Ear pain, hearing loss and tinnitus

Assess hearing and associated danger

Establish whether hearing loss is sudden or gradual, unilateral or bilateral, and associated with pain, discharge, tinnitus, vertigo, trauma or neurological symptoms. Examine the canal and tympanic membrane, assess cranial nerves and use tuning-fork tests when helpful. Audiometry distinguishes patterns and quantifies loss, but a delay in obtaining it must not postpone urgent review of sudden sensorineural loss. Check for cerumen and middle-ear disease without assuming that every blocked sensation is conductive. Patients may describe sudden sensorineural loss simply as a plugged ear.

NSW emergency guidance recommends urgent clinical review, ideally within twenty-four hours, and formal audiometry for sudden sensorineural hearing loss. Treatment decisions, including steroids, require prompt ENT assessment and contraindication review. Associated focal neurological signs, severe sudden vertigo or head trauma raises other emergency causes. A normal canal and tympanic membrane are therefore not reasons for reassurance. Document onset and affected side clearly and confirm urgent access rather than issuing an untriaged referral.

Common painful and discharging conditions

Otitis externa produces canal pain, often worsened by tragal/pinna movement, with canal inflammation. Keep the ear dry and use suitable local therapy after checking whether the tympanic membrane is intact. Some drops are unsuitable with a perforation. Severe disproportionate pain in an older person with diabetes or immunocompromise raises necrotising otitis externa and needs urgent ENT assessment, especially with granulation or cranial neuropathy. Do not repeatedly treat such a presentation as simple swimmer's ear.

Acute otitis media involves middle-ear inflammation; a bulging tympanic membrane and acute symptoms are more useful than redness alone. Pain control is important, while antibiotic decisions depend on age, severity, perforation, risk and the local pathway. Mastoid tenderness/swelling, a protruding ear or systemic deterioration raises mastoiditis. Persistent discharge through a perforation needs assessment for chronic suppurative disease and cholesteatoma, with hearing review. Cholesteatoma can erode structures and needs specialist care rather than indefinite repeated drops.

For Aboriginal and Torres Strait Islander children at risk of ear disease, use the current specific Australian pathway and timely hearing support. Persistent discharge through a perforation for at least two weeks meets the relevant CSOM definition in this high-risk guidance; waiting six weeks can delay care. Hearing loss affects language, schooling and social participation. Involve the family, community services and education supports with consent, and tailor follow-up to access rather than treating repeated missed visits as indifference.

Foreign bodies and trauma

A button battery in an ear or nose requires immediate removal by an appropriately skilled service because tissue injury can progress rapidly. Do not irrigate an ear containing a battery, vegetable material that may swell, or a suspected perforation. Avoid repeated unsuccessful attempts that cause bleeding and make later extraction harder. Use adequate cooperation, analgesia and specialist help when needed. A live insect can need an appropriate immobilisation/removal method after assessing the membrane and contraindications; a deep lodged object is not a task for blind probing.

Pinna haematoma needs prompt drainage/compression assessment to prevent cartilage deformity. Temporal-bone injury can cause hearing loss, facial weakness, vertigo or CSF leak; assess as head trauma and seek specialist care. Traumatic tympanic perforation needs water protection and follow-up, with urgent review for marked hearing loss, vertigo or infection. Avoid placing potentially ototoxic drops without checking suitability. A clear fluid leak after head injury should not simply be attributed to swimming water.

Tinnitus and gradual hearing loss

Ask whether tinnitus is pulsatile, unilateral or associated with asymmetric hearing, vertigo or neurological findings. Pulsatile tinnitus can reflect vascular disease and merits directed investigation. Unilateral persistent tinnitus or asymmetric sensorineural loss may require ENT assessment for retrocochlear pathology. Symmetrical age-related loss generally benefits from audiology, hearing aids and communication support. Review noise exposure and ototoxic medicines. Explain strategies such as facing the patient, reducing background noise and confirming understanding without shouting or assuming reduced cognition.

Tinnitus distress may benefit from education, hearing rehabilitation and psychological approaches, with assessment of sleep, mood and suicide risk when severe. There is no universal tablet that reliably cures all tinnitus. Avoid repeated low-value imaging for a clearly low-risk symmetrical presentation, while investigating red flags. Treating hearing impairment can improve function and reduce isolation; ask about device affordability, dexterity and use. Check whether difficulties hearing instructions are being mistaken for non-adherence.

Applied decisions

A person awakens with unilateral hearing loss and a normal otoscopic examination: arrange urgent sensorineural-loss assessment, not a two-week trial of wax drops. A child with discharge and language delay needs active ear/hearing management and support. An immunocompromised patient with severe nocturnal ear pain and a facial palsy needs emergency review. For all referrals, state onset, findings, neurological symptoms, treatments and urgency, and ensure the patient knows where and when to attend.

NSW sudden sensorineural hearing loss and NSW ENT emergencies.

Review checkpoints

• Sudden sensorineural hearing loss requires urgent specialist assessment.
• A nasal button battery needs emergency removal rather than routine follow-up.
• Mastoid swelling or facial weakness can signal complicated ear disease.