How do I order audiometric testing when hearing loss is suspected in the context of lightheadedness?

Audiometric Testing for Suspected Hearing Loss with Lightheadedness

When a patient presents with lightheadedness and suspected hearing loss, referral for a comprehensive audiometric evaluation is essential to establish diagnosis and guide management.

Initial Assessment and Referral Process

• For patients with lightheadedness and suspected hearing loss, pure tone audiometry (PTA) is the gold standard diagnostic test and should be ordered as part of the initial evaluation 1.
• Refer patients to an audiologist for comprehensive diagnostic testing that includes the following key components:
  • Thorough hearing-specific case history 1
  • Otoscopic examination with management of excessive or obstructive cerumen 1
  • Ear-specific air and bone conduction threshold measures with appropriate masking 1
  • Speech audiometry measures with appropriate masking 1
  • Otoacoustic emission (OAE) measures to determine cochlear function 1

Specific Testing Requirements

• The audiometric evaluation should include:
  • Pure tone thresholds measured at 250-8000 Hz, including 3000 and 6000 Hz with additional inter-octaves as appropriate 1
  • Speech recognition threshold or speech detection/awareness thresholds 1
  • Word recognition scores (WRS) measured in percentage of correct answers 1
  • Tympanometry to assess middle ear function 1

Clinical Considerations for Lightheadedness with Hearing Loss

• When lightheadedness is present with hearing symptoms, consider Ménière's disease in your differential diagnosis, which requires audiometric confirmation of low to mid-frequency sensorineural hearing loss 1.
• For patients with vertigo and hearing loss, audiometry is necessary to differentiate probable versus definite Ménière's disease 1.
• Asymmetric hearing loss (difference in PTA between ears of >15 dB or difference >15% between ears in word recognition scores) requires further evaluation 1.
• Vestibular migraine may coexist with Ménière's disease in up to 35% of cases and should be considered in patients with lightheadedness and hearing symptoms 1.

Interpretation of Results

• Pure tone audiometry results will help classify the type of hearing loss:
  • Conductive (middle ear problem)
  • Sensorineural (inner ear or nerve problem)
  • Mixed (combination of both) 2
• Unilateral or asymmetrical hearing loss can be symptomatic of central nervous system lesions and requires additional evaluation by an otolaryngologist 3.
• For patients with greater-than-mild sudden sensorineural hearing loss, OAEs may help distinguish sensory from neural hearing loss 1.

Follow-up Recommendations

• If audiometric testing reveals hearing loss, the patient should be referred to an otolaryngologist for further evaluation, especially with:
  • Asymmetric hearing loss 1
  • Conductive or mixed hearing loss 1
  • Poor word recognition on diagnostic testing 1
• For patients with persistent symptoms, re-examination at 3-6 month intervals is recommended until the condition resolves or additional intervention is needed 1.

Common Pitfalls to Avoid

• Do not rely on tuning fork tests alone for clinical screening, as they lack sufficient accuracy 1.
• Avoid ordering routine laboratory tests for patients with sudden hearing loss unless specific risk factors are present 1.
• Self-reported hearing assessment using a single question has reasonable accuracy at a population level but cannot substitute for formal audiometry in clinical diagnosis 4.
• Be aware that high-frequency hearing loss may be missed if testing is limited to lower frequencies, as 40% of patients may have high-frequency loss with "normal" low-frequency hearing 5.