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ONE of the common patient complaints to their GP or emergency department (ED) doctor is a sensation that one of their ears is suddenly blocked or feels full.
Unluckily for some of these patients, their symptoms will be brushed off and dismissed without even considering that a sudden nerve hearing loss, also known as sudden sensorineural hearing loss (SSNHL) can present just like this. Hearing loss is interpreted by the brain in many ways, including a sensation of blockedness or fullness.
What is so tragic is that if the diagnosis is not considered and not treated immediately, permanent deafness and troublesome tinnitus may be lifelong. SSNHL has a reported incidence of between 10 and 160 per 100 000 people depending on the country. It is distinctly different from progressive and gradual hearing loss, such as age-related presbycusis, which is usually bilateral and not sudden.
Unfortunately, there is a general ignorance of this condition that presents “out of the blue” in 90% of cases in completely well and healthy individuals. Simple high-dose steroids (50 mg prednisolone daily) for 10–14 days or until a diagnosis is confirmed will give most patients a greater chance of a recovery.
In fact, the American Academy of Otolaryngology – Head and Neck Surgery guidelines strongly recommend that practitioners offer steroids to patients in whom they suspect a sudden nerve hearing loss, even before an audiogram or definitive diagnosis is confirmed. The potential benefits of restoring hearing far outweigh the risk of side effects from what may be an unnecessary dose of steroids.
First, it is critical to differentiate between a conductive hearing loss and an SSNHL. There are several differential diagnoses of a painless sudden blocked ear in a completely well feeling patient.
Considering causes in the outer, middle and inner ear and remembering adjacent anatomical structures that refer sensations and pain to the ear are vital. The commonest conductive hearing loss cause is significant wax build-up in the canal or obvious otitis externa with swelling, inflammation and discharge. Wax is painless and moisture or water may expand the remaining wax to block the air pinhole. The hallmark of otitis externa is severe pain – which is unlikely in patients with SSNHL.
A sudden tympanic perforation or otitis media is associated with pain, dizziness and perhaps signs of infection. In my experience, a “red” or “dull” drum or fluid in the middle ear is too quickly and incorrectly diagnosed. It’s useful to always compare the blocked ear with the other healthy ear drum and canal. Unless the appearance is significantly different, your diagnosis is probably incorrect. However, if the patient has a severe upper respiratory tract infection or has just flown or dived, perhaps this is a more reasonable diagnosis.
Referred blocked or full feeling from temporomandibular joint inflammation, grinding or dental pathology is an essential exclusion.
Surprisingly, the appearance of the ear canal and tympanic membrane in sudden nerve deafness is almost always completely normal and this should raise your suspicions that you need to consider the inner ear. Simple tuning forks will demonstrate a Rinne negative test on the affected side and a Weber test that lateralises to the opposite good ear. If the Rinne lateralises to the affected (blocked) ear, it is likely a conductive loss (outer ear canal or middle ear pathology). If you don’t have a tuning fork, simply ask the patient to hum. The humming sound should be heard in both the patient’s ears. If the sound is heard only in the opposite ear, this may indicate an SSNHL in the blocked or full ear.
For most patients, the cause of SSNHL is idiopathic, but is thought to be due to inflammation of the cochlear. Viral aetiologies are the most common, together with vascular causes, microemboli, haemorrhage, head trauma, loud noise exposure (concert, explosion, firecracker), neurological diseases (multiple sclerosis) and, rarely, tumours (acoustic neuroma). Herpes simplex type 1 is a common virus and if herpes zoster is involved, vesicles maybe seen on the tympanic membrane.
If you suspect an SSNHL, discuss starting steroids immediately with the patient and arrange referral for an urgent hearing test. If steroids are commenced within 24–72 hours of onset, there is a 30–60% chance of recovery of the hearing loss. The patient can then be referred to an ear, nose and throat specialist for further monitoring and investigations.
The evidence for efficacy of antivirals, hyperbaric oxygen and other treatments is weaker. Antibiotics, decongestants, antihistamines and ear drops are totally ineffective and not indicated. Emergency imaging in the form of computed tomography and magnetic resonance imaging scans is not recommended unless an underlying serious pathology is suspected.
In a patient with SSNHL combined with vertigo, a complete labyrinthitis (inflammation of the cochlear and vestibular system) is suspected. Early steroids are again indicated to treat hearing loss.
The take-home message is if you see a well patient with a blocked or full feeling in their ear, please exclude an SSNHL. If in doubt, request an urgent audiogram and commence steroids within 24–72 hours until the diagnosis is confirmed or excluded.
Dr Peter Friedland is an ear, nose and throat consultant at Sir Charles Gairdner Hospital in Perth. He is Head of Clinical Research at the Ear Science Institute Australia, associate professor at the University of Western Australia and professor at Notre Dame University. He can be found on Twitter at @entperth.
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Have hearing loss in one ear but fullness in both ears. I have been to ent and he says there’s no fullness there . I’ve had to be put on anxiety and antidepressants because if this .
Also consider Ménières disease. SSNHL can also be an indication of this condition. Eventually with Ménières permanent deafness in the affected ear often occurs but it takes several episodes to start causing long term effects.
Ménières also causes mild to severe vertigo, along with tinnitus, fullness and hearing loss – usually in one ear.
The cause is often idiopathic but is thought to be due to fluid buildup in the labyrinth. This could be caused by numerous problems. Usually the aqueducts are affected but some research has indicated a virus may be one major cause.
In any case a patient with Ménières should never be without corticosteroids since it is not possible to differentiate between idiopathic SSNHL and Ménières.
Good piece of information you have provided here. While a lot of inner ear blockage is harmless, there are severe cases which can be considered a medical emergency like you’ve described here
Hi Lyne. I read your comment about your husband’s ear problem and it sound exactly like my problem. I would be very interested to know if you’ve found and help already? Doc just prescribes antibiotics that did zero.
I woke up one day and presented to the GP as I had lost all hearing in my right ear. For the next three days I had severe vertigo. I went back to the GP and told them my hearing was still gone and I had vertigo. They gave me vertigo tablets and sent me home. My ear was checked both times by the GP who said there was no obstruction and no inflammation in my ear and at no time was I told about steroids and I was told it will just come back. A couple weeks later I went back to the GP and saw a different one my hearing had still not returned. The first thing she asked is was I put on steroids. She then sent me to an urgent ENT appointment and he said it was SSNHL and the first thing he asked was did the GP put me on steroids.The ENT did give me a course of steroids but he also stated that it should have been given at initial presentation. Is it common knowledge for a GP to use steroids for sudden hearing loss in one ear? Is there any guidelines for GPs to follow regarding this treatment in australia? Where can I get a copy of it? Is this article based on the most current research? I am extremely upset that I missed out on steroid treatment as I now have lost all my hearing in that ear and lost my job because I need three directional hearing to be able to work in my chosen field, If there is a possibility I could have regained my hearing I would have taken it.
I nearly committed suicide on the 28th June because a doctor at Wyong Hospital denied me steroids to treat my case of SSNHL in my right ear which I woke up with on the 26th June this year. This is even after I told her the same thing happened to my left ear 13 years ago. I told her back then the GP gave me prednisolone 50mg for a week or so. My hearing came back in my left ear. This year my right ear went out. So I got an ambulance and presented to Wyong ED. She dismissed everything I said and gave me Sofradex which is not even indicated for SSNHL. The ear drops are used to treat Swimmer’s Ear, not SSNHL!!! Hell, this doctor even said that SSNHL was rare. So why the hell did she deny me the steroids I needed? Was she trying to punish me for calling an ambulance because I was so terrified of losing my hearing forever? I will never know.
I got lucky this time because it came back spontaneously (Yes this does happen!).
If it didn’t I wouldn’t be alive today.
I have referred the matter to the HCCC and the matter is ongoing. That doctor needs to realise what she could have caused. I am very, very, very, angry at this doctor. And after what she did.
Hi my husband who is 62 has suffered the last 2 years of right ear feeling constantly blocked, he as to keep on popping it.
He did go to a ENT Dr in the beginning who could not find anything. Driving him crazy. Have you any ideas what he should do. He hasn’t lost any earring. Just very irritating.
A great article. Thank you. I wish I read it earlier!
Hi
I had feeling of fullness in ear and partial hearing loss since last one month, I started steroid on 12 day but no imrovent,
The fork sounds better when touched to bone of skull in affected ear.
Eustachian tube is also blocked, I opened it with force, I felt vertigo for 3 days, so I am not putting force
My question to you is that, will I have this feeling of blocked ear for rest of my life or there is any solution for it?
Hi Peter I live in Midland WA and over two weeks ago I had a blocked ear. About twenty four hours later this switched to my other ear. I went to GP and she thought it might be an ear infection. So I was put on a course of antibiotics for five days. My ear is still blocked and I was booked in to a hearing place for an audiogram but I rang first and asked if there was any point in going for this test as my ear felt blocked and she said no there was not. I am now in limbo land. Any advice would be greatly appreciated?
Regarding a blocked ear from putty ear plugs, this should be seen on ear examination and hopefully removed.Once removed, the hearing should be restored back to normal.If not, need to work up for hearing loss with urgent audiogram. This will differentiate conductive (middle ear problem) or sensorineural problem
SSNHL is children is a challenge to diagnose. If a child is older they may report decreased hearing orr a”blocked ear”. An audiogram is always essential. If its a very young child/baby an OAE (Oto- Acoustic Emissions test and possibly an ABR (Auditory Brainstem response test ) are required
What if you are afraid you may have SSNHL due to being an idiot and using putty as earplugs? Is that going to be a more serious condition?
I woke up this wed 7/8/18 with no hearing in my left ear and a feeling that it may be full of wax. Luckily a doctor friend was a were of SSNHL and informed my GP. I started taking steroids that day. Just left the ENT Specialist SSNHL confirmed. Bugger!!
Thank you. Great article. Any advice for assessing for SSNHL in kids?
Great article Peter and I agree its misdiagnosed. I see patients who woke up with a blocked ear and saw their GP who prescribed antibiotics, ear drops, or decongestant sprays. They eventually see an ENT specialist and the diagnosis is made but its usually too late for a benefit with steroids.
Likewize when oral steroids have not been effective, intratympanic injection of steroids is also advocated with mixed results.
Thank you for your query on hyperbaric oxygen. In centers where this is available it has been offered over a period of three months with varying results. There is evidence that it can improve blood supply to the cochlear and improve hearing loss.However this evidence is much weaker grade and not supported by Cochrane
Role for Hyperbaric Oxygen Therapy?
Thanks, that was simple and helpful
Also consider Fabry disease