Hearing loss — Frequently asked questions (FAQ)
1) What does this algorithm cover?
This algorithm guides the structured assessment of patients with hearing loss, from history taking and identification of red flags to otoscopic examination and interpretation of tuning fork tests (Rinne and Weber). It helps distinguish conductive hearing loss from sensorineural hearing loss, define the need for audiometry and guide referral, including urgent situations such as sudden sensorineural hearing loss (SSNHL).
2) What are the main causes of hearing loss?
Causes may be conductive — for example impacted cerumen, otitis media, otitis media with effusion, tympanic membrane perforation or otosclerosis — or sensorineural, such as presbycusis, chronic noise exposure, ototoxicity, SSNHL or retrocochlear causes. The algorithm helps prioritise likely aetiologies according to examination findings and the temporal pattern.
3) What initial assessment should I perform?
Assessment should include the mode of onset — sudden ≤72 h versus progressive — unilateral involvement, associated symptoms such as tinnitus, aural fullness, vertigo, otalgia or otorrhea, exposure to noise and ototoxic drugs, as well as trauma and comorbidities. Examination should include otoscopy, a brief neurological assessment and, when available, tuning fork tests (Rinne/Weber).
4) Which red flags require urgent referral?
Urgent referral is required in the presence of acute neurological deficits — suspected stroke — recent head trauma, clinical instability and sudden unilateral hearing loss with no obvious cause on otoscopy, suggesting possible SSNHL. The presence of ataxia, diplopia, dysarthria or other focal neurological signs requires assessment in an emergency setting.
5) What does a negative Rinne test mean?
A negative Rinne means that bone conduction is greater than air conduction in that ear, suggesting conductive hearing loss. This may occur due to disease of the external ear, such as cerumen or oedema, or the middle ear, such as otitis media, effusion or perforation. Even with normal otoscopy, it may indicate conditions such as otosclerosis or ossicular abnormalities.
6) If Rinne is positive bilaterally, why is Weber needed?
Bilateral positive Rinne excludes significant conductive hearing loss, but may be seen in normal hearing or in sensorineural hearing loss. The Weber test assesses lateralisation and helps identify unilateral sensorineural hearing loss, where the affected side is the opposite of the lateralisation. If Weber is central, this suggests normal hearing or symmetrical bilateral hearing loss.
7) Is Weber mandatory when Rinne is negative?
When there is a unilateral negative Rinne, a conductive hearing loss in that ear has already been identified, and Weber is not strictly necessary for the main decision. However, it may be useful to confirm lateralisation and to suspect mixed hearing loss or technical error, particularly if the result is discordant with the clinical picture.
8) What is SSNHL and why is it an emergency?
SSNHL stands for sudden sensorineural hearing loss, typically unilateral, developing within ≤72 hours and associated with normal otoscopy. It is an otological emergency because there is a short therapeutic window, making urgent ENT assessment and early audiometry essential. Treatment is based on early corticosteroid therapy, ideally started within the first 72 hours, according to the local pathway.
9) When should audiometry be requested?
Audiometry is indicated to confirm and quantify hearing loss, characterise the pattern — conductive versus sensorineural — and guide referral. It should be urgent when SSNHL is suspected. In other situations, it may be scheduled, particularly in progressive or unilateral hearing loss, or when there is functional impact.
10) When should the patient be referred to Otolaryngology?
Urgent ENT referral should be considered when SSNHL is suspected and whenever serious pathology is suspected. Planned referral is appropriate for persistent or recurrent conductive hearing loss, including otosclerosis, for progressive sensorineural hearing loss and when hearing rehabilitation may be required. Unilateral or asymmetric sensorineural hearing loss may warrant investigation for retrocochlear causes in specialist care.
