Hearing Loss
What are 3 examples of chemicals substance that can lead to SENSORINEURAL HEARING LOSS (ototoxin exposure)?
less common *salicylates (Aspirin), aminoglycosides (antibiotics), chemotherapeutics*
How can you test the reliability of patient response to WEBER test?
repeat while they *occlude one ear* and ask which ear hears the sound better. It should be *heard best in the occluded ear*
What is tinnitus?
*"Ringing" in the ears*, perceived internal noise heard by patient, usually will have associated hearing loss Most commonly secondary to *bilateral SENSORINEURAL HEARING LOSS* Can be secondary to vascular problem, intracranial mass, metabolic disorder
What is an acoustic neuroma (vestibular schwannoma)?
*Benign tumor* that arises from the *schwann cells of CN VIII*
What is pathogenesis of tympanosclerosis?
*Calcium patches* on TM in response to infection
Treatment options and efficacy for tinnitus?
*Effective treatment= finding the underlying cause* Medications *not very helpful* Can try antidepressants or biofeedback, masking noises
What are questions related to family and social history that should be asked of hearing loss patient?
*Family History*: Hearing loss in the family? *Social History*: Occupation or previous occupation Environment and noise level Tobacco, ETOH, illicit drugs
What sound frequency and communication ability is affected in presbycusis?
*High frequency* hearing -and- *speech discrimination ability* are affected
What regions of ear effected in sensorineural hearing loss? What are common pathologies underlying these issues?
*Inner Ear*: Hereditary, congenital viral infections (CMV), congenital malformations, presbycusis (age related decrease in inner hair cells), meningitis, thyrotoxicosis, viral cocleitis, ototoxic drugs, otologic surgery, Meniere disease, noise exposure, barotrauma, penetrating trauma, acoustic neuroma, meningioma, autoimmune disease, MS, cerebrovascular ischemia
What type of diseases is Menieres disease?
*Labrynthine disorder (inner ear- cochlea and vestibule)* uncertain etiology-thought to be caused by *increased fluid pressure within the ear*
What regions of ear are cause of conductive hearing loss? What are common pathologies underlying these issues?
*Outer and middle ear* Outer Ear: Congenital microtia or atresia, trauma, SCC, exostosis (abnormal bone growth; usually multiple and bilateral ), osteoma (benign tumor of bone growing on bone), psoriasis, cerumen Middle Ear: Congenital atresia (narrowing) or ossicular chain malformation, otitis media, cholesteatoma, otosclerosis, TM perforations, temporal bone trauma, glomus tumors (frequently used incorrectly--actually paragangliomas) *slow-growing but highly vascular tumors*
Symptoms of Acute Labrynthitis?
*Sudden and severe vertigo* - lasts DAYS Associated with acute hearing loss SENSORINEURAL HEARING LOSS
If tinnitus is unilateral and patient hears "blood rushing" or "heart beat" what should you order?
*concerns about vascular problem* Consider work-up to include: Radiography: MRI/MRA *carotid dopplers* LABS: CBC, thyroid panel
What is actual underlying disease process that lead to CONDUCTIVE HEARING LOSS in OM?
*effusion* in middle ear *decrease TM mobility*
What age demographic most commonly effect by sensorineural hearing loss?
*mainly adults*
If sudden sensorineural hearing loss and cannot determine cause during H&P. What should you do?
*urgent ENT referral*
What diagnostic tests should be performed if suspect Meniere's disease?
-Audiometry to document fluctuating hearing loss -Vestibular testing to identify diseased ear -MRI to *rule out acoustic neuroma*
Explanation of RINNE AND WEBER (words)
-In patients complaining of a unilateral decrease in hearing, the Weber test suggests sensorineural hearing loss if the sound lateralizes (is louder on) to the "good" side; conductive hearing loss is suspected if the sound lateralizes to the "bad" side. -An abnormal Rinne test, with bone>air conduction, is consistent with conductive loss, particularly if the Weber test also lateralizes to that side. -When the Weber test lateralizes to an ear in which the Rinne is positive (normal), the Rinne test in the opposite ear should be performed. A normal Rinne test in the contralateral ear suggests sensorineural hearing loss in this contralateral ear (ie, the Weber lateralized to the normal ear). An audiogram is indicated in this situation.
A patient presents with unilateral hearing loss. Weber reveals lateralization to the right ear. Rinne test reveals the following: RIGHT: bone conduction =10 seconds, air conduction = 5 seconds; LEFT: bone conduction = 5 seconds, air conduction = 10 seconds. Which of these other physical exam findings is to be expected: A. Cerumen impaction in the right ear B. Effusion in the left ear C. Otitis media in the left ear D. Pain on palpation of tragus or mastoid area on right ear
A. Cerumen impaction in the right ear -WEBER: lateralization to right ear -negative rinne test in right ear (BC>AC) Indicate conduction deafness.
What is conductive hearing loss?
Conductive Hearing Loss - *sound is unable to pass through the middle ear to the inner ear* *Mechanical issue* somewhere along pathway of sound including the outer ear, tympanic membrane (eardrum), or middle ear (ossicles)
Treatment for Meniere's disease?
Antiemetic for N&V Vestibular suppressant for vertigo (*meclizine*) Diuretics Decrease sodium intake
Treatment option for presbycusis?
Audiology consult, hearing aids
52 yo male patient presents with unilateral left-sided hearing loss that has progressed over 2 months. His wife states that he has difficulty discriminating words, although he can hear sounds. He has also experienced some imbalance lately, but he contributes this to trying to do too many things too quickly. Which of the following is the likely pattern of testing on physical exam? A. Rinne air conduction greater than bone conduction; Weber lateralizes to left B. Rinne air conduction greater than bone conduction; Weber lateralizes to right C. Rinne bone conduction greater than air conduction; Weber lateralizes to right D. Rinne bone conduction greater than air conduction; Weber lateralizes to left
B -Slow progression -difficulty discriminating words -imbalance *Indicative of sensorineural disease*: *Weber would localizes to UNAFFECTED ear* Rinne would be positive in both ears (AC>BC)
What should be next step if you suspect tympanosclerosis or tumors of auditory canal?
BOTH require ENT referral
What are Exostoses and Osteomas? What normally results from these growths and how can they be treated?
CONDUCTIVE HEARING LOSS *Bony overgrowths* in the canal Causes impaired cerumen migration TX: surgery, rarely necessary
What typically precedes Tympanic membrane perforation and what is reason for decreased sound transmission?
CONDUCTIVE HEARING LOSS *Reduces surface area available for sound transmission* Usually secondary to *chronic OM or trauma*
What is ostosclerosis and what structure does ti directly effect?
CONDUCTIVE HEARING LOSS *abnormal bone deposition* at the base of stapes leads to *fixation of the stapes* preventing vibration
What structures are typically effected by tympanosclerosis
CONDUCTIVE HEARING LOSS Usually involves the *TM, ossicles, middle ear mucosa* *"stiffens" the system*
What are considerations that must be addressed in tinnitus? What questions must you ask of the patient?
Can be bilateral or unilateral Need to ascertain the quality - pitch/volume *Sound like "blood rushing" or "heartbeat"* - concerns about vascular problem
What are possible causes of tinnitus?
Can be secondary to vascular problem, intracranial mass, metabolic disorder Also, caused by medications: -NSAIDS -Aspirin -Aminoglycosides -Loop diuretics
What is cause of the INNER EAR DISORDER Benign Paroxysmal Positional Vertigo (BPPV)?
Caused by otoconia (*Calcium carbonate*) particles/crystals from the utricle or saccule lodging in the posterior semicircular canal (*canalithiasis*)
What age group is most commonly affected by otitis media (OM)?
Children
What are the physical exam tests performed for BPPV?
Complete ENT exam, check for orthostatic hypotension, complete an ocular exam, balance tests (Romberg's), assess gait, CN assessment Dix-Hallpike Maneuver
A 32 yo male presents with complaints of recurrent, episodic vertigo lasting up to 8 hours per episode for 6 months. The vertigo is associated with unilateral, low-frequency hearing loss and tinnitus. What is the most likely diagnosis? A. Labyrinthitis B. Multiple Sclerosis C. Acoustic Neuroma D. Meniere Syndrome
D. MENIERE -episodic -lasts HOURS -fluctuating hearing loss: LOW frequency, unilateral All symptoms of MENIERE
What is diagnostic work up and treatment for acoustic neuroma?
Diagnostic Work-up: *MRI* Tx: *Surgery or radiotherapy*
What age demographic most commonly effected by Acoustic neuroma? What are the presenting symptoms?
Most common in *middle age* Main symptoms: are *hearing loss and tinnitis* -hearing loss usually *gradual* and progressive, *unilateral* (can be sudden)
What is the most common preventable cause of SENSORINEURAL HEARING LOSS? Which frequency of sound effected?
NOISE TRAUMA high-frequency affected first
What are the presenting symptoms of Vestibular Neuritis?
INNER EAR DISORDER -*Acute vertigo* - lasting DAYS with associated N&V -*No hearing loss*
What is Acute Labrynthitis? What typically proceeds this condition?
Inflammation of inner ear Commonly follows a *viral upper respiratory infection*
What aspects of ears should be examined in PE of ears?
Inspect and palpate auricles *Inspect auditory canals* -Cerumen -Foreign bodies -Abnormalities of skin lining the canal *TM's*: -Mobility -Color -Bony landmarks, light reflex
TX for tympanic membrane perforation?
May need surgical correction
To summarize the RINNE/WEBER test results:
Normally: *Weber doesn't lateralize*, and both ears have *+Rinne (AC>BC).* Conductive loss: *Weber localizes to AFFECTED ear*, *-Rinne in affected ear (BC>AC)* Sensorineural loss: *Weber localizes to UNAFFECTED ear*, +Rinne in both ears (AC>BC)
What precedes Vestibular Neuritis and what is the onset/duration of symptom?
Occurs spontaneously or following URI Symptoms *peak within 24 hours* and usually *last 3-4 days*
What are specific factors of OLDCHARTS that should be emphasized in hearing loss?
Onset and Duration ----Sudden or gradual Location ----Unilateral or bilateral Severity ----Degree and if have any pain Associated symptoms: *Tinnitus, pain, dizziness, vertigo, drainage, HA or visual disturbances* Alleviating and Aggravating Factors Treatments
What are a couple questions related to past medical history that should be asked in patient presenting with hear loss?
Previous episodes: *recurrent ear infections, trauma to the ear* Medications and Health history
What is etiology of presbycusis and ultimate result of disease process (structure affected)?
Result: *Loss of cochlear hair cell function* Etiology: combination of *genetic disposition and environmental factors* -May also be secondary to neurovascular injury from chronic conditions: *HTN, DM*
What is typical development and presentation of Presbycusis?
SENSORINEURAL HEARING LOSS *Symmetric, progressive deterioration of hearing* - usually in older adults and elderly Diagnosis of exclusion
What is sensorineural hearing loss?
Sensorineural Hearing Loss - damage to any part of the *specialized nervous system* of the ear such as *auditory nerve, hair cells in inner ear, other parts of cochlea*
How do you perform WHISPER test?
Stand at *arm's length behind* the patient (to prevent lip reading) Patient *occludes opposite ear* Examiner *whispers a short sequence of letters, words or numbers and asks the patient to repeat them* *Avoid testing with finger snapping or ticking watch* Test the other ear in same manner
TRIAD of symptoms associated with Menieres disease: (SENSORINEURAL HEARING LOSS )
TRIAD of Symptoms: 1. *Episodic vertigo* with Nausea & Vomitin - lasts *HOURS* 2. *Tinnitis with aural fullness* and noise recruitment 3. Fluctuating hearing loss - *LOW frequency, unilateral*
What are indications for treatment of OM? What is the treatment if indicated?
Treat OM if *recurrent* or *no resolution after 3 months*, possible *myringotomy tubes*
Treatment for BPPV?
Treat symptoms --meclizine --positional maneuvers
Treatment options for acute Labrynthitis?
Treat symptoms - antiemetic (*compazine*) and vestibular suppressant (*meclizine*) If suspect bacterial infection - antibiotics Vestibular rehabilitation Oral steroids Antivirals (*Acyclovir*) for recurrent symptoms- Herpes
Treatment for Vestibular Neuritis?
Tx: for symptoms -antiemetic and vestibular suppressant
All the following are needed in order to provide effective care for patients with hearing loss:
Understanding the pathophysiology involved Being aware of the indications for medical management Options for surgical treatment Amplification options
Although adult sensorineural hearing loss is more common, in what circumstances are children sometimes affected?
Usually *secondary to congenital hearing loss* Both hereditary and non-hereditary
What are symptoms and aggravating circumstances?
Vertigo or spinning sensation - *lasts for SECONDS* Sensation *worsens with head movement, looking up, or rolling over* when supine *No neurologic symptoms* present
How common are *tumor/cyst* of auditory canal?
Very uncommon
Patient #1 "I'm not hearing well out of my right ear." WEBER: "I hear that better in my right ear!" RINNE: Can hear it on the mastoid process, but can't hear it when moved to his ear (negative Rinne) Diagnosis?
We have now identified that the patient has a conductive hearing loss on the right.
What are three hearing tests that can be performed in clinic to assess conductive or sensorineural hearing loss?
Weber Test Rinne Test Whisper Test
Treatment for Noise trauma?
aggressive use of noise protection
If tinnitus is *bilateral, NOT pulsatile, not intrusive, and mild hearing loss* what is it considered secondary to?
considered secondary to hearing loss
Treatment for Otosclerosis:
hearing aids or surgery (stapedectomy)
What structures are effected in Conductive hearing loss?
involving *any cause* that in some way *limits the amount of external sound* from gaining access to the inner ear. *Examples include cerumen impaction, middle ear fluid, or ossicular chain fixation (lack of movement of the small bones of the ear)*
What is a "mixed hearing loss"?
is a combination of conductive and sensorineural hearing loss
What structures are involved in sensorineural loss?
occurs with dysfunction of the inner ear, cochlea, or the auditory nerve.
What are typical presentation symptoms of Otosclerosis?
present as *progressive bilateral hearing loss* in adults
Patient #2 "I can't hear out of my right ear!" WEBER: "I hear it better on left side" RINNE: on the left AC>BC (normal, +Rinne). Now we do the Rinne on the right and AC>BC too.
sensorineural hearing loss WEBER: The patient, no matter what, can't hear it on the affected (right) side due to sensory loss RINNE: normal on both sided b/c conduction is normal.
How do you perform the RINNE TEST?
strike the tuning fork and *pressing the handle of the tuning fork to the mastoid bone* and ask the patient to tell the examiner when the sound is no longer audible. *Examiner times this.* At that point, the vibrating end of the tuning fork is *placed 1-2cm from external auditory canal (EAC)* and ask when they can no longer hear the sound. *Examiner also times this.* Compare the number of seconds sound is heard by bone conduction versus air conduction. *Air conducted sound should be heard twice as long as bone* conducted sound. Ex: if bone conducted sound is heard for 15sec, air should be for an additional 15 seconds. Ratio should be 2:1. *Positive Rinne test = normal*; when air conduction is heard longer than bone conduction by *2:1 ratio.*
Describe the process of Weber test:
striking the tuning fork and pressing the handle of the tuning fork on the *middle of the patient's head* and asking the patient if the *sound is louder in one ear or the other*. NORMAL: The sound is heard equally in both ears in patients with normal hearing or symmetric hearing loss. ASK: Is the sound heard equally in both ears or is it better in one ear (lateralization of sound) RESULT: If the sound is lateralized, have them tell you which ear hears the sound better CONDUCTIVE LOSS: *lateralization to affected ear* SENSORINEURAL LOSS: *lateralization to opposite ear*