September 22, 2009

Blast-Related Ear Injury in Modern Warfare

Blast-Related Ear Injury in Modern Warfare

Three years after Gulf War I in 1990-1991, the Army had its first increase in hearing loss since 1974 when new hearing loss tracking methods where adopted (Chandler, 2006; Mcllwain, Gates, and Ciliax, 2008). With a 360 degree battlefield with no defined frontlines, as high as 90% of soldiers have served in a battle zone and 68% have actually engaged in combat. The realities of modern warfare have placed more than 469,095 soldiers on two to three tours of duty, fast becoming the norm. Never before have our combat troops been exposed to more than 200 days of combat in one tour, an operational tempo superior to that of WWII and Vietnam (Lee, 2009).

Further, the survival rate of wounded warriors has risen to 88%, up from 78% from the first Gulf War. About 68% of the wounded have a blast-related injury directly related to the improvised explosive device (IED), the leading weapon in the enemy’s arsenal (Mcllwain, et al., 2008). With new technology and the latest in medical advances, more soldiers survive their wounds (Chandler, 2006). The risk of hearing related injuries have exponentially exploded for the modern warrior.

According to Chandler (2006), of the 257 combat soldiers examined they found that 64% had ear injuries and hearing loss. Mcllwain et al. informs us that 47% of all medical evacuations were blast related injuries, accounting for the majority of battle related wounds. The report makes an exclamatory claim that 51.8% of combat soldiers have “moderately severe hearing loss or worse.” Lew, Jerger, Guillory, Henry (2007) report that 62% of soldiers studied and diagnosed with a blast-related traumatic brain injury (TBI) had self-reported hearing loss while 38% reported tinnitus. The majority of blast-related ear injuries were sensorineural in nature and the soldiers hearing potential will worsen over his or her lifetime (Chandler, 2006, Lew, et al., 2007).

In the coming future the Department of Defense (DoD) and the Veterans Administration (VA) will have increasing difficulties and possibilities of misdiagnosing hearing loss as an affect related to a traumatic brain injury (TBI) and or psychological problems (Chandler, 2006; Fagelson, 2007; Henry et al., 2007). Fagelson (2006) reports that, “34% of the first 300 patients enrolled in the [Veterans Administration Medical Center] VAMC Tinnitus Clinic also carried the diagnosis of [Posttraumatic Stress Disorder] PTSD” (p. 107). Further exacerbating the already precarious situation for our war wounded. Military interdisciplinary teams work together to prevent such misattributions and diagnoses and provide a holistic approach to meeting the needs of the wounded soldiers.

In the last two decades the military has cut funding to hearing conservation programs, even after research has proven the program works. As a result we have seen a marked increase in soldiers and veterans with hearing problems that tend to plague them in later years as most hearing problems increase over the years. A dreary outlook as the increase of blast-related ear injuries will continually add to the already overburdened VA (Chandler, 2006; Mcllwain et al., 2008) .

Insights and Infantry Soldiers Concerns with Hearing Conservation

The modern military Hearing Conservation Program (HCP) has been an evolution of procedures, laws and acts dating back to the General Law of 1862 and the Disability Act of 1890 that recognized hearing loss as a disability. In the first half of the twentieth century little headway was made in the advancement of hearing conservation. In the beginning of the 1900’s it was assumed that hearing loss could be prevented if a solider developed a tolerance to loud noises. This belief in a “tolerance theory” fed the Army attitude that if a soldier avoided loud noises they were considered weak (Mcllwain et al, 2008).

Soldiers in the British Army were largely ignorant of a HCP as late as 2007, fueling increases in hearing related disabilities. With noise levels of 90 decibels (dB) were enough to cause hearing damage. The infantry units were regularly exposed to levels ranging from 145 to 200 dB, enough to cause hearing impairment to a high percentage of soldiers. The report estimates that only 22% knew about a military HCP and the majority (91%) of troops said that their reasons for not wearing hearing protection or use them improperly was due to personal experiences in firearm training and combat. The soldier firing their weapons in many different atmospheres evokes a situation where extreme conditions could foster greater advancement in the research and study of hearing loss, hearing loss prevention and tinnitus (Okapala, 2007).

Tinnitus and Posttraumatic Stress Disorder

Approximately 3 to 4 million veterans have tinnitus with almost 1 million in need of varying levels of interventions (Henry et al., 2007). An avalanche of research finds evidence for a connection between tinnitus and PTSD, suggesting a co-occurring relationship and related neural mechanisms. Similarities in diagnostic criteria for symptoms of increased arousal compared to the diagnostic criteria for tinnitus, such as difficulty in falling asleep, irritability or outburst of anger, difficulty concentrating, hypervigilance and exaggerated startle response. Sleep disorders symptomology and concentration difficulties translate directly to tinnitus screening measures (Fagelson, 2007).

Several neural mechanisms linked to both tinnitus and PTSD affect auditory behaviors. Audiologists should be aware that patients with tinnitus and PTSD will require test protocols and referrals that address these powerful responses (p. 107).

Such misattributed symptoms as hypervigilance and exaggerated startle response have a relational context to irritation and anger and could be associated with tinnitus and or PTSD. The overlap of symptoms suggests that the presence of both diagnoses would exacerbate either condition bi-directionally, of 300 patients studied, 34% had both conditions.

Audiology testing must incorporate sensitivities to patients with diagnosed and undiagnosed PTSD as the startle reflex could be increased with the sudden tones and high pitches related to auditory testing. Many patients self-report the resounding silence within the sound booth as an anxiety stressor, and listed many offending characteristics of the hearing screening regimen. Trauma related disorders and audiology assessments should include screening criteria for both tinnitus and PTSD along with clinical evaluations in mental health primary-care settings.

Recognition from both clinical practices in terms of assessment protocols and treatment modalities would benefit both conditions and clinicians in. By combining a hybrid system of assessment and treatment of best-practices from audiological procedures, mental health practices and primary-care physicians on the psychological effects and the similarities in assessing for PTSD, tinnitus and hearing loss with a central focus on the impact of proper appraisals on effective treatment.

Auditory Dysfunction in Traumatic Brain Injury

“Hearing loss and tinnitus are highly prevalent in the growing population of returning soldiers who have a blast related TBI. Thus we need to develop and implement strategies for diagnosis and management of auditory dysfunction in this population” (Lew et al., 2007, p. 925). Inpatients in the VA’s rehabilitation unit admissions for TBI have increased 47% since the beginning of Operation Iraqi Freedom (OIF). A subgroup of blast related (BR) veterans were reported as having 62% hearing loss with 38% of this group with tinnitus giving a clearer picture of the growing population of veterans with hearing loss attributed to TBI’s.

Forty months before the beginning (group I) of OIF and forty months after (group II), the two groups were compared, and found that group II had a significant amount of younger veterans with BR-TBI and hearing loss. This matter of younger veterans with TBI and hearing loss marks a significant change in the topology and identification of a growing population of veterans who have limited resources within the VA for an ever growing pool of patients. “In light of the high prevalence of hearing loss and tinnitus in this growing population of returning soldiers, we need to develop and implement strategies for diagnosis and management of these conditions” (p. 921).

Hence, while identifying issues with the assessment and services the full exposure and extent of problems within the continuum of care along with the bureaucratic entanglement and a lack of funding impeding effective treatments. With the battlement of statistics and cross-analytics encompassing the VA’s endless study of the problem we will see an insignificant addressing of the quandary in the short term. Endless speculation as to the causes and no end in sight to the ramblings of those that need “proof positive” before treatment remedies can begin to trickle down to the masses of veterans needing services.

Mental Health Services and Veterans with Auditory Disorders

In stark contrast to Lew et al., Kendall and Rosenheck (2008) declares that, “Although veterans disabled by auditory disorders seem to readily connect with VA mental health services, the reduced frequency or repetition of services use may require intervention” (p. 1357). They hypothesize that veterans with auditory disorders would use the VA mental health facilities less due to communication difficulties. The initial results found that disabled veterans with hearing issues had used VA mental health services at least once. Later the article states that although veterans with auditory disorders were more likely to seek initial mental health care, they were less likely to follow up on subsequent visits. This remains a national problem due to the steadily increasing in this population since 2001 will undoubtedly rise rapidly with our modern wars. In fact the report indicates that in the years 2005 there were 822,413 veterans diagnosed with a service-connected disability, a 176.2% increase in auditory disorders.

There has been some evidence that veterans with posttraumatic stress disorder (PTSD) and tinnitus have a link; it was reported that 34% of veterans seeking mental health care have both disorders. As in the VA means testing system, once you have a diagnosis equal care is given on a scale of service-connection to the medically retired.

Psychometric measures including; audio disorders, mental health disorders and traumatic brain injuries when assessed properly can be maximized through better assessments, best-care practices and joint cooperation among the differing divisions of the VA. “Mental health providers may also benefit from working as a team with other providers such as audiologist, otologists and primary care providers” (p. 1357).

Progressive Audiologic Tinnitus Management

The underlying nascence of this report collocates within the audiologic disorder of tinnitus. Tinnitus pervades and overlaps many of the audiological disorders and weaves its influence on PTSD. As we begin to better understand the nature of the most prevalent of combat injuries we perceive a depth and breadth of understanding what this actually means. PTSD, tinnitus, hearing loss and TBIs intersect into an astounding colloquial arraignment giving new meaning to the walking wounded. To meet this new paradigm we must garner new and improved assessments and treatments encompassing an amalgamation of best-fit practices and effect implementation immediately. Progressive Audiologic Tinnitus Management (PATM) modality fits this description and seeks to raise awareness to a multitude of divisions, service centers, physicians and practitioners from a holistic approach (Henry et al., 2008).

About 20% of veterans suffering from tinnitus require a clinical intervention which necessitates a progressive management approach, providing triage guidelines to facilitate appropriate care for the veteran with tinnitus and other presenting problems such as physical trauma, mental health problems, ear pain or drainage and depending on a categorical fit they would be referred to Ear, Nose and Throat (ENT), the audiology department, mental health or other specialist.

The PATM delineates which level of care the veteran would need based on a few short surveys and gives direction on the next steps such as education, interventions and treatments. The PATM consists of a five level “hierarchical approach [that] minimizes the impact of tinnitus on the patient’s life as efficiently as possible while simultaneously providing cost-effective management” (p. 14). By bringing together a concise and efficient overview of the helping process for the clinician in a generic way highlights and reinforces a collaborative spirit in assessments and treatments. Disseminating standardized direction to the helper that will best serve the veteran, a solution that would benefit from a system wide adoption within the VA system today.

Tinnitus Treatment with Customized Acoustic Neural Stimulus

Various types of treatments can significantly reduce the symptomology of hearing disorders and comorbid PTSD such as the PATM program and the Nueromonics Tinnitus Treatment (NTT) program which combines the use of acoustic stimulus augmented by a clinician and providing a structured counseling program for tinnitus management. The overall success rate of 86% gives ample reason to suspect replication of the new treatment modality and assessments across the VAMC, affecting clinical care settings such as; primary care, mental health, and emergency rooms would bring about much needed systemic change. Clinicians looking to improve the assessment of veterans with auditory disorders with mental health comorbidity would benefit from NTT.

The NTT approach “involves the use of a customized neural stimulus. This stimulus is delivered to the patient in the form of a pleasant acoustic sensation that is spectrally modified according to each patient’s individual audiometric profile” (Davis, Wilde, Steed, and Hanley, 2008, p. 330).

With the ever increasing soldiers joining the walking wounded, we need clear and concise assessment tools and treatment practices that can translate easily across the VAMC so that we can better serve those who served us. Practitioners who become more aware of the culture of the deaf and hard of hearing veterans could better accommodate their needs and help evolve the person-in-environment approach within the VAMC. By becoming aware of the unique needs of our returning soldiers and veterans we will gain an honorable response to their honorable service.


Chandler, D. (2006). Blast-related ear injury in current U. S. military operations: Role of audiology on the interdisciplinary team. The ASHA Leader, 11(9), 8-9, 29.

Davis, P. B., Wilde, R. A., Steed, L. G., and Hanley, P. J. (2008). Treatment of tinnitus with a customized acoustic neural stimulus: A controlled clinical study [Abstract]. ENT-Ear, Nose and Throat Journal, 87(6), 330-339.

Fagelson, M. A. (2007). The association between tinnitus and posttraumatic stress disorder. American Journal of Audiology, 16, 107-117.

Henry, J. A., Zaugg, T. L., Myers, P. J., and Schechter, M. A. (2008). Progressive audiologic tinnitus management. The ASHA Leader, 13(8), 14-17.

Kendall, C. J., and Rosenheck, R. R. (2008). Use of mental health services veterans disabled by auditory disorders. Journal of Rehabilitation Research and Development, 45(9), 1349-1360.

Lee, S. A. (2009). Government and private service providers: Soldiers and veterans stuck in between. Unpublished manuscript, Kent School of Social Work, University of Louisville.

Lew, H. L., Jerger, J. F., Guillory, S. B., and Henry, J. A. (2007). Auditory dysfunction in traumatic brain injury. Journal of Rehabilitation Research and Development, 44(7), 921-928.

Mcllwain, D. S., Gates, K. and Ciliax, D. (2008). Heritage of army audiology and the road ahead: The army hearing program. American Journal of Public Health, 98(12), 2167-2172.

Myers, P. J., Henry, J. A., Zaugg, T. L., and Schechter, M. A. (n. d.). Progressive audiologic tinnitus management for veterans [Brochure]. Portland, Oregon, and Tampa, Florida: Veterans Administration (VA) National Center for Rehabilitative Auditory Research, VA Medical Center, Department of Otolaryngology/Head and Neck Surgery, and James A. Haley VA Medical Center.

Okapala, C. E. (2007). Knowledge and attitude of infantry soldiers to hearing conservation. Military Medicine, 172(5), 520-522.


  1. Scott,
    A great paper that will hopefully help veterans suffering from hearing problems. I know the issues you write about in your blog are making a difference with veterans, soldiers and their families.
    May God continue to bless you.

  2. Most of my flashbacks are triggered by silence because I remember the second my ears started ringing.It happened when a IED blew up on my platoon. I can't help but being reminded of that day every time it gets silent enough to not cover up the ringing in my ears.

  3. I remember when the ringing started in my ears too. We were outside of our vehicle taking a break from the battle. I was standing on the back of my vehicle and enemy artillery impacted far enough out of the kill zone. When I jumped back into my vehicle it was difficult to hear over the intercom and differentiate voices from the ringing. I've never been without since.


Please share your comments, stories and information. Thank you. ~ Scott Lee