W/a/J, ABR opinion?

[Nancy T]

Hey Wear/a/Jimmy, you sound like an audiologist. Do you mind my asking whether you think the following abnormal ABR results could be from "a virus," or from a hearing loss on the left and a vascular loop on the right? This is what my otoneurologist suggested (7 years ago)--after all but telling me a year earlier that I had MS (despite having a normal MRI report in his hands, which had been done a year previously to rule out AN after the hearing loss) and then telling me I didn't (although the same radiologist later compared the original MRI to later ones and said there were scattered and changing small foci, though certainly nothing diagnostic). I HAVE had some suspicious symptoms (e.g., Lhermitte's and bilateral electric shocks in my face, etc.) but I think I will never get an explanation for my symptoms. The ABR is the one big abnormal thing I've had, and the neuro wrote in his last report that we might eventually want to do a spinal tap because of the abnormal ABR (though that never happened).

(My left-side hearing loss is normal to 500 Hz, then "waterfalls" to about 75 dB at 750 Hz and another drop to about 110 at 6000 Hz. On the right side, my hearing is normal, but on that side there's a "small vascular loop that extends into the right internal auditory canal and also passes close to the root entry zone of the right cochleovestibular nerve....This is a small artery, probably the anterior-inferior cerebellar artery.")

ABR results (October 2000):

Absolute latencies (wave -- right ear -- left ear)
I -- 2.11 -- 3.60
II -- 2.93 -- 5.04
III -- 4.08 -- 6.88
IV -- 6.34 -- 8.56
V -- 7.73 -- 10.40

Interwave latencies:
I-III: right 1.97 msec; left 3.28 msec
I-V: right 5.62 msec; left 6.80 msec

The "stimulus presentation level," if that makes any difference, was 75 dBnHL for the right ear and 95 for the left.

"Audiometric impression: ABNORMAL absolute and interwave latency prolongation for BOTH EARS for click stimulus. See also enclosed 500 Hz tone burst data."

The "500 Hz tone burst" graph, which also had written on it "headphone ABR @ 100 dB SPL (75 dBnHL)," showed wave V marked at about 13 ms for both ears (the left ear waveform was very vague and the "V" had a question mark after it). She wrote "normative V X-bar = 11.0 msec", which I presume means these were abnormal too.

Acoustic reflex decay test result was plotted against a background from Cartwright and Lilly (1977) and exactly followed the line for "N VIII disease" for the left ear at 500 Hz, and the line for "normals" for right ear. The "audiometric impression" for this was "Highly abnormal decay pattern left consistent with N. VIII disease [I know that means 8th nerve disease]. Normal decay pattern R at 500 Hz, slightly elevated R at 1000 Hz. (Due to elevated threshold decay could not be measured/obtained for L at 1000 Hz.) Normal decay patterns for the right ear for both 2000 and 4000 Hz."

So, have you ever heard that a bilaterally bad ABR can be caused by a virus? Or by a vascular loop? I understand that the severe hearing loss makes the left-side results unreliable, but why would it be abnormal on the right, too?

Thanks for any insight you might be able to give me into this. It's just a matter of idle curiosity at this point, since I haven't been followed by a neurologist since 2003 and the neurotologist is only interested in checking my hearing (which I believe remains unchanged), giving me allergy shots, and waiting til I can get on some insurance that'll pay for a BAHA.

Nancy

[Nancy T]

Thanks so much for the recommendations. They are rather far from me, and my symptoms are either inconsequential or under good control; so despite my frustration with the contradictions and with having been labeled a hypochondriac, I don't plan to see anyone else unless something changes.

Hmm, I didn't know that audiologists can't have independent practices. I can understand why that would be frustrating, if the ENT controls your pay and employment. Lots that we out there don't know!

Have a good weekend,
Nancy

[Wear/a/Jimmy]

Reg Audiology and pay:   It does not matter what the bill states for diagnostic work, the money goes to the ENT. Audiologist, unlike chiropractors, speech pathologist, Nutrional therapists, physical therapists etc, can not bill directly to 3rd parties (insurance,medicare, medicaid).

They have to bill under ENTs....  that is the crux of the issue. Until they have the ability to bill insurance companies, they will always be the slave paid servant of the ENT.

The doctorate degree is a mandate, but that does not include a pay raise & it does not make the audiologist independent from ENTs....  it just makes it harder to be an audiologist, and drops the school to pay ratio even worse than when a Masters degree was required.

What ENTs are doing to prevent paying audiologist is using their power of "supervision" which is defined as being within the same building....  to replace audilogist that demand high pay. Basically the law is, any physician including a foot doctor, can perform audiology tasks including fitting and dispensing hearing aids. So the ENTs aquire a high school kid, put a lab coat of them and dub them qualified....

You the public do not know the difference, and you just have to hope the diagnostic results are accurate.

Now back to your concerns.  This is of little conselation, but AN are benign and have slow growth. So even if it were a tumor, it is taking its time to manifest itself clinically. (ie, MRI)

I don't know if I have been of much help. There is a woman (PT) named Bridget Nelson that runs/owns a balance center in Austin Texas....  she is one of the best I have met. Then there is a Doctor Barring (sp) at Ohio State.....   very very knowledgable. You may want to talk to one of those folks if not both.

[Nancy T]

Darn--I was quoting parts of your previous message, but they disappeared between the brackets.

[Nancy T]

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Yes--but BPPV was only a tiny part of my overall dizziness, which is/was a constant and very slowly worsening low-level wooziness since 1983. It became significantly worse in 1999 after the sneezes, though with a lot of variation. Worsened by body/head/eye movement. Definitely not a tumor, though. At one point I thought it must be migraine-related (though I have few migraines and extremely mild ones, rarely a headache), but the otoneurologist said no.

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Nobody has! I have never seen it in all my (layperson's) reading on dizziness, never heard any of dozens and dozens (or more) of dizzy patients I've talked to in person or online mention it. I told at least 4 balance or neurology experts about that cross-ear fluttering with the BPPV, but none had any idea, except one suggested "aberrant regeneration," i.e., crossed wires. (But regeneration from WHAT?)

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I should have clarified--she did the 500 Hz tone burst AFTER doing click stimulus in both ears. The absolute and interwave latencies I listed are all from the clicks. I listened to a LOT of clicks... in both ears.

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I don't know what else they'd do, after having clear MRI. I thought maybe the otoneurologist would want to repeat the ABR eventually, or do a spinal tap or test further for autoimmune disease. But nope, he said he didn't need to see me anymore (after helping me find the right kind of medication to help my dizzy-woozy-fogginess with "attention and concentration deficits", and he'd also let me go to vestibular therapy, which didn't make much difference except with visual sensitivity).

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Yes, I think it's probably that way in investigating a lot of types of medical problems or symptoms. Not surprising.

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Really? Wow, I didn't know that (that it's a form of tinnitus and happens to everyone). I never had that "cross-over fake-deafness" feeling happen until after my hearing loss. It became less and less frequent, and I don't think it's happened for years now, at least not the very definite and strong type. I still do get occasional "extra" ringing or static, alarm clocks, chirping, etc. in my hearing-loss ear, above and beyond the constant whirring tinnitus (fortunately not loud--I am very lucky I am not bothered by the tinnitus).

I do have one other odd tinnitus manifestation--a sudden burst of "extra" static in my bad ear simultaneous with a split-second "whump!" feeling in my head, originally so strong it felt like I was going to pass out. This started maybe six weeks after my hearing loss. It occurred most frequently upon hearing a sudden sound, even if not a loud sound, and also a lot in the twilight between sleep and wake and also upon cessation of a staticky noise, such as when I'd change the radio station or turn off running water. Later, I realized that it often happened if I moved my eyes--usually side to side, sometimes up. Eventually I decided it must be something like the gaze-evoked tinnitus that some fellows in Buffalo, NY (can't remember their names now) studied in acoustic neuroma patients. I didn't have an AN, but I must have had some kind of injury to the nerve or inner ear that caused this. A tinnitus researcher in town was very interested in this, wanted to do an fMRI on me, but decided it wouldn't work because the "burst" of static when moving my eyes only lasted a second, not long enough to catch on MRI, and it didn't happen all the time either. (I could have got into the machine and if it wasn't a "whumpy-head" period of the day, too bad.)

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I thought the charges for my hearing tests were pretty low! (My insurance pays everything anyway.)

I thought it was funny when the insurance report for my auditory testing in 2000 came. The lab charged something over $1000 for "earwax removal" (and the insurance paid!). Actually, what they did was AR testing, ABR, and fistula pressure test, but it was all apparently put under "earwax removal"!

(Not that doctors and nurses in the past haven't had epic struggles to get my huge impactions out... they would always exclaim at the huge chunks they excavated. I use drops and a bulb now to try to keep it from getting so bad.)

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Huh, VERY unfair. I suppose it has something to do with the high demand for dental hygienists. Maybe the demand (and pay) for audiology will grow as the baby boomers age? Also, I thought that audiologists are starting to do more stuff independent of ENTs, diagnosing and treating BPPV themselves and so on, getting doctoral degrees, etc.?

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Congrats on the success of your company! It's good that you've found a work situation that you enjoy and where you earn a good living. Also, I (and surely others here) greatly appreciate your participation on this forum. All the exhortations you hear on TV, from other people, and even from other doctors or official Web sites to "Ask Your Doctor" and "don't leave until all your questions are answered" make me laugh out loud. The doctors don't have time, and many of them don't have the interest. (There are exceptions. My neurotologist and former otoneurologist do/did have some great qualities, but one is ALWAYS left with unexplained contradictions in what they say and do, and how this relates to the history of your actual symptoms.) Thus it is very, very helpful to find experts online who are willing to take time to answer people's questions, point them in the right direction, dispel myths, or what have you.

Sorry to write so much again.... Thanks much,

Nancy

[Wear/a/Jimmy]

BPPV is common, a lot of every thing you described sounds like BPPV, vertigo related to head position. Not to mention you state tha you self cured yourself through an Epley...  if it were a tumor it would not have made a difference.   Regarding fluttering sounds....  that is a puzzle to me. Never heard of that as a symptom of BPPV

Regarding your suposed abnoraml ABR on the right ear. I don't think it is abnormal, again tone burst w/ a 500 Hz 75 dB stimuli, has no normative data that I am aware of...  If that is the case, how can one determine normal from abnormal.  If it were a click done in the right ear with an 80dB stim also done with alternating stim rates....   now we are talking normative data.

Regarding reflex decay, that test to me indicates further investigation is waranted, but it is not definitive.  You see, in audiology, there is NO SINGLE test that tell all the information needed to deterime the status of the auditory mechanisim. NO SINGLE TEST.... so what one has to do, is do many different tests, and put all the information together like a puzzle. At times maybe 9 out of 10 peices of the puzzle lead toward one direction, one diagnosis, but there is a single one piece that does not....  that one piece of the puzzle is usually tossed out, chalked up to wierdness becuase the majority of the other pieces are in agreement.

So again AR is just a part of the puzzle and not a full piece.  If you were working with me, I would re-do an ABR on the right ear using a click stim.   If I have time today I may investigate this 500 Hz stim of AN investigation.

Regarding the alternating hearing....  Believe it or not that to me sounds normal. Basically what happens is the ears at times turn off; It is a strange and freakish thing, and I do not know why they  do this. It happens to me, and it happens to most everyone. It is classified as a form of Tinnitus.  Fortunatley, it does not last very long.  But if you have one bad ear and one good ear, and the good ear shut down, then you would rely on the bad ear for a moment or 2. Ofcourse the hearing is going to muffled etc because it is the bad ear.  That is assumeing if the bad ear has some risidual hearing.

To be honest, there are specialties within Audiology ex. balance, hearing aids, pediatrics, geriatric, Cochlear implant, routine diagnostics, hearing consevation/industrial audiology etc.

I am not a balance expert for sure & oddly enough I am more of a jack of all trades, and I am heavy in the business end. I had to go where the money is, because there is no money in Audiology.

For example, the average audiolgy earns as much as a dental hygeniest. (50-60k) To become an audiologys, the tuiton is around 100K & the time in school is about 8 years. To become a dental hygeinest, 2 years post High School....

So after playing mother may I for ENTs for some time, I started my own co, eventually moved over seas, joined up with my supplier for my original company, and expanded that company. Since joining we have opened 2 subsidary companies, and on schedule to open a 3rd. Fun times & I earn the type of money one should have shelling out so much on tuition and time.  Too bad I had to do all that just to earn a living. I really think the future of audiology is at risk, and after they are gone.....  the public will have to rely strictly on ENTs  & wow....   what a sad day that will be.

[Nancy T]

Oh, and hooray for the Epley. I did it on myself at home and cured my four-day BPPV episode (after it became more bothersome than amusing. It works!!

[Nancy T]

Also I forgot to say that I've had a couple of really strange things involving "cross-ear" symptoms, at least one of which seems unheard-of.

A few years ago I had a four-day episode of BPPV. I'd had a handful of one-time BPPV episodes since my left-side hearing loss, nothing unusual (although at least one of the previous episodes was my RIGHT side). During this long episode a few years ago, every time I'd lie down on my left side or tip my head a little up and left, the ceiling would start jerking up and down for a bit--normal BPPV, I presume.

But what was very weird was that every time during the ceiling-jerking phase, my RIGHT ear (therefore opposite to the BPPV side) would get a strong beating/fluttering that I could both hear and feel in the ear. It corresponded exactly in intensity and duration to the ceiling-jerking, i.e., as the jerking faded out, so did the beating/fluttering.

OK, that's NOT normal BPPV, is it? Does that mean some wrong connection in the brainstem?

The other weird thing I had many times in the years after my hearing loss was a sudden feeling of having "gone deaf" in my left ear (even though it was already mostly deaf)--a sudden, distinct "closed-off" feeling that would instantaneously "jump" over to my right ear. This did not seem to affect the actual hearing in my right ear; if I was playing music, for example, I could still hear it perfectly well. But the right ear would FEEL as if it had suddenly gone deaf. This sensation would fade out after less than half a minute.

I presume this had something to do with the acoustic reflex, but this would happen WITHOUT any sound stimulus. Just randomly and spontaneously.

Do you think these things could reflect "bad wiring" in the brainstem? How could things in one ear affect the other?

Sorry again for "TMI." It's not really important--it's just that I have always wondered how these things can happen and what might have gone wrong in there. Once the docs have seen a good MRI and seen that your hearing is stable, they pretty much stop trying to explain or figure anything out.

[Nancy T]

Thanks VERY much for all the info. The thing is, when the ABR was ordered (by the otoneurologist), I had already had an MRI (with gadolinium) a year earlier to rule out AN, after my sudden hearing loss. No tumor was seen.

Everyone I've mentioned this to is puzzled, too--why would one do an ABR after an MRI already gave me the all-clear?

I presume he ordered it to look for any abnormalities that might be found related to my many (minor) neurological symptoms, including dizziness. The otoneurologist wrote in his report that I had "cranial neuropathy" (because of the abnormal ABR) but that the referring doctor should "please remember" that a tumor had been ruled out already.

To me, he said that the ABR result was typical of what you'd see for a tumor (drew me a diagram and everything), but that the MRI hadn't showed anything, so I didn't have one. He did NOT tell me it was abnormal on the right side as well--I only found that out when I got the report myself months later.

I don't know why the audiologist did the tests she did (the 500 Hz tone burst). I do remember that before she did the ABR, the acoustic reflex decay test turned out abnormal (she was explaining everything to me as she went along), and she suddenly started talking about her mother (?), whose MRI had been normal, but the audiologist kept doing ABRs on her because she was suspicious due to an abnormal result, and sure enough an AN eventually showed up in the mom. So maybe the audiologist, after seeing the abnormal ARD result, suspected a tumor too teeny or hidden to show up on MRI and thus did some odd stuff with the ABR? A neurotology nurse in another practice once told me that occasionally (rarely) very small ANs can "hide."

Now, I do NOT suspect I have an AN--in the years since, I've had 3 more brain MRIs, one with gad, to look for MS. And my hearing hasn't changed and I have no new facial symptoms that might suggest an AN. But I still have electric shocks on both sides of my face and other very strange symptoms (minor).

I think both the otoneurologist and the audiologist who did the ABR were pretty sharp people and just trying anything to figure out what was going on with me, audiologically. The doctor/professor had a PhD in auditory neuroscience as well as an MD, and the audiologist was part of his team. But after the first round of tests, he gave up on me.

Leaving aside the difficulties of testing a mostly-deaf ear, do you know of any reason BESIDES AN for such a bad ABR result in the normal-hearing ear?

Thanks again & sorry for "too much information."

Nancy

[Wear/a/Jimmy]

Wow....  that was a ton of information.....  unfortunatley I am not going to disect it.  But I can share with you some puzlement. I have never heard of doing a 500Hz ABR in the search for an Acoustic Neuroma. A click is uses for the stimulus, and technically speaking it should be presented at 80dB. This is because there is no normative data beyond 80dB.  Although most audiologist do use stimuli above 80dB under the theory that GROSS abnormalaties should appear better. While this may be the case, I am not in a position just where I can just crank up the volume and hope for the best. I have got to use what the texts say, normative data states and what that particular diagnostic equipment mfg states to use.

Secondly as you mentioned, due to your hearing, in my opinion, ABR test results are essentially unreliable. Here is the deal. The idea behind an ABR for acoustic neuromas is to stress the acoustic nerve. Well if someone has hearing thresholds at around 70-90dB at 2K-4K Hz and the ABR click stimulus is presented at 80dB then the person being tested may not hear the stimulus at all or just slightly. Well a slight stimulus is not going to stress the acoustic nerve....

So many times when I see thresholds of 70dB, I recommend a MRI, because again how can you perform an ABR on a person that can not hear the stimulus?

This may have been the reason they used 500Hz as a stimulus for you. But right off hand without consulting with any text books, and have not heard of normative data or a test protocal using 500Hz as a test stimuli in search of an acoustic neuroma. I have heard of it for tone burst ABR for looking for hearing thresholds, but that would be useless in your case. You are an adult. I am sure you are capable of raising your hand to a "beep."

Now I can tell you that getting a bad ABR test results in the NON COMPLAINT ear is a sign of an acoustic neuroma.

I'd say wave V does appear to be late, but when you use a 500Hz tone burst....  what do I know. The standard protocol is a click. Oh and yes the intensity does make a difference, the louder the sound the faster the waves appear. So if say we used a click, and 80 dB stim. you may have normal ABR results in the right ear.

All speculative at this point.