Use of intratympanic dexamethasone for the therapy of low frequency hearing loss

Prognosis of Acute Low-Tone Hearing Loss Without Vertigo: A Scoping Review

OBJECTIVE

Despite its relatively high prevalence, our understanding of the natural clinical course of acute low-tone hearing loss (ALHL) without vertigo remains incomplete. The purpose of this study is to summarize the findings of studies that evaluated recovery from hearing loss (HL), recurrence and/or fluctuation of HL, and progression to Meniere's Disease (MD) of patients presenting with ALHL without vertigo.

METHODS

A scoping review of the English literature was performed. On May 14, 2020 and July 6, 2022, MEDLINE, Embase, and Scopus were searched to identify articles related to the prognosis of ALHL. To be included, articles had to present outcomes that were clearly distinguishable for patients with ALHL without vertigo. Two reviewers evaluated articles for inclusion and extracted data. Disagreements were adjudicated by a third reviewer.

RESULTS

Forty-one studies were included. There was extensive heterogeneity between studies in regard to defining ALHL, treatment methods, and time of follow-up. Most of the cohorts (39 out of 40) reported partial or complete recovery of hearing in the majority (>50%) of patients, although reports of recurrence were relatively common. Progression to MD was infrequently reported. Shorter time from onset of symptoms to treatment predicted better hearing outcomes in 6 of 8 studies.

CONCLUSION

The literature suggests that although the majority of patients with ALHL experience hearing improvement, recurrence and/or fluctuation are common, and progression to MD occurs in a minority of patients. Additional trials utilizing standardized inclusion and outcome criteria are needed to determine the ideal treatment for ALHL.

LEVEL OF EVIDENCE

NA Laryngoscope, 133:2457-2469, 2023.

Optimal First-Line Therapy for Acute Low-Tone Sensorineural Hearing loss

Background and Objectives

We aimed to analyze treatment outcomes following different initial management approaches and confirm treatment regimens for acute low-tone sensorineural hearing loss (ALHL) that would yield the best results.

Subjects and Methods

We retrospectively analyzed the medical records of 106 patients with ALHL who visited a university hospital’s otology clinic from March 2013 to June 2019. Pure-tone averages at the initial visit and at 2 and 4 weeks after the initial visit were evaluated.

Results

Forty-nine patients were enrolled in this study; of them, 41 (83.7%) exhibited complete recovery (CR) at 2 weeks and 43 (87.8%) exhibited CR at 1 month after the initial visit. Regression analysis revealed that CR at 2 weeks after the initial visit was associated with diuretic use [Exp(B): 10.309, 95% confidence interval (CI): 1.007-100]. An initial daily low-dose steroid use was marginally significant [Exp(B): 1.042, 95% CI: 0.997-1.092; p=0.066]. Isolated diuretic use [Exp(B): 25.641, 95% CI: 1.121-90.909; p=0.039] was an independent, good prognostic factor at 1 month after the initial visit. However, other treatment regimens did not affect the final results.

Conclusions

A combination of initial daily administration of ≤30 mg prednisolone plus diuretics was sufficient as the first-line treatment for ALHL. High-dose steroids and salvage intratympanic steroid injections can be applied as a second choice; however, the predicted outcome would not be good in that case.

Sequential versus Combination Treatment Using Steroids and Diuretics for Acute Low-Frequency Sensorineural Hearing Loss: A Noninferiority Trial

OBJECTIVE

Acute low-frequency hearing loss (ALHL) is typically treated with combination therapy, including steroids and diuretics. To avoid unnecessary use of steroids we proposed a method of sequential administration using these two drugs, and compared the efficacy of our protocol with that of existing combination treatments.

METHODS

A prospective, randomized, open-label, single-blind, noninferiority clinical trial was conducted to investigate whether the effectiveness of sequential treatment is noninferior to that of combination treatment for ALHL. Ninety-two patients with ALHL received either steroids and diuretics simultaneously for 2 weeks (combination group), or diuretics for 2 weeks followed by steroids for another 2 weeks if they did not respond to diuretic treatment (sequential group). The primary outcome measure was a change in mean hearing threshold at three frequencies (125, 250, and 500 Hz) at 4 weeks after treatment.

RESULTS

The mean hearing threshold of the low frequencies improved 20.0 and 17.2 dB in the combination and the sequential group, respectively. The 95% lower confidence interval was -8.0 dB and noninferiority was established at p < 0.05. At 4 weeks after treatment, the complete recovery rate was 80.5 and 82.9% in the combination and sequential groups, respectively.

CONCLUSION

This is the first study on ALHL treatment following the establishment of Consolidated Standards of Reporting Trials (CONSORT). The sequential treatment is not inferior to combination treatment for ALHL, and therefore may be a better treatment guideline for ALHL considering that patients receive less steroid exposure and smaller restrictions in diuretic use compared with steroids.

Intratympanic dexamethasone injection vs methylprednisolone for the treatment of refractory sudden sensorineural hearing loss

Background:

During the past years various drugs have been used for sudden sensorineural hearing loss (SSNHL) treatment including steroids that are shown to be beneficial. Directed delivery of high doses of steroids into the inner ear is suggested for its potential and known as intratympanic steroids therapy (IST). Despite the use of dexamethasone and methylprednisolone as the traditional treatments, there are still debates about the optimal dosage, preferred drug, and the route of administration.

Materials and Methods:

We performed a randomized clinical trial study in which 50 patients suffering from SSNHL and resistant to standard therapy were employed. Each patient took 0.5 ml methylprednisolone (40 mg/mg) along with bicarbonate or dexamethasone (4 mg/mL) through direct intratympanic injection. This method was performed and scheduled once every 2 days for three times only for the dexamethasone receiving group. Hearing test was carried out and the results were analyzed according to a four-frequency (0.5, 1.0, 2.0, 3.0 kHz) pure tone average (PTA) and Siegel's criteria.

Results:

According to Siegel's criteria, three out of 25 (12%) dexamethasone receiving patients were healed in 1 and 4 (16%), 9 (32%) were respectively recovered in Siegel's criteria 2, 3, and 9 (32%) showed no recovery. In the group receiving methylprednisolone, recovery was found in 6 (24%), 8 (32%), 7 (28%) patients in the Siegel's criteria 1, 2, 3, respectively, and in 4 (16%) patients no recovery was recorded. In methylprednisolone group, hearing was significantly improved compared to the dexamethasone group (P < 0.05). The general hearing improvement rate was 84% in methylprednisolone receiving patients showing a significantly higher improvement than 64% in the dexamethasone group.

Conclusions:

Topical intratympanic treatment with methylprednisolone is safe and an effective treatment approach for those SSNHL cases that are refractory to the common therapies by Dexamethasone.

Potential Benefits of Combination Therapy as Primary Treatment for Sudden Sensorineural Hearing Loss

Objective

We analyzed the effectiveness of combination therapy (CT) for idiopathic sudden sensorineural hearing loss (ISSNHL) and the utility of intratympanic dexamethasone injection (ITDI) reapplication as salvage treatment for ISSNHL refractory to CT.

Study Design

Case series with chart review.

Setting

Academic university hospital.

Subjects and Methods

We reviewed 229 patients with ISSNHL and divided these patients into 2 groups according to treatment: systemic steroid therapy (SST) and CT groups. The SST group received prednisolone therapy. The CT group also received ITDI daily. Patients who demonstrated no recovery (<10 dB) after initial treatment were defined as refractory and received salvage ITDI therapy: ITDI reapplication in the CT group and ITDI application in the SST group.

Results

Hearing recovery rates were 77.8% (77/99) in the CT group and 60.8% (79/130) in the SST group. The difference was statistically significant ( P = .011). Initial pure-tone audiometry and vertigo were affective factors on hearing recovery rates in the CT group. After salvage therapy, hearing improvement of 10 dB or greater was noted in 6 of the 22 (27.3%) patients in the CT group and 16 of the 51 (31.4%) patients in the SST group. The difference in efficacy of salvage therapy between the CT and SST groups was simply not significant ( P = .612).

Conclusions

Combination therapy was more effective for ISSNHL in achieving hearing gain than SST alone. Furthermore, ITDI reapplication for ISSNHL refractory to CT was as effective as salvage ITDI for ISSNHL refractory to SST.

Clinical characteristics and prognosis of low frequency sensorineural hearing loss without vertigo

CONCLUSION

Factors prognostic of recovery from low frequency sensorineural hearing loss without vertigo are co-occurrence of tinnitus, PTA determined hearing level on the affected side before treatment initiation, and time from onset to treatment initiation. The rate of hearing recovery was higher in the oral steroid than in the intra-tympanic steroid and combined groups.

OBJECTIVES

Although many studies have assessed acute sudden hearing loss, few have analyzed low-frequency hearing loss. Clinical characteristics of patients with hearing loss may vary by type of hearing loss. This study, therefore, analyzed the clinical characteristics, recovery rates, and factors associated with hearing recovery in patients with low-frequency sensorineural hearing loss unaccompanied by vertigo.

METHOD

This study included 50 patients with severe low frequency hearing loss unaccompanied by vertigo and with normal tympanic membrane status who visited hospitals from July 2005 to May 2014 due to sudden tinnitus, ear fullness, or hearing loss. Of these patients, 29 were treated with oral steroids, eight with tympanic steroid injections, and 13 with both. Clinical and auditory characteristics before and after treatment, as well as treatment outcomes, were compared in these three groups.

RESULTS

Age, sex, affected side, co-occurrence of ear fullness, and accompanying chronic diseases were similar in the three groups. All patients started on treatment within 10 days of hearing loss showed significant recovery, with complete recovery, unaccompanied by tinnitus, observed in 10 patients. Treatment outcomes were not affected by hearing thresholds on the unaffected side. Of the patients treated with both oral and intra-tympanic steroids, 39% showed complete recovery, and 77% showed audiometric improvement. The complete recovery rate was significantly higher in the oral steroid than in the other two groups (p = 0.029); and the audiometric improvement rate tended to be lower in the intra-tympanic steroid group than in the other groups. Cure rates, defined as complete disappearance of symptoms and normal findings on pure tone audiograms (PTA), in the oral, intra-tympanic, and combined steroid groups were 49%, 25%, and 23%, respectively. There were no significant differences among the three groups in cure, subjective improvement, and audiometric improvement rates. Factors prognostic of non-recovery of hearing included late treatment initiation (p = 0.044), accompanying tinnitus (p = 0.049), and higher hearing thresholds on the affected side before treatment initiation (p = 0.005).

Intratympanic steroid treatment for idiopathic sudden sensorineural hearing loss after failure of intravenous therapy

Purpose. The aim of this study is the investigation of the effectiveness of intratympanic steroids therapy (IST) in patients with idiopathic sudden sensorineural hearing loss (ISSHL) who had not responded to intravenous treatment, evaluating the overall hearing recovery and comparing the results with different variables. Materials and Methods. Our study consisted of 55 patients with refractory ISSHL who, at the end of 10 days of therapy with intravenous steroids, had puretone 4-frequency average (PTA) of worse than 30 dB. The patients received 0.5 mL of methylprednisolone by direct intratympanic injection. The procedure was carried out up to 7 times within a 20-days period. Statistical analysis was carried out. Results. Overall 29 patients (52.7%) showed improvement in PTA, 24 (43.8%) had no change in hearing, and 2 (3.5%) worsened. There was a significant statistical correlation between hearing recovery and time to onset of symptoms, severity of hearing loss and frequency of hearing loss. Conclusions. IST is an effective and safe therapy in sudden sensorineural hearing loss cases that are refractory to standard treatment. The earlier IST, the hearing losses less than 90 dB and the involvement of the low frequencies seem to influence positively the hearing recovery.

Intratympanic steroid therapy for sudden hearing loss: a review of the literature

OBJECTIVE

Administration of steroids systematically is considered to be the most commonly accepted treatment for idiopathic sudden sensorineural hearing loss (ISSNHL). In recent years there has been increasing scientific interest in treating ISSNHL by means of local steroid delivery. Usually, intratympanic steroids are used in three main protocols, as initial treatment, as adjunctive treatment given concomitantly with systemic steroids and as salvage treatment after failure of standard therapy. The purpose of this review is to examine the published literature regarding the therapeutic value of each method of treatment and to seek answers about the best delivery technique and the optimal administration schedule.

DATA SOURCES

Literature review from 1996 to 2009, PubMed and Medline.

STUDY SELECTION

We searched for trials concerning clinical evaluation of intratympanic steroids in ISSNHL patients, as a salvage treatment, as a first line therapy and in combination with the conventional therapy. Randomized and non-randomized case control studies and case series studies were the types of trials available for review.

DATA EXTRACTION

All the articles described in the study selection were used for this review.

DATA SYNTHESIS

Statistical techniques were not used.

CONCLUSION

On the basis of the available literature, it seems that topical steroids can be a valuable solution for ISSNHL patients who either cannot tolerate systemic steroid therapy or are refractory to it. Concerning the combined therapy, due to the controversial results of the existing studies, it cannot be determined yet whether this treatment protocol could yield superior results as a first line therapy. The need for establishment of standard criteria of hearing recovery should be underlined.