- Email: [email protected]
Sensorineural hearing loss after select procedures
CONTINUING EDUCATION
Sensorineural Hearing Loss After Select Procedures Susan M. Irvin, MSN, RN, CS, CAPA
Hearing is one of the most significant senses; therefore, any loss can be frightening. Previous studies have found that certain surgical and medical procedures can result in hearing loss. Cardiac surgical procedures are most commonly associated with hearing loss owing to the use of the cardiopulmonary bypass pump. Other noncardiac, nonotologic surgical procedures also may result in hearing loss. Additionally, medical procedures such as myelogram and lumbar puncture have been associated with hearing loss. Studies suggest that hearing loss can result any time cerebrospinal fluid is leaked. This report highlights the effect of dural puncture on hearing loss. The implication that any dural puncture procedure may result in a cerebrospinal fluid leak and subsequent hearing loss is a significant clinical topic. Perianesthesia nurses are advised to educate themselves and their patients regarding this complication. © 2002 by American Society of PeriAnesthesia Nurses.
Objectives—Based on the content of this article, the reader should be able to (1) describe the concept of hearing loss; (2) identify medical/surgical procedures that may result in a hearing loss; and (3) identify symptoms of a postdural puncture complication. HEARING IS ONE OF the most significant human senses. Loss of the ability to hear can be frightening, seriously affect one’s life, jeopardize safety and livelihood, and diminish self-esteem. More than 40 million Americans suffer from hearing loss.1 Problems reported by hearing-impaired individuals include hearing words but not comprehending speech and lack of understanding by others.1 Hearing impairment is the leading disability in this country.2 Not only is effective communication impaired,1 but personal, structural, and social integrity is also threatened.3-5 Changes in health care delivery methods during the last 2 decades have stimulated the increasJournal of PeriAnesthesia Nursing, Vol 17, No 2 (April), 2002: pp 89-101
ing shift from inpatient to outpatient medical and surgical procedures. These changes have resulted in shorter lengths of patient stay and a more compressed time frame for preprocedure workup and patient education. Complete medical history, physical examination, and comprehensive patient education remains the gold stanSusan M. Irvin, MSN, RN, CS, CAPA, is the Clinical Coordinator of the Ambulatory Surgery Unit at the Veterans Affairs Medical Center, Memphis, TN. Address correspondence to Susan M. Irvin, MSN, RN, CS, CAPA, Nursing Service (118), 1030 Jefferson Ave, Memphis, TN 38104. © 2002 by American Society of PeriAnesthesia Nurses. 1089-9472/02/1702-0006$35.00/0 doi:10.1053/jpan.2002.31683 89
90
dard for successful outcomes for short-stay patients. Because nursing is concerned with patient advocacy, protection, energy preservation, stability, balance, and harmony, appropriate nursing assessment and intervention is critical in assisting the patient to adapt or to make informed choices about their care.4,5 Previous findings6-11 show that certain surgical and medical procedures may result in hearing loss of varying degrees. The implication that any dural puncture procedure may result in a cerebrospinal fluid leak and subsequent hearing loss is a significant clinical topic. This hearing loss can involve one or both ears,6 usually affects the lower hearing tones,7,8 and usually is temporary,9 although permanent loss has been reported.10 Past or current history of inner ear disturbances, hearing loss, vertigo, ataxia, tinnitus, diagnosis of Meniere’s disease, or previous ear surgical procedures should alert providers or nursing staff of potential hearing loss after dural puncture procedures.7,11 This report identifies 3 main concepts: dural puncture, hearing, and sensorineural hearing loss (SNHL). Dural puncture and how it potentially relates to hearing loss are discussed.
Background Hearing is a sensory ability that is critical for normal speech development and communication.2 Hearing results from sounds being collected and directed to the brain, resulting in cortical awareness and interpretation.2,12 Hearing loss is a well-known phenomenon. SNHL is an inability or decreased ability to hear caused by problems with the inner ear structure. This may be caused by a disorder, dysfunction, or destruction of the auditory nerve, nerve pathway, cochlea, hair cells, basilar membrane, organ of Corti, labyrinths, or semicircular canals.2,13 Little consistent information exists about hearing loss after medical or surgical procedures. There is, however, some information documented about individuals who experience hear-
SUSAN M. IRVIN
ing loss after cardiac surgical procedures,14,15 general anesthesia,16-21 spinal anesthesia,6,22-28 myelogram procedures,26,28 lumbar puncture,7,26,29,30 and spinal manipulation.31 The use of the cardiopulmonary bypass pump revolutionized cardiac surgery; however, the machine’s high association with microemboli16 can result in intraoperative and postoperative complications, including SNHL.14,15 When cardiopulmonary bypass is used during cardiac surgery, hearing loss may occur in 1 of 1,000 surgical procedures.16,20 SNHL after general anesthesia for noncardiac, nonotologic surgical procedures occurs significantly less often, with a reported rate of 0.02%.20 By 1997, only 18 cases of SNHL had been documented after noncardiac, nonotologic surgical procedures.16 Possible causes of hearing loss after general anesthesia include theories of perilymphatic fistula formation,16 breach in cochlear membrane,16 increased intratympanic pressure changes,21 labyrinthine membrane rupture,19 cochlear ischemia,32 cochlear anoxia,33 and implosive or explosive forces related to the administration of nitrous oxide.16-18,20 SNHL after spinal anesthesia occurs at a rate of 0.4%, a rate higher than that associated with the hearing loss related to cardiac surgery.16,20 Reasons often theorized include leaks in cerebrospinal fluid caused by spinal needle size,6,23,24,27,28,34 shape,28,34 needle direction,35 specific drugs used,22,25 the development of endolymphatic hydrops,22,23,28,36 and plasma hypo-osmolarity.37 Diagnostic dural puncture procedures such as myelograms26,28 and lumbar punctures (LP)7,26,29,30 also are associated with hearing loss. Dural puncture, in which a needle is inserted into the subarachnoid area and cerebrospinal fluid (CSF) is aspirated, is a common procedure performed in myelogram, LP, and spinal anesthesia.26,38,39 The dural puncture site for a myelogram may be the cervical, thoracic, or
SENSORINEURAL HEARING LOSS
91
Fig 1.
Endolymphatic Hydrops Theory.
lumbar area of the spinal cord. Myelography includes the withdrawal of CSF and the injection of contrast dye to better visualize areas for vertebral disk or spinal abnormalities.40 Findings suggest that hearing loss occurs as a result of leaking cerebrospinal fluid.6,8,9,22,28 Patient position,41 number of dural punctures,42 amount of CSF lost,9,29 needle insertion direction,41 needle size,6,23,24,26-28,34 and needle shape28,34 are associated factors. Although hearing loss associated with certain medical and surgical procedures was first reported in 1914,43 inconsistent information exists, and the topics are not addressed in educational material or clinical care management resources.29 Most information is clinical and anecdotal, and the topic has yet to be studied systematically. Scientists still disagree on the exact mechanism of hearing loss after selected surgical and medical procedures; however, the theory of en-
dolymphatic hydrops (ELH) is the most accepted in current literature.8,22,28,36 Figure 1 shows a physiologic model of ELH. This theory indicates that a puncture in the subarachnoid space causes a leak of CSF, resulting in a decrease of CSF pressure.28,43 This pressure drop is transmitted via the cochlear aqueduct to the perilymph,29 resulting in perilympathic hypotonia22 or decreased pressure.29 This reaction leads to an excess accumulation of fluid or ELH, producing symptoms similar to Meniere’s disease.36 Meniere’s is a disease of unknown etiology, but the characteristics include fluctuating SNHL, tinnitus, and vertigo.44
Anatomic Overview Hearing is the result of collected sounds being directed by the outer ears, through the ear canals, to eardrums. Figure 2 shows the 3 areas of the ear: the outer ear, middle ear, and inner ear.45 The outer ears are collection devices that direct sound inward. The outer ears have 2
SUSAN M. IRVIN
92
Fig 2.
Anatomic overview of the ear. Reprinted with permission.45
basic parts, the auricle (pinna) and the external canal. A membrane stretches over the canal. This tympanic membrane, also called the eardrum, separates the external and the middle ear.1,2 The middle ear cavity contains 3 tiny bones (incus, malleus, and stapes), the oval window, round window, and the eustachian tube.1 The inner ear (labyrinth) contains the hearing sense organs, balance control mechanisms, and 2 cranial nerves (VII and VIII). The primary structures within this system are the membranous labyrinth and the protective bony labyrinth.2 The bony labyrinth consists of the cochlea and semicircular canals. The cochlea is further divided into upper (scala vestibuli) and lower (scala tympani) labyrinths. The bony and membranous labyrinths are filled with fluid,
perilymph, and endolymph, respectively.2 Four connections exist between the inner ear and temporal bone. These include the internal auditory canal, the vestibular aqueduct, the cochlear aqueduct, and the subarcuate fossa.46 The perilymph maintains communication with CSF by way of the cochlear aqueduct.2 The primary function of the cochlear aqueduct is poorly understood. It resembles a bony channel and serves as a connecting mechanism linking the perilymphatic compartment to the subarachnoid space, where fluid exchange occurs between these 2 structures.10,46 The cochlea contains the sense mechanism for hearing, the organ of Corti. This hard-walled end organ, attached to the basilar membrane, is bathed in endolymph and contains thousands of hairlike cells.1,2,47
SENSORINEURAL HEARING LOSS
Physiology of Hearing The method for hearing is extraordinary. To better understand how this sensory phenomenon occurs, basic terms will be described. Sound occurs because energy is moved as a series of vibrations or sound waves. These sound waves can travel 1,100 feet per second; however, the speed is dependent on environmental conditions. For example, air is a more favorable medium for sound conduction than water. Distance also influences sound wave travel.1 The external ears collect sound waves and direct them through the canal toward the eardrum. This pressure ultimately causes movement of the eardrum.1 As sound reaches the middle ear, the tympanic eardrum vibrates. This action stimulates the ossicles in the middle ear to vibrate, resulting in stapes vibration against the oval window. This stimulates perilymph fluid to vibrate, causing a simultaneous endolymphatic fluid vibration within the cochlear aqueduct and vibration of the basilar membrane. Sound vibrations, thus, reach the organ of Corti, which transforms and separates them. Sounds then are transformed as electrochemical impulses to the temporal cortex, traveling by way of the acoustic nerve (VIII) for final interpretation. When these impulses arrive and are interpreted, hearing occurs.1
Hearing Loss Hearing loss can be caused by both known and unknown factors. Some commonly known causes include aging, otosclerosis, infectious diseases, autoimmune diseases, ototoxic drugs, noise-induced losses, and Meniere’s disease.1 Different types of hearing loss include SNHL, conductive loss, or a mix of both; functional loss; and central dysacusis. To accurately diagnose hearing loss, it must be determined what part of the auditory system has been affected: for example, inner ear versus middle ear involvement.1
93
SNHL is caused by inner ear damage of cochlear hair cells or dysfunction or destruction of the auditory nerve.1,48 SNHL, the leading disorder of inner ears, is a challenging problem for health care professionals, because it cannot be cured, and the prognosis for hearing restoration is poor.1,2 It is common to speak of SNHL as nerve deafness; however, both sensory and neural components should be separately considered for accuracy of diagnosis. Sensory loss is applicable when damage occurs to the inner ear or cochlea. The term neural loss is more accurate when describing actual auditory nerve damage. Hearing loss that is classified as both sensory and neural or cases in which damage is not identifiable are considered SNHL owing to basic and similar characteristics.1 Conductive hearing loss results from an impediment of the conduction of sounds through the outer or middle ear. Interference at any point along this anatomic path, external canal, eardrum, ear bones, eustachian tube, or oval/round windows can result in hearing loss. No neural or sensory damage is found, and these types of hearing losses usually can be corrected.1,48 A mixed hearing loss is diagnosed when an individual suffers from both conductive and SNHL in the same ear.1 Functional loss involves an emotional aspect, whereas central loss, or dysacusis, is not mechanical but rather within the central nervous system.1 Affected patients simply are not able to interpret what is heard.1
Hearing Loss Related to Drugs, Disease, and Noise Some 200 ototoxic drugs are known to damage hearing. Certain drugs, when used over time, are associated with irreversible SNHL, damage to inner ear hair cells, and renal damage. Some commonly used antibiotics that may cause hearing loss include all “mycin” drugs.1,2 A miscellaneous category of ototoxic agents includes alcohol, lead, arsenic, mercury, barbiturates, salicylates, certain diuretics, and some alkaloids.1
SUSAN M. IRVIN
94
Some infectious diseases that cause SNHL include measles, mumps, or meningitis.2 Labyrinthitis, both viral or bacterial, can lead to SNHL.1,2 SNHL also can be related to noise. Exposure to prolonged periods of intense noise can result in hearing loss, initially in the higher frequencies, that then advances to the lower, speech recognition frequencies. At the start, the outer hair cells are damaged. As prolonged noise continues, the inner and supporting cells also become affected. The diagnosis is irreversible SNHL with a poor prognosis.1
and certain other neurosurgical procedures. Stoeckli and Bohmer10 challenged the concept that hearing loss after these interventions always is transient, by attributing the possible cause and continuation of one patient’s hearing loss caused by the CA. The poorly understood CA is implicated because of its role or position between the perilymphatic compartment and subarachnoid space during fluid exchange. Loss of CSF, the subsequent fluid exchange, resulting ELH, and hearing loss are physiologic mechanisms yet to be proven.10
Meniere’s disease traditionally is associated with hearing loss, usually caused by tinnitus. Other accompanying symptoms include vertigo and nausea. Tinnitus is defined as noise or ringing sounds and may be caused by irritating neural discharges. At least 32% of all Americans have experienced tinnitus to some degree.1 Meniere’s disease is characterized by tinnitus accompanied by ELH.1 This term was first described in 1926 as increased volume of endolymph, with subsequent distension of surrounding membranes.49
A number of contributing factors relative to dural puncture have been the focus of many researchers. Some research has reported that hearing loss after dural puncture is associated with the anesthetic injected during spinal anesthesia (bupivacaine)25 or the drug injected during myelogram (metrizamide),11 rather than the actual dural procedure itself. The size and type of needle used for dural puncture also often are implicated in hearing loss. Researchers agree that smaller gauge needles, such as 25 gauge or 26 gauge, are more likely to reduce CSF leak. Tapered needles versus cutting needles also can be less traumatic.8,23,27,28,34,35,50 Patient position also is critical for minimal postoperative complications because the spine should be maximally flexed during the procedure.24,41 Other factors implicated in the etiology of ELH are the number of times the dura is punctured and the amount of CSF removed.6,9,29,41
Hearing Loss Related to Dural Puncture Any dural puncture can result in a physiologic cascade leading to a hearing loss (Fig 1). This cascade occurs because of a disturbance in the balance of fluid pressures in the neurologic system. Dural puncture procedures can lead to a decrease in CSF that is transmitted to the inner ear by way of the cochlear aqueduct (CA). This results in an excess accumulation of fluid in the perilymph, creating an ELH, affecting lower frequency hearing47 similar to the hearing loss associated with Meniere’s disease.27 Any dural puncture procedure or opening of the dura can result in a loss of CSF. This CSF loss can result in a hearing deficit. What procedures cause a CSF loss, and the degree and duration of this hearing loss, remain the focus of many scientists. A transient hearing loss can occur as a result of lumbar puncture, myelogram, spinal anesthesia,
Hearing Loss Related to Neurosurgery Hearing loss also can occur after certain neurosurgical procedures. The CA is the link between the perilymph and the CSF. Transient hearing loss has been shown after craniotomy procedures. Possible causes include loss of CSF,47 histologic changes in the cochlea,51 and cochlear fluid shifts.52
Treatment Options Broome28 reported that despite studies linking dural puncture procedures and hearing loss, it
SENSORINEURAL HEARING LOSS
was not a commonly reported complication nor regarded as clinically significant. There were also conflicting data as to whether this phenomenon was temporary or permanent or if treatment was needed to promote hearing restoration. Because other symptoms such as severe headache, vomiting, tinnitus, or dizziness may overshadow hearing loss, treatment may be delayed or secondary. Although there are treatment options available, prevention should be emphasized. Treatment for hearing loss after dural puncture varies. The foremost concept, however, is to prevent excess CSF leak. If hearing does not return eventually, various strategies and agents are suggested for treatment. These interventions include vasodilators,20,33 anticoagulants,20,32,33 volume expanders,20,33 steroids,32,33 intravenous contrast agents,32,33 use of oxygen mixed with air in place of nitrous oxide,18 diuretics,33 antiviral agents,32 analgesics,26,42 intravenous fluids,29,42 bed rest,30,53 a quiet environment,42 carbon dioxide and oxygen combinations,20 and the epidural blood patch.2,16,28,30,32,33,42,54 The more CSF leaked, the more likely complications will occur. Proper technique using the smallest possible tapered needle, such as a 26 gauge, may prevent excessive dural leakage. If symptoms of dural headache, hearing loss, nausea, vomiting, or tinnitus occur after dural puncture procedure, an epidural blood patch (EBP) may be used to alleviate some or all of these complaints. Lybecker et al54 reported on the effects of using a blood patch to restore hearing. They concluded that leaking CSF caused decreased CSF pressure, which is communicated by the cochlear aqueduct to the inner ear, resulting in vestibulocochlear dysfunction. They identified that debilitating postoperative headaches often accompany hearing loss. Further, treatment for postdural puncture headache (PDPH) usually was the EBP. The investigators suggested that
95
use of the EBP might restore the hearing loss that occurs because of dural puncture procedure. Their study involved 16 patients suffering from PDPH. Preprocedure otoscopic examinations were conducted. Subjective data regarding cochlear and vestibular complaints were documented. Sitting and supine audiograms were conducted 15 minutes before the EBP procedure and again one hour postprocedure. Hearing thresholds before and after the procedure were compared for each patient in all frequencies. Threshold change was defined as 10 dB in 2 or more frequencies or 5 dB in 4 or more. All patients experienced headache relief by one hour. All other associated symptoms disappeared by 2 hours. Seven of the 16 subjects experienced improved hearing just by lying down. After the EBP, 12 of 16 reported improved hearing. Investigators suggest that the hearing loss that occurs after dural puncture procedure may be related to posture. Further, EBP could restore hearing loss within one hour. The investigators advised practitioners to prevent excessive CSF leaks and to restore CSF volume promptly.
Nursing Implications Comprehensive and consistent information on the topic of hearing loss and dural puncture is lacking. Identifying which specific patients lose hearing, for how long, to what degree, and in which frequency, are grounds for meaningful nursing research. Any association found between dural puncture procedures and hearing loss can have extensive implications, particularly on patient education, prompt intervention, and informed consent. Appropriate assessment and intervention are critical to a positive patient outcome. Assessment Before Procedure
A thorough nursing assessment should be completed on any perianesthesia patient scheduled for dural puncture procedures such as spinal anesthesia, lumbar puncture, or myelogram. Questions regarding current hearing, past otologic surgical procedures, and past medical con-
SUSAN M. IRVIN
96
ditions may be assessed quickly and incorporated into the nursing assessment record. Patients with a history of Meniere’s disease or patients who are already hearing impaired may be at a higher risk for postprocedure complications.7 Signs and Symptoms
Nurses can identify easily individuals who are hearing impaired. Signs of hearing loss in patients include irritability, anger, inattention, lip reading, turning their head to one side, complaints that people do not speak clearly or loudly enough, social isolation, friction within relationships, answering questions with the wrong information, noncompliance, and consequent embarrassment.1,2 Time Frames of Problem Occurrence
Researchers disagree on the specific time that this procedure-related hearing loss may occur. Hearing loss and other associated dural puncture complications such as severe headache, tinnitus, vertigo, visual disturbances, and nausea have been reported after dural puncture procedures. These symptoms may occur immediately,29 a few hours later,30 the following day,11 or between 24 to 48 hours after.7,8,36 Appropriate Nursing Care
Patients undergoing dural puncture procedures must be flexed and positioned properly for optimal needle insertion technique. Less than optimal technique includes multiple punctures,42 excessive loss of CSF,28 and tearing of dural fibers with larger sized cutting needles.35,50 Postoperative nursing assessment after any dural puncture procedure includes monitoring the patient for complications such as pain, headache, pain at needle insertion site, lower limb immobility, postoperative/postprocedure urinary retention, nausea, and any complaints of visual or hearing disturbances. Interventions for any of these problems should be initiated promptly and evaluated for success before patient discharge.
Patient and Family Teaching
Education for patients and family should include comprehensive instructions before and after any dural puncture procedure. Patients must be educated on their responsibility to comply with dietary restrictions, positioning requirements, and postoperative orders such as bed rest or lying flat or upright for several hours. It is critical that patients understand the need for asking nursing staff for assistance rather than attempting any activity without nursing intervention. Patient and family education also should address possible signs, symptoms, and interventions if hearing loss or other complications resulting from dural puncture occur. The family also must show an understanding and acceptance of caring for patients after dural puncture procedures before the patient is discharged. Nursing Follow-up
Nursing assessment after same-day procedures involving spinal anesthesia, lumbar puncture, or myelogram is a standard practice. Follow-up telephone calls represent the communication link that patients and family members have with health care professionals after discharge. Any postoperative/postprocedure problems such as headache, hearing loss, visual disturbances, pain, nausea, or incontinence can be discussed and appropriate measures taken for continued assessment and follow-up with the practitioner.
Conclusion Controversy exists regarding what can occur after dural puncture. Most scientists do agree that dural puncture procedures can lead to CSF loss and, potentially, some degree of hearing loss. However, researchers do not agree on the exact mechanism of cause, duration of symptoms, degree of severity, length of complications, or treatment strategies. Pressures of the CSF and the perilymphatic space are the same. When a decrease occurs in CSF pressure, a decrease in perilymph pressure
SENSORINEURAL HEARING LOSS
97
results.9 The cochlear aqueduct likely is the connecting mechanism. Perilymphatic hypotonia initiates endolymphatic hypertension and results in endolymphatic hydrops. Hearing thereby is affected as these fluid shifts occur, and lower frequency hearing loss can result. Whether this loss occurs immediately after a dural puncture procedure, 48 hours later, or a week later, remains a topic for study. Restoration of hearing with or without treatment also
needs further examination. Needle characteristics, amount of CSF lost, and multiple punctures also are factors for consideration in any further study of this topic. The potential volume of dural puncture procedures performed throughout this country makes this issue clinically relevant. There is a need to further study this topic and to caution practitioners to educate perianesthesia patients and nursing staff about this complication.
References 1. Sataloff RT, Sataloff J: Hearing Loss (ed 3). New York, NY, Marcel Dekker, Inc, 1993 2. Sigler BA, Schuring LT: Ear, Nose, and Throat Disorders. St Louis, MO, Mosby, 1993 3. Levine ME: Introduction to clinical nursing (ed 2). Philadelphia, PA, Davis, 1973, pp 1-19 4. Meleis AI: Theoretical nursing: Development & progress (ed 3). Philadelphia, PA, Lippincott, 1997 5. Neswick RS, Levine ME: A theoretic basis for ET nursing. Journal of Wound Ostomy Continence Nursing 24:6-9, 1997 6. Michel O, Brusis T: Hearing loss following spinal anesthesia. Regional Anaesthesia 14:92-95, 1991 7. Conde M, Villanueva A, Sanchez P, et al: Sordera secundaria a la puncion lumbar. Revista De Neurologia 25:12181220, 1997 8. Dreyer M, Migdal H: Transient medium and deep tone hearing disorders following spinal anesthesia. Regional Anaesthesia 13:138-141, 1990 9. Walsted A: Effects of cerebrospinal fluid loss on the auditory system. Danish Medical Bulletin 45:268-281, 1998 10. Stoeckli SJ, Bohmer A: Persistent bilateral hearing loss after shunt placement for hydrocephalus. J Neurosurg 90:773775, 1999 11. Grant MG, Weiss KS, Novak MA, et al: Transient hearing loss with Metrizamide. Laryngoscope 95:67-69, 1985 12. Tonndorf J: Introduction to acoustics, in Glorig A (ed): Audiometry: Principles and Practices. Baltimore, MD, Williams & Wilkins, 1965, p 15 13. Luckmann J: Caring for people with ear, nose, throat, head and neck disorders, in Luckmann J (ed): Saunders Manual of Nursing Care. Philadelphia, PA, Saunders, 1997, pp 795-866 14. Ness JA, Stankiewicz JA, Kaniff T, et al: Sensorineural hearing loss associated with aortocoronary bypass surgery: A prospective analysis. Laryngoscope 103:589-593, 1993 15. Plasse HM, Mittleman M, Frost JO: Unilateral hearing loss after open heart surgery: A detailed study of seven cases. Laryngoscope 91:101-109, 1981 16. Evan KE, Tavill MA, Goldberg AN, et al: Sudden sensorineural hearing loss after general anesthesia for nonotological surgery. Laryngoscope 107:747-752, 1997 17. Hochermann M, Reimer A: Hearing loss after general anesthesia: A case report and review of literature. J Laryngol Otol 101:1079-1082, 1987 18. Journeaux SF, Master B, Greenhalgh RM, et al: Sudden sensorineural hearing loss as a complication of non-otologic surgery. J Laryngol Otol 104:711-712, 1990
19. Segal S, Man A, Winerman I: Labyrinthine membrane rupture caused by elevated intratympanic pressure during general anesthesia. Am J Otol 5:308-310, 1984 20. Velazquez FA: Hearing loss after general anesthesia for cecectomy and small bowel resection. J Am Assoc Nurse Anesth 60:553-555, 1992 21. Patterson ME, Bartlett PC: Hearing impairment caused by intratympanic pressure changes during general anesthesia. Laryngoscope 86:399-404, 1976 22. Gultekin S, Yilmaz N, Ceyhan A, et al: The effect of different anaesthetic agents in hearing loss following spinal anaesthesia. Eur J Anaesthesiol 15:61-63, 1998 23. Oncel S, Hasegeli L, Zafer Uguz M, et al: The effects of epidural anesthesia and size of spinal needle on post-operative hearing loss. J Laryngol Otol 106:783-787, 1992 24. Vandam L: Spinal anesthetic complications revisited. Current Review PACN 15:61-68, 1993 25. Hussain SS, Heard CM, Bembridge JL: Hearing loss following spinal anesthesia with bupivacaine. Clin Otolaryngol 21:449-454, 1996 26. Flaaten H, Krakenes J, Vedeler C: Post-dural related complications after diagnostic lumbar puncture, myelography and spinal anesthesia 98:445-451, 1998 27. Fog J, Wang LP, Sundberg A, et al: Hearing loss after spinal anesthesia is related to needle size. Anesth Analg 70:517522, 1990 28. Broome IJ: Anaesthesia: Hearing loss and dural puncture. The Lancet 34:667-668, 1993 29. Michel O, Brusis T: Hearing loss as a sequel of lumbar puncture. Ann Otol Rhinol Laryngol 101:390-394, 1992 30. Arnvig JC: Transitory decrease of hearing after lumbar puncture. Acta Oto-Laryng 56:699-705, 1963 31. Brownson RJ, Zollingen WK, Maden T: Sudden sensorineural hearing loss following manipulation of the cervical spine. Laryngoscope 96:166-170, 1986 32. Thurmond M, Amedee RG: Sudden sensorineural hearing loss: Etiologies and treatments. Journal of Louisiana State Medical Society 150:200-203, 1998 33. Shikowitz MJ: Sudden sensorineural hearing loss. Med Clin North Am 75:1239-1250, 1991 34. Sundberg A, Wang LP, Fog J: Forum: Influence on hearing of 22 G Whitacre and 22 G Quincke needles. Anaesthesia 47:981-983, 1992 35. Duffy BL: Don’t turn the needle! Anaesth Intensive Care 21:328-330, 1993 36. Walsted A, Salomon G, Olsen KS: Low-frequency hearing
SUSAN M. IRVIN
98
loss after spinal anesthesia. Perilymphatic hypotonia? Scand Audiol 20:211-215, 1991 37. Wang LP, Magnusson M, Lundberg A, et al: Auditory function after spinal anesthesia. Regional Anesthesia 18:162165, 1993 38. Miller RD: Spinal anesthesia: Technique, in Miller RD (ed): Anesthesia, Vol 2 (ed 4). New York, NY, Churchill Livingstone, 1992, pp 1512-1522 39. Wagle WA: Neuroradiology, in Joynt RJ, Griggs RC (eds): Clinical Neurology vol 1. Philadelphia, PA, Lippincott-Raven, 1996, pp 200-230 (chap 2) 40. Hickey JV: Diagnostic evaluation, in Hichey JV (ed): The Clinical Practice of Neurological and Neurosurgical Nursing (ed 3). Philadelphia, PA, Lippincott, 1992, pp 95-101 41. Brown DL: Spinal, epidural, and caudal anesthesia, in Miller RD (ed): Anesthesia (ed 5). Philadelphia, PA, ChurchillLivingstone, 2000, pp 685-707 42. Kalbach LR: Spinal headache: Cause and cure. Orthopedic Nursing 8:51-55, 1989 43. Panning B, Lehnhardt E: Letters to the editor. Laryngoscope 96:1303, 1986 44. Gulya AJ: Sensorineural hearing lossess of adulthood, in Cummings CW (ed): Otolaryngology—Head and Neck Surgery (ed 2). St Louis, MO, Mosby, 1996, pp 200-230 45. Jarvis C: Physical Examination and Health Assessment (ed 3). Philadelphia, PA, Saunders, 2000, p 347
46. Lee KJ: Anatomy of the ear, in Lee KJ (ed): Essential Otolaryngology: Head & Neck Surgery (ed 3). New York, NY, Medical Examination Publishing Co, 1983, pp 31-62 47. Walsted A, Nielsen OM, Borum P: Hearing loss after neurosurgery. The influence of low cerebrospinal fluid pressure. J Laryngol Otol 108:637-641, 1994 48. England MA, Wakely J: Functional systems of the central nervous system: Sensory and motor pathways, in England MA, Wakely J (eds): Color atlas of the brain and spinal cord. St Louis, MO, 1991, pp 211-217 49. Walsted A, Nilsson P, Gerlif J: Cerebrospinal fluid loss and threshold changes. Audio Neuro Oto 1:247-255, 1996 50. Kang SB, Rudrud L, Nelson W, et al: Postanesthesia nursing care for ambulatory surgery patients post-spinal anesthesia. JOPAN 9:101-106, 1994 51. Walsted A, Garbarsch C, Michaels L: Effects of craniotomy and cerebrospinal fluid loss on the inner ear. Acta Otolaryngol 114:626-631, 1994 52. Walsted A, Salomon G, Thomsen J, et al: Hearing decrease after loss of cerebrospinal fluid. A new hydrops model? Acta Otolargngol 111:468-476, 1991 53. Wang LP, Schmidt JF: Central nervous side effects after lumbar puncture. Danish Medical Bulletin 44:79-81, 1997 54. Lybecker H, Andersen T, Helbo-Hansen HS: The effect of epidural blood patch. J Clin Anesth 7:457-464, 1995
Sensorineural Hearing Loss After Select Problems Posttest 1.2 Contact Hours Directions: The multiple-choice examination below is designed to test your understanding of hearing loss after dural puncture procedures according to the objectives listed. To earn contact hours from the American Society of PeriAnesthesia Nurses (ASPAN) Continuing Education Provider Program: (1) read the article; (2) complete the posttest by indicating the answers on the test grid provided; (3) tear out the page (or photocopy) and submit postmarked before April 30, 2004, with check payable to ASPAN (ASPAN member, $12.00 per test; nonmember, $15.00 per test); and (4) return to ASPAN, 10 Melrose Ave, Suite 110, Cherry Hill, NJ 08003-3696. Notification of contact hours awarded will be sent to you in 4 to 6 weeks.
Posttest Questions 1. Hearing loss can a. be frightening. b. seriously affect one’s life. c. jeopardize one’s safety and/or livelihood. d. all of the above. 2. Hearing impaired individuals a. report difficulty comprehending speech. b. are poor employment risks. c. complain of lack of understanding by others. d. both a and c. 3. Certain research shows that dural puncture procedures may result in hearing loss. a. True b. False
SENSORINEURAL HEARING LOSS
99
4. Dural puncture procedures are performed during a. spinal/epidural anesthesia. b. diagnostic myelogram. c. lumbar puncture. d. all of the above. 5. Hearing loss after dural puncture procedures a. affects only the left ear. b. is always permanent. c. usually affects the lower hearing frequencies. 6. A patient history of Meniere’s disease should alert providers/nursing staff to a potential hearing loss during/after dural puncture procedures. a. True b. False 7. Hearing is a sensory ability, critical for normal speech development and communication. a. True b. False 8. A sensorineural hearing loss (SNHL) results from problems with a. inner ear structures. b. middle ear structures. c. external ears. 9. The most well-known surgical procedure associated with hearing loss is cardiac surgery. a. True b. False 10. Hearing loss after using general anesthesia for noncardiac, nonotologic surgical procedures occurs in a. 0.02% of the cases. b. 10% of the cases. c. never. 11. Spinal anesthesia is associated with hearing loss more often than general anesthesia, for noncardiac, nonotologic surgical procedures. a. True b. False 12. Diagnostic dural puncture procedures include myelogram and lumbar puncture. a. True b. False 13. Myelogram procedures may involve the a. cervical spinal area. b. thoracic spinal area. c. lumbar spinal area. d. all of the above.
100
SUSAN M. IRVIN
14. Studies suggest that hearing loss after dural puncture procedures occurs because of a. leaking cerebrospinal fluid (CSF). b. patient position. c. spinal needle insertion direction, size, and shape. d. all of the above. 15. Although the exact mechanism of hearing loss after dural puncture procedure is not known, the most accepted theory is a. Newton’s theory of gravity. b. endolymphatic hydrops (ELH). c. fluid overload. 16. General hearing loss may involve a. sensorineural hearing loss. b. conductive loss. c. a combination of both SNHL and conductive. d. all of the above. 17. Hearing loss may occur as a result of a. aging. b. otosclerosis. c. infectious disease. d. autoimmune disease. e. drugs. f. noise. g. Meniere’s disease. h. all of the above. 18. Surgical procedures can correct sensorineural hearing loss (SNHL). a. True b. False 19. More traditional treatment strategies for hearing loss after dural punctures vary and can include a. vasodilators. b. intravenous fluids. c. steroids. d. analgesics. e. epidural blood patch. f. all of the above. 20. Nursing staff may be instrumental in identifying and intervening when postprocedure complications occur. Such complications include a. hearing loss. b. headache. c. visual disturbances. d. vertigo. e. all of the above.
SENSORINEURAL HEARING LOSS
101
Sensorineural Hearing Loss After Select Procedures Susan M. Irvin, MSN, RN, CS, CAPA
Hearing is one of the most significant senses; therefore, any loss can be frightening. Previous studies have found that certain surgical and medical procedures can result in hearing loss. Cardiac surgical procedures are most commonly associated with hearing loss owing to the use of the cardiopulmonary bypass pump. Other noncardiac, nonotologic surgical procedures also may result in hearing loss. Additionally, medical procedures such as myelogram and lumbar puncture have been associated with hearing loss. Studies suggest that hearing loss can result any time cerebrospinal fluid is leaked. This report highlights the effect of dural puncture on hearing loss. The implication that any dural puncture procedure may result in a cerebrospinal fluid leak and subsequent hearing loss is a significant clinical topic. Perianesthesia nurses are advised to educate themselves and their patients regarding this complication. © 2002 by American Society of PeriAnesthesia Nurses.
Objectives—Based on the content of this article, the reader should be able to (1) describe the concept of hearing loss; (2) identify medical/surgical procedures that may result in a hearing loss; and (3) identify symptoms of a postdural puncture complication. HEARING IS ONE OF the most significant human senses. Loss of the ability to hear can be frightening, seriously affect one’s life, jeopardize safety and livelihood, and diminish self-esteem. More than 40 million Americans suffer from hearing loss.1 Problems reported by hearing-impaired individuals include hearing words but not comprehending speech and lack of understanding by others.1 Hearing impairment is the leading disability in this country.2 Not only is effective communication impaired,1 but personal, structural, and social integrity is also threatened.3-5 Changes in health care delivery methods during the last 2 decades have stimulated the increasJournal of PeriAnesthesia Nursing, Vol 17, No 2 (April), 2002: pp 89-101
ing shift from inpatient to outpatient medical and surgical procedures. These changes have resulted in shorter lengths of patient stay and a more compressed time frame for preprocedure workup and patient education. Complete medical history, physical examination, and comprehensive patient education remains the gold stanSusan M. Irvin, MSN, RN, CS, CAPA, is the Clinical Coordinator of the Ambulatory Surgery Unit at the Veterans Affairs Medical Center, Memphis, TN. Address correspondence to Susan M. Irvin, MSN, RN, CS, CAPA, Nursing Service (118), 1030 Jefferson Ave, Memphis, TN 38104. © 2002 by American Society of PeriAnesthesia Nurses. 1089-9472/02/1702-0006$35.00/0 doi:10.1053/jpan.2002.31683 89
90
dard for successful outcomes for short-stay patients. Because nursing is concerned with patient advocacy, protection, energy preservation, stability, balance, and harmony, appropriate nursing assessment and intervention is critical in assisting the patient to adapt or to make informed choices about their care.4,5 Previous findings6-11 show that certain surgical and medical procedures may result in hearing loss of varying degrees. The implication that any dural puncture procedure may result in a cerebrospinal fluid leak and subsequent hearing loss is a significant clinical topic. This hearing loss can involve one or both ears,6 usually affects the lower hearing tones,7,8 and usually is temporary,9 although permanent loss has been reported.10 Past or current history of inner ear disturbances, hearing loss, vertigo, ataxia, tinnitus, diagnosis of Meniere’s disease, or previous ear surgical procedures should alert providers or nursing staff of potential hearing loss after dural puncture procedures.7,11 This report identifies 3 main concepts: dural puncture, hearing, and sensorineural hearing loss (SNHL). Dural puncture and how it potentially relates to hearing loss are discussed.
Background Hearing is a sensory ability that is critical for normal speech development and communication.2 Hearing results from sounds being collected and directed to the brain, resulting in cortical awareness and interpretation.2,12 Hearing loss is a well-known phenomenon. SNHL is an inability or decreased ability to hear caused by problems with the inner ear structure. This may be caused by a disorder, dysfunction, or destruction of the auditory nerve, nerve pathway, cochlea, hair cells, basilar membrane, organ of Corti, labyrinths, or semicircular canals.2,13 Little consistent information exists about hearing loss after medical or surgical procedures. There is, however, some information documented about individuals who experience hear-
SUSAN M. IRVIN
ing loss after cardiac surgical procedures,14,15 general anesthesia,16-21 spinal anesthesia,6,22-28 myelogram procedures,26,28 lumbar puncture,7,26,29,30 and spinal manipulation.31 The use of the cardiopulmonary bypass pump revolutionized cardiac surgery; however, the machine’s high association with microemboli16 can result in intraoperative and postoperative complications, including SNHL.14,15 When cardiopulmonary bypass is used during cardiac surgery, hearing loss may occur in 1 of 1,000 surgical procedures.16,20 SNHL after general anesthesia for noncardiac, nonotologic surgical procedures occurs significantly less often, with a reported rate of 0.02%.20 By 1997, only 18 cases of SNHL had been documented after noncardiac, nonotologic surgical procedures.16 Possible causes of hearing loss after general anesthesia include theories of perilymphatic fistula formation,16 breach in cochlear membrane,16 increased intratympanic pressure changes,21 labyrinthine membrane rupture,19 cochlear ischemia,32 cochlear anoxia,33 and implosive or explosive forces related to the administration of nitrous oxide.16-18,20 SNHL after spinal anesthesia occurs at a rate of 0.4%, a rate higher than that associated with the hearing loss related to cardiac surgery.16,20 Reasons often theorized include leaks in cerebrospinal fluid caused by spinal needle size,6,23,24,27,28,34 shape,28,34 needle direction,35 specific drugs used,22,25 the development of endolymphatic hydrops,22,23,28,36 and plasma hypo-osmolarity.37 Diagnostic dural puncture procedures such as myelograms26,28 and lumbar punctures (LP)7,26,29,30 also are associated with hearing loss. Dural puncture, in which a needle is inserted into the subarachnoid area and cerebrospinal fluid (CSF) is aspirated, is a common procedure performed in myelogram, LP, and spinal anesthesia.26,38,39 The dural puncture site for a myelogram may be the cervical, thoracic, or
SENSORINEURAL HEARING LOSS
91
Fig 1.
Endolymphatic Hydrops Theory.
lumbar area of the spinal cord. Myelography includes the withdrawal of CSF and the injection of contrast dye to better visualize areas for vertebral disk or spinal abnormalities.40 Findings suggest that hearing loss occurs as a result of leaking cerebrospinal fluid.6,8,9,22,28 Patient position,41 number of dural punctures,42 amount of CSF lost,9,29 needle insertion direction,41 needle size,6,23,24,26-28,34 and needle shape28,34 are associated factors. Although hearing loss associated with certain medical and surgical procedures was first reported in 1914,43 inconsistent information exists, and the topics are not addressed in educational material or clinical care management resources.29 Most information is clinical and anecdotal, and the topic has yet to be studied systematically. Scientists still disagree on the exact mechanism of hearing loss after selected surgical and medical procedures; however, the theory of en-
dolymphatic hydrops (ELH) is the most accepted in current literature.8,22,28,36 Figure 1 shows a physiologic model of ELH. This theory indicates that a puncture in the subarachnoid space causes a leak of CSF, resulting in a decrease of CSF pressure.28,43 This pressure drop is transmitted via the cochlear aqueduct to the perilymph,29 resulting in perilympathic hypotonia22 or decreased pressure.29 This reaction leads to an excess accumulation of fluid or ELH, producing symptoms similar to Meniere’s disease.36 Meniere’s is a disease of unknown etiology, but the characteristics include fluctuating SNHL, tinnitus, and vertigo.44
Anatomic Overview Hearing is the result of collected sounds being directed by the outer ears, through the ear canals, to eardrums. Figure 2 shows the 3 areas of the ear: the outer ear, middle ear, and inner ear.45 The outer ears are collection devices that direct sound inward. The outer ears have 2
SUSAN M. IRVIN
92
Fig 2.
Anatomic overview of the ear. Reprinted with permission.45
basic parts, the auricle (pinna) and the external canal. A membrane stretches over the canal. This tympanic membrane, also called the eardrum, separates the external and the middle ear.1,2 The middle ear cavity contains 3 tiny bones (incus, malleus, and stapes), the oval window, round window, and the eustachian tube.1 The inner ear (labyrinth) contains the hearing sense organs, balance control mechanisms, and 2 cranial nerves (VII and VIII). The primary structures within this system are the membranous labyrinth and the protective bony labyrinth.2 The bony labyrinth consists of the cochlea and semicircular canals. The cochlea is further divided into upper (scala vestibuli) and lower (scala tympani) labyrinths. The bony and membranous labyrinths are filled with fluid,
perilymph, and endolymph, respectively.2 Four connections exist between the inner ear and temporal bone. These include the internal auditory canal, the vestibular aqueduct, the cochlear aqueduct, and the subarcuate fossa.46 The perilymph maintains communication with CSF by way of the cochlear aqueduct.2 The primary function of the cochlear aqueduct is poorly understood. It resembles a bony channel and serves as a connecting mechanism linking the perilymphatic compartment to the subarachnoid space, where fluid exchange occurs between these 2 structures.10,46 The cochlea contains the sense mechanism for hearing, the organ of Corti. This hard-walled end organ, attached to the basilar membrane, is bathed in endolymph and contains thousands of hairlike cells.1,2,47
SENSORINEURAL HEARING LOSS
Physiology of Hearing The method for hearing is extraordinary. To better understand how this sensory phenomenon occurs, basic terms will be described. Sound occurs because energy is moved as a series of vibrations or sound waves. These sound waves can travel 1,100 feet per second; however, the speed is dependent on environmental conditions. For example, air is a more favorable medium for sound conduction than water. Distance also influences sound wave travel.1 The external ears collect sound waves and direct them through the canal toward the eardrum. This pressure ultimately causes movement of the eardrum.1 As sound reaches the middle ear, the tympanic eardrum vibrates. This action stimulates the ossicles in the middle ear to vibrate, resulting in stapes vibration against the oval window. This stimulates perilymph fluid to vibrate, causing a simultaneous endolymphatic fluid vibration within the cochlear aqueduct and vibration of the basilar membrane. Sound vibrations, thus, reach the organ of Corti, which transforms and separates them. Sounds then are transformed as electrochemical impulses to the temporal cortex, traveling by way of the acoustic nerve (VIII) for final interpretation. When these impulses arrive and are interpreted, hearing occurs.1
Hearing Loss Hearing loss can be caused by both known and unknown factors. Some commonly known causes include aging, otosclerosis, infectious diseases, autoimmune diseases, ototoxic drugs, noise-induced losses, and Meniere’s disease.1 Different types of hearing loss include SNHL, conductive loss, or a mix of both; functional loss; and central dysacusis. To accurately diagnose hearing loss, it must be determined what part of the auditory system has been affected: for example, inner ear versus middle ear involvement.1
93
SNHL is caused by inner ear damage of cochlear hair cells or dysfunction or destruction of the auditory nerve.1,48 SNHL, the leading disorder of inner ears, is a challenging problem for health care professionals, because it cannot be cured, and the prognosis for hearing restoration is poor.1,2 It is common to speak of SNHL as nerve deafness; however, both sensory and neural components should be separately considered for accuracy of diagnosis. Sensory loss is applicable when damage occurs to the inner ear or cochlea. The term neural loss is more accurate when describing actual auditory nerve damage. Hearing loss that is classified as both sensory and neural or cases in which damage is not identifiable are considered SNHL owing to basic and similar characteristics.1 Conductive hearing loss results from an impediment of the conduction of sounds through the outer or middle ear. Interference at any point along this anatomic path, external canal, eardrum, ear bones, eustachian tube, or oval/round windows can result in hearing loss. No neural or sensory damage is found, and these types of hearing losses usually can be corrected.1,48 A mixed hearing loss is diagnosed when an individual suffers from both conductive and SNHL in the same ear.1 Functional loss involves an emotional aspect, whereas central loss, or dysacusis, is not mechanical but rather within the central nervous system.1 Affected patients simply are not able to interpret what is heard.1
Hearing Loss Related to Drugs, Disease, and Noise Some 200 ototoxic drugs are known to damage hearing. Certain drugs, when used over time, are associated with irreversible SNHL, damage to inner ear hair cells, and renal damage. Some commonly used antibiotics that may cause hearing loss include all “mycin” drugs.1,2 A miscellaneous category of ototoxic agents includes alcohol, lead, arsenic, mercury, barbiturates, salicylates, certain diuretics, and some alkaloids.1
SUSAN M. IRVIN
94
Some infectious diseases that cause SNHL include measles, mumps, or meningitis.2 Labyrinthitis, both viral or bacterial, can lead to SNHL.1,2 SNHL also can be related to noise. Exposure to prolonged periods of intense noise can result in hearing loss, initially in the higher frequencies, that then advances to the lower, speech recognition frequencies. At the start, the outer hair cells are damaged. As prolonged noise continues, the inner and supporting cells also become affected. The diagnosis is irreversible SNHL with a poor prognosis.1
and certain other neurosurgical procedures. Stoeckli and Bohmer10 challenged the concept that hearing loss after these interventions always is transient, by attributing the possible cause and continuation of one patient’s hearing loss caused by the CA. The poorly understood CA is implicated because of its role or position between the perilymphatic compartment and subarachnoid space during fluid exchange. Loss of CSF, the subsequent fluid exchange, resulting ELH, and hearing loss are physiologic mechanisms yet to be proven.10
Meniere’s disease traditionally is associated with hearing loss, usually caused by tinnitus. Other accompanying symptoms include vertigo and nausea. Tinnitus is defined as noise or ringing sounds and may be caused by irritating neural discharges. At least 32% of all Americans have experienced tinnitus to some degree.1 Meniere’s disease is characterized by tinnitus accompanied by ELH.1 This term was first described in 1926 as increased volume of endolymph, with subsequent distension of surrounding membranes.49
A number of contributing factors relative to dural puncture have been the focus of many researchers. Some research has reported that hearing loss after dural puncture is associated with the anesthetic injected during spinal anesthesia (bupivacaine)25 or the drug injected during myelogram (metrizamide),11 rather than the actual dural procedure itself. The size and type of needle used for dural puncture also often are implicated in hearing loss. Researchers agree that smaller gauge needles, such as 25 gauge or 26 gauge, are more likely to reduce CSF leak. Tapered needles versus cutting needles also can be less traumatic.8,23,27,28,34,35,50 Patient position also is critical for minimal postoperative complications because the spine should be maximally flexed during the procedure.24,41 Other factors implicated in the etiology of ELH are the number of times the dura is punctured and the amount of CSF removed.6,9,29,41
Hearing Loss Related to Dural Puncture Any dural puncture can result in a physiologic cascade leading to a hearing loss (Fig 1). This cascade occurs because of a disturbance in the balance of fluid pressures in the neurologic system. Dural puncture procedures can lead to a decrease in CSF that is transmitted to the inner ear by way of the cochlear aqueduct (CA). This results in an excess accumulation of fluid in the perilymph, creating an ELH, affecting lower frequency hearing47 similar to the hearing loss associated with Meniere’s disease.27 Any dural puncture procedure or opening of the dura can result in a loss of CSF. This CSF loss can result in a hearing deficit. What procedures cause a CSF loss, and the degree and duration of this hearing loss, remain the focus of many scientists. A transient hearing loss can occur as a result of lumbar puncture, myelogram, spinal anesthesia,
Hearing Loss Related to Neurosurgery Hearing loss also can occur after certain neurosurgical procedures. The CA is the link between the perilymph and the CSF. Transient hearing loss has been shown after craniotomy procedures. Possible causes include loss of CSF,47 histologic changes in the cochlea,51 and cochlear fluid shifts.52
Treatment Options Broome28 reported that despite studies linking dural puncture procedures and hearing loss, it
SENSORINEURAL HEARING LOSS
was not a commonly reported complication nor regarded as clinically significant. There were also conflicting data as to whether this phenomenon was temporary or permanent or if treatment was needed to promote hearing restoration. Because other symptoms such as severe headache, vomiting, tinnitus, or dizziness may overshadow hearing loss, treatment may be delayed or secondary. Although there are treatment options available, prevention should be emphasized. Treatment for hearing loss after dural puncture varies. The foremost concept, however, is to prevent excess CSF leak. If hearing does not return eventually, various strategies and agents are suggested for treatment. These interventions include vasodilators,20,33 anticoagulants,20,32,33 volume expanders,20,33 steroids,32,33 intravenous contrast agents,32,33 use of oxygen mixed with air in place of nitrous oxide,18 diuretics,33 antiviral agents,32 analgesics,26,42 intravenous fluids,29,42 bed rest,30,53 a quiet environment,42 carbon dioxide and oxygen combinations,20 and the epidural blood patch.2,16,28,30,32,33,42,54 The more CSF leaked, the more likely complications will occur. Proper technique using the smallest possible tapered needle, such as a 26 gauge, may prevent excessive dural leakage. If symptoms of dural headache, hearing loss, nausea, vomiting, or tinnitus occur after dural puncture procedure, an epidural blood patch (EBP) may be used to alleviate some or all of these complaints. Lybecker et al54 reported on the effects of using a blood patch to restore hearing. They concluded that leaking CSF caused decreased CSF pressure, which is communicated by the cochlear aqueduct to the inner ear, resulting in vestibulocochlear dysfunction. They identified that debilitating postoperative headaches often accompany hearing loss. Further, treatment for postdural puncture headache (PDPH) usually was the EBP. The investigators suggested that
95
use of the EBP might restore the hearing loss that occurs because of dural puncture procedure. Their study involved 16 patients suffering from PDPH. Preprocedure otoscopic examinations were conducted. Subjective data regarding cochlear and vestibular complaints were documented. Sitting and supine audiograms were conducted 15 minutes before the EBP procedure and again one hour postprocedure. Hearing thresholds before and after the procedure were compared for each patient in all frequencies. Threshold change was defined as 10 dB in 2 or more frequencies or 5 dB in 4 or more. All patients experienced headache relief by one hour. All other associated symptoms disappeared by 2 hours. Seven of the 16 subjects experienced improved hearing just by lying down. After the EBP, 12 of 16 reported improved hearing. Investigators suggest that the hearing loss that occurs after dural puncture procedure may be related to posture. Further, EBP could restore hearing loss within one hour. The investigators advised practitioners to prevent excessive CSF leaks and to restore CSF volume promptly.
Nursing Implications Comprehensive and consistent information on the topic of hearing loss and dural puncture is lacking. Identifying which specific patients lose hearing, for how long, to what degree, and in which frequency, are grounds for meaningful nursing research. Any association found between dural puncture procedures and hearing loss can have extensive implications, particularly on patient education, prompt intervention, and informed consent. Appropriate assessment and intervention are critical to a positive patient outcome. Assessment Before Procedure
A thorough nursing assessment should be completed on any perianesthesia patient scheduled for dural puncture procedures such as spinal anesthesia, lumbar puncture, or myelogram. Questions regarding current hearing, past otologic surgical procedures, and past medical con-
SUSAN M. IRVIN
96
ditions may be assessed quickly and incorporated into the nursing assessment record. Patients with a history of Meniere’s disease or patients who are already hearing impaired may be at a higher risk for postprocedure complications.7 Signs and Symptoms
Nurses can identify easily individuals who are hearing impaired. Signs of hearing loss in patients include irritability, anger, inattention, lip reading, turning their head to one side, complaints that people do not speak clearly or loudly enough, social isolation, friction within relationships, answering questions with the wrong information, noncompliance, and consequent embarrassment.1,2 Time Frames of Problem Occurrence
Researchers disagree on the specific time that this procedure-related hearing loss may occur. Hearing loss and other associated dural puncture complications such as severe headache, tinnitus, vertigo, visual disturbances, and nausea have been reported after dural puncture procedures. These symptoms may occur immediately,29 a few hours later,30 the following day,11 or between 24 to 48 hours after.7,8,36 Appropriate Nursing Care
Patients undergoing dural puncture procedures must be flexed and positioned properly for optimal needle insertion technique. Less than optimal technique includes multiple punctures,42 excessive loss of CSF,28 and tearing of dural fibers with larger sized cutting needles.35,50 Postoperative nursing assessment after any dural puncture procedure includes monitoring the patient for complications such as pain, headache, pain at needle insertion site, lower limb immobility, postoperative/postprocedure urinary retention, nausea, and any complaints of visual or hearing disturbances. Interventions for any of these problems should be initiated promptly and evaluated for success before patient discharge.
Patient and Family Teaching
Education for patients and family should include comprehensive instructions before and after any dural puncture procedure. Patients must be educated on their responsibility to comply with dietary restrictions, positioning requirements, and postoperative orders such as bed rest or lying flat or upright for several hours. It is critical that patients understand the need for asking nursing staff for assistance rather than attempting any activity without nursing intervention. Patient and family education also should address possible signs, symptoms, and interventions if hearing loss or other complications resulting from dural puncture occur. The family also must show an understanding and acceptance of caring for patients after dural puncture procedures before the patient is discharged. Nursing Follow-up
Nursing assessment after same-day procedures involving spinal anesthesia, lumbar puncture, or myelogram is a standard practice. Follow-up telephone calls represent the communication link that patients and family members have with health care professionals after discharge. Any postoperative/postprocedure problems such as headache, hearing loss, visual disturbances, pain, nausea, or incontinence can be discussed and appropriate measures taken for continued assessment and follow-up with the practitioner.
Conclusion Controversy exists regarding what can occur after dural puncture. Most scientists do agree that dural puncture procedures can lead to CSF loss and, potentially, some degree of hearing loss. However, researchers do not agree on the exact mechanism of cause, duration of symptoms, degree of severity, length of complications, or treatment strategies. Pressures of the CSF and the perilymphatic space are the same. When a decrease occurs in CSF pressure, a decrease in perilymph pressure
SENSORINEURAL HEARING LOSS
97
results.9 The cochlear aqueduct likely is the connecting mechanism. Perilymphatic hypotonia initiates endolymphatic hypertension and results in endolymphatic hydrops. Hearing thereby is affected as these fluid shifts occur, and lower frequency hearing loss can result. Whether this loss occurs immediately after a dural puncture procedure, 48 hours later, or a week later, remains a topic for study. Restoration of hearing with or without treatment also
needs further examination. Needle characteristics, amount of CSF lost, and multiple punctures also are factors for consideration in any further study of this topic. The potential volume of dural puncture procedures performed throughout this country makes this issue clinically relevant. There is a need to further study this topic and to caution practitioners to educate perianesthesia patients and nursing staff about this complication.
References 1. Sataloff RT, Sataloff J: Hearing Loss (ed 3). New York, NY, Marcel Dekker, Inc, 1993 2. Sigler BA, Schuring LT: Ear, Nose, and Throat Disorders. St Louis, MO, Mosby, 1993 3. Levine ME: Introduction to clinical nursing (ed 2). Philadelphia, PA, Davis, 1973, pp 1-19 4. Meleis AI: Theoretical nursing: Development & progress (ed 3). Philadelphia, PA, Lippincott, 1997 5. Neswick RS, Levine ME: A theoretic basis for ET nursing. Journal of Wound Ostomy Continence Nursing 24:6-9, 1997 6. Michel O, Brusis T: Hearing loss following spinal anesthesia. Regional Anaesthesia 14:92-95, 1991 7. Conde M, Villanueva A, Sanchez P, et al: Sordera secundaria a la puncion lumbar. Revista De Neurologia 25:12181220, 1997 8. Dreyer M, Migdal H: Transient medium and deep tone hearing disorders following spinal anesthesia. Regional Anaesthesia 13:138-141, 1990 9. Walsted A: Effects of cerebrospinal fluid loss on the auditory system. Danish Medical Bulletin 45:268-281, 1998 10. Stoeckli SJ, Bohmer A: Persistent bilateral hearing loss after shunt placement for hydrocephalus. J Neurosurg 90:773775, 1999 11. Grant MG, Weiss KS, Novak MA, et al: Transient hearing loss with Metrizamide. Laryngoscope 95:67-69, 1985 12. Tonndorf J: Introduction to acoustics, in Glorig A (ed): Audiometry: Principles and Practices. Baltimore, MD, Williams & Wilkins, 1965, p 15 13. Luckmann J: Caring for people with ear, nose, throat, head and neck disorders, in Luckmann J (ed): Saunders Manual of Nursing Care. Philadelphia, PA, Saunders, 1997, pp 795-866 14. Ness JA, Stankiewicz JA, Kaniff T, et al: Sensorineural hearing loss associated with aortocoronary bypass surgery: A prospective analysis. Laryngoscope 103:589-593, 1993 15. Plasse HM, Mittleman M, Frost JO: Unilateral hearing loss after open heart surgery: A detailed study of seven cases. Laryngoscope 91:101-109, 1981 16. Evan KE, Tavill MA, Goldberg AN, et al: Sudden sensorineural hearing loss after general anesthesia for nonotological surgery. Laryngoscope 107:747-752, 1997 17. Hochermann M, Reimer A: Hearing loss after general anesthesia: A case report and review of literature. J Laryngol Otol 101:1079-1082, 1987 18. Journeaux SF, Master B, Greenhalgh RM, et al: Sudden sensorineural hearing loss as a complication of non-otologic surgery. J Laryngol Otol 104:711-712, 1990
19. Segal S, Man A, Winerman I: Labyrinthine membrane rupture caused by elevated intratympanic pressure during general anesthesia. Am J Otol 5:308-310, 1984 20. Velazquez FA: Hearing loss after general anesthesia for cecectomy and small bowel resection. J Am Assoc Nurse Anesth 60:553-555, 1992 21. Patterson ME, Bartlett PC: Hearing impairment caused by intratympanic pressure changes during general anesthesia. Laryngoscope 86:399-404, 1976 22. Gultekin S, Yilmaz N, Ceyhan A, et al: The effect of different anaesthetic agents in hearing loss following spinal anaesthesia. Eur J Anaesthesiol 15:61-63, 1998 23. Oncel S, Hasegeli L, Zafer Uguz M, et al: The effects of epidural anesthesia and size of spinal needle on post-operative hearing loss. J Laryngol Otol 106:783-787, 1992 24. Vandam L: Spinal anesthetic complications revisited. Current Review PACN 15:61-68, 1993 25. Hussain SS, Heard CM, Bembridge JL: Hearing loss following spinal anesthesia with bupivacaine. Clin Otolaryngol 21:449-454, 1996 26. Flaaten H, Krakenes J, Vedeler C: Post-dural related complications after diagnostic lumbar puncture, myelography and spinal anesthesia 98:445-451, 1998 27. Fog J, Wang LP, Sundberg A, et al: Hearing loss after spinal anesthesia is related to needle size. Anesth Analg 70:517522, 1990 28. Broome IJ: Anaesthesia: Hearing loss and dural puncture. The Lancet 34:667-668, 1993 29. Michel O, Brusis T: Hearing loss as a sequel of lumbar puncture. Ann Otol Rhinol Laryngol 101:390-394, 1992 30. Arnvig JC: Transitory decrease of hearing after lumbar puncture. Acta Oto-Laryng 56:699-705, 1963 31. Brownson RJ, Zollingen WK, Maden T: Sudden sensorineural hearing loss following manipulation of the cervical spine. Laryngoscope 96:166-170, 1986 32. Thurmond M, Amedee RG: Sudden sensorineural hearing loss: Etiologies and treatments. Journal of Louisiana State Medical Society 150:200-203, 1998 33. Shikowitz MJ: Sudden sensorineural hearing loss. Med Clin North Am 75:1239-1250, 1991 34. Sundberg A, Wang LP, Fog J: Forum: Influence on hearing of 22 G Whitacre and 22 G Quincke needles. Anaesthesia 47:981-983, 1992 35. Duffy BL: Don’t turn the needle! Anaesth Intensive Care 21:328-330, 1993 36. Walsted A, Salomon G, Olsen KS: Low-frequency hearing
SUSAN M. IRVIN
98
loss after spinal anesthesia. Perilymphatic hypotonia? Scand Audiol 20:211-215, 1991 37. Wang LP, Magnusson M, Lundberg A, et al: Auditory function after spinal anesthesia. Regional Anesthesia 18:162165, 1993 38. Miller RD: Spinal anesthesia: Technique, in Miller RD (ed): Anesthesia, Vol 2 (ed 4). New York, NY, Churchill Livingstone, 1992, pp 1512-1522 39. Wagle WA: Neuroradiology, in Joynt RJ, Griggs RC (eds): Clinical Neurology vol 1. Philadelphia, PA, Lippincott-Raven, 1996, pp 200-230 (chap 2) 40. Hickey JV: Diagnostic evaluation, in Hichey JV (ed): The Clinical Practice of Neurological and Neurosurgical Nursing (ed 3). Philadelphia, PA, Lippincott, 1992, pp 95-101 41. Brown DL: Spinal, epidural, and caudal anesthesia, in Miller RD (ed): Anesthesia (ed 5). Philadelphia, PA, ChurchillLivingstone, 2000, pp 685-707 42. Kalbach LR: Spinal headache: Cause and cure. Orthopedic Nursing 8:51-55, 1989 43. Panning B, Lehnhardt E: Letters to the editor. Laryngoscope 96:1303, 1986 44. Gulya AJ: Sensorineural hearing lossess of adulthood, in Cummings CW (ed): Otolaryngology—Head and Neck Surgery (ed 2). St Louis, MO, Mosby, 1996, pp 200-230 45. Jarvis C: Physical Examination and Health Assessment (ed 3). Philadelphia, PA, Saunders, 2000, p 347
46. Lee KJ: Anatomy of the ear, in Lee KJ (ed): Essential Otolaryngology: Head & Neck Surgery (ed 3). New York, NY, Medical Examination Publishing Co, 1983, pp 31-62 47. Walsted A, Nielsen OM, Borum P: Hearing loss after neurosurgery. The influence of low cerebrospinal fluid pressure. J Laryngol Otol 108:637-641, 1994 48. England MA, Wakely J: Functional systems of the central nervous system: Sensory and motor pathways, in England MA, Wakely J (eds): Color atlas of the brain and spinal cord. St Louis, MO, 1991, pp 211-217 49. Walsted A, Nilsson P, Gerlif J: Cerebrospinal fluid loss and threshold changes. Audio Neuro Oto 1:247-255, 1996 50. Kang SB, Rudrud L, Nelson W, et al: Postanesthesia nursing care for ambulatory surgery patients post-spinal anesthesia. JOPAN 9:101-106, 1994 51. Walsted A, Garbarsch C, Michaels L: Effects of craniotomy and cerebrospinal fluid loss on the inner ear. Acta Otolaryngol 114:626-631, 1994 52. Walsted A, Salomon G, Thomsen J, et al: Hearing decrease after loss of cerebrospinal fluid. A new hydrops model? Acta Otolargngol 111:468-476, 1991 53. Wang LP, Schmidt JF: Central nervous side effects after lumbar puncture. Danish Medical Bulletin 44:79-81, 1997 54. Lybecker H, Andersen T, Helbo-Hansen HS: The effect of epidural blood patch. J Clin Anesth 7:457-464, 1995
Sensorineural Hearing Loss After Select Problems Posttest 1.2 Contact Hours Directions: The multiple-choice examination below is designed to test your understanding of hearing loss after dural puncture procedures according to the objectives listed. To earn contact hours from the American Society of PeriAnesthesia Nurses (ASPAN) Continuing Education Provider Program: (1) read the article; (2) complete the posttest by indicating the answers on the test grid provided; (3) tear out the page (or photocopy) and submit postmarked before April 30, 2004, with check payable to ASPAN (ASPAN member, $12.00 per test; nonmember, $15.00 per test); and (4) return to ASPAN, 10 Melrose Ave, Suite 110, Cherry Hill, NJ 08003-3696. Notification of contact hours awarded will be sent to you in 4 to 6 weeks.
Posttest Questions 1. Hearing loss can a. be frightening. b. seriously affect one’s life. c. jeopardize one’s safety and/or livelihood. d. all of the above. 2. Hearing impaired individuals a. report difficulty comprehending speech. b. are poor employment risks. c. complain of lack of understanding by others. d. both a and c. 3. Certain research shows that dural puncture procedures may result in hearing loss. a. True b. False
SENSORINEURAL HEARING LOSS
99
4. Dural puncture procedures are performed during a. spinal/epidural anesthesia. b. diagnostic myelogram. c. lumbar puncture. d. all of the above. 5. Hearing loss after dural puncture procedures a. affects only the left ear. b. is always permanent. c. usually affects the lower hearing frequencies. 6. A patient history of Meniere’s disease should alert providers/nursing staff to a potential hearing loss during/after dural puncture procedures. a. True b. False 7. Hearing is a sensory ability, critical for normal speech development and communication. a. True b. False 8. A sensorineural hearing loss (SNHL) results from problems with a. inner ear structures. b. middle ear structures. c. external ears. 9. The most well-known surgical procedure associated with hearing loss is cardiac surgery. a. True b. False 10. Hearing loss after using general anesthesia for noncardiac, nonotologic surgical procedures occurs in a. 0.02% of the cases. b. 10% of the cases. c. never. 11. Spinal anesthesia is associated with hearing loss more often than general anesthesia, for noncardiac, nonotologic surgical procedures. a. True b. False 12. Diagnostic dural puncture procedures include myelogram and lumbar puncture. a. True b. False 13. Myelogram procedures may involve the a. cervical spinal area. b. thoracic spinal area. c. lumbar spinal area. d. all of the above.
100
SUSAN M. IRVIN
14. Studies suggest that hearing loss after dural puncture procedures occurs because of a. leaking cerebrospinal fluid (CSF). b. patient position. c. spinal needle insertion direction, size, and shape. d. all of the above. 15. Although the exact mechanism of hearing loss after dural puncture procedure is not known, the most accepted theory is a. Newton’s theory of gravity. b. endolymphatic hydrops (ELH). c. fluid overload. 16. General hearing loss may involve a. sensorineural hearing loss. b. conductive loss. c. a combination of both SNHL and conductive. d. all of the above. 17. Hearing loss may occur as a result of a. aging. b. otosclerosis. c. infectious disease. d. autoimmune disease. e. drugs. f. noise. g. Meniere’s disease. h. all of the above. 18. Surgical procedures can correct sensorineural hearing loss (SNHL). a. True b. False 19. More traditional treatment strategies for hearing loss after dural punctures vary and can include a. vasodilators. b. intravenous fluids. c. steroids. d. analgesics. e. epidural blood patch. f. all of the above. 20. Nursing staff may be instrumental in identifying and intervening when postprocedure complications occur. Such complications include a. hearing loss. b. headache. c. visual disturbances. d. vertigo. e. all of the above.
SENSORINEURAL HEARING LOSS
101