Severe self‐limiting acute bilateral hearing loss following a low dose of methylphenidate for ADHD treatment: A case report

Attention deficit hyperactivity disorder (ADHD) is marked by inattention, impulsivity, and hyperactivity, and is a neurodevelopmental disorder. Early diagnosis and treatment may improve neural connections and overall functioning. ¹ The prevalence of ADHD is approximately 6.7% in children aged 3–12 and 5.6% in teenagers aged 12–18. ² Treatment options include both stimulant and non‐stimulant medications. ³ Methylphenidate is a commonly prescribed stimulant that has shown improvements in ADHD symptoms. While generally safe, it may cause non‐serious side effects like sleep disturbances and decreased appetite. ⁴ Long‐term use has minimal evidence of significant adverse effects, though it is associated with increased pulse rate and higher blood pressure. ⁵

This study discusses a case of severe, self‐limiting bilateral hearing loss that occurred shortly after a patient began treatment with a low dose of methylphenidate for ADHD.

The patient is a 10‐year‐old schoolgirl experiencing attention and concentration difficulties, particularly in schoolwork and homework. Her struggles have intensified over the past 2 years, prompting her parents to seek help from a psychiatric clinic after a decline in academic performance. Following an evaluation, she was diagnosed with ADHD based on DSM‐5 criteria and began treatment with methylphenidate (for the first week, half of a 10 mg tablet of immediate‐release methylphenidate; after 1 week of starting the medication, half a tablet twice a day).

Due to the limited availability of prescription stimulants in Iran, treatment began approximately 1 week after the medication was prescribed. After 1 week of treatment, the patient's parents reported a sudden loss of hearing that had occurred over the past few days. Previously able to hear distant sounds, she now could only hear close, loud voices, including difficulty hearing her teacher. The child's parents stopped administering methylphenidate after the fourth dose. There was no history of infections, trauma, or hearing disorders noted in her family. A thorough examination indicated no physical abnormalities or psychiatric concerns. The initial differential diagnosis suggested her hearing loss may be related to methylphenidate use, leading to a recommendation for discontinuation of the medication.

This was particularly significant due to the absence of any auditory system issues in the patient's past and present medical history. The patient had no history of previous or current ear infections, nor any symptoms suggesting other infectious causes, such as viral infections like chickenpox or herpes. Additionally, the absence of tinnitus made alternative diagnoses, such as endolymphatic hydrops, less likely. To ensure a more accurate diagnosis, she was referred to an ear, nose, and throat (ENT) specialist for further evaluation.

One week after the referral (approximately 10 days after the onset of clinical symptoms), the patient visited an otolaryngologist, who recommended hospitalization; however, the family declined. The doctor ordered a paraclinical evaluation, which included an audiometry test, and prescribed oral prednisolone. The patient's family decided against the latest treatment due to concerns about the drug's side effects.

About 2 days after this last visit (12 days after the onset of symptoms), the family observed a relative improvement in the patient's hearing and decided not to pursue any further interventions, including the mentioned items.

About 2 weeks later, a psychiatrist followed up, and both the patient and family noted complete hearing improvements without treatment (16 days after the onset of symptoms). After 2 months, the focus shifted to ADHD, and the patient began taking 10 mg of atomoxetine with short‐term nonpharmacological support. One month into ADHD treatment, there was a relative improvement, and no hearing issues were reported (Figure 1).

Figure 1.

Timeline of the patient's clinical course.

The onset of sudden and severe hearing loss following the start of methylphenidate therapy in an ADHD patient highlights the need for careful monitoring of this potential side effect. While this case involved temporary symptoms, it raises concerns about the medication's adverse effects.

A report described an 8‐year‐old girl who experienced complete hearing loss in her left ear after her first dose of methylphenidate. Audio tests showed abnormalities without identifiable causes, and treatments, including corticosteroids and hyperbaric therapy, did not improve her hearing. ⁶ The key difference between our presentation and the recent study is that our patient presented with bilateral hearing loss. In contrast, the clinical course was completely reversible (self‐limiting) despite the bilateral and severe nature of the hearing loss. Also, the dose we used in this patient was low.

In a broader study of adverse effects involving 123 questionnaires from parents, 213 adverse effects were reported, with loss of appetite and headaches being the most common. Notably, only three cases of hearing issues were mentioned, suggesting a low prevalence of such side effects among children on methylphenidate. ⁷

Another study of 30 children found no significant changes in hearing tests after 3 months of treatment, indicating that observed hearing loss may be coincidental or linked to other factors rather than the medication itself. ⁸ Based on the results of this study, the researchers implicitly considered cases such as the coincidence of methylphenidate treatment and sudden hearing loss, endolymphatic hydrops (in cases with tinnitus as one of the accompanying symptoms), or an unrecognized perilymph fistula as possible causes of such progressive sensorineural hearing loss.

In sudden sensorineural hearing loss, the unilateral condition is more common and mostly idiopathic, and the possibility of hearing recovery is much greater than in the bilateral type. The bilateral type is a medical emergency that is more associated with toxic, autoimmune, neoplastic, and vascular diseases, has a lower prevalence of vestibular symptoms, and requires a thorough and immediate evaluation for diagnostic and therapeutic assessment of the reversible condition. ⁹

While individuals with ADHD often experience auditory inattention deficits as a chronic condition, these deficits typically do not fluctuate acutely. In the case of the patient presented, however, we observed a sudden and severe bilateral hearing loss accompanied by distinct changes over a short period of time. This sudden change makes it less likely that there is a direct connection to the underlying ADHD. ¹⁰

Further investigation is necessary to determine the impact of methylphenidate on hearing and whether the effects are reversible. Enhanced reporting on similar cases could lead to improved diagnostic and therapeutic strategies.

One of our limitations in describing this clinical study is the descriptive nature of this report of hearing loss and its improvement (subjective report) due to the reluctance of the patient and her family to perform relevant paraclinical measures, which limited information on the type of hearing loss (sensorineural vs. conductive) and laterality. The descriptive nature of this case study limits any causal conclusions regarding the effects of this medication on the acute drug reaction in question.

AUTHOR CONTRIBUTIONS

Atefeh Zandifar: Conceptualization; investigation; writing—review and editing. Rahim Badrfam: Conceptualization; investigation; writing—review and editing.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

ETHICS APPROVAL STATEMENT

N/A.

PATIENT CONSENT STATEMENT

Since the patient is a minor, consent for publication of the disease course was obtained from the patient and her legal guardians.

CLINICAL TRIAL REGISTRATION

N/A.

DATA AVAILABILITY STATEMENT

Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.