A patient who says one ear went deaf overnight is either blocked or in trouble, and the difference is a 512 Hz tuning fork and an otoscope. Wax and effusion are visible; if the drum looks normal and Weber lateralises to the good ear with Rinne positive on both sides, that is sensorineural loss and the clock started when the hearing did.
The error is almost never the diagnosis. It is the delay - a course of antibiotics, a decongestant, an audiology appointment in three weeks. Steroids should start on the day of presentation, before the formal audiogram if that is what it takes, because the benefit is time-dependent and the window is measured in days. Arrange the audiogram to confirm and to grade, not to permit treatment.
And examine the rest: an ear that has gone suddenly deaf needs cranial nerves checked and an MRI arranged for retrocochlear disease, and in an adult, the nasopharynx looked at if there is any effusion at all.
- Use a 512 Hz tuning fork at first contact; Weber lateralising away from the deaf ear means sensorineural.
- Start steroids the same day rather than waiting for the audiogram.
- Book the audiogram to grade and document, not to authorise treatment.
- Examine the cranial nerves and arrange MRI to exclude retrocochlear pathology.
- Tell the patient explicitly that delay costs recovery, so they return if anything worsens.
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