What is the recommended management for sudden sensorineural hearing loss?

Management of Sudden Sensorineural Hearing Loss

Oral corticosteroids should be initiated within 14 days of symptom onset as first-line treatment for sudden sensorineural hearing loss (SSNHL), with intratympanic steroid therapy recommended for salvage treatment when initial therapy fails. 1, 2

Diagnosis and Initial Assessment

• Distinguish sensorineural from conductive hearing loss through history and physical examination 1
• Audiometric confirmation should be obtained as soon as possible and within 14 days of symptom onset 1
  • SSNHL is defined as ≥30 dB hearing loss at 3 consecutive frequencies occurring over a 72-hour period 1, 2
• Assess for red flags including bilateral hearing loss, recurrent episodes, or focal neurologic findings that may indicate specific underlying causes 1
• Avoid routine head CT in the initial evaluation of presumptive SSNHL 1
• Avoid routine laboratory tests as they provide limited benefit in SSNHL evaluation 1
• Evaluate for retrocochlear pathology with MRI (preferred), CT (if MRI contraindicated), or auditory brainstem response 1

Treatment Algorithm

First-Line Treatment (within 14 days of 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 2
   • Most effective when started early, with better outcomes when initiated within 14 days 2, 3

2. Consider combination therapy with both oral and intratympanic steroids for severe to profound hearing loss 2

Salvage Therapy (if incomplete recovery after initial treatment)

1. Intratympanic steroid therapy:

   • Recommended within 2-6 weeks following onset of SSNHL 1
   • Typically methylprednisolone 40 mg/mL injected into the middle ear 2-3 times per week for 2 weeks 2, 4
   • Particularly useful for patients with contraindications to systemic steroids 2

2. Hyperbaric oxygen therapy (HBOT):

   • May be offered in conjunction with steroids within 2 weeks of diagnosis for initial treatment or up to 1 month for salvage therapy 1, 2
   • More beneficial for younger patients (<50-60 years) with moderate to severe hearing loss (>60 dB) 2

Treatments to Avoid

• Do not routinely prescribe:
  • Antivirals
  • Thrombolytics
  • Vasodilators
  • Vasoactive substances 1

Monitoring and Follow-up

• Audiometric evaluation should be obtained:
  • At the conclusion of treatment
  • Within 6 months of completing treatment 1, 2
• Most recovery occurs within 1 month (78% of patients) and by 3 months (97% of patients) 2
• Approximately one-third to two-thirds of patients recover some hearing within 2 weeks 2, 5

Management of Residual Hearing Loss and Associated Symptoms

• Counsel patients about the natural history of SSNHL, benefits and risks of interventions, and limitations of existing evidence 1
• Provide audiologic rehabilitation for patients with residual hearing loss and/or tinnitus 1, 2
  • Options include hearing aids, cochlear implants, and hearing-assistive technology 2
• Consider psychological support for patients struggling with hearing loss and tinnitus 2
• For acute vertigo, consider short-term use of:
  • Vestibular suppressants (e.g., meclizine 25-50 mg every 4-6 hours as needed)
  • Antiemetics for nausea (e.g., ondansetron 4-8 mg every 8 hours as needed) 2

Important Considerations and Caveats

• Treatment efficacy: Studies comparing oral vs. intratympanic steroids show similar efficacy, with intratympanic treatment not inferior to oral prednisone 4
• Steroid side effects: Monitor for common adverse effects including sleep disturbances, weight gain, hypertension, hyperglycemia, and increased risk of infection 2
• Prognosis factors: Poorer outcomes are associated with:
  • Delayed treatment initiation
  • Presence of vertigo
  • Greater degree of initial hearing loss
  • Advanced age 6, 3
• Recovery rates: Without treatment, spontaneous recovery occurs in 32-65% of cases, though clinical experience suggests this may be an overestimation 1

Early intervention is critical for maximizing hearing recovery and improving quality of life for patients with SSNHL. The evidence strongly supports prompt initiation of steroid therapy as the mainstay of treatment.