Chapters Transcript Video From a Sow’s Ear to a Silk Purse: Innovations in Ear Perforations and Otology Breakthroughs There's a percentage of people who are actually very bothered by it, uh, where the sound becomes very loud and disruptive, and it just basically takes over their entire being and thinking and concentration, etc. Um, and what we have found in our research, um, is that that actually is a phenomenon related to this condition we call central sensitivity. Basically, the brain becomes very sensitive and is paying a lot more attention to that tinnitu signal and prioritizes it over other signals that are occurring in the brain. Hi, I'm Lindsay Carrillo, director of business development at UCI Health. Hi, I'm Doctor Sunil Verma, Associate Chief Medical Officer of Ambulatory here at UCI Health. I'm also a trained laryngologist. Welcome to Physician Huddle by UCI Health. Today, I'm really honored to be joined by Doctor Hamid Jalilian. He's a professor of otolaryngology, head and neck surgery, and the director of otology, neurotology and skull-based Sy here at UCI Health. Welcome, Hamid. Thank you. Dr. Jalilian, tell us a little bit about your clinical role at UCI. Sure, so, um, my specialty is the ear, so my subspecialty is the ear, so I'm ENT, but, um, primarily deal with deal with ear problems and problems of um issues that occur around the temporal bone. So this would include things like cerebrospinal fluid leaks, um, tumors that occur in that area of the facial nerve or Um, acoustic neuromas, uh, which are tumors of the, the balanced nerve. And um So I deal with all medical problems and surgical problems. Um, this would include things like hearing loss and tinnitus, and dizziness, as well as holes in the eardrum, chronic infections, tumors in the ear, etc. So I've, I've, I, you know, fun fact for the audience, so I actually have known Hamid since I was a medical student. Um, he was a professor and I was a medical student rotating and was one of the big factors of why I chose otolaryngology and actually, frankly came here to UCI Health. Um, despite how long I've known him, I frankly know very little about what he does because our divisions are so separate. So let's start out with something that I mean you just, you mentioned a lot of problems, but let's start out with something that a lot of people face, which is tinnitus or or ringing in the ear. I mean, I get questions about that all the time and frankly don't know what to do, but this is an area of interest in research for you. Definitely want to get to the surgery, but let's start there and and tell us about what what we know about this condition. Sure, so tinnitus is basically the perception of sound and the absence of sound. Um, in the vast majority of tinnitus that that we know of, which is usually ringing in the ear or hissing and buzzing, that kind of sound, it's produced in the brain. Um, now, Uh, that sound is, uh, is there in a lot of people, then a lot of people don't necessarily know they have it unless you put them in a very quiet environment and then they'll be able to hear it. So if you check actually, um, your general population and put them in a super quiet room where there's no external sounds they can get in, um, up to 30% of people can actually hear a sound. But um there's a percentage of people who are actually uh very bothered by it, uh, where the sound becomes very loud and disruptive, and it just basically takes over their entire being and thinking and concentration, etc. Um, and what we have found in our research, um, is that that actually is a phenomenon related to this condition we call central sensitivity. Basically, the brain becomes very sensitive and is paying a lot more attention to that tinnitu signal and prioritizes it over other signals that are occurring in the brain. So people sometimes say that I, you know, I'm talking to someone and the ringing is so loud, I can't hear them. It's not that they can't hear them, it's more that the brain is paying so much more attention to the ringing. That it's not paying attention to the person who's talking to them. So are you saying this is, I mean, is this more of a brain than an ear problem you're saying? Definitely, yes. So, um, tinnitus is really a brain problem. Um, it manifests as this sensation of ringing because the, the underlying cause is sort of ultimately the underlying cause of it is actually loss of cells in the inner ear, which is happens from noise and happens from aging. Um, and when we say aging, everyone thinks, well, you know, when you're 7 years old, but we actually get age-related hearing loss starting in our twenties. Um, it's just in pitches that we don't, um, use much in normal conversation, so we don't notice that we're actually losing it. Um, and around age 40 to 50 is when then it starts coming into the the pitches where we actually can see on a hearing test. And you can actually um have lost a lot of cells in the inner ear without your hearing test being abnormal, so you can lose up to 30% of cells in a certain area of the inner ear and you'll have a completely normal hearing test. So just in because there's someone who has a normal hearing test doesn't mean they don't have damage to their hearing. Um, so. First, it's, there's damage in the uh hearing uh areas and then the brain compensates by having an increase in activity, and that increased activity is what that tinnitus signal is. Um, the more attention the patient's brain pays to it, the, the. it's gonna seem to them. And what we have found is that there are a subset of patients that have either like a fluctuating um tinnitus, um, they have their tinnituss where it's sort of changed in level it used to be quiet and then suddenly becomes loud and stays loud, or those who have kind of an intermittent tinnitus, and there's some who can manipulate the tinnitus by pressing on somewhere around their jaw or head or face or something. And those are actually now treatable. We actually have figured out how to actually treat them. Um, medically, um, and so by treating the brain disorder, really, um, and these are medications that we use for this central sensitivity condition, um, and sort of directed towards that. So what sort of medications are these? Are they safe and is this something that most ENTs are prescribing to know about? Yeah, um, unfortunately, patients with tinnitus kind of fall in this sort of group, um, where, um, they, what they really have is actually a brain problem. Um, they, they will present to an ENT because they have an, an ear issue. Um, most ENTs are not aware of the, the sort of new treatments that are available, so usually they'll tell them there's nothing that could be done. Um, and then sometimes they'll go to a neurologist and the neurologist says, no, this is a, this is an ear issue, you got to go see the ear doctor. So they, they're kind of stuck in the middle with nothing. Um, the medications that we use are medications that are primarily used uh for the uh prevention of migraine. So, um, but it has to be combined with the lifestyle changes that are necessary to control this sort of central sensitivity condition. So just doing Um, just giving them a pill alone, a lot of times doesn't, doesn't fix it. And as I said, unfortunately, most ENTs aren't aware. this is very new. I mean, we just discovered this probably in the last 67 years, um, and have just completed our clinical trial, uh, to show that the treatment that we do is effective. And we've developed a an internet-based cognitive behavioral therapy that, that um basically goes through all the lifestyle changes that people need to make, um, is sort of the dietary changes, the sleep changes, and then uh doing things that help reduce stress, which is the cognitive behavioral therapy part. Um, and then we use um what we call sound therapy, which is also kind of an internet-based thing that then they can access and and listen to particular sounds that target the regions of the brain, um, that are producing the sound, and so they can actually quiet down those um those brain cells that are hyperactive. So I've heard it is vicious, people really suffer, it can be terrible, like torture, when they're showing up at their clinic, at your clinic. I mean, what kind of state are these people in? Yeah, I mean, it, it ranges. I mean, uh, so there are generally two groups of patients with tinnitus. One group, um, you know, which, you know, tends to be generally older and um they'll come in and say, well, I've had this ringing for many years. I got it when I was in the military, you know, 30, 40 years ago, and it doesn't bother me at all, but, you know, I'll hear it when it's quiet. And then there's a group that comes in and says this is taken over my life and I can't tolerate this anymore. I got to do something, you know, um, you know, and they're very anxious and upset about the tinnitus. Um, the treatable group, um, is the, is the group that I can get, uh, is the one that's greatly bothered by it. So those are when we can actually bring the volume down to a quieter level. Um, it is something that does require a lot of kind of cooperation by the patient. So, um, we, uh, call it, it's sort of actually a well-known phenomenon in, in psychology called uh readiness to change. So they have to be uh ready to change, um, meaning they have to uh be uh able to, to make those changes to their diet, to their sleep, to their stress habits, things like that, that. Or potentially are the ones that generally the ones that are that make the tinnitus loud. Um, so there are people who come and say, I just want to take a pill to get better, and I just tell them, I'm not gonna give you a pill because you got to make some changes, otherwise the pill is not gonna work anyways if you don't make those changes. So what we have found in some of our trials is that when we use medication alone with no other lifestyle changes, the effectiveness rate is less than 40%. Um, or sometimes less than 50 depending on the medicine, but when we combine it with the lifestyle changes, then we get about 90% of patients get significant improvement. So the lifestyle changes are, are very critical to this. Um, you know, just yesterday I had a patient who said, well, I, I don't think I can quit caffeine. I said, well, that's fine, you know, at first I said. Um, well, I think you can quit caffeine, uh, because I, I quit caffeine. I have, I have a history of migraines, so I, I quit caffeine, and it helped me tremendously, um, and I said you can quit caffeine, um, but unless you're willing to quit caffeine, um, I'm not gonna start you on medication because I don't want you to go through a whole course of medicine. It's a waste of your time and And to to go through medicine when it's not going to work as well if you're not making the lifestyle changes, you have to fix your sleep, you have to fix your stress, you have to fix your diet. That has to change in order to get better. And you mentioned that caffeine is one of the major triggers diet related, and I imagine a lot of patients don't want to hear that. Yes, and, you know, I've had patients who said, you know, this is sort of my identity is is drinking coffee all day and I like, you know, I drink 6 cups of coffee a day and I just said, well, it, you know, it's fine. I mean, tinnitus isn't gonna kill you. Um, it's bothersome, but you just have to weigh which is more important for you. If the caffeine's more important, then that's fine. Drink the caffeine. If you're not gonna damage anything by drinking caffeine in your ears, but your tin is just gonna be louder. But, um, and I've had patients who, you know, after several months of, of doing their best to, to not quit caffeine, they just finally decided to kind of give it up and then they emailed me saying, It made a tremendous difference in in terms of the loudness of the ringing. So, um, it, it makes a difference, you know, it's not just caffeine, there are many other things that that do it um and uh so it there's there's more to it than just caffeine, but um. But yeah, caffeine is, is probably the most prominent of the dietary triggers. Well, I think this is pretty impressive because it's, it's a condition that affects so many people despite, as you mentioned, it not being life threatening, it really affects the quality of life um for patients and can be rather debilitating, um, for certain individuals. Um, and it certainly sounds like you say Health is on the forefront of, of really change because this was something 5, 10 years ago, probably in most places there, there isn't, like you said, really a great treatment. Um, what else is changing in, in the field of otology and neurology? Uh, what's different now about the conditions that, that we were treating, uh, in the past that, that we've really changed? I mean, I, I imagine you see, um, especially here things from, uh, there's so many chronic ear conditions, um, tympanic membrane perforations, um, even surfer's ear. I mean, I, you hear so many things, um. And then the history has been that when you lose your hearing because of any any insult to the ear, it's almost not able to be regained. Is that, is that the case or what's changed? So, um, you know, there's been a lot more emphasis on minimally invasive, um, sort of treatments, and, um, you know, we have actually developed some new methods of actually treating uh holes in the eardrums or perforations of the somatic membrane. Um, using, um, this sort of novel, um, tissue that's derived from, uh, pigs, uh, so it's like a porcine, um, tissue that's processed, and, uh, we use it, um, in, in the office, um, so meaning that if somebody has a perforation that's less than 50% of the eardrum, we can actually fix it in the office for them. Most of the time, um, we basically do a lot of the same things we do in the, in the operating room, um, by kind of, uh, using some medication around it, the holes that sort of uh stimulate growth, and then, um, we can place the, the patch, um, and then we take some blood from the patient and spin it down and take the, the serum from the blood, mix it with um. Some antibiotic drops and then give that to them as eardrops to use after we've done the procedure. Uh, and we found that that enhances the uh closure of, of the perforation. So most other places in the country, um, uh, if somebody goes in with a perforation, they're gonna get a surgery. Yeah, I mean that's the way I trained, right? depending on the size, like you said, a 50%. If I remember correctly, that buys a patient a trip to the operating room with a I mean, somewhat of a morbid surgery with cutting part of the eardrum out and even potentially moving the ear around. And then a pretty long healing process. I'm sure you still do that, but it sounds really different, uh, in the office. What, what's, what has changed it? Is it? This blood concoction that you're talking about, is it the is it the pig porcine or is it all of the above? Yeah, it's a great question. It's it's all of the above. I mean, um, one of the things I I really enjoy about sort of the kind of a clinician scientist, I try to think about every problem that I face and think how can I treat this. Um, how can I make this less invasive? How can I do this something in the office so that the patient doesn't have to go to the operating room and all the expense and the loss of work and all that other stuff that that comes with it. Um, so I, I've sort of, it's kind of been a continuously refined procedure. Um, I, I don't know if anybody else in the country does this, um. You know, when I tell people at uh at the conferences about uh this, this technique they're using, how they, they get very curious and they are like, hey, can you write down how exactly you do it because I, I want to start doing this, um, because it, um, we like to sort of continually advance in how we care for patients and sort of it's, it's, it's the way we, I mean, I, I think all of us and at least in orderaryngology and, and I think as a. As UCI health in general, um, we're, we're trying to advance medicine. I mean, if, if we're doing the same thing over and over, then, then there's really no progress and, and we want to be continually getting better and better at it. Um, and I, I always say it's like right now is the best time to ever be sick in, in the history of, of a sort of human life because there is continuous. Advancement and tomorrow will be better and the next year will be even better. So, um, and so that's that's how it's been. It's uh refining the technique, um trying to make it less painful, um so that we can actually manipulate the eardrum a little more because we have to kind of sometimes kind of scratch up the edge of the hole so we can get um a sort of this neurovascularization. Into the eardrum, um, uh, we've refined how we put the tissue in so that we can get very good contact with the edges, um, and, uh, and then we refined the, the procedure with the blood and all that other stuff. So it's all of it together. Um sometimes it requires doing it a couple of times to get it to fully close, um, but we've been able to avoid um operating room trips for so many patients. Um, and when I tell my colleagues and national conferences, um, you know, I tell them it's, you know, in terms of the surgeries that I do, um, the number of perforation surgeries I do has dropped tremendously because so many of the patients I actually can fix in the office. Now, some people enjoy doing surgery and they're like, well, it's a lot easier for me to just do this in the operating room. It takes too much time to do it in the clinic. Um, but I tell them, you know, I, I'm willing to put up with some pain for myself for, for the gain of the patients so that I can save them from an operation. I think there's a joke in there about a pig's ear, but I'm it's not coming to mind right now. I do have a question like, so when you're explaining this to the patients. What's their response? Are they looking forward to avoiding a trip to the OR? Do they really understand how revolutionary this is? Yeah, so a lot of patients are actually sometimes a little doubtful because they're like, you know, everyone told me before coming here that I'm going to get surgery and you're now telling me you can do this in the office, and it's, yeah, this can be done in the office, um. And um they say, you know, you know, have you done this before? And I say, yeah, I've done it in like hundreds of patients. Um, and so then uh they say, OK, well then I'll, I'll, I'm willing to try it. So, um, it, you know, it, uh, I, I tell them, you know, I always tell them that surgery is an option if you want, and surgery is kind of a, you know, at a one time, uh, procedure, it's like 95% successful. So the success rate of a one-time surgery is, is much higher than us doing in, in the office. Um, but, uh, you know, if you want to avoid anesthesia, avoid missing work, you know, avoid all of the, the sort of the, usually the areas is kind of clogged for a couple of months after surgery until. The hearing starts coming back around 3 months. So if I, I tell them if you want to avoid that, then that's something we can do right here and you know, you go home and go back to work today. And a lot of times they're surprised, but uh they're always, I should say always, but most of the time pleasantly surprised surprised. What, what drives you to make these changes? I mean, we've, we've talked about two things that have, that you're sort of at the forefront of. Leading change and, and not letting um things stay the way they are. How do you balance that with a busy clinical, uh, busy surgical practice? I mean, we share our operating room days, so I absolutely know you're there, um, very frequently. How do you balance this all and keep striving to make change and, and, and get, keep that energy going? Yeah, I mean, I, um, I sort of, uh, always, I'm thinking when I'm looking in the patient's ear and I'm, or they tell me about their condition, I'm always thinking is like, how can I, what's the most fundamental thing that needs to be solved to solve this problem, um, you know, you know, when it comes to like perforations, um, you know. What is it that that needs to happen for a perforation to close, because most of the time if it's a traumatic perforation, the, the body heals itself, it closes it. So um the ability exists and we know what we're doing in the operating room. The only thing we're using in the operating room is we're using human tissue, their own tissue, um, uh, you know, and this is a sort of a processed, um, you know, porcine tissue. So it's a little different, but I'm just always thinking, what can I do to make this easier for the patient? What can I do to make, you know, if, if it were me, as a patient, I had this problem, what would I want, um, in order to kind of solve this problem? Um, and, you know, I, I like that sort of thinking process because that's really, uh, that's what excites me about medicine is, is, is, is. The the possibilities that we can make whatever we think that we're doing such a perfect job of right now that we can make it even better, um, and that sort of possibility and, and, you know, going to conferences, learning new things, um, I like going to conferences in other countries because sometimes there's there's sort of this groupthink that happens in the United States, um, because people in other countries have been trained differently, they have a different perspective, and I see something there and I say that's interesting, um. You know, I wonder if I could adapt that to, to what we're doing and sort of make that change. And so, um, you know, I ultimately want to be able to do the best I can possibly do for my patient because I, I like to think as, you know, if this patient was my brother or sister or aunt or uncle, what would I do for them? Um, I want to do the exact same thing I would do for my own family member and if I I think I can solve this problem without a surgery for a patient, then that's what I'm gonna try to do my best to do. What's coming up on the horizon? What's in the future? What are you looking forward to? What do you think is going to develop over the next 5 to 10 years? So, um, I think in the next 5 to 10 years, um, we're going to have, um, I'm very hopeful and, and somewhat confident, um, that we're going to have a, probably a device that's gonna cure ringing in the ears. So currently the medical therapy that we do really primarily just lowers the volume. Um, it doesn't actually completely make it go away. The only time we've been able to make it go is when it's an intermittent state. Um, but if it's become constant, then, then usually we can just reduce the volume. Um, we have been working on a device that is, um, it's kind of a semi- implantable device, um, that, uh, can, when we've experimentally done it with a little electrode passing an electrode through the eardrum behind the eardrum, we've been able to quiet the ringing um in a majority of patients. So these are patients who'd had ringing for many, many years and then suddenly they came in and, and we stimulated them for like 5 minutes and we can make the, the, the tinnitus go away for sometimes up to hours. So, um, we're very excited about that. That's a device that we're building with multiple people on campus here with electrical engineers and hearing scientists. And um some external um electrical engineers have been helping us. Um, so, uh, we're in the sort of the, the stage where we're trying to actually make a device that, that could be um uh kind of FDA approved for the purpose of a trial, um, so we'll call an investigational device exemption. Um, so we're in that sort of stage for that, um. Uh, we have developed a device for the detection of ear infection, so most of the time in a primary care setting, it's really hard to see the eardrum. There's um ceruin in the ear canal, um, and, uh, we've developed a device that can spectroscopically determine uh what actually is occurring at the eardrum level, and, um, what's amazing about it is that she can shine through wax. So even if wax is present, you can actually detect whether there is fluid uh in the middle ear. Um, we've developed a new type of, um, hearing aid, um, that directly drives the eardrums, so most hearing aids basically have a tiny speaker in the ear canal, and they take the sound and amplify it and put it through this tiny speaker. The disadvantage of a regular hearing aid is that the sound of this tiny hearing aid or tiny speaker in the hearing aid. Is that it just doesn't sound as as high quality, you know, um, when we want high quality headphones, we put these big things on our ears or we put, you know, an AirPod, which is a much kind of a bigger head to it than a hearing aid does. Um, but Uh, what we thought about is what's the, what, you know, what's the biggest speaker we could put in the ear canal, and, um, you know, we, we're thinking about, you know, if we can have a speaker that that spans the entire surface of the ear canal, you know, the, the sort of circle of the or the ovoid shape, um, and then we have all the eardrums there, so we can just use the eardrum. So our device sits right next to the eardrum and directly moves the eardrum, and it produces a very high quality sound and when we've tested in about um close to 30 patients so far. The patient said it was the best quality sound I've ever heard. They were able to appreciate music. We had actually a patient that we placed it in both sides, and these are all patients who are hearing aid users. So we placed it on both sides. We took them to the shopping mall across the street from the hospital and just took her to a sort of real world environment to see, and she said. It was the first time she could actually appreciate the music in a in a store because she could actually recognize the music, um, whereas with her hearing aid, she'd never been able to understand what what kind of music was being playing in in um in the cans on if it's Christmas you may not want to hang out at the malls. So we, there are a lot of exciting things happening, um, you know, uh, we at at UCR is sort of at the forefront, we, um, are sort of center for hearing research and, and we have one of the biggest centers for research in uh hearing in, in the country, and, um, we've developed a lot of things that are now being implemented in patients and or hopefully will be in the next 5 to 10 years, um. I think there's gonna be much better um implants for the deaf, um, so patients who have significant hearing loss who can't use hearing aids, they currently get a cochlear implant. A cochlear implant basically is a device that goes inside the inner ear and stimulates the nerve and can restore hearing for a deaf individual. However, there is a limit to the number of electrodes you can put in the inner ear, um, and currently it stands at around 16 to 20 some electrodes, uh, because anything beyond that has not been found to be very useful because the, the, the electric signal spreads in in the inner ear and so it, it stimulates too many nerves and so then the sound's not as good. So, um, uh, UCI, we've been developing a Doctor um John Middlebrooks in our department and Harrison Lynn, my colleague and my partner in in autoology has been developing a device that goes into the nerve of the, um, uh, hearing directly and so it can produce much higher quality sound and more directly stimulate individual nerve fibers, um, and it, so people could potentially appreciate music with a cochlear implant, um, which currently they can't. Um, it would allow them to understand speech at a much higher level than they currently can, and it will reduce the need for um potentially having a battery and and processor on the outside of the body because the electric signal that is necessary would be much lower and so you can actually have an implantable battery that could last you 10 to 20 years potentially. I'm so glad you're at UCI. So last question, obviously, I mean, very well known, you're pushing the edges of your field well into your career now. What kind of advice would you give to other physicians just starting out, maybe other ENTs or even other specialties? You know, um, the advice I give my, you know, let's say residents who graduating, I tell them a few things. One is, um, Always be thinking about sort of how to do things better, um, and I, I tell them 20 years from now if you're doing what I'm doing right now, you're probably doing the wrong thing because 20 years from now I will definitely be doing something different because I'm gonna change with time. um, I'm gonna learn new things and I'm gonna adapt my practice and you need to do the same thing. Because if we don't, then, then, you know, then there's really, there may be progress out there, but we're not implementing it for our patients, so we're really not doing the best thing for our patients. So um I tell them to, to read, um, I don't tell them to go to conferences. I, I, you know, I tell them to go to international conferences sometimes go to the, the major national conferences we have because um the science is continually advancing, um, you know, some of the, the things that, um, you know, we've been talking about now, it, it. You know, it, what what's been found, it takes 17 years from a time of discovery until 50% of physicians are actually practicing that new discovery, which that means like for 17 years, a lot of patients are, are potentially suffering from something where they could actually Been treated. Um, and so the only way that could be learned is by physicians going to conferences and reading journals and, you know, listening to, you know, podcasts like this, um, to sort of learn new things because if you're not continuously learning, you're not doing the best thing for your patient. Well, thank you so much, Doctor Joloian for being with us today. Despite being in the same department, I learned more in this half hour than I have um been hanging out with you over the last dozen years. So thank you so much. This has been Physician Huddle by UCI Health. Thank you for joining us. Thank you. This was an episode of the Physician Huddle podcast by UCI Health, produced by Brett Shaheen, Angelika Yugubi, and Victor Ting. For more episodes, information on clinical trials at UCI Health, or to refer a patient, review the show notes or visit clinicalconnection. UIhealth.org. Created by
