Treatment of Idiopathic Sudden Deafness With Hyperbaric Oxygen Based On Research

Article by Dr. Dimitriou N. Geli – MD, ORL, DDS, PhD, Medical Life Coach.

Hyperbaric oxygen therapy of patients with idiopathic sudden sensorineural hearing loss, when applied in time, at the beginning of the sudden hearing loss and tinnitus, and at the same time corticosteroids are administered, is a safe and effective practice, especially when there is early coordinated cooperation between the patient’s ear, nose and throat specialist, the hyperbaric doctor and the technical staff of the hyperbaric oxygen chamber.

What is Idiopathic sudden sensorineural hearing loss

Idiopathic sudden sensorineural hearing loss (ISSNHL) is defined as a sudden hearing loss of more than 30 dB, occurring at least in three adjacent audiometric frequencies within 72 hours or less. ISSNHL is a disease of unknown etiology. [1]. Also known as sudden deafness, it usually occurs in just one ear, and is usually preceded by a loud popping sound.

The pathogenesis of ISSNHL remains, at present, unclear. Nevertheless, ISSNHL seems to be characterized by the presence of hypoxia in the periosteum of the inner ear and therefore in the vestibular scale and the organ of Corti, which are present in the inner ear [2].

Sudden hearing loss is an emergency otolaryngological condition. The American Academy of Otolaryngology-Head and Neck Surgery guidelines focus primarily on idiopathic sudden hearing loss in adult patients over 18 years of age. Early diagnosis and treatment of ISSNHL can improve hearing restoration and quality of life for patients [3].

Sudden sensorineural hearing loss affects 5 to 20 in 100,000 people with 4000 new cases occurring per year in the USA [3].

In male patients with sudden sensorineural hearing loss, the use of anti-static dysfunction medications is investigated when taking their history.

Phosphodiesterase type 5 inhibitors [phosphodiesterase type 5 (PDE5) inhibitors] are considered first-line treatments for men with erectile dysfunction. The instruction leaflets accompanying the proprietary formulations of Levitra® (Vardenafil HCl), Cialis® (Tadalafil) and Viagra® (Sildenafil Citrate) state that their side effects include sudden hearing loss [23, 24, 25].

Treatments of idiopathic sudden sensorineural hearing loss

If ISSNHL is left untreated it can lead to permanent disability. Corticosteroids, vasodilators, immunosuppressants, antiviral drugs and hyperbaric oxygen therapy have been used therapeutically to date, although there are conflicting opinions about all of them.

Administration of corticosteroids

Currently, the most accepted treatment, of ISSNHL in general, is the administration of corticosteroids, although there is no worldwide standardized guideline for its practical application [4].

A variety of corticosteroid regimens have been used with different dosages and different routes of administration. A high dose of oral or intravenous corticosteroid is believed to restore hearing ability. Oral corticosteroid administration takes 10-14 days [5].

Systemic administration and intratympanic administration of corticosteroid are widely applied for the treatment of ISSNHL, and vasodilators, immunosuppressants and antiviral drugs are also administered. Nevertheless, only 61% of patients have complete hearing restoration and therefore there are still controversial opinions about the treatment of ISSNHL [6].

Therefore, treatment of ISSNHL with corticosteroids administered by any route is not considered satisfactory, as only 61% of sufferers have their hearing restored [7].

In those in whom systemic corticosteroid administration proved fruitless, intratympanic corticosteroid injection was widely applied to release the corticosteroid into the inner ear. Intratympanic corticosteroid injection may be accompanied by complications such as eardrum perforation, myringitis and otitis media.

The results of the treatment of sudden sensorineural hearing loss with corticosteroid administration, which was performed in three ways. [20]

Lim HJ and colleagues (2012) at the Department of Otolaryngology, Ajou University School of Medicine, Suwon, Republic of Korea treated patients with sudden sensorineural hearing loss by adhering to various outpatient protocols.

In their study they compared three different treatment modalities by administering corticosteroid. The study was prospective randomized controlled trial.

They studied 60 patients diagnosed with sudden sensorineural hearing loss who were treated as outpatients.

Patients were divided at random and into equal numbers of three groups based on the treatment administered.

• The first group of patients took oral corticosteroid for 10 days.

• The second group got an intratympanic injection of dexamethasone, with 4 injections over 10 days.

• And the third group was given corticosteroid in both ways, i.e. oral and intratympanic.

Hearing improvement was tested by measuring 4 frequencies in the affected ear (0.5, 1, 2, and 3 kHz). The change in hearing was assessed by comparing the findings of the hearing measurements before and after the treatments

The frequency of recovery was assessed according to the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) Clinical Practice Guidelines

The treatment results in the three groups were hearing gain for Group I 12.8 ± 15.4 decibels (dB), for Group II 12.1 ± 14.6 dB and for Group III 21.9 ± 26.2 dB. The frequency of recovery was 60% in Groups I and III and 55% in Group II. The overall recovery frequency was 58.3% (35 of 60 patients).

There was no significant difference in hearing gain and frequency of hearing recovery between the three groups.

There was no significant difference in hearing gain at any specific frequency between the three groups.

Conclusion: The three different treatment protocols for sudden sensorineural hearing loss with oral or intratympanic corticosteroid administration or a combination of them produced the same hearing recovery frequency results in patients

Despite the above, in a severe sudden hearing loss, combined intratympanic and oral corticosteroid administration can be used as initial treatment [21].

Treatment with hyperbaric oxygen (HBO2)

The improvement of acute disorders of the inner ear using hyperbaric oxygen therapy was first reported in the literature in the late 1960s, both by French and German authors [11].

Idiopathic sudden sensorineural hearing loss [ISSNHL] is the most recently accepted therapeutic indication for the use of hyperbaric oxygen by the Undersea and Hyperbaric Medical Society’s Hyperbaric Oxygen Therapy Committee. Unfortunately, only naval hospitals have hyperbaric oxygen chambers.

To date, the treatment of ISSNHL with hyperbaric oxygen has been evaluated in more than 100 medical publications in the international literature, of which eight are randomized controlled clinical trials.

Although the causes of sudden hearing loss are not fully established, it is believed to be related to oxygen deprivation induced after a vascular problem that has not yet been identified. During hyperbaric oxygen therapy (HBOT), the patient inhales pure oxygen under increased atmospheric pressure in a specially designed chamber.

This method increases the supply of oxygen to the brain and ear, thus reducing the severity of hearing loss and tinnitus [12].

The best results are obtained when hyperbaric oxygen therapy is started in the first two weeks after the onset of symptoms and combined with cortisone therapy. According to Fujimura and colleagues, patients treated with the combination of cortisone therapy and hyperbaric oxygen had better therapeutic results than those treated with cortisone therapy alone. [13].

The average hearing gain for a moderate hearing loss can reach 19.3 dB and 37.7 dB for severe cases.

These levels of hearing improvement shift moderate and severe hearing deficits to minor hearing losses, which significantly improves the quality of life of the sufferers, both clinically and functionally [2].

Hyperbaric treatment requires effective communication and cooperation between the otolaryngologist, the specialist doctor in hyperbaric medicine and the patient and his/her relatives. Patients have the right to know the risks and benefits of treatment, especially when there are no other standardized treatment alternatives. The criteria used by the treating otolaryngologist should be explained to the patient, as well as the possible expected therapeutic outcomes, always in collaboration with the doctor in charge of the hyperbaric oxygen chamber.

Several times patients with ISSNHL desperately request the use of hyperbaric oxygen, under the unpleasant sensation of hearing loss and tinnitus in their ears. Hyperbaric treatment, in some cases, can be applied up to day 36 from the onset of symptoms.

At this stage, an automatic improvement of the patient’s condition is no longer expected, as the process of inflammation in the inner ears [inner ears] does not last more than 2-3 weeks.

Read Also: How hyperbaric oxygen therapy helps with brain injury?

Although the intratympanic corticosteroid injection may have produced some benefits in hearing ability, which are objectively visible on the patient’s audiogram, one cannot generally expect further improvement after 36 days.

Patients with bilateral moderate hearing loss may benefit more from the combination of hyperbaric and cortisone therapy.

In many cases, treatment with hyperbaric alone can fully restore normal hearing levels and eliminate tinnitus without complications [13].

The standardized treatment regimen of hyperbaric oxygen administration for ISSNHL has not yet been established. However, the usual treatment plan applied is of the 45/90 treatment panel (2 ATA 90 minutes) for ten sessions. If the patient shows a return of hearing without tinnitus in both ears during the third and fifth sessions, the remaining sessions do not need to be performed.

Topuz and colleagues propose a treatment regimen of hyperbaric administration to ISSNHL patients at 2.5 ATA for 90 minutes twice a day for the first 5 days and then once a day for the next fifteen days. This treatment regimen has shown good results. Individuals over 50 years of age with severe sensorineural hearing loss greater than 60 dB, treated with hyperbaric oxygen without delay, showed a higher rate of hearing recovery [14].

Hearing restoration results of ISSNHL patients who received a combination of treatments

The American Academy of Otolaryngology-Head and Neck Surgery [AHAHS] of the USA makes evidence-based recommendations regarding the evaluation of patients with sensorineural hearing loss, with particular emphasis on ISSNHL [16].

Emphasis is placed on the differential diagnosis of sensorineural hearing loss when it is the main discomfort of a patient’s visit to an otolaryngologist or any other clinician.

Hyperbaric oxygen therapy has been shown to exert a significant additional effect when used in combination with corticosteroid therapy, particularly when primary treatment with corticosteroid administration by either route has failed [8] [22].

The results of ISSNHL treatment are generally improved when hyperbaric oxygen therapy is combined with any other medication [9].

Systemic corticosteroid therapy plus intratympanic corticosteroid injection may be more effective than systemic corticosteroid therapy plus hyperbaric oxygen therapy and therefore may become first-line treatment for ISSNHL if a hyperbaric oxygen chamber is not available [10].

Treatment of idiopathic sudden hearing loss with HBOT in patients in whom drug therapy has failed

Muzzi E, and colleagues reported nineteen cases of patients with sudden sensorineural hearing loss who did not respond to drug treatment, in the acute or chronic phase of the disorder. These patients were placed in a hyperbaric oxygen chamber and inhaled pure oxygen at an absolute pressure of 2.5 atmospheres for 90 minutes and 30 sessions.

Patients were subjected to audiometric testing before and after hyperbaric oxygen treatment. The number of hyperbaric oxygen sessions, the age of the patients and the delay in the start of treatment were considered as quantitative variables that probably influenced the treatment outcome.

Multivariate analysis showed that hyperbaric oxygen rescue therapy appeared to improve patients’ pure-tone hearing scores, especially at low frequencies. Positive results were more likely the older the patients were and the more advanced the age of the patients and the more delayed the start of hyperbaric oxygen therapy.

Hyperbaric oxygen therapy is based on strong scientific evidence supporting its use to improve the hearing ability of patients with idiopathic sudden sensorineural hearing loss in those cases that do not respond to medication [17].

READ ALSO: How to Choose the Best Hyperbaric Oxygen Therapy Chamber

Final Take

In conclusion, hyperbaric oxygen therapy can be used as an adjunct to drug therapy in patients with idiopathic sudden sensorineural hearing loss. Best results are obtained when applied simultaneously with drug treatment. Hyperbaric oxygen can promote oxygenation of the inner ear and restore hearing ability.

Patients who have failed oral or intravenous corticosteroid therapy or after intratympanic corticosteroid injection may benefit from hyperbaric oxygen therapy.

Investigations to understand the action of hyperbaric oxygen at the molecular and histological level are continuing in experimental animals. And in randomized double clinical trials in humans, the results of which will be announced in the near future.

In addition to scientific international communications on the usefulness of hyperbaric oxygen, the personal clinical experience of the first of the authors of this scientific article has shown that hyperbaric oxygen treatment of patients with idiopathic sudden sensorineural hearing loss, when applied in time, at the beginning of the onset of sudden hearing loss and tinnitus and corticosteroids are administered at the same time, is a safe and effective practice, especially when there is timely coordinated cooperation between the patient’s treating otolaryngologist, the hyperbaric physician and the technological staff of the hyperbaric oxygen administration chamber.

Hyperbaric oxygen administration is a safe medical practice when performed by an experienced hyperbaric therapist and technical staff.

For the treatment of ISSNHL, 20 sessions of hyperbaric oxygen administration at a pressure of 2.5 atmospheres are tolerated by patients, with insignificant, rare complications. Hyperbaric oxygen therapy should definitely be chosen in all cases of total or very severe sudden hearing loss [18].

The results of hearing restoration in ISSNHL patients vary, depending on the degree of hearing loss and the type of audiogram accompanying the hearing loss.

Corticosteroid pharmacotherapy combined with hyperbaric oxygen administration may promote clinical outcomes in patients with moderate to severe hearing loss and with a type of flat or cationic sensorineural hearing loss [19].

Hyperbaric oxygen administration is a safe medical practice when performed by an experienced hyperbaric therapist and technical staff. For the treatment of ISSNHL, 20 sessions of hyperbaric oxygen administration at a pressure of 2.5 atmospheres are tolerated by patients, with insignificant, rare complications. Hyperbaric oxygen therapy should be chosen in all cases of total or very severe sudden hearing loss.

source: Dr. Dimitriou N. Geli – MD, ORL, DDS, PhD, Medical Life Coach – pharmagel.gr

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