To the Editor:
The Editorial in the March, 1991 issue ofThe American Journal of Otologyentitled “Noise-Induced Hearing Loss: The Sixth Question,” authored by Sidney N. Busis, M.D., has kindled anew concerns that I have increasingly experienced in the last decade when I am called upon to evaluate hearing-impaired persons who claim their hearing loss is noise-induced.
I take issue with the focus of the editorial on there needing to be a more meaningful assessment of the hearing and communication ability of individuals claiming loss of hearing attributed to occupational noise exposure. The need for a more definitive determinant of the real-life handicap of a hearing impairment does indeed exist, but this need is for all hearing-impaired persons, not just those who may have noise-induced hearing loss (NIHL).
Of greater concern, and a more pressing focus for the editorial, is the need for a much more thorough evaluation by otologists of individuals who claim to have NIHL. I am continually appalled by the frequency with which I see the reports of others in our specialty, who make very positive statements that a hearing loss is noise-induced, when they have seen the person only one time and have only their own single audiogram. Furthermore, their reports do not reflect the taking of a thorough and complete medical history, nor a scrupulous documentation of the manner and timing of the acquisition of the hearing loss in relation to their work history and noise exposure. There is an abundance of individuals, both men and women, seen daily in otologic practices who have acquired sensorineural hearing loss (SNHL), with the principle loss in the same frequency range affected by noise exposure, yet these persons do not have a history of noise exposure. When such SNHL occurs in a person who has been exposed to noise in the work place, making the distinction between NIHL and non-noise-induced SNHL is a major, exhaustive diagnostic challenge. Nevertheless, this is the responsibility of the otologist and, if not thoroughly attempted, many non-noise-induced SNHL cases will be allowed to pass as NIHL at a tremendous, needless cost to industry and to society.
By no means do I negate the harmful potential of noise exposure, and the need for hearing conservation in the work place. Neither would I minimize the right to proper compensation of workers who have experienced NIHL. As a profession we need to emphasize the need for documentation of hearing of all persons by periodic serial audiograms throughout life. Every high school graduate should possess at least a current pure-tone audiogram documenting hearing status at that time. Periodic audiograms thereafter, at least every 5 years, should follow, and more often when circumstances warrant. This will result in the American population being more hearing conscious and attentive to hearing preservation. No longer should it be acceptable for a hearing loss to be discovered for the first time that is already in the range of 35 to 40 dB, or greater. With periodic audiograms so recorded and present in the medical records of all persons, otologists can become better informed in their diagnostic evaluation of the hearing-impaired, and can certainly more easily, and reliably, make a distinction between SNHL and NIHL. This responsibility is a first priority. Dealing with the impairment, assessing the extent of the handicap, and determining the appropriate rehabilitation, is the second pressing priority, whether the loss be SNHL or NIHL.
James T. Spencer, Jr., M.D.
Ear, Nose, and Throat Associates of Charleston, Inc.
Charleston, West Virginia
I concur with Dr. Spencer that there is a need to broaden the focus of this editorial, for it is indeed time to develop seriously better means of assessing the communication ability of all hearing-impaired patients, not just those with occupational noise-induced hearing loss (NIHL). However, better assessment is especially important in the Commonwealth of Pennsylvania because in this state the legal measure of hearing loss for workers' compensation is “loss of use for all practical intents and purposes.” Formulae to calculate hearing loss are irrelevant in Pennsylvania.
I also fully endorse Dr. Spencer's comments concerning our responsibility to evaluate thoroughly every patient suspected of having NIHL. For example, we know that presbycusis can produce an audiometric curve identical to the “typical” curve of NIHL. For the best diagnosis and most effective treatment and management, every patient deserves a complete study.
Dr. Spencer has introduced a new idea that elevates the hearing test to the level of importance it should have. If we are truly to understand the hearing capacity and the course of a hearing loss in an individual throughout the years, we need more ongoing data. His concept of universal hearing testing early in life followed by scheduled, periodic retests is one that should be ratified by organized otolaryngology, then promoted and instituted.
Dr. Spencer's observations and recommendations are thoughtful and insightful and I thank him for them. They will benefit all of us, physicians, patients, and the general population.
Sidney N. Busis, M.D., F.A.C.S.,
Oakland Otological Association,