2Introduction

Impact

Hearing loss is a major public health issue affecting about 9 million people in England. Because age-related hearing loss is the single biggest cause of hearing loss, it is estimated that by 2035 there will be around 13 million people with hearing loss in England – a fifth of the population.⁸⁶ Hearing loss ranks second in terms of prevalence of impairment globally and is third for disease burden in England (years lived with disability).⁴⁸

Hearing loss has a significant impact on individuals leading to difficulty with communication at work, socially and at home. This can affect family relationships, employment or educational opportunities, enjoyment of leisure pursuits such as music and family gatherings, and independence. Hearing loss can cause feelings of isolation and low self-esteem and can lead to a significant reduction in people’s quality of life.

Research shows that hearing loss doubles the risk of developing depression and increases the risk of anxiety and other mental health issues.^28,34,56,113 Research also suggests that the use of hearing aids reduces these risks.⁵⁶ Although hearing loss affects all ages it is more prevalent in older people and there is an association between hearing loss and cognitive performance as well as dementia.⁷⁴ This association is more marked with more severe hearing loss.⁷³

It is estimated that in 2013 the UK economy lost more than £28.4 billion in potential output because of high unemployment rates among people with hearing loss.⁵⁹ The cost may be higher if rates of underemployment are also taken into account. These high rates of unemployment and underemployment reflect the communication and participation difficulties experienced by people with hearing loss. One recent study estimated that the cost of hearing loss to society in 2013 was more than £136 million when considering the costs of GP and social services. In addition the cost of a reduced quality of life as a consequence of hearing loss was estimated at £26 billion.⁷

The vast majority of permanent hearing loss is bilateral (in both ears) and progresses slowly, with the most common complaint of adults with hearing loss being difficulty in hearing speech against a background of other noise. It can take time for people to accept they have a difficulty and studies have found that on average there is a 10 year delay in people aged 55 to 74 years seeking help for their hearing loss.^28,38 Studies have identified that between 30% and 45% of adults who report hearing problems to their GP are not referred to NHS hearing services, with reports that they are advised to wait until their symptoms are more severe.^14,34,86 The figures are worse for those under 75 years of age. Only 1 in 3 adults who would benefit from hearing aids has had them prescribed and fitted.²⁸

Pathways

The main referral pathway for an adult with hearing loss is directly from their GP to local audiology services, although some areas have adopted open access where people do not need a GP referral to access audiological care For those who require medical input, referral is direct to ear, nose and throat (ENT) or audiovestibular medicine services with referral coming from GPs or audiologists. In many cases the hearing loss can be managed by the local service in parallel with medical investigation or treatment, but in other cases, where audiological care is complicated, access to specialist audiology services is important. Each local area will have their own care pathway developed around the skills and expertise available within the different services.

Audiology services are provided in a number of NHS settings. In some parts of England this is through the AQP (any qualified provider) scheme, which means that people have a choice of providers ranging from traditional hospital or clinic-based audiology services, to independent high street providers. Basic assessment for hearing loss includes, as a minimum, a history, examination of the ears, pure tone audiometry and, if required, tympanometry. In addition, it is important to establish if the individual recognises a hearing problem and if they are ready and willing to seek help. Primary management of hearing loss involves provision of hearing aids through the NHS by audiology services.

The findings on pure tone audiometry are often summarised using descriptors such as mild, moderate, severe or profound; however, this classification should not be used as the sole determinant for the provision of hearing support because this is not a reliable indicator of the difficulty experienced with communication in background noise. Although important, assessment of functional hearing and impact of the loss on the individual is variable and currently does not always occur routinely.

Management pathways for adults with disabling hearing loss vary. In general, if there is hearing loss in both ears, hearing aids are recommended for both ears, unless there are reasons why this is inappropriate. However, in some areas of the country, adults are not offered NHS hearing aids for disabling hearing losses where the pure tone audiogram findings are described as mild or moderate, while others are offered 1 hearing aid rather than 2. Low uptake of hearing aids and adherence to treatment are often dependent on the individuals’ recognition of their loss as well as the support given. Hearing aids are sometimes trialled but discontinued because the person has not had advice about strategies to improve hearing and listening nor the aftercare necessary to enable effective use of the hearing aids.

Referral to secondary care allows access to a range of services which include ear nose and throat surgery, audiovestibular medicine, specialist audiology, hearing therapy and psychology. Referral into these services occurs for several reasons. It may be important to determine the cause of the hearing loss particularly in younger people and in those with sudden or progressive hearing losses. For some, surgery may offer treatment to improve hearing or prevent deterioration. For those whose hearing loss is too severe to benefit from hearing aids available through local audiology services there is the question of implantable devices such as cochlear implants, bone anchored hearing aids or middle ear implants. In addition, secondary care may provide additional specialist support for those with tinnitus and hyperacusis and those with complex needs.

Causes

Treatable difficulties in hearing can arise from problems such as occluding earwax or infection which can be managed in primary care. However, the identification and management of these causes of hearing difficulty is not always robust, leading to some people waiting a long time to see a specialist when they could have been treated successfully in primary care. When earwax or infection prevents the use of hearing aids it compounds the difficulties faced by those with hearing loss; delay in resolving the problem can have a significant impact.

In this guideline we consider ‘diagnosis’ to refer to the medical diagnosis of the underlying cause, or the aetiology, of the condition. When hearing is measured and a loss discovered, this is referred to as ‘identification’. Identifying a hearing loss is not an end point in itself and it is important to consider what has caused the loss. For the majority, this will be permanent damage due to ageing, noise exposure or both, but for others there may be an underlying pathology, for example, middle ear disease, or hearing loss may be part of a significant systemic illness, such as autoimmune or renal disease, or the first symptom of neurological disease, or it may have a specific genetic cause. Addressing the diagnosis is beyond the scope of this guideline but is important because treatment will affect the eventual outcome for the individual and their family. It is for this reason that we have considered the symptoms and signs that should alert a GP or audiologist to the need for a medical assessment by an ENT surgeon or an audiovestibular physician, without wishing to limit discretion in other cases.

Summary

Variations in assessment and management pathways for hearing loss can have a major impact, adversely affecting individuals’ outcomes and prognoses, and contributing to the overall financial and psychological burden of hearing loss. Encouraging people to seek help early, and identifying the correct routes of referral and optimal management pathways for people with hearing loss is therefore very important.

This guideline explores the most urgent questions about referral, assessment and management of hearing loss in adults in order to offer best practice advice. It cannot address the whole topic. One of the issues the guideline committee has encountered when preparing this guideline is that the quality of evidence on which to base recommendations is not high in many areas. There is scope for more robust research in all areas.

This guideline seeks to inform people with hearing difficulties, their families and carers, all healthcare professionals dealing with adults, social care professionals and commissioners of health and social care services about best practice in assessing and managing hearing loss. It is important that audiological care is patient-centred and that people should have the opportunity to make informed decisions about their care and treatment in partnership with their healthcare professionals (NICE guideline CG138) and this is reflected in the guideline.