Hearing loss

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)

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

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.