Initial Treatment for Sudden Sensorineural Hearing Loss
Initiate systemic corticosteroids immediately—ideally within 14 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 standard first-line therapy for sudden sensorineural hearing loss. 1
Systemic Corticosteroid Protocol
Primary treatment regimen:
- Prednisone: 1 mg/kg/day (usual maximum 60 mg/day) 1
- Alternative options: Methylprednisolone 48 mg/day OR Dexamethasone 10 mg/day 1
- Duration: Full dose for 7-14 days, then taper over similar time period 1
- Critical timing: Treatment should begin immediately, ideally within first 14 days of symptom onset, though benefit has been reported up to 6 weeks 1
- Do not divide doses—give as single daily dose 1
Patient Selection Considerations
Contraindications to systemic steroids (use intratympanic steroids instead):
- Insulin-dependent or poorly controlled diabetes 1
- Labile hypertension 1
- Glaucoma 1
- Active tuberculosis 1
- Peptic ulcer disease 1
- Prior psychiatric reactions to corticosteroids 1
For these patients, intratympanic steroid therapy is not inferior in efficacy and should be offered as initial treatment. 1
Intratympanic Steroids as Initial Therapy
When systemic steroids are contraindicated, intratympanic administration provides equivalent outcomes: 1
- Dexamethasone: 24 mg/mL (compounded) or 10 mg/mL (stock) 1
- Methylprednisolone: 40 mg/mL or 30 mg/mL 1
- Technique: Inject 0.4-0.8 mL into middle ear space, patient maintains head in otologic position (affected ear up) for 15-30 minutes 1
- Frequency: Up to 4 injections over 2-week period 1
Research comparing oral versus intratympanic steroids shows comparable outcomes when initiated within 2 weeks of symptom onset, with no statistically significant difference between routes. 2, 3
Monitoring and Follow-Up
Essential audiometric assessments:
- Baseline: Obtain audiometry within 14 days of symptom onset to confirm diagnosis 1, 4
- Mid-treatment: Consider interval audiograms between intratympanic injections to guide early termination if hearing resolves 1
- Post-treatment: Audiogram at completion of treatment course 1, 4
- Final assessment: Repeat audiometry at 6 months post-treatment regardless of perceived recovery 4
Monitor for adverse effects:
- Hyperglycemia and hypertension in susceptible patients 1
- Common side effects include insomnia, increased appetite, weight gain, mood changes 1
- Most serious adverse events occur with chronic use; short 10-14 day courses have rare and manageable side effects 1
Prognostic Factors
Better outcomes are associated with:
- Earlier presentation and treatment initiation 5, 6
- Milder degree of hearing loss at presentation 2, 5, 6
- Age younger than 60 years 3
- Absence of vertigo 2
Patients with severe-to-profound hearing loss show significant improvement with steroid treatment compared to no treatment (p <0.01). 6
Salvage Therapy Planning
If incomplete recovery at 2-6 weeks after initial treatment:
- Offer intratympanic steroid therapy as salvage treatment 1
- Typical salvage protocol: 4-6 injections of dexamethasone 5 mg/mL over 2 weeks 1, 4
- Hyperbaric oxygen therapy combined with steroids may be considered within 1 month of onset 7, 4
Critical Pitfalls to Avoid
Do not delay treatment waiting for "spontaneous recovery"—the majority of patients who recover do so within the first month, with 54.5% achieving improvement within 10 days. 4 Early steroid initiation is critical for optimal outcomes. 5, 6
Do not rely on patient self-report of hearing recovery—objective audiometry is essential as patients cannot accurately assess degree or type of hearing loss. 4
Do not assume all recovery occurs within 2 weeks—while most improvement happens early, 45.5% of recoverers show continued improvement between 10 days and 1 month. 4
Shared Decision-Making
The evidence supporting systemic steroids is equivocal, and potential adverse effects exist, making shared decision-making essential. 1 Educate patients about: