What is the treatment for sudden hearing loss?

Treatment of Sudden Hearing Loss

Corticosteroids are the primary recommended treatment for sudden sensorineural hearing loss (SSNHL), with oral steroids or intratympanic injections initiated within 14 days of symptom onset showing the best outcomes. 1

Initial Evaluation and Diagnosis

• SSNHL is defined as ≥30 dB hearing loss at 3 consecutive frequencies occurring over a 72-hour period
• Audiometric testing is essential to confirm diagnosis and establish baseline hearing level
• MRI of the brain and internal auditory canals is recommended to rule out acoustic neuroma or other structural causes
  • Auditory brainstem response (ABR) can be used as an alternative screening tool if MRI is contraindicated

Treatment Algorithm

First-Line Treatment (within 14 days of symptom onset):

1. Oral Corticosteroids:
   • Prednisone 1 mg/kg/day (maximum 60 mg daily) for 10-14 days, followed by a taper over a similar period 1
   • Recovery rates of approximately 87.5% have been reported 2

OR

1. Intratympanic (IT) Steroid Injections:
   • Dexamethasone 24 mg/mL (compounded) or 10 mg/mL (stock) 1
   • Typically administered 2-3 times per week for 2 weeks 3, 2
   • Recovery rates of approximately 84.2% have been reported 2

Research shows that oral and intratympanic steroids have comparable effectiveness, with no statistically significant difference in hearing outcomes 2, 4, 5. A large randomized trial of 250 patients found that intratympanic methylprednisolone was not inferior to oral prednisone for primary treatment of SSNHL 5.

Considerations for Treatment Selection:

• For patients with contraindications to systemic steroids (diabetes, hypertension, glaucoma, tuberculosis, peptic ulcer disease, psychiatric disorders):
  • Choose intratympanic steroid injections as first-line therapy 1
• For patients with severe to profound hearing loss:
  • Consider combination therapy with both oral and intratympanic steroids 3

Salvage Therapy (for incomplete recovery after initial treatment):

• Intratympanic steroid injections if oral steroids were used initially 3
• Multiple studies support the use of IT steroids as salvage therapy, with success rates ranging from 25-55% 3

Adjunctive Therapy:

• Hyperbaric Oxygen Therapy (HBOT):
  • May be offered within 2 weeks of diagnosis or up to 1 month in conjunction with steroids 3
  • Most beneficial for:
    • Younger patients (under 50-60 years)
    • Moderate to severe hearing loss (>60 dB)
    • Early initiation (within 2 weeks to 3 months) 3

Important Clinical Considerations

Timing of Treatment

• Early intervention is critical - treatment initiated within 14 days of symptom onset has significantly better outcomes 1, 6
• One-third to two-thirds of patients may recover some hearing within 2 weeks 1

Monitoring and Follow-up

• Audiometric evaluation should be performed after completion of treatment
• Final follow-up evaluation within 6 months of diagnosis 3, 1
• Most recovery occurs within 1 month in 78% of patients and by 3 months in 97% of patients 3

Potential Side Effects

• Oral steroids: Sleep disturbances, weight gain, hypertension, hyperglycemia, insulin resistance, metabolic syndrome, adrenal suppression, peptic ulcer, increased cardiovascular risks 1
• Intratympanic steroids: Transient pain at injection site, brief caloric vertigo 3

Rehabilitation for Residual Hearing Loss

• Audiologic rehabilitation should be addressed as soon as hearing loss is identified
• Options include hearing aids, cochlear implants, and hearing-assistive technology
• Consider psychological support for patients experiencing anxiety, depression, or social isolation 3, 1

Common Pitfalls to Avoid

1. Delayed treatment - SSNHL is an otological emergency requiring prompt intervention 7
2. Inappropriate use of medications:
   • Antibiotics should not be routinely prescribed for presumed viral labyrinthitis
   • Antivirals, thrombolytics, vasodilators, or vasoactive substances are not recommended 1
3. Inadequate follow-up - Regular audiometric testing is essential to monitor recovery and detect complications
4. Overlooking psychological impact - SSNHL can cause significant emotional distress requiring counseling and support

Remember that SSNHL is an otological emergency, and early intervention is critical for improving hearing outcomes and quality of life.