Back toÌýmain page
Ìý
BRITISH BROADCASTING CORPORATION
RADIO SCIENCE UNIT
CASE NOTES
Programme 8. - Ears
RADIO 4
TUESDAY 08/11/06 1630-1700
PRESENTER:
MARK PORTER
REPORTER: CLAUDIA HAMMOND
CONTRIBUTORS:
DAVID GAULT
TONY WRIGHT
RICHARD GLEDHILL
IAN BOTTRILL
PRODUCER:
NOT CHECKED AS BROADCAST
BACKGROUND CHATTER
PORTER
Hello. If you struggle to hear what people are saying in crowded rooms like that, then this is the programme for you.
I'll be finding out how easy it is to get the latest hearing aid technology on the NHS, and how it transformed this woman's appreciation of what's going on around her.
CLIP
The most freaky thing was the background noise, I hadn't realised how much I didn't hear. And when they were fitting it they had the window open and suddenly hearing cars going by I was really quite shocked at how echoey and strange it all sounded.
PORTER
And we'll be meeting a 10 year old who was born without an ear - something plastic surgeon David Gault is keen to put right.
CLIP
We'll take a little rib from the chest that's not quite attached, which we will be able to bend to make the round outer rim of the ear.
It's a terrible roller coaster ride for a surgeon, it goes from oh goodness this is never going to look like anything other than a bag of spanners to my goodness I think we've got an ear on our hands.
PORTER
Or even the side of the patient's head - hopefully. More from David Gault and how he builds new ears later.
My guest today is Professor Tony Wright from University College, London Ear Institute.
Tony, what proportion of the population have a problem with their hearing?
WRIGHT
Well a surprisingly high proportion, it depends how bad the hearing is but for a mild hearing loss about 1 in 7 of the population have troubles and that amounts to 7.7 million in the UK.
PORTER
And presumably the older you are the more likely you are to be included in that group?
WRIGHT
Indeed yes, the prevalence increases and it's been estimated that by 2016 there'll be three quarter of a million people with a severe hearing loss, as the population ages.
PORTER
Why is it that hearing tends to go as we get older, is it simply an effect of ageing or is it exposure to all that noise throughout our lives?
WRIGHT
There are two factors in humans. Firstly there's an inherent ageing problem, in that the microphones - the hair cells in the inner ear - do deteriorate from birth and so the total number reduces with time. Fortunately you have more than you need to start with so there's redundancy in the inner ear but once you've lost a certain number then you start losing crispness, clarity - the cocktail party syndrome where you can't hear in background noise. An additional factor seems to be the increasing problems with noise exposure in our modern technological age.
PORTER
Yeah although we're more sensitive to this, I mean you see people wearing ear defenders to mow the lawn these days, but you also see lots of youngsters walking around with their iPods and other MP3 players plugged into their ears, I mean do you worry about - does that worry you as an ear doctor?
WRIGHT
Well I think we all worry, those of us who are involved with people with hearing loss are very concerned about this. The exposure to noise, especially continuous noise without breaks to allow the ear to recover, continuous noise can damage the microphones, damage the hair cells, and although it may not be apparent immediately that you've got a hearing loss it builds - it adds to the natural age related loss, so that we predict that with a combination of the two the onset of hearing loss in the population will start earlier in the life.
PORTER
Well the definitive treatment for hearing loss of course is a hearing aid - and the NHS has recently adopted digital technology that was previously only available at high cost from the high street. What's the difference between the conventional old fashioned analogue and the modern digital?
WRIGHT
Well the analogue aid simply amplified the whole range of sound that was presented to it. Digital technology allows you to fit the aid precisely to the individual's hearing loss.
PORTER
Well the first step in getting one of these new aids is to have your hearing formally assessed. My wife and daughters are convinced that I have a hearing problem. And they could be right - I was a keen shot during my twenties and I'm embarrassed to say rarely wore ear defenders. As I confessed to Richard Gledhill, Head of Audiology at the Radcliffe Infirmary in Oxford, when he offered to put my hearing to the test.
GLEDHILL
Okay Mark let's just have a look in your ears. Tiny bit of wax there, which is not unusual. I can see the eardrums, they look quite clear. So we're going to test your hearing, so I'll give you this button to press. You're going to be wearing a pair of earphones and we're in a soundproofed room, so I want you to listen for the sounds in the earphones, when you hear something press the button, when the sound has gone off let go again and just keep doing that for every sound you hear.
So we'll start delivering the sound to one ear. What I'm doing now is turning the sound down, so I started with one he could hear quite easily, it's getting fainter and eventually it'll be too faint and he won't be able to hear the sound. So it looks like the faintest sound he hears there is 10 decibels, which is normal, so that's fine. Now I'm going to go to a higher pitch of sound. He's got a slight dip at the high pitched end, not really enough to affect his hearing for most everyday things.
Right that's finished the hearing test. So we'll let him out of the soundproofed room.
Right, you've got a very, very mild high tone drop, not really enough to cause any significant problem but somebody your age shouldn't have that, so the most likely cause as you did admit to doing some shooting, that may be …
PORTER
Without ear defenders rather stupidly.
GLEDHILL
Yeah that may be the reason.
PORTER
So how would that - I mean if it was more marked how might that have caused me difficulty?
GLEDHILL
Well the first thing that people notice is probably that they're mishearing conversations, particularly in noisy surroundings and background noise.
PORTER
Because presumably the high frequency is the Ss and the Ts …
GLEDHILL
It's the consonants in speech yes. The vowels are lower pitch and they've got more energy, so you can hear them more easily. So you tend to start mishearing consonants against noise. The TV volume is higher than other people in the room might like it.
PORTER
Yeah that rings a few bells.
GLEDHILL
Well this is a selection of some of the aids that we have available on the NHS now. So this is a typical NHS digital hearing aid, I've actually got a hearing loss and I wear one of these models myself. The aid fits on the back of the ear, most of the electronics is round the back with a battery in it.
PORTER
I mean it's quite small, I mean it's only what 4 centimetres long and very slim and so that almost hides completely behind …
GLEDHILL
It does pretty well and the ones I've got here are sort of boring NHS beige but we can get other colours - darker browns, greys, to match hair colouring or some of the children like the bright colours, we can get them in red, blue, green colours.
PORTER
So that's the body and the microphone and that's connected to the ear via - the tube comes over the front.
GLEDHILL
The tube comes over the top delivering the sound and that's then joined to the patient's ear mould and that's the part which is made individually to the shape of the patient's ear. So we have to take an impression of the ear to make that, everybody's ear's different, a bit like fingerprints.
PORTER
And why is it important that that's such a good fit?
GLEDHILL
It has to deliver the sound well into the ear canal so that we can get the best out of the frequency response of the hearing aid. Also if you are using, particularly if you're using a lot of power and the aid doesn't fit the ear terribly well you can get feedback, you get a whistling sound.
PORTER
Yeah you often people with whistling aids, that's an ill fitting aid.
GLEDHILL
That's usually a problem with the fit in the ear which sounds like this.
PORTER
My sister wore an aid from a very young age, it's a very familiar sound to me that. The first point to make is that they look identical, there is a sort of perception that new digital aids are the invisible tiny ones aren't they, but actually the analogue aids and the digital aids I mean they basically look exactly the same.
GLEDHILL
They do and the NHS for the most part fits behind the ear models.
PORTER
Why are digital aids more advanced, what would the patient notice?
GLEDHILL
The patient with a digital aid would notice if they changed over say from an analogue model would notice the sound quality much clearer and crisper - more hi fi if you like. If you look at an analogue aid you'll see that the analogue aid normally will have a volume control, so the patient can turn the sound up and down and in fact they need to because the analogue aid doesn't adjust itself, so if you walk into a noisy place you're going to have to turn your volume down a bit or adjust it up if you want to listen to something very quiet. With the digital aids many of them don't have a volume wheel at all, you can see on this one the casing has no wheel on it, the aid will adjust itself once it's been tuned. You connect the aid to a computer which then programmes the hearing aid, starting from the patient's hearing test result.
PORTER
Richard Gledhill with some of the new digital aids now offered by the NHS.
Professor Tony Wright, those aids may be theoretically available on the NHS but getting hold of one can be tricky.
WRIGHT
They are actually available on the NHS but you're quite right about the difficulty because it takes much longer to fit a digital aid than it did an old fashioned analogue aid. And there just simply aren't the staff or the facilities to get through the numbers of people who would benefit from an aid.
PORTER
The RNID talk about people waiting often three years or more and in fact Richard alluded to the fact that the waiting lists for people who are moving up from the old analogue aids is almost indefinite at the moment, there's no movement in it.
WRIGHT
That may be true and I think there's a local postcode lottery almost with hearing aids, it really does depend on the local facilities - a number of highly qualified staff that it takes to fit the aids, you can't just plug them in, you have to really program them properly.
PORTER
But is something being done about that backlog?
WRIGHT
Yes the Department of Health are - have introduced a BSc in audiology to train - to actively train staff to fill this vacuum. So there is an activity but it'll take time to get the staff up to numbers.
PORTER
So it's not a shortage of aids itself, it's the expertise to put them in.
WRIGHT
Cupboards are full of aids.
PORTER
Okay what about people who go privately, they want to perhaps not wait two or three years, are they getting better technology? We heard Richard there talking about in the air versus behind the air, are these little aids that hide in your ear canal better or are they just cosmetically more acceptable?
WRIGHT
In the trial that the government ran for the digital aids, in the canal aids, the small aids, were included in that trial. And the patients did like them but they were unreliable and needed extra - much, much more time. So they stopped for all intents and purposes doing canal aids on the health service. And that's the big difference between the health service and privately.
PORTER
And do you think - I mean are people buying anything else other than cosmetic appearance by going privately, because these aids can cost two or three thousand pounds on the high street?
WRIGHT
Indeed it can and there is some of the newer technologies coming into the newer private aids are in advance of the NHS digital technology. So there is an added value, whether that added value us significant for most users is difficult.
PORTER
Ok, well I want to move on to another of the ear's functions now - its role in balance and what happens when this goes wrong.
Meniere's disease is a condition of the inner ear that leads to hearing loss, dizziness, tinnitus - more about that later - and a feeling of pressure inside the ear - but it's the dizziness and resulting loss of balance that drives most people to seek medical help.
There are a number of different treatments available for Meniere's - from drugs to pressure relieving surgery - but the results are unpredictable and some surgeons advocate a more drastic approach - injecting a toxic drug, the antibiotic gentamicin, deep into the ear to destroy the faulty apparatus on the affected side.
While I was at the Radcliffe Infirmary I met up with Peter who has undergone the treatment, and his surgeon Ian Bottrill, to find out more.
BOTTRILL
It's a very poorly understood condition and because of its unknown nature it's very difficult to manage in terms of diagnosis, we're left with controlling symptoms, rather than often being able to actually turn the process off.
PORTER
And of those symptoms the disturbance in balance can be very disabling.
BOTTRILL
Absolutely, it's the balance that tends to cause most of the disability.
PETER
I went to the bathroom and just collapsed. And my wife thought I'd had a heart attack. But I'd got my head in the toilet and was being very sick. When I tried to get up I had no balance at all, vision went completely and I just laid in the bathroom for an hour. Eventually I crawled to my bedroom - fortunately I live in a bungalow - I crawled to the bedroom and we got into bed. Progressively the attacks got worse - in a period of 12 months I had 48 attacks. It can also happen in bed at night, when you're fast asleep and all of a sudden you wake up and the bed's moving as if you're in a boat and it's going all over the place. And the only thing then to relieve you is to be sick.
BOTTRILL
Gentamicin's an antibiotic that was developed to treat TB in the '30s and the initial patients treated with high doses were noted to have very severe dizziness afterwards. And it was then found out that not only is the antibiotic active against bacteria, it was also toxic to the cells that register movement in the inner ear and also for the hearing cells as well. And so these patients would often lose their hearing and also have very severe balance problems.
PORTER
Surely if you're giving a drug that damages somebody's balance mechanism does that mean they lose their balance mechanism altogether, it might not give them any trouble but then how do they go about their normal day-to-day life?
BOTTRILL
The analogy I use for patients is if a light switch is faulty and the light is flashing on and off then what the gentamicin is doing is cutting the wires between the switch and the light, so the light is permanently switched off but not sending any bad signals through. What we would like ideally is a very nice screwdriver to fix the light switch but we don't have that unfortunately, so it's slightly a blunderbuss technique but it switches the balance system off.
PORTER
Which leaves the patient hopefully with a good balance system in their other ear. Now how do people get on with only have one side?
BOTTRILL
Well initially the balance after the treatment is very severely impaired, the patients have what is in effect the mother of all Meniere's attacks because they're very severely dizzy afterwards. But then what happens is the body has a marvellous capacity to compensate, for the balance to re-calibrate itself after the treatment. Our balance involves our vision, our joints and our balance organs and so effectively the treatment is removing one fifth of that system. And the brain is then able to recalibrate the system provided the signals from the balance organ are either absent or stable.
PORTER
And by injecting the gentamicin into the affected side does that have implications for the patients' hearing on that side?
BOTTRILL
Yes because the drug is toxic to the inner ear as well there is a small chance of making the hearing worse. In my own personal series that risk over a two year period is 24% but you have to remember the people that we're treating are the very severely affected ones who already have a hearing loss to start with and even though we measure a hearing loss quite often the patients are not aware of the change in hearing. And as a surgeon we'd like to try and preserve as much function as possible and I'm always quite amazed that I tend to be more bothered by the potential hit on the hearing and the patient just wants the vertigo to stop because that's what's the most distressing part of the condition.
PETER
It's a little bit disconcerting because when you only have hearing in one ear you're not aware where the noise is coming from. So you think the noise is coming from your right side but it isn't it's coming from your left side and vice versa.
PORTER
You haven't got stereo hearing so you can't locate the sounds very well.
PETER
No that is the only problem.
PORTER
But it's a small price you consider for the benefit of not having to worry about Meniere's.
PETER
Yes, yes. I thought well as I had very little hearing in my right ear that the loss if I was going to lose the hearing it was a better thing to do than to continue as I was going on.
PORTER
Have you had problems adjusting to the fact that you're not working on your full balance mechanism, because in between attacks you had good balance?
PETER
At the start yes, I would wobble a bit and people would say to me in the village - You had a good skin full…
PORTER
You've been in the pub again.
PETER
Yeah. I think I'm 99% back to normal.
BOTTRILL
It is largely available in most areas of the UK in ear, nose and throat departments but there are some people who feel that because the condition destroys the balance organ on one side they're worried that this may cause problems should the patient develop Meniere's disease in the opposite ear. But at the end of the day you're treating someone with severe disabling condition and to deny a potential treatment that can change the quality of their life even with the small risk of second side problems then these people will still actively want treatment.
PORTER
Surgeon Ian Bottrill. You are listening to Case Notes, I'm Dr Mark Porter, and I am discussing problems of the ear with my guest Professor Tony Wright.
Tony, when I described that as a drastic approach you frowned because you do the operation as well don't you.
WRIGHT
Yes you use the word operation and that suggests an inpatient with a general anaesthetic but the intratympanic gentamicin, as it's called, is an outpatient procedure. It is drastic in the sense that it takes away the malfunctioning balance system but it's not drastic in terms of impact on the patient.
PORTER
It's a quick and simple procedure.
WRIGHT
It's a straightforward simple procedure.
PORTER
I want to move on to some of the more common problems that we see in general practice. Infections in the ear, one of the infections we commonly see in adults - infections of the ear canal - and often in people who've been away on holiday and been swimming, what's happening there?
WRIGHT
Well the otitis externa - that's infection of the external ear are very common in the summer when people have been especially in the swimming pool a lot and what that's done is taken away the normal protective wax that lines the ear canal and allowed access to bacteria which invade the hair follicles in the ear canal and the skin of the ear canal to cause inflammation, pain, discharge and if it blocks the ear canal it can cause deafness as well.
PORTER
So what can we do - if I'm going away on holiday with the family is there anything we can do with our ears to prevent that happening?
WRIGHT
Well you shouldn't be using cotton buds to clean the ear because then you take away the protective wax.
PORTER
Nothing smaller than your elbow should ever go in your ear.
WRIGHT
Exactly and it even says on the cotton bud packet don't put in your ear. You can wear certain ear plugs or if you're prone to this you can have some custom made ear plugs - swim plugs made for you which seems to almost eliminate the problem.
PORTER
And that's through keeping the ear dry.
WRIGHT
Through keeping the ear dry.
PORTER
Okay, so that's good advice on how we should be cleaning our ears but what if you don't have an ear to clean? Every year in the UK around 1 in 6,000 babies is born with the condition known as microtia - a congenital deformity, or complete absence, of the outer part of the ear.
Fortunately advances in plastic surgery now mean that doctors can create new ears. Beverly and Keith Redguard chose surgery for their seven-year-old son Kyran, after he started getting teased at school about his appearance. Claudia Hammond went to talk to Kyran as he got ready to go into theatre with plastic surgeon David Gault, who pioneered the new technique at the Clementine Churchill Hospital at Harrow in Middlesex.
HAMMOND
So what do you know about the operation today?
KYRAN
I'm off to sleep.
HAMMOND
What are they going to do while you're asleep?
KYRAN
My ear drum - ear and they'll take that off.
HAMMOND
Yeah so they're going to take off the bit of ear that is there and what build you a new one?
KYRAN
Yeah.
HAMMOND
Why do you want to have a new ear?
KYRAN
Because I want to.
BEVERLY REDGUARD
Want it to look like your other ear Ky? Yes.
When he was born I just noticed that his ear was sort of folded - flapped over, so the top ear sort of flapped over the bottom ear but I've always been quite adament that he's not deaf.
HAMMOND
Some children are born without an ear at all but he does have some ear there.
BEVERLY REDGUARD
Yeah he does have an ear, I mean Kyran has the upper lobe and he almost has too much really, it's quite big - the upper part of the ear. He has the small part of his ear - the lobe - and it's the middle bit that's missing.
NURSE
Kyran why don't you like down for me and try this mask okay?
GAULT
This is a very unusual case because normally with microtia all you get is a little tiny bit of earlobe left and you build the whole ear. But this boy has actually got a little bit of ear at the top and that you would think would make the job easier but sometimes it makes a little bit more difficult because what you do in fact have to do is to blend the new ear framework with the existing component. You can see it's a sort of jigsaw and we're trying to sort it out.
HAMMOND
So you're taking the cartilage from the chest wall.
GAULT
We'll take the cartilage from the chest, a little floating rib if you like, a lower rib that's not quite attached, which we will be able to bend to make the round outer rim of the ear. If you view an ear as function this outer bit of the ear, it holds on earrings, it holds on glasses, and occasionally it gets nibbled I suppose but doesn't have any great function but it's the cosmetic aspect that we're trying to solve. I'm trying to keep all the skin, the skin envelope I'm viewing as absolutely precious. Can I have some tooth forceps please?
BEVERLY REDGUARD
I mean initially I'll say that it didn't really both Kyran, I think it was more a case for us really and I suppose that's in terms of like vanity - you want your child to look the same. It's curiosity but sometimes it can be quite negative - you can't go shopping without people pointing at you, staring at you, making comments, having little kids running around and bringing their other friends to have a look. But it has come at a time where it's become quite important for him and he's really excited about having a new ear.
HAMMOND
And what sort of difference do you think it'll make to him?
KEITH REDGUARD
With his new ear I don't think anyone will know any difference, he'll be just like a normal kid because he'll run around, he can talk, so it'll make him more confident I believe.
HAMMOND
What have you done while I've been away? Oh look at that.
GAULT
Well we've harvested a little floaty bit, you see this bit here is going to go round and blend in with the bit that's there to make the missing pieces.
HAMMOND
So you've got the template there that's from the good ear and then you've got to try and fit the bits to make it be a bit like that.
GAULT
Well a bit like that, we want it exactly like that.
HAMMOND
Sorry exactly like that of course. Oh to give you your due it is exactly like it.
GAULT
I'm just - we've got earphones on mono, I'm just going to look to see where the rim starts, I sort of think it starts about there.
HAMMOND
So you're literally carving bits off it to - almost sculpting it into the shape that you need it to be. This is the artistic bit isn't it.
GAULT
You can say artistic and you're probably right in saying so but it's a sort of craft.
HAMMOND
And then you sew together the different bits of lines of cartilage.
GAULT
Right could I have some light here because I think I've given up carving now I want to work here.
HAMMOND
So you've opened up the whole of the back of the ear so that you can stick the …
GAULT
This piece is going in there…
HAMMOND
…bone in there, that's amazing. So you've put the framework into the envelope and now you stitched it inside. What's amazing is that now that you've put the carved ear in there - in the shell, you know you're holding it together, but it really looks like an ear.
GAULT
Ah well you've got to wait for that moment when we apply the suction then it really will come through.
HAMMOND
Oh because it sucks round it, sort of shrink wraps round it.
GAULT
Exactly, shrink wrap - that's the word we've been looking for. We want to shrink wrap it. When you buy olives or bacon and it's vacuum packed you find they've got some mouldable packaging and they've put the shape in there and they vacuum pack it, you can see the shape through the packaging. Well we're going to try and recreate that same sort of thing here by placing a new shape in this skin envelope and suck the skin on to it, so after a few days it will conform to its new shape, stick down and then that ear shape will be there. That hollow's brilliant isn't it - ah see a bit of luck. You see the key to an ear is actually this bit here, it's like a polo mint and if you've got a hole in the middle it would look like an ear and it isn't exactly the same but it's jolly close.
HAMMOND
Oh it's very close to that template isn't it.
GAULT
We've got that bit, that bit, so we've got the two triangle bits, which he didn't have, we've got a round bit, we've got everything else. It's a terrible roller coaster ride for a surgeon, it goes from oh goodness this is never going to look like anything other than a bag of spanners to my goodness I think we've got an ear on our hands, to the bag of spanners and back again. And we're home and dry. We're getting to the sort of exciting phase now. But the biggest excitement I've got is from that - the fact that we've got a polo mint rather than a trebor mint.
PORTER
Plastic surgeon David Gault showing Claudia Hammond how to make the perfect ear. And I am pleased to say that Kyran is doing well and went back to school this morning.
Tony, I'd like to finish on a different subject again. We've already briefly mentioned tinnitus - troublesome noises in the ear like this:
TINNITUS NOISES
Now we mentioned that people with Meniere's disease can get tinnitus but what else causes it?
WRIGHT
Tinnitus can arise from anywhere in the auditory pathway - from the ear drum up to the higher centres of the brain where hearing's perceived. And anything happening along that system can induce the perception of sound when there is none.
PORTER
And what is the latest thinking on the best way to treat it?
WRIGHT
Managing tinnitus is quite difficult, tinnitus is a perception of sound when there is none and what we're trying to do nowadays is to get the brain to habituate - to filter out the tinnitus before it reaches perception. We're trying to get the brain to put the tinnitus into a little filing cabinet in a side room and just forget about it.
PORTER
You're using some behavioural therapy.
WRIGHT
Yes some behavioural cognitive therapy which is a therapy in getting you to think about your symptoms in a different way.
PORTER
And how successful is that?
WRIGHT
It's really quite successful now …
PORTER
Most people or …?
WRIGHT
Once you've excluded an underlying cause, which may need treatment in itself, then the intrinsic - the inherent tinnitus can usually be made to a state where they're tolerable or even not noticed at all.
PORTER
We must leave it there. Professor Tony Wright, thank you very much. Don't forget you can review any part of today's programme by using the Listen Again facility on the website at bbc.co.uk/radio4.
This is the last in the current series of Case Notes but we'll be back for another run in the New Year. Until then goodbye.
Ends
Back to main page
|
ÌýPrint this page
