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Presbyacusis Dr. Vishal Sharma.

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1 Presbyacusis Dr. Vishal Sharma

2 Synonyms Age-related sensori-neural hearing loss
Age-associated hearing loss (AAHL) Presbycusis (in USA) No official agreed age above which a person suffers from presbyacusis & below which he/she does not. Arbitrary agreed age is 50 years.

3 Definitions Presbyacusis: B/L symmetric, progressive SNHL due to aging, in absence of other etiologies Socioacusis: B/L symmetric SNHL due to non- occupational noise, fatty diet & lack of exercise Nosoacusis: B/L symmetric SNHL due to diseases with ototoxic effects SNHL after 50 yrs age = presbyacusis + nosoacusis + socioacusis + occupational NIHL

4 Diagnosis of exclusion
Exclude other causes of hearing loss in elderly: Noise induced hearing loss Atherosclerosis (hyperlipidemia), diabetes, hypertension, myxoedema, Paget’s bone disease CSOM, Meniere’s disease, acoustic neuroma, cochlear otosclerosis, ear trauma & ototoxic drug

5 History Toynbee (1849) first wrote about age-related hearing loss & prescribed a treatment (application of silver nitrate solution to external auditory canal) Zwaardemaker (1891) gave first accurate description of presbyacusis. He detected high frequency involvement & origin in cochlea.

6 Mechanism of Presbyacusis
Age-related arteriosclerosis  hypo-perfusion &  oxygenation of cochlea  formation of reactive oxygen metabolites & free radicals  damage inner ear structures & mitochondrial DNA of inner ear  Presbycusis

7 Genetic Predisposition
Genetic programming for early aging of parts of auditory system  early development of presbycusis Genetically programmed susceptibility to environmental factors (noise, ototoxic drugs, stress) may be involved

8 Types of Presbyacusis (Gacek & Schuknecht, 1993)
Sensory Neural Metabolic or strial or vascular Mechanical or cochlear conductive Mixed Indeterminate or intermediate

9 Sensory Presbyacusis Loss of sensory hair cells in organ of Corti due to accumulation of lipofuscin pigment granules Process originates in basal turn (for a length > 10 mm) & slowly progresses toward apex Audiogram: abrupt, steep, high-frequency SNHL Speech discrimination score: good

10 Sensory Presbyacusis

11 Neural Presbyacusis Atrophy of spiral ganglion & cochlear neurons (> 50%) mainly in basal turn of cochlea Slowly progressive HL (Pure Tone Average not affected until 90% neurons are destroyed) Audiogram: ski-slope toward high frequencies Speech discrimination score: poor (disproportionate)

12 Neural Presbyacusis

13 Metabolic Presbyacusis
Atrophy of stria vascularis (> 30% destroyed) Stria vascularis maintains chemical + bioelectric balance & metabolic health of cochlea Results in slowly progressive deafness Audiogram: Flat (as entire cochlea is affected) Speech discrimination score: good

14 Metabolic Presbyacusis

15 Mechanical Presbyacusis
Slowly progressive SNHL due to thickening & stiffening of basilar membrane of cochlea More severe in basal turn of cochlea where basilar membrane is narrow Audiogram: ski-slope toward high frequencies Speech discrimination score: slightly impaired

16 Mechanical Presbyacusis

17 Other Types Mixed Presbyacusis:
Many ears have a combination of 4 pathologies Indeterminate or Intermediate Presbyacusis: SNHL which progresses with age, without light microscopic evidence of cochlear pathology Pathology: altered cellular metabolism / ed synapse numbers / change in endolymph composition / central auditory pathway changes

18 Other age-related changes
Outer ear: ed cerumen formation, ed epithelial migration, ed hair growth, collapse of EAC Middle ear: stiffening of TM, Arthritis + ossicular joints ossification, degeneration of middle ear muscles They do not make marked contribution in deafness

19 Clinical Features Gradually progressive hearing loss
Difficulty in understanding conversation around high level of ambient background noise Recruitment: abnormal growth in perception of loudness (at high intensity) in pt with hearing loss Tinnitus (30-50%): indicate worsening of deafness Social isolation & depression

20 Investigations Pure Tone Audiometry
Speech Audiometry: diminished scores MRI: to rule out vestibular schwannoma Indications of MRI in presbyacusis pt: Asymmetry > 10 dB of PTA between both ears Asymmetry > 20 dB of any single frequency Unilateral tinnitus

21 Audiogram

22 Treatment Medical: no medical cure Diet modification & supplementation
Psychological counseling Amplification devices or hearing aids Lip reading & assisted listening devices Cochlear Implantation Tinnitus retraining therapy Avoidance of aggravating factors

23 Dietary advice 30% caloric dietary restriction
Use of antioxidant dietary supplements (vitamins A, C, E; selenium) reduce production of reactive oxygen metabolites that harm inner ear & lead to age-related hearing loss Neuro-vitamins & Gingko biloba have no role

24 Hearing Aids Binaural hearing aids give more benefit
Candidacy for hearing aids: speech reception threshold > 30 dB in better ear hearing level > 40 dB at 3 & 4 kHz in better ear Pt with poor speech discrimination score are poor candidates for hearing aids

25 Body worn

26 Spectacle

27 Spectacle




31 Completely in canal

32 Completely in canal

33 Completely in canal

34 Behind the ear

35 In the ear

36 In the canal

37 Completely in canal

38 Lip reading or speech reading
Skill of understanding spoken message by looking at speaker's lips, jaws, tongue, teeth, facial expressions, gestures & body language Lip reading is helpful in patients with diminished speech discrimination & hearing aid users who have hearing difficulty in noisy environments



41 Assisted Listening Devices
They are NOT hearing aids They are NOT used instead of hearing aids Help pt with hearing loss to function better in communication situations to overcome distance, background noise, or poor room acoustics Can be used with or without hearing aids

42 Vibrating wrist watch & alarm clock

43 CO2 & smoke alarm with strobe light

44 Amplified & captioned telephone

45 T.V. & F.M. amplifiers

46 Personal & multi-user amplifier

47 Alerting Devices

48 Amplified Stethoscope

49 Cochlear Implantation
Patients with cochlear damage & relatively intact spiral ganglia + central pathways are best candidates Cochlear implantation have been performed on patients up to 85 years old, with good results


51 Pawel Jastreboff: 1990

52 Tinnitus Retraining Therapy (TRT)
Based on neuro-physiological model of tinnitus Blocks tinnitus-related neuronal activity from reaching cerebral cortex (where it is perceived) & from activating limbic & autonomic nervous systems Uses combination of low level, broad-band noise & counseling to achieve habituation of tinnitus. Tinnitus never masked in TRT. Retraining takes months. Success rate = %

53 Avoidance Avoid following aggravating factors: Noise exposure
Ototoxic drugs Uncontrolled diabetes mellitus Hyperlipidemia

54 Future research Gene therapy to avoid early hair cell death in cochlea
Medications to stimulate a genetic cascade for hair cell regeneration Better programmed hearing aids

55 Alden, Alfred, Arthur, Eastman, Fletcher, Hisswald,
Luke, Matthew, Oom, Richard, Shirmer & Theodore

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