Patient Summary

Presenting Complaints

• Ear hole (likely ear discharge / perforation)
• Ear pain (Otalgia)
• Both ears (bilateral)

Audiogram Interpretation

Right Ear

• PTA average: 40 dB HL
• The audiogram shows a downward-sloping curve — hearing thresholds are mildly impaired at low frequencies and worsen toward high frequencies (~70–80 dB at 4K–8K Hz)
• Pattern: Mild-to-moderate sensorineural hearing loss (SNHL), predominantly affecting high frequencies

Left Ear

• PTA average: 35 dB HL
• The audiogram shows a similar downward-sloping (high-frequency) pattern, with thresholds around 30 dB at low frequencies and dropping to ~75–80 dB at 4K–8K Hz
• Pattern: Mild-to-moderate SNHL, high-frequency predominance

Loss Type (as checked on the form): SENSORINEURAL

Local Examination Findings (from OP sheet)

• Ear: Bilateral TM (tympanic membrane) — Intact
• Mesei (Mastoid): Normal (N)
• Throat: Normal (N)

The TM being intact rules out active perforation or chronic suppurative otitis media (CSOM) causing conductive loss.

Diagnosis

• Right ear: Moderate SNHL (~40 dB PTA), high-frequency sloping
• Left ear: Mild-to-moderate SNHL (~35 dB PTA), high-frequency sloping
• History: Gradual onset, bilateral, present for approximately 2 years
• Associated: Tinnitus (noted in case history — "Tinnitus" listed)

• Noise-induced hearing loss (NIHL) — classic downward slope with notch pattern
• Early presbycusis (age-related SNHL) — though typically >60 years, can occur earlier
• Could have a mixed or overlapping cause (noise exposure + metabolic/vascular factors)

Treatment Plan

Immediate Management

1. Avoid further noise exposure — use ear protection (earplugs/earmuffs) in loud environments
2. Investigate and treat any underlying cause:
   • Rule out diabetes, hypertension (common causes of SNHL in middle age)
   • Lipid profile, blood sugar, BP
3. No ototoxic medications (avoid aminoglycosides, loop diuretics, aspirin in high doses)

Audiological Rehabilitation

1. Hearing Aid Fitting — the primary treatment for bilateral SNHL:
   • Both ears qualify: Right 40 dB, Left 35 dB (both in the mild-moderate range where hearing aids are highly effective)
   • Bilateral hearing aids recommended — improves speech discrimination, sound localization, and quality of life
2. Auditory rehabilitation / counseling — communication strategies, lip reading

If Sudden Onset Component Suspected

1. Rule out sudden SNHL (though history here says gradual) — if acute exacerbation, oral corticosteroids (prednisolone 1 mg/kg/day for 7–14 days) ± intratympanic steroid injection

Follow-Up

• Repeat PTA in 1 month (as per doctor's note)
• Monitor for progression
• Tinnitus management: Tinnitus retraining therapy (TRT) or sound therapy if bothersome

Summary Table