Management of Sensorineural Hearing Loss
Initial Evaluation: Distinguish SSNHL from Other Causes
Immediately perform Weber and Rinne tuning fork tests to differentiate sensorineural from conductive hearing loss, as this fundamentally determines the entire management pathway. 1, 2
- Obtain formal audiometry within 24-48 hours (ideally within 14 days maximum) to confirm sensorineural hearing loss, defined as ≥30 dB loss at 3 consecutive frequencies occurring within 72 hours. 1, 2
- Assess specifically for red flags requiring alternative workup: bilateral hearing loss, recurrent episodes, fluctuating hearing, focal neurologic symptoms (weakness, dysarthria, ataxia, diplopia), severe headache, or concurrent vestibular symptoms. 1, 3, 2
- The combination of unilateral sensorineural hearing loss with unsteadiness is the classic presentation of vestibular schwannoma (94% of cases), which worsens prognosis for hearing recovery. 3
Immediate Treatment for Sudden Sensorineural Hearing Loss
Start oral prednisone 1 mg/kg/day (maximum 60 mg) as a single daily dose immediately for 7-14 days followed by taper—every day of delay worsens prognosis. 1, 2
- Treatment initiated within 2 weeks shows benefit, but starting within 5 days demonstrates statistically significantly better outcomes than delayed treatment. 2, 4
- Do not wait for MRI results before initiating steroids if sudden hearing loss is confirmed on audiometry. 3
- Educate patients that 32-65% may recover spontaneously, but treatment improves outcomes, and the underlying cause remains unknown in 85-90% of cases. 1, 2
Workup for Retrocochlear Pathology
Order MRI of the brain with internal auditory canal sequences (with gadolinium) to evaluate for vestibular schwannoma and other retrocochlear pathology. 1, 3, 2
- If MRI is contraindicated, obtain CT or auditory brainstem response (ABR) testing as alternatives. 1, 5
- Do NOT order routine head CT scans—they are not useful for evaluating sudden sensorineural hearing loss. 1
- Do NOT obtain routine laboratory tests in idiopathic sudden sensorineural hearing loss, as they lack benefit. 1
Salvage Therapy for Incomplete Recovery
If hearing recovery is incomplete at 2-6 weeks after initial oral steroid treatment, offer intratympanic steroid perfusion: 4-6 injections of dexamethasone over 2 weeks. 1, 2, 5
- Intratympanic steroids can also be offered as primary therapy if oral steroids are contraindicated. 2, 5
- Hyperbaric oxygen therapy may be considered only when combined with steroid therapy, initiated within 2 weeks for initial treatment or within 1 month for salvage therapy, though cost and limited availability make it impractical in most settings. 1, 5
Treatments to AVOID
Do NOT routinely prescribe antivirals, thrombolytics, vasodilators, vasoactive substances, or antioxidants—there is insufficient evidence supporting their use. 1, 5
Follow-Up and Rehabilitation
Obtain audiometric evaluation at the conclusion of treatment and again within 6 months to document final hearing status. 1, 2
- The majority of recovery occurs within 1 month (90% of final hearing levels), with 98.3% reaching final levels by 3 months. 1
- Counsel all patients with residual hearing loss or persistent tinnitus about hearing aids, assistive listening devices, and audiologic rehabilitation—initiate these discussions early as temporary measures may provide immediate benefit and reduce anxiety. 1, 2
- Schedule at least annual audiometric monitoring for adults to assess hearing stability and amplification device function. 1
Prognostic Factors
Mid-frequency "flat" audiometric configuration shows the highest slight recovery rates compared to other patterns. 4
The presence of vertigo at onset significantly worsens prognosis for complete hearing recovery. 3, 6
Bilateral sudden sensorineural hearing loss has substantially worse outcomes (29% recovery in children, lower in adults) and should prompt evaluation for specific systemic causes including meningitis, autoimmune inner ear disease, Lyme disease, syphilis, ototoxic medications, or trauma. 1, 7