What is the best course of management for a 33-year-old male patient with noise-induced hearing loss and tinnitus in the left ear after a gunshot exposure, with normal external ear structures and tympanic membrane on physical examination?

From the Guidelines

The best management for this 33-year-old male with noise-induced hearing loss and tinnitus after gunshot exposure should include a comprehensive audiological evaluation followed by appropriate hearing rehabilitation. I recommend referral to an audiologist for complete hearing assessment including pure tone audiometry, speech audiometry, and tinnitus pitch/loudness matching, as suggested by the American Academy of Otolaryngology and Head and Neck Surgery Foundation (AAO-HNS) guidelines 1. Based on the evaluation results, hearing aids should be considered, particularly those with tinnitus masking features. For tinnitus management, a combination approach is recommended including sound therapy (using white noise generators, hearing aids with masking features, or smartphone apps with soothing sounds), tinnitus retraining therapy, and cognitive behavioral therapy, as recommended by the ACR Appropriateness Criteria1. Patient education is crucial - explaining that while the hearing loss is permanent due to cochlear hair cell damage from the acoustic trauma, tinnitus can often be effectively managed. Counseling should address hearing protection strategies for the future, including custom-molded earplugs (NRR 25-33) for any shooting activities. No medications have FDA approval specifically for noise-induced hearing loss or tinnitus, though some patients may benefit from short-term anxiolytics if severe anxiety accompanies the tinnitus, as noted in the clinical practice guideline for tinnitus 1. Regular follow-up is important to monitor hearing status and adjust management strategies as needed. Key points to consider in management include:

• Comprehensive audiological evaluation
• Hearing aids with tinnitus masking features
• Sound therapy
• Tinnitus retraining therapy
• Cognitive behavioral therapy
• Patient education on hearing protection and management of tinnitus
• Regular follow-up to monitor hearing status and adjust management strategies. Given the patient's symptoms of unilateral, persistent tinnitus and hearing difficulties, a prompt and comprehensive audiological examination is recommended, as suggested by the AAO-HNS guidelines 1. Imaging studies are not recommended unless the patient has pulsatile tinnitus, focal neurological abnormalities, or asymmetric hearing loss, as stated in the ACR Appropriateness Criteria1.

From the Research

Management of Noise-Induced Hearing Loss and Tinnitus

The patient's symptoms of noise-induced hearing loss and tinnitus in the left ear after a gunshot exposure, with normal external ear structures and tympanic membrane on physical examination, require a comprehensive management approach.

• The first step is to assess the patient's hearing loss using pure-tone audiometry, as it is the most accurate method for hearing loss detection 2.
• The patient should undergo examination for cerumen impaction, exostoses, and other abnormalities of the external canal and tympanic membrane, in addition to a neurologic examination 3.
• Since the patient has asymmetrical sensorineural hearing loss, additional evaluation by an audiologist and otolaryngologist, as well as imaging studies, may be warranted 2, 3.
• The patient should be referred to an audiologist for consideration of hearing aids, as they can help improve communication and reduce the risk of negative emotional, cognitive, economic, and social consequences 2, 3, 4.
• The patient's tinnitus symptoms can be managed using cognitive behavioral therapy (CBT) or notched sound therapy (NST), both of which have been shown to be effective in reducing tinnitus severity and improving quality of life 5.

Prevention and Protection

• Prevention and protection are the first lines of defense against noise-induced hearing loss, and the patient should be counseled on the importance of protecting their hearing 2, 6.
• The patient should be advised to avoid further exposure to loud noises and to use ear protection when engaging in activities that may put them at risk for noise-induced hearing loss 6.

Treatment Options

• Treatment options for noise-induced hearing loss include hearing aids, auditory rehabilitation, and education 2, 3, 4.
• In some cases, cochlear implants may be helpful for patients with severe or refractory hearing loss 3.
• The patient's treatment plan should be individualized and based on their specific needs and circumstances.