Contraindications for referral

​Contraindications which should not be referred into or treated by the Direct Access Adult Hearing Service


  • 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).


  • 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.


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)