What is the management plan for a patient with hearing loss at low and high frequencies, but preserved hearing at mid frequencies on audiometry?

Management of Hearing Loss with Preserved Mid-Frequencies and Loss at Low and High Frequencies

This audiometric pattern—preserved mid-frequency hearing with loss at low and high frequencies—is highly suggestive of Ménière's disease and requires immediate referral to an audiologist or otolaryngologist for comprehensive evaluation and management. 1

Immediate Diagnostic Considerations

This "cookie-bite" or "U-shaped" audiogram pattern warrants urgent evaluation because:

• Ménière's disease characteristically presents with low- to mid-frequency sensorineural hearing loss that fluctuates, though over time it may involve all frequencies 1
• The American Academy of Otolaryngology-Head and Neck Surgery defines definite Ménière's disease as requiring two or more spontaneous vertigo attacks (20 minutes to 12 hours duration), audiometrically documented fluctuating low- to mid-frequency sensorineural hearing loss, and fluctuating aural symptoms including tinnitus and ear fullness 1
• Any atypical audiological test results showing a loss of more than 15 dB at 1000–8000 Hz require referral to an audiologist, auditory clinic, or ear, nose, and throat physician 2

Essential Diagnostic Workup

Audiometric Assessment

• Complete audiometric evaluation including pure tone thresholds, speech audiometry, tympanometry, and acoustic reflex testing must be obtained 3
• Document whether hearing loss is fluctuating or stable, as fluctuation strongly suggests Ménière's disease 1
• Assess for asymmetry: differences in pure tone average between ears >15 dB or word recognition scores >15% warrant MRI evaluation 3

Imaging Studies

• MRI of the internal auditory canal and posterior fossa should be performed if hearing loss is asymmetric or nonfluctuating to rule out retrocochlear pathology such as vestibular schwannoma 3, 1, 4
• Non-contrast MRI is cost-effective for screening vestibular schwannoma 3

Clinical History

• Inquire specifically about vertigo episodes (duration, frequency), tinnitus, aural fullness, and fluctuation of symptoms 1
• Document any history of ototoxic medication exposure (platinum agents, aminoglycosides) or radiation therapy if applicable 2

Management Algorithm

If Ménière's Disease is Diagnosed

Initial Conservative Management:

• Dietary sodium restriction to less than 1500 mg daily as recommended by the American Heart Association 1
• Diuretics may help reduce symptoms by decreasing fluid retention 1
• Patient education about the natural history: unpredictable vertigo attacks, fluctuating hearing/tinnitus/fullness, and potential for progressive hearing loss 1

For Acute Vertigo Attacks:

• Vestibular suppressants should be offered for limited courses to manage acute episodes 1

Escalation for Refractory Disease:

• Intratympanic steroids may be offered to patients with active Ménière's disease not responsive to conservative measures 1
• Intratympanic gentamicin should be offered for active disease not responsive to nonablative therapy, though this carries risk of vestibular ablation 1

If Alternative Diagnosis or Stable Hearing Loss

Hearing Rehabilitation:

• Hearing aids are first-line management for serviceable hearing (typically word recognition scores >50%) 4, 2
• For profound unilateral hearing loss, contralateral routing of sound (CROS) devices or cochlear implantation may be considered 3
• Referral to audiologist for amplification and hearing-assistive technology should occur as soon as hearing loss is identified 2

Supportive Measures:

• Remote microphone technology for hearing loss at 6 kHz and above in one or both ears 2
• Personal hearing aids plus remote microphone technology for high-frequency loss at 3 kHz and above 2
• Speech and language therapy as needed to ensure clear speech development and appropriate social skills 2
• Accommodations at school, college, or workplace 2

Follow-Up Monitoring

• Audiometric follow-up should be obtained within 6 months of any treatment completion and at least annually thereafter 2, 4
• More frequent monitoring (every 3-6 months) is warranted for fluctuating hearing loss to assess disease progression and treatment efficacy 2
• Quality of life assessment should be performed before and after therapeutic interventions to evaluate long-term outcomes 2
• Behavioral interventions to preserve hearing include avoiding loud noise exposure 2

Critical Pitfalls to Avoid

• Never rely solely on patient self-report of hearing status, as patients cannot accurately differentiate degree or type of hearing loss 2, 3
• Do not delay evaluation if sudden hearing loss component is present (loss of 30 dB or more within 72 hours requires immediate otolaryngology referral and consideration of corticosteroids within 2 weeks) 2, 4, 5
• Avoid dismissing this pattern as "normal aging" without proper workup, as it may represent treatable Ménière's disease or require imaging to exclude retrocochlear pathology 1, 3
• Do not overlook the need for tinnitus management if present—referral to audiologist is recommended for bothersome tinnitus 2