the Mouths of Babes
Charles R. Attwood, M.D., F.A.A.P.
he first clue came during a rare moment of solitude five years ago. I'd seen the last of ninety sick children, most of whom were frightened and crying, so the stillness was especially serene.
Instead of rushing to the hospital to make rounds like I'd usually done during thirty years of pediatric practice, this time, I just sat alone at my desk in the empty office. The chaos was over for another day, and I savored the silence. For no particular reason, I picked up the little portable audiometer laying on the desk in front of me and placed it into my right ear. I couldn't hear the highest frequency tone. I tried it in the other ear -- again nothing at 4,000 hertz. Defective instrument, I thought, making a mental note to have it checked out. My hearing was normal -- I could hear subtle heart tones with my stethoscope. The audiometer needed calibration, I decided.
A year later, while sitting on a boulder, deep inside a volcano crater in Hawaii -- it was probably the most soundless place I'd ever been -- I heard a distinct ringing noise in both ears, a little louder on the right. I soon realized that the ringing was always there, and would later learn that, though sometimes masked by other noises, it would probably encumber me for the rest of my life.
Returning to the mainland, I visited my otolaryngologist, who, after doing a thorough audiogram, told me that I had a hearing loss. Unnoticed during normal conservation and using the telephone, it was limited to high frequency sounds, a type of deafness often caused by prolonged exposure to loud noises. Also, it's often accompanied by a ringing sound in the ears, referred to by physicians as tinnitus --correctly pronounced tin-night-us. The alternate, tin'-ni-tus, is found in 25 year old medical dictionaries.
Like my ringing, the hearing loss was slightly worse on the right. I knew what he was going to as me next -- had I been exposed to firearm or loud industrial noises -- so I assured him that I had not. Searching my memory, I could recall nothing. "What else could cause it," I asked him -- already knowing from my medical training that he would say an acoustic neuroma, a benign brain tumor, was a rare cause of high frequency hearing loss and continuous ringing of the ears.
Tinnitus, when due to an acoustic neuroma, is usually unilateral, he had said. This worried me, because mine seemed to be mostly on the right. He also said that acoustic neuromas often cause a ringing sound with a "metallic" quality. Now I had just the right word to describe my own tinnitus.
During the following weeks, I became more aware of the ringing -- or was it getting louder? Going back to the otolaryngologist, I told him it was getting worse, especially in bed at night without the relief of masking ambient noises. He examined my visual fields, which are sometimes distorted by brain tumors. Mine were normal. But recognizing my growing concern, he said, "why don't we get a CT scan of your brain. But I'm sure it'll be normal,"
Reassured, I forgot about getting the brain scan, and for nearly a year I tried to ignore the ringing. The following winter, while skiing in Colorado, I was more aware of the ringing, especially on the high, quiet slopes. The altitude was making it worse, I thought. However, returning to sea level didn't help; it was more noticeable and distracting than ever. Finally, I'd had enough. I called a radiologist friend and scheduled the brain scan.
A few days later, sitting in the darkened room with the radiologist after the 45 minute procedure, I watched as she casually threw the films onto the eerie white screens over her desk. The ringing seemed almost deafening. She kept staring at each the dozens of "slices" through my brain. Finally, she said there was nothing. We both inspected the internal auditory canal where an acoustic neuroma could cause bony erosion. Nothing. The entire head was normal.
"I would suggest that we get an M.R.I. (Magnetic Resonance Imaging)," she said. "It'll show more detail in the areas we're looking at." I was already tremendously relieved but quickly told her to schedule the M.R.I. as soon as possible. One week later, as I was inserted head-first into this giant machine, I learned first hand what my patients experience with this modern scientific monster, and understood why the radiologist asked me if I had any claustrophobic tendencies. Thank God, I didn't, I thought, as I was pushed deeper into the narrow cavern, which finally surrounded me like a cocoon only an inch or so away from any point on my head and face. I was told to yell at the technician in case of unexpected panic. Fortunately, I remained calm for the 45 minutes required for the procedure, while a whirring sound moved about my head. Then something containing iodine, a contrast media, was injected into a vein in my right arm; and another 20 minutes of whirring. I wasn't claustrophobic, just very happy to get out into the open room when the procedure was finished.
The radiologist called several hours later. "Your brain looks great," she said, "you have no brain atrophy at all." I hadn't realized that some brain atrophy wasn't uncommon for a healthy sixty-year-old. I quickly asked the fateful question about any signs of a tumor.
"Oh no," she said, "there's nothing suggestive of a tumor in the areas of the acoustic canal." The M.R.I., she reassured me, was normal. Just to make sure, she had reviewed it with a neuroradiologist colleague. "To bad," she added, "a neurosurgeon could have cured your ringing with brain surgery." Surely, I thought, this remark was tongue-in-cheek.
Again, I searched my memory for exposures to loud noises. Decibel levels of 85 or above are known to have a permanent, damaging effect on the inner ear (the choclea), resulting in both ringing and high frequency hearing loss. The Occupational Safety and Health Administration cautions against unprotected noise of 85 decibels (slightly less than a lawnmower) for more than eight hours a day. At levels above 120 decibels (a pneumatic drill), permanent damage to the choclea can occur within minutes. I could recall nothing in those ranges. I'd never used firearms and had practically no exposure to industrial noises or loud music.
Could, I wondered, my hair dryer or electric tooth brush be the culprit? I was a frequent flyer on commercial jets during the years before the malady made its appearance. Noise inside a plane isn't considered loud enough to be damaging, but the duration of exposure was always quite long, so I couldn't discount the possibility. I had spent more time than most people listening to the radio, watching T.V., and attending movies, but at quite ordinary volumes. Typically I had driven my car an average of one hour daily, but the engine sound was hardly loud enough to cause the vestibular damage I was experiencing. It occurred to me, however, that some of these sounds may have been borderline, but long lasting enough to be damaging. Recent studies of industrial noises had suggested this possibility. On the other hand, surely these were common noises to most people.
I had to find out for sure, so I purchased a decibel meter and carefully made measurements of practically every sound I regularly encountered. The highest readings for my radio were 60 decibels; my car at high speeds, 65 decibels; television, 55 decibels; electric toothbrush, 50 decibels; hair dryer, 60 decibels, and movies, 60 decibels, none high enough to be damaging, even when prolonged.
I developed a habit of protecting myself from loud noises. When attending concerts or symphonies my wife and I often carried tissues or paper napkins, stuffing pieces into our ears to reduce the intensity of the music. Surely, we thought, the musicians themselves were victims of deafness and tinnitus. If not, how did they avoid it? Later, I learned that it was a well-known occupational hazard of rock musicians. My ringing continued. Exasperated, I knew there must be some explanation, but couldn't, for the life of me, think of anything else.
Had the ringing not been so distracting and irritating, I would have ignored it. Forgetting it would have been a great relief. I likened it to holding a heavy weight in my hands without ever being allowed to set it down--not a pleasant experience. As I delved into the medical literature, I found that a wide variety of drugs and even vitamins had been recommended with only occasional success. Sinus drugs and other decongestants weren't helpful. Megadoses of vitamins didn't help. I tried vitamin B12 and antidepressant drugs after reading articles about how some victims of tinnitus had found them helpful. The studies were always inconclusive, but I tried them anyway.
Nothing helped. Nothing, that is, except the welcomed masking by soft music or other noises such as fans or air conditioners. Soon, this was to be the only way I could fall asleep at night. I read every article I could find in the medical journals and soon realized that my malady was far more common than I had expected. The journal of the American Tinnitus Association, Tinnitus Today, recommended to me my the Tinnitus Clinic of the University of Oregon, reported that up to 50 million Americans have this disturbing symptom. I literally prowled the medical library and searched the internet for anything I could find on tinnitus, uncovering little I didn't already know. Certain drugs such as aspirin can cause it, but I've never taken them. I did a computer search at the National Library of Medicine, again finding no clue to explain my tinnitus.
Unable to discover the cause, I tried to relieve the distress by trial-and-error. Holding my nose and blowing air pressure into my middle ears (the space behind the eardrum) created a momentary muffling of the ringing, but it was still there after a few moments and was obviously unchanged. I discovered that firm pressure with my hand over the scalp above the ears intensified the ringing, especially on the right. It returned to its former volume when the pressure was removed. What on earth can this mean? I wondered. Violent shaking of my head from side-to-side intensified the ringing with each sudden change of direction. Biting or chewing hard increased the ringing only during the bite. I'm a devoted jogger, and the ringing remained before, during, and after a long run of 610 miles.
Reading in Tinnitus Today, I found a letter to the editor from Mrs. B. from Kansas. She said that she had had tinnitus since childhood and for many years had thought that it was normal. She said that she could change the intensity of her ringing by shaking her head violently from side to side and increase the intensity by biting down as hard as possible. The editor suggested that the later observation may mean that her tinnitus was part of a tempero-mandibular joint (the jaw joint) problem, usually called TMJ syndrome. I excitedly called my friend Winston Morris, a Florida dentist who specializes in TMJ problems. Yes, he said, that tinnitus was a common complaint among his patients with TMJ pain. But, he added, it usually doesn't improve with treatment of the jaw joint. I decided that the relationship between TMJ pain and tinnitus was probably coincidental, since 50 million people had it.
On Christmas Day in 1990 I wrote across the bottom of my appointment book: The ringing has been persistent for nearly six years now. Today something happened that may eventually lead me or my doctors to a cause for this terribly distracting and maddening condition. While sitting in my study -- the room was very quiet -- I was suddenly aware of a sharp increase in intensity of the ringing on the right, followed immediately by a pause with total silence lasting a fraction of a second.
Then the sound resumed its original qualities. A moment later the ringing changed in tone, briefly -- only for a couple of seconds, becoming very high pitched -- like a string instrument suddenly tightened. Then, again, the original sound returned. I have no idea what this means and haven't found anything in the medical literature to shed any light upon it.
Shortly after this I noticed something else for the first time. My medical office was unusually hectic and there were hospital calls throughout the night. After having almost no sleep for 24 hours, the following day I finally slept from 6 PM until 8 AM, uninterrupted. Immediately on awakening, I noticed a strange calmness. After a few moments I realized that the ringing was barely audible. This was the first time its intensity had ever decreased. Within 24 hours the ringing was back to its former intensity.
This kind of sleep has not occurred again naturally, and on several attempts to induce it by drugs, the ringing remained the same. I remained hopeful, however, that this observation may be important and might lead me to a solution. I've found that ambient sounds of certain kinds render the tinnitus to be almost imperceptible. For this reason I've developed the ritual of going directly from my office, in the late afternoon, to a nearby cafeteria, where, during dinner, I read, and sometimes write, surrounded by the sounds of people talking and eating. The clinking of glasses, plates, and silverware are like music. At home, I listen to music or keep the T.V. on while writing. Reading in bed is difficult, but not impossible. If my attention is riveted to a book, the tinnitus is diminished.
I was having lunch with a former colleague, a pediatrician, now retired, and several other physicians at our local hospital. We all noticed that his hearing had further deteriorated since his retirement five years before. I recalled once telling him that I was going to the library, to which he responded: "Say you're going to Japan?"
His hearing was terrible, and I always suspected that he "faked it" while listening to patients with his stethoscope. He finally retired after 45 years of practice. During lunch I noticed that he talked and joked a lot, actually dominating the conversation. I suspected that he did this because he couldn't easily hear anything we said. It was during one of his long monologues that I suddenly thought about a possible connection between our hearing losses.
Finally finding an opening, "Jack, do you have ringing in your ears?" He cupped his hand behind his ear and leaned toward me. "Do you have ringing in your ears?" I almost yelled.
"Oh yeah," he said, smiling, "I've been ringing for the past 30 years. Never stops." He quickly changed the subject to an upcoming trip he had planned to Africa. I made a mental note to call other pediatricians, especially those who were retired or had practiced years or more. I wasn't sure what I was thinking, but subconsciously associations were forming.
Calling a pediatrician in a nearby city who was recently retired after 30 years, I ask him if he had experienced a hearing loss or tinnitus. "Oh yes," he said, "It's because of my shooting." He had been an avid duck hunter for many years. Next, I called a pediatric allergist, who had recently retired after seeing 5060 children daily for twenty-five years. I asked him if he had experienced tinnitus. "My ears ring constantly, day and night," he said. He had also been told by an otolaryngologist that he had a hearing loss in the high frequency range. He couldn't remember any exposure to loud noises.
After several more calls to pediatricians who had been in practice for 20 years or more, or those already retired, I was convinced that pediatricians as a group are experiencing tinnitus and high frequency hearing loss. Could it be caused by what I was thinking? It was time, I decided, to find out for sure about the decibel levels of crying infants and children at close range. I could hardly wait to get to my office the next day with my decibel meter.
My first patient of the day was a seven month old boy, who, according to the mother, had an earache. First holding him, with his mother's help, in the usual position on his back for examining his middle ears, I held the decibel meter near him while he was crying. It registered 125! During the course of the day I measured decibel levels, at close range, of 12 infants undergoing various procedures and receiving injections. All measured over 125, some 130. Several infants crying, apparently from hunger, recorded decibel levels over 110. Later in the day 125 decibels was recorded during a newborn circumcision at the hospital. It was incredible!
These babies were producing sounds high enough to cause permanent hearing loss and tinnitus! According to data published by the U.S. Department of Labor, exposure to 120 decibels for 15 minutes per day leads to permanent cochlear damage. Almost all pediatricians are exposed to such levels several hours daily. My search was over, I thought, this must be the answer. If I was right most pediatricians would develop tinnitus and high frequency hearing loss if they practiced long enough or saw enough children. But if pediatricians are at high risk, how about family doctors, nurses, day care workers, teachers, and even parents?
I prepared a questionnaire for distribution by Pediatric Management magazine at the 1991 and 1992 annual meetings of the American Academy of Pediatrics. Thirty percent of 162 pediatricians responding had experienced tinnitus continuing after office hours. Furthermore, most of them had practiced pediatrics for ten years or more. It appeared that years of practice and numbers of children seen were both risk factors for tinnitus. Convinced that exposure to crying infants and children produced permanent tinnitus and high frequency hearing loss in pediatricians -- and possibly in other professionals working with children -- I was certain that, even though incurable, it could be prevented.
My first idea created a sensation in the office. I kept balloons filled with helium in each examining room. As soon as a child started crying loudly, I delivered a blast of helium toward the mouth. This changed the character of the cry into something like Donald Duck, while I finished my examination. This was awkward and the duration of the Donald Duck cry was very short. Some parents considered this child abuse, but others thought it was ingenious and ask me where they could buy helium tanks.
Searching for other, more acceptable solutions, I talked with musicians who had, for many years, recognized the same problem from exposure to amplified music in the range of 100-125 decibels. Various earplugs had been successfully used to dampen the decibel levels of their music. This would have been awkward for a pediatrician, who must remove and replace them repeatedly when using the stethoscope and talking with parents. The concept, however, was certainly on the right track. Ear plugs could be used by day care workers and parents. Physicians and teachers would need some modification of this kind of decibel-reducing device.
While driving to work I passed a neighbor's yard where a gardener was using a power lawn mower. He was wearing ear plugs connected by a spring-like band hanging under his chin. I could see that it enabled him to quickly remove the plugs and replace them. They could even hang around his neck. This would be ideal for a physician, I thought. He referred me to a hardware store, where I found several versions of these plugs. I bought one and tried it with the first crying infant I encountered. It worked very well! I could easily remove it and place the stethoscope in my ears. Also, I was able to hear parents talking with the ear plugs in place.
I ordered more plugs for my staff and encouraged them to wear them during any encounter with crying infants. Eventually, I discovered that just by placing my regular stethoscope into my ears served as well as earplugs as long as the bell wasn't near the childs mouth. This is the method I finally settled on. After writing about my new theory with an article in Pediatric Management magazine, I received a letter from an otolaryngologist in Oregon. He suggested that there must be another answer to my tinnitus. He wanted to see my audiogram, which I FAXed to him the same day. Quickly, he agreed that my pattern of high-frequency hearing loss was typical of noise-induced tinnitus. It was common, he said, to have decreased hearing in the high frequencies, with some improvement or recovery in the still higher frequencies.
The audiogram would look like a roller coaster, gradually climbing, then a slight dip followed by a slight climb again. This was my pattern, more prominent on the right than the left. Since I am right handed, my right ear is closer to the infant's mouth during most examinations. "It's from noise expose," he said. Reluctantly, he agreed that maybe sounds from crying children could do this. "Maybe it's an occupational disease we haven't recognized."
Wearing the stethoscope while seeing my patients hasn't decreased the ringing, but I've noticed that whenever I don't wear it, the intensity may increase for a day. or even two. As I write, the ringing is especially loud following a busy day during which I saw over 80 children. As I approached a mother and her 6 month old infant, the child was smiling at me and absolutely serene. My stethoscope remained in my coat pocket, seeming unnecessary. After a brief chat I reached toward the baby to look into its ear. The sudden high pitched scream was deafening, and my already damaged inner ear, once again, screamed back! Now, nine hours later, the intensified ringing is still at its peak. If I sleep an uninterrupted eight hours, it may be tolerable tomorrow -- or the next day. On the other hand, I don't know.
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