A 75-year-old man comes to the office due to progressive hearing loss. The patient reports a decline in his ability to hear conversations, especially in noisy places like restaurants, and difficulty tolerating loud sounds. He also hears a constant buzzing noise in both ears. The patient does not know when the symptoms began, but they have worsened over the past year. Medical history includes hypertension and type 2 diabetes mellitus. He takes atorvastatin, metformin, and lisinopril. He has a 40-pack-year history of smoking but stopped 20 years ago. Otoscopic examination is normal. A tuning fork placed in the middle of the forehead is heard equally on both sides, and air conduction is greater than bone conduction bilaterally. Which of the following is the most likely diagnosis in this patient?

Question

A 75-year-old man comes to the office due to progressive hearing loss.  The patient reports a decline in his ability to hear conversations, especially in noisy places like restaurants, and difficulty tolerating loud sounds.  He also hears a constant buzzing noise in both ears.  The patient does not know when the symptoms began, but they have worsened over the past year.  Medical history includes hypertension and type 2 diabetes mellitus.  He takes atorvastatin, metformin, and lisinopril.  He has a 40-pack-year history of smoking but stopped 20 years ago.  Otoscopic examination is normal.  A tuning fork placed in the middle of the forehead is heard equally on both sides, and air conduction is greater than bone conduction bilaterally.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

This elderly man has progressive hearing loss, and his tuning fork results (eg, Weber heard well bilaterally, air conduction [AC] > bone conduction [BC] bilaterally) suggest bilateral, symmetric sensorineural hearing loss. The most likely diagnosis is presbycusis (age-related hearing loss), which affects >50% of adults by age 75 and initially involves the high frequencies. Presbycusis is likely caused by cochlear hair cell loss and cochlear neuron degeneration. Patients with presbycusis often hear well in one-on-one conversations in a quiet room; however, this ability declines in the presence of competing noise (eg, restaurants). The ability to understand speech is often significantly impaired because many consonant sounds (eg, "t" and "s") are high frequency, leading patients to report they can "hear" but not "understand" others. There is no curative treatment for presbycusis. Hearing aids can be helpful, although their benefit may be limited if hearing loss is severe or if patients have an intolerance to louder sounds (as with this patient) due to auditory recruitment (whereby the functioning cochlear hair cells attempt to compensate for their damaged neighbors). Therefore, management also includes family education (eg, limit background noise, look directly at the patient when speaking). (Choice A) Vestibular schwannomas (acoustic neuromas) arise from the Schwann cells covering the vestibular branch of CN VIII. They typically present with asymmetric sensorineural hearing loss (AC > BC, Weber lateralizes to unaffected ear). (Choice B) Cholesteatomas are erosive, expansile collections of squamous cell debris in the middle ear. They typically present with recurrent otorrhea and asymmetric conductive hearing loss (Weber lateralizes to affected ear, BC > AC in affected ear). (Choice C) Ototoxic medications can cause progressive, bilateral tinnitus and sensorineural hearing loss (usually symmetric, but sometimes asymmetric) as a result of damage to the cochlear hair cells and/or CN VIII. The list of ototoxic substances (eg, aminoglycosides, loop diuretics) is extensive; however, this patient is taking no medications that typically cause hearing loss. (Choice D) Ménière disease causes sensorineural hearing loss that is usually asymmetric. It also typically presents with recurrent episodes of vertigo with aural fullness and tinnitus. (Choice E) Otosclerosis causes stiffening of the ossicles. Patients have conductive hearing loss (Weber lateralizes to affected ear, BC > AC in affected ear) rather than sensorineural hearing loss. Educational objective: Presbycusis is common in the elderly and presents with bilateral, symmetric, sensorineural hearing loss. References: Evaluation of age-related hearing loss. (http://www.ncbi.nlm.nih.gov/pubmed/24653906) Pathophysiology of age-related hearing loss (peripheral and central). (http://www.ncbi.nlm.nih.gov/pubmed/24653905)

A 75-Year-Old Man Comes to the Office Due to Progressive