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Standing Committee on Health, Aged Care and Sport
14/02/2017
Hearing health and wellbeing in Australia

MAKEHAM, Dr Timothy, Private capacity

Committee met at 11:50

CHAIR ( Mr Zimmerman ): I declare open this public hearing of the House of Representatives Standing Committee on Health, Aged Care and Sport and would like to thank everyone for their attendance today. Today is quite a significant day for the accessibility of committee meetings; this is actually the first parliamentary committee public hearing that has been live captioned, which I think is a great innovation. I suspect that the needs of this inquiry have helped expedite that process. However, unfortunately, I should report that our Auslan interpreter was at the last minute not available today. One step forward, one step back. If anyone needs assistance with the live captioning, they should speak to one of the committee secretariat staff.

Before we begin, I ask a member to move that the media be allowed to film the proceedings today in accordance with the rules set down for committees, which includes not interfering with committee proceedings and not taking footage or still images of members', committee staff or witnesses' papers or laptop screens.

Mr GEORGANAS: So moved.

CHAIR: It is moved and seconded. All those in favour and against? I declare that carried.

I welcome Dr Timothy Makeham, who is an ear, nose and throat surgeon from Canberra ENT. Do you as a witness appearing before this committee have any objection to being recorded by media during participation in this hearing?

Dr Makeham : No, I do not.

CHAIR: These hearings are formal proceedings of the parliament. The giving of false or misleading evidence is a serious matter and may be regarded as a contempt of the parliament. The evidence given today will be recorded by Hansard and attracts parliamentary privilege.

The reason that we were keen to have you giving evidence today is that this is obviously the commencement of our public hearing process in relation to our inquiry on hearing health and we thought that it would be worthwhile for committee members, particularly those of us who do not have a medical background—and Dr Freelander will be here shortly to show us all up!—to basically get a layman's overview of the primary causes of hearing loss and treatment and also of the likely pathway of future research and things like that.

Dr Makeham : Fair enough.

CHAIR: If you are happy to, I will hand over to you to make an opening statement.

Dr Makeham : Yes. It is a very broad brief, but I will do my best to provide some direction to, hopefully, be directed by yourselves. Like you said, I am an ENT surgeon in Canberra, and this is a semiregional city. I come from Canberra and came here to try to provide resources and ENT services in a more regional setting. We do some things very well in this setting, and that is recognising children born with hearing loss. We have an active screening program for that. From there, we have a streamlined process of introducing those families and patients to Australian Hearing habilitation services, speech therapy and then, ultimately, a Cochlear implant. Usually that takes place within six months.

In some groups we do really well with screening for hearing loss, identifying it, treating it early and providing excellent outcomes with it. Hearing loss is more diverse than that, and a lot of people who suffer hearing loss have some impaired insight into the degree of hearing loss and accommodate for it, and their presentation with it can be delayed. To that end, a lot of people with moderate hearing loss may not seek out hearing aids. They may modify the work they do, or they may modify the social interactions they have—ultimately, perhaps, to their greater detriment, but also in the sense that there are solutions available for them. Part of the challenge we face is finding a way not only to identify those people but also to make them aware of the benefits or the treatment possibilities and to reduce the barriers to them seeking those out.

One of the biggest things which face us in the community, I guess, is particularly the younger children, when we talk about the group that pass the newborn screening hearing test but then develop ear disease at a young age. This can be anywhere from 12 months of age on to five years of age. Five years is typically the next point of screening, when children enter preschool. Chronic suppurative otitis media can develop. It can cause problems with speech and language acquisition. If it becomes uncontrolled, it can go on to impact hearing rehabilitation solutions. To that end, patients with hearing loss due to chronic suppurative otitis media often have difficulty using hearing aids, and the condition makes it worse. Our challenge is to identify those people and provide treatment.

CHAIR: I might kick off. Medically, can you run through the principal causes of deafness and hearing loss?

Dr Makeham : Acquired hearing loss, which can be from either noise or disease; genetic hearing loss, so either being born with hearing loss or having a subsequent predilection towards adult onset hearing loss; and age related hearing loss. They are the main things. There is disease, being a broad range of things.

Hearing is divided broadly into conductive hearing loss and neural hearing loss. Neural hearing loss—and I hope this is not getting bogged down in detail—is the hearing that one takes from the cochlea to the brain. Conductive hearing loss is moving the sound from the eardrum and the ear canal to the inner ear. Neural hearing loss is one which is predominantly genetic, for those born with it, but there is also a susceptibility that occurs with ageing, noise exposure and disease as well.

Mr GEORGANAS: Neural is the one from the cochlea to the brain?

Dr Makeham : Correct.

Mr GEORGANAS: So any damage to the cochlea would be neural?

Dr Makeham : Yes. Some people have mixed hearing loss. Conductive hearing loss can be acquired from disease. There are genetic causes of conductive hearing loss, and there are congenital, so people are born with conductive hearing loss.

Mr GEORGANAS: I was going to ask about neural hearing loss, which is the damage to the cochlea. Can that be caused, not through genetic or through other—

Dr Makeham : It can absolutely be acquired. It can be acquired through a viral illness or immune disease. Noise is probably the largest cause of sensorineural hearing loss in our community, plus the change with age, but noise is by far and away the largest—either industrial or occupational or, increasingly, exposure to loud noise in nightclubs and so on.

Mr DRUM: I was going to change the subject slightly to the new generations that are listening to music with earplugs. Is that a concern at all to the sector? Is there an onset of issues coming our way, or not really?

Dr Makeham : I think, from the earplug point of view, often the intensity of sound from those is not sufficient to cause long-term permanent damage. The difference is that music is listened to, and noise is presented in different ways. There are safe recommendations for how much noise you can be exposed to before you see irreversible loss; that is in the order of 80 decibels for eight hours, and for every three decibels you add to that you halve the amount of time. When you are at a nightclub or in a loud environment where you cannot hear conversation, the noise level is often at 100 decibels. At that point, the amount of time you can spend there without expecting to see irreversible damage is actually quite short—often less than an hour.

Mr DRUM: Wow!

Dr Makeham : So there is a risk in society from that.

CHAIR: I am just following up the earplug question For someone who is listening to their smartphone regularly with music at a high volume, is that likely to be of an intensity that could do damage?

Dr Makeham : For most people, not usually, no. They do not drive it that loud.

CHAIR: If I could just follow that up again. Is it mainly industrial noise then that does—

Dr Makeham : Industrial noise and social exposure to noise, yes.

CHAIR: What are the primary diseases that affect hearing?

Dr Makeham : The most common is infective, so bacterial, or otitis media. That would be the main cause of most ear disease, but there are others. For inner-ear diseases it tends to be more of a viral-type cause, causing a loss of inner-ear function. A lot of ear disease is often related to upper-airway disease, so often patients will have sinus disease and immune susceptibility to a disease process.

In the community, in the younger age group, particularly when children are starting in child care, we see major incidents—in my practice, we see a lot more children who are in child care presenting with ear disease than those who are not. Once children get a bit older, five to seven years of age, the incidence drops off significantly, so there is a peek period where this really takes hold, starts and then resolves.

CHAIR: Once detected, are they easily treatable?

Dr Makeham : Yes—not always but the vast majority are.

Mr GEORGANAS: With the neural disease, once the cochlea is damaged by viral infections, how would you treat it? Can you reverse the damage that has been done?

Dr Makeham : Yes and no. If you get the disease early, which usually means within 24 hours, there is a chance of reversing.

Mr GEORGANAS: Is that by treating it with—

Dr Makeham : With steroids, usually. There are other conditions—you raised Meniere's disease, which is another common community disease—but for the viral-acute things, yes, you have a short window where you can treat and you can reverse. Other than that, patients either make a recovery or they do not, and it tends to be one ear, not both. But unilateral deafness still really impacts someone's ability to function, for most employments. To hear well in a quiet room with one person talking is easy, but as soon as you add in noise the challenge becomes—

Mr GEORGANAS: Gone.

Dr Makeham : Yes, and most people find that—

Mr GEORGANAS: Speaking from personal experience, sorry.

Dr Makeham : When someone restores that hearing or improves it, the first thing the patient says is that they can hear in group situations and that they do not have to be so proactive in managing background noise.

Mr DRUM: Cleaning our ears: some people will say that throwing a cotton bud in your ear to give it a clean is a bad thing because you can just push other stuff further in. On this issue, are there any glaring areas of ear health that you think this committee should be trying to study or inquire into, or is there a particular message we need to get out to the people?

Dr Makeham : In answer to the first part about the cotton buds, we tend to stay away from them, usually because they often make the problem worse rather than better. There are simple preventative treatments that can be encouraged and used, such as using wax softeners to help the wax come out of the ear naturally. Some patients—

Mr DRUM: How does an average Joe—

Dr Makeham : If you have a major problem—some people do get to the extreme where they have to have the ear cleaned by an ENT surgeon on a regularly basis, every three months or so. Some patients just use regular wax-softening drops, such as olive oil even, and that can thin out the wax and make it much more manageable. Prevention can be effective, and there is a range of options.

In terms of the big areas that we miss, one of them is providing access to people once we move outside the major centres. In my experience, we see much greater incidence of ear disease, end-stage ear disease and complicated ear disease, in this region, from the coastal areas down towards Bega and the South Coast but also out towards Wagga and the central-west area that we service. I think it is part accessibility but also part recognition of the problem in those areas and whether we actually identify those people at the right time. That is a big challenge. And also Indigenous—we have not mentioned that, but it is an equally massive problem that we do not do well at as a community.

CHAIR: And that is mainly simply not deducting—

Dr Makeham : Not knowing about it, not being present to detect it and the patients not having access or knowledge of the resources to help them.

CHAIR: Are most ear diseases easily detected and treated by general practitioners?

Dr Makeham : I think some are and some are not. There are screening processes where you can detect hearing loss, and you do not need a specialist to detect the presence of hearing loss, but for complicated chronic subdural otitis media you often do need a specialist to actually look to see that. Probably a specifically trained practitioner could achieve some of that screening end point, to be more accurate in identifying that. Telehealth, where you have a camera that can go into the ear and take high-quality pictures, would mean you could find another way of screening. There are different solutions to the problem, but asking someone who is not skilled at recognising the uncommon but serious pathology is a challenge for GPs in that setting.

Mr GEORGANAS: In your opening statement you said there are some groups that we do really well in and there are other groups that we do not. You mentioned a couple of them in Indigenous communities. From your point of view, what groups do you miss in urban areas: linguistically diverse perhaps, people of non-English-speaking backgrounds, older people?

Dr Makeham : All of those, and older people definitely. The propensity to travel to seek out care is less; it really depends on their support structure around them. Most patients who are elderly who come to treatment are often brought by a younger family member who is noticing that they have a problem or communication has become a major problem.

Mr GEORGANAS: Because you would not notice is yourself; it is gradual, very minute.

Dr Makeham : That very much encapsulates what is the problem with hearing loss. In the individual who suffers hearing loss, it tends to be a gradual thing that they accommodate for incredibly well. I could relate to you the stories of patients who—I had one patient who was at one stage the best employee in their workplace because they could lip-read someone putting an order in, before someone else could hear it, so they could prepare the order beforehand. It is incredible what people do to cope, and yet there are solutions that would make their lives easier and it would make their ability to engage in education easier, and maybe fulfil a great potential in time.

Mr GEORGANAS: A very broad question: can you give us some examples of how you would treat some of these?

Dr Makeham : Someone with profound sensorineural hearing loss who is not getting a benefit from hearing aids, in this day and age a cochlear implantation offers incredible improvement in quality-of-life functionality and the ability to engage in the community and also hold down a job—the basics. It is really transformative for those people. Adequate access to hearing aids, knowing how to set them up, using them. Using other aids to hearing, so having lip-reading facilities and courses available to people, having a broader base of Auslan, where needed, for those patients who are not able to have their hearing restored via the technology available. One of the greatest things we take part in, that I personally take part in, is the cochlear implant program that we run. There are very few things that transform a person more than that program; it is almost a gift to us to be able to work in that area.

Mr GEORGANAS: Talking about all of these services that you have just mentioned—Auslan, hearing aids—are governments delivering them in a good way? Is that anything that perhaps is not quite working, that we could change to deliver those services in a better way?

Dr Makeham : I am not sure I am well placed to answer every aspect of that question.

Mr GEORGANAS: But you do see a lot of ads around the place for hearing aids, free hearing aids; we will give you free tests et cetera. You start to wonder whether—

Dr Makeham : It probably does raise the question of whether the private good or public good model works best in this setting, because there is always a challenge when you have a vested interest in one of the particular hearing solutions when there is a broad number there. If you have a vested interest in one, you are always going to be biased towards recommending that over the other. It is big challenge in the industry that you do see these ads; you do see people who are offered hearing aids where perhaps that might be appropriate for other treatments or whether there are other alternatives there.

The question then becomes whether the net spend that a person places into a hearing aid is necessarily reflective of their benefit. It becomes like buying a car—that is the analogy I use anyway. A person with hearing loss needs to work out, within their budget, what they can afford to get the benefit that they need, but also to update their car—or their hearing aid—on a periodic basis. And when they invest, they do not want to take away their ability to update. There is some data that shows you are better off updating more regularly and not buying the top-of-the-line hearing aid. I guess from a seller of hearing aids, you are probably looking to make the greater margin on the top end. It is a vexed issue, and the technology advances of hearing aids have been excellent. What people achieve from it is impressive, and it really helps a lot of people.

Mr GEORGANAS: Unlike a car, where you might know what you are buying, with a hearing aid most people would not have a clue—

Dr Makeham : Well, you take it on face value, I guess, and on expert advice.

Mr DRUM: With the disparity that you spoke about earlier between our larger cities and our rural and regional areas and/or the Indigenous outcomes, are there documented statistics that we could find to support that?

Dr Makeham : No, there are not. There is some good evidence for the parlous state of Indigenous ear health, but we have very little actual epidemiological evidence of what the disease impact is in our communities, how it differentiates between urban and regional areas. We just do not have great quality evidence of that. Working in the area, it would be truly beneficial. I think it would create a great yardstick for what we actually do. It would feed back on whether we are identifying the people and whether we are treating them well or not. Something we probably really need is the ability to know how prevalent it is; whether people are accessing the services and, if not, why not; and whether we can make them better.

CHAIR: I have one medical question. If you have something like otitis media, does it usually present with pain? Can people have hearing or ear diseases and not realise it?

Dr Makeham : Absolutely, yes. Usually the otitis media scenario is typically an acute infection. It can be either a viral upper respiratory infection—a cold or something of the like—or an acute bacterial disease, which tends to be painful. But the resolution can often leave someone with a hearing loss, which in most cases can resolve spontaneously but, in up to 25 per cent of people, will persist beyond three months and need intervention. A group of those will go on to develop a complication—that really means problems with the eardrum itself. That can lead to a situation of being a chronic sufferer of otitis media, which broadly becomes an unsafe ear scenario where the hearing loss can be permanent. So there is a group where, if they resolve it, they do not necessarily need any further treatment; but the ones who do not resolve and persist are the ones we need to intervene with. Something as simple as grommet insertion can prevent progression of their ear disease to something more sinister—irreversible.

CHAIR: Some submissions to the inquiry have stated that only a small proportion of adults that could benefit from a cochlear implant are receiving cochlear implants. Is that your experience and do you have any hypothesis as to why that would be so?

Dr Makeham : That is my observation and experience, and I think the challenge for us working in the area is to try to reach the purported 90 per cent that we do not reach. I think a big part of it comes back to the fact that people with hearing loss do habituate to it. I think some of the elderly patients perhaps think they are too old to receive benefit. Often the understanding of the severity of the hearing loss and the alternative is poor. The analogy is when you go out to the waiting room and you call someone's name and they do not answer, so you call a bit louder; they do not answer. You yell out; they answer and you say, 'Do you have a problem hearing?' and they say, 'No, I heard you clearly.' So we adapt for it—we raise our voice. I guess the point is that you do not know what you miss. I think a lot of people with hearing loss are not acutely aware of what they are missing; they habituate to it. I think the challenge is to challenge that. One thing you can do in a consultation for other reasons is to say, 'Are you hearing well? Can we measure it more objectively?' I guess we then have a process to measure that objectively.

CHAIR: So there is not a system problem in terms of availability or accessibility to people who can implant cochlear implants?

Dr Makeham : No. I think it is patients' recognition and awareness of the problem, and as soon as you are not seeing specialists or interacting with patients who have had cochlear implants or otherwise, the awareness of that solution is just not there. I guess that is where a screening program can help you, but the question is how you do that. What we do observe is that, once you do one cochlear implant in the community, you often see a number of other people present, because someone has gone from being a problem to having this wonderful thing, and they walk around telling all their mates that they can now hear.

CHAIR: How it has changed their lives.

Dr Makeham : How it has changed their lives.

CHAIR: I have one final, broad question. How do you think we as a country perform in researching hearing loss? Are there some exciting developments on the horizon? Where do you think research and science is taking us in relation to treatments?

Dr Makeham : I think there are two aspects to the research. In the pure science I think we do incredibly well and punch well above our weight. In terms of the exciting developments, it is hard to say where that will go. We already have some great technologies, but they will evolve. A lot of press is given to stem cells, but we do not really know where that will evolve. Where I do not think we do so well in the research is in quantifying the problem that we face.

CHAIR: This comes back to your earlier point.

Dr Makeham : Yes. We do not really know what the true incidence is; we do not know how many people we miss. We do not know the economic cost of having untreated ear disease in a lot of communities. We have estimates of it, based on some studies within the community but also international norms. We know quite well the disease burden in the Indigenous community but, as a whole, we do not necessarily know how much we are missing and how much we are treating.

Mr DRUM: I have one further question, possibly to you, Chair. Is the inquiry going to move into things like vertigo or Meniere's, which is an inner ear problem, or are we mainly just talking about hearing?

Dr Makeham : There is a big overlap, to answer part of that. In Meniere's, obviously hearing is a big part of the problem, and a big core of people benefit from hearing restoration by implantation in the end stage, but also hearing aids, with their balance. Again, I think that is probably something we do not do so well. We have world-leading centres of balance disorders units in Sydney and Melbourne—second to none—but does that translate into everyone having access to those services, rehabilitation services? The answer is probably no.

CHAIR: I am advised by the secretary that we have a large number of submissions looking at those areas, so I think they will be areas that we look at in the course of the inquiry. As there are no further questions, thank you, Dr Makeham, for joining us today. It has been really helpful, and I am very grateful for your time. We hope you bulk-bill, particularly for Mr Drum's questions! The secretariat will provide you with a copy of the Hansard of today's proceedings. If you would like to make any corrections to the transcript or provide further information to the committee, please feel free to do so. Thank you again for joining us.