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 Background Hobart ID: 1032769
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1. Hearing LossDr Ryan De FreitasENT Head and Neck SurgeonMBBS BMedSci DOHNS MRCS FRACS WAVERLEY PRIVATE HOSPITALGP EDUCATION SESSION PROGRAM
2. About MeSubspecialty InterestsHead and NeckThyroidBackgroundHobartBelfast – Melbourne – Dublin – London – Gold Coast – MelbourneInterestsFamilyTravel
3. Topics CoveredSudden onset hearing lossConductive vs Sensorineural vs MixedHearing Loss as Red Flag (NPC, AN, TB#)The AudiogramHearing AidsThe deaf childTinnitusMeniere’s DiseasePrevention of hearing lossHow to use a tuning forkFree field testing
4. Topics not coveredDetailed surgical treatments of conductive and sensorineural hearing lossUnnecessary detail on hearing physiology or fine print on specific conditionsExhaustive list of differential diagnoses
5. Case example – sudden hearing loss35 yo violinist flying back from EuropeSudden left hearing loss during flightFollowing morning GP sees patient as a ‘fit in’How would you manageQuestions?
6. ManagementHistoryGeneralSpecificExaminationGeneralSpecificMinimal hearing on left notedTympanic membranes normalInvestigation(s)Treatment(s)Referral(s)? To whomUrgent/non urgent
7. Actual OutcomeDiagnosis: Eustachian Tube DysfunctionTreatment:Intranasal steroidInvestigation(s): noneReferral(s)Non-urgent ENTOutcomeSeen by ENT Surgeon 2 months laterAudio: Profound left sensorineural hearing lossMRI IAM: NormalTreatment Prognosis and career implicationsAwkward conversation…
8. Sudden hearing lossDefinitionsSHL: Subjective symptomRapid onset over 3 day periodSSNHL: Pure tone audiogram30dB loss 3 consecutive frequencies3 days or lessISSNHL: No identifiable causeAetiologyOuter ear (CHL)Wax, infection, exostosesMiddle ear (CHL)Effusion, trauma, cholesteatomaInner ear (SNHL)IdiopathicInfectiveTraumaticTumourToxicAutoimmmune
9. Sudden onset hearing lossHistoryUnilateral vs bilateralSudden vs gradualPrecipitantsTrauma (physical/acoustic)InfectionMedical HistoryAutoimmune, diabetes, sarcoidosisOtotoxic medicationOther featuresPain, rash, tinnitus, vertigo, aural fullnessExaminationEars including OtoscopyCranial nerves (V and VII)Tuning fork and free field testingRed flagsUnilateral middle ear effusionNeurological signs or symptomsConcurrent head trauma (BOS#)
10. Sudden onset hearing lossInvestigation (GP and ENT)PTACHL vs SNHLResponse to treatmentTympanometryRoutine bloods for ISSNHL?Flexible Nasendoscopy PNSImagingRole of MRIRole of CT
11. Sudden onset hearing loss - treatmentConductive hearing lossGP may be able to manageWaxForeign bodiesOtitis externa (mild)Referral to ENTUnilateral OMEPerforationCholesteatomaIdiopathic sensorineural hearing lossOral steroids 7-14 daysEarly!Hyperbaric oxygenIntratympanic steroids (salvage)Role of education and informed patient choiceNo role for antiviralsRehabilitation
12. The basics of hearingAnatomyPhysiology
13. Physiology – objective assessmentHair 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 loss
14. Classification of hearing lossConductive or Sensorineural MixedCongenital or acquiredAcute or chronicUnilateral or bilateral
15. Hearing loss – important questionsAge of onsetRate of progressionSudden vs gradual vs stableUnilateral/bilateralFamily historyNoise exposureMedicationsOther featuresOtalgia, otorrhea, vertigo, tinnitus, aural fullness, neurological deficits
16. Conductive Hearing LossOuter EarMiddle EarAssessmentOtoscopyRinne and Weber TestingAudiometryTympanometry
17. AudiometryPure tone threshold audiometryShows severity of lossFrequencies from 250Hz to 8000HzAudiological unitsdB HL: hearing levelLogarithmicNormal: 0 - 20dB Mild: 20 - 40dBModerate: 40 – 60dBSevere: > 60 dBDetermine if loss is conductive, sensorineural or mixed
18. TympanometryMeasures compliance of tympanic membraneType A, B, CUseful in diagnosing specific conductive pathologiesEffusionPerforationOtosclerosis
19. Management of conductive hearing lossConductive deafness is treatable:Medical treatmentsSyringing or microsuction for waxAmplificationSurgeryGrommet for chronic middle ear effusionMyringoplasty for chronic perforationStapedectomy for otosclerosisOssiculoplasty for ossicular chain disruption
20. Sensorineural hearing loss (SNHL)Bilateral progressiveUnilateral progressiveSudden SNHL (SSNHL)
21. Bilateral progressive SNHLPresbyacusis - age degenerationAcoustic trauma – noise inducedOtotoxic drugs - aminoglycosides,frusemideHigher risk with elderly and renal impairmentAutoimmune (SLE, Wegners, Cogans
22. Unilateral progressive SNHLMeniere’s DiseaseAssociated vertigo, tinnitus, aural fullnessAcoustic neuromaTinnitus, unsteadiness, other cranial nerve involvement
23. Causes of SSNHLMajority are idiopathicTraumaViral infections (HSV, VZV)CVA – VB territory and inferior cerebellar arteryRarely – Syphilis
24. Management of SNHLAmplificationBody Worn Hearing AidsBehind the ear BEIn the ear ITERadio Aid/loop systemBone ConductingCutaneousBone Anchored Hearing Aids (BAHA)
25. Management of SNHLCochlear implantStrict criteriaPatients who have no benefit from amplification
26. TinnitusSound without an external stimulus.Causes anxietyWhen to referUnilateral may indicate an Acoustic neuromaNo effective drug treatmentExplanation and reassuranceTinnitus Retraining Therapy, CBTNeuromonics device
27. Education of hearing lossAvoiding noise traumaEar plugsEar muffsLimiting iPod volume level in childrenHearing aid programmingAvoidance of ototoxic medicationHigh risk populationsPermanent Single sided deafnessImportance of preserving normal ear
28. The deaf childWhen to refer in regards to consideration of grommetsUnilateral vs bilateralSpeech deteriorationSuspected profoundly deaf in childCongenital vs acquiredPlasticity of brain in regards to timing of cochlear implantationMeningitis and cochlear ossification
29. Thank youQuestionsEar examinationInspectionGeneralOtoscopy (canal, TM, mastoid)HearingStart with better earFree field testing using maskingTuning forksTinnitusOtoscopyPalpation AuscultationOther – CNs, fundoscopy (BIH)