When to refer a patient with hearing loss to an audiologist versus an ENT (Ear, Nose, and Throat) specialist?

Audiology versus ENT Referral for Hearing Loss

Patients with significant asymmetric hearing loss, conductive or mixed hearing loss, or poor word recognition on diagnostic testing should be referred to an ENT specialist, while patients with symmetric age-related hearing loss can be referred directly to an audiologist for audiogram and hearing aid evaluation. 1

Initial Assessment Algorithm

1. Screening for hearing loss

   • All patients aged 50+ should be screened for hearing loss at healthcare encounters 1
   • Screening can be done using:
     • Whispered voice test
     • Handheld audiometry
     • Hearing Handicap Inventory for the Elderly-Screening (HHIE-S)

2. Otoscopic examination

   • If screening suggests hearing loss, examine ear canal and tympanic membrane
   • Look for cerumen impaction, infection, or other abnormalities 1
   • If abnormalities found, treat or refer to a clinician who can examine the ears

3. Audiogram referral

   • If screening suggests hearing loss, refer for audiogram 1
   • This is a strong recommendation based on multiple RCTs and systematic reviews

ENT Referral Indications

Refer to ENT specialist when:

• Significant asymmetric hearing loss 1

  • Various definitions exist (see below)
  • Requires evaluation for retrocochlear pathology

• Conductive or mixed hearing loss 1, 2

  • Indicates pathology in external ear canal or middle ear
  • May be correctable with medical/surgical intervention

• Poor word recognition 1

  • Generally considered when unaided monosyllabic word score ≤60%

• Sudden sensorineural hearing loss 2, 3

  • Loss of 30 dB or more within 72 hours
  • Requires urgent ENT referral as an otologic emergency

• Suspected medical causes of hearing loss 2

  • Requires evaluation for conditions that may coexist with hearing loss
  • May include imaging (MRI/CT) for asymmetric or sudden hearing loss

Audiologist Referral Indications

Refer directly to audiologist when:

• Symmetric age-related hearing loss (ARHL) 1

  • Bilateral hearing loss with similar degrees in both ears
  • No concerning features requiring ENT evaluation

• Known hearing loss requiring amplification 1

  • For hearing aid evaluation and fitting
  • For counseling on communication strategies and assistive devices

• Routine monitoring of known hearing loss 1

  • At least every 3 years for patients with known hearing loss
  • More frequently if there are concerns about changes in hearing

Definitions of Asymmetric Hearing Loss

Asymmetric sensorineural hearing loss (ASNHL) has several definitions, including:

• Difference of >15 dB at any frequency
• Difference of >10 dB at two adjacent frequencies
• Difference of >10 dB in pure tone averages between ears 1

Important Considerations

• Workup of asymmetric hearing loss typically includes MRI of internal auditory canals to exclude retrocochlear pathology such as vestibular schwannoma or meningioma 1

• Age-related hearing loss should be symmetric—both ears exhibiting similar degrees of hearing loss 1

• Conductive hearing loss causes include cerumen impaction, otitis media, tympanic membrane perforation, and otosclerosis, which may be correctable with intervention 2, 4

• Hearing aid success is greater when patients are referred early in the course of hearing loss, before significant communication difficulties develop 5

Common Pitfalls to Avoid

1. Delayed referral for sudden hearing loss - This is an emergency requiring immediate ENT evaluation and possible steroid treatment 2, 3

2. Missing conductive components - Always perform otoscopy to identify potentially treatable causes before assuming age-related hearing loss 1

3. Ignoring asymmetry - Asymmetric hearing loss requires investigation for potentially serious pathology 1

4. Underestimating impact - Even mild hearing loss (15-30 dB) can significantly impact cognitive, language, and reading skills, especially in children 1

5. Assuming hearing loss is normal aging - While common, hearing loss should not be dismissed as an inevitable part of aging; it requires proper evaluation and management 5

By following this evidence-based approach to referral, clinicians can ensure patients receive appropriate evaluation and treatment for their hearing loss, potentially improving outcomes related to communication, safety, function, cognition, and quality of life.