A 62-Year-Old with Sudden Hearing Loss and Vertigo
A 62-year-old woman presents to the emergency department with a 3-day history of sudden profound hearing loss in the left ear, associated with severe rotatory vertigo, nausea, and vomiting. She has no prior ear disease. She has a history of hypertension and type 2 diabetes, both well controlled. On examination, she is unable to stand unaided due to vertigo. Otoscopy is normal bilaterally. There is no facial weakness. Nystagmus is present, beating to the right. She has a mild left-sided sensorineural hearing loss on bedside tuning fork testing, with a negative Rinne on the left. The on-call junior doctor has arranged a CT head, which is reported as normal.
1. What is the most likely diagnosis, and what is the critical error in the current workup?
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Most likely diagnosis: Idiopathic sudden sensorineural hearing loss (SSNHL) - left-sided, with associated vertigo. The combination of sudden unilateral SNHL and vertigo in a patient with vascular risk factors raises the possibility of a labyrinthine infarct (anterior inferior cerebellar artery territory), which must be considered.
Critical error: A CT head is the wrong first-line investigation for sudden SNHL.
- CT is insensitive for acute ischaemia and for inner ear pathology; it does not exclude a retrocochlear lesion or stroke.
- The correct imaging is MRI with contrast (including diffusion-weighted imaging) to exclude:
- AICA territory infarct / labyrinthine ischaemia - DWI is essential.
- Vestibular schwannoma - although a 3-day history makes this less likely as the cause of sudden loss, it must be excluded.
- Audiometry should be performed urgently to confirm and quantify the loss; bedside tuning forks are a screening tool only.
Other critical gaps in the workup:
- No formal audiogram.
- No assessment of the vertigo pattern (peripheral vs central) - the right-beating nystagmus with left SNHL is consistent with a left peripheral lesion (destructive left labyrinth), but central causes must be excluded.
- No assessment of posterior circulation symptoms (diplopia, dysarthria, dysphagia, limb weakness).
Immediate action: Urgent MRI with DWI, urgent audiometry, and involvement of stroke neurology if any central features are present.
2. Assuming MRI excludes stroke and a retrocochlear lesion, and audiometry confirms a left severe-to-profound SNHL, outline your management and the evidence base for it.
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Management of idiopathic SSNHL:
High-dose corticosteroids - the mainstay. Options:
- Oral prednisolone 1 mg/kg/day (max 60 mg) for 7-14 days, then taper. Start as soon as possible - outcomes are best with early treatment (within 72 hours, and up to 2 weeks).
- Intratympanic steroids (e.g., dexamethasone 10 mg/mL or methylprednisolone) - used as primary therapy where systemic steroids are contraindicated (uncontrolled diabetes, peptic ulcer, severe hypertension) or as salvage therapy after failed oral steroids.
- Combination oral + intratympanic is used in severe/profound loss in some protocols.
Salvage intratympanic steroids if no recovery after 2 weeks of oral therapy - reasonable evidence for modest benefit.
Address vascular risk factors - optimise blood pressure and glycaemic control; involve physicians.
Vestibular suppressants and antiemetics for acute vertigo (short course), with early vestibular rehabilitation.
Hearing rehabilitation - hearing aid or CROS aid if loss is permanent; cochlear implant assessment if profound bilateral loss (not applicable here unless contralateral ear affected).
Evidence base:
- Corticosteroids are supported by systematic reviews and are standard of care, although the evidence is modest and some trials show limited benefit.
- Intratympanic steroids have good evidence as salvage therapy and as primary therapy in patients who cannot take systemic steroids.
- Vasodilators, antivirals, and hyperbaric oxygen have limited or no consistent evidence; antivirals are not routinely recommended.
Prognosis: Recovery is best with milder loss, younger age, and early treatment. Severe-to-profound loss with vertigo carries a poorer prognosis.
3. The patient's vertigo persists at 6 weeks despite steroid therapy, and her hearing has not recovered. She is now housebound. How would you manage her vertigo, and what is the role of imaging at this stage?
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Management of persistent vertigo after SSNHL:
Confirm the diagnosis - repeat MRI with contrast (internal auditory meatus protocol) if not already done, to exclude a missed vestibular schwannoma or other retrocochlear pathology. At 6 weeks, imaging is still indicated if not already performed.
Vestibular rehabilitation therapy (VRT) - first-line for chronic unilateral vestibular hypofunction. Refer to a vestibular physiotherapist; this is the single most effective intervention for chronic dizziness.
Vestibular suppressants (e.g., prochlorperazine, betahistine, cinnarizine) - only for short-term symptom control; prolonged use impairs central compensation and should be avoided.
Treat contributing factors - anxiety, sleep disturbance, and deconditioning are common and worsen symptoms; consider psychological support.
Counselling - explain the expected course of central compensation (weeks to months) and set realistic expectations.
If vertigo remains disabling despite VRT and conservative measures - consider:
- Chemical labyrinthectomy (intratympanic gentamicin) - reasonable when hearing is already non-serviceable.
- Surgical labyrinthectomy - reserved for intractable cases with non-serviceable hearing.
- Vestibular nerve section - rarely needed.
Role of imaging at this stage:
- MRI with contrast remains indicated if not already done, to exclude a retrocochlear lesion.
- If MRI was normal at presentation, repeat imaging is not routinely required unless new symptoms (e.g., facial weakness, progressive loss) develop.
Key point: The priority is rehabilitation and compensation, not indefinite suppression. Escalation to ablative procedures is reserved for failure of conservative management with non-serviceable hearing.