Hearing loss- NICE guidance

An easy to follow visual of the latest NICE guideline NG 98 on hearing loss.

Hearing difficulties or suspected hearing 
difficulties-Adults presenting for first time or you suspect hearing difficulty-Exclude impacted wax and acute infections such as otitis externa-Refer audiology or additional diagnostic test if needed

Sudden or rapid onset of
 hearing loss-Sudden onset of rapid worsening of hearing loss in one or both ears which is not explained by external or middle ear causes-If developed suddenly – 

(over a period of 3 days or less ) refer immediately – to be seen

 within 24 hrs to

○ ENT or
○ Emergency department-If the hearing loss developed suddenly -refer to be seen within 2 weeks to
○ ENT or
○ Audiovestibular medicine service-If the hearing loss worsened rapidly ( over a period of 4-90 days ) refer urgently

-to be seen within 2 weeks to

○ Audiovestibular medicine services

Hearing loss with specific additional symptoms or signs-Acquired unilateral hearing loss and altered sensation or facial drop on the same side to
○ ENT or
○ If stroke suspected – follow local stroke pathway
 Hearing loss in people who are Immunocompromised and have otalgia ( ear ache ) with otorrhoea ( discharge from ear ) that has not responded to treatment within 72 hrs to

○ ENT-Consider urgent ENT referral for adults of Chinese or South-East Asian family origin who have hearing loss and a middle ear effusion NOT associated with an URTI-Adults with hearing loss not explained by acute external or middle ear causes to 
ENT / Audiovestibular medicine / Specialists audiology services for 
Diagnostic investigations
 if they present with any of the following

-Unilateral or asymmetric hearing loss as a primary concern
 Hearing loss that fluctuates and is not associated with an URTI
 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

After initial assessment of any ear wax or acute 
infection- they have any of-Partial or complete obstruction of the external auditory canal that prevents full examination of the ear drum 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 h/o discharge ( not wax ) from either ear that has not resolved , has not responded to treatment or recurs
 Abnormal appearance of the outer ear or the eardrum such as
○ inflammation
○ polyp formation
○ perforated ear drum
○ abnormal bony or skin growths
○ swelling of the outer ear
○ blood in the ear canal
 A middle ear effusion in the absence of , or that persists after an acute URTI

Adults with suspected or 
diagnosed dementia , mild 
cognitive impairment or a 
learning disability-Consider referring
○ diagnosed or suspected dementia
○ mild cognitive impairment
 Consider referring adults with 
○ diagnosed dementia OR
○ mild cognitive impairment
 Consider referring people with
learning disability when they 
transfer from child to adult 
services and then

 Hearing loss in adults : assessment and management NICE guideline NG 98 June 2018 NICE Pathways – Haring loss overview