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Do you routinely ask your patients if they have a history of military service? You should. -- either as an active duty, Reserve, or National Guard member -- is associated with an increased risk of auditory injuries, including hearing loss, tinnitus and hyperacusis, and those injuries can negatively affect veterans' quality of life for years to come.

At least . Tinnitus and hearing loss, in fact, are the two most common service-related disabilities.

Auditory injuries are so prevalent among veterans that they have been called

Moreover, unlike in the general population where hearing loss is more common in older individuals, auditory injuries are startlingly common among younger veterans who have served in Afghanistan and Iraq. According to the Hearing Health Foundation, 60% of veterans who served in Afghanistan and Iraq returned home with hearing loss and/or tinnitus.

Yet, because auditory injuries are often not readily apparent, they are frequently overlooked.

The Soldier's Life

Modern military life is noisy.

In addition to noise typically found in civilian life -- cars, machines, loud music -- soldiers are also faced with military-specific auditory insults.

Military-grade weapons are "often louder and more damaging to the ears than standard sportsman-type weapons," said Col. Mark Packer, MD, director of the Department of Defense's Hearing Center of Excellence. "The transport systems we use to move troops and equipment are much louder than their civilian counterparts. We also put folks in environments where we have to use generators to make electricity, so we have people living next to generators. There are also unexpected, impact noises from blasts and combat."

Both chronic and acute noise exposure can damage enlisted personnel's hearing, and it's not uncommon to see veterans whose hearing has been degraded both by chronic and acute noise exposure. Acute auditory events -- such as the explosion of an improvised explosive device -- can cause sudden dramatic changes in hearing and may get more attention than auditory injuries that occur over time.

But, unfortunately, even acute auditory injuries can be overlooked because blast exposures result in other serious, obvious, and potentially life-threatening injuries. In that scenario hearing often becomes a low priority concern.

The uniformed services are, however, trying to diagnose -- and possibly prevent -- auditory injuries with a robust hearing health program that emphasizes screening, education, and hearing protection.

In 2009, the Department of Defense established the Hearing Center of Excellence, which "deals with everything from prevention through rehabilitation for every case of hearing loss and auditory injury," Packer said. "We're also working to develop a registry system that will be used to encourage and facilitate the conduct of research, the development of best practices, and the development of educational tools."

Consistent and regular auditory screening is an important part of the program. Ideally, members will undergo a baseline audiogram at the start of service. Audiograms will be repeated at least annually, or more often, depending on members' occupational exposure. Audiograms and other hearing screenings will also be performed as needed. ("If someone has hearing symptoms, intervention at that time provides documentation of the injury, as well as an opportunity to give education and recommend appropriate levels of hearing protection," Packer said.) An exit audiogram, performed at the end of service, will document the effect of service on any particular service member's hearing.

After Discharge

Because many veterans seek healthcare outside of the VA medical system, all primary care providers should assess all patients for a history of military service, regardless of age, sex, or gender. Ask veterans about the details of their service:

Where did they serve? When? What kind of work did they do? Did they suffer any acute or chronic auditory injuries or assaults?

These details may provide insights into their auditory health -- but be careful of generalizations based on service history. According to a 2010 epidemiological study reported in the general officers and executives, enlisted trainees and scientists and professionals reported higher rates of noise-induced hearing injuries (NIHI) than infantry and gun crews.

Although the AJPM authors note that "this finding may indicate under-reporting of NIHI among combat arms and equipment repair occupations," it's important to remember that all veterans -- even those who worked far from the front lines -- are at risk of auditory injury.

Create individually-tailored auditory screening programs based on veterans' current auditory health and past medical history. (Need help obtaining military medical records? Contact the nearest VA medical center.) At a minimum, "screening for high-frequency sounds should be standard protocol for any primary care physician working with veterans," said audiology clinic director at Syracuse University. Patients who don't pass a basic screening, as well as those who have known or suspected hearing issues, should be referred to audiology for further evaluation.

Note, however, that a normal audiogram, or audiogram records that demonstrate a return to baseline thresholds after an injury, do not necessarily mean the absence of hearing impairment. New research suggests that noise exposures cause cochlear neuronal degeneration, which can cause hearing loss, hyperacusis, and tinnitus. "Threshold recovery does not mean hearing recovery," said , director of Eaton-Peabody Laboratories at Massachusetts Eye and Ear Infirmary, who believes that auditory injuries may be cumulative, in much the same way head concussions can cause brain damage over time. "Your thresholds can go back to normal, but probably every time this happens, you're losing a few neurons."

While there is currently no way to restore hearing, great strides have been made in hearing technology. "Hearing aids are starting to become kind of cool," Pellegrino said. "Some hearing aids now have Bluetooth connectivity; you can pair your hearing aids to your iPhone and answer your phone or listen to music wirelessly through your hearing aids. If you ask Siri for directions, she can speak directly to you through your hearing aids."

FDA-approved middle ear implants and cochlear implantation are options for veterans with profound hearing loss.

"We live in a time when there are a lot of technological advances and devices. There's a solution for just about everybody out there," Packer said. Adequately assessing, protecting, and rehabilitating our veterans' hearing will increase their quality of life and ease their transition to civilian life.

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