Sensorineural Hearing Loss

Comprehensive modern algorithm for diagnosis and management

Step 1

Step 1 of 6

Initial Clinical Assessment

History · examination · bedside tests

A complete bedside workup anchors every SNHL evaluation. The history reveals the dominant pattern (sudden vs. fluctuating vs. progressive vs. congenital), associated symptoms, exposures, and family clues — often more informative than any single test.

Outer (pinna + EAC, gold), middle (ossicles, amber), and inner (cochlea + vestibular system, teal) ear. SNHL localises to the cochlea or proximal CN VIII.

Bedside tests · tuning-fork interpretation

Weber (512 Hz)

Fork on vertex / forehead

Central — Symmetric hearing

Lateralises → bad ear — Conductive loss in that ear

Lateralises → good ear — SNHL in opposite ear

Rinne (512 Hz)

AC vs BC at each ear

AC > BC (positive) — Normal or SNHL

BC > AC (negative) — Conductive loss ≥25 dB

False negative — Severe SNHL — sound crosses to better ear

Hitselberger sign

Posterior EAC sensation

Normal — Intact CN VII sensory branch

Hypoaesthesia — Suggests vestibular schwannoma (large)

Detailed history
Otologic examination
Neurological examination
Tuning fork tests
Otoscopy

Evidence base

5 sources

HIGH
Does this patient have hearing impairment?
Bagai A, Thavendiranathan P, Detsky AS · JAMA · 2006Rational Clinical ExaminationPMID 16434633
Quantifies the diagnostic accuracy of bedside whispered-voice and tuning-fork tests — the evidence base for the Step 1 examination. Vol 295(4):416-428.
HIGH
Whispered voice test for screening for hearing impairment in adults and children: systematic review
Pirozzo S, Papinczak T, Glasziou P · BMJ · 2003Peer review
Systematic review establishing sensitivity / specificity of the whispered-voice test — the most-cited evidence base for this simple bedside screen. Vol 327:967.
MOD
Clinical utility of the 512-Hz tuning fork in hearing loss evaluation
Burkey JM et al. · Otolaryngol Head Neck Surg · 1998Peer review
Quantifies the operating characteristics of the 512-Hz tuning fork in routine ENT practice — anchors the Weber / Rinne component of Step 1.
HIGH
Clinical Practice Guideline: Sudden Hearing Loss (Update)
Chandrasekhar SS et al. · Otolaryngol Head Neck Surg · 2019AAO-HNSPMID 31369359
Defines the history elements that distinguish SNHL from conductive loss and identify time-critical presentations. Vol 161(1_suppl):S1-S45.
LOW
World Report on Hearing
World Health Organization · 2021WHO policy report (non-peer-reviewed)
WHO global policy report framing history-taking and bedside examination as the universal first step in any hearing-loss workup. Authoritative as policy/burden source, not peer-reviewed evidence.

Disclaimer

For educational purposes only. Not for clinical use. This platform is an instructional resource intended to support learning about clinical decision-making and the interpretation of investigations. Clinicians remain completely responsible for the interpretation of findings, the formulation of a differential diagnosis, and any clinical decision. Nothing in this application replaces individualized assessment, hands-on training, expert consultation, or established practice guidelines.

Not for profit effort by

Dr. Prahlada N.B

MBBS (JJMMC), MS (PGIMER, Chandigarh)
MBA in Hospital & Healthcare Management (BITS, Pilani)
Postgraduate Certificate in Technology Leadership and Innovation (MIT, USA)
Executive Programme in Strategic Management (IIM, Lucknow)
Senior Management Programme in Healthcare Management (IIM, Kozhikode)
Advanced Certificate in AI for Digital Health and Imaging Program (IISc, Bengaluru)

Supporting organisations

Karnataka ENT Hospital and Research Centre (R)
Champions Educational and Medical Society (R)
Amogh Foundation