What is the recommended treatment for sensorineural hearing loss?

Treatment of Sensorineural Hearing Loss

For idiopathic sudden sensorineural hearing loss, offer oral or intratympanic corticosteroids as soon as possible (ideally within 14 days of symptom onset), obtain MRI to rule out retrocochlear pathology, and immediately counsel patients about audiologic rehabilitation options regardless of whether hearing recovers. 1, 2

Immediate Diagnostic Confirmation

• Obtain formal audiometry within 14 days of symptom onset to confirm sensorineural (versus conductive) hearing loss and establish baseline severity 1, 3
• Use tuning fork tests (Weber and Rinne) at initial presentation to distinguish sensorineural from conductive patterns 4
• Assess for bilateral involvement, recurrent episodes, or focal neurologic findings that suggest non-idiopathic causes requiring different management 1, 4

Primary Treatment for Sudden Sensorineural Hearing Loss

Corticosteroid therapy is the mainstay of treatment for idiopathic sudden sensorineural hearing loss, though the evidence has limitations that must be discussed with patients 1, 5:

• Initiate treatment as soon as possible after diagnosis confirmation, ideally within the first 2 weeks 2, 5
• Either oral or intratympanic steroid delivery can be used as initial therapy 2
• For incomplete recovery at 2-6 weeks, offer intratympanic steroid injections as salvage therapy 2
• Hyperbaric oxygen therapy combined with steroids may be considered as salvage therapy within 1 month of onset, though this is an option rather than a routine recommendation 2

What NOT to Do

The American Academy of Otolaryngology-Head and Neck Surgery made strong recommendations against several interventions 1:

• Do not routinely prescribe antivirals, thrombolytics, vasodilators, or vasoactive substances - there is strong evidence against their efficacy 1, 2
• Do not order routine CT of the head in initial evaluation 1
• Do not obtain routine laboratory tests unless systemic illness is specifically suspected 1, 6

Mandatory Workup for Retrocochlear Pathology

All patients with confirmed sensorineural hearing loss require evaluation for retrocochlear pathology 1, 2:

• MRI with gadolinium of the brain and internal auditory canals is the gold standard to detect acoustic neuromas, cerebellopontine angle lesions, or other structural pathology 2, 7
• This imaging is essential even if hearing completely recovers, as 18.75% of patients in one series had significant pathology despite clinical improvement 7
• If MRI is contraindicated, auditory brainstem response testing is an acceptable alternative 2, 4

Audiologic Rehabilitation Planning

Begin counseling about audiologic rehabilitation immediately, without waiting to see if hearing recovers 2:

• Delaying rehabilitation planning wastes valuable time and can lead to auditory deprivation with poorer long-term outcomes 2
• For residual hearing loss, hearing aids are first-line management 2, 6
• For severe to profound bilateral hearing loss with insufficient benefit from hearing aids, cochlear implantation should be considered 2, 6
• Address tinnitus management as part of comprehensive rehabilitation, as tinnitus significantly impacts quality of life 1, 2

Patient Education Requirements

Clinicians must educate patients about the natural history, treatment limitations, and realistic expectations 1:

• Discuss that over 90% of sudden sensorineural hearing loss is idiopathic (no identifiable cause) 1
• Explain that spontaneous recovery occurs in some patients even without treatment 5
• Review the benefits and risks of medical interventions and acknowledge the limitations of existing evidence regarding efficacy 1
• Inform patients that presence of vertigo at onset typically indicates more severe disease and poorer prognosis 2, 5

Prognostic Factors

Several factors predict worse hearing outcomes 5:

• Greater severity of initial hearing loss predicts poorer recovery 5
• Presence of vertigo indicates worse prognosis 2, 5
• Advanced age is associated with poorer outcomes 5
• Downsloping audiogram configuration suggests worse prognosis 5

Critical Pitfalls to Avoid

• Do not assume recovery is impossible just because diagnosis was delayed - salvage therapy options exist up to 6 weeks from onset 2
• Do not skip MRI workup even if hearing recovers, as retrocochlear pathology can present as sudden hearing loss 2, 7
• Do not delay audiometric confirmation beyond 14 days, as this is essential for accurate diagnosis and treatment decisions 4, 3
• Remove impacted cerumen before establishing diagnosis, as it causes conductive hearing loss that confounds the clinical picture 4