Hearing loss

Affecting nearly 16 million Americans, hearing loss may be temporary or permanent and partial or complete. This common symptom may involve reception of low-, middle-, or high-frequency tones. If the hearing loss doesn’t affect speech frequencies, the patient may be unaware of it. (See Understanding sound transmission, page 328.)

Hearing loss can be classified as conductive, sensorineural, mixed, or functional. Conductive hearing loss results from external or middle ear disorders that block sound transmission. Sensorineural hearing loss results from disorders of the inner ear or of the eighth cranial nerve. Mixed hearing loss combines aspects of conductive and sensorineural hearing loss. Functional hearing loss results from psychological factors rather than identifiable organic damage.

Hearing loss may also result from trauma, infection, allergy, tumors, certain systemic and hereditary disorders, and the effects of ototoxic drugs and treatments. In most cases, though, it results from presbycusis, a type of sensorineural hearing loss that usually affects people older than age 50. Other physiologic causes of hearing loss include cerumen (earwax) impaction; barotitis media (unequal pressure on the eardrum) associated with descent in an airplane or elevator, diving, or close proximity to an explosion; and chronic exposure to noise over 90 decibels, which can occur on the job, with certain hobbies, or from listening to live or recorded music.

History

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, 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 any dizziness? If so, when did he first notice it?

Physical assessment

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.)

Medical causes

Acoustic neuroma

An acoustic neuroma is an eighth cranial nerve tumor that causes unilateral, progressive, sensorineural hearing loss. The patient may also develop tinnitus, vertigo and, with cranial nerve compression, facial paralysis.

Adenoid hypertrophy

With adenoid hypertrophy, eustachian tube dysfunction gradually causes conductive hearing loss accompanied by intermittent ear discharge. The patient also tends to breathe through his mouth and may complain of a sensation of ear fullness.

Allergies

Conductive hearing loss may result when an allergy produces eustachian tube and middle ear congestion. Other features include ear pain or a feeling of fullness, nasal congestion, and conjunctivitis.

Cholesteatoma

Gradual hearing loss is characteristic in cholesteatoma. It can be accompanied by vertigo and, at times, facial paralysis. Examination reveals eardrum perforation, pearly white balls in the ear canal and, possibly, a discharge.

External ear canal tumor (malignant)

Progressive conductive hearing loss is characteristic of a malignant external ear canal tumor and is accompanied by deep, boring ear pain; purulent discharge; and eventually facial paralysis. Examination may detect the granular, bleeding tumor.

Furuncle

Reversible conductive hearing loss may occur when a furuncle (a painful, hard nodule) forms in the ear. The patient with a furuncle may report a sense of fullness in the ear and pain on palpation of the tragus or auricle. Boil rupture relieves the pain and produces a purulent, necrotic discharge.

Glomus jugulare tumor

Initially, glomus jugulare (a benign tumor) causes mild, unilateral conductive hearing loss that becomes progressively more severe. The patient may report tinnitus that sounds like his heartbeat. Associated signs and symptoms include gradual congestion in the affected ear, throbbing or pulsating discomfort, bloody otorrhea, facial nerve paralysis, and vertigo. Although the tympanic membrane is normal, a reddened mass appears behind it.

Head trauma

Sudden conductive or sensorineural hearing loss may result from ossicle disruption, ear canal fracture, tympanic membrane perforation, or cochlear fracture associated with head trauma. Typically, the patient reports a headache and exhibits bleeding from his ear. Neurologic features vary and may include impaired vision and altered level of consciousness.

Hypothyroidism

Hypothyroidism may produce reversible sensorineural hearing loss. Other effects include bradycardia, weight gain despite anorexia, mental dullness, cold intolerance, facial edema, brittle hair, and dry skin that’s pale, cool, and doughy.

Ménière’s disease

Initially, Ménière’s disease produces intermittent, unilateral sensorineural hearing loss that involves only low tones. Later in this inner ear disorder, hearing loss becomes constant and affects other tones. Associated signs and symptoms of Ménière’s disease include intermittent severe vertigo, nausea and vomiting, a feeling of fullness in the ear, a roaring or hollow-seashell tinnitus, diaphoresis, and nystagmus.

Osteoma

Commonly affecting women and swimmers, osteoma may cause sudden or intermittent conductive hearing loss. Typically, bony projections are visible in the ear canal, but the tympanic membrane appears normal.

Otitis externa

Conductive hearing loss resulting from debris in the ear canal characterizes both acute and malignant otitis externa. With acute otitis externa, ear canal inflammation produces pain, itching, and a foul-smelling, sticky yellow discharge. Severe tenderness is typically elicited by chewing, opening the mouth, and pressing on the tragus or mastoid. The patient may also develop a low-grade fever, regional lymphadenopathy, headache on the affected side, and mild-to-moderate pain around the ear that may later intensify. Examination may reveal greenish white debris or edema in the canal.

With malignant otitis externa, debris is also visible in the canal. This life-threatening disorder, which most commonly occurs in diabetics, causes sensorineural hearing loss, pruritus, tinnitus, and severe ear pain.

Otitis media

Otitis media is a middle ear inflammation that typically produces unilateral conductive hearing loss. In patients with acute suppurative otitis media, the hearing loss develops gradually over a few hours and is usually accompanied by an upper respiratory tract infection with sore throat, cough, nasal discharge, and headache. Related signs and symptoms include dizziness, a sensation of fullness in the ear, intermittent or constant ear pain, fever, nausea, and vomiting. Rupture of the bulging, swollen tympanic membrane relieves the pain and produces a brief, bloody, purulent discharge. Hearing returns after the infection subsides.

Hearing loss also develops gradually in patients with chronic otitis media. Assessment may reveal a perforated tympanic membrane, purulent ear drainage, earache, nausea, and vertigo.

Commonly associated with an upper respiratory tract infection or nasopharyngeal cancer, serous otitis media commonly produces a stuffy feeling in the ear and pain that worsens at night. Examination reveals a retracted — and perhaps discolored — tympanic membrane and, possibly, air bubbles behind the membrane.

Otosclerosis

In otosclerosis, a hereditary disorder, unilateral conductive hearing loss usually begins when the patient is in his early 20s and may gradually progress to bilateral mixed loss. The patient may report tinnitus and an ability to hear better in a noisy environment. The deafness is usually noticed between ages 11 and 30.

Skull fracture

Auditory nerve injury from a skull fracture causes sudden unilateral sensorineural hearing loss. Accompanying signs and symptoms include ringing tinnitus, blood behind the tympanic membrane, scalp wounds, and other findings.

Temporal arteritis

Temporal arteritis may produce unilateral sensorineural hearing loss accompanied by throbbing unilateral facial pain, pain behind the eye, temporal or frontotemporal headache and, occasionally, vision loss. The hearing loss is usually preceded by a prodrome of malaise, anorexia, weight loss, weakness, and myalgia that lasts for several days. Examination may reveal a nodular, swollen temporal artery. Low-grade fever, confusion, and disorientation may also occur.

Temporal bone fracture

Temporal bone fracture can cause sudden unilateral sensorineural hearing loss accompanied by hissing tinnitus. The tympanic membrane may be perforated, depending on the fracture’s location. Loss of consciousness, Battle’s sign, and facial paralysis may also occur.

Tuberculosis

Tuberculosis, a pulmonary infection, may spread to the ear, resulting in eardrum perforation, mild conductive hearing loss, and cervical lymphadenopathy. Other signs and symptoms include chest pain, crackles, dyspnea, fatigue, fever, and tachypnea.

Tympanic membrane perforation

Commonly caused by trauma from sharp objects or rapid pressure changes, perforation of the tympanic membrane causes abrupt hearing loss along with ear pain, tinnitus, vertigo, and a sensation of fullness in the ear.

Other causes

Drugs

Ototoxic drugs typically produce ringing or buzzing tinnitus and a feeling of fullness in the ear. Chloroquine, cisplatin, vancomycin, and aminoglycosides (especially neomycin, kanamycin, and amikacin) may cause irreversible hearing loss. Loop diuretics, such as furosemide, ethacrynic acid, and bumetanide, usually produce a brief, reversible hearing loss. Quinine, quinidine, and high doses of erythromycin or salicylates (such as aspirin) may also cause reversible hearing loss.

Radiation therapy

Irradiation of the middle ear, thyroid, face, skull, or nasopharynx may cause eustachian tube dysfunction, resulting in hearing loss.

Surgery

Myringotomy, myringoplasty, simple or radical mastoidectomy, or fenestrations may cause scarring that interferes with hearing.

Special considerations

When talking with the patient, remember to face him and speak slowly. Don’t shout, smoke, eat, or chew gum when talking.

Prepare the patient for audiometry and auditory evoked-response testing. After testing, the patient may require a hearing aid or cochlear implant to improve his hearing.

Pediatric pointers

About 3,000 profoundly deaf infants are born in the United States each year. In about half of these infants, hereditary disorders (such as Paget’s disease and Alport’s, Hurler’s, and Klippel-Feil syndromes) cause the  hearing loss (typically sensorineural). Nonhereditary disorders associated with congenital sensorineural hearing loss include albinism, cochlear dysplasia, and onychodystrophy, Usher’s, Pendred’s, Waardenburg’s, and Jervell and Lange-Nielsen syndromes. This type of hearing loss may also result from maternal use of ototoxic drugs, birth trauma, and anoxia during or after birth.

Mumps is the most common pediatric cause of unilateral sensorineural hearing loss. Other causes are meningitis, measles, influenza, and acute febrile illness.

Disorders that may produce congenital conductive hearing loss include atresia, ossicle malformation, and other abnormalities. Serous otitis media commonly causes bilateral conductive hearing loss in children. Conductive hearing loss may also occur in children who put foreign objects in their ears.

Hearing disorders in children may lead to speech, language, and learning problems. Early identification and treatment of hearing loss is thus crucial to avoid incorrectly labeling the child as mentally retarded, brain damaged, or a slow learner.

When assessing an infant or a young child for hearing loss, remember that you can’t use a tuning fork. Instead, test the startle reflex in infants younger than age 6 months, or have an audiologist test brain stem evoked response in neonates, infants, and young children. Also, obtain a gestational, perinatal, and family history from the parents.

Geriatric pointers

In older patients, presbycusis may be aggravated by exposure to noise as well as other factors.

Patient counseling

Instruct the patient to avoid exposure to loud noise and to use ear protection to arrest loss. If the patient has an upper respiratory tract infection, tell him to avoid flying and driving. Explain the importance of completing the full course of prescribed antibiotics.

Pictures

Book Source Details

• Book Title: Signs & Symptoms: A 2-in-1 Reference for Nurses
• Author(s): Springhouse
• Year of Publication: 2007
• Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2007 Lippincott Williams & Wilkins.

Other Book Chapters Related to Ear sounds

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Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2008 Williams & Wilkins.

More About Causes of Ear sounds

• Back to symptom: Ear sounds: Introduction (review 109 causes)
• Next Book Extract About Ear sounds: Tinnitus (Signs & Symptoms: A 2-in-1 Reference for Nurses)
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More About This Book: Title: Signs & Symptoms: A 2-in-1 Reference for Nurses Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-58255-318-1

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