Conductive or Sensorineural? Making Sense of a Hearing Diagnosis

Most families meet these two words for the first time in an appointment that lasted eight minutes, on a page they were handed on the way out. Then they go home and search for them.

The difference is worth understanding, because it changes almost everything that follows: whether it is likely to resolve, what the treatment is, and what it means for your child's speech.

The two kinds, in plain terms

Sound has to travel through the outer and middle ear before it reaches the inner ear, which converts it into a signal the brain can read. A problem can occur in either part.

Conductive hearing loss is a blockage or a mechanical problem in the outer or middle ear. The inner ear works perfectly well — the sound simply is not getting through to it clearly. Imagine listening to someone speak normally while you have your fingers in your ears: everything is quieter and muffled, but nothing is distorted.

Sensorineural hearing loss is a problem in the inner ear or in the nerve carrying the signal to the brain. Sound arrives, but parts of it are not being converted or transmitted properly. It is not simply quieter — particular frequencies can be missing, which is why turning the volume up does not fully solve it.

Two practical consequences follow. Conductive loss is usually temporary and often treatable, and it typically makes everything quieter. Sensorineural loss is usually permanent, is managed rather than cured — with hearing aids, and in some cases cochlear implants — and distorts as well as reduces. Some children have both at once, which is called a mixed loss.

Glue ear: the common one nobody takes seriously enough

By far the most common conductive hearing loss in children is otitis media with effusion — glue ear. Fluid collects behind the eardrum after colds and infections and stops it moving freely. It is extremely common, it usually clears on its own, and it frequently comes and goes for months.

The NICE guideline on glue ear in under-12s lists what these children commonly present with, and reading it as a parent is illuminating:

• Hearing difficulties — mishearing when not looking at whoever is speaking, difficulty in a group, asking for things to be repeated
• Delayed speech and language development
• Ear discomfort
• Tinnitus

And it separately lists what else can be associated with it. This is the part that matters most on this page:

• Behavioural problems, particularly lack of concentration or attention
• Being withdrawn, irritable
• Poor educational progress
• Balance difficulties

Read that list again with a school report in mind. A child who does not concentrate, does not follow instructions, seems withdrawn, is falling behind and is clumsy is a child who gets described as inattentive — and a fluctuating conductive hearing loss produces every single one of those.

This is why we ask about hearing before almost anything else, and why "he can hear when he wants to" is one of the most misleading things a family can conclude. With glue ear, some days genuinely are better than others.

What happens next, and what does not

Families are often surprised by how much of the answer is watchful waiting, and by how much is explicitly ruled out.

NICE advises reassessing hearing after three months where glue ear affects both ears with hearing loss, and considering reassessment after three months where it affects one ear. That waiting is deliberate, not neglect — a great many cases resolve in that window.

The management options the guideline says should be discussed with families are monitoring and support, auto-inflation, hearing aids, and grommets (ventilation tubes).

What the guideline explicitly says not to offer for glue ear is worth knowing before somebody suggests it:

• Do not offer antibiotics to treat it.
• Do not offer oral or nasal steroids for it or for the hearing loss it causes.
• Do not offer antihistamines, mucolytics, anti-reflux medicines or decongestants for it.

That list is unusually clear for a clinical guideline, and it will save some families a good deal of money and several courses of medicine that were never going to help.

What you can do while you wait

NICE also sets out what parents can do to support a child with glue ear and hearing loss, and it is all practical:

• Be close to your child and face them when you speak. Not louder — closer, and visible.
• Cut the background noise. Television off during conversation. A child straining to hear cannot filter competing sound the way you can.
• Use visual cues — pointing, showing, gesture.
• Tell the teacher, and ask what adjustments the school can make, including where your child sits.

None of that is a treatment. All of it reduces how much your child is missing in the meantime, which is what protects their language and their confidence while the fluid clears.

Which children are more likely to be affected

The guideline notes that these can be associated with glue ear — while being clear that their absence does not rule it out: a history of upper respiratory infections or ear infections; craniofacial differences such as Down syndrome and cleft palate; asthma, wheezing, eczema; sneezing and nasal itching; sucking habits and bottle feeding; mouth breathing; conjunctivitis; and snoring.

Two of those deserve highlighting. Children with Down syndrome or a cleft palate are considerably more likely to have persistent glue ear, and it should be actively looked for rather than waited for. And mouth breathing and snoring point at the airway, which is worth raising in the same appointment.

Questions worth asking

1. Is this conductive, sensorineural, or both?
2. How much hearing loss is there, and in which ear?
3. Is it likely to be temporary, and when will you check again?
4. What should we do at home in the meantime?
5. What should the school be told, and what can they change?
6. Does my child need a speech and language assessment as well?

That last question is the one families most often do not think to ask. A child who has been hearing through fluid for a year has been learning language on incomplete information, and catching that up does not always happen automatically once the hearing is restored.

Where we fit

We do not test hearing and we do not treat it. Testing is for an audiologist and the ear itself is for an ENT, and if your child has not had a proper hearing test we will ask you to arrange one before we start anything.

What we do is the consequence: the speech sounds a child never heard clearly enough to learn, the vocabulary and grammar that did not go in while they were listening through fluid, and the listening and attention skills that a child with fluctuating hearing has genuinely not had a fair chance to build. Our page on hearing and speech covers that work, and our auditory processing page covers the different problem of a child who hears perfectly well and still cannot make sense of what they hear.

A consultation is Rs 1,500 and lasts up to 50 minutes, we work in Urdu or English, and you do not need a referral.

Source

• Otitis media with effusion in under 12s. NICE guideline NG233 (2023), which replaced the earlier CG60.