Combination Therapy (Intratympanic Dexamethasone + High-Dose Prednisone Taper) for the Treatment of Idiopathic Sudden Sensorineural Hearing Loss

Natural History of Untreated Idiopathic Sudden Sensorineural Hearing Loss

OBJECTIVE

Although corticosteroids and other treatments for idiopathic sudden sensorineural hearing loss (ISSNHL) have been described, understanding its prognosis without intervention provides valuable information for patient management. The objective of this study is to provide a comprehensive, quantitative statistical analysis of the natural history of untreated idiopathic sudden sensorineural hearing loss (ISSNHL).

STUDY TYPE AND DESIGN

A systematic review and meta-analyses.

METHODS

Two independent searches of PubMed, Scopus, Web of Science, and Cochrane Library databases up to June 30, 2022, were performed. Adults with idiopathic sudden sensorineural hearing loss who received placebo or were untreated and had audiometric outcome measures in all study types were reviewed. These data indicative of the natural history of ISSNHL were analyzed, as were study characteristics related to risk of bias. Heterogeneity as assessed via I2 and random effects analyses were performed.

RESULTS

Six studies meeting the inclusion criteria yielded 319 untreated patients whose natural history could be assessed. Heterogeneity among studies was moderate, with a variety of reported outcomes. A hearing improvement of at least 30 dB HL was observed in 36% (95% CI 0.28-0.44) of untreated patients, and of at least 10 dB HL was observed in 70% (95% CI 0.57-0.82) of untreated patients at 3 months. The mean hearing gain among untreated patients was 24.0 dB HL (95% CI 2.65-45.37) at 2-3 months.

CONCLUSIONS

The observed natural history of ISSNHL suggests that patients can regain some hearing without active treatment. In the absence of future studies collecting prospective natural history data from untreated or placebo-treated ISSNHL patients, the data presented here provide the best available historical control data for reconsideration of results in past ISSNHL studies, as well as a roadmap for design and interpretation of future ISSNHL treatment clinical trials. Furthermore, knowing there is a statistically significant mean hearing gain of 24.0 dB HL in the untreated/placebo group provides an ethical basis for future placebo study of ISSNHL. The current status on ISSNHL management calls for a multi-institutional, randomized, double-blind placebo-controlled trial with validated outcome measures to provide science-based treatment guidance. Laryngoscope, 134:S1-S15, 2024.

Primary versus salvage intratympanic steroid treatment for idiopathic sudden sensorineural hearing loss

Objective

The objective of this research is to compare primary and salvage intratympanic (IT) steroid treatments in terms of hearing outcomes in patients with idiopathic sudden sensorineural hearing loss (ISSNHL).

Methods

The patients were randomized into two (primary and salvage) groups. Both groups received systemic steroid treatment for 2 weeks. The primary group also received IT dexamethasone injection three times during the treatment period, whereas the salvage group received IT dexamethasone injection only if no or slight recovery was noted at the 2-week follow-up. If needed, salvage steroid injection was administered three times during the following 2 weeks. Hearing recovery was analyzed according to the modified American Academy of Otolaryngology-Head and Neck Surgery criteria.

Results

The degrees of hearing improvement at the 3-month follow-up were similar in the two groups. Compared with baseline, the pure-tone average values and speech discrimination scores improved by 38.45 ± 21.95 dB HL and 34.32% ± 30.55%, respectively, in the primary group and 36.80 ± 22.33 dB HL and 31.87% ± 27.88%, respectively, in the salvage group (p = .762 and .659, respectively). In addition, the complete or partial hearing recovery rates were also similar in the primary and salvage groups (67.7% vs. 73.3%, respectively; p = .780). In the salvage group, 18 patients required no IT steroid injection because they recovered after systemic steroid treatment.

Conclusion

Primary and salvage IT steroid treatments for ISSNHL led to similar outcomes. In summary, salvage IT steroid injection is recommended for patients with ISSNHL patients to prevent unnecessary IT injection.

Level of evidence

2.

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.

Analysis of the vestibular aqueduct development on the risk for suffering from idiopathic sudden sensorineural hearing loss

OBJECTIVE

Large vestibular aqueduct syndrome (LVAS) is one of the etiology of hearing loss. Clinically, we observed that the VA size of patients with idiopathic sudden sensorineural hearing loss (ISSNHL) did not meet the diagnostic criteria of VA enlargement, but there were individual variations. Through this study, we want to understand the VA development and explore its risk for suffering from ISSNHL.

METHODS

74 patients with ISSNHL were retrospectively reviewed in our department from June 2018 to September 2021. Meanwhile, 57 people with no ear diseases were randomly selected as the control group. All their clinical information were systematically collected. The axial thin-slice CT images of temporal bone were used to observe and measure the VA in ISSNHL and controls. ISSNHL were classified as different types and grades according to pure tone audiometry and the degree of hearing loss, respectively. Logistic regression analysis was adopted to evaluate the risk factors of different types and grades of ISSNHL.

RESULTS

The operculum morphology could be funnel-shaped, tubular and invisible, but they had no statistical difference in the morbidity of ISSNHL. The operculum width of the affected sides in the case group was significantly wider than that of the matched sides in the control group (0.84±0.35mm vs 0.68±0.34mm, p=0.009), but the midpoint width had no statistical difference (p=0.447). The operculum width was an independent risk factor for the total hearing loss type (p=0.036, OR=4.49, 95% CI=1.10-18.29), moderate (p=0.013, OR=17.62, 95% CI=1.82-170.95) and profound (p=0.031, OR=4.50, 95% CI=1.14-17.67) grade of ISSNHL. Hypertension was an independent risk factor for the severe grade (p=0.004, OR=12.44, 95% CI=2.19-70.64) of ISSNHL. Both the operculum width (p=0.048, OR=7.14, 95% CI=1.02-50.26) and hypertension (p=0.014, OR=6.73, 95% CI=1.46-30.97) were the risk factors for the flat type of ISSNHL. The midpoint width of the VA, gender, age, diabetes mellitus, hyperlipidemia, and plasma fibrinogen concentration had no significant effect on the risk for suffering from ISSNHL.

CONCLUSION

The development of the VA operculum is a risk factor for some types and grades of ISSNHL. Hypertension remained a risk factor for ISSNHL.

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.

Standardization of Outcome Measures for Intratympanic Steroid Treatment for Idiopathic Sudden Sensorineural Hearing Loss

OBJECTIVE

To identify variability in reported hearing outcomes for intratympanic (IT) steroid treatment of idiopathic sudden sensorineural hearing loss (ISSNHL) by comparing outcomes using the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) guideline with other published criteria.

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary otology practice.

PATIENTS

Patients with ISSNHL treated with IT steroid between April 2003 and December 2020.

INTERVENTIONS

IT steroid injection and audiometric evaluation.

MAIN OUTCOME MEASURES

1) Rates of full, partial, or no recovery using the AAO-HNS guideline versus other reported criteria, and 2) correlation analyses of demographic and clinical variables with response to IT steroid.

RESULTS

Using AAO-HNS reporting criteria, full recovery of the pure-tone average was noted in 25.68% of patients. Applying eight other published outcomes criteria to this patient cohort classified full recovery in 14.87 to 40.54% of patients. Similarly, AAO-HNS criteria classified "no recovery" in 51.35% of our patients, whereas applying the other reported criteria showed an average rate of 62.16% no recovery and as high as 82.43% of patients without recovery. Younger age ( p = 0.003; effect size, 0.924) and IT injection within a week of onset ( p < 0.001; effect size, 1.099) positively correlated with full recovery. There was no impact of prior or concurrent oral steroids, or number of steroid injections on outcome.

CONCLUSION

Great variability exists in the literature for assessment of IT steroid outcomes in ISSNHL. Standard reporting of outcomes as per the AAO-HNS SSNHL guideline is recommended to consistently characterize IT steroid efficacy and allow comparison across studies.

Idiopathic sudden sensorineural hearing loss: A critique on corticosteroid therapy

Idiopathic sudden sensorineural hearing loss (ISSNHL) is a condition affecting 5-30 per 100,000 individuals with the potential to significantly reduce one's quality of life. The true incidence of this condition is not known because it often goes undiagnosed and/or recovers within a few days. ISSNHL is defined as a ≥30 dB loss of hearing over 3 consecutive audiometric octaves within 3 days with no known cause. The disorder is typically unilateral and most of the cases spontaneously recover to functional hearing within 30 days. High frequency losses, ageing, and vertigo are associated with a poorer prognosis. Multiple causes of ISSNHL have been postulated and the most common are vascular obstruction, viral infection, or labyrinthine membrane breaks. Corticosteroids are the standard treatment option but this practice is not without opposition. Post mortem analyses of temporal bones of ISSNHL cases have been inconclusive. This report analyzed ISSNHL studies administering corticosteroids that met strict inclusion criteria and identified a number of methodologic shortcomings that compromise the interpretation of results. We discuss the issues and conclude that the data do not support present treatment practices. The current status on ISSNHL calls for a multi-institutional, randomized, double-blind trial with validated outcome measures to provide science-based treatment guidance.

The Impact of Intratympanic Steroid Dosage on Hearing Recovery in Sudden Sensorineural Hearing Loss

OBJECTIVE

To investigate how dexamethasone dosage impacts intratympanic steroid therapy (IST) for treatment of sudden sensorineural hearing loss (SSNHL).

STUDY DESIGN

Retrospective review.

METHODS

Inclusion criteria identified subjects who received IST between January 1, 2010 and June 1, 2020 for iSSNHL. Subjects with Meniere's disease, autoimmune inner ear disease, subjects who received injections of non-dexamethasone steroid formulations, and subjects with missing audiogram data were excluded. Subjects were stratified by dexamethasone dosage: low-dose (10 mg/ml) versus high-dose (24 mg/ml), time-to-treatment and oral corticosteroid use. Outcome measures included post-treatment improvement in 4-frequency pure tone average (4F-PTA [500, 1000, 2000,4000 Hz]), low- and high-frequency PTA (250-1000 Hz and 2000-8000 Hz, respectively).

RESULTS

Of the 55 included subjects (50.9% male, mean age 48.9 ± 16.4 years), 31 received high-dose while 24 received low-dose injections. 90.9% of subjects were treated with oral steroids prior to or during IST. No significant differences in hearing outcomes were observed between low- and high-dose cohorts or when stratifying by oral steroid use. Time-to-treatment analysis comparing ≤1 month (67.3%) versus >1 month (32.7%) groups demonstrated a significant improvement in post-treatment 4F-PTA (P = .01) in the ≤1 month group.

CONCLUSIONS

Hearing recovery was not significantly different between the 10 mg/ml versus 24 mg/ml doses of intratympanic dexamethasone, suggesting that steroid dose may not impact the efficacy of IST. A shorter time-to-treatment was observed to be favorable for hearing improvement.

Combined Intratympanic and Systemic Steroid Therapy in Sudden Sensorineural Hearing Loss

Sudden sensorineural hearing loss (SSNHL) is a true otological emergency that must be diagnosed and treated immediately. This study aimed to assess the efficacy of treatment with intratympanic dexamethasone (ITD) plus oral prednisolone with that of oral prednisolone or intratympanic dexamethasone alone and to determine factor affecting treatment outcome for SSNHL. Forty-five patients with SSNHL that had been present within 2 weeks of onset of symptoms were included in this prospective case control study. Patients were allocated to three different groups. Patients in group A were treated with oral prednisolone 1 mg/kg/d full dose 14 days then tapered over next 14 days. Patients in group B were treated with ITD 0.5 ml (4 mg/ml) every 7 days for a total 4 weeks along with oral prednisolone 1 mg/kg/d in tapering dose for 4 weeks. Patients in group C were got ITD 0.5 ml (4 mg/ml) every 7 days for a total 4 weeks. Audiogram was performed before each subsequent injection and at completion of treatment course. Among all participants, 22 patients (48.89%) showed improvement in pure tone audiogram to within 50% of pre- sudden hearing loss. On comparing the results of group A, B and C, there were no statistically significant difference with each other (p value 0.185). The mean audiometric gain was 37.71 dB in recovered cases. The combination therapy of intratympanic dexamethasone and oral steroid is more effective in comparison with intratympanic or oral steroid alone in the treatment of SSNHL as the patients benefitted from the therapeutic effects of both local and systemic steroids.

Intratympanic Corticosteroid Administration as a Primary Treatment for Idiopathic Sudden Sensorineural Hearing Loss

A retrospective review of 34 patients was done who had idiopathic sudden sensorineural hearing loss and were administered intratympanic corticosteroid in the form of dexamethasone (4 mg/ml). The results were interpreted based on pure tone audiometry and Speech discrimination score of the patient before commencing the treatment and after the treatment.

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.

Effects of oral N-acetylcysteine combined with oral prednisolone on idiopathic sudden sensorineural hearing loss

BACKGROUND

Idiopathic sudden sensorineural hearing loss (ISSNHL) is an acute condition that presents with sudden hearing loss, for which steroids remain the main treatment. N-acetylcysteine (NAC), as a precursor of glutathione, can reduce the production of reactive oxygen species to protect hair cells in the inner ear from damage. However, data regarding the therapeutic outcomes of oral steroid combined with oral NAC for ISSNHL are still limited. This study was performed to investigate this issue.

METHODS

Between June 2016 and October 2021, 219 patients (219 ears) diagnosed with ISSNHL and treated with oral prednisolone were enrolled in this retrospective study. Oral NAC was prescribed to 94 of these patients (NAC group) but not to the remaining 125 patients (non-NAC group). The clinical and audiological findings were assessed.

RESULTS

The NAC group showed a mean hearing level gain of 29.5 ± 21.8 dB, speech reception threshold (SRT) gain of 26.2 ± 34.4 dB, and speech discrimination score (SDS) gain of 25.5 ± 30.4%. Although the NAC group had better mean hearing level, SRT, and SDS gains than the non-NAC group, the differences were not statistically significant (all P > .05). The only significant difference between the NAC and non-NAC groups was the posttreatment pure tone audiometry (PTA) thresholds at 8 kHz, which were 54.2 ± 24.4 and 60.9 ± 34.1 dB, respectively (P = .046).

CONCLUSIONS

This study demonstrated the effect of oral steroid combined with oral NAC for ISSNHL. Both the NAC and non-NAC groups showed obvious improvement in all PTA thresholds, as well as mean hearing level, SRT, and SDS gains. The NAC group showed significantly better PTA performance at a high frequency (8 kHz) than the non-NAC group. Therefore, for oral treatment of ISSNHL, we advocate concurrent use of oral prednisolone and oral NAC.

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.

Intratympanic corticosteroid injection as a first-line treatment of the patients with idiopathic sudden sensorineural hearing loss compared to systemic steroid: A systematic review and meta-analysis

OBJECTIVES

The current study aimed to investigate if there is a difference in the use of intratympanic steroid therapy (IST), compared to systemic steroid treatment (SST), as an initial treatment for patients with sudden sensorineural hearing loss (SSNHL) by a meta-analysis design performed on the mean pure-tone average (PTA) improvement and the complete recovery rate.

METHODS

A systematic literature review was performed on randomized controlled trials published from 1990 to August 2020 in some databases including PubMed/MEDLINE, Scopus, Embase, Web of Science, Cochrane library/CENTRAL, Ovid, ProQuest, Google Scholar, and clinical trials.gov. The primary outcomes of interest were pure-tone average improvement and complete recovery rates.

RESULTS

Six eligible studies with 496 patients (250 patients in the IST group and 246 subjects in the SST group) were included in this study. The pooled standardized mean difference of the PTAs was estimated as 0.07 (95% CI = -0.10 to 0.25; I² = 0.0%, P = 0.668), and the pooled odds ratio of complete recovery rate was obtained as 1.00 (95% CI = 0.66 to 0.151; I² = 31.6, P = 0.199). Moreover, the pooled standardized mean difference of pure-tone average for the intratympanic steroid treatment group compared to the patients with oral steroid treatment was 0.07 (95% CI = -0.12 to 0.26; I² = 0.0%, P = 0.526).

CONCLUSIONS

The current study demonstrated that the effect of intratympanic injection of corticosteroid, as a first-line treatment, is not statistically different from the systemic route in improving the hearing outcomes among patients with SSNHL.

Intratympanic Versus Systemic Steroid Therapy for Idiopathic Sudden Hearing Loss: A Systematic Review and Meta-Analysis

Idiopathic sudden sensorineural hearing loss (ISSHL) is a common condition characterized by hearing threshold reduction, most often of unknown causes. The patient experiences a sudden reduction of the hearing threshold in one or both ears. Steroids are the mainstream of the treatment. This study aims to investigate the effectiveness of intratympanic steroid administration compared with systemic administration and the combination of the two steroid treatments in the hearing recovery of patients with idiopathic sudden sensorineural hearing loss. We searched electronic databases such as PubMed, ScienceDirect, CINAHL, Cochrane (Central), Ovid, and Medline from August 31, 2021, to November 31, 2021, and from February 5 to 10, 2022. We included 12 randomized controlled trials (RCTs) and performed a meta-analysis comparing the efficiency in the hearing recovery of intratympanic versus systemic steroid treatment, systemic versus combined, and intratympanic versus combined steroid treatment. The results of the intratympanic versus systemic steroid therapy comparison showed no actual difference in efficiency and no statistical significance (odds ratio: 1.07 (Mantel-Haenszel (M-H), fixed, 95% confidence interval (CI): 0.76-1.51)). Systemic steroid treatment was inferior to combined steroid treatment and was the only outcome with statistical significance (odds ratio: 0.55 (M-H, fixed, 95% CI: 0.38-0.80)). Intratympanic steroid treatment was inferior to combined steroid treatment, although the results were not statistically significant (odds ratio: 0.65 (M-H, fixed, 95% CI: 0.37-1.16)). In conclusion, systemic steroid therapy was inferior to combined steroid therapy. The comparison of intratympanic with systemic therapy and intratympanic with combined therapy showed no statistical significance. Further research is needed with more RCTs, and side effects should be considered.

[Corticosteroids for acute sensorineural hearing loss treatment. The contemporary state of problem. Literature review. Part 1]

The article presents modern literary data relating to the expediency of the purpose of glucocorticosteroids in sudden sensorineural hearing loss (SSHL) of various genes. In detail, the radar molecular mechanisms and the anatomo-physiological features of the exposure to the inner ear, side effects, the introduction methods, their comparative efficacy and modern schemes of the SSHL.

Comparison of Drug Availability in the Inner Ear After Oral, Transtympanic, and Combined Administration

Although combination of oral and transtympanic drug therapy (CT) has been proved more effective and safer for idiopathic sudden sensorineural hearing loss (ISSNHL) by some clinical trials, there are few laboratory researches on the pharmacokinetics in the inner ear following CT on account of structural limitations of the inner ear. The aim of the present study was to investigate the pharmacokinetic behaviors of CT in the inner ear of mice. Eighteen transgenic GFAP-Luc mice which express luciferase in cochlear spiral ganglion cells were divided into oral administration (OR) group, transtympanic injection route (TT) group and CT group, and luciferin was delivered into the inner ear of these mice through oral, transtympanic or combined routes, respectively. A new in vivo imaging system was used to observe luciferin/luciferase signals and the compare the pharmacokinetics of different administration routes in the inner ear of mice. Bioluminescence signals were observed in the inner ear 3.3 ± 2.6 min after CT, significantly earlier than that of OR group (15.8 ± 7.4 min). CT owned the longest reaching-peak time and largest area under the curve (AUC) among three groups. Compared to TT, CT had longer biological half-life and higher AUC value, but did not displayed stronger peak value. There were significant differences in the peak values between OR group and TT group and between OR group and CT group. This study suggests that the OR route is less effective than the TT or CT route, and combination of OR and TT can deliver more drugs into the inner ear and confer a longer therapeutic window, but cannot increase drug intensity.

Biologics for Immune-Mediated Sensorineural Hearing Loss

Immune-mediated hearing losses include autoimmune inner ear disease, sudden sensorineural hearing loss, and Meniere's disease. Standard therapy for an acute decline in hearing is timely use of corticosteroids. Although 60% to 70% of patients are initially corticosteroid-responsive, that responsiveness is lost over time. In corticosteroid-resistant patients, increased expression of interleukin (IL)-1 is observed, and these patients may benefit from IL-1 inhibition. Autoinflammatory diseases are characterized by dysregulation of the innate immune response, clinically include sensorineural hearing loss, and benefit from IL-1 inhibition, thereby further establishing the relationship of IL-1 with immune-mediated sensorineural hearing loss.

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 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.

Combination of Pulse Steroid with Intratympanic Injections in Sudden Sensorineural Hearing Loss

Introduction

Oral prednisolone was suggested as the first step to treat idiopathic sudden sensorineural hearing loss (ISSHL). This study aimed to investigate the effect of pulse therapy with methylprednisolone and intratympanic methylprednisolone, compared to traditional oral prednisolone therapy on patients with ISSHL.

Material and Methods

This randomized control trial included an experimental group receiving 500 mg intravenous methylprednisolone for three sequential days, followed by 1 mg/kg oral prednisolone for 11 days, and intratympanic Depo-Medrol four times twice a week. On the other hand, the control group received 1 mg/kg oral prednisolone for 14 days. Hearing change was assessed through pure tone audiometry. Subsequently, hearing recovery was investigated and analyzed in this study.

Result

This study was conducted on 51 patients who were divided into two groups of experimental (n=26) and control (n=25). The result revealed no significant difference between the two groups in terms of hearing improvement (P=0.28).

Conclusion

This revealed no added benefit in pulse steroids combined with intratympanic injections in cases with sudden hearing loss.

Prediction of hearing outcomes by auditory steady-state response in patients with sudden sensorineural hearing loss

BACKGROUND

There has been no report on the predictive value of auditory steady-state response (ASSR) in the hearing prognosis of sudden sensorineural hearing loss (SSNHL).

AIMS/OBJECTIVES

To investigate whether ASSR can be a prognostic indicator of hearing outcome in patients with SSNHL after systemic steroid treatment.

MATERIAL AND METHODS

Fifty-three patients with unilateral mild to severe SSNHL (≤90 dB HL at 0.5k, 1k, 2k, and 4 kHz, 4FA) were included. All patients received systemic high dose steroid therapy within one month after onset. The difference between the threshold levels measured by ASSR and PTA on the same day [ASSR - PTA] was calculated. The hearing recovery (HR) was defined as a < 30 dB HL of final degree of hearing loss and a > 15 dB HL of hearing gain.

RESULTS

The HR (+) group showed significantly worse ASSR predicted threshold than pure-tone threshold in univariate (t(51) = 2.412, p = .020) and multivariate analysis (OR 0.910, p = .012). The [ASSR - PTA] threshold showed significantly moderate correlation with hearing gain (r = -0.303, p = .028).

CONCLUSIONS

Worse ASSR predicted threshold than pure-tone threshold predicted poor hearing outcome after systemic steroid treatment in mild to severe unilateral SSNHL.

Predicting hearing recovery following treatment of idiopathic sudden sensorineural hearing loss with machine learning models

PURPOSE

Idiopathic sudden sensorineural hearing loss (ISSHL) is an emergency otological disease, and its definite prognostic factors remain unclear. This study applied machine learning methods to develop a new ISSHL prognosis prediction model.

MATERIALS AND METHODS

This retrospective study reviewed the medical data of 244 patients who underwent combined intratympanic and systemic steroid treatment for ISSHL at a tertiary referral center between January 2015 and October 2019. We used 35 variables to predict hearing recovery based on Siegel's criteria. In addition to performing an analysis based on the conventional logistic regression model, we developed prediction models with five machine learning methods: least absolute shrinkage and selection operator, decision tree, random forest (RF), support vector machine, and boosting. To compare the predictive ability of each model, the accuracy, precision, recall, F-score, and the area under the receiver operator characteristic curves (ROC-AUC) were calculated.

RESULTS

Former otological history, ear fullness, delay between symptom onset and treatment, delay between symptom onset and intratympanic steroid injection (ITSI), and initial hearing thresholds of the affected and unaffected ears differed significantly between the recovery and non-recovery groups. While the RF method (accuracy: 72.22%, ROC-AUC: 0.7445) achieved the highest predictive power, the other methods also featured relatively good predictive power. In the RF model, the following variables were identified to be important for hearing-recovery prediction: delay between symptom onset and ITSI or the initial treatment, initial hearing levels of the affected and non-affected ears, body mass index, and a previous history of hearing loss.

CONCLUSIONS

The machine learning models predictive of hearing recovery following treatment for ISSHL showed superior predictive power relative to the conventional logistic regression method, potentially allowing for better patient treatment outcomes.

Intratympanic vs Systemic Corticosteroids in First-line Treatment of Idiopathic Sudden Sensorineural Hearing Loss: A Systematic Review and Meta-analysis

Importance

To our knowledge, evidence-based recommendations on the intratympanic vs systemic administration of corticosteroids for the treatment of idiopathic sudden sensorineural hearing loss remain unestablished, and contradictory conclusions have been reported in previous meta-analyses.

Objective

To compare recovery from idiopathic sudden sensorineural hearing loss based on systemic, intratympanic, or a combined treatment with corticosteroids as first-line treatment.

Data Sources

We adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. We searched PubMed, Embase, OvidSP, CINAHL, and Cochrane Library from January 1, 1966, to July 1, 2018. This study was registered in the International Prospective Register of Systematic Reviews (CRD42018109314).

Study Selection

We included randomized studies. Included studies must have excluded identifiable causes. Corticosteroids must have been administered solitarily. We excluded studies that did not define hearing loss as a minimum 30 dB within 72 hours.

Data Extraction and Synthesis

We identified 170 titles, of which 56 (32.9%) were eligible for full-text screening. We independently extracted data. We applied a fixed-effects model to investigate our objectives.

Main Outcomes and Measure

We aimed to (1) estimate the difference in mean pure tone average (PTA) gain in decibels from intratympanic treatment vs systemic treatment and (2) investigate odds ratios for recovery between the different treatment groups.

Results

We included 7 eligible studies. A total of 710 patients were allocated to receive either intratympanic treatment (IT group, 235 [33%]), systemic treatment (ST group; 325 [46%]) or combined intratympanic and systemic treatment (CB group; 150 [21%]). The PTA was measured by taking the mean of 4 frequencies: 4 studies measured at 500, 1000, 2000, and 3000 Hz and 3 studies measured at 500, 1000, 2000, and 4000 Hz. The ST group had a 2.01-dB higher PTA gain (95% CI, -5.61 dB to 1.59 dB; P = .96; I2 = 0%) compared with the IT group and the odds for achieving complete recovery was not significantly different at an odds ratio of 0.94 (95% CI, 0.61 to 1.44; P = .19; I2 = 34.5%). For the CB group vs the ST group, the odds ratio was 1.11 (95% CI, 0.68 to 1.82; P = .75; I2 = 0%). The analysis of the CB group vs IT group comprised only 2 studies.

Conclusions and Relevance

This study does not suggest that corticosteroid delivered intratympanically is more beneficial than systemic treatment in the case of moderate to severe idiopathic sudden sensorineural hearing loss. There were no indications that combined treatment was associated with improved hearing outcomes compared with either systemic or intratympanic treatment.

Early hearing improvement predicts the prognosis of idiopathic sudden sensorineural hearing loss

PURPOSE

To determine pre- and post-treatment factors that are useful for predicting the prognosis of hearing improvement in idiopathic sudden sensorineural hearing loss (ISSHL).

METHODS

This retrospective study included 332 patients with ISSHL. Patients received intravenous steroid treatment (prednisolone sodium succinate; 120 mg/day followed by dose tapering). Complete recovery of hearing levels was defined as a final pure-tone audiometry of ≤ 20 dB HL or the same level as the contralateral ear. Patients' age; sex; side of hearing loss; initial hearing level; days from onset to treatment; presence of vertigo, diabetes, and hypertension; and hearing improvement on days 3-4 and 6-7 after treatment initiation were analyzed as potential prognostic factors.

RESULTS

Overall, 109 patients (32%) had complete recovery. Results of the multivariate logistic regression model identified age (odds ratio [OR] = 0.974), initial hearing level (OR = 0.949), vertigo (OR = 0.409), and hearing improvement on days 6-7 after treatment initiation (OR = 1.11) as significant independent predictors of complete recovery. Age ≥ 60 years, initial hearing level ≥ 72.5 dB HL, and vertigo contributed to poor prognosis. Patients without these three factors and a hearing improvement of ≥ 10 dB HL on days 6-7 post-treatment had a complete recovery rate of 80%. Only 1.5% of the patients with 2-3 of these factors and a hearing improvement of < 10 dB HL on days 6-7 after treatment initiation achieved complete recovery.

CONCLUSION

Age, initial hearing level, vertigo, and hearing improvement on days 6-7 after treatment initiation were independent predictors of hearing recovery in ISSHL.

Trends in Use and Timing of Intratympanic Corticosteroid Injections for Sudden Sensorineural Hearing Loss

OBJECTIVE

Oral corticosteroids are treatment mainstays for idiopathic sudden sensorineural hearing loss (SSNHL). Recent studies suggest that intratympanic (IT) steroid injections may be effective as an alternate or adjunctive therapy. We sought to investigate nationwide trends in treatment patterns for SSNHL.

STUDY DESIGN

Retrospective cross-sectional study.

SETTING

A large nationwide health care claims database spanning 2007 to 2016.

METHODS

Patients with SSNHL were identified from the IBM Watson Health MarketScan Database. Multivariable logistic, linear, and Cox regression were used for demographic- and comorbidity-adjusted analyses.

RESULTS

Overall, 19,670 patients were included. Between 2007 and 2016, use of oral corticosteroids alone decreased (83.6% to 64.6%, P < .001), while use of IT corticosteroids alone and combination IT-oral corticosteroids increased (IT only, 7.9% to 15.1%, P = .002; IT-oral, 8.5% to 20.4%, P < .001). During the study period, time to treatment initiation decreased for both administration modalities, though more dramatically for IT corticosteroids (IT, 124.0 to 10.6 days, P < .001; oral, 42.6 to 12.7 days, P < .001). In patients receiving both IT and oral corticosteroids, concurrent first-line use increased (25.2% to 52.8%, P < .001). Repeat injections have also become more common but may raise risk of persistent tympanic membrane perforations (vs no injection; hazard ratio [first injection] = 7.95, 95% CI = 5.54-11.42; hazard ratio [fifth or higher injection] = 17.47, 95% CI = 6.93-44.05).

CONCLUSION

SSNHL management increasingly involves early IT steroids as an alternative or adjunctive option to oral steroids. Use of repeat IT corticosteroid injections has also increased but may raise risk of persistent tympanic membrane perforations and subsequent tympanoplasty. Future decision analysis and cost-effectiveness studies are necessary to identify an optimal care pattern for SSNHL.

Idiopathic Sudden Sensorineural Hearing Loss in Children: A Systematic Review and Meta-analysis

Objective

Idiopathic sudden sensorineural hearing loss (ISSNHL) is uncommon in children, and its treatment and outcome are debated. We aimed to critically review evidence in the literature about treatment options and functional outcomes of pediatric ISSNHL. Additionally, we performed a meta-analysis of the results of combined systemic-intratympanic steroid therapy versus solely systemic treatment.

Data Sources

A search was run in the PubMed, Scopus, and Google Scholar databases.

Review Methods

Included articles were original ISSNHL case series, written in English, with a population age ranging from 2 to 19 years. Other study types (single case reports, editorials, and reviews) and case series with known etiology of sudden hearing loss were excluded. Descriptive data of patients, treatments, outcomes, and possible prognostic factors were extracted and recorded for every included study.

Results

Twelve articles (7 cohort and 5 case-control studies) met all the selection criteria. Based on only the studies that provided sufficient data about clinical outcome, the pooled overall recovery rate was 67.91% (95% CI, 58.34%-77.48%). No studies showed a significant difference between systemic steroid and combined systemic-intratympanic steroid. The pooled odds ratio for combined systemic-intratympanic steroid versus systemic steroid alone was 0.90 (95% CI, 0.36-2.27) based on a random effects model, ruling out any significant difference between these treatment options.

Conclusions

The results of our meta-analysis did not support combination therapy more than systemic steroid alone. Further prospective clinical trials are necessary to establish evidence-based therapies.

Steroid Administration Approach for Idiopathic Sudden Sensorineural Hearing Loss: A National Survey in China

OBJECTIVE

To optimize a protocol for the steroid administration approach for idiopathic sudden sensorineural hearing loss (ISSNHL) in China.

METHODS

A questionnaire was distributed to otolaryngologists. The data on demographics, indications for first-line and salvage treatment, such as intratympanic administration of steroids (ITS) and postauricular steroids (PAS), and procedures were analyzed.

RESULTS

74 respondents used oral steroids, 112 used intravenous injections, 10 used ITS and 6 used PAS as a monotherapy for first-line treatment, and 135 used ITS or PAS in conjunction with oral or intravenous injection as a first-line treatment. Of the 249 respondents who used ITS, 97.19% adopted it as salvage therapy. The most commonly used steroid was 0.5 ml dexamethasone at 5 mg/ml and the most common side effect was pain. Of the 174 respondents who used PAS, 94.25% used it as salvage therapy. The most commonly used steroid was 0.5 ml methylprednisolone mixed with 0.5 ml lidocaine.

CONCLUSIONS

The obtained data suggested that intravenous injection of steroids was the most popular treatment for ISSNHL and that ITS or PAS were used as a salvage treatment in China.

Clinical Features and Hearing Outcomes of Sudden Sensorineural Hearing Loss in Diabetic Patients

Background and Objectives

This study aimed to evaluate the clinical features and the clinical factors associated with prognosis of sudden sensorineural hearing loss (SSNHL) in diabetic patients.

Subjects and Methods

Forty-nine diabetic with unilateral SSNHL were retrospectively included. All patients received systemic high dose steroid therapy within one month after onset and had more than one month of follow-up audiogram. The basic characteristics of the patients, initial and follow-up audiograms, laboratory data, and methods of steroid treatment were collected.

Results

Compared to reference values in healthy subjects, 79%, 55%, and 45% of the patients had higher values of mean neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), and lymphocyte-monocyte ratio (LMR), respectively. Older patients had significantly less degree of hearing loss, but they also had significantly worse hearing thresholds in the unaffected ear. After steroid treatment, less than half patients (47%) showed hearing recovery. Simultaneous intratympanic dexamethasone (ITD) injections with systemic steroid did not confer an additional hearing gain or an earlier recovery rate in diabetic patients with SSNHL. In the multivariate analysis, initial hearing thresholds of affected ear and timing of steroid treatment were significantly associated with hearing prognosis in diabetic patients with SSNHL.

Conclusions

Diabetic patients with SSNHL tended to have increased NLR, LMR, and PLR, which are reported to be associated with microvascular angiopathy. Simultaneous ITD injections to improve hearing recovery in diabetic patients with SSNHL seems unnecessary.

Comparing the Efficiencies of Hyperbaric Oxygen Therapy and Intratympanic Steroid Treatment for Sudden Hearing Loss

OBJECTIVES

To compare the efficiencies of hyperbaric oxygen therapy (HBOT) and intratympanic steroid (ITS)treatment for idiopathic sudden sensorineural hearingloss (ISSHL).

MATERIALS AND METHODS

A total of 136 patients who were treated for ISSHL were reviewed fromthemedical records. All of the patients were given systemic steroid therapy (SST). Among them,33patients received HBOT and 36 patients received ITS treatment following SST. The starting time to treatment, risk factors, hearing level, hearing gain (HG), and recovery rate were evaluated from retrospectiverecords.

RESULTS

No substantial change in HG was observed for either the HBOT or ITS treatment cohort (p>0.05). But the time to recovery was higher in the ITS treatment cohort (40%) than in theHBOT cohort (17%). The starting time to ITS treatment was 4 days (range: 1-30) and that to HBOT was 8 days (range:3-30). There was a significant difference in the starting time to treatment (Mann-Whitney U-test, p=0.043). Also, hearing loss in the HBOT group was significantly higher than in the ITS treatment group. A significant difference was observed before and after ITS treatment (p<0.05).

CONCLUSION

In patients compared with late-onset treatment, ITS may be more effective than HBO after SST failure. It can be used as salvage therapy in patients with ISSHL who are unresponsive to a primary systemic steroid. We observed that HBOT didnot improve results when it was started late. Therefore, more studies that include both ITS treatment and HBOTas anearly treatment option are needed.

The Outcome of Prompt Concomitant Single-Dose High-Concentration Intratympanic and Tapered Low-Dose Oral Systemic Corticosteroid Treatment for Sudden Deafness

OBJECTIVES

To investigate the efficacy of prompt concomitant corticosteroid treatment with single application of high-concentration intratympanic (IT) dexamethasone and tapered low-dose systemic methylprednisolone of an idiopathic sudden sensorineural hearing loss (ISSNHL).

MATERIALS AND METHODS

Between September 2017 and September 2019, 86 adult patients met the criteria for the diagnosis of ISSNHL at baseline evaluation. The patients received immediate concomitant treatment with single high-concentration (24 mg/mL) IT dexamethasone and low-dose (48 mg) oral methylprednisolone for 1 week followed by tapered doses. Improvement in pure-tone average (PTA) and word recognition score (WRS) was determined after 1 and 6 months.

RESULTS

A total of 63 patients met the requirements for the analysis. PTA improved in 71% and WRS improved in 59% of patients with ISSNHL. PTA and WRS were statistically significantly different at different time points during the intervention (p<0.0005). Hearing improved in all measured frequencies from 125 to 8000 Hz until the second follow-up. In 65.4% of patients with tinnitus, the WRS has improved compared with 27.3% without tinnitus (p<0.05). In 69.2% of patients without vertigo, the WRS has improved compared with 41.7% with vertigo (p<0.05).

CONCLUSION

Prompt concomitant single high-concentration IT and low-dose systemic corticosteroid treatment is efficient in recovering hearing loss and speech discrimination in ISSNHL. Tinnitus positively predicts hearing outcome. Vertigo negatively predicts speech discrimination recovery.

Should air travel be avoided shortly after an idiopathic sudden sensorineural hearing loss?

Introduction: The effect of air travel on the recovery rate after idiopathic sudden sensorineural hearing loss (ISSNHL) has not been established. The advice to avoid flights is essentially based upon conjecture.Objectives: To analyze the recovery rate of patients who traveled by air shortly after they were treated for ISSNHL.Materials and methods: The hospital records of 115 newly diagnosed adult patients with unilateral ISSNHL were retrospectively collected. Included were patients who traveled by air within 90 days since the ISSNHL occurrence. The treatment protocol included oral prednisone and intratympanic dexamethasone injection when indicated. Audiograms performed upon presentation and 90 days later were compared.Results: Twelve patients were included (median age 45.5 years). The median treatment delay was 3 days. The average time from the ISSNHL to air-travel was 37 days, and the average air-travel distance was 13,362 km. The degree of HL was moderate, moderately severe, and severe (4 patients each). Seven patients (58%) underwent full recovery. No patients experienced further deterioration of their audiometric results after air-travel.Conclusions: This study does not support the avoidance of air-travel after ISSNHL.Significance: This study is the first to investigate the effect of air-travel on ISSNHL recovery rates, a clinical question that rises commonly.

Potential benefits of salvage intratympanic dexamethasone injection in profound idiopathic sudden sensorineural hearing loss

PURPOSES

To compare hearing recovery levels after initial treatment or salvage intratympanic dexamethasone injection (ITDI), and to find the prognostic factor on salvage ITDI therapy in profound ISSNHL.

METHODS

We retrospectively reviewed 115 patients with profound ISSNHL. All patients were treated with combination or systemic steroid therapy as the initial treatment. Next, we used salvage ITDI therapy on patients who showed slight or no improvement according to Siegel's criteria. To find the prognostic factors for the effectiveness of salvage ITDI therapy, we analyzed clinical data, such as, age, sex, vertigo, symptom duration, diabetes, hypertension, initial PTA, pre-salvage PTA, and treatment methods, using multiple regression analyses.

RESULTS

The rate of serviceable hearing recovery were 10.4% (12/115) in the initial-treatment group and 20.4% (21/103) in the salvage group. The difference was statistically significant (p = 0.041). Pre-salvage PTA, diabetes mellitus, and symptom duration were affective factors for the effectiveness of salvage ITDI therapy in profound ISSNHL refractory to initial treatment, with odds ratios of 1.169 (95% confidence interval, 1.088-1.256), 0.069 (95% confidence interval, 0.005-0.889), and 9.242 (95% confidence interval, 1.079-79.146).

CONCLUSIONS

Salvage therapy should be considered for profound ISSNHL, which is expected to result in poor prognosis or hearing recovery: ITSI therapy might be an effective treatment as salvage therapy.

Efficacy of Various Corticosteroid Treatment Modalities for the Initial Treatment of Idiopathic Sudden Hearing Loss: A Prospective Randomized Controlled Trial

OBJECTIVE

To evaluate the efficacy of systemic and intratympanic steroid treatment in patients with idiopathic sudden sensorineural hearing loss (ISSNHL).

METHODS

Ninety patients who met the inclusion criteria were randomly divided into 3 groups (n = 30 per group). Group I patients were given oral methylprednisolone (MEPD) tablets, group II received intravenous MEPD injection, and group III received intratympanic MEPD injection. Pure-tone average (PTA) hearing threshold was recorded before and after treatment as well as 1 month later. The general efficacy rate was the ratio of patients whose hearing improved by >10 dB in each group.

RESULTS

Thirty-two of the 60 patients (53.3%) in groups I and II together showed a hearing improvement of >10 dB hearing level (HL) in the pure-tone audiogram, compared to 21 patients (70%) in group III, respectively. The mean improvements were 16.1, 14.3, and 21.6 dB HL measured in Groups I, II, and III, respectively. Both the general efficacy rate and hearing improvement were significantly greater in group III than in groups I and II.

CONCLUSIONS

Our study showed that intratympanic injection rendered better treatment efficacy than systemic administration.

Intratympanic steroid injection for sudden sensorineural hearing loss: Impact of injection interval on therapeutic efficacy

OBJECTIVE

To compare the effect of injection time intervals of intratympanic (IT) dexamethasone (DEX) in patients with idiopathic sudden sensorineural hearing loss (ISSNHL).

METHODS

Seventy-five adults with ISSNHL were grouped into four groups according to the IT DEX interval. In addition to concurrent oral steroid medication for two weeks, patients received IT DEX injections every 1, 2, 3, and four days, respectively. (Group 1, Group 2, Group 3, and Group 4). We evaluated the treatment outcomes according to modified criteria from "Clinical Practice Guideline: Sudden Hearing Loss" of the American Academy of Otolaryngology-Head and Neck Surgery (AAOHNS) to justify treatment success.

RESULTS

There were no significant differences in demographic and baseline audiometric data. The mean of pure tone audiometry (PTA) and speech discrimination score (SDSs) were significantly improved after oral steroid and IT DEX treatment in all four groups. Group 1 showed significantly higher improvement than Group 4 in PTA after treatment. There was a significantly higher complete recovery (CR) rate in Group 1 than Group 4.

CONCLUSION

We found a statistically significant difference in the complete hearing recovery rate and audiometric results (PTA) between the group with a daily interval of injections and the group with a four-day time interval. Therefore, daily time intervals in intratympanic steroid injection may be considered as an option for better improvement of hearing in patients with ISSNHL.

Intratympanic injection of dexamethasone 4 mg/mL versus 10 mg/mL for management of idiopathic sudden sensorineural hearing loss

Background

The aim of this study was to determine whether different concentrations of intratympanic (IT) injection of dexamethasone at a dose of 4 and 10 mg/mL have an effect on hearing outcomes in patients with idiopathic sudden sensorineural hearing loss (ISSNHL).

Results

Our study was conducted on 30 adult patients with unilateral ISSNHL who failed to respond or with contraindications to systemic steroids. Patients were categorized into two groups; each one included 15 patients. IT injection of 4 mg/mL dexamethasone was done in one group (IT dexamethasone (Dex) 4 mg/mL), while 10 mg/mL dexamethasone was administered intratympanically in the other group (IT Dex 10 mg/mL). IT injection was performed twice weekly for two successive weeks. PTA thresholds were assessed at 0.5, 1, 2 and 4 kHz before and 1 month after the treatment.

In the group with IT Dex 10 mg/mL, the average PTA improved significantly from 75.50 ± 12.59 to 49 ± 24.04 dB with an average gain of 26.50 ± 14.25 (p = 0.0007). In the group with IT Dex 4 mg/mL, there was a significant change of PTA from a pretreatment value of 76.92 ± 11.89 dB to a post-treatment value of 59.27 ± 92.10 dB with an average gain of 17.65 ± 8.36 dB.

A comparison of the post-treatment gain of PTA in both groups showed better improvement of hearing in a group treated by IT Dex 10 mg/mL compared with 4 mg/mL.

Conclusion

This study demonstrated that IT injection of dexamethasone at a dose of 10 mg/ml was associated with better hearing outcomes compared with 4 mg/mL for the treatment of ISSNHL.

Sudden sensorineural hearing loss - A contemporary review of management issues

Sudden sensorineural hearing loss (SSNHL) is an enigmatic entity, with obscure pathophysiology and debatable efficacy of the treatment agents used. An underlying cause is identified in only 10-15% of cases. The management of the remaining patients, classified as 'idiopathic', is empirical, and is conventionally with systemic steroids, vasodilator therapy, rheological agents, and antioxidants, to list a few amongst the host of the agents employed for the treatment. The availability of conflicting outcomes and lack of conclusive evidence has resulted in the propagation of consensus-based treatment protocols. In the present review, we discuss the various controversial issues and newer developments in the management of idiopathic SSNHL. The current review aims to present a narrative outlook of the updated evidence base available from PUBMED, augmented with relevant designated publications.

Effectiveness of Steroid Treatment for Sudden Sensorineural Hearing Loss: A Meta-analysis of Randomized Controlled Trials

Background:

The best way to administer steroids for sudden sensorineural hearing loss (SSHL) is still unclear. The present study was aimed at estimating the efficacy of steroids by intratympanic, systemic, and combined therapy (CT) routes.

Methods:

A systematic literature search was performed from 1950 to October 2019 for randomized controlled trials comparing the use of intratympanic, systemic, and combined steroid therapy for SSHL. The outcomes of recovery rate and pure tone average (PTA) improvement were assessed by random-effects and fixed-effects meta-analysis.

Results:

A total of 20 articles identified from 7 countries were eligible for analysis. Although no significant difference in recovery rate was observed between intratympanic steroid therapy (IST) and systemic steroid therapy (SST), IST did demonstrate better hearing improvement, as evidenced by a higher PTA than SST. Compared with SST, CT comprising IST and SST had significant recovery rate improvement. Patients treated with CT had a significantly higher PTA than those treated with SST. Through subgroup analysis based on the equivalent dose of prednisone, it was shown that CT led to a significantly higher PTA than SST only in the high-dose CT versus high-dose SST groups and moderate-dose CT versus high-dose SST groups.

Conclusion:

Moderate and high dose of CT could accelerate hearing improvement in SSHL.

Comparison of 2 Different Intratympanic Methylprednisolone Injection Schedules in Combination With Intravenous Dexamethasone for Unilateral Sudden Sensorineural Hearing Loss

Sudden sensorineural hearing loss is a common otologic disease in clinic. Systemic and intratympanic steroid treatment have been proved to be effective, but the regimens vary from center to center. The purpose of the study is to analyze the effects of the combined application of intravenous dexamethasone and intratympanic methylprednisolone injection in different time strategies for the treatment of unilateral sudden sensorineural hearing loss. A retrospective chart review was performed for the period from March 2016 to June 2018 at our Department of Otorhinolaryngology-Head and Neck Surgery. A total number of 61 patients who met the academy criteria for unilateral sudden hearing loss were included and grouped based on the time to introduce intratympanic methylprednisolone. All the patients received intravenous dexamethasone 10 mg once daily for 5 days, followed 5 mg once daily for the next 7 days. Intratympanic methylprednisolone (40 mg) was injected every other day 4 times into all patients. This regimen was commenced on day 1 in group 1 and on day 6 in group 2. The pre and posttreatment pure-tone audiograms were analyzed. Sixty-one patients met our inclusion criteria. No significant differences were observed between patients' demographics or pretreatment hearing thresholds. In the 3 months posttreatment pure-tone audiogram assessment, the mean hearing threshold improvement were similar between groups with no frequency specificity. The curative rate in both groups were similar and satisfying. Two patients with diabetes mellitus had persistent small perforations. Some patients had other transient discomfort that disappeared before discharge. The different timing of initiation of intratympanic methylprednisolone injection does not significantly affect the outcome of the treatment for sudden sensorineural hearing loss. Thus, we suggest that intratympanic steroid injection should not be applied as a first-line method except for patients who do not respond early to systemic steroid therapy.

Addition of intratympanic steroid or hyperbaric oxygen treatment to systemic steroid treatment in sudden idiopathic sensorineural hearing loss treatment, and long-term results of salvage treatment

Background/aim

This study aims to determine the therapeutic superiority of the addition of intratympanic steroid or hyperbaric oxygen therapy to systemic steroid treatment in idiopathic sudden sensorineural hearing loss as initial treatment, and evaluate the long-term results of salvage treatment.

Materials and methods

This study was a retrospective clinical trial with a total of 96 patients with idiopathic sudden sensorineural hearing loss. Patients were divided into 3 groups. Group 1 (n: 32) received systemic steroid treatment. Group 2 (n: 32) received the Group 1 protocol plus intratympanic steroid treatment. Group 3 (n: 32) received the Group 1 protocol plus hyperbaric oxygen treatment. Pretreatment and postinitial audiologic evaluations were performed, and the hearing outcome was analyzed with Furuhashi criteria. All patients, except those who experienced total recovery after initial treatment, were directed to salvage treatment. Audiologic assessment was performed again after salvage treatment and a mean follow-up period of 36.5 months.

Results

Each group was homogenous according to demographics, audiologic data, and prognostic factors. There was no statistically significant difference in recovery and success rate within the 3 groups after initial treatment. (P: 0.66, P: 0.248, respectively). Successful results were obtained after salvage treatment in only 3 patients (5%). These patients received follow-up treatment at a mean of 36.5 months, but there was no spontaneous recovery after the end of salvage treatment.

Conclusion

The addition of intratympanic steroids or hyperbaric oxygen to systemic steroids caused no significant hearing improvement as the initial treatment of idiopathic sudden sensorineural hearing loss. The efficacy of salvage treatment was limited, and there was no spontaneous hearing improvement after the long-term follow-up.

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.

Early Intratympanic Methylprednisolone in Sudden SNHL: A Frequency-wise Analysis

Sudden sensorineural hearing loss is a dire medical emergency which must be treated at the earliest to get better long term hearing results. Our study aims to determine the efficacy of intratympanic steroid (Methylprednisolone) on auditory outcomes in patients of sudden sensorineural hearing loss and study the relation between time of onset of hearing loss to start of therapy and frequency-wise recovery of hearing loss. A prospective cohort clinical study with 33 patients with sudden hearing loss of 30 dB or more were treated with the intratympanic injection of methylprednisolone and the effect of the drug was observed. In this study, 33 patients with sudden onset (unilateral or bilateral) of hearing loss were treated with intratympanic methylprednisolone. The duration at which the drug was administered and the age of the participants was taken into consideration. Main outcome measures included audiometry results at low, medium and high hearing loss frequencies. The specific frequency at which the hearing improvement took place was tabulated. It was observed that hearing improved significantly if the steroid is injected within the first 4 days of onset (p < 0.05) at all the frequencies. A gain of 15 dB or more was achieved in more than 78% patients after injecting methylprednisolone intratympanically. A statistically significant association was found between recovery rate and frequency of hearing loss with patients showing greater improvement at low hearing loss frequency in comparison to mid and high frequencies (p < 0.05). The drug efficacy does not change with the age of the patient.

Comparison of inner ear drug availability of combined treatment with systemic or local drug injections alone

Combination of systemic and local drug therapy has been proved more effective and safer for idiopathic sudden sensorineural hearing loss by some clinical trials, and there are few laboratory researches on its pharmacokinetic behaviors in the inner ear. In the present study, we use a new in vivo imaging system to compare the pharmacokinetics of combined therapy (CT), with intravenous (IV) or transtympanic (TT) injection alone in both ears of transgenic GFAP-Luc mice. Biological half-life, total photon counts and the area under the curve (AUC) value significantly increased after CT. However, adding IV to TT injection cannot strengthen the peak photon of the drug in the inner ear. In addition, when D-luciferin is injected to the left ear the volume of total photon count and AUC value of CT-left ear are larger than the combined volume of TT-left ear and IV-left ear, suggesting a synergistic effect, and those of CT-right ear are almost equal to the summation of those of IV-right group and TT-right group, suggesting no amplifying effect on the risk of systemic side effect. This study showed that CT could deliver more drugs into the inner ear, and brought a longer therapeutic window, and were more effective than intravenous or transtympanic injection alone in the pharmacokinetics.

Intratympanic steroids for combined treatment of idiopathic sudden hearing loss: when is it too late?

Background: Idiopathic sudden sensorineural hearing loss (ISSNHL) requires early treatment. Objective: To describe our experience on intratympanic steroid treatment (ITS) of ISSNHL analyzing the delay to start therapy as prognostic factor. Material and methods: We perform a retrospective study on ISSNHL treated with systemic steroids without full recovery on PTA (pure tone average) according to Siegel criteria. They were divided into two different groups: one group that additionally received ITS as combined therapy (treatment group), and another without it (control group). We analyzed the hearing recovery at 6 months and 2 years, and the influence of the delay to start ITS in the recovery. Results: After ITS was added, further complete recovery was achieved in 10 patients of the treatment group. After 6 months, PTA improvement in the treatment group was 10.84 dB, compared to 1.13 dB in the control group (p<.0001). Nevertheless, patients starting such combination of oral steroids and ITS within 8 days of diagnosis had an additional gain of 15 dB in the first 6 months, that increased to 19.17 dB after 24 months (p<.022). Conclusions: When ITS was added within the first 8 days, a significantly better and more stable response was obtained.

Prediction of hearing recovery in sudden deafness treated with intratympanic steroids

The present study aims to obtain a probability model allowing prediction of auditory recovery in patients affected by sudden sensorineural hearing loss treated exclusively with intratympanic steroids. A monocentric retrospective chart review of 381 patients has been performed. A Probit model was used to investigate the correlation between the success of treatment (marked or total recovery according to Furuashi’s criteria) and the delay between onset of disease and beginning of therapy. The age of patients and audiometric curve shapes were included in the analysis. The results show that delay is negatively correlated with variable success. Considering the entire sample, each day of delay decreases the probability of success by 3%. The prediction model shows that for each day that passes from the onset of the disease the probability of success declines in absence of the medical treatment, hence we conclude that early treatment is strongly recommended.

Local Drug Delivery for the Treatment of Neurotology Disorders

Neurotology disorders such as vertigo, tinnitus, and hearing loss affect a significant proportion of the population (estimated 39 million in the United States with moderate to severe symptoms). Yet no pharmacological treatments have been developed, in part due to limitations in effective drug delivery to the anatomically protected inner ear compartment. Intratympanic delivery, a minimally invasive injection performed in the office setting, offers a potential direct route of administration. Currently, off-label use of therapeutics approved to treat disorders via systemic administration are being injected intratympanically, mostly in the form of aqueous solutions, but provide variable levels of drug exposure for a limited time requiring repeated injections. Hence, current drug delivery approaches for neurotology disorders are sub-optimal. This review, following a description of pharmacokinetic considerations of the inner ear, explores the merits of novel delivery approaches toward the treatment of neurotology disorders. Methodologies employing local delivery to the inner ear are described, including direct intracochlear delivery as well as intratympanic methods of infusion and injection. Intratympanic injection delivery formulation strategies including hydrogels, polymers and nanoparticulate systems are explored. These approaches represent progress toward more effective delivery options for the clinical treatment of a variety of neurotology disorders.

Comparison of Different Treatment Methods for Idiopathic Sudden Sensorineural Hearing Loss

Objective

To evaluate the effectiveness of different therapies for idiopathic sudden sensorineural hearing loss and prognostic factors, and determine the most successful treatment according to the audiogram type and time from onset to treatment.

Methods

A total of 90 cases from February 2009 to January 2015 were classified under Group I oral treatment (methylprednisolone, acyclovir, betahistine-dihydrochloride, and vitamin B12); Group II oral treatment + intratympanic steroids (ITS); Group III oral treatment + hyperbaric oxygen; and Group IV only ITS. A pure tone average (PTA) improvement of less than 10 dB was assessed as "no improvement," a PTA of 10 dB or more or a 10% or more increase in the speech discrimination score (SDS) as "partial improvement," and a hearing threshold within 10 dB and SDS within 5%-10% of the unaffected ear as "full improvement."

Results

Overall, 32.2% patients showed full and 28.9% showed partial improvement, whereas 38.9% showed no improvement. There was no significant difference in terms of mean hearing gain between the different treatment methods. As the degree of hearing loss and time from onset to treatment increased, improvement worsened (p<0.05). Descending audiogram had lower mean hearing gains compared to other groups (p=0.014). There was no significant effect of age, sex, tinnitus and/or vertigo, and systemic disease on treatment success (p>0.05).

Conclusion

The most important factors affecting prognosis were the time from onset to treatment, hearing loss severity, and audiogram type. Only ITS avoided side effects and reduced hospitalization. ITS in the first two weeks, followed by hyperbaric oxygen were considered as the treatment priority.

The Efficacy of Concurrent or Sequential Intravenous and Intratympanic Steroid for Idiopathic Sudden Sensorineural Hearing Loss

Objective: The purpose of this retrospective study was to investigate the difference in treatment outcomes for patients with idiopathic sudden sensorineural hearing loss (SSNHL) undergoing concurrent or sequential intravenous (IV) and intratympanic (IT) steroid therapies. Methods: Patients with idiopathic SSNHL admitted to Taipei Veterans Hospital from August 2011 to August 2012 were enrolled. Patients were treated with both IV dexamethasone 5 mg b.i.d. for 5 days, then tapered over 6 days, and IT injections of dexamethasone 5 mg daily. The administration of IV and IT steroids was given either concurrently or sequentially (IV steroid was administered from days 1–5 followed by IT steroid treatment starting on day 4 or day 5). The hearing outcomes of the concurrent and sequential groups were analyzed. Results: Overall, after ≥2 months following treatment, across frequencies ranging from 250 to 8,000 Hz and pure-tone average (PTA) assessments, hearing improvements were similar between treatment groups, except at the frequencies of 4,000 and 8,000 Hz where the concurrent treatment group had greater hearing gain than the sequential group (4,000 Hz: 30.68 ± 28.96 vs. 14.52 ± 24.06 dB, respectively, p = 0.042; 8,000 Hz: 22.62 ± 23.59 vs. 7.67 ± 21 dB, p = 0.030). Across frequencies and PTA assessments, a similar percentage of patients had ≥20-dB gains in hearing compared with patients treated sequentially, except at 8,000 Hz where a greater percentage of patients in the concurrent group (57.1%) than the sequential group (23.3%) (p = 0.014) had ≥20-dB hearing gains. Conclusion: The findings suggest that both concurrent and sequential treatment improve hearing in patients with idiopathic SSNHL, and that concurrent treatment may show greater benefit than sequential therapy, particularly at high frequencies.