Unilateral Sudden Hearing Loss With Poor Word Recognition

The next step is an urgent ENT referral, ideally within the same week, not a hearing-aid fitting. The audiogram shows a large unilateral asymmetry: left PTA 62 dB HL versus right 16 dB HL, with poor left word recognition. Unilateral or asymmetric sensorineural hearing loss of recent onset is a red flag because it may represent sudden sensorineural hearing loss, which is treated as an otologic emergency, or a retrocochlear lesion such as vestibular schwannoma. Although the patient is already 3 weeks from onset, referral is still warranted; steroid treatment is most effective early, but late presentation does not remove the need for assessment. MRI of the internal auditory canals with contrast is the key investigation to exclude retrocochlear pathology, and it should not be delayed while a hearing aid is tried. Fitting an aid now could delay diagnosis, create false reassurance, and complicate interpretation of later changes. The patient should be told that the aid may be useful later, but medical clearance and imaging come first. Because he lives far from ENT, the referral should be marked urgent and followed up by telephone rather than simply given as a routine appointment.

The left word-recognition score of 44% at 80 dB HL is disproportionately poor for a PTA of 62 dB HL and suggests degraded supra-threshold encoding, which can occur with cochlear damage but is also a retrocochlear warning sign. A single presentation level is insufficient: a performance-intensity function would show whether scores roll over at higher levels, and rollover would strengthen suspicion of retrocochlear disease. The absent left ipsilateral acoustic reflex at 105 dB HL must be interpreted cautiously. With a 62 dB HL PTA and a sloping loss, the reflex may be absent simply because the probe or eliciting stimulus falls in a region of significant cochlear loss; absence at maximum output is therefore not strongly localizing by itself. Reflex decay testing at 10 dB above reflex threshold could support retrocochlear involvement if positive, but a normal decay result does not exclude it. Neither test replaces imaging. Immediate management remains urgent ENT referral and MRI, with repeat audiometry to confirm the asymmetry and monitor change. The clinician should avoid over-interpreting one reflex result or one word-recognition score in isolation.

Counsel in plain language, without either minimising the problem or causing unnecessary alarm. Explain that the hearing in the left ear is markedly different from the right, that this pattern needs medical investigation, and that the scan is used to check the hearing nerve and inner ear, not because a specific diagnosis has already been made. Mention that many causes are treatable or benign, but that a unilateral loss should not be assumed to be ordinary age-related hearing loss. Advise him to report immediately any new vertigo, facial weakness, severe headache, or sudden further hearing loss. Discuss communication strategies for the waiting period: preferential seating, facing the speaker, reducing background noise, and asking others to speak clearly rather than shouting. Explain that a hearing aid may be considered after medical assessment, but that it is not the first step. Document the counselling, give written contact details, and arrange audiological review after ENT or MRI so that the plan is not lost between services.