For more than four decades, Dr. Herb Silverstein has been a leader in otology and has developed surgical and diagnostic procedures in the area of Ménière’s disease and hyperacusis. He is recognized as a world authority and patients come from all corners of the globe to consult with him.

President and Founder of the Florida Ear and Sinus Center in Sarasota Florida, he is also the founder and head of the Ear Research Foundation, which he describes in his interview.

Doctor Silverstein has more honors than space to describe them all. I was privileged to have him take time from his busy schedule to sit down for this interview.

I wanted to cover the basics of Ménière’s and hyperacusis and as a bonus within the interview, I learned of his leading role in the trials of FX322, and experimental drug being researched for its efficacy to restore the hair cells within the cochlea. This is a subject close to the heart of many with hearing loss hoping for a cure.

His love of research shines through this interview. That love will keep him going forward for many years to come.

Transcript

Voiceover:

Cochlear Implant Basics is a site for candidates and their families and friends. If you have been told you qualify for a cochlear implant, these podcast interviews tell how receiving a cochlear implant can be a life-changing experience. You will meet recipients who face a hearing loss and then hearing aids could no longer provide comprehension of speech or music. They face growing isolation, inability to socialize or compete in the world of business. The joy of music disappeared. They explain how receiving a cochlear implant changed their lives.

Welcome to Cochlear Implant Basics. A reminder, Cochlear implant Basics is not sponsored by anyone, nor is it offering medical advice. Please consult your own healthcare provider.

Richard:

This afternoon, we’re talking to Herb Silverstein, the world’s foremost expert in Ménière’s and hyperacusis. Would you just tell me your name?

Doctor Herbert Silverstein:

Herbert Silverstein at the Silverstein Institute in Sarasota.

Richard:

Can you briefly tell me what Ménière’s disease is? Because my own impression is it has a lot of different components, and I’m very confused.

Doctor Herbert Silverstein:

It’s a disease that involves the inner ear. Most of the patients complain of vertigo attacks, recurrent episodes of dizziness where they’re spinning around, nauseated, they throw up. It usually lasts about a half an hour to an hour. And with that, they have some usual problem with their ear hearing. The hearing goes down in the ear and they feel pressure and fullness in the ear and ringing in the ear. So that triad of symptoms of ringing in the ear, hearing loss, and vertigo are what Ménière’s disease is.

There are various types of Ménière’s disease. That’s the classic type. Many times, patients have problem with their hearing part first and they’ll have pressure and fullness in their ear and a hearing loss without the dizziness, and they’ll come to the doctor with that complaint. A lot of times, the doctor will look in the ear and the ear looks normal, and they won’t know what’s going on because the patient’s just saying that the ear feels funny and it’s pressure and it’s got ringing in the ears and maybe a little hearing loss. So it can be hard to diagnose when it’s early. Fortunately, we have some tests that can diagnose this before it becomes serious with the vertigo attacks and whatnot.

Richard:

The question I have is this, if there are components and you go to your general practitioner who has no knowledge of Ménière’s, that can cause a long delay in getting the proper diagnosis?

Doctor Herbert Silverstein:

The practitioners, they have trouble making the diagnosis. They say the patients complain of dizziness. They’ll say, “Go take some meclizine or Antivert and you’ll get over it,” and they may not go into trying to find out what it is or treat it.

Richard:

Well, you mentioned a few minutes ago about if you have a diagnosis, you can do some kind of treatment or to slow it down or whatever. I’m curious about that.

Doctor Herbert Silverstein:

We’re pioneers in early treatment for Ménière’s disease. And I’ve written some papers called the Subclinical Hydrops, or subclinical Ménière’s disease, which is what I was telling about. Just a little pressure in the ear, hearing loss, and some ringing in the ear.

The way we diagnose that is that it’s very interesting. We have a tuning fork that at 256, so a C, low C, and we take that tuning fork and we put it near the ear that the patient’s complaining of, and we put it on the other ear and they’ll say that they hear the sound at a different pitch. That’s the only disease that causes that. When there’s too much pressure in the inner ear, they hear the sound at a different pitch than the other ear.

Richard:

Interesting. I never knew that before. So-

Doctor Herbert Silverstein:

Yeah, so that’s all you need is that tuning fork. I hold that up when I give lectures and I say, “That’s all you need to make a diagnosis of Ménière’s disease.”

And then what causes Ménière’s disease is when we look under the microscope after somebody’s passed, we see that the inner ear is swollen, the membranes are all blown out and they’re blown out like a balloon. What happens in Ménière’s disease, we believe that the pressure builds up in the ear and the fluid builds up in the inner ear. All of a sudden, it ruptures, boom. And there’s a mixing of the inner ear fluids and the patients get the vertigo attack and the hearing loss and all this other stuff. And then when it collapses back and starts to heal, the patient feels better and they start getting back to normal or less symptoms.

Richard:

Is there a period of time between the onset and sometimes feeling normal? Is it weeks, months?

Doctor Herbert Silverstein:

Actually, with the Ménière’s attack, usually after they get over it, after a couple hours, they feel pretty good.

Richard:

Then it might come back at any time.

Doctor Herbert Silverstein:

Yeah, it comes back. And then it’s a very fickle disease. We can’t tell whether it’s going to come back the next day or next week or next month or a year later. It’s very fickle the way it goes.

Richard:

Well, some of the people that I’ve mentored over time, because I’m not a doctor, I’m an interviewer, some of the people I’ve mentored over time had to give up driving because they just never knew if they were going to have an attack while they were driving. Is that common?

Doctor Herbert Silverstein:

Very good comment. This is one of the only times that somebody can drive with dizziness. The reason being is that usually before they get the attack, they get something in the ear, they feel the ear fills out with pressure and they start losing their hearing and there’s some noise in the ear and they can pull over to the side and live through the attack. If they can’t do that, some patients have a situation where they don’t have any warning, they can’t drive. But there are not that many that don’t know that they’re going to get one, get an attack.

Richard:

One of your patients that I mentored came from Colorado to see you. My impression was that she hadn’t driven for like 11 years. So I guess that must have been very rare, severe.

Doctor Herbert Silverstein:

Yes. It can scare the person that they don’t want to drive. Even if they can tell, they feel that they don’t have time to pull over to the side and they don’t want to take a chance of having vertigo.

Richard:

What are your treatments for somebody who has this?

Doctor Herbert Silverstein:

There’s a whole bunch of treatments for this. Early on, the treatment is steroids. Low salt diet. We put the patients on a low salt diet. We put them on a diuretic that decreases the fluid pressure in the ear. And there’s a drug called betahistine. The betahistine causes increased circulation in the ear and very little side effects, and we treat patients with that.

For the attack of dizziness, we have the patients put Ativan under their tongue, half a milligram. What that does is it’s sort of like a mild tranquilizer, but it has something to do with the inner ear and it just calms the Ménière’s attack down. They may have the attack, but it may be a lot less severe. And if they take two Ativan, it may even be better. They even get less symptoms.

Richard:

Is that an off-label use of that drug?

Doctor Herbert Silverstein:

Off-label, yeah.

Richard:

You’ve been using that a long time?

Doctor Herbert Silverstein:

Right. That, we use instead of meclizine or Antivert, because that, you have to take by mouth and it takes about 45 minutes to go down. Patients are nauseated a lot of times when they have the attack. With the Ativan, it takes just a couple minutes because it’s absorbed into the bloodstream from under the tongue.

Richard:

So that’s the treatment for Ménière’s. What about hyperacusis? Can you explain that, please?

Doctor Herbert Silverstein:

Hyperacusis is a strange thing that is becoming more and more common. We all worry about not being able to hear and doing all kinds of things to help the hearing better and whatnot. Cochlear implants and hearing aids and all that stuff. There’s a problem that patients have, that some people have where they hear too much. They can have normal hearing or slight hearing loss, and when their sound comes in, it bothers them. It hurts their ear. They can’t be near people, they can’t go in a restaurant, they can’t go to movies, and they become recluse. They stay in the house. They don’t want to be talking to anybody because it bothers their ear. The sound of the voice or the sound of the environment just drives them crazy

Richard:

With hyperacusis and somebody who suffers from it, is it a particular sound or is it all sound?

Doctor Herbert Silverstein:

That’s a good question. There are various types of sensitivity of the inner ears to sound. There’s a thing called recruitment. Recruitment is where in patients with Ménière’s disease, when they have a hearing loss of, say, 50%, when the sound gets up to 50%, they’ll suddenly hear a tremendous increase in the sound in their ear, and it’ll bother them tremendously. So that’s called recruitment.

And then there’s a thing called misophonia, which is they don’t like sound, like the chalk on the board where it squeaks. I don’t know if you ever remember that when you were a kid. So it just bothers you. You don’t like that.

And then there’s another thing called phonophobia. Phonophobia is fear of sound.

So those things are not something that you can treat with surgery that I developed. But the hyperacusis where the patient is having a problem all the time, various sounds are bothering them and it’s changing their lifestyle, the surgery that I developed seems to work very well to help them.

Richard:

Could you describe the surgery?

Doctor Herbert Silverstein:

Yeah, so it’s a very simple operation. It’s not very dangerous and the side effects are very minimal. What we do is we take a little bit of tissue from above the ear. The muscle above the ear has a covering called fascia, and we take a little bit of this tissue and we make little pieces, round pieces of tissue, about two millimeters in size, and then we go lift the eardrum up. We go into the ear while the patient’s asleep and we look inside the ear. And a lot of times, we’ll find that the little stapes bone, the third bone of hearing, is loose and it’s jiggling around in the oval window too much. About half the patients have that. When you touch it, it’s very mobile. So we call it hypermobile stapes. So we put a whole bunch of tissue down there on top of the stapes on the footplate and around the stapes, about 10 pieces.

And then the round window, which is the window that moves out when the stapes moves in, that window we cover with some pieces of tissue. So what we’re doing is dampening the sound waves that are going in. It’s like wearing a earplug inside your ear, and it stays there all the time. It seems to work very well, and the patients are able to go into sound and live a normal life again.

Richard:

Well, there’s no rejection because you’re using their own-

Doctor Herbert Silverstein:

Own tissue, right. There’s no rejection. But sometimes it doesn’t work. Sometimes the ears are too hypersensitive. You put the tissue down and it’s not enough to dampen the sound waves and the patients will still have the problem. But fortunately, it’s not very many of those.

Richard:

Is there a future for using computer-generated parts to replace what’s loose? Have you looked at that?

Doctor Herbert Silverstein:

No. I don’t know what that would do. But the problem seems to be more of putting something down there to stop the motion of the ossicles, rather than replace them.

Richard:

Well, if somebody has a sensitivity to a sound and certain frequencies, their audiogram would look a little bit strange, a little bit off, right? They would have certain normal hearing and then sensitivity someplace else, or no?

Doctor Herbert Silverstein:

No. So what we do is we do what we call a loudness discomfort test. It’s called a LDL. We put them in a sound booth and we increase the sound slowly into their ear and find out what level they can tolerate when it becomes uncomfortable to them. So you and I, or normal people, can have 90 to 100 dB of sound and they can stand that. These people, anything below 90, 80, 70, 60, they get upset when they hear sound at that level.

Richard:

What about the recovery? You do this surgery, and the recovery for the patients is what?

Doctor Herbert Silverstein:

They go on outpatient. They go home the same day. Very little pain. And we take the packing out of the ear in a week, and then they can fly back to wherever they are. And they come in from all over the world for this surgery.

Richard:

Where’s your furthest patient from?

Doctor Herbert Silverstein:

We’ve done somebody from Ireland recently. Yeah. They come from all over for it.

There’s something that we should talk about in the Ménière’s, the treatment when the medicines don’t work. The treatment is… I invented a thing called the MicroWick, which is a little sponge. My wife used to call it a mouse tampon. Tiny little thing. Well, we would stick that in the ear through the eardrum. What that does is it allows the patients to put the steroids into their ear directly by themselves. So the doctor doesn’t have to inject it in. And then we treat the patients a month with the steroids. And if you catch the Ménière’s disease early, you may abort the whole problem by doing that.

In fact, my wife had that in her only hearing ear. She developed Ménière’s disease in her only hearing ear. She had a temporal bone fracture when she was a kid. We gave her steroids in her ear for a week. Fortunately, it brought back her hearing. It cured her Ménière’s. Actually, that was the beginning of starting to treat patients with that treatment, because of her hearing loss. She was one of the first patients to treat-

Richard:

Using the mouse tampon.

Doctor Herbert Silverstein:

Yeah, the mouse-

Richard:

Use this. The patient is putting the drug in themselves for an amount of time. And then after a month or so-

Doctor Herbert Silverstein:

We take it out. We just pull it out. It doesn’t hurt or anything. And we put a little paper patch over it and it heals up. The hole heals up.

Richard:

That’s amazing.

Doctor Herbert Silverstein:

So then the next thing is if that doesn’t work, they may still have problems with that. The next thing is a thing called gentamicin, which is an antibiotic that kills the balance center in the inner ear. We put that into the ear. We inject that in and that kills the balance cells and it will stop the attacks of Ménière’s.

Before the gentamicin, the gentamicin has been used for 20, 30 years. Before that, I invented an operation to cure the Ménière’s disease vertigo, just the vertigo, by cutting the balance nerve going next to the brain. So we go in through behind the ear and we find the nerve of hearing and balance, and we just cut the balance nerve and that stops all the vertigo. You don’t see the patient again ever after that. It preserves their hearing, what hearing they have, and it cures the vertigo. We did that from about 1977 to the ’90s.

When the gentamicin came out, it was an office procedure. So that was easier to do to the patients than the nerve section, where they had to be in the hospital for a couple days. So if the gentamicin doesn’t work, we then go back to the nerve section again. So-

Richard:

How often do you have to go back and use the alternative?

Doctor Herbert Silverstein:

The nerve sections we don’t do very often. We maybe do three or four a year. But most of the time, the gentamicin seems to work.

Richard:

So the gentamicin is being used by [inaudible 00:16:13].

Doctor Herbert Silverstein:

By everybody. All over. By everybody. Yeah.

Richard:

And if it doesn’t work, then they call you.

Doctor Herbert Silverstein:

They’ve learned how to do the nerve section too. So they do that too.

Richard:

Now my question is this, if it’s on one side, you have a balance center on the other, hopefully, you can’t cut both.

Doctor Herbert Silverstein:

So here’s the situation with that. It’s usually in one ear, but in 15%, it goes in both ears. So you have bilateral. We call that autoimmune inner ear disease when it’s in both ears, because we think it’s related to the immune system that they hit this in both ears.

Dr. Dandy used to, in the ’30s, he would cut both balance nerves in both ears. So if the patient had a bilateral. What that means, that they have trouble with balance forever. But they walk with a wide-based gait, but they don’t have an attack of Ménière’s disease. And they have some other symptoms with this when you lose both the stimuli systems. But you can recover from it with therapy. But it’s much better to recover from loss of balance nerve on one side than on both sides. If you lose the balance nerve on one side, you’re almost normal after a while, after you do therapy and time.

Richard:

How much therapy is involved in this?

Doctor Herbert Silverstein:

They usually do it for a couple months. And they do the exercises at home, balance exercises at home. Just a couple times a day.

Richard:

What’s the most important thing a person with Ménière’s or hyperacusis should know?

Doctor Herbert Silverstein:

Well, that there’s treatment for it. We know how to take care of it. And that they need to get it diagnosed and treated, and how severe it is and treated.

Richard:

I have four Facebook sites, but one of them is called Hearing Loss, the Emotional Side. This is where people who are totally lost come to find out what’s going on, find sympathy, which is what we do. But Ménière’s is mentioned so often. I have not really had an opportunity to explain to people. Thank you for your time to do this.

Doctor Herbert Silverstein:

Okay. Well, good.

Richard:

And if somebody needs treatment, where do they go? Where do you suggest they go?

Doctor Herbert Silverstein:

Well, they should go to a center. Somebody specialized in ear work, ear surgery, and ear diseases.

Richard:

So you advise them to get help?

Doctor Herbert Silverstein:

Yeah, definitely.

Richard:

I would love to know more about the Ear Research Foundation, what you do, what the objectives are. If you’d take a few minutes to tell us about that.

Doctor Herbert Silverstein:

Sure. The foundation, I started in 1979, because I was involved in research all my life and research and development. I felt that research should be part of your practice of medicine, so I started the foundation. So our mission was to do research into finding better treatments for dizziness and for hearing loss, and for also educating the public and educating doctors. That’s why we started a training program here, where we have trained 49 doctors now in the procedures that we do, teaching them about Ménière’s disease and hyperacusis and all, and many other things that we do with the inner ear.

And then there’s community service that we give. So we’ve treated many indigent patients in Sarasota County or in the area where they have a problem with their ears, hearing loss or dizziness. And we’ve given hearing aids to people that can’t afford hearing aids.

It’s been a great thing, the foundation, because we’ve made a lot of discoveries and made a lot of progress and different treatments for hearing loss and dizziness through the years, and we keep on the forefront of research and development. We’re one of the top offices for research in the country.

One of the exciting things that we’re doing right now, as far as hearing loss, is that we’re injecting a medication into the ear that causes regeneration of the little hairs in the inner ear and restores some hearing to patients. We’re involved in that and probably have the biggest selection of patients that we’re doing that on.

Richard:

Is that the RX 322?

Doctor Herbert Silverstein:

Yes.

Richard:

I had no idea you were doing it here.

Doctor Herbert Silverstein:

We’re the top office in the country, and we’ll be the lead author in the paper that’s coming out on it.

Richard:

When’s the paper expected?

Doctor Herbert Silverstein:

We’re just terminating or closing down the study now. It usually takes months till they get that done.

Richard:

Is this the second or third phase of it?

Doctor Herbert Silverstein:

I’m not sure about that. I think it’s the third phase. We’re going into another phase. We’re getting ready to start another series of patients where they increase the concentration of the medication. We’re just going to start on that, so that we can get more patients that will have a result from the injection.

Richard:

Can you talk about the test at all or that’s still under wraps?

Doctor Herbert Silverstein:

I can talk about it.

Richard:

What about the results that you’ve seen?

Doctor Herbert Silverstein:

Well, I can’t talk about that.

Richard:

Okay.

Doctor Herbert Silverstein:

Yeah, because it’s a double-blind study. So we don’t know the results. We know that some patients have shown improvement, and we don’t know who’s had the placebo and who’s had the real stuff. But we believe that by increasing the dose of the medication, more patients will have a result and have hearing improvement.

Richard:

I find it fascinating because I had a progressive loss from scarlet fever, and I had a sudden loss when I was 30. And I did not get a cochlear implant back then because it was very primitive and I didn’t want to lose music and I was waiting for science to find a cure in deafness. I waited 35 years until I got cochlear implants.

So again, one of the most common things I find online discussions are about these tests, that people are waiting to get a cochlear implant until they know what the results of these tests are. They’re afraid that if they get a cochlear implant, it will destroy their chances of ever getting something else that comes along.

Doctor Herbert Silverstein:

I think that they’re trying to do the cochlear implant now and preserve hearing. Try to preserve what hearing is in the ear without destroying it. It’s possible that they’d still be able to use the drugs, but I’m not sure about that, because the implant may block the medications going in and whatnot. So it’s hard to say.

Richard:

They might have to remove the implant in order to see if it works.

Doctor Herbert Silverstein:

Right. But I’m not sure that-

Richard:

Wow.

Doctor Herbert Silverstein:

… they can do that.

Richard:

We’ve covered a lot of ground, and I thank you. Do you have something you would like to add before we close?

Doctor Herbert Silverstein:

Just that it’s been a great honor and a privilege to be able to help a lot of patients and to come up with a lot of new treatments and different procedures and instruments and things like that that I’ve done throughout my life. It’s been a lot of fun and I’m still working at that advanced age.

Richard:

Keep working.

Doctor Herbert Silverstein:

I’m going to keep working until the end.

Richard:

I want to live to 140. My work is the budget. I mean, you have the education series coming up. Is that something new that-

Doctor Herbert Silverstein:

No, we have that all the time.

Richard:

Okay.

Doctor Herbert Silverstein:

Yeah.

Richard:

I’m going to be promoting the education series on my sites-

Doctor Herbert Silverstein:

Good. Great.

Richard:

… and the Facebook sites.

Doctor Herbert Silverstein:

Great.

Richard:

I’ve built up an audience. Dr. Silverstein, it has been an absolute pleasure. Thank you so much for your time.

Doctor Herbert Silverstein:

All right, Richard. Thank you.