CURRENT Diagnosis & Treatment in Otolaryngology-Head & Neck Surgery, 3e

CURRENT Diagnosis & Treatment in
Otolaryngology—Head & Neck Surgery, 3e
The external ear collects sound pressure waves and funnels them toward the tympanic membrane. The
middle ear ossicles transmit the sound waves to the inner ear (cochlea). The middle ear acts to match
the impedance difference between the air of the external environment to the fluid within the cochlea.
This permits maximal sound transmission.
The task of the cochlea is to analyze environmental sounds and transmit the results of that analysis to
the brain. The inner ear first determines how much energy is present at different frequencies that make
up a specific sound. The cochlea can do this because of its tonotopic organization.
 May affect patients of all ages

 For patients who have unilateral hearing loss
 Weber tuning fork test lateralizes to the unaffected side
 Rinne tuning fork test demonstrates air conduction greater than bone conduction
 Pure-tone thresholds result in equally diminished air and bone conduction
 Speech discrimination testing less than 90% correct.
Hearing loss is extremely common and has a wide spectrum ranging from a nearly undetectable
degree of disability to a profound loss of ability to function in society. Nearly 10% of the adult
population has some hearing loss. Often, this impairment presents early in life. One to three of
every 1000 newborn in the United States is completely deaf, and more than 3 million children
have hearing loss. However, hearing loss can present at any age. Between 30% and 35% of
individuals over the age of 65 have a hearing loss sufficient to require a hearing aid. Forty
percent of people over the age of 75 have hearing loss.
Hearing loss can result from disorders of the auricle, external auditory canal, middle ear, inner
ear, or central auditory pathways. In general, lesions in the auricle, external auditory canal, or
middle ear cause conductive hearing loss. The focus of this chapter is sensorineural hearing loss
that tends to result from lesions in the inner ear or eighth nerve. See Table 52–1 for a list of the
common causes of hearing loss.
Table 52–1. Etiology of Sensorineural Hearing Loss.

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Sensorineural hearing loss may result from damage to the hair cells caused by intense noise, viral
infections, fractures of the temporal bone, meningitis, cochlear otosclerosis, Meniere disease, and
aging. The following drugs can also produce sensorineural hearing loss: ototoxic drugs (eg,
salicylates, quinine, and the synthetic analogs of quinine), aminoglycoside antibiotics, loop
diuretics (eg, furosemide and ethacrynic acid), and cancer chemotherapeutic agents (eg,
cisplatin).
Age-Related Hearing Loss (Presbycusis)
Presbycusis, age-associated hearing loss, is the most common cause of hearing loss in adults.
Initially, it is characterized by symmetric, high-frequency hearing loss that eventually progresses
to involve all frequencies. More important, the hearing loss is associated with a significant loss
in clarity.
Congenital Hearing Loss
Congenital malformations of the inner ear cause hearing loss in some adults. Genetic
predisposition alone or in concert with environmental influences may also be responsible.
Otolaryngologists often rely on audiologic test results to determine the course of treatment for a
given patient. Many of the tests constituting the diagnostic audiologic battery of 20 years ago
have now been replaced with newer procedures with greater specificity, sensitivity, and site of
lesion accuracy. This is exemplified by the fact that the terms “sensory” or “neural” can now
frequently replace the term “sensorineural.” In addition, audiologic tests have gone beyond the
realm of identifying anomalies in structure to identifying anomalies in function. The logical
extension of this advancement is to provide the audiologist and otolaryngologist with
information related to prognosis and rehabilitation.
Tes audiologi
Audiologic tests can be classified according to measures of hearing threshold, suprathreshold

recognition of speech, assessment of middle ear function, assessment of cochlear function,
determination of neural synchrony and evaluation of vestibular function. The test correlates
associated with these measures are pure-tone audiometry, speech recognition, the immittance
battery, otoacoustic emissions, electrophysiology, videonystagmography, and rotary chair
assessment. The latter two procedures are discussed elsewhere in this textbook.
Audiologic test results should always be interpreted in the context of a battery of tests because no
single test can provide a clear picture of a specific patient. In addition, the combination of
objective and subjective (behavioral) tests provides a cross-check of the results. There are no age
restrictions for audiologic testing; it is now possible and recommended to test newborns within
days of birth.
The audiogram is a graph that depicts threshold as a function of frequency. Threshold is

defined as the softest intensity level that a pure tone (single frequency) can be detected 50% of
the time. Intensity is designated on a normalized decibel hearing level (HL) scale that takes into
account the differences in human sensitivity as a function of frequency. The typical range of
frequencies tested does not cover the entire range of human hearing (20–20,000 Hz). Instead, the
range includes the frequencies considered to be essential for understanding speech (250–8000
Hz). Most testing is administered at discrete octave frequencies. However, when threshold
differences between adjacent octaves exceed 15 dB, inter-octave frequencies should be tested.
This is particularly true at 3000 and 6000 Hz, where “notches” in audiometric configuration
often typify noise-induced hearing loss. Thresholds are measured clinically in 5-dB steps. There
is a test-retest variability of ±5 dB. Therefore, a change of 10 dB may not necessarily represent a
true threshold shift.
Thresholds can be obtained using air conduction (AC) or bone conduction (BC). Sound
transmission via earphones, foam inserts, or loudspeakers requires the movement of air
molecules; therefore, it is termed air conduction. This testing assesses the entire auditory system
from the outer ear to the auditory cortex. Testing through loudspeakers (sound field) cannot
isolate differences between ears. The advantages of insert earphones over over-the-ear (supra-
aural) earphones include the prevention of collapsing ear canals, greater attenuation from
ambient noise, and greater interaural attenuation (the loss of sound energy ...

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CURRENT Diagnosis & Treatment in

Otolaryngology—Head & Neck Surgery, 3e

 May affect patients of all ages

Table 52–1. Etiology of Sensorineural Hearing Loss.

Age-Related Hearing Loss (Presbycusis)

Congenital Hearing Loss

Audiologic tests can be classified according to measures of hearing threshold, suprathreshold

The audiogram is a graph that depicts threshold as a function of frequency. Threshold is

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