Hearing Problems

Assessment of Hearing Loss

Basic assessment of hearing loss in primary care can help establish the correct referral pathway.

Advice on hearing tests including Rinne's and Webber's tests can be found in this hearing loss guide.

In acute hearing loss these tests can help distinguish between conductive hearing loss (which is less urgent) and sensorineural hearing loss (which may need immediate management and/or urgent referral - see Red Flags below).

Please see sections below for advice on management of hearing loss in patients with chronic tympanic membrane perforation, eustachian tube dysfunction and otitis media with effusion.

Referral Guidance

For patients 15 and under audiology referrals should be sent directly to Children's hearing centre at UHB (Email:ubh-tr.paediatricaudiologyreferrals@nhs.net and Tel no. 0117 342 1611).

For information on making an audiology referral for adults (age 16 and over) please see the Audiology section

For adults of any age who require a hearing aid replacement due to a lost, broken/faulty hearing aid, a new audiology referral is not required. Instead, the patient should contact the provider of the original hearing aid. The provider should repair or replace any faulty aids and arrange replacement of lost hearing aids (CCG will fund this up to one lost hearing aid pair per year – more than this, the patient must self-fund).

Please note that the referral must state that ears have been checked and cleared for wax otherwise it may be returned.

If wax is obstructing the ear canal then please do not refer until it has been cleared. Please note that referrals for the removal of wax in secondary care is subject to the Microsuction for Ear Wax, Discharge or Debris Removal in Secondary Care policy.

Red Flags

Sudden SensoriNeural Hearing Loss (SSNHL)

Sudden sensorineural hearing loss (SSNHL) should be considered an otological emergency yet often goes unrecognised. It can have debilitating long-term effects upon individuals, yet early treatment with steroids has been shown to be effective in helping recovery in what is a time-critical clinical scenario (2).

Acute hearing loss therefore requires immediate (same day) assessment in primary care and examination should include otoscopy and tuning fork tests*.

If SSNHL (either bilateral or unilateral) with onset within the last 4 weeks is suspected, then start oral steroids immediately (local ENT advice is prednisolone 1mg/kg up to maximum dose of 60mg daily for 7 days - no need to taper). In cases where oral steroids may be contraindicated (pregnancy, glaucoma, brittle diabetes etc) then speak to the on call ENT registrar to discuss intratympanic steroid injections. 

A referral to the ENT HOT clinic* via eRS should also be made but this should not delay treatment which can be started in primary care prior to assessment. 

If the onset of symptoms was over 4 weeks before presentation, then steroids are not likely to be effective. An urgent referral to audiology at St Michaels should be made to confirm diagnosis and they can advise if patients will need onward referral to ENT for further investigation if this is required.

* The most likely cause of sudden hearing loss is still conductive pathology such as ear wax or glue ear. It is therefore important that patients are adequately assessed in primary care prior to referral to HOT clinic as otherwise the hot clinic system becomes overwhelmed which means that those with genuine emergencies have to wait longer.

Research

The ENT department will be recruiting patients to a research trial on treatment of SSNHL from September 2023. Patients who express an interest can be discussed with the on call ENT team prior to commencing treatment.

Indications for 2WW referral include:

• Unexplained unilateral serous otitis media/ effusion in a patient aged over 18.

• Referred otalgia as a symptom of laryngeal or pharyngeal malignancy.

Chronic Tympanic Membrane Perforation

The evidence on hearing loss and tympanic membrane perforations appears to be rather sparse. Expert opinion is that surgery for perforation is not indicated for hearing loss but only for recurrent infections. We have discussed this with Graham Porter one of the ENT consultants and his advice is below:

'Hearing loss alone is not a good indication for myringoplasty. It can improve hearing but the most likely outcome is unchanged hearing and there is a small risk (c. 1%) of further hearing loss due to surgery including dead ear. If dead ear occurs there is also usually severe vertigo which delays recovery significantly.

The primary indication for myringoplasty is recurrent infection/discharge with a secondary indication of drum closure to allow occupations/pastimes that allow water in the ear. Some professions particularly the military will not consider applicants if they have a perforation so this is another indication.'

Referrals for repair of tympanic membrane perforation may be triaged by BNSSG Referral Service and returned with this advice.

Eustachian Tube Dysfunction

Overview

Eustachian Tube Dysfunction (EDT) is usually due to a cold, the symptoms are typical and it clears up after a few weeks (2).

More persistent EDT is closely related to the development of chronic otitis media and is often accompanied by chronic inflammatory disease of the nasal cavity (1) . Treatment involves supportive care and management of contributing disease factors. Some patients may benefit from a trial of intranasal corticosteroids. Decongestants and antihistamines are ineffective in the treatment of ETD (1).

Management in primary care

If there are no red flags (see above), then in most patients Eustachian tube dysfunction can be managed conservatively and does not require specialist investigation or treatment (3).

Patient information should be provided

• Eustachian Tube Dysfunction: Symptoms and Treatment | Patient

Treatment involves supportive care and management of contributing disease factors. Some patients may benefit from a trial of intranasal corticosteroids using nasal spray initially, and stepping up to nasal drops if necessary.. Decongestants and antihistamines are ineffective in the treatment of ETD (1).

The Valsalva manoeuvre can help open the Eustachian tube (2). Some people try an otovent balloon to help with this.   

Who to Refer

If symptoms are unilateral or persistent then a referral to ENT or audiology should be considered.

Please note that referrals requesting grommets are subject to a Criteria Based Access policy which requires hearing loss to be confirmed by audiology.

References

(1) Eustachian tube dysfunction - Symptoms, diagnosis and treatment | BMJ Best Practice

(2) Eustachian Tube Dysfunction: Symptoms and Treatment | Patient

(3) Eustachian tube dysfunction (blocked ears) (myhealth-devon.nhs.uk)

Otitis Media with Effusion

Referral for adult patients with OME to consider myringotomy or grommets is subject to criteria based access. Please see the Grommets – Surgical Referral for Patients over 12 yrs with Persistent Otitis Media with Effusion Policy (Criteria Based Access) for further information.

Resources

(1) Recommendations | Hearing loss in adults: assessment and management | Guidance | NICE

(2) Sudden sensorineural hearing loss and bedside phone testing: a guide for primary care | British Journal of General Practice (bjgp.org)

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

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