Makindo Medical Notes

⚠️ Urgent referral of hearing loss is required if it develops suddenly, is associated with Bell’s palsy, immunosuppression, or suspected stroke.

🛏️ Bedside Assessment

• Check comprehension and speech — dysphasia may confound assessment.
• Whisper test: whisper numbers in one ear while masking the other with finger rubbing.
• If unilateral loss detected → use Rinne and Weber to distinguish conductive vs sensorineural causes.

🧾 Key History Points

• Rapid onset (<3 days) = red flag → urgent ENT referral.
• Laterality: one or both ears affected?
• Associated symptoms: pain, discharge, tinnitus, vertigo, neurological symptoms (facial weakness, diplopia).
• Medication history: ototoxic drugs (aminoglycosides, loop diuretics, chemotherapy agents).
• Past/family history: hearing loss, noise exposure.
• Risk factors: immunosuppression, recent infections.

🔎 Examination

• Inspect outer ear, canal, and tympanic membrane.
• Look for discharge, swelling, perforation, cholesteatoma features.
• Check cranial nerves (esp. facial nerve palsy).

📏 Rinne & Weber Tests

• Weber: – Conductive → sound localises to affected ear. – Sensorineural → sound localises to unaffected ear.
• Rinne: – Normal & sensorineural loss → AC > BC. – Conductive loss → BC > AC.

🧬 Causes of Hearing Loss

• Conductive: Wax, otitis externa/media, otosclerosis, barotrauma, perforated TM, local tumours.
• Sensorineural: Presbyacusis, noise-induced, Meniere’s, congenital, ototoxic drugs, acoustic neuroma, autoimmune inner ear disease.

🚨 Referral Criteria

• Immediate (<24h):
  • Sudden hearing loss (≤30 days, developing in ≤3 days).
  • Unilateral loss with facial droop or neurological features → urgent ENT / stroke pathway.
  • Immunocompromised + hearing loss + otalgia/otorrhoea not improving within 72h.
• Urgent (within 2 weeks):
  • Sudden loss developing over 3 days but >30 days ago.
  • Rapidly progressive loss over 4–90 days.
  • Adults of Chinese or SE Asian origin with unexplained middle ear effusion (ENT rule out nasopharyngeal carcinoma).
  • Unexplained cases with: unilateral/asymmetric loss, fluctuating loss, hyperacusis, persistent distressing/pulsatile tinnitus, recurrent vertigo, or non-age-related loss.

📚 Reference

• NICE NG98: Hearing Loss in Adults (2018)