Intratympanic Steroids for Idiopathic Sudden Sensorineural Hearing Loss

White Matter Hyperintensity in Patients with Sudden Sensorineural Hearing Loss

OBJECTIVE

To compare white matter hyperintensities (WMHs) on T2-weighted magnetic resonance imaging (MRI) of patients with sudden sensorineural hearing loss (SSNHL) and analyze subpopulations with age-matched controls.

METHODS

T2-weighted MRI scans of 150 patients with SSNHL were assessed for WMHs and compared with the data of 148 healthy age-matched adults. Assessments of WMHs included independent grading of deep white matter hyperintensities (DWMHs) and periventricular hyperintensities (PVHs). WMH severity was visually rated using the Fazekas and Mirsen scales by two independent observers.

RESULTS

Fazekas grades for PVHs (p < 0.001) and DWMHs (p < 0.001) of SSNHL patients were found to be significantly greater than those of healthy participants. The average Mirsen grades for DWMHs of healthy and SSNHL patients were evaluated to be 0.373 ± 0.550 and 2.140 ± 0.859, respectively. Mirsen grades for DWMHs of SSNHL patients were found to be significantly greater (p < 0.001) than those of healthy participants. The Mirsen scale was found to have higher sensitivity (p < 0.001) than the Fazekas scale in grading PVHs and DWMHs. No significant difference (p = 0.24) was found in specificities between the two scales.

CONCLUSIONS

Patients with sudden hearing loss have a much higher likelihood of having periventricular and deep white matter hyperintensities compared to age-matched controls. These findings indicate that sudden hearing loss patients are more likely to have microvascular changes in the brain, which may indicate a vascular and/or migraine origin to sudden sensorineural hearing loss.

Treatment of Long-term Sudden Sensorineural Hearing Loss as an Otologic Migraine Phenomenon

OBJECTIVES

To describe a cohort of patients presenting with long-term sudden sensorineural hearing loss (SSNHL) treated with prophylactic migraine and intratympanic steroid therapy.

METHODS

Patients presenting to a neurotology clinic at least 6 weeks from SSNHL onset were included. All patients received migraine prophylactic medication (nortriptyline, topiramate, and/or verapamil) and lifestyle changes for at least 6 weeks, as well as intratympanic steroid injections, if appropriate.

RESULTS

Twenty-one patients (43% female) with a mean age of 64 ± 11 years who presented 9 ± 8 months (median = 5) from symptom onset were included. Posttreatment hearing thresholds were significantly improved compared with pretreatment thresholds at 500 Hz (49 ± 19 dB versus 55 ± 20 dB, p = 0.01), 1000 Hz (52 ± 19 dB versus 57 ± 21 dB, p = 0.03), low-frequency pure-tone average (53 ± 15 dB versus 57 ± 17 dB, p = 0.01), and speech-frequency pure-tone average (57 ± 13 dB versus 60 ± 15 dB, p = 0.02). Posttreatment word-recognition-score (WRS) and speech-recognition-threshold (SRT) were also significantly improved (45 ± 28% versus 70 ± 28% and 57 ± 18 dB versus 50 ± 16 dB, respectively, both p < 0.01). Notably, ≥15% improvement in WRS and ≥10 dB improvement in SRT was observed in 13 (68%) and 8 (40%) patients, respectively. Of the 11 patients who presented with initial < 50% WRS, 8 (73%) had improved posttreatment >50% WRS with an average improvement of 39 ± 9%.

CONCLUSIONS

Migraine medications in addition to intratympanic steroid injections significantly improved SRT and hearing frequencies in 40% and 29% of SSNHL patients, respectively, while significant WRS recovery was observed in most (68%) patients. This suggests SSNHL may be an otologic migraine phenomenon, which may be at least partially reversible even after the traditional 30-day postonset window.

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 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.

Therapeutic Efficacy of the Combination of Intratympanic Methylprednisolone and Oral Steroid for Idiopathic Sudden Deafness

Objective

The purpose of this study was to compare the efficacy of systemic steroid alone and combined with intratympanic methylprednisolone in the treatment of patients with idiopathic sudden sensorineural hearing loss.

Study Design

Prospective, randomized controlled trial.

Settings

Katip Celebi University Ataturk Training and Research Hospital, Izmir, Turkey.

Subject and Methods

Seventy-nine patients who met the inclusion criteria for idiopathic sudden sensorineural hearing loss were included in this study. Patients were randomly divided into 2 groups according to treatment: group A received combination therapy (intratympanic methylprednisolone + oral steroid) and group B received oral steroid alone. Of the 79 patients included, 6 patients missed the 1-month follow-up visit. Overall, 73 patients (37 combination group, 36 oral steroid group) who completed the 1-month follow-up and study intervention were included in the per-protocol analysis. Both the relationship between certain prognostic factors and the clinical outcome after treatment were analyzed.

Results

Combination therapy showed significant hearing improvement and speech discrimination scores compared with the use of systemic steroids alone ( P < .05). In hearing outcomes in patients with severe hearing loss, combination therapy had statistically significant hearing improvement compared with oral steroid alone ( P < .05).

Conclusion

We recommend that combination therapy can be considered as initial treatment especially for patients with severe hearing loss.

Endolymphatic space imaging in idiopathic sudden sensorineural hearing loss with vertigo

OBJECTIVES/HYPOTHESIS

To investigate endolymphatic space images in patients with idiopathic sudden sensorineural hearing loss (ISNHL) and vertigo using three-dimensional fluid-attenuated inversion recovery magnetic resonance imaging (3D-FLAIR MRI).

STUDY DESIGN

This is a prospective study of an analysis using the imaging technology of 3D-FLAIR MRI for patients with ISNHL and vertigo.

METHODS

3D-FLAIR MRI was performed 24 hours after intratympanic injection of gadolinium-diethylenetriamine penta-acetic acid.

RESULTS

In four of seven cases of ISNHL with vertigo, endolymphatic hydrops were confirmed in the cochlea and/or the vestibule of the affected ears.

CONCLUSIONS

The results of the study imply that there may be some relationship between endolymphatic hydrops and ISNHL with vertigo.

Clinical Practice Guideline

Objective. Sudden hearing loss (SHL) is a frightening symptom that often prompts an urgent or emergent visit to a physician. This guideline provides evidence-based recommendations for the diagnosis, management, and follow-up of patients who present with SHL. The guideline primarily focuses on sudden sensorineural hearing loss (SSNHL) in adult patients (aged 18 and older). Prompt recognition and management of SSNHL may improve hearing recovery and patient quality of life (QOL). Sudden sensorineural hearing loss affects 5 to 20 per 100,000 population, with about 4000 new cases per year in the United States. This guideline is intended for all clinicians who diagnose or manage adult patients who present with SHL.

Purpose. The purpose of this guideline is to provide clinicians with evidence-based recommendations in evaluating patients with SHL, with particular emphasis on managing SSNHL. The panel recognized that patients enter the health care system with SHL as a nonspecific, primary complaint. Therefore, the initial recommendations of the guideline deal with efficiently distinguishing SSNHL from other causes of SHL at the time of presentation. By focusing on opportunities for quality improvement, the 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.

Results. The panel made strong recommendations that clinicians should (1) distinguish sensorineural hearing loss from conductive hearing loss in a patient presenting with SHL; (2) educate patients with idiopathic sudden sensorineural hearing loss (ISSNHL) about the natural history of the condition, the benefits and risks of medical interventions, and the limitations of existing evidence regarding efficacy; and (3) counsel patients with incomplete recovery of hearing about the possible benefits of amplification and hearing-assistive technology and other supportive measures. The panel made recommendations that clinicians should (1) assess patients with presumptive SSNHL for bilateral SHL, recurrent episodes of SHL, or focal neurologic findings; (2) diagnose presumptive ISSNHL if audiometry confirms a 30-dB hearing loss at 3 consecutive frequencies and an underlying condition cannot be identified by history and physical examination; (3) evaluate patients with ISSNHL for retrocochlear pathology by obtaining magnetic resonance imaging, auditory brainstem response, or audiometric follow-up; (4) offer intratympanic steroid perfusion when patients have incomplete recovery from ISSNHL after failure of initial management; and (5) obtain follow-up audiometric evaluation within 6 months of diagnosis for patients with ISSNHL. The panel offered as options that clinicians may offer (1) corticosteroids as initial therapy to patients with ISSNHL and (2) hyperbaric oxygen therapy within 3 months of diagnosis of ISSNHL. The panel made a recommendation against clinicians routinely prescribing antivirals, thrombolytics, vasodilators, vasoactive substances, or antioxidants to patients with ISSNHL. The panel made strong recommendations against clinicians (1) ordering computerized tomography of the head/brain in the initial evaluation of a patient with presumptive SSNHL and (2) obtaining routine laboratory tests in patients with ISSNHL.

Early posttreatment audiometry underestimates hearing recovery after intratympanic steroid treatment of sudden sensorineural hearing loss

Objective. To review our experience with intratympanic steroids (ITSs) for the treatment of idiopathic sudden sensorineural hearing loss (ISSNHL), emphasizing the ideal time to perform follow-up audiograms. Methods. Retrospective case review of patients diagnosed with ISSNHL treated with intratympanic methylprednisolone. Injections were repeated weekly with a total of 3 injections. Improvement was defined as an improved pure-tone average ≥20 dB or speech-discrimination score ≥20%. Results. Forty patients met the inclusion criteria with a recovery rate of 45% (18/40). A significantly increased response rate was found in patients having an audiogram >5 weeks after the first dose of ITS (9/13) over those tested ≤5 weeks after the first dose of ITS (9/27) (P = 0.03). Conclusions. Recovery from ISSNHL after ITS injections occurs more frequently >5 weeks after initiating ITS. This may be due to the natural history of sudden hearing loss or the prolonged effect of steroid in the inner ear.

Intratympanic Steroids for Sudden Sensorineural Hearing Loss

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

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

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

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

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

Intratympanic steroid therapy for sudden hearing loss: a review of the literature

OBJECTIVE

Administration of steroids systematically is considered to be the most commonly accepted treatment for idiopathic sudden sensorineural hearing loss (ISSNHL). In recent years there has been increasing scientific interest in treating ISSNHL by means of local steroid delivery. Usually, intratympanic steroids are used in three main protocols, as initial treatment, as adjunctive treatment given concomitantly with systemic steroids and as salvage treatment after failure of standard therapy. The purpose of this review is to examine the published literature regarding the therapeutic value of each method of treatment and to seek answers about the best delivery technique and the optimal administration schedule.

DATA SOURCES

Literature review from 1996 to 2009, PubMed and Medline.

STUDY SELECTION

We searched for trials concerning clinical evaluation of intratympanic steroids in ISSNHL patients, as a salvage treatment, as a first line therapy and in combination with the conventional therapy. Randomized and non-randomized case control studies and case series studies were the types of trials available for review.

DATA EXTRACTION

All the articles described in the study selection were used for this review.

DATA SYNTHESIS

Statistical techniques were not used.

CONCLUSION

On the basis of the available literature, it seems that topical steroids can be a valuable solution for ISSNHL patients who either cannot tolerate systemic steroid therapy or are refractory to it. Concerning the combined therapy, due to the controversial results of the existing studies, it cannot be determined yet whether this treatment protocol could yield superior results as a first line therapy. The need for establishment of standard criteria of hearing recovery should be underlined.

The efficiency of intratympanic dexamethasone injection as a sequential treatment after initial systemic steroid therapy for sudden sensorineural hearing loss

The effect of intratympanic steroid injection is controversial as salvage or initial treatment option for sudden sensorineural hearing loss (SSNHL) and almost unknown if it is consecutively to use after initial systemic steroids. This study aimed to analyze the efficiency of intratympanic dexamethasone injection (ITDI) as a sequential treatment in the patients who failed initial systemic steroid treatments for SSNHL. Forty-six patients with SSNHL who did not respond to initial systemic steroids were prospectively included in the study. The patients were randomly classified into two groups; the ITDI group (21 patients) did not take four sequential ITDI within 2 weeks after systemic steroids, and the control group (25 patients) took any more medications. Hearing improvement was defined as a 10 dB or more decrease in the pure tone average (PTA) of the four-frequencies (0.5, 1, 2, and 3 kHz). Hearing improvement was observed in 10 (47.6%) of 21 ITDI patients and in 4 (16.0%) of 25 control patients (P = 0.027). An improvement of the mean PTA was 11.4 dB in the ITDI group and 1.7 dB in the control group (P = 0.004). The ITDI group showed significant hearing improvement at low frequency (500 Hz) than the control group. The patients with 70 or more dB in PTA before ITDI showed significant hearing improvement than the other patients with better PTAs (P = 0.038). The sequential ITDI, which is performed immediately after initial systemic steroid therapy, may be a simple, effective second-line treatment of choice for the patients who show poor response to initial treatments for SSNHL.

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

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

[Intratympanic dexamethasone as therapeutic option in sudden sensorineural hearing loss]

INTRODUCTION AND OBJECTIVES

The administration of systemic corticosteroids has demonstrated effectiveness on the treatment of idiopathic sudden sensorineural hearing loss. However, its systemic toxicity and subsequent difficulty for its justification in some patients have led to it being applied intratympanically. The main aim of this study is to determine the effectiveness of intratympanic dexamethasone in these patients. In addition we evaluate the relationship between the prognosis of this condition and the magnitude of initial hearing loss, the presence of vertigo or delay in the beginning of therapy.

METHODS

We performed a retrospective case study of 18 patients. All of them were treated with intratympanic dexamethasone (4 mg/ml), administered weekly for 3 weeks. The follow-up was 1 month at least. The therapeutic success was arbitrarily defined to be a mean improvement of 25 dB or greater.

RESULTS

72.2% of the population recovered hearing successfully. The mean auditory threshold prior to treatment was 91+/-25 dB versus 51+/-35 dB after the end of it (p<0.0005). In addition, we observed that the initial severity of the hearing loss, the presence of vertigo and the delay in starting therapy cannot be considered as indicators of poor auditory prognosis.

CONCLUSIONS

Intratympanic dexamethasone appears to be an effective therapeutic option for patients with sudden onset sensorineural hearing loss who, for whatever reason, cannot be treated with systemic steroids. Nonetheless, randomized controlled trials should be instituted to improve levels of scientific evidence.

Clinical significance of endolymphatic imaging after intratympanic gadolinium injection

CONCLUSION

Using three-dimensional real inversion recovery (3D-real IR) and three-dimensional fluid-attenuated inversion recovery (3D-FLAIR) magnetic resonance imaging (MRI), various degrees of endolymphatic hydrops were observed in the basal and upper turns of the cochlea and in the vestibular apparatus after intratympanic gadolinium (Gd) injection. MRI may contribute to our understanding of inner ear diseases and may be a useful addition to intratympanic drug therapy in the management of inner ear diseases.

OBJECTIVE

To evaluate 3D-real IR MRI and 3D-FLAIR MRI with clinical symptoms and signs in patients with inner ear disease.

PATIENTS AND METHODS

Gd was diluted in saline and injected intratympanically in 73 patients with inner ear disease. The endolymphatic space was evaluated with 3-Tesla MRI at 1 day after the intratympanic Gd injection.

RESULTS

3D-real IR MRI was generally better than 3D-FLAIR MRI in discriminating between the perilymphatic space and endolymphatic space in the cochlear turns and in the vestibular apparatus. However, when Gd concentration was insufficient in the perilymph, it was more difficult to visualize the Gd with 3D-real IR MRI than with 3D-FLAIR MRI. Endolymphatic hydrops was observed using MRI in patients with 'probable' Meniere's disease based on the criteria.

Issues, indications, and controversies regarding intratympanic steroid perfusion

PURPOSE OF REVIEW

Office-based intratympanic inner ear steroid perfusion (ITPs) treatment for Ménière's disease, autoimmune inner ear disease, and sudden sensorineural hearing loss has been expanding over the past 10-15 years, yet remains controversial. The purpose of this review is to examine the current literature of basic science and human studies of ITPs treatment.

RECENT FINDINGS

Animal studies exist regarding the delivery, distribution, biochemical, and microbiological changes in the inner ear post ITPs. However, few clinical studies exist on ITPs treatment in sudden sensorineural hearing loss and even less in treating Ménière's disease. There are no consistent studies regarding drug delivery methods, type, and concentration of steroids. Moreover, there are no studies comparing ITPs results to the natural history of Ménière's disease.

SUMMARY

ITPs has impacted otology and neurotology practice due to increased utilization. A sound understanding of the basic science and clinical studies is needed to establish long-term efficacy of ITPs in controlling hearing loss in Ménière's disease by comparison to its natural history, as well as, potential application to other disorders.

Can intratympanic dexamethasone added to systemic steroids improve hearing outcome in patients with sudden deafness?

OBJECTIVE

To evaluate the therapeutic efficacy of intratympanic dexamethasone (ITD) injections added to systemic steroids in patients with idiopathic sudden sensorineural hearing loss (HL).

MATERIALS AND METHODS

A total of 120 patients diagnosed with sudden HL were treated with ITD injections (0.3 mL on days 1, 3, and 5) plus 48 mg methylprednisolone (ITD group) or methylprednisolone alone (control group).

RESULTS

The total recovery rate after the treatment was 73.3% in the ITD group and 70.0% in the control group. Although improvements in pure-tone average were the same in the two groups, the ITD group showed significantly better hearing improvement at 250 Hz than the control group.

CONCLUSION

The addition of ITD to systemic steroids did not result in significant improvements in the treatment of idiopathic sudden HL.