OSCE-Type Case

58-year-old male patient, with no past medical history, presents with a complaint of hearing loss for the past 2-4 weeks.

History Elements (these also indicate the questions that should be asked)

• The patient didn’t notice hearing loss until family members noticed it weeks ago.
• Hearing loss is bilateral, with a gradual onset rather than sudden or rapid.
• The patient feels the hearing loss is mild and very slowly getting worse.
• Admits to ringing in the ears.
• Tinnitus is non-pulsatile, subjective, and bilateral.
• Denies using Q-tips to clean ears.
• Denies any recent viral infections.
• Denies any recent trauma to the head or ears.
• Denies ear pain, itchy ears, pressure, headache, double vision, or discharge.
• Denies dizziness or loss of balance.
• Loud noises do not bother the patient.
• The patient does not need to shout at someone at arm’s length away.
• The patient has worked in construction since young adulthood.
• Admits to using machinery sometimes with loud sounds.
• Denies wearing protective ear wear.
• No previous significant medical history.
• Admits to having chronic lower back pain for several months.
• Admits to using aspirin almost daily for the last two months.
• Denies any other medication use.
• Denies anyone in the family having early deafness.
• No fever, flu-like symptoms, or lymphadenopathy.

Physical Exam (also indicates what procedures should be done)

• Vital signs: P70, BP 124/82, R 14, T 98.6°F
• Gen: Alert and oriented x3, of medium build, appears of stated age, good posture, dressed appropriately for the weather, and in no acute distress.
• Head: Normocephalic, atraumatic with no evidence of contusions, ecchymoses, hematomas, or lacerations; nontender to palpation throughout.
• Ears: Tympanic membranes pearly white/intact with light reflex in good position bilaterally. Auditory acuity intact to whispered voice bilaterally. Weber test midline, Rinne test reveals air conduction > bone conduction bilaterally.
• Neck: Supple, nontender to palpation, full range of motion, no stridor noted, 2+ carotid pulses, no thrills or bruits bilaterally.
• Oropharynx: Well hydrated, no injection, exudate, masses, lesions, or foreign bodies. Grade 1 tonsils present with no injection or exudate. Uvula pink with no edema or lesions.
• Heart: Regular rate and rhythm, S1 and S2 distinct with no murmurs, S3, or S4. No splitting of S2 or friction rubs appreciated.
• Lungs: Clear to auscultation and percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus symmetric throughout. No adventitious sounds, no evidence of drooling or stridor noted.
• Abdomen: Nontender to palpation and tympanic throughout, no guarding or rebound noted.
• Cranial Nerves: II-XII intact.

Differential Diagnosis

• Hearing loss due to ototoxic substances: Hearing loss caused by medications usually begins at high frequencies. With continued medication use, hearing loss becomes more pronounced and may continue to worsen even after the drug is discontinued. High-dose aspirin (6 to 8 g/day) or other salicylates can cause hearing loss, but this is reversible with discontinuation of the drug.
• Presbycusis: Age-related hearing loss, presenting as progressive, symmetric loss of high-frequency hearing over many years in older adults. Common complaints include difficulty hearing or understanding speech in crowded or noisy environments, difficulty understanding consonants, and inability to hear high-pitched voices or noises. Tinnitus is often present, described as a roaring sound, crickets, or bells in the ear.
• Noise-induced hearing loss: Caused by excessive noise exposure, either recreational or occupational. It has a slight male predominance and usually affects the middle-aged population. Symptoms include the insidious progression of worsening hearing loss over many years, often accompanied by tinnitus. Bedside otological examination is usually normal. Diagnosis is based on history and the characteristic finding of a notched appearance at 4kHz on a pure tone audiogram. Reducing further noise exposure using ear protection is essential.

Tests (student will be given results for any that are ordered)

• Audiologic evaluation: To determine the presence, degree, and type of hearing loss, and to define the site of abnormality within the auditory system or confirm normal functioning. Such testing is performed in an audiologist’s office.

Treatment

• Immediate discontinuation of aspirin to determine if there is improvement. Ototoxicity from aspirin is reversible, unlike other medications such as antibiotics and antineoplastic drugs.
• For patients with bothersome tinnitus related to hearing loss lasting more than six months, using an appropriately fitted hearing aid may mask the tinnitus and improve hearing loss. Correcting hearing loss (e.g., with a hearing aid) relieves tinnitus in about 50% of patients.

Patient Counseling

• Explain the importance of discontinuing aspirin, as it is associated with reversible hearing loss and tinnitus.
• Advise the patient to trial another over-the-counter medication, such as an NSAID, as needed for back pain after the current auditory symptoms improve.
• Recommend ear protection during work and emphasize the need to protect ears from loud noise to prevent hearing loss.
• Invite questions and use teach-back to ensure the patient has understood the important points.
• If symptoms do not resolve after discontinuing aspirin or if hearing loss suddenly worsens, advise the patient to return and urgently refer to an ENT specialist.