What are the treatment options for unilateral hearing loss?

Treatment Options for Unilateral Hearing Loss

Patients with unilateral hearing loss require immediate audiologic evaluation to determine the type and severity of hearing loss, followed by appropriate amplification options including conventional hearing aids, CROS/BiCROS devices, bone-anchored hearing aids, or cochlear implantation depending on the underlying etiology and degree of hearing loss. 1, 2

Initial Diagnostic Evaluation

Audiometric Assessment

• Refer immediately to an audiologist for comprehensive audiometric testing including pure-tone audiometry, acoustic reflex testing, and otoacoustic emissions (OAEs) to differentiate between conductive, sensorineural, and neural hearing loss 1, 3, 4
• Use validated self-assessment tools such as the Hearing Handicap Inventory for Adults (HHIA) to quantify the functional impact on quality of life, as 86% of patients with unilateral sensorineural hearing loss report significant hearing handicap 1, 2
• Document the presence of associated symptoms including tinnitus (present in nearly all cases of sudden sensorineural hearing loss) and vertigo (present in 30-60% of cases, indicating poorer prognosis) 2

Imaging and Further Workup

• MRI is the gold standard imaging modality for unilateral sensorineural hearing loss to exclude retrocochlear pathology, particularly acoustic neuromas and other cerebellopontine angle tumors, as well as cochlear nerve aplasia (the most common cause of unilateral neural hearing loss in children) 3, 4, 5
• In children with conductive hearing loss from outer/middle ear malformations, CT may be appropriate to evaluate bony anatomy 6

Treatment Based on Hearing Loss Type

Conductive Hearing Loss

• Medical management of otitis media with effusion (OME) through prompt referral to primary care or otolaryngology, with definitive resolution never delaying amplification fitting 6
• Consider tympanostomy tubes for chronic OME (≥3 months duration), particularly in at-risk children where even unilateral OME without apparent hearing loss can degrade binaural processing 6
• Surgical reconstruction of outer/middle ear malformations or bone-anchored hearing aids when patients reach appropriate age for skull bone maturity 6, 7

Sensorineural Hearing Loss

Amplification Options

• Conventional hearing aids: Trial fitting is indicated depending on the degree of residual hearing, with decisions to continue based on demonstrated benefit 6, 1
• CROS (Contralateral Routing of Signal) hearing aids: Appropriate for single-sided deafness, where a microphone on the affected ear transmits sound to the better ear 2, 7
  • Critical caveat: CROS amplification is specifically NOT recommended for children with unilateral hearing loss 6, 7
• BiCROS hearing aids: Suitable when preexisting hearing loss exists in the better ear 2
• Osseointegrated bone conductive devices: Surgical option using bone conduction to transfer sound to the better-hearing cochlea, particularly appropriate for congenital aural atresia or when conventional amplification cannot be used 2, 7
• Cochlear implantation: Appropriate for severe to profound unrecovered sensorineural hearing loss, especially with associated tinnitus (96% report tinnitus improvement post-implantation) 2

Neural Hearing Loss

• Trial fitting with hearing aids is indicated until usefulness can be determined, as benefit is variable in this heterogeneous condition 6
• Cochlear implants show growing use with positive outcomes reported for many children with neural hearing loss 6

Communication Strategies and Counseling

Immediate Implementation

• Look directly at the patient when speaking to facilitate lip reading 1
• Minimize background noise in communication environments 1
• Consider speech-to-text applications for challenging listening situations 1

Patient Education

• Counsel about realistic treatment outcomes and the very low risk of sudden sensorineural hearing loss in the contralateral ear 2
• Address safety concerns related to impaired sound localization, including difficulty crossing streets and determining sound origin 2, 7
• Provide information about support groups such as the Hearing Loss Association of America 2
• Discuss amplification and rehabilitation options even during initial treatment periods, as most patients will benefit from intervention 2

Follow-Up Monitoring

• Schedule regular audiologic assessments every 2-3 years or more frequently if hearing status changes 1
• Monitor for changes in hearing and adjust amplification accordingly 1
• For children with risk indicators for progressive hearing loss, maintain heightened surveillance 6

Important Clinical Pitfalls

• Do not delay amplification while treating concurrent OME in patients with sensorineural hearing loss, as OME further reduces auditory access and negatively affects hearing aid prescriptive targets 6
• Do not assume tinnitus invalidates audiometry—pure-tone audiometry remains the gold standard regardless of tinnitus severity 2
• Do not use CROS amplification in children with unilateral hearing loss, as this is contraindicated by current guidelines 6, 7
• Recognize bilateral sudden sensorineural hearing loss as a medical emergency requiring urgent investigation to exclude life-threatening conditions, as it carries a 35% mortality rate and is associated with serious systemic diseases 8, 9