The paper from ENT in Gloucester makes slightly depressing reading by advising that GPs should ignore the NICE recommendation to refer sudden hearing loss urgently to ENT because ENT departments can’t offer this service.1
I would strongly recommend reading the full NICE Guideline2 section 11, pages 137–174, in particular sections 11.2 and 11.3, which show the extensive evidence surveyed and debated by the committee. Evidence was scarce, especially for oral steroids, which made it difficult to draft a recommendation for routes of administration.
A key issue is that five studies showed clinical benefit from intratympanic (IT) steroids for patients refractory to oral or intravenous steroids.
When administration of both oral and IT steroids was compared with either route alone, the committee commented on the clinical benefit of dual administration for recovery, PTA scores, and speech discrimination scores. There was uncertainty about the optimal route and timing (first or second line) owing to the limited number and quality of the studies.
It noted that practice varies considerably between centres and expressed concern about any delay in offering treatment.
Oral steroids are certainly the current favoured first-line treatment, and GPs should not delay starting them. I believe it is advisable to then contact their preferred ENT department as soon as practicable to agree a plan of action for follow-up and possible IT therapy in the event of failure of oral steroids. A ‘non-urgent’ referral that might cause several weeks’ delay is not appropriate.
Notes
Competing interests
Ted Leverton was a member of the NICE Guideline Committee on Adult Hearing Loss mentioned above.
- © British Journal of General Practice 2020
