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Dosage of prednisone for sudden hearing loss.Sudden Hearing Loss
The mean initial hearing level was The final hearing level in group I was A Comparison of the pretreatment hearing levels at each frequency. B Comparison of the posttreatment hearing levels at each frequency. The hearing improvement rates did not differ between groups I and II Regarding severe adverse events during treatment, one patient in group II experienced pulmonary edema and upper gastrointestinal bleeding.
However, other major complications, such as myocardial infarction and death, did not occur in any of the groups. However, the occurrence rates of these adverse events were not significantly different between the two groups Table 3. Our study showed that patients receiving conventional steroid treatment had slightly better hearing recovery than patients who received reduced steroid doses, although the difference was marginally significant.
Similar trends were found when the final audiograms at all frequencies were compared, with the exception of the 4 kHz frequency. No significant differences in the occurrence rates of adverse effects were found between the two groups. These findings may suggest that steroid dose reduction is not preferable to the conventional steroid regimen in geriatric patients with ISSNHL.
In contrast, a prospective randomized trial reported that therapeutic outcomes did not differ between 7-day prednisolone and mg dexamethasone pulse therapies [17]. The colleagues of those authors also reported newly developed myocardial infarctions in patients following the pulse therapy and urged clinicians to consider the severe risks of steroid treatment [18]. These findings suggest that the potential benefits of high-dose pulse therapy may not exceed the risks of severe complications.
In addition, the duration of steroid use as well as the dosage may be important variables, both of which determine the cumulative steroid dose that may affect the hearing outcome or occurrence of adverse events.
The relatively short-term duration of treatment in group II 8 days compared with that in group I 14 days might have affected the treatment outcome in our study. A recent survey conducted in the United States reported that This may be attributed to the fact that the optimal dosage and duration of steroid treatment, particularly in elderly population with comorbidities, have not been determined.
With aging, liver function, which is primarily responsible for the metabolism of steroids, is mostly maintained, but phase I metabolism catalyzed by cytochrome P tends to decrease, and an increase in interindividual variability is distinctive [20].
Moreover, the affinities of the receptor protein for dexamethasone and corticosterone tend to decrease [21]. Therefore, the use of higher steroid doses might be more rational than lower-dose steroid treatment; however, excessively high-dose steroid treatments have failed to show additional benefits [17]. Based on these findings, we suggest that further studies comparing a greater range of steroid regimens for the treatment of ISSNHL should be performed to identify the optimal dose because we still do not have many options other than steroid treatment [9].
Apart from systemic steroid treatment, intratympanic steroid injection is currently recommended after the failure of the initial treatment [1]. Other possible treatment options include hyperbaric oxygen therapy, and a significant improvement in hearing was reported in the acute stage of ISSNHL following this therapy [22].
The mechanism of action in this therapy is now thought to be the control of cochlear ischemia by increasing oxygen partial pressure. However, in most hospitals, this therapy is not available because it requires a specific sealed chamber. Moreover, it is an expensive and time-consuming treatment method. Other possible options include medications such as antiviral agents [23] , vasodilators such as carbogen, alprostadil, naftidrofuryl, and low-molecular-weight dextran [24] , high-dose vitamins [25] , [26] , and zinc supplementation [27].
However, the effects of these agents have not been sufficiently studied and there is no evidence to support their use. To reduce the confounding effects between diverse treatment options and the observed baseline characteristics, we performed the PSM analysis [28] , [29]. Selection bias was decreased as far as possible by controlling for the diverse prognostic factors and cointerventions that may have influenced the treatment outcomes. As a result, we were able to compare the intervention effects of the examined steroid regimens by the PSM analysis in order to overcome the limitations of the retrospective, observational study design [29].
Our study has several limitations. It seems unnatural to include covariates such as IT-DEX, alprostadil, and zinc, which may act as confounding factors to the outcome, in the PSM analysis.
However, the exclusion of all patients who were treated with cointerventions could result in insignificant conclusions owing to a small sample size. Therefore, we controlled cointerventions as covariates to be able to evaluate the sole effect of steroid dose by minimizing the between-group difference. In conclusion, conventional steroid regimens produced the occurrence rates of adverse events that were similar to those of low-dose treatment but may also have produced better recoveries.
The use of steroid dose reduction in geriatric patients with ISSNHL is not preferable to conventional steroid regimen. Browse Subject Areas? Click through the PLOS taxonomy to find articles in your field.
Abstract We aimed to compare the treatment outcomes and the occurrence rates of adverse events associated with different steroid regimens in geriatric patients aged 65 years or older with unilateral idiopathic sudden sensorineural hearing loss ISSNHL. Introduction According to recent guidelines, initial corticosteroid treatment can be administered to patients with idiopathic sudden sensorineural hearing loss ISSNHL [1].
Patients Based on retrospective medical chart reviews, we enrolled patients who were aged 65 years or older and had been diagnosed with ISSNHL and admitted to the university hospital between May and December Calculation of Hearing Levels and Estimation of Recoveries Hearing levels were calculated using the arithmetic mean of the hearing levels at Hz, 1 kHz, 2 kHz, and 4 kHz.
Statistical Analyses The details of the estimation of the propensity scores were as follows: 1 age, sex, accompanying hypertension and diabetes, presence of tinnitus or dizziness, initial hearing levels of the lesion and healthy sides, IT-DEX treatment, and other cointerventions alprostadil or zinc injection were selected as covariates based on the results of the previous studies [12] — [16] ; 2 treatment assignment group I or II was used as the outcome variable; 3 logistic regression was performed, and propensity scores were calculated.
Results A total of patients were enrolled in this study, including 44 men Download: PPT. Figure 1. Changes in hearing levels at each frequency before and after treatment in propensity-score matched population. Table 2. Comparison of the posttreatment hearing levels at each frequency. Table 3. Treatment outcomes according to different steroid regimens. Discussion Our study showed that patients receiving conventional steroid treatment had slightly better hearing recovery than patients who received reduced steroid doses, although the difference was marginally significant.
References 1. View Article Google Scholar 2. Lancet — View Article Google Scholar 3. View Article Google Scholar 4. JAMA — View Article Google Scholar 5. World J Cardiol 4: — View Article Google Scholar 8. Diabetes Care — View Article Google Scholar 9.
This involves testing the ability to hear tones and to understand speech. It is one thing to be able to hear tones, but far more important is the ability to hear and understand speech. A tympanogram is performed to assess the mobility of the eardrum to ensure it is appropriately mobile. Hearing loss is best described in terms of a descriptive term such as mild, moderate, moderately-severe, severe and profound. People are frequently told a percentage of hearing they have lost, which is a complicated calculation that is rarely performed.
Another important diagnostic test is an MRI scan. An imaging center must have some expertise to be able to appropriately perform this study with sufficiently high quality, therefore contrast may be required at some centers. With an open MRI, contrast will also be required. If an MRI cannot be performed as in the case of a pacemaker , other studies can be used to lessen the suspicion of a vestibular schwannoma, such as auditory brainstem response testing [ 16 ].
Once the diagnosis of SSNHL is confirmed, a discussion of available treatment options must be carried out with a physician knowledgeable in the disorder. A great number of treatments have been described over time, but most have been found to be unhelpful. Treatments found to be unhelpful include: antiviral medications [ 17 ], volume expanding agents dextran [ 18 ], and vasodilators [ 19 ].
One possible treatment is no treatment at all, or a period of observation. As described previously, some patient will improve without any medical intervention. There are some features of the hearing loss that may indicate a favorable result with simple observation. These include a low frequency hearing loss and a mild hearing loss. Most hearing improvement noted with observation is seen within the first two weeks after onset [ 6 ]. Although controversial, the most commonly prescribed treatment for SSNHL is the use of oral steroids.
A randomized, placebo-controlled trial in demonstrated two-third of patients treated with steroids showed improvement while only one-third of patients treated with placebo had improvement of their hearing[ 20 ]. Other studies have shown no effect with steroid use [ 21 , 22 ].
Prednisone is typically used at doses ranging from mg daily for days, then a tapering of the dosage over the following days. The optimal dosage of steroid and the time needed for treatment in not defined by any medical study. Steroids are clearly not effective in all patients, as not all patients have improvement with their use.
However, some patients are clearly responsive to steroids which is demonstrated in trials of patients receiving steroids injected into the middle ear space discussed below. Steroids are associated with side-effects that can include: elevation in blood glucose, increased pressure within the eye, hip joint problems with possible need for joint replacement surgery, inability to sleep, weight gain, fluid retention, bone weakening, psychiatric disturbances, among others.
In an ideal situations, steroids would only be prescribed to patients that will benefit from their use, and avoided in those who will improve with no treatment. However, we do not currently have a laboratory test that will demonstrate who will or will not respond to steroids. While treating some patients that will derive benefit, some patients are exposed to the side effects of steroids without hearing benefit. In our opinion, since major long-term complications of steroids are rare, we feel the benefit of treatment with oral steroids outweighs the risk.
Steroids can be delivered to the inner ear by injection of medication through the eardrum into the middle ear. The steroid then passes through a membrane called the round window and into the inner ear. Delivery of steroid by this injection achieves much higher concentrations of steroid within the inner ear than that seen with oral steroid administration [ 23 , 24 ]. In animals, the medicine within the inner ear lasts for less than 24 hours [ 23 ].
For this reason, to maintain a prolonged, adequate dosage of steroid within the inner ear, multiple injections are performed.
The steroid injection procedure is well-tolerated and performed in the office. The eardrum is visualized under a microscope, and a small needle is used to inject the medicine into the middle ear. The patient lies in the exam chair with her head turned for 30 minutes to allow the medicine to diffuse into the inner ear. The patient does her best not to swallow or speak during this period to minimize opening of the eustachian tube.
Eventually, the fluid will exit the middle ear via the eustachian tube and run into the back of the nose. A small amount of steroid is absorbed into the bloodstream, but at much lower concentrations than that seen with oral use. There is a tiny chance that a persistent hole in the eardrum may form. Transtympanic steroids have been shown to be equally effective to oral steroids [ 25 ].
In addition, transtympanic steroids have been shown, in a majority of studies, to be effective in treating patients who have failed to improve with observation, oral steroids alone, or other treatments[ ]. Combination therapy with oral and transtympanic steroids have been shown to be superior to one form of steroid alone [ 30 ]. For most patients, we recommend an initial treatment with a combination of oral and transtympanic steroids for SSNHL. The transtympanic steroids result in a high dose of steroid within the inner ear, and we know a higher dosage of steroid leads to better results [ 31 ].
Because steroid within the inner ear persists for less than 24 hours, we recommend daily injections. We typically recommend a minimum of three injections, but do not have a set maximum of injections, instead we treat until the hearing improvement stabilizes.
We utilize oral steroids due to the fact that transtympanic steroids alone will not reach the hearing cochlear nerve. Oral steroids will deliver steroid to the hearing nerve, which may be a site of dysfunction. By way of this combination, the fluid of the inner ear and the hearing nerve can be treated with steroids to maximize treatment success. Each patient much be treated on an individual basis and only with a thorough examination and history can a treatment regimen be recommended.
Byl, F. Laryngoscope, Alexander, T. Harris, Incidence of sudden sensorineural hearing loss. Otol Neurotol, Stachler, R. Otolaryngol Head Neck Surg, Conlin, A. Parnes, Treatment of sudden sensorineural hearing loss: I. A systematic review.
Arch Otolaryngol Head Neck Surg, Fetterman, B. Luxford, and J. Saunders, Sudden bilateral sensorineural hearing loss. Mattox, D. Simmons, Natural history of sudden sensorineural hearing loss. Ann Otol Rhinol Laryngol, Parnes, Treatment of sudden sensorineural hearing loss: II. A Meta-analysis. Rauch, S.
Idiopathic sudden sensorineural hearing loss. N Engl J Med,
We aimed to compare the treatment outcomes and the occurrence rates of adverse events associated with different steroid regimens in geriatric patients aged 65 years or older with unilateral idiopathic sudden sensorineural hearing loss ISSNHL. After thorough medical chart reviews of patients with ISSNHL between May and Decemberwe performed a propensity score-matched analysis using previously known prognostic factors, steroid regimens, and other cointerventions.
Patients were divided based on their steroid regimens into group I which initially received 48 mg of methylprednisolone daily with a subsequently tapered dose and group II which initially received 24 mg of methylprednisolone daily with a subsequently tapered dose. We compared final hearing and the occurrence of adverse events between the two groups. Group I patients showed better final hearing levels compared with group II patients In conclusion, conventional steroid regimens produced adverse event occurrence rates that were similar to those of low-dose treatment but may also have produced superior hearing recovery.
The use of steroid dose reduction in geriatric patients with ISSNHL is not preferable to conventional steroid regimens. This is an open-access article distributed under the terms of the Creative Commons Attribution Licensewhich permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: The authors confirm that all data underlying the findings are fully available without restriction. All relevant data are within the paper and its Supporting Information files.
The funders had no role in study design, data collection and analysis, decision to publish, and had a role in the preparation of the manuscript. Competing interests: The authors have declared that no competing interests exist.
According to recent guidelines, initial corticosteroid treatment can be administered to patients with idiopathic sudden sensorineural hearing loss ISSNHL [1]. Such treatment is commonly used on the basis of the hypothesis that it may affect the inner ear and induce suppression of the immune response, changes in microcirculation, and a decrease in endolymphatic pressure [2].
However, the effects of steroids on the treatment of sudden hearing loss remain unclear [3]. Although the adverse effects that occur after a to day course of steroids are usually acceptable and manageable [1]various symptoms may occur, including weight gain, gastritis, hypertension, hyperglycemia, cataracts, avascular necrosis of the hip, as well as changes in appetite, mood, sleep patterns, and even death [1][4][5].
A study of patients with diabetes revealed that patients with diabetes and chronic obstructive pulmonary disease who used high-dose corticosteroids were at a greater risk of diabetes-related hospitalization and suggested that the minimally effective corticosteroid dose should be used [6].
Therefore, the burden of complications associated with corticosteroid use may be larger in the elderly population than in younger patients. Prednisone at a dose of 60 mg daily or methylprednisolone MPD at a dose of 48 mg for 7 to 14 days is frequently used as an initial medication in the treatment of ISSNHL, and the doses are subsequently tapered [1]. However, many clinicians use slightly different protocols in terms of the type of steroid, dosage, and duration in different clinical settings, and the number of comparative studies of different steroid protocols is limited [1][9].
Based on these findings, we assumed that, if treatment outcomes following low-dose steroid treatments were as effective as those following higher-dose steroid treatments, the low-dose treatments would be accompanied by a reduced risk of adverse effects and that the use of low-dose steroid treatments for ISSNHL in geriatric patients would be more rational.
In this study, we aimed to compare the treatment outcomes and the occurrence rates of adverse events according to different steroid regimens in ISSNHL patients aged 65 years or older by using a propensity score-matched PSM analysis.
The Board granted a waiver of written informed consent for this retrospective study. Based on retrospective medical chart reviews, we enrolled patients who were aged 65 years or older and had been diagnosed with ISSNHL and admitted to the university hospital between May and December Oral MPD treatment was administered between and From earlyan additional intratympanic dexamethasone injection IT-DEX administered as a salvage therapy following oral MPD treatment has been the main treatment for sudden deafness.
The total cumulative dose of MPD was mg equivalent to mg of prednisolone over 14 days. These patients were classified as group I.
The total cumulative dose of MPD was mg equivalent to mg of prednisolone over 8 days. These patients were classified as group II. Hearing levels were calculated using the arithmetic mean of the hearing levels at Hz, 1 kHz, 2 kHz, and 4 kHz. Hearing improvement rates were calculated as the hearing gain divided by the initial hearing difference between the lesion side and the healthy side and then multiplied by [10][11].
Complete recovery was defined by a final hearing level within 20 dB or equal to the hearing level of the unaffected ear [10][11]. Good recovery was defined as hearing gains greater than 30 dB [10][11].
Fair recovery was defined as hearing gains of 10 to 29 dB. Hearing gains of less than 10 dB were defined as no change or deterioration [10][11].
Additionally, major complications such as myocardial infarction, gastrointestinal bleeding, and death were also documented.
The details of the estimation of the propensity scores were as follows: 1 age, sex, accompanying hypertension and diabetes, presence of tinnitus or dizziness, initial hearing levels of the lesion and healthy sides, IT-DEX treatment, and other cointerventions alprostadil or zinc injection were selected as covariates based on the results of the previous studies [12] — [16] ; 2 treatment assignment group I or II was used as the outcome variable; 3 logistic regression was performed, and propensity scores were calculated.
Next, a test of the balance of the covariates was performed, and the treatment effects were finally compared using paired t-tests and McNemar's tests. All statistical analyses were performed using the SPSS software ver. A total of patients were enrolled in this study, including 44 men Diabetes was reported in 26 patients Of accompanying symptoms, 76 patients The mean initial hearing level was The final hearing level in group I was A Comparison of the pretreatment hearing levels at each frequency.
B Comparison of the posttreatment hearing levels at each frequency. The hearing improvement rates did not differ between groups I and II Regarding severe adverse events during treatment, one patient in group II experienced pulmonary edema and upper gastrointestinal bleeding. However, other major complications, such as myocardial infarction and death, did not occur in any of the groups.
However, the occurrence rates of these adverse events were not significantly different between the two groups Table 3. Our study showed that patients receiving conventional steroid treatment had slightly better hearing recovery than patients who received reduced steroid doses, although the difference was marginally significant.
Similar trends were found when the final audiograms at all frequencies were compared, with the exception of the 4 kHz frequency. No significant differences in the occurrence rates of adverse effects were found between the two groups.
These findings may suggest that steroid dose reduction is not preferable to the conventional steroid regimen in geriatric patients with ISSNHL. In contrast, a prospective randomized trial reported that therapeutic outcomes did not differ between 7-day prednisolone and mg dexamethasone pulse therapies [17].
The colleagues of those authors also reported newly developed myocardial infarctions in patients following the pulse therapy and urged clinicians to consider the severe risks of steroid treatment [18]. These findings suggest that the potential benefits of high-dose pulse therapy may not exceed the risks of severe complications.
In addition, the duration of steroid use as well as the dosage may be important variables, both of which determine the cumulative steroid dose that may affect the hearing outcome or occurrence of adverse events. The relatively short-term duration of treatment in group II 8 days compared with that in group I 14 days might have affected the treatment outcome in our study.
A recent survey conducted in the United States reported that This may be attributed to the fact that the optimal dosage and duration of steroid treatment, particularly in elderly population with comorbidities, have not been determined. With aging, liver function, which is primarily responsible for the metabolism of steroids, is mostly maintained, but phase I metabolism catalyzed by cytochrome P tends to decrease, and an increase in interindividual variability is distinctive [20].
Moreover, the affinities of the receptor protein for dexamethasone and corticosterone tend to decrease [21]. Therefore, the use of higher steroid doses might be more rational than lower-dose steroid treatment; however, excessively high-dose steroid treatments have failed to show additional benefits [17].
Based on these findings, we suggest that further studies comparing a greater range of steroid regimens for the treatment of ISSNHL should be performed to identify the optimal dose because we still do not have many options other than steroid treatment [9].
Apart from systemic steroid treatment, intratympanic steroid injection is currently recommended after the failure of the initial treatment [1]. Other possible treatment options include hyperbaric oxygen therapy, and a significant improvement in hearing was reported in the acute stage of ISSNHL following this therapy [22]. The mechanism of action in this therapy is now thought to be the control of cochlear ischemia by increasing oxygen partial pressure. However, in most hospitals, this therapy is not available because it requires a specific sealed chamber.
Moreover, it is an expensive and time-consuming treatment method. Other possible options include medications such as antiviral agents [23]vasodilators such as carbogen, alprostadil, naftidrofuryl, and low-molecular-weight dextran [24]high-dose vitamins [25][26]and zinc supplementation [27]. However, the effects of these agents have not been sufficiently studied and there is no evidence to support their use.
To reduce the confounding effects between diverse treatment options and the observed baseline characteristics, we performed the PSM analysis [28][29].
Selection bias was decreased as far as possible by controlling for the diverse prognostic factors and cointerventions that may have influenced the treatment outcomes. As a result, we were able to compare the intervention effects of the examined steroid regimens by the PSM analysis in order to overcome the limitations of the retrospective, observational study design [29]. Our study has several limitations. It seems unnatural to include covariates such as IT-DEX, alprostadil, and zinc, which may act as confounding factors to the outcome, in the PSM analysis.
However, the exclusion of all patients who were treated with cointerventions could result in insignificant conclusions owing to a small sample size.
Therefore, we controlled cointerventions as covariates to be able to evaluate the sole effect of steroid dose by minimizing the between-group difference. In conclusion, conventional steroid regimens produced the occurrence rates of adverse events that were similar to those of low-dose treatment but may also have produced better recoveries. The use of steroid dose reduction in geriatric patients with ISSNHL is not preferable to conventional steroid regimen. Browse Subject Areas? Click through the PLOS taxonomy to find articles in your field.
Abstract We aimed to compare the treatment outcomes and the occurrence rates of adverse events associated with different steroid regimens in geriatric patients aged 65 years or older with unilateral idiopathic sudden sensorineural hearing loss ISSNHL. Introduction According to recent guidelines, initial corticosteroid treatment can be administered to patients with idiopathic sudden sensorineural hearing loss ISSNHL [1].
Patients Based on retrospective medical chart reviews, we enrolled patients who were aged 65 years or older and had been diagnosed with ISSNHL and admitted to the university hospital between May and December Calculation of Hearing Levels and Estimation of Recoveries Hearing levels were calculated using the arithmetic mean of the hearing levels at Hz, 1 kHz, 2 kHz, and 4 kHz.
Statistical Analyses The details of the estimation of the propensity scores were as follows: 1 age, sex, accompanying hypertension and diabetes, presence of tinnitus or dizziness, initial hearing levels of the lesion and healthy sides, IT-DEX treatment, and other cointerventions alprostadil or zinc injection were selected as covariates based on the results of the previous studies [12] — [16] ; 2 treatment assignment group I or II was used as the outcome variable; 3 logistic regression was performed, and propensity scores were calculated.
Results A total of patients were enrolled in this study, including 44 men Download: PPT. Figure 1. Changes in hearing levels at each frequency before and after treatment in propensity-score matched population. Table 2. Comparison of the posttreatment hearing levels at each frequency. Table 3. Treatment outcomes according to different steroid regimens. Discussion Our study showed that patients receiving conventional steroid treatment had slightly better hearing recovery than patients who received reduced steroid doses, although the difference was marginally significant.
References 1.
Prednisone, Disp: 20 mg tabs, # 30; sig: 60 mg (3 tabs) po once daily × 7 days; 40mg (2 tabs) × 3 days; 20 mg (1 tab) × 2 days; 10 mg (1/2 tab) × 2 days. If SSNHL is confirmed or clinically suspected (awaiting formal audiometry) then high dose oral steroids should be considered for 1 week. It would be helpful if. Sudden sensorineural hearing loss affects 5 to 27 per , people annually, oral steroid therapy and salvage IT steroid therapy. The AAO-HNS guidelines recommend the following single-dose regimen: prednisolone 1 mg/kg/day for 7–14 days, then taper medication over a similar period. Other studies have shown no effect with steroid use [21, 22]. Prednisone is typically used at doses ranging from mg daily for days, then a tapering. Calculation of Hearing Levels and Estimation of Recoveries Hearing levels were calculated using the arithmetic mean of the hearing levels at Hz, 1 kHz, 2 kHz, and 4 kHz. Mech Ageing Dev —The onset of sudden hearing loss can be the cause of significant stress and worry in the affected individual. Sudden hearing can be the result of numerous different causes. In general, there are two types of hearing loss. One is conductive hearing loss, in which there is a problem getting sound from the environment to the inner ear.
In conductive hearing loss, there is typically a problem with the external ear canal, eardrum, or middle ear. In the second general category of. In the second general category of hearing loss, sensorineural hearing loss, the ear canal, eardrum, and middle ear space are normal.
The problem is located in a site out of view of the physical exam, namely the inner ear or nerve to the inner ear. Patients with sudden sensorineural hearing loss SSNHL most commonly present to their physician with a rapid onset of hearing loss, but a normal physical exam of the ear. SSNHL is not a common problem, in a population of , people, between people will develop this type of hearing loss each year [ 1 , 2 ]. In the United States, there are reports of up to 66, new cases diagnosed each year [ 2 ].
SSNHL is most commonly defined as a sensorineural hearing loss of at least 30 dB at three frequencies developing over a time period less than a 3 days [ 3 , 4 ]. If spontaneous recovery does occur, it most commonly occurs within the two weeks after onset [ 6 ]. In those cases of unknown cause, most are generally thought to be of a virally-mediated process [ 9 , 10 ].
Direct sampling of fluid from the inner ear or tissue from the hearing nerve to sample for viruses is not possible without the likely result of irreversible hearing loss. One of the most common symptoms that occurs is a sensation of fullness or pressure in the ear. This frequently leads patients or primary care doctors to treat patients as if the problem is caused by fluid in the middle ear space.
Treatment and the correct diagnosis can be delayed by treatment with unhelpful medications such as antibiotics, decongestants, and nasal sprays. This involves testing the ability to hear tones and to understand speech. It is one thing to be able to hear tones, but far more important is the ability to hear and understand speech.
A tympanogram is performed to assess the mobility of the eardrum to ensure it is appropriately mobile. Hearing loss is best described in terms of a descriptive term such as mild, moderate, moderately-severe, severe and profound. People are frequently told a percentage of hearing they have lost, which is a complicated calculation that is rarely performed. Another important diagnostic test is an MRI scan.
An imaging center must have some expertise to be able to appropriately perform this study with sufficiently high quality, therefore contrast may be required at some centers. With an open MRI, contrast will also be required. If an MRI cannot be performed as in the case of a pacemaker , other studies can be used to lessen the suspicion of a vestibular schwannoma, such as auditory brainstem response testing [ 16 ]. Once the diagnosis of SSNHL is confirmed, a discussion of available treatment options must be carried out with a physician knowledgeable in the disorder.
A great number of treatments have been described over time, but most have been found to be unhelpful. Treatments found to be unhelpful include: antiviral medications [ 17 ], volume expanding agents dextran [ 18 ], and vasodilators [ 19 ]. One possible treatment is no treatment at all, or a period of observation.
As described previously, some patient will improve without any medical intervention. There are some features of the hearing loss that may indicate a favorable result with simple observation. These include a low frequency hearing loss and a mild hearing loss. Most hearing improvement noted with observation is seen within the first two weeks after onset [ 6 ].
Although controversial, the most commonly prescribed treatment for SSNHL is the use of oral steroids. A randomized, placebo-controlled trial in demonstrated two-third of patients treated with steroids showed improvement while only one-third of patients treated with placebo had improvement of their hearing[ 20 ]. Other studies have shown no effect with steroid use [ 21 , 22 ]. Prednisone is typically used at doses ranging from mg daily for days, then a tapering of the dosage over the following days.
The optimal dosage of steroid and the time needed for treatment in not defined by any medical study. Steroids are clearly not effective in all patients, as not all patients have improvement with their use. However, some patients are clearly responsive to steroids which is demonstrated in trials of patients receiving steroids injected into the middle ear space discussed below.
Steroids are associated with side-effects that can include: elevation in blood glucose, increased pressure within the eye, hip joint problems with possible need for joint replacement surgery, inability to sleep, weight gain, fluid retention, bone weakening, psychiatric disturbances, among others. In an ideal situations, steroids would only be prescribed to patients that will benefit from their use, and avoided in those who will improve with no treatment.
However, we do not currently have a laboratory test that will demonstrate who will or will not respond to steroids. While treating some patients that will derive benefit, some patients are exposed to the side effects of steroids without hearing benefit. In our opinion, since major long-term complications of steroids are rare, we feel the benefit of treatment with oral steroids outweighs the risk.
Steroids can be delivered to the inner ear by injection of medication through the eardrum into the middle ear. The steroid then passes through a membrane called the round window and into the inner ear. Delivery of steroid by this injection achieves much higher concentrations of steroid within the inner ear than that seen with oral steroid administration [ 23 , 24 ]. In animals, the medicine within the inner ear lasts for less than 24 hours [ 23 ].
For this reason, to maintain a prolonged, adequate dosage of steroid within the inner ear, multiple injections are performed. The steroid injection procedure is well-tolerated and performed in the office. The eardrum is visualized under a microscope, and a small needle is used to inject the medicine into the middle ear.
The patient lies in the exam chair with her head turned for 30 minutes to allow the medicine to diffuse into the inner ear. The patient does her best not to swallow or speak during this period to minimize opening of the eustachian tube.
Eventually, the fluid will exit the middle ear via the eustachian tube and run into the back of the nose. A small amount of steroid is absorbed into the bloodstream, but at much lower concentrations than that seen with oral use. There is a tiny chance that a persistent hole in the eardrum may form.
Transtympanic steroids have been shown to be equally effective to oral steroids [ 25 ]. In addition, transtympanic steroids have been shown, in a majority of studies, to be effective in treating patients who have failed to improve with observation, oral steroids alone, or other treatments[ ]. Combination therapy with oral and transtympanic steroids have been shown to be superior to one form of steroid alone [ 30 ].
For most patients, we recommend an initial treatment with a combination of oral and transtympanic steroids for SSNHL. The transtympanic steroids result in a high dose of steroid within the inner ear, and we know a higher dosage of steroid leads to better results [ 31 ]. Because steroid within the inner ear persists for less than 24 hours, we recommend daily injections. We typically recommend a minimum of three injections, but do not have a set maximum of injections, instead we treat until the hearing improvement stabilizes.
We utilize oral steroids due to the fact that transtympanic steroids alone will not reach the hearing cochlear nerve. Oral steroids will deliver steroid to the hearing nerve, which may be a site of dysfunction. By way of this combination, the fluid of the inner ear and the hearing nerve can be treated with steroids to maximize treatment success.
Each patient much be treated on an individual basis and only with a thorough examination and history can a treatment regimen be recommended. Byl, F. Laryngoscope, Alexander, T. Harris, Incidence of sudden sensorineural hearing loss. Otol Neurotol, Stachler, R. Otolaryngol Head Neck Surg, Conlin, A. Parnes, Treatment of sudden sensorineural hearing loss: I. A systematic review. Arch Otolaryngol Head Neck Surg, Fetterman, B.
Luxford, and J. Saunders, Sudden bilateral sensorineural hearing loss. Mattox, D. Simmons, Natural history of sudden sensorineural hearing loss. Ann Otol Rhinol Laryngol, Parnes, Treatment of sudden sensorineural hearing loss: II.
A Meta-analysis. Rauch, S. Idiopathic sudden sensorineural hearing loss. N Engl J Med, Schuknecht, H. Donovan, The pathology of idiopathic sudden sensorineural hearing loss. Arch Otorhinolaryngol, Linthicum, F. Doherty, and K. Berliner, Idiopathic sudden sensorineural hearing loss: vascular or viral?
Nakashima, T.
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