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Healthy living after treatment of childhood, adolescent, and young adult cancer

Hearing Loss after Cancer Treatment
Some chemotherapy drugs, other medications, or radiation needed for treatment of childhood cancer can damage
hearing. Hearing loss interferes with daily living. If you received these treatments, it is important to have your hearing
checked and to obtain treatment if hearing loss is found.
How do the ears work?
It’s easier to understand hearing loss if you understand how theears work. The ear is made up of three main parts, known as theouter, middle, and inner ear.
Outer earSound waves travel through the air and first enter the bodythrough the outer ear. The part of the ear that can be seenoutside the body is called the pinna. The pinna collects andfunnels sound into the auditory (ear) canal. The auditory canal islike a tunnel. It makes the sound louder and directs it toward themiddle ear.
Middle Ear
The eardrum separates the outer ear from the middle ear, a chamber that is normally filled with air. Inside the middle
ear are three tiny bones (ossicles) that form a chain connecting the eardrum to the opening of the inner ear. Soundwaves cause the eardrum to vibrate. These vibrations cause the three tiny bones in the middle ear to move, transmitting
the sound to the inner ear.
Inner EarThe inner ear is known as the cochlea, and it is filled with fluid. The cochlea contains thousands of tiny nerve endings,known as sensory hair cells. Sounds travel in waves through the fluid of the inner ear. The sensory hair cells change
the sound waves into nerve impulses that are sent to the brain by way of the auditory nerve (also known as the eighth
cranial nerve). In the cochlea, the sensory hair cells are arranged in order of pitch, from low-pitched sounds (such asa man’s voice) to very high-pitched sounds (such as a bird’s chirping). Each hair cell is sensitive to a specific range ofpitches.
What are the types of hearing loss?
Hearing loss that occurs in the outer or middle ear is called conductive hearing loss. This means that the hearing
loss is due to a problem in transmission of sound from the air to the inner ear. An example of this would be changes
in hearing because of fluid collection in the middle ear. Sometimes this happens when people have ear infections. The
fluid “muffles” the sound when it is traveling through the middle ear.
Hearing loss that results from damage to the inner ear or auditory nerve is called sensorineural hearing loss. An
example of this would be damage to the sensory hair cells in the inner ear from chemotherapy. Even though soundwaves still move through the inner ear fluid, they can no longer be changed into nerve impulses, so the sound does notreach the brain. Sensory hair cells that process high-pitched sounds are usually damaged first, followed by damage tothe sensory hair cells that process lower-pitched sounds.
Hearing loss with both conductive and sensorineural components is called mixed hearing loss.
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Healthy living after treatment of childhood, adolescent, and young adult cancer

What types of cancer therapy increase the risk of hearing loss?
The following cancer treatments can potentially cause hearing loss:• Cisplatin chemotherapy• Carboplatin chemotherapy if given in high doses for hematopoietic cell transplant (HCT) conditioning• High doses of radiation (30 Gy or 3000 cGy/rads or higher) to the head or brain• Surgery involving the brain, ear or auditory (eighth cranial) nerve• Certain antibiotics (medicines used to treat infections) and diuretics (medicines that help the body get rid ofexcess water)
What are the effects of childhood cancer treatment on hearing?
High doses of radiation to the ear or brain can cause inflammation or ear wax buildup in the outer ear, problems withfluid buildup in the middle ear, or stiffness of the eardrum or middle ear bones. Any of these problems can result in
conductive hearing loss. Radiation can also damage the sensory hair cells in the inner ear, causing sensorineural hearing
loss. Damage from radiation may affect one or both ears, depending on the area of radiation treatment. Conductive
hearing loss may improve over time, but sensorineural hearing loss is usually permanent.
Platinum chemotherapy (cisplatin and/or carboplatin) can cause damage to sensory hair cells in the inner ear, resulting
in sensorineural hearing loss. Most often, the effect is similar in both ears and is permanent.
What are the symptoms of hearing loss?
Symptoms of hearing loss may include:• Ringing or tinkling sounds in the ear• Difficulty hearing in the presence of background noises• Not paying attention to sounds (such as voices, environmental noises)• School problems (see related Health Link: School after Cancer Treatment)• Some people may have no symptoms at all
What monitoring is recommended?
People who are age 6 or older should be screened with a pure tone audiogram (hearing screening test). Children
younger than age 6 or those who have abnormal results on their screening test should be evaluated by an experienced
audiologist (a professional trained in hearing disorders).
• H earing is usually evaluated by a series of tests. During an audiogram, the person wears earphones and listens forsounds of different pitches and different degrees of loudness. Speech audiometry tests the person’s ability hearsingle words and sentences. Tympanometry tests the status of the middle ear and the movement of the eardrum
in response to a puff of air.
• People who are not able to have an audiogram (such as those who are too young or who cannot understand thetest instructions) can have their hearing tested using Auditory Brainstem Response (ABR). The person having thistest is usually given medicine so that they go to sleep, and then their brainwave responses to various sounds arerecorded.

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Healthy living after treatment of childhood, adolescent, and young adult cancer

How often should hearing be tested?
Everyone who had cancer treatment that can affect the ears (such as cisplatin and high doses of carboplatin, highdoses of radiation to the brain) should have their hearing tested yearly until they are 6 years old, then every 2 years
until they are 12 years old and then every 5 years. If hearing loss is found, testing should be repeated yearly or asadvised by an audiologist. In addition, hearing should be tested anytime a hearing problem is suspected.
What can be done if hearing loss is detected?
If hearing loss is detected, it is important to be under the care of an audiologist or otologist (doctor who specializes
in hearing disorders). Hearing loss can cause problems with a person’s ability to communicate and carry out daily
activities. Younger children are at higher risk for school, learning, and social difficulties, and problems with language
development. It is therefore very important for a person with hearing loss to find the services that will best help tomake the most of their ability to communicate well. There are many options available, and these can be used invarious combinations, depending on the hearing problem.
•Hearing aids make sounds louder. Several types are available, depending on the age and size of the person
and the extent of hearing loss. Most children under 12 years of age wear a behind-the-ear model to allow foradjustments as the child grows. These are available in a variety of colors—allowing for personalization andassisting with the child’s acceptance of the hearing aid. Teenagers and adults may benefit from a smaller,
in-the-ear or in-the-canal model. It is very important that the hearing aid batteries are fresh and that thehearing aid is turned to the “on” position when in use.

•Auditory trainers (also known as “FM trainers”) are devices that are particularly useful in the school setting.
The person who is speaking (usually the teacher) wears a microphone that transmits sound over FM radio
waves. The person with hearing loss wears a receiver that picks up the sound. This device can be worn
alone or attached to the hearing aid and allows the person with hearing loss to hear the speaker clearly,
even in a noisy environment.

•Other assistive devices are also available for people with hearing loss. These include telephone
amplifiers and teletypewriters (TTYs—sometimes also referred to as Telephone Devices for the Deaf orTDDs). Specialized appliances designed for people with hearing loss include alarm clocks that vibrate andsmoke detectors with flashing lights. Closed captioning for television is widely available. The Internet isalso a helpful communication tool for people with hearing loss, providing options such as e-mail, online
discussions, and access to information via websites. Additionally, cell phones offer text messaging, instantmessaging, Internet access, and photo transmission.

•Telecommunication relay services are available in video and voice/text formats. The video relay service
is internet-based and allows a person using signed language to communicate via a video interpreter, whotranslates the signed language into voice or text. The voice/text relay service allows a person using ateletypewriter to communicate through an operator, who then relays the message to the hearing person in
spoken form.

•Cochlear implants may be an option for people with profound hearing loss who are unable to benefit fromhearing aids. These electronic devices are surgically placed behind the ear and electrodes are threaded
into the inner ear. A microphone and speech processor are then used to transmit sound to the electrodes,
stimulating the auditory nerve and allowing sound perception by the brain. After the cochlear implant isinstalled, auditory training is given for a period of time to teach the individual to recognize and interpretsounds.

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Healthy living after treatment of childhood, adolescent, and young adult cancer•

Alternate or supplementary communication methods, including speechreading, signed language andcued speech, are available for people with significant hearing loss. Spoken language may also be an option,
but usually requires an intensive educational approach with speech therapy. In the United States, healthcareorganizations that receive federal funding are required to provide sign language interpreters when requested
by a patient.

•Community and educational resources in the United States include services through local public school
districts or referral agencies (available under the IDEA legislation, PL 105-17), such as intensive speechtherapy and auditory trainers for classroom use. Sometimes special accommodations, such as seatingin the front of the classroom are all that is needed, but this usually requires that the parent request an
Individualized Education Plan (IEP) for the child through the school district (see related Health Link: Schoolafter Cancer Treatment). Many hospitals have a teacher or school liaison that can assist with arranging for
the IEP and other specialized services that may be needed. The Americans with Disabilities Act (ADA, PL101-336) guarantees people with hearing loss equal access to public events, spaces and opportunities,
including text telephones and telephone amplifiers in public places, and assistive listening devices intheaters. Some theaters also offer special showings of newly released movies with captioning.

What can I do to protect my hearing?
If you have experienced hearing loss, or have received therapy that has the potential to damage your hearing, youshould discuss this with your healthcare provider. Be sure to obtain prompt evaluation and treatment for ear infections,swimmer’s ear, and earwax impaction. Whenever possible, ask your healthcare provider to consider alternatives tomedications that have the potential to cause further hearing loss, including certain antibiotics (aminoglycosides suchas gentamicin), certain diuretics (“loop diuretics, such as furosemide), salicylates (such as aspirin) and medications
for high iron levels. You should also take care to protect your ears from loud noises. In fact, loud noises can causesignificant damage to your ears. Examples of items and activities that can be hazardous to your hearing include:
Appliances
Power saws
Vacuum cleaners
Lawn mowers
Yard trimmers or leaf blowers

Occupations
Firefighters
Construction workers
Farmers
Airport workers
Cab, truck, and bus drivers
Hair stylists: constant exposure to loud hair dryers

Recreation
HuntingBoating or water skiing
Motorcycling or four-wheeling
Stereo headphones
Amplifiers

If you cannot avoid exposure to noise, you should:• Wear hearing protectors such as ear plugs or ear muffs• Limit periods of exposure to noise (for example, if you are at a loud concert go to a quieter area for a while togive your ears a break)•Be aware of the noise in your environment and take control of it when you canWritten by Wendy Landier, PhD, CPNP, Children’s Hospital of Alabama, Birmingham, AL. Portions adapted from “Noise and Hearing
Loss, Do You Know…An Educational Series for Patients and Their Families,” St. Jude Children’s Research Hospital, Memphis, TN(used with permission).
Reviewed by L. Foster, MD, MPH; Beth Fisher, DNP, APRN, CPNP; and Melissa Acquazzino, MD, MS.
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Healthy living after treatment of childhood, adolescent, and young adult cancer

Additional health information for childhood cancer survivors is available atwww.survivorshipguidelines.org
Note: Throughout this Health Links series, the term “childhood cancer” is used to designate pediatric cancers that may occur during childhood, adolescence, or young adulthood.
Health Links are designed to provide health information for survivors of pediatric cancer, regardless of whether the cancer occurred during childhood, adolescence, or young
adulthood.
Disclaimer and Notice of Proprietary Rights
Introduction to Late Effects Guidelines and Health Links: The Long-Term Follow-Up Guidelines for Survivors of Childhood, Adolescent, and Young Adult Cancers and accompanying Health
Links were developed by the Children’s Oncology Group as a collaborative effort of the Late Effects Committee and Nursing Discipline and are maintained and updated by the Children’sOncology Group’s Long-Term Follow-Up Guidelines Core Committee and its associated Task Forces.
To cancer patients (if children, their parents or legal guardians): Please seek the advice of a physician or other qualified health provider with any questions you may have regarding a
medical condition and do not rely on the Informational Content. The Children’s Oncology Group is a research organization and does not provide individualized medical care or treatment.
To physicians and other healthcare providers: The Informational Content is not intended to replace your independent clinical judgment, medical advice, or to exclude other legitimate
criteria for screening, health counseling, or intervention for specific complications of childhood cancer treatment. Neither is the Informational Content intended to exclude other reasonable
alternative follow-up procedures. The Informational Content is provided as a courtesy, but not intended as a sole source of guidance in the evaluation of childhood cancer survivors. The
Children’s Oncology Group recognizes that specific patient care decisions are the prerogative of the patient, family, and healthcare provider.
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