DR ROOHIA

STEROIDS IN SSNHL

First described in 1944 by DeKleyn Incidence: 5-20 per 100,000 4,000 new cases/year in US Idiopathic Hearing loss in 3 contiguous frequencies of at least 30 dB Some authors use at least 20 dB loss Onset of hearing loss occurs in less than 72 hours Recovery rate without treatment 32% - 79% Usually within 2 weeks of onset Only 36% with complete recovery No middle ear disease Otologic emergency!

The two principal indications for intratympanic steroids are sudden sensorineural hearing loss (SNHL) and Meniere's disease

STEROIDS

•decreasing the number of circulating blood leukocytes and inhibiting the formation and liberation of inflammatory mediators

•inhibit the release of chemoattractive and vasoactive factors, decrease the secretion of lipolytic and proteolytic enzymes, and inhibit the release of proinflammatory cytokines

•These actions decrease the damage from an inflammatory response, whether the insult is secondary to mechanic, hypoxic, ischemic, infectious, or autoimmunologic causes

Steroids mitigate the destructive processes caused by the immune response

On exposure to lipopolysaccharidecultured endothelial modiolar cells and tissue

exhibit a generic response and release proinflammatory cytokines

vasculitis, vascular leakage syndrome, entry of immunocompetent cells, and perivasculitis, ultimately leading to cochlear ischemia, intracochlear tissue damage, and hearing loss

DEXAMETHASONE-interrupt the beginnings of the inflammatory cascade at the level of cytokine expression

steroids attenuate pathogen-induced immune responses in the ear

Serum glucocorticoid levels are directly correlated with activity and concentration of Na+,K+-ATPase in the inner ear

potassium secretion by marginal cells is immediately increased after the administration of steroids

role of steroids in ion homeostasis in the inner ear

Intratympanic administration yields much higher concentrations of steroids in the inner ear than either intravenous or oral administration

Parnes and colleagues:intravenous and intratympanic administration

successfully penetrated the blood-labyrinthine barrier.

Methylprednisolone had the highest concentration and longest duration in perilymph and endolymph

therapeutic efficacy may rely on other mechanisms of action(Na+-K+ channel activity)

Pharmacokinetics

choice for sudden SNHL and acute vestibular vertigo

protocol of oral steroids for inner ear disease is 60 mg of prednisone (or 1 mg/kg/day for adults) taken for 10 to 14 days in idiopathic sudden SNHL or for 1 month in suspected autoimmune inner ear disease

If hearing loss returns during the taper, a higher dose of prednisone is restarted

Relapse of hearing loss is often preceded by tinnitus

Systemic Steroids

SSNHL-STEROIDS Systemic and intratympanic

steroid therapy has also been used for treatment of sudden SNHL

prognostic factors predicting response –

initial severity of hearing loss and time between onset and treatment.[

There is a high spontaneous recovery rate of 30% to 60%

Oral steroid therapy within the first 2 weeks has shown recovery rates approaching 80% and decreasing thereafter

intratympanic steroids do provide an excellent method for salvage of hearing in the case of systemic steroid treatment failure

Gianoli and Litrial of intratympanic steroids for patients with

sudden SNHL who had failed to improve after high-dose systemic steroids (1 mg/kg/day of prednisone for a minimum of 1 week).

tympanostomy tube placement 0.5 mL of steroid solution consisting of either 25 

mg/mL of dexamethasone or 62.5 mg/mL of methylprednisolone

Four treatments were administered over 10 to 14 days, and audiometric data were recorded 1 to 2 weeks after treatment

Kopke and colleaguesRWM microcatheter -62.5 mg/mL of

methylprednisolone at a continuous rate of 10 ?L/hour for 14 days with an electronic pump

Chandrasekhar10 patients treated with intratympanic

dexamethasone6 experienced hearing improvements greater than

10 dB, howeverParnes and colleagues13 patients 6 showed hearing improvements of 10 

dB or more.

If intratympanic steroids are to be usedthey should be used as soon as possible after

it becomes clear that oral steroids are not improving hearing, preferably within the first 2 weeks of the original insult

dexamethasone, followed by methylprednisolone Intratympanic dexamethasone preparations vary from 1 to

25 mg/mLhyaluronic acid preparation consisting of a 1 : 1 mixture of

16 mg/mL of dexamethasone and 0.5 mg/mL of hyaluronate sodium

intratympanic methylprednisolone studies use a solution of 62.5 mg/mL

protocol is designed to fill the middle ear space (which is 0.3 to 0.5 mL

self-administration through tympanostomy tubes have every-other-day dosing

“shotgun” dosing with multiple injections over the first 2 weeks of treatment

Dosing

compromise of the immune system leading to infections, osteoporosis, peptic ulcers, hypertension, myopathy, ocular effects, impaired healing, psychologic effects, and avascular necrosis

Side Effects

Advantages to IT steroids May be used when systemic steroids arecontraindicated or refused Greater concentration achieved at targetend organ May be performed in outpatient setting Possible use for salvage of hearing Relatively low complication rate

Sudden Sensorineural Hearing Loss

Challenges for IT steroids Not well established as primarytreatment strategy Dosing? Best delivery technique? Long term effects? Why does it work? .... Sometimes

Sudden Sensorineural Hearing Loss

Take Home Messages: SSNHL is an otologic emergency Systemic steroids are mainstay of therapy Prednisone 60 mg/day for 3-5 days, tapered 5-7

daysBetter prognosis if treatment started early

(within 4 weeks of onset) IT steroids may be an alternative when

systemic steroids are contraindicated IT steroids is another option when oral steroids

fail to restore hearing

Sudden Sensorineural Hearing Loss

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