For patients who present with new hearing loss, it remains essential to exclude conductive hearing loss when evaluating for sudden sensorineural hearing loss (SSNHL), according to an updated clinical practice guideline by the American Academy of Otolaryngology–Head and Neck Surgery Foundation published August 1 in Otolaryngology–Head and Neck Surgery. The updated guideline, which replaces the 2012 document, includes the addition of 29 new systematic reviews and 36 new randomized controlled trials, as well as an algorithm for clinical implementation of its key action statements. Most cases of SSNHL are idiopathic. SSNHL can result in permanent hearing loss, tinnitus, and lower quality of life if not recognized and swiftly treated. An estimated five to 27 people per 100,000 have SSNHL. The annual incidence is 66,000 cases, according to the guideline. "The initial recommendations of this guideline update address distinguishing sensorineural hearing loss from conductive hearing loss" and "clarify the need to identify rare, nonidiopathic sudden sensorineural hearing loss to help separate those patients from those with idiopathic sudden sensorineural hearing loss," which is the guideline's target population, write Sujana S. Chandrasekhar, MD, of ENT & Allergy Associates in New York City, and colleagues. "By focusing on opportunities for quality improvement, this guideline should improve diagnostic accuracy, facilitate prompt intervention, decrease variations in management, reduce unnecessary tests and imaging procedures, and improve hearing and rehabilitative outcomes for affected patients," the authors write. Patients often first present in their primary care office or in an urgent care clinic or emergency department with dizziness, which occurs in 30% to 60% of cases. "Sudden hearing loss is a frightening symptom for patients that can dramatically decrease their quality of life," coauthor Seth R. Schwartz, MD, MPH, of Virginia Mason Medical Center in Seattle, Washington, said in a news statement. "Prompt recognition and management of sudden sensorineural hearing loss may improve hearing recovery and quality of life." The new guideline includes 14 key action statements, several of which advise against unnecessary, routine interventions in the evaluation or management of SSNHL. These include routine CT scanning of the head during initial evaluation. Targeted CT, such as temporal bone CT to evaluate possible pathology, may be appropriate when indicated, however. "The most clinically important for nonotolaryngologists to know is the guideline advising avoidance of noncontrast head CTs for patients with sudden hearing loss who do not have any other neurologic signs/symptoms," Pamela Roehm, MD, PhD, director of the Division of Otology and Neurotology at Temple University's Lewis Katz School of Medicine, Philadelphia, Pennsylvania, told Medscape Medical News. Roehm was not involved with writing the guideline. "A huge amount of money is spent on these scans for these patients, and these scans are invariably not useful in the evaluation of patients with sudden hearing loss who have otherwise normal neurologic examinations," she said. The guideline also advises against routine laboratory testing of patients with SSNHL and routine prescribing of antivirals, thrombolytics, vasodilators, or vasoactive substances. "Laboratory testing is also very very frequently not helpful and should be directed based on the patient's presentation, because it also drives up the cost of healthcare and sometimes can yield false positive diagnoses, which contribute further to patient anxiety and healthcare expense," Roehm explained. The updated guideline further excludes audiometric follow-up in retrocochlear pathology workups. Instead, it recommends MRI, or if MRI isn't an option, CT or auditory brain-stem response evaluation. The guidance highlights in particular the importance of obtaining audiometric confirmation of patients' hearing status within the first 2 weeks after symptom onset. It also indicates that corticosteroids may be offered as initial therapy for patients with SSNHL within 2 weeks of symptom onset. A related addition to the guideline is a recommendation for follow-up audiometry after treatment ends and at 6-month follow-up. The guideline further discusses intratympanic steroid therapy for salvage within 2 to 6 weeks after SSNHL and no longer advises against use of antioxidants. Although Roehm said she still prescribes steroids to her patients who have sudden hearing loss, it is not a universally accepted practice and is less common in Europe. "The natural history of idiopathic sudden sensorineural hearing loss is that it will often improve within the first month without treatment at all," she told Medscape Medical News. "It can be very difficult to disentangle the natural history of the disease from the treatment, and most studies of use of steroids or other treatments for these patients do not have sufficient power to address this controversy." Roehm was surprised that the guideline continues to recommend hyperbaric oxygen therapy. Although it remains a treatment option, the guideline recommends that it be used only concurrently with steroids for initial treatment (within 2 weeks of onset) or salvage therapy (within 1 month of onset). The new guideline emphasizes the importance of shared decision making — along with tools for doing so — and strongly recommends that patients be educated regarding the natural history of SSNHL, the risks and benefits of medical interventions, and the limited evidence on efficacy of interventions. The authors strongly recommend, "Clinicians should counsel patients with sudden sensorineural hearing loss who have residual hearing loss and/or tinnitus about the possible benefits of audiological rehabilitation and other supportive measures." The research was funded by the American Academy of Otolaryngology–Head and Neck Surgery Foundation. Lead author Chandrasekhar has financial relationships with Novus Therapeutics, Tusker Medical, Castle Creek Pharma, and Scientific Development and Research. Relevant financial relationships for other authors are listed in the original article. Roehm has disclosed no relevant financial relationships. The guideline also advises against routine laboratory testing of patients with SSNHL and routine prescribing of antivirals, thrombolytics, vasodilators, or vasoactive substances. "Laboratory testing is also very very frequently not helpful and should be directed based on the patient's presentation, because it also drives up the cost of healthcare and sometimes can yield false positive diagnoses, which contribute further to patient anxiety and healthcare expense," Roehm explained. The updated guideline further excludes audiometric follow-up in retrocochlear pathology workups. Instead, it recommends MRI, or if MRI isn't an option, CT or auditory brain-stem response evaluation. The guidance highlights in particular the importance of obtaining audiometric confirmation of patients' hearing status within the first 2 weeks after symptom onset. It also indicates that corticosteroids may be offered as initial therapy for patients with SSNHL within 2 weeks of symptom onset. A related addition to the guideline is a recommendation for follow-up audiometry after treatment ends and at 6-month follow-up. The guideline further discusses intratympanic steroid therapy for salvage within 2 to 6 weeks after SSNHL and no longer advises against use of antioxidants. Although Roehm said she still prescribes steroids to her patients who have sudden hearing loss, it is not a universally accepted practice and is less common in Europe. "The natural history of idiopathic sudden sensorineural hearing loss is that it will often improve within the first month without treatment at all," she told Medscape Medical News. "It can be very difficult to disentangle the natural history of the disease from the treatment, and most studies of use of steroids or other treatments for these patients do not have sufficient power to address this controversy." Roehm was surprised that the guideline continues to recommend hyperbaric oxygen therapy. Although it remains a treatment option, the guideline recommends that it be used only concurrently with steroids for initial treatment (within 2 weeks of onset) or salvage therapy (within 1 month of onset). The new guideline emphasizes the importance of shared decision making — along with tools for doing so — and strongly recommends that patients be educated regarding the natural history of SSNHL, the risks and benefits of medical interventions, and the limited evidence on efficacy of interventions. The authors strongly recommend, "Clinicians should counsel patients with sudden sensorineural hearing loss who have residual hearing loss and/or tinnitus about the possible benefits of audiological rehabilitation and other supportive measures." The research was funded by the American Academy of Otolaryngology–Head and Neck Surgery Foundation. Lead author Chandrasekhar has financial relationships with Novus Therapeutics, Tusker Medical, Castle Creek Pharma, and Scientific Development and Research. Relevant financial relationships for other authors are listed in the original article. Roehm has disclosed no relevant financial relationships. Otolaryngol Head and Neck Surg. Published online August 1, 2019. Full text Source
