When sudden hearing loss in an adolescent patient should be treated as an emergency
Hearing loss is common in all ages and has three main categories: conductive, sensorineural and mixed.
The leading causes of conductive hearing loss are cerumen impaction, otitis media and otosclerosis. The main cause of sensorineural hearing loss include inherited disorders, noise exposure and presbycusis.1 This adolescent case study focuses on diagnosis of a potentially complex hearing loss etiology.
Clinical Presentation
Mary is a 17-year-old, white adolescent teen who developed sudden hearing loss in the right ear, along with a burning sensation and a vesicular rash behind the same right ear.
She reported acute hearing loss two days subsequent to the rash. Mary denies any trauma to head or ear.
Past Medical History
Mary has not had the chickenpox because she had two doses of the Varicella vaccine. The weakened Varicella vaccine can reactivate in rare instances to cause herpes zoster (HZ).2 It is also assumed that a decline in cell-mediated immunity may play a critical role in the reactivation of the weakened Varicella vaccine.3
Mary denies HIV, asplenia and medication use at this time. Therefore, she has no history of past or present immunosuppression. There is no family history of inherited sensorineural hearing loss or gradual hearing loss over time. Mary denies the use of headphones and has never attended a concert. Mary does admit to listening to music in her car loudly.
Mary denies use of alcohol or illicit drugs and has no known drug allergies. Mary is up to date with all state required immunizations. She and her mother presented to ambulatory acute care awake, alert and oriented to person, place, and time.
Mary’s vital signs were blood pressure, 98/62; heart rate, 86 beats per minute and regular; afebrile; respiratory rate of 16 saturating at 98% on room air, and weight, 120 lbs. A complete blood count and blood chemistry were done to rule out any immunocompromised state. A Varicella titer was also performed to confirm if there were any Varicella antibodies indicating immunity to varicella.
A Physical Examination
Objective findings included a 3cm by 2cm unilateral, red, and raised vesicular rash behind her right ear. Surrounding skin was red and inflamed. Some vesicles were oozing yellow serous fluid from Mary scratching the area.
Otoscopic evaluation revealed redness and vesicles inside the right ear canal. There was scant cerumen in both ears. Mary’s tympanic membrane was pearly grey with boney landmarks visible. There was no abnormal bone growth seen in the middle ear. A tuning fork was used to perform the Weber hearing test. Mary was able to feel the vibrations in her left ear, which suggested the possibility of sensorineural hearing lost.
Diagnosis
Sudden Sensoneural Hearing Loss (SSNHL) Secondary to HZ, also known as shingles, is caused by the varicella-zoster virus (VZV).2
HZ is an illness triggered by the reactivation of VZV, which lies dormant in sensory ganglia after primary infection.3 Clinically, HZ is usually evidenced by unilateral radicular pain and vesicular eruptions limited to a single dermatome innervated by a single spinal or cranial sensory ganglion.4
The incidence and severity of HZ disease increases with age, with a noticeable rise after 50 years of age, however, although relatively rare, HZ also occurs in children.5 Sadly, there is not enough data at this point to assess whether the varicella vaccine, which became available in 1995, is consistently associated with milder cases of chicken pox and fewer occurrences of shingles later in life.6
Studies have shown that one dose of the varicella vaccine has been effective at preventing 85% of varicella cases.6 It is estimated that 1 million people annually are affected with HZ.3 HZ-associated pain tends to resolve over time, but some patients suffer from post neuropathic pain beyond resolution of visible cutaneous manifestations. 2
Making a Referral
The decision to refer Mary to the next level of care was made when vesicles were found inside the ear canal along with hearing loss. The referral was made to try to keep Mary’s hearing intact. Mary was referred to urgent care because SSNHL is one of the few emergencies in otology.5 This emergency is also a terrifying experience for patients as they lose the ability to effectively communicate.5
Sudden sensorineural hearing loss is a rather common otologic disorder characterized by newly onset unilateral or bilateral hearing loss that develops rapidly, within 72 hours.5
Viral infections such as HZ can lead to SSNHL.5 Studies showing the connection between HZ and SSHNL are lacking at this time. 5 Therefore, no definitive numbers can be assigned for the incidence in adolescents.
Follow-up
During a follow up call the next day, it was learned that Mary was diagnosed with herpes zoster. She was diagnosed by clinical presentation alone. A Varicella titer was performed to prove the antibodies of the vaccination were present, which they weren’t due to varicella vaccination.
Mary was placed on Valtrex 1000mg by mouth three times a day for 7 days, Tylenol #3 30mg/300mg every 8 hours as needed for pain, and prednisone dose pack starting at 60mg and tapering off over 2 weeks. It is recommended for HZ to be treated with antiviral agents, pain medication and corticosteroids for pain control. 7
Mary was given an appointment to follow-up one week after completion of Valtrex with her ear, nose, and throat specialist and instructed to go directly to ED if symptoms worsened.
Conclusion
Proper and prompt referral is vital to the improved outcomes of adolescents who present with HZ symptoms affecting organs vital to communication.
It is key to remember that prompt treatment of disease can deter hearing loss.1 Recovery is variable, and patients with more severe losses display poorer recovery of hearing since the hearing loss is due to degeneration in the cochlear nerve, as well as inflammation around the brain lining. 1 Therefore, it is important to remember to educate patients on importance of up-to-date immunizations and early treatment of diseases, which can also lower the chances of hearing loss. 1
Since there aren’t many large studies on the connection of HZ and SSNHL, additional DNP capstone research should be conducted to collect more information on this topic.
- References
Appold K. 11 surprising medical causes of hearing loss. Hear Health. 2012;28(2):36-9. - Pahud BA, et al. Varicella zoster disease of the central nervous system: Epidemiological, clinical, and laboratory features 10 years after the introduction of the varicella vaccine. J Infect Dis. 2011;203(3):316-23. doi: 10.1093/infdis/jiq066
- Donahue JG, et al. Herpes zoster and exposure to the varicella zoster virus in an era of varicella vaccination. Am J Public Health. 2010;100(6):1116-22. doi: 10.2105/AJPH.2009.160002
- Naveen KN, et al. Herpes zoster affecting all three divisions of trigeminal nerve in an immunocompetent male: a rare presentation. Indian J Dermatol. 2014;59(4):423-423. doi: 10.4103/0019-5154.135548
- Sheu J, Keller JJ, Chen Y, Wu C, Lin H. No increased risk of sudden sensorineural hearing loss following recent herpes zoster: A nationwide population-based study. Acta Otolaryngol. 2012;132(2):167-72. doi: 10.3109/00016489.2011.633227
- Kane E. The truth about shingles. Better Nutr. 2014;76(11):26-7.
- Gan EY, et al. Management of herpes zoster and post-herpetic neuralgia. Am J Clin Dermatol. 2013;14(2):77-85. doi: 10.1007/s40257-013-0011-2.
