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  1. Hearing Loss in Primary Care Hearing Loss in Primary Care Aaron C. Moberly, MD Ot l Otolaryngologist Department of Otorhinolaryngology The Ohio State University Wexner Medical Center l i t Overview Overview - Review ear anatomy Review ear anatomy - Evaluation of hearing - Types of hearing loss - Specific causes of hearing loss 1

  2. Normal Ear Anatomy Normal Ear Anatomy Images from Wellcome Images Evaluation of Hearing Evaluation of Hearing • Bedside Testing – Whisper test – Tuning forks (512 Hz): Weber and Rinne • Audiometry • Electrical Tests ABR: Auditory Brainstem – ABR: Auditory Brainstem Response – Otoacoustic emissions • Tympanometry 2

  3. Types of Hearing Loss Types of Hearing Loss • Conductive - Loss at level of external ear or - Loss at level of external ear or middle ear • Sensorineural - Loss at level of inner ear, auditory nerve, or brain y • Mixed - Combination of conductive and sensorineural loss , Weber Test Weber Test • Tuning fork (512 Hz) F h d b • Forehead bone conduction • Patient will hear: – ON side of conductive loss – AWAY from side of sensorineural loss Image from Wellcome Images 3

  4. Rinne Test Rinne Test • Tuning fork (512 Hz) C • Compare bone conduction (mastoid) with air conduction • Patient will hear: – Louder BONE if conductive hearing conductive hearing loss – Louder AIR if normal or sensorineural loss b Images from Wellcome Images Normal Audiogram Normal Audiogram Frequency (Hz) 100 1000 10000 0 ure Level (dB SPL) Sound Pressu 10 20 30 40 50 60 60 70 80 90 100 Right Left Discrimination: R: 96 % L: 100% 4

  5. Sensorineural Hearing Loss Sensorineural Hearing Loss Frequency (Hz) 100 1000 10000 0 0 ) sure Level (dB SPL) Sound Press 10 20 30 40 50 60 60 70 80 90 100 Air Bone Discrimination R: 40 % Conductive Hearing Loss Conductive Hearing Loss Frequency (Hz) 100 1000 10000 0 ure Level (dB SPL) Sound Press 10 20 30 40 50 60 60 70 80 90 100 Bone Air Discrimination R: 96 % L: 100% 5

  6. Causes of C d C d Conductive Hearing Loss: External Ear External Ear Causes of Conductive Hearing Loss: ti ti Cerumen Cerumen Cerumen Impaction or Foreign Body Body Body Body Cerumen Impaction or Foreign Wikimedia Commons Image from Wellcome Images 6

  7. Infectious Disease Disease Infectious – Otitis Externa – Cellulitis – Herpes Zoster (Ramsay-Hunt Syndrome) Wikimedia Commons Congenital Malformation Malformation Malformation of External Ear of External Ear Congenital Malformation Microtia/Atresia Wikimedia Commons 7

  8. Ear Canal Ear Canal Exostoses Exostoses Wikimedia Commons Carcinoma of the Ear Canal Carcinoma of the Ear Canal Image from Wellcome Images 8

  9. Causes of C d C d Conductive Hearing Loss: Middle Ear Middle Ear Causes of Conductive Hearing Loss: ti ti Acute Otitis Media Acute Otitis Media Wikimedia Commons 9

  10. Etiology of Acute Otitis Media Otitis Media Etiology of Acute • S. pneumoniae S. pneumoniae 25% • H. influenzae 20-25% • M. catarrhalis 10-20% • S. pyogenes (gr. A) 2% • S aureus • S. aureus 1% • No growth up to 35% 25% 1% Beta-lactam resistance is growing in all isolates Otitis Media with Effusion Otitis Media with Effusion Wikimedia Commons 10

  11. Medical Treatment of OME Medical Treatment of OME • Observation A tibi ti • Antibiotics – Beneficial short-term resolution of OME – Unclear long-term impact A di t 3 • Audiogram at 3 months with persistent effusion • Follow -up every 6 weeks th ith Complications of Otitis Media Complications of Otitis Media Wikimedia Commons Image from Wellcome Images 11

  12. Otitis Media Otitis Media • When to refer to Oto-HNS? 3 b t AOM i 6 – 3 bouts AOM in 6 months – 4 bouts AOM in 12 months – Chronic OME >3mos, hearing loss, speech delay Complication – Complication – Earlier if anatomic or immune problem th Hemotympanum Hemotympanum Wikimedia Commons 12

  13. TM Perforation TM Perforation Wikimedia Commons Cholesteatoma Cholesteatoma Wikimedia Commons 13

  14. Otosclerosis Otosclerosis Wikimedia Commons Causes of Sensorineural Sensorineural Sensorineural Hearing Loss: Inner Ear or A dit A dit Auditory Nerve Auditory Nerve Causes of Sensorineural Hearing Loss: Inner Ear or N N 14

  15. Presbycusis Presbycusis Wikimedia Commons Sudden Sensorineural Hearing Loss Sudden Sensorineural Hearing Loss Frequency (Hz) 100 100 1000 1000 10000 10000 d Pressure Level (dB Sound 0 10 20 30 40 50 60 70 80 90 SPL) Right Left Discrimination: R: 96 % L: 72% 100 15

  16. Sudden Sensorineural Hearing Loss Sudden Sensorineural Hearing Loss Viral? … Vascular? … Autoimmune? R l f Thi d Rule of Thirds 1/3 full recovery 1/3 partial recovery 1/3 permanent hearing loss (15% progressive) progressive) WITHOUT INTERVENTION EARLY STEROID THERAPY Noise Induced Hearing Loss Noise Induced Hearing Loss • Related to intensity, duration, and frequency of noise exposure • May affect the ears asymmetrically • Sustained work day (8-hour) exposures >85 dB require the hearing protection and annual audiograms annual audiograms • Initially affects the 3000-4000 Hz frequency range 16

  17. Noise Induced Loss Noise Induced Loss Frequency (Hz) 100 1000 10000 B ressure Level (dB Sound P 0 10 20 30 40 50 60 70 80 90 100 SPL) Early Later Later Discrimination: Early: 96 % Later: 72% Vestibular Vestibular Neuronitis/Labyrinthitis Neuronitis/Labyrinthitis • Put simply, “ “an inner ear infection” ” • Usually viral. Treated symptomatically. Steroids may help. Antibiotics not usually required. May takes weeks to resolve. • Labyrinthitis causes hearing loss and vertigo. Hearing loss can be permanent. 17

  18. Meniere’ ’s Disease Meniere’ ’s Disease • Episodic vertigo, tinnitus, aural fullness & hearing loss Treatment: low salt diet, Treatment: low salt diet, thiazide diuretics and PRN vestibular suppressants. Other interventions: transtympanic gentamicin/steroid injection, endolymphatic shunt surgery, e do y p at c s u t su ge y, labyrinthectomy, or vestibular nerve section Up to 30% bilateral • • • Wikimedia Commons Acoustic Neuroma/Vestibular Schwannoma Schwannoma Acoustic Neuroma/Vestibular T1 post-contrast MRI • 8th cranial nerve • Hearing loss, tinnitus, g & disequilibrium early • Facial numbness, facial weakness, hydrocephalus late • 5% are associated with Type II Neurofibromatosis • Tx: Surgery, gamma knife, observation Wikimedia Commons 18

  19. Summary Summary - Review ear anatomy Review ear anatomy - Evaluation of hearing - Types of hearing loss - Specific causes of hearing loss Hearing Loss for Primary Care Physicians Primary Care Physicians Hearing Loss for Laura Feeney, Au.D. A di l Audiologist Department of Otolaryngology The Ohio State University Wexner Medical Center i t 19

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  21. Medical Clearance Medical Clearance • Medical Clearance is required prior to a patient being fit with hearing aids patient being fit with hearing aids. • Medical Clearance may be obtained 3 ways – Evaluation by an ENT/Otologist – Evaluation by PCP provided results do Evaluation by PCP, provided results do not warrant referral to an ENT – Patient Medical Waiver 21

  22. What to look for when giving medical clearance for amplification amplification What to look for when giving medical clearance for • Asymmetrical air conduction thresholds • Conductive component of hearing loss – ‘air-bone gap’ • Asymmetrical speech discrimination • Chronic middle ear disease A i l i d i h h ld Hearing Aids : Factors to consider Hearing Aids : Factors to consider • Age of patient • Dexterity • Dexterity • Severity/configuration of hearing loss • Cosmetics • Battery life • Anatomy of the patient’s ear 22

  23. Styles of Hearing Aids Styles of Hearing Aids Completely-In-The Canal (CIC) In-The-Canal (ITC) In-The-Ear (ITE) Behind-The-Ear (BTE) Photos courtesy of Phonak ‘Open Fitting’ Hearing Aids ‘Open Fitting’ Hearing Aids • Appropriate for hearing loss that is normal/mild in the low frequencies. • Inappropriate if much gain is needed at 250- 500H 500Hz – Can be coupled to an earmold, however to give low frequency gain • Designed to eliminate the occlusion effect and improve cosmetics Photos courtesy of Phonak 23

  24. Newer Features in Hearing Aids Newer Features in Hearing Aids • In some advanced level products the following features are now available: g – Wireless connectivity between ears – Automatic program changes – Better feedback control Adaptive directionality – Adaptive directionality – Wireless connectivity to bluetooth devices Bluetooth compatibility Bluetooth compatibility • Some hearing aids now have capability to connect with bluetooth devices • Phone compatibility • TV compatibility Photos courtesy of Phonak 24

  25. CROS/BICROS amplification CROS/BICROS amplification • For use when one ear is not aidable • Transmitter on the poorer hearing ear • Receiver and hearing aid on the better hearing • Receiver and hearing aid on the better hearing ear • Wireless communication Photos courtesy of Phonak FM System FM System • Transmitter • Receiver • Options for CI/BAHA Photos courtesy of Phonak and Cochlear Americas 25

  26. When hearing aids are not enough not enough When hearing aids are Cochlear implants and bone • Cochlear implants and bone anchored hearing solutions are options for patients who cannot benefit from traditional amplification • What are bone anchored hearing solutions? – Bone anchored hearing solutions are surgically implanted devices that transmit sound via bone conduction bypassing the middle ear to a normally hearing cochlea (either ipsi or contralaterally). – Often referred to as BAHA Often referred to as BAHA – Implications for single sided deafness and conductive/mixed hearing losses that cannot be conventionally amplified. 26

  27. BAHA Candidacy BAHA Candidacy • Single Sided Deafness – Poorer ear- Profound SNHL – Good Ear- PTA AC threshold ≤20dB @ 500, 1000, 2000, and 3000Hz • Mixed/Conductive – PTA BC threshold ≤65dBHL @500, 1000, 2000, 3000Hz. BAHA BAHA Photos courtesy of Cochlear Americas 27

  28. Cochlear Implant Cochlear Implant • Consists of an external speech processor and a surgically implanted device • Electrode implanted in the hl cochlea to electrically stimulate the nerve t Photos courtesy of Cochlear Americas Cochlear Implant Candidacy- Children Cochlear Implant Candidacy- Children • Profound sensorineural hearing loss bilaterally – Age 12-24 months • Severe to profound sensorineural hearing loss – Age 2-17 years • Limited benefit from binaural amplification trial 28

  29. Cochlear Implant Candidacy- Adults Cochlear Implant Candidacy- Adults • Moderate to profound i sensorineural hearing loss bilaterally • Limited benefit from amplification defined by preoperative sentence y p p recognition scores l h i l Watch out for: Watch out for: • Cochlear Implant Patients – Redness at magnet site • Hearing Aid Patients – Otitis Externa caused by earmold closing off ear canal • BAHA – Skin overgrowth at abutment site Ski th t b t t it • Patients who have hearing concerns 29