Hearing Loss in Adults
Hearing loss is one of the most common reasons people come to see an ENT surgeon. It can come on gradually over years without anyone noticing at first, or it can appear suddenly out of nowhere, and it can affect one ear or both. Some causes are simple to deal with, others need more involved treatment, and a small number need urgent attention.
I see a lot of patients with hearing loss in my NHS and private practice. The majority do not need surgery. What most people do need is a careful examination of the ears, the right hearing tests, and a clear explanation of what is going on so they can decide what to do next. That is what I aim to offer at every appointment.
This page covers how the ear works, the different types of hearing loss, the causes you might come across, and what can be done about them. It doesn't cover every possible cause of hearing loss, just the main ones, and any unusual or unexpected pattern of hearing loss is always worth a proper assessment in person. There is also a separate page on this site dealing with tinnitus, which often goes hand in hand with hearing loss.
How does the ear work?
The ear has three parts that all need to work together for normal hearing:
The outer ear: the part you can see (the pinna), and the ear canal that runs from there into the head.
The middle ear: a small air-filled space that sits behind the eardrum. It contains three tiny hearing bones (the ossicles) which pass vibrations from the eardrum across to the inner ear. The middle ear is connected to the back of the nose by the Eustachian tube, which keeps the air pressure inside balanced.
The inner ear: a fluid-filled chamber that contains the cochlea (the hearing organ) and the balance organ. Inside the cochlea are tiny hair cells that turn the vibrations into electrical signals, which then travel along the hearing nerve to the brain.
Sound enters the outer ear, travels down the ear canal, and makes the eardrum vibrate. Those vibrations are passed through the three hearing bones to the inner ear, where they are converted into electrical signals. The brain then interprets those signals as sound.
If you would like a clear and engaging explanation of all this with animations, this video is excellent: Crash Course: Hearing & Balance. It is around 10 minutes long and is the clearest patient-friendly overview of how hearing works that I know of.
What can go wrong?
Hearing loss happens when something goes wrong anywhere along this pathway. Looking at it in order from outside to inside:
The outer ear can be blocked by wax, an infection of the ear canal, or (occasionally) a growth in the canal.
The eardrum can have a hole in it (see my Hole in the Eardrum page) or be pulled inwards by problems with middle ear ventilation.
The middle ear can fill with fluid (called glue ear, or middle ear effusion), particularly if the Eustachian tube is not working well. Children often get this and it is one of the reasons grommets are sometimes needed (see my Glue Ear and Grommets pages); adults get it too, sometimes after a heavy cold or for less obvious reasons.
The hearing bones in the middle ear can become stiff, eroded, or disconnected from each other. The most common reason for this is erosion of one of the hearing bones (typically the incus, the middle bone of the three) from years of chronic ear infections or inflammation. A separate, distinct cause is otosclerosis, in which one of the hearing bones (the stapes) becomes gradually fixed by abnormal bone growth.
The cochlea or hearing nerve in the inner ear can be damaged by ageing, noise exposure, certain medications, infections, or other less common conditions.
The location of the problem determines what type of hearing loss it is, and that in turn determines what can be done about it.
The three types of hearing loss
Hearing loss is divided into three main types depending on where in the hearing pathway the problem lies:
Conductive hearing loss
The problem is in the outer or middle ear, so sound is not being conducted (passed) properly through to the inner ear. The inner ear and hearing nerve themselves are working normally; it is just that the sound is not getting through. Examples include wax, glue ear, a hole in the eardrum, and otosclerosis. Conductive hearing losses are often treatable, sometimes very simply (for example by removing wax) and sometimes with surgery.
Sensorineural hearing loss
The problem is in the inner ear (the cochlea) or the hearing nerve, so the sound is reaching the right place but cannot be converted into a signal the brain can use. The most common cause by far is age-related hearing loss (presbycusis), followed by noise-induced hearing loss. Sensorineural hearing loss is usually permanent, but well-fitted hearing aids can make a very significant difference and are the mainstay of treatment.
Mixed hearing loss
A combination of conductive and sensorineural loss in the same ear. This is fairly common, particularly in older adults or in patients with a long history of ear disease, and the management depends on which part of the loss is contributing the most to the symptoms.
Sudden hearing loss is an emergency
This is the single most important message on this page. If you wake up with hearing loss in one ear, or your hearing in one ear suddenly drops over hours or a day or two without an obvious explanation, you may have a sudden sensorineural hearing loss, and this needs to be assessed and treated as soon as possible. Ideally within 72 hours, certainly within the first week.
The reason urgency matters is that the standard treatment is a course of steroids, which works much better the sooner it is started. Waiting weeks to see if the hearing comes back on its own is the most common reason patients miss the window where treatment can help.
If this happens to you:
Do not wait. See your GP urgently or come straight to A&E and ask to be seen by ENT.
Do not assume it is just wax. Wax-related blockage normally feels like a slow build-up of fullness over days or weeks, not a sudden drop overnight.
Even if there are other symptoms (dizziness, ringing, a sense of fullness), the hearing loss itself still needs treating quickly.
A new sudden hearing loss in one ear is one of the few situations in ENT where time really does make a difference.
How can I tell what type of hearing loss I have? The "hum test"
There is a simple test you can try at home that often gives a useful clue. It is called the Weber test, or the hum test, and it is the same test I will do in clinic with a tuning fork.
Here is how to do it:
Hum a steady note (any pitch) with your mouth closed.
While humming, listen carefully and notice which ear the hum sounds louder in, or whether it sounds equal in both.
Interpreting the result:
If the hum sounds equal in both ears, your hearing is probably either normal or affected equally on both sides.
If the hum sounds louder in your better-hearing ear (the one you think hears more sharply), the hearing loss in the worse ear is likely to be sensorineural.
If the hum sounds louder in your worse-hearing ear (the one you think is muffled), the hearing loss in that ear is likely to be conductive.
This is a useful starting point but it is not a substitute for a proper assessment. The hum test cannot tell you the cause of the loss, how severe it is, or what to do about it. It is well worth seeing an ENT surgeon for a proper examination of the ear and a formal hearing test, particularly if the hearing loss has come on suddenly, is in one ear only, or is associated with any other symptoms.
Common causes of hearing loss in adults
Wax
By far the simplest cause. Wax is normally cleared from the ear by the ear's own self-cleaning process, but it sometimes builds up and blocks the ear canal completely. Removal in clinic with microsuction (gentle suction under the microscope) is quick, painless, and usually gives an immediate improvement in hearing. Cotton buds make wax problems worse, not better, by pushing the wax deeper.
Age-related hearing loss (presbycusis)
The single most common cause of hearing loss in adults. The hair cells in the cochlea wear out gradually with age, particularly the ones that pick up high-pitched sounds. People often notice that they can hear someone speaking but cannot quite make out the words, particularly in background noise. Hearing aids are the mainstay of treatment and modern aids are excellent.
Noise-induced hearing loss
Damage to the hair cells in the cochlea from loud noise, either a single very loud event (a blast or shooting incident) or, more commonly, from repeated exposure over years (industrial noise, loud music, power tools, motorbikes). Noise-induced hearing loss is permanent. The most important thing is prevention, which I cover further down this page.
Glue ear (middle ear effusion) in adults
Fluid behind the eardrum, usually because the Eustachian tube is not ventilating the middle ear properly. In adults this often follows a heavy cold or an infection, but in some cases it is more persistent. Treatment depends on the cause and can include nasal sprays, treatment of any underlying allergy or reflux, and occasionally grommets.
A persistent one-sided glue ear in an adult always needs the back of the nose checking too. The reason is that, rarely, a growth at the back of the nose (the nasopharynx) can block the opening of the Eustachian tube on that side and cause a persistent middle ear effusion as the only sign. Most one-sided glue ears in adults are benign in cause, but a quick look at the back of the nose with a small flexible camera in clinic, sometimes with a scan, is part of being thorough. There is more on this on my Glue Ear page.
Hole in the eardrum
Covered in detail on my Hole in the Eardrum page.
Otosclerosis
A condition where the stapes (the smallest of the three hearing bones, sitting against the inner ear) becomes fixed by abnormal bone growth, so it cannot vibrate properly. It typically causes a gradual conductive hearing loss in early to middle adulthood and often runs in families. Treatment options include hearing aids or an operation called a stapedectomy, in which the fixed stapes is replaced with a tiny prosthesis.
Cholesteatoma
A condition in which skin grows in the wrong place behind the eardrum and can cause hearing loss as well as recurrent ear infections. Covered on my Cholesteatoma page.
Less common but important causes
Vestibular schwannoma (acoustic neuroma)
This is a benign (non-cancerous) growth on the hearing and balance nerve, usually on one side. It typically causes a gradual one-sided hearing loss, sometimes with one-sided tinnitus or unsteadiness. Patients understandably worry when they hear about this, but it is important to know that vestibular schwannoma is not cancer and most are slow-growing. Many are kept under observation rather than actively treated.
The diagnosis is made on an MRI scan. If you have any unexplained one-sided hearing loss or one-sided tinnitus, an MRI is usually arranged to rule this out, even though the vast majority turn out to be normal. It is one of the most important reasons to take one-sided hearing loss seriously and not just attribute it to wax or ageing. When a vestibular schwannoma is found, most are kept under observation with serial scans. A small proportion need active treatment, either with surgery or radiotherapy, and that decision is made jointly with a specialist skull base team.
Autoimmune inner ear disease
Rare, but does happen. This is when the body's own immune system attacks the inner ear, causing a hearing loss that often progresses over weeks to months and may affect both ears. It can sometimes occur on its own, and sometimes alongside other autoimmune conditions. Diagnosis is based on the pattern of hearing loss and blood tests, and treatment is usually with steroids and other immune-modulating medications.
Genetic causes
Some adults have a hearing loss that is inherited. This may have been present from childhood and become more obvious with age, or it may only show up in adult life. Where there is a clear family history of hearing loss not explained by ageing or noise exposure, a referral for genetic assessment can sometimes be helpful.
Ototoxic medications
Certain medications can damage the inner ear. The most well-known are some chemotherapy drugs (particularly cisplatin), some antibiotics (the aminoglycosides such as gentamicin, in certain situations), and very high doses of aspirin. If you are on any of these, hearing should be monitored. Stopping or substituting the medication is sometimes possible, but in many cases (chemotherapy, for example) the medication is essential and the priority is to monitor for change so it can be picked up early.
Trauma and surgery
A head injury, particularly one that involves the temporal bone (the bone the ear sits within), can cause hearing loss. The mechanism varies depending on the injury: blood or fluid in the middle ear, disruption of the small hearing bones, a hole in the eardrum, or damage to the inner ear itself. Anyone who develops a new hearing loss after a head injury, no matter how minor it seemed, should be assessed properly.
Direct injury to the ear can do the same. A slap to the ear or a sudden pressure change (a blast injury, or a hard fall onto water) can rupture the eardrum, dislocate the hearing bones, or damage the inner ear.
Ear surgery itself can occasionally cause a hearing change, which is why the risks of every operation include some discussion of hearing. For most ear operations, hearing is either unchanged or improved, but a small number of patients can end up with hearing slightly worse than before, and rarely with a significant or permanent loss. This is something I always go through honestly with patients before any operation.
Ménière's disease
A condition causing episodes of vertigo, fluctuating hearing loss, tinnitus, and a sense of fullness in the ear. The hearing loss is usually in one ear at first and tends to fluctuate during attacks before gradually becoming more permanent over time. Treatment options include lifestyle and dietary changes (particularly reducing salt and caffeine), medications to reduce the frequency and severity of attacks, and in some cases more involved interventions for difficult-to-control cases. I will be writing a more detailed page on Ménière's disease in due course.
Infections
A range of infections can damage the inner ear and cause sensorineural hearing loss. Bacterial infections doing this are rare, but viral infections are not as uncommon. Mumps and measles were classic causes, although both are now less common thanks to vaccination. Other viruses can also affect hearing, and during the COVID pandemic we saw more cases of sudden sensorineural hearing loss linked to recent COVID infection than would normally be expected. Proving a specific virus is responsible in any individual case is often difficult, but the link between a recent viral illness and a new hearing loss is well recognised. This is another reason it is important to be assessed quickly when hearing loss comes on suddenly, particularly after a viral illness.
Tumours at the back of the nose
Rare, but worth knowing about. The Eustachian tube opens into the back of the nose (an area called the nasopharynx). A growth in the nasopharynx can occasionally block the Eustachian tube on that side, leading to a persistent one-sided glue ear and a one-sided conductive hearing loss as the only obvious sign. This is uncommon, and the vast majority of one-sided glue ears in adults turn out to be benign in cause, but it is exactly why a one-sided middle ear effusion in an adult should not just be left or treated with grommets without first looking at the nasopharynx. The check itself is straightforward: a quick look with a thin flexible camera in clinic, sometimes followed by a scan if anything looks unusual. A vestibular schwannoma (covered above) is the equivalent rare-but-not-to-be-missed cause for one-sided sensorineural loss.
Hearing tests and hearing aids
Formal hearing tests (audiograms) are carried out by an audiologist. They measure exactly how well each ear is hearing across a range of pitches, and they give the detailed picture needed to make sense of any treatment recommendation. I work closely with audiologists and will arrange a hearing test for you whenever it is needed.
Hearing aids, similarly, are fitted and tuned by an audiologist rather than by an ENT surgeon. Modern hearing aids are extraordinarily good, and a well-fitted aid often makes a much bigger difference to someone's day-to-day life than any operation would. If you would benefit from a hearing aid, I am happy to recommend an audiologist who will look after you well, both for the test and for the fitting.
For most patients with hearing loss, a conventional hearing aid is the right answer. There are two other options worth being aware of, but they are usually only considered when standard hearing aids are not working well or are not suitable.
Bone-anchored hearing aids (BAHA)
A bone-anchored hearing aid works by sending sound through the bone of the skull directly to the inner ear, bypassing the outer and middle ear altogether. The principle is the same as a pair of bone conduction headphones (the kind some runners and cyclists use), except the device is attached to a small implant placed in the bone behind the ear. They tend to suit patients with conductive or mixed hearing losses where a normal in-the-ear hearing aid does not work well, for example because of an open mastoid cavity, a chronically discharging ear, a narrow or absent ear canal, or single-sided deafness. The fitting and assessment are done jointly with an audiologist who specialises in this area.
Cochlear implants
A cochlear implant bypasses the damaged hair cells in the cochlea entirely. A small device is implanted under the skin behind the ear, and a fine electrode is threaded into the cochlea, where it stimulates the hearing nerve directly. An external sound processor worn behind the ear sends sound to the implant. Cochlear implants are considered for patients with severe to profound sensorineural hearing loss in whom conventional hearing aids no longer give useful benefit. They do not restore normal hearing, but for the right patient they can restore the ability to understand speech and reconnect with the world. Cochlear implant assessment is done through specialist regional centres, and I will refer you on if I think you might benefit.
How can I protect my hearing? A practical guide
Most permanent hearing loss in adults is caused by ageing or noise. There is not much you can do about ageing, but noise damage is largely preventable. The simple practical points:
If you are around loud noise regularly (concerts, festivals, motorbikes, clubs, power tools, lawnmowers, leaf blowers, shooting), wear hearing protection. Foam earplugs from the chemist are cheap, effective, and fine for occasional use.
For musicians, regular gig-goers, motorbike riders, and anyone exposed often, custom-moulded musician's earplugs are a much better long-term option. They reduce volume evenly across the pitch range so music and speech still sound natural, just quieter. Any high-street audiologist can take impressions and arrange these.
If you work in a noisy environment, your employer is legally required to provide hearing protection and regular hearing tests. Use what you are given.
Use the volume warnings on your phone. If your earphones are loud enough that someone next to you can hear them, they are too loud.
If your ears ring or feel muffled after a noisy event, that is your inner ear telling you it has taken a hit. Cumulatively, these add up.
The general principle: the louder the noise and the longer the exposure, the more important the protection. You only get one set of hair cells in the cochlea, and they don't grow back.
When should you come and see me?
Come and see me if:
You have noticed a gradual change in your hearing in one or both ears
You have hearing loss in one ear that is worse than the other
You have ringing or noise in the ear (covered in detail on my tinnitus page)
You have recurrent ear infections, discharge, or a feeling of blockage
You suspect wax but it does not seem to be settling
You have been told you might benefit from a hearing aid and would like a thorough ENT assessment first
And come and see someone urgently (your GP, A&E, or any ENT surgeon you can get to) if:
You have a sudden hearing loss in one or both ears
You have hearing loss alongside dizziness, weakness on one side of the face, severe pain, or recent head injury
If you would like to be seen by me urgently, please contact my secretary and I will do my best to accommodate.
I'll examine your ears under the microscope, arrange a hearing test, and where needed organise a scan. By the end of the appointment you should have a clear understanding of what is going on and a plan that makes sense for you.
Helpful resources
Disclaimer
This page is intended as general information only. It does not replace a consultation, examination, hearing assessment, or individual medical advice. If you are concerned about your hearing, please get in touch to book an appointment so I can examine your ears properly and give you advice specific to your situation.