What is the best approach for a patient presenting with hearing loss?

Approach to a Patient Presenting with Hearing Loss

All patients presenting with hearing loss should undergo pure-tone audiometry (PTA) as soon as possible—ideally within 14 days—to distinguish the type and severity of hearing loss, as this determines the entire management pathway and identifies potentially treatable or urgent conditions.

Initial Assessment and Urgent Triage

Distinguish Sudden vs. Gradual Onset

• If hearing loss occurred within 72 hours (sudden sensorineural hearing loss): This is an otologic emergency requiring immediate evaluation and potential steroid therapy 1.
• If gradual onset: Proceed with systematic evaluation as outlined below 1.

History and Physical Examination

Focus on specific red flags rather than generic assessment:

• Laterality: Unilateral or asymmetric hearing loss (≥15 dB difference at 2+ frequencies OR ≥15% difference in speech recognition) suggests retrocochlear pathology requiring MRI 1.
• Associated symptoms: Vertigo, tinnitus, focal neurologic findings, or recurrent episodes warrant urgent otolaryngology referral 1.
• Otoscopic examination: Identify cerumen impaction, tympanic membrane perforation, middle ear effusion, or external auditory canal obstruction—all potentially reversible causes 1, 2.
• Medication review: Identify ototoxic medications that may be contributing 2.

Diagnostic Testing: The Gold Standard

Pure-Tone Audiometry (Required)

Obtain or refer for comprehensive audiometric evaluation including 1:

• Pure-tone air and bone conduction thresholds (500-8000 Hz)
• Speech audiometry (speech reception thresholds and word recognition scores)
• Tympanometry
• Acoustic reflex testing

PTA is the only way to accurately determine the type (conductive, sensorineural, or mixed) and severity of hearing loss, which dictates all subsequent management 1.

Alternative Testing (When PTA Unavailable)

• App-based or online hearing tests may be used when audiometry access is limited, though these are Grade B evidence compared to Grade A for audiometry 1.

What NOT to Order

• Do NOT routinely order: CT head/brain, routine laboratory tests (CBC, metabolic panel, thyroid function) unless specific systemic illness is suspected 1.
• Laboratory testing should only be directed by specific historical findings (e.g., Lyme, syphilis, HIV if clinically indicated) 1.

Classification and Referral Based on Audiometry Results

Conductive or Mixed Hearing Loss

Refer to otolaryngology for evaluation and treatment 1:

• Causes include cerumen (treat immediately with irrigation/curettage), middle ear effusion, cholesteatoma, ossicular discontinuity, otosclerosis, or superior canal dehiscence 1, 2.
• These conditions are often surgically correctable 1.

Symmetric Sensorineural Hearing Loss

This represents age-related hearing loss (ARHL) or noise-induced hearing loss 1:

• Refer to audiology for hearing aid evaluation and fitting 2, 3.
• Educate patient and family about impact on communication, safety, cognition, and quality of life 1.
• Discuss over-the-counter hearing aids for mild-to-moderate loss as a cost-effective option 4.

Asymmetric Sensorineural Hearing Loss

Obtain MRI of internal auditory canals to exclude vestibular schwannoma or meningioma 1:

• Asymmetry definitions: ≥15 dB at 2+ frequencies, ≥15 dB at 3000 Hz, or ≥20 dB at 2 contiguous frequencies 1.
• If MRI unavailable or contraindicated, auditory brainstem response (ABR) is an alternative 1.

Poor Word Recognition (≤60% monosyllabic word score)

Refer to otolaryngology for evaluation of retrocochlear pathology 1:

• Poor word recognition disproportionate to pure-tone thresholds suggests neural dysfunction 1.
• May require MRI and specialized testing 1.

Patient Education and Counseling (Mandatory)

Educate all patients with confirmed hearing loss about 1:

• Impact on communication, safety (fall risk), cognitive function, and social isolation 1, 3.
• Natural history of their specific condition 1.
• Benefits and limitations of hearing aids, cochlear implants, and assistive listening devices 1.
• Importance of hearing protection to prevent further damage 4.

Address Sociodemographic Barriers

Identify and address 1:

• Financial constraints and insurance coverage limitations (Medicare Parts A/B do not cover hearing aids) 4.
• Transportation difficulties and access to audiology services 1.
• Cultural attitudes toward hearing loss and hearing aid stigma 1.

Follow-Up and Monitoring

For Sudden Sensorineural Hearing Loss

• Audiometry at conclusion of treatment and within 6 months 1.
• Most recovery occurs within 1 month; 98.3% of final hearing levels reached by 3 months 1.

For Age-Related Hearing Loss

• Annual audiometry to monitor progression 1.
• Annual evaluation of hearing aid function and benefit 1.
• More frequent monitoring if hearing loss is fluctuating 1.

Common Pitfalls to Avoid

• Do not rely on patient self-report alone—patients cannot accurately differentiate type or severity of hearing loss 1.
• Do not delay audiometry—waiting beyond 14 days for sudden hearing loss significantly worsens outcomes 1.
• Do not assume symmetric hearing loss is benign—always verify symmetry with objective testing 1.
• Do not order CT scans routinely—MRI is the imaging modality of choice for sensorineural hearing loss 1.
• Do not prescribe antivirals, vasodilators, or thrombolytics for sudden hearing loss—these have no proven benefit and potential harm 1.