Hearing Loss — Sudden Onset

A patient calls, to say that yesterday they seemed to suddenly lose hearing in the Left Ear.  Today, they still can hardly hear from it.

FIRST โ€“ I ask if at the same time theyโ€™ve also have new vertigo (room spinning), slurred speech, and/or trouble swallowing.  A bad headache along with it would be worst.

  • If so, it could be a stroke, I tell them to go to an E.R.
  • If everything had begun within the last few hours, Iโ€™d have them call an ambulance to rush to the E.R. of a hospital with a stroke center (see Stroke)

But they say โ€œNo,โ€ nothing like that, just hearing loss.

NEXT — I tell them to Hum (โ€œHummโ€ฆโ€), and I ask, in which ear do they hear it best?

If they say, โ€œthe Leftโ€ (perhaps to their surprise), I have them make an appointment with me.

BUT if they say, โ€œthe Rightโ€ (the other side, as they expected), I prescribe steroid pills (e.g. prednisone) over the phone, and arrange an urgent appointment with an Ear-Nose-Throat (ENT) specialist.

Whatโ€™s Going On Here ???

The main purpose in presenting this topic is to alert readers to a condition for which rapid treatment may significantly preserve hearing, but one for which treatment is often delayed merely because many clinicians are unaware of it.ย  Itโ€™s called idiopathic Sudden-onset Sensorineural Hearing Loss (SSNHL); the latter is a standard medical abbreviation for it (try Google if you want).ย  โ€œIdiopathicโ€ means that we donโ€™t know why it happens.

โ€œSensorineuralโ€ means the hearing loss is caused by nerve involvementย  There are three parts to the ear: the external ear, middle ear, and inner ear (see Diagram โ€“ The Ear).ย  Hearing loss due to wax build-up in the external ear, or otitis media (common ear infection) in the middle ear, is called โ€œconductiveโ€ loss (conduction of sound waves, nothing to do with the nerve).ย  SSNHL involves the inner ear.

The reason SSNHL is so important is that corticosteroid treatment might prevent permanent hearing loss.ย  But it has to be given within 10-14 days, and the sooner the better, ideally within the first 72 hours.ย  Unfortunately, many patients donโ€™t realize this, so they seek care late, & wind up left with permanent hearing loss.ย  More unfortunately, clinicians often donโ€™t know about this either, so they schedule a far-off appointment.

How do we tell if itโ€™s SSNHL or conductive hearing loss, which are completely different?ย  There are tests that clinicians do with high-pitched tuning forks, but an easy way is to hum (โ€œHmmmโ€) and see which ear you hear it best.ย  If you hear it best in the bad ear, itโ€™s conductive hearing loss.ย  Hearing it best in the good ear is sensorineural loss in the other.

Other causes of sudden hearing loss that are not idiopathic, i.e. they have an explanation, include:

**  Recent Trauma: either physical (to the ear), very loud noise, or pressure (e.g. diving)

**ย  Stroke:ย  we worry about this if there are other symptoms like double vision, slurred speech, new difficulty swallowing, sudden bad headache, vertigo

**ย  Meniereโ€™s Disease:ย  if there were prior episodes of hearing loss that got better, recurred, got better again, etc. At the time of the very first episode, nobody would ever consider this; diagnosis would become clear with the recurrences.

**ย  External or Middle Ear infections (Otitis Externa or Media) bad enough to work their way to the inner ear.ย  Thereโ€™d be ear pain or pus from the ear.ย  Very rare.

**ย  Lyme Disease:ย  Transmitted by ticks in high-risk areas, usually April to September.ย  Hearing loss is a rare symptom; it would occur weeks-to-months after the tick bite.

**ย  Certain medications & toxins:ย  certain IV antibiotics, furosemide (a diuretic, aka โ€œwater pillโ€), certain cancer chemotherapy, very-high-dose aspirin, certain anti-malarial meds, rarely meds for impotence (Viagraยฎ, etc.), rarely cocaine, certain fumes (e.g. toluene, styrene). Would likely affect both ears.

**  severe eye pain along with hearing loss suggests a very rare condition: Coganโ€™s Syndrome

However, all of the above are most uncommon.ย  SSNHL is almost always idiopathic, so patients should contact their primary provider or find an urgent care as soon as possible.ย  The priority is to begin steroid treatment. They should see an ENT specialist within a few days or a week, to document the extent of hearing loss, and continue management of the condition.

Since many clinicians are unaware of SSNHL, and maybe still wonโ€™t believe you even if you show them this website, a more authoritative source (youโ€™ll have to maneuver around the ads) is: https://emedicine.medscape.com/article/856313-guidelines.ย  Note under โ€œTreatmentโ€ it says โ€œCorticosteroids mayย  be offeredโ€ฆโ€ โ€“ insist on it. See discussion of steroids for the rare reasons not to take a short 10-day course.

By the way, why would someone with conductive hearing loss (not sensorineural) hear the Hum better in the affected ear? It’s because that ear isn’t distracted by outside noise (can’t hear it), so hears internal sound conduction better than the “good” ear. Try it yourself: stop up one ear with a finger, and “Hummm”. That’s conductive hearing loss, having to do with sound conduction through air, not with nerve sensation (sensorineural). If the nerve is affected, it can’t hear well no matter what.

This article only addresses Hearing Loss of sudden onset.  Eventually weโ€™ll add more, about hearing loss in general.  But SSNHL is common enough, thereโ€™s an effective strategy to diagnose and manage, and few clinicians have heard of it (pardon the pun).  So weโ€™ve begun with it.

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