Sudden hearing loss:
how urgent is it really — and what helps?

1. What is sudden hearing loss?

Sudden hearing loss is a hearing loss of the inner ear that sets in suddenly, usually affects only one ear and has no external cause that can be found. The technical term is acute idiopathic sensorineural hearing loss — “idiopathic” means without an identifiable cause. Sudden hearing loss is therefore a diagnosis of exclusion.^¹

The timing is typical: the hearing loss develops within seconds to a few hours and is often noticed on waking. Many people describe it as feeling like cotton wool in the ear. There is often ringing in the ear as well.

The damage lies in the inner ear, not in the outer or middle ear. That is why the ENT practice's first task is to rule out everything that can be treated: a plug of earwax, a middle ear infection, fluid behind the eardrum or an injury to the eardrum.

2. How urgent is it really?

This question deserves a calm answer. As a rule, sudden hearing loss is not an emergency in the sense of calling 112 (emergency number in Germany). You do not have to go to the emergency department in the middle of the night, and not every hour decides the fate of your hearing — this long-standing dramatisation can no longer be upheld today.^¹,²

Even so, it is not something to sit out for days. The specialist societies recommend seeing an ENT doctor within one to three days. There are three reasons for this: it has to be clarified whether it really is sudden hearing loss. Cortisone treatment makes more sense when started in the first few days than after weeks. And the first pure-tone audiogram serves as the baseline for every follow-up check.

Isolated sudden hearing loss is urgent, but not an emergency. Sudden hearing loss with accompanying neurological signs is an emergency.

3. Symptoms and accompanying signs

• One-sided hearing loss — from slight muffling to practical deafness. Sudden hearing loss in both ears is rare.
• A cotton-wool feeling or pressure in the ear — the ear feels blocked.
• Ringing in the ear (tinnitus) — whistling, rushing or humming, often starting at the same time.
• Sensitivity to loud sounds — quiet sounds are barely audible, loud ones unpleasantly loud. This phenomenon, known as recruitment, points to damage in the inner ear.

Fever, earache, discharge from the ear, and hearing loss that developed slowly or came on after a loud bang all argue against sudden hearing loss. Mild swaying dizziness can accompany sudden hearing loss — as long as you can walk safely, it is not a warning sign. Severe spinning vertigo with a tendency to fall most certainly is.

4. Causes and risk factors

In most cases of sudden hearing loss, the cause remains unknown. Three models are discussed, none of which has been proven:^¹,³

• Impaired blood flow in the inner ear — the cochlea depends on a single end artery and has no reserve. A popular idea, never proven in humans.
• Viral processes — reactivation of herpes viruses in the auditory nerve is suspected; however, antiviral medicines have shown no additional benefit.
• Autoimmune or membrane processes — such as a tear in the fine membranes of the inner ear. Here too: a model, not proof.

And what about stress?

In German popular wisdom, sudden hearing loss is known as a “heart attack of the ear” — understandable, because many people affected are going through a stressful phase. However, stress has not been proven to be a cause. The only thing that has been proven is that it intensifies the perception of tinnitus. A reason to take it seriously — but not a reason to feel guilty.

Diabetes, high blood pressure and smoking are also being discussed — not an explanatory model for the individual case, but a reason to have your blood vessels checked.

5. Diagnosis: what happens at the ENT practice

The examination usually takes less than half an hour and does not hurt. It is meant to confirm that the hearing loss lies in the inner ear — and to rule out that something else is behind it.

• History: When did it start, in which ear, with ringing in the ear or dizziness? Was there loud noise or an infection? Which medicines do you take?
• Ear microscopy: a look at the ear canal and eardrum — earwax, inflammation and injuries show up straight away.
• Tuning fork test: distinguishes in seconds between inner-ear hearing loss and a problem with sound conduction.
• Pure-tone audiogram: the centrepiece — it shows the extent and frequency range of the hearing loss and serves as the baseline for all follow-up checks.
• MRI later on: useful if one-sided hearing loss persists, to rule out a benign tumour of the auditory nerve.

Only when none of this reveals anything does the diagnosis of sudden hearing loss stand. For the appointment, your medication list and when the symptoms started are worth more than any amount of research — see the guide Prepare for a doctor's appointment.

6. Treatment: wait and see or cortisone?

Let us say it directly: the evidence for the standard treatment of sudden hearing loss is weaker than you would expect for such an established treatment. This is down to a peculiarity of the condition — in a considerable proportion of cases it heals on its own.^¹,²

The high rate of spontaneous recovery

A relevant proportion of cases of sudden hearing loss improve without any treatment, often within the first two weeks. That is the good news — and at the same time the methodological problem of every study on sudden hearing loss: if many people recover anyway, very large, properly blinded studies are needed to make an additional benefit visible. Precisely such studies are largely lacking.

The consequence: after an improvement, it can never be said for certain whether the cortisone worked or whether the body would have sorted it out by itself.

7. Glucocorticoids in practice

Usually prednisolone or a comparable glucocorticoid is used. Over a few days it is generally well tolerated — but the typical pitfalls are well known.

Blood sugar and blood pressure: the practical point

High-dose cortisone makes blood sugar rise — in diabetes sometimes markedly and as early as the first day. Never adjust insulin or tablets on your own; clarify beforehand how often you should measure. Blood pressure can also rise; on top of that there is often fluid retention and disturbed sleep.

• Take it in the morning: this comes closest to the natural cortisol rhythm and disturbs sleep the least.
• Think about stomach protection: if you take anti-inflammatory painkillers or have a history of stomach problems, a proton pump inhibitor is often added.
• Measure your blood sugar: more often than usual if you have diabetes.
• Watch for signs of infection: cortisone dampens the immune system — fever needs to be assessed by a doctor.

What glucocorticoids do in the body, and which side effects only become relevant with long-term use, is set out in the cortisone guide.

8. What is not proven

Around sudden hearing loss, treatments persist that used to be standard or are offered as private, self-pay services — here is a sober assessment.

9. Outlook, follow-up and tinnitus

The outlook is better than the first moment of shock would suggest. Mild to moderate hearing loss often recovers to a large extent; very marked hearing loss, accompanying vertigo and older age are considered less favourable signs. Plenty of exact percentages are in circulation — hardly any of them are reliable.^²,⁴

• Follow-up audiogram — after a few days and after a few weeks. How well you feel you are hearing can be misleading in both directions.
• MRI if one-sided hearing loss persists — planned calmly, not as an emergency.
• Check your vascular risk — have your blood pressure, blood sugar and blood lipids measured once; this is a sensible occasion to do so.
• Do not put off a hearing aid — if an impairment remains after months, a hearing aid helps more than waiting.

If the ringing in the ear remains

For many, this is a greater burden in the long run than the hearing loss itself: tinnitus can remain even if hearing recovers. There are effective ways of dealing with it — from education through hearing therapy to psychotherapeutic methods; more in the article on tinnitus. Chronic ringing in the ear does not mean that something was missed.

10. Everyday life after sudden hearing loss

• Avoid noise, but do not retreat into silence — silence intensifies the perception of tinnitus.
• Use your good ear — in restaurants, sit so that speech reaches your healthy side. It sounds trivial, but it saves a lot of effort.
• Take sleep seriously — cortisone and new ringing in the ear both disturb it.
• Record the course — briefly note down your hearing, tinnitus and dizziness every day. At the follow-up appointment this is worth more than any memory.
• Keep all your medicines in one place — especially when cortisone is added.

Sudden hearing loss feels threatening because a sense suddenly fails. This fear is understandable, but a poor adviser when it comes to expensive additional treatments. The two most effective things are unspectacular: get examined promptly and keep your follow-up appointments.

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