Hearing loss and ear wax

20th August 2018 by Louise Hudman

Hearing loss and ear wax

This is a new guideline from NICE on managing hearing loss and ear wax, published in June 2018. Exciting? Well, there are a couple of good bits in here, especially given how common a problem this is. Some top tips that were new for me:

  • Consider an urgent referral to ENT for someone of Chinese or South East Asian origin with hearing loss AND a middle ear infusion, which is not due to an URTI.
  • Consider referring patients with newly diagnosed dementia, or people with learning disabilities for a hearing assessment every 2 years. Also consider referring at diagnosis for people with dementia and on transfer to adult services for people with a learning disability.
  • NICE advises that we should NOT be advising patients to use home syringing kits. See below for more detail on why this is.
  • GP surgeries should be offering irrigation for wax removal, or aural probing.
  • Drops don’t have to be used for several days before irrigation. Studies suggest that using drops immediately before irrigation is safe and effective.
  • If irrigation is unsuccessful, then water can be instilled 15 mins before a second attempt, or a 5 day course of drops can be advised.
  • What drops to suggest patients use? NICE advises that any can be used, even hydrogen peroxide, which has gone out of fashion a bit. See below for more detail on this (I know it’s a bit trivial, but it always really annoys me that I don’t know the evidence base for something we advise on all the time).

Hearing loss and when to refer

Sudden or rapidly worsening hearing loss

Patients should be referred whether it is unilateral or bilateral if it is not explained by external or middle ear problems.

  • Sudden loss (i.e. developed suddenly over 3d or less) in the last 30d – refer immediately (within 24 hrs) to ENT or ED.
  • Sudden loss > 30d ago – refer urgently (within 2w) to ENT or an audiovestibular service.
  • Rapidly worsening loss (ie 4 to 90d) refer urgently (within 2w) to ENT or an audiovestibular service.

Hearing loss with other signs or symptoms

Refer immediately (to be seen within 24 hrs) to ENT if:

  • Acquired unilateral hearing loss AND altered sensation OR facial droop on the same side. NB If stroke is suspected then obviously manage as that.
  • Hearing loss in immunocompromised patients with otalgia AND otorrhoea IF treatment hasn’t worked within 72 hrs (beware malignant otitis externa).


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