Evaluation and Treatment

All Service Members that develop symptoms consistent with noise trauma (acute tinnitus, muffled hearing, fullness in the ear, vertigo) should be educated and directed to self-report for evaluation and treatment as soon as practicable. Patients exposed to hazardous noise occurring from exposure to battle (improvised explosive devices, rockets, and small arms fire) and all patients exposed to a blast should be asked specifically about hearing loss and tinnitus during their initial trauma evaluation, unless other more urgent treatment or mental status conditions do not allow. This should be documented as soon as safe evaluation permits. All patients presenting to concussion care centers should be evaluated for hearing loss and tinnitus.

If there is debris in the External Auditory Canal (EAC) or in the middle ear (as seen through a TM perforation), treat the patient with a fluoroquinolone and steroid containing topical antibiotic (e.g., four (4) drops of ciprofloxacin/dexamethasone or ofloxacin in the affected ear three (3) times a day for seven (7) days). Do NOT irrigate the ear as it may provoke pain and vertigo and move the debris medially in the ear canal and middle ear, as well as promote infection. Also, do not use any topical drops containing aminoglycosides (i.e., the neomycin in Cortisporin) since these are ototoxic. Patients should observe strict dry ear precautions and keep ALL water out of the EAC until the TM perforation has healed or is repaired. A trained medical professional or ENT surgeon should only remove debris to avoid further injury to the EAC or the middle ear.

Hearing loss that persists 72 hours after acoustic trauma warrants a hearing test or audiogram. If available, test hearing as soon as possible after acoustic injury to document TTS (before 72 hours). When hearing loss is present, individuals should be restricted from continuous noise great then 85dB or weapon firing period. This is important to allow time for healing since the inner ear is more susceptible to additional noise-induced damage while it is under the oxidative stress and glutamate toxicity of an acute injury. A Service Member with hearing loss is less effective during missions and can negatively impact mission performance.25

Vestibular trauma may manifest dizziness, unsteadiness, or vertigo. Please refer to the Veteran Affairs/DoD vestibular clinical recommendations for a detailed review of traumatic dizziness patients with positional vertigo and without other contraindicating injuries should undergo Dix-Hallpike testing. An Epley maneuver or canalith repositioning should be performed if Dix-Hallpike testing was positive. (See Appendix A and Appendix B.) There is evidence between BPPV recurrence and low serum vitamin D levels. In patients with BPPV, we recommend vitamin D serum testing and supplementation in patients when levels are deficient.26,27