Tinnitus and hearing loss persist as the two most common injuries in members of the military, in spite of efforts to conserve hearing by teaching the importance of protective devices. The ability to hear and communicate is crucial for safe and successful missions and training.
The Department of Defense (DOD) Hearing Center of Excellence (HCE) is focused on the prevention, diagnosis, mitigation, treatment, rehabilitation, and research of hearing loss and auditory–vestibular injury. Col. Mark Packer, MD, executive director of the HCE, spoke with The Hearing Journal about the challenges of addressing hearing loss in the military, how the center of excellence is addressing these hurdles, and priorities for future work.
Dr. Packer: The Hearing Center of Excellence is one of four congressionally mandated Centers of Excellence. The model was set up to look at some of the most prevalent injuries of war.
In 2007, the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury [TBI] was set up, followed by, in 2008, the Vision Center of Excellence. Then in 2009, the Hearing Center of Excellence came aboard with the Extremity Trauma and Amputation Center of Excellence. The Centers of Excellence were distributed to the different services as a lead component to help support them, and the Air Force picked up the Hearing Center of Excellence.
The organizational setup is a network of centers; it's not an actual center. Within the Department of Defense, there are seven primary medical treatment facilities that have audiologic and otologic capabilities to diagnose, take care of, and rehabilitate hearing loss, tinnitus, and vestibular disorders, and six acoustic research labs. We've been working together between the clinicians and researchers to try to develop a solid programmatic translational research endeavor by which the subject matter experts, from acoustic engineers to clinicians, identify the problems and gaps that are necessary to overcome this big issue and then provide solutions through research and technology that can be translated back into the field and the hospitals.
HJ: How common are audiologic problems among members of the military?
Dr. Packer: We have identified tinnitus and hearing loss as the first and second most prevalent injuries based on Veterans data and the Annual Veterans Benefits Report. As of 2011, there are 840,000 cases of tinnitus and 700,000 cases of hearing loss, so it's a huge population health issue. We've found that much of that is attributed to the noisy environment that we put folks in. Military is a loud system. There are impact and impulse training exposures, as well as enemy strategies that create loud noises in active war.
HJ: What are the challenges of addressing hearing loss and tinnitus in the military?
Dr. Packer: There are several. One is the lack of awareness. Hearing loss and tinnitus are invisible injuries, so they oftentimes get a backseat to other more pressing injuries that are readily visible or bleed and cause immediate threat to life or limb. If hearing loss is noise induced and not a blast-related injury, then oftentimes it's insidious and invisible, and members may not even realize that they've had a change in their hearing until all of a sudden they can't hear very common conversations at regular speaking tones. It sneaks up on them.
The other problem we have is that prevention efforts are plagued by misconceptions that the hearing protection devices make you less lethal on the battlefield and influence your survivability in an adverse way. Even though the military provides and teaches and trains with protective devices, oftentimes they aren't worn, and so I think that we have to provide better awareness at higher levels of leadership. We also need to include in our training the awareness that if you are in a firefight and you have your hearing protectors on, then you won't have those temporary threshold shifts and hearing loss that make you ineffective for the duration of the fight.
The story's told of the guy out on the front line who's ambushed, and his team starts taking fire. With the explosions going off everywhere, the noise is nearly deafening. This individual is not wearing his protection, as many don't, and so he doesn't realize the effect of the situation around him. He's standing up like Rambo firing his shots off, and it takes another member in his unit to tackle him to the ground and keep him safe. This was all due to his temporary threshold shift and tinnitus. He couldn't communicate; he didn't have the awareness that they were taking on fire, and so he put not only himself but his unit buddies at a disadvantage.
HJ: What is the Hearing Center of Excellence working on right now?
Dr. Packer: One of the current projects is the Auditory Fitness for Duty effort to create a standard that we can judge our military members by when they are injured. The diagnostic efforts of putting somebody in a sterile hearing booth and collecting data don't often translate into how well they're going to perform when they go back to work.
We've identified critical hearing tasks in environments where our operators work, such as aboard ship or out in the field, and created word lists in those noise environments. Then we'll be able to use their diagnostic audiogram with this signal-in-noise testing that will hopefully link their hearing ability with their performance ability. That will help in sharing with them the potential risks and threats of their hearing status, but also it will help enforce management in that their leadership will have a good understanding of how well they will do in their current jobs and whether or not they should be transitioned to a different opportunity so that they don't threaten further hearing loss.
HJ: How about priorities for future work?
Dr. Packer: Right now there are several different regulations and instructions within each of the services that do things a little bit differently, and we think we can do a better job of identifying best practice standards and create a better system.
We also think that hearing restoration and rehabilitation is such a technologically driven field that there are a lot of new and emerging technologies and devices that have not been tested for military use. We have a strong interest in being part of the team that vets those solutions so we can offer them to our members.
In addition, we are working to create a better pathway between the Department of Defense and the VA [Veterans Affairs] so that our members have a smoother, more seamless transition from their DOD days to their VA days, and the health information that was collected in the DOD can transition with them to the VA.
We're looking at ways to identify value in our systems and share resources within the services and the VA so that we can take care of troops closer to home without compromising care. We're looking at telehealth, care extension, and augmenting care, which are trends in many different realms. For our members, who move often and aren't often near the main treatment facilities, we want to be able to provide a way for them to conveniently access consultation services and rehabilitative care, and hopefully manage their rehab devices and products through telephonic programming and the like.
HJ: How have you personally seen hearing loss affect members of the military?
Dr. Packer: I'm an otologist and neurotologist by training, so I deal with the surgical rehabilitation of hearing loss. A lot of the individuals whom I treat not only have problems with hearing and tinnitus but, because of blast injury, may have other confounding injuries, such as amputations, vagal problems, cognitive problems, or traumatic brain injury.
A couple of my most recent cochlear patients had various levels of vision loss and/or prosthetic limbs to deal with. We can restore hearing through cochlear implantation, but we still need to understand that there may be difficulties manipulating the devices with the prosthesis, or the visual displays may not be adequate.
One patient I'm thinking of now was exposed to a blast and had a lower extremity amputation, and ended up with bilateral near total perforations and bilateral mixed hearing loss. He came in after multiple surgeries and a lot of rehab, and presented to me with the main complaint of tinnitus. He said that far and away, the tinnitus was the most aggravating thing, and the inability to hear his wife and his kids really impacted his quality of life. We were able to recreate the tympanic membranes, so now he's slated for a semi-implantable hearing device to help restore some of his hearing. Those are the stories that catch me.
HJ: What should the community expect next from the Hearing Center of Excellence?
Dr. Packer: We're about ready to unveil a prevention campaign that is geared toward information that patients and their families will find useful. It's an awareness campaign to change behaviors and to modify behaviors that may add to the injury.
It's also a push to develop awareness in leadership circles so that we can create institutional support and continuity by developing the regulations and the instructions that will make hearing loss something that we don't qualify as just an unfortunate sequelae of military service. We want to be able to take care of our folks better and prevent injury before it happens.
For more information on the Department of Defense Hearing Center of Excellence, visit hearing.health.mil.
Dod Hearing Center Of Excellence: Cause For Collaboration
Podcast Interview by Michelle Hogan
Only in the July iPad issue, listen in as Col. Mark Packer, MD, executive director of the Department of Defense Hearing Center of Excellence (HCE), discusses what the HCE has accomplished so far, and how the larger hearing healthcare community can contribute, now and in the future.
Part of the mission of the Hearing Center of Excellence is to establish and maintain a collaborative network of research laboratories, medical treatment facilities, nonprofit groups or foundations, industry, academia, international bodies, and other government centers of excellence.
“We feel that it's becoming a smaller and smaller world, and we know that to capitalize on the knowledge of this injury, we need to partner with folks who do it well, especially in the areas of research and education,” Dr. Packer says in the podcast. “We have a strong interest in trying to develop those partnerships with local academic centers.”
To learn more, download The Hearing Journal app, and this podcast, for free today at bit.ly/AppHearingJ.