What management strategies do you use as a family physician (FP) for hearing loss?

Management of Hearing Loss in Family Practice

As a family physician, you should screen for hearing loss in adults over 50, obtain or refer for audiometry when hearing loss is suspected, identify treatable causes requiring specialist referral, and counsel all patients on the impact of untreated hearing loss while facilitating access to amplification and communication strategies. 1

Initial Screening and Detection

• Actively screen patients over 50 years of age for hearing loss, as age-related hearing loss (ARHL) affects approximately 40% of adults over 65 and is often unrecognized by patients who consider it a normal part of aging 2
• Look for behavioral indicators including difficulty understanding conversations, increasing television volume, asking for repetition, or family members reporting communication difficulties 3
• Perform simple in-office tests such as the whispered voice test when hearing loss is suspected 3
• If screening suggests hearing loss, obtain or refer for a comprehensive audiogram - this is the gold standard for determining type and severity of hearing loss 1

Distinguish Type and Urgency of Hearing Loss

Immediate Referral Situations (Same Day to Otolaryngology)

• Sudden sensorineural hearing loss (≥30 dB loss within 72 hours) requires urgent otolaryngology referral and treatment with high-dose corticosteroids (prednisone 60-80 mg for 10 days) 1, 4
• Significant asymmetric hearing loss between ears requires evaluation for retrocochlear pathology (acoustic neuroma) with MRI or auditory brainstem response testing 1
• Pulsatile tinnitus requires imaging (CTA or MRA) to identify vascular abnormalities 5, 6
• Conductive or mixed hearing loss on audiometry requires otolaryngologic evaluation for potentially reversible causes 1
• Poor word recognition scores disproportionate to pure tone thresholds warrant specialist evaluation 1

Examine for Treatable Causes in Your Office

• Check for cerumen impaction - irrigation or curettage is potentially curative and should be your first intervention 3
• Examine tympanic membrane for perforation, effusion, or abnormalities 3
• Review medications for ototoxic agents (aminoglycosides, loop diuretics, platinum-based chemotherapy, high-dose aspirin) and eliminate or reduce when possible 3
• Assess for noise exposure history (occupational or recreational) and counsel on hearing protection 7

Patient Education and Counseling (Critical Step)

Educate every patient with hearing loss about the serious consequences of untreated hearing loss - this is not optional counseling but essential to patient safety and outcomes 1:

• Cognitive decline and dementia risk: Untreated hearing loss is clearly linked to cognitive decline, and properly fitted hearing aids may reduce this risk 1
• Falls and safety: Hearing loss is associated with balance problems, increased fall risk, and inability to hear safety warnings 1
• Social isolation and depression: Communication difficulties lead to withdrawal from social activities and increased depression risk 1
• Quality of life: Affects relationships at home, work, and healthcare settings for both patients and family members 1
• Involve family members or care partners in education sessions, as they are also affected by communication challenges 1

Communication Strategies (Implement Immediately)

Teach and implement these strategies during every clinical encounter with hearing-impaired patients 1:

• Face the patient at eye level in good lighting; never talk while walking away or from another room 1
• Speak clearly and slowly but naturally; avoid shouting 1
• Get the patient's attention before speaking 1
• Minimize background noise (turn off TV, close doors) 1
• Rephrase rather than repeat when not understood 1
• Provide written instructions for medications, appointments, and important information 1
• Educate patients about assistive listening devices (ALDs) for specific situations like telephone use or TV watching 1

Amplification and Hearing Aids

• Refer to audiology for hearing aid evaluation for all patients with sensorineural hearing loss, even if mild or unilateral 1, 3
• Counsel that hearing aids should be fitted within 1 month of diagnosis for optimal outcomes 8
• Discuss both traditional audiology-fitted devices and over-the-counter options now available for mild-to-moderate hearing loss 2
• Address cost barriers and insurance coverage limitations, particularly for underserved populations 1
• Emphasize that hearing aids may delay cognitive decline and improve safety, function, and quality of life 1

Cochlear Implant Referral

Refer for cochlear implant evaluation when patients have appropriately fitted amplification but continue to have poor speech understanding and significant hearing difficulty 1:

• This is a strong recommendation as cochlear implants significantly improve outcomes but are vastly underutilized 1
• Do not wait until hearing loss is profound - candidacy criteria have expanded and earlier referral improves outcomes 1
• Patients with severe-to-profound sensorineural hearing loss who struggle despite hearing aids are candidates 1

Follow-Up and Monitoring

• Reassess hearing at least every 3-5 years in patients with known hearing loss, as progression is common 1
• Monitor adherence to hearing aid use and address barriers to consistent use 1
• Obtain follow-up audiometry within 6 months for patients with sudden sensorineural hearing loss to document recovery 1
• Screen for depression and social isolation in patients with untreated or undertreated hearing loss 1

Common Pitfalls to Avoid

• Do not obtain CT scans for hearing loss evaluation - MRI is the appropriate imaging modality when needed 1
• Do not order routine laboratory tests (CBC, metabolic panel, thyroid function) in patients with typical ARHL unless systemic illness is suspected 1
• Do not dismiss mild hearing loss - even mild loss benefits from amplification and affects cognitive function 1, 6
• Do not assume hearing aids are the patient's only option - communication strategies, ALDs, and cochlear implants are part of comprehensive management 1
• Do not delay referral waiting for hearing loss to worsen - earlier intervention produces better outcomes 8, 2