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What is Ototoxicity?

Certain classes of medications can affect your organ of hearing. Awareness of a potential risk of hearing loss, and knowing when and how to monitor your hearing health during your treatment regimen is essential. Listen in as Dr. Loffredo walks us through the process.




Hi, I'm Jim Cuddy and this is Ask The Hearing Doctors. And I'm joined today by Dr. Jenna Loffredo, doctor of audiology with Hearing Doctors. The Washington DC area's highest-rated audiology practice with over 1500, five-star reviews. Jenna, as always great to see you. Thank you so much for having me. I really appreciate it. Oh, absolutely. 


So we're talking today about ototoxicity. What exactly is ototoxicity?


So ototoxicity simply is medication that causes either hearing loss, ringing in the ears, or balance disorders. Basically a type of medication that affects our organ of hearing. 


What are some of those medications that you would say are most concerning? Where is this most likely to happen?


Sure. A lot of the medications that we see this happen with are the ones that help us to fight cancer. So our cisplatins, our carboplatins and a type, a class of drug called aminoglycosides or gentamicin. So a lot of times some of our patients that are receiving chemotherapy are on one of those four families or classes of drugs.


We also see this sometimes at very high levels of aspirin for an extended period of time. As well as loop diuretics which affect our kidney function.


Now obviously you're being treated, let's use cancer as an example. You're being treated for cancer. You're on a chemo regimen. You can't just stop chemotherapy. You have to have that in order to survive obviously based on the diagnosis. What's the balance there? How do you, how do you find that balance especially and you know if you don't want to lose your hearing but you also need to fight the cancer?


Absolutely. That's a great question. It's a question that a lot of professionals both in our field and in the medical field have. What do we do? We need to fight the cancer and we need to fight it at this level of medication. Ototoxicity has become a hot topic as soon as there was more and more research coming out to show that okay this type of medication does cause hearing loss. Where do the audiologists fit into that?  We're not the ones that are treating the cancer nor do we believe we should be. That's the role of the managing physician.


But something at some of these bigger hospital networks that we have is they have an audiologist on their team or their cancer team. Meaning before anyone starts treatment whether it is a pediatric or an adult patient they have what's called a baseline hearing test. Meaning we don't have any chemotherapy in our body or into our systems yet. We want to see how our hearing system is working. Do we have hearing loss that's already established? Already managed by an audiologist? Or do we have normal hearing? This is especially important for pediatrics because their doses of chemotherapy tend to be much higher than some of an adult depending on the type of cancer, of course. So a lot of times we make sure that our patients, or ones that are about to receive chemotherapy, have a baseline hearing test. And then that they're treated before every treatment that they're given. 


You bring up a great point though because we can't just stop treating the cancer. But what we're looking at from the role of an audiologist is the quality of life. Thankfully with research, with science people are surviving cancer, which is incredible and we're so grateful for that. But they're starting to notice like okay my quality of life with this hearing loss or this tinnitus. Or I can't walk straight, I'm running into walls, I'm falling over. Those things weren't happening to them before. So that's why audiologists have really taken a role in the management following the cancer treatments. 


Um, there are some times that physicians, if we are noticing a hearing loss or a change in hearing that, they'll say okay what do you recommend? And that's where the team, the team meetings and the team conferences come in to say okay can we lower the dose of chemotherapy and still be as effective treating the cancer? If we can't, then what we'll do is we'll really work on a consult with the family to talk to them about realistic expectations. That we can't change your treatment regimen. That's important to help you fight this cancer. What we do is we can help you to manage it afterwards and we always assure them that we have solutions for them.


Is the, is the auditory damage always permanent or can it sometimes come back?


That's a great question. So, for the most part once a hearing loss happens at what's called the sensory neural level, meaning it's not a hearing loss caused by build up or congestion or fluid or an ear infection, it tends to be permanent. Now sometimes if we catch it early and we're able to change those drugs or the dosage or things like that for the patient. Then sometimes we either can prevent more hearing loss from happening happening or a slight increase. It's always best to consult with the managing physician to say okay we might be dealing with something permanent. Is now the time to change it? Can we stop? Can we take a break? But we want to make sure that we're not having any setbacks in their, in their treatment.


So ototoxicity is not necessarily reversible if I'm hearing you correctly, but it can be manageable? 


Absolutely. Absolutely. We see so many patients that have fought so hard and are just they've come out on the other side. And they just really want to communicate with people. They really want to be able to see and talk with their friends and family that they haven't seen in a while. And we don't want a potential hearing loss or communication difficulty getting in their way. So the best thing to do is to have routine hearing screenings or hearing tests. 


What we do at the Hearing Doctors is we have what's called an extended high frequency testing. So for the most part a typical audiology evaluation has low tones to high tones to around 8000 Hertz. And that basically encompasses all of our speech signals. It's the most important when we're trying to hear. But we also know just as professionals that your hearing loss is affected in the high frequencies first with this type of treatment that you're given. That's the  cisplatin, carboplatin, gentamicin, all of those types of drugs. They affect the high frequencies of hearing. So we do an ultra-high frequency testing, meaning we're able to identify if we're seeing hearing loss in those higher levels that might not be caught on the average or typical audiogram. Once we see that we tend and make sure that we follow our patients. We don't want to lose these patients because we want to, if we catch something early then we can help them manage it much more effectively.


Are there basic ototoxicity monitoring programs?


Yes. And a lot of larger universities systems do have one in place. But in fact there are a lot of doctors that their main goal like we said is to treat the cancer. Sure. There are so many side effects that sometimes it's hard to keep them all straight. So what we tell professionals is to if you are involved in an ototoxic monitoring program, one check to see if there's any changes in dizziness and eliminate that the some of the changes are off balance isn't caused by maybe some hip pain, knee pain, achy joints which sometimes could also be a symptom of either their type of cancer or a side effect of the medication. But look to see if there's any changes in the ringing of the ear. That's tends to be what our patients notice first if they're on a chemotherapy based drug is they're ringing in the ear. And then also making sure that they're in regularly for a hearing test. Even after their treatment is done I follow the protocol that they should be treated, they should be evaluated, excuse me, yearly to make sure we aren't seeing any long-term effects of chemotherapy. Actually the other day I just had someone celebrate their two-year mark of his cancer diagnosis and his type of cancer he was cured at that point. Which I was felt so fortunate to be a part of just even a little bit of his journey. But I recommended to him I was like your hearing is normal and that's fantastic but let's make sure it stays that way. 


So something that I look for is I look for a shift in frequencies. Are we seeing a significant shift in those frequencies or those tones, those beeps that you hear? If we see a significant shift during the course of treatment we then would let their managing physician know that hey we're either seeing a really big shift at one frequency or slightly smaller one at some consecutive ones. That lets us know it's possible that that hearing is starting to change.


And that in turn I guess would allow the physician to also understand that maybe there's something they can do on their end?


Absolutely. Absolutely. They would, the nice thing is is with a managing physician on a cancer team is they are looking at all areas of the patient's health. So they'll be able to evaluate whether the level or the dosage that they're on is something that can be modified. If not, let's talk about getting them involved in either management techniques. If they are feeling dizzy or having vestibular symptoms meaning they feel dizzy, off balance or when they turn their head they get like a little uneasy. What they could do is they could also create a referral to a physical therapist to help them regain some confidence in walking and things like that. So it's really nice to be a part of a team and be able to be a helping hand in that patient's cancer journey. 


It's a tough situation for a lot of people but it's comforting to know that there are some solutions.


Absolutely. Absolutely. And just because you're treated with some of these drugs just like um the gentleman who I saw a few weeks ago he doesn't have any hearing loss and it's not a guarantee that just because you're receiving chemotherapy that it's going to come with a hearing loss. But the only way we're going to make sure that we're on top of things is with those routine tests.


Okay, Jenna. Thank you so much for your time today. Thank you so much for having me. I appreciate it.


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