What is the best approach to taking a history for hearing loss in an adult patient via a telephone call in a primary care setting?

Taking a Telephone History for Hearing Loss in Primary Care

When conducting a telephone assessment for hearing loss, begin by asking the single screening question: "Do you have difficulty with your hearing?" followed by systematic inquiry about onset, laterality, associated symptoms, and functional impact—this approach has comparable accuracy to more detailed questionnaires and is practical for telephone encounters. 1

Initial Screening Questions

Primary Screening

• Ask the single-question screen: "Do you have difficulty with your hearing?" This has a positive likelihood ratio of 3.0-5.1 and negative likelihood ratio of 0.03-0.52, making it nearly as accurate as detailed questionnaires for detecting hearing loss greater than 25-30 dB 1
• This simple approach is particularly well-suited for telephone encounters where physical examination and handheld audiometry are not possible 1

Characterize the Hearing Loss

Onset and Duration:

• Determine if onset was sudden (within 72 hours) or gradual—sudden sensorineural hearing loss (loss of 30 dB or more within 72 hours) requires urgent otolaryngology referral 1, 2
• Ask specifically: "When did you first notice the hearing loss?" and "Did it come on suddenly or gradually?" 1
• Inquire about any prior episodes of hearing loss, as fluctuating hearing loss suggests Meniere disease, autoimmune inner ear disease, or Cogan syndrome rather than typical age-related hearing loss 1

Laterality:

• Establish whether hearing loss is unilateral, bilateral, or asymmetric 1
• Bilateral sudden hearing loss is rare and should raise concern for meningitis, autoimmune inner ear disease, Lyme disease, syphilis, ototoxic medications, or significant head trauma 1
• Asymmetric hearing loss warrants imaging evaluation 2

Associated Symptoms to Elicit

Red Flag Symptoms

• Tinnitus: Ask about ringing, buzzing, or other sounds in the ears, which frequently accompanies sudden hearing loss 1
• Vertigo or dizziness: Concurrent vestibular symptoms may indicate Meniere disease, autoimmune disorders, or neurological causes 1
• Neurological symptoms: Specifically ask about focal weakness, dysarthria, hemiataxia, encephalopathy, severe headaches, or diplopia—these suggest stroke or structural lesions 1
• Ear pain, discharge, or fullness: May indicate infection or other treatable middle ear pathology 2
• Recent head trauma or acoustic trauma: Direct temporal relationship suggests causation 1

Systemic and Historical Factors

• Ototoxic medication exposure: Ask about aminoglycosides, loop diuretics, chemotherapy agents, or high-dose aspirin 1
• Infectious symptoms: Fever, headache, rash (erythema migrans for Lyme disease), or multiorgan involvement suggesting syphilis 1
• Autoimmune history: Prior autoimmune conditions may suggest autoimmune inner ear disease 1

Functional Impact Assessment

Communication and Safety

• Ask: "Do you alert to your phone ringing?" 1
• Ask: "Do you alert to your alarm clock?" 1
• Ask: "Do you alert to your smoke detector?" 1
• Ask: "Are you able to use your phone to communicate?" 1
• These questions assess safety and independence, as patients with hearing loss often don't realize what alerting signals they're missing 1

Social and Quality of Life Impact

• Inquire about difficulty understanding conversations, especially in noisy environments 3, 2
• Ask about social isolation, withdrawal from activities, or emotional dysfunction related to hearing difficulties 1
• Question whether family members have noticed the patient increasing television volume or asking for repetition 2

Distinguishing Conductive from Sensorineural Loss

Critical Limitation: Physical tuning fork tests (Weber and Rinne) cannot be performed over the telephone, which limits your ability to definitively distinguish conductive from sensorineural hearing loss during the call 1, 4

History-Based Clues

• Conductive hearing loss indicators: Recent upper respiratory infection, ear fullness, history of chronic ear infections, or sensation of "plugged" ears suggests possible middle ear effusion or cerumen impaction 1, 2
• Sensorineural hearing loss indicators: Gradual onset in older adults, difficulty with speech discrimination (especially in noise), and bilateral symmetric pattern suggests presbycusis 1, 2

Documentation and Next Steps

Essential Documentation

• Document the duration of hearing loss, laterality, and specific reason for concern 1
• Record all associated symptoms, particularly red flags 1
• Note functional impact on communication and safety 1

Immediate Referral Criteria

• Urgent otolaryngology referral: Sudden sensorineural hearing loss (within 72 hours), bilateral sudden hearing loss, or hearing loss with neurological symptoms 1, 2
• Routine audiology referral: Gradual hearing loss without red flags for comprehensive audiometric testing 1, 2
• In-person primary care visit: All patients require otoscopic examination to rule out cerumen impaction, infection, or other external/middle ear abnormalities before establishing a diagnosis 1, 2

Common Pitfalls

• Never assume the type of hearing loss without audiometric confirmation—misdiagnosing sensorineural hearing loss as conductive can delay critical treatment 4
• Don't overlook sudden hearing loss—patients may not recognize the urgency, but loss of 30 dB or more within 72 hours requires prompt evaluation 1, 2
• Family members are often more accurate reporters of hearing difficulties and alerting to signals than patients themselves 1
• Telephone limitations require in-person follow-up—you cannot perform otoscopy or tuning fork tests remotely, so all patients with suspected hearing loss need physical examination 1, 4, 2