RISK FACTORS Nasal allergy and other causes of eustachian tube obstruction; exposure to loud noise levels; use of ototoxic antibiotics; prematurity; heredity (otosclerosis)
GENERAL MEASURES
o Conductive (mechanical)
? Cerumen: Remove with suction and irrigation (not if perforation is present). Don't direct water against drum but against canal wall. Manipulation with wire curette may help.
? Tympanic membrane perforation: Surgical correction
? Serous otitis (primarily in children). Treat underlying conditions. Use decongestants, antibiotics. Urge
inflation of eustachian tube (hold nose and blow).
? Adhesive otitis: Looks like perforation. Treat eustachian tube problem. May need surgery.
? Damage to ossicles: Don't manipulate. Refer to otolaryngologist.
? Tympanosclerosis: Drum has white plaques. Treat only if hearing loss is present.
? Otosclerosis: Suspect on basis of history of onset, early in life, that is progressive, with positive family history of hearing loss. Consider surgery. Refer to otolaryngologist.
? Cholesteatoma: Identify by perforation that is located near margin of drum. Refer to otolaryngologist.
? Middle ear tumor: May see through drum. Most commonly will be glomus tumor, which has red color and may cause pulsation. Significant problem, needs prompt referral to otolaryngologist.
? Congenital deformity: Don't attribute all hearing loss in children to infections and middle ear fluid. Refer to
otolaryngologist.
? Temporal bone injury: If limited, may only involve middle ear. Drum likely to appear blue. Refer to
otolaryngologist.
o Sensorineural (nerve)
? Acoustic tumor: Most significant type of hearing loss. Very important to diagnose promptly. Suspect when
unilateral hearing loss and tinnitus (with or without dizziness) are present. Needs much higher degree of
suspicion on part of primary care physician. Refer to otolaryngologist.
? See topic on Ménière disease
? Noise damage: The most common cause of hearing loss in this country. Very frequent on occupational basis, and has the attention of federal government (OSHA regulations). Also occurs secondary to sports
and recreation (hunting, use of guns, loud music, chain saws, shop tools). Needs much greater level of
recognition at primary care level. Refer to otolaryngologist.
? Hereditary/congenital: Needs immediate recognition early in life, so that if significant, hearing aids can be
placed. For total or near total hearing loss, cochlear implantation may be suitable with placement of electronic device into mastoid and cochlea.
? Viral: A relatively common cause of permanent hearing loss, frequently unilateral, e.g., mumps
? Ototoxic (medication): Needs much more recognition at primary care level. Suspect when hearing loss, and perhaps dizziness and tinnitus come on during course of treatment with certain antibiotics (and many other medications). See Medications.
? Syphilis: Treat with high dose penicillin given intravenously, as well as steroids
? Presbycusis: No specific treatment available, but important to provide hearing rehabilitation. This includes counseling patient to avoid factors that may cause further loss (noise exposure, ototoxic drugs).
Emphasize development of lip reading skills, and counseling family to pronounce words clearly, face patient when speaking, etc. Offer hearing aid trial when patient is a suitable candidate.
? Temporal bone injury: No treatment available specifically for hearing loss unless middle ear is involved
? Metabolic: Treatment of specific problem (e.g. hyperlipidemia, hypothyroid)
? Perilymphatic fistula: Diagnosis based on history of injury to ear including barotrauma during diving.
Treatment is early exploration to confirm fistula in round or oval window of middle ear, with repair of fistula. Refer to otolaryngologist.
? Total or near total sensorineural hearing loss:
Cochlear implant (electronic device inserted into mastoid and inner ear)
? Autoimmune sensorineural hearing loss: Steroids and chemotherapy. Refer to otolaryngologist.
ACTIVITY
o Patients having perforation of the ear drum or ventilation tube in place should be advised not to swim or
allow water to enter the ear
o Patients having hearing loss secondary to noise exposure should be advised to avoid loud noise, or to use suitable protection (ear plugs or ear muffs)
DIET Patients whose hearing loss is due to Ménière disease should avoid excessive use of salt
DRUG(S) OF CHOICE
o Cerumen impaction - it is frequently helpful to soften the wax prior to removing it. Triethanolamine polypeptide oleate-condensate (Cerumenex) is popular, but shouldnot be used in the presence of a perforation, and may produce a skin reaction. A good alternative is simply to place, or have the patient place mineral oil in the ear canal overnight prior to wax removal. Hexachlorophene (pHisoHex) and topical docusate sodium (Colace) are also useful to soften very hard wax.
o Acute otitis media - erythromycin or amoxicillin
o Chronic otitis media with purulent drainage - neomycinpolymyxin B-hydrocortisone (Cortisporin) otic drops (or
an equivalent) placed into the ear canal (3-6 drops bid)
o Serous otitis media - decongestant, e.g., pseudoephedrine - guaifenesin (Entex PSE) and erythromycin
o Sudden sensorineural hearing loss with no apparent cause - steroid therapy in high dosage form (80 mg/day
of prednisone, or equivalent steroid) may be helpful
ALTERNATIVE DRUGS
o Acute otitis media - cefaclor
o Chronic ear infection with drainage - ear drops and powder containing ciprofl oxacin. Gentamicin drops is
another alternative.
PATIENT MONITORING Hearing testing (audiometry) is the primary means of monitoring patient progress
PREVENTION/AVOIDANCE
o Impaired eustachian tube function (serous otitis media, acute otitis media) - improve tubal function with
treatment of allergic and sinus disease. Treat upper respiratory infections (URI) promptly and aggressively if
ear problems are frequent.
o Sensorineural hearing loss due to noise exposure (or any type of nerve deafness) - advise against excessive
noise exposure; recommend ear plugs/ear muffs
o Nerve deafness due to ototoxic medications may be prevented by the avoidance, or careful use of drugs
known to be ototoxic (consider audiometric monitoring if used). The most frequently implicated antibiotics are
gentamicin, kanamycin, neomycin, vancomycin, and streptomycin. Other implicated drugs include lidocaine,
morphine, digitalis, quinidine, and furosemide. Use of these drugs cannot always be avoided. Be more
suspicious of the possibility that a given medication might be ototoxic, and when hearing loss is a problem,
to prescribe with care.
o Serious nerve deafness resulting from CNS disease (meningitis, lues) may be prevented by thorough treatment of the primary problem
o If URI present, avoid flying or diving
POSSIBLE COMPLICATIONS
o Middle ear problems may progress to chronic ear problems (perforations, cholesteatoma)
o Cholesteatoma is capable of producing major complications including permanent loss of hearing, balance
problems, facial nerve paralysis, meningitis, lateral sinus thrombosis, and brain abscess. Glomus tumors and acoustic tumors must be identifi ed, or major CNS complications may result.
o Ménière disease may proceed to total and permanent hearing loss if not treated, and may occur in spite of
treatment
o Severe nerve deafness, particularly associated with tinnitus may produce such an emotional impact on the patient that suicide may occur. Treat the patient with empathy and understanding, offer help even if it seems limited. Encouragement and followup care are extremely helpful in managing these patients.
EXPECTED COURSE/PROGNOSIS
Sensorineural hearing loss is usually permanent, but in a few instances, may be stabilized, improved, or even cured