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Doc: I think my hearing is going down! What should I do?

Updated: Feb 12

TGIF folks! What a week it has been .............what with the arrival of yet another new COVID 19 variant ......the mysterious OMICRON! My children think it sounds like a new Transformer Knight! Or should that be decepticon? hmm ๐Ÿค” as it seems to have wreaked chaos and havoc around the world ๐ŸŒŽ with several countries rapidly shutting their borders once again!


This week, we will look at the common symptoms people experience as they lose their hearing, most commonly due to ageing. With our rapidly ageing population in Singapore and the region, the term "Sliver Tsunami" has become more and more relevant in all aspects of our daily lives.



Q: what are the main types of hearing loss and their associated signs & symptoms?

There are three main types of hearing loss:


1. Sensorineural Hearing Loss

Permanent hearing loss occurs when inner ear hair cells or nerve endings become damaged and do not properly transmit their signals to the brain. Those who suffer from this condition may complain that people seem to mumble or that they hear, but do not understand, what is being said. The ageing process is a very common cause of sensorineural hearing loss. As we get older, the inner ear nerves and sensory cells gradually die. The condition is not often medically or surgically treatable. In most cases, the symptoms can be significantly minimised with the use of hearing aids.

In addition to ageing, sensorineural hearing loss may be caused by:

  • Traumatic Injury, related to head injuries

  • Excessive noise exposure: this can be work related or even leisure induced with heavy usage of in ear headphones

  • Viral infections, eg: measles or mumps

  • Ototoxic drugs, (medications that can damage hearing)

  • Meningitis

  • Diabetes

  • Stroke

  • High fever

  • Meniere's disease: this syndrome is often seen with fluctuating hearing loss, tinnitus and vertigo

  • Acoustic tumours, eg: vestibular schwannoma

  • Hereditary causes

2. Conductive Hearing Loss

Such hearing loss can be either temporary or permanent. They are caused by problems in either the outer or middle ear, which prevent sound from reaching the inner ear. People who experience this condition may find that voices and sounds appear faint. Many forms of conductive hearing loss can be treated medically or surgically. Some common causes include:

  • Infection of the ear canal (Otitis Externa) or middle ear (Otitis Media): which may cause ear ache and discharge

  • Fluid in the middle ear (Otitis Media with effusion) : common in young children

  • Perforation or scarring (Tympanosclerosis) of the eardrum

  • Excessive wax build-up

  • Unusual growths or tumours in the ear eg osteomas

  • Otosclerosis, a hereditary condition in which there is an abnormal formation of bone in parts of the middle ear. This bone prevents structures within the ear from vibrating properly impairing the transmission of sound and resultant hearing loss. In advanced cases of otosclerosis, the hearing loss may become severe.

3. Mixed Hearing Loss

Some people have a combination of both sensorineural and conductive hearing loss.

This type of hearing loss is often gradual and not immediately noticed by the person affected. Sometimes friends or family will notice a person's hearing problems before the person with the hearing loss recognises it. For instance, family members may complain that the person with hearing loss turns up the volume on the the television or radio and often asks them to repeat what they have just said.


Sometimes, the person with hearing loss does not answer the telephone or doorbell because they did. not hear it ringing.

Although each person may experience symptoms of hearing loss differently, some of the most common symptoms may include:

  • Inability to hear people clearly. To them, other people may seem to mumble and they miss out on parts of a conversation. For instance, someone with hearing loss may miss the plot of a story or punch line of a joke that someone just told.

  • Tinnitus , or ringing in the ears / head, are a common symptom with hearing loss.

  • Frequent requests for repetition or clarification.

  • Tendency to need to stare at people when they are talking in order to make it easier to understand what they are saying. They may resort to lip reading to assist their own hearing loss.

  • Fatigue & tiredness at the end of the day from straining to hear.

  • Avoidance of social situations because of difficulty following conversations in noisy environments. Speech in Noise presents a major difficulty to them.

  • Tendency to pretend when not hearing someone because of the fear of asking them to repeat themselves.

Q: How can we test and diagnose Hearing Loss?

Although hearing loss is very common among older adults, particularly those over age 65, the condition is often missed / under diagnosed in older people. Hearing loss can greatly impact a person's quality of life. Therefore, if hearing loss is suspected, it is important that the advice of a doctor specialising in ear, nose and throat (ENT) conditions, is sought in order to make a definite medical diagnosis. The ENT specialist will work in close cooperation with audiologists, specialists in hearing disorders.


There are a variety of tests available to accurately diagnose the type and severity of hearing loss. These include:

  • Air Conduction, Conventional or Pure Tone Audiometry This test is commonly used to measure the hearing of adults and older children. A range of test tones, from low to high frequency (perceived as "pitch"), is transmitted through earphones placed on or in each ear, and patients are asked to indicate with a hand raise, button push or verbal response when they can hear each sound. This testing determines the very softest signals you can hear at each of the presented frequencies, and indicates frequency regions in which hearing may be impaired. The louder the sounds must be made to be heard, the greater the degree of hearing loss at that particular frequency or frequencies. The frequencies tested are those important for hearing and understanding speech and other environmental sounds.


  • Bone Conduction If testing reveals a hearing loss, another type of headset, a bone vibrator, is used to determine hearing by bone conduction in order to determine the type of hearing loss. This device sends sounds directly to the inner ear, bypassing the outer and middle ear. If the sounds are heard better by bone conduction, the hearing loss is conductive in nature and is likely located in the outer or middle ear. If the sounds are heard equally well with the earphones and the bone vibrator, the hearing loss is sensorineural in nature. A combination of conductive and sensorineural hearing loss also may be present; this is called a mixed hearing loss.


  • Word Recognition / Speech Discrimination. In addition to tests with tones, word recognition testing is usually performed to evaluate the ability to discriminate differences between the speech sounds of various words, and how clearly the words are heard. During this test, you will be asked to listen to and repeat words.


  • Acoustic Immittance. These tests are used to assess the status of the middle ear and related structures. A type of acoustic immittance test called Tympanometry, measures the movement of the eardrum to see if it moves normally when pressure changes are applied. Restricted eardrum movement could indicate a problem with the eardrum or middle ear structures. Acoustic reflex testing isa method of determining how the middle ear reacts to loud sounds also might be tested eg for otosclerosis.


  • Oto-acoustic Emissions (OAEs). OAEs are used to assess the function of the inner ear or cochlea. OAEs are typically present when hearing is normal or near normal, and are typically absent when there is a problem in the cochlea.


  • Auditory Brainstem Response (ABR). ABR is a procedure used to measure hearing sensitivity and determine if the auditory neural pathways within the brainstem are transmitting sound properly. This test is used to rule out auditory-neurological problems. Brainwave activity in the auditory centres of the brain is recorded in response to a series of clicks or tones presented to each ear. During this procedure, electrodes are placed on the head to detect the electrical response of the brains to sounds presented while you rest or sleep. The electrodes do not cause pain or discomfort. They form an objective measure of hearing status in individuals, even for babies.


Q: what can be done for my hearing loss?


Many options are now available for hearing loss, ranging from medical treatment to listening devices, such as hearing aids. Treatment depends on the cause and severity of hearing loss. For age-related hearing loss, there is no cure, but hearing aids and other listening devices help manage the problem and improve quality of life.


Medical Treatment

Medical treatment, including medications and surgery, is recommended for many types of hearing problems, particularly conductive hearing loss.

Some of the most common causes of conductive hearing loss are fluid in the middle ear, with or without infection, and earwax blocking the ear canal. In cases where there is a bacterial infection of the middle ear, antibiotics are often used. Although these conditions often can be diagnosed and treated by a primary care doctor, persistent problems may require the care of an ENT specialist. Conductive hearing loss also may be caused by a problem with the bones of the middle ear, which, in many cases, can be treated with surgery e.g., Otosclerosis.


Hearing Aids

Oftentimes, your ENT specialist will recommend a hearing aid evaluation and consultation with an audiologist. This consultation appointment will help determine which hearing aids or other assistive listening devices would be most appropriate for you. Lifestyle, listening needs and hearing concerns are important in determining the appropriate hearing aids.


Assistive Listening, Hearing Enhancement and Alerting Devices

In some cases, hearing or alerting assistive devices may be recommended in addition to, or instead of, hearing aids. These devices come in two forms:

  • Signalling or Test Display Devices. These are designed to convert sound or keystrokes into visual or vibratory stimulus, or into a written text.


  • Assistive Listening Devices These instruments are designed to enhance the sound that is received by picking up the sound closer to its source. This reduces the effects of distance, noise and reverberation and transmits sound directly to the ears or hearing aids.

There are a number of devices that can assist hearing in a variety of settings, such as:

  • Large Area Listening Systems

  • Television Listening Systems

  • Conference Microphones

  • Personal FM Systems

  • Amplified Telephones

Signalling and Text Display Systems

People with hearing loss can benefit from signalling and substitution systems, which convert sound or key strokes into another mode, such as text or flashing lights. These systems include:

  • Signalling and Warning Systems

  • Telephones

  • TV Closed Captioning

Digital Cell Phones and Hearing Aid Use

A common complaint of hearing aid users is the inability to use cell phones, particularly digital cell phones, with their hearing aids, or that they experience interference when trying to do so. Digital hearing aids are being continually updated to provide shielding from this interference. Cell phone technology also is changing.


In fact, in 2003, the Federal Communications Commission (FCC) developed a report requiring a number of future actions by manufacturers and service providers to make digital wireless phones that are capable of being used effectively with hearing aids. In the meantime, there are many strategies that will improve listening when using cell and land based telephones with hearing aids.


Cochlear Implants

A cochlear implant is a small implantable electronic device that can help improve the hearing of people with severe to profound, irreversible hearing loss. Although a cochlear implant does not restore normal hearing, it can allow a person to hear and understand more speech than was possible with a hearing aid.

Please refer to our website for more information on cochlear implants.


Aural Rehabilitation and Listening and Auditory Communication Enhancement

Unfortunately, hearing aids will not correct hearing loss or restore hearing to normal levels. However, the use of hearing aids and assistive listening devices along with auditory training can help maximise hearing abilities. Training may consists of:

  • Audiologic rehabilitation classes

  • Learning good listening strategies

  • Establishing guidelines for communicating with those around you

Well, thank you for your attention once again, folks!

Here are some useful references in case you would like to look up more detailed information on hearing loss for yourself or your loved ones.

If in doubt, do consult your ENT Specialist or GP who can help arrange an assessment with an Audiologist to check your hearing levels to determine if you need help. Remember: help is now readily available to ensure the best possible Quality of Life for you despite hearing loss.

References:
  1. Nieman CL, et al. Otolaryngology for the internist: Hearing loss. Medical Clinics of North America. 2018;102:977.

  2. Weber PC. Etiology of hearing loss in adults. https://www.uptodate.com/contents/search. Accessed Jan. 2, 2021.

  3. Age-related hearing loss. National Institute on Deafness and Other Communication Disorders. https://www.nidcd.nih.gov/health/age-related-hearing-loss. Accessed Jan. 1, 2019.

  4. Jameson JL, et al., eds. Disorders of hearing. In: Harrison's Principles of Internal Medicine. 20th ed. New York, N.Y.: The McGraw-Hill Companies; 2018. https://accessmedicine.mhmedical.com. Accessed Dec. 27, 2018.

  5. Noise-induced hearing loss. National Institute on Deafness and Other Communication Disorders. https://www.nidcd.nih.gov/health/noise-induced-hearing-loss. Accessed Jan. 1, 2019.

  6. Decibel levels. Hearing Health Foundation. https://hearinghealthfoundation.org/decibel-levels?gclid=EAIaIQobChMI6seW4KvO3wIVlohpCh3L1AMKEAAYASAAEgKsQPD_BwE. Accessed Jan. 1, 2019.

  7. Occupational noise exposure. Occupational Safety & Health Administration. https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.95. Accessed Jan.1, 2019.

  8. Weber PC. Evaluation of hearing loss in adults. https://www.uptodate.com/contents/search. Accessed Jan. 2, 2021.

  9. Morrow ES Jr. Allscripts EPSi. Mayo Clinic. Accessed Nov. 2, 2020.

  10. Michaels TC, et al. Hearing loss in adults: Differential diagnosis and treatment. American Family Physician. 2019; https://www.aafp.org/afp/2019/0715/p98.html. Accessed Jan. 2, 2021.

  11. Hearing loss. Merck Manual Professional Version. https://www.merckmanuals.com/professional/ear,-nose,-and-throat-disorders/hearing-loss/hearing-loss#. Accessed Jan. 2, 2021.

  12. Amieva H, et al. Does treating hearing loss in older adults improve cognitive outcomes? Journal of Clinical Medicine. 2020; doi:10.3390/jcm9030805.

  13. Hearing loss and older adults. National Institute on Deafness and Other Communication Disorders. https://www.nidcd.nih.gov/health/hearing-loss-older-adults. Accessed Jan. 1, 2019.

  14. AskMayoExpert. Idiopathic sudden sensorineural hearing loss. Rochester, Minn.: Mayo Foundation for Medical Education and Research; 2018.

  15. Chandrasekhar SS, et al. Clinical Practice Guideline: Sudden hearing loss (update). Otolaryngology โ€” Head and Neck Surgery. 2019; doi:10.1177/0194599819859885.

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