It can be a medical emergency or stem from something as simple as earwax build-up.
Hearing loss can show up in many ways: the employee who keeps missing words in meetings. The couple who have a hard time hearing each other at busy restaurants. The father who can no longer hear his children whisper.
For me, it showed up suddenly, when I lost high-frequency hearing in my right ear at 32. Now, it can be hard for me to follow conversations in groups. Noisy environments are especially challenging. My hearing loss affects my sense of safety, and it rattles my confidence when meeting new people.
But the way hearing loss changes your life isn’t the only thing that varies. So do its underlying causes – and the treatments that can help.
“Hearing loss is just a symptom,” said Konstantina Stankovic, an otolaryngologist and auditory neuroscientist at California’s Stanford University. “It can result from problems in different parts of the auditory system.”
Identifying the type of hearing loss can help you get the right care sooner. In some cases, hearing can be fully restored. “You cannot ignore this symptom,” Stankovic said. “You need to be evaluated.”
How doctors diagnose hearing loss
If you notice changes in your hearing, start by talking to your primary care provider, an audiologist or an ear, nose and throat doctor (ENT), and explain what you’ve noticed. Keep in mind that some signs of hearing loss can be easy to miss, such as ringing in your ears, vertigo or dizziness, needing to turn up the TV, a family member or friend noticing a change, or simply feeling like everyone is mumbling.
Your healthcare provider should examine your ears for anything blocking the ear canal or abnormalities of the eardrum. They may recommend a diagnostic hearing evaluation, which measures the softest sounds you can hear at different pitches and how well you can repeat specific words. “Hearing it and understanding it are two really different things,” said Sarah Sydlowski, audiology director of the hearing implant programme at Cleveland Clinic.
Together, clinicians use your description of the problem, an ear exam and hearing tests to identify one of three broad types of hearing loss. Sensorineural loss, the most common type, often makes sounds less clear. Conductive loss, by contrast, generally reduces volume, Stankovic said. Mixed hearing loss is a combination of the two. In rare cases, a sudden, severe change in hearing can be a medical emergency that requires immediate treatment for the best chance of preventing permanent loss.
Sensorineural hearing loss is the most common
Sensorineural hearing loss occurs when the hair cells in the inner ear or auditory nerve pathways are damaged or dysfunctional. It usually develops gradually, most commonly due to ageing and noise exposure.
Trouble hearing becomes more common with age, affecting one in three Americans between ages 65 and 74, and nearly half of those 75 and older, because of natural changes in the ear, including the deterioration of hair cells.
Cumulative noise exposure over decades or even one extremely loud sound can also damage your hearing. You can reduce the risk by lowering the volume of your personal devices below 60%, moving away from loud sounds like speakers and machinery, and using hearing protection like earplugs at a concert or when operating loud equipment.
Gradual sensorineural loss is usually permanent, but it can be difficult to recognise because you adapt to it and the people around you compensate, said Catherine Palmer, director of audiology at the University of Pittsburgh Medical Centre. You turn up the volume, and friends and family speak louder. You may also start to avoid activities you used to love, especially in loud or crowded places.
Less common causes of sensorineural loss include Meniere’s disease, an inner-ear disorder often accompanied by vertigo, autoimmune diseases and, rarely, tumours.
Certain medications, including some used to treat cancer or serious infections, can also cause sensorineural loss. In some cases, hearing may improve once the drug is stopped. If you suspect a medication is affecting your hearing, talk to your doctor before making any changes.
With conductive loss, something gets in the way of sound
Conductive hearing loss occurs when something interferes with sound travelling through the outer or middle ear to the inner ear. Many cases are treatable, and hearing can sometimes be fully restored, Stankovic said.
Unlike sudden sensorineural loss, conductive loss is not usually an emergency. But ear pain or drainage, an injury or an object lodged in the ear should be evaluated promptly.
Earwax helps clean, protect and lubricate the ear, but when it builds up, it can cause conductive hearing loss. The severity “depends on the degree of the impaction”, said Mallory Raymond, a Mayo Clinic otologist-neurotologist.
Earwax build-up accounts for about 12 million healthcare visits and 8 million removal procedures in the United States each year. If you think earwax or a foreign object is affecting your hearing, have a healthcare professional evaluate you – they can remove any blockage if necessary. And as a general rule, never stick things into your ear canal yourself: Raymond joked not to put anything “smaller than the elbow” in your ear.
Other common conditions can also interfere with sound travelling through the outer or middle ear, temporarily causing muffled hearing. Swimmer’s ear, an infection of the outer ear canal, can trigger swelling that narrows the canal; it is typically treated with medicated ear drops.
Fluid behind the eardrum can also temporarily reduce hearing. It can clear on its own, but may also occur with a middle-ear infection that requires antibiotics. The eustachian tube, which connects your ear to your nose and throat, can also become blocked or dysfunctional, often because of inflammation from a cold or allergies. Persistent fluid and pressure problems may require surgery, such as ear tube placement.
The eardrum itself can also be damaged, interfering with sound travelling through the ear. A sudden pressure change, trauma, a loud blast or pushing an object like a cotton swab too far into the ear canal can tear the eardrum. Most ruptures heal on their own, but a persistent tear may need to be patched or surgically repaired by an ENT.
If damage to the outer or middle ear cannot be repaired, or hearing loss remains after treatment, a clinician may recommend a bone-conduction device, which sends vibrations through the skull directly to the inner ear.
When two types of hearing loss overlap
Some people have a mix of conductive and sensorineural hearing loss. Treatment depends on what causes each component. “For example, someone could have wax buildup and some noise-induced hearing loss on top of it,” Stankovic said. The wax can be removed, but the noise-induced loss will likely be permanent. A bone disease called otosclerosis can also cause mixed hearing loss by affecting both the middle and inner ear. In general, treating the conductive component may improve hearing, while damage to the inner ear may remain.
When hearing loss is an emergency
Any abrupt change to your hearing – especially in one ear – may be a medical emergency known as sudden sensorineural hearing loss. It can be accompanied by tinnitus, vertigo or dizziness and should be treated urgently. In about 90% of cases, including mine, no cause is identified. Steroids can improve the odds of recovery when given early, but it’s not guaranteed. Some people recover spontaneously, while others have permanent hearing loss despite prompt treatment. Two years on, I am part of the latter group.
How hearing devices can help
Permanent hearing loss cannot be reversed, but hearing devices can make listening easier and improve your quality of life. “We don’t want the brain to be using its cognitive resources just to fill in the blanks,” Palmer said. “We want hearing to be as easy as possible.”
How much hearing aids help depends partly on a person’s ability to hear speech clearly. People who can still recognise words well may benefit substantially, while those who hear speech as distorted may find that these devices make speech louder but not clearer. Hearing aids change the signal, but they don’t restore what you’ve lost, Palmer said.
When well-fitted hearing aids don’t provide adequate support, a cochlear implant may be an option. “Most people look at it as a last resort,” Sydlowski said. “That’s a really outdated view.” Cochlear implants bypass damaged hair cells to directly stimulate the auditory nerve, helping some people understand speech when hearing aids provide little benefit.
Despite the potential benefits, people wait an average of about nine years to get hearing aids. Cost, stigma and difficulty accepting the loss can all contribute to the delay. Palmer said people often seek help only after an inciting incident, like an embarrassing misunderstanding or family intervention.
That process of acceptance can be especially difficult for younger people. “Hearing loss can affect anyone at any age, literally across your lifespan,” Palmer said. “But the reality is most people associate it with older people. So, for my younger patients, part of that grieving is, ‘This wasn’t meant to happen to me now’.”
I’ve felt that grief myself. I initially sought treatment for tinnitus and was given a nasal spray. It took another week to receive the right diagnosis and care. Now, I wear a hearing aid, continue to adjust to my new reality and ask my loved ones to adapt with me.
My story is just one version of what hearing loss can look like. If you notice a change, don’t ignore it or assume it’s simply part of getting older. Finding the cause can lead to treatment that makes hearing easier – or, in some cases, restores what you’ve lost.