NICE guidance - referral criteria for deafness in adults

Last edited 09/2018 and last reviewed 07/2021

Referral criteria for deafness (1):

Hearing difficulties or suspected 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 arrange an audiological assessment and
  • refer for additional diagnostic assessment if needed

Sudden or rapid onset of hearing loss

• refer adults with sudden onset or rapid worsening of hearing loss in one or both ears, which is not explained by external or middle ear causes, as follows:
  
  
  • if the hearing loss developed suddenly (over a period of 3 days or less) within the past 30 days
    • immediate referral (to be seen within 24 hours) to an ear, nose and throat service or an emergency department
      
      
  • if the hearing loss developed suddenly more than 30 days ago
    • urgent referral (to be seen within 2 weeks) to an ear, nose and throat or audiovestibular medicine service
      
      
  • if the hearing loss worsened rapidly (over a period of 4 to 90 days)
    • urgent referral (to be seen within 2 weeks) to an ear, nose and throat or audiovestibular medicine service

Hearing loss with specifific additional symptoms or signs

• adults with acquired unilateral hearing loss and altered sensation or facial droop on the same side
  • refer immediately (to be seen within 24 hours) to an ear, nose and throat service or, if stroke is suspected, follow a local stroke referral pathway
    
    
• adults with hearing loss who are immunocompromised and have otalgia (ear ache) with otorrhoea (discharge from the ear) that has not responded to treatment within 72 hours
  • refer immediately (to be seen within 24 hours) to an ear, nose and throat service
    
    
• for adults of Chinese or south-east Asian family origin who have hearing loss and a middle ear effusion not associated with an upper respiratory tract infection (see notes)
  • consider an urgent referral (to be seen within 2 weeks) to an ear, nose and throat service
    
    
• referral for adults with hearing loss that is not explained by acute external or middle ear causes should be considered to an ear, nose and throat, audiovestibular medicine or specialist audiology service for diagnostic investigation, using a local pathway, if they present with any of the following:
  • unilateral or asymmetric hearing loss as a primary concern
  • hearing loss that fluctuates and is not associated with an upper respiratory tract infection
  • 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 changed in nature or is causing distress
  • vertigo that has not fully resolved or is recurrent hearing loss that is not age related
    
    
• referral for adults with hearing loss should be considered to an ear, nose and throat service if, after initial treatment of any earwax or acute infection, they have any of:
  • partial or complete obstruction of the external auditory canal that prevents full examination of the eardrum or taking an aural impression
  • pain affecting either ear (including in and around the ear) that has lasted for 1 week or more and has not responded to first-line treatment
  • a history of discharge (other than wax) from either ear that has not resolved, has not responded to prescribed treatment, or recurs
  • abnormal appearance of the outer ear or the eardrum, such as:
    • inflammation
    • polyp formation
    • perforated eardrum
    • abnormal bony or skin growths
    • swelling of the outer ear
    • blood in the ear canal
  • a middle ear effusion in the absence of, or that persists after, an acute upper respiratory tract infection

Notes:

• unilateral persistent middle ear effusion not associated with upper respiratory tract infection in people of Chinese and South-East Asian family origin (1)
  • there is a high incidence of nasopharyngeal carcinoma in people of Chinese and South-East Asian family origin and presentation is often a middle ear effusion not associated with, or not resolving after, an upper respiratory tract infection (1)
  • in most parts of the world, nasopharyngeal carcinoma (NPC) occurs at an annual incidence rate of <1/100,000, yet in South East Asia and Southern China, it is endemic (2)
    • NPC appears to be most widespread in central of Guangdong province, where the city of Sihui, for instance, shows incidence rates of 30.94/100,000 in males and 13.00/100,000 in females (2)
  • this condition is also more common in other racial groups such as those from North Africa and Eskimos but is generally rare in people of European family origin (1)
  • NICE assessed this scenario as likely to be associated with a positive predictive value of 3% or above for nasopharyngeal carcinoma and should prompt the clinician to consider urgent referral (1)

Reference:

• NICE (June 2018). Hearing loss in adults: assessment and management
• Hong-Lian R et al. Developing Genetic Epidemiological Models to Predict Risk for Nasopharyngeal Carcinoma in High-Risk Population of China. PLoS One. 2013; 8(2): e56128.