What are the causes and treatment options for a patient with hearing loss for 3 months?

Causes and Treatment of Hearing Loss Persisting for 3 Months

For hearing loss persisting for 3 months, the most appropriate approach is audiometric evaluation followed by targeted treatment based on the type of hearing loss identified, with corticosteroid therapy recommended for sudden sensorineural hearing loss if within the treatment window, and surgical options for conductive hearing loss when indicated. 1

Differential Diagnosis of 3-Month Hearing Loss

Sensorineural Causes

• Idiopathic Sudden Sensorineural Hearing Loss (ISSNHL): Defined as hearing loss occurring over less than 72 hours

  • Prognosis worsens when treatment is delayed beyond 2 weeks 2
  • Recovery rates significantly lower when treatment starts in second week (30-43.8%) 2
  • 97% of patients reach final hearing level by 3 months 1

• Age-related hearing loss (presbycusis): Most common type in adults 3

• Ototoxic medications: Aminoglycosides, loop diuretics, chemotherapy 1

• Post-infectious: Following meningitis or viral infections 1

• Trauma: Especially basal skull/temporal bone fractures 1

Conductive Causes

• Chronic otitis media with effusion (OME): Common in children
  • 75-90% of OME resolves spontaneously within 3 months 1
  • Persistent OME beyond 3 months requires intervention 1
• Cerumen impaction: Potentially curative when treated 3
• Tympanic membrane perforation
• Ossicular chain abnormalities

Mixed Hearing Loss

• Combination of conductive and sensorineural components

Diagnostic Approach

1. Comprehensive audiometric evaluation is essential for any hearing loss persisting ≥3 months 1

   • Pure-tone audiometry (PTA)
   • Word recognition scores (WRS)
   • Tympanometry to assess middle ear function

2. Otoscopic examination to identify:

   • Cerumen impaction
   • Tympanic membrane abnormalities
   • Middle ear effusion

3. Imaging studies indicated for:

   • Asymmetrical hearing loss
   • Sudden sensorineural hearing loss
   • Suspected ossicular chain damage
   • MRI or CT based on suspected pathology 3

Treatment Recommendations

For Sudden Sensorineural Hearing Loss (ISSNHL)

• If within 2 weeks of onset: Corticosteroid therapy is recommended 1, 2

  • Systemic corticosteroids: Prednisone 1 mg/kg/day (maximum 60 mg) for 7-14 days 2
  • Intratympanic corticosteroids: Consider as salvage therapy for those who fail systemic treatment 1
  • Combined therapy may offer better hearing recovery (odds ratio of 2.5) 2

• If beyond 2-4 weeks: Limited benefit from corticosteroid therapy 2

  • Recovery after 6 months is extremely rare (0.6% of cases) 1, 2

For Otitis Media with Effusion (OME)

• Watchful waiting for first 3 months if no risk factors present 1
• After 3 months of persistence:
  • Hearing evaluation is mandatory 1
  • For children <4 years: Tympanostomy tubes recommended if surgery needed 1
  • For children ≥4 years: Tympanostomy tubes, adenoidectomy, or both 1

For Conductive Hearing Loss

• Cerumen impaction: Irrigation or curettage 3
• Chronic OME: Surgical intervention if persistent beyond 3 months with significant hearing loss 1
• Structural abnormalities: Referral to otolaryngologist for surgical evaluation 3

For Permanent Hearing Loss

• Hearing aids: First-line for sensorineural hearing loss 3
• Cochlear implants: For severe to profound hearing loss not responsive to hearing aids 3
• Auditory rehabilitation: Education and communication strategies 1

Follow-Up Recommendations

• Follow-up audiometric evaluation within 6 months of diagnosis for ISSNHL 1
• For OME, re-evaluation every 3-6 months until resolution or intervention 1
• Document resolution of hearing loss, improved hearing, or improved quality of life 1

Important Considerations

• Treatment outcomes for ISSNHL are significantly better when initiated within the first 14 days 2
• Antihistamines and decongestants are ineffective for OME 1
• Antimicrobials and corticosteroids do not have long-term efficacy for routine OME management 1
• Regular audiological follow-up is essential to determine treatment efficacy and consider rehabilitation options 2

By following this structured approach to diagnosis and treatment, patients with persistent hearing loss can receive appropriate care that maximizes their chances of hearing recovery or effective management of permanent hearing loss.