Overview Snapshot A 30-year-old man presents with constant right ear pain and hearing loss for the last 3 months. He also states that at times he experiences ringing of the right ear. He was previously diagnosed with an ear infection that was treated with antibiotics. On physical examination, there is amorphous and white debris in the right middle ear. A tuning fork was placed on the mastoid process and sequently by the external auditory canal. Bone conduction was louder than air conduction on the right ear. When the tuning fork is placed in the middle of the patient's ear, the tone was louder in the right ear. It is explained to the patient that a non-contrast computer tomography (CT) scan of the temporal bone will be scheduled. (Conductive hearing loss secondary to a cholesteatoma) Introduction Hearing loss basic principles unilateral hearing loss can result from lesions affecting the external auditory canal middle ear cochlear cranial nerve VIII cochlear nuclei bilateral hearing loss suggests a lesions after the auditory pathways enter the brainstem this is because auditory information crosses bilateraly immediately after entering the brainstem hearing loss is generally divided into conductive hearing loss secondary to lesions affecting the external auditory canal middle ear sensorineural hearing loss secondary to lesions affecting the cochlea cranial nerve VIII Conductive hearing loss etiologies include otitis externa squamous cell carcinoma osteoma cerumen otitis media cholesteatomoa otosclerosis tympanic membrane perforation Sensorineural hearing loss etiologies include hereditary hearing loss presbycusis ototoxic drugs Meniere disease barotrauma acoustic neuroma multiple sclerosis Physical exam maneuver Rinne test compares air conduction to bone conduction air conduction is tested by placing the vibrating tuning fork by the outside of the ear bone conduction is tested by placing the tuning fork on the mastoid process normal findings are air conduction is more than bone conduction pathology in conductive hearing loss bone conduction is greater than air conduction this is because bone conduction bypasses issues involving the external and middle ear in sensorineural hearing loss air conduction is greater than bone conduction bilaterally (just like in normal conditions) there is decreased hearing in the affected ear Weber test the vibrating tuning fork is placed in the middle of the patient's forehead the patient is subsequently asked to say which side is loudest normal findings sound is equally heard in both ears pathology in conductive hearing loss the tone is louder on the affected side this is because of compenstatory mechanism aimed at increasing the perceived volume of the affected side in sensorineural hearing loss the tone is decreased on the affected side