Ear, Nose & Throat
Question 26 of 300
A 32 year old man presents to the Emergency Department complaining of hearing loss. On examination Weber's test lateralises to the right and Rinne's test is positive in the right and left ear. What do these examination findings suggest?
Answer:
Unilateral sensorineural hearing loss- Weber's
- Sound lateralises to unaffected ear.
- Rinne's
- In affected ear AC > BC (Rinne positive).
- In unaffected ear AC > BC (Rinne positive).
Hearing Loss
Ear, Nose & Throat
Last Updated: 3rd February 2024
Hearing loss is common and can occur at any age — depending on the underlying cause it can be temporary or permanent, of sudden onset (developing within 72 hours) or slowly progressive.
Hearing loss can be categorised as:
- Conductive, sensorineural or mixed
- Conductive hearing loss occurs due to abnormalities of the outer or middle ear which impair conduction of sound waves from the external ear (pinna, ear canal or tympanic membrane) through the ossicles (malleus, incus and stapes) in the middle ear to the cochlea in the inner ear.
- Sensorineural hearing loss occurs due to abnormalities in the cochlea, auditory nerve or other structures in the neural pathway leading from the inner ear to the auditory cortex.
- Mixed hearing loss occurs when abnormalities causing both conductive and sensorineural hearing loss are present.
- Mild, moderate, severe or profound based on the quietest sound that can be heard measured in decibels (dB HL [decibel hearing level]) on pure tone audiometry.
Causes of hearing loss in adults
- Conductive hearing loss
- Cerumen impaction
- Foreign bodies
- Otitis externa
- Necrotising otitis externa
- Otitis media
- Tympanic membrane perforation
- Middle ear effusion
- Otosclerosis
- Cholesteatoma
- Neoplasm e.g. squamous cell carcinoma of external ear, vascular glomus tumour
- Exostoses
- Sensorineural hearing loss
- Age-related hearing loss (presbycusis)
- Noise-related hearing loss
- Sudden sensorineural hearing loss (SSHL)
- Labyrinthitis
- Meniere's disease
- Acoustic neuroma (vestibular schwannoma)
- Ototoxic exposure e.g. aminoglycoside antibiotics, loop diuretics, NSAIDs, antimalarials, and cytotoxic drugs, environmental toxins
- Systemic infections e.g. meningitis, HIV, measles, shingles, mumps
- Congenital infections e.g. CMV, toxoplasmosis
- Neurological conditions e.g. MS, stroke
- Trauma to head or ear
- Malignancy e.g. nasopharyngeal cancer, intracranial tumours
- Autoimmune conditions
- Hereditary conditions e.g. Alport's syndrome
Assessment
Take a history asking about:
- Onset and progression of symptoms:
- Is hearing loss of sudden onset (over 72 hours), rapidly progressive (within 90 days), slowly progressive or fluctuating.
- Are symptoms unilateral or bilateral.
- Associated features such as:
- Tinnitus — if present is this persistent, unilateral, pulsatile or recently changed in nature.
- Vertigo.
- Otorrhoea (ear discharge) or otalgia (ear pain).
- Sensation of fullness or pressure in the ear.
- Head/neck trauma, pain or swelling.
- Neurological symptoms.
- Past medical history including:
- Previous chronic ear infections or hearing loss.
- ENT surgery or head trauma.
- Exposure to noise (including occupational).
- Chronic disease such as immunosuppression, diabetes, cardiovascular disease, neurological and autoimmune conditions.
- Cognitive impairment or learning disability.
- Medication including:
- Use of ototoxic drugs.
- Occupation including:
- Exposure to environmental toxins.
- Family history of hearing loss.
- Impact of hearing loss on:
- Communication, relationships, function (at home, in work/education and socially), quality of life and mood.
Examine the person, checking:
- The pinna and surrounding skin looking for signs of inflammation, infection or abnormal lesions.
- The ear canal and tympanic membrane (using an otoscope) to identify clinical features suggestive of conductive hearing loss.
- If full visualisation is not possible due to earwax arrange wax removal and review to reassess.
- Weber and Rinne tuning fork tests to help distinguish between conductive and sensorineural hearing loss.
- Cranial nerves and cerebellar function to exclude focal neurology.
- The head and neck for lymphadenopathy or other masses.
- For clinical features of underlying systemic causes such as infective, autoimmune, metabolic or neurological conditions.
Otoscopy
- Start with the unaffected ear to get an idea of what is normal for this patient.
- Pick the largest speculum that will comfortably fit in the ear to ensure a good view.
- Hold the otoscope like a pen and use your right hand for the patient’s right ear and left hand for the patient’s left ear.
- Have your little finger extended to rest on the patient’s cheek to ensure you stay a constant distance away.
- Have a quick look behind the ear and at the pinna for any scars or signs of infection.
- The junction and anatomy between the bony and cartilaginous portion of the external auditory canal varies in adults and children; to straighten the canal in adults, gently pull the pinna upwards and backwards. In children, pull the pinna directly backwards alone.
- Pull the pinna to straighten the canal and insert the otoscope gently. Then put your eye to the window to visualise.
Make sure you inspect the external auditory canal on your way in, for:- Canal swelling/stenosis/infection
- Wax obscuring ear drum
- Foreign body
- Once you can see the drum, ensure you visualise every aspect, and assess for:
- Colour: normal (pinkish gray), red, white, yellow
- Position: normal (neutral position), retracted, bulging
- Translucency: normal (translucent), opaque, white patches, air fluid level
- Extent: normal (completely intact), perforations
- Repeat the procedure with the other ear.
Normal Tympanic Membrane. (Image modified by FRCEM Success. Original image by EMAD KAYYAM [CC BY-SA (https://creativecommons.org/licenses/by-sa/3.0)])
Tuning fork screening tests
A 512 Hz tuning fork is preferred as at this frequency tone does not fade too quickly. To strike the tuning fork, the 512 Hz tuning fork should be held by its stem and struck on one side (two thirds of the way from the base) on a padded surface or the ball of the hand. The tuning fork should not be struck on hard surfaces as this may damage it or produce harmonic overtones.
The practitioner should start with the Weber test first as the results of this can influence missing a 'false Rinne negative'. A ‘false Rinne negative’ may occur with severe sensorineural hearing loss (predominantly on the test side) when bone conduction to the contralateral ear is better than air conduction. Consider a ‘false Rinne negative’ if the Weber test result is contradictory and ask the person which ear the bone conduction part of the test was heard in.
| Hearing Tests | Weber's test | Rinne's test |
|---|---|---|
| Screening | Test of lateralisation to assess for asymmetric conductive or sensorineural hearing loss. | Test of comparison of perceived air conduction to bone conduction to assess for conductive hearing loss. |
| Method | Strike tuning fork, place on midline of patient's forehead and hold for up to 4 s. Ask patient to report where the tone is heard: centrally (in the head or in both ears) or towards the left or right. | Start with ear that Weber test has lateralised to. Strike tuning fork and hold about 25 mm from ear canal entrance for about 2 s. Immediately then place against the mastoid and hold for a further 2 s. Ask patient to report whether tone is louder next to the ear (Air conduction: AC) or behind the ear (Bone conduction: BC). |
| Normal hearing | Sound is heard centrally. | AC > BC in both ears (Rinne positive). |
| Unilateral conductive hearing loss | Sound lateralises to affected ear. | In affected ear BC > AC (Rinne negative).
In unaffected ear AC > BC (Rinne positive). |
| Unilateral sensorineural hearing loss | Sound lateralises to unaffected ear. | In affected ear AC > BC (Rinne positive).
In unaffected ear AC > BC (Rinne positive). |
| Bilateral symmetrical hearing loss | Sound is heard centrally. | Sensorineural: AC > BC in both ears (Rinne positive).
Conductive: BC > AC in both ears (Rinne negative). |
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
