The 70-Year-Old with Sudden Hearing Loss and Vertigo
A 70-year-old woman presents with sudden onset of right-sided hearing loss and rotatory vertigo that began 2 days ago. She also reports tinnitus in the right ear. She has hypertension and type 2 diabetes, both reasonably controlled. She has no facial weakness, no headache, and no neurological symptoms. Otoscopy is normal bilaterally. She is concerned and asks whether she should 'wait and see' because her GP said it might settle.
1. Is 'wait and see' appropriate? Justify your answer.
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No - sudden sensorineural hearing loss (SSNHL) is an otological emergency.
Reasoning:
- SSNHL is defined as ≥30 dB loss across three contiguous frequencies over ≤72 hours. It is a medical emergency because outcomes are time-dependent: early treatment (particularly corticosteroids) improves the chance of recovery.
- The presence of vertigo suggests a more severe insult (possibly vestibular involvement) and is associated with a worse prognosis, but does not change the need for urgent action.
- Her vascular risk factors (hypertension, diabetes) raise the possibility of a vascular cause, but the management principle is the same: urgent assessment and treatment.
Action: Urgent same-day/next-day ENT assessment with pure-tone audiometry to confirm and quantify the loss, and initiation of treatment without delay. 'Wait and see' risks permanent hearing loss.
2. What investigations and treatment would you initiate, and what would you exclude?
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Investigations:
- Pure-tone audiometry (essential to confirm and grade the loss).
- MRI of the internal auditory meatus with contrast (to exclude retrocochlear pathology such as vestibular schwannoma, and to look for causes such as stroke or demyelination) - particularly given vertigo and vascular risk factors.
- Blood tests: full blood count, glucose/HbA1c, lipids, autoimmune screen (e.g. ANA, ANCA) if indicated, and syphilis serology where relevant.
Treatment:
- High-dose oral corticosteroids (or intratympanic steroids, or both) started promptly, with tapering.
- Consider intratympanic steroids if oral steroids are contraindicated (e.g. poorly controlled diabetes) or as salvage therapy.
- Manage vascular risk factors.
- Vestibular rehabilitation for persistent vertigo.
Exclude/consider:
- Retrocochlear lesion (MRI).
- Vascular event (posterior circulation stroke) - red flags would include neurological symptoms, but MRI is still warranted.
- Autoimmune inner ear disease, infection (e.g. syphilis, Lyme where relevant).
Judgement: The critical decision is to treat urgently rather than observe, and to arrange MRI to exclude a structural cause.