REMEDY : BNSSG referral pathways

Hearing problems

Checked: 17-04-2018 by hana.cavill Next Review: 16-04-2019

Assessment of Hearing Loss

Basic assessment of hearing loss in primary care can help establish the correct referral pathway.

Advice on hearing tests including Rinne's and Webber's tests can be found in this hearing loss guide.

In acute hearing loss these tests can help distinguish between conductive hearing loss (which is less urgent) and sensorineural hearing loss (which indicates urgent referral - see Red Flags below).

Please see sections below for advice on management of hearing loss in patients with chronic tympanic membrane perforation, eustachian tube dysfunction and otitis media with effusion.

Referral Guidance

For patients 15 and under audiology referrals should be sent directly to Children's hearing centre at UHB (Fax no. 342 5615 and Tel no. 342 1611).

For information on making an audiology referral for adults (age 16 and over) please see the Audiology section

For adults of any age who require a hearing aid replacement due to a lost, broken/faulty hearing aid, a new audiology referral is not required. Instead, the patient should contact the provider of the original hearing aid. The provider should repair or replace any faulty aids and arrange replacement of lost hearing aids (CCG will fund this up to one lost hearing aid pair per year – more than this, the patient must self-fund).

Please note that the referral must state that ears have been checked and cleared for wax otherwise it may be returned.

If wax is obstructing the ear canal then please do not refer until it has been cleared. Please note that referrals for removal of wax in secondary care requires prior approval.

Red Flags

Acute sensorineural hearing loss requires urgent assessment. If this is suspected then discuss with the on call ENT team who can arrange assessment in their HOT clinic. Sometimes high dose steroids are also advised in these cases.

Indications for 2WW referral include:

  • Unexplained unilateral serous otitis media/ effusion in a patient aged over 18.

  • Referred otalgia as a symptom of laryngeal or pharyngeal malignancy.

Chronic Tympanic Membrane Perforation

The evidence on hearing loss and tympanic membrane perforations appears to be rather sparse. Expert opinion is that surgery for perforation is not indicated for hearing loss but only for recurrent infections. We have discussed this with Graham Porter one of the ENT consultants and his advice is below:

'Hearing loss alone is not a good indication for myringoplasty. It can improve hearing but the most likely outcome is unchanged hearing and there is a small risk (c. 1%) of further hearing loss due to surgery including dead ear. If dead ear occurs there is also usually severe vertigo which delays recovery significantly.

The primary indication for myringoplasty is recurrent infection/discharge with a secondary indication of drum closure to allow occupations/pastimes that allow water in the ear. Some professions particularly the military will not consider applicants if they have a perforation so this is another indication.'

Referrals for repair of tympanic membrane perforation may be triaged by Bristol Referral Service and returned with this advice.

Eustachian Tube Dysfunction

Eustachian tube dysfunction can be difficult to treat, even in ENT. When the symptoms are bilateral, a malignant cause is very unlikely, so it is reasonable to persist for a while more with treatment in primary care. The ENT GPSIs advise the following:

Give the patient the leaflet on ETD.  This explains about the Valsalva manoeuvre which can help open the Eustachian tube. Some people try an otovent balloon to help with this.  Especially if the patient has significant nasal congestion it is worth maximising their rhinitis treatment, using nasal spray initially, and stepping up to nasal drops if necessary. There are some helpful leaflets on patient.co.uk to ensure patients use the correct technique.

Occasionally people do need referral, and have grommets, but this is a last resort.  Referrals for grommets needs prior approval which requires hearing loss to be confirmed by audiology.

Otitis Media with Effusion

Referral for adult patients with OME to consider myringotomy or grommets requires prior approval unless the following criteria apply:

Assessment to exclude underlying malignancy (2WW referral appropriate)

Acute or chronic otitis media with complications: facial palsy or intracranial infection eg meningitis

Eustachian tube dysfunction that prevents the commencement or completion of hyperbaric oxygen treatment.