“Can You Hear Me Now?”Evaluation & Treatment of Hearing Loss

Devon M. Fagel

Ambulatory Clerkship

January 14, 2010

Learning Objectives

• Understand epidemiology of hearing loss

• Review relevant anatomy and pathophysiology

• Describe the differential diagnosis for hearing loss

• Identify primary care patients at risk for hearing loss

• Evaluate hearing loss based on history and physical

• Interpret audiometry results and learn when to refer

• Select the most appropriate treatment for hearing loss

Epidemiology

• Third most prevalent chronic condition (28 million Americans).

• 40% of the population age 65 and older is hearing impaired.

• 65% of patients over 75 and 80% of those over 85 have HL.

• Prevalence of age-adjusted HL drastically risen since 1960s.

• Significant association between hearing loss and depression.

• 9% of internists offer hearing testing to patients over 65.

• 25% of patients with treatable HL receive hearing aids.

Cruickshanks et al., Am J Epidemiol 148: 879-886, 1998

Wallhagen et al., Am J Public Health 87: 440-442, 1997

Yueh et al., JAMA 289: 1976-1985, 2003

Anatomy

Yueh et al., JAMA 289: 1976-1985, 2003

Conductive vs. Sensorineural

* Hearing defects affecting both ears will produce normal results.

Conductive

Hearing Loss

Sensorineural

Hearing Loss

Anatomical SiteMiddle Ear

Tympanic Membrane

Inner Ear

Inner Ear

Cranial Nerve VIII

Central Processing

Center

Weber Test*Sound localizes

to affected ear

Sound localizes

to normal ear

Rinne TestNegative = BC>AC

(Bone/Air Gap)

Positive = AC>BC

Both decreased

equally

Case #1• CC: “Trouble having a conversation, especially in noisy

places”

• HPI: Patient reports difficulty understanding people in social situations. Having particular problems on the phone. Friends and family mention they often have to repeat themselves. Symptoms have become progressively worse over past few weeks.

• PE: Pt speaks very loudly. Negative Rinne (BC>AC), Weber normal. Unable to perform otoscopic exam (you forgot to charge the battery).

• What kind of hearing loss? Differential diagnosis?

Differential (Conductive Hearing Loss)

• Mechanical

• Cerumen: Most common cause of CHL (30% of elderly).

• Foreign body: Common objects include ear plugs, pencil tips.

• Infectious

• Otitis externa (swimmer’s ear):

• Common causes include cotton swabs, polluted water.

• Otitis media (glue ear):

• Common in children (shorter horizontal Eustacian tube).

• Destructive

• Cholesteatoma: Keratinizing squamous epithelium.

• Otosclerosis: Abnormal growth of bone near middle ear.

Audiometry 101:

Audiometry 101:

• Interpret these results:

• Mild-Moderate HL (cannot hear <30 dB)

• Bilateral HL = Normal Weber

• BC>AC = Conductive HL

• Repeat test after treatment

[ ] = Bone Conduction

X O = Air Conduction

What is the primary diagnosis?

Treatment for Cerumen Impaction

• Use of small cerumen curette to remove impaction.

• Gentle warm water irrigation to loosen and remove.

• Prescribe hydrogen-peroxide solutions if history of tympanic membrane perforation or ear surgery.

• Refer to otolaryngologist for deep impactions.

• Refer for audiology testing to rule out damage.

Audiometry 101:

Case #2• CC: “Depression”

• HPI: 78 yo M reports feeling depressed and socially isolated after wife passed away last year. No longer talks to brother on the phone. Nearly arrested last week after getting into argument with Walmart cashier. Accused him of yelling and screaming at her. Spends most of the day watching TV (daughter complains too loud).

• PMH: CAD, CHF, CRI, HTN, DM, GERD, Low-back pain.

• SH: Retired airport mechanic, 50 pack-year smoker.

• Meds: Oxycodon, Lasix, Asparin.

• PE: BMI 35. Positive Rinne (AC>BC), Weber normal. Otoscopic exam unremarkable.

• Is there hearing loss? What evidence? Differential diagnosis?

Screening for Hearing Loss in Primary Care

0-8 = 13% probability 10-24 = 50% probability 26-40 = 84% probability

Differential (Sensorineural Hearing Loss)• Age-Related

• Prebyacusis: Hearing loss mostly in high frequency (>2kHz).

• Traumatic

• Temporal Bone Fracture: Cochlear, auditory nerve damage.

• Noise-Induced: Prolonged exposure (>90 dB). HL (>4kHz).

• Infectious

• Meningitis, Measles, Mumps, HIV: Cochlear, auditory nerve.

• Ototoxic

• Gentamicin, Furosemide, Methotrexate, Aspirin, Heavy Metals.

• Neoplastic

• Acoustic Neuroma, Meningioma, Cerebellopontine Tumor.

• Sudden-Hearing Loss

• Vascular ischemia of the inner ear and surrounding area.

• Idiopathic: Responds to prompt injection of corticosteroids.

Audiometry 201:

• Interpret these results:

• Sloping high frequency HL

• Bilateral HL = Normal Weber

• AC>BC = Positive Rene

• Treatment options?

[ ] = Bone Conduction

X O = Air Conduction

Patient Experience:

Treatment for Presbyacusis

SizeCompletely

in CanalIn Canal In Ear Behind Ear

CostDigital

$1500-$4000

Analog

Programable

$1000-$2000

Analog Non-

Programmabl

e $700-

$1500

Technolog

yRemote

Volume Control

Directional

Microphones

Programmabilit

y

Analog vs

DigitalBogardus et al., JAMA 289: 1986-1990, 2003

Case #3• CC: “Fell on sidewalk”

• HPI: 47 yo F presents to urgent care after falling and hitting her head on the pavement. She reports 1 week of nausea/vomiting. Husband states that she has been “stumbling” lately. She also complains of HA which are getting progressively worse. Pt reports tinnitus in left ear and though left handed has been using rt hand to talk on the phone.

• PE: Positive Rinne (AC>BC), Weber lateralizes rt. Otoscopic exam unremarkable.

• What kind of hearing loss? Differential diagnosis?

Audiometry 202:

• Interpret these results:

• Unilateral HL = Weber rt

• AC>BC = Positive Rene

• What next?

X = Lt Ear

O = Rt Ear

Unilateral Sensorineural Hearing Loss:

Recap:

• Covered epidemiology of hearing loss

• Covered anatomy and pathophysiology

• Covered differential diagnosis for hearing loss

• Covered primary care patients at risk for hearing loss

• Covered evaluation of hearing loss (history and physical)

• Covered interpretation of audiometry testing results

• Covered most appropriate treatment for hearing loss