Clinical study of acute low-tone sensorineural hearing loss: survey and analysis of glycerol test and orthostatic test

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

NA Laryngoscope, 133:2457-2469, 2023.

Volume ratio and distribution rate in patients with orthostatic vertigo/dizziness using MR imaging: a comparison with vertiginous diseases

BACKGROUND

Orthostatic dizziness/vertigo (ODV) is characterized by lightheadedness owing to postural changes.

AIMS/OBJECTIVES

To measure the endolymphatic space (ELS)/total fluid space (TFS) volume ratio and the distribution rate of endolymphatic fluid (ELF) of patients with ODV and compare them with those of control subjects (CS).

MATERIALS AND METHODS

This study included 22 patients (44 ears) with ODV and 52 controls (104 ears, CS). The ELS/TFS volume ratio (%) and distribution rate (%) of the inner ear components were measured using 3-dimensional magnetic resonance imaging.

RESULTS

In the ODV group, the mean ELS/TFS volume ratios of the cochlea, vestibule, and semi-circular canals (SCCs) were 12.1%, 18.6%, and 18.1%, respectively; the mean ELS distribution rates for the cochlea, vestibule, and SCCs were 27.3%, 26.2%, and 46.6%, respectively. The ELS distribution rate of the vestibule was significantly lower (p < .01) and the ELS distribution rate of the SCCs was significantly higher in the ODV than in the CS group (p < .01).

CONCLUSIONS AND SIGNIFICANCE

The ELS distribution rate in the vestibule + SCCs among patients with ODV did not differ from that in the CS; ELF in the vestibule moved to the SCCs, and a large amount of ELF was distributed only in the SCCs.

Combination Therapy and Single-Modality Treatment for Acute Low-Tone Hearing Loss: A Meta-Analysis with Trial Sequential Analysis

Acute low-tone hearing loss (ALHL) is a common clinical disease and was first proposed by Abe in 1981 as sensorineural hearing loss confined to low frequencies. The best strategy for initiating medication is still unclear, as the superiority of steroids and diuretics is still debated, and combination therapy might yield additional benefits. However, no study regarding combination therapy has been published. The objective of this study was to evaluate the efficacy of steroid therapy versus combination therapy of diuretics with steroids by conducting a systematic review with a meta-analysis and trial sequential analysis (TSA). Studies enrolling patients with a diagnosis of acute low-tone hearing loss were considered eligible. After searching the PubMed, Cochrane Library, Embase, Scopus and Web of Science databases from inception to 31 December 2021, five studies including 433 patients were enrolled. Overall, the comparison between combination therapy with steroids and diuretics and single-modality treatment with steroids (OR, 1.15; 95% CI, 0.51 to 2.59; p = 0.74; I2 = 34%) and the comparison between combination therapy and treatment with diuretics alone (OR, 1.73; 95% CI, 0.93 to 3.23; p = 0.09; I2 = 5%) showed that combination therapy did not confer significant benefits when compared to single-modality treatments. A trial sequential analysis (TSA) showed conclusive nonsignificant results of the comparison between the combination of steroids and diuretics and a single-modality treatment. In conclusion, we reported that the combination of steroids and diuretics did not yield significant benefits when compared to single-modality treatment with steroids or diuretics. We suggest that treatment should be initiated with steroids or diuretics alone to avoid potential adverse effects.

Cochlear Meniere's: A Distinct Clinical Entity With Isolated Cochlear Hydrops on High-Resolution MRI?

Objective: Describe the clinical characteristics of patients with isolated cochlear endolymphatic hydrops (EH). Study design: Clinical case series. Setting: Tertiary Neurotology referral clinic. Patients: All subjects presenting to a University Neurotology clinic during a 1-year period from July 2015 until August 2016 who had isolated cochlear EH on MRI. Patients with a history of temporal bone surgery prior to the MRI were excluded. Intervention: High-resolution delayed-intravenous contrast MRI. Main outcome measures: Audiometric and vestibular testing, clinical history analysis. Results: 10 subjects demonstrated isolated, unilateral cochlear hydrops on MRI. None of these patients met the criteria for Meniere's disease. Mean age of the group was 66.4 years and most were males (70%). Unilateral aural fullness (70%), tinnitus (80%), and hearing loss (90%) were frequently observed. Only one patient presented with unsteadiness (10%) and one patient had a single isolated spell of positional vertigo 1 month prior to the MRI (10%) but no further vertigo spells in the 4 years following the MRI. The mean PTA was 37.8 dB which was significantly decreased from the non-affected ear with PTA of 17.9 (p < 0.001). One patient developed vertiginous spells and unsteadiness 4 years after initial presentation and a repeat MRI revealed progression to utricular, saccular and cochlear hydrops. Vestibular testing was obtained in five patients with one patient presenting with 50% caloric paresis and all others normal. The most common treatment tried was acetazolamide in seven patients with 86% reporting subjective clinical improvement. Two out of the 10 patients had a history of migraine (20%). Conclusions: Patients with MRI exhibiting isolated cochlear EH present with predominantly auditory symptoms: mild to moderate low-frequency hearing loss, aural fullness, tinnitus without significant vertigo. Isolated cochlear hydrops is more common in males, average age in mid-60's and there is a low comorbidity of migraine headaches. This contrasts significantly with patients with isolated saccular hydrops on MRI from our prior studies. We believe that isolated cochlear EH with hearing loss but no vertigo is distinct from Meniere's disease or its variant delayed endolymphatic hydrops. We propose that cochlear Meniere's disease represents a distinct clinical entity that could be a variant of Meniere's disease.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Significance of 1 kHz Pure-tone Threshold in Acute Low-frequency Sensorineural Hearing Loss

OBJECTIVES

To analyze risk factors for acute low-frequency hearing loss (ALFHL), and compare treatment outcomes in the presence or absence of such risk factors.

STUDY DESIGN

A case series featuring retrospective chart review.

SETTING

An academic university hospital.

PATIENTS

We included 170 ALFHL patients without vertigo. All of the patients received one of four treatments: low-dose steroid (LD-steroid), high-dose steroid (HD-steroid), LD-steroid and diuretics (LD-combination therapy), and ITDI (intratympanic dexamethasone injection) and diuretics (ITDI-combination therapy). To identify risk factors, we reviewed the clinical features of patients such as age, sex, chief complaint, accompanying symptoms, diabetes, hypertension, time from disease onset, the extent of hearing loss, treatment methods, and 1 kHz involvement.

INTERVENTIONS

ALFHL was diagnosed based on the average hearing loss >30 dB at 250 and 500 Hz.

RESULTS

The overall rates of hearing recovery were 70-80% in the four treatment groups. In terms of the prognosis of ALFHL patients, we found that a longer time from disease onset and 1 kHz involvement were independent risk factors for poor prognosis. In addition, we compared treatment outcomes of four treatment methods in the presence or absence of risk factors. In ALFHL patients with risk factors, we found statistically significant differences (p = 0.042) among treatment methods; effectiveness ranged in the order if ITDI-combination therapy, LD-combination therapy, HD-steroid, and LD-steroid.

CONCLUSIONS

Risk factors for poor hearing recovery in ALFHL included longer symptom duration and 1 kHz involvement. In ALFHL with such risk factors, combination therapy was more effective than oral steroid therapy.

Short-Term Outcomes of Acute Low-Tone Sensorineural Hearing Loss According to Treatment Modality

BACKGROUND AND OBJECTIVES

We compared improvements in hearing thresholds in acute low-tone sensorineural hearing loss (ALHL) patients after two different treatments: steroid alone and steroid and diuretic combined. We analyzed how the duration between the onset of symptoms and the initiation of treatment affected hearing loss improvement and investigated the relation between presence of vertigo in ALHL patients and ALHL progression to Ménière's disease (MD).

SUBJECTS AND METHODS

We retrospectively analyzed the medical records of 47 ALHL patients aged 21 to 76 years. Patients received either orally administered steroid alone (n=12) or steroid and diuretic combined (n=35). We compared improvements in the two groups' hearing thresholds at three lower frequencies (125, 250, and 500 Hz) after participants had received one month of each respective treatment.

RESULTS

Our two treatments did not show any statistical difference in hearing loss improvement after one month. Forty percent of ALHL patients with vertigo developed MD, which was a significantly higher rate than the 12.5% of ALHL patients without vertigo who developed MD. The shorter duration between the onset of symptoms and the initiation of treatment significantly increased improvement in the sum of lower frequency hearing threshold after one month.

CONCLUSIONS

The current study suggests that steroid and diuretic administered together and steroid alone similarly improve the hearing threshold in ALHL patients after one month. We concluded that patients should initiate ALHL treatment as soon as they experience symptoms. ALHL patients should also be notified of their higher risk of developing MD.

The Short- and Long-Term Outcome of Intratympanic Steroid Therapy as a Salvage Treatment for Acute Low-Tone Sensorineural Hearing Loss without Episodes of Vertigo

OBJECTIVES

To evaluate the hearing outcomes of intratympanic steroid (ITS) treatment for patients with acute low-tone sensorineural hearing loss (ALHL) after failure of initial therapy and to investigate the recurrence and progression to definite Ménière's disease (MD) during a long-term follow-up.

METHODS

We retrospectively reviewed the medical records of 90 patients with refractory ALHL who were followed up for at least 1 year between January 2000 and April 2014. Patients who responded poorly to initial medical treatment received intratympanic dexamethasone injections (ITS group) or isosorbide administration for 4 weeks (diuretic group) as salvage treatment options according to their choice of management. The control group did not receive ITS or the diuretic, due to their refusal of both medical treatments. The hearing outcomes were evaluated 1 month, 1 year and 5 years after the completion of the second-line therapy, and the rates of recurrence and progression to MD were measured during a follow-up period of at least 1 year.

RESULTS

Twenty-seven patients in the ITS group, 39 patients in the diuretic group and 24 patients in the control group were enrolled. Of these, 12 patients in the ITS group, 15 patients in the diuretic group and 12 patients in the control group were followed up for over 5 years. We found that the recovery rates and the audiometric functional values after 1 month and 1 year in the ITS group were significantly higher than those in the diuretic and control groups. However, there were no significant differences in the recovery rates or the audiometric functional values after 5 years, or in the rates of recurrence and progression to MD between the groups.

CONCLUSIONS

Salvage ITS therapy can provide a relatively good short-term hearing outcome for ALHL patients who have persistent hearing loss despite conventional treatment. However, both recurrence and progression to MD after treatment were observed in some patients during the long-term follow-up.

Endolymphatic hydrops revealed by magnetic resonance imaging in patients with acute low-tone sensorineural hearing loss

OBJECTIVE

Acute low-tone sensorineural hearing loss (ALHL) has been reported to be associated with endolymphatic hydrops (EHs). However, evaluation of the size of the endolymphatic space has not been reported. We attempted to visualize EH in ALHL using magnetic resonance imaging (MRI).

STUDY DESIGN

Prospective diagnostic study.

SETTING

University hospital.

METHODS

We evaluated 25 ears of 25 unilateral ALHL patients. Three-tesla MRI was obtained 24 hours after intratympanic injection of gadolinium (Gd) (n = 5) or 4 hours after intravenous injection of Gd (n = 20). A radiologist blinded to the patients' clinical data classified the degree of EH in the vestibule and cochlea into 3 groups: none, mild, and significant.

RESULTS

On the affected sides, cochlear EH was recognized in 23 ears (92%) and was classified as significant EH (n = 15) or mild EH (n = 8); vestibular EH was detected in 22 ears (88%), classified as significant EH (n = 16) or mild EH (n = 6). Cochlear EH was more frequently observed in the affected ear than in the contralateral ear (90% versus 40%, p < 0.05).

CONCLUSION

In ALHL, EH was observed not only in the cochlea but also in the vestibule as in Ménière's disease.

Trial of Chinese medicine Wu-Ling-San for acute low-tone hearing loss

PURPOSE

We used new criteria to elucidate the demographics of acute low-tone sensorineural hearing loss (ALHL) and tested the Chinese medicine Wu-Ling-San as a treatment for ALHL.

PROCEDURES

We reviewed the medical records of patients with ALHL seen at the outpatient clinic of the Social Insurance Central General Hospital in Tokyo from April 2006 through August 2011. Patients were treated with an oral steroid, a diuretic, or Wu-Ling-San; alone or in combination.

RESULTS

We identified 130 definite and 48 probable ALHL cases. The mean age and male-to-female ratio in probable cases were significantly higher than those in definite cases (p < 0.05). The steroid-Wu-Ling-San combination was significantly more effective (100% recovery) than the diuretic alone (59%), Wu-Ling-San alone (62%), or the steroid-diuretic combination (60%, p < 0.05).

CONCLUSIONS

ALHL can develop in older patients more frequently than we expected. The steroid-Wu-Ling-San combination is a possible new treatment for ALHL.

Prognosis of sudden low-tone loss other than acute low-tone sensorineural hearing loss

CONCLUSION

In clinical practice, sudden low-tone loss other than acute low-tone sensorineural hearing loss (ALHL) shows a potential for recurrence.

OBJECTIVE

ALHL is often associated with recurrence and/or progression to Ménière's disease. We examined the prognosis of patients with sudden low-tone loss who were not classified in the audiometric definition of ALHL.

METHODS

Sixty-three patients diagnosed at the university hospital with idiopathic sudden low-tone loss of sensorineural hearing loss and without subjective vertigo were followed up in the long term with a mean of over 4 years. The rates of recurrence and/or progression to Ménière's disease for patients with low-tone loss type other than ALHL (non-ALHL) were compared with those for ALHL patients.

RESULTS

The recovery rate at the initial treatment was 47.6% for non-ALHL and 62.9% for ALHL. A Kaplan-Meier plot indicated that cumulative recurrence rates for non-ALHL were 20.2% at 1 year and 43.5% at 5 years, whereas the rates for ALHL were 12.2% at 1 year and 31.3% at 5 years. There was no statistically significant difference between the two patient groups.

[Clinical statistics of recurrent acute low-tone senseorineural hearing loss]

Recently, acute low-tone senseorineural hearing loss (ALHL) has become common, and its good prognosis is known well. On the other hand, several reports have suggested that ALHL is frequently associated with Meniere's disease. We retrospectively examined the clinical course of 357 cases that were diagnosed and treated as ALHL at our hospitals. Forty-four of these cases that showed high-tone hearing loss in association with age-related changes were classified as atypical cases. The clinical futures of 49 "poor prognosis cases", who experienced recurrent hearing loss and/or profound hearing loss, are reported. Eight of the 49 cases who experienced recurrences had progressive hearing loss upto middle or high tones. Seventeen cases complained of vertiginous sensation, and 8 of these cases experienced recurrent attacks of vertigo and were diagnosed as having Meniere's disease. The former seventeen cases accounted for 34.7% of the "poor prognosis cases", and the latter eight accounted for 16.3% of these cases. Our results suggest that the hearing loss is more frequently associated with Meniere's disease in cases who experience recurrent hearing loss. Thus, cases initially diagnosed as ALHL may include some cases of progressive hearing loss and Meniere's disease. Even in cases in which hearing improvement is obtained, careful clinical observation is necessary, especially in older patients with bilateral affliction and atypical presentation. ALHL has been generally considered to have a good prognosis, however our examination revealed a relatively high frequency of recurrences, progressive hearing loss and complication by vertigo. We recommend, based on this evidence, that careful explanation of this disease is necessary at time of initial informed consent.

Effect of Corticosteroids or Diuretics in Low-Tone Sensorineural Hearing Loss

OBJECTIVES

We retrospectively analyzed 225 patients with acute low-tone sensorineural hearing loss (ALSHL), comparing the effectiveness of corticosteroid and diuretic therapy, and also determining the factors affecting hearing recovery.

DESIGN

Retrospective clinical record review.

METHODS

Multivariate logistic regression analysis.

RESULTS

Analyses identified unfavorable factors such as aging, late initiation of treatment, and pretreatment pure-tone hearing thresholds at three lower frequencies adding up to 95 dB and more. Multivariate logistic regression analysis indicated a significantly greater improvement in hearing in patients treated with corticosteroids at high initial and total doses than in those treated with vitamin B12 and ATP without adding corticosteroids. In 145 patients treated with corticosteroids, multivariate logistic regression analysis showed a trend toward greater improvement with high initial and total doses than with low doses.

CONCLUSION

Corticosteroids should be changed from low to high doses within 7 days after onset of ALSHL, if low doses are failing.

Recurrent hearing loss after myelography treated with epidural blood patch

Transient hearing impairment is a known sequel after various procedures that result in loss of cerebrospinal fluid, such as lumbar puncture, spinal anesthesia and myelography. But persistent or recurrent hearing loss after dural puncture is a rare entity. We present a case with recurrent low-frequency sensorineural hearing loss after myelography. The patient was treated successfully by means of an epidural blood patch, although the conservative treatment was ineffective.

Vestibular Evoked Myogenic Potentials in Acute Low-Tone Sensorineural Hearing Loss

OBJECTIVE/HYPOTHESIS

It was the authors' premise that the vestibular evoked myogenic potential (VEMP) test may be used to differentiate acute low-tone hearing loss (ALHL) from Meniere's disease with low-tone HL.

STUDY DESIGN

Prospective study.

METHODS

From January 2000 to December 2002, consecutive 12 patients with ALHL and another 12 patients with definite Meniere's disease with low-tone HL were enrolled in this study. All patients underwent audiometry and VEMP test, before and after treatment with isosorbide for 3 consecutive months.

RESULTS

Before treatment, 12 patients with ALHL revealed normal VEMPs (11, 92%) and augmented VEMPs (1). After treatment, 11 (92%) patients had resolved to normal hearing within 3 days. One year later, two (17%) patients progressed to Meniere's disease. In comparison with Meniere's disease, 6 (50%) of 12 patients showed normal VEMPs before treatment, and 7 (58%) patients had their hearing improved 3 months after treatment. Comparison of VEMP responses or hearing outcome between both groups exhibited significant differences.

CONCLUSION

Most patients with ALHL reveal normal VEMPs throughout the episode, indicating that the saccule is spared. In contrast, 50% of Meniere's disease patients with low-tone HL demonstrate abnormal VEMPs, showing a significant difference. Therefore, the VEMP test can be used to differentiate ALHL from Meniere's disease with low-tone HL.

Comparison of acute low-tone sensorineural hearing loss versus Meniere's disease by electrocochleography

To clarify the pathogenesis of acute low-tone sensorineural hearing loss (ALHL), we retrospectively compared the electrocochleographic findings from 20 patients with ALHL with those from 58 patients with Meniere's disease (MD) classified into 4 groups (MD1 through MD4) according to their pure tone average. The mean summating potential-action potential ratio in the ALHL group was 0.35 +/- 0.13, which was significantly higher than the control ratio but similar to the ratio seen in the MD1 group (pure tone average < 25 dB hearing level). The mean detection threshold of the cochlear microphonics in the ALHL group was 32.0 +/- 9.4 dB normal hearing level, which was again similar to that seen in the MDI group. Moreover, more than 50% of patients with ALHL had normal cochlear microphonics input-output curves. We therefore conclude that the pathogenesis of ALHL arises from an endolymphatic hydrops with little or no impairment of hair cells that resembles early-stage MD.