Demystify hearing loss, identify who will benefit from hearing aids and learn to evaluate hearing complaints in primary care including an overview of tinnitus and how to recognize and treat Meniere’s disease with guest expert, Dr. Steven Rauch (Harvard University).
Audiograms are used to diagnose conductive or sensorineural hearing loss across audible frequencies. Dr Rauch highlights two of audiograms’ key parts:
Unilateral hearing loss that develops over 72 hours or less (in patients for whom other etiologies such a stroke have been ruled out) is a hearing loss emergency that requires immediate referral to ENT to reduce potential permanent loss. Patients can wake up deaf on one side, or experience rapidly progressive loss in a few hours. It can be associated with clicking sounds or balance disturbance. Patients might attribute a benign cause, such as earwax or congestion, and may delay seeking medical attention. Sudden sensorineural hearing loss should be evaluated with an audiogram, and the specialist may consider MRI to rule out acoustic neuroma (Fishman 2018, Ahsan 2015). Patients are recommended to be evaluated by audiology and ENT within 24 hours of referral or within 14 days of hearing loss onset depending on the guideline makers respectively (NICE 2019, Chandrasekhar 2019). There may be a benefit to urgent high dose oral or intratympanic steroid treatment to improve outcomes after sudden sensorineural hearing loss, but this is primarily based on expert opinion and data is not strong (Plontke 2022, Wei 2013, Chandrasekhar 2019). In his experience, Dr. Rauch estimates about 80% will have some continued hearing loss even with intensive treatment.
Asymmetric sensorineural hearing loss is concerning for intracranial pathology and referral to ENT and consideration for evaluation for acoustic neuroma/vestibular schwannoma or other brain pathology should be considered (Sweeney 2018).
Following an audiogram, hearing aids are prescribed according to the loss and the type or fit of the device. Frequencies and volume can be adjusted in the future if the hearing loss worsens. Dr. Rauch states that any stigma about wearing hearing aids may be overcome if you explain the benefits of improved communication. Companies typically allow money back guarantee for the devices and many states (but not all of them) mandate a return period. Some patients find it hard to adjust to the new acoustics they hear with an aid.
Over the counter hearing aids have recently been approved in the US. In Dr. Rauch’s opinion, these devices offer the significant benefit of costing around one-third of a traditional hearing aid prices, but at this point, it is difficult to guarantee the quality and durability of those alternative aids. Patients might buy over the counter aids and benefit from scheduling audiologist appointments to learn how to use the aids.
Some hearing deficits can not be improved by traditional hearing aids. The only alternative available treatment is a cochlear implant. But, according to Dr Rauch, the cochlear implants only significantly improves quality of hearing for those patients that have a word recognition score below 50% and they can still struggle in a noisy environment (Varadarajan 2021).
People with unilateral hearing loss often have difficulty localizing where sounds are coming from, and some research shows significant impact on hearing and comprehension (Snapp 2020). In the US, unilateral hearing loss has not been regarded as a medical-legal disability (Mengel vs Reading Eagle Co). After proper workup, if there are no actionable findings, in Dr. Rauch’s opinion, patients should be reassured that they usually adjust to the changes.
“Tinnitus is just a generic indication of an unhappy ear” says Dr. Rauch. Tinnitus is often caused by hearing loss. When there is damage to the auditory process, the neurological auditory centers in the brain that receive and process the sound signal increase the gain to attempt to hear and these amplified signals are perceived as tinnitus. Distracting from the tinnitus can help lessen symptoms.
Pulsatile tinnitus should be investigated, as it can be a sign of vascular disease (Grierson 2018).
Tinnitus is often accompanied by hearing loss, so hearing assessment is useful.
Tinnitus is often exacerbated by stress, sickness, sleep deprivation, muscle tension. Lifestyle modifications and improving quality of life can diminish the bothersome effect of tinnitus.
Encourage patients to use self help resources:
The British Tinnitus Association
Meniere’s Disease is a degenerative disease of the inner ear that impairs sensorineural hearing and balance. Dr Rauch looks at this as there is a degenerative process that we don’t yet understand, and the ear’s response to this is the symptoms of Meniere’s, not that Meniere’s is a specific disease causing inner ear damage. The exact etiology is unknown. It can be due to a trauma, a congenital abnormality, or ear infection. One-third of Meniere’s disease patients have a congenital malformation of the vestibular aqueduct, which is a canal where inner ear fluid recycling happens. Abnormal fluid recycling can be due to aqueduct hypoplasia, degenerative changes in the epithelial lining of the endolymphatic sac, leading to homeostatic failure of inner ear (Rauch 2016).
Onset is often in the fourth or fifth decade, and the degenerative process leads to loss of function of the inner ear. Fluctuating and progressive episodes of vertigo last a few hours. Vertigo episodes commonly come in clusters and are associated with tinnitus, progressive unilateral hearing loss, and aural fullness (Paparella 2008).
A clinical diagnosis of Meniere’s Disease is made based upon the following criteria (Lopez-Escamez 2015):
Around 25% of Meniere’s disease patients will develop bilateral symptoms, but it typically occurs sequentially, not concurrently (Noij 2019).
There is a significant overlap with Meniere’s symptoms and migraine. Vestibular Migraine may cause episodic vertigo, hearing impairment, and tinnitus. Dr. Rauch suggests assessing for migraine symptoms (headaches, nausea, visual disturbance, photophobia) especially in young female patients, as migraine is a more common diagnosis. If clinically there are strong suggestions of migraine, focusing on migraine treatment is appropriate.
Meniere’s is a clinical/audiologic diagnosis. MRI is optional according to AAOHNS guidelines. Dr Rausch’s practice is to get an MRI on new patients with Meniere’s to rule out structural causes, and he notes that with new technology, changes associated with Meniere’s can be seen on MRI scan (Conte 2018, Sang Cho 2021), but this is not yet widely available.
Dr Rauch recommends a patient-centered, conservative approach, controlling their symptoms with minimum intervention if possible. Patients should be counseled on the following:
Listeners will gain confidence in assessing hearing loss in adults, spot the red flags that indicate
urgent referral to a specialist, and provide management advice for tinnitus and Meniere’s disease.
After listening to this episode listeners will…
Dr. Steven Rauch reports no relevant financial disclosures. The Curbsiders report no relevant
Grant K, Perdigão A, Rauch S, Williams PN, Watto MF. “#379 Hearing loss, Tinnitus and Meniere’s
disease”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list January
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Excellent discussion - clinically relevant, practical and targeted at primary care providers. Dr Rauch is clear, concise and an incredible practitioner who makes the "sick ear" so much more manageable, both in terms of diagnosis and treatment. Pragmatic and articulate while comprehensive and educational. A talented clinician educator!
Such great practical information! Thanks so much!
Thank you for the great feedback!!
I thought this talk was the best. Great information and funny
As a 60 year old primary care physician struggling to keep up with progress in medicine, this episode exemplifies what I love about the Curbsider podcast. It provides practical and detailed information (with citations if desired) about common problems with humor to make it memorable. (Am I the only one who never heard an MRI called the “truth tunnel”? 😂 ) Thank you
Thank you so much for the great feedback!