REASONING GP · Clinical algorithm · Quick reference

Hearing loss in adults — triage and diagnostic approach

Daytime GP and OOH/111. Establish sudden or gradual, one ear or both, conductive or sensorineural — then decide who needs ENT today. Hearing-aid fitting and long-term care are in the full Steps pathway.

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AdultsGP + OOHDiagnosis firstv1.0 · Sep 2026

Core rule. Sudden sensorineural hearing loss is an emergency, not a wax problem: treatment is time-critical and the window is days. Three questions decide everything — sudden or gradual, one ear or both, conductive or sensorineural? Otoscopy plus Weber and Rinne answer the third at the bedside. Normal otoscopy with a sudden unilateral loss means sensorineural until proved otherwise — refer immediately (NG98). Never explain a unilateral loss by wax you have not removed and re-tested, and never dismiss unilateral tinnitus or asymmetric loss: that is the vestibular schwannoma presentation.

Before any history: is this an emergency now? Stop the consultation and call 999 or speak to ENT immediately

Hearing loss with any central sign — facial weakness, diplopia, dysarthria, limb weakness or ataxia, inability to walk unaided · sudden loss with severe vertigo · fever with post-auricular swelling, a protruding pinna, headache, neck stiffness, drowsiness or seizure (mastoiditis with intracranial spread) · severe otalgia with granulation in the canal in diabetes or immunosuppression (necrotising otitis externa) · head injury with blood or clear fluid from the ear, or haemotympanum · new facial palsy with ear symptoms. ABCDE and observations where unwell; record exact onset and the side; hand over.

Define the loss in four lines Enough to place the patient in the table below

Onset

Instantaneous or over up to 3 days (sudden — treat as an emergency) · 4–30 days (still urgent) · months to years (presbycusis, noise, otosclerosis) · fluctuating (Ménière's, effusion) · after barotrauma, trauma, blast or a loud event.

Side and pattern

One ear or both; symmetrical or asymmetric. Unilateral is the worrying pattern. Worse in noise, on the telephone, or needing the television louder. Hearing that fluctuates with fullness.

Associated

Vertigo, imbalance · tinnitus, and whether it is unilateral or pulsatile · otalgia, discharge, itch · aural fullness · facial weakness · nasal obstruction or epistaxis, a neck lump, sore throat, dysphagia.

Context

Occupational or recreational noise · ototoxic drugs — aminoglycosides, cisplatin, high-dose loop diuretics, some antimalarials · head injury, ear surgery, grommets, perforation · diabetes or immunosuppression · mumps, measles or meningitis · family history of early hearing loss · cognitive impairment.

Red-flag screen: trigger → concern → destination → what to do before handover One row is enough; do not add up reassuring features

Trigger / red flag	Leading concern · destination	Do now · do not delay
Sudden hearing loss, onset within the last 3 days, with no evidence of an outer- or middle-ear cause on otoscopy — so the loss is sensorineural. Includes the patient who woke deaf in one ear, whatever their age.	Sudden sensorineural hearing loss Refer immediately — seen within 24 hours · NICE NG98	Otoscopy both ears plus Weber and Rinne: normal canals and drums with Weber lateralising to the better ear, and Rinne positive bilaterally, is sensorineural. Telephone ENT or the emergency clinic the same day — high-dose steroids and audiometry are hospital decisions with a window of days. Do not prescribe an antibiotic, a decongestant or a nasal steroid and review; do not defer for wax softening; do not wait for an audiology appointment.
Sudden sensorineural loss that began 4–30 days ago, now stable or partly recovered.	Sudden sensorineural hearing loss, later presentation Refer urgently — seen within 2 weeks · NICE NG98	Still an urgent referral, not a routine one; state the exact date of onset in the letter, because it determines whether treatment is still offered. Partial recovery does not downgrade it.
Hearing loss with vertigo and a central feature: facial weakness, diplopia, dysarthria, limb ataxia, direction-changing nystagmus, or inability to walk unaided; vascular risk factors.	Posterior circulation or AICA infarct 999 now	A labyrinthine infarct presents exactly as "labyrinthitis" with deafness. Say "acute vestibular syndrome with hearing loss, query posterior stroke": CT misses about half of posterior strokes, so MRI is the test. Do not give a vestibular sedative and review.
Ear infection with systemic or local complication: fever with post-auricular swelling or tenderness, a protruding pinna, severe unremitting otalgia, headache, neck stiffness, confusion, seizure, or new facial palsy.	Acute mastoiditis · intracranial extension · facial nerve involvement 999 or immediate ENT	Oral antibiotics and review is not a safe plan once there is post-auricular swelling or any neurological feature. Record temperature, the drum appearance and the facial nerve. Cholesteatoma features — attic crust, retraction pocket, foul painless discharge, granulation — need urgent ENT even when the patient feels well.
Severe otalgia with granulation tissue in the canal, in diabetes, immunosuppression or old age, often with discharge failing topical treatment; cranial nerve palsy in severe cases.	Necrotising (malignant) otitis externa Same-day ENT assessment	This is osteomyelitis of the temporal bone and needs imaging plus prolonged systemic antibiotics — never a second course of drops. Check glucose and HbA1c, and send the same day rather than reviewing in a week.
Asymmetric or unilateral sensorineural loss, or unilateral or pulsatile tinnitus, with or without imbalance; also unilateral loss that persists after wax removal.	Vestibular schwannoma · other retrocochlear lesion · vascular cause of pulsatile tinnitus Urgent ENT or audiology for MRI of the internal auditory meati · NICE NG98	Document the audiometric asymmetry or the tuning-fork findings and the side. Unilateral tinnitus alone, with normal hearing, still warrants referral. Pulsatile tinnitus needs imaging, not reassurance. A normal MRI does not remove the need for audiological follow-up if the asymmetry progresses.
Hearing loss with a head-and-neck cancer feature: an unexplained persistent neck lump · unilateral middle-ear effusion (glue ear) in an adult, especially with nasal obstruction, epistaxis or cranial nerve signs · persistent unexplained sore throat, hoarseness or dysphagia · oral ulceration or a mass lasting over 3 weeks.	Nasopharyngeal, laryngeal or other head-and-neck cancer Urgent suspected-cancer referral within 2 weeks · NICE NG12	A unilateral effusion in an adult is a nasopharyngeal carcinoma until the postnasal space has been examined (NG98 requires urgent ENT referral) — it is not adult glue ear to be treated with a nasal spray. Examine the neck and the mouth, and ask directly about nasal obstruction and epistaxis. Hoarseness for over 3 weeks in a smoker aged 45 and over is its own NG12 route.
Ototoxic exposure or bilateral rapid progression: current or recent aminoglycoside, cisplatin or high-dose loop diuretic · rapidly worsening bilateral loss over weeks · loss after meningitis, mumps or head injury · loss with systemic autoimmune features.	Ototoxicity · autoimmune inner-ear disease · post-infective or traumatic loss Same-day advice and urgent ENT / audiology	Aminoglycoside cochleotoxicity is usually permanent: stop the drug and seek specialist advice the same day rather than completing the course. Bilateral rapid progression is urgent, not routine. Record any perforation before prescribing — topical aminoglycoside drops should be avoided with a perforated drum or a grommet.

Trigger / red flag

Leading concern · destination

Do now · do not delay

Sudden hearing loss, onset within the last 3 days, with no evidence of an outer- or middle-ear cause on otoscopy — so the loss is sensorineural. Includes the patient who woke deaf in one ear, whatever their age.

Sudden sensorineural hearing loss
Refer immediately — seen within 24 hours · NICE NG98

Otoscopy both ears plus Weber and Rinne: normal canals and drums with Weber lateralising to the better ear, and Rinne positive bilaterally, is sensorineural. Telephone ENT or the emergency clinic the same day — high-dose steroids and audiometry are hospital decisions with a window of days. Do not prescribe an antibiotic, a decongestant or a nasal steroid and review; do not defer for wax softening; do not wait for an audiology appointment.

Sudden sensorineural loss that began 4–30 days ago, now stable or partly recovered.

Sudden sensorineural hearing loss, later presentation
Refer urgently — seen within 2 weeks · NICE NG98

Still an urgent referral, not a routine one; state the exact date of onset in the letter, because it determines whether treatment is still offered. Partial recovery does not downgrade it.

Hearing loss with vertigo and a central feature: facial weakness, diplopia, dysarthria, limb ataxia, direction-changing nystagmus, or inability to walk unaided; vascular risk factors.

Posterior circulation or AICA infarct
999 now

A labyrinthine infarct presents exactly as "labyrinthitis" with deafness. Say "acute vestibular syndrome with hearing loss, query posterior stroke": CT misses about half of posterior strokes, so MRI is the test. Do not give a vestibular sedative and review.

Ear infection with systemic or local complication: fever with post-auricular swelling or tenderness, a protruding pinna, severe unremitting otalgia, headache, neck stiffness, confusion, seizure, or new facial palsy.

Acute mastoiditis · intracranial extension · facial nerve involvement
999 or immediate ENT

Oral antibiotics and review is not a safe plan once there is post-auricular swelling or any neurological feature. Record temperature, the drum appearance and the facial nerve. Cholesteatoma features — attic crust, retraction pocket, foul painless discharge, granulation — need urgent ENT even when the patient feels well.

Severe otalgia with granulation tissue in the canal, in diabetes, immunosuppression or old age, often with discharge failing topical treatment; cranial nerve palsy in severe cases.

Necrotising (malignant) otitis externa
Same-day ENT assessment

This is osteomyelitis of the temporal bone and needs imaging plus prolonged systemic antibiotics — never a second course of drops. Check glucose and HbA1c, and send the same day rather than reviewing in a week.

Asymmetric or unilateral sensorineural loss, or unilateral or pulsatile tinnitus, with or without imbalance; also unilateral loss that persists after wax removal.

Vestibular schwannoma · other retrocochlear lesion · vascular cause of pulsatile tinnitus
Urgent ENT or audiology for MRI of the internal auditory meati · NICE NG98

Document the audiometric asymmetry or the tuning-fork findings and the side. Unilateral tinnitus alone, with normal hearing, still warrants referral. Pulsatile tinnitus needs imaging, not reassurance. A normal MRI does not remove the need for audiological follow-up if the asymmetry progresses.

Hearing loss with a head-and-neck cancer feature: an unexplained persistent neck lump · unilateral middle-ear effusion (glue ear) in an adult, especially with nasal obstruction, epistaxis or cranial nerve signs · persistent unexplained sore throat, hoarseness or dysphagia · oral ulceration or a mass lasting over 3 weeks.

Nasopharyngeal, laryngeal or other head-and-neck cancer
Urgent suspected-cancer referral within 2 weeks · NICE NG12

A unilateral effusion in an adult is a nasopharyngeal carcinoma until the postnasal space has been examined (NG98 requires urgent ENT referral) — it is not adult glue ear to be treated with a nasal spray. Examine the neck and the mouth, and ask directly about nasal obstruction and epistaxis. Hoarseness for over 3 weeks in a smoker aged 45 and over is its own NG12 route.

Ototoxic exposure or bilateral rapid progression: current or recent aminoglycoside, cisplatin or high-dose loop diuretic · rapidly worsening bilateral loss over weeks · loss after meningitis, mumps or head injury · loss with systemic autoimmune features.

Ototoxicity · autoimmune inner-ear disease · post-infective or traumatic loss
Same-day advice and urgent ENT / audiology

Aminoglycoside cochleotoxicity is usually permanent: stop the drug and seek specialist advice the same day rather than completing the course. Bilateral rapid progression is urgent, not routine. Record any perforation before prescribing — topical aminoglycoside drops should be avoided with a perforated drum or a grommet.

Safety rule. Wax, a cold, an aeroplane flight, a previous ear infection and a plausible noise history are all common, and none of them explains a sudden or unilateral loss until otoscopy and tuning forks say so. If wax is present and the loss persists after removal, the referral still stands. If a row applies and the safe destination is unavailable, escalate rather than observe.

Colour is semantic: red = emergency now · amber = same-day or urgent assessment · blue = define/assess · green = primary-care diagnosis · purple = uncertain / specialist route (including 2WW). Continued on page 2: examination, classification, cause classifier, routine referral, primary-care treatment, endpoint.

REASONING GP · Hearing loss in adults — triage and diagnostic approach

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Focused examination and investigation Remote assessment cannot do otoscopy or tuning forks, so it cannot exclude sudden sensorineural loss

Otoscopy, both ears

Canal: wax, debris, otitis externa, granulation. Drum: perforation and its site, retraction pocket, attic crust or keratin (cholesteatoma), effusion, grommet, tympanosclerosis. Record which ear and what you saw — "wax" without a post-removal re-examination is not a finding.

Tuning forks (512 Hz)

Weber lateralises to the worse ear in conductive loss, to the better ear in sensorineural loss. Rinne: air better than bone (positive) is normal or sensorineural; bone better than air (negative) is conductive. Combine with otoscopy before deciding the route.

Beyond the ear

Whispered voice test at arm's length. Facial nerve on both sides. Neck and supraclavicular nodes. Mouth, oropharynx and — where the effusion is unilateral — the postnasal space. Cranial nerves if any central feature.

Tests

Audiological assessment (pure-tone audiometry) for anything not fully explained and resolved, per NG98; tympanometry where available. Bloods only to answer a question — glucose and HbA1c in suspected necrotising otitis externa. Not in primary care: steroids for sudden loss, or an MRI request outside the ENT/audiology route.

Classify: three exits, not two "Probably wax" is a finding to re-test, not a diagnosis

Time-critical or serious

Sudden sensorineural loss, a central sign, mastoiditis, necrotising otitis externa, cholesteatoma, or an NG12 feature. Output: name the concern, use the destination above, record onset date, side, otoscopy and tuning forks.

Cause established in primary care

Conductive cause seen and treated — wax, otitis externa, acute otitis media — with hearing confirmed restored on re-testing, or a clear symmetrical gradual loss for audiology. Output: cause, treatment, re-test result, onward route.

Unclassified / uncertain

Asymmetry that is not explained, loss persisting after a treated conductive cause, fluctuating loss, or tuning forks that do not fit the otoscopy. Output: state the uncertainty, send the §6 route, and say who reviews when.

Cause classifier: conductive above, sensorineural below Only once the red-flag screen is negative

Wax impaction

Conductive, often bilateral, with fullness or itch; canal occluded on otoscopy. Diagnosis is confirmed only by hearing restored after removal; persisting loss afterwards needs audiology or the relevant red-flag route.

Otitis externa / acute otitis media

Conductive with pain, discharge or an inflamed drum, usually recent and unilateral. Post-auricular swelling, severe pain in diabetes, or a facial palsy moves it to page 1. Effusion persisting after an episode needs re-examination, not repeat antibiotics.

Otitis media with effusion

Conductive, fullness, fluctuating; a dull retracted drum with fluid. Bilateral in an adult is usually post-viral or allergic. Unilateral in an adult is an NG12/NG98 route — examine the postnasal space.

Presbycusis

Sensorineural, bilateral, symmetrical, gradual over years; worse in noise and on consonants, often with tinnitus. Normal otoscopy, Weber central, Rinne positive. Route is audiology for a hearing-aid assessment, not "nothing can be done".

Noise-induced

Sensorineural, bilateral, gradual, with a history of occupational or recreational exposure; tinnitus common. Asymmetry beyond what the exposure explains needs imaging via §6. Document exposure and give hearing-protection advice.

Otosclerosis

Conductive, progressive, often bilateral, starting in early adulthood; family history; normal drum with paradoxically better hearing in noise. Rinne negative with a normal drum is the clue — ENT for audiometry and surgical options.

Do not label by default

Ménière's needs the full triad with audiometry and ENT confirmation, not a primary-care label. Vestibular schwannoma is the reason any asymmetric loss or unilateral tinnitus is referred. Sudden loss is never "stress" or "wax". In cognitive impairment, unaddressed hearing loss worsens confusion and isolation — treat it rather than accepting it.

Refer routinely from this consultation Not same-day, not urgent — the cases that leave by letter; §7 is what primary care treats today

Gradual bilateral symmetrical loss (presbycusis, noise) → routine audiology for assessment and hearing aids (NG98); do not wait to be asked · conductive loss persisting after wax removal or a treated infection → audiology · suspected otosclerosis (Rinne negative, normal drum) → ENT · bothersome persistent tinnitus, no red flag → audiology or tinnitus service (NG155) · recurrent or persistent bilateral effusion in an adult → ENT · severe or profound loss not benefiting from hearing aids → cochlear implant assessment (TA566) · hearing loss with cognitive impairment or learning disability → audiology with an adjusted pathway, not no assessment. State the findings and the side in the letter.

The only treatment decisions that belong in this consultation What primary care treats today

Wax

Olive oil or sodium bicarbonate drops for several days, then irrigation or microsuction per local service. Do not irrigate with a perforation or grommet, previous ear surgery, an only-hearing ear, active infection or a recent middle-ear problem. Re-test hearing afterwards and record the result — an unresolved loss is a referral, not a repeat of the drops.

Otitis externa and acute otitis media

Externa: aural toilet where available plus topical treatment for 7–14 days, analgesia, keep the ear dry. Avoid topical aminoglycoside with a perforated drum or a grommet. Failure to settle, or severe pain in diabetes or immunosuppression, is the necrotising route on page 1 — not a second course. AOM: analgesia first; most settle without an antibiotic. Antibiotic if systemically unwell, at high risk of complications, symptoms beyond 2–3 days, or discharge with perforation (NG91). Re-examine the drum and the hearing afterwards — a persisting effusion needs re-examination, not repeat antibiotics.

Ototoxic drugs

Review every hearing-loss consultation for aminoglycosides, cisplatin and high-dose loop diuretics; stop or seek advice the same day where cochleotoxicity is suspected. Do not continue a course "to finish it" once hearing is changing.

Communication and prevention, every patient

Face the patient, reduce background noise, one speaker at a time, written backup for instructions; check existing aids work and the moulds are clear. Hearing-protection advice for noise. Explain the link with isolation and cognitive decline.

Sudden sensorineural loss, mastoiditis, necrotising otitis externa, cholesteatoma, stroke

The referral is the treatment. Do not start oral steroids, an antibiotic, a decongestant or a nasal spray in place of it; do not soften wax and review; do not order audiometry and wait. Record the exact onset date and the side — the treatment window depends on it.

Endpoint and documentation Finish with one of four conclusions

1 · Time-critical

Immediate ENT or 999 route taken; suspected diagnosis, exact onset date, side, otoscopy findings, Weber and Rinne, who was spoken to and when the patient will be seen.

2 · Urgent

Urgent ENT or audiology referral sent with the 2-week expectation; the question being asked (asymmetry, unilateral effusion, ototoxicity), findings, and the deadline.

3 · Cause established

Cause, treatment given, hearing re-tested and the result recorded, communication advice, onward audiology route, review date.

4 · Unclassified

Uncertainty stated; §6 referral or NG12 route sent, with date; interim advice; review owner and timeframe; escalation criteria.

Why a primary-care conclusion is safe today, in one line: no row on the page-1 screen applies · both ears examined and the findings recorded · Weber and Rinne done and consistent with the otoscopy · the loss is gradual, bilateral and symmetrical, or a conductive cause was treated and hearing confirmed restored · no unilateral tinnitus or unexplained asymmetry · ototoxic drugs reviewed · audiology route and written safety-net given, with a booked review. Safety-net wording: contact us the same day if hearing drops suddenly in either ear, or you develop dizziness with deafness, facial weakness, severe or worsening ear pain, swelling behind the ear, fever with confusion, or ringing in one ear only — sudden hearing loss is treatable but only if seen within days.

OOH / remote limitation. A telephone or video consultation cannot perform otoscopy or tuning forks and therefore cannot exclude sudden sensorineural hearing loss. Convert to face-to-face or emergency assessment for any hearing loss of sudden onset, any unilateral loss, loss with vertigo, facial weakness, severe pain, discharge or fever, or where the patient is diabetic, immunosuppressed or has had ear surgery. Under time pressure the default is the safer destination.

Clinical decision support only; follow local ENT, audiology and antimicrobial policies and check doses against the current BNF. Source hierarchy: NICE guidelines and CKS first, then BNF/MHRA for doses and safety, then national specialty guidance. Sources: NICE NG98 Hearing loss in adults · NG12 Suspected cancer (May 2025) · NG91 Otitis media (acute) · NG184 Otitis externa · NG155 Tinnitus · NG128 Stroke and TIA · TA566 Cochlear implants · NICE CKS Hearing loss in adults, Earwax, Otitis externa · BNF · MHRA. Review after any guidance or medicines-safety update, otherwise every 6 months. © Reasoning GP · gpreasoning.uk