Who is Heather Whitestone McCallum? And what’s her connection to Bill Clinton, Lou Ferrigno, Helen Keller, and Ronald Reagan?¹ In 1995, McCallum became the first Miss America with a hearing disability. This problem has also plagued the other famous people who are listed above.

Hearing loss will be a major concern for older adults in this millennium. The population age 65 and over will grow from 34.6 million in 1999 to 82 million in 2050 ,fueled by a surge in the year 2011 as the surviving “baby boomers” begin passing age 65.² Society at large as well as health professionals must become aggressive to minimize correctable hearing loss. As nurses hear more patients say, “I can’t hear you,” they will need to be armed with advanced knowledge to detect hearing loss and make the appropriate referrals to medical specialists, audiologists, and otolaryngologists.

More than 40 million Americans have some kind of hearing impairment.³ Hearing loss is the third leading chronic disability, following arthritis and hypertension.³ Worldwide 500 million people are hard of hearing.⁴ In fact, approximately 40% of the hearing impaired are under age 65, one third of Americans between the ages of 65 and 74, and one-half of those age 85 and older have some form of hearing loss.³ In addition, an estimated 90% of institutionalized elderly have some kind of hearing problem.⁶ Between 7 and 10 million people in American industry have noise-induced hearing loss, virtually all of which was preventable, and about 15% of college graduates have a level of hearing loss equal to or greater than their parents which is caused significantly by listening to loud music.³ Three out of 1,000 children are born with hearing loss, and 1.4 million children have hearing loss.⁴

It’s not just a growth in the number of older adults that fuels the problem. Baby boomers have listened to record levels of environmental noise over their lifetimes. Stereos, rock clubs, and radios with the volume cranked up have pounded the ears of this generation. As this aging group grows, so will the demand for services, treatments, and educational programs to prevent hearing loss.

At the same time, prejudice, embarrassment, and stigma prevent close to 15 million people with hearing losses from seeking help.³ And only 13% of physicians routinely screen for hearing loss.⁴ Nurses have daily opportunities to recognize hearing loss in patients and help them become aware of multiple treatment options. Early detection is important because if hearing loss is left untreated, it can isolate older adults and prevent them from enjoying life. Early treatment may improve their self-esteem and willingness to participate in activities.

Anatomy Review

Unlike crickets that have their hearing organs in their knees and cicadas that have their hearing organs in their stomachs, humans have their hearing organs on their head. In simple terms, we use our ears and brains to interpret sounds.

The human ear is made up of three parts: outer ear, middle ear, and inner ear. The outer ear has two parts called the pinna and the auditory canal.

The middle ear houses the tympanic membrane (eardrum). The middle ear chamber is filled mostly with air. The opening from the middle ear that goes to the pharynx is called the Eustachian tube. This tube normally remains closed until a person swallows or yawns. The opening of the Eustachian tube helps to equalize pressure between the middle ear and the air pressure outside. During air travel ascents and descents, people are told to swallow. Swallowing helps to equalize air pressure. Equal pressure on both sides of the tympanic membrane allows it to vibrate normally. The middle ear includes three tiny bones called ossicles. The ossicles are the malleus, incus, and stapes.

The inner ear is a fluid-filled chamber. The cochlea contains the acoustic nerve (Cranial Nerve ⁸), which is responsible for making sound possible, and the vestibular labyrinth, which maintains a person’s position sense and balance.

How do we hear?

Most of us take our hearing for granted, when in fact “hearing” is a very amazing and complex process. The ear’s shape, for instance, is naturally designed to collect, focus, and transmit sound through the auditory pathway. Sound waves are collected by the outer ear and pass along the ear canal to the tympanic membrane. The ear canal is approximately an inch long. Sounds waves need to travel through the ear by two mechanisms: air conduction and bone conduction. In air conduction, sound waves travel in the air through the external and middle ear to the inner ear. When a sound wave travels through the ear canal, it comes in contact with the tympanic membrane, causing it to vibrate. In bone conduction, sound waves travel through the bone to the inner ear. Vibration transmitted through air and bone stimulate nerve impulses in the inner ear. The impact of sound hitting the eardrum creates vibrations that cause the malleus, incus, and stapes to move. The inner ear contains the cochlea and vestibular labyrinth. In the inner ear, microscopic hair cells are moved by the fluid inside the cochlea. The cochlea is fluid filled, snail shaped, and the size of a pea. The cochlear branch of the acoustic nerve transmits these vibrations to the auditory center of the cerebral cortex, where the temporal lobe of the brain interprets the sound. Sound is actually heard with our brains.

The vestibular labyrinth consists of three semicircular canals that are responsible for balance and position sense. The canals contain fluid and cells that are sensitive to movement. The cells in the vestibular labyrinth detect body movement and allow a person to be aware of where his or her head is in relation to the rest of the world.

Common types of hearing loss

Hearing loss can be conductive, sensorineural, or a combination (or mixed) loss. In conductive hearing loss, the deficit results from external ear disorders — impacted or large amounts of cerumen; foreign bodies, such as food, bugs, soap, or small toys; otitis media; rheumatoid arthritis; and otosclerosis. Treatment depends on the cause — for example, removal of cerumen and foreign bodies or the use of antibiotics for an ear infection. Hearing aids seem to work better in conductive hearing loss, particularly if the loss is between 55 dB and 80 dB.⁷

Sensorineural hearing loss disease impairs the hearing process anywhere from the organs of Corte to the brain. In this case, hearing fails when hair cells of the inner ear are damaged by medications, acoustic trauma, vascular insufficiency, central nervous diseases,⁸ or even air bag deployment.⁹ High- or low-tone hearing is lost, depending on the location of hair cells that are atrophied or reduced.

Presbycusis is sensorineural hearing loss from aging of the inner ear. Presbycusis affects 60% of individuals over age 65 in the U.S.¹⁰ Its onset begins between 30 and 60 years and worsens with age. People with presbycusis have difficulty sensing speech of frequencies above 1000 Hz. High-frequency consonants and sibilants become hard to distinguish. Words beginning with f, g, l, t, s, ch, sh, sk, and th are unintelligible. For example, “The friendly little children screamed, shouted, and laughed all the way to their grandparents’ house” may be unrecognizable for a person with high-frequency loss. As presbycusis progresses, low frequency sounds also begin to diminish. Family and caregivers may attribute a person’s misunderstanding to confusion, forgetfulness, or inattention.

Tinnitus is a disturbing condition of both conductive and sensorineural hearing loss. Tinnitus is most common in people over age 40, and it affects men more than women.¹¹ Out of the 50 million people affected, tinnitus incapacitates 12 million.¹⁵

Tinnitus is an intermittent or continuous hissing, buzzing, or ringing. The sound is generally high-pitched with sensorineural loss and low-pitched with conductive loss. Tinnitus does not usually interfere with sleep or pleasurable activities. Although the cause of tinnitus is unknown, contributing factors include trauma; labyrinthitis; Meniere’s disease; metabolic conditions, such as diabetes mellitus; antibiotics, such as gentamicin; and other medications, such as aspirin, furosemide, and quinidine.¹⁰ A complaint of tinnitus should be investigated to rule out a more serious problem. Treatment may be as simple as masking the sound with music, a ticking clock, or other competing noise. Biofeedback can also be useful. Tinnitus retraining therapy is a new, scientifically tested approach that uses a combination of low-level, broadband noise and counseling.¹¹

Assessing hearing loss

Nursing assessment for hearing loss begins with the initial introduction and interview. While gathering information about any patient, look for clues of a hearing loss, such as inappropriate responses to questions, requests for repeated statements, and attempts to read your lips, facial expressions, and body language. Patients with hearing loss may lean closer to you. Others may seem withdrawn and show signs of social isolation, so ask questions about their participation in social activities. Also, inquire about television and radio volume, pain or ringing in the ears, previous ear infections and treatment, environmental exposures to noise, and the use of aspirin, aminoglycoside antibiotics, diuretics, and other potentially ototoxic medications. If possible, include significant others in the questioning. For example, patients may think their hearing is just fine, while those around them know they blast radio and television volume just to hear.

Continue the hearing assessment by conducting watch tick, whisper, Weber, Rinne, and Schwabach tests. The watch tick test is a crude but easy way to evaluate a person’s ability to hear high-frequency sounds. Occlude one ear, and hold a ticking watch a few inches away from the patient’s other ear.¹² Gradually move the watch away until he or she no longer hears the sound, and then document your findings. A person with normal hearing can usually hear the tick from two to three inches away from the ear.¹³ Compare the two sides to see if the hearing is equal. You can also use this test to evaluate bilateral hearing by holding the watch above the patient’s head and asking if the ticking is heard in both ears.

The whisper test evaluates higher-range auditory acuity. Standing one to two feet away, ask the patient to occlude one ear, and then whisper softly toward the unoccluded ear. Depending on the person’s manual dexterity, you may need to occlude the patient’s ear. Choose numbers or words with two equally accented syllables, such as “ninety-nine” or “baseball.” Shield your lips to prevent lip reading. If the person cannot hear you, increase the intensity of your voice to a medium and then loud whisper, gradually increasing your voice from soft to loud. Note the voice level at which the patient can hear the word. Conduct the test on both ears. A person with normal acuity should be able to repeat the words that were softly whispered.

Human hearing lies in the range of 20 Hertz to 20,000 Hertz (Hz).³ The Weber, Rinne, and Schwabach tests help detect whether hearing loss is conductive or sensorineural. Use a tuning fork in the range of 512 Hz to 1,024 Hz, which falls within the frequency of human speech (300 Hz to 3,500 Hz).

The Weber test assesses lateralization. Holding only the stem, place a vibrating tuning fork on the top of the patient’s head or top of the forehead. Ask if the sound is heard equally in both ears. Normally, the sound seems to come from the middle, not laterally from only one ear. Document normal findings as “Weber — negative for lateralization” and abnormal findings as “positive for lateralization,” either left or right. Sound is heard better in the ear where conductive loss is present, and bone conduction makes up for the deficit. In the case of a sensorineural problem, the affected ear will not sense any sound; instead, it is heard in the “good” ear.⁸

The Rinne test is performed by applying the stem of a struck tuning fork to the mastoid process behind the ear. Use a watch to determine how long the sound is heard via bone conduction (BC). When the person no longer hears the sound, immediately place the “U” part of the tuning fork (do not strike the tuning fork again) by the external ear canal. Note the amount of time the person hears the sound through air conduction. Normally, air conduction (AC) is two times greater than BC. For example, if the sound through bone conduction is heard for 15 seconds, those via air conduction should be heard for an additional 30 seconds. Document findings, for example, as “AC>BC, 30 sec/15 sec, with a 2:1 ratio.” Conduct the Rinne test on both ears. Suspect conductive hearing loss when BC is equal to or longer than AC, for example, “BC>AC, 20 sec/10 sec.” With sensorineural loss, AC is greater than the BC, but the ratio will be less than 2:1. For example, BC sound might be heard for eight seconds and AC sound for 12 seconds, documented as “AC>BC, 12 sec/8 sec,” a ratio of less than 2:1.

The least popular tuning fork test, the Schwabach test, subjectively compares the hearing of the examiner and the patient. The examiner needs to have normal hearing. Place the vibrating tuning fork’s stem on the patient’s mastoid process. When the patient no longer hears the sound, place the tuning fork on your own mastoid process. If you are able to hear a sound, suspect a sensorineural deficit.^{12, 13,14} With conductive hearing loss, the patient will hear the sound longer than the examiner.

Otoscope exam in the adult

An otoscopic examination assesses the structures of the internal ear. Before the exam, inspect and palpate the ears for tenderness, nodules, masses, lesions, and drainage. Then choose a speculum large enough to fit comfortably into the patient’s ear. While pulling the ear up and back, gently insert the otoscope into the inner two-thirds of the canal, which is sensitive to pressure. With infants and children younger than three years old, straighten the canal by gently pulling the pinna down and back. Position part of your hand holding the otoscope against the patient’s head, so you can avoid trauma to the ear if the patient’s head moves suddenly. Inspect the ear canal as the otoscope is inserted, looking for dried cerumen, signs of inflammation, drainage, foreign bodies, and perforations. The tympanic membrane, which is pearly gray in color, may appear thickened with a diminished light reflex in older adults. The light reflex — the reflection from the otoscope light — is usually seen on the tympanic membrane between the four and six o’clock positions in the right ear and between the six and eight o’clock positions in the left ear. The reflection of the light in a different area may indicate a tympanic membrane that is inflamed, bulging, or retracted. Note any bony landmarks, such as the handle of the malleus, the short process of the malleus, and the umbo, the most depressed point of the membrane. The malleus is usually noted at a one- to two-o’clock position with the umbo in the center. In a conductive hearing loss, except with otosclerosis, the otoscopic exam can help visualize an abnormality, for example, a tympanic membrane that is bulging due to pus or fluid in the middle ear or reddened due to a middle ear infection.

Putting it all together

A thorough, methodical assessment can uncover many common hearing problems. For example, an adult patient tells you he cannot hear with his right ear. He obviously favors the left ear because he turns the left side of his head toward you when you speak. Watch tick and whisper tests substantiate better hearing on the left side. Because a Weber test is positive for lateralization to the “bad” ear on the right, you suspect conductive hearing loss. You proceed with the Rinne test and document that in the left ear, “AC>BC (30 sec/15 sec),” and in the right ear, “BC>AC (20 sec/10 sec).” This finding also indicates conductive hearing loss. You inspect the ears for redness, nodules, and drainage and palpate the tragus in the front of the ear and the mastoid process behind the ear for tenderness. None are noted in this patient.

After checking that your equipment is working properly, you perform an otoscopic exam. In the left ear, the tympanic membrane is pearly gray with the light reflex at seven o’clock. The malleus is at one to two o’clock and the umbo is in the center, all normal findings. There is no drainage, perforation, or redness. Lifting the ear upward and backward, you insert the speculum into the right ear and visualize a normal external canal. However, visualization of the tympanic membrane is obscured by a large amount of impacted cerumen, suggesting the cause for this. Wax buildup is a common and treatable cause of conductive hearing loss. Although you remove the cerumen by lavage, you teach the patient how to remove it in the future with an over-the-counter medication and lavage.

Hearing aids, cochlear implants, and other devices

When assessments reveal deficits that are not so easily corrected, hearing aids can help. They’ve come a long way from the 1600s, when ear trumpets funneled sound into the ear. Technology has made hearing aids more sensitive and practically invisible. They can be worn behind or in the outer ear, in the canal, completely in the ear, or on the body.¹ However, the choice of device depends on the visual acuity and manual dexterity of the user and the kind of hearing loss. Patients with conductive loss are the largest group to benefit. Newer digital hearing aids, such as the one former President Clinton uses, can cost from $2,000 to $3,500 each, compared with about half that price for traditional analog devices.¹⁵ As more manufacturers get involved in the production of hearing aids, the prices should go down. Health insurance and health maintenance organizations have various reimbursement policies for hearing aids, so consumers should consult their policies.

Cochlear implants offer help for those with severe and profound bilateral sensorineural types of hearing loss. In the late 1950s, researchers wondered how to relay the electric signals lost from missing hair cells in these patients. In 1957 at the University of California, the first single-channel cochlear implant was tested in human volunteers. Multielectrode cochlear implants were added in the early 1970s through a few key findings, for example, the discovery that frequencies of speech could be divided into six or seven channels to simulate intelligible speech sounds, instead of using 30,000 electrodes to stimulate individual nerve fibers. Technology advanced quickly after scientists figured out how to send signals to electrodes sequentially instead of simultaneously. Today, more than 18,000 hearing-impaired people, including children, have cochlear implants.¹⁶

Cochlear implants send electrical energy through a group of tiny electrodes threaded directly into the cochlea. Remaining nerve fibers are activated that, in turn, send signals to the eighth cranial nerve and the brain for interpretation. However, some patients may still continue to have difficulty determining sound direction, even with the best results. The cost for the implant, surgery, and mapping and rehabilitation procedures to fine tune the device’s function can reach $50,000, which most insurance plans cover.¹⁷

Although most recipients of cochlear implants are young infants and children, these implants are being used more frequently in adults, especially those who had hearing all of their lives and then lost it, in addition to having impaired or deteriorating vision.¹⁷

In addition to hearing aid and cochlear implants, there are other treatment options that direct and/or amplify sound. Some treatments work better than others depending on the hearing problem. For example, personal listening systems can improve hearing because they eliminate or lower other noises in the environment. Auditory training systems and loop systems make it easier for people to hear in a crowd setting, while personal amplifiers are better for one-to-one conversations.¹⁸

Television listening systems help people hear the television or the radio without being bothered by other noises in the room. These systems may be used with or without hearing aids and do not require the television to be on high volume. There are direct audio input hearing aids that can be plugged into the television and stereos.

Telephone amplifying devices work in conjunction with hearing aids. If the hearing aid has a “T” switch, then an amplifying coil (T-coil) can be installed by the telephone company. The coil is activated when the phone is picked up, which allows the person to listen at a comfortable volume and helps lessen background noise.¹⁸

The rippling effects from a hearing loss can overwhelm the activities of daily living and rob people of the simple pleasures of life. Helen Keller once said that blindness separates you from things, whereas deafness separates you from people. But early detection and identifying the right treatment options can often remedy hearing loss and improve a patient’s quality of life.

Nurses can provide early and ongoing hearing assessments for their patients. By staying aware of the causes of hearing problems and developing assessment skills for detecting them, nurses will be better equipped to treat, refer, and advise patients about treatments and support resources. Nurses need to listen carefully for the signs of hearing loss in their patients to make a difference in their lives.