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Ambulatory Care Topics: Hearing Loss. Gustavo R. Heudebert, MD Division of General Internal Medicine. Road Map. Physiology of hearing Topography of hearing loss Differential Diagnosis Clues from history / physical examination Evaluation. Case.

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ambulatory care topics hearing loss

Ambulatory Care Topics: Hearing Loss

Gustavo R. Heudebert, MD

Division of General Internal Medicine

road map
Road Map
  • Physiology of hearing
  • Topography of hearing loss
  • Differential Diagnosis
    • Clues from history / physical examination
  • Evaluation
slide3
Case

34 yo male comes to the walk-in clinic with a 36 hour

history of hearing loss. Onset has been sudden, the the

hearing loss is associated with mild bilateral ear pain

but no drainage. There is no dizziness or tinnitus.

Patient is healthy and takes no medications. Family

history is non contributory. There is no exposure to

alcohol, tobacco, or illicit drugs. He works at a hospital.

Physical examination is unrevealing except for the

following:

physiology of hearing
Physiology of Hearing
  • Outer / middle ear
    • Amplifier of sound
  • Internal ear
    • Transducer
      • Liquid media
  • Neural pathways
topography
Topography
  • Conductive
    • Outer / middle ear
  • Sensorineural
    • Inner ear and neural pathways
  • Mixed
    • Combination of middle and inner ear
history
History
  • Acute (< 72 hours) versus chronic
  • Unilateral versus bilateral
  • Sudden versus insidious onset
  • Rate of progression
  • Associated symptoms
    • Tinnitus, vertigo, otorrhea
  • Exposures: toxins, environment
physical examination
Physical Examination
  • Confirming hearing loss
    • Whisper test
    • Hum test
  • Rinne and Weber test
  • Otoscopy with insufflation
interpretation
Rinne test

AC > BC

If BC > AC

Conductive disorder on affected ear

Weber test

Normal test

No lateralization

Lateralizes to “good ear”

SNHL on bad ear

Lateralizes to “bad ear”

Conductive disorder of that ear

Interpretation
laboratory testing
Laboratory Testing
  • Audiologic assessment
    • Pure tone audiometry
    • Speech audiometry
    • Tympanometry
  • Evoked responses
  • Imaging (selective)
slide15

Hearing Loss

Acute

History

Chronic

Normal

Exam

Audiologic

Evaluation

Conductive

SNHL

Abnormal

SOM / AOM

Perforation

Otitis

conductive hearing loss
Outer / external

Cerumen

Tumors

Osteoma

SCCA

External otitis

Middle

Otitis media

Otosclerosis

Choleastatoma

TM pathology

Perforation

Hemorrhage

Conductive Hearing Loss
sensorineural hearing loss
Inner Ear

Hereditary

Presbycusis

Meniere’s

Drugs

Environmental

Sound

Barotrauma

Neural Pathways

Tumors

Schwannoma

Demyelinating disorders

Vascular

CVA

Sensorineural Hearing Loss
sudden snhl
Sudden SNHL
  • Less than 72 hours duration
  • Uncommon: 5 to 20 / 100,000
  • Age 43 to 53 years; equal gender
  • Variable recovery
    • Old age / vestibular symptoms
  • Vestibular symptoms: 305 to 60%
sudden snhl19
Sudden SNHL
  • Etiology
    • 1% “retrocochlear”: tumors, MS, CVA
    • 15% other: CTD, Lyme, syphilis
    • Remainder: idiopathic
    • Rare: decrease ICP (post tap), paraneoplastic, encephalitis, dural process.
  • Delay in diagnosis common: patient and doctors
sudden snhl20
Sudden SNHL
  • Quick evaluation
    • Alternate ears during phone conversation
    • Hum test
  • If suspicious for SNHL
    • Audiometry: if confirmatory then MRI
  • Therapy: controversial
    • Prednisone 1 mg/kg then over 10 days
    • Intratympanic steroids
summary
Summary
  • Common problem
  • Acuteness, associated symptoms, age, physical examination
  • Occasional needs further assessment
    • SNHL: acute or chronic
    • Conductive with normal otologic examination
pearls
Pearls
  • Presbycusis
    • High frequency hearing loss
    • Worse in loud environments
  • Speech recognition more affected than hearing
    • Neural pathway pathology
  • Associated symptoms: neural causes
ad