What is the recommended treatment protocol for a patient with sudden sensorineural hearing loss, including the role of Hyperbaric Oxygen Therapy (HBOT)?

Hyperbaric Oxygen Therapy for Sudden Sensorineural Hearing Loss

HBOT combined with steroid therapy may be offered as either initial treatment within 2 weeks of symptom onset or as salvage therapy within 1 month for patients with sudden sensorineural hearing loss, though it remains an optional rather than strongly recommended intervention. 1

Initial Treatment Approach

Timing-Based Treatment Algorithm

For patients presenting within 2 weeks of symptom onset:

• HBOT combined with systemic corticosteroids may be offered as initial therapy, recognizing this is classified as an "option" rather than a strong recommendation by the American Academy of Otolaryngology-Head and Neck Surgery 1
• Systemic corticosteroids alone (prednisone 60 mg daily or equivalent) remain the standard initial option 2
• Treatment must be initiated within 14 days of symptom onset for optimal outcomes 1

The evidence supporting HBOT as initial therapy:

• A 2022 meta-analysis of randomized controlled trials demonstrated that HBOT combined with steroids produced a mean absolute hearing gain of 10.3 dB greater than control treatments (95% CI, 6.5-14.1 dB) 3
• The odds ratio for hearing recovery (≥10 dB improvement) was 4.3 times higher with HBOT versus control therapy (95% CI, 1.6-11.7) 3
• A 2020 study showed significantly greater hearing improvement in severe hearing loss patients (≥70 dB) receiving HBOT plus steroids versus steroids alone (28.1 dB vs 14.8 dB improvement, p < 0.05) 4

Salvage Therapy Protocol

For patients with incomplete recovery 2-6 weeks after initial treatment:

• Intratympanic steroid therapy should be offered first as this carries a stronger "recommendation" level versus HBOT's "option" classification 1, 5
• HBOT combined with steroids may be offered as salvage therapy if initiated within 1 month of symptom onset 1, 6
• The salvage window extends to 3 months in some protocols, though earlier intervention yields better outcomes 6

Specific HBOT Treatment Protocol

Treatment parameters:

• 10-25 sessions of HBOT, with 20 sessions being the typical recommendation 6, 7
• Initiation within 7 days of symptom onset produces the most favorable results (OR = 27.763,95% CI [4.209,183.115], p = .001) 8
• Treatment should be completed within 3 months of symptom onset 6

Patient selection considerations:

• HBOT shows particular benefit in patients with severe to profound hearing loss (≥70 dB) 4
• Patients with complete hearing loss showed 57.14% recovery rate with combined HBOT 8
• Low-frequency hearing loss responds particularly well to HBOT 4, 7

Critical Diagnostic Requirements Before Treatment

Mandatory confirmatory testing:

• Audiometry must demonstrate ≥30 dB hearing loss across at least 3 consecutive frequencies to confirm SSNHL diagnosis 1, 6
• Distinguish sensorineural from conductive hearing loss through audiometric evaluation 1
• MRI or auditory brainstem response testing to rule out retrocochlear pathology (vestibular schwannoma) 1, 2

Avoid unnecessary testing:

• Do not order routine CT of the head 1
• Do not obtain routine laboratory tests 1

Adverse Effects and Risk Counseling

Common HBOT-related complications:

• Difficulty equalizing middle ear pressure occurs in up to 17% of patients 6
• Ear or sinus barotrauma affects approximately 6.25% of SSNHL patients 6
• Eustachian tube dysfunction 6
• Confinement anxiety during treatment sessions 6

These risks are generally acceptable given the potential for hearing recovery, particularly in patients who have already failed standard steroid therapy 6

Patient Education Requirements

Mandatory counseling topics:

• Natural history of SSNHL, including spontaneous recovery rates 1
• Benefits and risks of all medical interventions, including HBOT 1
• Limitations of existing evidence - HBOT remains an "option" rather than a strong recommendation due to moderate quality evidence 1
• Shared decision-making is essential given the optional nature of HBOT and considerations of cost, accessibility, and time commitment 1

Follow-Up and Rehabilitation

Audiometric monitoring:

• Obtain follow-up audiometry at completion of HBOT treatment 1, 3
• Repeat audiometry within 6 months of treatment completion 1, 6

For patients with residual hearing loss:

• Counsel about audiologic rehabilitation benefits including hearing aids and assistive listening devices [1, @13@]
• Address tinnitus management if present, noting that prolonging HBOT course does not significantly improve tinnitus 7
• Consider cochlear implantation for severe to profound bilateral hearing loss with insufficient benefit from hearing aids 9

Treatments to Avoid

Do not routinely prescribe:

• Antivirals 1, 7
• Thrombolytics 1, 7
• Vasodilators 1, 7
• Vasoactive substances 1, 7

Key Clinical Pitfalls

Common errors to avoid:

• Delaying treatment beyond 2 weeks - the therapeutic window is narrow and outcomes decline significantly with delayed intervention 1, 8
• Using HBOT as monotherapy - HBOT should always be combined with steroid therapy, not used alone 1, 6
• Failing to rule out retrocochlear pathology before attributing hearing loss to idiopathic SSNHL 1, 2
• Not offering intratympanic steroids as salvage - this carries a stronger recommendation than salvage HBOT 1, 5