Deafness and hearing loss toolkit

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Date: Friday, 19 April 2024, 3:51 AM


Guidance for GPs on the care of patients dealing with deafness and hearing loss.


There are 12 million people with hearing loss across the UK and this is expected to increase to 14.2 million by 2035. Hearing impairment can have a major impact on daily functioning and quality of life. It can affect communication, social interactions and work leading to loneliness, emotional distress and depression. The toolkit supports GPs and GP trainees to implement the latest NICE guidelines and NHS Accessibility Quality Standard and guidance across the UK. The resources developed aim to educate GPs and trainees on Deafness and hearing loss, help reduce variations in accessibility to GP practices and ensure Deafness and hearing loss are considered across all aspects of primary care activity including consultations and continued care.

The RCGP Deafness and hearing loss project team, led by Dr Devina Maru, RCGP Clinical Champion for Deafness and hearing loss, collaborated with The Royal National Institute for Deaf People (RNID) and NHS England and Improvement in developing the toolkit. This project was funded, thanks to an external educational grant from the British Irish Hearing Manufacturers Association (BIHIMA) in accordance with the RCGP’s sponsorship policy.

Resources include an Essential Knowledge Update (EKU) Screencast, GPVTS Teaching Powerpoint, Podcasts, EKU Online eLearning Module, RCGP Accredited Deaf Awareness Online Course, Hearing Friendly Practice Animation Video and much more.

Overview and facts


These are generally accepted definitions for a person’s hearing loss but please note definitions are not always clear cut.

Regardless of how they identify, individuals may use a combination sign language, speech, hearing aids, cochlear implants, lip reading (synonymously used with speech reading) etc. to communicate effectively. Also, they may or may not use their voice.

  • deaf (lower case ‘d’) - people who have hearing loss, whether at birth or acquired later through injury, disease or associated with ageing. They may communicate orally and may also be users of sign language.
  • Deaf (upper case ‘D’) - deaf individuals who identify as being part of the Deaf community and who communicate almost exclusively with sign language.
  • Hard of hearing - people who have lost some but not all hearing.
  • Hearing impaired - anyone with any level of hearing loss.
  • Acquired hearing loss - people who were born with hearing but have lost some or all of their hearing.
  • Congenital hearing loss - born with hearing loss which may become progressively worse.
  • Deafened - people who were born with hearing and have lost most or all of their hearing later in life.


Facts and figures

  • Globally, over 80% of ear and hearing care needs remain unmet. Over 5% of the world’s population (430 million people) require rehabilitation to address their disabling hearing loss.
  • 12 million adults in the UK are deaf, have hearing loss or tinnitus. That is roughly 10.1 million people in England, 1 million people in Scotland, 610,000 people in Wales and 320,000 people in Northern Ireland.
  • By 2035, we estimate there’ll be around 14.2 million adults with hearing loss greater than 25 dB HL across the UK.
  • 6.7 million could benefit from hearing aids but only about two million people use them.
  • Unassisted hearing loss have a significant impact on older people leading to social isolation, depression, reduced quality of life and loss of independence and mobility.
  • About 12,000 people in the UK use cochlear implants.
  • Many people with hearing loss also have tinnitus which affects one in 10 adults. They may also have balance difficulties.
  • Evidence suggests that people wait on average 10 years before seeking help for their hearing loss.
  • The employment rate for those with hearing loss is 65%, compared to 79% of people with no long-term health issue or disability.
  • Recent estimates suggest that the UK economy loses £25 billion a year in lost productivity and unemployment due to hearing loss.



There are legal requirements around disability rights and access.

Accessible Information Standard (AIS)

From August 2016, all NHS care or other publicly funded adult social care providers must meet the terms of the Accessible Information Standard (section 250 of the Health and Social Care Act 2012).

This legislation is designed to ensure that people with disabilities, impairments or sensory loss can get information in a form they can access and understand and are provided by health and social care providers with the professional communication support services they require.

During CQC inspections, five steps of Accessible Information Standard will be looked at by talking to the staff and people using the service and asking providers how they are meeting the AIS through annual provider information requests/collections:

  • Identify
  • Record
  • Flag
  • Share
  • Meet

Equality Act 2010

Equality Act 2010 (applies in England, Wales, Scotland) combined and replaced previous discrimination legislation, including the Disability Discrimination Act 1995. The Disability Discrimination Act 1995 still remains in Northern Ireland. It offers protection against discrimination to those with protected characteristics. These include age, disability, gender reassignment, race, religion or belief, sex, sexual orientation, marriage and civil partnership, and pregnancy and maternity.

Deafness and Hearing Loss is a disability. To ensure disabled people can use services to a similar standard (as much as possible) as their non-disabled counterparts, service providers are required to make reasonable adjustments.

Recognition of British Sign Language (BSL)

The British Government on 18 March 2003 made a formal statement recognising BSL as a language in its own right.

The British Sign Language (Scotland) Act 2015 acted to promote the use of BSL and making provision for the preparation and publication of a British Sign Language National Plan for Scotland.

The UN Convention on the Rights of People with Disabilities (121 KB PDF) includes specific mention of rights to sign language use.


  • Access All Areas Report [PDF] - report into the experiences of people with hearing loss when accessing healthcare including contacting their GP surgery, consultations with medical staff and access to pharmacies.
  • Hearing Matters Report [PDF] - report analysing the scale and impact of hearing loss in the UK and sets out what needs to be done by Government in tackling hearing loss.
  • Sick of It Report - how the health service is failing Deaf people and suggestions as a 'prescription for change'.

Preventing Hearing Loss

A decibel dB, is the unit used to measure the intensity of a sound – 85dBA and above is the level at which noise becomes unsafe without the use of hearing protection

The ‘dosage’ of noise exposure is dependent on two main things:

  1. the ‘volume’ or intensity of the noise
  2. the time or duration of the exposure to that noise.

The British Tinnitus Association has produced some guidance on 'how loud is loud'.

Deafness and hearing loss noise chart, showing decibels and noise ranges

Chart showing noise intensity in decibels. Hours, minutes and seconds of maximum unprotected exposure and their examples

Identifying loud noise

  1. If you have to shout to be heard by somebody around a metre away, the background noise is loud enough to be potentially damaging.
  2. If your hearing is dulled after exposing yourself to noise, then your hearing has been damaged. This may be temporary, but if you expose yourself repeatedly to these situations, the damage may become permanent.
  3. If you find a ringing or buzzing in your ears (tinnitus) after exposing yourself to noise, then the noise is likely to have been damagingly loud.
  4. If a sound is painfully or uncomfortably loud, stop exposure immediately.


  • Hearing loss at certain frequencies. If noise is the suspected cause, this is termed noise-induced hearing loss.
  • The hearing loss can be temporary, and recover within a day or two, or permanent, and not recover at all.
  • If temporary, it should be taken as a warning that permanent damage is likely if this exposure is repeated.
  • Loud noise exposure can sometimes cause a ringing or buzzing in the ears called tinnitus. Sometimes tinnitus goes away after a few minutes or hours after a loud noise exposure. However, sometimes it can persist for weeks, years, or even indefinitely, especially if you have a noise-induced hearing loss.

Prevention Tips

World Health Organization (WHO) has launched 'hearWHO', a free application for mobile devices which allows people to check their hearing regularly and intervene early in case of hearing loss. The app is targeted at those who are at risk of hearing loss or who already experience some of the symptoms related to hearing loss.

  1. Remove yourself from the noise, reducing the time of exposure 
  2. Take frequent breaks from the loud noise if you cannot remove yourself from the noise
  3. If you know you will be in a noisy environment wear hearing protection to reduce the intensity of the noise eg. ear plugs or ear defenders
  4. Limit the time and volume when listening to music through earbuds or headphones. As earbuds are placed directly into the ear this can boost the audio signal by as many as 9dB. Larger earmuff-style headphones are to be preferred. Another protective measure is to adhere to the 60/60 rule, which simply put means never turn your volume up past 60%, and only listen to music with earbuds for a maximum of sixty minutes per day. You can also get noise-cancelling headphones which will allow you to listen to music for a longer extension of time, at a much lower decibel level
  5. At work your employer has a responsibility to protect your hearing and you should be issued with hearing protection if the noises you are exposed to are loud enough to be damaging. You must wear this hearing protection if it is issued.


Signs of hearing loss and red flags

Hearing loss can affect people of any age. The prevalence of hearing loss increases exponentially with age and approximately 42% of individuals over the age of 50 and 71% of individuals over the age of 70 have some degree of hearing impairment. Only one third of individuals who could benefit from hearing aids in the UK wear them.

Most age-related hearing loss is a gradual process, and often individuals will not notice that they are having difficulty hearing. Relatives, friends or carers may be the first people to notice that an individual may have a hearing loss. It is important to remember that even if someone can communicate on a one to one basis, in a quiet room without difficulty, that they may still have a hearing loss that will benefit from hearing aids.

It is important not to disregard communication difficulties as a dementia and behavioural related issue.

More information:

Potential indicators for hearing loss

  • Age 50+
  • Difficulty hearing in background noise such as pubs and restaurants
  • Having to turn the TV up so that others complain about the volume
  • Asking people to repeat themselves
  • Unaware of conversation when the speaker is not facing the individual
  • Speech sounds muffled or people do not speak clearly
  • Avoiding social situations
  • Withdrawal from conversation
  • Mishearing, and inappropriate responding
  • Unable to hear bird song
  • Reporting tinnitus- noises in the ear, ringing, buzzing, whooshing etc.
  • Difficulty hearing on the telephone

Other risk factors

  • Family history
  • History of occupational or social noise exposure
  • Ototoxic medication- aminoglycosides (such as gentamicin) or chemotherapy drugs (platinum-based chemotherapy)
  • Medical history: diabetes, cardiovascular disease and stroke, and autoimmune disorders

Red Flags

  • Asymmetrical or Unilateral Hearing Loss - Age related hearing loss should be symmetrical. If an individual is reporting hearing loss that is greater in one ear than the other, then further investigation is required.
  • Sudden hearing loss (over >72 hours or less) within the past 30 days is considered a medical emergency. Individuals should be seen within 24 hours by an ear, nose and throat service or an emergency department.
  • If the hearing loss worsened rapidly (over a period of four to 90 days), refer urgently (to be seen within two weeks) to an ear, nose and throat or audiovestibular medicine service.
  • For otalgia (earache) with otorrhoea (discharge from the ear) that has not responded to treatment within 72 hours and the individual is immunocompromised,refer to an ear, nose and throat service to be seen immediately within 24 hours.
  • Persisting middle ear effusion in patients of Chinese or Southeast Asian origin
  • Fluctuating hearing loss
  • 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 changes in nature or is causing distress

Online hearing check

Royal National Institute for Deaf People (RNID) has launched a new Check Your Hearing campaign to encourage people to take their quick, easy, and free online hearing check.

The digital check, which can be found on RNID’s website and is signposted by the NHS, takes only 3 minutes and can be done easily at home on a desktop, laptop or mobile. While the hearing check is accurate in identifying indicators of hearing loss, it is not a diagnostic tool. Therefore, RNID offers clear and concise next steps for people whose results show signs of hearing loss.

RNID also provides a letter that people can take to their GP explaining the result and recommended next steps for investigation and referral.


Referral Guidelines Timeline

NICE guidelines: Hearing Loss in Adults was updated in September 2019. The recommendations on the timeliness of referrals for patients with a hearing loss to Ear Nose Throat (ENT) specialist, emergency department or audiovestibular medicine service are based on the guidance from the British Academy of Audiology and expert opinion in review articles.

The guideline covers timelines of when to:

Refer immediately (for assessment within 24 hours by ENT or an emergency department):
  • Sudden onset (over three days or less) unilateral or bilateral hearing loss which has occurred within the past 30 days and cannot be explained by external or middle ear causes
  • Unilateral hearing loss associated with focal neurology
  • Hearing loss associated with head or neck injury
  • Hearing loss associated with severe infection, for example, necrotising otitis externa
Refer to be seen urgently (within two weeks):
  • Sudden onset (over three days or less) unilateral or bilateral hearing loss which developed more than 30 days ago and cannot be explained by external or middle ear causes
  • Rapidly progressive hearing loss (over a period of four to 90 days) which cannot be explained by external or middle ear causes.
  • Suspected head and neck malignancy — refer using a two-week cancer pathway
Refer routinely to ENT or audiovestibular medicine (using a local pathway) anyone presenting with hearing loss (not explained by acute external or middle ear causes):
  • Unilateral or asymmetric gradual onset hearing loss as their main symptom
  • Fluctuating hearing loss that is not associated with an upper respiratory tract infection
  • Hearing loss associated with hyperacusis
  • Hearing loss associated with persistent tinnitus which is unilateral, pulsatile, significantly changed or causing distress
  • Hearing loss associated with persistent or recurrent vertigo
  • Hearing loss that is not age related
Referring (to an audiology service) all adults at risk of having or developing hearing loss who have limited ability to seek help and in whom hearing loss might otherwise be missed:
  • Diagnosed dementia or mild cognitive impairment
  • Suspected dementia
  • Diagnosed learning disability

If unsure if to refer to ENT or AVM or Audiologists, please refer to the referral pathways section of the toolkit.

Referral Pathways

Regional variations exist, please check local services.

Adult Rehabilitation (Audiology)

Referring patients as a direct referral for routine hearing difficulties:
  • Some audiology services are now taking direct referrals from age 16, but most take referrals from age 18 onwards or from age 50 onwards. Please check with local services for age criteria.
  • A hearing assessment is undertaken and further management in the form of hearing aid provision or assistive listening devices
  • Patients are followed-up and are routinely reassessed at the discretion of the local audiology service. Please refer to sections 1.5, 1.6, 1.7 in the NICE guidance NG98 for further details on assessment and management undertaken in audiology services.
  • If an exclusion criterion is met during the patient’s assessment in audiology they will be referred onwards to the local Ear, Nose, Throat (ENT) Department, audiovestibular medicine (AVM) service, or GP for further investigation and management.
  • The British Academy of Audiology has produced this 'Guidance for Primary Care: Direct Referral of Adults with Hearing Difficulty to Audiology Services' (PDF), which contains further details and explanation of the exclusion criteria.


  • If patient meets any of the exclusion criteria outlined in the guidance, please refer onwards to the local ENT department, AVM, or specialist audiology practitioner depending on local services/protocols.
  • Refer to AVM for complex hearing and/or balance disorders (i.e. central pathologies).
  • Refer to ENT for conditions that may require surgical management (i.e. otosclerosis, otitis media with effusion, cholesteatoma etc

Audiology Led Clinics (ALC)

  • Please check your local area if this service exists.
  • It is a direct access clinic for adults aged 18 to 75 with non-complex: tinnitus and/or hearing loss or balance problems (peripheral, inner ear disorders i.e. BPPV, vestibular neuritis etc.) Patients are seen by audiologists with an extended scope of practice and expertise beyond routine hearing assessments.

Hearing Therapy/Clinical Psychology

  • For patients who have had all necessary medical investigations completed by ENT/AVM, GP or audiologists
  • Refer complex patients for counselling, habilitation and further management of tinnitus, hyperacusis, auditory processing disorder management, and mindfulness

Auditory Implant Services

  • Please refer adults with severe to profound deafness for a cochlear implant assessment if they do not receive adequate benefit from acoustic hearing aids
  • Please refer to NICE guidance for further details and criteria

Sensory Services

  • Sensory services is under adult social services and is for those who are visually impaired, deaf or hard of hearing, or dual sensory impairments. The team provides specialist equipment to aid mobility, communication and daily living in response to assessed needs, for example, vibrating alarms, flashing smoke alarms, telecoil systems and others
  • Please check with your local council.

Psychosocial Effects of Hearing Loss

Hearing loss can have a major impact on daily functioning and quality of life of a person. It can affect communication, their occupation, social interactions leading to loneliness and affect their families. Research shows that hearing loss doubles the risk of developing depression and increases the risk of anxiety and other mental health issues, while many sufferers remain undiagnosed or untreated. It also suggests that the use of hearing aids reduces these risks and is cost effective. GPs should routinely screen for depression during consultations of patients with hearing loss.

Research around the experience of people with hearing loss and employment found that: 68% of people with hearing loss felt isolated at work because of their hearing loss and 41% had retired early due to the impact of their hearing loss and struggles with communication at work.1


  1. Hearing Link: Facts about deafness and hearing loss

Hearing Loss and the risk of developing dementia

A study in the Lancet found that hearing loss is a major risk factor of cognitive decline resulting in dementia. It is estimated that at least £28 million per year could be saved in England by properly managing hearing loss in people with dementia.1

Evidence found that mild hearing loss doubles the risk of developing dementia, with moderate hearing loss leading to three times the risk, and severe hearing loss five times the risk. Hearing loss can be misdiagnosed as dementia or make the symptoms of dementia appear worse. Although dementia is diagnosed in later life, changes in the brain usually start developing many years before. The study looked at the benefits of building a "cognitive reserve", meaning that if the brain’s networks were strengthened, it could continue to function in later life regardless of the damage.2,3

A study by the University of Exeter and King’s College London also found that people who wore hearing aids for age-related hearing problems maintained better cognitive functions than those with similar hearing who did not use them. Those who wore them had brains that performed as if they were, on average, eight years younger. NICE Guidelines state that hearing aids are the primary management option for permanent hearing loss.4

Individuals with memory complaints often present at their GP and assessment of hearing is now recommended as a first step in its investigation. The communication difficulties and misunderstanding caused by hearing loss commonly mimic memory loss. Screening for hearing loss in high-risk populations such as those attending memory clinics or people older in age has been suggested to ensuring hearing loss is identified and managed in a timely manner to facilitate healthy aging. It is accepted that earlier provision of hearing aids leads to better utilisation and concordance. Treating hearing loss in people with dementia also has the potential to reduce the severity of dementia related behaviours such as confusion and simplify communication with families and carers.

At Imperial College London, the Clinical Lead for Adult Audiology has conducted research around the relationship between hearing loss and dementia. A sound clip has been developed (available on the powerpoint on the GPVTS teaching and curriculum section). It demonstrates to clinicians administering cognitive assessments how a common age-related hearing loss can completely distort speech and negatively affect scores on these cognitive assessments. This is particularly in cases that require the patient to repeat back a sentence they have heard.


  1. Hearing Link: Facts about deafness and hearing loss
  2. RNID: 'Why and how are dementia and hearing loss linked? Our Audiologist explains the latest research'
  3. The Hearing Review: Nine Risk Factors Associated with Dementia
  4. NICE, Hearing loss in adults: assessment and management. 2018, National Institute for Health and Care Excellence

Interpretation of Investigations

Please note an audiologist/AVM/ENT will send a summary/copy of the basic investigations below to you after the assessment has taken place.


The British Society of Audiology produced a detailed procedure for ear examination.

Tuning Forks

Provides preliminary diagnostic information.


  • Comparison of air conduction (AC) and bone conduction (BC) sensitivity
  • Tuning fork is alternated between entrance of ear canal and mastoid process
  • Rinne Positive: Tuning fork is louder via AC= sensorineural hearing loss (SNHL)
  • Rinne Negative: Tuning fork is louder on mastoid= conductive hearing loss (CHL)


  • Test of lateralisation and therefore may be used for patients who report unilateral hearing loss.
  • The tuning fork is placed midline on the patients’ forehead.
  • If sound lateralises to ear with loss= CHL as the improved BC is due to the occlusion effect.
  • If soundlateralises to ear without loss=SNHL or mixed hearing loss (MHL) as the best cochlea is detecting the signal. In normal hearing= midline

Types of hearing loss

  • CHL is a result of dysfunction in the middle or outer ear (BC >AC)
  • SNHL is a result of cochlea damage (sensory) and/or neural (8th nerve) (BC = AC)
  • Mixed hearing loss is a combination of dysfunction in middle/outer ear and cochlea/8th nerve (A certain amount of AC and BC loss)
  • Central hearing loss refers to everything in the auditory cortex (Brain) whereas peripheral hearing loss is the result of everything before the brain (outer, middle, inner ear)

Interpreting a Pure-tone Audiogram (PTA)

  • An audiogram is a plot of frequency in Hertz (Hz) against intensity measured in decibels hearing level (dB HL). The frequency range for a PTA is 250 Hz to 8000Hz as this range of frequencies is similar to the range important for speech understanding.
  • The intensity ranges from -10dB HL to 120dB HL. Thresholds (lowest acoustic intensity perceived at a given frequency) for both the right and left ear are plotted based on the frequency. Refer to image below.
  • Masked AC/BC thresholds are an accurate assessment of the test ear.
  • Further interpretation and explanations on Pure-tone Audiogram are available on the BSA website:
Descriptor Average hearing threshold levels (dB HL)
Normal Hearing < 20
Mild hearing loss 21 - 40
Moderate hearing loss 41 - 70
Severe hearing loss 71 - 95
Profound hearing loss > 95

pure tone audiogram chart, right and left

Interpreting a Tympanogram

  • Tympanogram is graphic display of tympanic membrane compliance (ml or cm3) as a function of pressure changes in the external auditory meatus. See figure 1.

Image of tympanogram chart

  • Tympanometry is sensitive to middle ear effusion, cholesteatoma, ossicular adhesions, and space occupying lesions in contact with the eardrum, ossicular discontinuity, perforations and ear canal occlusions.
  • The shape of the tympanogram should also be described and simple descriptions such as ‘normal’, ‘rounded’, ‘flat’, ‘wide’ or ‘W-shaped’.
  • The BSA has further interpretation and explanations on Tympanometry.

Examples of Types of Hearing Loss

Conductive Hearing Loss

  • An audiogram illustrating a mild conductive hearing loss in the right ear. The air-conduction thresholds for the right ear are shown as O’s and the masked, bone-conduction thresholds are shown as brackets.

Image of a conductive hearing loss chart

  • Examples of a conductive hearing loss included a perforated tympanic membrane, and otitis media with effusion etc.

Sensorineural Hearing Loss

  • An audiogram illustrating a mild-moderate, high-frequency sensorineural hearing loss in the right ear.

Sensorineural Hearing loss chart

  • Examples of a SNHL includes presbycusis, an acoustic neuroma, Meniere’s disease, and noise-induced hearing loss etc.

Mixed hearing loss

  • An audiogram illustrating a moderate-to-severe, mixed hearing loss in the left ear. Both the air-conduction thresholds (X’s) and the bone-conduction thresholds (brackets) indicate hearing loss.

Mixed hearing loss chart

  • Examples of mixed hearing loss includes otosclerosis, a SNHL with a perforation/otitis media with effusion.


Stanley A. Gelfand (2011). Essentials of Audiology, 3rd Edition. Thieme, New York NY 2011

Aural Care

Ear Wax - Key Facts

Symptomatic ear wax is common with around 2.3 million primary care consultations a year. If earwax is contributing to hearing loss, other symptoms, or needs to be removed to examine the ear, NICE recommends removal (in adults) in primary care or community ear care services. Access to services is important as the condition is prevalent among older people and those with reduced cognitive function.


  • Commonly presents with discomfort and sensation of fullness or blockage.
  • Occasionally causes earache, tinnitus, itching or cough.
  • Prevents diagnosis of other conditions, including hearing loss.
  • Is a common cause of deafness and must be excluded or treated before referral to audiology?
  • Can cause safety and occupational issues, for example, for builders, drivers, railway workers, police.


  • Can be confused with foreign material including cotton bud tips or wool.
  • Even a small quantity may cause symptoms if resting against the eardrum.
  • Wax may be of various colours or consistency.
  • Rarely painful.


  • Items placed in ear can make the effect of wax worse, including cotton buds and hearing aids.
  • Wax commonly exacerbates hearing loss, especially in older adults. Good practice includes preventive checks for people with reduced cognitive function.
  • There is no good evidence preventive ear drops work.


These include electronic irrigation, microsuction, mechanical removal with specially designed instruments, and self-irrigation. Relief of symptoms is almost immediate and appreciated by patients.

The practitioner must have training and expertise in using the method to remove earwax and be aware of its contraindications.

Never use metal or plastic syringes as they can be dangerous.

Some localities have purposive ear wax clinics which may be useful for more difficult cases. NICE advises that referral to secondary care is not an appropriate use of resources.

Irrigation with an electric irrigator is effective and can be carried out in the practice by a trained member of staff.

It should be recorded in the patient notes as ‘irrigation’ not ‘syringing’ as the latter refers to the obsolete method:

  • two attempts may be needed
  • drops may be instilled 15 minutes before irrigation, this can save patient appointments and clinician time
  • poor evidence of any difference between drops (olive oil or sodium bicarbonate) other than side effects, so water can be used there is little evidence for courses of drops longer than 3-5 days help

Microsuction and mechanical removal (for example, with a Jobson-Horne probe) can be used where irrigation fails but are resource-intensive requiring skilled staff and equipment.

Self-irrigation with bulb syringes can be effective, reduce the demand for treatment (Coppin, 2011), and is commonly used in Europe and the US. An NHS treatment pathway from City and Hackney CCG is available online.


Coppin R, Wicke D, Little P. Randomized trial of bulb syringes for earwax: impact on health service utilization. Annals of Family Medicine. 2011; 9(2):110-4

Patient Support

RNID has produced advice on what to do if wax builds up.


Assistive Technology

What are assistive listening devices?

Assistive listening devices are designed to help people with hearing loss hear better in certain situations, for example, when it’s difficult to hear speech in noisy places, or when watching TV. They amplify the sound they want to hear (make it louder) and send it straight to their ears, helping them to hear over background noise.

For non-hearing aid users, it is advisable to send them to have their hearing tested. If they are unable to use hearing aids (older patients with poor cognition and dexterity) personal amplifiers can be helpful. If they have a hearing aid and are continuing to struggle, assistive technology can help - especially in noisy places for example when they are trying to have a conversation or when the sound they want to hear is far away like the TV or at a theatre. The RNID website has more information on assistive technology.

If the person is still in employment, they can obtain assistive devices through the Access to Work government scheme. If they are still in education, they can obtain these devices through the Disabled Students’ Allowances scheme. For older adults who are not in employment, some boroughs may also be able to provide some equipment through their Sensory Services team if available.

The Veterans Hearing Fund funded by the Government and provided by the Royal British Legion, provides support to veterans who suffered hearing loss during service, but their needs cannot be helped through statutory services such as the NHS. The programme may be able to fund hearing aids, peripherals or therapies such as lip reading and tinnitus management therapies.

Communicating with people with hearing loss and deafness

BT provides a free of charge text relay telephone service, where the person with hearing loss receives text translation of what is being said over the phone. Video relay services are available for deaf BSL users where an interpreter will translate what is being said into BSL.

Communication Tips

  1. Gain the person’s attention before you begin to speak.
  2. Avoid speaking from another room. Place yourself at a reasonable distance so they can see your face and lips.
  3. Avoid having the conversation with a lot of background noise.
  4. Remember hearing aids will amplify all background noise, so speech can get lost.
  5. Keep your face well lit. Do not stand with the light or a window behind you as your face will be in a shadow.
  6. Do not cover your face or your lip movements.
  7. Do not look away when talking.
  8. Do not shout! Speak clearly and not too fast or too slow.
  9. Repeat the sentence again (just once) if necessary, then rephrase.
  10. Write down important facts - times, dates, names, places, instructions.
  11. Be calm and patient and leave enough time for the consultation.
  12. Gestures and facial expressions will help augment your message.


  1. RNID: Communication tips if you have hearing loss
  2. RNID: Communication tips for people with hearing loss
  3. UCL: Deaf Awareness - Online Courses for Health Professionals

Practical Tips for your GP Surgery

  • On the record communication card: RNID has produced a communication card which patients' can download and print, fill in, and hand to the GP receptionist, so that the GP surgery meets their needs as required under the NHS Accessible Information Standard.
  • RNID created a summary of practical information to enable patients to contact their surgery more confidently, communicate well during appointments and fully understand the information given to them, that meets legal requirements of the accessible information standard.
  • Speech to Text apps during consultations are useful where the patient cannot hear or struggles to lip read. There are many free downloadable speeches to text apps on phones where speech is converted into text for the patient to read.
  • Deaf awareness training for all practice staff. The RCGP has accredited an online deaf awareness course. This two-hour self-directed course which enables understanding of the communication needs of Deaf and hearing-impaired patients. It provides practical workplace strategies to help meet the Accessible Information Standard. Videos of patients' and Doctor’s real-life experiences convey information and enrich the learning experience.
  • InterpreterNow is a service that enables deaf and hearing people to communicate with each-other. They deliver immediate access to online interpreting for deaf British Sign Language (BSL) users. InterpreterNow already provides deaf people access to many different public, private and charitable organisations such as NHS England, Police 101, Public Health England and the Scottish Government.
  • A personal listening device is a small, personal amplifier which is used for communicating with people who cannot hear at conversational levels. The patient wears headphones whilst the GP speaks into the microphone (amplifier). The patient or clinician can adjust the volume dial on the amplifier to suit the patient’s individual hearing loss.
  • Telecoil System in GP surgeries practice will be beneficial for some people wearing hearing aids whom have the function to switch to the 'T' loop system to help reduce the unwanted background noise in the GP waiting area.


Hearing aids are essentially amplifiers adjusted to the individual's frequency loss. While they improve hearing, the sensory organs remain damaged and deterioration will progress. The hearing aid requires reassessment and adjustment every few years. GPs are well placed to remind patients of this. This is done locally where their hearing aids were initially provided i.e privately, high street stores or through their local NHS audiology department.

Disposable parts of the hearing aid such as tubes and some ear moulds need replacing every few months if they are to remain effective. Patients are given this advice and guidance from their audiology service when initially given the hearing aids. If they are unsure, please direct them back to their original service.

The C2Hear website has interactive multimedia videos on hearing aids to aid your consultations.

Hearing Loss, a Global Problem

Around 466 million people worldwide (over 5% of the world’s population) have disabling hearing loss and 34 million of these are children. Disabling hearing loss refers to hearing loss greater than 40dB in the better hearing ear in adults and a hearing loss greater than 30dB in the better hearing ear in children.1

Disabling hearing loss is unequally distributed across the world with the low- and middle-income countries affected the most. The greatest burden of disabling hearing loss is in the Asia-Pacific area, southern Asia, and sub-Saharan Africa.2

It is estimated that by 2050 over 900 million people will have disabling hearing loss across the globe. Unaddressed hearing loss poses an annual global cost of US $750 billion. This includes health sector costs (excluding the cost of hearing devices), costs of educational support, loss of productivity, and societal costs.1

Hearing loss has been ranked as the fifth leading cause of years lived with disability in the Global Burden of Disease Study 2013, higher than many other chronic diseases such as diabetes, dementia, and chronic obstructive pulmonary disease. However, hearing loss receives limited research funding, public awareness and is presented as a silent epidemic. Global multidisciplinary and collaborative efforts are urgently needed to address the health needs of the child and adult with hearing loss.2

Interventions to prevent, identify and address hearing loss are cost-effective and can bring great benefit to individuals. Despite the fact that hearing loss can be prevented and treated, many people with hearing loss in both resource-poor and high-income settings do not seek or receive hearing health care, and the current production of hearing aids meets less than 10% of the global need and less than 3% of developing countries’ needs. The lack of availability of services for fitting and maintaining these devices, and the lack of batteries are also barriers in many low-income settings.2

In developing countries, children with hearing loss and deafness rarely receive any schooling. Improving access to education and vocational rehabilitation services and raising awareness especially among employers about the needs of people with hearing loss, will decrease unemployment rates for people with hearing loss.

Screening can be done using the hearWHO app. This app can be downloaded and used by adults to check and track their hearing regularly. It can also be used by health workers to screen people in the community with a view to referring them for hearing testing, when indicated.

The World Health Organisation (WHO) suggests that half of all cases of hearing loss can be prevented through public health measures. Some simple strategies for prevention of hearing loss include immunisation, avoiding the use of ototoxic drugs, early identification and intervention for both acute and chronic ear conditions, following healthy ear care practices, reducing exposure (both occupational and recreational) to loud sounds by raising awareness about the risks, developing and enforcing relevant legislation and encouraging individuals to use personal protective devices such as earplugs and noise-cancelling earphones and headphones.1

Educating young people and population in general on hearing loss, its causes, prevention and identification is essential. WHO suggests governments and manufacturers of smartphones and MP3 players to implement the WHO-ITU global standard for personal audio systems and devices.

If adhered to, the standard could help prevent hearing loss due to listening practices that are harmful to hearing. In 2017, the 70th World Health Assembly adopted a resolution on the prevention of deafness and hearing loss. This resolution calls upon Member States to integrate strategies for ear and hearing care within the framework of their primary health care systems, under the umbrella of universal health coverage. It also requests WHO to undertake a number of actions for promotion of ear and hearing care at global level.

A few actions WHO have already undertaken include:

  • promoting safe listening to reduce the risk of recreational noise-induced hearing loss through the WHO Make Listening Safe initiative
  • launching and hosting the World Hearing Forum, which is a global advocacy alliance of all stakeholders in the field of hearing.
  • launching and promoting the WHO-ITU global standard for personal audio systems and devices;
  • promoting World Hearing Day as an annual advocacy event;
  • providing technical support to Member States in development and implementation of national plans for hearing care


  1. WHO: Deafness and hearing loss - key facts
  2. The Lancet: Hearing loss - an important global health concern

Information for NHS Managers and Carers

NHS England Commissioning Services for People with Hearing Loss: A framework for clinical commissioning groups or networks

The commissioning framework is designed to support the commissioning of non-specialist services for people with hearing loss, across a spectrum of providers to improve quality, access and consistency; therefore, benefitting the people who need to use hearing loss services. The framework provides clear guidance on what good commissioning for hearing loss services looks like. Responsibility is placed firmly at a local level to meet the needs of varying populations. The framework aims to support the delivery of more integrated hearing services, closer to home delivering better outcomes and value for people with hearing loss.

The document sets out clear information and guidance on the following topics

  1. Why we need a Commissioning Framework for Hearing Services
  2. What Matters to People with Hearing Loss
  3. Principles for Commissioning Hearing Services
  4. Planning Hearing Services
  5. Securing Hearing Services that Deliver Improved Outcomes and Value
  6. Monitoring for Quality Improvement
  7. Commissioning Models – Case Studies
  8. Moving Forward

NHS England has published the full commissioning framework online.

Key points and important messages for GPs from the hearing loss commissioning framework

Local commissioning services should be aware of the impact of hearing loss and its association with physical health, mental health, dementia, falls and other health issues. These remain as policy priorities for the Government and the NHS along with addressing the continuing variation in access and quality of hearing loss services.

The Adult Hearing Service must be seen as part of wider integrated adult health and social care hearing services that work in partnership with GPs, primary health care teams, ENT departments, audio-vestibular medicine (AVM) audiology departments, local authorities (including social care and educational services), the voluntary and community sector and independent providers.

The Hearing Loss and Deafness Alliance has developed principles to help inform the commissioning of services to protect and deliver complete hearing wellbeing for individuals and populations. The main themes for the principles are focused on ensuring that commissioning:

  • Promotes excellence in outcomes for patients;
  • Is clinically and service user led;
  • Supports evidence-based practice; and
  • Facilitates choice and flexibility in provision of services

It is very important that a clear local pathway is developed and understood to deal with ear wax before audiological assessment is undertaken; visits to audiology, prior to wax being checked and removed, are a significant source of inappropriate referrals.

The NICE guidance 2018 (NG98) and NICE Quality standard (2019) are clear that such a common condition should be treated by trained staff in primary care. Commissioners should ensure that they commission services with the appropriate equipment, capacity and expertise to carry out earwax removal for adults in primary or community care. For adults with earwax that is affecting hearing, causing other symptoms, stopping appropriate ear examination or blocking an impression of the ear canal to be taken, earwax removal closer to home should be provided. Ideally this would be in primary care or community-based ear care services, preventing the inappropriate use of specialist services.

Community-based aftercare support significantly reduces the burden on audiology departments, contributing to significant cost savings for the system. It also reduces unnecessary GP appointments and other health and social care interventions resulting from basic needs not being met.

Hearing aids, information, tinnitus retraining therapy, cognitive behavioural therapy and other specialist support are among the services that can provide help for people with tinnitus, which are usually accessed in audiology departments after referral from the GP.

Providers should provide domiciliary care to individuals who require it – the Provider should provide all parts of the service at the patient’s domicile (including residential or nursing homes) where this is requested in writing by a GP.

Commissioning should be outcome driven. Figure 1. Sets out the key outcomes for hearing services.

Outcomes for adult hearing care

Example hearing services pathway can be seen on figure 2.

Examples of hearing service pathways

Key Performance indicators for non-specialist hearing services include:

Referral to Assessment - Time Assessments to be completed within 16 working days following receipt of referral, unless patient requests otherwise.

Assessment to Fitting - Time Hearing aids to be fitted within 20 working days following assessment, unless patient requests otherwise


  1. NHS England: Commissioning Services for People with Hearing Loss - A framework for clinical commissioning groups

Quality Improvement Initiatives

Hearing impairment can have a major impact on daily functioning and quality of life. It can affect communication, social interactions and work, leading to loneliness, emotional distress and depression. The RCGP is working in partnership with RNID on the Deafness and Hearing Loss in Primary Care project. This project will create resources to help give GPs confidence to recognise symptoms of hearing loss and appropriately refer people for a hearing assessment. The project seeks to support the implementation of changes in surgeries to improve access to primary care services.

Hearing loss affects around 12 million people across the UK. Due to our aging population, this expected to rise to 14.2 million by 2035. There is a clear foundation for providing access to healthcare for people with hearing loss set by the Equality Act and Disability Discrimination Act 1995. From August 2016, all NHS and social care providers have been required to meet the terms of the Accessible Information Standard (section 250 of the Health and Social Care Act 2012).

Evidence shows there is a severe lack of deaf awareness amongst GPs and patients end up feeling unclear after a consultation. This short powerful video highlights the importance of deaf awareness and the need for good communication skills amongst health professionals.

The process of improving quality in general practice is continuous

In January 2019, NHS England agreed a new five-year framework for GP contract reform to implement the NHS Long Term Plan. This included several improvements to 2019-20 Quality and Outcomes Framework (QOF) (1.19 MB PDF), including the introduction of the Quality Improvement (QI) Domain.

The challenge of improving the effectiveness and efficiency of the healthcare we offer to our patients is continuous. QI represents one way for clinicians to improve the care they provide to patients whilst also improving their own professional satisfaction. A QI plan may include government-selected items but can also incorporate areas reflective of your practice setting which your staff and patients feel are important.

Here are some suggestions for QI initiatives in your practice in relation to deafness and hearing loss:

  • Deaf Awareness Training: Provide deaf awareness training for all practice staff including effective communication tips, types of communication support available and good practice.
  • Accessibility: Ensuring your practice has a range of ways for patients to contact their GP surgery and ensure that practice staff are trained in how to use these methods. Remembering that a patient who is deaf or has hearing loss may have difficulty hearing over the phone. Having policies and procedures in place to enable communication support such as BSL interpreting services to be booked as and when required.
  • Communication: Implementing technology within the practice that can help improve the patient experience for people with hearing impairment, such as visual display screens in waiting rooms and induction loop or infrared systems.
  • Patient Records: Your QI project could involve reviewing the notes of patients and ensuring patient records clearly indicate when a person has a hearing impairment. You could include basic information about their preferred method of communication and any communication support requirements.
  • Mental Health: Hearing impairment can have a major impact on daily functioning and quality of life. It can affect communication, social interaction and work. This can lead to loneliness, emotional distress and depression. Screening questions can be used to identify patients in need of support, so they can then be treated and signposted to voluntary support organisations.

The RCGP QI Guide is a resource which can be used to understand the principles and tools of QI. The guide introduces the simple QI Wheel for primary care (see visual representation below). This illustrates the main elements to consider in design, delivery and evaluation of a QI project and brings it together as a cohesive whole.

RCGP Quality improvement wheel

QI Ready is a useful online tool developed by the RCGP to help implement and embed new QI approaches more effectively and efficiently into practice. It includes e-modules, resources and tools to help you with your quality improvement in practice. It also provides access to case studies which you can duplicate, thus preventing you from 're-inventing the wheel', and a network to link with others to help you and give advice.

GPVTS Teaching and Curriculum

Powerpoint to present at your VTS scheme

Powerpoint to present at your VTS scheme

Download Deafness and Hearing Loss in Primary Care presentation (2,121 KB PDF)

Examples of regional GPVTS teaching around Deafness and hearing loss

  • “We have run ENT mornings, part of which deals with hearing loss and reading audiograms”
  • “We arranged for the RNID to send one of their hearing-impaired trainers to come and lead a session for us - it was very professional and impactful”
  • “Sign language session; session from GP with special interest in ENT covering some aspects of hearing loss”
  • “Sessions on dizziness, neuro-otology, general ENT, hearing protection/UK noise protection regulations”
  • “We have had a session on disability that included how to adapt consulting for patients with deafness. We plan a session next year with a patient and a local charity specifically focussing on sensory impairments”
  • “Session on sensory deprivation in the elderly which included hearing loss and was presented by one of our ST1 to our trainees”
  • “Veterans - we have compassion cases where we may role play a person with hearing difficulties and the challenges it poses in a consultation”
  • “Talks from ENT include section on H-L”
  • “performing arts medicine - which covers noise-related hearing loss”

Examples of Innovation

North Wales Audiology Primary Care Service

North Wales Audiology Primary Care Service is an example of innovation in hearing services in primary care. The first clinics started December 2016 and over 22,000 patient contacts have been recorded since its conception. The purpose of the service is to direct patients with reported hearing loss, tinnitus and symptoms of dizziness likely attributed to benign paroxysmal positional vertigo (BPPV) to an audiologist in a primary care setting, preferably as the first point of contact.

Patients can self-refer, be triaged by trained reception staff, referred by their GP following a telephone or face to face consultation or from the Practice Nurse or other health professionals such as pharmacy or physiotherapy. The advanced audiology practitioners (AAP) currently hold specialist clinics in 39 GP practices across North Wales. A cluster-based approach is utilised in some areas and enables three or more GP practices to be covered from one location.

The audiologist has a 25-minute appointment to assess and treat, reassure and discharge, triage patients to secondary care audiology or ENT services, or refer back to the GP when necessary. The aims of the service are to reduce the demand on GP appointments by directing patients to AAPs, rather than reducing secondary care services which are still provided in the hospital. The improved integration between primary and secondary care Audiology services will assist with patient care and appropriateness of onward referrals to both Audiology and ENT.

Innovation in England - Hearing Birdsong

Hearing Birdsong is a new innovative project utilising an environment created with the sounds of birdsong to help participants understand the health of their hearing and identify any problems. It is a patient-led project that brings together art, science and technology to encourage early identification and intervention of hearing loss.

The concept was born at a two-day ‘sandpit innovation workshop’, inspired by Angela’s story of being motivated to get her hearing tested after losing the ability to hear birdsong. The ‘hackathon’ type workshop was run by the NIHR Imperial Patient Safety Translational Research Centre.

The project is led by Tom Woods (Kennedy Woods Architecture) with a diverse Steering Group and funding from the UCL Centre for Co-production in Health Research. Design engineers from the Dyson School of Design Engineering (Imperial College, London) have modulated six familiar bird calls to match the frequency bands of a traditional hearing test. Visitors are invited into a safe space to interact with the exhibition and listen to the birdsongs emitted from beautiful handmade bird boxes. For visitors struggling to hear any of the bird calls, this can be an indicator that further medical investigation into their hearing is required. Healthcare professionals will be on site for further support, of which the exact details are being defined.

The first public installation was in March 2019 at the Helix Centre Pop-Up, St Mary’s Hospital. 120 visitors attended the installation, nine people signed up for a hearing test at the hospital. The team is now working with harder to reach groups to hold the installation in diverse areas in London. They are currently developing a fully bespoke software interface with interactive elements, which is closer to a “screen” and will continue to co-produce the project with the diverse stakeholders.

Hearing birdsong

Queen’s University Belfast, Ireland

‘I’m sorry but I didn’t hear that….’: developing a simulation-based hearing impairment learning experience for healthcare professional students. Living with hearing impairment, and deafness, can have a significant impact on individual’s lives and wellbeing. This is now more important within healthcare – particularly within GP consultations and the crucial reliance on the understanding of the spoken word.

Many have called for greater training of healthcare professionals in how best they interact with individuals with such communication disorders. Evidence would suggest that allowing doctors to experience what the patient feels and hears can enhance their empathy skills towards patients. An interprofessional team at Queen’s University Belfast (QUB) have been developing a VR experience - of a patient (with hearing impairment) consulting with a GP. In addition to the visual experience, experts from the Sonic Arts Research Centre (SARC) at QUB have developed a realistic aural experience of from the perspective of impairment, and also deaf charities, in developing this immersive learning experience. Currently the team are researching the impact of this education experience and look forward to sharing their findings in early 2020.

Virtual reality experience Queens University Belfast


Deafness and hearing loss in primary care: In conversation with a patient with hearing aids and an audiologist

This podcast has been produced for primary care clinicians who care for patients with Deafness and hearing loss. Dr Devina Maru, GP Specialist Registrar and RCGP Clinical Champion for Deafness and hearing Loss, speaks to Linda Parton, a patient who wears hearing aids, about the challenges accessing GP services if you have a hearing loss and how GPs can help support patients in the community. This episode is packed with useful information for clinicians and is a must for anyone who would like to better support the needs of people with hearing loss. She also speaks to Frankie Oliver, an audiologist, about the range of services and technology used by audiology services. These podcasts were recorded in February 2020 in London.

Podcast transcript

Deafness and hearing loss in primary care: In conversation with a GP and an ENT surgeon

This podcast has been produced for primary care clinicians who care for patients with deafness and hearing loss. Dr Devina Maru, GP Specialist Registrar and RCGP Clinical Champion for Deafness and hearing Loss, speaks to Dr Graham Easton, a GP with interest in ENT and contributor to NICE guideline development on hearing loss. She also interviews former ENT surgeon, Dr Krishan Ramdoo, now GP Speciality Registrar and NHS England Clinical Entrepreneur, who has developed an innovative product to improve wax removal services. Both discuss better ways GPs can help support patients in the community.

This episode is packed with useful information for clinicians and is a must for anyone who would like to better support the needs of people with hearing loss. These podcasts were recorded in February 2020 in London.

Podcast transcript

COVID-19 and Patients with Deafness and Hearing Loss

Last update 3 September 2020

Communication Tips

A document from charity RNID, giving some simple accessibility tips for ensuring good communication with patients (129 KB DOC) with deafness and hearing loss during the pandemic.

Remote Consulting

Some tips for remote consulting:

  • Ask for and meet communication needs where possible Instead of using the telephone, where possible use video conferencing tools and add live captioning through video conferencing software
  • Utilise RelayUK for people with hearing loss
  • Utilise Video Relay Services, such as InterpreterNow, for British Sign Language users

British Sign Language (BSL) interpreters

BSL Health Access service provides immediate, on-demand access to BSL interpreters for communication with Deaf people in all health settings, including pharmacy, opticians, general practice and dentists, free of charge during the current coronavirus situation. Access to BSL interpreters take place through two methods: Video Relay Services (VRS)—when a BSL interpreter relays information over a telephone call between a BSL user and the hearing person receiving or making the call; and Video Remote Interpreting (VRI)—where a remote interpreter is used to facilitate communication with a Deaf and hearing person in the same location.

Audiology services in the UK

Audiology and Otology guidance during COVID-19 (1.61 MB PDF) - from UK's audiology professional bodies - 1 September 2020


Articles for Further Reading

Further Reading

Positioning manoeuvres to diagnose BPPV

  • British Society of Audiology: Position tests (PDF)
  • Uneri A, Polat S. Vertigo, dizziness and imbalance in the elderly. J Laryngol 546 Otol 2008; 122: 466-9.
  • Dix MR, Hallpike CS. The pathology, symptomatology and diagnosis of certain 515 common disorders of the vestibular system. Proc Royal Soc Med 1952; 45: 516 341-354.
  • Baloh RW, Honrubia V, Jacobson K. Benign positional vertigo: clinical and 502 oculographic features in 240 cases. Neurology 1987; 37: 371-378.

Repositioning Manoeuvres

Vestibular Migraine Management

  • NICE CKS: Scenario: Migraine in adults
  • Li Vivien, McArdle Helen, Trip S Anand. Vestibular migraine BMJ 2019; 366 :l4213
  • Dieterich M, Obermann M, Celebisoy N. Vestibular migraine: the most frequent entity of episodic vertigo. J Neurol. 2016;263 Suppl 1:S82–S89. doi:10.1007/s00415-015-7905-2
  • Kaski, D. Neurological update: dizziness. J Neurol (2020).

Abnormal Head Impulse Test: Central vs Peripheral

  • Huh YE, Kim JS. Bedside evaluation of dizzy patients. J Clin Neurol. 2013;9(4):203–213. doi:10.3988/jcn.2013.9.4.203
  • Baloh, R. W. (1998). Differentiating between peripheral and central causes of vertigo. Otolaryngology–Head and Neck Surgery, 119(1), 55–59.

HINTS Exam- Ruling out Central Pathology