suddensensorineuralhearing loss - tums.ac.ir sensorineural hearing loss.pdf · management&...

Sudden Sensorineural Hearing Loss Evidence-‐based Key Points

Sasan Dabiri, M.D. Assistant Professor Department of Otorhinolaryngology – Head & Neck Surgery

Amir A’lam hospital Tehran University of Medical Sciences

January 2014

DefiniKon

The US NaKonal InsKtute for Deafness and CommunicaKon Disorders (NICDC) criteria:

! Hearing loss ≥ 30 dB

! In ≥ 3 consecu1ve frequencies

! Occurring ≤ 3 days

Sudden Sensorineural Hearing Loss : Evidence-‐based Key Points

However, some studies use differing criteria

Epidemiology

•  Incidence : 5 – 20 in 100,000 in year •  Men = Women •  Mean age : 40 – 60 years •  Mostly occur on awakening •  Bilateral involvement : Less than 5% (rare)

Simultaneous bilateral : very rare


EKology Sudden Sensorineural Hearing Loss : Evidence-‐based Key Points

However, up to 90% of cases are idiopathic

Prognosis

•  Spontaneous improvement is common (in days)


1/3 to 2/3 experience complete or parKal recovery

Recovery scales : !  Complete, <10 dB deficit !  Par1al, ≥ 50 % of deficit !  None, <50 % of deficit

Prognosis

•  Variables that affect the Prognosis of untreated : –  Age (children or older than 40 years) –  Audiogram shape (downslope or flat)

–  Severity of Loss (severe) – WRS in speech audiometry (poor)

–  Ves1bular status (presence of verKgo)


No Definite conclusions for these variables from Published papers

•  Spontaneous improvement is common (in days)

EvaluaKon Sudden Sensorineural Hearing Loss : Evidence-‐based Key Points

!  History !  Clinical ExaminaKon (including neurologic)

•  Exclusion of Specific Causes rouKnely on the basis of: •  Audiologic ConfirmaKon of SSNHL

Recommended


•  Laboratory TesKng as rouKne work-‐up

Strong Recommended

Against


•  Computed Tomography (CT) for ini9al evalua9on

Strong Recommended

Against

Adverse Effects: !  Radiation Exposure

!  Intravenous Contrast

RelaKve RadiaKon Level for Head CT is 3 For CXR = 1 For MRI = 0


•  Retrocochlear EvaluaKon

•  MRI (Gold Standard) •  ABR •  Audiometric follow-‐up

Recommended

CP angle tumor prevalence

in SSNHL: 2.5 – 10 %

Management

SSNHL is an Otologic Emergency

Thus should be managed as soon as possible

(best results in early 3 days)


Management

•  PaKent EducaKon

–  about natural history –  benefits and risks of medical IntervenKons –  limitaKons of exisKng evidence regarding efficacy


Strong Recommended

barrier is 1me rather than aOtude or skill

Shared Decision Making

Management Sudden Sensorineural Hearing Loss : Evidence-‐based Key Points

Steroid type Equivalent dose (mg)

RelaKve anK-‐inflammatory

DuraKon of acKon (hrs)

Endogenous cor1sol 20 1 8 -‐ 12

HydrocorKsone 20 1 8 -‐ 12

Prednisolone 5 4 12 -‐ 36

Methylprednisolone 4 5 12 -‐ 36

Dexamethasone 0.75 30 36 -‐ 72

OpKonal •  PaKent EducaKon •  Steroid


Suggested protocol: 10-‐day course of high-‐dose steroid (prednisolone : 1 mg/kg/day)

Does need to taper?

!  any dose of steroid for < 3 weeks

!  alternate-‐day steroid therapy

Not in

studies are contradictory on the effec1veness of steroid therapy

How long is conKnued? Repeat 10-‐day course unKl

parKal recovery (≥ 50%) is seen

•  PaKent EducaKon •  Steroid – Systemic


Methylprednisolone had the highest concentra1on and longest dura1on in perilymph and endolymph compared to dexamethasone & hydrocor1sone; It does not mean greater efficacy. Dexamethasone seems to be beaer tolerated.

Dexamethasone: vary from 1 to 25 mg/mL. Methylprednisolone: mostly 62.5 mg/mL.

IT access way: •  Transmembrane inject •  VT & drop •  Micropump •  MicroWick

RouKne Drugs: •  Hydrocor1sone •  Dexamethasone •  Methylprenisolone

•  PaKent EducaKon •  Steroid – Systemic – Intratympanic


Suggested protocol : •  0.3 to 0.5 mL of drug •  InjecKon at anterior of Tympanic membrane •  At least 15 minutes in dependent posiKon •  Twice weekly for 2 weeks



Recommended •  PaKent EducaKon •  Steroid – Systemic – Intratympanic

! Salvage Patients who fail to recover spontaneously or after initial management (steroid and/or observe)

Management


•  Other MedicaKons


Recommended Against

Management


•  Other MedicaKons ! anKviral


Recommended Against

Randomized trials have not demonstrated effec1veness

•  Valacyclovir 1 gram 3 Kmes a day •  Famciclovir 500 mg 3 Kmes a day •  Acyclovir 800 mg 5 Kmes a day



•  Other MedicaKons •  Hyperbaric O2

OpKonal

Beoer response in: !  Younger PaKents !  Earlier Therapy (Within 3 months of Dx) !  Severe Hearing Loss



•  Other MedicaKons •  Hyperbaric O2 •  RehabilitaKon

Strong Recommended

Hearing Aids Nonsurgical

•  Air conducKng –  Behind The Ear –  In The Ear –  In The Canal –  Complete In Canal

•  Bone ConducKng –  Eyeglasses –  Headbands

Surgical •  Air conducKng

!  Middle ear implants

•  Bone conducKng !  BAHA

•  Nerve ConducKng !  Cochlear Implant



•  Other MedicaKons •  Hyperbaric O2 •  RehabilitaKon

Strong Recommended

Hearing Aids

Hearing AssisKve Technologies

Summary Sudden Sensorineural Hearing Loss : Evidence-‐based Key Points

NICDC criteria: ! Hearing loss ≥ 30 dB ! In ≥ 3 consecu1ve freq. ! Occurring ≤ 3 days

•  PaKent EducaKon +++ •  Steroid – Systemic –  Intratympanic

! Salvage + •  Other MedicaKons +++ •  Hyperbaric O2 •  RehabilitaKon +++

•  Clinical EvaluaKon + •  Audiometric Confirm + •  Lab. Tests +++ •  CT Scan +++ •  MRI +

Thanks for your attention

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