Hyperbaric Oxygen Therapy as Salvage Therapy for Sudden Sensorineural Hearing Loss

Efficacy of Intratympanic Glucocorticoid Steroid Administration Therapy as an Initial Treatment for Idiopathic Sudden Sensorineural Hearing Loss During the COVID-19 Pandemic

OBJECTIVE

Systemic administration of glucocorticoid steroids is the most common initial treatment for idiopathic sudden sensorineural hearing loss (ISSNHL); however, due to the prevalence of coronavirus disease, the indications for this treatment must be carefully determined. The aim of this study was to investigate the efficacy of intratympanic steroid therapy as an initial treatment for idiopathic SSNHL.

METHODS

Sixty-eight patients with idiopathic ISSNHL who were treated with intravenous or intratympanic steroids were included in this study. Patients were retrospectively evaluated regarding preoperative grade, type of additional treatment, outcome of treatment, and side effects of each treatment.

RESULTS

In 46 cases, patients received intravenous steroid therapy as the initial treatment, while 22 patients received intratympanic steroid therapy; 10 patients underwent salvage treatment due to inadequate improvement of symptoms. Regarding additional treatment, intravenous steroid monotherapy was used in 37 patients. The outcomes were similar after both treatments; 16 (43%) and 11 (52%) patients treated exclusively with intravenous and intratympanic steroids, respectively, were completely cured. There were no significant differences in the effects between the 2 treatments, indicating that they were almost equally effective. The side effects observed in patients treated with intravenous steroid therapy were increased blood pressure, acute gastric mucosal disorder, and insomnia. None of these side effects were observed in any of the patients treated with intratympanic steroids; however, 1 case of perforation of the tympanic membrane occurred due to the procedure.

CONCLUSION

There were no significant differences in posttreatment outcomes between patients treated with either intratympanic or intravenous steroids. The therapeutic effects were comparable, and no severe side effects were observed; therefore, intratympanic steroid therapy may be considered useful as an initial treatment for ISSNHL in the context of widespread coronavirus disease.

Osteopathic Cranial Manipulative Medicine as a Proposed Addition to the Treatment Regimen for Idiopathic Sudden-Onset Unilateral Sensorineural Hearing Loss: A Case Report

Adult sudden-onset unilateral sensorineural hearing loss is primarily idiopathic. There are few treatment options with high success rates, but the literature suggests there is equally moderate success with oral or intratympanic steroids, with some evidence to support the use of acupuncture as a salvage treatment. Here, we present a case of sudden unilateral sensorineural hearing loss with otolaryngology evaluation and audiograms before and after osteopathic manipulative treatment (OMT). Osteopathic cranial manipulative medicine (OCMM) directed at eustachian tube dysfunction elicited findings indicating resolution of symptoms was at least partly due to cranial treatment. This report explains a probable anatomic mechanism contributing to hearing loss and suggests treatment options that should be considered as part of the treatment of idiopathic unilateral hearing loss. Future research opportunities are also proposed.

Effect of the Timing of Hyperbaric Oxygen Therapy on the Prognosis of Patients with Idiopathic Sudden Sensorineural Hearing Loss

This study aimed to evaluate the effects of hyperbaric oxygen therapy (HBOT) on the hearing recovery of patients with idiopathic sudden sensorineural hearing loss (ISSNHL). The clinical data of 79 patients diagnosed with ISSNHL and treated with HBOT between January 2017 and December 2019 were retrospectively reviewed. The pure tone audiometry (PTA) scores before and after HBOT were recorded. The associations of HBOT efficacy with demographic and clinical characteristics and the duration from disease onset to HBOT administration were determined. The average PTA score was 80.06 ± 25.94 dB before and 60.75 ± 21.26 dB after HBOT; the difference was significant. HBOT improved the hearing of 55.7% of the patients with ISSNHL (defined as an average PTA ≥ 11dB or a final average PTA score below 29 dB). There was a significant inverse relationship between the duration from symptom onset to HBOT administration and PTA score reduction after HBOT, which was adjusted for factors including age, sex, laterality of hearing loss, initial PTA score, reception of intratympanic steroid injections, tinnitus, dizziness, vertigo, diabetes, hypertension, and coronary artery disease. Commencing HBOT at an earlier stage is closely linked to greater improvements in hearing for patients with ISSNHL.

Hyperbaric Oxygen Therapy Promotes Hearing Gain with Increases in Serum IGF-1 and HSP70 in Patients with Idiopathic Sudden Sensorineural Hearing Loss

Objective

Hyperbaric oxygen therapy (HBOT) has been recommended for the initial and salvage treatment of patients with idiopathic sudden sensorineural hearing loss (ISSHL), but its underlying mechanisms remain unclear. In this study, we investigated whether HBOT alters serum levels of insulin-like growth factor 1 (IGF-1) and heat shock protein 70 (HSP70) in patients with ISSHL. Then, we identified the relationship between hearing recovery and changes in serum IGF-1 and HSP70 levels.

Methods

Moderately severe to profound unilateral ISSHL patients (n = 70) and healthy control participants (n = 30) were enrolled. The ISSHL patients were randomly assigned to receive medical therapy alone (MT group, n = 35) or both HBOT and medical therapy (HBOT + MT group, n = 35). Audiometric testing was performed before and after treatment. Serum IGF-1 and HSP70 levels were assessed by ELISA in ISSHL patients pre-and posttreatment and healthy controls.

Results

Before treatment, compared with the healthy controls, serum IGF-1 and HSP70 were lower in ISSHL patients. After treatment, serum IGF-1 and HSP70 increased in both the HBOT + MT and MT groups, although they were significantly higher in the HBOT + MT group (p < 0.01). In the HBOT + MT group, these increases were associated with hearing gains. In addition, IGF-1 was strongly associated with HSP70 (r = 0.621, p = 0.001). No such association was found in the MT group (p = 0.757).

Conclusion

Administering HBOT in addition to medical therapy can improve the hearing of patients with moderately severe to profound unilateral ISSHL. The improvement is related to the upregulation of IGF-1 and HSP70.

Idiopathic Sudden Sensorineural Hearing Loss: Is Hyperbaric Oxygen Treatment the Sooner and Longer, the Better?

(1) Background: We aimed to evaluate hearing benefits from hyperbaric oxygen (HBO) therapy in patients with Idiopathic Sudden Sensorineural Hearing Loss (ISSHL). (2) Methods: We performed a retrospective analysis of chart reviews on patients with ISSHL between Jan 2016 and Dec 2021. All patients were referred to receive HBO therapy by the department of Ear, Nose and Throat (ENT). Hearing gain was assessed based on pure-tone audiometry (PTA). Data were analyzed for 102 patients after 1 to 5 therapy sessions, and for 46 patients after 6 to 10 therapy sessions. (3) Results: After 1−5 HBO sessions, patients (N = 102) showed an improvement in 45 (44.1%) of the patients (p < 0.000). Also, improvements were found with patients showing different grades of ISSHL: 11 (26.8%) with slight-moderate, 11 (40.7%) with severe, and 23 (67.6%) with profound ISSHL. Significant treatment effects were found at different affected frequencies, especially the low frequency range. After 6−10 HBO sessions, patients (N = 46) showed similar treatment effects as after 1−5 HBO sessions, but no additional improvement. Moreover, patients who received HBO treatment within 12 days showed improvement effects 6.484 times greater (p < 0.000) compared with those who received treatment after 13 days. (4) Conclusions: The improvement of HBO therapy on ISSHL was significant after 1−5 sessions, with larger improvements for those suffering more serious symptoms. Further adding more HBO treatment sessions to 6−10, no further improvement was found. Patients starting HBO therapy within 12 days of ISSHL showed 6.484 times greater improvements compared with those starting HBO therapy later.

Better late than never: initial experience of intra-arterial pulsed-urokinase-injection as a salvage therapy for refractory sudden sensorineural hearing loss

BACKGROUND AND PURPOSE

Cochlear vascular micro-thrombosis has been hypothesized as one of the pathogenic mechanisms for sudden sensorineural hearing loss (SSNHL) refractory to regular management. This study aimed to evaluate the feasibility and safety of intra-arterial pulsed-injection urokinase (IAPU) as a salvage therapy for SSNHL after the failure of conventional therapy.

METHODS

We retrospectively reviewed our patient database to identify refractory SSNHL patients between November 2017 and July 2020. Study outcomes before and after the IAPU therapy were compared between IAPU and conventional therapy groups.

RESULTS

Sixty-seven moderate-profound SSNHL patients (29 in IAUP group, 38 in control group) were included in this study. Compared to the control group, patients in the IAPU group showed more significant improvement in pure tone average (PTA) (34.2 ± 23.5 vs. 10.7 ± 13.1, p < 0.001) and degree of hearing recovery (total: 20.7% vs. 5.3%, partial: 24.1% vs. 10.5%, mild: 27.6% vs. 13.2% and non: 27.6% vs. 71.1%) 2 weeks after admission. In the IAPU group, a significant improvement of PTA (86.6 ± 11.5 vs. 54.6 ± 20.1 dB, p < 0.005) was observed on the first day after IAPU treatment.

CONCLUSION

In carefully selected SSNHL cases with a highly suspected vascular origin, IAPU is a safe and effective therapy when conventional treatments have failed. Despite the encouraging findings of our work, large studies are needed to better investigate the strengths and limitations of this salvage therapy.

Hyperbaric Oxygenation as Adjunctive Therapy in the Treatment of Sudden Sensorineural Hearing Loss

Sudden sensorineural hearing loss seems to become a serious social health problem in modern societies. According to the World Health Organization (WHO) reports, adult-onset sensorineural hearing loss is found to be one of the leading diseases at the global level, especially in high-income countries, and is foreseen to move up from the 14th to 7th leading cause of the global burden of diseases by the year 2030. Although the direct mortality rate of this disease is very low, its influence on quality of life is huge; that is the reason why the implementation of the most effective and the safest therapies for the patient is crucial for minimizing the risk of complications and adverse reactions to treatment. The aim of this paper is to present hyperbaric oxygen therapy (HBOT) as a medical procedure useful in the treatment of sudden sensorineural hearing loss as adjunctive therapy of high efficacy. This paper focuses on the molecular mechanisms of action and clinical effectiveness of HBOT in the treatment of idiopathic sudden deafness, taking into consideration both the benefits and potential risks of its implementation.

The Effectiveness of Hyperbaric Oxygen Therapy as Salvage Treatment for Sudden Sensorineural Hearing Loss: A Retrospective Study

Background

Sudden sensorineural hearing loss (SSNHL) is a medical emergency; its etiology is unknown in most cases, The treatment, in turn, is empiric and usually consists of various pharmacological agents, mainly steroids. Hyperbaric oxygen (HBO) therapy is used routinely as salvage therapy for refractory SSNHL. While several studies have demonstrated the effectiveness of HBO therapy as salvage treatment for refractory SSNHL, its results have varied among studies, and its efficacy is still unclear.

Aim

We aimed to stratify the effect of HBO therapy as salvage treatment after the failure of steroid therapy for SSNHL.

Method

This is a retrospective case series that involved eight SSNHL patients in the past three years at King Faisal Specialist Hospital & Research Centre (KFSHRC) in Riyadh, Saudi Arabia. Patients' records were reviewed and statistical analysis was performed.

Results

Eight patients were included in this case series; six of them were males, and the mean age of all patients was 46.88 ±20.9 years. One patient had herpes zoster as the cause of SSNHL and seven patients' disease was of unknown etiology. The mean period for the onset of disease was 4.12 ±2.17 days. One patient was managed with intravenous dexamethasone and the other patients were managed with oral steroids, and all patients were then treated by HBO therapy. Of the patients, two showed significant improvement but the others did not. The cause of SSNHL, age of patients, HBO start and cessation, comorbidities, and disease onset did not affect the improvement in disease in patients (p: ˃0.05).

Conclusion

Moderate-to-severe cases of SSNHL can be improved by HBO treatment along with oral steroids, while this therapy was ineffective in severe and profound cases. No factors could be found to predict improvement in patients.

White Matter Abnormalities of Auditory Neural Pathway in Sudden Sensorineural Hearing Loss Using Diffusion Spectrum Imaging: Different Findings From Tinnitus

Sudden sensorineural hearing loss (SSNHL) is a complex and challenging emergency which requires evidence regarding its pathophysiological changes to guide the treatment. The aim of this study was to evaluate the white matter integrity of the auditory neural pathway in patients with unilateral SSNHL in acute stage by using diffusion spectrum imaging tractography. In the present study, 60 individuals with acute SSNHL (29 males, 50.7 ± 11.8 years) and 25 healthy controls (13 males, 45.2 ± 13.2 years) underwent diffusion spectrum imaging tractography and high resolution T1 structural examinations using a 3T magnetic resonance imaging system. The areas of the auditory neural pathway were defined as regions of interest (ROIs). The quantitative anisotropy (QA) and the generalized fractional anisotropy (GFA) were compared between the patients with unilateral SSNHL and controls in these ROIs. We further evaluated the correlation between the parameter values and hearing loss level. The mean pure tone audiometry of patients at the onset presentation was 63.2 ± 26.2 dB. The right-sided SSNHL was involved in 25 (41.7%) cases and the left-sided in 35 (58.3%) cases. The QA values in the contralateral medial geniculate body, the bilateral anterior corona radiata and the anterior limb of internal capsule were significantly reduced in SSNHL patients compared to controls. In addition, the decrease QA value of the contralateral medial geniculate body was related to the increase severity of disease, even after controlling potential confounding factors. The present study demonstrated that patients with SSNHL exhibited altered integrity of white matter in the auditory neural pathway. Furthermore, the decreased QA values in the contralateral medial geniculate body might predict the severity of this disease. In the present study, tinnitus has not been found to effect in brain area obviously.

Hyperbaric Oxygen Treatment Ameliorates Hearing Loss and Auditory Cortex Injury in Noise Exposed Mice by Repressing Local Ceramide Accumulation

Noise-induced hearing loss (NIHL) relates closely to auditory cortex (AC) injury, so countermeasures aiming at the AC recovery would be of benefit. In this work, the effect of hyperbaric oxygen treatment on NIHL was elucidated, which was imposed on mice before (HBOP), during (HBOD) or after (HBOA) noise exposure. Morphology of neurons was assayed by hematoxylin-eosin or Nissl staining. Ceramide (Cer) level was measured through immunohistochemistry analysis. Apoptotic neurons were counted using transferase-mediated dUTP nick end labeling (TUNEL) staining. We demonstrated that the intense, broad band noise raised the threshold of auditory brainstem response, evoked neuronal degeneration or apoptosis and triggered the Cer accumulation in AC, all of which were restored significantly by HBOP, but not HBOD or HBOA. Cer over-generation reversed the advantages of HBOP significantly, while its curtailment recapitulated the effect. Next, noise exposure raised the superoxide or malondialdehyde (MDA) production which was blocked by HBOP or Cer repression. Oxidative control not only attenuated the hearing loss or neurodegeneration but, in turn, reduced the Cer formation significantly. In summary, mutual regulation between Cer and oxidative stress underlies the HBOP’s curative effect on hearing loss and neuronal damage in noise-exposed mice.

The use of hyperbaric oxygen therapy in acute hearing loss: a narrative review

INTRODUCTION

Acute hearing loss can have a major impact on a patient's life. This holds true for both acute acoustic trauma (AAT) and idiopathic sudden sensorineural hearing loss (ISSHL), two devastating conditions for which no highly effective treatment options exist. This narrative review provides the rationale and evidence for HBOT in AAT and ISSHL.

METHODS

Narrative review of all the literature available on HBOT in acute hearing loss, studies were retrieved from systematic searches on PubMed and by cross referencing.

DISCUSSION

First, the etiological mechanisms of acute hearing loss and the mechanism of action of HBOT were discussed. Furthermore, we have provided an overview of 68 studies that clinically investigated the effect of HBOT in the last couple of decades. For future studies, it is recommend to start as early as possible with therapy, preferably within 48 h and to use combination therapy consisting of HBOT and corticosteroids.

IMPLICATIONS FOR PRACTICE

HBOT has been used quite extensively for acute hearing loss in the last couple of decades. Based on the amount of studies showing a positive effect, HBOT should be discussed with patients (shared decision making) as optional therapy in case of AAT and ISSHL.

Use of Gases to Treat Cochlear Conditions

Although the cochlear vascular supply (stria vascularis) is designed to block to certain compounds and molecules, it must enable gas exchange to survive. The inner ear capillaries must deliver oxygen and remove carbon dioxide for the cochlea to function. These gases diffuse through tissues across a concentration gradient to reach the desired target. Tight junctions or the endothelial basement membrane do not impede them. Therefore, gases that can diffuse into the inner ear are attractive as therapeutic agents. The two gases most often used in this way are oxygen and hydrogen, although carbon dioxide, ozone, and argon have also been investigated. Typically, oxygen is delivered as hyperbaric oxygen (HBO) (oxygen at pressure higher than atmospheric) to provide increased oxygen levels to the inner ear. This not only relieves hypoxia, but also has anti-inflammatory and other biochemical effects. HBO is used clinically to treat idiopathic sudden sensorineural hearing loss, and both animal and human studies suggest it may also assist recovery after acute acoustic trauma. Laboratory studies suggest hydrogen works as a free radical scavenger and reduces the strong oxidants hydroxyl radicals and peroxynitrite. It also has anti-apoptotic effects. Because of its anti-oxidant and anti-inflammatory effects, it has been studied as a treatment for ototoxicity and shows benefit in an animal model of cisplatinum toxicity. Gas diffusion offers an effective way to provide therapy to the inner ear, particularly since some gases (oxygen, hydrogen, carbon dioxide, ozone, argon) have important therapeutic effects for minimizing cochlear damage.

Efficacy and Prognostic Factors of Combined Hyperbaric Oxygen Therapy in Patients With Idiopathic Sudden Sensorineural Hearing Loss

Purpose Idiopathic sudden sensorineural hearing loss is a clinical emergency with an increased incidence of occurrence in recent years. Hyperbaric oxygen has been widely used in the clinical treatment of sudden hearing loss. However, prognostic factors related to its curative effects are still not clear, which hinders its clinical application. The aim of this study was to investigate the efficacy and prognostic factors of hyperbaric oxygen therapy (HBOT) plus drug therapies in the treatment of sudden hearing loss. Method Patients with sudden hearing loss who were treated with hyperbaric oxygen from April to October 2017 were retrospectively included. Clinical information was collected, including pure-tone audiometry data before and after hyperbaric oxygen treatment, age, gender, hearing curve classification, concomitant symptoms, history of diseases (diabetes and hypertension), history of hormone therapy, start time of hyperbaric oxygen treatment, and total number of hyperbaric oxygen treatments. The prognostic factors were analyzed with univariate and multivariate analyses. Results Sixty-four patients with sudden hearing loss were enrolled, including 7 cases of low-frequency loss, 4 cases of high-frequency loss, 32 cases of flat loss, and 21 cases of complete hearing loss. After HBOT, there were 16 cases (25%) of complete recovery, 15 cases (23.43%) of partial recovery, 7 cases (10.93%) of slight improvement, and 26 cases (40.63%) of no improvement. The total effective rate was 59.37%. Twelve of 21 cases (57.14%) of complete hearing loss showed recovery. Multivariate logistic regression analysis showed that the start time of HBOT ≤ 7 days from disease onset was independently associated with hearing recovery ( OR = 27.763, 95% CI [4.209, 183.115], p = .001). Conclusion Combined HBOT can improve the hearing impairment of sudden hearing loss. The early HBOT showed the most promising therapeutic effects, especially among patients with complete hearing loss.

Markers of Oxidant-Antioxidant Equilibrium in Patients with Sudden Sensorineural Hearing Loss Treated with Hyperbaric Oxygen Therapy

The concentration of thiobarbituric acid reactive substances (TBARSs) in plasma and erythrocytes, the activity of selected antioxidant enzymes in erythrocytes: catalase (CAT), superoxide dismutase (SOD), and glutathione peroxidase (GPx), and the levels of hemoglobin (HGB) and haematocrit (HCT) were determined in 40 patients with sudden sensorineural hearing loss (SSNHL) subjected to 14 treatment sessions in a Haux Starmed 2200 hyperbaric chamber. Hyperbaric oxygen (HBO) therapy involved breathing 100% oxygen at 0.25 MPa. Blood for analysis was collected from the basilic vein at three time points: before the first HBO session, approximately 5 min after the first session, and after the 14th session. The control group included 20 healthy individuals never before treated with HBO therapy. Compared to the pre-HBO values, a 10% increase (P < 0.05) in the TBARS concentration in erythrocytes, a 28% increase in the GPx activity (P < 0.05), and a 7% decrease in the SOD activity (P < 0.05) were observed after 14 HBO sessions. The CAT activity decreased by 6% (P < 0.05) after the first session. The TBARS concentration in plasma was 13% higher (P < 0.01), while that in erythrocytes was 24% lower (P < 0.001) in the SSNHL patients before the first HBO session compared to the control group. The CAT activity in the SSNHL patients before HBO therapy was 26% higher (P < 0.001) than that in the control group. A statistically significant reduction in HGB and HCT after 14 HBO sessions (P < 0.01) compared to the pre-HBO values was demonstrated. SSNHL is accompanied by disturbance in the oxidant-antioxidant equilibrium. Repeated stimulation with hyperbaric oxygen modulates the activity of antioxidant enzymes. It seems that the increased generation of hydrogen peroxide is responsible for the changes in the activity of antioxidant barrier enzymes observed after HBO sessions.

The effectiveness of hyperbaric oxygen in patients with idiopathic sudden sensorineural hearing loss: a systematic review

Objective

To evaluate the effectiveness of hyperbaric oxygen in the treatment of patients with idiopathic sudden sensorineural hearing loss (ISSHL).

Data sources

An Embase, MEDLINE and Cochrane search were utilised to identify various clinical trials on the treatment of ISSHL. Studies that were published between 2002 and 2018 and written in the English, Dutch or German language were included. Search terms included synonyms for idiopathic sudden hearing loss.

Data synthesis

A total of 16 articles were identified regarding hyperbaric oxygen therapy. All patients were evaluated with pure-tone audiometry. A major part of the cases presented with unilateral hearing loss(bilateral hearing loss less than 5%). In several studies, the average of the mean hearing gain at five contiguous frequencies was significantly higher in the hyperbaric oxygen (HBO) therapy and systemic steroid (SS) group in patients with severe or profound hearing impairment. They recorded a significant treatment effect (p = 0.005) of HBO + SS therapy on patients with an initial hearing loss of ≥ 81 dB.

Conclusions

On the whole group of ISSHL patients, no significant difference was demonstrated between the intervention and control group. However, in severe or profound hearing-impaired ISSHL patients, significant benefit was observed in the intervention group. These results likely indicate that adding HBO to steroid therapies might be of benefit in cases of severe and profound hearing impairment.

Update on consensus on diagnosis and treatment of idiopathic sudden sensorineural hearing loss

INTRODUCTION

Idiopathic sudden sensorineural hearing loss (ISSNHL) is a sudden, unexplained unilateral hearing loss.

OBJECTIVES

To update the Spanish Consensus on the diagnosis, treatment and follow-up of ISSNHL.

MATERIAL AND METHODS

After a systematic review of the literature from 1966 to March 2018, on MESH terms «(acute or sudden) hearing loss or deafness», a third update was performed, including 1508 relevant papers.

RESULTS

Regarding diagnosis, 11ISSNHL is clinically suspected, the following diagnostic tests are mandatory: otoscopy, acumetry, tonal audiometry, speech audiometry, and tympanometry, to discount conductive causes. After clinical diagnosis has been established, and before treatment is started, a full analysis should be performed. An MRI should then be requested, ideally performed during the first 15 days after diagnosis, to discount specific causes and to help to understand the physiopathological mechanisms in each case. Although treatment is very controversial, due to its effect on quality of life after ISSNHL and the few rare adverse effects associated with short-term steroid treatment, this consensus recommends that all patients should be treated with steroids, orally and/or intratympanically, depending on each patient. In the event of failure of systemic steroids, intratympanic rescue is also recommended. Follow-up should be at day 7, and after 12 months.

CONCLUSION

By consensus, results after treatment should be reported as absolute decibels recovered in pure tonal audiometry and as improvement in speech audiometry.