Tympanic Membrane Perforation After Intratympanic Steroid Injection: A Systematic Review and Meta-analysis

Therapeutic effectiveness of intratympanic and retroauricular methylprednisolone sodium succinate for refractory sudden sensorineural hearing loss in diabetic patients

BACKGROUND

Managing refractory sudden sensorineural hearing loss (RSSHL) in patients with diabetes mellitus (DM) presents significant therapeutic challenges, highlighting the importance of identifying effective treatment strategies.

AIM

To analyze the therapeutic effectiveness of intratympanic injection plus retroauricular injection for RSSHL complicated with DM.

METHODS

This study included 84 patients with RSSHL complicated with DM from April 2021 to April 2024, all receiving routine treatment. Participants were categorized into the control group (40 cases), receiving an intratympanic injection of methylprednisolone sodium succinate (MPSS), and the research group (44 cases), treated with retroauricular MPSS injection the next day in addition to the treatment administered in the control group. The efficacy, adverse reactions (tympanic membrane perforation, middle ear infections, burning sensation, vertigo, and tinnitus), blood glucose (BG) [fasting BG (FBG), 2-hour postprandial BG (2hPBG), and glycosylated hemoglobin (HbA1c)], hearing thresholds at different frequencies (250 Hz, 500 Hz, and 1000 Hz), serum biochemical indexes [interleukin (IL)-6, C-reactive protein (CRP), and procalcitonin (PCT)], and quality of life assessed by the short-form 36 item health survey (SF-36) were comparatively analyzed.

RESULTS

The research group demonstrated a markedly higher total effectiveness rate (81.82% vs 60.00%, P = 0.027) and a comparable incidence of total adverse reactions than the control group. Further, the research group exhibited notably reduced FBG, 2hPBG, HbA1c, IL-6, CRP, and PCT post-treatment (P < 0.01), which were lower compared with the pre-treatment levels and the control group (P < 0.05), as well as reduced hearing thresholds at different frequencies (250 Hz, 500 Hz, and 1000 Hz, P < 0.05). Furthermore, the post-treatment SF-36 scores of the research group in terms of energy, social functioning, role functioning, physical functioning, mental health, and overall health were all significantly improved than the pre-treatment levels and the control group (P < 0.05).

CONCLUSION

The above results indicate that intratympanic plus retroauricular injections of MPSS are effective in treating RSSHL complicated with DM without increasing the incidence of adverse reactions, which has a health promotion value.

Ultra-tiny-scale technology for engineering human ear therapeutics

Ultra-tiny-scale technology representing engineered micro- and nano-scale materials has gained considerable attention for a wide range of applications, including hearing restoration. The advent of hearing loss and its recovery has been the topic of intense discussion since many decades. Although conventional treatments partially support hearing recovery, they present certain limitations such as subsequent immune response and donor site morbidity leading to even worsened sensory disturbances. Microscale- and nanoscale-based approaches such as tissue engineering, nanoparticle-assisted drug delivery systems, and micro/nanofabrication-aided auditory stimulations have been shown to play an efficient role in recovery from hearing disorders. In particular, the introduction of different biomaterials and biopolymers (natural and synthetic) with influential topographical cues and excellent biocompatibility has been found to conveniently bypass previous challenges posed by rigid human ear structures and provided a new path for improved and advanced hearing-recovery approaches. This review is focused on the development of micro/nanoengineering-based hearing recovery therapeutics and their significant impact on the future of hearing research. It discusses the physiological functions associated with the human ear and the mechanism underlying distinct hearing loss disorders as well as highlights various engineered ultra-tiny-scale-assisted strategies for developing advanced hearing therapeutics. Finally, we deliberate on commercialization aspect and future perspectives of implementing micro/nanotechnologies for hearing restoration platforms.

The efficacy of methylprednisolone acetate nanogel in treating patients with sudden sensorineural hearing loss

Intratympanic injection of methylprednisolone acetate is considered to be one of the effective drugs in the treatment of sudden sensorineural hearing loss. In this study, the efficacy of intratympanic injection of methylprednisolone acetate nanogel in patients with sudden sensorineural hearing loss was investigated. It is a double-blind randomized clinical trial in one of Iran's hospitals. 96 patients diagnosed with sudden sensorineural hearing loss were examined. The intervention group (40 patients) was treated with intratympanic nanogel form of methylprednisolone acetate (four times, one day in between) along with oral prednisolone, and the control group (56 patients) was treated with the usual ampoule form of methylprednisolone acetate along with oral prednisolone. The patients were followed up two weeks and two months after the treatment by checking the audiometric findings. 22.9% of all patients had complete response to treatment and 58.3% partial response to treatment. Complete response to treatment was more common in patients of the intervention group, and non-response to treatment was more common in the control group. The frequency of tinnitus two months after the start of treatment was significantly lower in the intervention group, but the frequency of dizziness was not significantly different between the two groups. In both groups, a significant improvement in audiometric findings was observed after treatment compared to before treatment (p < 0.0001). In both groups, a significant improvement in audiometric findings was observed after treatment compared to before treatment (p < 0.0001), and this improvement rate was slightly higher in the intervention group than in the control group. Combined treatment of systemic steroid with both nanogel and or conventional intratympanic methylprednisolone acetate can be effective in the treatment of sudden sensorineural hearing loss, but the effectiveness of the nanogel form of the drug is slightly higher. Therefore, drug transfer based on nanogels can be considered to achieve better treatment results.

Preventing Cisplatin-Induced Hearing Loss in Adults: A Systematic Review and Meta-Analysis

OBJECTIVE

Ototoxicity is a known side effect of cisplatin chemotherapy. The efficacy of various medications used to prevent or reduce ototoxicity in adults receiving cisplatin has not been thoroughly described in the literature.

DATA SOURCES

CINAHL, Cochrane Library, PubMed, and SCOPUS.

REVIEW METHODS

Literature was searched between 1990 and 2024. Studies evaluating interventions to prevent hearing loss in adults receiving cisplatin were included. Audiometric data including pure tone threshold, pure tone average, and incidence of hearing loss were extracted from included studies.

RESULTS

Eight studies (N = 431 total patients) pertaining to cisplatin-induced hearing loss in adults were included. Of these studies, six were randomized control trials (N = 372 patients) and two were prospective cohort studies (N = 59 patients). The cytoprotective treatments included diethyldithiocarbamate (intravenously), dexamethasone (intratympanic), N -acetylcysteine (intratympanic), sodium thiosulfate (intravenously), calcium gluconate (intravenously), and aspirin (PO). The treatment group had an incidence in overall hearing loss of 63.3% compared to the 66.2% incidence in the control group ([95% CI, -6.2 to 11.9] p = 0.53). Patients treated with dexamethasone had lower degrees of hearing loss compared to those treated with N -acetylcysteine. However, neither of these interventions were superior to the control group.

CONCLUSIONS

These results show no difference in reducing the incidence nor severity of hearing loss between the treatment and control groups. Standardization of evaluated frequencies and ototoxicity grading scales will improve investigators' ability to compare various treatments. Unfortunately, the power of this study is limited by the sample size.

Summary of Japanese clinical practice guidelines for Bell's palsy (idiopathic facial palsy) - 2023 update edited by the Japan Society of Facial Nerve Research

OBJECTIVE

The "Summary of Japanese clinical practice guidelines for Bell's palsy (idiopathic facial palsy) - 2023 update edited by the Japan Society of Facial Nerve Research" aims to review the latest evidence regarding the treatment of Bell's palsy and to provide appropriate recommendations.

METHOD

Regarding the treatment of Bell's palsy, a guideline panel identified key clinical questions using an analytic PICO framework. The panel produced recommendations following the standards for trustworthy guidelines and the GRADE approach. The panel considered the balance of benefits, harm, and preferences when making recommendations.

RESULTS

The panel identified nine key clinical questions: systemic (high/standard dose) corticosteroids, intratympanic corticosteroids, systemic antivirals, decompression surgery, acupuncture, physical therapy, botulinum toxin, and reanimation surgery.

CONCLUSION

These guidelines strongly recommend systemic standard-dose corticosteroids for the clinical management of Bell's palsy. Other treatments are weakly recommended due to insufficient evidence. The absolute risk reduction of each treatment differed according to the disease severity. Therefore, physicians and patients should decide on treatment based on the disease severity.

Searching for a Better Animal Model for Chronic Tympanic Membrane Perforation

Chronic tympanic membrane perforation represents a prevalent otological condition, necessitating a reliable animal model for the validation and safety assessment of surgical techniques and materials employed in myringoplasty. This prospective study involved the establishment of chronic tympanic membrane perforation animal models in 16 chinchillas. A thermic myringotomy was conducted on the right ear (study group), followed by cold instrument myringotomy, coupled with the topical application of mitomycin C and dexamethasone solution on the left ear (control group). Results revealed that tympanic membrane perforations in the study group persisted for a minimum of 4 weeks in 93.7% of cases and extended to 12 weeks in 62.5% of the cases. In contrast, all tympanic membrane perforations in the control group were present at 4 weeks, with only 37.5% persisting after 12 weeks, although statistical tests did not find significant differences between the two groups (chi-square: p-value = 0.157, Kruskal-Wallis: p-value = 0.093, Mann-Whitney: p-value = 0.121). The thermic myringotomy employed to induce chronic tympanic membrane perforation in animals demonstrated efficiency and sustainability. This model, characterized by stability and reproducibility, holds promise for future experimental applications in the field.

Comparison of side effects of different steroids used in intratympanic injections

OBJECTIVES

This study aimed to compare the side effects of different steroids used in the intratympanic injections (IT).

METHODS

One hundred and sixty patients diagnosed with sudden sensorineural hearing loss and undergoing IT were assigned to four groups based on the type or concentration of steroids administered (Group DM5: 5 mg/ml Dexamethasone sodium phosphate; Group DM10: 10 mg/ml Dexamethasone sodium phosphate; Group MP: 40 mg/ml Methylprednisolone sodium succinate; Group BM: 4 mg/ml Betamethasone sodium phosphate). Each group comprised 40 patients, and all participants received IT six times. The study assessed and compared the degrees and duration of pain, dizziness, and tympanic membrane damage following IT. Patients were asked to report the pain they felt using the numeric rating scale (NRS).

RESULTS

NRS scores for pain after IT showed significant differences among the four groups (p < 0.001). The average NRS scores for pain in each group were as follows: Group DM5: 1.53 ± 1.04; Group DM10: 1.45 ± 1.30; Group MP: 4.33 ± 2.22; Group BM: 6.03 ± 1.46. The durations of pain after IT also exhibited significant differences among the four groups (p < 0.001), with the longest duration observed in Group MP at 31.93 ± 15.20 min.

CONCLUSION

Different types of steroids could lead to varying degrees of pain when used in IT. Betamethasone could cause the most severe pain, and methylprednisolone could result in the longest duration of pain.

[Role of intratympanic glucocorticoid treatment in sudden hearing loss]

Idiopathic sudden sensorineural hearing loss (ISSNHL) is one of the most common diseases in otolaryngology. Its etiology remains unknown. Furthermore, there is only a low level of evidence for the efficacy of established treatment modalities. In addition to systemic glucocorticoids, intratympanic corticosteroid treatment (ICT) has become increasingly important for treatment of ISSNHL. Different application strategies and treatment regimens have been described; however, uniform standards do not yet exist. ICT may be used for primary treatment as well as salvage therapy. Current data from meta-analyses show no benefit of intratympanic versus systemic primary therapy for sudden hearing loss (moderate evidence) but suggest a benefit of intratympanic secondary treatment over no treatment or placebo (high effect size, low evidence). Regarding combination of systemic and local glucocorticoid therapy in primary treatment of hearing loss, there may be a small benefit over systemic treatment alone (low effect size, low evidence).

Biosafety and potency of high-molecular-weight hyaluronic acid with intratympanic dexamethasone delivery for acute hearing loss

Objective: This study evaluated the potential of high-molecular-weight hyaluronic acid (HHA) as an intratympanic (IT) drug delivery vehicle for dexamethasone (D) in treating acute hearing loss. We compared the efficacy, safety, and residence time of HHA to the standard-of-care IT drug delivery method. Methods: Endoscopic examinations were used to track tympanic membrane (TM) healing post-IT injection. Micro-computed tomography (CT) was used to gauge drug/vehicle persistence in the bulla air space. Histological analyses covered the middle ear, TM, and hair cell counts. Auditory brainstem responses (ABR) were used to measure hearing thresholds, while high-performance liquid chromatography (HPLC) was employed to quantify cochlear perilymph dexamethasone concentrations. Results: The HHA + D group had a notably prolonged drug/vehicle residence time in the bulla (41 ± 27 days) compared to the saline + D group (1.1 ± 0.3 days). Complete TM healing occurred without adverse effects. Histology revealed no significant intergroup differences or adverse outcomes. Hearing recovery trends favored the HHA + D group, with 85.0% of ears showing clinically meaningful improvement. D concentrations in cochlear perilymph were roughly double in the HHA group. Conclusion: HHA is a promising vehicle for IT drug delivery in treating acute hearing loss. It ensures extended residence time, augmented drug concentrations in targeted tissues, and safety. These results highlight the potential for HHA + D to excel beyond existing standard-of-care treatments for acute hearing loss.

Effects of Oral Steroids Combined with Postauricular Steroid Injection on Patients with Sudden Sensorineural Hearing Loss with Delaying Intervention: A Retrospective Analysis

Background

In the otology clinic, we often receive some sudden sensorineural hearing loss (SSNHL) patients accompanied by annoying tinnitus, who usually visited over three weeks after the onset. Nevertheless, due to the high treatment cost and relatively low cure rate, there are still great disputes about hospitalization or not for these patients. Aim: This study aimed to perform a retrospective analysis for analyzing the efficacy of treatment with oral steroids combined with postauricular steroid injection in patients with delaying effective treatment.

Material/Methods

A total of 157 eligible SSNHL patients with delaying effective treatment over three weeks were enrolled in this study. According to different treatment methods of oral steroids with or without postauricular steroid injection, these patients were divided into three groups: PO (prednisone oral) group, PSI (prednisone oral and postauricular steroid injection) group, and PII (prednisone oral and postauricular lidocaine injection) group. The changes in level of hearing, mean subjective tinnitus loudness, and side effects were analyzed in the three groups.

Results

Hearing improvement and tinnitus remission were all observed in three groups after treatment. Compared with PO and PII groups, those patients in PSI groups had more improvement in level of hearing and mean subjective tinnitus. The level of tinnitus loudness was statistically significantly correlated with the level of PTA both before treatment and after treatment.

Conclusion

Oral steroids combined with postauricular steroid injection should be employed for treatment of SSNHL patients with delaying effective treatment over three weeks.

Designing a Prolonged Method of Therapeutic Delivery to Support Rehabilitation From Ototoxic Damage in a Schwann Cell Model

HYPOTHESIS

The ototoxicity of gentamicin and cisplatin can be evaluated with a Schwann cell model to screen for otoprotective agents that can be encapsulated into poly (lactic-co-glycolic acid) (PLGA) microparticles for drug delivery to the inner ear.

BACKGROUND

Aminoglycosides and cisplatin are widely prescribed but known to cause ototoxicity. There is strong evidence that compromise to Schwann cells ensheathing inner ear afferent neurons results in inner ear dysfunction mimicking drug-induced ototoxicity. There is a need for a model for ototoxic demyelination to screen medications for protective potential and to subsequently target and tune the delivery of any promising agents.

METHODS

RT4-D6P2T rat schwannoma cells were used as a Schwann cell model to assess gentamicin and cisplatin toxicity and to screen for protective agents. Cell viability was evaluated with the MTT cell proliferation assay. N -acetylcysteine (NAC) was encapsulated into a PLGA microparticle, and its elution profile was determined.

RESULTS

The estimated 50% lethal concentration dose for gentamicin was 805.6 μM, which was 46-fold higher than that for cisplatin (17.5 μM). In several trials, cells dosed with NAC and cisplatin demonstrated a 22.6% ( p < 0.001) increase in cell viability when compared with cisplatin alone. However, this protective effect was not consistent across all trials. NAC was encapsulated into a PLGA microparticle and elution plateaued at 5 days.

CONCLUSION

When dosed at their respective therapeutic ranges, cisplatin is more likely than gentamicin to induce damage to the Schwann cell model. Although NAC demonstrates an uncertain role in protecting against cisplatin-induced Schwann cell cytotoxicity, this study establishes a method to screen for other otoprotective medications to encapsulate into a tunable microparticle for localized drug delivery.

Retrospective study of risk factors for tympanic membrane perforation in the early period after intratympanic steroid injection

OBJECTIVE

Intratympanic steroid injection (ITSI) can be an effective treatment for sudden sensorineural hearing loss or Meniere's disease. Tympanic membrane (TM) perforation after ITSI is a major complication which needs additional treatment. The purpose of this study is to assess the factors associated with TM perforation after ITSI.

METHODS

We obtained the clinical data of patients who underwent ITSI treatment at the Department of Otolaryngology JR Tokyo General Hospital from April 2013 to March 2021. The data included age, sex, treated side, number of injections, average interval between injections, TM anesthesia with Zentöl solution, which contains phenol, any history of diabetes and any concurrent use of oral or intravenous steroids. We evaluated the association between these variables and TM perforation after ITSI using the Student's t-test, the chi-squared test, univariate logistic regression analysis and multivariate logistic regression analysis. TM perforation was defined as a case in which perforation was observed at least once during outpatient visits.

RESULTS

Records of 205 ears in 190 patients were analyzed. The overall proportion of TM perforation in the early period after ITSI was 12.7% (26 out of 205 ears), which decreased to 9.3% (19 out of 205 ears) and 5.9% (12 out of 205 ears) at the 1- and 3-month follow-ups, respectively. The proportion of TM perforation in the early period after ITSI without TM anesthesia was 3.5% (5 ears out of 145 ears), which decreased to 1.4% (2 ears) or 0% at the 1- or 3- month follow-ups, respectively. The use of tympanic anesthetics which contain phenol was significantly associated with TM perforation in univariate logistic regression analysis (odds ratio: 15.08, 95% confidence interval: 5.34-42.56, p < 0.001) and in multivariate analysis (odds ratio: 20.76, 95% confidence interval: 6.31-68.3, p < 0.001). All TM perforation cases without TM anesthesia healed spontaneously or with paper tympanic closure treatment. TM perforation in 6 ears out of 21 ears with TM anesthesia did not heal during the follow-up.

CONCLUSION

The overall proportion of TM perforations from the early period after ITSI was 12.7%, 9.3% at the 1-month post-ITSI outpatient follow-up, 5.9% at the 3-month post-ITSI outpatient follow-up. Tympanic anesthesia was significantly associated with TM perforation after ITSI, which indicated that TM anesthesia with solutions containing phenol is not recommended for ITSI.

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

OBJECTIVE

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

PATIENTS

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

INTERVENTIONS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

Effectiveness of Intratympanic Dexamethasone Injection for Tinnitus Treatment: A Systematic Review and Meta-Analysis

Objectives

Intratympanic dexamethasone injection (ITDI) has been introduced as a treatment option for subjective tinnitus. However, the effects of ITDI on patients with tinnitus remain unclear. In the present systematic review and metaanalysis, we evaluated the effectiveness of ITDI for tinnitus treatment.

Methods

We searched Medline, the Cochrane Central Register of Controlled Trials, and Embase. Four double-blind randomized controlled trials that tested the efficacy of ITDI compared with a placebo were deemed eligible for a quantitative meta-analysis, while four prospective studies and seven retrospective studies reporting the effectiveness of ITDI on tinnitus treatment were included in a qualitative synthesis.

Results

In the four studies included in the quantitative meta-analysis, ITDI did not show evidence of tinnitus improvement compared with placebo (odds ratio [OR], 1.38; 95% confidence interval, 0.53-3.61). In the 11 studies included in the qualitative synthesis, seven retrospective studies without controls reported rates of tinnitus improvement after ITDI ranging from 35.9% to 91.3%. In the four prospective studies with controls, ITDI seemed to be effective when combined with other drugs for tinnitus treatment.

Conclusion

ITDI alone did not show a significant effect for treating tinnitus compared with placebo. However, the potential of combination treatment of ITDI with other drugs for tinnitus therapy should be further studied in more systematic research.