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Procedure: Intratympanic Corticosteroid Therapy for Idiopathic Sudden Sensorineural Hearing Loss

August 15, 2016 by ASK DR BLOOM

Sudden sensorineural hearing loss (SSNHL) is a condition in which sensorineural hearing loss occurs in less than 72 hours. It usually affects adults between the ages of 43 and 53 years of age with a sense of fullness in the ear with muffled hearing. Approximately 28% – 57% will present with transient vestibular or balance symptoms. Many patients will recover spontaneously, but treatment with high-dose steroids, either oral or intravenous, has been shown to improve overall outcome. Recently, the use of intratympanic steroids has been increasing and several recent articles have addressed this treatment. The proposed benefits of intratympanic steroids include increased drug concentration at the cochlea and reduced systemic steroid exposure and associated adverse effects.

A recent systematic review by Spear and Schwartz of 176 articles, 32 representing initial or salvage intratympanic steroid injections for hearing loss demonstrated a consistent benefit of intratympanic steroids with a magnitude of improvement of 13 dB. Therapy needs to be started within 10 – 30 days of onset of hearing loss. For minor initial losses, this improvement may be sufficient for full recovery. For more severe losses, this improvement may return the hearing to a serviceable level. Overall, these authors concluded that intratympanic steroids are comparable to oral steroids for initial therapy and of benefit as a salvage therapy for patients who do not respond to an initial course of oral steroids for SSNHL.

Rauch et al. in a prospective, randomized, noninferiority trial involving 250 patients with unilateral sensorineural hearing loss presenting within 14 days onset of 50 dB or higher pure tone average (PTA) hearing threshold from 2004 – 2009 at 16 academic community-based otology practices with at least 6 months follow-up found that initial treatment with intratympanic steroids was not inferior to oral prednisone therapy. Overall, 32% (11 of 34) patients in the placebo group and 61% (20 of 33) in the steroid-treated group had full recovery. In subgroup analysis they found that patients with the worse prognosis for hearing recovery (PTA at least 90 dB and/or dizziness) showed a trend for improved outcome with oral versus intratympanic steroids.

Method of intratympanic steroid injection:

The intratympanic steroid injection uses four 1-mL dose of 40mg/mL of methylprdnisolone or 10 mg/ml of dexamethasone (less painful) over 2 weeks with a dose given every 3 to 4 days through the tympanic membrane (ear drum) into the middle ear space where it can diffuse via the round window into the cochlea (organ of hearing). Anesthesia can be provided with phenol but many patients prefer no local because the injection is brief. Patients are positioned supine at the operating microscope with the affected ear slightly up and remain in this position for 30 minutes after the injection.

Risks of oral and intratympanic steroids:

Adverse effects from oral steroids include change in appetite, mood or sleep pattern, worsening of psychiatric illness, weight gain, gastritis, increased thirst, hypertension, hyperglycemia, cataract formation and avascular necrosis of the hip.

Adverse effects from intratympanic treatment are generally local effects and include, ear pain, transient caloric vertigo, tympanic membrane perforation and infection (acute otitis media). Intratympanic treatment is more costly at approximately $688 versus a 2-week course of oral prednisone costing approximately $10.

Overall, intratympanic steroids are safe and equally effective as oral steroids. I offer it to all patients but prefer to use it for patients who seek to avoid the potential complications of oral steroids, have contraindications for oral steroid use or as a salvage therapy for patients who do not respond to oral steroid therapy.

AskDrBloom references:

Spear SA, Schwartz SR. Intratympanic steroids for sudden sensorineural hearing loss: a systematic review. Otolaryngol Head Neck Surg. 2011;145(4):534-543.

Rauch SD, Halpin CF, Antonelli PJ et al. Oral vs intratympanic corticosteroids therapy for idiopathic sudden sensorineural hearing loss. JAMA. 2011;305(20):2071-2079.


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