What is the best course of action for a patient with sudden sensorineural hearing loss (SSNHL) in one ear, who was recently treated with Rocephin (Ceftriaxone) for an ear infection, has a mildly retracted but otherwise normal tympanic membrane (TM), and a clear external ear canal (EEC), with no reported pain?

Immediate Management of Sudden Sensorineural Hearing Loss

This patient requires urgent formal audiometry within 24-48 hours to confirm sudden sensorineural hearing loss (SSNHL), followed by immediate initiation of systemic corticosteroids if the diagnosis is confirmed—every day of delay worsens prognosis for hearing recovery. 1, 2

Critical First Steps: Distinguish Type of Hearing Loss

The mildly retracted tympanic membrane with clear external ear canal suggests the recent ear infection may have been middle ear pathology, but the sudden hearing loss pattern now requires you to definitively rule out SSNHL versus residual conductive hearing loss:

• Perform Weber and Rinne tuning fork tests immediately at the bedside to differentiate conductive from sensorineural hearing loss, as this fundamentally changes your management pathway 1, 2, 3
• Weber test lateralizing to the affected (right) ear suggests conductive hearing loss from middle ear fluid or eustachian tube dysfunction 2
• Weber test lateralizing to the unaffected (left) ear suggests sensorineural hearing loss—this is a medical emergency 2
• Rinne test showing bone conduction better than air conduction confirms conductive pathology 2

Obtain formal audiometry within 24-48 hours regardless of tuning fork results, as patients cannot accurately distinguish subjective hearing loss type, and objective testing is mandatory for diagnosis and treatment planning 2, 3

If SSNHL is Confirmed (≥30 dB loss at 3 consecutive frequencies)

Immediate Treatment Protocol

• Start oral prednisone 1 mg/kg/day (maximum 60 mg) as a single daily dose immediately for 7-14 days, followed by taper 1, 3
• Treatment initiated within 2 weeks of symptom onset is associated with better outcomes, but earlier treatment (within 5 days) shows statistically significantly lower rates of unchanged hearing 1, 4, 5
• For patients with contraindications to systemic steroids, offer intratympanic dexamethasone 24 mg/mL as initial therapy 3

Patient Education Requirements

The American Academy of Otolaryngology-Head and Neck Surgery mandates that you educate this patient about:

• Natural history: 32-65% of SSNHL cases may recover spontaneously, though clinical experience suggests this may be an overestimation 1
• Treatment limitations: The underlying etiology is unknown in 85-90% of cases, and comparative efficacy of treatments is uncertain 1
• Time-critical nature: Prognosis depends on age, presence of vertigo, degree of hearing loss, audiometric configuration, and critically, time between onset and treatment 1, 4

Mandatory Workup to Exclude Non-Idiopathic Causes

• Assess for bilateral hearing loss, recurrent episodes, or focal neurologic findings that would suggest stroke, vestibular schwannoma, or other serious pathology 1
• Obtain MRI of internal auditory canals or auditory brainstem response (ABR) to evaluate for retrocochlear pathology such as vestibular schwannoma 1, 3
• Do NOT order CT head in the initial evaluation—the American Academy of Otolaryngology-Head and Neck Surgery makes a strong recommendation against this 1
• Do NOT obtain routine laboratory tests—these add cost without benefit 1, 3

If Conductive Hearing Loss is Confirmed Instead

• Refer to otolaryngology for microscopic examination to assess for persistent middle ear effusion or eustachian tube dysfunction 2
• Most post-infectious conductive hearing loss resolves with conservative management over 2-3 months 2
• Keep the ear dry and avoid ototoxic drops until tympanic membrane integrity is fully confirmed 2

Follow-Up Protocol

• If incomplete recovery at 2-6 weeks after initial steroid treatment, offer intratympanic steroid perfusion: 4-6 injections of dexamethasone over 2 weeks 1, 3
• Obtain audiometric evaluation at conclusion of treatment and within 6 months to document final hearing status 1, 3
• For patients with residual hearing loss or tinnitus, counsel about audiologic rehabilitation, hearing aids, and assistive listening devices 1, 3

Critical Pitfalls to Avoid

• Do not assume this is just residual conductive hearing loss from the recent ear infection without objective testing—patients cannot distinguish between conductive and sensorineural hearing loss subjectively 2
• Do not delay treatment waiting for "spontaneous improvement"—if SSNHL is present, every day of delay worsens the prognosis for hearing recovery 1, 4, 5
• Do not misattribute the hearing loss to the recent Rocephin treatment—while the temporal relationship is notable, ceftriaxone is not a known ototoxic agent, and this presentation is more consistent with either SSNHL or persistent middle ear dysfunction 1
• Do not order routine laboratory tests or CT imaging—these do not improve outcomes and are specifically recommended against by guidelines 1, 3