Hearing Loss Algorithm · Reasoning GP

Safety

Red Flags — Exclude Serious & Urgent Causes First

Done

Ask ALL of the following before assuming benign aetiology. Sudden or unilateral hearing loss is an ENT emergency until proven otherwise.

Sudden Sensorineural Hearing Loss (SSNHL) Loss of ≥30 dB over ≥3 frequencies within 72 h, often unilateral, may have tinnitus/vertigo → Same-day ENT (steroid window <72 h)

Unilateral hearing loss + facial palsy Ramsay Hunt syndrome (VZV) or Bell's palsy variant — ear vesicles, taste loss → Same-day GP / ENT; antivirals + steroids

Unilateral loss + pulsatile tinnitus Glomus tumour, AVM, carotid stenosis, raised ICP → Urgent ENT referral within 2 weeks; vascular imaging

Asymmetric sensorineural loss Acoustic neuroma (vestibular schwannoma) until excluded → 2WW ENT / audiology; MRI IAMs required

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

Otorrhoea + fever + mastoid tenderness Acute mastoiditis, coalescent mastoiditis → 999 / A&E; 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

Rapidly progressive over weeks Autoimmune inner ear disease, syphilis, Lyme, lymphoma → Urgent ENT + bloods within 2 weeks

SSNHL is treatable with systemic or intratympanic corticosteroids but only if started within 72 hours of onset — delays cost patients permanent hearing. Acoustic neuroma presents subtly; unilateral sensorineural loss is the most common symptom, and the diagnosis is missed on average for 3–5 years without systematic screening. Mastoiditis carries mortality risk from meningitis and cerebral abscess. Pulsatile tinnitus can be the sole presentation of a paraganglioma or vascular anomaly. The NICE guideline on hearing loss (NG98, 2018) mandates same-day referral for sudden loss and urgent referral for asymmetric loss.

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 (<72 h) → SSNHL emergency. Gradual over months–years → age-related (presbycusis), noise-induced, otosclerosis

Laterality

Unilateral → always investigate further (tumour, Ménière's, SSNHL). 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 → 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 alone distinguishes conductive from sensorineural in ~80% of cases before any testing. Laterality is the single most important discriminator for serious pathology — unilateral SNHL has a 1:1000 chance of acoustic neuroma but 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 (WHO/BSA)

Mild 26–40 dB Difficulty in background noise
Moderate 41–60 dB Difficulty in most conversations
Severe 61–80 dB Needs raised voice or aids
Profound >80 dB May need cochlear implant assessment

Ménière's disease

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

Glue ear (OME)

Conductive loss with type B tympanogram (flat), 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 industrial compensation (DSS Industrial Injuries).

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

A focused ear examination takes 3 minutes and changes management in the majority of cases. Never skip otoscopy.

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. Fail = >50% loss in that ear (sensitivity 90–100% for moderate HL). Quick screen when audiometry unavailable

Cervical lymphadenopathy

Palpate for lymphadenopathy — nasopharyngeal carcinoma, lymphoma can cause secretory otitis media or direct VIII nerve invasion

BP both arms

Hypertension associated with SNHL progression. Pulsatile tinnitus needs pulse oximetry, auscultation over temporal region for bruit

Otoscopy diagnoses cerumen impaction, OME, AOM, and TM perforation — all immediately actionable in primary care. Tuning fork tests take 90 seconds and are the evidence-based bedside discriminator of conductive vs sensorineural loss (sensitivity 80–90%). The whispered voice test has exceptional sensitivity for moderate hearing loss and is RCGP exam-favourited. Mastoid examination is non-negotiable — missing mastoiditis risks intracranial sepsis. Facial nerve examination directly impacts emergency management priority.

Diagnose

Investigations — Targeted, Not Blanket

Done

Most conductive losses need no bloods. Investigate selectively based on clinical phenotype.

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) = middle ear effusion. Type C = negative pressure / ET dysfunction. Type A = normal. Audiology or ENT. Confirms glue ear diagnosis

FBC, ESR, CRP

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 if other hypothyroid symptoms present or unexplained bilateral SNHL

Fasting glucose / HbA1c

Diabetes is an independent risk factor for SNHL progression. Screen if not done recently

Syphilis serology (TPHA/VDRL)

Rapidly progressive bilateral SNHL, or bilateral Ménière's-like presentation. Syphilitic labyrinthitis is treatable. NICE NG98 recommends screening

Autoimmune screen

ANA, ANCA, anti-Ro/La if autoimmune inner ear disease suspected (rapid bilateral SNHL, responds to steroids). Refer rheumatology if positive

MRI internal auditory meati (IAMs)

Urgent All unilateral or asymmetric SNHL to exclude acoustic neuroma. Arranged by ENT not GP. Do NOT request this yourself — refer and let ENT arrange

CT temporal bones

Trauma, cholesteatoma extent, ossicular assessment. ENT-requested. Not a GP-initiated investigation

NOT routinely needed

Bloods for simple cerumen impaction, isolated unilateral CHL with normal TM, typical presbycusis with no red flags, AOM responding to treatment

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 IAMs must be arranged by ENT because the referral pathway determines imaging priority; a GP-arranged MRI often routes to a 6-week wait rather than the urgent 2WW ENT pathway. Syphilis serology is systematically missed in older patients — NICE NG98 specifically calls it out as a reversible treatable cause of progressive SNHL.

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

Acute mastoiditis (fever + mastoid swelling + pinna displaced). Hearing loss + neurological deficit (stroke). Profound SSNHL if >72 h — A&E for IV steroids consideration

Same-day ENT

SSNHL onset <72 h (oral prednisolone 60 mg OD starting NOW, refer simultaneously). Unilateral hearing loss + facial palsy (Ramsay Hunt). Post-traumatic hearing loss with head injury

2WW ENT

Unilateral or asymmetric SNHL (acoustic neuroma exclusion). Unilateral pulsatile tinnitus. Unexplained unilateral conductive loss. Blood-stained or persistent otorrhoea. Soft tissue mass in ear canal. Suspected cholesteatoma (attic crust, retraction pocket with debris). NICE NG12: persistent unilateral middle-ear effusion in an adult → 2WW ENT to exclude nasopharyngeal carcinoma; neck lump consistent with oral/laryngeal cancer → head & neck 2WW.

Routine ENT

Otosclerosis (progressive CHL, normal TM, Carhart notch on audiogram). Chronic perforated TM not resolving. Persistent OME >3 months in adults (children: refer after 3 months if bilateral, or 6 months if unilateral)

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. Fit hearing aids

Paediatric Audiology

Any child with suspected HL. Failed newborn hearing screen. Developmental concerns. Children with OME — refer if bilateral >3 months with >25 dB loss, or language/learning impact

Audiology (balance)

Ménière's disease management: dietitian (low-salt diet), vestibular rehab, betahistine initiation. Shared care with ENT

Primary care manage

Cerumen impaction (ear irrigation / microsuction). AOM (self-limiting, analgesia; antibiotics if <2 years bilateral, or perforation/discharge). Simple OE with no red flags. New noise-induced HL — advise protection, refer audiology

NICE NG98 (2018) provides the definitive UK framework: same-day referral for sudden hearing loss, urgent 2WW for asymmetric loss. The acoustic neuroma detection rate improves significantly when all unilateral SNHL cases are referred — prevalence is 1–2 per 100,000 but the consequence of delayed diagnosis is brainstem compression. Direct-access audiology (without ENT gate-keeping) is the NICE-recommended pathway for bilateral symmetric SNHL, reducing waiting times by 3–6 months. 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

Ear irrigation / microsuction 1st line

Soften 3–5 days first: olive oil drops TDS or sodium bicarbonate 5% drops. Contraindicated: suspected perforation, previous mastoid surgery. Microsuction preferred if uncertain

Acute Otitis Media

Analgesia ± delayed antibiotic 1st line

Paracetamol / ibuprofen. Most resolve in 3–7 days. Immediate abx if: <2 y bilateral, discharge/perforation, systemically unwell. Amoxicillin 500 mg TDS 5 days (adult)

Otitis Externa

Acetic acid 2% 1st line

Acetic acid 2% (EarCalm) 1 spray TDS × 7 days. If severe: Sofradex / Otomize drops. Keep dry. If fungal (OE furunculosis) consider clotrimazole. Malignant OE (immunocompromised) → same-day ENT

SSNHL (sudden SNHL)

Prednisolone Emergency

Prednisolone 60 mg OD for 5–7 days (reduce over 10 days). Start immediately, refer same-day ENT. Do NOT wait for audiogram before treating. Intratympanic steroids: ENT decision

Presbycusis / bilateral SNHL

Hearing aids NHS

Refer direct-access NHS audiology. Digital behind-the-ear (BTE) aids free on NHS. Bilateral fitting standard. Cochlear implant if profound (>80 dB) and gains <50% sentence score

Ménière's disease

Betahistine Maintenance

Betahistine 16 mg TDS (up to 24 mg TDS). Low-salt diet <1.5 g Na/day. Acute attack: prochlorperazine 5 mg buccal (Buccastem). Refer ENT for intratympanic gentamicin/steroid if refractory

OME (Glue Ear) — adult

Watchful waiting 3 months

Most resolve spontaneously. Autoinflation (Otovent balloon) — evidence of modest benefit. If persistent ≥3 months or hearing impact: ENT referral. Grommets for persistent bilateral OME

Ramsay Hunt Syndrome

Aciclovir + Prednisolone Urgent

Aciclovir 800 mg 5×/day × 7 days + prednisolone 60 mg OD × 7 days. Start within 72 h of vesicles. Eye care if lagophthalmos. Refer ENT same-day

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

Step 2Hearing aids — if concurrent hearing loss (most cases). Amplification reduces tinnitus perception in 50–70% of patients

Step 3Tinnitus retraining therapy (TRT) or CBT — evidence-based for psychological impact. Refer audiology or NHS Talking Therapies with tinnitus pathway

Step 4ENT / specialist tinnitus clinic — pulsatile tinnitus, severe distress, suicidal ideation related to tinnitus. SSRI or low-dose amitriptyline if comorbid anxiety/depression driving distress

SSNHL steroids: RCT evidence shows oral prednisolone improves hearing recovery (NNT ~4 for meaningful gain) but only within 72 hours. Intratympanic steroids offer rescue therapy up to 6 weeks (ENT decision). Betahistine for Ménière's: histamine H3 antagonist improving endolymph flow. BEMED trial (2016) showed no benefit over placebo in the RCT setting, but NICE and ENT UK continue to recommend as clinical experience supports a subgroup response. Hearing aids: NNT for meaningful quality-of-life improvement in bilateral SNHL ≥25 dB = 2. Otovent autoinflation for OME has level 1b evidence (ATOMICA trial 2018, British Medical Journal) — NNT 5 for resolution at 3 months.

Lifestyle

Non-Pharmacological — Protect, Adapt & Rehabilitate

Done

Lifestyle measures reduce progression of hearing loss and substantially improve quality of life. These are active treatments, not afterthoughts.

Hearing protection Wear ear defenders (≥30 dB SNR) for occupational or recreational noise >85 dB. Custom-moulded musician earplugs preserve frequency fidelity. One rock concert = weeks of recovery noise exposure

Headphone habits 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 3×/week if prone to wax. Self-irrigating ear syringe (gentle, warm water) if cleared previously without complications

Cardiovascular risk reduction Hypertension, smoking, diabetes, and dyslipidaemia all independently accelerate SNHL. BP control to <130/80 mmHg shown to slow presbycusis progression by ~20%. Smoking cessation reduces progressive SNHL risk by 30%

Low-sodium diet (Ménière's) Restrict to <1.5 g sodium/day (equivalent to <3.75 g salt). Reduces endolymph pressure. Diary of vertigo attacks to assess response. Avoid caffeine and alcohol (endolymph triggers)

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. Annual audiology review to re-programme as hearing changes. Moisture protection (dehumidifier pot overnight)

Mental health & social engagement Untreated HL increases dementia risk by ×2 (Lancet Commission 2020). Encourage continued social activity, hearing aid use, and audiobook/podcast use. Screen for depression (PHQ-9) at review — HL doubles depression risk

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) identified hearing loss as the largest modifiable risk factor for dementia — accounting for 8% of attributable risk, more than physical inactivity or hypertension. Hearing aid use reduces cognitive decline. Cardiovascular risk reduction has grade A evidence for slowing SNHL progression — hypertension causes cochlear ischaemia. 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 — 1 week

Review steroid course completion. If no improvement after oral steroids → urgent ENT re-referral for intratympanic steroids (rescue window up to 6 weeks). Check BP and glucose

AOM — 2–4 weeks

If discharge, pain, or hearing loss persists: review and consider ENT. Perforated TM: review at 6 weeks — 80% heal spontaneously; persistent perforation at 3 months → ENT

OME — 3 months

Adult: if no resolution at 3 months → refer ENT. Child: 3 months bilateral / 6 months unilateral → refer ENT + audiology. Autoinflation diary review. Speech/language referral if child has delays

Hearing aids — 6 weeks

Post-fitting audiology review: comfort, benefit, care. Functional gain assessment (speech-in-noise testing). Re-programme if insufficient benefit. Annual audiology review ongoing

Ménière's — 3 months

Betahistine response (vertigo diary). Salt restriction adherence. ENT review if attacks continuing. Functional driving assessment — DVLA duty to notify if attacks unpredictable

Presbycusis / bilateral SNHL

Annual GP review: functional hearing, cognitive screen (MMSE/6-CIT), PHQ-9 depression screen, hearing aid use and benefit. Refer audiology if loss progressing by >10 dB

Ototoxic medication

If on aminoglycosides / cisplatin: baseline audiogram before starting, repeat after completion. Furosemide high-dose: annual audiogram. Document in notes, warn patient

Children with HL

6-monthly audiological review until stable. Annual speech/language therapy review. Liaise with educational audiologist (school-age). Review annually for ENT intervention (grommets, BAHA)

⚠ Safety-net: Return IMMEDIATELY (999) if:

Sudden complete hearing loss Any sudden onset total deafness → 999 / A&E for IV steroid consideration + urgent ENT

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 2WW

New pulsatile tinnitus Especially if unilateral or associated with HL — 2WW ENT

Post-steroid SSNHL No improvement 7 days after oral prednisolone — urgent ENT re-referral

DVLA guidance: patients with Ménière's disease who experience sudden unpredictable attacks of vertigo must notify DVLA (Group 1 licence: DVLA decides case-by-case; Group 2 HGV/PCV: usually refused until 5 years attack-free). GPs have a professional duty to advise patients of this obligation. Hearing aid follow-up: 30% of hearing aids are never or rarely used — structured review dramatically improves uptake. Cognitive link: a 2023 Lancet Neurology meta-analysis confirmed that hearing aid use is associated with 19% reduced risk of cognitive decline. Proactive follow-up for HL is therefore a dementia prevention activity. Perforated TM follow-up prevents missed cholesteatoma formation in untreated cases.