6 quiz questions available for this topicTake Quiz
Hearing loss in adults
💡
Exam Tips
- In OSCEs, first classify hearing loss as conductive vs sensorineural using history, otoscopy, and Rinne/Weber before naming causes.
- Sudden unilateral hearing loss developing within 72 hours is sudden sensorineural hearing loss until proven otherwise; urgent same-day ENT action is high-yield.
- Unilateral persistent middle-ear effusion in an adult is a red flag for nasopharyngeal pathology and needs urgent ENT assessment.
- Normal ear examination does not exclude significant sensorineural disease (for example presbycusis, noise injury, vestibular schwannoma).
- Use audiogram patterns to score marks: air-bone gap suggests conductive loss; parallel elevation of air and bone thresholds suggests sensorineural loss.
- For visual revision, review standard textbook figures of ear anatomy, otoscopic pathology, and audiogram archetypes (conductive vs sensorineural vs mixed).
Definition
Adult hearing loss is a reduction in hearing sensitivity that may be temporary or permanent, and may present suddenly (within 72 hours) or as a gradual decline. Clinically it is classified as conductive (outer/middle ear sound transmission problem), sensorineural (cochlear or auditory nerve pathway damage), or mixed, and severity is graded on pure-tone audiometry in dB hearing level.
Pathophysiology
Conductive hearing loss results from impaired mechanical transmission of sound from the external canal and tympanic membrane through the ossicular chain to the cochlea (for example wax impaction, otitis media with effusion, tympanic membrane perforation, otosclerosis). Sensorineural hearing loss reflects injury to cochlear hair cells, stria vascularis, spiral ganglion, or retrocochlear pathways; common mechanisms include age-related degeneration (presbycusis), noise-induced hair-cell damage, ototoxic injury, inflammatory/infective damage, vascular compromise, and compression of CN VIII (for example vestibular schwannoma). Mixed loss combines both mechanisms. Central auditory pathway disease (for example stroke, demyelination) may further impair speech discrimination even when peripheral thresholds are less affected.
Risk Factors
- Age over 50 years (risk rises markedly with advancing age)
- Chronic occupational or recreational noise exposure (machinery, firearms, loud music)
- Ototoxic medicines (for example gentamicin, furosemide, cisplatin, high-dose salicylates/NSAIDs)
- Previous ear disease (recurrent otitis media/externa, cholesteatoma, tympanic membrane perforation)
- Head or acoustic trauma, including barotrauma
- Family history of presbycusis or otosclerosis
- Smoking and toxin/heavy-metal exposure
- Systemic disease (diabetes, autoimmune disease, vascular risk factors, neurological disease)
- Immunocompromise (higher risk of severe ear infection complications)
Clinical Features
Symptoms
- Progressive or sudden hearing reduction (unilateral or bilateral)
- Difficulty following conversation, especially in background noise
- Need to increase TV/phone volume; asking others to repeat themselves
- Tinnitus (including unilateral or pulsatile tinnitus)
- Aural fullness or blocked-ear sensation
- Otalgia and/or otorrhoea in conductive/infective causes
- Vertigo or imbalance (labyrinthine/Meniere-related causes)
- Communication strain, social withdrawal, low mood, cognitive complaints
Signs
- Otoscopy: wax impaction, foreign body, canal inflammation/debris, perforation, middle-ear effusion, cholesteatoma features
- Normal otoscopy can still occur in sensorineural causes (for example presbycusis, noise injury)
- Rinne test: bone conduction greater than air conduction in conductive loss
- Weber test: lateralizes to affected ear in conductive loss; to better ear in unilateral sensorineural loss
- Abnormal retro-tympanic mass may suggest glomus tumour
- Cranial nerve or cerebellar signs raise concern for retrocochlear/central pathology
Investigations
Otoscopy (including pneumatic otoscopy where available):Identifies reversible conductive causes (wax, otitis externa/media, perforation, effusion) or suspicious lesions
512 Hz tuning fork tests (Rinne and Weber):Helps distinguish conductive from sensorineural pattern at bedside
Pure-tone audiometry:Quantifies degree/type of hearing loss; air-bone gap in conductive loss, elevated bone thresholds in sensorineural loss
Speech discrimination testing:Disproportionately poor scores can suggest retrocochlear pathology
Tympanometry:Type B/C traces support middle-ear effusion or Eustachian tube dysfunction; normal trace often in sensorineural loss
MRI internal auditory meatus/cerebellopontine angle (for asymmetrical or unilateral sensorineural loss, unilateral tinnitus, or neurological signs):Excludes vestibular schwannoma and other CPA lesions
Targeted blood tests (if indicated: FBC, ESR/CRP, glucose/HbA1c, autoimmune or syphilis serology):May identify inflammatory, metabolic, autoimmune, or infectious contributors
Management
Lifestyle Modifications
- Early communication strategies: face-to-face speaking, reduce background noise, good lighting for lip reading
- Noise protection (properly fitted ear defenders/plugs) and avoidance of further acoustic trauma
- Medication review to reduce/stop ototoxic exposure where clinically safe
- Smoking cessation and vascular risk-factor optimisation
- Prompt safety-netting for red flags: sudden loss, unilateral progressive loss, persistent otorrhoea/otalgia, focal neurology, pulsatile tinnitus
Pharmacological Treatment
Cerumenolytics for wax-related conductive loss
- Sodium bicarbonate 5% ear drops: 3-4 drops once or twice daily for up to 7 days
- Olive oil ear drops: 2-3 drops twice daily for 3-7 days
Avoid ear drops/irrigation if tympanic membrane perforation, active infection, grommet, previous mastoid surgery, or only-hearing ear without specialist advice.
Idiopathic sudden sensorineural hearing loss (urgent ENT pathway)
- Prednisolone oral: 1 mg/kg once daily (maximum 60 mg) for 7-14 days, then taper as per specialist plan
- Intratympanic dexamethasone (specialist-delivered) if oral steroids unsuitable or for salvage therapy
Treat as an otological emergency; best outcomes when started early (ideally within 72 hours). Check steroid cautions (uncontrolled diabetes, active peptic ulcer, severe infection, psychosis risk, osteoporosis) and monitor adverse effects.
Treat underlying ear infection where present
- Acetic acid 2% ear spray: 1 spray three times daily for otitis externa
- Amoxicillin oral: 500 mg three times daily for 5 days (if acute otitis media and antibiotic indicated)
Use cause-specific treatment rather than routine antibiotics for all hearing loss. Avoid aminoglycoside-containing ear drops if perforation/grommet because of ototoxicity risk unless specialist-directed.
Surgical / Interventional
- Microsuction/manual wax removal when drops fail or are contraindicated
- Myringoplasty/tympanoplasty for persistent tympanic membrane perforation
- Stapedotomy or stapedectomy for otosclerosis in selected patients
- Ventilation tubes for persistent middle-ear effusion in selected adults
- Cholesteatoma surgery (for example mastoidectomy) to prevent destructive complications
- Hearing rehabilitation devices: conventional hearing aids, bone-conduction systems, and cochlear implantation for severe/profound sensorineural loss
- Vestibular schwannoma management (observation, stereotactic radiotherapy, or microsurgery) guided by MDT
Complications
- Social isolation, reduced confidence, and reduced quality of life
- Depression, anxiety, irritability, and communication-related distress
- Cognitive decline and increased dementia risk association
- Falls, reduced mobility, and functional decline in older adults
- Medication errors and poorer healthcare engagement from miscommunication
- Progression of missed serious causes (for example cholesteatoma, skull-base infection, neoplasm)
Prognosis
Prognosis depends on cause and speed of recognition. Many conductive causes are reversible with primary-care or ENT treatment, whereas presbycusis and chronic noise-related sensorineural loss are usually permanent and progressive. Sudden sensorineural hearing loss has variable recovery (including spontaneous improvement in a proportion), but earlier treatment is associated with better outcomes.
Sources & References
🏥BMJ Best Practice(1)
💊BNF Drug References(1)
- Vancomycin[contraindications]
✅NICE Guidelines(1)
- Hearing loss in adults[overview]
📖Textbook References(20)
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1833)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 630)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 622, 623)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1461)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1833)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1801)[context]
- Guyton and Hall Textbook of Medical Physiology (John E. Hall, Michael E. Hall) (Z-Library).pdf(pp. 661)[context]
- Guyton and Hall Textbook of Medical Physiology (John E. Hall, Michael E. Hall) (Z-Library).pdf(pp. 659)[context]
- Netter F. Netter Atlas of Human Anatomy. A Systems Approach 8ed 2022.pdf(pp. 1989, 1990)[context]
- Netter F. Netter Atlas of Human Anatomy. A Systems Approach 8ed 2022.pdf(pp. 1989, 1990)[context]
- Netter F. Netter Atlas of Human Anatomy. Classic Regional Approach 8ed 2022.pdf(pp. 231)[context]
- Oxford Handbook of Clinical Diagnosis (Huw Llewelyn, Hock Aun Ang, Keir Lewis etc.) (Z-Library).pdf(pp. 495)[context]
- Oxford Handbook of Clinical Diagnosis (Huw Llewelyn, Hock Aun Ang, Keir Lewis etc.) (Z-Library).pdf(pp. 526, 527)[context]
- Oxford Handbook of Clinical Diagnosis (Huw Llewelyn, Hock Aun Ang, Keir Lewis etc.) (Z-Library).pdf(pp. 324, 325)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 529)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 688)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 685)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 657)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 685)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 690, 691)[context]