An Older Adult in the Family Practice Clinic Reports a Decrease in Hearing Over a Week
Hearing Loss in Adults: Differential Diagnosis and Treatment
Am Fam Doc. 2019 Jul 15;100(2):98-108.
This clinical content conforms to AAFP criteria for continuing medical education (CME). See the CME Quiz Questions.
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Article Sections
- Abstract
- Classification
- Clinical Aspects
- Primary Care Management
- Assistive Technologies
- References
More than than 30 million U.S. adults take hearing loss. This status is underrecognized, and hearing aids and other hearing enhancement technologies are underused. Hearing loss is categorized every bit conductive, sensorineural, or mixed. Historic period-related sensorineural hearing loss (i.eastward., presbycusis) is the about common type in adults. Several approaches can be used to screen for hearing loss, but the benefits of screening are uncertain. Patients may present with self-recognized hearing loss, or family members may observe behaviors (east.g., difficulty agreement conversations, increasing television volume) that advise hearing loss. Patients with suspected hearing loss should undergo in-office hearing tests such as the whispered voice examination or audiometry. Patients should and then undergo exam for cerumen impaction, exostoses, and other abnormalities of the external canal and tympanic membrane, in improver to a neurologic examination. Sudden sensorineural hearing loss (loss of 30 dB or more than within 72 hours) requires prompt otolaryngology referral. Laboratory evaluation is not indicated unless systemic illness is suspected. Computed tomography or magnetic resonance imaging is indicated in patients with asymmetrical hearing loss or sudden sensorineural hearing loss, and when ossicular chain damage is suspected. Treating cerumen impaction with irrigation or curettage is potentially curative. Other aspects of treatment include auditory rehabilitation, education, and eliminating or reducing use of ototoxic medications. Patients with sensorineural hearing loss should be referred to an audiologist for consideration of hearing aids. Patients with conductive hearing loss or sensorineural loss that does not ameliorate with hearing aids should be referred to an otolaryngologist. Cochlear implants can be helpful for those with refractory or severe hearing loss.
More than thirty million U.S. adults, or about 15% of all Americans, have some caste of hearing loss.ane It is most mutual in older adults, occurring in about i-half of adults in their 70s and eighty% of those 85 years and older.ane,2 Despite this high prevalence, hearing loss is underdetected and undertreated. Only about one-third of people with self-reported hearing loss have ever had their hearing tested, and only fifteen% of people eligible for hearing aids consistently use them, citing factors such equally cost, difficulty using them, and social stigma.i,three,4
WHAT IS NEW ON THIS TOPIC
The FDA Reauthorization Human activity of 2017 allows direct-to-consumer sale of hearing aids for mild to moderate hearing loss, for which express event studies prove improved hearing, advice, and social engagement. The toll of over-the-counter hearing aids is expected to range from approximately $200 to $1,000 compared with $800 to $4,000 for conventional hearing aids.
Among patients with dementia in a U.Due south. population-based longitudinal accomplice study, the use of hearing aids was associated with decreased social isolation and a slower rate of cerebral pass up, even after adjusting for multiple confounders.
SORT: Primal RECOMMENDATIONS FOR Practice
| Clinical recommendation | Evidence rating | Comments |
|---|---|---|
| The U.Southward. Preventive Services Chore Force and the American Academy of Family unit Physicians conclude that the current prove is insufficient to assess the balance of benefits and harms of screening for hearing loss in asymptomatic adults 50 years and older.22,28 | C | Based on randomized controlled trials and observational studies with disease-oriented outcomes. The only good-quality randomized trial of hearing screening included many patients with baseline concerns about hearing loss; there was no comeback in hearing-related quality of life. |
| Patients with suspected presbycusis should be referred for audiometry.Laboratory evaluation or imaging is not needed initially.12,xiii,17,29 | C | Based on skilful stance and clinical reviews |
| Patients with sudden sensorineural hearing loss should exist referred to an otolaryngologist for audiologic evaluation.33 | C | Based on a clinical exercise guideline |
| Information on hearing aid use should be provided to patients. It should contain patient expectations, perceived self-benefit, satisfaction, readiness to have change, and support from significant others.38,39 | C | Systematic reviews on hearing aid use found only limited prove for increased use of hearing aids when these factors are incorporated into the treatment plan. |
| Over-the-counter hearing aids should be recommended for patients with mild hearing loss.49–51 | C | Based on a depression-quality study and expert opinion. Over-the-counter hearing aids are now approved by the U.S. Food and Drug Administration for mild to moderate hearing loss, but the American Speech-Language-Hearing Clan recommends these devices merely for patients with mild hearing loss. |
All-time PRACTICES IN OTOLARYNGOLOGY
| Recommendations from the Choosing Wisely Campaign | |
| Recommendation | Sponsoring organization |
|---|---|
| Do not order computed tomography of the caput/encephalon for sudden hearing loss. | American Academy of Otolaryngology–Head and Neck Surgery Foundation |
Hearing loss is associated with adverse effects, even later on adjusting for misreckoning factors. Difficulty hearing speech adversely affects social date and partner relationships. Hearing loss is also associated with decreased quality of life, dementia, depression, debility, delirium, falls, and mortality.5–7 Medical costs resulting from hearing impairment are estimated to range from $3.3 million to $12.8 meg annually in the U.s..8 This includes direct medical costs, disability expenditures, and indirect costs from lost productivity and caregiver expenses.
Classification
- Abstract
- Nomenclature
- Clinical Aspects
- Primary Care Management
- Assistive Technologies
- References
Hearing loss is grouped into conductive, sensorineural, or mixed types. Conductive problems involve the tympanic membrane and middle ear, and interfere with transmitting sound and converting it to mechanical vibrations (Table 1).9–15 Sensorineural problems affect the conversion of mechanical sound to neuroelectric signals in the inner ear or auditory nerve (Table 2).ix–15
TABLE i.
Causes and Selected Clinical Features of Conductive Hearing Loss in Adults
| Location | Condition | Typical history* | Concrete examination findings† | Management‡ |
|---|---|---|---|---|
| Middle ear | Cholesteatoma | Recurrent otitis media, history of perforation, gradual onset of hearing loss, otorrhea, otalgia tardily | Tympanic membrane with retraction pocket and debris; white mass behind tympanic membrane | Not–contrast-enhanced computed tomography of temporal bone; excision, ofttimes with mastoidectomy, with ossicular chain reconstruction if possible |
| Ossicular concatenation disruption | Trauma, recurrent otitis media | Usually normal; sometimes abnormal location of malleus or incus | Non–contrast-enhanced computed tomography of temporal bone; ossicular chain reconstruction | |
| Otitis media with effusion§ | Fever, otalgia | Erythematous tympanic membrane; immobile on pneumatic otoscopy | Antibiotics, expectant management; myringotomy for refractory effusion | |
| Otosclerosis§ | Gradual, painless, bilateral hearing loss presenting at 30 to 50 years of historic period; tinnitus; better at hearing spoken language in noisy environments | Tympanic membrane ordinarily normal | Hearing aid; consider stapedectomy or other surgical procedure | |
| Pinna, external auditory canal | Obstruction of external canal by cerumen§ | Gradual onset; otalgia uncommon | Occlusive cerumen | Cerumen removal past irrigation or curettage |
| Obstruction of external canal by exostoses (surfer's ear) | Gradual onset; otalgia uncommon | Abnormally shaped canal with mass | Excision of obstructing exostosis | |
| Obstruction of external canal past foreign torso | Gradual onset; otalgia uncommon | Foreign body in culvert | Strange body removal | |
| Otitis externa | Otalgia, drainage | Inflamed canal with debris | Topical antimicrobial and anti-inflammatory | |
| Tympanic membrane | Perforation, tympanosclerosis | Barotrauma or head/ear trauma, recent or recurrent otitis media | Visible defect or scarring | Antibiotics if infection present; tympanoplasty if perforation not healed inside two months; referral and imaging for vertigo, astringent symptoms, or facial paralysis |
TABLE 2.
Causes and Selected Clinical Features of Sensorineural Hearing Loss in Adults
| Condition | Typical history* | Concrete examination findings† | Management‡ |
|---|---|---|---|
| Autoimmune condition (idiopathic or part of recognized autoimmune disease) | Bilateral, rapidly progressive hearing loss; clutter; vertigo; symptoms of recognized autoimmune affliction | Normally normal | Autoimmune laboratory evaluation, immunosuppressive drugs, transtympanic corticosteroids |
| Cerebellopontine angle tumor/neoplasm | Hearing loss that is usually slowly progressive and unilateral, but sometimes sudden; tinnitus; headache (belatedly); vertigo (typically balmy) | Usually normal; some patients have ataxia, facial weakness, or decreased facial sensation | Contrast-enhanced magnetic resonance imaging, surgical excision |
| Infectious status (e.g., meningitis, labyrinthitis) | May exist a complication of otitis media; hearing loss develops over hours to days; respiratory symptoms and vertigo may be present | Signs of otitis media; nuchal rigidity and fever in meningitis; nystagmus and clutter in labyrinthitis | Computed tomography or magnetic resonance imaging, lumbar puncture; antibiotics for meningitis; expectant management or vestibular rehabilitation for labyrinthitis; consultation with otolaryngologist, neurologist, or infectious disease subspecialist |
| Meniere affliction | Episodic, fluctuating ear fullness associated with tinnitus, hearing loss, and vertigo | Often normal; during episode may accept rotary nystagmus and ataxia, and noises may seem much louder than they are (auditory recruitment) | Acute episodes tin be treated with vestibulosuppressants (east.g., antihistamines, benzodiazepines); long-term treatments include diuretics, vestibular residue/rehabilitation therapy, transtympanic injection of corticosteroids or gentamicin, or surgery (due east.chiliad., decompression of endolymphatic sac) |
| Noise exposure§ | Acute exposure to sudden loud (130 dB) impulse (acoustic trauma); chronic exposure to loud (85 dB) noises; tinnitus | Normal | Prevention; referral to audiologist for possible hearing aid; referral to otolaryngologist if hearing assistance is ineffective or for consideration of cochlear implant for profound hearing loss Audio-visual trauma lasts hours to days (typically resolves within 48 hours) |
| Ototoxin exposure | Hearing loss develops over weeks; exposure to medications or industrial toxins (eTable A) | Normal | Prevention, referral to audiologist, hearing aid |
| Presbycusis§ | Older age, family history | Normal | Referral to audiologist for possible hearing assistance; referral to otolaryngologist if hearing help is ineffective or for consideration of cochlear implant for profound hearing loss |
| Trauma | Electric current or past head or neck trauma | Signs of other head or neck injuries, hematoma of ear or mastoid, hemotympanum, tympanic membrane perforation | Non–dissimilarity-enhanced computed tomography, referral to trauma subspecialist or otolaryngologist |
Presbycusis, or historic period-related hearing loss, is the most mutual type of sensorineural loss. The crusade of presbycusis is multifactorial, with contributions from genetic factors, aging, oxidative stress, cochlear vascular changes, and environmental factors (e.g., noise, tobacco, alcohol, ototoxins).16–18
There is no universally accepted definition of hearing damage, nor is in that location a universally adopted scale of hearing loss. Notwithstanding, some widely used descriptions are listed in Table 3.19–21 Characterizing hearing loss requires pure tone audiometry. A person with normal hearing tin hear sounds every bit soft as 25 dB; conversational spoken communication is 45 to lx dB.
Table 3.
Models for Classifying Severity of Hearing Impairment
| Severity | Degree of hearing loss in amend ear (dB) | Examples of sounds that can or cannot be heard | ||
|---|---|---|---|---|
| Clark model19 | Centers for Disease Command and Prevention model20 | Globe Health Organization model21 | ||
| Normal | 10 to xv | ≤ 25 | ≤ 25 | Can hear normal animate |
| Slight | 16 to 25 | — | — | Infrequent difficulty in some situations; can hear whispering from 5 ft (one.5 m) away |
| Balmy | 26 to forty | 26 to 40 | 26 to 40 | Difficulty hearing soft spoken communication, quiet library sounds, or speech from a distance or over background noise |
| Moderate | 41 to 55 | 41 to 55 | 41 to sixty | Difficulty hearing regular speech, even at close distances, or sound of a refrigerator |
| Moderately severe | 56 to seventy | 56 to 70 | — | Extreme difficulty hearing normal chat; can hear electric toothbrush |
| Severe | 71 to 90 | 71 to xc | 61 to 80 | Cannot hear most conversational speech, simply loud spoken communication or sounds (e.g., an warning clock) |
| Profound | ≥ 91 | ≥ 91 | ≥ 81 | May perceive loud sounds (eastward.g., factory machinery, car horn) as vibrations |
Clinical Aspects
- Abstract
- Classification
- Clinical Aspects
- Primary Care Management
- Assistive Technologies
- References
SCREENING
Screening for decreased hearing in asymptomatic people tin be washed in several means. Ane is the apply of cocky-administered questionnaires; a validated questionnaire is available at https://www.asha.org/public/hearing/Cocky-Examination-for-Hearing-Loss/. In-office hearing tests are the most accurate for ruling out hearing loss (Table iv).14,15,22–25 Of these, the finger rub test, the whispered voice exam, and audiometry (automated handheld or manual tabletop) are the about accurate and easy to use.12,13,15,24 Remote screening is feasible and reasonably accurate (sensitivity of various tests = 87% to 100%; specificity = 60% to 96%), and a diverseness of tests are available online or every bit smartphone apps.26 However, there are concerns virtually variability of results and interference from ambient racket.
Table iv.
In-Clinic Hearing Tests
| Test | Description | Hearing loss threshold | Sensitivity (%) | Specificity (%) | Likelihood ratio | ||
|---|---|---|---|---|---|---|---|
| Positive | Negative | ||||||
| Clinical examination | |||||||
| Finger rub test | Examiner gently rubs fingers together six inches from patient's ear; a positive consequence is failure to identify the rub in at least three of 6 attempts | > 25 dB | 98 | 75 | 10 | 0.75 | |
| Whispered voice test | Examiner stands at arm'due south length behind patient, and patient occludes i ear while examiner whispers letter/number combinations six times; a positive examination is inability to repeat at least three of the six letter of the alphabet/number combinations | 30 dB | 95 | 82 | 5.ane | 0.03 | |
| Direct question | Yes or no question to patient nearly whether he or she has hearing loss | > 25 dB | 67 | fourscore | iii.0 | 0.four | |
| > 40 dB | 81 | 72 | 2.5 | 0.26 | |||
| Handheld audiometry | Examiner holds device in patient'due south ear, and patient indicates awareness of each tone; a positive test is failure to identify the 1,000-Hz or 2,000-Hz frequency in both ears, or the ane,000-Hz and two,000-Hz frequency in i ear | thirty to 45 dB | 96 | 72 | 3.four | 0.05 | |
| Hearing Handicap Inventory for the Elderly | x-item, self-administered questionnaire measuring social and emotional handicap due to hearing harm; score > viii is aberrant | > 25 dB | 75 | 67 | 3.eight | 0.38 | |
| Tabletop transmission audiometry | Diverse models of small, portable audiometers or audiometric program designed for portable electronic devices | ≥ xl dB | 88 | 96 | 21.iii | 0.thirteen | |
| Tuning fork tests (512 Hz) | |||||||
| Rinne test | Examiner strikes a tuning fork and places it on mastoid bone behind ear, then when patient indicates no further sound, the nevertheless-vibrating fork is moved to the ear (air conduction will be better than bone conduction); disability to detect air-conducted sound indicates conductive hearing loss | 20 dB | 65 | 95 to 98 | 2.vii to 62* | – 0.01 to 0.85* | |
| Weber examination | Examiner strikes a tuning fork and places it midforehead; normal issue is perceiving audio on both sides (no lateralization) | Lateralization to practiced ear indicates sensorineural hearing loss | 58 | 79 | 1.half-dozen | 0.seven | |
| Lateralization to bad ear indicates conductive hearing loss | 54 | 92 | Not specified | 0.v | |||
Despite the availability of these screening modalities, there are questions nigh whether screening is worthwhile. There take been few studies on the consequence, and the only good-quality study evaluated screening in people with self-perceived hearing loss at baseline.27 Thus, the population studied was not asymptomatic, and there was no improvement in hearing-related quality of life. This has led the U.S. Preventive Services Job Strength to conclude that current evidence is insufficient to assess the residue of benefits and harms of screening for hearing loss in asymptomatic adults 50 years or older.22 The American Academy of Family unit Physicians supports this determination.28
HISTORY
People with hearing damage may nowadays with self-recognized hearing loss or concerns from family members who have observed difficulty understanding everyday conversation, turning up television volume, often request others to repeat things, social avoidance, and difficulty hearing with background racket. People with decreased hearing may also nowadays with sensitivity to loud noises, tinnitus, or vertigo.12,thirteen The history tin advise an etiology and help in planning treatment.
Presbycusis characteristically involves gradual onset of bilateral loftier-frequency hearing loss associated with difficulty in speech discrimination. Conversations with groundwork noise get hard to empathise.xviii
Clinicians should ask about duration of hearing loss and whether symptoms are bilateral, fluctuating, or progressive. The evaluation should also include a neurologic review; history of diabetes mellitus, stroke, vasculitis, head or ear trauma, and use of ototoxic medications; and family unit history of ear conditions and hearing loss.nine–xi
PHYSICAL Exam
Important concrete test components are listed in Table i and Table 2.ix–fifteen The ear should exist examined for cerumen impaction, exostoses, or other abnormalities of the external canal, in add-on to perforation or retraction of or effusion behind the tympanic membrane. An atlas of otoscopy that illustrates fundamental findings is available at http://world wide web.entusa.com/eardrum_and_middle_ear.htm.
Examination should include the cranial nerves because tumors of the auditory nervus (acoustic neuroma) and stroke may affect cranial fretfulness V and VII. The head and cervix should be examined for masses and lymphadenitis; if present, they suggest infection or cancer.12,13 Bedside hearing tests and tuning fork tests tin assistance determine the presence and type of hearing loss.15
AUDIOMETRIC EVALUATION
Patients in whom hearing loss is suspected should exist referred for pure tone audiometry, in which signals are delivered through air conduction and bone conduction to appraise hearing thresholds.12,13,29 This differentiates conductive from sensorineural hearing loss and characterizes the design of hearing loss at various frequencies. A complete audiologic evaluation as well includes evaluation of speech perception in tranquility and with background racket, and may include tympanometry, acoustic reflex, otoacoustic emissions, and auditory evoked potentials (Tabular array 5).15,20,30,31
TABLE 5.
Components of Audiologic Evaluation
| Component | Clarification | Comments |
|---|---|---|
| Hearing health history | Questions most symptom duration and variability, tinnitus, vertigo, trauma, medical conditions, medications, dissonance and ototoxin exposure, family history | Frequently completed via questionnaire |
| Hearing-focused physical examination | Inspection of external ear and otoscopy | Must exclude cerumen impaction before further testing |
| Pure tone audiometry | Pure tones presented to one ear at a time via headphones or earbuds, typically in a audio berth | Determines softest level at which each frequency can be heard (pure tone threshold) |
| Speech reception threshold | Recorded or live oral communication presented to one ear at a fourth dimension via headphones or earbuds | Determines softest level at which speech can be heard |
| Speech discrimination (word recognition score) | Syllables repeated to each ear at volume previously identified equally hearable | May identify central processing difficulties not expected based solely on hearing ability |
| Hearing in noise examination | Sentences repeated in quiet and with background noise; competing noise comes from varying directions | Patients with presbycusis typically have more difficulty hearing with background noise; helps predict indicate-to-noise ratio that may be needed in hearing aids; directional hearing loss non explained by pure tone thresholds may reflect central auditory processing problem |
| Immittance audiometry: tympanometry and acoustic reflex | Occlusive probe inserted into canal that generates pressure | Can narrate conductive and sensorineural hearing loss; acoustic reflex disuse (contraction of middle ear muscles to decrease transmission of sound, which should occur only with loud sounds) suggests retrocochlear (central nervous system) pathology |
| Bone conduction | Pocket-sized bone oscillator placed over mastoid | Used to narrate conductive hearing loss |
| Auditory evoked potentials (auditory brainstem response) | Click introduced past earphone or headphone; transmission through brainstem to auditory cortex measured past scalp electrodes | Often used for newborn hearing screening |
| Otoacoustic emissions | Click introduced in ear canal with measurement of emissions from inner ear (cochlea) by microphone | Measures integrity of cochlea and, indirectly, middle ear; tin can be used for newborn screening; highly sensitive merely less specific than auditory evoked potentials |
Boosted EVALUATION
Laboratory evaluation for primary intendance patients with hearing loss is not indicated unless systemic illness is suspected. There is no demand for imaging if the hearing loss design suggests presbycusis.12 However, imaging is useful to evaluate and characterize conductive hearing loss, asymmetrical hearing loss (a deviation of at to the lowest degree 15 dB at 3,000 Hz),32 and sudden sensorineural hearing loss (loss of at to the lowest degree xxx dB in less than 72 hours).33 Patients with these conditions should be referred to an otolaryngologist for imaging and further evaluation.12
DIFFERENTIAL DIAGNOSIS
Depression and dementia should exist considered in the differential diagnosis of hearing loss. Both conditions may present with the apathy, inattentiveness, and social detachment that can occur with hearing loss. Patients with dementia should be evaluated for hearing loss because hearing harm can create disengagement and make cognitive impairment seem more severe than it is.5,half dozen Similarly, if hearing loss is detected, cognitive screening should be performed considering cognitive damage often accompanies hearing loss.
Primary Intendance Management
- Abstract
- Classification
- Clinical Aspects
- Master Intendance Direction
- Assistive Technologies
- References
An audiologist will typically presume responsibility for treating patients in whom hearing aids are indicated. However, family unit physicians still have an essential role in caring for these patients. Important considerations for main intendance clinicians are summarized by the SCREAM mnemonic: sudden hearing loss, cerumen impaction, auditory rehabilitation, education, assistive devices, and medications (Tabular array half dozen).33–43
TABLE six.
SCREAM Mnemonic for Principal Intendance Management of Adults with Hearing Loss
| Concern | Description | Evaluation | Implementation |
|---|---|---|---|
| Sudden hearing loss (idiopathic sudden sensorineural hearing loss) | Evolution of ≥ 30 dB hearing loss at iii sequent frequencies over 72 hours or less | Rule out conductive hearing loss or readily identifiable cause | Place hearing loss by in-role tests and directed history and physical examination; urgent referral (within one week) to otolaryngologist |
| Cerumen impaction | Occlusive cerumen causing hearing loss | Otologic examination | Culvert irrigation with or without cerumenolytics or manual extraction of cerumen |
| Auditory rehabilitation | Training and treatment to amend the hearing surroundings | Determine patient's and family unit members' current habits and knowledge | Provide information about improving environment and communication strategies* |
| Education | Data for the patient and his or her family about hearing loss, evaluation, hearing protection, and management | Determine patient's noesis, beliefs, and stage of modify | Provide resources on hearing protection and expectations, benefits, and apply of hearing aids |
| Assistive devices | Technology to augment hearing, including over-the-counter assistive devices | Determine whether patient is a candidate for over-the-counter assistive devices or audiologic cess for hearing aids | Patients with mild sensorineural hearing loss may attempt over-the-counter devices initially; instruct patients on other technologies (e.thousand., tv and telephone amplification) |
| Medications | Evaluating and mitigating medications with ototoxicity | Make up one's mind current and past use of ototoxic medications | Discontinue or avoid unnecessary ototoxic medications (eTable A); mitigate ototoxicity by assuring adherence to protocols when such drugs are needed |
SUDDEN SENSORINEURAL HEARING LOSS
Sudden sensorineural hearing loss refers to hearing loss of at least thirty dB involving three sequent frequencies occurring over less than 72 hours for which no apparent cause can be plant on initial history and examination. History and physical examination findings may suggest a treatable etiology (Tabular array 7).33–35 If no cause requiring emergency intervention is identified, hearing loss should be confirmed with audiometry, and consultation with an otolaryngologist should occur within one calendar week.33
TABLE 7.
Causes of Sudden Sensorineural Hearing Loss
| Type of hearing loss | Cause | Treatment |
|---|---|---|
| Idiopathic (eighty% to ninety% of cases) | Unknown | Corticosteroids; hyperbaric oxygen in younger patients unresponsive to corticosteroids |
| Infectious | Epstein-Barr virus, grouping A streptococcus, canker simplex virus, canker zoster virus, HIV,* Lyme disease,* meningitis, syphilis | Specific antimicrobial if identified |
| Otologic | Autoimmune condition, Meniere disease | Vestibulosuppressants for vertigo, corticosteroids, diuretics, surgery for Meniere illness |
| Trauma | Barotrauma, ear trauma, or caput trauma | Manage trauma; otologic surgery when stable |
| Vascular | Cerebrovascular affliction | Stroke management |
| Neoplastic | Angioma, hyperviscosity,* meningioma, neurofibromatosis 2, schwannoma | Surgical excision; radiation therapy in select cases |
| Other | Genetic crusade,* mitochondrial disorder,* ototoxins,* pregnancy | Avoid ototoxins; treat underlying disorder if possible |
Although a Cochrane review establish unclear benefit for the utilize of glucocorticoids for idiopathic sudden sensorineural hearing loss, some studies accept institute benefit from systemic or intratympanic steroids, and referral to an otolaryngologist for this handling is the standard of care.34 If steroids are used, they should be started within 2 weeks. Limited data bear witness that hyperbaric oxygen therapy may improve outcomes in younger patients if started inside two weeks. This therapy is unremarkably reserved for patients who do not respond to steroids.35
CERUMEN IMPACTION
Occlusion of the external auditory culvert past cerumen results in conductive hearing loss, and removal is curative. Cerumen can be removed by irrigation, manual extraction, cerumenolytic agents, or a combination of these methods. Evidence is express to support one method of removal over others.36 Considering of minimal preparation requirements, favorable side effects, and effectiveness, irrigation may exist the optimal method of removal in primary care practices. The effectiveness and safety of jet irrigators vs. syringe irrigation accept not been studied. Data supporting the use of cerumenolytics are express, and some studies conclude that they offering no advantage over irrigation alone.36,44,45
AUDITORY REHABILITATION
Auditory rehabilitation has been variably defined, only it generally refers to services that focus on adjusting patients and their families to hearing deficits and providing listening and speaking strategies to improve communication. These strategies include facing people when talking, improving lighting, minimizing background noise, summarizing what was heard, and rephrasing. This practice is by and large regarded equally benign, but studies supporting auditory rehabilitation are mostly of poor quality.37 A patient handout on communication strategies is bachelor at https://www.nia.nih.gov/health/hearing-loss-common-problem-older-adults#communicate.
EDUCATION
Clinicians should provide data about the nature and causes of hearing loss, hearing aids (if applicable), and hearing protection. At that place is poor adherence to hearing conservation programs and personal hearing protection.three,46,47 Patient expectations, perceived self-benefit, satisfaction, readiness for change, and support from family are important determinants of hearing assistance employ.38,39 Strict standards are in place for noise and ototoxin exposure in work settings, simply patients may not use the aforementioned protections with habitation activities.
ASSISTIVE DEVICES
Clinicians can help patients ameliorate advice challenges by being enlightened of bachelor hearing technologies (discussed in the post-obit section) and their appropriateness for individual patients.
MEDICATIONS
Hundreds of medications are associated with ototoxicity (eTable A). Physicians should ask nigh current and past use of these medications, and when current apply is necessary, assure that protocols are in place to minimize gamble. Ototoxicity is typically dose-dependent and more than probable to occur in patients with heart failure and chronic kidney disease.40,41 Guidelines for monitoring patients for ototoxicity are available from the American University of Audiology.48
eTABLE A
Ototoxic Substances
| Substance | Risk factors for exposure |
|---|---|
| Chemicals, metals, and other toxins Asphyxiants: carbon monoxide, tobacco smoke Metals: lead, mercury compounds, organic can compounds Nitriles: acrylonitrile, 3-butenenitrile Solvents: p-xylene, styrene, toluene, trichloroethylene | Automotive repair; boat building; construction; manufacturing of metal, leather, petroleum products, or batteries; occupational or household painting; pesticide spraying; smoking; vehicle or aircraft fueling |
| Pharmaceuticals Aminoglycoside antibiotics (e.g., gentamicin, streptomycin) Other antibiotics (east.g., erythromycin,* tetracyclines*) Analgesics* and antipyretics* (e.grand., acetaminophen, nonsteroidal anti-inflammatory drugs, salicylates) Antineoplastic agents (east.g., bleomycin, carboplatin, cisplatin) Loop diuretics* (east.m., ethacrynic acid, furosemide [Lasix]) Other drugs* (chloroquine [Aralen], hydrocodone, misoprostol [Cytotec], phosphodiesterase inhibitors, quinine) | Chemotherapy, congestive heart failure, hospital inpatients, renal disease |
Assistive Technologies
- Abstract
- Classification
- Clinical Aspects
- Main Care Management
- Assistive Technologies
- References
HEARING ASSISTIVE DEVICES
Hearing assistive devices include visual cues for doorbells, telephones, or alarms, and audio amplifiers for televisions, telephones, or theaters. In public venues such equally theaters, assistive listening systems are required to exist attainable for people with hearing impairment, fifty-fifty if they do not have hearing aids. These systems transmit sound from a public system to the telecoil of a hearing aid or to specialized headphones using FM radio, electromagnetic field induction loops, or infrared systems.42
Direct-TO-CONSUMER HEARING AIDS
The FDA Reauthorization Act of 2017 includes an amendment assuasive directly-to-consumer sales of hearing aids for balmy to moderate hearing loss.43 Although there are limited effect studies, they prove improved hearing, communication, and social engagement with these devices.49 The toll of over-the-counter hearing aids is expected to range from approximately $200 to $1,000 compared with $800 to $iv,000 for conventional hearing aids. The American University of Audiology and the American Speech-Language-Hearing Association recommend that these devices be restricted to patients with mild hearing loss and annotation that the all-time outcomes are achieved with a comprehensive audiologic evaluation and rehabilitation program.50,51 A recent written report plant slightly better voice communication recognition and lower listening endeavor with fitted hearing aids vs. personal sound amplifying devices, but both devices improved hearing performance over baseline.52
CONVENTIONAL HEARING AIDS
Multiple studies show that hearing aids provide benefit.53 A 2017 Cochrane review of hearing aids for mild to moderate hearing loss establish evidence that these devices improve hearing-related quality of life and overall health-related quality of life.54 The use of hearing aids in patients with dementia decreases social isolation and slows cognitive pass up, fifty-fifty after adjusting for multiple confounders.55
There are several types of hearing aids to accommodate various patient requirements and preferences (eTable B). Digital processing has permitted many adaptive features, such as improved sound quality, multiple listening programs for different environments, advanced noise reduction strategies, acoustic feedback reduction, remote control options, and the power for the user to adapt volume beyond frequencies.
eTABLE B
Comparison of Conventional Hearing Aids
| Hearing aid type | Description | Available as | Discreteness | Ease of apply | Risk of damage from cerumen and moisture | Comments |
|---|---|---|---|---|---|---|
| Behind the ear | All parts are in a small example at the back of the ear and are joined to the ear canal with a sound tube and a custom mold or tip | Mini, standard, or powered | Least | Easiest | Least | Typically the most fully functional with the most available hardware and software; may include telecoil for listening in public places; tin be used for all degrees of hearing loss |
| Receiver in canal | Similar to backside-the-ear hearing aids, except the receiver (speaker) has been removed from the example and moved into the canal, and is continued to the case with a thin wire | Receiver in the ear | Very | Moderate | Moderate | Contraindications include permanent tympanic membrane perforation, mastoid surgery, and excessive cerumen; piece of cake to modify receivers; typically limited to balmy to moderate hearing loss |
| In the ear | Custom-made devices; all of the electronics sit in a device that fits in the ear | Completely in culvert, invisible in culvert, or mini in culvert | Usually most | Unremarkably requires nearly dexterity | Moderate | Contraindications include permanent tympanic membrane perforation, mastoid surgery, and excessive cerumen; typically express to mild to moderate hearing loss |
Audiologists measure and adjust the hearing aid'southward functions (eastward.g., volume at each frequency, intensity, microphone power output, compression ratios) based on private patient requirements. They also provide education and training in the use and handling of hearing aids and audiologic rehabilitation. An audiologist should refer patients to an otolaryngologist for evaluation and treatment of conductive hearing loss, sudden sensorineural hearing loss, asymmetrical hearing loss, or failure of hearing to improve with hearing aids.
COCHLEAR IMPLANTS AND OTHER SURGICAL INTERVENTIONS
Most causes of conductive hearing loss are potentially correctable with surgery. However, cochlear implants are used for moderate to profound bilateral sensorineural hearing loss. A cochlear implant is a surgically placed device that bypasses damaged portions of the ear and directly stimulates the auditory nervus (Figure 1). Medicare covers approved cochlear implants if patients meet hearing loss criteria and have limited benefit from hearing aids, practise not have middle ear illness, and have the cerebral ability to employ them.56,57 Studies show do good in speech communication perception, social function, and overall quality of life after placement of cochlear implants.58 Cochlear implants and other surgical treatments for hearing loss are summarized in eTable C.
Figure 1.
Diagram of ear showing components of a cochlear implant.
Analogy by National Institutes of Health Medical Arts and National Establish on Deafness and Other Communication Disorders
eTABLE C
Surgical Treatment of Hearing Loss
| Blazon of hearing loss | Condition | Surgical procedure | Comments |
|---|---|---|---|
| Conductive* | Cholesteatoma | Excision, ossicular chain reconstruction | Treatment depends on location and severity |
| Chronic heart ear effusion | Myringotomy with pneumatic equalization tube insertion | Ofttimes secondary to refractory eustachian tube dysfunction | |
| Malformations of pinna or external auditory canal (e.g., osteomas, exostoses), foreign trunk | Resection of osteoma or exostosis, reconstructive procedures, foreign body removal | May allow fitting of traditional hearing assist if indicated | |
| Ossicular concatenation disruption, erosion | Ossicular concatenation reconstruction | Can be caused by trauma, infection, otosclerosis, cholesteatoma, or tumors | |
| Otosclerosis | Stapedectomy with prosthesis, ossicular chain reconstruction | Should be free from other external or middle ear disease | |
| Tympanic membrane perforation† | Tympanoplasty, myringoplasty | For conditions limited to tympanic membrane | |
| Sensorineural | Meniere illness | Endolymphatic sac decompression, vestibular nerve section, labyrinthectomy | For severe symptoms not controlled with medication, noninvasive therapy, or middle ear injections |
| Moderate to profound sensorineural hearing loss with limited benefit from hearing aids | Cochlear implant | Microphone backside ear transmits to processor placed under pare, which converts sound to electronic signals to transmitter and through implanted electrodes to cochlea (bypasses hair cells) | |
| Severe to profound sensorineural hearing loss with relatively preserved hearing at lower frequencies | Electroacoustic stimulation (hybrid cochlear implant) | Cochlear implant placed into basal turn of cochlea (high-frequency area) with hearing help to dilate residual low-frequency hearing | |
| Unilateral profound sensorineural hearing loss | Os-anchored hearing aid: external portion attaches over device imbedded in bone and transmits vibration to skull | Percutaneous osseointegrated titanium post implanted in the postauricular skull stimulates cochlea in the meliorate ear | |
| Mixed | Malformed ear, inability to use hearing aid, unilateral profound loss with excellent hearing in contralateral ear | Os-anchored hearing assist: external portion attaches over device imbedded in os and transmits vibration to skull | Requires performance cochlea, at least in the proficient ear |
| Stable bilateral moderate to severe sensorineural hearing loss with relatively preserved word recognition and limited benefit or adverse local reaction to hearing aid | Implantable center ear hearing device: microphone conducts sound to center ear transducer | Requires functioning cochlea, at to the lowest degree in the good ear |
Information Sources: The authors used the key words hearing loss and hearing impairment to search PubMed, the Cochrane database, USPSTF, BMJ Best Evidence, Essential Evidence Plus, JAMA Evidence, the National Guideline Clearinghouse, and Trip database. Additional queries in PubMed were made for specific topics addressed. Search dates: August 15, 2018; November 16, 2018; and April 25, 2019.
Effigy 1 courtesy of National Institutes of Health Medical Arts and National Institute on Deafness and Other Communication Disorders.
The authors thank June Hensley, MA, CCC-A, for her review of the manuscript.
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The opinions and assertions contained herein are the private views of the authors and are non to exist construed equally official or as reflecting the views of the U.S. Army Medical Department or the U.S. Army Service at big.
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