Hearing loss: assessment and management — the AU general practice approach

Hearing loss affects approximately one in six Australians — around 3.6 million people — and remains substantially underdiagnosed and undertreated in general practice. Prevalence rises steeply with age: roughly 50% of Australians over 60 and 75% of those over 75 have measurable hearing impairment, most commonly the progressive bilateral high-frequency sensorineural loss of age-related presbycusis. At the other end of the life course, permanent congenital hearing loss affects 1–2 per 1,000 newborns and is the most common sensory impairment in childhood, with consequences for speech, language, and education that grow more severe the later intervention begins.

The 2024 Lancet Commission on Dementia Prevention elevated hearing loss to the single most important modifiable risk factor for dementia — larger than physical inactivity, smoking, and social isolation combined. This places the identification and management of hearing loss squarely within the preventive-health remit of Australian general practice.

Hearing loss is classified by anatomy (conductive, sensorineural, mixed, central), tempo (congenital, acute sudden, progressive, fluctuating), severity (mild 26–40 dB, moderate 41–60 dB, severe 61–80 dB, profound above 81 dB), and laterality. Each dimension shapes the differential and the management pathway.

A. Core clinical — the AU general-practice framework

Taking a hearing history

Establish onset — sudden within 72 hours versus progressive over months or years — alongside laterality and severity. Ask specifically about:

• Tinnitus — associated with sensorineural pathology; if pulsatile, consider vascular cause (glomus tumour, AVM, dural sinus thrombosis, carotid atherosclerosis).
• Vertigo or dizziness — suggests Meniere’s disease, vestibular schwannoma, or labyrinthitis.
• Otalgia — acute otitis media, otitis externa, or referred pain from temporomandibular joint or cervical spine.
• Otorrhoea — chronic suppurative otitis media, cholesteatoma, or, rarely, malignancy.
• Aural fullness — Meniere’s disease, Eustachian tube dysfunction, or sudden sensorineural hearing loss.
• Facial weakness — always a red flag: Ramsay Hunt syndrome, cholesteatoma, vestibular schwannoma, Bell’s palsy, or brainstem lesion.

Screen for occupational or recreational noise exposure (workshops, construction, concerts, personal audio devices), ototoxic medications (aminoglycosides, cisplatin, loop diuretics, NSAIDs at high chronic doses, quinine, hydroxychloroquine), family history, and prior ear infections or surgery. Functional impact deserves direct assessment: social withdrawal, depression, relationship strain, occupational difficulty, and falls risk all associate with untreated hearing loss.

Clinical examination

eTG complete and RACGP guidelines recommend:

• Bilateral otoscopy — cerumen, tympanic membrane appearance (perforation, retraction, cholesteatoma, effusion, foreign body).
• Tuning fork tests (512 Hz): Weber test — sound placed on the skull vertex, lateralises to the worse ear in conductive loss and to the better ear in sensorineural loss. Rinne test — air conduction versus bone conduction; bone greater than air is a positive Rinne (abnormal, suggesting conductive loss).
• Whisper test at 60 cm — useful screen when audiometry is unavailable.
• Cranial nerve assessment — V (corneal sensation), VII (facial movement), VIII (balance testing).
• Vestibular screen — head impulse test, nystagmus assessment, Romberg, Dix-Hallpike (BPPV).
• Speech and language milestones in paediatric presentations.

Investigations

• Pure-tone audiometry (PTA) — gold standard. Air conduction (250 Hz–8 kHz) and bone conduction; the air–bone gap localises conductive loss. MBS item 11324.
• Tympanometry — middle ear pressure and mobility. Type A: normal. Type B: flat, suggesting effusion or perforation. Type C: negative pressure (Eustachian dysfunction). MBS item 11332.
• Otoacoustic emissions (OAE) — cochlear hair cell function; newborn screening and when audiometry is difficult.
• Auditory brainstem response (ABR) — diagnostic in newborns; neural pathway integrity.
• MRI internal auditory meati — essential for all cases of asymmetric or unilateral sensorineural hearing loss; excludes vestibular schwannoma and brainstem pathology.
• CT temporal bones — otosclerosis, congenital malformations, cholesteatoma extent assessment.
• Bloods (selective): FBC, ESR, ANA, syphilis serology, autoimmune markers for suspected autoimmune inner ear disease; CMV PCR (urine or saliva) before 3 weeks of age for congenital hearing loss.

B. Sudden sensorineural hearing loss — the otological emergency

Sudden sensorineural hearing loss (SSNHL) is defined as ≥30 dB of sensorineural hearing loss across at least three contiguous audiometric frequencies within 72 hours. It is an otological emergency because the treatment window for steroid therapy narrows sharply beyond two weeks from onset.

SSNHL affects approximately 5–20 per 100,000 people per year and is most commonly idiopathic (~85–90%), with proposed mechanisms including viral cochleitis, cochlear microvascular ischaemia, and autoimmune injury. Spontaneous recovery occurs in roughly 30% of cases without treatment, making all cases candidates for intervention.

Treatment per eTG and the AAO-HNS Clinical Practice Guideline 2019:

• Oral prednisolone 1 mg/kg/day (maximum 60 mg) for 7–14 days then taper. Initiate as early as possible within the two-week window.
• Intratympanic methylprednisolone (40 mg/mL weekly ×3) if oral steroids are contraindicated or as salvage at two weeks after failed oral treatment.
• Avoid noise exposure and ototoxic drugs during the recovery period.
• MRI internal auditory meati once stable, to exclude vestibular schwannoma.
• Audiological reassessment at 4–6 weeks to document recovery or residual loss.

Referral: Same-day or next-day referral to an Audiology Australia-accredited audiologist and ENT surgeon is the standard of care. If audiometry is not immediately available in general practice, initiate prednisolone (if not contraindicated) and refer urgently — do not wait for audiological confirmation before prescribing. Document the time of symptom onset; this is medico-legally important.

Red flag features associated with SSNHL requiring MRI: asymmetric loss, pulsatile tinnitus, facial weakness, vestibular schwannoma risk factors (neurofibromatosis type 2 family history), suspected autoimmune inner ear disease (bilateral rapid progressive loss with systemic autoimmune markers), and barotrauma-related perilymph fistula.

C. Chronic progressive hearing loss and rehabilitation

Presbycusis

Presbycusis is age-related sensorineural hearing loss — the most common cause of hearing impairment in Australian adults. It begins with bilateral symmetrical high-frequency loss (4–8 kHz), extending to mid-frequencies over years. Loss of outer hair cells in the cochlear base produces the characteristic functional deficit: difficulty hearing consonants and following speech in background noise, while pure tones in a quiet room may still be perceived reasonably well. This explains the common patient complaint: “I can hear, I just can’t understand.”

Management is hearing aids and communication strategies. Modern hearing aids incorporate directional microphones, background noise suppression, and Bluetooth integration. Bilateral fitting is preferred when bilateral loss is present. NICE NG98 and NHMRC guidance both support prompt hearing aid fitting rather than deferral. Cognitive decline risk reduction is an additional evidence-based reason to fit aids early.

Noise-induced hearing loss

Occupational and recreational noise exposure — workshops, construction, concerts, personal audio devices — causes permanent outer hair cell damage with a classical “4 kHz notch” on audiometry. Prevention is the only effective intervention; damage is irreversible. Safe Work Australia specifies the occupational standard: LAeq,8h 85 dB(A) or peak 140 dB. Approximately 1.6 million Australians have noise-induced hearing loss. GPs managing working-age adults in noisy industries should support referral for baseline and annual audiometry and document noise exposure history for workers’ compensation purposes.

Meniere’s disease

Meniere’s disease is characterised by episodic vertigo (20 minutes to several hours), tinnitus, aural fullness, and fluctuating low-frequency sensorineural hearing loss. The underlying mechanism is endolymphatic hydrops. Low-frequency loss may become permanent over years. Management includes low-sodium diet (below 2 g/day), betahistine 16 mg three times daily per eTG (evidence is moderate; trial and discontinue if no benefit at 3 months), and ENT referral for refractory cases (intratympanic gentamicin or steroid, endolymphatic sac surgery).

Otosclerosis

Otosclerosis is abnormal bone remodelling at the stapes footplate producing conductive hearing loss in young to middle-aged adults, often with a family history and acceleration during pregnancy. Otoscopy is normal; audiometry shows conductive loss with a Carhart’s notch at 2 kHz on bone conduction. Refer to ENT for consideration of stapedectomy or hearing aids.

D. Australian operations

The Commonwealth Hearing Services Program subsidises hearing aids, audiology assessments, and rehabilitation for eligible adults. Eligibility includes pension card holders, DVA Gold Card, DVA White Card (hearing-related condition), NDIS participants, Australian Defence Force members, and Aboriginal and Torres Strait Islander Australians aged 50 and over. Hearing Australia is the sole approved provider for all children and young adults under 26.

Universal newborn hearing screening operates through state-based programs:

• NSW: SWISH (health.nsw.gov.au)
• Victoria: VIHSP (health.vic.gov.au)
• Queensland: Healthy Hearing (health.qld.gov.au)
• Additional programs in SA, WA, Tasmania, NT, and ACT.

The national 1-3-6 rule applies: screen by 1 month, diagnostic ABR by 3 months, intervention by 6 months. Earlier intervention consistently produces better language and developmental outcomes.

ATSI ear health: The 715 ATSI Health Check (MBS item 715) includes hearing assessment at every annual review. Hearing for Learning Initiative (Menzies Institute) supports community-level hearing health in remote NT and FNQ. Refer early in Aboriginal and Torres Strait Islander children — do not wait for the three-month persistence criterion when developmental impact is already apparent.

Cochlear implants are publicly funded (Medicare) for eligible adults and children with bilateral severe-to-profound hearing loss who do not benefit adequately from hearing aids. Refer to specialist cochlear implant centres including Royal Victorian Eye and Ear Hospital Melbourne, Royal Prince Alfred Sydney, and equivalent state centres.

Relevant MBS items: GP consultations (23, 36, 44), ATSI health check (715), 75+ health assessment (707), audiometry by audiologist (11324), tympanometry (11332), ENT consultations (104/105).

E. Special populations

Aboriginal and Torres Strait Islander children: Rates of otitis media with effusion are among the highest globally. Every 715 Health Assessment should include hearing screen and tympanometry. Refer early; chronic suppurative otitis media requires active treatment and ENT involvement.

Older adults: Hearing loss is a major, often unaddressed contributor to social isolation, depression, cognitive decline, and falls risk. Normalise hearing aid discussion at the 75+ assessment. Combat “I’m too old for hearing aids” attitudes with dementia-risk-reduction data. Treat hearing loss as actively as you would manage blood pressure or cholesterol.

Occupationally exposed workers: Annual audiometry is best practice in noisy industries. GPs can facilitate pre-employment baseline audiograms, annual monitoring referrals, and workers’ compensation navigation for noise-induced loss.

Ototoxic drug monitoring: Patients on aminoglycosides (including nebulised gentamicin), cisplatin, or high-dose chronic loop diuretics require baseline audiometry and monitoring during and after treatment courses.

Genetic and congenital hearing loss: GJB2 (connexin 26) genetic testing is first-line in paediatric sensorineural hearing loss without identified cause. For confirmed congenital CMV hearing loss, antiviral therapy (valganciclovir) initiated within the first month of life may limit audiological deterioration — specialist paediatric infectious disease input is required.

When to escalate

Emergency (same-day) referral to audiology and ENT:

• Sudden sensorineural hearing loss — ≥30 dB across three frequencies within 72 hours — even if diagnosis is uncertain; treat as SSNHL and refer.
• Hearing loss with facial palsy (Ramsay Hunt syndrome, cholesteatoma, vestibular schwannoma, brainstem lesion).
• Severe acute vertigo with hearing loss, particularly first presentation with neurological features.

Urgent ENT referral (within 1–2 weeks):

• Asymmetric or unilateral sensorineural hearing loss without explanation — MRI internal auditory meati to exclude vestibular schwannoma.
• Suspected cholesteatoma — destructive; surgical management required.
• Newborn failing hearing screen — diagnostic ABR must occur within 3 months of birth.

Routine referral:

• Conductive hearing loss with normal otoscopy (otosclerosis — stapedectomy or hearing aids).
• Paediatric OME persisting beyond 3 months with developmental impact.
• Hearing aid candidacy — refer to Hearing Australia or accredited audiologist.
• Bilateral severe to profound hearing loss — cochlear implant assessment.

What this article is and is not

This is general health information drawn from current Australian general practice and specialist guidelines — Therapeutic Guidelines, RACGP, NHMRC, AAO-HNS SSNHL Guideline 2019, Hearing Australia, and the Lancet 2024 dementia commission. It is not personal medical advice and does not create a doctor–patient relationship. Decisions about hearing tests, hearing aids, referrals, and specific treatments are made with your GP, audiologist, and ENT surgeon.

For Australian resources: Hearing Australia, Hearing Services Program, HealthDirect — Hearing loss, Better Health Channel, Deafness Forum Australia.

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Sources cited

1. Therapeutic Guidelines (eTG) — Sudden sensorineural hearing loss
2. RACGP — Hearing loss in adults
3. NHMRC — Adult cochlear implant guidelines
4. Hearing Australia
5. Audiology Australia
6. Hearing Services Program
7. Hearing for Learning Initiative — Menzies Institute
8. Safe Work Australia — Noise-induced hearing loss
9. AAO-HNS Clinical Practice Guideline — Sudden Hearing Loss 2019
10. NICE NG98 — Hearing loss in adults
11. Lancet Commission on Dementia Prevention 2024
12. NSW SWISH — Statewide Infant Screening Hearing
13. HealthDirect — Hearing loss
14. Better Health Channel — Hearing problems