What is the treatment for sudden hearing loss?

Treatment for Sudden Hearing Loss

Corticosteroids should be offered as initial therapy for sudden sensorineural hearing loss (SSNHL), ideally within 14 days of onset, using oral prednisone 1 mg/kg/day (maximum 60 mg daily) for 7-14 days followed by a taper, or intratympanic dexamethasone injections if systemic steroids are contraindicated. 1

Initial Evaluation and Diagnosis

Before initiating treatment, distinguish between conductive and sensorineural hearing loss through audiometry confirming ≥30 dB hearing loss at 3 consecutive frequencies. 1 The primary presenting symptom is often ear fullness or blockage rather than obvious hearing loss, which frequently delays evaluation. 1

Key diagnostic steps:

• Perform audiometry immediately—this is essential and non-negotiable 1
• Assess for bilateral involvement, recurrent episodes, or focal neurologic findings that suggest non-idiopathic causes 1
• Obtain MRI with gadolinium of internal auditory canals to exclude vestibular schwannoma, stroke, or malignancy 1, 2
• Do NOT order routine laboratory tests or CT head—these are not recommended 1

Primary Treatment Algorithm

First-Line: Systemic Corticosteroids (Within 2 Weeks)

Dosing regimen: 1

• Prednisone: 1 mg/kg/day as single daily dose (usual maximum 60 mg/day)
• Alternative: Methylprednisolone 48 mg/day OR Dexamethasone 10 mg/day
• Duration: Full dose for 7-14 days, then taper over similar period
• Critical timing: Greatest benefit occurs when started within first 2 weeks; some benefit reported up to 6 weeks 1

Important caveat: The evidence for systemic steroids is somewhat equivocal, but faced with the serious consequences of severe hearing loss, corticosteroids represent one of the few treatment options with data showing efficacy. 1 Between one-third and two-thirds of patients recover spontaneously, with maximum improvement typically occurring within 2 weeks. 1

Alternative First-Line: Intratympanic (IT) Corticosteroids

For patients who cannot receive systemic steroids (insulin-dependent diabetes, poorly controlled diabetes, labile hypertension, glaucoma, tuberculosis, peptic ulcer disease, prior psychiatric reactions to corticosteroids): 1

• Dexamethasone 24 mg/mL (compounded) or 10 mg/mL (stock)
• Methylprednisolone 40 mg/mL or 30 mg/mL
• Inject 0.4-0.8 mL into middle ear space
• Up to 4 injections over 2-week period
• Patient maintains head in otologic position (affected ear up) for 15-30 minutes after injection 1

Evidence note: IT steroids are not inferior to systemic steroids in efficacy, making them a valid first-line option when systemic steroids are contraindicated. 1

Salvage Therapy (2-6 Weeks After Onset)

For incomplete recovery after initial treatment, offer intratympanic steroid injections. 1 This is a recommendation with preponderance of benefit over harm based on systematic reviews of RCTs. 1

The definition of "incomplete recovery" is intentionally flexible, as varying degrees of residual hearing loss affect patients differently and should guide aggressiveness of salvage therapy. 1

Adjunctive Treatment Options

Hyperbaric Oxygen Therapy (HBOT)

Two potential windows: 1

• Initial therapy: May offer HBOT combined with steroids within 2 weeks of onset (option with balance of benefit and harm)
• Salvage therapy: May offer HBOT combined with steroids within 1 month of onset (option with balance of benefit and harm)

What NOT to Use

Do NOT routinely prescribe: 1

• Antivirals (insufficient evidence despite common use) 1, 3
• Thrombolytics
• Vasodilators
• Vasoactive substances

This is a strong recommendation against based on systematic reviews showing preponderance of harm over benefit. 1

Watchful Waiting Alternative

Observation without active treatment is a legitimate option given that 32-65% of patients may recover spontaneously. 1 This should be discussed with patients as part of shared decision-making, particularly for those with contraindications to steroids or mild hearing loss. 1

Follow-Up and Rehabilitation

Mandatory follow-up audiometry: 1

• At completion of treatment
• Within 6 months of initial diagnosis
• Long-term follow-up recommended as underlying causes may emerge later 1

Immediate counseling and rehabilitation: 1

• Address amplification options early—do not wait for treatment completion 1
• For unilateral hearing loss: CROS (contralateral routing of signal) or BiCROS hearing aids 1
• For severe-to-profound unrecovered loss: Consider cochlear implantation (96% report tinnitus improvement) 1
• Osseointegrated bone conductive devices for single-sided deafness 1
• Hearing assistive technology systems for specific listening situations 1

Psychological support is critical: 86% of patients with unilateral SSNHL report hearing handicap, and 56% with tinnitus demonstrate handicap. 1 Address anxiety, depression, and social isolation through counseling. 1

Prognostic Factors

Better prognosis: 2

• Early presentation and treatment initiation
• Recovery begins within first 2 weeks
• Mild hearing loss (<90 dB)
• Upward-sloping audiogram
• Absence of vertigo

Poorer prognosis: 1, 2

• 90 dB hearing loss

• Flat or downward-sloping audiogram
• Advanced age
• Presence of vertigo at onset
• No improvement within first 2 weeks

Common Pitfalls to Avoid

• Delaying evaluation: Ear fullness is often dismissed by both patients and physicians, but new-onset ear blockage warrants prompt evaluation 1
• Ordering unnecessary tests: Avoid routine labs and CT head 1
• Prescribing antivirals: Despite common practice, evidence does not support their use 1
• Waiting to address rehabilitation: Counseling and amplification discussion should begin immediately, not after treatment completion 1
• Missing bilateral involvement or neurologic signs: These require urgent evaluation for stroke, malignancy, or other serious causes 1