Chandrasekhar SS, Tsai Do BS, Schwartz SR, Bontempo LJ, Faucett EA, Finestone SA, Hollingsworth DB, Kelley DM, Kmucha ST, Moonis G, Poling GL, Roberts JK, Stachler RJ, Zeitler DM, Corrigan MD, Nnacheta LC, Satterfield L, Monjur TM, et al.
Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-.... Date of publication 2019 Aug 1;volume 161(2):195-210.
1. Otolaryngol Head Neck Surg. 2019 Aug;161(2):195-210. doi:
10.1177/0194599819859883.
Clinical Practice Guideline: Sudden Hearing Loss (Update) Executive Summary.
Chandrasekhar SS(1)(2)(3), Tsai Do BS(4), Schwartz SR(5), Bontempo LJ(6),
Faucett EA(7), Finestone SA(8), Hollingsworth DB(9), Kelley DM(4), Kmucha
ST(10), Moonis G(11), Poling GL(12), Roberts JK(11), Stachler RJ(13), Zeitler
DM(5), Corrigan MD(14), Nnacheta LC(14), Satterfield L(14), Monjur TM(14).
Author information:
(1)1 ENT & Allergy Associates, LLP, New York, New York, USA.
(2)2 Zucker School of Medicine at Hofstra-Northwell, Hempstead, New York, USA.
(3)3 Icahn School of Medicine at Mount Sinai, New York, New York, USA.
(4)4 University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma,
USA.
(5)5 Virginia Mason Medical Center, Seattle, Washington, USA.
(6)6 University of Maryland School of Medicine, Baltimore, Maryland, USA.
(7)7 The Hospital for Sick Children, Toronto, Canada.
(8)8 Consumers United for Evidence-based Healthcare (CUE), Baltimore, Maryland,
USA.
(9)9 Ear, Nose & Throat Specialists of Northern Virginia, P.C., Manassas,
Virginia, USA.
(10)10 Gould Medical Group-Otolaryngology, Stockton, California, USA.
(11)11 Columbia University Medical Center, New York, New York, USA.
(12)12 Mayo Clinic, Rochester, Minnesota, USA.
(13)13 StachlerENT, West Bloomfield, Michigan, USA.
(14)14 American Academy of Otolaryngology-Head and Neck Surgery Foundation,
Alexandria, Virginia, USA.
OBJECTIVE: Sudden hearing loss is a frightening symptom that often prompts an
urgent or emergent visit to a health care provider. It is frequently, but not
universally, accompanied by tinnitus and/or vertigo. Sudden sensorineural
hearing loss affects 5 to 27 per 100,000 people annually, with about 66,000 new
cases per year in the United States. This guideline update provides
evidence-based recommendations for the diagnosis, management, and follow-up of
patients who present with sudden hearing loss. It focuses on sudden
sensorineural hearing loss in adult patients aged 18 and over and primarily on
those with idiopathic sudden sensorineural hearing loss. Prompt recognition and
management of sudden sensorineural hearing loss may improve hearing recovery and
patient quality of life. The guideline update is intended for all clinicians who
diagnose or manage adult patients who present with sudden hearing loss.
PURPOSE: The purpose of this guideline update is to provide clinicians with
evidence-based recommendations in evaluating patients with sudden hearing loss
and sudden sensorineural hearing loss, with particular emphasis on managing
idiopathic sudden sensorineural hearing loss. The guideline update group
recognized that patients enter the health care system with sudden hearing loss
as a nonspecific primary complaint. Therefore, the initial recommendations of
this guideline update address distinguishing sensorineural hearing loss from
conductive hearing loss at the time of presentation with hearing loss. They also
clarify the need to identify rare, nonidiopathic sudden sensorineural hearing
loss to help separate those patients from those with idiopathic sudden
sensorineural hearing loss, who are the target population for the therapeutic
interventions that make up the bulk of the guideline update. 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.
METHODS: Consistent with the American Academy of Otolaryngology-Head and Neck
Surgery Foundation's Clinical Practice Guideline Development Manual, Third
Edition, the guideline update group was convened with representation from the
disciplines of otolaryngology-head and neck surgery, otology, neurotology,
family medicine, audiology, emergency medicine, neurology, radiology, advanced
practice nursing, and consumer advocacy. A systematic review of the literature
was performed, and the prior clinical practice guideline on sudden hearing loss
was reviewed in detail. Key action statements (KASs) were updated with new
literature, and evidence profiles were brought up to the current standard.
Research needs identified in the original clinical practice guideline and data
addressing them were reviewed. Current research needs were identified and
delineated.
RESULTS: The guideline update group made strong recommendations for the
following: clinicians should distinguish sensorineural hearing loss from
conductive hearing loss when a patient first presents with sudden hearing loss
(KAS 1); clinicians should educate patients with sudden sensorineural hearing
loss about the natural history of the condition, the benefits and risks of
medical interventions, and the limitations of existing evidence regarding
efficacy (KAS 7); and 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 (KAS 13). These strong recommendations were modified from the initial
clinical practice guideline for clarity and timing of intervention. The
guideline update group made strong recommendation against the following:
clinicians should not order routine computed tomography of the head in the
initial evaluation of a patient with presumptive sudden sensorineural hearing
loss (KAS 3); clinicians should not obtain routine laboratory tests in patients
with sudden sensorineural hearing loss (KAS 5); and clinicians should not
routinely prescribe antivirals, thrombolytics, vasodilators, or vasoactive
substances to patients with sudden sensorineural hearing loss (KAS 11). The
guideline update group made recommendations for the following: clinicians should
assess patients with presumptive sudden sensorineural hearing loss through
history and physical examination for bilateral sudden hearing loss, recurrent
episodes of sudden hearing loss, and/or focal neurologic findings (KAS 2); in
patients with sudden hearing loss, clinicians should obtain, or refer to a
clinician who can obtain, audiometry as soon as possible (within 14 days of
symptom onset) to confirm the diagnosis of sudden sensorineural hearing loss
(KAS 4); clinicians should evaluate patients with sudden sensorineural hearing
loss for retrocochlear pathology by obtaining a magnetic resonance imaging or
auditory brainstem response (KAS 6); clinicians should offer, or refer to a
clinician who can offer, intratympanic steroid therapy when patients have
incomplete recovery from sudden sensorineural hearing loss 2 to 6 weeks after
onset of symptoms (KAS 10); and clinicians should obtain follow-up audiometric
evaluation for patients with sudden sensorineural hearing loss at the conclusion
of treatment and within 6 months of completion of treatment (KAS 12). These
recommendations were clarified in terms of timing of intervention and
audiometry, as well as method of retrocochlear workup. The guideline update
group offered the following KASs as options: clinicians may offer
corticosteroids as initial therapy to patients with sudden sensorineural hearing
loss within 2 weeks of symptom onset (KAS 8); clinicians may offer, or refer to
a clinician who can offer, hyperbaric oxygen therapy combined with steroid
therapy within 2 weeks of onset of sudden sensorineural hearing loss (KAS 9a);
and clinicians may offer, or refer to a clinician who can offer, hyperbaric
oxygen therapy combined with steroid therapy as salvage therapy within 1 month
of onset of sudden sensorineural hearing loss (KAS 9b).
DIFFERENCES FROM PRIOR GUIDELINE: Incorporation of new evidence profiles to
include quality improvement opportunities, confidence in the evidence, and
differences of opinion Included 10 clinical practice guidelines, 29 new
systematic reviews, and 36 new randomized controlled trials Highlights the
urgency of evaluation and initiation of treatment, if treatment is offered, by
emphasizing the time from symptom occurrence Clarification of terminology by
changing potentially unclear statements; use of the term sudden sensorineural
hearing loss to mean idiopathic sudden sensorineural hearing loss to emphasize
that over 90% of sudden sensorineural hearing loss is idiopathic sudden
sensorineural hearing loss and to avoid confusion in nomenclature for the reader
Changes to the key action statements (KASs) from the original guideline: KAS 1:
When a patient first presents with sudden hearing loss, conductive hearing loss
should be distinguished from sensorineural. KAS 2: The utility of history and
physical examination when assessing for modifying factors is emphasized. KAS 3:
The word routine is added to clarify that this statement addresses a nontargeted
head computed tomography scan that is often ordered in the emergency room
setting for patients presenting with sudden hearing loss. It does not refer to
targeted scans such as a temporal bone computed tomography scan to assess for
temporal bone pathology. KAS 4: The importance of audiometric confirmation of
hearing status as soon as possible and within 14 days of symptom onset is
emphasized. KAS 5: New studies were added to confirm the lack of benefit of
nontargeted laboratory testing in sudden sensorineural hearing loss. KAS 6:
Audiometric follow-up is excluded as a reasonable workup for retrocochlear
pathology. Magnetic resonance imaging, computed tomography scan if magnetic
resonance imaging cannot be done, or, secondarily, auditory brainstem response
evaluation are the modalities recommended. A time frame for such testing is not
specified, nor is it specified which clinician should be ordering this workup;
however, it is implied that it would be the general or subspecialty
otolaryngologist. KAS 7: The importance of shared decision making is
highlighted, and salient points are emphasized. KAS 8: The option for
corticosteroid intervention within 2 weeks of symptom onset is emphasized. KAS
9: Changed to KAS 9a and 9b; hyperbaric oxygen therapy remains an option but
only when combined with steroid therapy for either initial treatment (9a) or for
salvage therapy (9b). The timing is within 2 weeks of onset for initial therapy
and within 1 month of onset of sudden sensorineural hearing loss for salvage
therapy. KAS 10: Intratympanic steroid therapy for salvage is recommended within
2 to 6 weeks following onset of sudden sensorineural hearing loss. The time to
treatment is defined and emphasized. KAS 11: Antioxidants were removed from the
list of interventions that the clinical practice guideline recommends against
using. KAS 12: Follow-up audiometry at conclusion of treatment and also within 6
months posttreatment is added. KAS 13: This statement on audiologic
rehabilitation includes patients who have residual hearing loss and/or tinnitus
who may benefit from treatment. Addition of an algorithm outlining KASs Enhanced
emphasis on patient education and shared decision making with tools provided to
assist in the same.
DOI: 10.1177/0194599819859883
PMID: 31369349 [Indexed for MEDLINE]
