Definition
A.A neurosensory hearing loss associated with aging.
B.Usually bilateral with a gradual onset.
Incidence
A.Hearing loss is common in elders and increases with age. Presbycusis affects approximately 75% of adults who are 70 years of age or older; this increases to almost 80% for those older than age 85.
B.Males tend to be affected slightly earlier and experience more impairment.
Pathogenesis
A.Multiple factors of heredity, cumulative noise exposure, and age-related physiologic changes to the ear are thought to be factors in the degree of hearing loss. Although presbycusis is multifactorial, physiologic changes in the cochlea have been identified as the primary underlying mechanism of decreased hearing.
Predisposing Factors
A.Age.
B.Family history (genetics).
C.Ototoxic medications (such as gentamicin and aspirin).
D.Cumulative noise exposure.
E.Cardiovascular disease (hypertension [HTN], hyperlipidemia).
F.Smoking.
Common Complaints
A.Partial hearing loss.
B.Difficulty understanding the television, phone conversations, and people talking.
Subjective Data
A.Elicit the onset, duration, progression, and severity of symptoms. Note whether symptoms are bilateral or unilateral.
B.Review the patient’s family history.
C.Review the patient’s occupational and recreational exposure to noise.
D.Review the patient’s medical history for cardiovascular disease, hypertension, and hyperlipidemia.
E.Ask specifically about all medications, including over-the-counter (OTC) drugs and prescriptions.
F.Review the patient’s history for recent upper respiratory infection (URI), or ear infections, especially for chronic ear infections.
G.Elicit data about any previous hearing loss, how it was treated, and how it affected daily activities. There is often a history of previous ear disease with conductive hearing loss.
H.Review the patient’s other symptoms, such as dizziness, fullness or pressure in the ears, and noises.
I.Review what causes difficulty with hearing; high tones versus low frequencies. Can patient hear people talking, the television at normal volume, doorbells ringing, telephone ringing, and watch ticking?
Physical Examination
A.Inspect:
1.Examine head, neck, and ears for signs of trauma, asymmetry, masses, or edema.
2.Externally inspect ears for discharge; note color and odor. Obstruction of the auditory canal by impacted cerumen, a foreign body, exostoses, external otitis, otitis media with effusion (OME), or scarring or perforation of the eardrum due to chronic otitis may be present.
3.Conduct otoscopic examination to observe the auditory canal for cerumen impaction or foreign body.
4.Inspect tympanic membrane for color, landmarks, contour, perforation, and acute otitis media (AOM). A tympanic membrane that is opaque rather than translucent can be a variation of normal in elders and is not related to hearing loss.
B.Common screening tests:
1.Whispered voice: From 2 feet behind the patient, the examiner whispers words or short phases while occluding one ear at a time.
2.Patient report: Ask the patient, Do you have difficulty hearing?
3.Screening version of the Hearing Handicap Inventory for the elderly.
4.Weber and Rinne testing to differentiate conductive from sensorineural hearing loss. The Rinne test is performed by placing the struck tuning fork against the mastoid bone. Begin counting or timing the interval from the start to when the patient can no longer hear. Continue counting or timing the interval to determine the length of time sound is heard by air conduction. Air-conducted sound should be heard twice as long as bone-conducted sound after bone conduction stops.
Diagnostic Tests
A.Audiogram in primary setting.
Differential Diagnoses
A.Presbycusis.
B.Sudden sensorineural hearing loss.
C.Ototoxicity.
D.Ménière’s syndrome.
E.Acoustic neuroma.
F.Cholesteatoma.
G.Chronic otitis media.
H.Cerumen impaction.
Plan
A.General interventions:
1.All patients with suspected hearing loss should undergo formal testing.
2.Goals are to prevent further hearing loss and assist the patient in lifestyle changes that increase quality of life.
B.Patient teaching:
1.Let patients know that a follow-up with a specialist is important to identify the correct diagnosis.
2.Summarize treatment options of aural rehabilitation, hearing aids and, when applicable, cochlear implants.
3.Assess for and teach patient the consequences of excessive environmental noise; consider protective mechanisms such as earplugs.
C.Nonpharmaceutical therapy:
1.Aggressive management of comorbidities such as HTN and hyperlipidemia may slow progression of hearing loss.
2.Evaluate for polypharmacy and the role it may play in hearing loss. Specifically assess for ototoxic medications. Eliminate when possible.
Follow-Up
A.Stress the importance of follow-up with the audiologist and otologist. Often the patient does not pursue viable options that would improve quality of life.
Consultation/Referral
A.The patient should be referred to an otolaryngologist immediately for sudden, severe, or rapidly progressing hearing loss and hearing loss that is unilateral; that is associated with pain, bleeding, or drainage; or that involves other neurologic deficits.
Individual Considerations
A.Geriatrics:
1.Studies have strongly suggested that music training and education among the elderly positively affected presbycusis, and were important factors in slowing deterioration of music perception and perhaps speech intelligibility.
2.Elder adults may try out
OTC hearing aids. Studies have strongly suggested that these OTC devices are not efficient secondary to ineffective volume control, high equivalent input noise, and irregular frequency response. Encourage patients to talk about their feelings regarding hearing loss and their motivation to improve it with appropriate auditory devices. This will help build a foundational willingness from the patient for a consultation/referral.