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Hearing Loss

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Devon Fagel, MD, JD
Devon Fagel, MD, JD

Evaluation and Treatment

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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 Site Middle 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 Test Negative = 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 (swimmers 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 Size Completely in Canal In Canal In Ear Behind Ear Cost Digital $1500-$4000 Analog Programable $1000-$2000 Analog Non- Programmabl e $700- $1500 Technolog y Remote 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

More Related Content

Hearing Loss

  • 1. Can You Hear Me Now? Evaluation & Treatment of Hearing Loss Devon M. Fagel Ambulatory Clerkship January 14, 2010
  • 2. 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
  • 3. 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
  • 4. Anatomy Yueh et al., JAMA 289: 1976-1985, 2003
  • 5. Conductive vs. Sensorineural * Hearing defects affecting both ears will produce normal results. Conductive Hearing Loss Sensorineural Hearing Loss Anatomical Site Middle 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 Test Negative = BC>AC (Bone/Air Gap) Positive = AC>BC Both decreased equally
  • 6. 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?
  • 7. 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 (swimmers 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.
  • 9. 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
  • 10. What is the primary diagnosis?
  • 11. 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.
  • 13. 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?
  • 14. Screening for Hearing Loss in Primary Care 0-8 = 13% probability 10-24 = 50% probability 26-40 = 84% probability
  • 15. 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.
  • 16. 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
  • 18. Treatment for Presbyacusis Size Completely in Canal In Canal In Ear Behind Ear Cost Digital $1500-$4000 Analog Programable $1000-$2000 Analog Non- Programmabl e $700- $1500 Technolog y Remote Volume Control Directional Microphones Programmabilit y Analog vs DigitalBogardus et al., JAMA 289: 1986-1990, 2003
  • 19. 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?
  • 20. Audiometry 202: Interpret these results: Unilateral HL = Weber rt AC>BC = Positive Rene What next? X = Lt Ear O = Rt Ear
  • 22. 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

Editor's Notes

  • #4: - Third only to hypertension and arthritis (how many of you have treated HTN, arthritis, hearing loss?) - Almost half population of 65 (how many of you have treated those over 65?) - HL rising drastically (Why? iPods can deliver 115 dB) (Noise-induced hearing loss begins at 90 dB) - How many have asked about depression?
  • #5: - Outer part of the ear (Pinna) collects sound. - Sound pressure is amplified through canal (middle ear) and transmitted to the cochlea via the tympanic membrane. - Air is contained in the outer and middle ear but not the inner, as TM moves, the Stapes transmits to the cochlea. - Inner ear is hollow, embedded in the temporal bone (densest bone of the body). - Chochlea contains sensory epithelium studded with hair cells (mechanoreceptors) which move with the fluid causing them to fire. - Sound is thus transformed into nerve impulses and delivered via CN 8 traveling through the brain stem to the temporal lobe.
  • #7: What indicates hearing loss? Any clues as to what kind?
  • #8: Cholesteatoma and Otosclerosis can eventually presents as mixed conductive/sensorineural
  • #9: Normal hearing between 20 and -10 dB. Human speech occurs between 60 and 20 dB. Certain sounds have higher frequencies thus with certain types of HL may not be able to hear F, S, Th but no problem with M, N, O.
  • #13: Normal hearing, common as we age that one ear is slightly better than other especially at higher frequencies. Here the lt ear is better than right. Possibly due to rt handed person and years of phone use.
  • #14: Atherosclerosis may diminish vascularity of cochlea. What are indications of athlerosclerosis. High BMI Diabetes may causes vasculitis and endothelial proliferation in blood vessels of cochlea, reducing blood supply. Hypertension - vascular changes Ototxic drugs Smoking - accentuate atherosclerotic changes Noise trauma - airport mechanic Explain why Weber is normal?
  • #16: Given pt info what is he at risk for - -Age-related, noise-induced, Ototoxic (Lasix, Asparin, Oxy) - Vascular ischemia
  • #20: Did fall cause hearing loss or something else cause the fall? Explain Webere lateralizing rt (towards unaffected ear)