Presbycusis

Douglas J Lanska MD FAAN MS MSPH (Dr. Lanska of the Great Lakes VA Healthcare System and the University of Wisconsin School of Medicine and Public Health has no relevant financial relationships to disclose.)
Originally released April 21, 2013; last updated January 29, 2017; expires January 29, 2020

This article includes discussion of presbycusis, age-related hearing impairment, and presbyacusis. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations.

Overview

In this article, the author explains the clinical presentation, pathophysiology, diagnostic workup, and management of presbycusis.

Key points

 

• Presbycusis (literally “elder hearing”) is the gradual loss of hearing that occurs in most people as they grow older.

 

• Presbycusis is a complex disease with multifactorial etiology that results from accumulated damage to the inner ear with aging.

 

• Presbycusis results primarily from accumulated damage to the inner ear, particularly a loss of sensory hair cells in the cochlea (ie, sensory presbycusis).

 

• Patients with presbycusis develop an insidiously progressive bilateral sensorineural hearing loss, which becomes functionally problematic in late life.

 

• The main presenting symptoms are hearing loss, subjective tinnitus, or both.

 

• Presbycusis is the most prevalent sensory impairment in the elderly and the third most prevalent chronic condition in older Americans, after hypertension and arthritis.

 

• Risk factors for presbycusis can be grouped into 4 major categories: (1) aging; (2) environmental (eg, noise exposure); (3) genetic predisposition; and (4) health comorbidities (eg, cigarette smoking and atherosclerosis).

 

• Remediation of hearing loss is an important contributor to quality of life among elderly persons with presbycusis.

 

• Useful management approaches include education about communication effectiveness, hearing aids, assistive listening devices, and cochlear implants for severe hearing loss.

Historical note and terminology

Presbycusis (literally “elder hearing”) is the gradual loss of hearing that occurs in most people as they grow older (Lanska 2014). The term “presbycusis” is generally used to incorporate all processes that contribute to hearing loss over time, including both extrinsic insults (eg, noise, ototoxic agents, disease) and physiologic degeneration (Lanska 2014).

Presbycusis results primarily from accumulated damage to the inner ear, particularly a loss of sensory hair cells in the cochlea (ie, sensory presbycusis) (Lanska 2014; Roth 2015). In some individuals there may be contributions from other sources, including central (ie, brainstem), neural (ie, ganglion cell loss), strial or “metabolic” (ie, strial atrophy), and possibly cochlear conductive or mechanical (eg, stiffness of the basilar membrane) sources (Working Group on Speech Understanding and Aging 1988; Gates and Rees 1997; Bao and Ohlemiller 2010). The term “metabolic” presbycusis for presbycusis associated with strial atrophy is so-named because the stria vascularis is the metabolic pump that generates the endocochlear potential (Gates and Rees 1997).

Presbycusis has also been categorized into a variety of different types (or "phenotypes") on the basis of the pattern of sensorineural hearing loss on the audiogram (Schuknecht 1964; Schuknecht and Gacek 1993). Most cases have patterns that are intermediate to the extremes of either flat or sloping loss (Allen and Eddins 2010). In addition, the audiometric profiles do not naturally separate into discrete classes, indicating that the previously reported "subtypes" are actually the result of categorical segregation of a continuous and heterogeneous distribution (Allen and Eddins 2010). Furthermore, quantitative studies of human temporal bones with flat or sloping audiometric configurations suggest that audiometric classification alone is insufficient to predict underlying otopathology (Nelson and Hinojosa 2003; Nelson and Hinojosa 2006). Nevertheless, many studies utilize such subtypes, and clinically it is important to recognize the common patterns because the patterns are associated with different etiologies. In general, the high-frequency steeply sloping, high-frequency gently sloping, and flat patterns are similar in frequency and collectively represent more than 90% of cases (Demeester et al 2009; Angeli et al 2012): other patterns are rare, including low-frequency ascending, mid-frequency U-shape, and mid-frequency reverse U-shape patterns. The flat subtype is more common in women, whereas the high-frequency steeply sloping subtype is more common in men (do Carmo et al 2008; Demeester et al 2009).

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