We like to keep it light and easy here at HHTM, if for no other reason than getting older and not hearing well is hard sledding, so why make a visit to an audiologist any harder than it has to be? But, like the proverbial duck floating smoothly on the surface, there’s a whole lotta action going on below the light and easy surface. Smooth sailing is all about about Competency and Trust, as it should be whenever healthcare transactions take place. And no, we’re not talking money when we say “transaction,” we’re talking about a balanced exchange . Patients give us their time and trust; we give them our time and expertise.
In order to make a satisfactory exchange, we Audiologists have to know what we’re doing and get it done efficiently and completely while chatting with patients. At the same time, they have to believe that we know what we’re doing and are doing all we can to help them, even as they chat with us.
It’s easy to get sidetracked, overlook warnings signs, or get too comfortable with the status quo of a long-time patient. That’s what today’s post is about: errors made when the Audiologist knowingly or unknowingly took short cuts that were not in patients’ best interests, thus voiding the value of the transactions.
The Case: A 65 year old man with a long history of occupational noise exposure (railroads) came to an office (we will call it ACME Audiolgy, or AA for today’s post) for diagnostic testing. He brought a 5-year-old audiogram with him, performed by a certified and licensed Audiologist, which showed a big hearing difference (asymmetry) between his ears. The only comments on the audiogram were: “history of noise exposure” and “recommend hearing aid.”
AA Comment: Ear asymmetries ALWAYS demand investigation, even in the presence of a history of noise exposure. Think about it: noise is like any other acoustic signals — the sound wave propagates throughout the environment as an expanding sphere (see picture above). That means BOTH ears are exposed when a head in within the propagating sphere.
Unless there is a unique situation reported (e.g., gun blast on one side of the head), there is no reason to expect or assume that noise exposure is consistent with asymmetrical hearing. Even then, the Audiologist should maintain a high index of suspicion until tests are performed to rule out medical problems as the source of the ear asymmetry.
What Short Cuts Were Taken? The original audiogram was far from complete. At the very least, additional tests were required, all of which are performed routinely at AA whenever there is a new patient. None of the tests take more than a few minutes or pad the patient’s bill by much. All of the tests are designed to investigate ear asymmetries and allow the Audiologists to arrive at a differential diagnosis.
What did we do at AA? Basic audiometry to validate the old test results and determine whether the loss was progressive. The standard battery of Acoustic Immittance, Threshold Tone Decay, and Speech Performance was performed to screen for middle ear disorders, cochlear oddities, acoustic (VIIIn) nerve disorders, and/or basic between-ear transmissions problems within the brain.
That sounds like a lot, but it’s basic Audiology. Total test time was 25 minutes, including history taking. Most patients don’t realize we’re looking at so many auditory systems until we present the results. Sadly, they often comment that they’ve “never had a hearing test like THAT before.” They should have.
What did AA recommend? One year follow-up and MRI if the patient and/or his PCP had concerns (we sent the PCP a report). AA didn’t force the MRI because none of the tests indicated progressive loss or problems of the middle ear, hearing nerve, or brain processing. But, MRI referral was in order if a noted increased asymmetry at follow-up or if the patient noticed a change in hearing.
AA did not recommend a hearing aid at this time. The patient reported NO communication problems and his only concern was the difference in his ears. Too bad it took 5 years and two audiograms to address his concern. When he does experience communication problems, he will be in the system and those concerns will be addressed at as part of annual audiometric follow-up at AA.
photo courtesy of Dr Kapoor