BackTable / ENT / Podcast / Transcript #87

Podcast Transcript: Sudden Sensorineural Hearing Loss

with Dr. Sujana Chandrasekhar

In this episode of BackTable ENT, Dr. Shah and Dr. Agan interview Dr. Sujana Chandrasekhar, a private practice neurotologist, about diagnosis and treatment of patients with sudden sensorineural hearing loss (SNHL). You can read the full transcript below and listen to this episode here on BackTable.com.

(1) Evaluating Sudden Sensorineural Hearing Loss

(2) Defining Sudden Sensorineural Hearing Loss

(3) Risk Factors for Sudden Sensorineural Hearing Loss

(4) The Workup for Sudden Sensorineural Hearing Loss

(5) Audiogram Findings in Sudden Sensorineural Hearing Loss

(6) Differential Diagnosis of Sudden Sensorineural Hearing Loss

(7) Treatment of Sudden Sensorineural Hearing Loss

(8) Intratympanic Steroids for Sudden Sensorineural Hearing Loss: Dr. Chandrashekar’s Approach

(9) Emerging Therapies for Sudden Sensorineural Hearing Loss

(10) Follow-up for Sudden Sensorineural Hearing Loss

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[Dr. Gopi Shah]
This week on The BackTable Podcast.

[Dr. Sujana Chandrashekhar]
Consider sudden hearing loss as an otologic emergency. Consider that the loss of a sense is frightening and can be rather devastating to the patient and their family. I think keeping the end in mind is really important on the first minute that you see the patient. Really talking to them about what you are looking at, what you're generally considering in the future is really important. I think being the hearing doctor is a really important part of who we are.

[Dr. Gopi Shah]
Hi, everybody. Welcome to The BackTable ENT Podcast. We're a podcast that focuses on all things otolaryngology, and we've got a really great show for you today. Thanks for stopping by. Now, a quick word from our sponsor. Cook Medical's Otolaryngology, Head and Neck Surgery clinical specialty strives to provide otolaryngologists with minimally invasive solutions to address unmet needs.

Areas of focus include head and neck, otology, and laryngology with products ranging from a full suite of interventional full endoscopy products and the Doppler Blood Flow Monitoring System to the Biodesign Otologic Repair Graft, and the Hercules 100 Transnasal Esophageal Balloon. For more information, visit cookmedical.com/otolaryngology. Now back to the show. My name is Gopi Shah. I'm a pediatric ENT, and I'm here today with my partner in crime, Dr. Ashley Agan.

[Dr. Ashley Agan]
Hey, everybody. Ashley Agan, general ENT, and we have an awesome guest on the show today. I'll introduce her now. Dr. Sujana Chandrashekhar. She's a neurotologist practicing at ENT and Allergy Associates in New York City. She has made many contributions to our field serving as President and Past Chair of the Board of Governors of the AAO-HNS and serving as Secretary/Treasurer of the American Otological Society, the AOS.

She's the President-elect of the AOS, Eastern Section VP of the Triological Society, and Consulting editor of Otolaryngologic Clinics of North America. She records a podcast per issue with the guest editors. She's also a host for her show She's On Call, which is a video show with 59 episodes all on YouTube, and also podcasts of each show. Dr. Chandrashekhar is here to talk to us today about sudden sensorineural hearing loss. Welcome to the show.

[Dr. Gopi Shah]
Welcome to the show.

[Dr. Sujana Chandrashekhar]
Thank you, Ashley and Gopi. It's really a pleasure to make it onto The BackTable ENT. Very exciting.

[Dr. Gopi Shah]
Sure. We're very excited to have you. Can you first tell us a little bit about yourself and your practice?

[Dr. Sujana Chandrashekhar]
Sure. As Ashley said, my practice is limited to Otology and Neurotology. I am in private practice with a heavily personal academic bent to my life. I just enjoy that. I began my career after fellowship in academic medicine, academic otolaryngology, in two institutions. Then since the end of 2004, I've been in private practice first just hanging my shingle on the upper east side of Manhattan and seeing if patients come, and they did, and then sharing some space with a couple of other people, and now as a partner in the largest single specialty otolaryngology group in the world, which sounds very amazing, ENT and Allergy Associates, and it's a lot of fun. Frankly, my practice allows me to provide the clinical care at the level that I want and also continue to do research and teach and publish and speak and meet engaging people like you guys.

[Dr. Gopi Shah]
That sounds like an amazing practice.

[Dr. Ashley Agan]
Can you tell us a little bit about, She's On Call? What's it about? Tell us about it.

[Dr. Sujana Chandrashekhar]
As the pandemic closures began, and people were really scared at COVID-19, nobody really understood, I was quite surprised how many people did not actually understand how to wash their hands or what six feet is from somebody. Marina Kurian is a general surgeon who does minimally invasive bariatric surgery and medical and surgical treatment of obesity. Marina and I have been friends since we were young. She and I separately appeared on a show by a guy named Sree Sreenivasan, who is the Walter Cronkite professor of journalism at Arizona State University now, previously at Stony Brook, previously at Columbia School of Journalism, and he had us on for the last half hour of his weekly New York Times Sunday read along to really talk about COVID-19 and answer viewer questions.

Then he suggested, he said, "You guys would be really good on a show." That took us a little bit to process. In that June of 2020, we started She's On Call and it's a video show. We did 59 episodes, 1 a week in the first year plus, and then 1 every 2 weeks, then we did our final 59th show December of 2021, where we talked about COVID-19 in the beginning, but then we really talked about various medical issues. They could range from pediatric cardiology, adult cardiology, orthopedics, infectious disease, psychiatry, dating and dating apps was our Valentine's show.

That was really interesting. School health, school nurses, medical school. I learned a lot on that show. We address a lot of topics that are near and dear to both of our hearts. Gun violence in America, other endemic issues that affect populations. I think we accomplished what we wanted to, which was to share complex medical information in a way that engages audiences ranging from a lay person to a professor whose specialty is that. We were able to break it down in ways that I thought were very interesting. We had real-time questions and answers, and it was really quite a lot of fun.

[Dr. Ashley Agan]
That's awesome. Let's get into our topic today, shall we? We're going to talk about sudden sensorineural hearing loss and so maybe we can just start with definitions and is it always sensorineural?

(1) Evaluating Sudden Sensorineural Hearing Loss

[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.

[Dr. Ashley Agan]
Yes, but unfortunately, most urgent cares or primary cares are not going to have a tuning fork.

[Dr. Sujana Chandrashekhar]
Yes, because it's $10. It's $10.

Frankly, it's $10. A poor man's Weber test is you ask the patient to say, "Mm, mm." If they have a conductive loss on one side, they will lateralize to that side, and you can check that by pushing on your tragus, close your ear canal on that side and say, "Mm, mm," and you will lateralize to your now 25 to 30 DB conductive loss ear.

That's a good Weber test, and frankly, if you're post-oping somebody in the recovery room and you left your tuning fork in the other building, it's actually a nice way to, for after ear surgery, just make sure that they're lateralizing correctly. If you don't have a tuning fork, then you just jump right to an audiogram, but it's very nice to do simple things that can help you determine the emergent nature or non-emergent nature of what you're dealing with.

[Dr. Ashley Agan]
It's good to have an idea to know what you're looking for, what the audiogram's probably going to look like or have a suspicion for it with your exam. How long does it usually take, or what's the time on average between when the patient initially notices it, to the time they actually see you or see one of your colleagues you think? I feel like we don't usually see them right away. It's not common even sometimes in the first 24 hours. Sometimes it's a couple days later.

[Dr. Sujana Chandrashekhar]
That is a big issue. Patients don't know when it's an emergency, and if they have an internist or a family physician, it may also be cold and flu season. It may also be allergy season. It may also be something where on the phone or even in the office or the urgent care, the patient is told, "Oh, take some pseudoephedrine, take some intranasal steroid spray, an antihistamine and wait." The delay in reaching an ENT provider can be 7 to 14 days, if we're lucky, and often over 3 weeks, by the time the patient navigates and realizes that their hearing has not recovered. Sometimes they're knee-jerk reaction given amoxicillin for something, I don't know what they're given it for, but they're given it.

I think one, there's a delay in the patient really realizing. This is true really for the mild to moderate hearing loss patients where they're like, "Oh, I'm a little congested." They don't have vertigo, they don't really have significant tinnitus with it. They don't have anything that's scaring them. They may actually delay care either by accessing care and minimizing their symptoms, or not accessing care because their symptoms are not great. The patients who have severe to profound hearing loss, particularly the ones who have tinnitus or vertigo with that hearing loss, do access care very quickly, and then any delay in care is from that initial healthcare entryway to the ENT.

In a closed system like Kaiser Permanente, Bob Cueva, who just stepped down as the head of Neurotology in the San Diego Kaiser, and Erica Woodson is now the head of Otology Neurotology there, he established a clinical care pathway within the system, where if a patient appears in the ER or primary care with this complaint, they are actually able to get into ENT within 24 hours. That's really a fantastic intervention to help patients get the care that they need.

[Dr. Gopi Shah]
We definitely have tried to set up sudden loss as one of those red flag emergency let's walk them in sooner patient visit types, but it can be tricky, like you said, if the patient doesn't recognize the urgency. A lot of times people chalk it up to allergies or maybe have a cold or the urgent care, whoever, they looked in their ear said, "Maybe it looks a little red, here's a Medrol Dosepak or amoxicillin."

[Dr. Sujana Chandrashekhar]
I'll tell you, in my practice, now we have online booking, and you really can see an otolaryngologist within 24 to 48 hours max. They can get you in to see the otologist in the practice the next day. Again, the patient has to know that there is an urgency to this, and they have to really say the words I suddenly can't hear. Because if they're calling in-- The telephone operators know, like you said, the red flags, I'm bleeding, I'm this, I'm that. They need to hear the correct words to trigger the correct pathway of an appointment.

[Dr. Ashley Agan]
Because I can't hear, or I have hearing loss. Is it sudden? "Oh, we got an appointment in three to six weeks with audiology and ENT." Our phone decision tree after you have hearing loss says, "Was it sudden or is it chronic?" That they will prompt to ask. Going back to definitions, what counts as sudden? Does it need to be overnight, like I woke up and boom it's out, or can it be like, "Oh, maybe over the last week it seems not as good"?

(2) Defining Sudden Sensorineural Hearing Loss

[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?"

These are frightening things for patients. Then unfortunately what happens is they get this weird stroke workup in the ER, which can sometimes also provide maybe a delay in care, or a road bump to care. Normally the definition is, as I said, in real life, we treat people with sudden hearing loss that is less than that degree of intensity and even fewer frequencies, and certainly we treat people with much worse hearing loss than that.

(3) Risk Factors for Sudden Sensorineural Hearing Loss

[Dr. Gopi Shah]
Are there certain risk factors for patients who might be that unlucky one that gets sudden hearing loss?

[Dr. Sujana Chandrashekhar]
The short answer is yes, and the longer answer to that is pregnancy and any other thrombotic state. Cancer is another one. There is some vague association with sudden hearing loss and stroke, although it is not a predictor of stroke. Certainly we have toxins that can be ingested or placed intravenously in the case of either chemotherapeutic agents or aminoglycoside antibiotics or even IV push of furosemide, can cause a sudden drop in hearing.

High dose aspirin that people may not even know that they are ingesting, for example, over-the-counter antacid preparations like Alka-Seltzer, have a lot of aspirin in them, and people may not be realizing what they're ingesting, so it's very important to ask about that. I wrote a paper and Jim Saunders wrote a paper and did a very nice lab study looking at PDE five inhibitors, six inhibitors, Viagra, Cialis, the impotence medications, and I apologize for that small brain issue of mine. Looking at that with sudden hearing loss and the universe of people who use these agents is large, but there seems to be a higher than expected incidence of sudden hearing loss in that subset of patients who get sudden hearing loss and are on these medications.

There is a timeline with it, and certainly in 2022, we can't not talk about COVID. There is an association with COVID infection and hearing loss, including sudden hearing loss and tinnitus and Tina Stankovic at Stanford has shown the inflammatory changes in the inner ear with COVID infection. There is much less data to support COVID vaccination and sudden hearing loss. We have the occasional patients who will say that this happened to them within one to seven days of having a vaccine, and it is part of the VAERS database, but when the database has been queried, we're not seeing more sudden hearing loss after vaccine than we would in the normal population, historically.

[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. Ashley Agan]
Before we get into treatment, any other questions that we need to be asking when we're taking that history?

[Dr. Sujana Chandrashekhar]
I think we're all doctors. When a symptom occurs you're going to look for, have you been traveling? Have you eaten something different? Have you done something different? I don't think there's anything. In particular, it's good to know, for example, if you're contemplating and we'll get into treatment in a second, but if you're contemplating an intratympanic injection of steroid it's good to know if they're on a blood thinner. If you're contemplating systemic steroids it's very important to know if they have diabetes, or high blood pressure, or some other issue for which there is a relative or in fact real contraindication to that kind of intervention. I think being a doctor is possibly your first step.

(4) The Workup for Sudden Sensorineural Hearing Loss

[Dr. Ashley Agan]
Then, in terms of patient presentation, how common is it to have vertigo and tinnitus? Is that 10% of your patients? Is it just the patients that have severe hearing loss, or a higher degree, or more frequencies involved? Who's that group?

[Dr. Sujana Chandrashekhar]
Tinnitus is extremely common in sudden hearing loss. Now, you started by saying, is it conductive or sensorineural? We have moved on to sudden sensorineural hearing loss, and 90% of sudden sensorineural hearing loss is idiopathic. I tell the patients that means the doctor is an idiot, and you have a pathology. I can try to help you figure it out, but as Ashley said, let's move along and see if we can recover your hearing, and then we'll do everything else. We didn't talk about vestibular schwannoma or retrocochlear pathology, but every single person at some point in their course, whether they recover or not from a sudden sensorineural hearing loss, should have a retrocochlear evaluation.

Because even if they recover there is a significant chance that they have a vestibular schwannoma. I would say engaging that dialogue to explain to them that even if I don't know the cause my chance of helping you when you don't present with vertigo or profound hearing loss, but you actually present with what used to be called the steroid-responsive zone, which is mild to moderately severe hearing loss in the mid-frequencies is really very high. Tinnitus is quite common. Vertigo is less common, but to me it indicates more inner ear damage. Vertigo is different than that dizziness disequilibrium that you feel with a moderate hearing loss. I am muddying the waters like nobody's business, right?

[Dr. Ashley Agan]
With vertigo, you're thinking the person who's got nystagmus, and they're throwing up, and they're just having almost a labyrinthitis, they're sick, it's a different picture than, "Oh, I'm a little woozy."

[Dr. Sujana Chandrashekhar]
Correct. They've been seen in the ER. They've had their stroke workup, they're staggering and they're ready to exit the world. That's how bad they feel.

[Dr. Ashley Agan]
Once you're seeing them in your office you mentioned you're going to get an audiogram, and you may talk to them about doing some other workup to evaluate for retrocochlear pathology. I assume the most common thing would be MRI, but maybe there's other options as well.

[Dr. Sujana Chandrashekhar]
Let's talk about the audiogram first. The audiogram should obviously have bone and air conduction. It should have masked bone because we're assuming that the other ear will be normal, or near normal, or wherever their affected ear was before this happened. You really want to look at word discrimination scores. That's something to really keep in mind because restoring aidable hearing by pure tones, that has very poor word discrimination may not be doing much of anything for the patient other than making the world toxically uncomfortable in that ear.

I think being cognizant of the entirety of the audiogram is really important. The correct retrocochlear workup is an MRI scan. It's still considered the gold standard for retrocochlear pathology. It is very loud to do an MR, and you will not do anything different by delaying that MRI until such time as you've been able to treat and hopefully recover the hearing. Even with the earmuffs that they put in the MRI machine, it's a pretty loud machine. It's pretty scary. I will tell patients, "Listen, let's do first things first. Here's your hearing loss. Here's your degree of hearing loss. Here's where your word recognition is. Let's treat, and I will sometime in the next month or so get an MRI scan on you."

Because I want to see if there's a tumor, or inflammation along the nerve, or multiple sclerosis, or any of the other things we're looking for, that are these outliers that can cause sudden hearing loss. There's no negative to delaying an MRI for these patients, but it is certainly something that you should discuss at the outset. Having said that, I have a colleague Larry Meiteles, who's in my practice now. We were just colleagues in New York when he did this, but now we're colleagues in the same practice. He, of course, an orthopedic surgeon's wife had a sudden hearing loss and appeared with an MRI because—

[Dr. Ashley Agan]
We know how to get fast!

[Dr. Sujana Chandrashekhar]
She was found to have a vestibular schwannoma, and Larry removed the tumor and restored the hearing. That is one in a million. I just love that case. He presented it at the New York Otologic Society, and I'm like, "You totally rock, man." That's a superhuman thing. I talk to them about the pros and cons of MRI, and I really think that the noise damage to a currently damaged ear of MR is pretty significant. ABR, auditory brainstem response testing, or BAER, or BSER, they're all the same thing, is an option. ABR will miss 19% to 20% of intracanalicular vestibular schwannomas. I presented that right after my fellowship.

Way the heck back in 1994, I gave that presentation at COSM and my fellow resident and I did my fellowship at the House Institute, and Tom Roland did his fellowship at NYU, where we were both residents in the same year. Thank goodness, somehow I got on the podium giving this presentation a couple of papers before Tom gave the same presentation from the NYU experience. It's either 19% or 20%, depending on whether you're at the first presentation or second presentation, but it's about a fifth of intracanalicular tumors are missed by regular ABR. There's a new way to do ABR called stacked ABR, which is better at detection of small tumors but still will miss 10% to 15%. Frankly, is not done other than in research institutions or with really highfalutin ABR studying audiologists.

[Dr. Ashley Agan]
For these patients, how often or when do you need an ABR for the patient that comes in with sudden hearing loss? What makes you actually get one for a patient that comes in for this?

[Dr. Sujana Chandrashekhar]
I will tell you that if it's a significantly older person on whom there would be no intervention for an intracanalicular tumor, you can offer an ABR. However, if their hearing loss is worse than ADDB at 4K, you cannot offer them an ABR because you won't get wave forms. Their hearing has to be at essentially the severe level and you have to have had a discussion with the patient and their family and yourself about why you're getting this test and what you would do with the information should there be something abnormal. If you are willing to have a normal ABR in somebody and therefore 20% chance of missing an intracanalicular, vestibular schwannoma, that's fine.

That's an appropriate counselling. If you're going to not accept a normal ABR and go to an MRI anyway, there's no point of adding the noise and expense of an ABR and frankly waste of your audiologist's time and energy. If the ABR is abnormal, you're going to end up getting an MRI because that may be either inflammation along the cochlear nerve or a vestibular schwannoma or a meningioma or something that's affecting the cerebella pontine angle. You really have to think about it. The time I would get an ABR is if I thought that this was a fortuitous or a facetious or a fake hearing loss, so audiologists know how to do stinger.

You know how to do a stinger by just talking to patients wearing your mask at a normal tone when they're not looking at you and, this is where I think using clinical judgment to say, hey, I don't want to hurt this person by throwing treatment at them for something that may not exist. You're really looking at whether the pure tone and the SRT and the word rec match and you're asking for a stinger and maybe your audiologist did OAEs and there are these robust OAEs with a putative threshold at 60 or 70 DB, well that doesn't make any sense, right? Or their word rec is completely out of proportion of whatever their hearing loss appears to be. Then a threshold ABR is actually a very valid instrument.

[Dr. Ashley Agan]
What about CT? What if the patient was in an ER and they got a CT, they show up with a CT or if they're like, no, I'm claustrophobic, you can't make me get into an MRI or other reasons for not being able to get an MRI, does a CT help you at all?

[Dr. Sujana Chandrashekhar]
The CT scan that the patient has received in the ER for this workup is pointless and it's basically a waste of radiation and money and time and energy because they have done very thick cuts looking for a stroke, so that doesn't help you at all. We did the clinical practice guideline from the American Academy of Otolaryngology Head and Neck Surgery on sudden hearing loss, and then we did the clinical practice guideline update and we paired with Consumer's Union, which makes consumers reports and has a Choosing Wisely campaign, which is a way to engage with patients and the public to have them participate more knowledgeably in their interactions with healthcare, and so they really are focused on trying to avoid unnecessary interventions such as the head brain CT in the ER.

We strongly urge against that. However, if the patient has a sudden hearing loss and either as you said, can't take an MRI for whatever number of reasons including they have a pacemaker, et cetera, and you have the correct concern, which you should about the retrocochlear pathology, then cut CT temporal bone with contrast is a very reasonable substitute and you can pair that with an ABR to be as thorough as possible for these patients. Also, if you are subsequently looking at an unrecovered or an inadequately recovered sudden sensorineural hearing loss and you're thinking about implantable devices, that thin cut CT is actually very helpful.

[Dr. Gopi Shah]
I like that point because those alternatives and options are very helpful in practice. Is there ever a time where you get labs for these patients? Has that ever indicated?

[Dr. Sujana Chandrashekhar]
It's a great question. Shotgun labs, no. That means just randomly ticking every box or clicking everything in this panel and that panel and the other panel. We all know that as soon as you order a panel, you are going to be chasing two weird abnormals that actually have nothing to do with anything. However, patient was out hiking last week and pulled a tick off of them and now they have sudden hearing loss. Yes, Lyme is one of the things that causes sudden hearing loss and so that goes from a sudden idiopathic hearing loss to a Lyme related hearing loss and identification of Lyme infection and then treatment of that is very important.

Syphilis is very prevalent, especially in the homosexual population, so asking the correct questions and frankly, I'm from New York, I don't trust anybody and I don't believe anybody and even if you walk in with a nun's habit, I'll probably have a low threshold for checking a VDRL and FTA on you because it's something I can treat. It's something that a couple of shots of penicillin are good for the soul. Targeted testing I think is very important. Shotgun testing, not at all.

[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]
I think I've been a resident once under the microscope in the OR putting tubes in and then I felt so bad about it, whether it's fluid or not because I'm like, it might take anyway, sorry, sidetracked.

[Dr. Sujana Chandrashekhar]
No, but it's true, right? You worry about it, but then you think about why you didn't go to the OR because they have fluid once. You went to the OR for some indications. I'm old and all I do is look in ears. The other day I punctured an eardrum for an intratympanic injection and a big blugh of mucus and yes, the word is blugh of mucus dropped out of the ear and I was like, ah. I was like, oh, I lose in the validation today. Until it happens and then you fix where you were and you continue on. Physical exam, I think is not to be belittled in any possible way. Then you had asked me about something and I forgot what you asked me.

(5) Audiogram Findings in Sudden Sensorineural Hearing Loss

[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.

[Dr. Ashley Agan]
On those initial visits. Do y'all mention that as a differential just for expectations or is that not really part of the conversation until that follow-up where you actually think that that's what's going on?

[Dr. Sujana Chandrashekhar]
I hesitate to mention Meniere's because people Google Meniere's and there's really stupid stuff on the internet about Meniere's. I do not use that word lightly. I don't mind that my patients are on the internet, clearly, I'm on the internet, but there is some really just ridiculous stuff on the internet about Meniere's and they think you've given them the death sentence when you make that diagnosis. That's not true. I don't think that's as meaningful of a conversation to have as the I will get an MRI scan on you, even though your likelihood of having something going on is very low.

I'm just treating you first so I don't hurt your hearing, bringing your hearing back up and then I will get an MRI, but I really couch that in the words of this is not going to mean something crazy to you in the future most likely. The Meniere's dialogue, if they present with a low frequency or that Meniere's pattern I might say, "Hey, we see this sometimes in fluid overpressure in the inner ear so we can treat you with my first-line treatment for sudden sensorineural hearing loss but maybe add the other things that I do for cochlear hydrops or endolymphatic hydrops at the same time or in quick succession.

(6) Differential Diagnosis of Sudden Sensorineural Hearing Loss

[Dr. Ashley Agan]
Then in terms of differentials, we said that most are idiopathic, but obviously the differential is crucial so we don't miss something. We've talked about tumors, we've talked about potential stroke, we've talked about infections, we've talked about Meniere's or endolymphatic hydrops. Is there anything else on y'all's differential that you're just wanting to make sure, hey, it's definitely not this? I know we've talked about medications as well.

[Dr. Sujana Chandrashekhar]
In addition to the things we've mentioned, I would say the other thing that I do ask about is the family history. You're looking for a congenital if it's a cookie-bite shape, particularly if it's a child. None of the clinical practice guidelines address children. The clinical practice guidelines and the update were age 18 and above, but a child comes in, blew a trumpet for the first time, has a cookie bite hearing loss. You're going to think differently.

I had a child come in with vitiligo in their midface and the middle portion of one eyebrow, and a slightly lighter-colored skin on a slightly broad nasal dorsum. Then I looked over at mom, she hadn't dyed her hair in a while, and she had a white four-lock. Just keep your eyes peeled because we should be the best observers of people and start thinking about potential syndromic and nonsyndromic genetic hearing losses. That's the other thing that I might talk about. The other thing is obviously we didn't mention perilymphatic fistula. If the patient gives you a trauma history, whether it's barrow trauma or head trauma you really want to think about perilymphatic fistula as a possibility.

(7) Treatment of Sudden Sensorineural Hearing Loss

[Dr. Gopi Shah]
We've done a pretty good job of setting the stage as far as evaluating our patient and testing. Maybe we can move on and talk about management, treatment, setting expectations, that sort of discussion.

[Dr. Sujana Chandrashekhar]
There's a great deal to do with explaining the audiogram to the patient, all the things that we talked about, the shape of the audiogram, the degree of hearing loss, the word recognition score. Most people do not have a premorbid audiogram. We explain to them that we assume that the ear in question was just like the other ear prior. If they have a premorbid audiogram, obviously it's very nice to look at that and be able to counsel. I counsel patients in the mild hearing loss category that their chance of getting better is extraordinarily high. Often some of the literature on sudden hearing loss is skewed because mild hearing loss people have their hearing loss, then recover their hearing, and never come in.

They may be more uptight or easier to access healthcare if they're coming in with a mild hearing loss, but the chances are they're going to get better. The severe to profound hearing loss, the anacusic patients, the ones who present with severe vertigo, they have a less of a likelihood of hearing improvement no matter what we do but we should try everything to try to get their hearing back. Then there's that steroid-effective zone that was defined by Wilson, Byl, and Laird in the '70s, and that still holds true. The mild to moderately severe mid-frequency hearing loss, they respond about four to one to steroid treatment.

That's a huge number four to one. I talk to all my patients about the things I'm thinking about because I truly believe in shared decision-making with patients. There's nothing we're doing that could not potentially have a negative outcome in one way or another. Whether we're not treating, whether we're giving oral steroids, whether we're injecting with steroids. This is where shared decision-making is really very important, including the shared decision-making of delaying the retro-cochlear workup and why we're doing that, et cetera.

I think setting proper expectations and having the patient understand where you're coming from as the treating physician is really important. The other thing we didn't mention is age. Under 18, unfortunately, has a less good prognosis than 18 to 60. Above 60, 65 has a less good prognosis as well. One of my residents presented that over age 45, "Old people." He said.

[Dr. Gopi Shah]
Gosh.

[Dr. Sujana Chandrashekhar]
I just looked at him and I was like, "Dude, do you want to graduate from this residency program?" Really, it's the under 18 and over 60 have a little bit less good prognosis than working years people.

[Dr. Gopi Shah]
I appreciate the shared decision making a lot. Does that mean you are less likely to do steroids in the patients that have significant profound hearing loss? How does that change your management if you had your choice? I realize when you have a hammer, everything isn't a nail, but are you less likely to do steroids for that very mild hearing loss, or is it one of those, "Hey, if you can tolerate intratympanic steroids," or, "Let's go ahead and get something in today while you're here," or maybe that's naive, I don't know?

[Dr. Sujana Chandrashekhar]
No, no, it's a terrific question, and it's actually something I think about a lot. Let's start with the mild. The mild hearing loss patients, I say to them, "This is great. You're probably going to get better no matter what, but I think it's really reasonable to give you some steroids." For them, oral steroids are plenty, but the oral steroids are an actual treatment and not a Medrol dose pack. An actual treatment of steroids is prednisone one milligram per kilogram per day for seven days. Some people use it for 10 days or 2 weeks. I use it for seven days, followed by a taper over seven days.

All the medicine that I give, I ask the patients to take in the morning with breakfast. One, it increases the bioavailability based on studies done in asthma and in arthritis. Two, it prevents them from having insomnia related to their prednisone when they're taking their evening dose of the prednisone. I have them take it with breakfast daily, and I have them protect their stomach with an over-the-counter antacid daily while they're on the prednisone. Normally, I will give 20-milligram tablets, so three tablets, or 60 milligrams a day for 7 days, followed by 40 milligrams a day for 4 days, 20 milligrams a day for 3 days and stop.

It is possible in just one-week course of prednisone to just stop, but they feel really horrible. It doesn't feel good for patients, so I do the taper. When they have mild hearing loss, a lot of times my patients will take that first dose or two, and then they'll say, "Listen, my hearing's back." Nowadays one of the advantages of the COVID pandemic closures was that these smartphone-related hearing apps became better and better. Either they'll come in for a hearing test, or I'll ask them, "Why don't you take one of those online hearing tests? Some are commercial products, but the World Health Organization has a free product, which is an online hearing test," and they can take that and send it to me.

Frankly, if their hearing is back, they can just stop the steroids right then and there. I let them know that there's a very good likelihood that they won't actually be taking the full course of this depending on their response. Then let's move on to the sort of steroid-responsive zone people. Those people get that same oral steroid dose, and I will say to them, "This is a very, very high likelihood that this is going to get your hearing back, but I'm going to see you in a week. As you're starting the taper part, if your hearing is not where you and I want it to be, I would like to start injections into your ear at that point. This is how I do the injections, and this is what it's going to feel like," and I give them a chance to process.

There is a psychological aspect to sudden hearing loss that we really have very poor literature exploring, but it is scary as all get out to lose a sense. They're very panic-stricken, and it's really important that we have this dialogue, and we explain why we're doing what we're doing, and the fact that in my reading of the literature, and in my vast experience with sudden hearing loss, I do not think that there is a delay or a lack of recovery if I do it in that way.

If I give them the one week of oral followed by offering them the intratympanic starting on day seven or eight. For the anacusic patients, or the severe to profound, I actually throw everything at them on day one. I actually treat them more. That is based on Robert Cueva's studies from Kaiser in San Diego. This is why they did that clinical pathway within their system of getting the patients in, that because they have actually a very poor likelihood of recovery, giving them everything, belt and suspenders at the same time, it seems to be much more effective than doing it in a sequential fashion.

(8) Intratympanic Steroids for Sudden Sensorineural Hearing Loss: Dr. Chandrashekar’s Approach

[Dr. Gopi Shah]
For your IT steroids, are you using dexamethasone, and are you doing that three injections one week apart, or how do you do that?

[Dr. Sujana Chandrashekhar]
I do it the right way.

[Dr. Gopi Shah]
Of course.

[Dr. Sujana Chandrashekhar]
We had to cut out somewhere, because we're talking about anacusic patient. I use Dexamethasone 24 milligrams per ml. I have that made for me at a compounding pharmacy. Sometimes institutional pharmacies will make it, but often there's quite a bit of resistance, but the data is so compelling that 24 milligrams per ml is significantly better than 10 milligrams per ml, and frankly, 4 milligrams per ml, you might as well just be injecting some saline into their ear from literature that I have reviewed. I get it compounded for me. I have a practice in midtown Manhattan, so if you're ever at the Rockefeller Center Christmas tree, come visit me.

I'm just two blocks away, and I'll get you a nice cup of hot chocolate. I have a practice in midtown Manhattan, and I have a practice in Wayne, New Jersey. After the debacle many years ago of a compounding pharmacy in Massachusetts that had a contamination problem, and there were intrathecal injections of compounded material that caused really horrific complications, the federal law changed, and you can no longer get compounded medications across state lines. You will actually have to find a compounding pharmacy that will make the medicine for you in the state that you're practicing in. I have one compounding pharmacy in New York State and one compounding pharmacy in New Jersey.

You can find them in your state. They just have to be within your state. I get the 24 milligrams per ml, and I use a phenol applicator, but I do not use that strange cotton tip thing that comes with the disposable phenol packets, because that's like half the size of the TM, and nobody needs to burn half of the TM for this. There's actually a phenol applicator that looks like a right angle hook, but it has two little parallel hooks of the right angle hook, and you dip that into the phenol, whether you get it in a big bottle, or in a tiny little applicator bottle. You just need that microdose that's between the tips of that right angle. I inject, and this is different than some of my colleagues, but I told you I do it right. Ha ha.

I inject anterosuperior. I take the tines of that right angle, and I tell the patient, "This is going to burn like crazy for about a second." I tell them to hold still for that one second, because you don't want to touch the canal wall with the phenol. You don't want to touch any other portion of the drum with that phenol. I touch the anterosuperior quadrant of the drum, and I see the blanch instantaneously, and it burns, and I touch and I come out. The patients are really quite, again, if you explain something to somebody, they'll hold still. I have injected as young as nine years old in the office, frankly. You can inject as long as you set expectations correctly.

I wait for the blanch, and as it blanches that horrific burn, because it can be really horrific for the majority of people, goes away. I say, "Okay, does it feel better?" They're like, "Yeah, you weren't kidding." I'm like, "Yes, I kid about a lot of stuff, but I don't kid about that." Then you see the blanche, so you know that you are well anesthetized. Then I take a 25 gauge spinal needle, and I've drawn up about 0.5/0.6 ml of the dexamethasone, 24 milligrams per ml into a one ml syringe. So you don't want it in a 3 mL or a 5 mL, you don't want a big pressure head of a too big syringe.

I connect that to my long spinal needle, and I bend the spinal needle like an otologic instrument so that I can actually see around my fingers and my thumb on the plunger. Then I make a small puncture, very anterosuperior at that blanche spot, and that's my air egress hole. Then I just move my needle, and I make a second puncture just inferior to that. It's less than a millimeter away from that, and then I start injecting. What I see is initially nothing because the fluid fills the hypotympanum first, and then the air-fluid level moves up and up and up the middle ear, and then air bubbles, and then fluid come out of that first hole that I made, and I'm kind of done. Normally, the middle ear, in my experience, holds somewhere between 0.3 and 0.5 ml. If you happen to just put all of the stuff in and let the rest of it spill out into the ear canal, you've done nothing wrong. The patient has been lying at a basically 45 to 60-degree angle with the affected ear up. I move them now so that their nose is pointing straight to the ceiling, because I really want that round window membrane bathed, and I don't want that fluid going out anterosuperior to the eustachian tube.

Then I ask them not to swallow for 20 minutes. I'm still the 20-minute girl. There was a paper that came out of Asia several years ago, I think it was out of Korea, that said 12 minutes was as good as 20 minutes, but I haven't seen that replicated anywhere, so I'm still 20 minutes. A patient of mine came in who has Ménière's, and I've injected her several times. She likes her wine, and she came in one day with a cork, and I'm like, "Maureen, what is this?" She's like, "I realized if I keep my teeth the distance of the width of this cork apart, my tongue won't touch the roof of my mouth or, she was trying to say palate, and I won't want to swallow." We learn a lot of things from our patients.

She brings her cork when she needs her injection. I don't drink enough wine to have enough corks, so I have a couple of tongue blades, and I wrap up some gauze, some four-by-fours, and I make it about the width of a cork. I place that between the front teeth of the patient, and they can drool into the gauze if they want. They basically are asked to do their best not to swallow. I ask them not to swallow. I say, "I'm going to tell you when it's your last swallow." They will immediately swallow because don't think about pink elephants, right, it's the same concept.

I get that out of their system. Frankly, when I say to them, "This is your last swallow." I take my last swallow, and then I do the injection. Then they're there for about 20 minutes. They can become very dizzy, vertiginous with the injection. The way to prevent that to some degree is to make sure that the injection is warmed to body temperature. I have some lovely nurses and MAs who will hold it in their hands while they're preparing everything else for me. You can put it under your armpit to expedite the warming. You really don't want to put cold fluid into the ear unless you just really hate the patient. Even with that, there's some people who get vertigo, and I prepare them for that.

If you feel like you're getting vertigo or really dizzy, look at that coat hook on the door, or look at the edge of one of my millions of diplomas that's hanging up on the wall, and just focus your eyes on that, and you'll overcome the dizziness. You'll see their nystagmus, and then you'll see it slow down, and then you'll see that they're okay. I think we have to stay in the room until they feel comfortable. Then my nurse lets them exit after 20 minutes. They're given silicon putty earplugs to use in the shower during the week that I don't see them, and then they come back in a week, they get a hearing test, and we repeat the injection. It's normally up to three to four injections once weekly. It's really based on subjective and objective descriptions of their hearing.

[Dr. Gopi Shah]
If you're at the third injection and you've seen no change, do you keep going for the fourth?

[Dr. Sujana Chandrashekhar]
It's a wonderful question. If the patient says to me, "I do better for a day or two, and then it just gets bad again," or, "I know you inject me on Tuesdays, and I can feel the hearing come back on Friday and Saturday, and then by the time I see you it's bad again." I will do that fourth injection. If they are echoing what the audiogram is showing, that there's really no improvement, I think if there's no movement after three shots, subjectively or objectively, you can offer as a Hail Mary that fourth, or you can wait. In the clinical practice guidelines, we did talk about salvage regimens.

You can in fact wait for a month, see if anything happens, and now you're maybe seven, eight weeks out, which is outside of the six weeks guideline for salvage, but then if they're like, "I want to try again," or I think, or this or that.

The downside to me for intratympanic injection of steroid is so little that I have a low threshold for offering it for salvage. That is outside the guideline, and again, I know shared decision-making, but these are really important things that you have to talk to patients about. Like I said, I am very, very Pollyanna about the ability to restore hearing, and I have colleagues whom I respect greatly who are not.

[Dr. Gopi Shah]
The timeframe, if the steroids are going to work, it's three weeks from the time of onset of hearing loss?

[Dr. Sujana Chandrashekhar]
The initial treatment for sudden hearing loss is best if instituted within two to four weeks. There are papers that say 72 hours, and then there are papers that say a week. Clearly, in that window, one to two weeks is better than five to six weeks.

[Dr. Gopi Shah]
We talked about how in the beginning it's hard for patients to get to us at that week, three to six. Is it the same though? Do you go ahead and use that same protocol of potential oral steroids depending on the severity of hearing loss or intratympanic plus-minus?

[Dr. Sujana Chandrashekhar]
Yes, with the caveat that if it's closer to that four to six to seven to eight-week mark, because, unfortunately, we live in the real world, I might do the simultaneous treatment. If by then they are upset about their hearing loss, but they're not as petrified that they're about to drop dead. It's a different patient who is seeing you if the hearing loss has been there for several weeks as opposed to a few days. They may be more receptive to this concept of this lady attacking them with a big needle.

[Dr. Gopi Shah]
Then, how does your management or your algorithm change with steroids for the diabetic patient?

[Dr. Sujana Chandrashekhar]
If they have a systemic problem where oral steroids could really compromise their health, an out-of-control diabetic is not going to heal their hearing loss, just like they're not going to heal their gangrenous toe, and they're not going to heal everything else. If they're in that steroid-effective zone, the multi-institutional trial that was run by Steve Roush, a head-to-head comparison of intratympanic versus oral steroids showed that efficacy was at least equal between the two, and complications or side effects were significantly worse with the oral steroids.

In that steroid-effective zone, you could say, "Listen, the safest thing for you is for me to do the injections of steroids, and then have that steroid injection conversation right away." They may say, "You know what, I measure my glucose every day, and I have this non-implantable thing that keeps track of me, and I'm really an amazingly well-controlled diabetic, able to manage myself, I would like the best possible chance." Then I might do both at the same time, and we can discuss that with their internist or their endocrinologist. If they are on blood thinners, you really don't want to start putting them on steroids.

They're already at such a risk for bleeding that an intratympanic injection is very nice, the blood supply of the tympanic membrane is radial, so you're going to be fine just doing two small punctures like I talked about. You're not going to cause any significant bleeding. If there's an underlying issue, and you can do just as well with intratympanic, I think it's very reasonable to only give intratympanic. If they are profound, and the data is clear that both treatments are better, if they can tolerate both treatments, that's great. If they cannot, we can always do a cochlear implant in these people. We can always give them a cross-hearing aid. We can always do an osteointegrated implant. There are other options available. You're a doctor first, always be a doctor first.

[Dr. Ashley Agan]
It can be tricky when patients are not just the classic textbook, just one thing. When you get through with your-- let's say you do your oral steroids, and then you do your IT injections, and now you're at that point where you've really seen no improvement, is there anything else left to talk about if patients are just like, "Anything. Bring my hearing back."

(9) Emerging Therapies for Sudden Sensorineural Hearing Loss

[Dr. Gopi Shah]
Does acupuncture help, or what about hyperbaric oxygen?

[Dr. Sujana Chandrashekhar]
We didn't talk about hyperbaric. Acupuncture has not shown benefit in sudden hearing loss. There is some benefit that has been shown in tinnitus overall for acupuncture. There is a benefit for complementary and integrative medicine techniques in tinnitus. If it's a noise-induced hearing loss, there are some agents like Resveratrol and acetyl-cysteine that can be used to try to ameliorate the tinnitus, which is the secondary symptom of the noise-induced hearing loss, and possibly help with the hearing loss. Hyperbaric oxygen. The first clinical practice guideline considered it an option. The update based on all the data that we reviewed said it was an option only if combined with steroid therapy for either primary or salvage treatment of sudden hearing loss.

There are countries in which hyperbaric oxygen is like the baseline treatment, everybody gets that. The outcomes are not better than countries such as ours where that is not the baseline treatment in most patients. I have not seen compelling data, which is why that remained an option in the clinical practice guidelines, and only an option now with concomitant steroid therapy, and in my personal practice, I have yet to see compelling data for hyperbaric oxygen.

In America, you cannot talk about healthcare without talking about finances, and coverage, and there are some insurances that will cover hyperbaric oxygen. Then you say, well, the worst thing you're going to lose is time and energy, making the dives. The dives themselves are pretty safe. The days where everybody needed a tube for a hyperbaric dive for their non-healing ulcer or whenever, those days are pretty much gone. The dives are better done now in the hyperbaric chambers.

If all they're going to lose is time and energy, that's the conversation to have with the patient. When patients are paying out-of-pocket for it, I find it really difficult to agree with that as one of their treatment protocols. There's some old-fashioned stuff that I can talk about. There's papaverine, which is a smooth vessel vasodilator, and there was a supply chain issue sometime in the middle of this pandemic where we couldn't get papaverine anywhere, but it's given us Pavabid.

It's twice daily, very old-fashioned. If you read some of the older literature like from the House Ear Institute, you'll see it mentioned, and there are certain patients of mine who really do respond very well to papaverine alongside these other treatments that we've talked about. There's niacin, which is vitamin B6, and B vitamins in general are considered very neuroprotective, Lipo-Flavonoid vitamins which are marketed as LBC, lipo-bioflavonoids with B and C seem to be very neuroprotective.

There's not a lot of data for them. They're very safe, and sometimes I'll try those. If there's a hint of a viral phenomenon, I will at the onset start them on an antiviral, but this is not a knee-jerk like you might do with a Bell's Palsy.

(10) Follow-up for Sudden Sensorineural Hearing Loss

[Dr. Gopi Shah]
In terms of follow-up, we said at the initial, then weekly. Let's say you're at week six now, and you've completed the three injections, and the hearing loss went from moderate to mild to moderate. We got a little improvement. What are your next steps? When do you see them again, the discussion of amplification, when does that come up?

[Dr. Sujana Chandrashekhar]
If they're still improving and I've gotten them from a moderate severe to a mild or mild to moderate, I will offer them that fourth injection, and then I normally will say, "Let me see you in a month," but during the time of the injections, I've actually asked them to try to stimulate their brain to hear from the pore side. To use headphones or earbuds or whatever only in the bad ear to listen to either podcasts that they like, or better yet music that they're very familiar with, where their brain will fill in the details.

There's a couple of nice papers that came out about auditory stimulation for recovery of sudden hearing loss. I think that cannot hurt them, and can potentially help quite a bit, and we see this in hearing aid users. We see people go from fair word discrimination to good word discrimination simply by having used their hearing aid on a consistent basis. Because I explain to patients, we use our ears to transmit sound, but we hear with our brains. The more you're stimulating your brain, the better.

I will ask them to do auditory stimulation in that way if they can tolerate it. Some people just hate it and won't do it, but most people like the dispensation to do that. I will see them in a month, and then per the clinical practice guidelines, you should see them at six months. Six months from the end of your treatment. If they are aidable, they need to be aided as soon as possible. That again helps your brain interface very much.

I had a patient who I treated when she was several months pregnant. She was seven or eight months pregnant when I first met her. She's pregnant, and back then a little bit of concern about oral steroids, but I think talking with her OB, we gave her oral, we gave her injections. I brought her hearing from profound to aidable, which is a huge difference. She started wearing her hearing aid, baby's growing, she's happy, and the baby's about five, six months, seven months old.

By then we had become friends. She's like, "Sujana, I think my hearing aid is too loud," and she came in, and she had had further improvement of her hearing. I never count an ear out. I think you got to really be aware that it may take a little while to recover, but aiding is very, very helpful. Then, at that six-month mark, having done all of the things we just talked about, if they really have not recovered, then it's a good time to talk to them about amelioration for their now unrecovered usually severe to profound hearing loss. Unrecovered, unaidable.

You can start as simple as a CROS device, which stands for contralateral routing of sound or signal, and that I explain to the patients, looks like two hearing aids. The one in your bad ear picks up the sounds and sends it to the microphone in your good ear, and then your good ear hears from your bad side and your good side. The brain is really quite capable of distinguishing the analog sound from the normal side, and the digital sound from the poor side pretty fast.

It takes a little bit of getting used to, but the brain does it pretty well, and certainly, there are osseointegrated implants if they like that, but they want something more robust, the sound from either percutaneous implant like a BAHA or Ponto, or transcutaneous like a Bonebridge or an Osia implant, those hearing outcomes are really nice. They're all cross-technology, so they're very based on how good the good ear is, and then cochlear implants for single-sided deafness are really outstanding.

When we first thought about them, again we thought, "How's the brain going to cleave together normal analog sounds from the good ear, and then completely electrical sound from the bad ear?" But it turns out the brain is quite a plastic thing, and can really make those adjustments at even advanced age. That's a really good option, but that's not an option that I would do until six months have passed, because I think that we can really look to see improvement, and we can look to see how the patient is managing with their non-surgically implantable amelioration in that timeframe.

Then, aha, the future is going to be intratympanic therapies to try to regrow hair cells. I'm just wrapping up being one of the clinical sites of the Frequency Therapeutics FX 322 trial. There, you have to do the injection not with phenol, but with EMLA, and posterior-central, right above where the round window orifice would be, because it's a very small amount, and it's a gel, and you essentially want it to enter the round window niche and sit against the round window membrane so that the injection technique is a little different for that particular investigational device or investigational drug.

In the future, the dream is, we'll be able to take these people and really improve their word recognition, and this is where I'm going to keep harping on word recognition, because even if you have a moderately severe pure tone loss, but your word rec now goes from 50% to 80%, man, you will love your hearing aid. I think that's really important to talk to patients, and get them to understand what part of hearing is actually what they are missing.

I think in the future, these drug therapies, gene therapies are going to come. If you have a profound hearing loss, you're severe to profound no discrim, I wouldn't wait around for that. Cochlear implants work beautifully right now, but if you've got something a little bit less than that, and you can play the field a little bit with the other devices, it might be nice not to open the inner ear on these people.

[Dr. Ashley Agan]
It's exciting.

[Dr. Sujana Chandrashekhar]
Yes. It's really cool. I have to say I'm such a nerd. I'm like, "Oh my God." I come home to my normal husband, and I'm like, "Oh my God, guess what? Research is going well."

He's just like, "Okay, honey."

[Dr. Gopi Shah]
"That's all you know."

[Dr. Gopi Shah]
"That's all I know."

[Dr. Sujana Chandrashekhar]
That's all I know.

That's my four kids. It's probably what they think too.

[Dr. Gopi Shah]
Oh. Well, I think this has been amazing, and we've really covered the topic deeply. Any pearls or tips, anything that we just want to leave listeners with as a summary, or anything we've missed?

[Dr. Sujana Chandrashekhar]
One, I want to thank you guys, because this is really a wonderful opportunity. Our audience cannot see, but we're all wearing matching BackTable ENT swag. I've got both my sweatshirt and my t-shirt on. I'm really proud of you both for creating this really accessible learning tool. This is really incredible, so congratulations.

[Dr. Gopi Shah]
Thank you.

[Dr. Ashley Agan]
Thank you.

[Dr. Sujana Chandrashekhar]
Thank you for including me. I was like, "What's up with me? All my friends get to be on BackTable! I just got a T-shirt.”

[Dr. Gopi Shah]
Thank you for always being so supportive on social media as well, because that's how we get it out to listeners. Thank you for contributing to the content of it. I got the easy side. I just ask questions.

[Dr. Sujana Chandrashekhar]
It's a lot of fun, and I think exploring new media and new ways to learn is very exciting. As a pearl, I would say, consider sudden hearing loss as an otologic emergency. Consider that the loss of a sense is frightening, and can be rather devastating to the patient and their family. There are handouts from the clinical practice guidelines from the academy that can be purchased as card stock, or downloaded onto smartphones.

You can actually give those out to your referring docs or your local urgent care centers and say, "Hey, this is why this is important." Maybe gift them a tuning fork with a link to the handouts, because I think that's really important. I think keeping the end in mind is really important on the first minute that you see the patient. Really talking to them about what you are looking at, what you are generally considering in the future is really important.
Making sure you do that retrocochlear workup and you don't forget, because none of us are infallible. Write it down and tell them, "Remind me, I'm supposed to order an MRI scan on you when we're all said and done, even if we're better." Absolutely, get that retrocochlear workup even if the patient recovers completely. I think being the hearing doctor is a really important part of who we are.

[Dr. Gopi Shah]
Well, thank you so much. For our listeners, please check out She's On Call. It's on YouTube for the video chat, as well as the podcast. I believe I listened to it on Apple, so it's on Apple Podcast.

[Dr. Sujana Chandrashekhar]
Yes, everywhere you get podcasts, I guess.

[Dr. Gopi Shah]
Absolutely. Please check those out.

[Dr. Ashley Agan]
You're on social media, right? Can listeners find you on Twitter?

[Dr. Sujana Chandrashekhar]
Yes, I am @DrSujanaENT, so D-R S-U-J-A-N-A-E-N-T on Twitter. My first name and my last name on Instagram, to make it as difficult as possible to find me, it's SujanaChandshakar. I'm pretty sure if you just start typing Sujana, I'm possibly the only one that comes up. Please check out the podcasts per issue for Otolaryngologic Clinics of North America that you can get on the clinic's website, or you can get wherever you get podcasts. Those are really fun. I get to be the two of you on those podcasts.

[Dr. Gopi Shah]
Thanks.

[Dr. Sujana Chandrashekhar]
I just get to ask really smart people questions about stuff, and nerd me is in heaven doing that too. If you haven't made plans yet, come to the January sections meeting at the Trilogic. It's in beautiful, sunny San Diego at the Del Coronado. I'm the Eastern section vice president this year, but I'm also the program chair. I think that I've put together, along with the other Vice president, a really engaging program, which actually one of the last panels of the program is on using social media as an otolaryngologist. Hopefully, you guys will attend and chime in.

[Dr. Gopi Shah]
Thank you again.

[Dr. Sujana Chandrashekhar]
Thanks so much. This was really fun.

[Dr. Ashley Agan]
Thank you.

Podcast Contributors

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.