Kembara Xtra - Medicine - Hearing Loss
A decline in the capacity to hear and understand sound. It may be unilateral, bilateral, partial, or all of the above. – Usually described as a loss of more than 25 dB conductive hearing loss (CHL or air-bone gap), sensorineural hearing loss (SNHL), and mixed hearing loss are among the different types of hearing loss. Auditory; outer and middle ear (CHL) or inner ear, auditory nerve, and/or brainstem (SNHL) system(s) are afflicted. Sudden hearing loss is the subjective feeling of hearing loss that develops suddenly in one or both ears. All ages are affected; youngsters (CHL) and the elderly (SNHL) are more frequently impacted. Men are typically more severely affected at a younger age. The prevalence of sudden sensorineural hearing loss (SSHL), which rises with age, ranges from 5 to 27 per 100,000 people per year. Prevalence Aspects of Geriatrics In the United States, 24.7% of adults aged 60 to 69 have bilateral speech-frequency hearing loss, and 80% of those over 85 have hearing loss. For the elderly, a lack of communication poses a medical risk in addition to an emotional one. Think on auditory rehabilitation (speaking to people directly, better lighting, reducing background noise). Child Safety Considerations Early detection and intervention increase results. Approximately 60% of hearing loss in children can be avoided. Requiring otoacoustic emission (OAE) and auditory brainstem response (ABR) testing for >97% of infants Pathophysiology and Etiology CHL: Middle ear effusion, canal obstruction (cerumen/foreign body, osteomas/exostoses, cholesteatoma, tumor), loss of continuity (ossicular discontinuity), stiffening of the components (myringosclerosis, tympanosclerosis, and otosclerosis), and perforation can all cause hearing loss. Damage to the brainstem, cochlea, auditory nerve, and oval window along the SNHL pathway. Vascular/metabolic injury, mass effect, infection and inflammation, and acoustic trauma are a few examples. – Acoustic injury, which affects the outer hair cells in the organ of Corti, results in noise-induced hearing loss by making them less rigid. Over time, stereocilia fuse and disappear, causing significant harm. This may eventually spread to the auditory nerve and inner hair cells. Third moveable window shunts acoustic energy away from cochlea in cases of large vestibular aqueduct or superior canal dehiscence. Genetics: Otosclerosis: familial; Connexin 26 (13q11–13q12), the most prevalent cause of nonsyndromic hereditary hearing loss; Several congenital syndromes, include Alport syndrome and Stickler syndrome. Loud noise/acoustic trauma, medications (aminoglycosides, loop diuretics, aspirin, nonsteroidal anti-inflammatory drugs [NSAIDs], quinine, chemotherapeutic agents, especially cisplatin, and vancomycin), tobacco use, and alcohol use, vestibular schwannoma/skull base neoplasm, prior ear surgery, and sensorineural, pediatric-specific, are risk factors. - Perinatal suffocation - A 5-day mechanical ventilation period - Congenital infections (herpes simplex [TORCH] syndrome, rubella, CMV, toxoplasmosis, and other agents) - Pregnancy-related toxicemia - Maternal diabetes - Rh incompatibility - Extreme hyperbilirubinemia; exchange transfusions - Prematurity or birth weight under 1,500 g - Anomalous temporal bone (Mondini or big vestibular aqueduct) - Infectious illnesses (mumps, bacterial meningitis, encephalitis, chickenpox, measles, and encephalitis) Vasculitis, or Kawasaki disease Prevention Avoid using instruments (like cotton swabs) in the ear canal and limit your exposure to loud noises. Limit or avoid using ototoxic drugs. Accompanying Conditions Patients who have tinnitus frequently also have hearing loss. History: Social issues and remarks from family and friends are sometimes the first signs of presbycusis (age-related hearing loss); patients frequently are unaware of the extent of their hearing loss and how it affects their lives; sneaky beginning and progression Rapid versus slow deterioration in hearing ability: Rapid loss (3 days) is a medical emergency. Steroid therapy and immediate ear, nose, and throat referral are advised. - needing trouble distinguishing between sounds, hearing in crowded places, or turning up television level - Frequently needing to ask speakers to repeat themselves - Family and friends have reported hearing loss. Tinnitus, bilateral or unilateral; otalgia; otorrhea, clear or purulent; vertigo; aural fullness; autophony (hearing one's own voice louder or echoing); prior ear infections or surgeries; prior trauma or noise exposure; a family history of hearing loss; recent viral infection history clinical assessment Whispered voice test: Hearing a whisper at a distance of about two feet is a reliable indicator of hearing health. Due to the fact that SNHL patients typically experience high frequency hearing loss, they often struggle with this. In cases of abrupt SNHL (an emergency), a straightforward 512-Hz tuning fork test lateralizes to the unaffected ear, while in cases of CHL (not an emergency), it lateralizes to the affected ear. Tuning fork testing at 512 Hz: - Loss of sensory nerves When applied to the forehead, it lateralizes to the unaffected ear (Weber test). When the tuning fork's end is put next to the ear, it is audible more clearly since air is louder than bone (+ Rinne test). Loss of conductivity Placed on the mastoid and then next to the ear, heard louder behind the ear on the side of conductive deficit bone > air (Rinne test); placed on the forehead or teeth lateralizes to affected or symptomatic ear Through otoscopy, you can check for deformity, canal patency, and otorrhea as well as TM integrity/retraction/mobility with insufflation, canal or middle ear mass, and cerumen impaction. Nasopharyngoscopy: adenoid hypertrophy or nasopharyngeal tumor (necessary in adult patients with new unilateral serous effusion) Facial symmetry Cranial nerve examination Multiple Diagnoses Conductive loss as a result of mechanical problems (such as cerumen impaction/foreign body, TM perforation, and acoustic neuroma, for example) Sensorineural impairment: - Presbycusis (hearing loss brought on by aging) - Noise pollution (recreational and professional) - Ménière illness - Ototoxicity (NSAIDs, aminoglycosides, aspirin) - Labyrinthitis caused by a virus - Cerebellopontine angle (CPA) tumor fracture of a temporary bone - Thyroid (hyper-/hypothyroidism) metabolic - Paget syndrome - Perilymphatic fistula in the inner ear Vasculitis (includes immune-complex related vasculitis, systemic lupus erythematosus, giant cell arteritis, Takayasu arteritis, polyarteritis nodosa, granulomatous with polyangiitis, microscopic polyangiitis, eosinophilic granulomatosis with polyangiitis, and others) Laboratory Results MRI of the brain and brainstem with gadolinium to assess SNHL in congenital, early-onset, and asymmetric hearing loss should be taken into account as clinically warranted. The examination of CHL may be aided by fine-cut, contrast-free CT of the temporal bones. OAE and/or ABR screening for newborns TORCH screening (congenital infection), Rapid Plasma Reagin (RPR), or Venereal Disease Research Laboratory (VDRL) confirmed by fluorescent treponemal antibody absorption (FTA-ABS), Lyme titer in endemic areas, Antinuclear antibodies and sedimentation rate as a screen for autoimmune disease, Connexin 26 genetic testing, mitochondrial studies for children with SNHL, Lyme titer, and Lyme disease. Perchlorate test and thyroid function tests are required for Pendred syndrome (goiter, mental retardation, and SNHL). Urinalysis and renal function testing for Alport syndrome (nephritis and SNHL). ECG for Jervell and Lange-Nielsen syndrome (syncope, unexpected death in the family, and significant SNHL) Other/Diagnostic Procedures Audiometry: assessment of speech, impedance (middle ear pressure), and pure tone (air and bone). Tympanometry: Type B or C tympanograms, respectively, indicate fluid or retraction. Even with normal (type A) tympanograms, negative middle ear peak pressures were seen. ABR, OAEs: "echo" of the cochlea, and behavioral audiometry for children aged 6 months to 5 years old are additional examinations. For persistent fluid with hearing loss, myringotomy and tubes may be options. Management Differentiating sudden hearing loss (SNHL) from congenital sudden hearing loss (CHL); testing for bilateral sudden hearing loss in patients with unilateral sudden hearing loss; obtaining an MRI, ABR, or audiometric follow-up to evaluate for retrocochlear pathology; offering intratympanic steroid perfusion for refractory cases after initial management fails to treat idiopathic sudden SNHL (ISSNHL); and so forth are some clinically useful recommendations for sudden hearing loss. – Patients with ISSNHL may receive corticosteroids as their first line of treatment along with hyperbaric oxygen therapy (HBOT) within two weeks of the onset; within one month of the onset, HBOT may be considered as a salvage measure. - Advise avoiding giving patients with ISSNHL antivirals, thrombolytics, vasodilators, vasoactive agents, or antioxidants. - Advise individuals with ISSNHL to avoid normal laboratory tests. High-dose oral steroids should be administered as soon as symptoms appear, within 1 to 2 weeks after the onset: 1 mg/kg of prednisone or 12 to 16 mg/day of dexamethasone for 7 to 14 days, followed by a taper. Steroids administered intra-tympanically exhibit equal efficacy to oral steroids and lessen systemic side effects. Some studies support the use of mixed intratympanic and oral steroids for the first management of abrupt SNHL. Referral: Failure of newborn screening; Audiology for probable hearing loss for formal evaluation; Speech therapist: if speech delay or speech obstruction is present; Neurology and neurosurgery: CPA lesion, intracranial consequence of middle ear disease Further Treatments Aural rehabilitation: interdisciplinary method involving family doctors, otologists, audiologists, and other members of the medical staff as necessary Procedures Tympanostomy and tube implantation, tympanoplasty, mastoidectomy, ossicular chain repair, stapedectomy/stapedotomy, and canaloplasty are surgical possibilities for CHL. Cochlear implantation is a surgical therapy for SNHL in people with substantial, bilateral hearing loss. Patient Follow-Up Monitoring The two main methods of patient monitoring are the audiogram and clinical examination. Diet Patients with Ménière disease benefit from a salt limit of no more than 2 g per day. Reduce your alcohol intake. Modifying one's lifestyle can help prevent noise-induced hearing loss. To do this, one should avoid excessive and prolonged noise exposure and use protective equipment. ISSNHL may heal spontaneously in 32–70% of patients, although prompt referral and treatment are advised to maximize recovery. SNHL is typically persistent and may progress. Complications Acute middle ear issues (perforations, cholesteatoma) may develop into chronic issues.
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