International Journal of Otorhinolaryngology and Head and Neck Surgery

Samor V et al. Int J Otorhinolaryngol Head Neck Surg. 2020 May;6(5):821-825

http://www.ijorl.com pISSN 2454-5929 | eISSN 2454-5937

DOI: http://dx.doi.org/10.18203/issn.2454-5929.ijohns20201551
Original Research Article

The role of intratympanic dexamethasone in sudden

sensorineural hearing loss
Vivek Samor1, Sukhdev Khadav1*, Pooja Arya2, Deepchand1, Ramniwas Dhaka1

1
Department of ENT, Sardar Patel Medical College, Bikaner, Rajasthan, India
2
Department of ENT, SK Medical College, Sikar, Rajasthan, India

Received: 11 March 2020

Revised: 20 March 2020
Accepted: 27 March 2020

*Correspondence:
Dr. Sukhdev Khadav,
E-mail: sukhdevkhadav@gmail.com

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Present study was conducted to assess the efficacy of intratympanic dexamethasone in patients with
sudden sensorineural hearing loss and to determine factor affecting treatment outcome for sudden sensorineural
hearing loss.
Methods: Prospective study was conducted on 24 patients of sudden sensorineural hearing loss between October
2019 to February 2020 in the department of ENT, OPD, SPMC, Bikaner. Group A were given oral steroids:
prednisolone 1 mg/kg/day (maximal dose is 60 mg/day) full dose 14 days, then tapered over next 14 days. Group B
were given intratympanic dexamethasone 4 mg/ml, 0.5 ml into middle ear space (into the posterior inferior quadrant)
every 7 days for a total of 4 weeks. Audiogram was performed at end of every week for 4 weeks.
Results: Overall, 58% (n=14) patients showed improvement in pure-tone average. For ≤3 days of presentation; out of
total 6 patients, 83.33% cases recovered. For 4 to 7 days of presentation; out of total 10 patients, 80% cases
recovered. For 8 to 14 days presentation; out of total 8 patients 12.5% cases recovered (p=0.005).
Conclusions: We suggest the treatment approach in which interaural time difference is used adjuvantly with oral
steroids.

Keywords: Intratympanic dexamethasone, Sudden sensorineural hearing loss, Audiogram

INTRODUCTION all areas of the country and treated as a true emergency

often without the timeframe to allow for tertiary referral.
Idiopathic sudden sensorineural hearing loss (SNHL) is
defined as a decline in hearing over 3 days or less The aetiology, natural history and treatment of this
affecting 3 or more contiguous frequencies by 30 dB or disorder have been subjects of debate for many years.
greater with no identifiable etiology.1 The hearing loss The actual number of patients recovering spontaneously
(HL) is nearly always unilateral and is commonly from sudden SNHL without having sought medical
associated with tinnitus and aural fullness. Although this attention is not known. High rate of spontaneous
disorder is not one of the more common aetiologies for recovery, up to 65%, also confounds reviews as to the
HL, disproportionate interest in sudden SNHL exists therapeutic efficacy.3
most likely because it is one of the few reversible
(sensorineural) hearing losses encountered by clinicians.2 It occurs in 5 to 20 cases per 100000 population. This is
Another potential reason for high interest level is that approximately the same incidence as Meniere’s disease
sudden SNHL is encountered by all otolaryngologists in (15 per 100000) and twenty times more common than
acoustic neuroma (1 per 100000).2,4 The true incidence of

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idiopathic sudden sensorineural hearing loss (ISSNHL) is procedure of intratympanic steroid injection was
probably underestimated because many who recover performed under a microscope and with patient in supine
hearing early are unlikely to seek medical therapy. position. After confirming intact tympanic membrane and
middle ear status, local anaesthesia was administered
The treatment of patients with sudden SNHL remains with a cotton ball soaked with 10% lidocaine (xylocaine),
varied among otologic centers with no standard protocol which was applied on the tympanic membrane for 10 to
universally accepted. With no specific etiology and a 15 minutes. While the patient tilted the head 45◦ to the
short timeline for effective therapy realized, a technique healthy side.
termed “shotgun” therapy is often used. This therapy
entails multiple therapeutic agents geared toward the Table 1: Grading of severity of hearing loss.7
hypothetical etiologies given at once, because the narrow
therapeutic window prevents trials with each agent Grade
singly. Notwithstanding the timeframe in which Mild 26-40 dB
maximum recovery may occur, from several days to Moderate 41-55 dB
possibly several months, also leads to errors in
Moderately severe 56-70 dB
determining treatment efficacy versus natural history.5,6
Severe 71-90 dB
This study was undertaken to assess the efficacy of Profound >90 dB
intratympanic dexamethasone (4 mg/ml) in patients with
Sudden sensorineural hearing loss and to study the factor The dexamethasone solution of 4 mg/ml is checked and
affecting treatment outcome for Sudden sensorineural warmed to body temperature before injection. Before
hearing loss. each procedure, the patients were counselled regarding
the risks and expectations of the procedure and informed
METHODS consent obtained.

This prospective study was conducted between October A 25-gauge spinal needle was introduced into the
2019 to February 2020 in the department of ENT OPD, postero-inferior portion of tympanic membrane and
SPMC, Bikaner. approximately 0.5 ml of dexamethasone (4 mg/ml) was
injected into the middle ear.
Inclusion criteria
The patients were asked to lie in the supine position with
Patients with sudden unilateral hearing loss of at least 30 the head turned 45° away from the treated ear for
dB across 3 contiguous frequencies occurring in less than
approximately 20 minutes on average and avoid
72 hours and ppresentation to OPD within 2 weeks of
onset of hearing loss were included. swallowing.

Exclusion criteria 24 patients of either sex fulfilling inclusion and exclusion

criteria were taken up for the study. Written informed
Patients with hearing loss history with onset over 2 consent was taken. Detailed evaluation of the patient was
weeks, history of ear surgery or ear disease in the past, done including detailed history and complete ENT
evidence of retrocochlear disease, oncologic history with examination. All patients underwent PTA to confirm
recent chemotherapy or radiation therapy, congenital Sensorineural hearing loss. All patients underwent
cochlear malformations, Ménière’s disease, fluctuating Gadolinium enhanced MRI brain and BERA to rule out
hearing loss, acute or subacute otitis media with retrocochlear pathology. Patients were allocated into 2
abnormal tympanometry, neurological disorders, recent groups and each group consist of 12 patients.
use of ototoxic medications, recent trauma, consent
refusal for treatment or to be a part of study were Group A were given oral steroids. Prednisolone 1
excluded. mg/kg/d (maximal dose is 60 mg/day) full dose 14 days,
then tapered over next 14 days. Audiogram was
Audiometric data
performed at end of every week for 4 weeks.
Patients were all evaluated using standardized methods
Group B were given intratympanic dexamethasone 4
for pure-tone threshold audiometry by certified
audiologists pre- and post-injection. Pure-tone average mg/ml, 0.5 ml into middle ear space (into the posterior
(PTA) was calculated as an average of the threshold inferior quadrant) every 7 days for a total of 4 weeks via
measured at 0.5, 1.0 and 2.0 kHz (speech frequencies). narrow-gauge spinal needle to fill middle ear. Patients
also got prednisolone 1 mg/kg/day (maximal dose is 60
Operative procedure of intratympanic injection mg/d) full dose 14 days, then tapered over next 14 days.
Audiogram was performed before each subsequent
The correct ear was confirmed for injection by patient injection and at completion of treatment course.
response and audiometric review. The operative

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Treatment response 32.66 dB. Here, in group-A out of total 12 patients 50%
(n=6) were recovered and in group-B, 66.67% (n=8) were
Complete: If the follow-up PTA (dB HL) improved to recovered out of total 12 patients.
within 10 dB of pre-sudden hearing loss hearing levels.
Association between recovery and sex
Partial: If the follow-up PTA (dB HL) improved to
within 50% of pre-sudden hearing loss hearing levels. Out of 13 male patients, 62% (n= 8) were recovered and
among 11 female patient 55% (n=6) were recovered. Out
No recovery: If the follow-up PTA (dB HL) was less than of 6 males and 6 females, 50% were recovered in both
50% of recovery of pre-sudden hearing loss hearing males and females in group-A. In group-B, out of 7 male
levels. patients 71% (n=5) were recovered, while 60% (n=3)
female patients recovered out of 5 (p value=0.4175).
Statistical analysis
Association between recovery and age
Data are presented in numeric and percent form.
Categorical data analysis was performed using χ2 (chi- In our study, hearing recovery related to patient’s age was
square) techniques and ANOVA. A p value of less than studied. 79% (n=19) patients were under 60 years of age
0.05 was considered statistically significant. and had an overall recovery rate of 57.89%. 21% (n=5)
patients were 60 years of age or older and had an overall
RESULTS recovery of 60%. For age <60 years, in group-A recovery
rate was 50%, in group-B it was 66.67%. For age ≥60
In present study, after meeting the requirements of years, in group-A recovery was 50%, in group-B it was
inclusion exclusion criteria, 24 patients were available for 66.67% (p value=0.099).
study. Patients were divided in two groups consist of 12
patients in each group. The mean age at enrolment for all Recovery related to time of onset of symptoms
patients was 40.50 years with range from 24 to 70 years.
The mean age for male was 44.50 years and for female For ≤3 days of presentation; out of total 6 patients,
38.94 years. The mean age for group-A was 44.66 years, 83.33% cases recovered. For 4 to 7 days of presentation;
for group-B was 38.50 years. out of total 10 patients, 80% cases recovered. For 8 to 14
days presentation; out of total 8 patients 12.5% cases
In our study, out of 24 patients there were 13 (54%) male recovered (p value=0.005) (Figure 2).
and 11 (46%) female. In group-A, there were 6 (50%)
male and 6 (50%) female. In group-B, there were 7 (58%) 9 8
male and 5 (42%) female. 8 7
7
6 5
5
4
3 2
42%
2 1 1
Recovery 1
58%
No recovery 0
≤3 days 4-7 days 8-14 days

Recovery No Recovery

Figure 2: Recovery related to time of onset of

symptoms.
Figure 1: Overall hearing recovery.
Table 2: Mean time of onset of symptoms.
Overall hearing recovery
Recovery No recovery
Twenty-four patients fit the criteria for inclusion in the Time of onset of Time of onset of
study. Overall, 58% (n=14) patients showed improvement Group
symptoms (days) symptoms (days)
in PTA. Out of 14 recovered cases 8 were fully recovered Mean SD Mean SD
and 6 were partially recovered and 42% (n=10) were not Group-A 4.30 2.01 8.38 3.07
recovered (Figure 1). For those 58% patients showing
Group-B 3.90 2.16 11.80 2.38
improvement in PTA, the mean gain was 34.61 dB. In
group-A, the mean gain was 38.85 dB. In group-B, it was

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The average number of days from onset of symptoms to The natural history of untreated patients with ISSNHL
treatment was 6.01±3.17 days with a range from 1 to 14 states that the recovery rates varies from 31% to 65%,
days. For recovered cases, the mean days of presentation while the hearing recovery in treated patients ranges from
in group-A was 4.30 days, in group-B it was 3.90 days (p 35% to 89%.1,4,6,8 Such a result may be related to different
value=0.001) (Table 2). factors: the variable treatment protocols, the type of
steroid used, the length of therapy, the patient data, the
Recovery related to severity of hearing loss severity of hearing loss, the duration from onset of
symptoms to treatment, the method of statistical analysis.
For hearing loss >90 dB, there were total 8 patients with
recovery rate of 25% (n=2). For hearing loss <90-50 dB, Usually, intratympanic steroids are used in three main
there were total 12 patients with recovery rate of 75% protocols, as initial treatment, as adjunctive treatment
(n=9). For hearing loss <50-30 dB, there were total 4 given concomitantly with systemic steroids and as
patients with recovery rate of 75% (n=3) (p=0.0081) salvage treatment after failure of standard therapy.
(Figure 3).
In our study, patient age, interval from hearing loss onset
to treatment and severity of hearing loss were not
7 6 different between the two groups, making comparison of
6
therapeutic effects relatively straightforward.
5 4
4 3 On review of the studies published to date in
3 2 2 2 intratympanic steroids, it is clear that studies in the
2 1 1 1 1 1 literature also differ on the definition of “success” for
1 0 significant improvement after therapy. No definitive
0 criteria exist to define recovery in patients with sudden
A B A B A B SNHL. The criteria to which the authors define recovery
>90dB <90-50dB <50-30dB range from any improvement in PTA or SDS to an
improvement in 10-dB PTA or 10% SDS to the criteria
Recovery No recovery
described by Wilson et al that describes recovery as
>50% of the initial loss.1,8,9 They showed a statistically
Figure 3: Recovery related to severity of hearing loss. significant benefit with systemic steroids in recovery of
hearing in patients with sudden SNHL.1 Other studies
Hearing gain with treatment have also demonstrated the benefit of systemic steroids in
hearing recovery in sudden SNHL.5,11 On the contrary,
In our study, the hearing gain after 1 week was 21.21 dB, systemic steroids were shown to be of little benefit in the
in 2nd week gain was 9.13 dB, in 3rd week it was 6.97 treatment of sudden SNHL in several other studies.6,12,13
dB and in 4th week gain was 4.33 dB (Figure 4).
Results of our study were consistent with those of Byl
25 Hearing gain (dB) who found that increasing incidence with increasing age,
21.21 with a peak incidence of 47/100 000 in patients 45 years
20 and older.4

15 The increase in the incidence of SSNHL with increasing

age may be due to differences in the etiology between
9.13
10 6.97 younger and older patients.
4.33
5 Results of the current study were consistent with those of
Fuse et al. noted that the majority of patients who
0 recovered completely after treatment with oral steroids
1st week 2nd week 3rd week 4th week did so within 7 to 10 days after administration of steroids.
In long-term follow up of 3 months to 2 years, none of
Figure 4: Hearing gain with treatment. the patients with no recovery or partial recovery
recovered to normal hearing levels. They noted that
DISCUSSION patients resistant to steroids with regard to early outcome
continued to have poor hearing recovery during long-
The sudden SNHL is considered as an otologic term follow up.13 Lefebre reported that 100% of patients
emergency and it severely impairs patient’s quality of life treated with steroids for sudden SNHL recovered within 7
and social interaction, but, if treated at correct time, it can days.15
be potentially reversed. Considering the high rate of
spontaneous recovery, it is difficult to determine if any In our study, dexamethasone related side effects are very
therapeutic intervention actually improves the hearing. less and they include ear fullness, slight otalgia during

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 Samor V et al. Int J Otorhinolaryngol Head Neck Surg. 2020 May;6(5):821-825

injection and transient dizziness post injection. Majority 2. Chen CY, Halpin C, Rauch SD. Oral steroid
of these events are technique related, very short term and treatment of sudden sensorineural hearingloss: a ten
self-resolving. year retrospective analysis. Otol Neurotol.
2003;24:728-33.
Availability of dose of dexamethasone (more than 4 3. Mattox DE, Lyles CA. Idiopathic sudden
mg/ml) is limiting factor in our country. sensorineural hearing loss. Am J Otol.
1989;10(3):242-7.
CONCLUSION 4. Byl FM. Sudden hearing loss: eight years
experience and suggested prognostic table.
Difficulty in proving safety and efficacy of a single Laryngoscope. 1984;94 (5):647-61.
modality of steroid treatment is present in all studies on 5. Slattery WH, Fisher LM, Iqbal Z, Liu N. Oral
ISSNHL, due to a multiple treatment protocols, a variable steroid regimens for idiopathic sudden sensorineural
rate of recovery and a high rate of spontaneous recovery. hearing loss. Otolaryngol Head Neck Surg.
Moreover, the hearing losses less than 90 dB, the 2005;132:5-10.
involvement of the low frequencies and the earlier 6. Cinamon U, Bendet E, Kronenberg J. Steroids,
treatment seem to influence positively the hearing carbogen or placebo for sudden hearing loss: a
recovery, although the success could be attributed to the prospective double-blind study. Eur Arch
natural history of the disease. Otorhinolaryngol. 2001;258:477-80.
7. Humes LE. The World Health Organization's
More well-controlled clinical trials and standard criteria hearing-impairment grading system: an evaluation
of hearing recovery are required to document the real for unaided communication in age-related hearing
efficacy of this option in the treatment of ISSNHL and to loss. Int J Audiol. 2019;58(1):12-20.
determine the most appropriate use and the correct timing 8. Slattery WH, Fisher LM, Iqbal Z, Friedman RA, Liu
and dosage of this therapeutic modality in the emerging N. Intratympanic steroid for the treatment of sudden
field of inner ear medicine delivery. hearing loss. Otolaryngol Head Neck Surg.
2005;133:251-9.
We can affirm, according to the retrospective and 9. Haynes DS, O’Malley M, Cohen S, Watford K,
prospective studies examined, that interaural time Labadie RF. Intratympanic dexamethasone for
difference (ITD) has not been shown to be systemically sudden sensorineural hearing loss after failure of
absorbed at a clinically significant level and has not been systemic therapy. Laryngoscope. 2007;117(1):3-15.
shown to lead to systemic and severe cortisol related 10. Chandrasekhar SS. Intratympanic dexamethasone
adverse events. It is therefore suitable to suggest that ITD for sudden sensorineural hearing loss: clinical and
therapy is a safe and reasonable procedure and that laboratory evaluation. Otol Neurotol. 2001;22:18-
dexamethasone injected intra-tympanically is not 23.
absorbed systemically and does not carry risks of cortisol 11. Gianoli GJ, Li JC. Transtympanic steroids for
related metabolic or endocrine side effects. treatment of sudden hearing loss. Otolaryngol Head
Neck Surg. 2001;125:142-6.
Finally, we suggest the treatment approach in which ITD 12. Moskowitz D, Lee KJ, Smith HW. Steroid use in
is used adjuvantly with oral steroids. idiopathic sudden sensorineural hearing loss.
Laryngoscope. 1984;94:664-6.
ACKNOWLEDGEMENTS 13. Mattox DE, Simmons FB. Natural history of sudden
sensorineural hearing loss. Ann Otol Rhinol
The author would like to thank Dr Gaurav Gupta for their Laryngol. 1977;86:463-80.
valuable assistance in building the research strategy and 14. Fuse T, Aoyagi M, Funakubo T, Sakakibara A,
retrieving the articles from various databases. Yoshida S. Short-term outcome and prognosis of
acute low-tone sensorineural hearing loss by
Funding: No funding sources administration of steroid. ORL J Otorhinolaryngol
Conflict of interest: None declared Relat Spec. 2002;64(1):6-10
Ethical approval: The study was approved by the 15. Lefebvre PP, Staecker H. Steroid perfusion of the
Institutional Ethics Committee inner ear for sudden sensorineural hearing loss after
failure of conventional therapy: a pilot study. Acta
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1. Wilson WR, Byl FM, Laird N. The efficacy of Cite this article as: Samor V, Khadav S, Arya P,
steroids in the treatment of idiopathic sudden Deepchand, Dhaka R. The role of intratympanic
hearing loss. A double blind clinical study. Arch dexamethasone in sudden sensorineural hearing loss.
Otolaryngol. 1980;106:772-6. Int J Otorhinolaryngol Head Neck Surg 2020;6:821-
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