Why is my Pure Tone Audiometry (PTA) result unchanged despite improvement in symptoms, including decreased tinnitus and improved hearing, after receiving intratympanic dexamethasone (10mg) injections for sudden sensorineural hearing loss (SSNHL) associated with Systemic Lupus Erythematosus (SLE)?

Why Your PTA Remains Unchanged Despite Subjective Hearing Improvement

Your subjective hearing improvements—decreased tinnitus, better sound differentiation in crowds, and improved conversational hearing—are real and clinically meaningful, but PTA may not capture these changes because it measures only pure tone thresholds at specific frequencies and has inherent test-retest variability of ±5-10 dB, which means small improvements may not register as statistically significant changes on formal audiometry. 1, 2

Understanding the Disconnect Between Symptoms and PTA

Test-Retest Reliability Limitations

• A 10 dB change in PTA is barely above the test-retest reliability threshold for measuring pure tone thresholds, meaning your hearing may have improved by 5-10 dB but this wouldn't show as a meaningful change on your audiogram 1
• Standard audiometric variability typically fluctuates by ±5 dB across frequencies, so changes less than 10 dB may not represent true threshold shifts 2

What PTA Actually Measures vs. What You're Experiencing

• Pure tone audiometry only measures your ability to detect single-frequency tones in a quiet testing booth, which doesn't reflect real-world hearing function like understanding speech in noise, sound localization, or tinnitus severity 1, 2
• Your improvements in differentiating sounds in crowds and reduced tinnitus at Mass represent functional hearing gains that PTA simply doesn't assess 1
• Word recognition scores (WRS) and speech-in-noise testing would better capture the improvements you're describing, but these aren't always included in routine follow-up audiometry 1

The Timeline of Recovery in SSNHL

Expected Recovery Patterns

• The majority of hearing recovery (78%) occurs within 1 month, and 97-98% of patients who will recover reach their final hearing levels by 3 months 1
• You're currently on your 3rd intratympanic injection, which means you're still within the critical recovery window where changes are most likely to occur 1
• Recovery of hearing after SSNHL is often accompanied by improvement of attendant tinnitus, which aligns perfectly with your experience 1

Why Early Subjective Improvements Matter

• Your decreased tinnitus and improved sound differentiation may represent early neuroplastic changes or partial hair cell recovery that precede measurable threshold improvements on formal audiometry 1
• In patients with profound hearing loss (90-120 dB like yours), even small improvements in the mid-frequency range may dramatically improve functional hearing without significantly changing the overall PTA average 1

SLE-Specific Considerations

Autoimmune Hearing Loss Characteristics

• Sensorineural hearing loss occurs in 26.7% of SLE patients, and the mechanism involves vasculitis and immune-mediated damage to the cochlea 3
• SLE-associated hearing loss may respond differently to treatment than idiopathic SSNHL, with immunosuppression (steroids plus azathioprine) showing benefit in case reports 4
• Your rapid initiation of steroids within 6 hours was optimal and likely prevented further deterioration 5

What Your Symptoms Actually Indicate

Positive Prognostic Signs

• Decreased tinnitus is a strong indicator of cochlear recovery, as tinnitus improvement typically parallels hearing recovery in SSNHL 1
• Improved ability to differentiate sounds in crowds suggests improved frequency discrimination and temporal processing, which are higher-order auditory functions not measured by PTA 1
• Reduced headache and tinnitus at Mass (loud environment) indicates improved tolerance to sound and possibly recruitment reduction 1

Why You May Be Perceiving Mid-Tone Return

• Your brain may be adapting to use the limited high-frequency hearing (2kHz and up) more effectively, creating the perception of improved mid-tone hearing through central auditory processing changes 1
• Alternatively, you may have genuine threshold improvements in the 1-2 kHz range that don't significantly change your overall PTA if the lower frequencies remain severely impaired 1

Critical Next Steps

Comprehensive Audiometric Assessment Needed

• Request word recognition scores (WRS) at your next audiometry, as a 10-20% improvement in WRS would confirm functional hearing improvement even if PTA is unchanged 1
• Ask for frequency-specific thresholds at 250,500,750,1000,1500,2000,3000,4000,6000, and 8000 Hz to identify which specific frequencies are improving 2
• Speech-in-noise testing would directly measure the improvements you're experiencing in crowds 1

Treatment Continuation

• Complete your intratympanic dexamethasone series, as combined therapy (systemic plus intratympanic) shows 75% improvement rates in poor-prognosis SSNHL compared to 41% with systemic alone 5
• Given your SLE, discuss with your rheumatologist whether additional immunosuppression (like azathioprine) should be considered, as this has shown benefit in SLE-associated hearing loss 4

Follow-Up Timeline

• Obtain repeat comprehensive audiometry at 1 month, 3 months, and 6 months post-treatment, as delayed recovery can occur up to 3 months in 21.8% of patients 1
• Only 0.6% of patients show recovery beyond 6 months, so your 6-month audiogram will establish your final hearing status 1

Common Pitfall to Avoid

Do not dismiss your subjective improvements as placebo or wishful thinking—tinnitus reduction and improved sound discrimination are objective indicators of cochlear recovery that may precede measurable PTA changes, and these functional improvements significantly impact your quality of life regardless of what the audiogram shows 1. Your experience is consistent with early recovery patterns in SSNHL, and continued improvement over the next 1-3 months is entirely possible 1.