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Diagnosis and management of hearing loss

Surgeon Mr Peter Robb and GP Dr Alex Watson put forward the clinical options when patients start to lose their hearing

Surgeon Mr Peter Robb and GP Dr Alex Watson put forward the clinical options when patients start to lose their hearing

Hearing loss is both common, and important, because it can have significant consequences including effects on the development of speech and language and social behaviour. In adults the condition can lead to social and professional isolation.

Presbyacusis or age-related hearing loss typically affects the high frequencies and is due to a progressive loss of hair cells in the cochlea. The age of onset is variable, although most people will present clinically from 65 years onwards.

Consonants, which are crucial for understanding speech are generally in the high frequency range (compared with vowels in the lower frequency range) so it is not surprising that those people with significant high-frequency hearing loss find it difficult to understand others speaking to them, especially in group situations and where there is a lot of background noise.

Treatment

Currently there is no treatment to prevent this type of hearing loss but it is important to reassure patients that they will almost never lose their hearing completely. One should emphasise that their hearing at lower frequencies may be very good. Management is aimed at educating both patients and their families, friends and or work colleagues about potential communications activities, and enhancing any significant hearing loss with a hearing aid.

Sudden hearing loss should be urgently referred to the local on-call ENT team. This is an uncommon ENT emergency. Causes may be head injury, viral (such as mumps) or microvascular acoustic neuroma, although often no cause is identified.

There is no high-level evidence that intervention with steroids, hyperbaric oxygen, vasodilators or other treatments are predictably effective in restoring hearing. There is a 70% spontaneous recovery. Sudden loss in one ear is generally not a predictor of the same in the contralateral ear.

Children with hearing aids, and who are being investigated for genetic conditions, are generally managed by audiological physicians rather than an ENT specialist. As the training of audiologists is now to degree and postgraduate level, some of the current workload of audiological physicians may be incorporated into the audiology and ENT departments.

Adults and children with a hereditary hearing loss may be referred for assessment, genetic investigations and genetic counselling in conjunction with a clinical geneticist.

Hearing aids

Where a diagnosis of presbyacusis has been made clinically, the tuning fork tests are normal and the eat canals free of any wax, direct referral for a hearing aid is possible in most hospitals.

The standard NHS hearing aid is now a behind-the-ear digital gearing aid. There are also body-worn aids for those with dexterity problems or when a very strong hearing aid is required. Bone conductor hearing aids are available when an aid cannot be worn in the ear. Bone anchored hearing aids are available when a normal air conduction aid is not suitable.

It is difficult to predict what level of hearing loss will benefit from a hearing aid. The central auditory discrimination of complex sounds such as speech is not usually assessed when prescribing an NHS hearing aid. As a rough guide, those with bilateral hearing thresholds worse than 30dB hearing level will probably benefit from a hearing aid.

All patients who need a hearing aid will now have to have a digital aid because the manufacturers are discontinuing production of analogue hearing aids. The common problems associated with wearing hearing aids relate to the comfort of the mould. Occasionally the mould can cause an otitis externa or the individual may be sensitive to the acrylic mould material. More often, the complaint is that the aid does not give normal hearing and this is very difficult to address.

Hearing aids may be cleaned with warm soapy water and left to dry in a warm place if they become dirty or blocked with wax. They should never be heated as they can melt. Most NHS community clinics will supply spare tubing and batteries.

Cochlear implants are small electronic devices that may help provide a sense of sound to those aptiens who are profoundly deaf and have little or no benefit from hearing aids. In congenitally deaf children, implantation is usually advised within the first four years of life to get the maximum benefit. Older children or adults who lose their hearing (for example following meningitis) may also benefit.

This is an extract from ENT in Primary Care by consultant ENT surgeon Mr Peter Robb and Surrey GP Dr Alex Watson, published by Rila. To order go to the Rila website or call 020 7637 3544


Resources

• Antneatal infections

• Such as rubella, CMV or toxoplasmosis

• Perinatal – prematurity, hypoxia, jaundice

• Postnantal – childhood viral infections

• Genetic syndromes

• Chromosomal abnormalities

• Trauma

• Noise-induced

• Inflammatory

• Drugs• Antneatal infections

• Such as rubella, CMV or toxoplasmosis

• Perinatal – prematurity, hypoxia, jaundice

• Postnantal – childhood viral infections

• Genetic syndromes

• Chromosomal abnormalities

• Trauma

• Noise-induced

• Inflammatory

• DrugsCommon causes of senorineural hearing loss

• Antneatal infections
• Such as rubella, CMV or toxoplasmosis
• Perinatal – prematurity, hypoxia, jaundice
• Postnantal – childhood viral infections
• Genetic syndromes
• Chromosomal abnormalities• Trauma
• Noise-induced
• Inflammatory
• Drugs
• Acoustic neuroma
• Radiotherapy to the head
• Meniere's disease
• Iatrogenic (after ear surgery)

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