What is the recommended treatment for a patient reporting sudden hearing loss?

Management of Sudden Hearing Loss

Oral corticosteroids are recommended as the first-line treatment for idiopathic sudden sensorineural hearing loss (ISSNHL), which should be started promptly, ideally within the first 2 weeks of symptom onset. 1

Initial Assessment and Diagnosis

1. Distinguish between sensorineural and conductive hearing loss:

   • Use tuning fork tests (Weber and Rinne) at initial presentation 2, 1
   • This distinction is crucial as management differs significantly

2. Obtain audiometry promptly:

   • Should be performed within 14 days of symptom onset 1
   • Establishes baseline hearing status and helps monitor treatment response

3. Imaging:

   • MRI with gadolinium is recommended to rule out retrocochlear pathology (e.g., vestibular schwannoma) 1, 3
   • If MRI is contraindicated, consider auditory brainstem response testing 1

Treatment Protocol

For Idiopathic Sudden Sensorineural Hearing Loss:

1. First-line treatment:

   • Oral corticosteroids (prednisone 60-80 mg daily for 10 days) 1, 4
   • Should be initiated as soon as possible, ideally within first 2 weeks 1
   • Early intervention is critical as maximum improvement typically occurs within 2 weeks of onset 4

2. Second-line/salvage therapy:

   • Intratympanic steroid perfusion if incomplete recovery with oral steroids 1
   • Typically offered 2-6 weeks after symptom onset 1

3. Treatments to avoid:

   • Routine use of vasoactive substances, vasodilators, and thrombolytics (including blood thinners) is not recommended due to lack of consistent evidence 1

For Specific Etiologies:

• Conductive hearing loss: Address underlying cause (e.g., cerumen removal, myringotomy for effusions, antibiotics for infections) 1
• Perilymphatic fistula: Surgical repair may be indicated, especially in divers or fliers with sudden hearing loss 5
• Migraine-associated: Consider antispasmodic agents if migraine history is present 6

Follow-up and Rehabilitation

1. Audiometric evaluation:

   • Perform after treatment completion to assess recovery 1
   • Regular follow-up to monitor hearing status

2. For patients with residual hearing loss:

   • Counsel about rehabilitation options 2
   • Consider amplification devices:
     • Traditional hearing aids
     • Contralateral routing of signal (CROS) hearing aids for unilateral loss
     • Osseointegrated bone conduction devices 2, 1
   • Consider cochlear implantation for severe to profound unrecovered SSNHL, especially with associated tinnitus 1

3. Psychosocial support:

   • Assess impact on quality of life using standardized tools (e.g., Hearing Handicap Inventory) 2, 1
   • Refer to consumer-based organizations like Hearing Loss Association of America 2, 1

Prognostic Factors

• Favorable prognosis: Early presentation, mild hearing loss (<90 dB), upward-sloping audiograms, recovery beginning within 2 weeks 4
• Poor prognosis: Severe hearing loss (>90 dB), flat or downward-sloping audiogram, advanced age, presence of vertigo 4

Common Pitfalls to Avoid

• Delaying treatment (corticosteroids should be started promptly)
• Failing to distinguish between conductive and sensorineural hearing loss
• Overlooking potential specific causes requiring targeted treatment
• Neglecting the psychosocial impact of hearing loss
• Not offering rehabilitation options for residual hearing loss 2, 1

Remember that one-third to two-thirds of patients may achieve spontaneous recovery, most likely within the first 2 weeks, but this should not delay treatment initiation 3.