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Hearing loss & Tinnitus

by
Professor Hassan Wahba
Professor of OtoRhinoLaryngology
Ain Shams University
Privileges of hearing:
• Functions all the time
• Auditory field is very large
• First special sense to function (intra uterine)
• Special sense responsible for development of speech & communication
• The means of education is through hearing

Auditory Pathway:
1. Sound is collected by the auricle
2. Sound passes through the external auditory canal
3. Sound vibrates the tympanic membrane
4. Sound is transmitted along the auditory ossicles to the oval window
5. Sound passes into the inner ear as a fluid wave and vibrates the basilar membrane
6. Hair cells convert sound to an electrical nerve impulse
7. The cochlear nerve transmits the nerve impulse to the cochlear nuclei in the brain
stem along the auditory pathway to the auditory center in the temporal lobe

The function of the tympano-ossicular system of the middle ear is to convert a mechanical vibration
wave in air to a mechanical vibration wave in the fluid of the inner ear. This action involves
transmitting the sound wave into the inner ear as well as amplifying the sound wave to compensate
for any energy loss.

The organ of Corti in the inner ear is responsible for the creation of an electrical nerve impulse by
an intricate mechanism that relies on vibration of the basilar membrane to and from the tectorial
membrane with the hair cells collecting the electrical stimulus. The organ of Corti is the region
were the volume of sound is determined by the amplitude of the vibration of the basilar membrane
and the frequency of sound is determined by the site of vibration along the length of the cochlea;
hence, the cochlea is the site were the physical properties of sound are analyzed and are send along
the cochlear nerve in a ready format to the auditory center.

Binaural hearing (hearing with both ears) is necessary for the determination of the source of sound
and is important in life especially when crossing the road.

Hearing loss when complete is called deafness. Some sources may use the word deafness to
describe a hearing loss.

Types of hearing loss are:

 Conductive hearing loss
 Sensorineural hearing loss
 Central hearing loss
 Mixed hearing loss
 Malingerer
 Hysterical
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Clinical detection of hearing loss:
 The patient uses his hand to direct the auricle towards the speaker while bringing his
head closer
 The patient shouts in a raised non-modulated voice this indicates a sensorineural
hearing loss
 The patient complains of hearing loss and raises the radio or TV and asks speakers to
raise their voice but has a low well-modulated voice this indicates a conductive hearing loss

Tuning fork tests:

• Rinne
• Weber
• Schwabach
• ABC

Audiometry:
 Pure tone audiometry
 Speech audiometry
 Tympanometry

Neonatal screening for hearing loss:

Auropalpebral reflex
Auditory brainstem response (ABR)
Otoacoustic emission (OAE)

Degrees of hearing loss:

Normal hearing: 0-25dB
Mild hearing loss: 26-40dB unable to hear soft sounds problems with speech clarity
Moderate hearing loss: 41-55dB unable to hear soft and moderately loud sounds problems with
speech clarity especially with background noise
Severe hearing loss: 56-90dB can hear some loud sounds needs hearing aid for recognition and
understanding speech
Profound hearing loss: +91dB relies on other means of communication (lip reading or sign language
and needs cochlear implantation

Causes of conductive hearing loss:

External auditory canal:
 Congenital aural atresia
 Foreign body
 Large furuncle
 External otitis
 Exostosis
 WAX commonest cause
Tympanic membrane:
 Traumatic rupture
 Pathological perforation due to otitis media
 Tympanosclerosis
 Myringitis
Middle ear:
 Atresia
 Longitudinal fracture of the temporal bone
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 Otitis media
 Glomus tumor
 Otosclerosis
 Ossicular disruption
Eustachian tube:
 Otitic barotrauma
 Otitis media with effusion – commonest cause for conductive hearing loss in
children

Factors affecting hearing loss in tympanic membrane perforation:

• Size
• Exposure of round window
• Presence of ossicular discontinuity

Sensorineural hearing loss:

Cochlear:
 Genetic malformations
 Transverse fracture of the temporal bone
 Labyrinthitis (viral, otogenic, meningitis commonest cause in Egyptian children,
syphlytic)
 Ototoxicity
 Metabolic (diabetes mellitus, thyroid disorders)
 Meniere's disease
 Presbyacusis (senile hearing loss commonest cause in adults)
Cochlear nerve:
Acoustic neuroma (must be suspected in case of unilateral SNHL with tinnitus)

Congenital sensorineural hearing loss:

Dating since birth or develops later on in life due to genetic or hereditary cause
Endogenous:
• Genetic syndromal disorders
• Cochlear malformations
Exogenous:
• Prenatal (german measles)
• Natal (fetal hypoxia)
• Postnatal (erythroblastosis fetalis)

Sound is what we hear & Noise is an uncomfortable sound

Acoustic trauma:
• Acute noise exposure
• Chronic noise exposure (occupational)

Labyrinthine insult:
• Secondary to meningitis (commonest cause of SNHL in Egyptian children)
• Secondary to otitis media
• Secondary to viral infections (measles & mumps)
• Syphilis
• Metabolic (diabetis mellitus, thyroid gland dys.)
• Transverse fracture temporal bone
• Labyrinthine concussion
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• Vascular (embolism, hemorrhage or thrombosis)
• Meniere’s disease
• Otosclerosis (cochlear type - commonest cause of mixed hearing loss)
• Ototoxicity

Ototoxic drugs
Aminoglycosides
gentamicin streptomycin tobramycin neomycin amikacin kanamycin
erythromycin, loop diuretics, acetyl salicylic acid

Central hearing loss:

• Encephalitis
• Vascular lesion especially in hypertensive and diabetics
• Brain tumors
• Multiple sclerosis
• Psychogenic causes
• Kernectrus
• Epilepsy
• Brain injury
• Post operative after brain surgery

Sudden SNHL:
Viral or Vascular or Acute acoustic trauma
Treatment according to the cause:
• Viral: antivirals and steroids
• Vascular: vasodilators, hyperbaric oxygen and steroids
• Noise trauma: good prognosis so wait and steroids

Otologic work up for hearing loss patients:

Associated otologic complaint (symptom):
Otorhea:
• Pure pus ∨cholesteatoma – furuncle
• Mucopus ∨acute supp OM – tubotympanic OM
• Blood ∨glomus – carcinoma
• CSF ∨temporal bone fracture
Tinnitus:
• Low pitched ∨CHL
• High pitched ∨SNHL
• Pulsating ∨vascular lesion as glomus
Vertigo:
• Attacks ∨Meniere’s disease
• Continuous ∨labyrinthitis
Earache:
• Severe increases with TMJ movement ∨external otitis
• With fever ∨acute otitis media
• After air flight ∨otitic barotrauma
• Itching ∨otomycosis
Otologic examination:
External auditory canal:
• Aural atresia
• Wax
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• Furuncle
• Exostosis
• Foreign body
Tympanic membrane:
• Perforated ∨acute & chronic OM – traumatic rupture – aural polyp
• Not perforated:
 Normal ∨otosclerosis – SNHL: history and genetic
 Abnormal:
1. Retracted ∨OME
2. Chalky patches ∨tympanosclerosis
3. Flamingo red ∨otosclerosis
4. Bulging ∨Acute OM
5. Bullae ∨bullous myringitis
Incident preceding hearing loss:
• Placing a foreign body in the ear
• After a bath or shower ∨ wax
• A slap to the ear ∨traumatic perforation
• A car or cycling accident ∨skull base fracture
• Pregnancy ∨otosclerosis
• Air plane flight ∨otitic barotrauma
• Post adenoidectomy ∨Eustachian tube trauma
• Exposure to loud noise ∨acoustic trauma
• Use of ototoxic drugs
• Straining ∨perilymph fistula
• Common cold ∨acute OM or viral labyrinthitis
• Psychic trauma ∨hysterical
• Fevers ∨meningitis – mumps – measles
• Surgery to the ear ∨operative trauma

Tinnitus:
Hearing loss is accompanied by tinnitus
Subjective tinnitus (patient only):
• Hypo & hypertension
• Anemia
• Thyroid dysfunction
• Atherosclerosis
• Spondylosis
• Menopause
Objective tinnitus (patient & examiner):
• Aneurysms
• Vascular tumors (glomus)
• AV fistula
• Myoclonus