17 Oct 2018 ▪ Dr.

Jose Jonathan Franco

TBL: Hearing Loss and Tinnitus 03

Te a m Ba s e d Le a r ni ng 01

Outline • The use of cotton buds can push the cerumen inward and cause it to
I. Hearing Loss 1 accumulate and get stuck in the area of the isthmus, the narrowest
A. Common Causes of Hearing Loss 1 portion of the EAC, leading to impaction
II. Tinnitus 4 ○ The patient will usually complain of hearing loss or ear fullness
B. Introduction 4 (a feeling like there’s water in the ear)
C. Causes and Related Factors 5
D. Diagnosis 5
○ Pain is uncommon
E. Treatment 6 • Otoscopy is diagnostic
F. Prevention 6 • Treatment is manual extraction/removal
G. Summary 6
III. Documenting Hearing Loss 6
A. Types of Hearing Loss 6
B. Testing Models 7
C. Tuning Fork Tests 7
D. Pure Tone Audiometry 7
E. Tympanometry 9
Review Questions 9
References 9
Freedom Space Error! Bookmark not defined.
Appendix 10
A. Hearing Loss 10
B. Tinnitus 10
C. Documenting Hearing Loss 11

Abbreviation Meaning
EAC External Auditory Canal
TM Tympanic Membrane
T/N: Those marked with an asterisks (*) are information that are
related to the TBL or the cases. Please study the pictures since
most of them were asked. Also we included some tips that we
gathered during the session. If you just want a quick review of the
topics, just breeze through the appendix where you'll find a summary
version instead.
Tips:
• ALWAYS report otoscopy findings for BOTH ears even for normal
ears. Note the laterality of the findings.
• When formulating a diagnosis, ALWAYS correlate your physical
(otoscopy) findings with complaints and the history of the patient!
I. Hearing Loss
• Any disturbance in the auditory pathway (external canal, middle ear,
inner ear, central pathway) can cause hearing loss.
Figure 1*. Otoscopy of Impacted Cerumen within the external ear canal
Keratosis Obturans and Cholestatomas of the EAC
• Both represent abnormal accumulation of keratin in the EAC
• These present as keratin (epithelial) plugs, which can occlude the
EAC and cause hearing loss
• Keratosis Obturans
○ The underlying mechanism is unknown. Thought to be:
▪ Overproduction of squamous epithelium
▪ Faulty migration of epithelium with subsequent accumulation
and impaction
○ It usually affects adults
○ Secondary canal skin inflammation or infection (otitis externa)
may cause pain
○ There is diffuse widening of the ear canal, caused by the
pressure exerted by the enlarging keratin plug
○ Treatment
▪ Removal of the epithelial debris and antibiotic drops for
accompanying infection or inflammation
▪ Lifelong periodic debridement is sometimes necessary

Tips:
• Familiarize yourself with what can cause a unilateral or bilateral
hearing loss.

A. Common Causes of Hearing Loss

External Ear

Cerumen Impaction
• Cerumen
○ A product of modified sweat gland and sebaceous gland
secretions located in the outer 1/3 (cartilaginous portion) of the
EAC
○ Contains epithelial debris and contaminants
○ The type of cerumen, whether wet or dry, is inherited
▪ Most Caucasians (80%) have wet cerumen
▪ Asians have dry cerumen
○ The rate of cerumen production varies widely among individuals
• Cerumen has protective qualities
○ Antibacterial/ antifungal properties
○ Natural lubricant
• However, excessive accumulation can block the ear canal and
cause hearing loss and ear fullness
○ In the Philippines, the most common cause of hearing loss,
overall, is impacted cerumen.
• Normally, EAC epithelium migrates outward, carrying cerumen and
debris with it
○ Failure of this mechanism may predispose to cerumen
accumulation
Figure 2. Keratosis Obturans. Note the epithelial debris; contrast with
cerumen
• External canal cholesteatoma
○ Presents with epithelial plug similar to keratosis obturans
○ However, unlike keratosis, there may be areas of focal skin
ulceration or bone necrosis*
○ Presence of granulation tissue and otitis externa is common
○ Treatment
▪ Removal of debris and necrotic tissue
▪ Antibiotic therapy for the infection
• CT scan
○ Best imaging modality for these conditions
○ Both will show widened EAC
○ However, cholesteatoma, which invades bone*, will show bone
erosion while keratosis obturans will not

Group 1: Acosta, Atanante, España, Ocat, Padaoan, Santos 1 / 11

 • This is more common in the younger age group who are in their
exploratory phase of development
○ These are commonly everyday objects such as toys, foam,
paper, erasers, batteries, etc.
• In adults, the most common would be retained cotton detached from
a cotton bud
• Insects can also crawl into the ear canal

Tumors
• A variety of benign tumors can be encountered in the EAC
• It can be any benign growth from any of the components of the EAC
○ Ex: nevi, chondroma and osteoma, and papilloma
• Patients usually have no symptom except hearing loss
Figure 3. Coronal CT Scan. Note the canal cholesteatoma (white arrow) and the • Malignant tumors are uncommon
bone erosions (black arrows)
Middle Ear
Otitis Externa • Any disease that affects the integrity and compliance of the TM can
• This is infection and inflammation of the canal skin result in hearing loss
• Three common types:
○ Acute circumscribed otitis externa Direct Trauma
○ Acute diffuse otitis externa • Sometimes seen in:
○ Otomycosis ○ Overzealous cleaning with cotton buds
• Acute circumscribed otitis externa ○ Compressive barotrauma
○ Also known as furunculosis ▪ When there is a rapid rise in pressure in the EAC (e.g. slap
○ A circumscribed swelling in the outer third of the canal on the ear), can cause traumatic TM perforation
○ Most commonly caused by Staphylococcus aureus • Hearing loss experienced right after the trauma
▪ Caused by infection usually arising from trauma (ear • Patient may also complain of low pitched ringing in the ear (tinnitus)
cleaning)
○ If the swelling becomes big enough, it can cause obstruction of
the EAC, and subsequently, hearing loss, ear pain and tragal
tenderness (pain when pressing the tragus)
○ Otoscopic findings
▪ Circumscribed swelling in the outer third of the canal
▪ Sometimes with purulent discharge

Figure 5. Otoscopy of Traumatic Tympanic Membrane Perforation. Note the

jagged edge of the perforation and surrounding hematoma

• Otoscopy findings
○ TM perforation with jagged edges
○ Ear drum may be congested or with hematoma, and there may
be blood in the ear canal
Figure 4. Otoscopy of Diffuse Otitis Externa. Note the diffuse swelling and ▪ May have bloody otorrhea (ear bleeding)
subsequent narrowing of the canal
Otitis Media
• Diffuse otitis externa
• Middle ear infections can cause perforation of the TM
○ Also known as swimmer’s ears
▪ Associated with an antecedent dip in water • Chronic Otitis Media (COM)
▪ May also result from vigorous ear manipulation ○ Persistent infection of the middle ear
○ Pseudomonas: most common infecting agent ○ There is drainage accompanied by perforation of the TM
○ Presents with diffuse/circumferential swelling of the whole • Acute Otitis Media (AOM)
canal ○ TM may also perforate during its suppurative stage
▪ Causes hearing loss ○ The combination of the TM perforation and ear discharge
▪ The accompanying pain is usually more severe than in blocking the canal results in hearing loss.
acute circumscribed otitis externa
○ Otoscopy is diagnostic
• Otomycosis
○ The EAC can also be infected by fungi; the most common are
▪ Aspergillus sp.
▪ Candida sp.
○ Accumulation of cotton-like fungal debris and discharge can
block the EAC and cause hearing loss
○ The hallmark of otomycosis: ear pruritus
○ Pain may also be a presenting symptom symptom
○ Otoscopy will show fungal elements and purulent discharge
○ Treatment is with topical antifungal

Foreign Body
• A foreign body in the EAC will obviously cause obstruction and
subsequent hearing loss

06.03 TBL: Hearing Loss and Tinnitus 2 / 11

VERSION 01
 Figure 6. Otoscopy of Chronic Otitis Media. Note the smooth edge of the ▫ Nasopharyngeal carcinoma
perforation, absence of bleeding/hematoma, and mucoid discharge coming from
the middle ear (black arrow)
Persistent Middle Ear Negative Pressure
• Otoscopy findings: • May lead to two sequalae
○ TM perforation with a smooth edge ○ TM retraction
○ With or without congestion ▪ Adhesive Otitis Media
○ With or without discharge ▫ Most severe form of TM retraction
▫ Pars tensa becomes adherent to the bony medial wall of
the middle ear
Tympanosclerosis
▫ TM can be seen draped over the ossicles and adherent
• Thickening of the fibrous middle layer of the TM, seen as whitish
to the middle ear medial wall
patches in the TM
▫ This will result in persistent conductive hearing loss if
• Decreased compliance* of the intact TM may result in hearing loss not addressed promptly
○ Accumulation of middle ear fluid
▪ Otitis Media with Effusion*
▫ Negative pressure in the middle ear may induce
transudation of fluid from the middle ear mucosa into the
middle ear space
▫ Unlike in acute otitis media, the patient will have only
mild or no ear pain accompanying the hearing loss
▫ There is also a sense of ear fullness (like there is water
in the ear)
▫ Otoscopic finding: middle ear fluid is commonly clear

Figure 7. Tympanosclerosis. Note the white plaques on the TM

Myringitis
• Primary inflammation of the TM
• Bullous myringitis
○ Common form, associated with upper respiratory tract infection
○ Finding of a bleb, blister or bulla in the lateral surface of the TM
▪ Filled with fluid or blood or both
○ Caused primarily by Mycoplasma pneumonia or viruses, but
some studies have shown that it is also caused by the same
organisms that cause otitis media (S. pneumonia, Moraxella) Figure 9*. Otoscopy of Otitis Media with Effusion. Note the air fluid level
○ Patients present with acute progressive otalgia and hearing loss (white arrow)
○ Self-limiting, treatment is supportive.
Otitic Barotrauma
• Barotrauma is secondary to acute injury to middle ear tissue from
drops in barometric pressure during diving or flying
• As environmental pressure increases, the air in the middle ear is
compressed
• The Eustachian tube needs to let in air to restore volume and
equalize pressure
○ If this fails and the pressure becomes big enough (>100 mm
Hg), the ear drum retracts and small TM vessels rupture,
causing hemorrhagic areas in the TM
○ Occasionally, the TM might rupture
○ The vessels in the middle ear mucosa may also rupture, causing
accumulation of blood in the middle ear, causing
hemotympanum
Figure 8. Bullous Myringitis. Note the vesicle on the TM
• Patients with barotrauma will present with:
○ Acute pain
○ Ear fullness
Eustachian Tube Problem
○ Decreased hearing
• Eustachian Tube
• Otoscopic findings:
○ Connects the middle ear to the nasopharynx
○ Hemorrhagic ear drum
○ Its most important function is ventilation of the middle ear
○ Hemotympanum
▪ Ventilation provides equalization of atmospheric pressure on
○ Both hemorrhagic ear drum and hemoptympanum
both sides of the TM
▪ Compliance is greatest in this situation
• Anything that compromises eustachian tube patency or function will Ossicular Abnormalities
result in negative pressure within the middle ear • The ossicular chain conducts vibration from the TM to the cochlea.
○ Stiffness of the TM increases (or compliance is reduced*) when Increased stiffness or discontinuity of the ossicular chain will result in
there is negative pressure in the middle ear and the TM is pulled decreased hearing
or sucked inwards • In children
• Causes ○ Ossicular stiffness may result from congenital
○ Nasopharyngeal or nasal inflammation (most common) underdevelopment of the ear structures
▪ Allergic rhinitis ○ Varying degrees of atresia, ankylosis and deformity of the
▪ Infectious rhinitis ossicular chain may be found
▪ Sinusitis and nasopharyngitis • In adults
○ Eustachian tube obstruction ○ Ossicular stiffness may result from recurrent middle ear
▪ Mechanical compression from a mass infections
▫ Hypertrophic adenoid ○ Scarring in the area of the ossicular joints reduces their mobility

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VERSION 01
 ○ Chronic middle ear infection may cause ossicular chain
discontinuity, where there is a gap between the bony parts of the Table 1. Drugs that affect inner ear
chain Antibiotics
○ This is most likely seen in association with middle ear • Aminoglycosides • Other antibiotics
cholesteatoma ○ Streptomycin ○ Vancomycin
○ Dihydrostreptomycin ○ Erythromycin
Cholesteatoma ○ Neomycin ○ Chloramphenicol
• A complication of chronic middle ear infection ○ Gentamicin ○ Ristocetin
• By several possible mechanisms, squamous epithelium starts to ○ Tobramycin ○ Polymixin B
accumulate in the mastoid and middle ear ○ Amikacin ○ Viomycin
• As it accumulates, may erode surrounding bones, including the bony ○ Pharmacetin
ossicular chain ○ Colistin
○ Thus, ossicular discontinuity can result Analgesics and Antipyretics Antineoplastic Agents
○ This may lead to severe conductive hearing loss • Salicylates 
 • Bleomycin
• Quinine • Nitrogen mustard
Otosclerosis • Chloroquine • cis-Platinum
• An occasional cause of hearing loss in adults Miscellaneous Chemicals
• A hereditary condition which causes progressive conductive hearing • Pentobarbital • Carbon monoxide 

loss starting early adulthood • Hexadine 
 • Oil of chenopodium 

• In this condition, otospongosis (“soft bone”) forms at the lip of the • Madelamine 
 • Nicotine 

stapes, causing fixation of the stapes to the otic capsules in the oval • Practolol • Aniline dyes 

window • Alcohol
○ As a result, they cannot conduct vibration to the cochlea. • Potassium bromate
Otoscopy is usually normal Heavy Metals Diuretics
• Mercury 
 • Furosemide 

Inner Ear • Gold 
 • Ethacrynic acid 

• Problems in the inner ear is a significant cause of hearing loss • Lead • Bumetanide 

• Two (2) broad categories: • Arsenic • Acetazolamide
• Mannitol
Congenital
• May occur alone or in association with other abnormalities • Tumors
• Majority of the genetic deafness comes from aplasia or under ○ Fibers of the eighth nerve ascend to the central nervous system
development of the cochlea via a narrow canal, called the internal acoustic canal (IAC)
○ Scheibe aplasia* ▪ Enlarging masses or tumors in this area can compress and
▪ Aplasia of the cochlear duct cause dysfunction of CN VIII, resulting to hearing loss
▪ Most common ▪ Since the vestibular portion of CN VIII also passes through
○ Michel aplasia this canal, the patient may also experience vertigo.
▪ Total lack of development of the inner ear ▪ May be a cause of unilateral hearing loss*
○ Mondini aplasia ○ Other tumors in the IAC include:
▪ The underdeveloped cochlea has 1 1⁄2 instead of 2 1⁄2 turns ▪ CN VII schwannomas
• May be associated with or part of genetic syndromes ▪ Meningiomas
○ Waardenburg disease ▪ Hemangiomas
○ Pendred syndrome ▪ vascular malformations
○ Alport’s disease ○ The patient may present with slowly progressive hearing loss,
○ Paget disease tinnitus and usually mild dizziness.
○ Cretinism • Presbycusis*
○ One of the most common causes of inner ear related hearing
Acquired loss
• Infection ○ Age- elated progressive sensorineural hearing loss
○ Middle ear infections or their toxic metabolic by-products can ▪ As we age, there is loss of hair cells and cochlear neurons
gain access to the cochlea by several mechanisms and damage ▪ The hair cells and neurons in the basal turn are usually lost
the hair cells through: first, leading to high frequency hearing loss
▪ Oval or round windows ○ Clinically, this may present as decreased speech discrimination
▪ Pre-formed pathways or understanding
▪ Blood (hematogenous) ○ Not reversible.
○ This is usually unilateral ○ Hearing loss is usually bilateral*
• Viral infections can gain access by the same mechanisms and • Noise exposure
cause damage in the inner ear ○ With industrialization, noise exposure becomes more prevalent
○ Mumps ○ Physical trauma from the strong vibration transmitted to the
▪ Leading cause of unilateral acquired hearing loss in children cochlea is believed to lead to hair cell loss
○ Other viruses that can damage the inner ear are: ○ Since the closest to the oval window is the basal turn, the basal
▪ Chickenpox hair cells are affected most
▪ Measles ○ Noise-induced hearing loss is, therefore, typically biased
▪ Influenza towards the high frequencies.
▪ Adenovirus ○ Hearing loss is usually bilateral*
○ Hearing loss can be unilateral or bilateral
• Ototoxic drugs II. Tinnitus
○ Can cause sensorineural hearing loss
○ Hearing loss is bilateral*
B. Introduction
○ Since the vestibular system and cochlea are intimately related,
these drugs can cause both hearing and vestibular symptoms • Abnormal noise perceived in one or both ears or in the head
▪ Although the effect of some medications, like salicylates, are ○ Intermittent, constant or continuous
reversible, most are not ○ Ringing, hissing, whistling, buzzing, or clicking sound
▪ The decision to use these ototoxic drugs must be weighed ○ Vary in pitch from a low roar to a high squeal
against the potential benefit for the disorder being treated • A symptom, not a diagnosis*
▪ The patient should always be warned about the side effects • Tinnitus is very common

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VERSION 01
 ○ Most studies indicate the prevalence in adults as 10% to 15%,
with a greater prevalence at higher ages, through the sixth or
seventh decade of life.
○ Gender distinctions are not consistently reported across studies.
• Most common form of tinnitus is subjective tinnitus, which is noise
that other people cannot hear
• A rare form of tinnitus is objective tinnitus, occurring in less than
1% of cases
○ Can be heard by an examiner positioned close to the ear (or
with a stethoscope)
Chronic Tinnitus
• Annoying, intrusive, and in some cases devastating to a person’s life
○ Up to 25% of those with chronic tinnitus find it severe enough to
seek treatment
• Can interfere with a person’s ability to hear, work, and perform daily
activities
○ 33% of persons being treated for tinnitus reported that it
disrupted their sleep, with a greater degree of disruption directly
related to the perceived loudness or severity of the tinnitus
C. Causes and Related Factors
• Most are associated with damage to the auditory system
○ Also associated with jaw, head, or neck injury, exposure to
certain drugs, nerve damage, or vascular (blood-flow) problems
• With severe tinnitus in adults, coexisting factors may include:
○ Hearing loss, dizziness, head injury, sinus and middle-ear
infections, or mastoiditis (infection of the spaces within the
mastoid bone)
• Significant factors associated with mild tinnitus may include:
○ Meningitis, dizziness, migraine, hearing loss, or age
• 40% of tinnitus patients have decreased sound tolerance, identified
as the sum of:
○ Hyperacusis (perception of over-amplification of environmental
sounds)
○ Misophonia/ phonophobia (dislike/fear of environmental
sounds)
• However, up to 18% of cases do not involve reports of abnormal
hearing.
• Most of the time, no cause can be identified for tinnitus, hence
termed idiopathic tinnitus
○ Most common cause of tinnitus*
Hearing Loss from Exposure to Loud Noise
• Acute hearing depends on the microscopic endings of the hearing
nerve, or hair cells, in the inner ear
○ Exposure to loud noise can injure these nerve endings and
result in both hearing loss and tinnitus.
• Perilymph fistula
○ A tear or defect in one or both of the thin membranes between
the middle and inner ear
Vestibulocochlear Nerve Damage and Central Auditory System
Changes
• The vestibulocochlear nerve carries signals from the inner ear to the
brain.
○ Tinnitus can result from damage to or compression of this nerve.
○ Some causes of damage
▪ Acoustic neuroma, aka vestibular schwannoma
▫ Benign tumor on the vestibular portion of the nerve
▪ Vestibular neuritis
▫ Viral infection of the nerve
▪ Microvascular compression syndrome
▫ Irritation of the nerve by a blood vessel
• Hyperactivity in the central auditory system, especially in the
auditory cortex
○ Associated with chronic tinnitus
○ Tinnitus is thought to be triggered by damage to the cochlea (the
peripheral hearing structure) or the vestibulocochlear nerve.
Head and Neck Trauma
• Tinnitus due to head or neck trauma tends to be perceived as louder
and more severe
○ Accompanied more frequently by headaches, greater difficulties
with concentration and memory, and a greater likelihood of
depression
• Somatic tinnitus
○ When the tinnitus is associated with head, neck, or dental
injury—such as misalignment of the jaw or temporomandibular
joint (TMJ) dysfunction— and occurs in the absence of hearing
loss
○ Characteristics include intermittency, large fluctuations in
loudness, and variation in the perceived location and pattern of
its occurrence throughout the day
Medications
• Many drugs can cause or increase tinnitus.
○ Certain non-steroidal anti-inflammatory drugs (NSAID)
○ Certain (ototoxic) antibiotics (such as gentamicin and
vancomycin)
○ Loop diuretics (such as furosemide)
○ Aspirin and other salicylates
○ Quinine-containing drugs
○ Chemotherapy medications (such as carboplatin and cisplatin)
• Depending on the medication dosage, the tinnitus can be temporary
or permanent.

Presbycusis Vascular Sources

• General impairment of the cochlear apparatus that occurs with aging • Pulsatile tinnitus is a rhythmic pulsing sound that sometimes
• Age-related degeneration of the inner ear occurs in 30% of people occurs in time with the heartbeat.
aged 65 – 74, and in 50% of people 75 years or older. • Typically a result of noise from blood vessels close to the inner ear
• Not usually serious
Middle Ear Problems ○ However, sometimes it is associated with serious conditions
• Otosclerosis such as high or low blood pressure, hardening of the arteries
○ Condition where abnormal bone growth causes the stapes to be (arteriosclerosis), anemia, vascular tumor, or aneurysm.
fixated in the round window of the cochlea
○ 65% of people with this condition have tinnitus Other Possible Causes
▪ Tinnitus sound typically occurs as a high- pitched tone or • High stress levels
white noise rather than as a low tone • Onset of a sinus infection or cold
• Otitis media (middle-ear infection) can be accompanied by • Autoimmune disorders (such as rheumatoid arthritis or lupus)
tinnitus, which usually disappears when the infection is treated • Hormonal changes
• If repeated infections cause a cholesteatoma (benign mass of • Diabetes
epithelial cells in the middle ear), hearing loss, tinnitus, and other • Fibromyalgia
symptoms can result • Lyme disease
• Myoclonus • Allergies
○ Contraction or twitching of the small muscles in the middle ear • Depletion of cerebrospinal fluid
○ Associated with objective tinnitus • Vitamin deficiency
▪ Accumulation of ear wax in the ear canal can sometimes • Exposure to lead
cause tinnitus especially if it comes into contact with the TM • Excessive amounts of alcohol or caffeine
Vestibular Disorders D. Diagnosis
• Ménière’s disease • Good history
• Secondary endolymphatic hydrops ○ Age of onset, noise exposure, duration and pattern, drug intake,
○ Resulting from abnormal amounts of endolymph collecting in the associated symptoms and concomitant illnesses
inner ear

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 ○ Many cases of tinnitus appear to have no obvious cause
(idiopathic tinnitus)
• Audiometric testing
○ pure tone audiometry, tympanometry, otoacoustic emission,
auditory brainstem response audiometry and cochleography
• MRI to assess the central pathways
• Neuropsychiatric testing
○ Screen for the presence of anxiety or depression which may
modify the perception of tinnitus
E. Treatment
• Depends on specific cause
○ If a TMJ dysfunction is the cause, a dentist may be able to
relieve symptoms by realigning the jaw or adjusting the bite with
dental work
○ If an infection is the cause, successful treatment of the infection
may reduce or eliminate the tinnitus
○ If no identifiable cause, more difficult to treat
• Although a person’s tolerance of tinnitus tends to increase with time,
severe cases can be disturbing for many years
• In chronic cases, a variety of treatment approaches are available:
○ Medication, dietary adjustments, counseling, and devices that
help mask the sound or desensitize a person to it
• Not every treatment works for every person.
Masking Devices
• A masking device emits sound that obscures, though does not
eliminate, the tinnitus noise
• Usefulness is based on the observation that tinnitus is usually more
bothersome in quiet surroundings
○ A competing sound at a constant low level, such as a ticking
clock, whirring fan, ocean surf, radio static, or white noise may
disguise or reduce the sound of tinnitus, thus making it less
noticeable
• Some report that they sleep better when they use a masker
• In some users, maskers produce residual inhibition—tinnitus
suppression that lasts for a short while after the masker has been
turned off
• Hearing aids are sometimes used as maskers.
○ If hearing loss is involved, properly fitted hearing aids can
improve hearing and may reduce tinnitus temporarily.
○ However, tinnitus can actually worsen if the hearing aid is set at
an excessively loud level.
Tinnitus Retraining Therapy (TRT)
• Designed to help a person retrain the brain to avoid thinking about
the tinnitus
• Employs a combination of counseling and a non-masking sound that
decreases the contrast between the sound of the tinnitus and the
surrounding environment
• Goal is not to eliminate the perception of the tinnitus sound itself, but
to retrain a person’s conditioned negative response (annoyance,
fear) to it*
○ Masking was found to provide the greatest benefit in the short
term (3 - 6 months)
○ TRT provided the greatest improvement with continued
treatment over time (12 – 18 months)
Psychological Treatments
• Chronic tinnitus can disrupt concentration, sleep patterns, and
participation in social activities, leading to depression and anxiety
○ Tends to be more persistent and distressful if a person
obsesses about it
• Consulting with a psychologist or psychiatrist can be useful when the
emotional reaction to the perception of tinnitus becomes as
troublesome as the tinnitus itself and when help is needed in
identifying and altering negative behaviors and thought patterns
Medication
• No drug* is available to cure tinnitus; however, some drugs have
been shown to be effective in treating its psychological effects.
○ Anti-anxiety medications in the benzodiazepine family
▪ Clonazepam (Klonopin) or lorazepam (Ativan)
○ Antidepressants in the tricyclic family
▪ Amitriptyline (Elavil)
▪ Nortriptyline (Aventyl, Nortrilen, Pamelor)
○ Some selective serotonin reuptake inhibitors (SSRIs)
06.03 TBL: Hearing Loss and Tinnitus
VERSION 01
▪ Fluoxetine (Prozac)
• Some alternative approaches may eventually yield helpful options in
tinnitus treatment with more research
Surgery
• Limited to cases when:
○ Source of the tinnitus is identified
▪ Such as acoustic neuroma, perilymph fistula, or otosclerosis
○ Surgical intervention is required to treat that condition
Other Proposed Treatments
• Stress-reduction techniques
○ Relaxation training, the use of biofeedback to augment
relaxation exercises, and hypnosis
○ Limited research is available on the effectiveness of these
methods
• Acupuncture, electrical stimulation, application of magnets,
electromagnetic stimulation, and ultrasound have been found to be
placebo treatments for tinnitus or to have limited scientific support
for their effectiveness.

• Recent and ongoing research studies have attempted to assess
whether transcranial magnetic stimulation could be an effective
tinnitus treatment.
○ Based on the thought that tinnitus is associated with an irregular
activation of the temporoparietal cortex, and thus that disturbing
this irregular activation could result in transient reduction of
tinnitus.
F. Prevention
• Two most important interventions for reducing the risk of tinnitus
○ Avoiding exposure to loud sounds (especially work-related
noise)
▪ Wearing ear protection against loud noise at work or at
home and avoiding listening to music at high volume
can both help reduce risk.
○ Getting prompt treatment for ear infections
G. Summary
• Tinnitus is a common condition that can disrupt a person’s life.
• Understanding of the mechanisms of tinnitus is incomplete, and
many unknown factors remain.
○ These limitations contribute to the lack of medical consensus
about tinnitus management, stimulate continued research
efforts, and motivate anecdotal and commercially based
speculation about potential but unproven treatments.
• Prior to receiving any treatment for tinnitus, it is important for a
person to have a thorough examination.
○ Understanding the tinnitus and its possible causes is an
essential part of its treatment.
III. Documenting Hearing Loss
• Easiest way is to do a tuning fork test
○ Can be done in the clinic with minimum of equipment
○ However, this test is qualitative and not very accurate
• Most useful and widespread method is the pure tone audiometry
(PTA)*
○ PTA can document presence of hearing loss, determine the
kind of hearing loss (conductive, sensorineural, mixed) and the
degree of hearing loss
• Other tests that can be done: speech audiometry, immitance
audiometry, otoacoustic emission, and auditory brainstem response.
○ These tests help in localizing and diagnosing the source of
hearing loss
A. Types of Hearing Loss
• Conductive hearing problems are due to disorders of the external or
middle ear.
• Sensorineural hearing problems are secondary to disturbance of
the cochlea (sensory), or eighth nerve / central auditory channels
(neural).
• Mixed or combined hearing loss involves disturbances of both
conductive and sensorineural mechanisms.
6 / 11
 B. Testing Models Negative Test Conductive External or middle
• Air conduction (AC) utilizes the external and middle ear in the AC<BC impairment ears
transmission of sound to the cochlea and beyond Weber Test
• Bone conduction (BC), the skull is set into vibration by direct • The stem of the vibrating fork is held to the midline of the forehead,
contact with a periodically oscillating body, such as a tuning fork and the patient is asked to report whether the sound is heard in the
○ Normal bone conduction hearing strongly suggests normal left, right, or both ears.
cochlear, nerve, and brain stem function.
○ If the sensorineural component (BC) is normal, while the total
system (AC) is impaired (BC>AC):
▪ Impairment is judged to have resulted from damage to the
remaining portion of the system
▫ i.e., the middle ear and/or external ear, not measured by
the normal bone conduction finding
○ If the bone conduction measurement is no more sensitive than
the air conduction (BC≤AC):
▪ Impairment is judged to have resulted from damage or
change in the cochlear or retrocochlear (eighth nerve or
central pathway) mechanism
Figure 11. Weber Test
C. Tuning Fork Tests
• Hz (hertz) or “cycles per second”, is the unit of frequency • In general, the patient perceives the sound of the fork in the ear with
• The higher the frequency, the higher the pitch better bone conduction or greater conductive component
○ Limiting the survey to the so-called speech frequencies - 512, ○ If the tone is heard in the reportedly poorer ear, a conductive
1024, and 2048 Hz - is usually sufficient hearing loss should be suspected for that ear
○ If heard in the better ear, sensorineural loss is suspected for the
Threshold or Schwabach’s Test poorer ear.
• The tuning fork is held by the stem, and one of the tines is struck • The Weber test is most useful in instances of unilateral impairment,
against a firm but resilient surface, such as the heel of the hand or but ambiguity may develop when one ear has both conductive and
the elbow/knee sensorineural (combined or mixed) involvement.
○ Do not to strike the fork against the edge of a table or some Used only in conjunction with other tests
other unyielding object that will produce overtones, some of
which are audible at some distance from the fork, and may even D. Pure Tone Audiometry
cause permanent alteration in the vibratory pattern of the fork
• The fork is held close to the patient’s ear, and the patient is asked to
report when the sound is no longer audible.
• At that report, the fork is placed next to the examiner’s ear
○ If the examiner cannot hear any sound, then the patient’s
hearing is deemed normal
○ If the examiner can still hear a sound, then the hearing of the
patient is deemed impaired
• The procedure provides a rough estimate of the patient’s hearing
sensitivity. The examiner is presumed to have a normal hearing
threshold

Rinne Test
• Compares the patient’s hearing by bone conduction against that by
air conduction
• The hilt of the vibrating fork (512 Hz) is held against the patient’s
mastoid (bone conduction, BC) until sound is no longer heard; the
Figure 12. Pure Tone Audiometry
tines are then placed close to the same ear (air conduction, AC).
• The normal ear will resume hearing the fork by air conduction, a
finding called the positive Rinne (AC>BC) • Audiometers sample the octave series of the C scale in the tradition
of tuning forks
• Tonal intensity could be maintained at a fixed level rather than one
that immediately began a steady decay, as with tuning forks
• The tone could be interrupted as desired, or the intensity could be
attenuated at fixed intervals with arrays of electrical impedance -
hence an opportunity to quantify the intensity of the sound.

Air Conduction and Bone Conduction

• Two sources of sound
○ One is from earphones held snugly against the ears by a
headband
Figure 10. Rinne Test ▪ Each ear is tested separately, and the results are graphed
as the air conduction audiogram
• The patient with sensorineural hearing impairment will also yield a ○ Second is from the bone conduction oscillator or vibrator held
positive Rinne since the sensorineural disturbance should affect snugly against the mastoid (or forehead) by a headband
both air conduction and bone conduction routes equally (AC>BC). ▪ The vibrator sets the skull into oscillation with associated
• The term negative Rinne is applied when the patient cannot disturbance of the fluids of the cochlea
resume hearing by air conduction after the fork is no longer audible • The results, graphed as the bone conduction audiogram, are
by bone conduction (AC<BC) usually interpreted as bypassing the middle ear, being a measure of
“cochlear reserve” and reflecting the status of the auditory nervous
Table 1. Rinne test results* system.
Rinne Test Result Hearing Status Locus ○ The latter interpretation is not entirely accurate but is generally
Positive Test Normal or None or cochlear- useful.
AC≥BC sensorineural retrocochlear
impairment

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 Objective
• The objective of the measurement is to determine the lowest
intensity level in decibels that can be heard for each frequency and
thus the threshold of audibility for that sound.

Audiometric Zero and Intensity Range*

• The threshold hearing level derived for a patient is compared against
audiometric “zero”
○ This is the median average threshold of a large sample of
young adults with no hearing complaints, no history of ear
disease, and no recent colds
○ Each frequency has its separate zero with zero-calibrated
values built into the audiometer output
○ There are patients with sensitive hearing who will register a
reading of less than zero (negative). Thus, the audiometer
should have the capability to measure lesser intensities.
• Audiometer intensities may range from -10 dB to as high as 110
dBs. Figure 14. Pure Tone Audiogram. Right ear (left) audiogram is normal. Left ear
(right) audiogram depicts conductive hearing loss). Explanation found below.
○ If a patient requires 45 dB of intensity above the normal to
perceive a particular sound, his hearing threshold level is 45 dB
○ If his sensitivity is closer to the normal and he requires an • Normal hearing (depicted by right ear in Figure 14)
increase of only 20 dB above normal, his threshold is a 20dB ○ Bone and air conduction thresholds are within 10 dB of each
hearing level other on the average
○ If it is 10 dB more sensitive than the average, his hearing ○ Both are normal (25 dB and below)
threshold level is designated as a negative value, or -10 dBs. • Conductive hearing loss (depicted by left ear in Figure 14)
○ Bone conduction thresholds are normal (25 dB and below) but
Audiogram* better (less dB) than air conduction thresholds by 10 dB or
• The audiogram is a graph of the patient’s hearing sensitivity for more (air-bone gap >10 dB on average)
various frequencies
• Measures are recorded for each ear separately, with frequency
displayed on the abscissa and intensity on the ordinate
• Air conduction symbols are connected by a solid line as illustrated
on the audiogram
• Bone conduction symbols are connected by a broken line
• Color coding is not necessary for identifying sidedness in this
symbol system
○ However, if color is employed, red should be used for the right
ear symbols and connecting lines and blue for the left ear.
• Graphing the right and left ears on separate audiograms has been
used to avoid audiogram clutter.

Figure 15. Pure Tone Audiogram. Right ear (left) audiogram depicts
sensorineural hearing loss. Left ear (right) audiogram depicts conductive hearing
loss.

• Sensorineural hearing loss (depicted by right ear in Figure 15)

○ Bone conduction thresholds are close to air conduction
thresholds (less than 10 dB gap)
○ Neither is normal (more than 25 dB)
• Mixed or combined hearing loss (depicted by left ear in figure 15)
○ Bone conduction and air conduction thresholds are reduced
Figure 13. Audiogram. X-axis shows frequencies, Y-axis shows hearing level in (more than 25 dB) but are still better than air conductions by 10
dB. The lower the point is, the louder the sound must be to be heard, suggesting dB or more (air-bone gap > 10 dB)
potential hearing loss. Sensorineural Hearing Loss (left), Conductive Hering Loss
(right).
Normal Values
• In the Philippines, the hearing levels classification usually used is
Classic Interpretation* the American Speech Language Hearing Association (ASHA)
• Audiograms may be interpreted according to degree of loss, Standard
configuration or pattern of loss, and air conduction-bone conduction
relationships. Table 2. ASHA Hearing Level Classification
Description Range in dB
Slight 16 - 25 dB
Mild 26 - 40 dB
Moderate 41 - 55 dB
Moderately Severe 56 - 70 dB
Severe 71 - 90 dB
Profound >90 dB

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 E. Tympanometry
• Indirect measure of the compliance (mobility) of the TM and
ossicular system under conditions of positive, normal, and
negative pressure
○ Goal is to determine the point and magnitude of the greatest
compliance of the TM
○ The greater the compliance, the more sound is transmitted.
• To measure compliance:
○ High acoustic energy is introduced into the ear by a probe tube
○ Some is absorbed, and the remainder is reflected back out the
canal and collected by a second channel of the probe tube
▪ In the normal ear, a measuring device shows the reflected
energy to be less than the incident energy
▪ On the other hand, when the ear is filled with fluid, the
drum is thickened, or the ossicular system is stiffened, the
energy reflected is greater than that in the normal ear
▪ The amount of reflected energy is more equivalent to the
incident energy. This relationship is used as a measure of
compliance.
• Compliance is measured at different pressures to find the point of Figure 16. Tympanogram Types
greatest compliance

Tips: Review Questions

• The patient may have normal tympanogram despite presence of 1. True for keratitis obturans and Cholesteatosis
hearing loss! For example, a patient with presbycusis and normal A. Both have necrotic lesions
TM, the tympanogram result will be normal B. Best imaging modality is CT scan
C. Presence of bony erosion in both
Tympanogram
• A graphic representation of relative compliance in the tympano- 2. Hereditary condition where the stapes is fixed to the oval window
ossicular system while air pressure changes are produced in the that causes hearing loss
external meatus A. Otosclerosis
• Maximum compliance will be obtained at normal air pressure, while B. tympanosclerosis
compliance is reduced as air pressure is increased or decreased C. Scheibe
from normal. D. Cholesteatoma
• Persons with normal hearing and with sensorineural hearing
impairments will demonstrate a normal tympano-ossicular system. 3. Tinnitus caused by overproduction or inadequate drainage of
endolymph fluid
A. Pulsatile tinnitus
Classification* B. Vestibular neuritis
• Type A (Normal Tympanogram) C. Meniere’s disease
○ Maximum compliance occurs at or near ambient air pressure, D. Idiopathic
suggesting normal middle ear pressure.
• Type B 4. Physical exam finding of AC>BC on both ears. Audiogram
○ The tympanogram is relatively “flat” or “dome-shaped”, showing difference between AC and BC is 5dB with an average threshold of
little change in the reflective quality of the tympano-ossicular 43dB
system as air pressures change in the external canal A. Normal
○ Associated with middle ear fluid or pressure, perforated ear B. Mixed
drum, thickened drum, or impacted cerumen C. Conductive
○ The impedance characteristics of the tympano-ossicular system D. Sensorineural
are dominated by the incompressible nature of the abnormality
present. Small pressure changes have little effect. 5. Patient presents with ear discharge for the past 3 months. On and
• Type C off ear fullness and hearing loss but with no pain. On otoscopy
○ Maximum compliance occurs with negative equivalent pressure tympanic membrane is perforated. What is the diagnosis?
in excess of 200 mm H2O in the external canal A. Acute otitis media
○ Otoscopic examination usually reveals a retracted TM and may B. Tinnitus
show some fluid in the middle ear C. Chronic otitis media
D. Otomycosis

Answer Key: 1b, 2a, 3c, 4d, 5c

References
(1) Hearing Loss and Tinnitus TBL Handout (2018).

Figure 15. Tympanogram Curves. The types are super imposed onto one
another in one graph.

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 ○ Majority of the genetic deafness comes from aplasia or under
Appendix development of the cochlea
▪ Scheibe aplasia*
T/N: Trans too long? Think you've aced that TBL and read the handout ▫ Aplasia of the cochlear duct
already but just looking for an easy read or refresher? Here's a quicker ▪ Michel aplasia
version of the trans. ▫ Total lack of development of the inner ear
▪ Mondini aplasia
A. Hearing Loss ▫ The underdeveloped cochlea has 1 1⁄2 instead of 2 1⁄2
turns
External Ear ○ May be associated with or part of genetic syndromes
• Cerumen Impaction • Acquired
○ In the Philippines, the most common cause of hearing loss, ○ Can arise from infection
• Keratosis Obturans and Cholestatomas ▪ This is usually unilateral
○ Keratosis Obturans ○ Viral infections can gain access by the same mechanisms and
▪ Secondary canal skin inflammation or infection (otitis cause damage in the inner ear
externa) may cause pain ▪ Mumps
○ External canal cholesteatoma ▫ Leading cause of unilateral acquired hearing loss in
▪ there may be areas of focal skin ulceration or bone children
necrosis* ○ Ototoxic drugs
▪ Presence of granulation tissue and otitis externa is common ▪ Can cause sensorineural hearing loss
○ CT scan ▪ Hearing loss is bilateral
▪ Best imaging modality for these conditions ○ Tumors
• Otitis Externa ▪ May be a cause of unilateral hearing loss*
○ This is infection and inflammation of the canal skin ○ Presbycusis*
○ Three common types: ▪ Age- elated progressive sensorineural hearing loss
▪ Acute circumscribed otitis externa ▪ Not reversible.
▪ Acute diffuse otitis externa ▪ Hearing loss is usually bilateral*
▪ Otomycosis ○ Noise exposure
• Foreign Body ▪ Hearing loss is usually bilateral
○ This is more common in the younger age group who are in their
exploratory phase of development B. Tinnitus
• Tumors • Abnormal noise perceived in one or both ears or in the head
○ A variety of benign tumors can be encountered in the external • Can be intermittent, constant or continuous
auditory canal • A symptom, not a diagnosis*
○ Malignant tumors are uncommon • Most common form of tinnitus is subjective tinnitus, which is noise
that other people cannot hear
Middle Ear • A rare form of tinnitus is objective tinnitus, occurring in less than
• Trauma 1% of cases
○ Hearing loss experienced right after the trauma
• Otitis Media Chronic Tinnitus
○ Middle ear infections can cause perforation of the tympanic ○ Chronic tinnitus can be annoying, intrusive, and in some cases
membrane devastating to a person’s life
○ Chronic Otitis Media (COM) ○ Can interfere with a person’s ability to hear, work, and perform
○ Acute Otitis Media (AOM) daily activities
• Tympanosclerosis
• Myringitis Causes and Related Factors
○ Bullous myringitis • Most of the time, no cause can be identified for tinnitus, hence
• Eustachian Tube Problem termed idiopathic tinnitus
○ Causes ○ Most common cause of tinnitus*
▪ Nasopharyngeal or nasal inflammation (most common) • Hearing Loss from Exposure to Loud Noise
▪ Eustachian tube obstruction • Presbycusis
• Persistent Middle Ear Negative Pressure ○ Age-related degeneration of the inner ear occurs in 30% of
○ Tympanic membrane retraction persons age 65–74, and in 50% of persons 75 years or older
▪ Adhesive Otitis Media • Middle Ear Problems
▫ Most severe form of TM retraction ○ Otosclerosis
○ Accumulation of middle ear fluid ○ Otitis media
▪ Otitis Media with Effusion* ○ Cholesteatoma
▫ Negative pressure in the middle ear may induce ○ Myoclonus
transudation of fluid from the middle ear mucosa into the ▪ Associated with objective tinnitus
middle ear space • Vestibular Disorders
• Otitic Barotrauma ○ Ménière’s disease
• Ossicular Abnormalities ○ Secondary endolymphatic hydrops
○ Increased stiffness or discontinuity of the ossicular chain will ○ Perilymph fistula
result in decreased hearing • Vestibulocochlear Nerve Damage and Central Auditory System
• Cholesteatoma Changes
○ A complication of chronic middle ear infection ○ Acoustic neuroma
○ By several possible mechanisms, squamous epithelium starts to ○ Vestibular neuritis
accumulate in the mastoid and middle ear ○ Microvascular compression syndrome
○ As it accumulates, may erode surrounding bones, including the ○ Hyperactivity in the central auditory system, especially in the
bony ossicular chain auditory cortex
• Otosclerosis • Head and Neck Trauma
○ A hereditary condition which causes progressive conductive ○ Somatic tinnitus
hearing loss starting early adulthood • Medications
Inner Ear • Vascular Sources
• Congenital ○ Pulsatile tinnitus
○ May occur alone or in association with other abnormalities • Other Possible Causes
○ High stress levels

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 ○ Onset of a sinus infection or cold • When bone conduction thresholds are normal (25 dB and below),
○ Autoimmune disorders (such as rheumatoid arthritis or lupus) but are better (less dB) than air conduction thresholds by 10 dB or
○ Hormonal changes more (air-bone gap>10 dB on the average), the hearing loss is
○ Diabetes conductive
○ Fibromyalgia • When bone conduction thresholds are close to air conduction
○ Lyme disease thresholds (less than 10 dB gap) and neither is normal (more than
○ Allergies 25 dB), the hearing loss is sensorineural
○ Depletion of cerebrospinal fluid • When bone conduction and air conduction thresholds are reduced
○ Vitamin deficiency (more than 25 dB) but are still better than air conductions by 10 dB
○ Exposure to lead or more (air-bone gap > 10 dB), the loss is mixed or combined

Diagnosis Tympanometry
• Good history • Tympanometry is an indirect measure of the compliance (mobility) of
• Audiometric testing like pure tone audiometry, tympanometry, the tympanic membrane and ossicular system under conditions of
otoacoustic emission, auditory brainstem response audiometry and positive, normal, and negative pressure
cochleography Classification*
• MRI to assess the central pathways • Type A (Normal Tympanogram)
• Neuropsychiatric testing to screen for the presence of anxiety or ○ Maximum compliance occurs at or near ambient air pressure,
depression which may modify the perception of tinnitus suggesting normal middle ear pressure.
• Type B
Treatment ○ The tympanogram is relatively “flat” or “dome-shaped”, showing
• Depends on specific cause of tinnitus little change in the reflective quality of the tympano-ossicular
• Many cases of tinnitus have no identifiable cause, however, and system as air pressures change in the external canal
thus are more difficult to treat ○ Associated with middle ear fluid or pressure, perforated ear
• Masking Devices drum, thickened drum, or impacted cerumen
○ A masking device emits sound that obscures, though does not ○ The impedance characteristics of the tympano-ossicular system
eliminate, the tinnitus noise are dominated by the incompressible nature of the abnormality
• Tinnitus Retraining Therapy (TRT) present. Small pressure changes have little effect.
○ Goal*: not to eliminate the perception of the tinnitus sound itself, • Type C
but to retrain a person’s conditioned negative response ○ Maximum compliance occurs with negative equivalent pressure
(annoyance, fear) to it in excess of 200 mm H2O in the external canal
• Psychological Treatments ○ Otoscopic examination usually reveals a retracted tympanic
• Medication membrane and may show some fluid in the middle ear
○ No drug* is available to cure tinnitus; however, some drugs
have been shown to be effective in treating its psychological
effects.
• Surgery
• Other Proposed Treatments
○ Stress-reduction
○ Recent and ongoing research studies have attempted to assess
whether transcranial magnetic stimulation could be an effective
tinnitus treatment.

Prevention
• Avoiding exposure to loud sounds (especially work-related noise)
• Getting prompt treatment for ear infections

C. Documenting Hearing Loss

Types of Hearing Loss

• Conductive
• Sensorineural
• Mixed

Tuning Fork Tests

• Threshold or Schwabach’s Test
• Rinne Test
• Wever Test

Rinne Test Result Hearing Status Locus

Positive Test Normal or None or cochlear-
AC≥BC sensorineural retrocochlear
impairment
Negative Test Conductive External or middle
AC<BC impairment ears

Pure Tone Audiometry

• The objective of the measurement is to determine the lowest
intensity level in decibels that can be heard for each frequency and
thus the threshold of audibility for that sound

Classic Interpretation
• When bone conduction and air conduction thresholds are within 10
dB of each other on the average and both are normal (25 dB and
below), hearing is said to be normal

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