Approach to hearing loss

Abstract

Objective: To provide family physicians with a practical evidence-based approach to the management of patients with hearing loss.

Sources of information: MEDLINE and PubMed databases were searched for English-language hearing loss research, review articles, and guidelines published between 1980 and 2020. Most of the retrieved articles provided level II or III evidence.

Main message: Hearing loss is one of the most common sensory impairments worldwide and causes great detriment to a patient's overall well-being by affecting physical health, finances, social inclusion, and mental health. A robust clinical assessment of hearing loss includes a history and physical examination that effectively characterizes the deficit as conductive, sensorineural, or mixed. Patients presenting with red flags (such as sudden unilateral sensorineural hearing loss) must be urgently referred to otolaryngology-head and neck surgery or immediately assessed in the emergency department. Many nonurgent presentations of hearing loss will also require referral for further audiological assessment, diagnosis, and management.

Conclusion: As primary care providers, family physicians are well equipped to manage the psychological concerns associated with hearing loss and to reinforce conservative treatment strategies. Frequently, referral or urgent workup, including imaging, is necessary to confirm a patient's diagnosis and initiate management in order to prevent further complications.

Figure 1.

Approach to the differential diagnosis of hearing loss

Figure 2.

Rinne and Weber tests for differentiating between conductive, sensorineural, and mixed hearing loss: Typically, a 512-Hz tuning fork is used in the clinical setting. Note that the Weber test will only lateralize in cases of asymmetrical hearing loss. In cases of symmetrical hearing loss (conductive and sensorineural hearing loss) the Weber test findings will be equal at the midline.

Figure 3.

Tympanometry patterns that accompany middle ear or tympanic membrane pathology: A tympanometer is inserted into the ear canal and generates a constant tone that alters the air pressure within the external auditory canal. The device then measures the amount of sound that returns from the tympanic membrane as a function of air pressure change. The type A pattern is normal and denotes normal middle ear air pressure and tympanic membrane mobility.

Figure 4.

Representative audiograms for conditions associated with hearing loss: A) Normal findings; B) presbycusis (bilateral high-frequency SNHL); C) noise-induced hearing loss (bilateral SNHL); D) acoustic neuroma (unilateral high-frequency SNHL); E) Ménière disease (low-frequency SNHL); F) middle ear effusion (unilateral CHL); and G) otosclerosis (bilateral MHL; note Carhart notch at 2000 Hz).