Hearing loss categorized by site of pathology: conductive (outer/middle ear) vs sensorineural (cochlea/CN VIII/central).
Also known as: hearing loss, SNHL, conductive hearing loss, presbycusis, sudden sensorineural hearing loss, SSNHL
Overview
Hearing loss is a reduction in auditory acuity. Conductive hearing loss (CHL) results from impaired sound transmission through the external or middle ear. Sensorineural hearing loss (SNHL) results from damage to the cochlea, cochlear nerve, or central auditory pathways. Mixed loss has both components.
Epidemiology
Affects ~15% of US adults; prevalence rises with age — ~50% of adults ≥75 have disabling hearing loss. Presbycusis is the most common form of adult SNHL. Sudden SNHL incidence ~5-27/100,000/year.
Try two board-style Sensorineural and Conductive Hearing Loss questions
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Question 1EENTMedium
A 55-year-old woman has progressive unilateral right sensorineural hearing loss and right-sided tinnitus without vertigo over 6 months. Weber lateralizes to the left ear. Audiogram confirms right-sided sensorineural hearing loss. Which of the following is the most appropriate next diagnostic step?
AAuditory brainstem response audiometry
BComputed tomography of the temporal bones
CMRI with gadolinium of internal auditory canals
DRepeat pure-tone audiometry in 3 months
ETympanometry with acoustic reflex testing
Reveal answer & full explanation
Correct answer: C — MRI with gadolinium of internal auditory canals
AAuditory brainstem response audiometry
BComputed tomography of the temporal bones
CMRI with gadolinium of internal auditory canals✓
DRepeat pure-tone audiometry in 3 months
ETympanometry with acoustic reflex testing
Why MRI with gadolinium of internal auditory canals is correct
Acoustic neuroma (vestibular schwannoma) is a benign Schwann cell tumor of the vestibular division of cranial nerve VIII located in the internal auditory canal
Classic presentation: unilateral sensorineural hearing loss (SNHL), tinnitus, and mild or absent vertigo (slow growth allows central compensation)
Weber lateralizes to the better (contralateral) ear in sensorineural hearing loss
MRI with gadolinium of the internal auditory canals is the gold standard for diagnosis
Why the others are wrong
Tympanometry with acoustic reflex testing — assesses middle ear function and eardrum mobility; not useful for SNHL or retrocochlear pathology (confused-with conductive workup)
Auditory brainstem response audiometry — a screening test for retrocochlear disease with poorer sensitivity than MRI, especially for small tumors, so it does not replace gadolinium-enhanced imaging (premature closure)
Computed tomography of the temporal bones — defines bony anatomy but is insensitive for small intracanalicular schwannomas, which MRI detects far better (right-test-wrong-modality)
Repeat pure-tone audiometry in 3 months — tempting as a way to document progression before committing to imaging, but asymmetric SNHL with unilateral tinnitus already warrants evaluation for a retrocochlear lesion, and a repeat audiogram cannot identify one; it only delays the diagnosis (right-test-wrong-time)
Additional high-yield points
Size-based management: small (below 1.5 cm) — observation with serial MRI; medium (1.5-3 cm) — stereotactic radiosurgery or microsurgical resection; large (above 3 cm) or growing — microsurgical resection
Neurofibromatosis type 2: bilateral acoustic neuromas are a diagnostic criterion
Question 2EENTMedium
A 60-year-old male has gradual hearing loss in both ears over 5 years. Audiometry shows symmetric high-frequency sensorineural hearing loss. Weber lateralizes to neither ear; Rinne is positive bilaterally. Which of the following is the most likely diagnosis?
AOtotoxic hearing loss
BOtosclerosis
CNoise-induced hearing loss
DPresbycusis
EAcoustic neuroma
Reveal answer & full explanation
Correct answer: D — Presbycusis
AOtotoxic hearing loss
BOtosclerosis
CNoise-induced hearing loss
DPresbycusis✓
EAcoustic neuroma
Why Presbycusis is correct
Presbycusis is age-related sensorineural hearing loss characterized by bilateral symmetric high-frequency loss
Symmetric bilateral sensorineural hearing loss: Weber stays midline (a unilateral or asymmetric SNHL lateralizes to the better ear), Rinne is positive bilaterally (air conduction (AC) > bone conduction (BC))
This patient's presentation — gradual bilateral high-frequency loss in a 60-year-old, Weber midline, Rinne positive bilaterally — is classic for presbycusis
Why the others are wrong
Otosclerosis — conductive hearing loss; caused by stapes fixation, autosomal dominant, affects young adults, often progressive; Weber lateralizes to affected ear, Rinne negative (BC > AC) on affected side
Noise-induced hearing loss — also sensorineural, but characterized by a 4 kHz notch on audiometry, not generalized high-frequency symmetric loss; history of noise exposure would be expected
Acoustic neuroma — sensorineural but typically asymmetric; diagnosed by MRI
Ototoxic hearing loss — aminoglycoside or cisplatin ototoxicity can also cause bilateral, symmetric high-frequency sensorineural hearing loss, but the diagnosis requires a history of ototoxic drug exposure, which this vignette does not give; a slow, symmetric decline over 5 years at age 60 is the signature of age-related loss
Treatment for presbycusis: hearing aids; cochlear implants if severe
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Otoscopy: cerumen, effusion, perforation, retraction pocket, mass
Weber test: tuning fork on midline forehead. CHL lateralizes to AFFECTED ear. SNHL lateralizes to UNAFFECTED ear.
Rinne test: tuning fork on mastoid, then at ear canal. Normal/SNHL: AC > BC (positive Rinne). CHL: BC > AC (negative Rinne).
Whisper test, finger rub for bedside screening
Speech recognition disproportionately poor for the degree of pure-tone loss suggests retrocochlear (CN VIII) pathology
Classic findings
CHL: negative Rinne (BC > AC), Weber lateralizes to affected ear. SNHL: positive Rinne, Weber lateralizes to unaffected ear.
Differential diagnosis
Cerumen impaction — Conductive loss, ear fullness, exam shows occluding wax; treat with ceruminolytic, irrigation, or curettage
Otosclerosis — Progressive conductive loss in young adult, family history, Schwartze sign (pink TM), low-frequency loss; surgical stapedectomy or hearing aid
Presbycusis — Gradual bilateral high-frequency SNHL in older adult, difficulty understanding speech in noise; hearing aids
Noise-induced hearing loss — Bilateral SNHL with notch at 4 kHz on audiogram; occupational/recreational noise exposure
Sudden sensorineural hearing loss (SSNHL) — ≥30 dB loss over ≥3 contiguous frequencies within 72 h; idiopathic in 90%; urgent audiometry and ENT referral, oral corticosteroids, then MRI to exclude vestibular schwannoma
Cholesteatoma — Conductive loss, foul otorrhea, retraction pocket or attic perforation; CT and surgical excision
Ototoxic drug exposure — Bilateral SNHL temporally related to aminoglycoside, cisplatin, or loop diuretic; high-frequency loss earliest
Diagnostic workup
Diagnostic criteria
Type determined by audiogram: CHL = air-bone gap ≥10 dB with normal bone conduction. SNHL = both AC and BC thresholds elevated with no air-bone gap. Mixed = elevated BC plus an air-bone gap. SSNHL = ≥30 dB SNHL across ≥3 contiguous frequencies developing within 72 h.
Labs
Not routine; consider TSH, ANA, RPR/FTA-ABS, Lyme, autoimmune panel in atypical or rapidly progressive SNHL
Genetic testing (GJB2/connexin 26) for congenital nonsyndromic SNHL
Imaging
Pure-tone audiometry — defines type, severity (mild 26-40 dB, moderate 41-55, moderately severe 56-70, severe 71-90, profound >90 dB), and configuration
Bedside and audiometric distinction of conductive vs sensorineural hearing loss.
Treatment
First-line
Cerumen impaction: ceruminolytic (carbamide peroxide), warm-water irrigation, or curettage under direct visualization
Conductive loss from OME persisting >3 months with hearing loss: tympanostomy tubes
Otosclerosis: hearing aids OR surgical stapedectomy/stapedotomy
Presbycusis and chronic SNHL: hearing aids; cochlear implant if severe-to-profound bilateral SNHL with poor aided speech recognition
Sudden SNHL: oral corticosteroids (prednisone 1 mg/kg/day, usual max 60 mg/day, × 7-14 days, then taper) within 2 weeks of onset; do not routinely give antivirals, thrombolytics, or vasodilators (AAO-HNS 2019); intratympanic dexamethasone salvage if oral course incomplete response
Counsel on hearing protection (earplugs/muffs) for ongoing noise exposure
Second-line / adjunct
Intratympanic dexamethasone for SSNHL — primary or salvage therapy, especially if systemic steroids contraindicated (diabetes, immunosuppression)
Cochlear implantation for severe-to-profound bilateral SNHL with limited benefit from hearing aids
Bone-anchored hearing aid (BAHA) for unilateral SNHL or chronic conductive loss
Treat underlying cause: discontinue ototoxic medication, manage Meniere with diet/diuretic, surgical removal of vestibular schwannoma when appropriate
Complications
Speech and language delay in untreated congenital/early-childhood hearing loss
Social isolation, depression
Cognitive decline and increased dementia risk in untreated adult hearing loss
Falls (linked to age-related hearing loss)
Reduced occupational performance and earning capacity
PANCE pearls
Weber lateralizes to BAD ear in conductive loss; to GOOD ear in sensorineural loss.
Sudden SNHL is an ENT emergency — confirm SNHL (tuning forks, otoscopy), get urgent audiometry (as soon as possible, within 14 days of onset) and ENT referral, offer oral steroids within 2 weeks, then MRI internal auditory canals with gadolinium (or ABR) to exclude retrocochlear pathology such as vestibular schwannoma. No routine head CT or labs.
Universal newborn hearing screening: failed screen → confirmatory audiologic evaluation by 3 months; intervention by 6 months ('1-3-6 rule').
4 kHz notch on audiogram = noise-induced hearing loss.
Bilateral conductive loss in a young adult with family history and normal otoscopy → otosclerosis.
References
AAO-HNS 2019 — Chandrasekhar SS et al. Clinical Practice Guideline: Sudden Hearing Loss (Update). Otolaryngol Head Neck Surg 2019;161(1S):S1-S45
USPSTF 2021 — Screening for Hearing Loss in Older Adults. JAMA 2021;325(12):1196-1201 (I statement)
AAP/JCIH 2019 — Joint Committee on Infant Hearing. Year 2019 Position Statement. J Early Hear Detect Interv 2019
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