The Pathology of Hearing - Essay Example

Introduction: The ability to hear is a gift that has quite the significance in today. Without such a luxury, mankind would not have advanced to its present status today. From this auditory medium, this world has the capability to function linguistically and coherently. Some may claim that hearing has more importance than sight because without it, one becomes deaf and lacks the elocution or suffers from speech impediment which can hinder communication. In this dissertation, we discuss direct access hearing tests and the how and why they are referred to an NHS Audiology department. The pathology of hearing, and look at assessing how general practitioners consider the importance of getting a patients hearing assessed and whether the referral from them is appropriate. Literature Review: The ear is sensory organ that detects sounds. The range of hearing is differentiates from species to another. Dogs are able to use their keen sense of hearing to hear minute disturbances within its atmosphere. A bat, whose auditory ability exceeds greatly in comparison to a dog, uses their ears to fly in the dark and avoid obstacles that it unable to perceive via vision. In general, the human ear is structured accordingly so that we can be aware of our surroundings acoustically. The ear is classified into three basic structures. That is, the outer ear, middle ear, and inner ear assemble the essential sub-organ components to hearing. The outer ear is the exterior component of the ear which coax sounds waves into the ear. It is composed of the auricle, the ear canal, and the tympanic membrane known today as the eardrum. In animals, the auricle possesses skeletal muscles that move to ear a distinct sounds. For humans, to focus on a particular sound requires a mental honing of neurological circuits of the central nervous systems. Then, the sounds travel through the ear canal and meet the tympanic membrane. (www.wikipedia.com) After tympanic membrane, the middle ear structures appear. They are composed of three bones which are technically called ossicles. These bones consist of the hammer, anvil, and stapes or generically called malleus, incus, and stirrup. The malleus which is connected to the eardrum reverberates the sound it receives to the incus. Then the incus transfers its vibrations to the oval window in the cochlear. In humans and other land animals, the middle ear is normally filled with air. Unlike the open ear canal, however, the air of the middle ear is not in direct contact with the atmosphere outside the body. The Eustachian tube connects from the chamber of the middle ear to the back of the pharynx. (saladin, pg. 598) The middle ear is very much like a specialized paranasal sinus, called the tympanic cavity; it, like the paranasal sinuses, is a hollow mucosa-lined cavity in the skull that is ventilated through the nose. The mastoid portion of the human temporal bone, which can be felt as a bump in the skull behind the ausicle, also contains air, which is ventilated through the middle ear. The inner ear is formed by the vestibule, semi-circular canals, and cochlear. The fluid in the cochlear absorbs vibrations from the stirrup and transfers it to the vestibule. Vestibular hair cells are stimulated by movement of fluid in the semicircular canals and the utricle and saccule. Firing of vestibular hair cells stimulates the Vestibular portion of the eighth cranial nerve. Hair cells are also the receptor cells involved in balance, although the hair cells of the auditory and vestibular systems of the ear are not identical. (saladin, pg. 600) The eighth cranial nerve comes from the brain stem to enter the inner ear. When sound strikes the ear drum, the movement is transferred to the footplate of the stapes, which presses into one of the fluid-filled ducts of the cochlea. The fluid inside this duct is moved, flowing against the receptor cells of the organ of Corti. These stimulate the spiral ganglion, which sends information through the auditory portion of the eighth cranial nerve to the brain. (Saladin, pg.609) Eustachian tube has a special importance in the human body. It is also termed auditory tube or the. The Eustachian tube is a membrane lined tube that connects the middle ear space to the back of the nose. Its primary function is to ventilate the middle ear, ensuring that the pressure inside the ear remains at near normal ambient air pressure. The secondary function of the Eustachian tube is to drain any accumulated secretions, infection, or debris from the middle ear space. Several small muscles located in the back of the throat and palate controls the opening and closing of the tube. Swallowing and yawning cause contraction of these muscles, and help to regulate Eustachian tube function. If it were not for the Eustachian tube, the middle ear cavity would be an isolated air pocket inside the head that would be vulnerable to every change in air pressure and lead to an unhealthy ear. Normally, the Eustachian tube is sealed shut which aids the prevention of an inadvertent contamination of the middle ear by the normal secretions found in the back of the nose. A tube that is always open is called a patulous Eustachian tube. Patients with this rare condition are plagued by chronic ear infections. A much more common problem is a failure of the Eustachian tube to regulate pressure effectively. Partial or complete blockage of the Eustachian tube can cause popping, clicking, and ear fullness. The Eustachian tube is closed, but it can open to let a small amount of air through to equalize the pressure between the middle ear and the atmosphere. When this occurs, we hear a small pop, a predicament familiar to aircraft passengers, drivers in mountainous regions or those diving under water into the deep sea. Yawning or swallowing can pull on muscles in the neck, causing the tube to open. Some people are born with the ability to contract just these muscles voluntarily, similar to people who can wiggle their ears. Doing so will make ones voice sound deeper to ones self. Without this airway, the middle ear would be isolated from the atmosphere, and could be easily damaged by pressure changes. (Saladin, pg.845) The anatomy and physiology of ear as aforementioned functions for the sense of hearing. Many pathogens can cause the mitigation of hearing. For example, and ear ache can be bacteria affecting the Eustachian tube. But also, excessive sound or noise can influence bad health as well as hearing loss. As modernization has evolved over the centuries, complex machinery has bellowed sounds that could be nuisance to those who are victims of hearing it. Noise can disturb anyone’s solace and can definitely serve as distraction. In addition, there was not any political delegation that would consider mitigating such a nuisance because noise seems menial and not life-threatening in the past few decades. However, political reforms has been engendered and executed by European governments in response to discoveries that claim that noise pollution is more than a nuisance but a hazard to human health. Noise pollution at first glance will seem as insignificant. However, as research has shown, noise pollution has had a powerful impact of the lives of people. Noise has always been a problem for Europeans since the ancient times. Juvenal, a satirist Roman poet, seemed to take notice of the nuisance. He once wrote “carts clattering through the winding cities………the sick die here because they can’t sleep.” (www.savethis.com, Associated Press) Another French author Marcel Proust loaded his room with cork to dull the clamour of the streets of Paris. (Same source, Internet) As one would expect, the Industrial Revolution catapulted Europe and the United States in production frenzy. Thus, the large level of production increased the noise levels in Europe. The increase of goods spurred the interest of faster transportation. Therefore, the rise of railroads sprung all over Europe to satiate the need of quick transportation. Furthermore, this increased the noise levels of Europe. In today’s era, planes as well as automobiles has joined the factories and railroads in the noise contribution.  The noise generated from these vehicles is distributed over the population and has subtly affected their persons. For instance, the noise levels has been said to prevent sleep. That is a fact that Juvenal and Proust has illuminated. In the European Union, three quarters of 376 million people live in urban areas. Most of these residents have no choice because of their fiscal issues that deter them from purchasing a home away from the clamorous ambience. While some may consider noise as an ensign to economic development, they belittle its consequences. In 1996, the World Health Organisation (WHO) reported on the dangerous consequences to noise which are sleep disturbances, hearing disorders, and psychological disturbances. (www.tvlink.org/vnr) WHO also reported 40 percent of people are exposed to road traffic noise and that over 30 percent experience disturbances of sleep. The Belgium airport of Bierset also reports nearly 100 million people suffer from these disorders prompted by high noise levels. In light of these effects, elevated noise levels engender stress, increase workplace accident rates, and muster aggression as well as other anti-social behaviours. (www.wikipedia.com)  Moreover, the noise levels intervene in the biological constructs of the human body. For instance, high noise levels stimulate the body to increase cardiovascular blood flow by excreting adrenaline in the bloodstream. Therefore, after being activated by this hormone (adrenaline), the blood vessels constrict. This vascular flow increases the risk of high blood pressure and hypertension. For a person to reach that level, he or she must be exposed to 8-16 hours of high noise levels to trigger that threshold. In addition, in the studies of victims of noise pollution,  a plethora of proven effects of high noise levels are increased frequency of headaches, fatigue, stomach ulcers and head rush. Another study establishes links between high noise levels and fetal development. Extensive research proposes a correlation between low-birth-weight babies and high sound levels. Also correlations have been detected in abnormally high rates of birth defects in a locus where expectant mothers are exposed to elevated sound levels, such as typical airport sections. These birth abnormalities include harelip, cleft palate, and defects in the spine. According to Lester W. Sontag of the Fels Research Institute: “There is ample evidence that environment has a role in shaping the physique, behaviour and function of animals, including man, from conception and not merely from birth. The fetus is capable of perceiving sounds and responding to them by motor activity and cardiac rate change." (www.wikipedia.com) Noise exposure is said to be particularly hazardous to babies when it occurs between 15 and 60 days after conception. During this critical juncture, major internal organs and the central nervous system are developing in the baby. Their bodies are sensitive to sound as well as light. Other developmental effects occur when vessels constrict in the mother reducing blood flow, transportation and delivery of oxygen and nutrients to the fetus. The unborn child’s nutrition is compromised. Low birth weights and noise were also associated with lower levels of certain hormones, essential for protein synthesis in the baby and its fetal development, in the mother. The difference between the hormone levels of pregnant mothers in noisy versus quiet areas increased as conception drew near. (www.wikipedia.com) Also, it can mildly affect the mental health of residents near those hazardous venues. The annoyance effects of aircraft noise are widely recognized in Europe. In the United States, aircraft noise is deemed responsible for a significant amount of hearing loss as well as an accomplice to a plethora of diseases. (www.wikipedia.com) High levels of aircraft noise that commonly exist near major commercial airports indicates that it contributes to heart diseases, immune problems, neurodermatitis, asthma, and other stress related diseases. Further research studies are formed to better understand those symptoms. Research also indicated clearly that hearing loss is less a product of aging than a result of extended exposure to transportation related noise such as aircrafts (Rosen, 1965). Sounds that rise above a reasonable conversation can damage the delicate hair cells in the cochlea, the structure in the inner ear that converts sound waves into auditory nerve signals. Continuing damage to the cochlea could permanently prompt hearing loss and tinnitus may develop. Tinnitus is not a disease but an unwelcome symptom in which people cognitively experience hissing, buzzing, humming, or whistling sounds in their ears.   Disease in the ear happens to affect the nose, and the throat. They are connected through mucous membranes and the Eustachian tube. Therefore, if one is affected, there is potentiality to affect other connected constituents. This can be seen visibly by eyes, ear and throat vetnerain specialists when analyzing animals; Cats and dogs in particular. The auricle can be affected by diseases processes which affect the skin generally. Thus, lacerations are common in cats that fight, and ultraviolet-induced solar dermatitis typically results in the development of squamous cell carcinoma (Electronic source) in cats with non-pigmented ears that spend a lot of time outdoors. Cats occasionally develop aural haematomas, usually as a result of irritation affecting the ear canal that results in scratching. Harvest mite infestations can cause severe irritation of the head and ears of cats; the diagnosis is easily made by identification of orange or yellow lesions on the ears of affected cats. Smears of these coloured lesions demonstrate the large, orange/yellow mites. We have also seen a small number of cats with sarcoptic mange affecting the skin of the auricle or the external ear canal; in these cases mites were extremely abundant, as in Norwegian scabies of human patients. Young cats, outdoor cats and cats (also humans) that live in clans are commonly afflicted with Otodectes cyanotis, which results in an irritant/allergic otitis externa. A crusty black discharge is said to be characteristic, but a similar discharge can occur with other diseases of the external canal. All cats with otitis externa should be suspected of having ear mites until proven otherwise and the availability of modern, safe and effective products makes it worthwhile to treat tentatively for this disease even when mites are not detected. Direct visualisation of mites is facilitated by the use of a video otoscope, which provides both excellent illumination, magnification and a good depth of field. Material should also be obtained from the ear canal for cytological examination, as some mites or eggs can be seen in smears when adult mites have been missed using otoscopy. Mites are large, pearly white, very active and are said to run away from the light source, although this is not my experience. A variety of modern treatments are now available for treating Otodectes infections e.g., friponil, ivermectin, milbemycin and selamectin. It is important to treat the whole cat, not just the ear canal, to repeat the treatment after three weeks, and to treat in-contact cats and dogs. The same approach should be applied to humans. Occasionally, Demodex catii can cause parasitic otitis externa in cats. The diagnosis is made by microscopic examination of smears from the lining of the ear canal. Usually these cats have some underlying cause for immuno-suppression, for example corticosteroid therapy or FIV infection. Treatment using topical or systemic therapy is generally successful. Bacterial otitis is rare in cats, but does occur, and should be treated using a combination of systemic and topical therapy. Systemic therapy is often easier in cats with irritated ears that otic therapy and this is not cost-prohibitive as in larger canine patients. Occasional cats with allergic dermatitis get otitis externa as a component of their tolerance to their allergic reaction, and treatment should be directed at the underlying allergic condition as well as the irritated ear canal. (Electronic source) Patients with eye, ear, nose, throat, or oral (EENTO) conditions or communication disorders have necessities that they will increasingly expect the health care system to meet in a more organized manner in the future. (Electronic source)These needs include the obligation to educate and inform patients at appropriate times to assist them to make sound decisions. People need education on risk factors and how to maintain their health. When symptoms first appear, access to a rapid screening process is necessary. Patients require involvement in their treatment plan, and they expect respect and guidance if they choose to use complementary therapies (Victor R. Fuchs, pg.). Those with EENTO malignancies particularly need diagnostic results without hesitation and immediate intervention once treatment is decided upon. Patients with EENTO conditions will require periodic as well as systematic interventions but services that are well organized and comprehensive. In the commencement, throughout, and after interventions, they and their families need appropriate follow-up care and support. Frequently, EENTO surgical treatments or other procedures temporarily or permanently affect individuals abilities to see, communicate, or continue their nutrition normally. They need help to withstand and work through these challenges. All these services must be well coordinated across all sites particularly if the person requires a long tenure follow-up involving several service providers. This maintains and sustains continuity of care and smooth transitions. Individuals also need to have care provided in a way that respects their confidentiality and, it will stimulate trust within the system. (Electronic source) In ear, nose, and throat care, important technological trends include three-dimensional surgical planning programs and image-guided surgery, which will proliferate a more discreet representation of the patients anatomical features for greater precision; better intra-operative techniques, such as micro-invasive surgery that will mitigate surgical trauma, improve the quality of treatment options, and reduce the number of surgical complications; and applications of growth factor that help engender tissue and increase the wound-healing process. In the discipline of otology, speech-language pathology and audiology, it is expected that inner ear hair cells can be regenerated; there will be inner ear and cochlear microsurgery and middle ear robotic nanosurgery; improved laryngeal voice prostheses and augmentative communication devices (i.e. automated auditory brainstem response) and better hearing aids will be utilized, such as better bone-conduction implantable hearing aids, cochlear implants, or brainstem implants, other implantable hearing aids, etc. In one or two decades, there may be a conjugated pneumococcal vaccine that can be dispensed at an early age to prevent otitis media. In the field of rhinology, there will be better understanding of olfaction and better chemoreceptor technology, (Saladin, pg. 599) leading to medical treatment that may help in rehabilitation of anosmia (the inability to perceive smells). Minimally invasive sinus surgery with micro-powered instruments, together with three-dimensional endoscopy, will improve our ability to diagnose and treat sinus conditions. In addition, these interventions, if gradually implemented over the next 10 to 20 years, will result in greater success in preserving the larynx and improving surgical outcomes and rehabilitation of elocution, hearing, and balance functions. (Schwartz, pg. 589) Patients with ear pathology require the availability of specialized diagnostic services and the presence of professionals with highly developed dexterity in testing and rehabilitation. Diagnostic services required but not available in the community include otoacoustic emissions, and auditory brainstem response testing. Patients with balance disease require a fully equipped vestibular laboratory with specialized equipment. A multidisciplinary approach to understanding and managing the often multisystemic affliction that causes their instability must be organized for and available to patients in a timely fashion. Furthermore, the needs of these individuals dictate that the physician practices should play a key role in community physician education and the dissemination of information regarding care of the patient with a balance disorder. Treatment for sinonasal disorders will likely become the leading type of ENT surgery performed at the at clinic, while the evolution of care will see such disorders develop as a major subspecialty. As these disorders become more identifiable and the disease processes more clearly understood, outcomes and individualized treatments will be established. That also involves treatment for allergies and pathological infestations. Thus, patients with rhinologic disease require a setting that promotes close collaboration of the rhinologist with an allergist, an infectious disease specialist, and an ophthalmology specialist. One of objectives of physician is also to access the need of a hearing aid. Highly trained specialists and the great laboratories are required to access such needs. Incredibly competitively priced, the huge range of flexible hearing-aid options available to patients includes: ‘Digital Instruments that can amplify soft, difficult-to-hear sounds, such as a whisper, to more natural levels, while amplifying loud sounds only fractionally, if at all.’ ‘Hearing aids that automatically adjust to rising ands falling noise levels, increasing and decreasing volumes as you move from quiet conversation to a noisy listening environment.’ ‘A choice of models to suit your lifestyle, your cosmetic preference and your pocket, from a virtually invisible completely-in-the-canal unit to a mini behind-the-ear unit with a power option.’ ‘A choice of as many as five different performance parameters in the instrument you choose, allowing the unit to be adapted to your individual needs for a completely personalised fit.’ ‘Fully programmable hearing aids that can be digitally tuned by a computer – and your hearing specialist – so that they are precisely tailored to fit your precise level of hearing loss.’ ‘Full-shell hearing aids that effectively address the complaint of amplified background noise by offering a directional option that helps decrease the sensitivity to background noise.’ (Electronic source) A hearing aid is ordered to the specific requirements of each patient following a consultation with an audiologist and, once the instrument has been fitted, the patient can enjoy it for a trial period of between two and three weeks, although a follow-up visit for any adjustments is recommended after two weeks. If the hearing aid is of no benefit to the client, he or she will only be required to pay a make-up fee, as the instrument will be returned to the manufacturer. If the hearing aid proves effective, however, payment is made at the end of the trial period. Follow-up procedures may be required from time to time to address minor problems such as wax build-up or ear infections, while the instrument will need to be serviced once a year. Ear moulds for behind-the-ear devices also need to be replaced at least once a year, as they gradually harden and break. These procedures can be done in the patient’s home country. Ultimately, when patient has a problem with his or her ear, physicians especially otologists must refer them to the appropriate audiologists depending on the severity of hearing impairment. As mentioned above, there are many complications a patient may have, whether pathologically or environmental hazards. Documentation of a diagnosis of certain patient is critical and it is the ethical obligation of physician to do so. (Electronic source) To refer to the correct audiologist, physicians may need, depending on the severity of the malady, a team composed of anaesthesiologist, nurses, and otolaryngologists to give their input on the severity of that disease involving the ear and help decide where the patient can be referred. This prolific approach will definitely help get the patient the proper referral. Physicians should work under the ambience that one brand only hearing instrument stores do not necessarily address and serve your particular needs. The hearing aid industry is lucrative and sadly, many instruments are inappropriately dispensed, overpriced and ill–fitted, which results in guaranteed repeat business for many of the single brand stores who take advantage of public ignorance. Physicians should be interested to protect the rights of its patients and certify that the first purchase and fitting is the only one necessary for many years. Statistics: Hearing Type 1 2 3 4 5 6 7 8 9 10 11 Total 9 8 1 1 0 2 4 16 3 1 5 Referral Type 1 2 3 4 5 Total 14 0 15 11 10 Referral Type Description 1 Referral is not advised unless there are other ENT symptoms, e.g. acute rotatory vertigo, severe tinnitus, severe pain/discharge from ears. 2 Early ENT referral is advised in view of hearing loss and/or signs of significant ENT pathology. 3 Referral to routine ENT clinic is recommended. 4 This patient may benefit from hearing aid provision following ENT investigation of hearing loss. Referral to routine ENT clinic is recommended. 5 This patient may benefit from hearing aid provision. Referral to the direct access hearing aid clinic using the blue form is recommended. Hearing Type Description. 1 Thresholds are within normal limits. 2 Mild unilateral conductive hearing loss. 3 Severe unilateral conductive hearing loss. (>30dB between ears) 4 Bilateral conductive hearing loss. 5 Unilateral mixed hearing loss. 6 Bilateral mixed hearing loss. 7 Asymmetric sensory-neural hearing loss. 8 Bilateral symmetric sensory-neural hearing loss. 9 Responses variable and inconsistent with informal observation of communication ability. 10 Mild asymmetric sensory-neural hearing loss. 11 Very mild bilateral symmetrical high frequency loss. Hearing Impairment       Mean Mode Median Standard Deviation 8 8 6   The data above represents the assessment of the symptoms of patients by NHS audiology department. Each patient seen expressed an individual analysis of how they feel. From that opinion, physicians will utilize the appropriate methodology to accommodate the dilemma. If the physicians at NHS are unable to fix the situation, then it is their obligation to send patient to specialists of audiology. The mean of the hearing impairment was 8. That is, an average amount of patients experience bilateral symmetric sensory-neural hearing loss. The patients by far had an overall moderate to extreme circumstantial auditory impairment and the physicians saw the urgent need to refer them to major audiologist that specializes in the procedure of prescribing an accurate hearing aid. The hearing would be very beneficial to them. The follow up procedure performed by any physicians after the patient has been analyzed is -of course- is to see well-being of that patient under the ideology of their professional etiquette. These results from the analysis does not goad or persuade anything other than the appropriateness of the physicians of NHS to refer the patients accordingly to the respective audiologists. Conclusion : As this dissertation and analysis has depicted, ear has a great significance to the body. A French quote may be appropriate for this conclusion- “the ear is the path to the heart." Some may dispute the physiological veracity of that statement but connotational reference proves true. Ear as aforementioned provides an acoustic venue in the constructs of the body. From high blood pressure to prenatal deformations, noise can have an effect on human growth. As depicted by the brief description of animal diseases, pathogens affecting the ear have an impact on the throat and nose. Later in the literature review, we saw how physicians seriously take into account audiological problems as well as retrieval of appliances to aid audiologically handicapped in some way or form. Furthermore, in the data shown, we saw the scale of how patients are judged and classified to what type of specialist the need to appeal to their maladies. Bibliography: Fucks, Victor R. (1986) The Health Economy. Harvard Massachusetts Press: London Schwartz, Shires, & Spencer (1989) Principles of Surgery. 5th Edition. New York: McGraw Hill pp.1935 Wilson, Braunwald, Isselbacher, Petersdorf, Martin, Fauci, & Root. (1991). Principles of Internal Medicine. 12th Edition. Volume 1. New York: McGraw Hill Wilson, Braunwald, Isselbacher, Petersdorf, Martin, Fauci, & Root. (1991). Principles of Internal Medicine. 12th Edition. Volume 2. New York: McGraw Hill Saladin, Kenneth S. (2004) Anatomy and Physiology: Unity of Dorm and Function. Third Edition. McGraw Hill: London Electronic Sources: http://www.fda.gov/ohrms/dockets/ac/99/minutes/3522m1.pdf http://www.medicinenet.com/eustachian_tube_problems/page3.htm http://www.herbdatanz.com/ear_nose_throat_harry_benjamin_nd.htm http://www.muhc.ca/construction/documentation/ppg/5/ http://www.mediscapes.com/medical_procedures/ear_nose_throat.htm Read More