Skip to main content

Main menu

  • HOME
  • ONLINE FIRST
  • CURRENT ISSUE
  • ALL ISSUES
  • AUTHORS & REVIEWERS
  • SUBSCRIBE
  • BJGP LIFE
  • MORE
    • About BJGP
    • Conference
    • Advertising
    • eLetters
    • Alerts
    • Video
    • Audio
    • Librarian information
    • Resilience
    • COVID-19 Clinical Solutions
  • RCGP
    • BJGP for RCGP members
    • BJGP Open
    • RCGP eLearning
    • InnovAIT Journal
    • Jobs and careers

User menu

  • Subscriptions
  • Alerts
  • Log in

Search

  • Advanced search
British Journal of General Practice
Intended for Healthcare Professionals
  • RCGP
    • BJGP for RCGP members
    • BJGP Open
    • RCGP eLearning
    • InnovAIT Journal
    • Jobs and careers
  • Subscriptions
  • Alerts
  • Log in
  • Follow bjgp on Twitter
  • Visit bjgp on Facebook
  • Blog
  • Listen to BJGP podcast
  • Subscribe BJGP on YouTube
British Journal of General Practice
Intended for Healthcare Professionals

Advanced Search

  • HOME
  • ONLINE FIRST
  • CURRENT ISSUE
  • ALL ISSUES
  • AUTHORS & REVIEWERS
  • SUBSCRIBE
  • BJGP LIFE
  • MORE
    • About BJGP
    • Conference
    • Advertising
    • eLetters
    • Alerts
    • Video
    • Audio
    • Librarian information
    • Resilience
    • COVID-19 Clinical Solutions
Clinical Intelligence

Sudden sensorineural hearing loss: early diagnosis improves outcome

Simon KW Lloyd
British Journal of General Practice 2013; 63 (613): e592-e594. DOI: https://doi.org/10.3399/bjgp13X670877
Simon KW Lloyd
University Department of Otolaryngology Head and Neck Surgery, Manchester Royal Infirmary and honorary clinical senior lecturer, Manchester Academic Health Science Centre, University of Manchester.
Roles: Consultant otolaryngologist and skull base surgeon
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Data
  • Info
  • eLetters
  • PDF
Loading

INTRODUCTION

Sudden sensorineural hearing loss (SSNHL) is one of the most under recognised medical emergencies. Unilateral loss of hearing does not produce the same immediate concerns as unilateral loss of vision and the differential includes very common and benign conditions such as wax obstruction and otitis media with effusion. These two factors often conspire to delay the patient’s initial consultation and subsequent referral to the ear, nose, and throat (ENT) specialist. This is unfortunate as there is now evidence that early action significantly improves the chances of obtaining some recovery in hearing thresholds.

DEFINITION

There is no universal definition of SSNHL but based on the patient’s pure tone audiogram, it is often defined as an increase in pure tone threshold of greater than 30 decibels (dB) in at least three adjacent frequencies occurring within 72 hours. Its peak incidence is between 50 and 70 years of age although it can occur at any age. Figure 1 shows a typical audiogram of someone with a sudden unilateral sensorineural hearing loss.

Figure 1.
  • Download figure
  • Open in new tab
  • Download powerpoint
Figure 1.

A typical pure tone audiogram of a patient with a sudden unilateral sensorineural hearing loss. For each frequency of sound the tester reduces the sound intensity of the tone to a level at which the patient can only just hear it. This is the hearing threshold. The overall hearing threshold is marked as a red circle for the right and a blue cross for the left ear. In this case, there is no measurable hearing threshold at any frequency in the left ear but normal thresholds in the right ear. The pattern is variable however.

DEMOGRAPHICS AND AETIOLOGY

SSNHL is uncommon with around 20 people in every 100 000 being affected every year. The cause is not known in around 70% of cases.1 In these idiopathic cases the assumption is that there is either a viral or a vascular aetiology. Table 1 shows the more common pathologies that make up the 30% of cases that have an identifiable underlying cause for their SSNHL.

View this table:
  • View inline
  • View popup
Table 1.

Identifiable causes of sudden sensorineural hearing loss

The hearing loss may be associated with tinnitus, vertigo, and aural fullness. Other otological symptoms are rare.

A number of negative prognostic factors have been suggested including advanced age, the presence of vertigo, audiogram shape, and a family history.2 A recent review of the literature undertaken by Lin et al also suggests that there is greater risk of SSNHL in patients with risk factors for cardiovascular disease.3

INVESTIGATION

Certain investigations for specific causes of SSNHL should be undertaken even though they only infrequently identify any underlying pathology. The most important investigation is a magnetic resonance scan of the internal auditory meati to exclude a vestibular schwannoma. Serological investigations are of limited use although rare treatable infections such as syphilis and toxoplasmosis should be excluded.

TREATMENT

There are a number of different treatments that have been used in sudden sensorineural hearing loss. This includes oral or intravenous steroids, antiviral agents, vasodilating agents such as carbogen gas inhalation (this is a mixture of 95% oxygen and 5% carbon dioxide), and diuretics. There is no evidence that any of these have any material effect on hearing.

Recently, however, there has been a great deal of interest in the use of intratympanic (IT) injection of steroids through the tympanic membrane. This has been shown to deliver up to a 250 times greater dose of steroid to the inner ear than oral steroids, and is not associated with the potential adverse effects of systemic steroids; although some clinicians use this technique in conjunction with systemic steroids. There are a large number of papers investigating the influence of IT steroids for the management of SSNHL.4 However, many of the studies are flawed, not least because up to 60% of SSNHL can make some degree of spontaneous recovery and large scale studies are required to obtain useful results in what is a fairly rare condition.

A meta-analysis of the literature regarding the use of IT steroid in SSNHL showed that in general, between 50 and 75% of patients show an improvement in hearing threshold of 10–15dB or more with IT steroid, compared to 0–50% in controls who in the main received oral steroids.4 The mean improvement in pure tone average in the IT steroid group ranged from 15–30dB compared to 0–15dB in controls. The mean benefit of IT steroid relative to controls was 13dB. Some evidence suggests that IT steroid therapy is more useful to salvage hearing following ineffective oral steroid therapy than if it had been used as a primary treatment.4,5 Various types of steroids have been used but there is no evidence that one is better than another. The key is to treat early. The earlier the treatment is commenced the higher the chance of obtaining a significant improvement in hearing thresholds. By 2 weeks the chances of gaining any significant benefit are very low.

The injections are performed under local anaesthetic. The tympanic membrane is anaesthetised by using either 10% xylocaine spray, phenol, or a eutectic agent such as Ametop® (Smith & Nephew Healthcare) gel or EMLA® (AstraZeneca) cream. After the injection, the patient lies on their side for half an hour to allow diffusion of the steroid through the round window membrane.

The subsequent protocol varies from centre to centre but a course of daily injections over 3 days followed by an audiogram is common practice. If there is ongoing improvement in the audiogram then injections can be continued until the audiogram has stabilised or returned to normal.

OPTIMISING OUTCOMES

Many of the common differential diagnoses of sudden hearing loss are conductive in nature. Therefore tuning-fork tests such as Reine’s and Weber’s tests can be useful in differentiating a sudden sensorineural loss from a conductive loss and may be used to determine the urgency of the referral. If the sudden hearing loss is apparently sensorineural then an urgent referral to the local ENT department should be made so that early treatment can be started. The key to effective treatment is patient and doctor awareness of the need for early presentation and rapid onward referral.

Notes

Provenance

Freely submitted; not externally peer reviewed.

Discuss this article

Contribute and read comments about this article on the Discussion Forum: http://www.rcgp.org.uk/bjgp-discuss

  • Received September 14, 2012.
  • Accepted October 10, 2012.
  • © British Journal of General Practice 2013

REFERENCES

  1. 1.↵
    1. Chau JK,
    2. Lin JR,
    3. Atashband S,
    4. et al.
    (2010) Systematic review of the evidence for the etiology of adult sudden sensorineural hearing loss. Laryngoscope 120(5):1011–1121.
    OpenUrlCrossRefPubMed
  2. 2.↵
    1. Byl FM Jr.
    (1984) Sudden hearing loss: eight years experience and suggested prognostic table. Laryngoscope 94(5):647–661.
    OpenUrlPubMed
  3. 3.↵
    1. Lin RJ,
    2. Krall R,
    3. Westerberg BD,
    4. et al.
    (2012) Systematic review and meta-analysis of the risk factors for sudden sensorineural hearing loss in adults. Laryngoscope 122(3):624–635.
    OpenUrlCrossRefPubMed
  4. 4.↵
    1. Spear SA,
    2. Schwartz SR
    (2011) Intratympanic steroids for sudden sensorineural hearing loss: a systematic review. Otolaryngol Head and Neck Surg 145(4):534–543.
    OpenUrl
  5. 5.↵
    1. Garavello W,
    2. Galluzzi F,
    3. Gaini RM,
    4. Zanetti D
    (2012) Intratympanic steroid treatment for sudden deafness: a meta-analysis of randomized controlled trials. Otol Neurotol 33(5):724–729.
    OpenUrlPubMed
Back to top
Previous ArticleNext Article

In this issue

British Journal of General Practice: 63 (613)
British Journal of General Practice
Vol. 63, Issue 613
August 2013
  • Table of Contents
  • Index by author
Download PDF
Download PowerPoint
Article Alerts
Or,
sign in or create an account with your email address
Email Article

Thank you for recommending British Journal of General Practice.

NOTE: We only request your email address so that the person to whom you are recommending the page knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Sudden sensorineural hearing loss: early diagnosis improves outcome
(Your Name) has forwarded a page to you from British Journal of General Practice
(Your Name) thought you would like to see this page from British Journal of General Practice.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
Sudden sensorineural hearing loss: early diagnosis improves outcome
Simon KW Lloyd
British Journal of General Practice 2013; 63 (613): e592-e594. DOI: 10.3399/bjgp13X670877

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero

Share
Sudden sensorineural hearing loss: early diagnosis improves outcome
Simon KW Lloyd
British Journal of General Practice 2013; 63 (613): e592-e594. DOI: 10.3399/bjgp13X670877
del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One
  • Mendeley logo Mendeley

Jump to section

  • Top
  • Article
    • INTRODUCTION
    • DEFINITION
    • DEMOGRAPHICS AND AETIOLOGY
    • INVESTIGATION
    • TREATMENT
    • OPTIMISING OUTCOMES
    • Notes
    • REFERENCES
  • Figures & Data
  • Info
  • eLetters
  • PDF

More in this TOC Section

  • How to manage low testosterone level in men: a guide for primary care
  • Hyperparathyroidism (primary) NICE guideline: diagnosis, assessment, and initial management
  • The atypical presentation of COVID-19 as gastrointestinal disease: key points for primary care
Show more Clinical Intelligence

Related Articles

Cited By...

Intended for Healthcare Professionals

BJGP Life

BJGP Open

 

@BJGPjournal's Likes on Twitter

 
 

British Journal of General Practice

NAVIGATE

  • Home
  • Current Issue
  • All Issues
  • Online First
  • Authors & reviewers

RCGP

  • BJGP for RCGP members
  • BJGP Open
  • RCGP eLearning
  • InnovAiT Journal
  • Jobs and careers

MY ACCOUNT

  • RCGP members' login
  • Subscriber login
  • Activate subscription
  • Terms and conditions

NEWS AND UPDATES

  • About BJGP
  • Alerts
  • RSS feeds
  • Facebook
  • Twitter

AUTHORS & REVIEWERS

  • Submit an article
  • Writing for BJGP: research
  • Writing for BJGP: other sections
  • BJGP editorial process & policies
  • BJGP ethical guidelines
  • Peer review for BJGP

CUSTOMER SERVICES

  • Advertising
  • Contact subscription agent
  • Copyright
  • Librarian information

CONTRIBUTE

  • BJGP Life
  • eLetters
  • Feedback

CONTACT US

BJGP Journal Office
RCGP
30 Euston Square
London NW1 2FB
Tel: +44 (0)20 3188 7400
Email: journal@rcgp.org.uk

British Journal of General Practice is an editorially-independent publication of the Royal College of General Practitioners
© 2023 British Journal of General Practice

Print ISSN: 0960-1643
Online ISSN: 1478-5242