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Treatment for Sudden Sensorineural Hearing Loss (SSHL): Steroids & Beyond
Julia Casazza • Oct 9, 2023 • 35 hits
Steroids, both oral and intratympanic, are the bedrock of sudden sensorineural searing loss (SSHL) treatment. However, all treatment decisions should be made in the context of shared decision making. Additional therapies, such as hyperbaric oxygen and auditory stimulation, can assist when response to treatment is more modest than expected. In this article, otologist Dr. Sujana Chandrashekar shares her pearls for treatment of sensorineural hearing loss.
This article features excerpts from the BackTable ENT Podcast. We've provided the highlight reel in this article, but you can listen to the full podcast below.
The BackTable ENT Brief
• Intratympanic (IT) injection of high-concentration dexamethasone is a first-line treatment for SSHL. Oral steroids are also effective, but carry a greater side effect burden.
• IT steroid injections are performed in the office, once a week, for up to six weeks from the initial hearing loss. Topical analgesia with phenol is used, and patients must lie still without swallowing for twenty minutes after the procedure.
• The American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) recommends that patients with moderate-to-severe hearing loss receive IT steroid injections weekly, for up to six weeks, until their hearing recovers. In select patients, further injections may be appropriate.
• While alternative treatments such as resveratrol and N-acetyl-cysteine are ineffective for hearing loss, they may help with associated tinnitus.
• Patients whose hearing recovers to an aidable range should be fitted with hearing aids. Patients whose hearing does not recover should be referred for unilateral cochlear implantation.
Table of Contents
(1) Steroid Treatment of Sudden Sensorineural Hearing Loss
(2) Intratympanic Injection for SSHL Treatment: A Step-by-Step Guide
(3) Hyperbaric Oxygen, Antivirals, & Supplements for Sudden Sensorineural Hearing Loss
(4) Following Up On Sudden Sensorineural Hearing Loss Treatment
Steroid Treatment of Sudden Sensorineural Hearing Loss
Treatment of SSHL varies based on severity of hearing loss. In cases of mild hearing loss, a one to two week course of prednisone is appropriate. Patients can discontinue prednisone if hearing rapidly recovers. For patients with moderate hearing loss in the “steroid responsive zone,” treatment can include systemic and possibly intratympanic steroids. Dr. Chandrashekar prescribes these patients one week of oral prednisone; if their hearing does not recover in this week, she starts intratympanic injections immediately. Anacusic patients have the worst prognosis and require what she calls the “belt & suspenders” approach: both oral and intratympanic steroids. Regardless of the level of hearing loss, all treatment plans should rest on shared decision making between the otolaryngologist and the patient.
[Dr. Gopi Shah]
We've done a pretty good job of setting the stage as far as evaluating our patient and testing. Maybe we can move on and talk about management, treatment, setting expectations that sort of discussion.
[Dr. Sujana Chandrashekhar]
There's a great deal to do with explaining the audiogram to the patient, all the things that we talked about, the shape of the audiogram, the degree of hearing loss, the word recognition score. Most people do not have a premorbid audiogram. We explain to them that we assume that the ear in question was just like the other ear prior. If they have a premorbid audiogram, obviously it's very nice to look at that and be able to counsel. I counsel patients in the mild hearing loss category that their chance of getting better is extraordinarily high. Often some of the literature on sudden hearing loss is skewed because mild hearing loss people have their hearing loss, then recover their hearing, and never come in.
They may be more uptight or easier to access healthcare if they're coming in with a mild hearing loss, but the chances are they're going to get better. The severe to profound hearing loss, the anacusic patients, the ones who present with severe vertigo, they have a less of a likelihood of hearing improvement no matter what we do but we should try everything to try to get their hearing back. Then there's that steroid-effective zone that was defined by Wilson, Byl, and Laird in the '70s, and that still holds true. The mild to moderately severe mid-frequency hearing loss, they respond about four to one to steroid treatment.
That's a huge number four to one. I talk to all my patients about the things I'm thinking about because I truly believe in shared decision-making with patients. There's nothing we're doing that could not potentially have a negative outcome in one way or another. Whether we're not treating, whether we're giving oral steroids, whether we're injecting with steroids. This is where shared decision-making is really very important, including the shared decision-making of delaying the retro-cochlear workup and why we're doing that, et cetera.
I think setting proper expectations and having the patient understand where you're coming from as the treating physician is really important. The other thing we didn't mention is age. Under 18, unfortunately, has a less good prognosis than 18 to 60. Above 60, 65 has a less good prognosis as well. One of my residents presented that over age 45, "Old people." He said.
[Dr. Gopi Shah]
[Dr. Sujana Chandrashekhar]
I just looked at him and I was like, "Dude, do you want to graduate from this residency program?" Really, it's the under 18 and over 60 have a little bit less good prognosis than working years people.
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Intratympanic Injection for SSHL Treatment: A Step-by-Step Guide
Intratympanic steroids are a highly effective treatment for SSHL. With appropriate counseling, patients as young as nine years of age are appropriate candidates for this approach. Literature shows that patients treated with dexamethasone at higher concentrations than commercially available (24 mg/ml versus 10 mg/ml) have better outcomes. When injecting a patient, Dr. Chandrashekar talks through the procedure first, warning about potential pain and vestibular symptoms. Dr. Chandrashekar then anesthetizes the tympanic membrane with phenol, injects dexamethasone into the middle ear, then instructs the patient to lie still for twenty minutes. During these twenty minutes, patients are instructed not to swallow so that steroid remains in the middle ear. Per AAO-HNS guidelines, patients can continue with injections for up to six weeks after initial presentation, but Dr. Chandrashekar extends this window where appropriate.
[Dr. Gopi Shah]
If you're at the third injection and you've seen no change, do you keep going for the fourth?
[Dr. Sujana Chandrashekhar]
It's a wonderful question. If the patient says to me, "I do better for a day or two, and then it just gets bad again," or, "I know you inject me on Tuesdays, and I can feel the hearing come back on Friday and Saturday, and then by the time I see you it's bad again." I will do that fourth injection. If they are echoing what the audiogram is showing, that there's really no improvement, I think if there's no movement after three shots, subjectively or objectively, you can offer as a Hail Mary that fourth, or you can wait. In the clinical practice guidelines, we did talk about salvage regimens.
You can in fact wait for a month, see if anything happens, and now you're maybe seven, eight weeks out, which is outside of the six weeks guideline for salvage, but then if they're like, "I want to try again," or I think, or this or that.
The downside to me for intratympanic injection of steroid is so little that I have a low threshold for offering it for salvage. That is outside the guideline, and again, I know shared decision-making, but these are really important things that you have to talk to patients about. Like I said, I am very, very Pollyanna about the ability to restore hearing, and I have colleagues whom I respect greatly who are not.
Hyperbaric Oxygen, Antivirals, & Supplements for Sudden Sensorineural Hearing Loss
While steroids remain the gold standard for treatment of SSHL, alternative therapies have their place, particularly in difficult-to-treat cases. Patients whose examination reveals any “hint of viral phenomenon” are appropriate candidates for antiviral therapy. The benefit of hyperbaric oxygen for SSHL is limited, but risks of this treatment are low enough that the AAO-HNS considers it a second-line option. While acupuncture, resveratrol, and N-acetyl-cysteine do not improve hearing loss, they may be effective for associated tinnitus.
[Dr. Gopi Shah]
Does acupuncture help, or what about hyperbaric oxygen?
[Dr. Sujana Chandrashekhar]
We didn't talk about hyperbaric. Acupuncture has not shown benefit in sudden hearing loss. There is some benefit that has been shown in tinnitus overall for acupuncture. There is a benefit for complementary and integrative medicine techniques in tinnitus. If it's a noise-induced hearing loss, there are some agents like Resveratrol and acetyl-cysteine that can be used to try to ameliorate the tinnitus, which is the secondary symptom of the noise-induced hearing loss, and possibly help with the hearing loss. Hyperbaric oxygen. The first clinical practice guideline considered it an option. The update based on all the data that we reviewed said it was an option only if combined with steroid therapy for either primary or salvage treatment of sudden hearing loss.
There are countries in which hyperbaric oxygen is like the baseline treatment, everybody gets that. The outcomes are not better than countries such as ours where that is not the baseline treatment in most patients. I have not seen compelling data, which is why that remained an option in the clinical practice guidelines, and only an option now with concomitant steroid therapy, and in my personal practice, I have yet to see compelling data for hyperbaric oxygen.
Following Up On Sudden Sensorineural Hearing Loss Treatment
Treatment of the patient with SSHL does not end with steroids. AAO-HNS clinical practice guidelines suggest these patients see an otolaryngologist again six months after their initial presentation. This visit should include audiometric testing. For patients whose recovery is incomplete, auditory stimulation can facilitate further improvements in hearing. For patients whose recovery places them in an aidable range of hearing loss, hearing aids (including implantable devices, where appropriate) should be considered. Patients with single-sided deafness from SSHL are candidates for unilateral cochlear implantation.
[Dr. Sujana Chandrashekar]
Then, aha, the future is going to be intratympanic therapies to try to regrow hair cells. I'm just wrapping up being one of the clinical sites of the Frequency Therapeutics FX 322 trial. There, you have to do the injection not with phenol, but with EMLA, and posterior-central, right above where the round window orifice would be, because it's a very small amount, and it's a gel, and you essentially want it to enter the round window niche and sit against the round window membrane so that the injection technique is a little different for that particular investigational device or investigational drug.
In the future, the dream is, we'll be able to take these people and really improve their word recognition, and this is where I'm going to keep harping on word recognition, because even if you have a moderately severe pure tone loss, but your word rec now goes from 50% to 80%, man, you will love your hearing aid. I think that's really important to talk to patients, and get them to understand what part of hearing is actually what they are missing.
I think in the future, these drug therapies, gene therapies are going to come. If you have a profound hearing loss, you're severe to profound no discrim, I wouldn't wait around for that. Cochlear implants work beautifully right now, but if you've got something a little bit less than that, and you can play the field a little bit with the other devices, it might be nice not to open the inner ear on these people.
[Dr. Ashley Agan]
Dr. Sujana Chandrasekhar
Dr. Sujana Chandrasekhar is an otologist / neurotologist practicing at ENT and Allergy Associates in New York City.
Dr. Ashley Agan
Dr. Ashley Agan is a practicing ENT and assistant professor at UT Southwestern Medical Center in Dallas, TX.
Dr. Gopi Shah
Dr. Gopi Shah is a practicing ENT at UT Southwestern Medical Center in Dallas, TX.
Cite This Podcast
BackTable, LLC (Producer). (2023, January 31). Ep. 87 – Sudden Sensorineural Hearing Loss [Audio podcast]. Retrieved from https://www.backtable.com
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