A 72-year-old man, a former construction worker, is evaluated as a new patient. His wife accompanies him to his visit and notes that his hearing is not as acute as it used to be. She says that he cannot participate in conversations in restaurants and has trouble talking on the telephone. He needs to turn the television up so loudly that she fears for her own hearing. You need to speak up in the office to get an appropriate response from him. He has trouble hearing finger-rubbing bilaterally. You refer him for an audiogram. The left ear demonstrates mild decreased hearing in the upper frequencies consistent with aging. The right ear shows significant down-sloping sensorineural loss in the upper frequencies, up to 40 dB lower than the left ear at 8000 Hz.
What is the most appropriate next step in the management of this patient?
A. Refer the patient to an otologist for stapedectomy.
B. Refer the patient for a hearing aid fitting.
C. Order MRI of the cerebellopontine angle.
D. Order a contrast-enhanced CT scan of the head
b?
id actually just refer him !!!
Answer: B
and some additional notes....
The principal differences between occupational noise-induced hearing loss and age-related hearing loss are as follows.
¢ It is always sensorineural, affecting hair cells in the inner ear.
¢ Since most noise exposures are symmetric, the hearing loss is typically bilateral.
¢ The rate of hearing loss due to chronic noise exposure is greatest during the fi rst
10“15 years of exposure, and decreases as the hearing threshold increases. This is
in contrast to age-related loss, which accelerates over time.
¢ Typically, the first sign of hearing loss due to noise exposure is a ˜notching™ of the
audiogram at 3000, 4000, or 6000 Hz, with recovery at 8000 Hertz (Hz) (2). The
exact location of the notch depends on multiple factors including the frequency
of the damaging noise and the length of the ear canal. Therefore, in early noiseinduced
hearing loss, the average hearing thresholds at 500, 1000, and 2000 Hz are
better than the average at 3000, 4000, and 6000, and the hearing level at 8000 Hz
is usually better than the deepest part of the ˜notch™. If exposure is continued, the
notch gradually deepens and widens. Eventually, retention of good hearing in the
higher frequencies is lost, and the resulting hearing loss appears only as a relatively
steep high-frequency loss beginning at 3000 Hz and becoming more severe at
each higher frequency over a period of many years. Persistent noise exposure
progressively encroaches on the middle frequencies. In the most severe cases,
even the lower frequencies may eventually become involved. This ˜notching™ is in
contrast to age-related hearing loss, which also produces high frequency hearing
loss, but in a down-sloping pattern without recovery at 8000 Hz (3).
¢ Noise exposure alone usually does not produce a loss greater than 75 decibels
(dB) in high frequencies, and 40 dB in lower frequencies. However, individuals with
superimposed age-related losses may have hearing threshold levels in excess of
these values.