One of his top take-home messages, he said, was that all patients should be evaluated for retrocochlear pathology. “That doesn’t necessarily mean that all patients should get an MRI scan, although in my practice, I strongly advise most patients to get an MRI scan,” he added.
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November 2014His bottom line regarding SSNHL is that there are a variety of causes and that these possible causes aren’t necessarily mutually exclusive. “Perhaps what we’re really dealing with is some sort of a trigger that provokes it, perhaps vascular or viral, and that sets in motion a common cellular-stress pathway within the hair cells that results in cellular death,” he said.
Sujana Chandrasekhar, MD, director of New York Otology and a member of the guideline panel, said that, despite what might be a prevailing view in the field, steroids are not a true gold standard for SSNHL. The guidelines suggest that a clinician “may offer” steroids as an initial treatment.
“That was a surprising finding based on the literature,” Dr. Chandrasekhar said. “Most of us went into the guidelines panel thinking that steroid is, quote unquote, the gold standard for sudden hearing loss management.”
Actually, though, while some studies have found a benefit, others have not. A Cochrane review of the best available evidence found mixed results with steroids, she said. Three studies made the cut for the review, but all had a high risk of bias. So, in the end, she said, steroids are an option, not a recommendation.
Oral v. Intratympanic Administration
When it comes to oral administration versus intratympanic (IT) injection of steroids, the best guidance might come from a landmark 2011 study that found no benefit difference but a “less worrisome” side effect profile for IT injection (JAMA. 2011;305:2071-2079).
Contrary to the administration of steroids (systemic or IT) as an option for initial treatment, however, is the clinical practice guideline panel’s recommendation that physicians offer IT steroid injection as salvage if the patient fails any type of initial management, which might include observation, systemic or IT steroids, hyperbaric oxygen, or other treatment. “The literature on utility of IT steroid injections for salvage is actually very clear and shows a benefit,” she said.
Still, there might be a benefit to using IT injection in addition to systemic steroids, because delivery time is longer with IT injection if the round window is closed because of fibrous adhesions, Dr. Chandrasekhar said.