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Yueh B, Shapiro N, MacLean CH, Shekelle PG. Screening and Management of Adult Hearing Loss in Primary Care: Scientific Review. JAMA. 2003;289(15):1976–1985. doi:10.1001/jama.289.15.1976
Author Affiliations: Veterans Affairs Puget Sound Health Care System, Departments of Otolaryngology–Head and Neck Surgery and Health Services, University of Washington, Seattle (Dr Yueh); RAND Health, Santa Monica, Calif (Drs Shekelle and MacLean); and Divisions of Head and Neck Surgery (Dr Shapiro) and Rheumatology (Dr MacLean), University of California Los Angeles, and the Greater Los Angeles Veterans Affairs Healthcare System (Dr Shekelle), Los Angeles, Calif.
Scientific Review and Clinical Applications Section
Editor: Wendy Levinson, MD, Contributing Editor.
Context Hearing loss is the third most prevalent chronic condition in older
adults and has important effects on their physical and mental health. Despite
these effects, most older patients are not assessed or treated for hearing
Objective To review the evidence on screening and management of hearing loss of
older adults in the primary care setting.
Data Sources and Study Selection We performed a search from 1985 to 2001 using MEDLINE, HealthSTAR, EMBASE,
Ageline, and the National Guideline Clearinghouse for articles and practice
guidelines about screening and management of hearing loss in older adults,
as well as reviewed references in these articles and those suggested by experts
in hearing impairment.
Data Extraction We reviewed articles for the most clinically important information,
emphasizing randomized clinical trials, where available, and identified 1595
Data Synthesis Screening tests that reliably detect hearing loss are use of an audioscope,
a hand-held combination otoscope and audiometer, and a self-administered questionnaire,
the Hearing Handicap Inventory for the Elderly-Screening version. The value
of routine screening for improving patient outcomes has not been evaluated
in a randomized clinical trial. Screening is endorsed by most professional
organizations, including the US Preventive Services Task Force. While most
hearing loss in older adults is sensorineural and due to presbycusis, cerumen
impaction and chronic otitis media may be present in up to 30% of elderly
patients with hearing loss and can be treated by the primary care clinician.
In randomized trials, hearing aids have been demonstrated to improve outcomes
for patients with sensorineural hearing loss. Nonadherence to use of hearing
aids is high. Prompt recognition of potentially reversible causes of hearing
loss, such as sudden sensorineural hearing loss, is important to maximize
the possibility of functional recovery.
Conclusion While untested in a clinical trial, older adults can be screened for
hearing loss using simple methods, and effective treatments exist and are
available for many forms of hearing loss.
Hearing loss is the third most prevalent chronic condition in older
Americans, after hypertension and arthritis1;
between 25% and 40% of the population aged 65 years or older is hearing impaired.1-4 The prevalence
rises with age, ranging from 40% to 66% in patients older than 75 years5-7 and more than 80% in
patients older than 85 years.3 Alternative
definitions of hearing loss would raise estimates of prevalence even higher.8 In addition, the impact of hearing loss on society
will increase not only because the population is aging, but also because the
prevalence of age-adjusted hearing loss has increased significantly since
The diminished ability to hear and to communicate is frustrating in
and of itself, but the strong association of hearing loss with depression
and functional decline adds further to the burden on individuals who are hearing
loss in older patients strongly correlates with depression. For example, in
a study of 253 patients aged 70 years or older, a strong statistical association
was reported between the threshold of a low-frequency pure tone greater than
35 dB and depression.17 In addition, a cross-sectional
study of 1191 community-dwelling older persons aged 70 to 75 years found that
hearing impairment was significantly associated with depression as assessed
by the Beck Depression Inventory (odds ratio, 1.76; 95% confidence interval
[CI], 1.15-2.71).14 These associations have
been found to be independent of age and socioeconomic status.12 Furthermore,
Mulrow et al16 have reported the impact of
hearing loss on social isolation, poor self-esteem, and functional disability.
Other authors also have reported a strong relationship between hearing loss
Despite the prevalence and burden of hearing loss, hearing impairment
is underdiagnosed in older persons. Only 9% of internists offer hearing testing
to patients aged 65 years or older.20 Hearing
loss also is undertreated: only 25% of patients with aidable hearing loss
receive hearing aids.3,21 The
underdetection and undertreatment of hearing loss are discouraging, because
strong evidence supports that the treatment of hearing loss improves quality
Given the prevalence and disease burden of undetected hearing impairment
in older persons and the availability of effective treatments, it is important
for primary care physicians to screen, recognize, treat, and appropriately
refer patients with hearing impairment. This article reviews the literature
relevant to the care of older adults with hearing loss in the primary care
setting and provides insight into the treatment of hearing loss by hearing
We conducted literature searches from 1985 to 2001 in the databases
MEDLINE, HealthSTAR, EMBASE, and Ageline, using search terms hearing, hearing loss, hearing aids, hearing impairment, screening, and other relevant terms. Articles chosen for review were
those with the most clinically important information, emphasizing randomized
clinical trials, when available. We identified 1595 articles. Additional articles
from our personal files and those suggested by experts in hearing impairment
were added. A further search was conducted for clinical practice guidelines
for hearing impairment in the literature and using the National Guideline
Clearinghouse Web site search (http://www.guidelines.gov). Details
of the search terms, databases used, and citations retrieved are available
from the authors.
The healthy ear is an exquisitely sensitive organ. It processes sound
frequencies ranging from 20 Hz to 20 kHz. It detects sounds as soft as 0.0002
dynes/cm2 (0 dB) and can tolerate stimuli up to a million times
more intense (200 dynes/cm2 or 120 dB) for limited periods of exposure.
The ear is particularly sensitive to signals between 500 and 4000 Hz, which
includes the frequencies most important for speech processing.
The ear is composed of the external ear, the middle ear, and the inner
ear (Figure 1). The external ear
consists of the pinna (auricle) and the external auditory canal, and it is
immediately accessible to physical examination. Its function is thought to
be largely protective, although its physical configuration may provide moderate
(5-15 dB) passive augmentation of sounds at the upper range of speech processing
The middle ear is bounded laterally by the tympanic membrane (eardrum)
and medially by the osseous labyrinth, which is the bone-encased structure
that houses the end organs of hearing (cochlea) and balance (semicircular
canals). The healthy middle ear is an air-filled cleft that contains the 3
ossicles (malleus, incus, and stapes) that transduce vibrations from the tympanic
membrane to the oval window of the fluid-filled cochlea. The substantially
larger area of the tympanic membrane, compared with that of the oval window,
and the relatively minor mechanical gain from the ossicular configuration
combine to amplify sound pressures by 20 to 30 dB (approximately the difference
between a whispered voice and normal conversational speech).
The inner ear includes the cochlea, the vestibular apparatus, and the
vestibulocochlear (acoustic) nerve (cranial nerve VIII). The fluid channels
within the cochlea are stimulated by the vibrating stapes footplate through
the membranous oval window at the base of the cochlea. These fluid-filled
channels (scala vestibuli, tympani, and media) are lined by hair cells, which
are organized tonotopically (by sound frequency) in a coiled, spiral shape.
The base of the cochlea responds to high-frequency sounds, and the apex responds
to low-frequency sounds. Inner hair cells are innervated by a rich array of
afferent nerve fibers (10-20 fibers per hair cell) that synapse with auditory
division of the vestibulocochlear nerve at the spiral ganglion. Further discussion
of cochlear and brain stem physiology is beyond the scope of this review article.
The 2 major forms of hearing loss are conductive and sensorineural disorders.
Conductive hearing losses usually involve abnormalities of the middle and
external ear, and generally have a mechanical cause (eg, perforated eardrum,
fluid in the middle ear, disarticulations of the ossicular chain, cerumen
accumulation). As a result, treatment is often surgical (eg, repair of the
perforated eardrum, drainage of fluid-filled middle ear, reconstruction of
the ossicular chain, removal of cerumen). However, more than 90% of hearing
loss is sensorineural (nerve deafness), which typically results from permanent
damage to the hair cells of the cochlea.
Sensorineural loss related to aging, or presbycusis, is the most common
cause of hearing loss in the United States. This type of hearing loss is typically
gradual, bilateral, and characterized by high-frequency hearing loss. Patients
with presbycusis typically have difficulty filtering background noise, which
makes listening especially challenging in common social settings. Because
no known treatment is available for damaged hair cells, presbycusis is typically
treated with amplification devices, such as hearing aids. Note that profound
deafness can be treated with cochlear implantation, which bypasses the hair
cells to stimulate the vestibulocochlear nerve directly.
The value of routine screening for undiagnosed hearing impairment has
not been studied in clinical trials. In the absence of direct clinical trial
data, screening programs can be advocated if evidence is available to support
each of the 3 commonly accepted criteria for a community screening program.26,27 These criteria are that (1) the burden
of disease must be significant enough to justify the effort of screening,
(2) an effective treatment must be available for the detected condition, and
(3) an accurate, practical, and convenient screening test must exist. Mulrow
and Lichenstein28 have argued that these conditions
are satisfied for screening hearing impairment. The US Preventive Service
Task Force, the Canadian Task Force on Preventive Health Care (formerly called
the Canadian Task Force on the Periodic Health Examination), and other groups
have concurred and recommend screening older adults for hearing impairment
Although screening tests exist and effective treatment is available,
it has not been established that routine screening leads to improved long-term
outcomes. The first clinical trial to study long-term outcomes after routine
screening for hearing impairment in older adults is now under way by the Screening
for Auditory Impairment-Which Hearing Aid Test trial, conducted by the Health
Service Research and Development Service of the Veterans Health Administration.31
In addition, routine screening may be helpful because it is difficult
to diagnose hearing loss in the primary care setting. The onset of presbycusis
is insidious and patients themselves are frequently unaware of their hearing
loss. Physicians may overlook presbycusis in a quiet examination room, since
the symptoms of early presbycusis are more apparent in settings with background
noise. In addition, the diagnosis of hearing loss must be confirmed with formal
audiometric testing, which is the diagnostic criterion standard.
Many simple tests for hearing loss have been used as a routine part
of the physical examination, but they are difficult to implement in systematic
screening programs because they cannot be standardized. For example, the Whispered
Voice Test is performed by examiners who whisper words from behind the patient
at varying distances.32,33 The
degree of hearing loss is reflected by the furthest distance from which patients
may still reliably reproduce what is whispered. Attempts to standardize the
test have been made (eg, by whispering only after full expiration), but there
is no reliable way to control the loudness of the whispers, and robust descriptions
of interobserver variability and test-retest reliability are lacking.31,34 Screening with a vibrating tuning
fork or the sounds of an examiner's fingers rubbing also has been proposed.32,35 Judgments about hearing loss generally
rely on measuring the threshold distance beyond which the sounds cannot be
heard. Alternatively, the hearing thresholds of the patient and the examiner
can be compared by placing the vibrating tuning fork on each person's mastoid
process (Schwabach test). Again, although reasonable test accuracy has been
reported in small series,32,35 the
intrinsically subjective nature of these tests (What is the degree of the
examiner's hearing loss? How hard should the tuning fork be struck?34) is a serious limitation.28
In contrast, 2 inexpensive and simpler approaches to screening—a
self-administered questionnaire and a simple physiologic test—have demonstrated
excellent accuracy in detecting hearing loss and have gained widespread interest.
Hearing Handicap Inventory for the Elderly-Screening. The self-administered instrument is the Hearing Handicap Inventory
for the Elderly-Screening version (HHIE-S),36,37 a
10-item, 5-minute questionnaire that measures the degree of social and emotional
handicap from hearing loss (Box 1).
Does a hearing problem cause you to feel embarrassed
when meeting new people?
Does a hearing problem cause you to feel frustrated
when talking to members of your family?
Do you have difficulty hearing when someone speaks
in a whisper?
Do you feel handicapped by a hearing problem?
Does a hearing problem cause you difficulty when
visiting friends, relatives, or neighbors?
Does a hearing problem cause you to attend religious
services less often than you would like?
Does a hearing problem cause you to have arguments
with family members?
Does a hearing problem cause you difficulty when
listening to TV or radio?
Do you feel that any difficulty with your hearing
limits or hampers your personal or social life?
Does a hearing problem cause you difficulty when
in a restaurant with relatives or friends?
*The HHIE-S scores are yes, 4 points; sometimes, 2 points; or no, 0
points, to each question about a particular handicap. Scores range from 0
(no handicap) to 40 (maximum handicap). Adapted with permission.36,37
The patient responds yes (4 points), sometimes (2 points), or no (0
points) to each question about a particular handicap. Scores range from 0
(no handicap) to 40 (maximum handicap). A total score of 0 to 8 indicates
a 13% probability of hearing impairment, a score of 10 to 24 indicates a 50%
probability of a hearing impairment, and a score of 26 to 40 indicates an
84% probability of a hearing impairment.38
Several cross-sectional studies 7,36,38-41 have
investigated the performance of the HHIE-S. Each study has a slightly different
patient population and definition of hearing loss, but substantial evidence
shows that patients with abnormal HHIE-S scores have high rates of hearing
impairment. Cutoff scores of 10 and above provide reasonable sensitivity and
specificity, with values for both scores ranging from 0.63 to 0.80 (Table 2). It should be emphasized that
the HHIE-S screens for functional not physiologic hearing loss. Therefore,
when audiometric testing (a physiologic measure) is used as the criterion
standard, the sensitivity of the HHIE-S appears low. Higher cutoff scores
provide significantly improved specificity and likelihood ratios (data not
shown), but poorer sensitivity.
Audioscope. The physiologic test uses an audioscope,
a hand-held, combination otoscope and audiometer that delivers a 25- to 40-dB
pure tone at 500 Hz, 1000 Hz, 2000 Hz, and 4000 Hz, the most commonly tested
frequencies needed to hear speech. The listed price for the Audioscope (Welch
Allyn Medical Products, Skaneateles Falls, NY) is $500 to $600, according
to the company's Web site (http://www.welchallyn.com/medical/).
The audioscope is held directly in the external auditory (ear) canal with
a probe tip sealing the canal. Tones are presented at each frequency, and
the listener is asked to indicate whether he or she can hear the tone.6 Minimal training is required. Patients unable to hear
a predetermined series of tones may then be referred for formal evaluation.
Audioscope testing is recommended by the Canadian Task Force on Preventive
Health Care.30 In addition to screening for
hearing loss, the audioscope also allows for direct inspection of the ear
canal to assess external ear abnormalities, such as cerumen, otitis, and foreign
The audioscope also has been tested against the diagnostic criterion
standard of formal audiogram in several reports (Table 3).7,38,40 Each
study used the 40-dB threshold for both screening and audiometry, which is
the threshold that the Veterans Health Administration uses to adjudicate hearing
loss.42 Despite small differences in methods,
all 3 studies7,38,40 demonstrated
excellent sensitivity (≥0.94) and good specificity (0.69-0.80) for hearing
loss. Each study concluded that the most efficient screening frequencies would
be at 2 kHz,7,40 or a combination
of 1 and 2 kHz.38 These studies also tested
the performance of the HHIE-S, and the study by McBride et al40 concluded
from the performance using receiver-operating curves for both the HHIE-S and
the audioscope (using the formal audiometric testing as the criterion standard)
that the audioscope performed better. A review of 185 patients aged 60 years
or older who were screened consecutively by both the audioscope and the HHIE-S
in a primary care clinic reported that patients preferred the audioscope (60%)
over the HHIE-S (13%) as a screening tool.40
Because the HHIE-S and the audioscope screen different aspects of hearing
loss, it is possible that they preferentially identify different types of
hearing-impaired patients. The audioscope detects only physiologic loss, so
it may identify more patients with hearing loss,40 but
not necessarily those patients who are motivated to seek treatment. On the
other hand, because the HHIE-S identifies individuals with handicap from hearing
loss, it may be less sensitive to early disease, but more likely to identify
motivated individuals. Therefore, it is unclear whether the HHIE-S or the
audioscope is likely to be more successful in detecting hearing impairment.
Several authors have proposed that a combination of both physiologic and self-report
screenings may represent a viable third alternative,38,40 which
is the focus of the ongoing Screening for Auditory Impairment-Which Hearing
Aid Test trial.31
Several otologic abnormalities can be identified and treated by the
primary care physician. Cerumen impaction may result in substantial hearing
loss and can be found in up to 30% of elderly patients with hearing loss.43 If physical inspection of the external auditory canal
reveals cerumen impaction, the cerumen may be removed by several techniques.
A small cerumen curette, if available, may be used to remove the cerumen if
the practitioner is comfortable and familiar with this technique. Alternatively,
gentle warm water irrigation may be used to loosen and remove the cerumen
if the patient has no history of tympanic membrane perforation or ear surgery.
Hydrogen peroxide–containing solutions (sold over-the-counter, such
as Debrox or Murine) can be prescribed to loosen firm cerumen impactions if
the patient has no history of tympanic membrane perforation or ear surgery.
Deep cerumen impactions may be resistant to these maneuvers and the patient
can be referred to an otolaryngologist for safe removal of the cerumen under
Chronic otitis media with effusion is a common problem in older adults.
This condition, also known as serous otitis since
the middle ear becomes filled with a serous fluid, may result in discomfort
and a conductive hearing loss. We were unable to identify any randomized,
placebo-controlled trials that documented the efficacy of antibiotic therapy
or other treatments in older adults with this condition. In children, systematic
reviews of randomized placebo-controlled trials suggest that antibiotics44,45 and oral steroids46,47 both
shorten the course of disease, but that decongestants and antihistamines had
no significant effect on effusion clearance.44,48 Serous
otitis may persist for weeks or months, and such patients should be referred
to an otolaryngologist either for more aggressive treatment (eg, surgical
aspiration of fluid) or to rule out an underlying disorder with resultant
obstruction of the eustachian tube (eg, nasopharyngeal carcinoma).
Early intervention by the astute primary care physician may halt or
reverse 2 forms of sensorineural hearing loss: unilateral sudden sensorineural
hearing loss (or sudden deafness) and hearing loss caused by ototoxicity.
Sudden Hearing Loss. The etiology of sudden
sensorineural hearing loss is not yet clear. A variety of mechanisms ranging
from viral infections to microcirculatory injuries to immune-mediated disorders
have been proposed,49,50 although
expert opinion is that viral infection may be the most important contributor.50-52 However, 2 recent
randomized trials failed to show benefit from antiviral agents.53,54 To
date, the only treatment to show efficacy in placebo-controlled trials has
been glucocorticoid administration. In an earlier randomized trial, nearly
twice as many patients (61% vs 32%) receiving glucocorticoids experienced
at least partial recovery of hearing as those receiving placebo.55 To
document the hearing loss, and to rule out masquerading retrocochlear processes
such as acoustic neuromas,56,57 these
patients should be referred urgently for specialty care.
Ototoxicity. The ototoxic effects of antibiotics
and antineoplastic agents are well documented. The aminoglycosides and platinum
compounds are particularly ototoxic, but a variety of other agents have been
implicated as well in case reports (Box 2).58-63 When
known ototoxic agents need to be administered, ultra high-frequency audiometry
is available for early detection of ototoxicity in adult populations,64 but currently no guidelines are available on the
use of ultra high-frequency audiometry. Because high-frequency hearing loss
usually precedes loss in the normal range, early detection of such loss may
lead to modifications in treatment that prevent clinically important hearing
loss. A frequently overlooked ototoxic agent is aspirin. Little is known about
what level of dosage causes ototoxicity, but it is generally believed that
80 mg of aspirin on a daily basis is safe. Fortunately, in most cases, the
resulting tinnitus and hearing loss are temporary and reversible with cessation
Antibiotics: aminoglycosides, erythromycin, and vancomycin
Antineoplastics: cisplatin, carboplatin, and vincristine sulfate
Loop diuretics: furosemide, ethacrynic acid
Anti-inflammatory: aspirin and quinine
When disease management lies beyond the scope of the primary care setting,
it is important to refer patients to hearing specialists for additional evaluation.
Audiometric testing by audiologists is not only the criterion standard for
diagnosing hearing loss, but critical for determining whether hearing loss
is sensorineural or conductive in origin, which strongly influences choice
of therapy. It is important to recognize that certain hearing disorders, such
as traumatic injury with vestibular symptoms and/or deafness, and erosive
lesions, such as cholesteatoma, require urgent consultation.
Referrals for hearing loss are best directed to audiologists, otolaryngologists,
or both. Audiologists have expertise in hearing testing, use of assistive
listening devices (eg, telephone amplifiers, infrared systems, pocket talkers,
and visual/tactile alerts for the doorbell, telephone, and smoke alarm), and
the selection and fitting of hearing aids. Otolaryngologists have specialty
training in a range of disorders in the head and neck, which include the medical
and surgical treatment of otologic problems.
The first step in the clinical workup of hearing loss is formal audiometric
testing by an audiologist. The audiometric tests are performed in a sound-protected
environment. These tests include a standard test battery consisting of pure-tone
audiometry that assesses the patient's threshold of hearing for tones from
low frequency (250 Hz) to high frequency (8 kHz); word recognition tests that
measure the percentage of monosyllabic words that a patient can repeat (discrimination
scores); the speech reception threshold that measures the lowest intensity
level at which a patient can repeat 50% of spondaic words (ie, 2-syllable
words with equal emphasis on each syllable, such as baseball, cowboy, and
pancake); and bone-conduction testing, acoustic reflexes, and tympanometry,
which primarily target the presence or absence of specific disorders, such
as otosclerosis, acoustic neuromas, or otitis media.
The majority of hearing loss is sensorineural. In mild-to-severe loss,
the most effective treatment is hearing amplification with hearing aids. In
a seminal randomized clinical trial of 194 elderly veterans, patients randomly
assigned to receive a hearing aid experienced significant improvements in
social and emotional function, communication function, and depression after
4 months, compared with patients in the control group.22 The
authors subsequently found that the improvements were sustained 1 year after
being fit with a hearing aid.23 These findings
were confirmed by a cross-over trial involving 180 older patients, comparing
a hearing aid, an assistive listening device, and in combination.24 The most significant improvements in emotional and
social function were noted with the hearing aid. More recently, in a 4-arm,
randomized trial of 60 older veterans comparing 2 types of hearing aids and
2 types of control arms, substantial improvements in quality-of-life measures,
communication function, patient preferences, and adherence were noted for
patients using hearing aids, with particular preference for a programmable
hearing aid with a directional microphone.25
However, treatment effectiveness is not guaranteed even if patients
receive hearing aids. Nonadherence to use of hearing aids is high. Several
authors have conservatively estimated that up to 30% of patients who receive
hearing aids do not use their aids.3,67-69 As
patients age, handling the hearing aid can become increasingly difficult.70 Older patients experience more problems with inserting
the earmold into the ear, switching on and off the hearing aid, changing the
battery, cleaning the earmold, and changing the volume.71 These
difficulties are among the most common explanations for failure to wear a
hearing aid. Among a group of 138 hearing aid users who were older than 90
years, 33% to 79% experienced difficulty with any or all of these tasks.5 However, age (or any other predetermined variable)
has not yet been identified as an accurate predictor of hearing aid use. In
a group of 87 elderly male veterans, variables such as subjective functional
handicap, age, education, and number of medications had no consistent correlation
with hearing aid use.23
A number of hearing aid technologies have been a focus of study, including
digital sound processing. Despite the promise of this technology, to date,
little evidence is available to show that digital hearing aids result in improved
hearing, since no trials involving digital technology have used adequate concurrent
control groups.72 Valente et al73 have
suggested that features, such as directional microphones confound existing
comparisons between digital and analog hearing aids. Another recent study
found that expectations strongly influence outcomes in patients who receive
digital aids.74 The investigators provided
digital aids to the entire cohort, but they led half of the patients to believe
that they received analog aids. Significantly lower satisfaction rates were
observed in these patients. Since digital hearing aids cost substantially
more than analog hearing aids, they cannot yet be considered cost-effective.
However, advances in digital technology may lower cost and improve effectiveness
and thereby improve the cost-effectiveness ratio.
The size and shape of hearing aids may influence satisfaction. In one
randomized study, 244 elderly patients were fitted with either behind-the-ear,
in-the-ear, or in-the-canal hearing aids.75 The
in-the-ear aid was rated as the easiest to manipulate, but surprisingly, cosmetic
judgments were unaffected by the size of the hearing aid.76 Another
study of 40 patients compared patient satisfaction with behind-the-ear vs
in-the-canal hearing aids.77 Patients with
in-the-canal hearing aids used their aids more frequently than patients with
behind-the-ear aids (45.4 h/wk vs 19.5 h/wk, P<.005).
In both studies, patients with behind-the-ear aids reported significantly
more "undesirable experiences" (operational difficulties, ear discomfort,
and negative sound experiences).76,77
Audiologists also commonly use assistive listening devices in auditory
rehabilitation.78 We are unaware of randomized
controlled trials demonstrating that assistive listening devices have benefit
over placebo. However, these devices have face validity and are commonly accepted
and prescribed by audiologists. In patients with moderate hearing loss, devices
such as infrared systems and telephone amplifiers may supplement the use of
hearing aids. For patients with profound hearing loss in whom conventional
amplification is unsuccessful, frequency-modulated systems, consisting of
a microphone placed near the source of sound, a transmitter, and a receiver
worn by the patient, are commonly used. In addition, visual and/or tactile
alerts for the doorbell, telephone, and smoke detector have been used in place
of hearing aids.79,80
Surgical treatment of common causes of hearing loss are briefly discussed.
Less common causes of hearing loss, such as acoustic neuromas, are beyond
the scope of this review. Because few controlled trials of surgical treatment
of hearing loss in adults have been conducted, our intent is not to provide
a formal evidence-based review, but rather to provide the primary care physician
with insight into how patients are treated after referral.
For persistent chronic otitis media with effusions, the use of myringotomy
(incision in the tympanic membrane) and pressure-equalization tubes are routinely
used to aspirate the contents and aerate the middle ear cleft, which immediately
restores hearing. It also is important for the otolaryngologist to examine
the patient's nasopharynx to rule out both benign (eg, allergic disease) and
malignant (eg, nasopharyngeal carcinoma) underlying conditions that might
obstruct the eustachian tube and predispose the patient to otitis media.
Small tympanic membrane perforations from recent traumatic events or
otitis media frequently heal spontaneously (Figure 2). However, large persisting perforations may cause substantial
conductive hearing loss and predispose patients to recurrent otitis. Surgical
repair of the perforation with fascial grafts (tympanoplasty) has an extremely
high success rate. Ossicular chain discontinuities also may result from trauma
or long-standing ear infections and are readily treated with ossicular chain
reconstructions using transposed ossicles or surgical implants.
A cholesteatoma is a cystic mass of the middle ear or mastoid cavity
that contains trapped squamous epithelium (Figure 2). It is not a neoplasm, but the slowly growing mass can
destroy surrounding structures, including the ossicles. Patients with chronic
ear infections are predisposed to cholesteatoma formation. Examination frequently
reveals a superior and posterior tympanic membrane perforation, with the presence
of white keratinaceous debris. No medical treatment for cholesteatoma is currently
available, although topical antibiotic drops may help to alleviate superinfections.
Surgery (mastoidectomy) is required to remove the cholesteatoma.
Bony sclerosis of the otic capsule is termed otosclerosis. When this common condition involves the stapes footplate, immobility
of the stapes prevents sound transduction to the oval window. This typically
results in a conductive hearing loss.81 Otoscopic
examination results of a patient with otosclerosis are most often normal.
Surgery on the footplate (stapedectomy or stapedotomy) provides excellent
aural rehabilitation. Hearing aids may be an alternative if surgery is not
appropriate. Elderly patients should be offered both options since several
studies have shown no increased surgical risk based on age alone, and they
appear to benefit from the surgery as much as younger patients.82-84
Profound sensorineural hearing loss (defined as >80 dB of loss in the
better ear), or true deafness, is increasingly amenable to treatment with
cochlear implantation. Rapid technological advances in implant technology
in the past 2 decades has led to successful rehabilitation of these patients
who previously had no reasonable alternative forms of treatment. Much of the
literature has focused on the effectiveness of treatment in the pediatric
population,85 but recent findings from systematic
reviews86 and prospective cohorts87,88 suggest
that cochlear implantation results in such substantial improvements in quality
of life, and patient preference states that implantation is cost-effective
in the adult patient as well.
Substantial evidence exists that hearing loss in older persons is underdiagnosed
and undertreated, despite the availability of effective treatment. The primary
care physician should vigilantly ask about hearing loss in older patients
and recognize common symptoms of hearing impairment, such as communication
impairment and social withdrawal. A variety of screening tests are available
for use in the primary care setting, most notably the portable audioscope
and the HHIE-S questionnaire. The Screening for Auditory Impairment-Which
Hearing Aid Test trial will assess whether mass screening leads to better
patient outcomes; results are expected in 2005. In the meantime, it seems
reasonable to provide hearing screening to older patients using either the
audioscope or HHIE-S. Many cases of hearing loss are treatable in the primary
care setting, and prompt recognition of sudden hearing loss may prevent further
deterioration or permanent deafness. In addition, recognition of hearing loss
facilitates referral to appropriate hearing professionals for treatment that
may lead to better quality of life.