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Pathogenesis of Hearing Loss

The mechanism of hearing loss will be much more understood if we first know about
how is the physiology or the nature of hearing process is occured, start from the
sound that move into the ear until reach the brain and recognise as sound is a
multistep process and need a comprehensive understanding. This process of hearing
can be divided into six basic steps: (Figure 1730) (sitasi1)

1. Sound waves arrive at the tympanic membrane. Sound waves enter the
external acoustic meatus and travel toward the tympanic membrane. The
orientation of the auditory canal provides some directional sensitivity. Sound
waves approaching a particular side of the head have direct access to the tympanic
membrane on that side, whereas sounds arriving from another direction must bend
around corners or ass through the auricle or other body tissues.

2. Movement of the tympanic membrane causes displacement of the auditory


ossicles. The tympanic membrane provides a surface for the collection of sound,
and it vibrates in resonance to sound waves with frequencies between
approximately 20 and 20,000 Hz. When the tympanic membrane vibrates, so do
the malleus, incus, and stapes. In this way, the sound is amplified.
3. Movement of the stapes at the oval window establishes pressure waves in the
perilymph of the scala vestibuli. Liquids are not compressible: If you push
down on one part of a waterbed, the bed bulges somewhere else. Because the rest
of the cochlea is sheathed in bone, pressure applied at the oval window can be
relieved only at the round window. Although the stapes actually has a rocking
movement, the inout component is easiest to visualize and describe. Basically,
when the stapes moves inward, the round window bulges outward, into the middle
ear cavity. As the stapes moves in and out, vibrating at the frequency of the sound
arriving at the tympanic membrane, it creates pressure waves within the
perilymph.
4. The pressure waves distort the basilar membrane on their way to the round
window of the scala tympani. The stapes create pressure waves that travel
through the perilymph of the scala vestibuli and scala tympani to reach the round
window. In doing so, the waves distort the basilar membrane. The location of
maximum distortion varies with the frequency of the sound, due to regional
differences in the width and flexibility of the basilar membrane along its length.
Highfrequency sounds, which have a very short wavelength, vibrate the basilar
membrane near the oval window. The lower the frequency of the sound, the
longer the wavelength, and the farther from the oval window will the area of
maximum distortion occur (Figure 1731ac). Thus, information about frequency
is translated into information about position along the basilar membrane. The
amount of movement at a given location depends on the amount of force applied
by the stapes, which in turn is a function of energy content of the sound. The

louder

the

sound,

the

more

the

basilar

membrane

moves.

5. Vibration of the basilar membrane causes vibration of hair cells against the
tectorial membrane. Vibration of the affected region of the basilar membrane
moves hair cells against the tectorial membrane. This movement leads to the
displacement of the stereocilia, which in turn opens ion channels in the plasma
membranes of the hair cells. The resulting inrush of ions depolarizes the hair

cells, leading to the release of neurotransmitters and to the stimulation of sensory


neurons. The hair cells of the spiral organ are arranged in several rows. A very
soft sound may stimulate only a few hair cells in a portion of one row. As the
intensity of a sound increases, not only do these hair cells become more active,
but additional hair cellsat first in the same row and then in adjacent rowsare
stimulated as well. The number of hair cells responding in a given region of the
spiral organ provides information on the intensity of the sound.
6. Information about the region and the intensity of stimulation is relayed to
the CNS over the cochlear branch of cranial nerve VIII. The cell bodies of the
bipolar sensory neurons that monitor the cochlear hair cells are located at the
center of the bony cochlea, in the spiral ganglion (Figure 1728a). From there,
the information is carried by the cochlear branch of cranial nerve VIII to the
cochlear nuclei of the medulla oblongata for subsequent distribution to other
centers in the brain.

From the explanation above, there are at least two types of hearing lost: conductive
and sensorineural hearing loss. The conductive hearing loss occurs when sound
waves cannot get conducted efficiently through the outer ear canal to the eardrum and
ossicles and in the end reach the cochlea. The second types is sensorineural hearing
loss, this is the most common type of permanent hearing loss, occurs when there is a
problem with the cochlea or with its nerve connections to the brain. Most of the case
cannot be treated by medicine or surgical. This sensorineural deafness will reduces
the ability to hear faint sound, even if the speech is loud enough to hear, it may still
be unclear or sound muffled. (sitasi2, sitasi3)
Some possible causes of conductive hearing loss are fluid in the middle ear from
colds, ear infection (otitis media), allergies (serous otitis media), poor eustachian tube
function, perforated eardrum, benign tumors, impacted earwax (cerumen), infection
in the ear canal (external otitis), presence of a foreign body and malformation of the
outer ear, ear canal, or middle ear. (sitasi3) Whereas the sensorineural deafness can be
caused by toxic drug, genetic (congenital), aging process, head trauma, malformation
of inner ear, and exposure to loud noise. (sitasi3).
The patogenesis on how this disease or situation can cause hearing loss is vary
depend on the disease. First let we discuss conductive hearing loss. Any obstruction
that lies between the outer part of ear and eardrum like: benign tumors, impacted
earwax (cerumen), infection in the ear canal (external otitis), presence of a foreign
body and malformation of the outer ear and ear canal can cause this type of hearing
loss. This obstruction (cerumen, benign tumor, infection, foreign body, malformation)
will block sound wave to reach the cochlea then cause deafness. The presence of fluid
in middle ear or infection (otitis media), allergies (serous otitis media), poor
eustachian tube function (poor balance preasure between middle and outer ear), or
even perforated eardrum will disturb amplification process of sound wave in middle
ear, so that the wave poorly transfer to the cochlea and cause deafness.(sitasi2,
sitasi3)
The sensorineural deafness occur when the cochlea or nerve pathways from the inner
ear to the brain is damage.(sitasi3) This can be caused by toxic drug that damage the
cranial nerve VIII, head trauma that damage cochlea or nerve hearing, and
malformation of inner ear. This sensorineural deafness also can be caused by aging

process and long exposure to loud noise such as loud music, machinery, lawn
mowers, etc. This long exposure to loud noise make injury of the hair cell in cochlea,
so that cochlea gradually loss their ability to change sound energy to electrical signal
that will send to brain.(sitasi4)

References
1. Anonim. National Institute of Deafness and Other Communication
Disorders (NIDCD). [Online].; 2014 [cited 2015 January 11. Available
from: http://www.nidcd.nih.gov/health/hearing/pages/noise.aspx.
3. Martini F, Judi N, Edwin B, William O. Fundamentals of Anatomy &
Physiology. 9th ed. CA: Pearson Education; 2011.
4. Anonim. American Speech Language Hearing Association. [Online].
[cited 2015 January 10. Available from:
http://www.asha.org/public/hearing/.

2. Warren E. ENT in primary care: part 6 Deafness and tinnitus. Practice Nurse 2008
Jul 25;36(2):15-18.

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