Hearing Loss in Adults: Differential Diagnosis and Treatment


Am Fam Physician. 2019 Jul 15;100(2):98-108.

Author disclosure: No relevant financial affiliations.

More than 30 million U.S. adults have hearing loss. This condition is underrecognized, and hearing aids and other hearing enhancement technologies are underused. Hearing loss is categorized as conductive, sensorineural, or mixed. Age-related sensorineural hearing loss (i.e., presbycusis) is the most common type in adults. Several approaches can be used to screen for hearing loss, but the benefits of screening are uncertain. Patients may present with self-recognized hearing loss, or family members may observe behaviors (e.g., difficulty understanding conversations, increasing television volume) that suggest hearing loss. Patients with suspected hearing loss should undergo in-office hearing tests such as the whispered voice test or audiometry. Patients should then undergo examination for cerumen impaction, exostoses, and other abnormalities of the external canal and tympanic membrane, in addition to a neurologic examination. Sudden sensorineural hearing loss (loss of 30 dB or more within 72 hours) requires prompt otolaryngology referral. Laboratory evaluation is not indicated unless systemic illness is suspected. Computed tomography or magnetic resonance imaging is indicated in patients with asymmetrical hearing loss or sudden sensorineural hearing loss, and when ossicular chain damage is suspected. Treating cerumen impaction with irrigation or curettage is potentially curative. Other aspects of treatment include auditory rehabilitation, education, and eliminating or reducing use of ototoxic medications. Patients with sensorineural hearing loss should be referred to an audiologist for consideration of hearing aids. Patients with conductive hearing loss or sensorineural loss that does not improve with hearing aids should be referred to an otolaryngologist. Cochlear implants can be helpful for those with refractory or severe hearing loss.

More than 30 million U.S. adults, or nearly 15% of all Americans, have some degree of hearing loss.1 It is most common in older adults, occurring in about one-half of adults in their 70s and 80% of those 85 years and older.1,2 Despite this high prevalence, hearing loss is underdetected and undertreated. Only about one-third of people with self-reported hearing loss have ever had their hearing tested, and only 15% of people eligible for hearing aids consistently use them, citing factors such as cost, difficulty using them, and social stigma.1,3,4


The FDA Reauthorization Act of 2017 allows direct-to-consumer sale of hearing aids for mild to moderate hearing loss, for which limited outcome studies show improved hearing, communication, and social engagement. The cost of over-the-counter hearing aids is expected to range from approximately $200 to $1,000 compared with $800 to $4,000 for conventional hearing aids.

Among patients with dementia in a U.S. population-based longitudinal cohort study, the use of hearing aids was associated with decreased social isolation and a slower rate of cognitive decline, even after adjusting for multiple confounders.

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Clinical recommendationEvidence ratingComments

The U.S. Preventive Services Task Force and the American Academy of Family Physicians conclude that the current evidence is insufficient to assess the balance of benefits and harms of screening for hearing loss in asymptomatic adults 50 years and older.22,28


Based on randomized controlled trials and observational studies with disease-oriented outcomes. The only good-quality randomized trial of hearing screening included many patients with baseline concerns about hearing loss; there was no improvement in hearing-related quality of life.

Patients with suspected presbycusis should be referred for audiometry.Laboratory evaluation or imaging is not needed initially.12,13,17,29


Based on expert opinion and clinical reviews

Patients with sudden sensorineural hearing loss should be referred to an otolaryngologist for audiologic evaluation.33


Based on a clinical practice guideline

Information on hearing aid use should be provided to patients. It should incorporate patient expectations, perceived self-benefit, satisfaction, readiness to accept change, and support from significant others.38,39


Systematic reviews on hearing aid use found only limited evidence for increased use of hearing aids when these factors are incorporated into the treatment plan.

Over-the-counter hearing aids should be recommended for patients with mild hearing loss.4951


Based on a low-quality study and expert opinion. Over-the-counter hearing aids are now approved by the U.S. Food and Drug Administration for mild to moderate hearing loss, but the American Speech-Language-Hearing Association recommends these devices only for patients with mild hearing loss.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence;

The Author

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THOMAS C. MICHELS, MD, MPH, is an outpatient family physician at Olympic Medical Center in Port Angeles, Wash....

MARIBETH T. DUFFY, MD, is a residency faculty family physician at Madigan Army Medical Center in Tacoma, Wash.

DEREK J. ROGERS, MD, is chief of otolaryngology at Madigan Army Medical Center and an assistant professor of surgery and pediatrics at the Uniformed Services University of the Health Sciences in Bethesda, Md.

Address correspondence to Thomas C. Michels, MD, MPH, 800 N. 5th Ave., Ste. 101, Sequim, WA 98382 (email: thomasmichels@harbornet.com). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the U.S. Army Medical Department or the U.S. Army Service at large.


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