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Hearing Loss - Complete Overview

1. History of Hearing Loss (H/O)

A thorough history is the cornerstone of evaluating any patient with hearing loss. The following key points must be elicited:

Key History Points

Characteristics of the hearing loss:

Duration and age of onset - congenital vs. acquired
Rate of progression - sudden onset vs. gradual/insidious
Pattern - stable, slowly progressive, or fluctuating
Laterality - unilateral vs. bilateral
Better-hearing ear - always ask which ear hears better

Associated symptoms:

Tinnitus (ringing in the ears)
Vertigo or imbalance
Aural fullness
Otalgia (ear pain)
Otorrhea (ear discharge)
Headache
Facial nerve dysfunction
Head and neck paresthesias

Relevant background history:

History of head trauma
Exposure to ototoxic drugs (aminoglycosides, loop diuretics, cisplatin, quinine)
Occupational or recreational noise exposure
Previous ear surgery
Prior use of hearing aids

Family history:

Family history of hearing loss or ear surgery
In children, additionally: gestational, perinatal, and postnatal history; syndromic associations (renal, cardiac, craniofacial, neurological, metabolic disorders)

Signs and symptoms suggestive of hearing loss (Table 36-2, Harrison's):

Frequently saying "huh?"
Reduced clarity of hearing
Difficulty understanding in background noise
Family members complaining about the patient's hearing
Turning up volume on TV/radio
Avoiding social settings
Sensitivity to loud noises

2. Clinical Features of Hearing Loss

Types of Hearing Loss

Type	Key Feature
Conductive	Problem in outer or middle ear; bone conduction > air conduction (Rinne negative)
Sensorineural (SNHL)	Problem in cochlea or auditory nerve; air conduction > bone conduction in both ears
Mixed	Both components present

Clinical Pointers by Cause

Sudden unilateral loss + tinnitus → viral labyrinthitis, vestibular schwannoma, stroke
Gradual progressive loss → otosclerosis, noise-induced hearing loss, vestibular schwannoma, Meniere's disease
Fluctuating loss + episodic vertigo + tinnitus + aural fullness → Meniere's disease
Sound-induced vertigo + autophony + hearing own eye movements → superior semicircular canal dehiscence
Hearing loss + otorrhea → chronic otitis media or cholesteatoma
Unilateral serous effusion → must exclude nasopharyngeal carcinoma
Bilateral loss + renal disease → Alport's syndrome
Loss + retinitis pigmentosa → Usher's syndrome
Loss + pigmentary changes → Waardenburg's syndrome
Loss + goitre → Pendred's syndrome
Loss + prolonged QT → Jervell and Lange-Nielsen syndrome

Tuning Fork Tests

Rinne Test (512 Hz):

Normal / SNHL: Air conduction (AC) > Bone conduction (BC) - Rinne positive
Conductive HL ≥ 30 dB: BC > AC - Rinne negative

Weber Test:

Unilateral conductive loss: sound lateralizes to the affected ear
Unilateral SNHL: sound lateralizes to the unaffected (better) ear
A 5 dB difference between ears is needed for lateralization

3. Hearing Assessment

Minimum Audiologic Battery (Harrison's, p. 1307)

A complete hearing assessment should include:

Test	Purpose
Pure tone audiometry (PTA)	Establishes air- and bone-conduction thresholds (250-8000 Hz); determines type and degree of loss
Speech reception threshold (SRT)	Lowest intensity at which patient correctly repeats 50% of spondee words
Word recognition score (WRS)	% of words correctly identified at suprathreshold levels
Tympanometry	Middle ear pressure, compliance, Eustachian tube function
Acoustic reflexes	Stapedial reflex; differentiates cochlear from retrocochlear loss
Acoustic reflex decay	Suggests retrocochlear (VIIIth nerve) pathology if present

Degrees of Hearing Impairment

PTA Threshold	Degree
0-25 dB	Normal
26-40 dB	Mild
41-55 dB	Moderate
56-70 dB	Moderately severe
71-90 dB	Severe
>90 dB	Profound

Additional Tests

Otoacoustic Emissions (OAEs) - assess outer hair cell (OHC) function; present in conductive loss, absent/reduced in cochlear SNHL; used in newborn screening
- TEOAEs (transient evoked) - click-stimulated; present if response ≥ 4 dB above noise floor in at least 3 octave bands
- DPOAEs (distortion product) - frequency-specific OHC testing using two continuous tones (f1, f2); largest DPOAE at 2f1-f2
Auditory Brainstem Response (ABR) - electrophysiological; used in neonates, non-cooperative patients, retrocochlear pathology; prolonged I-V latency suggests retrocochlear disease
Electronystagmography / VEMP - for vestibular component
CT/MRI temporal bone - structural pathology, cholesteatoma, vestibular schwannoma
Genetic testing - connexin 26 (GJB2), GJB6 mutations in congenital/hereditary SNHL

4. Management of Hearing Loss

Management depends on the type, severity, and etiology of hearing loss.

A. Conductive Hearing Loss

Cause	Management
Cerumen impaction	Removal (suction, cerumenolytics, irrigation - avoid irrigation if TM perforation)
Otitis media with effusion	Conservative (3 months); then ventilation tubes (grommets)
Otitis externa	Topical antibiotics, aural toilet
Tympanic membrane perforation	Tympanoplasty
Ossicular discontinuity	Ossiculoplasty
Otosclerosis	Stapedectomy / stapedotomy; fluoride therapy; hearing aid
Cholesteatoma	Mastoidectomy + ossicular reconstruction

B. Sensorineural Hearing Loss

Type	Management
Sudden SNHL	Systemic/intratympanic corticosteroids (within 4-6 weeks of onset)
Noise-induced	Prevention (ear protection); no curative treatment; hearing aids
Presbycusis	Hearing aids; auditory rehabilitation
Meniere's disease	Low-salt diet, diuretics, betahistine; intratympanic gentamicin/steroids; endolymphatic sac surgery
Ototoxicity	Stop offending drug if possible; monitor; hearing aids
Autoimmune inner ear disease	Systemic steroids, immunosuppressants

C. Hearing Rehabilitation Devices

Conventional hearing aids (BTE, ITE, ITC, CIC types) - for mild to severe loss; recommended from 6 months of age in congenital loss
Bone-anchored hearing aids (BAHA) - for single-sided deafness or conductive loss in patients unable to use conventional aids
Cochlear implants (CI) - for profound bilateral SNHL; indicated from age 1-2 years in children with profound SNHL; pre-lingual and post-lingual candidates
Auditory brainstem implants (ABI) - for bilateral vestibular schwannomas (NF2) where cochlear implant is not possible

D. Communication and Auditory Rehabilitation

Lip reading / speechreading training
Sign language (especially for pre-lingual deafness)
Assistive listening devices (ALDs), FM systems
Auditory-verbal therapy in children
Counselling for patients and families

Sources: Harrison's Principles of Internal Medicine 22e, p. 1283-1307; Shambaugh Surgery of the Ear, pp. 3411-3441; Scott-Brown's Otorhinolaryngology Head & Neck Surgery Vol 2; Cummings Otolaryngology Head and Neck Surgery; K.J. Lee's Essential Otolaryngology.

Now kindly just refer dhingra textbook and make it

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I'm sorry - Dhingra's "Diseases of Ear, Nose and Throat & Head and Neck Surgery" is not available in the medical textbook library. The ENT books available are:

Cummings Otolaryngology Head and Neck Surgery
K.J. Lee's Essential Otolaryngology
Scott-Brown's Otorhinolaryngology Head & Neck Surgery (Vol 1 & 2)
Shambaugh Surgery of the Ear

Would you like me to:

Answer using K.J. Lee's Essential Otolaryngology - which is a widely used exam-oriented ENT reference (similar style to Dhingra)
Answer using Scott-Brown's - the most comprehensive ENT textbook available
Answer using all available ENT textbooks combined

Dhingra is not in the library, so I cannot pull content directly from it. However, I can use the closest available alternative and present it in the structured, concise style that Dhingra is known for.

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