Good morning and TGIF! Welcome to another Dr Euan's ENT blogpost!
Today's topic is about Sudden Hearing Loss and a procedure that can potentially help to treat it, known as IntraTympanic Dexamethasone Injection. So let's take a look together, shall we?
Q: What is sudden sensorineural hearing loss (SSNHL)?
Sometimes, we may be afflicted by a sudden DROP in hearing in one of our ears; this loss is usually associated with tinnitus (a ringing/humming sound) in the affected ear, and also a sense of "blocked ear" and sometimes some fullness or discomfort. There is NO associated ear discharge or vertigo (spinning sensation for SSNHL). You can read more about these conditions in our blog posts covering tinnitus, and vertigo respectively.
Sudden sensorineural hearing loss (SSNHL) can be a frightening experience for the patient and is perceived as an otologic emergency. It has been defined as a loss of at least 30 dB over at least three frequencies in an audiogram within three days (Stachler et al., 2012).
Plotted hearing test results showing the difference in hearing ability between the left and right ear
As shown on the chart above, the higher the decibel count or volume needs to be in order for someone to hear the frequency played, the poorer their hearing ability is. For normal hearing function, the hearing results should at least be in, or above the conversation speech range.
The incidence of SSNHL varies from two to 30 per 1,00,000 adult individuals. However, an incidence of as high as 160 per 1,00,000 individuals per year has been reported in Germany (Kleyn, 1944). Usually affected age group is in the fifth and sixth decade, although the range is quite wide.
There is no apparent gender predilection. It can occur as a part of a systemic disorder or without any identifiable systemic or local abnormality. The latter is termed ‘idiopathic’ (ISSNHL), meaning that the cause is unknown.
Q: What causes sudden hearing loss?
To be honest, most of the time, we do not find any identifiable cause/reason.
Some of the KNOWN causes include:
Infections.
Head trauma.
Autoimmune diseases.
Exposure to certain drugs that treat cancer or severe infections, or what we call OTOTOXIC drugs.
Blood circulation problems.
Neurological disorders, such as multiple sclerosis.
Disorders of the inner ear, such as Ménière's disease.
Q: What are the signs and symptoms of sudden hearing loss?
The signs & symptoms of SSNHL are:
Hearing Loss
Tinnitus
Blocked Ear sensation or Fullness
Difficulty in hearing conversations or others speaking on the affected side
Difficulty in Stereo-scopic sound, and sound localisation
Also, differentiating between conductive from a sensorineural hearing loss is of utmost importance since the presentation of the two may be similar but the treatment implications are poles apart.
For SSNHL, a history of associated tinnitus, vertigo, focal neurological signs and previous history of recurring hearing loss should be specifically enquired.
The clinical ear examination involves otoscopic inspection to look for impacted cerumen (wax) and the condition of the tympanic membrane (the presence of otitis media with effusion should be specifically looked for).
Otoscopic photo of the eardrum and tympanic membrane
Clinical examination is followed by a detailed audiometric evaluation with pure tone audiometry and speech audiometry.
Q: How is Sudden Hearing Loss treated?
THE TAKE HOME MESSAGE for this blog post is:
You have a brief window to seek treatment.
The treatment should IDEALLY begin within 2 weeks of the onset of the hearing loss. After this window, we see that the steroid rescue results fall off dramatically!
Treatment involves a STEROID rescue.
Currently, the most widely used method is a course of ORAL steroid tablets eg Prednisolone over 2 weeks, with a course of PPI / Antacid treatment to protect against gastritis / gastric irritation. The steroid dosing may vary based on your age / BMI / medical conditions.
Treatment period (within 2 weeks) after which the steroid rescue results fall off dramatically!
For patients who are UNABLE to tolerate ORAL steroids, eg for Diabetic patients, there is the option of Intra-Tympanic (IT) Dexamethasone, or IT Dexa Injection.
This is also offered as an adjunct to ORAL steroid therapy. There are now many case reports and studies which have looked at IT dexa as a SALVAGE treatment when oral steroids have failed to restore hearing.
Q: What is an Intra-Tympanic (IT) Dexa injection? and how is it administered?
Screenshot of video from youtube video example of the IT Dexa Injection procedure
Your doctor may recommend an Intratympanic Dexamethasone Injection for you. Here are some common questions and answers about this procedure:
Q: What is an intratympanic (IT) dexamethasone injection?
Dexamethasone is a steroid that we usually give intravenously (through the vein) or intramuscularly (through the muscles). Steroids are typically given for conditions when we want to reduce inflammation, swelling or scar tissue formation in the body.
Intratympanic means through the ear drum into the middle ear.
Medicines that are placed into the middle ear space can be absorbed into the inner ear structures such as the cochlea (hearing) organ or the vestibule (balance) organ.
So we can give dexamethasone locally through the ear drum, to specifically allow it to get into the inner ear at a much higher concentration than if it was given by the ORAL route.
Q: Why may I be offered intratympanic (IT) dexamethasone?
You may have been offered IT Dexa so we can get a large concentration of steroids into the inner ear. Typically we offer this for conditions such as SSHL when patients can’t have oral steroids, and/or have not had any improvement in their hearing with the oral steroids.
It is also offered for patients with Meniere’s Disease.
Q: What can I expect during the procedure?
Local anaesthetic is injected into the ear, then the Dexamethasone steroid is injected through the drum into the middle ear. Immediately after the injection, you may experience some dizziness due to the caloric effect.
You may also feel some medicine going down the back of the nose/ throat area as it drains down the Eustachian tube. At this point, it is important that you try not to swallow or talk; each time you do this, some of the dexamethasone drains down the Eustachian tube.
You will be asked to lie down for 15-20 minutes with the injected ear facing the ceiling.
The intent is to allow the dexamethasone to be in the middle ear so it gets absorbed as much as possible into the inner ear.
Q: What can I expect after the procedure?
Most patients feel very little difference after the injection other than a numb and blocked ear that resolves quickly, after 24 hours.
However, some patients may have some burning or a stinging sensation for 1-2 days post IT injection. Paracetamol or simple NSAIDs are usually enough to treat this.
Most people are well enough to drive afterwards, although occasionally patients can experience a few hours of giddiness or spinning vertigo. It is best to have a family member or driver with you at least for your first injection. Depending on your consequent hearing results, you may want to do further injections to recover hearing to a greater degree if the doctor thinks better hearing results are possible.
Q: What is my chance of recovering my hearing in the affected ear?
Overall the prognosis for recovering your hearing is quite good, so long as you seek treatment EARLY, ideally within 2 weeks of onset.
Here are some of the better-known prognostic factors:
In general, up to 65% of the patients recover hearing to varying extents. The various factors related to the likelihood of recovery are as follows:
1. Age – has been the most consistent adverse factor, with elderly patients having significantly lower rates of recovery.
2. Associated features – The presence of vertigo has been reported in some studies to be associated with poor prognosis. However, it has not been a universal observation. Tinnitus has been reported as a varying (good, bad, and neutral) prognostic factor in various studies.
3. Duration of hearing loss – The patients presenting to the physician within a week are more likely to have a better recovery rate compared to the late presenters. This occurrence may not be related to early onset of treatment, but rather to the fact that a longer duration of hearing loss lessens the chances of recovery.
4. Severity of hearing loss at presentation – the patients presenting with profound hearing loss have a significantly lesser probability of recovery than the patients presenting with milder hearing loss.
5. Pattern of hearing loss – Among the patients with a mild-severe degree of hearing loss, the prospects of hearing recovery are lesser for the flat audiogram configuration. For the non-flat configuration, an ascending audiogram has a better prognosis than the descending type.
6. Systemic comorbidities – the presence of diabetes mellitus, hyperlipidemia, and hypertension have been variably associated with a poorer outcome in various studies(Capaccio et al., 2007; Chau et al., 2010).Metabolic syndrome has been documented to be an independent risk factor for SSNHL(Chien et al., 2015). The rate of recovery has been shown to be lower in patients with metabolic syndrome, with poorer results associated with four or more features of the syndrome(Jung et al., 2018).
Well, I hope this blog post will have helped to explain better the condition of Sudden Sensorineural Hearing Loss (SSNHL) and how we can help better your chances of a good recovery.
Thanks for reading and see you next time!
If you would like to consult or seek treatment for sudden hearing loss, please feel free to Contact Us at Euan's ENT Surgery & Clinic to make an appointment.
If you are interested to read deeper into this topic, here are some useful references you can look up.
References:
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