P303, 312, 313
The gold standard of hearing evaluation includes pure tone
audiometry with speech testing, as well as impedance (middle ear
pressure) testing
1. Diagnosing Conductive vs. Sensorineural Hearing Loss
A. History
• Conductive: Ear pain, fullness, drainage, history of recurrent
infections, trauma, cerumen impaction, surgery.
• Sensorineural (SNHL): Gradual hearing loss (presbycusis), loud
noise exposure, tinnitus, vertigo, ototoxic medications, sudden
onset without infection.
B. Exam
• Otoscopy:
o Conductive → cerumen, foreign body, effusion, perforated
TM, cholesteatoma.
o SNHL → usually normal ear exam.
C. Bedside Tests
• Weber test (tuning fork, mid-forehead):
o Conductive → lateralizes to affected ear.
o SNHL → lateralizes to unaffected ear.
• Rinne test (tuning fork at mastoid vs. ear canal):
o Conductive → bone > air conduction in affected ear.
o SNHL → air > bone (normal pattern) but decreased overall
hearing.
D. Formal Audiometry (Gold Standard)
• Conductive: Air-bone gap (bone conduction better than air).
• SNHL: Both air and bone reduced, no gap.
E. Additional Testing
, • Imaging (CT/MRI):
o Conductive → if cholesteatoma, trauma, malformation.
o SNHL → unilateral/asymmetric → MRI to rule out acoustic
neuroma.
• Lab work: If autoimmune or infectious cause suspected.
🔹 2. Management
A. Conductive Hearing Loss
Causes & Treatment:
• Cerumen impaction / foreign body → removal.
• Otitis externa / media → topical or systemic antibiotics.
• Otitis media with effusion → often observation;
myringotomy/tympanostomy tubes if persistent.
• Tympanic membrane perforation → often heals spontaneously;
surgery if chronic.
• Cholesteatoma → surgical excision.
• Otosclerosis → stapedectomy surgery or hearing aids.
B. Sensorineural Hearing Loss (SNHL)
Causes & Treatment:
• Presbycusis (age-related) → hearing aids, communication
strategies.
• Noise-induced hearing loss → prevention, hearing aids.
• Ototoxicity (aminoglycosides, cisplatin, loop diuretics,
salicylates) → stop offending drug, audiology follow-up.
• Sudden SNHL (ENT emergency) → high-dose corticosteroids (oral or
intratympanic) within 72 hours; urgent ENT referral.
• Ménière’s disease → salt restriction, diuretics, vestibular
suppressants; ENT referral for refractory cases.
The gold standard of hearing evaluation includes pure tone
audiometry with speech testing, as well as impedance (middle ear
pressure) testing
1. Diagnosing Conductive vs. Sensorineural Hearing Loss
A. History
• Conductive: Ear pain, fullness, drainage, history of recurrent
infections, trauma, cerumen impaction, surgery.
• Sensorineural (SNHL): Gradual hearing loss (presbycusis), loud
noise exposure, tinnitus, vertigo, ototoxic medications, sudden
onset without infection.
B. Exam
• Otoscopy:
o Conductive → cerumen, foreign body, effusion, perforated
TM, cholesteatoma.
o SNHL → usually normal ear exam.
C. Bedside Tests
• Weber test (tuning fork, mid-forehead):
o Conductive → lateralizes to affected ear.
o SNHL → lateralizes to unaffected ear.
• Rinne test (tuning fork at mastoid vs. ear canal):
o Conductive → bone > air conduction in affected ear.
o SNHL → air > bone (normal pattern) but decreased overall
hearing.
D. Formal Audiometry (Gold Standard)
• Conductive: Air-bone gap (bone conduction better than air).
• SNHL: Both air and bone reduced, no gap.
E. Additional Testing
, • Imaging (CT/MRI):
o Conductive → if cholesteatoma, trauma, malformation.
o SNHL → unilateral/asymmetric → MRI to rule out acoustic
neuroma.
• Lab work: If autoimmune or infectious cause suspected.
🔹 2. Management
A. Conductive Hearing Loss
Causes & Treatment:
• Cerumen impaction / foreign body → removal.
• Otitis externa / media → topical or systemic antibiotics.
• Otitis media with effusion → often observation;
myringotomy/tympanostomy tubes if persistent.
• Tympanic membrane perforation → often heals spontaneously;
surgery if chronic.
• Cholesteatoma → surgical excision.
• Otosclerosis → stapedectomy surgery or hearing aids.
B. Sensorineural Hearing Loss (SNHL)
Causes & Treatment:
• Presbycusis (age-related) → hearing aids, communication
strategies.
• Noise-induced hearing loss → prevention, hearing aids.
• Ototoxicity (aminoglycosides, cisplatin, loop diuretics,
salicylates) → stop offending drug, audiology follow-up.
• Sudden SNHL (ENT emergency) → high-dose corticosteroids (oral or
intratympanic) within 72 hours; urgent ENT referral.
• Ménière’s disease → salt restriction, diuretics, vestibular
suppressants; ENT referral for refractory cases.
