What is the initial treatment for sudden sensorineural hearing loss?

Initial Treatment for Sudden Sensorineural Hearing Loss

Initiate oral corticosteroids immediately—ideally within 3 days of symptom 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 that may prevent permanent hearing loss. 1

Urgency of Treatment

• Sudden sensorineural hearing loss is a medical emergency requiring treatment initiation within 14 days of symptom onset, though outcomes are significantly better when treatment begins within 3 days (OR 0.42 for recovery versus later treatment). 2
• The odds of hearing recovery decrease progressively: treatment within 7 days yields OR 0.35 compared to later treatment, and within 14 days yields OR 0.31. 2
• Prompt recognition and management may improve hearing recovery and quality of life, making urgent evaluation critical. 3

Confirm the Diagnosis First

Before initiating treatment, you must distinguish sensorineural from conductive hearing loss:

• Perform audiometry immediately (within 14 days) to confirm ≥30 dB hearing loss at 3 consecutive frequencies—this is the diagnostic gold standard. 3, 1
• Use tuning fork tests (Weber and Rinne) at initial presentation to differentiate sensorineural from conductive loss. 4
• Remove impacted cerumen before establishing diagnosis, as it can cause conductive hearing loss that confounds the clinical picture. 4

Primary Treatment Protocol

Corticosteroid therapy is the cornerstone of initial management:

• Oral prednisone: 1 mg/kg/day as a single daily dose (usual maximum 60 mg/day) for 7-14 days, then taper over a similar period. 1
• The American Academy of Otolaryngology-Head and Neck Surgery recommends offering corticosteroids as initial therapy, though this is presented as an option rather than a mandate due to evidence limitations. 3, 1

Intratympanic corticosteroids as first-line alternative:

• Use when systemic steroids are contraindicated (uncontrolled diabetes, severe hypertension, psychiatric contraindications). 1
• Dexamethasone 24 mg/mL or 10 mg/mL, up to 4 injections over a 2-week period. 1
• This represents a valid first-line option with comparable efficacy to oral steroids. 1

What NOT to Do

The American Academy of Otolaryngology-Head and Neck Surgery makes strong recommendations against the following:

• Do not routinely prescribe antivirals (acyclovir, valacyclovir)—insufficient evidence despite historical use. 3, 1
• Do not prescribe thrombolytics, vasodilators, or vasoactive substances—preponderance of harm over benefit. 3, 1
• Do not order routine CT of the head—it does not aid in diagnosis or management. 3
• Do not obtain routine laboratory tests—they rarely change management. 3

This represents a significant departure from older practices that included antiviral therapy, which is no longer supported by evidence. 5, 6

Mandatory Concurrent Workup

While initiating treatment, you must evaluate for retrocochlear pathology:

• Obtain MRI with gadolinium of internal auditory canals to exclude vestibular schwannoma, stroke, or malignancy—this is mandatory, not optional. 3, 1, 4
• Alternative: auditory brainstem response testing if MRI is contraindicated. 3, 4
• Assess for bilateral involvement, recurrent episodes, or focal neurologic findings that suggest non-idiopathic causes requiring different management. 3, 4

Adjunctive Treatment Consideration

Hyperbaric oxygen therapy may be offered:

• As initial therapy combined with steroids within 2 weeks of onset, OR as salvage therapy within 1 month of onset. 1
• This represents an option with a balance of benefit and harm, not a routine recommendation. 1
• Availability and patient factors (claustrophobia, barotrauma risk) limit practical application. 1

Patient Education at Initial Visit

You must educate patients about:

• Natural history: 32-65% may recover spontaneously, though this may overestimate actual recovery rates. 3, 7
• Benefits and risks of corticosteroids: potential for hearing recovery versus side effects (hyperglycemia, hypertension, mood changes, gastritis). 3
• Limitations of evidence: no treatment is definitively proven, and outcomes vary significantly. 3, 7
• Prognostic factors: Better outcomes with early treatment, mild hearing loss, upward-sloping audiogram, and absence of vertigo; poorer outcomes with >90 dB loss, flat/downward-sloping audiogram, and presence of vertigo. 1

Follow-Up Protocol

• Repeat audiometry at completion of treatment (2-6 weeks) to assess response. 3, 1
• Follow-up audiometry within 6 months of initial diagnosis is mandatory. 3, 1
• If incomplete recovery at 2-6 weeks, offer intratympanic steroid injections as salvage therapy—this is a formal recommendation based on systematic reviews showing preponderance of benefit. 3, 1

Rehabilitation Planning

For patients with residual hearing loss:

• Counsel about audiological rehabilitation immediately, including amplification options (hearing aids, CROS/BiCROS systems for unilateral loss). 3, 1
• Consider cochlear implantation for severe-to-profound unrecovered loss. 1
• Address psychological impact: 86% of patients with unilateral sensorineural hearing loss report hearing handicap, and 56% with tinnitus demonstrate handicap. 1
• Provide counseling for anxiety, depression, and social isolation. 1

Common Pitfalls to Avoid

• Delaying treatment beyond 3 days dramatically reduces recovery odds—treat this as an emergency, not an urgent consult. 2
• Assuming it's cerumen impaction without audiometric confirmation—always confirm with formal testing. 4
• Prescribing antivirals based on outdated protocols—current evidence does not support this practice. 3, 1
• Failing to obtain MRI—retrocochlear pathology must be excluded in all cases. 3, 1, 4
• Not counseling about rehabilitation early—patients need realistic expectations and support from the outset. 3, 1