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![PURETONE AUDIOMETRY (PTAPURETONE AUDIOMETRY (PTA((
PTA is the key hearing test used to identify hearing threshold level of an
individual, enabling determination of the degree, types and configuration
of hearing loss.
Provides the basis for diagnosis and management.
The symbols used on most audiograms are:
x - left, air conduction
o - right, air conduction
] - left, bone conduction
[ - right, bone conduction](https://image.slidesharecdn.com/hearingimpairmentandrehabilitation-150529135704-lva1-app6891/85/Hearing-impairment-and-rehabilitation-21-320.jpg)
![ Acute mAnAgement::
Bed rest, antiemetics, antivertiginous drugs [e.g. betahistine].
Long term mAnAgement mAy incLude:
Medical:Medical:
low salt diet,
Local application of gentamicin, betahistine
Surgical.Surgical.
Decompressing the inner ear ( draining the endolymphatic sac)
Vestibular neurectomy
Labyrinthectomy](https://image.slidesharecdn.com/hearingimpairmentandrehabilitation-150529135704-lva1-app6891/85/Hearing-impairment-and-rehabilitation-45-320.jpg)
Uploaded byNassr ALBarhi
Hearing impairment and rehabilitation
Patients can experience different types of hearing loss, including conductive, sensorineural, and mixed. A history and physical exam including tuning fork tests help distinguish the type of loss. Common etiologies include otosclerosis, presbycusis, noise exposure, and Meniere's disease. Formal audiologic testing is needed to diagnose the condition and guide management, which may include hearing aids, surgery, or lifestyle modifications.
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Hearing impairment and rehabilitation
- 1. Hearing impairment andHearingimpairment and rehabilitationrehabilitation
- 2. OUTLINEOUTLINE Types ofhearing loss Classification of hearing loss Diagnosing and managing different kinds of hearing loss; e.g congenital hearing loss otosclerosis, presbyacusis, noise Induced Hearing Loss ,Meniers disease ,ototoxicity Performing and interpreting various subjective and objective hearing tests Tuning fork test PureTone Audiometry Impedance Audiometry Brain Stem Evoked Response Audiometry
- 3. HEARING IMPAIRMENTHEARING IMPAIRMENT Hearingimpairment, also called deafness or hearing loss, occurs when there’s a problem with or damage to one or more parts of the ear. U.S. population 270+ million 2 million Deaf 26 million Hard of Hearing 1 of every 10 people has a hearing loss Over age 65, 1 in every 3 persons has some degree of hearing loss 80% of hearing people are in denial
- 6. TYPES OF HEARINGLOSSTYPES OF HEARING LOSS 1. Conductive Hearing Loss (CHL) • the conduction of sound to the cochlea is impaired • can be caused by external and middle ear disease 2. Sensorineural Hearing Loss (SNHL) • due to a defect in the conversion of sound into neural signals or in the transmission of those signals to the cortex • can be caused by disease of the cochlea, acoustic nerve ( CNVlll), brainstem, or cortex
- 7. TYPES OF HEARINGLOSSTYPES OF HEARING LOSS 3. Mixed Hearing Loss • the conduction of sound to the cochlea is impaired, as well as transmission through the cochlea to the cortex
- 8. DIFFERENTIAL DIAGNOSIS OFHEARING LOSSDIFFERENTIAL DIAGNOSIS OF HEARING LOSS
- 9. DIFFERENTIAL DIAGNOSIS OFHEARING LOSSDIFFERENTIAL DIAGNOSIS OF HEARING LOSS
- 10.
- 11. HISTORYHISTORY HPI: Onset (sudden orgradual) Duration Unilateral/ bilateral Continuous / Intermittent
- 12. HISTORYHISTORY HPI: Exposure- noise, drugs,viral illness History of ear of head trauma History of surgeries Associated symptoms- pain, discharge, tinnitus, vertigo
- 13. HISTORYHISTORY PMH: Chronicillness: DM, HTN, Hypothyroidism Previous surgeries Rx: Ototoxic drugs Amino glycosides, diuretics, quinine, aspirin Social history: Occupation Tobacco Alcohol Cocaine Marijuana
- 15. PHYSICAL EXAMINATIONPHYSICAL EXAMINATION General assessment Ear exam: Deformities of Pinna & EAC Pre & post-auricular region Otoscopy - EAC, TM Tuning Fork Test - Rinne - Weber Cranial Nerves
- 16. INVESTIGATIONSINVESTIGATIONS Specific hearing tests TuningFork Tests Pure tone audiometry Impedance audiometry Brain stem evoked response audiometry Radiology - CT & MRI of skull & temporal bones
- 17. HEARINGTESTSHEARINGTESTS Subjective Tonic Forktest Pure tone audiometry (PTA) Objective Tympanometry (impedance audiometry) Electric response audiometry (ERA).
- 18. TUNING FORKTESTSTUNING FORKTESTS Test:Weber Technique:Tuning Fork placed at midline forehead Normal: Sound radiates to both ears equally Abnormal: Sound lateralizes to one ear Ipsilateral Conductive Hearing Loss OR Contralateral Sensorineural Hearing Loss
- 19. TUNING FORKTESTSTUNING FORKTESTS Test:Rinne’s Technique First: Bone Conduction VibratingTuning Fork held on Mastoid Patient covers opposite ear with hand Patient signals when sound ceases Move the vibrating tuning fork over the ear canal Near, but not touching the ear Next: Air Conduction Patient indicates when the sound ceases
- 20. TUNING FORKTESTSTUNING FORKTESTS Test:Rinne’s Normal:Air Conduction is better than Bone Conduction Air conduction usually persists twice as long as bone Referred to as "positive test" Abnormal: Bone conduction better than air conduction Suggests Conductive Hearing Loss Referred to as "negative test"
- 21. PURETONE AUDIOMETRY (PTAPURETONEAUDIOMETRY (PTA(( PTA is the key hearing test used to identify hearing threshold level of an individual, enabling determination of the degree, types and configuration of hearing loss. Provides the basis for diagnosis and management. The symbols used on most audiograms are: x - left, air conduction o - right, air conduction ] - left, bone conduction [ - right, bone conduction
- 22.
- 24. TYMPANOMETRY (IMPEDANCE AUDIOMETRYTYMPANOMETRY(IMPEDANCE AUDIOMETRY(( Assess the function of middle ear and Eustachian tube.function of middle ear and Eustachian tube. Very useful when screeningscreening for middle ear effusion. It is not a hearing testnot a hearing test, but rather a measure of energy transmission through the middle ear. It can also assess the integrity of stapedius refluxstapedius reflux..
- 25.
- 27. AUDITORY BRAINSTEM RESPONSE(ABR)AUDITORY BRAINSTEM RESPONSE (ABR) AUDIOMETRYAUDIOMETRY An objective neurologic test of auditory brainstem function in response to auditory (click) stimuli. Procedure:The stimulus either in the form of click or tone pip is transmitted to the ear via a transducer placed in the insert ear phone or head phone.The wave froms of impulses generated at the level of brain stem are recorded by the placement of electrodes over the scalp.
- 28. AUDITORY BRAINSTEM RESPONSE(ABR)AUDITORY BRAINSTEM RESPONSE (ABR) AUDIOMETRYAUDIOMETRY These peaks are considered to originate from the following anatomical sites: 1. Cochlear nerves - waves I and II 2. Cochlear nucleus - wave III 3. Superior olivary complex - wave IV 4. Nulclei of lateral lemniscus - waveV 5. Inferior colliculus - wavesVI andVII
- 29.
- 30. CASE 1CASE 1 A30 years old lady presented with 3 months history of progressive bilateral hearing loss that has worsend during present pregnancy, associated with tinnitus in both ears. Her sistert was having the same problem. o/e: Normal ears, no evidence of middle ear infection, normal TM ± pink blush (Schwartz's sign) What is next?
- 31.
- 32. OTOSCLEROSISOTOSCLEROSIS Fusion of stapesfootplate to oval window so that it cannot vibrate. Etiology autosomal dominant female> male, progresses during pregnancy (hormone responsive) Symptoms include slowly progressive hearing loss,bilateral in 70% of cases. Vertigo is uncommon. Tinnitus may be present and often resolves after successful surgical management
- 33. OTOSCLEROSISOTOSCLEROSIS Conductive hearing loss In80-90% of patients, lesions are limited to the anterior oval window and affect its pathology by involving the stapes sensorineural hearing loss In 8% of patients, the process involves the cochlea and parts of the labyrinth (labyrinthine otosclerosis)
- 34. OTOSCLEROSISOTOSCLEROSIS Tx: monitor withserial audio grams if coping with loss hearing aid (air conduction, bone conduction, BAHA) stapedectomy or stapedotomy (with laser or drill) with prosthesis is definitive treatment
- 36. CASE 2CASE 2 70years old gentleman , a known hypertensive, presented with gradual hearing loss in both ears, started to notice that since 5 months, hearing people like they are mumbling, associated with tinnitus and difficulty understanding speech, especially in noisy situations. Otoscopy: normal external auditory canal & TM, no signs of middle ear infection
- 37. PRESBYCUSISPRESBYCUSIS Sensorineural hearing lossassociated with aging (staging in 5th and 6th decades). Etiology hair cell degeneration age related degeneration of basilar membrane cochlear neuron damage ischemia of inner ear
- 38. Accumulated exposure tonoise Drug and environmental chemical exposure Stress Genetics Arteriosclerosis Diet and metabolism CAUSESCAUSES
- 39. The inabilityto hear or understand speech in a crowded or noisy environment Difficulty understanding consonants The inability to hear high pitched voices or noises Tinnitus is often present COMMON COMPLAINTSCOMMON COMPLAINTS
- 40. Tx: hearing aidif patient has difficulty functioning, hearing loss >30-35 dB, and good speech discrimination ±lip reading, auditory training, auditory aids (doorbell and phone lights)
- 41. NOISE-INDUCED HEARING LOSSNOISE-INDUCEDHEARING LOSS Constant exposure to loud noises can cause high frequency sensorineural hearing loss The mechanism by 1- Direct mechanical damage of cochlear structures 2- Metabolic overload due to overstimulation
- 42. OTOTOXICITYOTOTOXICITY Antibiotics 1-Aminoglycosides (gentamicin >tobramycin > amikacin > neomycin) 2-Erythromycin and tetracycline Chemotherapeutic agents are known to cause hearing loss.The worst ototoxicity occurs with cisplatin. High-dose aspirin. Antimalarial medications such as quinine and chloroquine
- 43. MÉNIÈRE DISEASEMÉNIÈRE DISEASE Endolymphatichydrops refers to a condition of increased hydraulic pressure within the inner ear endolymphatic system. Episodic attacks of tinnitus, hearing loss, aural fullness, and vertigo lasting minutes to hours. peak incidence 40 to 60 years
- 45. Acute mAnAgement:: Bed rest, antiemetics, antivertiginous drugs [e.g. betahistine]. Long term mAnAgement mAy incLude: Medical:Medical: low salt diet, Local application of gentamicin, betahistine Surgical.Surgical. Decompressing the inner ear ( draining the endolymphatic sac) Vestibular neurectomy Labyrinthectomy
- 46. SUMMARYSUMMARY Patients withhearing loss may have conductive, sensorineural, or mixed hearing loss. Patients with hearing loss should undergo a directed history and examination. Weber and Rinne tests to distinguish conductive from sensorineural hearing loss Patients with conductive hearing loss should undergo physical examination of the auricle and external auditory canal (EAC) looking for evidence of blockage to explain the hearing loss. Patients without an obvious etiology for hearing loss (such as external otitis or cerumen impaction) should undergo formal audiologic testing.
- 47. SUMMARYSUMMARY Otoscelerosis isthe second most common cause of conductive hearing loss in 15-50 years olds (eftar cerumen impation). Presbycusis is the most common cause of SNHL Short exposure to louder sounds can cause significant SNHL Features of Ménière disease; tinnitus, hearing loss, aural fullness, and vertigo
- 48. QUIZQUIZ Q.With negatives Renne’stest on the right side and Weber’s test lateralized to the right ear could be suffering from: Bilateral chronic suppuratiove otitis media Right CSOM Bilateral otosclerosis Right secretory otitis media and left Eustachian tube dysfunction Left CSOM only
- 49. Q.A progressing conductivehearing loss in an adult with a normal appearing, mobile tympanic membrane is most likely due to: a. serous otitis media b. otosclerosis c. acute otitis media d. external otitis media
- 50. Q.Most common causeof conductive hearing loss in children: C.S.O.M. Acute O.M. Chronie recurrent S.O.M Otitis externa.
- 51. Q. Meniere's syndromeis a symptom complex characterized by: a) conductive hearing loss and tinnitus. b) fluctuating Sensorineural hearing loss, tinnitus, and constant vertigo. c) intermittent vertigo lasting several days each time. d) fluctuating Sensorineural hearing loss, vertiginous episodes lasting 1-2 hours, and tinnitus. e) vertigo precipitated by lying down and turning over to one side.
- 52. REFERENCESREFERENCES Ear, nose andthroat and head and neck surgery, R. S. Dhillon, C.A East, third edition. Otolaryngology- head and neck surgery,Toronto notes 2011 http://www.ncbi.nlm.nih.gov http://www.uptodate.com
Editor's Notes
- #2 — Hearing loss is a common problem that everyone experiences from time to time. Most commonly it occurs when flying or traveling up a mountain, and a full sensation develops in the ears, leading to the feeling of wanting to pop the ears open in order to hear better. Diminished hearing also may occur during an ear infection. These causes of hearing loss are usually short-lived. The other extreme is the permanent sensorineural hearing loss that occurs with aging, which we will all experience to some degree
- #3 The causes of hearing loss are reviewed here, along with brief discussions of the management of certain conditions &The evaluation of a patient with hearing loss
- #4 Hearing impairment is considered the most prevalent impairment worldwide. Almost 600 million, an estimated 10% of people worldwide, have mild or worse hearing impairment.
- #5 The ear is divided into three segments (figure 1): ●The outer ear, comprising the auricle and ear canal ●The middle ear, comprising the tympanic membrane (TM), ossicles, and the middle ear space ●The inner ear, comprising the cochlea, semicircular canals, and internal auditory canals.
- #6 Anatomically the auricle, or outer ear, is a uniquely constructed organ. It is perfectly designed to "catch" incoming sound waves and then funnel them down the external auditory canal. Sound waves vibrate the TM, causing motion of the ossicles that results in the piston-like effect of the stapes. The piston motion of the stapes then pushes the inner ear fluid around the two-and-one-half turns of the cochlea. Frequency-specific movement sets up fluid waves within the cochlea, which in turn sets into motion the organ of Corti (figure 2). The organ of Corti movement bends the stereocilia, depolarizing the subsequent action of the auditory message traveling through the hair cells via the cochlear (auditory) nerve to the brain. The brain organizes the information into what we perceive as complex sounds.
- #9 It is useful to begin the evaluation by classifying the loss as sensorineural or conductive, since this helps focus the remainder of the patient assessment. Conductive hearing loss is usually related to abnormalities of the outer or middle ear; sensorineural hearing loss is related to inner ear pathology.
- #11 — Any patient complaining of hearing loss should have a full auditory history and examination performed
- #12 Important questions in the history include: ●What was the onset and progression of the hearing loss? ●How well can the patient understand spoken words? ●Is the problem mainly with background noise (eg restaurants, parties) or is it just as bad in quiet settings? ●Is there pain or drainage out of the ear associated with the hearing loss?
- #13 ●Is there a history of significant trauma, including noise and barotrauma? ●Is there a history of major infections? ●Is there a history of previous ear surgery?
- #14 Is there associated tinnitus, vertigo, or disequilibrium? ●Is there a family history of hearing loss? There are a number of congenital and hereditary causes of hearing loss; presbycusis also can run in families. ●What medications are taken? ●Do headaches or visual disturbances occur before, during, or after episodes of hearing loss? ●What medications, including over-the-counter drugs, is the patient taking? ●History of other medical disorders such as diabetes, smoking, coronary artery disease, autoimmune diseases. Patients with sudden hearing loss require urgent referral as treatment success is related to early initiation of treatment
- #16 Examination of the ear — Patients with conductive hearing loss should have an examination of the auricle and EAC performed to look for blockage of the EAC. The tympanic membrane (TM) should be viewed to ensure that there is no middle ear abnormality such as fluid or TM perforations. The examination for some patients will involve only simple tests that can be performed in a primary care office. Many patients, however, will require formal audiologic testing or other specialized tests
- #17 Patients with unexplained conductive hearing loss should have a CT scan of the temporal bone. ●Patients with unilateral, fluctuating, or unexplained asymmetric sensorineural hearing loss should have an MRI with gadolinium
- #28 Audiometry brainstem response: Measures the time taken for impulse to pass from the cochlea to brainstem Useful in screening for acoustic neuromata Useful in objective test of hearing in babies
- #32 pure-tone audiometry demonstrates low-frequency conductive hearing loss. Carhart notch... Tympanometry usually reveals a type As or A tympanogram
- #33 is an abnormal growth of bone near the middle ear an autosomal dominant condition Measles virus infection Pregnancy and estrogen therapy can accelerate the progression of otosclerosis. Symptom onset usually occurs by the early 3rd decade of life
- #35 Medical Therapy : hearing aids are usually helpful. Fluoride supplementation Surgical Therapy Indicated if conductive hearing loss with a greater than 20 dB air-bone gap a small hole is created in the footplate of the stapes, or a portion of the footplate of the stapes is completely removed. then stapes superstructure is removed. A piston prosthesis is then placed from the incus into the stapedotomy hole, which returns the piston-like action of the ossicular chain.
- #37 Audiometric testing with pure-tone average and speech discrimination forms the cornerstone of diagnostic testing for presbycusis
- #38 Presbycusis, or age-related hearing loss, is a common cause of hearing loss worldwide. The hallmark of presbycusis is the progressive, symmetric loss of high frequency hearing over many years in an elderly individual age-related hearing loss The term comes from the Greek “presbys” meaning “old” and “(a)kousis” meaning “hearing. a progressive bilateral symmetrical age-related sensorineural hearing loss hair cell degeneration of the cochlea
- #40 Common complaints associated with presbycusis include the inability to hear or understand speech in a crowded or noisy environment, difficulty understanding consonants, and the inability to hear high pitched voices or noises. Tinnitus is often present and may be described as either a roaring sound, crickets, or bells in the ear.
- #41 Hearing aids are able to benefit most patients with presbycusis. The progression of hearing loss rarely becomes so severe that hearing aids are not effective in restoring the ability to communicate. At times hearing amplification is not tolerated by patients either because they produce too much ear wax, which plugs the device, the meatus is too small, or the device has increased static or noise. The aid may also cause discomfort, and it is a cosmetic concern to many patients. Cochlear implantation may benefit patients of any age who are not helped by hearing aids.
- #42 Everyday noise exposure, compounded over time, has an impact upon our ability to hear. Excessive noise can ultimately affect the degree of the presbycusis that develops. Constant exposure to loud noises can cause high frequency sensorineural hearing loss (figure 3). The mechanism by which excessive noise induces hearing loss includes direct mechanical damage of cochlear structures and metabolic overload due to overstimulation [55,56]. Some potential metabolic effects are excess nitric oxide release that can damage hair cells, generation of oxygen free radicals that become toxic to membranes, and low magnesium concentrations that weaken hair cells by reducing the concentration of intracellular calcium
- #44 Patients with Meniere disease complain of episodic spells of vertigo that last for hours, associated with aural fullness, tinnitus, and sensorineural hearing loss. Occasionally the auditory system is affected in what is commonly called cochlear Meniere or cochlear hydrops; in these cases the patient experiences episodic hearing loss that recovers within a 12- to 24-hour period, usually with associated aural fullness and tinnitus. The spells of hearing loss may occur on a daily, weekly, or monthly basis. The hearing loss is almost always low frequency. Over time and with repeated attacks, the hearing deficit can become permanent and may even eventually involve all frequencies
- #52 Feeling of fullness in the ear, sensorineural Deffness, Tinnitus, Vomiting and Vertigo lasting for hours.