Page 109 - 2020 JSOM Winter

noise. On a practical level this presents a difficulty because we embarrassment, sleep loss, and/or unfavorable changes
are currently unable to authoritatively advise on the long-term in personal relationships;
prognosis after treatment of AAT and how further exposures – living with tinnitus leads to feelings of despair;
might affect the service member, even when the pure tone au- – more than 1 in 10 respondents had been medically
diogram appears to have returned to normal. downgraded and were unable to progress in their ca-
reer; and
If the DAT audiogram is abnormal, then this, the endoscopic – veterans under the age of 75 were more than 3 times
picture of the TM, and a tympanogram are electronically for- likely to report hearing loss than was the general public.
warded to the multidisciplinary ear, nose, and throat (ENT)
surgical team (consisting of the otolaryngologist, audiologist, The financial impact of AAT is substantial; from 2012 to 2018,
and occupational health physician) based at the Role 4 facility more than 9000 claims for NIHL were awarded to members
at the Queen Elizabeth Hospital, Birmingham, UK. After ref- of the British Armed Forces under the Armed Forces and Re-
erence to the predeployment audiogram, advice is given as to serve Forces Compensation Scheme (AFCS) or in common-law
whether that service member requires continuation of oral ste- claims amounting to more than £58 million (US$75.4 million)
roids and evacuation to the United Kingdom for consideration in lump sum awards alone, not including guaranteed income
of hearing rescue with intratympanic steroid injection (ITSI). payment. In the United States, since the beginning of the war
52
in Afghanistan in 2001, total payments for disability caused
If the DAT audiogram is abnormal and the endoscopic picture by tinnitus and NIHL have increased enormously, amounting
shows a perforation of the ear drum, the hearing loss is likely to a reported payout of more than $1 billion in 2006. Indi-
12
to be mixed. The DAT data are forwarded to the Role 4 ENT rect costs from loss of tax revenue from personnel discharged
surgical team, which then determines the degree of injury and from the service and additional Social Security payments also
assesses how much is likely to be sensorineural in nature, and add to the overall financial burden.
advises on the Role 3 or 4 options for hearing rescue. Keeping
steroid within the middle ear in the presence of a perforated Accurate diagnosis and early treatment can save the hearing of
TM is difficult and, in the future, this may be facilitated by SP; however, timely assessment and specialist intervention are
novel methods of drug delivery, such as insertion of a ste- necessary so that treatment is undertaken in the requisite time
roid-impregnated sponge. Currently at Role 1, the regular use frame—currently considered to be within 2 weeks—cognizant
of steroid topical drops may be recommended in these cases. of the fact that evidence exists showing better hearing outcome
with earlier intervention. The DAT project has introduced a
53
If oral steroids are prescribed, prednisolone is given at 1mg/ best-practice protocol, equipment, and medication to efficiently
kg up to 60mg daily. At present, competency to deliver endo- assess and treat AAT and uses telemedicine, which has a proven
scopic ITSI is available only occasionally at Role 3 but always track record in otology. 54,55 The DAT enables rapid, simple, and
at Role 4. ITSI has some advantages over other steroid delivery accurate assessment of far-forward AAT by obtaining and shar-
modalities, possibly in both efficacy and in reducing the risk ing high-quality audiometry, otoscopic images, and/or videos
of systemic side effects associated with the administration of of the external auditory canal and TM to otolaryngologists in
high-dose oral steroids, because it provides immediate, high the home base, allowing treatment to be commenced without
intracochlea concentrations 46,47 without major systemic ab- delay, followed by urgent repatriation for ITSI if needed. Ef-
sorption. If ITSI is recommended by the Role 4 otolaryngol- fective treatment stratification via a remote, multidisciplinary
ogist but no competency exists at Role 3, urgent repatriation ENT surgical team allows retention of the deployed teams’
should be arranged. capabilities by reducing inappropriate CASEVAC. In addition,
disseminating the protocol to military healthcare providers at
Role 1 and making the assessment of postacute acoustic ex-
Discussion
posure routine will raise awareness of treatment options and
Military occupational noise exposure continues to be a major remove the need for individual SP to self-present, reducing the
challenge, and the prevalence of hearing loss remains higher stigma associated with “going sick” and identifying those with
in the military population compared with civilians. 22,48 Mil- hearing loss who do not realize the implications. In the future,
itary hearing loss secondary to AAT may be, in part, due to it may be possible to optimize the toolbox because future it-
failures of compliance with and relative limitations of HPDs. erations of the boothless headset may provide bone conduc-
However, acute military noise exposure remains unpredictable tion audiometry and acoustic reflectometry delivered by smart
for frontline personnel and is also a risk for civilians during phone, which may make it possible to remove the tympanome-
urban terrorism events, such as the Boston Marathon bomb- ter from the DAT, reducing cost, weight, and bulk. 56
ing (2013) and recent marauding shooter attacks in civilian
settings. 49
Conclusion
For the military, the immediate effect of acute hearing loss is Military AAT continues to be a major challenge. This proj-
a critical reduction in the operational effectiveness of the de- ect creates an innovative solution to promptly assess and treat
ployed team. 50,51 Long-term NIHL affects both the individual AAT on the frontline by combining a novel acoustic toolbox
and the collective. In 2014, the Royal British Legion “Lost with the diagnostic skills of an offsite otolaryngologist via tele-
Voices” found that medicine. Early recognition and treatment of frontline AAT
5
will preserve hearing and enable retention of personnel in
– a quarter of all service members reported hearing loss service, optimizing service members’ quality of life and mit-
on return from conflicts; igating subsequent occupational health compensation claims.
– up to half of all respondents believed hearing loss had We invite other nations to adopt the DAT to improve their
a “significant [adverse] effect,” causing social isolation, identification and treatment of AAT in the far-forward setting.

The Downrange Acoustic Toolbox | 107