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Hearing loss

Medicine > Medicine of older adult

Differential Diagnosis Schema 🧠

Conductive Hearing Loss

  • Cerumen Impaction: Common cause of hearing loss; presents with a feeling of fullness in the ear and reduced hearing, typically unilateral.
  • Otitis Media: Middle ear infection; often presents with ear pain, fever, and conductive hearing loss.
  • Otosclerosis: Abnormal bone growth in the middle ear; typically causes progressive conductive hearing loss, often bilateral.
  • Tympanic Membrane Perforation: May result from trauma, infection, or barotrauma; presents with sudden hearing loss, ear pain, and sometimes otorrhea.
  • Cholesteatoma: Abnormal skin growth in the middle ear; can lead to chronic ear discharge and progressive conductive hearing loss.
  • Eustachian Tube Dysfunction: Often associated with allergies or upper respiratory infections; presents with a sensation of fullness, popping, and reduced hearing.
  • External Otitis (Swimmer’s Ear): Inflammation of the ear canal; presents with ear pain, discharge, and sometimes conductive hearing loss.

Sensorineural Hearing Loss

  • Presbycusis: Age-related hearing loss; typically affects high-frequency sounds and is usually bilateral.
  • Noise-Induced Hearing Loss: Due to prolonged exposure to loud noise; presents with high-frequency hearing loss and difficulty understanding speech, especially in noisy environments.
  • Sudden Sensorineural Hearing Loss: Rapid onset of unilateral hearing loss; often idiopathic, but may be associated with viral infections or vascular events.
  • Meniere’s Disease: Characterized by episodic vertigo, tinnitus, and fluctuating sensorineural hearing loss, typically unilateral.
  • Acoustic Neuroma: Benign tumor of the vestibulocochlear nerve; presents with unilateral hearing loss, tinnitus, and sometimes balance issues.
  • Ototoxic Medications: Certain drugs (e.g., aminoglycosides, chemotherapy agents) can cause bilateral sensorineural hearing loss.
  • Multiple Sclerosis: May cause hearing loss as part of a broader neurological syndrome; often associated with other neurological symptoms.
  • Congenital Causes: Genetic disorders or prenatal infections (e.g., CMV) can lead to sensorineural hearing loss from birth or early childhood.
  • Autoimmune Inner Ear Disease: Rare cause of progressive sensorineural hearing loss; may be associated with systemic autoimmune disorders.
  • Trauma: Temporal bone fractures or acoustic trauma can cause sensorineural hearing loss.
  • Infectious Causes: Bacterial or viral infections (e.g., meningitis, mumps) can result in sensorineural hearing loss.
  • Vascular Causes: Strokes or transient ischemic attacks affecting the auditory pathways can cause sudden or progressive sensorineural hearing loss.
  • Neurosyphilis: A late manifestation of untreated syphilis that can cause progressive sensorineural hearing loss.
  • Idiopathic: In many cases, the cause of sensorineural hearing loss remains unknown despite thorough investigation.

Key Points in History 🥼

Symptom Onset and Characteristics

  • Onset: Sudden onset suggests causes like sudden sensorineural hearing loss, trauma, or infection; gradual onset is more typical of presbycusis or noise-induced hearing loss.
  • Unilateral vs. Bilateral: Unilateral hearing loss may suggest acoustic neuroma, Meniere’s disease, or sudden sensorineural hearing loss, while bilateral loss is more common in presbycusis and ototoxicity.
  • Associated Symptoms: Tinnitus, vertigo, ear pain, or fullness can help localize the pathology (e.g., Meniere’s disease, otitis media).
  • Noise Exposure: History of exposure to loud noise at work, during leisure activities, or in military service suggests noise-induced hearing loss.
  • Trauma: Recent head injury, barotrauma (e.g., from diving or flying), or exposure to loud sounds can cause acute hearing loss.
  • Infection: Recent upper respiratory infections, meningitis, or otitis media can lead to conductive or sensorineural hearing loss.
  • Medication History: Use of known ototoxic drugs, such as aminoglycosides, loop diuretics, or chemotherapy agents, may be relevant.
  • Family History: Consider genetic causes of hearing loss, especially if there is a family history of hearing impairment or congenital hearing loss.
  • Occupational History: Assess for occupational noise exposure or exposure to ototoxic chemicals.
  • Systemic Symptoms: Signs like joint pain, rashes, or neurological symptoms might suggest systemic autoimmune or neurological causes of hearing loss.
  • Psychosocial Impact: Assess the impact of hearing loss on the patient’s quality of life, social interactions, and mental health.

Background

  • Past Medical History: Include any history of chronic ear infections, surgeries, head injuries, or neurological conditions.
  • Drug History: Detailed review of medications, particularly focusing on ototoxic drugs.
  • Family History: Ask about hereditary hearing loss or related syndromes.
  • Social History: Consider smoking, alcohol use, and occupational history, which may contribute to hearing loss.
  • Environmental Exposures: Assess for exposure to loud noises, toxins, or infectious agents that might affect hearing.
  • Developmental History: In children, consider developmental milestones and any concerns about speech and language development.
  • Travel History: Consider exposure to infections or environments that may have contributed to hearing loss.
  • Psychosocial History: Consider the psychological and social impact of hearing loss, including any previous use of hearing aids or communication strategies.

Possible Investigations 🌡️

Initial Assessments

  • Otoscopy: Visual examination of the external auditory canal and tympanic membrane to identify cerumen impaction, perforation, or otitis media.
  • Tuning Fork Tests (Rinne and Weber): To differentiate between conductive and sensorineural hearing loss.
  • Pure Tone Audiometry: Standard test to assess the severity and type of hearing loss across different frequencies.
  • Speech Audiometry: To assess the ability to understand speech, often more relevant in assessing functional impact.
  • Tympanometry: To evaluate middle ear function, useful in diagnosing conditions like otitis media with effusion or Eustachian tube dysfunction.
  • Otoacoustic Emissions (OAE): Screening test for cochlear (outer hair cell) function, often used in newborn hearing screening.
  • Acoustic Reflex Testing: Assesses the reflex pathway of the middle ear muscles, useful in diagnosing retrocochlear pathologies like acoustic neuroma.
  • High-Frequency Audiometry: May be useful in detecting early ototoxicity or presbycusis affecting high frequencies.
  • Vestibular Testing: Considered in patients with associated vertigo, to assess the function of the vestibular system.
  • Evoked Potentials (e.g., Auditory Brainstem Response, ABR): Used to assess the auditory pathway up to the brainstem, particularly in diagnosing acoustic neuroma or other central causes of hearing loss.

Imaging and Further Tests

  • MRI with Contrast: Gold standard for assessing retrocochlear pathology, such as acoustic neuroma.
  • CT Temporal Bone: Useful for assessing bony abnormalities such as otosclerosis, temporal bone fractures, or congenital anomalies.
  • Blood Tests: Consider if systemic or infectious causes of hearing loss are suspected, including syphilis serology, autoimmune markers, and thyroid function tests.
  • Genetic Testing: Consider in cases of congenital or early-onset sensorineural hearing loss, especially with a family history.
  • Electrocochleography (ECoG): May be useful in diagnosing Meniere’s disease or other inner ear fluid balance disorders.
  • Cerebrospinal Fluid Analysis: Rarely indicated, but may be considered if there is suspicion of central nervous system involvement or meningitis.
  • Bone Conduction Implant Candidacy Testing: For patients with conductive hearing loss who may benefit from bone-anchored hearing aids (BAHA).
  • Audiological Rehabilitation Assessment: To determine the need for hearing aids, cochlear implants, or other assistive devices.

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Medicine of older adult