Lyme disease sudden hearing loss can develop up to one year after initial infection, demonstrating how neuroborreliosis symptoms can manifest long after tick exposure. A woman in her 40s developed sudden bilateral sensorineural hearing loss, tinnitus, and rapidly progressive facial palsy — yet only upon further questioning did she mention removing a tick from her ear canal one year earlier. Her case reveals a diagnostic challenge: connecting sudden hearing loss and facial palsy to Lyme meningitis when symptoms appear months or years after the tick bite, and emphasizes why complete medical history including past tick exposure is essential when evaluating cranial nerve dysfunction.

Sudden Loss of Hearing in Both Ears

In their article “Lyme neuroborreliosis as a cause of sudden sensorineural hearing loss and facial palsy,” Nitro and colleagues present a case involving a woman in her 40’s who developed a sudden loss of hearing in both ears, along with facial palsy and was later diagnosed with Lyme meningitis.

“Bilateral hearing loss is rare,” the authors point out.

Sudden sensorineural hearing loss (SSNHL) affecting both ears simultaneously is uncommon. When it occurs with facial palsy, the differential diagnosis narrows significantly — yet Lyme disease is rarely considered unless tick exposure is elicited in the history.

The Emergency Presentation

The patient was admitted to the emergency department reporting hearing loss in both ears and tinnitus. Her symptoms had been ongoing for 3 days. She also complained of dizziness, neck pain and stiffness.

She was admitted to the hospital overnight for observation and received oral amoxicillin/clavulanate for a possible ear infection. “During the night, a new urgent neurological consult was requested following sudden right facial palsy,” the authors wrote.

The clinical picture worsened rapidly. Bilateral hearing loss, tinnitus, dizziness, and neck stiffness were concerning enough. When facial palsy developed overnight, this signaled multiple cranial nerve involvement — a hallmark of neurologic Lyme disease.

Rapidly Progressive Neurologic Symptoms

Patient with neuroborreliosis presented with a sudden sensorineural hearing loss and rapidly progressive facial palsy.

The patient was then started on intravenous methylprednisolone, valaciclovir and intravenous ceftriaxone.

Over the next 2 days, her neck pain improved but her hearing loss and facial palsy did not get any better.

The treatment covered multiple possibilities: steroids for inflammatory hearing loss, valaciclovir for viral causes (Ramsay Hunt syndrome from varicella-zoster), and ceftriaxone for bacterial infection. The neck pain improvement suggested meningeal inflammation was responding to treatment, but the cranial nerve deficits persisted.

Lyme Meningitis Diagnosed 1 Year After Tick Bite

Upon further questioning, the patient mentioned that one year earlier she had removed a tick from her right ear canal.

Tests results were positive for Lyme disease and an MRI showed suggestive signs of Lyme meningitis with multiple cranial nerve involvement.

This is the critical diagnostic moment. Without asking about past tick exposure, the connection to Lyme disease would have been missed. The tick removal one year earlier — from the right ear canal, the same side as the facial palsy — provided the key to diagnosis.

The MRI findings confirmed neuroborreliosis with multiple cranial nerves affected: cranial nerve VII (facial palsy) and cranial nerve VIII (hearing loss and balance/dizziness).

Complete Resolution With Treatment

The woman was treated successfully with IV steroids and ceftriaxone. “At the end of the therapy, the patient showed a complete resolution of the meningeal inflammation, facial palsy, and sensorineural hearing loss.”

Complete resolution of both hearing loss and facial palsy proves these deficits were caused by active infection and inflammation, not permanent nerve damage. This is remarkable — sudden sensorineural hearing loss from other causes (viral, vascular) often results in permanent deficit. Her recovery demonstrates the reversibility of Lyme-induced cranial neuropathy when treated appropriately.

The Diagnostic Challenge

“The most challenging feature of this case was identifying a diagnostic connection between SSNHL [Sudden sensorineural hearing loss] and rapidly progressive unilateral facial palsy.”

The combination is rare. Sudden hearing loss alone has multiple potential causes: viral infection, vascular ischemia, autoimmune disease, acoustic neuroma. Facial palsy alone commonly suggests Bell’s palsy or Ramsay Hunt syndrome. But both together, bilaterally, with meningeal signs — this pattern should prompt consideration of infectious meningitis affecting cranial nerves.

Authors’ Takeaways

• “This case report highlights the importance of collecting a complete medical history in all cases of facial palsy and sudden hearing loss while presenting an infrequent clinical presentation of early disseminated Lyme disease with neuroborreliosis.”
• “… no literature reports association or correlation between [sudden sensorineural hearing loss] and facial palsy except for one case report in which they have been described after a tick bite.”
• “One of the most peculiar features of neuroborreliosis can manifest up to 1 year after a disseminated infection, as in this case report.”

Why Symptoms Appeared One Year Later

The one-year delay between tick bite and neurologic symptoms represents early disseminated Lyme disease. After initial infection, Borrelia spirochetes can disseminate throughout the body and persist in tissues — including the central nervous system — for months or years before causing overt symptoms.

Several factors may trigger symptom onset after prolonged latency:

• Immune suppression: Stress, illness, or other factors weaken immune control of chronic infection
• Spirochetal replication: Low-level infection reaches critical threshold triggering inflammation
• Gradual CNS invasion: Spirochetes slowly infiltrate meninges and cranial nerves
• Delayed immune response: Adaptive immune response takes months to mount inflammatory attack

This delayed presentation is why asking about tick exposure within the past year — not just recent weeks — is essential when evaluating unexplained neurologic symptoms.

Clinical Perspective

This case demonstrates several critical teaching points about Lyme disease and sudden hearing loss. First, the one-year delay between tick removal and symptom onset challenges the misconception that Lyme disease presents acutely after tick bite. Early disseminated Lyme can manifest months or even years later, which is why historical tick exposure must be elicited.

Second, the bilateral nature of the hearing loss is unusual and significant. Most causes of sudden sensorineural hearing loss affect one ear. Bilateral involvement suggests systemic disease — infection, autoimmune process, or ototoxic exposure — rather than isolated viral or vascular events.

Third, the rapid progression from hearing loss to facial palsy within 24 hours indicates aggressive neurologic involvement. When cranial nerve deficits develop or worsen acutely, this signals active inflammation requiring immediate treatment.

Fourth, the neck pain and stiffness were meningeal signs. Combined with cranial neuropathies, this pattern strongly suggests infectious meningitis. The differential includes viral meningitis, bacterial meningitis, and neuroborreliosis — all requiring different treatments.

Fifth, the MRI showed multiple cranial nerve involvement. Cranial nerves VII (facial) and VIII (vestibulocochlear) were clearly affected. The imaging findings supported neuroborreliosis diagnosis and helped exclude alternative causes like acoustic neuroma or multiple sclerosis.

Sixth, the complete resolution of both hearing loss and facial palsy with treatment is exceptional. Sudden sensorineural hearing loss from viral or vascular causes often results in permanent deficit despite treatment. The fact that her hearing returned completely validates the diagnosis of reversible infection-induced inflammation rather than permanent nerve damage.

Finally, the authors’ point about lack of literature on this presentation is important. The combination of sudden hearing loss and facial palsy is so rare that only one prior case report described it after tick bite. This means clinicians unfamiliar with Lyme disease won’t recognize the pattern, leading to missed diagnoses.

Frequently Asked Questions

Can Lyme disease cause sudden hearing loss?

Yes. Lyme disease sudden hearing loss can occur when spirochetes invade the eighth cranial nerve (vestibulocochlear nerve) causing sensorineural hearing loss. This case showed bilateral hearing loss that resolved completely with IV antibiotics and steroids.

How long after a tick bite can hearing loss develop?

Neurologic symptoms including hearing loss can develop up to one year or more after tick bite. This represents early disseminated Lyme disease where spirochetes have spread to the nervous system and remained dormant before causing symptoms.

Can Lyme disease hearing loss be reversed?

Yes. This patient had complete resolution of bilateral sensorineural hearing loss after treatment with IV ceftriaxone and steroids. Unlike hearing loss from viral or vascular causes, Lyme-induced hearing loss can be fully reversible when treated promptly.

What is the connection between facial palsy and hearing loss in Lyme disease?

Both represent cranial nerve involvement from neuroborreliosis. Facial palsy affects cranial nerve VII, while hearing loss affects cranial nerve VIII. When both occur together, this indicates multiple cranial nerve inflammation from meningeal infection.

Should sudden hearing loss patients be asked about tick bites?

Yes. Complete medical history should include tick exposure within the past year, especially when hearing loss is bilateral, occurs with facial palsy, or is accompanied by neck stiffness, headache, or other neurologic symptoms.

Why did the initial antibiotics not help?

Oral amoxicillin/clavulanate for “ear infection” doesn’t adequately treat neuroborreliosis. Lyme meningitis requires IV ceftriaxone to achieve therapeutic levels in cerebrospinal fluid and penetrate the blood-brain barrier.

Can tinnitus be caused by Lyme disease?

Yes. Tinnitus is a common symptom of Lyme-related eighth cranial nerve involvement. This patient had both hearing loss and tinnitus, which resolved together after treatment for neuroborreliosis.