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American Academy of Otolaryngology - Head and Neck Surgery FoundationOtolaryngology2019advanced

Sudden Hearing Loss

Published by American Academy of Otolaryngology-Head and Neck Surgery Foundation · Oxford Centre for Evidence-Based Medicine (OCEBM) Levels and American Academy of Pediatrics classification scheme

14Recommendations

273References

13Tables

1Figures

Read Full Guideline

Summary

AI-generated

Sudden hearing loss is a frightening symptom that often prompts an urgent medical visit. Sudden sensorineural hearing loss affects 5 to 27 per 100,000 people annually in the United States. This guideline update provides recommendations for diagnosing, managing, and following up on adult patients with sudden hearing loss to improve diagnostic accuracy, reduce unnecessary testing, and enhance patient outcomes.

sudden hearing lossSSNHLAAO-HNSotolaryngologysteroid therapyintratympanic steroidshyperbaric oxygenguidelines

Key Takeaways

1
Distinguish sensorineural hearing loss from conductive hearing loss at presentation.
2
Do not order routine head CT scans or laboratory tests.
3
Perform audiometry to confirm diagnosis within 14 days of symptom onset.
4
Evaluate patients for retrocochlear pathology using MRI or ABR.
5
Educate patients on natural history, treatment risks/benefits, and shared decision making.
6
Consider initial corticosteroid therapy within 2 weeks of onset.
7
Intratympanic steroids are recommended for salvage therapy 2-6 weeks post-onset if initial treatments fail.
8
Hyperbaric oxygen therapy is an option alongside corticosteroids for both initial and salvage therapy.
9
Routinely prescribing antivirals or vasodilators is strongly discouraged.
10
Follow-up with audiometry 6 months post-treatment and refer for audiologic rehabilitation if hearing loss persists.

What's New in This Version

Included 10 new guidelines, 29 systematic reviews, and 36 RCTs. Emphasized the urgency of evaluation and timeframes. Clarified terminology (using SSNHL to mean ISSNHL). Added specific time windows for audiometry (<14 days), initial steroids (<2 weeks), and salvage IT steroids (2-6 weeks). Removed antioxidants from KAS 11. Modified HBOT to be an option combined with steroids for initial or salvage therapy. Added KAS regarding 6-month follow-up audiometry.

Key Recommendations

Exclusion of conductive hearing loss

KAS 1
Clinicians should distinguish sensorineural hearing loss (SNHL) from conductive hearing loss (CHL) when a patient first presents with SHL.
Strong recommendationEvidence: Grade B/CDiagnosis

Modifying factors

KAS 2
Clinicians should assess patients with presumptive SSNHL through history and physical examination for bilateral SHL, recurrent episodes of SHL, and/or focal neurologic findings.
RecommendationEvidence: Grade CDiagnosis

Computed tomography

KAS 3
Clinicians should not order routine computed tomography (CT) of the head in the initial evaluation of a patient with presumptive SSNHL.
Strong recommendation againstEvidence: Grade BDiagnostic Imaging

Audiometric confirmation of SSNHL

KAS 4
In patients with SHL clinicians should obtain, or refer to a clinician who can obtain, audiometry as soon as possible (within 14 days of symptom onset) to confirm the diagnosis of SSNHL.
RecommendationEvidence: Grade CDiagnosis

Laboratory testing

KAS 5
Clinicians should not obtain routine laboratory tests in patients with SSNHL.
Strong recommendation againstEvidence: Grade BDiagnosis

Retrocochlear pathology

KAS 6
Clinicians should evaluate patients with SSNHL for retrocochlear pathology by obtaining an MRI or auditory brainstem response (ABR).
RecommendationEvidence: Grade B/CDiagnostic Imaging

Patient education

KAS 7
Clinicians should educate patients with SSNHL about the natural history of the condition, the benefits and risks of medical interventions, and the limitations of existing evidence regarding efficacy.
Strong recommendationEvidence: Grade BCounseling

Initial corticosteroids

KAS 8
Clinicians may offer corticosteroids as initial therapy to patients with SSNHL within 2 weeks of symptom onset.
OptionEvidence: Grade CTreatment

Initial therapy with hyperbaric oxygen therapy

KAS 9a
Clinicians may offer, or refer to a clinician who can offer, hyperbaric oxygen therapy (HBOT) combined with steroid therapy within 2 weeks of onset of SSNHL.
OptionEvidence: Grade BTreatment

Salvage therapy with hyperbaric oxygen therapy

KAS 9b
Clinicians may offer, or refer to a clinician who can offer, hyperbaric oxygen therapy (HBOT) combined with steroid therapy as salvage within 1 month of onset of SSNHL.
OptionEvidence: Grade BTreatment

Intratympanic steroids for salvage therapy

KAS 10
Clinicians should offer, or refer to a clinician who can offer, intratympanic steroid therapy when patients have incomplete recovery from SSNHL 2 to 6 weeks after onset of symptoms.
RecommendationEvidence: Grade BTreatment

Other pharmacologic therapy

KAS 11
Clinicians should not routinely prescribe antivirals, thrombolytics, vasodilators, or vasoactive substances to patients with SSNHL.
Strong recommendation againstEvidence: Grade BTreatment

Outcomes assessment

KAS 12
Clinicians should obtain follow-up audiometric evaluation for patients with SSNHL at the conclusion of treatment and within 6 months of completion of treatment.
RecommendationEvidence: Grade CFollow-up

Rehabilitation

KAS 13
Clinicians should counsel patients with SSNHL who have residual hearing loss and/or tinnitus about the possible benefits of audiologic rehabilitation and other supportive measures.
Strong recommendationEvidence: Grade BRehabilitation

Scope & Objectives

Clinical Topic

Sudden Hearing Loss

Objectives

Provide evidence-based recommendations for the diagnosis, management, and follow-up of patients who present with sudden hearing loss.

Target Patient Population

Adult patients aged 18 years and older with sudden hearing loss, primarily idiopathic sudden sensorineural hearing loss.

Diagnostic Criteria

A decrease in hearing of >=30 decibels affecting at least 3 consecutive frequencies occurring within a 72-hour window.

Target Providers

OtolaryngologistsPrimary Care PhysiciansAudiologistsEmergency Room PhysiciansNeurologistsRadiologistsAdvanced Practice Nurses

Patient Criteria & Setting

Therapeutic Area

Otolaryngology

Guideline Scope

DiagnosisManagementFollow-up

Inclusion Criteria

Adults aged >=18 years
Patients presenting with sudden hearing loss

Exclusion Criteria

Patients under 18 years of age

Care Settings

Emergency roomWalk-in/urgent care clinicPrimary care officeOtolaryngology clinic

Evidence Grading

System: Oxford Centre for Evidence-Based Medicine (OCEBM) Levels and American Academy of Pediatrics classification scheme

Evidence Distribution

10included_guidelines

36randomized_controlled_trials

29systematic_reviews_and_meta_analyses

Evidence Levels

Grade ASystematic review of randomized trials, or observational studies with dramatic effect. High quality of evidence.

Grade BRandomized trials or observational studies with dramatic effects or highly consistent evidence. High quality of evidence.

Grade CNonrandomized or historically controlled studies, including case-control and observational studies. Moderate quality of evidence.

Grade DCase reports, mechanism-based reasoning, or reasoning from first principles.

Grade XExceptional situations where validating studies cannot be performed and there is a clear preponderance of benefit over harm.

Recommendation Strength

OptionEither the quality of evidence is suspect (Grade D) or well-done studies show little clear advantage to one approach versus another. Clinicians should be flexible; patient preference should have a substantial influencing role.

RecommendationBenefits exceed harms. Quality of evidence is Grade B or C. Clinicians should generally follow but remain alert to new information and sensitive to patient preferences.

Strong recommendationBenefits clearly exceed harms (or vice versa for negative recommendation). High quality of evidence (Grade A or B). Clinicians should follow unless a clear and compelling rationale for an alternative approach is present.

Safety & Contraindications

Contraindications

Insulin-dependent or poorly controlled diabetes
Labile hypertension
Glaucoma
Tuberculosis
Peptic ulcer disease
Prior psychiatric reactions to corticosteroids

Monitoring Guidance

Obtain follow-up audiometric evaluation at the conclusion of treatment and within 6 months of completion of treatment.

Authors & Contributors

Sujana S. ChandrasekharMD; Betty S. Tsai DoMD; Seth R. SchwartzMDMPH; Laura J. BontempoMDMEd; Erynne A. FaucettMD; Sandra A. FinestonePsyD; Deena B. HollingsworthMSNFNP-BC; David M. KelleyMD; Steven T. KmuchaMDJD; Gul MoonisMD; Gayla L. PolingPhDCCC-A; J. Kirk RobertsMD; Robert J. StachlerMD; Daniel M. ZeitlerMD; Maureen D. Corrigan; Lorraine C. NnachetaMPHDrPH; Lisa SatterfieldMSMPH

Guideline Features

Dosing informationFlowcharts includedBased on systematic reviewMultidisciplinaryPatient involvementDrug interactions discussed

Learning Context

Difficulty

advanced

Learning Paths

Sudden Sensorineural Hearing Loss (SSNHL)Clinical Practice GuidelinesOtolaryngologyAudiologyCorticosteroid TherapyHyperbaric Oxygen Therapy (HBOT)

Read Full Guideline

American Academy of Otolaryngology-Head and Neck Surgery Foundation

AI Podcast

Deep-dive audio (~10 min)

Study Guide

Structured study document

Infographic

Visual overview of key points

Sudden Hearing Loss: Why "Wait and See" is a Dangerous Strategy

Read the full blog article

Guideline Info

SocietyAmerican Academy of Otolaryngology - Head and Neck Surgery Foundation

Full nameAmerican Academy of Otolaryngology-Head and Neck Surgery Foundation

SpecialtyOtolaryngology

Year2019

VersionUpdate

Evidence systemOxford Centre for Evidence-Based Medicine (OCEBM) Levels and American Academy of Pediatrics classification scheme

RegionUnited States

LanguageEnglish

DOI10.1177/0194599819859885

Key Figures

Recommendations14

References273

Tables13

Figures1

Clinical Areas

OtolaryngologyOtologyNeurotologyFamily MedicineAudiologyEmergency MedicineNeurologyRadiologyAdvanced Practice Nursing

MeSH Terms

Hearing Loss, Sudden

American Academy of Otolaryngology - Head and Neck Surgery Foundation

United States

American Academy of Otolaryngology-Head and Neck Surgery Foundation

All American Academy of Otolaryngology - Head and Neck Surgery Foundation guidelines

Sudden Hearing Loss

Summary

What's New in This Version

Key Recommendations

Exclusion of conductive hearing loss

Modifying factors

Computed tomography

Audiometric confirmation of SSNHL

Laboratory testing

Retrocochlear pathology

Patient education

Initial corticosteroids

Initial therapy with hyperbaric oxygen therapy

Salvage therapy with hyperbaric oxygen therapy

Intratympanic steroids for salvage therapy

Other pharmacologic therapy

Outcomes assessment

Rehabilitation

Scope & Objectives

Patient Criteria & Setting

Evidence Grading

Safety & Contraindications

Authors & Contributors

Guideline Features

Related Guidelines

Learning Context