Family medicine
Hearing Loss
Hearing loss is a partial or complete inability to perceive sounds in one or both ears, classified as conductive, sensorineural, or mixed based on the anatomical site of impairment.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding |
|---|---|---|---|
| Probability Diagnosis | Presbycusis (age-related SNHL) | Bilateral, gradual, high-frequency loss, elderly | 「你今年幾歲？兩隻耳聽嘢係咪差唔多一齊差？」 |
| Cerumen impaction | Unilateral, sudden/gradual, blocked feeling, CHL on examination | 「有冇覺得耳仔塞住咗？」→ Otoscopy: wax occluding canal | |
| Chronic otitis media with effusion (OME) | Blocked feeling, flat tympanogram, conductive HL, post-URTI | 「最近有冇傷風感冒？耳仔有冇脹脹哋？」 | |
| Serious Not To Miss | Nasopharyngeal carcinoma (NPC) | Unilateral HL + bloody post-nasal drip + neck mass; HK high prevalence | 「痰有冇血？頸有冇粒嘢？」 |
| Acoustic neuroma (vestibular schwannoma) | Unilateral SNHL + tinnitus ± unsteadiness; asymmetric SNHL on PTA [1] | 「一隻耳聽差咗？有冇耳鳴？行路有冇唔穩？」 | |
| Sudden sensorineural hearing loss (SSHL) | Acute onset ( < 72h), ≥30 dB over 3 frequencies; ENT emergency | 「係咪突然間聽唔到？幾時開始？」→ Urgent referral | |
| Cholesteatoma | Foul-smelling discharge, marginal TM perforation, conductive or mixed HL | 「耳仔有冇流臭嘅膿？」→ Otoscopy: pearly white mass/retraction pocket | |
| Pitfalls | Otosclerosis | Young adult, progressive bilateral CHL, FHx, Schwartz sign | 「屋企人有冇聽力問題？你幾大開始聽差？」 |
| Ménière's disease | Episodic vertigo + fluctuating HL + tinnitus + aural fullness | 「有冇成set耳鳴、頭暈、耳塞一齊嚟？」 | |
| Masquerades | Ototoxic drug-induced SNHL | Temporal relation to aminoglycosides, loop diuretics, cisplatin, TB drugs | 「最近有冇食過新藥？抗生素？結核藥？」 |
| Depression presenting as poor concentration/perceived HL | Low mood, anhedonia, social withdrawal | 「心情點？有冇覺得咩都冇興趣？」 | |
| Trying to Tell Me Something? | Occupational noise concern / compensation | Wants documentation or referral for ODCB claim [3] | 「你係咪擔心工作嘅嘈音整到你聽力差咗？想唔想了解職業性失聰賠償？」 |
| Social isolation / family conflict due to HL | Frustration, family asking to "get checked" | 「屋企人有冇話你聽唔到佢哋講嘢？」 |
Minute-by-Minute 6-Minute Consultation
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Friendly opening, rapport, set agenda | 「你好，我係X醫生。今日想同你傾吓你嚟睇醫生嘅原因，可以嗎？」(Hello, I'm Dr X. I'd like to chat about why you've come today, is that OK?) | Scores interpersonal marks: greeting, introduction, permission |
| 0:30–2:00 | HPI – symptom analysis | 「你耳仔聽嘢有咩問題？幾時開始？邊隻耳？係慢慢差咗定突然間聽唔到？有冇耳鳴？有冇耳仔流嘢？有冇頭暈/天旋地轉？」 | Covers onset, laterality, progression, associated symptoms – core HPI marks |
| 2:00–2:45 | Red flags & targeted Hx | 「有冇試過突然間完全聽唔到？有冇耳痛？有冇面部麻痺或者面歪？有冇流膿？食緊咩藥？以前有冇做過耳仔手術？做咩工作？有冇長期接觸嘈音？」 | Catches serious disorders; drug/occupational history |
| 2:45–3:30 | ICE – hidden agenda | 「你自己覺得點解會聽差咗？（Idea）你最擔心啲咩？（Concern）你嚟睇醫生最希望我幫到你啲咩？（Expectation）」 | Directly tested on Case Report Form; uncovers hidden agenda |
| 3:30–4:15 | PMHx, FHx, Social Hx, Functional impact | 「以前有冇耳仔或者其他長期病？屋企人有冇聽力問題？你平時聽嘢有冇影響到你做嘢或者同人溝通？」 | BPS problems; functional impact = social marks |
| 4:15–5:15 | Signpost, summarise, check understanding | 「我總結吓，你最主要係…聽力差咗…，有冇邊度我講漏咗？」 | Signposting + summarising scores highly |
| 5:15–6:00 | Explain plan, safety net, close | 「我想幫你檢查吓耳仔，之後可能要安排聽力測試。如果突然間聽唔到、好暈或者耳痛加劇，要即刻返嚟睇。你有冇嘢想問？」 | Safety-net advice + patient-centred closing |
Uncovering the hidden agenda: The patient may present with "hearing loss" but actually be worried about a brain tumour (acoustic neuroma), NPC (common HK fear), occupational compensation, or social isolation/depression. Always ask 「你最擔心啲咩？」 and 「點解今日先嚟睇？」(Why come today specifically?).
| Domain | English Question | Cantonese Question | Why It Matters | If Positive, Think Of |
|---|---|---|---|---|
| Onset/Duration | When did it start? Sudden or gradual? | 「幾時開始聽差咗？係慢慢差定突然間？」 | Sudden = emergency (SSHL, stroke); gradual = presbycusis, otosclerosis | Sudden → SSHL, stroke; Gradual → presbycusis, chronic OME |
| Laterality | One ear or both? | 「邊隻耳聽差咗？定係兩隻都係？」 | Unilateral = acoustic neuroma, cerumen, NPC; bilateral = presbycusis, noise, ototoxic drugs | Unilateral → acoustic neuroma, NPC; Bilateral → presbycusis |
| Progression | Getting worse, stable, or fluctuating? | 「有冇越嚟越差？定係時好時壞？」 | Fluctuating = Ménière's disease | Fluctuating → Ménière's |
| Tinnitus | Any ringing/buzzing in ear? | 「有冇耳鳴？即係耳仔入面有啲聲？」 | Unilateral tinnitus with hearing loss = red flag for acoustic neuroma / NPC [1] | Acoustic neuroma, Ménière's, NPC |
| Vertigo | Any spinning dizziness? | 「有冇天旋地轉嘅感覺？」 | Vertigo + HL + tinnitus = Ménière's triad; vertigo alone → BPPV | Ménière's, acoustic neuroma, labyrinthitis |
| Ear discharge | Any fluid/pus from the ear? | 「耳仔有冇流嘢？流膿？流血？」 | Otorrhoea → CSOM, cholesteatoma | CSOM, cholesteatoma |
| Ear pain | Any ear pain? | 「耳仔有冇痛？」 | AOM, otitis externa, referred pain (NPC) | AOM, OE, malignancy |
| Ear fullness/blocked | Feeling of blockage? | 「有冇覺得耳仔塞住咗？」 | Cerumen impaction, OME, Ménière's | Cerumen, OME, Ménière's |
| Nasal symptoms | Blocked nose, nosebleed, post-nasal drip with blood? | 「鼻塞唔塞？有冇流鼻血或者痰有血？」 | Blood-stained post-nasal drip is significant in early NPC diagnosis [1][2] | NPC |
| Cranial nerve Sx | Diplopia, facial numbness, facial weakness? | 「有冇嘢睇到兩個？面有冇痺或者面歪？」 | CN involvement → NPC with skull base erosion, acoustic neuroma | NPC, acoustic neuroma |
| Neck mass | Any neck lump? | 「頸有冇摸到有粒嘢？」 | Upper neck mass is the most common initial presenting symptom of NPC [2] | NPC |
| Noise exposure | Exposed to loud noise at work? How long? | 「做咩工作？有冇長期喺好嘈嘅環境做嘢？做咗幾耐？」 | Occupational deafness requires ≥5-10 yrs noisy work, ≥40 dB SNHL [3] | Noise-induced hearing loss (NIHL) |
| Drug history | Taking any medications? Antibiotics? Chemo? | 「食緊咩藥？有冇食過抗生素、結核藥或者化療藥？」 | Aminoglycosides, TB drugs → ototoxicity [1][4] | Drug-induced SNHL |
| PMHx | DM, HT, CKD, meningitis, head injury, RT? | 「有冇糖尿、高血壓、腎病？以前有冇腦膜炎、撞過頭或者做過電療？」 | Meningitis, head trauma, RT → SNHL [1] | Post-meningitis, post-RT SNHL |
| FHx | Family hearing loss? | 「屋企人有冇聽力問題？」 | Otosclerosis (AD), Alport syndrome (XL), genetic SNHL | Otosclerosis, hereditary SNHL |
| Functional impact | How does it affect daily life/work/communication? | 「聽差咗有冇影響你同人傾偈、做嘢或者出街？」 | Key for biopsychosocial assessment | Social isolation, work disability |
| Psychological | Feeling low, frustrated, isolated? | 「有冇因為聽唔到而覺得唔開心或者唔想出街？」 | Depression / social withdrawal secondary to HL | Depression, anxiety |
| Sexual/Menstrual | (Usually not directly relevant unless pregnancy/ototoxic drugs) | — | — | — |
Case Report Form Answer Builder
Template: "Hearing loss for [duration], [unilateral/bilateral], [gradual/sudden] onset."
High-yield HPI points to capture:
- Onset, duration, laterality, progression (sudden vs gradual, stable vs worsening vs fluctuating)
- Associated: tinnitus, vertigo, ear discharge, ear pain, aural fullness
- Nasal symptoms (bloody post-nasal drip → NPC)
- Noise exposure, ototoxic drugs, head injury, RT, meningitis
- Functional impact on communication/work
- PMHx, DHx, FHx, social Hx
| Likely RFC Examples | How to Phrase |
|---|---|
| Hearing getting worse, interfering with work/social life | "Progressive hearing difficulty affecting daily communication" |
| Family/colleague noticed patient can't hear | "Noticed by family that hearing has deteriorated" |
| Worried about tumour/NPC | "Concern about underlying serious cause (e.g. NPC)" |
| Wants hearing aid referral | "Seeking referral for hearing assessment and hearing aid" |
| Occupational noise exposure, wants compensation assessment | "Assessment of hearing loss related to occupational noise" |
Tip: Write the RFC that explains why today, not just "hearing loss."
| Component | Likely Content | Suggested Wording |
|---|---|---|
| Idea | "Thinks it's just aging" or "Worried it could be a tumour" or "Thinks it's from noisy workplace" | "Patient thinks hearing loss is age-related / due to noise at work" |
| Concern | Fear of NPC, brain tumour, going deaf, social embarrassment | "Patient is worried about NPC / going completely deaf / becoming isolated" |
| Expectation | Hearing test, hearing aid, specialist referral, reassurance, compensation letter | "Patient hopes for hearing test and specialist referral / hearing aid fitting" |
Choose based on the clinical stem:
| Stem Clue | Most Likely Diagnosis | Minimum Supporting Evidence |
|---|---|---|
| Elderly, bilateral, gradual, high-frequency loss | Presbycusis | Age > 60, bilateral symmetric SNHL, Rinne +ve both ears, Weber midline or to better ear |
| Unilateral blocked ear, visible wax | Cerumen impaction | Otoscopy showing impacted wax, CHL pattern |
| Post-URTI, blocked ear, flat TM | OME / Secretory otitis media | Dull/retracted TM, fluid level, CHL |
| Unilateral HL + tinnitus + unsteady | Acoustic neuroma (refer) | Asymmetric SNHL, MRI to confirm |
| HL + bloody post-nasal drip + neck mass | NPC (refer) | Nasopharyngoscopy, EBV DNA |
| DDx | One Key Discriminator |
|---|---|
| Cerumen impaction | Conductive HL, visible wax on otoscopy, resolves after removal |
| Chronic otitis media (COM/OME) | History of ear infections/URTI, TM perforation or effusion, conductive HL |
| Noise-induced hearing loss (NIHL) | Occupational noise > 5 yrs, bilateral high-frequency SNHL with 4 kHz notch on audiogram |
| Acoustic neuroma | Unilateral SNHL + tinnitus, asymmetric on PTA, MRI shows CP angle mass |
| NPC | Unilateral CHL (Eustachian tube blockage) + bloody post-nasal drip + upper neck LN |
| Ménière's disease | Episodic triad: vertigo + fluctuating HL + tinnitus + aural fullness |
| Otosclerosis | Young adult, progressive bilateral CHL, normal TM, FHx, absent stapedial reflex |
| Drug-induced (ototoxicity) | Temporal relation to aminoglycosides / cisplatin / TB drugs |
Pick three that best fit the stem. Default "safe trio" for elderly gradual bilateral HL: Presbycusis (Dx) + NIHL + OME; add NPC or acoustic neuroma if unilateral.
| Domain | Example Problem |
|---|---|
| Biological | Progressive sensorineural hearing loss requiring audiological assessment and possible hearing aid |
| Psychological | Anxiety/fear about underlying serious cause (NPC/tumour); frustration; risk of depression from social isolation |
| Social/Functional | Communication difficulty affecting work performance, social interactions, family relationships; safety concerns (cannot hear alarms/traffic) |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports This Diagnosis |
|---|---|---|---|
| Presbycusis | Weber lateralises to the better-hearing ear; Rinne positive bilaterally [5] | 256 Hz tuning fork on forehead (Weber); on mastoid then beside ear (Rinne) | Bilateral SNHL: AC > BC both sides (Rinne +ve), Weber to better ear |
| Cerumen impaction | Impacted wax visible on otoscopy | Otoscope examination of EAC | Occluding wax explains conductive HL; removal is both diagnostic and therapeutic |
| Chronic OM / OME | TM perforation or dull/retracted TM with effusion on otoscopy [1] | Otoscopic examination | Perforation or effusion confirms middle ear pathology causing CHL |
| Acoustic neuroma | Asymmetric SNHL on Rinne/Weber; reduced corneal reflex (CN V) in large tumours | Rinne/Weber; corneal reflex testing | Unilateral SNHL + CN V involvement suggests CP angle lesion |
| NPC | Upper cervical lymphadenopathy (Level II) on neck palpation [2] | Palpate bilateral cervical LN systematically | Most common initial presenting sign of NPC; in HK context, high yield |
| Otosclerosis | Rinne negative (BC > AC) with normal TM on otoscopy | Rinne test + otoscopy | CHL with pristine TM = fixation of stapes (otosclerosis) |
| Ménière's disease | No reliable physical sign in brief FM station | Diagnosis is clinical (episodic triad); audiogram shows low-frequency SNHL | Best clue is characteristic history; refer for audiometry |
| NIHL | Rinne positive bilaterally, Weber midline | Tuning fork tests | SNHL pattern; audiogram 4 kHz notch is gold standard [3] |
Must-Not-Miss Red Flags – Urgent Referral
- Sudden sensorineural hearing loss ( < 72 hrs) → ENT emergency, steroids within 2 weeks improves outcome
- Unilateral SNHL + tinnitus → rule out acoustic neuroma (MRI IAM) [1]
- Unilateral HL + bloody post-nasal drip + neck mass → NPC until proven otherwise (most common initial presenting symptom is cervical lymphadenopathy) [2]
- HL + foul ear discharge + marginal TM perforation → cholesteatoma (surgical referral)
- HL with new cranial nerve palsies (facial weakness, diplopia, facial numbness) → malignancy/skull base pathology
Top Traps That Lose Marks:
- Not distinguishing conductive vs sensorineural – always describe Rinne/Weber findings; this is the single most examined physical sign [1][5]
- Forgetting NPC in a HK patient with unilateral CHL – Eustachian tube blockage by NPC → conductive HL; always ask about nasal symptoms and examine neck [2]
- Not asking about ototoxic drugs – aminoglycosides, cisplatin, loop diuretics, TB drugs (streptomycin, kanamycin) [1][4]
- Writing "hearing loss" as the RFC instead of the real reason – the patient may have come because of fear, functional impact, or compensation need
- Not asking about occupational noise exposure – NIHL requires ≥5-10 yrs in specified noisy occupation for ODCB compensation claim [3]
- Forgetting to assess psychological impact – HL → depression, social isolation; easy BPS mark
Shortest safe management/safety-net line: 「如果突然間聽唔到、好暈、耳痛加劇、或者有面歪，一定要即刻返嚟或者去急症室。」
Key GC Lecture Points (High Yield):
- Types of deafness: Conductive (eardrum/ossicles), Sensorineural (cochlea/auditory nerve/brainstem), Mixed [1]
- Causes of conductive deafness: congenital meatal stenosis, eardrum perforation, ossicular chain problems (infection, post-op, otosclerosis, tumour), middle ear fluid [1]
- Causes of SNHL in adults: meningitis, ear/head trauma, noise, inner ear dysplasia, drug-induced (TB drugs), chronic ear infection, cochlear otosclerosis, radiotherapy [1]
- Rinne test: Normal/SNHL = AC > BC (positive); CHL = BC > AC (negative). Weber test: SNHL → lateralises to good ear; CHL → lateralises to bad ear [5]
- Occupational deafness compensation: SNHL ≥40 dB, ≥5-10 yrs noisy work, apply to ODCB [3]
High Yield Summary
What to ASK: Onset/laterality/progression, tinnitus, vertigo, discharge, ear pain, nasal symptoms (bloody PND for NPC), noise exposure, ototoxic drugs, FHx, functional/psychological impact, ICE (especially "why today?").
What to WRITE on CRF: (1) Clear HPI with timeline and associated symptoms. (2) RFC = the real reason they came (fear/function/compensation, not just "hearing loss"). (3) ICE with specific patient words. (4) Most likely Dx supported by Rinne/Weber or otoscopy finding. (5) Three DDx with discriminators. (6) BPS: biological (the HL itself), psychological (anxiety/depression), social (communication/work/isolation). (7) Physical sign: Rinne/Weber result or otoscopy finding matching your Dx.
What NOT to MISS: Sudden SNHL (emergency), unilateral HL + tinnitus (acoustic neuroma), bloody PND + neck mass (NPC), ototoxic drugs, occupational noise (compensation).
Active Recall - Family Medicine Clinical Test
[1] Lecture slides: GC 214. Common ear diseases and hearing loss.pdf [2] Senior notes: MBBS Final MB (Surgery) (Felix PY Lai).pdf (NPC section, p251) [3] Lecture slides: HKU OM lecture 2023.09.09.pdf (Occupational Deafness, p38-39) [4] Senior notes: Block A - Drugs and the Kidney.pdf (Aminoglycosides, p10) [5] Lecture slides: MBBS IV Clinical Skills Session Ear and Nose 2025 (1).pdf (Rinne/Weber table, p25)
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