Hearing Loss

	Overview
	Health Tools
	Frequently Asked Questions
	Cause
	Symptoms
	When to Call a Doctor
	Exams and Tests
	Treatment Overview
	Prevention
	Living With Hearing Loss
	Other Places To Get Help
	Related Information
	References
	Credits

What is hearing loss?

Hearing loss is a sudden or gradual decrease in how well you can hear. Depending on the cause, it can range from mild to severe and can be reversible, temporary, or permanent. Hearing loss is also known as hearing impairment, which includes being born without hearing (congenital hearing loss). This topic focuses only on gradual hearing loss.

Gradual hearing loss affects people of all ages and is the third most common long-term (chronic) health problem in older Americans.¹ It affects up to 40% of people age 65 and older and up to 80% of people older than 85.²

If you have hearing loss, you may not be aware of it, especially if it has developed gradually. Your family members or friends may be the first to notice. For example, they may notice that you are having difficulty understanding what people are saying, especially when many people are talking at the same time or there is background noise, such as a radio playing.

Hearing loss can affect what and how much you do in the workplace and at home and can also affect your personal safety. Because it may result in less social interaction, hearing loss may contribute to loneliness, depression, and loss of independence. However, hearing aids and other devices are available to help you hear.

What causes hearing loss?

In adults, the most common causes of hearing loss are:

• Noise. Noise-induced hearing loss can affect people of all ages and most often develops gradually over many years. Over a long period of time, the noise you experience at work, during recreation (such as listening to very loud music), or even during common chores (such as using a power lawn mower) can lead to hearing loss.
• Age. In age-related hearing loss (presbycusis), changes in the inner ear that occur as you grow older cause a gradual but steady hearing loss. The loss may be mild or severe, but it is always permanent.

Other causes of hearing loss include earwax buildup, an object in the ear, injury to the ear or head, ear infection, a ruptured eardrum, and other conditions that affect the middle or inner ear.

What are the symptoms?

Common symptoms of hearing loss include muffled hearing and a feeling that your ear is plugged. You may have difficulty understanding what people are saying, and you may listen to the television or radio at higher volume than in the past and avoid conversation and interaction with other people. Other symptoms may include ringing, roaring, hissing, or buzzing in the ear (tinnitus). Or you may have ear pain, itching, or irritation, or fluid leaking from the ear. You may also have a feeling that you or your surroundings are moving when there is no movement (vertigo).

How is hearing loss diagnosed?

Your doctor will diagnose hearing loss by asking questions about your symptoms and past health and by doing a physical exam. If your doctor thinks you have hearing loss, he or she may use a "whisper" test or tuning fork to test your hearing. If these tests suggest or show hearing loss, your doctor will do a more complete hearing (audiologic) test to see whether you have hearing loss, how severe the loss is, and which part of the ear is affected.

How is it treated?

You treat noise-induced or age-related hearing loss by using hearing devices (such as hearing aids) and learning how to live with reduced hearing, such as paying attention to people's gestures, facial expressions, posture, and tone of voice. In other types of hearing loss, treating the problem that caused the hearing loss, such as removing earwax or taking medicine for an infection, results in the return of normal hearing.

Can you prevent hearing loss?

You can prevent noise-related hearing loss by avoiding loud noise such as that made by machines in the workplace, power tools, very loud music, and very loud motorcycles. Wear hearing protection, such as earplugs or earmuffs, if necessary. To protect yourself from hearing loss because of injury, avoid putting objects in your ear, wear seat belts when you drive, and wear helmets when you bike, ski, or participate in similar activities in which there is the potential for ear injury.

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	Should I get a hearing aid?

In adults, the most common causes of hearing loss are:

• Noise.Noise-induced hearing loss can affect people of all ages and most often develops gradually over many years. Over time, the noise experienced at work, during recreation (such as riding motorcycles), or even common chores (such as using a power lawn mower) can lead to hearing loss.
• Age. In age-related hearing loss (presbycusis), changes in the nerves and cells of the inner ear that occur as you get older cause a gradual but steady hearing loss. The loss may be mild or severe, but it is always permanent.

Other causes of hearing loss include:

• Earwax buildup or an object in the ear. Hearing loss because of earwax is common and easily treated.
• Ototoxic medicines (such as certain antibiotics) and other substances (such as arsenic, mercury, tin, lead, and manganese) that can damage the ear.
• Injury to the ear or head. Head injuries can also damage the structures in the ear and cause a sudden hearing loss.
• Ear infection, such as a middle ear infection (otitis media) or an infection of the ear canal (otitis externa or swimmer's ear).
• Fluid in the middle ear after a cold or the flu, or after traveling on an airplane.
• Otosclerosis, a condition that affects the bones of the middle ear.
• Acoustic neuroma, a noncancerous tumor on the nerve that helps people hear.
• Ménière's disease. Ménière's disease may result in temporary or permanent hearing loss.
• Noncancerous (benign) growths in the ear canal, such as exostoses, osteomas, and glomus tumors. Exostoses are bone growths that often develop when the ear canal is repeatedly exposed to cold water or cold air. Osteomas and glomus tumors are noncancerous tumors. These all can cause hearing loss if they block the ear canal. A glomus tumor that occurs elsewhere in the head can also affect hearing.

Other medical conditions that do not affect the ear directly may also cause hearing loss.

• An interruption of the blood flow to the inner ear or parts of the brain that control hearing may lead to hearing loss. This may be caused by heart disease, stroke, high blood pressure, or diabetes.
• Autoimmune hearing loss can occur in one or both ears and can come and go or get worse over 3 to 4 months. An autoimmune disease, such as rheumatoid arthritis, may be present.

What happens in hearing loss?

We hear sounds when sound energy goes through the ear's three main structures. In hearing loss, one or more of these structures is damaged. These structures are the:

• External ear canal.
• Middle ear, which is separated from the ear canal by the eardrum.
• Inner ear, which contains the cochlea, the main sensory organ of hearing.

Which part of the ear is affected determines the type of hearing loss.

• In conductive hearing loss, sound energy is blocked before it reaches the inner ear. Examples of conductive hearing loss include earwax or a growth blocking sound, such as occurs in otosclerosis.
• In sensorineural hearing loss, sound reaches the inner ear, but a problem in the inner ear or the nerves that allow you to hear (auditory nerves) prevent proper hearing. Examples of sensorineural hearing loss include both noise-induced and age-related hearing loss. More than 90% of hearing loss is sensorineural, and of this group, age-related hearing loss is the most common.²

A mixed hearing loss, in which both the conductive and sensorineural systems are affected, can also occur.

Another type of hearing loss is central hearing loss. In this type of hearing loss, the ear works, but the brain has trouble understanding sounds because the parts that control hearing are damaged. It may occur after a head injury or stroke. This type of hearing loss is rare.

Undiagnosed and untreated hearing loss can contribute to depression, social isolation, and loss of independence, especially in older adults.

Symptoms of hearing loss include:

• Muffled hearing.
• Difficulty understanding what people are saying, especially when there are competing voices or background noise. You may be able to hear someone speaking, but you cannot distinguish the specific words.
• Listening to the television or radio at higher volume than in the past.
• Avoiding conversation and social interaction. Social situations can be tiring and stressful if you do not hear well. You may begin to avoid those situations as hearing becomes more difficult.
• Depression. Many adults may be depressed because of how hearing loss is affecting their social life.

Other symptoms that may occur with hearing loss include:

• Ringing, roaring, hissing, or buzzing in the ear (tinnitus).
• Ear pain, itching, or irritation.
• Pus or fluid leaking from the ear. This may result from an injury or infection that is causing hearing loss.
• Vertigo, which can occur with hearing loss caused by Ménière's disease, acoustic neuroma, or labyrinthitis.

The type of hearing loss you have often determines how well you hear in certain situations:

• If something is blocking sound from moving to the inner ear (conductive hearing loss), then the loss will be the same for low and high tones. As long as people speak loudly enough, you will still be able to tell the difference between similar sounding words (such as "thigh" and "high") and be able to hear with a noisy background. Examples of conductive hearing loss include earwax or a growth blocking sound, such as occurs in otosclerosis.
• If the inner ear is not working correctly (sensorineural hearing loss), then high tones (such as women's or children's voices) will be more difficult to hear than low sounds. It will probably be difficult to hear when there is background noise. Examples of sensorineural hearing loss include age-related and noise-induced hearing loss.

People who have hearing loss are sometimes not aware of it, especially when the loss has developed gradually, as is often the case in noise-induced and age-related hearing loss. Family members or friends often are the first to notice the hearing loss. Evaluate your hearing by taking a hearing loss self-test.

Call 911 or other emergency services immediately if:

• Hearing loss occurs with an injury to the head or ear.
• Hearing loss occurs suddenly with other symptoms such as:
  • Facial droop.
  • Numbness or paralysis on all or one side of the face or body.
  • Eye or vision problems, including blurred or double vision or only being able to see out of one eye.
  • Slurred speech, not being able to speak, or difficulty understanding speech.
  • Difficulty standing or walking (ataxia).
  • Severe nausea or vomiting.

Call a doctor immediately if you:

• Develop sudden, severe hearing loss.

Call your doctor if you:

• Have hearing loss that you think may be caused by earwax.
• Have hearing loss after taking medicine.
• Have hearing loss after having cold or flu symptoms.
• Have hearing loss after traveling on an airplane.
• Feel your hearing is gradually getting worse.
• Wonder if you need a hearing aid.
• Think your baby or child may not be hearing well.

Watchful waiting

Watchful waiting is when you and your doctor watch symptoms to see if the health problem improves on its own. Although hearing loss is not usually dangerous, it can affect your personal safety. It can also reduce how much you can do in the workplace and at home and limit you socially. It is important that you talk to your doctor about hearing loss.

Who to see

Hearing loss can be diagnosed by:

• Family medicine physicians.
• Pediatricians.
• Internists.
• Physician assistants.
• Nurse practitioners.

If your doctor suspects or diagnoses hearing loss, he or she may have you see an ear, nose, and throat specialist (otolaryngologist) or an audiologist.

Your doctor will diagnose hearing loss by asking questions about your symptoms and past health (medical history) and by doing a physical exam. He or she may find during a routine visit that you have some hearing loss.

If you report symptoms of hearing loss or your doctor finds a possible hearing problem, he or she may ask you about recent or long-term exposure to loud noise, any medicine you are taking, and physical symptoms (such as muffled hearing, ringing in your ears, or vertigo). Your answers to these questions may help determine the cause of the hearing loss.

You will also have a physical exam of the ears. Your doctor will use a lighted instrument (an otoscope) and may find problems in the ear canal, eardrum, and middle ear, including earwax, an object or obstruction in the ear canal, infection or fluid in the ear, or injury to the ear.

If your exam, history, or symptoms suggest a hearing problem, your doctor may do a standard hearing (audiologic) evaluation.

Standard hearing evaluation

A standard hearing evaluation may consist of any or all of the following tests:

• The whisper test checks how well you hear whispered speech across a short distance and how well you understand speech.
• The tuning fork test helps to separate conductive hearing loss from sensorineural hearing loss.
• Pure tone audiometry checks how well you hear sounds traveling through the ear canal (air conduction) and through the bones (bone conduction). A doctor may be able to figure out what kind of hearing loss you have by comparing how well you hear using these two types of conduction. You listen to tones through earphones in this test.
• Speech reception and word recognition tests check how well you hear and understand speech.
• Acoustic immittance tests (tympanometry and acoustic reflex tests) measure the amount of sound energy that "bounces" back from the eardrum (tympanic membrane) and the bones of the middle ear instead of being sent on to the inner ear.
• Otoacoustic emissions (OAE) testing measures the inner ear's response to sound. Otoacoustic emissions are sounds made by the cochlea in response to a sound, such as a tone or click—think of them as a quiet echo. Ear specialists can record and interpret these sounds to help rule out hearing loss. OAE testing is often used to screen newborns for hearing problems.

Depending on the suspected cause of hearing loss, you may also have other tests:

• Imaging tests such as a CT scan or MRI may be done when an injury or tumor is suspected.
• Auditory brain stem response (ABR) testing may be used to test nerve pathways in the brain if your doctor suspects an acoustic neuroma or another nerve problem. This test measures how well the nerve that helps you hear is working and how fast sound travels along this nerve.

Early Detection

Hearing problems, even those that are mild, can delay your child's speech and language development. Early screening for hearing loss can help prevent a variety of learning, social, and emotional problems that can be related to speech and language development.³ Many states in the United States require newborn hearing tests for all babies born in hospitals. Talk to your doctor about whether your child has been or should be tested.

Signs of noise-induced hearing loss are appearing at earlier ages and in children.⁴ Be sure your child has regular hearing exams.

Treatment for temporary or reversible hearing loss usually depends on the cause of the hearing loss. Treatment for permanent hearing loss includes using hearing devices.

Although you and your family may view permanent hearing loss as part of aging, proper treatment is important. Hearing loss may contribute to loneliness, depression, and loss of independence. Treatment cannot bring back your hearing, but it can make communication, social interaction, and work and daily activities easier and more enjoyable.

Initial treatment

Treatment for reversiblehearing loss depends on its cause. It is often treated successfully. Hearing loss caused by:

• Ototoxic medicines (such as aspirin or ibuprofen) often improves after you stop taking the medicine.
• An ear infection, such as a middle ear infection, often clears up on its own, but you may need antibiotics.
• An injury to the ear or head may heal on its own, or you may need surgery.
• Otosclerosis, acoustic neuroma, or Ménière's disease may require medicine or surgery.
• An autoimmune problem is treated with corticosteroid medicines, generally prednisone.
• Earwax is treated by removing the wax. Do not use a cotton swab or a sharp object to try to remove the wax, since this may push the wax even deeper into the ear or may cause injury. For information on how to remove hardened earwax safely, see the topic Earwax.

In permanent hearing loss, such as age-related and noise-induced hearing loss, hearing devices can often improve how well you hear and communicate. These devices include:

• Hearing aids. Hearing aids make sounds louder (amplify). They do not restore your hearing, but they may help you function and communicate more easily. See a picture of a hearing aid.
• Assistive listening devices, alerting devices, and other communication aids.

  Should I get a hearing aid?

Ongoing treatment

Reversible hearing loss, such as loss that occurs because of earwax or ear infections, is generally cured after treating its cause. If you continue to have hearing problems in this situation, work with your doctor. You may need more medicine or surgery, depending on the cause of your hearing loss.

If you have permanent hearing loss, such as age-related and noise-induced hearing loss, you probably will continue to use a hearing aid. Your doctor or other hearing specialist may suggest occasional hearing tests to see whether your hearing has changed. If it has, your hearing aid may need adjustment.

See a picture of a hearing aid.

Other hearing devices you may consider include:

• Assistive listening devices. These devices make certain sounds louder by bringing the sound directly to your ear. You can use different types of devices for different situations, such as one-on-one conversations and classroom settings or auditoriums. Commonly used listening devices include telephone amplifiers, personal listening systems (such as auditory trainers and personal FM systems), and hearing aids that you can connect directly to a television, stereo, radio, or microphone.
• Alerting devices. These devices alert you to a particular sound (such as the doorbell, a ringing telephone, or a baby monitor) by using louder sounds, lights, or vibrations to get your attention.
• Television closed-captioning. Television closed-captioning makes it easier to watch television by showing the words at the bottom of the screen so that you can read them. Most newer TVs have a closed-captions option.
• TTY (text telephone). TTYs (also called TDD, or telecommunication device for the deaf) allow you to type messages back and forth on the telephone instead of talking or listening. When messages are typed on the TTY keyboard, the information is sent over the phone line to a receiving TTY and shown on a monitor. A telecommunications relay service (TRS) makes it possible to call from a phone to a TTY or vice versa.

Treatment if the condition gets worse

Age-related and noise-induced hearing loss may get worse, especially if you are continually exposed to harmful noise levels. Talk to your doctor or hearing specialist about adjusting your hearing aid. See an illustration of a hearing aid.

If you have severe hearing loss, a cochlear implant may be an option. This is a small electronic device that can help "make" sound if you have severe or total hearing loss. The implant does the job of the damaged or absent nerve cells that in a normal ear make it possible to hear.

What to think about

You can prevent your hearing loss from getting worse by avoiding loud noise as much as possible and using hearing protectors when you are in noisy environments, including the workplace.

Ask your family and friends to make adjustments when they talk with you, such as facing you so that you can better see their facial expressions and gestures, and speaking clearly.

You can prevent some types of hearing loss.

Noise-related hearing loss

Being exposed to loud noise over and over is one of the most common causes of permanent hearing loss. It usually develops slowly and without pain or other symptoms, and you may not notice that you have hearing loss until it is severe.

Steps you can take to lower your risk of noise-induced hearing loss include the following:

• Be aware of and avoid harmful noise. You can be exposed to harmful noise at work, at home, and in many other settings. This exposure builds up over time and can result in ear damage and hearing loss. Harmful noise can come from commonly used tools such as power lawn mowers and snowblowers or from activities such as riding motorcycles and snowmobiles. Know what kinds of situations can generate harmful noise levels, and avoid these situations whenever possible. For information about recommended noise limits and hearing protection in workplaces in the United States, contact the Occupational Safety and Health Administration (OSHA). (For more information, see the Other Places to Get Help section of this topic.)
• Use hearing protectors. If you know you are going to be around harmful noise, wear hearing protectors, such as earplugs or earmuffs. Cotton balls or tissues stuffed in the ears do not offer much protection. When used correctly, hearing protectors can go a long way in reducing the level of sound that reaches the ear. Lawn mowers, power tools, and some basic household appliances can damage your hearing if you do not wear hearing protectors.
• Control the volume when you can. Don't buy noisy toys, appliances, or tools when there are quieter alternatives. Reduce the noise in your life by turning down the volume on the stereo, television, or car radio, and especially on personal listening devices with earphones.

Do not wait until you notice a hearing loss to start protecting yourself from harmful noise. After noise-related damage to the ear is done, it cannot be reversed. But if you already have some noise-related hearing loss, it is not too late to prevent further damage and preserve the hearing that you still have.

Other preventable causes of hearing loss

To lower your risk of injury-related, medicine-related (ototoxic), and other types of hearing loss:

• Never stick a cotton swab, hairpin, or other object in your ear to try to remove earwax or to scratch your ear. In general, the best way to prevent earwax problems is to leave earwax alone. For information on how to remove hardened wax, see the topic Earwax.
• Ask your pharmacist or doctor whether the medicine you are taking may cause hearing loss (ototoxic medicine). If you develop a new hearing problem while taking medicine, tell your doctor.
• Always blow your nose gently and through both nostrils.
• During air travel, swallow and yawn frequently when the plane is landing. If you have an upper respiratory problem (such as a cold, the flu, or a sinus infection), take a decongestant a few hours before landing or use a decongestant spray just before landing.
• Learn and practice proper underwater descent techniques if you are going to scuba dive.
• Always wear your seat belt in the car, and wear a helmet when you bike, ski, or skate. These habits can lower your risk of head and ear injury.
• Stop smoking. You are more likely to have hearing loss if you smoke.

Signs of noise-induced hearing loss are appearing at earlier ages and in children.⁴ Be sure your child has regular hearing exams and follows the above suggestions to prevent noise-induced hearing loss.

Evaluate your hearing by taking a hearing loss self-test.

If you have hearing loss, you may find that it takes extra effort and energy to talk with others. Hearing may be especially difficult in settings where there are many people talking or there is a lot of background noise. The increased effort it takes to be with other people may cause stress and fatigue, and you may begin to avoid social activities, feel less independent, and worry about your safety.

Hearing devices you may want to use include:

• Hearing aids.Hearing aids make all sounds louder (amplify), including your own voice. Common background noises, such as rustling newspapers, magazines, and office papers, may be distracting. When you first get a hearing aid, it may take you several weeks to months to get used to this. See an illustration of a hearing aid.
• Assistive listening devices. These devices make certain sounds louder by bringing the sound directly to your ear. They shorten the distance between you and the source of sound and also reduce background noise. You can use different types of devices for different situations, such as one-on-one conversations and classroom settings or auditoriums, theaters, or other large public spaces. Commonly used listening devices include telephone amplifiers, personal listening systems (such as auditory trainers and personal FM systems), and hearing aids that you can connect directly to a television, stereo, radio, or microphone.
• Alerting devices. These devices alert you to a particular sound (such as the doorbell, a ringing telephone, or a baby monitor) by using louder sounds, lights, or vibrations to get your attention.
• Television closed-captioning. Television closed-captioning makes it easier to watch television by showing the words at the bottom of the screen so that you can read them. Most newer TVs have a closed-captions option.
• TTY (text telephone). TTYs (also called TDD, or telecommunication device for the deaf) allow you to type messages back and forth on the telephone instead of talking or listening. When messages are typed on the TTY keyboard, the information is sent over the phone line to a receiving TTY and shown on a monitor. A telecommunications relay service (TRS) makes it possible to call from a phone to a TTY or vice versa.

Many other communication devices, such as pagers, fax machines, e-mail, and custom calling features offered by phone companies, can be helpful. To get more information about selecting and using listening, alerting, and telecommunicating devices, talk to an audiologist or contact one of the organizations in the Other Places to Get Help section of this topic.

A listening technique that also may help you adjust to reduced hearing is called speech-reading. Speech-reading is paying attention to people's gestures, facial expressions, posture, and tone of voice. These clues can help you understand what a person is saying and can make taking part in the conversation easier. Clues include facing the person you are talking to and having him or her face you, and making sure the lighting is good so that you can see the other person's face clearly.

Speech-reading is not the same as lip-reading. You can know how to speech-read without knowing how to read lips.

For family and friends of people with hearing loss

A person with hearing loss may feel cut off from conversations and social interaction. The extra effort and stress needed to take part in conversations can be tiring for all people involved. If you live with someone who has hearing loss, you may improve your communication by:

• Making sure the person knows you are speaking to him or her. Use his or her name.
• Speaking to the person at a distance of 3 ft (0.9 m) to 6 ft (1.8 m). Make sure that the person can see your face, mouth, and gestures. Arrange furniture and lighting so that everyone in the conversation is completely visible.
• Not speaking directly into the person's ear. Your facial expressions and gestures can provide helpful visual clues about what you are saying.
• Speaking slightly louder than normal, but do not shout. Speak slowly and clearly. Don't repeat the same word over and over again. If a particular word or phrase is misunderstood, find another way to say it.
• Telling the person when the topic of conversation changes.
• Cutting down on background noise. Turn off the television or radio during conversations. Ask for quiet sections in restaurants, and try to sit away from the door at theaters.
• Including the person in discussions and conversations. Don't talk about the person as though he or she isn't there.

Online Resource

Organizations

• Ear Infections
• Ear Problems and Injuries, Age 11 and Younger
• Ear Problems and Injuries, Age 12 and Older
• Early Disease Detection

Citations

1. Bogardus ST Jr, et al. (2003). Screening and management of adult hearing loss in primary care: Clinical applications. JAMA, 289(15): 1986–1990.

2. Yeuh B, et al. (2003). Screening and management of adult hearing loss in primary care: Scientific review. JAMA, 289(15): 1976–1985.

3. Joint Committee on Infant Hearing, American Academy of Pediatrics (2000). Principles and guidelines for early hearing detection and intervention programs. Year 2000 position statement. Available online: http://www.aap.org/policy/jcihyr2000.pdf.

4. Niskar AS (2001). Estimated prevalence of noise-induced hearing threshold shifts among children 6 to 19 years of age: The Third National Health and Nutrition Examination Survey, 1988–1994, United States. Pediatrics, 108(1): 40–43.

Other Works Consulted

• Beasley DJ, Amedee RG (2001). Hearing loss. In KH Calhoun et al., eds., Expert Guide to Otolaryngology, pp. 53–74. Philadelphia: American College of Physicians.

• Biernath KR, et al. (2006). Bacterial meningitis among children with cochlear implants beyond 24 months after implementation. Pediatrics, 117(2): 284–289.

• Cruickshanks KJ, et al. (1998). Cigarette smoking and hearing loss: The epidemiology of hearing loss study. JAMA, 279(21): 1715–1719.

• Isaacson JE, Vora NM (2003). Differential diagnosis and treatment of hearing loss. American Family Physician, 68(6): 1125–1132.

• Rabinowitz PM (2000). Noise-induced hearing loss. American Family Physician, 61(9): 2749–2756.

• Reefhuis J, et al. (2003). Risk of bacterial meningitis in children with cochlear implants. New England Journal of Medicine, 349(5): 435–445.

• Weller KA (2000). Impaired hearing. In RE Rakel, ed., Saunders Manual of Medical Practice, 2nd ed., pp. 68–70. Philadelphia: W.B. Saunders.