Management of Severe Conductive Hearing Loss
For severe conductive hearing loss, immediate otoscopic examination to identify and treat reversible causes is the priority, as conductive hearing loss is often highly treatable or reversible, unlike sensorineural hearing loss. 1, 2
Initial Diagnostic Evaluation
Perform otoscopic examination immediately to identify treatable causes, as patients with conductive hearing loss will often show abnormalities on examination (unlike sensorineural hearing loss where examination is typically normal). 1, 2
Key Examination Findings to Identify:
- Cerumen impaction - remove immediately as this alone may resolve the hearing loss and is potentially curative 1, 3
- Middle ear effusion - assess for fluid behind tympanic membrane 1
- Tympanic membrane perforation - requires otolaryngology referral for repair consideration 1
- Otitis media or otitis externa - look for infection and canal edema 1
- Cholesteatoma - requires surgical management 1
Perform pneumatic otoscopy and tympanometry to assess middle ear function and identify fluid or negative pressure. 1
Confirmatory Testing
Conduct Weber test (256 or 512 Hz tuning fork at midline) - sound should lateralize to the affected ear(s) in conductive hearing loss. 1, 2
Perform Rinne test - bone conduction will be better than air conduction in the affected ear(s) with conductive hearing loss. 1, 2
Obtain comprehensive audiometry including air and bone conduction thresholds at 250-8000 Hz with appropriate masking, plus speech recognition thresholds and word recognition scores. 1
- High word recognition scores (approaching 100%) confirm purely conductive pathology without cochlear involvement 1
- This indicates excellent prognosis - if sound is amplified adequately, hearing will be excellent 1
Treatment Based on Etiology
Reversible Causes (Treat Immediately):
- Cerumen impaction: Remove via irrigation or curettage 1, 3
- Middle ear effusion: Treat underlying cause (allergies, upper respiratory infection, Eustachian tube dysfunction) 1
- Otitis media: Administer appropriate antibiotic therapy 1
- Chronic otitis media with effusion: Consider myringotomy with ear tube placement to optimize hearing 4
Structural Causes Requiring Referral:
Refer to otolaryngology for patients with: 4, 1
- Tympanic membrane perforation requiring repair
- Ossicular discontinuity or fixation (including otosclerosis)
- Cholesteatoma requiring surgical management
- External auditory canal stenosis or atresia
- Superior canal dehiscence or other third window phenomena 5
Surgical Options for Severe Cases:
- Stapedectomy for otosclerosis 6
- Ossicular chain reconstruction for ossicular discontinuity 7
- Fully implantable hearing devices (e.g., Carina MET ossicular stimulator) for severe conductive loss with external auditory canal agenesis or severe middle ear malformation 8
Hearing Amplification
For patients with persistent severe conductive hearing loss not amenable to medical or surgical correction, or while awaiting definitive treatment: 4, 3
- Conventional hearing aids provide excellent benefit due to intact cochlear function
- Bone-anchored hearing aids (BAHA) for cases with canal atresia or chronic drainage
- Cochlear implants reserved for cases with severe sensorineural component 3
Patient Counseling
Emphasize that conductive hearing loss is often reversible or highly treatable, unlike sensorineural hearing loss, and does not represent "nerve damage." 1, 2
Explain that excellent word recognition scores indicate intact cochlear function, meaning once the conductive problem is corrected, hearing will be excellent. 1
Reassure that low-frequency tinnitus often resolves when the underlying conductive pathology is corrected. 1
Critical Pitfall to Avoid
Do not delay treatment or referral - many causes of conductive hearing loss are readily treatable, and misdiagnosis or delayed treatment may result in permanent complications or reduced quality of life. 2 The key distinction is that conductive hearing loss has markedly different (and often more favorable) management strategies compared to sensorineural hearing loss. 2, 6