What are the treatment options for hearing loss?

Treatment of Hearing Loss

The treatment of hearing loss depends critically on distinguishing between conductive and sensorineural types, as management pathways are completely different and time-sensitive treatment windows may be closing. 1

Immediate Diagnostic Distinction Required

You must first determine the type of hearing loss through otoscopic examination and pure tone audiometry with air and bone conduction thresholds. 1, 2

• Conductive hearing loss: Otoscopy will show abnormalities (cerumen impaction, middle ear effusion, tympanic membrane perforation, cholesteatoma) 1
• Sensorineural hearing loss: Otoscopy typically normal; dysfunction involves inner ear, cochlear nerve, or central auditory pathways 1
• Mixed hearing loss: Combination of both conductive and sensorineural components requiring specialist referral 1

Conductive Hearing Loss Treatment

Conductive hearing loss has excellent prognosis with appropriate intervention, as many causes are medically or surgically correctable. 1

• Cerumen impaction: Irrigation or curettage is potentially curative 2
• Middle ear pathology: Requires otolaryngology referral for surgical management (tympanoplasty, ossiculoplasty, cholesteatoma removal) 1
• Follow-up: Audiometry every 3-6 months for stable conditions without cholesteatoma 1

Sudden Sensorineural Hearing Loss (SSNHL)

This represents an otologic emergency requiring immediate treatment within 2 weeks of symptom onset for maximum benefit. 3, 1

Time-Critical Treatment Protocol

• Corticosteroids as initial therapy: Offer oral corticosteroids (prednisone, methylprednisolone, dexamethasone) within 2 weeks of symptom onset 3, 1
• Intratympanic corticosteroids: Offer as salvage therapy for incomplete recovery after initial oral therapy, or as primary treatment when oral steroids contraindicated 3, 1
• Hyperbaric oxygen: May be offered within 2 weeks of diagnosis or up to 1 month in conjunction with steroids 3

Critical Prognostic Information

• One-third to two-thirds of patients recover spontaneously within 2 weeks 3, 1
• Patients recovering half their hearing in first 2 weeks have better prognosis 3
• Minimal change within first 2 weeks predicts unlikely significant recovery 3
• Presence of dizziness at onset indicates poorer prognosis 3

Mandatory Workup

• MRI of brain and internal auditory canals: Required to rule out vestibular schwannoma 3, 1, 4
• Alternative: Auditory brainstem response (ABR) if MRI contraindicated, though less sensitive; abnormal ABR requires MRI 3, 4
• Follow-up audiometry within 6 months to assess treatment outcome 3, 1, 4

Treatment NOT Recommended

Antivirals are commonly prescribed but have insufficient evidence supporting effectiveness in treating sudden hearing loss. 3

Age-Related Hearing Loss (Presbycusis)

Age-related hearing loss affects 1 in 3 adults aged 65-74 and nearly 50% over age 75, with permanent and progressive prognosis requiring amplification and rehabilitation. 1

Primary Treatment Approach

• Hearing aids as first-line management: Recommended for residual hearing 4, 2, 5
• Cochlear implantation: Consider for severe to profound bilateral hearing loss when hearing aids provide insufficient benefit 4, 2, 5
• Assistive listening devices (ALDs): Alternative for those who cannot afford hearing aids 3, 5

Essential Patient Education Points

Untreated age-related hearing loss has clear links to cognitive decline, including memory loss and increased risk of dementia; properly fitted hearing aids may reduce cognitive decline and dementia risk. 3

• Communication impact: Limits understanding, affects relationships at home, work, and healthcare settings 3
• Safety concerns: Increases risk of work-related injuries, reduces situational awareness and ability to hear warnings 3
• Quality of life: Causes listening fatigue, social isolation, depression; treating hearing loss reduces these risks 3
• Fall risk: Associated with balance problems and increased fall risk 3, 5

Communication Strategies for Patients and Families

• Face the person on same level in good lighting; do not talk while walking away 3
• Speak clearly, slowly, distinctly but naturally; get attention before talking 3
• Minimize extraneous noise (TV, water running); provide important information in writing 3
• Rephrase rather than repeat if message not understood 3

Ménière's Disease Management

For Ménière's disease (spontaneous vertigo attacks lasting 20 minutes to 12 hours with documented low-to-mid-frequency sensorineural hearing loss), use a stepwise approach starting with dietary modifications, progressing to pharmacotherapy, then invasive treatments only if necessary. 6

First-Line: Dietary and Lifestyle Modifications

• Sodium restriction: 1500-2300 mg daily to reduce endolymphatic fluid accumulation 6
• Limit alcohol and caffeine: Both can trigger attacks 6
• Identify and manage allergies: Contribute to symptoms in up to 30% of patients 6
• Stress management: Relaxation techniques, regular exercise, adequate sleep 6
• Symptom diary: Identify personal triggers 6

Second-Line: Pharmacotherapy

• Acute vertigo attacks: Limited course of vestibular suppressants (antihistamines like meclizine, dimenhidrinato; benzodiazepines with caution for dependence risk) only during acute episodes 6
• Maintenance therapy: Diuretics to modify electrolyte balance and reduce endolymph volume 6
• Betahistine: Cannot make definitive recommendation due to questionable efficacy; BEMED trial showed no significant difference versus placebo 6

Third-Line: Intratympanic Therapies

• Intratympanic steroids: Offer to patients with active disease not responsive to non-invasive treatment; 85-90% improvement in vertigo symptoms 6
• Intratympanic gentamicin: For persistent vertigo after failed conservative therapies; 73.6% complete vertigo control rate, but risk of hearing loss 6

Fourth-Line: Surgical Options

• Labyrinthectomy: For active disease failed less definitive therapy with non-usable hearing 6
• Avoid ablative procedures in only hearing ear: 10-25% of cases eventually become bilateral 6

Treatment NOT Recommended

Do not prescribe positive pressure therapy (Meniett device); multiple systematic reviews show no significant difference compared to placebo and may worsen hearing levels. 6

Vestibular Rehabilitation

• Not recommended for acute vertigo attacks 6
• Offer for chronic imbalance between attacks or following ablative therapy: Improves symptom control and reduces fall risk 6

Audiologic Rehabilitation (All Types)

Audiologic rehabilitation must be addressed as soon as hearing loss is identified, as delay leads to auditory deprivation and poorer outcomes. 3, 4

• Counseling on amplification options: Hearing aids, cochlear implants, assistive listening devices 3, 4
• Address psychological impact: Hearing loss causes embarrassment, frustration, anxiety, depression, social isolation; individual or group counseling helpful 3
• Financial concerns: Address to ensure appropriate follow-up and optimal outcomes 3
• Involve family members: Include in education and consultation as appropriate 3

Referral Criteria

Refer to otolaryngology for: 1, 2

• Sudden sensorineural hearing loss (emergency referral)
• Asymmetric sensorineural hearing loss (rule out vestibular schwannoma)
• Conductive or mixed hearing loss
• Poor word recognition scores
• Sensorineural hearing loss not improving with hearing aids

Refer to audiology for: 2

• Hearing aid evaluation and fitting
• Comprehensive audiometric assessment

Monitoring Requirements

• Follow-up audiometry at conclusion of treatment and within 6 months 3, 1, 4
• Regular monitoring at least every 3 years for known hearing loss 1
• Document resolution, improvement, or worsening of symptoms after each intervention 6

Common Pitfalls to Avoid

• Delaying treatment of sudden sensorineural hearing loss: Greatest benefit occurs within first 2 weeks; late recovery rare 3, 1
• Prescribing antivirals for sudden hearing loss: Insufficient evidence despite common practice 3
• Using vestibular suppressants chronically in Ménière's disease: Only for acute attacks 6
• Failing to screen for vestibular schwannoma: Required in asymmetric or sudden sensorineural hearing loss 3, 1, 4
• Not addressing audiologic rehabilitation early: Delay worsens outcomes 4