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Evaluating Sudden Sensorineural Hearing Loss (SSHL) Symptoms
Julia Casazza • Oct 9, 2023 • 38 hits
Sudden sensorineural hearing loss (SSHL) is a frightening experience for affected patients. SSHL represents a true otologic emergency, and therefore, timely workup and treatment may make the difference in helping patients recover their hearing. Dr. Sujana Chandrashekar, otologist in New York City and author of the 2019 American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) guidelines on the condition, recently joined the BackTable ENT podcast to discuss SSHL. While many causes can account for SSHL, most patients present similarly, and knowledge of common etiologies can help direct patients to the most appropriate care.
This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable ENT Brief
• Sudden sensorineural hearing loss (SSHL) is defined as a hearing loss of 30 dB or more across three consecutive audiometric frequencies within 72 hours.
• SSHL is most commonly unilateral and rarely presents bilaterally.
• SSHL is an otologic emergency and mandates immediate referral to an otolaryngologist.
• Weber and Rinne tests are low-cost tools to determine whether a hearing loss is conductive, sensorineural, or mixed.
• Medical conditions associated with SSHL include pro-thrombotic states such as pregnancy and malignancy.
• Medications associated with SSHL include aminoglycoside antibiotics, platinum-based chemotherapeutics, loop diuretics, anti-malarials, and phosphodiesterase-5 inhibitors.
Table of Contents
(1) Initial Presentation of Sudden Sensorineural Hearing Loss (SSHL)
(2) Defining Sudden Sensorineural Hearing Loss
(3) Conditions & Medications Associated with Sudden Sensorineural Hearing Loss
Initial Presentation of Sudden Sensorineural Hearing Loss (SSHL)
Patients with sudden sensorineural hearing loss classically present with acute-onset unilateral hearing loss. As conductive etiologies can also produce acute-onset hearing loss, the first step in evaluating a SSHL patient is determining the nature of the loss. Dr. Chandrashekar recommends taking a look in the ear to assess whether obvious causes of hearing loss, such as cerumen or tympanic membrane perforations, are present. If otoscopy is unrevealing, Weber and Rinne tests can discern the nature of the loss. Extent of hearing loss will be evident on audiometry.
[Dr. Sujana Chandrashekhar]
The patient doesn't know whether they have sensorineural loss or conductive loss or mixed loss. They don't. They just know they can't hear. When you start with sudden hearing loss, a really nice way, I think, to think about it is to follow the patient's path as they access healthcare. They wake up, or they're in the middle of a conversation, and they suddenly can't hear, generally out of one ear. It's extraordinarily rare to have bilateral sudden sensorineural hearing loss. That throws you out of this particular conversation into some other conversations. They suddenly can't hear, and let's say they access healthcare in a timely fashion.
The first thing you want to do is you want to determine, as the healthcare provider, whether this is a conductive loss or a sensorineural loss primarily. That can be done very simply. One, you should examine the patient. You see a big giant wad of wax and tissue paper and cotton blocking the ear canal, and you remove it and you've restored hearing and all is good in the world. Take out your handy dandy 512 Hz tuning fork, that's the only one you really need. You vibrate it on your elbow or on your knee, and not on the edge of the table where it makes a horrible shrieking sound, but really where you're having a nice vibration at Middle C.
512 Hz is basically middle C, and you want to put the trunk part of it on their mastoid bone, and you say, "This is sound number 1." Then you put the parallel portion of it vibrating next to the ear canal. In a parallel plane and not a perpendicular plane to the opening of the ear canal and you say, "This is sound number 2." You say, "Which one is louder? Number 1 or number 2?"
If number 2 is louder than number 1, and they can now hear, they're probably done. If number 2 is louder than number 1 and they still can't hear, they're not done. If number 1 is louder than number 2, look again and make sure you haven't missed a perforation, some fluid in the ear canal, some other reason for the conductive hearing loss. Now, they may have something that you can't really see like otosclerosis or malleus fixation, but an exam and a tuning fork is a very nice way to start this process.
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Defining Sudden Sensorineural Hearing Loss
The AAO-HNS defines SSNHL as a 30 dB hearing loss, occurring over three consecutive audiometric frequencies and within a 72 hour time frame. In practice, Dr. Chandrashekar offers treatment to patients with losses less dramatic than those detailed in the AAO-HNS guidelines. Hearing loss might be accompanied by debilitating vestibular symptoms that cloud the diagnostic waters. For this reason – and the fact that odds of recovery are dependent on time to treatment – patients with sudden hearing loss should see an otolaryngologist immediately.
[Dr. Sujana Chandrashekhar]
The textbook definition is 30 DB over 3 consecutive frequencies in 72 hours. When you're doing studies on sudden hearing loss, you really are confined to that as the entry diagnosis criteria. In real life, and really in my experience and I see, sometimes my husband says that I don't know anything about sudden hearing loss and I'm like, "I know one or two other things, but yes you're right, not that many other things." I see a ton of sudden hearing loss. I talk about sudden hearing loss a lot. I rarely see somebody who tells me, "Oh yes. Saturday morning, I was a little bad and Saturday afternoon I was a little worse, and Sunday da, da, da." I really hear of a single timeframe.
Then they may feel worse over the course because it's quite horrible to suddenly not be able to hear out of one ear, you suddenly start getting-- Even if you don't have vertigo, you feel very off balance, your external sounds, noisy environments are very off-putting, especially in the acute phase. It's very frightening. If you think about, if you woke up suddenly and you couldn't see out of one eye, even if it was just blurry and not out, you'd be like, "Oh my God, what's going to happen to me?"
Conditions & Medications Associated with Sudden Sensorineural Hearing Loss
While the pathophysiology of SSHL remains incompletely understood, there are conditions and medications that confer a higher risk of developing the condition. Prothrombotic states, including pregnancy and cancer, increase the risk of SSHL. Ototoxic medications can also trigger rapid-onset hearing loss. These medications include but are not limited to loop diuretics, aminoglycoside antibiotics, platinum-based chemotherapeutics, and anti-malarial drugs. Patients who experience sudden hearing loss shortly after starting any of these medications should start an alternative medication where appropriate. Intriguingly, recent research shows that patients on phosphodiesterase-5 inhibitors (including Viagra and Cialis) suffer from SSHL at a higher rate than the general population.
[Dr. Ashley Agan]
Well. In knowing all of these risk factors then, when you're talking to patients and getting that history are you digging for all of these details, or screening for them, or asking you about them? I can't say that I'm always asking about all these things because it doesn't change the treatment that I know of, but maybe I should be asking.
[Dr. Sujana Chandrashekhar]
The answer to that is most of the time ask most of the questions. Part of it is, the patient has already given you a lot of that information in their review of systems and in their medication list, so that actually just requires a quick perusal of those two pages in your EMR. It is important because, for example, anti-malarial agents are one of the toxins that cause sudden otovestibular symptoms.
Somebody who develops sudden hearing loss after their first dose of an anti-malarial agent should not actually take their second dose. That hearing loss is often reversible either with treatment or without, and the treatment may simply be not exposing to that agent again. Same thing with the anti-impotence drugs, they may be able to use something else, particularly, if their hearing loss is not recovered. There are other things that can be done to help that issue while not putting their hearing at risk or their remaining hearing at risk. You're right, Ashley, the treatment whether the cause is known, or surmised, or unknown is basically the same.
Dr. Sujana Chandrasekhar
Dr. Sujana Chandrasekhar is an otologist / neurotologist practicing at ENT and Allergy Associates in New York City.
Dr. Ashley Agan
Dr. Ashley Agan is a practicing ENT and assistant professor at UT Southwestern Medical Center in Dallas, TX.
Dr. Gopi Shah
Dr. Gopi Shah is a practicing ENT at UT Southwestern Medical Center in Dallas, TX.
Cite This Podcast
BackTable, LLC (Producer). (2023, January 31). Ep. 87 – Sudden Sensorineural Hearing Loss [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.