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;
- 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.
- 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