Makindo Medical Notes

Related Subjects: |Assessing Hearing Loss |Benign Paroxysmal Positional Vertigo (BPPV) |Cholesteatoma |Epistaxis (Nosebleeds) |Acute Mastoiditis |Nasal polyps |Acute Sinusitis |Sudden Sensorineural Hearing loss (SNHL) |Causes of Vertigo |Tympanic (Eardrum) membrane perforation

Urgent referral of hearing loss is needed if it comes on suddenly, is associated with Bell's palsy, immunosuppression, or suspected stroke.

Bedside Assessment

• Speak to the patient and assess comprehension and language, as dysphasia may impact the ability to assess and respond to speech.
• Whisper numbers in one ear while rubbing a finger near the other, and ask the patient to repeat. If unilateral hearing loss is detected, determine whether it is conductive or sensorineural as follows.

History

• Rapid onset hearing loss with no obvious conductive cause warrants urgent referral.
• Determine if the loss affects one or both ears.
• Ask about pain, ear discharge, and tinnitus.
• Enquire about vertigo or any additional neurological symptoms, especially facial weakness or diplopia.
• Ask about recent medications that could be ototoxic.
• Note any family history of hearing loss or exposure to loud noises.
• Examine the outer ear, canal, and tympanic membrane for signs of facial weakness, pain, or discharge.
• Ask about immunosuppression.

Assessment with Rinne and Weber’s Tests

Rinne and Weber’s Tests

• Weber's Test: In conductive hearing loss, the patient hears the tuning fork louder in the affected ear. In sensorineural hearing loss, the sound is louder in the unaffected ear.
• Rinne's Test: Normally, air conduction (AC) is greater than bone conduction (BC). In sensorineural hearing loss, AC > BC. In conductive hearing loss, BC > AC.

Causes of Hearing Loss

• Conductive: Wax buildup in the canal, otitis media and externa, otosclerosis, barotrauma, tympanic membrane damage, localized tumors.
• Sensorineural: Presbyacusis, noise-induced hearing loss, Meniere's disease, congenital causes, ototoxic drugs, acoustic neuroma, autoimmune disorders.

Management: Urgent Referral Criteria

• Exclude impacted wax and acute infections like otitis externa.
• Arrange an audiological assessment if indicated.
• Refer for further diagnostic assessment if needed.
• Immediate (< 24 hours) Referral:
• Sudden hearing loss (within the past 30 days) over 3 days or less should be referred immediately to ENT or an emergency department.
• Unilateral hearing loss with altered sensation or facial droop on the same side requires immediate ENT referral or follow local stroke protocol if stroke is suspected.
• Immunocompromised patients with hearing loss, otalgia, and otorrhoea not responding to treatment within 72 hours should be referred immediately to ENT.
• Urgent (within 2 weeks) Referral:
• Hearing loss that developed suddenly over 3 days, occurring more than 30 days ago, should be referred to ENT or audiovestibular medicine.
• Hearing loss that worsens rapidly over 4-90 days requires urgent referral to ENT or audiovestibular medicine.
• Adults of Chinese or South-East Asian origin with hearing loss and middle ear effusion (unrelated to upper respiratory infection) may need urgent ENT referral.
• Referral is advised for unexplained hearing loss if the patient presents with:
  • Unilateral or asymmetric hearing loss as a primary concern.
  • Fluctuating hearing loss not associated with upper respiratory infection.
  • Hyperacusis causing significant distress.
  • Persistent, unilateral, pulsatile, or distressing tinnitus.
  • Vertigo that is recurrent or unresolved.
  • Non-age-related hearing loss.

References

• Hearing Loss in Adults: Assessment and Management - NICE Guideline (Published: 21 June 2018)