## 4 Discussion
Therefore, the improvement in the groups that presented earlier may not be due to the treatment but instead may reflect a natural process of hearing improvement that took place similarly in the group that presented later. However, the late-arriving groups do not have earlier audiograms for comparison; hence, we cannot conclusively say that their thresholds improved over the first weeks. It is possible that they had the same hearing loss as presented, and they had not improved over time. Comparing the severity of hearing loss and its subsequent improvement among different patients carries significant, intrinsic difficulties. Usually, the patient's hearing threshold prior to the hearing loss event is unknown; thus, it is not possible to determine the severity of the hearing loss and the degree of subsequent improvement. This problem can be overcome using the approach of [PERSON] et al. [23]: in cases of unilateral hearing loss, the audiometry results from the healthy ear are used as a reference for the initial state of the affected ear prior to hearing loss, since we can assume that for most patients hearing was symmetrical before the onset of hearing loss (unless otherwise known). According to this method, we note that hearing loss severity and improvement are presented in relative and absolute terms (comparing the affected ear before and after treatment). Few randomized control trials (RCTs) have been published that evaluate the efficacy of corticosteroid treatment for SSNHL. All of them included a low number of patients and had inherent biases. [PERSON] et al. concluded that \"steroids have a definite positive effect on recovery\" [14]; however, their study included only 67 patients from more than one institution with different therapy protocols. Furthermore, they did not use randomization to determine which patients received the study drug or placebo. In an RCT that included 41 patients in four groups (only 10 were treated with OCS), [PERSON] et al. did not find any benefit compared to the placebo group [24]. In an RCT that included 93 SSNHL patients, [PERSON] et al. concluded that prednisolone does not seem to influence the recovery of SSNHL [25]. These three studies were the sole sources of data for the meta-analysis published by [PERSON] et al., based on only 201 patients, which suggested no benefits from OCS treatment [16]. In a previous meta-analysis, [PERSON] et al. also did not find any benefit from OCS treatment vs. the placebo [19]. [PERSON] et al., in another meta-analysis, observed a 60.28% pooled spontaneous recovery from SSNHL, which was no less than the outcome following treatment recovery [26]. Nevertheless, the clinical practice guidelines of AAO recommend OCSs as the only treatment on offer to patients that has a reasonable therapeutic effect [22]. A meta-analysis by [PERSON] and [PERSON] found no significant difference in recovery from SSNHL following treatment based on OCS or IT alone. Moreover, no significant difference was found between combined treatment (OCS followed by IT) vs. OCS or IT alone [20]. This meta-analysis did not compare the treatments to untreated patients regarding the studies it analyzed. It is hard to find a similar example in medicine with no valid proof of benefit that is still common practice worldwide. There are several limitations to this study. First and foremost, this study is retrospective, and as such does not include a control group for comparison. We believe the untreated groups (weeks 3 and 4) can represent the control group in real life. It can be assumed that their late arrival was due to insufficient availability of urgent hearing tests. All the other parameters: demographic, medical background, and associated symptoms, were without difference across all groups (Table 1). Furthermore, since this study's final cohort constitutes a larger study sample than all other studies conducted to date (794), our results carry critical statistical and clinical significance.