Overview

Hearing loss that occurs gradually as you age (presbycusis) is common. Almost half the people in the United States older than age 65 have some degree of hearing loss.

Hearing loss is defined as one of three types:

• Conductive (involves outer or middle ear)
• Sensorineural (involves inner ear)
• Mixed (combination of the two)

Aging and chronic exposure to loud noises both contribute to hearing loss. Other factors, such as excessive earwax, can temporarily reduce how well your ears conduct sounds.

You can’t reverse most types of hearing loss. However, you and your doctor or a hearing specialist can take steps to improve what you hear.

Symptoms

Signs and symptoms of hearing loss may include:

• Muffling of speech and other sounds
• Difficulty understanding words, especially against background noise or in a crowd
• Trouble hearing consonants
• Frequently asking others to speak more slowly, clearly and loudly
• Needing to turn up the volume of the television or radio
• Withdrawal from conversations
• Avoidance of some social settings

Causes

To understand how hearing loss occurs, it can be helpful to first understand how you hear.

How you hear

Your ear consists of three major areas: outer ear, middle ear and inner ear. Sound waves pass through the outer ear and cause vibrations at the eardrum. The eardrum and three small bones of the middle ear amplify the vibrations as they travel to the inner ear. There, the vibrations pass through fluid in a snail-shaped structure in the inner ear (cochlea).

Attached to nerve cells in the cochlea are thousands of tiny hairs that help translate sound vibrations into electrical signals that are transmitted to your brain. Your brain turns these signals into sound.

How hearing loss can occur

Causes of hearing loss include:

• Damage to the inner ear. Aging and exposure to loud noise may cause wear and tear on the hairs or nerve cells in the cochlea that send sound signals to the brain. When these hairs or nerve cells are damaged or missing, electrical signals aren’t transmitted as efficiently, and hearing loss occurs.
  Higher pitched tones may become muffled to you. It may become difficult for you to pick out words against background noise.
• Gradual buildup of earwax. Earwax can block the ear canal and prevent conduction of sound waves. Earwax removal can help restore your hearing.
• Ear infection and abnormal bone growths or tumors. In the outer or middle ear, any of these can cause hearing loss.
• Ruptured eardrum (tympanic membrane perforation). Loud blasts of noise, sudden changes in pressure, poking your eardrum with an object and infection can cause your eardrum to rupture and affect your hearing.

Risk Factors

Factors that may damage or lead to loss of the hairs and nerve cells in your inner ear include:

• Aging. Degeneration of inner ear structures occurs over time.
• Loud noise. Exposure to loud sounds can damage the cells of your inner ear. Damage can occur with long-term exposure to loud noises, or from a short blast of noise, such as from a gunshot.
• Heredity. Your genetic makeup may make you more susceptible to ear damage from sound or deterioration from aging.
• Occupational noises. Jobs where loud noise is a regular part of the working environment, such as farming, construction or factory work, can lead to damage inside your ear.
• Recreational noises. Exposure to explosive noises, such as from firearms and jet engines, can cause immediate, permanent hearing loss. Other recreational activities with dangerously high noise levels include snowmobiling, motorcycling, carpentry or listening to loud music.
• Some medications. Drugs such as the antibiotic gentamicin, sildenafil (Viagra) and certain chemotherapy drugs, can damage the inner ear. Temporary effects on your hearing — ringing in the ear (tinnitus) or hearing loss — can occur if you take very high doses of aspirin, other pain relievers, antimalarial drugs or loop diuretics.
• Some illnesses. Diseases or illnesses that result in high fever, such as meningitis, may damage the cochlea.

Diagnosis & Treatment

Patients who suspect something is wrong with their hearing will initially go and see their doctor.

The doctor will talk to the patient and ask several questions regarding the symptoms, including when they started, whether or not they have gotten worse, and whether the individual is feeling pain alongside the hearing loss.

The doctor will look into the ear using an otoscope. This is an instrument with a light at the end. The following may be detected during the examination:

• a blockage caused by a foreign object
• a collapsed eardrum
• an accumulation of earwax
• an infection in the ear canal
• an infection in the middle ear if a bulge is present in the eardrum.
• cholesteatoma, a skin growth behind the eardrum in the middle ear. fluid in the ear canal
• a hole in the eardrum

The doctor will ask questions about the person’s experiences with hearing, including:

• Do you often find yourself asking people to repeat what they said?
• Do you find it hard to understand people on the telephone?
• Do you miss the doorbell when it rings? If so, does this happen frequently?
• When you chat with people face-to-face, do you have to focus carefully?
• Has anybody ever mentioned to you that you might have a problem with your hearing?
• Do you find more people mumble today than they used to?
• internal you hear a sound, do you often find it hard to determine where it is coming from?
• When several people are talking, do you find it hard to understand what one of them is telling you?
• Are you often told that the television, radio, or any sound-producing device is too loud?
• Do you find male voices easier to understand than female voices?
• Do you spend most of each day in a noisy environment?
• Have you often found yourself misunderstanding what other people say to you?
• Do you hear rushing, hissing, or ringing sounds?
• Do you avoid group conversations?

If you answered “yes” to most of the above questions, see a doctor and have your hearing checked.

General Screening Test

A doctor may ask the patient to cover one ear and describe how well they hear words spoken at different volumes, as well as checking sensitivity to other sounds.

If the doctor suspects a hearing problem, they will probably be referred to either an ear, nose, and throat (ENT) specialist or an audiologist.

Further tests will be carried out, including:

A tuning fork test: This is also known as the Rinne test. A tuning fork is a metal instrument with two prongs that produces a sound when it is struck. Simple tuning fork tests may help the doctor detect whether there is any hearing loss, and where the problem is.

A tuning fork is vibrated and placed against the mastoid bone behind the ear. The patient is asked to indicate when they no longer hear any sound. The fork, which is still vibrating, is then placed 1 to 2 centimeters (cm) from the auditory canal. The patient is asked again whether they can hear the fork.

As air conduction is greater than bone conduction, the patient should be able to hear the vibration. If they cannot hear it at this point, it means that their bone conduction is superior to their air conduction.

This suggests a problem with sound waves getting to the cochlea through the ear canal.

Audiometer test: The patient wears earphones, and sounds are directed into one ear at a time. A range of sounds is presented to the patient at various tones. The patient has to signal each time a sound is heard.

Each tone is presented at various volumes, so that the audiologist can determine at which point the sound at that tone is no longer detected. The same test is carried out with words. The audiologist presents words at various tones and decibel levels to determine where the ability to hear stops.

Bone oscillator test: This is used to find out how well vibrations pass through the ossicles. A bone oscillator is placed against the mastoid. The aim is to gauge the function of the nerve that carries these signals to the brain.

Routine Screening of Children

The American Academy of Pediatrics (AAP) recommends that children have their hearing tests at the following times:

• when they start school
• at 6, 8, and 10 years of age
• at least once when they are in middle school
• once during high school

Treatment

Help is available for people with all types of hearing loss. Treatment depends on both the cause and severity of the deafness.
Sensorineural hearing loss is incurable. When the hair cells in the cochlea are damaged, they cannot be repaired. However, various treatments and strategies can help improve quality of life.

NASAL BLEEDING (EPISTAXIS)?

“Epistaxis” is the medical term for a nosebleed. A nosebleed, meaning a loss of blood from the tissue that lines the inside of your nose, can occur in one or both nostrils. Usually, it only affects one nostril. Your nose has many tiny blood vessels in it. These vessels help warm and moisten the air you breathe. But they lie close to the inner surface of your nose. When air moves through your nose, it can dry and irritate your blood vessels. This makes them very easy to injure or break, causing a nosebleed.

How common is Nasal Bleeding?

Epistaxis is common. About 60% of people will have at least one nosebleed in their lifetime. Only about 10% of cases are severe enough to require medical treatment.

Who Gets Nasal Bleeding?

Anyone can get nasal bleeding. Most people will have at least one case in their lifetime. However, some people are more likely to have a nosebleed. They include:

• Children between the ages of two and 10: Dry air, colds, allergies and sticking fingers and objects into their noses make children more prone to nosebleeds.
• Adults between the ages of 45 and 80: Blood may take longer to clot in mid-life and in older adults. These adults are also more likely to have high blood pressure, atherosclerosis (hardening of the walls of arteries) or a bleeding disorder.
• Pregnant people: Blood vessels in your nose expand while you’re pregnant, which puts more pressure on the delicate blood vessels in the lining of your nose.
• People taking blood-thinning medications:  These drugs include aspirin and warfarin.
• People who have blood clotting disorders: These include hemophilia and von Willebrand disease.

Types of Nosebleeds

There are two main types of nosebleeds.

Anterior nosebleed

An anterior nosebleed starts in the front of your nose on the lower part of the wall that separates the two sides of your nose (septum). Capillaries and small blood vessels in this front area of your nose are fragile and can easily break and bleed. This is the most common type of epistaxis and usually isn’t serious. These nosebleeds are more common in children. You can usually treat these nosebleeds at home.

Posterior nosebleed

A posterior nosebleed occurs deep inside your nose. A bleed in larger blood vessels in the back part of your nose near your throat causes this type. It can result in heavy bleeding, which may flow down the back of your throat. You may need medical attention right away for this type of nosebleed. This type is more common in adults.

Symptoms and Causes

A nosebleed, or epistaxis, is the loss of blood from the tissue that lines the inside of your nose.

What are the symptoms of a nosebleed?

Most often, you won’t have any symptoms other than blood coming from your nose. If you have a posterior nosebleed, some blood may drain down the back of your throat into your stomach. This can cause a bad taste in the back of your throat and make you feel nauseated.

If you have additional symptoms, it may be a sign of a medical condition.

What causes a nosebleed in one nostril?

Most nosebleeds only affect one nostril, but they can affect both at the same time. Epistaxis has many causes. Fortunately, most aren’t serious.

The most common cause of nosebleeds is dry air. Hot, low-humidity climates or heated indoor air cause dry air. Both environments cause your nasal membrane (the delicate tissue inside your nose) to dry out and become crusty or cracked. This makes it more likely to bleed when rubbed or picked or when blowing your nose. You may also experience epistaxis after inserting an object in your nose or injuring your nose and/or face.

Other nosebleed causes may include:

• Infections:  Colds (upper respiratory infections) and sinusitis, especially episodes that cause repeated sneezing, coughing and nose blowing.
• Allergies: Allergic and nonallergic rhinitis (inflammation of your nasal lining).
• Blood-thinning medications: Drugs such as aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), warfarin and others.
• Recreational drugs: Cocaine and other drugs you inhale through your nose.
• Chemical irritants: Chemicals in cleaning supplies, chemical fumes at workplaces and other strong odors.
• High altitudes: The air is thinner (lack of oxygen) and drier as the altitude increases.
• Deviated septum: An abnormal shape of the wall that separates the two sides of your nose.
• Nasal sprays: Frequent use of nasal sprays and medications to treat an itchy, stuffy or runny nose. These medications — antihistamines and decongestants — can dry out your nasal membranes.

Other less common causes of nosebleeds include:

• Alcohol use.
• Bleeding disorders, such as hemophilia or von Willebrand disease.
• High blood pressure.
• Atherosclerosis.
• Facial and nasal surgery.
• Nasal tumors.
• Nasal polyps.
• Immune thrombocytopenia.
• Leukemia.
• Hereditary hemorrhagic telangiectasia.
• Pregnancy.

Diagnosis and Tests

What should I expect when I go to my provider about epistaxis?

A doctor will ask you questions about your nosebleed, including:

• Length (in minutes) of your nosebleed.
• Approximate amount of blood that was lost.
• How often you get them.
• If the bleed involved one or both nostrils.
• They’ll also ask about:
• Medications you’re taking, including over-the-counter blood-thinning medications such as aspirin, and drugs for colds and allergies.
• Your family history, including any history of blood disorders.
• Your use of alcohol and/or any recreational drugs in which you sniffed the drug up your nose.

Next, your provider will examine your nose to determine the source of the bleeding and what may have caused it. They’ll use a small speculum to hold your nostril open and use various light sources or an endoscope (lighted scope) to see inside your nasal passages.

Your provider may use topical medications to numb (anesthetize) the lining of your nose and to narrow blood vessels. Your provider may remove clots and crusts from inside your nose. This can be unpleasant but isn’t painful.

Occasionally, they may order X-rays, a CT scan or blood tests to check for bleeding disorders, blood vessel abnormalities or nasal tumors.

Management and Treatment

How to stop a Nosebleed

Use the following steps to stop a nosebleed at home.

• Sit upright and lean your body and your head slightly forward. This will keep the blood from running down your throat, which can cause nausea, vomiting and diarrhoea. (Don’t lay flat or put your head between your legs.)
• Breathe through your mouth.
• Use a tissue or damp washcloth to catch the blood.
• Use your thumb and index finger to pinch together the soft part of your nose. Make sure to pinch the soft part of the nose against the hard bony ridge that forms the bridge of your nose. Squeezing at or above the bony part of your nose won’t put pressure where it can help stop the bleeding.
• Keep pinching your nose continuously for at least five minutes before checking if the bleeding has stopped. If your nose is still bleeding, continue squeezing your nose for another 10 minutes.
• If you’d like, apply an ice pack to the bridge of your nose to further help narrow blood vessels (which will slow the bleeding) and provide comfort. This isn’t a necessary step, but you can try it.
• You can spray an over-the-counter decongestant spray into the bleeding side of your nose and then apply pressure to your nose. You shouldn’t use these topical decongestant sprays over a long period. Doing so can cause an increase in the chance of a nosebleed.
• After the bleeding stops, don’t bend over, strain and/or lift anything heavy. Don’t blow or rub your nose for several days.

When Should I see my Doctor About Nasal Bleeding?

• You get epistaxis often.
• You have symptoms of anemia (feeling weak, faint, tired, cold or short of breath or having pale skin).
• You have a child under age 2 who has had a nosebleed.
• You’re taking blood-thinning medications (such as aspirin or warfarin) or have a blood-clotting disorder and the bleeding won’t stop.
• You get a nosebleed that seems to have occurred with the start of a new medication.
• You get epistaxis, as well as notice unusual bruising all over your body. This combination may indicate a more serious condition such as a blood-clotting disorder (hemophilia or von Willebrand disease), leukemia or a nasal tumor.

What Are the Treatments For Epistaxis?

Nosebleed treatment depends on the cause of the bleeding. Epistaxis treatment may include:

• Nasal packing: Your doctor will insert gauze, special nasal sponges or foam, or an inflatable latex balloon into your nose to create pressure at the site of the bleed. Your provider may want to leave the material in place for 24 to 48 hours before removing it.
• Cauterization: This procedure involves applying a chemical substance (silver nitrate) or heat energy (electrocautery) to seal the bleeding blood vessel. Your provider will spray a local anesthetic in your nostril first to numb the inside of your nose.
• Medication adjustments/new prescriptions:  Reducing or stopping the amount of blood-thinning medications can be helpful. In addition, medications for controlling blood pressure may be necessary. Your provider may prescribe Tranexamic (Lystedaâ®), a medication to help blood clot.
• Foreign body removal:  If the cause of the nosebleed is a foreign object, your provider will remove it.
• Surgery: Surgical repair of a broken nose or correction of a deviated septum (septoplasty) if this is the cause of the nosebleed.
• Ligation: In this procedure, your provider will tie off the culprit blood vessel to stop the bleeding.

Prevention

What can I do to prevent Nosebleeds?

• Use a saline nasal spray or saline nose drops two to three times a day in each nostril to keep your nasal passages moist. You can purchase these products over-the-counter or you can make them at home. To make the saline solution at home, mix 1 teaspoon of salt into 1 quart of tap water. Boil water for 20 minutes, and let cool until lukewarm.
• Add a humidifier to your furnace or run a humidifier in your bedroom at night to add moisture to the air.
• Spread water-soluble nasal gels or ointments in your nostrils with a cotton swab. Bacitracin®, Vaseline® or Ayr Gel® are examples of over-the-counter ointments you can use. Be sure not to insert the swab more than 1/4 inch into your nose. You can purchase these gels and ointments in most pharmacies.
• Avoid blowing your nose too forcefully.
• Sneeze through an open mouth. Always sneeze into a tissue or your elbow.
• Avoid putting anything solid into your nose, including your fingers.
• Limit your use of medications that can increase bleeding, such as aspirin and ibuprofen. Remember that any medication adjustment, especially prescribed medication such as warfarin (Coumadin®) and nonsteroidal anti-inflammatory drugs (NSAIDs), should only be done under your doctor’s supervision.
• See your provider if you can’t easily control your nasal allergy symptoms with over-the-counter or prescription medications. Make sure you closely follow the directions when using over-the-counter products. Overusing them can cause nosebleeds.
• Quit smoking. Smoking dries out your nose and irritates it.
• Wear protective headgear if involved in activities that could result in an injury to your face and nose.
• Keep your child’s fingernails short.

If you have any questions or concerns, don’t hesitate to call your doctor.

Outlook / Prognosis

When to Worry About a Nosebleed

Although seeing blood coming out of your nose can be alarming, most nosebleeds aren’t serious. You can usually manage them at home. However, you should have some cases of epistaxis checked by a doctor. For instance, if you have frequent nosebleeds, see a provider. This could be an early sign of another medical issue that they’ll want to look into.

Some nosebleeds can start in the back of your nose. These cases of epistaxis usually involve large blood vessels resulting in heavy bleeding and can be dangerous. You’ll need medical attention for this type of bleed, especially if the bleeding occurs after an injury and the bleeding hasn’t stopped after 20 minutes of applying direct pressure to your nose.

Can You Die From a Nosebleed?

Nosebleeds that occur higher on your septum or deeper in your nose may be harder to control. However, nosebleeds are rarely fatal. They account for 4 out of every 2.4 million deaths in the United States.

Living with

Why do I get Frequent Nosebleeds in One Nostril?

There are many non-serious reasons you may be getting frequent nosebleeds. They can affect one or both nostrils. The most common causes are:

• Frequent use of nasal sprays for the treatment of allergy symptoms or colds/congestion. You may need to stop using these drugs for a short period or may need to stop them altogether. Talk with your provider if you use these products.
• Living in dry air conditions.
• Snorting drugs into your nose.
• In rare cases, repeated epistaxis could be a sign of a bleeding disorder or other more serious conditions. If you have frequent nosebleeds, see a doctor.

What Causes Nosebleeds While Sleeping?

The reasons for nosebleeds during sleep are the same as the reasons why they occur during the daytime — dried nasal membranes caused by dry air, allergies and upper respiratory infections that damage the delicate nasal membrane lining your nose. Sleeping with your head to the side may also put direct pressure on your nasal cavity and may be another reason for epistaxis at night.

Can I Drink Water After a Nosebleed?

Yes, you should drink plenty of fluids after a nosebleed. Good options include water, juice and other non-caffeinated liquids. After you experience epistaxis, some blood may drain down the back of your throat into your stomach. This may give you a bad taste in the back of your throat or make you feel nauseated. But drinking water won’t affect a nosebleed.

When Should I go to the Emergency Room If I Have a Nosebleed?

Call your doctor immediately, have someone drive you to the nearest emergency room or call 911 if:

• You can’t stop the bleeding after more than 15 to 20 minutes of applying direct pressure on your nose as described in the steps above.
• The bleeding is rapid or the blood loss is large (more than 1 cup).
• You’re having difficulty breathing.
• You’ve vomited because you’ve swallowed a large amount of blood.
• Your nosebleed has followed a blow to your head or a serious injury (fall, car accident or a smash to your face or nose).

Additional Common Questions

Is it normal to have blood clots in a nosebleed?

Yes. Blood clots are clumps of blood that form in reaction to an injured blood vessel. Blood clotting prevents excessive bleeding when a blood vessel is damaged. When you pinch your nose to stop a nosebleed, the blood will begin to clot. It’ll normally remain there until you remove it or gently blow your nose.

Why do I Have a Headache and a Nosebleed?

Many factors can lead to headaches and nosebleeds. A common cause of both symptoms is a deviated septum (a shifted wall in your nose). One study found that epistaxis may be a precursor to migraines. Other common causes of headaches and nosebleeds may include:

• Allergies
• Weather changes.
• Severe injuries.
• Other medical conditions.