Common Red Flags and 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.

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.

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.

Additional information and further reading: