Case 3
A 65-year-old woman, Mrs. Edna West, is concerned about her hearing and has made an appointment to see you. Lately, she finds herself ask- ing her husband to repeat things because she does not hear him well the first time he says them. Two days ago she went to the movies and had trouble hearing the dialogue.
Vital Signs:
Temperature Blood pressure Heart rate Respiratory rate
Examinee’s Tasks
98.6°F
120/80 mmHg
84 beats per minute 14 breaths per minute
SP CHECKLIST FOR MRS. WEST
History of Present Illness. The Examinee:
asked about the onset of the hearing loss (“It started gradually 6 months ago.”)
asked if one ear or both ears were affected (“It seems to be only the left ear.”)
asked if hearing loss was complete or partial in the affected ear (“Oh, I do hear something but not much.”) asked about a history of vertigo (“No.”)
asked about a history of tinnitus (“No.”)
asked about ear discharge (“None.”)
asked about ear pain (“None.”)
asked about any history of trauma to the ear (“No.”)
asked about exposure to loud noises for extended periods of time, i.e., in the armed forces or due to occupation (“No; I was never in the armed forces and I work as a seamstress.”)
asked about any ear infections (“None.”)
asked about the use of any medications that may be ototoxic, i.e., diuretics, antibiotics (“None.”)
asked about a family history of hearing loss (“Yes, my mother wears hearing aids.”)
Physical Examination. The Examinee:
___13. tested my hearing by covering each ear separately and whispering or rubbing fingers or by watch ticking (SP cannot hear in left ear).
___14 looked into both ears properly with otoscope (normal examination).
___15. performed the Weber test properly (SP will state that the stimulus is perceived on the right side).
___16. performed the Rinne test properly (SP will state that both air and bone conduction are decreased in left ear but air conduction is still greater than bone conduction).
Communication Skills. The Examinee:
___17. discussed the diagnostic possibilities for hearing loss with me (i.e., normal aging, noise exposure, previous infection).
___18. gently informed me that I needed a full audiologic evaluation.
___19. offered to schedule the audiology appointment for me.
___20. stated that I would benefit from an amplification device (hearing aid).
___21. did not cause me discomfort when examining me with the otoscope.
___22. was empathetic toward me.
___23. addressed my concerns about looking old with a hearing amplification device.
A SATISFACTORY PATIENT NOTE
HISTORY—Include significant positives and negatives from the history of present illness, past medical history, review of systems, and social and family history.
Mrs. West is a 65-year-old seamstress who presents with a partial left-sided hearing loss that has progressively worsened over the last 6 months. She is having difficulty hearing her husband when he speaks to her and recently could not hear the dialogue at the movie theater. She denies tinnitus, vertigo, ear pain, or discharge. She did not suffer from ear infections as a child. She has never been exposed to loud noises and denies any history of trauma to the ear. She has never taken any medications that may have contributed to her hearing loss. She does not smoke or drink and eats a healthy diet. She tries to exercise regularly by taking long walks at least three times a week. Her family history is significant for hearing loss in her mother, who wears hearing aids.
PHYSICAL EXAMINATION—Indicate only the pertinent positive and nega- tive findings related to the patient’s chief complaint.
Patient appears anxious over hearing loss but is otherwise in NAD. Vital signs are normal. Patient cannot perceive spoken voice in left ear. HEENT: Left ear examination reveals no cerumen or foreign body. Tympanic membrane is normal. No perforation or sclerosis is evident. Cannot hear whisper or rubbed fingers when left ear is checked. Right ear is normal.
Weber test: Lateralizes to the right side.
Rinne test: Air and bone conduction are decreased in left ear but air conduction remains greater than bone conduction.
Heart, lungs, and abdomen: Normal.
DIFFERENTIAL DIAGNOSIS
In order of likelihood, write no more than five differential diag- noses for this patient’s current problems.
sensorineural hearing loss
presbycusis
familial hearing loss
4.
5.
DIAGNOSTIC WORKUP
Immediate plans for no more than five diagnostic studies.
1. audiometry 2.
3.
4.
5.
CASE 3
LEARNING OBJECTIVE FOR MRS. WEST
THE PROPER ASSESSMENT OF HEARING LOSS
Approximately 50 percent of people over 65 years of age are hearing- impaired. A loss of hearing can occur from lesions in the external audi- tory canal or middle ear, causing a conductive hearing loss. Examples of conductive hearing loss include impaction due to cerumen, otitis externa, foreign body in the external canal, and tympanic membrane perforation.
Lesions of the inner ear or eighth cranial nerve cause a sensori- neural hearing loss. When sensory hearing loss is suspected, the examinee must inquire about a history of infection, intense exposure to noise, and use of ototoxic drugs. Aging (presbycusis) may also cause sensory hearing loss. Neural hearing loss is due mainly to trauma, vascular events, an infectious process, and tumors such as acoustic neuroma.
The Rinne and Weber tuning fork tests are used to differentiate between conductive and sensorineural hearing losses. In conductive hearing loss, the Weber test lateralizes and the tone is perceived in the affected ear. The Weber test in a patient with a sensorineural hearing loss, as in the case of Mrs. West, results in the tone being perceived in the unaffected ear.
The Rinne test further helps to differentiate between a conductive and a sensorineural hearing loss. In conductive hearing loss, bone- conduction stimuli are perceived to be louder than air-conduction stimuli, while in sensorineural hearing loss, both air and bone con- duction are diminished but air-conduction stimuli remain greater.
Mrs. West complains of gradual deterioration of her hearing. She has no vertigo or tinnitus, which are seen with tumors such as acoustic neuroma. Her otoscopic examination was unremarkable. She has no obvious risk factors to explain the hearing loss, such as trauma, noise exposure, infections, or medication use. She does, however, have a family history of hearing loss and a preexisting congenital abnormal- ity may explain her recent deficit.
The Weber and Rinne examinations confirm a sensorineural hear- ing loss in this patient. An audioscope, if available, would have been the best instrument for accurately assessing the patient’s hearing loss. The patient would benefit from a full audiologic evaluation followed by the fitting of an amplification device.
Physical Examination Pearl: Check for hearing loss by turning your face away from the patient and speaking. Practice the Rinne and Weber tests described above.
Patient Note Pearl: In adults, the differential diagnosis for conductive hearing loss includes cerumen impaction, otitis externa, foreign body in the external canal, and tympanic membrane perforation. The dif- ferential diagnosis for sensory hearing loss includes aging, infection, noise exposure, and medication use. The differential diagnosis for neural hearing loss includes infection, trauma, a vascular event, and tumor. You should review the differential diagnosis for hearing loss in children.
Sensorineural hearing loss may be: congenital
TORCH (toxoplasmosis, rubella, cytomegalovirus, herpesvirus) infections
chromosomal abnormalities (trisomy 18, 21)
syndromes (Alport’s, Usher’s)
anatomic (aplasia of the cochlea)
acquired
bacterial infections (meningitis, otitis)
viral infections (mumps, cytomegalovirus, herpesvirus, rubeola) vascular insufficiency (sickle cell disease, diabetes)
trauma (noise, temporal bone fracture)
tumor (leukemia, acoustic neuroma, neurofibromatosis) autoimmune, hypothyroidism, hypoparathyroidism
Conductive hearing loss may be due to:
impacted cerumen, a foreign body, or otitis with effusion