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SSNHL

SSNHL. By Saisuree Nivatwongs ENT PMK. SSNHL. Incidence: 5-20 per 100,000 4,000 new cases/year in US Idiopathic Hearing loss at least 30 dB over 3 contiguous frequency Onset of hearing loss occurs in less than 72 hours Recovery rate without treatment 32% - 79%

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SSNHL

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  1. SSNHL By Saisuree Nivatwongs ENT PMK

  2. SSNHL • Incidence: 5-20 per 100,000 • 4,000 new cases/year in US • Idiopathic • Hearing loss at least 30 dB over 3 contiguous frequency • Onset of hearing loss occurs in less than 72 hours • Recovery rate without treatment 32% - 79% • Usually within 2 weeks of onset • Only 36% with complete recovery • No middle ear disease • Otologic emergency!

  3. SSNHL • Clinical Presentation • Sudden onset hearing loss • Less than 3 days • Usually unilateral • Left side possibly more common (55%) • Bilateral 2% • Median age 40-54 • Male = Female • Awakening from sleep • Hearing a “popping” prior to hearing loss • Aural fullness • Tinnitus • Vertigo

  4. Etiology Viral infection • Association of SSNHL with viral URI in 25% - 63% • Serology confirming active viral infection • HSV, VZV, CMV, influenza, measles parainfluenza, rubeola, mumps, rubella • Immunoreactivity against virus • Histopathology of human temporal bones • Atrophy of organ of Corti, spiral ganglion, tectorial membrane • Hair cell loss • Unraveling of myelin

  5. Etiology Vascular injury • Sudden onset suggesting infarction • Perlman (1959) demonstrated loss of cochlear microphonic 60 seconds after occlusion of labyrinthine artery in guinea pig • Polycythemia ,Buerger’s, macroglobulinemia, sickle cell, fat embolism, DM

  6. Etiology Intracochlear membrane rupture • Loss of endocochlear potential due to mixing of endolymph and perilymph • Gussen (1981) histologic evidence • Fallen out of favor Autoimmune cross-reacting circulation Ab

  7. DDX • Infectious • Bacterial: meningitis, labyrinthitis, syphilis • Viral: Mumps, CMV • Inflammatory • Autoimmune, Cogan syndrome, Lupus, MS • Traumatic • Temporal bone fracture, acoustic trauma, perilymph fistula • Neoplastic • CPA tumor, temporal bone metastasis • Toxic • Aminoglycosides, aspirin • Vascular • Thromboembolism, macroglobulinemia, sickle cell disease, cerebral infarct, TIA • Congenital • Mondini malformation, enlarged vestibular aqueduct

  8. Clinical Evaluation • Hx • Complete ENT exam • Audiogram include PTA, SRT, SDS • Tympanogram • ABR

  9. Radiograph • MRI with Gd 0.8-2 %of pt with SSNHL have been diagnosed CPA /IAC tumors • Non-contrasted CT temporal bone : R/o congenital malformation

  10. Laboratory Evaluation • CBC with diff • Polycythemia, leukemia, thrombocytosis • FBS , Electrolytes • Erythrocyte sedimentation rate (ESR) • FTA-Abs (Syphilis) • Coagulation profile • Thyroid function testing • Lipid profile • BUN, Creatinine • UA • ANA , rheumatoid factor , viral study

  11. Prognosis • Severity of HL • Audiogram shape • Presence of vertigo • Age • Without Rx : 30-65 % will experience complete or partial recovery

  12. Medical Rx • Bed rest • Low salt diet < 2 gm/day • Diuretics : HCTZ • Steroids

  13. Steroids • Historical perspective: Reduce inner ear inflammation • Rx as early as posible • Oral, IV 10 days • Cannot be used for all patients • Diabetics, ulcers, TB, glaucoma • Intratympanic steroids

  14. Medical Rx • Antivirals • Volume expanders : Dextran , hypaque • Vasodilators : Histamine phosphate , Ca antagonist , nicotinic acid • Anticoagulants : heparin • Carbogen inhalation (95%O2,5%CO2)

  15. SSNHL • Cochrane Database of Systematic Reviews • Wei (2003, Updated 2006): Steroids for idiopathic sudden sensorineural hearing loss • Only 2 prospective, double-blind, randomized, controlled trials evaluating therapy of SSNHL

  16. Intratympanic steroid • Administration of steroids to middle ear round window niche/membrane directly targeting the inner ear • Very little systemic absorption • May benefit patients for whom systemic steroids are contraindicated • Higher concentration to end organ • May salvage hearing loss when non-responsive to systemic steroids

  17. Advantage of IT steroids • May be used when systemic steroids are contraindicated or refused • Greater concentration achieved at target end organ • May be performed in outpatient setting • Possible use for salvage of hearing • Relatively low complication rate

  18. Take Home Messages: • SSNHL is an otologic emergency • Systemic steroids are mainstay of therapy • Better prognosis if treatment started early (within 4 weeks of onset) • IT steroids may be an alternative when systemic steroids are contraindicated • IT steroids is another option when oral steroids fail to restore hearing

  19. Thank you for your attention

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