Seminar 11

Approach to
Hearing Loss
1. Muhammad Ramzy bin Ismail (72440)
2. Roxanne anak Richi (72654)
3. Zulaikha Farzana (72740)
4. Muhammad Zul Faiz (73594)
 Table Of Contents

01 02
Anatomy of the Mechanism of
Ear Hearing

03 04
Hearing Classification of
Assessments Hearing Loss
Anatomy of
Ear
1. External ear
2. Middle ear
3. Inner ear
Division of Ear
The ear is anatomically divided into 3 parts:
1) External ear
• Auricle
• External acoustic meatus
• Tympanic membrane
2) Middle ear
• Tympanic cavity
• Ossicles
• Eustachian tube
3) Inner ear
• Cochlea
• Vestibule
• Semicircular canals
The External ear
Auricle

● Most cartilaginous structure,

except the lobule
● Function: To capture and
direct sound waves towards
external acoustic meatus
External Acoustic Meatus
• Sigmoid shaped tube – extends from deep
part of the concha to tympanic membrane
• Function: To transmit sound from pinna to
tympanic membrane
• Divided into 2 parts;
• Cartilaginous
• Outer 1/3 of the wall of the canal
• Lined with hair follicles, sebaceous
glands and ceruminous glands
(within the subcutaneous tissue)
• Bony
• Inner 2/3 of the wall of the canal by
temporal bone
• Lined with thin skin, no hair and
ceruminous gland
Tympanic Membrane
• Separates the external acoustic
meatus from the middle ear cavity
• Connected to surrounding temporal
bone by a fibrocartilaginous ring
• Can be divided into 2 parts;
• Pars tensa
• Pars flaccida (Shrapnell’s
membrane)
• Function: Moves in response to sound
waves and transmit vibration to
auditory ossicles
Tympanic Membrane (cont.)
• Has 4 quadrants: • Has 3 layers;
• Anterosuperior • Outer layer – continuous with
• Anteroinferior the skin on the external acoustic
• Posterosuperior meatus
• Posteroinferior • Middle fibrous layer – encloses
the handle of malleus and 3
types of fibers (radial, circular
and parabolic)
• Inner mucosal layer –
continuous with the mucous
membrane lining the middle ear
Vasculature of External Ear

• The external ear is supplied by

branches of the external carotid
artery:
• Posterior auricular artery
• Superficial temporal artery
• Occipital artery
• Maxillary artery (deep auricular
branch) – supplies the deep aspect of
the external acoustic meatus and
tympanic membrane only
Innervation of External Ear
• Greater auricular nerve –
innervates the skin of the auricle
• Lesser occipital nerve –
innervates the skin of the auricle
• Auriculotemporal nerve –
innervates the skin of the auricle
and external auditory meatus.
• Branches of the facial (CN VII)
and vagus (CN X) nerves –
innervates the deeper aspect of
the auricle and external auditory
meatus
The Middle ear
Tympanic Cavity
• An air-filled cavity on the
temporal bone and extends from
tympanic membrane to the lateral
wall of inner ear
• Divided into 3 compartments;
• Mesotympanum
• Epitympanum
• Hypotympanum
• Function: To transmit sound
waves from the tympanic
membrane to the inner ear via
auditory ossicles
Borders
• Can be visualized as six-sided box, representing six walls

Formed by a thin bone from the petrous part of the temporal bone. It
Roof separates the middle ear from the middle cranial fossa
Known as the jugular wall, it consists of a thin layer of bone, which separates
Floor the middle ear from the internal jugular vein
Made up of the tympanic membrane and the lateral wall of the Epitympanic
Lateral Wall recess
Formed by the lateral wall of the internal ear, containing a prominent bulge,
Medial Wall produced by the facial nerve as it travels nearby
Thin bony plate with two openings; for the auditory tube and the tensor
Anterior Wall tympani muscle. It separates the middle ear from the internal carotid artery
Posterior Wall Consists of a bony partition between the tympanic cavity and the mastoid air
(mastoid wall) cells

• Superiorly, there is a hole in this partition, allowing the two areas to communicate. This
hole is known as the aditus to the mastoid antrum
Ossicles • Connected in chain-like manner, linking the tympanic
membrane to the oval window of inner ear
• Malleus
• The largest and most lateral of the ear bones,
attaching to the tympanic membrane, via the
handle of malleus
• The head of the malleus lies in the epitympanic
recess, where it articulates with the next auditory
ossicle, the incus
• Incus
• Consists of a body and two limbs
• The body articulates with the malleus, the short
limb attaches to the posterior wall of the middle,
and the long limb joins the stapes
• Stapes
• joins the incus to the oval window of the inner ear.
It is stirrup-shaped, with a head, two limbs, and a
base
• The head articulates with the incus, and the base
joins the oval window
Middle Ear Muscles
• 2 muscles that serve as protective function;
tensor tympani and stapedius
• Contract in response to loud noise, inhibiting
vibrations of the malleus, incus and stapes,
and reducing the transmission of sound to the
inner ear (acoustic reflex)
• Tensor tympani
• Attaches to the handle of malleus
• Tenses the tympanic membrane
• Innervated by the tensor tympani nerve
• Stapedius
• Attaches to the stapes
• Dampen very loud sound
• Innervated by the facial nerve.
Eustachian Tube

• Connects the middle ear to the

nasopharynx

• Function: Equalizes the pressure

of the middle ear to that of the
external auditory meatus

• The tube is shorter and straighter

in children, therefore middle ear
infections tend to be more
common in children than adults
The Inner ear
Cochlea

• Located within the petrous

part of the temporal bone

• Innermost part of the ear

and contain
vestibulocochlear organs

• 2 components;
• Bony labyrinth
• Membranous labyrinth
Bony Labyrinth
• Consists of 3 parts;
• Cochlea
• Located anterior to vestibule and twists around
modiolus forming coiled shell.
• Contains 3 components: scala vestibule, scala media
and scala tympani.
• Vestibule
• Central part of bony labyrinth and separated from
the middle ear by the oval window.
• Communicates anteriorly with the cochlea and
posteriorly with the semi-circular canals.
• Two parts of the membranous labyrinth; the saccule
and utricle, are located within the vestibule.
• Semi-circular canals
• 3 semicircular canals – anterior, lateral, posterior
• Contain the semi-circular ducts, which are
responsible for balance (along with the utricle and
saccule)
Membranous Labyrinth
• A continuous system of ducts filled with endolymph, and it lies within
the bony labyrinth, surrounded by perilymph.
• Composed of;
• Cochlear duct
• Situated within the cochlea and is the organ of hearing
• Basilar membrane houses the epithelial cells of hearing – the
Organ of Corti.
• Saccule and utricle
• Membranous sacs located in the vestibule
• Organs of balance - detect movement or acceleration of the
head in the vertical and horizontal planes, respectively
• Saccule – globular shape and receives the cochlear duct
• Utricle – receive 3 semicircular ducts
• Semicircular ducts
• Located in semicircular canals
• Balance organ – detect changes in speed and direction of head
movement through flow of endolymph within the ducts
Vasculature Innervation
Bony labyrinth Vestibulocochlear nerve
• Anterior tympanic branch (CNVIII)
(from maxillary artery) • Vestibular nerve (balance)
• Petrosal branch (from middle • Supply the utricle,
meningeal artery) saccule and three semi-
• Stylomastoid branch (from circular ducts
posterior auricular artery) • Cochlear nerve (hearing)
• Supply the receptors of
Membranous labyrinth the Organ of Corti
• Labyrinthine artery – divided
into 3 branches; cochlear
branch and 2 vestibular
branches
Hearing
Mechanism
Functional Structure of the Ear
Structure Function
Ear Canal Air conduction of sound wave
Tympanic Membrane Transmit sound wave by vibration
Transmit vibrations from tympanic membrane to
Ossicles (Malleus, Incus,
cochlea through the movement of stapes against
Stapes)
perilymph-filled scala vestibuli of cochlea
Amplify the pressure of sound wave necessary to
Oval Window
set the cochlear fluid in motion
Contain organ of corti (converts the auditory
Cochlear
signals to neural impulses
Mechanism of Hearing
● Mechanical conduction of sound (conductive apparatus)
● Transduction of mechanical energy to electrical impulse (sensory
system of cochlea)
● Conduction of electrical impulses to brain (neural pathways)
 Mechanical Conduction Of Sound
(Conductive Apparatus)
1. Sound signal collected by
pinna
2. Sound signal passes through
the external auditory canal
3. Strikes the tympanic
membrane
 Transduction of Mechanical Energy to
Electrical Impulse (Sensory System of Cochlea)

1. Movements of stapes footplate

transmitted to the cochlear fluids
2. Basilar membrane moved and set
up shearing force between
tectorial membrane and hair cells
3. Distortion of hair cells gives rise to
cochlear microphonics triggering
nerve impulse
Conduction of Electrical Impulses to
Brain (Neural Pathways)
Mnemonics for Hearing Pathway
ECOLIMA
● E : Eighth cranial nerve (cochlear
nerve)
● C : Cochlear nuclei
● O : Superior olivary complex
● L : Lateral Lemniscus
● I :Inferior colliculus
● M : Medial geniculate nucleus
● A : Auditory cortex
Hearing
Assessment
A. Clinical Tests of Hearing
B. Audiometric Tests
C. Special Hearing Tests
 A. Clinical Tests of Hearing

1. Finger Friction Test

2. Watch Test
3. Speech Test
4. Tuning Fork Test

Diseases of Ear, Nose, Throat & Head and Neck Surgery, Dhingra, 7th Edition
 A. Clinical Tests of Hearing (cont.)
1. Finger Friction Test 2. Watch Test 3. Speech Test

• Rough, but quick • Clicking watch is • Conducted in quiet

method brought close to ear surroundings
• Rubbing or and • Patient standing with the test
snapping thumb and • The distance where ear towards examiner at 6
finger close to ear it is heard is meter
• Distance which conversational
measured
and whispered voice are heard
is measured
• Disadvantage:
• Lack of standardization in
intensity & pitch of voice
used AND ambient noise
of testing place

Diseases of Ear, Nose, Throat & Head and Neck Surgery, Dhingra, 7th Edition
 4. Tuning Fork Test

Rinne Test Weber Test

• Tuning fork is placed on mastoid bone • Tuning fork is placed in middle of

(BC). When the patient stops hearing, forehead or vertex
brought the tuning fork beside the • Ask the patient, in which ear the sound
external auditory meatus (AC) is heard
• If still hear, AC > BC • Results:
• Results: • Normal: equal in both ears
• Normal: AC > BC • Sensorineural deafness: Louder on
• Sensorineural deafness: AC > BC normal ear
(Rinne +) • Conductive deafness: Louder on
• Conductive deafness: BC > AC affected ear
(Rinne -)

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 Tuning Fork tests and its Interpretations
Conductive Sensorineural
Test Normal
Deafness Deafness
Rinne AC > BC (Rinne +) BC > AC (Rinne -) AC > BC
Lateralized to poor Lateralized to better
Weber Equal both ears
ear ear

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 B. Audiometric Tests
1. Pure Tone Audiometry
2. Speech Audiometry:
i. Speech Reception Threshold (SRT)
ii. Speech Discrimination Score
3. Bekesy Audiometry
4. Impedance Audiometry:
i. Tympanometry
ii. Acoustic Reflex

Diseases of Ear, Nose, Throat & Head and Neck Surgery, Dhingra, 7th Edition
 B. Audiometric Tests (cont.)
1. Pure Tone Audiometry (PTA)
• Electronic device that produces pure tones, where
the intensity can be increased or decreased
• It is charted in graph form – audiogram
• Uses of PTA:
• Measure the air & bone conduction threshold and the
degree and type of hearing loss
• A record can be kept for future reference
• For prescription of hearing aid
• Help to find degree of handicap for medico-legal
purpose
• Help to predict speech reception threshold

Diseases of Ear, Nose, Throat & Head and Neck Surgery, Dhingra, 7th Edition
 B. Audiometric Tests (cont.)
2. Speech Audiometry
• To measure patient’s ability to hear and understand speech

Speech Reception Threshold (SRT) Speech Discrimination Score

• Set of two syllable-spondee words • To measure the ability to understand

are delivered (e.g. baseball, sunlight, speech
daydream) • Single syllable words are delivered
• Minimum 50% of the words are (e.g. pin, sin, day, bus)
repeated correctly • Score of 90-100% can be obtained
in normal person or those with
conductive hearing loss

Diseases of Ear, Nose, Throat & Head and Neck Surgery, Dhingra, 7th Edition
 B. Audiometric Tests (cont.)
3. Bekesy Audiometry
• A self-recording audiometry where various pure tone frequencies automatically
move from low to high
• Seldom performed nowadays

Diseases of Ear, Nose, Throat & Head and Neck Surgery, Dhingra, 7th Edition
4. Impedance Audiometry
• An objective test, widely used clinically and particularly useful in children
Tympanometry Acoustic Reflex
• Principle: • Principle:
• When a sound strikes tympanic • Loud sound produced at one ear produces
membrane, some of the sound is absorbed bilateral contraction of stapedial muscles
while rest is reflected of both ears
• Stiffer tympanic membrane reflect more • Useful in
sound • Test hearing in infants and young children
• A probe is placed into the ear canal, consisting • To find malingerers
of: • To detect cochlear pathology
• Speaker • To detect CN VIII lesion
• Microphone • To detect facial nerve lesions
• Manometer pressure pump • To detect brainstem lesion
 C. Special Hearing Tests
1. Evoked Response Audiometry
i. Electrocochleography (EcoG)
ii. Auditory Brainstem Response (ABR)
2. Otoacoustic Emissions (OAEs)

Diseases of Ear, Nose, Throat & Head and Neck Surgery, Dhingra, 7th Edition
 1. Evoke Response Audiometry
Measures electrical activity in the auditory pathways in response to stimuli

Electrocochleography (EcoG) Auditory Brainstem Response (ABR)

• Measures electrical potentials arise in cochlear • Non-invasive technique to elicit brainstem
and CN VIII in response to stimuli within 5 ms responses
• Can be done under LA in adult, or GA in • Able to evaluate the integrity of central
children or anxious patients auditory pathways
• Useful: • Useful in:
• Finding threshold of hearing in young • Screening for infants
infants and children within 5-10 dB • Determine hearing threshold in infants, in
• Differentiate lesions of cochlear from CN children and adults who do not cooperate
VIII lesion and in malingerers
• Diagnose retrocochlear pathology e.g.
acoustic neuroma
• Diagnose brainstem pathology e.g.
multiple sclerosis, pontine tumour
• Monitoring CN VIII intraoperatively in
surgery of acoustic neuroma

Diseases of Ear, Nose, Throat & Head and Neck Surgery, Dhingra, 7th Edition
 C. Special Hearing Tests (cont.)
2. Otoacoustic Emissions (OAEs)
• Are low-intensity sounds produced by outer hair cells of normal cochlear and can be
elicited by very sensitive microphone placed in the external ear canal and analyzed
by computer
• Travels in reverse direction; outer hair cells  basilar membrane  perilymph  oval
window  ossicles  tympanic membrane  ear canal
• Present when outer hair cells are healthy and are absent when damaged
• Uses:
• Screening test in neonates and uncooperative or mentally challenged patient
• To distinguish cochlear from retrocochlear hearing loss
• Diagnose retrocochlear pathology, especially auditory neuropathy (CN VIII)

Diseases of Ear, Nose, Throat & Head and Neck Surgery, Dhingra, 7th Edition
Classification of
Hearing Loss
1. Conductive Hearing Loss
2. Sensorineural Hearing Loss
3. Non-organic Hearing Loss
Classification of Hearing Loss
1. Conductive Hearing Loss (CHL)

● Due to any disease process which

interferes with the conduction of sound
to reach cochlea
● Lesion may lie in the external ear and
tympanic membrane, middle ear or
ossicles up to stapediovestibular joint
(annular stapedial ligament)
Characteristic of CHL
• Negative Rinne test (BC > AC) – tuning fork sound louder when pressed against the
skull
• Weber lateralized to poorer ear – tuning fork loudest in the affected ear
• Normal absolute bone conduction
• Low frequencies affected more
• Audiometry shows bone conduction better than air conduction with air-bone gap
• Greater the air-bone gap, more is the conductive loss is
• Loss is not more than 60 dB
• Speech discrimination (ability to understand speech in both quiet and noisy
environments) is good
Aetiology of CHL: Congenital Causes
• Meatal Atresia (malformation of the external auditory canal)
• Ossicular Discontinuity (separation of the middle ear ossicles)
• Fixation of Malleus Head
• Fixation of Stapes Footplate (maldevelopment of the annular ligament of the oval
window)
• Ossicular Discontinuity (separation of the middle ear ossicles)
• Congenital Cholesteatoma (Cholesteatoma = Cyst made up of skin)
• An abnormal growth of squamous epithelium in the middle ear and mastoid.
• Progressively enlarge to surround and destroy the ossicles, resulting in CHL.
• It may form due to skin tissue that is trapped behind the tympanic membrane
during fetal development with no history of:
• Tympanic membrane perforation or;
• Significant ear infections
Aetiology of CHL: Acquired Causes (External Ear)

Wax Furuncle Foreign Body

Inflammatory
• Inflamed external
Benign/Malignant
auditory canal with
serous fluid on the Swelling
tragus, auricular lobule, • SCC
and antitragus
• Purulent material within
Atresia of Acute the canal
Canal Swelling
Aetiology of CHL: Acquired Causes (Middle Ear)

• Perforation of tympanic membrane, traumatic or infective

• Fluid in the middle ear, e.g. acute otitis media, serous otitis media or haemotympanum
• Mass in middle ear, e.g. benign or malignant tumour

Perforationof tympanic membrane Fluid in themiddleear

Aetiology of CHL: Acquired Causes (Middle Ear)
• Disruption of ossicles, e.g. trauma to ossicular
chain, chronic suppurative otitis media,
cholesteatoma
• Fixation of ossicles, e.g. otosclerosis,
tympanosclerosis, adhesive otitis media
• Eustachian tube blockage, e.g. retracted
tympanic membrane, serous otitis media

Severely
retracted right
eardrum with
retraction pocket
formation and
tympanosclerosis
Management of CHL

● Removal of canalobstructions
● Removal of fluid – myringotomy with or without grommet insertion
● Removal of mass from middle ear – tympanotomy and removal of small
middle ear tumours or cholesteatoma behind intact tympanic membrane.
● Stapedectomy, as in otosclerotic fixation of stapes footplate
● Tympanoplasty– Repair of perforation, ossicular chain or both
● Hearing aid –in cases where surgery is not possible, refused or has failed
2. Sensorineural Hearing Loss (SNHL)

• Occurs as a result from lesions of

the cochlea (sensory) or CN VIII
and its central connections
(neural)
• May be congenital or acquired
Characteristic of SNHL
• A positive Rinne test (i.e. AC > BC)
• Weber lateralized to a better ear
• Bone conduction reduced on Schwabach and absolute bone conduction
tests
• More often involving high frequencies
• No gap between air and bone conduction curve on audiometry
• Loss may exceed 60 dB
• Speech discrimination is poor
• Difficulty in hearing the presence of noise
Aetiology of SNHL
Congenital Acquired

• Prenatal: • Infections of labyrinth

• Infant factors • Trauma to labyrinth or VIIIth nerve
• Maternal factors • Familial progressive SNHL
• Perinatal • Ototoxic drugs
• Presbycusis
• Postnatal • Noise-induced hearing loss
• Genetic • Sudden hearing loss
• Nongenetic • Ménière’s disease
• Acoustic neuroma
• Systemic disorders (DM, autoimmune,
hypothyroid, kidney disease)
Aetiology of SNHL – Acquired Causes
• Inflammation of Labyrinth

Viral Labyrinthitis
Bacterial Labyrinthitis
• Through the blood stream
• Reach labyrinth through the
affecting stria vascularis, the
middle ear (tympanogenic) or
endolymph and organ of
through CSF (meningogenic)
Corti
• Bacteria can invade the
• Measles, mumps and
labyrinth along nerves,
cytomegaloviruses are well-
vessels, cochlear aqueduct or
documented to cause
the endolymphatic sac
labyrinthitis
Aetiology of SNHL – Acquired Causes
• Familial Progressive SNHL:
• Genetic disorder
• Progressive degeneration of cochlea
• Starting in late childhood and early adult life
• Hearing loss is bilateral with flat or basin shaped audiogram but an excellent
speech discrimination
Aetiology of SNHL –
Acquired Causes

• Ototoxicity
Aetiology of SNHL – Acquired Causes
• Presbycusis:
• Associated with physiological aging process in
the ear (manifested at 65 years, but can be
earlier if there is hereditary predisposition)
• Great difficulty in hearing in the presence of
background noise though they may hear well in
quiet surroundings
• Complain of speech being heard but not
understood
• Tinnitus in some may be the only complaint
• 4 pathological types: Sensory, Neural,
Strial/Metabolic, Cochlear conductive
Aetiology of SNHL – Acquired Causes

• Noise-Induced SNHL
• Follows chronic exposure to less intense sound and is mainly a hazard of noisy
occupations
• Temporary threshold shift (TTS):
• Hearing is impaired immediately after exposure to noise but recovers after
an interval of a few minutes up to 2 weeks
• Depends on intensity, frequency and duration
• Permanent threshold shift (PTS):
• Hearing impairment is permanent and does not recover at all
Aetiology of SNHL – Acquired Causes

• Sudden Hearing Loss Aetiology

• Defined as 30 dB or more of SNHL over at
least three contiguous frequencies • Infections
• Trauma
occurring within a period of 3 days or less • Vascular
• Mostly it is unilateral • Ear (otologic)
• Toxic
• It may be accompanied by tinnitus or • Neoplastic
temporary spell of vertigo • Miscellaneous
• Psychogenic
Aetiology of SNHL – Acquired Causes

• Ménière’s Disease (Endolymphatic hydrops)

• Characterized by
• Episodic vertigo
• Fluctuating hearing loss
• Tinnitus
• Sense of pressure in the involved ear
• Due to increased production of endolymph, or
absorption impairment, or both
Aetiology of SNHL – Acquired Causes
• Acoustic Neuroma
• Benign tumour affecting the Schwann cell in auditory
nerve (aka Vestibular Schwannomas)
• Clinical presentation
• Site: Usually unilateral
• Onset: Gradual
• Associated: tinnitus, dizziness/imbalance, aural
fullness, facial nerve palsy
• Investigation
• Audiometry: pattern of SNHL
• Brain imaging: MRI & CT
• Management:
• Conservative with monitoring
• Surgery
• Radiotherapy: restrict growth of tumour
Investigation of SNHL
• Hearing assessment:
• Otoacoustic Emission (OAE)
• Brainstem Evoked Response (BSER)
• Play Audiometry
• Pure Tone Audiometry
• Imaging:
• HRCT Temporal Bone
• MRI Cerebellopontine Angle
Management of SNHL
• Treat the cause
• Conservative management: family support & advice
• Refer to ENT Specialist
• Hearing Aids:
• Binocular air conduction hearing aids
• Contralateral routing of sound
• Cochlear implant for < 3 years old
• Auditory Brain Stem Implant
• Rehabilitation
3. Non-Organic Hearing Loss

• In this type of hearing loss, there is no organic lesion

• It is either due to malingering or is psychogenic
• Patient may present with any of the three clinical situation:
• Total hearing loss in both ears
• Total loss in only one ear
• Exaggerated loss in one or both ears
• Confirmation test:
• Stenger test
• Acoustic reflex threshold
• Electric response audiometry