by the The middle ear is normally air-filled, the air begins to pass to the ear What What happens? happens? Hearing difficulties affectsleeping speech development, reading and spelling) of Loss balance ofirritability, balance(may Loss Unusual difficulty anddecreased decreased appetite An effusion frequently begins with an upper respiratory infection. The middle irritability, irritability, difficulty difficulty sleeping sleeping and and decreased appetite appetite NasalUnusual congestion Eustachian Eustachian tube. tube. Thebylatter The may become may become obstructed obstructed by may viral-induced bybecome viral-induced swelling swelling Unusual from the nose thelatter Eustachian tube. The latter Fever (sometimes with febrile convulsions) Poor Poor classroom classroom performance performance due to due lack to of lack hearing of hearing An effusion An effusion frequently frequently begins begins with an with upper an upper respiratory respiratory infection. infection. The middle The middle ear is normally air-filled, the air begins to pass to the ear from the nose by the Loss Nasal congestion Nasal congestion What happens? ofcongestion balance or dueor todue bacterial to bacterial infection. Fluidswelling Fluid then accumulates then accumulates in theinear theasear theasmiddle the middle Nasal obstructed byinfection. viral-induced orto due to Unusual irritability, difficulty sleeping and decreased appetite ear isear normally is normally air-filled, themay airthebegins air begins toobstructed pass to pass thebacterial to the from earinfection. from the nose the nose by theby theInLoss Eustachian tube. Theair-filled, latter become byear viral-induced swelling of Loss balance of balance addition In addition to these toperformance these symptoms, symptoms, untreated untreated ear gluecan earresult can result in permanent in permanent Poor classroom due to lackglue of hearing Loss of balance An effusion frequently begins with an upper respiratory infection. The middle ear airear is air reabsorbed is reabsorbed into the into blood the blood stream. stream. Fluid then in the ear asobstructed theobstructed middlebyear airviral-induced is reabsorbedswelling Nasal congestion Eustachian Eustachian tube.accumulates tube. Theinfection. latter The latter may become may become by or due to bacterial Fluid then accumulates inviral-induced the ear as theswelling middle Poorhearing Poor classroom classroom performance performance due todue lack to of lack hearing ofdevelopment, hearing loss, problems loss, problems with speech with speech and language and language development, and other and other ear isinto normally air-filled, the air begins to pass to the ear from the nose by the hearing the blood stream. addition Poor due to lack hearing of classroom balance In Loss to these performance symptoms, untreated glueofear can result in permanent or orto bacterial to bacterial infection. Fluid then accumulates then accumulates in theinear theasear theasmiddle the middle more eardue air isdue reabsorbed intoinfection. theFluid blood stream. more substantial substantial and permanent and permanent ear damage. ear damage. Eustachian tube. The latter may become obstructed by viral-induced swelling In addition In classroom addition toproblems these toperformance these symptoms, symptoms, untreated untreated glue ear gluedevelopment, can earresult can result in permanent in permanent due to lack of hearing hearing loss, with speech and language ear airearis air reabsorbed is reabsorbed into the intoblood the blood stream. stream. InPoor addition to these symptoms, untreated glue ear can result in and other or due to bacterial infection. Fluid then accumulates in the ear as the middle hearing hearing loss, problems loss,and problems with speech with speech and language and language development, development, and other and other more substantial permanent ear damage. permanent hearing loss, problems with speech and language In addition to these symptoms, untreated glue ear can result in permanent Investigations Investigations ear air is reabsorbed into the blood stream. more more substantial substantial and permanent and permanent ear damage. ear damage. development, and other more substantial and permanent ear damage. hearing problems and language development, and other The Australian Theloss, Australian Society Society ofwith Otolaryngology ofspeech Otolaryngology recommends: recommends: Investigations Fluid inFluid the in Middle the Middle Ear Ear more substantial and permanent ear damage. Investigations Paediatric Paediatric Hearing Hearing Testing – Determines – Determines if a child if a child has hearing has hearing loss. loss. (The normal (The normal ear is filled ear iswith filledair) with air) Investigations The Australian Society ofTesting Otolaryngology recommends: Investigations Fluid in the Middle Ear The Australian The Australian Society Society of Otolaryngology of Otolaryngology recommends: recommends: Im Im ance ance Audiometry Audiometry – Determines – Determines the flexibility the flexibility of the of eardrum. the eardrum. mitt mitt Investigations Paediatric – Determines if a child has hearing loss. (The normal ear filled Fluid inFluid the in Middle theisMiddle Ear with Ear air) The AustralianHearing Society ofTesting Otolaryngology recommends: It does It does not assess not assess hearing, hearing, but helps but helps to detect to detect any changes any changes in pressure in pressure Paediatric Paediatric Hearing Hearing Testing Testing – Determines – Determines if a child if a child has hearing has hearing loss. (The normal (The normal ear is filled ear iswith filledair) with air) The Australian of Otolaryngology recommends: Im Audiometry – Determines the flexibility of the eardrum. loss. mittanceSociety in the Paediatric Hearing Testing Determines inmiddle the middle ear orear anoreffusion, an effusion, if– present. if present.if a child has Fluid in the Middle Ear Impedance Impedance Audiometry Audiometry – Determines –Determines Determines the ifflexibility the flexibility of the ofeardrum. the eardrum. It does not assess hearing, but to detect any changes in pressure Paediatric Hearing Testing –helps a child has hearing loss. (The normal ear is filled with air) hearing loss. Reassessment Reassessment is assess performed isanperformed fourhelps to four six toweeks sixtoweeks post-infection to pressure establish to pressure establish It does not assess not hearing, hearing, but but helps to detect detect any post-infection changes any changes in in indoes theIt middle ear or effusion, if present. Impedance Audiometry – Determines the flexibility of the eardrum. that hearing that hearing thresholds thresholds have have returned returned topresent. normal to levels.levels. in the Immittance Audiometry – Determines thenormal flexibility of the in middle the middle ear or ear an or effusion, an effusion, if present. if Reassessment is performed fourhelps to sixtoweeks to pressure establish It does not assess hearing, but detectpost-infection any changes in eardrum. Itthresholds does not assess hearing, but helps to detect any changes Ifthat glue If ear gluepersists ear persists referral referral tofour an toEar, an Nose Ear, Nose and Throat and Throat Surgeon Surgeon is to establish is Reassessment Reassessment is performed is performed to four six to weeks six weeks post-infection post-infection to establish hearing have returned to normal levels. in the middle ear or an effusion, if present. strongly strongly recommended. recommended. in pressure in the middle ear or an effusion, if present. that hearing that thresholds thresholds have have returned returned to normal to normal levels.levels. If glue earhearing persists referral tofour an Ear, and Throat Surgeon is Reassessment is performed to sixNose weeks post-infection to establish Ifthat glue Reassessment is performed four to six weeks post-infection to is is If ear glue persists ear persists referral referral to an to Ear, an Nose Ear, Nose and Throat and Throat specialist specialist strongly recommended. hearing thresholds have returned to normal levels. Management Management strongly strongly recommended. recommended. establish that hearing thresholds have returned to normal levels. If glue earNose persists to anSurgeon Ear, Nose andassist Throat is Attune Attune Ear, Ear, Nose and referral Throat and Throat s can sassist can your patient yourspecialist patient with with Surgeon Management strongly Ifappropriate glue recommended. ear persists referral to an Ear, Nose and Throat Surgeon is appropriate management. management. Management Management Attune Ear, Nose and Throat Surgeons can assist your patient with strongly recommended. Attune Attune Ear, Ear, and Throat andantibiotic Throat specialists specialists can assist your patient your patient with Aappropriate child A child mayNose require mayNose require antibiotic therapy therapy ifcan appropriate. ifassist appropriate. The patient The patient maywith benefit may benefit management. Management appropriate management. management. from appropriate from temporary temporary grommets grommets (tiny tubes) (tiny tubes) put input theineardrum the eardrum to letto airletinto airthe into the Attune andantibiotic Throat specialists assist your patient with AManagement child Ear, mayNose require therapy ifcan appropriate. The patient may benefit middle middle ear and eardrain and drain the fluid. the fluid. This will Thisimprove will improve hearing hearing and often and often prevents prevents Blocked Blocked Eustachian Eustachian Tube Tube Aappropriate child Atemporary child may require maygrommets require antibiotic antibiotic therapy therapy ifput appropriate. if appropriate. The patient The patient mayinto benefit may management. from (tiny tubes) in the eardrum to let air thebenefit Attune Nose and Throat can assist your patient with pain. pain. ThisEar, procedure This procedure should should beSurgeons confined be confined to skilled, to skilled, practised practised hands hands because because of of from from temporary temporary grommets grommets (tinyThis tubes) (tinywill tubes) put input theinhearing eardrum the eardrum to let to airlet into airthe into the middle ear and drain the fluid. improve and often prevents management. Blocked Eustachian Tube Aappropriate child require ifear appropriate. Thecontents. patient may benefit the risk themay ofrisk damage of damage toantibiotic thetomiddle thetherapy middle ear and inner and inner ear contents. ear middle earprocedure and eardrain and drain the fluid. the This will Thisimprove will improve hearing hearing and hands often and often prevents prevents pain.middle This should befluid. confined to skilled, practised because of Figure Figure 1 The1ear Theshowing ear showing fluid influid theinmiddle theBlocked middle earBlocked cavity ear Eustachian cavityTube Tube Eustachian from temporary grommets (tinytherapy tubes) put in the eardrum to let air into the A child may require antibiotic if appropriate. Thepractised patient may Image used Imagewith usedpermission with permission of Cochlear™ of Cochlear™ Limited.Limited. pain. pain. Thisof procedure This procedure be confined be skilled, to ear skilled, practised handshands because because of of the risk damage toshould the should middle earconfined andtoinner contents. middle ear and drain thegrommets fluid. This (tiny will improve hearing and often to prevents benefit from temporary tubes) put thecontents. eardrum let Figure 1 The ear showing fluid in the middle ear Eustachian cavity Blocked Tube the risk theof risk damage of damage to thetomiddle the middle ear and ear inner and inner ear in contents. ear Image Figure used with1permission Cochlear™ Limited. pain. Thisthe procedure should be confined to This skilled, Figure 1 The ear Theshowing ear ofshowing fluid influid theinmiddle the middle ear cavity ear cavity air into middle ear and drain the fluid. willpractised improve hands hearingbecause and of Image used Imagewith usedpermission with permission of Cochlear™ of Cochlear™ Limited.Limited. the riskprevents of damage the procedure middle earshould and inner ear contents. often pain.toThis be confined to skilled, Figure 1 The ear showing fluid in the middle ear cavity practised hands because of the risk of damage to the middle ear and Image used with permission of Cochlear™ Limited. inner ear contents. Audiology Audiology Report Report withwith recommendations recommendations is sent is sent to your to your practice practice within within 24 hours 24 hours (same (same day service day service for urgent for urgent requests). requests). Audiology Report with recommendations is sent to your Audiology Audiology Report Report with recommendations recommendations sent isurgent sent to your to your practice within 24with hours (same day serviceis for requests). Factpractice sheet Factpractice contents sheetwithin contents provided provided by Dr Bruce by Dr Black, Bruce MD, Black, Professor, MD, service Professor, Otolaryngology Otolaryngology University University of Queensland. of Queensland. within 24 hours 24 hours (same (same day day service for urgent for urgent requests). requests). Audiology Report with recommendations is sent to your Factpractice sheet contents provided24 by Dr Bruce Black, MD, Professor, Otolaryngology University requests). of Queensland. within hours (same day service for urgent Fact sheet Factcontents sheet contents provided provided by Dr Bruce by DrBlack, BruceMD, Black, Professor, MD, Professor, Otolaryngology Otolaryngology University University of Queensland. of Queensland. Fact sheet contents provided by Dr Bruce Black, MD, Professor, Otolaryngology University of Queensland.

SERVICES

Services Services Hearing Hearing Aid Assessment Assessment and Rehabilitation and Rehabilitation | Hearing | Hearing Tests |Tests Noise Plugs Plugs and Accessories and Accessories | Tinnitus |Management Tinnitus Management Management Cochlear | Cochlear Implant Implant Program Program Hearing Tests forAidAdults & Children | Hearing Aid Fitting and| Noise Rehabilitation | Tinnitus ||Balance Testing | Auditory Processing | Hearing

Implant Program |your Custom Plugs for or Swimming, and more | Workplace| Noise Assessment, Management and Solutions. Phone Phone 1800 1800 195 155 195 for 155 fornearest your nearest Attune Attune clinic clinic visit or www.attune.com.au visit www.attune.com.au current for current clinic details. clinic Management details. Services Hearing Aid Assessment andEar Rehabilitation | Hearing TestsMusicians, | Noise PlugsMotorcyclists andfor Accessories | Tinnitus Cochlear Implant Program

CLINICS Attune™ Attune™ is a195 registered is 155 a registered trademark trademark of Attune ofclinic Attune Hearing Hearing Pty Ltd. PtyFounded Ltd. Founded in 1986, in 1986, Attune delivers the most the accurate most accurate hearing hearing Phone 1800 for your nearest Attune or visit www.attune.com.au for currentAttune clinic delivers details. evaluations evaluations andsee the and most the appropriate most appropriate treatments treatments making us the195 uspreferred the preferred choice choice for Ear,for Nose Ear, and Nose Throat andlocations. Throat (ENT) (ENT) specialists specialists in Queensland. in Queensland. Please www.attune.com.au or making call 1800 155 for current Attune clinic Attune™ is a registered trademark of Attune Hearing Pty Ltd. Founded in 1986, Attune delivers the most accurate hearing TM the most appropriate treatments making us the preferred choice for Ear, Nose and Throat (ENT) specialists in Queensland. evaluations Attuneand is supported and supervised by local Ear, Nose and Throat (ENT) specialists.

Glue Ear Dementia and Hearing Loss

Dementia and Hearing Loss

Frank R. Lin , M.D. Ph.D. Assistant Professor, Division of Otology, Neurotology and Skull Base Surgery Assistant Professor, Department of Epidemiology, Bloomberg School of Public Health

NEW EVIDENCE ON THE DANGERS OF UNTREATED HEARING LOSS Hearing Loss May Signal Increased Dementia Risk In recent years, researchers around the world have discovered that there are scientific reasons to address hearing loss earlier. Seniors with hearing loss are significantly more likely to develop dementia over time than those who retain their hearing. Although the exact reason for the link between hearing loss and dementia is unknown, the investigators suggest that a common pathology may or both the strain of trying to decode sounds over the years may overwhelm the brain of people with hearing loss leaving them more vulnerable to dementia. Hearing is a special gift and our ability to hear sounds is essential to our enjoyment and well being. Hearing loss could lead to dementia by making individuals more socially isolated. Low levels of social engagement have been shown to increase the risk for Alzheimer’s disease. UNDERSTANDING SPEECH - “USE IT OR LOSE IT” As hearing is lost with increasing age, a persons ability to understand speech in an unaided ear deteriorates faster over time than his ability to understand speech in an aided ear. For most people this is reversible if a hearing aid is fitted to the unaided ear. However if the period without a hearing aid extends over some years, then full recovery is unlikely. THAT IS, IF WE DON’T USE IT, WE MAY LOSE IT. NEUTRAL BRAIN PLASTICITY - We listen with our ears but hear with our brains Research has shown that we listen with our ears but hear with our brains. It is not possible to separate audition (hearing) and cognition (brain). When neurons (brain cells) in that area of the brain responsible for understanding speech are denied stimulation due to hearing loss, the brain will reprogram those neurons to do something else and that comes at the expense of cognition. This may in part explain why straining to hear conversations over background noise can be mentally exhausting for anyone. The fitting of hearing aids sooner rather than later can significantly delay this unwanted process i.e., “USE IT OR LOSE IT “ or the brain will start doing something else. DEMENTIA In a large study over some 20 years*, researchers found that patients with hearing loss at the beginning of the study were significantly more likely to develop dementia by the end of the study. The greater the hearing loss, the more likely they were of developing dementia. Even after all other risk factors for dementia were accounted for, hearing loss and dementia were still strongly connected. Another good reason to treat hearing loss early rather than waiting until it is a significant social problem. Whatever the cause, the scientists report, their finding may offer a starting point for interventions — even as simple as hearing aids — that could delay or prevent dementia by improving patients’ hearing.

Core Faculty Member, Johns Hopkins Center on Ageing and Health

CLINICAL INTERESTS: earing rehabilitation in aging populations H Cochlear implantation Bone anchored and implantable hearing devices Chronic ear surgery Dr Lin’s research focuses on how hearing loss impacts the health and functioning of older adults and the role of different treatment modalities (hearing aids, cochlear implantation) in mitigating these effects. In particular, he is interested in examining the potential causal associations between hearing loss and dementia, cognition, functional decline, social isolation, and health economic costs. Much of his research is conducted in collaboration with aging researchers and established centers for clinical and aging research such as the Longitudinal Studies Section of the National Institute on Aging, the Johns Hopkins Center for Aging and Health, and the Johns Hopkins Dana Center for Preventive Ophthalmology. Hearing loss in older adults is independently associated with an increased risk of developing dementia over time, new findings from the Baltimore Longitudinal Study on Aging suggest. “Whether hearing loss is a marker for early-stage dementia or is actually a modifiable risk factor for dementia deserves further study,” concludes the study team in the February 2011 issue of Archives of Neurology. “We’ll need to do more research to figure out what the exact mechanism may be and whether interventions such as hearing aids or cochlear implants could have an effect on delaying cognitive decline,” first study author Frank R. Lin, MD, PhD, of the Center on Aging and Health, Johns Hopkins Medical Institutions, in Baltimore, Maryland, told Medscape Medical News. “Including hearing in a neurologic assessment is long overdue,” said George A. Gates, MD, of the University of Washington in Seattle, who was not involved in the study. Dr. Gates’ own research has also shown a link between hearing difficulties and dementia. http://www.hopkinsmedicine.org/otolaryngology/our_team/faculty/lin_frank.html http://www.hopkinsmedicine.org/otolaryngology/ http://www.grc.nia.nih.gov/branches/blsa/blsanew.htm Arch Neurol. 2011;68:214-220. Abstract

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Glue Ear Meniere’s Meniere’s Disease Disease Meniere’s Disease Otitis GlueMedia Earwith Effusion – OME Otitis Media with Effusion – OME

Vestibular VestibularLabyrinth Labyrinth Semicircular Semicircular Utricle Utricle Canals Canals Semicircular Semicircular Utricle Utricle Canals Canals

Outer OuterEar Ear Outer OuterEar Ear

Blocked Eustachian Tube

Figure 1 The ear showing fluid in the middle ear Eustachian cavity Blocked Tube Image used with permission of Cochlear™ Limited.

Cochlea Cochlea

Eardrum Eardrum Figure 1 The ear showing fluid in the middle ear cavity Image used with permission of Cochlear™ Limited.

Figure Figure11Anatomy Anatomyofofthe theear ear

Eardrum Eardrum

Eustachian EustachianTube Tube Cochlea Cochlea Eustachian EustachianTube Tube

dB dB

Investigations Investigations Symptoms and effects PureTone Tone Audiometry (hearingtest) test)––Determines Determinesififaapatient patienthas has Pure Audiometry (hearing Investigations Investigations a characteristic fluctuant, low frequency sensorineural hearing loss. This a characteristic fluctuant, low frequency sensorineural hearing loss. This Otalgia (pain or pressure in the ear) – frequently severe andififaof Pure PureTone ToneAudiometry Audiometry (hearing (hearing test) Determines Determines apatient patienthas has audiological pattern rarely foundinintest) other––conditions. conditions. audiological isisrarely found other Symptoms andpattern effects brief duration aacharacteristic characteristic fluctuant, fluctuant,low lowfrequency frequencysensorineural sensorineuralhearing hearingloss. loss.This This Hearing difficulties (may affectfound speech development, reading and spelling) KHz KHz –ininfrequently audiological audiological pattern pattern isisrarely rarely other otherconditions. conditions. Otalgia (pain or pressure in thefound ear) severe and of Fever (sometimes with.5.5febrile11convulsions) .25 .25 2 2 4 4 8 8 brief duration KHz KHz and decreased appetite Unusual irritability, difficulty sleeping Hearing difficulties (may affect speech development, reading and spelling) .25 .25 .5 .5 11 22 44 88 Nasal congestion Fever (sometimes with febrile convulsions) Loss20 20of balance Unusual irritability, difficulty sleeping and decreased appetite Poor classroom performance due to lack of hearing Nasal 20 20 congestion 40 40of balance InLoss addition to these symptoms, untreated glue ear can result in permanent Poor classroom performance due and to lack of hearing hearing loss, problems with speech language development, and other 40 40 60 more60 substantial and permanent ear damage. In addition to these symptoms, untreated glue ear can result in permanent 60 60 loss, problems with speech and language development, and other hearing 80 80 Investigations more substantial and permanent ear damage. The Australian Society of Otolaryngology recommends: 80 80 100 100 Investigations Paediatric Hearing Testing – Determines if a child has hearing loss. dB dB

Meniere’s Meniere’sdisease diseaseresults resultsfrom froman anincrease increaseofoffluid fluidpressure pressureininthe theinner innerear, ear, disrupting disrupting balance and andhearing. hearing. Generally Generally Meniere’s Meniere’s disease diseaseoccurs occurs inonly only Glue ear (or balance Otitis Media with Effusion – OME) is an accumulation of influid Meniere’s Meniere’s disease disease results results from an an increase increase ofoffluid fluid pressure pressure ininthe the inner inner ear, ear, one oneear ear and isiscommonly commonly found found ininadults, adults adultsalthough who who are areitin in their thirties thirties or older. older. within theand middle ear. It canfrom affect istheir primarily a or condition disrupting disrupting balance balance and and hearing. hearing. Generally Generally Meniere’s Meniere’s disease disease occurs occurs in in only only that occurs in children younger than 7 years of age. Presentation is usually Glue (or Otitis Media with Effusion – OME) anininaccumulation oforfluid one oneear ear ear and and is iscommonly commonly found ininadults adults who whoisare are their theirthirties thirtiesor older. older. Signs Signs and and symptoms symptoms during winter and spring. found within the middle ear. It can affect adults, although it is primarily a condition Criteria Criteria according according to toThe TheAmerican American Otolaryngology Otolaryngology –Head Head and and that occurs insymptoms children younger than Academy 7Academy years ofofof age. Presentation –is usually Signs Signs and and symptoms What Neck Neckhappens? Surgery Surgeryand (AAO-HNS): (AAO-HNS): during winter spring. Criteria Criteria according according to toThe TheAmerican AmericananAcademy Academy ofofOtolaryngology Otolaryngology ––The Head Head and and An effusion frequently upper respiratory infection. middle Sudden, severe episodes ofofvertigo or often Sudden,sometimes sometimesbegins severewith episodes vertigo ordizziness, dizziness, often Neck Neck Surgery Surgery(AAO-HNS): (AAO-HNS): ear is normally air-filled, the air begins to pass to the ear from the nose by the What happens?by accompanied accompanied bynausea nauseaand andvomiting. vomiting. Sudden, Sudden, sometimes sometimes severe severe episodes episodes of of vert.igo vert.igo or or dizziness, dizziness, often often Eustachian tube. The latter may become obstructed by viral-induced swelling ear ––fluctuant. Hearingloss lossininthe theaffected affected earan fluctuant. An Hearing effusion frequently begins with upper respiratory infection. The middle accompanied accompanied by by nausea nausea and vomiting vomiting or due to bacterial infection. Fluid then accumulates in the ear as the middle (loud buzzing or ringing ininto the ear) constant or Tinnitus (loud buzzing orand ringing the ear)to––the constant orvariable. variable. earTinnitus is normally air-filled, the air begins pass ear from the nose by the Hearing Hearing loss lossininthe the affected affected ear ear–stream. –fluctuant fluctuant earA airsensation is reabsorbed into the blood of fullness or pressure in the ear – increasing with above A sensation of fullness or pressure in the ear – increasing with the above.. Eustachian tube. The latter may become obstructed by viral-inducedthe swelling Tinnitus Tinnitus(loud (loudbuzzing buzzingor orringing ringingininthe theear) ear)––constant constantor orvariable variable or due to bacterial infection. Fluid then accumulates in the ear as the middle AAsensation sensationofoffullness fullnessor orpressure pressureininthe theear ear––increasing increasingwith withthe theabove above Causes Causes ear air is reabsorbed into the blood stream. The Thebalance balancereceptors receptorsofofthe theinner innerear earconsist consistofofsmall smallloops loops(semicircular (semicircular Causes Causes canals) canals)that thatcontain containfluid fluidand andhair-like hair-likesensors, sensors,which whichcontrol controlsense senseofofbalance. balance. The The balance balancereceptors receptors ofofthe theinner inner ear consists consists small loops loops (semicircular (semicircular Fluid in inner the Middle Ear In disease, from excess fluid in the ear (referred InMeniere’s Meniere’s disease,pressure pressure fromear excess fluidofof insmall the inner ear (referredto to canals) canals) that thatcontain contain fluid fluidand and hair-like hair-like sensors, which which control control sense ofand balance. balance. (Thesensors, normal eardistorting issense filled of with air) as hydrops) impacts on the asendolymphatic endolymphatic hydrops) impacts onsensors, thedelicate delicate sensors, distorting and InIn Meniere’s Meniere’srupturing disease, disease,pressure pressure from fromexcess excess fluid fluid ininthe theofofinner inner ear earand (referred (referred to to occasionally them, sudden attacks vertigo increased occasionally rupturing them,causing causing sudden attacks vertigo and increased Fluidsensors, in the Middle Ear and as as endolymphatic endolymphatic hydrops) hydrops) impacts impacts on onthe the delicate sensors, distorting distorting and pressure ininthe organ (cochlea). As the progresses the cells pressure thehearing hearing organ (cochlea). Asdelicate thedisease disease progresses the cells (The normal ear is filled with air) occasionally occasionally rupturing rupturing them, them,causing causingsudden suddenattacks attacksofofvertigo vertigoand andincreased increased become damaged. becomeirreparably irreparably damaged. pressure pressureininthe thehearing hearingorgan organ(cochlea). (cochlea).As Asthe thedisease diseaseprogresses progressesthe thecells cells become becomeirreparably irreparablydamaged. damaged. Vestibular VestibularLabyrinth Labyrinth

100 The Australian of Otolaryngology recommends: Im100 Audiometry – Determines the flexibility of the eardrum. mittanceSociety It does not assess hearing, but helps to detect changes in pressure Paediatric Hearing Testinginin–Meniere’s Determines if any a child has hearing loss. Figure Figure22Pure PureTone ToneAudiometry disease in the middle ear orAudiometry an effusion, ifMeniere’s present.disease Impedance Audiometry – Determines the flexibility of the eardrum. Reassessment is performed four to sixtoweeks post-infection to pressure establish Figure 2not 2Pure Pure Tone Tone Audiometry Audiometry ininhelps Meniere’s Meniere’s disease disease Figure Balance Balance testing Balance testing testing It does assess hearing, but detect any changes in that hearing thresholds have returned to normal levels. in the middle ear or an effusion,(ENG) if present. VElectronystagmography ideo/Electronystagmography (VNG/ENG) –vestibular Evaluatesfunction vestibular (ENG) Evaluatesvestibular function by Electronystagmography ––Evaluates by Balance testing testing function byabnormal abnormal rhythmic eye movement (nystagmus) often IfBalance glue ear persists referral tofour an Ear, Nose and Throat Surgeon is present detecting abnormal rhythmic eye movement (nystagmus) often present detecting rhythmic eye (nystagmus) often Reassessment isdetecting performed to sixmovement weeks post-infection to establish Electronystagmography Electronystagmography (ENG) (ENG) – – Evaluates Evaluates vestibular vestibular function function by by present with Meniere’s disease. strongly recommended. with Meniere’s disease. Meniere’s disease. thatwith hearing thresholds have returned to normal levels. detecting detectingabnormal abnormalrhythmic rhythmiceye eyemovement movement(nystagmus) (nystagmus)often oftenpresent present Caloric testing – Involves stimulating thehorizontal horizontal semicircular canalin Caloric testing – Involves stimulating the horizontal semicircular canal If glue ear persists referral to anstimulating Ear, Nose and Throat specialist is canal Cwith aloric testing – Involves the semicircular with Meniere’s Meniere’s disease. disease. Management in the inner ear by introducing warm or cold water (or air) into the outer in the inner ear by introducing warm or cold water (or air) into the outer strongly recommended. theEar, inner earand by introducing warm or cold water (or air) into ear Attune Nose Throat s can assist your patient withthe outer Surgeon Caloric Caloric testing testing ––Involves Involves stimulating stimulating the horizontal horizontal semicircular semicircular canal canal ear canal and recording theresulting resulting eyethe movements. ear canal and recording movements. canal and recording the the resulting eye eye movements. appropriate management. ininthe theinner innerear earby byintroducing introducingwarm warmor orcold coldwater water(or (orair) air)into intothe theouter outer Management Auditory Brainstem Response (ABR)–––Shows Showsloss lossor ordistortion distortionof the Brainstem Response (ABR) ofofthe the Auditory Auditory Brainstem Response (ABR) Shows loss or distortion ear earEar, canal canal and and recording recording the theresulting resulting eye eye movements. movements. Attune Nose and Throat specialists can assist your patient with A child may require antibiotic therapy if appropriate. The patient may benefit cochlearmicrophonic microphonicresponses responsesproduced producedby bysound soundwaves wavesininthe theinner innerear. ear. cochlear cochlear microphonic responses produced soundloss waves in Auditory Auditory Brainstem Brainstem Response Response (ABR) (ABR) ––byShows Shows loss or distortion distortion ofofear. the the appropriate management. from temporary grommets (tiny put inlevel the eardrum to let airthe intoinner the This indicates damageat at thetubes) endorgan organ level asfound found Meniere’s disease This indicates damage the end as ininor Meniere’s disease This indicates damage at the end organ level as found in Meniere’s disease cochlear cochlear microphonic microphonic responses produced produced byhearing sound soundwaves waves ininthe the inner innerear. ear. middle ear and drain the responses fluid. This will improveby and often prevents at histology. at histology. A child may require antibiotic therapy if appropriate. The patient may benefit atThis histology. This This indicates indicates damage damage the the end endorgan organ level levelas as found foundininhands Meniere’s Meniere’s disease disease pain. procedure shouldatatbe confined to skilled, practised because of from temporary grommets (tiny tubes) put in the eardrum to let air into the at at histology. histology. the risk of damage to the middle ear and inner ear contents. Management Management middle ear and drain the fluid. This will improve hearing and often prevents Once diagnosed, prompt treatment indicated topractised avoidsensorineural sensorineural Once diagnosed, isisindicated avoid pain. This procedureprompt shouldtreatment be confined to skilled,to hands because of Management Management deafness, whichmay may beirreversible. irreversible. Management mayinclude: include:Hearing HearingAids, Aids, deafness, which be Management may the risk of damage to the middle ear and inner ear contents. Once Oncediagnosed, diagnosed, prompt prompt treatment treatment isSurgical indicated indicated to toavoid avoidsensorineural sensorineural Tinnitus Management, Medical andisSurgical Management, Physiological Tinnitus Management, Medical and Management, Physiological deafness, deafness,which whichmay maybe beirreversible. irreversible.Management Managementmay mayinclude: include:Hearing HearingAids, Aids, Management. Management.

Image Imageused usedwith withpermission permissionofofCochlear™ Cochlear™Limited. Limited.

Figure Figure11Anatomy Anatomyofofthe theear ear Image Imageused usedwith withpermission permissionofofCochlear™ Cochlear™Limited. Limited.

The Theunderlying underlyingcause causeofofMeniere’s Meniere’sdisease diseaseisisnot notknown, known,although althoughseveral several factors factorsare aresuspected suspected(viral (viralinfections, infections,allergic allergicresponses, responses,vascular vascularirregularities irregularities The The underlying cause cause ofofMeniere’s Meniere’s disease diseaseisisnot not known, known,although although several several and blockage damage to structures among andunderlying blockageor or damage tothe theendolymphatic endolymphatic structures amongothers). others).

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Fact Fact sheet sheet contents contents provided provided by Dr Dr Bruce Bruce Black, Black, MD, MD, Professor, Professor, Otolaryngology Otolaryngology University University ofQueensland. Queensland. Fact sheet contents provided byby Dr Bruce Black, MD, Professor, Otolaryngology University ofofQueensland. practice within 24 hours (same day service for urgent requests). Fact sheet contents provided by Dr Bruce Black, MD, Professor, Otolaryngology University of Queensland.

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Meniereâ&#x20AC;&#x2122;s Disease Otology Photographs

Otology Photographs (dirty pictures)

Allergic Otitis Externa (Hairspray sensitivity)

AURAL FURUNCULOSIS

Erythema, oedema and serous exudate are seen. Pruritus is marked. Avoid further allergen exposure, clean well and apply steroid cream (Celestone-V1/2 Cream) liberally, Resolution should be complete in 1-2 days.

A localised Staphylococcus aureus pustule is seen in the superficial canal. Dry mop and instill a topical antistaphylococcal agent, e.g. bacitracin/neomycin (Nemdry Otic Ointment). Use an appropriate systemic antibotic (flucloxacillin [Flopen, Floxapen], dicloxacillin [Diclocil], cefaclor [Ceclor CD, Ceclor Suspension]).

Minor abrasions and excoriation of the conchal bowl Self trauma is often by minor otitis externa. Persistent scratching may result in severe infection, oedema and blockage. Discourage trauma and clean. Use oral systemic antibotoics (amoxicillin + potassium clavulanate [Augmentin, Clavulin]; cefactor [Ceclor] and topical steriod-anitbotic wicks (betamethasone + gentamicin [Celestone-VG]) to clear infection.

CONGENITAL CHOLESTEATOMA A small pearly cyst is seen in typical location, just anterior to the handle of the malleus. The lesion may remain stable for years, perhaps enlarging after an episode of acute otitis media. Removal via a transcanal approach should be curative.

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Otology Photographs (dirty pictures)

Diffuse, acute bacterial otitIs externa

Advanced adhesive otitIs

Suspect Gram-negative bacteria or Streptococcus faecalis. Sloppy debris and canal oedema present. Clean thoroughly and use a steroid-broad spectrum antibotic wick (Nemdyn Otic, Kenacomb Otic) plus oral amoxicillin (Amoxil, Cilamox, Moxacin) or cefaclor (Ceclor CD, Ceclor Suspension) if otalgia is troublesome. Resolution should be rapid.

Advanced adhesive otitis with early keratin accumulation. The posterior pars tensa has collapsed secondary to chronic eustachian insufficiency. Poor self-cleaning activity is leading to keratin accumulation, seen on the posterior scutum. As in the attic case above, infection and granulation formation will follow.

Chronic myringitis

PARS TENSA CHOLESTEATOMA

A velvety raw surface covers the drum and deep canal. This condition often occurs after chronic otitis externa or middle ear surgery. Early cases respond to topical cleaning, then boric 5% and spirit 70% otic drops BP. Advanced cases may require surgery. Refer these cases for specialist care.

Established pars tensa pattern cholesteatoma. Generalised drum collapse has been followed by invagination and sac information under the posterosuperior scutum. Infected keratin is seen protruding from the sac. There is probably destruction of the incus and stapes superstructure. The malleus handle is retracted. Granulations obscure the anterior drum.

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