Bojana S. Transcript

I’m an audiologist by background. I trained in Australia in a place called Adelaide, South Australia. And once I finished my master of clinical audiology, I worked for a period of 10 years as a clinical audiologist in various private and public sectors in Australia. After that, I decided to move into the academic space and work at a university. 

So I worked at La Trobe University in Melbourne for a period of 13 years, and during that time, I taught audiology students — master of audiology students — to become audiologists. And so we have a very particular curriculum that we provide our students with to teach them about how to diagnose hearing loss, how to rehabilitate hearing loss, and so on. And during that time, I decided to also do a PhD in audiology. And as I was looking at potential topics of interest, I learned about brain injury, and I decided to do my PhD in brain injury, and during that period of time, I realized just how prevalent hearing loss and vestibular or balance problems are following any type of brain injury. 

My focus was on non-blast related brain injuries. So, you know, things like closed head injury, but also motor vehicle accident or anything that, you know, where you receive some sort of an impact to the brain, whether through, you know, hitting an object or an object hitting you.

So during that period, as I was doing a lot of research and trying to find out what the prevalence was of hearing loss and balance disorders, I realized that it was quite large. So something like anywhere between 30 to 35 to 40% of some cases — irrespective of severity of brain injury — were presenting with hearing loss, tinnitus, which is a ringing in the ears in the absence of an external sound source, and then various vestibular disorders, with the most common one called benign paroxysmal positional vertigo, which is a type of vertigo or sort of spinning sensation that’s elicited when you move in a particular direction. 

So patients often report this happening when they’re lying in bed, when they wake up in the morning, and they turn to a particular side, and then they experience this very violent spinning sensation, almost like they’re very, very drunk. So this happens in the general population as well. It’s highly treatable, which is amazing, through several — this particular type of maneuver called the Epley maneuver. But for patients who experience some sort of brain injury, this is much more common, and it’s much more bilateral, so it happens to both sides, versus in the general population, it’s more to one particular side.

So then, as I was sort of going through that research and trying to find out what we as audiologists do when patients come to clinic — I would ask audiologists through the several interviews that I’d conducted, “When you are taking a case history, do you ask the patient if they’ve had a head injury?” And most of them would say, “Oh, yes, that’s part of our case history. We do ask that.” 

And so then my next question to them was, “And when the patient says yes, what do you do then?” And they didn’t have an answer to that. So they would merely record that into their notes and move on and continue providing the exact same assessment and the exact same rehabilitation as they would to any other patient. 

So that obviously raised concerns for me that we are working with a large proportion of audiologists who are not aware — they don’t know what to do. Then I went and interviewed program directors of all the audiology programs in Australia to ask them if they teach this material as part of their curriculum, and they did not. So then we can’t expect audiologists to be able to do these things when they’re actually not taught this at university level. So then I went even further than that and looked at guidelines. 

Some of the guidelines, particularly the American and Canadian guidelines, are much stronger in the sense that there is a very particular component in those guidelines — a multidisciplinary aspect where people from various disciplines will come in, and they will play their part in the rehabilitation journey of the patient — but audiology was nowhere to be found. 

So there were some mentions around, you know, dealing with balance disorders and potentially hearing, but an audiologist was not part of that team. So as you can imagine, this was quite shocking to find out, particularly given the quite strong prevalence of 30 to 40%. So then I thought, okay, this is a real issue, a real gap, and we are doing a disservice to patients with brain injury. We really need to do something about this. 

So that’s kind of how I developed an interest and started raising awareness, and that’s part of the reason why I opened up several of these channels on social media to, number one, fight misinformation, and number two, to raise awareness, and hopefully find other people such as yourselves to collaborate with and bring this to the face of where it really should be so that we can potentially do something about it.

Concussion — the symptoms from any type of brain injury or concussion are very varied. You know, from fatigue, from vision, from hearing, from balance, going into the ability to concentrate, the heightened sensitivity to light and all of these things, and then isolation, dealing with relationships and all of those things. I think when we as an audiologist or any other allied health clinician meets with a patient who’s suffered from a concussion, they really need to have this at the back of their mind, because it’s not just any regular patient. 

And I think one of the major issues that I found is that when you have some of these — let’s call them larger issues — like inability to concentrate, heightened sensitivity to light, or cognitive brain fog and things like that, patients are more likely to complain about those things to begin with, and those things take the priority. So then we focus on that, but nobody really thinks about hearing. Firstly, they don’t know that it’s an issue, so unless the patient complains about it, they’re not going to look into it.

And so when we look at hearing as a separate sort of sense, we know that there are three different types of hearing loss. One is what we call a sensorineural hearing loss, where the damage has occurred in the hair cells of the human ear, and that damage is irreversible. So it can range in terms of severity from mild to moderate to severe, and then to profound, where people actually don’t have any measurable hearing levels — they can’t hear anything. They’re deaf. 

What we find in patients with concussion, particularly mild brain injury, is that when we test them on a regular assessment — which is effectively sitting in a soundproof booth with headphones on and presenting some sounds that are what we call pure tones, so it’s like a beeping sound, and every time you hear that sound, you’re asked to press a button — what research tells us is the vast majority of people after concussion, when they’re measured through those headphones in a soundproof booth, record a normal hearing if they had normal hearing previously. 

But what we also find is when we place these people in conditions where there’s a lot of background noise, like in restaurants, or any kind of non-ideal listening environments where we don’t have carpets or drapes over the windows or something that’s actually going to absorb that noise, people have significant difficulties understanding speech in the presence of background noise. 

So then when we go back and we assess further — rather than just that beeping test — and we assess more frequencies into the higher range that we generally don’t assess, and when we assess these people for a speech-in-noise-related test, we find that there’s actually damage in the brain, the part of the brain that actually processes the sound, that wasn’t necessarily there before. So it’s very easy to miss the fact that there’s been a change in their hearing ability based on just that assessment that any regular audiologist would do in clinic. So that’s one aspect. That’s something that’s definitely there that research tells us. It’s coming out more and more now in the last sort of five or six years — a lot more literature is coming confirming this.

And then there’s the other piece around tinnitus. So as I was saying to you before we started recording, tinnitus is an awareness of a sound. It can be something like buzzing, humming, ringing. It can be high-pitched, it can be low-pitched, it can be pulsatile. It can be to one ear, it can be to the other, in the absence of an external sound source. And most people experience tinnitus when they, for example, go to a concert or they go clubbing for a number of hours with their friends, as young people do, and then they go home and wake up in the morning, and then they have that high-pitched sort of dull sound in their ears which goes away. 

For some people, unfortunately, tinnitus can come and it can stay, and it can stay forever. For some people, tinnitus can be very loud, raging, constantly there, never goes away. Now, unfortunately, at this point in time, we don’t have a cure for tinnitus. So what we do as audiologists, we work with people who have tinnitus in managing how they perceive tinnitus and how much it actually distresses them and affects their activities of daily living. 

So we also know that after concussion, somewhere around 30% of people will also develop tinnitus. Which is why it was shocking that most audiologists were not aware of this. And most other professions as well. So that’s the other thing that I have done — developed and provided CPD sessions for other allied health clinicians like speech pathology, physiotherapy, neurologists, just to raise awareness amongst them that this is something that happens as well and who they should then refer these patients to.

And then lastly are the balance problems that I was also telling you about — that people can develop what we call benign paroxysmal positional vertigo. That’s just one, but the most prevalent again.

People can develop other balance disorders as a result of concussion, but BPPV is the most prevalent. So that’s that violent sense of spinning that people can have that’s positional, so turning to a particular side. And in patients post-concussion, versus the general population, we find that it tends to be more bilateral rather than unilateral — so on both sides rather than on just one.

So for people to experience something called BPPV, what happens is we have crystals in the inner ear that should sit in a particular place. When those crystals move out of there, they send signals to the brain that they are in motion when in fact they’re not. So there’s a mismatch between where you are in terms of your posture and your being, versus what the ear is sending to the brain. And that mismatch causes this sensation of spinning, right? So we have ears on both sides. If those crystals are affected on the right side, then if the person moves to the right, that gives that sensation and the person starts feeling a sense of spinning.

So I think — I’m not saying that every single person who experiences concussion will develop difficulties with hearing, tinnitus, or BPPV. But what I’m saying is that 30% of those people will, and of those 30%, they may only experience one of the three. Some may experience all of them, but it doesn’t necessarily mean that all of the 30% will experience all three of them.

It’s certainly something that’s in the back of my mind, to set up a clinic that helps patients who have experienced concussion when it comes to these things. So at the moment, most of my work relates to research and to providing these talks and CPD events for allied health clinicians, and then the social media aspect. So that’s kind of where most of my work is now.

I think for allied health clinicians, one major thing that is really, really important is to understand — and I’m sure that most people do understand this, and I in no way want to offend any allied health clinician out there because they’re doing incredible work — but what I do find is, depending on where people work and how much pressure they’re under, when a patient does come to them, a lot of people in those moments don’t realize that when a patient with concussion enters your room, those people may not be in the position to advocate for themselves. 

And what we do as allied health clinicians, particularly if it’s out of our scope of practice, we go, “Okay, not my problem. Here’s a referral, go see somebody else.” But when you are someone who has just gone through something like a concussion, you are finding it very challenging on a cognitive level to be able to absorb that information and to follow through. So I think then the onus needs to go back to the person in that room to pick up the call, to make that appointment, and to follow through on behalf of that patient. Because if they don’t, that patient will fall through the cracks. And we don’t want that to happen. No allied health clinician wants that to happen.

I also think there is something called cross-disciplinary care. And cross-disciplinary care effectively means if I’m an audiologist and you’re a physiotherapist, and I diagnose the balance disorder, you could treat that balance disorder. That’s cross-disciplinary care. Now, multidisciplinary care is where we all come together. I do my bit, you do your bit. We meet, we discuss what’s happened for this patient, and that is the only way that we can actually create positive outcomes for this patient — if there’s actually communication and we work together to do that. 

So I think much more of that needs to happen. Much greater communication needs to happen. The notes that I take on my laptop during a clinical appointment remain on my hard drive. They don’t go anywhere. So I think it’s really important that we find ways to work more with one another, and to advocate for those patients who can’t advocate for themselves.

So I think that’s my main message out there to the allied healthcare workforce. But also, if you are the significant other of a patient with brain injury and if you have high health literacy, I also want those people to remember that. So if they don’t observe this happening for their loved one, they need to push for that. But then what do we do with the people who don’t have high health literacy? Who is going to look after them? And this is where it’s critical for those allied health clinicians to find time in their day to do that for them.

I think also for patients — if they do notice difficulties with understanding speech in noise, and if they go and see an audiologist and they tell them, “It’s all fine. You’re good. Go home.” I just want those people to feel validated to know that even though that hearing test comes up normal, that doesn’t mean that you can hear normally in background noise. So there are definitely strategies there that can be utilized to minimize that. I’m happy if there’s anything or any way that I can assist — I’m happy for people to contact me directly. I’m happy to advocate for people if they need that. So please share that around. I’m not afraid of hard work, and I’m not afraid of helping people where it’s needed.