ConditionEar, nose & throat
Mixed Hearing Loss
Mixed hearing loss is a combination of two types of hearing loss in the same ear: conductive loss, where sound cannot pass properly through the outer or middle ear, and sensorineural loss, where the inner ear or hearing nerve is damaged. For example, someone with age-related inner ear loss may also have fluid behind the eardrum or a stiff middle ear bone. A hearing test shows both parts. The conductive part can often be treated medically or surgically, while the sensorineural part is usually managed with hearing aids or implants.
Also called: Combined hearing loss, mixed conductive and sensorineural hearing loss
At a glance
- What it is
- Conductive and sensorineural hearing loss occurring together in the same ear.
- Common causes
- Otosclerosis, chronic ear infections, cholesteatoma, head injury, age-related loss plus middle ear problems.
- Diagnosis
- Audiogram showing a gap between air- and bone-conduction thresholds, both below normal.
- Treatment
- Treat the conductive part (wax removal, surgery, ear tubes), plus hearing aids or implants for the rest.
- Outlook
- Hearing can usually be improved, though the sensorineural part is usually permanent.
When to get help
Call 911 or go to the ER
- Hearing loss after a head injury with clear fluid from the ear or nose, dizziness, or facial weakness
See a doctor within a day or two
- Sudden hearing loss in one ear over hours to 3 days, especially without a cold or wax (see a doctor within 72 hours)
- Ear discharge with pain, fever, swelling behind the ear or facial weakness
- Hearing loss with severe vertigo
Book a routine appointment
- Gradual hearing loss, difficulty following conversations, or turning up the TV
- Long-standing ear discharge or repeated ear infections
- Hearing loss in one ear only, or with tinnitus in one ear
- A child with speech delay, inattention or not responding to sounds
Types of hearing loss
| Type | Where the problem is | Typical causes | Typical treatment |
|---|---|---|---|
| Conductive | Outer or middle ear | Earwax, fluid, infection, perforated eardrum, otosclerosis, cholesteatoma | Often medical or surgical |
| Sensorineural | Inner ear (cochlea) or hearing nerve | Aging, noise, genetics, some medicines, Ménière's disease | Hearing aids, cochlear implants |
| Mixed | Both | Combination of the above | Treat each part |
See conductive hearing loss and sensorineural hearing loss.
Causes of mixed hearing loss
- Otosclerosis: abnormal bone growth fixes the stapes (a tiny middle ear bone), causing conductive loss. It can later affect the inner ear, causing a mixed loss.
- Chronic otitis media: long-term infection damages the eardrum and middle ear bones, and toxins can reach the inner ear.
- Cholesteatoma: a skin growth in the middle ear that erodes bone and can damage the inner ear.
- Head injury: temporal bone fractures can disrupt the middle ear bones and damage the cochlea.
- Two separate conditions together: for example age-related hearing loss (presbycusis) or noise damage, plus earwax, fluid behind the eardrum or a perforated eardrum.
- Congenital conditions: some genetic syndromes and ear malformations.
- Ear surgery complications and some infections.
Symptoms
- Gradual or sudden reduction in hearing in one or both ears
- Sounds seem both quieter and less clear or distorted
- Difficulty understanding speech, especially in noise
- Tinnitus (ringing or buzzing)
- Ear fullness, discharge or pain if there is a middle ear problem
- Dizziness in some cases
Diagnosis
- History and examination: an otoscope examination of the ear canal and eardrum.
- Tuning fork tests: quick bedside tests that suggest whether loss is conductive or sensorineural.
- Pure-tone audiogram: the key test. Sounds are played through headphones (air conduction) and a bone vibrator behind the ear (bone conduction). In mixed hearing loss, both thresholds are worse than normal, and there is also a gap between them (an air-bone gap) showing the conductive part.
- Tympanometry: tests eardrum movement and middle ear pressure.
- Speech testing: how well words are understood.
- CT or MRI: to examine the middle and inner ear, look for cholesteatoma, otosclerosis or other causes, and rule out tumors of the hearing nerve when loss is one-sided.
Treatment
Treating the conductive part
- Earwax removal
- Medicines for ear infections
- Ear tubes for persistent middle ear fluid
- Surgery: eardrum repair (tympanoplasty), reconstruction of the middle ear bones (ossiculoplasty), stapedectomy or stapedotomy for otosclerosis, and removal of cholesteatoma
Managing the sensorineural part
- Hearing aids: conventional hearing aids are the main option. People with ear discharge or ear canal problems may need different types.
- Bone-conduction hearing devices: implanted or worn devices that send sound through the skull bone directly to the inner ear. Useful when the outer or middle ear cannot be fixed.
- Middle ear implants for selected people.
- Cochlear implants for severe to profound loss.
Communication strategies
Assistive listening devices, captioning, facing the speaker, reducing background noise, and hearing rehabilitation help in daily life.
Outlook
Treating the conductive component can significantly improve hearing. The sensorineural component is usually permanent, but modern hearing aids and implants help most people communicate well. Regular hearing checks track changes over time.
Frequently asked questions
What is mixed hearing loss?
Mixed hearing loss is when a person has both conductive hearing loss, a problem with sound passing through the outer or middle ear, and sensorineural hearing loss, damage to the inner ear or hearing nerve, in the same ear. Both parts are visible on a hearing test.
What causes mixed hearing loss?
Common causes include otosclerosis, chronic middle ear infections, cholesteatoma and head injuries. It also occurs when two separate problems combine, such as age-related inner ear loss plus earwax, fluid behind the eardrum or a perforated eardrum.
Can mixed hearing loss be treated?
Yes, in part. The conductive part can often be improved with wax removal, ear tubes, medicine or surgery. The sensorineural part is usually permanent but can be managed with hearing aids, bone-conduction devices or cochlear implants.
How is mixed hearing loss diagnosed?
An audiologist performs a hearing test comparing air conduction (through headphones) and bone conduction (through a vibrator behind the ear). In mixed loss, both are below normal, with a gap between them. Tympanometry and sometimes CT or MRI help identify the cause.
Sources
This guide was written from current patient and clinical guidance, including:
- American Speech-Language-Hearing Association (ASHA): Mixed hearing loss; Type, degree and configuration of hearing loss
- National Institute on Deafness and Other Communication Disorders (NIDCD): Hearing loss
- American Academy of Otolaryngology-Head and Neck Surgery: Hearing loss
- MedlinePlus: Hearing loss
- CDC: Types of hearing loss