Intratympanic Steroids for the Treatment of Sudden
Sensorineural Hearing Loss
Alex Malone, Marion Ridley
USF Dept. of Otolaryngology – Head & Neck Surgery
12901 Bruce B Downs Blvd, MDC 73
Tampa, FL 33612
Introduction:
Idiopathic sudden sensorineural
hearing loss (SSNHL) is a poorly
understood clinical entity. It is classically
defined as hearing loss that occurs in less
than three days, involves a drop of at least
30 decibels in three contiguous frequencies
on an audiogram, and with no other
identifiable cause identified 1. There are
66,000 new cases reported annually in the
US2. Some patients will experience
spontaneous return of hearing to baseline
while others suffer permanent deficits. No
treatment regimen has been definitively
shown to improve hearing outcomes but
steroids have been proposed as a possible
treatment and are commonly used in
clinical practice. As many patients cannot
tolerate steroids due to side effects
intratympanic injections have arisen as a
novel alternative, allowing higher doses to
be delivered to the inner ear while
minimizing systemic exposure3. Here we
will report on the results of intratympanic
injections performed at the James A Haley
VA.
Methods:
A retrospective chart review was
performed from 2010-2016 to identify all
patients who presented to the James Haley
VA Otolaryngology clinic with sudden onset
hearing loss. All patients diagnosed with
SSNHL after a thorough clinical exam and
work-up were included. An audiogram
demonstrating a 30 dB drop or greater in at
least three contiguous frequencies was
required to be included. In cases where no
previous audiogram was available the
contralateral ear was used to assess
baseline-hearing threshold. All patients
treated with intratympanic steroids were
included in our analysis.
Treatment modality, clinical notes,
and serial audiogram results were
evaluated to assess patient outcomes. The
earliest audiogram occurring at least one
year following pre-treatment audiogram was
used to assess for changes in hearing level.
If no audiogram greater than one year
following treatment was available then the
most recent audiogram was used. Time
until treatment was also evaluated to
assess for difference in outcome base on
the time of presentation from initial reported
symptoms.
Treatment outcomes were broken
down into ordinal categories based on
recommendations from the American
Academy of Otolarygnology – Head & Neck
Surgery clinical practice guidelines1.
Hearing recovery (using pure tone average)
to within 10 dB of baseline and word
recognition score (WRS) within 10% of
baseline was defined as complete recovery.
Case
Number
Age
1
2
3
4
5
6
7
9
11
12
13
15
16
17
19
20
23
24
25
26
27
29
30
31
34
35
77
59
60
65
62
72
80
74
70
76
66
85
33
39
70
39
84
68
61
65
63
67
65
65
56
87
Time Until
Treatment
(Days)
10
11
14
92
2
10
10
38
6
1
23
10
7
42
2
9
6
5
67
37
2
18
3
1
3
17
Initial
Primary or Salvage
Audiogream
Treatment
Shape
Salvage
Flat
Salvage
Flat
Primary
Flat
Primary
Down Sloping
Primary
Down Sloping
Primary
Down Sloping
Primary
Down Sloping
Primary
Flat
Primary
Flat - Profound
Primary
Up Sloping
Primary
Flat
Primary
Flat - Profound
Primary
Down Sloping
Primary
Down Sloping
Primary
Flat - Profound
Primary
Flat
Primary
Flat - Profound
Primary
Flat - Profound
Primary
Flat
Primary
Down Sloping
Primary
Down Sloping
Primary
Flat
Primary
Down Sloping
Primary
Flat - Profound
Primary
Flat - Profound
Primary
FlatProfound
Recovery Type
Complete
Partial-Significant
Complete
None
Complete
Partial-Significant
Partial-Significant
Partial-Insignificant
Partial-Significant
Complete
None
None
Complete
None
Complete
Complete
Partial-Insignificant
Partial-Insignificant
None
Partial-Insignificant
Partial-Insignificant
Partial-Insignificant
Complete
Partial-Insignificant
Partial-Significant
None
Audiogram Shape and Recovery
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Flat
Complete
Profound
Partial-Significant
Down Sloping
Up Sloping
Partial-Insignificant
None
Bibliography
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Partial-significant recovery was defined
as improvement in hearing to of an aidable
level of hearing with improvement in WRS to
50% or greater. Partial-insignificant recovery
was defined as hearing improvement of pure
tone average of >10 dB or improvement of
WRS of >10%. No recovery was defined as
improvement hearing improvement of <10 dB
with improvement in WRS of <10%.
Discussion:
SSNHL is a clinical conundrum. Owing
to the intricacy of the inner ear no pathologic
specimens are able to be obtained from living
subjects and because of its rarity there and
relatively benign nature there are an extremely
small number of post-mortem specimens
available for review – with only one such
specimen in existence during the acute phase
of onset of this process4. A litany of treatment
options have been proposed and studies but
there is scant evidence to prove any
effective5. Steroids had shown some
evidence of efficacy in early trials but this has
since come under question6-9. There has
been some recent evidence that intratympanic
steroids may have an effect on patient
outcomes but more data is needed10,11.
Historical data has suggested that
approximately two-thirds of patients will
experience some level of recovery in hearing,
with one-third failing to improve5,12. Our data
are similar, with approximately ½ of patients
experiencing significant improvement and ¼ of
patient’s experiencing no improvement. When
examined more closely several interesting
findings do arise.
Most notable, our demonstration of
some level of improvement in 94% of patients
treated with intratympanic injection less than
14 days following onset of symptoms is
dramatically higher than reported outcomes.
Also noteworthy, our patient population was
predominantly over the age of 60, which is
associated with significantly decreased odds
of recovery. Our only treatment failure of those
treated within 14 days was an 85 year old with
profound hearing loss, one of the oldest
subjects in our cohort. All patients 60 and
younger had a significant level of recovery
aside for one patient who presented over one
month after initial onset of hearing loss.
Conclusion:
Our data demonstrate the importance
of early identification of SSNHL and
importance of prompt referral to an audiologist
and otolaryngologist. We have also
demonstrated an improved chance of overall
recovery compared to the historical literature
in cohort. Our data supports the importance
of intratympanic steroids in the treatment of
SSNHL. Further studies are needed to verify
our findings.