1. Hearing Loss ACOVE March 15-June 28, 2013 Brad Keith, MD MUSC

2. Hearing Loss - Demographics Prevalence of hearing loss increases with age. “30% to 60% of population 65 and older have hearing impairment.” “Estimate over 6 million people 65 and up with hearing loss.” “3 rd most prevalent chronic condition behind HTN and OA. Only 25% of patients who would benefit hearing aids after testing actually get hearing aids. Yueh et al.

3. Hearing Loss – Is it a bad thing? “Associated with depression, social isolation, and function disability” JAMA 1-21-2013, Hearing loss and Cognitive Decline in Older Adults: “Hearing loss is independently associated with accelerated cognitive decline and incident cognitive impairment in community-dwelling adults” Yueh et al. Lin et al.

4. Hearing Loss – Should it be evaluated? Negative effects on quality of life have been shown for those with hearing impairments without intervention. Positive effects on quality of life have been shown for the use of hearing aids and / or surgical interventions.

5. Learning Objectives for Residents: Behavior: If a VE reports hearing loss which interferes with daily activity or bothers him or her enough for it to be evaluated and treated, then residents will perform Otoscopic exam to identify any immediately treatable cause of conductive hearing loss. If there is no immediately treatable cause of hearing loss, then residents will offer further audiologic or ENT evaluation /referral to patient if they would like. If patient does not want audiologic or ENT evaluation, then residents will offer information on hearing assistance devices.

6. Learning Objectives for Residents: Skill: Residents will demonstrate how to perform an otoscopic exam to an attending (does not have to be on a patient) Attitude: Residents will report improved confidence in their ability to accurately diagnose visible causes of conductive hearing loss by otoscopic exam.

7. Learning Objectives for Residents Knowledge. Residents will be able to identify: middle ear effusion (purulent or serous) on otoscopic exam cerumen impaction (foreign body) on otoscopic exam tympanosclerosis on otoscopic exam tympanic membrane perforation on otoscopic exam

8. Types of Hearing Loss - Sensorineural Sensorineural Hearing loss – Due to damage to neurons or hair cells transmitting auditory signals to the brain for interpretation. Loud environments, neural tumors, viral insults (acoustic neuritis) Most common form in aging for hearing decline over time. Sensorineural hearing loss due to aging is known as “presbycusis”

9. Types of Hearing Loss - Conductive Conductive Hearing Loss – Due to mechanical damage or obstruction of the middle ear or external auditory canal Examples of middle ear issues would be effusions (purulent – otitis media, serous – eustachian tube dysfunction), trauma to the boney structures or tympanic membrane (scarring –tympanosclerosis), or growths such as cholesteotomas or otosclerosis Examples of external auditory canal issues would be foreign body (cerumen, insect, crayon), inflammation (otitis externa), or growth (polyp, malignancy)

10. Objectives of our Hearing Loss ACOVE in simple terms 1.Identify if hearing loss is a problem for our patients 65 and up. 2.Treat any immediately reversible causes (cerumen or effusion). These are usually CONDUCTIVE causes. 3.Refer to Audiology for audiometric testing for hearing aids if feasible for patient. 4.Refer to ENT for treatment if any surgical intervention is warranted and feasible for patient. 5.Offer auditory assistance devices to those who can’t be helped by ENT or can’t afford hearing aids.

11. The Otoscope! Insert Image of Otoscope

12. Normal Anatomy Insert Image of a Normal Anatomy Ear

13. Middle Ear Effusion – Purulent Otitis Media Insert Image of Middle Ear Effussion – Purulent Otitis Media

14. Middle Ear Effusion – Serous Effusion Insert Image of Middle Ear Effusion – Serous Effusion

15. Cerumen Impaction (Foreign Body) Insert Image of Cerumen Impaction

16. Tympanosclerosis Insert Image of Tympanosclerosis

17. Perforated Tympanic Membrane Insert Image of Perforated Tympanic Membrane

18. Cholesteatoma Insert Image of Cholesteatoma

19. Insert Image of a Tuning Fork

20. It’s Tuning Fork Time! Weber Testing. To help differentiate between conductive and sensorineural hearing loss. (Board Review for Residents) Weber test: Strike the tuning fork and place on the forehead, teeth, or nose. -Normal Test: No lateralization of sound at all -Unilateral Conductive Loss: Lateralizes to affected ear -Unilateral Sensorineural Loss: Lateralizes to the normal ear or side you hear better in.

21. It’s Tuning Fork Time! Rinne Testing. To help test for conductive hearing loss. Rinne test: Strike the tuning fork and place on the mastoid. Have the patient tell you when they stop hearing the sound. Move the fork to beside the ear and check to see if they can hear the sound again. -Normal Test: Air conduction > Bone conduction – Patient hears the fork when placed BESIDE the ear. -Abnormal Test: Bone conduction > Air Conduction – Patient does not hear the fork placed BESIDE ear. Signifies a conductive hearing loss on the affected side.