CASE REPORT

SUDDEN DEAFNESS

Presentator : dr. Pradhana Fajar Wicaksana

Moderator : dr. Agus Surono, M.Sc, PhD, Sp.T.H.T.K.L (K)

Otorhinolaryngologist Head & Neck Department

Faculty of Medicine Universitas Gadjah Mada/ RS
DR.SardjitoYogyakarta
2017
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INTRODUCTION underestimate. Likely, there is an equal

Sudden sensory hearing loss is a distribution of female-to-male cases. Gender

deceptively simple term, yet the concept does not seem to be a risk factor. Several

defies strict definition. The terms sudden studies have not delineated right versus left

hearing loss, sudden sensory hearing loss, ears affected, other than to state an equal

and sudden sensorineural hearing loss distribution. 1,2

(SSNHL) each imply an acute insult of the SSNHL can be divided into

cochlea and/or retrocochlear structures. categories of defined causes and idiopathic

Thus, the term SSNHL is perhaps the most sudden sensorineural hearing loss

accurate to denote this clinical entity. (ISSNHL). Defined causes of SSNHL are

Various investigators have put forth varied and less common include infection,

definitions based on the severity, time inflammation, trauma, neoplasm, toxins,

course, and frequency spectrum of the loss, cardiovascular disease, otologic disease, and

as well as specific audiometric criteria. genetic. Approximately 10% to 15% of

The most commonly used definition is a cases are due to an identifiable etiology.

30-decibel (dB) or greater sensorineural Three main theories exist to explain

hearing loss over three continuous ISSNHL: viral infection, vascular

frequencies occurred within 3 days. Abrupt compromise, and intracochlear membrane

and rapidly progressive losses have both rupture. There is additional evidence to

been encompassed under a single support a fourth explanation: autoimmune

1,3
definition. Awakening with a hearing loss, inner ear disease.

hearing loss noted over a few days, Patient evaluation should proceed

selective low- or high-frequency loss, and promptly and expeditiously. Early

distortions in speech perception have all presentation to a physician and early

been classified as SSNHL. 1 institution of treatment improve the

In recent years there has been a prognosis for hearing recovery. A diligent

significant increase in the diagnosis of search for a treatable or defined cause of

sudden sensory hearing loss in western the sudden hearing loss is an immediate

countries with an incidence of 20 of goal. Information about the onset, time

100,000 people affected every year. course, associated symptoms, and recent

Because many patients do not seek activities may give helpful dues.

medical attention after spontaneous Reviewing the past medical history,

resolution, and others are misdiagnosed especially risk factors for hearing loss, is

initially, this incidence figure is an necessary. All medications, including

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over-the-counter products, must be The treatment regimens for

delineated. A thorough head and neck ISSNHL are legion, and this diversity

examination, with special attention to the reflects both the different etiologies that

otologic and neurologic examination, is a may cause sudden hearing loss and the

requisite. Pneumatoscopy, in search of a uncertainty in diagnosis. Primary treatment

fistula sign, should be included. A is guided by the specific cause, if one is

cardiovascular examination should also be identified. As discussed previously, no

performed to evaluate for atrial fibrillation, specific cause is identified in the vast

aortic and mitral valve pathology, and majority of cases, and empirical treatments

carotid bruits. Pure tone and speech testing can be considered. The most commonly

are mandatory components of the used treatment has been corticosteroids

audiometric evaluation of SSNHL.1 (systemic and/or intratympanic). A large

Tinnitus is usually present in array of other treatments such as antivirals,

SSNHL (>90%) and vertigo is frequent. diuretics, vasodilators, osmotic agents,

Because SSNHL is often accompanied plasma expanders, anticoagulants, mineral

with the sensation of aural fullness, the supplements, and hyperbaric oxygen rich

hearing loss is often attributed to the more gases, among others, have been used. 1,3,4

common conditions of cerumen impaction, A maximum of 32–65% of cases of

acute upper respiratory tract infection with SSNHL may recover spontaneously,

associated middle ear dysfunction, or although clinical experience indicates that

allergy by primary care providers, and no even this recovery rate may be an

further investigation is performed. Because overestimation. The prognosis for recovery

a delay in diagnosis and treatment can is dependent on a number of factors,

negatively impact the ultimate hearing including patient age, presence of vertigo at

outcome, it is essential that all health care onset, degree of hearing loss, audiometric

providers are capable of differentiating configuration, and time between onset of

SSNHL from other routine presentations hearing loss and treatment. 4

of acute hearing loss. Testing with a 512

Hz tuning fork is very valuable in CASE REPORT

categorizing the hearing loss as conductive A 58 years-old male adult (MR

or sensorineural. Referral to an 01.83.04.50) came to Sardjito hospital

otolaryngologist and audiometric testing with chief complain sudden hearing loss in

should proceed for any patient with a left ear since 1 weeks. He complained

suspected SSNHL.1,4

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ringing sensation and then followed by sensation, dizziness, vertigo, pain, ear

hearing loss. He denied any dizziness, fulness, itchyness, paralysis, or discharge

vertigo, pain, ear fulness, itchyness, from the ear. She also denied any nose and

paralysis, and discharge from the ear. She throat problems. From physical

also denied any nose and throat problems. examination, we also found normal

Patient suffered diabetic mellitus for 4 external auditory canal. Both tympanic

years and having medication of its disease. membrane was intact and we could see

From physical examination, we cone of light. Rhinoscopy examination,

found normal external auditory canal. Both anteriorly and posteriorly, showed normal

tympanic membrane was intact and we result. Oropharyngeal examination within

could see cone of light. Rhinoscopy normal limit. Indirect laryngoscopy also

examination, anteriorly and posteriorly, within normal limit. Tuning fork test also

showed normal result. Oropharyngeal still showed same result, AS SNHL and

examination within normal limit. Indirect AD SNHL. She was treated with piracetam

laryngoscopy also within normal limit. 400mg three times daily, methylprednison

We performed tuning fork 8mg 1-0-1, Mecobalamine 500mg 1 times

examination. Rinne test positif on the left daily. Patient was advised to come again

ear, negative result on the right ear. Weber one week after. The problem which I

test showed right lateralitation, Schwabach kindly would to discuss is the treatment.

test showed shortening in the left ear and

equal perception with examiner in right DISCUSSION

ear. Pure tone audiometry showed AD The incidence of sudden

mild SNHL and AS SNHL Profound. OAE sensorineural hearing loss in children is

examination showed refer to both ears less than the incidence in adults and the
low incidence in children has resulted in
Diagnosis of sudden deafness was
very limited data for pediatric age group.
made and He was treated with piracetam
The natural history of Sudden Deafness is
400mg three times daily, methylprednison
variable, since its causes are multiple.
8mg 1-0-1, Mecobalamin 500mg 1 times
Some patients recover completely without
daily. Patient was advised to come again
medical intervention, usually during the
one week after.
first three days (spontaneous recovery) and
When we followed up the next one
generally do not see a doctor. Most patients
week, from anamnesis we found the
do not recover their hearing without
hearing loss complaint was getting better,
treatment, and up to 10% of patients
and the patient still denied any ringing
experience a worsening of their
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hearing over time, despite the introduction of prognostic sign for hearing recovery, but

adequate treatment4,5 ‘longer duration’ predicts poor results in

Chen YS et al., in a series of 14 hearing improvement. Further detailed

children with sudden sensorineural hearing investigation of tinnitus at the time of

loss between 9 and 18 years old, reported a SSNHL may elucidate mechanisms of

complete recovery rate of 57% and a tinnitus generation and may lead to

partial recovery rate of 36%. This study, development of effective treatments for

including only the pediatric age group, had tinnitus.6,7

a total recovery rate of 93%. The Most of the patients who had

definitions of recovery were partial associated conditions of diabetes mellitus,

recovery: ≥10 dB gain in 3 frequencies, hypertension and hyperlipidaemia had

complete recovery: same hearing level poor hearing improvement of less than

compared to the non-affected ear.6 56%. This suggests that the associated

The most commonly accepted conditions could be contributory factors to

factors of poor prognosis in sudden deafness poor prognosis, and the prognostic factors

in the literature are the following: advanced of management of sudden sensorineural

age of the patient, cardiovascular risk factors hearing loss should take the associated

(arterial hypertension, etc.), exposure to conditions or comorbidities into

noise trauma, intensity of the initial loss, consideration.8 In this case, patient was

type of audiometric curve, healthy ear pediatric group and didn’t have history of

auditory function, associated symptoms, hyperlipidemia, diabetes mellitus or

promptly initiated treatment, Speed of onset hypertension, so it should be have better

of clinical improvement 4,5 prognosis.

Tinnitus, early-onset of treatment, The clinical features of sudden

unilateral nature of the disease were deafness differed in adults and children.

considered as positive prognostic factors Higher complete ratio rates were observed

for sudden sensorineural hearing loss, in children than in adults with sudden

whereas vertigo, delayed-onset of sensorineural deafness and in children than

treatment and bilateral nature of hearing in adults with profound hearing loss.

loss were considered as negative Vascular degeneration increases with age,

prognostic factors. Tinnitus at the onset of thus decreasing the peripheral blood

sudden sensorineural hearing loss is supply. This decrease may be a factor

important as a prognostic factor for causing otologic diseases, such as sudden

hearing. ‘tinnitus often’ is a positive deafness and Bell’s palsy. Cochlear blood

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flow decreases with age, reducing rates of frequency deafness experience fast hearing

recovery from otologic diseases. In recovery, with the prognosis of patients

addition, it has been reported that sudden with the descending type being poor in

deafness has a poor prognosis if children. In contrast, no significant

accompanied by vestibular symptoms such difference in hearing recovery was

as dizziness. However, this concurrent observed among audiogram types, except

symptom was rarely present in the for the profound type. Na SY et al., found

children’s group in this study.9 In this no significant differences in hearing

patient, we didn’t find vertigo and recovery rates among audiogram types,

dizziness, so the prognosis should be better. indicating that audiogram type is not a

The hearing recovery rate was higher in prognostic factor for hearing recovery.9

adults than in children with moderate Most authors again agree that the

hearing loss, but higher in children than in shorter the treatment delay, the greater the

adults with profound hearing loss. Thus, chances of recovery. Treatment should

overall, the recovery rates were similar in ideally start before 7 days, and hearing

adults and children. The higher recover improvement can occur within 30 days of

rate in adults than in children with hearing loss onset.10

moderate hearing loss was likely due to the

CONCLUSION
distribution of patients, not to adults
A 58 years-old male adult was
having a higher recovery rate. We thought
reported with sudden deafness,
that the retrieval of hearing still remains in
complaining sudden hearing loss in left ear
children with more severe hearing loss,
since 1 weeks. We treated the patient with
whereas little is left in adults. 9 In this case,
methylprednison 8mg 1-0-1, piracetam
patient age is 13 years old and it should be
400mg three times daily, Mecobalamin
have better prognostic than in adult.
500mg 1 times daily, and did follow up
This patient audiogram in this case
one week after.
showed decreasing of hearing threshold in
nearly same at all frequency, gave picture
of flat audiogram. Treatment outcomes
have been reported to be better in patients
with a flat or ascending type audiogram
than in those with a descending or
profound type. Patients with low

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