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MIXED HEARING LOSS Whenever the hearing loss of a patient includes a mixture of both conductive and sensorineural characteristics, is said to have a mixed hearing loss.
Superior ventral cochlear nucleus (SVCN) Erythroblastosis typically causes hearing loss that centers around 3000–4000 Hz.
Central Auditory Processing Disorders (CAPD) CAPD characterized by decreased understanding of speech in the presence of background noise. FUNCTIONAL HEARING LOSS Functional or psychogenic hearing loss is the customary diagnosis when there is no organic basis for the patients apparent deafness. Functional Overlay It is entirely possible for hearing loss of functional origin to be superimposed on true organic hearing impairment.
History: A 34-year-old woman with otosclerosis and hearing loss for over 10 years Refuse to use hearing aids She often says, What?
Audiometric Patterns in Functional Hearing Loss There is no characteristic audiometric pattern in functional hearing loss, but the consistent inconsistencies serve to alert the physician.
Malingering Malingering is the deliberate fabrication of symptoms that the patient knows do not exist. Background: Acoustic shock injury has been described as a permanent injury to the auditory system either due to daily noise dose of in excess of 85 decibels or very loud impulse sound reputed to be in excess of 120 decibels and acoustic incidents.
13.Acoustic shock injury (ASI) MYRIAM WESTCOTT Dineen and Westcott Audiologists, Heidelberg, Victoria, Australia. Hearing deficiency may have started originally as a conductive failure (otosclerosis) and later developed a superimposed sensorineural component. In clinical practice, most cases with an original sensorineural etiology remain in that classification without an added conductive element.
In chronic otitis media some toxic inflammatory metabolite produces a cochleitis or labyrinthitis. This example a warning to physicians to avoid assuring any patient that his hearing loss can be corrected merely by removing cerumen, because mixed hearing loss may be found subsequently. In every case of mixed hearing loss one should determine how much of the deficit is conductive and how much is sensorineural.
If the patient does not understand any better with a hearing aid or when the voice is raised, hearing is not improved even if the conductive portion of the mixed hearing loss is corrected.
17 The auditory pathway consists of a series of transducers that repeatedly change the speech stimulus so that it can be handled effectively by the cortex. Characteristic Features of central hearing loss : Hearing tests do not indicate peripheral hearing impairment.
This may be caused by injury to SVCN spheroid cells, the second-order neurons of the ascending auditory pathway, even in the presence of normal hair cells in the organ of Corti.
Common complaints include inability to study or read in the presence of noise, slowing of reading speed caused by noise(vacuum cleaners or air conditioners ) and suspicion by family members that the patient has a hearing loss. The inability to hear results entirely or mainly from psychological or emotional factors, and the peripheral hearing mechanism may be essentially normal. Psychogenically induced hearing loss usually is a uniform flat- tone loss in all frequencies, suggestive of a well-marked conductive impairment. Usually, the hearing impairment is bilateral, and the bone conduction level is the same as the air conduction level.
This study was performed to compare the results of audiogram and the newer diagnostic method distortion product otoacoustic emissions (DPOAEs) parameters due to acoustic shock injury in call center professionals working in a noisy environment and prone to acoustic injury.
Evaluation of acoustic shock induced early hearing loss with audiometer and distortion product otoacoustic emissions. There is a concern regarding issues of health and safety that are unique to this new and developing industry. Effects of industrial noise exposure on distortion product otoacoustic emissions (DPOAEs) and hair cell loss of the cochlea - long term experiments in awake guinea pigs.
The relation among hearing loss, sensory cell loss and tuning characteristics in the chinchilla.
Sensitivity of transient evoked and distortion product otoacoustic emissions to the direct effectsof noise on the human cochlea. Monitoring noise susceptibility: Sensitivity of otoacoustic emissions and subjective audiometry.
The difficulty may have been sensorineural in the beginning ( presbycusis ), and a conductive defect (middle-ear infection ) may have developed subsequently. In contrast, most cases that start as conductive hearing impairment later develop some sensorineural involvement. The sensorineural deficit may be caused by penetration of the oval window with exposure of the perilymph. Prognosis: In mixed hearing loss the prognosis depends on the relative proportion of conductive and sensorineural pathology.

There is no characteristic audiometric pattern, except that the disparity between the hearing level and the speech interpretation is quite marked. Central pathology must be included in the differential diagnosis of the hearing loss producing a 4000-cycle dip on the audiogram. If people talk to a person with CAPD while he or she is involved in auditory concentration such as listening to a television program, the person will often not hear.
The basis for functional hearing loss in most patients is psychogenic, the product of emotional conflict, ( neurotic anxiety ). Hysterical blindness and paralysis are other examples of the same type of somatization or conversion reaction.
In a patient with unilateral functional deafness there may be complete absence of bone conduction on the side of the bad ear, though the good ear has normal acuity. If the patient claims he has one good and one bad ear, and the examiner obstructs his good ear with a finger, then shouts into it loudly enough to be heard easily by bone conduction alone, the malingerer claims he hears nothing. Materials and Methods: Hearing functions of 340 subjects were first assessed with pure tone audiometry and then DPOAEs results were compared among acoustic shock exposed subjects with normal audiogram and those with abnormal audiogram. In some cases the conductive and the sensorineural elements may have started simultaneously ( severe head injury affecting both the inner ear and the middle ear ). Despite meticulous surgical care, the inner ear also can be traumatized readily and made more susceptible to infection. The best way to approximate the conductive and the sensorineural components of a hearing loss is to perform all possible tests for estimating the patients sensorineural potential or cochlear reserve. If the sensorineural component is slight, the surgical prognosis is good, and under favorable circumstances the hearing may approximate the level of the bone conduction.
In certain cases, central hearing loss may mimic peripheral causes of deafness, including occupational deafness.
However, if one gets the persons attention by calling his or her name before speaking, the first sentence will not be missed, and hearing is normal. Tinnitus is a characteristic feature of hysterical deafness, and patients often claim that the noise is unbearable.
Too spectacular an improvement with a hearing aid, especially when the patient has set the controls at minimal amplification, or a sudden disproportionate improvement in hearing after a simple procedure such as drum massage or insufflating the eustachian tube.
Such a patient even may deny hearing shouts directed at the bad ear in spite of the good hearing in the opposite ear. Results: Out of 340 acoustic shock exposed subjects 304 were normal on audiometric testing and 34 had abnormal audiograms. It has been defined as the temporary or permanent disturbance of the functioning of the ear or of the nervous system which may be caused to the user of a telephone ear phone by a sudden sound in the acoustic pressure produced by it. The DPOAE test consisted of presenting two primary tones at frequencies f1 and f2 at levels L1 and L2.
In surgical trauma to the inner ear, high-frequency hearing loss often falls below the preoperative level, and the patient may complain of reduced discrimination though his pure-tone threshold is improved.
However, the discrimination is not improved much, even after correction of the conductive defect. The chief function of the auditory cortex is to interpret and to integrate these impulses and to provide the listener with the exact meaningful information intended by the speaker, or to permit the listener to react appropriately to the actual implication of the sound.
The spheroid cells of the superior ventral cochlear nucleus (SVCN) show an anatomical frequency gradient, low ventral to high dorsal. Treatment : altering the listening environment to obtain the best possible signal-to-noise ratio.
Hearing acuity usually varies, depending on the patients emotional state at the time of testing.
In complete deafness the presence of cochlear nerve reflexes with loud noises indicates either malingering or hysteria. Subsequently on DPOAE testing out of 304 acoustic shock exposed subjects with normal audiogram 125 failed and 181 passed.
If the patient hears and discriminates well when speech is made louder, then the conductive element probably is a major cause of the hearing difficulty, and there is a good chance that surgery will improve the hearing. A similar adverse effect is noted in the ear opposite the tumor when certain words are interrupted periodically or accelerated. Conclusions: This study showed that DPOAEs are more sensitive than audiometry to detect pre-symptomatic inner ear damage. These are the results of regular and repeated acoustic shock, which has damaged the outer hair cells of the inner ear that interpret sound vibrations as words, music, or other sounds.Acoustic shock-induced hearing loss is permanent and not correctable by medical or surgical treatment, but is the most preventable type of hearing impairment. The stimuli levels were held constant at L1=65 dB sound pressure level (SPL) and L2=55 dB SPL. Acoustic shock-induced hearing loss is currently detected and monitored with pure-tone audiometry.

Labyrinthitis Otosclerosis was at one time thought to retain its purely conductive character for years; today it is recognized that this condition develops sensorineural impairment in same cases. This method is subjective, time consuming, and not quite sensitive to small changes in pure tone thresholds.
Since recently, a modern diagnostic method, otoacoustic emissions (OAEs), may be used as an accurate, objective, fast, and noninvasive tool for assessing the function of outer hair cells in clinical practice. Also, acoustic shock differs from noise-induced hearing loss as it is believed to occur at sound pressure levels below those which present an immediate risk to hearing damage.OAEs are low-level sounds originating within the cochlea. The pure tone audiometry thresholds for 4000 Hz were significant in group with abnormal audiogram. Through reverse propagation, some of this acoustic energy leaks from the cochlea and travels through the middle ear to the external auditory meatus, where it can be recorded using a sensitive microphone. Signal noise ratio >6 dB was regarded as an indication of a DP being present, and the subjects were assigned as a pass (normal) case.
DPOAEs may be an alternative to pure-tone audiometry in monitoring cochlear changes in subjects exposed to occupational noise.
This method is subjective, time consuming, and not quite sensitive to subtle small changes in pure tone thresholds. OAEs are a diagnostic method that is used as an accurate, objective, sensitive, fast, and noninvasive tool for assessing the function of outer hair cells.
Subjects had no underlying disease (diabetes mellitus, hypertension, dyslipidemia) and were selected on the basis of the lack of exposure to ototoxic agents, ear trauma or surgery, chronic ear diseases, and a family history of hearing loss.
For these reasons, OAES have been proposed as an alternative method for monitoring cochlear function in cases with noise exposure. Results from several studies have demonstrated that OAES parameters are depressed following noise exposure.
They had no history of upper respiratory tract infection or ear problems and were not under the influence of alcohol, so any confounding effects were avoided.
Exclusion criteria were the presence of cardiovascular events, diabetes, hyperlipidemia, and immeasurable audiometric data because of poor collaboration by the participant. Cochlear dysfunction in noise-induced hearing loss may extend beyond the frequency region suggested by the audiogram. The inclusion criterion was exposure to a mean (SD) noise level equivalent to 85 dB (A) for 2 years and use of the same noise-protection equipment.The research proposal was approved by the ethical committee, Vydehi Institute of Medical Sciences and Research Center, and informed consents were obtained in all subjects. Procedures The subjects completed a questionnaire regarding the history of noise exposure, ear diseases, and underlying diseases.
Conventional pure-tone audiometry and DPOAEs were conducted after otoscopic examination, which included the removal of wax from the ear canal.
Results range from very slight dips at 4 and 6 kHz to a moderate degree of hearing impairment with flat pattern, similar to that noted by Beastall (1992) [11] and in those cases of cordless telephone handset injury reported by other researchers.
Conventional pure-tone audiometry The conventional pure-tone audiometry was conducted in a sound-treated room. Myriamwescott [13] attributed the acoustic shock injury to the possible neurophysiological phenomenon, in particular the tonic tensor tympani syndrome. A cluster of symptom-attributed acoustic shock were complained by the subjects in our study too, but we could not correlate our study outcome with any middle ear pathology and neurophysiological syndrome. The examined ear was defined as "normal" if a threshold shift larger than 25 dB was not found over the whole frequency range. 26 out of 34 subjects in the acoustic shock-exposed group with abnormal audiogram were found to have failed in the OAES test which was expected, whereas 125 out 304 subjects of the group with normal audiogram were found to have failed in the OAES test which forms significant proportion.Though overall pass percentage was more than fail percentage giving audiometry its existing due credibility what was more shocking to observe was that the majority in the acoustic shock-exposed group with normal audiogram failed in OAES leading to lower pass percentages.
Lower pass rates in the acoustic shock-exposed group with normal audiograms we found out with our study will clearly indicate the importance of DPOAE testing to detect early changes due to acoustic shock. DPOAEs provided functional information about well-defined frequency-specific regions of the cochlea.It has been shown that there is little intra-subject variability in OAE measurements. Workers with abnormal DP screening results, even if audiometric results are normal, should have follow-up counseling and evaluation of hearing-protective-device effectiveness to prevent irreversible noise-induced hearing loss. However, there are no guidelines for the use of OAEs to detect and monitor noise-induced hearing loss now. Clarifying advantages of DPOAEs in terms of sensitivity to early manifestations of noise insults, or their utility in predicting future loss in hearing, will require a longitudinal follow up in which the same people are watched over time to see how their hearing changed with their OAEs.In conclusion, the presenting results are in agreement with the findings of previous studies, in that DPOAE testing was shown to be more sensitive to pre-symptomatic inner ear damage than conventional audiometry but cannot estimate hearing thresholds. DPOAE testing should be implemented as a screening and monitoring test for noise-exposed workers rather than as a replacement of audiometry.

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