Unilateral hearing loss

Background: Otitis media with effusion is fluid medial to the tympanic membrane.  It is categorised by conductive hearing loss in the affected ear in the absence of pain or discharge.  The condition is far more common in children but can occur in adults.  It may occur after an URTI.  Rare causes of unilateral OME include CSF leak and tumour obstructing the Eustachian tube.

How to assess:

Examine the ear

Perform Freefield hearing test

Management:

If symptoms persist more than 3 weeks then patients should be referred to ENT on a routine basis

Background: Chronic mucosal otitis media is the presence of a tympanic membrane perforation.  The patient may have intermittent discharge (particularly if there is water ingress) without pain or a degree of hearing loss.  It may be an incidental finding on examination.  It may be a consequence of childhood ear problems or previous trauma.  Most patients can be managed conservatively.  The condition is categorised by the following:

• Active – there is active inflammation with pus present
• Inactive – the middle ear is dry and there is no pus present
• Healed – tympanic membrane is now intact likely due to surgery with scarring evident

How to assess:

Examine the ear

Perform Freefield hearing test

How to manage:

Ensure patient keeps their ear dry, advise the use of cotton wool with Vaseline to prevent water ingress when in the bath or shower.

If discharging

Take a swab of any pus if possible

There is NO role for oral antibiotics

Topical antibiotic and steroid drop (ciprofloxacin and dexamethasone)

Referral guidance:

Referral to ENT as routine if no improvement after 2 courses of topical treatment

Referral to ENT as routine if hearing loss and patient would consider intervention to assist hearing loss (hearing aid / surgery).

Note:

Surgery to close the tympanic perforation does not normally result in hearing improvement but can reduce the frequency of ear discharge and can facilitate the patient being able to wear a hearing aid in some cases. 

Of note, if swabs show bacteria resistant to ciprofloxacin, topical gentamicin and prednisolone drops can be used in patients with tympanic membrane perforation if no alternatives exist– treat until otorrhoea stops, then treat for another 2 days, then stop. This minimises the risk of ototoxicity.

Background: Chronic squamous otitis media is the presence of squamous epithelium medial to the tympanic membrane.  The patient may have foul discharge (particularly if there is water ingress) and a degree of hearing loss. There is no pain. If active disease is left untreated there is the potential for significant complications including intracranial sepsis, facial palsy and labyrinthine failure.  Management with surgery and or regular aural care is normally recommended.

The three principal aetiologies are:

1. Tympanic membrane retraction with “trapping” of squamous cells within it – typically in the attic
2. Squamous implantation (iatrogenic) during surgery
3. Congenital – appears as a white “pearl” behind an intact tympanic membrane

Chronic squamous otitis media can be classified as:

               Active – Inflammation around retraction often with foul smelling discharge

Inactive – stable retraction with no discharge.  There may not be any cholesteatoma present/visible.

How to manage:

Ensure patient keeps their ear dry, advise the use of cotton wool with Vaseline to prevent water ingress when in the bath or shower.

Topical steroid and antibiotic drops (ciprofloxacin and dexamethasone) when inflammation / discharge is present

Referral to ENT if no improvement with conservative measures after 2 courses of topical treatment

Referral to ENT if cholesteatoma identified

Cautions:

Complications of cholesteatoma are rare but have high morbidity if they do occur.  If a patient with cholesteatoma develops an ipsilateral facial palsy or evidence of vestibular failure please refer to ENT as an Emergency.

Background: Sudden sensorineural hearing loss is a sudden (occurs over less than 72 hours) loss of hearing in one ear.  This may be associated with unilateral tinnitus.  The aetiology is unknown. Examination of the ear should exclude other causes such as impacted wax or middle ear effusion.  If associated with sudden rotational vertigo then may be due to labyrinthitis however CVA should be considered.

How to assess: Exclude common causes of hearing loss with otoscopy – if another cause is present, please manage as per their individual section

Perform tuning fork tests. (webers with 512Hz tuning fork ideally).

If not available, perform the “hum” test which can be interpreted in the same way as webers test – If the patient hums in a deep voice to themselves, the patient will hear a low pitched “hum” better on the side with a conductive hearing loss, or, will hear the sound better on the contralateral side to a sensorineural hearing loss.

Check cranial nerves – pathology may indicate central compression of the vestibulocochlear nerve

Referral guidance: We would recommend a short course of oral prednisolone (with PPI cover if required) if within 4 weeks of symptom onset

We are aware NICE guidelines recommend same-day referral to ENT for sudden sensorineural hearing loss. This is to allow baseline pure tone audiogram assessment, however, audiology are currently unable to accommodate this testing. Therefore, please referral patients to Audiology on an urgent basis.

Background: Patients can have asymmetrical hearing loss for multiple reasons including childhood infection, surgery and idiopathic causes. The hearing loss may be longstanding.  There may be hearing rehabilitation options for these patients such as:

• Hearing aid to the poorer hearing ear
• Hearing aid to the better hearing ear, if there is hearing loss on that side
• CROS or BiCROS hearing devices (Contralateral Routing Of Sound) - this device utilises a device on both ears to relay sound information from the non-working ear to the contralateral ear
• Bone conduction hearing device – device is surgically implanted onto the non-working side to allow transmission of sound to the contralateral ear

Referral guidance: If no clear cause, refer to Audiology on a routine basis.

Wax management in the absence of chronic ear disease is not managed by secondary care.

Link to NHS inform: Earwax build-up | NHS inform