Interpreting the results of the study, Dr. Gurgel said. “Since IT drug therapy was noninferior to oral steroids, we are not doing a disservice to our patients if we offer it to them as an option, especially if they can’t tolerate the side effects of systemic steroids.”
Explore This IssueJanuary 2013
Side effects of systemic therapy are only one aspect of care that clinicians will need to discuss with patients who present with sudden hearing loss; choice of therapy also needs to be explored, Dr. Gurgel said. “I do offer IT steroid injections to these patients but, frankly, many patients opt not to have it because they feel somewhat uncomfortable having something injected into their ear,” he said. “On the other side of the spectrum, I have patients who are so devastated by their sudden hearing loss that they are willing to try anything.” For those patients, he noted, combination therapy with systemic and IT steroids is another viable option.
There is evidence to support combination therapy but, again, the data are equivocal. In one positive study, a combination of a high-dose prednisone taper with IT steroids yielded a partial or complete hearing recovery in 14 of 16 patients (Otol Neurotol 2008;29:453-460). But, in another study, there was no statistically significant difference in hearing recovery as a result of combination therapy vs. steroids alone (Laryngoscope. 2008;118:279-282).
Those divergent results should not obscure the fact that combination therapy has a definite role in the management of ISSNHL, Dr. Gurgel noted. David S. Haynes, MD, professor in the department of otolaryngology/The Otology Group of Vanderbilt in Nashville, Tenn., echoed that view. “Most clinicians would opt for the combination approach—it’s what I would ask for,” he said. The main driver of that decision, he noted, is the fact that “we don’t fully understand what causes sudden hearing loss. Is it inflammation? An electrolyte dysfunction of the cochlea? A blood flow phenomenon? With all of those multifactorial processes occurring, I’d want a combined approach to cover all potential [causes].”
Having said that, however, Dr. Haynes said that he generally tends to take a more conservative approach to managing patients with ISSNHL than some of his colleagues. As a result, for one important consideration—whether to use IT steroids as initial or salvage therapy (i.e., after a patient has not responded to oral steroids or another treatment)—he comes down on the side of salvage. “If a patient persists with a two-day history of sudden hearing loss, I probably would not inject him or her right away, especially as we see patients improve spontaneously or with systemic therapy,” he said. “So my first-line approach is usually to tell patients that a week of systemic steroids is worth a try before injecting the ear. If systemic therapy fails, then we would certainly consider IT salvage therapy. We want to put patients in the best position to recover their hearing.”