In the wake of the Boston Marathon bombings, healthcare professionals at area hospitals are diagnosing familiar types of hearing losses in an unfamiliar and remarkable patient population.
“It's not something that you normally would see in the practice I have, which is all elective surgery and patients who have conditions that are not caused by trauma in general, and I've never worked in the military, so it's definitely a new experience for many of us,” said Daniel J. Lee, MD, an ear surgeon at Brigham and Women's Hospital (BWH). “It's been a privilege to care for these wonderful patients.”
BWH has seen about a dozen patients with hearing-related symptoms from the blasts, Dr. Lee said.
“For example, I saw a lovely woman in her 30s who was within maybe two or three feet of the second bombing, and she lost her left-lower extremity, I think. Then, when she was stabilized from her soft-tissue injuries, she was told that there were concerns about her right ear, and it turns out that she has an eardrum perforation on that side and a mixed hearing loss.
“It can be very challenging for these patients—who are already in complete shock and experiencing some post-traumatic stress disorder features, who are young and active and vibrant people—not only to be told, you need your leg rehabilitated, but your hearing also may need some surgical care as well.
“I've been very moved by the strength and the courage that these patients exhibited in the office with me. In every case that I saw a patient with significant soft-tissue injuries, it was, ‘I'm going to get back on my feet; I'm going to get back to work; I'm going to run again; I'm going to dance again.’ I was most impressed by the attitudes I saw uniformly from family members as well as from patients. It was humbling to see.”
MILD CONDUCTIVE HEARING LOSS
Among the patients who were close to the blasts, the most common ear injuries have been tympanic membrane perforations and mild conductive hearing loss, Dr. Lee said.
“We've had a few patients with a mild sensorineural hearing loss in the ear that was closer to the blast. Then there are a few patients who had more of a moderate conductive hearing loss, and those patients had much more extensive tympanic membrane perforations.”
In most cases, the hearing loss is thought to be temporary, he added.
“The vast majority of these patients will have a hearing loss that should recover fully or nearly fully with time. In the patients who've been able to come to the otology clinic, we have attempted to unfurl the skin edge. The skin edge is essentially imploded toward the middle ear, and we want to try to unfurl that skin edge so that the skin doesn't grow in the wrong direction, and then we place a small cigarette paper patch to try to promote healing across the perforation.
“It's important to know that these patients may be at risk long-term of developing a cholesteatoma if the skin happens to grow in the wrong direction, so they need to be monitored at some point in the future. The risk is very low but something that we think about in a traumatic ear situation.
“In some cases where there's a sensorineural component to the hearing loss, we have been giving oral steroids. In the military, they routinely give high doses of steroids to treat blast injury patients from the field—to treat their ear as well as treat their other associated intracranial head injury-type events—and there's been some talk about whether this use of steroids is going to affect soft-tissue wound healing because some of these patients have shrapnel injuries, for example.
“A short term of pulse steroids is not going to hurt the healing process. The hair cells have a very short half-life. They don't grow back, so, if they're injured, that's it. We have a very short window of opportunity to try to treat them with steroids. With one acoustic exposure, hearing loss is not felt to then progress over time, but that certainly has been seen in some cases in which there's been a significant sensorineural loss with the blast injury.”
At Tufts Medical Center, where eight patients from the bombings were seen for acoustic trauma, improvements in hearing were observed from one day to the next, said Audrey Winans, AuD, an audiologist there.
“The marathon blasts happened on a Monday, and the patients reported a significant decline in hearing and tinnitus. By Tuesday, all the patients I saw said their hearing had gotten better and the tinnitus had decreased or resolved, so there was a big shift.”
The hearing losses themselves were mild to moderate in severity, she added.
“There are a lot of unilateral noise notches, and they occur at different frequencies—3, 4, 6. They look like what you'd see in someone who's really big into recreational firearm use; they kind of have that same asymmetry.”
INNER EAR DAMAGE
For Massachusetts Eye and Ear Infirmary providers, who have seen at least 20 patients with audiological symptoms from the blasts, either at Mass. Eye and Ear or in consultation with Massachusetts General Hospital, the balance of ear injury type is shifting, said Alicia M. Quesnel, MD, an otologist/neurotologist at Mass. Eye and Ear and instructor in otology and laryngology at Harvard Medical School.
“Certainly the conductive hearing loss problems with holes in the eardrum were what we were seeing early on because I think we were tending to see the patients who were unfortunately closer to the bombings and closer to the blasts, so they tended to suffer those types of injuries, and sometimes in combination with sensorineural hearing loss. At this point, we're seeing more patients with some more mild sensorineural hearing loss or mild signs of damage to the inner ear.”
A lot of these hearing loss cases likely will get better without treatment, Dr. Quesnel said.
“Many of the injuries to the outer ear canal or to the eardrum will heal on their own; they just require a little care to be sure that there aren't any infections that develop in the ensuing weeks. If they don't heal on their own, then they could be fixed with a surgical procedure to reconstruct the eardrum, and those would not be expected to be permanent hearing losses.
“For injuries to the inner ear in which there's been sensorineural hearing loss, those can resolve on their own, sometimes within seconds, minutes, hours, or days. But when a sensorineural hearing loss persists for more than a couple of days to a week, it's likely to be permanent.”
Providers expect the flow of patients to the hearing healthcare clinics for blast-related symptoms to continue.
“At this point patients have realized that either the hearing loss they suffered hasn't gone away and they want to be evaluated, or they're just at a point in time when they can deal with getting care for their ears,” Dr. Quesnel said.
Dr. Lee reported a similar experience.
“We're already getting referrals to see patients who were perhaps 20, 30, 40 feet away from the blasts but close enough to have been exposed to a significant sound stimulus who have tinnitus and a sense of slightly decreased hearing, and they want to come in and get an audiogram,” he said.
Selena E. Heman-Ackah, MD, MBA, medical director of otology, neurotology, and audiology at Beth Israel Deaconess Medical Center, recommended hearing screening for those who think they may have symptoms and anyone within 100 feet of the blasts.
“Here at Beth Israel, they've done an excellent job of tracking all the patients who came to the hospital from the blasts on that Monday, whether they were seen and admitted to the hospital or seen in the emergency department briefly, and made sure that all those patients either have or will come in for a hearing evaluation.” The institution saw 20 or 25 patients with ear injuries from the bombings, she said.
Dr. Lee, Dr. Quesnel, and Aaron Remenschneider, MD, plan to continue to follow patients injured from the blasts in a formal way. They got IRB approval from Mass. Eye and Ear to conduct a study, which the researchers hope to expand to all area hospitals that saw these patients, Dr. Lee said.
“Basically it's a clinical study to examine outcomes from the blast injury, and we'll be looking both at subjective measures such as tinnitus and hearing handicap, as well as examining to see if the eardrum healed and if the hearing has improved.”
The researchers saw a need for information on outcomes with this type of injury.
“There wasn't a lot of data that we could share with the patients,” Dr. Lee said. “This is a different sort of situation, so we wanted to do this in a way that would allow us to capture as many patients as possible and follow them long-term.”
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