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* For Best Viewing: Open in Slide Show Mode Click on icon or From the View menu, select the Slide Show option * To help you as you prepare a talk, we have included the relevant text from ITC in the notes pages of each slide © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. in the clinic Hearing Loss © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. Who is at risk for hearing loss? Children Prenatal infections Family history of childhood hearing loss Stay in the neonatal ICU >5d Craniofacial abnormalities or head trauma Central nervous system disease Chemotherapy Adults Noise exposure Family history of hearing loss before age 50y Age >65 years Smoking Diabetes Exposure to ototoxic medications © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. When and how often should children and adults be screened for hearing loss? Childhood Newborns in first month 6 months to 3 years and from 11 to 18 years: risk assessment at each well visit 4 through 10 years: formal assessment with audiometer at each well visit Adults Anyone with perceived hearing loss or risk factors Then interval screening depending on continuing risks ASLHA: every decade until age 50, then every 3y Medicare: part of annual wellness exam if >65y © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. What are the appropriate screening tests? Self-administered questionnaire Single: Do you feel you have hearing loss? (yes/no) Multiple: 10-item Hearing Handicap Inventory for Elderly Positive and negative predictive value 70%–80% compared with pure tone audiometry Office-based screening tests Finger rub Whisper test Pure tone audiometry with hand-held device Weber and Rinne tests (once hearing loss identified) helps identify cause © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. To which specialists should a patient with hearing loss be referred? Audiologist All patients with having hearing loss: for audiogram Ear, nose, and throat specialist Urgent referral: sudden sensorineural hearing loss or hearing loss associated with trauma Severe or recurrent infections Associated vertigo Conductive or fluctuating hearing loss Failure of hearing aides to be useful © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. CLINICAL BOTTOM LINE: Screening… Hearing loss can occur at any time in lifespan Risk factors Noise exposure Family history Age, smoking Diabetes Exposure to ototoxic medications Screen at-risk persons or those with signs of hearing loss Specialty referral: audiologist for audiogram; ENT specialist © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. Can hearing loss be prevented? Limit exposure to excessive noise Short exposure to very loud sounds and extended exposure to moderate-level noises can be damaging Avoid or closely monitor ototoxic medications Avoid or closely monitor chemical exposure Follow of patients with recurrent ear infections carefully Institute measures to avoid head trauma © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. CLINICAL BOTTOM LINE: Prevention… Limit exposure to excessive noise Avoid or closely monitor ototoxic medications Avoid or closely monitor chemical exposure Carefully follow patients with recurrent ear infections Avoid head trauma © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. What symptoms should make patients and clinicians consider hearing loss? Any functional or cognitive decline Depression or anxiety, social withdrawal Poor word discrimination Family members report patient has hearing difficulty Health care providers notice they’re repeating themselves and re-asking questions Infants: Lack of response to sounds, delayed language development © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. Are there conditions that make it more difficult to diagnose hearing loss or that can mask as hearing loss? Patient may think losses are “normal”, untreatable Patient may be embarrassed by their deficits Others may misperceive to be cognitive impairment or inattentiveness Hearing loss may contribute to neurologic impairment of speech and language centers © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. What physical examination findings indicate possible hearing loss? Finger rub test (failure ≥3 of 6 times) Whisper test (failure ≥3 of 6 times) Hand-held audiometer (failure to identify 1000- or 2000Hz in both ears or 1000- and 2000-Hz in 1 ear) Weber and Rinne tests (tuning fork ) guide diagnosis Abnormalities of the tympanic membrane Scarring or visible perforations Suggest conductive hearing loss © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. What diagnostic tests should be done when hearing loss is suspected? Audiogram All patients diagnosed with hearing loss Cerumen removal For cerumen impaction (defer audiogram until after removal) Laboratory evaluation Only if history & physical exam suggests systemic illness Imaging studies Characterize conductive and sensorineural hearing loss If hearing loss + audiology evaluation point to presbycusis © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. CLINICAL BOTTOM LINE: Diagnosis… Conduct hearing screen if functional or cognitive decline occur Offer audiogram to all patients diagnosed with hearing loss No lab evaluation: unless exam suggests systemic illness Imaging tests: for conductive and sensorineural hearing loss Refer patient to ENT doctor if specialty care is needed © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. Are there medical treatments for hearing loss? Cerumen impaction May cause loss of 40dB + contribute to other hearing loss To remove: cerumenolytics, irrigation, or manual removal If Hx of abundant cerumen: ceruminolytic drops 1x-2x/wk Wipe hearing aids daily: avoids buildup, decreased efficacy Sudden hearing loss Oral prednisone: 1st-line treatment Consider intratympanic steroids if oral steroids fail Co-manage patients with an ENT specialist © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. What surgical therapies are available for hearing loss? Conductive hearing loss due to mechanical problems To remove foreign body or bony lesions in ear canal To fix malformation of ear canal Sensorineural hearing loss that’s profound, bilateral, doesn’t improve with hearing aids Cochlear implant Other criteria for implant: short duration of hearing loss; good speech, language, and communication skills; adequate cognition; motivation to participate in rehab © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. What types of hearing aids are available? Assistive-listening devices Least expensive, simplest approach External microphone + headphones transmit sound to ears Microphone may be in pocket, on a table, worn on neck Hearing aids Can sit behind ear, in bowl of pinna, or in ear canal Larger, external units easier to use; smaller units have less amplification capacity but more cosmetically acceptable Analog units less expensive but less adaptable than digital Amplification device useful for telephones can be added Bilateral amplification best for most © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. What environmental adaptations are useful for persons with hearing loss? Health care setting Ask patient how he or she prefers to communicate Reduce background noise and have patient’s attention Face the patient; don’t obscure your mouth with hands Speak toward the better ear, slowly and distinctly Don’t shout, and rephrase rather than repeat Write down key points of communication Home of hearing-impaired patients and public spaces Amplified phones with vibrating, flashing ringer; text phones Flashing, vibrating clocks, smoke alarms, doorbells Infrared or wireless FM devices may be available FM copper loop technologies in halls, restaurants, churches © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. What medications should be avoided in persons with hearing loss? Known Ototoxic Potentially Ototoxic Aminoglycosiades Propylene glycol Gold Salicylates Povidone-iodine Arsenic Erythromycin Industrial solvents Nicotine Vancomycin Bleomycin Lead Loop diuretics Carbon monoxide Alcohol Quinine Methylmercury Caffeine Cisplatin Potassium bromate Chloramphenicol Nitrogen mustard © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. CLINICAL BOTTOM LINE: Treatment… Remove any accumulated cerumen Sudden hearing loss: oral prednisone, then intratympanic steroids if needed Conductive hearing loss: consider surgery, if appropriate Sensorineural hearing loss: consider cochlear implantation Improve sound perception and communication Assistive listening devices and hearing aids Environmental adaptations Adequate lighting, access to pen and paper or computer, amplified or text telephones Avoid ototoxic medications, particularly aminoglycosides © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. What is the effect of hearing loss on quality of life and mortality? Hearing loss is associated with… Social isolation Functional decline Poor quality of life Depression Cognitive deficits Proposed mechanisms for this decline include… Social isolation Increased cognitive load Altered cortical processing © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. When is hearing loss considered a protected disability? ADA: disability is a mental or physical impairment that substantially limits ≥1 major life activities Hearing is considered central to daily life Severe and long term hearing deficit is covered under ADA Businesses should offer services for hearing impaired Qualified sign language interpreters Written materials Headset amplifiers Open and closed captioning Teletype machines © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. What is the definition of “deafness,” and what is meant by the term “deaf culture”? Deafness Degree of hearing impairment such that a person can’t understand speech, even with amplification Profound deafness is when no sound is perceived Deaf culture Set of learned behaviors and perceptions that shape values, norms of deaf people based on common experiences Shared struggles can create strong sense of community Deaf persons tend to prefer sign language to communicate Some don’t perceive hearing loss as disability © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. What is “signing” and “lip reading”? Signing Transmitting meaning based on manual communication and body language, rather than based on sounds Signed languages may not resemble spoken language Lip reading Oralism is a tradition of communication among deaf: spoken language remains the basis of communication Lip reading and speech are the techniques used in this system as opposed to sign language 30%-40% accuracy; higher with intensive training © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. What is current opinion on the superiority of signing, lip reading, or using a combination of techniques? For children: controversy over schools Mainstreaming in regular schools seems less restrictive But specialized schools can provide better a peer group, better classroom technology, richer culture For those who become hearing impaired in adult life Training in signing can improve QOL Auditory rehab programs can offer combined programs in lip reading and simple signing © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1. CLINICAL BOTTOM LINE: Social ramifications of hearing loss… Hearing loss can be associated with… social isolation and depression functional decline poor quality of life cognitive deficits Definition of deaf: If person if unable to understand speech even in presence of amplification Many deaf people don’t consider themselves disabled The Deaf community is a defined cultural and linguistic group © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (3): ITC2-1.