Sudden Sensorineural Hearing Loss (AAO-HNSF 2019)

Algorithm Steps

1. ▶

   Start

   Sudden Hearing Loss Presentation

   Patient reports acute onset hearing loss. Definition: ≥30dB hearing loss in ≥3 consecutive frequencies occurring within ≤72 hours.

   1. ●

      Action

      Distinguish SNHL from Conductive

      KAS 1 (Strong): Perform Weber/Rinne tests. SNHL: Weber lateralizes to GOOD ear, Rinne positive bilaterally. Conductive: Weber to affected ear, Rinne negative affected side.

      • 512 Hz tuning fork preferred
      • Examine ear canal and TM for obstruction/perforation
      • Confirm with audiometry ASAP
      1. ●

         Action

         Urgent Audiometry

         Obtain audiogram within 14 days of symptom onset (ideally immediately). Documents degree and configuration of hearing loss. Establishes baseline for monitoring.

         1. ◆

            Decision

            Identifiable Cause?

            History and exam to exclude: Ototoxic drugs, Meniere's disease, acoustic neuroma, stroke, trauma, infection (otitis, meningitis), autoimmune disease.

            1. ●

               Action

               Treat Underlying Cause

               If identifiable cause found: treat accordingly. This algorithm focuses on IDIOPATHIC SSNHL. Stroke protocol if neurological signs.

            2. ◆

               Decision

               MRI Indicated?

               Consider MRI with gadolinium to evaluate for retrocochlear pathology (acoustic neuroma). Especially if: asymmetric hearing, unilateral tinnitus, focal neurological signs.

               1. ●

                  Action

                  Initial Steroid Therapy

                  Offer oral corticosteroids as initial therapy (Option, may offer). Typical: Prednisone 1mg/kg/day (max 60mg) x 10-14 days with taper. OR Dexamethasone 10mg x 7 days. Start within 2 weeks of onset.

                  • Benefit decreases with delay
                  • Discuss risks: hyperglycemia, insomnia, mood changes
                  • No benefit from antivirals (strong against)
                  1. ◆

                     Decision

                     Response to Initial Therapy?

                     Reassess hearing at 2-6 weeks. Complete recovery? Partial recovery? No recovery?

                     1. ✓

                        Outcome

                        Hearing Recovered

                        If hearing recovers fully, routine follow-up with audiometry. Counsel on hearing protection. No specific restrictions.

                     2. ●

                        Action

                        Salvage: Intratympanic Steroids

                        KAS: Offer intratympanic steroids 2-6 weeks after symptom onset for incomplete recovery. Dexamethasone 10-24mg/mL or methylprednisolone 40mg/mL. 3-4 injections over 2 weeks.

                        1. ✓

                           Outcome

                           Residual Hearing Loss/Tinnitus

                           KAS 13 (Strong): Counsel on audiologic rehabilitation: hearing aids, CROS/BiCROS, cochlear implant evaluation if profound. Tinnitus management. Support groups.

                     3. ●

                        Action

                        Consider HBOT

                        Hyperbaric oxygen therapy within 2 weeks of onset (in combination with steroids) OR as salvage within 1 month. 10-20 sessions at 2.0-2.5 ATA for 90 minutes.

                     4. ●

                        Action

                        Education & Counseling

                        KAS 7 (Strong): Educate on natural history (1/3 recover, 1/3 partial, 1/3 permanent). Discuss treatment limitations. Address tinnitus if present.

            3. ⚠

               Warning

               ⚠️ DO NOT Order Routinely

               KAS: Do NOT order routine CT head (strong against). Do NOT order routine labs (strong against). Do NOT prescribe antivirals, thrombolytics, vasodilators (strong against).