Symptom Reviews: Panel discusses the nuances of otology cases

Dr. Welling agreed that his level of suspicion of a perilymphatic fistula would be “fairly low.”

There was general agreement that it would be worthwhile to do an MRI in this case.

Dr. Welling noted that studies have shown that antivirals don’t show advantage over steroids.

“An MRI is reasonable since a percentage of patients with acoustic tumors present with sudden hearing loss,” Dr. Welling said. “I don’t typically do the full battery of OAE (otoacoustic emissions) and BAERs (brainstem auditory evoked response) unless there’s some other indication. But it seems like, with a good audiogram and ruling out retrocochlear disease with an MRI, that would be useful.”

He said he also might order labs, such as viral titers, if something specific in the history suggested the need, but added that “I don’t always do them on sudden hearing loss.”

Dr. Micco said he doesn’t consider lab tests unless the hearing loss is bilateral. “I think there’s enough evidence, though, especially in patients that have had recovery after sudden loss, there still could be a retrocochlear lesion. So I think an MRI is essentially imperative,” he said.

The panelists also agreed that oral steroids would be the best course. And Dr. Shelton said he often uses a vasodilator in a case like this.

“I usually will treat patients or follow patients for four months and feel like that’s the time period where if they’re going to recover they will recover,” he said. “And so many times after the course of steroids, if they don’t get better, I’ll put them on a vasodilator. I don’t have good evidence, scientific evidence, that it works, but I think that it certainly doesn’t hurt. And it may help some people recover. And [it’s] something that I can treat them with for the full four-month period that I’m watching them.”

Dr. Welling noted that studies have shown that antivirals don’t show any advantage over steroids, but Dr. Micco said he might use them in some cases.

“I’ll have patients that will come in with a sudden (hearing) loss that will have these pain symptoms and some of them do seem to respond to the antivirals,” he said.

Panelists generally agreed that intratympanic therapy is worthwhile as a salvage treatment.

Dr. Selesnick asked, “Is our best argument that it probably won’t hurt you and it may help? In other words, the downside is down? Or is our best argument that there’s a benefit to this? And this is a question that is in evolution.”