Assessment of

Deafness
Dr. AJAY MANICKAM
JR – DEPT OF ENT
RG KAR MEDICAL COLLEGE
History taking
• Name
• Age Age group Disease
• Sex Infancy to adulthood COM causes CHL
6months – 6 years Recurrent AOM
School going children OME causes CHL
10 – 40 years Otosclerosis (CHL)

Male Female
Meniere’s disease Otosclerosis
Acoustic neuroma Glomus tumours
In india otosclerosis more Acoustic neuroma
common in males
History taking
•Name
•Age
•Sex
•Occupation – Persons
/Professionals exposed to
noise trauma
History of presenting illness
•Hard of hearing / deafness
•Tinnitus
•Ear ache
•Ear discharge
Hard of hearing

• Present history of deafness

1. Onset of deafness – congenital /
acquired
2. Duration of deafness
3. Severity of deafness –
mild/moderate/mod
severe/profound - found only in
audiometry
4. Progression of deafness
Present history contd….
• Hearing impairment
• Onset
Sudden – impacted wax, vascular/viral, acoustic trauma
Gradual – presbycusis,CSOM, acoustic neuroma, otosclerosis,
NIHL
Unilateral - COM, mumps, Herpes zoster oticus, acoustic
neuroma
Bilateral – presbycusis, meniere’s disease, otosclerosis, NIHL
Progressive – meniere’s disease,presbycusis, otosclerosis,
acoustic neuroma. tympanosclerosis
Fluctuating – meniere’ disease, perilymph leak
Hearing impairment
• Autophony – hearing ones voice
louder
• Paracusis willsi - hearing better in
noisy place
• Diplaucusis – difference in pitch of ear
in meniere.s disease
Otalgia
• Onset
• Duration
• Nature
• Aggravating factors / relieving
factors
Otalgia – ear ache
• Pain in ear can be local or referred

• Onset
Sudden - AOM, furunculosis, otitic barotrauma
Gradual – OE secondary to COM, malignancy, malignant OE
• Duration
Short – AOM, perichondritis pinna
Long – malignancy
• Nature of pain
Dull – eczematous OE, secretory OE, wax
Sharp – furunculosis, otitic barotrauma
Throbbing – AOM
• Aggravating factors
with swallowing – AOM
With yawning furunculosis . On pulling pinna – OE
• Relieving factors – relieves on discharge from ear - AOM
Referred otalgia
• Referred pain via 5th nerve
Dental – caries, impacted molar, malocclusion
Oral cavity – benign / malignant ulceration
TM joint disorders – costen syndrome, arthritis
• Referred pain via 9th nerve
BOT malignancy, acute tonsillitis, peritonsillar abscess,
ulcers of soft palate, elongated styloid process (Eagle’s
syndrome)
• Referred pain via 10th nerve
Ulcerative lesions of vallecula, epiglottis, larynx,
laryngopharnx
• Referred pain via C2,3
cervical spondylosis, caries spine
Ear discharge
• Onset
• Duration
• Type
• Consistency
• Odour
• Quantity
• Associated conditions
Ear discharge - otorrhoea
• Onset
Sudden – AOM, otomycosis, OE
Gradual – COM
• Duration
Long COM, Eczematous OE
Short –AOM, ruptured furunculosis
Intermittent – tubotympanic COM
• Type
Watery – CSF otorrhoea, OE
Serosanguinous – fungal, diffuse OE
Mucopurulent – COM tubotympanic, tuberculous COM
Mucoidal – COM tubotympanic, granular myringitis, fungal
Purulent – furunculosis, mastoiditis, malignant OE, unsafe COM
Blood stained – COM with granulation, glomus tumour, malignant
OE
Ear dischage contd…
• Consistency of discharge
viscous & tenacious in tubotympanic variety of COM
• Odour
Odourless – allergic OE, COM safe type
Foul smelling – unsafe COM
• Quantity
Profuse – tubotympanic COM
Scanty – unsafe COM
• Associated conditions
Discharge increases with cold, head bath, pharyngitis,
tonsillitis, adenoiditis seen in tubotympanic variety of
COM
Past history
•H/O ototoxic medications
•H/O trauma or head injury
•H/O viral infection (Ramsay
Hunt syndrome)
•H/O ear surgery
Personal history
•Hypertension
•Smoking & alcohol
•Diabetes
•Family history of deafness
Examination of the EAR
• Examination of external
ear - pinna – inspection &
palpation of pinna, pre &
post auricular region .
Look for deformity,
thickening, preauricular
sinus, scar mark,
tenderness
• Tenderness over tragus /
tenderness over mastoid
Examination
• Examination of EAC –
look for wax,
stenosis, deformity,
mass, sagging of post
wall of meatus
Examination of the TM
• Colour, position, mobility,
changes in surface.
• Perforation if present-
shape of the perforation,
ant inf, post sup quadrant
• Discharge present / not
• Margins of perforation
regular / irregular.
• Part of ME mucosa seen
through perforation –
edematous / congested/
healthy
Neuro otological examination
• To rule out symptoms like
• Fever
• Headache
• Stiffness of neck
• Facial palsy
• Vomiting
• Diplopia
• Cervicofacial pain
Investigations
•Complete hemogram
•Biochemical reports
•Thyroid function test
Audiological
• Tuning fork test – Rinne , Weber,
Absolute bone conduction test
• PTA
• Tympanometry
• Speech audiometry
• BERA
• OAE
Tuning fork test
• Rinne
• Weber
• ABC
Pure Tone Audiometry
• Measurement of
hearing acuity by
using pure tones to
estimate the air
conduction & bone
conduction
thresholds of
hearing for various
frequencies
PTA
• Gives a graphical
representation of different
hearing loss both quantity &
quality can be studied
• Normal hearing (0-25dB)
• Mild hearing loss (26-40dB)
• Moderate hearing loss (41-
55dB)
• Moderately severe (56-70dB)
• Severe hearing loss (71-90db)
• Profound hearing loss (>90dB)
Tympanometry
• Main objective audiometric test
• Three factors impede the flow of
sound
1. Stiffness of the TM
2. Mass provided by the ossicles
3. Friction or resistance by ligaments
in the ME
• 2 apparatus
Apparatus 1 – ear probe containing 3
tubes
I. Tube for delivering tone
II. Microphone to pick up energy
III. Manometer to change pressure
Apparatus 2 – in the opposite ear used
to measure acoustic reflex
Tympanometry
• Jerger described 5 types of tympanograms
BERA
• Measurement of tiny physiological
electric events occuring in response to
sound stimulation are assessed by this
audiometry
• BERA – Brain Stem Evoked Response
Audiogram
• Sound waves entering cochlea
transmitted through VIII nerve to
brain stem, these electrical responses
are picked up by surface electrodes
and represented graphically
• Wave 1 – Eighth nerve
• Wave 2 – Cochlear nuclei
• Wave 3 - superior Olivary nuclei
• Wave 4 – Lateral lemniscus
• Wave 5 – Inferior colliculus (E COLI)
Vestibular functions test
•Romberg’s test
•Sharpened Romberg’s test
•Heal – toe walking test
•Unterberger test
•Caloric test
Romberg’s test
• Patient asked to stand
with feet together and
arms by the sidewith eyes
open first and then eyes
closed
• In peripheral system
lesion patient sways to
the side of the lesion but
in central lesion patient
shows instability
Sharpened Romberg’s test
• If Romberg’s test is
normal, the patient is
asked to stand with
one heel of one foot in
front of the toes of the
other arm folded
across chest.
• Inability to perform
indicates peripheral
system impairment
Gait test
•The patient is asked to walk
along a straight line to a fixed
target with eyes opened and
then eyes closed.
•In case of peripheral lesion
patient deviates to the
affected side
Unterberger test
• Patient asked to stand
hands outstretched
and closed eyes
• He will be asked to
march on the spot
inside a circle
• Patient having
unilateral vestibular
lesion will deviate
towards that side
Caloric test
• Patient will be in a couch with head end
elevated 45 degrees and each ear will be
irrigated with hot and cold water to
stimulate vestibular labyrinth
• Hot water 44 degree causes nystagmus
with quick component to the simulated
side
• Cold water 30 degree produces
nystagmus in the opposite direction
• Normal duration of nystagmus is 3-4
minutes
• CANAL PARESIS – nystagmus is reduced.
If no nystagmus that indicates a dead
labyrinth
Radiological investigations
• X-Ray mastoids
bilateral lateral
oblique view
• HRCT temporal
bone
• MRI brain
Diagnosis
History & complaint Disease Investigations
Ear ache, itching, Wax/ otomycosis Otoscopy , CHL
decreased hearing
Ear ache & bleeding FB living/dead Otoscopy, EUM – CHL
Severe tenderness Furuncle Otoscopy , CHL
Otorrhoea COM, AOM Otoscopy, EUM
PTA, C/S of pus, CT scan,
Tinnitus & vertigo BPPV, SNHL, ENG, PTA,
Labyrinthitis, Meniere’s Tympanometry, ECoG,
disease, acoustic Caloric test, MRI
neuroma, otosclerosis
Tragal tenderness OE Clinical examination
Syndromes
• Waardenburg’s syndrome – widest eyes, white forelock,
progressive hearing loss
• Alport’s syndrome – deafness & kidney disease
• Crouzon’s syndrome – craniofacial dysostosis
• Apert’s syndrome – syndactyly + crouzon syndrome
• Vander Hoeve’s syndrome – osteogenesis imperfecta, blue
sclera, hearing loss
• Stickler’s syndrome – small jaw, cleft palate, myopia, cataract,
SNHL
• Down’s symdrome
• Goldenhar’s syndrome – oculo-auriculo-vertebral syndrome
THANK YOU