Evaluation of hearing loss
Summary
Hearing loss is one of the most common sensory impairments. 23% of Americans aged 12 years and older have some degree of hearing loss.[1] It affects people of all ages and can be permanent if not treated correctly. Proper diagnosis rests on a thorough understanding of ear anatomy and physiology.
Anatomy
The human ear is divided into 3 parts: the external ear, the middle ear, and the inner ear.[Figure caption and citation for the preceding image starts]: Anatomy of the earCreated by BMJ Knowledge Centre [Citation ends].
The external ear consists of the auricle (or pinna), the ear canal, and the tympanic membrane (or ear drum). The tympanic membrane divides the external ear from the middle ear.
Like the external ear, in its normal state, the middle ear is filled with air. Connected to the malleus (or hammer) is the incus (anvil), which is then connected to the stapes (stirrup). On the medial wall of the middle ear is the promontory, which demarcates the inner ear and, specifically, the basal turn of the cochlea. The stapes sits in an area called the oval window. The round window is inferior to the oval window. These windows lead to the inner ear.
The inner ear is fluid-filled and contains the organs of hearing (the cochlea) and the organs of balance (the semicircular canals, utricle, and saccule). The cochleovestibular nerve connects the end organs to the auditory and vestibular pathways.[Figure caption and citation for the preceding image starts]: Picture of a normal left earFrom the collection of Dr Richard Buckingham [Citation ends].
Physiology
Sound waves require a medium, such as air or water. The compression in a sound wave is channeled down the ear canal to the tympanic membrane. Vibrations of the tympanic membrane are then transmitted by the ossicular chain through the oval window into the cochlea. The vibrations of the cochlea cause a fluid wave, which stimulates hair cells within the cochlea. This generates an electrical impulse, which is transmitted along the cochlear nerve to the brain, where it is interpreted. Anything that interferes with the movement of sound from the external ear to the middle ear to the inner ear, and then to the brain, can cause a hearing loss. The external ear and middle ear may appear normal on exam if the cause is in the inner ear or brain.
Classification of hearing loss
Generally, hearing loss is classified as conductive or sensorineural.
Conductive hearing loss is caused by pathology of the external ear, tympanic membrane or middle ear which disrupts sound transmission to the inner ear. Many causes can be treated successfully with surgery.
Sensorineural hearing loss is caused by abnormal function of the cochlea, auditory nerve, or higher auditory processing pathways.[2] Many sensorineural hearing losses are permanent because the human inner ear and hair cells have only limited ability to repair themselves.[3]
Differentials
Common
- Cerumen impaction
- Foreign body
- Benign tumors (e.g., exostosis, osteoma, polyps)
- Uncomplicated otitis externa
- Acute otitis media
- Serous otitis media/middle-ear effusion
- Cholesteatoma
- Labyrinthitis
- Noise-related hearing loss
- External ear canal trauma
- Complication of meningitis
- Stroke
- Presbycusis
Uncommon
- External ear canal neoplasm
- Necrotizing otitis externa
- Tympanic membrane perforation
- Temporal bone fracture
- Isolated developmental abnormality
- Congenital hearing loss
- Alport syndrome
- Jervell Lange-Nielsen syndrome
- Craniofacial abnormalities (e.g., Pierre Robin, Crouzon, Apert syndromes)
- Waardenburg syndrome
- Acoustic neuroma (vestibular schwannoma)
- Glomus tumor
- Cytomegalovirus (CMV) infection
- Toxoplasmosis infection
- Syphilis infection
- Paget disease
- Systemic lupus erythematosus (SLE)
- Granulomatosis with polyangiitis (formerly known as Wegener granulomatosis)
- Diabetes mellitus
- Osteogenesis imperfecta
- Vertebral artery dissection
- Multiple sclerosis (MS)
- Arnold-Chiari malformation
- Auditory neuropathy
- Idiopathic sudden sensorineural hearing loss
- Ototoxic drugs
- Meniere disease
- Neonatal hyperbilirubinemia
- Otosclerosis
- Autoimmune inner ear disease
- Perilymphatic fistula
Contributors
Authors
Seth R. Schwartz, MD, MPH
Otolaryngologist (Otology/Neurotology)
Department of Otolaryngology
Virginia Mason Medical Center
Medical Director
The Listen for Life Center at Virginia Mason
Seattle
WA
Disclosures
SRS is an author of a reference cited in this topic.
Acknowledgements
Dr S.R. Schwartz would like to gratefully acknowledge Dr S.J. Marzo, Dr J.P. Leonetti, and Dr R.J. Buckingham, previous contributors to this topic. SJM, JPL, and RJB declare that they have no competing interests.
Peer reviewers
Alan Micco, MD, FACS
Assistant Professor
Department of Otolaryngology
Department of Neurosurgery
Northwestern University Feinberg School of Medicine
Chicago
IL
Disclosures
AM declares that he has no competing interests.
George Browning, MD ChB FRCS (Ed & Glasg)
Professor of Otorhinolaryngology
MRC Institute of Hearing Research
Glasgow
UK
Disclosures
GB is an author of several books that include discussion of evaluation of hearing loss.
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