What is the next step in treatment for sudden unilateral sensorineural hearing loss after starting prednisolone (corticosteroid) 25mg and intratympanic steroid injections with dexamethasone (corticosteroid) 10mg?

Next Steps in Management After Initial Treatment

Continue your current treatment regimen and schedule follow-up audiometry at 10-14 days to assess response; if hearing recovery is incomplete at 2-6 weeks, proceed with salvage intratympanic steroid therapy. 1

Immediate Management (Days 7-14)

Current Treatment Assessment

• You are already on dual therapy (oral prednisolone + intratympanic dexamethasone), which represents appropriate initial management started within the critical first 24 hours 1
• However, your oral prednisolone dose of 25mg appears significantly underdosed - the standard recommendation is 1 mg/kg/day (typically 60mg for adults) as a single morning dose for 10-14 days, followed by a taper 1, 2
• Your intratympanic dexamethasone 10mg/mL concentration is appropriate and within recommended ranges 2, 3

Optimize Systemic Steroid Dosing

• Increase oral prednisolone to 1 mg/kg/day (approximately 60mg for most adults) immediately if you haven't already completed the course 1, 2
• Continue for a total of 10-14 days at full dose, then taper over 7-14 days 1, 2
• Alternative: High-dose dexamethasone (40mg daily for days 1-3, then 10mg daily for days 4-6) has shown excellent recovery rates of 87% functionally relevant recovery in recent studies 4

Continue Intratympanic Therapy

• Standard protocol: 4 total injections over 2 weeks (twice weekly) 1, 5
• Since you started at 18 hours, continue with injections every 3-4 days 1, 5
• Recent evidence shows less frequent injections (twice weekly) provide similar outcomes to daily injections when combined with systemic steroids 5

Assessment at 10-14 Days

Obtain Repeat Audiometry

• Schedule audiogram at completion of initial treatment (10-14 days from onset) to assess response 1
• This determines whether salvage therapy is needed 1
• Look for improvement defined as: ≥10 dB improvement in pure tone average OR ≥10% improvement in word recognition score 1

Prognostic Indicators to Monitor

• Recovery of ≥50% of hearing loss within first 2 weeks predicts better final outcome 1
• Minimal change in first 2 weeks suggests unlikely significant recovery without additional intervention 1
• Your severe loss (only 90-100 dB at 1-2kHz) places you in a poorer prognostic category, with functionally relevant recovery in only 43% of patients with initial near-deafness 4

Salvage Therapy (If Incomplete Recovery at 2-6 Weeks)

Intratympanic Steroids for Salvage

• If hearing recovery is incomplete at 2-6 weeks, proceed with salvage intratympanic steroid therapy 1
• This is a strong recommendation from the 2019 AAO-HNS guidelines 1
• Salvage IT steroids show 37.5-47.6% improvement rates versus 0-16% in controls 1
• Typical salvage protocol: 4-6 injections of dexamethasone 5mg/mL over 2 weeks 1

Hyperbaric Oxygen as Salvage Option

• Consider hyperbaric oxygen therapy (HBOT) combined with steroids within 1 month of onset if available 1
• HBOT is an option (not a recommendation) and must be combined with steroid therapy 1
• May provide additional benefit, particularly for severe to profound losses 1

What NOT to Do

Avoid Ineffective Treatments

• Do not use antivirals, thrombolytics, vasodilators, or vasoactive substances - these have no proven benefit 1
• Do not order routine laboratory tests (CBC, metabolic panel, inflammatory markers) - these are not helpful 1
• Do not order routine head CT - this is not indicated unless focal neurologic findings present 1

Essential Follow-Up

Retrocochlear Workup

• Obtain MRI with contrast of internal auditory canals and brain to exclude vestibular schwannoma 1
• This can be done at any point but is essential given unilateral presentation 1
• Alternative: Auditory brainstem response (ABR) if MRI contraindicated, though less sensitive 1

Long-Term Audiometric Monitoring

• Repeat audiometry at 6 months post-treatment regardless of initial response 1
• Delayed recovery can occur up to 6-8 months in rare cases (2% of patients) 1
• 98.3% of patients who recover reach final hearing levels by 3 months 1

Audiologic Rehabilitation

• Counsel about hearing aids, assistive devices, and tinnitus management if residual hearing loss persists 1
• Consider referral for individual or group counseling - sudden hearing loss causes significant psychological impact including anxiety, depression, and social isolation 1

Critical Pitfall to Avoid

The most significant issue in your case is the underdosing of oral prednisolone at 25mg - this is approximately 40% of the recommended dose for an average adult 1, 2. While you initiated treatment rapidly (excellent), the subtherapeutic systemic steroid dose may compromise your recovery potential. Discuss immediate dose escalation with your treating physician.