When a patient reports hearing loss in both ears, it’s essential to evaluate the problem systematically. Hearing loss can result from many causes — from simple earwax buildup to nerve damage in the inner ear. A careful combination of history-taking, physical examination, and audiological testing helps determine the type, degree, and possible cause of hearing loss.
Let’s explore the step-by-step process used by ENT specialists and audiologists to accurately identify hearing loss.
Contents
1. Detailed Case History
The first step is to gather information about the patient’s symptoms and medical background.
Key questions include:
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When did the hearing loss start — suddenly or gradually?
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Is it constant or does it fluctuate?
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Is there pain, discharge, or ringing (tinnitus)?
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Any dizziness or balance problems?
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Any history of loud noise exposure, ear infections, trauma, or family history of hearing loss?
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Has the patient used any ototoxic medications (certain antibiotics, painkillers, or chemotherapy drugs)?
The answers help guide the direction of clinical evaluation — for example, a sudden hearing loss may indicate a medical emergency, while a gradual decline may point to age-related or noise-induced causes.
2. Physical Examination of the Ear
An otoscopic examination is performed to visually inspect the outer ear and eardrum.
Findings may include:
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Earwax impaction: Common cause of temporary hearing loss.
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Ear infections: Redness, fluid, or perforation of the eardrum.
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Scarring (tympanosclerosis) or structural abnormalities.
If the ear canal or eardrum appears normal, the cause may lie deeper in the middle or inner ear.
3. Basic Hearing Screening Tests
A. Whisper Test:
A quick and simple bedside test. The examiner whispers words at a set distance, and the patient repeats them. Difficulty in repeating words suggests hearing impairment.
B. Tuning Fork Tests:
Two key tests — Rinne’s test and Weber’s test — are performed using a 512 Hz tuning fork to differentiate between conductive and sensorineural hearing loss.
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Rinne’s Test:
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The tuning fork is placed on the mastoid bone (bone conduction) and then near the ear canal (air conduction).
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Normally, air conduction is louder than bone conduction (Rinne positive).
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If bone conduction is louder, it indicates conductive hearing loss.
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Weber’s Test:
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The tuning fork is placed on the center of the forehead.
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If sound is heard louder in one ear, it suggests either conductive loss in that ear or sensorineural loss in the opposite ear.
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If sound is heard equally in both ears, hearing is likely normal or equally affected.
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4. Audiological Evaluation
If the initial screening suggests hearing loss, a comprehensive audiological test is conducted by an audiologist.
A. Pure-Tone Audiometry (PTA):
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The most common hearing test.
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Determines the type (conductive, sensorineural, or mixed) and degree (mild, moderate, severe, or profound) of hearing loss.
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Results are shown on an audiogram, a visual chart mapping hearing thresholds across different frequencies.
B. Speech Audiometry:
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Assesses how clearly the patient can understand speech at different loudness levels.
C. Tympanometry:
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Evaluates the function of the middle ear and eardrum mobility.
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Helps detect fluid buildup, eustachian tube dysfunction, or ossicular chain problems.
D. Otoacoustic Emissions (OAE):
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Measures sound waves produced by healthy inner ear hair cells.
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Absence of these emissions may indicate sensorineural damage.
E. Auditory Brainstem Response (ABR or BERA):
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Assesses the nerve pathways from the inner ear to the brainstem.
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Useful when hearing loss is suspected in patients who can’t respond actively (infants or uncooperative adults).
5. Imaging and Additional Tests
If tests suggest retrocochlear pathology (problems beyond the inner ear, such as tumors or nerve disorders), imaging may be ordered:
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CT Scan – Evaluates middle ear structures.
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MRI Scan – Assesses auditory nerve and brain structures.
Blood tests may also be done to check for autoimmune or infectious causes of hearing loss.
6. Diagnosis and Management
After all evaluations, the clinician identifies:
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Type of hearing loss – conductive, sensorineural, or mixed.
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Degree of hearing loss – mild, moderate, severe, or profound.
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Possible causes – infection, wax, noise exposure, aging, trauma, etc.
Treatment depends on the cause:
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Earwax removal or medical treatment for infections.
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Surgery (tympanoplasty or stapedectomy) for middle ear issues.
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Hearing aids for sensorineural loss.
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Cochlear implants for severe or profound cases.
Conclusion
When a patient complains of hearing loss in both ears, a thorough and structured evaluation is essential. From simple bedside tests to advanced audiological and imaging studies, each step helps identify the exact cause and guide appropriate treatment.
Early detection not only improves hearing outcomes but also prevents further deterioration and enhances quality of life.
If you or someone you know experiences difficulty hearing in both ears, visit a qualified audiologist or ENT specialist for a comprehensive hearing assessment.