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Wednesday, July 30, 2014
By Dennis A. Colucci, AuD, MA
Dr. Colucci is a clinical and forensic audiologist in private practice in Laguna Hills, CA.
With high healthcare costs and a patient’s quality of life at stake, it is important that audiologists recognize benign paroxysmal positional vertigo (BPPV) during the intake process and provide a repositioning procedure or appropriate referral that can save someone’s life.
Benign paroxysmal positional vertigo is a mechanical anomaly in which calcium carbonate crystals, called otoconia, detach from the otolithic organs and find their way into the semicircular canals.
A variety of causes for BPPV are postulated in the healthcare literature, including reduced bone density, cardiovascular and cerebrovascular disease, head and neck trauma, infection, Ménière’s disease, vitamin D deficiency, space launch, surgical drilling, and migraine, although most cases remain idiopathic.
In an eight-year study that evaluated 731 patients 70 years of age and older who were seen in a multidisciplinary dizziness clinic, 27.6 percent of the patients had BPPV (Ear Nose Throat J 2014;93[4-5]:162,164,166-167).
Photo credit: © Shutterstock/Image Point Fr
According to the Centers for Disease Control and Prevention (CDC), one in three adults age 65 and older falls annually, with 20 percent to 30 percent sustaining injuries that prevent them from returning to normal activities and increase their risk for early death.
Furthermore, seniors are hospitalized five times more often for falls than for any other cause, and the direct and indirect costs of fall injuries are expected to reach $67.7 billion by 2020.
The research on BPPV has yielded a revolution in its treatment, with an 80 percent to 90 percent cure rate. Given the treatable nature of the condition and the financial and health consequences of falls, it is critical that audiologists distinguish and extinguish benign paroxysmal positional vertigo.
The primary diagnosis of BPPV is made from a patient’s medical history: namely, a sudden onset of symptoms in the absence of other complications and true vertigo that resolves in less than a minute when the patient is motionless. The diagnosis is qualified by a bedside examination revealing the presence of nystagmus with a short delay after a change of position.
Between bouts, the patient may have some sensation of dizziness, but not vertigo.
The most frequent site of lesion is the posterior semicircular canal (80%), with anterior canalolithiasis and horizontal canal involvement occurring five percent and 15 percent of the time, respectively (Acta Otorhinolaryngol Ital 2013;33[4]:254-260).
Multifocal variants may occur in combination with other disorders, especially in cranio-cervical trauma. In these cases, a complete balance evaluation is warranted.
The Dix-Hallpike maneuver is used to identify benign paroxysmal positional vertigo in the posterior vertical canal during bedside testing. The procedure starts with the patient in the sitting position, head turned 45 degrees, and proceeds with the patient reclining to the supine position, with the head in slight retroflexion at 20 degrees.
In anterior vertical canal BPPV, symptoms are often worse when the patient moves from the sitting position to the supine position without head turning. For the diagnosis of horizontal canal BPPV, a simple supine head roll test is used, with the patient’s head starting at the center and turning to the right, pausing, returning to the center, pausing, and then repeating on the left.
Benign paroxysmal positional vertigo usually can be extinguished during a single visit. For the common posterior canal BPPV, a simple protocol known as the Epley maneuver is most effective. The maneuver is also used for anterior canal BPPV, with some variation.
For the small population in which posterior canal BPPV is not easily resolved, the patient is instructed to do Brandt-Daroff exercises a few times a day, with results seen in 10 days.
For horizontal BPPV, maneuvers by Lempert (barbecue roll) and Gufoni are highly effective.
The bedside tests and extinguishing procedures are shown on the American Academy of Neurology YouTube channel.
Every audiologist should ask patients about balance, know how to diagnose posterior canal BPPV and other variants, and extinguish the condition or guide patients to balance clinics that specialize in treating this debilitating disorder.

Wednesday, July 30, 2014
Diagnosis: Cholesteatoma of the Pars Flaccida
By Hamid R. Djalilian, MD
Dr. Djalilian is director of neurotology and skull base surgery and associate professor of otolaryngology and biomedical engineering at the University of California, Irvine.
Patients often present with a diagnosis that they may have come up with themselves. In cases like this, caution is advised. That diagnosis should certainly be considered in the differential, but not exclusively. A wide differential diagnosis must always be considered in order to prevent tunnel vision when evaluating the patient.
While many surfers develop exostoses because of the water temperature and the wind that blows into and cools the ear canal, not all surfers will develop them right away. Usually, many years of exposure are required for this problem to occur.
The same relationship holds true for otitis externa. Many patients with exposure to contaminated ocean water can develop otitis externa secondary to manipulation of the ear. However, all drainage from the ear after water exposure is not otitis externa.
When ear drainage is present, cleaning the ear canal is of the utmost importance. Using suction, the clinician should remove debris all the way to the level of the tympanic membrane in order to fully visualize the membrane. The diagnosis can be considered only after a full visualization of the ear canal and tympanic membrane.
After this patient’s ear canal is thoroughly cleaned, it becomes evident that the ear canal itself is normal and not edematous, erythematous, or the likely source of the drainage.
Visualization of the tympanic membrane shows a small section of granulation tissue, which appears as red beefy tissue, in the area of the pars flaccida. The pars flaccida is located superior to the lateral process of the malleus. It is bound superiorly by the ear canal, which can sometimes be eroded in this setting.
Unlike the rest of the tympanic membrane, which is called the pars tensa, the pars flaccida has a more disorganized fibrous layer, causing it to be more flaccid—hence the name.
Otoscopy of the patient’s other ear shows a retraction of the pars flaccida as well, indicating poor Eustachian tube function.
Most commonly, a drop in middle ear pressure secondary to Eustachian tube dysfunction will initially cause the pars flaccida area to retract. The retraction may progress, leading to the formation of a pocket. Accumulation of dead skin, called squamous debris, in this pocket results in cholesteatoma formation.
This patient has a cholesteatoma of the pars flaccida area. The presence of granulation tissue in the pars flaccida is considered to indicate cholesteatoma until proven otherwise.
The granulation represents the intense inflammatory response of the surrounding tissue to inflammation or infection caused by the cholesteatoma.
Workup of cholesteatoma includes a CT scan of the temporal bones to evaluate the degree of bony destruction and the anatomy of the temporal bone prior to surgery.
This coronal CT of the right temporal bone of a different patient demonstrates bony destruction and opacification (indicated by the gray area) starting in the superior aspect of the medial canal (pars flaccida) and growing into the mastoid. IAC=internal auditory canal. EAC=external auditory canal.
Occasionally, an MRI is obtained when the diagnosis of cholesteatoma is in question. Diffusion-weighted images can be used to distinguish a cholesteatoma from other types of pathology in the temporal bone. Modern software and imaging techniques, termed non-coplanar diffusion weighting, can be used to identify a cholesteatoma as small as 3 mm.
Patients with cholesteatoma should undergo surgical treatment in order to avoid the potentially disastrous complications of cholesteatoma, including meningitis, brain abscess, bony labyrinth destruction (and resultant deafness), and facial nerve paralysis, among others.
Extremely rarely, observation may be performed in very old patients or those with significant medical problems and an open cholesteatoma that can be debrided.
The choice of surgical approach depends on the patient’s cholesteatoma and anatomy. Most commonly, cholesteatomas are treated using tympanoplasty with mastoidectomy.
The adjunctive use of otoendoscopy has allowed surgeons to have a much lower residual cholesteatoma rate. Though it’s not widely used by surgeons yet, we believe that otoendoscopy is an invaluable tool for looking around corners of the temporal bone to ensure that all portions of the cholesteatoma have been removed.
Despite the surgeon’s best efforts, though, it is possible for part of the cholesteatoma to remain behind. This happens because of the extensively infiltrative cholesteatomas that can penetrate even the deepest areas of the temporal bone.
In the presence of inflammation, which almost always exists with a cholesteatoma, it is not always possible to identify residual areas. For these patients, a second surgery is scheduled between six and 12 months after the first surgery to evaluate for any residual cholesteatoma. Reconstruction of the ossicles is performed during the second surgery.
At our institution, we use annual MRIs for the first few years to look for residual cholesteatoma. A second-look operation is reserved for those who have very infiltrative cholesteatomas—approximately 10 percent of patients.
Cholesteatoma patients will continue to have Eustachian tube dysfunction postoperatively and will be at a higher risk of developing a cholesteatoma in the future. Therefore, lifelong follow-up is needed for these patients on a yearly basis, at least, to identify recurrence early.

Wednesday, July 30, 2014
By Hamid R. Djalilian, MD
Dr. Djalilian is director of neurotology and skull base surgery and associate professor of otolaryngology and biomedical engineering at the University of California, Irvine.
A 47-year-old patient presents with a history of drainage from the ear after surfing. The drainage has occurred every time he’s gone surfing over the past six months.
He thinks he has exostoses, or surfer’s ear, the patient said. His surfer buddies have had a similar problem, requiring antibiotics for it every time, and some have needed surgery.
The patient also thinks he has bony growths in his ear canal, and he wants to get the “Roto-Rooter” done.
His audiogram shows a moderate conductive hearing loss in the affected ear. His ear, which is filled with debris, is cleaned. The otoscopic image taken after cleaning is shown here:
What is your diagnosis? Click here for the answer.

Wednesday, July 30, 2014
By Cynthia A. Hogan, PhD

Dr. Hogan is a consultant in the Division of Audiology and director of the Hearing Aid Program at the Mayo Clinic.
Effective communication has been shown to improve patient outcomes and satisfaction in a number of studies (Scand J Caring Sci 2006;20[2]:143-150; J Eval Clin Pract 2010;16[3]:560-568). Hearing loss is a very common diagnosis in the general population that also happens to be invisible to many. As we all know, it can cause significant barriers to successful communication.
Working as an audiologist in a busy medical facility, I often find that my patients are other medical professionals—physicians, physician assistants, nurse practitioners, nurses, clinical medical assistants, and transcriptionists, among other medical staff members.
Although the challenges that hearing loss poses for these professionals are common to most of my patients, this group of healthcare providers presents some unique communication issues.

Healthcare professionals with hearing loss reported using certain communication strategies, such as working face-to-face with patients, moving closer to them, and asking for repetition.
Photo credit: © iStock/andresrimaging
Medical professionals must accurately hear their patients and coworkers in a variety of environments where inaccuracy can result in devastating outcomes. In addition, many of these professionals routinely use a stethoscope and must diagnose medical problems based on what they hear.
As a result, making proper recommendations for patients who work in medical fields is not only important for their daily function, but also vital for their communication with colleagues and patients. The Americans with Disabilities Act (ADA) of 1990 governs the accessibility and accommodations that employers and educators are required to provide to employees and students with disabilities of all kinds.
In that vein, The Hearing Journal published an article about the legal case brought by Michael Argenyi, a medical student with hearing loss, against Creighton University in Omaha, NE (April 2013 issue, p. 12). Mr. Argenyi asked for Communications Access Realtime Transcription (CART) and interpreter services; however, his repeated requests were denied by the university.
In September 2013, a jury in federal court concluded that Creighton University discriminated against Mr. Argenyi and must provide reasonable accommodations. Then, in December 2013, a judge made the final ruling that interpreters and CART must be provided at no charge to Mr. Argenyi, who had previously paid for interpreter services himself.

Alanna R. Trotter, Susan B. Matt, and Danuta Wojnar conducted a pilot project investigating the impact of hearing loss on the work of professionals in a number of different medical fields, particularly on the communication strategies and accommodations they used.
The authors developed a 28-point survey that included basic demographic information and items specific to hearing loss, such as age, gender, work environment, years of experience in the medical profession, hours of direct patient care, and onset of hearing loss, as well as questions about accommodations and communication strategies.
Subjects were recruited in the digests and Facebook page of the Association of Medical Professionals with Hearing Losses (AMPHL). The survey was completed by 32 healthcare professionals—11 registered nurses, six medical doctors/doctors of osteopathic medicine, four doctors of veterinary medicine, four nurse practitioners/advanced practice registered nurses/masters of science in nursing, two pharmacists, and one in each of the following professions: audiologist, medical assistant, echo/ultrasound technician, radiation therapy technician, and dietitian.
Of the participants, 25 were woman, and more participants were in the 40- to 49-year-old age group than in any other age group.
In terms of additional characteristics related to work environment and hearing loss:
  • Eleven participants worked at hospitals, six participants worked in private clinics, and the remaining professionals worked in other settings.
  • Nineteen respondents reported onset of hearing loss at birth or early childhood, and the remaining participants had progressive loss.
  • Assistive communication modes included hearing aids (21 participants), cochlear implants (10 participants), captioning (13 participants), and American Sign Language (ASL; seven participants).
  • Twenty respondents used amplified stethoscopes; the Cardionics E-Scope was most popular (12 participants). Of note, all respondents who had cochlear implants used the Cardionics E-Scope, and several participants used the Steth-O-Mate adapter tips on Littman stethoscopes.


The healthcare providers differed as to whether they told their patients about their hearing loss. Nineteen professionals reported sometimes sharing that fact, while only three participants said they always told patients. Two respondents reported never divulging their hearing loss to patients.

The decision to share the presence of hearing loss was based on several factors, including the need for repetition from the patient; use of assistive technology, such as an amplified stethoscope or frequency modulation (FM) system; and the development of a rapport with a patient who has hearing loss, participants said.

Many of the respondents reported difficulty in their relationships with employers, colleagues, or staff; 17 said they received no special accommodations because of their hearing loss, while several were granted a decreased patient load, amplified or other special type of telephone, or other assistive technologies, such as interpreter services, CART, or note takers.

On the other hand, most of the healthcare providers reported satisfaction with the accommodations in their work environments—19 participants—while nine said they were not satisfied. Communication strategies used by the respondents included working face-to-face with people, moving closer to patients, asking for repetition, repeating what they heard, and using visual displays, such as e-mail or other written communication.

The healthcare professionals made a variety of recommendations for additional resources, including improved education about the ADA, the use of clear face masks, a better technology interface with hearing aids and cochlear implants, and more affordable hearing aids and assistive devices.


This study reported communication approaches and accommodations used by a small number of medical professionals in a variety of work settings. The respondents described using the same strategies that are recommended by most clinical audiologists for all patients with hearing loss.

It’s interesting that 15 of 29 participants reported difficulty finding an audiologist who could help them with work-related priorities, including the need for an appropriate stethoscope. It is important for audiologists working with medical professionals who have hearing loss to identify internal and local resources for them and to develop strategies that will help the providers be successful in their own work environments. The Association of Medical Professionals with Hearing Losses website is a very good starting point for medical professionals to find support and information about particular tools, such as specialized stethoscopes.

One suggestion from an audiology practice where many patients work in medical professions is to develop a list of mentors or peers with whom the professionals can collaborate and share ideas.

I recommend that patients who have difficulty hearing with their stethoscope work with an expert who can help them identify particular heart, lung, and other body sounds through the stethoscope, and verify that what the professional hears and reports is accurate. Some amplified stethoscopes, such as the Cardionics E-Scope, can be used as a teaching/learning tool, allowing the teacher to hear what the student (in this case, a medical professional with hearing loss) is hearing via headphones.

Accommodations that use visual displays and the Bluetooth/wireless capabilities of hearing aids and cochlear implants will likely become more readily available in stethoscopes and medical communication in the future, allowing more seamless transition between work and nonwork environments for medical professionals with hearing loss.

Tuesday, July 08, 2014
Using a digital sound level meter, Sonova audiologist Thiago Diniz recorded fans' noise levels during the World Cup quarterfinals.
By Alissa Katz
What does victory sound like? During the World Cup quarterfinals, fans of Brazil’s team registered as the noisiest—their collective cheers reached 116 dB—leading the Hear the World Foundation to predict that Brazil will be the world champion.

The Hear the World Foundation, a hearing loss awareness initiative by manufacturer Sonova, used a digital sound level meter to determine noise level in a large public fan zone in the Vila Madalena neighborhood of São Paulo, Brazil, the host country of the 2014 World Cup.

When the decibel level spiked above 90, Sonova audiologist Thiago Diniz recorded the level, for which team the crowd was cheering, and the length of time for which the noise level was sustained. At the end of every game, the average decibel level of each team’s fans was calculated by adding the decibel levels at each spike and dividing that number by the total number of spikes.

Here are the noise levels of fans cheering the other seven quarterfinal teams:
  • France, 99 dB.
  • Colombia, 97 dB.
  • Argentina, 95 dB.
  • Netherlands, 95 dB.
  • Costa Rica, 93 dB.
  • Belgium, 91 dB.
  • Germany, 90 dB. 
Since the decibel level gets so high, hearing protection is particularly important at sporting events, the foundation noted in a news release. To prevent noise-induced hearing loss, Hear the World suggested using earplugs during games and giving the ears a break by stepping away during halftime, or muting or shutting off the radio or television if spectating from the couch.
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