Executive summary
- Split the problem fast: acute vs gradual; unilateral/asymmetric vs bilateral; conductive vs sensorineural clues; associated red flags.
- Do the basics well: history + otoscopy + simple bedside checks (tuning fork if available) and address reversible causes (wax, acute otitis).
- Do not miss emergencies: sudden hearing loss (especially sensorineural), focal neurology, severe otalgia/otorrhoea in immunocompromised, suspected malignant otitis externa, or suspected stroke.
- Unilateral/asymmetric hearing loss often needs onward investigation (local ENT/audiovestibular pathway; consider imaging triggers per local audiology/ENT guidance).
- Earwax: NICE discourages manual syringing; consider irrigation with appropriate kit/training, microsuction, or referral if unsuccessful/contraindicated.
- Hearing aids + support are effective; encourage early audiology involvement when hearing loss affects communication and safety.
Primary care assessment (what to document)
- Time course: sudden (hours–days), subacute (days–weeks), gradual (months–years); fluctuating vs progressive.
- Laterality: unilateral/asymmetric is a referral trigger more often than bilateral age-related loss.
- Associated symptoms: tinnitus (unilateral/pulsatile/distressing), vertigo, otalgia/otorrhoea, aural fullness, recent URTI, facial weakness/numbness, headache, trauma, noise exposure.
- Risk factors: immunosuppression/diabetes (otitis externa complications), ototoxic drugs, autoimmune disease, prior ear surgery, cholesteatoma history.
- Examination: otoscopy (wax, infection, perforation, effusion, inflammation, polyp/granulation), cranial nerves (esp VII), cerebellar signs if dizzy/unsteady.
- Bedside differentiation: if you have a tuning fork, use Weber/Rinne to help frame conductive vs sensorineural patterns (don’t over-trust it — use it to guide urgency and pathway).
Earwax and common reversible causes (practical workflow)
- Wax softening: short course of olive oil/sodium bicarbonate drops can be helpful before removal attempts (local protocols vary).
- Removal options: irrigation with electronic irrigator (where trained/equipped), microsuction, or manual removal by a trained practitioner.
- Avoid/contraindications (typical): current otitis externa, perforation or grommets, prior ear surgery with uncertain anatomy, single hearing ear, or inability to cooperate — consider microsuction/referral.
- If you cannot fully visualise the tympanic membrane after initial measures, or there is persistent pain/discharge/abnormal otoscopy, follow local ENT/community ear-care pathway.
- Acute otitis media/externa can cause transient conductive loss; treat appropriately and re-check hearing once acute symptoms settle.
When to refer (high-yield “don’t miss” list)
- Same day / urgent (local pathway): sudden hearing loss (especially with tinnitus/vertigo), suspected stroke, or new focal neurology (e.g., facial droop).
- Urgent ENT (esp immunocompromised): otalgia + otorrhoea not improving within ~72h, concern for complications, or severe pain with granulation tissue (possible malignant otitis externa).
- ENT/audiovestibular/specialist audiology: unilateral/asymmetric hearing loss, fluctuating loss (not simply URTI), persistent unilateral/pulsatile/distressing tinnitus, recurrent/persistent vertigo, non–age-related patterns.
- Consider suspected cancer pathway where appropriate (e.g., persistent middle ear effusion without URTI in higher-risk groups per NICE/local policy).
- Safety-net: advise urgent reassessment if rapid deterioration, new neuro symptoms, severe pain, fever/systemic features, or new otorrhoea.
Frequently asked questions
What is the single most important urgent presentation to recognise?
Sudden hearing loss (particularly sudden sensorineural hearing loss). Treat it as time-critical: same-day/urgent ENT pathway (local policy) and avoid delays from “watch and wait”.
If the ear canal is full of wax, do I still need to think about red flags?
Yes. Wax can be a red herring. If the story suggests sudden loss, unilateral neuro symptoms, severe pain/discharge in immunocompromised, or significant vestibular/neuro features, escalate per pathway.
Should I routinely request MRI for unilateral hearing loss?
Imaging decisions are usually triggered by audiology/ENT criteria (e.g., degree of asymmetry, localising symptoms). Refer into the local pathway rather than ordering ad hoc unless your service explicitly supports it.
How soon should hearing aids be considered?
Early — once hearing loss affects communication, safety, or quality of life. Audiology referral is often appropriate even before ENT, depending on your local pathway and otoscopy findings.
What should I tell patients about ear cleaning?
Avoid inserting objects (e.g., cotton buds) as they can cause trauma and push wax deeper. Use drops short-term and seek safe removal if symptomatic.
Transparency
This page is an educational, clinician-written summary of publicly available NICE guidance intended for trained healthcare professionals. It uses original wording (not copied text) and should be used alongside the full NICE source, local pathways, and clinical judgement. Doses provided are for general reference; always check the BNF/SPC.