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What causes hearing loss?Losing your hearing is a normal and inevitable part of the ageing process. Action on Hearing Loss: Enjoy the sparks but avoid the ringing in your ears this bonfire night. Michael Rothschild, MD, director, pediatric otolaryngology, Mount Sinai Medical Center, New York. National Institute on Deafness and Other Communication Disorders, National Institutes of Health.
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An in-vitro comparison of the disintegration of human ear wax by five cerumenolytics commonly used in general practice. Methotrexate in the management of immune mediated cochleovestibular disorders: clinical experience with 53 patients.
Just as with all other aspects of human biology, there is a broad range of Eustachian tube function in children- some children get lots of ear infections, some get none.
Allergies are common in children, but there is not much evidence to suggest that they are a cause of either ear infections or middle ear fluid. Ear infections are not contagious, but are often associated with upper respiratory tract infections (such as colds). Acute otitis media (middle ear infection) means that the space behind the eardrum - the middle ear - is full of infected fluid (pus). Any time the ear is filled with fluid (infected or clean), there will be a temporary hearing loss.
The poor ventilation of the middle ear by the immature Eustachian tube can cause fluid to accumulate behind the eardrum, as described above. Ear wax (cerumen) is a normal bodily secretion, which protects the ear canal skin from infections like swimmer's ear.
Ear wax rarely causes hearing loss by itself, especially if it has not been packed in with a cotton tipped applicator. In the past, one approach to recurrent ear infections was prophylactic (preventative) antibiotics.
For children who have more than 5 or 6 ear infections in a year, many ENT doctors recommend placement of ear tubes (see below) to reduce the need for antibiotics, and prevent the temporary hearing loss and ear pain that goes along with infections. For children who have persistent middle ear fluid for more than a few months, most ENT doctors will recommend ear tubes (see below). It is important to remember that the tube does not "fix" the underlying problem (immature Eustachian tube function and poor ear ventilation).
Adenoidectomy adds a small amount of time and risk to the surgery, and like all operations, should not be done unless there is a good reason. In this case, though, the ventilation tube serves to drain the infected fluid out of the ear.
The most common problem after tube placement is persistent drainage of liquid from the ear. In rare cases, the hole in the eardrum will not close as expected after the tube comes out (persistent perforation).
I see my patients with tubes around 3 weeks after surgery, and then every three months until the tubes fall out and the ears are fully healed and healthy. If a child has a draining ear for more than 3-4 days, I ask that he or she be brought into the office for an examination. Once the tube is out and the hole in the eardrum has closed, the child is once again dependant on his or her own natural ear ventilation to prevent ear infections and the accumulation of fluid. About 10-15% of children will need a second set of tubes, and a smaller number will need a third set.
Children who have ear tubes in place and who swim more than a foot or so under water should wear ear plugs. Deep diving (more than 3-4 feet underwater) should not be done even with ear plugs while pressure equalizing tubes are in place. The outer ear consists of the visible part of the ear (pinna), the ear canal and the ear drum. The middle ear is an air-filled space that contains the three smallest bones in the human body: the malleus, the incus and the stapes. With glue ear associated with upper respiratory tract symptoms or with proven atopy, the use of an antihistamine and nasal steroid spray assist the resolution of the middle-ear effusion.
A similarly blue appearance of the tympanic membrane is seen following injury when bleeding occurs in the middle ear (hemotympanum). An arrow indicates the radial incision of the myringotomy into which the grommet may be inserted. The grommet usually extrudes spontaneously between 6-18 months to leave an intact drum, and is found in wax in the meatus.
It is estimated that hearing loss affects more than half of adults living in the UK aged 60 and over.Hearing loss can have a detrimental impact on your quality of life, emotional and physical well-being, and can even lead to psychological and social problems.
Since hearing loss usually develops gradually over time it can be many years before people become aware of it. If hearing loss has gone unnoticed or left untreated for too long it can possibly lead to 'auditory deprivation'. Outer EarSounds are collected by the external part of the ear (pinna) and travel through the ear canal (external auditory meatus).
Foreign bodies – any object that appears in the ear canal that should not be there is referred to as a foreign body.
Otitis externa – this is an inflammation of the outer ear skin due to an infection or an eczema type problem. Exotosis – also known as 'surfer's ear', this is an abnormal growth(s) or lump(s) of the bony portion of the ear canal (near to the eardrum) that can cause it to constrict and narrow. Stenosis – a gradual narrowing of the external auditory meatus usually as a result of repetitive (chronic) ear canal infections.
Cholesteotoma – this is a rare condition caused through the collection of dead skin cells inside your ear. Ossicular discontinuity – this is a disconnection (disarticulation) of the three middle ear bones meaning they are loosely or no longer connected together. Eustachian tube dysfunction – the Eustachian tube is a narrow passage connecting the back of the nose to the air-filled middle ear. Middle ear effusion (MEE) – this is a build-up of fluid in the middle ear which normally occurs secondary to Eustachian tube dysfunction because fluid can no longer drain away. Inner EarThe vibrations transmitted through the middle ear lead to the movement of fluid that fills the organ of hearing (cochlea). Presbyacusis - this is age-related hearing loss that gradually and progressively deteriorates due to the ageing process. Action on Hearing Loss (formerly RNID) says more than 70% of people over the age of 70 have some degree of hearing loss. It is intended for general information purposes only and does not address individual circumstances. The differential diagnosis of hearing loss can be simplified by considering the three major categories of loss. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference.
The cochlea is a snail-shaped bone filled with fluid and thousands of tiny a€?hair cellsa€? that process sound vibrations. The conductive hearing loss associated with this injury resolves with resorption of the middle-ear hematoma. To achieve sharp hearing acuity and understanding, each individual part in the process must function normally: Outer Ear, Middle Ear, and the Inner Ear. Sound signals travel from the natural environment into the ear canal and ultimately to the eardrum itself.
The harmonious concert of each element within the outer, middle and inner ear are necessary to complete the sense of hearing. More specifically, hearing loss can impair individuals' ability to hear loved ones, reduce clarity when listening to the TV and radio, create moments of uncertainty and indecision when following conversation in group situations and background noise, and pose challenges when trying to judge the distance and direction of sounds such as oncoming traffic when crossing the road. The gradual nature of hearing loss can also make some people inclined to believe that others are 'mumbling' and no longer speaking clearly, rather than it being due to them developing and suffering from hearing loss. Auditory deprivation is when your ears and brain are starved of detecting and hearing sounds for a prolonged period of time whereby they begin to lose their abilities to function effectively. The type of hearing loss you have depends upon which region of the hearing pathway is affected. It serves to lubricate the ear canal preventing it from drying out, reduce the likelihood of fungi and bacterial infections by creating a slightly acidic environment within the ear, capture dead skin cells (keratin) and small foreign bodies (e.g. Examples of foreign bodies are cotton wool, insects and small toys such as marbles (usually placed into the ear canal by children themselves!).
It is caused usually through regular exposure to cold winds and water, hence why it is most prevalent amongst surfer’s. Usually dead skin cells migrate out of the ear but sometimes they can collect inside the ear canal, especially if you have stenosis or an inwards buckled (retracted) eardrum. Its function is to equalise the air pressure in the middle ear to the air pressure in the atmosphere (i.e.
Over time, the build-up of fluid becomes thick and sticky (viscous) leading to the middle ear becoming infected. As a result, tiny hair cells in the cochlea begin to ‘sway’ generating electrical impulses that travel up the hearing nerve to the brain.
First and foremost, it affects the higher frequencies leading to difficulties hearing speech clearly especially in the presence of background noise. Examples of ototoxic drugs are chemotherapy drugs (cisplatin), antibiotics drugs ending in either –micin or –mycin (e.g. It is believed to be as a direct result of excess inner ear fluid (endolymph) either through over-production (hyperactive endolymphatic sac) or an inability for it to drain out of the inner ear (blocked endolymphatic duct).


It is a benign tumour that usually develops on the balance nerve that intertwines with the hearing nerve to form the VIII nerve. However, while many of us will experience gradual loss of hearing over the years, noise exposure at home, work or leisure can also cause impairment. It is not a substitute for professional medical advice, diagnosis or treatment and should not be relied on to make decisions about your health.
Conductive hearing loss occurs when sound conduction is impeded through the external ear, the middle ear, or both. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP.
The middle ear is also connected to the throat via the Eustachian tube, which makes sure the air pressure is the same on both sides of your eardrum, and allows your ears to a€?popa€? when youa€™re flying in a plane or driving through mountains. Vibrations enter the cochlea and the fluid is set into motion, like a wave, and the hair cells move in response. A persisting conductive hearing loss following injury, however, suggests injury to the ossicles with an ossicular discontinuity (see Fig. If otitis media with effusion with poor hearing persists for over three months, myringotomy (under general anesthetic in children) with aspiration of the fluid is often necessary.
If normal eustachian tube function has not returned and otitis media with effusion recurs, the grommet is replaced.
The natural resonance of the ear canal functions to boost high frequency sounds which are critical to speech understanding.
The ossicles boost the mechanical energy from the vibrating eardrum and transfers it into the Inner Ear through the Cochlea’s Oval Window.
If left untreated, the cholesteotoma can develop and begin to erode the middle and inner ear structures. This is because the nerve fibers that code for high frequency sounds are situated near the entrance (apex) of the organ of hearing (cochlea) meaning they are more susceptible to general wear and tear over the years. Excess endolymph causes a swelling in the inner ear which can lead to vertigo, tinnitus, feeling of pressure and hearing loss. The tumour can grow and compress against the hearing nerve affecting the electrical signals created by the swaying of hair cells being transmitted to the brain.
It's estimated that 10 million people in the UK – that's one in six - have some level of hearing loss. Never ignore professional medical advice in seeking treatment because of something you have read on the BootsWebMD Site.
Sensorineural hearing loss occurs when there is a problem within the cochlea or the neural pathway to the auditory cortex. When the hair cells move, they send electrical signals along the hearing nerve and toward the brain. For most people, ear wax naturally migrates out of the ear and so there is no need to clean the ears. If vibrations are not transmitted through the middle ear it can again cause a conductive hearing loss.
This is because the eardrum is at its most mobile and efficient when the air pressure is equalised on either side.
It is usually accompanied by tinnitus and causes high frequency hearing loss since the nerve fibers that code for high frequency sounds are more exposed. Loud noise at workExposure to continuous loud noise during your working day can make you permanently hard of hearing in the long term.
The ear is divided anatomically into three sections (external, middle, and inner), and pathology contributing to hearing loss may strike one or more sections. Mixed hearing loss is concomitant conductive and sensorineural loss.EvaluationA thorough history and a careful physical examination are essential to the diagnosis and treatment of hearing loss.
However, ear wax can get impacted and trapped in those people who use cotton buds or have narrow ear canals. Jobs that are hazardous to hearing include construction, the military, mining, manufacturing, farming or transportation. To learn everything you need to know about hearing aids, read the eBook, Hearing Aids Inside Out. Normally, the Eustachian tube is closed and it only opens during moments of yawning, swallowing and chewing.
Leading causes of conductive hearing loss include cerumen impaction, otitis media, and otosclerosis. However, if the Eustachian tube becomes blocked and does not open when it should, air in the middle ear gets absorbed to create a 'vacuum' and negative middle ear pressure. The Health and Safety Executive says employers have a duty to protect employees from hearing loss. Leading causes of sensorineural hearing loss include inherited disorders, noise exposure, and presbycusis. An understanding of the indications for medical management, surgical treatment, and amplification can help the family physician provide more effective care for these patients. An otoscope should be used to examine the external auditory canal for cerumen, foreign bodies, and abnormalities of the canal skin.
Injury damage or pressure changesTrauma to the head can impact the ear and cause permament hearing loss. The mobility, color, and surface anatomy of the tympanic membrane should be determined (Figure 1).
Sudden pressure changes, like scuba diving or flying, can also harm the eardrum, middle ear or inner ear.
While eardrums may take a few weeks to get better, serious inner ear damage may require an operation. The sound remains midline in patients with normal hearing.The Rinne test compares air conduction with bone conduction. When the patient no longer can hear the sound, the tuning fork is placed adjacent to the ear canal (air conduction). These are called ototoxic drugs, which may cause damage to the inner ear, resulting in hearing loss, balance problems and tinnitus.
In the presence of normal hearing or sensorineural hearing loss, air conduction is better than bone conduction.
Antibiotics linked to possible permanant hearing loss include: gentamicin, streptomycin and neomycin.
Audiograms objectively measure hearing levels and compare them with standards adopted by the American National Standards Institute in 1969.1 Normal hearing levels are 20 dB or better across all frequencies. Chronic diseaseSome chronic diseases that are not directly linked to ear issues may trigger hearing loss. The audiogram measures air conduction and bone conduction and presents them graphically across the hearing frequencies. Audiographically demonstrated conductive hearing loss results in the air line falling below the bone line, creating an air-bone gap.Speech testing should be performed using standard word lists.
The speech reception threshold is the sound level at which 50 percent of presented words are understood. Some types of hearing loss are also linked to autoimmune diseases like rheumatoid arthritis. The speech recognition score is the percentage of words understood at 40 dB above the speech reception threshold.Conductive Hearing LossEXTERNAL EARComplete occlusion of the ear canal by cerumen is a frequent cause of conductive hearing loss.
How you hear – anatomy of the earSound causes the eardrum and its tiny attached bones in the middle part of the ear to vibrate.
Warm water (body temperature) irrigation is a safe method of removing cerumen in patients who have no history of otitis media, perforation of the tympanic membrane, or otologic surgery. The spiral-shaped cochlea in the inner ear transforms sound into nerve impulses that travel to the brain.
The fluid-filled semicircular canals attach to the cochlea and nerves in the inner ear and send information on balance and head position to the brain. The distance to the tympanic membrane must be kept in mind, because otoscopes do not allow for depth perception. Growths and tumoursHearing loss can be caused by benign, non-cancerous growths, such as osteomas, exostoses or polyps that block the ear canal.
Aqueous-based preparations, including docusate sodium, sodium bicarbonate, and hydrogen peroxide, are effective cerumenolytics.2,3Foreign bodies in the external auditory canal also can cause unilateral conductive hearing loss.
If the object is not impacted or hygrostatic, warm water irrigation probably should be attempted first.
If this approach is not effective, the foreign body can be removed with an instrument if the patient is cooperative. A large neuroma can cause headaches, facial pain or numbness, lack of limb coordination and tinnitus.
If the patient is uncooperative, removal in an operating room may be necessary.Otitis externa is an infection of the skin of the external auditory canal. Patients with otitis externa experience pain on manipulation of the pinna or tragus, and their ear canal is edematous and filled with infectious debris. Loud bangs!Remember, remember the 5th of November – but also remember to take care of your ears on Bonfire Night! Exposure to loud noise over 85 decibels can cause permanent hearing loss and while fireworks are lovely to watch, some can break that sound limit with a searing 155 decibels.
The most common pathogens in otitis externa are Pseudomonas aeruginosa and Staphylococcus aureus.4 Treatment involves debridement of the canal, followed by the application of ototopical drops. Gunshots and other explosive noises also pack a punch to your ear, in some cases rupturing eardrums or causing damage to the inner ear.
In patients with severe otitis externa, a wick is placed in the ear for two to three days to ensure delivery of the medication. Loud concerts and tinnitusThat loud buzzing sound in the ears after a loud concert is called tinnitus. The average rock concert exposes you to sound as loud as 110 decibles which can do permamant damage after just 15 minutes.


Other noises that break the 85 decibel range and risk permanent hearing loss include power tools, chain saws and leaf blowers. The conductive hearing loss resolves after the inflammation subsides.Exostoses and osteomas are benign bony growths of the external auditory canal that interfere with normal cerumen migration, leading to occlusion and conductive hearing loss. Prevent tinnitus and potential hearing loss, which can last days, months or years by using earplugs and limiting noise exposure. Personal music playersIf other people can hear the music you're listening to through your earphones, you may be at risk of permanent hearing loss. Osteomas are single and unilateral, and are found at the bony-cartilaginous junction (Figure 2).
A recent survey revealed that over 92% of young people listen to music on a personal player or mobile phone. Recent EU standards limited the sound on these devices to 85 decibels, but many listeners plan to override the new default volume – saying they want to wipe out background noise. Sebaceous cysts, fibromas, papillomas, adenomas, sarcomas, carcinomas, and melanomas also have been reported.
Action for Hearing Loss suggests using noise-cancelling headphones rather than pressing override and risking lifelong damage to your hearing.
If a malignancy is suspected, prompt biopsy is indicated.MIDDLE EARMiddle ear pathology may lead to conductive hearing loss.
EarwaxIt may be yucky and unsightly but earwax does serve a useful purpose, protecting the ear canal from dirt and bacteria.
Perforations of the tympanic membrane cause hearing loss by reducing the surface area available for sound transmission to the ossicular chain (Figure 3). However, if earwax builds up and hardens, it can dull your hearing and give you an earache.
If you feel your ears are clogged, see your GP or nurse who may suggest olive oil drops to soften and disperse the wax.
In patients who have had chronic otitis media with tympanic membrane perforation, otoscopic examination and debridement are essential. Ototopical antibiotics (ofloxacin [Floxin]) are necessary, and oral antibiotics may be helpful. Don't be tempted to do it yourself with a cotton bud – or any other implement - which only risks damage to the ear. Childhood illnessChildren are susceptible to ear infections, which are among many childhood illnesses that can cause hearing loss.
Small perforations (less than 2 mm) often heal spontaneously.5 In the acute setting, blood may obstruct the ear canal and prevent visualization of the membrane.
Usually, infections that fill the middle ear with fluid cause only temporary hearing loss but some may cause harm to the middle or inner ear and lead to permanent hearing loss. Illnesses linked to hearing loss in children include chickenpox, influenza, measles, meningitis, encephalitis and mumps. If the perforation or hearing loss persists beyond two months, the patient should be referred for consideration of surgical correction. Born with hearing lossIn the UK, one or two babies in every thousand are born with significant hearing loss.
The diagnosis of otitis media can be confirmed by tympanometry and audiometry, and resolution of the effusion restores hearing. Although congenital hearing loss often runs in families, it can also be triggered by an infection in the mother during pregnancy.
Hearing loss can also develop after lack of oxygen or trauma at birth, or if a newborn is premature. AgeRegardless of how you protect your ears, getting older reduces your hearing as you gradually lose inner ear hair cells. Congenital cholesteatoma presents as a pearly white mass located behind an intact tympanic membrane in a patient with unilateral conductive hearing loss.
Acquired cholesteatoma results from a retracted or perforated tympanic membrane with an ingrowth of epithelium.
Conductive hearing loss caused by ossicular erosion is present in 90 percent of patients with cholesteatomas.8 Longstanding cholesteatomas expand to involve the mastoid, inner ear, and facial nerve. If you are struggling to hear and it is affecting your quality of life, go to your GP or NHS clinic to arrange a hearing test. Suspicion of cholesteatoma warrants surgical consultation.Myringosclerosis of the tympanic membrane develops in response to infection or inflammation (Figure 3). Irregular white patches consisting of calcium are visible on the membrane.9 Isolated myringosclerosis of the tympanic membrane rarely causes significant conductive hearing loss.
However, extensive myringosclerosis, referred to as tympanosclerosis, involves the tympanic membrane, ossicular chain, and middle ear mucosa, and causes significant conductive hearing loss by stiffening the entire system.Otosclerosis is characterized by abnormal bone deposition at the footplate (base of stapes).
This bone deposition leads to fixation of the stapes at the oval window, preventing normal vibration.
Otosclerosis typically presents as progressive bilateral conductive hearing loss in middle-aged white women.
It is the leading cause of conductive hearing loss in adults who do not have a middle ear effusion or a history of otitis media.10 There is usually a positive family history. These neuroendocrine tumors arise from the adventitia of the jugular bulb or the neural plexus within the middle ear space. Characteristically, patients presenting with glomus tumors are women 40 to 50 years of age who report pulsatile tinnitus and hearing loss. On examination, a pulsating reddish-blue mass may be seen behind an intact tympanic membrane.
However, diagnosis of these tumors is difficult, and computed tomography of the temporal bones is required. Although most patients with this type of hearing loss are adults, children also can be affected. Hereditary and non-hereditary congenital hearing loss are the two major pediatric classifications. The majority of hereditary losses are autosomal recessive and are frequently associated with other systemic findings. More than 100 congenital syndromes are associated with sensorineural hearing loss.The consequences of delayed detection can be significant.
Neonates considered at high risk for congenital hearing loss (Table 3)11 traditionally have been screened, and 30 states now require universal newborn auditory screening.12 The American Academy of Pediatrics and several other organizations endorse universal auditory screening. Year 2000 position statement: principles and guidelines for early hearing detection and intervention programs.
The etiology is a combination of inherited and environmental factors, including lifetime noise exposure and tobacco use.
High frequencies are affected first, typically at 4,000 Hz, followed by middle and lower frequencies.
The use of foam-insert earplugs decreases noise exposure by 30 dB.A less common cause of hearing loss is ototoxin exposure, typically from diuretics, salicylates, aminoglycosides, and many chemotheraupetic agents. These medications must be administered carefully in patients who are elderly, have poor renal function, require a prolonged course of medication, or require simultaneous administration of multiple ototoxic agents.
Patients with ototoxin exposure may experience hearing loss or dizziness.Autoimmune hearing loss has been diagnosed with increasing frequency since the 1980s. Patients present with rapidly progressive bilateral sensorineural hearing loss and poor speech discrimination scores, and they also may have vertigo or disequilibrium.
Hearing loss progresses over three to four months, and an associated autoimmune disorder may be present. Symptoms usually improve with the administration of oral prednisone, and response to this steroid is currently the best way to make the diagnosis.
Low-dose methotrexate therapy is becoming an accepted alternative to long-term prednisone therapy.14UNILATERAL HEARING LOSSTemporal bone fractures can cause unilateral sensorineural and conductive hearing loss. When the fracture line involves the bony labyrinth (cochlea or vestibule), sensorineural hearing loss occurs. Temporal bone injuries are associated with facial nerve paralysis, cerebrospinal fluid leakage, and other intracranial injuries.
Early consultation is essential, and prompt surgical intervention may be required.Trauma may cause rupture of the round or oval window membranes, with perilymph leaking into the middle ear (fistula).
Perilymph fistulas also may occur after straining, lifting, coughing, or sneezing, and are managed with three to six weeks of bed rest, followed by surgical repair if symptoms do not improve.15Meniere's disease is another cause of sensorineural hearing loss.
Patients report unilateral fluctuating hearing loss with aural fullness, tinnitus, and episodic vertigo. Initially, the hearing loss is in the low frequencies, but higher frequencies are affected as the disease progresses. The etiology of Meniere's disease remains unclear, but endolymphatic hydrops (increased fluid pressure within the inner ear) has been identified. The work-up consists of serial audiometry to document a fluctuating loss, vestibular testing to verify the diseased ear, and radiographic imaging to rule out an acoustic tumor.
Hearing aids are often ineffective because patients suffer from poor speech discrimination, as well as diminished tolerance to amplified sound. A history of upper respiratory infection within a month of the hearing loss is often described in patients who have a viral etiology.
The work-up includes audiometry, followed by radiographic imaging to rule out an acoustic tumor.
One study found that patients with minimal hearing loss, no vestibular symptoms, and early treatment have better outcomes.18Patients with acoustic neuromas present with unilateral sensorineural hearing loss approximately 10 to 22 percent of the time19 (Figure 6).
Patients with asymmetric sensorineural hearing loss require evaluation for a retrocochlear tumor.



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