Hearing Test Administered Over the Phone

I was just made aware of this service in a Washington Post article published May 16, 2014. This screening hearing test is taken over the telephone and accomplished by listening to three-digit sequences presented in a background of white noise. The test-taker has to then enter the digits using the telephone keypad. Based on accuracy of the response, the test than adjusts the next query.

Normally, the cost to take this telephone hearing test is $8, but at least for the month of May 2014, it is free in celebration of "Better Hearing and Speech Month."

Here's how to take the test by phone:

1. Find a quiet place to take the test that is free from distractions. 
2. If you hang up in the middle of your test, you will have to start from the beginning. 
3. Use a telephone that plugs into a wall-mounted jack. Please do not use a cell phone. 
4. Dial our toll-free number: 1-866-223-7575 
5. Listen to the recorded instructions. 
6. At the end of the test, write down your test results for each ear and the date. The categories are: 

Within the Normal Range

Slightly Below the Normal Range

Poor

Further details of this test can be found here, but the test essentially is based on the speech-to-noise ratio (SNR) that is adjusted using an adaptive procedure seeking a threshold for 50% correct identification of the digit sequences. A set of 25 sequences provides a reliable SNR threshold in about four minutes of testing per ear. This method of testing is different from most hearing tests in that it uses digits in static noise, rather than pure tones. Because the test measures an SNR threshold rather than one based on the absolute level of tones, a reliable screening measure of hearing, despite the differences in sound levels produced by different telephones, can be achieved.

Of note, this method of testing was validated in Europe by scientists at VU University Medical Center in the Netherlands in 2004. The U.S. version began in 2008 with funding from the National Institute of Health and was validated in two studies performed at the Indiana University Hearing Clinic and the other in collaboration with clinics administered by the VA Health System.

If hearing is assessed to be abnormal, you can contact our office to undergo a more sophisticated hearing test for confirmation and next steps.

Source: 
Take this hearing test right now. I did, and the results were disturbing. Washington Post 5/16/14.

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Man Files $15 million Lawsuit Against NYC Citi Bike Claiming Smell Loss From Bike Crash

Image by Pharos of Wikipedia

In 2013, a man rented a bicycle from New York City's Citi Bike program. Apparently while riding this rental bike, the front wheel struck a wheelstop installed near a bicycle docking station which the man did not notice, flipping him resulting in head trauma. This head trauma resulted in permanent smell and taste loss. [link]

The wheelstop is meant to prevent cars from from backing into bike stations, but the lawsuit alleges "no cones or colored warnings to alert a bicyclist of its existence... constituted a trap for the unwary."

Regardless of the legal merits of the case, how does head trauma like this cause smell and taste loss?

The smell nerve is located right between the eyes and is analogous to the roots of a plant where the plant is the nerve next to the brain and the roots are the nerve endings that go through the skull bone (cribiform plate) and into the nose where "smell" is detected (the yellow in pic below). With significant head trauma, the brain suddenly moves and "bounces" around in the skull when struck. When this happens, the delicate smell nerve endings which are going through the bone "tear" when the brain moves relative to the bone.

With such nerve damage, smell can be permanently lost. With complete smell loss, taste can be adversely affected given so much of flavor is attributable to smell. As such, the man can technically probably still taste (salt, sweet, sour, bitter, etc), but not smell.

BTW... Did you know that the tongue taste map we all learn in school is incorrect?


Source:
Conn. man files $15 million lawsuit against NYC, Citi Bike, claiming nerve damage from bike crash. Daily News 2/27/14

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How Ears Tune In and Out Certain Sounds

Ever wonder how humans with normal hearing are able to "hear" what one person is saying in a crowded room where many people are talking? How is it that the ear is able to tune in and out of conversations going around, especially when everybody in a room is talking equally loud?

To understand this ear "tuning" ability, one needs to first understand that the ear incorporates two "aspects" that allow for good hearing: a volume knob and an antenna. Should the volume knob not work, hearing aids boost the frequencies where hearing loss is present. However, if the antenna does not work, simply increasing the volume does not necessarily make sounds/speech more understandable. This situation is analogous to an old radio where turning the volume up on a station with a lot of static does not make sounds more understandable (fiddling with the antenna to get a clear signal is better).

We have a very good understanding the volume knob of the human ear. What we do NOT have a good understanding (nor how to fix) is the antenna.

However, researchers have begun to clarify how the human ear "fiddles" the antenna to make certain sounds more understandable relative to others providing humans the ability to tune into what one person is saying in a loud restaurant.

Apparently, part of the answer is the tectorial membrane found within the cochlea (membrana tectoria in the Gray's illustration below).

Note that this membrane found inside the cochlea rests on the inner and outer hair cells which allow for hearing (the volume knob). When the ear hears a sound, "waves" are created within the cochlea stimulating the hair cells which allow us to hear. Depending on which hair cells are stimulated, a specific sound frequency is heard.

Using mutant mice, MIT researchers have determined that the viscosity of tectorial membrane depends on the size and distribution of tiny pores. This viscosity provides mechanical filtering that helps to sort out specific sounds by influencing the speed and decay of tectorial membrane waves when a sound is heard.

Although the precise way how the tectorial membrane allows for such exquisite frequency selectivity is still not fully understood, this may be the first step towards that comprehension.

Because once we firmly understand how the ear's antenna works, we hopefully can make better hearing aids that not only act as a volume knob, but can also fiddle the antenna as well.

Reference:
Porosity Controls Spread of Excitation in Tectorial Membrane Traveling Waves. Biophysical Journal, Volume 106, Issue 6, 1406-1413, 18 March 2014 doi:10.1016/j.bpj.2014.02.012

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Infant Sound Machines for Sleep May Cause Hearing Loss

As a father of two young kids who still use a sound machine to help them sleep, I was quite curious about a recent paper that warned that such devices may cause permanent hearing loss. Researchers compared a total of 65 sounds produced by 14 machines and measured the maximum sound level at a distance of 30 cm (crib-rail placement), 100 cm (beside crib placement), and 200 cm (across room placement).

Why is placement important?

When it comes to risk of hearing loss due to loud noise exposure, there are three factors that come into play: 1) how loud is it; 2) how close is it; 3) how long are you exposed to it. Clearly, a person is at a higher risk for permanent hearing loss the louder a sound is, the closer the sound is, and the longer one is exposed to the loud sound.

When it comes to infant sound machines, two of the three risk factors are typically present given such machines are usually placed in or on the crib (close) and is typically played all night (duration).

Alarmingly, 3 machines produced sound levels 85+dBA which exceeds current occupational limits (if exposed for 8+ hours) for adults in the workplace which would mandate use of hearing protection. All 14 machines were capable of producing noise 50+dBA at distances of 30 and 100cm. 13 machines were capable of 50+dBA at 200 cm.

Which machines were tested? Beyond stating "procured from major online and brick-and-mortar infant-accessory stores," the machines were not identified. I wonder if the authors were fearful of lawsuits from sound machine manufacturers and as such, kept it anonymous.

Of course, one can always try contacting the ENT department at University of Toronto where this research was done and get an off-the-record answer.

Given lack of identification, the main steps a parent can take to minimize noise-induced hearing loss is to:

1) place sound machines as far away from infants as possible
2) set volume as low as possible
3) limit duration of sound machine usage


Reference:
Infant Sleep Machines and Hazardous Sound Pressure Levels. Published online March 3, 2014 (doi: 10.1542/peds.2013-3617)

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Hearing Protection and NRR (Noise Reduction Rating)

For all hearing protection devices from ear plugs to ear muffs, there is a NRR (Noise Reduction Rating) score that informs consumers how much of a decrease in noise exposure to expect with use. For example, if an ear plug has a NRR score of 30, use of the device would be expected to reduce a 90 decibel sound by 30 decibels resulting in a noise exposure of 60 decibels.

If two hearing protection devices are used, an ear plug inside the ear canal followed by ear muffs over the ear, the ultimate noise exposure would be an additional 5 to 10 decibels greater than the higher rated NRR of the two devices.

How is NRR determined anyways? This single number rating is determined by the Environmental Protection Agency as specified under 40 CFR (Code of Federal Regulations) Part 211, Product Noise Labeling, Subpart B - Hearing Protective Devices. The raw data compiled from test subjects is than plugged into a formula which than produces the NRR:

Given that, there are MANY different types of hearing protection devices on the market. Regardless of style, most devices offer a NRR between 20-30. However, as a general rule, ear plugs typically offer a higher NRR than ear muffs. Among high NRR earplugs, disposables offer higher NRR than reusables. BUT... ear muffs typically block sound more consistently than ear plugs which require some degree of molding and fit for optimal effectiveness. Using both obviously is better than using just one.

Also, keep in mind that unless hearing protection devices are correctly fit and used properly, the attenuation suggested by NRR may not over-estimated. Indeed, lay-use of such devices without training typically result in sound attenuation far below what NRR may suggest.

The highest rated NRR disposable ear plugs are around 33:


The highest rated NRR ear muffs are around 30:

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Accurate Hearing Testing Using an iPhone

There is an iPhone app called "EarTrumpet" that apparently can provide accurate hearing testing... almost as good as a professionally administered test (conventional audiometry) and certainly as good (if not better) than medical-quality automated testing machines (ie Otogram).

Created with the assistance of the ENT department at the University of California, Irvine...

According to one study, this iPhone application provided results as good as one administered by an audiologist:

• 96% of the threshold values when obtained in a sound booth
• 94% of the threshold values when testing was done in just a "quiet" room

When accuracy was defined as "within 10 dB of the corresponding threshold value obtained using conventional audiometry."

Given how accurately the iPhone application performs, it may potentially be a very helpful screening tool to evaluate patients with ear/hearing complaints. If the testing comes back normal hearing (between 0-20db at ALL frequencies), than the patient probably hears just fine.

However, if there's any hearing loss detected, it is advised to seek professional opinion because there  are weaknesses to this program and further testing WILL be necessary.

• It ONLY performs air conduction testing. Given the lack of bone conduction testing, pure nerve testing is not possible, especially when hearing loss is detected. For example, the iPhone application will not be able to test hearing loss due to earwax/fluid versus actual nerve hearing loss.
• Speech audiometry is not present. Only pure tone audiometry. Speech audiometry provides information regarding how well spoken words are understood... one can potentially "hear" a beep at a specific frequency just fine, but still mishear a spoken word which is composed of many different sound frequencies.
• As it pertains to this research study, while there was excellent agreement in masked threshold values between the iPhone app and conventional audiometry, the sample size was limited. Masking is especially important when significant asymmetric hearing loss is present.

There may also be potential bias with the research. The developer of the EarTrumpet iPhone app, Allen Foulad, is also the lead researcher of the paper. It would be worthwhile to have other independent labs reproduce and verify the findings.

However, I applaud Dr. Foulad for his work in this area as well as entrepreneurial spirit!

You can download his app here.

As a bonus, this iPhone application can also act as a personal sound amplifier. It can enhance environmental sounds via earphones attached to the iPhone.


Reference:
Automated Audiometry Using Apple iOS-Based Application Technology. Otolaryngol Head Neck Surg. 2013 Aug 20. [Epub ahead of print]

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Teens (People) Who Listen to Music Loudly... A Possible Solution

Now parents may not like this, but I do have a possible solution to getting teenagers to turn the music volume down so not to damage their hearing... Get them noise-cancelling headphones.

As an occasional audiophile myself, I understand that when listening to music with headphones, you invariably HAVE to turn the music volume up in order to hear everything clearly, especially when listening to music in noisy environments. Such environments include city sounds while walking, airplane buzz when flying, and car engine/road drone while driving.

Test this out yourself next time you drive a car. First, listen to the car radio with the engine turned off. Note the volume.

Now, see how well you hear the music from the car radio when driving on the highway.

It's the main reason why one may constantly fiddle with the volume knob while driving. It's also why people have to raise their voice in order to be heard in a loud restaurant.

For teens and other people who are audiophiles, the only solution is to turn the music volume up in order to hear the music clearly... which can damage their hearing over time.

So what to do? One can listen to music only when the environment is silent, but that's not going to happen for music-loving individuals who want to hear it all the time.

The other solution is to get a nice pair of noise-cancelling headphones.

A good pair of NC headphones significantly reduces if not eliminates the buzz, drone, white noise of the environment which is a very common cause of requiring a volume increase.

Now, not all NC headphones are created equal. Bose NC headphones are perhaps the best but are pricey at around $300.

However, cheaper brands do not noise-cancel at all or do so poorly even if they are labelled as noise-cancelling.

Generally speaking, Bose is by far the best followed by Panasonic, Sony, and AKG. You can read a Pogue's New York Times review of different noise-cancelling headphones here.

So... perhaps you can make a deal with your teen or adult loved one to turn the music volume down to protect their ears by getting them a Bose NC headphones which come in headphones and earbud models. Available for purchase on Amazon.

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What Caused Beethoven's Hearing Loss?

Image from Wikipedia

When Beethoven composed his 9th Symphony, it was an amazing accomplishment especially when considering he did so totally deaf.

It has been a medical mystery as to what caused his slowly progressive hearing loss to the point of deafness, but a recent publication suggests it was due to chronic low-level lead exposure consumed from wine tainted with lead.

FACT: High levels of lead were found deep in the bone suggesting chronic lead exposure over a long period of time.

FACT: Beethoven's physicians noted that he had alcohol dependence (profound liver damage was found on autopsy).

FACT: It is not unusual that wine in that time period was tainted with lead.

More significantly, the paper disputed the more common thought that his lead poisoning was due to taking excessive doses of lead-based medications administered by his doctor: lead was found deep in the bone indicating lead exposure over a long period of time and absence of physical exam signs/symptoms (ie, wrist drop) indicative of acute lead poisoning (lead consumed over a short period of time).

The paper also did rule out other causes of hearing loss including otosclerosis, autoimmune hearing loss, autoimmune inflammatory conditions, mercury poisoning, and syphilis.

Reference:
Lead and the deafness of Ludwig van Beethoven. Laryngoscope. 2013 May 17. doi: 10.1002/lary.24120. [Epub ahead of print]

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Can Melatonin Stop Ringing in the Ears (Tinnitus)?

In a rigorous study, researchers have found that taking melatonin 3mg nightly for 1 month did significantly help with patients suffering from chronic tinnitus (ringing in the ears).

Of course, the caveats are that melatonin significantly helped in patients with these specific characteristics:

• Male
• No history of depression
• Tinnitus has been present for a long time
• History of loud noise exposure
• Tinnitus is severe and on both sides

Given melatonin is a relatively benign supplement that can be purchased over-the-counter, it can't hurt to give it a try!

BTW... what did I mean by rigorous study above? It means that it was a prospective, randomized, double-blind, crossover clinical trial. That's pretty much as good a study as one reasonably achieve!

Reference:
Melatonin: can it stop the ringing? Ann Otol Rhinol Laryngol. 2011 Jul;120(7):433-40.

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Pop Singer Nathan Sykes Undergoes Vocal Cord Surgery

Nathan Sykes, singer for the boy band The Wanted, underwent vocal cord surgery on April 18, 2013 for a "hemorrhaged nodule" according to media reports.

Rather than a nodule, I am suspecting he actually suffered from a hemorrhagic polyp which makes more medical sense. And along with surgery... he is now on voice rest for an indefinite period of time.

This condition is the same reason Adele underwent vocal cord surgery in 2011 which mandated a several month period of voice rest leading to cancelled concerts.

Typically, a hemorrhagic polyp is treated with strict voice rest followed by extensive voice therapy prior to surgical consideration. However, this (safe) course of action takes time and as such, much more aggressive approaches can be pursued in order to recover the voice as quickly as possible.

For professional singers like Nathan Sykes and Adele, the desire to have a restored voice as soon as possible is understandable. However, there are always downsides.

To explain, a lesson in some basic anatomy first...

Normally, the vocal cords are pearly white without any vasculature. Watch a video of how this exam is performed.

However, when a blood vessel is present in the vocal cords, they may look something like this:

When there is a hemorrhagic polyp with a blood vessel as in Nathan's case (presumably), the vocal cords may have looked like this where the blue arrowhead is pointing to a hemorrhagic polyp. The green arrow is pointing towards a feeding blood vessel.

The issue with a blood vessel within the vocal cord itself is that it fluctuates in size due to phono-trauma or even hormones especially in females. When a polyp is present, the vocal changes are even more dramatic. Such fluctuation in size causes the voice to change in pitch and quality on an hour to hour basis depending on how much swelling occurs. For a singer, it makes the voice very unpredictable.

When the blood vessel becomes engorged and traumatized, it may even rupture leading to a vocal cord hemorrhage. Especially in a woman, the blood vessel may be more prone to hemorrhage during her menstrual cycle.

This is a dangerous situation for a singer because of their regular voice use and need to use it forcefully. However with too much force, the blood vessel may suddenly rupture (even in the middle of a performance) resulting in a hemorrhage into the vocal lining itself causing a sudden and complete loss of voice. There may even be mild pain associated with this occurrence.

It is unknown what exactly happened in Nathan Syke's case.

But, in Adele's case, she remembers the very moment this occurred during a radio interview when she "felt a pop" and her vocal pitch suddenly dropped into the bass range.

This makes perfect sense... To use the analogy of a violin string, the thicker the violin string the deeper the pitch. When hemorrhage occurs, the vocal cord becomes thicker due to blood pooling resulting in a deeper voice instantly.

To the right is a picture of a vocal cord hemorrhage. Note the entire vocal cord on one side (which is the patient's right side for those in the know) is brilliant red indicative of the presence of blood throughout the cord.

How is this treated?

Initially, during an acute vocal cord hemorrhage, STRICT VOICE REST is mandatory. With continued voice use, the patient risks abnormal healing that may result in the development or exacerbation of a vocal cord polyp. With repetitive cycles of healing and trauma, vocal cord scarring may even develop. Along with strict voice rest, steroids are often prescribed to help reduce the inflammatory swelling that often occurs as well as minimize risk of scarring.

Unfortunately, though such treatment may resolve the hemorrhage, it will typically not get rid of the culprit blood vessel and associated polyp.

For that, surgical intervention is required.

One option is to precisely cut out the polyp and cauterize the feeding blood vessel at the same time. This approach was the course that Adele pursued and probably what happened with Nathan Sykes as well. Watch a video on this approach (video shows a generic vocal cord mass removal, but the approach is identical).

The other option is use of a laser first to extinguish blood vessels present which may also significantly resolve the polyp followed by excision of the residual polyp at a later date. This latter approach is typically what I recommend. Why? It is relatively non-invasive and I feel the risk of scarring to be less compared with excision and vessel obliteration with a laser at the same time (though not zero). Furthermore, a smaller polyp also means a smaller wound that needs to heal.

Shown at end of this blog article is a video of a vascular polyp being obliterated using a pulsed-dye laser (courtesy of Dr. Chandra Marie-Ivey). Another type of laser that may be used is a KTP laser. Read more about laser treatment of vocal cord pathology here.

Regardless of how or in what order the surgery is performed, strict voice rest is mandatory for a period of time post-operatively. For Adele, that was strict voice rest for nearly two months (Nov and Dec 2011). Why? Because with talking or any other vocal activity, the vocal cords come together. After surgical removal of a polyp, there is a raw surface present which won't heal as well if the other vocal cord is banging against it. Talking after vocal cord surgery is analogous to jogging right after foot surgery.

The vocal cord surgical wound MUST heal prior to talking let alone singing for normal recovery. That means strict voice rest. Strict voice rest means no talking, no singing, no whispering, no mouthing words, no throat-clearing, no humming, etc.

Read more about vocal cord polyps here.

Source:
The Wanted's Nathan Sykes Taking 'Unforeseen Hiatus'. MTV News 4/17/13

The Wanted say they 'fear' for Nathan Sykes' voice. BBC News 4/29/13

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Cicadas Can Cause Permanent Hearing Loss!

Cicadas are pretty darn ugly... But beyond their ugliness and making cars look pretty messed up... the sound they make is not only irritating, but potentially harmful.

Sometime the end of this April 2013, billions of large flying insects called cicadas will make their appearance along with their characteristic stridorous noise. The male cicadas are the ones making this mating noise with "tymbal" soundmakers amplified by large resonance chambers found on body.

Occurring every 17 years, this year's swarm is known as Brood II and has not been seen since 1996. Expected to cover much of the East Coast, the buzz created by these insects can reach 90 decibels... about as loud as a jackhammer. If one is right next to your ear, the sound can reach 120 decibels are equivalent to sandblasting or a loud rock concert. [see noise chart]

At 90 decibels, possible hearing damage may occur if a human ear is exposed to this level noise for more than 8 hours a day. At 120 decibels, less than 15 minutes of exposure can induce possible permanent hearing loss.

So... keep a pair of ear plugs in your purse or pants pocket and use them if the sound starts to get too loud.... or too irritating.

Sources:
17 years in the making, this spring's cicada invasion generates early buzz. NBC News 4/10/13.

Cicada. Wikipedia

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UFC Boss Dana White Underwent Surgery for Meniere's Disease

Balance is very important in martial arts... So imagine have a condition like Meniere's Disease and being the boss of the Ultimate Fighting Championship organization.

Dana White who is the president of the UFC organization apparently has Meniere's Disease since 2011 causing  symptoms of ringing, ear fullness, fluctuating hearing loss, and spinning attacks that last for hours to days at a time. Usually, one ear is the culprit though it can occur on both sides as well.

Presumably, he already tried conservative measures without improvement and therefore underwent surgery for this condition on January 15, 2013. [link]

What is Meniere's Disease?

It is simplistically hypothesized that Meniere's Disease, also known as endolymphatic hydrops, is due to a fluid overload within the inner ear residing inside the skull (DIFFERENT location from fluid that occurs with ear infections).

When too much fluid accumulates in the inner ear, symptoms of tinnitus, ear fullness, and hearing loss occurs followed by the spinning attack. The spinning vertigo lasts until the fluid overload dissipates.

Treatment

Treatment occurs as follows (there are variations, but these are the steps overall):

Step 1: Diet Changes

Avoid all salt, caffeine, and alcohol. Salt avoidance typically means less than 1000mg of sodium per day. Caffeine avoidance is not just coffee, but also decaffeinated coffee, coke, pepsi, tea, chocolate, etc. Alcohol avoidance is pretty self explanatory.

By avoidance of these substances, it seems to substantially minimize the amount of fluid retention that occurs in the inner preventing fluid overload and the symptoms that go with it.

If symptoms persist with dietary restrictions, than...

Step 2: Diuretic Medications

In addition to dietary avoidance of salt, caffiene, and alcohol, a prescription water pill (diuretic) is added. I typically prescribe maxzide though any diuretic will do. Diuretics force the kidneys to produce more urine to be expelled from the body. If you can believe it, the inner ear also behaves like the kidney and does the same thing preventing fluid overload within the inner ear.

If step 1 and 2 do not work, than...

Step 3: Surgery

Surgical drainage of the inner ear is called endolymphatic shunt decompression (ELS surgery). This operation is what Dana White underwent. Essentially, the mastoid bone located behind the ear is completely removed and once the inner ear structure called the endolymphatic sac is reached, it is opened and a plastic-like tubing (the shunt) is placed. Risks of surgery include permanent hearing loss and facial paralysis.

Essentially, the surgery is trying to physically drain the fluid out of the inner ear rather than medications or diet adjustments which attempts to prevent fluid from building up in the first place.

Step 4: More Surgery

There are other surgical procedures that may be tried beyond step 3, but these are considered destructive procedures and have a high risk of permanent hearing loss (consider it likely to happen) as well as the possibility of making the dizziness worse. In essence, the balance system of the ear is permanently destroyed whether thru injection of a neuro-toxic drug like gentamycin into the ear itself or surgically cutting the balance nerve completely from the brain.

Source:

UFC's White hopes surgery relieves debilitating disease. USA Today 1/14/13

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Taste Changes after Tonsillectomy

Very rarely, patients will complain of taste changes after tonsillectomy. Such taste changes (aka dysgeusia) is most often described as metallic though other taste variations or absences may be reported.

Depending on what study you look at, this complaint occurs anywhere from 0.3% to as high as 9% of tonsillectomy cases. Dysgeusia after tonsillectomy is felt to be due to a number of different causes including:

1) medication side effect
2) injury to the lingual branch of the glossopharyngeal nerve
3) zinc deficiency

Regardless of the etiology, most cases of post-tonsillectomy dysgeusia spontaneously resolves within a few months without any specific intervention.

However, there are a few things a patient can try that might help accelerate normal taste recovery including:

1) Stopping all unnecessary medications
2) Zinc gluconate 50mg 3 times per day
3) Alpha Lipoic Acid 200mg 3 times per day
4) Rinsing mouth with watered down milk-of-magnesia
5) Chewing non-mint flavored gum

I did want to point out that there are no comprehensive studies to support any of these interventions. But, it certainly can't hurt to try it.

References:
Taste disturbance after tonsillectomy. Acta Otolaryngol Suppl. 2002;(546):164-72.

Taste disorders after tonsillectomy: case report and literature review. Ann Otol Rhinol Laryngol. 2005 Mar;114(3):233-6.

Posttonsillectomy taste distortion: a significant complication. Laryngoscope. 2004 Jul;114(7):1206-13.

Taste disturbance after tonsillectomy and laryngomicrosurgery. Auris Nasus Larynx. 2005 Dec;32(4):381-6. Epub 2005 Jul 19.

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Mozart May Help with Tinnitus

Currently, there is no fast, good, and cheap way of resolving tinnitus. Tinnitus is in essence hearing a ringing or buzzing that does not exist in reality. At best, it may be something you hear, but does not bother.

At worst, it can literally drive a person crazy.

Neuromonics is perhaps one of the very few treatment protocols that has been proven to work resolving/improving tinnitus in 80-90% of patients over a period of months.

However, it is expensive... typically around $6000 out-of-pocket.

In a study out of Italy, a group of patients between 22 and 78 years of age who suffered from tinnitus were told to listen to Mozart's Sonata k448for 1 hour daily for 1 month. This was followed by instruction to listen to Beethoven's Fur Elisesonata for 1 hour daily for another month.

For all the parameters investigated, there was a general significant improvement between the pre- and post-listening evaluation. Significant improvement in several parameters were seen even after a single exposure to Mozart's sonata.

So apparently listening to Mozart may not help only baby's to become smarter (debatable), but it can help adults as well.

It's also cheap... about as much as it takes to download the songs from a music store.

Some other thoughts that may require additional research...

• What if a patient hates classical music?
• Does "how" a patient listens to the music affect results? (Playing the music in background while doing some other activity versus doing nothing other than listening to the music.)
• How long does the improvement last after treatment?
• What about other songs by Mozart?

But... all in all... given it is cheap... it certainly can't hurt to give it a try.

Reference:
The Mozart effect in patients suffering from tinnitus. Acta Oto-laryngologica. Posted online on October 1, 2012. (doi:10.3109/00016489.2012.684398)

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Noise Hyper-Sensitivity in Kids

Although we mainly see kids for hearing loss due to fluid in the ears, chronic ear infections, or eustachian tube dysfunction, every so often, a child will show up with the exact opposite problem.

The child hears just fine, but suffers from noise hypersensitivity, also known as auditory hypersensitivity. Such children are overwhelmed from everyday noises whether doorbells, sirens, key clanking, etc; typically high-pitched sounds. The hands will go over the ears in an attempt to dampen the sound and may even become tearful.

This phenomenon is not uncommon in kids with developmental delays, autism, central auditory processing disorders (CAPD), Down's syndrome, etc. But "normal" kids may suffer from this condition as well.

Before going into treatment, one first needs to understand how sound is perceived first.

Human hearing is a complex listening device composed of not just the ability to "hear" the sound, but also to "comprehend" the sound. Disorders like CAPD is analogous to dyslexia where the patient can "hear" sounds perfectly normally, but has trouble understanding what they hear.

As a child develops, the auditory neural pathways in the brain that govern the comprehension of sounds are either reinforced or dampened down with time. For example, auditory neural pathways that allow for speech comprehension are reinforced whereas neural pathways perceiving background noises and other random sounds are dampened with time.

In auditory hypersensitivity, for whatever reason, the auditory neural pathways governing the perception of certain miscellaneous noise like sirens or doorbell are reinforced causing the perception of the sound to be more significant and tremendous than it should be. In a normal child without sensitivity, such pathways are suppressed.

To use an analogy, consider the auditory neural pathway like the road system in the United States. Over time, certain roads like the interstate highway is "reinforced" leading to more drivers using such streets to get from point A to point B far more quickly than if they used local roads. Problems occur if for some reason, cars avoid the highways and local roads are taken preferentially leading to traffic jams and irate drivers.

Auditory hypersensitivity is kind of like that... local roads being "reinforced" when it should be suppressed.

So what can be done to treat this frustrating condition?

In essence, therapy is geared towards reinforcing good auditory neural pathways and suppressing the bad ones that lead to noise hypersensitivity.

Such therapy programs include listening to special music and ear training exercises. One such program is "The Listening Program".

But one thing is clear... keeping someone with noise sensitivity in silence is the worst thing that can be done. It just reinforces the bad pathways!

Of course, there are other causes of noise sensitivity:

1) Migraines (children may not exhibit the classic head pain, but they still can suffer from noise sensitivity)
2) Cochlear hydrops (if associated with hearing loss, tinnitus, sound distortion)

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Stem Cells Restore Toddler's Congenital Hearing Loss

In a potentially revolutionary treatment, a two years old toddler born deaf has had her hearing restored after receiving stem cells from her banked umbilical cord blood. (Reported in ABC News)

Madeline Connor at age 1 year old was completely deaf in the right ear and had severe hearing loss on the left. Normally hearing aids or cochlear implant would have been the only options.

However, in January 2012 at the age of 2 years old, Madeline underwent a "simple" experiment whereby stem cells were infused into her damaged inner ear. The stem cells were derived from umbilical cord blood that was banked at the time of her delivery at the Memorial Hermann-Texas Medical Center.

Over the next 6 months, there has been dramatic improvement in her hearing. She is also now talking for the first time.

Madeline also is not the only child who has undergone this revolutionary stem cell treatment. Apparently, there are ten other children who are being followed after undergoing similar stem cell infusion derived from banked cord blood.

It must be stressed that though Madeline's progress is quite amazing, it is still too early to say if this is a "bona fide" treatment for congenital hearing loss.

• Will the improvement continue and more importantly, last over years to decades?
• Will it work for other children?
• What is the expected hearing improvement with stem cell infusion?
• Will it treat ALL forms of nerve-damaged hearing loss?
• Does it have to be stem cells derived from cord blood or are stem cells derived from other sources possible (i.e., skin)?
• Can adults with non-congential hearing loss also benefit?

I eagerly await the outcome of this FDA approved trial which hopefully will be published at some point in the near future.

I also eagerly await the protocol used to obtain and infuse the stem cells. I suspect the infusion of stem cells is similar to that done when steroids are infused into the ear for sudden hearing loss as shown in this video below. However, this is just a guess of mine.

Source:

Cord Blood Stem Cells Restore Toddler's Hearing. ABC News 7/11/12

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Singer Florence Welch Cancels Concerts Due to Vocal Injury

CBS news reported that Florence Welch, the lead singer for British band Florence + The Time Machine, had to cancel two upcoming concerts due to a vocal injury.

Florence Welch (@flo_tweet) herself provided most of the details in a series of tweets today:

July 11, 2012 @ 11:15AM : hello everyone, thankyou so much for all your messages of support, yes its true..it finally happened, I've lost my voice..:(

July 11, 2012 @ 11:18AM : I've sustained a vocal injury and been told i cannot sing for a week.., seriously i felt something snap, it was very frightening.

July 11, 2012 @ 11:20AM : unfortunately this means i will not be able to perform at Benicassim and Optimus alive festival this weekend..i am so so sorry..

Florence used the words "felt something snap" which is pretty classic for a vocal hemorrhage. For those who are Adele fans, something similar happened to her as well in November which mandated a prolonged period of voice rest (months) and even resulted in vocal cord surgery. (read more)

I am guessing that Florence had a blood vessel on her vocal cords that was causing minimal vocal impact. But with the "snap," the blood vessel likely ruptured causing instant vocal decompensation whereby the vocal pitch suddenly becomes much deeper and if bad enough, even complete voice loss as it appears to have happened to Florence.

Normally, the vocal cords are pearly white without any vasculature. Watch a video of how this exam is performed.

However, when a blood vessel is present in the vocal cords, they may look something like this which is what Florence's vocal cords prior to the "snap" might have looked like:

When there is a hemorrhagic polyp with a blood vessel as in Adele's case, her vocal cords may have looked like this where the blue arrowhead is pointing to a hemorrhagic polyp. The green arrow is pointing towards a feeding blood vessel.

The issue with a blood vessel within the vocal cord itself is that it fluctuates in size due to whether it is irritated from phono-trauma or even hormones. If it is small, the changes may be non-existent. If it is more pronounced, the vocal instability may be noticeable and for a singer, it may make the voice very unpredictable.

When the blood vessel becomes engorged and traumatized (singing forcefully, screaming, coughing), it may even rupture leading to a vocal cord hemorrhage. Especially in a woman, the blood vessel may be more prone to hemorrhage during her menstrual cycle (typically right before period).

This is a dangerous situation for a singer because of their regular voice use and need to use it forcefully which increases chance of vocal cord hemorrhage. Rupture (even in the middle of a performance) results in hemorrhage into the vocal lining itself causing a sudden and complete loss of voice (see picture to right). There may even be mild pain associated with this occurrence. This is the "snap" sensation Florence felt.

In Adele's case, she remembers the very moment this occurred during a radio interview when she "felt a pop" and her vocal pitch suddenly dropped into the bass range.

This makes perfect sense... To use the analogy of a violin string, the thicker the violin string the deeper the pitch. When hemorrhage occurs, the vocal cord becomes thicker due to blood pooling resulting in a deeper voice instantly. If significant hemorrhage is present, the vocal cord may not even be able to vibrate causing vocal loss.

How is this treated?

Initially, during an acute vocal cord hemorrhage, STRICT VOICE REST is mandatory. With continued voice use, the patient risks abnormal healing that may result in the development or exacerbation of a vocal cord polyp. With repetitive cycles of healing and trauma, vocal cord scarring may even develop. Along with strict voice rest, steroids are often prescribed to help reduce the inflammatory swelling that often occurs as well as minimize risk of scarring.

Unfortunately, though such treatment may resolve the hemorrhage, it will typically not get rid of the culprit blood vessel and associated polyp if present.

In Florence's case where she was told to be on strict voice rest for only one week, I suspect no polyp is present. Just hemorrhage.

If polyp is present, surgical intervention may be required.

One option is to precisely cut out the polyp and cauterize the feeding blood vessel at the same time. This approach was the course that Adele pursued. Watch a video on this approach (video shows a generic vocal cord mass removal, but the approach is identical).

The other option is use of a laser first to extinguish blood vessels present which may also significantly resolve the polyp followed by excision of the residual polyp at a later date. This latter approach is typically what I recommend. Why? It is relatively non-invasive and I feel the risk of scarring to be less compared with excision and vessel obliteration with a laser at the same time (though not zero). Furthermore, a smaller polyp also means a smaller wound that needs to heal.

Shown at end of this blog article is a video of a vascular polyp being obliterated using a pulsed-dye laser (courtesy of Dr. Chandra Marie-Ivey). Another type of laser that may be used is a KTP laser. Read more about laser treatment of vocal cord pathology here.

Regardless of how or in what order the surgery is performed, strict voice rest is mandatory for a period of time post-operatively. For Adele, that was strict voice rest for nearly two months (Nov and Dec 2011). Why? Because with talking or any other vocal activity, the vocal cords come together. After surgical removal of a polyp, there is a raw surface present which won't heal as well if the other vocal cord is banging against it. Talking after vocal cord surgery is analogous to jogging right after foot surgery.

Source:
Florence Welch told not to perform "to avoid permanent damage" to voice.  CBS News 7/11/12

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R&B Singer Maxwell with Vocal Cord Hemorrhage

At least that's what the Washington Post reported on June 22, 2012. This has resulted in cancellation of his summer tour.

Per media reports, his vocal cords are swollen with hemorrhage.

Some fans may recall that something similar happened to Adele in winter of 2011 which resulted in her also canceling a number of engagements. She ultimately had surgery to correct her problem.

Normally, the vocal cords are pearly white without any vasculature. Watch a video of how this exam is performed.

However, when a blood vessel is present in the vocal cords, they may look something like this:

The issue with a blood vessel within the vocal cord itself is that it fluctuates in size due to whether it is irritated from phono-trauma or even hormones. Such fluctuation in size causes the voice to change in pitch and quality on an hour to hour basis depending on how much swelling occurs. For a singer, it makes the voice unpredictable.

When the blood vessel becomes engorged and traumatized, it may even rupture leading to a vocal cord hemorrhage. Especially in a woman, the blood vessel may be more prone to hemorrhage during her menstrual cycle.

This is a dangerous situation for a singer because of their regular voice use and need to use it forcefully. However with too much force, the blood vessel may suddenly rupture (even in the middle of a performance) resulting in a hemorrhage into the vocal lining itself causing a sudden and complete loss of voice. If a voice is present, it is much deeper than normal due to the additional "weight" of blood and edema (just like a violin string where the thicker the string, the deeper the pitch). There may even be mild pain associated with this occurrence.

To the right is a picture of a vocal cord hemorrhage. Note the entire vocal cord on one side (which is the patient's right side for those in the know) is brilliant red indicative of the presence of blood throughout the cord.

How is this treated?

Initially during an acute vocal cord hemorrhage, STRICT VOICE REST is mandatory. With continued voice use, the patient risks abnormal healing that may result in a vocal cord polyp or vocal cord scarring. Along with strict voice rest, steroids are often prescribed to help reduce the inflammatory swelling that often occurs as well as minimize risk of scarring.

Unfortunately, though such treatment may resolve the hemorrhage, it will typically not get rid of the culprit blood vessel.

For that, surgical intervention is required.

Such surgical intervention is much like trying to get rid of varicose veins in the leg.

One option is to precisely cut it out. Watch a video on this approach (video shows a vocal cord mass removal, but just pretend the mass is a blood vessel as the approach is identical).

The other option is use of a laser which is typically what I recommend. Why? It is relatively non-invasive and I feel the risk of scarring to be less compared with excision (though not zero). Shown below is a video of a vascular polyp being obliterated using a pulsed-dye laser (courtesy of Dr. Chandra Marie-Ivey). Another type of laser that may be used is a KTP laser.

Read more about laser treatment of vocal cord pathology here.

Read the Washington Post story here.

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