In this episode of BackTable ENT, Dr. Shah and Dr. Agan interview Dr. Sujana Chandrasekhar, a private practice neurotologist, about diagnosis and treatment of patients with sudden sensorineural hearing loss (SSNHL).

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SHOW NOTES

First, Dr. Chandrasekhar explains the formal definition of sudden hearing loss, which is a loss of 30 dB over 3 consecutive frequencies over 72 hours, and notes that it is usually unilateral. She explains that the time from hearing loss presentation to ENT referral is usually delayed, as many patients attribute their hearing loss to a cold, the flu, or allergies. Frequently, they are also told over phone to take nasal sprays or prescribed amoxicillin. However, severe / profound hearing loss with or without tinnitus and vertigo necessitates immediate ENT consultation. Upon initial presentation, she usually gets a thorough health history, review of systems, and medication list from the patient. Common causes of SSNHL include: pregnancy and other thrombotic states, stroke, injected or intravenous drugs, high dose aspirin, PDE-5 inhibitors, and COVID-19 infection. She also describes how she uses the physical exam to distinguish between conductive and sensorineural hearing loss. First, she checks the outer ear and visualizes the tympanic membrane to look for external pathologies. Then, she utilizes the Weber and Rinne tests on every patient.

Next, she explains her further workup for patients determined to have SSNHL. She emphasizes the need for retrocochlear examination to check for vestibular schwannoma, which is best done through MRI. If patients have MRI contraindications, a CT temporal bone with contrast paired with auditory brainstem response (ABR) testing may be an alternative option. Dr. Chandrasekhar explains that a single ABR test has a low specificity for vestibular schwannomas, missing up to 15-20% diagnoses. She also notes that patients with audiograms showing low frequency hearing loss have a better prognosis than those with high frequency hearing loss. Additional symptoms to look for are otalgia, erythema, healing vesicles, facial palsy, and blebs on the tympanic membrane. These symptoms may point to an infectious cause, such as syphilis, Lyme disease, and herpes zoster. Additionally, children may have syndromic causes of SSNHL.

Dr. Chandrasekhar also explains her treatment options for SSNHL of different severities. For patients with mild and moderate hearing loss, she prescribes an oral prednisone taper, which patients can stop taking if hearing comes back. Intratympanic steroid injections with dexamethasone may be implicated if patients with moderate SSNHL do not respond to oral prednisone. She explains her steroid injection technique as well as tips for how to make patients more comfortable during and after the procedure. For patients with severe SSNHL, she emphasizes the importance of self-training to listen in the affected ear, starting to wear hearing aids early, and considering BAHA devices. Then, the doctors discuss the value of additional therapies for SSNHL, such as acupuncture, hyperbaric oxygen, papaverine, and B vitamins. Finally, she speaks about intratympanic stem cell injections to regrow inner hair cells as an exciting future treatment of sudden hearing loss.

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RESOURCES

She’s on Call Podcast:
https://podcasts.apple.com/us/podcast/shes-on-call-weekly-medical-show/id1582727930

WHO Free Hearing Test:
https://www.who.int/teams/noncommunicable-diseases/sensory-functions-disability-and-rehabilitation/hearwho