Dr. Haynes is the lead author of a study that is often cited as evidence that IT steroid therapy can be an effective salvage treatment for patients with ISSNHL (Laryngoscope. 2006;117:3-15). In the study, 16 of 40 ISSNHL patients who had failed systemic steroid therapy achieved “modest” benefits after IT steroid injections. The response was based on patients showing any gain in PTA and speech reception threshold, Dr. Haynes said. But when a 20-db improvement in PTA or a 20 percent improvement in speech discrimination score was used as the criteria for success, the response rate fell to 27.5 percent.
Explore This IssueJanuary 2013
“These were hardly dramatic results,” Dr. Haynes said. But in the intervening years, his own clinical experience, additional studies and new treatment guidelines on sudden hearing loss from the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) have helped clarify some of the issues surrounding both systemic and IT steroid therapy (Otolaryngol Head Neck Surg. 2012;146:3 suppl S1-S35). Unfortunately, he said, those guidelines don’t appear to have resolved all the issues affecting treatment choice.
Seth Schwartz, MD, MPH, neurotologist in the department of otolaryngology at Virginia Mason Medical Center in Seattle, who co-authored the new AAO-HNS guidelines, acknowledged that the recommendations that addressed systemic and IT steroids for SSHNL led to some confusion.
“The main criticism we heard was that there is some inherent lack of logic in how we worded those recommendations: specifically, our stating that clinicians may offer steroids as initial therapy to patients with ISSNHL, but that IT steroids should be used for salvage therapy,” he said. “I understand that position—why would a drug work for salvage when it failed a patient initially? Despite that, the strength of those recommendations was based on the best available data.”
The reason for the somewhat weaker wording on the initial steroid recommendation—and the lack of specificity on whether initial therapy should be systemic or IT—is the divergent nature of the data, Dr. Schwartz said. In reviewing the literature, he said, “we found studies saying that initial steroids are better than placebo, and also studies that showed no difference between placebo and steroids.”
The use of steroids as initial therapy for ISSNHL “has always been something of a sacred cow among ENT physicians,” he added. “So it is hard to challenge that. But there’s logic in our choice of wording: The harm to patients from sudden hearing loss is so great, and the risk from steroids is fairly low, that we deemed it worthwhile to characterize steroids as an option, even though the data are very soft on using it as initial therapy.”