SSNHL

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SSNHL

• By Saisuree Nivatwongs ENT PMK

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SSNHL

• Incidence 5-20 per 100,000
• 4,000 new cases/year in US
• Idiopathic
• Hearing loss at least 30 dB over 3 contiguous
  frequency
• Onset of hearing loss occurs in less than 72
  hours
• Recovery rate without treatment 32 - 79
• Usually within 2 weeks of onset
• Only 36 with complete recovery
• No middle ear disease
• Otologic emergency!

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SSNHL

• Clinical Presentation
• Sudden onset hearing loss
• Less than 3 days
• Usually unilateral
• Left side possibly more common (55)
• Bilateral 2
• Median age 40-54
• Male Female
• Awakening from sleep
• Hearing a popping prior to hearing loss
• Aural fullness
• Tinnitus
• Vertigo

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Etiology

• Viral infection
• Association of SSNHL with viral URI in 25 - 63
• Serology confirming active viral infection
• HSV, VZV, CMV, influenza, measles parainfluenza,
  rubeola, mumps, rubella
• Immunoreactivity against virus
• Histopathology of human temporal bones
• Atrophy of organ of Corti, spiral ganglion,
  tectorial membrane
• Hair cell loss
• Unraveling of myelin

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Etiology

• Vascular injury
• Sudden onset suggesting infarction
• Perlman (1959) demonstrated loss of cochlear
  microphonic 60 seconds after occlusion of
  labyrinthine artery in guinea pig
• Polycythemia ,Buergers, macroglobulinemia,
  sickle cell, fat embolism, DM

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Etiology

• Intracochlear membrane rupture
• Loss of endocochlear potential due to mixing of
  endolymph and perilymph
• Gussen (1981) histologic evidence
• Fallen out of favor
• Autoimmune
• cross-reacting circulation Ab

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DDX

• Infectious
• Bacterial meningitis, labyrinthitis, syphilis
• Viral Mumps, CMV
• Inflammatory
• Autoimmune, Cogan syndrome, Lupus, MS
• Traumatic
• Temporal bone fracture, acoustic trauma,
  perilymph fistula
• Neoplastic
• CPA tumor, temporal bone metastasis
• Toxic
• Aminoglycosides, aspirin
• Vascular
• Thromboembolism, macroglobulinemia, sickle cell
  disease, cerebral infarct, TIA
• Congenital
• Mondini malformation, enlarged vestibular
  aqueduct

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Clinical Evaluation

• Hx
• Complete ENT exam
• Audiogram include PTA, SRT, SDS
• Tympanogram
• ABR

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Radiograph

• MRI with Gd
• 0.8-2 of pt with SSNHL have been diagnosed CPA
  /IAC tumors
• Non-contrasted CT temporal bone R/o congenital
  malformation

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Laboratory Evaluation

• CBC with diff
• Polycythemia, leukemia, thrombocytosis
• FBS , Electrolytes
• Erythrocyte sedimentation rate (ESR)
• FTA-Abs (Syphilis)
• Coagulation profile
• Thyroid function testing
• Lipid profile
• BUN, Creatinine
• UA
• ANA , rheumatoid factor , viral study

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Prognosis

• Severity of HL
• Audiogram shape
• Presence of vertigo
• Age
• Without Rx 30-65 will experience complete or
  partial recovery

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Medical Rx

• Bed rest
• Low salt diet lt 2 gm/day
• Diuretics HCTZ
• Steroids

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Steroids

• Historical perspective Reduce inner ear
  inflammation
• Rx as early as posible
• Oral, IV 10 days
• Cannot be used for all patients
• Diabetics, ulcers, TB, glaucoma
• Intratympanic steroids

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Medical Rx

• Antivirals
• Volume expanders Dextran , hypaque
• Vasodilators Histamine phosphate , Ca
  antagonist , nicotinic acid
• Anticoagulants heparin
• Carbogen inhalation (95O2,5CO2)

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SSNHL

• Cochrane Database of Systematic Reviews
• Wei (2003, Updated 2006) Steroids for idiopathic
  sudden sensorineural hearing loss
• Only 2 prospective, double-blind, randomized,
  controlled trials evaluating therapy of SSNHL

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Intratympanic steroid

• Administration of steroids to middle ear round
  window niche/membrane directly targeting the
  inner ear
• Very little systemic absorption
• May benefit patients for whom systemic steroids
  are contraindicated
• Higher concentration to end organ
• May salvage hearing loss when non-responsive to
  systemic steroids

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Advantage of IT steroids

• May be used when systemic steroids are
  contraindicated or refused
• Greater concentration achieved at target end
  organ
• May be performed in outpatient setting
• Possible use for salvage of hearing
• Relatively low complication rate

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Take Home Messages

• SSNHL is an otologic emergency
• Systemic steroids are mainstay of therapy
• Better prognosis if treatment started early
  (within 4 weeks of onset)
• IT steroids may be an alternative when systemic
  steroids are contraindicated
• IT steroids is another option when oral steroids
  fail to restore hearing

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Thank you for your attention