Hearing Loss in Adults: Differential Diagnosis and Treatment
Am Fam Physician. 2019 Jul 15;100(2):98-108.
Author disclosure: No relevant financial affiliations.
More than 30 million U.S. adults have hearing loss. This condition is underrecognized, and hearing aids and other hearing enhancement technologies are underused. Hearing loss is categorized as conductive, sensorineural, or mixed. Age-related sensorineural hearing loss (i.e., presbycusis) is the most common type in adults. Several approaches can be used to screen for hearing loss, but the benefits of screening are uncertain. Patients may present with self-recognized hearing loss, or family members may observe behaviors (e.g., difficulty understanding conversations, increasing television volume) that suggest hearing loss. Patients with suspected hearing loss should undergo in-office hearing tests such as the whispered voice test or audiometry. Patients should then undergo examination for cerumen impaction, exostoses, and other abnormalities of the external canal and tympanic membrane, in addition to a neurologic examination. Sudden sensorineural hearing loss (loss of 30 dB or more within 72 hours) requires prompt otolaryngology referral. Laboratory evaluation is not indicated unless systemic illness is suspected. Computed tomography or magnetic resonance imaging is indicated in patients with asymmetrical hearing loss or sudden sensorineural hearing loss, and when ossicular chain damage is suspected. Treating cerumen impaction with irrigation or curettage is potentially curative. Other aspects of treatment include auditory rehabilitation, education, and eliminating or reducing use of ototoxic medications. Patients with sensorineural hearing loss should be referred to an audiologist for consideration of hearing aids. Patients with conductive hearing loss or sensorineural loss that does not improve with hearing aids should be referred to an otolaryngologist. Cochlear implants can be helpful for those with refractory or severe hearing loss.
More than 30 million U.S. adults, or nearly 15% of all Americans, have some degree of hearing loss.1 It is most common in older adults, occurring in about one-half of adults in their 70s and 80% of those 85 years and older.1,2 Despite this high prevalence, hearing loss is underdetected and undertreated. Only about one-third of people with self-reported hearing loss have ever had their hearing tested, and only 15% of people eligible for hearing aids consistently use them, citing factors such as cost, difficulty using them, and social stigma.1,3,4
WHAT IS NEW ON THIS TOPIC
The FDA Reauthorization Act of 2017 allows direct-to-consumer sale of hearing aids for mild to moderate hearing loss, for which limited outcome studies show improved hearing, communication, and social engagement. The cost of over-the-counter hearing aids is expected to range from approximately $200 to $1,000 compared with $800 to $4,000 for conventional hearing aids.
Among patients with dementia in a U.S. population-based longitudinal cohort study, the use of hearing aids was associated with decreased social isolation and a slower rate of cognitive decline, even after adjusting for multiple confounders.
SORT: KEY RECOMMENDATIONS FOR PRACTICE
|Clinical recommendation||Evidence rating||Comments|
The U.S. Preventive Services Task Force and the American Academy of Family Physicians conclude that the current evidence is insufficient to assess the balance of benefits and harms of screening for hearing loss in asymptomatic adults 50 years and older.22,28
Based on randomized controlled trials and observational studies with disease-oriented outcomes. The only good-quality randomized trial of hearing screening included many patients with baseline concerns about hearing loss; there was no improvement in hearing-related quality of life.
Based on expert opinion and clinical reviews
Based on a clinical practice guideline
Information on hearing aid use should be provided to patients. It should incorporate patient expectations, perceived self-benefit, satisfaction, readiness to accept change, and support from significant others.38,39
Systematic reviews on hearing aid use found only limited evidence for increased use of hearing aids when these factors are incorporated into the treatment plan.
Based on a low-quality study and expert opinion. Over-the-counter hearing aids are now approved by the U.S. Food and Drug Administration for mild to moderate hearing loss, but the American Speech-Language-Hearing Association recommends these devices only for patients with mild hearing loss.
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence;
The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the U.S. Army Medical Department or the U.S. Army Service at large.
Referencesshow all references
1. Mahboubi H, Lin HW, Bhattacharyya N. Prevalence, characteristics, and treatment patterns of hearing difficulty in the United States. JAMA Otolaryngol Head Neck Surg. 2017;144:65–70....
2. Lin FR, Thorpe R, Gordon-Salant S, et al. Hearing loss prevalence and risk factors among older adults in the United States. J Gerontol A Biol Sci Med Sci. 2011;66(5):582–590.
3. Centers for Disease Control and Prevention; National Center for Health Statistics. National Health and Nutrition Examination Survey: NHANES 2015–2016 questionnaire data. Accessed September 3, 2018. https://wwwn.cdc.gov/nchs/nhanes/ContinuousNhanes/Default.aspx?BeginYear=2015
4. Chien W, Lin FR. Prevalence of hearing aid use among older adults in the United States. Arch Intern Med. 2012;172(3):292–293.
5. Li CM, Zhang X, Hoffman HJ, et al. Hearing impairment associated with depression in US adults, National Health and Nutrition Examination Survey 2005–2010. JAMA Otolaryngol Head Neck Surg. 2014;140(4):293–302.
6. Zheng Y, Fan S, Liao W, et al. Hearing impairment and risk of Alzheimer's disease: a meta-analysis of prospective cohort studies. Neurol Sci. 2017;38(2):233–239.
7. Jiam NT, Li C, Agrawal Y. Hearing loss and falls: a systematic review and meta-analysis. Laryngoscope. 2016;126(11):2587–2596.
8. Huddle MG, Goman AM, Kernizan FC, et al. The economic impact of adult hearing loss: a systematic review. JAMA Otolaryngol Head Neck Surg. 2017;143(10):1040–1048.
9. Walling AD, Dickson GM. Hearing loss in older adults. Am Fam Physician. 2012;85(12):1150–1156.
10. Kerber KA, Baloh RW. Neuro-otology: diagnosis and management of neuro-otological disorders. In: Daroff RB, Jankovic J, Mazziotta JC, et al., eds. Bradley's Neurology in Clinical Practice. 7th ed. Elsevier; 2016:583–604.
11. Hall JW, Antonelli PJ. Assessment of peripheral and central auditory function. In: Johnson JT, Rosen CA, et al., eds. Bailey's Head and Neck Surgery: Otolaryngology. 5th ed. Lippincott Williams & Wilkins; 2014:2274–2290.
12. Uy J, Forciea MA. In the clinic. Hearing loss. Ann Intern Med. 2013;158(7):ITC4–ITC1.
13. Edmiston R, Mitchell C. Hearing loss in adults. BMJ. 2013;346:f2496.
14. McGee SR. Hearing. In: Evidence-Based Physical Diagnosis. 4th ed. Elsevier; 2018:195–202.
15. Simel DL, Bagai A, Thavendiranathan P, et al. Hearing impairment. In: Simel DL, Rennie D, Keitz SA, eds. The Rational Clinical Examination: Evidence-Based Clinical Diagnosis. McGraw-Hill; 2009.
16. Cunningham LL, Tucci DL. Hearing loss in adults. N Engl J Med. 2017;377(25):2465–2473.
17. Zahnert T. The differential diagnosis of hearing loss. Dtsch Arztebl Int. 2011;108(25):433–443.
18. Pacala JT, Yueh B. Hearing deficits in the older patient: “I didn't notice anything”. JAMA. 2012;307(11):1185–1194.
19. Clark JG. Uses and abuses of hearing loss classification. ASHA. 1981;23(7):493–500.
20. Centers for Disease Control and Prevention. National Health and Nutrition Examination Survey (NHANES) audiometry procedures manual. January 2016. Accessed November 12, 2018. https://wwwn.cdc.gov/nchs/data/nhanes/2015-2016/manuals/2016_Audiometry_Procedures_Manual.pdf
21. World Health Organization. Prevention of blindness and deafness: grades of hearing impairment. Accessed February 20, 2019. https://www.who.int/pbd/deafness/hearing_impairment_grades/en/#.WfOdhGPyUV4.email
22. U.S. Preventive Services Task Force. Hearing loss in older adults: screening. U.S. Preventive Services Task Force. August 2012. Accessed February 19, 2019. https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/hearing-loss-in-older-adults-screening
23. Chou R, Dana T, Bougatsos C, et al. Screening for hearing loss in adults ages 50 years and older: a review of the evidence for the U.S. Preventive Services Task Force. Evidence synthesis no. 83. Agency for Healthcare Research and Quality; 2011.
24. Shojaeemend H, Ayatollahi H. Automated audiometry: a review of the implementation and evaluation methods. Healthc Inform Res. 2018;24(4):263–275.
25. Saliba J, Al-Reefi M, Carriere JS, et al. Accuracy of mobile-based audiometry in the evaluation of hearing loss in quiet and noisy environments. Otolaryngol Head Neck Surg. 2017;156(4):706–711.
26. Barczik J, Serpanos YC. Accuracy of smartphone self-hearing test applications across frequencies and earphone styles in adults. Am J Audiol. 2018;27(4):570–580.
27. Yueh B, Collins MP, Souza PE, et al. Long-term effectiveness of screening for hearing loss: the Screening for Auditory Impairment—Which Hearing Assessment Test (SAI-WHAT) randomized trial. J Am Geriatr Soc. 2010;58(3):427–434.
28. American Academy of Family Physicians. Clinical preventive services recommendation: hearing. Accessed May 6, 2019. https://www.aafp.org/patient-care/clinical-recommendations/all/hearing.html
29. Joint Audiology Committee on Clinical Practice. Audiology clinical practice algorithms and statements. Accessed May 6, 2019. https://audiology-web.s3.amazonaws.com/migrated/ClinicalPracticeAlgorithms.pdf_53994824786af8.17185566.pdf
30. Hoth S, Baljić I. Current audiological diagnostics. GMS Curr Top Otorhinolaryngol Head Neck Surg. 2017;16:1–41.
31. Walker JJ, Cleveland LM, Davis JL, et al. Audiometry screening and interpretation. Am Fam Physician. 2013;87(1):41–47.
32. Saliba I, Martineau G, Chagnon M. Asymmetric hearing loss: rule 3,000 for screening vestibular schwannoma. Otol Neurotol. 2009;30(4):515–521.
33. Stachler RJ, Chandrasekhar SS, Archer SM, et al.; American Academy of Otolaryngology-Head and Neck Surgery. Clinical practice guideline: sudden hearing loss. Otolaryngol Head Neck Surg. 2012;146(3 suppl):S1–S35.
34. Wei BP, Stathopoulos D, O'Leary S. Steroids for idiopathic sudden sensorineural hearing loss. Cochrane Database Syst Rev. 2013;(7):CD003998.
35. Bennett MH, Kertesz T, Perleth M, et al. Hyperbaric oxygen for idiopathic sudden sensorineural hearing loss and tinnitus. Cochrane Database Syst Rev. 2012;(10):CD004739.
36. Schwartz SR, Magit AE, Rosenfeld RM, et al. Clinical practice guideline (update): earwax (cerumen impaction) [published correction appears in Otolaryngol Head Neck Surg. 2017;157(3):539]. Otolaryngol Head Neck Surg. 2017;156(1):14–29.
37. Michaud HN, Duchesne L. Aural rehabilitation for older adults with hearing loss: impacts on quality of life–a systematic review of randomized controlled trials. J Am Acad Audiol. 2017;28(7):596–609.
38. Ng JH, Loke AY. Determinants of hearing-aid adoption and use among the elderly: a systematic review. Int J Audiol. 2015;54(5):291–300.
39. Barker F, Mackenzie E, Elliott L, et al. Interventions to improve hearing aid use in adult auditory rehabilitation. Cochrane Database Syst Rev. 2016;(8):CD010342.
40. Ganesan P, Schmiedge J, Manchaiah V, et al. Ototoxicity: a challenge in diagnosis and treatment. J Audiol Otol. 2018;22(2):59–68.
41. Occupational Safety and Health Administration. Preventing hearing loss caused by chemical (ototoxicity) and noise exposure. Accessed February 19, 2019. https://www.cdc.gov/niosh/docs/2018-124/pdfs/2018-124.pdf?id=10.26616/NIOSHPUB2018124
42. National Institute on Deafness and Other Communication Disorders. Assistive devices for people with hearing, voice, speech, or language disorders. March 6, 2017. Accessed February 19, 2019. https://www.nidcd.nih.gov/health/assistive-devices-people-hearing-voice-speech-or-language-disorders
43. FDA Reauthorization Act of 2017, Pub L No. 115-52, 131 Stat 1005, §709 (2017).
44. Michaudet C, Malaty J. Cerumen impaction: diagnosis and management. Am Fam Physician. 2018;98(8):525–529.
45. Aaron K, Cooper TE, Warner L, et al. Ear drops for the removal of ear wax. Cochrane Database Syst Rev. 2018;(7):CD012171.
46. Khan KM, Bielko SL, McCullagh MC. Efficacy of hearing conservation education programs for youth and young adults: a systematic review. BMC Public Health. 2018;18(1):1286.
47. Eichwald J, Scinicariello F, Telfer JL, et al. Use of personal hearing protection devices at loud athletic or entertainment events among adults – United States, 2018. MMWR Morb Mortal Wkly Rep. 2018;67(41):1151–1155.
48. American Academy of Audiology position statement and clinical practice guidelines: ototoxicity monitoring. October 2009. Accessed February 24, 2019. https://audiology-web.s3.amazonaws.com/migrated/OtoMonGuidelines.pdf_539974c40999c1.58842217.pdf
49. Reed NS, Betz J, Kendig N, et al. Personal sound amplification products vs a conventional hearing aid for speech understanding in noise. JAMA. 2017;318(1):89–90.
50. Manchaiah V. Direct-to-consumer hearing devices for adults with hearing loss: definitions, summary of literature, and analysis of risks and benefits. Perspect ASHA Special Interest Groups. 2018;3(SIG 7):5–11.
51. Jilla AM, Johnson CE, Danhauer JL. Disruptive hearing technologies and mild sensorineural hearing loss I: accessibility and affordability issues. Semin Hear. 2018;39(2):135–145.
52. Brody L, Wu YH, Stangl E. A comparison of personal sound amplification products and hearing aids in ecologically relevant test environments. Am J Audiol. 2018;27(4):581–593.
53. Chisolm TH, Johnson CE, Danhauer JL, et al. A systematic review of health-related quality of life and hearing aids: final report of the American Academy of Audiology Task Force On the Health-Related Quality of Life Benefits of Amplification in Adults. J Am Acad Audiol. 2007;18(2):151–183.
54. Ferguson MA, Kitterick PT, Chong LY, et al. Hearing aids for mild to moderate hearing loss in adults. Cochrane Database Syst Rev. 2017;(9):CD012023.
55. Maharani A, Dawes P, Nazroo J, et al.; SENSE-Cog WP1 group. Longitudinal relationship between hearing aid use and cognitive function in older Americans. J Am Geriatr Soc. 2018;66(6):1130–1136.
56. Agency for Healthcare Research and Quality. Technology assessment: effectiveness of cochlear implants in adults with sensorineural hearing loss. June 17, 2011. Accessed February 19, 2019. https://www.cms.gov/Medicare/Coverage/DeterminationProcess/downloads/id80TA.pdf
57. Centers for Medicare and Medicaid Services. Cochlear implantation. December 13, 2018. Accessed February 19, 2019. https://www.cms.gov/Medicare/Coverage/Coverage-with-Evidence-Development/Cochlear-Implantation-.html
58. Hilly O, Hwang E, Smith L, et al. Cochlear implantation in elderly patients: stability of outcome over time. J Laryngol Otol. 2016;130(8):706–711.
59. Isaacson JE, Vora NM. Differential diagnosis and treatment of hearing loss. Am Fam Physician. 2003;68(6):1125–1132.
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