AgingEye, Ear, Nose. ThroatProcedures


Being hard of hearing is far more disabling than people think. Folks who are deaf from birth live in a world of silence. They have never heard a voice and the inflections that give it meaning. They have never heard music and experienced the joy and satisfaction it brings. They have never heard birds tweeting, dogs barking, a crowd roaring, or even footsteps on a hardwood floor. There’s is a world devoid of auditory stimuli. Conversations are missed, alarms aren’t heard, and television is just images without description.

Folks who have acquired hearing loss also live in a silent world, too, but during their hearing life, they have heard a voice speak, birds tweet, a dog bark, and a crowd roar. Although, now, they can’t hear them, they remember what those sounds were like, and in certain scenarios can imagine what what sounds are being heard by others. Acquired hearing loss has a wide range of severity, from mild requiring amplification, to severe where lip reading becomes a necessity. 

Once acquired hearing loss begins, it progressively worsens but at varying degrees. It is irreversible and permanent. Diagnosing it is very easy, but there are differing opinions on whether hearing screening is advisable. The ultra-conservative United States Preventive Services Task Force, USPSTF, finds insufficient reason to screen adults over age 50 for hearing loss, but the World Health Organization, WHO, says adults over age 50 should be screened every 5 years until age 65, then every 1-3 years if hearing loss is suspected. What harm could there be to screen for hearing loss. The USPSTF is once again ridiculously out of touch!

Audiometry is the procedure to definitively diagnose hearing loss. The end result/report in an Audiogram. There are varying types of audiometry all the way from hearing beeps over your phone at home to sophisticated testing by an audiologist in a sound-proof booth. The former gives an idea of the possibility while the latter definitively diagnoses the type and severity of the disability. Any abnormal screening test should be followed up by a consultation with an audiologist and complete testing. 

Loud noise exposure, medications, diabetes, tobacco use, head or neck trauma, and childhood infectious diseases are risk factors and causes of hearing loss. Primary ear disorders such as acoustic neuroma (auditory nerve tumor), Ménière’s disease, and otosclerois (stiffening of the hearing bones) are other causes. The majority of hearing loss, however, is simply from aging and degeneration of the auditory nerve and is called presbycusis. Trouble with balance and equilibrium are frequent accompaniments of hearing loss. The 8th cranial nerve has two functions: 1. To enable hearing. 2. To maintain balance and positional awareness. 

Three types of hearing loss exist: 1. Conductive    2. Sensorineural    3. Mixed

The ear has 3 parts—outer (eardrum to outside), middle (eardrum to cochlea), inner (cochlea). 

The sounds we hear every day are transmitted through the air. Sound waves pass through the external auditory canal and cause the eardrum (tympanic membrane) to vibrate. Three ossicles (hearing bones), the malleus, incus, and stapes, form a “chain” that attaches to the back side of the eardrum (the malleus attaches to the tympanic membrane). The other end of the ossicles (the stapes) attaches to the cochlea where sound waves are transformed into nerve impulses. Those nerve messages are sent to  the brain which interprets them as sound. 

Conductive Hearing Loss occurs when something causes the ear structures (outer, middle) to function improperly or not function at all. Something prevents the “conduction” of sound waves to the inner ear. An ear canal plugged with wax, a perforated eardrum, otosclerosis of the ossicles, infection of the ear with fluid in the space behind the eardrum, or trauma to the ossicles are examples. Many of these are reversible causes of hearing loss, but when a child has a lot of ear infections, damage may occur that permanently affects the eardrum and hearing. 

Sensorineural Hearing Loss is the most common form found in the elderly population because it involves degeneration of the auditory nerve (inner ear). Loud noise exposure, head trauma, infections, and simply aging are causes of deterioration of the nerve. The nerve is no longer able to transmit impulses to the brain. Usually in this situation, high frequency sounds are lost first while lower frequency sounds are still audible. 

Mixed Hearing Loss is obviously a combination of both. 

A complete audiogram tests normal air conduction sound, sounds heard by bone conduction, the vibratory capacity of the eardrum, and the person’s ability to hear and interpret speech. Various patterns appear on the audiogram print-out which enable the audiologist to determine the type of hearing loss and to define the origin of the deficit. 

The overall message of this blog is to be aware of how frequently doctors see hearing loss, and how not to deny its existence. So many people insist they don’t have a hearing problem when everyone else knows they do. Getting the individual to understand they have a problem is sometimes a difficult challenge.

A personal anecdote I can share involves a couple, one of whom was truly deaf and the other one was not. The man had the very latest assistive hearing technology while his wife minimized her problem despite having to be told things 2 or 3 times before she heard them. She steadfastly denied she had a hearing problem. One day we finally decided to test her and help her identify her problem. 

A group of us were watching TV. The volume control on the TV has a number system to determine the level of loudness. The numeric range of volume is usually from 0 to 100. Zero is no sound, 100 is as loud as the set will get. The couple, and “normal” hearing people, participated in this test. The normal hearing folks could hear the TV well at level 8. The deaf man could not hear the TV until the volume reach 95-100. The friend we were testing couldn’t hear the TV well until the volume level reached 39; that’s five times louder than the level at which normal-hearing people could hear. This is a crude test that lacks specificity, but it certainly showed our friend she had a problem that needed evaluation. 

If your wife or husband is constantly insisting you have a hearing problem, don’t be stubborn and deny it. Don’t be a curmudgeon. You won’t win any friends that way. When you have severe chest pain or when you can’t urinate, you do something about it. Not being able to hear is not a life or death matter nor does it make you miserable, but it affects your friends and family who become annoyed having to repeat everything they say to you. The hearing-impaired person is occasionally incorrectly thought to have dementia because they say things that aren’t appropriate to the current conversation or not related to the subject. So it is important for people with hearing problems to be evaluated and receive treatment that is appropriate for their situation.

Reference: Sehgal M, Sellers A, Biggs WS. Audiometry Interpretation for Hearing Loss in Adults. Am Fam Phys 2024 Apr;109(4):316-323.

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