Hearing Loss

Sudden onset (24 hours - 1 week)
Associated facial nerve palsy
Systemically unwell
Neurological signs
Suspected mastoiditis - red fluctuant swelling behind ear, unwell patient with otitis media
Out-of-proportion pain +/- granulation tissue in the ear canal in an immunocompromised individual (suspected lateral skull base osteomyelitis)

History

Examination

Inspect pinna and post-auricular area for microtia, swellings, erythema, surgical scar or hearing aids
Otoscopy: often normal, but check for perforation, scarring, discharge, retraction/middle ear fluid, cholesteatoma in attic
Facial nerve exam
Rinne and Weber test

Hearing loss can be divided into conductive, sensorineural or mixed patterns. It can help to conceptualise them into acute and chronic causes.

Acute history (days to weeks)

Wax impaction - otoscopy confirms the diagnosis. Syringing is slowly falling out of favour due to the risk of infection. Get patients to use sodium bicarbonate eardrops regularly for a week or two. If still present after that, refer to a microsuction service.

*link to wax impaction image*

Sudden sensorineural hearing loss - sudden unilateral decrease in hearing, +/- tinnitus. Usually presumed to be viral, but could be a vascular event or related to some medications. First exclude other causes with otoscopy (should be normal), and check the hearing loss is sensorineural with Rinne/Weber tests. Patients suspected of having SSNHL should be started on 1 mg/kg of prednisolone (max 60 mg) for a week, with a PPI. Refer to ENT emergency clinic for audiometry and further treatment (e.g. intratympanic injection if appropriate).

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Trauma - Usually presents to ED. Traumatic hearing loss can be due to blood in the canal or middle ear, ossicular disruption or direct fracture of the inner ear. Check facial nerve function: patients with facial palsy should be referred on the same day. Haemotympanum can be left to resolve and reassessed later. Ear canal debris can usually be cleared with sodium bicarbonate drops. All other patients can be referred routinely.
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Otitis externa. Mainly presents with pain/itching/blockage. Examination reveals a red, oedematous ear canal with thick, coated exudate. Give a two-week course of antibiotic-steroid eardrops (e.g. Gentisone HC or Sofradex) and water precautions. No need to swab initially. If not settling, refer to ENT emergency clinic.
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Acute otitis media - Mainly presents with pain, fever and mucopurulent discharge. Examination at initial stages shows a bulging and red TM, which can perforate to allow the pus to discharge into the external ear. This usually results in the otalgia resolving. Treat as per NICE guidelines with analgesia delayed antibiotic prescribing.

Chronic history

Presbycusis - commonest cause of hearing loss in adults. Presents initially with difficulty with speech comprehension, especially in noise. Examination will be normal; an audiogram is essential for diagnosis. If patients are struggling, refer (usually direct to audiology) for hearing aids. Suspected unilateral sensorineural hearing loss is usually referred routinely to otology/ENT.
Otitis media with effusion (OME, glue ear) - commonest cause of hearing loss in children. Otoscopy may revealed a retracted TM with fluid behind it, but may also appear normal. Tuning forks can help but are not useful in young children. Many cases settle spontaneously, but refer if not settling after 3-4 months, or there are developmental/educational concerns. Otovent autoinflation balloons have been shown to help improve OME and are available on prescription. Unilateral glue ear in adults requires cancer-wait referral.
Noise-induced hearing loss - usually present in individuals who have had significant loud noise exposure in their lifetime (either from professional or personal situations). An audigram is characteristic. if they are struggling, hearing aids are an option. It is important that they continue to wear ear defenders / refrain from loud noise and have their hearing checked once to twice a year to monitor any deterioration.

Auditory processing disorder - These patients have normal ear examinations and normal audiograms but feel that they struggle in crowded environments, multiple conversations or in meetings. It is thought to be due to issues with sound interpretation by the brain despite normal hearing mechanisms. Hearing therapy and listening skills (provided by many audiology units) may be helpful.

Chronic otitis media - this is a term that has replaced chronic suppurative otitis media. Either cholesteatoma (a collection of keratin/crust in a retraction pocket) or mucosal COM (a discharging perforation). Both generally present with ear discharge and hearing loss. Refer routinely to Otology/ENT.

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Cerebellopontine angle tumours (including Vestibular schwannoma) - Presents with unilateral (chronic or sudden) hearing loss, sometimes with tinnitus. Very rare, benign slow-growing tumours. Refer to routinely to audiology or ENT (regional guidelines vary). An MRI IAM is performed after audiometry. Do not refer via cancer-wait pathway, or scare the patient by talking about this rare diagnosis (98-99% of MRI IAMs are normal).

Same day

Cancer pathway

ENT emergency clinic

Routine

All chronic causes of hearing loss. Some regional pathways include direct-to-audiology for bilateral hearing loss (and sometimes unilateral)

Author: Mr Ananth Vijendren BM MRCS MRCS (ENT) FRCS (ORL-HNS) PhD, Consultant Otologist/ENT Surgeon, Lister Hospital, Stevenage