A 49-year-old woman comes to the emergency department due to hearing loss. Upon awakening this morning, she was unable to hear out of her right ear. She also hears a loud ringing noise in her right ear. The patient has no ear pain or dizziness. This has never occurred before. She has no other medical conditions and takes no medications. Vital signs are within normal limits. On examination, the ear canals and tympanic membranes are clear. There is no middle ear effusion. Weber tuning fork examination lateralizes to the left. Air conduction is greater than bone conduction bilaterally. The remainder of the neurologic examination is normal. Which of the following is the most appropriate next step in management of this patient?

Question

A 49-year-old woman comes to the emergency department due to hearing loss.  Upon awakening this morning, she was unable to hear out of her right ear.  She also hears a loud ringing noise in her right ear.  The patient has no ear pain or dizziness.  This has never occurred before.  She has no other medical conditions and takes no medications.  Vital signs are within normal limits.  On examination, the ear canals and tympanic membranes are clear.  There is no middle ear effusion.  Weber tuning fork examination lateralizes to the left.  Air conduction is greater than bone conduction bilaterally.  The remainder of the neurologic examination is normal.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c12b_b477_8f63_2549e7e984d1_MD0005_00 This patient has a sudden hearing loss with no history of trauma or pain, a normal ear examination, and an otherwise normal neurologic examination. Tuning fork examination shows the hearing loss is sensorineural rather than conductive (Table). The etiology of sudden sensorineural hearing loss (SSNHL) is often not determined. Most cases likely represent viral infection, microvascular events, or an autoimmune process; in some cases, a tumor (eg, schwannoma) or other cause of sensorineural hearing loss is identified. SSNHL can lead to permanent hearing loss. Therefore, once isolated SSNHL (ie, otherwise normal examination) is recognized, urgent otolaryngology evaluation is indicated. Although study results have not been definitive, high-dose corticosteroids (and/or corticosteroids injected into the middle ear) are recommended soon after the onset of SSNHL (ideally within 24 hours) as they may improve hearing outcomes, particularly among patients with severe hearing loss. Their efficacy decreases over time, with no effect after 6 weeks; therefore, reassurance is inappropriate (Choice D). Many patients recover at least some (but often not all) hearing over a few weeks. Antiviral therapy (eg, valacyclovir) in combination with corticosteroids was not found to improve outcomes but is sometimes used if a viral etiology (eg, herpes simplex) is suspected. In addition, an MRI should be obtained to exclude vestibular schwannoma, and a formal audiogram should be performed for full characterization of the hearing loss and follow-up. (Choice A) Amoxicillin-clavulanic acid is often used to treat acute otitis media, which can cause a sudden hearing loss. However, the hearing loss would be conductive rather than sensorineural, the patient would likely have significant pain, and examination of the ears would show an opaque, bulging tympanic membrane. (Choice B) Aural irrigation is sometimes used to remove cerumen. Cerumen impaction can cause acute hearing loss, but it would be conductive rather than sensorineural, and the impaction would prevent examination of the tympanic membranes. (Choice C) Ciprofloxacin ear drops may be used to treat otitis externa. Although it can cause an acute conductive hearing loss, patients would have pain and itching of the ear, and examination would show a swollen, erythematous external auditory canal. Educational objective: Sudden hearing loss should be evaluated to determine if it is conductive or sensorineural. Sudden sensorineural hearing loss should be evaluated urgently by otolaryngology with a formal audiogram, MRI, and corticosteroid therapy. References: Clinical practice guideline: sudden hearing loss. (http://www.ncbi.nlm.nih.gov/pubmed/22383545)

A 49-Year-Old Woman Comes to the Emergency Department Due to Hearing