Eur Arch Otorhinolaryngol (2011) 268:17351741 DOI 10.

1007/s00405-011-1563-5

OTOLOGY

EYcacy comparison of oral steroid, intratympanic steroid, hyperbaric oxygen and oral steroid + hyperbaric oxygen treatments in idiopathic sudden sensorineural hearing loss cases
Yalcin Alimoglu Ender Inci Deniz Tuna Edizer Alper Ozdilek Mehmet Aslan

Received: 26 September 2010 / Accepted: 3 March 2011 / Published online: 23 March 2011 Springer-Verlag 2011

Abstract Idiopathic sudden sensorineural hearing loss is a rare disorder of unknown pathogenesis in which hearing is lost partially or totally. About 60 treatment modalities have been described. We aimed to compare the eYcacy of hyperbaric oxygen, oral steroid, intratympanic steroid therapy and their combinations in idiopathic sudden sensorineural hearing loss patients. Files of patients who were followed up between 2004 and 2010 in our clinic were examined retrospectively. Patients were divided into four groups according to the therapy received: Oral steroid, oral steroid + hyperbaric oxygen, intratympanic steroid and hyperbaric oxygen. Treatment success was assessed by Siegel criteria and mean gains using pre-treatment and posttreatment audiograms. 217 patients and 219 ears were examined. The proportion of patients responding to therapy was the highest in the oral steroid + hyperbaric oxygen group with 86.88% (53/61) followed by the oral steroid group with 63.79% (37/58), the intratympanic steroid group with 46,51% (20/43) and the hyperbaric oxygen group with 43.85% (25/57). The proportion of patients who had complete recovery was the highest in the oral steroid + hyperbaric oxygen group with 42.6% (26/61) followed by the oral steroid group with 19.0% (11/58), the hyperbaric oxygen group with 17.5% (10/57) and the intratympanic steroid group with 11.6% (5/43). The oral steroid + hyperbaric oxygen group has the highest mean hearing gain among all groups (p < 0.05). Idiopathic sudden sensorineural hearing loss patients receiving oral steroid + hyperbaric oxygen

combination therapy have a higher likelihood of recovery than patients receiving oral steroids, hyperbaric oxygen or intratympanic steroids alone. Keywords Sudden hearing loss Sensorineural hearing loss Hyperbaric oxygen therapy Steroids Intratympanic

Introduction Idiopathic sudden sensorineural hearing loss (ISSNHL) is a rare disease characterized by total or partial hearing loss. Its etiopathogenesis is not entirely known. The US National Institute for Deafness and Communication Disorders has deWned ISSNHL as a hearing loss of at least 30 dB occurring in 3 days in three consecutive test frequencies [1]. Authors who accept 20 dB as the threshold for loss also exist [2, 3]. Sudden hearing loss has been a topic of debate and study since the advent of otology. Sudden hearing loss was Wrst described by Everberg in 1869 in a case after mumps. Politzer made detailed description of the disease for the Wrst time in 1887 and named it angioneurotische Oktavuskrise (angioneurotic eighth nerve crisis). In 1904, Bing reported a case of sudden hearing loss not accompanied by vertigo. With advancements in clinical audiology De Kleyn presented the Wrst case series in 1944. De Kleyn thought that the disorder originated from brain stem and was caused by a vitamin deWciency. Savene-Knudson presented another case series of 100 patients in 1957 [4]. The incidence of sudden hearing loss is generally reported as 520 per 100,000 per year [4]. Because of patients recovering rapidly or seeking no medical attention, the true Wgure might be higher. The spontaneous remission rate has been reported as 4565% [4, 5].

Y. Alimoglu E. Inci (&) D. T. Edizer A. Ozdilek M. Aslan Cerrahpasa Medical Faculty, Otolaryngology Department, Istanbul University, Istanbul, Turkey e-mail: enderinci@gmail.com

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Klemm et al. [6] reported an incidence of 160 in 100,000 in an epidemiologic study performed in Germany. Moreover, according to a study performed in Japan the number of patients treated for sudden hearing loss increased from 4,000 in 1972 to 35,000 patients in 2001 [7]. Studies conducted in the USA, Europe and Japan with a total of 7,500 patients have found that sudden hearing loss occurs typically between 43 and 53 years with no sex predilection. Shaia and Sheey have also found equal sex distribution in their study with 1,220 patients [8]. In 1015% of cases, a cause may be found. About 1% of sudden sensorineural hearing loss cases are due to retrocochlear pathologies such as vestibular schwannomas, demyelinizating diseases or stroke. [5, 9]. The remaining are idiopathic. Hearing loss is unilateral in idiopathic cases and bilateral involvement has been reported in less than 5% of cases [10]. Bilateral cases may occur due to functional (psychiatric reasons) and neurologic processes such as encephalitis or paraneoplastic syndromes [11]. Proposed mechanisms for ISSNHL include vascular occlusion, viral infections, labyrinthine membrane breaks, immune associated mechanisms and abnormal stress response in the cochlea. Prognosis is related to factors such as hearing loss at the initiation of therapy, presence of vertigo, tinnitus, audiogram conWguration at presentation and age. Many treatment modalities are used. The most commonly used therapy is oral steroid therapy. Its use is sometimes limited because of its side eVects. Intratympanic steroids have been used more often in patients who have not beneWted from oral steroid therapy and various results have been obtained. Hyperbaric oxygen therapy is used more and more commonly. We aimed to investigate the eYcacy of hyperbaric oxygen, oral steroid, intratympanic steroid therapy and their combinations in a retrospective Wle study. Records of 217 patients and 219 ears with ISSNHL treated in our clinic between 2004 and 2010 were reviewed retrospectively and treatment success rates were compared.

obtained and patients who received therapy after 30 days of the onset of symptoms were excluded from the study. Pretreatment and post-treatment audiograms were examined and hearing thresholds at 250, 500, 1,000, 2,000, 4,000 and 8,000 Hz were noted. Audiogram conWgurations were categorized as upsloping (hearing loss aVecting 250, 500 Hz more), Xat (less than 20 dB diVerence between the highest and the lowest threshold), downsloping (hearing loss aVecting 4,000, 8,000 Hz more) and profound (thresholds of 90 dB or more in each test frequency) hearing loss. Treatment groups Patients diagnosed as ISSNHL were categorized according to therapy received into four groups: Oral steroid (group A), oral steroid + hyperbaric oxygen (group B), intratympanic steroid (group C), hyperbaric oxygen (group D). Patients in each treatment group were subdivided into subgroups by time of therapy initiation (before and after 3 days, before and after 15 days). The audiogram conWguration (upsloping, downsloping, Xat and profound) of each patient was noted. The oral steroid protocol for sudden hearing loss in our clinic consisted of 1 mg/kg prednisolone or equivalent and a 10 mg taper every 3 days. Oral steroid therapy lasted about 3 weeks. Meanwhile patients received proton pump inhibitors (e.g. lansoprazole or pantoprazole) for gastrointestinal protection and patients were instructed to avoid diet with salt and high carbohydrate content. The group who received hyperbaric oxygen had received two sessions per day in the Wrst 3 days and one session per day in the following days for a total of 20 sessions at 2.5 ATA with 120 min per session. The group who received oral steroid + hyperbaric oxygen had received 1 mg/kg prednisolone or equivalent and 10 mg taper every 3 days and 20 sessions of hyperbaric oxygen at 2.5 ATA with 120 min per session. Intratympanic steroid treatment had been applied 2 days/ week to the aVected side for 3 weeks, with a total of six times. The external ear canal is Wlled with 10% lidocaine and after a pause of 15 min the patients are placed in a supine position. Under microscope all of the lidocaine is aspirated from the ear canal. The head is directed 45 to the opposite side. Afterwards, a perforation is made in the anterosuperior quadrant with the tip of a dental syringe and about 0.5 ml of 0.4% dexamethasone is injected through anteroinferior quadrant into the middle ear. The patient is instructed not to talk or swallow for about 30 min. Evaluation criteria Treatment results were evaluated using the Siegel criteria [12] semiquantitatively and using mean gain, which is the

Materials and methods Files of patients diagnosed as sudden sensorineural hearing loss and treated between 2004 and 2010 in our clinic which is a tertiary referral center were examined retrospectively. Patients The criteria to diagnose sudden hearing loss were at least 30 dB sensorineural hearing loss in three consecutive frequencies in 3 days [1]. Patients in whom primary etiology could be found were not included to the study. Patients under 14 years, whose pre-treatment and post-treatment audiograms could not be

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change of 500, 1,000, 2,000 and 4,000 Hz frequencies threshold mean changes quantitatively. Response to therapy was categorized according to Siegel criteria as follows: 1. Healing: Final threshold more than 25 dB. 2. Partial improvement: gain of more than 15 dB, Wnal hearing threshold 2545 dB. 3. Slight improvement: gain of more than 15 dB, Wnal hearing threshold more than 45 dB. 4. No response: gain of less than 15 dB and Wnal hearing threshold more than 75 dB. One-way ANOVA, KruskalWallis, Chi square, and MannWhitney U tests were used for statistical analysis. The study was conducted with the approval of the ethics committee.
Fig. 1 Patient ratio responding to therapy according to Siegel criteria in each study group. Po steroid: Group receiving oral steroid (group A). HBO + po steroid: Group receiving hyperbaric oxygen + oral steroid (group B). IT steroid: Group receiving intratympanic steroid (group C). HBO: Group receiving only hyperbaric oxygen (group D). 1 Complete recovery, 2 Partial recovery, 3 Slight improvement, 4 No improvement

Results Our study included 217 patients and 219 diseased ears, which were treated at our clinic. Groups Oral steroid group (Group A) consisted of 58 patients (26.5%), oral steroid + hyperbaric oxygen group (Group B) 61(27.9%), intratympanic steroid group (Group C) 43(19.6%) and hyperbaric oxygen group (Group D) 57 cases (26%). Pure tone audiometry (PTA) Pretreatment PTA (mean of thresholds at 500, 1,000, and 2,000 Hz) of all patients was 66.08 24.61 dB. Pretreatment PTA of group A was 72.12 20.68 dB, of group B was 63.68 22.97 dB, of group C was 61.08 22.97 dB and of group D was 66.28 28.20 dB. There was no statistically signiWcant diVerence between groups in terms of pretreatment PTA (p > 0.05). Audiogram type Response to therapy There were no statistically signiWcant diVerences in terms of the number of audiogram types between treatment groups (p > 0.05). Time of therapy initiation There was no statistically signiWcant diVerence between groups in terms of time of therapy start (p > 0.05). Totally and in each study group, there was no statistically signiWcant diVerence between mean gains of cases in Treatment response according to Siegel criteria and the number of patients are shown in Table 1 and Fig. 1. The proportion of patients with complete recovery was the highest in the oral steroid + hyperbaric oxygen group (26/61) 42.6% followed by the oral steroid group (11/58) 19.0%, the hyperbaric oxygen group (10/57) 17.5% and the intratympanic steroid group (5/43) 11.6% (Fig. 1). The ratio of patients responding to therapy was the highest in the oral steroid + hyperbaric oxygen group (53/61)
1 2 3 4 Complete recovery Partial recovery Slight improvement No improvement Total Table 1 Patient numbers responding to therapy according to Siegel criteria in each study group Group A 11 15 11 21 58 B 26 14 13 8 61 C 5 8 7 23 43 D 10 6 9 32 57 52 43 40 84 219 Total

A Oral steroid group, B Hyperbaric oxygen + oral steroid group, C Intratympanic steroid group, D Hyperbaric oxygen group

whom therapy was started in the Wrst 3 days and thereafter (p > 0.05). Mean gains of cases in whom therapy was started in the Wrst 15 days mean gains were signiWcantly higher in each group (p < 0.05). Mean ages were compared and patients with ascending type audiogram were found to have lower age (p < 0.05).

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Fig. 2 Cases responding to therapy in each study group. Po steroid: Group receiving oral steroid (group A). HBO + po steroid: Group receiving hyperbaric oxygen + oral steroid (group B). IT steroid: Group receiving intratympanic steroid (group C). HBO: Group receiving only hyperbaric oxygen (group D). Response: Cases responding to therapy (cases with more than 15 dB gain of mean gains at thresholds 500, 1,000, 2,000 and 4,000 Hz or cases cured). No response: Cases not responding to therapy (cases with less than 15 dB gain of mean gains at thresholds 500, 1,000, 2,000 and 4,000 or worsening cases)

Fig. 3 Mean gains in each study group. Po steroid: Group receiving oral steroid (group A). HBO + po steroid: Group receiving hyperbaric oxygen + oral steroid (group B). IT steroid: Group receiving intratympanic steroid (group C). HBO: Group receiving only hyperbaric oxygen (group D). Mean gain: Means of gains at 500, 1,000, 2,000 and 4,000 Hz thresholds in dB

86.88% followed by the oral steroid group (37/58) 63.79%; the intratympanic steroid group (20/43) 46.51% and the hyperbaric oxygen group (25/57) 43.85% (Fig. 2). Mean gain Mean gains according to Siegel criteria in each group were compared to other groups. Mean gain of group A was statistically signiWcantly better than group C (Z = 2.232; p = 0.026) and group D (Z = 2.486; p = 0.013). Group B was statistically signiWcantly better than group A (Z = 2.049; p = 0.040), group C (Z = 4.569; p = 0.0) and group D (Z = 4.275; p = 0.0). No diVerence was found between C and D groups (p > 0. 05) (Fig. 3).

Discussion Even though about more than 60 treatment protocols have been described, there is no consensus about the treatment modality of choice in ISSNHL. The most widely accepted therapy is tapered oral corticosteroid therapy; however, data supporting this therapy is limited. Steroids have many eVects in the inner ear. Suppression of immune response, improvement of decreased microvascular circulation, mineralocorticoid eVects, or decrease in endolymphatic pressure are thought to be the ways corticosteroids help. However, the exact mechanism is unknown [13, 14].

The Wrst randomized controlled study with steroids by Wilson et al. consisted of 67 sudden hearing loss patients who were given dexamethasone or methylprednisolone at various doses. The patients were divided into recovery and no recovery groups. The patients treated with steroids had statistically higher recovery than placebo group (61 vs 32%) [15]. In another study, 10 patients received carbogen inhalation and 11 patients received oral prednisone for 5 days. No diVerence could be found between steroid, carbogen and placebo results [16]. In a meta-analysis, when data of two studies were combined statistically insigniWcant diVerence was found [17]. Moreover, cure rate reported in the study by Wilson et al. [15] was roughly equal to the spontaneous cure rate (65%) reported in another study [5]. In a prospective randomized study, the group treated with corticosteroids was compared to the placebo group. The corticosteroid-receiving group had 89% recovery compared to 44% in the control group [18]. Eight hundred and thirty-seven sudden hearing loss patients were studied retrospectively and the corticosteroid-receiving group was found to have the best chance for recovery; however, no statistical signiWcance could be found [19]. One hundred and eighty-three sudden hearing loss patients were studied prospectively between 1980 and 1985, and no statistically signiWcant diVerence between group using steroids and controls was found [20]. Byl reported his experience with 225 patients he followed for 8 years and questioned the eYcacy of steroids [4]. Kubo et al. [21] compared batroxobin with oral steroids. The authors concluded that better results were obtained with batroxobin but Conlin et al. [17] stated that using criteria of Cinamon et al. no diVerence could be found.

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Cochlear activity is known to require a high oxygen supply. Especially, stria vascularis and the organ of Corti have a high energy demand [22]. Perilymphatic oxygen tension decreases signiWcantly in patients with sudden hearing loss [23]. Oxygen administration may improve cochlear metabolism. Oxygen inhalation has been shown to increase intracochlear oxygen tension [24]. Fattori et al. [25] administered hyperbaric oxygen therapy (HBO) to 30 and vasodilator buXomedil to 20 sudden hearing loss patients who were admitted within 48 h of onset of symptoms. Patients who received hyperbaric oxygen had better hearing outcomes. We were not able to Wnd another study where HBO was solely used as the primary treatment for ISSNHL. In our study, HBO therapy alone provided worse results than hyperbaric oxygen + oral steroid or oral steroid therapy. Cekin et al. [26] administered 1 mg/kg oral steroid and HBO therapy to 36 patients and oral steroid therapy alone to 21 patients and did not Wnd any statistically signiWcant diVerence between hearing results. Aslan et al. [27] performed a retrospective Wle study where 25 patients receiving betahistin hydrochloride, prednisone, and daily stellate ganglion block were compared to 25 patients who received the before-mentioned therapy plus HBO. Especially, patients in the HBO group younger than 50 had better hearing outcome. In a retrospective Wle study, 65 patients receiving HBO and steroid were compared to 63 patients receiving just steroids. No diVerence in terms of cure and hearing recovery could be found. Categorically considered, better improvement was present in the HBO receiving group. ISSNHL patients with severe hearing loss beneWted from HBO [28]. We could not Wnd this relationship. Twenty-one ISSNHL patients were given steroid, diazepam, pentoxyphyllin and salt restriction, and 30 patients were given the before-mentioned therapy and HBO. The group with HBO had better results in thresholds higher than 60 dB in test frequencies except for 2,000 Hz [29]. According to our results, the addition of HBO to oral steroid therapy provided better treatment response, cure and mean gains. Our results are in concordance with those of Fujimara et al. and Topuz et al. [28, 29]. The lack of beneWt of the addition of HBO to oral steroids in other studies may be attributed to small patient groups. Inci et al. [30] reported that late cases (1545th day) of ISSNHL who had not responded to medical therapy were given HBO and about 55% showed improvement. HBO may be a management option for late cases. The use of intratympanic steroids in the management of inner ear disorders has advanced in the last 1015 years. It has been used primarily for Menieres disease and sudden hearing loss. In many studies, they have been reported to

give better results as salvage therapy in cases where oral therapy is ineYcient compared to placebo or follow-up without treatment [2, 31, 32]. The use of intratympanic steroids as a primary treatment is limited to case series and success rates similar to oral therapy have been reported [33, 34]. In the Wrst multicentric placebo-controlled doubleblinded study investigating intratympanic steroids as primary treatment by Battaglia et al. [3] the patients were divided into three groups: Intratympanic dexamethasone + oral placebo, intratympanic placebo + oral steroid, intratympanic dexamethasone + oral steroids. The gain in PTA did not diVer among groups. However, if patients were categorized into response and no response groups, intratympanic dexamethasone + oral steroid group showed treatment results only better than oral steroid group. This study was criticized by other authors because of small sample size (17, 18 and 16 patients in each group respectively). Kara et al. [35] administered to 31 patients oral steroid and 29 patients intratympanic steroid treatment. The intratympanic steroid group had statistically better results. Hong et al. have administered to 32 of 63 sudden hearing loss patients primary intratympanic dexamethasone for 8 days, and oral prednisolone to the rest for the same duration. They could not found any diVerence. However, the oral steroid receiving group had better results in high frequencies [36]. Our intratympanic steroid treatment group had worse mean gains and worse response to treatment compared to the oral steroid group. The diVerence in the treatment outcomes may be due to geographical diVerences or diVerent pathophysiological mechanisms responsible for the same clinical picture. We aimed to compare oral steroid, hyperbaric oxygen + oral steroid, intratympanic steroid and hyperbaric oxygen alone therapies for their eVectiveness in the management of ISSNHL. When mean gains in the frequencies 500, 1,000, 2,000 and 4,000 Hz above 15 dB were considered as response to therapy, i.e. changes in mean gains diVerent from no response according to Siegel criteria, the best response was in the oral steroid + hyperbaric oxygen group with 86.88%; the second best response was in oral steroid group with 63% followed by intratympanic steroid group with 46.5%, and hyperbaric oxygen group with 43.85% (Fig. 2). The group where complete recovery was seen most commonly is hyperbaric oxygen + oral steroid group (42. 6%). This was followed by oral steroid (19%), hyperbaric oxygen (17.5%), and intratympanic steroid (11.6%) groups (Fig. 1). When the mean gains in the frequencies 500, 1,000, 2,000, 4,000 Hz were compared, oral steroid + hyperbaric oxygen group had higher gains than all other study groups. The oral steroid group had higher mean gains than intratympanic steroid and hyperbaric oxygen groups

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Eur Arch Otorhinolaryngol (2011) 268:17351741 the treatment of idiopathic sudden sensorineural hearing loss. Otol Neurotol 29(4):453460 Byl FM Jr (1984) Sudden hearing loss: 8 years experience and suggested prognostic table. Laryngoscope 94(5 Pt 1):647661 Mattox DE, Simmons FB (1977) Natural history of sudden sensorineural hearing loss. Ann Otol Rhinol Laryngol 86(4 Pt 1):463 480 Klemm E, Deutscher A, Msges R (2009) A present investigation of the epidemiology in idiopathic sudden sensorineural hearing loss. Laryngorhinootologie 88(8):524527 Teranishi M, Katayama N, Uchida Y, Tominaga M, Nakashima T (2007) Thirty-year trends in sudden deafness from four nationwide epidemiological surveys in Japan. Acta Otolaryngol 127(12):12591265 Shaia FT, Sheehy JL (1976) Sudden sensori-neural hearing impairment: a report of 1,220 cases. Laryngoscope 86(3):389398 Hughes GB, Freedman MA, Haberkamp TJ, Guay ME (1996) Sudden sensorineural hearing loss. Otolaryngol Clin North Am 29(3):393405 Oh JH, Park K, Lee SJ, Shin YR, Choung YH (2007) Bilateral versus unilateral sudden sensorineural hearing loss. Otolaryngol Head Neck Surg 136(1):8791 Rauch SD (2008) Clinical practice. Idiopathic sudden sensorineural hearing loss. N Engl J Med 359(8):833840 Siegel LG (1975) The treatment of idiopathic sudden sensorineural hearing loss. Otolaryngol Clin North Am 8(2):467473 Garca Berrocal JR, Ramrez-Camacho R (2000) Immune response and immunopathology of the inner ear: an update. J Laryngol Otol 114(2):101107 Mort DJ, Bronstein AM (2006) Sudden deafness. Curr Opin Neurol 19(1):13 Wilson WR, Byl FM, Laird N (1980) The eYcacy of steroids in the treatment of idiopathic sudden hearing loss. A double-blind clinical study. Arch Otolaryngol 106(12):772776 Cinamon U, Bendet E, Kronenberg J (2001) Steroids, carbogen or placebo for sudden hearing loss: a prospective double-blind study. Eur Arch Otorhinolaryngol 258:477480 Conlin AE, Parnes LS (2007) Treatment of sudden sensorineural hearing loss: I A systematic review. Arch Otolaryngol Head Neck Surg 133(6):573581 Moskowitz D, Lee KJ, Smith HW (1984) Steroid use in idiopathic sudden sensorineural hearing loss. Laryngoscope 94(5 Pt 1):664 666 Fetterman BL, Saunders JE, Luxford WM (1996) Prognosis and treatment of sudden sensorineural hearing loss. Am J Otol 17(4):529536 Kanzaki J, Taiji H, Ogawa K (1988) Evaluation of hearing recovery and eYcacy of steroid treatment in sudden deafness. Acta Otolaryngol Suppl 456:3136 Kubo T, Matsunaga T, Asai H, Kawamoto K, Kusakari J, Nomura Y, Oda M, Yanagita N, Niwa H, Uemura T et al (1988) EYcacy of deWbrinogenation and steroid therapies on sudden deafness. Arch Otolaryngol Head Neck Surg 114(6):649652 Cavallazzi GM (1996) Relations between O2 and hearing function. n: Marroni A, Oriani G, Wattel F (eds) Proceedings of international joint meeting on hyperbaric and underwater medicine, Milano (Italy), pp 633645, September 48 Nagahara K, Fisch K, Yagi M (1983) Perilymph oxygenation in sudden and progressive sensorineural hearing loss. Acta Otolaryngol 96:5769 Tsunoo M, Perlman MB (1960) Temporary arterial obstruction. EVects on perilymph oxygen and microphonics. Acta Otolaryngol 67:460466 Fattori B, Berrettini S, Casani A, Nacci A, De Vito A, De Iaco G (2001) Sudden hypoacusis treated with hyperbaric oxygen therapy: a controlled study. Ear Nose Throat J 80(9):655660

(Fig. 3). Oral steroid + hyperbaric oxygen group seemed to provide the best therapy in almost every aspect. The eYcacy of the steroid and hyperbaric oxygen may be due to edema resolving and inXammation suppressing eVects of steroids combined with the oxygenation enhancing, edema resolving eVects of the added hyperbaric oxygen treatment. Therefore, both more oxygen is delivered to a region where due to edema and inXammation ischemia is present, and through decreased edema ischemia is reversed. The causes of sudden sensorineural hearing loss still continue to remain obscure. Moreover, it is not known where in the auditory system the damage is localized. This limits the development of new treatment strategies. We think that studies investigating etiopathogenesis should be conducted. There is limited evidence about the treatment eYcacy of oral corticosteroids, hyperbaric oxygen and intratympanic steroids. Moreover, there are few placebo-controlled studies. In our study, we compared treatment modalities to one another and to spontaneous remission rate reported in the literature. Considering all of the studies performed up to now, whether the main event is vascular, viral or cellular stress mechanisms associated, an inXammatory process and a secondary vascular insuYciency in the cochlea occurs. According to all results obtained from this study, the best treatment to improve this catastrophic process is the combination of the steroids and hyperbaric oxygen, which is now used more and more commonly in the last years. The estimated cost of hyperbaric oxygen treatment is about 45 US dollars per session and is covered by insurance companies in our country. HBO therapy and intratympanic steroid therapy alone should not be used as the primary treatment for ISSNHL. Prospective randomized double-blinded controlled studies are needed.

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Conclusion
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Hyperbaric oxygen and concomitant steroid therapy is an eVective method of treating patients with ISSNHL.
ConXicts of interest Authors declare no conXict of interest. 22.

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1741 31. Chandrasekhar SS (2001) Intratympanic dexamethasone for sudden sensorineural hearing loss: clinical and laboratory evaluation. Otol Neurotol 22(1):1823 32. Ho HG, Lin HC, Shu MT, Yang CC, Tsai HT (2004) EVectiveness of intratympanic dexamethasone injection in sudden-deafness patients as salvage treatment. Laryngoscope 114(7):11841189 33. Fitzgerald DC, McGuire JF (2007) Intratympanic steroids for idiopathic sudden sensorineural hearing loss. Ann Otol Rhinol Laryngol 116:253256 34. Alles MJ, der Gaag MA, Stokroos RJ (2006) Intratympanic steroid therapy for inner ear diseases, a review of the literature. Eur Arch Otorhinolaryngol 263(9):791797 35. Kara E, Cetik F, Tarkan O, Srmelioflu O (2010) ModiWed intratympanic treatment for idiopathic sudden sensorineural hearing loss. Eur Arch Otorhinolaryngol 267(5):701707 36. Hong M, Park CH, Lee JH (2009) Hearing outcomes of daily intratympanic dexamethasone alone as a primary treatment modality for ISSHL. Otolaryngol Head Neck Surg 141(5):579583

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