HNY Policy and Pathway Repository - York

Noticeable and symptomatic / disruptive continued functional reduction of hearing compared to previous ability, or compared to peers.

Exclude Red Flag Symptoms (contact on-call ENT same day)

• Sudden onset of complete or significant loss for no apparent reason or after a local trauma / head injury
• Associated dramatic symptoms such as severe vertigo, pain, confusion, sickness etc.

Management

The most common causes are physical obstruction (usually with dry wax; or Eustachian tube dysfunction), age-related hearing loss (presbyacusis) or noise exposure.

Other causes, such as physical trauma, genetic conditions (e.g. otosclerosis, the onset may be during pregnancy) or ototoxic side effects of medications (e.g. diuretics, antibiotics, high-dose NSAIDs etc.) and others are comparatively rare.
 

History:

• Establish history and time-line of onset
• Is this intermittent or permanent, or in certain contexts / environments (e.g. one-to one conversations versus background noise conversations with a group)?
• Does it respond to a Valsalva manoeuvre?
• Is it bilateral or more on one side than the other?
• Is there intermittent or regular tinnitus with it?
• Previous or current noise exposure or hazards (at work or leisure activities)?
• Regular use of headphones, habit of cleaning ears etc.?
• Who is mostly troubled by the hearing loss – the patient themselves, or other people?
• Would the patient be prepared to wear hearing aids, if this was the recommended outcome?

Examination:

Are there any apparent difficulties of hearing in conversation with the patient?

Examine the ears for wax, debris or discharge, possible infection, inflammation, swelling, foreign bodies, any abnormal appearance of the tympanic membranes (dullness, perforations etc.).

If there are signs for obstruction with wax:

• Advise patients to use ear drops for at least a week initially, to soften wax and aid removal.
• Olive oil, or almond oil drops can be used 3-4 times daily for 7 -14 days (do not prescribe almond oil ear drops to anyone who is allergic to almonds).
• Sodium bicarbonate 5% ear drops

Both these ear drops can be purchased OTC from a pharmacy – please do not prescribe.

Please warn the patient that the hearing may worsen temporarily, as the wax dissolves and moves out. After clearance, if improved, advise on intermittent drop use, e.g. once weekly and advise against any mechanical “cleaning” (with cotton wool buds, ear candles, hooks, pins etc. etc.).

Consider a “whisper-test”: ask the patient to move a finger rapidly on the tragus of the non-test ear whilst you stand behind them and whisper some multi-syllable words or numbers, e.g. 47, 32 with at least 20cm distance to their ear. More than 50% correct answers is acceptable.

Please do a tuning fork test, if possible:

Sensory-neural hearing loss will show air conduction better than bone conduction (= Rinne +ve) and Weber away from bad ear.

Conductive Hearing loss will show bone conduction better than air conduction (=Rinne -ve) and Weber towards the bad ear.

In case of otitis externa treat as per North Yorkshire Antibiotic Guidelines:

First line: acetic acid 2% spray (Ear-calm®) 1 spray TDS for 7 days and analgesia. Ear-calm® can be purchased OTC from a pharmacy without a prescription.

Alternative: flumetasone 0.02% + clioquinol 1% ear drops (Locorten-Vioform®) 2-3 drops into the affected ear(s).

If you suspect Eustachian tube dysfunction consider a course of decongestants, antihistamines, a steroid nasal spray (see CCG Medal Ranking for preferred choices) and steaming, but advise that it may intermittently recur.

If the problem is mostly tinnitus, please refer to the tinnitus RSS guideline.

Advise the patient about possible options of a free non-medical hearing screener assessment, which may be useful despite their limitations:

• Online, by Action on Hearing Loss: Check your hearing - Take the test
• Action on Hearing Loss also offers a free and completely automated (therefore anonymous) over-the-phone hearing check on 0844 800 3838 (local rate call)
• No-obligation hearing test at hearing aid shops in town
• Several opticians offer free and no-obligation self-directed automated hearing tests

Refer to Audiology

• Over 60 with age-related sensory deafness
• Under 60 who have or have had a hearing aid or are previously known to them
• IMPORTANT: When referring to audiology it is essential to examine ears & document that they are clear from wax otherwise the patient will be sent away without a hearing test.
• If ear-drop use for 2-3 weeks, or ear syringing not available, practical or do-able for the patient, consider a one-off clear-out with micro suction at the ENT primary care clinic (bookable via the on-call SHO).
   

Refer to ENT

• Persistent troublesome non-reversible hearing problems for more than three months, and under 60 years old
• Additional associated symptoms such as (intermittent or continuous) vertigo, pain, discharge, tinnitus, asymmetry
• Other concerns (e.g. abnormal appearances of the ear canal or tympanic membranes, foreign bodies or growths etc., tuning fork test asymmetry for no apparent reason).
   

Information to include in referral letter

• Duration of hearing loss, possible causes or maintaining factors
• Impact on work or daily living
• Noise exposure (occupational or other activities)
• Relevant past medical / surgical history
• Any associated symptoms
• Findings during conversation / whisper test, and examination of ears / Tuning fork testing • Community or online/telephone hearing screener done?
• Current regular medication
• Smoking status
• Have you discussed willingness to trial / use hearing aids?

Patient information leaflets/ PDAs

• https://patient.info/health/hearing-loss-of-older-people-presbyacusis 
• Action on Hearing Loss online hearing screener: https;//www.actiononhearingloss.org.uk/yourhearing/look-after-your-hearing/check-your-hearing/take-the-check.aspx 
• Action on Hearing Loss free and completely automated (therefore anonymous) over-the-phone hearing check on 0844 800 3838 (local rate call)
   

References

Hearing Loss in Adults. BMJ 2013;346:f2496 http://www.bmj.com/content/346/bmj.f2496