Hearing Loss Algorithm

Safety

Red Flags — Exclude Serious & Urgent Causes First

Done

Ask ALL of the following before assuming benign aetiology. Sudden hearing loss, or rapidly worsening hearing loss, that is not explained by wax or external/middle-ear disease requires immediate or urgent specialist assessment. Gradual unilateral or asymmetric hearing loss requires diagnostic referral but is not automatically an emergency.

Sudden Sensorineural Hearing Loss (SSNHL) Sudden hearing loss in one or both ears over 3 days or less, not explained by external or middle-ear disease, may have tinnitus/vertigo. Onset within the past 30 days → refer immediately — seen within 24 hours; onset more than 30 days ago, or rapid worsening over 4–90 days → urgent referral — seen within 2 weeks (NICE NG98). Do not delay referral while waiting for audiometry — the audiometric definition (≥30 dB over 3 frequencies) is not a primary-care gatekeeper; tuning forks may support, but should not delay, referral

Hearing loss + new ipsilateral facial weakness, facial sensory change or other neurological signs → Immediate ENT assessment; use the stroke pathway if clinically indicated. Vesicles and severe otalgia suggest Ramsay Hunt syndrome (facial palsy is not automatically Ramsay Hunt). Protect the eye if closure is incomplete. Antiviral and steroid treatment discussed with ENT or per the local facial-palsy/Ramsay Hunt pathway

Persistent pulsatile tinnitus Glomus tumour, AVM, carotid stenosis, raised ICP → clinical examination, audiological assessment and imaging through the local ENT/neuro-otology/radiology pathway (NICE NG155 — modality depends on synchronous/non-synchronous and findings). Discuss urgently if unilateral, with hearing loss, neurological signs, papilloedema, objective bruit or severe headache. Carotid Doppler alone is not adequate

Asymmetric sensorineural loss Acoustic neuroma (vestibular schwannoma) until excluded → diagnostic referral via ENT / audiovestibular / specialist audiology; MRI IAM per NICE NG98 thresholds and local pathway

Post-traumatic hearing loss / head injury Temporal bone fracture, perilymph fistula, haemotympanum → A&E / Same-day ENT depending on mechanism

Suspected mastoiditis Post-auricular erythema/swelling, pinna displacement, severe otalgia, systemic illness, otorrhoea, cranial nerve or neurological signs → same-day hospital assessment (999 only if critically unwell); risk of intracranial spread, meningitis

Neurological symptoms concurrent Diplopia, dysarthria, dysphagia, ataxia alongside hearing loss → stroke / posterior fossa lesion → 999

Child: failed newborn hearing screen or speech delay Congenital loss, missed NICU-grade risk → Urgent paediatric audiology; language outcomes time-critical. All suspected hearing loss in children requires paediatric audiology/ENT referral — this page is an adult pathway

Rapidly progressive over weeks Autoimmune inner ear disease, syphilis, Lyme, lymphoma → Urgent ENT within 2 weeks (NICE NG98: rapid worsening over 4–90 days); targeted bloods only where indicated, discussed with ENT/audiovestibular medicine

SSNHL: any steroid treatment for idiopathic sudden sensorineural loss is decided with ENT and is time-sensitive, so referral must not be delayed. Acoustic neuroma presents subtly; unilateral sensorineural loss is the most common symptom, and diagnosis can be delayed. Mastoiditis carries mortality risk from meningitis and cerebral abscess. Pulsatile tinnitus can be the sole presentation of a paraganglioma or vascular anomaly. NICE NG98 (Hearing loss in adults, 2018) says to refer immediately (to be seen within 24 hours) if hearing loss developed suddenly within the past 30 days, urgently (within 2 weeks) if it developed suddenly more than 30 days ago, urgently if it worsened rapidly over 4–90 days, and to consider MRI of the internal auditory meati for sensorineural loss without localising signs with an asymmetry of 15 dB or more at any two adjacent frequencies (0.5, 1, 2, 4, 8 kHz), and offer it when there are localising signs such as facial weakness, irrespective of thresholds.

Diagnose

History — Characterise the Hearing Loss

Done

A structured history differentiates conductive from sensorineural loss and guides investigation. Use the mnemonic SOCRATES + Risk.

Onset

Sudden (over 3 days or less) within the past 30 days → immediate referral; sudden >30 days ago or rapid worsening over 4–90 days → urgent referral (NICE NG98). Gradual over months–years → age-related (presbycusis), noise-induced, otosclerosis

Laterality

Unilateral/asymmetric → diagnostic referral (tumour, Ménière's, SSNHL) — urgency depends on onset, not laterality alone. Bilateral → usually presbycusis or bilateral OME

Character

Muffled (all frequencies) → conductive. High-frequency first → sensorineural. Fluctuating → Ménière's, OME, patulous ET

Tinnitus

Unilateral pulsatile → vascular. Unilateral non-pulsatile → consider retrocochlear lesion (e.g. acoustic neuroma). Bilateral high-pitched → presbycusis

Vertigo / balance

Episodic vertigo + hearing loss + tinnitus → Ménière's triad. Positional → BPPV (unrelated to hearing loss usually)

Otalgia / otorrhoea

Pain + discharge → otitis media, cholesteatoma. Painless discharge → CSOM. Bloody discharge → malignancy

Noise exposure

Occupational, recreational (concerts, headphones). Document dB level and duration if possible

Ototoxic drugs

Aminoglycosides (gentamicin), cisplatin, loop diuretics (furosemide high-dose), quinine, aspirin high-dose

Family history

Otosclerosis (autosomal dominant), connexin-26 mutations (commonest genetic SNHL in children)

Systemic illness

Diabetes → SNHL risk. Autoimmune (SLE, RA, Wegener's) → autoimmune inner ear disease. Syphilis → bilateral SNHL

Functional impact

Use HHIE-S (Hearing Handicap Inventory for the Elderly — Screening) or ask: "Do you struggle in noisy places? In conversation? On the phone?" Score 1–5 items

The history helps distinguish conductive from sensorineural loss before any testing. Laterality is an important discriminator for serious pathology — unilateral SNHL is commonly dismissed. Establishing functional impact is an RCGP consultation skill domain and drives shared decision-making around hearing aids. NICE NG98 recommends structured assessment of impact using validated tools.

Diagnose

Classify — Conductive vs Sensorineural vs Mixed

Done

Classify type and severity to direct management. Most diagnoses in primary care fall into four main categories.

Conductive HL

Problem in outer/middle ear. Causes: cerumen impaction (most common), otitis media with effusion (OME/"glue ear"), acute otitis media, otosclerosis, perforated TM, cholesteatoma. Weber lateralises to affected ear. Rinne: BC > AC.

Sensorineural HL (SNHL)

Cochlear or auditory nerve pathology. Causes: presbycusis (age-related), noise-induced, ototoxicity, SSNHL, acoustic neuroma, Ménière's, viral. Weber lateralises to better ear. Rinne: AC > BC (normal pattern maintained).

Mixed HL

Both components. Common in chronic otitis media with ossicular damage, or otosclerosis advanced. Requires formal audiometry to quantify air-bone gap.

Severity (BSA, average 0.25–4 kHz)

Mild 20–40 dB HL Difficulty in background noise
Moderate 41–70 dB HL Difficulty in most conversations
Severe 71–95 dB HL Needs raised voice or aids; cochlear implant assessment if only sounds louder than 80 dB HL heard at 2 or more frequencies in both ears (NICE TA566)
Profound >95 dB HL Cochlear implant assessment

Ménière's disease

AAO-HNS/Bárány criteria (international): ≥2 episodes vertigo ≥20 min + documented low-frequency SNHL + tinnitus/aural fullness in same ear. Fluctuating course.

Glue ear (OME)

Conductive loss with a flat (type B) tympanogram consistent with effusion, no acute inflammation. Common in children 3–7 y; also adults post-URTI or with Eustachian tube dysfunction.

Noise-induced HL

Bilateral symmetric SNHL with characteristic notch at 4 kHz on audiogram. History of prolonged noise exposure. May qualify for DWP Industrial Injuries Disablement Benefit (prescribed disease A10, occupational deafness).

Classification drives every downstream decision. Conductive losses are often reversible (wax removal, OME watchful waiting, surgery for otosclerosis) while SNHL is usually permanent and managed with amplification or implantation. Severity classification determines hearing aid eligibility under NHS Audiology thresholds. Ménière's requires specialist input — its fluctuating nature makes audiometric timing critical. WHO classification aligns with NHS adult audiology referral criteria.

Diagnose

Examination — Otoscopy, Tuning Fork Tests & Beyond

Done

Otoscopy is the central primary-care examination — never skip it. Include: bilateral otoscopy; external ear and canal; tympanic membrane appearance and mobility where feasible; mastoids; Weber/Rinne if competent and available; cranial nerves and brief neurological assessment where indicated; tinnitus characteristics; nasal/oral examination and neck palpation where there is unilateral effusion, persistent otorrhoea, mass or cranial neuropathy.

Otoscopy (both ears)

Wax — extent, impaction? TM — intact, dull/retracted (OME), bulging/red (AOM), perforation, cholesteatoma pearl/retraction pocket. Discharge — character and colour

Weber test (512 Hz)

Tuning fork on vertex of skull. Lateralises to worse ear → conductive. Lateralises to better ear → SNHL in worse ear. Midline = normal or symmetric loss

Rinne test (512 Hz)

AC > BC (Rinne positive) = normal or SNHL. BC > AC (Rinne negative) = conductive loss in that ear. False-negative Rinne in profound unilateral SNHL

External auditory canal

Vesicles → Ramsay Hunt (VZV). Tender tragus/pinna → otitis externa. Canal wall sagging → mastoiditis

Mastoid palpation

Tenderness, erythema, swelling over mastoid → acute mastoiditis — same-day A&E. Post-auricular swelling with pinna displaced forward = emergency

Facial nerve

Asymmetry of face, ability to close eye, nasolabial fold flattening. Facial palsy + ear disease → Ramsay Hunt / malignant OE / cholesteatoma

Whispered voice test

Occlude one ear, whisper 3 numbers at 60 cm. Screening test only — cannot reliably quantify hearing loss or distinguish conductive from sensorineural loss. Quick screen when audiometry unavailable

Cervical lymphadenopathy

Palpate for lymphadenopathy and examine nose and mouth where there is unilateral effusion, persistent otorrhoea, mass or cranial neuropathy — nasopharyngeal carcinoma, lymphoma can cause secretory otitis media or direct VIII nerve invasion

Pulsatile tinnitus (selected patients)

Auscultation for bruit, BP and fundoscopy (papilloedema) where clinically appropriate — BP both arms and pulse oximetry are not routine parts of a hearing-loss consultation

Otoscopy diagnoses cerumen impaction, OME, AOM, and TM perforation — all immediately actionable in primary care. Tuning fork tests are a quick bedside aid to separate conductive from sensorineural loss, combined with otoscopy. The whispered voice test is a screening test only. Mastoid examination is non-negotiable — missing mastoiditis risks intracranial sepsis. Facial nerve examination directly impacts emergency management priority.

Diagnose

Investigations — Targeted, Not Blanket

Done

Do not request routine blood tests for typical presbycusis, uncomplicated conductive hearing loss, wax or isolated SSNHL. Investigate selectively when there are systemic features, rapidly progressive bilateral loss, inflammatory symptoms, immunosuppression, relevant sexual/travel exposure, or another specific clinical indication. Discuss extensive autoimmune or infectious testing with ENT/audiovestibular medicine.

Pure Tone Audiogram (PTA)

First-line SNHL Refer to NHS audiology. Defines air-bone gap, frequency profile, severity. Required before hearing aid fitting. Air-bone gap >15 dB = conductive component

Tympanometry

OME suspected Type B (flat) is consistent with middle ear effusion but may also occur with a perforation, patent grommet or technical problems. Type C = negative pressure / ET dysfunction. Type A = normal. Audiology or ENT. Supports (does not confirm) glue ear

FBC, ESR, CRP

Not routine — only if systemic or autoimmune cause suspected (rapidly progressive SNHL, systemic features). Anaemia may cause pulsatile tinnitus. Polycythaemia → hyperviscosity

TFTs

Hypothyroidism causes SNHL and can mimic presbycusis or worsen OME (myxoedematous middle ear). Check only if other hypothyroid symptoms are present — not for hearing loss alone

Fasting glucose / HbA1c

Diabetes is a risk factor for SNHL. Screen per the patient's usual preventive-care indications, not because of hearing loss alone (check in suspected necrotising otitis externa)

Syphilis serology (TPHA/VDRL)

Rapidly progressive bilateral SNHL, or bilateral Ménière's-like presentation. Syphilitic labyrinthitis is treatable — test only when the history, sexual/travel exposure or risk factors suggest it, ideally after discussion with ENT/audiovestibular medicine

Autoimmune screen

Not routine. ANA, ANCA, anti-Ro/La only if autoimmune inner ear disease suspected (rapid bilateral SNHL, inflammatory/systemic features) — discuss with ENT/audiovestibular medicine

MRI internal auditory meati (IAMs)

Per NICE NG98 Consider for SNHL without localising signs with asymmetry of 15 dB or more at any two adjacent frequencies (0.5, 1, 2, 4, 8 kHz); offer when there are localising signs such as facial weakness, irrespective of thresholds. Follow the local pathway — MRI may be requested by ENT, audiovestibular medicine or an appropriately commissioned specialist audiology service

CT temporal bones

Reserved for selected otological, traumatic or bony pathology (trauma, cholesteatoma extent, ossicular assessment) — normally specialist-led

NOT routinely needed

Bloods for simple cerumen impaction, uncomplicated conductive loss, typical presbycusis with no red flags, isolated SSNHL, AOM responding to treatment. Diabetes and thyroid screening solely because of bilateral SNHL

Over-investigating hearing loss wastes NHS resource and delays correct referral. PTA is the cornerstone — it quantifies loss and guides hearing aid fitting, and NHS audiology provides direct-access PTA in most regions (no ENT referral needed for straightforward bilateral SNHL). MRI IAM should follow the local pathway (ENT, audiovestibular medicine or commissioned specialist audiology) so that imaging and follow-up are linked. Otosyphilis is a treatable cause of progressive SNHL — test selectively where exposure or risk factors suggest it.

Refer

Referral Criteria — Who, Where and How Urgently

Done

Match urgency to clinical phenotype. ENT and audiology have separate referral pathways — choose correctly.

999 / A&E

Hearing loss + neurological deficit (suspected stroke) or acute uncontrolled vertigo with central features. Mastoiditis only if critically unwell (otherwise same-day hospital). Significant head injury or temporal-bone trauma. Sudden hearing loss within the past 30 days when ENT cannot see the patient within 24 hours — emergency department (NICE NG98)

Same-day ENT

Sudden hearing loss (over 3 days or less) within the past 30 days — refer immediately, to be seen within 24 hours (NICE NG98); steroid treatment is started by, or after discussion with, ENT and never replaces the referral. Hearing loss with new facial weakness, altered facial sensation or other neurological deficit (immediate ENT; stroke pathway if indicated). Suspected mastoiditis (same-day hospital). Severe otalgia and otorrhoea in an immunocompromised patient not responding within 72 hours. Post-traumatic hearing loss with head injury

Urgent ENT (2 weeks)

Sudden loss more than 30 days ago, or rapid worsening over 4–90 days — seen within 2 weeks (NICE NG98). Unilateral or asymmetric SNHL (acoustic neuroma exclusion; MRI per NG98 thresholds and local pathway). Persistent pulsatile tinnitus — imaging via the local ENT/neuro-otology/radiology pathway (NICE NG155), discuss urgently if red features. Unexplained unilateral conductive loss. Abnormal otoscopy — attic crust/debris, retraction pocket with keratin, persistent offensive otorrhoea, polyp, blood or suspected cholesteatoma — via the local urgent pathway; escalate immediately with facial palsy, severe infection, neurological symptoms or mastoiditis. Soft tissue mass in ear canal. NICE NG98: persistent or unexplained adult middle-ear effusion → ENT; consider a suspected cancer pathway referral particularly in adults of Chinese or south-east Asian family origin when not associated with URTI; assess nasal symptoms, epistaxis, headache, cranial neuropathy, cervical lymphadenopathy and smoking history. NICE NG12 (updated April 2026): unexplained neck lump, or persistent unexplained hoarseness, at 45 and over → suspected cancer pathway (head and neck) — a separate criterion, not a hearing-loss criterion.

Routine ENT

Otosclerosis (progressive CHL, normal TM, Carhart notch on audiogram). Chronic perforated TM not resolving. Persistent OME in adults. Fluctuating loss not associated with URTI, recurrent or unresolved vertigo, non-age-related hearing loss (ENT / audiovestibular / specialist audiology). Children with OME: see Paediatric Audiology (NICE NG233)

NHS Audiology (direct)

Bilateral symmetric SNHL (typical presbycusis). Confirmed bilateral SNHL after red flags excluded. No ENT referral needed first. Most regions have open-access audiology. Audiological assessment (otoscopy, pure-tone audiometry, tympanometry where indicated); offer hearing aids when hearing loss affects communication

Paediatric Audiology

All suspected hearing loss in children → paediatric audiology/ENT. Failed newborn hearing screen. Developmental concerns. Suspected OME (NICE NG233): refer for formal assessment including hearing testing and tympanometry; bilateral OME with hearing loss is reassessed after 3 months; consider earlier intervention where day-to-day communication is significantly affected; do not offer antibiotics, oral steroids or nasal steroids; consider auto-inflation where developmentally appropriate; hearing aids or grommets according to hearing loss and functional impact

Audiology (balance)

Suspected Ménière's disease → ENT/audiovestibular assessment; vestibular rehabilitation; any betahistine trial under the local ENT/formulary pathway (uncertain benefit). Shared care with ENT

Primary care manage

Cerumen impaction (microsuction, electronic irrigation or manual removal by trained practitioners — no manual syringing; refer after two unsuccessful irrigation attempts). Adult AOM (usually self-limiting, analgesia; antibiotics per NICE CKS if systemically unwell or at high risk of complications) — paediatric AOM per NICE NG91. Simple OE with no red flags. New noise-induced HL — advise protection, refer audiology

NICE NG98 (2018) provides the definitive UK framework: immediate referral (seen within 24 hours) for sudden hearing loss within the past 30 days, urgent referral for older sudden loss or rapid progression, and MRI of the internal auditory meati to be considered for asymmetric loss. Acoustic neuroma is uncommon, but the consequence of delayed diagnosis can be brainstem compression. Direct-access audiology (without ENT gate-keeping) is the NICE NG98 pathway for bilateral symmetric SNHL. Confusing ENT and audiology referral routes is a common GP error — ENT for structural/surgical issues, audiology for amplification/rehabilitation.

Treat

Treatment — Condition-Specific Management Ladder

Done

Treatment is highly condition-specific. Match intervention to diagnosis.

Cerumen Impaction

Wax removal if symptomatic or preventing examination NICE NG98

Microsuction, electronic irrigation or manual removal by trained practitioners with appropriate equipment, per local service capability. Do not use manual syringing. Softeners (olive oil or sodium bicarbonate 5% drops) immediately before or for up to 5 days before irrigation. Do not irrigate if perforation/grommet, previous ear surgery, active infection, foreign body or previous significant irrigation complication is suspected. Refer after two unsuccessful irrigation attempts

Acute Otitis Media

Analgesia ± delayed antibiotic 1st line

Paracetamol / ibuprofen; antibiotics not routinely indicated. Adults: consider antibiotics if systemically unwell, high risk of complications, persistent symptoms or otorrhoea — amoxicillin 500 mg TDS for 5 to 7 days (NICE CKS acute otitis media; check the current CKS and local formulary — NG91 covers under 18s); check allergy, pregnancy, renal and hepatic function. Children (NICE NG91, under 18s): immediate antibiotics considered if <2 y bilateral, otorrhoea, systemically unwell

Otitis Externa

Acetic acid 2% 1st line

Acetic acid 2% (EarCalm) 1 spray TDS × 7 days — only when the tympanic membrane is intact or judged safe per product information/local policy. If severe: topical steroid/antibiotic drops per the local formulary (check availability — Otomize discontinued); avoid potentially ototoxic aminoglycoside drops with a perforation or patent grommet unless directed by ENT. Keep dry. If fungal (otomycosis) consider clotrimazole. Severe pain, granulation, cranial neuropathy, systemic illness, or disease in a diabetic/immunocompromised patient → urgent ENT for necrotising otitis externa

SSNHL (sudden SNHL)

Immediate referral ± steroid Emergency

Refer immediately — seen within 24 hours (NICE NG98). Do not delay immediate referral for audiometry or steroid prescribing. NG98 makes no steroid recommendation: oral corticosteroids for idiopathic SSNHL are decided with ENT or per the local ENT pathway (any specific regimen is the locally agreed ENT protocol). Check diabetes, hypertension, infection risk, psychiatric history, peptic-ulcer risk, glaucoma and other cautions; monitor glucose and BP when clinically indicated. Intratympanic steroids: ENT decision

Presbycusis / bilateral SNHL

Hearing aids NHS

Refer direct-access NHS audiology; offer hearing aids when hearing loss affects communication, with face-to-face audiology follow-up 6–12 weeks after fitting (NICE NG98). Digital behind-the-ear (BTE) aids free on NHS. Bilateral fitting standard. Cochlear implant assessment if severe to profound loss (hearing only sounds louder than 80 dB HL at 2 or more frequencies in both ears without aids) and a phoneme score below 50% on the Arthur Boothroyd word test with well-fitted aids (NICE TA566)

Ménière's disease

Refer ENT/audiovestibular Specialist

Refer suspected Ménière's disease for ENT/audiovestibular assessment. Discuss regular meals, hydration and avoidance of personally identified triggers (e.g. an individual trial of reducing caffeine/alcohol). A trial of betahistine may be considered under the local ENT/formulary pathway, explaining that benefit is uncertain — cautions include asthma, peptic ulcer disease and phaeochromocytoma; check the current SPC/formulary. Vestibular suppressants (e.g. prochlorperazine — check SPC) only for short-term relief during acute attacks, not as chronic treatment. ENT for intratympanic gentamicin/steroid if refractory

OME (Glue Ear) — adult

Watchful waiting 3 months

Often post-URTI and self-resolving. Autoinflation (Otovent balloon) — evidence of modest benefit. Persistent or unexplained adult effusion → ENT; consider a suspected cancer pathway particularly in adults of Chinese or south-east Asian family origin when not associated with URTI. Grommets for persistent bilateral OME (ENT)

Ramsay Hunt Syndrome

Aciclovir + Prednisolone Urgent

Urgent ENT/neurology review the same day. Antiviral and steroid treatment per the local facial-palsy/Ramsay Hunt protocol or after ENT discussion — not an unqualified GP regimen; renal-dose consideration for aciclovir; particular care in pregnancy, frailty and immunocompromise. Eye protection if incomplete closure

Tinnitus management ladder (if prominent and distressing):

Step 1Explanation & reassurance — "tinnitus is rarely a sign of serious disease; your brain can habituate." Avoid silence: background sound/radio. Offer audiological assessment (NICE NG155). If tinnitus is associated with high suicide risk → immediate mental-health assessment

Step 2Hearing aids — amplification where hearing loss affects communication (NICE NG155)

Step 3Psychological therapy — CBT preferred for tinnitus-related distress (NICE NG155; tinnitus retraining therapy is not a NICE-endorsed first-line treatment). Refer audiology or NHS Talking Therapies with tinnitus pathway

Step 4ENT / specialist tinnitus clinic — pulsatile tinnitus, severe distress. Imaging (NICE NG155): offer imaging for all pulsatile tinnitus (modality by synchronous/non-synchronous and findings); non-pulsatile tinnitus — imaging only where unilateral/asymmetric or with associated neurological, otological or head-and-neck signs, via the specialist pathway. Do not offer betahistine for tinnitus. SSRIs or amitriptyline are not tinnitus treatments — consider only for a separately diagnosed comorbid condition

Next steps: see Glue ear · Otitis media and externa · Ménière's disease

SSNHL steroids: whether to use a steroid for idiopathic SSNHL, the regimen and any intratympanic rescue therapy are ENT decisions. Betahistine for Ménière's: histamine H3 antagonist improving endolymph flow. BEMED trial (2016) showed no benefit over placebo in the RCT setting, so efficacy for preventing attacks remains uncertain; any trial should be under the local ENT/formulary pathway. Hearing aids: offered when hearing loss affects communication (NICE NG98). Otovent autoinflation for OME is supported by a randomised trial in children (Williamson et al, CMAJ 2015; NNT about 9 for a normal tympanogram at 3 months); adult evidence is limited.

Lifestyle

Non-Pharmacological — Protect, Adapt & Rehabilitate

Done

Advise safe listening, smoking cessation, cardiovascular risk management and appropriate hearing rehabilitation as part of general health promotion.

Hearing protection Wear suitable hearing protection for loud occupational or recreational noise (UK Control of Noise at Work Regulations action values: 80 and 85 dB(A)). Custom-moulded musician earplugs preserve frequency fidelity

Headphone habits A common rule of thumb (not a guideline) is the "60/60 rule": no more than 60% volume for 60 minutes. Use noise-cancelling headphones (reduces urge to turn up volume). Recommend WHO "Make Listening Safe" resources

Cerumen prevention Do not insert cotton buds — impaction and TM trauma. Olive oil drops if prone to wax. Self-irrigation is not a general recommendation — particularly not with uncertain drum status, diabetes, immunosuppression, previous ear surgery or a single hearing ear

Cardiovascular risk reduction Smoking cessation and cardiovascular risk management as part of general health promotion

Ménière's — self-management Regular meals, hydration and avoidance of personally identified triggers; reducing salt, caffeine or alcohol can be tried as an individual trial rather than mandatory treatment. Diary of vertigo attacks to assess response

Communication strategies Face the person, reduce background noise, lip-read. Advise family to get attention before speaking. NHS Hearing Link and RNID offer free communication training for patient and carers

Assistive technology NHS-provided: amplified phones, TV loop systems, door-bell flashers, vibrating alarm clocks. Local authority Social Services assessment. Refer to RNID / Action on Hearing Loss for equipment guide

Hearing aid maintenance Clean daily with dry cloth. Replace tubing every 3–6 months. Free NHS batteries and tubing. Audiology review to re-programme if hearing or benefit changes. Moisture protection (dehumidifier pot overnight)

Mental health & social engagement Hearing loss is a modifiable risk factor for dementia (Lancet Commission 2020). Encourage continued social activity and hearing aid use. Assess communication difficulties, social isolation, mood and cognitive concerns clinically. NICE NG98: for diagnosed or suspected dementia or MCI, consider audiology referral; if dementia is diagnosed and no hearing loss is found, consider reassessing every 2 years

Swimming / water protection Custom swim plugs for chronic perforation or grommets. Standard cotton wool with Vaseline for acute OE. Avoid submersion until healed. Hair dryer on low setting after swimming (30 cm distance, 30 seconds)

The Lancet Commission on Dementia Prevention (2020) estimated hearing loss as one of the largest modifiable risk factors for dementia (a modelled population attributable fraction of about 8%; observational data, not a NICE figure). Hearing aid use may be associated with less cognitive decline. Noise-induced HL is entirely preventable: WHO estimates 1.1 billion young people globally at risk from recreational noise. RNID (formerly RNID/Action on Hearing Loss) provides free UK-specific patient resources and assistive technology guidance. Social isolation secondary to untreated HL is a major driver of depression and early mortality in older adults.

Safety

Follow-Up, Monitoring & Safety-Netting

Done

Close the loop. Safety-net all patients with clear return triggers. Hearing loss is frequently undertreated due to poor follow-up systems.

SSNHL — ENT-directed

Follow-up after SSNHL treatment is ENT-directed. If no improvement after ENT-started steroids → contact ENT (any intratympanic rescue is an ENT decision). Check BP and glucose when clinically indicated

AOM — 2–4 weeks

If discharge, pain, or hearing loss persists: review and consider ENT. Perforated TM: review — most heal spontaneously; persistent perforation → ENT

OME — 3 months

Adult: if no resolution at 3 months → refer ENT. Child: per NICE NG233 — bilateral OME with hearing loss reassessed after 3 months (paediatric audiology/ENT). Autoinflation diary review. Speech/language referral if child has delays

Hearing aids — 6–12 weeks

Face-to-face audiology follow-up 6–12 weeks after fitting (NICE NG98): comfort, benefit, care. Functional gain assessment (speech-in-noise testing). Re-programme if insufficient benefit. Further review as needed

Ménière's — 3 months

Response to any betahistine trial (vertigo diary). Personally identified triggers. ENT review if attacks continuing. Functional driving assessment — DVLA duty to notify if attacks unpredictable

Presbycusis / bilateral SNHL

Individualised review: functional hearing, hearing aid use and benefit; assess communication, isolation, mood and cognitive concerns clinically. Re-refer audiology if hearing or benefit worsens

Ototoxic medication

Aminoglycosides / cisplatin / high-dose loop diuretics: monitoring per the relevant audiology/oncology/ototoxicity protocol. Review if hearing changes. Document in notes, warn patient

Children with HL

Review schedule individualised by paediatric audiology. Speech/language therapy as needed. Liaise with educational audiologist (school-age). Review annually for ENT intervention (grommets, BAHA)

⚠ Safety-net: Seek help immediately — same-day ENT / A&E, or 999 where stated — if:

Sudden complete hearing loss Any sudden onset total deafness → same day: ENT or emergency department, seen within 24 hours (NICE NG98)

Facial paralysis develops Any new facial weakness alongside ear symptoms → same-day ENT / A&E

Severe ear pain + fever + mastoid swelling → A&E immediately. Mastoiditis can progress within hours

Neck stiffness / photophobia / new headache Alongside ear disease → 999 (meningitis)

📋 Safety-net: Same-day GP / urgent if:

Worsening unilateral loss Any progression of previously stable unilateral HL — re-refer ENT urgently (within 2 weeks)

New pulsatile tinnitus Imaging via the local pathway (NICE NG155) — discuss urgently if unilateral, with hearing loss, neurological signs or severe headache

New neurological symptoms, mastoid swelling or severe systemic illness Same-day assessment

Persistent discharge, pain or hearing loss despite treatment Review and refer ENT/audiology

Post-steroid SSNHL No improvement after ENT-started oral prednisolone — contact ENT promptly, per the ENT follow-up plan

DVLA guidance: patients with Ménière's disease who experience sudden unpredictable attacks of vertigo must notify DVLA (sudden, disabling, unpredictable vertigo: stop driving and notify the DVLA; driving may resume when symptoms are controlled — check the current DVLA Assessing fitness to drive guidance — the Group 2 (bus and lorry) rules are stricter than Group 1). GPs have a professional duty to advise patients of this obligation. Hearing aid follow-up: many hearing aids are rarely used — structured review improves uptake. Cognitive link: a 2023 JAMA Neurology meta-analysis (Yeo et al) reported that hearing aid use was associated with less long-term cognitive decline (observational data; the reported 19% figure is not a NICE estimate). Proactive follow-up for HL is therefore a dementia prevention activity. Perforated TM follow-up prevents missed cholesteatoma formation in untreated cases.