Diagnostic Tests for Noise-Induced Hearing Loss
Noise-Induced Hearing Loss Tests: Book Excerpts
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Noise-Induced Hearing Loss Diagnosis: Book Excerpts
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DEAFNESS:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
Audiometry and caloric testing or electronystagmography should be done in almost all cases in which the ear examination is normal. It is probably wise to consult an otolaryngologist at this point. Tympanography will be helpful in diagnosing subtle cases of serous otitis media. X-rays of the mastoids, petrous bones, and internal auditory canal should be done for chronic otitis media, cholesteatoma, and acoustic neuroma. If an acoustic neuroma is suspected, however, an MRI of the brain and auditory canals must be done. If basilar artery insufficiency is suspected, four-vessel cerebral angiography should be done. Magnetic resonance angiography is an excellent noninvasive alternative for diagnosing vertebral-basilar artery disease. If multiple sclerosis is suspected, MRI of the brain, BSEP and VEP studies, and a spinal tap for spinal fluid analysis may be done.
Rather than perform these tests, the most cost-effective approach would be to refer the patient to a neurologist if other focal neurologic findings are evident.
» READ BOOK EXCERPT ONLINE »
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
TINNITUS:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
The basic workup includes a CBC, sedimentation rate, urinalysis, chemistry panel, thyroid profile, VDRL test, audiometry, caloric tests (electronystagmography), and x-rays of the mastoids and petrous bones. Specialized audiometry may be performed, such as impedance audiometry, Békésy audiometry, and BSEP studies.
If an acoustic neuroma is strongly suspected, CT scans with iodine infusion or instillation of 4 cc of oxygen in the subarachnoid space would be indicated. Gadolinium-enhanced MRI may also diagnose an early acoustic neuroma. Angiography and venography may help diagnose objective tinnitus. A spinal tap may be helpful in diagnosing multiple sclerosis and central nervous system syphilis. A glucose tolerance test may be indicated to rule out diabetes mellitus.
» READ BOOK EXCERPT ONLINE »
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
Hearing loss:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
If the patient reports hearing loss, ask him to describe it. Is it unilateral or bilateral? Continuous or intermittent? Ask about a family history of hearing loss. Then obtain the patient’s medical history, noting chronic ear infections, ear surgery, and ear or head trauma. Has the patient recently had an upper respiratory tract infection? After taking a drug history, have the patient describe his occupation and work environment.
Next, explore associated signs and symptoms. Does the patient have ear pain? If so, is it unilateral or bilateral, or continuous or intermittent? Ask the patient if he has noticed discharge from one or both ears. If so, have him describe its color and consistency, and note when it began. Does he hear ringing, buzzing, hissing, or other noises in one or both ears? If so, are the noises constant or intermittent? Does he experience dizziness? If so, when did he first notice it?
Begin the physical examination by inspecting the external ear for inflammation, boils, foreign bodies, and discharge. Then apply pressure to the tragus and mastoid to elicit tenderness. If you detect tenderness or external ear abnormalities, notify the physician to discuss whether an otoscopic examination should be done. (See Using an otoscope correctly, page 237.) During the otoscopic examination, note color change, perforation, bulging, or retraction of the tympanic membrane, which normally looks like a shiny, pearl gray cone.
Next, evaluate the patient’s hearing acuity, using the ticking watch and whispered voice tests. Then perform Weber’s and the Rinne tests to obtain a preliminary evaluation of the type and degree of hearing loss. (See Differentiating conductive from sensorineural hearing loss, page 316.)
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Tinnitus:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
Ask the patient to describe the sound he hears, including its onset, pattern, pitch,
location, and intensity. Ask whether it’s accompanied by other symptoms, such as vertigo, headache, or hearing loss. Next, take a health history, including a complete drug history.
Using an otoscope, inspect the patient’s ears and examine the tympanic membrane. To check for hearing loss, perform the Weber and Rinne tuning fork tests. (See Differentiating conductive from sensorineural hearing loss, page 316.)
Also, auscultate for bruits in the neck. Then compress the jugular or carotid artery to see if this affects the tinnitus. Finally, examine the nasopharynx for masses that might cause eustachian tube dysfunction and tinnitus.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Introduction: Trauma:
Head-to-toe assessment
(Professional Guide to Diseases (Eighth Edition))
Secondary assessment also includes a thorough head-to-toe assessment of the patient. Quickly and carefully look for multiple injuries by systematically examining the patient. If you detect no spinal injury, carefully logroll the patient over to inspect his back for other wounds.
In chest trauma, assess for open wounds, tension pneumothorax, hemothorax, cardiac tamponade, bruises and hematomas, flail chest, and fractured larynx. Cover open wounds and apply direct pressure to the wound as necessary. Be ready to assist with insertion of chest tubes, pericardiocentesis, cricothyrotomy, or tracheotomy, as appropriate.
Insert an indwelling urinary catheter and a nasogastric tube, and give prophylactic antibiotics and immunizations, as indicated. Appropriate diagnostic studies — such as X-rays, computed tomography (CT) scans, peritoneal lavage, magnetic resonance imaging (MRI), and excretory urography — may be performed based on assessment findings and patient stabilization. Notify medical or surgical specialists, as appropriate.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Hearing loss:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If the patient reports hearing loss, ask him to describe it fully. Is it unilateral or bilateral? Continuous or intermittent? Ask about a family history of hearing loss. Then obtain the patient’s medical history, noting chronic ear infections, ear surgery, and ear or head trauma. Has the patient recently had an upper respiratory tract infection? After taking a drug history, have the patient describe his occupation and work environment.
Next, explore associated signs and symptoms. Does the patient have ear pain? If so, is it unilateral or bilateral? Continuous or intermittent? Ask the patient if he has noticed discharge from one or both ears. If so, have him describe its color and consistency, and note when it began. Does he hear ringing, buzzing, hissing, or other noises in one or both ears? If so, are the noises constant or intermittent? Does he experience any dizziness? If so, when did he first notice it?
Begin the physical examination by inspecting the external ear for inflammation, boils, foreign bodies, and discharge. Then apply pressure to the tragus and mastoid to elicit tenderness. If you detect tenderness or external ear abnormalities, ask the physician whether an otoscopic examination should be done. (See Using an otoscope correctly, page 289.) During the otoscopic examination, note any color change, perforation, bulging, or retraction of the tympanic membrane, which normally looks like a shiny, pearl gray cone.
Next, evaluate the patient’s hearing acuity, using the ticking watch and whispered voice tests. Then perform the Weber and Rinne tests to obtain a preliminary evaluation of the type and degree of hearing loss. (See Differentiating conductive from sensorineural hearing loss.)
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Tinnitus:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Ask the patient to describe the sound he hears, including its onset, pattern, pitch, location, and intensity. Ask whether it’s accompanied by other symptoms, such as vertigo, headache, or hearing loss. Next, take a health history, including a complete drug history.
Using an otoscope, inspect the patient’s ears and examine the tympanic membrane. To check for hearing loss, perform the Weber and Rinne tuning fork tests. (See Differentiating conductive from sensorineural hearing loss, page 396.)
Also, auscultate for bruits in the neck. Then compress the jugular vein or carotid artery to see if this affects the tinnitus. Finally, examine the nasopharynx for masses that might cause eustachian tube dysfunction and tinnitus.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Hearing Loss:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
Gross tests of hearing are only helpful to confirm significant hearing asymmetry or to detect profound hearing loss. With one ear covered, the patient tries to hear soft sounds such as the tick of a watch, scratching of two fingers rubbed together, or a softly whispered voice.
A. Visual examination of ears. Inspect the canal and TM to rule out obvious causes of CHL. Cerumen impaction is a remarkably common and easily corrected cause of hearing loss. Pneumoscopy to check for normal movement of the TM helps rule out perforation, atelectasis, eustachian tube dysfunction, stiffened TM, ossicular disruption, and middle ear effusion.
B. Weber test. With a vibrating tuning fork placed on the top of the head, the patient is asked to describe the sound heard. The patient will perceive the sound to be louder in the affected ear in CHL, because the background noise will be absent on that side. The unaffected ear will be perceived as louder in SNHL.
C. Rinne test. With the vibrating tuning fork placed on the mastoid, the patient detects bone conduction (BC). The tuning fork is removed when the patient can no longer hear the sound. Then the tuning fork is held next to the ear to test for air conduction (AC). In an individual with normal hearing, AC is significantly better than BC. CHL will reduce AC, with little effect on BC.
Testing
A simple audiogram performed at several frequency responses may detect individuals at risk for hearing loss. Although the sensitivity is good (93% to 95%), the poor specificity (60% to 74%) can result in many false-positive findings (3).
A. Audiography. Two forms of testing provide reproducible information about the patient. Pure tone testing documents the exact number of decibels heard at a given frequency. Unfortunately, it describes nothing about the ability to discriminate language. On the other hand, speech detection better estimates impairment of actual language function, but requires a much more cooperative and attentive patient.
B. Auditory-evoked response. Able to detect the electroencephalographic stimulation caused by repetitive sounds, this examination is useful in the obtunded, uncooperative, or very young patient.
C. Computed tomography (CT). In the setting of traumatic loss of hearing, CT is fast, less expensive than magnetic resonance imaging (MRI), and able to detect abnormalities within the petrous ridge where fractures can affect hearing (4). Likewise, bleeding in the CNS is readily seen. CT is also useful to examine for causes of CHL such as tumors, middle ear anomalies, myringosclerosis, and cholesteatoma.
D. MRI. In patients with SNHL, MRI with gadolineum is superior to CT because certain CNS diseases (MS or vascular infarcts) are more easily identified. In addition, acoustic neuromas and labyrinth disorders, often too small to be seen with CT, may be visualized with MRI (4).
Diagnostic assessment
Separation into CHL and SNHL, and assessment of severity help determine the best diagnostic approach (2).
A. Conductive hearing loss. Although bothersome, these disorders are rarely severe or life threatening. Systematic history and physical examination normally will easily localize the site of hearing loss.
B. Sensorineural hearing loss. Acoustic neuroma (AN), one of the most feared causes of hearing loss, is actually a nerve sheath tumor accounting for 1% of SNHL; 95% of patients with AN present with gradual progression of unilateral hearing loss (4). Tinnitus and vestibular symptoms are less common. In contrast, Ménière’s disease causes a fluctuating but progressive loss of hearing associated with tinnitus and episodic vertigo. Other causes of SNHL can be severe, rapidly progressive, and associated with severe side effects or potential mortality. Rapid systematic evaluation, including MRI in patients aged less than 65 years, should be conducted. For patients over the age of 65 years, exclusion of presbycusis and otosclerosis should prompt the same thorough evaluation.
References
1. Maggi S, Minicuci N, Martini A, et al. Prevalence rates of hearing impairment and comorbid conditions in older people: the Veneto Study. J Am Geriatr Soc 1998;46:
1069–1074.
2. Weber P, Klein A. Hearing loss. Med Clin North Am 1999;83:125–137.
3. Weissman J. Hearing loss. Radiology 1996;199:593–611.
4. Moore A, Siu A. Screening for common problems in ambulatory elderly: clinical confirmation of a screening instrument. Am J Med 1996;100:438–443.
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Tinnitus:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
Focus on the head, ears, eyes, nose, throat, and neck as well as the cardiovascular and neurologic systems. Assess vital signs and perform a complete ear examination, including evaluation for obstruction of the external auditory canal. Look for tympanic membrane landmarks, tympanic pulsations, or signs of tumor. Auscultate the external auditory canal for transmitted sounds and use tuning forks to assess air and bone conduction. Observe the neck for thyroid masses and auscultate for thyroid or carotid bruits. Evaluate extraocular movements, speech discrimination, and the integrity of the central nervous system (gait, equilibrium, sensation). If appropriate, include evaluation of mood, affect, and perception (e.g., hallucinations).
Testing
A. Clinical laboratory tests. Most tinnitus patients will need only audiometry (4,5). If indicated by history and physical examination, consider thyroid functions, electrolytes, lipids, sedimentation rate, toxicology, syphilis serology, or rheumatology screen. A complete audiometric evaluation (pure tone and speech thresholds, speech discrimination, acoustic reflexes, and impedence testing) should always be done, especially to search for sensorineural hearing loss (4,5). A tympanogram may reveal pulsations coincident with the heart rhythm or respirations.
B. Imaging. Plain radiographs are rarely useful. Evaluation for neoplasm, especially an acoustic neuroma, is best done with magnetic resonance imaging (MRI), which will also delineate eighth nerve lesions and cortex damage. Computed tomography (CT) with contrast is superior to MRI in suspected lesions of the temporal bone and mastoids (5). Auditory brainstem-evoked responses can help to localize cortical lesions or MS (1,5). Duplex ultrasound will reveal carotid stenosis. An angiogram may be necessary to examine vasculature near the inner ear. Patients with pulsatile tinnitus may need MRI, CT, and angiography before a definitive cause is found (5).
Diagnostic assessment
Because tinnitus is a symptom, not a disease, the focus of evaluation should be on identifying those few patients with serious or treatable causes and convincing the remaining patients of the nonthreatening nature of the symptom. The key to diagnosing tinnitus is determining if it is vibratory or nonvibratory. If vibratory, search for a structural source (e.g., vascular complex, muscular component, eustachian tube) of the sound through audiometry and imaging. Nonvibratory tinnitus, although more common, often has a less easily definable cause. Consider drug effects and hearing loss first, then search for altered metabolic states (e.g., diabetes, hyperthyroidism, or infection), not forgetting psychiatric causes. Evaluate for neurologic conditions (acoustic neuroma, damage to the organ of Corti or a brain lesion) as indicated.
References
1. Pfeifer KJ, Rosen GP, Rubin AM. Tinnitus: etiology and management. Clin Geriatr Med 1999;15:193–203.
2. Vesterager V. Fortnightly review: tinnitus—investigation and management. BMJ 1997;314:728–731.
3. Seligmann H, Podoshin L, Ben-David J, et al. Drug-induced tinnitus and other hearing disorders. Drug Saf 1996;14:198–212.
4. Seidman MD, Jacobson GP. Update on tinnitus. Otolaryngol Clin North Am 1996;
29:455–465.
5. Fortune DS, Haynes DS. Tinnitus—current evaluation and management. Med Clin North Am 1999;83:153–162.
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Hearing Loss:
Diagnostic Approach
(Field Guide to Bedside Diagnosis)
Conductive hearing loss presents with loss of low tones and vowels. Sensorineural hearing loss produces impaired high tone perception, with diminished speech discrimination—especially for female voices—and hearing ringing sounds (tinnitus). Hyperacusis (the sensation that sounds are overly loud to the point of discomfort) is associated with sensorineural cochlear hearing loss. Paracusis (words perceived more clearly in a noisy environment) is associated with conductive middle ear hearing loss.
A reliable qualitative screen for high frequency hearing loss is the ability to hear whispered speech. Stand behind the patient at arm’s length and test one ear at a time. Whisper a combination of 3 letters and numbers (e.g., 4-K-2), and ask the patient to repeat it. The screen is passed when 3/6 are correctly identified. The 256 Hz tuning fork tests 10 to 15 dB, and the 512 Hz 20 to 30 dB. The Rinne test (bone conduction . air conduction) is sensitive to a 20 dB hearing loss. The Weber test is sensitive to 5 dB of hearing loss. A tuning fork is placed in the midline. With conductive loss, it lateralizes to the affected ear, and with sensorineural loss, to the unaffected ear.
Pneumoscopy is performed by first insufflating the ear then releasing. A nonmobile TM may be due to fluid or a mass in the middle ear cavity, or a stiff or sclerotic TM. A hypermobile TM may indicate ossicular chain disruption. A TM that moves only with negative pressure can be due to a retracted TM or a middle ear with a blocked eustacian tube, with resulting negative ear pressure.
Acute hearing loss occurs with infection, traumatic tympanic membrane rupture, or acute vascular event. Unilateral sensorineural loss suggests an inner ear disorder such as Meniere disease or an acoustic neuroma.
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
Tinnitus:
Diagnostic Approach
(Field Guide to Bedside Diagnosis)
A high-pitched continuous tone is the most common type, due to a sensorineural hearing loss or cochlear injury. Low-pitched tinnitus is seen with Meniere disease. Vascular tinnitus is most often pulsatile and occurs with hypertension, berry aneurysm, arteriovenous malformation, internal carotid stenosis, a tortuous carotid within the temporal bone, increased intracranial pressure or glomus tumor. A clicking noise, or irregular or rapid pulsations that do not follow the pulse originate in myoclonus of the palatal, stapedial, or tensor tympani muscles. Tinnitus that can be heard with a stethoscope is usually a result of a tumor, aneurysm, or arteriovenous malformation.
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
Hearing loss:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Begin the physical examination by inspecting the external ear for inflammation, boils, foreign bodies, and discharge. Then apply pressure to the tragus and mastoid to elicit tenderness. If you detect tenderness or external ear abnormalities, notify the physician to discuss whether an otoscopic examination should be done. During the otoscopic examination, note any color change, perforation, bulging, or retraction of the tympanic membrane, which normally looks like a shiny, pearl gray cone.
Next, evaluate the patient’s hearing acuity, using the ticking watch and whispered voice tests. Then perform the Weber’s and Rinne tests to obtain a preliminary evaluation of the type and degree of hearing loss. (See Differentiating conductive from sensorineural hearing loss, page 330.)
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Tinnitus:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Using an otoscope, inspect the patient’s ears and examine the tympanic membrane. To check for hearing loss, perform Weber’s and Rinne tuning fork tests. Also, auscultate for bruits in the neck. Then compress the jugular or carotid artery to see if this affects the tinnitus. Finally, examine the nasopharynx for masses that might cause eustachian tube dysfunction and tinnitus.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Hearing Loss and Deafness:
Diagnostic Approach
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
Auditoryand language findings listed in Table26.1 are indications for possible hearing loss or deafness.Suspected hearing loss should be investigatedto determine the type, severity, and cause.Any child with suspected hearing lossshould be referred for audiologic evaluation. Speech and languageassessment is often necessary. Neurologic and otolaryngologic consultationmay be required, depending on suspected problem.
» READ BOOK EXCERPT ONLINE »
Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Hearing loss:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
If the patient reports hearing loss, ask him to describe it. Is it unilateral or bilateral? Continuous or intermittent? Ask about a family history of hearing loss. Then obtain the patient's medical history, noting chronic ear infections, ear surgery, and ear or head trauma. Has the patient recently had an upper respiratory tract infection? After taking a drug history, have the patient describe his occupation and work environment.
Next, explore associated signs and symptoms. Does the patient have ear pain? If so, is it unilateral or bilateral, or continuous or intermittent? Ask the patient if he has noticed discharge from one or both ears. If so, have him describe its color and consistency, and note when it began. Does he hear ringing, buzzing, hissing, or other noises in one or both ears? If so, are the noises constant or intermittent? Does he experience dizziness? If so, when did he first notice it?
Begin the physical examination by inspecting the external ear for inflammation, boils, foreign bodies, and discharge. Then apply pressure to the tragus and mastoid to elicit tenderness. If you detect tenderness or external ear abnormalities, notify the physician to discuss whether an otoscopic examination should be done. (See Using an otoscope correctly, page 223.) During the otoscopic examination, note color change, perforation, bulging, or retraction of the tympanic membrane, which normally looks like a shiny, pearl gray cone.
Next, evaluate the patient's hearing acuity, using the ticking watch and whispered voice tests. Then perform Weber's and the Rinne tests to obtain a preliminary evaluation of the type and degree of hearing loss. (See Differentiating conductive from sensorineural hearing loss, page 304.)
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
Tinnitus:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Ask the patient to describe the sound he hears, including its onset, pattern, pitch, location, and intensity. Ask whether it's accompanied by other symptoms, such as vertigo, headache, or hearing loss. Next, take a health history, including a complete drug history.
Inspect the patient's ears and examine the tympanic membrane. To check for hearing loss, perform the Weber and Rinne tuning fork tests.
Also, auscultate for bruits in the neck. Then compress the jugular or carotid artery to see if this affects the tinnitus. Finally, examine the nasopharynx for masses that might cause eustachian tube dysfunction and tinnitus.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
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