Deafness and Hearing Loss

Last updated 31 May 2026 · ENT

📋 Key Information Summary

📋

Hearing loss is classified as conductive (outer/middle ear), sensorineural (cochlea/auditory nerve), or mixed; differentiation guides investigation and management.
Conductive hearing loss common causes include cerumen impaction, otitis media with effusion (OME), tympanic membrane perforation, and otosclerosis.
Sensorineural hearing loss (SNHL) common causes include presbycusis, noise exposure, Ménière's disease, sudden sensorineural hearing loss (SSNHL), and congenital infections.
Rinne test compares air conduction (AC) vs bone conduction (BC): Rinne positive (AC > BC) is normal or SNHL; Rinne negative (BC > AC) suggests conductive loss.
Weber test lateralises to the affected ear in conductive loss and to the unaffected ear in sensorineural loss.
Pure-tone audiometry is the gold standard for quantifying hearing loss; audiometry thresholds >20 dB HL indicate hearing loss.
Sudden sensorineural hearing loss (SSNHL) is an ENT emergency — refer within 24 hours; oral corticosteroids should commence within 72 hours of onset.
All Australian newborns should receive hearing screening via the Newborn Hearing Screening Programme before discharge or by 1 month of age.
Otitis media with effusion is the most common cause of hearing loss in Aboriginal and Torres Strait Islander children, with prevalence rates 5–10 times higher than non-Indigenous children.
Chronic suppurative otitis media (CSOM) in remote communities requires early aggressive management to prevent permanent conductive and secondary sensorineural loss.
Hearing loss in children >3 months impacts speech, language, and cognitive development — early intervention with amplification and speech therapy is critical.
Adults with bilateral hearing loss benefit from audiological assessment and hearing aid fitting; referrals for cochlear implant assessment are appropriate for severe-to-profound SNHL.

Introduction & Australian Epidemiology

Hearing loss is one of the most prevalent chronic conditions in Australia, affecting approximately 3.6 million Australians (14.5% of the population). It is the leading cause of disability-adjusted life years (DALYs) attributable to sensory loss globally. General practitioners are often the first point of contact for patients presenting with hearing difficulties, and timely recognition, classification, and referral are essential to prevent irreversible complications — particularly in children, where undetected hearing loss impairs speech, language, social development, and educational outcomes.

The Australian Institute of Health and Welfare (AIHW) reports that hearing loss prevalence increases sharply with age: approximately 50% of Australians aged 60–69 years and over 70% of those aged 70 years and older have clinically significant hearing loss. Occupational noise exposure remains a significant modifiable risk factor, with industries such as construction, mining, manufacturing, and agriculture over-represented. Noise-induced hearing loss (NIHL) accounts for an estimated 37% of all adult-onset hearing loss in Australia.

Among Aboriginal and Torres Strait Islander peoples, the burden of ear disease and hearing loss is disproportionately high. Chronic otitis media affects up to 40% of Indigenous children in some remote communities, compared with approximately 4% of non-Indigenous children in urban settings. This disparity drives significant gaps in educational attainment, employment, and social engagement, and represents a national health priority under the National Agreement on Closing the Gap.

This article provides a comprehensive guide to the diagnosis, classification, assessment, and management of hearing loss in general practice, with a focus on Australian clinical guidelines, PBS-listed therapeutics, and referral pathways.

Statistic	Detail
Australians with hearing loss	~3.6 million (14.5% of the population)
Prevalence ≥65 years	~58–73%
Noise-attributable proportion (adults)	~37% of adult-onset cases
Indigenous children with OME/CSOM	Up to 40% in remote communities
Newborn hearing screening coverage	~95% nationally (varies by jurisdiction)
Annual SSNHL incidence	~5–20 per 100,000 per year

Conductive vs Sensorineural Hearing Loss

Hearing loss is classified by the anatomical location of the pathology into conductive, sensorineural, or mixed types. Accurate classification is the cornerstone of diagnosis and determines the appropriate investigation pathway and management strategy.

Conductive Hearing Loss (CHL)

Conductive hearing loss results from obstruction or dysfunction of the outer or middle ear that impedes sound transmission to the cochlea. Air conduction is impaired while bone conduction remains intact. CHL is often medically or surgically treatable.

💡

Key principle: Conductive hearing loss is frequently reversible. Identifying and treating the underlying cause can restore normal hearing thresholds.

Location	Cause	Typical Features
Outer ear	Cerumen impaction	Most common cause; bilateral or unilateral; gradual onset
Outer ear	External otitis	Pain, oedema, discharge; often unilateral
Outer ear	Exostoses / osteomata	Cold-water swimmers; bilateral narrowing of canal
Outer ear	Atresia / microtia	Congenital; associated syndromes (Treacher Collins, hemifacial microsomia)
Tympanic membrane	Tympanic membrane perforation	History of trauma, infection, or grommet insertion
Middle ear	Otitis media with effusion (OME / "glue ear")	Most common cause in children; conductive loss up to 30–40 dB
Middle ear	Acute otitis media	Pain, fever, bulging TM; usually self-limiting conductive loss
Middle ear	Cholesteatoma	Progressive conductive loss; retraction pocket; foul discharge; requires ENT surgical referral
Middle ear	Otosclerosis	Stapes fixation; bilateral; onset age 20–40; family history; pregnancy may worsen
Middle ear	Tympanosclerosis	Calcification of TM/ossicles post-infection or surgery
Middle ear	Ossicular discontinuity	Post-trauma; incus necrosis; large air-bone gap

Sensorineural Hearing Loss (SNHL)

Sensorineural hearing loss arises from pathology of the cochlea (sensory), auditory nerve (neural), or central auditory pathways. Both air and bone conduction are equally reduced. SNHL is generally permanent and is managed with amplification (hearing aids, cochlear implants) rather than medical or surgical correction.

⚠️

Sudden sensorineural hearing loss (SSNHL) — defined as ≥30 dB SNHL over ≥3 consecutive frequencies within 72 hours — is an ENT emergency. Urgent audiology and ENT referral within 24 hours is mandatory. Systemic corticosteroids (prednisolone 1 mg/kg up to 60 mg daily) should be commenced within 72 hours of onset if ENT assessment will be delayed.

Cause	Typical Features
Presbycusis (age-related)	Bilateral high-frequency loss; gradual onset >50 years; family history common
Noise-induced hearing loss (NIHL)	4 kHz notch on audiogram; occupational or recreational noise history
Ménière's disease	Low-frequency fluctuating SNHL, episodic vertigo, tinnitus, aural fullness
Sudden SNHL	Rapid unilateral loss; often idiopathic; may be viral or vascular aetiology
Acoustic neuroma (vestibular schwannoma)	Unilateral asymmetric SNHL; progressive; MRI with gadolinium confirms
Congenital CMV / rubella / toxoplasmosis	Congenital SNHL; may present at birth or delayed onset in early childhood
Genetic / syndromic	Connexin-26 (GJB2) mutation — most common genetic cause; Usher, Pendred, Waardenburg syndromes
Ototoxic medications	Aminoglycosides, cisplatin, high-dose loop diuretics, salicylates; often irreversible
Autoimmune inner ear disease	Bilateral progressive SNHL; fluctuating; responsive to immunosuppression
Meningitis (bacterial)	Post-meningitic SNHL; pneumococcal and meningococcal; bilateral; children at higher risk

Mixed Hearing Loss

Mixed hearing loss involves both conductive and sensorineural components. Typical examples include chronic suppurative otitis media (CSOM) with cochlear involvement, advanced otosclerosis, and temporal bone fractures affecting both the middle ear and cochlea. Audiometry demonstrates both elevated bone conduction thresholds and an air-bone gap.

Feature	Conductive	Sensorineural	Mixed
Site of lesion	Outer / middle ear	Cochlea / auditory nerve	Both
Air conduction	Reduced	Reduced	Reduced
Bone conduction	Normal	Reduced	Reduced
Air-bone gap	Present (≥10 dB)	Absent	Present
Speech discrimination	Usually preserved	May be disproportionately poor	Variable
Often reversible?	Yes	Usually no	Conductive component may be

Rinne & Weber Tests Interpretation

Tuning fork tests are fundamental bedside clinical tests for differentiating conductive from sensorineural hearing loss. A 512 Hz tuning fork is the standard frequency used, as it provides the best balance between sensitivity and clinical practicality. These tests should be interpreted in the context of the full clinical history and are not a substitute for formal audiometry.

Weber Test

Technique: Strike the tuning fork and place it on the vertex (or midline of the forehead). Ask the patient: "Where do you hear the sound — in the middle, left, or right?"

💡

Interpretation principle: Sound lateralises to the ear with the greater conductive advantage — either the normal ear (if the affected ear has SNHL) or the affected ear (if the affected ear has conductive loss, because the conductive loss "masks" background noise).

Weber Result	Interpretation	Likely Diagnosis
Midline (no lateralisation)	Normal hearing or symmetrical hearing loss	Normal / bilateral symmetrical SNHL
Lateralises to affected ear	Conductive loss in that ear	OME, perforation, otosclerosis, cerumen
Lateralises to unaffected ear	Sensorineural loss in the contralateral (affected) ear	Presbycusis, acoustic neuroma, SSNHL

Rinne Test

Technique: Strike the tuning fork and hold it ~2 cm from the external auditory meatus (air conduction, AC). Then place the base of the fork on the mastoid process (bone conduction, BC). Ask: "Which is louder — the one near your ear or the one on the bone?"

Rinne Result	Meaning	Interpretation
Positive (AC > BC)	Air conduction louder than bone conduction	Normal or sensorineural loss (AC still exceeds BC)
Negative (BC > AC)	Bone conduction louder than air conduction	Conductive hearing loss in the tested ear
Equal (AC = BC)	Approximately equal loudness	Mild conductive loss (air-bone gap ~15–20 dB)

⚠️

Pitfall: In severe-to-profound sensorineural loss, the Rinne test may appear falsely negative because bone conduction sound can cross to the contralateral normal cochlea. Always occlude the non-test ear with noise (press tragus) when testing bone conduction to prevent crossover. If there is any doubt, refer for formal audiometry.

Combined Rinne–Weber Interpretation

Weber Lateralisation	Rinne (affected ear)	Diagnosis
To affected ear	Negative (BC > AC)	Conductive loss in affected ear
To unaffected ear	Positive (AC > BC)	Sensorineural loss in affected ear
Midline	Positive (AC > BC)	Normal hearing or bilateral symmetrical loss
To affected ear	Positive (AC > BC)	Inconsistent — suspect bilateral mixed loss; refer for audiometry

Clinical Pearl — Noise Occlusion Test

When the Weber test lateralises to the apparently "normal" ear but the clinical suspicion is for conductive loss bilaterally, use the noise occlusion test: occlude one ear with a finger while performing Weber. If sound shifts to the occluded ear, conductive loss is confirmed bilaterally. This is useful in children with suspected bilateral OME.

Audiometric Assessment

Formal audiological evaluation is the gold standard for characterising hearing loss. GPs should refer for audiometry when hearing loss is identified on clinical examination, the patient reports progressive or sudden hearing decline, or tuning fork tests are inconclusive. In Australia, audiology services are available through private audiology clinics, public hospital audiology departments, Australian Hearing (for eligible children and pensioners), and some Aboriginal Community Controlled Health Organisations (ACCHOs).

Types of Audiometric Tests

Essential Pure-Tone Audiometry (PTA) Thresholds at 250–8000 Hz via air and bone conduction. Gold standard for type, degree, and configuration of hearing loss. MBS Item 82310 (bulk-billed at most audiology clinics). Bilateral ear-specific thresholds plotted on an audiogram.

Essential Tympanometry Assesses middle ear function (tympanic membrane mobility, middle ear pressure, ear canal volume). Type A (normal), Type B (flat — effusion/atresia), Type C (negative pressure — Eustachian tube dysfunction). Not a hearing test per se but essential adjunct. Available in most GP practices with appropriate equipment.

Available Speech Audiometry Speech Reception Threshold (SRT) and Word Recognition Score (WRS). Assesses functional hearing ability and aids in hearing aid fitting. Useful when pure-tone thresholds do not correlate with reported disability.

Available Otoacoustic Emissions (OAE) Assesses outer hair cell function. Used in newborn hearing screening and in differentiating cochlear from retrocochlear pathology. Absent OAE with intact middle ear suggests cochlear dysfunction.

Specialist Auditory Brainstem Response (ABR) Objective test of auditory neural pathway function. Used in newborn screening confirmatory testing, medicolegal assessment, and evaluation of unconscious patients. Performed in hospital audiology departments.

Specialist MRI Brain (with gadolinium) — Internal Auditory Meatus Indicated for asymmetric sensorineural hearing loss to exclude vestibular schwannoma (acoustic neuroma). Also for SSNHL workup. MBS Item 63001/63004 (Medicare-rebated with appropriate indication).

Referral High-Resolution CT Temporal Bone Indicated for conductive hearing loss with suspected cholesteatoma, congenital atresia, or pre-surgical assessment of ossicular chain. Ordered by ENT specialist.

Degrees of Hearing Loss (WHO Classification)

Degree	PTA Threshold (dB HL)	Functional Impact
Normal	≤20 dB HL	No functional difficulty
Mild	21–40 dB HL	Difficulty hearing soft speech, especially in noise
Moderate	41–60 dB HL	Difficulty with conversational speech
Severe	61–80 dB HL	Only hears loud speech; significant communication difficulty
Profound	>80 dB HL	May perceive only very loud sounds; relies on visual/tactile cues

Audiogram Configurations and Their Significance

Pattern	Description	Common Causes
Downsloping	Worse thresholds at high frequencies	Presbycusis, NIHL, ototoxicity
Upsloping	Worse thresholds at low frequencies	Ménière's disease, superior canal dehiscence
4 kHz notch	Dip at 4 kHz with recovery at 8 kHz	Noise-induced hearing loss (classic pattern)
Flat	Equal loss across frequencies	Conductive loss (OME), some genetic SNHL
Asymmetric	≥15 dB inter-ear difference at ≥2 frequencies	Acoustic neuroma, Ménière's, SSNHL — requires MRI
Cookie-bite	U-shaped mid-frequency loss	Genetic/hereditary SNHL (e.g., DFNA mutations)

⚠️

Asymmetric hearing loss (≥15 dB inter-ear difference at two or more adjacent frequencies) warrants urgent ENT referral and MRI to exclude a retrocochlear lesion (vestibular schwannoma). This applies even if the patient attributes the asymmetry to a prior ear infection.

Referral Pathways in Australia

GP Initial Assessment

History, otoscopy, tuning fork tests (Weber & Rinne), pneumatic otoscopy if available.

Audiology Referral

Refer to audiologist for PTA ± tympanometry ± speech audiometry. Bulk-billed for pensioners and children via Australian Hearing or Medicare. MBS items available.

ENT Referral

Asymmetric loss, suspected cholesteatoma, SSNHL, conductive loss not explained by cerumen/OME, congenital malformations, unilateral tinnitus.

Cochlear Implant Assessment

For severe-to-profound bilateral SNHL with limited benefit from hearing aids. Referral to one of the Australian cochlear implant centres (e.g., Royal Victorian Eye and Ear Hospital, Sydney Cochlear Implant Service, Hear and Say Centre Brisbane).

Deafness in Children

Hearing is critical for speech, language, and cognitive development in the first three years of life. The Joint Committee on Infant Hearing (JCIH) and the Australasian Newborn Hearing Screening Committee recommend universal newborn hearing screening, with diagnostic audiologic evaluation completed by 3 months of age and early intervention commenced by 6 months of age for all infants identified with permanent hearing loss.

Newborn Hearing Screening in Australia

All Australian states and territories have implemented universal newborn hearing screening (UNHS) programmes. Screening is performed using automated auditory brainstem response (AABR) or otoacoustic emissions (OAE), typically before hospital discharge or within the first month of life.

✅

Key milestones (Australian Early Hearing Detection and Intervention — EHDI):
• Screening completed by 1 month of age
• Diagnostic audiologic assessment by 3 months if screen referred
• Early intervention commenced by 6 months of age

Causes of Hearing Loss in Children

Congenital / Permanent

Genetic (50–60% of congenital SNHL) — Connexin-26 (GJB2) most common autosomal recessive; Pendred syndrome; Usher syndrome; Waardenburg syndrome
Congenital CMV infection (most common non-genetic cause; may present with delayed-onset SNHL)
Congenital rubella, toxoplasmosis, syphilis
Syndromic associations (Down syndrome, Treacher Collins, CHARGE, Stickler)
Prematurity and NICU stay (hyperbilirubinaemia, aminoglycoside exposure, hypoxia)
Inner ear malformations (Mondini dysplasia, enlarged vestibular aqueduct)

Acquired / Potentially Reversible

Otitis media with effusion (OME / "glue ear") — most common cause of acquired hearing loss in children aged 1–6 years
Acute otitis media
Chronic suppurative otitis media (CSOM) — particularly prevalent in Aboriginal and Torres Strait Islander children
Cerumen impaction
Foreign body in ear canal
Bacterial meningitis (pneumococcal, meningococcal, H. influenzae)
Mumps (post-lingual unilateral SNHL)
Head trauma / temporal bone fracture

Red Flags for Hearing Loss in Children

🚨

Refer urgently for audiological assessment if any of the following are present:

Failed newborn hearing screen (did not pass on two screening occasions)
No startle response to loud sounds by 3 months
No head-turning toward sounds by 6 months
No babbling by 9 months
No single words by 12 months
No two-word phrases by 24 months
Speech is unclear or not understood by strangers by age 3
Parental concern about hearing at any age
Regression of speech or language skills at any age
Risk factors: family history of childhood hearing loss, NICU >5 days, congenital CMV, syndromic features, post-meningitis

Otitis Media with Effusion (OME) in Children

OME is the most common cause of conductive hearing loss in childhood, with a peak prevalence between ages 1 and 3 years. Up to 80% of children experience at least one episode of OME by age 4 years. Most cases are self-limiting, resolving within 3 months. The Australasian Society of Clinical Immunology and Allergy (ASCIA) and RACGP recommend a watchful waiting approach for OME without hearing loss.

Management Step	Recommendation
Watchful waiting	3 months for unilateral or asymptomatic OME; review with audiology
Audiological assessment	If OME persists >3 months, hearing loss detected, or speech/language delay present
Auto-inflation (Otovent®)	Evidence supports use in children >3 years; may improve resolution of OME
Antibiotics	NOT routinely recommended for OME; consider only if concurrent AOM
Grommet insertion (bilateral myringotomy)	If bilateral OME with confirmed hearing loss ≥25 dB persisting >3 months with speech/language impact. ENT referral.
Adenoidectomy	May be performed with grommets in children >4 years with recurrent OME; reduces recurrence

Management of Permanent Childhood Hearing Loss

🎧

Hearing Aids

Behind-the-ear (BTE) · Receiver-in-canal (RIC) · Bone-anchored (BAHA)

Indication Mild-to-profound bilateral SNHL or persistent CHL not amenable to surgery

Fitting By qualified audiologist; bilateral fitting recommended for bilateral loss

Children <3 years BTE moulds preferred; replaced frequently as ear canal grows

PBS status ✔ Government-funded via Australian Hearing for eligible children

🦻

Cochlear Implant

Nucleus® · MED-EL · Advanced Bionics

Indication Severe-to-profound bilateral SNHL with limited benefit from hearing aids (≤50% open-set word recognition)

Optimal timing (children) As early as 9–12 months to maximise critical period for auditory cortical development

Post-operative Regular audiological mapping; intensive speech-language therapy; auditory-verbal therapy

PBS status ✔ Funded by Australian Government under the Hearing Services Program and state health services for eligible patients

Support Services and Early Intervention

Children with confirmed permanent hearing loss should be referred to early intervention services. In Australia, these include:

Australian Hearing — Federal government agency providing hearing services to eligible children and young people under 26 years
State-based early intervention programmes — e.g., RIDBC (Royal Institute for Deaf and Blind Children, NSW), The Shepherd Centre (NSW/ACT), Hear and Say (Qld), Telethon Speech & Hearing (WA)
National Disability Insurance Scheme (NDIS) — early childhood approach for children 0–9 years with developmental concerns including hearing loss
Deaf Australia / Deaf Connect — advocacy, Auslan interpreter services, and community support
Auslan (Australian Sign Language) — for families choosing a bilingual-bicultural approach; deaf mentors and Auslan classes available

Management of Hearing Loss in Adults

Management of adult hearing loss depends on the type, severity, and aetiology. GPs play a central role in identifying hearing loss, initiating treatment for reversible causes, and referring for audiological assessment and amplification.

Medical and Surgical Management of Conductive Hearing Loss

Cause	Treatment
Cerumen impaction	Ear drops (olive oil, sodium bicarbonate 5%, or cerumol®) for 3–5 days ± microsuction / irrigation by GP or practice nurse. Avoid irrigation if perforation suspected.
Otitis externa	Topical antibiotics ± corticosteroid (e.g., Sofradex®, Ciproxin HC® drops); aural toilet; avoid water entry. Oral antibiotics only if systemic signs or immunocompromise.
Acute otitis media	Amoxicillin 500 mg PO TDS (1 g TDS if severe) for 5–7 days if bacterial; analgesia (paracetamol, ibuprofen); most cases self-limiting. Observation without antibiotics reasonable in mild, uncomplicated cases ≥2 years.
OME (adults)	Investigate underlying cause (nasopharyngeal carcinoma in unilateral adult OME — always consider); ENT referral for persistent effusion.
Otosclerosis	Hearing aids (initial); stapedectomy/stapedotomy (ENT surgical option for significant conductive loss). Sodium fluoride 20 mg PO BD may slow progression (limited evidence).
Cholesteatoma	Surgical — canal wall up or canal wall down mastoidectomy. ENT referral mandatory.

Sudden Sensorineural Hearing Loss (SSNHL) — Emergency Protocol

🚨

SSNHL is an ENT emergency. Hearing recovery rates decline significantly if treatment is delayed beyond 72 hours.

Refer to ENT or emergency department within 24 hours
Commence prednisolone 1 mg/kg (max 60 mg) PO daily immediately if ENT access will be delayed; taper over 10–14 days
Audiometry should be performed within 24 hours of presentation
If oral steroids commenced by GP, ensure ongoing ENT follow-up for intratympanic steroid consideration
Investigations: MRI IAC (exclude acoustic neuroma), FBC, ESR, CRP, glucose, syphilis serology, autoimmune screen

💊

Prednisolone (SSNHL)

Panafcortelone® · Solone® · Generic · Corticosteroid

Adult dose 1 mg/kg (max 60 mg) PO daily for 7–14 days, then taper over 7–10 days

Paediatric dose 1 mg/kg/day (max 60 mg) PO daily — specialist supervision required

Renal adjustment No adjustment required

Hepatic adjustment Use with caution in severe hepatic impairment

Key precautions Diabetes (monitor BSL), peptic ulcer risk (consider PPI cover), psychiatric effects

PBS status ✔ PBS General Benefit

💊

Betahistine

Serc® · Generic · Histamine analogue (H1 agonist / H3 antagonist)

Indication Ménière's disease — vertigo control and possibly hearing preservation

Adult dose 16 mg PO TDS; titrate from 8 mg TDS if needed

Renal adjustment No specific adjustment; use caution in severe renal impairment

Hepatic adjustment No specific adjustment

PBS status ⚠ PBS Authority Required

Hearing Aid Fitting and Rehabilitation

For adults with bilateral hearing loss impacting communication, hearing aids are the primary intervention. The Australian Government Hearing Services Program (HSP) provides fully subsidised hearing aids and rehabilitation services to eligible persons, including pensioners, veterans (DVA cardholders), Aboriginal and Torres Strait Islander peoples aged ≥50 years, and those with special clinical needs.

Hearing aids should be fitted by a qualified audiologist (Holders of a Certificate of Clinical Practice from Audiology Australia)
Bilateral fitting is recommended for bilateral hearing loss
Adjustment period: 4–6 weeks; follow-up appointments essential
Assistive listening devices (ALDs) — FM systems, loop systems, amplified phones — supplement hearing aids in challenging environments
Aural rehabilitation programmes improve communication strategies and reduce social isolation

Prevention and Noise Protection

Prevention of noise-induced hearing loss (NIHL) is a key role for GPs, particularly in workers in high-risk industries. The Work Health and Safety Regulations 2011 (Cth) mandate that workplace noise exposure must not exceed an 8-hour equivalent of 85 dB(A) (LAeq,8h) and a peak of 140 dB(C).

Noise Exposure Guidelines

Exposure Level	Maximum Duration (without hearing protection)	Example Sources
85 dB(A)	8 hours	Heavy traffic, busy restaurant
88 dB(A)	4 hours	Lawnmower, power tools
91 dB(A)	2 hours	Motorcycle, workshop machinery
94 dB(A)	1 hour	Chainsaw, nightclub
100 dB(A)	15 minutes	Power drill, jackhammer
110+ dB(A)	Avoid exposure	Concert speakers, shotgun blast

GPs should advise patients on:

Use of properly fitted hearing protection (earplugs with appropriate noise reduction rating, NRR) in occupational and recreational noise settings
Avoiding insertion of cotton buds or objects into the ear canal
Safe listening practices with personal audio devices (60/60 rule: ≤60% volume for ≤60 minutes)
Regular audiometric surveillance for workers in high-noise industries
Hearing screening for patients ≥65 years as part of preventive health assessments

Special Populations

👶

Paediatric

Newborn screening All neonates should have hearing screen before discharge or by 1 month. NICU graduates (≥48 hours) at higher risk.

OME management Watchful waiting for 3 months; avoid antibiotics unless concurrent AOM. Bilateral grommets if persistent OME with confirmed hearing loss ≥25 dB affecting speech.

Congenital CMV Valganciclovir within first month of life may reduce SNHL progression (specialist-initiated; authority required).

Speech-language therapy should commence at the time of hearing aid fitting. Auditory-verbal therapy and/or Auslan depending on family preference.

🤰

Pregnancy

Otosclerosis May worsen during pregnancy; hearing loss may become more apparent. Audiometric monitoring recommended.

OME in pregnancy Hormonal changes and fluid retention may exacerbate Eustachian tube dysfunction. Conservative management preferred.

Congenital infection screening Maternal CMV, rubella immunity, and toxoplasmosis serology should be checked early in pregnancy.

Avoid ototoxic medications during pregnancy where possible. Gentamicin and other aminoglycosides carry risk of fetal ototoxicity.

👴

Elderly

Presbycusis screening Screen all patients ≥65 years; hearing loss is independently associated with cognitive decline, depression, falls, and social isolation.

Hearing aid uptake Only ~20–30% of eligible older Australians use hearing aids. Barriers include cost (addressed by HSP), stigma, and dexterity issues.

Cognitive link Emerging evidence supports hearing aid use reducing cognitive decline risk (ACHIEVE trial, Lancet 2023).

Medication review is essential — anticholinergics, aminoglycosides, and loop diuretics may worsen hearing in elderly patients.

🫘

Renal Impairment

Alport syndrome X-linked hereditary nephritis with progressive SNHL. Screen hearing in all patients with suspected Alport syndrome and their family members.

Ototoxicity risk Aminoglycosides and loop diuretics accumulate in renal impairment, increasing ototoxicity risk. Monitor hearing with extended aminoglycoside courses.

Avoid concurrent aminoglycoside and loop diuretic use where possible. TDM of aminoglycosides is mandatory.

🛡️

Immunocompromised

Meningitis risk Patients post-splenectomy, on immunosuppression, or with complement deficiency are at increased risk of bacterial meningitis — a cause of bilateral SNHL. Ensure pneumococcal and meningococcal vaccination.

CMV reactivation Transplant recipients at risk of CMV-related SNHL. Regular audiological monitoring recommended.

Autoimmune inner ear disease Immunosuppression (corticosteroids, methotrexate, biologics) may be required. ENT and rheumatology co-management.

Ototoxic medication monitoring is particularly important in immunocompromised patients receiving aminoglycosides for Gram-negative infections.

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Health — Ear Disease and Hearing Loss

Ear disease and hearing loss represent one of the most significant health disparities affecting Aboriginal and Torres Strait Islander peoples. Otitis media (OM) prevalence in Indigenous Australian children is among the highest in the world. The Northern Territory Ear Disease Program and the Darwin Otitis Guidelines (updated 2020, Menzies School of Health Research) provide the primary evidence base for managing ear disease in this population.

Key Epidemiological Facts

OM affects up to 40% of Indigenous children in remote communities compared to ~4% of non-Indigenous urban children
Chronic suppurative otitis media (CSOM) prevalence is 10–20 times higher in remote Indigenous communities
Hearing loss in Indigenous children is estimated at 30–40% in some communities — a rate comparable to developing nations
The onset of OM is earlier (often within weeks of birth), more persistent, and more severe than in non-Indigenous populations
Conductive hearing loss secondary to OM is the primary driver, but secondary sensorineural loss from chronic infection and cholesteatoma also occurs

Risk Factors and Barriers

Housing overcrowding

Increases transmission of respiratory pathogens. Overcrowded housing in remote NT communities averages 9–10 persons per dwelling (vs. national average of 2.5).

Remote access to care

Many remote communities have visiting ENT/audiology services only 2–4 times per year. GPs and Aboriginal health practitioners (AHPs) are the primary point of care.

Chronic disease burden

High rates of smoking exposure (including second-hand smoke), malnutrition, and environmental factors (dust, poor sanitation) exacerbate OM risk.

Cultural and language factors

English as a second or third language in many communities amplifies the educational impact of hearing loss. Health literacy challenges affect treatment adherence.

Hearing aid and ENT service gaps

Hearing aid loss and breakage rates are high in children. Maintenance and replacement services may be infrequent. ENT surgical waiting lists are prolonged in some jurisdictions.

Management in Remote and Community Settings

⚠️

Darwin Otitis Guidelines key principles for managing ear disease in Indigenous children:

Acute otitis media (AOM): Amoxicillin 50 mg/kg/day TDS for 5–7 days is first-line. Single-dose intramuscular ceftriaxone (50 mg/kg) is an option when oral adherence is uncertain or vomiting.
OME: No antibiotics indicated. Watchful waiting; hearing assessment at 3 months. Topical intranasal corticosteroids are not recommended.
CSOM (discharging ear ≥2 weeks): Aural toilet (dry mopping) + topical ciprofloxacin 0.3% ear drops (Ciloxan®) BD for 2–4 weeks. Systemic antibiotics reserved for periauricular cellulitis, mastoiditis, or systemic illness.
Perforated TM: Keep ear dry; topical antibiotics if discharging; refer to ENT for persistent perforation or cholesteatoma.
Screening: Ear checks should be integrated into all child health assessments (MBS Item 715 for Aboriginal and Torres Strait Islander health assessments).

💊

Amoxicillin (AOM — first-line)

Amoxil® · Generic · Penicillin antibiotic

Paediatric dose 50 mg/kg/day in 3 divided doses for 5–7 days (max 500 mg TDS)

Renal adjustment Reduce dose if eGFR <30 mL/min

PBS status ✔ PBS General Benefit

💊

Ciprofloxacin 0.3% Ear Drops (CSOM)

Ciloxan® · Generic · Fluoroquinolone (topical)

Paediatric dose 4–6 drops into affected ear BD for 2–4 weeks after aural toilet

Adult dose 4–6 drops into affected ear BD for 2–4 weeks

Key notes Safe with perforated TM; avoid aminoglycoside drops if perforation present (ototoxicity risk)

PBS status ✔ PBS General Benefit

💊

Ceftriaxone IM (single dose — AOM)

Rocephin® · Generic · Third-generation cephalosporin

Paediatric dose 50 mg/kg IM single dose (max 1 g)

Indication When oral adherence uncertain, vomiting, or in remote settings without reliable follow-up

Key notes Monitor for allergy (cross-reactivity with penicillin ~1–2%); IM injection — local anaesthetic (EMLA) pre-injection recommended

PBS status ✔ PBS General Benefit

Closing the Gap — Hearing Health Initiatives

National Aboriginal and Torres Strait Islander Eye and Ear Health Program — funded screening and surgical outreach in remote communities
Healthy Ears, Better Hearing, Better Listening — Commonwealth-funded programme providing ear and hearing services through ACCHOs
Territory Hearing Health Program (NT) — school-based screening, audiology, and ENT telehealth
Australian Hearing Indigenous Services — dedicated program for Aboriginal and Torres Strait Islander peoples, with community-based clinics
MBS Item 715 health assessments should include ear examination and hearing assessment for all Aboriginal and Torres Strait Islander children
Trachoma and ear health teams often co-deliver services in remote areas — ear checks should be integrated into every health visit

📚 References

1. World Health Organization. World Report on Hearing. Geneva: WHO; 2021. Available from: https://www.who.int/publications/i/item/world-report-on-hearing
2. Australian Institute of Health and Welfare. Hearing loss in Australia. Cat. no. EAR 3. Canberra: AIHW; 2024.
3. Menzies School of Health Research. Darwin Otitis Guidelines: Diagnosis and Management of Otitis Media in Aboriginal and Torres Strait Islander Populations. 3rd ed. Darwin: Menzies School of Health Research; 2020.
4. Stach BA. Clinical Audiology: An Introduction. 3rd ed. San Diego: Plural Publishing; 2020.
5. Joint Committee on Infant Hearing. Year 2019 position statement: principles and guidelines for early hearing detection and intervention programs. J Early Hear Detect Interv. 2019;4(2):1–44.
6. Royal Australian College of General Practitioners. Guidelines for Preventive Activities in General Practice (Red Book). 9th ed. Melbourne: RACGP; 2016 (updated 2023).
7. Stucken EZ, Brown C, Elisevich K, et al. Systematic review of quality of life in the era of cochlear implantation. JAMA Otolaryngol Head Neck Surg. 2022;148(11):1043–1051.
8. Chandrasekhar SS, Tsai Do BS, Schwartz SR, et al. Clinical practice guideline: sudden hearing loss (update). Otolaryngol Head Neck Surg. 2019;161(1_suppl):S1–S45.
9. Australian Government Department of Health. Hearing Services Program. Canberra: Commonwealth of Australia; 2024. Available from: https://www.health.gov.au/our-work/hearing-services-program
10. Smith RJH, Bale JF Jr, White KR. Sensorineural hearing loss in children. Lancet. 2005;365(9462):879–890.
11. Australian Institute of Health and Welfare. Ear disease in Aboriginal and Torres Strait Islander children. Cat. no. IHW 236. Canberra: AIHW; 2023.
12. Livingston G, Huntley J, Sommerlad A, et al. Dementia prevention, intervention, and care: 2020 report of the Lancet Commission. Lancet. 2020;396(10248):413–446.
13. Lin FR, Pike JR, Albert MS, et al. Hearing intervention versus health education control to reduce cognitive decline in older adults with hearing loss in the USA (ACHIEVE): a multicentre, randomised controlled trial. Lancet. 2023;402(10404):786–797.
14. Safe Work Australia. Work Health and Safety Regulations 2011 — Managing Noise and Preventing Hearing Loss at Work. Canberra: Safe Work Australia; 2023 (updated guidance).
15. Rosenfeld RM, Shin JJ, Schwartz SR, et al. Clinical practice guideline: otitis media with effusion (update). Otolaryngol Head Neck Surg. 2016;154(1_suppl):S1–S41.

for PBS scripts. Utilise ACCHS pharmacies and Remote Area Aboriginal Health Worker programs for medication supply in remote areas. Avoid initiating benzodiazepines; support holistic pain management including community-based exercise programs.

Preventive health

Promote bone health: encourage vitamin D supplementation (1000 IU daily in deficient individuals), smoking cessation support, reduction of alcohol intake, and weight-bearing exercise. MBS Item 715 health checks provide a structured opportunity to assess bone health, screen for osteoporosis risk factors, and discuss musculoskeletal health in a culturally safe context.

Quick Reference: Differential Diagnosis at a Glance

Costovertebral dysfunction

Paracetamol ± NSAID; manual therapy

2–6 weeks

Provocable on palpation; no red flags

Thoracic compression fracture

Paracetamol; ± calcitonin; DXA + osteoporosis Rx

6–12 weeks healing

Elderly; osteoporosis; acute onset

ACS (posterior MI)

Aspirin 300 mg, GTN, heparin; urgent PCI

Time-critical

ECG, troponin; CV risk factors

Aortic dissection

IV labetalol; urgent CT aortogram; surgery (Type A)

Time-critical

Tearing pain; BP differential >20 mmHg

Vertebral osteomyelitis

IV antibiotics (vancomycin + ceftriaxone initially); ID consult

6 weeks IV antibiotics

Fever, elevated CRP, IV drug use

Biliary colic / cholecystitis

Paracetamol ± morphine; lap cholecystectomy

Surgical within 72 h (cholecystitis)

RUQ/infrascapular; post-prandial; RUQ US

📚 References

1. Briggs AM, Smith AJ, Straker LM, Bragge P. Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskelet Disord. 2009;10:77.
2. National Health and Medical Research Council (NHMRC). Evidence-based management of acute musculoskeletal pain. Canberra: NHMRC; 2003 (updated 2020).
3. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Canberra: AIHW; 2023.
4. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268(6):760–765.
5. Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Europ Spine J. 2018;27(1):60–75.
6. Erwin WM, Jackson PC, Homonko DA. Innervation of the human costovertebral joint: implications for clinical back pain syndromes. J Manipulative Physiol Ther. 2000;23(6):395–403.
7. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice. 9th edn. Melbourne: RACGP; 2018 (updated 2023).
8. Hirsch JA, Singh V, Falco FJE, et al. Thoracic facet joint interventions. Pain Physician. 2016;19(4):E581–E593.
9. Erwin WM, Jackson PC. The costovertebral joint: anatomy, biomechanics, and clinical significance in thoracic back pain syndromes. J Can Chiropr Assoc. 2003;47(2):112–120.
10. Strayer RJ, Gunnerson JM, Brown LH, et al. Aortic dissection: clinical features, diagnosis, and management. Aust Crit Care. 2019;32(2):144–153.
11. Ombregt L. A system of orthopaedic medicine. 3rd edn. Edinburgh: Churchill Livingstone Elsevier; 2013. Chapter 18: Thoracic spine.
12. Lin CC, Chen KH, Li DM, et al. Characteristics and outcomes of patients presenting with thoracic back pain to the emergency department. Emerg Med Australas. 2020;32(5):805–811.

for PBS-listed medicines at participating pharmacies.

Cultural safety

Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.

Medication adherence

Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.

Specific conditions

Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.

Referral pathways

Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).

for PBS-listed medicines at participating pharmacies.

Cultural safety

Medication adherence

Specific conditions

Referral pathways

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).