Assessment and management of hearing loss in adults: a summary of recommendations

  • NICE

  • curated by Antara Ghosh
  • Clinical Guidance Summaries
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Guideline name: Hearing loss in adults: assessment and management [NG98]

Update type: New guideline

Published: June 2018


  • Sudden onset hearing loss can be a result of significant pathology, and may merit urgent assessment.
  • Patients with impaired cognition or learning difficulties should be considered for referral to audiological service hearing assessment every 2 years.

Assessment and referral

  • An audiological assessment should be arranged for adults with first time/suspected hearing difficulties.
  • Referral to an ear, nose and throat (ENT) service, emergency department or audiovestibular medicine service is required in case of sudden/rapid hearing loss onset that develops:
    • over a period of ≤3 days (immediate – within 24 hours),
    • ≥30 days ago (urgent – to be seen within 2 weeks) and
    • if symptoms worsen rapidly (urgent).
  • Symptoms in addition to hearing loss requiring immediate/urgent referral:
    • altered sensation or facial droop on the same side (immediate),
    • immunocompromised patients having otalgia with otorrhoea not responding to treatment within 72 hours (immediate),
    • adults of Chinese/south-east Asian family with hearing loss and a middle ear effusion not associated with an upper respiratory tract infection (urgent) and
    • For information about recognition and referral for suspected cancer, see the National Institute for Health and care Excellence guideline on suspected cancer.
  • Consider referring adults with hearing loss not explained by acute external/middle ear causes with:
    • unilateral/asymmetric hearing loss;
    • fluctuating hearing loss not associated with an upper respiratory tract infection;
    • hyperacusis;
    • persistent tinnitus that is unilateral, pulsatile, has significantly changed in nature or is causing distress;
    • resolved/recurrent vertigo and
    • age-unrelated hearing loss.
  • Consider onwards referral after initial treatment of earwax if:
    • pain affecting either ear (including in and around the ear) that has lasted for 1 week or more and has not responded to first-line treatment.
    • partial or complete obstruction of the external auditory canal that prevents full examination of the eardrum.
    • a history of discharge (other than wax) from either ear that has not resolved, has not responded to prescribed treatment or recurs.
    • abnormal appearance of the outer ear or the eardrum and
    •  a middle ear effusion in the absence of, or that persists after, an acute upper respiratory tract infection.
  • In adults with suspected or diagnosed dementia, mild cognitive impairment or a learning disability:
    • Consider referral for a hearing assessment because hearing loss may be a comorbid condition.
    • Consider referral for a hearing assessment, every 2 years, if they have not previously been diagnosed with hearing loss.
    • Consider referring people with a diagnosed learning disability to an audiology service for a hearing assessment when they transfer from child to adult services, and then every 2 years.

Earwax removal

  • Offer to remove earwax for adults in primary care or community ear care services if the earwax is contributing to hearing loss or other symptoms.
  • Do not offer adults manual syringing to remove earwax.
  • Electronic irrigator, microsuction can be used to remove earwax.
  • When carrying out ear irrigation in adults use pretreatment wax softeners, either immediately before ear irrigation or for up to 5 days beforehand.
  • If irrigation is unsuccessful:
    • repeat use of wax softeners or
    • instil water into the ear canal 15 minutes before repeating ear irrigation.
  • If irrigation is unsuccessful after the second attempt, refer the person to a specialist ear care service or an ENT service for removal of earwax.
  • Adults should be advised not to use small objects like cotton buds to clean their ears.

This summary is reviewed by Prof. Rishabh Prasad MBBS, MA, MSC, FRCGP FRSA