Presbycusis Clinical Presentation

Updated: Mar 29, 2021
  • Author: Robert A Saadi, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
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The clinical presentation of presbycusis varies from patient to patient and is a result of the various combinations of cochlear and neural changes that have occurred. Patients typically may have more difficulty understanding rapidly spoken language, vocabulary that is less familiar or more complex, and speech within a noisy, distracting environment. Patients may often complain that they have more difficulty understanding women than men, given the higher pitch at which women speak. In addition, localizing sound is increasingly difficult as the disease progresses. Patients with presbycusis may rely strongly on lip reading to improve intelligibility of spoken words. [3]

The patient’s only report may be a gradually progressive hearing loss with particular difficulty understanding words and conversation when a high level of ambient background noise is present. This may interfere with the individual's effectiveness at meetings. The patient may have a history of noise exposure (eg, armed services, hunting, use of power tools, industrial occupation). A high-frequency sloping sensorineural hearing loss may be found. However, the patient's speech discrimination score may be normal unless tested in the presence of background noise. Hearing aids with more gain in the higher frequencies to match the hearing loss may provide substantial benefit, depending on the patient's needs and motivation. The patient may also be counseled to avoid excessive noise exposure. Presbycusis may have significant negative impacts on daily living, leading to social withdrawal and depression. [24]

Tinnitus may become a problem as hearing loss progresses. Tinnitus related to the symmetrical hearing loss of presbycusis should also be symmetrical. Unilateral tinnitus should prompt investigation for other etiologies. [24]  

Many patients may be delayed in presentation and may assume that some hearing loss is expected with age and is likely not treatable. A review for the United States Preventive Services Task Force (USPSTF) stated that additional research is needed to recommend screening for hearing loss in patients greater than age 50 years to demonstrate health-related benefits. [25]  In general, for patients reporting symptoms of hearing loss, careful history and referrals for further testing will detect the majority of cases of presbycusis. The questionnaire entitled the Hearing Handicap Inventory for the Elderly-Screening (HHIE-S) can aid in recognizing significant hearing loss in older adults. [26]



In patients with presbycusis, no abnormalities are found on physical examination.

  • Presbycusis is a diagnosis of exclusion that should not be made until all other possible etiologies of hearing loss in elderly individuals have been evaluated and excluded.

  • Etiologies as simple as cerumen impaction and as complex as otosclerosis or cholesteatoma must not be overlooked in the elderly patient with hearing loss because these are amenable to treatment.



Although the precise etiology of presbycusis is currently not known, the cause of presbycusis is generally agreed to be multifactorial. Proposed causes include the following:

  • Arteriosclerosis: Arteriosclerosis may cause diminished perfusion and oxygenation of the cochlea. Hypoperfusion leads to the formation of reactive oxygen metabolites and free radicals, which may damage inner ear structures directly as well as damage mitochondrial DNA of the inner ear. This damage may contribute to the development of presbycusis.

  • Diet and metabolism

    • Diabetes accelerates the process of atherosclerosis, which may interfere with perfusion and oxygenation of the cochlea.

    • Diabetes causes diffuse proliferation and hypertrophy of the vascular intimal endothelium, which may also interfere with perfusion of the cochlea.

    • In 2009, Kovacií et al studied auditory brainstem function in elderly diabetic patients with presbycusis. Their data supported a hypothesis that brainstem neuropathy in diabetes mellitus can be assessed with auditory brainstem response, even in elderly patients with sensorineural hearing loss. [27]

    • Le and Keithley have demonstrated diets high in antioxidants such as vitamins C and E reduce the progression of presbycusis in a mouse model.

  • Accumulated exposure to noise

  • Drug and environmental chemical exposure

  • Stress

  • Genetics

    • Genetic programming for early aging of parts of the auditory system may influence the development of presbycusis. Often, concomitant impairment of hearing, balance, sense of smell, taste, and visual acuity is associated with the aging process.

    • Likewise, genetically programmed susceptibility to environmental factors (eg, noise, ototoxic drugs and chemicals, stress) may be involved.