One-liner#
Distinguish conductive (outer/middle ear) from sensorineural (inner ear/nerve) hearing loss, recognize sudden sensorineural hearing loss (SSNHL) as an emergency, and identify reversible causes (cerumen, OME, ototoxicity).
Quick nav#
- Red flags / send to ED
- Key history
- Focused exam
- Differential (quick pattern recognition)
- Workup
- Initial management
- Management by diagnosis
- Follow-up
- Patient instructions
- Smartphrase snippets
Red flags / send to ED#
- Sudden hearing loss (over hours to days) with no obvious cause → SSNHL is an emergency
- Hearing loss with vertigo, facial weakness, or other cranial nerve deficits
- Hearing loss after head trauma
- Hearing loss with severe headache or altered mental status
- Pulsatile tinnitus with hearing loss (vascular lesion)
- Rapidly progressive bilateral hearing loss
Key history#
Onset and progression:
- Sudden (hours to days): SSNHL emergency vs cerumen vs OME
- Gradual (months to years): presbycusis, noise-induced, otosclerosis
- Fluctuating: Meniere’s disease
- Unilateral vs bilateral
Associated symptoms:
- Tinnitus: common with SNHL; pulsatile suggests vascular cause
- Vertigo: Meniere’s, labyrinthitis, acoustic neuroma
- Ear pain: infection, trauma
- Ear fullness: OME, Meniere’s, cerumen
- Otorrhea: infection, cholesteatoma
- Facial weakness: acoustic neuroma, cholesteatoma, Ramsay Hunt
Conductive vs sensorineural clues:
- Conductive: “sounds muffled,” own voice sounds loud, hears better in noise
- Sensorineural: difficulty understanding speech (especially in noise), tinnitus common
Risk factors and exposures:
- Noise exposure: occupational, recreational (concerts, firearms, power tools)
- Ototoxic medications: aminoglycosides, loop diuretics, cisplatin, high-dose aspirin
- Family history: otosclerosis, hereditary hearing loss
- Recent URI: OME, labyrinthitis
- Diabetes, cardiovascular disease: microvascular damage
- Autoimmune disease: autoimmune inner ear disease
Relevant history:
- Prior ear infections, surgeries, or tubes
- Head trauma
- Meningitis (can cause SNHL)
- Occupational noise exposure
- Hearing aid use
Focused exam#
- Otoscopy: Cerumen, TM perforation, effusion, cholesteatoma, mass
- Whisper test: Stand behind patient, occlude one ear, whisper 3 words/numbers at arm’s length; abnormal if <50% correct
- Weber test (512 Hz tuning fork on forehead):
- Lateralizes to affected ear → conductive loss
- Lateralizes to better ear → sensorineural loss in affected ear
- Rinne test (tuning fork on mastoid then near ear canal):
- Air > bone (normal, or sensorineural loss)
- Bone > air (conductive loss)
- Cranial nerves: Facial nerve (VII), other CNs if acoustic neuroma suspected
- Neck: Lymphadenopathy, masses
Tuning fork interpretation:
| Weber | Rinne (affected ear) | Interpretation |
|---|---|---|
| Lateralizes to affected ear | Bone > Air | Conductive loss (affected ear) |
| Lateralizes to unaffected ear | Air > Bone | Sensorineural loss (affected ear) |
| Midline | Air > Bone bilaterally | Normal or symmetric SNHL |
Differential (quick pattern recognition)#
Common/likely (outpatient)#
| Diagnosis | Keywords patients use | Key clues | Focused exam clues | Initial next step |
|---|---|---|---|---|
| Cerumen impaction | “Blocked,” “plugged,” “sudden after shower” | Acute onset; often after water exposure or Q-tip use | Cerumen obscuring TM | Cerumen removal; reassess hearing |
| Presbycusis (age-related) | “Can’t hear in restaurants,” “people mumble” | Gradual bilateral; age >60; difficulty with speech discrimination | Normal otoscopy; symmetric SNHL on tuning fork | Audiometry; hearing aid evaluation |
| Noise-induced hearing loss | “Ringing,” “worked around loud machines” | Occupational/recreational noise; bilateral; high-frequency loss; tinnitus | Normal otoscopy; SNHL pattern | Audiometry; hearing protection counseling |
| Otitis media with effusion | “Muffled,” “fullness,” “after a cold” | Post-URI; fullness; no pain | Retracted TM; air-fluid level; decreased mobility | Watchful waiting 3 months; ENT if persistent |
| Otosclerosis | “Gradual,” “family history,” “young adult” | Progressive conductive loss; age 20-40; family history; often bilateral | Normal TM; conductive loss on tuning fork | Audiometry; ENT referral for surgery discussion |
| Eustachian tube dysfunction | “Popping,” “pressure,” “worse with flying” | Fullness; pressure changes; associated allergies | Retracted TM; negative middle ear pressure | Nasal steroids; autoinflation; decongestants |
| Ototoxicity | “Started after new medication” | Temporal relationship to medication; often bilateral; tinnitus | Normal otoscopy; SNHL | Review medications; audiometry; consider stopping offending agent |
Can’t-miss / urgent#
| Diagnosis | Keywords patients use | Key clues | Focused exam clues | Initial next step |
|---|---|---|---|---|
| Sudden sensorineural hearing loss (SSNHL) | “Woke up deaf,” “sudden,” “one ear” | Onset over hours to 3 days; unilateral; ≥30 dB loss over 3 frequencies | Normal otoscopy; SNHL on tuning fork (Weber to good ear) | URGENT: ENT within 24-48h; start steroids; audiometry ASAP |
| Acoustic neuroma (vestibular schwannoma) | “Gradual one ear,” “ringing,” “balance off” | Unilateral SNHL; tinnitus; subtle imbalance; facial numbness | Normal otoscopy; unilateral SNHL; may have subtle CN V/VII findings | MRI IAC with contrast; ENT/neurosurgery referral |
| Cholesteatoma | “Foul drainage,” “recurrent infections” | Chronic drainage; progressive hearing loss; history of perforations | Retraction pocket or pearly mass; foul discharge; conductive loss | ENT referral; CT temporal bone |
| Meniere’s disease | “Attacks of spinning,” “ear fullness,” “roaring” | Episodic vertigo (20 min to hours) + fluctuating hearing loss + tinnitus + aural fullness | May be normal between attacks; low-frequency SNHL | Audiometry; ENT referral; salt restriction |
| Autoimmune inner ear disease | “Both ears getting worse fast” | Bilateral progressive SNHL over weeks to months; may have systemic autoimmune disease | Normal otoscopy; bilateral SNHL | Audiometry; ESR/CRP; ANA; ENT referral; may need steroids |
| Temporal bone fracture | “After head injury” | Trauma; may have hemotympanum, CSF otorrhea, facial weakness | Hemotympanum; Battle sign; facial weakness | ED; CT temporal bone; neurosurgery |
Workup#
Office evaluation:
- Otoscopy: rule out cerumen, perforation, effusion, mass
- Tuning fork tests: Weber and Rinne to differentiate conductive vs sensorineural
- Whisper test: quick screen for significant hearing loss
Audiometry:
- Gold standard for characterizing hearing loss
- Order for: any unexplained hearing loss, suspected SNHL, asymmetric hearing, tinnitus
- Provides: type (conductive, sensorineural, mixed), severity, speech discrimination
When to order MRI (IAC with contrast):
- Asymmetric sensorineural hearing loss (>15 dB difference between ears)
- Unilateral tinnitus
- Suspected acoustic neuroma
- SSNHL (after initial treatment, to rule out retrocochlear pathology)
When to order CT temporal bone:
- Suspected cholesteatoma
- Trauma
- Conductive loss with normal TM (otosclerosis evaluation)
- Pre-operative planning
Labs (limited role):
- SSNHL workup: consider CBC, BMP, glucose, TSH, RPR/FTA-ABS (syphilis), Lyme if endemic
- Autoimmune SNHL: ESR, CRP, ANA, RF
- Not routinely indicated for gradual presbycusis
When NOT to order imaging:
- Bilateral symmetric gradual hearing loss in elderly (presbycusis)
- Clear conductive loss with visible cause (cerumen, OME)
- Noise-induced hearing loss with classic history
Initial management#
Sudden sensorineural hearing loss (SSNHL):
- This is an EMERGENCY—treat within 24-48 hours for best outcomes
- Start high-dose oral steroids immediately (prednisone 60 mg daily or 1 mg/kg)
- Urgent ENT referral for audiometry and consideration of intratympanic steroids
- Do NOT wait for audiometry to start steroids if clinical suspicion high
Cerumen impaction:
- Remove cerumen and reassess hearing
- If hearing normalizes, no further workup needed
Suspected acoustic neuroma:
- MRI IAC with contrast
- ENT/neurosurgery referral
Presbycusis:
- Audiometry to characterize
- Hearing aid evaluation
- Communication strategies
Management by diagnosis#
Cerumen impaction#
Education:
- Earwax is normal and protective; ears are self-cleaning
- Q-tips push wax deeper—avoid putting anything in your ear
- If you make a lot of wax, periodic cleaning may be needed
Treatment:
- Irrigation: Warm water irrigation with bulb syringe or ear irrigation system (contraindicated if perforation, tubes, or prior ear surgery)
- Cerumenolytics: Soften wax before removal
- Carbamide peroxide (Debrox): 5-10 drops, wait 15-30 min, then irrigate
- Mineral oil or olive oil: 2-3 drops BID x 3-5 days before office visit
- Docusate sodium (liquid): 1 mL in ear, wait 15 min
- Manual removal: Curette under direct visualization (requires training and equipment)
Follow-up: None needed if hearing normalizes. If hearing still impaired after cerumen removal, proceed with audiometry.
Sudden sensorineural hearing loss (SSNHL)#
Definition: ≥30 dB hearing loss over at least 3 contiguous frequencies, occurring over ≤72 hours.
Education:
- This is a medical emergency—early treatment improves outcomes
- Cause is often unknown (viral, vascular, autoimmune theories)
- About 1/3 recover spontaneously, 1/3 partially recover, 1/3 have permanent loss
- Steroids are the main treatment; must start within 2 weeks, ideally within 48 hours
Treatment:
| Drug | Dose | Contraindications | Monitoring | Cost | Notes |
|---|---|---|---|---|---|
| Prednisone | 60 mg daily (or 1 mg/kg) x 10-14 days, then taper | Active infection, uncontrolled DM | Glucose, BP | $ | Start immediately; do not wait for audiometry |
| Intratympanic dexamethasone | 10-24 mg/mL injected by ENT | None | None | $$ | ENT performs; for primary treatment or salvage if oral steroids fail |
Steroid taper: After 10-14 days at full dose, taper over 5-7 days (e.g., 40 mg x 3 days, 20 mg x 3 days, 10 mg x 2 days).
Diabetes considerations: Steroids will raise glucose significantly. Options:
- Proceed with oral steroids + intensive glucose monitoring and insulin adjustment
- Use intratympanic steroids as primary treatment (ENT performs; avoids systemic effects)
- Discuss risk/benefit with patient—untreated SSNHL has permanent consequences
Workup: Audiometry ASAP (same day if possible); MRI IAC with contrast (can be done after starting treatment); consider labs (glucose, CBC, RPR).
Follow-up: ENT within 24-48 hours. Repeat audiometry at 2-4 weeks to assess recovery.
Presbycusis (age-related hearing loss)#
Education:
- Gradual hearing loss with age is very common
- Affects ability to understand speech, especially in noisy environments
- Hearing aids can significantly improve quality of life
- Untreated hearing loss is associated with cognitive decline and social isolation
Treatment:
- Hearing aids: First-line treatment; refer to audiology for evaluation and fitting
- OTC hearing aids: FDA-approved for adults with mild-moderate loss; available without prescription at pharmacies and online; good option for cost-conscious patients or those wanting to try amplification before investing in custom aids; limitations include less customization and no professional fitting
- Assistive devices: Amplified phones, TV listening systems, captioning
- Communication strategies: Face the speaker, reduce background noise, ask for repetition
Follow-up: Audiology for hearing aid fitting and follow-up. Annual audiometry to monitor progression.
Noise-induced hearing loss#
Education:
- Damage from loud noise is permanent and cumulative
- Prevention is key—hearing protection is essential
- Tinnitus often accompanies noise-induced loss
- Hearing aids can help if loss is significant
Prevention:
- Hearing protection (earplugs, earmuffs) in loud environments
- Limit exposure time to loud sounds
- Keep personal audio devices at <60% volume
- Occupational hearing conservation programs
Follow-up: Audiometry to document baseline and monitor. Hearing aid evaluation if significant loss.
Otosclerosis#
Recognition: Progressive conductive hearing loss in young adult (20-40), often bilateral, family history common, normal TM, Carhart notch on audiometry.
PCP role:
- Recognize pattern and refer to ENT
- Audiometry to confirm conductive loss
- Discuss options: hearing aids vs surgery (stapedectomy)
Referral: ENT for surgical evaluation. Stapedectomy has >90% success rate for hearing improvement.
Acoustic neuroma (vestibular schwannoma)#
Recognition: Unilateral SNHL (often gradual), unilateral tinnitus, subtle imbalance, facial numbness (late).
PCP role:
- Order MRI IAC with contrast
- Refer to ENT/neurosurgery
Management options (specialist decision): Observation with serial MRI (small tumors), stereotactic radiosurgery, microsurgical resection.
Ototoxicity#
Common ototoxic medications:
- Aminoglycosides (gentamicin, tobramycin): dose-dependent, often irreversible
- Loop diuretics (furosemide): usually reversible; worse with renal impairment
- Cisplatin and carboplatin: dose-dependent, often irreversible
- High-dose aspirin/NSAIDs: usually reversible
- Quinine: usually reversible
Management:
- Review medication list for ototoxic agents
- If possible, discontinue or substitute offending medication
- Audiometry to document loss
- Monitor with serial audiometry if ototoxic medication must continue
- ENT referral if significant or progressive loss
Follow-up#
- SSNHL: ENT within 24-48 hours; repeat audiometry at 2-4 weeks
- Cerumen: None if hearing normalizes; audiometry if still impaired
- Presbycusis: Audiology for hearing aids; annual monitoring
- Asymmetric SNHL: MRI to rule out acoustic neuroma; ENT referral
- OME: 3 months; ENT if persistent with hearing loss
Return precautions (all patients):
- Sudden worsening of hearing
- New dizziness or vertigo
- Facial weakness or numbness
- Severe headache
- Drainage from the ear
Patient instructions#
- If you suddenly lose hearing in one ear, this is an emergency—call your doctor or go to urgent care immediately. Early treatment can save your hearing.
- Protect your hearing: wear earplugs or earmuffs around loud noise (concerts, power tools, firearms).
- Do not put anything in your ears, including Q-tips—this can damage your ear or push wax deeper.
- If you have gradual hearing loss, hearing aids can make a big difference in your quality of life and are worth trying.
- Untreated hearing loss can lead to social isolation and may be linked to memory problems—don’t ignore it.
- Call or return immediately if you have sudden hearing loss, dizziness, facial weakness, or drainage from your ear.
Smartphrase snippets#
Sudden sensorineural hearing loss:
Sudden unilateral hearing loss x [X] days. Otoscopy normal. Weber lateralizes to unaffected ear consistent with SSNHL. Started prednisone 60 mg daily. URGENT ENT referral placed for audiometry and consideration of intratympanic steroids. MRI IAC ordered. Patient counseled on importance of early treatment.
Presbycusis:
Gradual bilateral hearing loss over [X] years, difficulty understanding speech in noise. Otoscopy normal. Tuning fork consistent with bilateral SNHL. Audiometry ordered. Discussed hearing aid options and referred to audiology for evaluation.
Cerumen impaction:
Hearing loss with cerumen impaction. Cerumen removed with [irrigation/curette]. TM visualized and normal. Hearing subjectively improved. Counseled on avoiding Q-tips. No further workup needed.
Asymmetric hearing loss:
Unilateral hearing loss R > L with tinnitus. Otoscopy normal. Audiometry confirms asymmetric SNHL. MRI IAC with contrast ordered to rule out retrocochlear pathology. ENT referral placed.
Coding/billing notes#
- Document onset (sudden vs gradual), laterality, and associated symptoms
- For SSNHL, document timing of symptom onset and treatment initiation
- Document tuning fork findings (Weber, Rinne) and interpretation
- If ordering MRI, document indication (asymmetric loss, unilateral tinnitus, etc.)
- For cerumen removal, document method and post-removal TM appearance