İşitmeAtölyesiAt a glance
Functional damage of therapeutic drugs to the cochlea (hearing) and/or vestibular system (balance), starting at the cellular level.
Early: tinnitus and high-frequency loss. Vestibular: imbalance, swaying while walking, visual blurring (oscillopsia).
Tinnitus/balance complaints in a patient on an at-risk drug must be taken seriously and reported immediately.
Prevention first: lowest effective dose, regular monitoring; device/CI for permanent loss, vestibular rehabilitation.
Medical disclaimer. This content is for informational purposes only and does not replace a physician’s examination, diagnosis or treatment; it should not be used as medical advice. For your complaints or personal situation, always consult an ear, nose and throat physician and an audiologist.
If you are using an at-risk drug such as an aminoglycoside or cisplatin and notice tinnitus, reduced hearing or a balance problem, report it immediately to the physician managing your treatment. Because these drugs are often used for a life-threatening illness, make the decision only together with your physician; do not skip periodic audiological follow-up.
Definition and epidemiology
Ototoxicity is functional damage of therapeutic drugs or chemicals, starting at the cellular level, to the cochlea (hearing) and/or vestibular system (balance). The degree of damage depends on the type, dose and duration of the drug and on individual susceptibility.
Hearing loss typically begins bilaterally and symmetrically, affecting high frequencies first. Therefore, in the early period, damage may have started before the person feels difficulty in everyday conversation (Ganesan et al., 2018).
While the effect of some drugs is reversible (e.g., high-dose aspirin), in others (e.g., aminoglycosides, cisplatin) the damage can be permanent.
Symptoms and signs
In cochlear involvement, tinnitus and high-frequency hearing loss are early symptoms. As it progresses, speech discrimination becomes difficult.
In vestibular involvement, imbalance, a sense of swaying while walking and visual blurring (oscillopsia) may be seen; these symptoms increase especially in the dark or on uneven ground.
Symptoms can appear during or after drug use; therefore, in patients on at-risk drugs, tinnitus and balance complaints must be taken seriously.
Causes and risk factors
The main ototoxic drug groups are aminoglycoside antibiotics, platinum-containing chemotherapeutics (especially cisplatin), loop diuretics and high-dose salicylates (aspirin).
Risk increases with high dose and prolonged use, kidney failure, advanced age, concurrent noise exposure and genetic susceptibility (e.g., aminoglycoside sensitivity in individuals carrying the mitochondrial m.1555A>G variant).
More than one ototoxic drug at the same time, or concurrent noise exposure, can markedly increase the damage (Rybak & Ramkumar, 2007).
Audiological and clinical assessment
Before starting an at-risk drug, a baseline hearing assessment is done, and regular monitoring during and after treatment is essential (ASHA ototoxicity monitoring guideline).
- High-frequency audiometry: catches early damage before standard audiometry; it is the most sensitive step in monitoring.
- OAE: objectively shows early changes in cochlear outer hair cells.
- Pure-tone and speech audiometry: determine the degree of loss and impact on communication.
- Vestibular tests (vHIT, VEMP, caloric): assess involvement of the balance system.
- Monitoring programme: comparative measurements before, during and after treatment.
When damage is detected early through monitoring, the physician can review the drug dose/protocol.
Treatment and audiological rehabilitation
The most effective approach is prevention: the lowest effective dose, regular monitoring and, where possible, alternative drugs. The decision always rests with the treating physician; an ototoxic drug is often used for a life-threatening illness.
In children, protective agents such as sodium thiosulfate can be used in certain protocols to reduce cisplatin-induced hearing loss (Brock et al., 2018). Otoprotective strategies are an active research area.
In patients who develop a permanent loss, a hearing aid, and in very severe losses a cochlear implant, are considered. In permanent vestibular loss, vestibular rehabilitation improves balance by supporting central compensation.
Impact on quality of life and advice
Hearing and balance loss can lower quality of life by adding an extra burden during treatment of a serious illness. Patient-reported scales are valuable for monitoring this impact.
Patients using an at-risk drug who notice tinnitus, reduced hearing or a balance problem should report it to their physician and not skip periodic audiological follow-up. Avoiding additional noise exposure is protective.
If you used this review, you can cite it as follows (APA 7):
İşitme Atölyesi. (2026). Ototoxicity (Drug-Induced Inner-Ear Damage). Hearing & Balance Health Guide. https://www.isitmeatolyesi.com/en/guncel-haberler/categories/isitme-sagligi-rehberi/ototoksisite/Permanent link: isitmeatolyesi.com/en/guncel-haberler/categories/isitme-sagligi-rehberi/ototoksisite/ · Last reviewed: July 2026 · License: CC BY-NC-ND 4.0
References
- Brock, P. R., Maibach, R., Childs, M., et al. (2018). Sodium thiosulfate for protection from cisplatin-induced hearing loss. New England Journal of Medicine, 378(25), 2376-2385.
- Ganesan, P., Schmiedge, J., Manchaiah, V., et al. (2018). Ototoxicity: A challenge in diagnosis and treatment. Journal of Audiology & Otology, 22(2), 59-68.
- Rybak, L. P., & Ramkumar, V. (2007). Ototoxicity. Kidney International, 72(8), 931-935.
- American Speech-Language-Hearing Association. (1994). Guidelines for the audiologic management of individuals receiving cochleotoxic drug therapy. ASHA.
Frequently asked questions
Will aspirin damage my hearing permanently?
Tinnitus and reduced hearing from high-dose aspirin are usually dose-dependent and mostly reverse when the drug is stopped. This effect is not expected at low doses. Still, if you have persistent tinnitus, it is appropriate to consult your physician.
Could my balance system be affected while my hearing test is normal?
Yes. The hearing and balance structures can be affected to different degrees; the balance system may be damaged while hearing is normal, or vice versa. That is why both hearing and balance tests are done when needed with at-risk drugs.
I’m on chemotherapy; how do I protect my hearing?
The most important step is regular hearing monitoring: a baseline test before treatment and check-ups during and after. This way damage is detected early and your physician can review the treatment plan accordingly. Avoiding additional noise is also protective.
Can I refuse to take an ototoxic drug?
These drugs are often necessary for serious and life-threatening illnesses; you should make the decision only together with your treating physician. If you share your concerns about hearing, your physician can consider monitoring and alternatives.
Is there a solution if I have permanent hearing loss?
Yes. For permanent losses, hearing aids, and for very severe losses cochlear implants, are very effective solutions. If balance loss persists, vestibular rehabilitation exercises markedly improve balance.
Scales that can be used to monitor hearing handicap and balance impact: