Dexamethasone eardrop with grommet placement vs intratympanic steroid injection for sudden sensorineural hearing loss: A randomized prospective clinical trial

Perfusion Steroid via Ventilation Tube as Salvage Treatments for Sudden Sensorineural Hearing Loss

Objectives: Intratympanic steroid injection (ISI) for sudden sensorineural hearing loss (SSNHL) is a relatively popular and effective method, but there is no standardized method for intratympanic steroids for the treatment of SSNHL and no consensus on how to deliver steroids to the middle ear. The purpose of this study was to compare 2 means of intratympanic steroid delivery as therapy for SSNHL. Methods: A retrospective chart review was performed for the period from November 2018 to October 2022 at our Department of Otorhinolaryngology-Head and Neck Surgery. Sixty patients with profound SSNHL who have failed initial steroid therapy were divided into the continuously transtympanic steroid perfusion (TSP) therapy and the intermittent ISI therapy. Results: Posttreatment pure-tone average was 60.3 ± 18.2 dB in the TSP group and 67.5 ± 22.6 dB in the ISI group, 70.0% of subjects in the TSP group, and 46.7% of subjects in the ISI group had improved by 15 dB or more after the therapy. The increased hearing threshold of the TSP group (24.6 ± 14.1 dB) was better than the ISI group (16.6 ± 14.9 dB), and the hearing recovery was significantly different (P < .05) in the 2 groups. Besides the hearing improvement was most obvious in low-frequency areas in the TSP group, the most significant hearing improvement was at 250 Hz, reaching 30.8 ± 3.3 dB. Conclusions: In SSNHL patients who have failed initial steroid therapy, TSP therapy via a ventilation tube can achieve good hearing outcomes and serve as a salvage therapy for patients with SSNHL.

Assessing the Efficacy of Tragal Pumping in a Novel Tympanostomy Tube-Rat Model

Objective

Tragal pumping (TP) is a practice of pushing on the tragus to raise pressure within the external auditory canal and is a commonly recommended adjunctive maneuver believed to facilitate the introduction of ototopical medications into the middle ear cavity via a tympanostomy tube. To investigate the efficacy of TP in the penetration of eardrops into the middle ear cavity via tympanostomy tube, we established the novel tympanostomy tube-rat model. We investigated the histology of the middle ear to determine the efficacy in moving fluid into the middle ear.

Study Design

Prospective controlled animal study.

Setting

Animal laboratory in a university hospital.

Methods

Ten rats were recruited, and a tympanostomy tube insertion and green dye eardrops into outer ears were performed on bilateral ears. TP was performed only on 1 ear and was not applied on the other ear in each rat. Green dye in a middle ear cavity in hematoxylin and eosin-stained temporal bone sections was evaluated by blinded experts in microscopic anatomy (staining grade) and by using Image J software (staining level). The results of these 2 methods were statistically validated.

Results

The staining grade (P < .001) and the staining level (P < .001) were significantly higher in the ears which we applied TP than in the control ears. The results of 2 methods were significantly and positively correlated (r = .898, P < .001).

Conclusion

Our results showed that the TP accelerate the penetration of eardrops into the middle ear cavity in the tympanostomy tube-rat model.

Intra-Tympanic Dexamethasone Therapy via Grommet Insertion for Improved Auditory Outcome in Sudden Sensorineural Hearing Loss

Idiopathic sudden-sensorineural hearing loss (ISSHL) is an emergent otological condition needing prompt treatment for better recovery. In our study we aimed to determine the efficacy of intra-tympanic dexamethasone therapy after inserting a grommet in postero-inferior quadrant of the tympanic membrane for dexamethasone instillation. This is a prospective cohort study of 31 patients of ISSHL, in whom grommet was inserted and dexamethasone drops were instilled for 5 days. Several factors such as time of initiation of therapy, age of patient was considered, and inferences were drawn. Auditory outcomes were divided into low, mid and high frequency and the results were tabulated. Paired t tested was applied for all frequencies for both pre-test and post-test. P-value was (< 0.05) in all the three ranges of frequencies. Also, statistical significance was found between early treatment from onset of disease and auditory outcome. The earlier the therapy was initiated, better were the results.

Delivery of Dexamethasone to the Round Window Niche by Saturated Gelatin Sponge for Refractory Sudden Sensorineural Hearing Loss: A Preliminary Study

OBJECTIVE

The aim of this study was to evaluate the hearing outcome of dexamethasone sodium phosphate (DSP) delivery to the round window niche by saturated gelatin sponge for refractory sudden sensorineural hearing loss.

PATIENTS

Twenty patients with unilateral sudden sensorineural hearing loss with an improvement of pure-tone average (PTA) less than 10 dB after primary systemic treatment with steroids.

INTERVENTIONS

Delivery of DSP to the round window niche via saturated sponge gelatin for 2 weeks.

MAIN OUTCOME MEASURES

Pure-tone audiometry was taken at the beginning and 4 to 8 weeks after the end of the salvage treatment.

RESULTS

PTA thresholds were improved at least 10 dB in 11 of 20 patients (55%) by a mean value of 11.9 dB. The hearing threshold at 500, 1000, and 2000 Hz were improved after salvage treatment, but there was no significant change at 4000 Hz. The PTAs also recovered after the salvage treatment.

CONCLUSIONS

Delivery of DSP to the round window niche via saturated gelatin sponge is a simple and feasible way to treat refractory sudden sensorineural hearing loss with a risk of permanent tympanic membrane perforation.

Intratympanic corticosteroids for sudden sensorineural hearing loss

BACKGROUND

Idiopathic sudden sensorineural hearing loss (ISSNHL) is common, and defined as a sudden decrease in sensorineural hearing sensitivity of unknown aetiology. Systemic corticosteroids are widely used, however their value remains unclear. Intratympanic injections of corticosteroids have become increasingly common in the treatment of ISSNHL.

OBJECTIVES

To assess the effects of intratympanic corticosteroids in people with ISSNHL.

SEARCH METHODS

The Cochrane ENT Information Specialist searched the Cochrane ENT Trials Register; CENTRAL (2021, Issue 9); PubMed; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials (search date 23 September 2021).

SELECTION CRITERIA

We included randomised controlled trials (RCTs) involving people with ISSNHL and follow-up of over a week. Intratympanic corticosteroids were given as primary or secondary treatment (after failure of systemic therapy).

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods, including GRADE to assess the certainty of the evidence. Our primary outcome was change in hearing threshold with pure tone audiometry. Secondary outcomes included the proportion of people whose hearing improved, final hearing threshold, speech audiometry, frequency-specific hearing changes and adverse effects.

MAIN RESULTS

We included 30 studies, comprising 2133 analysed participants. Some studies had more than two treatment arms and were therefore relevant to several comparisons. Studies investigated intratympanic corticosteroids as either primary (initial) therapy or secondary (rescue) therapy after failure of initial treatment. 1. Intratympanic corticosteroids versus systemic corticosteroids as primary therapy We identified 16 studies (1108 participants). Intratympanic therapy may result in little to no improvement in the change in hearing threshold (mean difference (MD) -5.93 dB better, 95% confidence interval (CI) -7.61 to -4.26; 10 studies; 701 participants; low-certainty). We found little to no difference in the proportion of participants whose hearing was improved (risk ratio (RR) 1.04, 95% CI 0.97 to 1.12; 14 studies; 972 participants; moderate-certainty). Intratympanic therapy may result in little to no difference in the final hearing threshold (MD -3.31 dB, 95% CI -6.16 to -0.47; 7 studies; 516 participants; low-certainty). Intratympanic therapy may increase the number of people who experience vertigo or dizziness (RR 2.53, 95% CI 1.41 to 4.54; 1 study; 250 participants; low-certainty) and probably increases the number of people with ear pain (RR 15.68, 95% CI 6.22 to 39.49; 2 studies; 289 participants; moderate-certainty). It also resulted in persistent tympanic membrane perforation (range 0% to 3.9%; 3 studies; 359 participants; very low-certainty), vertigo/dizziness at the time of injection (1% to 21%, 3 studies; 197 participants; very low-certainty) and ear pain at the time of injection (10.5% to 27.1%; 2 studies; 289 participants; low-certainty). 2. Intratympanic plus systemic corticosteroids (combined therapy) versus systemic corticosteroids alone as primary therapy We identified 10 studies (788 participants). Combined therapy may have a small effect on the change in hearing threshold (MD -8.55 dB better, 95% CI -12.48 to -4.61; 6 studies; 435 participants; low-certainty). The evidence is very uncertain as to whether combined therapy changes the proportion of participants whose hearing is improved (RR 1.27, 95% CI 1.15 to 1.41; 10 studies; 788 participants; very low-certainty). Combined therapy may result in slightly lower (more favourable) final hearing thresholds but the evidence is very uncertain, and it is not clear whether the change would be important to patients (MD -9.11 dB, 95% CI -16.56 to -1.67; 3 studies; 194 participants; very low-certainty). Some adverse effects only occurred in those who received combined therapy. These included persistent tympanic membrane perforation (range 0% to 5.5%; 5 studies; 474 participants; very low-certainty), vertigo or dizziness at the time of injection (range 0% to 8.1%; 4 studies; 341 participants; very low-certainty) and ear pain at the time of injection (13.5%; 1 study; 73 participants; very low-certainty).  3. Intratympanic corticosteroids versus no treatment or placebo as secondary therapy We identified seven studies (279 participants). Intratympanic therapy may have a small effect on the change in hearing threshold (MD -9.07 dB better, 95% CI -11.47 to -6.66; 7 studies; 280 participants; low-certainty). Intratympanic therapy may result in a much higher proportion of participants whose hearing is improved (RR 5.55, 95% CI 2.89 to 10.68; 6 studies; 232 participants; low-certainty). Intratympanic therapy may result in lower (more favourable) final hearing thresholds (MD -11.09 dB, 95% CI -17.46 to -4.72; 5 studies; 203 participants; low-certainty). Some adverse effects only occurred in those who received intratympanic injection. These included persistent tympanic membrane perforation (range 0% to 4.2%; 5 studies; 185 participants; very low-certainty), vertigo or dizziness at the time of injection (range 6.7% to 33%; 3 studies; 128 participants; very low-certainty) and ear pain at the time of injection (0%; 1 study; 44 participants; very low-certainty).  4. Intratympanic plus systemic corticosteroids (combined therapy) versus systemic corticosteroids alone as secondary therapy We identified one study with 76 participants. Change in hearing threshold was not reported. Combined therapy may result in a higher proportion with hearing improvement, but the evidence is very uncertain (RR 2.24, 95% CI 1.10 to 4.55; very low-certainty). Adverse effects were poorly reported with only data for persistent tympanic membrane perforation (rate 8.1%, very low-certainty).

AUTHORS' CONCLUSIONS

Most of the evidence in this review is low- or very low-certainty, therefore it is likely that further studies may change our conclusions.   For primary therapy, intratympanic corticosteroids may have little or no effect compared with systemic corticosteroids. There may be a slight benefit from combined treatment when compared with systemic treatment alone, but the evidence is uncertain. For secondary therapy, there is low-certainty evidence that intratympanic corticosteroids, when compared to no treatment or placebo, may result in a much higher proportion of participants whose hearing is improved, but may only have a small effect on the change in hearing threshold. It is very uncertain whether there is additional benefit from combined treatment over systemic steroids alone. Although adverse effects were poorly reported, the different risk profiles of intratympanic treatment (including tympanic membrane perforation, pain and dizziness/vertigo) and systemic treatment (for example, blood glucose problems) should be considered when selecting appropriate treatment.

Residual Perforation Risk Assessment of Intratympanic Steroids via Tympanostomy Tube Versus Transtympanic Injections

OBJECTIVES/HYPOTHESIS

To investigate the risk of residual tympanic membrane (TM) perforation after intratympanic (IT) steroidal treatment administered via transtympanic injection compared with trans-tympanostomy tube (TyT).

STUDY DESIGN

Case series, systematic review and meta analysis.

METHODS

Data were retrieved from the medical files of an original cohort of all consecutive patients with sudden sensorineural hearing loss necessitating IT steroidal treatment in a tertiary medical center between January 1, 2016 and November 20, 2020. A systematic literature search of "MEDLINE" via "PubMed," "Embase," and "Web of Science" on comparable published cases was performed and meta-analysis was established.

RESULTS

Eighteen studies describing 818 ears were included in the quantitative meta-analysis in addition to a local cohort of 140 ears. The proportion of residual TM perforation was 1.11% and 1.14% (95% confidence interval: 0.01%-3.27% and 0.028%-2.38%) in the TyT and trans-tympanic groups, respectively, suggesting no significant difference in residual TM perforation risk between these techniques.

CONCLUSION

IT steroid therapy via trans-TyT is not associated with more residual perforations than IT steroid therapy via transtympanic injections.

LEVEL OF EVIDENCE

NA Laryngoscope, 131:E2583-E2591, 2021.