A Healthy 64-Year-Old Man With Sudden Hearing Loss

A 64-year-old man presents to his internist’s office complaining of hearing difficulty of several day’s duration. He believes it is the right ear that is affected. There had been a feeling of “fullness” in his ear for about a week. He noted having difficulty in following speech when watching the television. He also noted difficulty hearing people when speaking to them in person unless he was in a position to read their lips or by turning his head to direct the sounds to his left ear. The deficit of the right ear was continued when he used the telephone. He denies any vertigo or dizziness.

Otherwise, the patient’s health seems excellent with only mild hypertension controlled by losartan. There has been no remote exposure to ototoxic medicines; he does not smoke; he has no history of exposure to excessive noise; and there is no history of recent head trauma.

Office examination revealed normal blood pressure (BP). Cranial nerves II-VII and IX-XII were normal. There was no nystagmus. The left and right ear canals had small amounts of cerumen: the right side contained more cerumen than left, but the tympanic membrane was visible bilaterally. Tuning Fork examination revealed marked loss of hearing on the right side when a Rinne test was performed. The Weber test revealed distinct sound laterization favoring the left ear.

Which of the following is the most appropriate next step in managing the presented patient?

1. As an initial evaluation, obtain a comprehensive set of laboratory studies including CBC and metabolic.
2. Send the patient electively for audiologic studies and evaluation for a hearing aid for suspected age-related hearing loss.
3. Send the patient electively to an otolaryngologist for evaluation and manual extraction of presumed cerumen impaction.
4. Send the patient urgently to an otolaryngologist and initiate a course of corticosteroids (prednisone 1 mg/kg) in the interim.