Dr Ryan De Freitas ENT Head and Neck Surgeon MBBS BMedSci DOHNS MRCS FRACS WAVERLEY PRIVATE HOSPITAL GP EDUCATION SESSION PROGRAM About Me Subspecialty Interests Head and Neck Thyroid ID: 585365
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Hearing Loss
Dr
Ryan De FreitasENT Head and Neck SurgeonMBBS BMedSci DOHNS MRCS FRACS
WAVERLEY PRIVATE HOSPITAL
GP EDUCATION SESSION PROGRAMSlide2
About Me
Subspecialty InterestsHead and Neck
ThyroidBackgroundHobartBelfast – Melbourne – Dublin – London – Gold Coast – MelbourneInterests
Family
TravelSlide3
Topics Covered
Sudden onset hearing loss
Conductive vs Sensorineural vs MixedHearing Loss as Red Flag (NPC, AN, TB#)
The Audiogram
Hearing Aids
The deaf childTinnitus
Meniere’s Disease
Prevention of hearing loss
How to use a tuning fork
Free field testingSlide4
Topics not covered
Detailed surgical treatments of conductive and sensorineural hearing lossUnnecessary detail on hearing physiology or fine print on specific conditions
Exhaustive list of differential diagnosesSlide5
Case example – sudden hearing loss
35
yo violinist flying back from EuropeSudden left hearing loss during flightFollowing morning GP sees patient as a ‘fit in’How would you manageQuestions?Slide6
Management
HistoryGeneralSpecific
ExaminationGeneralSpecificMinimal hearing on left notedTympanic membranes normal
Investigation(s)
Treatment(s)
Referral(s)? To whom
Urgent/non urgentSlide7
Actual Outcome
Diagnosis: Eustachian Tube Dysfunction
Treatment:Intranasal steroidInvestigation(s): noneReferral(s)Non-urgent ENT
Outcome
Seen by ENT Surgeon 2 months later
Audio: Profound left
sensorineural
hearing loss
MRI IAM: Normal
Treatment
Prognosis and career implications
Awkward conversation
…Slide8
Sudden hearing loss
DefinitionsSHL: Subjective symptom
Rapid onset over 3 day periodSSNHL: Pure tone audiogram30dB loss 3 consecutive frequencies3 days or lessISSNHL: No identifiable cause
Aetiology
Outer ear (CHL)
Wax, infection,
exostoses
Middle ear (CHL)
Effusion, trauma,
cholesteatoma
Inner ear (SNHL)
Idiopathic
Infective
Traumatic
Tumour
Toxic
AutoimmmuneSlide9
Sudden onset hearing loss
HistoryUnilateral
vs bilateralSudden vs gradualPrecipitantsTrauma (physical/acoustic)InfectionMedical History
Autoimmune, diabetes,
sarcoidosis
Ototoxic medication
Other features
Pain, rash, tinnitus, vertigo, aural fullness
Examination
Ears including
Otoscopy
Cranial nerves (V and VII)
Tuning fork and free field
testing
Red flags
Unilateral middle ear effusion
Neurological signs or symptoms
Concurrent head trauma (BOS#)Slide10
Sudden onset hearing lossInvestigation (GP and ENT)
PTACHL
vs SNHLResponse to treatmentTympanometryRoutine bloods for ISSNHL?Flexible Nasendoscopy PNS
Imaging
Role of MRI
Role of CT Slide11
Sudden onset hearing loss - treatment
Conductive hearing loss
GP may be able to manageWaxForeign bodiesOtitis externa (mild)Referral to ENTUnilateral OMEPerforation
Cholesteatoma
Idiopathic
sensorineural
hearing loss
Oral steroids 7-14 days
Early!
Hyperbaric oxygen
Intratympanic
steroids (salvage)
Role of education and informed patient choice
No role for antivirals
RehabilitationSlide12
The basics of hearing
AnatomyPhysiologySlide13
Physiology – objective assessment
Hair cells reproduce the sound which is presented to the ear - Cochlear microphonics.These can be detected as Cochlear Echoes or Oto
-Acoustic emissions.Screening tool for infants.BSER records auditory nerve impulsesScreening tool for infantsRole in assessment of suspected non- organic hearing lossSlide14
Classification of hearing loss
Conductive or Sensorineural MixedCongenital or acquired
Acute or chronicUnilateral or bilateralSlide15
Hearing loss – important questions
Age of onsetRate of progressionSudden vs gradual
vs stableUnilateral/bilateralFamily historyNoise exposureMedicationsOther featuresOtalgia, otorrhea
, vertigo, tinnitus, aural fullness, neurological deficitsSlide16
Conductive Hearing Loss
Outer Ear
Middle Ear
Assessment
Otoscopy
Rinne
and Weber Testing
Audiometry
TympanometrySlide17
Audiometry
Pure tone threshold audiometryShows severity of lossFrequencies from 250Hz to 8000Hz
Audiological unitsdB HL: hearing levelLogarithmicNormal: 0 - 20dB
Mild: 20
- 40dB
Moderate: 40
– 60dB
Severe: >
60 dB
Determine
if
loss is conductive,
sensorineural
or mixedSlide18
Tympanometry
Measures compliance of tympanic membraneType A, B, C
Useful in diagnosing specific conductive pathologiesEffusionPerforationOtosclerosisSlide19
Management of conductive hearing loss
Conductive deafness is treatable:Medical
treatmentsSyringing or microsuction for waxAmplificationSurgeryGrommet for chronic middle ear effusion
Myringoplasty
for chronic perforation
Stapedectomy
for
otosclerosis
Ossiculoplasty
for
ossicular
chain disruptionSlide20
Sensorineural hearing loss (SNHL)
Bilateral progressiveUnilateral progressiveSudden SNHL (SSNHL)Slide21
Bilateral progressive SNHL
Presbyacusis - age degenerationAcoustic trauma – noise inducedOtotoxic drugs -
aminoglycosides,frusemideHigher risk with elderly and renal impairmentAutoimmune (SLE, Wegners, CogansSlide22
Unilateral progressive SNHL
Meniere’s DiseaseAssociated vertigo, tinnitus, aural fullnessAcoustic neuromaTinnitus, unsteadiness, other cranial nerve involvementSlide23
Causes of SSNHL
Majority are idiopathicTraumaViral infections (HSV, VZV)CVA – VB territory and inferior cerebellar arteryRarely – SyphilisSlide24
Management of SNHL
AmplificationBody Worn Hearing AidsBehind the ear BE
In the ear ITERadio Aid/loop systemBone ConductingCutaneousBone Anchored Hearing Aids (BAHA)Slide25
Management of SNHLCochlear implant
Strict criteriaPatients who have no benefit from amplificationSlide26
Tinnitus
Sound without an external stimulus.Causes anxietyWhen to referUnilateral may indicate an Acoustic neuroma
No effective drug treatmentExplanation and reassuranceTinnitus Retraining Therapy, CBTNeuromonics deviceSlide27
Education of hearing loss
Avoiding noise traumaEar plugsEar muffsLimiting iPod volume level in children
Hearing aid programmingAvoidance of ototoxic medicationHigh risk populationsPermanent Single sided deafnessImportance of preserving normal earSlide28
The deaf child
When to refer in regards to consideration of grommetsUnilateral vs bilateralSpeech deterioration
Suspected profoundly deaf in childCongenital vs acquiredPlasticity of brain in regards to timing of cochlear implantationMeningitis and cochlear ossificationSlide29
Thank you
Questions
Ear examinationInspectionGeneralOtoscopy (canal, TM, mastoid)
Hearing
Start with better ear
Free field testing using masking
Tuning forks
Tinnitus
Otoscopy
Palpation
Auscultation
Other – CNs,
fundoscopy
(BIH)