Some Causes of Acquired Hearing Loss 

Cause*

Suggestive Findings

Diagnostic Approach†

External ear (conductive loss)

Obstruction (eg, caused by cerumen, a foreign body, otitis externa, or, rarely, tumor)

Visible during examination

Otoscopy

Middle ear (conductive loss)

Otitis media (secretory)

Hearing loss that may fluctuate

Sometimes also dizziness, pain, or fullness in the ear

Usually abnormal-looking TM

Often a history of acute otitis media or other causative event

Otoscopy

Tympanogram

Otitis media (chronic)

Chronic ear discharge

Usually visible perforation

Granulation tissue or polyp in the canal

Sometimes cholesteatoma

Otoscopy

For cholesteatoma, CT or MRI

Ear trauma

Apparent by history

Often visible perforation of the TM, blood in the canal or behind the TM (if intact)

Otoscopy

Otosclerosis

Family history

Age at onset in 20s to 30s

Slowly progressive

Tympanogram

Tumors (benign and malignant)

Unilateral loss

Often lesion visible during otoscopy

CT or MRI

Inner ear (sensory loss)

Genetic disorders (eg, connexin 26 mutation, Waardenburg syndrome, Usher syndrome, Pendred syndrome)

Sometimes a positive family history (but usually negative)

Consanguinity

Connexin 26 mutations account for the vast majority of non-syndromic hearing loss cases and should be screened for initially

Sometimes a white forelock of hair or different colored eyes suggests Waardenburg syndrome

Loss of both vision and hearing can suggest Usher syndrome

Genetic testing

CT and/or MRI

Autoimmune inner ear disease

Bilateral fluctuating or progressive hearing loss

Serologic testing (to rule out systemic rheumatic and other autoimmune disorders)

Noise exposure

Usually apparent by history

Clinical evaluation

Presbycusis

> 55 years in men, > 65 years in women

Progressive, bilateral loss

Normal neurologic examination

Clinical evaluation

Ototoxic medications

History of use

Bilateral loss

Variable vestibular symptoms

Renal failure

Clinical evaluation

Blood tests to measure medication levels

Infections (eg, meningitis, purulent labyrinthitis)

Obvious history of infection

Symptoms that begin during or shortly after an infection

Clinical evaluation

Systemic rheumatic disorders (eg, rheumatoid arthritis, systemic lupus erythematosus)

Joint inflammation, rash

Sometimes a sudden change in vision or eye irritation

Often known history of the disorder

Serologic testing

Meniere syndrome

Episodes of unilateral, fluctuating hearing loss accompanied by aural fullness, tinnitus, and vertigo

Gadolinium-enhanced MRI to rule out tumor

Barotrauma (with perilymphatic fistula)‡

History of abrupt pressure change (eg, scuba diving, rapid descent in airplane) or a blow to the ear canal

Sometimes severe ear pain or vertigo

Tympanometry and balance function tests

CT of temporal bone

Surgical exploration if vertigo persists

Head trauma (with basilar skull fracture or cochlear concussion)‡

History of significant injury

Possibly vestibular symptoms, facial weakness

Sometimes blood behind the TM, CSF leak, ecchymosis over the mastoid

CT or MRI

Auditory neuropathy‡

Good sound detection, but poor word understanding

Auditory testing (auditory brain stem response [ABR], otoacoustic emissions)

MRI

Central nervous system (neural loss)

Tumors of the cerebellopontine angle (eg, vestibular schwannoma, meningioma)

Unilateral hearing loss, often with tinnitus

Vestibular abnormalities

Sometimes facial or trigeminal nerve deficits

Gadolinium-enhanced MRI

Demyelinating disease (eg, multiple sclerosis)

Unilateral loss

Multifocal neurologic deficits

Waxing and waning symptoms

MRI of the brain

Sometimes lumbar puncture

* Each group is listed in approximate order of frequency.

† All patients should have otoscopy and audiologic testing.

‡ Mixed conductive and sensorineural loss may also be present.

CSF = cerebrospinal fluid; TM = tympanic membrane.

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