Assessment and referral
Hearing difficulties or suspected hearing difficulties
- For adults who present for the first time with hearing difficulties, or in whom you suspect hearing difficulties:
- exclude impacted wax and acute infections such as otitis externa, then
- arrange an audiological assessment and
- refer for additional diagnostic assessment if needed (see recommendations on sudden or rapid onset of hearing loss and hearing loss with specific additional symptoms or signs).
Sudden or rapid onset of hearing loss
- Refer adults with sudden onset or rapid worsening of hearing loss in one or both ears, which is not explained by external or middle ear causes, as follows
- If the hearing loss developed suddenly (over a period of 3 days or less) within the past 30 days, refer immediately (to be seen within 24 hours) to an ear, nose and throat service or an emergency department
- If the hearing loss developed suddenly more than 30 days ago, refer urgently (to be seen within 2 weeks) to an ear, nose and throat or audiovestibular medicine service
- If the hearing loss worsened rapidly (over a period of 4 to 90 days), refer urgently (to be seen within 2 weeks) to an ear, nose and throat or audiovestibular medicine service.
Hearing loss with specific additional symptoms or signs
- Refer immediately (to be seen within 24 hours) adults with acquired unilateral hearing loss and altered sensation or facial droop on the same side to an ear, nose and throat service or, if stroke is suspected, follow a local stroke referral pathway. For information about diagnosis and initial management of stroke, see the NICE guideline on stroke and transient ischaemic attack in over 16s
- Refer immediately (to be seen within 24 hours) adults with hearing loss who are immunocompromised and have otalgia (ear ache) with otorrhoea (discharge from the ear) that has not responded to treatment within 72 hours to an ear, nose and throat service
- Consider making an urgent referral (to be seen within 2 weeks) to an ear, nose and throat service for adults of Chinese or south-east Asian family origin who have hearing loss and a middle ear effusion not associated with an upper respiratory tract infection. For information about recognition and referral for suspected cancer, see the NICE guideline on suspected cancer
- Consider referring adults with hearing loss that is not explained by acute external or middle ear causes to an ear, nose and throat, audiovestibular medicine or specialist audiology service for diagnostic investigation, using a local pathway, if they present with any of the following:
- unilateral or asymmetric hearing loss as a primary concern
- hearing loss that fluctuates and is not associated with an upper respiratory tract infection
- hyperacusis (intolerance to everyday sounds that causes significant distress and affects a person’s day-to-day activities)
- persistent tinnitus that is unilateral, pulsatile, has significantly changed in nature or is causing distress
- vertigo that has not fully resolved or is recurrent
- hearing loss that is not age related
- Consider referring adults with hearing loss to an ear, nose and throat service if, after initial treatment of any earwax (see recommendations on removing earwax) or acute infection, they have any of:
- partial or complete obstruction of the external auditory canal that prevents full examination of the eardrum or taking an aural impression
- 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
- 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, such as:
- polyp formation
- perforated eardrum
- abnormal bony or skin growths
- swelling of the outer ear
- blood in the ear canal
- a middle ear effusion in the absence of, or that persists after, an acute upper respiratory tract infection.
Adults with suspected or diagnosed dementia, mild cognitive impairment or a learning disability
- Consider referring adults with diagnosed or suspected dementia or mild cognitive impairment to an audiology service for a hearing assessment because hearing loss may be a comorbid condition
- Consider referring adults with diagnosed dementia or mild cognitive impairment to an audiology service 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, or needs to be removed in order to examine the ear or take an impression of the ear canal
- Do not offer adults manual syringing to remove earwax
- Consider ear irrigation using an electronic irrigator, microsuction or another method of earwax removal (such as manual removal using a probe) for adults in primary or community ear care services if:
- the practitioner (such as a community nurse or audiologist):
- has training and expertise in using the method to remove earwax
- is aware of any contraindications to the method
- the correct equipment is available
- the practitioner (such as a community nurse or audiologist):
- When carrying out ear irrigation in adults:
- use pre-treatment 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 ear, nose and throat service for removal of earwax
- Advise adults not to remove earwax or clean their ears by inserting small objects, such as cotton buds, into the ear canal. Explain that this could damage the ear canal and eardrum, and push the wax further down into the ear.
Investigation using MRI
- Offer MRI of the internal auditory meati to adults with hearing loss and localising symptoms or signs (such as facial nerve weakness) that might indicate a vestibular schwannoma or CPA (cerebellopontine angle) lesion, irrespective of pure tone thresholds.
- Consider MRI of the internal auditory meati for adults with sensorineural hearing loss and no localising signs if there is an asymmetry on pure tone audiometry of 15 dB or more at any 2 adjacent test frequencies, using test frequencies of 0.5, 1, 2, 4 and 8 kHz.
Treating idiopathic sudden sensorineural hearing loss
- Consider a steroid to treat idiopathic sudden sensorineural hearing loss in adults.
Information and support
- Follow the principles on tailoring healthcare services for each person and enabling people to actively participate in their care in the NICE guideline on patient experience in adult NHS services by, for example:
- taking into account the person’s ability to access services and their personal preferences when offering appointments
- taking measures, such as reducing background noise, to ensure that the clinical and care environment is conducive to communication for people with hearing loss, particularly in group settings such as waiting rooms, clinics and care homes
- establishing the most effective way of communicating with each person, including the use of hearing loop systems and other assistive listening devices
- ensuring that staff are trained and have demonstrated competence in communication skills for people with hearing loss
- encouraging people with hearing loss to give feedback about the health and social care services they receive, and responding to their feedback.
NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication.
Published date: 21 June 2018