ENT

Age-Related Hearing Loss

SUMMARY:

Age-related hearing loss (ARHL) is the most common sensory deficit in older adults, with nearly two thirds of American adults over the age of 71 reporting some degree of hearing loss. While there are many etiologies of hearing loss, ARHL refers to progressive bilateral sensorineural hearing loss (SNHL) associated with aging. Despite its ubiquity it remains underdiagnosed and undertreated, leading to increased social isolation and impacting the mental and physical wellbeing of patients with hearing loss. The American Academy of Otolaryngology – Head and Neck Surgery Foundation (AAO-HNSF) has published guidelines to assist healthcare practitioners in screening, diagnosing, and treating ARHL.

Screening
Diagnosis
Treatment
Follow Up
Key Points

Screening

Clinicians should screen all adults ≥ 50 years old for hearing loss during healthcare encounters
- Screening can be simple, such as with the prompt, “Do you have any difficulty with your hearing?”
- Screening can also be more complex, such as using questionnaires (e.g., HHIE-S | SAC. See “Learn More”)
- Exam techniques that may be used to screen include: Whispered voice | Finger rub | Watch tick test
For patients who screen negative, repeat testing should be done at regular intervals
- The World Health Organization (WHO) recommends screening every 5 years for ages 50 to 65 and every 1 to 3 years after age 65
If a patient reports hearing loss during screening, otoscopic exam should be done to rule out anatomic causes
- Cerumen impaction | Infection (e.g. Otitis media) | Tympanic membrane disease | Otitis media with effusion | Foreign bodies | Structural abnormalities (e.g., Stenosis | Atresia)
If screening for hearing loss is positive and otoscopic exam is unrevealing, clinicians should obtain an audiogram, either in office or via referral
When screening is positive, clinicians should also consider patient’s social determinants of health that may influence their access and utilization of hearing related health care

Diagnosis

Patients with suspicion for ARHL should undergo audiometric evaluation via audiogram
Determining degree and type of hearing loss requires comprehensive testing
- Measurement of pure tone thresholds | Speech audiometry | Tympanometry | Acoustic reflex testing
Pure tone average (PTA) is considered the gold standard for detecting hearing loss
- Measures hearing sensitivity to various frequencies via bone and air conduction pathways
- Can be repeated and compared to previous testing to monitor for changes in hearing loss
Online (e.g., Pure tone testing | Word recognition) and at home screening tests may be helpful for patients without access to audiometric testing
- Online hearing tests can detect degree of hearing loss but cannot distinguish between types of hearing loss
Patients with hearing loss not due to ARHL (e.g., Patients with significant asymmetric hearing loss | Conductive or mixed hearing loss | Poor word recognition on diagnostic testing)
- Should receive further evaluation and treatment via their primary care provider
- Consider referral to ENT or hearing loss specialist

Treatment

Patients with ARHL should be counseled on the impact of hearing loss
- Decreased situational awareness | Difficulty in communication with peers | Difficulty hearing safety warnings | Increased fall risk | Difficulty orienting to external environment
- ARHL is also associated with: Increased cardiovascular and all-cause mortality | Declines in bone mineral density | Increased risk of rheumatoid arthritis | More common in patients with diabetes | Difficulty with ADLs | Cognitive loss
- Decreased quality of life due to listening effort and fatigue | Increased risk of depression | Difficulty with employment and relationships
Family members should also receive guidance on expectations and impact of ARHL
Treatment focuses on: Communication strategies to improve hearing | Auditory rehabilitation | Assistive listening devices (ALDs)
Patients and partners should be counseled on communication strategies
- Communication strategies for patient: Facing a person when speaking | Moving away from noise | Take turns speaking
- Communication strategies for speaking partners: Do not talk as you walk away or from another room | Speak clearly and slowly | Get person’s attention prior to starting communication | Avoid complex sentences | If message is not understood, rephrase
- Communication strategies for healthcare workers: Avoid masks when there is not a concern for infectious diseases | Give important information in writing
Assistive listening devices (ALDs) are devices that solve specific listening challenges and can be broken down into four main groups
- Solutions targeted at a specific listening situation without the use of hearing aids (e.g., Amplification devices in doctors’ offices)
- Accessories to hearing aids to improve hearing in noise (e.g., Remote microphone)
- Telephone communication assistance (e.g., A federally funded program provides free landline amplified and captioned phones to any individual in the United States with hearing loss)
- Alerting devices (e.g., Phone flashes and vibrates for texts and calls)
Hearing aids are also grouped in as ALDs and should be appropriately fitted and programmed by a professional
- First line treatment for patients with mild-moderate ARHL
Patients with persistent hearing difficulty and poor speech comprehension despite appropriately fitting amplification devices should be referred for cochlear implantation consideration
Cochlear implants are surgically implanted hearing devices that bypass damaged cochlear hair cells to directly stimulate the cochlear nerve
- Standard of treatment for patients with severe hearing loss
- Safe and effective, even for elderly patients (e.g., > 80 years old)

Follow Up

Patients with hearing loss
- Assess for improvement in quality of life, communication and hearing goals at subsequent health encounters, at least withing one year
- Reassess hearing via audiometric testing at least every 3 years, or more often if new hearing related concerns arise

KEY POINTS:

Clinicians play a vital role in the diagnosis and treatment of ARHL, and should screen all older patients (i.e., ≥50 years old) for hearing loss
Patients who screen positive for hearing loss with no mechanical explanation identified on otoscopic exam should be referred for audiometric testing to determine degree and cause of hearing loss
Patients should be offered communication strategies to cope with hearing loss, as well as properly fitted assistive listening devices to improve hearing
If hearing fails to improve or if hearing loss is severe, patients should be referred for cochlear implant consideration
Follow up encounters should reassess hearing goals and quality of life, as well as intermittent repeat hearing testing via audiogram