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ALL YOU NEED TO KNOW ABOUT : HEARING LOSS Imran reviewed by Dr Zainab Rathore Here’s what we do: ■ Weekly tutorials open to all! ■ Focussed on core presentations and teaching diagnostic technique If you’re new here… ■ Bstudentsl students, for medical ■ Reviewed by doctors to ensure W elcome to accuracy T eaching ■ We’ll keep you updated about our Things! upcoming events via email and groupchats!TOPIC ONE Elena BobyWhat this tutorial will cover ■ General anatomy of the ear ■ Types of hearing loss ■ Commonly examined pathologies causing hearing loss ■ Taking a focused history for a patient presenting with hearing loss Anatomy Plus Vestibular nerve = CN VIII Connects the ear to the back of the the throat. In children this tube is shorter and more horizontal than in adults, which is why children develop ear infections frequentlyT ypes of hearing loss: Conductive What is it? When sound is impaired in its passage through the external or middle ear to the inner ear.Which of these pathologies typically causes conduction hearing loss A) Presbycusis B) Otitis Media C) Meniere's disease D) Temporal bone fracture E) Vestibular neuronitis Clinical Symptoms A) Presbycusis - Sensorineural hearing loss associated with age B) Otitis Media - inflammation of the middle ear C) Meniere's disease - sensorineural hearing loss D) Temporal bone fracture - damage to temporal bone would typically damage the cochlea and cochlear nerve, so it would cause sensorineural hearing loss E) Vestibular neuronitis - does not typically cause hearing lossWhat is the pathology behind these common causes conductive hearing loss ?- Person who is systematically well with insignificant / no comorbidities - Hearing loss came on with no warning factors, typically noticed on wakingEar wax impaction By far the commonest cause of conductive hearing loss - luckily very easily treatable! - IRecommend softening drops (e.g. sodium bicarbonate 5%, olive oil) 3–4 times daily for 3–5 days. Warn about temporary hearing loss, discomfort, or skin irritation. Avoid use in suspected ear infections, perforations, or almond allergy. - If Symptoms Persist: Consider ear irrigation with prior softening, checking for complications afterward. If unsuccessful after two tries, refer for microsuction or specialist removal. Do not use manual syringing in adults. - Patient Advice and Safety: Advise against inserting objects (e.g. cotton buds) or using ear candles due to risk of injury. Encourage follow-up for signs of infection like pain, discharge, or swelling.- 3 year old with a cold and fever for the past week - Constantly tugging her ear - Recently started asking for the iPad volume to be tuned up higher - When she wakes up in the morning, her mother sometimes says the pillow can feel a little dampOtitis media with effusion (AKA Glue Ear) Middle ear effusion without signs of ear infection Common in children due to eustachian tube anatomical differences Effusion in the middle ear is found using an otoscope which will show - Bulging and erythema of tympanic membrane -> loss of light reflex - Otorrhoea if tympanic membrane perforation Bulging membrane Normal membaneOtitis media with effusion - complications - Mastoiditis (tenderness over the mastoid process) - Meningitis - Brain abscess - Facial nerve paralysisManagement ■ Otitis media generally is managed with analgesia and generally not with antibiotics ■ Extra considerations in children: recurrent otitis media and otitis media with effusion can impair speech and language development so delayed language development should raise concernsOtitis media - management Abx prescription for: ● Age <2 ● Otorrhea Stage of treatment Antibiotic IF penicillin allergy First-line Amoxicillin 5-7 days Clarithromycin Second-line (worsening symptoms after Co-amoxiclav Refer to guidelines 2-3 days on amoxicillin)Otitis media with effusion - management OM with effusion but NO hearing loss:Tympanometry: Measures sound Reassure, most cases resolve energy reflected by tympanic membrane when probe placed in OM with effusion AND hearing loss: ear canal (compliance of tympanic Referral for tympanometry, potential treatment with tympanostomy tube membrane in response to different air pressures) insertion (grommets) ■ Tympanic membrane mobility ■ Eustachian tube function ■ Middle ear function OM with effusion: ● No tympanic membrane movement (type B, L) ● Eustachian tube dysfunction (type C, R)A scuba diving instructor in his 50s booked an appointment immediately after his session yesterday due to sudden hearing loss and ear pain. Now he says the symptoms have disappeaed and he feels fine. No history of infection or other comorbiditiesT ympanic membrane perforation Common causes include - Barotrauma (pressure differences ie due to air travel, scuba diving, rapid altitude changes, explosions). Pain may impove suddenly when the pressure is released - Trauma: cotton bud injury, slap or punch to the ear - Infection: the membrane suddenly ruptures after a build up of puss, typically caused by otitis mediaOtoscopy showing perforated tympanic membrane. Usually otorrhea is also presentManagement - Generally heals after 6-8 weeks - Advise to avoid getting water in the ear - Antibiotics if perforation occurs due to otitis media - Myringoplasty if the membrane does not self heal23 year old with bilateral hearing loss and ringing in her ear. He mentions his father had similar symptoms that started around the same age, and so did his paternal grandmother Otosclerosis Flamingo tinge can sometimes be seen on otoscopy, but this is rare Autosomal dominant condition: Normal bone is replaced with vascular spongy bone, causing the stapes to be fixed at the oval window -> stapes can’t vibrate -> sound can’t be transmitted. Managed with hearing aids and stapedectomy63 year old man present with ear pain, itch and discharge. He has presented to the GP previously due to severe dandruff and multiple episodes of blepharitis Otitis externa ■ Causes: infection, seborrhoeic dermatitis, recent swimming ■ Otoscopy will show red and swollen ear canal ■ Associations: blepharitis and seborrheic dermatitis ■ Management: topical antibiotic + steroidSensorineural hearing loss What is it? Damage to the inner ear (cochlea) or the auditory nerve (CN VIII), affecting the conversion of sound waves into nerve signals or their transmission to the brain.What is the pathology behind these common causes sensorineural hearing lossA 72 year old woman presents to the GP as she’s struggling to hear conversations like she used to. She says some words are fine but others she can't quite make out. Telephone calls are especially difficult and the symptoms worsen in noisy environments There is no other medical history of notePresbycusis Hearing loss that affects the elderly, especially high frequency sounds Diagnosed with audiometry Investigations like otoscopy and blood tests should be done to rule out other abnormalities Management is supportive, usually hearing aids are requiredA 40 year old construction worker presents with reduced hearing in both ears accompanied by tinnitus. She says she has been at work for longer hours recently due to a new project her company has been contractedNoise induced hearing loss Investigate for underlying causes but otherwise treatment is supportive and hearing aids are generally usedA 65-year-old man being treated for sepsis with intravenous gentamicin develops gradually worsening hearing loss and constant ringing in both ears. He reports feeling slightly off balance when walking, and has no history of prior ear problems.Ototoxic Medications C – Cisplatin (and carboplatin) A – Aminoglycosides (eg gentamycin) N – NSAIDs (like high-dose aspirin) L – Loop diuretics I - IV erythromycin (rare, but more likely with IV) S – Salicylates T – Toxins (industrial solvents, heavy metals) N – Non-selective chemo agents (like cyclophosphamide – rare)A 45-year-old patient presents with episodes of spinning vertigo lasting several hours, accompanied by a sensation of fullness in one ear, fluctuating hearing loss, and intermittent tinnitusMeniere's disease Triad of vertigo, tinnitus and hearing loss Aural fullness usually present Episodes last minutes to hours and disease course is usually 5-10 years Management - ENT referral - Cease driving (DVLA informed) - Acute attacks: buccal/ IM prochlorperazine - exercisesn : betahistine and vestibular rehbillitationA 38-year-old patient reports sudden onset of vertigo lasting several days, accompanied by nausea and vomiting, along with hearing loss and tinnitus in one ear following a recent viral upper respiratory infectionViral labyrinthitis - Typically presents with a URTI - Abnormal head impulse test will be present due to impaired vestibulo-ocular reflex - Management: symptoms usually resolve without intervention; antihistamines may be given to control the feeling of dizziness Same symptoms but WITHOUT hearing loss? Suspect vestibular neuronitisOSCE Style History taking Mark is a 64 year old gentleman who has presented to to GP with hearing loss, take a history from MarkMain things to ask in a focused history Presenting complaint - Unilateral or bilateral?gradual? - Associated symptoms: tinnitus, vertigo, otorrhea, pain HPC - Medications: any ototoxic drugs - Family history of hearing loss - Social history: occupation linked to noise exposure? Red Flags…Sudden onset hearing loss Especially unilateral; may indicate sudden sensorineural hearing loss → needs urgent steroid treatment Associated facial weakness or numbness May suggest vestibular schwannoma, stroke, or skull base tumor Asymmetrical hearing loss Unilateral SNHL without obvious cause → consider acoustic neuroma Persistent or worsening otorrhea (discharge) Possible chronic suppurative otitis media or cholesteatoma Vertigo with hearing loss If recurrent, may suggest Ménière’s disease, labyrinthitis, or central pathology Mark’s history Onset: Sudden, noticed upon waking Laterality: Unilateral — right ear only Nature: Feels like “blocked ear” but no improvement with yawning or pressure Associated symptoms: ● Mild tinnitus (ringing) ● No vertigo, no pain No discharge, no preceding upper respiratory tract infection Tried cleaning ear and taking decongestants — no effectRed flags No history of noise trauma, trauma, or ototoxic medication use No neurological symptoms or facial weakness No prior hearing issues Medical / Drug / Family History No improvement over several hours ● No relevant past medical history ● No regular medications ● No family history of hearing loss Social History ● No recent travel, diving, or barotrauma ● Non-smoker, occasional alcohol ● Works in a quiet office environment ● No recreational noise exposureWhat is the most likely diagnosis A) Meniere's disease B) Cholesteatoma C) Presbycusis D) Sudden sensorineural hearing loss E) Acoustic neuromaA) Menieres disease - no history of aural fullness or vertigo B) Cholesteatoma - no discharge from ear C) Presbycusis - sudden onset makes this unlikely D) Sudden sensorineural hearing loss - management will be covered in tutorial 2 E) Acoustic neuroma - symptoms other than hearing loss and tinnitus would be present eg facial nerve palsyTOPIC TW O Sumayyah ImranCase Back to Mark…. How do we investigate and manage hearing loss?Ear exam ● Inspection of ear ● Tuning fork tests ● Otoscopy ● Audiometry ● CN VIIIEar exam ● Inspection of ear - pinnae, mastoid process, conchal bowl and pre-auricular region ❏ Congenital deformities ❏ Inflammation and erythema ❏ Cauliflower ear ❏ Scars ❏ Recent piercings ❏ Skin lesionsT uning fork tests 1. Strike 512Hz tuning fork against knee and ask if patient can hear the sound 2. Perform Rinne and Weber’s tests Rinne under the pinna! Rinne’s test 1. Place base of vibrating tuning fork on mastoid process and ask patient to inform you when they can no longer hear it 2. Move prongs of tuning fork in front of ear and ask if patient can hear it at this point 3. If patient can still hear, AC>BC, but if not, then BC>AC 4. Repeat for both ears AC>BC Positive Rinne test BC>AC Negative Rinne test Weber’s test 1. Place base of vibrating tuning fork on centre of head 2. Ask patient where they hear the sound Centre Normal/bilateral hearing loss One side Ipsilateral conductive/contralateral sensorineural hearing lossT uning fork tests - interpretation Mark’s results Weber’s test: Sound localises to RIGHT ear Rinne’s test: Positive Rinne test in both ears Mark has a left sensorineural hearing loss ● Positive Rinne’s test in both ears -> AC>BC in both ears→ NO conductive hearing loss→ Must be sensorineural ● Sound localises to right side → Sound localises on opposite side to affected ear in sensorineural hearing loss → LEFT ear affectedOtoscopy - procedure 1. Ensure the light is working on the otoscope and apply a sterile speculum ( largest that will comfortably fit in the external auditory meatus). 2. Start with the less painful ear/patient’s better ear 3. Pull the pinna upwards and backwards with your other hand to straighten the external auditory canal. 4. Position the otoscope at the external auditory meatus 5. Gently advance the otoscope under direct vision 6. Inspect the external auditory canal 7. Assess the tympanic membrane 8. Withdraw the otoscope and repeat for the other ear, changing the speculum if evidence of infection 9. Discard the speculum into the clinical waste binOtoscopy - procedure ■ Right ear - right hand, left ear - left hand ■ Hold otoscope like pencil ■ Pull pinna upwards and backwards Otoscopy - healthy tympanic membrane ■ Pearly grey/white ■ Translucent ■ Light reflex in anterior inferior quadrant 4 o’clock- 7 o’clock- 5 o’clock 8 o’clockOtoscopy - pathologies Otitis media Cholesteatoma Otitis media with effusion Case Mark’s tympanic membranes and auditory canals are normal on otoscopy What is the single most appropriate next step? 1) Routine referral for hearing aids 2) Urgent referral for CT head 3) Urgent ENT referral for pure tone audiometry 4) Immediate ENT referral for pure tone audiometry 5) Review in 3 days Case Mark’s tympanic membranes and auditory canals are normal on otoscopy What is the single most appropriate next step? 1) Routine referral for hearing aids 2) Urgent referral for CT head 3) Urgent ENT referral for pure tone audiometry 4) Immediate ENT referral for pure tone audiometry 5) Review in 3 days Air conduction Bone conduction ● △ = Right ear maskeded ● < = Right ear unmasked ● X = Left ear unmasked ● [ = Right ear masked ● ▢ = Left ear masked ● > = Left ear unmasked Audiometry ● ] = Left ear masked Increasing pitch Louder sound needed for patient to hear at given frequencyCase Mark’s audiogram is below:Case Mark’s audiogram is below: ● Right ear ● AC = BC ● Hearing loss at higher frequencies - 3 adjacent tonesAudiometry - sensorineural hearing loss ■ Hearing loss at higher frequencies ■ No difference between air and bone conduction ■ Presbyacusis, SSHL, noise-induced, acoustic neuromaCase What is the next step in managing this patient? 1) Oral corticosteroids 2) Routine audiology referral 3) Oral antibiotics 4) Intratympanic steroids 5) Watchful waitingCase What is the next step in managing this patient? 1) Oral corticosteroids 2) Routine audiology referral 3) Oral antibiotics 4) Intratympanic steroids 5) Watchful waitingSudden sensorineural hearing loss (SSHL) Rule of three for diagnosis Investigation Sensorineural hearing loss of ● Hearing loss in 3 adjacent ● Gold-standard: Pure tone pure tones sudden onset (<3 days) ● Hearing loss of 30 dB or audiometry more ● MRI head to identify acoustic ● Onset over 3 days neuroma Aetiology Management ● Unclear ● URGENT referral to ENT for ● 5% of patients have pure-tone audiometry and acoustic neuromas Presentation review after initial treatment ● Unilateral hearing loss ● Short course of oral steroids ● Tinnitus (if refractory, three doses of ● Aural fullness/blocked ear ● Balance disturbance intratympanic steroids in Prognosis ● Otalgias secondary care) ● Spontaneous recovery, ● Hearing aids for incomplete usually within 2 weeks, in hearing recovery 32-65% of patientsAcoustic neuroma/vestibular schwannoma Tumour of vestibulocochlear nerve - abnormal growth of Schwann cells Presentation ● Unilateral hearing loss Investigation Focal neurological signs→ Urgent (progressive in 90% of ENT referral patients, sudden onset in only Gold-standard: MRI head 5%) Hearing tests show unilateral ● Facial weakness (facial nerve sensorineural hearing loss Complications ● Hearing loss compression) ● Loss of facial sensation/facial ● Facial paralysis pain (trigeminal nerve ● Hydrocephalus compression) Management ● Compression of cerebellum, ● If raised ICP: headaches, ● Active surveillance - small nausea, vomiting tumour, no facial nerve cranial nerves 9-12, cerebellar involvement, comorbidities peduncles or brainstem Usually benign and slow-growing, ● Microsurgery but compression of local structures ● Stereotactic radiosurgery - Risk factors can lead to complications including less invasive approach for ● High-dose head and neck cranial nerve palsies, brainstem tumours <3cm in diameter radiation exposure compression and raised ICP ● NF2 Focal neurological signs→ Urgent ENT referral Cholesteatoma Abnormal accumulation of squamous epithelium and skin cells Presentation Management in middle ear cleft and mastoid air ● Otalgia ● Surgical intervention cells ● Persistent foul-smelling otorrhea ● ENT follow-up for recurrence ● Headaches monitoring Rare complication of chronic OM, most common in children aged 5-15 Complications ● Progressive conductive hearing Investigations ● White area loss in attic ● Recurrent ear infections Risk factors behind tympanic ● Facial nerve palsy ● Congenital middle ear membrane ● Meningitis abnormalities which ● Conductive ● Intracranial abscess compromise Eustachian tube function hearing ● Mastoiditis ● Male sex loss on ● Cavernous sinus thrombosis ● Middle ear disease audiometry ● Prior ENT surgery ● CT/MRICN VIII Vestibular nerve: ● Unterberger test: Ask patient to march on spot 40 times with eyes closed and arms outstretched in front of them ❖ Vestibular pathology - head turns towards side of lesion ● Vestibular-ocular reflex: AFTER confirming patient has no neck pain or problems, ask them to fix their eyes in front of them while you quickly turn their head to one side and the other ❖ Vestibular pathology - eyes move in direction of head, followed by correctional saccade Cochlear nerve: ● Whisper test: Mask one ear whilst speaking three two-digit numbers at 60cm distance from ear that is being tested, and ask patient to repeat numbers. Perform on both ears ❖ ⅔ of numbers correctly identified indicates 12dB or better hearing level ❏ If patient cannot hear, repeat test at conversational volume, followed by loud volume ❏ If patient cannot hear, repeat test at 15cmHearing loss - criteria for immediate ENT referral ■ Sudden onset hearing loss (<72 hours) within the past 30 days not explained by external or middle ear causes ■ Unilateral hearing loss with focal neurological symptoms, e.g. unilateralfacial nerve weakness ■ Associated with head or neck injury ■ Potentially serious underlying infective cause, e..g necrotising otitis externa ENT specialist within 24 hours Emergency DepartmentHearing loss - criteria for urgent specialist referral ■ Sudden onset hearing loss (<72 hours) which developed over 30 days ago ■ Rapidly progressive hearing loss (develops over 4-90 days) not explained by external or middle ear causes ■ Suspected head and neck cancer on 2ww pathway: ❖ Evidence e.g. Chinese or Southeast Asian origin individual + Middle ear effusion without evidence of infectionAudiometry - conductive hearing loss ■ Air-bone gap in affected ear ■ Trauma to ossicles, earwax, foreign body, otitis media or externa, tympanic membrane perforationAudiometry - osteosclerosis ● Carhart’s notch indicating loss of BC at 2000HzAudiometry - Meniere’s disease ● Low-frequency hearing lossAudiometry - noise-induced hearing loss ● Bilateral hearing loss at 4000HzAudiometry - presbyacusis ● Bilateral hearing loss at higher frequenciesHearing aids/implants Hearing aids Consist of microphone which amplifies sounds via speaker placed in auditory canal Multiple types which differ in ease of use and visibility Non-invasive Cochlear implants For mild to moderate hearing loss; can Consist of external processor and internal treat sensorineural hearing loss implant which receives digital signals and leads to direct auditory nerve stimulation For severe to profound hearing loss and auditory neuropathy Allow individuals to hear and understand speech Invasive; surgery required THANKS FOR W ATCHIN G! on Medall and see you next week!