Eye care practitioners see patients on a regular basis so are ideally placed to detect conditions other than just those specific to the eye that might otherwise not be directly reported. They can then ensure that patients understand that help is available and how this might be sought. Eye care practitioners should be aware of the nature of hearing loss, be able to identify patients where there may be a concern, and know the best advice to help the patient address the deficit. It is also essential to be able to communicate effectively with patients who have hearing loss in order to provide adequate eye care.
The first article (click here to read it) gave an overview of the cause and nature of hearing loss. This article looks at the various ways of assisting those with hearing impairment so that, when an eye care practitioner identifies such a concern with a patient, they may be able to offer the appropriate advice and support.
Types of help
It is important to remember that a wide range of assistance is available, and should be known about, to assist those with hearing impairment. Hearing loss may range from the profound, causing significant communication problems and major handicap, to the barely recognised which may have subtle negative social impact.
Congenital severe loss may result in developmental problems, particularly with regards to language skills, and so alternatives to standard verbal language might be helpful. Where loss is acquired, often enhancement of ability, such as through hearing aids and better communication skills adoption by correspondents, might be sufficient. Each case is different and this article can only offer an overview of different strategies.
Figure 1: The practitioner should face the patient as much as possible
From an eye care practitioner point of view, initial identification of the problem, adoption of good techniques, and awareness of where help might be sought to develop a tailored management approach is paramount. Our privileged position in seeing people on a regular basis, especially those at risk of sight loss such as the young and elderly, means we are also well-placed to check if ongoing strategies are appropriate and working well. How many readers, for example, have found they are regularly required to offer advice to an elderly patient about switching on their hearing aid more?
For this overview I have considered management in three main areas:
- Communication strategies
- Treatment strategies
- Support services
Communication strategies
Patient considerations
It is always important to recognise that hearing impairment affects people in different ways. Acquired loss, particularly in the elderly, may even be considered a normal ageing change and highlighting it as otherwise may result in a negative or even aggressive response. Always accentuating the positive, by reminding people that help may make things easier, is usually the best approach.
It is rare for the eye care practitioner to be the first to identify a severe hearing loss. The opposite is true for less severe acquired loss and typical indicative behaviours to look out for include:
- Calls for repetition.
- Irrelevant or nonsensical answers.
- Misinterpreted instructions.
- Hand cupping around ears.
- Leaning forward when listening.
- Staring at practitioner’s lips during conversation.
- Speaking loudly.1
Recognising such clues might not automatically lead to the question ‘how is your hearing?’ Indeed, some authorities2 suggest this is more often than not met with the answer ‘fine.’ A better approach might be a more direct inquiry, such as ‘does your hearing loss cause you any problems?’
Congenital hearing loss may be profound and require specialist communication strategies. That said, it is worth remembering that deafness in children has a strong association with ocular and visual problems in both the young3 and the elderly4 and so one should never exclude assessment of the other.
Finally, as with sight loss and use of words such as ‘blind’, it is useful to be aware of the stigma associated with terminology such as ‘deaf’ and ‘deafness.’ Even though these terms have an acceptance among the deaf community and may be used by charitable organisations, it might not necessarily be the case that recently acquired loss as might be commonly met in eye care practice should be described as such and so doing risks alienating the patient and perhaps reducing the opportunity for encouraging the sufferer to seek help.
TABLE 1 Summary of communication strategy for hearing impaired patients
Practitioner communication skills
When communicating with a patient with a hearing impairment in eye care practice, the general points outlined in table 1 should be considered. Visual clues, traditionally written on paper, are often useful and the advent of tablets, both with electronic fonts and handwritten touch capability, are often very useful to support verbal technique (figure 2). When working in the low vision environment, it is worth remembering that vision of at least 6/96 is required for useful lip reading and visual cues should be tailored to the expected vision capability of the patient.
Figure 2: Tablets are very useful to support verbal technique
Rabbitt5 reported that even low levels of acquired hearing loss may impact upon subjective assessment, for example seeming to impair recall when a patient is being asked to compare current and previous image quality. Tolerance is the key and always be aware of the indicative behaviours mentioned previously.
In general, improved listening and speaking (auditory-oral) techniques help maintain communication and, in children, may help with the development of some literacy skills. Often a combination of techniques is adopted and may include:
- Cued speech – this uses hand shapes to represent the sounds of English visually. Technically it can be used to supplement other approaches, either auditory-oral or sign based, but its major function is to support the understanding of spoken English and the development of literacy. Hand shapes are ‘cued’ near to the mouth to make clear the sounds of English which when lip read look the same. It is based on the principle that cueing in this way will make every sound and word clearer to those with significant hearing loss, especially the young, and therefore enable them to have full access to spoken language.
- Lip reading – sometimes called speech-reading, this is the ability to read words from the lip patterns of the person speaking. It is hard to say how much speech can be understood just by relying on lip reading, as many speech sounds are not visible on the lips and lip patterns also vary from person to person, but it is estimated that only about 30% to 40% of speech sounds can be lip read even under the best conditions. Lip reading is never enough on its own and is used to support other communication approaches.
- Fingerspelling – this uses the hands to spell out English words and letters. Each letter of the alphabet is indicated by using the fingers and palm of the hand. It is used to support sign language to spell names and places and for words that do not have an established BSL sign.
Specialist languages
British Sign Language (BSL)
Although the United Kingdom and the United States share English as the predominant oral language (‘two countries divided by a common language’), British Sign Language (BSL) is quite distinct from American Sign Language (ASL) – having only 31% signs identical, or 44% with shared derivation. BSL is also distinct from Irish Sign Language which is more closely related to French Sign Language (LSF) and ASL. It is also different from Signed English (see later).
BSL is a complete language with a unique vocabulary, construction and grammar. In the UK there are more than 70,000 people whose first or preferred language is BSL. It is based upon the manual construction of individual letters (figure 3) combined with facial and other gestures to signify individual phrases, terms or concepts. It may be learned through a recognised certified education programme and is used both by those with hearing loss and those in charge of their care.
Figure 3: British Sign Language alphabet
People who use BSL may well bring a communication partner with them when they attend for an eye examination. Remember to maintain eye contact and talk directly to the person you are communicating with, not the interpreter. Also, make sure the person using sign language has an uninterrupted view of their communication partner. This will be especially important while giving directions and explanations during procedures such as ophthalmoscopy and retinoscopy when the lights are off and you effectively block their view.6
Let Sign Shine is a campaign started by Norfolk teenager Jade Chapman to raise the awareness of British Sign Language (BSL) and attract signatures for a petition for BSL to be taught in schools. The campaign’s petition to the UK Parliament has attracted significant support.
Signed English (SE) or Sign Supported English (SSE)
There is a wide variety of signed languages which do not have a distinct vocabulary, such as BSL, but instead follow the word order of spoken English with supportive signs or, in some case, contact patterns. These are usually described as SE or SSE. Variety is wide and even might be self-designed by groups or pairings.
Makaton
Makaton is a language that uses signs, symbols and speech. It was developed by a speech and language therapist and two individuals from the Royal Association for Deaf People7 and is an acronym of their names. It is used by more than 100,000 children and adults in the UK.8 The symbols used in the Kay Picture acuity test all have simple and widely used and understood Makaton signs.6
Treatment strategies
Whether acquired or congenital, hearing loss may be classified as of two types; conductive and sensorineural. Management of conductive loss might be possible through a removal of whatever is preventing the normal conduction of sound. This might be:
- Wax removal – wax build up is common and a major cause of reversible conductive hearing loss. Though the obvious strategy is the removal of the wax, simply suggesting this to someone suspected of having wax build-up without careful otoscopic examination by someone trained to do so is not advisable. As the waxy build-up is often linked to skin secretion type, those with this form of hearing loss tend to have recurrence and so should know themselves when the time is right to either self-treat or seek help, usually via a practice nurse at the GP. Because a similar blockage may be due to or exacerbated by inflammation, a careful assessment prior to wax removal is usually advised. Softening of the wax, typically by twice daily use of an oily base such as olive oil, should give resolution within days. Cleaning with cotton buds is not advised due to risk of damage to the ear drum. Syringing (electric pumps rather than plunger syringes are now used) with body temperature water is less used today for the same reason but might be required in particularly stubborn cases.
- Medications – if the underlying problem is a build-up of sound blocking material from infection or inflammation, then medical treatment of the underlying condition itself is required.
- Surgery – where conduction is caused by non-resolvable residual material or bone growth then surgical intervention may be required and possibly adapted to prevent future problems, as when a grommet is fitted.
In persistent or difficult to treat cases of conductive loss, or where the initial problem has caused sensorineural loss, a hearing aid may be required. Sensorineural loss, where permanent loss of hearing has been caused by damage to the cochlea or neural pathway for hearing, usually benefits from a hearing aid. These may be of several types;
Figure 4: Cochlear implant
- Cochlear implant – though more likely considered a surgical intervention than a hearing aid as such, in severe cases of cochlear disruption, it is possible for an implant to be fitted which takes on some of the lost functionality of the cochlea. The implant comprises four elements (see figure 4):
1 A sound processor fitted behind the ear which converts sound into a digital code and also contains the battery.
2 The sound processor transmits the coded signal into the implant within the skull.
3 The implant converts digital coded signal into electrical impulses that pass to an electrode placed within the patient’s cochlea.
4 The electrode stimulates the auditory nerve in place of the faulty cochlea.
- Hearing aids – these may be either analogue or, more likely digital devices fitted in or around the ear that amplify sound. Analogue and digital hearing aids look very similar, but they process sound differently. Analogue aids amplify electronic signals, while digital aids use a tiny microprocessor to process sound in a way that can be pre-programmed to match the profile dictated by the initial audiologist assessment, usually by a computer hook-up during the assessment. Many digital aids can be programmed with different settings for different sound environments, for example a quiet living room or a crowded restaurant. Some even switch settings automatically to suit the environment. Digital hearing aids are designed to reduce background noise, which makes listening in noisy places more comfortable. They are also less likely to ‘whistle’, or give feedback. Thanks to extensive lobbying by groups such as Action on Hearing Loss, digital hearing aids are now available as standard on the NHS. Styles vary, though it is rare now to see aids incorporated into spectacle frames as once was the case. Designs include:
- Behind the ear (BTE) – for all ranges of loss and can be connected to assisted listening devices such as FM or Bluetooth. They include a tube and mould fitted into the ear canal.
- Open and receiver in canal (Open/RIC) – the ear mould is replaced with an open dome so most patients find them more comfortable as they do not occlude the ear. Also, lack of a tube means the sound is less likely to be distorted.
- In the ear (ITE or full shell) – fitting into the concha or opening, they are sometimes required where more power is required for amplification than might be possible with other in-ear devices.
- In the canal (ITC or half shell) – filling only the bottom half of the external ear, they may be cosmetically more comfortable but offer less power than the ITE.
- Completely in the canal (CIC) – these fit entirely inside the canal so are pretty much invisible, as portrayed on some recent TV adverts. Fitting requires skilled input by an audiologist and batteries and unit are at the more expensive end of the range.
- Invisible in the canal (IIC) – the most recent addition to the hearing aid range, this is based on an impression of the deeper recesses of the canal so is cosmetically superior but requires skilled fitting and has a price to match.
Most of the concerns regarding cosmesis with hearing aids have now been addressed. There is even a website called ‘pimp my hearing aid’ with tips on doing just that.
Support services
To find out what hearing services are available in any UK area, including access to an audiologist assessment, a good start is to go to www.nhs.uk/Service-Search/Hearing-impairment/LocationSearch/1799.
Table 2: Benefits available for those registered as disabled through hearing loss
Just as with sight loss, there is a whole range of non-optical and electronic aids and gadgets, professional help and financial and social support available to those with either registered or non-registered hearing loss. Here are just a few of note, but it is worth visiting the Action on Hearing Loss website (www.actiononhearingloss.org.uk) for a comprehensive and up to date list of services and benefits.
- Registration – either via GP referral or self referral to a hearing specialist, hearing loss causing impact beyond levels required for continued living standards may lead to registration and access to a number of benefits (see table 2).
- Access to work – hearing impaired people in employment may benefit from the scheme requiring employer supported help to enable them to continue working.
- Special educational needs (SEN) – a child in education may be assessed for a special educational need of which hearing loss is one (as is sight loss) and by so doing gain support through adapted teaching staff and aids.
- Equipment – there is a wide array of helpful aids available, from amplified telephones and mobiles, conversation amplifiers, aided assistance for television viewing, flashing doorbells and text phones. These may be accessed through private suppliers or via groups like Action on Hearing Loss.
- Loops – digital hearing aids may be set (usually to a ‘T’ setting) such that they detect signals primarily from a loop microphone which may be placed near to the person requiring attention. This may be a clinician, bank worker and so on – typically a counter loop – or might amplify sound and minimise background noise in a whole area – a room loop.
Conclusion
The analogy with sight loss when it comes to help is strong and I hope this article offers enough of a flavour of the wide range of help that exists for those with a hearing impairment for the reader to agree there really should be no need for anyone to miss out on assistance as required. And it is likely, in some instances, the eye care practitioner may be responsible for starting the ball rolling.
- Comments or queries to bill.harvey@markallengroup.com.
- An interactive CET exercise in this topic will be published in the autumn.
Useful resources
References
1 Shute RL. (1991). Psychology in vision care. Butterworth-Heinemann.
2 Karp A. (1984). Hearing impairment. Chp in Clinical Low Vision. (Faye. E ed.), Boston, Little, Brown.
3 Suchman RG. (1968). Visual impairment among deaf children. Volta Review, 70, 31-37.
4 Crews JEand Campbell VA. Vision Impairment and Hearing Loss Among Community-Dwelling Older Americans: Implications for Health and Functioning. American Journal of Public Health: May 2004, Vol. 94, No. 5, pp. 823-829.
5 Rabbitt R. (1988). Social psychology, neurosciences and cognitive psychology need each other. Psychologist, 1, 500-506.
6 Millington A. Look at me when you’re talking. Optician 20.02.15.
7 Sheehy, K. and Duffy, H. Attitudes to Makaton in the ages of integration and inclusion International Journal of Special Education 2009