Evaluation of hearing loss

hearing loss with or without tinnitus and/or pain, common in patients with hearing aids or those who clean their ears with instruments, such as cotton swabs

hard or soft yellow, amber, or brown cerumen visible on otoscopy

often a child who has been playing with small objects, such as beads, pebbles, or crayons, or adult using cotton buds to clean the ears, delayed presentation may be with infection or pain

foreign body visible in external ear canal on otoscopy

swimming or surfing in cold water (exostosis), recurrent ear infections, may be asymptomatic

otoscopy: new bone growth along upper part of tympanic bone or squamotympanic junction, osteoma usually a solitary growth, exostosis may be multiple and arise from anterior and posterior canal

pain, ear-canal drainage, recent swimming, recent ear-canal irrigation

otoscopy findings of yellowish otorrhea, ear-canal swelling and erythema

fever, pain, muffled sounds, postauricular swelling if mastoid is involved

otoscopy: erythematous, bulging tympanic membrane

recently treated acute otitis media, recent upper respiratory tract infection, or airplane travel, no sign of acute infection, aural fullness, or pressure, hearing loss, failed hearing screen, speech delay, signs of ear discomfort, slow progress in an educational setting

standard otoscopy: fluid behind tympanic membrane; tympanic membrane may appear normal, and there are no signs or symptoms of acute inflammation

ear pain, chronic ear infections, ear drainage with strong odor, history of tympanic-membrane perforation, dizziness, tinnitus

may see hole in tympanic membrane, necrotic epithelial debris in middle ear or ear canal, and/or purulent drainage

acute-onset vertigo with nausea and vomiting, sudden hearing loss with or without tinnitus, lightheadedness, fatigue

normal otoscopic exam, Weber test lateralizes toward contralateral ear, horizontal nystagmus, post-headshake nystagmus, deficits of coordination and gait

gradual hearing loss, working in noisy environment, use of power tools, use of motorcycles, shooting hobby, difficulty hearing speech in loud environments, occasionally ringing in the ears

otoscopy: usually normal, may have tympanic-membrane perforation with sudden excessively loud noise exposure

blunt or sharp trauma to the ear or head, pain, bloody drainage, recent ear-canal irrigation, or instrumentation

bloody or clear drainage from the ear, laceration, excoriation, and/or swelling of external canal

exposure to viral or bacterial meningitis, particularly pneumococcal, other neurologic complications, such as seizures or developmental delay in children

normal otoscopic exam, associated focal cranial nerve palsies and/or ataxia

smoking, elevated cholesterol, hypertension, previous myocardial infarction or stroke, symptoms of stroke; word-finding difficulties, ataxia, tinnitus, vertigo, nausea and vomiting

normal otoscopic exam, may have residual hemiparesis and/or hemisensory loss, dysarthria, ataxia, facial nerve palsy, nystagmus, diplopia

slow, gradual hearing loss, usually bilateral

normal otoscopic exam, Weber test may lateralize to least affected side

pain, drainage, history of chronic otitis externa

persistent granulation tissue in ear canal

fever, severe pain, necrotising infection in older patients, patients with diabetes, or immunocompromised; pain wakes patient from sleep even after apparent resolution of signs in external ear canal

otoscopy findings of edema and granulation tissue at the bony cartilaginous junction in the ear canal

acute or chronic ear infection, ear trauma from blow to the head or use of cotton buds, barotrauma from scuba diving, failure to heal after myringotomy

otoscopy: hole or tear in the tympanic membrane

trauma to ear or head, facial paralysis on affected side, bloody otorrhea, cerebrospinal fluid otorrhea

blood behind tympanic membrane, laceration of ear canal, bruising behind the ear, often a ruptured tympanic membrane

hearing loss from birth, absence of associated syndromes

atresia or stenosis or external canal, normal otoscopic exam if abnormality is within the middle or inner ear

parents may have normal hearing (autosomal-recessive disorder), present at birth or develops later in childhood, may fluctuate in severity

normal otoscopic exam

fatigue, breathlessness, hematuria, renal failure, family history of sensorineural hearing loss, renal failure

systemic hypertension, normal otoscopic exam

profound hearing loss from birth, parents may be unaffected (autosomal recessive), episodes of syncope

irregular pulse

babies with difficulties in breathing and feeding

Pierre Robin: micrognathia, retracted tongue, cleft palate; Crouzon: characteristic facies, low-set ears, exophthalmos, mandibular prognathism, ear-canal abnormalities may be present on otoscopy; Apert: syndactyly of hands and feet, characteristic facies with wide-set eyes and low-set ears, ear-canal abnormalities may be present on otoscopy

parent may be affected, autosomal-dominant inheritance, hearing loss can affect one or both ears

wide flat nose, different-colored eyes, white lock of hair, premature gray hair

unilateral hearing loss, tinnitus, dizziness, nausea, unilateral facial weakness, known neurofibromatosis

normal otoscopic exam, may have abnormal gait, unilateral facial weakness and numbness, or lateral gaze palsy, with neurofibromatosis may have cutaneous cafe au lait spots or nystagmus, acoustic neuromas are usually bilateral

pulsatile tinnitus, ear fullness, bruit

red, bulging mass behind intact tympanic membrane

asymptomatic or neurologic sequelae include spasticity, hemiparesis, seizures, and developmental delay, onset of hearing loss may be delayed

normal otoscopic exam, Weber test lateralizes to the opposite side, may have microcephaly and/or hepatosplenomegaly[97]Centers for Disease Control and Prevention. Babies born with congenital cytomegalovirus (CMV). May 2022 [internet publication]. https://www.cdc.gov/cmv/congenital-infection.html

asymptomatic in infant, mother tests positive for toxoplasma during pregnancy

normal otoscopic exam, Weber test lateralizes to the opposite side

history of exposure through mother to fetus or through sexual contact with affected person, may affect both ears at once or sequentially, associated with disequilibrium and vertigo

normal otoscopic exam, other features of syphilis; firm painless skin ulceration or rash

known Paget disease affecting the skull, pain and deformity in other bones, or may be asymptomatic, more common aged >50 years, hearing loss may be unilateral or bilateral

normal otoscopic exam, Weber test lateralizes to the opposite side

known SLE, sudden hearing loss

normal otoscopic exam

rhinitis, nosebleeds, gingivitis and loosening of teeth, arthritis, eye pain, blurred vision, diplopia

skin: palpable purpura or petechial, nodular, vesicular, hemorrhagic, and ulcerative lesions, eyes: redness, tearing, proptosis, visual loss, and retinal exudates/hemorrhages.

known diabetes, gradual hearing loss, usually bilateral, may complain of difficulty understanding speech, with necrotizing infection; pain wakes patient from sleep even after apparent resolution of signs in external ear canal

usually normal otoscopic exam, Weber test may lateralize to least affected side, with necrotizing infection; granulation tissue, and edema in external canal and/or cranial nerve palsies (VII, VIII, or IX)

known osteogenesis imperfecta, gradual hearing loss, most common onset in second to fourth decade of life

normal otoscopic exam

sudden unilateral hearing loss, neck pain, history of minor neck trauma, occipital headache, unilateral facial weakness, dysesthesia

normal otoscopic exam, may be no neurologic signs initially, cerebellar signs can develop (e.g., nystagmus and ataxia)

known MS, symptoms of visual disturbance, localized sensory phenomena, fatigue, cramps, urinary or bowel disturbance

normal otoscopic exam, abnormal eye movements (internuclear ophthalmoplegia) may be present, deep tendon reflexes may be increased

headaches, muscle weakness, fatigue, facial pain

normal otoscopic exam, hydrocephalus and paralysis may be present with type II malformation

hyperbilirubinemia, prematurity, ototoxic drug exposure, or family history of hearing loss

normal cochlear function, worse speech understanding than expected for the level of hearing loss

tinnitus, dizziness, vertigo and/or aural fullness, unilateral, no history of trauma, no concurrent neurologic or ophthalmic symptoms

normal otoscopic and neurologic examination; Weber’s test lateralizes to unaffected side

current use of aminoglycosides, nonsteroidal anti-inflammatory drugs, chemotherapeutic agents, antimalarial drugs, or high doses of loop diuretics

normal otoscopic exam

recurrent episodic vertigo associated with fluctuating hearing loss, tinnitus, and a feeling of aural pressure

normal otoscopic exam; Weber test lateralizes to the opposite side

baby with severe jaundice requiring an exchange transfusion, low birth weight, prematurity

jaundice, normal otoscopic exam

gradual hearing loss, usually bilateral, may have tinnitus, paracusis, or vertigo

normal otoscopic exam, Rinne test negative in affected ear(s)

fullness in the ear; vertigo; a ringing, hissing, or roaring sound in the ear may be experienced; prior history of sudden hearing loss; both ears may be affected; coexisting systemic autoimmune disease may be present

usually normal findings; associated systemic autoimmune diseases may affect the external ear skin or middle-ear mucosa

vertigo and fluctuating hearing loss, aural fullness, and dizziness may be present, surgery on the stapes or history of barotrauma

normal otoscopic exam, direct visualization by surgical exploration confirms diagnosis