> Table of Contents > Presbycusis
Matthew J. Richter, DO
John T. Ewing, DO
image BASICS
  • Age-related, bilateral sensorineural hearing loss (SNHL) typically symmetric
  • Represents a lifetime of insults to the auditory system from toxic noise exposure and natural decline
  • Initially presents as high-frequency SNHL with tinnitus (ringing)
  • Impacts the “clarity” of sounds (i.e., ability to detect, identify, and localize sounds)
  • Due to mild and progressive nature, presbycusis is often treated with amplification alone.
  • Can lead to adverse effects on physical, cognitive, emotional, behavioral, and social function in the elderly (e.g., depression, social isolation)
According to an ongoing community-based epidemiologic study, the 10-year cumulative incidence rates of hearing loss (HL) are as follows (1):
  • Age 48 to 59 years: M (31.7%), F (15.6%); all (21.8%)
  • Age 60 to 69 years: M (56.8%), F (40.7%); all (45.5%)
  • Age 70 to 79 years: M (87.1%), F (70.6%); all (73.7%)
  • Age 80 to 92 years: M (100%), F (100%); all (100%)
  • 10% of the population develops SNHL severe enough to impair communication.
  • Increases to 40% in the population >65 years of age
  • 80% of HL cases occur in elderly patients.
  • Only 10-20% of older adults with HL have ever used hearing aids.
  • Predominant sex: male > female
  • Hearing levels are poorer in industrialized societies than in isolated or agrarian societies.
  • The external ear transmits sound energy to the tympanic membrane. The middle ear ossicles amplify and conduct the sound waves into the inner ear (cochlea) via the oval window. The organ of Corti, located in the cochlea, contains hair cells that detect these vibrations and depolarize, producing electrical signals that travel through the auditory nerve to the brain. Toxic noise exposure traumatizes the hair cells and leads to cell death and hearing loss. New research also suggests that overexcitation of the neurosynapses causes increased glutamate, which is also neurotoxic (2).
    • Sensory presbycusis: primary loss of the hair cells in the basal end of the cochlea (high frequency HL)
    • Neural presbycusis: loss of spiral ganglion cells (nerve cells induced by hair cells to produce action potentials to travel to the brainstem)
    • Strial (metabolic) presbycusis: atrophy of the stria vascularis (the cochlear tissue that generates the endocochlear electrical potential)
    • Cochlear conductive (mechanical) presbycusis: no morphologic findings (presumed stiffening of the basilar membrane)
    • Mixed presbycusis: combinations of hair cell, ganglion cell, and stria vascularis loss
    • Indeterminate presbycusis: no morphologic findings (presumed impaired cellular function)
  • Presbycusis is caused by the accumulated effects of noise exposure, systemic disease, oxidative damage, ototoxic drugs, and genetic susceptibility.
Presbycusis has a clear familial aggregation (3)[B]:
  • Heritability estimates show 35-55% of the variance of sensory presbycusis is from genetic factors; even greater percentage in strial presbycusis
  • Heritability is stronger among women than men.
  • Noise exposure (military, industrial, etc.)
  • Ototoxic substances
    • Organic solvents
    • Heavy metals
    • Carbon monoxide
  • Drugs
    • Aminoglycosides
    • Cisplatin
    • Salicylates
    • Diuretics
  • Tobacco smoking
  • Alcohol
  • Lower socioeconomic status
  • Family history of presbycusis
  • Head trauma (temporal bone fractures)
  • Cardiovascular disease (hypertension, atherosclerosis, hyperlipidemia); labyrinthine artery is terminal artery to the cochlea.
  • Diabetes mellitus
  • Autoimmune disease (autocochleitis/labyrinthitis)
  • Metabolic bone disease
  • Endocrine medical conditions: levels of aldosterone
  • Alzheimer disease
  • Otologic conditions (e.g., Ménière disease or otosclerosis)
  • Avoid hazardous noise exposure.
  • Use hearing protection.
  • Maintain healthy diet and exercise.
  • Screening
    • In the only published RCT on screening for HL, hearing aid use was significantly higher in three screened groups (4.1% in those using a questionnaire, 6.3% using handheld audiometry, and 7.4% using both modalities) versus unscreened control participants (3.3%) at 1-year follow-up (4)[B].
    • Based on a 2011 review, according to the USPSTF, there is insufficient evidence to assess the relative benefits and harms of HL screening in adults ≥50 years (5)[A].
  • Rinne and Weber tests are helpful for determining conductive versus sensorineural hearing loss but not recommended for general screening (7)[B].
  • Pneumatic otoscopy to evaluate for simple middle ear effusion as cause of conductive hearing loss
  • Acute noise-induced traumatic loss (explosion)
  • Autoimmune HL
  • Perilymph fistula (trauma/iatrogenic)
  • Ménière disease
  • Acoustic neuroma
  • Complete canal occlusion (cerumen)
  • Otitis externa
  • Chronic otitis media or effusion
  • Otosclerosis/osteogenesis imperfecta
  • Large middle ear tumors (e.g., facial nerve schwannomas, paragangliomas)
  • Vascular anomaly
  • Cholesteatoma
  • Handheld audiometry; insert probe in ear (sealing canal) and have patient indicate if tones can be heard.
    • Positive likelihood ratio (LR) range, 3.1 to 5.8; negative LR range, 0.03 to 0.40 (7)[B]
  • Screening audiometry
    • Symmetric high-frequency hearing loss in descending slope pattern
    • SNHL frequencies >2 KHz initially
    • Essential to determine global clinical hearing status and if etiology is conductive hearing loss versus SNHL or pseudohypacusis (conversion)

  • Hearing aids (HAs)
    • Types
      • Analog HA: picks up sound waves through a microphone; converts them into electrical signals; amplifies and sends them through the ear canal to the tympanic membrane
      • Digital HA: programmable; may reduce acoustic feedback, reduce background noise, detect and automatically accommodate different listening environments, control multiple microphones
    • HAs have an average decibel gain of 16.3 dB
    • Associated with hypersensitivity to loud sounds (“loudness recruitment”)
  • Hearing-assistive technologies (HATs) (8)[A]
    • Can be used alone or in combination with HAs (for difficult listening conditions)
    • Addresses face-to-face communication, broadcast or other electronic media (radio, TV), telephone conversation, sensitivity to alerting signals and environment stimuli (doorbell, baby's cry, alarm clock, etc.)
    • Includes personal FM systems, infrared systems, induction loop systems, hardwired systems, telephone amplifier, telecoil, TDD (telecommunication device for the deaf), situation-specific devices (e.g., television), alerting devices
  • Aural rehabilitation (also known as audiologic orientation or auditory training) (6)[A]
    • Adjunct to HA or HATs
    • Involves education regarding proper use of amplification devices, coaching on how to manage the auditory environment, training in speech perception and communication, and counseling for coping strategies to deal with the difficulties of HAs or HATs
Refer to audiologist for formal evaluation and optimal fitting of HAs and/or HATs.
  • Individuals receiving postfitting orientation/education have significantly fewer HA returns.
  • Individuals receiving >2 hours of education and counseling report higher levels of satisfaction.
  • Cochlear implants (CIs) (9,10)[B]
    • Indications include hearing no better than identifying ≤50% of key words in test sentences in the best aided condition in the worst ear and 60% in the better ear.
    • Works by bypassing the ear canal, middle ear, and hair cells in the cochlea to provide electric stimulation directly to the auditory nerve
    • Incoming sounds are received through the microphone in the audio processor component (resembles a small HA), which converts them into electrical impulses and sends them to the magnetic coil (located on the skin). The impulses transmit these across intact skin via radio waves to the implanted component (directly subjacent to the coil). The pulses travel to the electrodes in the cochlea and stimulate the cochlea at high rates.
    • Receiving a unilateral CI is most common; some may receive bilateral CIs (either sequentially or in the same surgery). Others may wear a CI in 1 ear and an HA in the contralateral ear (bimodal fit).
    • Younger age at CI placement derives greatest benefit (10)[A].
  • Active middle ear implants (AMEIs) (9)[B]
    • Suitable for elderly adults who cannot wear conventional HAs for medical or personal (cosmetic) reasons and whose HL is not severe enough for a CI
    • Comes in different models and may include components that are implantable under the skin
  • Electric acoustic stimulation: use of CI and HA together in one ear
    • Addresses the specific needs of patients presenting with good low-frequency hearing (a mild to moderate sensorineural HL in frequencies up to 1,000 Hz) but poorer hearing in the high frequencies (sloping to 60 dB or worse HL above 1,000 Hz) (9)[B]
      • Contraindications: progressive HL, autoimmune disease; HL related to meningitis, otosclerosis, or ossification; malformation of the cochlea; a gap in air conduction and bone conduction thresholds of >15 dB; external ear contraindications, active infection, or unwillingness to use amplification devices (9)[B]
Patient Monitoring
  • During follow-up visits, check for compliance of HA use.
    • 25-40% of adults will either stop wearing them or use them only occasionally.
  • Assess perceived benefit of HA and, if ineffective, for indications for possible surgical treatments.
  • Annual audiograms
  • Can follow up with audiologists for HA fittings if HA becomes uncomfortable
  • Asymmetric hearing loss should have evaluation via MRI for acoustic neuroma.
  • Sudden SNHL is atypical and warrants urgent otolaryngologic evaluation/audiometry. The most recent recommendations by the American Academy of Otolaryngology recommend steroids empirically.
  • Should be face-to-face; spoken clearly and unhurriedly, without competing background noise (e.g., radio, TV); and include a confirmation that the message is received.
  • Formal speech reading classes may be beneficial; however, availability may be limited.
1. Cruickshanks KJ, Nondahl DM, Tweed TS, et al. Education, occupation, noise exposure history and the 10-yr cumulative incidence of hearing impairment in older adults. Hear Res. 2010;264(1-2):3-9.
2. Yamasoba T, Lin FR, Someya S, et al. Current concepts in age-related hearing loss: epidemiology and mechanistic pathways. Hear Res. 2013;303:30-38.
3. Huang Q, Tang J. Age-related hearing loss or presbycusis. Eur Arch Otorhinolaryngol. 2010;267(8):1179-1191.
4. Yueh B, Collins MP, Souza PE, et al. Long-term effectiveness of screening for hearing loss: the screening for auditory impairment—which hearing assessment test (SAI-WHAT) randomized trial. J Am Geriatr Soc. 2010;58(3):427-434.
5. Chou R, Dana T, Bougatsos C, et al. Screening adults aged 50 years or older for hearing loss: a review of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2011;154(5):347-355.
6. Pacala JT, Yueh B. Hearing deficits in the older patient: “I didn't notice anything.” JAMA. 2012;307(11):1185-1194.
7. Bagai A, Thavendiranathan P, Detsky AS. Does this patient have hearing impairment? JAMA. 2006;295(4):416-428.
8. Valente M. Summary guidelines: audiological management of adult hearing impairment. Audio Today. 2006;18:32-37.
9. Sprinzl GM, Riechelmann H. Current trends in treating hearing loss in elderly people: a review of the technology and treatment options—a mini-review. Gerontology. 2010;56(3):351-358.
10. Lin FR, Chien WW, Li L, et al. Cochlear implantation in older adults. Medicine (Baltimore). 2012;91(5):229-241.
  • H91.10 Presbycusis, unspecified ear
  • H91.13 Presbycusis, bilateral
  • H91.11 Presbycusis, right ear
Clinical Pearls
  • Presbycusis is an age-related hearing loss (HL), showing increased incidence with age. It is often bilateral and initially begins as high-frequency HL. It presents as difficulty communicating in noisy conditions.
  • There are more affected males than females.
  • Compliance is only from 25-40% for those who own hearing aids (HA). A referral to an audiologist is key for optimal evaluation, fitting for HAs, and other assistive technologies or surgical treatment.
  • Indication for CIs include hearing no better than identifying ≤50% key words in test sentences in the best aided condition in the worst ear and 60% in the better ear.
  • Early audiology referral for individuals with suspected HL may improve treatment efficacy.