What is the treatment for sensorineural hearing loss (SNHL) following a varicella infection?

Treatment of Sensorineural Hearing Loss Following Varicella Infection

Treat post-varicella SNHL with immediate systemic corticosteroids (prednisone 1 mg/kg/day, maximum 60 mg daily for 7-14 days followed by taper) as first-line therapy, initiated within 14 days of hearing loss onset, while recognizing that antiviral therapy provides no additional benefit beyond standard corticosteroid treatment. 1, 2, 3

Initial Assessment and Diagnosis

When a patient presents with hearing loss following varicella infection, confirm the diagnosis through:

• Tuning fork examination (Weber and Rinne tests) to distinguish sensorineural from conductive hearing loss 4
• Formal audiometry within 14 days of symptom onset to document baseline hearing thresholds and confirm SNHL diagnosis 4, 2
• Document the temporal relationship between varicella infection and hearing loss onset, as sudden hearing loss (within 72 hours) requires emergency intervention 1

Varicella-associated SNHL is recognized as a non-idiopathic cause of sudden sensorineural hearing loss, though it should be managed using the same treatment protocols as idiopathic SSNHL. 1

Primary Treatment: Corticosteroids

Systemic corticosteroid therapy remains the cornerstone of treatment:

• Prednisone 1 mg/kg/day (maximum 60 mg/day) given as a single daily dose for 7-14 days, followed by a taper over a similar duration 4, 2
• Alternative regimens include methylprednisolone 48 mg/day or dexamethasone 10 mg/day 2
• Timing is critical: Treatment should begin immediately, ideally within the first 14 days of symptom onset, though benefit has been reported up to 6 weeks 2

For patients with contraindications to systemic steroids (insulin-dependent diabetes, poorly controlled hypertension, glaucoma, active tuberculosis, peptic ulcer disease, or prior psychiatric reactions):

• Intratympanic dexamethasone 24 mg/mL as initial therapy, with 0.4-0.8 mL injected into the middle ear space 4, 2
• Patient maintains head in otologic position (affected ear up) for 15-30 minutes 2
• Up to 4 injections over a 2-week period 2

Antiviral Therapy: Not Recommended

The evidence strongly argues against routine antiviral use in post-varicella SNHL:

• Multiple randomized controlled trials comparing antiviral therapy plus steroids versus steroids alone found no statistically significant benefit from adding antivirals 1
• A study specifically examining HSV-seropositive ISSNHL patients found no significant difference in prognosis between those receiving acyclovir combined with corticosteroids versus corticosteroids alone (hearing threshold improvement 18.7±37.1 dB vs 11.0±44.5 dB, P=0.619) 3
• The American Academy of Otolaryngology-Head and Neck Surgery recommends against routinely prescribing antivirals to patients with sudden sensorineural hearing loss 1

This represents a critical clinical distinction: while varicella is a viral infection, the hearing loss mechanism does not respond to antiviral intervention once SNHL has developed. 1, 3

Salvage Therapy for Incomplete Recovery

If hearing recovery is incomplete at 2-6 weeks after initial treatment:

• Offer intratympanic steroid therapy as salvage treatment 4, 2
• Typical salvage protocol: 4-6 injections of dexamethasone 5 mg/mL over 2 weeks 2
• Hyperbaric oxygen therapy combined with steroids may be considered within 1 month of onset, though evidence is limited and cost is substantial 1, 2

Diagnostic Workup Considerations

What TO do:

• Obtain MRI of internal auditory canals or auditory brainstem response (ABR) to evaluate for retrocochlear pathology, as varicella can cause isolated cochlear neuritis that mimics vestibular schwannoma on imaging 4, 5

What NOT to do:

• Do NOT order routine CT of the head in the initial evaluation unless focal neurologic findings are present 1, 4
• Do NOT obtain routine laboratory tests in patients with SNHL 1, 4

Follow-Up Protocol

Structured audiometric monitoring is essential:

• Mid-treatment audiogram can be considered between intratympanic injections to guide early termination if hearing resolves 2
• Post-treatment audiogram at completion of treatment course 4, 2
• Final assessment at 6 months post-treatment regardless of perceived recovery 4, 2

For patients with residual hearing loss or tinnitus, counsel about audiologic rehabilitation, hearing aids, and assistive listening devices. 4

Clinical Context and Prognosis

Important prognostic considerations:

• Patients with non-idiopathic SSNHL (including varicella-associated cases) show hearing improvement more often than those with idiopathic SSNHL: 48.8% achieved ≥10 dB improvement versus 34.3% in idiopathic cases (P=0.011) 6
• Varicella-associated SNHL can present as the first symptom of chickenpox, even before fever or rash develop 7
• The mean interval from hearing loss onset to treatment is typically 7-9 days 6

Critical Pitfalls to Avoid

• Do not delay audiometric confirmation beyond 14 days, as this is essential for diagnosis and treatment planning 4, 2
• Do not assume bilateral SNHL is typical post-varicella hearing loss—bilateral presentation mandates evaluation for other syndromic causes including meningitis, which commonly presents with fever, headache, and abnormal cerebrospinal fluid 1
• Do not add antiviral therapy expecting additional benefit—the evidence does not support this practice despite the viral etiology 1, 3
• Do not divide corticosteroid doses—give as a single daily dose for optimal efficacy 2