What is the treatment for a patient with conductive hearing loss on the right side and sensorineural hearing loss on the left side, with air conduction (AC) hearing greater on the left and bone conduction (BC) hearing greater on the right?

Treatment for Mixed Hearing Loss with Conductive Loss on Right and Sensorineural Loss on Left

The appropriate treatment approach for a patient with conductive hearing loss on the right side and sensorineural hearing loss on the left side requires addressing each type of hearing loss separately with specific interventions tailored to the underlying pathology.

Diagnostic Assessment

• Clinicians must first distinguish between conductive hearing loss (CHL) and sensorineural hearing loss (SNHL) through comprehensive audiometric testing, as these conditions have markedly different management strategies 1.
• The pattern of air conduction (AC) hearing greater on the left and bone conduction (BC) hearing greater on the right confirms a conductive component on the right side and sensorineural component on the left side 1.
• Weber and Rinne tuning fork tests should be performed to confirm the mixed hearing loss pattern:
  • Weber test will likely lateralize to the right ear (better bone conduction) 1
  • Rinne test will be negative (BC>AC) on the right and positive (AC>BC) on the left 1

Treatment for Right-Sided Conductive Hearing Loss

• High-resolution CT of the temporal bone is the first-line imaging modality for evaluating conductive hearing loss to identify potential causes such as:

  • Otosclerosis
  • Ossicular chain abnormalities
  • Superior semicircular canal dehiscence
  • Middle ear masses 1

• Treatment options based on underlying pathology:

  • For cerumen impaction: irrigation or curettage 1, 2
  • For otitis media: appropriate antibiotic therapy 2
  • For ossicular chain abnormalities: surgical reconstruction 3
  • For otosclerosis: stapedectomy or hearing amplification 1
  • For persistent conductive loss: bone-anchored hearing aid consideration 3

Treatment for Left-Sided Sensorineural Hearing Loss

• If the sensorineural hearing loss is sudden (defined as ≥30 dB loss occurring within 72 hours):

  • Urgent otolaryngology referral is required 1, 2
  • Oral corticosteroids should be offered as initial therapy within 14 days of symptom onset 1
  • MRI or auditory brainstem response testing should be performed to evaluate for retrocochlear pathology 1

• For established sensorineural hearing loss:

  • Referral to an audiologist for hearing aid evaluation 2
  • Avoidance of ototoxic medications 2
  • Audiologic rehabilitation for residual hearing loss 1

Comprehensive Management Approach

• Follow-up audiometric evaluation should be obtained at the conclusion of treatment and within 6 months 1
• Patient education about the natural history of each condition, treatment options, and realistic expectations is essential 1
• Counseling about possible benefits of audiologic rehabilitation and supportive measures for residual hearing loss and/or tinnitus 1
• For severe or refractory sensorineural hearing loss, cochlear implant evaluation may be considered 2

Special Considerations

• Patients with asymmetric hearing loss patterns require careful evaluation for retrocochlear pathology, particularly vestibular schwannoma 1, 4
• Avoid unnecessary testing:
  • Routine CT of the head is not recommended for initial evaluation of presumptive SNHL 1
  • Routine laboratory tests are not indicated unless systemic illness is suspected 1, 2
  • Antivirals, thrombolytics, vasodilators, or vasoactive substances are not routinely recommended for SNHL 1