Deaf or Death? A New Answer to Ototoxicity's Oldest Question

Ototoxicity is the negative effect of certain medications that can cause hearing loss. Even common medication such as Aspirin or ibuprofen pose a risk.  It is well documented but largely ignored and rarely discussed. If you have ever found yourself advocating for ototoxicity monitoring, a question such as “Would you rather the patient die or go deaf?” will not likely be new to you.  While this argument has historically carried validity, advancements in both technology and medication alike offer a new and more helpful answer, “Neither!”.

Tuberculosis is a global health problem and is second only to HIV in deaths caused by infectious disease. Drug-resistant and Multidrug-resistant tuberculosis (DR-TB and MDR-TB) are virulent forms of TB that do not respond to anti-TB drugs available today. MDR-TB necessitates use of medications which are associated with permanent sensorineural hearing loss. Hearing loss following treatment for MDR-TB using aminoglycosides has been reported to occur in up to 57% of patients. This number is as big as it looks!

The main focus is on curing the patient and as an unfortunate result not enough attention is given to the negative side effects of the medication (i.e., permanent hearing loss). Which is why the question: “Death or deaf?” has become so common.

Today the answer is different, we no longer have to make such a choice.

Hearing loss brought on by medication is preventable through appropriate monitoring, early diagnosis and appropriate audiological and medical intervention, but it is not without its challenges.

In South Africa, healthcare institutions are embracing monitoring programs and are providing high frequency audiological testing to patients while undergoing treatment for MDR-TB. This is a huge step forward in combating the effects of drug relateed hearing loss and promises to stem the tide of related hearing loss.

Like many regions in the developing world, Africa has a shortage of both audiologists and the required equipment, making it difficult to create and maintain sustainable monitoring programs.

Traditional, booth-based audiometry equipment is expensive and takes up a large amount of space that could otherwise be used more effectively. Booths are difficult and expensive to move, thus treatment is reliant on the patient’s ability to travel great distances to where the equipment is available. Cross-contamination in MDR-TB is a major concern and without expensive measures to ensure otherwise, the soundbooth becomes a source of contamination risk.

 

The impact of hearing loss

Drug related hearing loss can be prevented provided all possible measures have been taken. In cases where hearing loss prevention was unsuccessful, the severity of hearing loss can be minimised.

Of those now living with permanent hearing loss, few are fitted with hearing aids. The South African health department’s financial strain results in limited resources being made available for hearing aids due to their cost. Further highlighting the importance of preventative care.

Hearing loss impacts quality of life and leads to communication difficulties, social isolation and depression. Permanent hearing loss may result in difficulties for patients to return to their normal lives with profound psychological, financial and social consequences. The impact is particularly bad in the developing world where income loss may not only affect the individual, but the extended family who often depend on a single income which could be as low as a few dollars a day.

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Challenges in providing monitoring services

There are currently 574 audiologists and 1542 dual registered, speech-language therapists and audiologists (STA) registered with the Health Professions Council of South Africa (HPCSA) (HPCSA, 2017). South Africa, like many developing countries, is burdened with a high clinician to patient ratio where 2116 registered audiologists are available for 55,91 million people (StatsSA, 2016). That is just over 26442 patients per audiologist. Further exacerbated by the fact that most hearing health professionals are concentrated in and around urban areas.

Existing traditional audiometric equipment (sound booth based) installed in health institutions cannot be moved around easily and is costly to maintain. This means that the large populations living in remote and rural areas must travel long distances to receive care. Travel is expensive and often necessitates time off from work and requires multiple trips to the hospital due to staff or equipment shortages. Many simply cannot afford the travel, despite the care being free of charge.

The financial constraints of many institutions mean that resources such as ultra-high frequency (>8kHz) audiometry, required for early detection of changes in hearing status prior to the individual’s speech frequencies being affected, are not readily available. This means that patients  may be diagnosed with hearing loss when it is already too late.  


So what do we do about this?

The good news is that new technologies like tele-audiology and portable, booth free audiological equipment are meeting the challenges that traditional technology cannot.  

teleaudiology practice

What is tele-audiology?

Tele-Audiology is an offshoot of Telehealth also known as Telemedicine where patient evaluations are done over the internet using video, audio and specifically designed and connected medical equipment. Tele-Audiology uses telehealth to connect patients audiologists for audiological care. This provides patients with access to audiological services that are otherwise unavailable where they are.

But, on its own, teleaudiology is not enough, we need to connect equipment that makes it all work.

That is where we come in.

KUDUwave™ – A portable solution

KUDUwave™ is a portable solution which can be used to provide audiology services or test extended high frequencies in the field without a traditional sound proofed/treated booth.
The KUDUwave™, is a soundbooth, headset and audiometer combined in a single lightweight device enabling the required mobility and functionality to solve many of the problems already mentioned.

  1. KUDUwave™ is portable – this allows the hearing healthcare professional to deliver audiological services to clinics around their work station,  covering more  patients, wherever they are. Patient monitoring can literally be done outside the patient’s yard for patients that are unable to get to the clinic or health institution! This reduces travelling costs and travelling time and ensures the preservation of both the patient’s hearing and quality of life.
  2. Extended high-frequency KUDUwave™ Pro (>8kHz)  - The key too early detection and helping  to avoid permanent hearing loss. The KUDUwave™ is capable of testing up to 16 kHz, making the portable audiometer ideal for durg related hearing loss monitoring. The KUDUwave™ is able to detect ultra-high frequency hearing losses, therefore, detecting hearing loss prior to speech frequencies being affected.

But what about the shortage of qualified audiologists. How do these technologies address the shortage?


As individual technologies, they don't. But when combined, we can see the stack of benefits to not only MDR-TB and ototoxicity monitoring, but also to the industry at large.

Shortages of audiologists is not limited to South Africa, or the developing world, it is a global issue where very few countries have adequate numbers of professionals to address the need for hearing care services.

 

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Just one of the benefits is Task-shifting.

Task-shifting is the assignment of tasks to less qualified healthcare personnel in areas where there’s a shortage of specialized healthcare workers (i.e. audiologists). Tele-Audiology enables task-shifting by allowing hearing healthcare professionals to train less qualified health workers (i.e. nurses) to conduct or facilitate a hearing assessments without a hearing healthcare professional being present in the area.

Automation assists these less qualified personnel to provide high quality testing, quickly and easily while providing the audiologist with accurate test results at a distance. Taking one audiologist to many patients simultaneously.

You can read more about task shifting here

How does tele-eaudiology work, practically?

There are three different ways in which telemedicine, in this case teleaudiology, is applied to analyze, interpret and provide recommendations to patients. Below are the three principles of telemedicine which can be applied:

  • Synchronous: This audiovisual happens in real-time by having a computer at the patient’s site and at the clinician’s site connected to the internet. The clinician remotely controls the computer at the patient’s site to monitor the status of the patient’s hearing. The clinician will then analyze and interpret the patient data in real-time, and provide recommendations.
  • Asynchronous: The trained healthcare worker assesses the patient’s hearing, then forward the patient’s data to an audiologist once the healthcare worker has access to the internet. The audiologist then interprets the patient data and sends back recommendation (i.e. ‘ototoxicity detected, please reduce drug dosage or frequency’) to the patient site.  
  • Hybrid: This is the use of both synchronous and asynchronous methods.

This ensures improved access to audiological services in urban, rural and remote areas even without a hearing healthcare professional being present at the site.

With the advantages such as its portability and affordability, the KUDUwave™ has allowed for the decentralization (from hospitals to clinics, from clinics to homes!) of MDR-TB patients’ management from the onset of treatment; consequently, resulting in improved service delivery, greater access to care and management of MDR-TB patients. The KUDUwave™ ensures that both the patient’s life and hearing are put at equal importance, by using the extended high-frequency audiometer (KUDUwave™ Pro) to detect ototoxicity early and ensure patient hearing preservation.

Click below to find out more about the KUDUwave™ Pro

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Hlolo Ramatsoma

Written by Hlolo Ramatsoma

Hlolo is a clinical, research & support Audiologist at eMoyo. He is involved in many parts of the business, from consulting to R&D to supporting and training customers. He earned his BSc in Audiology from the University of Cape Town and is an experienced clinical audiologist specialized in ototoxicity monitoring, product specialist and training audiologist.

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