Management of Sudden Bilateral Hearing Loss in HIV Patients

Introduction to Diagnostic Approach

The American Academy of Otolaryngology-Head and Neck Surgery recommends that a patient with HIV and sudden bilateral sensorineural hearing loss should undergo a dedicated magnetic resonance imaging (MRI) protocol of the internal auditory canal (IAC) that includes high-resolution 3D T2 sequences (FIESTA/CISS) combined with T1 sequences with gadolinium contrast 1, 2

Sudden bilateral hearing loss in an HIV patient is not considered idiopathic and requires thorough evaluation for underlying specific causes, as suggested by the American Academy of Otolaryngology-Head and Neck Surgery 3, 4, 5

The MRI protocol should include thin slices (≤1 mm) through the IAC and inner ear, and is highly sensitive for detecting vestibular schwannomas and other IAC pathologies, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 1, 2
T1 sequences with gadolinium contrast are essential for detecting meningeal enhancement (meningitis), enhancement of the eighth cranial nerve (neuritis), and inflammatory or neoplastic lesions, as suggested by the American Academy of Otolaryngology-Head and Neck Surgery 1, 2

Although the diagnostic yield for vestibular schwannoma in sudden hearing loss is low (<3%), MRI reveals abnormalities in 57% of cases, with 11% directly related to hearing loss, including inflammation of the cochlea or labyrinthitis, labyrinthine hemorrhage, meningeal enhancement suggestive of meningitis, vascular lesions or cerebrovascular disease, and demyelinating lesions, as reported by the American Academy of Otolaryngology-Head and Neck Surgery 2, 3, 5

In addition to MRI, the patient requires a lumbar puncture for cerebrospinal fluid (CSF) analysis if there is suspicion of meningitis or neurosyphilis, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 6, 3
Serology for syphilis (FTA-abs) should be performed, as syphilis can cause fluctuating bilateral hearing loss in HIV patients, as suggested by the American Academy of Otolaryngology-Head and Neck Surgery 6, 3
A complete audiometry should be performed as soon as possible and within 14 days of symptom onset, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 1

Initiate systemic corticosteroids immediately if the patient is within 2 weeks of onset (better prognosis with early treatment), as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 1
Request an MRI with a dedicated IAC protocol with FIESTA/CISS + T1 with contrast + FLAIR sequences, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 1, 2
Perform a lumbar puncture if there is clinical suspicion of meningitis or if the MRI shows meningeal enhancement, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 6, 3
Follow-up audiometry should be performed after completing treatment and within 6 months, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 1