Abstracts, Learner Objectives and Summaries

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DIABETES AND AUDIOLOGICAL MONITORING FOR ORAL AND INJECTABLE MEDICATIONS


Abstract

There are at least 59 prescription medications (including oral and injectables) for patients with diabetes that have auditory, vestibular and/or cognitive side effects. Not knowing which medications have these side effects could lead to inappropriate recommendations thus leading to management errors. 


This program will review the signs and symptoms of hearing loss in adults and who is considered “at risk.” Next, there will be a review of the diabetes medications that could cause any one or all of these side effects. The program continues with a discussion about the importance of audiometric testing for Type II diabetes patients as well as for patients who might be “at risk” for diabetes.


Finally, because the internet is a major source of reliable and oftentimes questionable drug information several preferred websites will be suggested to obtain up-to-date drug information (including side effects). 


Suggestions for improved communication strategies between the referring physician, the patient and their pharmacist are given at the end of the program. 


NOTE: Dr. DiSogra has compiled a list of diabetes medications and all the possible auditory/vestibular/cognitive side effects. The list is available at www.drbobdisogra.com. 


  

Summary

Diabetes affects more than 30 million persons in this country – almost as many as persons with hearing loss. Because diabetes can be life-threatening, the diagnosis happens sooner rather than later as with hearing loss.

Diabetes-related hearing loss occurs when the microscopic capillaries in the stria vascularis in the cochlea begin to constrict thus reducing the blood flow to the Organ of Corti. The resultant outer hair cell damage and subsequent cell death is a natural progression of the disease.


Microangiopathy in the cochlea is very similar to the microangiopathy of the blood vessels in the eye (retinopathy). Unlike hearing loss, eye disease and the associated visual disturbances could result in mobility issues for the patient. Thus, help is sought as soon as the symptoms appear. Persons with hearing loss can still “hear” albeit not well but well enough to postpone getting an audiological evaluation despite concerns by family members and friends.


Type II diabetes is an adult disease usually managed by oral medications and diet and nutrition. There are several tests that screen for diabetes. The Centers for Disease Control and Prevention (CDC) has published a document titled Take Charge of Your Diabetes that lists Pharmacy, Podiatry, Optometry and Dentistry (PPOD) as the four “go to” allied health professions for diabetes management. Audiology is not listed but soon will be added to the list (PPOD-A) thsnsks to the work of The Audiology Project (www.theaudiologyproject.com).


The diabetic ear can present as high frequency hearing loss "of unknown etiology” for persons under age 60 years. The hearing loss audiogram configuration can be flat, too.


There are 59 oral and injectable medications for diabetes. Most have either auditory, vestibular and/or cognitive (A-V-C) side effects. Of these side effects, the vestibular side effects are most prevalent (85%) followed by cognitive (61%) and auditory (25%)


Also, 17% have no A-V-C side effects and 25% have all three. This makes up ~42% of the total of oral and injectable medications.


Because hearing loss is gradual, diabetes patients must be educated and made aware of the symptoms of hearing loss. This is the goal of The Audiology Project through the CDC. To that end, a monitoring program will need to be developed that would help Diabetes Educators (American Association of Diabetes Educators – AADE) and their patients look to audiologists for guidance.


The American Academy of Audiology’s audiological monitoring protocols for ototoxicity can be used a guide. Additional management with amplification and other hearing assistance technology will also need to be considered when applicable.


When audiologists see patients who are under the age of 60 years of age with high frequency hearing loss bilaterally “of unknown etiology” it is incumbent on the audiologist to consider diabetes as a possible cause and refer for a diabetes screening.


This program will also emphasize the importance of establishing a better relationship with endocrinologists and diabetes educators in their community.


Learner Objectives

After this presentation, participants will be able to: 


  1.  Recognize why and how diabetes affects the auditory system
  2.  Plan a hearing screening and monitoring program for adult diabetic patients
  3.  Learn effective management strategies for the diabetic patient, their family as well as with allied      health professionals



PHARMACEUTICALS AND NUTRACEUTICALS FOR HEARING LOSS AND TINNITUS 


NOTE: This is two part three hour AAA/ABA Tier 1 CEU Program  


Abstract  

The number of pharmaceuticals available to manage hearing loss and tinnitus continues to grow. Also, there are over 80 over-the-counter products claiming relief or a cure for tinnitus however none of these products are FDA approved. Of concern is that there are some products that contain ingredients that could be harmful to special patient populations.   


This program reviews the current pharmaceutical research for hearing loss and tinnitus as well as reviewing the efficacy and safety OTC tinnitus relief products. Patient management strategies are also reviewed.      


Summary  

There are many FDA approved pharmaceuticals that have been used for hearing loss and/or tinnitus regardless of the etiology of the problem. Several new drugs that are currently undergoing clinical trials are showing promise with certain hearing loss etiologies (i.e., noise induced hearing loss).   


Several off-label drugs are also being used for hearing loss/tinnitus management. For example, Valium, an antidepressant drug, has been used with limited success with tinnitus patients.   


The FDA loosely monitors over-the-counter nutraceuticals (i.e., vitamin supplements) and classifies nutraceuticals as ‘food.’ This means that efficacy (does it really work?) and safety do not have to be demonstrated. The scientific guidelines for evidence-based clinical research do not apply.   Patients who are prescribed pharmaceuticals for tinnitus are under the care of a licensed physician, however, there are some patients can self-medicate with OTC products.   Management strategies differ greatly with pharmaceutical and nutraceuticals.   It is incumbent upon the audiologist to ask the appropriate drug and OTC questions while taking a case history in order to develop a management strategy appropriate for the patient    


This instructional course is divided into two (2) ninety (90) minute programs.


Learner Objectives (long) 

After this presentation, participants will be able to:   


1. Identify current pharmaceutical research for hearing loss and tinnitus 

2. Identify nutraceuticals recommended for hearing loss and tinnitus 

3. Understand the FDA loophole that allows supplement manufacturers to make claims of efficacy without 

          having to proved scientifically efficacy and safety 

4. Recognize which herbals have efficacy and safety data published in peer reviewed journals 

5. Improve communication between patient and referring physician concerning adverse drug or OTC tinnitus

          relief product side effects 

6. Know how to report an adverse herbal/supplement reaction to the FDA     


Learner Objectives  (short)   

After this program is completed, attendees will be able to:   


1. Identify pharmaceuticals used for hearing loss and tinnitus management

2. Identify nutraceutical/over-the counter products used for hearing loss and     tinnitus management 

3. Discuss patient management strategies with patients using these compounds     



NUTRACEUTICALS FOR TINNITUS RELIEF 


Abstract

The number of over-the-counter (OTC) dietary supplements available for tinnitus relief continues to grow. Currently there are over 80 OTC products claiming relief or with some products, a cure for tinnitus. However, none of these products are FDA approved. Of concern is that there are some products that contain ingredients that could be harmful with special patient populations.   


This program reviews the FDA regulations on OTC tinnitus products and the law that allows supplement manufacturers to make claims about “cures” for tinnitus without having to show evidence-based, scientific data for efficacy and safety.    


Attendees will be have an opportunity to see the variety of supplement products available and even experience a vibratory repetitive tapping device for tinnitus.   


Patient counseling and other management strategies will be presented in order for attendees help their patients make informed decisions about starting or discontinuing an OTC tinnitus relief product.


Summary  

The FDA loosely monitors over-the-counter nutraceuticals (i.e., vitamin supplements) and classifies nutraceuticals as ‘food.’ This means that efficacy (does it really work?) and safety do not have to be demonstrated. The scientific guidelines for evidence-based clinical research do not apply.   


The Dietary Supplement and Health Education Act (DSHEA) of 1994 allows nutraceuticals manufacturers to make statements of their product’s efficacy and safety to influence public opinion without having to back up their claims with evidence-based research.    


The Federal Trade Commission (FTC), along with the FDA, share responsibility of efficacy and safety of nutraceuticals however these agencies put the burden of proof on the manufacturer. Using the disclaimer “These statements have not been evaluated by the FDA. This product is not intended to diagnose, treat, cure or prevent any disease” opens the door for opportunity to not only market the product but also give false hope to patients experiencing tinnitus.   


Attendees will not only learn which federal and commercial websites provide accurate drug information but also learn about how several of the 80 known over-the-counter (OTC) products that claim tinnitus relief (and in some cases a cure) can be more harmful than helpful with certain patient populations.    


The last section of this program will review management strategies which could be helpful to the patient, their family, the prescribing physician and pharmacist.  

 

Learner Objectives   

After this presentation, participants will be able to:   


1. Identify nutraceuticals recommended for tinnitus; 

2. Understand the FDA loophole that allows supplement manufacturers to make claims of efficacy without

          having to proved scientifically efficacy and safety; 

3. Improve communication between patient and referring physician concerning an OTC tinnitus  relief product

          side effect; 

4. Know how to report an adverse herbal/supplement reaction to the FDA.       



EAR CANAL PATHOLOGIES AND MANAGEMENT   


Abstract

This is a comprehensive review of the developmental anatomy and physiology of the human ear canal along with an in depth review of the pathological conditions that would result in a medical referral for intervention and management.    


Over 20 ear canal pathologies are identified along with management strategies for each pathology.    


Also, there is a review of first aid procedures for bleeding during cerumen management. Finally, a case study is presented that involved a patient who passed out during video otoscopy.     


The program uses numerous ear canal pathology images. This is an excellent program for students as well as experienced audiologists.

     

Learner Objectives    

After this presentation, participants will be able to:   


1. Identify the cranial nerves and the blood supply to the ear canal 

2. Understand the role of the cerumen glands 

3. Recognize various pathologies that need medical intervention 

4. Understand the procedures when an ear canal is lacerated 

5. Understand the safety procedures when a patient has a syncope episode     during video otoscopy     



DRUG SIDE EFFECTS ON AUDIOLOGICAL AND VESTIBULAR TESTING   


Abstract

There are over 2000 drugs with a combined total of over 400 side effects that could result in obtaining inaccurate case history information or the selection of tests whose results could lead to misdiagnosing the patients hearing, cognitive or vestibular problem. The recommendations that you make could be inappropriate thus leading to management errors.   


This program reviews auditory/vestibular and cognitive side effects of many of the drugs patients take regularly and offers suggestions to obtain a more accurate case history. A review of preferred websites to obtain drug side effect information is included.   


Suggestions for improved communication strategies between the referring physician, the patient and their pharmacist are given at the end of the program.   


Several case studies are presented to enhance the learning experience.   


There is one handout listing all the possible auditory/vestibular side effects that should be of concern to the audiologist.     


Summary

No one person is knowledgeable of all the FDA approved drugs and their side effects. However, there are many excellent reliable resources on-line and in print that can guide the audiologist through the maze of questions need to ascertain if the patient's auditory/vestibular complaints are truly pathological or a side effect of a drug (or drugs) the patient is taking for some unrelated medical problem.   


Historically, we have been taught to identify drugs that can cause hearing loss or tinnitus or medications that should be curtailed temporarily prior to a balance assessment.   


The first problem lies with our ability to know where to look for information about the patient’s drugs to determine if their auditory/vestibular complaint is truly pathological or a side effect of one or more of their drugs.   


The second problem occurs when test results are ‘inconclusive” or ‘discrepant.” Why is that? Do we just report it the data and let the referring physician figure it out or do we step up and truly “doctor” our patients by committing ourselves to our clinical impression that the discrepancy lies in the fact that the patient’s time-line from when the drug was started and the symptoms appeared are tied together?   


The program cites two case studies from the speaker’s patient files where a drug’s auditory/cognitive/vestibular side effect was the real reason for the referral.   


The information in this program can be used immediately by the attendees. 


There are several reliable websites that were analyzed as well as several publications for reference.   


Although this case history data collection on the patient’s drugs can add more time in your analysis. It can save you, your patient and the referring physician even more time when the correct diagnosis is made.   


Suggestions for improved communication strategies between the audiologist, the physician, the patient and the pharmacist are another highlight of this program.   


Learner Objectives   

After this presentation, participants will be able to:   


1. Recognize the importance of obtaining detailed drug information on the case     history questionnaire 

2. Identify how a drug side effect can affect audiological and vestibular testing 

3. Identify preferred websites for accurate drug side effect information 

4. Improve test reporting when data are discrepant 

5. Improve communication between the referring physician, the patient and their     pharmacist         



AUDIOLOGICAL MONITORING FOR OTOTOXICITY     


Abstract   

Audiologic monitoring for ototoxicity continues to evolve. Throughout the years there have been several suggested monitoring protocols that have been published and more research is being conducted for this issue. This program will review several monitoring protocols as well as discussing strategies to improve communication between the referring physician, your patient and their families. Three case studies will be presented that involve 1) a well known antibiotic 2) an over-the-counter nutritional supplement and 3) malingering.     


Learner Objectives 

After this presentation, participants will be able to:  

 

1. Identify how certain pharmaceutical agents result in outer hair cell damage in     the cochlea 

2. Identify common ototoxic drugs – chemotherapy agents and antibiotics 

3. Design an audiologic monitoring protocol (including a protocol for vestibulo-     toxicity) 

4. Understand the importance of close documentation of test findings 

5. Utilize appropriate procedures for billing 

6. Improve counseling strategies with the patient and family 

7. Improve communication with the oncologist and primary care physician 

8. Identify audiometric test discrepancies that suggest malingering.       


NOTE: If your program has a Grand Rounds section

            please consider this case:  



 GRAND ROUNDS - OTOTOXICITY    


Summary

This is a worker’s compensation case report of a patient who was allegedly given an ototoxic drug for an ear infection. He later complained of hearing loss from the drug. He had diagnostic tests by another audiologist in an ENT office and all indicators of malingering were present but the ENT and audiologist missed the test discrepancies. The attorney for the pharmacy that allegedly dispensed the drug contacted my office for a second opinion. After my evaluation it was determined that the patient was truly malingering and the lawsuit was dropped.   


Suggestions for ototoxic management with compensation cases are given.  



AUDIOLOGIST’S GUIDE TO INTERNET WEBSITES FOR DRUG INFORMATION

Abstract

This 90 minute program uses the internet extensively to analyze federal, professional, commercial and support group websites (per AMA Guidelines) for accuracy and reliability of the information intended for professionals and consumers. It also analyzes commercial websites that provide less than accurate information despite a slick, professional look.   


Counseling and communication strategies - including how to contact the drug manufacturer to report an adverse drug event - will be reviewed so that audiologists and speech-language pathologists can be more effective in patient management especially when audiometric/vestibular/speech-language test results are discrepant.  

Strategies will be reviewed to guide your patient to those websites that offer reliable drug information.      


Learner Objectives 

After this presentation, participants will be able to:   


1. Recognize the AMA's criteria for website validity 

2. Identify websites that offer reliable drug information 

3. Navigate quickly through federal, commercial and professional websites     offering drug information 

4. Effectively identify websites that offer questionable or less than accurate drug     information 

5. communicate with the FDA and drug manufacturers   



ADVERSE DRUG AND HERBAL MEDICINE REACTIONS AND PATIENT MANAGEMENT  

 

Abstract

Adverse drug reactions (ADRs) and herbal medicine reactions can mimic or exacerbate hearing loss, affect vestibular function, alter auditory perception, influence test data interpretation and directly impact on effective patient management.   


This program is geared to audiologists who have little or no direct experience in pharmacology.    The course content will be an overview of basic pharmacology concepts, identify the reasons why ADRs are more prevalent than ever before and sensitize the audiologist to a variety of medications that play a critical role in patient management.  


Case studies will be presented and analyzed using a patient’s medication/herbal history and symptom correlation time lines.   


Counseling strategies with the patient and communication strategies with the prescribing physician will highlight this program.   


Learner Objectives 

After this presentation, participants will be able to:   


1. Understand the pharmacodynamics of pharmaceuticals 

2. Learn the advantages and disadvantages of direct-to-consumer ads 

3. Recognize the clinical relationship between adverse drug and adverse herbal     medicine reactions with auditory perception and the vestibular system 

4. Improve communication between patient and referring physician