ENT

6
5
Anatomy & Physiology of Hearing
1. Anatomy of the Ear
4
The ear is divided into three main parts:
A. External Ear
3
● Auricle (Pinna): Collects sound waves and directs them into the ear
canal.
● External Auditory Canal: Amplifies sound and channels it to the
tympanic membrane.
2
● Tympanic Membrane (Eardrum): Vibrates in response to sound
waves.
1
B. Middle Ear
● Ossicles:
○ Malleus (hammer)
○ Incus (anvil)
○ Stapes (stirrup)

Function: Transmit and amplify vibrations from tympanic

membrane to oval window.
● Eustachian Tube: Equalizes air pressure on both sides of the
tympanic membrane.
C. Inner Ear
● Cochlea: Spiral-shaped organ containing sensory receptor cells (hair
cells) in the Organ of Corti.
● Vestibulocochlear Nerve (Cranial Nerve VIII): Transmits electrical
signals to the brain.

2. Physiology of Hearing
. Sound Collection:
○ Pinna → directs sound into auditory canal.

. Vibration Transmission:
○ Sound waves hit tympanic membrane → ossicles vibrate → stapes

pushes on oval window.

. Fluid Wave Generation:
○ Movement at oval window sets up waves in cochlear fluid.

. Hair Cell Stimulation:

○ Basilar membrane movement bends stereocilia on hair cells in

Organ of Corti → opens ion channels.

. Signal Conversion:
○ Mechanical energy → electrochemical nerve impulse.

. Neural Transmission:
7
○ Impulse travels via cochlear branch of vestibulocochlear nerve →
brainstem → auditory cortex (temporal lobe).
. Sound Perception:
○ Brain interprets pitch, loudness, and location of sound.

Audiometry in Assessment of Hearing

1. Definition
Audiometry is the clinical measurement of a person’s ability to hear sounds of
varying frequencies and intensities, using standardized tests and equipment.

2. Types of Audiometry
A. Pure Tone Audiometry (PTA)
● Purpose: Measures hearing thresholds for pure tones at various
frequencies (250–8000 Hz).
● Procedure:
○ Patient wears headphones → listens to tones at different pitches

and volumes.
○ Threshold: Lowest intensity at which the tone is heard 50% of the

time.
● Use in OT: Determines severity of hearing loss, helps plan assistive
device recommendations.
B. Speech Audiometry
● Purpose: Measures ability to detect and understand speech.
● Tests:
○ Speech Reception Threshold (SRT)
○ Word Recognition Score (WRS)

C. Tympanometry
● Purpose: Assesses middle ear function and eardrum mobility.
● Use: Detects fluid, perforation, ossicular problems.
D. Otoacoustic Emissions (OAE)
● Purpose: Tests cochlear hair cell function.
● Use: Screening in newborns and non-verbal patients.
E. Auditory Brainstem Response (ABR)
● Purpose: Measures neural activity from auditory nerve to brainstem.
● Use: For neurological hearing loss diagnosis.

3. Importance in Occupational Therapy

● Functional Assessment: Determines communication limitations
affecting social and occupational performance.
● Treatment Planning: Guides selection of hearing aids, FM systems, or
environmental adaptations.
● Monitoring: Tracks changes in hearing over time in conditions like
meningitis, noise exposure, or head injury.
● Rehabilitation Goals: Supports auditory training, speech reading, and
environmental modifications.
4. Summary Table
Structure Function in Hearing OT Relevance
External Ear Sound collection Detects directional
hearing loss
Middle Ear Sound amplification Tympanometry for
functional hearing
Inner Ear Sound transduction PTA & OAE for sensory
loss
Auditory Pathway Signal transmission ABR for neural
pathway integrity

⸻⸻⸻⸻⸻⸻⸻—

Classification of Causes of Hearing Loss

1. Conductive Hearing Loss
Defect in external or middle ear → prevents sound from reaching inner ear.
● Causes:
○ Wax impaction
○ Otitis externa / media
○ Tympanic membrane perforation
○ Otosclerosis (ossicle fixation)
○ Eustachian tube dysfunction

2. Sensorineural Hearing Loss

Defect in inner ear (cochlea) or auditory nerve → affects sound perception.
● Causes:
○ Age-related degeneration (Presbycusis)
○ Noise-induced damage
○ Meniere’s disease
○ Ototoxic drugs (e.g., aminoglycosides)
○ Viral infections (e.g., mumps, measles)
○ Acoustic neuroma

3. Mixed Hearing Loss

Combination of conductive and sensorineural loss.
● Causes:
○ Chronic otitis media with cochlear damage
○ Trauma affecting multiple ear structures

4. Central Hearing Loss

Defect in auditory pathways or brain (beyond cochlea).
● Causes:
○ Brainstem lesions
 ○ Cortical damage (temporal lobe stroke, tumors)
○ Multiple sclerosis

⸻⸻⸻⸻⸻⸻⸻

I. Conservative Interventions
1. Medical Treatment
● Ear wax removal:
○ Ear drops (cerumenolytics), syringing, manual removal.
● Infections:
○ Antibiotic ear drops (otitis externa), systemic antibiotics (otitis

media).
● Anti-inflammatory / anti-vertigo drugs:
○ For Meniere’s disease, labyrinthitis.
● Allergy management:
○ Antihistamines, decongestants for Eustachian tube dysfunction.

2. Hearing Rehabilitation
● Hearing Aids:
○ Amplify sound for residual hearing.
○ Fitted after audiometric assessment.
○ OT role: Training in device use, maintenance, environmental

modifications.
● Speech Reading / Lip Reading Training:
○ To improve communication skills.
● Auditory Training:
○ Exercises to improve listening and sound discrimination.
● Environmental Adaptations:
○ Visual alarms, captioned telephones, FM systems.

II. Surgical Interventions

1. Middle Ear Surgery
● Myringoplasty: Repair of tympanic membrane perforation.
● Ossiculoplasty: Reconstruction of ossicular chain.
● Stapedectomy: Replacement of stapes with prosthesis in
otosclerosis.
● Tympanoplasty: Repair of middle ear structure & eardrum.
2. Cochlear Implantation
● Indication: Severe–profound sensorineural loss not benefiting from
hearing aids.
● Components:
○ External microphone & speech processor.
○ Internal electrode array in cochlea.
3. Bone-Anchored Hearing Aid (BAHA) Surgery
● For conductive/mixed loss or single-sided deafness.

III. Types of Hearing Aids

A. Based on Placement
. Behind-The-Ear (BTE):
○ Most common, suitable for mild–profound loss.

. In-The-Ear (ITE):
○ Fits into outer ear; for mild–severe loss.

. In-The-Canal (ITC) / Completely-In-Canal (CIC):

○ Smaller, discreet; for mild–moderate loss.

B. Based on Technology
. Analogue Hearing Aids:
○ Amplify all sounds equally (less common now).

. Digital Hearing Aids:

○ Process and selectively amplify sounds; better clarity.

C. Special Types
● Bone-Conduction Hearing Aids: For conductive loss.
● FM Systems: Wireless systems for classrooms or meetings.

IV. Availability in India

● Government Schemes:
○ ADIP Scheme (Assistance to Disabled Persons) – free / subsidised

hearing aids.
● Public Sector Hospitals:
○ ENT departments in AIIMS, state medical colleges.
● Private Sector:
○ Hearing aid companies (Siemens, Phonak, Widex, Oticon).
● NGOs:
○ National Association of the Deaf, ALIMCO (Artificial Limbs

Manufacturing Corporation of India).

V. Role of Occupational Therapy

● Assessment of functional hearing & daily activity impact.
● Training in hearing aid use & care.
● Environmental modifications at home/work.
● Communication skill development.
● Integration into social & occupational roles.

⸻⸻⸻⸻—

Functions of the Vestibular Apparatus

The vestibular apparatus (in the inner ear) maintains balance, posture, and
spatial orientation. Its main functions are:
 . Detection of Head Position (Static Equilibrium)
○ Utricle & Saccule (otolith organs) detect head position relative to

gravity and linear acceleration.

. Detection of Head Movement (Dynamic Equilibrium)
○ Semicircular Canals detect rotational movements of the head in

three planes.
. Maintenance of Balance & Posture
○ Sends sensory input to brainstem & cerebellum for postural reflex

adjustments.
. Coordination of Eye Movements (Vestibulo-Ocular Reflex)
○ Stabilizes visual images during head movements by adjusting eye

position.
. Spatial Orientation
○ Helps the brain perceive body position in space for coordinated

movement.

⸻⸻⸻⸻⸻⸻—

1. Conditions Affecting Hearing

Condition Effect Management
Otitis Externa (outer Pain, discharge, Ear drops (antibiotic/
ear infection) temporary conductive antifungal), cleaning,
hearing loss avoid water entry
Otitis Media (middle Ear pain, fever, hearing Antibiotics,
ear infection) loss, possible analgesics,
perforation myringotomy if
needed
Otosclerosis Fixation of stapes → Hearing aids,
progressive hearing stapedectomy
loss
Wax Impaction Conductive hearing Wax softeners,
loss syringing/manual
removal
Meniere’s Disease Vertigo, fluctuating Low-salt diet,
hearing loss, tinnitus diuretics, vestibular
rehab, surgery if
severe

2. Conditions Affecting Breathing

Condition Effect Management
Rhinitis (allergic/ Nasal congestion, Antihistamines, nasal
infective) sneezing, runny nose sprays, allergen
avoidance
Sinusitis Nasal blockage, Decongestants,
headache, postnasal antibiotics, steam
Rhinitis (allergic/ Nasal congestion, Antihistamines, nasal
infective) sneezing, runny nose sprays, allergen
avoidance
Sinusitis Nasal blockage, Decongestants,
headache, postnasal antibiotics, steam
drip inhalation
Deviated Nasal Chronic blockage, Septoplasty
Septum (DNS) mouth breathing
Adenoid Hypertrophy Mouth breathing, Adenoidectomy
(children) snoring, nasal speech
Nasal Polyps Blockage, hyposmia Steroid sprays,
polypectomy

3. Conditions Affecting Speech

Condition Effect Management
Laryngitis Hoarseness, loss of Voice rest, steam
voice inhalation, hydration
Vocal Cord Nodules/ Hoarseness, strained Voice therapy, surgical
Polyps voice removal if persistent
Cleft Lip/Palate Speech defects, nasal Surgical repair, speech
tone therapy
Tonsillitis Pain, swallowing Antibiotics,
difficulty, muffled analgesics,
voice tonsillectomy if
recurrent
Vocal Cord Paralysis Weak/breathy voice, Voice therapy, surgical
aspiration medialization

Occupational Therapy Relevance

● Hearing: Training in hearing aid use, environmental adaptations,
communication skills.
● Breathing: Energy conservation, breathing techniques, positioning.
● Speech: Collaboration with speech therapists, environmental
modifications, assistive communication devices.