PUID: 62 || PLAB 2 Mock 4 :: Hearing Loss1: Idiopathic Sensorineural Hearing Loss

Summary

A patient presents with sudden unilateral hearing loss suggestive of SSNHL. This is an urgent condition requiring same-day ENT referral for confirmation with audiometry and early treatment (ideally within 72 hours).
While most SSNHL is idiopathic (i.e., exact cause unknown, not “no reason”), you must exclude retrocochlear pathology, especially vestibular schwannoma (acoustic neuroma), with appropriate imaging.

SSNHL: ≥30 dB sensorineural loss over ≥3 contiguous frequencies occurring within ≤72 hours.
Idiopathic: cause is not currently known after initial assessment; avoid saying “no apparent reason.”
Acoustic neuroma (vestibular schwannoma): benign Schwann cell tumor at the cerebellopontine angle, typically causing unilateral progressive SNHL, but can present suddenly; associated features include tinnitus, imbalance/vertigo, facial numbness/weakness (CN V/VII), not visual pathway symptoms.

Immediate help if any worsening hearing, severe vertigo or balance problems, new facial weakness/asymmetry, facial numbness, severe headache or other focal neurological deficits.
Family history of Neurofibromatosis type 2 (NF2) → think bilateral vestibular schwannomas.

Laterality (one ear vs both), sudden vs gradual, exact time of onset, progression.
Preceding triggers: recent viral illness, trauma/barotrauma, loud noise exposure, ototoxic drugs.
Associated symptoms: tinnitus, aural fullness, vertigo/imbalance, otalgia/otorrhoea, facial symptoms.
Systemic & risk: vascular risk factors, autoimmune history, FHx NF2.
Functional impact & patient concerns (work, driving, communication).

General: vitals, general inspection.
Otoscopy: to exclude external/middle ear pathology.
Tuning-fork tests: Rinne (air > bone in SNHL) and Weber (lateralises to good ear in SNHL). If you don’t specify tests, you won’t be handed results in OSCE.
Cranial nerves: V, VII (and cerebellar signs) to screen for CP-angle involvement.

Urgency: Treat SSNHL as a medical urgency—same-day ENT assessment and start steroids early improves chance of recovery.
Language & clarity: Use plain English and avoid jargon; if you use the term “idiopathic,” immediately explain it in lay terms. This aligns with GMC guidance on clear, accurate, understandable information and checking understanding.
Avoid stock phrases/over-promising: Communicate naturally; be precise about what may happen at specialist level; avoid rehearsed lines.
Primary care scope: In PLAB 2, you’re usually in a primary/urgent care role—use words like “may prescribe steroids,” “will arrange urgent referral,” and avoid definitive specialist decisions.

Confirm SNHL
- Rinne and Weber (state explicitly).
- Document any neurological or vestibular signs.
Urgent ENT Referral (same day)
- Pure-tone audiometry & tympanometry to confirm sensorineural loss and quantify severity.
- Consider MRI internal auditory meatus/brain to exclude vestibular schwannoma (especially if asymmetry, persistent loss, or neurological signs).
Initial Labs (case-dependent; not mandatory before referral)
- If history suggests: autoimmune panel, syphilis serology, glucose, lipids, thyroid—do not delay referral/treatment for these.
Differentials to hold in mind
- Idiopathic SSNHL, vestibular schwannoma, viral neuritis/labyrinthitis, Menière’s disease (aural fullness + episodic vertigo + tinnitus), otosclerosis (usually CHL), barotrauma, vascular/autoimmune causes, ototoxicity.

Acknowledge urgency; arrange same-day ENT.
Explain that the specialist may start corticosteroids (usually systemic, not ear drops, due to bioavailability), ideally within 72 hours of onset for best prognosis.
Analgesia/anti-emetics if symptomatic vertigo/nausea (as appropriate).
Safety net: clear return advice (see Red Flags), and document.

Audiometry today to confirm/grade SNHL.
Systemic corticosteroids (e.g., oral or IV) or intratympanic steroids if systemic contraindicated or as salvage.
MRI IAM/brain to exclude tumor if indicated.
Follow-up: typically 2–3 weeks to reassess hearing and adjust plan.

Many patients experience partial or full recovery, especially with early treatment; set realistic expectations and avoid guarantees. This matches examiners’ advice to be realistic and not over-promise.

Open questions first, then focused questions; avoid disjointed, rote history.
Signpost transitions (“I’d like to ask about your hearing in each ear…”) to stay structured and time-efficient.
Plain language: translate “idiopathic SSNHL” → “a sudden hearing drop in one ear where we don’t yet know the cause.” Check understanding (“Could you tell me what you’ll do after we finish today?”).
Empathy without stock phrases; natural, patient-centred rapport.
Be precise about actions you can take now and what the specialist may do; avoid over-referring or promising everything.

Urgent, competent care within your scope; refer promptly when needed.
Clear, accurate, up-to-date information to support shared decisions; check capacity/consent for examination/referral.
Record-keeping: contemporaneous notes including findings, information given, decisions and safety-netting.

GMC Good medical practice (2024) — communication, consent, clarity, scope.
GMC/PLAB Examiner Top Tips — avoid stock phrases, be realistic, focus and structure.
(For personal study) NICE CKS/ENT UK guidance on SSNHL and Acoustic neuroma work-up and steroid windows.