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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 22  |  Issue : 1  |  Page : 35-39

Sudden sensorineural hearing loss in adults: Our experience with multidrug high dose steroid regimen at tertiary care hospital


Department of ENT and Head and Neck Surgery, JLN Hospital and RC, Bhilai, Chhattisgarh, India

Date of Web Publication16-Feb-2016

Correspondence Address:
Abhineet Jain
Department of ENT and Head and Neck Surgery, JLN Hospital and RC, Sector-9, Bhilai - 490 009, Chhattisgarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-7749.176510

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  Abstract 


Introduction: Sudden sensorineural hearing loss is a confusing and controversial issue in our practice since no standard definition, evaluation method and treatment protocol exists. It is an otological emergency with narrow golden period of treatment. Objective: To establish the early diagnosis, treatment and study the outcome of treatment. Design and Method: In a prospective study, including patients >18 year age who had presented with sudden sensorineural hearing loss in ENT opd; after ENT examination, PTA, impedance audiometry and necessary imaging, were treated with i.v. methylprednisolone and inj.methylcobalamine i.m. along with tablet Pentoxyfylline and tablet prednisolone. PTA was repeated on 4th day, 3 week, and 6 weeks after diagnosis. Results: Total 37 patients were diagnosed and treated. Majority of patients had sudden SNHL of <72 hrs. duration with severe hearing loss and tinnitus as commonest associated symptom. Idiopathic cause was commonest followed by acoustic trauma and head trauma. 35.14% patients had complete recovery while 40.54% and 24.32% patients had partial and no recovery respectively. Conclusion: PTA is single most important investigation. Prompt treatment in <72 hrs. carry good prognosis. Associated vertigo, flat audiogram, DM, HTN are of poor prognosis.

Keywords: Methylprednisolone, Pure tone audiogram, Sudden sensorineural hearing loss


How to cite this article:
Gupta V, Jain A, Banerjee PK, Rathi S. Sudden sensorineural hearing loss in adults: Our experience with multidrug high dose steroid regimen at tertiary care hospital. Indian J Otol 2016;22:35-9

How to cite this URL:
Gupta V, Jain A, Banerjee PK, Rathi S. Sudden sensorineural hearing loss in adults: Our experience with multidrug high dose steroid regimen at tertiary care hospital. Indian J Otol [serial online] 2016 [cited 2021 Jun 22];22:35-9. Available from: https://www.indianjotol.org/text.asp?2016/22/1/35/176510




  Introduction Top


Sudden sensorineural hearing loss (SNHL) is a confusing and controversial issue in our practice sudden SNHL is a common otological emergency. The most accepted definition is SNHL of at least 30 db or more on at least three consecutive frequency over a period of <3 days. However, there is no well-accepted definition, method of evaluation and so treatment for the disease. Approximately, 50% patients complaint of associated dizziness, tinnitus. The window of opportunity is narrow and early administration of high-dose methylprednisolone is more efficacious than watchful waiting. The overall incidence is likely underestimated, as many who recover quickly will never seek medical attention. A wide spectrum of etiology including local, systemic, retro-cochlear diseases are associated with sudden SNHL, like viral diseases, temporary breaks of the inner ear membranes, and immune-mediated reactions. Vascular sclerosis of the microcirculation in the inner ear [1] but still “idiopathic unilateral” feature of the disease is predominant. The aim of this study is to study identify and define the disease at earliest and to study the efficacy of multidrug high dose steroid treatment.


  Materials and Methods Top


Patients attending the Department of ENT at JLN Hospital and Research Centre, Bhilai, India. During the period of August 2012 to November 2013 with complaint of sudden SNHL were included in the study. A total of 37 patients were included. We considered a SNHL of 30 db or more at 3 consecutive frequencies of <3 days of duration as criteria for sudden SNHL.

Those with age >18 years and with mixed and conductive hearing loss (HL) were excluded.

Evaluation

A complete general systemic and ENT examination was done audiometric evaluation included pure tone audiogram, impedance audiometry and if required imaging. Pure tone audiometry was repeated on day 4, 3 weeks and 6 weeks after the onset of HL.

Treatment

Intravenous methylprednisolone 2 g loading dose on day 1 followed by 1 g BD for 2 days and then tablet prednisolone (1 mg/kg/day) for 5 days, gradually tapered over next 10 days along with tablet pentoxyfylline 400 mg TDS for 14 days with injection methylcobalamine OD for the first 3 days.

Data analysis

The following definition for recovery considering normal hearing contralateral ear as an indicator of the status of affected ear before HL.

  1. Complete recovery (type 1) - recovery to within 10 db of contralateral ear hearing pure tone average
  2. Partial recovery (type 2) - recovery of hearing to within 50% or more of contralateral ear pure tone average
  3. No recovery (type 3) - <50% recovery of hearing.


Statistical method

It was done using mean, standard deviation, and Chi-square analysis to determine statistically significant relation. Level of significance was set at < 0.05.


  Results Top


A prospective study of 37 cases of sudden SNHL in >18 years age group was carried out in Department of ENT, Jawaharlal Nehru Hospital and Research Centre, Bhilai over a period of 15 months from August 2012 to November 2013 and the following results were drawn:

  • Patients who presented with symptoms of sudden SNHL in <72 h. 52.38% patients experienced complete recovery while 38.10% and 9.52% had partial and no recovery, respectively. Those who presented beyond 72 h. of onset, 12.5% experienced complete recovery while 43.75% and 43.75% patients had partial and no recovery of hearing [Graph 1]
  • In the study, of 24 patients with idiopathic sudden SNHL, 11 patients had complete recovery while 7 and 6 patients had partial and no recovery, respectively. Of 9 patients with acoustic trauma associated sudden SNHL 6 and 3 patients had partial and no recovery while none had a complete recovery. Of 4 patients with a head injury associated sudden SNHL 2 patients in each had a complete and partial recovery [Graph 2]
  • In the study, patients with mild HL (n = 2), both had complete recovery of hearing. In moderate HL (n = 11) 6 patients (16.22%) and 5 patients (13.51%) had complete and partial recovery, respectively, while none had no recovery. In moderately severe HL (n = 9) 4 patients (10.81%) and 5 patients (13.51%) had a complete and partial recovery while none had no recovery. In severe HL (n = 13) 2.7% had a complete recovery while 13.51% and 18.92% had partial and no recovery of hearing respectively. In profound HL category (n = 2) recovery was nil [Graph 3]
  • In the study group, 9 patients had flat audiogram and remaining 28 had downsloping audiogram. In flat audiogram category 3 (8.11%) and 6 (16.21%) patients head partial and no recovery, while in downsloping audiogram category 13 (35.41%), 12 (32.43%) and 3 (8.11%) patients had complete, partial and no recovery respectively [Graph 4]
  • In the study group, 34 patients had type A and 3 patients had type A/As tympanogram distributed among various categories of HL at initial evaluation. Following treatment at the end of follow-up after 6 weeks 36 patients had type A, 1 had type A/As tympanogram [Table 1]. Thus, no significant change was observed after treatment, and no correlation could be established between severity and recovery in HL
  • In group of 37 patients, 29 patients had associated tinnitus only of which 13 (35.14%) had a complete recovery while rest 13 (35.14%) and 3 (8.11%) had partial and no recovery. Rest of 8 patients had both tinnitus and vertigo of which 2 (5.41%) and 6 (16.22%) had partial and no recovery [Graph 5]
  • In study group, 6 patients had associated diabetes mellitus (DM) type 2 of which 4 (10.81%) and 2 (5.41%) had partial and no recovery. There was only 1 patient with associated hypertension (HTN) who had a partial recovery. Six patients had associated DM and HTN of which 2 (5.41%) and 4 (10.81%) patients had partial and no recovery. Thus, none of the patient with associated comorbidity had complete recovery [Graph 6].















  Discussion Top


Sudden SNHL is a common otological emergency. Surprising number of patients report that the HL was noticed immediately on awakening suggesting that HL occurred during sleep. Our study revealed that most of the patients (idiopathic cause) developed HL on awakening from sleep.
Table 1: Distribution pattern of various tympanograms among patients (N)

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  1. According to Byl [2] the average age of onset is reported to be 46–49 years with increasing incidence with age. According to H. Alexander Arts [3] any age group can be affected and the peak incidence appears to be in the sixth decade of life. Our study revealed that most of the patients ranged from 40 to 60 years (59.465)
  2. Most of the patients do not seek advice immediately at the onset of symptom and typical presentation is generally delayed by 48–96 h.[4] Vijayendra et al. studied 34 patients with idiopathic SSNHL, of which 18 patients presented within 3 days.[5] In our study, 21 out of 37 patients presented within 3 days. Delay in presentation and so in starting treatment is a negative prognostic factor as concluded by Bullo et al.[6] In our study also poor recovery was seen in those who presented beyond 72 h [Graph 1]
  3. Tinnitus is a common associated symptom in SSHL. According to Cvorovic et al. tinnitus has been considered a positive prognostic factor for hearing recovery. In our study, 29 out of 37 patients had associated tinnitus.[7] Out of this 35.14% had complete and partial recovery each, while 8.11% had no recovery
  4. According to Nakashima et al. the association of vertigo has the worst prognosis.[8] Pajor et al. found recovery rate of 51% for SSNHL without vertigo, while only 33% for those with vertigo.[9] In our study, none of the patient with vertigo had complete recovery. 5.14% and 16.22% patients, who had associated vertigo had partial and no recovery, respectively
  5. The shape of audiogram was related to recovery and patients with low frequency, or mid frequency audiogram contour shows better recovery.[10] In our study, we found that flat audiogram has a worst prognosis for recovery than downsloping audiogram. Among 24.32% patients with flat shape audiogram, 16.21% and 8.11% patients had no and partial recovery, respectively
  6. In our study, severe SNHL at presentation was found to be a poor prognostic factor for recovery. 35.14% patients with severe SNHL had complete and partial recovery in 2.7% and 13.51% patients, respectively, while majority 18.92% had no recovery. Vijayendra et al.[5] and Bullo et al.[6] studied and found that more severe HL was poor prognostic factor
  7. Common systemic disease such as DM and HTN may affect the recovery in patients by virtue of associated microangiopathy.[11] Hirano et al. demonstrated that patients with DM, HTN and hyperlipidemia had a poor prognosis.[12] Similarly, Li Lin et al. concluded that patients with DM, coronary artery disease, retinopathy had increased the risk of developing SSNHL.[13] In a study conducted by Bullo et al. the presence of comorbidities in the sample did not negatively influence the final recovery.[6] In our study also patients with DM, HTN or both experienced more severe HL along with partial or no recovery and thus poor prognosis [Graph 6]
  8. The role of imaging is still not well-defined in SSNHL work up since it does not seem to affect treatment much, however, to label SSNHL as idiopathic MRI is essential to rule out vestibular schwannoma since it is found in about 2% of SSNHL and has been associated with partial recovery.[14] In our study, no such retrocochlear pathology was seen, although in those with head injury (10.81%) computed tomography scan head had extra dural hemorrhage
  9. In most of the cases of SSNHL, it will not be possible to arrive at a particular diagnosis. However, the assessment of all possible mechanism leading to SSNHL should still be investigated to find out approximate 10% of cases for which one can arrive at an identifiable and hopefully treatable diagnosis.[14] in our case series, idiopathic cause (64.86%) was followed by acoustic trauma (24.32%) and head injury (10.81%). Complete recovery was most common even in idiopathic etiology (29.73%) followed by acoustic trauma and head injury (5.41%), while no recovery was seen in 50% of patients with head injury followed by acoustic trauma (33.3%) and idiopathic group (25%).



  Conclusion Top


The diagnosis of SSNHL should be prompt. Unnecessary, nontargeted tests should be avoided while MRI should be considered in all cases with idiopathic SSNHL, regardless of recovery. Treatment protocol, i.e., combination regimens (high dose methylprednisolone, pentoxyfylline, and Vitamin B12) is highly recommended in view of good recovery in 75% of cases. Associated symptom like vertigo and comorbidities like DM, HTN along with flat shape audiogram are poor prognostic factors in hearing recovery.

Since SSNHL can have serious impact on lifestyle, it needs a long-term follow-up (>6 months) to pick up early morbidities and to initiate rehabilitation program as early as possible.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Plaza G, Durio E, Herráiz C, Rivera T, García-Berrocal JR; Asociación Madrileña de ORL. Consensus on diagnosis and treatment of sudden hearing loss. Asociación Madrileña de ORL. Acta Otorrinolaringol Esp 2011;62:144-57.  Back to cited text no. 1
    
2.
Byl FM Jr. Sudden hearing loss: Eight years' experience and suggested prognostic table. Laryngoscope 1984;94 (5 Pt 1):647-61.  Back to cited text no. 2
    
3.
Charles W. Cummings Otolaryngology Head and Neck Surgery. 4th ed. Philadelphia: Elsevier; 2005. p. 3554.  Back to cited text no. 3
    
4.
O'Malley MR, Haynes DS. Sudden hearing loss. Otolaryngol Clin North Am 2008;41:633-49, x-xi.  Back to cited text no. 4
    
5.
Vijayendra H, Buggaveeti G, Parikh B, Sangitha R. Sudden sensorineural hearing loss: An otologic emergency. Indian J Otolaryngol Head Neck Surg 2012;64:1-4.  Back to cited text no. 5
    
6.
Bullo F, Tzamtzis S, Tirelli G. Update on the sudden hearing loss. Indian J Otol 2013;19:95-9.  Back to cited text no. 6
  Medknow Journal  
7.
Cvorovic L, Deric D, Probst R, Hegemann S. Prognostic model for predicting hearing recovery in idiopathic sudden sensorineural hearing loss. Otol Neurotol 2008;29:464-9.  Back to cited text no. 7
    
8.
Nakashima T, Tanabe T, Yanagita N, Wakai K, Ohno Y. Risk factors for sudden deafness: A case-control study. Auris Nasus Larynx 1997;24:265-70.  Back to cited text no. 8
    
9.
Pajor A, Durko T, Gryczynski M. Predictive value of factors influencing recovery from sudden sensorineural hearing loss. Int Congr Ser 2003;1240:287-90.  Back to cited text no. 9
    
10.
Mattox DE, Lyles CA. Idiopathic sudden sensorineural hearing loss. Am J Otol 1989;10:242-7.  Back to cited text no. 10
    
11.
Nagaoka J, Anjos MF, Takata TT, Chaim RM, Barros F, Penido Nde O. Idiopathic sudden sensorineural hearing loss: Evolution in the presence of hypertension, diabetes mellitus and dyslipidemias. Braz J Otorhinolaryngol 2010;76:363-9.  Back to cited text no. 11
    
12.
Hirano K, Ikeda K, Kawase T, Oshima T, Kekehata S, Takahashi S, et al. Prognosis of sudden deafness with special reference to risk factors of microvascular pathology. Auris Nasus Larynx 1999;26:111-5.  Back to cited text no. 12
    
13.
Lin SW, Lin YS, Weng SF, Chou CW. Risk of developing sudden sensorineural hearing loss in diabetic patients: A population-based cohort study. Otol Neurotol 2012;33:1482-8.  Back to cited text no. 13
    
14.
Fetterman BL, Saunders JE, Luxford WM. Prognosis and treatment of sudden sensorineural hearing loss. Am J Otol 1996;17:529-36.  Back to cited text no. 14
    



 
 
    Tables

  [Table 1]


This article has been cited by
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Nippon Jibiinkoka Gakkai Kaiho. 2019; 122(5): 757
[Pubmed] | [DOI]



 

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