#379 Hearing Loss, Tinnitus, and Meniere's Disease

you know Paul I've never I've never seen the inside of my ears I feel like there's not even really a question there what what are you having to get out of me Matt Paul but I hear all good things great no no no no all right thanks to uh 40best earpuns.com for that one and uh let's get to the show the curbside podcast is for entertainment education and information purposes only and the topics discussed should not be used or prevent any diseases or conditions aside from possibly and affiliate Outreach programs if indeed there are any in fact there are none pretty much we are responsible if you screw up you should always do your own homework foreign [Music] welcome back to the curbsiders I'm Dr Matthew watto here with my great friend America's primary care doctor and a national Treasurer Dr Paul Nelson Williams Paul how are you doing I'm great Matt thanks for asking how are you look very uncomfortable with that phrase I'm heaping upon you but it's not gonna stick I think it will tonight we are going to be talking about hearing loss and tinnitus we're going to talk about how to counsel patients who are experiencing hearing loss and go through some cases maybe some worst case scenarios of the patient that walks into our office with hearing loss paw and uh but before we get to that and tell them about our guest Paul can you tell them what is it that we do on curbsiders you're happy to as always Matt we are as a reminder the internal medicine podcast we use expert interviews from your clinical pearls and practice changing knowledge and we have an amazing expert interview tonight with our guest uh Dr Stephen D Roush and I will let you Matthew tell us all about his amazing accomplishments before we get into the show sure Dr Rausch is a professor and vice chair for clinical research in the department of otolaryngology at Harvard Medical School he is an otology division member and vestibular division Chief in the Otto laryngology department at Massachusetts eye and ear in Massachusetts General Hospital in Boston Dr rausch's clinical and research interests are combined in disorders of Hearing and Balance including Meniere's autoimmune inner ear disease sudden deafness and migraine his clinical otology and neurotology practice is in medical management of Hearing and Balance disorders which is why we wanted to speak with him and before we get to the interview a reminder that this and most episodes are available for CME for all health professionals through VCU Health at curbsiders.vcuahealth.org and now let's get to the interview [Music] so Steve we're going to start with our first case we're going to be talking about Mr Weber he is a 73 year old retired factory worker he's coming to our Primary Care office he says his wife has sent him because he seems distracted and inattentive he watches the television louder than his family and they're getting frustrated with him when he asks them to repeat what they just said he says you can't listen to a conversation when there's a lot of background noise and he has a hard time joining conversations on the car journey and struggles in a restaurant kind of any situation where there seems to be a lot of background noise he seems to have to work a little bit harder he gets annoyed and embarrassed since actually it's impacting how much he socializes no prior history of head injury no history of Barrow trauma that we can elicit because we're taking much more a thorough history than I typically take no ear infection or previous surgeries he says that he spent some time in the military as a young man and this included detachments in Asian Africa which required to take anti-malarials and now we're at high level med student uh history taking at this point he tells you that his hearing has gradually become worse in recent years and since the pandemic with everyone wearing masks this has made things much more difficult as he realizes that he may have been lip reading for a while to compensate and it's just recognizing that now that he doesn't have the opportunity to do so so I think before we get into the workup I I think it's often helpful just to hear broadly how you think about the patient who comes to you with what sounds like sort of chronic progressive hearing loss like what what big categories you think about and what's your what's your general approach before we get granular we know that by age 65 at least here in the U.S by age 65 about one-third of the population uh has enough hearing loss to wear hearing aids and by age 75 it's about two-thirds of the population is hearing aid eligible so if you just look at their date of birth you can kind of guess whether or not they're going to have hearing loss and the best understanding of age-related loss now is that it's a combination of genetics plus lifetime wear and tear on the ears the the most modifiable health risk being noise exposure uh ototoxic drugs are out there but they're not the common ones it's aminoglycosides and as you say you know an anti-malarial or something but for most citizens Auto toxicity it's not really the main event some chemotherapy drugs uh platinum-based drugs particularly can be autotoxic but yeah it's noise and age you know and it was the age being really noise plus genetics and and we say age-related hearing loss probably more correctly than old age hearing loss because the the likelihood of you losing hearing over time is a bit like uh you know like going bald or going gray it uh some people start in their 20s and some people may not ever lose their hair or go gray and it's just it's a program degenerative process it varies across the population but we do know that we see more age-related loss in men than women probably because they were more likely to be using power tools and playing in garage bands and other stuff um at least the people who are in their 60s and 70s and 80s now um the the exposure to to loud sound and in youth nowadays is pretty um uh equally distributed everybody's blasting their ears with loud sound so I don't know that we're going to see a sex difference uh anyway when I see the patient uh um the story that was in your case is absolutely archetypical uh the patients notice it only gradually there was a precipitous uptick in people coming to have their ears checked when covet hit because of the Mask uh depriving them of visual cues and the the dependence or the Reliance on visual cues is something that all humans do subliminally it's not something you have to teach people you know if the if you want to communicate with somebody who's hearing impaired you have to be face to face in a quiet place medically I really I mean I take that kind of a history too all those things you listed but it doesn't really matter this person's problem is hearing loss and the cause is a bit irrelevant um what you have to deal with is what's on his plate now for us in primary care I mean I know we we talked a little bit ahead of time I think the easy the easy answer is just refer anyone with hearing loss to audiometry which I think uh at least if you're practicing in the U.S is fairly available so that that's something that I commonly do I just as far as things in a history that that might make might might make you refer quicker to see the the the ENT doctor maybe you can say red flags can you can you point out what are some of those that you might listen for as you're taking the history from the patient yeah so the the reddest flag the only real otologic emergency in this category is sudden hearing loss which is unilateral and it's defined as a loss of hearing within 72 hours some people wake up deaf on one side some people feel their hearing dropping like air going out of a tire you know and over a period of 20 30 minutes or an hour they feel the hearing set disappearing some people feel a click or a pop and the hearing suddenly drops uh in about a little less than half of those cases there may be some balance symptoms that accompany the hearing loss but in the majority of these cases it's just hearing sometimes somebody will get a head cold or an allergy thing or an airplane flight and both ears block up but the next day one year opened and the other one doesn't and uh um the problem with this kind of sudden hearing loss is that it's not scary um everybody's had a stuffy ear once in a while and you don't go running to the doctor and so it gets neglected and and unfortunately it really is an emergency there's a short window of time to address it medically or it's too late besides that um we worry more about things like ear pain and drainage you know if you have blood or pus coming out of the ear that needs prompt attention if somebody has acute whirling vertigo you know that's come on rapidly or suddenly that needs to be evaluated um if it's the first episode it needs to be evaluated for the go no-go decision about stroke but if it's relapsing vertigo it's not an emergency anymore if it's gradual hearing loss it's not an emergency we do have a reddish flag for somebody who has unilateral Progressive hearing loss and it's not an emergency but you know both years are approximately the same age and both ears have the same life ex have the same life experiences and if somebody comes in in one ear has been going down over the last number of weeks or months that's concerning and it's even more concerning if there's an expanding repertoire of neurological stuff you know that they've lost their hearing but now they're feeling like their balance is not quite right their face is twitching you know other other neuro flavored symptoms that's very worrisome it needs to be evaluated but it's not a red you know not a lights and siren emergency it's just important so taking it back to Mr Weber who's got this The Fragile non-alarming hearing loss what what exam should we be doing in the primary care office before we sort of send them out for audiometry I know for me I'll probably look and see if there's anything blocked up in there I'll maybe do sort of a finger rub or a whisper test but above me on that is there should we be banging to uniforms around and stick them on the foreheads or like is there any anything else fancy that we should be doing to sort of help set everyone up for success yeah I actually know I think I think trying to look in the ear get you know practicing looking in the ear um you know if you if you put your otoscope speculum in the ear and you're still seeing little hairs blocking your view you're not in Far Enough the speculum should always go in past all the hair and if you can't get in past all the hair you need to send the patient to somebody else um the uh if you get past all the hair you know hopefully you can see the eardrum and you know what an eardrum looks like and it kind of looks like wax paper it's kind of gray and a little shiny and uh if that's not what you see either you don't know what you're looking at or there's something wrong with the eardrum but in in either case they need to go see somebody else I mean I I don't think that there are a lot of branches on the decision tree I I do think that a finger rub is a perfectly acceptable simple hearing test and you can do that on each side and probably the patient was already doing it um I don't really think you need to do tuning Forks tuning Forks or you know there's an era of medical diagnosis uh you know depending on when you train and where you trained there are many of us in medicine who like to do the Sherlock Holmes thing and we love to pick up on every little nuance and we look at the fingernail beds and we look at the soles of their shoes and we ask them what they have in their pockets and we you know we try to come up with the diagnosis without having to send them to the truth tunnel for an MRI or something and I I I I I think if that's your that's some of the joy of the work you do absolutely get some tuning forks and look in their ears and and do all that stuff but the reality is if they complain of hearing loss they need a hearing test and if they're what you know wife deafness doesn't show up on an audiogram it's a it's a separate problem but if their family is complaining somebody who has gradually Progressive hearing loss really doesn't notice it it's one of those boiling a frog things that it's so gradual that they know what they're hearing but they don't actually know what they're missing they don't have a clue and so uh people around them are much more aware of the hearing loss than the patient is and uh you know the patients who have hearing loss get they get very defensive because you know they don't want to seem old and they they learn to smile and Nod and make believe they know what you're talking about and they you know they try to laugh when they see everybody else laughing and they have all kinds of of adaptive strategies to try to mask the problem that they're they're kind of out of it and it's that's sad hearing loss is very isolating and um it's also a problem because in our culture where we're so biased about age if you see somebody who's gray or bald and they're you know they're like not laughing at your joke or you ask one question and they answer a different one or you speak to them and they ignore you you know they seem like kind of a space shot and the the assumption is that they're they're experiencing cognitive decline and hearing loss can masquerade you know can can mask or look like cognitive decline really the only problem is a patient didn't hear you and so uh it's a it's a critical thing to think about when you're doing a mental status exam or any kind of cognitive formal or informal cognitive assessment on your older patients that's a great point I wanted to ask about so if we sent this patient let's say they had audiometry it showed a bilateral sensorineural pattern of hearing loss and it looks like it's worse at the higher frequencies now they're seeing you in the office Steve what what might that conversation how might you explain that to them and what sort of things might you tell them you know prognosis treatment that sort of thing right so um when we when we do a hearing test a comprehensive audiogram has has two parts it has a measurement of hearing threshold or loudness which is basically plotting out what's the softest thing they can hear across a range of frequencies kind of like you know going up the piano looking from lower lower pitch to higher pitch and see how they are how their sensitivity varies and we do a measure of hearing Clarity it's called a word recognition score discrimination test and so the threshold is done first and we figure out what level of loudness does the patient have and this is plotted on an audiogram where the the x-axis has frequency from low to high and the vertical axis has loudness and decibels and and uh the the plot is standardized internationally and it's normalized for normal human hearing so normal people have hearing between 0 and 20 decibels all the way across the top of the audiogram and is a loose sensitivity the curve gets lower and lower on the page and so you might see a flat pattern where it's reduced at all frequencies or you might see one that's worse in the highs or worse in the lows the most common pattern of age-related loss is worse than the high frequencies and that high frequency roll off starts very high and it erodes across the page as you have more and more birthdays um speech sits right in the middle of the frequency domain that we measure and so uh in human speech different speech sounds have different characteristic frequencies so vowel sounds are low pitch relatively low pitch and some of the consonants um like s or F or th are very high frequency hissing sounds and so those are the things that get clipped out first and and so somebody with a high frequency hearing loss it would it you could sort of simulate it on your radio if you turn up the bass and turn off the treble and it just sounds like old time FM radio voice that sort of booming low frequency sound and you can't make out what the guy is saying and uh that's what a high frequency hearing loss sounds like to the patient um on the once we know their threshold then we do the word recognition test and we turn up the sound so it's loud enough it's well above their auditory threshold so we're we're Beyond audibility and we're measuring intelligibility and we deliver a list of words or hundreds of lists but basically we the voice on the recording it's usually a digital recording so it's pretty standard it says you will say and it gives a monosyllable with a consonant envelope and a vowel in the middle you will say hit you will say bike you will say muff you will say Hut you will say bat you will say you know and it goes to a big long list and the audiologist records the percent correct so there's no contextual cues like listening to a sentence there's no syntactic or prosodic cues it's just a bit a little blip of sound and did you get it and in a normal person they should have more than 90 percent of the words correct and and so when we measure hearing loss some people have lost loudness but if you correct for the loudness their hearing is actually crystal clear but many people as they lose hearing they lose both loudness and clarity and uh it's a little bit of a of a rough approximation but but generally if you lose auditory hair cells you lose loudness and if you lose neurons you lose clarity and uh many people depending on the on their genetics and on the cause of their hearing loss they lose both hearing aids make stuff louder hearing aids are amplifiers and so whatever aspect of their hearing loss is a loudness deficit is very correctable hearing aids don't do anything for clarity and so if somebody has a loss of clarity that's like a radio station that doesn't tune in very well and you can crank up the volume and it is still not a satisfying listening experience and so patients with poor discrimination are they may still get some benefit from hearing aids and the benefit may still outweigh the aggravation but they're not happy about it they are not enthusiastic hearing aid users because they hear a lot more but they don't hear a lot better is there a fix for the clarity or is that still is that like a cochlear implant or I'm totally I I'm ignorant on this subject so um right now cochlear implant is the only remedy for clarity but it's not a Cochlear implants are generally done when the clarity scores get down below 50 percent on that word recognition test and uh at least historically we haven't done cochlear implant until both ears are down below 50 percent um in the last few years a few medical centers around the world are beginning to do cochlear implant for single-sided hearing loss and they are beginning to at least in the U.S there are now some insurance companies that will pay for that but it claw it costs close to a hundred thousand dollars to get a cochlear implant so if your insurance isn't going to pay for it you're not likely to get one patients who've had cochlear implant get a post-op word score typically around 50 to 60 percent so if if your word score was at 20 and you bring it up to 50 it's fantastic if you're already at 50 and you go through a couple of hours of surgery and you know all of the recovery and you still have 50 or 60 percent it's disappointing and if your other ear has a hundred percent Clarity a 50 percent here sounds like junk and you won't even want to wear your cochlear implant so um it really it's a it's a last resort for people who are unaidably deaf on both sides and for those patients it is fantastic and nobody lives in silence anymore you know everybody hearing with Hardware lots of people do that but living in silence you know for people who've had hearing and lose it who have acquired deafness we can always bring back some usable hearing now there's a huge Biotech biopharma Industry trying to figure out how to regenerate hair cells and neurons and all kinds of other ways of of restoring sensory neural hearing loss but but we're not there yet stay tuned yeah I hear Elon Musk is thinking of a neural link some sort of brain implant that's gonna and then eventually he's good that's gonna then we're gonna start using it not just for hearing but to uh you know to access the web and things like that yeah it's gonna we'll be cyborgs Paul great finally I welcome our robot of Lords I was I was gonna ask I I know typically for me you know as we discussed it sort of are you having a hard time hearing yes okay then we should have you see you know an audiologist and and from there it's kind of mysterious what happens I wonder if you couldn't share I know there's gonna be some variability geographically and with insurance and that kind of stuff but typically if someone needs hearing aids can you sort of talk us through what that process looks like like how easy is that for the average patient to get I know this is not exactly a clinical topic but it still seems fairly relevant to the discussion so uh in the U.S in all 50 states every single state has a state law mandating that anyone who wants to sell you a hearing aid has to give you a minimum of 30 days money back trial so we can look at somebody's audiogram and I described a moment ago about how that's acquired uh it's done it should be done in a soundproof booth by a licensed audiologist who knows something about what they're doing and the equipment is calibrated and all that other stuff but assuming you've had a good audiogram somebody can look at the audiogram and we have audiometric criteria for recommending a hearing aid and specifically we see that the hearing in the speech range in the mid-range is is worse than 30 decibel threshold normal is zero to twenty twenty to Thirty is kind of you know you it begins to be a problem when you get worse than 30 patients uh are much more aware they're having a problem and and often they they notice it very suddenly and I'd give you the analogy of somebody who's standing in a swimming pool and the water is like at their upper lip and they're doing fine but if the water gets a half inch deeper they all of a sudden have a big hit on their quality of life and and that's kind of what we see on a 30 decibel audiogram they go from 30 to 35 and all of a sudden they're drowning you know they're missing a ton even though the actual change in hearing was very small the impact is big so if we see an audiogram in that range we recommend a hearing aid fitting and hopefully the audiologist will interview the patient about their listening needs you know do they go to the symphony do they go bowling do they you know have to work in big groups little groups do they watch TV all day do they you know work in a machine shop like whatever what environments are they in and what what do they need and want to hear and based on that uh the audiologist can make some recommendations about what hearing aid instruments are worth trying there are over 400 models of hearing aid on the market there are about five big companies that that currently hold about 80 percent of the world market share for hearing aids wow the rumor is that they all get their chips from the same Factory in Taiwan um there there really is very little difference from one company to another and and when I talk with patients about this I this is all the same stuff I tell them shopping for hearing aid is like buying a car all the cars have four wheels and a motor and a steering wheel all the hearing aids have um you know a microphone an amplifier and some you know speaker and every company that every car company you know makes a two-seater sports car and a family sedan and a station wagon and an SUV and for hearing aids it's kind of the same thing you know there's a two-seater sports car and there's a minivan you can get the economy model or leather upholstery in a sunroof and all of that is the same for hearing aids and so there are some people who really just want like uh you know like on and off twitch like the simplest No Frills basic and other people want a Swiss army knife you know with all the features and all the options and I I don't know I expect all of you have a microwave in your home and you know the microwave can bake a pie and roast a turkey and you know do all kinds of things but you said it for 20 seconds and heat up your coffee and you know do you really want to buy something that's got all of those fantastic features and just use the on off switch so the audiologist is trying to figure that out by interviewing the patient and then match them with something they're going to teach them how to use it try to coach them about when to use it and how to use it and then you send them home for a month or longer some places have a longer trial period and at the end of that then the patient can make a an informed decision about whether or not to try the hearing aid and I I really push on my patients um many of them are worried about the Cosmetic aspect of the hearing aid you know that they're going to look old now everybody's got stuff stuck in their ears you know it's a stigma of having something in your ear has vanished makes you look young and and that's such a good hearing aids that are you know our fashion statement but um especially seniors are concerned about looking old and they're really not thinking about the Cosmetic aspect of the hearing loss about not responding when people speak to them about not laughing at the joke about you know misunderstanding the questions and and appearing senile and and if you tell them about that all of a sudden they have a very different attitude about trying the hearing aid and so I I really push them to not to make the emotional decision but to get the hearing aid use it for a month then decide if you want it and if you don't you return it and you get your money back less a service charge now I have just one last thing to say well two two last things to say about that one of them is that the whole game has changed recently in the U.S because there's a new federal law about direct to Consumer hearing aids sales and uh and so now just emerging and and I'm sure you're going to see tons of it over the next two or three years uh you'll be able to walk into you know big hearing uh big Pharmacy chain stores uh you know the CVS and Walgreens and you know everybody else and and uh electronic stores and you know Target and Best Buy and like anywhere and they're gonna sell hearing aids just like you can walk into the drugstore and buy reading glasses and uh these uh are not regulated by the FDA to the same degree as traditional hearing aids traditional prescription hearing aids are three to five thousand dollars each and uh so and the uh over-the-counter hearing aids are projected to be in the sort of two to eight hundred dollar range uh so you know one tenth the price one-fifth the price now prescription hearing aids typically last about five years if the over-the-counter hearing aids need to be replaced every year at the end of five years you may have spent the same amount of money but but these instruments are going to be um they're going to be millions of them out there I don't know which ones are good ones and not you know that information will trickle out and if you read Consumer Reports or you read wire cutter in the New York Times there are all kinds of tech review services that are going to be watching this very attentively most of these devices are going to have a controller app that you put on your phone and it'll let you you know set the loudness and the balance and it'll be Bluetooth compatible so your phone can can broadcast directly into your hearing aid there's going to be all kinds of of cool technology available in the next few years but you know what if your grandma is 80 something years old and still uses a landline phone teaching her all of this stuff about using a hearing aid is really a challenge and right now audiologists who dispense hearing aids are the ones who do that and it's going to be tough for Grandma to walk into CVS and you know buy a hearing aid off the rack and go home and get the best use of it uh I think there may be some hybrid situation where people buy their own hearing aids but then they go make an appointment with the audiologist to learn how to use it just like the uh you know like calling tech support for your computer you know or even like insulin teaching in the primary care office is not that different that's great I think we should try to recap the first case and and resolve this Paul and then and then move on to the the next case because we have we'll we'll put uh we'll we'll go through some other cases but so big big points so far at age 75 about two-thirds of people Paul have would be criteria to get hearing aids so just looking at the patient's age is a good guess of you know do they have hearing loss or not and uh what type they might have the the true red flag is if someone has sudden hearing loss within 72 hours unilateral that's you know that's that's a red flag diagnosis we're going to talk about a case of that um and then as far as uh hearing aids go they they work to make stuff louder but the clarity portion of things Paul they they don't really help as much with that Cochlear implants maybe can address that a little bit but like as we said uh we talked that in depth about who may benefit from Cochlear implants and they have to have pretty severe bilateral hearing loss um that's that's severe and then uh as far as the hearing aids go this we just talked about there's going to be some over-the-counter products coming that'll be cheaper but we don't know the quality and how long they'll last and the traditional hearing aids last three to five years they cost around three to five thousand dollars and uh you know they're they're prescribed by or an audio in an audiometrics is that the right word teach them audiologists it's late Paul I guess an audiologist would uh fit them and show them how to use them and sort of talk to them about the products there so let's say we I just want to add two things to your summary because that was that was great there are two dirty little secrets about hearing aids and and uh I I try to warn the patients about it so that they're not disappointed or upset one of them is that they only work if you put them in your ears and and so so buying the hearing aid and sticking it in your dresser drawer your glove compartment is not economical and the second thing is that the hearing aids don't know what you want to listen to they just make everything louder they don't discriminate and uh so that in a quieter environment having a conversation around the house uh talking to the kid at the checkout counter at the grocery store or you know everyday life hearing aids can be very useful if your complaint is discriminating speech in noise you have trouble at social events and uh and Loud restaurants hearing aid is not going to make you happy and there are there are a few workarounds you can get remote microphone that you clip on your dinner date that Bluetooths into the hearing aid but it it it only can hang on one other person not everybody you might encounter at the party so it's really hearing aids are AIDS but they're not perfect remedies yeah this has been great this is total total new ground for me Paul I I didn't know hardly any of this stuff that that we just learned here and this is I think this is very useful to counsel patients when we're sending them to audiometry because right now I'm just sending them with no you know I'm not I have nothing to add I'm like yeah we'll send you there somebody else should do something I don't know what happens either but maybe maybe tell me what happens next time so okay so Mr Weber we hook him up uh we we teach them all this great stuff we've just learned he gets some hearing aids he's happy but now Paul I think you have another case why don't you why don't you tell us about Miss is it Eustis I was gonna give you Stace just to say and keep you safe but I could be mispronouncing but we'll say Ms Eustace is a 50 year old diving instructor who enjoys Cold Water Swimming uh has recently had covet and comes to your office saying she's had sudden hearing loss in her right ear for the past three days it is not painful she thinks she maybe has water in her hair she feels like she always has wax in there and she does endorse instrumentation with cotton tips to try to clean the things out um we look in her ears in the office the notoscope because we're excellent doctors and we don't see anything abnormal we do see the tympanic membrane so we feel very proud of ourselves the patient also endorses that she hears some buzzing in that same ear as well and so we do the right thing having just listened to this episode remember for this patient promptly to the ENT clinic and so I wonder for this patient who has we talked a little bit about this who now has this acute unilateral hearing loss how is your approach different and sort of what how are you thinking about this patient differently than the last patient that we just saw right so the majority of people with sudden hearing loss have conductive hearing loss they have earwax that's occluding the canal or they have fluid behind the drum from a head called or hay fever or taking an airplane trip and having you know impaired eustachian tube function and so most of the people with unilateral sudden hearing loss don't really have an emergency but there are some who do because it's a unilateral sensory neural hearing loss it's a sudden nerve deafness and that is an emergency and uh traditionally the way we would assess that at the bedside you know in the examining chair is with a tuning fork test you know doing a Weber test where you put the fork on the front of the forehead and you ask if the sound lateralizes so you know most primary care settings and most emergency rooms don't have tuning forks and if they do the people don't necessarily know how to do the test properly and it turns out there's a very easy thing you can do without a tuning fork which is to ask the patient to hum to just go and uh it turns out that if they have a conductive hearing loss they will hear their voice in the blocked ear and you can do the experiment if you if you stick your finger in your ear that's a 40 decibel conductive hearing loss so you can put your finger in your ear and and hum or you can start humming with your ears open and then block one ear and your voice jumps into the blocked ear if they have a sensory neural loss their voice lateralizes to the healthy ear opposite direction so the the if you want to have it as a mnemonic if they hum and their voice goes to the bed and you're that's good if it goes to the goodie or that's bad but this is the same way to interpret the Weber right it's the same because you're doing essentially doing the same thing right yes but you don't need the tuning fork they just hum I love it your clinic nurse could do it over the telephone when they call for an appointment you ask the nurse can ask them to hum and if the voice lateralizes to their good ear the one that does not feel blocked they need to get to an ENT within the next 24 hours it's urgent see Paul this is why we do the show this is just you know I love that okay okay so we're yeah and then and then you know yeah I hope you can look in their ear and I hope you can clean the wax and see the drum and you know be able to tell if they have an air fluid level or you know some other retracted drums some other abnormality that might explain a conductive loss but if they if they have a normal looking ear in their and they're uh and their their hum test lateralizes away from that blocked ear that's an emergency that's idiopathic sudden sensory neural hearing loss and about one percent of those patients have something neurological like a vestibular schwannoma or a stroke or a meningioma uh Ms you know demyelinating disease but 99 of those patients their MRI is normal and they need uh they need some corticosteroids ASAP can I ask because I the the differential for this they I so idiopathic idiopathic sensorineural hearing loss that's you know that's on the differential but there's a bunch of different infections like viral infections all sorts of things autoimmune conditions trauma toxins all sorts of things so we're still taking a history asking like drug exposures trauma a few infectious symptoms do we think they have like like lupus or other some autoimmune thing it sounds like that's probably not going to be the majority of the time uh that that we're gonna need to do like I said earlier if you're that Sherlock Holmes guy and you want to take time collecting all that information feel free but no matter what they need an MRI and steroids and got it it's it there is a a window of time that arguably is the first two weeks so most of us will treat our patients even if they come in up to four weeks but if they've had that hearing loss more than four weeks they're out of luck nothing's going to bring it back and every day that passes without treatment the chance of of hearing recovery goes down so it it really is an emergency to get them evaluated and if an audiogram confirms a significant sensory neural hearing loss we all treat them with steroids either by mouth or by injection directly into the ear some docs do both um but the the the standard treatment in almost everywhere is steroids for a couple of weeks Steve I'll tell you a secret about internists they all think they're Sherlock Holmes they all want to be they all want to be Sherlock Holmes but you know you I mean you gotta admit you got to make your day fun you know you have to you have to have that we don't get to we don't get to surgerize people so we have to we have to do this cognitive weightlifting of trying to think through it are not critical of that but no matter what you discover Sherlock you need to send them for a hearing test and and you need to get on the phone to your local ENT person and tell them that you think this person as idiopathic sudden hearing loss they can't wait until you know next May right for an appointment yeah so I'm thinking about how Paul what would would you would would you be pulling the trigger on the MRI and the steroids Paul before sending this person I'm I'm I'm I'm not sure depending on I possibly the steroids this is not something I encounter very often but I it sounds like that's the thing that has emergency to us I would probably I was gonna actually ask what steroid dose or what steroids that you actually use Steve I that might be something I would start while trying to get them to EMT the MRI from a practical standpoint like it's not going to happen within the next 24 hours unless I send them to the emergency department probably yeah you don't you don't need to wait for the MRI to start the steroids but you really do want an audiogram before you start the steroids if it's at all possible because you want to document what their hearing was before you intervene if the hearing isn't that bad you might if they have other medical putting somebody on high-dose Prednisone for a couple weeks is not chicken soup you know they can have side effects and and uh different centers use different routines uh our Center and and a lot of places will put patients on 60 milligrams of Prednisone every day for 14 days and then a five day taper you know 50 40 30 20 10. that's a that's a real blast of steroids and uh you're not going to make somebody cushing-oid but you certainly can throw their diabetes out of whack and you can give them you know upset stomach and sleep disturbances and all kinds of other stuff so that uh I think if you're going to do that you really want to have an audiogram to show that they truly have a unilateral sensory neural hearing loss and then you know when they come back for follow-up you you've got the MRI by then uh yeah so so it's an MRI with contrast correct yep and uh and and we Paul this this reminds me of like if we think someone has a temporal arteritis generally I'm referring the person I'm calling either an ophthalmologist or a rheumatologist sometimes both and it's like a warm handoff situation it's not like I say hey yeah call the number on the paper and I'll see you in three months yeah yeah it's not it's not like that so that's right okay and and the the the this condition of uh idiopathic sudden hearing losses strikes about one person in five thousand per year so I'm in Metro Boston we see you know three to five hundred cases a year um but that's not tens of thousands of cases a year it's you know a few hundred cases in a city um so I don't know how many you're going to see in your practice the prevailing theories are that it might be viral it might be ischemic and it might be immune mediated and we think those are probably all true and different patients but we don't have any way to discern who is who so we just hose everybody down with corticosteroids and hope for the best and uh and uh in patients who are treated within the first 10 to 14 days about 75 percent of them will get some improvement on the steroid but only about 20 percent will come back to normal and the the tinnitus that this person has is that is that typical of somebody with this condition yeah so in the acute setting it tinnitus is just a generic indication of an unhappy ear um but everybody with hearing loss has tinnitus it doesn't matter what the cause of the tinnitus or how long they've had it so it's over 90 percent of people with hearing loss of any cause or magnitude experience some tinnitus but if the ear is acutely stick if there's a you know Trauma from loud noise if they have this kind of a sudden loss if they have a an effusion or they're they have Barrow Trauma from an airplane trip yeah they're going to have tinnitus and that's not really very informative medically it's annoying but it's not informative and uh uh if the situation if the damage in there is is permanent they will always have tinnitus but the tinnitus during the acute phase is much louder and much more intrusive and uh over time tinnitus that begins as a peripheral process really becomes a central process and it's exactly the same as Phantom limb in an amputee but in this case it's hearing that's been amputated and so those auditory centers in the brain that are expecting an incoming signal and not getting it say Hey where's my signal and they turn up the gain in the brain and you begin to hear the random electrical activity in that circuitry just like static on your radio and there's no station and that kind of central tinnitus uh somewhere between 30 and 90 days after ear damage it transitions from peripheral to Central and then it doesn't matter you could remove their ear you could cut the nerve the tinnitus is still there it's living in the brain do you have any tips for the patient that's suffering from that chronically I I know this you could do a whole episode on tinnitus but what what could we tell them to do so the first thing is that you want to assess Hearing in somebody who's got tinnitus because if they have hearing loss they're going to have tinnitus but they might have tinnitus for other reasons they might have normal hearing um for people with chronic tinnitus whether it's unilateral or bilateral we don't really care what it sounds like it could be hissing humming buzzing chirping quacking shrieking it doesn't make any difference we do separate pulsatile tinnitus to a separate category but if it's just a you know a a more or less steady sound a variable intensity we think of that like an alarm system for your General Health and well-being when you are sick when you're tired when you're stressed out when your muscles tighten up it's going to be louder and when you're at Club Med on the beach you're not going to hear it and so if you are finding your tinnitus to be more intrusive you're it's bugging you more you're noticing it more it's a time to take inventory about those other health and wellness metrics sleep stress Fitness Nutrition you know your neck are you hunched over your computer keyboard all day or just carry tension in your neck and so if you take care of that stuff the tinnitus kind of moves into the background it's also important to know that tinnitus is an attentional process that means when you attend to it you put it right on center stage and amplify it and when you attend to something else it kind of gets pushed aside I'd give you the vision analogy of windshield wipers when you drive on a rainy day those wipers are going back and forth in front of your face you don't even see them because you're looking at the road if you watch the wipers you couldn't drive your car and so people who fall into the Trap of checking on their tinnitus or noticing it or listening to it uh uh it makes it worse when when I was young in training we had a very famous ear professor and he would ask his tinnitus patients what size shoe they wore size 10 go out and buy a pair of size nine by the end of the day you won't notice that tennis what an empathic this was not wrong yeah he was very empathic he also used to say to the patients don't worry about it unless it stops because that means you're dead comfort yeah I don't say that to patients generally but all right so with so to recap what we talked about so with Miss Eustace Paul you Stace for eustachian I guess uh she so we've we've sent her for an audiogram she was started on the steroids 60 of Prednisone uh for about two weeks or so then it was tapered she had an MRI no schwannoma no multiple sclerosis uh no other retrocochlear pathology and um hope we're hoping that she will will fully recover anything else uh Steve you think to talk about with this case here so patients who lose one ear you know or lose some of the hearing who have asymmetric hearing loss they have only two real well three symptoms if you count tinnitus they all have tinnitus but that's intense at the beginning and it gradually tends to move into the background over six to 12 months regardless of the hearing outcome but the two auditory things that persist they lose the ability to localize where sound is coming from so if they hear if they're driving and they hear a siren they have to check all their mirrors looking for the flashing lights and if they lose their cell phone in the house and it's ringing they can't find it oh my gosh and uh and the other person so they lose down localization and they have increased difficulty discriminating voices in noise because all the noise and the voice are funneling into the same ear you know they can't position themselves with one ear toward the noise and one ear toward the their dinner date um and those two Sky those two manifestations of single-sided hearing loss are very annoying but they're not really a big handicap and uh if you had single-sided deafness you could not get a job as a commercial airline pilot or an FBI agent but that's about it and uh in medical legal instances uh single-sided deafness is considered zero handicap there are you know formulas to calculate percent disability it isn't a disability to be deaf on one side A lot of people are born deaf on one side they don't even know they they've no you know they never noticed or they lost hearing on one side in early childhood they play sports they you know do whatever they want they become musicians it doesn't really cause a handicap if you're used to having stereo binaural hearing and you lose it it's very disturbing but gradually people get used to it and it's not it's not life-altering for most patients and so um I try to um calm down my patience and we go through the treatment and all of that stuff but I I really you know tell them to don't rush to try unproven therapies don't rush to have you know buy expensive electronic equipment or get implants in your head or anything give it a year see if you get used to it and almost everybody gets so used to it a year later they're hardly really noticing it but if that neural link thing happens for real Elon Musk thing I you know I think everyone should get that but anyway uh I all right that's this is this is great uh I think with the rest of our time we should go through one more case Paul I think this is Miss Anita do you want to read that sure so our last patient of the the day will be Miss Anita she's a 28 year old patient she's coming to the primary care office with a two-year history of fluctuating hearing loss she also needs a sensation of fullness and muffling of sounds in the right ear she notices in written buzzing noises in that same year the last couple of months she's been experiencing episodes of severe dizziness they last about four hours they resolve spontaneously and when she has them she's experiencing nausea and vomiting no other significant past medical history uh we do otoscope in the office it shows no pathologic findings um and we audiometry reveals that she has low frequency sensorial hearing loss with normal Hearing in the mid frequencies so we're painting a picture for Ms Anita but for you seeing this patient is there a broad differential that you think about as you're approaching this patient who has these symptoms of both vertigo as well sort of waxing and waning hearing loss right so she meets all of the international diagnostic criteria for Meniere's disease which includes low to mid frequency sensory neural hearing loss either fluctuating or Progressive epithetic vertigo uh on multiple you know more than one occasion and the vertigo should be anywhere from 20 minutes to 12 hours and typically with some tinnitus or aural fullness so she meets all those diagnostic criteria however uh Meniere's disease strikes about one person in five thousand per year it's very similar to sudden hearing loss in the U.S in the whole United States it's estimated they're about 60 000 cases uh that pop up and uh it's typically people who are in their 40s and 50s and 60s and she's quite Young and it turns out that vestibular migraine which is migraine causing vertigo and auditory symptoms um could cause all of these symptoms and migraine in a young woman between puberty and menopause 30 percent of women meet diagnostic criteria for migraine headache or ocular migraine and so anytime we see a dizzy patient regardless of sex or age or anytime we see dizzy patient it's imperative to take a headache history and and even I would say even broaden that out to say a migraine history because not everybody with migraine headaches has headaches you know they may have ocular migraine or they may have irritable bowel syndrome or they may have fibromyalgia which are all various manifestations of migraine and they may have first degree family members who are migranters or they may have had benign recurrent vertigo of childhood or they may have had severe recurring abdominal pain in childhood which are all pediatric versions of migraine and so a young woman who's coming in with ear symptoms and vertigo the chance of this being migraine is 10 to 15 times greater than the chance of it being Garden variety Meniere's disease now there is no test for migraine it's a clinical judgment but uh you certainly should get the headache history and if it turns out that every one of her dizzy spells transitions to a killer headache or every headache transitions to vertigo or they tend to you know Co occur their comorbidities or if there are migraine indicators if every time this patient has one of her vertigo attacks she's intensely photophobic for example that would be a you know many years doesn't cause photophobia migraine is a neurological condition and if you listen to migranters tell their story they have Vision things they have other sensory do they have numbness and tingling they they have nausea vomiting brain fog they've got this laundry list of sensory distortions and disturbances and in many years is an ear thing and so if you listen to the story and it sounds Irish it's probably many years if it sounds brainish it's probably migraine and you know Sherlock this is right up your alley this is a this is the perfect instance for you to really stretch your stuff you're going to be a hero by listening carefully to them tell their story and then put them on a you know migraine diet and you know some other migraine trigger management stuff uh and see what happens I have diagnosed some people with chronic sinusitis as having migraine headaches now so that one feels good that one does feel good yeah oh you were gonna ask something oh I was gonna say so let's let's say Matt takes the spectacular two-hour history um his office was just his entire opposition doing nothing else and it feels very eerie to him I I guess it's other than sort of giving me vague flashbacks to medical school I feel like I don't have a great handle on sort of what causes many years like it's I feel like I'm reading about like endolymph High Drops as a thing I don't know what that means I think actually the paper Euro talks about the fragile ear and the treatment of that is actually pampering the ear which I thought was a a funny way of framing things but like what what do we know about why why this is happening if we actually nailed the diagnosis it happens in one in five thousand patients uh what I've written and what I teach and what I think is widely accepted not just by me uh is that the ear like every other organ in the body every organ in the body has a limited repertoire of response to injury you know if you beat up a liver it makes cirrhosis and you can beat it up with a virus or with a toxic drug or with radiation or you know but it gets erotic if you if you beat up an eyeball you know the redneck can degenerate the lens can go opaque or the pressure can go up those are the three things eyes do when they're sick and unhappy and and if you beat up an ear it can be you can get dizzy or you can get deaf or both if a patient has a problem that affects both Hearing and Balance and if the symptoms are episodic we call it Meniere's disease and so it you know at kind of the the most basic level that's the label on the dumpster full of all the people with erratic inconsistent ear function and you know we we try to draw a slightly tighter boundary by saying that the hearing loss you know early on is predominantly low frequency and the vertigo is 20 minutes to 12 hours but you know it's a thick ear and um we've learned in the last few years that um uh let me back up and just say that if we look you know at hundreds of meniere patients we see that it's about equal male and female most people develop symptoms in their 40s and 50s two-thirds of patients have their vertigo attacks in clusters and then have smooth sailing for months at a time and one-third of patients just have sporadic attacks it's very uncommon maybe five percent of meniere patients identify reliable triggers you know every year during hay fever season or every you know a woman where every month when she's perimenstrual she might get an attack but for the vast majority it's pretty random and we don't really know what's wrong in that ear we don't know if it's you know genetics or trauma childhood infection Bad Karma alien Ray Beams I mean we don't really know what's wrong with the ear we just know it doesn't work right and if we tested if we did those bedside tests this is like more of the sensor and oral pattern it's a sensory neural loss we've learned in the last few years that at about one-third almost one-third of meniere patients have a congenital malformation of the vestibular Aqueduct which is a little Canal where inner ear fluid recycling happens and if you know to look for it you can see that on a high resolution CT scan but hardly anybody looks for it because it's quite new information and there's nothing you can do about it however the the phenotype of patients with that that hypoplastic Aqueduct is interesting because there's much more likely to affect both ears and lead to binaural menus and it's much more common in men than women and people who have that their meniere symptoms usually start in their 20s or 30s not in their 50s so where we've had this dumpster full of meniere patients we're beginning to find that we can lift subgroups we can begin to bin you know into into smaller groups certain subtypes of Meniere's Disease by other uh clinical features the people who do not have that vestibular Aqueduct hypoplasia have degenerative changes in the mucosal lining of the or the epithelial lining of the end lymphatic sac and we don't know why that Sac lining is degenerating but it leads to all kinds of homeostatic failure in the inner ear what's really important to convey to a patient if they do have Meniere's disease is that we can always get rid of their vertigo attacks over 99 success controlling meniere vertigo attacks but nothing we do preserves the hearing and at least currently in 2022 everybody with Meniere's disease gradually loses Hearing in the affected ear and none of the treatments seem to prevent that so a meniere ear is a degenerating ear it's not that many years causes degeneration is the degeneration causes the symptoms that we call meniere syndrome and we don't know why the ear is degenerating and eventually 75 percent of meniere ears degenerate to a point we call burned out within about 10 to 15 years a burnt out ear has no usable hearing and the hearing is so poor that they can't use it or wear an aid and it doesn't have the horsepower to make vertigo anymore not everybody burns out in 10 years but 75 percent of people burn out in in about 10 to 15 years I do want to get on to treatment of this but I want to recap quickly so this is not as common as vestibular migraine and so we should really take that history which I think that's a great that's a great Pearl for the audience and that this is most commonly in people Ford in their 40s and 60s so if it's a younger person you might even think more likely this is a migraine and then we mentioned that this was more a low to mid frequency hearing loss as opposed to our classic old age hearing loss of older age is the higher frequency is there other testing besides audiometry like do because this is often unilateral right so would we often would we also be obligated to get an MRI for these patients MRI with contrast or a CT scan if they can't get an MRI if you take all people with Meniere's disease about 25 to 30 percent of the may eventually involve both ears but it's almost unheard of for them to be involved simultaneously it's sequential one a year goes and then 5 10 20 years later the other ear may act up it's very very rare to see both ears active in the same time frame and in fact it's so rare that you would want to look for some other weird problem like autoimmunity or some other rare thing um it tends if it's going to be by lateral it's sequential if it's a new manure patient we do recommend an MRI scan and the traditional MRI we do with and without contrast looking for retrocochlear lesions like schwannoma and and meningioma and tumor and straw you know stroke and demyelinating disease however there is a new way of doing MRI you need a 3T scanner you have to have the right equipment and you have to have the software and you have to have a radiologist who knows how to read it but now for the first time you can absolutely see if somebody has Meniere's disease very cool and uh so I that is not widely available yet it's you know showing up at hot seatazzi academic centers but not not all over the place it sounds like this condition is on you uncommon enough that probably we're not going to be diagnosis diagnosing and treating this ourselves in Primary Care without the involvement of uh them seeing an audiologist and an otolaryngologists and getting some getting some medication advice there what what might you do for this if you if we have a convincing case right so I would just say in a general ENT practice they might only see one or two cases of men years in a year mm-hmm it you know in an otology practice we see a lot of it but in general ENT it is still very uncommon um so when we see patients we do an audiogram we you know get an MRI we say well yep sounds like Meniere's disease and for me I'm a treatment minimalist and I'm looking for the least intervention that will satisfy the patient so I I use patient-centered outcome metrics and and and so my first line of intervention is some adjustments of diet and lifestyle three things patients do best if they have a very regular daily schedule so they get their body in a rhythm every day they get up at the same time every night they go to bed at the same time they eat meals about the same time every day try to get a little regular exercise it doesn't mean they can't skip a meal or stay up late for a ball game or a party but generally we want their schedule to be very regular people who work rotating shifts people who Skip meals and binge people who do a lot of international travel tend to be much more symptomatic so number one is regular schedule number two is a general medical tune-up the ear is fragile and any other systemic stresses and strains might fire up the symptoms hay fever on allergies sleep disturbances acute or chronic pain anxiety and depression hormone dysregulation other metabolic disturbances you basically want to set all the dials to healthy as best you are able and I will tell you that in the general population uncontrolled sleep apnea and hormone dysregulation and and uncontrolled migraine are the three biggest triggers that make many years unmanageable you have to deal with those things if you want to ever calm down somebody's menu attacks and then the third thing is is their diet and when we talk about diet what we're really talking about is fluid and electrolyte management so I ask meniere patients to limit caffeine to one hit per day maximum could be coffee tea Coke or chocolate and not a super-sized you know gigantic cup of something but you know a regular sized cup of coffee or tea One A Day same with alcohol one drink in a day could be beer or wine or spirits but maybe not one of each and the most important thing is we want to even out their sodium intake and there's a ton of literature that old literature about putting many patients on low salt diet it is totally bogus and there is no reason to put people on low salt diet unless you don't like them they're well I mean if they need it for congestive heart failure or you know chronic renal insufficiency fine but from a meniere point of view the the ideal is to have very consistent sodium through the day so it isn't spiking up and down but it doesn't have to be low so if we take all the meniere patients who walk in and do those three things regular schedule medical tune-up manage the fluid electrolytes within a couple of months two-thirds of patients have no more vertigo well Matt this actually sounds kind of encouraging to me because I feel like this is this actually feels like Primary Care stuff like we can we can diagnose and treat Osa you can do that we can manage diabetes we can manage hypertension we can talk about diets so like this this feels squarely within our wheelhouse great so I'm happy to deputize you again everybody else is listening now the diuretic recommendation came from the very early you know mid 20th century when people first learned about endolymphatic High Drops they said oh they're retaining fluid in their ear we should put them on a low salt diet and then they said oh there's too much fluid in the ear put them on a diuretic well do you believe that taking a diuretic makes you pee endolymph questions I guarantee it doesn't so the the reason that a diuretic might help is because there's all this fluid and electrolyte fussiness in the inner ear and the homeostatic systems are not working the same you know potassium and sodium ion pumping things that the the channels and pumps that are in your kidney you know are also in your ear and so diuretics act on the ear to to bolster this inadequate homeostatic stuff and so we usually use a drug that's a combination of HCTZ and triamterene because we're ear doctors and we don't want to deal with metabolism like potassium so you know the HCTZ and triamterene one waste potassium and one one uh saves it and so they cancel out and they're you know there are a couple of proprietary names for that that I won't mention so but but easy to find and you get them the generic and they take it once a day and within and so two-thirds of the patients get better on the diet and lifestyle it leaves one-third who are symptomatically put them on a diuretic and within a couple of months two-thirds of them are under control so diet plus diuretic we have about 90 percent of meniere patients are have their vertigo under control the last 10 percent need an invasive treatment which usually is medication injected through the drum into the middle ear where it diffuses into the inner ear and that can either be a corticosteroid which works sometimes it's controversial how well it works um but it is reimbursable so that uh it's a it's a popular treatment um and when it does work it's quite similar to injecting steroid into a joint you know into a shoulder into a knee it improves the symptoms for a while but eventually it kind of wears off and you haven't really cured anything and patients who benefit from inter-tympanic steroid typically need it repeated a couple of times a year the alternative is inter-tympanic Gentamicin which in my hands is much more effective but it is you know your it's ototoxic you're killing off some of the vestibular signaling and the right the idea is you want to weaken the ear so much that it doesn't have the horsepower to make vertigo anymore and in fact you can kind of think about it like a fast forward button it achieves in two weeks what Mother Nature was going to do in 10 or 15 years this has been amazing I I mean I think we are out of time as far as this show goes so I think we're gonna we're gonna say that with our Miss Anita here we we got her on the three we got a regular we got her on a regular schedule medical tune-up and we counseled her on the fluid and electrolyte management she fortunately didn't need diuretics or enter to pen or yeah the I.T gent as you as you abbreviated it so we've talked about a ton today but if you had to give a couple take-home points that you definitely wanted the audience to remember what would those be yeah so I would say that that being uh uh attuned being mindful that hearing impairment is a barrier to you providing the best medical care if your patients are hearing impaired they can't receive what you're trying to give them because they're not hearing very well and it it isolates them and it makes the interactions with the medical profession more anxiety provoking and there it erodes their quality of life and the more you are mindful of wondering about your patients hearing and considering the possibility of hearing loss either to just do the finger rub or to send them for the hearing test or recommend the ENT consultation uh every little thing you do to get their hearing taken care of uh is to their benefit and we will be back with our lightning round Steve can you give us a hobby or interest that you have outside the field of Medicine uh I'm a closet musician I mostly play clarinet and bass clarinet and some guitar a job that sounds like a very healthy diversion from what I imagine is a demanding career and if people are watching on the video they can see you have a nice setup there's a there's a guitar in the background uh it looks great uh I I Paul we we should we should get some more talents and hobbies in life yeah watching movies no you're right I'm not well-rounded we make that point repeatedly um well so along those lines Steve maybe I'll ask uh we'll narrow down I usually ask for a sort of broad culture recommendation but why don't I ask you about a music recommendation specifically something that you've enjoy that you think our listeners might enjoy listening to as well oh um well my uh my two favorite genres are klezmer which is what I actually aspire to play and and uh gypsy jazz also known as Django Jazz because Django Reinhardt was the the originator of it and there's tons of it you can find uh streaming online it's fantastic stuff I I bet you Paul knows what what that is but I am the former not the latter I have some I've been thinking yeah I always like to ask the question about advice or feedback that you've gotten throughout your career Steve so you've you've accomplished a lot in your career but what's what's some advice or feedback along the way that you would pass on to our listeners I went through a woodworking phase many years ago and Carpenter friends all had the same advice which was measured twice cut once and uh I think it's broadly applicable I think woodworking is also one of those hobbies that is it's just a good hobby because a lot of times you have to wear ear protection you're just sort of uh it's a good way to take your mind off other things you really have to focus on what you're doing if you want to keep all your fingers that sort of thing so I enjoy it this has been another episode of the curbside is bringing you a little knowledge food for your brain hole yummy great stuff get your show notes at the curbside.com and while you're there it's time for our mailing list to get our weekly show notes in your inbox plus twice each month you'll get our curb ciders digest recapping the latest practice changing articles guidelines and news in Internal Medicine and we're committed to high value practice changing knowledge and to do that we want your feedback so please subscribe rate and review the show on Apple podcast or on Spotify you can also email us at ask curbsideers gmail.com reminder that this and most episodes are available through VCU Health at curbsides.vcuhealth.org for CME credit and a special thanks to our writers and producers for this episode Dr Kate Grant and Andrea batigao the curbsiders is produced and edited by the team at pod paste Elizabeth Proto runs our social media Stuart bringham composed our theme music and with all that Paul until next time I've been Dr Matthew Frank watto and as always our main doctor Paul Nelson Williams thank you and goodbye foreign

Channel: The Curbsiders Internal Medicine Podcast

Views: 6,595

Keywords: Internal Medicine, Education, Curbsiders, Hearing loss, tinnitus, Meniere’s disease, vertigo, audiogram, audiology, ent, hearing aid, primary care, assistant, care, doctor, education, family, FOAM, FOAMim, FOAMed, health, hospitalist, hospital, internal, internist, meded, medical, medicine, nurse, practitioner, professional, primary, physician, resident, student

Id: MksesK3QVmU

Length: 77min 18sec (4638 seconds)

Published: Mon Jan 30 2023