Upload
lamcong
View
221
Download
0
Embed Size (px)
Citation preview
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
Sudden Sensorineural Hearing Loss : Evidence-‐based Key Points
EKology Sudden Sensorineural Hearing Loss : Evidence-‐based Key Points
However, up to 90% of cases are idiopathic
Prognosis
• Spontaneous improvement is common (in days)
Sudden Sensorineural Hearing Loss : Evidence-‐based Key Points
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)
Sudden Sensorineural Hearing Loss : Evidence-‐based Key Points
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
EvaluaKon Sudden Sensorineural Hearing Loss : Evidence-‐based Key Points
• Laboratory TesKng as rouKne work-‐up
Strong Recommended
Against
EvaluaKon Sudden Sensorineural Hearing Loss : Evidence-‐based Key Points
• 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
EvaluaKon Sudden Sensorineural Hearing Loss : Evidence-‐based Key Points
• 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)
Sudden Sensorineural Hearing Loss : Evidence-‐based Key Points
Management
• PaKent EducaKon
– about natural history – benefits and risks of medical IntervenKons – limitaKons of exisKng evidence regarding efficacy
Sudden Sensorineural Hearing Loss : Evidence-‐based Key Points
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
Management Sudden Sensorineural Hearing Loss : Evidence-‐based Key Points
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
Management Sudden Sensorineural Hearing Loss : Evidence-‐based Key Points
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
Management Sudden Sensorineural Hearing Loss : Evidence-‐based Key Points
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
• PaKent EducaKon • Steroid – Systemic – Intratympanic
Management Sudden Sensorineural Hearing Loss : Evidence-‐based Key Points
Recommended • PaKent EducaKon • Steroid – Systemic – Intratympanic
! Salvage Patients who fail to recover spontaneously or after initial management (steroid and/or observe)
Management
• PaKent EducaKon • Steroid – Systemic – Intratympanic
• Other MedicaKons
Sudden Sensorineural Hearing Loss : Evidence-‐based Key Points
Recommended Against
Management
• PaKent EducaKon • Steroid – Systemic – Intratympanic
• Other MedicaKons ! anKviral
Sudden Sensorineural Hearing Loss : Evidence-‐based Key Points
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
Management Sudden Sensorineural Hearing Loss : Evidence-‐based Key Points
• PaKent EducaKon • Steroid – Systemic – Intratympanic
• Other MedicaKons • Hyperbaric O2
OpKonal
Beoer response in: ! Younger PaKents ! Earlier Therapy (Within 3 months of Dx) ! Severe Hearing Loss
Management Sudden Sensorineural Hearing Loss : Evidence-‐based Key Points
• PaKent EducaKon • Steroid – Systemic – Intratympanic
• 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
Management Sudden Sensorineural Hearing Loss : Evidence-‐based Key Points
• PaKent EducaKon • Steroid – Systemic – Intratympanic
• 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 +