Hearing loss is among the most common chronic conditions in adults and is linked to social isolation, depression, falls, and cognitive decline. Classification is based on where the pathway fails:
| Type | Site | Common causes | Features |
|---|
| Conductive | External or middle ear — sound cannot reach the inner ear | Cerumen impaction, otitis media, effusion, perforation, otosclerosis | Sounds are quieter but clear when loud; often treatable |
| Sensorineural | Cochlea (hair cells) or auditory nerve | Presbycusis (aging), noise exposure, ototoxic drugs, sudden sensorineural loss, Ménière disease, acoustic neuroma, infection (meningitis, congenital) | Sounds are quieter and distorted; usually permanent |
| Mixed | Both | e.g., chronic otitis media with inner ear damage | Features of both |
Presbycusis is gradual, bilateral, symmetric sensorineural loss that affects high frequencies first. Consonants (s, f, th, sh) become hard to hear, so speech sounds mumbled, and understanding in background noise is especially poor.
Noise-induced hearing loss results from repeated or intense sound damaging hair cells; it is permanent but preventable. Early signs are temporary threshold shift and tinnitus after exposure; the audiogram shows a characteristic notch near 4,000 Hz.
Sudden sensorineural hearing loss (SSNHL) is loss of at least 30 dB in three consecutive frequencies developing within 72 hours, usually in one ear. It is an otologic emergency because treatment benefit falls with time.
Ototoxicity — drugs that damage the cochlea or vestibular system:
| Drug group | Notes |
|---|
| Aminoglycosides (gentamicin, tobramycin, amikacin, streptomycin) | Can be permanent; risk rises with high levels, long courses, kidney impairment, loop diuretics |
| Platinum chemotherapy (cisplatin) | Dose-related, often permanent; baseline and serial audiograms |
| Loop diuretics (furosemide, bumetanide) | Mostly with high doses, rapid IV push, or kidney failure; often reversible |
| High-dose salicylates | Tinnitus is an early sign; reversible |
| Others | Quinine and hydroxychloroquine, vancomycin (especially combined with aminoglycosides), high-dose IV macrolides (erythromycin, azithromycin) |
Benign paroxysmal positional vertigo (BPPV), often grouped with ear disorders, is caused by displaced otoconia (ear crystals) in a semicircular canal; brief spinning vertigo is triggered by changes in head position. Hearing is normal.
Subjective
- Asking others to repeat, turning up the TV, difficulty on the phone or in groups
- Tinnitus, aural fullness, dizziness
- Noise, medication, family, and infection history; onset (sudden vs. gradual)
Objective
- Speaking loudly, leaning in, watching lips, inappropriate answers
- Whisper test, otoscopy (cerumen, fluid, perforation)
- Withdrawal, frustration, apparent confusion (can be mistaken for cognitive impairment)
| Test | Interpretation |
|---|
| Pure-tone audiometry | Compares air conduction and bone conduction thresholds. Air–bone gap = conductive; both reduced equally with no gap = sensorineural; both reduced with a gap = mixed |
| Weber test (fork on the midline of the skull) | Sound lateralizes to the affected ear in conductive loss and to the better ear in sensorineural loss |
| Rinne test (fork on mastoid then beside the ear) | Normal: air conduction longer than bone. Bone longer than air = conductive loss |
| Speech audiometry | Word recognition; helps hearing aid fitting |
| Tympanometry | Middle ear fluid or eardrum mobility |
| MRI with gadolinium | One-sided or asymmetric sensorineural loss — exclude acoustic neuroma (vestibular schwannoma) |
| Dix–Hallpike maneuver | Reproduces positional vertigo and nystagmus in BPPV |
| Drug levels | Aminoglycoside peak and trough (or AUC) monitoring |
- Cerumen impaction: softening drops, irrigation, or manual removal (avoid irrigation with a perforated eardrum)
- Conductive causes: treat infection or effusion; tympanoplasty; stapedectomy for otosclerosis
- SSNHL: audiometry as soon as possible (within 14 days); corticosteroids (oral or intratympanic) may be offered within 2 weeks of onset; hyperbaric oxygen with steroids within 2 weeks is an option; MRI to rule out retrocochlear cause
- Hearing aids: amplify sound; over-the-counter hearing aids are available in the US for adults 18 and older with perceived mild to moderate loss; prescription devices for severe loss and children
- Cochlear implants: for severe to profound sensorineural loss with limited benefit from hearing aids; an internal receiver and electrode array plus an external processor. Extensive auditory rehabilitation follows
- Assistive devices: captioned phones, TV listening systems, visual or vibrating alarms and doorbells
- BPPV: canalith repositioning (Epley maneuver) is first-line; routine vestibular suppressant drugs are not recommended
Drug safety — preventing iatrogenic loss
| Drug | Nursing safety actions |
|---|
| Aminoglycosides | Monitor levels and kidney function (creatinine, urine output); avoid combining with loop diuretics when possible; ask daily about tinnitus, fullness, hearing change, dizziness; also nephrotoxic |
| Loop diuretics | Give high IV doses slowly (furosemide not faster than about 4 mg/min at high doses); monitor potassium and hearing |
| Cisplatin | Baseline audiogram before treatment and monitoring during treatment; hydration protocols |
| Salicylates | Report tinnitus — may signal toxicity |
| Systemic corticosteroids (SSNHL) | Hyperglycemia (monitor glucose in diabetes), insomnia, mood change, GI upset, BP rise; take in the morning with food; do not stop abruptly after longer courses |
Listed in priority order.
- Safety
- Make sure the client can call for help — a standard voice intercom may not work; provide a light-signal or vibrating call system, check on the client often, and flag the chart and door ("Hearing impaired")
- Visual fire alarms; ensure alarms and important instructions are communicated visually
- BPPV and vestibular problems: fall precautions; rise slowly, sit before standing
- Communication strategies
- Get attention first (gentle touch or wave); face the client in good light, at eye level, with the mouth visible
- Speak slowly and clearly in a normal or slightly louder voice — do not shout (shouting distorts speech and raises pitch); lower the pitch
- Reduce background noise (TV off, close door)
- Rephrase rather than repeat the same words if not understood
- Use writing, pictures, captioned devices, or qualified sign-language interpreters — not family members — for consent and complex information
- Confirm understanding with teach-back
- Hearing aid and implant care in hospital
- Keep devices with the client and in use; document; store in a labeled case when removed
- Check batteries or charge; remove before MRI, showering, or radiology as required
- Sudden hearing loss — establish the exact time of onset and arrange urgent evaluation
- Prevention — medication review for ototoxic drugs; hearing conservation in the workplace
Hearing aids
- Wear them daily and increase wearing time gradually; the brain needs weeks to adjust
- If sounds seem too loud or whistle (feedback), first check fit and adjust the volume — contact the audiologist if discomfort persists
- Clean daily with a dry soft cloth; keep dry — remove for bathing, swimming, and hair spray; store in a dry case; open the battery door at night (disposable-battery models; place rechargeable aids in their charger)
- Keep batteries away from children and pets (swallowing hazard)
Cochlear implant
- Always tell providers before any MRI; many implants need special precautions, magnet removal, or are MRI-unsafe
- Protect the external processor from water; watch the incision and skin under the magnet for redness or swelling (infection)
- Keep up with rehabilitation; progress in speech understanding is gradual
Noise protection
- Use earplugs or earmuffs around loud machinery, concerts, and firearms; follow the "too loud, too long, too close" rule; keep personal audio at a moderate level
- Workers exposed to hazardous noise should have regular hearing tests through a hearing conservation program
BPPV
- Avoid sudden head movements, rise slowly, sleep with the head slightly raised; repositioning exercises as taught
General
- Report sudden hearing loss the same day
- Report tinnitus, fullness, or dizziness while taking aminoglycosides, cisplatin, or high-dose aspirin
- Do not use cotton swabs; have wax removed by a clinician if impacted
| Issue | What to watch for |
|---|
| Sudden hearing loss | Rapid one-sided loss — urgent referral |
| One-sided loss with tinnitus | Acoustic neuroma — MRI |
| Ototoxicity | New tinnitus, fullness, hearing loss, unsteadiness during drug therapy |
| Social isolation and depression | Withdrawal, low mood |
| Misattributed confusion | Hearing loss mistaken for dementia or delirium |
| Falls | Vestibular involvement, BPPV |
| Implant infection | Redness, swelling, fever near the implant |
- Face the client, show the mouth, speak slowly, clearly, lower pitch — do not shout
- Reduce background noise; rephrase rather than repeat
- Call system the client can use is a safety priority on admission
- Presbycusis: high-frequency sensorineural loss; worst in background noise
- Air–bone gap = conductive; no gap with both reduced = sensorineural
- Weber lateralizes to the bad ear in conductive, good ear in sensorineural
- Sudden hearing loss: record exact time of onset; steroids within 2 weeks
- Ototoxic drugs: aminoglycosides, cisplatin, loop diuretics (fast IV), high-dose salicylates
- Hearing aid too loud: adjust volume and fit first
- Cochlear implant: check before MRI
- Noise-induced loss: preventable — ear protection, regular workplace audiograms
- BPPV: avoid sudden head movements; Epley maneuver
Country Notes
United States
- OTC hearing aids (FDA final rule effective October 2022) can be bought without an exam by adults with perceived mild to moderate loss; children and severe loss still need prescription devices.
- Occupational noise exposure is regulated by OSHA, which requires hearing conservation programs above set exposure levels.
Philippines
- RA 9709 (Universal Newborn Hearing Screening and Intervention Act of 2009) requires hearing screening of hospital-born infants before discharge, or within 3 months for infants born outside hospital, unless parents decline.
- Hearing aids are largely paid out of pocket; clients may benefit from referral to government or charitable assistance programs.