Management of Hearing Loss After Gunshot Exposure
Treat this as sudden sensorineural hearing loss (SSNHL) and initiate oral corticosteroids immediately if the patient presents within 2 weeks of the acoustic trauma, using prednisone 1 mg/kg/day (maximum 60 mg daily) for 7-14 days. 1
Immediate Diagnostic Evaluation
Obtain formal audiometry within 24-48 hours to confirm the diagnosis and establish baseline hearing thresholds. 1, 2 The audiometric evaluation must include:
- Ear-specific air and bone conduction thresholds at 250-8000 Hz to distinguish sensorineural from conductive hearing loss 1
- Speech recognition threshold (SRT) and word recognition scores (WRS) using standardized word lists 1
- Otoscopic examination to rule out tympanic membrane perforation, blood in the canal, or external auditory canal trauma 3
Gunshot-induced acoustic trauma typically causes asymmetric hearing loss worse in the ear closer to the muzzle blast, with the left ear more affected in right-handed shooters. 4, 5 Complete unilateral deafness (cophosis) can occur immediately after exposure. 4
Treatment Protocol
Primary Treatment (Within 2 Weeks of Onset)
Systemic corticosteroids are the only evidence-based treatment option for SSNHL, though data are somewhat equivocal. 1 Given the serious consequences of severe hearing loss and limited treatment alternatives, corticosteroids should be offered despite imperfect evidence. 1
Recommended regimen: 1
- Prednisone 1 mg/kg/day (usual maximum 60 mg) as a single daily dose
- Duration: 7-14 days at full dose, then taper over similar time period
- Alternative: Methylprednisolone 48 mg/day or dexamethasone 10 mg/day
The greatest benefit occurs when treatment is initiated within the first 2 weeks, with little benefit after 4-6 weeks. 1 Do not delay treatment waiting for specialty referral.
Salvage Therapy (After Failed Primary Treatment)
Intratympanic (IT) steroid injections may be offered as salvage therapy after incomplete recovery from initial treatment. 1 This involves:
- Dexamethasone 24 mg/mL, 16 mg/mL, or 10 mg/mL injected through anterosuperior myringotomy 1
- Methylprednisolone 40 mg/mL or 30 mg/mL as alternative 1
- Audiogram before each subsequent injection to monitor response 1
What NOT to Do
Avoid routine laboratory testing ("shotgun" panels) unless systemic illness is suspected, as these do not improve management and have associated costs and false-positive risks. 1
Avoid routine head CT scanning in patients with no other neurologic findings, as this is very low-yield with significant cost and radiation exposure. 1
Do not offer hyperbaric oxygen therapy (HBOT) routinely, as evidence is insufficient despite some promising data. 1
Mandatory Specialty Referral
Refer urgently to otolaryngology within 24-48 hours for all patients with confirmed SSNHL. 2, 3 Specialist evaluation is critical because:
- Retrocochlear pathology must be ruled out with MRI of brain and internal auditory canals, particularly for asymmetric hearing loss 2, 6
- Vestibular function testing may reveal additional labyrinthine damage beyond cochlear injury 4
- Specialist management allows consideration of IT steroid salvage therapy if initial treatment fails 1
Audiologic Rehabilitation and Counseling
Address hearing rehabilitation immediately upon diagnosis, not after treatment completion. 1, 2 This includes:
- Counseling about communication strategies, safety concerns, and quality of life impacts 1, 2
- Discussion of amplification options including traditional hearing aids for serviceable hearing or specialized devices for single-sided deafness 1
- Hearing assistive technology systems can bridge the treatment period or serve as long-term solutions 1
- Psychological support for anxiety, depression, and social isolation that commonly accompany sudden hearing loss 1
86% of patients with unilateral SSNHL report hearing handicap, and 56% with tinnitus demonstrate significant tinnitus-related disability. 1
Follow-Up Monitoring
Obtain repeat audiometry:
- At completion of initial treatment course (2-4 weeks) 1, 2
- Within 6 months of treatment completion 2
- At 3-6 month intervals until hearing stabilizes 7
Meaningful recovery is defined as: 1
- Return to serviceable hearing (if initially nonserviceable)
- ≥10 dB improvement in pure tone average
- ≥10% improvement in word recognition scores
Critical Pitfalls to Avoid
Do not assume spontaneous recovery will occur. While one-third to two-thirds of SSNHL patients may recover spontaneously, the window for effective treatment is narrow and unpredictable. 1 The risk of permanent hearing loss and its devastating impact on quality of life justifies immediate treatment.
Do not delay treatment for specialty consultation. Primary care providers should initiate oral corticosteroids immediately upon diagnosis, then arrange urgent ENT referral. 1, 3
Do not underestimate the impact of unilateral hearing loss. Even single-sided deafness causes significant difficulty with conversation, localization, and hearing in noisy environments, particularly if preexisting hearing loss exists. 1
Emphasize hearing protection for future exposures. Unilateral hearing protection is effective for preventing gunshot-induced hearing loss while maintaining ability to hear instructions. 5