What are the next steps in managing a 21-year-old male with persistent left ear pain, 70% hearing loss, and eustachian tube dysfunction, despite previous treatment with prednisone (Deltasone) and Flonase (fluticasone) nasal spray, and would a high-dose steroid regimen be beneficial?

From the Guidelines

For a 21-year-old male with persistent left ear hearing loss (70%) despite previous treatment with a prednisone taper, I strongly recommend a higher-dose steroid regimen of prednisone 60mg daily for 10 days, as suggested by the most recent and highest quality study 1, to potentially improve hearing loss. The patient should continue with the ENT referral as the primary next step, and while waiting for the specialist appointment, continue daily Flonase nasal spray to address eustachian tube dysfunction. Additionally, I recommend adding a decongestant such as pseudoephedrine 60mg every 6 hours (if no contraindications) for 5-7 days to help improve eustachian tube function. The patient should be instructed to perform the Valsalva maneuver several times daily (pinching the nose and blowing gently with closed mouth) to help equalize pressure in the middle ear. This combination approach addresses both potential inflammatory causes of hearing loss and mechanical eustachian tube dysfunction, as outlined in the clinical practice guideline for sudden hearing loss 1. The higher-dose steroid treatment is justified because significant hearing loss that persists beyond initial treatment may require more aggressive anti-inflammatory therapy, particularly if there's a risk of permanent damage to inner ear structures, and is supported by the guideline's recommendation for corticosteroid therapy for SSNHL 1. The ENT evaluation remains crucial for definitive diagnosis and specialized treatment, including possible audiometric testing and tympanometry to better characterize the hearing loss, as recommended by the guideline 1. It is essential to consider patient preferences and values in the management decision, and shared decision making is extremely useful in cases where evidence is weak or benefits unclear, as emphasized in the guideline 1. The patient should be educated about the natural history of the condition, the benefits and risks of medical interventions, and the limitations of existing evidence regarding efficacy, as recommended by the guideline 1. Regular follow-up audiometric evaluations should be performed to assess the patient's response to treatment and adjust the management plan as needed, as recommended by the guideline 1.

Some key points to consider in the management of this patient include:

• The importance of distinguishing sensorineural hearing loss from conductive hearing loss, as recommended by the guideline 1
• The potential benefits and risks of corticosteroid therapy, including the risk of adverse effects such as insomnia, hyperglycemia, and hypertension, as outlined in the guideline 1
• The need for individualized treatment and shared decision making, taking into account patient preferences and values, as emphasized in the guideline 1
• The importance of regular follow-up and monitoring to assess the patient's response to treatment and adjust the management plan as needed, as recommended by the guideline 1.

From the FDA Drug Label

The initial dosage of PredniSONE tablets may vary from 5 mg to 60 mg per day, depending on the specific disease entity being treated. IT SHOULD BE EMPHASIZED THAT DOSAGE REQUIREMENTS ARE VARIABLE AND MUST BE INDIVIDUALIZED ON THE BASIS OF THE DISEASE UNDER TREATMENT AND THE RESPONSE OF THE PATIENT

The patient is currently experiencing 70% hearing loss in the left ear, and the previous treatment with a prednisone taper did not fully resolve the issue.

• The initial dosage of prednisone can range from 5 mg to 60 mg per day, and the dosage requirements must be individualized based on the disease and patient response.
• Considering the patient's condition, a high-dose steroid regimen of 60 mg daily for 10 days may be worth trying, but it is essential to monitor the patient's response and adjust the dosage accordingly.
• The patient has already been advised to use Flonase daily, and referral to an ENT specialist is also recommended for further evaluation and management.
• It is crucial to closely monitor the patient's condition and adjust the treatment plan as needed to avoid any potential adverse effects of high-dose steroid therapy 2.

From the Research

Eustachian Tube Dysfunction Management

• The patient's condition involves Eustachian tube dysfunction, which is a common complication in various cases, including cleft palate 3.
• Studies suggest that treatment of obstructive dysfunction includes steroid nasal sprays, such as Flonase, and regular performance of the Valsalva maneuver, as well as tube dilation with the Bielefelder balloon catheter 4.
• The use of high-dose steroids, such as 60mg daily for 10 days, may be considered in some cases, but its effectiveness in this specific scenario is not clearly supported by the provided evidence.
• The patient has already been advised to use Flonase daily and has been referred to an ENT specialist for further evaluation and management.

Hearing Loss and Eustachian Tube Function

• The patient's 70% hearing loss in the left ear may be related to the Eustachian tube dysfunction, as seen in cases of cleft palate where hearing evaluation revealed abnormal hearing thresholds before tympanostomy tube placement 3.
• The study suggests that most children with cleft palates eventually recover normal Eustachian tube function after palatoplasty, but this may take several years 3.
• The patient's condition and treatment plan should be closely monitored by the ENT specialist to determine the best course of action for managing the hearing loss and Eustachian tube dysfunction.

Treatment Options and Next Steps

• The patient's current treatment plan includes a prednisone taper and Flonase nasal spray, which may help alleviate symptoms and improve Eustachian tube function 4.
• Further treatment options, such as tube dilation or other interventions, may be considered based on the patient's response to current treatment and the ENT specialist's evaluation.
• Regular follow-up appointments with the ENT specialist will be crucial in determining the effectiveness of the treatment plan and making any necessary adjustments.