Question: People do not die from hearing loss, so why should it be added to the list of public health concerns like tobacco use and obesity? Answer: Because hearing loss is highly prevalent, with numerous associated health risks that burden affected individuals, their family, and their community.
Older adults in the United States are disproportionately afflicted with hearing loss, with as many as one-third of adults over 65 years old exhibiting hearing loss (Ear Hear. 2012;33:437 http://bit.ly/2lT6zo6). The World Health Organization (WHO) estimates the number of people with hearing impairment increased from 42 million in 1985 to about 360 million in 2011 (Bull World Health Organ. 2014;92:367 http://bit.ly/2m4dw4G).
Because hearing loss is highly prevalent, patients are often told “your hearing is normal for your age,” or “you’ll have to learn to accept and deal with your hearing loss.” However, research tells us that hearing loss has a tremendous impact on a person’s quality of life. It is associated with numerous health issues, including accelerated cognitive decline, depression, increased risk of dementia, poorer balance, falls, hospitalizations, and early mortality. Therefore, despite what patients are told, hearing loss and related health issues are not easy to “accept” or “deal” with.
Hearing loss is a burden. The WHO measures the burden of all health conditions and diseases with the Disability-Adjusted Life Year (DALY). One DALY equals one year of healthy life lost. In the case of hearing loss, DALYs are primarily related to years lived with disability (YLD). The number of years lived with a disability because of hearing loss is significant. In 2013, the top five causes of global YLD were back pain, major depression, iron deficiency anaemia, neck pain, and hearing loss (Lancet. 2015;386:743 http://bit.ly/2lAsUsK).
Traditionally, hearing health care falls within a medical model where diagnostic assessments are used to determine if the hearing loss can be treated with medications and/or surgery. However, when there is no evidence of medical pathology, as is the case with most age-related hearing problems, there’s also no clear and effective pathway of care. Without a known cure for hearing loss at this time, people with hearing loss, as well as those in their communication circles, have needs that are not being met because they require services that fall outside the medical model. Such services include education and counselling (e.g., increasing knowledge, changing attitudes, and reducing stigma), support in promoting behavior change (e.g., adapting communication strategies), and environmental modifications (e.g., reducing noise; Gerontologist. 2016;56 Suppl 2:S25 http://bit.ly/2lAChsi). In other words, what is lacking is a hearing health care system that can serve a broader population of people with hearing loss and include the larger ecological context within which hearing loss occurs. For these reasons, there is increased awareness that hearing loss is not only a medical problem but also a public health concern.
When hearing loss is viewed from a public health perspective, the mission expands to include improving health and quality of life, not only through prevention and treatment of hearing loss but also through the promotion of healthy behaviors. An essential component of public health is the “collective action for sustained population-wide health improvement” (Lancet. 2004;363:2084 http://bit.ly/2lALIIj; Bull World Health Organ. 2014;92:367 http://bit.ly/2lAFqIq). As such, there are many ongoing initiatives aimed at making hearing health care more accessible and affordable within and outside of the medical model (Ear Hear. 2016;37:376 http://bit.ly/2lAL6SW; Ear Hear. 2010;31:2 http://bit.ly/2lAIMew).
Some initiatives include specialized pre-conferences such as the U.S. Department of Veterans Affairs’ National Center for Rehabilitative Auditory Research biennial conference, “Hearing Loss as a Public Health Concern,” in 2015. Another is the establishment of a special interest group called the Population Hearing Health Care Group, which held a pre-conference at the 33rd World Congress of Audiology 2016 and an upcoming one at the American Auditory Society Annual Meeting in 2017. At these meetings, scientists and clinicians gather evidence to identify gaps in knowledge, service, and policy to develop new approaches to hearing health care.
The hearing health care landscape is changing rapidly. The time is right for bold and innovative changes. As an example, the Food and Drug Administration (FDA) announced in December 2016 that they were waiving the requirement that individuals 18 and up have to receive a medical evaluation or sign a waiver prior to purchasing most hearing aids, in addition to possibly creating a new category for over-the-counter hearing devices. This month, the Federal Trade Commission (FTC) is hosting a workshop called “Now Hear This: Competition, Innovation, and Consumer Protection Issues in Hearing Health Care.” The workshop is open to stakeholders such as health care providers, consumers, hearing health advocates, industry representatives, and policymakers. The goal is to explore how innovation and competition in the hearing health care industry can improve access to and use of hearing aids by those who need them.
What we are witnessing is “collective efforts” aimed at providing sustainable, population-wide hearing health improvement. Depending on who you are (audiologist, engineer, or patient with hearing loss) the proposed changes may or may not sit well with you. Shifts in perspective can be challenging and time-consuming. However, when hearing health care is viewed from a public health perspective, it becomes clear that change is needed. There is a high prevalence of hearing loss and only about one-fifth of people who could benefit from a hearing aid seek intervention. Even fewer make use of technology or communication strategies that might help them. Thus, we have a large population of people living with unmet communication needs.
According to the Centers of Disease Control and Prevention (CDC) Morbidity and Mortality Weekly Report (February 7, 2017), 1 out of 4 US adults who report excellent to good hearing already have hearing damage. The new CDC Vital Signs report by Yulia Carroll, MD, PhD and colleagues finds that many of those with hearing damage report no workplace noise exposure.
According to the new study, about 40 million US adults aged 20-69 have hearing damage in one or both ears that may be due to noise exposure. CDC found that more half (53%) of those report no exposure to loud noise at work. Based on the information they provided, researchers believe their exposure to loud sounds comes from everyday activities in their homes and communities.
The study was based on analyzed data from the 2011–2012 National Health and Nutrition Examination Survey (NHANES) to estimate the prevalence of audiometric notches and exposure to noise among adults aged 20-69 years. Using the standard NHANES audiometric protocols, audiograms were analyzed using an algorithm to identify high-frequency audiometric notches that suggest hearing loss caused by exposure to noise. The presence of a high-frequency audiometric notch was indicated when any threshold at 3, 4, or 6 kHz exceeded the average threshold at 0.5 and 1 kHz by ≥15 decibel (dB) hearing level (HL) and the 8 kHz threshold was at least 5 dB HL lower (better) than the maximum threshold at 3, 4, or 6 kHz.
The study showed the presence of an audiometric notch increased with age, ranging from 19.2% among people aged 20–29 years to 27.3% among persons aged 50–59 years. The prevalence of notches was consistently higher in males than in females for both reported work exposure to noise and for no reported work exposure to noise—and this was true for both unilateral and bilateral notches.
The results also showed that 21 million US adults (19.9%) who reported no exposure to loud or very loud noise at work had an audiometric notch (bilateral or unilateral). People exposed to loud noise at work were twice as likely to have bilateral or unilateral notches than those not exposed. However, 23.5% of persons who self-reported excellent or good hearing (irrespective of noise exposure reported) had bilateral or unilateral notches (5.5% and 18.0%, respectively). A total of 70% of people exposed to loud noise in the past 12 months never or seldom wore hearing protection.
The report concludes that “Hearing screenings can help reduce delays in diagnosis and improve access to hearing aids for those with hearing loss, thus improving health-related quality of life, yet a 2014 report found that only 46.0% of adults who had any trouble hearing had seen a health care professional about their hearing in the past 5 years. Hearing loss often progresses for years before being self-perceived or diagnosed. Talking to one’s personal health care provider about hearing loss symptoms, tests, and ways to protect hearing, might support early diagnosis and access to hearing rehabilitation if needed.”
The report also discusses hearing conservation standards and guidelines, as well as steps people can take to prevent hearing loss. According to the CDC, noise exposure is the second most common cause of hearing loss (aging is the first). The louder a sound is and the more often a person is exposed to it, the more likely it will damage hearing. Common activities in homes and communities—such as using gas-powered lawnmowers or leaf blowers or attending a rock concert or ball game—can cause permanent hearing loss.
The report’s conclusions also state that, during routine exams, primary care providers can examine patients’ hearing; ask about patients’ hearing and noise exposures and inform them about the benefits of hearing protection; monitor patients with hearing loss symptoms, recommend or provide hearing tests when indicated; and counsel patients with hearing loss. However, that 40%–77% of primary care providers have not asked about or screened for hearing loss. Although there is currently a lack of data to support the benefits of regular hearing screening in adults aged >50 years, the American Speech-Language-Hearing Association (ASHA) recommends adults be screened at least every decade through age 50 years and every 3 years thereafter. Healthy People 2020 includes objectives to increase the proportion of adults who have had a hearing examination in the past 5 years and to increase the number referred by their health care provider for hearing evaluation and treatment.
The CDC recommends that clinicians—especially primary care providers—can play an important role in identifying hearing in its early stages. Doctors, nurses, and other health professionals can ask patients about exposure to loud noise and trouble hearing during routine exams. When patients show or report hearing problems, healthcare providers can make referrals to hearing specialists. And they can explain how noise exposure permanently damages hearing and counsel patients in how to protect their hearing.
Clear Choice Hearing and Balance, an audiology practice specializing in tinnitus and other hearing and imbalance disorders, recently opened a new office in Westfall Surgery Center, 1065 Senator Keating Blvd., Rochester.
The hearing center expanded to Brighton to meet the growing demands of hearing loss. Since opening its Greece office on Canal Landing Boulevard in 2008, the need for diagnosis and treatment for hearing loss, vertigo, poor equilibrium and tinnitus continues to grow due to an aging population and environmental issues that put ears at risk, said founder and owner Christine Tirk.
“We see the growing need to provide quality health care for hearing loss and other disorders of hearing and balance,” Tirk said. “We are excited to be expanding our practice to the Westfall Surgery Center, where we can better serve even more patients who suffer from tinnitus, vertigo and other debilitating disorders that affect quality of life.”
Americans with hearing loss have doubled between 2000 and 2015, with one in five adults and one in five teens having hearing loss and tinnitus, or ringing in the ears, according to the Hearing Health Foundation.
“Our state-of-the art diagnostic tools enable us to precisely diagnose and address hearing loss better than before by guiding options or treatment of a variety of disorders of the ears,” audiologist Ron D’Angelo said. “Often the clinical signs we discover result in referrals for appropriate medical care.”
D’Angelo said hearing loss has been associated with cognitive decline, dementia, depression, hospitalization and heart disease, among other diseases and conditions.
Clear Choice Hearing and Balance serve thousands of patients in the five-county area and is recognized as a leader in tinnitus treatment.
Most audiologists will agree that musicians are not like other patients. Clinical encounters with musicians are often and affectionately described as challenging, with the potential to be highly rewarding. Musicians often push our understanding of sound and hearing to the limits, not because they are inherently difficult, but because they live and breathe sound. Music professionals have a thorough understanding of how sound and hearing interact in their personal and professional lives, from the practical, scientific, to emotional aspects. The purpose of this article is to discuss the implicit distinction of hearing conservation services for musicians, and to help transform clinical interactions with this patient group into positive, supportive, and productive dialogues.
Hearing conservation services and education are important to avoid noise-induced hearing loss (NIHL). This is especially true for workers exposed to significant occupational noise levels. The traditional hearing conservation message is simple and compelling: Protect your ears from loud and unwanted noise to avoid permanent hearing loss. However, this message has two major flaws when conveyed to patients who are musicians.
First, music is not noise. Music can be grossly defined as an organized, consonant, and desirable sound. This is in relatively stark contrast with “noise,” which is defined as a random, dissonant, and unwanted sound. In practice, there are surprisingly extensive overlaps between these two types of sound, depending on the musical genre. The simple use of the term “noise” in NIHL may lead many to believe that the warnings do not apply to their music exposure.
The second flaw in applying traditional hearing conservation education to musicians is that its primary emphasis is on hearing loss; other hearing issues such as tinnitus, hyperacusis, and diplacusis are often mentioned as footnotes. However, with musicians’ reliance on sound quality, these associated hearing disorders can represent a much greater risk to their health and profession. To address these two flaws, the term music-induced hearing disorders (MIHD) has been used in recent literature and public messaging: Sound, including music and noise, can damage one’s hearing, and hearing loss is not the only auditory disorder that results from excessive sound exposure.
In an effort to define a musician, it is important to recognize that most wear more than one hat. For example, it is not uncommon for a symphony violinist to moonlight in a folk group, a jazz pianist to teach at an after-school rock music program, or a heavy metal drummer to have a passion for fine woodworking. While it is a typical and convenient practice in audiology to categorize musician patients into clearly defined sub-groups (e.g., rock musicians, classical musicians, music teachers, etc.), doing so may only provide limited benefits in creating an intervention plan that fully addresses a patient’s wide array of musical activities and problem areas. Instead of presenting patients with cookie-cutter-type recommendations based on their primary musical genre or role, a better approach may be to empower patients with information and engage them in the process of determining feasible solutions and options.
Despite the conventional focus of hearing conservation on a musician’s stage performances, the vast majority of musical activities actually occur in non-public events and spaces. Individual practice, group rehearsals, lessons, sound checks, production activities, and studio recording sessions constitute the bulk of musicians’ time and contribute significantly to their total sound exposure. By exploring the musical settings beyond public performances, audiologists can better work with musicians in developing a comprehensive intervention plan.
Just like dealing with any patient, audiologists should evaluate the musician’s complete noise history and possible sound sources, including non-musical activities. Chasin pointed out that musicians can be the most voracious consumers of recorded and live music (Chasin. Plural, 2009 http://ow.ly/SlZQ3082QhL). Whether it be routine chores such as running a lawn mower or hobbies such as riding a motorcycle or recreational firearm use, non-occupational sound sources must be considered in determining a patient’s daily exposure limits.
Music is a competitive field. This competition extends beyond landing a new gig or a coveted orchestra seat as musicians are constantly competing with themselves to improve and with others to demonstrate their worth. Being in such a high-pressure position, a musician patient’s primary concern is likely to be the impact on the quality of their performance (AudiologyOnline. 2015; Article 15268 http://ow.ly/wUYl3082QoA). Without addressing this basic priority, clinicians run the risk of being perceived by the patients as the safety police. As such, clinicians must discuss the benefits of hearing conservation interventions in a way that addresses the factors of performance quality, specifically self-monitoring, consistency of execution, and awareness of others’ simultaneous performance. As Santucci explained, some musicians highly value hearing health, but this concern is generally a second or distant priority, almost always trailing behind the concerns for one’s performance (Chasin. Plural, 2009 http://ow.ly/SlZQ3082QhL). With this in mind, it is clear that any barrier or perceived hindrance to musical performance may be seen as an unacceptable sacrifice to the goals of an aspiring or a professional musician.
Performance benefits accompany many of the solutions that audiologists can recommend to and provide for musicians. However, these solutions may not be discussed during an office visit. For example, hearing protection devices can reduce fatigue and distorted hearing from a temporary threshold shift (TTS) during the course of a performance (WHO, 2015 http://bit.ly/2knh6JX). In-ear monitor (IEM) systems can improve clarity of pitch and timing cues while also reducing the stage volume and risk of microphone feedback (Mix Online, 2007 http://ow.ly/j0z73082RjB). Although clinicians are generally focused on the important business of educating patients on excessive noise exposure and minimizing the risk of developing MIHD, it can be argued that otherwise appropriate hearing conservation efforts that fail to consider the patient’s performance priorities may not be met with open arms.
Since music is an unregulated field, music professionals have something that is not available to other people affected by occupational noise exposure: The choice to continue working in a potentially unsafe sound environment without direct risk to formal employment. The draw of behavioral inertia is strong, so clinical recommendations must be stronger.
It is necessary to balance the standard preventative warnings with positive counseling that focuses on both short- and long-term benefits. Analogous to amplification fitting, effective clinical counseling cannot focus exclusively on avoiding a potentially negative outcome. Instead, audiologists must highlight anticipated benefits to motivate patients and frame the recommended intervention. The role of clinicians is to define a patient’s problem and offer practical, serviceable solutions. For many musicians, hearing conservation does not only mean prevention of an abstract risk of developing MIHD; it also means maintenance of their hearing ability and hearing quality, which is crucial to avoiding the loss of performance potential.
Studies exploring provider-patient interactions report improved treatment compliance when patients feel susceptible to the ailment and believe that the intervention will be effective (Ther Clin Risk Manag. 2008;4:269 http://ow.ly/KGB43082Qsn). The standard “avoidance” message may accomplish this goal for the general population. However, for individuals who pride themselves on their extensive experience with music and thorough understanding of sound, a warning may not be sufficient. This is where positive and compassionate dialogue prevails. Treatment compliance is shown to improve when patients perceive their providers to be emotionally supportive, reassuring, and respectful (Ther Clin Risk Manag. 2008 http://ow.ly/JWS63082QvR). By considering the musician’s frame of mind, innate emphasis on performance, and emotional relationship with sound, audiologists can better discuss the overlapping interests in maintaining hearing health in terms of career longevity and quality of life.
As athletes and dancers learn to understand and respect body dynamics, musicians should be provided with the opportunity to learn about their amazing auditory system. As Kantors has demonstrated in the “Hear Tomorrow” Hearing Conservation Workshops, teaching auditory physiology and pathophysiology concepts can empower music students and professionals, and promote self-directed adoption of safe listening habits (HearTomorrow.org, 2016 http://ow.ly/rERf3082QBg). This approach is reflected in the National Association of Schools of Music and the Performing Arts Medicine Association’s joint Advisories on Hearing Health documents, which emphasize the responsibility of students to be informed about their noise exposure risks and act in their best interest (NASM, 2011 http://ow.ly/g17u3082QGj). In the clinical setting, non-adherence to intervention plans has been shown to decrease when patients are engaged in designing their own treatment plans (J Am Board Fam Pract. 2005;18:87 http://ow.ly/AzOu3082QPd; Ther Clin Risk Manag. 2008 http://ow.ly/JWS63082QvR). Therefore, helping patients understand the problem and the available options should preempt any discussion of treatment to encourage partnership between patients and clinicians in intervention planning.
Almost by definition, reducing the intensity and/or duration of a sound entering the ears is at the heart of all hearing conservation efforts. Having a brief refresher is helpful in framing the practical implications of auditory physiology concepts in the context of musician activities. While beyond the scope of this article, it is recognized that with sufficiently high sound pressure levels, the auditory system experiences distortions in the form of upward masking, gradual onset of TTS, subharmonic distortions, and activation of the middle-ear-muscle reflex (J Assoc Res Otolaryngol. 2012;13:461 http://ow.ly/oGw23082QVs). Taken in combination, these phenomena can result in relatively inaccurate audition when the ear is exposed to sufficiently high levels of sounds. It is important for musicians to understand that high-level monitoring can reduce the accuracy of their hearing.
In practical terms, inaccuracy means that the perceived musical performance differs from the actual performance. This describes a nightmare scenario for musicians who have dedicated their lives to the merit of their performance. It can be argued that if all the listeners in one area are listening to approximately the same sound level for the same duration, the shared perception of a live performance may be favorable, on balance. This argument holds until a recording of the same performance is later heard at a more reasonable listening level. This time, intensity-dependent distortions are absent and the true performance is heard, complete with any previously imperceptible errors in pitch and balance.
This is the final and perhaps the most crucial take-away message: Never say “stop.” It may be impossible to identify a single valid reason for an audiologist to counsel a musician patient to discontinue his or her musical activities. Behaviors and activities should be safely adjusted, but under no circumstances should a musician stop playing music. Music is not a hobby for a musician—it is their livelihood. More importantly, it is an emotional lifeline. If a crisis of any type, including and especially a hearing disorder, were to occur in a musician’s life, the audiologist may advise the patient to listen to a good record, write a song about the disruption, or lose oneself in one’s instrument of choice for a few healing hours. Discontinuation of music-making is not an option for most musicians and, as such, is hardly viable advice from a trusted hearing health professional. Audiologists can better ensure a rewarding experience by collaborating with musicians in developing a practical and comprehensive hearing conservation plan.