What is the recommended oral steroid dose and tapering schedule for acute sensorineural hearing loss?

Oral Steroid Dosing for Acute Sensorineural Hearing Loss

For acute sudden sensorineural hearing loss, administer prednisone 1 mg/kg/day (maximum 60 mg/day) as a single morning dose for 10-14 days, followed by a taper over a similar 7-14 day period. 1, 2

Specific Dosing Protocol

Standard Regimen

• Prednisone 1 mg/kg/day (usual maximum 60 mg daily) given as a single morning dose 1, 2
• Continue full dose for 10-14 days 1, 2
• Taper over 7-14 days after completing the full-dose period 2
• Total treatment duration is approximately 3-4 weeks including taper 1, 2

Equivalent Alternative Corticosteroids

• Methylprednisolone 48 mg/day (5 times more potent than hydrocortisone) 1, 2
• Dexamethasone 10 mg/day (25 times more potent than hydrocortisone) 1, 2

Critical Timing Considerations

• Initiate treatment immediately within 14 days of symptom onset for maximum benefit 3, 2
• The greatest spontaneous improvement and treatment benefit occur in the first 2 weeks 2, 4
• Some benefit has been reported up to 6 weeks following onset, but efficacy diminishes significantly after 2 weeks 2
• One study showed 93.1% of patients who improved began showing hearing recovery within 14 days of starting treatment 4

Evidence Quality and Strength

The American Academy of Otolaryngology-Head and Neck Surgery guidelines provide the strongest evidence base for this dosing recommendation 3, 1, 2. The 2012 and 2019 AAO-HNS guidelines consistently recommend this regimen across multiple publications 3.

A critical pitfall to avoid is underdosing: The standard methylprednisolone dose pack provides inadequate dosing compared to the recommended 540 mg total prednisone dose over 14 days for a 60 kg adult 1. Ensure the full 1 mg/kg/day is prescribed 1, 2.

Treatment Response and Follow-up

• Obtain audiograms before treatment, at completion of treatment, and at delayed intervals 2
• 80.4% of patients who improve reach complete recovery or end of change within 1 month after treatment 4
• 92.2% of patients complete their hearing improvement within 2 months after treatment 4
• Continue follow-up for at least 2 months in patients showing incomplete or delayed improvement 4

Alternative and Salvage Options

Intratympanic Steroids

• For patients who cannot tolerate systemic steroids (e.g., diabetics), intratympanic dexamethasone (24 mg/mL, 16 mg/mL, or 10 mg/mL) or methylprednisolone (40 mg/mL or 30 mg/mL) is an alternative 3, 1, 2
• One RCT showed equivalent efficacy between oral and intratympanic steroids when administered within 14 days of onset, with >75% of patients showing hearing improvement in both groups 3
• Intratympanic steroids have mainly local side effects (transient pain, brief caloric vertigo) rather than systemic effects 3, 1

Combination Therapy

• Some evidence suggests combining oral and intratympanic steroids may benefit patients with profound hearing loss, though results are inconsistent 3
• One study showed partial or complete recovery in 14 of 16 patients treated with high-dose prednisone taper plus intratympanic steroids 3

Safety Profile and Monitoring

Common Adverse Events (Short Course)

• Hyperglycemia and weight gain are the most frequent adverse events 3, 1
• Sleep disturbances and appetite changes occur in approximately 88% of patients on oral steroids 3
• Most serious side effects occur with chronic use; short 10-14 day courses have acceptable safety profiles 3, 2

High-Risk Populations

• Monitor glucose closely in diabetic or at-risk patients 1, 2
• Patients with pre-existing bone or joint problems (systemic lupus erythematosus, rheumatoid arthritis) have higher risk of osteonecrosis and fractures 3, 1

Late Presentation Considerations

For patients presenting beyond 14 days but within 90 days of symptom onset:

• Treatment can still be effective, with one study showing 47% of late presenters (7-90 days) achieving objective improvement using Wilson's criteria 5
• Hearing gains ranged from 10-23 dB in responders 5
• No benefit was seen beyond 90 days from symptom onset 5
• The average patient presents 55 days after symptom onset, emphasizing the need for urgent referral 5

Adjunctive Hyperbaric Oxygen Therapy

• May be offered within 1 month of diagnosis in combination with steroids for resistant cases 1
• More effective when administered within the first 2-4 weeks of symptom onset 3, 1
• Patients with moderate to severe hearing loss (≥60 dB) benefit more than those with mild loss 3, 1
• Standard protocol: 100% oxygen at >1 atmosphere absolute, typically 10-20 sessions of 30-90 minutes each 1