ENT MODULE LECTURE

HEARING LOSS

dr. Dyah Indrasworo, Sp.T.H.T.K.L. (K)

dr. Ahmad Dian Wahyudiono, SpT.H.T.K.L.

OTORHINOLARYNGOLOGY DEPARTMENT
MEDICAL FACULTY OF BRAWIJAYA UNIVERSITY
KBK 2016

1
 ENT MODULE LECTURE

HEARING LOSS

I. CONDUCTIVE HEARING LOSS

II. SENSORINEURAL HEARING LOSS
III. CONGENITAL DEAFNESS
IV. PRESBYCUSIS
V. ACUTE ACOUSTIC TRAUMA
VI. NOISE INDUCED HEARING LOSS
VII. OTOSCLEROSIS
VIII. ASSESMENT OF HEARING
IX. REHABILITATION OF THE HEARING IMPAIRED
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 HEARING LOSS

- is impairment of hearing
- its severity may vary, from mild to severe or
profound.
- hearing loss is a broad concept
that comprises many disorders.

3
- classification
o organic
* conductive
* sensorineural

sensory (cochlear)

neural

peripheral (VIIIth nerve)

central (central auditory pathways)
o non organic

4
- degree of hearing loss

WHO recommended the following

classification on the basis of pure tone
audiogram taking the average of the threshold
of hearing for frequencies of 500, 1000 and
2000,4000 Hz

5
Hearing loss and difficulty in hearing speech

Dhingra PL, 2004

6
I. CONDUCTIVE HEARING LOSS

characteristics
1. negative Rinne test, i.e BC>AC
2. Weber lateralized to poorer ear
3. normal absolute bone conduction
4. low frequencies affected more
5. audiometry shows bone conduction better
than air conduction, with air – bone gap.
6. loss is not more than 60 db
7. speech discrimination is good
7
(A) Audiogram of right ear showing conductive hearing loss
(B) Symbols used in audiogram charting

Dhingra PL, 2004

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etiology

- any disease process which interferes with the

conduction of sound to reach cochlea
- lesion in
o external ear and tympanic membrane,
including obstruction of the ear canal
o middle ear or ossicles
up to stapediovestibular joint
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- the cause may congenital or acquired
o congenital :
* meatal atresia
* fixation of stapes footplate
* fixation of malleus head
* ossicular discontinuity
* congenital cholesteatoma

10
o acquired :
* external ear :
any obstruction in the ear canal, e.g.

wax

foreign body

furuncle

acute inflammatory swelling

benign or malignant tumours

atresia of canal
* middle ear
11
 * middle ear :
a. perforation of tympanic
membrane, traumatic or infective
b. fluid in the middle ear, e.g.

acute otitis media,

serous otitis media

haemotympanum
c. mass in middle ear, e.g.
benign or malignant tumours

12
d. disruption of ossicles, e.g.

trauma to ossicular chain

chronic suppurative otitis media
e. fixation of ossicless, e.g.

otosclerosis,

tympanoclerosis

adhesive otitis media
f. eustachian tube blockage, e.g.

retracted tympanic membrane

serous otitis media
13
management

- most cases of conductive hearing loss can be

managed by medical or surgical means.
- briefly, the management consists of :
1. removal of canal obstruction, e.g.
impacted wax, foreign body, osteoma or
exostosis, keratotic mass, benign or
malignant tumours, meatal atresia
2. removal of fluid.
myringotomy with or without grommet
insertion 14
3 removal of mass from middle ear.
tympanotomy and removal of small
middle ear tumors or cholesteatoma
behind intact drum
4. stapedectomy.
as in otosclerotic fixation of stapes
footplate

15
5. tympanoplasty.
repair of perforation, ossicular, chain
or both
6. hearing aid.
in cases, where surgery is
- not possible
- refused
- or has failed

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II. SENSORINEURAL HEARING LOSS

characteristics
1. a positive Rinne test , i.e. AC> BC
2. Weber lateralized to better ear
3. bone conduction reduced on Schwabach
and absolute bone conduction tests
4. more often involving high frequencies
5. no gap between air and bone conduction
curve on audiometry
6. loss may exceed 60 dB
7. speech discrimination is poor
8. difficulty in hearing in the presence of noise
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Audiogram of right ear showing sensorineural loss
with no A-B gap
Dhingra PL, 2004
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etiology of SNHL
O disorders where morphological changes
could be shown in the cochlea (mostly
injures to outer hair cells)
O disorders where the morphological
abnormalities are located in the central
auditory nervous system.
o the etiology may congenital or acquired

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o acquired
* It appears later in life.
* the cause may be

genetic : - be a part of a larger syndrome
affecting other systems of the
body
- manifest late (delayed onset)
affect only the hearing

non – genetic.

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common causes of acquired SNHL :
- infections of labyrinth : viral, bacterial or
spirochaetal
- trauma to labyrinth or VIIIth nerve, e.g.
o fractures of temporal bone
o concussion of labyrinth
o ear surgery
- noise – induced hearing loss
- ototoxic drugs
- presbycusis
- Meniere’s disease 21
- acoustic neuroma
- sudden hearing loss
- familial progressive SNHL
- systemic disorders, e.g.
o diabetes,
o hypothyroidism,
o kidney disease,
o autoimmune disorders,
o multiple sclerosis
o blood dyscrasias.
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management

- early detection of SNHL

o is important as measures
o can be taken
* to stop its progress,
* reverse it
* to start an early rehabilitation program,
so essential for communication
- rehabilitation of hearing – impaired
with hearing aids and other devices
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- some diseases

o hearing loss of hypothyroidism

can be reversed with replacement therapy.
o serous labyrinthitis can be reversed
by attention to middle ear infection.
o early management of Meniere’s disease
can prevent further episodes of vertigo
and hearing loss.

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 o ototoxic drugs should be used with care
and discontinued if causing hearing
loss. In many such cases, it may be
possible to regain hearing, total or
partial, if the drug is stopped.

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III. CONGENITAL DEAFNESS

- present at birth and is the results of

anomalies of the inner ear or damage to the
hearing apparatus, by prenatal or perinatal
factors

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etiology
o prenatal causes

genetic defects

maternal infection (TORCHES)

drugs during pregnancy

radiation to mother in first trimester

nutritional deficiency, diabetes, toxemia
and thyroid deficiency
27
o perinatal causes

anoxia

prematurity

birth injuries

neonatal jaundice

neonatal meningitis

ototoxic drugs

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o postnatal causes

genetic

manifests later in childhood or adult life

occur alone as in familial progressive
sensorineural deafness

or in association with certain syndromes

non – genetic

essentially same as in adult

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management
o parental guidance
be told of child’s disability and how to care
o hearing aids
should be prescribed as early possible
o development of speech and language
o education of the deaf
there are residential and day schools for
the deaf
o vocational guidance
the deaf are sincere and good workers
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IV. PRESBYCUSIS
- sensorineural hearing loss associated with
physiological aging process in the ear
- usually manifest at the age of 65 years,
but may do so early if there is
o hereditary predisposition
o chronic noise exsposure
o generalized vascular disease

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- great difficulty in hearing in the presence of
background noise, though they may hear
well in quiet surroundings,
- may complain of speech being heard, but
not understood.
- recruitment phenomenon is positive, and
all the sound suddenly become intolerable
when volume is raised.
- tinnitus is another bothersome problem,
and in some it is the only complain.
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pathological types of presbycusis
1. sensory
2. neural
3. strial or metabolic
4. cochlear conductive

33
- sensory

degeneration of the organ of Corti,
starting at the basal coil and
progressing gradually to the apex.

higher frequencies are affected,
but speech discrimination remains
good

34
- neural

degeneration of the cells of spiral
ganglion, starting at the basal coil and
progressing to the apex.

neurons of higher auditory pathways
may also be affected.

this manifest with high tone loss,
but speech discrimination is poor and
out of proportion to the pure tone loss
35
- strial or metabolic

atrophy of stria vascularis, in all turns
of cochlea.

the physical and chemical processes
of energy productions are affected.

it runs in families.

audiogram is flat,
but speech discrimination is good
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- cochlear conductive.

this is due to stiffening of the basilar

membrane, thus affecting its movement.


audiogram is sloping type.

37
management
o patients of presbycusis can be helped
by a hearing aid.
o they should also have lessons in
speech reading through visual cues.
o curtailment of smoking and stimulants
like tea and coffee may help to
decrease tinnitus

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V. ACUTE ACOUSTIC TRAUMA

- permanent damage to hearing can be caused

by a single brief exposure to very intense
sound,
e.g. an explosion, gunfire or powerful cracker.

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- sudden loud sound may damage outer hair
cells, disrupt the organ of Corti and rupture
the Reissner’s membrane.
- a severe blast may concomitantly rupture
tympanic membrane and disrupt ossicular
chain

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VI. NOISE INDUCED HEARING LOSS
- follows chronic exposure to less intense
sounds than seen in acoustic trauma.
- mainly a hazard of noisy occupations.
- patient complains of high pitched tinnitus,
and difficulty in day hearing.
- hearing impairment becomes clinically
apparent to the patient when the
frequencies of 500,1000 and 2000 Hz
are also affected
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- threshold shift
o temporary threshold shift.
The hearing is impaired immediately
after exposure to noise but recovers
after an interval of a few minutes to a few
hours
o permanent threshold shift.
The hearing impairment is permanent
and does not recover at all
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- damage depends on several factors :
o frequency of noise.
a frequency of 2000 to 3000 Hz causes more
damage.
o intensity and duration of noise.
as the intensity increases, permissible time for
exposure is reduced.
o continuous vs interrupted noise.
continuous noise is more harmful.
o susceptibility of the individual.
o pre – existing ear disease.

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- audiogram in NIHL
o shows a typical notch at 4 kHz, both for
air and bone conduction.
o It is usually symmetrical on both sides.
o as the duration of noise exposure increases
the notch deepens, and also widens to
involve lower and higher frequencies.

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Early case of noise-induced hearimh loss.
Note dip at 4000 Hz

Dhingra PL, 2004

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- NIHL causes damage to hair cells, starting in
the basal turn of cochlea. Outer hair cells
are affected before the inner hair cells

- management
If hearing impairment has already occurred,
rehabilitation is similar to that employed for
other sensorineural hearing losses.

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- NIHL is preventable.
o persons who have to work at places where
noise is above 85 dB (A), should have pre –
employment and then annual audiograms for
early detection.
o ear protectors (ear plugs or ear muffs) should
be used where noise levels exceed 85 dB (A).
They provide protection up to 35 dB.
o noise induced hearing loss can be prevented
from further deterioration, if the person is
removed from the noisy surroundings.
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VII. OTOSCLEROSIS

- exact cause of otosclerosis is not known, facts :

o anatomical basis
fissula ante fenestram is the site of predilection
o heredity
about 50% of otosclerosis have family history
o race
white races are affected more than Negros
o sex
females are affected twice as often as males
o age of onset
deafness usually starts between 20-30 years
o other factors, eg. pregnancy, accident.
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- symptoms
o hearing loss
progressive with insidious onset,
often bilateral
o paracusis willisii
hears better in noisy surroundings
o tinnitus
in cochlear otosclerosis and active lesions
o vertigo (uncommon)
o speech (monotonous)

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- signs
o tympanic membrane is quite normal and
mobile
o eustachian tube function is normal
o audiometry

loss of air conduction, more for lower
frequencies

dip in bone conduction curve,
maximum at 2000 Hz (Carhart’s notch)

mixed hearing loss is not uncommon
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Otosclerosis, left ear. Note dip at 2000 Hz in bone
conduction (Carhat’s notch)

Dhingra PL, 2004

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- treatment
o medical
there is no medical treatment that cures
o surgical
stapedectomy is the treatment of choice
o hearing aid, an effective alternative for
patients who refuse surgery or are unfit
for surgery

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VIII. ASSESMENT OF HEARING

While assessing the auditory function, it is

important to find out:
1. Type of hearing loss (conductive,
sensorineural or mixed)
2. Degree of hearing loss (mild, moderate,
moderately severe, severe, profound or
total)

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3. Site of lesion.
• If conductive, the lesion may be at
external ear, tympanic membrane,
middle ear, ossicles or Eustachian tube.
• If sensorineural, find out whether the
lesion is cochlear, retrocochlear or
central. Special test of hearing will be
required to differentiate these types.

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4. Cause of hearing loss. The cause may be
congenital, traumatic, infective, neoplastic,
degenerative, metabolic, ototoxic, vascular
or autoimmune process.

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ASSESMENT OF HEARING

- clinical tests o finger friction test

o watch test
o speech test
o tuning fork test

- audiometry tests o pure tone audiometry

o speech audiometry
o bekesy audiometry
o impedance audiometry

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- special test of hearing
o alternate binaural loudness balance test
o short increment sensitivity index
o threshold tone decay test
o evoked response audiometry

electrocochleography

auditory brain – stem responses
o otoacoustic emissions
o central auditory tests
o hearing assessment in infant and
children
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finger friction test

- rubbing or snapping the thumb and finger

close to patient’s ear
- a rough but quick method of screeening

58
watch test

- clicking watch is brought close to the ear

and distance at which it is heard, is
measured
- popular as screening test before the
audiometric era

59
speech test
- normally a person hears
o conversational at 12 metres
o whisper (with residual air after normal
expiration) at 6 metres
- for purposes of test, 6 metres is taken
normal for both conversation and whisper

60
- conducted in reasonably quiet surroundings
o patient’s test ear towards the examiner
at a distance of 6 metres
o patient’s eyes are shielded to prevent
lip-reading
o the non test ear is blocked by intermittent
pressure on the tragus by an assistant
o examiner uses spondee words
o the distance at which voice are heards is
measured
61
tuning fork test

Tuning fork test. (A) Testing for air conduction.

(B) Testing for bone conduction. (C) Weber test
Dhingra PL, 2004
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 KBK 2010

- A tuning fork is activated by striking it gently

against the examiner’s elbow, heel of hand
or the rubber heel of the shoe
- To test air conductions a vibrating fork is
placed vertically, about 2 cm away from the
opening of external auditory meatus
- To test bone conductions , the footplate of
vibrating tuning fork is placed firmly on the
mastoid bone

63
- Test for air conduction hearing
1. Tuning fork of all frequencies available are
used
2. AC of patient is compared with that of the
normal hearing person (examiner)
- Rinne test
1. A vibrating tuning fork of 512 Hz is placed
on the patient’s mastoid
2. When patient stops hearing, tuning fork is
brought beside the meatus
3. If patient still hears, AC is more than BC.
Rinne test is called positive
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 KBK 09

- Weber test
1. A vibrating tuning fork of 512 is placed in
the middle of the forehead or the vertex
2. The patient is asked in which ear the
sound is heard
- Schwabach test
1. A vibrating tuning fork of 512 is placed on
the mastoid
2. BC of patient is compared with that of the
normal hearing person (examiner) with
meatus is not occluded.
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Tuning fork tests and their interpretation

Dhingra PL, 2004

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pure tone audiometry

- an audiometer is an electronic device which

produces pure tones, the intensity of which
can be increased or decreased in 5 dB
steps
- usually thresholds are measured
o air conduction thresholds for 125, 250,
500, 1000, 2000 and 4000 and 8000
Hz
o bone conduction thresholds for 250, 67
- the amount of intensity that has to be
raised above the normal level is measure of
the degree of hearing impairment at that
frequency
- it is charted in the from of a graph called
audiogram

68
- the threshold of bone conduction is measure
of cochlear function
- the difference in the thresholds of air and
bone conduction (A-B gap) is measure of
the degree of conductive deafness

69
- masking
o to avoid getting a shadow curve from
the non-test better ear
done by employing narrow – band
o
noise to the non test ear
in air conduction, when difference
o
between two ears is 40 dB or above
o is essential in all bone conduction

70
(A) Audiogram of right ear showing conductive hearing loss
(B) Symbols used in audiogram charting

Dhingra PL, 2004

71
Audiogram of right ear showing sensorineural loss
with no A-B gap
Dhingra PL, 2004
72
speech audiometry
- the patient’s ability to hear and understand
speech is measured
- speech reception threshold (SRT)
the minimum intensity, at which 50% of the
words are repeated correctly
- speech discrimination score (SDS) a
measure of patient’s ability to understand
speech, in percentage

73
 Relation of intensity and speech discrimination score
Speech discrimination score (%)

Intensity
(A) normal
(B) conductive hearing loss
(C) cochlear hearing loss
(D) retro cochlear hearing loss
Supardi, Efiati A (et.al), 2007
74
Bekesy audiometry

- a self recording audiometry

- this test is no longer in use

75
impedance audiometry

- an objective test
- widely used in clinical practice
- consists of
o tympanometry
o acoustic reflex measurement

76
- tympanometry

o charting the compliance of tympano-

ossicular system against various
pressure changes,

o different types of graphs called

tympanogram are obtained, which are
diagnostic of certain middle ear
pathologies
77
Principle of impedance audiometry. (A) Oscillator
to produce a tone of 220 Hz, (B) Air pump to
increase or decrease air pressure in the air
canal, (C) Microphone to pick up and measure
sound pressure level reflected from the tympanic
membrane

Dhingra PL, 2004

78
Dhingra PL, 2004

79
- acoustic reflex measurement

o based on the fact that a loud sound,

70 – 100 dB above the threshold
of hearing ,causes bilateral contraction
of the stapedial muscles which can be
detected by tympanometry
o tone can be delivered to one ear and
reflex picked from the same or the
contralateral ear

80
Acoustic reflex

Dhingra PL, 2004

81
- useful in

o to test the hearing in infants and young

children
o to find malingerers
o to detect cochlear pathology (recruitment)
o to detect VIIIth nerve lesion
o to detect lesions of facial nerve

82
alternate binaural loudness balance test
- used to detect recruitment in unilateral
cases
- recruitment
o is phenomenon of abnormal growth of
loudness
o the ear which does not hear low intensity
sound, begins to hear greater intensity
sounds as loud or even louder than
normal hearing ear 83
Dhingra PL, 2004
84
short increment sensitivity index

o SISI test is used to differentiate a

cochlear from a retrocochlear lesion

o patient with cochlear lesions distinguish

smaller changes in intensity of pure tone
better than normal person and those
with conductive or retrocochlear pathology

85
threshold tone decay test
- it is a measure of nerve fatigue and is used
to detect retrocochlear lesions.

- normally, a person can hear a tone

continuously for 60 seconds.

- in nerve fatigue, a person stops hearing

earlier

86
evoked response audiometry

- an objective test which measures electrical

activity in the auditory pathways in response to
auditory stimuli
- special equipment with an averaging compute
- they are
o electrocochleography
it is an invasive procedure
o auditory brain-stem response

87
- auditory brain-stem response
o It is a non – invasive technique to find
the intergrity of central auditory pathways
through the VIIIth nerve, pons and midbrain

o is of great value

to find out the threshold of hearing in
infants, particularly the high risk groups

in the diagnosis of retrocochlear
pathology
88
otoacoustic emissions
o are low – intensity sounds produced by
movements of the outer hair cells of the
cochlea
o produced either spontaneously
or in response to the acoustic stimuli
o prove valuable

in the diagnosis of hearing loss where
there is damage to the outer hair cells

in the assessment of hearing in infant
89
hearing assessment in infant and children
- assessment of auditory function in neonates,
infants and children demands special techniques
a. neonatal screening procedures
- arousal test
- auditory response cradle
- electric response audiometry
b. behaviour observation audiometry
- Moro’s reflex
- cochleo – palpebral reflex
- cessation reflex
90
c. distraction techniques, 6 – 7 months old
d. conditioning techniques
- visual reorientation audiometry
- play audiometry, 2 – 4 years old

e. objective test
- evoked response audiometry

electrocochleography

auditory brainsten response
- impedance audiometry
- otoacoustic emissions
- heart rate audiometry
91
IX. REHABILITATION OF THE HEARING IMPAIRED

- all hearing impaired individuals need some sort

of
aural rehabilitation for communication
- the various means available :
o instrumental devices : - hearing aids
- cochlear implants
- assistive devices
o training : - speech reading
- auditory training
- speech conservation 92
SUGGESTED READING
1. Supardi, Efiati A (et.al): Buku Ajar Ilmu Penyakit
Telinga Hidung Tenggorok, Edisi ke III, Balai penerbit
FKUI, 2007
2. Dhingra PL : Diseases of Ear Nose and Throat, 3rd
ed , New Delhi , Elsevier, 2004
3. Moller AR : Hearing : Anatomy Physiology, and
Disorders of the auditory system, Second edition,
Amsterdam - Tokyo, 2006
4. Sri Rukmini, Sri Herawati (editor) : Tehnik
Pemeriksaan Telinga, Hidung & Tenggorok, Buku
Kedokteran EGC, 2002 JBS 300910

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 KASIH
IMA
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