Eur Arch Otorhinolaryngol (2007) 264:99102
DOI 10.1007/s00405-006-0120-0
C AS E RE PO RT
Acute sensorineural hearing loss immediately following a local
anaesthetic dental procedure
T. S. Tan M. Shoeb S. Winter M. C. Frampton
Received: 20 March 2006 / Accepted: 3 July 2006 / Published online: 1 August 2006
Springer-Verlag 2006
Abstract Acute sensorineural hearing loss is an
uncommon phenomenon. We describe the Wrst case of
a 42-year-old lady who presented with acute sensori-
neural hearing loss occurring immediately after a den-
tal procedure. Possible mechanisms are discussed. She
was treated with high dose oral steroids, low molecular
weight dextran and vasodilators with beneWt.
Keywords Sensorineural hearing loss
Dental procedure Acute hearing loss
Introduction
Idiopathic sudden onset sensorineural hearing loss is
a well recognised phenomenon with a reported
annual incidence of Wve to twenty cases per 100,000
people [1]. Although there is no conclusive evidence
for the eYcacy of speciWc treatments, most centres
actively treat this condition. There are numerous aeti-
ologies postulated for sudden sensorineural hearing
loss (SSHL) but episodes following dental procedures
are poorly documented. After a full literature search,
we located four case reports of delayed onset of
T. S. Tan M. Shoeb S. Winter M. C. Frampton
Department of Otorhinolaryngology,
Head and Neck surgery, Bedford Hospital,
Kempston Road, Bedford, UK
T. S. Tan (&)
181 Fishguard Way, London, E16 2RX, UK
e-mail: tecksoon2000@yahoo.com
SSHL after dental procedures [2]. We present the Wrst
case of SSHL occurring immediately after a dental
procedure.
Case report
A 42-year-old female presented to the department
with acute hearing loss occurring immediately follow-
ing a local anaesthetic dental procedure. She had no
previous history of any ear, nose and throat disease.
She also denied any history of trauma/barotraumas
and she was well in herself prior to this. Immediately
following a right upper lateral tooth implant (expan-
sion ridge technique) performed using 4 ml of 4%
Articaine hydrochloride with 1:1000 adrenaline and
10 mg of intravenous midazolam, she experienced
acute vertiginous symptoms and left sided hearing
loss.
On presenting to the Ear Nose and Throat depart-
ment, examination revealed no nystagmus, Rinnes test
was positive on the right side and negative on the left
side. Weber lateralised to the right ear. Audiogram
showed a left sided sensorineural hearing loss with nor-
mal thresholds on the right. (Fig. 1a)
She was admitted and treated with high dose oral
steroids (1 mg/kg), low molecular weight dextran and
vasodilators. She had daily audiograms.
Routine haematological and biochemical investiga-
tions were normal as was a Magnetic Resonance Imag-
ing (MRI) scan of her brain and internal acoustic
meatus.
Her vertiginous symptoms resolved spontaneously
the next day. After 3 days her hearing started to
improve (Fig. 1b).
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100 Eur Arch Otorhinolaryngol (2007) 264:99102

Air conduction
Bone conduction
a Right Ear Left Ear
-10 -10
0 0

Hearing Level (dBISO)

10 10
Hearing Level (dBISO) 20 20
30 30
40 40
50 50
60 60
70 70
80 80
90 90
100 100
110 110
120 120
125 250 500 1000 2000 4000 8000 125 250 500 1000 2000 4000 8000
Frequency (Hz) Frequency (Hz)

b Right Ear Left Ear

-10 -10
0 0
10 10
Hearing Level (dBISO)

20 20

Hearing Level (dBISO)

30 30
40 40
50 50
60 60
70 70
80 80
90 90
100 100
110 110
120 120
125 250 500 1000 2000 4000 8000 125 250 500 1000 2000 4000 8000
Frequency (Hz) Frequency (Hz)

Fig. 1 a Audiogram on presentation to the department. b Audiogram showing improvement of hearing

Discussion Immunological including autoimmune conditions

Sudden hearing loss is deWned as 30 dB or more senso-
rineural hearing loss over at least three contiguous
audiometric frequencies occurring within 3 days or less
[3]. There are various possible aetiologies that could
account for this phenomenon which can be broadly
classiWed into infectious, traumatic, neoplastic, immu-
nological, toxic, circulatory, neurological or metabolic.
Often the pathogenesis of acute sensorineural hearing
loss is multi-factorial.
Infectious diseases have long been associated either
directly or indirectly with sensorineural hearing loss
with various organisms being implicated [46]. Trauma
is a well recognised cause both in association with tem-
poral bone fractures and otologic surgery [7], but also
in relation to non-otologic procedures [1, 8] and even
blunt neck trauma [9].
Perilymph Wstula is an uncommon and controversial
entity. The current consensus is that spontaneous peri-
lymph Wstula does not occur in an otherwise normal ear
without prior history of head injury, barotraumas, sur-
gery or congenital ear deformities [10].
represent another possible aetiology [11], and neo-
plasms such as vestibular schwannomas often present
with sensorineural hearing loss [12].
A normal MRI scan of the brain and internal acous-
tic meatus precludes a cerebello-pontine angle or
brainstem lesion causing the acute sensorineural hear-
ing loss in our patient, and there were no other symp-
toms or Wndings on the MRI scan to support a
neurological cause. All routine haematological and
biochemical blood tests were unremarkable and the
hearing loss improved after 3 days of treatment.
Neurotoxicity attributed to local anaesthetics is
usually related to drug overdose, accidental intravas-
cular injection or direct injection into the nerve [13,
14]. About 4 ml of 4% articaine hydrochloride pre-
cludes drug overdose in our patient. It is impossible to
rule out inadvertent intravascular injection even with
negative aspiration for blood during injection. Fur-
thermore the used of vasoconstrictor with the local
anaesthetic could induce vasospasm of the cochlear
division of the internal auditory artery resulting in
ischemia of the cochlea. However the contra-lateral

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Eur Arch Otorhinolaryngol (2007) 264:99102
ear to the dental procedure was aVected makes it less
likely.
Circulatory disorders or disruptions represent the
other major possible aetiologies, with various reports
of an association between arterial Xow [1416], and
blood viscosity [17, 18]. Dental extraction is known to
release microemboli into the circulation [2]. There
have been cases reported of sensorineural hearing loss
resulting from chiropractic manipulation of the cervical
spine secondary to vertebral artery injury [19]. Hyper-
extension and extreme rotation of the cervical spine
causes shearing, stretching or crushing of the vertebral
artery resulting in intra-luminal thrombus formation.
Microemboli released into the circulation can cause
ischaemia and infarction of the cochlea. Besides that
stretching and crushing of the vertebral artery during
the dental procedure could cause hypoperfusion of the
cochlea. Theoretically signiWcant cervical spine move-
ment and opening the jaw widely during the dental
procedure could cause the hearing loss through the
above mechanisms (Fig. 2).
Although the mechanism of acute sensorineural
hearing loss in this patient remains obscure to us, the
immediate onset of acute sensorineural hearing loss
Fig. 2 Proposed mechanism of vertebral artery injury resulting in
microemboli production. (Image kindly provided by Nucleus
Image)
101
following a dental procedure appears more than a coin-
cidental event. We feel that circulatory disruption from
mechanisms described above would be the most proba-
ble cause for her symptoms.
We described the Wrst case of sensorineural hearing
loss occurring immediately after a dental procedure.
Perhaps this rarity is due to poor recognition of the
association between SNHL and dental procedures. For
every severe case there may be many less severe or
minor cases where medical advice was delayed or not
sought.
Acknowledgment We would like to thank Nucleus image for
providing the picture in Fig. 2
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