December 2020 BSA APD SIG
The year 2020 has certainly been a challenging one on many levels.
We wish you and loved ones a healthy and happy 2021.
In this brief review we reflect on the difficulties that individuals with hearing loss as well as Auditory Processing Disorder (APD) face in the current pandemic and offer practical solutions.
Covid-19, hearing loss and auditory processing disorder (APD): Facemasks and social distancing.
Audiologists and hearing professionals are continuing to creatively adapt routine audiological and clinical practice to meet the challenges of the current Covid-19 pandemic. It is noteworthy that many individuals with hearing loss and auditory processing disorder (APD), diagnosed prior to the Covid-19 pandemic, are reporting greater difficulty hearing. In recent months there have also been reports that Covid-19 may be linked to hearing difficulty/loss, balance, vertigo and tinnitus, and these cases are now starting to be seen in audiological practice.
Almufarrij et al. (2020) published a rapid systematic review of coronavirus and the audio-vestibular system. The quantity of evidence was understandably low (five case reports and two cross-sectional studies) given that the virus was largely unknown until the beginning of 2020. Diverse audio-vestibular symptoms were identified including hearing loss (conductive and sensorineural), tinnitus, rotatory vertigo, otitis externa and undefined ear pain. In further work by this group, Munro et al. (2020) reviewed 138 adults hospitalised for Covid-19, around 8 weeks after discharge, using a detailed case history, adding questions about hearing and tinnitus. The results suggest that more than 1 in 10 COVID-19 adults report a change in their hearing status. The authors heed caution, however, in interpreting these early results given that the hearing status changes could be linked to SARS-CoV-2 but they could potentially also be linked to other variables such as ototoxic medications received, anxiety, changes in environmental surroundings, i.e. admission to hospital and the use of facemasks, which could potentially be exacerbating pre-existing hearing loss and tinnitus.
Post Covid-19 hearing assessment, particularly in those reporting hearing difficulty/loss, is essential. Equally, the needs of those with hearing loss and APD, diagnosed prior or unrelated to the Covid-19 pandemic, need to be met. In this brief review we consider the impact of facemasks and social distancing for those with hearing loss and APD and offer a few practical solutions.
Facemasks, required to limit Covid-19 transmission, reduce the acoustic quality of the target by reducing high frequency cues and attenuate speech by 3-12dB (Goldin, Weinstein, and Shiman, 2020). Additionally, solid medical-grade, N-95, or cloth facemasks eliminate access to lipreading and facial expression cues important to individuals not only with hearing loss but also those with APD (Ferre, 2020).
Social distancing increases the distance from the speaker, attenuating speech and reducing access to lipreading and facial cues. For example, it is well known that children with hearing loss and APD often miss spoken information in the classroom and then rely on additional repetition and cues, including as the responses of children seated near them. Given Covid-19 and social distancing, these children are being seated further from their teachers and further apart from their peers too, making it harder for them to both access and check information. Remote learning, online meetings and online social events pose challenges to both children and adults with hearing loss and APD as sound quality can be variable, dependent on the quality of Wi-Fi connectivity, microphones and resources available. Timing lag/desynchrony between speakers’ visual and auditory cues can be further confounding factors.
In the current Covid-19 pandemic, reducing background noise becomes even more important given the attenuation of the signal and reduced visual cues. Background noise can be monitored by doing an informal environment check at regular intervals, reducing noise where possible and introducing acoustic treatments such as carpets, curtains, seals and rubber shoes on furniture legs. The installation of noise absorbent partitions or screens and preferential seating also allow for better access to sound.
Many individuals with hearing loss and APD benefit from FM systems and assistive listening devices. These devices improve the signal-to-noise ratio reaching the ear and can also be helpful in ameliorating the problems caused by social distancing, i.e. being further from the speaker. There are, however, additional considerations when facemasks are worn. For example, the microphone cannot easily be placed underneath a facemask. If the microphone is placed on the other side of the mask the quality of the signal may be affected given that high frequency energy and signal loudness are reduced. The take home message is that some individuals using these devices, particularly children who may not be able to report deterioration of the signal quality, need to be monitored more closely in the current pandemic, with additional support offered as required (Ferre, 2020).
Where possible, facemasks with a clear panel should be used to retain access to visual clues. Other considerations include using ‘clear speech’ (speaking at a slightly reduced rate and slightly increased loudness with strategic pausing) (Ferre, 2020), ensuring attention before speaking and using additional visual cues (i.e. writing information down, pointing and natural gestures). Using captions for online learning and meetings and asking speakers to switch cameras on allows access to more visual cues. Finally, it is important to improve public awareness and empower individuals with hearing loss and APD, so that they are comfortable asking for repetition of missed information, clarification and additional support.
In summary, individuals reporting hearing difficulty/loss following Covid-19 should be seen for hearing assessment and, if required, further management. Individuals with hearing loss and APD, diagnosed prior or unrelated to the Covid-19 pandemic also need to be supported. This brief review highlights the difficulties that have arisen due to the use of facemasks and social distancing in the current pandemic and offers a few practical solutions. Finally, there is a need for high-quality studies to investigate the acute and temporary effects of COVID-19, as well as longstanding risks on the audio- vestibular system.
Almufarrij, I., Uus, K., & Munro, K.J. 2020. “Does Coronavirus Affect the Audio-Vestibular System? a Rapid Systematic Review.” International Journal of Audiology 59 (7): 487–491. DOI:10.1080/14992027.2020.1776406.
Ferre, J.M. 2020. Managaing CAPDS while mitigating COVID-19: some considerations and accomodations. Pathways (September). Retrieved from: https://hearinghealthmatters.org/pathways/2020/managing-capds-while-mitigating-covid-19-some-considerations-for-accommodations/
Goldin, A., Weinstein, B.E., & Shiman, N. 2020. How do medical masks degrade speech perception? Hearing Review, 27(5), 8-9.
Munro, K.J., Uus, K., Almufarrij, I., Chaudhuri, N., & Yioe, V. 2020. Persistent self-reported changes in hearing and tinnitus in post-hospitalisation COVID-19 cases, International Journal of Audiology, DOI: 10.1080/14992027.2020.1798519