HEARING IMPAIRMENT

AND
PERIPHERAL VESTIBULAR
DISORDERS

dr. Mukhlis Imanto Mkes. Sp.THT-KL

DEPT. OF ORL HNS ABDUL MOELOEK

GENERAL HOSPITAL / LAMPUNG UNIVERSITY
LAMPUNG
2015 Page 1
HEARING IMPAIRMENT

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 DEFINITION

Hearing impairment any degree and

type of auditory disorder.

Deafness an extreme inability to

discriminate conversation speech through
the ear.

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 HEARNG LOSS

The timing of the hearing loss :

Congenital present at birth.
Acquired :
Later in life.
Sudden or progressive.

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 TYPE OF HEARING IMPAIRMENT

Hearing
Impairment

Conductive Sensorineural Mixed

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 CONDUCTIVE IMPAIRMENT

A defect in the auditory system which interferes

with sound waves reaching the cochlea.
The outer or middle ear.

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 CAUSE of CONDUCTIVE
HEARING LOSS
The most common in kids and teens otitis media.
A buildup of fluid or pus behind the eardrum block the
transmission of sound.
If fluid goes away hearing returns to normal.
Blockages in the ear a foreign object, impacted earwax or
dirt.
A tear or hole in the eardrum interfere vibrate properly.
Etiology : inserting an object into the ear, a sudden
explosion or other loud noise, a sudden change in air
pressure, a head injury, or repeated ear infections.

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Page 8
Normal Eardrum

Otitis Media

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 Sensorineural Hearing Loss

Defect in the inner

ear or connection
to brain
Loss can be
complete
Loss greater at
high frequencies

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Sensorineural Hearing Loss

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 CAUSE of SENSORI NEURAL
HEARING LOSS
Genetic disorder development of the inner ear and the
auditory nerve.
Injuries to the ear or head.
Complications during pregnancy or birth.
Infections or illnesses development of the inner
ear.
Premature babies.

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 CAUSE of SENSORI NEURAL
HEARING LOSS
Infections or illnesses.
Repeated ear infections
Brain tumors
Damage the structures of the inner ear.
Medications.
Some antibiotics
Chemotherapy drugs
Loud noise.
A sudden loud noise or exposure to high noise levels over time
permanent damage to the tiny hairs in the cochlea
Can't transmit sounds effectively

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 RISK FACTORS

Risk factors for congenital loss are:

1. Family history of hereditary loss.
2. Prematurity, with birth weight less than approximately 1.5
kg.
3. Maternal rubella during pregnancy.
4. Maxillofacial deformities.
5. Kernicterus, with bilirubin levels greater than 12mg/dl.
6. Neonatal sepsis, especially with meningitis.
7. Forceps delivery, with temporal bone injury.

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 Mixed Hearing Loss

Mixed impairments involve both conductive and

sensorineural defects.
Hearing impairments after 19 years of age do not
seem to severely affect speaking ability and
language.
Hearing losses occurring from birth to 19 years of
age prevocational deafness or prelingual
deafness.

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 Children with a hearing difficulties
may have problems with :

Entering into a group, requesting, responding

and taking turns
Initiating conversations
Understanding subtle social rules
Accepting others points of view and others
feelings
Monitoring the listener

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 SPEECH FREQUENCIES

Speech frequencies range from 250 to 8000 hertz.

A pure tone audiogram tests the patients hearing at

the intervals of 250, 500, 1000, 2000, 4000, and 8000
hertz for each ear.

Normal hearing is defined as hearing the above hertz

at or below 25 decibels.

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 How Do Doctors Diagnose It?

History taking
Physical examination
Ancillary test
Hearing test
Radiology Examination

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 How Do Doctors Diagnose It?

Difficult to diagnose in infants and babies.

Screened before leave the hospital.
Sometimes parents notice her baby doesn't
respond to loud noises or to the sound of
voices.

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 HEARING TEST

1. Subjective

2. Objective

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 SUBJECTIVE HEARING TEST

1. Whisper test
2. Tuning fork Test
3. Pure tone Audiometry
4. Special audiometry : SISI, ABLB, Tone Decay
5. Behavioral Observational Audiometry (BOA)
6. Visual Reinforcement Audiometry (VRA)
7. Play Audiometry
8. Speech Audiometry

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 OBJECTIVE HEARING TEST

Ottoacustic Emission (OAE)

Brainstem Evoked Response Audiometry
Auditory Steady State Response (ASSR)
Acoustic Immitance Tests:
Tympanometry
Eustachian tube function
Acoustic reflex thresholds
Acoustic reflex decay

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 AUDIOMETRY

Measures hearing threshold

Subject wears headphones
Send pure tone to one ear at
audible level
Decrease level until subject
cant hear it
Repeat at other (standard)
frequencies

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 AUDIOGRAM

For children, hearing threshold levels exceeding 15 dB should

be considered abnormal. Page 24
 AUDIOGRAM of NORMAL
HEARING
-10

0
Hearing loss (dB)

10

20

30 left ear
right ear
40

50
125 250 500 1k 2k 4k 8k

Frequency (Hz)

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 AUDIOGRAM
CONDUCTIVE HEARING LOSS

BC threshold within
normal limits (0-20 Db)

AC Threshold Increased

BC-AC gap > 10 db

Gb. Gangguan dengar

konduktif

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 AUDIOGRAM
SENSORI- NEURAL HEARING LOSS

Increased BC thresholds

Increased AC thresholds

BC-AC gap < or = 10 db

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 AUDIOGRAM
SENSORI- NEURAL HEARING LOSS

Presbikusis

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 AUDIOGRAM
NOISE INDUCED HEARING LOSS
(NIHL)

Decreased hearing (increased

threshold levels) at higher
frequencies (3000- 6000 hz)
Usually starts with a dip at
4000 hz

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 TYMPANOMETRY

The dynamic recording of middle-

ear impedance / air pressure
in the ear canal
A sensitive measure of the integrity
of the tympanic membrane and of
middle-ear function.
Compliance of the middle ear
the vertical dimension of a
tympanogram

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 OTOACOUSTIC EMISSIONS

Newborn hearing screening.

Advantage :
The noninvasive .
Accuracy and objectivity in assessing cochlear, especially outer
hair cell.
OAEs may be recorded in severely impaired auditory function
mass lesion on the auditory nerve or auditory neuropathy.

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 AUDITORY BRAINSTEM RESPONSE

Inexpensive and sensitive initial evaluation.

Electrophysiologic recordings.
Activation of all levels of the auditory system, from
cochlea to cortex.
Estimation of hearing sensitivity in infants and young
children.

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AUDITORY BRAINSTEM RESPONSE

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 How Is It Treated?
Depending upon etiology.
Treatment :
Removing wax or dirt from the ear.
Treating an underlying infection.
Hearing aid or cochlear implant problem in the
cochlea or hearing nerve.
Surgery damage or a structural problem with the
eardrum or ossicles.

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TREATMENT OF HEARING IMPAIRMENT

Inflammation of middle ear

1. Medicamentous
2. Surgery
Mastoidectomy
Tympanoplasti

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 TREATMENT OF HEARING IMPAIRMENT

Sensorineural hearing loss :

Hearing aids
Cochlear implant
Special education SLB B
Speech therapy
Counseling

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 HEARING AIDS

Make sounds louder

hear clearly.
Various forms fit inside
or behind the ear.
In profound the hearing
loss a cochlear implant
recommendation.

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 COCHLEAR IMPALNT

Surgically implanted devices.

Bypass the damaged inner ear and send signals
directly to the auditory nerve.
These signals perceived as sound and allow the
person to hear.

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Can I Prevent Hearing Impairment?

Many cases of hearing loss or

deafness are not preventable.
Noise-induced hearing loss can be
prevented.
Any sounds over 80 decibels
considered hazardous with
prolonged exposure.
Like loud music, sirens and
engines.

Page 39
 Some ways to reduce it.
Turn down the volume on
your stereo, TV, headset on
your Walkman or CD player

Wear earplugs if going to a

loud concert and while
working around loud noise
such as power tools,
jackhammers.

See your doctor right away if

suspect any problems with Get your hearing tested on a
hearing. regular basis

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PERIPHERAL VESTIBULAR
DISORDERS

Page 41
 INTRODUCTION
Millions of people present annually to their
physicians with the complaint of dizziness
Dizziness is subjective sensations that usually
result from a disease of the vestibular system
Dizziness may be caused by :
poor vision, decreased proprioception (diabetes
mellitus), cardiovascular insufficiency, cerebellar
or brainstem strokes, neurologic conditions
(migraines, multiple sclerosis), metabolic
disorders, and side effects of medications

Johnson J, Lalwani AK. Menieres . Ballengers Otorhinolaryngology

Chapter 20. 2003 BC Decker Inc. Page 42
 ETIOLOGY
Peripheral vertigo Central & systemic vertigo

Benign Paroxysmal Positional Vertigo Multiple sclerosis

(BPPV)
Menieres Disease Other neurologic disorders (stroke,
seizures, middle cerebellar lesions,
parkinsonism, pseudobulbar palsy)
Vestibular Neuritis Metabolic disorders (hypo/hyperthyroidism,
diabetes)
Perilymphatic Fistula Medications & intoxicants (psychotropic
drugs, alcohol, analgesics, anesthetics,
antihypertensives, antiarrhytmics,
chemotheurapeutics)
Cerebellopontine Angle Tumors Vascular causes (vertebrobasilar
insufficiency, basilar migraine syndrome,
vascular loop compression syndrome)
Otitis Media

Traumatic Vestibular Dysfunction

MD, Pasha, Otolaryngology-HNS, Clinical Reference, 2006

Page 43
 DIFFERENTIAL DIAGNOSIS
General characteristics of peripheral & central cause of vertigo

Characteristics Peripheral Central

Intensity Severe Mild

Fatigability Fatigues, adaptation Does not fatigue

Associated Nause, hearing loss, sweating Weakness, numbness,

symptoms falls more likely

Eye closure Symptoms worse with eyes Symptoms better with

closed eyes closed

Nystagmus Horizontal, may be unilateral, Vertical, bilateral

rotary

Occular fixation Suppresses nystagmus (may not No effect or enhances

suppress during acute phase) nystagmus

MD, Pasha, Otolaryngology-HNS, Clinical Reference, 2006 Page 44

 ANATOMY - PERIPHERAL VESTIBULAR SYSTEM

Page 45
Probst-Grevers-Iro, Basic Otorhinolaryngology, 2006 Modul Ilmu Kesehatan THT-KL, 2008
 ANATOMY - PERIPHERAL VESTIBULAR SYSTEM

Types of hair cell bodies: type I (chalice) & type II (cylindrical)

Type I & type II are not evenly distributed throughout the neuroepithelium
of either the semicircular canal ampullae/the utricular maculae

Modul Ilmu Kesehatan THT-KL, 2008 Page 46

PHYSIOLOGY VESTIBULAR ORGAN

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BENIGN PAROXYSMAL POSITIONAL VERTIGO

First recognized by Barany in 1921

Further characterized by Dix and Hallpike in
1952

Epidemiology:
- The incidence may range from 10 to 100
cases per 100.000 persons per year.
- Men = women
- Average age presentation is in 5th decade.
Johnson J, Lalwani AK. Menieres . Ballengers Otorhinolaryngology
Chapter 20. 2003 BC Decker Inc. Page 48
BENIGN PAROXYSMAL POSITIONAL VERTIGO

Most common cause of peripheral vertigo

Cause: spontaneous, post-traumatic &
postviral (labyrinthitis, vestibular neuritis)
Typically self-limiting, may have recurrent
episodes

MD, Pasha, Otolaryngology-HNS, Clinical Reference, 2006 Page 49

BENIGN PAROXYSMAL POSITIONAL VERTIGO
Signs & symptoms:
Recurrent episodes of brief (lasting
seconds-minutes)
Positional vertigo (turning over in bed,
getting up, turning the head, bending over,
looking up)
Nausea& prolonged light-headedness
Induced positional nystagmus is torsional
(rotary to the downward side)
Typically exhibits a latency of 2-15
seconds with a crescendo & decrescendo of
nystagmus associated with vertigo, fatigable
& transient
Page 50
MD, Pasha, Otolaryngology-HNS, Clinical Reference, 2006
 BENIGN PAROXYSMAL POSITIONAL VERTIGO
Pathophysiology Theories
Free-floating debris (dislodged otoconia) in the
endolymph of the posterior canal moves when placed in a
dependent position
The inertial drag of the endolymp displacement of the
Canalithiasis cupula in latent vertigo which resolves the debris
theory settles

Debris (Ca carbonate) adheres to the cupula of the SCC

in an ampulla gravity sensitive (objection to theory
include no account for the transient nature of vertigo & the
Cupulolithiasis torsional nystagmus exhibited in BPPV)
theory

Page 51
MD, Pasha, Otolaryngology-HNS, Clinical Reference, 2006
BENIGN PAROXYSMAL POSITIONAL VERTIGO

Diagnostic Evaluation

- Dix Hallpike Test

Observing a characteristic nystagmus
- Imaging
MRI with gadolinium contrast to evaluate brainstem,
CPA(Cerebellopontin Angle) and IAC (Internal Auditory
Canal). For :
- Patients who do not have the characteristic nystagmus
- Have associated neurologic finding
- Do not respond to treatment

Johnson J, Lalwani AK. Menieres . Ballengers Otorhinolaryngology

Chapter 20. 2003 BC Decker Inc. Page 52
 BENIGN PAROXYSMAL POSITIONAL VERTIGO
Management
Education, reassurance & observation
Particle Repositioning Maneuver (Epley
Maneuver)
Home vestibular positional exercise induce
vertigo to stimulate vestibular compensation
Antivertiginious medications
Singular neurectomy: transection of the
nerve to the posterior SCC
Posterior SCC occlusion: occludes
ampullated end to prevent movement of
endolymph
MD, Pasha, Otolaryngology-HNS, Clinical Reference, 2006
INSTRUCTIONS FOR PATIENTS
AFTER OFFICE TREATMENTS:
Wait for 10 minutes after the
maneuver is performed before going
home
Sleep semi-recumbent for the next two
nights
For at least one week, avoid provoking
head positions
At one week after treatment, put
yourself in the position that usually
makes you dizzy
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BENIGN PAROXYSMAL POSITIONAL VERTIGO
Particle Repositioning Maneuver (Epleys Maneuver)

Series of head
positioning
completed in the
office, based on
repositioning
free-floating
particle in the
posterior canal
requires
patient to be
upright after
repositioning for
48 hours

Modul Ilmu Kesehatan THT-KL, 2008 Page 54

THANKS
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