Sudden sensorineural hearing loss (SSNHL) involves abnormalities of the cochlea, auditory nerve, or processes of central auditory perception causing sudden unilateral or bilateral hearing loss. The established criteria for this condition is defined as rapid-onset sensation of hearing impairment in one or both ears, involving a decrease in hearing of 30 decibels affecting at least three consecutive frequencies, within a 72-hour period. 1 Accompanying symptoms often include tinnitus, dizziness and/or vertigo. 1
The estimated incidence of SSNHL is 66,000 new cases in the United States, with between 5 to 27 per 100,000 people annually. 2,3 Data from other countries suggest this number may be 160 per 100,000. 4 Data from the All of Us research program, a U.S. sample that includes minority groups historically underrepresented in medicine, reported sudden hearing loss incidence to be 0.34%, suggesting the true incidence of SSNHL in the U.S. may be higher than prior estimates. 5,6 These estimates may be low due to strict diagnostic criteria for SSNHL and variable patient behavior with regard to seeking treatment. 2–4 Ninety percent of SSNHL cases are idiopathic (ISSNHL), while 10% are due to etiologies including viral, bacterial, tumors, thrombosis, and immunologic. 1
An estimate of the cost of diagnosis and treatment of ISSNHL is made at the individual and population levels for the U.S. health care system. Cost analysis utilizing practice clinical guidelines and Medicare reimbursement rates has not been published prior to this study. The calculated estimates are intended to form the foundation for further research into the economic impact of ISSNHL. Current costs and heterogenous response to medication in ISSNHL support the development of novel therapies as well as the wider use of rehabilitative therapies including hearing aids and cochlear implants.
The diagnosis and management of ISSNHL is summarized in the American Academy of Otolaryngology – Head & Neck Surgery (AAO-HNS) Clinical Practice Guideline. 1 Key Action Statements (KAS) convey the following guidelines: a) rapid diagnosis for ISSNHL requires a thorough initial assessment, including history and physical with tuning fork testing to distinguish between conductive and sensorineural hearing loss; b) blood work is not indicated when there is a high suspicion that etiology is idiopathic; c) audiometry is performed as soon as possible and within 14 days; d) MRI or auditory brainstem response is completed to evaluate for retrocochlear pathology; e) if treatment is pursued, oral corticosteroid intervention is initiated within two weeks of symptoms or intratympanic steroid therapy for salvage within two to six weeks following onset; and f) audiometric follow-up is conducted at the conclusion of treatment and at six months post treatment.
Patients that present to physicians less than one week after onset of ISSNHL have improved odds of recovery. 1,2,7–9. ISSNHL may spontaneously resolve in approximately half of patients that present early to an otolaryngologist. 7 When these patients receive steroid treatment orally or by intratympanic membrane infusion, the recovery rate may reach 78%, although lower rates are frequently reported. 7,10 Corticosteroid treatment has been shown to be most effective within the first two weeks after ISSNHL. 1 Successful treatment often results in improved tinnitus. 11 Thus, prompt diagnosis and treatment of ISSNHL has been shown to be an important prognostic factor.
Studies on the economic burden of ISSNHL on the U.S. health care system are lacking. An attempt at cost analysis is made using currently published estimates of annual incidence put together with estimates of health care costs. To appraise the health care costs of one case, we assembled Medicare reimbursement fees for timely diagnosis and initial management of ISSNHL (Table 1). Based on the costs of at least one initial plus one follow-up ENT assessment, one initial plus two follow-up audiometry testing post treatment and post six months, one set of imaging, and oral or intratympanic membrane steroid therapy, the estimated total range is $614.56 - $1,438.91 per person. Given the previously described estimated incidence of 5 to 27 per 100,000 patients, the minimum economic impact for health care costs on the U.S. economy ranges from $40.6 million to $95 million. One can appreciate how any additional care, such as emergency department visits, added blood work, additional imaging, and hospitalization can drive up costs that frequently accompany the diagnosis for ISSNHL. 12 Importantly, these estimates do not include the costs of reduced work productivity or auditory rehabilitation. These further costs are not estimated here due to the complexity of these estimates.
Studies indicate that adherence to clinical ISSNHL guidelines is low among non-otolaryngologists, and it is estimated that between 15,000 and 60,000 patients are seen in emergency rooms, urgent care centers, or primary care clinics for this diagnosis. 1,12 In these settings, basic testing such as the tuning fork exam is underutilized. 15 Incomplete physical exam likely delays care and elevates health care costs of ISSNHL. Innovative solutions such as cellphone vibrations in the place of a tuning fork may improve access to this crucial part of the exam that may be skipped in absence of readily-available equipment. 16
Failure to effectively diagnose and treat SSNHL leads to worse outcomes for patients physically and psychologically while driving up health care costs. A study found that after SSNHL, 42% of patients experienced persistent and detrimental tinnitus, and that among this cohort, there was a three-fold increase in sick leave from their occupation. 17 Patients experienced negative psychosocial consequences, lower quality of life, and those with higher persistent tinnitus were more likely to require expensive long-term rehabilitation. Factors such as poor speech understanding in noisy environments and improper sound localization exacerbates the negative psychological impact on patients. 18,19 Other studies have shown poorer quality of life with significant emotional distress and psychosocial burden on patients. 1,20,21 Proper diagnosis and treatment, therefore, are fundamental for streamlining care for ISSNHL, improving prognosis, and optimizing the effectiveness of health care expenditures.
Auditory rehabilitation is indicated for patients that have incomplete recovery and/or residual tinnitus from ISSNHL. Auditory rehabilitation options include hearing aids and cochlear implants. In some cases, osseointegrated bone conduction devices are necessary where degradation of central auditory pathways may play a larger role in the ability to benefit from cochlear implantation. 1 These interventions have been shown to improve quality of life and reduce psychological distress. 22–24 Cochlear implants are now the preferred treatment for non-longstanding single-sided deafness. 25 These devices restore hearing and improve sound localization. 23–29 Benefits include cost-effectiveness of cochlear implants due to positive trends in quality-of-life outcomes. The benefit of cochlear implantation for single-sided deafness is optimized when implanted closest to the onset of deafness, underscoring the value of timely diagnosis and management. 29 In-depth economic analyses is needed to support advocacy for coverage of cochlear implants for single-sided deafness under Medicare. While the costs of these interventions are not insignificant, the lack of auditory rehabilitation has consequences that impact individual health and wellness, as well as, some clear economic impacts related to both employment and reduced productivity at work which have broader impacts on our economy. 30–34 Teachers, specifically, have decreased employability with untreated hearing loss. 32 Further, untreated hearing loss is associated with increased incidence of health problems from significant morbidity, including myocardial infarction, stroke, dementia, and falls. 35
ISSNHL has a significant economic impact at both the individual and population levels. There is a significant fraction of patients that are seen initially in primary care, urgent care, or ER settings where care concordant with AAO-HNS clinical practice guidelines may not be followed. 12 Divergence from practice guidelines delays diagnosis, worsens prognosis, and drives up health care and workplace productivity costs. Educating physicians in urgent care/emergency department settings to use tuning forks or a potential equivalent such as the cell phone vibration test in order to distinguish sensorineural hearing loss from conductive hearing loss would be a quick and reliable tool for rapid referral for hearing testing and consultation with an otolaryngologist. 15,16 The persistence of hearing loss despite steroid pharmacotherapy emphasizes the importance of current and future efforts to find new treatments for ISSNHL. 36,37 Cochlear implantation offers some hope for SSNHL patients who both meet candidacy requirements and whose insurance covers this indication. This commentary is a call for more research into the economic impact of ISSNHL that will ultimately provide support for the need to develop accurate recognition, awareness of treatment recommendations, and novel therapies for patients who suffer from this disease.
Thoughts on something you read here? Write to us at [email protected]
1. Chandrasekhar SS, Tsai Do BS, Schwartz SR, et al. 2019 Clinical Practice Guideline: Sudden Hearing Loss (Update) Otolaryngology--Head and Neck Surgery 161 1_suppl S1 S45 https://doi.org/10.1177/0194599819859885
2. Byl FM Jr 1984 Sudden hearing loss: eight years' experience and suggested prognostic table The Laryngoscope 94 5 Pt 1 647 661 https://pubmed.ncbi.nlm.nih.gov/6325838/
3. Alexander TH, Harris JP 2013 Incidence of sudden sensorineural hearing loss Otology & Neurotology 34 1586 1589 https://doi.org/10.1097/mao.0000000000000222
4. Klemm E, Deutscher A, Mosges R 2009 A present investigation of the epidemiology in idiopathic sudden sensorineural hearing loss Laryngorhinootologie 88 524 527 https://doi.org/10.1055/s-0028-1128133
5. NIH 2019 NIH: All of Us Research Program. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/31412182/
6. Denny JC, Rutter JL, Goldstein DB, et al. 2019 The "All of Us" Research Program New England Journal of Medicine 381 668 676 https://doi.org/10.1056/nejmsr1809937
7. Kuhn M, Heman-Ackah SE, Shaikh JA, Roehm PC 2011 Sudden sensorineural hearing loss: a review of diagnosis, treatment, and prognosis Trends in Amplification 15 91 105 https://doi.org/10.1177/1084713811408349
8. Fetterman BL, Saunders JE, Luxford WM 1996 Prognosis and treatment of sudden sensorineural hearing loss The American Journal of Otology 17 529 536 https://pubmed.ncbi.nlm.nih.gov/8841697/
9. Battaglia A, Lualhati A, Lin H, Burchette R, Cueva R 2014 A prospective, multi-centered study of the treatment of idiopathic sudden sensorineural hearing loss with combination therapy versus high-dose prednisone alone: a 139 patient follow-up Otology & Neurotology 35 1091 1098 https://doi.org/10.1097/mao.0000000000000450
10. Labus J, Breil J, Stutzer H, Michel O 2010 Meta-analysis for the effect of medical therapy vs. placebo on recovery of idiopathic sudden hearing loss The Laryngoscope 120 1863 71 https://doi.org/10.1002/lary.21011
11. Michiba T, Kitahara T, Hikita-Watanabe N, et al. 2013 Residual tinnitus after the medical treatment of sudden deafness Auris Nasus Larynx 2013 40 162 6 https://doi.org/10.1016/j.anl.2012.06.007
12. Witsell DL, Khoury T, Schulz KA 2016 Evaluation of Compliance for Treatment of Sudden Hearing Loss: A CHEER Network Study Otolaryngology--Head and Neck Surgery 155 48 55 https://doi.org/10.1177/0194599816650175
13. Centers for Medicare & Medicaid Services 2022 Medicare Physician Fee Schedule Search. Retrieved from: https://www.cms.gov/medicare/physician-fee-schedule/search/overview
14. GoodRx.com 2022 Prednisone Taper Dose Pack 2022. Available from: https://www.goodrx.com/medrol?optly-test-group=price_page_refresh_1_5
15. Ng B, Crowson MG, Lin V 2021 Management of sudden sensorineural hearing loss among primary care physicians in Canada: a survey study Journal of Otolaryngology -- Head & Neck Surgery 50 22 https://doi.org/10.1186/s40463-021-00498-x
16. Yang A, Lewis RJ, Watson N, Riley CA, Tolisano AM 2021 The cell phone vibration test: a telemedicine substitute for the tuning fork test Laryngoscope Investigative Otolaryngology 6 1175 1181 https://doi.org/10.1002%2Flio2.665
17. Carlsson PI, Hall M, Lind KJ, Danermark B 2011 Quality of life, psychosocial consequences, and audiological rehabilitation after sudden sensorineural hearing loss International Journal of Audiology 50 139 44 https://doi.org/10.3109/14992027.2010.533705
18. Shaia FT, Sheehy JL 1976 Sudden sensori-neural hearing impairment: a report of 1,220 cases The Laryngoscope 86 389 398 https://doi.org/10.1288/00005537-197603000-00008
19. Wie OB, Pripp AH, Tvete O 2010 Unilateral deafness in adults: effects on communication and social interaction The Annals of Otology, Rhinology, and Laryngology 119 772 781
20. Chiossoine-Kerdel JA, Baguley DM, Stoddart RL, Moffat DA 2000 An investigation of the audiologic handicap associated with unilateral sudden sensorineural hearing loss The American Journal of Otology 21 645 651 https://pubmed.ncbi.nlm.nih.gov/10993452/
21. Chen J, Liang J, Ou J, Cai W 2013 Mental health in adults with sudden sensorineural hearing loss: an assessment of depressive symptoms and its correlates Journal of Psychosomatic Research 75 72 74 https://doi.org/10.1016/j.jpsychores.2013.03.006
22. Stachler RJ, Chandrasekhar SS, Archer SM 2012 Clinical practice guideline: sudden hearing loss Otolaryngology--Head and Neck Surgery 146 3 Suppl S1 35 https://doi.org/10.1177/0194599812436449
23. Blasco MA, Redleaf MI 2014 Cochlear implantation in unilateral sudden deafness improves tinnitus and speech comprehension: meta-analysis and systematic review Otology & Neurotology 35 1426 1432 https://doi.org/10.1097/mao.0000000000000431
24. Gaylor JM, Raman G, Chung M, et al. 2013 Cochlear implantation in adults: a systematic review and meta-analysis JAMA Otolaryngology--Head & Neck Surgery 139 265 272 https://doi.org/10.1001/jamaoto.2013.1744
25. FDA FDA Data Med-El Cochlear Implant for Single Sided Deafness. 2019 July 19, 2019.
26. Ontario Health Implantable devices for single-sided deafness and conductive or mixed hearing loss: a health technology assessment. (2020). Ontario Health Technology Assessment Series. 20(1):1-165. http://www.ncbi.nlm.nih.gov/pmc/articles/pmc7080453/
27. Seebacher J, Muigg F, Kuhn H, et al. 2021 Cost-utility analysis of cochlear implantation in adults with single-sided deafness: Austrian and German Perspective Otology and Neurotology 42 799 805 https://doi.org/10.1097/mao.0000000000003103
28. Dreyfuss M, Giat Y, Veraguth D, Roosli C, Huber AM, Laske RD 2021 Cost effectiveness of cochlear implantation in single-sided deafness Otology & Neurotology 42 1129 1135 https://doi.org/10.1007/s00405-013-2746-z
29. Bernstein JGW, Phatak SA, Schuchman GI, Stakhovskaya OA, Rivera AL, Brungart DS 2022 Single-sided deafness cochlear implant sound-localization behavior with multiple concurrent sources Ear and Hearing 43 206 219 https://doi.org/10.1097/aud.0000000000001089
30. Jung D, Bhattacharyya N 2012 Association of hearing loss with decreased employment and income among adults in the United States The Annals of Otology, Rhinology, and Laryngology 121 771 775 https://doi.org/10.1177/000348941212101201
31. Shan A, Ting JS, Price C, et al. 2020 Hearing loss and employment: a systematic review of the association between hearing loss and employment among adults The Journal of Laryngology and Otology 134 387 397 https://doi.org/10.1017/s0022215120001012
32. Schriemer AG, Roelen CAM, Abma FI, van Rhenen W, van der Klink JJL, Bultmann U 2021 Sustainable employability of teachers with hearing loss International Journal of Audiology ■ 1 8 https://doi.org/10.1080/14992027.2021.2000650
33. Chao PZ, Huang SW, Escorpizo R, et al. (2020). Effects of Hearing Disability on the Employment Status Using WHODAS 2.0 in Taiwan International Journal of Environtal Research and Public Health 17 ■ https://doi.org/10.3390/ijerph17249374
34. Tran P, Tran L 2021 National, Regional, and State Employment Rates of U.S. Adults Who Are Deaf or Hard of Hearing American Annals of the Deaf 166 85 93 https://doi.org/10.1353/aad.2021.0017
35. Deal JA, Reed NS, Kravetz AD, Weinreich H, Yeh C, Lin FR, et al. 2019 Incident Hearing Loss and Comorbidity: A Longitudinal Administrative Claims Study JAMA Otolaryngology Head & Neck Surgery
2019 145 36 43 https://doi.org.10.1001/jamaoto.2018.2876
36. Schilder AGM, Su MP, Blackshaw H, et al. 2019 Hearing protection, restoration, and regeneration: an overview of emerging therapeutics for inner ear and central hearing disorders Otology & Neurotology 40 559 570 https://doi.org/10.1097/mao.0000000000002194
37. McLean WJ, Hinton AS, Herby JTJ, et al. 2021 Improved speech intelligibility in subjects with stable sensorineural hearing loss following intratympanic dosing of FX-322 in a phase 1b study Otology & Neurotology 42 e849 e57 https://doi.org/10.1097/mao.0000000000003120