What are the treatment guidelines for sudden sensorineural hearing loss (SNHL)?

Treatment Guidelines for Sudden Sensorineural Hearing Loss (SNHL)

Corticosteroid therapy should be initiated as soon as possible, ideally within the first 14 days of symptom onset, as the primary treatment for sudden sensorineural hearing loss. 1, 2

Diagnosis and Initial Assessment

• Distinguish sensorineural hearing loss from conductive hearing loss through history and physical examination 1
• Obtain audiometry as soon as possible (within 14 days of symptom onset) to confirm SSNHL diagnosis 1
• SSNHL is defined as a rapid onset hearing loss occurring over a 72-hour period with ≥30 dB hearing loss at 3 consecutive frequencies 1
• Assess for bilateral hearing loss, recurrent episodes, or focal neurologic findings that may indicate specific underlying causes 1
• MRI with gadolinium or auditory brainstem response (ABR) testing should be performed to evaluate for retrocochlear pathology 1, 3

Treatment Protocol

First-Line Treatment: Corticosteroid Therapy

Systemic Corticosteroids

• Oral prednisone: 1 mg/kg/day (maximum 60 mg daily) for 10-14 days, followed by a taper over a similar time period 1, 2
• Equivalent doses: methylprednisolone 48 mg/day or dexamethasone 10 mg/day 1
• Administer as a single (not divided) dose 1
• Start treatment as early as possible, ideally within the first 14 days of symptom onset 1, 2

Intratympanic (IT) Corticosteroids

• Can be used as initial therapy or as salvage therapy when oral steroids fail 1, 2
• Recommended regimen:
  • Dexamethasone 24 mg/mL (compounded) or 10 mg/mL (stock) 1, 2
  • Methylprednisolone 40 mg/mL or 30 mg/mL 1
  • Inject 0.4 to 0.8 mL into middle ear space 1
  • Up to 4 injections over a 2-week period 1, 2
  • Keep head in otologic position (affected ear up) for 15-30 minutes after injection 1

Salvage Therapy

• Intratympanic steroid therapy should be offered when patients have incomplete recovery from SSNHL 2-6 weeks after onset of symptoms 1, 2
• Consider hyperbaric oxygen therapy combined with steroid therapy within 1 month of onset 1

Contraindications and Special Considerations

• Patients with insulin-dependent or poorly controlled diabetes, labile hypertension, glaucoma, tuberculosis, peptic ulcer disease, or prior psychiatric reactions to corticosteroids may not be candidates for systemic steroids 1
• For these patients, intratympanic steroid injections are not inferior in efficacy 1

Monitoring and Follow-up

• Obtain audiometric evaluation after completion of treatment 1
• Schedule follow-up audiometric evaluation within 6 months of diagnosis 1
• For IT therapy, consider audiograms between injections to assess for early resolution 1
• Inspect tympanic membrane to ensure healing after IT treatment 1

Prognosis and Rehabilitation

• Approximately one-third to two-thirds of patients recover some hearing within 2 weeks 1, 2
• Patients who recover half of their hearing in the first 2 weeks have a better prognosis 2
• Presence of vertigo at onset indicates poorer prognosis 2
• Factors associated with better outcomes:
  • Earlier presentation after symptom onset 4
  • Milder degree of initial hearing loss 4

Rehabilitation for Incomplete Recovery

• Counsel patients with residual hearing loss about audiologic rehabilitation options 1
• Discuss amplification options and hearing-assistive technology 1, 2
• Consider psychological support for patients with persistent symptoms 1

Treatments NOT Recommended

• Do not routinely prescribe antivirals, thrombolytics, vasodilators, or vasoactive substances 1
• Do not order routine CT of the head in initial evaluation 1
• Do not obtain routine laboratory tests 1

Shared Decision Making

• Educate patients about the natural history of SSNHL, treatment benefits/risks, and limitations of existing evidence 1
• Discuss that even with treatment, not all patients will recover their hearing completely 1
• Explain potential side effects of corticosteroid therapy, including acne, blurred vision, hypertension, increased appetite, weight gain, mood swings, and hyperglycemia 1

The evidence for corticosteroid therapy in SSNHL is not definitive, but it represents the best available treatment option with potential benefits that outweigh the risks of short-term use. Early intervention is critical, as the greatest recovery occurs within the first two weeks of symptom onset.