Hearing Aids and Otosclerosis
Hearing Aids have often been advocated as a treatment modality for otosclerosis. The basis for this arises from the concept that it is noninvasive, can be fitted in both ears and does not run the risk of causing a possible permanent irreversible sensorineural hearing loss. Stapedectomy when done in expert, experienced hands offers excellent results. Still, even under these conditions there still is a possibility of a permanent, irreversible sensorineural hearing loss. Most modern hearing aids are now digital and offer excellent amplification and are programmable. Technologically they are getting better and better and are a viable alternative to surgery. The only impediment is that they are expensive, not covered by insurance and require regular maintenance.
Most modern surgeons lack operative experience and are therefore unable to provide good results consistently because the number of patients suffering from otosclerosis has declined dramatically. Thus they lack operative experience and could inadvertently cause permanent irreversible sensorineural heating loss. Thus hearing aids are now an important option in the treatment that should be offered to patients.
Most patients with otosclerosis have a severe conductive hearing losses that is accompanied with a sensorineural component. A typical characteristic though is that most patients usually have a good to excellent speech discrimination score despite the severity of the conductive hearing loss.
Amplification via hearing aids or assistive listening devices as an alternative to surgery needs to be presented to patients as viable alternatives (Johnson 1993) . Not only are there medicolegal responsibilities in presenting these alternatives, but there are a number of patients who may be adequately managed with amplification.
In a paper that generated many rebuttals Howard (1998) states that hearing aids need to be offered to patients as an alternative to surgery to patients who have otosclerosis. O’Connor and Wiet (1991) state that when presenting management alternatives to the otosclerotic patient, amplification via hearing aids or assistive listening devices or both must be offered as a viable alternative to surgical and/ or medical intervention. This is necessary not only from the medicolegal point of view but also from the ethical aspect as well. This is because a significant number of patients can be managed appropriately with amplification.
Lundy (1999) in his letter to the editor in response to Howard’s paper notes that his reason for advising stapedectomy over a hearing aid is because hearing aids are expensive ($ 800 to $2500) per hearing aid which needs to be replaced every 3 to 4 years. Batteries also need to be changed every 2 weeks. In addition repair costs need to be included which further push up the costs of a hearing aid. He further notes that hearing aids are not covered by medicare or the vast majority of insurers. He considers that unless hearing aids become a covered benefit of medicare and insurers, then hearing aids are not truly an equal alternative for the patients who have otosclerosis.
In point 4 in response to the subject as to whether hearing aids as an alternative for conductive hearing loss are essentially risk free Lundy (1999) agrees that hearing aids are essentially risk free. In other words they do not subject the patient to the risk of a possible irreversible profound sensorineural hearing loss. He however further cautions that hearing aids are not always reliable or available and that the value of treatment is more than just the risks involved.
Most of the authors in response to Dr Howards paper concede that the major impediment to advocating a hearing aid lies in the problem that they are expensive and are not covered by medicare and most health insurers in the US.
Gauthier (1999) in a letter to the editor regarding Dr Howards paper raises the following points.
Gianoli et al (1999) raises several points in which he disagrees with the premise that hearing aids are an equal alternative to a successful stapedectomy. They note in point 4 that hearing aids are not an equivalent to a successful stapedectomy. They further note that the quality of sound produced by a hearing aid is not equivalent to normal hearing. A successful stapedectomy patient never has trouble with acoustic feedback, never runs out of batteries and never has to take out his hearing aid while bathing, swimming etc. A successful stapedectomy patient is less prone to accumulation of wax and otitis externa and has less problems with word discrimination in the presence of background noise.
In premise 5 that hearing aids are complication free ,Gianoli et al (1999) note that Gianoli has witnessed a patient lose his job because of discrimination caused by a hearing impairment.
Miller (1999) an audiologist, notes in his reply to the editor that he offers hearing aids as an alternative modality of treatment to otosclerotic patients. However he ‘tilts’ in favor of surgery when there is a large air bone gap, good to excellent word recognition scores and good cochlear reserve. Finally in his reply to the editor Howard (1999) concedes that hearing aids are not covered by medicare insurers. This would then cause patients to opt for surgery since stapedectomy is covered by insurance while hearing aids are not.
All the authors of the letters to the editor quoted above discuss not the ethicality of the procedure but the ethics of the surgeon who will do the procedure.
The questions they raise are
Finally it should be said that the surgeon should be honest with himself and discern which patients he feels would genuinely benefit from amplification and those from surgery.
Most modern surgeons lack operative experience and are therefore unable to provide good results consistently because the number of patients suffering from otosclerosis has declined dramatically. Thus they lack operative experience and could inadvertently cause permanent irreversible sensorineural heating loss. Thus hearing aids are now an important option in the treatment that should be offered to patients.
Most patients with otosclerosis have a severe conductive hearing losses that is accompanied with a sensorineural component. A typical characteristic though is that most patients usually have a good to excellent speech discrimination score despite the severity of the conductive hearing loss.
Amplification via hearing aids or assistive listening devices as an alternative to surgery needs to be presented to patients as viable alternatives (Johnson 1993) . Not only are there medicolegal responsibilities in presenting these alternatives, but there are a number of patients who may be adequately managed with amplification.
Situations in which amplification (hearing aids) may be considered.
Patients who can be managed in such a way include the following:-- Patients who cannot undergo surgery because of major systemic illnesses.
- The only hearing ear.
- Inadequate hearing reserve or poor speech discrimination scores or both.
- Congenital fixation of the stapes with the real risk of it developing into a nonhearing ear is surgery is contemplated.
- Surgery is not elected for by the patient.
- Early (mild) conductive hearing loss.
- Unsuccessful surgery for otosclerosis upon the other ear.
- The patient has otosclerosis and Menieres disease.
- Those patients who have stapedectomy for far advanced otosclerosis will now benefit from hearing aids
Lundy (1999) in his letter to the editor in response to Howard’s paper notes that his reason for advising stapedectomy over a hearing aid is because hearing aids are expensive ($ 800 to $2500) per hearing aid which needs to be replaced every 3 to 4 years. Batteries also need to be changed every 2 weeks. In addition repair costs need to be included which further push up the costs of a hearing aid. He further notes that hearing aids are not covered by medicare or the vast majority of insurers. He considers that unless hearing aids become a covered benefit of medicare and insurers, then hearing aids are not truly an equal alternative for the patients who have otosclerosis.
In point 4 in response to the subject as to whether hearing aids as an alternative for conductive hearing loss are essentially risk free Lundy (1999) agrees that hearing aids are essentially risk free. In other words they do not subject the patient to the risk of a possible irreversible profound sensorineural hearing loss. He however further cautions that hearing aids are not always reliable or available and that the value of treatment is more than just the risks involved.
Most of the authors in response to Dr Howards paper concede that the major impediment to advocating a hearing aid lies in the problem that they are expensive and are not covered by medicare and most health insurers in the US.
Gauthier (1999) in a letter to the editor regarding Dr Howards paper raises the following points.
- Stapedectomy is covered by most insurance plans, while a hearing aid is not.
- Would not an ethical situation demand that the patient have similar cost and benefit for both options? (for hearing aids as well as that for stapedectomy surgery).
- Is it ethical that only the rich can afford the low risk option of hearing aids?
In premise 5 that hearing aids are complication free ,Gianoli et al (1999) note that Gianoli has witnessed a patient lose his job because of discrimination caused by a hearing impairment.
Miller (1999) an audiologist, notes in his reply to the editor that he offers hearing aids as an alternative modality of treatment to otosclerotic patients. However he ‘tilts’ in favor of surgery when there is a large air bone gap, good to excellent word recognition scores and good cochlear reserve. Finally in his reply to the editor Howard (1999) concedes that hearing aids are not covered by medicare insurers. This would then cause patients to opt for surgery since stapedectomy is covered by insurance while hearing aids are not.
All the authors of the letters to the editor quoted above discuss not the ethicality of the procedure but the ethics of the surgeon who will do the procedure.
The questions they raise are
- Has the patient been offered amplification as an alternative modality?
--Our view is that amplification must be offered as an alternative modality not just from the aspect of compliance of medicolegal regulations but also from an ethical point of view. However everything should be placed in perspective. We feel that the patient should be allowed to meet and discuss with other patients who have undergone a successful stapedectomy as well as those who wear a hearing aid. This will help them appreciate the pro’s and cons of both modalities. - What is informed consent?
--Informed consent is a sine qua non of any procedure. It is incumbent upon the surgeon to make it clear to the patient the real, albeit low, risk of a permanent irreversible sensorineural hearing loss that may accompany an apparently uneventful and for all practical purposes, successful stapedectomy. And that the permanent irreversible sensorineural hearing loss could be immediate or could be delayed.
Finally it should be said that the surgeon should be honest with himself and discern which patients he feels would genuinely benefit from amplification and those from surgery.
References
- Gauthier MG (1999): Never say “ever”. American Journal of Otology 20(1); 138.
- Gianoli GJ, Gonsoulin T, Amedee R, Tabb H, Mann W(1999): Is stapedectomy ever ethical? Faulty premise, faulty conclusion. American Journal of Otology. 20(1) 138-139.
- Howard ML (1998): Is stapedectomy ever ethical? American Journal of Otology. 19:541-543.
- Howard ML (199): Authors reply in letters to the editor. American Journal of Otology.20(1)141.
- Johnson E W (1993): Hearing aids and otosclerosis. Otolaryngologic clinics of North America26:491-502.
- LundyLB (1999):”Ethics” of stapedectomy. American Journal of Otology.20(1):137-138.
- Miller M (1999): An audiologist replies (letters to the editor). American Journal of Otology 20(1) 140-141.
- O’Connor C and Wiet RJ (1991): Hearing aid use: An alternative to surgery.Otosclerosis (otospongiosis) eds Wiet RJ, Causse JB, Shambaugh GE, Causse JR. American Academy of Otolaryngology, Head and Neck Surgery Foundation Inc.pp129-133.
- Pohlman AG (1943): The diaphragm rod prosthesis of the middle ear. Archives of Otolaryngology37:628.
- Reger S (1940: Factors influencing the accuracy and interpretation of bone conduction and other tests. JASA 11: 378