Download Dr David Lyon Audiologist - Hearing Loss and Tinnitus

RCMP and VETERANS
AFFAIRS CANADA
May 31st, 2016
Hearing Loss, Tinnitus,
Hyperacusis & PTSD
Dr. David Lyon
DISABILITY
APPLICATIONS TO
VAC
Made to VAC under the Canadian
Forces Members and Veteran Reestablishment and Compensation Act.
TOP REASONS FOR DISABILITY PENSION CLAIMS BY
CURRENT/FORMER MOUNTIES TO VETERANS
AFFAIRS CANADA
Men
• 1. Tinnitus
• 2. Hearing Loss
• 3. PTSD
Women
• 1. PTSD
• 2. Depressive Disorder
• 3. Chronic Lower Back Pain
VAC CRITERIA
CLAIMS FOR DISABILITY MUST MEET
THREE SPECIFIC CRITERIA SET OUT BY
VAC FOR THE DISABILITY CLAIMED.
1. CRITERIA FOR THE
CONDITION/DISABILITY
2. CRITERIA FOR SERVICE RELATED CAUSE
OR PARTIAL CAUSE OF THE DISABILITY
3. CRITERIA FOR THE EFFECT OF THE
DISABILITY ON QUALITY OF LIFE
TABLE OF DISABILITIES
• The VETERANS AFFAIRS CANADA
TABLE OF DISABILITIES lists these criteria
for each disability
• Can be found on the Veterans Affairs website.
– PLUS
• Step by step guide to the application process.
OVERVIEW
– Hearing Loss measurement and effects
– Noise induced hearing loss (NIHL)
_ Tinnitus
– Hyperacusis
– The application process
• Sensorineural
• Conductive
• Mixed
TYPES OF HEARING LOSS
• Hearing loss can result when there is a problem
in any part of the auditory pathway
• Conductive loss is a problem in the outer or
middle ear (e.g. infection, wax, pressure, injury).
• Sensorineural hearing loss results from damage
to the inner ear ( the cochlea hair cells or nerves
of hearing) (e.g. aging, noise exposure or
disease).
• Treatment of hearing loss
SENSORINEURAL LOSS
• The most common type of hearing loss -NIHL
• Hair cells transform sound vibration into a
neural (nerve) impulse that is sent along the
auditory nerve to the brain along the which
interprets it.
• Hair cell loss can be due to aging (presbycusis),
noise exposure, ototoxic medication, toxins,
disease and genes.
HEARING LOSS
• Hearing loss is measured using an audiometer
which assesses the threshold (quietest Decibel
level) at which an individual can detect each of
the frequencies from 250Hz-8,000Hz.
• Results are plotted on an audiogram ( slide 13 )
• Normal hearing < =25 B across the frequencies
• Mild, moderate, severe, profound hearing loss
Audiogram
Frequency is measured in
Hertz (Hz)
Intensity is measured in
Decibels (dB)
Pure Tone Audiometry
VAC CRITERIA FOR HEARING
LOSS DISABILITY
• VAC criteria for eligibility for hearing loss are
based and defined on levels of hearing on the
DISCHARGE AUDIOGRAM
• A certain amount of loss must be present on
discharge for VAC to recognize that the
disability is related to service.
VAC HEARING LOSS
DISABILITY
• Hearing loss disability exists when the
discharge audiogram shows
– Decibel Sum Hearing Loss (DSHL) 100dB or
greater across the frequency range 500, 1000, 2000
and 3000Hz in either ear
– OR
– 50dB or more in both ears at 4000Hz
– AND
– A hearing loss of 100dB is present on application
NON DISABLING HEARING
LOSS
• VAC also defines a non-disabling hearing loss or
lesser degree of hearing as a decibel loss >=30dB
at any frequency from 250Hz-8000Hz i.e. there is
slight loss but the loss is not sufficient to meet
VAC’s definition of a hearing loss disability
• VAC will consider a hearing disability to be to be
partially caused by service when the service
discharge audiogram shows non-disabling hearing
loss AND a disabling hearing loss is established
after discharge
NOISE INDUCED HEARING
LOSS
• Noise normally first damages the frequencies
3,000Hz -6,000Hz.
• The typical NIHL audiogram shows a clear
notch at these frequencies in early stages.
• The loss spreads to other frequencies over time.
• Hearing loss disability is measured at frequencies
from 500Hz-3,000Hz on the basis that these are
the most important frequencies for
understanding speech.
NIHL
RCMP NOISE-INDUCED
HEARING LOSS (NIHL)
• Factors that contribute to NIHL:
– High levels of continuous and impulse
noise
– Traffic noise, sirens, radios, headsets,
planes, boats helicopters, snowmobiles
– Firearms use and training
– Inappropriate hearing protection or
inability to use it in some duties.
ACOUSTICAL FEATURES OF
POLICE & MILITARY NOISE
• IMPULSE NOISE: rapid changes of pressure
from the atmospheric level. Can reach as high as
160-190 dB in a very short time (1ms).
Cannons,, hand and stun grenades, shotgun,
Smith & Wesson, sirens etc. Acoustic trauma.
• CONTINUOUS NOISE: a continual
battering of auditory system by high and low
frequency noise. Headsets, traffic noise, sirens,
aircraft engines, engine rooms, galleys, sonar,
helicopters, vehicles, snowmobiles etc.
NOISE INDUCED HEARING
LOSS
• Impact:
People with NIHL can generally understand
conversational speech in quiet environments as long as
they are within several meters from their conversational
partner.
•
In noisy conditions, or when the person speaking is
further away, understanding speech is far more
challenging. High frequency speech sounds (ex. f, s, t)
are not heard so many words can be unclear and
misunderstood
CONSEQUENCES OF HEARING
LOSS
Impact:
• Patients complain that people “mumble”, while
their significant others and/or co-workers
complain that “he’s (she’s) not listening”, or
“ignores me” or “has selective hearing”.
• Those with hearing loss are more fatigued at the
end of the day as they have to strain to
understand what is said a lot of the time
• Misunderstandings often result
• Affects different people differently
CONSEQUENCES OF HEARING
LOSS
• Compared to age-matched peers with normal hearing, those with
hearing loss show
– Increased worry and anxiety in social situations
– Decreased social activity (may withdraw from certain
situations)
– Increased feelings of depression, paranoia & isolation
– Poorer overall health
– Poorer Quality of Life ratings
– Increased frustration among family members & friends
TINNITUS DISABILITY
• Tinnitus is the perception of sound in one or
both ears or in the head in the absence of
external sound.
• Common causes: noise damage, aging, disease.
• Must be diagnosed by medical practitioner or
certified audiologist
• Must be present for at least 6 months
TINNITUS
• Perceived differently by different people
normally ringing or buzzing or hissing sound
• Steady or intermittent
• Fluctuate in loudness or pitch
• May consist of more than one sound
• Pulsatile vs. Non-Pulsatile
EFFECTS OF TINNITUS
•
•
•
•
•
•
•
•
Concentration
Emotional stability
Focus
Ability to understand and follow conversation
Sleep irritation and maintenance
Anxiety
Depression
Overall quality of life
TINNITUS
• Problem: Inaccurate advice
“There’s nothing wrong”
“You have normal hearing”
“There’s nothing else we can do”
“Avoid being around noise”
“You’ll just have to live with it”
• “Knowledge is Power” is the most effective
intervention
VAC CRITERIA for TINNITUS
• Exposure to at least one episode of acoustic
trauma just prior or prior to onset
• Exposure to noise of sufficient intensity and
duration to cause hearing loss of 25dB or more
at 3000, 4000 or 6000Hz in the ear(s) with
tinnitus prior to onset.
• This loss must be present on a service
audiogram –not necessarily the discharge
audiogram.
VAC CRITERIA FOR
TINNITUS
• Other criteria related to injury, head trauma,
barotrauma, middle ear disease and malfunction
a number of medications and illnesses.
• If applicable these must be detailed in the
applicant statement for Tinnitus.
• Hopefully these factors are mentioned in the
medical records.
• 20% of tinnitus patients do not demonstrate
hearing loss from 250Hz-8000Hz.
HYPERACUSIS
• Decreased tolerance to loud sounds; loud
sound causes startle response, stress,
discomfort even pain
• Very narrow range between threshold (
quietest sound heard) and tolerance level
(loudest sound can tolerate)
• Usually triggered by sudden high-pitched
noises like alarms, bus brakes, silverware
and dishes, children’s crying, and clapping.
HYPERACUSIS
• Those reporting hyperacusis often, but not
always also have tinnitus and vice-versa
• VAC eligibility criteria consider the two
disabilities together (that hyperacusis is
subsidiary symptom of tinnitus) but
symptoms are different.
• Rely on 25dB on a service audiogram
3,000Hz-6,000Hz.
EFFECTS OF HYPERACUSIS
• Fear of going to places that may be noisy
• Avoidance of social situations, restaurants,
movie theatres, concerts etc.
• Difficulty listening to speaker announcements
e.g. in airports, planes
• Difficulty concentrating in noise
• Feel emotionally drained and tired after being in
sound
APPLICATION FORMS
• Formally request VAC to send Form 923APe
(2011-09) Application for Disability Benefits
• IT IS VERY IMPORTANT TO SPEND TIME
TO FILL IN THESE FORMS COMPLETELY
WITH AS MUCH DETAIL AS POSSIBLE
VAC CRITERIA
CLAIMS FOR DISABILITY MUST MEET
THREE SPECIFIC CRITERIA SET OUT BY
VAC FOR THE DISABILITY CLAIMED.
1. CRITERIA FOR THE
CONDITION/DISABILITY
2. CRITERIA FOR SERVICE RELATED CAUSE
OR PARTIAL CAUSE OF THE DISABILITY
3. CRITERIA FOR THE EFFECT OF THE
DISABILITY ON QUALITY OF LIFE
PEN 923 APe
• First section A (p1-2) requires personal details of
service, family etc.
• Second section B. (p.3) requires you to “Clearly
state how you relate each claimed condition to
your service or to a specific service period “
• For hearing loss, tinnitus and hyperacusis you
need to provide details of the specific types of
noise exposure you experienced in service.
APPLICANTS STATEMENT
• Section B. P.3. You must fill in a separate
section B each disability claimed.
• Hearing Loss, Tinnitus and Hyperacusis
applications requires three completed section B
statements.
• The information in each may be the same, as all
three are a result of noise exposure and related
to service in the same way but repeat it.
PEN 923 APe
• Section C ( P 4… ) is the Quality of Life
Questionnaire
• Requires you to indicate how the claimed
condition affects your everyday life
• E.g. “ I can shop and do errands”
• Check: Yes; yes with assistance/adaptations; no.
• Comments for each one and section for
additional comments.
PEN (23 APe)
• Fill in a section C QOL for each condition
claimed
• For most of the questions the answer will be
“yes with assistance or adaptations”
• Can be anything that is different than it would
be without the claimed condition e.g. asking
people to repeat themselves, turning up the
volume, avoiding noisy places, needing help to
sleep etc.
PEN 923 APe & VAC 928
• Section D is more personal information
• VAC 928 is Consent for VAC to collect
personal information from Third Parties –this
should be completes with the information for
whoever did the assessments of the conditions.
CLINICIAN’S
RESPONSIBILITIES
• The doctor or health professional
has a responsibility to ensure that
the report contains as much
information as possible to support
your application.
QUESTIONS??
TINNITUS, PTSD &
HYPERACUSIS
• PTSD and tinnitus share a number of symptoms
– Sleep problems
– Irritability/anger
– Difficulty concentrating
– Hyper vigilance
– Exaggerated startle response
– Difficulty tolerating loud sounds - hyperacusis
EXPLANATIONS?
• Both affect the same neural mechanism in
the brain especially those connected to the
limbic system that controls arousal and
emotional behavior.
• Mutual negative effects of one on the other
i.e. tinnitus is exacerbated by stress and in
turn stress is exacerbated by tinnitus
EXPLANATIONS?
• Tinnitus maybe triggered by cochlear damage –
damage to the hearing mechanism but it is
disorder of the brain -in a sense the network of
the brain gets rewired and interacts with other
brain networks-including the one controlling
stress.
• Increasing evidence that the damage to the ear
that triggers tinnitus may be subtle and not seen
on a conventional audiogram.
QUESTIONS