Hearing loss — persistent or reversible?

The most common causes of persistent hearing loss are ageing and exposure to excessive noise such as occupational sounds and personal audio devices/smartphones used at loud volumes for long periods.

In a small number of cases, past infection may have damaged the eardrum or middle ear and caused persistent conductive hearing loss. Chronic perforation of the drum may be seen on otoscopy.

Other causes of persistent deafness include exposure to ototoxic substances and a wide variety of genetic, systemic and infectious conditions.

Reversible conductive hearing loss is commonly caused by impacted earwax (cerumen). Build-up of earwax often aggravates long-term background hearing loss. Occasionally, problems may be exacerbated by foreign bodies such as cotton bud tips and other items inappropriately used to clean the ear (see later).

Infection due to otitis media or otitis externa (OE) may also cause or aggravate hearing loss. These conditions are usually associated with pain, alongside other symptoms such as itch or discharge.

Ear canal occlusion is not common with OE and is mainly due to swelling caused by cellulitis, which can be very painful and needs urgent referral. Build-up of squamous debris caused by OE may contribute to earwax impaction.

Impact of hearing loss

Patients may come to the pharmacy concerned that they may be going deaf.

Signs include difficulty hearing other people clearly and misunderstanding what they say (especially in noisy places), having to ask people to repeat themselves, listening to music or watching TV with the volume high enough to annoy other people, and difficulty hearing on the phone. 

Often other people, such as their spouse or children, have commented on problems such as the inability to keep up with conversations or no longer being able to hear a doorbell or knock at the door. Pharmacy teams will be aware of patients who they may suspect are hard of hearing and with whom they have to raise their voice in order to communicate.

Simple communication tips which may be useful here include:

• Before speaking, get the person’s attention
• Make eye contact with face and lips visible
• Use facial expressions and gestures
• Where possible, avoid background noise
• Get used to not looking away when talking
• Repeat the sentence once if necessary, then rephrase if needed
• Write down important facts or use a leaflet to point them out
• A longer consultation time may be needed.

The waiting times for NHS audiology services may be considerable. Some pharmacies and optometrists, and those supplying hearing aids, offer free hearing tests. Another option is for patients to try an online hearing test such as that provided by the RNID.

There are also hearing test features provided by some smartphones. For the RNID test, see: rnid.org.uk/information-and-support/take-online-hearing-check.

Symptoms due to earwax

It is important to exclude causes of hearing loss such as earwax impaction, particularly if symptoms are of recent onset. Many people with earwax are aware this is a recurrent issue and recognise the symptoms. Often, earwax exacerbates an underlying issue such as age-related hearing loss.

The main symptom caused by impacted earwax is hearing loss, but sometimes patients may complain of discomfort or a sensation that their ears are blocked. They may have ringing or buzzing in the ears (tinnitus) due to wax pressing against the eardrum and, on rare occasions, vertigo and nausea can occur. RNID estimates that 2.3 million people each year require earwax removal.