What is the initial treatment for sudden onset sensorineural hearing loss?

Management of Sudden Onset Sensorineural Hearing Loss

Immediate First-Line Treatment

Initiate oral corticosteroids immediately—ideally within 14 days of symptom onset—using prednisone 1 mg/kg/day (maximum 60 mg daily) given as a single daily dose for 7-14 days followed by a taper, as this represents the standard of care with the strongest evidence for hearing recovery. 1

Oral Corticosteroid Protocol

• Prednisone dosing: 1 mg/kg/day with usual maximum of 60 mg/day, administered as a single daily dose (not divided) 2, 1
• Alternative equivalent regimens: Methylprednisolone 48 mg/day or dexamethasone 10 mg/day 2, 1
• Treatment duration: Full dose for 7-14 days, then taper over a similar time period 2, 1
• Representative taper regimen: Maximum dose for 4 days, followed by 10 mg taper every 2 days 2

Critical Timing Considerations

• Optimal window: Treatment must begin within the first 14 days of symptom onset for maximal benefit 2, 1
• Extended window: Some benefit has been reported up to 6 weeks following onset, though efficacy diminishes significantly after 2 weeks 2, 1
• Spontaneous recovery pattern: The greatest spontaneous improvement occurs during the first 2 weeks, making early intervention critical 2

Alternative Initial Treatment: Intratympanic Steroids

When to Use Intratympanic Therapy as First-Line

Offer intratympanic steroid injections as initial treatment for patients with contraindications to systemic steroids, including insulin-dependent or poorly controlled diabetes, labile hypertension, glaucoma, active tuberculosis, peptic ulcer disease, or prior psychiatric reactions to corticosteroids. 1

• Equivalence data: Intratympanic methylprednisolone produces comparable hearing outcomes to oral prednisone, with both groups showing >75% improvement rates 2, 3
• Non-inferiority confirmed: A 2011 randomized trial of 250 patients demonstrated that intratympanic treatment improved hearing by 28.7 dB versus 30.7 dB for oral treatment (difference not statistically significant) 3

Intratympanic Steroid Protocol

• Dexamethasone concentration: 24 mg/mL (compounded), 16 mg/mL (compounded), or 10 mg/mL (stock) 2, 1
• Methylprednisolone concentration: 40 mg/mL or 30 mg/mL 2, 1
• Injection volume: 0.4-0.8 mL into the middle ear space 1
• Technique: Anterosuperior myringotomy after topical anesthetic 2
• Patient positioning: Head maintained in otologic position (affected ear up) for 15-30 minutes post-injection 1
• Frequency: Up to 4 injections over a 2-week period (typically twice weekly) 2, 1

Important Caveat on High-Dose Regimens

Do not use high-dose intravenous or oral glucocorticoid regimens (such as prednisolone 250 mg/day IV or dexamethasone 40 mg/day oral), as a 2024 randomized trial demonstrated no superiority over standard-dose oral prednisolone 60 mg/day, with significantly higher adverse event rates. 4

Monitoring Requirements

Audiometric Assessment Schedule

• Baseline audiometry: Within 14 days of symptom onset to confirm ≥30 dB hearing loss across at least 3 consecutive frequencies 5, 1
• Mid-treatment monitoring: Consider interval audiograms between intratympanic injections to guide early termination if hearing resolves 1
• Post-treatment evaluation: Audiogram at completion of treatment course 2, 1
• Long-term follow-up: Repeat audiometry at 6 months post-treatment regardless of perceived recovery 1

Adverse Effect Monitoring

• Systemic steroid side effects: Monitor for hyperglycemia, hypertension, mood changes, sleep disturbances, increased thirst, and appetite changes (reported in 88% of oral steroid patients) 2, 1
• Intratympanic side effects: Transient pain at injection site, brief caloric vertigo, and risk of tympanic membrane perforation (reported in 90% of intratympanic patients, though mostly minor) 2

Salvage Therapy for Incomplete Recovery

Intratympanic Steroids as Salvage

If incomplete recovery occurs at 2-6 weeks after initial oral corticosteroid treatment, offer intratympanic steroid injections as salvage therapy. 1

• Salvage protocol: 4-6 injections of dexamethasone 5 mg/mL over 2 weeks 1
• Evidence basis: Systematic review concluded intratympanic steroids provide valuable salvage for patients refractory to systemic therapy 2

Hyperbaric Oxygen Therapy

Consider hyperbaric oxygen therapy (HBOT) combined with steroids within 1-3 months of symptom onset for patients who have failed both oral and intratympanic steroids, particularly younger patients (<50-60 years) with moderate to severe hearing loss (>60 dB). 2, 6, 1

• Treatment protocol: Up to 20 sessions of 100% oxygen at >1 atmosphere absolute pressure 6
• Optimal timing: Early HBOT (within 2 weeks to 3 months) produces better outcomes than late treatment 2, 6
• Patient selection: Younger patients and those with moderate-to-severe hearing loss benefit more than older patients or those with mild loss 2
• Guideline classification: American Academy of Otolaryngology-Head and Neck Surgery classifies HBOT as an "option" with balance between benefit and harm 2
• Adverse effects: Difficulty equalizing middle ear pressure (17%), Eustachian tube dysfunction, ear/sinus barotrauma (6.25%), and confinement anxiety 6

Prognostic Factors Affecting Treatment Response

• Severity of hearing loss: Patients with severe-to-profound hearing loss show statistically significant improvement with steroid treatment compared to untreated cases (p<0.01) 7
• Associated vertigo: Presence of vertigo negatively affects treatment outcomes 8
• Age: Younger patients respond better to all treatment modalities 2
• Timing: Treatment within first 2 weeks produces optimal results; benefit diminishes substantially after 4-6 weeks 2

Shared Decision-Making Considerations

Engage patients in shared decision-making, as the evidence supporting corticosteroids is somewhat equivocal, with potential adverse effects that must be weighed against the serious consequences of permanent hearing loss. 2, 1

• Evidence limitations: Most studies do not meet highest quality criteria (RCTs, systematic reviews), and conclusions vary across trials 2
• Natural history: Educate patients that spontaneous recovery can occur, but corticosteroid treatment represents one of the few interventions with data showing efficacy 2, 1
• Risk-benefit balance: For patients facing severe-to-profound hearing loss, corticosteroid treatment is justified despite equivocal evidence, as it is one of few options with demonstrated benefit 2