What are the Causes of Hearing Loss?
It is necessary to classify the causes of hearing loss according to the location of the pathology
Causes Related to the Outer Ear
-Ear wax (plug)
-Foreign body in the external ear canal
– Absence of auricle or congenital deformity
-Congenital closure of the external ear canal
-External ear infections
-External ear tumors
Middle Ear Related Causes:
-Middle ear inflammation
-Low pressure in the middle ear (due to eustachian tube obstruction)
-Fixation of middle ear ossicles
-Middle ear tumors
Causes Related to Inner Ear and Auditory Nerve
-Inner ear inflammation (labyrinthitis)
Damage to hearing cells in the inner ear
-Sudden hearing loss
-Noise-induced hearing loss
-Hearing loss due to old age (presbiacusis)
-Meniere’s Disease (increased pressure in the inner ear fluids)
Tumors involving the auditory nerve
How is Hearing Loss Treated?
Hearing loss is not a disease but a symptom of other diseases. Therefore, the treatment of hearing loss is based on the treatment of the underlying disease. Treatments of diseases causing hearing loss are explained in its own section for each disease. But let’s talk about some points here. The treatment of earwax or foreign bodies in the external ear canal is their removal. Middle ear infections are usually treated with antibiotics or other medications. Treatment of chronic middle ear infections is sometimes surgery. In the disease called otosclerosis, which develops due to new bone formation arround stapes , the treatment is surgical removal of stapes superstructure and insertion of a prosthesis instead of it.
In inner ear hearing loss, the loss is usually permanent. In hearing loss due to tumors, the hearing must generally be sacrifised for the sake of proper tumor removal.
Which Tests Are Done?
The first procedure to determine the cause of hearing loss is the examination of the ear. A disease in the outer ear or eardrum can be easily seen during this examination. The image of the eardrum gives information about the condition of the middle ear, especially in middle ear infections. In cases where the examination is normal, it is thought that the cause of hearing loss may be related to the inner ear, but some tests are performed to determine this.
-Pure Sound Audiometry: It shows the type of hearing loss (conductive, sensorineural or mixed), its degree, which frequencies are retained. The information obtained here gives very valuable information about the degree of hearing loss.
-Speech Audiometry: It gives us information about pathologies in the middle ear, cochlea, auditory nerve, central auditory system and auditory pathways.
-Tympanometry: It is a test we use to measure middle ear pressure.
-Acoustic Reflex Test: We look at the stapes reflex to show any fixation in the ear ossicles.
-Computed tomography (CT) or magnetic resonance (MR): It is used to determine the cause of hearing loss, especially related to the middle and inner ear.
Otosclerosis is one of the common causes of hearing loss. In otosclerosis, the wall where the stapesi adjacent to the inner ear becomes stiff as a result of irregular bone development and movement restriction occurs in the stapes. As a result, sound waves cannot be transmitted to the inner ear fluids sufficiently and conductive hearing loss occurs. In this case, the inner ear is intact. Only sounds cannot be transmitted. However, in the later stages of the disease, this problem can also affect the inner ear and sensorineural hearing loss may also occur.
Otosclerosis can be an inherited disease. Studies show that young-middle-aged women are more at risk. In addition, it is suggested that the disease is also associated with pregnancy-related hormone changes. In addition to hearing loss, patients may also experience tinnitus, dizziness and balance problems.
Treatment in Otosclerosis
In patients with a preliminary diagnosis of otosclerosis, a treatment plan is made according to the severity of the disease and the patient’s preferences. In cases that are new and do not affect the person clinically much, the patient can be followed up with hearing tests. For patients whose hearing loss affects their social life, surgery or rehabilitation with hearing aids may be preferred. Apart from these, there are some drug treatments such as sodium fluoride that slow the progression of the disease, but these drugs are not the preferred treatment method.
Tinnitus is defined as the involuntary perception of sound without an external acoustic stimulus. Tinnitus can be in the form of ringing, buzzing, ringing, wave sound, machine noise, roar, water or wave sound. In general, the incidence of tinnitus is 10-15% of the adult population. There are many conditions that cause tinnitus and are associated with tinnitus. Although the most common known cause is hearing loss, it is accompanied by the following conditions.
* Causes related to the ear; infection, ear, brain and brain stem tumors, inner ear origin hearing loss, otosclerosis, ear wax, age and noise-related hearing loss.
*Causes related to the central nervous system; meningitis, migraine, multiple sclerosis and epilepsy.
*Blows and traumas to the head and neck.
*Cardiovascular system disorders (hypertension, orthostatic hypotension).
*Psychogenic causes; anxiety, depression, emotional trauma.
The treatment, on the other hand, is to determine the frequency and severity of tinnitus, especially with the pure tone audiometry available in our clinic. After the threshold is determined, the patient is asked whether the ringing has disappeared with the mask applied, and the patient is directed for appropriate treatments.
Tinnitus Threshold Test
With the pure tone audiometry available in our clinic, the frequency and severity of tinnitus are determined. After the threshold is determined, the patient is asked whether the tinnitus has disappeared with the mask applied, and the patient is directed for appropriate treatments.
Acute otitis media is an infection caused by microbes in the middle ear, which is usually seen in children, manifests with symptoms such as earache, fever, weakness and restlessness.
Acute otitis media in young children; may cause restlessness, drowsiness and malnutrition. In older children, complaints of pain and fullness in the ear may occur. Fever can be seen in children of any age group. These symptoms are often associated with upper respiratory tract infection symptoms such as a runny nose, congestion or cough.
The accumulation of pus in the middle ear causes pain and reduces the vibration of the eardrum. Thus, temporary hearing loss occurs. Serious ear infections can cause the eardrum to rupture, as fluid from the middle ear begins to flow into the ear canal. The hole in the eardrum caused by tearing can be corrected with treatment.
How common is acute otitis media?
According to studies, the rate of children who have had otitis media at least once before the age of three is 75% among all children. Middle Ear Inflammations are more common in boys than girls.
Is acute otitis media contagious?
Ear infections are not contagious, but many children develop ear infections following a cold or other viral infection and these infections are contagious.
What are the risk factors for acute otitis media?
Exposure to irritants such as cigarette smoke can also cause acute otitis media. Children with cleft palate or Down Syndrome are more prone to ear infections. Some problems in the Eustachian tubes (occlusion, structural disorder, inflammation, etc.) will increase the risk of acute otitis media.
Children who have had otitis media by the age of six months tend to have more otitis media later in life.
How is acute otitis media diagnosed?
There are three criteria for diagnosing acute otitis media:
- Acute onset of syptoms
- Erythema on tympanic membrane
- Pain (Earache)
Recurrent acute otitis media; It is defined as a case of inflammation that recurs three times in six months or four times in a year. A specific, definitive test method has not yet been developed for acute otitis media. Some tests may be required to diagnose chronic middle ear infections.
How is acute otitis media treated?
Treatment of acute otitis media varies depending on the age of the child and the symptoms of the inflammation. Generally, at the first stage of treatment, approximately 10 days of antibiotic use is recommended. Despite antibiotic therapy, 40% of children with otitis media remain fluid in their ears, which can cause temporary hearing loss that can last three to six months after treatment. In the vast majority of children, this fluid disappears on its own. Children who cannot take oral medication can also be given injections, but three days of antibiotic use is more effective than a single injection.
In children with recurrent inflammation, the use of an ear tube, which allows the fluid to come out of the middle ear, may be recommended. In addition, if the child has a swollen eardrum and intense pain, he may consider an operation to the eardrum. The eardrum usually heals within a week.
Chronic Otitis Media
Normally, the Eustachian tube allows fluid to flow through the tube, preventing accumulation. Chronic otitis media develops over time and often begins with an unresolved chronic middle ear effusion (fluid). Bacteria contaminate the liquid that remains for a long time.
After an acute infection, a chronic middle ear infection may develop when fluid (effusion) remains behind the eardrum for up to three months.
The bacteria in chronic otitis media are generally different from those found in acute otitis media. Therefore, anything that disrupts the working order of the Eustachian tube can cause chronic otitis media.
Chronic otitis media can cause ongoing damage to the middle ear and eardrum. The discomfort usually begins without pain and without fever. Pressure or throbbing in the ear can be felt for months.
What is the effect of chronic otitis media on the eardrum?
The eardrum (tympanic membrane) has three delicate layers that help make it thin but strong. Chronic otitis media causes changes that weaken the eardrum and often lead to a hole in the eardrum. Eventually, the eardrum loses its strength and begins to collapse into the middle ear cavity.
When the eardrum collapses, it attaches to middle ear structures, such as the middle ear bones (ossicles) or the periphery of the inner wall of the middle ear. This impairs sound transmission through the middle ear and hearing may be impaired.
How is chronic otitis media diagnosed and treated?
Some tests may be required to diagnose chronic middle ear infections. For this, hearing tests are performed and the degree of hearing loss is determined.
Pressure measurement is performed in cases where the pressure in the middle ear increases. Computed tomography (CT) can be used to determine the severity of the disease and the surgical status.
How is chronic otitis media treated?
Initially, the infection can be resolved with antibiotics. If there is a perforation in the eardrum, topical antibiotic drops may also be recommended. If there is a scratch (scar) on the eardrum or ossicles, this cannot be resolved with antibiotics alone. In this case, surgery is performed to repair the eardrum, remove the infected tissue and scar in the middle ear and mastoid bone.
The primary goal of chronic middle ear surgery is to remove all infected tissue to ensure that the infection does not recur. The second goal in surgery is to reconstruct the middle ear cavity with an intact eardrum. After these procedures, hearing can be restored.
It may seem strange that hearing is the end goal, but if the first two goals are not met, if the infection is not treated, hearing will still be damaged in a new infection and everything will be for nothing.
Dry Ears with Holes in The Eardrum
In these patients, the infection in the middle ear subsided. There is no active inflammatory process in the middle ear. However, as a sequelae of the infection, the eardrum remained perforated. This hole may be very small, or the entire eardrum may be completely lost. These ears are always at risk of recurrence of infection. When there is an infection, a discharge begins in the ear. In these patients, there is a hearing loss of around 20-40 dB due to the perforation of the eardrum. If there is damage to the ossicles in the middle ear, hearing loss may be greater. Perforations of the eardrum in early rotation may heal spontaneously and close. However, as the duration increases, the chance of closing decreases and if the period exceeds 3 months, there is no chance of spontaneous closing. In such a case, the eardrum needs to be repaired with a surgery called tympanoplasty.
Draining Ears With Holes in The Eardrum
In these patients, the eardrum is perforated and there is an active inflammatory process in the middle ear. As a result, there is usually a foul-smelling discharge in the ear. The patient has conductive hearing loss of 30-60 dB. In these patients, the chance of damage to the ossicular system is higher than in dry ears.
In these patients, it is primarily aimed to cure the infection with drug therapy. For this purpose, in addition to the use of oral antibiotics, antibiotic and cortisone drops are applied to the ear. If the infection is removed with drug treatment and the ear is made dry, then the hole in the eardrum is repaired with tympanoplasty. However, if the ear discharge does not stop despite drug treatment, surgical treatment should be applied in these patients. Because chronic infection in the middle ear can cause serious problems such as melting of the ossicles, meningitis, brain abscess and permanent hearing loss. In these patients, the middle ear infection is cleared and the eardrum is repaired with a method called tympanomastoidectomy.
Fluid accumulation in the ear (Serous otitis media)
Otitis media without infection is called serous otitis media. Large adenoids, sinus diseases, acute otitis media, allergies and rarely tumors can cause serous otitis media.
When the Eustachian tube is not functioning, ear ventilation cannot be performed. As a result, fluid accumulates in the middle ear. This can lead to reduced hearing and a feeling of fullness in the ear.
Serous otitis media is initially treated with antibiotics. However, if the person does not improve, surgical treatments such as inserting a ventilation tube into the eardrum are applied. If there is thinning of the eardrum, direct surgical intervention is performed without starting antibiotics. If the problem is caused by adenoid, in addition to the treatment, it will be beneficial to take adenoids.
“Acoustic trauma” caused by exposure to loud noise is “hearing loss caused by very severe noise. If the noise is excessively loud or long-lasting, ringing, humming and accompanying sensorineural hearing loss in the inner ear may occur.
Acoustic trauma is one of the most common causes of hearing loss and tinnitus.
The sudden noise of firearms such as cannons, rifles, pistols and explosives can cause acoustic trauma. For some people, even a single explosion sound is enough to cause acoustic trauma. Generally, the stronger the explosive, the greater the deafness. Explosions indoors are more harmful than outdoors. Underwater explosions do much more damage to the ear than in air.
Hearing loss often begins at high frequencies. There is almost always a ringing and humming complaint called tinnitus.
If there is ringing, humming, it can be noticed more easily. Especially in noisy environments, not understanding what people are saying may be the beginning of high frequency hearing loss and hearing tests should be done.
If the infection in the middle ear cavity continues for more than 3 months, it is called chronic otitis media.
Chronic ear infections and perforation of the eardrum are generally examined in 3 main sections.
- dry ears with a hole in the eardrum
- runny ears with a hole in the eardrum
- ears with cholesteatoma
Barotrauma is a condition caused by pressure differences between the inner and outer parts of the eardrum. The air pressure inside the middle ear is generally the same as the air pressure outside the body. Eustachian tube; The middle ear is the connection between the nose and the upper part of the throat.
Swallowing or yawning opens the Eustachian tube and keeps air pressure equal on both sides of the eardrum, allowing air to flow in and out of the middle ear. If the Eustachian tube is blocked, the air pressure in the middle ear and the pressure outside the eardrum will be different, resulting in ear congestion.
What are the causes of barotrauma?
Many people may experience barotrauma from time to time. ear congestion; occurs in situations that cause altitude changes, such as flying, diving, or mountain driving. If you have a stuffy nose due to allergies, a cold, or an upper respiratory tract infection, ear congestion is more likely to occur.
Obstruction of the Eustachian tube may also be present before birth (congenital). The obstruction can also occur due to swelling in the throat.
What are the symptoms of barotrauma?
- Discomfort or pain in one or both ears
- Hearing loss (mild)
- A feeling of fullness or stuffiness in the ears
- If the barotrauma is severe or prolonged:
- Sensation of pressure in the ears (as if under water)
- Moderate to severe hearing loss
- Nose bleeding
What is the course of the disease?
Barotrauma is a disease that is usually not malignant and can be cured without consulting a doctor. Hearing loss caused by discomfort is also temporary.
- Possible complications are;
- Acute ear infection,
- Hearing loss,
- Ruptured or perforated eardrum,
- It is vertigo.
In which cases should a doctor be consulted?
When you experience ear congestion, try to relieve the discomfort first with the techniques mentioned. If the problem still persists and especially if you have the following symptoms, contact a healthcare provider:
- Drainage or bleeding in the ear
- Severe ear pain
How is barotrauma treated?
To relieve ear pain or discomfort, the Eustachian tube should be opened first and the pressure should be relieved. For this, the person can chew gum; inhale and exhale by closing the nostrils and mouth; He can eat sugar, he can yawn.
While on the plane, you should not sleep during landing. Infants and children should be given fluids during descent.
Divers must be careful when descending and ascending in the water. Diving with allergies or a respiratory infection can be dangerous. If your condition does not improve with your own efforts within a few hours, or if the trauma is severe, medical attention may be required.
The following drugs can be recommended for treatment:
- Antihistamines: Oral or nasal spray decongestants (If you are planning to dive, consult your doctor before using decongestants.)
- Steroids: These drugs can be effective in relieving nasal congestion and opening the Eustachian tube. If the trauma is severe, antibiotics may be used to prevent ear infections.
- Surgery: If the Eustachian tube does not open with these interventions, surgical intervention may be required. With an incision in the eardrum, the pressure is taken out by making it equal and flowing (Myringotomy). However, there is not much need for surgical intervention in the treatment of barotrauma. If you are exposed to frequent altitude changes or are prone to barotrauma, you can have ear tube surgery.
Acoustic Neurinoma (Tumor of the Auditory Pathways)
What is an acoustic neuroma?
It is the name given to a benign tumor that forms on the hearing-balance nerve between the inner ear and the brain. The balance nerve coming out of the balance section called the semicircular canals in the inner ear and the auditory nerve coming out of the hearing section called the cochlea go from the inner ear to the brain together with the nerve that provides the movement of the face. It is a benign tumor that occurs in this area where these three nerves pass together to the brain. It grows very slowly, so it may take years before symptoms become obvious.
The first complaint to appear is usually tinnitus. As the tumor grows, the hearing part of the nerve is also affected and hearing loss occurs. Dizziness is not usually seen, but there may be a feeling of imbalance.
Acoustic neuroma diagnosis
Hearing tests, balance tests, computed tomography or magnetic resonance imaging are performed.
Acoustic Neuroma treatment
If the tumor is above a certain size, it is surgically removed. Many different methods have been defined in terms of both the entry site and the technique of the surgery. The most important problem in surgery is that it carries risks such as facial paralysis and hearing loss.
Most Common Balance Disorders Associated With Vertigo
Benign Paroxysmal Positional Vertigo (BPPV)
It is the most common ear-related cause of vertigo. Although it can be seen at any age, it is most commonly observed in adults. It is observed 2-3 times more in women than in men. Patients complain of short-term attacks of dizziness, which can be severe, triggered by angular movements of the head. The treatment of BPPV is carried out by determining which channel it affects with diagnostic tests and with the appropriate treatment maneuver for the affected channel. Maneuvers are the most commonly used forms of therapy. Other treatment options are; balance physical therapy exercises (vestibular rehabilitation) and pharmacotherapy.
Meniere’s disease also known as endolymphatic hydrops( high pressure in middle ear fluid) is an other common cause of vertigo. For diagnosis of Menieres disease there must be 2 or more spontaneous episodes of dizziness lasting 20 minutes – 12 hours. Audiologically, low and medium-frequency sensorineural hearing loss may be observed in the affected ear before or during at least one of the attacks. In addition, a feeling of fullness, pressure and tinnitus are seen in the affected ear. It is treated medically.
It is an inflammation of vestibular nerve thought to be caused by viruses, that starts suddenly, lasts for days (1-7 days), it is accompanied by severe dizziness, nausea, vomiting with no hearing loss . It is the third most common type of peripheral vertigo after BPPV and Meniere’s disease. It is most common between the ages of 35-50. In the treatment of vestibular neuronitis, vestibular rehabilitation following a short term medical therapy should be applied.
It is a disease that causes vertigo, accompanied by occasional headaches that occur in periodic attacks similar to normal migraine. There are also features such as seeing various shapes, bright spots or flashes of light, intensification of pain accompanied by increased physical activity and triggered by consumption of coffee, chocolate, milk and dairy products.
VNG Tests Are Used in The Evaluation of Balance Disorders
VNG tests: It is a set of tests that evaluate balance organs, brain and cerebellum functions by measuring eye and head movements by wearing glasses with a camera with a computer system to the eye with a special device.
It is important in terms of determining the lesion side and location in all patients presenting with dizziness (vertigo), feeling of imbalance (dizziness), feeling of drowsiness (unsteadiness) or ataxia.
VNG TESTS CONSIST OF THESE SUB-HEADINGS
GAZE TESTS: It is performed to determine the presence of eye beats (nystagmus) during visual stimuli.
SKEW DEVIATION TEST: It is used to differantiate between peripheric and central pathology
HEAD SHAKING: The test performed by closing the test glasses (goggle) on the patient’s eyes and shaking the patient’s head to the right and left at the same speed. the test is done by an audiologist. The clinician asks the patient to stop the nodding and not close their eyes. The resulting eye beats (nystagmus) help us in the diagnosis of patients with peripheral vestibular dysfunction.
SPONTANEOUS NISTAGMUS TEST: It is one of the important signs of vestibular dysfunction. In this test, the patient’s eyes are closed. Spontaneous blinks are measured in the dark without any visual stimuli.
SACCADE TEST: It is used to show the adaptation of the Central Nervous System to rapid eye movements.
VORS AND VORS TESTS. They are both used to differantiate between peripheric and central pathology
VNG tests specifically answer the question of whether the disease originates from the inner ear or the central nervous system (cerebellum).
V-HIT TEST: It is a test that evaluates each of the 6 semicircular canals in the inner ear balance organ and the associated vestibulo-ocular reflex (VOR). In case of weakness in any channel, it shows us this and guides us to the correct diagnosis and treatment.
Vestibular Rehabilitation (Balance Physical Therapy)
Vestibular rehabilitation; is a simple, low-cost solution used to improve balance control and quality of life in patients with weakness in the vestibular organs (vestibular neuronitis, vestibular migraine, etc.), to support visual stabilization with head movements, to improve vestibular-visual interaction during head movement, and to expand static and dynamic posture stability. It is an effective treatment method. Treatment is usually 10-14 sessions 3 times a week every other day. A patient-specific program is created and includes exercises that are completely suitable for the patient’s condition.
Vestibular Rehabilitation is used in patients with,
** Dizziness and balance disorders due to inner ear damage, that is, balance organ damage (Meniere’s disease, vestibular neuronitis, labyrinthitis, etc.)
**For vestibular migraine patients
** For patients with crystal play that does not improve despite maneuvers
** Patients with unexplained imbalance complaints
** Age related imbalance problem
** Imbalance problem that develops after brain surgeries
**Applied to patients with phobic vestibular vertigo.
The goals of vestibular rehabilitation are:
- Reducing the patient’s symptoms
- Improving gaze stabilization and correcting vision with head movements
- Improving balance during walking and standing
- Reducing the risk of falling, increasing safety in walking and activities of daily living
- Increasing mobility and general fitness
- Reduce anxiety
- Reducing activity restrictions
- Prevent social isolation