Immediate, urgent and routine referral

1.

Refer adults with sudden onset or rapid worsening of hearing loss in one or both ears, which is not explained by external or middle ear causes, as follows:

• If the hearing loss developed suddenly (over a period of 3 days or less) within the past 30 days, refer immediately (to be seen within 24 hours) to an ear, nose and throat service or an emergency department.
• If the hearing loss developed suddenly more than 30 days ago, refer urgently (to be seen within 2 weeks) to an ear, nose and throat or audiovestibular medicine service.
• If the hearing loss worsened rapidly (over a period of 4 to 90 days) refer urgently (to be seen within 2 weeks) to an ear, nose and throat or audiovestibular medicine service.

2.

Refer immediately (to be seen within 24 hours) adults with acquired unilateral hearing loss and altered sensation or facial droop on the same side to an ear, nose and throat service or, if stroke is suspected, follow a local stroke referral pathway. For information about diagnosis and initial management of stroke, see the NICE guideline on stroke and transient ischaemic attack in over 16s.

3.

Refer immediately (to be seen within 24 hours) adults with hearing loss who are immunocompromised and have otalgia (ear ache) with otorrhoea (discharge from the ear) that has not responded to treatment within 72 hours to an ear, nose and throat service.

4.

Consider making an urgent referral (to be seen within 2 weeks) to an ear, nose and throat service for adults of Chinese or south-east Asian family origin who have hearing loss and a middle ear effusion not associated with an upper respiratory tract infection. For information about recognition and referral for suspected cancer, see the NICE guideline on suspected cancer.

5.

Consider referring adults with hearing loss that is not explained by acute external or middle ear causes to an ear, nose and throat, audiovestibular medicine or specialist audiology service for diagnostic investigation, using a local pathway, if they present any of the following:

• unilateral or asymmetric hearing loss as a primary concern
• hearing loss that fluctuates and is not associated with an upper respiratory tract infection
• hyperacusis (intolerance to everyday sounds that causes significant distress and affects a person’s day-to-day activities)
• persistent tinnitus that is unilateral, pulsatile, has significantly changed in nature or is causing distress
• vertigo that has not fully resolved or is recurrent
• hearing loss that is not age related

6.

Consider referring adults with hearing loss to an ear, nose and throat service if, after initial treatment of any earwax (see recommendations 15-19 on removing earwax) or acute infection, they have any of:

• partial or complete obstruction of the external auditory canal that prevents full examination of the eardrum or taking an aural impression
• pain affecting either ear (including in and around the ear) that has lasted for 1 week or more and has not responded to first-line treatment
• a history of discharge (other than wax) from either ear that has not resolved, has not responded to prescribed treatment or recurs
• abnormal appearance of the outer ear or the eardrum, such as:

  1. inflammation
  2. polyp formation
  3. perforated eardrum
  4. abnormal bony or skin growths
  5. swelling of the outer ear
  6. blood in the ear canal.
• a middle ear effusion in the absence of, or that persists after, an acute upper respiratory tract infection.

MRI

7.

Offer MRI of the internal auditory meati to adults with hearing loss and localising symptoms or signs (such as facial nerve weakness) that might indicate a vestibular schwannoma or CPA (cerebellopontine angle) lesion, irrespective of pure tone thresholds.

8.

Consider MRI of the internal auditory meati for adults with sensorineural hearing loss and no localising signs if there is an asymmetry on pure tone audiometry of 15 dB or more at any 2 adjacent test frequencies, using test frequencies of 0.5, 1, 2, 4 and 8 kHz.

Subgroups

9.

Consider referring adults with diagnosed or suspected dementia or mild cognitive impairment to an audiology service for a hearing assessment, because hearing loss may be a comorbid condition.

10.

Consider referring adults with diagnosed dementia or mild cognitive impairment to an audiology service for a hearing assessment every 2 years if they have not previously been diagnosed with hearing loss.

11.

Consider referring people with a diagnosed learning disability to an audiology service for a hearing assessment when they transfer from child to adult services, and then every 2 years.

Early versus delayed management of hearing loss

12.

For adults who present for the first time with hearing difficulties, or in whom you suspect hearing difficulties:

• exclude impacted wax and acute infections such as otitis externa, then
• arrange an audiological assessment (for more information on audiological assessment see recommendation 13) and
• refer for additional diagnostic assessment if needed (see recommendations 1-6 on sudden or rapid onset of hearing loss and hearing loss with specific additional symptoms or signs).

Communications difficulties and limitations in function

13.

Include and record the following as part of the audiological assessment for adults:

• a full history including relevant symptoms, comorbidities, cognitive ability, physical mobility and dexterity
• the person’s hearing and communication needs at home, at work or in education, and in social situations
• any psychosocial difficulties related to hearing
• the person’s expectations and motivations with respect to their hearing loss and the listening and communication strategies available to them
• any restrictions on activity, assessed using a self-report instrument such as the Glasgow Hearing Aid Benefit Profile or the Client-Orientated Scale of Improvement
• otoscopy
• pure tone audiometry
• tympanometry if indicated.

14.

After the audiological assessment:

• discuss with the person:

  1. the pure tone audiogram and the impact their hearing loss might have on communication
  2. hearing deficits (such as listening in noisy environments) that are not obvious from the audiogram
  3. options for managing their hearing needs, such as acoustic or bone conduction hearing aids, assistive listening devices and communication strategies, and the potential benefits and limitations of each option.
  4. options for managing single-sided deafness if needed
  5. referral for implantable devices such as cochlear implants, bone-anchored hearing aids, middle-ear implants or auditory brain stem implants, if these might be suitable (see NICE’s technology appraisal guidance on cochlear implants for children and adults with severe to profound deafness and interventional procedure guidance on auditory brain stem implants)
  6. referral for medical or surgical treatments, if these might be suitable
• agree and record a personalised care plan, taking into account the person’s preferences, including goals, and give the person a copy.

Management of earwax

15.

Offer to remove earwax for adults in primary care or community ear care services if the earwax is contributing to hearing loss or other symptoms, or needs to be removed in order to examine the ear or take an impression of the ear canal.

16.

When carrying out ear irrigation in adults:

• use pre-treatment wax softeners, either immediately before ear irrigation or for up to 5 days beforehand
• if irrigation is unsuccessful:

  1. repeat use of wax softeners or
  2. instil water into the ear canal 15 minutes before repeating ear irrigation
• if irrigation is unsuccessful after the second attempt, refer the person to a specialist ear care service or an ear, nose and throat service for removal of earwax.

17.

Consider ear irrigation using an electronic irrigator, microsuction or another method of earwax removal (such as manual removal using a probe) for adults in primary or community ear care services if:

• the practitioner (such as a community nurse or audiologist):

  1. has training and expertise in using the method to remove earwax
  2. is aware of any contraindications to the method
• the correct equipment is available.

18.

Do not offer adults manual ear syringing to remove earwax.

19.

Advise adults not to remove earwax or clean their ears by inserting small objects, such as cotton buds, into the ear canal. Explain that this could damage the ear canal and eardrum, and push the wax further down into the ear.

Sudden sensorineural hearing loss

20.

Consider a steroid to treat idiopathic sudden sensorineural hearing loss in adults.

Information and support

21.

Give the person and, if they wish, their family or carers, information about:

• the causes of hearing loss, how hearing loss affects the ability to communicate and hear, and how it can be managed
• organisations and support groups for people with hearing loss.

22.

Follow the principles on tailoring healthcare services for each person and enabling people to actively participate in their care in the NICE guideline on patient experience in adult NHS services by, for example:

• taking into account the person’s ability to access services and their personal preferences when offering appointments
• taking measures, such as reducing background noise, to ensure that the clinical and care environment is conducive to communication for people with hearing loss, particularly in group settings such as waiting rooms, clinics and care homes
• establishing the most effective way of communicating with each person, including the use of hearing loop systems and other assistive listening devices
• ensuring that staff are trained and have demonstrated competence in communication skills for people with hearing loss
• encouraging people with hearing loss to give feedback about the health and social care services they receive, and responding to their feedback.

Assistive listening devices

23.

Give adults with hearing loss information about assistive listening devices such as personal loops, personal communicators, TV amplifiers, telephone devices, smoke alarms, doorbell sensors, and technologies such as streamers and apps.

24.

Tell adults with hearing loss about organisations that can demonstrate and provide advice on how to obtain assistive listening devices, such as social services, the fire service, or the government through programmes such as Access to Work or Disabled Student Allowance.

Hearing aids

25.

Offer hearing aids to adults whose hearing loss affects their ability to communicate and hear, including awareness of warning sounds and the environment, and appreciation of music.

26.

Offer 2 hearing aids to adults with aidable hearing loss in both ears. Explain that wearing 2 hearing aids can help to make speech easier to understand when there is background noise, make it easier to tell where sounds are coming from, and improve sound quality.

27.

For adults with hearing loss in both ears who chose a single hearing aid, consider a second hearing aid at the follow-up appointment.

Hearing aid microphone and noise reduction algorithms

28.

When prescribing and fitting hearing aids, explain the features on the hearing aid that can help the person to hear in background noise, such as directional microphone and noise reduction settings.

29.

Advise adults with hearing aids about choosing microphone and noise reduction settings that will meet their needs in different environments, and ensure that they know how to use them.

Monitoring and follow-up

30.

Offer adults with hearing aids a face-to-face follow-up audiology appointment 6 to 12 weeks after the hearing aids are fitted, with the option to attend this appointment by telephone or electronic communication if the person prefers.

31.

For adults with hearing loss who have chosen a management strategy other than hearing aids, such as assistive listening devices or communication strategies, offer a follow-up appointment when the effectiveness of the device or strategy can be evaluated.

32.

Tell adults with hearing loss who have chosen not to have a hearing aid or other device how to contact audiology services in the future.

33.

Consider having a system in place for recalling people with hearing devices for regular reassessment of hearing needs and devices.

Interventions to support the use of hearing aids

34.

Consider using motivational interviewing or engagement strategies and goal setting when discussing hearing aids with adults for the first time, to encourage acceptance and use of hearing aids.

35.

Show the hearing aids when they are first offered and discuss their suitability with the person.

36.

At the follow-up audiology appointment for adults with hearing aids:

• ask the person if they have any concerns or questions
• address any difficulties with inserting, removing or maintaining their hearing aids
• provide information on communication, social care or rehabilitation support services if needed
• tell the person how to contact audiology services in the future for aftercare, including repairs and adjustments to accommodate changes in their hearing
• ensure that the person’s hearing aids and other devices meet their needs by checking:

  1. the comfort, sound quality and volume of hearing aids, including microphone and noise reduction settings, and fine-tuning them if needed
  2. hearing aid cleaning, battery life and use with a telephone
  3. use of assistive listening devices
  4. hours the hearing aid has been used, if shown by automatic data-logging
• review the goals identified in the personalised care plan and agree how to address any that have not been met (for information on the personalised care plan see recommendation 14).
• update the personalised care plan and provide them with a copy.

37.

Give adults with hearing aids information about getting used to hearing aids, cleaning and caring for their hearing aids, and troubleshooting.

Key research recommendations

1. In adults with hearing loss, does the use of hearing aids reduce the incidence of dementia?
2. What is the prevalence of hearing loss among populations who under-present for possible hearing loss?
3. What is the clinical and cost effectiveness of microsuction compared with irrigation to remove earwax?
4. What is the most effective route of administration of steroids as a first-line treatment for idiopathic sudden sensorineural hearing loss?
5. What is the clinical and cost effectiveness of monitoring and follow-up for adults with hearing loss post-intervention compared with usual care?

For the full list of research recommendations please see appendix Q.