What is the treatment for sudden onset sensorineural hearing loss?

Treatment of Sudden Onset Sensorineural Hearing Loss

Initiate oral corticosteroids immediately—ideally within 3 days and no later than 14 days from onset—using prednisone 1 mg/kg/day (maximum 60 mg/day) for 7-14 days followed by a taper, as this represents the primary evidence-based treatment for idiopathic sudden sensorineural hearing loss. 1

Immediate Diagnostic Confirmation

Before initiating treatment, you must confirm sensorineural (not conductive) hearing loss through audiometry demonstrating ≥30 dB loss at 3 consecutive frequencies. 2 Perform tuning fork tests (Weber and Rinne) at presentation, but formal audiometry within 14 days is mandatory for accurate diagnosis. 3 A critical pitfall is assuming hearing loss without audiometric confirmation—patients often present complaining of "ear fullness" or "blockage" rather than obvious hearing loss, which frequently delays proper evaluation. 1

Primary Treatment Algorithm

First-Line Corticosteroid Therapy

The American Academy of Otolaryngology-Head and Neck Surgery strongly recommends corticosteroids as initial therapy: 1

• Oral prednisone: 1 mg/kg/day as a single daily dose (usual maximum 60 mg/day) for 7-14 days at full dose, then taper over a similar period 1
• Timing is critical: Treatment within 3 days yields an odds ratio of 0.42 for recovery compared to day 4 or later; within 7 days yields OR 0.35 compared to day 8 or later 4
• This is a medical emergency—not an elective condition 4

Alternative First-Line: Intratympanic Steroids

When systemic steroids are contraindicated (uncontrolled diabetes, active peptic ulcer, severe psychiatric disease), intratympanic dexamethasone injections are a valid first-line option: 1

• Dexamethasone 24 mg/mL or 10 mg/mL
• Up to 4 injections over a 2-week period 1

Salvage Therapy for Incomplete Recovery

If hearing recovery is incomplete after initial corticosteroid treatment, offer intratympanic steroid injections 2-6 weeks after onset. 1 This recommendation is based on systematic reviews of randomized controlled trials showing preponderance of benefit over harm. 1

Adjunctive Treatment Considerations

Hyperbaric Oxygen Therapy

Hyperbaric oxygen may be offered in two scenarios: 1

• As initial therapy combined with steroids within 2 weeks of onset
• As salvage therapy combined with steroids within 1 month of onset

The evidence shows a balance of benefit and harm, making this an option rather than a routine recommendation. 1

Treatments to AVOID

The American Academy of Otolaryngology-Head and Neck Surgery recommends against routinely prescribing: 2, 1

• Antivirals
• Thrombolytics
• Vasodilators
• Vasoactive substances
• Antioxidants

These lack sufficient evidence or demonstrate preponderance of harm over benefit. 2, 1

Mandatory Workup for Non-Idiopathic Causes

While initiating treatment, simultaneously evaluate for retrocochlear pathology: 2, 1

• MRI with gadolinium of internal auditory canals is the gold standard to exclude vestibular schwannoma, stroke, or malignancy 1, 3
• Alternative: Auditory brainstem response testing if MRI contraindicated 2
• Assess for bilateral involvement, recurrent episodes, or focal neurologic findings suggesting autoimmune, infectious, or central pathology 3

Critical pitfall: Do NOT order routine CT of the head/brain—this is specifically recommended against by guidelines. 2 Also avoid routine laboratory tests in idiopathic cases. 2

Follow-Up Protocol

Mandatory audiometric follow-up is required: 1

• At completion of treatment
• Within 6 months of initial diagnosis
• Long-term follow-up, as underlying causes may emerge later 2, 1

Rehabilitation for Residual Hearing Loss

Immediately counsel patients about rehabilitation options if hearing does not fully recover—do not wait. 2 Options include: 2, 1

• CROS or BiCROS hearing aids for unilateral hearing loss (transmits sound from affected ear to better ear)
• Cochlear implantation for severe-to-profound unrecovered loss, especially with associated tinnitus (96% report tinnitus improvement) 2
• Osseointegrated bone conductive devices as surgical or non-surgical options 2
• Hearing assistive technology systems for specific listening conditions 2

Psychological support is critical: 86% of patients with unilateral sudden sensorineural hearing loss report hearing handicap, and 56% with tinnitus demonstrate handicap. 1 Address anxiety, depression, and social isolation through counseling and refer to support organizations like the Hearing Loss Association of America. 2, 1

Prognostic Factors

Better prognosis is associated with: 1

• Early presentation and treatment initiation (especially within 3 days)
• Recovery beginning within first 2 weeks
• Mild hearing loss
• Upward-sloping audiogram
• Absence of vertigo

Poorer prognosis occurs with: 1

• 90 dB hearing loss

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

Spontaneous recovery occurs in 30-65% of cases, though clinical experience suggests this may be overestimated. 2, 5