Intended for healthcare professionals

Practice Rational Testing

Investigating sudden hearing loss in adults

BMJ 2018; 363 doi: (Published 12 November 2018) Cite this as: BMJ 2018;363:k4347
  1. Jonathan M Fishman, ear, nose, and throat consultant, honorary clinical lecturer, senior editor123,
  2. Laura Cullen, general practitioner, partner4
  1. 1The Royal National Throat, Nose and Ear Hospital, University College London Hospitals NHS Foundation Trust, London, UK
  2. 2University College London Ear Institute, London, UK
  3. 3The Journal of Laryngology and Otology, Cambridge University Press
  4. 4Heathfielde Medical Centre, London, UK
  1. Correspondence to J Fishman j.fishman{at}

What you need to know

  • Pure tone audiometry is the gold standard investigation to diagnose the type and severity of hearing loss

  • Offer referral for people with sudden sensorineural hearing loss, which is an acute otological emergency

  • Magnetic resonance imaging is recommended to rule out acoustic neuroma as a cause for sudden sensorineural hearing loss

A 55 year old woman presented with difficulty in hearing from the left ear. She first noticed this when she found it difficult to hear her husband over dinner yesterday. She also described a feeling of dizziness, where the room spins around, and ringing in the left ear. She was otherwise well. Clinical examination revealed a normal tympanic membrane.

Hearing loss affects 1 in 6 adults and has an enormous personal, social, and economic impact.1 Patients may be frightened by the sudden loss of hearing, and tinnitus can cause anxiety. Prompt diagnosis and management may improve hearing recovery.2

In this article, we review the assessment of sudden hearing loss in adults and provide an overview on initial diagnostic tests. A lack of specialist diagnostic tests within the primary care setting makes the condition challenging to diagnose, and an awareness and high index of suspicion are required when non-specialists are faced with a patient with acute hearing loss.

Box 1 lists common causes of conductive and sensorineural hearing loss.

Box 1

Common causes of adult onset hearing loss

Conductive hearing loss

Caused by any pathology in the external ear, tympanic membrane, middle ear air space, or ossicles, ie, structures that “conduct” sound waves to the cochlea:

  • ear wax and foreign bodies

  • otitis externa

  • otitis media (acute or chronic; serous or suppurative) ‡

  • tympanic membrane perforation

  • cholesteatoma

  • temporal bone trauma (resulting in haemotympanum or ossicular disruption) *

  • otosclerosis (stapes fixation)

Sensorineural hearing loss

Caused by abnormalities of the cochlea, auditory nerve, or other structures that translate neural impulses to the brain:

  • presbycusis (age related hearing …

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