Dr.

Abdur Rehman
Hearing loss/
Associate Professor
Deafness ENT
 Clinical Scenario
• A 19 year old girl presented to the ENT specialist
because of bleeding from the right ear, impairment
of hearing and tinnitus following a slap on the right
ear one hour before.
• Examination showed a bluish coloration along the
handle of the malleus and a central anteroinferior
perforation with irregular contused edges.
• Tuning fork testing revealed Rinne test negative in
the right ear and Weber lateralized to the right ear.
• What is the most likely diagnosis in this case?
• What is type of hearing loss?
 Learning objectives
By the end of this lecture, students of 3rd year MBBS
should be able to
• Classify deafness.
• Enumerate causes of conductive deafness in external
and middle ear.
• Enumerate causes of sensorineural hearing loss.
• Define tinnitus.
• Explain the effects of tinnitus.
• Explain the effects of loud sounds in presbycusis.
• Explain the effect of sensorineural hearing loss in
understanding speech.
 DEFINITIONS
HEARING LOSS:
Complete or partial loss of the ability
to hear from one or both ears.
The level of impairment can be mild,
moderate, severe or profound.
DEAFNESS :
Complete loss of ability to hear from
one or both ears.
 Types of Hearing Loss
• Conductive Two main
• Sensorineural categories:
• Mixed
Conductive
• Functional hearing loss
• Central
Sensorineural
hearing loss.
 Types of Hearing Loss
Conductive Hearing Loss

Happens when sound wave can't reach internal

ear, due to defect in the conducting mechanism
of the ear
• Affected outer or middle Ear
 Conductive Hearing Loss
Outer Ear - Causes
Anotia
Microtia
Wax
Otitis Externa
Otomycosis
Exostoses
Osteoma
Atresia
Stenosis
 Conductive Hearing Loss
Middle Ear – Causes
• Broken/Fixed
Ossicles – malleus,
incus and stapes ( e.g
otosclerosis)
• Traumatic
perforation of
tympanic membrane
• Tympanosclerosis
 Conductive Hearing Loss
Middle Ear – Causes
• Otitis media
• Otitis media with effusion
• Acute suppurative otitis
media
 Conductive Hearing Loss
Middle Ear – Causes
Chronic s.o.m -
Cholesteatoma
• Eustachian tube not
opening and closing
properly
– Cold or catarrh
– Allergic reaction
• Neoplasms
 Sensori-neural Hearing Loss
Affected inner ear(cochlea), auditory nerve
Occurs either the hair cells in the cochlea or the
nerve to the brain are damaged
Sound has not been passed onto the auditory
centre in the brain
Causes of Sensori-neural Hearing Loss
Local causes (inner • Infections:
ear)
• Mumps, syphilis,
• Congenital: tuberculous
• Trauma: meningitis, enteric
• Head injury fever, labyrinthitis.
• Surgical trauma to • Tumours:
labyrinth, • Acoustic neuroma
• Loud sounds • Meniere’s disease
(acoustic trauma/ • Ototoxic drugs:
noise induced hearing
• Streptomycin,
loss).
Kanamycin,
neomycin, salicylates,
 Causes of Sensori-neural Hearing Loss
General causes
Psychogenic
• Presbycusis deafness:
• CVS: atherosclerosis, • Functional: due to
HTN emotional cause, but
• CNS: Multiple the patient is not
aware.
sclerosis
• Malingering: non-
• DM organic. The patient is
• Hypothyroidism aware that he is
• Smoking pretending to be deaf
for personal gains.
• Alcoholism
Causes of Sensori-neural Hearing Loss
• Developmental/Congenital
: present at birth
Common causes:
– Genetic disorders
– Syndromic or Non-syndromic
May be
– Autosomal dominant
– Autosomal recessive
– Non-genetic disorders
– Prenatal- maternal infections (TORCHES),
drugs, radiation, alcoholism
– Perinatal- anoxia, sepsis, ototoxic drugs,
prematurity, Rh incompatibility
 Causes of Mixed Hearing Loss

• Trauma:
 Blast injury(acoustic trauma)
 Head injury.
• Chronic Suppurative Otitis Media.
• Otosclerosis
• Senile deafness superimposed on conductive
deafness.
 Sudden SNHL
Etiology
• Defined as 30 dB or  Vascular
more sensorineural
 Viral
hearing loss over at
least three contiguous  Trauma
audiometric  Head injury
frequencies occurring  Barotrauma
within 3 days or less.  Perilymph fistula
• Mostly unilateral  Meniere’s disease
 Acoustic neuroma
 Immune complexes
 Investigation of SNHL.
History: detailed. MRI brain
Clinical examination Blood investigations:
 Otoscopy  CP and ESR
 Random Glucose
 Cranial nerves :5th
 Lipid profile
,7th ,8th.
 Thyroid function
Cerebellar function test
tests  VDRL.
Tuning fork tests,
PTA.
 QUESTION ?

In a patient with retracted ear drum you

expect to find
a. Conductive hearing loss
b. Sensorineural hearing loss
c. Mixed hearing loss
d. Non-organic hearing loss
e. No hearing loss
 QUESTION ?

• Which of the following is a cause of

conductive hearing loss?
a. Old age
b. Acoustic neuroma
c. Loud sound
d. Meniere’s disease
e. Rupture of tympanic membrane
 Tinnitus Introduction
• Tinnitus is defined
as the aberrant
perception of sound
without any external
stimulation.
• The word tinnitus
originates from the
Latin tinnire, which
means ‘ring, jingle or
clink’
 Types of Tinnitus

• Objective: caused by sounds generated

somewhere in the body

• Subjective: perception of meaningless

sounds without any physical sound being
present

• Auditory hallucinations: perceptions of

meaningful sounds such as music or
speech
 Tinnitus Causes
• Noise exposure
• Medication
• Infection
• Older age hearing loss
• Meniere’s Disease
• Outer/Middle ear disease
• Acoustic neuroma
• Unknown (by far the most common)
 Effects of Tinnitus

• Concentration
• Hearing
• Insomnia
• Psychological
 Tinnitus Treatment
• Basic advice
• Hearing Aid
• Tinnitus Masking Device
• Tinnitus Instrument
• Tinnitus Retraining Therapy
• Psychological Treatment
• Medication
 Tinnitus Basic Advice
• Reassurance
• The first step is to understand the problem
• Avoid aggravating factors eg. noise,
NSAIDs
• Decreased intake of stimulants eg.
caffeine and nicotine
• Relaxation
• Avoiding silence
• White noise eg. Detuned radio
 Difference of
Conductive&Sensorineural Hearing Loss
Conductive Sensory Neural

1. Medical and No cure in most cases,

Amenable surgical there may be an
to treatment procedures improvement in some
can be patients if diagnosed
effective. and treated early.
Rehabilitation (Hearing
Aids & Cochlear
implant) is an option.
 Difference of
Conductive&Sensorineural Hearing Loss
Conductive Sensory Neural

2. Usually there is Usually the loss of

Characteristic loss for low hearing for high
s of hearing frequency frequencies is
loss sounds. greater than for
Usually a mild to low frequency
moderate degree sounds.
of hearing loss Hearing loss (may
(not more than exceed 60 dB )
60 dB). can range from
mild to profound.
Various positions of tuning fork
during tuning fork tests
At the opening of EAC

Midline of skull
On mastoid
Tuning fork test
 Difference of
Conductive&Sensorineural Hearing Loss
Conductive Sensory Neural

3. Negative Rinne’s Positive Rinne test

Hearing test Weber lateralized to
tests Weber lateralized better hearing ear
to poor hearing ear Bone conduction is
Normal (ABC) reduced on ABC
absolute bone test
conduction
PTA shows air No air bone gap on
bone gap audiometry (PTA)
Hearing loss is More often involving
more in low high frequencies
frequencies
Conductive Hearing loss Sensorineural Hearing loss
Conductive Hearing Loss
Sensori-neural Hearing Loss
 Difference of
Conductive&Sensorineural Hearing Loss
Conductive Sensory Neural
4. How Usually there is Distortion in the
speech is minimal distortion perception of
heard in the perception of speech. (Poor
the speech signal speech
(that is Good discrimination).
speech Recruitment
discrimination). phenomenon.
Hearing aids sound Hearing aids sound
very clear. somewhat distorted,
but are necessary.
 QUESTION ?
In a patient with conductive deafness, there
will be
a. Rinne’s test positive
b. Rinne’s positive and Weber lateralized to
poorer ear
c. Rinne’s positive and Weber lateralized to
good ear
d. Rinne’s negative and Weber lateralized to
poorer ear
e. Rinne’s negative and Weber lateralized to
good ear
 QUESTION ?
Which of the following is a cause for
sensorineural hearing loss?
a)Otitis media
b)Otosclerosis
c)Noise-induced hearing loss
d)Perforation of the tympanic membrane
e)Ossicular chain disruption
 Case 1
• A 68 years old retired bank manager
• Progressive bilateral hearing impairment
for the last few years.
• Marked difficulty in understanding speech
especially in the presence of background
noises.
• He also has ringing sounds in both ears
• His external ears and tympanic
membranes appeared to be normal.
 Case 1-cont.
• Rinne test was
positive in both the
ears,
• Weber test was
centralized and ABC
test was less than the
examiner in both
ears.
• Pure tone audiogram
• Diagnosis?
 Clinical Scenario
• A 19 year old girl presented to the ENT specialist
because of bleeding from the right ear, impairment
of hearing and tinnitus following a slap on the right
ear one hour before.
• Examination showed a bluish coloration along the
handle of the malleus and a central anteroinferior
perforation with irregular contused edges.
• Tuning fork testing revealed Rinne test negative in
the right ear and Weber lateralized to the right ear.
• What is the most likely diagnosis in this case?
• What is type of hearing loss?
• What investigations will you do?
Pure Tone Audiometry
 Take home message
• It is important to differentiate between
conductive and sensorineural hearing loss,
the two main types of hearing loss.
• Tinnitus is a common condition
• Basic advice and counseling as well as
empathic support is paramount
• More severe cases may require
psychological support, masking devices or
Tinnitus Retraining Therapy