Makindo Medical Notes.com

Urgent referral of hearing loss which came on suddenly or with Bell's palsy or on immunosuppression or suspected stroke

Bedside

• Speak to the patient and assess comprehension and language as dysphasia can make assessing and reacting to speech difficult
• Now whisper numbers in one ear while rubbing a finger close to the other and ask to repeat. If you demonstrate a unilateral hearing loss then determine if it is conductive or sensorineural loss as follows

History

• Rapid onset hearing loss with no obvious conductive cause needs urgent referral
• Is it one ear or bilateral disease
• Ask about pain and ear discharge and tinnitus
• Ask about vertigo or any other neurology especially facial weakness or diplopia
• Recent drugs taken that could be ototoxic
• Family history of hearing loss, exposure to loud noises
• Inspect the outer ear and canal and wear drum. Look for facial weakness, pain, discharge.
• Ask about immunosuppression

Assessment with Rinne and Weber's test

Rinne and Weber's test

• In Weber's test the patient with a conductive hearing loss will hear the tuning fork louder in the affected eat
• In weber's test the patient with a sensorineural hearing loss will hear the tuning fork louder in the unaffected eat
• In Rinne's test in a normal person Air conduction > Bone conduction
• In Rinne's test in a person with sensorineural hearing loss Air conduction > Bone conduction
• In Rinne's test in a person with conductive hearing loss Boner conduction > Air conduction

Causes

• Conductive: Wax in the canal and against the tympanic membrane, Otitis media and externa, Otosclerosis, Barotrauma, Tympanic damage, Localised tumour s
• Presbyacusis, Noise-induced, Meniere disease, Congenital, Drugs, Acoustic neuroma, Autoimmune

Management: Note Urgent referrals

• Exclude impacted wax and acute infections such as otitis externa
• Arrange an audiological assessment
• Refer for additional diagnostic assessment if needed
• Hearing loss which developed suddenly (over 3 days or less) within the past 30 days, refer immediately (to be seen within 24 hours) to ENT service or an emergency department.
• If the hearing loss developed suddenly more than 30 days ago, refer urgently (to be seen within 2 weeks) to an ear, nose and throat or audiovestibular medicine service.
• If the hearing loss worsened rapidly (over a period of 4 to 90 days), refer urgently (to be seen within 2 weeks) to an ENT or audiovestibular medicine service.
• Refer immediately (< 24 hours) adults with acquired unilateral hearing loss and altered sensation or facial droop on the same side to ENT or if stroke is suspected, follow a local stroke referral pathway.
• Refer immediately (< 24 hours) adults with hearing loss who are immunocompromised and have otalgia (ear ache) with otorrhoea (discharge from the ear) that has not responded to treatment within 72 hours to an ENT service.
• Consider making an urgent referral (to be seen within 2 weeks) to an ENT service for adults of Chinese or south-east Asian family origin who have hearing loss and a middle ear effusion not associated with an upper respiratory tract infection.
• Consider referring adults with hearing loss that is not explained by acute external or middle ear causes to an ear, nose and throat, audiovestibular medicine or specialist audiology service for diagnostic investigation, using a local pathway, if they present with any of the following:
  • Unilateral or asymmetric hearing loss as a primary concern
  • Hearing loss that fluctuates and is not associated with an upper respiratory tract infection
  • Hyperacusis (intolerance to everyday sounds that causes significant distress and affects a person's day-to-day activities)
  • Persistent tinnitus that is unilateral, pulsatile, has significantly changed in nature or is causing distress
  • Vertigo that has not fully resolved or is recurrent
  • Hearing loss that is not age related

References

• Hearing loss in adults:assessment and managementNICE guidelinePublished: 21 June 2018