Causes of Sudden Sensorineural Hearing Loss (SSHL): Many Potential Etiologies, One Otologic Emergency

[Dr. Ashley Agan]
Before we get into treatment, your physical exam, in my experience it's pretty normal. You're looking in the ear and they're like, are you sure? Are you sure there's not something there? You're like, ah, it looks normal. Then with your audiogram too, is there any patterns on the audiogram that change what you're thinking about whether it be a low frequency loss versus mid-range versus high frequency?

[Dr. Sujana Chandrashekhar]
For your physical exam, I will just add it's a patient has any complaints of otalgia and that's really different. Very few people with sudden hearing loss will tell you that their ear hurts, but really have a low threshold for looking for erythema or healing vesicles either in the canal or on the pinna. Obviously you're going to look for facial palsy, like oh my god, if you're missing a facial palsy and these people, I'm going to be really sad. That's going to throw you in a different direction. Look for blebs on the TM, so there are viral exams that happen where you have these blebs on the TM that are also associated with sudden hearing loss.

Your treatment may end up being the same for the sensorineural component of the hearing loss, but you may actually puncture the lateral surface of the bleb under a microscope and then put some boric acid powder on there to resolve that portion of it. I shockingly saw a patient who came after being admitted to a university hospital and being seen by staff there and residents there with a roaring herpes zoster oticus and I'm like, "What? Somehow that was missed." I don't think anyone is dumb. I think what happens is you get sidetracked by where you think you're going, and you don't step back and see where you are. I think that's really important in life and I think that's really important in medicine.

For your physical exam, I think those things are very important. We talked initially about conductive hearing losses and if you see fluid in the ear, you really have to be cognizant of that. A tympanogram, which we didn't mention, may help you with that, but you should be able to be what at Pittsburgh they used to call a validated otoscopist where you got it right over 90% of the time if you felt there was or was not fluid in the middle year, when the patient went to the OR was there fluid or not? I've never been validated at Pittsburgh.

[Dr. Ashley Agan]
90% is high.

[Dr. Sujana Chandrashekhar]
It's really high, right? I'm always playing that trick with myself to see what I see and what I don't see. I think that's really crucial for your own particular CME and assessments of your own.

[Dr. Ashley Agan]
Then about patterns on the audiogram. If you have a patient that-- it's predominantly a low-frequency loss, are you thinking that this could be Meniere's or cochlear hydrops and maybe their first episode versus if it's mid-range or high frequency and what your thoughts are with looking at those patterns.

[Dr. Sujana Chandrashekhar]
I think that's really important. We talked about pure tones, we talked about proper masking to get proper thresholds, we talked about word discrimination. Certainly, we can talk about tympanograms to help you validate yourself, but the shape of the audiogram is really important. Low frequency also called up-sloping audiograms, first, they tend to recover almost if you do whatever you do. Go tell the patient to stand on their head for a week, give them some steroids, give them some diuretics, tell them to stop eating salty foods whatever, they tend to recover. If they don't recover, that's really quite meaningful to me because these tend to recover.

The sloping or down-sloping or high-frequency hearing losses tend not to recover. I possibly am at least mentally more aggressive with those patients in terms of treatment, I don't know if I'm actually more aggressive. I think I'm pretty aggressive with treating sudden hearing loss. I'm very Pollyanna. I very much believe that I can help recover hearing loss. I do discuss that particular implicit bias in myself with the patients because it's very important that they know where their doctor is starting. The high frequencies tend not to recover. I'm pretty aggressive about those. The pan-tonal which is all frequencies can be mild, moderate, severe, or profound.

In those, the low frequencies have a tendency to recover faster and possibly better than the higher frequency. The low and mids tend to recover, but the highs can recover doesn't mean the highs can't recover, it means you just have to be cognizant that they can take their own sweet time a little bit. In the pan-tonal you're really looking at the severity across frequencies. Nora Penido, who is at the Universidade Federal de São Paulo in Brazil in Sao Paulo, she published looking a year later at her patients who presented with sudden hearing loss and 30% ultimately showed as Meniere's or cochlear hydrops so you really do have to follow these patients over time.

In a society with less mobility, it's easier to follow patients over time. Frankly, in private practice, it's easier to follow patients over time than it is in a more mobile society, a clinic practice, or somewhere where access to healthcare comes and goes. I think you really have to think about Meniere's as a potential cause that can only be determined sometime later in these patients and you do have to keep following them.