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ent.sudden-sensorineural-hearing-loss.core.v1PRODUCTION
ent.sudden-sensorineural-hearing-loss.core.v1

Sudden sensorineural hearing loss (SSNHL — otologic emergency)

general_internal_medicineacutesubacuteadultpediatric
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Frame SSNHL as an OTOLOGIC EMERGENCY (≥30 dB over ≥3 contiguous frequencies within ≤72 h) requiring the time-critical audiogram → MRI → steroid pathway. >90% is idiopathic (Chandrasekhar AAO-HNS 2019 PMID 31369359) but the engine first separates conductive loss and the can-not-miss vascular (AICA) cause. Stroke management is recognised then routed OUT, not authored here.

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SSNHL scope confirmed; not-this-engine concerns (stroke management) routed by engine_id

Patient inputs (16)

MRI internal auditory canal (or ABR if MRI contraindicated) evaluates retrocochlear pathology — vestibular schwannoma — and posterior fossa for infarction (AAO-HNS 2019 KAS 6 PMID 31369359)

Bedside tuning-fork triage: Weber lateralises to the BETTER ear (away from affected) and Rinne stays AC>BC in SNHL; opposite in conductive loss — the first decision point (AAO-HNS 2019 KAS 1)

Cerumen impaction, effusion, TM perforation, cholesteatoma → CONDUCTIVE loss (treat the ear, NOT a steroid SSNHL pathway); type-B tympanogram reframes the entire engine (AAO-HNS 2019 KAS 1)

Accompanying vertigo worsens SSNHL prognosis and raises Ménière / AICA priors; positional, episodic vs continuous pattern partitions the differential (Bogaz Braz J ORL 2015 PMID 26248967; Kim & Lee 2016 PMID 28030893)

Age >50, HTN, diabetes, AF, prior stroke/TIA, hypercoagulable state raise the labyrinthine-infarction prior for an otherwise "isolated" sudden deafness (Kim & Lee 2016 PMID 28030893)

Loss developing within ≤72 h over ≥3 contiguous frequencies defines SSNHL and opens the time-critical steroid window; gradual loss is not SSNHL (AAO-HNS 2019 KAS 1/4 PMID 31369359)

Unilateral is the idiopathic SSNHL norm; bilateral/recurrent sharply raises autoimmune / systemic / Ménière prior and changes workup (AAO-HNS 2019 KAS 2)

Formal audiogram CONFIRMS SNHL, quantifies severity and audiogram shape (flat/down-sloping/U-shaped worse prognosis), and dates the curve — obtain ASAP within 14 days (AAO-HNS 2019 KAS 4 PMID 31369359)

Any focal neuro deficit OR central HINTS (normal/abnormal-pattern head-impulse, direction-changing nystagmus, skew) → AICA/posterior-circulation stroke; can-not-miss pivot away from idiopathic SSNHL (Kim & Lee J Stroke 2016 PMID 28030893)

Treatment effect and prognosis decay with delay; initiating therapy ≥14 days from onset is an independent predictor of poor recovery (Perez Ferreira Neto Otolaryngol HNS 2021 PMID 33557702 — OR 0.250)

High-dose systemic corticosteroid causes hyperglycaemia; diabetes shifts the regimen toward intratympanic-primary steroid (AAO-HNS 2019 KAS 8/10 PMID 31369359)

Aminoglycosides, platinum chemotherapy, loop diuretics, salicylates — an identifiable (non-idiopathic) cause that changes management away from the steroid pathway (AAO-HNS 2019 KAS 2)

Lyme, syphilis, HIV, recent viral illness are identifiable causes that warrant targeted therapy rather than idiopathic-SSNHL steroids alone (AAO-HNS 2019 KAS 2/5)

Targeted (NOT routine — KAS 5 recommends against indiscriminate labs) ESR/CRP/ANA, RPR/treponemal, Lyme, HIV when bilateral/recurrent/young/systemic features point to a non-idiopathic cause (AAO-HNS 2019 KAS 2/5)

Baseline glucose (steroid hyperglycaemia) + creatinine/eGFR for steroid course safety and any contrast-MRI planning (AAO-HNS 2019 KAS 8)

Systemic high-dose steroid risk/benefit in pregnancy favours intratympanic delivery; gating for the corticosteroid axis (AAO-HNS 2019 KAS 8)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (7)

7 need judgement
  • informationallife_threateningaica_posterior_circulation_stroke_red_flag
    Sudden hearing loss WITH focal neuro deficit (diplopia, dysarthria, ataxia, facial palsy), central HINTS (normal/abnormal-pattern head-impulse with spontaneous nystagmus, direction-changing nystagmus, skew deviation), or sudden deafness on a high vascular-risk substrate (Kim & Lee J Stroke 2016 PMID 28030893; AAO-HNS 2019 KAS 2)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverebilateral_or_recurrent_ssnhl_autoimmune
    Bilateral simultaneous/sequential or recurrent sudden SNHL, especially rapidly progressive and steroid-responsive (AAO-HNS 2019 KAS 2 PMID 31369359)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveretreatment_window_closing
    Time from symptom onset approaching/exceeding 2 weeks (initial steroid window) or salvage approaching 6 weeks; treatment ≥14 days from onset is an independent poor-prognosis predictor (Perez Ferreira Neto Otolaryngol HNS 2021 PMID 33557702 — recovery OR 0.250)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereprofound_loss_poor_prognosis
    Severe-to-profound presenting loss on the first audiogram (the strongest independent poor-prognosis predictor) ± accompanying vertigo ± down-sloping/flat/U-shaped curve (Perez Ferreira Neto 2021 PMID 33557702 — OR 6.6; Bogaz Braz J ORL 2015 PMID 26248967; Wen Eur Arch ORL 2013 PMID 23771280)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateretrocochlear_mri_indicated
    Asymmetric/unilateral SNHL — MRI internal auditory canal (or ABR if MRI contraindicated) indicated to evaluate retrocochlear pathology (vestibular schwannoma) (AAO-HNS 2019 KAS 6 PMID 31369359)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateidentifiable_ototoxic_or_infectious_cause
    Identifiable non-idiopathic cause: aminoglycoside/platinum/loop-diuretic ototoxicity, or Lyme/syphilis/HIV/specific viral infection (AAO-HNS 2019 KAS 2/5)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildconductive_loss_exit_pathway
    Bedside Weber lateralises TOWARD the affected ear / Rinne BC>AC / abnormal otoscopy (cerumen impaction, middle-ear effusion, TM perforation, cholesteatoma) — conductive, not sensorineural (AAO-HNS 2019 KAS 1 PMID 31369359)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Idiopathic SSNHL — time-critical corticosteroid (systemic / intratympanic) ± HBOT salvage
axis: ssnhl_corticosteroid_time_criticalstep 1 - Step 1 — Confirm SNHL & exclude conductive / central before steroids
Selected step "Step 1 — Confirm SNHL & exclude conductive / central before steroids" — Sudden ≤72 h hearing loss; bedside Weber lateralises away from affected ear + AC>BC Rinne + normal otoscopy/tympanogram (SNHL, not conductive); no focal neuro deficit / central HINTS (AICA stroke excluded or routed)
  • audiogram_confirmation_no_steroid_if_conductive_or_central
    first line
    decision_gate
    triggers: conductive_pattern, central_hints, focal_neuro_deficit
    AAO-HNS 2019 KAS 1 (Chandrasekhar PMID 31369359) — distinguish SNHL from conductive FIRST; conductive loss → treat the ear (cerumen/effusion/ENT), do NOT enter the steroid pathway. Central HINTS / focal deficit → route to neuro.posterior-circulation-stroke.core.v1 (Kim & Lee 2016 PMID 28030893).

outpatient playbook — drug actions (3)

  1. 1. prednisone (idiopathic SSNHL, within 2 weeks)
    rxcui 8640
    60 mg/day • PO • once daily ×10-14 d then ~5-d taper
    trigger: Confirmed idiopathic SSNHL, no systemic-steroid contraindication, within 2 weeks of onset (AAO-HNS 2019 KAS 8; Rauch JAMA 2011 PMID 21610239)
    High-dose systemic corticosteroid as initial therapy; counsel evidence limits (KAS 7)
  2. 2. intratympanic dexamethasone (steroid-contraindicated primary OR 2-6 wk salvage)
    rxcui 3264
    ~10-24 mg/mL transtympanic • intratympanic • ~3-4 injections over 2-4 wk
    trigger: Diabetic/pregnant/oral-intolerant (primary) OR incomplete recovery 2-6 weeks (salvage) (AAO-HNS 2019 KAS 10)
    Non-inferior to oral as primary (Rauch JAMA 2011 PMID 21610239); recommended salvage 2-6 weeks (KAS 10)
  3. 3. HBOT + steroid (severe/profound, facility available)
    per HBOT protocol • hyperbaric • ≤2 wk initial / ≤1 mo salvage
    trigger: Severe/profound loss, combined with steroid (AAO-HNS 2019 KAS 9a/9b; Rhee JAMA Oto 2018 PMID 30267033)
    Adjunct only when combined with steroid; greatest benefit in severe/profound loss

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Sudden (≤72 h) unilateral hearing loss / aural fullness ± tinnitus — presumptive SSNHL until conductive loss excluded (AAO-HNS 2019 KAS 1, Chandrasekhar Otolaryngol HNS 2019 PMID 31369359); Sudden hearing loss WITH vertigo / imbalance — combined audiovestibular loss; raises vascular (AICA) and Ménière priors (Kim & Lee J Stroke 2016 PMID 28030893); Sudden hearing loss WITH any focal neurologic sign (diplopia, dysarthria, ataxia, facial weakness, central HINTS) — posterior-circulation/AICA stroke until proven otherwise (KAS 2; Kim & Lee 2016 PMID 28030893).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Sudden sensorineural hearing loss (SSNHL — otologic emergency)** (ent.sudden-sensorineural-hearing-loss.core.v1).
Phenotype framing: Terminal differential with named pivots: idiopathic SSNHL (isolated SNHL, normal MRI/neuro — the >90% default) vs conductive loss (Weber TOWARD affected ear + abnormal otoscopy/tympanogram pivot) vs vestibular schwannoma (asymmetric SNHL + MRI IAC enhancement + retrocochlear ABR pivot) vs Ménière (episodic vertigo + fluctuating low-frequency SNHL + aural fullness + tinnitus pivot) vs AICA / posterior-circulation infarction (other neuro signs / central-HINTS / vascular-risk pivot) vs autoimmune inner-ear (bilateral, rapidly progressive, steroid-responsive, recurrent pivot) vs ototoxic / infectious (identifiable exposure pivot)
Scope: Frame SSNHL as an OTOLOGIC EMERGENCY (≥30 dB over ≥3 contiguous frequencies within ≤72 h) requiring the time-critical audiogram → MRI → steroid pathway. >90% is idiopathic (Chandrasekhar AAO-HNS 2019 PMID 31369359) but the engine first separates conductive loss and the can-not-miss vascular (AICA) cause. Stroke management is recognised then routed OUT, not authored here.

No severity triggers fired against current inputs.

Plan

Regimen axis: **Idiopathic SSNHL — time-critical corticosteroid (systemic / intratympanic) ± HBOT salvage** — step "Step 1 — Confirm SNHL & exclude conductive / central before steroids".
1. audiogram_confirmation_no_steroid_if_conductive_or_central (decision_gate, first line) — AAO-HNS 2019 KAS 1 (Chandrasekhar PMID 31369359) — distinguish SNHL from conductive FIRST; conductive loss → treat the ear (cerumen/effusion/ENT), do NOT enter the steroid pathway. Central HINTS / focal deficit → route to neuro.posterior-circulation-stroke.core.v1 (Kim & Lee 2016 PMID 28030893).

Setting playbook (outpatient) — Urgent ENT/neurotology pathway: confirm SNHL vs conductive at the bedside, obtain audiogram ASAP (≤14 d), exclude the AICA/central cause, start systemic (or intratympanic) corticosteroid within the 2-week window, arrange MRI IAC, book recovery audiometry (AAO-HNS 2019 KAS 1/4/6/8/12 PMID 31369359)
2. prednisone (idiopathic SSNHL, within 2 weeks) 60 mg/day PO once daily ×10-14 d then ~5-d taper — Confirmed idiopathic SSNHL, no systemic-steroid contraindication, within 2 weeks of onset (AAO-HNS 2019 KAS 8; Rauch JAMA 2011 PMID 21610239) (High-dose systemic corticosteroid as initial therapy; counsel evidence limits (KAS 7))
3. intratympanic dexamethasone (steroid-contraindicated primary OR 2-6 wk salvage) ~10-24 mg/mL transtympanic intratympanic ~3-4 injections over 2-4 wk — Diabetic/pregnant/oral-intolerant (primary) OR incomplete recovery 2-6 weeks (salvage) (AAO-HNS 2019 KAS 10) (Non-inferior to oral as primary (Rauch JAMA 2011 PMID 21610239); recommended salvage 2-6 weeks (KAS 10))
4. HBOT + steroid (severe/profound, facility available) per HBOT protocol hyperbaric ≤2 wk initial / ≤1 mo salvage — Severe/profound loss, combined with steroid (AAO-HNS 2019 KAS 9a/9b; Rhee JAMA Oto 2018 PMID 30267033) (Adjunct only when combined with steroid; greatest benefit in severe/profound loss)

Non-pharmacologic actions:
- Order MRI internal auditory canal (or ABR if MRI contraindicated) for retrocochlear/posterior-fossa evaluation (KAS 6)
- Withhold routine non-targeted head CT and indiscriminate blood panels (KAS 3/5 — strong recs AGAINST)
- Counsel natural history, benefits/risks, and the limits of the evidence (KAS 7)
- Book audiometry at conclusion of treatment and within 6 months (KAS 12)

AVOID / contraindication checks:
- Do not steroid treat conductive loss (AAO HNS 2019 KAS 1 PMID 31369359 — treat the ear; cerumen/effusion/perforation is not the SSNHL pathway)
- Central hints or focal deficit route to stroke engine (Kim & Lee J Stroke 2016 PMID 28030893 — AICA/posterior circulation infarction is a stroke emergency, not managed here)
- Systemic high dose steroid hyperglycaemia in diabetes prefer intratympanic (AAO HNS 2019 KAS 8/10)
- Systemic high dose steroid pregnancy risk prefer intratympanic (AAO HNS 2019 KAS 8)
- Do not routinely prescribe antivirals thrombolytics vasodilators vasoactive (AAO HNS 2019 KAS 11 strong rec AGAINST; antivirals only if a specific infection is identified)
- Do not order routine non targeted head CT or indiscriminate labs (AAO HNS 2019 KAS 3/5 strong recs AGAINST)

Monitoring

Regimen monitoring:
- repeat audiogram at conclusion of treatment and within 6 months (AAO-HNS 2019 KAS 12 PMID 31369359)
- assess incomplete recovery at 2 to 6 weeks to trigger intratympanic salvage (KAS 10)
- steroid course glucose BP mood GI surveillance (KAS 8)
- intratympanic injection tolerance otalgia transient vertigo TM perforation
- closed loop MRI IAC or ABR retrocochlear result (KAS 6)

Setting (outpatient) monitoring:
- Recovery audiogram at end of treatment + within 6 months (KAS 12)
- Reassess at 2-6 weeks for incomplete recovery → intratympanic salvage (KAS 10)
- Return precautions: any new focal neuro sign/diplopia/ataxia/severe headache → emergent stroke pathway (Kim & Lee 2016 PMID 28030893)

Follow-up plan: Counsel natural history and the limits of the evidence (KAS 7); for residual hearing loss and/or tinnitus, offer or refer for audiologic rehabilitation — hearing aids, CROS/BiCROS, cochlear implant for profound non-recovery, tinnitus management (KAS 13). Ensure the retrocochlear MRI/ABR result is closed-looped; recurrent/bilateral disease → autoimmune/systemic and neurotology follow-up. Headache/neuro re-presentation → re-screen for delayed posterior-circulation events.
- Close-out criterion: rehabilitation plan + tinnitus counselling documented; MRI/ABR result closed; recurrence and stroke-recurrence safety-net set

Monitoring phase: Repeat audiometry at the conclusion of treatment and within 6 months of completion (KAS 12) to quantify recovery; assess for incomplete recovery at 2-6 weeks to trigger intratympanic SALVAGE (KAS 10); monitor steroid course (glucose, BP, mood, GI) and intratympanic-injection tolerance (otalgia, transient vertigo, TM perforation).

Disposition

Current setting: outpatient — Urgent ENT/neurotology pathway: confirm SNHL vs conductive at the bedside, obtain audiogram ASAP (≤14 d), exclude the AICA/central cause, start systemic (or intratympanic) corticosteroid within the 2-week window, arrange MRI IAC, book recovery audiometry (AAO-HNS 2019 KAS 1/4/6/8/12 PMID 31369359)

Disposition criteria:
- Outpatient urgent-ENT management for confirmed idiopathic SSNHL with steroid + MRI + audiology follow-up
- Conductive loss → exit SSNHL pathway, treat the ear (cerumen/effusion/ENT)
- Stroke / systemic-emergency cases → route OUT and admit per receiving engine

Escalation triggers (move to higher acuity):
- Focal neuro deficit / central HINTS / high vascular-risk → route to neuro.posterior-circulation-stroke.core.v1 (Kim & Lee 2016 PMID 28030893)
- Bilateral / rapidly progressive / recurrent → autoimmune inner-ear / systemic workup + neurotology
- Profound loss not recovering after salvage → cochlear-implant candidacy referral (KAS 13)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Sudden hearing loss WITH focal neuro deficit (diplopia, dysarthria, ataxia, facial palsy), central HINTS (normal/abnormal-pattern head-impulse with spontaneous nystagmus, direction-changing nystagmus, skew deviation), or sudden deafness on a high vascular-risk substrate (Kim & Lee J Stroke 2016 PMID 28030893; AAO-HNS 2019 KAS 2)
- [SEVERE] Bilateral simultaneous/sequential or recurrent sudden SNHL, especially rapidly progressive and steroid-responsive (AAO-HNS 2019 KAS 2 PMID 31369359)
- [SEVERE] Time from symptom onset approaching/exceeding 2 weeks (initial steroid window) or salvage approaching 6 weeks; treatment ≥14 days from onset is an independent poor-prognosis predictor (Perez Ferreira Neto Otolaryngol HNS 2021 PMID 33557702 — recovery OR 0.250)

Citations

- AAO-HNS Clinical Practice Guideline: Sudden Hearing Loss (Update) — Chandrasekhar et al, Otolaryngol Head Neck Surg 2019;161(1_suppl):S1-S45 (PMID 31369359) + Executive Summary (PMID 31369349) — verified 2026-05-17 as still the current AAO-HNS authority (no 2024/2025 replacement). Supplemented by Rauch JAMA 2011 oral-vs-intratympanic steroid RCT (PMID 21610239), Wei Cochrane 2013 steroid review (PMID 23818120), Rhee JAMA Otolaryngol HNS 2018 HBOT meta-analysis (PMID 30267033), and Kim & Lee J Stroke 2016 vascular audiovestibular loss / AICA infarction (PMID 28030893). [PMID:31369359](https://pubmed.ncbi.nlm.nih.gov/31369359/)
- Cited evidence (PMID 31369349) [PMID:31369349](https://pubmed.ncbi.nlm.nih.gov/31369349/)
- Cited evidence (PMID 21610239) [PMID:21610239](https://pubmed.ncbi.nlm.nih.gov/21610239/)
- Cited evidence (PMID 22805100) [PMID:22805100](https://pubmed.ncbi.nlm.nih.gov/22805100/)
- Cited evidence (PMID 23818120) [PMID:23818120](https://pubmed.ncbi.nlm.nih.gov/23818120/)

Last reconciled with current guidelines: 2026-05-17.
References
  • AAO-HNS Clinical Practice Guideline: Sudden Hearing Loss (Update) — Chandrasekhar et al, Otolaryngol Head Neck Surg 2019;161(1_suppl):S1-S45 (PMID 31369359) + Executive Summary (PMID 31369349) — verified 2026-05-17 as still the current AAO-HNS authority (no 2024/2025 replacement). Supplemented by Rauch JAMA 2011 oral-vs-intratympanic steroid RCT (PMID 21610239), Wei Cochrane 2013 steroid review (PMID 23818120), Rhee JAMA Otolaryngol HNS 2018 HBOT meta-analysis (PMID 30267033), and Kim & Lee J Stroke 2016 vascular audiovestibular loss / AICA infarction (PMID 28030893). — PMID:31369359
  • Cited evidence (PMID 31369349) — PMID:31369349
  • Cited evidence (PMID 21610239) — PMID:21610239
  • Cited evidence (PMID 22805100) — PMID:22805100
  • Cited evidence (PMID 23818120) — PMID:23818120