Patient will present as → a 72-year-old male with a progressively worsening hearing loss. He states that his trouble with hearing began 7-8 years ago. He can hear when someone is speaking to him; however, he has difficulty understanding what is being said, especially when there is background noise. In addition to his current symptoms, he reports a steady ringing in both ears, and at times experiences dizziness. Medical history is significant for three prior episodes of acute otitis media. His family history is notable for his father being diagnosed with cholesteatoma. His temperature is 98.6°F (37°C), blood pressure is 138/88 mmHg, pulse is 14/min, and respirations are 13/min. On physical exam, when a tuning fork is placed in the middle of the patient's forehead, the sound is appreciated equally on both ears. When a tuning fork is placed by the external auditory canal and subsequently on the mastoid process, air conduction is greater than bone conduction. (presbycusis)
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The most common causes of hearing impairment/loss are cerumen impaction, eustachian tube dysfunction (secondary to upper respiratory tract infection), and increasing age (presbycusis).
Hearing loss can be classified as conductive, sensorineural, or both (mixed loss)
- Conductive hearing loss occurs secondary to lesions in the external auditory canal, tympanic membrane (TM), or middle ear. These lesions prevent sound from being effectively conducted to the inner ear.
- Sensorineural hearing loss is caused by lesions of either the inner ear (sensory) or the auditory (8th) nerve (neural). This distinction is important because sensory hearing loss is sometimes reversible and is seldom life-threatening. A neural hearing loss is rarely recoverable and may be due to a potentially life-threatening brain tumor—commonly a cerebellopontine angle tumor.
- A mixed loss may be caused by severe head injury with or without fracture of the skull or temporal bone, by chronic infection, or by one of many genetic disorders. It may also occur when a transient conductive hearing loss, commonly due to otitis media, is superimposed on a sensorineural hearing loss.
Neurological deficits necessitate imaging
- Weber test: Tuning fork is placed on the center of the head and see if sound lateralizes - Sound lateralizes to affected ear in conductive hearing loss, Sound lateralizes to unaffected ear in sensorineural hearing loss
- Rinne test: Tuning fork placed on mastoid and then up to the ear (should continue to hear) conductive hearing loss if bone > air, sensorineural hearing loss if air > bone
The causes of hearing loss should be determined and treated
Question 1 |
The tympanic membrane is movable with pneumatic otoscopy Hint: A movable tympanic membrane indicates there is no effusion, and is not the Weber test. | |
The tympanic membrane is pearly gray with a sharp cone of light with apex at the umbo Hint: The tympanic membrane is evaluated by direct observation with an otoscope, and is not the Weber test. | |
Sound is heard equally in both ears when a vibrating tuning fork is placed on the mid forehead | |
Air conduction is greater than bone conduction when a vibrating tuning fork is moved from the mastoid bone to close to the ear canal Hint: A normal Rinne test means that tuning fork vibration is heard longer through the air than the bone. |
Question 2 |
auditory brainstem evoked response Hint: See B for explanation. | |
gadolinium-enhanced MRI | |
acoustic reflex testing Hint: See B for explanation. | |
vestibular testing Hint: Vestibular testing is not a useful screening test for acoustic neuromas. |
Question 3 |
otosclerosis Hint: See C for explanation. | |
cholesteatoma Hint: See C for explanation. | |
impacted cerumen | |
chronic serous otitis media Hint: See C for explanation. |
Question 4 |
audiometry Hint: Pure tone audiometry can be used to screen for hearing deficits in children over the age of 3 years. | |
tympanometry Hint: Tympanometry is used to identify an effusion as the cause of hearing loss, but in infants over the age of months. | |
acoustic reflectometry Hint: Acoustic reflectometry measures the spectral gradient of the tympanic membrane, but is not used clinically due to concerns about its reliability. | |
auditory-evoked potentials |
Question 5 |
Sounds best heard in the left ear on Weber test. | |
Air conduction longer than bone conduction in the left ear on Rinne test. Hint: With conductive hearing loss, bone conduction should be heard as long as or longer than air conduction of sound in the effected ear. Air conduction lasting longer than bone conduction of sound would indicate sensorineural hearing loss. | |
Sound best heard in the right ear on Weber test. Hint: Sound best heard in the ear with unaffected hearing on Weber test (in this case, the right ear) is indicative of sensorineural hearing loss. | |
Bone conduction longer than air conduction in the right ear. Hint: With conductive hearing loss, bone conduction should be heard as long as or longer than air conduction of sound in the affected ear. The right ear showed normal hearing on physical exam. |
Question 6 |
referred to the right ear | |
referred to the left ear Hint: See A for explanation. | |
equal in both ears Hint: See A for explanation. | |
louder with air conduction Hint: Bone conduction as noted with the Rinne test is louder than air with conductive hearing loss. |
Question 7 |
Advise him to discontinue use of cotton swabs | |
Encourage jet irrigator (i.e. WaterPik) to clean ears Hint: Use of jet irrigators designed for cleaning teeth (i.e. waterPik) for wax removal should be avoided since they may result in tympanic membrane perforations. | |
Instruct in ear irrigation with cold water Hint: Irrigation is performed with water at body temperature to avoid a vestibular caloric response. | |
Refer to dermatologist Hint: See A for explanation. |
List |
References: Merck Manual · UpToDate