Audiometric Testing for Suspected Hearing Loss with Lightheadedness

Initial Assessment and Referral Process

The American Academy of Otolaryngology-Head and Neck Surgery recommends pure tone audiometry (PTA) as the gold standard diagnostic test for patients with lightheadedness and suspected hearing loss, and it should be ordered as part of the initial evaluation 1.
A comprehensive diagnostic testing by an audiologist should include a thorough hearing-specific case history, otoscopic examination, ear-specific air and bone conduction threshold measures, speech audiometry measures, and otoacoustic emission (OAE) measures to determine cochlear function, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 2.

The audiometric evaluation should include pure tone thresholds measured at 250-8000 Hz, including 3000 and 6000 Hz with additional inter-octaves as appropriate, as well as speech recognition threshold or speech detection/awareness thresholds, and word recognition scores (WRS) measured in percentage of correct answers, according to the American Academy of Otolaryngology-Head and Neck Surgery 2.
Tympanometry is recommended to assess middle ear function, as suggested by the American Academy of Pediatrics 3.

The American Academy of Otolaryngology-Head and Neck Surgery suggests considering Ménière's disease in the differential diagnosis when lightheadedness is present with hearing symptoms, which requires audiometric confirmation of low to mid-frequency sensorineural hearing loss 4, 5.
Asymmetric hearing loss (difference in PTA between ears of >15 dB or difference >15% between ears in word recognition scores) requires further evaluation, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 5.
Vestibular migraine may coexist with Ménière's disease in up to 35% of cases and should be considered in patients with lightheadedness and hearing symptoms, according to the American Academy of Otolaryngology-Head and Neck Surgery 6.

Pure tone audiometry results can help classify the type of hearing loss, including conductive, sensorineural, or mixed, as suggested by the American Academy of Otolaryngology-Head and Neck Surgery 4.
For patients with greater-than-mild sudden sensorineural hearing loss, OAEs may help distinguish sensory from neural hearing loss, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 7.

If audiometric testing reveals hearing loss, the patient should be referred to an otolaryngologist for further evaluation, especially with asymmetric hearing loss, conductive or mixed hearing loss, or poor word recognition on diagnostic testing, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 1, 4.
For patients with persistent symptoms, re-examination at 3-6 month intervals is recommended until the condition resolves or additional intervention is needed, as suggested by the American Academy of Family Physicians 8.

The American Academy of Otolaryngology-Head and Neck Surgery recommends not relying on tuning fork tests alone for clinical screening, as they lack sufficient accuracy 5.
Routine laboratory tests for patients with sudden hearing loss should not be ordered unless specific risk factors are present, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 2, 7.