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Hearing Loss ACOVE
March 15-June 28, 2013
Brad Keith, MD
Hearing Loss - Demographics
 Prevalence of hearing loss increases with age.
 “30% to 60% of population 65 and older have hearing
 “Estimate over 6 million people 65 and up with hearing loss.”
 “3rd most prevalent chronic condition behind HTN and OA.
 Only 25% of patients who would benefit hearing aids after
testing actually get hearing aids.
 Yueh et al.
Hearing Loss – Is it a bad thing?
 “Associated with depression, social isolation, and
function disability”
 JAMA 1-21-2013, Hearing loss and Cognitive Decline in
Older Adults: “Hearing loss is independently associated
with accelerated cognitive decline and incident
cognitive impairment in community-dwelling adults”
 Yueh et al.
 Lin et al.
Hearing Loss –
Should it be evaluated?
 Negative effects on quality of life have been shown for
those with hearing impairments without intervention.
 Positive effects on quality of life have been shown for
the use of hearing aids and / or surgical interventions.
Learning Objectives for
 Behavior:
 If a VE reports hearing loss which interferes with daily
activity or bothers him or her enough for it to be evaluated
and treated, then residents will perform Otoscopic exam to
identify any immediately treatable cause of conductive
hearing loss.
 If there is no immediately treatable cause of hearing loss,
then residents will offer further audiologic or ENT
evaluation /referral to patient if they would like.
 If patient does not want audiologic or ENT evaluation, then
residents will offer information on hearing assistance
Learning Objectives for
 Skill:
 Residents will demonstrate how to perform an otoscopic
exam to an attending (does not have to be on a patient)
 Attitude:
 Residents will report improved confidence in their ability
to accurately diagnose visible causes of conductive hearing
loss by otoscopic exam.
Learning Objectives for Residents
Knowledge. Residents will be able to identify:
 middle ear effusion (purulent or serous) on otoscopic
 cerumen impaction (foreign body) on otoscopic exam
 tympanosclerosis on otoscopic exam
 tympanic membrane perforation on otoscopic exam
Types of Hearing Loss Sensorineural
Sensorineural Hearing loss – Due to damage to neurons or
hair cells transmitting auditory signals to the brain for
 Loud environments, neural tumors, viral insults
(acoustic neuritis)
 Most common form in aging for hearing decline over
 Sensorineural hearing loss due to aging is known as
Types of Hearing Loss Conductive
Conductive Hearing Loss – Due to mechanical damage or
obstruction of the middle ear or external auditory canal
 Examples of middle ear issues would be effusions
(purulent – otitis media, serous – eustachian tube
dysfunction) , trauma to the boney structures or
tympanic membrane (scarring –tympanosclerosis), or
growths such as cholesteotomas or otosclerosis
 Examples of external auditory canal issues would be
foreign body (cerumen, insect, crayon), inflammation
(otitis externa), or growth (polyp, malignancy)
Objectives of our Hearing Loss
ACOVE in simple terms
1. Identify if hearing loss is a problem for our patients 65
and up.
2. Treat any immediately reversible causes (cerumen or
effusion). These are usually CONDUCTIVE causes.
3. Refer to Audiology for audiometric testing for hearing
aids if feasible for patient.
4. Refer to ENT for treatment if any surgical intervention
is warranted and feasible for patient.
5. Offer auditory assistance devices to those who can’t
be helped by ENT or can’t afford hearing aids.
The Otoscope!
Insert Image of Otoscope
Normal Anatomy
Insert Image of a Normal Anatomy Ear
Middle Ear Effusion – Purulent
Otitis Media
Insert Image of Middle Ear Effussion – Purulent Otitis Media
Middle Ear Effusion – Serous
Insert Image of Middle Ear Effusion – Serous Effusion
Cerumen Impaction (Foreign
Insert Image of Cerumen Impaction
Insert Image of Tympanosclerosis
Perforated Tympanic Membrane
Insert Image of Perforated Tympanic Membrane
Insert Image of Cholesteatoma
Insert Image of a Tuning Fork
It’s Tuning Fork Time!
Weber Testing.
To help differentiate between conductive and sensorineural
hearing loss. (Board Review for Residents)
Weber test: Strike the tuning fork and place on the forehead,
teeth, or nose.
-Normal Test: No lateralization of sound at all
-Unilateral Conductive Loss: Lateralizes to affected ear
-Unilateral Sensorineural Loss: Lateralizes to the normal ear
or side you hear better in.
It’s Tuning Fork Time!
Rinne Testing.
To help test for conductive hearing loss.
Rinne test: Strike the tuning fork and place on the mastoid.
Have the patient tell you when they stop hearing the sound.
Move the fork to beside the ear and check to see if they can
hear the sound again.
-Normal Test: Air conduction > Bone conduction – Patient hears
the fork when placed BESIDE the ear.
-Abnormal Test: Bone conduction > Air Conduction – Patient
does not hear the fork placed BESIDE ear. Signifies a
conductive hearing loss on the affected side.