How to manage hyperacusis in a patient with aseptic meningitis?

Management of Hyperacusis in Aseptic Meningitis

For patients with hyperacusis in aseptic meningitis, the primary management approach should focus on treating the underlying meningitis while providing supportive care for auditory symptoms, as there are no specific guidelines for hyperacusis management in this context.

Initial Assessment and Stabilization

• Stabilization of the patient's airway, breathing, and circulation should be an immediate priority when managing any patient with meningitis 1
• Document the patient's conscious level using the Glasgow Coma Scale to monitor for deterioration 1
• Assess for signs of increased intracranial pressure, which may exacerbate neurological symptoms including hyperacusis 1

Diagnostic Approach

• Perform lumbar puncture (LP) within 1 hour of hospital arrival if safe to do so, to confirm aseptic meningitis 1
• Delay LP if there are contraindications such as focal neurological signs, papilledema, continuous seizures, or GCS ≤12 1
• Cerebrospinal fluid analysis typically shows lymphomonocytic pleocytosis (<500 cells/μL), mildly elevated protein, and normal glucose and lactate levels in aseptic meningitis 2
• Consider viral etiologies (particularly enteroviruses) as they account for most cases of aseptic meningitis 3, 2
• Rule out drug-induced aseptic meningitis, which can present with similar symptoms including auditory disturbances 4, 5

Management of Underlying Aseptic Meningitis

• If viral etiology is suspected or confirmed, provide supportive care as most cases are self-limited 3, 6
• Maintain euvolemia to support normal hemodynamic parameters 1
• Avoid fluid restriction as this is not recommended for reducing cerebral edema 1
• If empiric antibiotics were started, they can be discontinued once bacterial meningitis is ruled out 1, 3

Specific Management for Hyperacusis

• Provide a quiet environment to minimize auditory stimulation and reduce discomfort from hyperacusis 5
• Monitor for progression of auditory symptoms, as sensorineural hearing loss has been reported in cases of aseptic meningitis 5
• Consider discontinuation of any medications that might be contributing to the aseptic meningitis or auditory symptoms, particularly NSAIDs which have been associated with both conditions 4, 5
• Reassure the patient that auditory symptoms, including hyperacusis, often resolve with treatment of the underlying meningitis 5, 2

Critical Care Considerations

• Involve intensive care teams early if there is evidence of rapidly evolving symptoms, cardiovascular instability, respiratory compromise, frequent seizures, or altered mental state 1
• Transfer to critical care if GCS is 12 or less, if specific organ support is required, or if seizures are uncontrolled 1
• Maintain a mean arterial pressure (MAP) of ≥65 mmHg, though this may need to be individualized based on cerebral perfusion requirements 1

Follow-up and Monitoring

• Monitor auditory symptoms during recovery phase to ensure resolution 5, 2
• Most patients with viral aseptic meningitis have good to fair outcomes with appropriate supportive care 2
• Consider audiological assessment after recovery if hyperacusis or other auditory symptoms persist 5

Common Pitfalls and Caveats

• Do not delay treatment if bacterial meningitis cannot be ruled out immediately; empiric antibiotics should be started promptly 1, 3
• Avoid NSAIDs for symptom management as they can potentially cause or exacerbate drug-induced aseptic meningitis 4, 5
• Remember that hyperacusis may be an early symptom of sensorineural hearing complications that require monitoring 5
• Do not assume all auditory symptoms are directly related to meningitis; consider concurrent conditions or medication side effects 4, 5