Azathioprine with cortisone in treatment of hearing loss in only hearing ear

Azathioprine reduces the risk of audiometric relapse in immune-mediated hearing loss

INTRODUCTION

Current schemes for treatment of immune-mediated hearing loss with sporadic short-course, low-dose corticosteroids, are insufficient.

METHODS

To determine the role of azathioprine in the control of auditory impairment, a longitudinal, observational, descriptive study was performed with 20 patients treated with azathioprine (1.5-2.5mg/kg/day into two doses) for 1year. The loss of 10dB on two consecutive frequencies or 15dB on an isolated frequency was considered as relapse.

RESULTS

The mean age of the patients was 52.50years (95%CI: 46.91-58.17), half were women. Bilateral affectation was 65%. 75% had organ specific disease and 25% had systemic autoimmune disease. The difference between baseline PTA (46.49dB; DS18.90) and PTA at 12months (45.47dB; DS18.88) did not reach statistical significance (P=.799). There was a moderate positive correlation between female sex and the presence of systemic disease (R=.577). By applying Student's t for paired data, a significant difference (P=.042) was obtained between the PTA in frequencies up to 1000 Hz (PTA125-1000Hz). The relative incidence rate of relapse per year was .52 relapses/year (95%CI: .19-1.14]). The median time to audiometric relapse-free was 9.70months (DS1.03).

CONCLUSIONS

Azathioprine maintains the hearing threshold, decreases the risk of relapse, and slows down the rate at which patients relapse, altering the course of immune-mediated inner ear disease.

Sudden Sensorineural Hearing Loss in the Only Hearing Ear: Large Vestibular Aqueduct Syndrome

Sudden hearing loss in the only hearing ear cases are rarely published in the English literature; most of the cases are idiopathic. It is an otologic emergency needing urgent treatment. Delayed diagnosis can interfere with patient's social life with interrupting the verbal communication. In this case report we presented a 33-year-old female patient having sudden sensorineural hearing loss in the only hearing ear diagnosed as bilateral large vestibular aqueduct syndrome.

Idiopathic sensorineural hearing loss in the only hearing ear

A retrospective chart review was used for 31 patients with sudden, progressive or fluctuating sensorineural hearing loss (SHL) in the only hearing ear who had been consecutively evaluated at the ENT, Audiology and Phoniatrics Unit of the University of Pisa. The group of patients was evaluated with a complete history review, clinical evaluation, imaging exam (MRI, CT), audiologic tests (tone and speech audiometry, tympanometry, study of stapedial reflexes, ABR and otoacoustic emission) evaluation. In order to exclude genetic causes, patients were screened for CX 26 and CX30 mutations and for mitochondrial DNA mutation A1555G. Patients with sudden or rapidly progressive SHL in the only hearing ear were treated with osmotic diuretics and corticosteroids. In patients who did not respond to intravenous therapy we performed intratympanic injections of corticosteroid. Hearing aids were fitted when indicated and patients who developed severe to profound SHL were scheduled for cochlear implant surgery. The aim of this study is to report and discuss the epidemiology, aetiopathogenesis, therapy and clinical characteristic of patients affected by SHL in the only hearing hear and to discuss the issues related to the cochlear implant procedure in some of these patients, with regard to indications, choice of the ear to implant and results.

Steroids for idiopathic sudden sensorineural hearing loss

BACKGROUND

This is an update of a Cochrane review first published in The Cochrane Library in Issue 1, 2006 and previously updated in 2009.Idiopathic sudden sensorineural hearing loss (ISSHL) is a clinical diagnosis characterised by a sudden deafness of cochlear or retrocochlear origin in the absence of a clear precipitating cause. Steroids are commonly prescribed to treat this condition. There is no consensus on their effectiveness.

OBJECTIVES

To determine whether steroids in the treatment of ISSHL a) improve hearing (primary) and b) reduce tinnitus (secondary).To determine the incidence of significant side effects from the medication.

SEARCH METHODS

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 22 April 2013.

SELECTION CRITERIA

We identified all randomised controlled trials (with or without blinding) in which steroids were evaluated in comparison with either no treatment or a placebo. We considered trials including the use of steroids in combination with another treatment if the comparison control group also received the same other treatment. The two authors reviewed the full-text articles of all the retrieved trials of possible relevance and applied the inclusion criteria independently.

DATA COLLECTION AND ANALYSIS

We graded trials for risk of bias using the Cochrane approach. The data extraction was performed in a standardised manner by one author and rechecked by the other author. Where necessary we contacted investigators to obtain the missing information. Meta-analysis was neither possible nor considered appropriate because of the heterogeneity of the populations studied and the differences in steroid formulations, dosages and duration of treatment. We analysed and reported the quality of the results of each study individually. A narrative overview of the results is presented.

MAIN RESULTS

Only three trials, involving 267 participants, satisfied the inclusion criteria and all three studies were at high risk of bias. One trial showed a lack of effect of oral steroids in improving hearing compared with the placebo control group. The second trial showed a significant improvement of hearing in 61% of the patients receiving oral steroid and in only 32% of the patients from the control group (combination of placebo-treated group and untreated control group). The third trial also showed a lack of effect of oral steroids in improving hearing compared with the placebo control. However, this trial did not follow strict inclusion criteria for participant selection and analysis of data was limited by significant exclusion of participants from the final analysis and lack of participant compliance to the treatment protocol. No clear evidence was presented in two trials about any harmful side effects of the steroids. Only one study declared that no patients suffered from adverse effects of the steroid treatment.

AUTHORS' CONCLUSIONS

The value of steroids in the treatment of idiopathic sudden sensorineural hearing loss remains unclear since the evidence obtained from randomised controlled trials is contradictory in outcome, in part because the studies are based upon too small a number of patients.

Sensorineural hearing loss in systemic lupus erythematosus: case report and literature review

OBJECTIVES

We present a case of systemic lupus erythematosus with symptomatic sensorineural hearing loss which was successfully treated with azathioprine, as assessed both clinically and radiologically. We also present a review of the relevant literature.

CASE REPORT

A woman with systemic lupus erythematosus presented with sensorineural hearing loss, initially on the right and subsequently developing on the left over several months. An audiogram revealed profound neurosensory hearing loss bilaterally. The patient was treated with prednisone 60 mg daily and azathioprine 200 mg daily. An improvement on the left was noted on follow-up audiography as well as on magnetic resonance imaging of the internal auditory canals and surrounding structures.

CONCLUSION

Sensorineural hearing loss has been described in autoimmune disorders but is rare. Aural symptoms have been described, with varying incidences (0-57.5 per cent), in systemic lupus erythematosus. However, symptomatic sensorineural hearing loss is rare in systemic lupus erythematosus. Prednisone appears essential when an immunological or vasculitic cause is found. The use of azathioprine should be considered, as well as follow-up with magnetic resonance imaging to detect improvement.

Steroids for idiopathic sudden sensorineural hearing loss

BACKGROUND

Idiopathic sudden sensorineural hearing loss (ISSHL) is a clinical diagnosis characterised by a sudden deafness of cochlear or retrocochlear origin in the absence of a clear precipitating cause. Steroids are commonly prescribed to treat this condition. There is no consensus on their effectiveness.

OBJECTIVES

To determine the effectiveness and the side-effect profile of steroids in the treatment of idiopathic sudden sensorineural hearing loss.

SEARCH STRATEGY

We searched the Cochrane Ear, Nose and Throat Disorders Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 4, 2004), MEDLINE (1966 to December 2004) and EMBASE (1974 to December 2004). Reference lists of all trials were also manually searched.

SELECTION CRITERIA

We identified all randomised controlled trials (with or without blinding) in which steroids were evaluated in comparison with either no treatment or a placebo. Trials including the use of steroids in combination with another treatment were considered if the comparison control group also received the same other treatment. The full text articles of all the retrieved trials of possible relevance were reviewed by the two authors and the inclusion criteria applied independently. Any differences in opinion about which studies to include in the reviews were resolved by discussion.

DATA COLLECTION AND ANALYSIS

Trials were graded for methodological quality using the Cochrane approach. The data extraction was performed in a standardised manner by one author and rechecked by the other author, and where necessary investigators were contacted to obtain the missing information. Meta-analysis was neither possible nor considered appropriate because of the heterogeneity of the populations studied, the differences in steroid formulations, dosages and duration of the treatment. The quality of the result of each study was analysed and reported individually. A narrative overview of the result is presented.

MAIN RESULTS

Only two trials satisfied the inclusion criteria and both were of low methodological quality. One trial showed a lack of effect of oral steroids in hearing improvement compared with the placebo control group. The other trial showed a significant improvement of hearing in 61% of the patients receiving oral steroid and in only 32% of the patients from the control group (combination of placebo treated group and untreated control group). There was no clear evidence presented in the former study about any harmful side effects of the steroids. The latter study declared that no patients suffered from adverse effects from the steroid treatment.

AUTHORS' CONCLUSIONS

The value of steroids in the treatment of idiopathic sudden sensorineural hearing loss remains unclear since the evidence obtained from randomised controlled trials are contradictory in outcome, in part because the studies are based upon too small a number of patients.

Etanercept therapy for immune-mediated cochleovestibular disorders: preliminary results in a pilot study

OBJECTIVE

Immune-mediated cochleovestibular disorders (IMCVDs) continue to present a management challenge to the otolaryngologist. Antirheumatic agents, commonly used for IMCVDs, are associated with variable efficacy and sometimes with serious side effects. The authors describe the preliminary result of their experience in patients with IMCVDs who have been treated with etanercept, a tumor necrosis factor alpha receptor blocker, recently approved by the United States Food and Drug Administration for the treatment of rheumatoid arthritis.

STUDY DESIGN

Retrospective case series.

SETTING

Tertiary care hospital.

PATIENTS

Twelve patients suspected of having IMCVD who did not respond to conventional therapies or experienced side effects of the conventional therapies.

INTERVENTION

Etanercept 25 mg by subcutaneous injection twice per week.

MAIN OUTCOME MEASURES

The main outcome measurement was assessment of hearing change by air conduction pure tone audiograms and/or word discrimination. When present, vertigo, tinnitus, and aural fullness were assessed as well.

RESULTS

Follow-up of more than 5 months was available for all patients (range, 5-12 months). Eleven (92%) of 12 patients had improvement or stabilization of hearing and tinnitus, seven (88%) of eight patients who had vertigo and eight (89%) of nine patients who had aural fullness had resolution or significant improvement of their symptoms. The benefit persisted until the last visit (5-12 months after etanercept was begun). The condition of one patient improved dramatically at first but deteriorated after 5 months. The patient's hearing was rescued and stabilized with the addition of leflunomide to etanercept. Similarly, three other patients required a second antirheumatic agent to stabilize their hearing. There were no significant side effects from the etanercept therapy.

CONCLUSIONS

Our limited data suggest that etanercept therapy is safe and may be efficacious in carefully selected patients with IMCVDs, at least on a short-term basis. These preliminary efficacy and safety results appear encouraging enough to warrant further follow-up and studies for better determination of the potential clinical utility of etanercept for IMCVDs.

Autoimmune vestibulo-cochlear disorders

Autoimmune vestibulo-cochlear disorders (AVCD) represent a group of syndromes with overlapping clinical features, manifesting as sensorineural hearing loss, often associated with vertigo, tinnitus, and aural fullness, and believed to be caused by an autoimmune mechanism. Although definitive evidence of a classic "autoimmune process" is still lacking, substantial indirect evidence has accumulated to strongly indicate such a pathogenesis. Rapidly progressing AVCD is analogous to rapidly progressive glomerulonephritis in that inner ear inflammation progresses to severe, irreversible damage within 3 months of onset (and often much more quickly). Thus patients with rapidly progressive AVCD are treated with a sense of urgency. Prompt treatment with corticosteroids and other antirheumatic/immunosuppressive agents can preserve hearing and vestibular functions. We are not aware of any randomized controlled clinical trials evaluating the efficacy of antirheumatic/immunosuppressive agents in AVCD. In this article we review reports of various therapies that have been tried in this condition and our experience of etanercept therapy in AVCD.

Sudden total bilateral deafness due to asymptomatic mumps infection

Mumps is the most common cause of unilateral acquired sensorineural hearing loss in children. Although it usually affects the salivary glands. the inner ear may be involved. Deafness is usually unilateral, sudden in onset, profound and permanent. Bilateral total sensorineural hearing loss had been rarely reported in English literature. We present a case of total deafness due to asymptomatic mumps infection.