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听BRITISH BROADCASTING CORPORATION
RADIO SCIENCE UNIT
CASE NOTES
Programme 7 - Hearing and Balance
RADIO 4
THURSDAY 12/07/05 2100-2130
PRESENTER:
MARK PORTER
REPORTER: LESLEY HILTON
CONTRIBUTORS:
JEREMY LAVY
STEVE ATKINS
LUCY HANSCOMBE
MIKE GROCOTT
NEIL THOMAS
ELIZABETH DAVY
PRODUCER:
PAULA MCGRATH
NOT CHECKED AS BROADCAST
PORTER
Hello. In today's programme I'll be looking at problems with the ear - the organ responsible for hearing and balance.
Nine million people in the UK have difficulty hearing - that's one in seven of the population. I'll be discovering why it pays to look after your ears - particularly if you enjoy listening to music on a personal stereo or an MP3 player like the ubiquitous iPod.
Tinnitus - derived from the Latin tinnire, meaning "to ring" - is another common problem, and often associated with noise related damage. Around 1 in 12 of the UK population will consult their GP at some time complaining about strange clicks, whirrs, buzzes or ringing in their ears, most of whom will be told there's not much that can be done - but that's not strictly true. There is an effective, and often underused treatment, that can help the more persistent cases - even people who have had tinnitus for years.
And Lesley Hilton reports on how physiotherapy can provide almost instant relief from the most common type of vertigo - that awful sensation that everything is on the move, something my patients often liken to feeling like they are standing on a boat in rough seas.
My guest today is Jeremy Lavy, consultant surgeon at The Royal National Throat, Nose and Ear Hospital in London.
Jeremy, let's start with some basic anatomy. The ear has two functions - hearing and balance - let's start with hearing. How do sound waves get transmitted to the brain?
LAVY
Well the sound waves are focused into the ear by the outer ear, which we call the pinna, which I liken to a satellite dish.
PORTER
Which is why it works better if you cup your ear with your hand.
LAVY
Precisely, yes. And so the sounds are focused in and the sound waves then pass down the ear canal and then they hit the ear drum, which is just like the skin of an ordinary drum. The drum is then forced into motion and attached to the drum is the first of the three little hearing bones, which most people can remember from their biology days. So that bone then is set in motion and that vibration is transmitted down the three bones, across a space that's called the middle ear and this is again an air filled space that connects via a small tube to the back of your nose and if you go on an aeroplane flight and clear your ears, that's air passing up or down the Eustachian tube. So the sound waves are transmitted across the middle ear and into the inner ear and the inner ear I like to look at as the really the nuts and bolts of the ear, this is where sound waves in the air get converted into electrical impulses within the nerves system that then get passed to the brain. And so the inner ear is the very clever bit where mechanical waves get converted into electrical neural impulses.
PORTER
What's happening on the balance side - is the balance side a separate thing altogether?
LAVY
The whole inner ear is one system and it has a hearing element and it has a balance element and the two are very closely connected, so often if you have diseases affecting one they often affect the other too.
PORTER
And how do we maintain our balance - what is the balance system, how does it work?
LAVY
The balance system has a number of inputs, all of which are sort of put together by the brain, so you get impulses from the ears themselves on both sides and you've got detectors that can pick up acceleration of the head, other detectors that can tell you which position the head is in, in relation to gravity. Then you've got impulses coming from your eyes and you've got impulses coming from the joints. So this is often why dizziness and balance problems tend to affect people when they're older, as their vision starts to fail and as their joints may be replaced or they're suffering with arthritis, so they're getting - they're losing some of those inputs and the brain is struggling to put everything together.
PORTER
And these sensors, I mean what's actually happening, because they're fluid filled aren't they?
LAVY
There's fluid filled - there are different sensors - there's three fluid filled canals, so they will be constantly putting information into the brain, which the brain is - if you like - is like a central computer putting all this information together and saying this is equilibrium.
PORTER
Well we'll come back to hearing problems a little later but first let's look at balance in a bit more detail. We sent Lesley Hilton to the Balance Centre at York District Hospital, where a simple manipulation by physiotherapists - known as the Epley manoeuvre - has revolutionised the treatment of the most common form of vertigo - curing as many as 7 out of 10 cases. And the whole thing can be done in less than 10 minutes.
ATKINS
Well first of all I break out in an awful sweat and feel ill. Then it gradually gets that everything starts spinning not only one way but spinning left and right at the same time. It's like being on a height and you're looking over and then all at once you're falling over and you start slowly swirling round and then that of course brings the sickness on.
HILTON
Steve Atkins has been having attacks of vertigo for more than 20 years and still has no clear diagnosis. The attacks can make his life a misery - not helped by some people suggesting that he can't hold his drink.
Vertigo differs from dizziness in that while dizziness is usually a light headed feeling, an attack of true vertigo gives the illusion that either the person or the environment is moving even when standing still. It can be caused by problems in the inner ear or the brain. Neurologist Phil Duffy.
DUFFY
It can be sometimes associated with structural pathology within the brain stem and sometimes it's possible to determine from the history that the patients give that the vertigo may actually represent a structural abnormality within the brain. I also have a fair number of patients with multiple sclerosis who have experienced vertigo at some stage.
HILTON
The sensation of vertigo usually occurs when there is a clash between the various bits of information which help us to balance ourselves. Normally we use our eyes, the balance centres in the ears and the peripheral nervous system. Any mismatch has the potential to produce vertigo.
ACTUALITY - SALLY AND JACKIE
Now it's like some two weeks, is it, since we last saw you Jackie? And how have things been?
After you did the first treatment for the week it was fine. I didn't have it at all. But then it came back. And it seems to be - appears to be stronger. So - but it's the same symptoms.
And when are the symptoms actually happening now?
When I'm in bed mainly - exactly the same - moving from side to side ...
HILTON
Jackie Cooper has come to see Sally Winterburn, the physiotherapist at the York Balance Centre. Jackie has a type of vertigo called Benign Paroxysmal Positional Vertigo. It's the most common form and is characterized by the sensation of motion brought on by sudden movements of the head. It can often be successfully treated using physiotherapy, as Gerry Riley, ENT consultant at York explains.
RILEY
Benign Paroxysmal Positional Vertigo is usually treated by a series of physical manoeuvres. We think that the problem is that there is some crystalline material in part of the balance system where it shouldn't be and by moving the patient through a series of physical movements we can often return their crystalline material from the place where it's not supposed to be back to a part of the balance organ where it does no harm.
ACTUALITY - SALLY AND JACKIE
Now what I'm going to do is do the test that we did last time, so I'm going to turn your head towards me and then I'm going to lie you down so that your head's going to be just tilted over the end of the bed. Going to go down on the count of three, what I'd like you to do is to keep your eyes open and if you feel any dizziness then let me know. Okay. So if I can just ask you to shuffle up the bed an inch, that's it ...
HILTON
Other forms of vertigo caused by inner ear problems are Meniere's Disease, vestibular neuronitis - often called labyrinthitis, and a severe type of migraine. Physiotherapists, like Sally Winterburn, believe it's important to create an individual set of exercises for each patient.
WINTERBURN
We find out which movements they find difficult, tailor their exercise programme to that and also deal with them sort of functionally because a lot of these patients have difficulty when they're going into supermarkets, in busy environments, and we need to get them so that they're able to be confident to cope in that situation.
HILTON
Vertigo can also be a symptom of a whole host of diseases from mild thyroid conditions to diabetes to more serious problems with tumours, although those are rare. It can sometimes be hard to diagnose the specific cause, as in the case with Steve Atkins. No treatment has been totally effective for him and the fact that what he has is a common complaint is not much comfort.
ATKINS
When I've got this wretched feeling then you wish you could die because you shut your eyes you're still dizzy, you open your eyes and the whole room is just going round and round. It's a terrible feeling but after you've been ill it's a nice feeling to come back up on this earth again. But it's a terrible thing to feel.
PORTER
Steve Atkins talking to Lesley Hilton.
Jeremy, just to clarify - the Epley manoeuvre aims to remove bits of debris that are floating around in those sensors that you were talking about. Where do they go?
LAVY
Well that's right. I liken it to one of those puzzles we all have from our Christmas crackers where you have a ball bearing inside a maze and the ball bearing has basically gone into a place where it's causing problems and by moving the head in a certain way you can tip it from the very small diameter semi-circular canals into the larger reservoir where it doesn't really cause nearly the same degree of problem.
PORTER
And who might be suitable?
LAVY
It's classically people who, as in the clip there, people who have vertigo that is associated with certain movements of the head and the classic is to be lying in bed, to turn over on to one side and suddenly to feel very, very dizzy and just having to lie still and then it passes off in a matter of seconds, then you turn back into the original position and it happens again. And again lasts between 10 and 15 seconds usually.
PORTER
What about other treatments? There was no mention of medication there, let's assume you're not suitable for the Epley manoeuvre, what about pills?
LAVY
Well the classic treatment - the medication that most people go on are things called vestibular sedatives, such as stemetil - I'm sure many of your patients will have been on that. And what this does is just dampen down the nerve - the number of nerve impulses coming from the balance organs. So if there is an imbalance between one ear and the other ear, if the whole thing is dampened down there the actual degree of the imbalance is less. But in the long run recovery from dizziness depends on the brain often resetting the equilibrium, I've talked about all the different inputs and it comes to resetting that equilibrium. And it won't be able to do it if the imbalance is not sufficient, so you do need to take people often off these tablets to allow them to recover. So really people shouldn't be on them for a long time.
PORTER
What about Meniere's Disease? That's a term you hear banded round - I mean I get a lot of people coming in saying - My meniere's is playing up doctor.
LAVY
Meniere's Disease is a specific disease that can cause vertigo, it's associated with vertigo, what we call acute attacks of vertigo, so most of the time the patient is fine and then suddenly they'll have an acute attack, which have an onset of vertigo associated with hearing loss and feeling often of fullness in the ear and tinnitus - a noise in that ear. And that attack can last from minutes, sometimes up to, hours and it's severely disabling. If you're very, very sick they often have to take to their bed and they often have to call out their GP to give them an injection for the symptoms to settle.
PORTER
Is it one of the common causes?
LAVY
It is relatively common, it is relatively common but I think probably not as common as it's often diagnosed as but yeah, if you're looking for it, it is quite common.
PORTER
Well tinnitus - with or without related problems like hearing loss and Meniere's Disease - is a very common complaint And it can sound something like this:
FLUTTERING NOISE
As many as one in three of us will develop tinnitus at some time, though in many cases, thankfully, it soon disappears as mysteriously as it arrived. Not so for session drummer Mike Grocott, who blamed his persistent tinnitus on too much loud music, and thought he would just have to put up with it, until he was referred to hearing therapist Lucy Hanscombe.
GROCOTT
It was six years ago, I was doing session and usually after I've been doing - I had been doing things I would always get ringing in my ear, I think everyone does after they've been to a club or any nightclub. And usually within two or three days that goes, this time it stuck there, well it's still there now but after say four or five weeks I went to see the doctor because it just wouldn't go. And it was actually quite - I had some - well I had a lot of head pains as well from it, I had done some damage - I'd been really overexposed to noise.
HANSCOMBE
Tinnitus is really a very broad term which just describes any kind of noise which can be heard inside the head or inside the ears and it's different noises for different people. I mean most people have experienced some sort of tinnitus at some time, most of us have actually heard noises in our ears after going to a rock concert for example. Quite a lot of people have what's known as prolonged spontaneous tinnitus, which is tinnitus that lasts for over five minutes at a time and hasn't been triggered by any particular event like a rock concert. And it's still up to about 1 in 10 people have experienced this kind of tinnitus. It's also caused by many different types of hearing damage, so hearing damage that just comes about through older age, for example, any kind of hearing damage which maybe caused by an infection, sometimes just a temporary ear problem and sometimes it's not obviously related to hearing damage at all, so a lot of people with completely normal hearing have tinnitus as well and sometimes it comes about through stress.
GROCOTT
They tested me for earwax, I did explain what happened - I'd been in a really loud environment for a very long time. They tested me and gave me antibiotics, in case I had an ear infection. And then a few weeks after that the noise was still there - they referred me to a specialist. And that was almost a year later when I got through to the specialist, they said - Yes, you've got tinnitus and there's not a great deal that can be done about it, it may go, it may not. And that's go on for six years and now I've come to hearing therapy, which has been completely different, it's completely changed my outlook on the whole thing. I've had everything explained to me on how my hearing works, literally from scratch, from one side to the other, how your brain recognises signals and what it is that's wrong with me. Also the fact now I've been told that it is possible to not cure tinnitus but to live with it and to ignore it, so it's basically gone and there's different methods that are really great that I had no idea that existed.
HANSCOMBE
The type of therapy that I use for people with tinnitus is broadly known as habituation therapy because the whole aim of it is to get people to habituate their tinnitus to such an extent that they're not so aware of it anymore and it's not having the same kind of impact on their life, as it might have done in the first place.
The first thing is to explain to them about what tinnitus is and what it isn't because very often people come with worries, like maybe I've got a brain tumour, maybe this noise is going to make me go deaf, maybe it's the sign of something worse. So the first step is really to reassure people about all of those things and explain to them that what they're hearing is nothing more than a noise, although it can be very distressing and annoying it doesn't mean that worse things are to come.
GROCOTT
The main thing I can do is I can hear that noise now, I can say it's not a problem, there's nothing wrong with my ears, everything has this sort of thing, just forget about it and as you would with any noise in the street, if you live on a busy main road, you hear buses go past, even aeroplanes flying over, you just live with it and ignore it and I think that's what's going to be happening with this.
HANSCOMBE
Because we all have a certain ability to filter out background noises that we consider to be unimportant. If you think about things you have at home, like a fridge, for example, that makes a continuous humming noise, most of us don't notice the noise of our fridge - most of the time. And it's not because it doesn't come through our ears, we can hear it, but we don't notice it because it's part of the natural environment, it's not threatening in any way. Now one of the reasons why people become tuned into tinnitus is because it's perceived as something threatening, disturbing, something that's having an impact on life and if those associations can be taken away and the tinnitus can be considered as something neutral, then it's much easier for the brain to go through this normal habituation process, put it in the background and filter it out. So although the person can still hear it, they're no longer aware of it, at least not all the time.
PORTER
Hearing therapist Lucy Hanscombe. You are listening to Case Notes, I'm Mark Porter and my guest today is consultant ear, nose and throat surgeon, Jeremy Lavy.
Jeremy, what's typically involved in the average course of tinnitus habituation, how long and how often would you have to go?
LAVY
Well it tends to last about 18 months and people who are having it will have between six and eight sessions over that time.
PORTER
And success rates?
LAVY
Success rates are quoted at around 75-80% as far as improving the tinnitus.
PORTER
That's a pretty good result given that I mean we heard there that that chap had had problems for six years.
LAVY
Yes it is, I mean it is a very useful thing and I think it's, again, underused.
PORTER
Any clues to when tinnitus may be a sign of more sinister underlying problems? We heard there that there can be other causes that we might be more worried about.
LAVY
Certainly. I think the things to be aware of if you've had tinnitus for many years and it changes, either it changes in character or the volume of it changes, that's something to go along to see your GP about. Also if you've got it just on one side, that's an important feature. And if the tinnitus has a pulsatile quality to it - so if it's sort of pulsing away - again that's something I think it's worth pointing out to your GP.
PORTER
Let's go back to hearing. What are the most common causes of hearing loss in the UK?
LAVY
In the UK the commonest cause must be age related hearing loss and linked in with that hearing loss related to industrial causes and noise induced losses. And certainly as the population as a whole is concerned that would be the most common. But as far as my practice is concerned, as an ENT surgeon, as an ear surgeon, it's more the, what we call, the conductive causes, so anything that will interfere with the conduction of the sound from the eardrum into the inner ear.
PORTER
Across this middle ear cavity, we were talking about earlier on.
LAVY
That's right, across the middle ear cavity. If you like these are the mechanical problems, so you can see yourself as an inner ear mechanic basically. So these can be simple things from you can often get a condition where the ear canal itself just scars up and closes off and so sound physically can't get down the ear canal. Then you can have problems with the eardrum itself - the eardrum can develop a hole and much like your satellite dish on the side of your house if you take a big chunk out of it, it doesn't get such good reception, so the same thing happens with your eardrum. And then probably in children the commonest cause of hearing problems is what we call glue ear, which is where you have fluid behind the eardrum - and remember when we spoke at the beginning we talked about the ear canal and the middle ear both having air in them and that's important for the eardrum to be able to vibrate - so if there's fluid behind it you can't actually compress the eardrum and often deafness results.
PORTER
A bit like having a finger in your ear the whole time.
LAVY
A bit like having your finger in your ear yes.
PORTER
And now with those sorts of - I know the different conditions there require different approaches but basically you would aim to help most of those people get pretty good hearing back in, for instance, glue ear - you'd expect to return normal hearing to a child with glue ear.
LAVY
Yes, yes.
PORTER
By draining the fluid off with grommets or whatever. But if you've got industrial - been working in a noisy factory or you've just got age related deafness that you can't be helped and you have to wear a hearing aid - so it's something like five million people in the UK would benefit from aids but a fraction of those have actually got them and only about one in three of those who have got them wear them. Is it because the technology we offer on the NHS isn't up to the job?
LAVY
No the technology now on the NHS, particularly with the recent rolling out of digital aids - is excellent. I think there are two problems. One is because they - a lot of people now know the digital aids are available the service has become somewhat swamped and there's often a very long wait, often up to a year, to have a hearing aid fitted and to get your aid. And the other problem is that a hearing aid does have some sort of stigma attached to it, sadly it's not the same as putting on a pair of glasses, if someone sees a hearing aid on you they sort of make certain assumptions about you, which I think a lot of people find difficult to cope with.
PORTER
What about how well they work, we said that the NHS now offers the latest technology, but is that really good - does it work well for everyone?
LAVY
Again I think it's good to compare it to vision - if you put on a pair of glasses, if you're short-sighted and put on a pair of glasses you can be confident your vision will be returned to as good as it was when you were young - it's 20/20 vision. But with a hearing aid it's not the same, your hearing is not going to go back to that perfect level, it's an aid and the clue is there in the name - it's a hearing aid - so it will help you and again I think that's one of the third problems with these is that you have to get used to wearing it and often people will only use it in a very difficult situation when they're maybe at a party and they haven't got used to wearing it at home when there's not so much sound around, so the first time they put it in, in a noisy situation, and of course they struggle.
PORTER
Well from the acceptability angle Neil Thomas is product development manager at the RNID and involved in a pilot project to try and come up with ways of making devices more acceptable, and more exciting.
THOMAS
Well current hearing aids have been shown to have a massive influence on people's quality of life. One of the key issues though is that a large number of the people who would benefit from that technology often aren't actually getting benefit from it. Of more than five million people who would benefit from hearing - using hearing aids in the UK less 1.5 million are currently using their hearing aids.
PORTER
So what you're saying is that people are put off wearing hearing aids because of the way that they look and perhaps the way that they feel?
THOMAS
Well where we're coming from with this project is that we think they could be designed a lot better and that there should be a real rethinking in the way that we market, that we distribute, and that we brand products for hearing. We're also saying with this project we believe there's a lot of opportunity to do far more with the technology in terms of products for everyone, there's potential to have products that help everyone protect their hearing. And what we're looking at here is concept products for the future, products that don't exist now but that could exist in the future. And we've got devices that use furniture in bars to create quiet spaces and use hearing technology to be able to have a communication across a table in a noisy bar by cutting out the noise around you. We've got products that will enable you when you're on a train to put in a pair of hearing buds that would actually cut down the background noise while allowing you to listen to your MP3 player without having to turn it up incredibly loud, so you can actually listen in comfort in a noisy environment.
PORTER
Neil, at the moment most of the drive seems to be to make hearing aids "invisible", in inverted commas, they're either flesh coloured or they're hiding behind the ear or they're actually hiding in the ear canal itself. How would you like to see that change looking forward?
THOMAS
Some of the designers have proposed concepts where you can buy part of the core technology and then pick a different type of exterior product in form and shape in different materials, like you would an item of jewellery almost, to give a different style or different approach. You can go out and buy amazing MP3 players and blue tooth attachments to your mobile phones, those sort of stylistic products are products for hearing, why can't hearing aids be designed along those styles?
PORTER
Neil Thomas. And you can see some of those designs at the forthcoming Hear Wear Exhibition at the Victoria and Albert Museum.
In the '70s and '80s it was the Walkman, today it's the MP3 player. An explosion in popularity of the personal stereo is worrying some experts. Listening to music on headphones at around 80-90 decibels - the sort of volume that can be reached on a busy street - is unlikely to do any cumulative damage to your ears unless you listen for more than eight or nine hours a day. But for every five decibels increase, the safe listening time roughly halves - listen at 100 decibels, that's fairly loud on a personal stereo, and the safe limit plummets to less than two hours a day.
Elizabeth Davy is an audiologist.
DAVY
RNID research has shown that there are people who really struggle to resist the urge to turn the volume up when there's background noise around. So people may well be listening to personal stereos at loud volumes and there's also been some research to say that about 40% of 18-34 year olds admitted to listening to their personal stereos for an hour a day or more. So if you build that use up and combine that with other things in their life they could be exposed to quite a lot of noise.
PORTER
And a safe limit - in other words the length of time that you can listen to a personal stereo - varies tremendously depending on the volume, isn't it, it's not a straightforward linear relationship.
DAVY
Absolutely not, it's very, very difficult, the effect of noise exposure on hearing is cumulative and it's very difficult to say that a particular position of volume control on a particular model of personal stereo could cause damage, it really does depend on the loudness of the sound that they're listening to and the length of time.
PORTER
Elizabeth Davy from the RNID.
Jeremy, how real a risk is this type of noise induced damage? Because we had similar warnings, didn't we, with Walkmans 25 years ago, have you actually seen people coming in, in their 40s and 50s with damage as a result of that era?
LAVY
No I haven't in my clinic seen - certainly not coming in great numbers. I think it is important for all of us to realise that noise is probably globally or certainly in our population the biggest cause of hearing damage. And again it's a question of degrees - if you've got one of these MP3 players then try and listen to it on the lowest volume that you can hear it without the background noise. And the major problems are when there is a background noise - if you're on a busy commuter train or in a playground at school the tendency is always to turn it up and you can find it just getting louder and louder and louder and I'm sure over a long time that can be a problem.
PORTER
And I suppose commuters might be one of the groups at risk because they're listening to it for a long time as well, aren't they, in a noisy background, they've got the volume turned up and they're probably doing it for three hours a day, if they're unlucky enough to have that sort of length of commute.
LAVY
That's right, yes.
PORTER
The knobs aren't graduated in decibels, so what you're saying is if it's comfortable for you to listen at when you're in a quiet setting you're unlikely to be doing yourself any harm.
LAVY
I think you're unlikely to be doing yourself harm in those situations, it really is when you're - when it's very, very loud and usually that's because there's background noise, you're having to drown that out.
PORTER
Would somebody know if they were - whatever the cause, you know, personal stereo or whether they're working in a noisy factory - would they - what are the telltale signs, the early telltale signs, if there are any, that the noise is damaging their hearing?
LAVY
Well the early signs you'll get, as we'll all have noticed if we've been to a concert or disco, is we come out and we have that ringing, we have that high pitched tinnitus in our ears. And that is associated with what we call a temporary threshold shift, where the actual level at which you can hear has changed and you can't hear quite as clearly, so if you did a hearing test on people immediately coming out of a concert you would find their hearing was not as acute as it was before they went in. So those are the two things - slightly muffled hearing and the ringing sound. And you know that that is a noise that is potentially damaging your ears.
PORTER
Jeremy Lavy, thank you very much.
If you want anymore information on the Epley manoeuvre for vertigo, or psychotherapy for tinnitus, or indeed anything else mentioned in the programme, then please do call the Radio 4 Action Line, that's on 0800 044 044 or you can visit our website at www.bbc.co.uk/radio4
Next week's programme is about homeopathy on the NHS. I'll be discovering how doctors at the Bristol Homeopathic Hospital are using remedies to help NHS patients with everything from eczema to cancer.
ENDS
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