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Hyperbaric oxygen therapy for the idiopathic sudden sensorineural hearing loss

Idiopathic sudden sensorineural hearing loss (ISSNHL), defined as a greater than 30 dB sensorineural hearing loss occurring in at least three contiguous audiometric frequencies over 72 hours or less is a disease of unknown etiology [1].

 

 

Dr Vasilios P. Zachariadis, MD,PhD,

Specialized in Internal Medicine and Hyperbaric Medicine

Director of the Hyperbaric Medicine Center, Klazomenon 5, Athens 17778, Tavros (Pireos & Chamosternas, Greece. Tel. 210 3462898,

e-mail: This e-mail address is being protected from spambots. You need JavaScript enabled to view it

www.hbo.gr

 

  

Dr Dimitrios N. Gelis, MD, Otorhinolaryngologist, DDS, PhD, with special interest in Medical Nutrition, Complementary Medicine, Vitamin D, Medical properties of Red Wine, Hyperbaric Oxygen treatment.

Damaskinou 46, Korinthos 20100, Greece tel. 00302741026631, 00306944280764

www.gelis.gr, www.orlpedia.gr, www.allergopedia.gr, www.gkelanto.gr, www.pharmagel.gr

Idiopathic sudden sensorineural hearing loss appears to be characterized by hypoxia in the perilymph and therefore the scala tympani and the organ of Corti [2].

Sudden hearing loss (SHL) is an otoprhinolaryngological emergency .The guideline of the American Academy of Otolaryngology-Head and Neck Surgery primarily focuses on sudden sensorineural hearing loss (SSNHL) in adult patients (aged 18 and older). Prompt recognition and management of SSNHL may improve hearing recovery and patient quality of life (QOL) [3].

Sudden sensorineural hearing loss affects 5 to 20 per 100,000 population, with about 4000 new cases per year in the United States[3].

Available treatments

The idiopathic sudden sensorineural hearing loss, if left untreated may lead to permanent morbidity. Available treatments include corticosteroid, vasodilator, immunosuppressant, hyperbaric oxygen and antiviral medications, although controversies do still exist. To date, the use of corticosteroids is the most widely accepted treatment, but there are no worldwide standard practice guidelines accepted for the treatment of ISSNHL [4].


Various regimens of corticosteroid therapy are available, including various types, dosages, and administration routes. A high dosage of oral and intravenous corticosteroids is believed to revive hearing impairment. Oral corticosteroids are currently as administered following a tapered course over a period of 10 to 14 days [5, 6].


Systemic and intratympanic steroids are most widely used for treating idiopathic sudden sensorineural hearing loss. Other treatments include vasodilator, immunosuppressant and antiviral medication. However, only 61% of patients achieve full recovery, and controversies about the standard treatment still exist [6].

The efficacy of steroids in the treatment of idiopathic sudden hearing loss is not considered satisfactory, as only 61% of patients are experience recovery [7].


Intratympanic corticosteroid injections have been widely used to deliver corticosteroids directly into the inner ear for those whom systemic steroids have not been successful. Complications such as perforations of the tympanic membrane, myringitis and otitis media have been reported.

Hyperbaric oxygen therapy (HBOT) has been shown to provide a significant additional effect when used in combination with a steroid therapy for ISSNHL [8,9]. .

Systemic plus intratympanic steroid administration is more effective than systemic steroids plus HBO therapy, and can be a useful first-choice treatment for ISSNHL [10].


Idiopathic sudden sensorineural hearing loss (ISSHL) treatment with hyperbaric oxygen (HBO2)

Hyperbaric oxygen therapy (HBOT), was first reported to improve the outcome following acute inner ear disorders during the late 1960s by both French and German authors [11].

Idiopathic sudden sensorineural hearing loss (ISSHL) is the newest indication approved by the Undersea and Hyperbaric Medical Society's Hyperbaric Oxygen Therapy Committee of the USA. Unfortunately, in the majority of the countries allover the world, only the  Navy hospitals and a few private or state hospitals have been equipped with a hyperbaric chamber, and only a small number of medical schools is planning for installation of HBOT facilities.

 

More than 100 publications of the international literature, until now, valuated the use of hyperbaric oxygen (HBO2) for the treatment of ISSHL, including eight randomized controlled trials.

Although we cannot ascertain the causes of idiopathic sensorineural hearing loss, it may be related to a lack of oxygen secondary to a vascular problem not yet identified. HBOT involves breathing in pure oxygen from a specially designed chamber. This method is used to increase the supply of oxygen to the ear and the brain to reduce the severity of a hearing loss and tinnitus [12].


The best and most consistent results are obtained when HBO2 is initiated within two weeks of symptom onset and combined with corticosteroid treatment.

The average hearing gain is 19.3 dB for moderate hearing loss and 37.7 dB for severe cases.

 

This improvement brings hearing deficits from the moderate/severe range into the slight/no impairment range. This is a significant gain that can markedly improve a patient's quality of life, both clinically and functionally[2].

.Effective communication between doctors and patient is required. Patients have the right to know both the risks and benefits of the treatment, particularly when non-standard alternative treatment options are available.

In addition, the criteria of salvage treatments should be discussed in terms of time course and hearing levels.

 

In some cases of  ISSHL the HBOT started at the fifth week (day 36) after the onset of hearing loss. At this stage, spontaneous improvement is no longer expected, as the process of inflammation usually does not last beyond 2 to 3 weeks. Although the administration of intratympanic steroids may offer some benenfit, as can be demonstrated by the improved audiometry, additional improvement after day 36 generally is not expected. Bilateral moderate hearing loss is the other aspect in which patients may experience more benefit than harm from the salvage treatment.

 

The HBOT may result full recovery of the hearing thresholds without tinnitus or any complications. Patients who received HBOT in conjunction with corticosteroids presented with enhanced clinical outcomes compared to those receiving only corticosteroids in the study by Fujimura et al. [13].


The standard regimen of HBOT for treating ISSNHL has not yet . The usual initial plan is apply the treatment table 45/90 (2 ATA 90 minutes) for 10 sessions. In case that patient demonstrates return of normal hearing with no tinnitus in both ears during the third and the fifth session of HBOT, the last five sessions may be are unnecessary and eventually canceled.

 

Topuz et al proposed a regimen, which involves undertaking HBOT 2.5 ATA for 90 minutes twice daily for the first five days and then once daily for the next fifteen days. This regimen , also demonstrated good results. Patients over 50 years of age having a severe sensorineural hearing loss greater than 60 dB and receiving HBOT without delay experienced a higher rate of recovery [14]. .

 

Results of combination treatments

Systemic plus intratympanic steroid administration is more effective than systemic steroids plus HBO therapy, and can be a useful first-choice treatment for ISSNHL [15].

Academy of Otolaryngology-Head and Neck Surgery provides the evidence-based recommendations in evaluating patients with SHL, with particular emphasis on managing SSNHL [16].


It is accepted that patients enter the health care system with SHL as a nonspecific, primary complaint. It is mandatory the efficiently distinguishing SSNHL from other causes of SHL at the time of presentation.

It is recomanded  that clinicians should:

(1) Distinguish sensorineural hearing loss from conductive hearing loss in a patient presenting with SHL;

(2) Educate patients with idiopathic sudden sensorineural hearing loss (ISSNHL) about the natural history of the condition, the benefits and risks of medical interventions, and the limitations of existing evidence regarding efficacy; and

(3) Counsel patients with incomplete recovery of hearing about the possible benefits of amplification and hearing-assistive technology and other supportive measures. The panel made recommendations that clinicians should:

(1) Assess patients with presumptive SSNHL for bilateral SHL, recurrent episodes of SHL, or focal neurologic findings;

(2) Diagnose presumptive ISSNHL if audiometry confirms a 30-dB hearing loss at 3 consecutive frequencies and an underlying condition cannot be identified by history and physical examination;

(3) Evaluate patients with ISSNHL for retrocochlear pathology by obtaining magnetic resonance imaging, auditory brainstem response, or audiometric follow-up;

(4) Offer intratympanic steroid perfusion when patients have incomplete recovery from ISSNHL after failure of initial management; and

(5) Obtain follow-up audiometric evaluation within 6 months of diagnosis for patients with ISSNHL. The panel offered as options that clinicians may offer:

(1) Corticosteroids as initial therapy to patients with ISSNHL and

(2) Hyperbaric oxygen therapy within 3 months of diagnosis of ISSNHL.

The panel made a recommendation against clinicians routinely prescribing antivirals, thrombolytics, vasodilators, vasoactive substances, or antioxidants to patients with ISSNHL. The panel made strong recommendations against clinicians:

(1) ordering computerized tomography of the head/brain in the initial evaluation of a patient with presumptive SSNHL and

(2) obtaining routine laboratory tests in patients with ISSNHL [16].


HBO therapy of idiopathic sudden sensorineural hearing loss of cases unsuccessfully treated with medical therapy

Muzzi E, et al reported nineteen patients affected by sudden sensorineural hearing loss who were treated with HBOT, after unsuccessful medical therapy, either in an acute or chronic setting. Pure oxygen inhalation at 2.5 atmospheres absolute pressure was administered for 90 minutes, for 30 sessions. Frequency-specific and average pure tone hearing thresholds were determined before and after hyperbaric oxygen therapy. The number of hyperbaric oxygen therapy sessions, the patient's age and any therapeutic delay were considered as quantitative variables possibly influencing outcome.

 

The stepwise multivariate analysis demonstrated that the salvage hyperbaric oxygen therapy appeared to improve patients' pure tone hearing thresholds, particularly at low frequencies. Positive results were more likely with increased patient age and reduced delay in receiving hyperbaric oxygen therapy.

Hyperbaric oxygen therapy has a strong scientific rationale, and improves pure tone hearing thresholds in cases of sudden sensorineural hearing loss unresponsive to medical therapy [17].


Conclusion 

In conclusion, HBOT may be used for idiopathic sudden sensorineural hearing loss as and as an adjuvant therapy with corticosteroids. It may promote oxygenation to the inner ear apparatus and revive hearing ability. Patients who fail to respond to oral and intratympanic steroids may benefit from this treatment. Further investigation is warranted, including animal studies to understand the molecular and histopathological aspects of HBOT and randomized control clinical studies.

 

Our clinical suggests that HBOT has beneficial effects when administered in the early phase of the disease together with steroids. HBOT is a safe practice when used properly by an experienced hyperbaric team. In the treatment of ISSNHL, 20 sessions of HBOT at 2.5 ATA can be tolerated well besides some minor side effects. HBOT should be considered for the cases especially with total or profound hearing loss [18].


The effect of hyperbaric oxygen therapy varies with degree of hearing loss and audiogram type. Drug treatment combined with HBOT can promote clinical effect for patients in moderate deafness and severe deafness, the descending and flat type of audiogram [19].


References

1. Hughes GB, Freedman MA, Haberkamp TJ, Guay ME. Sudden sensorineural hearing loss. Otolaryngol Clin North Am. 1996 Jun;29(3):393–405. [PubMed]

2. Murphy-Lavoie H, Piper S, Moon RE, Legros T. Hyperbaric oxygen therapy for idiopathic sudden sensorineural hearing loss. Undersea Hyperb Med. 2012 May-Jun;39(3):777-92.

3, Stachler RJ, Chandrasekhar SS, Archer SM, Rosenfeld RM, Schwartz SR, Barrs DM, Brown SR, Fife TD, Ford P, Ganiats TG, Hollingsworth DB, Lewandowski CA, Montano JJ, Saunders JE, Tucci DL, Valente M, Warren BE, Yaremchuk KL, Robertson PJ; American Academy of Otolaryngology-Head and Neck Surgery. Clinical practice guideline: sudden hearing loss. Otolaryngol Head Neck Surg. 2012 Mar;146(3 Suppl):S1-35.

4. Rauch SD. Clinical practice: idiopathic sudden sensorineural hearing loss. N Engl J Med. 2008 Aug 21;359(8):833–840. [PubMed]

5. Conlin AE, Parnes LS. Treatment of sudden sensorineural hearing loss: I. a systematic review. Arch Otolaryngol Head Neck Surg. 2007 Jun;133(6):573–581. [PubMed]

6.  Imsuwansri T, Poonsap P, Snidvongs K. Hyperbaric oxygen therapy for sudden sensorineural hearing loss after failure from oral and intratympanic corticosteroid. Clin Exp Otorhinolaryngol. 2012 Apr;5 Suppl 1:S99-S102. Epub 2012 Apr 30.

7. Wilson WR, Byl FM, Laird N. The efficacy of steroids in the treatment of idiopathic sudden hearing loss: a double-blind clinical study. Arch Otolaryngol. 1980 Dec;106(12):772–776. [PubMed]

8. Fujimura T, Suzuki H, Shiomori T, Udaka T, Mori T. Hyperbaric oxygen and steroid therapy for idiopathic sudden sensorineural hearing loss. Eur Arch Otorhinolaryngol. 2007 Aug;264(8):861–866. [PubMed]

9. Topuz E, Yigit O, Cinar U, Seven H. Should hyperbaric oxygen be added to treatment in idiopathic sudden sensorineural hearing loss? Eur Arch Otorhinolaryngol. 2004 Aug;261(7):393–396. [PubMed]

10. Suzuki H, Hashida K, Nguyen KH, Hohchi N, Katoh A, Koizumi H, Ohbuchi T. Efficacy of intratympanic steroid administration on idiopathic sudden sensorineural hearing loss in comparison with hyperbaric oxygen therapy. Laryngoscope. 2012 May;122(5):1154-7. doi: 10.1002/lary.23245. Epub 2012 Mar 23.

11. Körpinar S, Alkan Z, Yiğit O, Gör AP, Toklu AS, Cakir B, Soyuyüce OG, Ozkul H. Factors influencing the outcome of idiopathic sudden sensorineural hearing loss treated with hyperbaric oxygen therapy. Eur Arch Otorhinolaryngol. 2011 Jan;268(1):41-7.

12. Bennett MH, Kertesz T, Yeung P. Hyperbaric oxygen for idiopathic sudden sensorineural hearing loss and tinnitus. Cochrane Database Syst Rev. 2007 Jan 24;(1):CD004739.

13. Fujimura T, Suzuki H, Shiomori T, Udaka T, Mori T. Hyperbaric oxygen and steroid therapy for idiopathic sudden sensorineural hearing loss. Eur Arch Otorhinolaryngol. 2007 Aug;264(8):861-6. Epub 2007 Mar 6.

14. Topuz E, Yigit O, Cinar U, Seven H. Should hyperbaric oxygen be added to treatment in idiopathic sudden sensorineural hearing loss? Eur Arch Otorhinolaryngol. 2004 Aug;261(7):393-6. Epub 2003 Oct 29.

15. Suzuki H, Hashida K, Nguyen KH, Hohchi N, Katoh A, Koizumi H, Ohbuchi T. Efficacy of intratympanic steroid administration on idiopathic sudden sensorineural hearing loss in comparison with hyperbaric oxygen therapy. Laryngoscope. 2012 May;122(5):1154-7. doi: 10.1002/lary.23245. Epub 2012 Mar 23.

16. Stachler RJ, Chandrasekhar SS, Archer SM, Rosenfeld RM, Schwartz SR, Barrs DM, Brown SR, Fife TD, Ford P, Ganiats TG, Hollingsworth DB, Lewandowski CA, Montano JJ, Saunders JE, Tucci DL, Valente M, Warren BE, Yaremchuk KL, Robertson PJ; American Academy of Otolaryngology-Head and Neck Surgery. Clinical practice guideline: sudden hearing loss. Otolaryngol Head Neck Surg. 2012 Mar;146(3 Suppl):S1-35.

17. Muzzi E, Zennaro B, Visentin R, Soldano F, Sacilotto C. Hyperbaric oxygen therapy as salvage treatment for sudden sensorineural hearing loss: review of rationale and preliminary report. J Laryngol Otol. 2010 Feb;124(2):e2. Epub 2009 Nov 30.

18. Körpinar S, Alkan Z, Yiğit O, Gör AP, Toklu AS, Cakir B, Soyuyüce OG, Ozkul H. Factors influencing the outcome of idiopathic sudden sensorineural hearing loss treated with hyperbaric oxygen therapy. Eur Arch Otorhinolaryngol. 2011 Jan;268(1):41-7.

19. Liu Y, Sun D, Shao S, Jiang W, Sun Z, Li Z. The effect of hyperbaric oxygen therapy to different degree of hearing loss and types of threshold curve in sudden deafness patientsLin Chung Er Bi Yan Hou Tou Jing Wai Ke Za Zhi. 2010 Oct;24(19):890-4.

 
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