Sudden sensorineural hearing loss – Sudden Deafness
Ross Hauser, MD
There is controversy in regard to the optimal management or treatment of sudden sensorineural hearing loss because frequently spontaneous recovery or remission occurs and the patient’s hearing “simply” returns. It is likely that if you are reading this article you had deafness come on suddenly, as the diagnosis implies, and you are now learning about this problem. Your doctors may have told you they are not sure what caused this problem but it may be related to other symptoms such as dizziness, tinnitus, or a sensation of ear fullness or “pressure within the ear.” Then again, it can be caused by many problems. As we will see in the research below, half of the patients may recover hearing without treatment or simple treatments and the use of steroid injections into the ear may bring this number closer to an 80% recovery of some hearing. But what if you do not respond? I hope this article will answer some questions for you.
- “They tell me I have suffered an ear stroke but I can hear during chiropractic adjustments.”
- Sudden sensorineural hearing loss, causes, and treatment.
- Concerns over ear drum injections: How accurate are patient outcomes for intratympanic steroid treatment of idiopathic sudden sensorineural hearing loss?
“They tell me I have suffered an ear stroke but I can hear during chiropractic adjustments.”
People will contact our center with a medical history that goes something like this:
I experienced sudden onset hearing loss (SSHL) with complete deafness in my right ear. Over the past few months, I have been to many specialists, and had many tests including MRIs, MRAs, CTA (Computed Tomography Angiography) scans, and more. I have been prescribed oral steroids, I have had steroid injections in my eardrum, I have tried a hyperbaric chamber, and more. Nothing helps except maybe a chiropractor. I have had major traumatic injuries to my right side. I have a history of migraine, shoulder pain, and injury and now a spine doctor is showing bone spurs and straightening of c spine.
ENTs and Neurologists are telling me I had an ear stroke but it just doesn’t make sense when the only time sound enters that ear is during a chiropractic adjustment. I feel strongly that it’s a structural issue and not an ear stroke.
Chronic sudden hearing loss
I am 59 years old and in otherwise good health. I have the sensation of fullness, pressure, deafness, headaches, and tinnitus high and low pitch. I have had these symptoms before. MRIs revealed nothing, ENT advised me to have no treatments and see if the symptoms would go away by themselves. Symptoms slowly disappeared over several weeks. The symptoms have now returned and they are staying. My doctor is following the same path as before and I am being referred to an ENT and I’m afraid this will amount to nothing. I am exploring the idea that this is a cervical spine issue.
Extensive symptomology following fusion
In many people we see, sudden or worsening deafness is not a symptom of its own. It comes among many other newly developing symptoms. For example, this is a type of story we hear:
I had a cervical discectomy and fusion almost ten years ago. In the last year or so I have had new symptoms of vertigo, and deafness to the point that I now use hearing aids. Tinnitus, sudden deteriorating vision, anxiety and depression, and heart palpitations.
As we can see and as seen in the medical literature, people’s histories with problems of hearing loss and problems with sound sensitivity, autophony, and misophonia we see are multiple causes of this problem.
Sudden sensorineural hearing loss, causes, and treatment.
A January 2023 paper in The Annals of Otology, Rhinology, and Laryngology (1) suggested that if you properly accounted for worsening of symptoms because of age, degree of vertigo, the interval between onset and treatment, low-density lipoprotein level, and type of hearing loss, traditional treatments (as described below) for sudden hearing loss would show overall hearing “improvement rate of 41.4%, comprising complete recovery (13.3%), marked recovery (17.0%), and slight recovery (11.1%).”
Another January 2023 paper published in the Annals of Ophthalmology and Otology (2) demonstrated that age, descending and flat audiogram (worsening hearing or loss of hearing) curves, profound hearing loss, and initiating treatment after one week of sudden sensorineural hearing loss onset were independent risk factors associated with a worse hearing recovery prognosis.”
Is treatment too soon?
It is likely that the sentence that says treatment after the first week of diagnosis leads to poorer outcomes may have caught your attention.
Both of the above papers refer to the 2019 published guidelines in the publication Otolaryngology–Head and Neck Surgery produced by The American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS). (3)
In this 2019 paper, a strong recommendation is given against the routine use of “antivirals, thrombolytics (drugs that break down blood clots), vasodilators, or vasoactive substances (blood pressure medications) to patients with sudden sensorineural hearing loss.” Further the same paper “(discourages) routine laboratory tests that do not improve management or care of patients with sudden sensorineural hearing loss but nonetheless have associated cost and potential harms related to false-positive results, false-negative results, or both. The word “routine” is used in this context to define automatic, sometimes called “shotgun,” or universal testing done as a “panel” without consideration of specific patient or geographic risk factors.”
Simply too much treatment and testing at the onset can lead to false positives, wrong treatments, and delays in recovery as cited above. Let’s now examine some of these treatments.
Concerns over ear drum injections: How accurate are patient outcomes for intratympanic steroid treatment of idiopathic sudden sensorineural hearing loss?
A September 2021 paper in the American Journal of Otolaryngology (4) examined the incidence of complications in sudden sensorineural hearing loss (SSNHL) patients treated with intra-tympanic (eardrum) steroid injection (ITSI) and compared hearing recovery rates.
- In this study, 123 patients with one-sided SSNHL received steroid injections.
- Post-steroid injection complications were documented including otalgia (ear pain), dysgeusia (loss or altered taste), vertigo (lasting more than one hour), and persistent eardrum perforation.
- 47.2% of patients experienced post-injection mild to moderate ear pain
- Five patients (4.1%) exhibited vertigo
- Six patients (4.9%) suffered from persistent eardrum perforations
There is a lot of controversy about steroid therapy in idiopathic sudden sensorineural hearing loss.
A February 2018 study (5) authored by Stefan K. Plontke of the Department of Otorhinolaryngology, Head & Neck Surgery, University Medicine Halle suggests that “(Research) with respect to the therapy of sudden hearing loss is very unsatisfactory – regarding the quality, not the quantity of trials. There is an existing rational basis for the treatment of acute cochlea-vestibular disorders with corticosteroids. The value of systemically applied corticosteroids in the initial treatment of sudden hearing loss (international standard with low/ medium systemic doses) remains unclear.”
Gold standard treatments are unpredictable
An April 2023 paper in the journal Otology & Neurotology (6) questioned the emergence and continued recommended use of corticosteroid therapy for idiopathic sudden sensorineural hearing. The researchers suggest that ” idiopathic sudden sensorineural hearing remains a condition with an unknown etiology and the therapeutic value of corticosteroids remains unpredictable despite their gold standard label.”
Also from April 2023 and published in the American Journal of Otolaryngology (7) is a study where doctors compared the audiological results of the patients treated with intravenous steroids with those treated with concurrent intravenous and intratympanic (inside the middle ear) steroids and concluded that both intratympanic steroids and systemic (intravenous) steroids alone appear equally effective, however, the use of both intratympanic and systemic steroids together is likely superior to either used alone.
Ginkgo biloba and cortisone
It has been suggested that Ginkgo biloba leaf extract may offer pharmacological effects against sudden sensorineural hearing loss. An August 2021 study in the Journal of Ethnopharmacology (8) examined past research comparing Ginkgo biloba leaves extract plus corticosteroids with corticosteroids alone for sudden sensorineural hearing loss treatment.
- A total of 11 random control studies involving 1069 patients were included.
- Meta-analysis indicated that the clinical cure rate and total effective rate in sudden sensorineural hearing loss patients receiving Ginkgo biloba leaf extract plus corticosteroids was superior to patients receiving corticosteroids alone.
- The results of this study suggested that Ginkgo biloba might be effective and promising as an adjuvant to corticosteroids in the initial treatment of moderate to profound sudden sensorineural hearing loss treatment. However, the overall strength of the evidence was not high.
A December 2023 paper in the journal Pharmaceutical Biology (9) evaluated the effectiveness and safety of Ginkgo biloba for sudden hearing loss. In reviewing 27 previously published research articles with a total of 2623 patients, results revealed that the effects of Ginkgo biloba adjuvant therapy were superior to many general treatments. The researchers concluded: “The efficacy of Ginkgo biloba and general treatments for the treatment of sudden hearing loss may be more promising than general treatments alone.”
Concerns surrounding anti-depressants
Many people that come to us have a long history of chronic health issues. For many of them, this has resulted in the prescription of anti-depressants. In some people we see, not all, the antidepressant medication has led to a worsening of their situation. A March 2021 study in the International Journal of Epidemiology (10) suggested that “antidepressants increased sudden sensorineural hearing loss risk, regardless of their class. Furthermore, patients who took a higher number of antidepressant classes showed an increased risk of developing sudden sensorineural hearing loss than those who took a lower number of anti-depressant classes. Therefore, physicians should estimate the risks and benefits of anti-depressant use and avoid prescribing anti-depressants concurrently.”
Is sudden sensorineural hearing loss a problem with cholesterol?
There has been much speculation in the medical community that sudden sensorineural hearing loss is caused by cardiovascular disorders. (A discussion of reduced blood flow is discussed below). A July 2021 study in the International Archives of Otorhinolaryngology (11) did not observe a significant correlation between the concentration of Thiobarbituric acid reactive substances (the presence of oxidized fatty acids) in the peripheral blood or the presence of arterial hypertension and the severity of the initial hearing loss or the prognosis of hearing recovery in patients with sudden sensorineural hearing loss. The study authors conclude: “The concentration of Thiobarbituric acid reactive substances in the peripheral blood may not adequately represent the abnormalities that occur in the intracochlear environment.” Possibly that this is not a cholesterol problem. This is taken on set further below after a brief discussion about oxygen.
An April 2023 paper (12) examined the relationship between the degree of sensorineural hearing loss and serum lipid level (total cholesterol, triglyceride, low-density lipoproteins, high-density lipoproteins). They suggest hyperlipidemia is a major risk factor for SNHL. Regular screening and monitoring of serum lipids might prevent morbid SNHL and improve patients’ quality of life in the long term.
Is sudden sensorineural hearing loss a problem of vitamin deficiency?
A May 2023 paper in the European archives of oto-rhino-laryngology (13) writes of the controversies surrounding the association between serum/plasma homocysteine (HCY) levels and sudden sensorineural hearing loss. The authors of this paper thus aimed to determine whether there is a significant difference in serum homocysteine levels between the sudden sensorineural hearing loss group and the control group.
Having too high of homocysteine (proteins) means you are at risk for coronary problems especially the risk of damage to the arterial walls. This problem occurs as a result of vitamin B6 (pyridoxine), B9 (folic acid), or B12 deficiency.
Looking at the medical histories of 766 participants in the 6 trials and three trials of 961 people, results revealed the same conclusion that serum/plasma homocysteine levels in the sensorineural hearing loss patients are higher than those in the controls.
Hyperbaric oxygen therapy
A December 2017 paper in the journal Medicine (14) offered a case history of a 44-year-old woman who had “abrupt hearing deterioration in the left ear with the sensation of aural fullness and loud tinnitus presented for 48 hours.” The patient received oral high-dose corticosteroids combined with Hyperbaric oxygen therapy that included 15 daily 1-hour exposures to 100% oxygen at 2.5 atmospheres absolute. (The pressure of the delivered oxygen).
The case history authors describe the rationale for the use of hyperbaric oxygen therapy to treat sudden sensorineural hearing loss citing “that the cochlea (auditory inner ear) and the structures within it, particularly the stria vascularis and the organ of Corti (that part of the inner ear that produces nerve impulses in response to sound vibrations) require a high oxygen supply. However, the direct vascular supply, particularly to the organ of Corti is minimal. . . It is quite well documented in the literature that patients receiving Hyperbaric oxygen therapy had statistically significant hearing gains across all frequencies, with tinnitus patients showing the greatest hearing improvement. . . Some authors consider that Hyperbaric oxygen therapy should be used to treat acute hearing deterioration only if patients do not recover their hearing ability following conventional treatment.”
Some people who contact us have had Hyperbaric oxygen therapy with limited or no results. Every treatment, even those we offer, will not help everyone. Treatments are selected based on each patient’s best chance of success with that treatment.
Oxidative stress, oxygen, and microvascular circulation
Let’s briefly return to the above study mentioned in the cholesterol segment. The researchers of this article write: “Oxidative stress induced by ROS (Simply Reactive oxygen species (ROS) is a chemical reaction that leads to oxidant damage) and disruption of the redox status (the balance between oxidants and antioxidants) have been reported to play a pivotal role in the cardiovascular, cerebrovascular and inner-ear systems. Several inner-ear pathologies, including acoustic trauma, sudden sensorineural hearing loss, presbyacusis (age-related hearing loss), and Meniere disease are hypothesized to involve dysfunction of the microvascular circulation (the circulation of blood into the smallest blood vessels).
Is it a problem with the neck? Vertebrobasilar insufficiency?
A September 2022 study (15) also discussed the challenges of treating idiopathic sudden sensorineural hearing loss. One item of note is that there are multiple causes of idiopathic sudden sensorineural hearing loss (as we have noted above) . . . “the most common are vascular obstruction (loss of blood flow to the ear), viral infection, or labyrinthine membrane breaks. Corticosteroids are the standard treatment option but this practice is not without opposition.” Let’s look further into vascular obstruction.
Over the many years of helping people with cervical instability problems, we have come across people who have a myriad of symptoms that seemingly go beyond the orthopedic, musculoskeletal, and neuropathic pain problems commonly associated with cervical spine disease. While many patients can understand that cervical instability can cause problems with pinched nerves and pain and numbness that can extend down into the hands or even into the feet, they can have a lesser understanding that their cervical spine instability also pinches on arteries and disrupts, impedes and retards blood flow into the brain.
A September 2017 paper in the journal Basic and clinical neuroscience (16) showed that among “patients with cervical spinal diseases, those with left (side neck rotation) limitation had higher odds of hearing loss than those who did not and that the prevalence of hearing loss following spinal diseases was more among men than among women. . . Sensorineural hearing loss can be caused by the inflammation of the blood vessels and nerves, the involvement of the middle ear bones, ligament injuries, or the effects of ototoxic drugs for relieving pain (salicylates and NSAIDs) in patients with cervical injuries.”
The subject of this article is to present evidence that sudden sensorineural hearing loss may be brought on by cervical spine instability. For the patient, this evidence is present once a medical examination cannot find a more obvious cause for your problems such as infections or autoimmune dysfunction.
Many people respond to corticosteroids. These are the people we do not usually see at our center, we usually see the people who have had these treatments, and results may have been short-term or not at all, and a corticosteroid was considered a failed conservative therapy. As mentioned in one patient story above, people can get oral steroids or an injection into the eardrum.
People who have a history of impact injuries to the head and neck or display other neurologic-like symptoms such as other ear problems, vision problems, and swallowing difficulties may be considered likely of hearing loss-induced cervical spine instability.
Cerebral spinal fluid pressure
A 2018 paper (17) noted that sudden and acute idiopathic sudden sensorineural hearing loss following lumbar spinal surgery is an exceedingly rare phenomenon. Regardless the researchers discuss sudden hearing loss following lumbar surgery and success which can be successfully treated with transtympanic steroids and hyperbaric oxygen therapy.
Let’s make a possible connection between hearing loss and cervical spine instability by way of an explanation of what is happening in lumbar surgery and how it can translate to similar problems in cervical spine instability patients.
How can a person who is having lower lumbar surgery develop hearing loss post-surgery? One explanation is cerebral spinal fluid pressure. The idea that hearing loss can be a complication of spinal surgery has been the subject of numerous “curious” case histories in the medical literature. In 2001, more than 20 years ago, doctors at the Spine Care Institute, Hospital for Special Surgery in New York reported on two patients, ages 72 and 71, who underwent lumbar decompressive surgery for spinal stenosis and were evaluated for postoperative sudden sensorineural hearing loss. The doctors write: “After two uncomplicated spinal procedures, both patients developed sudden sensorineural hearing loss immediately after surgery. Hearing loss was moderate to profound in these two patients. None of the patients had a significant otologic history. Nitrous oxide administration, Valsalva maneuvers during general anesthesia, and transient drops in cerebrospinal fluid pressure stemming from spinal decompression may, in some combination, lead to an implosive force on the inner ear, causing sudden sensorineural hearing loss.” Let’s start making some connections.
A July 2016 research paper in the Journal of the American Medical Association Otolaryngology, Head & Neck Surgery (18) offered these connections between Vertebrobasilar insufficiency and Sudden sensorineural hearing loss.
“The etiology of Sudden sensorineural hearing loss is unclear but is likely multifactorial. Some of the proposed mechanisms include infection, autoimmune conditions, vascular insufficiency, and rupture of the labyrinthine membrane (eardrum). Evidence suggests that there is a significant association between vascular events, such as thromboembolism, weak blood circulation, and vasospasm, and the development of sudden sensorineural hearing loss.
The vertebrobasilar system, which includes the two vertebral arteries and the basilar artery, perfuses the medulla, cerebellum, pons, midbrain, thalamus, and occipital cortex. Vertebrobasilar insufficiency can lead to a wide variety of symptoms, such as vertigo, visual disturbances (blurring, graying, and diplopia), drop attack, numbness or tingling, slurred or lost speech, confusion, and swallowing disturbance, mainly owing to impaired perfusion of the cerebellum, brainstem, and occipital cortex.
Vertebrobasilar insufficiency is normally caused by insufficient collateral circulation owing to atherosclerotic stenosis of the subclavian, vertebral, or basilar arteries but can also be owing to other causes, such as compression of vertebral arteries by cervical spondylosis or subclavian steal syndrome (a phenomenon of flow reversal in the vertebral artery.)
I have a comprehensive article on the subject of Treating Vertebrobasilar insufficiency, vertebrobasilar artery insufficiency, rotational vertebral artery occlusion syndrome, or Bow Hunter Syndrome. Highlights of that article are summarized here:
The complexity and challenges of cervical neck instability treatment are fully displayed in the controversies and confusions surrounding the diagnosis of vertebrobasilar insufficiency, also called vertebrobasilar artery insufficiency, rotational vertebral artery occlusion syndrome, or Bow Hunter Syndrome. The fact that this one diagnosis or description of symptoms is known by at least four diagnostic names should be evidence enough that patients and their doctors are sometimes not sure what they are dealing with.
- Many patients will tell us that they finally sought medical help because after a long period of symptoms, including sometimes or every time he/she turned his/her head they would get dizzy, lightheaded, and sometimes have to grab onto something because they felt like they were going to faint.
- During these episodes the patient would also experience fuzzy, blurry vision, ringing in the ears, and trouble with postural balance, even walking. In more advanced situations and certainly more frightening to this patient is the “drop attack,” where they would suddenly and for seemingly no reason at all.
When they went to their primary care physician, the patient tells us, the doctor started to suspect that they, the patient, were having some sort of blockage of blood to the brain.
- In the ruling out process, the physician started to look at atherosclerosis or the hardening of the arteries. This problem would be suspected in patients who were older, had diabetes, high blood pressure or hypertension, smoked, were obese, or led a very poor lifestyle devoid of activity or exercise. Most likely if you were in this risk group you would have received a referral to a vascular surgeon so they could take a look. However, this group of patients can suffer from both atherosclerosis and vertebrobasilar insufficiency. In this group of patients, it would not take much by way of neck rotation compression to cut off blood flow to the brain in arteries that are internally clogged. Here surgeons may see more of an urgency to recommend decompression surgery.
In this video, Ross Hauser, MD discusses general problems of ear pain, ear fullness, sound sensitivity, and hearing problems.
Below are the transcript summary and explanatory notes:
- As the video starts, Dr. Hauser makes a connection between cervical spine/neck instability and cause problems related to the ear and hearing.
- In many of these patients, their problems of tinnitus, Meniere’s disease, dizziness, ear fullness, decreased hearing, or sensitivity to sound may be traced to problems of cervical spine/neck instability.
- In the above video at 1:44, Dr. Hauser discusses this case history:
- A recent patient had been given hearing aids and had used them for much of the last ten years
- After three Prolotherapy sessions (dextrose injections described below) the patient has significant hearing improvement.
- NOTE: The patient was treated for cervical spine instability, of which hearing problems were one symptom. This treatment can help improve hearing in many people, it does not improve hearing in every patient. A careful evaluation of each person is needed to give a realistic assessment of possible outcomes.
We hope you found this article informative and it helped answer many of the questions you may have surrounding your problems. If you would like to get more information specific to your challenges please email us: Get help and information from our Caring Medical staff
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June 14, 2023