What is the management for a patient with acute onset unilateral severe sensorineural hearing loss, vertigo, and vomiting, with a history of diabetes (diabetes mellitus), hypothyroidism, and alcohol use?

Management of Acute Unilateral Severe Sensorineural Hearing Loss with Vertigo and Vomiting

This patient requires urgent systemic corticosteroid therapy initiated within 2 weeks of symptom onset, with MRI brain/internal auditory canal imaging to exclude stroke or vestibular schwannoma, particularly given the presence of vertigo which indicates more severe disease and poorer prognosis. 1

Immediate Diagnostic Priorities

Distinguish Central from Peripheral Causes

The combination of acute severe unilateral sensorineural hearing loss (SSNHL) with vertigo and vomiting demands urgent evaluation to exclude life-threatening central causes, particularly stroke involving the anterior inferior cerebellar artery (AICA) territory, which can present identically to labyrinthitis but may herald impending brainstem infarction. 2 This patient's diabetes increases stroke risk substantially.

Key red flags requiring immediate neuroimaging include:

• Severe vertigo lasting >24 hours with hearing loss 1
• Focal neurologic symptoms (dysarthria, diplopia, hemiataxia, facial numbness) 1
• Downbeating or gaze-evoked nystagmus 1
• Severe imbalance with inability to walk 1

Confirm Sensorineural vs Conductive Loss

Perform tuning fork testing (Weber and Rinne) immediately to confirm sensorineural rather than conductive hearing loss. 1 Weber should lateralize to the better ear, and Rinne should show air conduction better than bone conduction bilaterally. 1

Obtain Formal Audiometry

Pure tone audiometry must be performed urgently to document the severity and frequency pattern of hearing loss. 1 This is essential for diagnosis, prognosis, and monitoring treatment response. 1

Imaging Strategy

Order MRI brain with internal auditory canal sequences (with gadolinium contrast) rather than CT. 1 The AAO-HNS guideline makes a strong recommendation against routine CT head in SSNHL evaluation. 1 MRI is indicated to:

• Exclude AICA territory stroke (especially with vertigo present) 2
• Screen for vestibular schwannoma 1
• Rule out demyelinating disease (multiple sclerosis can present this way) 3

If MRI is contraindicated, auditory brainstem response (ABR) testing is a less sensitive alternative for schwannoma screening, but abnormal ABR mandates subsequent MRI. 1

Laboratory Testing

Do not obtain routine laboratory tests. 1 The AAO-HNS guideline strongly recommends against routine labs in SSNHL. However, given this patient's specific comorbidities, targeted testing is reasonable:

• Blood glucose (diabetes management)
• TSH (hypothyroidism management)
• Consider RPR/FTA-ABS only if clinical suspicion for otosyphilis (fluctuating bilateral symptoms would be more typical) 1

Primary Treatment: Corticosteroids

Initiate oral corticosteroids immediately (e.g., prednisone 1 mg/kg/day, maximum 60 mg daily for 7-14 days with or without taper). 1 This is the only treatment with evidence-based support for SSNHL.

Critical considerations for this diabetic patient:

• Monitor blood glucose closely during steroid therapy 1
• Adjust diabetes medications proactively
• The presence of vertigo indicates more severe disease and poorer prognosis for hearing recovery 1, 4
• Patients with vertigo/dizziness have significantly lower complete recovery rates across all severity levels 4

Alternative: Intratympanic Steroids

If oral steroids are contraindicated due to uncontrolled diabetes, intratympanic dexamethasone injections can be offered as initial therapy. 1 This delivers high local steroid concentrations while minimizing systemic effects.

Treatments to AVOID

Do not prescribe the following, as they lack evidence of benefit: 1

• Antiviral medications (acyclovir, valacyclovir)
• Thrombolytics
• Vasodilators
• Vasoactive substances

Symptomatic Management

For acute vertigo and vomiting:

• Short-term vestibular suppressants (meclizine 25 mg TID, dimenhydrinate 50 mg q6h, or ondansetron 4-8 mg q8h) for the first 2-3 days only 1
• Avoid prolonged vestibular suppressant use as it delays central compensation 1
• The hypothyroidism should be optimized but is unlikely the primary cause of acute symptoms

Alcohol cessation counseling is essential, as alcohol may contribute to progressive hearing loss. 5

Salvage Therapy

If hearing recovery is incomplete after 2-4 weeks of initial corticosteroid therapy, offer intratympanic steroid injections as salvage treatment. 1 This provides a second opportunity for hearing improvement.

Hyperbaric Oxygen

Hyperbaric oxygen therapy may be offered within 2 weeks of onset or up to 1 month when combined with steroids, though access is limited and evidence is mixed. 1

Follow-up and Rehabilitation

Obtain repeat audiometry within 6 months to document final hearing status. 1

For residual hearing loss:

• Counsel about hearing aids, bone-anchored devices, or cochlear implants depending on severity 1
• Address sound localization difficulties and safety concerns (crossing streets, detecting approaching vehicles) 1
• Provide counseling for psychological impact (anxiety, depression, social isolation) 1
• Manage persistent tinnitus if present 1

Prognosis

The presence of vertigo at onset significantly worsens prognosis. 1, 4 Approximately one-third to two-thirds of SSNHL patients recover some hearing within 2 weeks, but those with vertigo have substantially lower complete recovery rates. 1, 4 Patients with minimal improvement in the first 2 weeks are unlikely to show significant subsequent recovery. 1

Critical Pitfall

Do not dismiss this as simple labyrinthitis without neuroimaging. The combination of severe SSNHL with vertigo can represent AICA territory stroke, and audiovestibular loss may be the only warning sign before progression to brainstem infarction. 2 This patient's diabetes and alcohol use increase vascular risk substantially.