PODCAST Hearing Loss Myths with Dr Lawrence Lustig
Host: Welcome to another episode of the MSD Manual's Medical Myth Podcast. On this show, we set the record straight on today's most talked about medical topics and questions. Today, we're tackling the topic of hearing loss. What causes hearing loss? Is it a normal part of aging? And can untreated hearing loss really affect brain health? We'll also talk about everyday hearing health, from protecting your ears from damage to recognizing early warning signs. I'm your host, Jason Rocker, and to help answer those questions is Dr. Larry Lustig, who's one of the nation's leading experts in hearing loss and the chair of the Department of Otolaryngology at Columbia University Medical Center and New York Presbyterian Hospital. Thanks for joining us, Dr. Lustig.
Dr. Larry Lustig: It's a pleasure to be here, Jason. Thanks for having me on your podcast.
Host: Absolutely. So let's start, kind of kick it off a little high-level. Let's start by explaining to our listeners exactly how hearing loss works. How do you lose hearing?
Dr. Lustig: Well, there's a lot of ways to lose hearing, right? Really, hearing loss starts the moment after we're born. We are born into the world with a full population of these tiny little cells called hair cells that are the sensory cells of the inner ear that convert sound waves into an electric impulse, which goes off to the brain. As we grow and as we age and as we're exposed to noise in the world, that gradually leads to loss of those sensory hair cells. And all of us on the planet will lose hearing as we age. The difference between all of us is the rate at which that hearing loss occurs, and that rate is largely determined by genetics. So whatever genetic deck of cards you were dealt, that's going to determine how quickly you lose hearing. And interestingly, that will also determine how sensitive you are to things like noise exposure and noise trauma. So those are the two most common reasons why we start to lose hearing. Age-related hearing changes and loud noise exposure.
Host: As you talk about age-related hearing loss, is there sort of a typical point that's the average when people start losing hearing?
Dr. Lustig: Well, there's population statistics about where you would be on average, but it's a huge range. We see patients who are in their 40s and start to lose their hearing early on, and we see people in their 80s and still have basically normal hearing testing. So what typically happens is the first thing that people notice is that they start having more difficulty hearing in complex listening environments. There's a lot of background noise. Those restaurants and bars that you used to go to in your 20s and had no problems hearing, you start having more difficulties in your 40s and 50s, and then we start to see more difficulty hearing in even quieter situations. And the classic I get is “my spouse can't hear me.” Meanwhile, the spouse is talking from two rooms away with the TV in the background. So we see this gradual trend of hearing loss over that time period. So it's really broad in terms of when that happens.
Host: Yeah. Sometimes I use that excuse with my wife that I can't hear, but I don't think that's hearing loss so much.
Dr. Lustig: Well, there's what we call. There's hearing and there's listening, and those are two very different things. And sometimes we don't need an ear doctor in the room with someone with hearing loss. We need maybe a marriage counselor.
Host: So talk to me about some of the other causes of hearing loss, but beyond aging and loud noises.
Dr. Lustig: Well, if we want to get really broad, we divide hearing losses into two large categories, one called conductive hearing loss, and the other one is sensorineural. Conductive hearing loss is any type of hearing loss that prevents sound from getting to the inner ear. The most common reason that we would see would be an earwax plug in the ear canal, a hole in the eardrum, fluid in the middle ear, or fixation or a problem of the middle ear bones. All of those things give you a conductive hearing loss. In contrast, sensorineural hearing losses are those of the inner ear or the nerve going from the ear to the brain. Age-related hearing loss, noise trauma are the two most common. There could be tumors of the auditory nerve pathway or other problems within the brain that can also give hearing loss. So those are the really broad categories of hearing loss that we would see. Ear infections, cholesteatomas, those kinds of things, those are typically conductive hearing losses.
Host: So is it safe to say that the conductive hearing losses are reversible, whereas the other forms of hearing loss are not?
Dr. Lustig: Yeah, I think you can say that not all conductive hearing losses are reversible. They're the ones that we try to reverse. So for example, if you've got an earwax impaction, we can remove that. That's an easy fix. If you have a hole in the eardrum, we can patch the eardrum, and that's a relatively easy fix, though sometimes the ear's resistant to do that. Ear infections, we can treat those and sometimes recover the hearing, but sometimes if there's erosion of the middle ear bones, we can reconstruct those middle ear bones, but rarely are we as good as what Mother Nature had originally developed. So oftentimes there's some residual hearing. Now for sensorineural hearing losses, that tends to be a one-way ticket. Once you lose your hearing, it doesn't come back. Hearing aids help, but they don't really restore natural hearing and they just sort of compensate for the loss of hearing. The one exception to that would be if, let's just say your hearing was so severe, you would need a cochlear implant. That recreates hearing. It doesn't make it normal again though.
Host: Got it. So what sign should people be looking for in terms of how to identify hearing loss? And then how often should people get checked to ensure that their hearing is as best it can be, I guess, for lack of a better term?
Dr. Lustig: Yeah, so I think one thing is if people are constantly asking you to turn down the volume of your TV, your stereo, if you're constantly asking people to repeat themselves, if you're having difficulty hearing in a noisy environment, difficulty hearing on the phone or at work, if people are telling you they think you have a hearing loss even though you don't believe them. Danger signs would be hearing loss associated with ear pain, ear drainage, ear infections. Hearing loss just in one ear is also a red flag that needs to be looked at immediately. Those are some of the main things that we look for. I do think that anybody who suspects they have hearing loss should get it checked. And you can visit your primary care doctor for a screening exam. You can go to an otolaryngologist or even go directly to an audiologist to get that checked. And if we identify hearing loss, typically we'll screen it again within six months to a year afterwards to make sure it's not a progressive hearing loss. And if everything's stable, we generally recommend once every three to five years just to make sure things are stable over that time period.
Host: Got it. And obviously there are age-related components to this. And is there similar when people turn 50, they're like, "You should get a colonoscopy." Is there an age when people should say whether you're experiencing loss or not, or whether you think you are, that you should get your hearing checked for that sort of seminal age?
Dr. Lustig: Yeah, we don't have the same types of minimum age to get a hearing test because you can see hearing loss literally at any age. Obviously, the kids who failed screening hearing tests at school need to be checked and monitored. Anybody who feels they have a hearing loss really should go and get a hearing test. And if you've identified a hearing loss, it should be checked on a regular basis just to make sure it isn't progressive. But there is no one age where you say, "Oh, everybody should have a hearing loss by this age."
Host: Understood. Now let's talk a little bit about some of the side effects, if you will, I guess, of hearing loss from a social standpoint. Have you seen where hearing loss impacts people's ability or willingness to interact in social situations?
Dr. Lustig: Well, yes, we see that all the time. Once you start losing your hearing, you have difficulty. That makes people less likely to go out and socialize. It may cause difficulties at work, particularly if they're not willing to own up to the fact that they have a hearing loss, which I don't see why that should be a problem. I mean, people have visual difficulties and nobody seems to mind that. People are very much willing to talk about their visual difficulties, but for some reason people try to hide their hearing loss, and I think that's unfortunate. We should be open about those kinds of things.
Host: How do you get people to come to the other side of that? If there's a stigma attached to it, or how do we start to change that a little bit?
Dr. Lustig: Well, sometimes you can't. I think our society values health, youth. Hearing loss is associated not just with aging, but there's historical associations with hearing loss that are unfortunate, calling the deaf and the dumb, for example, which was completely erroneous understanding of what was going on in a lot of these individuals. I do think things are changing. If you put hearing aids on and kids now when they go to school, it's accepted. I think with everybody walking around with AirPods or Bluetooth headphones sticking out of their ears all day long, people are used to having things in their ears and using it to listen. And sometimes with these newer hearing aids, it's hard to tell that they're even wearing a hearing aid. So I think things are changing, but that perception of hearing loss being associated with being older still exists. And I think that's what drives a lot of the resistance that we see to adopt hearing aids.
Host: Can you talk a little bit about the advancements in hearing aids, not only from a functional standpoint, but from an aesthetic standpoint? Because you mentioned years ago it was very obvious when someone was wearing a hearing aid, and it seems like now maybe not so much so, and hopefully that's something that gives people the confidence to wear those and impact their daily lives in a positive way without losing confidence.
Dr. Lustig: Well, that's exactly right. I mean, the technology has gotten much better. The technology has been getting smaller and smaller. The behind the ear hearing aids used to be huge, very visible. Someone with hair like mine that's very short, you would see them very obviously. The behind the ear hearing aids are much more powerful. You can do a lot more with them, which is why the more hearing loss you have, they're preferable. But the sizes are getting smaller and smaller. You can have in the canal hearing aids or in the ear hearing aids, which are less visible, but still very effective. There's even some very deep-seated hearing aids that live in the ear canal for months on end that just need to be replaced every several months or so. These are all really big advances which has helped in the adoption of hearing aids. Another big advance that we're really starting to see over the past one to two years is the incorporation of artificial intelligence, AI chips.
Some of these companies have just fed millions of instances of speech within a noisy background and told the AI to figure out how to get rid of it. This is the earliest stages, but we have patients that were sort of borderline cochlear implant candidates, and these hearing aids have allowed them to stay in hearing aids for a longer period of time. So that's gradually going to start. Right now, it's just in the highest level of hearing aids. But as that technology gets more widespread and cheaper to implement, we're going to start to see that even in consumer level hearing products.
Host: Very cool. Very cool. Talk to me a little bit, because you said the behind the ear is more effective than inner ear. Is that correct? And that's somewhat counterintuitive.
Dr. Lustig: Yeah, no, the behind the ear hearing, there's just a lot more you can package in some of those behind the ear units that sit back there, and it allows you to do a lot more. Now, when you plug up the ear canal, that can be uncomfortable to people. That's why a lot of people don't like the canal in the ear hearing aids. The key to this is really finding a good audiologist or hearing aid dispenser that you trust and whose opinion you respect. Because the reality is the hearing aids are expensive and that cost should include the ability to go back and get them adjusted. So it's important to find a hearing health specialist that you feel comfortable with that's responsive to your needs and can really help you out.
Host: That's great. We started talking a little bit about the social dynamics as it relates to hearing loss. Can you talk a little bit about the connection or what the research says as it relates to hearing loss and potential dementia?
Dr. Lustig: Yes, this was research that was originally pioneered by Frank Lin, who was at Johns Hopkins. I think now he works with Apple. And he was the first person to identify that hearing loss and dementia were associated with each other. Now that just means that you saw hearing loss much more commonly in people with dementia than you would expect based on how they would naturally present within people. But association does not necessarily mean causation. And for a while it was unclear whether or not the hearing loss was caused or was specifically related to the dementia, but there's been an increasing number of studies that really show that they do influence each other. What we think is happening is that we know that hearing loss makes people socially isolated and withdrawn. And we think that's the key component that exacerbates dementia. It's not so much that hearing loss causes dementia, it's that the presence of hearing loss with dementia will accelerate the dementia.
So then the flip side of that question is if you then treat the hearing loss, will that slow down the dementia onset? And again, that's a much harder thing to study, but there's some interesting data that's been published more recently that suggests that yes, if you treat the hearing loss, that it will in fact slow down the onset of dementia. And that's some research that was developed by one of my partners, Dr. Justin Golub here at Columbia.
Host: That's very neat. Talk a little bit, if you can, about, we talked a little bit about social, we talk about dementia. Talk about how hearing loss may impact mental health, if you can.
Dr. Lustig: Yeah. Well, I mean, if you think about it, you've got hearing loss, you're having a harder time communicating with family, with friends, you become socially isolated and withdrawn. That can exacerbate any underlying health issues, mental health issues. It can lead to depression and it can lead to anxiety if you're having a hard time functioning in a social situation. So absolutely they go together. And when patients are experiencing those exacerbations of their mental health, it's really important that they seek out help with a therapist or psychiatrist to help them through that and obviously get the hearing loss treated.
Host: Well, it seems like that's the recurring theme here is it's not the hearing loss itself, but it's the impact it has on the social interaction and the connections that you have with the people and loved ones around you.
Dr. Lustig: Exactly.
Host: So we talked a little bit about some of the advancements in technology that can help once hearing loss has come on, but what about preventing hearing loss? What are some of the best tips that you can provide to our listeners about how to best maintain their hearing at the highest level and to prevent hearing loss?
Dr. Lustig: Well, the best thing is to have inherited a good set of genes from parents that have noise resistance, if you will. But we can't choose that. That's just sort of what you're born with. But the number one thing that you can do, the one modifiable risk factor is noise protection. That's the one thing that we can do to really prevent additional hearing loss. There's a new concept called cochlear synaptopathy. It was developed from research out of Boston at the Massachusetts Eye and Ear Infirmary. And there was some mice that they exposed to low levels of noise exposure, the kind of noise exposure that would lead to a temporary loss of hearing, but that hearing would spontaneously recover. Then if you follow those mice out over the course of a year, the mice that had noise exposure actually had a more accelerated age-related hearing loss pattern. So we think the exact same thing happens in humans, that if you've got a lot of early noise exposure, particularly harmful noise, guns, military exposure, things like that, that's going to probably accelerate your normal age-related hearing loss.
But we have good ear protection mechanisms. Earplugs are available at every drugstore around the planet. Really good earplugs for shooting. If you're into guns and going to the range or going hunting. If you're going to concerts, earplugs should be a must. I can't believe the sound exposure that people let themselves be exposed to. But the reality is when you're young, you think you're going to live forever and you're never going to have a problem, but it catches up to all of us, unfortunately. So I think ear protection is the number one thing that people can do. Now, all hearing protection devices have what's called an NRR, a noise reduction rating. That's the amount of noise reduction in decibels most of the population can expect when using that product. And the higher the number, the better. So if you've got an ear protective device with an NRR above 25, that's pretty good. Above 30 is even better.
Host: It's like SPF for sunblock almost for the ear.
Dr. Lustig: Exactly. People have been working on biologics to try to prevent hearing loss, but there's a lot of things that we know if you take before, during, and after the exposure, you can prevent the noise-induced hearing loss. But the problem is for most of us, we don't know that there's been a problem till after we've had the noise exposure, and by then it appears to be too late for most things that have been tried.
Host: Got it. What are some of the biggest myths you've heard over your career about hearing loss in general, and then maybe as it relates to aging or other facets of people's lives?
Dr. Lustig: Well, that hearing aids will solve the problem. Again, they're a good fix, but they won't solve the underlying hearing loss. It's not like you're restoring functionality that's been lost. You're just sort of helping the existing hearing that you have. I think that's one of the biggest myths. There's a myth that someday we're going to, in the immediate future, we'll be able to regrow those hair cells and restore hearing to its natural state. That's the hope. There's a lot of research that's been funneled into that. There's even been some regeneration trials. Unfortunately, they have not worked. So I think we're sort of back to the drawing board on that. And I think the biggest thing is that we're all going to age, we're all going to lose some degree of hearing as we get older, and the best thing you can do is prevent that with ear protection devices.
Host: Any way to build up, you exercise, build up your muscles, you build up your stamina. Is there any way to build up the stamina and I guess muscular aspects of your hearing?
Dr. Lustig: I wish there was, but I would not encourage continuous noise exposure as a way of preventing that. That's just going to exacerbate the problem.
Host: Fair enough. Anything else we haven't touched on here, Dr. Lustig, that you think our listeners might be interested in?
Dr. Lustig: Well, yeah, I think so. For years, the only treatments we've had for hearing loss are do nothing, hearing aids and cochlear implants for those with severe to profound hearing losses. The cochlear implants work terrific for those without hearing, but it's not natural hearing. And based on the genetics of hearing loss that there's been a gradual understanding of based on research in the lab and on large families and on the gen bank information that's been disseminated, we have a pretty good understanding of many causes of genetic hearing loss and all the genetic mutations that can lead to hearing loss. Now, finally, for the first time, there is a gene therapy for one particular form of genetic deafness. It's a rare form of deafness. It's the deafness due to a gene called otoferlin. Probably happens in about 30 to 50 kids in the United States per year, but it seems to be extraordinarily effective for that population.
And now that we finally have one FDA-approved gene therapy for genetic deafness, we think this is going to spark a lot of interest in developing gene therapies for other forms of genetic deafness. So that's really going to be a huge change as we go forward here. And it's going to be critical for any kid born with hearing loss to get genetically tested to see if they're one of the candidates for some of these future gene therapies.
Host: Very, very great stuff. Well, listen, thanks so much for joining us on the MSD Manual's Medical Myth Podcast today. As we close out, I'll let you, Dr. Lustig, leave us with a final word for our listeners.
Dr. Lustig: Medical knowledge is power. Pass it on.
Host: Awesome. Thanks again, Dr. Lustig.
Dr. Lustig: Thank you so much, Jason. It's been a pleasure being with you today.
