Approach to hearing loss
- Approach to a complaint
Decide whether hearing loss is conductive or sensorineural and whether it is sudden: sudden sensorineural loss is an emergency.
What it is
Hearing loss is sorted with three questions: is it conductive (outer or middle ear), sensorineural (cochlea, nerve or central pathway) or mixed? Is it sudden, progressive or fluctuating? Is it symmetric or one-sided? Otoscopy, Weber and Rinne answer most of this in clinic, and pure-tone audiometry confirms it. Two situations cannot wait: sudden sensorineural hearing loss, which is treated as an emergency, and unilateral or asymmetric sensorineural loss, which requires a vestibular schwannoma to be ruled out. This page is the approach; each disease has its own page.
Key questions in the history
- Since when and how fast? Hours to 3 days (sudden), weeks (rapidly progressive) or years (chronic).
- One ear or both? Does it fluctuate?
- Tinnitus, vertigo, aural fullness, earache or discharge?
- Occupational or recreational noise? Head injury or barotrauma?
- Ototoxic drugs (aminoglycosides, cisplatin, loop diuretics, salicylates)? Family history?
- Neurological symptoms or facial palsy?
Causes and classification
- Conductive (outer or middle ear): wax, foreign body, otitis externa, otitis media with effusion, eardrum perforation, chronic otitis media, cholesteatoma and otosclerosis.
- Sensorineural (cochlea, nerve or central pathway): presbycusis, noise, ototoxic drugs, Ménière disease, infections, genetic causes and vestibular schwannoma.
- Mixed: both together, for example chronic otitis media with cochlear damage.
- By time course: sudden (72 hours or less), rapidly progressive, chronic progressive or fluctuating (Ménière).
- By side: bilateral symmetric (age, noise, ototoxic drugs) versus unilateral or asymmetric, which is always investigated.
Step-by-step approach
- Pin down the onset: if it is sudden and sensorineural, treat it as an emergency.
- Do otoscopy: wax, otitis externa, effusion, perforation or a retraction pocket explain most conductive causes.
- Use Weber and Rinne with a 512 Hz tuning fork to separate conductive from sensorineural loss.
- Order pure-tone audiometry with air and bone conduction; add speech audiometry and tympanometry as needed.
- Look for associated symptoms: vertigo, one-sided tinnitus, fullness, discharge, facial palsy or neurological signs.
- Review ototoxic drugs and noise exposure.
- If sensorineural loss is unilateral or asymmetric, order MRI of the internal auditory canals.
Differential diagnosis by pattern
| Cause | Type and side | Key clue |
|---|---|---|
| Impacted wax | Conductive, one or both ears | Wax blocking the canal on otoscopy |
| Otitis media with effusion | Conductive | Dull eardrum or fluid level; common in children |
| Otosclerosis | Conductive, often bilateral | Young adult, normal eardrum, family history |
| Chronic otitis media or cholesteatoma | Conductive or mixed | Perforation, discharge, retraction pocket |
| Presbycusis | Bilateral symmetric sensorineural | Older adult; high tones; worse understanding in noise |
| Noise-induced hearing loss | Bilateral sensorineural | Noise exposure; deepest dip at 4000 Hz |
| Vestibular schwannoma | Progressive unilateral sensorineural | One-sided tinnitus and unsteadiness |
| Idiopathic sudden hearing loss | Sudden unilateral sensorineural | Loss of at least 30 dB over three adjacent frequencies within 72 hours |
Red flags
- Sudden hearing loss, especially sensorineural.
- Unilateral or asymmetric hearing loss, or one-sided tinnitus.
- Hearing loss with vertigo, headache, facial palsy or other neurological deficits.
- Persistent foul-smelling discharge with hearing loss (cholesteatoma).
- Hearing loss after head injury or barotrauma.
- A child with delayed speech or parents who suspect hearing loss.
Next step / Initial management
- First workup: otoscopy, Weber, Rinne and pure-tone audiometry; tympanometry if effusion is suspected.
- Sudden sensorineural loss: urgent same-day ENT referral; standard treatment is an oral or intratympanic corticosteroid, the earlier the better.
- Unilateral or asymmetric sensorineural loss: MRI and soon (priority) referral to ENT.
- Simple conductive causes: remove wax or treat otitis externa; routine referral for perforation, cholesteatoma or conductive loss with a normal eardrum.
- Occupational noise: in Colombia the GATI-HNIR guideline sets 85 dBA as the permissible limit and asks for surveillance audiometry in exposed workers.
- Permanent hearing loss: refer to audiology for hearing aids, a cochlear implant or other aids according to the degree.
Test yourself
Think of the answer, then tap the question to see it.
A 45-year-old woman woke with right-sided hearing loss one day ago. Weber lateralises to the left and Rinne is positive on both sides. What do you do?
Sudden right sensorineural hearing loss: urgent audiometry, a corticosteroid without delay and same-day ENT referral; then MRI to rule out a schwannoma.
What Weber and Rinne results do you expect with conductive hearing loss in the left ear?
Weber lateralises to the left ear and Rinne is negative on that side: bone conduction beats air conduction.
A 55-year-old man has progressive sensorineural hearing loss in the right ear only, with tinnitus on that side. Which test do you order?
MRI of the internal auditory canals to rule out a vestibular schwannoma.
At which frequencies is the typical audiometric dip of noise-induced hearing loss?
Between 3000 and 6000 Hz, usually deepest at 4000 Hz.
Connections
Educational content; it does not replace a medical assessment and is not a clinical instruction. For a real case, follow current guidelines and specialist advice.
Sources: Sensorineural Hearing Loss (StatPearls Publishing (NCBI Bookshelf), 2023); Conductive Hearing Loss (StatPearls Publishing (NCBI Bookshelf), 2023); Audiogram Interpretation (StatPearls Publishing (NCBI Bookshelf), 2026); Sudden Deafness (National Institute on Deafness and Other Communication Disorders (NIDCD), 2018); Vestibular Schwannoma (Acoustic Neuroma) and Neurofibromatosis (National Institute on Deafness and Other Communication Disorders (NIDCD), 2017); Guía de Atención Integral Basada en la Evidencia para Hipoacusia Neurosensorial Inducida por Ruido en el Lugar de Trabajo (GATI-HNIR) (Ministerio de la Protección Social, República de Colombia, 2006); Deafness and hearing loss (fact sheet) (World Health Organization, 2026).
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Representative model, for educational purposes only.