Your spouse is talking to you, telling you something vitally important and seated on your left side. All of a sudden, your hearing goes out, but only on that left side. There’s no ear pain, no drainage. You pull your ear, tap it a few times but nothing changes. Of course, she’s annoyed since, like multiple times before, it seems you’re not hearing (or “listening”) to a word she’s said.
“But only this time, I can’t hear a thing,” you say in a panic. “It’s the God’s honest truth! I can’t hear a freakin’ thing!”
Initially she believes you’re employing that age-old male weakness of ignoring one’s spouse. Only this time she realizes it’s legitimate. There are tell-tale signs: your panic-stricken face and the fact you’re running around the house slapping your ear screaming, “I can’t hear! I’m going deaf! And my ear is ringing!”
The only time she sees you running in the house is for the bathroom after you’ve devoured an absurdly huge chili dog, or when frantically searching for the T.V. remote. She takes you to the doctor.
After examining your ear and finding it looks normal, a
hearing test is then required. This is
called an audiogram in fancy parlance.
Usually a patient is then referred to an ENT doctor who has an
audiologist so that a more thorough ear exam and an audiogram are done, and
proper treatment is rendered.
Types of Hearing Loss
It’s important to determine the type of hearing loss in order to provide the right treatment. This was explained in The Tuning Fork but we’ll summarize here:
Conductive hearing loss (CHL): this arises when there is a problem in the middle ear, the part of the ear that includes the tympanic membrane and the ossicles attached to it. Sound is conducted along these small but moveable thingamajigs to the cochlea. Examples of problems causing CHL are a tympanic membrane (TM) perforation (hole in the TM), otitis media (where there is pus or fluid in the middle ear behind the TM), stiffness of the ossicles (otosclerosis is an example) to mention but a few. Also anything preventing the passage of the sound waves to the TM causes CHL, namely blockage of the ear canal with wax, a foreign object or a tumor.
Sensorineural hearing loss (SNHL): The cochlea is the snail-shaped sensory organ that ultimately receives input from the TM and ossicles. It is connected to the brain by the auditory nerve. Hearing loss due to a problem with either the cochlea or the auditory nerve is termed sensorineural hearing loss, since it is often difficult to determine whether the cochlea or the nerve or both are affected. One of the most common causes of SNHL is loud noise exposure. SNHL also often occurs as a normal decline of hearing with aging, known as presbycusis. Ear ringing or tinnitus often goes hand-in-hand with SNHL
Mixed hearing loss (MHL): This arises when both a conductive AND a sensorineural hearing loss is present. For instance, a hole in the tympanic membrane in a patient with noise-induced SNHL will create a mixed loss, or an elderly patient (with presbycusis, or age-related SNHL) with otitis media (fluid behind the TM). In both examples, the defect in middle ear prevents proper conduction of sound from the TM down the ossicular chain creating the CHL. The defective cochlea from prior noise injury or aging creates the SNHL.
Let’s assume there are no weird findings in the ear and the
anatomy looks normal and the hearing loss is purely a sensorineural
hearing loss, which is the focus of this article. When this occurs of rather sudden onset, the
site of involvement is suspected to be the cochlea rather than the auditory
nerve itself. This problem is called Sudden
Sensorineural Hearing Loss (SSNHL)
The Cause of SSNHL
For folks who present with SSNHL, we highly intelligent ENT docs tell them it’s idiopathic--a long, fancy term meaning, “we’re not really sure” or more to the point, “we don’t know.” However, in the case of SSNHL, the presumed cause is viral.
Often there are no illnesses (such as a cold or cough) along
with SSNHL or other known ear insults such as sudden noise exposure or ear trauma. Usually there’s no ear pain. Sometimes dizziness can occur, such as a
sense of off-balance or vertigo. If these vestibular symptoms are
significant, and providing there is no bacterial ear infection (ie, otitis
media or mastoiditis, often are associated with pain), then this condition
would be considered a viral
labyrinthitis.
Treatment
Treatment is not about eradicating the presumed virus, but the inflammatory insult it left behind. Steroids have powerful anti-inflammatory properties and thus are the mainstay of treatment. For those who can tolerated it, prednisone is often used starting at a high dose for 7 days, then the dose is gradually tapered down until it is completed. Total duration is about two weeks.
Side effects: You won’t bulge with muscles, develop an Austrian accent and become the next Governator of California. Some side effects are stomach upset, which can be alleviated with OTC meds such as Pepcid (famotidine) or Prilosec (omeprazole) or even Tums; mood changes can occur, ranging from euphoria and a sense of increased energy, to the polar opposite of anxiety or irritability. I tell patients if their family complains, tell them it’s the drugs, not them. If the side effects are intolerable, it is OK to simply stop the steroids; the taper isn’t necessary for this short duration of treatment.
Trans-tympanic steroids can also be used. This requires anesthetizing the ear drum (tympanic membrane) and injecting a steroid (such as dexamethasone) directly into the middle ear. The steroid then seeps through the round window of the cochlea (see Hearing and the Inner Workings of the Cochlea) and enters into the fluid that fills the cochlea and to treat the inflammation.
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This procedure is recommended for those who cannot take a steroid by mouth, such as poorly controlled diabetes, severe immunosuppressed states are have an active GI ulcer. It’s done in the office and folks tend to tolerate this well with little pain. With anything we do in medicine, there are of course risks like a persistent hole perforation in the TM, no help or worsening loss, dizziness, vertigo, infection, all low incidence…yes, these are scary risks but are quite rare.
What about anti-viral meds?
Since a particular virus has not been isolated, and there are really no studies showing the value of antiviral medications, these drugs are not recommended.
Many patients have a complete or partial recovery to their hearing with steroid treatment. Also, there are a few who will recover without medical treatment. However, the worse the hearing is and the longer the duration between onset and seeking treatment decreases the odds of hearing improvement. If hearing does not improve, we often consider an MRI (magnetic resonance imaging) in the future to make sure one does not have another cause, such as an acoustic neuroma (a benign tumor on the auditory nerve).
If there is no improvement after treatment, options include a hearing aid(s) to help with hearing. We usually wait several months, since once in a while, you’ll see a patient who has spontaneous recovery. I’ve seen two patients with complete deafness, who did not respond to steroids, have improvement many months afterwards. One guy came into our office having a completely deaf ear, shouting, “My hearing came back! It’s completely normal!” to which I said he likely had partial improvement, but he insisted on a hearing test that day. Lo-and-behold his audiogram showed his bad ear recovered completely, with normal hearing levels across every frequency! There was another patient, in his late teens, with sudden hearing loss, with no response after steroid treatment. His MRI was normal. His parents took him to a pediatric ENT subspecialist who agreed with the prior treatment and no further recommendations could be made. He returned a couple months later, and testing showed his hearing was much improved, though not completely like the first case, but enough such that it was quite noticeable to him, and he and his parents were pleased.
So, I tell patients sometimes spontaneous improvement can
occur if medical treatment does not help, but if and when cannot be predicted,
and such cases are not very common.
Aside: What about the COVID vaccine?
Does the COVID vaccine cause hearing loss or tinnitus? No clearcut data on this, but there does not
appear to be a significant number of cases to determine a cause-and-effect
relationship between COVID vaccine and sudden hearing loss. As such, the very remote risk of hearing loss
should not dissuade a person from being vaccinated, especially since the
effects of COVID can be devastating and deadly.
In other words, the benefits of the vaccine with the prevention of death or a severe impairment of quality of life due COVID far outweigh the very small otologic risks (if any) that are not life-threatening.
So if you notice a sudden drop in your hearing, it is best to seek medical attention as soon as possible. If you have SSNHL, the sooner treatment is started, the better the chances of hearing recovery.
©Randall S. Fong, M.D.
For more topics on medicine, health and the weirdness
of life in general, check out the rest of the blog site at randallfong.blogspot.com
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