Clinical Intelligence

Shilpa Ojha, Arthur Henderson, Warren Bennett and Matthew Clark

Sudden sensorineural loss and bedside phone testing: a guide for primary care

INTRODUCTION throat (ENT) departments to organise, such Sudden sensorineural that this guidance will prove impractical to (SSNHL) should be considered an otological many. emergency yet often goes unrecognised. The aim of this article is to provide a It can have debilitating long-term effects sensible algorithm to help guide GPs to upon individuals, yet early treatment with consider when to prescribe oral steroids to steroids has been shown to be effective in treat the SSNHL, as this is the time-critical helping recovery in what is a time-critical aspect of care, such that starting treatment clinical scenario. in the primary care setting is the most Recently published National Institute practical approach to helping the majority for Health and Care Excellence (NICE) of patients. Subsequent assessment from guidelines indicate that the sudden onset of an ENT referral will allow for non-urgent hearing loss in one or both ears, which is not investigation and management. explained by external or middle-ear causes, is an emergency.1 The guidance states that DEMOGRAPHICS AND AETIOLOGY sudden hearing loss that has developed It is estimated that between 1–6/5000 within the past 30 days needs immediate people suffer from this each year, though referral for specialist assessment within in reality the numbers may be considerably 24 hours. If it has developed more than greater as it often goes undiagnosed.2 The 30 days ago then urgent referral for cause is not known in 70% of cases, with specialist opinion is required within Box 1 outlining the common pathologies 2 weeks. While this may be considered that can cause SSNHL.3 ideal, the reality is that such rapid access is often impossible for GPs and ear, nose, and DIAGNOSIS The history should determine the duration of symptoms, the side (unilateral or bilateral), other relevant associated features, and Box 1. Causes of sudden potential precipitating or causative factors sensorineural hearing loss (Box 1). In most cases of conductive hearing Cause Diagnosis S Ojha, MSc, Med Ed, MRCS DO-HNS, ST6 ear, loss (CHL), including otitis externa, wax, nose, and throat (ENT) registrar; M Clark, FRCS Viral infection Mumps, measles, rubella middle-ear fluid, and infection or tympanic (ORL-HNS), consultant otologist, Department Bacterial infection Syphilis membrane perforation, there will be of ENT Surgery, Gloucestershire Hospitals NHS Lyme disease A Henderson positive findings on clinical examination. Trust, Gloucester. , FRCS (ORL- Meningitis HNS), ST7 ENT registrar; W Bennett, FRCS Otoscopy is therefore important as in most Acute (ORL-HNS), ST8 ENT registrar, Department of cases of SSNHL this will be normal. Formal ENT Surgery, University Hospital Bristol NHS Trauma Head injury audiological assessment is ideal yet is not Trust, Bristol. Blast injury available in most GP practices. Address for correspondence Barotrauma Tuning fork tests are simple and practical Shilpa Ojha, ENT Surgery Department, Pharmacological Ototoxic Gloucestershire Royal Hospital, Great Western for the GP setting. In Weber’s test the tuning Road, Gloucester GL1 3NN, UK. Autoimmune Wegener’s granulomatosis fork is placed firmly on the midline of the Email: [email protected] Central Ischaemic (cerebrovascular head (top of cranium, forehead, or bridge Submitted: 29 September 2019; Editor’s event) of nose); sound will localise to the deaf ear response: 7 October 2019; final acceptance: Multiple sclerosis in conductive cases and to the non-deaf ear 22 October 2019. Cerebellopontine angle in SSNHL. In conjunction with the otoscopic ©British Journal of General Practice 2020; tumour 69: 144–145. findings this helps to positively identify DOI: https://doi.org/10.3399/bjgp20X708761 Other Ménière’s disease cases of SSNHL. However, tuning forks are often not readily available. For this reason;

144 British Journal of General Practice, March 2020 DISCUSSION The authors believe that the urgency of 01 02 03 04 05 06 treatment in SSNHL needs to be practically considered. Rapid access to full ENT services in the desired time-frames Hearing loss? Conductive? Sensorineural? Webertest Results Treatment highlighted by NICE should remain the goal, Suddenloss —rapid Wax Placevibrating corner Vibrationheard in If SNHL: Normal otoscopy? Oral steroidfor 7days but the reality is that many departments change within 72 Foreignbody HistoryofURTI? of smartphone on DEAF ear= hours? Otitisexterna midlineofhead CONDUCTIVE Max. 60 mg OD Otitismedia (1 mg/kg) cannot offer this, such that many patients Conductive? TM perforation Vibrationheard in Reducing dose NOT Sensorineural? Glue ear NON-DEAF ear= needed miss the crucial time period for effective SENSORINEURAL RefertoENT fornon- urgent investigations treatment with steroids. It is hoped that the algorithm should allow GPs to feel more confident in correctly identifying and initiating treatment Figure 1. Sudden-onset hearing loss algorithm. a prospective study was conducted that for SSNHL. There are few scenarios where ENT = ear, nose, and throat. OD = once daily. looked at applying the vibration function of a a 1-week short course of oral steroids is SNHL = sensorineural hearing loss TM = tympanic smartphone to perform a Weber’s test as a contraindicated and the risks associated membrane. URTI = upper respiratory tract readily available alternative to a tuning fork. with this treatment are few. The authors infection. Data were collected on 74 adult patients would argue that the potential advantage post-middle-ear surgery. A Weber’s test in restoring the hearing outweighs many was performed at the bedside with both concerns and there should be an attitude a traditional 256 Hz tuning fork and a of ‘Why should I NOT prescribe steroids?’ vibrating smartphone. The Real Razor™ A smartphone can be a useful tool to mobile application on silent vibration mode assist with diagnosis for GPs, and, as was used. The smartphone vibrates at a well as hearing tests, it has widespread frequency of 163 Hz. The bottom corner of applications for ENT in the primary care the smartphone was placed in the midline setting, such as allowing image capture 5 of the forehead. The patient was then (useful for advice and guidance requests) 6 asked whether the vibration lateralised and for management. to either ear. The results demonstrated The data that support the findings of this study are available from the corresponding >97% agreement between the two tests. The smartphone was shown to be a reliable authors upon reasonable request. and more accessible way of administering a Weber’s test. With this in mind, presented here is an algorithm to help GPs determine if the immediate administration of oral steroids is appropriate for a given case of sudden REFERENCES 1. National Institute for Health and Care hearing loss (Figure 1). Excellence. Hearing loss in adults: assessment and management. NG98. 2018. https:// MANAGEMENT www.nice.org.uk/guidance/ng98/chapter/ The time-critical treatment for SSNHL Recommendations (accessed 31 Jan 2020). is the administration of steroids. This 2. National Institute on and Other Communication Disorders. Sudden deafness. may be effective orally or when injected 2018. https://www.nidcd.nih.gov/health/sudden- through the eardrum (intra-tympanic). In deafness (accessed 31 Jan 2020). the primary care setting a short course of 3. Chau JK, Lin JR, Atashband S,et al. Systematic oral steroids (for example, prednisolone review of the evidence for the etiology of 1 mg/kg to a maximum 60 mg for 7 days)4 adult sudden sensorineural hearing loss. Laryngoscope 2010; 120(5): 1011–1021. is recommended. Early treatment within 4. 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Mobile apps for management of tinnitus: recommended such that ENT assessment users’ survey, quality assessment, and content Discuss this article analysis. JMIR Mhealth Uhealth 2019; 7(1): will usually be required, but this becomes 1–14. non-urgent in nature provided that steroids Contribute and read comments about this have been prescribed in a timely manner. article: bjgp.org/letters

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