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Hearing Impairment
N i s a Maruthur, M.D., M.H.S.

Johns Hopkins Diabetes Guide

Complications and Comorbidities

Ophthalmology Otology

DEFINITION
Refers to either: 1 ) sensorineural hearing i m p a i r m e n t, characterized b y frequency a n d intensity o f hearing loss o r 2) conductive hearing loss . In diabetes, the increased prevalence o f sensorineural hearing i m p a i r m e n t likely related to microvascular disease .

EPIDEMIOLOGY
In those with diabetes, overall likelihood o f sensorineural hearing i m p a i r m e n t approximately 2 times that in those without diabetes[Bainbridge, 2008]. Both low- a n d high-frequency hearing i m p a i r m e n t far more c o m m o n a m o n g those with diabetes. Age-adjusted prevalence o f mild o r greater high-frequency hearing i m p a i r m e n t a m o n g those with diabetes is 54 .1%. Age-adjusted prevalence o f mild o r greater low-frequency hearing i m p a i r m e n t a m o n g those with diabetes is 21 .3%. Age, noise , ototoxic medications, a n d s m o k i n g increase risk o f hearing i m p a i r m e n t along with presence o f microvascular conditions.

DIAGNOSIS
History : presence o r absence o f subjective hearing i m p a i r m e n t, timing, occupational history, trauma, medications , family history, family m e m b e r response Self -report : defined b y audiometry pure -tone threshold . "Y e s " response h a s likelihood ratio (LR ) positive o f 2 .5 (95% C I 1.7 to 3.6). "No " response h a s LR negative o f 0.13 (95% C I 0 .09 - 0.19). Family m e m b e r response m a y have s o m e value. Whispered voice perception : standing behind patient with untested e a r occluded b y e x a m i n e rs finger, e x a m i n e r whispers combination o f 3 numbers a n d letters a n d can r e p e a t once more . Normal if 3/6 letters o r numbers repeated b y patient. Inability to perceive whispered voice h a s LR positive o f 6.1 (95 % C I 4.5 - 8.4). Normal perception h a s LR negative o f 0.03 (95% C I 0 -0 .24). Weber test : positive if tuning fork vibrating o n middle o f forehead perceived a s louder o n o n e side (lateralization). Suggests conductive hearing loss o n l o u d e s t side o r sensorineural loss o n diminished side. Not u s e f u l if bilateral, symmetric hearing loss since the test d e p e n d s o n lateralization. A b n o r m a l result: LR positive o f 1.6 (95% C I 1.0 - 2 .3). Rinne test : to evaluate for conductive hearing loss, place vibrating tuning fork o n mastoid process (b o n e conduction , BC ) until s o u n d is n o t heard , then move to 1 inch from external m e a t u s (air conduction , AC ) to s e e if s o u n d still heard . Normal: AC >BC . A b n o r m a l test: LR positive 2.7 to 62 . Normal test: LR negative 0.01 to 0 .85. Evaluate for other m e d i c a l causes o f hearing i m p a i r m e n t such a s syphilis (i.e . fluorescent t r e p o n e m a l antibody absorption test). Otoscopy to evaluate external e a r canal a n d tympanic m e m b r a n e I m a g i n g with M R I o r C T to evaluate for acoustic n e u r o m a o r other abnormality Referral for audiologic e x a m i n a t i o n b y audiologist

SIGNS AND SYMPTOMS

Progressive difficulty hearing a t low o r high-frequencies a n d /o r different s o u n d intensities Difficulty hearing a s evidenced b y self-report, whispered voice perception , W e b e r o r R i n n e tests M a y have associated vertigo o r tinnitus

CLINICAL TREATMENT
T r e a t m e n t o f external a n d middle e a r disorders (e .g ., cerumen impaction a n d otitis media ) Avoid /discontinue ototoxic medications (e .g . aminoglycosides, loop diuretics , salicylates a n d nonsteroidal antinflammatories , vancomycin , a n d erythromycin ). Consultation with audiologist a n d /o r otolaryngologist for hearing aids a n d other hearing assistive devices.

FOLLOW UP
Screen b y inquiring a b o u t subjective hearing i m p a i r m e n t periodically (Update from United States Preventive Services T a s k Force in progress) Counseling regarding hearing aids Referral for f o r m a l audiological e x a m i n a t i o n if hearing i m p a i r m e n t suspected.

EXPERT COMMENTS
Inquire a b o u t subjective hearing i m p a i r m e n t every 6 m o n t h s during regular diabetes follow-u p visits . I n p u t from family m e m b e r s m a y b e helpful in determining presence a n d e x t e n t o f hearing i m p a i r m e n t. T h o u g h there is n o convincing data a t this time, if diabetes-related hearing loss is i n d e e d d u e to microvascular d i s e a s e , blood pressure a n d glycemic control should p l a y a role in prevention a n d treatment o f this complication. C o m p a r i s o n o f initial office -b a s e d tests for hearing i m p a i r m e n t suggests that W e b e r a n d R i n n e tests have limited value a n d that referral for audiometry should b e b a s e d o n patients subjective report o f hearing loss a n d /o r a b n o r m a l whispered-voice test[B a g a i, 2006].

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References
1. Bainbridge KE, H o f f m a n HJ, Cowie C C : Diabetes a n d hearing i m p a i r m e n t in the United States: audiometric evidence from the National Health a n d Nutrition Examination Survey, 1999 to 2004. Ann Intern Med 149:1, 2008 July 1 [PMID:18559825]
Comment: Nationally- representative analysis of the relationship between diabetes and hearing impairment in the U .S .

2. B a g a i A, Thavendiranathan P , Detsky AS : D o e s this patient have hearing i m p a i r m e n t? JAMA 295:416, 2006 Jan. 25 [PMID:16434632]
Comment: Systematic review of bedside clinical maneuvers to evaluate hearing impairment.

3. Korsch B: C o m m e n t a r y : screening for psychosocial p r o b l e m s. Pediatrics 58:471, 1976

[PMID:972790 ]

Comment: Results from a cohort study of aging in Wisconsin showing a m o d e s t association between type 2 diabetes and hearing l o s s but no association between glycemic control and hearing l o s s

4. U .S. Preventive Services T a s k Force .; Screening for Hearing I m p a i r m e n t in O l d e r Adults , Topic P a g e . U .S. Preventive Services T a s k Force . A H R Q , Rockville , MD.; http ://www.ahrq .g o v/clinic /uspstf/u s p s h e a r.htm ;
Comment: Screening guidelines for hearing impairment in the U .S from U .S . Preventive Services T a s k F o r c e. Update in progress.

5. C u m m i n g s a n d H a u g h e y; C u m m i n g s Otolaryngology: H e a d & Neck Surgery , 4th edition., M o s b y , In c. (Sensorineural Hearing Loss: Evaluation a n d M g m t in Adults ). Section o n Etiology o f SNHL (pharmacologic toxicity) Elsevier; V o l. Part Fourteen, C h a p t e r 155
Comment: Preeminent reference for otolaryngology .

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