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© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
in the clinic
Hearing Loss
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
Who is at risk for hearing loss?
 Children
 Prenatal infections
 Family history of childhood hearing loss
 Stay in the neonatal ICU >5d
 Craniofacial abnormalities or head trauma
 Central nervous system disease
 Chemotherapy
 Adults
 Noise exposure
 Family history of hearing loss before age 50y
 Age >65 years
 Smoking
 Diabetes
 Exposure to ototoxic medications
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
When and how often should children and
adults be screened for hearing loss?
 Childhood
 Newborns in first month
 6 months to 3 years and from 11 to 18 years: risk
assessment at each well visit
 4 through 10 years: formal assessment with audiometer at
each well visit
 Adults
 Anyone with perceived hearing loss or risk factors
 Then interval screening depending on continuing risks
 ASLHA: every decade until age 50, then every 3y
 Medicare: part of annual wellness exam if >65y
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
What are the appropriate screening tests?
 Self-administered questionnaire
 Single: Do you feel you have hearing loss? (yes/no)
 Multiple: 10-item Hearing Handicap Inventory for Elderly
 Positive and negative predictive value 70%–80% compared
with pure tone audiometry
 Office-based screening tests
 Finger rub
 Whisper test
 Pure tone audiometry with hand-held device
 Weber and Rinne tests (once hearing loss identified) helps
identify cause
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
To which specialists should a patient
with hearing loss be referred?
 Audiologist
 All patients with having hearing loss: for audiogram
 Ear, nose, and throat specialist
 Urgent referral: sudden sensorineural hearing loss or
hearing loss associated with trauma
 Severe or recurrent infections
 Associated vertigo
 Conductive or fluctuating hearing loss
 Failure of hearing aides to be useful
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
CLINICAL BOTTOM LINE: Screening…
 Hearing loss can occur at any time in lifespan
 Risk factors
 Noise exposure
 Family history
 Age, smoking
 Diabetes
 Exposure to ototoxic medications
 Screen at-risk persons or those with signs of hearing loss
 Specialty referral: audiologist for audiogram; ENT specialist
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
Can hearing loss be prevented?
 Limit exposure to excessive noise
 Short exposure to very loud sounds and extended
exposure to moderate-level noises can be damaging
 Avoid or closely monitor ototoxic medications
 Avoid or closely monitor chemical exposure
 Follow of patients with recurrent ear infections carefully
 Institute measures to avoid head trauma
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
CLINICAL BOTTOM LINE: Prevention…
 Limit exposure to excessive noise
 Avoid or closely monitor ototoxic medications
 Avoid or closely monitor chemical exposure
 Carefully follow patients with recurrent ear infections
 Avoid head trauma
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
What symptoms should make patients
and clinicians consider hearing loss?
 Any functional or cognitive decline
 Depression or anxiety, social withdrawal
 Poor word discrimination
 Family members report patient has hearing difficulty
 Health care providers notice they’re repeating
themselves and re-asking questions
 Infants: Lack of response to sounds, delayed language
development
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
Are there conditions that make it more
difficult to diagnose hearing loss or that
can mask as hearing loss?
 Patient may think losses are “normal”, untreatable
 Patient may be embarrassed by their deficits
 Others may misperceive to be cognitive impairment or
inattentiveness
 Hearing loss may contribute to neurologic impairment of
speech and language centers
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
What physical examination findings
indicate possible hearing loss?
 Finger rub test (failure ≥3 of 6 times)
 Whisper test (failure ≥3 of 6 times)
 Hand-held audiometer (failure to identify 1000- or 2000Hz in both ears or 1000- and 2000-Hz in 1 ear)
 Weber and Rinne tests (tuning fork ) guide diagnosis
 Abnormalities of the tympanic membrane
 Scarring or visible perforations
 Suggest conductive hearing loss
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
What diagnostic tests should be done
when hearing loss is suspected?
 Audiogram
 All patients diagnosed with hearing loss
 Cerumen removal
 For cerumen impaction (defer audiogram until after removal)
 Laboratory evaluation
 Only if history & physical exam suggests systemic illness
 Imaging studies
 Characterize conductive and sensorineural hearing loss
 If hearing loss + audiology evaluation point to presbycusis
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
CLINICAL BOTTOM LINE: Diagnosis…
 Conduct hearing screen if functional or cognitive decline occur
 Offer audiogram to all patients diagnosed with hearing loss
 No lab evaluation: unless exam suggests systemic illness
 Imaging tests: for conductive and sensorineural hearing loss
 Refer patient to ENT doctor if specialty care is needed
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
Are there medical treatments for hearing loss?
 Cerumen impaction
 May cause loss of 40dB + contribute to other hearing loss
 To remove: cerumenolytics, irrigation, or manual removal
 If Hx of abundant cerumen: ceruminolytic drops 1x-2x/wk
 Wipe hearing aids daily: avoids buildup, decreased efficacy
 Sudden hearing loss
 Oral prednisone: 1st-line treatment
 Consider intratympanic steroids if oral steroids fail
 Co-manage patients with an ENT specialist
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
What surgical therapies are available for
hearing loss?
 Conductive hearing loss due to mechanical problems
 To remove foreign body or bony lesions in ear canal
 To fix malformation of ear canal
 Sensorineural hearing loss that’s profound, bilateral,
doesn’t improve with hearing aids
 Cochlear implant
 Other criteria for implant: short duration of hearing loss; good
speech, language, and communication skills; adequate
cognition; motivation to participate in rehab
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
What types of hearing aids are available?
 Assistive-listening devices
 Least expensive, simplest approach
 External microphone + headphones transmit sound to ears
 Microphone may be in pocket, on a table, worn on neck
 Hearing aids
 Can sit behind ear, in bowl of pinna, or in ear canal
 Larger, external units easier to use; smaller units have less
amplification capacity but more cosmetically acceptable
 Analog units less expensive but less adaptable than digital
 Amplification device useful for telephones can be added
 Bilateral amplification best for most
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
What environmental adaptations are
useful for persons with hearing loss?
 Health care setting
 Ask patient how he or she prefers to communicate
 Reduce background noise and have patient’s attention
 Face the patient; don’t obscure your mouth with hands
 Speak toward the better ear, slowly and distinctly
 Don’t shout, and rephrase rather than repeat
 Write down key points of communication
 Home of hearing-impaired patients and public spaces
 Amplified phones with vibrating, flashing ringer; text phones
 Flashing, vibrating clocks, smoke alarms, doorbells
 Infrared or wireless FM devices may be available
 FM copper loop technologies in halls, restaurants, churches
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
What medications should be avoided in
persons with hearing loss?
Known Ototoxic
Potentially Ototoxic
 Aminoglycosiades
 Propylene glycol
 Gold
 Salicylates
 Povidone-iodine
 Arsenic
 Erythromycin
 Industrial solvents
 Nicotine
 Vancomycin
 Bleomycin
 Lead
 Loop diuretics
 Carbon monoxide
 Alcohol
 Quinine
 Methylmercury
 Caffeine
 Cisplatin
 Potassium bromate
 Chloramphenicol
 Nitrogen mustard
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
CLINICAL BOTTOM LINE: Treatment…
 Remove any accumulated cerumen
 Sudden hearing loss: oral prednisone, then intratympanic
steroids if needed
 Conductive hearing loss: consider surgery, if appropriate
 Sensorineural hearing loss: consider cochlear implantation
 Improve sound perception and communication
 Assistive listening devices and hearing aids
 Environmental adaptations
 Adequate lighting, access to pen and paper or computer,
amplified or text telephones
 Avoid ototoxic medications, particularly aminoglycosides
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
What is the effect of hearing loss
on quality of life and mortality?
 Hearing loss is associated with…
 Social isolation
 Functional decline
 Poor quality of life
 Depression
 Cognitive deficits
 Proposed mechanisms for this decline include…
 Social isolation
 Increased cognitive load
 Altered cortical processing
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
When is hearing loss considered a
protected disability?
 ADA: disability is a mental or physical impairment that
substantially limits ≥1 major life activities
 Hearing is considered central to daily life
 Severe and long term hearing deficit is covered under ADA
 Businesses should offer services for hearing impaired
 Qualified sign language interpreters
 Written materials
 Headset amplifiers
 Open and closed captioning
 Teletype machines
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
What is the definition of “deafness,” and
what is meant by the term “deaf culture”?
 Deafness
 Degree of hearing impairment such that a person can’t
understand speech, even with amplification
 Profound deafness is when no sound is perceived
 Deaf culture
 Set of learned behaviors and perceptions that shape values,
norms of deaf people based on common experiences
 Shared struggles can create strong sense of community
 Deaf persons tend to prefer sign language to communicate
 Some don’t perceive hearing loss as disability
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
What is “signing” and “lip reading”?
 Signing
 Transmitting meaning based on manual communication
and body language, rather than based on sounds
 Signed languages may not resemble spoken language
 Lip reading
 Oralism is a tradition of communication among deaf:
spoken language remains the basis of communication
 Lip reading and speech are the techniques used in this
system as opposed to sign language
 30%-40% accuracy; higher with intensive training
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
What is current opinion on the superiority
of signing, lip reading, or using a
combination of techniques?
 For children: controversy over schools
 Mainstreaming in regular schools seems less restrictive
 But specialized schools can provide better a peer group,
better classroom technology, richer culture
 For those who become hearing impaired in adult life
 Training in signing can improve QOL
 Auditory rehab programs can offer combined programs in
lip reading and simple signing
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
CLINICAL BOTTOM LINE: Social
ramifications of hearing loss…
 Hearing loss can be associated with…
 social isolation and depression
 functional decline
 poor quality of life
 cognitive deficits
 Definition of deaf: If person if unable to understand speech
even in presence of amplification
 Many deaf people don’t consider themselves disabled
 The Deaf community is a defined cultural and linguistic group
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.