What is the treatment for sudden hearing loss?

Treatment of Sudden Sensorineural Hearing Loss

Initiate oral corticosteroids immediately—prednisone 1 mg/kg/day (maximum 60 mg/day) for 7-14 days followed by a taper—as this is the evidence-based first-line therapy that should be started within 14 days of symptom onset. 1

Immediate Diagnostic Confirmation

Before treating, confirm the diagnosis with:

• Audiometry showing ≥30 dB hearing loss at 3 consecutive frequencies to distinguish sensorineural from conductive hearing loss 1
• Recognize that patients often describe ear fullness or blockage rather than obvious hearing loss, which commonly delays presentation 1
• Order MRI with gadolinium of the internal auditory canals to exclude vestibular schwannoma, stroke, or malignancy 1, 2

Primary Treatment Protocol

Corticosteroids are the only proven first-line therapy:

Systemic Steroid Regimen (Preferred)

• Prednisone 1 mg/kg/day as a single daily dose (usual maximum 60 mg/day) 1
• Continue full dose for 7-14 days, then taper over a similar period 1
• Start within 14 days of onset, though earlier is better—prognosis improves with early treatment initiation 1, 2

Intratympanic Steroid Alternative

• Use as first-line only when systemic steroids are contraindicated (e.g., uncontrolled diabetes, active infection) 1
• Dexamethasone 24 mg/mL or 10 mg/mL, up to 4 injections over 2 weeks 1

Salvage Therapy for Incomplete Recovery

If hearing has not fully recovered after initial treatment:

• Offer intratympanic steroid injections 2-6 weeks after onset as salvage therapy 1
• This is supported by systematic reviews of randomized controlled trials showing benefit over harm 1

Adjunctive Therapies: Limited Role

Hyperbaric oxygen therapy may be considered:

• As initial therapy combined with steroids within 2 weeks of onset, OR
• As salvage therapy combined with steroids within 1 month of onset 1
• The benefit-to-harm ratio is balanced, making this optional rather than routine 1

Avoid routinely prescribing:

• Antivirals, thrombolytics, vasodilators, and vasoactive substances—these lack evidence of benefit and may cause harm 1
• Despite older literature suggesting vasodilators, plasma expanders, and carbogen inhalation, recent studies show no improvement over spontaneous recovery rates 3

Common Pitfall: Delayed Recognition

The most critical error is delayed diagnosis because patients describe "ear fullness" rather than hearing loss 1. Maintain high clinical suspicion and obtain urgent audiometry for any acute unilateral aural symptoms.

Mandatory Follow-Up

• Repeat audiometry at treatment completion and within 6 months of initial diagnosis 1
• Continue long-term follow-up as underlying causes (tumors, autoimmune disease) may emerge later 1
• Maximum spontaneous improvement occurs within 2 weeks of onset in most cases 2

Rehabilitation and Counseling

For patients with persistent hearing loss:

• Immediately counsel about amplification options—CROS or BiCROS hearing aids for unilateral loss 1
• Consider cochlear implantation for severe-to-profound unrecovered loss 1
• Provide psychological support, as 86% of patients with unilateral sudden sensorineural hearing loss report hearing handicap and 56% experience tinnitus-related disability 1

Prognostic Indicators

Favorable prognostic factors:

• Early presentation and treatment initiation 1, 2
• Recovery beginning within first 2 weeks 1, 2
• Mild hearing loss (<90 dB) 1, 2
• Upward-sloping audiogram 1, 2
• Absence of vertigo 1, 2

Poor prognostic factors:

• Hearing loss >90 dB 1, 2
• Flat or downward-sloping audiogram 1, 2
• Presence of vertigo at onset 1, 2
• No improvement within first 2 weeks 1
• Advanced age 2