Reasoning GP · Algorithm · 1-page summary
Hearing loss in adults
For: adults with new or changed hearing loss, face to face or remote, in hours or OOH. Not for: children (→ paediatric audiology/ENT); long-term hearing-aid and tinnitus care (full Steps pathway). Referral follows NICE NG98 via local ENT pathways.
Core rule: sudden sensorineural hearing loss is an emergency, not wax — the treatment window is days. Normal otoscopy with a sudden loss means sensorineural until proved otherwise. Never blame wax you have not removed and re-tested; never dismiss unilateral tinnitus or asymmetric loss.
0Stop — 999 or ENT now — before any history
- Any central sign — facial weakness, diplopia, dysarthria, limb weakness or ataxia, cannot walk unaided (posterior circulation stroke; CT can miss it) → 999. Sudden loss with severe vertigo → 999 or immediate ENT.
- Fever with post-auricular swelling or protruding pinna (mastoiditis) → Same-day hospital; with headache, neck stiffness, drowsiness, seizure or critically unwell → 999. Head injury with blood or clear fluid from the ear, or haemotympanum → 999 / A&E
- New facial palsy or facial sensory change with ear symptoms → Immediate ENT; stroke pathway if indicated. Protect the eye if closure is incomplete.
- While waiting: ABCDE and observations if unwell; record exact onset date and side; hand over. No vestibular sedative, and no oral antibiotic and review.
1Triage by onset — sudden = over ≤3 days
| Onset | Action (NG98) |
|---|---|
| Sudden, ≤30 days | No ear cause on otoscopy → phone ENT, seen ≤24 h; else emergency department. |
| Sudden, >30 days or worse over 4–90 d | Urgent ENT ≤2 weeks. Partial recovery does not downgrade it. |
| Gradual, asymmetric | Refer per block 2; not an emergency. |
| Gradual, symmetrical | Routine direct audiology. |
2Screen — one row is enough
- Severe otalgia + canal granulation in diabetes, immunosuppression or old age (necrotising otitis externa) → Same-day ENT; check HbA1c.
- Attic crust, keratin in a retraction pocket, offensive otorrhoea, polyp or blood (cholesteatoma) → Urgent ENT, even if well.
- Asymmetric sensorineural loss, unilateral tinnitus (even with normal hearing), or loss persisting after wax removal → Urgent ENT ≤2 weeks. MRI IAM per NG98 / local pathway.
- Persistent pulsatile tinnitus → imaging via local pathway; discuss urgently if unilateral, with hearing loss, neuro signs, papilloedema or bruit.
- Persistent or unexplained adult middle-ear effusion → ENT; consider cancer pathway, especially Chinese or SE Asian origin without URTI.
- Ototoxic drug (aminoglycoside, cisplatin, high-dose loop diuretic) or rapid bilateral loss → Same-day advice + urgent ENT / audiology.
3Assess — remote cannot exclude sudden loss
☐ Otoscopy both ears, side recorded ☐ Weber and Rinne (512 Hz) ☐ Mastoids, facial nerve, neck, mouth; cranial nerves if central feature
Weber to worse ear = conductive, to better ear = sensorineural; Rinne bone > air = conductive. Audiometry for anything not fully explained. Bloods only to answer a question.
4Classify — only if the screen is negative
- Wax — confirmed only when hearing is restored after removal.
- Otitis externa / AOM — conductive, pain, discharge or inflamed drum. Post-auricular swelling, severe pain in diabetes or facial palsy → blocks 0–2.
- Presbycusis / noise — bilateral, symmetrical, gradual; Weber central, Rinne positive → audiology.
- Otosclerosis — Rinne negative, normal drum, family history → ENT.
- Ménière's — ENT diagnosis, not a primary-care label. Unpredictable disabling vertigo → stop driving, notify DVLA (Group 2 rules stricter).
- Uncertain — unexplained asymmetry, fluctuation, or forks that do not fit the otoscopy: say so, refer, name who reviews and when.
5Treat today — only these
- Wax: softener up to 5 days, then microsuction, electronic irrigation or manual removal; no manual syringing. No irrigation with perforation, grommet, ear surgery, only-hearing ear, infection or foreign body. Refer after 2 failed attempts; re-test hearing.
- Otitis externa: topical 7–14 days, keep dry; no aminoglycoside drops with perforation or grommet; not settling → necrotising route, not a second course. AOM: analgesia; consider antibiotics only if unwell, high risk, persistent or otorrhoea (CKS; check doses in the SPC and local formulary).
- Ototoxic drug: stop or seek advice the same day.
- Sudden loss, mastoiditis, necrotising OE, cholesteatoma, stroke: referral is the treatment; steroids only after ENT discussion.
6Refer routinely
- Gradual symmetrical loss, or conductive loss persisting after treatment → audiology; hearing aids if communication is affected.
- Bothersome tinnitus, no red flag → audiology. Fluctuating loss, recurrent vertigo, perforation, persistent bilateral adult effusion → ENT. Severe–profound loss despite aids → cochlear implant assessment.
7Never reassure by
- Wax you have not removed and re-tested.
- A cold, flight, old infection or noise history, for sudden or unilateral loss.
- Normal otoscopy — with sudden loss it means sensorineural.
- Partial recovery of a sudden loss.
- A telephone or video assessment.
- A steroid, antibiotic, nasal spray or audiometry instead of referral.
8Safety-net — say it, then document it
999 “Call 999 for slurred speech or limb weakness, double vision, being unable to walk, or neck stiffness or new headache with ear trouble.” Same day: “Contact us today if hearing drops suddenly in either ear, or you get dizziness with deafness, facial weakness, severe ear pain, swelling behind the ear, fever with confusion, or ringing in one ear only.”
Remote or OOH: convert to face-to-face or emergency assessment for any sudden or unilateral loss, vertigo, facial weakness, severe pain, discharge, fever, diabetes, immunosuppression or ear surgery.
✓Safe to leave primary care only if — all five, documented
No block 0–2 row applies
Both ears examined; side recorded
Weber and Rinne fit the otoscopy
Symmetrical gradual loss, or cause treated and hearing re-tested
Ototoxic drugs reviewed; safety-net and review booked
Summary of the full Reasoning GP hearing loss algorithm, which holds the detail, examination, management and evidence. Sources: NICE NG98, NG12 (updated April 2026), NG155, NG128, TA566; NICE CKS; local ENT pathways; MHRA. Clinical reference — follow local policies and check doses in the SPC and your local formulary.