Slide 40

Nosoakusis : tuli terkait penyakit berefek ototoksisitas

Sosioakusis : tuli akibat bising selain tempat kerja, dan juga pengaruh gaya hidup (diet dan olahraga)
Slide 42
● Genetik : Perbedaan gen ekspresi DNA mitokondria mengakibatkan stres oksidatif
(detoxification of reactive oxygen species and include glutathione S-transferase polymorphisms
(in the GSTM1 and GSTT1 genes), an N-acetyltransferase 2 gene polymorphism, and superoxide
dismutase 2 promoter variants)
● Hormon : receptors for steroid hormones are indeed present in the cochlea.
 estrogen therapy slowed the development of ARHI in postmenopausal women
 Turner syndrome who synthesize inadequate levels of estrogen, ARHI sets in early
 progesterone replacement is berbaha l in postmenopausal women, negatively affecting
the auditory nerve pathway and neurotransmitters, underscoring the complexity of
hormonal regulation of ARHI
 protective effect of elevated serum levels of aldosterone on auditory thresholds and an
improvement of speech perception (“hearing-in-noise”) in older individuals. Although
aldosterone primarily acts on water and ion resorption in the kidney, aldosterone
receptors have also been localized to the inner ear. They are hypothesized to influence
the ionic composition of inner ear fluids, which is essential for cochlear homeostasis
and the transduction of sound
● Disease : deficit pendengaran lebih signifika pada DM type 2 diabetes aged 60 or older
compared with a group of age- and sex-matched controls and excluding those with other
significant health issues or a history of hearing problems.
○ increased blood glucose  cellular hypoxia  tumpukan of reactive oxygen speciesdan
sisa metab, as well as changes in the collagen and microtubule structure of the cells.
○ Also, the effects of diabetes on vasculature are profound, including atherosclerosis and
vessel wall dystrophy. In the inner ear, which depends on the stria vascularis to
carefully maintain the endocochlear potential, this could result in apoptosis of cells and
impaired sensory function.
● CVD Just as in diabetes, any disease leading to vascular compromise will impair the function of
this tissue and, by way of decreased endolymphatic potential and driving force for the
transduction process, diminish the sensitivity of the cochlear organ to sound.
● Lifestyle : execissve noise, ototoxic medication ( aminoglikoside, anti cancer agent klas cisplatin
Scala timpani dan vestibule : perilymph, scala media : endolimph (unik high K+ low NA+) ST- reisnerr
membrane – SM= membrane basilars – SV
Membrane basilar ada organon corti, enfolimph krn potensinya + jd untur kekuatan sbg transduksi yg
dibutuhkan sel2 sensoris
When sound reaches the ear, the vibrations of the tympanic membrane (ear drum) are passed
along the middle ear ossicles to the cochlea where they initiate a traveling wave in the fluids, which, in
turn, moves the basilar membrane. The tectorial membrane, an acellular structure, rests on the stereocilia
of the hair cells. Spiral ganglion neurons run from the organ of Corti where they contact the hair cells
through the modiolus to the central auditory system. The stria vascularis and spiral ligament, tissues
involved in setting up the ionic composition and high (+70 to +100 mV) potential of the endolymph, lie
along the lateral wall of the cochlea, juga untuk oksigenasi dan nutrisi

Sensory cells include one row of inner hair cells and three rows of outer hair cell
Inner hair cells are the primary sensory cells that convert the mechanical acoustic input into
receptor potential and release of neurotransmitter, triggering action potentials that are
carried to the brain by the spiral ganglion neurons. Most of the afferent innervation by this
auditory nerve converges on the inner hair cells. The major function of outer hair cells is to
enhance the performance of the cochlea, particularly at low intensities of sound. They
receive mostly efferent innervation from
auditory centers in the brain. Supporting cells include the inner pillar, outer pillar, Deiters,
Hensen, and Claudius cells, about whose function we know relatively little.

Slide 43

• Normalnya, mekanisme anti-aging > pro-aging.

• estrogen yang merupakan antioksidan poten dan neuroprotektif (kalo menopause jadi dapat
mengalami disfungsi mitokondrial, neuro-inflammation, gangguan kognisis, dan risiko lain dari
kelainan pada lansia) , Proses seperti autofag untuk menyapu sisa agregasi protein dan kerja
mitokondrial yang dinamis dapat membantu kinerja dari telinga.
• Butuh adanya balance antara mekanisme anti-aging dan pro-aging Apabila mekanisme pro-
aging lebih dominan  peningkatan pH lisosom yang menyebabkan penumpukan agregasi
protein, terjadi akumulasi mutasi DNA mitokondria, , dan kerusakan DNA nuclear sel yang
menyebabkan degenerasi sel koklea dan AHL.
● Oksidative stress  kondisi-kondisi dimana oksidatif stress seperti reactive oxygen species
(ROS) atau nitrogen species (RNS) (kayak DM)  menyebabkan kerusakan DNA, lipid, dan atau
protein. Dimana seharusnya ROS itu dicounter attack pakai glutathione peroxidase atau
reductase, atau antioksidan lainnya  kerusakan-kerusakan itu menyebabkan kerusakan sel
dan akhirnya ternyata cochlear hair-cell loss, berkurangnya ketebalan stria vascularis, dan
degenerasi neuron spiral ganglion.
Slide 45
● These changes frequently affect the perception of the upper frequencies first, resulting in high-
frequency hearing loss as a hallmark of presbycusis (hazard geriatric 7 th ed)
● In all species, however, the cochlea is tonotopically organized, meaning that high frequencies
are processed in its basal part, low frequencies in the apex.

Slide 46
• Kurangnya pendengaran secara bertahap dan progresif simetris pada kedua telinga
• Usia >60 tahun
 • Dizziness penurunan fungsi organ vestibular
• Tinnitus nada tinggi (kontinu, diffuse, bilateral)  tidak spesifik
• Cocktail party deafness  sulit memahami atau mendengar percakapandi suasana
ramai, membaik disuasana sepi
• Recruitment akibat kelelahan saraf menimbulkan peningkatan sensitivitas telinga tuli
terhadap kenaikan kecil intensitas bunyi pada frekuensi tertentu diatas ambang dengar,
selanjutnya akan timbuul nyeri telinga

• Tanyakan Riwayat:
• Occupational RF  Apakah pekerjaan dulu terpapar oleh suara keras
• Ototoksik drug RF Apakah pernah menggunakan obat-obatan yang bersifat ototoxic
• Herediter
• Dan faktor risiko lain

TYPE Conventional Hair Lost

Air conduction hearing aid. Suara yang ter amplified sound is di transfer ke ear canal lalu menuju
MT
1. Body-worn types. Most common type microphone and amplifier along with the battery
are in one case worn at the chest level while receiver is situated atthe ear level. This type of aid
allows high degree of amplification with minimal feedback. It is useful in severely
deaf persons or children with congenital deafness.
2. Behind-the-ear (BTE) types. Here microphone, amplifier, receiver and battery are all in
one unit which is worn behind the ear. It is coupled to the ear canal with a tubing and an earmould.
It is useful for slight to moderate cases of hearing loss particularly the high frequency ones.
3. Spectacle types. It is a modification of the “behind-theear” type and the unit is housed in the
auricular part of the spectacle frame. It is useful to persons who need both eye glasses for vision
and a hearing aid. It is not very popular now.
4. In-the-ear (ITE) types. The entire hearing aid is housed in an earmould which can be worn in the
ear. It is useful for mild to moderate hearing losses with flat configuration. They are very popular
because of their cosmetic appeal.
5. Canal types (ITC and CIC). The hearing aid is so small that the entire aid can be worn in the
ear canal without projecting into the concha. For using this aid, it is required that the ear canal
should be large and wide, and patient should have the dexterity to manipulate the minute controls in
the aid. It is useful for mild to moderate cases of hearing loss of high frequency (1–4 kHz).
Bone conduction hearing aid. Bukan recevier, ada bone vibrator yang ditaruh mastoid dan
langsung stimulates the cochlea. Brguna pada pasien actively draining ears, otitis externa or atresia of
the ear canal when ear inserts cannot be worn.

CROS (contralateral routing of signals). In this type, microphone is fitted on the side of the deaf ear and
the sound thus picked up is passed to the receiver placed in the better ear. This is useful for persons with
one ear severely impaired and helps in sound localization coming from the side of the deaf ear. Now
bone-anchored hearing aids (see infra) are being preferred for single-sided deafness and have replaced the use
of CROS aids.
BAHA This process eliminates the headshadow effect and allows for hearing from both sides of the
head. The BAHA substantially improves speech recognitionin quiet and in noise compared with
the CROS aids.

Indications for Hearing Aid

Any individual who has a hearing problem that cannot be helped by medical or surgical means is a candidate
for hearing
aid.
1. Sensorineural hearing loss, which interferes with day-today activities of a person. Hearing aid may not suit
all such persons because of the intolerable distortion of sound in some, particularly in those with recruitment.
2. Deaf children should be fitted with hearing aid as early as possible for development of speech and learning.
In severely deaf children, binaural aids (one for each ear and individually fitted) are more useful. Training in
lip reading is given simultaneously.
3. Conductive deafness. Most of such persons can be helped by surgery but hearing aid is prescribed when
surgery is refused or not feasible or has failed.

BONE-ANCHORED HEARING AID (BAHA)

which is based on the principle of bone conduction. Bagus utk tuli konduksi

• Surgically implanted  dipasang ditelinga yang sakit, konduksi langsung ditujukan dari
tulang ke koklea yang sehat bypassing the external auditory canaland middle ear

The titanium fixture is surgically embedded in the skull bone with abutment exposed outside the
skin. The titanium fixture bonds with the surrounding tissue in a process called osseointegration.
The sound processor is attached to the abutment once osseointegration is complete which usually
takes 2–6 months after implantation. The BAHA device transmits vibrations to the external abutment
which further vibratesthe skull and cochleae.

IMPLANT
Rather than delivering acoustic energy into the external auditory canal direct drive middle ear
implant systems use vibrations delivered directly to the ossicular chain, while leaving the ear canal
completely open.

Vibrant soundbridge device. The vibrant soundbridge is a semi-implantable device made of two
components: an internal and an external.
The internal component is called vibrating ossicular prosthesis (VORP) and is made up of three
parts: the receiver, floating mass transducer (FMT) and a conductor link between the two. FMT is
connected to the incus

Piezoelectric devices operate by passing an electric current into a piezoceramic crystal, which
changes its volume and thereby produce a vibratory signal. This piezoelectric transducer in turn is
coupled to the ossicles and drives the ossicular chain by vibration. Examples of such devices are
Envoy, middle-ear transducer (MET or also called otologic device), Rion and totally integrated
cochlear amplifier (TICA).
2. Electromagnetic hearing devices. Electromagnetic hearing devices function by passing an
electric current into a coil, which creates a that drives an adjacent magnet. The small magnet is
attached to one of the ossicles of the middle ear to convey vibrations to the cochlea. An example
of such a device is the vibrant soundbridge device (previously known as the Symphonix device; now
being manufactured by MED-EL).