Contemporary Clinical Management of Otosyphilis for Practicing Otolaryngologists—A Scoping Review

ABSTRACT

Objective

The COVID‐19 pandemic marked the resurgence of an old disease, syphilis. The CDC reported increased syphilis cases in the United States from 2016 to 2022, necessitating early recognition of syphilis to properly diagnose complications. We revisit otosyphilis management with the intent of developing an updated diagnostic testing algorithm and treatment plan for otolaryngologists to prevent worsening hearing loss.

Data Sources

MEDLINE, PubMed, Embase, Web of Science, and Cochrane databases.

Methods

A scoping review of diagnostic and treatment methods for otosyphilis was completed and reported in compliance with the guidelines outlined in the PRISMA‐ScR extension for scoping reviews statement. A retrospective case series was also conducted by reviewing patient charts from a tertiary care hospital network. Patients with otosyphilis or neurosyphilis with otic symptoms, as diagnosed by an otolaryngology or infectious disease specialist, were included.

Results

In 57 studies (222 patients), the mean reported symptom duration was 6.6 ± 5.0 weeks (n = 30) with nine outliers presenting after 6 months (65%) had hearing loss, 95 (43%) tinnitus, and 53 (24%) vertigo. Most (97%) received penicillin. Of 84 with outcomes, 48 (57%) improved. In 18 additional patients from the tertiary hospital system cohort (17 males, 1 female; 25–87 years, 9 HIV‐positive), penicillin or doxycycline was used. Six patients fully recovered, four required further therapy, two partially recovered, and one did not improve.

Conclusion

Otosyphilis has an insidious presentation and can mimic other audiovestibular demanding early testing. Complex serologic interpretation may require referral to infectious disease specialists. Clear diagnostic protocols ensure timely treatment and improved outcomes.

Otosyphilis has reemerged alongside increasing syphilis rates, highlighting the need for early recognition to prevent severe audiovestibular complications. A scoping review and retrospective case series indicate that most patients present with hearing loss, tinnitus, or vertigo and typically respond to penicillin‐based treatment. Clear diagnostic protocols, in collaboration with infectious disease specialists when needed, can ensure timely therapy and improve clinical outcomes.

1. Introduction

Syphilis, caused by the spirochete Treponema pallidum , has long been dubbed the “great imitator” for its myriad clinical presentations [1, 2]. Although prevalence declined dramatically following the advent of penicillin, recent epidemiological trends signal an alarming resurgence [3]. Both acquired and congenital forms of syphilis can result in cochleovestibular compromise, collectively referred to as otosyphilis—a rare but potentially debilitating manifestation. The disease progresses through well‐defined stages, beginning with a primary, often asymptomatic chancre. Even at early stages, patients may develop neurosyphilis with cochleovestibular sequelae [4], and SNHL rates of 17% in early latent, 25% in late latent, and 54% in tertiary neurosyphilis signify the importance of prompt detection and intervention [1, 4, 5].

Otosyphilis often presents with progressive or fluctuating SNHL or mixed hearing loss and is sometimes accompanied by Menière‐like symptoms, including episodic vertigo, tinnitus, and vestibular dysfunction [2, 6, 7, 8]. These features overlap with other otologic diseases, making timely diagnosis difficult. Immunocompromised patients, particularly those living with HIV, are at heightened risk of neurosyphilis and otosyphilis, even when their serum rapid plasma reagin (RPR) levels are low and CD4 counts are robust [4, 9, 10].

Although syphilis incidence once plummeted after penicillin became widely available, the rate of new infections has markedly increased in the United States over the past decade. Between 2016 and 2022, the incidence of primary, secondary, and early latent infectious syphilis rose from 8.6 to 19.7 cases per 100,000 persons [11]. This resurgence raises the specter of less commonly encountered complications, including otosyphilis. Without effective diagnostic and therapeutic interventions, the syphilis epidemic is poised for further expansion [12].

The increasing number of cases has rekindled clinical interest in the diagnostic challenges, treatment pathways, and sequelae of otosyphilis. Despite an increasing disease burden in the United States, robust, evidence‐based guidelines for diagnosing and managing this condition remain conspicuously absent. To address this void, we conducted a scoping review of the literature, detailing current insights into the epidemiology, clinical manifestations, diagnostic strategies, and therapeutic interventions for otosyphilis. Our goal is to guide otolaryngologists, infectious disease specialists, and primary care providers in recognizing and treating otosyphilis more effectively. Given the global upswing in syphilis cases, timely diagnosis and intervention are crucial to avert irreversible auditory and vestibular morbidity and to halt further expansion of this resurgent epidemic [11, 12].

2. Methods

2.1. Study Design

This study included two complementary components: (1) a systematic scoping review of the literature, and (2) a multicenter case series of individuals diagnosed with otosyphilis or neurosyphilis. The study followed the PRISMA extension for scoping reviews (PRISMA‐ScR) [13]. Institutional Review Board (IRB) approval was obtained from the (Medstar‐Georgetown University/IRB), with data de‐identified per ethical standards. All patient data were de‐identified before analysis. IRB approval was obtained under protocol STUDY00007531, and the requirement for individual informed consent was waived, given the retrospective design.

2.2. Systematic Review Eligibility Criteria

Studies were considered if they involved adults (≥ 18 years) with acquired syphilis, confirmed by serologic or CSF analysis, and who had otologic or neurologic manifestations such as sensorineural or mixed hearing loss, tinnitus, vertigo, or dizziness. Acceptable study designs included randomized controlled trials, cross‐sectional studies, case series, and case reports written in English between January 2013 and March 2025. This time frame aligns with the epidemiological resurgence of syphilis since 2016, as reported by the CDC, and captures the most current clinical practices, diagnostic advancements, and evolving treatment strategies for otosyphilis. Exclusions encompassed animal studies, non‐English publications, abstracts lacking full manuscripts, and papers solely addressing congenital syphilis. Cases with significant comorbidities that could confound symptom interpretation were excluded. Four reviewers (C.A.P., H.L., S.K., E.C.) independently screened articles, with consensus used to settle disagreements.

2.3. Information Sources and Search Strategy

Searches were conducted in Ovid MEDLINE, Ovid Embase, Cochrane Central Register of Controlled Trials, and Web of Science Core Collection. Controlled vocabulary (e.g., MeSH terms) and free‐text keywords captured “otosyphilis,” “neurosyphilis,” “syphilis,” “hearing loss,” “tinnitus,” and “vertigo,” or “dizziness.” Details of the search strategy are included in Table S1.

2.4. Study Selection and Data Extraction

All references were imported into Rayaan Systematic Literature Review for screening, which was used to remove duplicates. Each full‐text article meeting the inclusion criteria was assessed by all four reviewers independently. A standardized form was used to extract demographics (e.g., age, sex), laboratory findings (serum RPR, Venereal Disease Research Laboratory Test [VDRL], fluorescent treponemal antibody absorption [FTA‐ABS], Treponema Pallidum hemagglutination [TPHA]), CSF analyses (CSF VDRL, CSF TPHA, CSF FTA‐ABS, elevated CSF protein or leukocyte counts), HIV status, syphilis stage, otic, or neurological symptoms, and treatment. Details were entered into Microsoft Excel independently by two investigators (H.L., S.K.), with discrepancies resolved through discussion.

2.5. Case Series: Patient Identification and Data Collection

Concurrently, a retrospective case series was performed at a multicenter tertiary healthcare system. Patients with ICD 9 and 10 codes for syphilis (091.0–092.9 and A51.5, A51.9), neurosyphilis (094.0–094.9 and A52.1, A52.19, A52.2, A52.3), or otosyphilis (097.9 and A52.79, A53.9), respectively, were included. For the purposes of this study, otosyphilis is defined as a manifestation of syphilis that affects the cochleovestibular system, leading to sensorineural or mixed hearing loss, tinnitus, and balance disturbances. Neurosyphilis involves Treponema pallidum invasion of the central nervous system (CNS), resulting in varied neurological sequelae such as meningitis, cranial nerve deficits, stroke, and cognitive impairment [14]. These diagnoses can overlap when the spirochete extends from the inner ear to the CNS, necessitating thorough evaluation to ensure timely and accurate diagnosis [15]. Records were reviewed for confirmation of otosyphilis by an infectious disease or otolaryngology provider, evidence of neurosyphilis with otic symptoms, or a strong clinical suspicion supported by response to therapy. Data collected paralleled those extracted in the systematic review, including demographic characteristics, serologic and CSF results, HIV status, clinical staging of syphilis, and audiologic findings.

Electronic medical records were queried for formal audiograms. Exclusion occurred if only narrative audiogram summaries existed. Collected audiometric parameters included date of testing (relative to the syphilis diagnosis), air and bone conduction thresholds (recorded in decibels at multiple frequencies), speech discrimination scores, pure tone averages (PTAs) of 500, 1000, and 2000 Hz, and speech reception thresholds. Air‐bone gaps were calculated using three‐frequency PTAs at 500, 1000, and 2000 Hz. Audiograms were grouped into pre‐ and post‐syphilis diagnosis sets.

Descriptive analyses were performed for demographic, clinical, and audiometric data. A detailed description of the included studies may be found in Supplementary Table 2. Quantitative variables, such as age or hearing thresholds, were reported as means with standard deviations or medians with interquartile ranges, depending on the distribution and variability. Categorical variables, including HIV status or risk factors, were summarized as frequencies and proportions. A simple t‐test was performed to examine changes in audiometric outcomes before and after therapy.

3. Results

3.1. Literature Search

A total of 77 full‐text articles were evaluated and 10 met the initial inclusion criteria (Figure 1). These studies primarily investigated acquired syphilis with otic or neurological manifestations. In addition, 47 case reports focusing on syphilis‐associated hearing or vestibular symptoms were incorporated, resulting in 57 total studies. This decision sought to capture a broader range of real‐world clinical data, given the limited high‐level evidence on otosyphilis and neurosyphilis.

FIGURE 1.

PRISMA flow diagram of study selection process. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]

3.2. Systematic Review

Among 222 patients in 57 studies the mean duration of otic symptoms in 30 cases was 6.6 $\pm$ 5.0 weeks, with 9 individuals presenting after more 6 months. Neurological symptoms included vision disturbances in 20 (9.0%), headache in 10 (4.5%), gait changes in 5 (2.3%), facial weakness in 12 (5.4%), cognitive changes in 5 (2.3%), tremor or involuntary movement in 3 (1.4%), and seizure in 1 (0.5%). Hearing loss was reported in 144 (65%), tinnitus in 95 (43%), and vertigo in 53 (24%) (Table 1). About 172 (97%) patients received a penicillin‐based regimen, 4 (2.2%) were treated with doxycycline, 2 (1.1%) were treated with ceftriaxone, and 1 (0.6%) with ampicillin. Corticosteroids were used as an adjunct treatment in 13 (7.3%) patients. Of 84 documented outcomes, 48 (57%) noted improvement, 14 (17%) had partial improvement, and 22 (26%) reported no improvement.

TABLE 1.

Otosyphilis literature review results.

Population size (avg age 46.2 ± 2.16 years)	Total n = 222
Male	111 (85.3%), n = 130
Female	19 (14.6%), n = 130
HIV+	31 (29.5%), n = 105
HIV−	74 (70.5%), n = 105
Neurological symptoms
Visual disturbance	20 (9.0%), n = 222
Facial weakness	12 (5.4%), n = 222
Headache	10 (4.5%), n = 222
Gait changes	5 (2.3%), n = 222
Memory/confusion	5 (2.3%), n = 222
Tremor/involuntary movement	3 (1.4%), n = 222
Seizure	1 (0.5%), n = 222
Syphilitic symptoms
Symptom duration (weeks)	6.56 +/− 5.04, n = 30
Chancre	7 (3.2%), n = 222
Rash	23 (10.4%), n = 222
Otic symptoms
Hearing loss	144 (64.9%), n = 222
Tinnitus	95 (42.8%), n = 222
Vertigo	53 (24.0%), n = 222
Syphilis serology
RPR	129 (70.1%), n = 184
Reported CSF analysis	89 (70.4%), n = 126
VDRL	87 (69.6%), n = 126
TPPA	48 (26.1%), n = 184
FTA‐ABS	35 (27.2%), n = 126
TRUST	27 (14.7%), n = 184
TPHA	26 (14.1%), n = 184
CMIA	4 (2.2%), n = 184
IgG/IgM immunoblot	3 (1.6%), n = 184
Treatment
Primary
Penicillin	172 (97.2%), n = 179
Doxycycline	4 (2.2%), n = 179
Ceftriaxone	2 (1.1%), n = 179
Ampicillin	1 (0.6%), n = 179
Adjunct
Corticosteroid	13 (81.3%), n = 16
Valproate	1 (6.3%), n = 16
Antiretroviral	1 (6.3%), n = 16
Doxycycline	1 (6.3%), n = 16
Treatment outcomes
Complete resolution	48 (57.1%), n = 84
Partial resolution	14 (16.7%), n = 84
No resolution	22 (26.2%), n = 84

Abbreviations: CMIA, chemiluminescent microparticle immunoassay; CSF, cerebrospinal fluid; FTA‐ABS, fluorescent treponemal antibody absorption test; HIV, human immunodeficiency virus; RPR, rapid plasma reagin; TRUST, toluidine red unheated serum test; TPHA, Treponema pallidum haemagglutination; TPLA, Treponema pallidum latex agglutination; TPPA, Treponema pallidum particle agglutination; VDRL, venereal disease research laboratory test.

3.3. Multi‐Institution Case Series

Eighteen adults with serologically confirmed syphilis and otologic symptoms were identified (Table 2). The cohort comprised 17 males and 1 female aged 25 to 87 years, 9 (50%) being HIV‐positive. Sensorineural hearing loss or hearing changes were noted in 12 patients, tinnitus in 12, and vertigo in 5. Four patients had secondary syphilis, six had tertiary syphilis, and RPR titers ranged from 1:1 to 1:128. CSF analyses were performed on six patients. Treatment involved penicillin in 14, doxycycline in 1 (due to allergy), and combined therapy in 1. Among 13 patients with follow‐up data, 6 (46%) achieved full recovery, 4 (31%) required further intervention, 2 (15%) partially recovered, and 1 (8%) did not improve. Those presenting after a year of symptoms were more likely to have incomplete recovery.

TABLE 2.

Otosyphilis multi‐institution case series results.

Case number	1	2	3	4	5	6	7	8	9	10	11	12	13	14	15	16	17	18
Age at diagnosis	51	31	59	27	32	51	51	73	87	45	53	51	57	25	55	34	50	34
Gender	M	M	M	M	M	M	M	F	M	M	M	M	M	M	M	M	M	M
HIV	Positive	Positive	Negative	Positive	Negative	Negative	Positive	Negative	Negative	Positive	Negative	Positive	Positive	Positive	Negative		Negative	Positive
Sexual preference	MSM			MSM			MSM			MSM					MSM	MSM	Heterosexual	MSM
Syphilis symptoms		Y	Y			Y						Y	Y		Y	Y
Rash		Y	Y			Y							Y		Y	Y
Chancre						Y						Y				Y
Otologic symptoms	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
Hearing loss (HL)	Y	Y	Y	Y	Y			Y	Y	+	Y		Y		Y	Y
Normal Hearing (≤ 20 dB)			Y									Y		Y
Mild HL (21–40 dB)
Mod HL (41–55 dB)		Y
Severe HL (56–74 dB)	Y									Y
Tinnitus		Y	Y	Y	Y	Y	Y	Y		Y		Y	Y	Y	Y
Vertigo/dizziness									Y					Y		Y	Y	Y
Type of hearing loss	SNHL	SNHL	SNHL	SNHL	SNHL				SNHL	SNHL	SNHL
Neuro‐syphilis symptoms							Y					Y	Y	Y				Y
Stage of syphilis	Secondary			Secondary	Secondary		Tertiary	Tertiary	Tertiary	Tertiary					Secondary
RPR	Reactive	Reactive	Reactive	Reactive	Reactive	Reactive		Reactive	Reactive			Reactive	Reactive	Reactive			Reactive	Reactive
RPR titer						1:32′			1:2′				1:1′				1:64′	1:128′
FTA‐Ab				Positve	Positive				Positive
LP			Positive			Positive							Positive		Positive		Positive	Positive
Treatment	IM PCN	Steroid, PCN	Steroid, PCN	PCN	PCN	Steroid	IV PCN			IV PCN	PCN	Doxy (PCN allergy)	IV PCN (12 days)	IV PCN, (10–14 days)	Steroid, IV PCN (14 days)		PCN	PCN (10–14 days)
Post‐treatment	Required + treatment	Full recovery		Required + treatment	Required + treatment	Full recovery	Full recovery			Partial recovery		Full recovery	Full recovery	Full recovery	Partial recovery		No recovery	Required + treatment

Abbreviations: +, additional; CSF, cerebrospinal fluid; Doxy, doxycycline; F, female; IV, intravenous; LP, lumbar puncture; M, male; MSM, men who have sex with men; N, No; PCN, penicillin; Pred, predisone; serum RPR, rapid plasma reagin; SNHL, sensorineural hearing loss; Y, yes.

3.4. Audiogram Results

Of the 18 patients, 6 had available audiometric data; 2 underwent pre‐ and post‐diagnosis testing. Five had otosyphilis, and 1 had neurosyphilis, all showing a sensorineural pattern. Figure 2 illustrates average pre‐ and post‐treatment audiometric thresholds for affected ears, showing mild‐to‐moderate sensorineural hearing loss concentrated at mid‐to‐high frequencies. Post‐treatment audiograms, available for two patients, demonstrated no statistically significant improvement across frequencies (Table 3). Pre‐ and post‐treatment audiometric thresholds demonstrate variability between patients, showing minor improvements from 250 to 2000 Hz and one patient experiencing stable thresholds at higher frequencies (Table 3). Speech discrimination PTA and speech recognition threshold (SRT) exhibited minimal changes (Table 4). Additionally, one out of four patients who received adjunct oral steroids required an additional course of oral steroids to stabilize the hearing loss. These findings reflect the complexity and clinical unpredictability of the audiometric outcomes in otosyphilis, emphasizing the challenges associated with functional recovery, particularly in cases presenting with severe pre‐treatment hearing loss.

FIGURE 2.

Average audiometric data pre‐ (n = 6) and post‐otosyphilis (n = 2) treatment in the affected ear.

TABLE 3.

Average audiometric data for pre (n = 6) and post‐syphilis (n = 2) diagnosis in the affected ear. t‐test without a statistically significant difference at any frequency.

Frequency (Hz)	Affected ear (pre), dB HL (SD); n = 6	Affected ear (post), dB HL (SD); n = 2	p value
250	23.3 (10.8)	15.0 (0)	0.37
500	25.8 (14.3)	17.5 (3.5)	0.46
1000	35.8 (27.6)	20.0 (0)	0.47
2000	38.3 (25.6)	27.5 (17.7)	0.61
3000	41.7 (28.4)	40.0 (21.2)	0.94
4000	39.2 (25.3)	42.5 (17.7)	0.87
6000	38.3 (26.3)	40.0 (14.1)	0.94
8000	39.2 (29.9)	50.0 (21.2)	0.66

TABLE 4.

Descriptive audiogram data for pre‐ (n = 6) and post‐syphilis (n = 2) treatment in the affected ear.

	Speech discrimination (%, mean, [SD])	PTA dB HL (mean, [SD])	SRT dB HL (mean, [SD])
Affected ear (pre, n = 6)	88% (9)	32 (21)	26 (19)
Affected ear (post, n = 2)	92% (6)	27 (5)	23 (4)

Abbreviations: dB, decibel; HL, hearing level; PTA, pure tone average; SRT, speech recognition threshold.

4. Discussion

One of this study's foremost contributions is its dual approach: a systematic scoping review combined with a targeted case series of patients with confirmed otosyphilis or neurosyphilis. Previous studies have highlighted the diversity of clinical presentations in otosyphilis, ranging from classic manifestations such as sudden sensorineural hearing loss to atypical vestibular symptoms that can overlap with benign paroxysmal positional vertigo (BPPV) or Ménière's disease [1, 6]. However, many reports remain limited by small cohorts and inconsistent follow‐up [8]. By integrating literature findings with real‐world patient data, this study provides a more robust framework for understanding how syphilis can affect the auditory and vestibular systems and how these presentations may evolve. This two‐pronged approach demonstrates the disease's heterogeneity and the vital role that early, multidisciplinary intervention can play in preserving audiovestibular function.

Comparing our results with those of earlier work, our findings confirm that hearing loss, tinnitus, and vertigo rank among the most frequently encountered otologic symptoms in otosyphilis and neurosyphilis [4, 7, 16]. This aligns with recent cohort studies suggesting that even in earlier stages of syphilis, unexplained sensorineural hearing impairment or refractory vertigo may be the first sign of otosyphilis/neurosyphilis [4, 5, 17]. Despite standard serologic markers like RPR titers and abnormalities on CSF analysis, our data highlight that these measures do not reliably correlate with clinical severity or audiovestibular deficits, especially in the presence of HIV infection [1, 6, 17]. Diagnosis thus often depends on clinical acumen: new otic symptoms plus documented syphilis (or an unclear history of infection) that improve following penicillin therapy is compelling evidence of otosyphilis [10]. This observation resonates with Corrêa et al., who have advocated integrating imaging modalities, such as gadolinium‐enhanced MRI, with serologic assessments to better localize disease activity, particularly in atypical or equivocal presentations [18]. Furthermore, Ito et al. [19] have proposed revisiting and possibly lowering the threshold for lumbar puncture in cases of suspected neurosyphilis, an approach that aligns with our findings of persistent audiovestibular impairment in some patients despite treatment, as highlighted by our longitudinal audiometric data. However, further research is needed to explore the relationship between RPR titers and the severity of audiovestibular symptoms in otosyphilis. Added detail on longitudinal outcomes, especially in those who underwent pre‐ and post‐syphilis treatment audiograms, augments existing literature by documenting the degree to which audiometric parameters can improve or fail to improve after appropriate therapy.

Our findings provide some evidence of the variability in audiometric patterns and treatment outcomes observed in otosyphilis, while offering novel insights into the limitations of current diagnostic and therapeutic approaches. Studies such as those by Gleich et al. and Chang et al. have described a wide range of audiometric configurations, from mild high‐frequency loss to severe, with no single pattern reliably distinguishing otosyphilis from other causes of hearing loss [8]. Consistent with these reports, our data demonstrate that hearing outcomes remain unpredictable, with only modest improvements in thresholds observed in some patients post‐treatment. Importantly, our longitudinal pre‐ and post‐treatment audiometric data reveal that disease progression can occur even after appropriate therapy. This underscores the need to explore adjunctive treatments that may mitigate irreversible cochlear damage. Furthermore, the partial recovery observed aligns with findings from Kuhn et al. and Yimtae et al., who emphasized that hearing outcomes are heavily influenced by the severity and duration of the disease before treatment [1, 17]. By systematically correlating audiometric outcomes with treatment responses, our study highlights critical gaps in the current understanding of otosyphilis and the need for standardized protocols and prospective studies to refine diagnostic and therapeutic strategies.

Our results also highlight the impact of HIV co‐infection on the progression to neurosyphilis, consistent with Marra et al. [5] and Hobbs et al. [20], who reported that immunocompromised patients often progress more rapidly to neurologic involvement. About half of our single‐institution cohort were HIV‐positive MSM populations, reflecting the increased risk in this population for both syphilis and neurosyphilis [14, 20]. Other studies have similarly noted the multifaceted presentations of late‐stage syphilis, emphasizing that a heightened index of suspicion is warranted, especially for immunocompromised individuals [1, 17].

This need for vigilance extends to treatment strategies. While penicillin‐based regimens remain the mainstay, our findings reveal considerable variability in recovery of hearing thresholds and resolution of vestibular symptoms. For example, adjunctive treatments such as corticosteroids are occasionally employed to mitigate the inflammatory component of otosyphilis [1]. This parallels Ramchandani et al. [16], who observed that not all patients show significant improvement in hearing or vertigo control, underscoring the possibility that adjunctive therapies, including corticosteroids or other immunomodulatory agents, may bolster outcomes as syphilis has been associated with granulomatous inflammation even in the cases where spirochetes were absent [21]. In addition, our observations that prolonged otosyphilitic audiovestibular dysfunction appears to be irreversible suggest that early recognition and aggressive treatment are essential for preserving or recovering hearing thresholds, mirroring results from Fitzgerald and Mark [7], who reported better audiologic outcomes in patients receiving timely intervention. The CDC guidelines for neurosyphilis emphasize intravenous penicillin G regimens for 10–14 days [11]. Yet, no formal consensus exists for the management of otosyphilis, placing clinicians in a challenging position when crafting individualized treatment plans. Therefore, reliance on extrapolated protocols from neurosyphilis recommendations, alongside expert opinion, is often adopted to guide otosyphilis therapy, highlighting the need for dedicated prospective studies. Nonetheless, the heterogeneity in clinical presentations and therapeutic responses indicates that there may not be a “one‐size‐fits‐all” regimen for patients with advanced syphilis or coexistent HIV infection, and that further prospective research is necessary to determine optimal practice algorithms.

Taken together, our results and those of prior studies demonstrate that otosyphilis frequently presents with varied auditory and vestibular symptoms, which can lead to delayed diagnosis and permanent deficits if untreated. By demonstrating that late‐stage syphilis can commonly present with a constellation of auditory and vestibular symptoms, even in groups under close medical follow‐up, our work highlights a clinical blind spot that may result in delayed recognition and undertreatment of these serious manifestations. The confluence of (1) highly variable clinical presentations, (2) uncertain correlations with serologic markers, (3) inconsistencies in treatment regimens, and (4) limited knowledge about long‐term audiovestibular outcomes addresses the necessity for improved educational efforts, earlier diagnostic interventions, and careful monitoring of at‐risk populations. Collaboration among otolaryngologists, infectious disease specialists, HIV care providers, and neurologists is vital for rapid recognition and intervention. A robust, multicenter trial employing standardized diagnostic criteria, detailed audiometric follow‐up, and clear treatment protocols could help mitigate morbidity at a time when syphilis rates are again on the rise [18, 19].

4.1. Limitations

Despite employing both a scoping review and a targeted case series, certain constraints remain. The retrospective nature of the included case series can lack complete data and consistent diagnostic algorithms. Although the literature search was broad, relevant studies might have been missed if they were not indexed or if they fell outside the inclusion criteria. The analysis was limited to data in selected articles, and larger studies reporting otosyphilis cases without detailed demographic information limited the characterization of those patients. The inclusion of numerous individual case reports introduces both heterogeneity and bias, limiting the external validity of these findings. Inconsistencies in diagnostic criteria for otosyphilis, test thresholds, and treatment protocols across the included studies complicated direct comparisons. Additionally, the number of patients undergoing serial audiometric testing was modest, limiting conclusions on the impact of early intervention on long‐term cochleovestibular outcomes.

5. Conclusion

This study addresses key gaps in the otosyphilis and neurosyphilis literature by offering an integrated review of clinical manifestations, diagnostic strategies, and treatment results. It underscores how variable and severe these presentations can be and highlights the need for timely detection and intervention to prevent irreversible hearing loss. By combining our findings with existing knowledge, we establish a foundation for future research aimed at strengthening diagnostic precision, optimizing therapy, and improving patient outcomes as syphilis continues its global resurgence.

Disclosure

This abstract was presented as a podium presentation at The Triological Society Combined Sections Meeting—Session J, to the Otological Society in Orlando, Florida USA on 1/24/25.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Table S1. Otosyphilis literature search strategy.

Table S2. Descriptive information of included studies.

Pittman C. A., Liu H., Kowkuntla S., et al., “Contemporary Clinical Management of Otosyphilis for Practicing Otolaryngologists—A Scoping Review,” The Laryngoscope 135, no. 12 (2025): 4490–4498, 10.1002/lary.32421.