WHEN SOUND BE­COMES PAIN

Acous­tic shock dis­or­der and how we hear

The Monthly (Australia) - - WHEN SOUND BECOMES PAIN -

“The ear is like an open wound, ” says au­di­ol­o­gist Myr­iam West­cott. Even while we sleep, sound pours through in an un­dif­fer­en­ti­ated flow, which we rely on the brain to fil­ter. That’s of­ten the prob­lem.

It be­gan not with a sound but with pres­sure. A great pulse or force that pushed him back­wards away from the oven and into the kitchen bench. All around him he could see fly­ing frag­ments “like lit­tle mini jets or some­thing whirling past my ears”. It was about 7.30 in the evening, the pub restau­rant was buzzing, the ovens and grill plates “full blast”. Later, he would learn that the tiny pro­jec­tiles were pieces of shred­ded tin from two com­mer­cial spray cans of oil that had fallen be­hind the stove and ex­ploded in the heat. He would re­alise that the noise had been loud enough to stop pa­trons mid mouth­ful, to bring staff run­ning in from the din­ing room and his man­ager down from her up­stairs of­fice. But for now there was only shock. Fleet­ing ques­tions. Had a plane hit the restau­rant? Had he been shot? “It all hap­pened so quickly, of course. But the feel­ing – you can never forget.” Then his boss loom­ing, her face close to his, her mouth mov­ing but noth­ing com­ing out, no words, no sounds. And still the enor­mous pres­sure, now push­ing against his ears, as if he were un­der­wa­ter. And a ter­ri­ble in­ex­pli­ca­ble shriek­ing that he fi­nally re­alised was com­ing from in­side his own head.

Luke* is sit­ting at the ta­ble in his Mel­bourne lounge room. Out­side in the court­yard gar­den a wa­ter fea­ture bur­bles cease­lessly. In­side the tele­vi­sion mum­bles in the back­ground, as it al­ways does dur­ing wak­ing hours. Luke has an open imp­ish face, blue eyes and brown­ish­gold hair that corkscrews into way­ward spikes. He says he was a “prima donna chef” back in the day: provoca­tive, a per­fec­tion­ist, some­times a tease, some­times a tyrant, but above all fast. He had taught him­self to cook for the fam­ily by the age of six – “My mother was a ter­ri­ble cook!” – and worked in kitchens around Mel­bourne – some well known, oth­ers not. For a while he ran his own. Even­tu­ally he sold up and got a job in a ho­tel. Easy work, he thought. No stress. In the kitchen, he likened him­self to an air-traf­fic con­troller, al­ways in com­mand. Oth­ers likened him to Gor­don Ram­say. He didn’t care. There wasn’t time. He thrived on it. Then, on that day in 2007, it all stopped. Some­where in the chaos of the ex­plo­sion, Luke got him­self out­side. He turned off the gas at the mains, and then sat down and put his head in his hands. Peo­ple were talk­ing at him. What hap­pened? Was he okay?

He kept burst­ing into tears. Even the sound of his own car door clos­ing was un­bear­able.

Even­tu­ally he picked him­self up and drove home. All the way there, he could hear that shriek­ing sound. “I re­mem­ber think­ing I just could not live with this. I just re­mem­ber think­ing that sin­gu­lar thought, how aw­ful it was. But I was still hop­ing at the same time it was go­ing to abate.” The next morn­ing, the fright had less­ened and so had the pres­sure in his ears. But the noise was still there. In one sense, Luke was for­tu­nate. Not so far from where he lived was the of­fice of au­di­ol­o­gist Myr­iam West­cott. (If you’ve ever had a hear­ing test or your ears cleaned or had hear­ing aids fit­ted, it was prob­a­bly with an au­di­ol­o­gist – though they do a lot more be­sides.) In the med­i­cal hi­er­ar­chy of hear­ing, au­di­ol­o­gists, known as al­lied health pro­fes­sion­als, gen­er­ally sit a rung or sev­eral be­neath spe­cial­ist ear doc­tors. But these days West­cott is quite pos­si­bly the world ex­pert on an ob­scure, un­der­re­ported but some­times de­bil­i­tat­ing dis­or­der that, she con­cedes, may or may not ex­ist. She is con­vinced it does. Her opin­ion some­times puts her at odds with ear spe­cial­ists and work­ers’ com­pen­sa­tion bod­ies. If she is right (and there is emerg­ing ev­i­dence that she just might be), her find­ings may have broader im­pli­ca­tions for the 30 per cent of the pop­u­la­tion who will ex­pe­ri­ence a more com­mon con­di­tion called tin­ni­tus, and could shed new light on the hid­den world of hear­ing, and the ways in which it tries to pro­tect us from threat. Most of all, West­cott’s find­ings might help peo­ple like Luke.

Now let’s get in­side your head.

“We’ll start with the sim­ple things.” This is Michael Dob­son, a spe­cial­ist ear, nose and throat doc­tor (or oto­laryn­gol­o­gist) with a par­tic­u­lar in­ter­est in the strange things that can hap­pen to our hear­ing. A thin, fine-fea­tured man, he dis­cusses the ear in the same de­lighted ca­dence that David At­ten­bor­ough might ap­ply to an ob­scure species of shell­fish. In fact, Dob­son is hold­ing a small plas­tic model of some­thing that looks a bit like a mol­lusc. Snaking up its ex­te­rior are coloured lines that in­di­cate blood ves­sels. Now he opens it up, clam-like, to re­veal a 3D repli­ca­tion of what lies to each side of our head just be­yond the fleshy pro­tu­ber­ances we call ears. Over the next half-hour we jour­ney up the ear canal, where sound en­ters first as pres­sure waves in the air that waft (or crash) against the eardrum. Then into the en­gine room of the mid­dle ear with its tiny os­si­cles – malleus (ham­mer), in­cus (anvil), stapes (stir­rup) – that op­er­ate as a bony pis­ton to am­plify the vi­bra­tion and send it on through an oval open­ing into the wa­tery coils of the in­ner ear. Here in the spi­ral-shaped cochlea, the vi­bra­tion, now wa­ter­borne, washes through pal­isades of hair cells and is trans­formed first into chem­i­cal sig­nals and then into elec­tri­cal im­pulses that zap up the au­di­tory nerve and into the brain. Which is where things get less sim­ple. The first thing to know is that, un­like ev­ery other sense or­gan, the ear has no mech­a­nism to screen out unwanted in­put. We can blink and spit and snatch our hand from a flame. But we can’t stop sound com­ing in. “The ear is like an open wound,” Myr­iam West­cott has said. Even while we sleep, sound pours through in an un­dif­fer­en­ti­ated flow. Think about it: ket­tles, cat­tle, bird­song, screams, your neigh­bour’s dog, that bang­ing door, your lover on the phone, child in the bath, the click and shunt of your own swal­low­ing and breath. Ev­ery mo­ment of ev­ery day. Which is strange, be­cause that’s not at all how it seems. In fact, the last time you were aware of such a ca­cophony may have been as an in­fant (which might ex­plain the cry­ing). Or more re­cently, for many of us, when you had hear­ing aids fit­ted. (We’ll get to that.)

The reality is that we sim­ply don’t reg­is­ter most of the sounds around us. Our ears process them (and even add a few of their own), and send them up into the brain. But what you end up hear­ing is, well, what­ever you were hear­ing a few moments ago, be­fore you started think­ing about what you were hear­ing. In the ab­sence of a shut­ter to block out noise, it falls to the brain to do the job of fil­ter­ing. The brain learns what mat­ters and what doesn’t. Even in in­fancy we will turn our heads to fol­low our mother’s or fa­ther’s voice. To start with, most of the sounds out there are not rel­e­vant. (I don’t need to know that the traf­fic is still rum­bling down the main road near my house.) And even if they are, we can only fo­cus on one sound at a time. Which means the job of the au­di­tory cor­tex (tucked just above the ears) is to triage the in­for­ma­tion as it comes in. Sounds that we judge as im­por­tant (lover, child) are high­lighted and go to the part of the brain where we con­sciously no­tice them; unim­por­tant sounds sit there, fully heard, half no­ticed. We don’t con­sciously de­cide which noises to hear and which to ig­nore. All of this hap­pens sub­con­sciously and in­vol­un­tar­ily. Hear­ing is a prag­matic and gen­er­ally ef­fec­tive sys­tem, but some­times it breaks down. Au­di­tory in­for­ma­tion gets re­layed to brain cen­tres for mem­ory, com­mu­ni­ca­tion and emo­tion – peo­ple have writ­ten books on the ef­fects of mu­sic on our brains and bod­ies. But our ears, like all our senses, have also evolved to pro­tect us from harm by alert­ing us to po­ten­tial threats (a rus­tle in the grass, the creak of a floor­board). In hear­ing, the same sys­tem that so ef­fec­tively mutes some sounds can am­plify and dis­tort oth­ers. The more po­ten­tially dis­turb­ing or fright­en­ing the sound, the more our brain fo­cuses on it. Which is where things get com­pli­cated. Back at work a cou­ple of days after the ex­plo­sion, Luke started notic­ing other things. Ev­ery time some­one banged a pot, dropped a la­dle or slammed a door,

he jumped. These noises had been the sound­track of his work­ing life; now they were over­whelm­ing. “Ev­ery time I heard a loud sound – I mean, it wasn’t even nec­es­sar­ily loud – I’d be pan­ick­ing. I’d be back at the ex­plo­sion.” Al­most worse, he was floun­der­ing. Or­ders would come in and, in­stead of mem­o­ris­ing ev­ery item, he was lost. “All of a sud­den I was like all of those other peo­ple that I laughed at.” He saw a doc­tor who told him to take a week off. But when he got back noth­ing had changed. He was con­fused, in­ef­fec­tive. He kept burst­ing into tears. Even the sound of his own car door clos­ing was un­bear­able. And, still, that high-pitched ring­ing. Im­pos­si­ble to ig­nore or drown out. An elec­tri­cal whine. The louder the sur­round­ing noise, the louder the whine. “The ring­ing is as com­fort­able as hear­ing half a dozen stu­dents drag­ging their nails down a chalk­board, but with the vol­ume turned up from one to 30.” Luke went to another doc­tor, who di­ag­nosed him with tin­ni­tus.

When Michael Dob­son was in his 30s, he did some­thing he re­grets. He was at home build­ing shelves and used an elec­tric saw to cut up the chip­board. This was 1977 and he was not yet a spe­cial­ist ear doc­tor – nor was he us­ing proper ear pro­tec­tion. He shrugs wryly. “I was silly.” These days Dob­son lives with a per­sis­tent high­pitched squeal in his left ear. That squeal is tin­ni­tus. It can sound like buzzing or whistling or click­ing. Dob­son’s tin­ni­tus sounds like a ci­cada. Most suf­fer­ers learn to live with it (many barely no­tice they have it), but an es­ti­mated 10 to 15 per cent of the pop­u­la­tion are aware of con­stant noise. A smaller pro­por­tion – maybe 2 per cent – en­ter a kind of pur­ga­tory. Un­til about 30 years ago, doc­tors were taught that tin­ni­tus (from the Latin tin­nire, to ring) was some­how pro­duced by the in­ner ear. And that’s how it was treated, mainly by try­ing to im­prove blood flow to the re­gion. Then in the early 1990s an Amer­i­can neu­ro­sci­en­tist called Pawel Jas­tre­boff pro­posed a rad­i­cal model. Rather than fo­cus­ing on ear dam­age or pathol­ogy as the cause of these phan­tom sounds, he ar­gued, we should look to the brain it­self. Tin­ni­tus – the sort that peo­ple no­tice – could in­deed be trig­gered by dam­age or de­gen­er­a­tion in the cochlea, and the new sound might be the brain’s way of com­pen­sat­ing for the loss of sen­sory in­for­ma­tion from the ear (a bit like hum­ming to fill the si­lence in an empty room). Some con­di­tions and surg­eries also seem to pre­dis­pose peo­ple to the con­di­tion. But the trig­ger it­self is of­ten ir­rel­e­vant; it’s what the brain does with it that counts. Jas­tre­boff was in­trigued by ev­i­dence that rel­a­tively few of those re­port­ing tin­ni­tus symp­toms ap­peared to be dis­tressed by them, and that their lev­els of dis­tress had lit­tle to do with the in­ten­sity of the sound. He con­cluded that what mat­tered most was not the noise, but how peo­ple re­acted to it. He pos­tu­lated a pat­tern of links be­tween the parts of the brain that process sound and those that deal with emo­tions, threat and mem­ory. The more at­ten­tion we pay, even sub­con­sciously, the stronger the brain path­ways be­come, spark­ing a cas­cade of changes in the au­di­tory sys­tem. After a while the orig­i­nal sig­nal no longer mat­ters. The sys­tem has be­come self-sus­tain­ing. To­day’s clin­i­cians broadly ac­cept Jas­tre­boff’s neu­ro­phys­i­o­log­i­cal model of tin­ni­tus. Much about the con­di­tion, how­ever, re­mains a mys­tery. Tin­ni­tus can hap­pen in one ear or both, or seem­ingly in­side the head. It is com­monly as­so­ci­ated with hear­ing loss, but some peo­ple with per­fect hear­ing still com­plain of it. Why most peo­ple cope and some don’t is also un­clear. Anx­ious, per­fec­tion­ist per­son­al­i­ties might be more vul­ner­a­ble. The risk might be greater if the sound first ap­pears in re­sponse to a fright­en­ing sit­u­a­tion and rep­re­sents po­ten­tial dam­age or a threat.

Over the years, Dob­son has made peace with his con­di­tion. “When you walked in here to­day and we started talk­ing, I was un­aware of my tin­ni­tus. Now that we’re talk­ing, my tin­ni­tus has come from my sub­con­scious to my con­scious­ness. It’s not wor­ry­ing me, be­cause I know it doesn’t rep­re­sent any­thing bad. But a lot of peo­ple worry about their tin­ni­tus rep­re­sent­ing some­thing bad.” Dob­son knows what ag­gra­vates his: fa­tigue, stress, too much caf­feine. (Other recog­nised trig­gers in­clude qui­nine and anti-in­flam­ma­to­ries such as as­pirin.) These days, he says, he has learnt to use his tin­ni­tus as a sort of biofeed­back mech­a­nism. “When it’s roar­ing, I say, ‘You bet­ter back off; you’re do­ing too much.’”

It turns out that tin­ni­tus is just one of a group of some­times dis­tress­ing hear­ing prob­lems that can hap­pen not only in the ear but also in the brain – some­times en­tirely in the brain. Some peo­ple have full-blown au­di­tory hal­lu­ci­na­tions: hear­ing voices and con­ver­sa­tions that ex­ist only in­side their heads. Oth­ers de­velop an al­most pho­bic re­sponse to par­tic­u­lar sounds of­ten made or in­sti­gated by oth­ers; this con­di­tion is called miso­pho­nia. The sounds in­volved may be loud (the neigh­bour’s dog) or soft (chew­ing, swal­low­ing, even breath­ing). Ei­ther way they are ex­pe­ri­enced as in­tru­sive, some­times un­bear­able. Myr­iam West­cott says she sees a few pa­tients with hal­lu­ci­na­tions, whom she can’t gen­er­ally help, and one or two a week with miso­pho­nia, whom she can.

Suf­fer­ers de­velop a strong aver­sion to ev­ery­day sounds that oth­ers tol­er­ate with ease … When you ex­am­ine the ears they look per­fectly healthy.

For most, the symp­toms re­solved within a few days; for some, they con­tin­ued in­def­i­nitely.

Many years ago when I knew West­cott a lit­tle, she was a round-faced, dread­locked girl with a hy­per­bolic smile and a deep de­light­ful voice. These days she works from a prac­tice she jointly owns, speaks at con­fer­ences here and in­ter­na­tion­ally, gives ev­i­dence in court cases, runs work­shops, and men­tors other clin­i­cians on what to do when hear­ing goes rogue. In the early 2000s, West­cott’s par­tic­u­lar fo­cus had been on another odd set of symp­toms. Peo­ple ar­rived be­wil­dered, dis­tressed and com­plain­ing that some noises – es­pe­cially if loud, sud­den or sus­tained – were am­pli­fied, as if some­one had turned up the vol­ume in­side their heads, of­ten to the point of pain. This is hy­per­a­cu­sis. In the Venn di­a­gram of hear­ing dra­mas, miso­pho­nia and hy­per­a­cu­sis have a size­able over­lap. Suf­fer­ers of ei­ther de­velop a strong aver­sion to ev­ery­day sounds that oth­ers tol­er­ate with ease. Cer­tain sounds be­come un­nat­u­rally prom­i­nent, a process that can in­ten­sify and spread over time. When you ex­am­ine the ears they look per­fectly healthy. Yet the con­di­tions of miso­pho­nia and hy­per­a­cu­sis do dif­fer, in subtle but sig­nif­i­cant ways. West­cott says what is cen­tral is how the pa­tients in­ter­pret the sounds, con­sciously or oth­er­wise. She be­lieves that each con­di­tion has its own in­ner nar­ra­tive and its own sub­con­scious, in­vol­un­tary re­sponse (though not al­ways in that or­der). The miso­pho­nia story goes some­thing like this: “That noise (hus­band chew­ing, dog next door) is in­trud­ing into my space and is un­bear­able.” And the re­sponse of suf­fer­ers ranges from ir­ri­ta­tion through to dis­gust and rage. Those with hy­per­a­cu­sis have a dif­fer­ent in­ter­nal script: “This sound (a dropped plate, a car back­fir­ing) will hurt or dam­age me.” And the re­ac­tion this time is one of fear, even ter­ror. West­cott be­lieves that hy­per­a­cu­sis is a sub­con­scious “threat re­sponse” to sound – and it sets the scene for much that fol­lows. Luke has it. When clients come to West­cott with these symp­toms, the first thing she does is lis­ten. “I ask them to tell me about the se­quence of events, the symp­toms they have, and be­liefs they have around them.” Then she checks their ears, does an au­dio­gram, as­sesses for hear­ing loss, ex­cludes the pos­si­bil­ity of tu­mours. And if she finds noth­ing un­to­ward, she tells them what she thinks is wrong with them.

In the 1990s, anec­do­tal re­ports emerged of a clus­ter of bizarre and un­pleas­ant af­flic­tions af­fect­ing call-cen­tre work­ers who had been sub­jected to a loud, un­ex­pected sound through their head­sets. The phe­nom­e­non was recorded ini­tially in a 1999 Dan­ish pa­per. But it was in 2000 that an Aus­tralian team first iden­ti­fied the con­di­tion and named it. That year, at a Mel­bourne con­fer­ence, au­di­ol­o­gist Jan­ice Mil­hinch and au­di­tory phys­i­ol­o­gist Rob Patuzzi pre­sented a pa­per that they had co-au­thored with au­di­ol­o­gist Janet Doyle. In it they de­scribed work­ers at a large call cen­tre com­plain­ing of tin­ni­tus, hy­per­a­cu­sis, bal­ance prob­lems, headaches, numb­ness or burn­ing of the face, and empti­ness or some­times full­ness in the ear. And pain, of­ten acute – like be­ing “elec­tro­cuted”, “stabbed” and “punched” in the ear. Mil­hinch, Patuzzi and Doyle called it “acous­tic shock”. For most, the symp­toms re­solved within a few days; for some, they con­tin­ued in­def­i­nitely. West­cott knew about the study be­cause Mil­hinch was her boss. When Mil­hinch re­tired, she asked West­cott to con­tinue the work. In the orig­i­nal study, the au­thors had won­dered if some of the symp­toms – no­tably the feel­ings of block­age and pain – might be re­lated to the in­tense and per­sis­tent con­trac­tion of a tiny mus­cle, the ten­sor tym­pani, at­tached to the malleus bone in the mid­dle ear. This lit­tle-known star­tle re­flex was first de­scribed by Swedish ear spe­cial­ist Ing­mar Klock­hoff 30 years be­fore. He called it tonic ten­sor tym­pani syn­drome (TTTS; “tonic” as in “sus­tained”). When West­cott started go­ing through her files, she re­alised that many of the pa­tients she had been treat­ing for tin­ni­tus (40 per cent) and hy­per­a­cu­sis (80 per cent) also showed ev­i­dence of TTTS. It looked like a clus­ter. “The TTTS in­sight was a light-bulb mo­ment.” In the years since, West­cott has mapped these symp­toms ex­ten­sively, and pre­sented her find­ings to some­times scep­ti­cal au­di­ences here and over­seas. In 2012 she ca­joled clin­ics in New Zealand, Spain and Brazil into join­ing hers in tak­ing a snap­shot of ev­ery tin­ni­tus pa­tient on their books, look­ing for match­ing pat­terns. She found them, iden­ti­fy­ing a per­sis­tent clus­ter of symp­toms – trig­gered by a sud­den loud sound, of­ten in­clud­ing tin­ni­tus, al­ways in­volv­ing hy­per­a­cu­sis and TTTS. She calls this clus­ter of symp­toms “acous­tic shock dis­or­der”. (As with post-trau­matic stress, the symp­toms get el­e­vated to a dis­or­der when they don’t go away.) Acous­tic shock dis­or­der can be trig­gered ini­tially by a wide range of sounds. Here are a few ex­am­ples from West­cott’s notes: the starter pis­tol at a school sports event; a threat­en­ing voice at close range dur­ing an as­sault; metal ham­mer­ing on metal; loud ma­chin­ery; an un­ex­pected blow to the ear or head; glass crash­ing; a hand dryer in a pub­lic toi­let. Crit­i­cally, says West­cott, while the vol­ume of the ini­tial noise is a fac­tor, the com­mon link is that the sounds are un­ex­pected and star­tling. Another is the pres­ence of TTTS. The preva­lence of other symp­toms varies. A tan­gle of phys­i­o­log­i­cal and psy­cho­log­i­cal trip­wires can be set off by the sorts of noises on West­cott’s list or even by height­ened anx­i­ety about other sounds (in­clud­ing tin­ni­tus), which in turn can es­ca­late into hy­per­a­cu­sis, mag­ni­fy­ing and en­trench­ing the mid­dle ear’s pro­tec­tive re­flex into the chronic, in­vol­un­tary spasms of TTTS. This is when sound be­comes pain.

By the time Luke met Myr­iam West­cott he thought he was go­ing mad. He had stopped go­ing out, even to the shops. He smoked dope to man­age his symp­toms. He drank for dis­trac­tion. He had seen doc­tor after doc­tor and come away with the im­pres­sion that many saw his con­di­tion as ei­ther man­u­fac­tured or some­how his own fault. His part­ner, Paul, was sym­pa­thetic but be­wil­dered. Friends had stopped vis­it­ing. Painkillers didn’t help. Equally con­fus­ing were the other symp­toms: “The pres­sure in my ears, the type of fright I was feel­ing ev­ery time I heard a loud noise.” He spent days in bed, weep­ing, and thought about sui­cide. Luke says meet­ing with West­cott was the first time he ever heard the word “hy­per­a­cu­sis”. “I’m like, oh, what’s that? But when she ex­plained it I just felt like some­one had pulled the dag­ger out of me. I’m not com­pletely healed, but just by virtue of hav­ing some­one telling me about the con­di­tion and how it oc­curs, I just felt so much re­lief.” West­cott went on to di­ag­nose Luke with acous­tic shock dis­or­der. While he doesn’t get the stab­bing pain, she says his symp­toms place him clearly within the clus­ter. Other doc­tors dis­agree, how­ever. Luke de­scribes one spe­cial­ist walk­ing be­hind him dur­ing a con­sul­ta­tion and, with­out warn­ing, strik­ing a tun­ing fork close to his ear. Luke says he fell to the floor, sob­bing. But even­tu­ally, after years of to and fro, his em­ployer’s worker com­pen­sa­tion in­surer paid him a set­tle­ment based on his on­go­ing symp­toms. Mean­while, West­cott says her trav­els into the world of sub­con­scious hear­ing have af­fected all ar­eas of her prac­tice right down to the sim­ple task of fit­ting hear­ing aids. “Au­di­ol­ogy is a very con­crete pro­fes­sion. We’re taught how to do hear­ing tests. We’re taught how to do hear­ing aids. And we of­ten un­der­es­ti­mate the amount of coun­selling that goes around that.” The hun­dreds of thou­sands of Aus­tralians who’ll end up us­ing aids tend to walk into their au­di­ol­ogy ap­point­ments ex­cited at the prospect of be­ing able to hear again, only to find them­selves flooded with sounds they haven’t heard for a long time – some wel­come, some not. “This can be why peo­ple re­ject hear­ing aids, if they’re not pre­pared for it.” She

By the time Luke met Myr­iam West­cott he thought he was go­ing mad.

says that those who have ear­pieces fit­ted should wear them all the time. It gives our brain a chance to re­learn how to tune out the unim­por­tant in­put. Sim­i­larly, this is what peo­ple with hy­per­a­cu­sis and TTTS have great dif­fi­culty do­ing. West­cott has been a highly ef­fec­tive pro­po­nent for her view­point. She is en­gag­ing, per­sis­tent and some­times in­sis­tent. Google the words “acous­tic shock” and there she is. She ad­vo­cates fiercely on be­half of her pa­tients and has con­tin­ued the work of her pre­de­ces­sor in rais­ing the pro­file of the con­di­tion in­ter­na­tion­ally. Call cen­tres around Aus­tralia and over­seas now use noise­lim­it­ing de­vices and warn staff about risks of acous­tic shock. West­cott es­ti­mates that she has treated at least 150 pa­tients for the con­di­tion – as well as oth­ers with re­lated ail­ments – most of whose symp­toms even­tu­ally abate with ap­pro­pri­ate and care­ful man­age­ment. She says her ap­proach is slowly gain­ing ac­cep­tance from au­di­ol­o­gists and some spe­cial­ist doc­tors. But she is an­gered at the level of dis­tress she sees in clients who have re­peat­edly been told they are fab­ri­cat­ing or ex­ag­ger­at­ing their con­di­tions. She re­ceives emails most days from pa­tients and clin­i­cians around the world, seek­ing guid­ance. “To be frank, even I am a bit sur­prised by how dogged and de­ter­mined I’ve be­come.” So the sug­ges­tion that she might be making things not bet­ter but worse does not go down well.

Robin Hooper has a quiet, al­most halt­ing voice that some­times trails off be­fore the sen­tence has en­tirely fin­ished. On the walls of his small St Kilda Road of­fice are framed cer­tifi­cates: from the Univer­sity of Mel­bourne where he grad­u­ated in medicine and surgery in 1961, a fel­low­ship from the Royal Col­lege of Sur­geons of Eng­land, and another declar­ing him a fel­low of the Amer­i­can Academy of Oto­laryn­gol­ogy from his days liv­ing in New York in the early ’70s. “I was a bit of a rest­less soul for a while.” On the floor be­side his desk a black brief­case bulges with pa­pers and ar­ti­cles, in­clud­ing one he wrote in 2014 ti­tled “Acous­tic Shock Con­tro­ver­sies”. In it he ar­gues that much of what Myr­iam West­cott thinks about acous­tic shock is prob­a­bly wrong. Hooper be­lieves the fo­cus on acous­tic shock since the start of the cen­tury has be­come self-ful­fill­ing, cost­ing mil­lions of dol­lars and per­haps putting pa­tients’ longert­erm re­cov­er­ies at risk.

How do you test for a con­di­tion that is un­pre­dictable and sub­jec­tive – and that need not in­volve struc­tural dam­age to the ear?

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