What is the appropriate treatment and management for a patient experiencing sudden hearing loss?

Management of Sudden Hearing Loss

Initiate oral corticosteroids immediately (prednisone 1 mg/kg/day or 60-80 mg/day) as soon as sudden sensorineural hearing loss is confirmed by audiometry, ideally within 2 weeks of symptom onset, as this is the only evidence-based first-line treatment that may improve hearing recovery. 1, 2

Initial Diagnostic Evaluation

Distinguish sensorineural from conductive hearing loss immediately using tuning fork tests (Weber and Rinne) or audiometry, as this determines the entire treatment pathway. 1

• Perform audiometry to confirm ≥30 dB hearing loss at 3 consecutive frequencies occurring within 72 hours. 1
• Examine for cerumen impaction, tympanic membrane perforation, middle ear effusion, or other conductive causes that require different management. 3
• Assess for bilateral hearing loss, recurrent episodes, or focal neurologic findings that suggest non-idiopathic causes. 1

Do NOT order CT scan of the head/brain in the initial evaluation, as this provides no diagnostic value for sudden sensorineural hearing loss. 1

Do NOT obtain routine laboratory tests unless systemic illness is specifically suspected based on history and physical examination. 1

Immediate Treatment Protocol

Offer oral corticosteroids as initial therapy (prednisone 1 mg/kg/day or 60-80 mg/day for 10-14 days) to all patients with idiopathic sudden sensorineural hearing loss. 1, 2

• Treatment should begin as soon as possible, ideally within 2 weeks of onset, as earlier intervention correlates with better outcomes. 2, 4
• The maximal adrenal cortex activity occurs between 2 AM and 8 AM, so morning dosing minimizes HPA axis suppression. 5

Do NOT routinely prescribe antivirals, thrombolytics, vasodilators, vasoactive substances, or antioxidants, as these lack evidence of efficacy. 1

Salvage Therapy for Incomplete Recovery

Offer intratympanic steroid perfusion when patients have incomplete recovery after failure of initial oral corticosteroid management. 1

Hyperbaric oxygen therapy may be offered within 3 months of diagnosis as an option, though evidence is limited. 1

Evaluation for Retrocochlear Pathology

Obtain MRI with gadolinium of the brain and internal auditory canals to rule out vestibular schwannoma or other retrocochlear pathology, particularly in patients with asymmetric hearing loss. 1, 6, 3

• Auditory brainstem response testing may be used as a less expensive alternative screening tool when MRI cannot be performed. 6
• This evaluation should occur during the treatment course but should not delay initiation of corticosteroids. 1

Patient Education and Counseling

Educate patients about the natural history: spontaneous recovery occurs in approximately two-thirds of patients, with maximum improvement typically within 2 weeks of onset. 1, 7, 2

Discuss treatment benefits and risks: corticosteroids may improve hearing recovery but carry risks including hyperglycemia, mood changes, and gastric irritation. 1

Explain prognostic factors:

• Better prognosis: mild hearing loss (<90 dB), upward-sloping audiogram, early treatment initiation, recovery beginning within 2 weeks. 2, 4
• Worse prognosis: severe hearing loss (>90 dB), flat or downward-sloping audiogram, presence of vertigo, advanced age, delayed treatment. 2, 4

Rehabilitation for Incomplete Recovery

Counsel patients with residual hearing loss about amplification options including hearing aids, CROS/BiCROS systems, bone-anchored devices, or cochlear implants for severe-to-profound loss. 1

Refer to audiology for hearing-assistive technology and rehabilitation services to optimize communication function and quality of life. 1, 6

Discuss support resources such as the Hearing Loss Association of America for coping with unilateral hearing loss. 1

Follow-Up Care

Obtain audiometric evaluation within 6 months of diagnosis to document final hearing status and assess need for ongoing rehabilitation. 1

Monitor for progression and adjust amplification or rehabilitation strategies as needed. 6

Critical Pitfalls to Avoid

• Do not delay treatment waiting for laboratory results or imaging, as time to treatment initiation is the most modifiable prognostic factor. 2, 4
• Do not dismiss unilateral hearing loss as benign without audiometric confirmation and appropriate workup. 1
• Do not use dexamethasone or betamethasone for alternate-day therapy if considering that approach, as their prolonged suppressive effect on adrenal activity makes them unsuitable. 5
• Do not fail to address rehabilitation needs even during acute treatment, as early counseling about amplification improves long-term outcomes. 1, 6