Degree of hearing loss based on the hearing threshold. Source [5]: Clark JG: Uses and abuses of hearing loss classification. ASHA. 1981, 23:493–500.
Abstract
Hearing loss is the partial or total inability to hear sound in one or both ears. People with hearing loss make up a significant 5.3% of the world’s population. The audiogram is an important tool used to determine the degree and type of hearing loss. This chapter presents hearing loss classification, which can aid in clinical diagnosis and help in finding appropriate therapeutic management. Hearing loss is classified based on ear anatomy, type of hearing loss, degree of the disease, and configuration of the audiogram. When the hearing loss is fully characterized, appropriate medical intervention can be assigned.
Keywords
- Hearing loss
- Audiometry
- Conductive hearing loss
- Sensorineural hearing loss
1. Introduction
Hearing is a very important sensation for human beings. It helps to understand the surrounding environment and can alert of any coming danger around us. Hearing is an essential means of communication. Hearing loss is the impairment of the ability to hear sound. The most quiet sounds that people can hear are between 25 and 40 decibel (dB). Anybody who suffers from mild hearing loss has difficulty keeping up with normal conversations. People who suffer from profound hearing loss are deaf and can hear nothing at all. Hearing loss can impact learning and development in children, including speech and language. In adults, hearing loss can greatly affect the overall quality of life, since it impacts social interaction and general well-being. Consequently, hearing loss can cause many difficulties in various aspects of life. Hearing loss can occur in different types and degrees of severity. In normal hearing, sound vibrations pass from the outer ear through the middle ear to the inner ear. In conductive hearing loss (CHL), vibrations cannot pass from the outer ear to the inner ear. In sensorineural hearing loss (SNHL), there is a dysfunction in the inner ear. In mixed hearing loss, there is a combination of conductive and sensorineural components. At the end of the inner ear (cochlea), thousands of auditory nerve fibers detect the high and low sound frequencies and transmit action potentials to the brain, which interprets the signal as sound. Repeated exposure to loud noise can damage the sound-sensitive hair cells in the inner ear, so it is important to protect hearing from harmful environments.
2. Hearing loss
2.1. Defining hearing loss, its prevalence, and incidence
Hearing loss, the most common form of human sensory deficit, is the partial or total inability to hear sound in one or both ears. It may be a
2.2. Understanding the audiogram
Hearing is examined by making the subject listen to a number of different pure tone signals through a pair of headphones or earplugs to record air conduction. An audiometer examines hearing ability by testing the threshold of hearing a sound signal at various frequencies (pitch, in cycles per second or Hz). Hearing threshold may be defined as how soft a sound may get before it becomes inaudible
2.3. Classifying hearing loss according to
2.3.1. Anatomy of the ear
An examination with attention to the anatomy of the ear is critical for establishing a hearing loss diagnosis. The auditory system is typically divided into three main sections: the outer, middle, and inner ears (Figure 2).
2.3.2. Type of hearing loss
Functionally, the human ear can be divided into two major divisions, the conductive division, associated with the areas responsible for air conduction (the outer ear and the middle ear) and the sensorineural division associated with the inner ear. Accordingly, the three main types of hearing loss are classified as conducive, sensorineural, and mixed hearing losses.
CHL is a type of hearing loss characterized by having better hearing thresholds for bone-conducted signals compared with air-conducted signals. CHL is usually associated with dysfunction located in the outer and/or middle ear while having a normal inner ear function. In CHL, the audiogram typically shows normal bone conduction (0–25 dB) and abnormal air conduction threshold levels (higher than 25 dB). According to the American Speech-Language-Hearing Association, a difference greater than 10 dB is considered a significant air–bone gap and requires the use of masking to eliminate a response from the ear not being tested, hence obtaining true thresholds from the test ear [4]. CHL can affect all frequency ranges. However, the low (250–500 Hz) or low and mid-range (250 Hz–2 kHz) frequencies are most commonly affected (Figure 3). The worst scenario of CHL is a loss of 60 dB or more. In the case of a total absence of the conductive function of the ear, sound waves can reach the cochlea through skull vibration and fluid movement. Most of the CHL cases are treatable with medication, surgery, amplification, assistive devices, or a combination of these. A common cause of CHL is the absence or malformation of the outer ear, ear canal, or middle ear structures. Atresia and microtia are such examples. Conductive pathologies include otosclerosis and cholesteotoma. The latter being a cystic mass of epithelial cells and cholesterol that occlude the middle ear and produce enzymes that may destroy adjacent bones. Tympanosclerosis, a consequence of chronic otitis media, is a condition of the middle ear cleft in which there are calcareous deposits in the tympanic membrane and the ossicular chain leading to CHL due to stiffness and reduced mobility. Other common causes of CHL include occlusion of the ear canal due to wax buildup or by a foreign object, perforated or scarred eardrum, outer ear (otitis externa) inflammation, or inner ear (otitis media) inflammation, trauma which causes injury to the tympanic membrane and/or ossicles, fluid accumulation, allergies, dysfunction of the Eustachian tube that normally drains fluid from the ear to the back of the throat, and benign tumors.
SNHL is a hearing loss that occurs as a result of damage in the cochlea or beyond, that is, either along the 8th cranial nerve or in the brain. SNHL can cause complete loss of hearing, despite the outer ear and middle ear being normal. Individuals with SNHL demonstrate similar air and bone conduction thresholds. The sensory component is usually due to the damage to the organ of Corti or to an inability of hair cells to stimulate the auditory nerve. The neural component refers to when damage is proximal to the cochlea and auditory nerve; the term retrocochlear damage is also used. SNHL may be the result of perinatal infections such as rubella, herpes, toxoplasmosis, syphilis, and cytomegalovirus. Birth complications associated with SNHL include asphyxia and low birth weight. Later onset causes of SNHL include infections such as meningitis, labyrinthitis, mumps, scarlet fever, and measles. Long exposure to loud noise induces SNHL by direct mechanical damage of inner ear structures. The US Occupational Safety and Health Administration require ear protection in the work area when an average exposure of 85 dB is reached. Severe SNHL may also occur after sudden exposure to a loud noise at 120–155 dB, for example from explosions, fireworks, gunfire, and music concerts. Other causes of SNHL include malformation of the inner ear, aging, Meniere’s disease, drug-induced ototoxicity, and tumors such as acoustic neuroma. SNHL often cannot be reversed. Figure 4 shows an audiogram with SNHL.
Mixed hearing loss is a type of hearing loss that has a combination of conductive and sensorineural damage in the same ear. Cases where both an air–bone gap greater than 10 dB and an elevated bone conduction threshold are observed suggest a mixed hearing loss. While the conductive component may be treated, the sensorineural component is more of a challenge. Figure 5 shows an audiogram with mixed hearing loss.
2.3.3. Degree of hearing loss
Hearing loss can be classified according to the severity or degree of the disease. Hearing losses between 26 and 40 dB are considered mild, 41 and 55 dB moderate, 56 and 70 dB moderately severe, 71 and 90 dB severe, and greater than 91 dB profound (Table 1) [5, 6]. Severity of hearing loss is based on thresholds at individual frequencies. Once the type and degree of loss are established, an appropriate intervention may be assigned. This may include hearing aids, aural rehabilitation, cochlear implants, medical intervention, or surgery.
|
|
Normal hearing | –10–15 |
Slight | 16–25 |
Mild | 26–40 |
Moderate | 41–55 |
Moderately severe | 56–70 |
Severe | 71–90 |
Profound | >91 |
2.3.4. Configuration of hearing loss
Hearing losses may be categorized according to the audiometric configuration, that is, the shape or pattern of the audiogram across the frequency spectrum [7]. The configuration of an audiogram will tell you which sounds are best heard. A hearing loss that is more or less the same at all frequencies is depicted as a straight horizontal line on the audiogram and is thus appropriately called a
References
- 1.
Multi-country assessment of national capacity to provide hearing care. WHO [Internet]. 2013. Available from: http://www.who.int/pbd/publications/WHOReportHearingCare_Englishweb.pdf [Accessed: 20150215]. - 2.
Millions of people in the world have hearing loss that can be treated or prevented—awareness is the key to prevention. WHO [Internet]. 2013. Available from: http://www.who.int/pbd/deafness/news/Millionslivewithhearingloss.pdf [Accessed: 20150215]. - 3.
Kandel et al. Principles of Neural Science. 5th ed. McGraw-Hill, New York; 2013; 655p. - 4.
Guidelines for manual pure-tone threshold audiometry [Guidelines]. American Speech-Language-Hearing Association. 2005. Available from: www.asha.org/policy [Accessed: 20150215]. - 5.
Clark JG: Uses and abuses of hearing loss classification. ASHA. 1981 Jul;23(7):493–500. - 6.
Baiduc RR, Poling GL, Hong O, Dhar S: Clinical measures of auditory function: the cochlea and beyond. Dis Mon. 2013 Apr;59(4):147–156. DOI: 10.1016/j.disamonth.2013.01.005. - 7.
Pittman AL, Stelmachowicz PG: Hearing loss in children and adults: audiometric configuration, asymmetry, and progression. Ear Hear. 2003 Jun;24(3):198–205.