Corticosteroid Management of Sudden Sensorineural Hearing Loss

Initial Systemic Therapy

• The American Academy of Otolaryngology–Head and Neck Surgery (AAO‑HNS) recommends offering oral corticosteroids as first‑line treatment, initiating prednisone 1 mg/kg/day (maximum 60 mg) for 7–14 days followed by a taper of similar length; treatment should begin as soon as possible, ideally within 14 days of symptom onset but benefits have been reported up to 6 weeks. 1
• Evidence for systemic steroids is equivocal (Cochrane review identified high risk of bias in available trials), yet they remain recommended because of the potential for hearing recovery and the short treatment course that limits serious adverse effects. [2][3]

Intratympanic Steroid Therapy (Alternative or Adjunct)

• Intratympanic (IT) steroid injections are not inferior to systemic steroids for patients who cannot receive systemic therapy (e.g., due to contraindications). [1][4]
• IT steroids achieve higher perilymph drug concentrations than systemic administration, supporting their efficacy. 4
• Dosing protocol (AAO‑HNS):
  
  • Dexamethasone 24 mg/mL (compounded) or 10 mg/mL (stock) or methylprednisolone 40 mg/mL (or 30 mg/mL).
  • Inject 0.4–0.8 mL into the middle ear, up to four injections over a 2‑week period.
  • After injection, keep the treated ear up for 15–30 minutes. 4
• A comparative study showed that a 24 mg/mL dexamethasone concentration produced >30 dB improvement in 53 % of patients versus 17 % with a 10 mg/mL concentration, suggesting higher concentrations are superior. 4

Contraindications to Systemic Steroids

• The guideline lists the following as specific contraindications to oral corticosteroids (AAO‑HNS):
  
  • Insulin‑dependent or poorly controlled diabetes,
  • Labile hypertension,
  • Glaucoma,
  • Active tuberculosis,
  • Peptic ulcer disease,
  • Prior psychiatric reactions to steroids. [1][4]

Salvage Intratympanic Therapy

• If hearing does not fully recover after ≈2 weeks of initial therapy or after the initial course fails, IT steroids may be offered as salvage treatment (AAO‑HNS). [1][3]5

Monitoring, Safety, and Adverse Effects

• Common oral steroid adverse effects (AAO‑HNS): hyperglycemia and weight gain (most frequent), insomnia, gastric irritation, mood changes, and increased infection risk. [1][4]5
• Treatment discontinuation occurs in about 37 % of patients because of adverse events. 5
• Serious side effects are rare with the recommended short (10–14 day) course. [1][4]
• Audiometric monitoring: obtain a baseline audiogram, repeat at the end of therapy, and perform interval audiograms for IT injections to guide early termination if hearing improves. [1][4]

Prognostic Factors

• Age: Patients > 65 years have a <20 % full‑recovery rate with IT steroids but retain a ≈50 % full‑recovery rate with oral steroids, favoring systemic therapy in the elderly. 1
• Timing: Earlier treatment correlates with better outcomes; benefit is still observed when therapy starts within 14 days and may extend to 6 weeks after onset. 1
• Spontaneous recovery occurs in ≈33–66 % of patients within the first 2 weeks, underscoring the importance of shared decision‑making regarding treatment versus watchful waiting. [2][3]

Antiviral Therapy

• The AAO‑HNS states that antiviral agents have insufficient evidence of benefit for sudden sensorineural hearing loss and are not recommended. [2][3]