Recognizing and Evaluating Head Injury Associated Hearing Loss

Audiology Associates Leads the Way for Recognizing and Evaluating Head Injury Associated Hearing Loss

Dr. Peter Marincovich, Ph.D. of Audiology Associates has spent his career revolutionizing the way audiology and hearing diagnostics are performed and he is highly versed in the latest treatments for helping patients manage hearing loss associated with brain injury.

Sports Head Injuries
Traumatic brain injuries commonly seen in sports

The Center for Disease Control has estimated that as many as 5.3 million Americans are living with brain injuries at any given time, and a significant head injury occurs about every 21 seconds. In 2010, about 2.5 million emergency department visits, hospitalizations or deaths were associated with traumatic brain injury (TBI). The primary contributing factor for traumatic brain injuries among adults aged 65 and older are directly related to falls. Other contributing events include concussive high pressure waves from explosions and sports related injuries. A traumatic brain injury (TBI) is an injury to the brain caused by the head being hit by something or shaken violently. There are three severities of TBI: mild, moderate, and severe. A traumatic brain injury can change how someone learns, thinks, performs and behaves.  A concussion is a type of traumatic brain injury (TBI) caused by a blow or jolt to the head. Concussions can also occur from a fall or blow to the body that causes the head and brain to move quickly back and forth.  Medical diagnosis may describe a concussion as a “mild” brain injury because concussions are usually not life-threatening.  Even so, their effects can be serious and sometimes long-term. (Centers for Disease Control, www.CDC.GOV)

HOW HEAD INJURIES EFFECT HEARING and COMMUNICATION

Usually a concussion will present itself as a cognitive problem or a balance problem. The primary injury is often a contusion (bruising) from the brain moving in the skull. This motion affects the temporal cortex related to feature specific auditory processing. In moderate TBI, the injury can lead to a hemorrhage affecting the frontal/pre-frontal cortex which effects attention and listening.   A moderate injury can affect the parietal lobe effecting spatial processing, involve the occipital lobe which affects visual processing, and impair the cerebellum, affecting balance. In severe cases, the injury can be a more diffuse axonal injury in the corpus callosum affecting inter-hemispheric transfer or injury to the thalamus affecting organization and updating of cortical and brainstem connections, both of which are involved in the processing of language.  Often, the outer and inner ear is directly in the path of any trauma, and hearing specific problems often follow a concussion or TBI. There could be peripheral damage to the pinna, and or to the eardrum in the form of a rupture and or to the ossicular chain primarily affecting the ability to hear “soft” and “moderate “sounds. If damage has occurred to the inner ear hair cells in the cochlea, this will affect both the ability to hear as well as the ability to hear clearly.  For example, an individual may hear “ool”, but not sure if the word was “pool” or “tool” or “cool”.  Finally, our bodies maintain balance through touch, vision, and our inner ear balance system.  Trauma can cause inner ear vestibular damage, affecting our balance.

In summary, following a head injury, hearing problems can occur for several reasons, including mechanical and neurological complications. Specifically, when the inner ear or temporal lobes have been damaged, TBI can often lead to the following auditory symptoms:

  • Hyperacusis (normal listening situations seem very loud)
  • Tinnitus (ringing in the ears)
  • Hearing loss (sounds seem muffled, less clear, ears feel plugged)
  • Difficulty filtering one set of sounds from background noise
  •  Auditory agnosia (the person is unable to recognize the meanings of certain sounds)
  • Difficulty following  rapid speech
  • Difficulty following long conversations or instructions

THE PROBLEM WITH THE PROBLEM

Often the condition goes undetected by the patient. They may be slightly dazed but get up, or move away from the event and go on. (see the enclosed pamphlet addressing the most common warning signs and what you should do.) And in some cases, there are multiple events, such as military explosions and sports related injuries. The long-term effects of multiple concussions are currently being studied by researchers. Not only can repeated traumatic incidents contribute to the development of mild cognitive impairments, chronic traumatic encephalopathy and other adverse outcomes, but a concussion history can also result in ”post-concussion syndrome.” Individuals with a history of concussion are at an increased risk of sustaining a subsequent concussion

MAKING THE RIGHT DIAGNOSIS

  • It is recommended that anyone suffering from head trauma be evaluated medically.  Since many hearing problems cannot be detected by the patient, diagnostic evaluations may include neuroimaging, neuropsychological tests, and comprehensive audiologic evaluation including vestibular balance assessment with videonystagmography and posturography.

o    NOTE: It is strongly recommended on all audiology case history assessments that each patient is asked, not only have they ever suffered a concussion, but have they ever hit their head or been in a concussive event.

  •  Currently, the Balance Error Scoring System (BESS) is used to assess balance deficits indicating concussion. In addition to BESS, a paper test such as the Standardized Assessment of Concussion is commonly used. The Acute Concussion Evaluation (ACE) was developed to provide physicians with an evidence based protocol to conduct an initial evaluation and diagnosis of patients (bot children and adults with known or suspected MTBI.
  • With auditory processing evaluations  following an injury, it is important for audiologists and speech language pathologists to determine if other symptoms exist such as memory or attention difficulties, which can also interfere with normal hearing and may accompany a TBI. In addition, Speech Language Pathologists are involved with the collection of baseline cognitive-linguistic data that can be used not only as a reference point for determining severity of injury, but also as a benchmark for recovery, providing an indicator of improvement in subtle yet broad deficits to attention and concentration, that may not be readily evident on more traditional imaging studies such as CT scan or MRI.

REHABILITATION

Ensuring patients are open to using the interventions are an important part of this process.

Rest and careful management of physical and cognitive exertion are keys to recovery. To help with communication directly, improvements in the signal to noise ratio through Frequency Modulated (FM) listening systems help to reduce the background nose and improve listening.

Auditory Training programs combining FM are starting to be used more frequently to help with temporal processing, speech-in-noise understanding, reported cognitive processing difficulties and improving working memory.

Tinnitus management strategies through audiology evaluations are available which identify the pitch and loudness of the tinnitus. By analyzing the subjective rating and classification by the patient of their tinnitus, it is possible to determining if they are “hyper monitoring” their tinnitus. Then by evaluating if a hearing loss exists, it is possible to tune a graphic equalizing hearing system to filter a similar pitch to the auditory cortex which in turn appears to “help” the patient “manage” their  tinnitus. In cases of severe hyper monitoring, Cognitive Behavioral Therapy can also assist patients in managing their tinnitus.

In some cases following a brain MTBI injury, hearing problems resolve themselves within just a few weeks, but for others, hearing problems can last indefinitely. Because hearing loss directly affects the primary means with which we communicate, hearing loss has the potential to complicate and frustrate other effects of brain injury, particularly cognitive and social problems. Cognitive issues such as trouble finding words are only exacerbated if the patients cannot hear what is going on around them.

The Acute Concussion Evaluation (ACE) form can be used to serially track symptom recovery over time. It provides a systematic protocol for assessing the key components for diagnosing an MTBI and serves as the basis for management and referral recommendations provided by the ACE Care Plan.

Audiology Associates has provided comprehensive hearing loss prevention, diagnostics and hearing solutions to patients for 30 years. To make an appointment with Dr. Peter Marincovich or his team call (707) 827-1630 for their Santa Rosa office or visit their website http://www.audiologyassociates-sr.com, for more information on the other Bay Area location.

PATIENT PAMPHLET: The “Hard” Facts

Identifying various forms of Traumatic Brain Injury (TBI), mild, moderate or severe and understanding the potential causes and what to look for is everyone’s responsibility. TBI is an important public health issue due to the large number of people who acquire these injuries and their potential long-term effects. Concussions are not just sports related and can occur from any direct blow to the head or other body part or from a concussive blast that results in impulsive or whiplash like forces.

. CDC estimates revealed that 1.6 million to 3.8 million concussions or MTBI occur each year

. Blasts are a significant cause of Mild Traumatic Brain Injury (MTBI)

. 5 to 10% of athletes will experience a concussion in any given sports season

. Fewer than 10% of sport related concussions involve a loss of consciousness

. Football is the most common sport with concussion risk for males (75% chance for concussion)

. Soccer is the most common sport with concussion risk for females (50% chance for concussion)

. 78% of concussions occur during games (as opposed to practices)

. Some studies suggest that females are twice as likely to sustain a concussion as males

. Headache (85%) and dizziness (70 – 80%) are most commonly reported symptoms immediately following concussions by injured athletes

. Estimated 47% of athletes do not report feeling any symptoms after a concussive blow

. A professional football player will receive an estimated 900 to 1500 blows to the head during a season

. Impact speed of a professional boxer’s punch is 20 miles an hour

. Impact speed of a football player tackling a stationary player is 25 miles an hour

. Impact speed of a soccer ball being headed by a player is 70 miles an hour

Warning Signs and Raising Awareness

  1. If after a traumatic event:
    1.  You felt dazed.
    2. You had a loss of consciousness
    3. You saw flashing lights
    4. You feel like you have lost time
    5. You had nausea and or vomiting
    6. You are confused, feel “spacey”, or are not “thinking straight”
    7. You feel drowsy, or it is hard to wake up or similar changes
    8. You have visual acuity changes?
    9.  You have noticed balance changes?
    10. You have ringing in your ears
    11. You have hearing loss, or your ears feel “full” or “plugged” and sounds seem muffled
  2. If the next day after a traumatic event:
    1. You experience a headache
    2.  “everything” is blurry
    3. You are having trouble “processing what you say”
  3. If several days after a traumatic event
    1. Symptoms often are not immediate
    2. You have slurred speech
    3. You can’t recognize people or places
    4. You develop weakness or numbness in arms or legs

Emergency Signs

  1. Changes in alertness and consciousness
  2. Seizures
  3. Muscle weakness on one or both sides
  4. Persistent confusion
  5. Remaining unconscious
  6. Repeated vomiting
  7. Unequal pupils
  8. Unusual eye movements
  9. Walking problems

Next steps if you think you may have sustained a concussion

The first step is to seek medical attention. In addition a complete audiology assessment of hearing, balance, tinnitus and communication is necessary. Speech Language Pathology assessment of cognitive-linguistic data, memory, attention, naming and listening comprehension, and visual-perceptual skills is also an integral part of a comprehensive evaluation.

Communication TIPS to use when communicating with an individual with TBI

  1. Allow patients time to express themselves.  Be specific
  2. Speak slowly and clearly
  3. Use short sentences
  4. Repeat complex sentences when necessary
  5. Allow time for patients to comprehend
  6. Provide both spoken and written instructions and directions when appropriate
  7. Communicate in less complex environments both visual and auditory.

Source: National Institutes of Health

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