Ideal Timing of Audiograms After Intratympanic Steroid Injections to Treat Sudden Sensorineural Hearing Loss

Conclusions Department of Otolaryngology—Head and Neck Surgery, Georgetown University Hospital, Washington, D.C. References Georgetown University 1. Guan-Min H., et al. Effectiveness of intratympanic dexamethasone injection in sudden-deafness patients as salvage treatment. Laryngoscope 2004;114:1184-89. 2. Choung Y.H., et al. Intratympanic dexamethasone injection for refractory sudden sensorineural hearing loss. Laryngoscope 2006;116:747-52. Results Educational Objective: At the conclusion of this presentation, the participants should be able to appreciate the role of intratympanic steroids for the treatment of idiopathic sudden sensorineural hearing loss and to better determine the timing of posttreatment audiograms to assess response to treatment. Objectives: To review our experience with intratympanic steroids (ITS) for the treatment of idiopathic sudden sensorineural hearing loss (ISSNHL), emphasizing the ideal time to perform follow-up audiograms to assess treatment response. Study Design: Retrospective case review. Methods: Patients diagnosed with ISSNHL from 2001-2008 were treated with 40mg/cc or 62.5mg/cc methylprednisolone with 2% lidocaine. A 0.3-0.5 mL volume was administered through a single tympanotomy. Injections were repeated weekly for 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: 20 women and 20 men. Average age was 61 (range 13-84). Average days from onset to treatment was 22.7 (range 1-120). Twenty-five patients were treated with oral steroids prior to ITS. Average days from treatment initiation to post-treatment audiogram was 33.2. Overall recovery rate was 43% (17/40). A significantly increased response rate was found in patients having an audiogram >5 weeks after initiation of treatment (9/13) over those tested ≤5 weeks after initiation of treatment (8/27) (P = .04, Fisher exact test). There were no significant differences for age ≥60, gender, steroid dose, treatment within 14 days, prior treatment with oral steroids, or presence of vertigo. Conclusions: Our study indicates that recovery from ISSNHL after ITS injections occurs more frequently >5 weeks after initiating treatment. This may be due to the natural history of sudden hearing loss or the prolonged effect of steroid in the inner ear. The ideal time to perform post-treatment audiograms may be several weeks after completing treatment. Our observed response of a significant number of patients showing improvement when audiograms were performed > 5 weeks after initiating treatment is contrary to the idea that response to treatment occurs early after starting treatment. This may reflect a group of patients with delayed response to steroid treatment. To better define when to perform post-treatment audiograms and to attempt to stratify patients with ISSNHL as early or late responders, studies should report when audiograms are administered and, ideally, have multiple audiograms to monitor response. Introduction Intratympanic steroids (ITS) may treat idiopathic sudden sensorineural (ISSNHL) hearing loss more effectively than oral steroids. Data to support this hypothesis are limited almost exclusively to case series, which differ in the type of steroid used, the steroid dose, the dose frequency, the method of injection, the existence of previous treatment with oral steroids, and the outcome measurements. In addition, these studies do not specifically address the timing of the post-treatment audiogram in determining treatment success. We reviewed our experience with ITS, which included an analysis of the timing of posttreatment audiograms. Methods We performed a retrospective chart review of all patients undergoing ITS injection at our institution from October 2001 to July 2008. To be included in the study, patients had to have a sensorineural hearing loss of at least 30 dB in 3 contiguous frequencies occurring in less than 72 hours. Additional inclusion and exclusion criteria are listed in Table 1. Patients were evaluated for pure-tone thresholds and speech intelligibility both before and after steroid injection. The pure-tone average (PTA) was calculated as an average of thresholds measured at 0.5, 1.0, and 2.0 KHz. Speech-discrimination scores (SDS) were calculated as the percent of phonetically balanced, monosyllabic words pronounced correctly. Patients were offered 650 mg of acetaminophen prior to the injection. First, phenol was applied to topically anesthetize the posterior inferior quadrant of the tympanic membrane (the area overlying the round window niche). A single myringotomy was then performed with a disposable knife. Approximately 0.3 to 0.5 mL of either 40 mg/mL or 62.5 mg/mL methylprednisolone mixed 9:1 with 2% lidocaine at room temperature was then delivered through the myringotomy via a 22 gauge spinal needle. The patients were then instructed to maintain their heads turned 45° away from the injected ear in a reclined position for 30 minutes. Injections were repeated at approximately one week intervals for a total of 3 injections. This corresponds to 3 injections over approximately 15 days. The outcome measurement used to measure clinically significant hearing improvement was an increase in PTA of ≥ 20 dB or an improvement of SDS of ≥ 20%. Statistical analysis was performed using the two-tailed Fisher’s exact test and the two-tailed paired t test. Significance was defined as a P 5 weeks after starting treatment responded sooner, which would have been detected if their audiograms had been performed earlier. However, our data differs from the currently reported data in that it shows recovery occurring late, rather than early. In addition, our study highlights an area of ITS that is still yet to be defined: the timing of post-treatment audiograms in assessing treatment response. Table 1. Inclusion and Exclusion Criteria 30 dB loss in 3 consecutive frequencies in < 72 hours Pre and post treatment audiogram including PTA and SDS Normal otoscopic exam Normal MRI with contrast of the brain and internal auditory canals Negative serologic studies for infectious and inflammatory disease No history of chronic otitis media No history of trauma (head, acoustic, or barometric) No history of Meniere’s disease, hydrops, or fluctuating hearing loss No history of meningitis No history of prior ear surgery No history of radiation Table 2. Demographics Age (years) Mean Range 61 13 to 84 Gender Male Female 20 20 Ear Left Right 26 14 Days to treatment Mean Range ≤14 15‐28 ≥29 22.7 1 to 120 15 12 13 Prior treatment with oral steroids 25 Average days to post treatment audiogram Mean Range 33.2 9 to 70