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Ok, I let's go live. It's one minute past seven and I wanna go. So we are live. Ok. So we have, um, I think seven people have already joined us. Let's start. So it's Friday. So, um we can wind up as quick as possible. Um All right guys. Uh this is us um, back with our uh sixth teaching session, uh ent teaching series. Today's topic is hearing loss and um our lovely colleague, um, Doctor Ana Isiro is here with us. Um, she's a senior clinical fellow in Ent, she's gonna talk about hearing loss and how we can um get through a case of like hearing loss when we see it in A&E or when we get a GP referral or when we, one of our inpatients complain about hearing loss, how to uh manage it, how to treat it, uh how to refer them. Um According to the type of hearing loss. Ok, then I'll let a good to start it. Hi. Hi, everyone. Thank you for coming uh to the presentation um today. Um And now I also thank you for very graciously um, introducing me. Um, this topic today is about hearing loss and I've actually endeavored to keep this, um, presentation quite short and sweet and to keep it very much relevant to what I believe someone um, at the level of a sh or if one should be able to will, will come across and manage, so I won't go into anything overly complicated. It will be quite simple. But if anyone has any questions that fall slightly outside the scope, but you still feel irrelevant, then um please just um um put them inside the comments. I'll try and keep an eye on them or um maybe now if you're happy to flag them and when they come up any questions, yes, I am. Yes, ma'am. I'm, I'm constantly looking at the chat. So if anyone has any questions, any troubles in hearing or seeing the uh presentation or any questions, always, you can text us on the chat and uh we will get back to you and thank you so much much. So the first slide bear with me. Yeah. So I'm going through um basically some learning objectives such as, I mean, hearing loss in some ways might not. It's not always the easiest thing to present because there's various facets of it that you have to address. So I'll try to keep it to these, which is a type of hearing loss, severity things that can cause it um how you want to go through or approach the history for hearing loss examination and then how to manage or treat it. So what is hearing loss? Um Hearing loss is what is hearing, that is worse than that of a normal person affecting one or both ears and a normal hearing person can hear sounds, acting above 20 decibels. So someone that's classified as having hearing loss requires sounds of above 20 decibels to perceive sound at a particular frequency or page. Now, it's thought that about 5% of people in the world have quite disabling hearing loss that does require some form of input or assistance so that they can get around to their daily life. Now, the type of hearing loss um that one can have can be conductive sensory neural or mixed. I'll go into that in more detail, but basically conductive means difficulty of sound conducting through to the main hearing mechanism or, or um sensory organ or sensory um um apparatus and then sensory neuro means that that sensory apparatus and upstream of that is affected, mixed will means that one or other that both factors tend to be present in someone with hearing loss. Now, hearing loss, the pitch we're talking about frequency. So some people actually can hear well across a range of pitches, but there'll be certain pitches in which they cannot hear. OK. So that's what I'm talking about when I refer to pitch. So something that's high pitched might be say um a bird chirping or an Oper ing or hitting a high note and a low pitched sound might be, um, like a rumbling train or a dog barking. So some people might not be able to hear high pitches and then others might not be able to hear low pitches. Now, severity refers to the volume of a, of, um, of the deficit. So for example, you might have someone where you're having a conversation and a person can't hear you, but then you raise your voice, someone can hear you. So we're talking about the severity in terms of the volume. OK? Now, going back to the type of hearing loss, I'm talking about conductive versus sensory neural hearing loss. Now, the picture here just shows very um simple a anatomy of the ear. Let me get my mouse up here. So here you've got it sort of compartmentalized into outer ear, middle ear and inner ear. Excuse me. Now, conductive hearing loss is when you have issues with the sound traveling from outside up until like the outer and middle ears beyond those two areas is when you're most likely to encounter sensory neural hearing loss. So here's the main sensory um apparatus here, which is a cochlear and then you've got the nerve, which the sound communicates to the brain. OK. So this is where you've got sensory ie the sensory apparatus, neuro ie the nerve and conductive ie sound conduction through here and through the middle. Ok. Now, um before I do go on, does anyone, is anyone able to explain to me any causes of conductive hearing loss that they might, um, uh, that they might come across or be aware of if anybody wants to put some, um, some conductive hearing loss, um, problems in the chat, I'll probably give you a few seconds because we can go through this a little system a bit more systematically. Ok. I'm not seeing any messages. Um, so hopefully I'll be able to tell you some things. Oh, impacted ear. Yeah. Ih, I'm sure you mean wax Antonio. But yes, exactly. Can anyone or even Antonio yourself think of at least one more. Yes, max. Anyone can think of at least one more. Ok. So um I'll carry on. Um So basically what we're talking about here is if you're talking about from the outer ear, um tea and perforation. Yes, that's right. Benedictus. Yes, you can have a perforation. This is the eardrum here. So a hole in the eardrum can impede the, the transmission of sound. So anything from out here. So earwax, um anything that affects the foreign uh the the eardrum. So a perforation, sometimes even stiffening of the eardrum can cause problems. Then behind here in the middle ear you're talking about, about the ossicles, ie the small bones that help conduct sound. So if they're disrupted cholesteatoma, you're getting fancy. Now, Antonio. Yeah, that can definitely cause hearing loss and you tend to see it sort of on around the eardrum cholesteatomas. Um So yeah, So that can definitely be one. because cholestat tomas also can destroy um these bones here. Again, a conductive factor in the middle ear. This space here can get full of fluid or um or infection that can block the transmission of sound. And even though here you've got the Eustachian tube, which is kind of coming into the middle, the inner ear picture, many might classify it as part of the middle ear because this is what it communicates with and anything that can block the Eustachian tube can also cause problems with hearing. Um So for example, in kids, if they've got large adenoids that can block the Eustachian tube and that can cause a fusion to build up and then they've got hearing loss. So here we go, a whole bunch of examples um of of hearing loss, conductive hearing loss problems um that you have here. So we've got wax that was mentioned and we've also got the cholesteatoma um the dimension perforation. Um Yeah, perforation is there as well. So you were all correct. So yeah, these are all factors that can affect conductive. Now, I did mention here there can be air or bone conduction problems. Excuse me, air conduction is when the sound um is traveling as normal. You're hearing sounds, say by talking, the sound travels through the air and you can hear um bone conduction is excuse me and people have heightened bone conduction. It means that the the the the, the route for air travel of sound is impeded so they can hear better um say via the mastoid bone at the back. Ok. We'll go through that a bit later. Now, we're gonna get to um sensory neural um hearing loss and that's failure of the sensory or the nervous components of the auditory apparatus. Now, we're really mainly talking about the cochlea, the, the nerve, not the vestibular nerve, so much the a clear nerve and then downstream, when it can affect the brain and blood vessels from downstream, anyone able to give me some um uh examples of sensory neural hearing loss or things that might cause sensory neural hearing loss. I know we've got bright crowds over here, so I'll give you guys a few seconds. Acoustic neuroma benedictus, what are you doing here? I think you should be taking this lecture. Very good. Definitely acoustic neuroma. Um Is one anyone else have any other suggestions? Many years? Disease. Yes. Actually, it does. Um many years. Um It's one of those strange um uh um pathologies that we see that does affect the, the inner ear. You're absolutely right. Antonio. So I'll quickly move this along. So, yes, um surgery can be one that affects um the inner ear, especially when you're doing surgery. Neuroma. Yes. Um I would say that in acoustic neuroma, yes, you, you both are correct. Um You can have trauma and so often when you see trauma here, it can be in the context of head injury. Um head injury, we see people that fall, they hit their heads. You can actually get fractures of the um temporal bone um that can um cause hearing loss, both of a sensory neuro and the conductive nature. But you can also trauma can cause that um autotoxicity. So certain medications might affect um the auditory apparatus in this part, congenital problems, age related changes, probably the commonest one we see. And then of course, you've got neoplasms trauma. Again, I said infection mostly in the context of viral infections and ischemia such as stroke, especially um anterior inferior cere cerebellar arterial, um the artery that's involved because that does supply um the blood supply towards the inner ear. Ok. Now, severity of speech, I've tried to keep some of these slides simple. So like I say, if there's anything I'm missing or haven't explained properly, please just let me know um the unit of sound we use um to measure um hearing loss is decibels. It's a bit of a vague, vague term in terms of what exactly is a decibel, what does it mean in the context of sound? So I've put this table here so that you get an idea roughly of what we mean when we talk about decibels because often when we're testing someone's hearing, we're assessing it in decibels. So you'll get an impression as to what that means. So as I said before, normal hearing is generally at and above. Sorry, you can hear, um, 20 up to 20 decibels quite comfortably. So we're talking about the sound of a whisper. So generally speaking, kids should be hearing this very well. You tend to get older, your hearing tends to deteriorate. So 20 decibels will be about a whisper, sort of volume and as you get to sort of requiring more volume, so normal speech will be about 50 to 70 decibels is an important one to know, then you get louder and louder. So if you're on the tube or in a busy underground, you're getting close to like 100 decibels, actually, probably about 8090 decibels, actually more 90 decibels and then loud concerts and then gunshots which is like above 100 and 20. These are the kind of sounds actually that are very loud. And so you have to be particularly deaf if you can only hear at that volume. Now volume again, um is one factor you also wanna check frequency and I did briefly mention frequency before. So you might be able to hear sounds at a given frequency um but not be able to hear other other um noises that are given in frequency. So for example, in old age, people might hear quite well in lower frequencies. But when you get to the high frequencies, they require louder and louder volumes to be able to pick up the sound. Ok. Now I've put my surgical sieve which I did use the last time. Um I did my presentation, I find it very helpful. Um Like I say, this is not something that you necessarily need to go through when you're working up a patient because oftentimes the history will present itself as to what's going on. But it's also, but it's often quite nice to have it on hand if things become not so clear so that you can tease out what's going on. So I've put here um some um uh causes of conductive and sensory neural hearing loss that follow that you can use a surgical sieve with. So I'll just go through a few of these that some of you might not be familiar with. So sorry, let's start by conductive. We covered the the obvious ones like eardrum perforation, infections can cause it. Environmental. Now, environmental I've mentioned cold water swimming. Now, the reason I mention this is if you live in an environment like to swim outside, it can actually just start to distort the anatomy of the outer ear. When people get bony growths in the outer ear, we call it exostosis. So I used to live in an area where people used to swim a lot. So I used to see this presentation very, very frequently. So in oops, sorry. So the environment might be a factor in hearing loss for some people. Also, if you're living in a very noisy place like Central London, you might be more prone to having hearing loss versus someone that lives in a rural area. And their neighbors are like, probably the nearest neighbor is five miles away. Um, neoplasms. I've put cholesteatoma as a neoplasm as a pseudo neoplasm. Really. But yes, that can cause it. And congenital. Sorry, I keep clicking the mouse congenital. Now, these often are not things that you'll see because they'll often get picked up, um, at birth or seen in specialist pediatric clinics, um and then specialist pediatric ent clinics before a general ent person will see them. But kids that are born with certain genetic conditions will, may have um a hearing loss and you might see, for example, some Children will have a deformed ear and then you might get an idea that something more serious is going on beyond what you can see outside the pinna. So for example, they might have um atresia of the ear canal or they might have dysfunctional cochlear. Um These are things that um often, like I say, you won't necessarily see, but it's worth knowing. Then you've got sensory neuro um uh hearing loss. Um Now you've got idiopathic, this is a very, very frequent one that you'll likely come across. These people basically walk up to you and they will say doctor I woke up in the morning and I was deaf in my right ear and that's it. Basically, they might not, they might have some associated symptoms, but often it's just like I'm deaf and I don't know why, you don't know why you might do a bunch of investigations, but you'll not really understand what's caused it. Very gray area. And so there's a lot of hypotheses as to what's what causes idiopathic sudden onset hearing loss, sensory neural hearing loss. But a lot of it's still a very much of a gray area, iatrogenic. So, um, surgeries. So certain surgeries to, for example, uh where you're dealing with. Well, actually, sometimes when you're trying to even manage hearing loss, you might cause another problem. So, stapes surgery, for example, um when you're trying to deal with the foot plate of the stapes, which communicates with the cochlear, sometimes you can disrupt um the the labyrinth and cause fluid to leak out and that can cause hearing loss of a sensory neural nature. Acoustic neuroma was mentioned, presbycusis that's age related. It tends to affect high frequency sounds and vascular. So, cerebellar strokes or the artery that's responsible for supplying the hearing um mechanism, the labyrinthine artery that's affected you go deaf. Now, history, um history will be actually your most helpful tool in identifying hearing loss. And it's quite good if you go through it systematically, it's kind of like a modified Socrates onset duration, laterality, things like this. So you want to know when it started and how long ago it started? Um uh you want to know is it one ear or is it both ears associated symptoms that might help you identify the pathology. So if they got, if the patient got tinnitus, they got vertigo. So that's vertigo is basically the sensation of a room spinning. And then as the patient got facial weakness, that can tell you that the facial nerve is involved. Facial nerve actually, um like it is in very close proximity to a lot of these structures. So often times when you've got like a serious problem going on, then sometimes the facial nerve can get involved. One of the things that we of we can see, especially in the context of trauma can be um temporal um bone um fractures, and certain types of temporal bone fractures can also sever the facial nerve and affect the ears, uh the hearing as well, uh precipitant. Um So you're thinking about things like um loud noise. Um Well, actually, I can go through some of these later, but loud noise is a key factor um previous episodes. So some people might have had hearing loss before. Sometimes the way they live their life can tell you is to um uh is can actually develop a pattern. So for example, people that like to dive, um these people sometimes can get recurrent eardrum perforations. So they had previous similar episodes in the in the context of a certain activity and how was it managed before? Um Now, past medical and surgical history, um you can talk, you can ask them about if they had recent infections, upper respiratory tract infections, especially viral infections um can be particularly problematic. So, um the flu, um uh chickenpox, um COVID. So these are things that you want to be aware of uh vaccinations as well, especially anti um viral type. Um vaccinations such as the COVID jab, I've seen that a number of times in clinic, um CV. So, stroke and in some rare unusual cases, um anesthesia can also cause um hearing loss as well. Surgical really, there's not really much in the way of surgery apart from previous ent or neurological surgeries that can cause hearing loss, everything else. Um It's not really factor into it. Then you've got medication. So you've got autotoxic agents. Classical ones to be aware of are nsaids. Um aminoglycosides such as gentamicin, amikacin and then ce certain chemotherapeutic agents. We're talking about platinum based chemotherapeutic agents tend to be the most common offending factors and you've got allergies. Um Now, allergies are important because people with allergies um can have enlarged adenoids or enlarged tonsils. You can see that in kids, you can also see it in adults sometimes. Now when those structures become enlarged, they can block the eustachian tube and then they can become deaf as a result of that. Ok. Often as a conduct from a conductive nature. Now you've got family history, first degree relatives, not always, but sometimes you can see hearing loss in families. Um for example, autos sclerosis has an autosomal dominant. Um um, genetic, um, sort of, um, uh, and it's passed on in that manner. So, some people, if your mom or your dad has it, you may get it as well. So that's another fact. Um, genetic, um, awareness for hearing loss. There's many others, but that's just one example. And social history, um, that you need to be aware of occupations. Very important. Do you work in a construction site? Are you a DJ? Do you work in the armed forces? In fact, I had a gentlemen like that today. Do you work in the armed forces? Gunshots? You know, that can make you deaf um alcohol. Um actually, that's sometimes in the context of head injury. So people that are um excessive um head injuries that can cause deafness. Smoking is a vascular risk lifestyle and that goes for a lot of people using your ear buds, your apple, your apple, um ear buds or whatever it is. A lot of younger people are getting hearing loss because they use these things that are high volume. Sorry, I hope that wasn't too much. So, examination, um you want really want examination, as I always like to say, the consultation begins at the door, the minute the person opens the door and walks in, that's if you've seen them in the clinic, if it's in the ward or in the urgent care or, or A&E it's at the bedside. Ok. So you really want to be very observant as to um what's going on and that will also clue you in. So how old is the patient? Because that often will tell you what the most likely pathologies you're looking at for the hearing loss in kids. It classically tends to be infection, especially middle ear infections. Um, so that's, that will be a dead giveaway, especially if it's a little five year old and he's tugging his ear head bandage dressing, that might tell you if they had a ha accident or if they had recent surgery, hearing aid, that that tells you that's already established hearing loss. So it might be the the worst thing of the clinical picture with, with a patient. Um, that's got a hearing aid, lip reading. So is a patient intently staring at your mouth, um, when you're communicating with them or is the patient unable to understand you if you turn away response to verbal commands, if you talk to the patient, are they actually responding? Um And if they are, are they responding in a timely manner, are they taking their time and speech? I cannot say this word, intelligibility we got there and that how you, how easily are you able to understand a person's speak? I'll give you an example. Um, if you've ever been around someone who is deaf and has never actually been able to hear what speech sounds like, you might not be able to understand what they're saying. So their speech intelligibility will be poor. And that can also be the case for Children who are just learning to speak if they're deaf. Um or they've got a problem with the hearing, then the way they make sounds is is not very easy to understand. So observe these things and then you want to optimize the environment. So make it as best as able to communicate for that person, but also for your own benefit. So you can get a good history from them. So I'll just put some so good light and so they can see you face the patient so that if they need to let breath, they can speak clearly. And I'm not, don't, don't be patronizing and like speaking super loud or really slowly, don't make them see, it seems silly but speak loud enough that they can understand and paste your sentences and be patient with them. It's actually impressive, the amount of people that get impatient with those that cannot hear very well. OK. So the examination um as you want to start again looking at the ear, OK. So um basically what you want to do is you want to examine the pinna in the first instance, you wanna look at the anatomy of the pinna. So you're checking to see the actual contours of the ear. Are they normal? Um uh are they distorted from say infection or um injury or is it a congenital matter where the ear might not, might be misshapen or even in some cases it might be absent. Um And then you're looking for discharge in the case of people that do have a patent ear canal, you're looking for any wax, you can get waxy discharge, pus, blood or CSF you'll see in the context of um, head trauma or serious head trauma, inflammation and infection, scarring. Um I would say that's actually more for the post irregular area, but you can see sometimes, um, like I say, trauma of the pinna, which may lead you to suggest that something else is going on lesions and as well. And bruising, I didn't include that in the post irregular area. You're mainly looking for scars that can tell you if someone has had previous surgery in the past and then swelling. So in this picture here, you can see this young child has a very swollen, post irregular area with loss of the post irregular sulcus. So in this kind of clinical picture, you might be suspecting mastoiditis, which is the, the thing that everyone gets worried that they're gonna see in a child in the ante. OK. How are you going to examine this? Um Now, examination is very important. Um It's not just a fine to ACOP, but let's start there. Um You want to hold the ospe like a pen. So this picture is actually the perfect picture for how you hold a Osco. OK? And then you want to, so if you're examining someone's right ear, you hold the ospe in your right hand again, just like this picture and you just gently glide the tip of the otoscope into the ear canal. Now, the way you hold the pen is important because the shape of the ear canal actually changes. So in Children, it's um it's quite straight and in adults, it becomes a little more angulated. So the way you hold the ear back and down for babies and small Children and backing up for older kids and above and that's to straighten the ear canal in both cases. Now, I did mention I did consider other examinations in the context of hearing loss. So you might want to think about um, looking inside someone's mouth. So Children that have hearing loss, you might wanna think about looking in the mouth, for example, if they've got enlarged tonsils and that might be an indicator of something going on. Um And then of course, in an adult patient who might have, um, for example, you've got some sort of nervous problem and you're suspecting other nerves involved, you might want to do a neurological or a cranial nerve examination. Ok. So these are things definitely you want to bear in mind. Now to do a hearing test is um sorry to do investigations. You can do a, a few things. I'm just gonna keep things like I say very simple. Ok. So the hearing test that you'll do the first one, actually, the one that I would say you really should get accustomed with is a tuning fork test. And the reason why it's helpful is it will help you distinguish between conductive and sensory neural hearing loss. And it might also help you distinguish between air and bone conduction in terms of the problem going on. Um, like I say, I'm, I'm keeping this be. So any questions, please pop in the chat. Now, you won't always have an audiologist available and sometimes you'll be seeing a patient in A&E you wanna do a very quick test, you grab the tuning fork and you do the test. OK. I'm going to show you this video. It's only about a minute long, um which will show you how to do A R and Weber test um to help grossly distinguish the presence and nature of the hearing loss. OK? So I'll just play this for you now. I hope it plays wonderful. OK. So it's just a quick video cause like I say, it's always good to know how to do this test and you can do it very quickly by someone's bedside or in the clinic as well. OK. So what does this, this hearing test mean? I've put this little table here just for the purposes of reference for you to go back to. Now the gentleman in that test, what we really want to when someone's got normal hearing, you have good air conduction, that is what they're going to actually perceive better than bone conduction. That means that the travel of sound through the ear canal is going through the ear canal properly, vibrating, uh going through the eardrum, vibrating through the ossicles and making um communication with the cochlea. And then the nerve signal impulses are going through the cochlear nerve. Everything is work should be working fine. And then that's further clarified by a pos um uh a Weber's test which is normal. OK. And which you hear sound equally on both sides. OK. Now, the there are pathologies depending on whether you hear bone conduction better than air or the sound lateralizes to the left or to the right ear. I will leave this table here for you to refer to that um a little later and it can take your time to go over that, but it will show it, it describes how best to distinguish between sensory neuro and conductive using this simple test. OK. Now, a pure tone audiogram is a little more sophisticated. It is a subjective test for the patient in that you've got an audiologist here and they're playing sounds at various frequencies or various pitches. And then the person here will click a button when they hear the sound. OK? So just say I'm playing it at one particular pitch and you're not hearing the sound, you're not clicking the button, they will increase the volume at that pitch until you can hear that sound and then you click it. So then they do that across a range of pitches and then you click it depending on which volume you can best hear it at. OK. It's a little more sophisticated, but it is still subjective, right? So, uh the reason I've put this here is just to sort of better, sort of demonstrate a little bit more, um how the pitch and volume, um testing sort of interplay. This isn't really a um lecture on how to interpret hearing tests. It's just more a basis of what you're looking for roughly. OK. So I was talking about page you but low pitched, high pitched sounds and this is actually the measurement is done in Hertz. OK? And then you've got volume or decibels from low volume to high volume sounds. And we already sort of clarified that about 20 decibels, a whisper, 50 to 70 is normal speech. This is like gunshot levels getting to up here. OK? No, well, not quite gunshot levels a bit higher, but uh let's say a loud concert, loud concert up here. So you're looking at normal range is up to about 20th here. It's 25 de and decibels and you want to hear it to 20 decibels across all of these tested frequencies. OK? And that means you've got normal hearing if you're hearing at 20 decibels here, but you're hearing at um 50 decibels here. This means you've got normal, so sort of low to mid range hearing and then moderate hearing loss in the high frequency ranges. OK. I hope that makes sense. So this is normal, up to about 20 decibels, mild, up to 40 moderate, it's a broad spectrum, it's really up to 40 to 70 but it's split into moderate and moderate severe and you've got severe, up to 9070 to 90 profound is beyond that. Now, this yellow curve, I actually sort of um Microsoft um painted it in, this is roughly what we call the speech banana. What this is is this is the frequency and volume of normal speech. So if someone is hearing within this range of frequencies, they should still be able to hear speech. OK. Normal conversational speech. But if the hearing is below here and any of the uh below the yellow banana, they're not going to hear normal speech within that frequency. OK. Does that make sense to everyone? Um the other um measurement one can use for hearing loss is tympanometry. Now, what that is is you really actually you're testing conductive um hearing in that whereas this will help you test um you can test bone and conduct and uh sorry, uh sensory neuro and conductive hearing loss with um the um the pure tone audiogram because you can test it um with air conduction and with bone conduction that sounds OK. Now, tympanometry, you're really testing the vibration of the eardrum. You're testing to see how compliant it is um to changes in pressure and you want to have an eardrum that's steadily compliant to ear pressure so that, you know, it's transmitting sound in quite um a normal fashion. Now, this graph here is just a very brief overview just to tell you what it means. Now, you've got this little curve here, this means that the eardrum is vibrating normally in response to air pressure. Ok. Now what this means when it's below it is it's stiff, so it's not really vibrating the way it should or um uh you know, oscillating the way it should. And so that stiffness might impede sound from traveling through to the cochlear. Ok. Things that can cause stiffness of the eardrum, um can be, for example, previous surgery where you've got scarring or stiffness of the ossicles that attach actually to the eardrum. Ok. Now, this one means that the eardrum is hyper compliant ie it's moving too much. That can also indicate hearing loss. For example, one of the commonest causes will be a patient that has disarticulation of the ossicles or the bones, the, the the bones behind the eardrum. When they become disarticulated or dislocated, the eardrum moves a lot more freely because it's got nothing really holding it in place. So this can sort of if you see this in someone with hearing loss and say they've had head trauma, then you might want to do a CT scan to check the ossicles to make sure that they're not disarticulated. Similarly with a patient that's got this. If they've got a family history of hearing loss and the eardrum, the eardrum is rule compliance. Again, you might wanna consider a CT scan to check for stiffening of the um ossicles, which actually you can see on a CT scan. Now, I did allude to radiological studies um which again will be your next port of call. Um After you've done the hearing test in certain patient groups, it's not for everybody. OK. So CT scans are often very good as I've written here for assessing bony structures in middle ear pathology. So you want to assess a temporal bone and a temporal bone fracture. They also, but you can also use it for checking for cholesteatomas as well. So they're very good for middle ear pathology. MRI is is high resolution, you can use it for certain middle ear pathologies, but it's actually pretty good for inner ear um especially when you want to look at the nervous structures. Um So you can check for acoustic neuromas, meningiomas as well. And then cholesteatomas, we normally check for cholesterol using MRI special MRI studies. Um after surgery has been done because there are certain waiting, I don't, I won't get into it too much to cause confusion. But there are certain types of MRI scans that can help check for cholesteatomas that CT scans cannot, especially after surgery has been done initially to treat a cholesteatoma. And um and say that person comes back with hearing loss or discharging ear, then that can be very helpful. Ok? Um Any questions so far I'm gonna go on to treatment. So treatment for hearing loss is very variable depending on the nature of the insult. So basically, um it's very hard for a one size fits all to say this is what you do with someone that's got hearing loss because a hearing loss problem here, for example, if it's due to wax, all you might do is take the patient um into your clinic room and remove the wax problem pretty much solved. Ok. There wouldn't necessarily be a need for anything more um serious than that. But then say, for example, in the ear canal, excuse me, you've got someone with an ear infection such as otitis externa, then of course what you might still want to suction any debris. But then you wanna take the additional step of treating with antibiotics. So I'm just gonna put some examples here. Ok? So for conductive hearing loss that you might often see into the middle ear, you might conservative treatments might include, oh, sorry, I've cut off a little bit of this box. My apologies, wax removal. Um um or hearing aids. When I say conservative, I mean, you don't require any medicine or anything like that. You're just keeping things really, you know, pretty simple. Ok. So hearing aids in the context of conductive hearing loss where um a patient might have say canal atresia. Um, in those congenital cases, talked about and a hearing aid might be helpful in patients that get recurrent ear infections and um, do not want to have surgery. They can also have hearing aids, uh um as well. And there are many different types of hearing aids that, that do not go in the ear. That patient can still have reasonably reasonably good hearing with medical treatments in the context of infection. Largely you can do for antibiotics. Um And then of course, um you've got surgical treatments that you can consider. So, um you can do if they've got a hole in the eardrum, you can think of um uh repairing the hole with the tympanoplasty or if they've got um issues with um say constant infections because of the middle ear problems in the middle ear or the eustachian tube, you can give them a grommet if the issue is because of the enlarged adenoids or tonsils, which you often see in kids, remove the adenoids, remove the tonsils, the hearing loss often will go away. Ok. So you can think of it very systematically find the problem and just remove it. Um You can get conductive hearing loss. I did mention trauma. You can get um battle trauma such as divers, it can cause puncturing of the eardrum. Ask those people to um slow the sense when they swim, wear ear protection, when they swim. This kind of thing will help reduce the incidence of trauma there as well. Um, and then of course, you've got sensory neural hearing loss, um, conservative management. Again, you can use, um, hearing aids very much depends on the, on the severity of the hearing loss. But that's, that's helpful for a lot of elderly patients. People are on medications that cause hearing loss. You might want to ask them to stop it. Now, that's not necessarily possible for some patients such as those taking chemotherapy, all you can do with those patients is monitor their hearing and then consider a cochlear implant if the hearing is absolutely gone afterwards, um or if it's gone in, if it's gone in one ear, if it's gone in both ear, if it's gone in um one ear, you can also consider special hearing aids where you can allow the sounds to go from the side with no hearing to the better hearing side. Ok, then you've got medical treatments, antibiotics or antivirals. Um in the context of infection or steroids, which is commonly going to be used in cases of idiopathic hearing, um sudden onset sensory neural hearing loss, which is idiopathic. We tend to, to treat with steroids. And sometimes, you know, we we kind of, you know, um postulate that there might be some inflammation going on of the um of the nerve of the cochlear nerve and hopefully by dampening down that inflammation, the patient might get better hearing. But of course, the cause remains very unclear. And of course, you've got surgical cochlear implants being one where you put a special, um, um, probe, I say it's a probe but really, um, um, inside of the cochlear, it actually goes inside the, the, the cochlear, it is a very delicate surgery and then after everything has healed, um, you get a hearing aid that you wear outside that you can switch on and off and actually that can pick up any residual side of the cochlear um or any residual um hearing in the cochlear is amplified, using the implant. OK. Any questions so far, maybe I'll wait to the end. All right, case example. Um I tried to throw a few of these in because I always think it helps consolidate any learning that you have. So I've got this five year old boy um who comes to the clinic with his mom. He is very playful but does not respond readily to verbal commands and is hard to understand. So we're talking about low speech intelligibility mom says he snores and sometimes gets very painful ears. How would you manage this patient? First of all, let's think about it systematically examination. How would you go about examining him and then if you want to add in how you might investigate him and then how you might want to treat. Anyone can just put a few words in the comment. Give me a few seconds. No one knows, no one knows. I kind of alluded to how to treat this child in the previous slide. Um as to an option, options that you can do. Um So for a child like this, what you really want to think about is um you want to do an oral exam, you want to see does he have large tonsils? And you also wanna look inside of these ears. Now, it's not always possible to look at the adenoids which are situated at the back the nose. Um So oral and ear examination will be the only real examinations that you can do in the clinic. OK. When you're looking at the ears, you also want to make sure see if there's any sign of an acute otitis media, especially if there is painful ears going on. Ok. Now, investigation, you wanna do a hearing test. Now, I did mention a pure to audiogram, puretone audiograms. You can do quite easily in adults and older Children. But in a child of five, you might want to consider a um what we call a sort of uh amending pure to an audiogram. So we normally choose plate or visual ones which engages the child a lot more in a child that's very poor of hearing. You may wanna do a visual one, OK? Or one that's got special needs, OK? Treat. Um you might want to consider removing their adenoids and tonsils. Now, I know I said you can't see the adenoids when you're in the clinic. But when you're on the operating table. When you decide to remove the tonsils, you can always look in the adenoid at the, um, postnasal space and decide that the adenoids are there to remove. Ok? And then you might wanna consider grommets, especially if you get sore ears and you're concerned about, um, any fluid diffusion build up just because you don't ever really want to take a child back in for a two-step operation. Um, unless it's absolutely necessary, best to get it all done at once. Ok. Now the example too is you've got a 65 year old man. He comes to the urgent care center in a busy afternoon. He has severe ear pain and he's gone deaf on the right ear. Ok? He slurs and dribbles when he talks and do you notice a fascicular rash in his right ear and you can't get the ospe in due to him screaming out in pain. Um First of all, does anyone know what might be going on with this chap in the comments, please? And I ask you this because you might actually come across a patient like this in A&E and it's always just good to have your wits about you as to how to approach. So what would you do if you even don't know what's going on? How would you approach this patient? Anyone? Oh, it's Friday. Everyone wants. Oh Shingles. Yes. Antonio. Yes. Yes. Yes. Yes. Do you know the name for this? Pathology. So, yes, shingles, AFA, affecting the facial nerve. Do you know the name of this particular pathology? Bonus points. If you do Benedictus, we need to swap places. You need to be taking this lecture. Yes, Ramsay Hunt Syndrome. That's the one. So, um, you both were right. Absolutely correct. Um, Ramsay Hunt syndrome is basically, it's varicella zoster. So it's chicken pox, it's reactivation, basically. Um, they, they can lay dormant in the nerves and when they reactivate, um, especially because um, cranial nerve seven and eight, very in very close proximity, they can become affected. And this patient has basically manifested this unfortunate condition. So he's got, you can see a facial drip on his right side where the affected ear is in these vesicles. Ok. So the, the management would be like I say, oscopy isn't always just the only thing you do. You might wanna do a cranial nerve test on this chart. And with the cranial nerve test, you'll obviously see cranial nerve seven and eight will be out. Ok. Um Oscopy, if you can, you can, obviously, the pin examination shows you vesicles, but if you are able to slide the otoscope into his ear canal, you might see vesicles even inside the ear canal as well. All right. Um This is basically a disorder of the nerve, even though the external ear canal will be affected. It's the nerve that's really also affected. And so that's why it's generally sensory neural in nature and rather than conductive, um you want to investigate with a pure tone audiogram. So you'll do a hearing test on this chat. Um Now I put plus minus PCR PCR is preliminary chain reaction. Basically, it's a test for you. Sometimes when you want to do some vi viral um assays, you might want to do a blood test and see if you can get the viruses to zoster varicella zoster virus to show up doing a PCR test. So that is um a good indication if say in a very unlikely situation, this chap is negative for varicella zoster. You will um, consider an MRI so that you can have a good look at the inner ear and maybe even see if there's anything around the nerve structure that might indicate another underlying pathology. But this is very a clear cut case of Ramsay hunt. How would you treat this? Largely conservative? You treat this chap with steroids, you'll also give him, um, Acyclovir, which is an antiviral. I forgot to include that here. You'll give him good analgesia because he'll be in a lot of pain and you'll give him eye care because he cannot close his eye. So you'll get him, you'll, you'll pull the eye down and take the eye shut to protect the eye. And then you might want to consider physiotherapy that's mainly physiotherapy for the, um, for the facial nerve palsy. Unfortunately, Ramsey hunt tends to have a poor prognosis for either facial nerve restoration, hearing restoration or both. So, so if, if he's got permanent hearing loss or much reduced hearing loss, he may actually also require a hearing aid. But with these patients, you want to assess their hearing over a period of time. Ok. Now, I know that's two examples. It was quite a um try to be quite comprehensive. Uh I hope I've gone through all the learning points for you. Um So the cause is the type severity, history examination and treatments? Thank you very, very much. We're all done. That was quite long. Sorry. But thank you for tuning in now. Are you there? Yes, I'm here. Hi. Hi, Ros. It. Oh, it was nice, very comprehensive, very uh very relevant. Um Like even some of my doubts have gone now. No, I don't believe that Antonio. Thank you very much as well. Yes. Um II hope it was helpful, like I say, um it's just a comprehensive overview. Yeah. Yeah. Thank you so much for that. So, um I'll just release the uh feedback forms onto the chat and I would really like all of the audiences to leave their feedbacks on there and that's it. We'll be back with our sixth session very soon. Thank you. Thank you all. Take care. Have a nice night. Bye-bye. You too. Have a good weekend, everyone. Bye bye.