Ms Shantelle Chandra Charge Audiologist Dilworth Hearing Remuera and St Heliers
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Ms Shantelle Chandra
Charge Audiologist
Dilworth Hearing
Remuera and St Heliers
11:00 - 11:55 WS #33: Hearing Issues at Any Age: When to Refer your Patients to Audiology
12:05 - 13:00 WS #42: Hearing Issues at Any Age: When to Refer your Patients to Audiology
(Repeated)
Hearing Issues At Any Age: When To Refer Your
Patients To Audiology
Rotorua GPCME 2019
Presented by
SHANTELLE CHANDRA
BSc, MAud (Hons), MNZAS, CCC
Clinic Manager/Charge Audiologist
Dilworth Hearing Remuera & St Heliers
©Dilworth Hearing 2019
ABOUT
US
©Dilworth Hearing 2019
ABOUT US.
Dilworth Hearing.
• Over 50 years experience, established in
1960
• Focus is on high quality, client-centered
hearing care offering a complete range
of hearing services to the community
• Complete hearing care for the whole
family
• Southern Cross Healthcare Affiliated
©Dilworth Hearing 2019
OUR
SERVICES
©Dilworth Hearing 2019
ABOUT US.
Hearing Services.
• Hearing tests for all ages
• Hearing aid fitting & adjustments – we are not
owned by a manufacturer we fit what is best
for the patient
• Assistive devices
• Cochlear Implants
• Tinnitus assessment and management
• Auditory Processing assessments
• Hearing / ear protection
• Ear wax removal
©Dilworth Hearing 2019
Typical presentation- ARHL
Patients with hearing loss may report/present
with:
Regular requests for repetition.
Conversations carried out in a raised voice.
Complaints that others mumble.
Cannot hear in background noise
Social isolation/withdrawal and/or depression.
Tinnitus and/or hyperacusis.
Sensation of blocked ears.
Self reported change/deterioration in hearing.
©Dilworth Hearing 2019
Suspect hearing loss? What to do
next.
• Arrange a full diagnostic hearing test.
• During this test tonal hearing (air and bone
conduction), speech discrimination ability
and middle ear function will be assessed.
©Dilworth Hearing 2019
Funding for hearing aids
• There are several avenues for funding of
hearing aids in NZ
• -ACC
• -Veterans Affairs
• -Enable
• -WINZ
• -Hearing Aid Bank
©Dilworth Hearing 2019
Dilworth Need To Hear.
• Dilworth has committed to fitting up to 5 patients a month through our Need To Hear program with
a pair of Starter hearing aids, for the cost of the Hearing Aid Subsidy.
• Eligibility criteria:
– Must eligible for the MoH Hearing Aid Subsidy.
– Be in genuine financial hardship where they are not able to afford even our $495 Starter hearing
aids.
• All other funding options (including ACC) will be discussed with patients to ensure they are
receiving the best solution for their needs.
©Dilworth Hearing 2019Dilworth Need To Hear.
• Referrals can be made via our GP learning platform at www.dilworthaudiology.co.nz.
• Navigate to the Course Library where you can access the Need to Hear Referrals section.
©Dilworth Hearing 2019Evidence linking hearing loss and dementia.
• Research has identified hearing loss to be independently associated to incident all-cause
dementia. [1]
Study:
• Prospective, longitudinal study of 699 adults.
• Main outcome measure: all-cause dementia and Alzheimer's Disease.
Key finding:
• Risk of incident all-cause dementia increases with severity of baseline hearing loss.
[1] Lin FR, Metter EJ, O’Brien RJ, Resnick SM, Zonderman AB, Ferrucci L. Hearing Loss and ©Dilworth Hearing 2019
Incident Dementia. Arch Neurol. 2011;68(2):214–220• A further study was conducted which
indicated that hearing loss is independently
associated with accelerated cognitive
decline. [2]
Study:
• Prospective, longitudinal study of 1,984 older
adults.
• Hearing defined at baseline and cognition
measured using the 3MS and Digit Symbol
Substitution tests.
Key finding:
• The 3MS and Digit Symbol Substitution
scores of individuals with hearing loss
indicated greater rates of cognitive decline
compared to those with a normal hearing
baseline.
[2] Lin FR, Yaffe K, Xia J, et al. Hearing Loss and Cognitive Decline in Older Adults. JAMA Intern ©Dilworth Hearing 2019
Med.2013;173(4):293–299In December 2017, The Lancet Commission on
Dementia, Intervention and Care identified
hearing loss as a key modifiable risk factor for
dementia, based on a systematic review of the
available literature. [3]
Mechanisms for this increased risk are
hypothesised to be:
• Social isolation and/or depression. [4]
• Additional cognitive load. [5]
• Accelerated atrophy. [6]
[3] Livingston, Gill, et al. "Dementia prevention, intervention, and care." The Lancet 390.10113 (2017): 2673-2734.
[4] Gopinath, Bamini, et al. "Depressive symptoms in older adults with hearing impairments: the Blue Mountains Study." Journal of the American Geriatrics Society 57.7 (2009): 1306-1308.
[5] McCoy, S. L., Tun, P. A., Cox, L. C., Colangelo, M., Stewart, R. A., & Wingfield, A. (2005). Hearing loss and perceptual
©Dilwortheffort:
HearingDownstream
2019 effects on older adults’ memory for speech. The
Quarterly Journal of Experimental Psychology Section A, 58(1), 22-33.
[6] Lin, Frank R., and Marilyn Albert. "Hearing loss and dementia–who is listening?." (2014): 671-673.Do Hearing Aids prevent cognitive
decline due to hearing loss?
• Robust, longitudinal studies investigating this
are not currently available.
• But, hearing aids have been shown to
improve risk factors which contribute to
cognitive decline:
– Social isolation and depression
– Cognitive load
• “Management of hearing loss” included as a
preventative strategy in the report. [3]
[3] Livingston, Gill, et al. "Dementia prevention, intervention, and care." The Lancet 390.10113 (2017): 2673-
2734. ©Dilworth Hearing 2019Hearing loss in children
• A hearing loss of any degree or time frame
could potentially hinder the child’s ability to
develop adequate speech and language,
impact on the child’s academic competencies,
as well as social interactions.
• Therefore it is critical for a hearing loss to be
diagnosed as quickly and as accurately as
possible.
• This can be difficult, in light of the fact that
many children are unable to give a subjective
feedback of their hearing.
©Dilworth Hearing 2019• Most permanent congenital hearing losses
are picked up by:
– New Born Hearing Screening
Programme.
– B4School Hearing Check (VHT).
• Infants born with potential risk factors are
monitored by the local DHB.
• Dilworth Hearing is one of the few private
clinics which have equipment to do
paediatric testing and provide habilitation
(hearing aids).
©Dilworth Hearing 2019Delayed onset/progressive hearing
loss in children
• It has long been recognised that some
children have a progressive or late onset
hearing loss.
• Starship Study: Bilateral hearing loss is found
in 0.08% of newborns and children whose
hearing loss progresses or onset is delayed
account for 4 to 30% of all paediatric hearing
impairment. Some infants have no risk
factors for hearing loss
©Dilworth Hearing 2019Genetic causes of late onset hearing loss
• Syndromes associated with hearing loss or progressive or delayed-onset hearing loss,
• Neurofibromatosis
• Osteopetrosis
• Usher syndrome
• Waardenburg syndrome
• Alport syndrome
• Pendred syndrome
• Lange-Nielson syndrome
• Non-syndromic losses include:
• Dominant-progressive hearing loss
• Family history of late-occurring hearing loss
• Connexin 26, which may have late-onset hearing loss in rare occurrences. A small number of
studies have shown progressive hearing loss with Connexin 26
©Dilworth Hearing 2019Other causes of late onset hearing loss in children
• Acquired
• congenital CMV
• Viral or bacterial meningitis
• Mumps
• Head trauma with skull fracture is one type of traumatic late-onset loss.
• Chemotherapeutic agents containing platinum, such as cisplatin, are among the best
known ototoxic medications.
• Structural: Structural causes of late-onset hearing loss may occur with a number of syndromes.
Structural deformities of the cochlea such as LVA and Mondini malformation are congenital but not
always related to a specific syndrome. Cochlear malformations affect hearing differently in different
children. Some hearing losses may occur earlier and others may not present until later childhood.
Structural malformations of the inner ear are associated with sudden and extreme progression and
fluctuation of hearing.
©Dilworth Hearing 2019Otitis Media
• Otitis media is an inflammation in the middle ear (the area behind the eardrum) that is usually
associated with the build-up of fluid. The fluid may or may not be infected.
• Can range from being acute to extreme are repeated bouts with infection, thick "glue-like"
fluid and possible complications such as permanent hearing loss.
• Fluctuating conductive hearing loss nearly always occurs with all types of otitis media. In fact it is
the most common cause of hearing loss in young children.
• Acute Otitis Media may result in: severe ear pain, fever, grumpiness/misery and night waking.
Rarely, a child may have few symptoms even with very inflamed ears.
• Glue ear may have few symptoms. There is usually no fever or ear pain. There is usually hearing
loss.
• The hearing loss can be enough to delay speech and language development for many
years. This may have implications for effective learning at preschool and school.
©Dilworth Hearing 2019When to Refer?
• Speech-language delays
• If a child fails their B4School Hearing Check.
• If a child has persisting ear infections and may need grommets.
• If there are concerns regarding academic progress pertaining to reading/writing/spelling and/or
behavioural/learning concerns.
• General concerns regarding a child’s hearing, especially if they have not been seen via the NBHS
or B4School Hearing Check.
• Before you refer, please check for potential wax occlusion, as this will affect hearing test results.
Our Ear Nurse is unable to service children under the age of 12 years.
©Dilworth Hearing 2019Hearing Test.
• Testing is based on one of three age groups:
– 6 months ~ 2.5 years.
– 3 years ~ 4.5 years.
– 5 years ~ 15 years.
• Ages are developmental age and are
corrected for other conditions (e.g. premature
birth, developmental delay).
• Relies heavily on cross-check principles with
a mixture of both objective and subjective
testing of auditory acuity.
©Dilworth Hearing 2019Outcomes.
• Hearing Loss.
– Conductive temporary.
– Conductive permanent.
– Sensorineural.
– Severe-to Profound sensorineural.
• Auditory Neuropathy Spectrum Disorder.
– Refer to DHB for ABR Assessment.
• Auditory Processing Disorder.
– Minimum age of diagnosis is 7 years.
©Dilworth Hearing 2019Habilitation.
• If diagnosed with a permanent congenital hearing loss, funding for habilitation are given to all
children via the Ministry of Health.
• Habilitation can include one or more of the following:
– Amplification (These can also be used in conjunction with a Remote Microphone Hearing Aid
system.)
• Conventional Hearing Aids.
• Bone Anchored Hearing Aids.
• Cochlear Implants.
– New Zealand Sign Language.
– Speech and Language Therapy.
©Dilworth Hearing 2019Auditory Processing Disorder.
Auditory Processing Disorder
(APD).
• “APD is a hearing disorder that results from
atypical processing of auditory information in
the brain.
• APD is characterised by persistent limitations
in the performance of auditory activities and
has significant consequences for
participation.” [7]
• It does not solely result from a deficit in
general attention, language or other cognitive
processes.
[7] New Zealand Guidelines on Auditory Processing Disorder (Draft, April 2017), ©Dilworth Hearing 2019
Ministry of Education, Ministry of Health and NZASAuditory Processing Disorder.
APD in Adults.
• Adults with undiagnosed APD in childhood.
• Stroke [8] – may present with or without
hearing loss.
• Hearing loss
– As a result of poor signal processing in
sensorineural hearing loss.
• Traumatic brain injury
– Commonly reported result in auditory
processing disorder if it affects central auditory
centres but it has been difficult to find peer
reviewed literature on this.
[8] Koohi, N., Vickers, D. A., Lakshmanan, R., Chandrashekar, H., Werring, D. J., Warren, J. D., & Bamiou, D. E.
(2017). Hearing characteristics of stroke patients: prevalence and characteristics of hearing impairment and
©Dilworth Hearing 2019
auditory processing disorders in stroke patients. Journal of the American Academy of Audiology, 28(6), 491-
505.Auditory Processing Disorder.
APD in Children.
• Estimated to affect 6.2% of children in NZ. [9]
• Chronic OME may predispose children to
APD. [10]
• Children with APD have more psychosocial
difficulties. [11]
– Children reported greater emotional and
overall health difficulties.
– Parents reported that their children
experienced greater psychosocial
difficulties.
• Parents can be worried and needing support.
[9] Esplin & Wright (2014). Auditory Processing Disorder: New Zealand Review. http://www.health.govt.nz/publication/auditory-
processing-disorder-new-zealand-review
[10] Moore, David R., Douglas EH Hartley, and Sarah CM Hogan. "Effects of otitis media with effusion (OME) on central auditory
©Dilworth Hearing 2019
function." International journal of pediatric otorhinolaryngology67 (2003): S63-S67.
[11] Kreisman, N. V., John, A. B., Kreisman, B. M., Hall, J. W., & Crandell, C. C. (2012). Psychosocial status of children with auditory
processing disorder. Journal of the American Academy of Audiology, 23(3), 222-233. doi:10.3766/jaaa.23.3.8Auditory Processing Disorder.
Signs of APD.
Difficulty in the following areas:
• Understanding and remembering complex
verbal information or instructions.
• Listening to speech in noisy settings.
• Processing and remembering spoken
information.
• Learning language, spelling, vocabulary,
reading or writing.
©Dilworth Hearing 2019Auditory Processing Disorder.
ODD
APD Comorbidities. ADHD SID
• APD often occurs in conjunction with other Specific
Depression Learning
disorders, with particular overlap with: Difficulties
– Dyslexia
– Attention Deficit Disorder/Attention Auditory Autistic
Deficit Hyperactivity Disorder ADD Processing Spectrum
Disorder
– Language Impairment Difficulties
– Reading Disorder
• 94% of children in a University of Auckland Gifted Anxiety
study with APD also had language
impairment and/or reading disorder. [12] Developmental
Coordination Tourette’s
Disorder OCD
[12] Sharma, M., Purdy, S. C., & Kelly, A. S. (2009). Comorbidity of auditory processing, language, and reading
disorders. Journal of Speech, Language, and Hearing Research, 52(3), 706-722. ©Dilworth Hearing 2019Auditory Processing Disorder.
APD Assessment.
• Test battery approach involves:
– History.
– Questionnaires.
– Full diagnostic audiogram and OAEs.
– Range of APD tests in key areas of auditory processing:
• Binaural processing
• Temporal processing
• Speech in noise processing
• Auditory memory
©Dilworth Hearing 2019Auditory Processing Disorder.
Availability of APD Testing.
• An APD assessment is specialised and the testing takes approximately two hours.
– Dilworth Hearing, we can provide the initial diagnostic hearing test as well as APD Testing.
– Soundskills (Remuera): requires a recent diagnostic hearing test showing normal peripheral
hearing with the referral.
– Auckland DHB: unfortunately not available at Waitemata DHB.
– University of Auckland: unfortunately not able to accept new referrals for APD at this stage.
©Dilworth Hearing 2019Auditory Processing Disorder.
APD Management.
• Diagnosis provided by audiologist.
• Collaborative, family-centred approach recommended with appropriate engagement with:
– Speech and Language Therapists
– Psychologists
– Optometrists
– Schools and teachers
– Parents/caregivers
©Dilworth Hearing 2019Auditory Processing Disorder.
APD Management.
• Remote microphone hearing aids [13]:
– Aids listening in background noise.
– Funding may be available through
MoH, MoE or ACC.
• Improve listening skills:
– Learning a musical instrument. [14]
– Evidence-based auditory training
protocols e.g. Sound Storm, clear.
[13]Julien Zanin & Gary Rance (2016) Functional hearing in the classroom: assistive listening devices for
students with hearing impairment in a mainstream school setting, International Journal of Audiology,
55:12, 723-729 ©Dilworth Hearing 2019
[14] Tichko, Parker, and Erika Skoe. "Musical Experience, Sensorineural Auditory Processing, and Reading
Subskills in Adults." Brain sciences 8.5 (2018).Auditory Processing Disorder.
APD Management.
• Classroom/listening strategies:
– Preferential seating
– Reduce distractions
– Visual aids
– Check comprehension
©Dilworth Hearing 2019What is SSHL
SSHL or sudden deafness is the loss of hearing which occurs suddenly or over a few days (72 hours).
It usually affects one ear although can in 5-10% of cases affect both ears.
This rapid loss involves the inner ear or nerve of hearing.
SSHL can occur at any time and at any age.
It should be considered a MEDICAL EMERGENCY requiring immediate recognition and attention.
©Dilworth Hearing 2019Typical presentation of SSHL
• Loss of hearing in one ear
• Commonly patients report voices sound
muffled on that side compared to the
unaffected side, or they suddenly cannot hear
the telephone on one side
• Sounds seem to echo or be distorted on one
side
• Sudden tinnitus in one ear
• Pressure or blocked feeling in one ear
• A loss of balance or vertigo
©Dilworth Hearing 2019Prompt Diagnosis do not wait!
Step one: A history and careful physical
examination are important to rule out more
severe pathologies such as vascular events and
malignant diseases. loss or conductive hearing
loss.
Step two: An urgent full diagnostic hearing
assessment is essential for a definitive diagnosis
(ideally within 24 hours).
Step three: An urgent referral to Otolaryngology
(ORL) for imaging is required. Regardless of
whether the hearing returns, imaging is
recommended to exclude a CPA lesion (mostly a
vestibular schwannoma).
©Dilworth Hearing 2019What might you see on a diagnostic audiogram?
This patient has partial hearing loss in both
ears, much worse in the left ear where the This patient has total loss (dead ear) in their left ear,
overlay of sudden loss has occurred. accompanied by no useful hearing for speech
©Dilworth Hearing 2019Treatment
TREAT AS SOON AS POSSIBLE!
It is important to start active treatment as soon as possible. The acute phase is within three weeks of
the initial symptoms. After three weeks the opportunity to treat SSHL is greatly reduced.
Patients should be treated with a short course of oral high dose steroids (prednisone) if no
contraindications exist.
Relative contraindications to systemic steroid use include breast feeding, Cushing’s syndrome,
diverticulitis, peptic ulcer disease and bleeding ulcers, diabetes, heart failure, myasthenia gravis,
osteoporosis, psychosis, renal disease, and ulcerative colitis.
©Dilworth Hearing 2019Dosage
Call local hospital ORL registrar to confirm dosage,
however current accepted regimen is:
©Dilworth Hearing 2019Recovery
Around 50% of patients will recover completely within the first two weeks following onset.
Re-assess hearing with a follow-up full diagnostic hearing assessment following completion of the
medication.
If there is no improvement the ORL Specialist may consider intratympanic steroid infiltration for
salvage therapy e.g. dexamethasone-3 doses 7 days apart.
Post treatment hearing tests are important to document recovery as well as to discuss rehabilitation
options if needed.
©Dilworth Hearing 2019Stroke
• Strokes may disturb all levels of the auditory pathway and lead to hearing deficits that start acutely
before, during, or shortly after the stroke.
• Depending on the area that was damaged during the stroke, a patient may experience different
types of hearing loss.
• Unfortunately, health care providers do not routinely assess hearing loss after a stroke, perhaps
because of its “invisible” nature. Furthermore, the patient may not even be aware of their hearing
loss at the time of the stroke due to other severe symptoms.
©Dilworth Hearing 2019March 2019
2018
April 2019
©Dilworth Hearing 2019Chemotherapy & high dose antibiotics
• Platinum-based anticancer drugs and the aminoglycoside antibiotics are of critical clinical
importance.
• Both drugs cause sensorineural hearing loss in patients, a side effect that can be reproduced in
experimental animals.
• Hearing loss is reflected primarily in damage to outer hair cells, beginning in the basal turn of the
cochlea
©Dilworth Hearing 2019©Dilworth Hearing 2019
©Dilworth Hearing 2019
Noise-induced Hearing Loss
Noise-induced hearing loss.
• Noise-induced hearing loss (NIHL) occurs when there is excessive exposure to loud sounds.
• Over-stimulation of hearing cells lead to cell damage or death and/or hearing nerve damage.
• NIHL can be: 1) sudden hearing loss from a single intense noise incident, or 2) gradual hearing loss
over time from repeated noise exposure.
• Hearing loss is sensorineural.
– Can be temporary (typically initial 16-48 hours)
– Repeated or extremely loud noise incidents
will result in permanent hearing loss.
©Dilworth Hearing 2019Noise-induced Hearing Loss
Signs of noise-induced hearing loss.
• On the audiogram, NIHL is typically in the high
pitches (typically 4000 Hz notch) but can also
broaden to affect other pitches.
• This means a loss of audibility with consonant
speech sounds, e.g. “f”, “k”, leading to comments
such as “people mumble” or difficulties hearing
speech in background noise.
• Often causes high pitched tinnitus.
• Can also be linked to sensitivity to loud sounds.
©Dilworth Hearing 2019Noise-induced Hearing Loss
NIHL – ACC Funding.
• If the hearing loss is due to excessive noise exposure in the work place in NZ (and also for head /
ear injury or treatment injury), you as the GP can initiate a claim to ACC for your patients (ACC 45).
• If accepted, about $3000-5000 towards hearing device costs and fitting fees.
• Subsidised appointments, repairs, ear wax removal, and batteries provided.
• Must see a MNZAS audiologist to access funding.
©Dilworth Hearing 2019Noise-induced Hearing Loss
Summary of NIHL ACC process.
1) Initiate ACC 45 NIHL Claim with GP.
2) Completes ACC questionnaire.
3) Diagnostic hearing test with Dilworth –
funded by ACC.
4) ENT Consultation – funded by ACC.
5) Decision regarding claim mailed to patient.
©Dilworth Hearing 2019Noise-induced Hearing Loss NIHL – ACC Funding. • Patients must have >6% hearing loss which is attributed to the noise/injury. • Age-correction factor increases every year, which can sometimes render their net hearing loss to
Noise-induced Hearing Loss
NIHL – Veterans Affair Funding.
• Veterans Affair eligibility:
served in New Zealand Armed Services prior to 1974, or in approved operations after 1974.
• The Veteran initiates a hearing loss claim with Veterans Affair directly and books in for a diagnostic
hearing assessment.
• VA will cover the cost of basic hearing aids. In special cases, audiologist can apply for over scale
funding.
• Veteran Affairs fully covers the veteran’s appointment costs and an allowance is given for
purchasing batteries. Pay for repairs.
• Must be seen by an MNZAS Audiologist.
©Dilworth Hearing 2019Other ACC claims to consider- exposure to solvents
• Industrial hearing loss has generally been associated with noise exposure, but there is a growing
awareness that industrial solvents can have an adverse effect on the auditory and vestibular
system
• Solvents like toluene and styrene used in industrial settings, putting workers at risk for auditory side
effects.
– Toluene is most frequently used for the manufacture of paints, other chemicals, thinners,
adhesives, rubber; and in rotogravure printing and leather tanning.
– Styrene is used in industry in the production of plastics, paints, resins, synthetic rubber and
insulation.
– Xylene often found in thinners, paints and varnishes and is used as a solvent in printing, rubber
and leather industries
©Dilworth Hearing 2019Head/ear injury
• Can result in hearing loss
• Sensorineural, conductive or mixed in nature
• Patients could report:
– Tinnitus
– Hyperacusis
– Difficulty hearing in the presence of noise
Important to rule out hearing loss as a result of an head/ear accident
©Dilworth Hearing 2019Questions?
For any further queries please contact either myself of the
Dilworth Hearing Team on the following details:
SHANTELLE CHANDRA
E: shantelle.c@dilworth.co.nz
DILWORTH HEARING
E: gp@Dilworth.co.nz
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