Ms Shantelle Chandra. Charge Audiologist Dilworth Hearing Remuera and St Heliers

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1 Ms Shantelle Chandra Charge Audiologist Dilworth Hearing Remuera and St Heliers 12:05-13:00 WS #29: Sudden Sensorineural Hearing Loss, and Managing Single-Sided Deafness

2 Sudden Sensorineural Hearing Loss (SSHL) and Managing Single Sided Deafness Rotorua GP CME June 2018 Presented by Shantelle Chandra BSc, MAud, MNZAS CCC

3 Dilworth Hearing Services Hearing Tests for all ages Hearing Aid Fitting & Adjustments we are not owned by a manufacturer we fit what is best for the patient Assistive Listening Devices Cochlear Implants Tinnitus Assessment and Management Auditory Processing Assessments Hearing / Ear Protection Ear Nurses for wax removal

4 Today s talk will focus on To be able to identify SSHL To understand the urgency for prompt treatment To update your knowledge of treatment for SSHL To develop knowledge of rehabilitation options for patients who have presented with SSHL.

5 What is SSHL SSHL or sudden deafness is the loss of hearing which occurs suddenly or over a few days (72 hours). It usually affects one ear although can in 5-10% of cases affect both ears. This rapid loss involves the inner ear or nerve of hearing. SSHL can occur at any time and at any age. It should be considered a MEDICAL EMERGENCY requiring immediate recognition and attention.

Typical presentation of SSHL Loss of hearing in one ear Commonly patients report voices sound muffled on that side compared to the unaffected side, or they suddenly cannot

6 Typical presentation of SSHL Loss of hearing in one ear Commonly patients report voices sound muffled on that side compared to the unaffected side, or they suddenly cannot hear the telephone on one side Sounds seem to echo or be distorted on one side Sudden tinnitus in one ear Pressure or blocked feeling in one ear A loss of balance or vertigo

7 Prompt Diagnosis do not wait! Step one: A history and careful physical examination are important to rule out more severe pathologies such as vascular events and malignant diseases. It is important to exclude occluding wax (although this does not exclude a SSHL). The tympanic membrane should appear normal. Tuning fork tests can help differentiate between a sensorineural hearing loss or conductive hearing loss. Ask the patient which ear is affected and perform a Weber test and a Rinne test using a 512 Hz tuning fork. In a sensorineural hearing loss, the Weber test lateralises to the good side. The sound in the Rinne test is louder next to the affected ear than conducting through the bone behind it (Rinne positive ).

8 Prompt Diagnosis do not wait! Step two: An urgent full diagnostic hearing assessment is essential for a definitive diagnosis (ideally within 24 hours). Step three: An urgent referral to Otolaryngology (ORL) for imaging is required. Regardless of whether the hearing returns, imaging is recommended to exclude a CPA lesion (mostly a vestibular schwannoma).

9 What causes SSHL? Well over 80% of cases are idiopathic. A cerebellopontine angle (CPA) tumour may be present in 1% of SSHL patients. Other causes include Meniere s disease, autoimmune disease, vascular disease, infectious disease, Lyme disease, syphilis, demyelinating disease, endolymphatic hydrops and perilymphatic fistula.

the left ear where the overlay of sudden loss has occurred.

10 What might you see on a diagnostic audiogram? This patient has partial hearing loss in both ears, much worse in the left ear where the overlay of sudden loss has occurred. This patient has total loss (dead ear) in their left ear, accompanied by no useful hearing for speech

11 Treatment TREAT AS SOON AS POSSIBLE! It is important to start active treatment as soon as possible. The acute phase is within three weeks of the initial symptoms. After three weeks the opportunity to treat SSHL is greatly reduced. Patients should be treated with a short course of oral high dose steroids (prednisone) if no contraindications exist. Relative contraindications to systemic steroid use include breast feeding, Cushing s syndrome, diverticulitis, peptic ulcer disease and bleeding ulcers, diabetes, heart failure, myasthenia gravis, osteoporosis, psychosis, renal disease, and ulcerative colitis.

12 Dosage Call local hospital ORL registrar to confirm dosage, however current accepted regimen is:

13 Recovery Around 50% of patients will recover completely within the first two weeks following onset. Re-assess hearing with a follow-up full diagnostic hearing assessment following completion of the medication. If there is no improvement the ORL Specialist may consider intratympanic steroid infiltration for salvage therapy e.g. dexamethasone-3 doses 7 days apart. Post treatment hearing tests are important to document recovery as well as to discuss rehabilitation options if needed.

14 Causes of single-sided hearing loss (SSD) There are a number of potential causes of SSD, including: Sudden hearing loss Viral or bacterial infection Idiopathic Head trauma Vascular insult Acoustic neuroma Ménière s disease Genetics (congenital)

15 Is one ear enough? A recent qualitative analysis by Lucas et al. (2018) showed that SSD imposes a substantial degree of burden and can lead to negative effects on psychological well-being and restrictions on social participation. A hearing loss in to one ear only cannot therefore be assumed to have only minimal effects on well-being.

, 2018) http://sites.music.columbia.edu/cmc/musicandcomputers/chapter5/05_03.

16 Functional consequences of SSD Sound localisation Difficulty identifying which direction a sound is coming from I didn t know where the traffic was, it just seemed to be all around and that was quite scary. (Lucas et al., 2018) Poor awareness of sounds/speech on the poorer hearing side The head shadow effect

17 Functional consequences of SSD Difficulty understanding speech in the presence of background noise One of the major difficulties reported by individuals with SSD Following conversations in noisy environments will be challenging as it becomes very difficult to separate speech from background noise. If everyone s talking at once, it s very difficult to extract one person s conversation. It s just a noise. (Lucas et al., 2018) Speech perception abilities are also affected by the acoustics of a setting.

18 Psychological consequences of SSD People with SSD report that their hearing loss has a significant effect on both their mental and emotional wellbeing. Sudden losses are often associated with shock, fear, and devastation, and in some cases feelings of anxiety and depression. A prominent and recurring concern reported by those with SSD is anxiety regarding losing the hearing in their good ear. Many individuals report that they feel there is a social stigma about their hearing loss and comment that they often feeling stupid or embarrassed due to their communication difficulties Some felt like a hindrance as they had to rely on other people to be involved in a conversation, or felt guilty if they had missed what someone had said to them. From Lucas et al. (2018)

19 Social consequences of SSD Those with SSD also report that it has a significant effect on their social interactions, particularly with unfamiliar people. Social events where background noise is present is particularly hard for people with SSD and many report feeling marginalised at social events. Evidence suggests that this can lead those with SSD to withdraw from situations or withdraw within social situations where they are struggling to participate in conversations. Many workplaces also present challenging listening environments and SSD can impact social interactions in the workplace and perceived job performance. From Lucas et al. (2018)

20 Rehabilitation- dead ear This patient has total loss (dead ear) in their left ear, accompanied by no useful hearing for speech. If this loss remains after treatment, they would benefit from a CROS hearing aid system, which transfers sound from the dead side to the good ear.

understand speech even in noisy environments Engage in conversations

21 Phonak CROS/BI-CROS Follow conversations in quiet and noisy surroundings without having to reposition yourself Stay focused and understand speech even in noisy environments Engage in conversations that are happening on the side of your non-hearing ear No surgical procedures required

22 Patient L Sudden onset vertigo approx 2.5 hrs Vomiting Hearing drop and increased tinnitus on R No prednisone prescribed Changed to BICROS system

23 Cochlear Implant Restoration of the binaural signal Requires the brain to integrate electric and acoustic simuli Improvement to spatial orientation, speech perception in noise and tinnitus supression.

Rehabilitation- partial loss This patient has partial hearing loss in both ears, much worse in the left ear where the overlay of sudden loss has occurred.

24 Rehabilitation- partial loss This patient has partial hearing loss in both ears, much worse in the left ear where the overlay of sudden loss has occurred. Regardless of whether treatment improves the hearing loss, they would benefit from a pair of conventional hearing aids, given the excellent speech discrimination at elevated presentation levels.

25 Summary

26 Questions? Any further questions can be directed to:

Dilworth Hearing Clinic Locations Te Atatu 382 Te Atatu Road Ph (09) 557 5500 Epsom 160 Gillies Ave Ph (09) 631 1990 Remuera 139 Remuera Road Ph (09) 520 1274 Takapuna 15 Shea Terrace Ph (09) 485

27 Dilworth Hearing Clinic Locations Te Atatu 382 Te Atatu Road Ph (09) Epsom 160 Gillies Ave Ph (09) Remuera 139 Remuera Road Ph (09) Takapuna 15 Shea Terrace Ph (09) St Heliers 188 St Heliers Bay Rd Ph (09) Howick 260 Botany Road Ph (09) Papakura 6 Broadway Ph (09) Hamilton 8C Mills Lane Ph (07) Wellington 99 Upland Road Ph (04) Christchurch 9 Caledonian Road Ph (03) Tauranga 19 Bethlehem Road Ph (07) Palmerston North 619 Featherston Street Ph (06)

Ms Melissa Babbage. Senior Audiologist Clinic Manager Dilworth Hearing

Ms Melissa Babbage. Senior Audiologist Clinic Manager Dilworth Hearing Ms Melissa Babbage Senior Audiologist Clinic Manager Dilworth Hearing 14:00-14:55 WS #30: Sudden Sensorineural Hearing Loss and Management of Single Sided Deafness 15:05-16:00 WS #40: Sudden Sensorineural