Modified intratympanic treatment for idiopathic sudden sensorineural hearing loss

Sudden sensorineural hearing loss in diabetes mellitus patients receiving intra-tympanic steroid injections

BACKGROUND

Sudden sensorineural hearing loss is an acute hearing disorder typically managed using steroids. However, prognostic factors of diabetes mellitus (DM) patients undergoing intra-tympanic steroid injections (ITSIs) are unclear. We explored the prognostic factors for ITSI in DM patients with unilateral SSNHL.

METHODS

This retrospective study enrolled 89 DM patients with unilateral SSNHL from July 2016 to June 2022. All patients received ITSIs, and their clinical and audiological data were analyzed.

RESULTS

The patients' mean age was 49.31 ± 16.26 years. After ITSI, the mean hearing level gain was 14.91 ± 20.28 dB, the mean speech reception threshold (SRT) gain was 15.78 ± 32.16 dB, and the mean speech discrimination score (SDS) gain was 16.94 ± 35.06 %. Based on Siegel's criteria, 8 patients (8.98 %) had complete recovery, 14 (15.73 %) had partial recovery, 16 (17.98 %) had slight recovery, and 51 (57.31 %) had no improvement. Older age (odds ratio [OR] = 0.970, 95 % confidence interval [CI]: 0.941-0.999, p = 0.043) and profound hearing loss on pure-tone audiometry (PTA; OR = 0.058, 95 % CI: 0.007-0.462, p < 0.001) were adverse prognostic factors in univariate analyses. Older age (OR = 0.963, 95 % CI: 0.932-0.994, p = 0.023) and profound hearing loss (OR = 0.048, 95 % CI: 0.005-0.395, p = 0.004) were independent negative prognostic factors in a multivariate analysis.

CONCLUSIONS

ITSI is effective and avoids side effects of high-dose steroids in patients with SSNHL and DM. Among 89 DM SSNHL patients who underwent ITSI, older age and profound hearing loss were negative prognostic factors. Prompt and active management is necessary for DM patients with these risk factors.

The Effectiveness of Salvage Hyperbaric Oxygen Therapy Following Combined Steroid Therapy for Refractory Sudden Sensorineural Hearing Loss

OBJECTIVE

Hyperbaric oxygen therapy (HBOT) is an accepted treatment option for sudden sensorineural hearing loss (SSNHL), but it is still recommended in combination with corticosteroids. We investigated the efficacy of salvage HBOT in refractory SSNHL that does not respond to corticosteroid combination therapy.

METHODS

Eighty-four patients were included, who had unilateral SSNHL with an improvement of pure-tone average (PTA) less than 10 dB after using intratympanic plus systemic corticosteroids (combined therapy) as the initial therapy. The control group (n = 66) received no further treatment, and the HBOT group (n = 18) received additional treatment with HBOT (10 sessions in total with 2.5 atmospheres absolute for 1 hour).

RESULTS

No differences in PTA or WDS were found between the 2 groups. However, the mean hearing gain in the HBOT group (16.8 ± 4.49 dB) was significantly higher than that in the control group (4.45 ± 1.03 dB) (P = .015). The proportion of patients with hearing recovery (hearing gain of 10 dB or more) after treatment was significantly higher in HBOT group (38.9%) than in the control group (10.6%).

CONCLUSIONS

In patients with refractory SSNHL after steroid combined therapy, salvage HBOT showed a significant effect on hearing gain and recovery rate.

Clinical efficacy of intratympanic steroid injection for treating idiopathic sudden sensorineural hearing loss

BACKGROUND

Idiopathic sudden sensorineural hearing loss (ISSNHL) is an emergency that causes permanent hearing loss if timely treatment is not provided. However, the evidence supporting the effect of intratympanic steroid injection (ITSI) starting time on hearing outcome is limited.

METHODS

We retrospectively enrolled 582 patients with ISSNHL who were treated with ITSIs and reviewed their clinical and audiological variables. The relationship between ITSI starting time and hearing recovery was analyzed.

RESULTS

The mean starting time of ITSI was 13.17 ± 16.53 days. The overall hearing recovery rate was 55.15% (recovery = mean hearing level gain of ≥10 dB). The recovery rates were 79.2%, 67.4%, 50%, 36.6%, and 17.8% for the ITSI starting times of 1 to 3, 4 to 7, 8 to 14, 15 to 28, and ≥29 days, respectively. A multivariate analysis revealed that ITST starting time (odds ratio [OR] = 0.94, 95% CI, 0.92-0.96, p < 0.001) and salvage therapy (OR = 0.55, 95% CI, 0.35-0.86, p = 0.009) were independent poor prognostic factors for patients with ISSNHL.

CONCLUSION

Earlier ITSI treatment is associated with a higher hearing recovery rate. Comorbidities and post-ITSI complications were nonsignificant independent risk factors.

Idiopathic sudden sensorineural hearing loss: effectiveness of salvage treatment with intratympanic dexamethasone or hyperbaric oxygen therapy in addition to systemic steroids

Background

The development of standardized treatments for idiopathic sudden sensorineural hearing loss (ISSNHL) is hampered by uncertainty over the etiology of this disorder. Systemic steroids are historically the primary therapy, with variable hearing outcomes. Over the last two decades, intratympanic steroids (ITS) and hyperbaric oxygen therapy (HBOT) have been proposed as salvage treatments in case of failure of systemic steroids. The present study aims to evaluate the effectiveness of these salvage treatments in addition to systemic steroids.

Methods

We performed a retrospective study on 75 consecutive patients with a diagnosis of ISSNHL who were admitted to the Department of Otorhinolaryngology of our hospital between December 2018 and December 2022. All patients received primary treatment with systemic steroids. In case of slight or no hearing recovery within the 5th day from the beginning of the therapy (T1), a salvage treatment with ITS or HBOT was proposed. Patients were divided into three groups according to the therapy received: systemic steroids (group A), systemic steroids + HBOT (group B), and systemic steroids + ITS (group C). Pure-tone average at 500, 1000, 2000, and 3000 Hz and the mean gain were evaluated at T1 and 3 months after the beginning of the salvage treatment (T2). The hearing recovery was assessed according to the Siegel's criteria.

Results

Sixty-two patients (31 men and 31 women, mean age 56 years) with failure of the primary treatment were definitively enrolled in the study: 34 (54.8%) in group A, 16 (25.8%) in group B, and 12 (19.4%) in group C. The ratio of patients responding to therapy was higher in group A (29.4%) than in groups B (18.75%) and C (16.7%). We did not find any statistically significant difference between groups in terms of mean hearing gain at T2 (17.4 ± 15.4 dB in group A vs. 18.6 ± 21.1 dB in group B and 15.7 ± 14.2 dB in group C, p = 0.9).

Conclusion

In our experience, ITS or HBOT associated with systemic steroids, as salvage treatment, did not show significant improvement in hearing outcomes. The evolution of ISSNHL, regardless of the treatment, remains unpredictable.

Intratympanic Dexamethasone in Sudden Sensorineural Hearing Loss

Sudden sensorineural hearing loss can be a frightening experience for the sufferer and needs immediate treatment. Systemic steroid therapy has been the mainstay of treatment of this condition but concerns about their side effects has led to their use by intratympanic injection. We studied the results of intratympanic dexamethasone (IT-Dexa) both as a primary therapy and as salvage treatment after failure of oral steroids. A total of 39 patients of SSNHL were studied prospectively. Of these 23 were given oral steroids. Ten of these showed no response and were treated with IT-Dexa 4 mg/ml twice a week for two weeks. In addition, 16 patients who reported later than two weeks or had concomitant medical disorders like diabetes and/or hypertension were treated with IT-Dexa. While oral steroids showed hearing improvement (≥ 10 dB) in 56.5% patients, the recovery rate was 62.5% and 80% in those treated primarily with IT-Dexa and as salvage therapy respectively. There was a negative correlation of delay in institution of treatment with hearing recovery. Conclusion: intratympanic dexamethasone is a safe and effective treatment and should be offered to patients as a primary treatment modality and also as salvage therapy after failure of oral steroids. For best results the treatment should be started at the earliest.

Prognostic factors in elderly patients after an intra-tympanic steroid injection for idiopathic sudden sensorineural hearing loss

BACKGROUND

Idiopathic sudden sensorineural hearing loss (ISSNHL) presents with emergent hearing impairment and is mainly treated with steroids. However, limited data exist regarding the prognostic factors among elderly patients (>65 years old) who receive an intra-tympanic steroid injection (ITSI). Therefore, we investigated the prognostic factors in these patients.

METHODS

Between July 2016 and March 2022, we retrospectively enrolled 105 elderly patients (>65 years old) with unilateral ISSNHL who were treated with an ITSI, and recorded their clinical and audiological variables.

RESULTS

The patients had a mean age of 72.03 ± 6.33 years and mean hearing level gain of 22.86 ± 21.84 dB, speech reception threshold (SRT) gain of 15.77 ± 35.27 dB, and speech discrimination score (SDS) gain of 19.54 ± 27.81 %. According to Siegel's criteria, 5 (4.76 %), 44 (41.91 %), 46 (43.81 %), and 10 (9.52 %) patients had complete recovery, partial recovery, slight improvement, and no improvement, respectively. In the univariate analysis, vertigo (odds ratio [OR] = 0.290, 95 % confidence interval [CI]: 0.130-0.651, p = 0.002) and profound hearing loss on pure tone audiometry (PTA; OR = 0.233, 95 % CI: 0.101-0.536, p = 0.004) were negative prognostic factors among elderly ISSNHL patients. In the multivariate analysis, vertigo (OR = 0.300, 95 % CI: 0.128-0.705, p = 0.005) and profound pure tone audiometry (OR = 0.240, 95 % CI: 0.101-0.570, p = 0.001) were independent adverse prognostic factors among elderly ISSNHL patients.

CONCLUSIONS

We demonstrated the treatment outcomes of 105 elderly ISSNHL patients after an ITSI. Vertigo and profound PTA are independent adverse risk factors among elderly ISSNHL patients, and patients with these risk factors require active treatment.

Complications and prognosis associated with intra-tympanic steroid injection to treat sudden sensorineural hearing impairment

PURPOSE

The purpose of this study was to measure the incidence of complications in sudden sensorineural hearing loss (SSNHL) patients treated with intra-tympanic steroid injection (ITSI) and compare hearing recovery rates.

MATERIALS AND METHODS

123 patients with unilateral SSNHL receiving ITSIs were included in this study. Post-ITSI complications were documented including otalgia, dysgeusia, vertigo (duration>1 h), and persistent eardrum perforation. The pain intensity was evaluated with visual analog scale (VAS). Hearing was measured before ITSI and at 1 month after the final ITSI. We compared our patients' hearing threshold between presence and absence of different complications.

RESULTS

47.2% patients experienced post-injection otalgia with the average VAS score 3.2 (range 2-6). Five (4.1%) and six (4.9%) patients exhibited vertigo and persistent eardrum perforations, respectively. The patients were divided into three groups based on the absence of complications and the presence of vertigo and eardrum perforation. The hearing threshold improvements did not differ significantly among the three groups (p = 0.366). Although the difference was not significant (p = 0.664), the proportion of patients experiencing post-ITSI vertigo who were on contemporaneous oral steroids was lower than the proportion of non-vertigo patients on such steroids.

CONCLUSION

The incidences of otalgia, vertigo, and persistent eardrum perforation in SSNHL patients treated with ITSI were 47.2%, 4.1% and 4.9%, respectively. We found no association between concurrent oral steroid use and the incidence of post-ITSI eardrum perforation or vertigo. Although statistical significance was lacking, patients who did not take contemporaneous oral steroids may have a higher rate of prolonged post-ITSI vertigo.

Tympanic Membrane Perforation After Intratympanic Steroid Injection: A Systematic Review and Meta-analysis

OBJECTIVE

We investigated the incidence of tympanic membrane (TM) perforations induced after intratympanic steroid injection (ITSI) in patients with sudden sensorineural hearing loss (SSNHL) through a systematic review and meta-analysis.

DATA SOURCES

PubMed, Embase, and MEDLINE.

REVIEW METHODS

Primary database searches were performed, and 1901 records were identified. After removal of 1802 articles through abstract screening, the remaining 99 full-text journals were assessed for eligibility to be included in the study. Fifty-eight studies that used either ventilation tubing (VT) or tympanocentesis (TC) for ITSI were selected for analysis. The subjects were divided into VT and TC groups. The rate of TM perforation after ITSI in 2 groups, sites of ITSI, needle gauge, and influence on residual hearing were investigated.

RESULTS

The cohorts comprised patients who underwent VT (n = 257, 9.6%) and TC (n = 2415, 90.4%). The proportion of TM perforation after ITSI in each group was 0.073 (95% CI, 0.0469-0.1113) and 0.010 (95% CI, 0.0045-0.0215), respectively, which suggested that the VT group showed a significantly higher TM perforation rate than the TC group (P < .001). In the subgroup analyses, there was no significant difference in the odds ratio for the rate of TM perforation according to the injection site and needle gauge for TC. The proportion of surgical repair showed no significant difference between the 2 groups.

CONCLUSION

ITSI via VT may have a significantly higher risk of TM perforation than ITSI via TC, although those are relatively small overall. ITSI should be performed in the direction to minimize possible adverse effects.

Intratympanic Methylprednisolone versus Dexamethasone for the Primary Treatment of Idiopathic Sudden Sensorineural Hearing Loss

OBJECTIVES

The aim of the present study was to compare the therapeutic effectiveness of intratympanic (IT) methylprednisolone and dexamethasone in the initial treatment of patients with idiopathic sudden sensorineural hearing loss (ISSHL).

MATERIALS AND METHODS

A total of 46 patients with ISSHL who had been treated with IT methylprednisolone or dexamethasone were included in the present study. Dexamethasone (4 mg/mL) and methylprednisolone (20 mg/mL) were given transtympanically to 22 and 24 patients, respectively, one dosage per day for 5 consecutive days. Audiologic evaluations were performed pretreatment, daily in inpatient clinics, and in the first week and second month after discharge, using four-frequency pure-tone average (PTA) and speech discrimination score (SDS). Audiologic improvement was classified according to the Furuhashi criteria.

RESULTS

According to the Furuhashi criteria, the therapeutic success rate was 62.5% (complete improvement 16.7% and marked improvement 45.8%) in the methylprednisolone group, whereas it was 54.6% (complete improvement 27.3% and marked improvement 27.3%) in the dexamethasone group. Therapeutic success was higher in the methylprednisolone group; however, it was not statistically significant. When the audiologic improvement was accepted as >10 dB in PTA, the therapeutic success rates were 83.3% in the methylprednisolone group and 72.8% in the dexamethasone group. The mean (±SD) improvement of PTA before and after treatment was 30.8±21.4 in the methylprednisolone group and 24.7±2.5 in the dexamethasone group. The mean improvement in SDS was 32.6±25 in the methylprednisolone group and 23.7±26.9 in the dexamethasone group.

CONCLUSION

IT steroids are safe, effective, and well-tolerated agents in the initial treatment of patients with ISSHL. Despite having different pharmacokinetic characteristics, IT methylprednisolone and dexamethasone have no superiorities over each other in the primary treatment in patients with ISSHL.

Intratympanic glucocorticosteroid therapy for idiopathic sudden hearing loss: Meta-analysis of randomized controlled trials

BACKGROUND AND OBJECTIVE

Glucocorticoids are the standard treatment for idiopathic sudden sensorineural hearing loss (ISSNHL), but whether intratympanic or systemic therapy is superior remains controversial. Previous meta-analyses of this question have omitted key clinical trials or included observational studies.

METHODS

English-language randomized controlled trials in OvidSP, PubMed, Embase, CINAHL, and the Cochrane Library comparing intratympanic versus systemic glucocorticoid therapy for ISSNHL were meta-analyzed using RevMan 5.3. The primary outcome of interest was improvement in pure tone average (PTA) threshold.

RESULTS

Six trials involving 248 patients receiving intratympanic steroids and 236 receiving systemic steroids were meta-analyzed. PTA thresholds were similar between the 2 groups at 3 months after therapy initiation (mean difference, 0.24; 95% confidence interval [CI] -2.43 to 2.91, P = .86; I = 54%, P = .07, random-effects model). PTA thresholds were also similar at 6 months (mean difference, 4.69, 95% CI -5.84 to 15.22, P = .38), although the results showed extremely high heterogeneity (I = 98%). Sensitivity analysis indicated that a single trial containing 250 patients provided the strongest evidence for equivalence between the 2 types of therapy. Rates of recovery within 3 months (defined as PTA improvement >10 dB) were similar between the 2 types of therapy (odds ratio 0.92, 95% CI 0.59-1.43, P = .70), with no significant heterogeneity in the pooled data (I = 1%, P = .40).

CONCLUSION

Intratympanic and systemic steroids' therapies appear to show similar short-term efficacy for restoring hearing in patients with ISSNHL. Intratympanic therapy may reduce systemic side effects associated with steroid use.

Hearing Changes After Intratympanically Applied Steroids for Primary Therapy of Sudden Hearing Loss: A Meta-analysis Using Mathematical Simulations of Drug Delivery Protocols

OBJECTIVE

Controlled and uncontrolled studies with primary intratympanic or combined intratympanic and systemic application of glucocorticosteroids for idiopathic sudden hearing loss were analyzed by means of a meta-analysis in an attempt to establish optimal local drug delivery protocols.

STUDY DESIGN

A total of 25 studies with 28 treatment groups between January 2000 and June 2014 were selected that adequately described drug delivery protocols. Cochlear drug levels were calculated by a validated computer model of drug dispersion in the inner ear fluids based on the concentration and volume of glucocorticoids applied, the time the drug remained in the middle ear, and the specific timing of injections. Various factors were compared with hearing outcome, including baseline data, individual parameters of the application protocols, calculated peak concentration (Cmax), and total dose (area under the curve).

RESULTS

There was no dependence of hearing outcome on individual parameters of the application protocol, Cmax, or area under the curve. Final hearing threshold was notably independent of delay of treatment.

CONCLUSION

During primary intratympanic or combined steroid therapy of idiopathic sudden hearing loss, the tendency toward early treatment having a positive effect on hearing improvement is thought to be a "sham effect," likely related to spontaneous recovery. Change in pure-tone average may not be an adequate outcome parameter to assess effectiveness of the intervention, as it depends on the degree of initial hearing loss. Final pure-tone average provides a better alternative.

Sudden hearing loss: an effectivity comparison of intratympanic and systemic steroid treatments

Corticosteroid treatment has been considered the most effective treatment modality for sudden sensorineural hearing loss so far. Application route of corticosteroids may vary. We have designed a prospective randomized case-controlled clinical trial to evaluate the effectivenesses of the different application routes of steroids in the treatment of SSHL. Thirty-five patients were distributed randomly to two groups which were treated with either 'oral' or 'intratympanic' corticosteroids. Intratympanic steroid administration was performed three times every other day transtympanically. At the end of third month, recovery rate in the 'intratympanic' group was 84.2%, whereas in the 'oral' group, it was 87.5%. The difference between the recovery rates was not statistically significant. There were no major complications related to transtympanic steroid administration. These findings support that intratympanic steroid therapy is an alternative to systemic steroid therapy in the initial treatment of sudden hearing loss. In addition, transtympanic technique is an easy to perform and safe method for delivering steroids into the inner ear.

A comparison between systemic and intratympanic steroid therapies as initial therapy for idiopathic sudden sensorineural hearing loss: a meta-analysis

CONCLUSIONS

Intratympanic steroid (ITS) treatment groups exhibited better outcomes in PTA improvement and recovery rate than systemic steroid therapy (SST) groups. Whether initial hearing loss severity would influence the PTA improvement and recovery rate still requires further research.

OBJECTIVE

This article was aimed at evaluating whether intratympanic steroid (ITS) treatment would provide benefits over systemic steroid therapy (SST) as initial therapy in patients with idiopathic sudden sensorineural hearing loss (ISSHL). A meta-analysis was carried out based on published RCTs that included the hearing outcomes of ITS treatment and SST in ISSHL as initial therapy. Both PTA differences and recovery rate were analyzed.

METHODS

The literature search was based on the online database including Pubmed, Embase, and Cochrane trails, which completed in July 2016. This study extracted the relevant data following the selection criteria. Mean difference (MD) of PTA differences and Odds ratio (OR) of recovery rate were calculated within 95% confidence intervals.

RESULTS

Six eligible articles were reviewed. The pooled MDs of PTA differences was 3.42 (95% CI = 0.17-6.67, p = .04) and the pooled ORs of recovery rate was 2.05 (95% CI = 1.38-3.03, p = .0003), which indicated that ITS treatment yielded better PTA improvement than SST. Sub-group analyses based on the initial hearing loss were also conducted; however, the difference was insignificant according to our analysis results (p = .82 for PTA improvement and p = .26 for recovery rate).

The efficacy of combination therapy for idiopathic sudden sensorineural hearing loss

OBJECTIVES/HYPOTHESIS

The aim of this study was to compare the hearing results of patients with idiopathic sudden sensorineural hearing loss (ISSNHL) who initially were treated with either a combination therapy of systemic steroids (SS) and intratympanic steroid injection (IT-S) or SS only.

METHODS

The study followed a retrospective case-control design. One-hundred five patients who were diagnosed with ISSNHL and required treatment via admission were enrolled in this study. The control group (n = 53) was treated with SS, and the study group (n = 52) received SS as well as IT-S. We divided the patients according to pretreatment hearing levels. The outcome measured was improvement after the treatment audiology data at pretreatment were compared with those at day 10 and > 90 days after the treatment. Outcome data were analyzed using the t test, Pearson's χ(2) test, Fisher's exact test, and multivariate analyses of covariance with adjustment for pretreatment hearing levels.

RESULTS

After more than 90 days, the average pure tone audiometry (PTA) in the control and study groups were 54.8 ± 31.4 dB and 43 ± 31.2 dB, respectively (P = 0.013). Hearing recovery rate was 57.7% in the control group and 69.8% in the study group. The hearing gain of the study group was higher than that of the control group at high frequencies within the 10 days of the treatment period. Analysis between subgroups, divided according to the severity of pretreatment hearing level, showed that the recovery rate was higher at all frequencies in the study group than in the control group in patients with mild to moderate hearing loss (pretreatment PTA < 70 dB). However, in patients with severe to profound hearing loss (pretreatment PTA ≥ 70 dB), the hearing outcomes of the study and control groups were not significantly different, except at a low frequency.

CONCLUSION

The results of this study suggest that the treatment of ISSNHL with combination therapy results in higher hearing recovery rates when compared to treatment with SS alone, even in patients with severe hearing loss.

LEVEL OF EVIDENCE

3b. Laryngoscope, 126:1871-1876, 2016.

Comparison of steroid administration methods in patients with idiopathic sudden sensorineural hearing loss: a retrospective observational study

OBJECTIVES

To compare the recovery rates of patients with idiopathic sudden sensorineural hearing loss (ISSHL) treated with oral systemic steroids (PO) or intratympanic steroid injection (IT) or both.

DESIGN

A retrospective observational study.

SETTING

Tertiary referral centre.

PARTICIPANTS

Eight hundred and forty-four patients diagnosed with ISSHL within 14 days of the onset of symptoms. The patients were divided into three groups by treatment modality.

MAIN OUTCOME MEASURES

Threshold of pure-tone tests, age, accompanying symptoms and underlying diseases were compared. The level of final hearing recovery was evaluated by the application of the results of the pure-tone test that was performed at least 3 months after the completion of each treatment.

RESULTS

Final hearing recovery rate differed significantly by the type of treatment (P = 0.031). Recovery rates in the PO and combined groups were significantly higher in patients with mild (85.1% and 88.6%, respectively) than with profound (52.8% and 69.0%, respectively) hearing loss (P < 0.05). In contrast, severity and recovery rate were not significantly correlated in the IT group (P > 0.05). Combined treatment yielded significantly higher recovery rates than other treatment modalities in patients without hypertension (HTN) and diabetes mellitus (DM) (P = 0.021).

CONCLUSION

In the group treated with combined therapy, better hearing improvement was obtained than in the groups treated with systemic steroid only or with intratympanic steroid injection only without complications. These findings suggest that the combination of systemic administration and intratympanic injection may improve patient prognosis.

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.

Histone Deacetylase 2 in Sudden Sensorineural Hearing Loss Patients in Response to Intratympanic Methylprednisolone Perfusion

OBJECTIVE

To evaluate the expression of histone deacetylase 2 (HDAC2) in peripheral blood mononuclear cells (PBMCs) from patients with sudden sensorineural hearing loss (SSNHL) who were refractory to systemic glucocorticoid treatment and to identify the relationship between the level of HDAC2 and glucocorticoid insensitivity.

STUDY DESIGN

Prospective clinical study.

SETTING

This study was conducted in Nanjing Drum Tower Hospital, Nanjing University Medical School.

SUBJECTS AND METHODS

PBMCs were collected from 42 refractory SSNHL patients. After a 10-day intratympanic methylprednisolone perfusion (IMP) and systemic Ginkgo biloba extract treatment, the SSNHL patients were divided into 2 groups according to their hearing recovery after IMP (IMP sensitive and insensitive). Real-time polymerase chain reaction and HDAC2 protein assays were used to detect the relative expression levels of HDAC2 in PBMCs. The HDAC2 mRNA expression and protein levels in PBMCs collected from 17 volunteers were used as normal HDAC2 reference levels.

RESULTS

Compared with normal reference levels, HDAC2 protein levels were significantly reduced, while the HDAC2 mRNA expression was much higher in all refractory SSNHL patients before IMP. HDAC2 mRNA expression and HDAC2 protein levels were significantly elevated in the IMP-sensitive group, while no change was observed in the IMP-insensitive group after IMP plus systemic antioxidant treatment.

CONCLUSIONS

Reduced HDAC2 protein levels may be 1 of the mechanistic underpinnings of corticosteroid insensitivity in refractory SSNHL patients. IMP can increase HDAC2 protein levels and the expression of HDAC2 mRNA in IMP-sensitive patients. HDAC2 protein levels might be regulated through posttranslational modifications.

Intratympanic steroid injection as a first-line therapy in uremia patients with sudden sensorineural hearing loss

CONCLUSIONS

ITSI as a first-line therapy in uremia patients with SSNHL offers a valid and safe treatment compared with intravenous systemic steroid treatment. A specific pathophysiology caused by possible sodium pump paralysis may be explained for uremia patients with SSNHL.

OBJECTIVE

To compare the efficacy of intratympanic steroid injection (ITSI) with that of systemic intravenous steroids as a first-line therapy in uremia patients with sudden sensorineural hearing loss (SSNHL).

MATERIALS AND METHODS

A total of 23 consecutive uremia patients with SSNHL were enrolled in this study. Patients were divided into two groups: the ITSI group (n = 15) and the non-ITSI group (n = 8), in which patients received intravenous systemic steroid treatment. The two groups were homogeneous in all respects.

RESULTS

The hearing improvement and relative gain were statistically significant between the two groups. The value of hearing gain (ΔPTA = PTA pre - PTA post) in the ITSI group and the non-ITSI group was 24.6 ± 16.4dB and 8.4 ± 19.3dB. The value of relative gain (ΔPTA/PTApre) in the ITIS group and the non-ITSI group was 31.1 ± 22% and 9.4 ± 20.5%. In the ITSI group, 11 patients (73.3%) exhibited hearing recovery (ΔPTA > 10 dB).

Intratympanic steroids as a salvage treatment for sudden sensorineural hearing loss? A meta-analysis

Sudden sensorineural hearing loss is typically treated with systemic steroids. The aim of this meta-analysis was to evaluate the efficacy of salvage intratympanic steroid treatment in patients who have initial treatment failure with systemic steroids. A MEDLINE literature search was performed, supported by searches of Web of Science, Biosis, and Science Direct. Articles of all languages were included. Selection of relevant publications was conducted independently by three authors. Only randomized controlled trials were considered. In one arm of the studies, the patients received salvage intratympanic steroids. In the other arm, patients did not receive further treatment. The standard difference in mean (SDM) amount of improvement in hearing threshold between patients who did and did not receive salvage intratympanic steroids was calculated. From an initial 184 studies found via the search strategy, 5 studies met inclusion criteria and were included. There was a statistically significant greater reduction in hearing threshold on pure-tone audiometry in patients who received salvage intratympanic steroids than in those who did not (SDM = -0.401, p = 0.005). Subgroup analysis showed that administration by intratympanic injection (SDM = -0.375, p = 0.013) rather than a round window catheter (SDM = -0.629, p = 0.160) yielded significant improvement in outcome. The usage of dexamethasone yielded better outcomes (SDM = -0.379, p = 0.039) than the use of methylprednisolone (SDM = -0.459, p = 0.187). No serious side effect of treatment was reported. In patients who have failed initial treatment with systemic steroids, additional treatment with salvage intratympanic dexamethasone injections demonstrate a statistically significant reduction in the hearing thresholds as compared to controls.

Steroids for idiopathic sudden sensorineural hearing loss

BACKGROUND

This is an update of a Cochrane review first published in The Cochrane Library in Issue 1, 2006 and previously updated in 2009.Idiopathic sudden sensorineural hearing loss (ISSHL) is a clinical diagnosis characterised by a sudden deafness of cochlear or retrocochlear origin in the absence of a clear precipitating cause. Steroids are commonly prescribed to treat this condition. There is no consensus on their effectiveness.

OBJECTIVES

To determine whether steroids in the treatment of ISSHL a) improve hearing (primary) and b) reduce tinnitus (secondary).To determine the incidence of significant side effects from the medication.

SEARCH METHODS

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 22 April 2013.

SELECTION CRITERIA

We identified all randomised controlled trials (with or without blinding) in which steroids were evaluated in comparison with either no treatment or a placebo. We considered trials including the use of steroids in combination with another treatment if the comparison control group also received the same other treatment. The two authors reviewed the full-text articles of all the retrieved trials of possible relevance and applied the inclusion criteria independently.

DATA COLLECTION AND ANALYSIS

We graded trials for risk of bias using the Cochrane approach. The data extraction was performed in a standardised manner by one author and rechecked by the other author. Where necessary we contacted investigators to obtain the missing information. Meta-analysis was neither possible nor considered appropriate because of the heterogeneity of the populations studied and the differences in steroid formulations, dosages and duration of treatment. We analysed and reported the quality of the results of each study individually. A narrative overview of the results is presented.

MAIN RESULTS

Only three trials, involving 267 participants, satisfied the inclusion criteria and all three studies were at high risk of bias. One trial showed a lack of effect of oral steroids in improving hearing compared with the placebo control group. The second trial showed a significant improvement of hearing in 61% of the patients receiving oral steroid and in only 32% of the patients from the control group (combination of placebo-treated group and untreated control group). The third trial also showed a lack of effect of oral steroids in improving hearing compared with the placebo control. However, this trial did not follow strict inclusion criteria for participant selection and analysis of data was limited by significant exclusion of participants from the final analysis and lack of participant compliance to the treatment protocol. No clear evidence was presented in two trials about any harmful side effects of the steroids. Only one study declared that no patients suffered from adverse effects of the steroid treatment.

AUTHORS' CONCLUSIONS

The value of steroids in the treatment of idiopathic sudden sensorineural hearing loss remains unclear since the evidence obtained from randomised controlled trials is contradictory in outcome, in part because the studies are based upon too small a number of patients.

Efficacy of intratympanic steroid therapy for idiopathic sudden sensorineural hearing loss: comparison with systemic steroid therapy and combined therapy

CONCLUSION

Intratympanic steroid therapy (IT-S) was as effective as systemic steroid therapy (SST) or combined therapy (CT) and could be considered a first-line therapeutic modality for idiopathic sudden sensorineural hearing loss (SSNHL). Due to its known safety and efficacy, IT-S will be particularly suitable for patients with SSNHL who have chronic diseases such as diabetes mellitus, hypertension, or chronic renal failure.

OBJECTIVES

Systemic high dose steroid therapy is the main therapeutic modality for SSNHL. Comparable therapeutic efficacies for IT-S and CT with SST and IT-S for SSNHL have been reported recently. We compared the efficacy of IT-S, SST, and CT for treating SSNHL.

METHODS

A retrospective, multicenter study investigating the therapeutic efficacy of SST, IT-S, and CT for SSNHL was designed and involved 735 patients with idiopathic SSNHL who were diagnosed and treated at seven tertiary referral medical centers of the Catholic University of Korea between 2007 and 2011. Patients were divided into three groups according to the treatment methods they received: IT-S group, SST group, and CT group (SS plus IT-S). Hearing was evaluated by pure tone audiogram performed before initial treatment and at 4 weeks following the final treatment. More than a 10 dB HL decrease in average air conduction threshold of hearing at 500, 1000, 2000, and 3000 Hz was defined as improved hearing.

RESULTS

Among 735 patients with SSNHL, 94 were included in the IT-S group, 444 in the SST, and 197 in the CT group. Age, gender, interval from disease onset to start of treatment, and initial hearing level were not different among the three groups. Patients who had concomitant medical disorders such as diabetes mellitus, hypertension, or chronic renal failure were more frequently treated with IT-S. No difference in the level of hearing gain or ratio of hearing improvement was observed among the three groups (p = 0.147 and p = 0.067, respectively).

Intratympanic steroids as primary initial treatment of idiopathic sudden sensorineural hearing loss. The Hospital Universitario Ramón y Cajal experience and review of the literature

The objective of this study was to determine the effectiveness, dosage, safety and comfort of intratympanic steroids as primary initial treatment of idiopathic sudden sensorineural hearing loss (ISSHL). Prospective nonrandomized clinical practice study was performed in Tertiary referral center university hospital. A total of 35 consecutive patients suffering from newly diagnosed sudden sensorineural hearing loss with mean pure-tone average thresholds of 81 ± 21 dB were treated. No previous therapy had been undertaken. Intratympanic steroid injection as primary initial treatment was administered during 2 weeks on a twice a week schedule, between 2010 and 2011. Treatment was started on average within 2 days of symptoms onset. Pre and post-treatment audiometric evaluations were analyzed on follow-up as well as tolerance of the procedure and possible adverse effects. 66-85 % of patients achieved successful treatment according to the different outcome criteria used to evaluate hearing improvement (Furuhashi criteria/improvement of ≥10 dB in pure-tone average). Mean post-treatment improvement regarding pure-tone average was 34 ± 21 dB. A 48 ± 43 % improvement in speech discrimination score was observed. Patients received an average of 18 mg of methylprednisolone per injection and a total dose of 72 mg per treatment cycle. No serious adverse effects were noted. Intratympanic steroid injection is an effective, safe and well-tolerated office based-procedure for the treatment of ISSHL as primary initial treatment that can avoid the potential adverse effects of systemic steroids. A higher dose, schedule of administration as well as standardization of hearing recovery criteria still need to be established.

Efficacy of intratympanic steroid administration on idiopathic sudden sensorineural hearing loss in comparison with hyperbaric oxygen therapy

OBJECTIVES/HYPOTHESIS

The efficacy of intratympanic steroid administration was examined in comparison with hyperbaric oxygen (HBO) therapy in patients with idiopathic sudden sensorineural hearing loss (ISSNHL).

STUDY DESIGN

Retrospective study.

METHODS

Two hundred seventy-six consecutive patients with ISSNHL (average hearing levels at 250, 500, 1,000, 2,000, and 4,000 Hz ≥ 40 dB; time from onset to treatment ≤30 days) were enrolled. All the patients were given intravenous hydrocortisone (400 mg/day) followed by tapered doses. In addition, 174 patients underwent HBO therapy (HBO group), and 102 patients received intratympanic dexamethasone injection (IT group). The hearing outcomes were evaluated by six indices; the cure rate, marked-recovery rate (percent of patients with hearing gains ≥30 dB), recovery rate (percent of patients with hearing gains ≥10 dB), hearing gain, hearing level after treatment, and hearing improvement rate compared to the unaffected contralateral ear.

RESULTS

There was no significant difference in the cure rate, marked-recovery rate, hearing gain, hearing level after treatment, or hearing improvement rate between the two groups; however, the recovery rate was significantly higher in the IT group than in the HBO group (79.4% vs. 68.4%; P = .048). Multiple logistic regression analysis also showed that patients in the IT group were significantly more likely to recover than those in the HBO group (odds ratio: 2.045; 95% confidence interval: 1.097-3.812; P = .024).

CONCLUSIONS

Systemic plus intratympanic steroid administration is more effective than systemic steroids plus HBO therapy, and can be a useful first-choice treatment for ISSNHL.

Intratympanic Steroids for Sudden Sensorineural Hearing Loss

Objective. To determine the evidence for efficacy of intratympanic (IT) steroid treatment for the management of idiopathic sudden sensorineural hearing loss through a systematic review of the existing literature.

Data Sources. Online databases consisting of PubMed, Medline, OVID, Google Scholar, Cochrane Review, and collected additional publications cited in bibliographies.

Review Methods. Literature search by both authors with structured criteria to select studies evaluated for systematic review.

Results. The authors identified 176 articles, of which 32 represented studies of initial or salvage intratympanic steroid injections for sudden hearing loss that included 6 randomized trials and only 2 randomized controlled trials. Despite the paucity of well-executed trials, the vast majority of studies of intratympanic steroids for salvage treatment in all tiers demonstrated a benefit of intratympanic steroid therapy. A limited meta-analysis of the higher quality studies revealed a mean difference in improvement of 13.3 dB (95% confidence interval [CI], 7.7-18.9; P < .0001). Although statistically significant, it is still unclear if this difference is clinically significant. Initial intratympanic therapy was equivalent to standard therapy in the existing literature of all qualities.

Conclusion. Intratympanic steroid treatment as primary treatment for sudden sensorineural hearing loss appears equivalent to treatment with high-dose oral prednisone therapy. As salvage therapy, intratympanic steroids offer the potential for some degree of additional hearing recovery, although it remains uncertain if this improvement is clinically significant and what percentage of patients is likely to show benefit.

Intratympanic methylprednisolone as first-line therapy in sudden sensorineural hearing loss: preliminary results from a case-control series

BACKGROUND

Sudden sensorineural hearing loss is a true audiological emergency, and its management is much discussed. Currently, no single therapy has been proven effective according to evidence criteria. Recently, intratympanic application of steroids has been increasingly used in refractory cases; however, it has only rarely been reported as first-line therapy.

MATERIALS AND METHODS

Twenty consecutive patients with sudden sensorineural hearing loss treated between July 2008 and January 2010 were enrolled in this prospective, case-control study. Ten patients were treated with intratympanic steroids and 10 with systemic 'shotgun' therapy (including steroids, pentoxifylline, low molecular weight heparin and vitamin E). The two groups were homogeneous in all respects. Pure tone averages were assessed before and after treatment for both groups.

RESULTS

There were no statistically significant differences between the two groups.

CONCLUSION

Intratympanic steroids seem to offer a valid alternative to systemic therapy, with few risks, in sudden sensorineural hearing loss patients, and we recommend their use as first-line therapy.

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.

Round window perfusion dynamics: implications for intracochlear therapy

PURPOSE OF REVIEW

The treatments for inner ear diseases are evolving as the systemic administration of medication is replaced by novel intratympanic and intracochlear drug delivery. The current review explores the background and recent developments in this field.

RECENT FINDINGS

Although still in various stages of clinical development, novel drug delivery techniques such as the Silverstein MicroWick, the round window microcatheter, biodegradable hydrogels, biopolymers, nanoparticles, newly designed cochlear implant arrays, osmotic mini/micro pumps, and reciprocating perfusion systems hold significant promise. Animal data suggest that sustained delivery systems have more reliable inner ear pharmacokinetics than both systemic administration and intratympanic injections.

SUMMARY

As research scientists advance technologies for treating inner ear diseases, drug delivery techniques must keep pace. Viable treatment options for sensorineural hearing loss, tinnitus, and vestibular disorders are on the horizon and may usher in a new golden age for otology.

[Consensus on diagnosis and treatment of sudden hearing loss. Asociación Madrileña de ORL]

Idiopathic sudden sensorineural hearing loss is an unexplained unilateral hearing loss with onset over a period of less than 72 hours, without other known otological diseases. We present a consensus on the diagnosis, treatment and follow-up of this disease, designed by AMORL, after a systematic review of the literature from 1966 to June 2010. Diagnosis of sudden sensorineural hearing loss is based on mandatory otoscopy, acoumetry, tonal audiometry, speech audiometry, and tympanometry. After clinical diagnosis is settled, and before treatment is started, a full analysis should be done and an MRI should be requested later. Treatment is based on systemic corticosteroids (orally in most cases), helped by intratympanic doses as rescue after treatment failures. Follow-up should be done at day 7, with tonal and speech audiometries, and regularly at 15, 30, and 90 days after start of therapy, and after 12 months. By consensus, results after treatment should be reported as absolute dBs recovered in pure tonal audiometry, as improvement in the recovery rate in unilateral cases, and as improvement in speech audiometry.

Intratympanic steroids in severe to profound sudden sensorineural hearing loss as salvage treatment

OBJECTIVES

Intratympanic steroids are being increasingly used in the treatment of sudden sensorineural hearing loss (SSNHL) after the failure of systemic therapy. This study evaluated the efficacy of administering intratympanic dexamethasone (ITD) as a salvage treatment for severe to profound SSNHL.

METHODS

We reviewed the medical records of patients who presented with severe to profound SSNHL between January 2007 and December 2009. ITD was given about 14 days after the initial systemic treatment. Successful recovery was defined as complete or partial recovery using Sigel's criteria. We compared the results of treatment between the severe SSNHL (S-SSNHL) and profound SSNHL (P-SSNHL) groups.

RESULTS

All the patients in the S-SSNHL group showed significant improvement, as compared to the P-SSNHL group (P=0.017). The recovery rate after the initial systemic treatment was 36% (9/25) in the S-SSNHL group and 18.1% (4/22) in the P-SSNHL group (P=0.207). In comparison, the recovery rate of ITD as a salvage treatment was 37.5% (6/16) in the S-SSNHL group and 5.5% (1/18) in the P-SSNHL group (P=0.03).

CONCLUSION

Our comparative study dose not support the efficacy of ITD as salvage treatment for patients with P-SSNHL as compared with that for S-SSNHL. We recommend that patients with P-SSNHL be informed about the low efficacy of ITD as a salvage treatment.