What to Do? My Patient Presents with Sudden Hearing Loss: Sam J Daniel, MD

Transcription

1 My Patient Presents with Sudden Hearing Loss: What to Do? Sam J Daniel, MD Director Pediatric Otolaryngology Montreal Children s Hospital, McGill University

2 Disclosures There are no conflicts of interest to declare This program has received no commercial financial support This program has received no commercial in-kind support

3 Objectives At the end of this session, the participant will be able to 1. identify what questions to ask in a context of sudden hearing loss 2. Acquire physical examination pearls in patients with sudden hearing loss 3. develop a management algorithm for patients with sudden hearing loss

4 CONDUCTIVE HEARING LOSS SENSINEURAL HEARING LOSS

5 John 50 y.o, Diabetic on meds, hypertensive URI x 3 days Sudden-onset ringing in the left ear x 2 days Noticed decreased hearing yesterday same side Put off seeing a doctor because thought hearing loss caused by a sinus infection His wife felt that it was likely earwax plugging his ear canals and applied a Q-tip vigorously

6 Questions to ask John

7 Questions to ask John Side, onset, severity Tinnitus, vestibular symptoms History of otitis media, infection, systemic diseases, exposure to known ototoxic medications Head trauma, large ambient pressure changes Ear drainage Neurological symptoms: headache, weakness or asymmetry of the face

8 Questions to ask John Modifying factors eye irritation and redness HIV or syphilis infection and risk factors Family history of hearing loss

9 Diagnosis/Evaluation Patient history and physical examination Assessment with tuning fork tests and audiometry Distinguish SNHL from CHL Audiometric confirmation of idiopathic sensorineural hearing loss (ISSNHL) should evaluate patients with ISSNHL for retrocochlear pathology by obtaining a magnetic resonance imaging (MRI), auditory brainstem response (ABR), or audiometric follow-up.

10 SHOULD NOT AUTOMATICALLY order computerized tomography of the head/brain in the initial evaluation of a patient with presumptive SSHL obtain routine laboratory test

11 Physical examination TM inspected for perforation, drainage, or lesions. Neurologic examination, with attention to the cranial nerves (particularly 5, 7, 8) and to vestibular and cerebellar function.

12 Physical examination The eyes are examined for redness and photophobia, and the skin is examined for rash The Weber and Rinne tests require a tuning fork (512 Hz most common) to differentiate conductive from sensorineural hearing loss.

13 Physical examination What do you expect to find in John s case? Rinne Test + on left Rinne Test on left Rinne Test + on right Rinne Test on right

14 Physical examination What do you expect to find? Weber Test midline Weber Test lateralizes to the left side Weber Test lateralizes to the right side

15 Definitions SHL is a rapid-onset, occurring over a 72 hour period, of a subjective sensation of hearing impairment in one or both ears SSNHL is a subset of SHL that is a) sensorineural in nature and b) the decrease in hearing > 30dB, affecting at least three consecutive frequencies Idiopathic sudden sensorineural hearing loss (ISSNHL) is defined as SSNHL with no identifiable cause despite adequate investigation

16 ISSNHL The primary presenting symptom of SHL is a full or blocked ear Recovery depends on patient s age, presence of vertigo at onset, degree of hearing loss, and time between onset of hearing loss and treatment

17 Approach EXCLUSION OF CONDUCTIVE HEARING LOSS AUDIOMETRIC CONFIRMATION OF ISSNHL EXCLUDE RETROCOCHLEAR PATHOLOGY DISCUSSION OF OPTIONS WITH PATIENT INITIATE CORTICOSTEROID THERAPY!!!poorly controlled diabetes, TB, peptic ulcer disease!! Prednisone within 2 weeks after the diagnosis, with a recommended dose of 1 mg/kg/day (max: 60 mg/day), given as a single dose for day

18 Approach May offer HBOT within 3 months of diagnosis SALVAGE THERAPY: IT steroids CONSIDER BONE-ANCHORED IMPLANT FOLLOW-UP AUDIOMETRY within 6 months of diagnosis of ISSNHL. COUNSEL patients with incomplete recovery of hearing about the possible benefits of AMPLIFICATION and hearing-assistive technology (HAT)

19 Conclusion SSNHL is a life-altering disorder for patients and can be a challenging disorder for physician. SSNHL is an otologic emergency and requires early therapy to save hearing. The best form of therapy continues to be systemic steroids. However, IT steroids may provide another means of treating this disorder. IT steroids may be most beneficial as primary therapy in patients unable to take to systemic steroid therapy.

20 Conclusion Appropriate counseling for the patient with an audiologist is important to optimize hearing

21 One feels the excitement of hearing an untold story. John Franklin