What is the treatment for sudden sensorineural hearing loss (SSNHL)?

Treatment of Sudden Sensorineural Hearing Loss

Offer systemic corticosteroids (prednisone 1 mg/kg/day, maximum 60 mg daily) as initial therapy within 14 days of symptom onset, or intratympanic steroid injections if systemic steroids are contraindicated. 1, 2

Immediate Diagnostic Confirmation

• Obtain audiometry within 14 days to confirm sensorineural hearing loss (≥30 dB loss at 3 consecutive frequencies) and distinguish it from conductive hearing loss through tuning fork examination or tympanometry 1, 2
• Do not order routine CT scans of the head in initial evaluation 1
• Do not obtain routine laboratory tests (CBC, metabolic panel, inflammatory markers) as they do not change management 1
• Order MRI with gadolinium of internal auditory canals or auditory brainstem response (ABR) to exclude retrocochlear pathology like vestibular schwannoma 1, 2

Primary Treatment Protocol (Within 14 Days of Onset)

Systemic Corticosteroids (First-Line)

• Prednisone 1 mg/kg/day as a single daily dose (usual maximum 60 mg/day) for 7-14 days, followed by taper over similar period 1, 2
• Alternative equivalent dosing: Methylprednisolone 48 mg/day or Dexamethasone 10 mg/day 1
• Treatment within the first 7 days is associated with significantly better hearing outcomes 3
• The evidence for systemic steroids is equivocal, but this remains one of the few treatments with any data showing efficacy 1

Intratympanic Corticosteroids (Alternative First-Line)

• Use as primary therapy when systemic steroids are contraindicated (diabetes, hypertension, glaucoma, peptic ulcer disease, psychiatric contraindications) 1, 2
• Dexamethasone 24 mg/mL or 10 mg/mL: inject 0.4-0.8 mL into middle ear space 1, 2
• Alternative: Methylprednisolone 40 mg/mL or 30 mg/mL 1
• Administer up to 4 injections over 2-week period with patient keeping head in otologic position (affected ear up) for 15-30 minutes 1, 2
• Efficacy is not inferior to systemic steroids 1

Hyperbaric Oxygen Therapy (Optional Adjunct)

• May offer HBOT combined with steroid therapy within 2 weeks of onset as initial therapy 1, 2
• This is an option, not a recommendation, with balance of benefit and harm 2

Salvage Therapy (2-6 Weeks After Onset)

• Offer intratympanic steroid injections for incomplete recovery after initial treatment 1, 2
• This is a recommendation (stronger than option) based on systematic reviews showing preponderance of benefit 2
• HBOT combined with steroids may be offered as salvage within 1 month of onset 1, 2

Treatments to AVOID

Do not routinely prescribe antivirals, thrombolytics, vasodilators, or vasoactive substances due to insufficient evidence or preponderance of harm over benefit 1, 2

Follow-Up Protocol

• Obtain audiometry at completion of treatment and within 6 months 1, 2
• Interval audiograms between intratympanic injections may guide early termination if hearing recovers 1
• Long-term follow-up is essential as underlying causes (cerebellopontine tumors found in 7.5% of cases) may emerge later 3

Rehabilitation and Counseling

• Counsel all patients with residual hearing loss about audiologic rehabilitation including hearing aids, CROS/BiCROS systems for unilateral loss, and cochlear implantation for severe-to-profound unrecovered loss 1, 2
• Address tinnitus management as it accompanies nearly all cases and contributes to anxiety and depression 1, 2
• Provide psychological support as 86% of patients with unilateral SSNHL report hearing handicap 2

Prognostic Counseling

Better Prognosis Indicators:

• Treatment initiation within first 7 days 3
• Mild hearing loss (<81 dB) 2
• Upward-sloping or low-frequency audiogram 2, 4
• Absence of vertigo 2

Poor Prognosis Indicators:

• Hearing loss >90 dB 2
• Flat or downward-sloping audiogram 2, 4
• Presence of vertigo at onset 2
• No improvement within first 2 weeks 2

Critical Pitfalls to Avoid

• Do not dismiss ear fullness or blockage as benign—this is the primary presenting symptom, not obvious hearing loss, leading to dangerous delays 1, 2
• Do not underdose steroids—a standard methylprednisolone dose pack (84 mg total over 6 days) provides only equivalent of 105 mg prednisone versus the recommended 540 mg over 14 days 1
• Do not delay treatment beyond 14 days—greatest spontaneous and treatment-related recovery occurs in first 2 weeks, with little benefit after 4-6 weeks 1