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I don't hear well. What should I do? What should I expect?

First, visit a physician who can refer you to an otolaryngologist (an ear, nose and throat specialist), because many hearing problems can be corrected medically. If you have ear pain, drainage, excess earwax, hearing loss in only one ear, sudden or rapidly progressive hearing loss, or dizziness, it is especially important that you see an otolaryngologist, as these may be symptoms indicating a serious medical problem. After your exam, the otolaryngologist will help you obtain a hearing assessment from an audiologist (a non-physician healthcare professional). A screening test from a hearing aid dealer may not be adequate. Many otolaryngologists have an audiologist in their office to assess your ability to hear pure tone sounds and to understand words. The results of these tests will indicate the degree of hearing loss, the type of loss (conductive or sensorineural) and other medical information about your ears and health.

Conductive Hearing Loss: A hearing loss is conductive when there is a problem with the ear canal, the eardrum, and/or the three bones connected to the eardrum. This causes a mechanical (conductive) blockage, preventing the full energy of the sound from reaching your inner ear. Two common reasons for this type of hearing loss are excess wax in the ear canal or fluid behind the eardrum. Medical treatment or surgery may be available for these and other forms of conductive hearing loss.

Sensorineural Hearing Loss: A hearing loss is sensorineural when it results from damage to the inner ear (cochlea) or auditory nerve, often a result of the aging process and/or noise exposure, but also may be secondary to head trauma, systemic illness or infection, or inheritance. Sounds may be unclear or too soft. Sensitivity to loud sounds may occur. Medical or surgical intervention cannot correct most sensorineural hearing losses, but hearing aids may help you reclaim some sounds you are missing as a result of nerve deafness.

Where do I purchase hearing aids?

Federal regulation prohibits any hearing aid sale unless the buyer has first received a physician’s evaluation, so you will need to see your doctor before you purchase a hearing aid. However, the regulation also says that if you are over 18 and aware of the recommendation for a medical exam, you may sign a waiver to forego it.

An otolaryngologist, audiologist or independent dispenser can dispense aids. Hearing aids should be custom-fit to your ear and hearing needs. Mail-order hearing aids typically cannot be custom-fit.

What are costs and styles of hearing aids?

Hearing aids vary in price according to style, features and local market prices. Price can range from hundreds of dollars to more than $2,500 for a programmable, digital hearing aid. Purchase price should not be the only consideration in buying a hearing aid. Product reliability and customer service can save repair costs and decrease frustration of a malfunctioning hearing aid.

There are several styles:

  • Behind-the-ear (BTE) aids go over the ear and are connected with tubing to custom-fitted earpieces.
  • Open fit receiver-in-the-ear (RITE) aids are a newer design, and while still placed over the ear, they are extremely small and nearly invisible.
  • In-the-ear (ITE) hearing aids fill the entire bowl of the ear and part of the ear canal.
  • Smaller versions of ITEs are called half-shell and in-the-canal (ITC).
  • The least visible aids are completely-in-the-canal (CIC).

The best hearing aid for you depends upon your particular hearing loss and listening needs, the size and shape of your ear and ear canal, and the dexterity of your hands. Many hearing aids have tele-coil "T" switches for telephone use and public sound systems.
 
Other options, such as FM systems and Bluetooth devices in conjunction with hearing aids, may provide the best benefit for some patients.

Will I need a hearing aid for each ear?

Usually, if you have hearing loss in both ears, using two hearing aids is best. Listening in a noisy environment is difficult with amplification in one ear only, and it is more difficult to distinguish where sounds are coming from.

What other questions should I ask?

Ask about future service and repair. Also inquire about the trial period policy and what fees are refundable if you return the hearing aids during that period. And ask about warranty coverage for your hearing aids and the consumers' protection program for hearing aid purchasers in your state.

What will happen at my hearing aid fitting?

The hearing aids will be fitted for your ears. Then, while wearing them, you will be tested for word understanding in quiet and in noise, and for improvement in hearing tones. Real ear measurements may also be done, which determine how much gain your hearing aids give you.
 
Next, you will receive instruction about the care of your hearing aids and other helpful strategies.

How should I begin wearing the aids?

Start using your hearing aids in quiet surroundings, gradually building up to noisier environments. Then eventually work up to wearing your hearing aids all waking hours. Keep a diary to help you remember your experiences and report them accurately to your dispenser for adjustments as needed. Report any concerns on a follow-up appointment. Be patient and allow yourself to get used to the aids and the “new” sounds they allow you to hear.

Painful ear infections are a rite of passage for children, and by the age of five, nearly every child has experienced at least one episode. Most ear infections either resolve on their own (viral) or are effectively treated by antibiotics (bacterial). But sometimes ear infections and/or fluid in the middle ear may become a chronic problem leading to other issues, such as hearing loss, poor school performance or behavior and speech problems. In these cases, insertion of an ear tube by an otolaryngologist (ear, nose and throat specialist) may be considered.

What are ear tubes?

Ear tubes are tiny cylinders placed through the ear drum (tympanic membrane) to allow air into the middle ear. They also may be called tympanostomy tubes, myringotomy tubes, ventilation tubes or PE (pressure equalization) tubes.

These tubes can be made out of various materials and come in two basic types: short-term and long-term. Short-term tubes are smaller and typically stay in place for six to eighteen months before falling out on their own. Long-term tubes are larger and have flanges that secure them in place for a longer period of time. Long-term tubes may fall out on their own, but removal by an otolaryngologist may be necessary.

Who needs ear tubes and why?

Ear tubes are often recommended when a person experiences repeated middle ear infection (acute otitis media) or has hearing loss caused by persistent middle ear fluid (otitis media with effusion). These conditions most commonly occur in children, but can also be present in teens and adults and can lead to speech and balance problems, hearing loss, poor school performance, or changes in the structure of the ear drum. Other less common conditions that may warrant the placement of ear tubes are malformation of the ear drum or eustachian tube, Down Syndrome, cleft palate, and barotrauma (injury to the middle ear caused by a reduction of air pressure, usually seen with altitude changes as in flying and scuba diving).

Each year, more than a half million ear tube surgeries are performed on children, making it the most common childhood surgery performed with anesthesia. The average age for ear tube insertion is one to three years old. Inserting ear tubes may:

  • Reduce the risk of future ear infection;
  • Restore hearing loss caused by middle ear fluid;
  • Improve speech problems and balance problems; and
  • Improve behavior and sleep problems caused by chronic ear infections.
  • Help children do their best in school.

How are ear tubes inserted in the ear?

Ear tubes are inserted through an outpatient surgical procedure called a myringotomy. A myringotomy refers to an incision (small opening) in the ear drum or tympanic membrane, which is most often done under a surgical microscope with a small scalpel. If an ear tube is not inserted, the hole would heal and close within a few days. To prevent this, an ear tube is placed in the hole to keep it open and allow air to reach the middle ear space (ventilation).

What happens during surgery?

Most young children require general anesthesia but some doctors can do this as a brief office procedure. Some older children and adults may also be able to tolerate the procedure without anesthetic. A myringotomy is performed and the fluid behind the ear drum (in the middle ear space) is suctioned out. The ear tube is then placed in the opening. Ear drops may be administered after the ear tube is placed and may be prescribed for a few days. The procedure usually lasts less than 15 minutes and patients recover very quickly.

Sometimes the otolaryngologist will recommend removal of the adenoid tissue (lymph tissue located in the upper airway behind the nose) when ear tubes are placed for persistent middle-ear fluid. This is effective for children four years or older and is often considered when a repeat tube insertion is necessary. Current research indicates that removing adenoid tissue concurrent with placement of ear tubes for persistent middle-ear fluid can reduce the risk of recurrent ear infections and the need for repeat surgery in children four years and older.

What happens after surgery?

After surgery, the patient is monitored in the recovery room (if general anesthesia was used) and will usually go home within an hour or two if no complications occur. Patients usually experience little or no post-operative pain, but grogginess, irritability, and/or nausea from the anesthesia can occur temporarily. When done in the office recovery is immediate.

Hearing loss caused by the presence of middle ear fluid is immediately resolved by surgery. Children with speech, language, learning or balance problems may take several weeks or months to fully improve.

The otolaryngologist will provide specific post-operative instructions, including when to seek attention and to set follow-up appointments. He or she may also prescribe antibiotic ear drops for a few days. An audiogram should be performed after surgery, if hearing loss is present before the tubes are placed. This test will make sure that hearing has improved with the surgery.

Although the tube does have a small opening (about 1/20th of an inch) that could allow water to enter the middle ear, research studies show no benefit in keeping the ears dry and current guidelines do not recommend routine water precautions. Therefore, you do not need to restrict swimming or bathing while tubes or in place and do not need to use earplugs, head bands, or other water-tight devices unless specifically recommended by your doctor.

Consultation with an otolaryngologist (ear, nose, and throat specialist) may be warranted if you or your child have experienced repeated or severe ear infections, ear infections that are not resolved with antibiotics, hearing loss due to fluid in the middle ear, barotrauma, or have an anatomic abnormality that inhibits drainage of the middle ear.

Possible complications

Myringotomy with insertion of ear tubes is an extremely common and safe procedure with minimal complications. When complications do occur, they may include:

  • Perforation – This can rarely happen when a tube comes out or a long-term tube is removed and the hole in the tympanic membrane (ear drum) does not close. The hole can be patched through a surgical procedure called a tympanoplasty or myringoplasty.
  • Scarring – Any irritation of the ear drum (recurrent ear infections), including repeated insertion of ear tubes, can cause scarring called tympanosclerosis or myringosclerosis. In most cases, this causes no problem with hearing and does not need any treatment.
  • Infection – Ear infections can still occur with a tube in place and cause ear discharge or drainage. However, these infections are usually infrequent, do not cause hearing loss (because the infection drains out), and may go away on their own or be treated effectively with antibiotic ear drops. Oral antibiotics are rarely needed.
  • Ear tubes come out too early or stay in too long – If an ear tube expels from the ear drum too soon (which is unpredictable), fluid may return and repeat surgery may be needed. Ear tubes that remain too long may result in perforation or may require removal by an otolaryngologist.

Pneumococcal Vaccination is Key to Protecting Cochlear Implant Patients

Cochlear implants bring sound to thousands of people with hearing loss worldwide. People with cochlear implants are at increased risk for pneumococcal meningitis. Despite CDC recommendations that all cochlear implant patients receive pneumococcal vaccination, many patients remain unvaccinated. The American Academy of Otolaryngology – Head and Neck Surgery (AAO-HNS), in coordination with the CDC and FDA, has begun a campaign to help raise awareness about the importance of pneumococcal vaccinations for all cochlear implant patients.  Pneumococcal vaccination, the “Pneumo Shot”, is recommended by CDC for all patients who have, or will receive cochlear implants.

Brochure: Pneumococcal Vaccination for Cochlear Implant Patients

Ear deformities occur in a number of conditions. Some patients are born with absent (microtia), protruding or drooping ears, due to weak or poorly formed cartilage. Traumatic deformities of the ear also occur due to trauma (e.g. car wreck or dog bite) or torn earlobes. Deformity of the ears may cause social anxiety and may make children vulnerable to teasing. Regardless of the origin of the ear deformity, these ear conditions can be surgically corrected. These procedures do not alter the patient's hearing, but they may improve appearance and self-confidence.

Can ear deformities be corrected?

Formation of the ear during development is a complex choreography of moving skin and adjacent soft tissue to give rise to the different parts of the ear. If this process is interrupted, various differences in ear shape can occur, with the most severe being absence of the ear (and possibly the ear canal) called microtia, to mild folding differences of the ear.  The “fold” of hard, raised cartilage that gives shape to the upper portion of the ear does not form in all people. This is called “lop-ear deformity,” and it is inherited. The absence of the fold can cause the ear to stick out or flop down (see below). Some infants are born without an ear canal and hearing can be restored with a bone-anchored hearing aid or it can be surgically opened, and the outer ear reshaped to look like the other ear. Those who are born without an ear (microtia), or lose an ear due to injury, can have an artificial ear surgically attached for cosmetic reasons. These are custom formed to match the patient’s other ear. Alternatively, rib cartilage or a biomedical implant, in addition to the patient's own soft tissue, can be used to construct a new ear.

Surgical correction of prominent ears that lack folds

To correct this problem, the surgeon places permanent stitches in the upper ear cartilage and ties them in a way that creates a fold and props the ear up. Scar tissue will form later, holding the fold in place. Corrective surgery, called otoplasty, should be considered on ears that stick out more than 4/5 of an inch (2 cm) from the back of the head. It can be performed at any age after the ears have reached full size, usually at five or six years of age. Having the surgery at a young age has two benefits: the cartilage is more pliable, making it easier to reshape, and the child will experience the psychological benefits of the cosmetic improvement. However, a patient may have the surgery at any age.

The surgery begins with an incision behind the ear, in the fold where the ear joins the head. The surgeon may remove skin and cartilage or trim and reshape the cartilage. In addition to correcting protrusion, ears may also be reshaped, reduced in size or made more symmetrical. The cartilage is then secured in the new position with permanent stitches which will anchor the ear while healing occurs. Typically, otoplasty surgery takes about two hours. The soft dressings over the ears will be used for a few weeks as protection, and the patient usually experiences only mild discomfort. Headbands are sometimes recommended to hold the ears in place for a month following surgery or may be prescribed for nighttime wear only.

Can torn earlobes be corrected?

Earlobe trauma can occur related to tearing related to injury from small children grabbing the earring or having it caught on clothing or other objects. These tears can be easily repaired surgically, usually in the doctor’s office. In severe cases, the surgeon may cut a small triangular notch at the bottom of the lobe. A matching flap is then created from tissue on the other side of the tear, and the two wedges are fitted together and stitched. Earlobes usually heal quickly with minimal scarring. In most cases, the earlobe can be pierced again four to six weeks after surgery to receive light-weight earrings.

Does insurance pay for cosmetic ear surgery?

Insurance usually does not cover surgery solely for cosmetic reasons. However, insurance may cover, in whole or in part, surgery to correct a congenital or traumatic defect. Before cosmetic ear surgery, discuss the procedure with your insurance carrier to determine what coverage, if any, you can expect.

A cochlear implant is an electronic device that restores partial hearing to individuals with severe to profound hearing loss who do not benefit from a conventional hearing aid. It is surgically implanted in the inner ear and activated by a device worn outside the ear. Unlike a hearing aid, it does not make sound louder or clearer. Instead, the device bypasses damaged parts of the auditory system and directly stimulates the nerve of hearing, allowing individuals who are profoundly hearing impaired to receive sound.

What is normal hearing?

Your ear consists of three parts that play a vital role in hearing – the external ear, middle ear, and inner ear.

Conductive hearing: Sound travels along the ear canal of the external ear, causing the ear drum to vibrate. Three small bones of the middle ear conduct this vibration from the eardrum to the cochlea (auditory chamber) of the inner ear.
 
Sensorineural hearing: When the three small bones move, they start waves of fluid in the cochlea, and these waves stimulate more than 16,000 delicate hearing cells (hair cells). As these hair cells move, they generate an electrical current in the auditory nerve. The electrical signal travels through inter-connections in the brain to specific areas of the brain that recognize it as sound.

How is hearing impaired?

If you have disease or obstruction in your external or middle ear, your conductive hearing may be impaired. Medical or surgical treatment can probably correct this.

An inner ear problem, however, can result in a sensorineural impairment, or nerve deafness. In most cases, the hair cells are damaged and do not function. Although many auditory nerve fibers may be intact and can transmit electrical impulses to the brain, these nerve fibers are unresponsive because of hair cell damage. Since severe sensorineural hearing loss cannot be corrected with medicine, it can be treated only with a cochlear implant.

How do cochlear implants work?

Cochlear implants bypass damaged hair cells and convert speech and environmental sounds into electrical signals and send these signals to the hearing nerve.

A cochlear implant has two main components:

  • An internal component that consists of a small electronic device which is surgically implanted under the skin behind the ear, connected to electrodes that are inserted inside the cochlea.
  • An external component, which is usually worn behind the ear, that consists of a speech processor, microphone, and battery compartment.

The microphone captures sound, allowing the speech processor to translate the sound into distinctive electrical signals. These signals or “codes” travel up a thin cable to the headpiece and are transmitted across the skin via radio waves to the implanted electrodes in the cochlea. The electrodes’ signals stimulate the auditory nerve fibers to send information to the brain, where it is interpreted as meaningful sound.

Cochlear implant benefits

Cochlear implants are designed only for individuals who attain almost no benefit from a hearing aid. They must be 12 months of age or older (unless childhood meningitis is responsible for deafness).

Otolaryngologists (ear, nose and throat specialists) perform implant surgery, although not all of them do this procedure. Your local doctor can refer you to an implant clinic for an evaluation. The implant team (otolaryngologist, audiologist, nurse and others) will determine your candidacy for a cochlear implant and review the appropriate expectations as a result of the cochlear implant.  The implant team will also conduct a series of tests including: 
 
Ear (otologic) evaluation: The otolaryngologist examines the ear canal and middle ear to ensure that no active infection or other abnormality precludes the implant surgery.
 
Physical examination: Your otolaryngologist also performs a physical examination to identify any potential problems with the use of general anesthesia needed for the implant procedure.

Hearing (audiologic) evaluation: The audiologist performs extensive hearing tests to find out how much you can hear with and without a hearing aid.
 
X-ray (radiographic) evaluation: Special X-rays are taken, usually computerized tomography (CT) or magnetic resonance imaging (MRI) scans, to evaluate your inner ear anatomy.

Cochlear implant surgery

Cochlear implant surgery is usually performed as an outpatient procedure under general anesthesia. An incision is made behind the ear to open the mastoid bone leading to the middle ear space. Once the middle ear space is exposed, an opening is made in the cochlea and the implant electrodes are inserted. The electronic device at the base of the electrode array is then placed behind the ear under the skin.

Is there care and training after the operation?

Several weeks after surgery, your cochlear implant team places the signal processor, microphone, and implant transmitter outside your ear and adjusts them. They teach you how to look after the system and how to listen to sound through the implant. There are many causes of hearing loss and some patients may take longer to fit and require more training due to individual patient differences. Your team will ask you to come back to the clinic for regular checkups and readjustment of the speech processor as needed.

What can I expect from an implant?

Most adult cochlear implant patients notice an immediate improvement in their communication skills. Children require time to benefit from their cochlear implant, as the brain needs to learn to correctly interpret the electrical sound input. While cochlear implants do not restore normal hearing, and benefits vary from one individual to another, most users find that cochlear implants help them communicate better through improved lip-reading. Also, 90 percent of adult cochlear implant patients are able to discriminate speech without the use of visual cues. There are many factors that contribute to the degree of benefit a user receives from a cochlear implant, including:

  • How long a person has been deaf,
  • The number of surviving auditory nerve fibers, and
  • A patient’s motivation to learn to hear.

Your team will explain what you can reasonably expect. Before deciding whether your implant is working well, you need to understand clearly how much time you must commit. It is rare that patients do not benefit from a cochlear implant.

FDA approval for implants

The Food and Drug Administration (FDA) regulates cochlear implant devices for both adults and children and approves them only after thorough clinical investigation.

Be sure to ask your otolaryngologist for written information, including brochures provided by the implant manufacturers. You need to be fully informed about the benefits and risks of cochlear implants, including how much is known about safety, reliability, and effectiveness of a device; how often you must come back to the clinic for checkups; and whether your insurance company pays for the procedure.

Costs of implants

More expensive than a hearing aid, the total cost of a cochlear implant, including evaluation, surgery, the device, and rehabilitation can cost as much as $100,000. Fortunately, most insurance companies and Medicare provide benefits that cover the cost.