Steroid Course for Sudden Sensorineural Hearing Loss
For sudden sensorineural hearing loss, initiate oral prednisone 1 mg/kg/day (maximum 60 mg daily) as a single morning dose for 7-14 days, followed by a taper over 7-14 days, starting immediately and ideally within 14 days of symptom onset. 1, 2
Initial Treatment Regimen
Oral Corticosteroid Dosing
- Prednisone 1 mg/kg/day as a single morning dose (usual maximum 60 mg/day) for 7-14 days at full dose 1, 2, 3
- After full-dose treatment, taper over a similar time period (7-14 days) 2, 3
- Alternative equivalent doses include methylprednisolone 48 mg/day or dexamethasone 10 mg/day 2, 3
Critical Timing Considerations
- Treatment must begin immediately upon diagnosis, with greatest benefit within the first 2 weeks of symptom onset 1, 2, 3
- Some benefit has been reported up to 6 weeks, but efficacy diminishes significantly after 2 weeks 2, 3
- Obtain audiometry as soon as possible (within 14 days of symptom onset) to confirm diagnosis before initiating treatment 1
Common Dosing Pitfall to Avoid
The standard methylprednisolone dose pack is grossly inadequate. A typical dose pack provides only the equivalent of 105 mg prednisone total, whereas the recommended regimen for a 60-kg adult requires 540 mg total over 14 days (60 mg × 9 days of full dose). 3 This represents a 5-fold underdosing error that significantly compromises treatment efficacy.
Salvage Therapy for Incomplete Recovery
Intratympanic Steroid Therapy
- Offer intratympanic steroid therapy when patients have incomplete recovery 2-6 weeks after onset of symptoms 1
- Use dexamethasone 24 mg/mL, 16 mg/mL, or 10 mg/mL administered via anterosuperior myringotomy after topical anesthetic 2, 3
- Administer twice weekly for 2-3 weeks (minimum 4 injections over 2 weeks) 3
- Extended salvage therapy with 4-6 additional injections over 2 weeks shows 37-48% improvement rates in patients with incomplete initial recovery 3, 4
Alternative Primary Treatment
- Intratympanic methylprednisolone (40 mg/mL) is non-inferior to oral prednisone for primary treatment and can be used when systemic steroids are contraindicated 5, 6, 7
- This is particularly suitable for patients with diabetes mellitus, hypertension, chronic renal failure, or SLE with organ involvement 3, 4, 7
Monitoring and Follow-Up
Audiometric Assessment
- Obtain baseline audiogram before treatment to confirm sensorineural (not conductive) hearing loss 1, 3
- Repeat audiometry at 10-14 days to assess response 3, 4
- Follow-up audiometry at conclusion of treatment and within 6 months post-treatment 1, 3
Treatment Response Criteria
- Adequate recovery defined as ≥10 dB improvement in pure tone average OR ≥10% improvement in word recognition score 3, 4
- Partial response indicators include reduced tinnitus, decreased ear fullness, and improved ability to hear environmental sounds 3, 4
Safety Monitoring
- Monitor for hyperglycemia, especially in patients at risk 2, 4
- Most serious side effects occur with chronic use; short 10-14 day courses have acceptable safety profiles 2
What NOT to Do
The American Academy of Otolaryngology-Head and Neck Surgery makes strong recommendations against the following interventions:
- Do not routinely prescribe antivirals, thrombolytics, vasodilators, or vasoactive substances 1
- Do not order routine CT of the head in initial evaluation 1
- Do not obtain routine laboratory tests 1
Special Considerations
Evaluation for Underlying Causes
- Assess for bilateral sudden hearing loss, recurrent episodes, or focal neurologic findings through history and physical examination 1
- Evaluate for retrocochlear pathology with MRI or auditory brainstem response 1
- Consider specific etiologies requiring steroids: syphilitic labyrinthitis, autoimmune inner ear disease, post-viral labyrinthitis 3