Interview with Levi Reiter, Ph.D., CCC-A, Professor of Audiology, Hofstra University

Topic: The Kiss That Caused Hearing Loss, or Reiter's Ear Kiss Syndrome (REKS)

Carolyn Smaka: This is Carolyn Smaka from AudiologyOnline and I'm speaking today with Dr. Levi Reiter from Hofstra University. Dr. Reiter, welcome to AudiologyOnline.

Dr. Levi Reiter: Thank you very much for having me.

Smaka: Before we get into our exciting topic today, can you tell us about your background and what you do?

Reiter: Sure - it depends on how far back you want to go. I have a Ph.D. in experimental psychology and my interest in audiology actually started with some research I was doing at the University of Rochester with rats and rabbits on reflex inhibition behavior. It just so happened that the colony of rats that I was working with had upper respiratory infections, don't ask me why or how common that is, but I never saw it before. They were coughing and sneezing and the test that I was doing was an attempt to see if I could inhibit a reflex with a sound.

I had been working on reflex inhibition phenomenon for a few years already in James R. Ison's lab at the U of R. I was testing to see if a sound, a little "beep" actually, presented right before a small shock, could inhibit rats' response to the shock. Amazingly, I found that a sound actually did inhibit the response to the shock. But, only half of the animals I was testing showed a very strong effect and half showed no effect. I wondered why.

So I took the half that did not inhibit to the sound, and I blasted them with an intense acoustic startle stimulus that rats in our lab react to with an enormous jump response. In fact our acoustic startle stimulus - a 10,000 Hz tone pip of about 120 dB SPL - was so compelling that the startle reaction does not usually habituate, even over hundreds of trials.

Amazingly, the rats that did not inhibit to the little "beep" also failed to startle to the intense auditory stimulus.

Smaka: And you gave us a clue because you said the rats had an upper respiratory infection.

Reiter: Right. Exactly. So the point is, if the rats did not show the effect, it's either because it was just a crummy effect and only works in half the trials, if anything, or maybe the animal wasn't hearing the "beep" sound.

And this turned out to be the case. The animals that didn't inhibit to the quiet "beep" also did not jump to the intense sound, because they had fluid in their ears. They had serous otitis media. And the funny thing is you can't ask a rat to raise your paw when you hear. But yet, this little test was able to show me definitively which rats could hear ok and which rats couldn't. So that was kind of my first introduction to the world of hearing. So I asked my sister who was a Speech Language Pathologist, if there was any need for this kind of objective test thing in audiology and she said that there definitely was.

Smaka: What year was that?

Reiter: We're talking 1974 or 1975.

Smaka: So you went from psychology to audiology?

Reiter: Yes. My next experiments involved taking a friend of mine, and instead of putting him into a little cage and shocking him, I made a head apparatus that blew a puff of air next to his eye. And if I told him, "Don't blink", and then puffed him in the eye, he would blink involuntarily anyway, because you just can't stop your own eyeblink reflex. Yet it turns out that if a little, near- threshold level tone occurred 100 msec prior to the blast of air, then the person's blink was cut in amplitude and delayed measurably in latency. So I was actually able to plot out my friend's audiogram, and it matched his volitional audiogram without asking him any questions. In fact, he was reading a magazine during the entire procedure.

From there we did a lot of research to see what the nature of this reflex inhibition was. Is it just expectancy or is it conditioning? It's not conditioning since it happens in the very first trial and does not progress or change over trials. It's strictly a physiological interface between the sensory and motor pathways and it seems to be related to the reticular activating system based on ablations studies with rats done at the lab. Since then I've published articles on "Reflex Modulation" in children who were difficult-to-test, as well as adults who were malingering. It works.

Smaka: That is fascinating. And can you tell us about your current position at Hofstra?

Reiter: Sure. Briefly, I got an NIH post-doctoral fellowship and I worked at the University of Kansas Medical Center. I was working as a psychologist doing this research with Dr. Cornelius Goetzinger, who was an amazing person and mentor, and after a couple of years, I decided to go into audiology. I went back to school, became an audiologist in Kansas, and currently I'm a Professor of Audiology at Hofstra University and the head of the Audiology program here.
Smaka: And you also see patients, correct?

Reiter: Yes, I have a private practice as well. I'm also a professor at the Long Island Au.D. Consortium, which is a wonderful consortium consisting of three universities - Hofstra, Adelphi and St. Johns. So between the two academic involvements and then my private practice, it's been very, very exciting and interesting.

Smaka: Thank you. We wanted to talk today about a phenomenon, which I don't even believe has a name, that you've documented based on a case study of a patient of yours who was kissed on her ear by her daughter and lost the hearing in that ear. Can you start by telling us how this patient came to you and what she presented with?

Reiter: Sure. She was referred by doctors that could not diagnose what exactly was wrong with her. She also was a self-referral because she had seen a full page spread about me in Newsday, not because of anything scientific, but because one of my teaching methods is to do Audiology raps and songs, which are full of content about audiology for my students. So that became somehow widely known and that was in the press. And based on that, she called me up and made the appointment.

And her problem was, as you said, that she was kissed, a loving kiss, on the ear by her four-year old daughter. The kiss created a suction that was applied to her ear aperture and unfortunately, she had a terrible reaction. Initially, she lost total hearing in that ear. In addition to the total hearing loss, she had a very intense, screeching tinnitus. She had a lot of facial twitching, muscular twitching and pain. Her initial deafness only lasted several hours, and in a short time, she settled on a moderate sensorineural hearing loss in the kissed ear. The other ear is perfectly normal.

Smaka: How long after the kiss did she find her way to your office?

Reiter: About a year. In the interim she had seen other specialists. She had an ABR, a CT scan, and other various kinds of testing to find out what was going on. And unfortunately nobody had any answers or related it to the kiss. She had mentioned that she was given hormones, although it was more likely steroids. But nobody really understood the mechanism that was causing her problem. That's in part because the testing was really not very complete in terms of differential diagnosis.

Smaka: What symptoms did she present with when you first saw her, a year after the kiss incident?

Reiter: She reported decreased hearing in the kissed ear, and difficulty hearing on the telephone in that ear. She also had hyperacusis;any loud sound would just jostle her and send her through the roof. She had dysacusis;things were distorted in her ear. She had tinnitus in the kissed ear, but at this time, it had resolved itself to the point where in any kind of a quiet room she always heard a low frequency shooshing noise. And she had another interesting symptom, which is, I don't know how to exactly describe this, ear flutter. Basically, whenever she would turn her head from side to side, it felt like something was loose in her middle ear. And that was very disturbing to her. She had no dizziness, she never had any dizziness.

Smaka: What kinds of testing did you do?

Reiter: First of course I conducted a full comprehensive audiological examination, which showed that her hearing had been stable for a whole year since the kiss. In other words, her ear that had not been kissed had perfectly normal hearing, and there was no recovery to the hearing in her kissed ear. Her audiogram in the affected ear showed 35 dB thresholds at 250, 500 and 1000 Hz, and the loss was strictly sensorineural. At 1500 Hz her threshold was 25 dB and her thresholds at 2k, 4k and 8k were in the normal range. So it was a low frequency sensorineural hearing loss, which is very interesting in and of itself.

Smaka: Definitely. Because when you hear the headline that a kiss caused a hearing loss, you think of acoustic trauma which would manifest as a high frequency hearing loss.

Reiter: Right. Exactly. But my subsequent findings didn't support acoustic trauma either.

Smaka: Had she had any audiological evaluations prior to the kiss? For comparison?

Reiter: Interestingly and coincidentally, yes, she did. Apparently she always had accumulated excessive cerumen, so she had ear cleanings on a regular basis from an otolaryngologist. And at her last ear cleaning, six months prior to the ear kiss, the otolaryngologist sent her to the audiologist in his office for a routine hearing test, which showed completely normal hearing in both ears. I was blown away when I found that out, because I was initially thinking to myself that her hearing condition could have been a pre-existing thing, prior to the kiss. So that baseline hearing test was a very important piece of this puzzle.

Smaka: What other testing did you do?

Reiter: I did an ABLB test, Alternate Binaural Loudness Balancing, to see exactly what the loudness growth factor was in the poor ear and I used Hood's technique, which is more detailed and includes more balance levels than the Jerger method. So I was able to really plot out the gradual change in loudnesses as the stimulus intensity increased and it yielded some very interesting results. Basically, when I played a sound in her good ear at 80 dB, it sounded in her affected ear like 95 dB. So it wasn't complete recruitment, it was hyper-recruitment. And I think a 15 dB difference like that is a clear case of documented hyperacusis. So it jived precisely with her symptoms.

So I started thinking about this. Initially it seemed like, well, if you suck on the eardrum, and the vacuum stretches out the ossicular chain and the stapes pulls out of the oval window to some extent, I could see how turbulence created in the cochlea, because of that negative inner ear pressure, could result in hair cell damage. It's creating kind of a tsunami in the inner ear. But I would have thought also that the ossicular chain would be disrupted, at least between the incus and the stapes, right?

Smaka: But your audiological findings were totally sensorineural.

Reiter: Correct. I was very interested in the fact that there was no conductive component at all and her tymps were perfectly normal. So her ossicular chain is totally intact. So next I conducted extensive acoustic reflex testing. The acoustic reflex testing she had had in the past, prior to coming to me, was just done ipsilaterally. And it showed that in the affected ear, there was absolutely no ipsilateral reflex, even though the worst hearing threshold was only 35 dB HL. And in fact, even where the hearing was very good, like at 2000 Hertz (where the threshold was 10 dB HL), there was no ipsilateral reflex. There was no ipsilateral reflex at any frequency in her affected ear.

So I also did contralateral reflex testing and the results were very interesting. If the recording probe was in the affected ear, whether the stimulus was presented ipsilaterally or contralaterally, there was absolutely no reflex. Whereas if the recording probe was placed in her good ear, whether the sound was presented to the good ear or to the contralateral ear, there was a very good reflex. That combination of findings points to what we normally think of as a VII cranial nerve finding. In other words, the whole problem is on the motor side of the affected ear - the ear that was kissed or suctioned. It is not a stimulus problem, because if you make a loud sound in the affected ear (i.e. contralateral reflex testing), it triggers a reflex in the good ear. But whatever you do to the affected ear, you cannot get the stapedius muscle to contract, so it's a motor problem.

Smaka: So was this a facial nerve problem as opposed to acoustic trauma or something else?

Reiter: Well, with these reflex results, it normally indicates that there's a facial nerve problem, and the stapedial nerve is compromised in some way. Ok, but it doesn't ring right for this particular case, that a sucking on the eardrum would cause a facial nerve problem. The other possibility would be that the ligament that connects the neck of the stapes to the posterior wall of the middle ear perhaps broke in the stretching. So, I sent this patient to an excellent ear, nose, and throat physician, Dr. Elliot Goldofsky, for facial nerve testing. And he determined that her facial nerve is fine. So that leaves us with the only possible damage, and that is to the stapedial ligament itself.

You know, acoustic trauma is traditionally something that happens at about 140 decibels SPL. And this was not a loud sound that she experienced. As she describes, it just felt like the air was being drawn away out of her head. It was the suction and the pain from the suction that caused her to try to push her daughter off of her ear, but she was in so much pain she couldn't push. She was almost paralyzed there for a moment. So she didn't describe anything like a loud noise. Although, it would be very interesting to put a little probe mic in the ear and have somebody kiss near the ear and see how loud it is. But I don't think this is an acoustic trauma effect at all. Because in the end, you wouldn't have a paralyzed acoustic reflex, and you wouldn't have some of the other symptoms that she has.

I also want to mention that a perilymph fistula may at first seem like a reasonable conclusion, but there was no dizziness and no fluctuation in her hearing. She never had dizziness and her hearing loss is stable, so a perilymph fistula would be unlikely.

Smaka: Could a problem with her stapedial ligament be related to the hyperacusis?

Reiter: Absolutely. I believe so because she has a paralytic acoustic reflex, which means that she's not able to modulate sound coming into her inner ear. So if any sound exceeds thresholds, exceeds her most comfortable loudness level by enough of a sensation level, then it just rattles, probably rattles the ossicular chain, and it just rattles her ear. There's no reflex holding it back, there's really no muscle tonus modulating it. So she really does suffer from hyperacusis and it makes sense that that's the reason. This is also consistent with her report of ear flutter, or a rattling feeling in her affected ear when she turns her head from side to side.

Smaka: Interesting.

Reiter: Interesting also this facial twitching stuff. In the very beginning when she was first kissed, she had spontaneous facial twitching continuously that dissipated quite a bit over time. But even now, two years later, she experiences periodic facial twitching, but only when she is exposed to loud sound for a continuous period. For example, she went to a family wedding recently. It was loud;it was like a typical 2008 wedding. And for two days after the wedding, her facial musculature around her ear was twitching.

So that's a very interesting phenomenon. She still reports difficulty hearing on the telephone in the affected ear and she reports some dysacusis. Although on the actual discrim test that we gave, she did very well on that ear. But apparently, you know, in the real world, she still has problems.

Smaka: So what's the recommended treatment for this patient?

Reiter: Good question. Well, as far as the sensorineural aspect, it's just so hard to know if that can be improved or if it's going to spontaneously get better. Initially she reports that she was immediately given a hormone or steroid. She is under the care of an otolaryngologist. There are some interesting supplements being used with soldiers in Iraq to either avoid or treat sensorineural hearing loss from noise exposure. And sometimes they even work retroactively, and these are NAC, N-Acetyl-L-Cysteine, and ALCAR, Acetyl-L-Carnitine. The research on these supplements was done in part by Don Henderson at the U of Buffalo, through his work with government contracts. So that might be something to consider for her.

As far as the other part of it, the ossicular chain disorder, again, it's a totally intact ossicular chain except for that ligament. We discussed the possibility of surgery with Dr. Goldofsky specifically whether the stapedial ligament can be reattached to the neck of the stapes. There are some serious questions here. Remember, the stapedius muscle is the smallest muscle in the human body and the stapes is the smallest bone in the human body. So, in addition to the delicacy of the procedure, an important question is will the attachment even hold during the powerful contraction of the stapedius muscle in response to a loud sound. So whether surgery is even a possibility is something that needs to be explored. Of course the benefits of a successful outcome would be the reestablishment of the acoustic reflex with its attendant advantages.

Smaka: What about ear protection since her acoustic reflex apparently isn't intact?

Reiter: It's kind of a catch 22. She wants to hear from that side, very much. And an earplug of course is going to make that a little bit more difficult. A hearing aid may help her a little bit, but it may be a difficult fitting due to her hyperacusis.

Smaka: Have you heard of other cases like this, or is your patient the first?

Reiter: Excellent question. Well, I thought she was the first and I was thinking that that this would be a very rare anomaly. So I called a good friend of mine, the renowned and respected Dr. Mark Ross. And he said to me "Levi, fifty years ago I had a private practice with Fred Martin," another well-known audiologist, "and we found the same exact situation where somebody was kissed on the ear, and had a severe hearing problem following that." But you know, in those days they just didn't publish it, so it was never in the literature.

And then, ever since this case came out in the lay press and on the news, I've been getting phone calls from patients from all parts of the country that are telling me that they feel so good that now they have an answer for why they incurred a unilateral sensorineural hearing loss following a kiss on the ear.

I'll give you one example. I have one patient that I'll be seeing soon who told me that he was saying good-bye to his son-in-law at a little family gathering and his son-in-law kissed him on the cheek just as he was turning his head to look at something. The kiss landed on the aperture of his ear canal, and sure enough, he developed a sensorineural hearing loss on that side and he has had a lot of problems since. This happened four months ago. I haven't seen him yet as he's been on vacation, but I'm going to do some extensive testing to find out more about this kiss-related effect. It doesn't mean that every problematic ear kiss is going to have the same exact symptomology. I'm sure there are all kinds of variables that are going to play on this.

I've also spoken to a couple of audiologist friends who came across patients that wore hearing aids, got kissed on the ear, and felt their hearing get much worse. Again, they didn't publish their findings but this seems to be something that's happening. These patients either aren't making the connection to the kiss, or they go into their GP's, or even ENT's who feel "oh, it's probably a sudden idiopathic deafness that was coincidental with the kiss."

Smaka: Is there a name for this kiss-related hearing phenomena? I see other media has called it the "kiss of deaf," which doesn't accurately describe it.

Reiter: Do you have any suggestions?

Smaka: Well, this is audiology so an acronym is essential...maybe Reiter's Ear Kiss Syndrome? REKS? How does that sound?

Reiter: REKS sounds great. It sounds good and it also kind of implies that you're wrecking somebody's hearing! (laughs) It's functional. I think that'll stick.

Smaka: (laughs) Ok, well if you publish a paper, I want to see that, REKS.

Reiter: I'll have to give you credit for it, a little blurb on the bottom saying "Name was contributed by Carolyn from AudiologyOnline".

Smaka: Excellent! Are you planning on publishing your findings?

Reiter: Yes, I have an article coming out shortly. I would also really treasure it if my colleagues in audiology would contact me if they have any patients with kiss- or any suction-related hearing problem. This would make an invaluable contribution to an ongoing epidemiological study I am doing to find out how prevalent these effects are.

My biggest concern as far as warning the public and getting this out is regarding newborns and infants. Mothers and fathers, and even sisters and brothers or grandparents, they love to smooch up that little baby, give him a whole kissing frenzy. And the ear canal of an infant is very small, so the pressure, that negative pressure that you're applying to the ear canal is going to have a much greater impact than on an adult. I'm afraid there are infants out there who are experiencing this, but they can't say "Mommy, I can't hear in one ear," and the net result is that five years later, when they have a hearing test, they'll never know to relate it to this.



Dr. Reiter's daughter, Dvorah Leah and granddaughter, Chaya Mushka

Smaka: Since this has come to light, I know you've been asked some other interesting questions about how to kiss and where to kiss to avoid this phenomena, but I think that's beyond the scope of our interview today (laughing).

Reiter: (laughing). Right.

Smaka: Thank you very much again for your time, Dr. Reiter. I hope we can follow up with you in the future to hear what other data you've collected on this topic.

Reiter: That would be just great. I really appreciate talking to you;this has been a great experience.

Readers may contact Dr. Reiter at ears@drreiter.net.