Intratympanic steroid injection and hyperbaric oxygen therapy for the treatment of refractory sudden hearing loss

Salvage therapy for refractory sudden sensorineural hearing loss (RSSNHL): a systematic review and network meta-analysis

OBJECTIVE

Approximately 30-50% of sudden sensorineural hearing loss (SSNHL) patients show poor response to systemic steroid therapy. Additionally, the most appropriate treatment for patients with refractory sudden sensorineural hearing loss (RSSNHL) is unknown. This study aimed to explore the best treatment for RSSNHL.

DESIGN

Using a frequentist contrast-based model and PRISMA guidelines, this study compared five salvage regimes: intratympanic injection of steroids (ITS), hyperbaric oxygen (HBO) therapy, post auricle steroid injection (PSI), ITS combined with HBO therapy, and continued systemic steroids.

STUDY SAMPLE

We searched the PubMed, EMBASE, Web of Science, and Cochrane Library databases for randomised controlled trials and cohort studies comparing treatment regimens for RSSNHL.

RESULTS

Compared with the control group (no additional treatment), PSI and ITS demonstrated significant improvements. The mean hearing gain was greater after PSI (11.1 dB [95% CI, 4.4-17.9]) than after ITS (7.7 dB [95% CI, 4.8-10.7]). When a restricted definition of RSSNHL was used, the ITS + HBO therapy showed the largest difference in improvement for pure tone average compared with the control group (14.5 dB [95% CI, 4.2-25.0]).

CONCLUSIONS

The administration of either PSI or ITS leads to the greatest therapeutic effect in patients with RSSNHL. However, a consensus on the definition of RSSNHL is needed.

Efficacy of hyperbaric oxygen therapy in treating sudden sensorineural hearing loss: an umbrella review

Introduction

Our objective was to explore the efficacy of hyperbaric oxygen in the treatment of sudden sensorineural hearing loss by conducting an umbrella review of all existing evidence.

Methods

We conducted an umbrella review, searching for related articles in the PubMed, Web of Science, Embase, and Scopus databases. The search period covered from the inception of each database until April 2024. We extracted authors, country of publication, time of publication, number of included studies and participants, interventions, summary of results, P-values, I 2, relative risk (95% CI), and outcome measures. The methodological quality, evidence quality, and overlap rate of the included articles were assessed using AMSTAR 2, GRADE, and OVErviews (GROOVE).

Results

Methodological quality was assessed using AMSTAR 2. Of the nine included articles, two were assessed as "high," three as "moderate," two as "low," and the remaining two as "very low." The quality of evidence was assessed using the GRADE system. It was found that the quality of evidence in most of the studies was unsatisfactory. It was found that there was a slight overlap among the included articles. Six studies reported positive results (OR 1.37; 95% CI, 1.17-1.61; P = 0.04), with high heterogeneity observed (I 2 = 63%). Egger's test indicated bias (P = 0.000101). Three studies reported negative results (MD 1.49; 95% CI, -0.32 to 3.29; P = 0.43; I 2 = 0%), with no significant bias detected (P = 0.106) according to Egger's test.

Conclusion

HBO therapy is shown to be an effective treatment for SSNHL with fewer side effects. However, the methodological quality and evidence of the systematic reviews and meta-analysis included in this study were generally low. Therefore, more high-quality, large-scale, multi-center randomized controlled trials are needed in the future to verify the efficacy of HBO therapy for SSNHL.

Systematic review registration

https://www.crd.york.ac.uk/prospero, identifier [CRD42024523651].

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.

Comparison of Intratympanic Steroid and Hyperbaric Oxygen Salvage Therapy Hearing Outcomes in Idiopathic Sudden Sensorineural Hearing Loss: A Retrospective Study

OBJECTIVES

Systemic steroids are the most common first-line therapy in sudden sensorineural hearing loss (SSNHL), with significant improvement in hearing outcomes in over 60% of patients. It is unknown why 40% of patients do not respond to systemic steroid therapy. Salvage treatment includes intratympanic steroids (ITS) and hyperbaric oxygenation (HBO) therapy, with inconsistent results reported. This study aimed to compare the results of ITS and HBO therapy in patients with SSNHL that previously failed systemic steroid therapy.

DESIGN

This is a comparative retrospective nonrandomized interventional cohort study, enrolling 126 patients with SSNHL. Out of these, 35 patients received HBO therapy, 43 patients received ITS, and 48 patients did not receive any second-line therapy (control group). Pure-tone audiograms were performed before and after the salvage therapy in the IT and HBO groups and at the same time interval in the control group. Study variables included age, time until therapy initiation, tinnitus status, and hearing outcomes, with a cutoff criteria of cumulative >30 dB improvement on all frequencies indicating recovery.

RESULTS

ITS and HBO therapy were associated with statistically significant hearing recovery at all frequencies compared to systemic steroids. The results show an average hearing improvement of 13.6 dB overall frequencies (250 to 8000 Hz) after ITS therapy and 7.4 dB in HBO therapy in comparison to the control group. Presence of significant hearing improvement positively correlated with age, ITS therapy, and HBO therapy. Presence of tinnitus before therapy was negatively correlated with hearing improvement. Patients with tinnitus present at the start of therapy improve 4.67 dB less on average compared to those without tinnitus. ITS therapy significantly reduced tinnitus compared to the other two treatment options. Patients with tinnitus present before therapy significantly improve hearing at low frequencies, compared to the control group.

CONCLUSIONS

ITS and HBO therapy show superior hearing results compared to observation alone after failed oral steroid therapy for SSNHL. ITS shows an additional positive impact on tinnitus reduction and shows superior hearing outcomes after salvage therapy.

Idiopathic Sudden Sensorineural Hearing Loss: Is Hyperbaric Oxygen Treatment the Sooner and Longer, the Better?

(1) Background: We aimed to evaluate hearing benefits from hyperbaric oxygen (HBO) therapy in patients with Idiopathic Sudden Sensorineural Hearing Loss (ISSHL). (2) Methods: We performed a retrospective analysis of chart reviews on patients with ISSHL between Jan 2016 and Dec 2021. All patients were referred to receive HBO therapy by the department of Ear, Nose and Throat (ENT). Hearing gain was assessed based on pure-tone audiometry (PTA). Data were analyzed for 102 patients after 1 to 5 therapy sessions, and for 46 patients after 6 to 10 therapy sessions. (3) Results: After 1−5 HBO sessions, patients (N = 102) showed an improvement in 45 (44.1%) of the patients (p < 0.000). Also, improvements were found with patients showing different grades of ISSHL: 11 (26.8%) with slight-moderate, 11 (40.7%) with severe, and 23 (67.6%) with profound ISSHL. Significant treatment effects were found at different affected frequencies, especially the low frequency range. After 6−10 HBO sessions, patients (N = 46) showed similar treatment effects as after 1−5 HBO sessions, but no additional improvement. Moreover, patients who received HBO treatment within 12 days showed improvement effects 6.484 times greater (p < 0.000) compared with those who received treatment after 13 days. (4) Conclusions: The improvement of HBO therapy on ISSHL was significant after 1−5 sessions, with larger improvements for those suffering more serious symptoms. Further adding more HBO treatment sessions to 6−10, no further improvement was found. Patients starting HBO therapy within 12 days of ISSHL showed 6.484 times greater improvements compared with those starting HBO therapy later.

Hyperbaric Oxygen Therapy Versus Intratympanic Steroid for Salvage Treatment of Sudden Sensorineural Hearing Loss: A Systematic Review and Meta-analysis

OBJECTIVE

The aim of this meta-analysis is to compare the efficacy of hyperbaric oxygen therapy (HBOT) and intratympanic steroids (ITS) as salvage treatment for patients with refractory sudden sensorineural hearing loss (SSNHL).

DATA SOURCES

Electronic search was performed in the PubMed, Embase, Cochrane Library, CNKI, and Wan Fang databases to June 1, 2020.

METHODS

For each outcome measure, a forest plot was generated and a pooled relative risk (RR) or mean difference (MD) was calculated. Potential publication bias in the meta-analysis was assessed using funnel plot.

RESULTS

The numbers of cases with hearing improvements and pure tone averages (PTA) changes after salvage treatment were entered into the R software to calculate the pooled effect of HBOT compared with ITS. When pooling the results of the studies reporting the proportion of patients with hearing improvement, a fixed-effects model was used. We calculated the RR and found no significant difference when HBOT compared with ITS (RR = 1.09, 95% confidence interval [CI]: 0.83-1.42, p = 0.55). With respect to the PTA changes, a fixed-effects model was used. The improvement in the PTA (in dB) was calculated in MD and no significant difference was found between the two groups (MD = 0.55, 95% CI: -1.76-2.86, p = 0.64).

CONCLUSION

Both HBOT and ITS offer some benefits for refractory SSNHL patients, and there were no significant differences in hearing outcomes between the two modalities. Future RCTs that include large samples are needed to demonstrate superiority of one of the treatments.

Intratympanic steroid injection versus hyperbaric oxygen therapy in refractory sudden sensorineural hearing loss: a meta-analysis

OBJECTIVE

The present meta-analysis aims to compare the efficacy of intratympanic steroid (ITS) injection and hyperbaric oxygen (HBO) therapy as salvage treatments for refractory sudden sensorineural hearing loss (SSNHL).

DATA SOURCES

Comprehensive searches were performed in PubMed, EMBASE and the Cochrane Library from the date of the database inception to June 2020. All studies reporting the use of salvage ITS and HBO treatments in refractory SSNHL patients were included. Subsequently, the full texts of the eligible studies were evaluated.

METHODS

The quality and bias of the studies were assessed using the Newcastle-Ottawa Scale and Cochrane's risk of bias tools for nonrandomized and randomized studies, respectively. The data were analyzed using Comprehensive Meta-Analysis software (Version 3; Biostat, Englewood, NJ).

RESULTS

Three hundred and fourteen subjects in 3 observational studies and 1 randomized controlled trial met our inclusion criteria. The pooled results demonstrated that there were no significant differences in the mean posttreatment hearing gain between the ITS and HBO groups. The changes in word discrimination and hearing gain at 250, 500, 1000, 2000, 4000 and 8000 Hz were also comparable between the two salvage treatment groups.

CONCLUSIONS

The pooled results demonstrated that there were no significant differences in hearing improvements between salvage ITS injection and salvage HBO therapy after failed primary systemic steroid treatment in patients with SSNHL. However, spontaneous recovery could bias the treatment outcomes, and these results should be interpreted with caution. Clinicians may choose these salvage treatments according to personal experience and treatment availability. In cases in which specialized HBO facilities are difficult to access, salvage ITS injection can be provided with comparable responses.

Clinical Practice Guideline: Sudden Hearing Loss (Update)

OBJECTIVE

Sudden hearing loss is a frightening symptom that often prompts an urgent or emergent visit to a health care provider. It is frequently but not universally accompanied by tinnitus and/or vertigo. Sudden sensorineural hearing loss affects 5 to 27 per 100,000 people annually, with about 66,000 new cases per year in the United States. This guideline update provides evidence-based recommendations for the diagnosis, management, and follow-up of patients who present with sudden hearing loss. It focuses on sudden sensorineural hearing loss in adult patients aged ≥18 years and primarily on those with idiopathic sudden sensorineural hearing loss. Prompt recognition and management of sudden sensorineural hearing loss may improve hearing recovery and patient quality of life. The guideline update is intended for all clinicians who diagnose or manage adult patients who present with sudden hearing loss.

PURPOSE

The purpose of this guideline update is to provide clinicians with evidence-based recommendations in evaluating patients with sudden hearing loss and sudden sensorineural hearing loss, with particular emphasis on managing idiopathic sudden sensorineural hearing loss. The guideline update group recognized that patients enter the health care system with sudden hearing loss as a nonspecific primary complaint. Therefore, the initial recommendations of this guideline update address distinguishing sensorineural hearing loss from conductive hearing loss at the time of presentation with hearing loss. They also clarify the need to identify rare, nonidiopathic sudden sensorineural hearing loss to help separate those patients from those with idiopathic sudden sensorineural hearing loss, who are the target population for the therapeutic interventions that make up the bulk of the guideline update. By focusing on opportunities for quality improvement, this guideline should improve diagnostic accuracy, facilitate prompt intervention, decrease variations in management, reduce unnecessary tests and imaging procedures, and improve hearing and rehabilitative outcomes for affected patients.

METHODS

Consistent with the American Academy of Otolaryngology-Head and Neck Surgery Foundation's "Clinical Practice Guideline Development Manual, Third Edition" (Rosenfeld et al. Otolaryngol Head Neck Surg. 2013;148[1]:S1-S55), the guideline update group was convened with representation from the disciplines of otolaryngology-head and neck surgery, otology, neurotology, family medicine, audiology, emergency medicine, neurology, radiology, advanced practice nursing, and consumer advocacy. A systematic review of the literature was performed, and the prior clinical practice guideline on sudden hearing loss was reviewed in detail. Key Action Statements (KASs) were updated with new literature, and evidence profiles were brought up to the current standard. Research needs identified in the original clinical practice guideline and data addressing them were reviewed. Current research needs were identified and delineated.

RESULTS

The guideline update group made strong recommendations for the following: (KAS 1) Clinicians should distinguish sensorineural hearing loss from conductive hearing loss when a patient first presents with sudden hearing loss. (KAS 7) Clinicians should educate patients with sudden sensorineural hearing loss about the natural history of the condition, the benefits and risks of medical interventions, and the limitations of existing evidence regarding efficacy. (KAS 13) Clinicians should counsel patients with sudden sensorineural hearing loss who have residual hearing loss and/or tinnitus about the possible benefits of audiologic rehabilitation and other supportive measures. These strong recommendations were modified from the initial clinical practice guideline for clarity and timing of intervention. The guideline update group made strong recommendations against the following: (KAS 3) Clinicians should not order routine computed tomography of the head in the initial evaluation of a patient with presumptive sudden sensorineural hearing loss. (KAS 5) Clinicians should not obtain routine laboratory tests in patients with sudden sensorineural hearing loss. (KAS 11) Clinicians should not routinely prescribe antivirals, thrombolytics, vasodilators, or vasoactive substances to patients with sudden sensorineural hearing loss. The guideline update group made recommendations for the following: (KAS 2) Clinicians should assess patients with presumptive sudden sensorineural hearing loss through history and physical examination for bilateral sudden hearing loss, recurrent episodes of sudden hearing loss, and/or focal neurologic findings. (KAS 4) In patients with sudden hearing loss, clinicians should obtain, or refer to a clinician who can obtain, audiometry as soon as possible (within 14 days of symptom onset) to confirm the diagnosis of sudden sensorineural hearing loss. (KAS 6) Clinicians should evaluate patients with sudden sensorineural hearing loss for retrocochlear pathology by obtaining magnetic resonance imaging or auditory brainstem response. (KAS 10) Clinicians should offer, or refer to a clinician who can offer, intratympanic steroid therapy when patients have incomplete recovery from sudden sensorineural hearing loss 2 to 6 weeks after onset of symptoms. (KAS 12) Clinicians should obtain follow-up audiometric evaluation for patients with sudden sensorineural hearing loss at the conclusion of treatment and within 6 months of completion of treatment. These recommendations were clarified in terms of timing of intervention and audiometry and method of retrocochlear workup. The guideline update group offered the following KASs as options: (KAS 8) Clinicians may offer corticosteroids as initial therapy to patients with sudden sensorineural hearing loss within 2 weeks of symptom onset. (KAS 9a) Clinicians may offer, or refer to a clinician who can offer, hyperbaric oxygen therapy combined with steroid therapy within 2 weeks of onset of sudden sensorineural hearing loss. (KAS 9b) Clinicians may offer, or refer to a clinician who can offer, hyperbaric oxygen therapy combined with steroid therapy as salvage therapy within 1 month of onset of sudden sensorineural hearing loss.

DIFFERENCES FROM PRIOR GUIDELINE

Incorporation of new evidence profiles to include quality improvement opportunities, confidence in the evidence, and differences of opinion Included 10 clinical practice guidelines, 29 new systematic reviews, and 36 new randomized controlled trials Highlights the urgency of evaluation and initiation of treatment, if treatment is offered, by emphasizing the time from symptom occurrence Clarification of terminology by changing potentially unclear statements; use of the term sudden sensorineural hearing loss to mean idiopathic sudden sensorineural hearing loss to emphasize that >90% of sudden sensorineural hearing loss is idiopathic sudden sensorineural hearing loss and to avoid confusion in nomenclature for the reader Changes to the KASs from the original guideline: KAS 1-When a patient first presents with sudden hearing loss, conductive hearing loss should be distinguished from sensorineural. KAS 2-The utility of history and physical examination when assessing for modifying factors is emphasized. KAS 3-The word "routine" is added to clarify that this statement addresses nontargeted head computerized tomography scan that is often ordered in the emergency room setting for patients presenting with sudden hearing loss. It does not refer to targeted scans, such as temporal bone computerized tomography scan, to assess for temporal bone pathology. KAS 4-The importance of audiometric confirmation of hearing status as soon as possible and within 14 days of symptom onset is emphasized. KAS 5-New studies were added to confirm the lack of benefit of nontargeted laboratory testing in sudden sensorineural hearing loss. KAS 6-Audiometric follow-up is excluded as a reasonable workup for retrocochlear pathology. Magnetic resonance imaging, computerized tomography scan if magnetic resonance imaging cannot be done, and, secondarily, auditory brainstem response evaluation are the modalities recommended. A time frame for such testing is not specified, nor is it specified which clinician should be ordering this workup; however, it is implied that it would be the general or subspecialty otolaryngologist. KAS 7-The importance of shared decision making is highlighted, and salient points are emphasized. KAS 8-The option for corticosteroid intervention within 2 weeks of symptom onset is emphasized. KAS 9-Changed to KAS 9A and 9B. Hyperbaric oxygen therapy remains an option but only when combined with steroid therapy for either initial treatment (9A) or salvage therapy (9B). The timing of initial therapy is within 2 weeks of onset, and that of salvage therapy is within 1 month of onset of sudden sensorineural hearing loss. KAS 10-Intratympanic steroid therapy for salvage is recommended within 2 to 6 weeks following onset of sudden sensorineural hearing loss. The time to treatment is defined and emphasized. KAS 11-Antioxidants were removed from the list of interventions that the clinical practice guideline recommends against using. KAS 12-Follow-up audiometry at conclusion of treatment and also within 6 months posttreatment is added. KAS 13-This statement on audiologic rehabilitation includes patients who have residual hearing loss and/or tinnitus who may benefit from treatment. Addition of an algorithm outlining KASs Enhanced emphasis on patient education and shared decision making with tools provided to assist in same.

The use of hyperbaric oxygen therapy in acute hearing loss: a narrative review

INTRODUCTION

Acute hearing loss can have a major impact on a patient's life. This holds true for both acute acoustic trauma (AAT) and idiopathic sudden sensorineural hearing loss (ISSHL), two devastating conditions for which no highly effective treatment options exist. This narrative review provides the rationale and evidence for HBOT in AAT and ISSHL.

METHODS

Narrative review of all the literature available on HBOT in acute hearing loss, studies were retrieved from systematic searches on PubMed and by cross referencing.

DISCUSSION

First, the etiological mechanisms of acute hearing loss and the mechanism of action of HBOT were discussed. Furthermore, we have provided an overview of 68 studies that clinically investigated the effect of HBOT in the last couple of decades. For future studies, it is recommend to start as early as possible with therapy, preferably within 48 h and to use combination therapy consisting of HBOT and corticosteroids.

IMPLICATIONS FOR PRACTICE

HBOT has been used quite extensively for acute hearing loss in the last couple of decades. Based on the amount of studies showing a positive effect, HBOT should be discussed with patients (shared decision making) as optional therapy in case of AAT and ISSHL.

Therapeutic effect of Intra-Tympanic Dexamethasone-Hyaluronic Acid Combination in Sudden Sensorineural Hearing Loss

INTRODUCTION

Hearing loss is fairly a common disorder which is usually treated with corticosteroids via systemic administration and/or intra-tympanic injection. This study aimed to compare the effectiveness of intra-tympanic injections of dexamethasone with its combination with hyaluronic acid in patients with sudden sensorineural hearing loss.

MATERIALS AND METHODS

In this clinical trial, 40 patients were randomly assigned to two groups; in the first group, 20 patients received 2.4 mg intra-tympanic dexamethasone, while in the second group patients received injections of 2.4 mg of dexamethasone plus 2 mg of hyaluronic acid in combination. Patients in both groups were injected every other day to a total of three injections. The hearing status of patients was evaluated by pure tone audiometry (bone conduction threshold) before and 2 weeks after the intervention.

RESULTS

Assessment of hearing threshold before and after treatment in the two groups showed a significant difference between hearing thresholds at frequencies of 4,000 to 8,000 Hz (P<0.001). The difference at other frequencies was not meaningful; however, in general, we found a better therapeutic effect in patients who received the combination of dexamethasone and hyaluronic acid.

CONCLUSION

A combination of dexamethasone and hyaluronic acid in patients with sudden sensorineural hearing loss may be more effective than dexamethasone alone. Because hyaluronic acid lacks certain side effects, and also makes it possible to reduce the steroid dose, we recommend the use of this combination in the treatment of patients with sudden sensorineural hearing loss.