View source for Conductive hearing loss

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| name            = Conductive hearing loss
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'''Conductive hearing loss (CHL)''' is a type of hearing impairment that occurs when sound waves are unable to efficiently travel through the outer ear, tympanic membrane (eardrum), or middle ear structures such as the ossicles. This blockage or dysfunction prevents sound from being effectively conducted to the inner ear, resulting in reduced hearing ability. Common causes include ear infections, fluid in the middle ear, earwax buildup, damage to the eardrum, or abnormalities in the ossicles. 

CHL can occur alone or alongside sensorineural hearing loss, in which case it is classified as '''mixed hearing loss'''. Depending on the underlying cause, conductive hearing loss is often treatable and sometimes reversible through medical interventions, such as medication, surgery, or assistive devices like hearing aids. However, chronic or permanent cases may require long-term management to improve hearing and communication abilities.<ref name=":1">{{Cite journal |last1=Hill-Feltham |first1=Penny R. |last2=Johansson |first2=Martin L. |last3=Hodgetts |first3=William E. |last4=Ostevik |first4=Amberley V. |last5=McKinnon |first5=Brian J. |last6=Monksfield |first6=Peter |last7=Sockalingam |first7=Ravi |last8=Wright |first8=Tracy |last9=Tysome |first9=James R. |date=2021-04-01 |title=Hearing outcome measures for conductive and mixed hearing loss treatment in adults: a scoping review |journal=International Journal of Audiology |language=en |volume=60 |issue=4 |pages=239–245 |doi=10.1080/14992027.2020.1820087 |pmid=32985284 |s2cid=222161183 |issn=1499-2027|doi-access=free }}</ref>

== Causes ==
Common causes of conductive hearing loss include:<ref>{{cite web|url=http://www.healthcentral.com/encyclopedia/408/598.html|title=Hearing Loss|publisher=HealthCentral|access-date=8 June 2013}}</ref>

=== External ear ===
* [[Cerumen]] (earwax) or foreign body in the external auditory canal
* [[Otitis externa]], infection or irritation of the outer ear
* [[Exostoses]], abnormal growth of bone within the ear canal
* [[Tumor]] of the ear canal
* Congenital stenosis or [[atresia]] of the external auditory canal (narrow or blocked ear canal).
** Ear canal stenosis & atresia can exist independently or may result from congenital malformations of the [[Auricle (anatomy)|auricle]] such as [[microtia]] or [[anotia]].
* Acquired stenosis (narrowing) of the external auditory canal following surgery or radiotherapy

=== Middle ear ===
Fluid accumulation is the most common cause of conductive hearing loss in the middle ear, especially in children.<ref name="merck">{{cite web|url=http://www.merckmanuals.com/home/ear_nose_and_throat_disorders/hearing_loss_and_deafness/hearing_loss_and_deafness.html?qt=&sc=&alt=|title=Hearing Loss and Deafness|last=Ruben|first=Robert J.|date=April 2007|publisher=The Merck Manual|access-date=8 June 2013}}</ref> Major causes are ear infections or conditions that block the [[eustachian tube]], such as allergies or tumors.<ref name=merck/> Blocking of the eustachian tube leads to decreased pressure in the middle ear relative to the external ear, and this causes decreased motion of both the [[ossicles]] and the tympanic membrane.<ref name=Haberman/>
* Acute or serous [[otitis media]]
* Chronic suppurative otitis media (CSOM)
* [[Perforated eardrum]]
* [[Tympanosclerosis]] or scarring of the eardrum
* [[Cholesteatoma]]
* [[Eustachian tube dysfunction]], inflammation or mass within the nasal cavity, middle ear, or eustachian tube itself
* [[Otosclerosis]], abnormal growth of bone in or near the middle ear
* Middle ear [[tumour]]
* Ossicular discontinuity as a consequence of infection or [[temporal bone]] trauma
* Congenital malformation of the [[ossicles]]. This can be an isolated phenomenon or can occur as part of a syndrome where development of the 1st and 2nd branchial arches is seen such as in [[Goldenhar syndrome]], [[Treacher Collins syndrome]], [[branchio-oto-renal syndrome]] etc.
* [[Barotrauma]], unequal air pressures in the external and middle ear.<ref name=Haberman>Page 152 in:{{cite book |author=Rex S. Haberman |title=Middle Ear and Mastoid Surgery |publisher=Thieme Medical Pub |location=New York |year=2004 |isbn=1-58890-173-4 }}</ref> This can temporarily occur, for example, by the environmental pressure changes as when shifting altitude, or inside a train going into a tunnel. It is managed by any of various methods of [[ear clearing]] manoeuvres to equalize the pressures, like swallowing, yawning, or the [[Valsalva manoeuvre]]. More severe barotrauma can lead to middle ear fluid or even permanent sensorineural hearing loss.

=== Inner ear ===
Third window effect caused by:
* [[Superior canal dehiscence]] – which may require surgical correction
* [[Enlarged vestibular aqueduct]]
* [[Labyrinthine fistula]]

==Presentation==
Conductive hearing loss makes all sounds seem faint or muffled. The hearing loss is usually worse in lower frequencies. Congenital conductive hearing loss is identified through [[Universal neonatal hearing screening|newborn hearing screening]] or may be identified because the baby has [[microtia]] or other facial abnormalities. Conductive hearing loss developing during childhood is usually due to otitis media with effusion and may present with speech and language delay or difficulty hearing. Later onset of conductive hearing loss may have an obvious cause such as an ear infection, trauma or upper respiratory tract infection or may have an insidious onset related to chronic middle ear disease, otosclerosis or a tumour of the naso-pharynx. Earwax is a very common cause of a conductive hearing loss which may present suddenly when the wax blocks sound from getting through the external ear canal to the middle and inner ear.

==Diagnosis==
Diagnosis requires a detailed history, local examination of the ear, nose, throat and neck, and detailed hearing tests. In children a more detailed examination may be required if the hearing loss is congenital.

===Otoscopy===
Examination of the external ear canal and ear drum is important and help identify problems located in the outer ear up to the tympanic membrane.

===Differential testing===
For basic screening, a conductive hearing loss can be identified using the Rinne test with a 256&nbsp;Hz tuning fork. The [[Rinne test]], in which a patient is asked to say whether a vibrating tuning fork is heard more loudly adjacent to the ear canal (air conduction) or touching the bone behind the ear (bone conduction), is negative indicating that bone conduction is more effective that air conduction. A normal, or positive, result, is when air conduction is more effective than bone conduction.

With a one-sided conductive component the combined use of both the Weber and Rinne tests is useful. If the [[Weber test]] is used, in which a vibrating [[tuning fork]] is touched to the midline of the forehead, the person will hear the sound more loudly in the affected ear because background noise does not mask the hearing on this side.

The following table compares [[sensorineural hearing loss]] to conductive:
{| cellspacing=0 cellpadding=10 |
|bgcolor=#cccccc align=center|'''''Criterion'''''
|bgcolor=#eeeeee align=center|'''''Sensorineural hearing loss'''''
|bgcolor=#eeeeee align=center|'''''Conductive hearing loss'''''
|-
|bgcolor=#eeeeee|'''Anatomical site'''
|[[Inner ear]], [[cranial nerve]] VIII, or central processing centers
|[[Middle ear]] (ossicular chain), [[tympanic membrane]], or [[external ear]]
|-
|bgcolor=#eeeeee|'''[[Weber test]]'''
|Sound localizes to normal ear
|Sound localizes to affected ear (ear with conductive loss)
|-
|bgcolor=#eeeeee|'''[[Rinne test]]'''
|Positive Rinne; air conduction - bone conduction (both air and bone conduction are decreased equally, but the difference between them is unchanged).
|Negative Rinne; bone conduction - air conduction (bone/air gap)
|}

===Tympanometry===
[[Tympanometry]], or acoustic immitance testing, is a simple objective test of the ability of the middle ear to transmit sound waves from the outer ear to the middle ear and to the inner ear. This test is usually abnormal with conductive hearing loss.  A type B tympanogram reveals a flat response, due to fluid in the middle ear (otitis media), or an eardrum perforation.<ref name=":0">{{Cite journal|last=Onusko|first=Edward M.|date=2004-11-01|title=Tympanometry|url=https://www.aafp.org/afp/2004/1101/p1713.html|journal=American Family Physician|language=en|volume=70|issue=9|pages=1713–1720|pmid=15554489 |issn=0002-838X}}</ref> A type C tympanogram indicates negative middle ear pressure, which is commonly seen in eustachian tube dysfunction.<ref name=":0" /> A type As tympanogram indicates a shallow compliance of the middle ear, which is commonly seen in otosclerosis.<ref name=":0" />

===Audiometry===
[[Pure tone audiometry]], a standardized hearing test over a set of frequencies from 250&nbsp;Hz to 8000&nbsp;Hz, may be conducted by a medical doctor, [[audiologist]] or audiometrist, with the result plotted separately for each ear on an [[audiogram]]. The shape of the plot reveals the degree and nature of hearing loss, distinguishing conductive hearing loss from other kinds of hearing loss. A conductive hearing loss is characterized by a difference of at least 15 [[decibel]]s between the air conduction threshold and bone conduction threshold at the same frequency. On an audiogram, the "x" represents responses in the left ear at each frequency, while the "o" represents responses in right ear at each frequency.

===CT scan===
Most causes of conductive hearing loss can be identified by examination but if it is important to image the bones of the middle ear or inner ear then a CT scan is required. CT scan is useful in cases of congenital conductive hearing loss, chronic suppurative otitis media or cholesteatoma, ossicular damage or discontinuity, otosclerosis and third window dehiscence. Specific MRI scans can be used to identify cholesteatoma.

==Management==
Management falls into three modalities: surgical treatment, pharmaceutical treatment, and supportive, depending on the nature and location of the specific cause.<ref name=":1" />

In cases of infection, [[antibiotic]]s or [[antifungal medication]]s are an option. Some conditions are amenable to surgical intervention such as middle ear fluid, cholesteatoma, and otosclerosis. If conductive hearing loss is due to [[head trauma]], [[Surgery|surgical repair]] is an option.<ref>{{cite web|url=http://www.hearingloss.org/content/types-causes-and-treatment#conductive|title=Types, Causes and Treatment|publisher=Hearing Loss Association of America|access-date=8 June 2013}}</ref> If absence or deformation of ear structures cannot be corrected, or if the patient declines surgery, [[hearing aid]]s which amplify sounds are a possible treatment option.<ref name="merck" /> Bone conduction hearing aids are useful as these deliver sound directly, through bone, to the [[cochlea]] or organ of hearing bypassing the pathology. These can be on a soft or hard headband or can be inserted surgically, a bone anchored hearing aid, of which there are several types. Conventional air conduction hearing aids can also be used.

==See also==
* [[Hearing loss]]
* [[Sensorineural hearing loss]]

==References==
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== External links ==
{{Medical resources
|  DiseasesDB     = 3043
|  ICD10          = {{ICD10|H|90|0|h|90}}-{{ICD10|H|90|2|h|90}}
|  ICD9           = {{ICD9|389.0}}
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|  MeshID         = D006314
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{{Diseases of the ear and mastoid process}}
{{Hearing and balance}}

{{Authority control}}

[[Category:Hearing loss]]
[[Category:Audiology]]
[[Category:Otology]]