Hearing loss

Differential diagnosis

  • Acoustic neuroma
  • Presbyacusis (aging)
  • Noise induced
  • Trauma
  • Wax


Data gathering

  • Red flags
    • Sudden onset or rapidly progressing
    • Localising signs – facial weakness, facial numbness, unilateral tinnitus
    • Otalgia and otorrhoea in immunocompromised
    • Non-resolving otorrhoea
    • A middle ear effusion unrelated to URTI in a person of Chinese or South-East Asian descent (nasopharyngeal cancer common)
    • On examination: polyp, posterior or superior perforation, unexplained bleeding
    • unilateral tinnitus, balance, weight loss
  • Others
    • family history, previous ear problems, trauma, loud sounds
  • Examine
    • Otoscopy
    • Rinne’s + Weber’s (see table below for interpretation of Rinne/Webers)


Clinical management

  • Investigations
    • Audiometry
  • Explanation
    • conductive deafness due failure of structures that conduct sound through outer ear, the eardrum and the bones of the middle ear
    • sensorineural deafness is due to a problem in the inner ear either where the vibrations are converted to nerve signals or in any part of the brain that then processes these signals
  • Treatment
    • Hearing aid
    • ENT
    • Wax/antibiotics/surgery/cochlear implants
  • Follow-up / Safety net


How quickly should people be referred for a specialist medical opinion?
Immediate referral (to be seen within 24 hours)
  • Sudden hearing loss (≤3 days) in the past 30 days—Refer to on-call ENT
  • Acquired unilateral hearing loss with ipsilateral fifth or seventh cranial nerve symptoms and signs—Refer to ENT or, if stroke is suspected, follow local stroke referral pathway.
  • Immunocompromised adults with hearing loss, otalgia, and otorrhoea unresponsive to treatment within 72 hours—Refer to ENT.
Urgent referral (to be seen within 2 weeks)
  • Sudden hearing loss >30 days ago—Refer to ENT
  • Rapid-onset hearing loss (occurring between 4 and 90 days)—Refer to ENT
  • Middle ear effusion not associated with an upper respiratory tract infection in people of Chinese or South-East Asian family origin—Consider referral to ENT.
Offer proactive assessment of hearing in specific groups
  • Because of a high incidence of hearing loss and poor ability to recognise hearing difficulties, consider referring for hearing assessment every two years:
    • Adults with diagnosed or suspected dementia or mild cognitive impairment.
    • Adults with diagnosed learning disability.
ProblemRinne findingWeber finding
NormalAC > BCLocalises to midline
SensorineuralAC > BCLocalises to NORMAL ear
ConductiveBC > ACLocalises to affected ear