Intended for healthcare professionals

Practice Guidelines

Hearing loss in adults, assessment and management: summary of NICE guidance

BMJ 2018; 361 doi: https://doi.org/10.1136/bmj.k2219 (Published 22 June 2018) Cite this as: BMJ 2018;361:k2219
cropped thumbnail of infographic

Hearing loss: triaged referral

A summary of new NICE guidelines

  1. Saoussen Ftouh, senior research fellow1,
  2. Katherine Harrop-Griffiths, retired consultant in audiovestibular medicine (paediatric)2,
  3. Martin Harker, health economics lead1,
  4. Kevin J Munro, professor of audiology3,
  5. Ted Leverton, retired general practitioner, clinical advisor for RCGP4
  6. on behalf of the Guideline Committee
  1. 1National Guideline Centre, Royal College of Physicians, London NW1 4LE, UK
  2. 2Royal National Throat Nose and Ear Hospital, UCLH NHS Foundation Trust, London WC1X 8DA
  3. 3Manchester Centre for Audiology and Deafness, School of Health Sciences, University of Manchester, Manchester M13 9PL, UK
  4. 4Bere Alston, Devon
  1. Correspondence to: S Ftouh saoussen.ftouh{at}rcplondon.ac.uk

What you need to know

  • In those with sudden hearing loss, unilateral hearing loss with neurological signs, or otitis externa unresponsive to treatment in an immunocompromised patient offer immediate referral to ear, nose, and throat services (ENT) or accident and emergency department

  • Early audiological assessment for suspected hearing loss is recommended. Be proactive and offer an audiological assessment if you suspect hearing loss in patients seeing you for other reasons; they may be unaware of their hearing loss.

  • Early fitting of bilateral hearing aids is cost effective and is recommended.

  • People with dementia, mild cognitive impairment, or learning difficulties should have regular hearing assessments.

  • Earwax: offer ear drops followed by irrigation or, where available, microsuction, to remove earwax. Ear drops can be used 15-30 minutes before ear irrigation to avoid unnecessary delay

Hearing loss is common—Over 9 million people in England123 have hearing loss and this is increasing with the ageing population (fig 1).4 Hearing loss ranks third for disease burden in England (years lived with disability).5 The average GP sees at least four patients every day who have hearing loss sufficient to interfere with their ability to communicate with ease.

Fig 1
Fig 1

Estimated prevalence of people with hearing loss in the better hearing ear of ≥25 dB by age band in England4

Hearing loss is disabling—It affects communication at work and home, affecting educational attainment, employment opportunities, personal relationships, enjoyment of music, and social independence. It can lead to significant reduction in people’s quality of life and is associated with mental health problems including depression and dementia.

Hearing loss is expensive—The overall economic burden associated with hearing loss in adults in the UK is estimated to be more than £30bn per year.67

Hearing loss can be managed successfully—Early and effective intervention can minimise the impact of hearing loss on the individual and on his or her family.

The guideline covers adults (≥18 years old) with hearing loss, including those with onset before the age of 18 but presenting for the first time in adulthood. This includes acquired and late-onset genetic hearing loss. It excludes adults who presented with hearing loss before the age of 18.

This article summarises the most recent recommendations from the National Institute for Health and Care Excellence (NICE) on the assessment and management of hearing loss in adults.8 It focuses on those areas of most relevance to primary and community care.

Recommendations

NICE recommendations are based on systematic reviews of best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Committee’s experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets.

How might a clinician in primary or community care manage a person presenting with hearing difficulties?

  • For adults who present for the first time with hearing difficulties, or in whom you suspect hearing difficulties:

    • Exclude impacted wax and acute infections such as otitis externa, then

    • Refer to audiology services for an assessment and

    • Refer for additional medical assessment if needed (see infographic for details).

      [Based on the experience and opinion of the Guideline Committee (GC)]

Most adults have hearing loss as a consequence of age or chronic noise exposure, which requires no further investigation of cause. A few will have hearing loss that requires additional medical assessment.

See below for timings and criteria for people needing immediate and urgent referral. See also box of red flags particularly for clinically important referrals, and the infographic for information on people needing referral for medical care.

Red flags for referral for hearing loss

  • Sudden onset or rapidly progressive hearing loss

  • Hearing loss and additional localising symptoms and signs

  • Otalgia and otorrhoea in an immunocompromised patient

  • Otorrhoea (not wax) from either ear that has not resolved, has not responded to prescribed treatment, or recurs

  • A middle ear effusion unrelated to upper respiratory tract infections in a person of Chinese or South-East Asian family origin (nasopharyngeal carcinoma is common in this ethnic group)

  • Abnormal appearance of the ear canal or drum: polyp or squamous debris, posterior or superior perforation, mass, unexplained bleeding

How quickly should people be referred for a specialist medical opinion?

Immediate referral (to be seen within 24 hours)

  • Sudden hearing loss (occurring over a period of ≤3 days) within 30 days—Refer to ear, nose, and throat services (ENT) or emergency department.

  • Acquired unilateral hearing loss with ipsilateral fifth or seventh cranial nerve symptoms and signs—Refer to ENT or, if stroke is suspected, follow local stroke referral pathway.

  • Immunocompromised adults with hearing loss, otalgia, and otorrhoea unresponsive to treatment within 72 hours—Refer to ENT.

    [Based on the experience and opinion of the GC]

Urgent referral (to be seen within 2 weeks)

  • Sudden hearing loss >30 days ago—Refer to ENT or audiovestibular medicine services (AVM).

  • Rapid-onset hearing loss (occurring between 4 and 90 days)—Refer to ENT or AVM.

  • Middle ear effusion not associated with an upper respiratory tract infection in people of Chinese or South-East Asian family origin—Consider referral to ENT.

    [Based on the experience and opinion of the GC]

Offer proactive assessment of hearing in specific groups

  • Because of a high incidence of hearing loss and poor ability to recognise hearing difficulties, consider referring for hearing assessment every two years:

    • Adults with diagnosed or suspected dementia or mild cognitive impairment. [Based on the experience and opinion of the GC and original cost-effectiveness evidence]

    • Adults with diagnosed learning disability. [Based on the experience and opinion of the GC]

Investigation using magnetic resonance imaging (MRI) for suspected vestibular schwannoma

MRI is the investigation of choice when there is concern about the possibility of a vestibular schwannoma or cerebellopontine angle (CPA) tumour. Request for scanning should occur after treatment for impacted earwax or acute infections to exclude the possibility of a temporary hearing loss.

  • Offer MRI of the internal auditory meati to adults with hearing loss and localising symptoms or signs (such as facial nerve weakness, reduced sensation in the distribution of the trigeminal nerve, unilateral tinnitus) that might indicate a vestibular schwannoma or CPA lesion, irrespective of pure tone thresholds.

  • Consider MRI of the internal auditory meati for adults with sensorineural hearing loss and no localising signs if there is an asymmetry on pure tone audiometry of 15 dB or more at any two adjacent test frequencies, using test frequencies of 0.5, 1, 2, 4, and 8 kHz.

    [Based on very low to low quality evidence from prospective and retrospective cohort studies and the experience and opinion of the GC]

How should earwax be managed?

  • Offer to remove earwax for adults in primary care or community ear care services. [Based on very low to low quality evidence from randomised controlled trials and the experience and opinion of the GC]

  • Do not use manual ear syringing to remove earwax. This is inherently dangerous because of the high pressures that can be achieved which can cause damage. [Based on the experience and opinion of the GC]

  • Consider removing earwax by ear irrigation using an electronic irrigator, microsuction, or manual removal using a probe. [Based on very low to moderate evidence from randomised controlled trials]

  • If using electronic irrigation:

    • Use pre-treatment wax softeners, either immediately (water or sodium bicarbonate ear drops can be used 15-30 minutes before irrigation) or for up to five days beforehand.

    • Repeat once if needed before referral to a specialist ear care service or an ear, nose, and throat service for earwax removal.

      [Based on very low to moderate evidence from randomised controlled trials and the experience and opinion of the GC]

How can clinicians ensure that people with hearing difficulties are able to participate in their care?

Enable people with hearing difficulties to actively participate in their care by, for example:

  • Taking measures, such as reducing background noise, to ensure that the clinical and care environment is conducive to communication for people with hearing loss, particularly in group settings such as waiting rooms, clinics, and care homes.

  • Establishing the most effective way of communicating with each person, including the use of hearing loop systems and other assistive listening devices.

  • Ensuring that all healthcare staff are trained and have demonstrated competence in communication skills for people with hearing loss.

    [Based on low to moderate quality evidence from qualitative studies and the experience and opinion of the GC]

Assessment and management in audiology services

  • The need for hearing intervention should not be based on a pure tone audiogram alone, but on a comprehensive assessment by an audiologist. After assessment, a personalised care plan should be discussed and shared. [Based on the experience and opinion of the GC]

  • Different options for managing hearing needs should be discussed including personal hearing aids, listening devices for home, and hearing tactics. [Based on the experience and opinion of the GC]

  • Offer hearing aids to adults whose hearing loss affects their ability to communicate and hear. [Based on very low and moderate quality evidence from randomised controlled trials and original cost-effectiveness evidence]

  • Offer two hearing aids to adults with hearing loss in both ears if conversational speech can be amplified to a comfortable listening level in each ear. [Based on very low quality evidence from crossover studies and original cost-effectiveness evidence]

  • Offer adults a face-to-face audiology appointment 6-12 weeks after the hearing aids are fitted, with the option to attend this appointment by telephone or electronic communication if the patient prefers. [Based on the experience and opinion of the GC and original cost-effectiveness evidence]

  • Following hearing aid prescription and fitting, aftercare provided by a hearing health professional is important for continuing use of hearing aids. [Based on very low to high quality evidence from randomised controlled trials]

  • Audiology services should consider having a system in place for recalling people who use hearing devices for regular reassessment of their hearing needs and devices. [Based on the experience and opinion of the GC]

The guideline also makes recommendations pertinent to audiology care. These include the content of the appointments, aspects of hearing aid prescription and fitting, assistive listening devices, strategies to support hearing aid use, and cases where onward referral to specialist services should be considered.

Implementation

Most of the recommendations involve changes to practice requiring training and application. Local arrangements for prompt and effective earwax management may need review. The Guideline Committee noted the development of community-based ear care clinics and suggests further research into models of care. The Guideline Committee is also aware that there will be an increase in demand for audiological services, but expects that reorganisation to provide more effective care will limit that burden. Better support and follow-up is likely to improve hearing aid use, which should reduce the need for repeat GP consultation as well as improve quality of life for many.

A patient’s perspective from Ted Leverton

As a former GP, I welcome the guideline as a step to improving the primary care experience of people like myself who have hearing loss:

  • It will help GPs during around four consultations a day, and benefit their care of 70% of people in my age bracket

  • The clear statement on the clinical and cost effectiveness of early referral should lay to rest suggestions that GPs sometimes dissuade patients from being referred and getting hearing aids

  • Clinical commissioning groups now have clarity that I really can’t hear properly with only one hearing aid working

  • It specifies that, as soon as I have consulted my GP about my hearing loss, I need support and possibly hearing aids. The hearing loss which carried the audiometric descriptor of “mild hearing loss” can result in debilitating problems with understanding speech against background noise

  • Primary care nurses will be pleased with the simpler approach to wax removal, speeding up around two million consultations a year in the UK

  • Audiologists have been given a clear message to ensure patients are consistently supported with advice, care, and follow-up, and encouraged to discuss personal listening devices such as those without which the three of us on this NICE Guideline Committee could not carry out voluntary work or sit on the committee

  • Patients will be delighted to have a personalised care plan and the information needed to improve their quality of life and reduce isolation

  • I will be much more comfortable in NHS and care settings where the ambiance takes account of those with a hearing loss (such as reducing background noise) and where staff are trained to communicate effectively with those with a hearing loss. Maybe I will no longer miss my turn because I can't hear my name called, and I won't have to make an extra appointment because I did not hear everything said to me.

Guidelines into practice

  • Do you, after excluding an acute and treatable cause, refer promptly those complaining of hearing difficulty for an audiological assessment at first presentation?

  • Is your practice deaf aware? Have all your practice staff had training, and demonstrated competence, in communication skills for people with hearing loss?

  • Are your patients able to get prompt and effective earwax removal?

How patients were involved in the creation of this article

This NICE guideline committee had three members with moderately severe hearing loss who contributed significantly to the formulation of the recommendations summarised here. Two were lay members, and the third was a retired GP who is one of the authors of this article.

Further information on the guidance

Methods

  • The guideline was developed following standard NICE guideline methodology.9

  • The Guideline Committee (GC) developed clinical questions, collected and appraised clinical evidence, and evaluated the cost effectiveness of proposed interventions and management strategies through literature review and economic analysis. Evidence was discussed, and appropriate recommendations were made based on the evidence presented and on the experience and opinion of the GC where evidence was lacking.

  • Quality ratings of the evidence were based on GRADE methodology10 or an adapted GRADE methodology for qualitative and diagnostic reviews. These relate to the quality of the available evidence for assessed outcomes rather than the quality of the clinical study.

  • Original cost-effectiveness analysis was conducted for this guideline. A lifetime economic model was constructed of a hearing loss pathway comparing no treatment, early use of hearing aids, and delayed use of hearing aids. Additional analyses considered regular assessment of people with dementia, and compared the use of one or two hearing aids in people with bilateral hearing loss.

  • The draft guideline went through a rigorous reviewing process, in which stakeholder organisations were invited to comment; the group took all comments into consideration when producing the final version of the guideline. The guideline is available in three formats: a full version (www.nice.org.uk/guidance/ng98/evidence), a short version (www.nice.org.uk/guidance/ng98), and an online pathway (https://pathways.nice.org.uk/pathways/hearing-loss).

Future research

The full list of research recommendations is provided in the guideline and appendices but priorities include:

  • What is the most effective route of administration of steroids as a first-line treatment for idiopathic sudden sensorineural hearing loss?

  • What is the clinical and cost effectiveness of microsuction compared with irrigation to remove earwax?

  • In adults with hearing loss, does the use of hearing aids reduce the incidence of dementia?

  • What is the prevalence of hearing loss among populations who under-present for possible hearing loss?

  • What is the clinical and cost effectiveness of monitoring and follow-up for adults with hearing loss post-intervention compared with usual care?

Acknowledgments

Guideline Committee members were: Katherine Harrop-Griffiths (chair), Graham Easton, Melanie Ferguson, Julia Garlick, Richard Irving, Ted Leverton, Kevin Munro, Rudrapathy Palaniappan, Linda Parton, Neil Pendleton, Jane Wild. The co-opted expert advisors were Michael Ackeroyd, Caroline Carr, Chris Armitage, Steve Connor, Helen Gallacher and Padraig Kitterick. The members of the National Guideline Centre technical team were: Gill Ritchie (Guideline Lead), Saoussen Ftouh (Senior Research Fellow), Martin Harker (Health Economics Lead), Giulia Zuodar (Project Manager, from January 2017), Joanna Ashe (until November 2016), Katie Broomfield, Katrina Davis (until June 2016), Lefteris Floros (until November 2016), Lina Gulhane (from November 2016), Rishi Mandavia, Natalie Pink (until November 2016), Silvia Rabar (from February 2017), Joseph Runicles (from September 2017) and Eleanor Samarasekera (from October 2016 to July 2017).

Footnotes

  • Contributors: All authors contributed to the initial draft of this article, helped revise the manuscript, and approved the final version for publication. KHG is the guarantor.

  • Funding: This guideline was developed by the National Guideline Centre which received funding from the National Institute for Health and Care Excellence. The views expressed in this publication are those of the authors and not necessarily those of NICE

  • Competing interests: We declare the following interests based on NICE's policy on conflicts of interests (available at www.nice.org.uk/Media/Default/About/Who-we-are/Policies-and-procedures/code-of-practice-for-declaring-and-managing-conflicts-of-interest.pdf): Ted Leverton, retired GP, volunteer for Action on Hearing Loss, and clinical adviser for the Royal College of General Practitioners. The authors’ full statements can be viewed at www.nice.org.uk/guidance/ng98.

References

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