Chapter 4: Hearing Assessment

Types of Hearing Loss

1. Conductive Hearing Loss

o Cause: Issues in sound conduction (external ear to inner ear)
o Sites: External ear (obstructions), tympanic membrane (perforation),
middle ear (fluid), ossicles (fixation/disruption), eustachian tube
(obstruction)
2. Sensorineural (SN) Hearing Loss
o Cause: Lesions in cochlea (sensory) or VIIIth nerve (neural)
o Types: Cochlear, retrocochlear (VIIIth nerve), central (auditory
connections)
3. Mixed Hearing Loss
o Features: Both conductive and SN elements
o Examples: Otosclerosis, chronic otitis media

Key Aspects in Assessment

 Type: Conductive, SN, or mixed

 Degree: Mild, moderate, severe, profound, total
 Site: External ear, tympanic membrane, middle ear, cochlea, VIIIth nerve
 Cause: Congenital, traumatic, infective, neoplastic, metabolic, ototoxic,
vascular

A. Clinical Tests of Hearing

1. Finger Friction Test

o Method: Rubbing/snapping fingers near ear
o Purpose: Quick screening
2. Watch Test
o Method: Clicking watch near ear
o Status: Obsolete (audiometry preferred)
3. Speech (Voice) Tests
o Method: Whisper/conversation at 6 m distance
o Process: Block non-test ear, shield eyes (prevent enunciation), use
spondee words/numbers/disyllable words (bees, tees etc.)
o Limitations: Lack of voice standardization, ambient noise effect
4. Tuning Fork Tests (6 tests, 3 are important – Rinne, Weber, ABC)
ENT Notes Ahmed Ali Khan 2024
 o Frequency: 512 Hz (ideal) – tunic forks of lower frequencies – better bone
conduction
o !: higher frequency forks not used because of their shorter decay time
o Procedure: Activate by gentle strike on elbow

Tuning Fork Tests

OTHER SPECIAL TUNIC FORK TESTS ↓

1. Bing Test
o Method: Occlude/unocclude ear canal
during BC test
o Interpretation:
 Bing Positive: Louder with
occlusion (Normal or SN loss)
 Bing Negative: No change
(Conductive loss)
2. Gelle’s Test
o Method: Apply air pressure in ear canal
(Siegel’s speculum) with BC test
o Interpretation:
 Positive: Decreased hearing
(Normal or SN loss)
 Negative: No change in hearing (Ossicular chain fixation or
disconnection)

B. Investigations

1. Pure tone audiometry - PTA: (remember the symbols in the tympanogram:

below are important audiograms which you should be able to draw in exams)

NIHL, Presbycusis – Aviator’s notch

@ 4kHz

Otosclerosis - Carhartz notch

@ 2kHz
ENT Notes Ahmed Ali Khan 2024
2. Impedance Audiometry

 Objective Test: Commonly used,

especially in children
 Components:

1. Tympanometry

2. Acoustic Reflex Measurements

o Tympanometry: Assesses the

compliance of tympanic
membrane by varying pressure
in the EAM
o Types of Tympanograms:
 Type A: Normal
compliance
 Type As (s – sclerosis): Low compliance (ossicle fixation, e.g.,
otosclerosis)
 Type Ad (d – discontinuity): High compliance (ossicular
discontinuity or thin tympanic membrane)
 Type B: Flat graph (middle ear fluid or thickened membrane)
 Example: Otitis media with effusion
 Type C: Max compliance with negative pressure (retracted
membrane; possible fluid)
 Example: Eustachian tube dysfunction (e.g., from chronic
sinusitis or allergies causing retraction of the tympanic
membrane)

(b) Acoustic Reflex

 Loud Sound Response: Triggered by sound 70–100 dB above hearing

threshold
 Mechanism: Sudden loud sounds → Causes bilateral contraction of stapedial
muscles
 Detection: Measured by tympanometry; tone delivered to one ear, reflex
picked up from ipsilateral or contralateral ear
 Reflex Arc Pathways:
o Ipsilateral Pathway:
 CN VIII → Ventral cochlear nucleus → CN VII nucleus → Ipsilateral
stapedius muscle contraction
o Contralateral Pathway:
 CN VIII → Ventral cochlear nucleus → Contralateral medial superior
olivary nucleus → Contralateral CN VII nucleus → Contralateral
stapedius muscle contraction

C. Special Tests of Hearing

1. Recruitment; 2. Short Increment Sensitivity Index (SISI) Test; 3. Threshold

Tone Decay Test;

4. Evoked Response Audiometry

ENT Notes Ahmed Ali Khan 2024
  Objective Test: Measures auditory pathway activity
 Components:
o Electrocochleography (EcoG):
 Measures Cochlear & CN VIII Potentials: Assesses cochlear
microphonics, summating potential, action potential
 Procedure: Needle electrode on promontory
 Use: Determines hearing threshold in infants, differentiates
cochlear from CN VIII lesions (e.g., Ménière’s disease)
o Auditory Brainstem Response (ABR):

 Measures Brainstem Pathway Response: Elicits 7 brainstem

waves in first 10 ms
 Wave Sites:
 Wave I: Distal CN VIII
 Wave II: Proximal CN VIII near the brainstem
 Wave III: Cochlear nucleus
 Wave IV: Superior olivary complex
 Wave V: Lateral lemniscus
 Waves VI & VII: Inferior colliculus
 Use: Diagnoses retrocochlear pathology, hearing threshold in
infants, brainstem lesions (e.g., MS, pontine tumors)

5. Auditory Steady State Response (ASSR)

6. Otoacoustic Emissions (OAE)

 Detects Cochlear Health: Low-intensity sounds from outer hair cells

 Types:
o Spontaneous OAEs: Present in normal hearing (<30 dB loss); may be
absent in 50% of normal cases
o Evoked OAEs:
 Transient Evoked OAEs (TEOAEs): Elicited by clicks (80–85 dB)
 Distortion Product OAEs (DPOAEs): Uses two tones to test 1000–
8000 Hz range
 Uses:
o Neonatal Screening: Tests hearing in infants, uncooperative patients
o Differentiates Cochlear vs. Retrocochlear: Absent in cochlear lesions,
present in retrocochlear pathology
o Early Detection: Detects ototoxic effects before pure tone audiometry

7. Central Auditory Tests

 For Central Auditory Disorders: Identifies difficulties in noisy or distorted

speech
ENT Notes Ahmed Ali Khan 2024
  3 Types of speech discrimination tests are used:
o Monotic Test: Distorted speech presentation, difficult for people with
brain and cortex lesions
o Dichotic Test: Different messages to each ear; staggered spondaic word
test most commonly used; temporal lobe lesion detection
o Binaural Tests: Integrates both ears; brainstem lesions affect results;
binaural masking level difference test most commonly used

8. Hearing Assessment in Infants and Children

Chapter 5 – Hearing Loss

Causes of conductive hearing loss

Chapter 8: Diseases of the External Ear

I. Diseases of the Pinna

A. Congenital Disorders (11)

1. Anotia
o Complete absence of pinna and lobule.
o Often part of first arch syndrome.
2. Microtia
o Major ear development anomaly.
o May cause hearing loss; Peanut ear is a form.
3. Macrotia
o Excessively large pinna.
4. Bat Ear (Prominent Ear)
o Protruding ear; poorly developed antihelix/scapha.
o Corrected surgically after age 6.
5. Cup Ear (Lop Ear)
o Hypoplasia of upper third of auricle.
o Includes deformities like Cockle-shell ear.

ENT Notes Ahmed Ali Khan 2024

 6. Cryptotia (Pocket Ear)
o Upper auricle embedded under scalp skin.
o Treated by repositioning with skin graft.
7. Coloboma
o Transverse cleft in the middle of pinna.
8. Minor Deformities
o Includes absence of tragus, Darwin’s tubercle, Stahl’s ear, and Satyr ear.
9. Ear Lobule Deformities
o Variants like large, bifid, or attached lobules.
10. Preauricular Tags
o Skin-covered tags from tragus to mouth angle; may contain cartilage.
11. Preauricular Pit or Sinus
o Small pit near tragus; may cause infection/discharge.
o Treatment: surgical excision if infected repeatedly.

II. AURICLE

B. Trauma to the Auricle

1. Haematoma of Auricle
o Blood between cartilage and perichondrium (common in athletes).
o Complications:
o Perichondritis
o Can cause cauliflower ear (pugilistic or boxer’s ear) if untreated.
o Treatment:

1. Aspiration
2. or incision with drainage.
3. pressure dressing with dental rolls
4. prophylactic antibiotics and steroids

2. Lacerations
o Repaired early; sutures for perichondrium and skin.
o Antibiotics for 1 week.
3. Avulsion of Pinna
o Reattachment if partially attached; microvascular technique for complete
avulsion.
4. Frostbite
o Severity: erythema to complete tissue necrosis.
o Treatment: rewarming, silver nitrate, antibiotics, and delayed surgical
debridement.
5. Keloid of Auricle
o Common after trauma or piercing.
o Treatment: surgical excision with radiation (400-800 rad) or steroid
injections to prevent recurrence.

C. Inflammatory Disorders

1. Perichondritis
o Infection due to trauma or external otitis.
o Symptoms: red, hot, painful, stiff pinna.
o Treatment: antibiotics, 4% aluminum acetate compresses, drainage if
abscess forms.

ENT Notes Ahmed Ali Khan 2024

 2. Relapsing Polychondritis
o Rare autoimmune cartilage disorder.
o Involves ear, nasal, tracheal, and costal cartilage.
o Treatment: high-dose steroids.
3. Chondrodermatitis Nodularis Chronica Helicis
o Painful nodules on helix in older men.
o Treatment: excision with skin and cartilage removal.

D. Tumours of the Pinna

1. Benign Tumours
o Examples: sebaceous cysts, osteoma, lipoma.
o Simple excision for treatment.
2. Malignant Tumours
o Basal Cell Carcinoma: common; rarely metastasizes.
o Squamous Cell Carcinoma: aggressive; may metastasize.
o Melanoma: highly malignant; requires excision with margins.

Diseases of the External Auditory Canal

A. Congenital Disorders

1. Atresia of External Canal

o Definition: Congenital closure of the meatus.
o Causes: Failure of ectodermal canalization; may occur alone or with
microtia.
o Characteristics: Obliterated outer meatus (fibrous tissue/bone), normal
deep meatus and tympanic membrane.
o Associations: Often linked with abnormalities of middle/internal ear.
2. Collaural Fistula
o Definition: Abnormality of the first branchial cleft.
o Characteristics: Two openings (neck below mandible and external
canal/middle ear).
o Pathway: Track traverses through parotid near facial nerve.

B. Trauma to Ear Canal

1. Minor Lacerations
o Causes: Q-tip injuries, scratching with objects.
o Prognosis: Usually heal without complications.
2. Major Lacerations
o Causes: Gunshot wounds, car accidents, fights.
o Concerns: Mandible condyle may damage anterior canal wall.
o Treatment Goal: Achieve a skin-lined meatus of adequate diameter.
o Complications: Commonly leads to ear canal stenosis.

C. INFLAMMATIONS OF EAR CANAL

ENT Notes Ahmed Ali Khan 2024

A. Furuncle (Localized Acute Otitis Externa)

 Definition: Staphylococcal
infection of hair follicle,
located in the cartilaginous
part of the meatus.
 Presentation: Severe pain,
tenderness, painful pinna
movements, and jaw
movements.
 Symptoms: Edema over
mastoid, tender periauricular
lymph nodes.
 Treatment:
o Early: Systemic antibiotics, analgesics, local heat, 10% ichthammol
glycerine ear pack.
o If abscess: Incision and drainage.
o Exclude diabetes and staphylococcal sources for recurrent cases.
B. Diffuse Otitis Externa
 Definition: Diffuse inflammation of meatal skin, can involve pinna and
tympanic membrane.
 Aetiology: Common in hot/humid climates, trauma, pathogen invasion.
 Organisms: Staphylococcus aureus, Pseudomonas, E. coli (often mixed
infections).
 Clinical Features:
o Acute Phase: Burning sensation, pain, serous to purulent discharge,
meatal swelling, conductive hearing loss.
o Chronic Phase: Itching, scanty discharge, thickened meatal skin,
possible meatal stenosis.
 Treatment:
o Acute: Ear toilet, medicated wicks, broad-spectrum antibiotics, analgesics.
o Chronic: Reduce swelling, control itching with topical steroids, and ear
toilet.
C. Otomycosis
 Definition: Fungal infection of ear canal (Aspergillus, Candida).
 Symptoms: Intense itching, discomfort, watery discharge with musty odor,
visible fungal mass.
 Treatment: Ear toilet, antifungal agents (Nystatin, clotrimazole, salicylic acid).
D. Otitis Externa Haemorrhagica
ENT Notes Ahmed Ali Khan 2024
  Definition: Hemorrhagic bullae on tympanic membrane, likely viral.
 Symptoms: Severe ear pain, blood-stained discharge.
 Treatment: Analgesics, antibiotics for secondary infections.
E. Herpes Zoster Oticus
 Symptoms: Vesicles on tympanic membrane, meatal skin, and possible cranial
nerve involvement.
F. Malignant (Necrotizing) Otitis Externa
 Definition: Severe pseudomonas infection, common in
diabetics/immunocompromised.
 Symptoms: Severe otalgia, granulations in ear canal, facial paralysis.
 Diagnosis: CT scan, Gallium-67 for monitoring.
 Treatment: Control diabetes, ear canal toilet, prolonged antibiotics
(gentamicin, cephalosporins, quinolones).
G. Eczematous Otitis Externa
 Cause: Hypersensitivity to organisms or topical drops.
 Symptoms: Irritation, vesicle formation, oozing.
 Treatment: Withdraw offending agents, steroid cream application.
H. Seborrhoeic Otitis Externa
 Associated Condition: Seborrhoeic dermatitis.
 Symptoms: Itching, greasy yellow scales.
 Treatment: Ear toilet, salicylic acid/sulfur cream.
I. Neurodermatitis
 Cause: Compulsive scratching; may lead to bacterial infections.
 Treatment: Psychotherapy, secondary infection management, ear pack.
J. Primary Cholesteatoma of External Auditory Canal
 Definition: Squamous epithelium invades external canal bone.
 Symptoms: Purulent otorrhea, tympanic membrane normal.
 Treatment: Necrotic bone removal, cholesteatoma excision.
E. Miscellaneous Conditions
1. Impacted Wax (Cerumen)
o Definition: Accumulation of wax causing blockage.
o Symptoms: Hearing impairment, possible tinnitus, giddiness.
o Treatment: Syringing, instrumental manipulation, softening agents
(sodium bicarbonate, glycerine).

ENT Notes Ahmed Ali Khan 2024

 2. Foreign Bodies of Ear
o Common Items: Paper, seeds, cotton swabs.
o Removal Methods: Forceps, syringing, suction, microscopic removal,
postaural approach.
A. Furuncle (Localized Acute Otitis Externa)
 Definition: A staphylococcal infection of hair follicles confined to the
cartilaginous part of the ear canal.
 Clinical Features:
o Severe pain and tenderness disproportionate to size.
o Pain during pinna movement and jaw motion (chewing).
o Possible swelling of the mastoid and periauricular lymphadenopathy.
 Treatment:
o Early cases: systemic antibiotics, analgesics, local heat (e.g., 10%
ichthammol glycerine ear pack).
o Abscess formation: incision and drainage.
o Investigate recurrent cases for diabetes and nasal staphylococci.
B. Diffuse Otitis Externa
 Definition: Inflammation of the meatal skin that may involve the pinna and
tympanic membrane.
 Etiology:
o Common in hot, humid climates and among swimmers.
o Factors: trauma (scratching, foreign body removal), infection by
pathogens (Staphylococcus aureus, Pseudomonas, etc.).
 Clinical Features:
o Acute phase: burning sensation, pain, serous then purulent discharge,
meatal swelling, possible conductive hearing loss.
o Chronic phase: itching, scant discharge, scaling, and potential meatal
stenosis.
 Treatment:
o Acute: ear toilet, medicated wicks, broad-spectrum antibiotics, analgesics.
o Chronic: reduction of swelling, relief of itching, and potentially surgical
intervention for stenosis.
C. Otomycosis
 Definition: Fungal infection of the ear canal, typically caused by Aspergillus or
Candida.
 Clinical Features:
ENT Notes Ahmed Ali Khan 2024
 o Intense itching, discomfort, watery discharge with a musty odor, and ear
blockage.
o Appearance: fungal mass may be white, brown, or black.
 Treatment:
o Thorough ear toilet, topical antifungal agents (Nystatin, clotrimazole),
keratolytics (salicylic acid).
D. Otitis Externa Haemorrhagica
 Definition: Formation of haemorrhagic bullae on the tympanic membrane.
 Etiology: Likely viral, often associated with influenza.
 Clinical Features: Severe ear pain, blood-stained discharge when bullae
rupture.
 Treatment: Pain relief and antibiotics for secondary infections.
E. Herpes Zoster Oticus
 Definition: Viral infection characterized by vesicle formation on the tympanic
membrane and surrounding areas.
 Clinical Features: Vesicles on the tympanic membrane, meatal skin, and may
involve cranial nerves.
F. Malignant (Necrotizing) Otitis Externa
 Definition: Severe Pseudomonas infection, typically in elderly diabetics or
immunocompromised patients.
 Clinical Features: Excruciating pain, granulation tissue in the ear canal,
potential cranial nerve involvement.
 Diagnosis: High suspicion in appropriate patient demographics; imaging (CT,
Gallium-67) for further evaluation.
 Treatment:
o Control diabetes.
o Ear canal toilet, prolonged antibiotics (6-8 weeks or more), often including
Gentamicin and ticarcillin or third-generation cephalosporins.
G. Eczematous Otitis Externa
 Definition: Allergic reaction leading to intense irritation in the ear canal.
 Clinical Features: Vesicle formation, oozing, and crusting.
 Treatment: Withdraw offending agents, steroid cream application.
H. Seborrhoeic Otitis Externa
 Definition: Associated with seborrheic dermatitis.
 Clinical Features: Greasy yellow scales, primarily itching.
 Treatment: Ear toilet and topical treatments.
ENT Notes Ahmed Ali Khan 2024
I. Neurodermatitis
 Definition: Psychological factors leading to compulsive scratching of the ear.
 Clinical Features: Intense itching, potential secondary bacterial infection.
 Treatment: Psychotherapy, management of secondary infections.
J. Primary Cholesteatoma of External Auditory Canal
 Definition: Invasion of squamous epithelium into the bone of the external
canal.
 Clinical Features: Purulent discharge and pain; normal tympanic membrane.
 Treatment: Surgical removal of necrotic tissue and cholesteatoma.
E. Miscellaneous Conditions
1. Impacted Wax (Cerumen)
o Definition: Excessive earwax accumulation leading to blockage.
o Clinical Features: Hearing impairment, tinnitus, potential dizziness.
o Treatment: Wax removal through syringing or instrumentation, softening
agents (sodium bicarbonate, olive oil).
2. Foreign Bodies of the Ear
o Definition: Various objects lodged in the ear canal, common in children.
o Removal Methods: Forceps, syringing, suction, microscopy, or postaural
approach.
E. MISCELLANEOUS CONDITIONS
1. Impacted Wax or Cerumen
 Composition: Sebaceous and ceruminous gland secretions, hair, epithelial
debris, keratin, dirt.
 Function: Protects, lubricates ear canal; acidic pH, bacteriostatic, fungistatic.
 Symptoms: Hearing loss, blocked sensation, tinnitus, giddiness.
 Causes of Impaction:
o Excessive wax secretion
o Narrow, tortuous canal
o Obstructive lesions (e.g., exostosis)
 Treatment:
o Removal: Syringing or instrumental manipulation.
o Syringing Technique:
 Patient's ear tilted; water directed at posterosuperior wall.
 Inspect ear canal to ensure complete removal.

ENT Notes Ahmed Ali Khan 2024

 o Softening Agents: Sodium bicarbonate drops, hydrogen peroxide, olive
oil.
2. Foreign Bodies of Ear
 Types:
o Nonliving: Paper, seeds, matchsticks, cotton swabs.
o Living: Insects causing irritation/pain.

 Removal Methods:
o Forceps, syringing, suction, microscopy, postaural approach.
 Insect Management: Kill with oil or chloroform before removal.
 Maggots: Treat by instilling chloroform water; remove with forceps.

3. Keratosis Obturans
 Definition: Accumulation of keratin in
the deep meatus.
 Aetiology: Occurs mainly in ages 5-20;
linked to bronchiectasis, chronic
sinusitis.
 Symptoms: Ear pain, hearing loss,
discharge.
 Treatment: Removal of mass; possible recurrence managed with keratolytic
agents (salicylic acid and glycolic acid)
4. Acquired Atresia and Stenosis of Meatus
 Causes:
o Infections (chronic otitis externa)
o Trauma (lacerations, fractures)
o Burns (thermal, chemical)
 Treatment: Meatoplasty (excision of scar tissue, enlargement of meatus).
III. DISEASES OF TYMPANIC MEMBRANE
Normal Tympanic Membrane
 Appearance: Shiny, pearly grey, concave, visible cone of light.
1. Retracted Tympanic Membrane
 Characteristics: Dull, lustreless; negative pressure from eustachian tube
blockage.
2. Myringitis Bullosa

ENT Notes Ahmed Ali Khan 2024

  Description: Painful, haemorrhagic blebs; possible viral/Mycoplasma infection.
3. Herpes Zoster Oticus
 Involvement: Affects facial nerve; vesicles on tympanic membrane and
surrounding areas.
4. Myringitis Granulosa
 Features: Granulations on tympanic membrane; linked to infections or
impacted wax.
5. Traumatic Rupture
 Causes: Trauma, pressure changes, fluid column, temporal bone fracture.
 Management: Examine and reposition edges under microscope.
6. Atrophic Tympanic Membrane
 Description: Thin, collapsed membrane; loss of fibrous layer due to serous
otitis media.
7. Retraction Pockets and Atelectasis
 Definition: Inward collapse due to eustachian tube insufficiency; can lead to
cholesteatoma.
8. Tympanosclerosis
 Characteristics: Hyalinization and calcification in the tympanic membrane;
appears as white plaques.
9. Perforations
 Types: Central, attic, marginal; commonly associated with chronic otitis media.

ENT Notes Ahmed Ali Khan 2024