Monday Pharmaceutical Mystery: August 5

A patient presents with dizziness and is looking for ear wax treatment, but the cause is much more serious than expected.

Your patient, RM, presents to the pharmacy with a question about ear drops. She wants to know what is good for ear wax removal, and explains that she woke up in the morning with a clogged feeling in her right ear and cannot hear anything. She also feels a sense of dizziness. You show her the carbamide peroxide ear drops and counsel on appropriate usage, but something is nagging at you that this might not be the case. Would wax cause such a drastic change in hearing? You tell her to see her ENT as soon as possible, to be sure that nothing else is going on.

Mystery: What is causing this patient to have a clogged feeling in her ear, accompanied by hearing loss?

Solution: RM is experiencing Sudden Sensorineural Hearing Loss (SSHL), also known as sudden deafness. SSHL is an unexplained, rapid loss of hearing that occurs suddenly, or over a few days, frequently affecting only 1 ear.

People with SSHL may also feel fullness in the ear, dizziness/vertigo, and/or a ringing in their ears, such as tinnitus. Often, patients with SSHL may think that the hearing loss is caused by infections, wax, or allergies, and delay seeing an ENT specialist.

Symptoms of SSHL constitute a medical emergency and the patient should be referred to ENT immediately. About half of people with SSHL will recover some or all of their hearing within 1-2 weeks of symptom onset. A delay in diagnosis and treatment can lead to worse outcomes.

Occurrence is estimated at 1 to 6 per 5,000 people per year, most commonly in adults in their late 40’s to early 50’s, but the numbers are likely underreported because SSHL is often undiagnosed. The cause of SSHL is often unknown—only about 10% have an identifiable cause such as infection, head trauma, autoimmune disease, Ménière disease, neurological disorders, or blood circulation problems.

After ruling out a conductive hearing loss (for example, from a wax blockage), a hearing test can confirm SSHL.

Treatment is most commonly a high dose regimen of corticosteroids, most often by oral route, or sometimes by injection directly through the eardrum. Steroids should be started immediately for the best effect, as a delay in treatment of more than 2-4 weeks may lead to worse outcomes in terms of hearing loss.

Other treatment may be necessary - for example, if SSHL is caused by an infection, an antibiotic may be prescribed. Severe, unresolved cases of SSHL may lead to hearing aids or cochlear implants.

Any time a patient presents to the pharmacy with hearing loss, he/she should be referred to ENT immediately for quick diagnosis and treatment.

Reference

National Institute on Deafness and Other Communication Disorders. Sudden Deafness. HHS website. https://www.nidcd.nih.gov/health/sudden-deafness. Updated September 14, 2018. Accessed August 1, 2019