Decoding the Silent Warning: Sudden Sensorineural Hearing Loss as a Harbinger of Vascular Catastrophes—A Dual Case Study

Significance Statement

This article underscores the imperative for clinical physicians to consider sudden sensorineural hearing loss as a potential early indicator of cerebrovascular disease, advocating for prompt diagnostic imaging to facilitate timely intervention.

Otoscopic Clinic

Sudden sensorineural hearing loss (SSNHL) constitutes an otological exigency, characterized by a decline in hearing across at least 3 consecutive audiometric frequencies exceeding 30 dB, manifesting within a 72 hour timeframe. ¹ Predominantly, these instances lack an identifiable cause ² ; nonetheless, SSNHL can occasionally serve as the initial symptom of cerebrovascular ischemia. ³ This article delineates 2 instances of SSNHL attributable to vascular etiologies, notwithstanding the absence of conspicuous neurological deficits.

The first case involves a 62-year-old male with a medical history of hyperthyroidism, type II diabetes mellitus, and atrial fibrillation spanning a decade. He sought emergency care due to vertigo and abrupt auditory impairment on his right side on awakening. He negated any history of tinnitus, ear pain, or ear discharge. Physical examination did not reveal any focal neurological signs. Pure-tone audiometry (PTA) indicated profound hearing loss in the right ear (Figure 1A). In the emergency room, a computed tomography scan of the brain was conducted, which disclosed no evidence of intracranial hemorrhage. Subsequently, he was admitted to the otorhinolaryngology ward for further treatment. However, he complained of weakness in the left upper limb and numbness on the right side of his face within a day following his admission. Urgent magnetic resonance imaging (MRI) of the brain uncovered acute infarcts in the right cerebellum and vermis (Figure 1C and D). Treatment commenced with a heparin infusion at 900 U/h, transitioning to apixaban 5 mg twice daily after 1 week and undergoing multiple sessions of hyperbaric oxygen therapy. Hearing improvement was noted 2 weeks later and near completely recovered after 15 months (Figure 1B). The muscle power of the limbs also recovered uneventfully.

Figure 1.

(A) Pure-tone audiometry on first day of admission and (B) after 15 months follow-up. (C) Axial MRI in T2-weighted and (D) diffusion-weighted image demonstrate hyperintense foci involving the right cerebellum, vermis. MRI, magnetic resonance imaging.

The second case recounts a 58-year-old male with no prior systemic diseases, who experienced sudden left-sided hearing loss 2 weeks before presenting at our emergency department. Initial treatment at local medical clinics was in vain; his symptoms persisted and were occasionally accompanied by a sensation of spinning. No recent symptoms of a common cold, fever, ear discharge, ear pain, or history of recent head and ear trauma were reported. PTA revealed profound hearing loss in the left ear (Figure 2A). He was admitted for further evaluation and management. MRI of the brain revealed acute infarction in the left paramedian cerebellum (Figure 2C and D). Aspirin therapy was initiated, he was discharged without any neurological deficits but without any hearing improvement. Hearing level was slightly recovered after 5 years (Figure 2B).

Figure 2.

(A) Pure-tone audiometry on first day of admission and (B) after 5 years follow-up. (C) Axial MRI in T2-weighted and (D) diffusion-weighted image show hyperintense foci involving left paramedian cerebellum. MRI, magnetic resonance imaging.

The otorhinolaryngologists must remain vigilant for SSNHL with a vascular origin, given its distinct management and prognostic implications. A delayed diagnosis could imperil the patient’s life or lead to persistent neurological sequelae. Attention should be paid to focal neurological symptoms including vertigo, tinnitus, headache, and diplopia. Previous research posits SSNHL as a preliminary warning of potential cerebrovascular disease. ⁴ Furthermore, infarction is known to present a wide range of audiovestibular dysfunctions, ⁵ with SSNHL being a critical, albeit atypical, indicator for diagnosing infarction. Prompt identification of a vascular cause behind SSNHL and the administration of suitable care or referral is imperative. MRI is strongly recommended for individuals presenting with SSNHL to rule out infarction and tumors. ¹ In summation, otologists should acknowledge that SSNHL may occasionally herald an imminent infarction.