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Adult Audiology and Adult Hearing Loss Lisa Caulley, MD, MPH Otolaryngology—Head and Neck Surgery University of Ottawa Slides courtesy of Dr. Kristian Macdonald Objectives 1. Major Points in History Taking for Hearing Loss 2. Components of an Audiogram 3. Distinguish between a Sensorineural (SNHL) and Conductive hearing loss (CHL) 4. The role of noise exposure in some types of hearing loss 5. Recognize the significant historical elements, physical signs and audiogram findings for: Presbycusis, Otosclerosis, Sudden Sensorineural Hearing Loss, Noise Induced Hearing Loss, Vestibular Schwannoma Adult Hearing Loss Hearing: Perception of Sound Conversion of sound waves into action potentials; mechanoelectrical transduction Elements required for hearing: – Intact Ear – Intact CNS Adult Hearing Loss Importance of hearing: – Communication – Personal/Professional Isolation Scope of the problem: – 17% of adult population – 36% of adults between 65 and 74 yrs – 47% of adults over 75 Adult Hearing Loss Intact Ear – External ear Pinna, Ear Canal, Tympanic Membrane Intact CNS – CN VIII – Central Tracts – Auditory Cortex – Middle Ear Ossicular Chain – Inner Ear Cochlea – Details in the Physiology of Hearing Lecture Adult Hearing Loss EAR Adult Hearing Loss Adult Hearing Loss 60 year old (yo) female. Public servant – Periodic health assessment – Review of Systems: Embarrassed about asking people to repeat themselves. Feels people mumble. 55 yo male. Carpenter. – C.C.: Ringing in his ears. For the past 2 years 34 yo female. Stay-at-Home Mom. – Post partum. She noted a change in her hearing during pregnancy. 25 yo male. Semi-Pro baseball player. – Ringing in his left ear for 3 months. – No longer able to catch ‘Fly Balls’ Adult Hearing Loss Cardinal Signs and Symptoms of Otologic Disease – – – – – Hearing Loss Tinnitus Vertigo Otalgia Otorrhea Adult Hearing Loss Historical elements of hearing loss 1. Can’t Hear Pt: Repetitions Decreased ‘Speech in Noise’ People beginning to mumble Spouse/Family: ‘Won’t Listen’ TV/Music too loud Answers ‘wrong’ question Adult Hearing Loss Historical elements of hearing loss 2. Tinnitus Perception of sound in the absence of acoustic stimuli (Sound/noise) Bilateral Vs Unilateral Constant Vs Intermittent Bothersome Vs Non-bothersome Adult Hearing Loss Historical elements of hearing loss 3. Vertigo: hallucination of spinning Indicates vestibular/otologic involvement May be a peripheral vestibular disorder OR a central vestibular disorder Vs Lightheadedness/unsteadiness Indicates a non-vestibular cause. Multiple potential causes Adult Hearing Loss Physical examination – Observation, including otoscopy, – usually normal Needs to be done to rule out ear canal obstructions (Cerumen, foreign bodies) and Tympanic Membrane (TM) perforations Adult Hearing Loss Tests of Hearing – Tuning forks tests A vibrating tuning fork can be placed on the skull to quickly determine if a hearing loss is present – Audiometry Presentation of pure tones at specific frequencies and set volume levels to each ear independently Speech comprehension/discrimination Tympanometry Adult Hearing Loss Tuning fork Tests Weber Ernst Heinrich Weber Can detect unilateral hearing loss. Conductive or Sensorineural Rinne Heirich Adolf Rinne compares perception of sounds, as transmitted by air or by bone conduction through the mastoid Adult Hearing Loss Audiometry – testing of a person's ability to hear various sound frequencies. – Pure Tone Audiometry Audiometer: emits sounds or tones, like musical notes, at various frequencies, or pitches, and at differing volumes or levels of loudness – Speech Audiometry a series of simple recorded words spoken at various volumes into headphones worn by the patient being tested. The patient repeats each word back to the audiologist as it is heard. Adult Hearing Loss Tympanometry – measure of the stiffness of the eardrum to evaluate middle ear function. Helpful in detecting fluid in the middle ear, negative middle ear pressure, disruption of the ossicles, tympanic membrane perforation, and otosclerosis. To perform the test: – a soft probe is placed into the ear canal and a small amount of pressure is applied. The instrument then measures movement of the tympanic membrane (eardrum) in responses to the pressure changes. The result of the test is recorded in a visual output, called a tympanogram. Adult Hearing Loss Audiogram Elements of an audiogram – Pure Tone – Speech Audiometry – Tympanometry Adult Hearing Loss Audiogram Elements of an audiogram – Pure Tone – Speech Audiometry – Tympanometry Adult Hearing Loss Normal Audiogram/Hearing Adult Hearing Loss Severity of Hearing Loss Adult Hearing Loss Types of hearing loss – Sensorineural Hearing Loss (SNHL) – Conductive Hearing Loss (CHL) – Mixed Hearing Loss Adult Hearing Loss Sensorineural Hearing Loss – Hearing impairment of the inner ear resulting from damage to the sensory hair cells or to the nerves that supply the inner ear. Adult Hearing Loss Conductive Hearing Loss – Problem conducting sound waves through the outer ear, tympanic membrane (eardrum) or middle ear (ossicles). – Concept of Air-Bone Gap Adult Hearing Loss Air-Bone Gap – lag between the audiographic curves for air- and bone-conducted stimuli, as an indication of loss of sound conduction of the ear. – Reflects outer and middle ear dysfunction Adult Hearing Loss Mixed Hearing Loss – hearing loss that is both conductive and sensorineural Adult Hearing Loss Common Causes* of Sensorineural Hearing Loss – – – – – – – Age Noise Toxicity Trauma Infection Meniere’s Disease Acoustic Neuroma * Extensive lists and descriptions of causes for hearing loss can be found in any otolarygology text book Adult Hearing Loss Age related Hearing Loss Presbycusis – – – – – – Gradual and progressive Bilateral Decreased ‘Speech in Noise’ Tinnitus No Vertigo Familial predisposition Adult Hearing Loss Sudden Sensorineural Hearing Loss (SSHL) – aka Idiopathic SSHL Sudden (or rapid <3d) loss of hearing 30dB loss in 3 consecutive frequencies Adult Hearing Loss Noise Induced Hearing Loss – Acute Noise Exposure (Acoustic Trauma) Temporary Threshold Shift (TTS) – Chronic Noise Exposure Adult Hearing Loss Other causes of SNHL (partial list) – Ototoxicity Antibiotics Loop Diuretics ASA/Quinines Cancer/Chemotherapeutic meds – Trauma Temporal Bone Fracture Perilymphatic Fistula (PLF) Adult Hearing Loss Conductive Hearing Loss – Foreign Body in Ear Canal or Cerumen – Adult, with intact TM Otosclerosis Ossicular Dysfunction Trauma Acute Otitis Media Middle Ear Effusion – Tympanic Membrane (TM) perforation Traumatic Chronic Otitis Media Adult Hearing Loss Otosclerosis – disease of the otic capsule and the ossicles – abnormal resorption and then deposition of bone in the labyrinthine capsule and middle ear – progressive hearing loss – Most common cause of conductive hearing loss with an intact TM in adults Adult Hearing Loss Hearing Loss can be bilateral or unilateral Adult Hearing Loss Unilateral Sensorineural Hearing Loss – Meniere’s Disease – Vestibular Schwannoma Adult Hearing Loss Meniere’s Disease (aka Endolymphatic Hydrops) – Episodic Vertigo, Fluctuating Hearing Loss, Aural Fullness/Tinnitus – Unilateral* * up to 30% will be bilateral Adult Hearing Loss Vestibular Schwannoma – AKA Acoustic Neuroma – Benign Neoplasm of the myelin sheath of CN VIII – 5-10% of Intracranial Neoplasia – NF I and NF II Adult Hearing Loss 60 years old (yo) female. Public servant – Periodic health assessment – Review of Systems: Embarrassed about asking people to repeat themselves. Feels people mumble. Presbycusis Adult Hearing Loss 55 yo male. Carpenter. – C.C.: Ringing in his ears. For the past 2 years Noise Induced Hearing Loss Adult Hearing Loss 34 yo female. Stayat-Home Mom. – Post partum. She noted a change in her hearing during pregnancy. Otosclerosis Adult Hearing Loss 25 yo male. SemiPro baseball player. – Ringing in his left ear for 3 months. – No longer able to catch ‘Fly Balls’ Acoustic Neuroma Adult Hearing Loss Lecture Objectives Review 1. Major Points in History Taking for Hearing Loss – Ask about: Hearing Loss, Tinnitus, Vertigo, Otalgia, Otorrhea 2. Components of an Audiogram – Pure Tone Audiometry, Speech Audiometry. Tympanogram. 3. Distinguish between a Sensorineural (SNHL) and Conductive hearing loss (CHL) – Tuning Fork Tests, Air Bone Gap 4. The role of noise exposure in some types of hearing loss – TTS, ‘4K notch’ Adult Hearing Loss Lecture Objectives Review (Cont’d) – 5. Recognize the significant historical elements, physical signs and audiogram findings for: Presbycusis: Age, Family Hx, Audio Otosclerosis: Family Hx, Forks, Audio Sudden Sensorineural Hearing Loss: Hx, Audio Noise Induced Hearing Loss: Hx, Audio Vestibular Schwannoma: Hx, Unilateral HL Meniere’s Disease: Hx Foreign Body: Hx /Px Otitis media: Hx /Px: ?TM Status? Adult Hearing Loss MOST IMPORTANT. All unilateral hearing loss and/or unilateral tinnitus needs to be investigated. Audiogram, MRI