Step 1 of 8
Presentation & Urgency Triage
Hearing loss/fullness/otorrhoea/autophony — sort emergent (fracture, facial palsy, mastoiditis, CSF) vs urgent vs routine
Conductive hearing loss presents as hearing loss, a failed hearing screen, aural fullness, otorrhoea, tinnitus, autophony, or — in a child — speech and language delay, and the first task is to triage for urgency before settling into the orderly work-up. The emergent group needs urgent imaging and specialist management: temporal-bone fracture, facial paralysis, acute mastoiditis, a suspected intracranial complication, CSF otorrhoea, and acutely complicated cholesteatoma. The urgent group needs an expedited workup: pulsatile tinnitus, a retrotympanic pulsatile mass, progressive unilateral conductive loss, a persistent unilateral effusion in an adult, and any suspected neoplasm.
The routine group — chronic stable conductive loss, otosclerosis, congenital conductive loss, and a dry tympanic-membrane perforation — proceeds through history, examination, and audiology at standard pace. This triage is not a formality: it separates the patient who needs a CT scan and an operating theatre this week from the one who can be fully characterised in clinic, and it front-loads the two errors most worth avoiding — touching a vascular retrotympanic mass, and dismissing a unilateral adult effusion that is masking a nasopharyngeal carcinoma. Everything that follows assumes the emergent and urgent flags have already been actively sought and excluded.
- Presentation — hearing loss, failed screen, fullness, otorrhoea, tinnitus, autophony, paediatric speech delay
- Emergent — temporal-bone fracture, facial palsy, mastoiditis, intracranial complication, CSF otorrhoea, complicated cholesteatoma → urgent imaging + specialist
- Urgent — pulsatile tinnitus, retrotympanic pulsatile mass, progressive unilateral CHL, adult unilateral effusion, suspected neoplasm → expedite
- Routine — chronic stable CHL, otosclerosis, congenital CHL, dry perforation
★ High-yield pearls (chapter-wide)
- A negative Rinne and a Weber that lateralises to the worse-hearing ear confirm conduction at the bedside — but the air–bone gap on the audiogram, not the tuning forks, quantifies it and drives the decision.
- Conductive hearing loss behind a normal-looking tympanic membrane is the high-yield problem — think otosclerosis, congenital ossicular fixation, ossicular discontinuity, congenital cholesteatoma, and superior semicircular canal dehiscence, and let the acoustic reflexes and HRCT separate them.
- Preserved acoustic reflexes in an ear with a conductive loss are the tell of a third-window disorder — most often superior semicircular canal dehiscence — because a true ossicular conductive loss abolishes the reflex.
- Autophony, the Tullio phenomenon, and pressure-induced vertigo with a low-frequency air–bone gap are superior canal dehiscence until VEMP and high-resolution CT say otherwise — and stapes surgery on a misdiagnosed dehiscence makes the patient worse.
- A retrotympanic mass — pulsatile, blue, or vascular — must be imaged before it is biopsied or a myringotomy is performed, because an aberrant carotid, a dehiscent jugular bulb, or a glomus tumour bleeds catastrophically.
- A unilateral middle-ear effusion in an adult is nasopharyngeal carcinoma until a nasopharyngoscopy proves otherwise — never simply ventilate it and move on.
- Persistent conductive loss despite a patent ventilation tube means the problem is not the effusion — look for ossicular pathology, cholesteatoma, or adhesive middle-ear disease.
- In congenital aural atresia the Jahrsdoerfer score grades surgical candidacy — a score of 7 or more supports atresiaplasty, while a lower score favours a bone-conduction device, and early bone-conduction amplification protects speech and language regardless.
- Otosclerosis is the progressive conductive loss behind an intact drum in an adult — Carhart's notch on the audiogram is the clue, and stapedotomy reliably closes the gap while a hearing aid is an equally valid, lower-risk choice.
- The air–bone gap is closed by repairing the conductive lesion (tympanoplasty, ossiculoplasty, stapedotomy, atresiaplasty) or bypassed by amplification — and bone-conduction devices rescue the draining, atretic, or reconstruction-failed ear that a conventional aid cannot.
Evidence base
3 sources- HIGH
Wuthukananchai N, Hunsaker DH, Vance D · Ear Nose Throat J · 2024Systematic reviewPMID 38895947
Systematic review of conductive hearing loss behind an intact tympanic membrane — the differential of otosclerosis, ossicular fixation and discontinuity, congenital cholesteatoma and third-window lesions, and the role of acoustic reflexes and high-resolution CT in separating them.
- HIGH
Rosenfeld RM, Shin JJ, Schwartz SR · Otolaryngol Head Neck Surg · 2016Practice guidelinePMID 26832942
The AAO-HNS clinical practice guideline for otitis media with effusion — watchful waiting, the hearing and developmental assessment, and the tympanostomy-tube (with adenoidectomy) decision in children.
- HIGH
Ho ML · Neuroimaging Clin N Am · 2019Imaging reviewPMID 30466645
Imaging review of third-window lesions of the inner ear, detailing the CT appearances of superior and posterior canal dehiscence and related defects that cause a conductive hearing loss with intact ossicles.
Decision tree
The triage screen is the first gate. Classification routes the stable patient to one of the aetiology-keyed pathways below. Cross-cut cards capture the chapter's must-not-miss rules.