Patients can experience different types of hearing loss, including conductive, sensorineural, and mixed. A history and physical exam including tuning fork tests help distinguish the type of loss. Common etiologies include otosclerosis, presbycusis, noise exposure, and Meniere's disease. Formal audiologic testing is needed to diagnose the condition and guide management, which may include hearing aids, surgery, or lifestyle modifications.

1. Hearing impairment andHearing impairment and
rehabilitationrehabilitation

2. OUTLINEOUTLINE
 Types of hearing loss
 Classification of hearing loss
 Diagnosing and managing different kinds of hearing loss; e.g congenital hearing
loss otosclerosis, presbyacusis, noise Induced Hearing Loss ,Meniers disease ,ototoxicity
 Performing and interpreting various subjective and objective hearing
tests
 Tuning fork test
 PureTone Audiometry
 Impedance Audiometry
 Brain Stem Evoked Response Audiometry

3. HEARING IMPAIRMENTHEARING IMPAIRMENT
Hearing impairment, also called deafness or hearing loss, occurs
when there’s a problem with or damage to one or more parts of the ear.
U.S. population 270+ million
2 million Deaf
 26 million Hard of Hearing
 1 of every 10 people has a hearing loss
 Over age 65, 1 in every 3 persons has some degree of hearing loss
 80% of hearing people are in denial

6. TYPES OF HEARING LOSSTYPES OF HEARING LOSS
1. Conductive Hearing Loss (CHL)
• the conduction of sound to the cochlea is impaired
• can be caused by external and middle ear disease
2. Sensorineural Hearing Loss (SNHL)
• due to a defect in the conversion of sound into neural signals or in the
transmission of those signals to the cortex
• can be caused by disease of the cochlea, acoustic nerve ( CNVlll),
brainstem, or cortex

7. TYPES OF HEARING LOSSTYPES OF HEARING LOSS
3. Mixed Hearing Loss
• the conduction of sound to the cochlea is impaired, as well as
transmission through the cochlea to the cortex

8. DIFFERENTIAL DIAGNOSIS OF HEARING LOSSDIFFERENTIAL DIAGNOSIS OF HEARING LOSS

9. DIFFERENTIAL DIAGNOSIS OF HEARING LOSSDIFFERENTIAL DIAGNOSIS OF HEARING LOSS

10. APPROACH

11. HISTORYHISTORY
HPI:
Onset (sudden or gradual)
Duration
Unilateral/ bilateral
Continuous / Intermittent

12. HISTORYHISTORY
HPI:
Exposure- noise, drugs, viral illness
History of ear of head trauma
History of surgeries
Associated symptoms- pain, discharge, tinnitus, vertigo

13. HISTORYHISTORY
 PMH:
 Chronic illness: DM, HTN, Hypothyroidism
 Previous surgeries
 Rx:
 Ototoxic drugs
 Amino glycosides, diuretics, quinine, aspirin
 Social history:
 Occupation
 Tobacco
 Alcohol
 Cocaine
 Marijuana

15. PHYSICAL EXAMINATIONPHYSICAL EXAMINATION
 General assessment
 Ear exam:
 Deformities of Pinna & EAC
 Pre & post-auricular region
 Otoscopy
- EAC, TM
 Tuning Fork Test
- Rinne
- Weber
 Cranial Nerves

16. INVESTIGATIONSINVESTIGATIONS
Specific hearing tests
Tuning Fork Tests
Pure tone audiometry
Impedance audiometry
Brain stem evoked response audiometry
Radiology
- CT & MRI of skull & temporal bones

17. HEARINGTESTSHEARINGTESTS
Subjective
 Tonic Fork test
 Pure tone audiometry (PTA)
Objective
 Tympanometry (impedance audiometry)
 Electric response audiometry (ERA).

18. TUNING FORKTESTSTUNING FORKTESTS
Test: Weber
Technique:Tuning Fork placed at midline
forehead
Normal: Sound radiates to both ears equally
Abnormal: Sound lateralizes to one ear
 Ipsilateral Conductive Hearing Loss OR
 Contralateral Sensorineural Hearing Loss

19. TUNING FORKTESTSTUNING FORKTESTS
Test: Rinne’s
 Technique
 First: Bone Conduction
 VibratingTuning Fork held on Mastoid
 Patient covers opposite ear with hand
 Patient signals when sound ceases
 Move the vibrating tuning fork over the ear
canal
 Near, but not touching the ear
 Next: Air Conduction
 Patient indicates when the sound ceases

20. TUNING FORKTESTSTUNING FORKTESTS
Test: Rinne’s
 Normal:Air Conduction is better than Bone Conduction
 Air conduction usually persists twice as long as bone
 Referred to as "positive test"
 Abnormal: Bone conduction better than air conduction
Suggests Conductive Hearing Loss
Referred to as "negative test"

21. PURETONE AUDIOMETRY (PTAPURETONE AUDIOMETRY (PTA((
PTA is the key hearing test used to identify hearing threshold level of an
individual, enabling determination of the degree, types and configuration
of hearing loss.
Provides the basis for diagnosis and management.
The symbols used on most audiograms are:
 x - left, air conduction
 o - right, air conduction
 ] - left, bone conduction
 [ - right, bone conduction

22. NORMAL AUDIOGRAMNORMAL AUDIOGRAM

24. TYMPANOMETRY (IMPEDANCE AUDIOMETRYTYMPANOMETRY (IMPEDANCE AUDIOMETRY((
 Assess the function of middle ear and Eustachian tube.function of middle ear and Eustachian tube.
 Very useful when screeningscreening for middle ear effusion.
 It is not a hearing testnot a hearing test, but rather a measure of energy transmission
through the middle ear.
 It can also assess the integrity of stapedius refluxstapedius reflux..

25. NORMALTYMPANOGRAMNORMALTYMPANOGRAM

27. AUDITORY BRAINSTEM RESPONSE (ABR)AUDITORY BRAINSTEM RESPONSE (ABR)
AUDIOMETRYAUDIOMETRY
An objective neurologic test of auditory brainstem function in response
to auditory (click) stimuli.
Procedure:The stimulus either in the form of click or tone pip is
transmitted to the ear via a transducer placed in the insert ear phone or
head phone.The wave froms of impulses generated at the level of brain
stem are recorded by the placement of electrodes over the scalp.

28. AUDITORY BRAINSTEM RESPONSE (ABR)AUDITORY BRAINSTEM RESPONSE (ABR)
AUDIOMETRYAUDIOMETRY
 These peaks are considered to
originate from the following
anatomical sites:
 1. Cochlear nerves - waves I
and II
 2. Cochlear nucleus - wave III
 3. Superior olivary complex -
wave IV
 4. Nulclei of lateral lemniscus -
waveV
 5. Inferior colliculus - wavesVI
andVII

29. CASES

30. CASE 1CASE 1
A 30 years old lady presented with 3 months
history of progressive bilateral hearing loss
that has worsend during present pregnancy,
associated with tinnitus in both ears. Her
sistert was having the same problem.
o/e:
Normal ears, no evidence of middle ear
infection, normal TM ± pink blush (Schwartz's
sign)
What is next?

31. CASE 1CASE 1

32. OTOSCLEROSISOTOSCLEROSIS
Fusion of stapes footplate to oval window so that it cannot vibrate.
Etiology
 autosomal dominant
 female> male, progresses during pregnancy (hormone responsive)
Symptoms include slowly progressive hearing loss,bilateral in 70% of
cases.
 Vertigo is uncommon.
 Tinnitus may be present and often resolves after successful surgical
management

33. OTOSCLEROSISOTOSCLEROSIS
Conductive hearing loss
In 80-90% of patients, lesions
are limited to the anterior oval
window and affect its pathology
by involving the stapes
sensorineural hearing loss
In 8% of patients, the process
involves the cochlea and
parts of the labyrinth
(labyrinthine otosclerosis)

34. OTOSCLEROSISOTOSCLEROSIS
Tx:
 monitor with serial audio grams if coping with loss
 hearing aid (air conduction, bone conduction, BAHA)
 stapedectomy or stapedotomy (with laser or drill) with
prosthesis is definitive treatment

36. CASE 2CASE 2
70 years old gentleman , a known
hypertensive, presented with gradual
hearing loss in both ears, started to notice
that since 5 months, hearing people like
they are mumbling, associated with
tinnitus and difficulty understanding
speech, especially in noisy situations.
Otoscopy: normal external auditory canal
& TM, no signs of middle ear infection

37. PRESBYCUSISPRESBYCUSIS
Sensorineural hearing loss associated with aging (staging in 5th and 6th
decades).
Etiology
 hair cell degeneration
 age related degeneration of basilar membrane
 cochlear neuron damage
 ischemia of inner ear

38. Accumulated exposure to noise
Drug and environmental chemical exposure
Stress
Genetics
Arteriosclerosis
Diet and metabolism
CAUSESCAUSES

39.  The inability to hear or understand speech in a crowded or noisy
environment
Difficulty understanding consonants
The inability to hear high pitched voices or noises
Tinnitus is often present
COMMON COMPLAINTSCOMMON COMPLAINTS

40. Tx:
 hearing aid if patient has difficulty functioning, hearing loss >30-35 dB, and good
speech discrimination
 ±lip reading, auditory training, auditory aids (doorbell and phone lights)

41. NOISE-INDUCED HEARING LOSSNOISE-INDUCED HEARING LOSS
 Constant exposure to loud
noises can cause high
frequency sensorineural
hearing loss
 The mechanism by
1- Direct mechanical damage of
cochlear structures
2- Metabolic overload due to
overstimulation

42. OTOTOXICITYOTOTOXICITY
Antibiotics
1-Aminoglycosides (gentamicin > tobramycin > amikacin > neomycin)
2-Erythromycin and tetracycline
Chemotherapeutic agents are known to cause hearing loss.The worst
ototoxicity occurs with cisplatin.
High-dose aspirin.
Antimalarial medications such as quinine and chloroquine

43. MÉNIÈRE DISEASEMÉNIÈRE DISEASE
Endolymphatic hydrops refers to a condition of increased hydraulic
pressure within the inner ear endolymphatic system.
Episodic attacks of tinnitus, hearing loss, aural fullness, and vertigo lasting
minutes to hours.
peak incidence 40 to 60 years

45.  Acute mAnAgement::
 Bed rest, antiemetics, antivertiginous drugs [e.g. betahistine].
 Long term mAnAgement mAy incLude:
 Medical:Medical:
 low salt diet,
 Local application of gentamicin, betahistine
 Surgical.Surgical.
 Decompressing the inner ear ( draining the endolymphatic sac)
 Vestibular neurectomy
 Labyrinthectomy

46. SUMMARYSUMMARY
 Patients with hearing loss may have conductive, sensorineural, or mixed hearing loss.
 Patients with hearing loss should undergo a directed history and examination.
 Weber and Rinne tests to distinguish conductive from sensorineural hearing loss
 Patients with conductive hearing loss should undergo physical examination of the
auricle and external auditory canal (EAC) looking for evidence of blockage to explain
the hearing loss.
 Patients without an obvious etiology for hearing loss (such as external otitis or
cerumen impaction) should undergo formal audiologic testing.

47. SUMMARYSUMMARY
 Otoscelerosis is the second most common cause of conductive hearing loss in 15-50
years olds (eftar cerumen impation).
 Presbycusis is the most common cause of SNHL
 Short exposure to louder sounds can cause significant SNHL
 Features of Ménière disease; tinnitus, hearing loss, aural fullness, and vertigo

48. QUIZQUIZ
Q.With negatives Renne’s test on the right side and Weber’s test
lateralized to the right ear could be suffering from:
Bilateral chronic suppuratiove otitis media
Right CSOM
Bilateral otosclerosis
Right secretory otitis media and left Eustachian tube dysfunction
Left CSOM only

49. Q.A progressing conductive hearing loss in an adult with a
normal appearing, mobile tympanic membrane is most likely
due to:
a. serous otitis media
b. otosclerosis
c. acute otitis media
d. external otitis media

50. Q.Most common cause of conductive hearing loss in children:
C.S.O.M.
Acute O.M.
Chronie recurrent S.O.M
Otitis externa.

51. Q. Meniere's syndrome is a symptom complex
characterized by:
a) conductive hearing loss and tinnitus.
b) fluctuating Sensorineural hearing loss, tinnitus, and constant
vertigo.
c) intermittent vertigo lasting several days each time.
d) fluctuating Sensorineural hearing loss, vertiginous episodes
lasting 1-2 hours, and tinnitus.
e) vertigo precipitated by lying down and turning over to one side.

52. REFERENCESREFERENCES
Ear, nose and throat and head and neck surgery, R. S. Dhillon, C.A East,
third edition.
Otolaryngology- head and neck surgery,Toronto notes 2011
http://www.ncbi.nlm.nih.gov
http://www.uptodate.com