Management of Deafness in the Elderly Mrs R Kayarkar Consultant ENT Surgeon Mid Yorks NHS Trust British Geriatric Society Meeting 18.9.2013
Effects of hearing loss Embarrassment, loss of confidence, anger and resentment are among the most common feelings they have to deal with everyday. Noisy groups and strangers are avoided and there is a growing preference to remain at home rather than to go out, which in many cases leads to inactivity, depression and isolation. A persistent denial of the new situation springs from a view of it as illegitimate, something to be ashamed of and hidden; hence, in great part, a dislike for or rejection of hearing aids. Deafness in the elderly can bring about additional difficulties, such as the inability to insert the earmould. Age related hearing loss means both an adaptation to the hearing loss and to old age.
Anatomy
External Canal Acoustic Head shadow effect & reflections 2kHz 6dB gain Pinna flange resonance: at 3-5kHz 10dB gain. Concha resonance: at 5kHz. 3dB gain Total gain 15-20dB Absent or removal of pinna will cause localisation difficulty Ear canal resonance: at 4kHz. 10-15dB gain 4mm. critical diameter - no loss. 3mm. diameter - 14dB loss. 2mm. diameter - 21dB loss. Total occlusion - 54dB maximum loss
Physiological acoustics TM & ME transformer mechanism (gains) Effective areal ratio: TM / Footplate: 55/3.2=17.1, 26.5dB gain. Lever effect: LP malleus / LP incus: 1.3:1, 7.3dB gain. Phase difference: 16.2dB gain. Total gain 50dB in normal hearing or max. loss in ME pathology. TM Perf: 15% 16dB, 40% 22dB. 65% 26.9dB, 85% 28.7dB. Central perf. causes more HL than peripheral. Small perf. affect low Hz., large affect all Hz.. Maximum loss from TM up to 30dB. Clinical implications are in ME reconstruction surgery
Cochlear Physiology Hydrodynamics of Perilymph fluid & BM motion
BM motion Helmholtz s & Bekesey s theories BM motion according to Von Helmholtz- Piano theory BM motion according to Von Bekesey Travelling wave theory
Types of deafness Conductive Sensory neural Mixed
Conductive deafness Impacted wax Infection- Chronic - Acute Ossicular fixation,discontinuity Tumours Nasopharyngeal Carcinoma -- Glomus Tympanicum
Wax
Cholesteatoma
Nasopharyngeal tumour Unilateral conductive loss Unilateral otitis media with effusion
Sensory neural Presbyacusis Infections Trauma Ototoxic drugs Tumours Endocrine Systemic diseases
Presbyacusis Most common cause Atrophy of stria vascularis Degeneration of hair cells Degeneration of nerve fibres Stiffening of basilar membrane
Infection & Inflammation Pain Discharge Labyrinthitis Meningitis Granulomatous diseases- TB, Syphilis, Wegners Immunological diseases-temporal arteritis - relapsing polychondritis
Trauma Noise Physical Iatrogenic
Ototoxic drugs Aminoglycosides Gentamycin - Streptomycin - Vancomicin Diuretics - Furosemide -Ethacrynic acid NSAIDS & Salicylates Aspirin B blockers H2 Antagonists cimetidine Proton pump inhibitors Omeprazole Quinine Anticonvulsants - Phenytoin
Tumours Acoustic neuroma Carcinoma
Endocrine Diabetes Hypothyroidism Hyperparathyroidism Liver disease
Systemic diseases Paget s disease Osteomalacia
Conductive -Wax - OME Sensory neural -Ototoxic drugs - Neurological - Endocrine - Vascular - Autoimmune Sudden hearing loss
Investigations Audiogram Tympanogram
CT Scan Chronic infections Tumours
MRI Sensory neural
Management Hearing aids Surgical intervention
Antony Walker Chief Audiologist and Clinical Site Lead - Audiology
Degrees of hearing loss (normal)
Degrees of hearing loss (mild)
Degrees of hearing loss (moderate)
Degrees of hearing loss (severe)
Degrees of hearing loss (profound)
Conductive hearing loss L ear, normal hearing R ear
Tympanometry Normal shape (peaked) tympanogram Abnormal trace (no peak) tympanogram
Types of hearing aids Behind the ear Hearing Aid with earmould.
Cont:- Behind the ear Hearing Aid with slim tube (mild to moderate losses only, good manual dexterity needed).
Cont:- CIC Hearing Aid In-the-ear Hearing Aid
Communicators
Problems With Hearing Aids Feedback Recruitment Difficulty in insertion of mould Otitis externa
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