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 tumours.
- 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