Safe Haven

Do you hear what I hear?

Assessing your patient’s hearing

HEARING ACUITY, like visual acuity, usually diminishes Conductive loss

with age. Early losses may begin in young adulthood. Impaired conduction as in
They primarily involve high-frequency sounds beyond “destructed” ear canal
the range of human speech and have relatively little
functional significance. Gradually, however, the loss ex-
tends to sounds in the middle- and lower-frequency
ranges. When a person fails to hear the upper tones of
words but still hears the lower ones, words sound dis-
torted and are often difficult to understand, especially in
noisy environments.
Hearing loss associated with aging—known as presbycu-
sis—becomes increasingly evident after the age of 50. It’s
important to know how to perform a hearing assessment
to determine whether a patient has hearing loss and to Sensorineural loss
help determine what the cause may be. Impaired transmission of
sound impulses to the brain
The ears have it
Begin assessing your patient by asking a few simple
questions, such as “How’s your hearing?” or “Have you
had any trouble with your ears?” If the patient’s noticed
any hearing loss, ask whether it involves one or both
ears. Did it start suddenly or come on gradually? Does
he have any associated symptoms?
You’ll need to try and distinguish between two basic
types of hearing impairment: conductive loss, which
results from problems in the external or middle ear,
and sensorineural loss, which stems from problems in the Let’s hear the symptoms
inner ear, the cochlear nerve, or its central connections Ask about medications the patient’s taking. Some drugs
in the brain. To do this, ask a few more questions: “Do that may affect hearing include: aminoglycosides (gen-
you have difficulty understanding people when they tamicin, neomycin, streptomycin); aspirin; nonsteroidal
talk?” and “How does a noisy environment affect your anti-inflammatory drugs (NSAIDs), such as ibuprofen
hearing?” People with sensorineural loss have trouble (Motrin), nabumetone (Relafen), and naproxen (Aleve),
understanding speech, may complain that others are or a COX-2 inhibitor such as celecoxib (Celebrex); qui-
mumbling, or may tell you that a noisy environment nine; and furosemide (Lasix).
makes it harder to hear. A patient with conductive Next, ask whether the patient’s had an earache, ear
hearing loss may find that a noisy environment helps pain, or tenderness behind the ear. Does he have a fever,
him hear. sore throat, cough, or upper respiratory infection? Ear
If you’re examining an infant, ask the parents whether pain suggests a problem in the external ear, such as otitis
the child has failed to respond to their voices or to sounds externa, an inflammation of the skin of the visible ear and
in the environment. A toddler with hearing impairment the portion of the ear canal leading to the eardrum; it’s
may show a delay in speech development. These findings often caused by infection. If the patient has symptoms of
require thorough investigation by a health care provider respiratory infection, the ear pain may be otitis media,
or specialist. inflammation of the middle ear caused by infection. Pain

6 LPN2006 l Volume 2, Number 3

in the ear may also be referred from other structures in Vertigo is a challenging symptom for health care prac-
the mouth, throat, or neck. titioners because patients have widely differing ideas of
Has the patient noticed any ear discharge, especially if what vertigo or dizziness means. Be as specific as possible
it’s associated with earache or trauma? The discharge when asking about vertigo. For example, instead of ask-
may be unusually soft ear wax, debris from inflammation ing, “Are there times when you feel dizzy?” ask, “Do you
or rash in the ear canal, or discharge from a perforated feel unsteady, as if you’re going to fall or black out? Or
eardrum secondary to acute or chronic otitis media. do you feel the room spinning?” (That’s true vertigo.)
Does the patient have tinnitus? It’s often described as a Offer several choices of wording to get accurate informa-
musical ringing or a rushing or roaring noise in one or tion. For example, a feeling of being “pulled” suggests
both ears. Tinnitus is a common symptom that increases true vertigo from an inner ear problem or a central or
in frequency with age. When present with hearing loss peripheral lesion of cranial nerve VIII; feeling unsteady,
and vertigo, it may signal Ménière’s disease, a disorder of lightheaded, or “dizzy in the legs” may signal a cardiovas-
the inner ear that also causes a sensation of fullness in the cular problem. Be sure to find out whether the dizziness
affected ear. is related to a change in position or is accompanied by
Has your patient experienced vertigo? This isn’t quite diaphoresis (sweating), flushing, nausea, or vomiting.
the same as dizziness or lightheadedness; rather, it’s a Find out whether the patient’s taking any medications
sensation that the environment is rotating or spinning. with adverse effects of dizziness or vertigo.
This symptom points to a problem in the labyrinths of
the inner ear, peripheral lesions or lesions in the central What else to ask about
pathway of an acoustic nerve known as cranial nerve VIII, Here are a few more pieces of information you’ll need
or nuclei in the brain. to complete the examination:

May/June l LPN2006 7
PATIENT EDUCATION

Caring for hearing aids

Q. How do hearing aids work? to wear it as often as possible.

A. Hearing aids convert speech and other sounds to To remove your hearing aid: turn the hearing aid off
acoustic signals, which they then amplify. Some hearing and the volume all the way down. Then, rotate the ear
aids depress lower-frequency sounds and amplify mold forward and gently pull outward to remove it.
higher-frequency sounds. Q. How do I care for my hearing aid?
Developing technology has produced increasingly A. It’s important to keep your hearing aid—especially
smaller, more efficient hearing aids. There are several dif- the ear mold—clean, dry, and free of ear wax. You can
ferent types, informally named by their placement in or wash the mold part with mild soap and water, but be
around the ear: behind-the-ear, in-the-ear, or in-the- sure to detach it from the hearing aid part so you don’t
canal hearing aids. damage the electronics. If your hearing aid doesn’t de-
It’s important to remember that although hearing aids tach, you can simply wipe the mold section with a damp
can amplify sounds, they won’t make words clearer or cloth. Never immerse your hearing aid in water. Like-
speech easier to understand, except by making the sounds wise, be sure to store your clean, dry hearing aid in its
louder. case when you’re not wearing it.
Q. How will my health care provider know if I need Q. How do I change the batteries?
a hearing aid? A. Replace dead batteries in your hearing aid with new
A. Your health care provider will take a complete med- ones of the same type, following the manufacturer’s in-
ical history and do a physical exam to rule out other structions that came with your hearing aid. Before you
causes of hearing loss that may be treated medically or insert the new batteries, make sure you’ve turned off
surgically. He’ll also determine whether the loss is the your hearing aid. Check to be sure you’re matching the
result of medication, infection, or another problem. If positive and negative signs on the battery with those on
you have true hearing loss, your provider will recom- the hearing aid. If you wear your hearing aid 10 to 12
mend evaluation by a licensed audiologist to determine hours a day, you’ll probably need to change the batteries
the best type of hearing aid for you. about once a week.
Q. How do I use my hearing aid? Q. Are there any special precautions I should take?
A. First, you need to know how to insert your hearing A. Remember that moisture and excessive heat are ene-
aid: mies of your hearing aid.
• Wash your hands. • Don’t store your hearing aid near a stove, a heater, in
• Make sure the hearing aid is turned off and the vol- direct sunlight, or near any other heat source.
ume is all the way down. • Be careful wearing your hearing aid if it’s raining or
• If you have an ear mold-type hearing aid, check the snowing, or when you’re engaged in an activity that
mold to be sure you have the right one (they’re shaped causes you to perspire.
differently for each ear). Then line up the mold with • Don’t wear your hearing aid in the bathtub or shower
your ear, tip it forward slightly, and place in the canal. or while using a hair dryer, vaporizer, or hair spray.
• Gently push the hearing aid into place while rotating • Avoid dropping your hearing aid.
it backward slightly to line up with your ear. The ear If you experience ear pain, drainage, or infection or if
mold should fit snugly and comfortably. your ear mold doesn’t fit properly or is uncomfortable,
• Gently adjust the other pieces of your hearing aid. contact your health care provider.
Place the behind-the-ear section carefully over your ear.
• Turn on the hearing aid and slowly raise the volume
This patient-education guide has been adapted for the 5th-grade level using the Flesch-
until it’s at a comfortable level. Kincaid and SMOG formulas. It may be photocopied for clinical use or adapted to meet
Wearing a hearing aid takes some adjustments. You your facility’s requirements. Selected references are available upon request.

may want to start out by wearing it for short periods and

gradually increase wearing time until you feel you’re used
to having them on. Once you’ve adjusted, you should try LPN2006
May/June l LPN2006 9
 Safe Haven

• whether the patient’s had ear surgery or a recent ear

infection
• the date and results of the patient’s last hearing test
• whether he uses a hearing aid or aids
• what his ear-care habits are (such as using cotton-
tipped applicators to remove ear wax)
• whether he’s been exposed to loud noise and whether
he uses protective earplugs or headphones.
You’ve assessed and recorded your patient’s symptoms
and completed your report. What’s next?
Based on what you’ve reported, your patient will likely
undergo a physical exam by the health care provider. He
may be referred to an audiologist for additional hearing
and listening tests. If your patient has true hearing loss,
he may also be fitted for hearing aids or, if he has them
already, he may be fitted for new ones.
Whatever your patient’s treatment turns out to be,
you’ve helped him take the first steps toward solving his
hearing problem. LPN
Selected references
Bickley LS. Bates’ Guide to Physical Examination and History Taking, 8th edi-
tion. Philadelphia, Pa.: Lippincott, Williams & Wilkins, 2004.

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