The typical history is gradual, painless, progressive hearing loss over years, beginning in early or middle adulthood. It is usually bilateral but asymmetric, and often starts unilaterally, with the second ear following later. There is characteristically no pain, no discharge and no preceding infection — which distinguishes it from most other causes of conductive loss. Hearing quality. Sound is quiet rather than unclear. Speech discrimination is preserved, so patients typically say "if you speak up, I understand you perfectly" — the direct opposite of sensorineural loss, where volume does not solve the problem. This distinction is diagnostically useful and shapes communication advice. Paracusis willisii — hearing *better* in noisy surroundings — is a classic and fairly specific symptom. People raise their voices in noise, and the patient's conductive loss attenuates the background, so the signal-to-noise ratio improves. Speaking softly. Because bone conduction is preserved, patients hear their own voice loudly and therefore tend to speak quietly — the reverse of the sensorineural patient who speaks loudly. Tinnitus is common and is often the symptom that finally prompts presentation. Mild imbalance...