Sudden Hearing Loss Following a Traumatic Head Injury: A Case Study

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1 Unless otherwise noted, the publisher, which is the American Speech-Language- Hearing Association (ASHA), holds the copyright on all materials published in Perspectives on Language Learning and Education, both as a compilation and as individual articles. Please see Rights and Permissions for terms and conditions of use of Perspectives content: Sudden Hearing Loss Following a Traumatic Head Injury: A Case Study Catherine Schroy Amanda Ortmann Elizabeth Mauzé Department of Otolaryngology, Washington University School of Medicine St. Louis, MO Abstract This is a case study of a 40-year-old male with a sudden profound sensorineural hearing loss experienced secondary to a skull fracture incurred during a violent assault. Following the acute phase of his medical care, the patient received long-term multidisciplinary rehabilitative care in two states that included audiologic, psychologic, and vocational services. This case highlights the need to make resources available to the patient, but stresses the importance of a patient-centered approach. Service providers often think they know what is best for their patients and are frustrated, if not disappointed, when patients do not follow advice. In this case, it became apparent that the patient needed to decide when he was ready to address all of the issues related to his hearing loss and subsequent communication, psychosocial, and vocational difficulties. According to the Center for Disease Control and Prevention (CDC), traumatic brain injury (TBI) is a leading cause of death and disability in the United States, with an estimated incidence of 1.4 million persons each year (CDC, 2006, 2007). Motor vehicle accidents, unintentional falls, and physical assaults are the top three causes of TBI (CDC, 2007). Although closed brain injuries (i.e., concussions) are more common among TBI, skull fractures represent approximately 4 30% of head trauma cases. Temporal bone fractures represent about 14 22% of skull fractures (Johnson, Semaan, & Megerian, 2008; Nosan, Benecke, & Murr, 1997; Saraiya & Aygun, 2009) and bilateral temporal bone fractures occur in 10 15% of cases (Brodie & Thompson, 1997; Ishman & Friedland, 2004). Temporal bone fracture may lead to complications such as sensorineural hearing loss, conductive hearing loss, perilymphatic fistulas, brain ischemia, and cerebrospinal fluid leaks depending on the location and severity of the fracture (Saraiya & Aygun, 2009). Temporal bone fractures can be classified as being either longitudinal otic capsule sparing (OCS) or transverse otic capsule violating (OCV). Transverse fractures, which typically result from a fronto-occipital blow, transect the otic capsule, causing injury to the cochlear and vestibular structures (Brodie & Thompson, 1997; Johnson, et al., 2008). OCV fractures result in sensorineural hearing loss, with 14% of cases being profound losses (Ishman & Friedland, 2004). In the acute phase of the temporal fracture, the person often suffers from intense vertigo due to disruption of the semicircular canals. The symptoms of vertigo typically will resolve within 6 12 months due to central adaptation (Johnson, et al., 2008). 15

2 TBI extends beyond both acute and chronic medical complications to have a longstanding impact on psychosocial factors such as post-traumatic stress disorder (PTSD), depression, reduced memory/concentration, and reduced employment and recreational opportunities (Bryant, 2011; Engberg & Teasdale, 2004; Jorge et al., 2004). Individuals with transverse OCV fractures deal with the consequences of sudden and sometimes complete sensorineural hearing loss. Sudden profound sensorineural hearing loss has a negative effect on a patient s on quality of life, it interferes with and/or can break apart one s social structure and lead to feelings of isolation and rejection. Specifically, Hallam Ashton, Sherbourne, and Gailey (2006) surveyed of adults with acquired profound sensorineural hearing loss and found that the rate of clinical depression among individuals with acquired profound loss was 4.8 times greater than the clinical depression rate of the general population. They also found a subgroup of acquired profound hearing-impaired listeners who scored similarly to a group of Vietnam veterans diagnosed with PTSD on an inventory measuring PTSD. The effects of sudden profound sensorineural hearing loss extend beyond the emotional well-being of the individual and involve relationships with family, friends, and co-workers (David & Trehub, 1989). Audiologic intervention for sudden sensorineural hearing loss secondary to a temporal bone fracture may include hearing aids, assistive listening devices, and/or aural rehabilitation depending on the individual s particular needs (Tye-Murray, 2009). When treating a patient whose hearing is compromised as the result of physical damage to the temporal bone, cochlear implantation still may be an option. There have been several reports of successful cochlear implantation in individuals with bilateral transverse temporal bone fractures (Camilleri, Toner, Howarth, Hampton, & Ramsden, 1999; Shin, Park, Baek, & Kim, 2008; Zanetti, Campovecchi, & Pasini, 2010). Good prognostic indicators include the integrity of the cochlear nerve, the integrity of the cochlear structures, and the duration between onset of the hearing loss and time of implantation. The following is a case report of a 40-year-old male who came to our clinic for services with a history of sudden profound sensorineural hearing loss secondary to a depressed basilar temporal bone fracture. This case illustrates the importance of using a multidisciplinary approach for the treatment and rehabilitation of individuals with sudden profound sensorineural loss. Here, a multidisciplinary approach included resources for psychological and vocational support as well as comprehensive diagnostic and rehabilitative audiologic services. This case also will highlight implications of the patient s readiness to accept his hearing loss, to be a self-advocate, and to use additional resources. Background Case History The patient, who will be referred to as Edward, arrived at our clinic in late He brought letters from various neurosurgeons, social workers, and audiologists in his hometown documenting the following case history and diagnoses. In Fall 2009, Edward and his fiancée were assaulted by an individual with a baseball bat. His injuries included a depressed basilar skull fracture and he was subsequently diagnosed with Post-Concussion Syndrome, profound sensorineural hearing loss, tinnitus, vertigo, vision loss, and PTSD. His fiancée died as a result of the severity of her injuries. Prior to the incident, Edward was employed in sales and his duties included managing sales territories and conducting conference and sales calls. He never returned to work because he was no longer able to talk on the telephone and felt he would no longer be able to manage the communication necessary to perform his job, he consequently lost his job. The loss of employment led to the loss of his residence and possessions. At one point, he was forced to live in his car. In December of 2009, Edward was referred to the Department of Rehabilitation in his home state for services including psychological counseling, aural rehabilitation, and vocational counseling. Edward had attempted suicide once and was still considered a suicide risk at the time of the referral. In addition to medical treatment, he attended weekly 16

3 psychotherapy sessions from February through June At that point, he was no longer deemed a suicide risk, but continued to suffer from depression and anxiety related to difficulties adjusting to his hearing loss and the changes in his socio-economic status. In May 2010, he obtained audiologic services and received an in-the-ear hearing aid through the Department of Rehabilitation. He continued to look for employment throughout the summer of He decided to move to the St. Louis area in September of 2010 to live with his brother, as he was unable to find work or shelter in his home state. This contributed to ongoing feelings of despair and defeat. Clinicians in Edward s home state performed a full diagnostic hearing evaluation, the results are shown in Table 1. Table 1: Edward s Audiometric Results Edward had profound sensorineural hearing loss in his left ear and mild-to-profound sloping sensorineural hearing loss in his right ear. We conducted word recognition testing on the right ear using W-22 monosyllabic word lists in auditory, visual, and auditory-visual conditions. The results are shown in Table 2. Table 2: Results of Edward s Word Recognition Testing Using Versions of the W-22 Words Lists Condition Score Presentation level Right ear Audition only 12% 100 db Vision only 12% 0 db Right ear Audition and Vision 56% 105 db In the unimodal conditions, Edward exhibited very poor word recognition abilities. Although his recognition ability improved significantly in the auditory-visual condition, his score still indicated poor word recognition in quiet. 17

4 Provision of Services Upon Edward s arrival in St. Louis, his brother began calling various schools, clinics, and hospitals seeking assistance for him. An area hospital referred him to our office. His brother was very concerned and was eager to start any program that could help Edward function better in society. Edward s brother described him as deaf and withdrawn. There was concern about the cost of care due to Edward s lack of health insurance. He also reported that Edward was wearing a hearing aid in one ear, but was still having significant difficulty communicating. Edward s brother coordinated the appointment to discuss Edward s potential participation in an NIH-sponsored study involving a computerized auditory training program called I Hear What You Mean (Tye-Murray, Sommers, & Barcroft, 2011). Edward was unable to talk on the phone and was too depressed to seek help on his own. He was very quiet during the initial appointment and his brother did most of the talking. Edward did provide written documentation detailing the aforementioned background history. After discussing details of the auditory training study, we enrolled Edward in the program. The I Hear What You Mean computerized auditory training program consisted of two 1- hour visits per week for 6 weeks. The program included five activities per session that focused on meaning-based tasks that involved listening in adaptive four-talker babble. Edward interacted with the computer using a touchscreen monitor to enter his responses. Each of the five training activities concentrated on a different task: Activity 1 involved sound identification, Activity 2 was a 4-choice discrimination task, Activity 3 was a complete-the-sentence task, Activity 4 was a sentence identification task, and Activity 5 was a comprehension task that involved listening to a passage (Tye-Murray, et al., 2011). As part of the study, we conducted testing before training, immediately after training, and three months following the completion of training as indicated in Table 3. Table 3. Results of Edward s Testing as Part of Study Participation. Test Name Score Before Training Score Immediately After Training Score 3-months After Training Listening Self-Efficacy Questionnaire (LSEQ; Smith et al., 2011) Iowa Sentences (Tyler & Tye-Murray, 1986) Iowa Consonant Confusion Test (Tyler & Tye-Murray, 1986) Aided NU-6 (Tillman & Carhart, 1966) 6.1% 20% 28.89% 0% 6.84% 5.17% 15.98% 15.98% 23.08% 4% 6% 0% Four Choice Discrimination Test* (Tye- Murray et al., 2011) ST = 25% MT = 19.4% NT = 25% ST = 52.8% MT = 52.8% NT = 41.7% ST = 50% MT = 36.1% NT = 44.4% *NOTE: ST = single-talker stimuli; MT = multi-talker stimuli; NT = new talker stimuli Testing included several speech perception tests as well as questionnaires including the Listening Self-Efficacy Questionnaire (LSEQ; Smith, Pichora-Fuller, Watts, & La More, 2011) and an exit questionnaire concerning the auditory training program. The LSEQ consists of questions pertaining to everyday listening situations such as, I can understand one-on-one 18

5 conversation in a quiet place. Edward rated his perceived ability to do these tasks on a 0 to 100% scale. We instructed him to answer questions according to how well he could accomplish tasks while wearing his hearing aid. Although his scores remained low, the improvement from 6% to almost 30% in a 4-month period showed substantial improvement in his daily communication in quiet as shown in Table 4. Table 4. Sample Questions From Edward s LSEQ (Smith, et al., 2011) Question I can understand one-on-one conversation in a quiet place. I can understand one-on-one conversation when a person is speaking from another part of the house. I can understand one-on-one conversation while at a medical appointment. I can understand group conversations in a noisy background. I can understand a conversation spoken by a woman. I can understand a conversation spoken by a man. I can understand conversation spoken by a person I know well, such as a close friend or family member. Pretraining Immediately Post-training 3 Months Posttraining 40% 80% 100% 0% 0% 0% 10% 40% 80% 0% 0% 0% 0% 40% 60% 30% 60% 90% 30% 70% 90% The question about understanding one-on-one conversation improved from 40% to 100%. Questions about understanding conversation spoken by a woman improved from 0% to 60%. Finally, understanding close friends and family members improved from 30% to 90%. He reported no improvement hearing in noise or at a distance. Results from the Iowa Sentence Test (Tyler & Tye-Murray, 1986), the Iowa Consonant Confusion Test (Tyler & Tye-Murray, 1986), and the NU-6 (Tillman & Carhart, 1966), which were all administered in the aided condition in four-talker babble, did not change from before to after training. On a Four-Choice Discrimination listening test (Barcroft et al., 2011), however, Edward more than doubled his scores and maintained some improvement 3 months later. When Edward first enrolled in the study, we determined that he needed additional help, including a hearing aid as well as psychosocial and vocational services. He was unemployed; moreover, he was relying on his brother for housing, transportation, and telephone communication. Edward was first referred to the clinic at our facility for his hearing aid services. His initial visit to the clinic was to activate his t-coil and to identify the programs and features included on his hearing aid. He did not appear to be familiar with the features of his hearing aid or how it was programmed. Edward wore a Phonak Exelia art in-the-ear hearing aid in his right ear that was fitted in his home state. He reported that the benefits he received from his hearing aid were limited to sound and speech awareness rather than clarity. Real ear output measures of the hearing aid performance are shown in Table 5. 19

6 Table 5. Edward s Real Ear Aided Response of his Right Phonak Exelia Art in-the-ear Hearing Aid The output of the Phonak aid was within NAL-NL1 target for 50, 65, and 80 db inputs through 2 khz, and then the output of the aid was rolled off based on Phonak s SoundRecover algorithm. The hearing aid was programmed so that input at frequencies above 3 khz were compressed and transposed below this cut-off frequency. Edward continued to visit the audiologist in the clinic in the following weeks for further counseling about use of his hearing aid and about the use of other assistive devices, including a captioned telephone for the home and a captioning application for his cell phone. The audiologist working with Edward also had hearing loss. After several visits, we realized that Edward felt more comfortable discussing his hearing loss and his everyday difficulties with communication with her than with the audiologists working with him on the auditory training program. The audiologist was careful to give tempered encouragement so that Edward would be more accepting of his condition and more assertive in his communication with others. Because of his severe communication difficulties, she discussed the options of cochlear implantation and auditory brainstem implantation. She counseled Edward that he needed a full evaluation to determine cochlear implant candidacy. While the chance to hear better encouraged Edward, the appearance of the implant deterred him. He stated that he would rather wait until the implant was completely implantable because he didn t feel comfortable drawing attention to his disability. The team loaned an FM system to Edward and his brother so they could communicate more easily at home. After 1 week, Edward returned it saying that although he loved how much easier it was to communicate with his brother, it was too cumbersome and embarrassing for him to ask others to use. We referred Edward to a local hospital s Deaf Services Team, which provides clinical case management, psychiatric and psychological services, and evaluations to determine what additional services are indicated for people with hearing loss. Because individuals with hearing loss staffed the team, the audiologists working with him in the clinic and in the study felt that he would respond well to these service providers given Edward s need for continued counseling and the fact that he bonded well with the audiologist who had a hearing loss. However, Edward did not return to Deaf Services after his initial appointment because he felt that he could cope on his own and that it was a waste of his time. 20

7 Finally, we referred Edward to Missouri s Vocational Rehabilitation (VR) office to help him find a job and/or get additional services so that he could return to work. Once again, however, after the initial visit, Edward did not follow up with VR, stating that he did not need their services and was more willing to work odd jobs that he found on his own. By August 2011, he felt that he was ready to return to his home state and was more confident in his ability to communicate with others. He also was anxious to search for a permanent job. Before returning home, Edward was given a contact for his home state s VR office as well as the name of an audiologist in his area. He accepted the referral for the audiologist; however he had no interest in the information for the VR office. Since moving back home, Edward has obtained employment at a large retail store. Although he is not entirely satisfied with his job, Edward is proud that he has a job with excellent health insurance benefits. Once his health insurance is established, he plans to consider a cochlear implant evaluation. Although he was initially discouraged by the appearance of the implant, he has decided that the need and desire for socialization outweighs the risk of stigmatization associated with his hearing problem and the visibility of a cochlear implant. Discussion For individuals with sudden profound sensorineural hearing loss, there are many more issues to deal with than just the hearing loss. The individual must come to terms with the fact that the hearing loss is permanent and that his or her life has been changed forever. The individual and his or her community members must make adjustments at work, with family and friends, and within society. Individuals with sudden profound hearing loss generally are unaware of the options available to them; clinicians must explore these options with their patients to help facilitate adjustment to their new lives and new self-images. Interacting with other individuals with hearing problems who are functioning well in society may help individuals accept and adjust to hearing loss. Options the person with hearing loss may consider out of the question in the beginning (i.e., hearing aids, cochlear implants, etc.) may become more palatable after an individual has lived with hearing loss for a while and has begun to accept the many changes the loss of hearing entails. When Edward first came to our facility, it was obvious that many of his needs were psychosocial rather than audiologic or physical in nature. It was apparent to the three audiologists working with him that he was having difficulty adjusting to his sudden hearing loss. He had undergone many traumatic events and life changes before coming to our facility; it was difficult for him to acknowledge and undertake the steps necessary to become a contributing member of society again. Edward struggled with the fact that he had to change his definition of a normal life. To this end, we offered him all the services known to us to address each of his needs: employment, psychological health, and communication. Edward was willing to participate in our research study and work with the local audiologist, but he was not comfortable using the FM system or seeking additional help from counselors for his psychological or vocational needs. The auditory training and the sessions with the audiologists could be done without others knowing. Both the use of assistive devices and counseling services appeared to be more proactive activities that required him to admit to his difficulties and to enlist the help of those around him on a daily basis. Edward is a proud man who wanted to be autonomous, asking him to use an FM system or other devices required asking others to change how they communicated. Deaf Services dealt with psychological issues related to hearing loss and Edward did not appear ready for that. As stated previously, Edward had undergone counseling in his home state following his accident, this may have influenced his decision not to continue counseling. The audiologists working with Edward perceived that he associated counseling with the psychological impact of the attack and not the impact of the hearing loss. 21

8 We did see improvements in his communications abilities during the 6 weeks he was enrolled in the I Hear What You Mean computerized auditory training program and during the time he spent with the audiologist in the clinic. As seen in Table 3, his auditory scores improved on some tests. He became more confident and slowly began entering the social world. On an exit questionnaire following his participation in the auditory training study, Edward revealed this confidence as well as perceived improvements in his communication abilities. When asked how much the training improved his ability to understand spoken language he answered, It has eased my anxiety of listening through secondary noise. In response to the question regarding his self-confidence in conversation with family and friends following the training he answered, I feel more comfortable having them repeat and/or asking them to talk slow and clear. His LSEQ score also showed perceived improvement in his communication abilities in quiet. Finally, we administered a visual-only test when Edward first arrived and before he moved home. His scores improved dramatically and changed from 15.8% on his initial test to 68.4% on his final test. Although noise is still his greatest communication challenge, he is more comfortable in communication situations in which he can see the individual speaking. As professionals working with individuals with any type of hearing loss, we must remember that although we can advise patients and make recommendations, we must respect the patients decisions regarding their treatment. In Edward s case, by referring him to Deaf Services, VR, and other agencies, we tried to address psychosocial issues that were affecting his life due to his hearing loss, but he was not ready and/or willing. As difficult as it was, we had to respect his decision. Allowing patients to make decisions and not casting judgment is a more patient-centered approach (Erdman, Wark, & Montano, 1994) that may lead to better patient compliance. In Edward s case, he is now willing to consider a cochlear implant evaluation even though it was not an option he considered early in his journey. Nearly 2.5 years after his life-changing traumatic injury, Edward is finally ready to take on the challenges that lie ahead. He is back in his home state, employed, and seeking further treatment options. Acknowledgements This work was supported by a grant from the National Institutes of Health #RO1DC A1. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Deafness and Communication Disorders or the National Institutes of Health. We would also like to thank Microsoft for permission to use their clip art. Editor s Note This case history is presented to stimulate thought as well as discussion among clinicians regarding the importance of a person/patient-centered approach in audiology practice. Although the circumstances surrounding the onset of Edward s hearing loss are particularly traumatic, sudden hearing loss can be a devastating experience for anyone. We invite readers to post comments and questions regarding Edward s case on the SIG 7 forum and to share their experiences with other cases regarding sudden onset of hearing loss. Go to the SIG 7 Community through ASHA Communities and join our discussion. References Barcroft, J., Sommers, M. S., Tye-Murray, N., Mauzé, E., Schroy, C., & Spehar, B. (2011). Tailoring auditory training to patient needs with single and multiple talkers: Transfer-appropriate gains on a fourchoice discrimination test. International Journal of Audiology, 50, doi: doi: /

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10 Zanetti, D., Campovecchi, C. B., & Pasini, S. (2010). Binaural cochlear implantation after bilateral temporal bone fractures. International Journal of Audiology, 49, doi: /