So this is a really important topic that I bet you all have in your office a person comes in, I can't hear, I woke up something's wrong on the right side, this is a medical emergency. And so we all need to be on the same page for what sudden sensory neural hearing loss um presents like and how we should treat it right away. So um as you all know hearing loss breaks up into conductive loss and sensory loss, conductive loss. You can pretty much see with your own telescopic exam there's gonna be wax, there's gonna be a hole in the air drum, there's going to be fluid. Um If you don't see any of those items and you see a normal eardrum you can assume its sensory. Um You can do tuning fork exams which we'll talk about in order to determine which side but the presentation. You know they may not come in saying I can't hear, they may commencing I feel full pressure underwater, muffled clogged, plugged or can't hear or roaring loud tenderness. Any of those things. Red alert could be a profound sensory loss. You look in their ear looks good, looks normal. That is a big warning sign. Normal exam with any of those um presenting symptoms should automatically get a hearing test, tuning fork exam. You know a lot of my E. N. T. Residents can't get this right, it's very confusing. You put the tuning fork on, I usually just put it right on the teeth with a four by four. Just forget the whole on the head. People have thick thick soft tissue. If you go right on the teeth, this is the most conductive component of the skull. So I put a four by four to protect for sterility. Put it right on the teeth. If if if if the patient hears it on the non complaining ear bingo, that's bad. So noncoms came in from my right ear but I'm hearing the sound only in my left. Okay, audio graham, if they hear it on the complaining ear then there's probably fluid that you couldn't quite pick up on the autodesk, api exam fluids really hard to see. And so that also needs an audio graham but probably dealing with some fluid in the middle ear and a conductive loss. Um This is what the audio graham would look like when they came in right side is normal, left side profound. The definition is 30 DB or greater loss over three contiguous audio gram frequencies. I'm very liberal on interpreting that. Um it doesn't have to be an exact definition. Any hearing loss is important to treat. Um what is the exact incident? It's it's not clear because many patients don't present to the doctor. Many patients are presenting to many different kinds of doctors. Heart doctors, it's hard to collect this data but it's thought that around 11 to 77 per 100,000 people per year. Any age can be affected most commonly forties to fifties, males equal females, 90% is idiopathic sudden sensory neural hearing loss. We think there may be a viral infectious component. The data on that is very limited cadaver studies where we looked at cadaver temporal bone specimens, they seem to have a higher viral load is very wishy washy data. We still need more studies. People can also have autoimmune ideologies, neurologic, metabolic vascular, auto toxic trauma, Nioplias, plasm um unilateral is much more common than bilateral. But if they do come in with, I can't hear on both sides. Those patients are usually older, usually with significant cardiovascular disease and uh positive A and A titles have been contributing associated with bilateral loss. Um looking at the national guidelines for sudden sensory neural hearing loss, serology is not necessary if you have a run of the mill patient limited targeted serology is recommended in certain patient populations. So if you're worried about infections cbc cmp, if you're worried about inflammation or auto immune, you can get, you know, you guys are all more familiar with all of these than we are really, you know, set rates rheumatoid factors. C reactive proteins A and a travel history. So Lyme disease. Uh sexual history. Syphilis. Um just a side note to me to to add some some interest to the talk. When I was a resident ST louis. We uncovered a syphilis ring in um in in the suburbs of ST louis very affluent area and that was uncomfortable. Um because my my teachers would make me go in and and you know these were much older men. Um And they were uncomfortable talking about sexual history. So they would make me as the female you know younger residents go in and talk about all this. And then and then we realized that these groups of people were all living in the same area and there was some exchanging going on. So sexual history. Syphilis is a big sudden sensory neural hearing loss um contributor HSV HIV and then don't forget the thyroid. So if you have a hypo thyroid hyper thyroid patient this can cause sudden sensory neural hearing last. Don't forget Covid. I'm seeing a huge influx of sudden sensory neural hearing loss. Post covid post vaccine, post booster. It's usually in the week window. Obviously there's nothing we can do to prove it. But there is data now from covid cadaver studies that Covid does live in the inner ear, it does live in the temporal bone. People are presenting with tinnitus new onset dizziness and new onset hearing loss. So don't forget Covid um Always obtain an M. R. I. Sudden sensory neural hearing last. Even if they respond to steroids, even if we get their hearing back must have an M. R. I. 1 to 5% of acoustic neuroma says will present with a sudden loss, 95 99% will present with that slow progressive unilateral hearing loss. But 1 to 5% will present with an acute loss must get an M. R. I. I've uncovered multiple cases of multiple sclerosis as sudden hearing loss being their presenting symptoms. And um although you look for other neurologic factors you can't forget stroke. Now obviously these patients you know you think about iCA strokes with sudden hearing loss. They will have a laundry list of other neurologic factors. Horner syndrome, diplo pia nystagmus facial weakness. So just anyone with a sudden loss needs an MRI I get I. A. C. With and without contrast and no need for cT scan. This was in the guidelines. No ct scan. This is our guideline clinical practice guideline that was put together by our associates are are otolaryngology. Academy steroids steroids are the key. The earlier the steroids the better the day they walk in your office before you even send them um after you have evidence of loss we must give steroids oral if possible. Obviously if they're diabetic other contraindications. You know I'm happy to see him same day for an injection into the ear. The earlier you give steroids the better they will do the longer we delay the worse the hearing outcomes. This is the regimen. This is not a med drawl dose pack. This is high dose. This is high dose. This is 60 mg for seven days, taper it off over the next seven days. I always protect the stomach with PriLOSEC and Benadryl for sleep disturbance at night. Um You can even do that before you get the M. R. I no harm or foul. So while usually they come into my office they haven't had an M. R. I. Start them on the oral steroids. Get the M. R. I. Come back in retest the hearing. If people want a full court press I'm happy to do an I. T. Dex injection as well. At the same time. The traditional gold standard as you try oral first you get the M. R. I. And you do a salvage with I. T. Injection. I do 24 mg per mil. And um I usually do three weeks and get sequential audio grams to see how we're doing. Plus or minus on the hyperbaric oxygen treatment. It is um given equivocal herbal recommendations by our guidelines. There is the FDA does not suggest it and therefore we can't get insurance to pay for it. But I've had several patients who have had a great response with the hyperbaric oxygen. The data is limited across the country in europe. Um People are doing all sorts of things. They they admit these patients to the hospital. They're giving them I've even as a dilation ivy thrown politic sai viva. So active substances really none of it has panned out as far as data. And so this is not standard of practice for us. Also in the in our guidelines antivirals were not um recommended. However you know there's really no harm or foul if you give them. But in our guidelines they are not recommended and actually strongly recommended against because of the data When I counsel folks. I tell folks that um the data shows that people break up into 3rd. 1/3 of folks with steroid intervention have uh back to normal improvement. One third will have some objective measure of improvement on their audio graham but not back up to normal and one third, no matter what we do, Chorale's injectables, hyperbaric will not have any improvement. The problem is I can't predict which group they'll fall into and so we treat everyone the same. Um I do not usually talk about hearing devices in the beginning of our situation because people really are traumatized. I wait until I'm seeing them back more and more and kind of gently start to introduce the interventions of hearing aids and cochlear implants sort of as they're mentally um preparing if we're not making progress and Becky. And I usually talk behind you know in the hall with the patients is very traumatic for the patient. So you sort of have to hold their hands through the process. So you know, take home message when in doubt, get an audio graham when in doubt. Start steroids early. Um and another another plug. Um and um here is my cell phone. I really try to keep up with the email, I fail miserably but I'm pretty good with my cell phone, you can call me or text me anytime. So
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