Age related sensorineural hearing loss (Presbyacusis)

Presbyacusis

Typical hearing profile showing high frequency hearing loss with age

 This is hearing loss associated with the ageing process. Unfortunately with the ageing process there is neuronal degeneration of the inner ear hair cells which convert the energy of sound vibration  into electric impulses. This type of hearing loss occurs at a variable time in a patient’s life and is probably genetically determined. The ageing process is evident usually in the sixth decade but can be earlier. It is only when it causes social or professional disability that a hearing aid needs to be considered. Often the hearing loss is symmetrical and therefore a hearing aid in both ears gives the best rehabilitation. A simple hearing test can identify this, showing hearing loss particularly in the high frequencies. This usually manifests as difficulty in hearing when there is background noise such as in a bar or at a party. Often the problem is not the volume of people speaking but the loss of clarity of what is being said.

Arthritis involving the Cervical Spine

The nerves which supply the ear originate from the neck area and any arthritic condition in the neck can give rise to compression of the nerves thereby mimicking ear pain. This usually occurs in the slightly older population with a history of neck ache and arthritis. Physiotherapy is the initial therapy with anti-inflammatories for pain control.

Barotrauma

The eustachian tubes connect the back of the nose to the middle ear and allow air to pass between these two structures so as to equalise pressure. Following a flight particularly when a virus has caused blockage of the eustachian tubes,  the sudden rise in pressure during descent can give rise to a build up of fluid in the middle ear. This can be associated with pain if the rate of descent is rapid. It is for this reason patients are advised to chew gum or suck sweets during flight descent. In the vast majority of cases this middle ear fluid build up resolves without any active treatment but can be facilitated by nasal decongestants and self inflating the middle ear by pinching the nose and by either blowing or swallowing.

In severe cases, there is such rapid sucking in of the ear drum that it can perforate which is associated with severe pain and bleeding. The perforation however heals completely in most patients.

Problems can similarly occur during diving.

Chronic otitis media

CSOM1

Chronic infection of middle ear with perforated ear drum

 If the acute episode fails to resolve completely then the symptoms can be prolonged and when these exist for more than  three months the term chronic otitis media is used. In rare occasions then there can be the patient’s own skin growing internally forming a ball of infected material (cholesteatoma). This can be associated with active infection and can slowly erode the little bones in the middle ear giving rise to hearing loss and is usually associated with smelly ear discharge. There can also be intermittent episodes of pain. Another type of chronic otitis media is when there is a long standing perforation in the ear drum and here there are episodes of ear pain associated with discharge but this condition rarely progresses to any serious condition unlike that associated with cholesteatoma. After control of infection, the middle ear components can be reconstructed surgically.

Dental causes

Any cause of dental disease such as abscess in the root of the tooth can cause referred earache particularly when affecting the upper molars. Treatment usually requires a visit to a  Dentist.

Ear Blockage / Ear Wax

The sensation of ear blockage can be due to either foreign body material in the outer ear canal or due to either the presence of fluid in the middle ear or obstruction of the eustachian tube.

A build of wax is by far the commonest cause which can be made worse if the patient uses cotton buds to try and clear the ears.

In rare instances, a feeling of fullness can be described as a blockage sensation which occurs in Meniere’s disease, usually associated with dizziness.

Ear Discharge

Ear Discharge

Ear discharge due to an outer ear infection

Any discharge from the ear should be a reason to visit your Doctor. The commonest causes are ear infection either due to the outer or middle ear causation and are usually associated with pain in the ear as well as the presence of a perforation of the ear drum depending on the exact cause. Copious clear discharge could be fluid arising from the brain compartment and is seen following severe head injury. It is occasionally a complication of ear or brain surgery. Management of this symptom is to determine the cause and to treat with medications which usually involves both oral and topical treatment. Removal of debris from the ear canal is important as this allows examination of the ear more thoroughly especially using a microscope. Hearing tests are also required in order to determine the possibility of hearing loss as a consequence of the infection.

In rare instances imaging of the ear is required with either CT or MRI particularly in the presence of the condition mentioned above called cholesteatoma. Cholesteatoma is a condition that invariably requires surgical management in order to prevent any deeper erosion into the middle ear or indeed into the brain compartment. It is not unusual for episodes of ear discharge to come and go and can be made worse for example after allowing water to get into the ear. Occasionally the ear discharge can be blood stained and this usually implies an acute infection of the ear and is often associated with a polyp formation.

Earache

Earache or Otalgia can be caused by a large range of conditions. Perhaps more common in children due to recurrent infections, this symptoms can be extremely debilitating and considered one of the worst types of pain to endure. Features of earache to discuss with your Doctor include, the rate of onset, severity, whether intermittent or constant, nature or type of pain such as a throbbing pain, preciptating and relieving factors, associated hearing loss, presence of vertigo, tinnitus, or discharge.

A detailed history oftens leads to a diagnosis but occasionally other diagnostic tests are required especially if referred earache is suspected.

Other causes for earache sinus infection, dental cause, scalp condition, referred pain from the jaw joint, and neck spine arthritis.

Hearing Loss

Ear Anatomy

Hearing loss can occur with conditions affecting the outer, middle and inner ear areas.

Hearing loss can either be congenital or acquired following birth. It can either be caused by problems of the outer ear, the middle ear or the inner ear. It can also be divided into the speed of onset of symptoms.

Injury to the ear

pinna hematoma

Collection of blood under the skin following trauma to the ear

The ear can be injured during sporting activity or road traffic accident. The mode of injury often relates to the extent of the injury. For example an injury to the back of the head can lead to fracture of the temporal bone which houses the delicate bone structures and can lead to hearing loss, injury to the facial nerve and dizziness. During certain sports such as rugby an outer ear injury can lead to bleeding under the skin (haematoma) which gives rise to a swollen ear. Such conditions need urgent drainage and bandaging. Recurrent or untreated haematoma can give rise to cauliflower ears often seen in sportsmen.

The ear has a rich blood supply so if small to medium parts of the ear are severed or bitten off they can be re-attached and the severed part often survives.

Intermediate Onset of Hearing Loss

  • Otitis externa/Otitis Media

  • Build up of wax

  • Glue Ear (Otitis Media with Effusion)

These conditions have been discussed before. Glue ear is a very common condition affecting young children and usually due to the presence of blockage of the eustachian tubes. Children have eustachian tubes which are narrower and more horizontal relative to adults. Also they invariably have large adenoids which are like tonsil like tissue sitting at the back of the nose between the opening of the eustachian tubes. The adenoid tissue is often teeming with infective agents such as  viruses or bacteria and the eustachian tubes get obstructed. This results initially in a negative pressure in the middle ear and thereafter a compensatory effusion of fluid which then causes hearing loss due to the inability of the ear drum to vibrate. In the vast majority of children this requires no treatment and is usually short lived. However if the condition lasts for over three months during the formative years it can have a detrimental effect on speech. There is also a higher chance of developing episodes of otitis media with pain, discharge and fever. Other symptoms can occur apart from hearing loss which includes poor speech development, unsteadiness and poor social integration. There appears to be increased risks of glue ear when the child’s parents smoke. Depending on the severity and duration of symptoms the patient may require grommet insertion with removal of adenoids.

Otitis Media

Acute infection – Usually following a virus infection symptoms progress to a feeling of ear blockage, hearing loss and then pain of variable degree. This can also be associated with general malaise and a fever. Episodes of acute otitis media are very common in young children occurring in 65% of children below the age of two. The highest incidence is in the six months to two years of age. In the vast majority of cases the infection normally resolves without any active treatment but supportive measures such as analgesia including Paracetamol to reduce temperature and nasal decongestants may be of value in curtailing the severity of symptoms. In more severe cases a build up of fluid occurs in the middle ear which is under pressure and causes the severe ear pain. This may eventually lead to a perforation of the ear drum and this results in visible ear discharge. Often the advent of an ear drum perforation results in a reduction of ear pain symptoms.

There are various possible complications arising from acute otitis media which can include quite serious conditions such as mastoiditis (inflammation of the area behind the ear), meningitis and abscess in the brain.

Outer Ear Infections

Perichondritis – This is inflammation of the skin and cartilage of the outer ear. It is often due to a bacterial infection following a fairly minor injury to the ear. The ear has a very red appearance and can often exude pus like material. The patient often has severe pain. The causative organism is pseudomonas and treatment should include drugs such as Ciprofloxacin. Occasionally cartilage can be lost as a result of the infection giving rise to deformity of the ear once the infection has settled.

perichondritis

 Furuncle – This is often due to infection in a hair follicle on the outer ear canal. It results in a small collection of pus under the skin and as there is close apposition of the skin overlying the ear cartilage it gives rise to intense pain. There can be associated hearing loss and discharge from the ear. Treatment involves lancing the mini abscess and treating with oral antibiotics. Sometimes the build up of debris in the outer ear needs to be cleared.

furuncle of ear

View of ear canal with swelling coming from the top due to the furuncle

Otitis Externa – The skin of the outer ear canal is quite unique in that the surface skin cells migrate from the deep ear canal towards the outside. This process is facilitated by the production of ear wax which helps to soften the dead skin cells. Any disturbance to this process such as excessive use of cotton buds, swimming or outer ear skin conditions such as eczema can give rise to a condition known as otitis externa. Here the first symptom is usually a sense of itchiness and thereafter there can be pain, discharge and hearing loss. Sometimes the pain can be so severe and the ear canal so swollen that treatment cannot be offered in the outpatient setting and the patient may need a general anaesthetic in order that the debris can be removed. The main stay treatment at this stage is to remove any debris in the ear canal, to instil antibiotic drops/ointment and to treat the patient with oral and topical antibiotics. Very occasionally a patient needs to be admitted for intravenous therapy. In early cases treatment with topical ear drops alone can be sufficient. In an ideal world a swab is taken from the ear to see what bacteria are growing and the medical treatment can then be targeted accurately.

Although the vast majority of infections are due to bacteria it is possible to get infections due to viruses (myringitis) and occasionally due to fungus infection such as Candida or aspergillus. In addition to removing debris anti fungal preparations are instilled into the ear canal.

Otitis Externa

View of ear canal showing infected debris which looks like wet blotting paper

Outer Ear Obstruction

The commonest cause for this is the build up of wax. Wax normally extrudes but excessive use of cotton buds or other implements push the wax further in inadvertently. In some people there is excess hair in the outer ear canal which prevents the natural egress of wax and debris. There are some conditions that can give rise to narrowing of the ear canal which can either be congenital or occur in later life. A common example is the development of excess bone in the ear canal due to cold water exposure during childhood. This is seen in patients who live in warmer climates and who have enjoyed cold water swimming or surfing in their youth.

There are many agents available on the market for management of wax and probably the best one is Bicarbonate of Soda. It is recommended that five drops are instilled in each ear five times a day for a minimum of five days. This will really soften the wax and facilitate natural extrusion. If this fails to occur then syringing may be required or suction by an ENT Specialist with the aid of microscopic visualisation.

Scalp Conditions

Occasionally conditions involving the scalp can give rise to pain which can seem to arise from the ear region. These conditions are usually visible and a referral to a Dermatologist may be required.

Sinus Infection

Acute of chronic sinus infection can result in referred pain to the ear. Although not always present there are usually symptoms of nasal blockage and mucus production.

Sudden Onset

Sudden sensorineural hearing loss. This is a rare condition but can be quite devastating. The patient has sudden onset of hearing lose usually on one side and can be associated with a ringing tone in the ear. Although the cause has not yet been determined the cause is likely to be due to a virus. Other possible causes are a cessation of blood flow due to blockage of the feeding artery to the inner ear. This diagnosis requires urgent attention and the sooner treatment starts with high doses of oral steroids the more chance there is of recovery of hearing. The diagnosis and treatment is best made by an ENT Specialist.

Other causes of sudden onset of hearing loss include the impaction of a foreign body into the ear canal. The patent usually presents with a history of using either an implement or inserting a foreign body into the ear canal and this is usually visible. Other causes for sudden gearing loss include a stroke or head trauma.

Temportomandibular joint pain

As previously mentioned the ear has a rich nerve supply and neighbouring structures can be the source of ear pain. These include diseases of the joint which sits in front of the ear called the tempormandibular joint. In the presence of orthodontic problems, post trauma or nocturnal teeth grinding, earache can develop which can also be associated with a sense of fullness. Usually there is pain when lying on the affected side and symptoms are relieved by non steroid anti inflammatory medication such as Nurofen or Diclofenac. A soft diet is usually recommended but if symptoms persist an MRI examination of the joint may be required

Tympanosclerosis/Otosclerosis

In some patients there can be fixation of the little bones in the middle ear particularly the third called the Stapes or Stirrup. This results in a condition called otosclerosis. This tends to occur more commonly in females and the process is exacerbated by periods of hormonal change such as puberty and pregnancy. Diagnosis can be assisted by high resolution MRI/CT imaging. Once the diagnosis is made treatment can involve conservative measures such as a hearing aid but occasionally an operation called Stapedectomy is considered which involves replacing the fixed stirrup ossicle with prosthesis. Tympanosclerosis is due to scar tissue formation involving either the ear drum or the little bones in the middle ear. This can sometime be improved by surgical intervention but once caused for significant hearing loss hearing aids are required