Contraindications for referral

History:

• Persistent pain affecting either ear which has lasted for more than seven days within the last 90 days prior to the appointment.
  
• History of discharge, other than wax, from either ear within the last 90 days.
• Sudden loss or sudden deterioration of hearing (sudden is within one week, in which case send to A&E or Urgent Care ENT clinic).
• Rapid loss or rapid deterioration of hearing (rapid is within 90 days or less).
• Fluctuating hearing loss not associated with head colds or other respiratory tract infection.
• Unilateral or asymmetrical, pulsatile or distressing tinnitus lasting more than 5 minutes at a time.
• Troublesome tinnitus which may lead to sleep disturbance or be associated with symptoms of anxiety or depression
• Abnormal auditory perception (dysacusis).
• Vertigo (classically described as hallucination of movement) or other disturbances including dizziness, swaying or floating sensations that may indicate otological, neurological or medical conditions).
• Normal peripheral hearing but with abnormal difficulty hearing in noisy backgrounds, possibly having problems with sound localisation, or difficulty following complex auditory directions.

Ear examination:

• Complete or partial obstruction of the external auditory canal preventing proper examination of the eardrum and/or safe and accurate taking of an aural impression.
  
• Abnormal appearance of the outer ear and/or the eardrum (e.g. inflammation of the external auditory canal, perforated eardrum, active discharge).

Audiometry:

• Conductive hearing loss, defined as 25dB or greater air-bone gap present at two or more of the following frequencies: 500, 1000, 2000 or 4000 Hz.

• Unilateral or asymmetrical sensorineural hearing loss, as indicated by a difference in left and right bone conduction thresholds of 20dB or greater at two or more of the following frequencies: 500, 1000, 2000 or 4000 Hz.

• Evidence of deterioration of hearing by comparison with an audiogram taken in the last 24 months, defined as a deterioration of 15dB or more in air conduction threshold readings at two or more of the following frequencies: 500, 1000, 2000 or 4000 Hz.

References:

British Academy of Audiology Guidelines for Referral to Audiology of Adults with Hearing Difficulty (2009)

BSHAA Protocol and Criteria for Referral for Medical or other Specialist Opinion (2011)