Intended for healthcare professionals

Practice Rational Testing

Investigating sudden hearing loss in adults

BMJ 2018; 363 doi: https://doi.org/10.1136/bmj.k4347 (Published 12 November 2018) Cite this as: BMJ 2018;363:k4347

Re: Investigating sudden hearing loss in adults

We thank the authors, Hampton and Webb, for their letter dated 9 December 2018 in response to our article.1

As the authors mention, the ‘hum test’ may be a useful alternative where tuning forks are not immediately available in primary care settings. In addition, we are also aware of smartphone-based vibration applications being used to provide equivalent accuracy to tuning forks for assessment post-tympanomastoid surgery (e.g. iBrateMe© application on iPhone).

Cogan’s syndrome was mentioned in Box 1 to illustrate an example of autoimmune inner ear disease which results in sensorineural hearing loss. While we appreciate that Cogan’s syndrome is rare, this is true of autoimmune causes of hearing loss in general. We acknowledge that Granulomatosis with Polyangiitis and Eosinophilic Granulomatosis with Polyangiitis may also cause autoimmune sensorineural hearing loss and we thank the authors for bringing this to the readers’ attention, although one would expect other associated systemic features with these, such as sinonasal involvement (including nasal septal perforations), lung and/or renal abnormalities in the case of GPA, rather than hearing loss in isolation. However, we appreciate that hearing loss in isolation may be the initial manifestation of such systemic conditions.

We would like to point out that our article made no reference to “pituitary apoplexy” which has been misread and misunderstood by Hampton and Webb. Rather, the term “apoplexy” is used in Box 1 in relation to vascular causes of sensorineural hearing loss. “Apoplexy” in this context refers to hearing loss resulting from vascular insufficiency to the cochlea and auditory pathways.

We believe that Hampton and Webb have confused the terms “red flags for referral” with “referral on a two-week wait pathway”. The terms are not synonymous and it should be pointed out that we made no mention of referrals on two-week wait cancer pathways within the article. The term “red flag” in the context of Box 3 is used to guide GPs as to which patients should be referred on to ENT rather than being managed solely in primary care. We recommend that any patient experiencing the symptoms and signs listed in Box 3 be referred to ENT. Otherwise, the additional information provided by Hampton and Webb provides some useful guidance on the timing of referrals.

Jonathan M Fishman, ENT Consultant, The Royal National Throat, Nose & Ear Hospital, University College London Hospitals NHS Foundation Trust, London, UK

Laura M Cullen, GP Partner, Heathfielde Medical Centre, London, UK

References
1 Fishman JM, Cullen L. Investigating sudden hearing loss in adults. BMJ 2018;363:k4347. 10.1136/bmj.k4347

Competing interests: No competing interests

11 December 2018
Jonathan M Fishman
ENT Consultant Surgeon
Laura M Cullen, GP Partner, Heathfielde Medical Centre, London, UK
The Royal National Throat, Nose & Ear Hospital, University College London Hospitals NHS Foundation Trust, London, UK
The Royal National Throat, Nose & Ear Hospital, University College London Hospitals NHS Foundation Trust, London, UK