A 52-year-old man presents to the emergency department with sudden onset unilateral hearing loss noticed upon waking this morning. Audiometry confirms a flat severe sensorineural hearing loss of 45 dB across all frequencies developing over 18 hours. Weber test lateralizes to the better ear and Rinne shows air-bone conduction bilaterally. The pattern shown in the diagram marked **A** is consistent with idiopathic sudden sensorineural hearing loss (ISSHL). Which of the following is the MOST appropriate initial management?
A. Oral antivirals (acyclovir) combined with vasodilators (pentoxifylline) to address presumed viral etiology
B. Intratympanic dexamethasone 24 mg/mL injected through the tympanic membrane as sole therapy
C. High-dose oral prednisolone 1 mg/kg/day for 10–14 days with taper, initiated urgently within 72 hours
D. Hyperbaric oxygen therapy 2.0–2.5 ATA for 90 minutes daily as first-line monotherapy
Explanation
Why high-dose oral prednisolone is right
The clinical anchor defines ISSHL as an otologic emergency requiring URGENT initiation of high-dose oral corticosteroids (prednisolone 1 mg/kg/day, max 60–80 mg) for 10–14 days with taper, ideally within 72 hours of symptom onset. This patient presents within 18 hours with a flat severe SNHL pattern consistent with A (ISSHL), and oral corticosteroids are the first-line, evidence-based standard of care per AAO-HNS 2019 Clinical Practice Guideline and Cummings Otolaryngology 7e. The urgency of initiation within 72 hours is critical because prognosis improves significantly with early treatment.
Why each distractor is wrong
Intratympanic dexamethasone as sole therapy: While intratympanic steroids are an effective option (24 mg/mL or methylprednisolone 40 mg/mL, 4 doses over 2 weeks), they are recommended as salvage therapy for incomplete oral steroid response, as primary therapy when systemic steroids are contraindicated, or in combination with oral steroids—not as monotherapy in an otherwise healthy patient presenting acutely.
Hyperbaric oxygen therapy as first-line monotherapy: Hyperbaric oxygen (2.0–2.5 ATA × 90 min × 10–20 sessions) adds only modest benefit per the AAO-HNS 2019 guideline and is used as adjunctive therapy within 14 days, not as initial monotherapy. It should follow or accompany corticosteroid initiation.
Oral antivirals and vasodilators: The clinical anchor explicitly states "NO evidence for antivirals, vasodilators, anticoagulants, diuretics in isolated ISSHL." Although viral cochlear labyrinthitis is a leading pathophysiologic hypothesis, routine antiviral therapy is not supported by evidence and should not be used as first-line treatment.
High-YieldNEET PG
ISSHL is an otologic emergency—initiate high-dose oral corticosteroids within 72 hours (ideally <72 hrs) for best prognosis; intratympanic steroids are salvage or adjunctive, not monotherapy in acute presentation.
Cummings Otolaryngology 7e; AAO-HNS Clinical Practice Guideline SSNHL 2019 Update
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