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6. EARS a. Current atresia of the external ear (744.02) or severe microtia (744.23), congenital or acquired stenosis (380.

5x), chronic otitis externa (swimmers ear) (380.15-380.16, 380.23), or severe external ear deformity (380.32, 738.7, 744.01, 744.3) that prevents or interferes with the proper wearing of hearing protection. :
Atresia is the absence or closure of the external ear canal. Microtia is gross hypoplasia or aplasia of the pinna (external ear flap) with a blind or absent external auditory meatus. Sometimes you will see ear lobes with multiple or large holes from piercings. The holes may elongate over time even causing split ear lobes. Various types of trauma may hook into the lobe causing extensive damage. Whether a large hole or deformed lobe is disqualifying or not depends on your judgment as not only how it may interfere with the proper wearing of hearing protection, but also how it might affect military bearing and image of the soldier. When in doubt about a large hole in the ear or elongated lobe, check with the service liaison.

b. Current or history of Mnires Syndrome or other chronic diseases of the vestibular system (386.xx).
Any vestibular disorders that cause chronic or intermittent symptoms to such a degree as to interfere with military training/service activities, including vertigo, dizziness and imbalance is disqualifying. Mnires Syndrome always comes to mind with vertigo, but this is rare under the age 40. If you see this syndrome in a younger applicant, check for syphilis (otosyphilis), thyroid disease, or an old head injury.

c. History of cochlear implant.


This is a bionic ear with several pieces of apparatus. There are external pieces behind the ear (microphone, speech processer and transmitter). You will see this along with an implant scar. A receiver and a cochlear stimulator are buried in the mastoid bone.
Always look behind the ear for a mastoidectomy scar after checking the ear drum

d. Current or history of cholesteatoma (385.3x)


Most often cholesteatomas (keratomas) are acquired from the same chronic ear inflammations that are responsible for Eustachian tube dysfunction (ETD) that are discussed below. Cholesteatomas are more common in male 3:1. Once this small white waxy-like tumor of bacteria, cells and crystals starts growing in the middle ear, it can slowly destroy the ossicle chain bones remembered by M.I.S. (TM malleus incus stapes = M-I-S = ossicular chain = middle ear) and cause permanent hearing loss, as well as meningitis, brain abscess or other neurological deficits. Diagnosing a cholesteatoma is very difficult since you cannot see it with your otoscope. Mainly you see the history notation in their submitted MedDocs, or suspect it in any chronic ear discharge, hearing loss, tinnitus or severely retracted TM. The surgery to remove a cholesteatoma is extremely complicated with a recurrence rate as high as 50%. Ossicular Chain Reconstruction (OCR) will be seen in the MedDocs in the tympanoplasty OP reports due to ossicular chain bony erosion by a cholesteatoma.

e. History of any inner (P20) (CPT 69801-69930) or middle (P19) (CPT 69631-69636, 69676) ear surgery excluding successful tympanoplasty (CPT 69635) performed during the preceding 180 days.
Tympanoplasty type I is a simple patch of the TM, perhaps to patch up a perforation after the removal of PET (pressure-equalization tubes) inserted with a myringotomy for OM (otitis media), this is not PDQ after 180 days. But, tympanoplasty II or III also includes OCR that is Ossicular-Chain Reconstruction (malleus-incus-stapes) manipulation often done for a cholesteatoma, and is disqualifying. (TM Malleus Incus Stapes cochlear acoustic nerve CN-8)

f. Current perforation of the tympanic membrane (384.2x) or history of surgery to correct perforation during the preceding 180 days (P19) (CPT 69433, 69436, 69610, 69631-69646).
It is not uncommon to see ear tubes still stuck in applicants TMs. This is a perforation, and should be referred to their HCP. Also, any TM perforation should be closely evaluated for ETD discussed below.

g. Chronic Eustachian tube dysfunction (ETD) as evidenced by retracted tympanic membrane, or recurrent otitis

media, or the need for pressure-equalization (PE) tube within the last 3 years.
ETD is common in chronic sinusitis, allergies, GERD, cleft palate defects, and anyone who smokes. These patients often notice intermittent ear fullness or blocking, ear popping or cracking, mild hearing loss, tinnitus, and/or occasional poor balance. But, dont forget that a small tumor can cause this, especially if unilateral. On physical you will see a severely retracted TM, possibly with the prominent middle ear bones projecting through the TM. Recurrent OM is defined as 3 or more episodes of acute OM in 6 months, or 4 episodes in one year. With a history of 2 or more episodes of OM after the 13th birthday, there is a highly likelihood of ETD. Any ear infection after age 12, accurately detail all subsequent episodes

7. HEARING

(Use ICD-9 code 389 for all hearing defects)

a. Audiometric hearing levels are measured by audiometers calibrated to the standards in American National Standards Institute (ANSI S3.6-2004) (Reference (i)) and shall be used to test the hearing of all applicants. b. Current hearing threshold level in either ear greater than that described in subparagraphs 7.b.(1)-(3) of this enclosure does not meet the standard:

(1) Pure tone at 500, 1000, and 2000 cycles per second for each ear of not more than 30 decibels (dB) on the average with no individual level greater than 35 dB at those frequencies. (2) Pure tone level not more than 45 dB at 3000 cycles per second or 55 dB at 4000 cycles per second for each ear.
* 500-1000-2000 is now separated from 3000 and 4000 and has different criteria. Adding the 500, 1K and 2K cannot come to more than 90 or an average of 30, and no value over 35 on each one separately.

(3) There is no standard for 6000 cycles per second.


c. Current or history of hearing aid ICD-9 code is V53.2

More on Hearing Loss and Audiograms:


Most of the hearing losses (HL) in applicants are due to loud music, usually from mp3 players or car sound systems. Not uncommonly it can be due to firearms (hunting or prior service). A shotgun blast is 170 dB explained below) Always ask prior-service applicants if their original MEPS exam and/or separation physical showed any HL. On younger applicants, ask if they were screened for HL in school. For other background screening questions, use the worksheet below.

Hertz (Hz) and Decibels (dB) in the Hearing Test:


Scientists use the Bel as a unit of loudness (intensity) in physics (a power saw or drill would be about 1 bel. For human ear measurements, only 1/10 bel is used called the deciBel (dB). A whisper is 30 dB and normal conversation is 60 dB, while 140 dB is painful. Therefore, in MEPS hearing test, the applicant has to hear at least a whisper level. While a sounds intensity can be loud or soft as measured in dB, the pitch of that sound is rated by its frequency in cycles per seconds called Hertz (Hz). A mosquito beats its wings 600 times a second (600 HZ) when it makes its high pitched hum, as compared to a low frequency foghorn rumble of 40 to 80 Hz. The common conversational range for the human voice ranges from a males low voice of 85 Hz to a high screechy female voice of 1000 Hz. The ears as a whole can hear a range of 20Hz to 20,000 Hz.
(1000 Hz =1 kilohertz or 1 kHz usually noted as 1K).

MEPS Audiometer Test Strip: You will notice looking under FREQ on the left-hand side is a vertical column: 1kT - .5k 1k 2k 3k 4k 6k 8k (8k is not used)

The 1kT is an initial testing sound and is repeated as the 1k, and the medical techs write in box 71a the better of the two values. (Not using the lower of the two values is an IG hit.) You will also notice that box 71a uses 500, 1000, 2000, 3000, 4000 and 6000 Hz levels instead of kilohertz or K. The 6000 level is not used in MEPS profiling but it is used by the USAF. Their rule is 55 dB is H-2, and over 55 dB is disqualifying in this

6000 Hz range. The liaison may ask you to repeat the 6000 if the applicants first test value was too high. The paper test strip will print out the value in dB that the applicant hears in each FREQ level. (See b.(1) above) Under each ear you will see 2 columns. The CT column is the actual test value, and the BT column is baseline test used if the machine is comparing to a previous test. You will mostly see AA that means not used.

Grading the Degrees of Hearing Loss:


Only the FREQ 500 1000 2000 Hz are used in this grading scheme: Normal: Mild loss: Moderate: Moderate-Severe: Severe: 25 dB or less 26 TO 40 dB 41 TO 55 dB 71 to 90 dB > 90 dB (All 0 dB readings is perfect hearing) (They may not hear soft speech) (Difficulty hearing normal conversation) (Do not hear most conversational speech) (Deafness a profound hearing loss)

Applicants will often ask if they flunked the hearing test because they see all the zeros. They sit
so long in the morning looking at their records and think that zeros must be bad.

Types of Hearing Loss:


There are two basic types of hearing loss, conductive and sensorineural, and of course, you can have a little bit of both called a mixed hearing loss. To oversimplify, a conductive hearing loss is on the outside of the cochlea, and a sensorineural loss is on the inner side of the cochlea. The outer surface of the cochlea is the dividing line.
External ear canal TM Malleus Incus Stapes cochlea acoustic nerve CN-8 brain Conductive path ear canal to the Cochlea

C Sensorineural path cochlea to brain

Sensorineural hearing loss (SNHL) is the cause of 90% of all hearing loss. It requires finding the cause since the cause may be correctable to stop any further HL. It is called Nerve deafness and is due to either cochlea disease or a CN-8 disease see diagram above. Audiologists can do two other tests to differentiate between the two: Otoacoustic Emission testing (OAE) diagnoses cochlea disease, and Auditory Brainstem Response (ABR) diagnoses Cranial CN-8 disease, particularly an acoustic neuroma.

Diagnosing the type of HL from an audiogram: The conductive pathway


carries sound waves to the cochlea by two different paths the ear canal by air conduction (AC) and the skull bones (BC). The bone conduction pathway skips the ear canal and middle ossicular (MIS) bones and goes directly to the cochlea. Think of this as a Y with the top two branches being the AC pathway and the BC pathway, both meeting at the cochlea which is the bottom stem of the Y. Any hearing loss in the conductive pathway is always in the ear canal (AC) pathway i.e. ear canal wax, scarred or perforated TM, cholesteatoma or fluid in the middle ear. (There are no bone conduction defects) The audiogram will differentiate this by the Air-Bone Gap.

Air-Bone Gap: The audiologist will do two hearing tests, one using
pure-tones in the ear (standard hearing test) and the other by putting a bone vibrator over the mastoid bone for bone conduction, then plotting both curves on the audiogram chart. There should not be any more than a 10 dB difference between the two (AC & BC) in normal hearing with air conduction always being a little higher than bone conduction. If there is more than 10 dB difference (AC>BC), then there is an air conduction hearing loss. Bone conduction is never worse (higher) than air conduction. (BC>AC does not happen). A hearing loss with no air-bone gap (AC and BC are within 10 dB of each other) is a sensorineural hearing loss (SNHL). Mixed Hearing Loss (SNHL + AC HL), you will have both AC and BC high due to the SNHL, and AC>BC by more than 10 dB for the air conductive loss.

The Tuning Fork Tests (Weber-Rinne Tests): Although no replacement


for formal audiometry, a quick screening test can be made by combining the Weber test with the Rinne test, together called the Tuning Fork Tests. (These tests are only helpful for a one-sided (unilateral) hearing loss. When you find a one-sided HL in an applicant, first use the Rinne test on the side with the hearing loss to determine if bone-conduction is better than air-conduction (BC>AC) This tells you right off that there is some air-conductive hearing loss since normally AC>BC.

(To do a Rinne test, use a low-pitched tuning fork, 128 or 256 Hz is best. Tap it so it is vibrating and
quickly touch the base to the mastoid bone and count the seconds until the applicant no longer hears it. Immediately move it to 1-2 cm from the ear canal and count the seconds until the applicant no longer hears it. Normally the air-conduction time should be approximately twice as long as on the mastoid bone conduction time. If the BC>AC then you have a conductive hearing loss in that ear. (This is called a negative Rinne test. A normal Rinne test (AC>BC) is called a positive test. Confusing? Just note that Rinne test BC>AC.)

Once you have determined whether there is a conductive hearing loss in the ear with the one-sided hearing loss, then apply the Weber test to the middle of the skull (top of the head or center of the forehead or chin), then simply ask the applicant if the vibrating sound is louder in one ear or the same in both ears. (You can just ask the applicant to hum and ask him in which ear is the hum the loudest) If the applicant tells you it is louder in the same ear that you just confirmed a conductive hearing loss along with the Rinne test. But lets mix things up here. Take the same applicant with a one-sided hearing loss and in doing the Weber test, the applicant states that it is louder in the opposite ear from the side with the hearing loss. This is mixed up (Rinne indicates AC loss in one ear but the Weber is louder in the opposite ear (Rinne is negative in one ear and the Weber lateralizes (is louder) to the opposite ear). This indicates a mixed hearing loss (combined conductive and sensorineural loss in that same ear). If it gets much deeper than this, you had better rely on a formal audiology consult. Weber-Rinne Tests Summary: Weber without lateralization Rinne both ears AC>BC Rinne left BC>AC Rinne right BC>AC Normal Weber lateralizes left Weber lateralizes right

Sensorineural loss in right Sensorineural loss in left Conductive loss in left Combined loss : conductive and sensorineural loss in left

Combined loss : conductive and sensorineural loss in Conductive loss in right right

Waiver Authority Concerns:


The waiver authority will usually request additional audiology testing when considering a hearing loss waiver. Besides the standard puretone audiogram, they will request tests known collectively as Speech Audiometry, or how well you hear speech. This is a road test of your overall communication ability. Here are some of the ways this is done: Articulation Index: Predicts the amount of speech that an applicant hears on a scale of zero to 1.0 in a specific hearing loss frequency. The closer the AI is to 1.0 or 100%, the better the applicant is able to hear

speech. For example, if an applicants AI is .75, he is likely to hear 75% of a typical one-on-one conversation, or conversely, he will miss 25% of a conversation. This modifies a hearing loss into a single number making it easier for audiologists to advise patients on what to expect without aid. Speech Recognition Threshold (SRT): This is the lowest (softest) level at which you can barely understand speech 50% of the time. Spondee words (two-syllable words), e.g. baseball, cowboy, are spoken by the audiologist and the person is asked to repeat what they hear. If you have normal hearing (SRT 5dB), you hear perfectly at 21 feet and catch some words at 100 feet. If you have a mild loss (SRT 30 dB), you can hear perfectly only at one foot, and catch only some of the words at 18 feet. With an SRT of 70, you will hear nothing without the help of a hearing aid. (SRT and WR have nothing to do with each other, dont smoosh these two tests together in your mind.) Word Recognition (WR), older term is Speech Discrimination (SD): The purpose of WR testing is to determine how well you hear and understand speech in a perfectly-quiet environment when the volume is set at your Most Comfortable Level (MCL). Your WR score tells how much difficulty you will have communicating. If your WR is poor, speech will sound garbled to you, and you will not be able to repeat it. This is reported in percentages, 100% means you heard and repeated everything perfectly. WR score under 50% means your word recognition is poor, and you will understand only 50% of the conversation. You will have great difficulty following a conversation, even when it is loud enough for you to hear. SPRINT: SPeech Recognition In Noise Test: Sprint is a speech recognition test for military use. It predicts how different degrees of hearing loss might affect a soldiers ability to carry out their individual missions with background noise. In other words, a speech-in-noise test. The test is given with a background of multi-talker babble noise of +9dB. This does not affect normal hearing; they can identify over 95% of the monosyllabic words correctly. However, H-3 profiles may have a lot of difficulty, and SPRINT will tell if they are deployable or not.

Noise Induced Hearing Loss: (This is a common MEPS problem.).

First, you have to know when to suspect it. You will see a hearing loss only in the higher frequencies. Classically, it is described as a spike in the 4 KHz called a noise notch. Practically speaking, the loss will spill over to the frequencies on either side, 3 to 6 KHz. (Repeat the test on

a different hearing machine to be sure.) Then ask the applicant if he has been exposed to any loud noise or music in the past two days. This can range from listening to an iPod/mp3 player, long use of a cell, loud car radio, discos or rock concerts, or perhaps, they mow lawns. Often they remember the incident and tell you they had temporary ringing afterward. One MEPS station found a recruiter in his van that turned the radio up very loud on the 4-hour drive to the MEPS causing most of his applicants to have a temporary hearing loss. This is a noise-induced hearing loss (NIHL) seen as a high-frequency hearing loss (HFHL). If there is a positive history of recent noise exposure, you can temporarily disqualify the applicant with an RJ date of 2 days of noise deprivation, then repeat the hearing test. Impress on them that during this time that they do not listen to ANYTHING louder than the conversational voice you are now using with them, including little or no cell phone use. (See Applicant Handout below.) Do not disqualify a bilateral HFHL without the 3rd noise deprivation test, or the waiver authority will simply return it and ask you to do it.

Single Sided Hearing Loss: This is not uncommon in MEPS, 1% of


school children have a chronic or congenital unilateral hearing loss. These applicants will usually have documents of showing a full evaluation.

A sudden SSHL (past 72 hours) is a medical emergency to save their hearing. They usually will have some tinnitus and/or dizziness also. The most common cause is a viral infection (60%), although it can be autoimmune, vascular, and tumors (acoustic neuromas). Only about 70% fully regain their hearing. If the onset is progressive over time, the concern is always a slowgrowing acoustic neuroma. Although benign, if not treated, it can slowly and permanently erode the delicate inner ear bones (M-I-S). For this reason, the wavier authority will not waiver a one-side hearing loss without at least a formal audiology consult and inner ear imaging (MRI or CT).

Supplemental Information:
Commonly used abbreviations: AD is the right ear. AS is the left ear. AU is both ears. HFHL is high-frequency HL, LFHL is low frequency HL. SNHL is a sensorineural hearing loss.

VA 10% disability for tinnitus is commonly seen in prior service applicants. This would show up as a discrete HFHL in the ear with tinnitus. As you know, the pitch of the ring is usually only in one frequency, usually 3000 KHz or higher. The loudness of the tinnitus will add about 5-10 dB to the hearing levels on the hearing strip. Otherwise there are no tinnitus tests or physical examination findings that can be done in MEPS. On a practical note, you will seldom find any significant hearing loss in these individuals.

Sample of an Applicant Handout for noise-induced retesting


Your hearing test this morning indicated a hearing loss that may be due to loud noise exposure. Usually a short period of avoiding noise will help you pass the hearing test. Therefore the MEPS doctor has ordered a repeat hearing test after resting your hearing (noise deprivation) for at least two days. Please do not listen to any noise louder then a normal talking voice between now and the time you return for retesting. Your recruiter will return you to MEPS after at a minimum of at least 2 days for this repeat hearing test. In our MEPS applicants, the most common cause of loud noise exposure is listening to loud music such as iPods, mp3 players, headphones, boom boxes, car stereo systems, recent rock concerts, or going to discos. Even using your cell phone over one hour daily can affect your hearing. Below is a loudness scale of various types of noise. Loudness, or sound intensity, is measured in tenths of decibels (dB). The scale runs from 0 dB (which is the faintest sound a human ear can detect) to more than 180 dB (the noise at a rocket pad during launch). Decibels are measured on a logarithmic scale, meaning that every time the intensity increases by units of 10, each increase is 10 times the lower figure. So 40 decibels is 1000 times as intense as 10 dB. 30 dB 50 dB 60 dB 70 dB a whisper the sound of heavy rainfall normal conversation rush-hour traffic

85 dB Risk Level 90 dB 100 dB 115 dB 130 dB 140 dB 150 dB 170 dB subway train; lawn mower power saw iPod race-car noise jet engine Rock concert Shotgun blast

Noise does to your ears what the sun does to your skin, it burns it. It destroys the small hair cells in the inner ear. A single loud exposure, or lower chronic exposure over time can do it. Prolonged exposure to sounds above 85 dB without any protection can damage your hearing. A common example is using an iPod at 115 dB for only 15 minutes a day can cause a hearing loss; doctors are now making a diagnosis of iPod ear. Do not ever listen to an iPod for over 60 minutes a day, and even then keep it to less than 60% of the full volume, or you will likely suffer a hearing loss.

We want to leave you with these interesting bullets: The most common hidden disability in America Hearing Loss. More than one in 10 Americans has hearing loss, latest count 30 million and growing. Noise-induced hearing loss affects one in 30 Americans, and 15% of all teenagers. News item 14 March 2006: of all high school students have some hearing loss from their music players. Listening to your mp3 player 5 hours a week will cause hearing loss.