This week at Hearing International we are honored to present a submission from Maurice H. Miller, Ph.D., a world-renowned audiologist who has been instrumental in shaping our profession and influencing audiologists around the world through his outstanding career at New York University. Dr. Miller has conducted research and has had significant experience with what he calls “Spinal Manipulation Therapy.”
Dr. Traynor’s blog on the ineffectiveness of Chiropractic treatment in curing or restoring hearing in persons with sensorineural hearing loss is important for all audiological clinicians and for otorhinolaryngologists as well. Chiropractic, in my experience, is more than a treatment modality and less than a scientifically based therapy. It is almost a set of “religious beliefs” and convictions by many who believe chiropractic is a solution to virtually all the ills that affect human beings and is THE alternative to conventional medical management. Consequently, many of its practitioners reject vaccinations, antibacterial medication, and surgical intervention.
The above is my characterization of one group, increasingly growing in size and influence, that consists of relatively young practitioners. For them, chiropractic is a powerful belief system. This is not a criticism of conventional Chiropractors and Chiropractic Manipulation of the “old school,” which limits practice to patients with backaches and guides interventions with radiological studies.
Hearing International’s conclusion is that “there is still no evidence to support that chiropractic cures hearing loss” is one with which I strongly concur. However, my investigation goes beyond Traynor’s incisive conclusion. I believe that Chiropractic Manipulation is a possible cause of sudden sensorineural hearing loss (SSNHL) and tinnitus. Patients who have experienced SSNHL should be asked, as a routine part of their case history, whether they had a chiropractic manipulation during or prior to the onset of their hearing loss. A watershed article was published in 1986 reporting a patient with SSNHL and tinnitus which followed manipulation of the cervical spine.
Case #1, presented by Brownson et al (1986), is a 29-year-old female patient who went to an osteopathic physician with a complaint of a sprained shoulder, headaches, and tension. The osteopath “popped” her neck by rotating the head first rapidly in one direction and then the other. The following day, as she backed her car out of the driveway, she felt a right-sided neck pain, felt unsteady, and noticed tinnitus and reduced hearing in her left ear. Five days later, she awoke with increased hearing loss, tinnitus bilaterally, and severe vertigo accompanied by nausea and vomiting. Pure-tone audiometry revealed a moderately-severe sensorineural hearing loss in the “speech frequency range” (500, 1000, 2000 dB) averaging 65 dB in the left ear and within normal limits for the right ear. Following treatments with acetylsalicylic acid (aspirin) and dipyridamolet (a vasodilator), her hearing on the left ear improved dramatically with a pure-tone average of 18 dB.
Case #2, reported by Brownson et al . (1986), is a 45-year-old male who went to his osteopathic physician for an “adjustment” following pain in the neck and left shoulder. He described the “adjustment” as being “unusually rough.” The following day he visited a chiropractor (the power of the “belief system”), who placed him in a prone position with his head extended on his cervical spine. His head was rotated briskly to the left and then to the right. After this maneuver, he had an onset of vertigo with nausea, vomiting, and diminished vision.
The next day, the chiropractor again manipulated his neck. At this point his symptoms became worse and he reported a hearing loss and tinnitus in his right ear. The air- and bone-conduction audiogram demonstrated a moderate sensorineural hearing loss averaging 53 dB, an SRT of 50 dB, and a Word Recognition Score with masking in the opposite ear of 20%. There was no significant return of hearing upon subsequent audiometric testing. Cervical spine roentgenograms were interpreted as normal as well as the aortic arch and cerebral angiograms revealed normal carotid arteries. The caudal half of the basiliar artery was occluded, its cephalic portion filling through the posterior communicating artery.
In the above two cases reported by Brownson et al., the initial point vertebral artery injury is between the second and third cervical vertebrae. The shearing of the stretched artery by the anterior articular facet of the third cervical vertebrae during the extreme rotation is believed to be the mechanism involved in these arterial injuries. Chiropractic manipulation, especially when vigorous (“rough”), should be viewed as a possible cause of SSNHL and tinnitus. The hearing loss and tinnitus may be permanent or transitory. Followup audiological and radiologic studies are essential. In cases where hearing loss persists, audiologic rehabilitation is essential (Miller, 2012).
Other cases of SSNHL have been reported. Miller (1995) states that it is important to note that vigorous neck manipulation is not limited to chiropractic, although compared to other specialists it is virtually their “stock in trade.” Osteopathic physicians and others also partake in these maneuvers; therefore chiropractic manipulation should be referred to as Spinal Manipulation Therapy (SMT).
Persons with arteriosclerosis, osteoarthritis of the cervical spine, spinal deformities, and and tumors, especially osteophytes, may be particularly susceptible to SSNHL and tinnitus from SMT. Questions regarding SMT at or around the time of the onset of SSNHL and tinnitus should be part of the case history on these patients. Patients with these and related conditions should be warned about potential for SSNHL and tinnitus if they submit to SMT. However, in the view of the powerful “belief system” that exists, practitioners should not be surprised if their warnings fall on the proverbial “deaf ears.”
Maurice H Miller, PhD, Professor Emeritus of Audiology, Steinhardt School of Culture, Education and Human Development of New York University. Chairperson, Council for Accreditation in Occupational Hearing Conservation, 1981-1983. First nonphysician Audiologist to be elected to this position. Professor of the Year, Steinhardt School of NYU. Career award for outstanding life achievements, American Academy of Audiology, 1996. Award for outstanding teaching and other professional contributions, Amer Acad of Otolaryng-Head and Neck Surgery, 1975
Brownson, R., Zollinger, W., Madiera, T., & Fell, D. (1986). Sudden SNHL following manipulation of the cervical spine. Laryngoscope. 96:166-170. Retrieved February 27, 2012: http://onlinelibrary.wiley.com/doi/10.1288/00005537-198602000-00007/abstract
Miller, M., (2012). Audiology’s neglect of rehabilitation is growing increasingly troublesome. Hearing Health and Technology Matters. Retrieved February 26, 2012: http://www.google.com/search?rlz=1C1RNPN_enUS413&sourceid=chrome&ie=UTF-8&q=audiology’s+neglect+of+rehabilitation+is+growing+increasingly+troublesome