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  • Updated 08.17.2022
  • Released 04.21.2013
  • Expires For CME 08.17.2025




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 (55). 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 (55).

Between 1924, when the Johns Hopkins Otologic Research Laboratory was founded and 1938, otolaryngologist Samuel J. Crowe (1883-1955) and anatomist Stacy R. Guild (1890-1966) amassed a collection of about 1800 temporal bones that incorporated hearing thresholds (measured by the recently invented audiometer), new pathologic techniques (ie, for temporal bone decalcification, sectioning, and staining), and a method for the graphic reconstruction of the cochlea (02). Using this resource, Crowe and Guild made the first detailed otopathologic description of presbycusis. In 1931 and 1934, they observed the loss of spiral ganglion neurons and outer hair cells in the basal turn of the cochlea in individuals with high-frequency hearing loss, and they demonstrated that stria vascularis degeneration and middle ear pathology were not the most common causes for high-frequency hearing loss.

Presbycusis results primarily from accumulated damage to the inner ear, particularly a loss of sensory hair cells in the cochlea (ie, sensory presbycusis) (55; 83). 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 (101; 38; 05). 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 (38).

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 (84; 85). Most cases have patterns that are intermediate to the extremes of either flat or sloping loss (01). 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 (01). Furthermore, quantitative studies of human temporal bones with flat or sloping audiometric configurations suggest that audiometric classification alone is insufficient to predict underlying otopathology (69; 70). 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 (23; 03): 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 (25; 23).

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