00:00:00] Announcer: Welcome to episode 30 of empowEAR Audiology with Dr. Carrie Spangler.

[00:00:16] Carrie: Welcome to the empowEAR Audiology Podcast, which is part of the 3C Digital Media Network. My name is Dr. Carrie Spangler, and I am your host. I am a passionate audiologist with a lifelong journey of living with hearing challenges in this vibrant hearing world. This podcast is for professionals, parents, individuals, with your own challenges and those who want to be inspired.

[00:00:45] Thank you for listening, and I hope you will subscribe, invite others to listen and leave me a positive review. I also wanted to invite all of you to visit and engage in the conversation on the empowEAR Audiology Facebook group. Transcripts for each episode can be found at www dot 3, the number 3, C digital media network.com under the empowEAR Podcast tab.

[00:01:19] Now let's get started with today's episode. All right. Welcome listeners to the empowEAR Audiology Podcast. Today I have a special guest with me, Dr. Anita Jeyakumar. And I'm going to tell you a little bit about her history. Dr. Jeyakumar works for Mercy health otolaryngology in the Youngstown area and Ohio.

[00:01:40] She received a bachelor's degree in chemistry from Belmont university in Nashville, Tennessee. She received a master's in chemistry degree from Tennessee State university in Nashville, Tennessee and received a medical degree from Maharry medical college in Nashville. Dr. Jeyakumar completed an internship and general surgery and a residency in otolaryngology at Strong Memorial hospital university and Rochester and Rochester, New York.

[00:02:11] She completed her clinical fellowship in pediatric otolaryngology at the Cleveland Clinic Foundation in Cleveland, Ohio. She has over 20 years of experience and brings the new service line of otology and the advanced treatment of hearing loss to the Youngstown, Ohio area. She is starting a mock high disciplinary clinic for patients with hearing loss and a cochlear implantation and hearing rehab program.

[00:02:38] Dr. Jeyakumar’s current research into a study focused on the genetics of hearing loss And quality of life projects. So welcome to the empowEAR audiology podcast. And thank you for being here today.

[00:02:53] Anita: Thank you for having me very much excited to share this experience with you. Yes. And

[00:02:59] Carrie: I believe I always like to start out my podcast of how we know each other.

[00:03:05] And I think we met each other maybe around four years ago. Does that sound right?

[00:03:10] Anita: That sounds about right. And we have continued. It's like, I'm glad we like each other because we can't avoid each other. Cause we overlap all the time.

[00:03:20] Carrie: We do, we definitely share similar interest in a broad field and we both save on the American cochlear implant Alliance as the state champion for Ohio.

[00:03:31] Then we have our. In common. And I'm excited to talk a little bit more today about unilateral. And I think one of the big questions that I got as an audiologist, and I don't know if you get this as an otolaryngologist, is that while you have one good year, so you're good to go. Do you ever hear that?

[00:03:54] Anita: I hear that all the time.

[00:03:55] If I had a dime for how often I heard that I would be a very wealthy person, you know, just to kind of give context, when you talk about from a pediatric perspective, it's a little bit different than when you talk about it from an adult perspective, but from a pediatric perspective, it is not actually super rare.

[00:04:14] So about one in 1000 children are born with single-sided deafness. And that incidence goes up with age. So by the time children are age six to 19, about 14% of children can have some level of single-sided deafness. And we've known since the eighties really there's a pretty prolific author from then called Bess who wrote about children who had significant issues, both educationally, socially, cognitively, and behaviorally from single-sided deafness.

[00:04:46] In adult world, we often talk about the cocktail hour. So for anyone who likes to go to parties, whether you imbibe or not when you go to a party, you're typically surrounded by a lot of people, but your two ears then give you access to that full room of people. And there's a lot going on around you and your ears and brain learn to filter out what's important.

[00:05:08] And what's not for a child that cocktail hours sort of mirrored on a daily basis in the playground or a classroom, when a child goes to a playground, they are surrounded by the appears and their teachers or whatnot. And when you have single-sided hearing loss in either situation, you only have access to half of the information.

[00:05:28] So you're working that much harder to try to figure out what the context of the conversation. What the nuances of the situation are, and it's not unusual that you will get some of it wrong. So a lot of people end up being able to shy or reclusive because they don't want to put themselves in those environments, whether on the playground or in a party that expose them to what are perceived as sort of traumatic events.

[00:05:56] Quite frankly.

[00:05:58] Carrie: Yeah. That's a good point about playground or cocktail hour as you describe it. I think one of the things that I hear from an audiology perspective is that Parents or teachers, so, well, one on one that, you know, they seem to hear me quite fine. I don't see them having any difficulties. How do you explain to families or to other significant people in their life that there is more of an impact because they're not seeing it.

[00:06:32] Anita: So I think the best thing is twofold. One is that I often have what I call my poor man's video of what hearing loss sounds like to a person, because particularly when it's a family trying to make decisions for their child, you're really talking to people who probably have normal hearing most of the time.

[00:06:52] So they're trying to make a decision that's really important about something. They totally have no understanding of. So one I play a video? Then too, I try to relate to what's happens daily. So let's say Jack has a single sided deafness. I asked them things like, how does Jack do when you call him from another room?

[00:07:12] How does Jack do when you give him instructions? And he can't see you? And what I universally typically will get is some kind of acknowledgement that Jack does not do well in those situations. And they assume it's because Jack is being a kid and not listening. And of course, that's an element of that.

[00:07:31] It's not like these kids are always the model citizens of the world. But you know, it's really that Jack cannot follow an instruction if Jack doesn't know where the instructions are coming from or worse yet what the instructions are. So I try to relate on that level, because it's not too many families that don't want to relate to their loved ones, whether it's a child or a spouse or what not.

[00:07:55] So once you can get them to say that all these situations are happening. So these are some of the adjustments you want to think about taking, like, for example, exactly what you cited, Carrie that They will do better if you talk to them face to face, don't ask Jack for a bottle of water when you're in the kitchen and he's in the living room.

[00:08:14] Cause Jack won't know what you want, but if you go to Jack and say, you want a bottle of water, Jack will probably get you a bottle of water. You know? So things like face-to-face communication, the ability for them to integrate their lip reading and social cues are all going to be very important for them to communicate on a one-on-one basis.

[00:08:34] Now those don't solve the cocktail hour issue and things like that with echoing and sound localization, because that's the big thing that you're really losing when you don't have hearing in one ear.

[00:08:46] Carrie: So from a medical perspective, just kind of backing up, but what are some of the main causes of Unilateral hearing loss in children and then also in adults?

[00:08:58] Anita: So I would say it's fair to say that the differential for both are quite different. So if a child is born with unilateral hearing, Oftentimes a child is recommended to have some kind of a workup, which includes things like screening for congenital CMV. It has a high incidence of unilateral hearing loss.

[00:09:17] Children tend to have more anatomical anomalies. So oftentimes we get imaging because we want to diagnose those. And there's also a high incidence of Auditory nerve findings. They may have a nerve, but it's sometimes kind of what we call hyperplastic, which means it's kind of wimpy looking. So they have findings that you can actually concretely find and potentially address.

[00:09:39] If you know, they have the findings. By the time you start to get older, some of these are not as prevalent, probably acquired. And some amount of presbycusis causes more adult onset, unilateral hearing loss, you know, people don't protect their hearing at all. So there's a high prevalence of unilateral hearing loss in people who use weapons because they fire guns and don't necessarily use hearing protection.

[00:10:06] And those hair cells, as you, and I know are, are very fragile and don't like being traumatized. And so when it's gone, it's gone. So. Pathway and the mechanisms kind of are different, little different between kids and adults.

[00:10:20] Carrie: Yeah. So are there other, like co-existing factors that sometimes are red flags with unilateral hearing loss, medically.

[00:10:31] Anita: So medically, probably congenital CMV is the biggest one. Because unfortunately congenital CMV is something a child is typically born with and they get it in utero, but most places in our country do not do screening for congenital CMV because in the mother. It manifests as a cold. And if you don't know, you don't know what you don't know.

[00:10:53] Children with congenital CMV can be divided into symptomatic and asymptomatic. So unfortunately the symptomatic, maybe fortunately the symptomatic ones are a very small group. Those kids usually will show up as being really small birth weight or small head, or may have other medical issues going on.

[00:11:13] So those kids often times are identified in the nursery or in the NICU. And that testing for congenital CMV really needs to be done in the first two weeks to one month of life before you can't really rule it out. So you're in a, such a tight window. They're way more kids born with asymptomatic, congenital CMV, and those ones are often missed and there really is not a good way of finding them unless you have access to their newborn blood spot.

[00:11:41] Most states don't store that for clear periods of time. So you are kind of using some clues that you might get along the way to determine that, but you don't necessarily always know the etiology.

[00:11:56] Carrie: Yeah. Sounds like a hot topic as well, but I was going to ask you is my next question. Like, what are some of those hot topics that are surrounding unilateral hearing loss?

[00:12:09] Anita: So kind of like what we opened with, you know, back in the day, let's say the eighties. And prior they really weren't a lot of options for treatment of unilateral hearing loss. So I would say a lot of the hot topics focuses on, well, my grandfather had unilateral hearing loss and he did just fine.

[00:12:28] So why do we need to do anything for Jack or Jill? Well, it's 2021. And fortunately I will say there are options. So I think the big thing is to really kind of get it out there that, that you know, a family may choose not to exercise their options, but a family needs to know that they have options and really they have quite a range of options.

[00:12:51] So one, we do have to identify them, but hopefully with newborn screening and things like that, we can identify them effectively. Those kids need to be plugged into early intervention because it's important that the children get access to sound good Quality sound to kind of keep on target with the peers, because there's a high incidence that these kids will repeat a grade or will suffer in school.

[00:13:15] If they want to start with less interventions, things like preferential seating in the classroom can be really impactful as well as wearing an FM system in the classroom. So to provide those resources in a public school setting, as you well know, they often have to have a 504 plan or an IEP to make sure that those resources can be provided for them.

[00:13:36] And those kids have really measurable targets that follow them. A lot of these kids will need speech therapy. And then when we start to really go into the individual interventions, anything from a specialized kind of hearing aid called a CROS hearing aid, or a specialized kind of conduction hearing aid called a Baha or even a cochlear implant, which was FDA approved in 2019 for single-sided deafness five ages five and above are all options.

[00:14:05] And I think it's important for parents and families to understand that the options are there.

[00:14:11] Carrie: Yeah, which kind of brings me to my next question. And I know you've been heavily involved in the cochlear implants for many years, both children and now adults. But for kids who are five and above and even adults, what is a good candidate for a single sided deafness kid or an adult, I guess maybe talk from the child perspective.

[00:14:35] Anita: Okay. That's such a great question. And I think. Depending on who you talk to, you'll probably get different answers. So, as I mentioned, I think the FDA approved for five and above now, majority of our data really comes from Europe. Europe is sort of 10 years ahead of the US in terms of implant technology and outcomes.

[00:14:55] And what they seem to show is that even for single sided deafness, the younger, you implant them the better they do. Now the confounding factor. That makes sense for those of us in the implant world, because the sooner they have auditory stimulation in the affected ear, the better their brain knows what to do with the sound.

[00:15:13] The dilemma is when they have single-sided deafness, really it's the brain that hears. So the brain has a good ear that it can hold on to that whole time. So how do you focus a rehab option? Or focus the attention on the implanted ear. And I don't know that we have conclusively figured that out for children.

[00:15:35] Fortunately implants, if that's the route they go, they do have streaming technology. So really beyond just putting the implant in the child, there needs to be a dedicated rehab program for the child to use that ear. Otherwise, guess what? The child is always going to have better sound in their normal ear. And their child is always going to listen to the normal ear.

[00:15:58] The same really goes for adults. You know, I think auditory the duration of auditory deprivation matters. In adults, there's some literature saying that anywhere from four to seven years of auditory deprivation, meaning they've had no access to that sound can negatively impact the outcome. The confounding factors are always that most adult implant programs in our country don't have.

[00:16:22] Rehab as part of an implant program. So without giving them the structured guidance of how to use the new found access to sound, adults really struggle. You know, this is not necessarily all intuitive. It might be intuitive to you and me because we are in that world in such a different way. But it is not intuitive to the average adult who is seeking this.

[00:16:46] They just want access to sound on both sides, but without that rehab focus, streaming everyday focused therapy to that ear, they tend to always use their better ear and really rely on this only as a failed state. So that mechanism probably really needs to be even in better place for both adult and children.

[00:17:06] Carrie: Yeah, that's all good information. So one question I have out of that is you talked about that time of auditory deprivation from like four to seven years. Whatever, but for kids, if the child was using Some sort of amplification and that ear that was has the hearing loss, whether they, I was stimulating one hair cell.

[00:17:32] And that's it. Have you noticed, or is there any research that shows that they may Benefit or take, you know, ownership of that cochlear implant more so than someone that's never used any kind of technology in that ear?

[00:17:49] Anita: Yes, absolutely. And I think some of that is an extrapolation from bilateral cochlear implants, or just an unilateral implants and older children for other reasons.

[00:17:58] The reality is that the sooner you teach a child to leave a device on them, especially if they have a little bit of auditory benefit. Yeah. It may not be speech. It may not be clarity, but it's just some auditory awareness. Then the better they're going to accept something that'll give them more. The reality is when we first put an implant on anyone.

[00:18:20] It sounds awful. I don't care what we say. It sounds terrible. You know, you talk to anyone who can verbalize to you. They will say it sounds nothing like normal sound sounded to them, but they have to push through it. And if a child never accepts it in the first place, they're never going to get to a point that they push through it.

[00:18:39] Cause eventually it'll sound Greatish better than what they had before far better than what they had before, but they have to push through all of that. And that's really what the efforts of our audiology team or a speech pathologist both come in because they have to tinker with it to really get each person's individual program to be what is optimized for them.

[00:19:01] And there really is not a one size fits anybody. It has to be individualized to each person and that's where the dilemma with the young kids come in too. It's like, how do you get the feedback from a three year old? That the sounds awful when the three-year-old is saying five words, you know, it's, those are challenges.

[00:19:21] So there's a lot of effort that has to happen behind the scenes to really show that it's going to be beneficial. I think with the right infrastructure, it really is. I'm a believer for sure. It's just, I don't know that we always have the right infrastructure in place.

[00:19:38] Carrie: And you talked a little bit earlier that there are some other options that families or adults may want to try as well, such as a CROS type hearing aid or a bone conduction devices.

[00:19:53] What has been your experience with those types of devices or is it pretty individual? I have, depending on the person, but that is what.

[00:20:03] Anita: So, I guess I'll start with one is that I, as a cochlear implant surgeon probably have an innate bias against some of those devices. So maybe you might need to take everything I say with a pinch of that salt and it now the thing, but the reality.

[00:20:20] Before coconut implants became FDA approved for, you know, single-sided deafness. There was no FDA approved option for single-sided deafness for the affected ear. The only options were technologies that basically routed sound from the affected side to the normal side. So both the CROS and the Baha based on technology that doesn't use the affected ear at all.

[00:20:45] It just gets the sound from one ear, the affected ear and routes it in different ways to the unaffected ear. So the issue I've had, I think not, especially now that's the cochlear implants are an option is that you really are not getting information on that side. You're not using the ear that you were born with.

[00:21:05] Let's put it that way. You're basically your good ear is doing all the work for you and you're learning to say, oh, okay. That information was from my affected side. This information is for my good side and it's really, really confusing. And that's certainly what I saw in my patients is that yeah, there were certain situations that had worked.

[00:21:27] It's definitely not easily accepted. I would say both of those technologies have also come a long ways. When I first came out of training, I would have said I would never, ever, ever prescribe a CROS to anyone because they were awful. And they just seem like they muted the good ear as opposed to help to anything.

[00:21:47] But both of those technologies have become so much better. That the nice thing about them. The one benefit that they both have is that you can try them without surgery. You know, you can put hearing aids on people and try them without necessarily saying, this is what they've committed to for life. You can try a bone conduction device on a soft band that they would wear and get.

[00:22:09] Yeah, it's not a hundred percent what it would be like if it was put surgically, but at least it's a really good sense of what it could be like. That the cochlear implant is a leap of faith. You know, you have to say, okay, this is what we're doing, but you can't really test it out until you just do it.

[00:22:26] And I think that's probably the big advantage of the nonsurgical or less surgical approaches is that as a patient, I do think they should march along the algorithm, you know, they should try the non-surgical ones at least briefly to get a sense of, do we see any improvement in the. Does the child learn to wear this non-surgical thing well?

[00:22:49] before we put on the useful surgical thing, and I think there's value in the story for them.

[00:22:57] Carrie: Yeah. And I think that commitment piece that you said is so important. So if they're not going to be committed to a more non-surgical outcome, are they ever going to be committed to a surgical outcome?

[00:23:12] Anita: Yeah, the reality is we are Americans and we live in an instant gratification society. So when you tell people that they have to go through this one big hoop, but that leads to 800 little hoops, you know it's not necessarily what they want to hear. They are willing to go through the one hoop, but they want it to be done.

[00:23:33] They want it to be taken care of. And unfortunately with any of these options that. It really, we're talking about a lifetime of a journey. You know, I tell our pediatric patients and their families that you were going to see this through to high school because your kid needs to finish high school. A lot of children with hearing loss don't get that opportunity because the system doesn't work for them.

[00:23:56] Not because their intelligence is remotely an issue, it's just a system fails them. So that applies to the kids with single-sided deafness and the, and the literature shows that.

[00:24:08] Carrie: Yeah. I, I know it's been such a hot topic along, along the journey of working with families who are going through these different decisions.

[00:24:20] So if a patient decides to do nothing and you kind of mentioned this earlier, what can we do to still be supportive?

[00:24:30] Anita: So I, I think that is complete, you know, we have autonomy in our world and I think as long as they've heard their options and they decide to do nothing, that is not the worst thing in the world.

[00:24:46] I think things we need to do, we need to We need to not dismiss the patient just because they've chosen to do nothing. Doesn't mean they're not a patient still. We need to watch and see how they're doing in school. These kids have a high degree of depression and anxiety. So we need to make sure that we're not missing the boat on other things going on, that we can support them with.

[00:25:07] And it might be things like support groups, you know? Yeah. They may not be wearing technology, but maybe they'd benefit from meeting a peer who also has single-sided deafness to say whether it's an older peer that has been successful to say, how have you navigated the world? You know, what kinds of things, peers meeting peers has always been a win.

[00:25:27] You know, the biggest deficit that I always Personally is that I personally do not have hearing loss. So while I've read and read and read and I listen and all of these things, I truly don't. And you know, it's like saying a, guy's supposed to know what it feels like to have a baby. Well, good luck. You know, I mean, you can only do so much research.

[00:25:49] You really don't have an idea, but the peers know what the peers need. And there's something to be said for a support system that they can bank on. The one caveat, I would say the only one that probably as far as we know right now that does have a time. Limit on it is if someone is born with single-sided deafness and they don't, and the parents say, you know, they're doing okay, they're in speech, they're meeting their milestones.

[00:26:15] We're going to wait for them to have this decision as an adult. Well, that decision may not exist as an adult. And that's the one thing that is really hard for parents to understand. They're like, well, it's the same anatomy. It's the same brain. They have access to sound on the other side. The literature just doesn't seem to support that.

[00:26:35] Giving them access to sound when they're 10 plus years into a journey is going to be successful. But there are lots of caveats to that. We don't know if it's because they don't have therapy to match it. We don't know if it's because the commitment is not there. We don't know. We think that there is basically a.

[00:26:54] Neuro-plasticity that goes away why that would go away when they have access on one side, don't know, but that's just the data that we have. So I would say that's going to be an evolution. Hmm.

[00:27:07] Carrie: Interesting. So there's. I guess one of the questions that I wanted to throw out at you is that, is there anything that I didn't ask you that

[00:27:18] Carrie: I should've asked you about unilateral hearing loss and what, you know

[00:27:24] Anita: gosh, I think.

[00:27:26] You know, how do we create more awareness among our peers is what I'd say. I think, you know, we are an informed clientele, probably the people listening to this podcast, me and you. This is what we do on a daily basis, but how do we continue to keep the conversation going? How do we make sure our primary care providers know that this is an issue that their parents and patients deserve a conversation?

[00:27:55] How do we make sure general audiologists who haven't been in the CI world are made aware of that the conversation has changed. So people who are struggling past their hearing aid really should have that conversation to the next level. I think that's a nice thing about this. You know, getting the awareness out and continuing to have an open candid conversation is important because there are way too many patients that come to see me that say You know, we didn't even know this option existed and that's crazy to me that they wouldn't, but why would they, if they're not in the right circles in the right place?

[00:28:32] The other thing is a whole cohort of patients who come to talk about an implant because their insurance won't pay for hearing aid. Well, that's a whole different can of worms and probably its own podcast. But, you know, I would say that there there's some legislature going through to hopefully change some of that.

[00:28:50] To me personally, it's very exciting. It breaks my heart. When I see people come through and I think to myself, gosh, all you just need is a good hearing aid. And we have good hearing aids that you haven't reached the level that you should be talking to an implant surgeon, and that's no fault of theirs, but the reality is they figure, Hey, this is paid for that one.

[00:29:11] Isn't so I'm just going to go for the one that's paid for. And that’s Crazy to me. And I think more of the conversation to make that happen will be helpful to pay. That's my view anyway. No,

[00:29:23] Carrie: I think that's good. And I think what you had said previously, too, when I asked you about, you know, when a patient decides not to do anything, to keep them informed, because our conversation today is going to look really different in a year from now or five years from now, 10 years from now, when we have more data and research and evidence of what is supporting.

[00:29:47] Anita: Absolutely. I mean, the reality is when you think about medicine and the evolution implants have really only been around since the eighties, that is not a long time and we've come leaps and bounds ahead since the eighties, but obviously there's a lot more we need to know. So, you know, sometimes when people talk about, well five-year 10 year, well, it's only been since the eighties, we don't actually know the answers to a lot of these questions.

[00:30:16] So I think, you know, within our industry, a lot of people are talking about more standardized testing so we can report things more transparently among the companies. I think all of that is needed, but hopefully we'll continue to come forward because our consumers are Need transparency to help make better decisions.

[00:30:38] And right now, as you know, Carrie, if you send them out on the web, it is a Smorgasbord of stuff that it is going to come away with. I mean, Dr. Google is sometimes a tough place to be. And you know, we, we need to guide that conversation. I think a bit better. Right.

[00:30:53] Carrie: Yeah. We have come a long way. When you think about our conversation about unilateral hearing loss in the seventies was like, we, we don't do anything about it.

[00:31:04] And then with the eighties and more research, but again, I think we still have a long way to go in educating just the general public on the impact, but also I have families and patients who are experiencing that firsthand.

[00:31:20] Anita: Absolutely. And you know, when some of the, my primary care colleagues have said to me, things like, oh my, my patients like that are very quiet and I enjoy them.

[00:31:32] And, you know, with masking things have been particularly hard for anyone who has any level of a hearing issue, really. I mean, you'd never realize how much you lip read, even as a normal hearing person, how much you use facial cues until they're all gone away. And so. I just think we need to continue to be cognizant and we need to fight for our people.

[00:31:57] I had someone say to me recently, oh, I thought all people who are deaf and hard of hearing knew sign language and, you know, You hear things like this and you just realize, okay, we need to do a better job educating our own peers and our community because someone who's in my circle should never think that.

[00:32:17] Then I haven't talked about it enough or created aware enough awareness enough because that's clearly not the case.

[00:32:25] Carrie: Right. Yeah. And I guess masking there is a silver lining and the fact that like what you just said, individuals with typical hearing are seeing the impact of degraded speech, and hopefully it helps other individuals put themselves in the shoes of those who actually do have mild unilateral or any degree of hearing loss.

[00:32:51] Anita: I hope so. I hope so. We are much more and more very I guess this is a philosophical discussion as selfish and self-centered world. And it's hard to think about how much people are struggling around us, but man, people are. Really, really struggling. I mean, people have changed their lifestyle completely because of masking.

[00:33:11] Not because they wanted to, but because they had to, because it was miserable for them to do things as simple as going to the grocery store or, you know, certainly going out to dinner was a disaster. Because they couldn't, they felt dumb because they had to keep repeating themselves and they didn't understand what the menu was.

[00:33:29] you know, all kinds of things that just really are, are, are unfortunate and shouldn't happen. You know, I have people who are scared about their jobs because they have single-sided hearing loss and with masking, they're like, oh, their colleagues are mad at them because the colleague is sitting on the wrong side and they're afraid to advocate for themselves.

[00:33:50] So, you know, we just need to continue to encourage the conversation. That's really, really important. I think.

[00:33:58] Carrie: I think you're right. And I think that's a great way to end is that we need to continue to encourage the conversation and we'll have to have another conversation in the future because I'm sure what we talked about today is going to be updated in some way or form with research and, and new information.

[00:34:16] If anyone would like to get ahold of you, how could they do this.

[00:34:21] Anita: Well, they can always email me. My full, my email is an ajekumar@mercy.com, a J E Y a K U M a R. Ed mercy.com. I respond really well to emails. You can call my office and I will have to get back to you on that number. I was doing good on the email.

[00:34:40] You can

[00:34:40] Carrie: I can put that information in the show notes, and then people will be able to click on your email. The that way. And if you have a website with mostly, I can, I can link that up to the show notes as well, but I just want to thank you for taking the time and being a part of the empowEAR Audiology conversation.

[00:34:59] Anita: Well, Carrie, it was an honor. Thank you for having me really enjoyed our conversation as I always do. So hopefully this is useful to others and yeah. Please email or call us. We are here to help. I think. You're not alone in this. And that's just important to remember.

[00:35:17] Carrie: All right. Thank you listeners.

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