From the Guidelines
Otosyphilis symptoms include sudden unilateral or bilateral sensorineural fluctuating hearing loss, tinnitus, and/or vertigo, with vertigo attacks not typically associated with aural symptoms immediately before or after attacks. These symptoms occur when syphilis infection affects the inner ear structures. Patients may experience fluctuating hearing loss that eventually becomes permanent, similar to Meniere's disease. According to the most recent study 1, the management of adult syphilis, including otosyphilis, involves the use of penicillin as the first-line treatment.
Key Symptoms and Signs
- Sudden or progressive hearing loss
- Tinnitus (ringing in the ears)
- Vertigo (dizziness)
- Balance problems
- Abnormal eye movements (nystagmus)
- Positive Romberg test (inability to maintain balance with eyes closed)
- Abnormal results on audiometric testing showing sensorineural hearing loss
Diagnosis and Treatment
Diagnosis is confirmed through serologic tests for syphilis (VDRL, RPR, FTA-ABS) combined with clinical symptoms, as there is no specific test for otosyphilis. Treatment consists of intravenous penicillin G (18-24 million units daily) for 10-14 days, followed by intramuscular benzathine penicillin G (2.4 million units weekly) for 3 weeks. For penicillin-allergic patients, doxycycline (100 mg twice daily for 28 days) is an alternative, as suggested by 1 and 1. Corticosteroids are often added 24 hours before antibiotic therapy to prevent inflammatory response in the ear. Early treatment is crucial as hearing loss may become permanent if therapy is delayed. Otosyphilis typically occurs in late-stage syphilis but can appear at any stage of the disease.
Important Considerations
- All patients with syphilis should be tested for HIV, as recommended by 1.
- Patients with evidence of auditory disease caused by syphilis should be treated according to the recommendations for patients with neurosyphilis, regardless of CSF examination results, as suggested by 1.
- Repeated CSF examinations are not necessary for HIV-uninfected patients or HIV-infected patients on antiretroviral therapy who exhibit appropriate serologic and clinical responses after treatment for neurosyphilis, according to 1.
From the Research
Symptoms of Otosyphilis
- Unilateral tinnitus and hearing loss 2
- Asymmetric sensorineural hearing loss 2
- Sudden or fluctuating sensorineural hearing loss 3, 4
- Ringing or vertigo 4
- Hearing loss, tinnitus, headache, and nausea 5
- Dysequilibrium 4
Signs of Otosyphilis
- Positive syphilis serology 6, 4, 5
- Abnormal cerebrospinal fluid (CSF) analysis indicating neurosyphilis 5
- Cochleovestibular dysfunction of unknown aetiology 4
- Profound deafness 6
- Irreversible sensorineural hearing loss 2, 3
Treatment Response
- Complete audiologic recovery is rare but possible with appropriate treatment 2
- Improvement in hearing, tinnitus, and vertigo with penicillin and corticosteroid therapy 6, 4
- Factors associated with a good response to treatment include fluctuating symptoms, hearing loss less than five years, and age less than 60 4
- Patients with CSF abnormalities, including those with HIV disease, may experience subjective improvement 4