What is the management approach for sudden onset sensory neural hearing loss?

Management of Sudden Onset Sensory Neural Hearing Loss

Oral corticosteroids should be initiated as first-line treatment for sudden sensorineural hearing loss (SSNHL) within 14 days of symptom onset, using prednisone 1 mg/kg/day (maximum 60 mg daily) for 10-14 days followed by a taper. 1

Diagnosis and Initial Evaluation

• Confirm SSNHL through audiometric testing as soon as possible and within 14 days of symptom onset

  • SSNHL is defined as ≥30 dB hearing loss at 3 consecutive frequencies occurring over a 72-hour period 2, 1
  • Distinguish sensorineural from conductive hearing loss through tuning fork tests and physical examination 2

• Perform a complete audiological evaluation including:

  • Pure-tone audiometry (1000-8000 Hz)
  • Speech audiometry to assess word recognition
  • Distortion product otoacoustic emissions to detect cochlear damage 1

• Assess for red flags requiring urgent attention:

  • Bilateral hearing loss
  • Recurrent episodes
  • Focal neurologic findings 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 1
   • Do not divide doses 1
   • Monitor for adverse effects: sleep disturbances, weight gain, hypertension, and hyperglycemia (especially in diabetic patients) 1

Salvage Treatment (if incomplete recovery after initial therapy)

1. Intratympanic steroid therapy (2-6 weeks after onset):

   • Options include:
     • Dexamethasone 24 mg/mL (compounded) or 10 mg/mL (stock)
     • Methylprednisolone 40 mg/mL or 30 mg/mL
   • Administration: 0.4-0.8 mL injected into middle ear space, 2-3 times per week for 2 weeks (up to 4 injections) 2, 1
   • Patients should remain with affected ear up for 15-30 minutes after injection 1

2. Hyperbaric oxygen therapy (HBOT):

   • May be offered in conjunction with steroids within 2 weeks of diagnosis or up to 1 month after onset 2, 1
   • Particularly beneficial for younger patients (under 50-60 years) with moderate to severe hearing loss (>60 dB) 1

Combination Therapy

• Consider combination of oral and intratympanic steroids for patients with severe to profound hearing loss 1
• Research shows that adding intratympanic steroids to systemic steroids may provide additional benefit, though the optimal timing remains under investigation 3

Treatments to Avoid

• Do NOT routinely prescribe:

  • Antivirals
  • Thrombolytics
  • Vasodilators
  • Vasoactive substances 2, 1

• Do NOT order:

  • Routine head CT scans (non-targeted) 2
  • Routine laboratory tests 2

Imaging and Further Workup

• MRI is recommended to rule out retrocochlear pathology (e.g., vestibular schwannoma) 2
• If MRI cannot be performed, CT scan or auditory brainstem response evaluation are secondary options 2

Follow-up and Rehabilitation

• Obtain audiometric evaluation:

  • At the conclusion of treatment
  • Within 6 months of completing treatment 2, 1

• For patients with residual hearing loss and/or tinnitus:

  • Provide audiologic rehabilitation options
  • Consider hearing aids, cochlear implants, or hearing-assistive technology 1

Prognosis

• Without treatment, spontaneous recovery occurs in 32-65% of cases 1
• Most recovery occurs within 1 month (78% of patients) and by 3 months (97% of patients) 1
• Early intervention is critical for better outcomes 1
• Factors associated with poorer prognosis:
  • Older age
  • Presence of vertigo
  • Greater degree of initial hearing loss 4

Clinical Considerations

• Approximately 90% of SSNHL cases are idiopathic at presentation 2
• Evidence from comparative studies shows that intratympanic steroids are not inferior to oral steroids as primary treatment 5, but oral steroids remain the standard first-line approach due to ease of administration
• For patients with contraindications to systemic steroids (diabetes, hypertension, glaucoma, tuberculosis, peptic ulcer disease, prior psychiatric reactions), intratympanic steroids may be considered as primary therapy 1

Remember that prompt recognition and early intervention within 14 days of symptom onset is crucial for maximizing hearing recovery and improving quality of life.