What is the assessment and management plan for a patient reporting hard of hearing?

Assessment and Management of Hard of Hearing

For a patient reporting hard of hearing, obtain an audiogram immediately or refer to audiology for comprehensive audiometric testing, as this is the gold standard for diagnosis and guides all subsequent management decisions. 1

Initial Clinical Assessment

Ear Examination

• Perform otoscopy to examine the ear canal and tympanic membrane for cerumen impaction, infection, middle ear fluid, perforation, or other abnormalities that could cause conductive hearing loss 1
• Remove impacted cerumen if present before establishing a diagnosis, as this is potentially curative 1, 2
• Conduct Weber and Rinne tuning fork tests (256 or 512 Hz) to differentiate conductive from sensorineural hearing loss 1

Critical Red Flags Requiring Urgent Action

• If sudden hearing loss occurred within 72 hours (≥30 dB loss), refer immediately to otolaryngology for same-day evaluation and potential steroid therapy 1, 3
• Assess for bilateral sudden hearing loss, recurrent episodes, or focal neurologic findings that warrant urgent workup 1

Diagnostic Testing

Audiometric Evaluation

• Obtain comprehensive audiometry including pure-tone air and bone conduction thresholds, speech audiometry (word recognition scores), tympanometry, and acoustic reflex testing 1, 3, 4
• Schedule audiogram within 14 days for non-urgent cases, ideally within 4 weeks 1, 3
• This testing distinguishes conductive, sensorineural, or mixed hearing loss and quantifies severity 1, 2

Additional Workup Based on Audiogram Results

• For asymmetric sensorineural hearing loss (>10-15 dB difference between ears), order MRI of internal auditory canals to exclude vestibular schwannoma or other retrocochlear pathology 3, 2, 4
• For conductive or mixed hearing loss, refer to otolaryngology for evaluation of ossicular chain pathology, cholesteatoma, or otosclerosis 1
• Laboratory testing is not routinely indicated unless systemic illness is suspected 2

Patient Education and Counseling

Impact Discussion

• Educate the patient and family about hearing loss effects on communication, safety, cognitive function (including dementia risk), social isolation, and quality of life 1
• Discuss that untreated hearing loss is associated with depression, lower income, and higher unemployment 5

Communication Strategies

• Counsel on communication strategies: face the speaker, reduce background noise, use visual cues, and request repetition when needed 1
• Discuss assistive listening devices such as amplified telephones, TV listening systems, and alerting devices 1

Treatment and Rehabilitation

For Sensorineural Hearing Loss

• Offer appropriately fit amplification (hearing aids) or refer to audiology for hearing aid evaluation 1
• Over-the-counter hearing aids may be appropriate for mild to moderate hearing loss 4
• Review and eliminate or reduce ototoxic medications when possible 2

For Severe or Refractory Cases

• Refer for cochlear implant evaluation when patients have appropriately fit amplification but persistent hearing difficulty with poor speech understanding 1
• This is particularly important when word recognition scores are disproportionately poor relative to pure-tone thresholds 6

For Conductive Hearing Loss

• Treat cerumen impaction with irrigation or curettage 2
• Refer to otolaryngology for surgical evaluation if middle ear pathology is identified 1

Follow-Up and Monitoring

Reassessment Timeline

• Assess communication goals and hearing-related quality of life improvement at a subsequent encounter or within 1 year 1
• For sudden sensorineural hearing loss, obtain follow-up audiometry within 6 months to assess treatment outcome 1, 3
• Reassess hearing at least every 3 years in patients with known hearing loss or when changes are reported 1

Hearing Aid Follow-Up

• Evaluate hearing aid function and benefit annually 3
• Use validated questionnaires like the Hearing Handicap Inventory for Adults (HHIA) or Hearing Handicap Inventory for the Elderly (HHIE) to assess impact 1

Common Pitfalls to Avoid

• Do not rely on patient self-report alone to determine hearing status, as patients cannot accurately distinguish conductive from sensorineural loss 1
• Do not delay audiometry while waiting to see if symptoms improve 3
• Do not assume symmetric hearing loss is benign—always obtain objective testing 3
• Do not routinely order CT scans for hearing loss evaluation; MRI is preferred for asymmetric sensorineural hearing loss 3
• Do not prescribe antivirals, vasodilators, or thrombolytics for sudden hearing loss outside of specialist consultation 3
• Do not assume normal otoscopy rules out significant hearing loss—sensorineural hearing loss typically presents with normal ear examination 1