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How to treat
Pull-out section
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HEARING LOSS
in ADULTS
Background
HEARING impairment is a common
and often under-diagnosed condition
affecting almost one in five people aged
over 15 in Australia. This figure
increases to almost 40% in people
aged over 55, with men more likely to
be affected than women, particularly in
the older age groups.
While it is often thought of as
inevitable and part of the ageing
process, hearing loss can cause signifi-
cant disability with regard to a per-
sons’ employment prospects, social
interactions and, consequently, over-
all psychological wellbeing.
GPs are often the first port of call
for patients (or frustrated family mem-
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Complete How to Treat quizzes online (www.australiandoctor.com.au/cpd) or in every issue.
bers) who are experiencing hearing
difficulties. In most instances hearing
loss will have a simple aetiology.
However, there are a few important
conditions in which hearing loss is a
sign of more serious and possibly
malignant disease.
For some patients their hearing loss
may be untreatable, but others may
benefit from early diagnosis and refer-
ral to an otolaryngologist. This article
aims to assist GPs in improving their
otological examination skills and inter-
pretation of tympanometry tests and
audiograms, as well as reviewing some
of the more recent advances in treating
hearing loss in adults.
Types of hearing loss
Historically hearing loss has been
divided into three categories —
conductive, sensorineural and mixed.
Conductive hearing loss refers to con-
ditions affecting the pinna, external
auditory canal, tympanic membrane
or middle-ear structures, which can
impede the transmission of sound
impulses from the external environ-
ment through to the stapes footplate.
Such causes may be obvious on
physical examination and are often
amenable to treatment or surgical cor-
rection, although hearing aids may be
a satisfactory non-surgical option for
some patients.
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inside
Assessment
Common causes
of hearing loss in
adults
Treatment options
Case studies
The authors
DR PATRICIA MACFARLANE,
otolaryngology resident, Flinders
Medical Centre, Adelaide, SA.
DR A SIMON CARNEY,
senior lecturer and head of ENT
unit, Flinders Medical Centre,
Adelaide, SA.
Sensorineural hearing loss results
from conditions affecting the inner ear
or the central auditory pathway of the
eighth cranial nerve and may be fur-
ther subdivided into sensory (cochlear)
and neural (auditory nerve and path-
way) causes.
Sensorineural hearing loss may occa-
sionally be due to associated pre-exist-
ing medical conditions and may
improve with control of the underlying
disease process, but in most instances is
not amenable to surgery. In such cases
hearing devices may be of benefit.
Mixed hearing loss is due to a com-
bination of conductive and sensori-
neural processes.
31 August 2007 | Australian Doctor | 29
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How to treat – hearing loss in adults
Assessment
WHEN assessing a patient
with hearing loss it is impor-
tant to determine if they have
experienced an acute loss of
hearing (which is quite dis-
tressing and often prompts
patients to present immediately
to their GP or local emergency
department), or if it has been a
longstanding problem.
Other symptoms to inquire
about include the presence of
tinnitus, vertigo, otalgia and
otorrhoea, which together
with findings on physical
examination may identify the
underlying cause of the hear-
ing loss. In addition to taking
a detailed medical history it is
important to inquire about the
following risk factors associ-
ated with hearing loss:
■ Environmental exposure to
noise both at work and
through hobbies such as
hunting.
■ Family history of hearing
impairment.
■ Previous head trauma.
■ Exposure to medications or
chemicals known to be oto-
toxic (table 1).
■ Other medical problems
such as diabetes, hyperten-
sion or Paget’s disease.
As part of the initial physi-
cal examination in patients
presenting with hearing loss, a
brief cranial nerve examina-
tion as well as a basic assess-
ment of vestibular function
(simple recording of posture,
balance and gait) should be
undertaken.
Wax obstructing vision in
the external auditory canal
needs to be removed before
any assessment of hearing or
otoscopic examination (figure
1). Agents that soften and help
remove wax are available over
the counter from pharmacies,
although olive oil has been
shown to be equally effective.
Typically drops are applied to
the affected ear twice a day
for up to five days.
Syringing of ears to remove
wax is often performed in the
community setting, but must
not be undertaken in patients
with known or suspected tym-
panic membrane perforations,
a previous history of mastoid
surgery or in the presence of
acute infection or inflamma-
tion of the ear.
During otoscopy the cause
of a patient’s hearing loss may
become apparent. Large or
multiple bony exostoses of the
external auditory canal, a
condition also referred to as
‘surfer’s ear’ (figure 2), can
cause a conductive deficit by
significantly narrowing the
diameter of the canal.
The state of the tympanic
membrane can give further
clues as to the underlying aeti-
ology. Tympanic membrane
perforations or retractions,
cholesteatoma (which may
appear as wax or debris
‘stuck’ superiorly on the pars
flaccida) or effusions in the
middle-ear cleft may also be
apparent.
A conductive hearing deficit
30 | Australian Doctor | 31 August 2007
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Figure 1: Wax impaction. in the presence of an otherwise Figure 4A: Rinne’s test. Holding the tuning fork on the mastoid
normal-appearing external process.
auditory canal and tympanic
membrane (figure 3) is usually
due to otosclerosis.
With the exception of a sen-
sorineural hearing loss that
occurs as part of an underlying
genetic disorder or medical
condition (table 2), sen-
sorineural causes are usually
not associated with external
physical signs.
Screening tests, such as free-
Figure 2: Bony exostosis. field audiometry (the ‘whisper
test’), can be conducted in the
consulting rooms without the
need for special equipment
Figure 4B: Rinne’s test. Correct technique holding the tines of
and may detect hearing the fork parallel to the ear and (below) incorrect technique.
impairment. If a patient is
unable to hear a whisper at
half a metre, it is likely they
will have hearing-level thresh-
olds of 25dB or worse.
A more practical method of
screening for hearing loss is to
assess how well the patient
hears instructions given by
Figure 3: Normal tympanic membrane. you (delivered in a normal
conversational voice) as they
enter the quiet confines of the
consulting room.
Appropriately performed
Rinne’s and Weber’s tests
using a 256Hz or 512Hz
tuning fork can help deter-
mine the type of hearing loss.
Care should be taken not to
strike the tuning fork too hard
or against a hard object, as
this may produce overtones
and give false results.
Table 1: Medications and chemicals known to Before performing the tests
be ototoxic it is a good idea to ask the
Drug class or Example Comment
patient which ear they think
chemical agent
is the better hearing one. This
ear should be tested first.
Aminoglycoside Gentamicin, More likely with The simplest way of per-
antibiotics tobramycin, prolonged course or high forming Rinne’s test is to
amikacin doses and in people with gently strike the fork against
renal impairment. your knee or elbow, and then
May also cause vestibular place it on the patients’ mas-
damage toid process and ask the Figure 5: Weber’s test.
Loop diuretics Frusemide Reversible dose-related patient if they can hear it
hearing loss. More likely (figure 4A).
in people with renal The tuning fork should then
impairment be moved to the front of the
Alkylating Cisplatin Hyperpolarisation of ear and held about 2.5cm
agents hair-cell membranes and from the external auditory
raised auditory thresholds meatus, with the tines of the
Salicylates Aspirin Reversible sensorineural fork parallel to the ear (figure
hearing loss 4B). The patient is then asked
Others Phenytoin, beta Documented ototoxic which sound is louder, the
blockers, quinine potential tuning fork in front of or
Heavy metals Arsenic, cobolt, Documented ototoxic behind the ear.
lead, lithium, potential Rinne’s test is positive if air
mercury, thorium conduction is better than bone
conduction, as is the case in a
Chemicals Cyanide, benzene, May be ototoxic
‘normal’ ear. A conductive
aniline dyes,
deficit is present if bone con-
iodine, carbon
duction is louder than air con- Bone conduction correct
tetrachloride
duction (a negative Rinne’s
Solvents Toluene, styrene May be ototoxic
test). Figure 6: Air conduction masking with Barany box.
Rinne’s test has a high
specificity for conductive hear-
Table 2: Medical conditions associated with
ing loss, but a low sensitivity.
sensorineural hearing loss
If using a 512Hz tuning fork,
Aetiology Example there needs to be at least a
Hereditary Alport syndrome, Usher syndrome 30dB air-bone gap for Rinne’s
test to be accurate.
General Diabetes, hypertension, Paget’s disease
Weber’s test is performed
Infectious Viral, meningitis, syphilis by striking the tuning fork
Trauma Head injury, barotrauma, noise induced again, this time placing it on
Immune Polyarteritis nodosa, HIV/AIDS the patient’s forehead (figure
5) (the bridge of the nose or
Neurological Multiple sclerosis
apex of the skull may also be
Neoplasm Acoustic neuroma used) and asking the patient
Unknown Ménière’s disease where they hear the sound,
cont’d page 32 Air conduction masking correct
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How to treat – hearing loss in adults

from page 30 Figure 7: Audiograms. A: Normal. B: Conductive hearing loss. C: Presbyacusis. D: Noise-induced hearing loss.
either in the midline, or left or right
ear. A Audiogram B Audiogram C Audiogram D Audiogram
Weber’s test detects the better- Frequency in Hz Frequency in Hz Frequency in Hz Frequency in Hz
hearing cochlea, so it is heard in the -10
250 500 1000 2000 4000 8000
-10
250 500 1000 2000 4000 8000
-10
250 500 1000 2000 4000 8000
-10
250 500 1000 2000 4000 8000
midline in a patient with normal 0 0 0 0

10 10 10 10
hearing. In the presence of a conduc-
20 20 20 20
tive defect it localises towards the
30 Mild 30 30 30
affected ear, and away from an ear

dBHL (re AS1269)

dBHL (re AS1269)

dBHL (re AS1269)

dBHL (re AS1269)

40 40 40 40
with a sensorineural deficit. 50 50 50 50

The exception to this is the patient 60

Moderate 60 60 60
70 70
who has a severe sensorineural hear- 70 70

ing loss in one ear. While Weber’s 80 Severe 80 80 80

90 90 90 90
test correctly localises to the better- 100 100
100 100
hearing cochlea, there is a false-neg- 110
Profound 110 110 110
ative result for Rinne’s test on the 120 120 120 120

affected side because of bone con-

duction across the skull to the better
hearing ear.
Masking the tuning fork with a
Barany box (figure 6) will detect such
a false-negative Rinne’s test. A
Barany box is placed next to the non-
test ear, and produces a broadband
noise with a sound output of about
90dB, which will effectively mask
most ears.
A simpler method of masking can
be achieved by either rubbing the
tragus of the non-test ear, or rubbing
a piece of paper between the thumb
and index finger. Tragal rubbing will
mask noises up to 70dB, which
should be sufficiently loud enough
for most patients.
Imaging studies are generally not
required in the workup of patients
with hearing loss. The exception to
this rule is in patients with a unilat-
eral sensorineural hearing loss or
severe unilateral tinnitus. These
patients should have an MRI to
exclude the presence of an acoustic
neuroma, although this remains an
extremely rare diagnosis.
Audiometry and tympanometry
Pure-tone audiometry testing is used
to measure a patient’s threshold for
hearing. Sound stimuli of varying
intensity (dB) and across various fre-
quencies (Hz) are delivered to the
patient and the results recorded in
graphical form (the audiogram).
A standard scale called ‘decibel
hearing level’ is used in an audio-
gram. This scale is based on ‘aver-
age’ patients, so some individuals
may have hearing ‘better than zero’.
If there is a possibility of a con-
Modality Right Left Modality Right Left Modality Right Left Modality Right Left
Air conduction - Earphones Air conduction - Earphones Air conduction - Earphones Air conduction - Earphones
Unmasked Unmasked Unmasked Unmasked
Masked Masked Masked Masked
Binaural - Sound field Binaural - Sound field Binaural - Sound field Binaural - Sound field
Bone Conduction - Mastoid Bone Conduction - Mastoid Bone Conduction - Mastoid Bone Conduction - Mastoid
Unmasked < > Unmasked < > Unmasked < > Unmasked < >
Masked [ ] Masked [ ] Masked [ ] Masked [ ]
Figure 8: Normal (type A) tympanogram. Flat (type B) tympanogram indicating middle-ear effusion. Left-shifted (type C) not notice much improvement in
tympanogram, indicating eustachian tube dysfunction. their hearing, compared with some-
one with a severe or profound hear-
Type A Type B Type C ing loss after treatment or aiding.
1400 1400 1400 The pattern of hearing loss on
1200 1200 1200 audiological testing can help deter-
mine the underlying cause of hearing
1000 1000 1000 loss. Presbyacusis, the progressive
800 800 800 hearing loss associated with age, has a
600 600 600 downwards-sloping line across the
higher frequencies (figure 7C).
400 400 400
Noise-induced hearing loss also
200 200 200 shows a characteristic pattern of
-400 -300 -200 -100 0 +100 +200 -400 -300 -200 -100 0 +100 +200 -400 -300 -200 -100 0 +100 +200 impaired hearing across the 4-6kHz
range, recovering to a variable degree
at 8kHz (figure 7D).
ductive loss, bone conduction thresh- Speech audiometery can also be Serial audiograms may be used to
olds can also be tested. Masking is performed. This is an alternative monitor the progression of hearing
sometimes applied to the contralat- method of measuring hearing sensi- impairment in patients with poten-
eral ear to give a more accurate result tivity. The patient is asked to identify tially reversible causes of conductive
in the test ear. monosyllabic words that are pre- hearing loss, who are not keen for
All this information is recorded on sented by the audiologist to the surgical intervention.
the audiogram and is important in patient at supra-threshold (or at a Tympanometry is often also per-
interpreting the results of the hearing comfortable hearing) level. formed as part of audiometry testing,
test. Standard symbols are used in Again this information is often pre- to measure the compliance of the
audiology and are shown in figure sented in a graphical form or may tympanic membrane and give an indi-
7. be recorded as a percentage of words cation of the condition of the tym-
To be able to discriminate speech, correctly identified. If there is an air- panic membrane and middle-ear cleft.
people need to be able to hear sounds bone gap (figure 7B), the patient has A normal tympanogram is shown
in the 500Hz to 3kHz frequency a conductive hearing loss. in figure 8A. Patients with middle-
range. A person is considered to have It is important also to consider the ear effusions have flat (type B) tym-
normal hearing if they can detect severity of the hearing loss, as this panograms (figure 8B), while those
sounds of <20dB across a range of can predict whether a patient is likely with eustachian tube dysfunction
frequencies when tested by pure-tone to benefit from treatment. Patients have a curve that is shifted to the left
audiometry. with a moderate hearing loss may (type C tympanogram, figure 8C).

Common causes of hearing loss in adults

Sensorineural hearing
loss
Noise-induced hearing loss
NOISE-induced hearing loss
due to exposure at work,
recreation or in the home is
one of the most common
causes of hearing impairment
worldwide. Although not all
people exposed to loud noise
auditory nerve. It can be Figure 9: Sensorineural hearing loss. also be advised that their ears others retain normal hear-
avoided by use of well-fit- have been shown to be sus- ing, and we cannot predict
ting earmuffs or earplugs, Audiogram ceptible to noise damage and who will be affected.
which reduce the sound that they should wear ear pro- Patients often complain of
Frequency in Hz
intensity levels by 15-25dB -10
tection in other noisy environ- reduced speech discrimina-
on average, usually bringing 0
250 500 1000 2000 4000 8000
ments, such as motor racing tion, particularly in noisy
the noise thresholds back to 10
or rock concerts. Cotton wool environments, in addition to
an acceptable 85dB. placed in the ear is no substi- deafness itself. Presbyacusis
20
As a rule, for every 3dB tute for quality, well-fitting, is sensorineural in origin,
30
increase over 85dB, the max- personal protective equipment and its audiogram is diag-
dBHL (re AS1269)

develop noise-induced hear-
ing loss, there is a strong cor-
relation between prolonged
exposure to noises >85dB
and hearing loss.
People employed in indus-
trial workplaces and wear-
ing no hearing protection are
exposed to noises in the 90-
100+ dB range, with some
hand-operated machinery
producing noise up to
120dB.
The effect of such daily
exposure over several years
is cumulative and can result
in permanent damage to the
40
imum acceptable time to be that complies with Australian nostic (figure 7C).
50
exposed to the noise Safety Standards. Patients with presbyacusis
60
decreases by half. For exam- If noise-induced hearing benefit from hearing aids. In
70
ple, in an 88dB environment loss is due to occupational particular, older patients who
80
a worker has a maximum factors, patients may wish to have not done well with con-
90
exposure time of four hours, obtain legal advice as to ventional analogue hearing
100
and two hours in a 91dB their possible entitlement to aids should be encouraged to
110
environment. compensation, although this be reassessed for digital hear-
Physical examination of 120 is not always easy to prove. ing aids, which can be indi-
the patient with noise- vidually programmed and
Modality Right Left
induced hearing loss is unre- Air conduction - Earphones
Presbyacusis generally give better patient
markable, and the audio- Unmasked Presbyacusis is the progres- satisfaction rates.
gram has a characteristic Masked sive, symmetrical high-fre-
appearance (figure 7D). Binaural - Sound field quency hearing loss that Sudden-onset
Hearing aids may be of Bone Conduction - Mastoid occurs with age. It is not sensorineural hearing loss
Unmasked < >
benefit in correcting the clear why some people Sudden-onset sensorineural
Masked [ ]
hearing loss. Patients should develop presbyacusis while hearing loss is defined as an

32 | Australian Doctor | 31 August 2007 www.australiandoctor.com.au

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abrupt or rapidly progressive
hearing loss of at least 30dB
in three contiguous frequen-
cies (figure 9). It is usually
unilateral and may be asso-
ciated with tinnitus.
Sudden-onset sensori-
neural hearing loss is
believed to be viral in
origin; however, it may
occasionally be due to vas-
cular disease, autoimmune
disease or neurodegenera-
tive diseases. Physical
examination is unremark-
able.
Traditionally, high-dose
oral steroids (prednisolone
1mg/kg for five days in
patients with no con-
traindications to steroids)
have been given to speed
up recovery. More aggres-
sive treatment, such as the
intra-tympanic injection of
steroids, is advocated by a
minority of otologists but
is not standard practice.
Studies suggest that 50-
65% of people will spon-
taneously recover without
any treatment and, despite
numerous studies and a
Cochrane review, there is no
conclusive evidence to prove
that steroids improve the
outcome. Despite this,
because of the devastating
effect of a persistent loss,
most otologists still recom-
mend a short course of
steroids.
In patients for whom
steroids are not contraindi-
cated and who have pre-
sented promptly for assess-
ment (ideally within the first
24-48 hours), an oral course
of prednisolone is recom-
mended, and a phone call
for urgent review and audio-
logical testing made to the
nearest ENT unit.
Acoustic neuroma
Acoustic neuromas are rare,
benign slow-growing tumours
of the auditory nerve that
most commonly present with
a unilateral hearing loss. They
are often asymptomatic but if
large enough they may pre-
sent with imbalance or facial
weakness due to compression
of the facial or vestibular
nerve within the internal audi-
tory canal.
All patients with a unilat-
eral sensorineural hearing
loss on audiological testing
must be referred to an ENT
surgeon for review to
exclude an acoustic neu-
roma.
Convincing, unilateral
persistent tinnitus is also a
rare indication for an
acoustic neuroma screen.
Most acoustic neuromas are
identified while still small
and asymptomatic and are
monitored with MRI scans
on a yearly basis. Active
treatment is either stereotac-
tic radiosurgery or surgical
removal.
Conductive hearing loss
Chronic otitis media with
effusion
While far more common in
children than in adults, some
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Figure 10: Otitis media with effusion. Resolution of OME sec-
ondary to rhinosinusitis or
other nasal pathology can be
hastened by use of topical
nasal corticosteroids (eg,
mometosome, budesonide)
to control the underlying dis-
ease process.
Topical decongestants
should be avoided or at least
limited to a short course
(maximum three days) to
avoid rebound nasal conges-
tion and exacerbation of
Figure 11: Cholesteatoma. symptoms.
In addition, the patient
can be taught the Valsalva
or Frenzel manoeuvres,
which help to open the
nasopharyngeal opening of
the eustachian tube and
assist with drainage of
middle-ear fluid. The Fren-
zel manoeuvre is a modifica-
tion of the Valsalva, in
which the patient swallows
while simultaneously per-
forming the Valsalva
Figure 12: Traumatic perforation of the tympanic membrane. manoeuvre.
Adults with a middle-ear
effusion lasting more than
12 weeks must be referred
to an otolaryngologist for
review to exclude a
nasopharyngeal tumour
obstructing the eustachian
tube orifice.
For a persisting effusion
(with or without eustachian
tube dysfunction) the patient
may be offered a myringo-
tomy and grommet insertion
Figure 13: A: Chronic suppurative otitis media. to restore middle-ear venti-
B: Chronic dry otitis media. lation, improve hearing and
promote resolution of the
A effusion.
Patients with OME who
fly are at risk of barotrauma.
This risk tends to be less in
patients whose middle ears
are completely filled with
fluid (as there is no room for
gases to expand or contract),
compared with those who
have evidence of air-fluid
levels or air bubbles in the
middle ear.
B Ideally patients with an
URTI and evidence of an
effusion should be advised
not to travel because of the
risk of barotrauma. How-
ever, there are some simple
preventive measures patients
can take such as:
■ Chewing gum or yawning
on descent.
■ Valsalva and Frenzel
manoeuvres.
■ Topical nasal deconges-
tants just before take-off
adult patients do present and five minutes before
with reduced hearing and on decent begins.
examination may be found ■ Use of specialised occlusive
to have an effusion (figure ear plugs that allow for the
10) slow equalisation of pres-
Chronic otitis media with sure between the external
effusion (OME) is defined as environment and middle
a persistent effusion lasting ear.
more than 12 weeks. In Patients who travel fre-
most patients (children and quently and experience
adults alike) the effusion will repeated bouts of baro-
improve and disappear com- trauma may benefit from
pletely with time. myringotomy and grommet
In adults OME is most insertion.
likely to be due to associated
rhinosinusitis or other nasal Cholesteatoma
pathology leading to sec- Cholesteatoma is defined as
ondary eustachian tube dys- the presence of squamous
function. Barotrauma caused epithelium in the middle ear
by diving or air travel may or mastoid cavity. It is
also precipitate OME. thought to arise from a com-
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bination of factors, includ-
ing tympanic membrane
retraction due to eustachian
tube dysfunction, and
chronic inflammation of the
middle ear.
Cholesteatomas are most
commonly found in the
superior part of the tym-
panic membrane (pars flac-
cida), although the pars
tensa may occasionally be
involved.
A patient with a choles-
teatoma presents with hear-
ing loss and often recurrent
purulent ottorrhoea. There
may also be associated tin-
nitus. If the cholesteatoma is
extensive it may also pro-
duce imbalance due to
labyrinthine erosion, or a
facial nerve palsy from
inflammation or compres-
sion of the nerve.
On otoscopy a choles-
teatoma is characterised by a
retracted pocket of tympanic
membrane filled with squa-
mous epithelium, which
often has a pearly appear-
ance (figure 11).
The cholesteatoma may
be hidden behind a wax
plug on the tympanic mem-
brane, which requires
gentle ear toilet to remove.
This may need to be per-
formed under direct vision
with a microscope and suc-
tion equipment by an oto-
laryngologist.
Left untreated, choles-
teatomas continue to grow
and invade the middle-ear
structures and can lead to
bony erosion of the ossicular
chain, intracranial extension,
abscess formation or cranial
nerve defects.
The risk of these poten-
tially life-threatening com-
plications means that all
patients with suspected
cholesteatoma must be
referred to an otolaryngolo-
gist for assessment and dis-
cussion of surgical (or occa-
sionally conservative)
treatment options.
Tympanic membrane
perforations
Traumatic perforations of
the tympanic membrane are
usually associated with a
blow to the ear or inadver-
tent placement of a foreign
body in the ear canal. They
present with bloody otor-
rhoea and a conductive hear-
ing loss.
The history is diagnostic
and on examination there
is usually dried blood in the
external auditory canal,
with a perforation visible in
the pars tensa of the tym-
panic membrane (figure
12).
Traumatic perforations
frequently heal completely
within a few weeks and
require no special interven-
tion. However, it is impor-
tant to advise the patient to
take precautions with water
and to not try to clean their
ear, as this may introduce
bacteria into the middle ear,
with subsequent infection. If
the perforation persists at six
31 August 2007 | Australian Doctor |
weeks, it is unlikely to close
spontaneously.
Patients with a long or
recurrent history of middle-
ear infections may have
chronic tympanic membrane
perforations associated with
a conductive hearing deficit.
There may also be a history
of recurrent purulent dis-
charge from the affected ear
(active chronic otitis media
[figure 13A]) or the ear may
be dry (inactive chronic otitis
media [figure 13B]).
These patients will also
benefit from referral to an
otolaryngologist to discuss
surgical options to close the
perforation.
Otosclerosis
Otosclerosis tends to affect
people at an earlier age than
presbyacusis. It is more
common in women and its
typical onset is during the
third or fourth decade. It
presents as a slowly progres-
sive hearing loss that may be
unilateral or bilateral. Bilat-
eral losses are often asym-
metrical.
There may be a positive
family history of otosclero-
sis, and women may find
that the hearing loss wors-
ens when they are pregnant
or using oestrogen therapy
(eg, the oral contraceptive
pill).
The underlying pathologi-
cal process is restricted to
the otitic capsule and results
in fixation of the stapes foot-
plate, leading to a conduc-
tive deafness. Otoscopic
examination is normal, and
serial audiograms show a
progressive hearing loss.
Patients with otosclerosis
should also be referred to an
ENT surgeon for considera-
tion of a stapedectomy to
treat the hearing loss.
When to refer to an
otolaryngologist
Hearing loss in adults is
most commonly due to pres-
byacusis or noise exposure
and may be managed appro-
priately in the community by
GPs in association with
audiologists.
However, any of the fol-
lowing features in the his-
tory and/or on physical
examination of the patient
with hearing loss necessitate
referral to an otolaryngolo-
gist for further investiga-
tion:
■ A chronically discharging
ear.
■ A unilateral or asymmetri-
cal hearing loss.
■ A persistent middle-ear
effusion.
■ A suspicion of choles-
teatoma.
■ Postural imbalance or ver-
tigo.
■ Large exostosis.
■ A conductive hearing loss
and normal physical exam-
ination (for otosclerosis).
■ Non-healing tympanic
membrane perforation.
■ Facial weakness.
■ Unilateral or pulsatile tin-
nitus.
33
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How to treat – hearing loss in adults
Treatment options
Prevention
ADEQUATE, well-fitting
hearing protection is essen-
tial for preventing noise-
induced hearing loss and
should be worn both in the
workplace and during activ-
ities or hobbies that involve
exposure to loud noises.
Avoiding further exposure to
medications known to be
ototoxic is also important in
patients with hearing loss.
Hearing aids
For many patients the fitting
of an appropriately config-
ured hearing aid results in a
significant improvement in ing loss receive the greatest
hearing. Patients with a quality-of-life benefit from
moderate to severe hearing hearing aids, although music
impairment subjectively ben- lovers with high-tone losses
efit more from hearing aids also benefit. The circum-
than those with only mod- stances of each individual
erate impairment. patient need to be assessed
The audiologist plays an before a decision on a hear-
important role in choosing ing aid trial.
the most appropriate type of
hearing aid for the needs of Surgery
a given patient. In general, Depending on the underly-
patients with low-tone hear- ing aetiology, the degree of
Authors’ case studies
Sudden hearing loss in a
45-year-old woman
HR, 45 and with no significant med-
ical history apart from a history of
smoking a pack of cigarettes a day
for 20 years, presents to her GP in a
distressed state. She has woken up
this morning “completely deaf” in
the right ear.
There is no history of preceding
infection, air travel, head trauma or
ototoxic medication use. On exami-
nation there is minimal wax in the
external auditory canal, and a
normal tympanic membrane can be
visualised bilaterally.
The GP performs a screening
hearing test, which confirms a loss
in the right ear, followed by
Weber’s and Rinne’s test, which
confirm the presence of a sensori-
neural hearing loss.
After discussion with the on-call
ENT doctor at the nearest hospital,
HR is started on a course of oral
prednisolone (1mg/kg). She is seen
in the ENT outpatient clinic the next
day and reports no significant
improvement in her hearing.
Pure-tone audiology shows a
60dB right-sided sensorineural hear-
ing loss. The steroids were continued
for 10 days and she was advised to
rest at home. Arrangements were
made to review HR in the ENT
clinic every 48 hours and she was
reassured that many cases sponta-
neously resolve.
A week later there was some
improvement in hearing, which was
confirmed on audiological testing.
Her recovery was monitored through
the ENT clinic and at two months
she had almost fully recovered. How-
ever, an asymmetrical sensorineural
loss persisted on pure-tone audiome-
try.
An MRI of the right internal
acoustic meatus excluded the presence
of an acoustic neuroma. She was fitted
with a unilateral digital hearing aid,
which provided some limited benefit
in stereo sound perception.
34 | Australian Doctor | 31 August 2007
Pa ge 1 8 / 2 3 / 0 7 , 1 : 4 0 PM
Summary
■ Hearing loss is common and often goes undiagnosed or
hearing loss and whether the cells and convert acoustic untreated.
hearing loss is unilateral or impulses to electrical signals ■ Screening for risk factors for hearing loss may allow early
bilateral, some patients may that stimulate the auditory intervention and prevent further impairment (avoiding certain
have deafness that is nerve directly. The signal is medications, noise exposure, etc).
amenable to surgical correc- then transferred to the audi-
■ Otoscopy is an important part of the assessment of hearing
tion. With all surgery to the tory cortex in the usual
loss and often leads to the correct diagnosis.
ear there is the potential to manner, resulting in a
cause irreversible deafness in marked improvement in ■ Appropriately performed and interpreted tuning fork tests are
the operated ear, and this hearing. useful in identifying the underlying type of hearing loss in the
must be taken into consid- Patients likely to benefit absence of easily assessable audiology.
eration before embarking on most from cochlear implants ■ Audiometry identifies type and degree of hearing loss and
surgery. are those with bilateral helps determine the most appropriate treatment (observation,
severe to profound hearing aiding or surgery).
Cochlear implants loss, regardless of age or ■ The most common causes of hearing loss in Australia are
First introduced more than duration of hearing loss. noise induced and presbyacusis — both are amenable to
20 years ago, cochlear However, surgery does entail hearing aids.
implants were initially lim- a 3-4 hour anaesthetic and
■ Consider referral to an otolaryngologist when a patient
ited to post-lingually (after a two-day hospital stay,
presents with hearing loss and there are unusual features on
learning to speak) deaf which require the patient to
the history or examination findings.
adults with severe to pro- be relatively fit.
found bilateral hearing loss Some dizziness or
who derived little benefit unsteadiness on standing is
from hearing aids. As tech- expected in the postopera-
nology and surgical exper- tive period, although this set-
tise improves, more and tles for the most part in the
more patients are now being first week or so. The
considered for cochlear cochlear implant is turned
implants. on 3-4 weeks later and a
Cochlear implants are complex program of audio-
designed to bypass the non- logical rehabilitation then
functioning inner-ear hair begins.
Figure 14: A: HN’s otosclerosis before surgery. B: Stapes prosthesis. ness. She is wondering what the cause
C: Postoperative audiogram. is and if anything can be done about it.
Physical examination, including oto-
A Audiogram C Audiogram scopy was unremarkable. A pure-tone
Frequency in Hz Frequency in Hz audiogram was obtained (figure 14A)
-10 -10
0
250 500 1000 2000 4000 8000
0
250 500 1000 2000 4000 8000 and showed a bilateral, asymmetrical,
10 10
moderate to severe conductive hearing
20 20 loss, which was worse on the left. A
30 30 diagnosis of otosclerosis was made and
dBHL (re AS1269)
dBHL (re AS1269)
40 40 the pathogenesis and likely outcome
50 50
of the condition discussed with HN.
60 60
70 70
Treatment options were also dis-
80 80 cussed, including observation, hearing
90 90 aids and surgical correction by
100 100 stapedectomy. Given her age, degree
110 110 of hearing impairment and desire to
120 120
avoid the use of hearing aids if possi-
Modality Right Left Modality Right Left
ble, the decision was made to proceed
Air conduction - Earphones Air conduction - Earphones with surgery on the left ear (figure
Unmasked Unmasked 14B).
Masked Masked
Binaural - Sound field Binaural - Sound field Postoperatively the patient reported
Bone Conduction - Mastoid Bone Conduction - Mastoid a marked improvement in hearing with
Unmasked < > Unmasked < >
Masked [ ] Masked [ ]
the left ear, which was confirmed on
audiological testing (figure 14C).
B
Hearing loss in an older man
BB, 73, lives independently with his
wife in the community. His only med-
ical problems are hypertension and
diet-controlled prediabetes. He is on
an ACE inhibitor.
BB’s wife reports he has been deaf
for years, and indeed he admits he has
trouble hearing in a range of differ-
ent situations — watching television,
using the phone and in shopping cen-
tres. He has started withdrawing from
social situations because he is embar-
rassed about constantly asking people
to speak louder or to repeat them-
selves.
On examination BB has impacted
Conductive deafness in an and has not been exposed to oto- wax occluding both external auditory
otherwise healthy woman toxic medications in the past. canals, which is removed by micro-
HN is a 37-year-old mother of two. HN was aware that her hearing was suction toilet of the ears. The remain-
She has no significant past medical not as good as her peers, and she now der of the otoscopic examination is
history of note and presents with a reports that the hearing loss is worsen- normal. Online resources
gradual onset of deafness, worse on ing and has started to become intru- A pure-tone audiogram is per- ■ ENT UK:
the left, over several years, which sive. She finds it difficult to hear in formed, which shows a presbyacusis www.entuk.org
had worsened during her last preg- noisy environments, which is starting pattern of hearing loss (figure 7C, page ■ ENT Net:
nancy. There is no family history of to interfere with her ability to work, 32). He is referred to an audiologist www.entnet.org/health
hearing impairment, and HN does and her family members have also for fitting and provision of hearing info
not take any regular medications started to complain about her deaf- aids.
www.australiandoctor.com.au
AD_036___AUG31_07 Page 6 23/8/07 1:28 PM

How to treat – hearing loss in adults

GP’s contribution
She is an ex-smoker with weeks as recommended for emboli or thrombosis, with Should patients with a trau-
well-controlled hypertension this patient, have any benefit resulting ischaemia of the matic tympanic membrane
on telmisartan 80mg daily, over a five-day course? cochlea nerve and associated perforation be given any pro-
and no history of other vas- Conclusive evidence of the deafness. phylactic antibiotics orally or
cular or autoimmune condi- benefit of steroids in treating Established risk factors for as ear drops? I understand
tions. There is a family his- sudden-onset sensorineural ischaemic heart disease (such now that aminoglycoside
tory of presbyacusis in her hearing loss is not available, as hypercholesterolaemia) drops may not be safe in these
mother. with more research needed. have not been confirmed in circumstances.
DR ANN PARKER
On examination, Rinne’s Historically a five-day course patients with sudden-onset Traumatic tympanic mem-
Bowral, NSW
and Weber’s tests indicated a of steroids has been used, with sensorineural hearing loss; brane perforations do not nec-
sensorineural cause, with the Questions for the authors some studies advocating a however, the presentation essarily require prophylactic
Case study Weber’s test localising to the How common is sudden-onset slightly longer tapered course with sudden hearing loss is felt treatment. In the setting of an
JR, 51, presented with a his- right ear. Vestibular system sensorineural hearing loss? In (10-12 days). to be consistent with a vascu- actively discharging ear (acute
tory of sudden onset of hear- and ear examinations were 25 years in practice I had not The side effects of pro- lar insult. otitis media, barotraumas, etc),
ing loss in the early hours of normal. She was diagnosed come across this condition, longed oral steroid medication topical antibiotic drops may
that morning. She had woken with sudden-onset sensori- unless it may have been missed must be considered before General questions for the lead to faster resolution of
with vertigo while lying still neural hearing loss and if patients had not presented embarking on a treatment reg- authors symptoms.
and loud tinnitus. started on prednisone 50mg with the complaint at the time. imen that currently has limited Do you think we will see Perforations due to noise or
Over subsequent hours for 10 days, then 25mg for a Sudden-onset sensorineural evidence of efficacy. fewer cases of cholesteatoma head injury, for example, are
the tinnitus had persisted further two weeks. hearing loss is uncommon and in future because of better often dry and do not require
and her hearing was poor After referral to an ENT the incidence is quoted in the What is the nature of vascu- treatment of middle-ear dis- antibiotics; however, patients
on the left side. She had no surgeon she had an MRI that American literature to be in lar causes of sudden-onset sen- ease in children? should be advised to keep their
further vertigo but felt showed some white-matter the order of 5-20 per 100,000 sorineural hearing loss? As a specialty we have been ear dry and not attempt to
“fuzzy” in the left side of ischaemia, which was people. It is thought that the While the exact aetiology of treating middle-ear disease ear- clean their ear with cotton
her head and unable to thought to be unrelated. Her actual incidence is higher, but vascular causes of sudden- lier and more aggressively over buds that may introduce bac-
think clearly. audiogram 10 days after that many cases go unre- onset sensorineural hearing the past 2-3 decades than pre- teria and subsequent infection
She had no history of any onset showed moderate high- ported. In our teaching hospi- loss is unknown, we do know viously, to address hearing and into the middle-ear cleft.
other hearing problem, head frequency loss. Her hearing tal we have had five cases this that the cochlea is an end speech/language development When there is a perforation,
injury or neurological symp- has improved to about 75% year already. organ with little collateral concerns. As a consequence ciprofloxacin drops should be
tom. Her work is office of normal and tinnitus blood supply, making it vul- the number of cholesteatomas used to avoid ototoxicity,
based and she had had no remains but is no longer at Does a prolonged course of nerable to damage from we are seeing has probably which can occur with topical
real exposure to loud noises. distressing levels. prednisone, such as three vasospasm, hypotension, reached a plateau. antibiotics.

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Hearing loss in adults Photocopy form How to Treat quiz www.australiandoctor.com.au/cpd/
— 31 August 2007 and fax to Reply Paid 60416 for immediate feedback
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1. Which TWO statements about hearing loss 4. You refer Gina for an audiogram and tym- difficulty hearing you and she says she has about middle-ear effusion in adults are
in Australia are correct? panogram. Which TWO statements about been aware of reduced hearing for several correct?
❏ a) Nearly 20% of people aged over 15 are these tests are correct? years. Which THREE factors in the history ❏ a) Effusions in adults are unlikely to resolve on
affected ❏ a) Normal hearing is defined as the ability to would you consider as possibly related to her their own, so patients should be promptly
❏ b) The condition is more common in elderly hear sounds of )5-10dB across the range of deafness? referred for myringotomy
women than men frequencies ❏ a) She suffers from Paget’s disease ❏ b) Barotrauma from diving or air travel can
❏ c) Two of the most common causes are ❏ b) If an air-bone gap is found it indicates that ❏ b) She was given aminoglycoside antibiotics precipitate an effusion
presbyacusis and noise-induced hearing loss Gina has a sensorineural hearing loss for a septic episode four years ago ❏ c) Regular use of decongestant nasal sprays
❏ d) In patients aged over 55 the incidence rises ❏ c) If Gina has a middle-ear effusion she will ❏ c) Her brother has kidney failure and deafness is the best treatment for middle-ear effusion
to over 60% have a type B tympanogram ❏ d) She takes regular NSAIDs for osteoarthritis ❏ d) Patients with evidence of an air-fluid level
❏ d) To hear speech, people need to be able to on otoscopy should be counselled against
2. Gina, 42, presents complaining of hear sounds in the 500Hz to 3kHz range 7. Roman, 52, presents complaining of flying
reduced hearing in her left ear since waking reduced hearing and a smelly discharge from
this morning. She feels otherwise well. 5. Ron, 67, is becoming increasingly deaf in his right ear. The clinical examination 9. Which TWO conditions cause a conductive
Which THREE conditions would you consider both ears. He believes it is due to noise suggests Roman has a cholesteatoma. hearing loss?
in the differential diagnosis for Gina’s exposure in his previous work as a Which THREE statements about this ❏ a) Acoustic neuroma
presentation? boiler-maker. Which TWO statements condition are correct? ❏ b) Otosclerosis
❏ a) Wax in the external auditory canal about noise-induced hearing loss are ❏ a) Typical otoscopy findings include a ❏ c) Tympanic membrane perforation
❏ b) Otosclerosis correct? retraction pocket in the superior tympanic ❏ d) Hearing loss due to high-dose salicylates
❏ c) Sudden-onset sensorineural hearing loss ❏ a) All people who have worked in loud membrane, filled with pearly-looking material
❏ d) Middle-ear effusion after an URTI environments, such as Ron, will have some ❏ b) As cholesteatoma is a slow-growing 10. Which THREE statements about the
noise-induced hearing loss tumour and complications are rare, referral is timing of, and reasons for, referral to an
3. You examine Gina. Which TWO statements ❏ b) Ear protection needs to fit well and be able not necessary otolaryngologist are correct?
about your physical examination are correct? to reduce the sound level to )85dB to prevent ❏ c) Eustachian tube dysfunction is thought to ❏ a) Adults with chronic otitis media with
❏ a) Inability to hear a whisper at a distance of noise-induced deafness be one of the factors involved in formation of effusion should be referred if the problem has
half a metre suggests Gina has a hearing loss ❏ c) Investigations show a high-frequency cholesteatoma not resolved after 12 weeks
of 25dB or worse sensorineural hearing loss and a type A ❏ d) Cholesteatoma causes a conductive ❏ b) Patients with sudden-onset sensorineural
❏ b) The correct tuning fork to use for tympanogram hearing loss, which may be associated with hearing loss should be seen within two weeks
performing Rinne’s or Weber’s tests is 128Hz ❏ d) Hearing aids are of little use in this tinnitus ❏ c) Patients with a unilateral sensorineural
❏ c) If Gina has a conductive deafness in her left condition hearing loss should be referred to exclude
ear, her Rinne’s test will be negative in this ear 8. Elsa, 40, presents with a blocked feeling acoustic neuroma
❏ d) If Gina has a sensorineural deafness in her 6. Lien, 72, presents as a new patient to your and reduced hearing in her left ear for the ❏ d) Patients with a conductive hearing loss and
left ear on Weber’s test the sound will be practice for a prescription of her regular past two weeks. On examination she has a a normal otoscopic examination should be
heard in her left ear medications. You notice that she has middle-ear effusion. Which TWO statements referred for investigation of otosclerosis

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NEXT WEEK The next How to Treat, on adolescent gynaecology, aims to help GPs differentiate normal variations of puberty from true gynaecological problems, so appropriate advice can be given to young
women and their families, and referral for endocrine or gynaecological assessment can occur when needed. The author is Professor Jenny A Batch, director of endocrinology and diabetes, Royal
Children’s Hospital, Herston, Queensland.

36 | Australian Doctor | 31 August 2007 www.australiandoctor.com.au