Hearing Matters Podcast

Dr. Lori Zitelli on Comprehensive Care, Tinnitus, and Emotional Health

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How can audiology transform healthcare even when hearing loss isn't the primary concern? Join us as we uncover this and more with Dr. Lori Zitelli, audiology manager and adjunct instructor at the University of Pittsburgh. Dr. Zitelli shares her expert insights on the groundbreaking field of interventional audiology and the pivotal role it plays in identifying undiagnosed hearing issues. We discuss the limitations of basic screenings and the necessity for comprehensive audiometric evaluations, along with the crucial role audiology assistants have in ensuring follow-up care. Prepare to gain a deeper understanding of how audiology can enhance patient well-being by tackling hearing loss before it becomes life-altering.

In this compelling episode, we delve into the intricacies of real-ear measurements and how these practices can significantly improve patient outcomes despite common barriers like time and equipment constraints. We also take a sobering look at the serious relationship between tinnitus and suicide, highlighting the importance of recognizing warning signs and the resources available to help those in need. Dr. Zitelli's experiences and insights shed light on the evolving landscape of audiology, urging us to consider its expansive role in addressing both physical and emotional health challenges. Don't miss this opportunity to enrich your understanding of audiology's impact on healthcare.

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Blaise M. Delfino, M.S. - HIS:

Thank you. You to our partners. Sycle, built for the entire hearing care practice. Redux, the best dryer, hands down. CaptionC all by Sorenson - Life is calling. CareCredit - here today to help more people hear tomorrow. Fader Plugs - the world's first custom adjustable earplug. Welcome back to another episode of the Hearing Matters podcast. I'm founder and host Blaise Delfino and, as a friendly reminder, this podcast is separate from my work at Starkey.

Dr. Douglas L. Beck:

Good afternoon. This is Dr Douglas Beck with the Hearing Matters podcast, and today I am honored to interview Dr Lori Zitelli. Dr Zitelli is an audiology manager at the University of Pittsburgh Medical Center, UPMC, and she is an adjunct instructor at the University of Pittsburgh. She received her clinical doctorate in audiology from the University of Pittsburgh. Her special interests include evaluation and treatment of tinnitus, decreased sound tolerance, amplification, clinical education, clinical research and interventional audiology. She is a certificate holder in tinnitus management and she's a member and active volunteer of the American Academy of Audiology, and she was honored to be the recipient of the 2022 Early Career Audiologist Award by the AAA. So, Lori, welcome, Glad to have you here.

Dr. Lori Zitelli:

Thank you, I'm happy to be here.

Dr. Douglas L. Beck:

Well, and I want to cover a lot of things today, but I want to start by asking you a little bit about what the heck is interventional?

Dr. Lori Zitelli:

audiology? Thank you for asking. Interventional audiology is the idea that we as audiologists can make a big impact in a positive way on people's healthcare, even when hearing is not the primary concern of the patient or the health care provider. So, for example, if you have a patient who's going to see their primary care physician, they may be going for something that's completely unrelated to hearing loss and they may have a hearing loss that's interfering with their ability to communicate. So interventional audiology is the idea that if we can identify the hearing loss and intervene, we can improve outcomes.

Dr. Douglas L. Beck:

All right, I like that and I believe you've written a little bit on this right. You have a paper that came out in 23?.

Dr. Lori Zitelli:

And we, honestly, are always looking for new opportunities to provide this model of care. A poster that I was presenting at an ENT survivorship symposium where the data that we collected were very similar to previous data that have shown that about 40% of people recognize that they have hearing loss and about half of healthcare providers will recognize that their patients have hearing loss. So that just really goes to show that you can't ask people, because they don't always know, and it's not necessarily that they're denying, but they just don't recognize it, especially if it's gradual necessarily that they're denying, but they just don't recognize it, especially if it's gradual.

Dr. Douglas L. Beck:

Yeah, and there's a lot of literature that suggests 70% of all hearing loss, in Americans anyway, is mild to moderate, and what that means is that most of them would have no idea that they have any problem and they're not going to seek a solution for a problem that they don't perceive.

Dr. Lori Zitelli:

Absolutely, a hundred percent agree.

Dr. Douglas L. Beck:

Yeah, and this is a big problem with screening and all of the things that we do as outreach, because audiologists have been saying since World War II oh, everybody should get screened. I've been saying for about 30 years people should not get screened, everybody should get a comprehensive audiometric evaluation. It's kind of, in my mind, like if you have any concerns about your heart or any concerns about cancer or about diabetes, you don't go get a health screening. You need an in-depth evaluation. And I know, of course, you know the pushback as well. You know it's so expensive to test patients. Yes, it is, but no other profession works for free and volunteer screening. Think about dentists. Do they screen you? No, they don't. What about your OBGYN? Screening's there? No, what about your neurologist? What about your GP? What about your optometrist Podiatrist? No, nobody does. And I don't mind elementary school teacher or a nurse or somebody who wants to screen you. That's great, I appreciate that, I think that's wonderful, but when you and I screen, we're giving away services for free and the answer to that screening right.

Dr. Douglas L. Beck:

The result of that never quite tells us enough to make a diagnosis or to say anything other than well, you passed or you failed.

Dr. Lori Zitelli:

Yeah, that's true.

Dr. Douglas L. Beck:

Right. And the problem with that is, of course, if I say to somebody, I let them in my office, I do a screening an adult, 65 years old, and that fellow happens to pass the screening, he's going to go home and tell his wife. Well, I saw Dr Beck and he said that my hearing is normal. Yeah, that's exactly what's going to happen. We know that, Yet we continue to screen.

Dr. Lori Zitelli:

I think that's a really good point and that's one of the reasons why we employ assistants in our clinic. So in our interdisciplinary clinics I tend to be the person who kind of starts these activities and then, once we get a protocol that everybody's comfortable with, we hand them off to our assistants and I think that's a great role for them and really part of the the biggest part of the goal of a screening in a clinic like that is to mitigate the hearing loss. So if we say you failed the screening, we think you should use this amplifier for the rest of your appointment and then you should follow up for a full, comprehensive evaluation so that we can make a diagnosis and a rehab plan.

Dr. Douglas L. Beck:

Let me ask you a question when your assistants and technicians, audiology assistants, et cetera, when they identify somebody as having failed a screening, what percentage of them follow up and see an audiologist for a comprehensive audiometric evaluation?

Dr. Lori Zitelli:

It's way lower than we want. So we have some limitations on how we can track that, because a lot of the people that we see in our clinics travel specifically to our hospital because it's a big tertiary care system and there are a lot of specialty services. But in terms of who we can follow for this, it's a pretty low percentage of people who follow up on separate days for care. We do offer care on the day of the appointment as well. We say like, while you're here, do you want a hearing test? And some people do accept that, but a lot of people don't.

Dr. Douglas L. Beck:

Right. And again to me, if I ruled the world I wouldn't ask. I would say your doctor said you need an audiometric examination and the audiologist is booked, but they will get you in next week and do airborne speech impedance, we do otocoustic emissions, we do speech and noise, we do a listening and communication assessment and then, once we make a diagnosis, then we deal with treatment. I think we do this in such a ludicrous way in our profession. I love audiology, I love how it's evolved, but I think we're at that point where we have to say screening hasn't worked for anybody except the sole exception I always pointed out newborn infant screening.

Dr. Douglas L. Beck:

Brilliant. 99% of all children born in the USA at appropriate professional birthing centers get a hearing screening at birth, and I think that's brilliant. But our work doesn't end there, because a lot of those children will have cytomegalovirus and 18 months later they could have hearing loss. So you can't just say, well, they passed their screening at birth. If they passed their screening at birth, that's fantastic, that's excellent, and that still means that they need to be checked. You know two or three years later and you know through school and anywhere, preaching to the choir so.

Dr. Douglas L. Beck:

But you know there was a brilliant paper, larry Medwetsky, who used to be at Gallaudet when he was at NTID, national Technical Institute for the Deaf up in Rochester, new York, he did a similar thing where he was checking to see how many of the people that were screened would follow up when they got a positive result and I can't quote it exactly, but it was roughly 15 or 18%. In other words, about one out of five people who said you failed the screening. About one out of five took it seriously enough to go get help. Maybe I'm wrong, maybe it was two out of five, but I'm pretty sure it was one out of five.

Dr. Lori Zitelli:

Well, regardless.

Dr. Douglas L. Beck:

Yeah, yeah. And so that begs the question. Well, what's the point of a screening if you know one out of five people is going to follow up, no matter what you tell them?

Dr. Lori Zitelli:

Anyway, I also think that in the clinic that we were collecting these data in, it's a head and neck cancer survivorship clinic, so I think a lot of these people have things that are higher on their list than a hearing test. And you and I might not, you know feel the exact same way that they do about the importance of a hearing test. Yeah, but you know, when you can't swallow and you can't, you know your teeth need care and things like that. Hearing tends to be pushed further down on the list.

Dr. Douglas L. Beck:

And you're in pain and your life is very, very challenging. Absolutely, I agree, 100%. Tell me about TestBox and Real Ear Probe Mic Measures, because it's 2024 right now and I know you're on that bandwagon and so many of my colleagues and we've been talking about this for 30, 35 years now and I don't understand for the life of me how we're still not all on board with doing probe mic measures. Tell me your perspectives on this, tim.

Dr. Lori Zitelli:

Well, I was on a AAA committee a couple of years ago that helped to do the annual membership survey, and this is one of the questions that we specifically ask people about, because I 100% agree with you I think there is really no situation where someone should be fitting a hearing aid without doing measurements that tell them about audibility meeting prescriptive targets. So some of the questions that we asked people in this article and in this survey were related to their use of real-ear measurements. You know how often do you do it? Is it something that you've ever thought of? What are the barriers that you experience to do this, and then, also, what are the things that would help you to overcome these barriers?

Dr. Lori Zitelli:

So, historically, if you look at the data that Gus Mueller has reported, 30-some to 50-some percent of people report doing real-air measurements.

Dr. Lori Zitelli:

I think this is probably an overestimation, given that a lot of audiologists failed the validity screening and reported that they did a fake measurement. But in the 2020 survey that we did, more than 60% of the audiologists who responded to that survey indicated that they do real-air measurements, which is kind of a loose term. Right, there are a lot of real-air measurements regularly, so I think that's good if that's true. Some of the barriers that were reported included things like audiologists were not sure that including real-air measures would improve satisfaction. There were also timing constraints that were mentioned equipment constraints, spacing constraints, and then when this survey was being completed, it was in the middle of the COVID-19 pandemic, so I think there were some in-office limitations related to that as well. But the biggest barrier that people cited were that they weren't sure it would improve satisfaction, which I think is interesting because we have data to say that it increases patient loyalty and satisfaction and all of these other things that are really important.

Dr. Douglas L. Beck:

For over 30 years. Yeah, and there's no evidence that I'm aware of and correct me if I'm wrong that has ever said, when you do it all to best practice guidelines, which include, you know, hearing aid test box and doing real ear measures and verification of validate, there's no evidence that says you're going to do worse. In fact, as you mentioned, all of it says this is a much better protocol, higher satisfaction, higher retention, higher referral rates and and people will argue, well, my patients don't like it when I hit target. Stop saying that. You know, if the target when you hit target, that's an average, that means, given this hearing loss, this is the average amount of gain that we need.

Dr. Douglas L. Beck:

It doesn't mean it's right for every single person, but it's a starting point and it's a fair starting point that gets you in the ballpark and from there, as a professional, we adjust and we tweak and then we, you know- I like to think of that as the science and the art right.

Dr. Lori Zitelli:

So there's the science, where you're fitting to target and you're meeting these prescriptive targets, and then the art is figuring out for that specific individual, in their specific circumstances, what are the things that they need. To be science, the arch comes after you've done that.

Dr. Douglas L. Beck:

Anyway. Well, so I'm glad to see that you're still fighting this fight and I wish you nothing but success Back at you. You know, it's remarkable to me that anybody in hearing instrument dispensing and or audiology can basically do these things and just say well, my patients like it. They just do a first fit and they tweak from there, but they have absolutely no idea how much gain is actually occurring between the medial tip of the hearing aid and the eardrum.

Dr. Lori Zitelli:

Absolutely. You don't know, unless you measure it.

Dr. Douglas L. Beck:

You don't know what you don't measure. Yeah, absolutely.

Dr. Lori Zitelli:

Well, let me just say, for anyone who maybe feels like they could use a brush up, or someone who's interested in doing this and maybe is afraid to ask people, there is a free, open access edition of seminars and hearing that was just released 2024.

Dr. Douglas L. Beck:

Yes, yep, just released earlier this year, I think uh-huh, um, I think.

Dr. Lori Zitelli:

Uh, may, maybe, or June, um, hot off the press. Um, it's a whole edition of six chapters that are designed to help someone familiarize themselves with real ear and test box measurements. There are exercises that you can go through, activities, descriptions.

Dr. Douglas L. Beck:

So I'm a little bit biased because I'm one of the authors, but I read that before you and I met, met and I was so happy with that, which is one of the reasons I contacted you. You had an article in there called my Hearing Aid is Not Working as it did. That's also in that same issue of seminars. Can you give us a brief encapsulation of that? What did you find in that article? What did you read?

Dr. Lori Zitelli:

Yeah, so each of the chapters in the workbook are designed to help you do a specific set of measurements. So first you start with calibration, because of course you have to level and calibrate the equipment, and then each chapter tells you a little bit more about specific test box measurements that you could do, troubleshooting activities, information about the ANSI measurements and how to interpret them, distortion things like that. So it's set up so that it starts with a question or a patient complaint. So if the patient says my hearing aid sounds really noisy or my hearing aid doesn't sound the way that it used to, what are some troubleshooting tips that you can use and how can you use these tools and this equipment to get the information that you need to make an action plan?

Dr. Douglas L. Beck:

And if I can ask you as an aside, how often did it come up that there's moisture in a hearing aid and you should use something like a redux system to remove the moisture on a regular basis? How often did that come up?

Dr. Lori Zitelli:

Oh it's. I mean I wish we had a redux system and we have a vacuum in our clinic and there's a. It doesn't tell you how much moisture is removed, but I've seen a lot of people using a device like that and I think the results are always pretty, pretty astonishing. So I, when I'm checking hearing aids, and especially if people have issues related to intermittency and things like that, I'm always running them through a drying cycle and I think it does make a difference, especially in the summer.

Dr. Douglas L. Beck:

Well, you and I can follow up. Later this year we're doing a big study on that, and that's my impression as well. I don't want to say with certainty what the result will be, but I think I would align very well with what you've said. Let me ask you a question that has nothing to do with audiology per se. The first time I came across your name in the literature, I want to say it was five or six years ago. You wrote an article with Catherine Palmer and I think it was more of an editorial, and it was oddly about suicide, and you were taking the opinion that and please correct me if I say this wrong that it's part of the audiologist's job to be aware of suicide risk. I wonder if you can talk about that.

Dr. Lori Zitelli:

Absolutely so. I'm someone who spends a fair amount of my clinical time working with people who have tinnitus and sound intolerance, and tinnitus in particular has gotten some attention related to suicide over the last couple of years. I'm not sure if you remember hearing the CEO of Texas Roadhouse died by suicide, and there have been a lot of articles over the years looking at the association between suicide and tinnitus, and it's a very complicated relationship and it's not something that I ever thought twice about before. I was in a situation where one of my patients died by suicide and it's you know, it was a long time before I could even talk about it. It's something that's completely changed my practice patterns and my willingness and ability to address this topic, because I think it's something that's uncomfortable for a lot of people.

Dr. Douglas L. Beck:

And by saying that audiologists should be aware of or be members of the suicide watch team. So to say that doesn't mean we're going to counsel patients about suicide, but that does mean that we should be looking out for some of the red flags.

Dr. Lori Zitelli:

Absolutely. Yeah, we do not have the training that we would need to do a formal suicide risk assessment or ask about protective factors and things like that. That is beyond our scope and I think it's completely fine to acknowledge that, and I think someone who is providing therapy who has not been trained to do it can actually do a lot of harm. So I'm in no way telling people that they need to be able to do that kind of level of activity. But I agree with you that recognizing risk factors, warning signs you know, knowing what to look for, I think is important, particularly if you're working with a group of patients who may be prone to thoughts or feelings that are complicated.

Dr. Douglas L. Beck:

Yeah, and there are, of course, measures that we do as standard tinnitus assessment tools that we use that sort of indicate when somebody's at a higher risk. I remember and I don't want to go into details either, but probably 10, 12 years ago, 13, 14 years ago, something like that, I'd written a couple of papers on tinnitus and I had two patients that I had worked with committed suicide within about a 36-month period of time and that just underscored for me because I remember each of them saying oh, my tenderness is you know it's not so bad it's, you know, I'm okay with it. And I never did a THI on them and I attended this handicap inventory and you know there's a point at which the score and I believe it's on the THI says catastrophic right.

Dr. Douglas L. Beck:

And that should have been a heads up, but we never did the THI in that clinic. We didn't assess tinnitus patients other than speaking with them and saying, well, tell me about your tinnitus, what makes it worse, what makes it better? Can you tell me what it sounds like? And maybe we do some tinnitus matching loudness, matching pitch, matching things. Can you tell me what it sounds like? And maybe we do some tinnitus matching loudness, matching pitch, matching things like that Pretty common stuff.

Dr. Douglas L. Beck:

But we didn't do formal assessments. You know, such as and I don't, you know, there's the tinnitus functioning, there's the tinnitus handicap inventory, there's a bazillion of them. But I, you know, I had to wonder in retrospect and you know, shame on me but we didn't do that assessment and I had to wonder that. You know, had I done that, would that patient have scored in a catastrophic category such that I would have written in the chart patient? You know tinnitus is catastrophic and urge immediate. You know medical intervention or psychological intervention, psychiatric intervention. You know whatever. Had we known it was that bad, we would have done something.

Dr. Lori Zitelli:

But by not doing a formal assessment, we never got that information. Yeah, I think it's important to think about what you're going to do with the information if you have it right. So if you're doing some sort of assessment or asking a specific question about suicidal thoughts or, you know, addressing this area in some way, if the person says yes or indicates that suicide is something that they've thought about or they're at risk for it, you need to have a plan for what you're going to do so you can't just say like, oh okay, great, I'm glad I asked that, let's move on. So that's why I think the establishment of the 988 suicide hotline has been really important, because before that there was a suicide, a number that you could call, but it was like a long string of. It was a telephone number, and so now 988, hopefully, is something that a lot of people can recognize and remember much more readily. So when I used to talk about this, I used to make everybody pull out their phone and program in the hotline number.

Dr. Lori Zitelli:

But now 988 is kind of that just makes that a whole lot easier and it's also a number that people could call for advice. So like a provider could call and say I'm in this situation. I have a patient here with me. This is you know. This is what we're talking about. This is what we said. What do you suggest that we do from here? So good, resource.

Dr. Douglas L. Beck:

That's fantastic. I'm really happy to hear that.

Dr. Lori Zitelli:

Before I let you go, what's upcoming? What are you doing in 25, 26, 27? Any new giant projects underway and comparing different models of care related to audiologists providing care and assistance care and asking the patients and their family members and the staff members about the you know, different satisfaction measures. So we're always doing, you know, stuff like that. We've got a whole bunch of free clinics coming up, so we're always trying to promote hearing care in the Pittsburgh area in particular.

Dr. Douglas L. Beck:

That's fantastic, all right. Well, lori, it's a joy to meet you and to work with you, and I love your publications. I hope one day we get to meet face to face, but in the meantime, I'm very proud of your work and I underscore its importance and relevance to clinical audiology in 2024.

Dr. Lori Zitelli:

Thank, you so much. Thank you so much. Appreciate you having me.

Dr. Douglas L. Beck:

All right, take care.

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Blaise M. Delfino, M.S. - HIS

Host
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Dr. Douglas Beck

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