Case 23: Hearing loss

Opening scenario

Marvin Baker, a 65-year-old male; , comes to the doctor's office because of hearing loss.

Vital signs

• Temperature: 97.7°F (36.5°C)
• Blood pressure: 120/80 mm Hg
• Heart rate: 62/min
• Respirations: 15/min

Examinee tasks

• Take a focused history.
• Perform a relevant physical examination (do not perform corneal reflex, breast, pelvic/genitourinary, or rectal examinations).
• Explain the preliminary differential diagnoses and initial workup plan to the patient.
• Write the patient notes after leaving the room.

Patient instructions

• When the examinee tests your hearing by whispering or rubbing his/her fingers next to your ear, pretend not to hear on either side.
• You are not aware of the meanings of medical terms (e.g., audiometry) and ask for clarification if the examinee uses them.
• Use the checklists below for history, physical examination, and communication and interpersonal skills.

Challenge: Pretend to have trouble understanding the examinee unless she/he speaks in a loud voice and articulates him- or herself clearly.

Hovering over or clicking on the speech bubbles in the lists below will reveal extra information about the adjacent term. However, clicking on links will cause you to navigate away from the current case, at which point your progress (i.e., your check marks) will be lost. If you do want more information on a subject, either open the link in a new tab or wait until you and your partner have finished the case and reviewed the check marks. Following the link to the patient note form or the abbreviation list will not interrupt your progress.

History of present illness

• Chief complaint
• I cannot hear well anymore.
  • Both ears or single ear
  • I think it is the same with both ears.
  • All sounds/ specific sounds
  • Hmm, I think I hear higher tones a little less. I have a really hard time understanding my granddaughter sometimes.
• Onset
• It started about 5 years ago.
• Constant/intermittent
• It is there all the time.
• Precipitating events
• None.
• Progression
• It stayed almost the same for a while but it has gotten worse, especially in the past year.
• Previous episodes
• Never.
• Alleviating factors
• None.
• Aggravating factors
• When I attend family gatherings and a lot of people are speaking, it is hard for me to follow conversations.
• Associated symptoms
• None.

It is important to have the patient specify if both ears are affected, as this narrows down the possible differential diagnoses.

Review of systems specific to hearing loss

• Trauma
• No.
• Headache
• No.
• Nausea/vomiting
• No.
• Rash/skin changes
• No.
• Recent infections
• None.
• Dizziness
• No.
• Recent exposure to sudden loud noise
• Not that I remember.
• Tinnitus
• No.
• Ear pain
• No.
• Ear discharge
• No.
• Weakness
• No.
• Numbness
• No.
• Tingling
• No.

Past medical history, family history, and social history

• Past medical history
• I was treated for bladder cancer 3 years ago and got chemotherapy. And I have chronic shoulder pain.
  • Type of chemotherapy
  • It was something with “platin” in its name, maybe “cisplatin”?
• Allergies
• Penicillin
  • Describe allergic reaction
  • When I took it once, I felt very nauseous and short of breath.
• Medications
• I have been taking aspirin because of my chronic shoulder pain for the past 6 months. I take it daily, often more than one 500 mg pill.
• Hospitalizations
• Because of my bladder cancer, I had to go to the hospital several times.
• Past surgical history
• I had my bladder, prostate, and some lymph nodes removed because of the cancer.
• Family history
• My dad died from a heart attack when he was 72 years old.
• Work
• I am almost retired. I work in a steel plant. When I was younger I worked in the factory, but nowadays I just do some paperwork in an office. I'm too old for heavier work.
  • Noise level at workplace, ear protection
  • Not in the office. But in the factory it was loud sometimes. Most of the time I used my headphones, but sometimes I forgot to put them on.
• Home
• I live with my wife. Our son moved out years ago.
• Alcohol
• I often drink a beer after work, but not more than one.
• Recreational drugs
• Never!
• Tobacco
• Yes, I smoke. I have smoked a pack a day for the past 42 years.

• Washed hands
• Used respectful draping
• Head, eyes, ears, nose, and throat examination
  • Palpation of the head
  • Inspection of the ears
  • Palpation of the ears
  • Otoscopy
  • Rinne test and Weber test
• Neurologic examination
  • Focused examination of the cranial nerves
  • Focused examination of hearing
    • Decreased hearing bilaterally

When screening for hearing loss, examine each ear individually (ask the patient to cover the other ear) in a quiet room.

Patient interaction

• Examinee knocked on the door.
• Examinee introduced him- or herself and identified his/her role.
• Examinee correctly used the patient's name.
• Examinee asked open-ended questions.
• Examinee listened attentively (did not interrupt the patient).
• Examinee showed interest in the patient as a person (i.e., appeared caring and showed respect).
• Examinee demonstrated the ability to support the patient's emotions (i.e., offered words of support, asked for clarification).
• Examinee discussed initial diagnostic impressions with the patient.
• Examinee explained the management plan.
• Examinee used non-medical terms and provided reasons for planned steps in management.
• Examinee evaluated the patient's agreement with the next diagnostic steps.
• Examinee asked about concerns or questions.

Counseling and challenge

• Examinee offered counseling on smoking cessation.
• Examinee counseled patient to reduce intake of aspirin.
• Examinee reacted appropriately to challenge: articulated herself/himself clearly, spoke in a loud voice

Patient note

Differential diagnoses

1. Presbycusis: In older patients (> 50 years), a history of gradual bilateral sensorineural hearing loss, particularly of higher frequencies, is highly suggestive of presbycusis. Patients typically have a normal physical examination, as is the case here, and report that the symptoms are worse in noisy or crowded environments. Smoking is a risk factor for presbycusis.
2. Noise-induced hearing loss: As with presbycusis, noise-induced hearing loss is usually bilateral, sensorineural, and particularly affects the ability to hear higher frequencies. It occurs more commonly in people working in environments with chronic exposure to loud noises (> 85 dB) and insufficient ear protection. Patients typically report that the symptoms are worse in noisy or crowded environments and they also often develop tinnitus. Although this patient has a history of occupational noise exposure, which makes noise-induced hearing loss is likely, he does not have tinnitus and has a history of tobacco use that puts presbycusis slightly higher up on the list of differential diagnoses.
3. Medication-induced hearing loss: leads to sensorineural hearing loss that is also typically bilateral and affects higher frequencies. It often also leads to tinnitus and vertigo. This patient's exposure to ototoxic substances in the past (cisplatin 3 years ago) and present (aspirin for the past 6 months) puts him at risk for medication-induced hearing loss. However, his symptoms initially started 5 years ago, before he began treatment with cisplatin or aspirin, which makes medication-induced hearing loss the least likely of the differential diagnoses here. Since aspirin-induced hearing loss is usually reversible, he should be counseled to discontinue the agent.

Diagnostic studies

• Audiometry: determines the extent of hearing loss; also helps to differentiate presbycusis from noise-induced hearing loss

Other differential diagnoses to consider

For causes of hearing loss, remember the magic spell: COTICS MOTIC SIMANA OTI (Conductive hearing loss: Outer ear (Trauma, Infection, Cerumen, Squamous cell carcinoma), Middle ear (Otosclerosis, Trauma, Infection, Choleseatoma); Sensorineural hearing loss: Inner ear (Ménière disease, Age, Noise exposure, Autoimmune, Ototoxic drugs, Tumor, Infection).

• See also the article on hearing loss.