Can escitalopram (Lexapro) or fluoxetine (Prozac) cause hearing loss?

Hearing Loss Associated with Escitalopram or Fluoxetine

Hearing loss is a rare but possible side effect of SSRIs like escitalopram (Lexapro) and fluoxetine (Prozac), with fluoxetine having more documented cases of serious auditory effects.

Relationship Between SSRIs and Hearing Loss

Evidence for SSRI-Related Hearing Loss

• SSRIs can potentially affect the auditory system through serotonergic mechanisms in the cochlea and auditory pathways 1
• Documented cases show that fluoxetine can cause serious auditory side effects, including hearing loss 2
• Tinnitus has been reported as a side effect of sertraline (another SSRI) even at low doses, suggesting a class effect 1

Mechanism of Action

• Serotonin is involved in filtering auditory stimuli through complex interactions between serotonergic, glutamatergic, and GABAergic neurotransmitter systems 1
• SSRIs may reinforce or desensitize the activity of different serotonin receptor subtypes within the auditory system 1
• There may be a priming effect when SSRIs are used with other ototoxic medications (like aspirin or salicylates) 1

Clinical Presentation and Diagnosis

Symptoms to Monitor

• Sudden or progressive hearing loss
• Tinnitus (ringing in the ears)
• Sensation of ear fullness
• Balance problems or vertigo

Differential Diagnosis

When a patient on escitalopram or fluoxetine presents with hearing loss, consider other common causes:

1. Ménière's disease: Characterized by episodic vertigo, fluctuating hearing loss, tinnitus, and aural fullness 3
2. Sudden sensorineural hearing loss (SSNHL): Rapid onset hearing loss that may be idiopathic or have various causes 3
3. Autoimmune inner ear disease: Progressive fluctuating bilateral hearing loss that is steroid-responsive 3
4. Vestibular schwannoma: Usually presents with chronic imbalance and asymmetric hearing loss 3
5. Drug-induced hearing loss: Many medications can cause ototoxicity, including aminoglycosides, cancer drugs, and loop diuretics 4

Management Approach

If Hearing Loss Develops While on SSRIs

1. Immediate Assessment

   • Complete audiometric evaluation to document the extent and type of hearing loss
   • Consider MRI to rule out structural causes if symptoms persist 3

2. Medication Management

   • Consider discontinuation of the SSRI if temporal relationship is established
   • In cases of sudden hearing loss related to SSRIs, symptoms may resolve after discontinuation 1

3. Treatment Options

   • Corticosteroids may be offered as initial therapy for sudden hearing loss within 2 weeks of symptom onset 3
   • Intratympanic steroid injections can be considered as salvage therapy if oral steroids are contraindicated or ineffective 3

Prevention and Monitoring

• Regular monitoring of auditory symptoms in patients on SSRIs, particularly those with:
  • Pre-existing hearing issues
  • Concurrent use of other potentially ototoxic medications
  • Advanced age
  • Renal impairment (which may affect drug elimination) 4

Special Considerations

Risk Factors for SSRI-Related Hearing Loss

• Concomitant use of other ototoxic medications
• History of previous hearing problems
• Dehydration
• Reduced drug elimination (especially due to renal failure) 4

Medication Alternatives

If hearing loss occurs with escitalopram or fluoxetine, consider:

• Switching to a different class of antidepressants (e.g., bupropion, mirtazapine) 5
• Using lower doses of SSRIs if they must be continued 5

Key Pitfalls to Avoid

1. Delayed Recognition: Any new auditory symptoms in patients taking SSRIs should prompt immediate evaluation
2. Misattribution: Not all hearing loss in patients on SSRIs is medication-related; complete workup is essential
3. Polypharmacy: Be cautious about drug interactions that might increase ototoxicity risk
4. Permanent Damage: Some cases of drug-induced hearing loss can be irreversible if the medication is not promptly discontinued 4

In summary, while hearing loss is not among the common side effects of escitalopram and fluoxetine, case reports indicate it can occur. Prompt recognition, evaluation, and management are essential to prevent potential permanent hearing damage.