If there is no significant wax (or if the patient's deafness does not improve after removal) a more detailed history and examination are required.
The history should be guided according to the patient's age and risk factors but it is important to enquire about the onset of deafness, whether it is unilateral, and about any accompanying symptoms. Also enquire about any ototoxic drugs and if there is a family history of deafness.
Hearing assessment should be age appropriate. Rinne's and Weber's test will help to establish whether the hearing loss is conductive or sensorineural.
|Red flag symptoms|
A tuning fork (512 Hz) is applied to the forehead and the patient is asked in which ear they hear the sound louder.
In conductive deafness the patient will hear the sound louder in the affected ear. If the sound is heard in the unaffected ear there is sensorineural loss.
A tuning fork is struck and held with the base placed on the mastoid process. When the sound is no longer appreciated, the fork is moved to one inch from the meatus.
The patient is asked which is the loudest. Rinne's test is positive when air conduction is greater than bone conduction and negative when bone conduction is greater than air conduction.
If Weber's test lateralises to the left and Rinne's test is positive on left, this indicates sensorineural loss in the right ear.
If Weber's test lateralises to left and Rinne's test is negative on left, this indicates conductive hearing loss in the left ear.
Sudden onset of profound sensorineural deafness requires same day ENT assessment. Even if the underlying cause is a viral infection, oral steroids may be given to improve outcome.
Cases of unilateral progressive sensorineural deafness, especially if associated with tinnitus or vertigo, need to be referred to exclude an acoustic neuroma.
Postnasal space tumours present with persistent and unexplained conductive hearing loss and may be accompanied by nasal obstruction and epistaxis.
The incidence of this malignancy is particularly high in those of southeast Asian origin.
Hearing impairment associated with otitis media will resolve within a few weeks in most cases. It is important to convey this to the patient and explain that further antibiotics are seldom required. However, if the hearing impairment persists in an adult, referral is necessary to exclude a postnasal space tumour.
In young children hearing loss will delay speech and language development so it is important to take parental concern seriously and refer for audiometry and tympanometry if no self-limiting cause can be identified.
Otosclerosis usually causes bilateral conductive hearing loss and is typically due to fixation of the stapes. It is present in young adults and it is important to refer to diagnose and treat early. There may be associated tinnitus and positional vertigo and on examination the tympanic membrane is often normal.
- Dr Porter is a salaried GP in Rochford, Essex