AMERICAN JOURNAL OF OTOLARYNGOLOGY– HEAD AND NECK MEDICINE AND SURGERY 34(2013)296– 300
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S u d d e n Se nsorine ura l H e a ring L oss: R e sult s of in tra ty mpa nic steroids as salvage t r e a t m e n t ~~ ~ ,
Francesco Dispenza, MD, PhD a,~, Alessandro De Stefano, MD, PhD, FAINOT , Claudio Costantino, MD , Donatella Marchese, MD , Francesco Riggio, MD, PhD b
c
d
d
U.O. Otorinolaringoiatria, Azienda Sanitaria Provinciale 1 Agrigento, Ospedale “S. Giovanni di Dio ” , Italia ' ” b Dipartimento di Scienze Orali e Nano-Biotecnologiche-U.O. Otorinolaringoiatria, Università degli Studi “G. d Annunzio Chieti-Pescara, Italia c Istituto Igiene, Università degli Studi di Palermo, Italia a
d
Dipartimento Biomedicina e Neuroscienze Cliniche-U.O.
Otorinolaringoiatria, Università degli Studi di Palermo, Italia
ARTI CL E INFO
ABSTRAK
Article history: Received 22 October 2012
Tujuan: Tujuan dari penelitian ini adalah untuk memastikan efektivitas dan keamanan deksametason intratympani untuk mengobati tuli sensorineural yang mendadak. Bahan dan cara: Studi prospektif dilakukan pada pasien dengan tuli mendadak yang idiopatik yang dirawat sebelumnya dengan pengobatan sistemik, tetapi tanpa pemulihan pendengaran. Para pasien yang sesuai dengan kriteria penelitian, tetapi menolak pengobatan dianggap sebagai kelompok kontrol. Suatu larutan Deksametason 4 mg/ml kemudian disuntikkan melalui membran timpani kuadran posterior-inferior hingga memenuhi telinga tengah. Follow up dilakukan dalam 6 bulan termasuk pemeriksaan audiogram setiap bulan. Hasil: Jumlah pasien yang diobati dengan terapi ini adalah 36 orang. Pasien yang menolak pengobatan berjumlah 10 orang. Terapi dilakukan dengan penundaan rata-rata 24,3 hari dari timbulnya gejala. Ambang pendengaran rata-rata setelah onset tuli mendadak pada audiometri nada murni adalah 66,5 dB. Ambang pendengaran rata-rata setelah pengobatan yang gagal sebelumnya 59.6 dB. Hasil audiometri nada murni rata-rata setelah terapi steroid intra timpani adalah 46.8 dB, yang berarti terjadi peningkatan 12.8 dB.Tidak terjadi perubahan pada 10 pasien yang menolak terapi. Para pasien sebelumnya mendapat terapi steroid sistemik sebagai terapi awal menunjukkan hasil yang lebih baik setelah mendapat terapi steroid intratimpani (p <0,01). Terdapat perbedaan signifikan (p <0,05) terhadap perbaikan pendengaran pada orang tidak merokok dan orang dengan kebiasan merokok. Kesimpulan: Data kami menunjukkan bahwa pengobatan dengan deksametason intratimpani harus disarankan kepada semua pasien yang gagal dalam pengobatan sistemik awal. Terapi steroid sistemik harus dilakukan hingga tuntas terlebih dahulu sebelum memulai terapi steroid intratimpani karena nampaknya mampu memproteksi telinga dalam, seperti yang ditunjukkan oleh penelitian kami. Sebaliknya kebiasaan merokok menunjukan prognostis negatif dalam pemulihan pendengaran. © 2013 Elsevier Inc. All rights reserved.
No financial disclosure. Conflict of interest: None. ~ Corresponding author. Tel.: +39 3334565471(mobile). E-mail address:
[email protected] (F. Dispenza). ~
~ ~
0196-0709/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjoto.2012.12.010
AMERICAN JOURNAL OF OTOLARYNGOLOGY– HEAD AND NECK MEDICINE AND SURGERY 34(2013)296– 300
1
4
Introduction
The loss of hearing of at least 30 dB over at least 3 contiguous f r e que nc ie s oc c ur r in g w i th in 3 da y s or le ss i s k no w n a s S u d de n S e n s o r i n e u r a l H e a r i n g L o s s ( S S H L ) . I n m o r e t h a n 9 0% o f p a t i e n t s , t he t r ue c a u se o f t h e h e a r i n g l o s s i s n o t discovered, constituting an idiopathic disease. The estimated incidence of such disease is 5 to 20 cases per 100,000 annually [1]. Howe ver the exac t inc idence is undere stima ted, beca use ma ny pa tie nts w ho re cove r e ar ly ( w ithin f ir st fe w da ys) ar e u n l i k e l y t o se e k m e d i c a l c a r e [ 2] . T h e r a te of s p o n t a ne o u s r e c o ve r y i s a ppr ox im a te ly be tw e e n 3 2% a n d 7 0% w hi c h e n c o ur a ge s o m e o t o l o g i s t s n o t t o t r e a t S S H L pa t i e n t s [ 3 ] .
The lack of consensus in the management of SSHL is due to difficulty in finding the true etiology of the deafness. Numerous t r e a t m e n t s h a ve be e n d e sc r i b e d : s t e r o i d s , a n t i v i r a l d r u g s , osmotic diuretics, anticoagulants, vasodilators, hyperbaric oxy gen, carbogen; most therapies showed some benefits in restoring he a r i n g n o t w i t h s t a n d i n g t h e l a c k o f r o b u s t n e s s o f t he d a t a . T h e m o s t w i d e l y e m p l o y e d d r u g s i n t h e m a n a g e m e n t o f SS HL a re ste r oids tha t a re admin iste re d a s a sing le age nt or associated with other drugs. Several placebo-controlled trials reported encouraging results in terms of recovering of hearing loss [4,5], a lthough other author s disc usse d suc h eff icacy in t h e t r e a t m e n t o f S S H L [ 1 , 3 , 6 , 7 ] . Although the treatment is started within a reasonable time a f t e r o n s e t o f t h e h e a r i n g l o s s , t h e r e s u l t i s n o t a l w a y s achieved and about 30%–40% of patients have no benefits after s y s t e m i c t r e a t m e n t . The aim of the present study was to verify the efficacy and t h e s a f e t y o f i n t r a t y m p a n i c d e xa m e t h a s o ne ( I T D ) t o t r e a t S S H L p a t i e n t s a s s a l va g e t h e r a p y a f t e r o t h e r t r e a t m e n t s .
2
Materials a n d m e t h o d s
A prospective study was conducted on patients affected by idiopathic SSHL who were tr ea te d before with s o m e systemic t h e r a p y, b u t w i t h o u t r e c o v e r y of t h e h e a r i n g ( le s s tha n 10 dB of PTA threshold recovery) . T he patie nts included w e r e r e f e r r e d t o o u r d e p a r t m e n t s f r o m J a n u a r y 2 0 11 t o D e c e m b e r 2 0 11 . T he i n c l u s i o n c r i t e r ia w e r e : a n S S H L o f a t le a st 30 dB ac ross 3 contiguous f re que nc ie s ove r a per iod of 3 d a y s a n d a p r e v i o u s s y s t e m i c t r e a t m e n t t h a t g a v e n o r e c o v e r y o f h e a r i n g . T h e p a t i e n t s w i t h t h e f o l l o w i n g c h a r a c t e r i s t i c w e r e e x c l u de d : h i s t o r y o f m i d d l e e a r p a t h o l o g y, p r e v i o u s i n t r a t y m p a n i c t r e a t m e n t s a d m i n i s t e r e d e l se - w h e r e f o r t h e s a m e d i s e a s e . T h e p a t i e n t e v a l u a t i o n i n c l u d e d : t h o r o u g h h i s t o r y, o t o s c o p y, b e d s i d e p e r i p h e r a l v e s t i b u l a r s y s t e m e x a m i n a t i o n , p u r e t o n e a u d i o m e t r y ( r e p e a t e d w e e k l y ) a n d M R I of internal auditory canal and cerebello-pontine angle. History detailed: onset of hearing loss, otological symptoms r e la t e d w i t h h e a r i n g l o s s , dr u g s c o n s u m e d i n t h e p a s t d a y s a n d p r e s e n c e o f o t h e r s s y s t e m i c d i s e a s e s . T h e be d s i d e e xa m i n a t i o n w a s d o n e f o r s p o n t a ne o u s a n d p o s i t i o n a l n y s t a g m u s , R o m b e rg t e s t , F u k u da t e s t , H a l m a g y i t e s t a n d H e a d Shaking test.
T h e pa t i e n t s a b l e t o u n d e r g o t h e s t u d y, b u t w h o r e f u se d s a l v a g e t r e a t m e n t w e r e c o n s i d e r e d a s c o n t r o l g r o u p . I n tr a ty mp a n ic in je c ti on w a s d one in su pi ne po si t io n w i th t h e h e a d r o t a t e d t o 4 5 ° t o t h e u n a f f e c t e d s i d e . U n d e r mic r osc ope a myr ingotomy w a s done in the a nte r ior –infe r ior quadra nt of the tympanic me mbrane in orde r to a llow the exit of the air in the middle ear during drug injection. A solution of D e x a m e t h a s o n e 4 m g / m l w a s t h e n i n j e c t e d t h r o u g h t h e poster ior–inferior quadra nt filling comple te ly the middle ear. T h e pa t i e n t m a i n t a i n e d t h e p o s i t i o n of t h e he a d f or 2 0 m i n a n d was instructed to avoid swallowing, speaking and movements of the head. The intratympanic injection was repeated five times every two days.
An audiogram was done weekly during the treatment protocols in both the groups. The follow-up in the following 6 months included an audiogram every month. P a t ie n t s l o s t d u r i n g t h e f o l l o w - u p a n d w i t h e v i d e nc e of r e tr o c oc h l e a r d i s e a se a t M R I ( i . e . : ve s t i b u l a r sc h w a n n o m a ) w e r e excluded from the analysis. A r e s p o n s e t o t h e t r e a t m e n t w a s c o n s i d e r e d i f a c ha n g e w a s r e c o r de d in P TA by c a lc ul a t in g Δ P TA a s t he dif f e r e nc e be tw e e n th e PTA be f o r e sa l va ge tr e a t me nt a nd t he la st P TA r e c o r d e d d u r i n g f o l l o w - u p ( a t l e a s t a f t e r t w o m o n t h s ) .
AMERICAN JOURNAL OF OTOLARYNGOLOGY– HEAD AND NECK MEDICINE AND SURGERY 34(2013)296– 300
5
F i g . 1 – D e l t a P TA ( F i r s t T h e r a p y P TA - P o s t S a l v a g e P TA ) i n d e c i b e l f o r e v e r y p a t i e n t s .
AMERICAN JOURNAL OF OTOLARYNGOLOGY– HEAD AND NECK MEDICINE AND SURGERY 34(2013)296– 300
F i g . 2 – C o m p a r i s o n b e t w e e n F i r s t T he r a p y P TA a n d P o s t S a l v a ge P TA f o r e a c h p a t i e n t s .
6
AMERICAN JOURNAL OF OTOLARYNGOLOGY– HEAD AND NECK MEDICINE AND SURGERY 34(2013)296– 300
7 T he number of pa tients treate d w ith salvage therapy wa s 36, of w hic h 20 pa tie nts w er e fe ma le . T he pa tie nts who re f use d tr ea tme nt were fur ther 10. T he mea n age of the whole ser ies wa s 49.4 year s. T he sa lvage tr ea tme nt wa s per for med with a me a n (17– de la y of 24.3 da ys fr om the onse t of symptoms and 74) about 2 days from the end of the first therapy done (Table 1).
Ta b e l 1 – S o s i o d e m o g r a f i ka r a k t e r i s t i k , s i m p t o m , komor bidita s da n ha sil a udiome tr i da r i pa sie n ya ng me nga la mi tuli me nda da k ( n = 4 6 ) . U m u r , r a t a - r a ta ( t a h u n) ± S D (rentang) Jenis Kelamin, n (%) Laki-laki Perempuan Sisi, n (%) Kiri Kanan Penundaan terapi salvasi, Rata-rata (hari)±SD (rentang) PTA awal, rata-rata (dB)±SD (rentang) PTA terapi pertama , Rata-rata (dB)±SD (rentang) PTA setelah terapi salvasi , Rata-rata (dB)±SD (rentang) Delta PTA, Rata-rata (dB)±SD (rentang) Vertigo, n (%) Ya
49.4±1 4.7 21 25 23 23 24.3 ±23.9 66.5 ±17.1 59.6 ± 16.7 46.8 ±17.9 12.8 ±15.2
(45) (55)
Hearing threshold after the onset of sudden hearing loss at PTA was 66.5 dB (range 25–100 dB; SD
(50.0) ± 17.1 dB). After the failed treatment administered the (50.0) PTA was 59.6 dB (range 25–100 dB; SD ± 16.7 dB). (7– 153) The PTA after the intratympanic steroid adminis tration (25– was 46.8 dB (range 10–95 dB; SD ± 17.9 dB), with a 100) mean improvement of 12.8 dB (SD±15.2 dB) (Figs. (25– 1–2). No hearing change was noted in the 10 patients 100) (10– who refused salvage therapy. 95) (49– 55)
T h e o t o n e u r o l o g i c s y m p t o m s pr e se n t s i n t h e p a t i e n t s w e r e : t r ue v e r t i g o i n 4 7 . 2 % a n d t i n n i t u s
22 24
(48) i n 9 1 . 7 % . I n t h e gr oup of sa lva ge t r e a t me nt 9 (52) pa tie nts w er e smoker s of more tha n 20 cigar e tte s
38 8
(83) u n t r e a t e d h y p e r t e n s i o n . (17)
14 32
(30) (70)
Tidak
10 36
(21) (79)
Hipertensi, n (%) Ya Tidak
10 36
(21) (79)
Tidak Tinnitus, n (%) Ya Tidak Merokok, n (%) Ya Tidak Diabetes, n (%) Ya
per da y, 5 pa tie nts we re dia be tic s and 5 s uf f e r i n g
D a ta w er e ente re d in a da ta ba se c re a te d w ithin E piI nf o 3 . 5 . 1 s o f t w a r e . A l l t h e da t a w e r e a n a l yz e d u s i n g t h e R statistical software package. Absolute and relative frequencies we re c alc ula te d f or qua li ta tive var ia ble s, while qua nti ta tive variables were s u m m a r i z e d a s m e a n ( ± s t a n d a r d de v i a t i o n and range). Categorical variables were analyzed using the chi- s q u a r e te st ( Ma nte l–Ha e nsz e l) . Odds ra tio ( O R) w ith 95% c onf ide nce inte r va ls (95% CI s) we re a lso c a lc ula te d. D iffe r ence s in me a ns w er e compar e d w ith the S tude nt t- te st. A ll variables found to have a statistically significant association (two-tailed pvalue <0.05) with improved PTA in the univariate a na lysi s we re inc lude d in a mul tivar ia te r e gr e ssion mode l. T he signif ica nce le ve l chose n f or a ll a na lysi s wa s 0.05, tw o - t a i l e d . A l l pa t i e n t s s i g n e d a n i n f or m e d c o n s e n t be f o r e t h e trea tment and our Review Boards approved the present study.
3.
Results
AMERICAN JOURNAL OF OTOLARYNGOLOGY– HEAD AND NECK MEDICINE AND SURGERY 34(2013)296– 300
8 T he f ir st t r e a t m e n t admin iste re d w a s a syste mic ste r oid t h e r a p y i n 4 1 p a t i e n t s ( 8 9 % ) , of w h i c h 2 2 r e c e i ve d a l s o i n t r a v e n o u s o s m o t i c d i u r e t i c s ( i . e .
m a n n i t o l or g l y c e r o l ) . O s m o t i c d i u r e t i c s a l o ne w e r e a d m i n i s t e r e d i n 4 p a t i e n t s u na b l e t o t a ke systemic steroids. Hyperbaric oxygen and
9
AMERICAN JOURNAL OF OTOLARYNGOLOGY– HEAD AND NECK MEDICINE AND SURGERY 34 (2013) 296– 300
nilai-P Tabel 2– Terapi pertama yang didapatkan pasien yang mengikuti terapi salvasi intratimpani (n=36). N= 36 Terapi steroid, n (%) Ya Tidak
32 (88.9) 4 (11.1) 8 (22.2) 28 (77.8) 26 (72.2) 10 (28.8)
Oksigen hiperbarik, n (%) Ya Tidak Diuretik osmotik, n (%) Ya Tidak Antiviral, n (%) Ya Tidak
3 (8.3) 33 (91.7)
antiviral drugs, associated to steroids, were done respectively t o 8 a n d 3 p a t i e n t s ( Ta b l e 2) . A s a l v a ge t r e a t m e n t de l a y c a te g o r i z a t i o n w a s m a de i n accordance with median value (20 days). According to salvage t r e a t m e n t d e l a y c a te g o r i z a t i o n t he r e w e r e n o s t a t i s t i c a l l y significant difference s be twee n a de lay less t h a n or equal to 2 0 d a y s a n d m o r e t h a n 2 1 da y s ( Ta b le 3 ) . The patients th a t a s su me d systemic steroid as first therapy show e d a be tter P TA thre shold a f te r t h e sa lva ge intra tympa n i c t r e a t m e n t ( p < 0 . 0 1 ) a s d i s p l a ye d i n Ta b l e 4 . A sta tist ica lly signif ic a nt diffe re nce ( p<0.05) of he a r ing r e c o ve r y w a s e v i d e nc e d be t w e e n n o n - s m o k e r pa t i e n t s a n d those with smoking habit, which recovered respectively ( m e a n ) 1 5 . 9 d B v e r s u s 3 . 3 d B ( Ta b le 5 ) .
4.
Discussion
P enggunaa n ste r oid intr a timpa ni mer upa ka n pr ose dur ya ng te la h dike na l. I toh da n S a k a t a me r u pa k a n o r a n g y a n g p e r t a m a m e m a ka i n y a d i t a h u n 1 9 9 1 s e ba g a i pe n g o b a ta n p a da p a s i e n de n g a n pe n y a k i t m e n i e r [8]. Penggunaan terapi intratimpani pada tuli sensorineural mendadak pertama kali dilakukan oleh Silverstein di tahun 1996 [9]. Ta b l e 3 – P TA R a t a - r a ta p a da t a ha p y a n g be r b e da d i k a t e g or i k a n m e n u r u t pe n u n d a a n t e r a p i sa l v a s i ( n = 3 6 ) . ~ 20
ha r i (n=19)
> 2 1 ha r i (n=17)
62.6±20 .8
70.9±10 .8
0.33
56.3±19 .5
63.2±12 .4
0.18
46.8±20 .0
46.8±15 .9
0.95
9.5±11 .2
16.5±18 .3
0.28
PTA awal, rata-rata dalam dB±SD PTA pertama , rata-rata (dB)±SD PTA setelah salvasi, rata-rata dB)±SD Delta PTA, rata-rata (dB)±SD
Penundaa n tera pi salvasi
Alasan rasional mendukung terapi ITD adalah permeabilitas membran jendela bundar terhadap obat-obatan. Konstentrasi steroid perilimfe yang lebih tinggi dapat dicapai dengan pemberian transtimpani, lebih tinggi dibandingkan pemberian sistemiki [10,11]. Distribusi dari obat ini menunjukkan penurunan konsentrasi
AMERICAN JOURNAL OF OTOLARYNGOLOGY– HEAD AND NECK MEDICINE AND SURGERY 34(2013)296– 300
Dari basal koklea hingga ke bagian apikal, dengan konsentrasi maksimum dekat dengan telinga bagian dalam da r i me mbra n je nde la bunda r [12]. Difusi molekul ke dalam cairan telinga dalam dan kompartemennya mengikuti beberapa jalur berbeda: bersama aliran perilimfatik melewati helikotrema (longitudinal) dan melewati ligamentum spiral (komunikasi interscalar) . Salt et al. menemukan bahwa apa pun protokol diadopsi, tidak mempengaruhi distribusi relatif obat ke cairan telinga bagian dalam, percaya bahwa fakta ini adalah sekunder untuk clearance obat dari perilimfe tersebut [13] . N a m u n , f a r ma k o k i n e t i k da r i k o k l e a be l u m d i pa h a m i s e c a r a j e l a s da n p e n d i s t r i b u s i a n o b a t s e pa n j a n g k o k l e a m a n u s i a b e r b e da d i b a n d i n g k a n de n g a n t i k u s ya n g d i g u n a k a n u n t u k pe n e l i t i a n i n i , da n m e n u r u t p e n da p a t M i k u l e c e t a l . i t u b u ka n m o d e l y a n g ba i k [ 1 4 ] . Ta b e l 4 – R a ta - r a t a P TA p a da t a ha p a n ya n g b e r be d a me n u r u t p e m b e r i a n t e r a p i s t e r o i d s e be l u m n y a ( n = 3 6 ) . Te r a p i S te r o i d PTA, awal Rata-rata(dB) ±SD PTA pertama, ratarata(dB)±SD PTA setelah salvasi, ratarata(dB)±SD Delta PTA,
p-
va l u e Ya ( n = 3 2 )
Ti d a k ( n = 4 )
64.5±16.7
82.5±13.2 <0.05
44.1±15.3
68.7±24.9 <0.01
pe ngoba ta n ste r oid siste mik diter ima se ca ra lua s da n dir e kome nda sika n se ba ga i ter a pi lini pe r ta ma pa da se ba gia n be sa r ne ga ra [15] dan pada wilayah kita sesuai dengan protokol pengobatan yang paling banyak diadopsi, bahkan ketika pasien mengacu pada spesialis THT swasta atau spesialis THT rawat jalan . D e f i n i s i da r i i n t e r v e n s i te r a pe u t i k y a n g b e na r p a da p e n i n g k a ta n pe n d e n ga r a n s u l i t d i t e n t u k a n , ka r e n a s i f a t da r i S S H L y a n g s e m b u h se n d i r i s e c a r a c e p a t de n g a n p r e s e n t a s i 3 1 % - 8 9% [4]. Me skipun de mikia n, hasil ya ng dida pat dari pe nelitian ini me mbuktika n ef isie nsi dari ITS seba gai tera pi sa lvasi, meskipun jumlah pa sie n hanya se dikit, namun sejala n de nga n la pora n yang diter bitkan . Ta b e l 5 – r a t a - r a ta P TA pa d a ta h a pa n y a n g be r be d a m e n ur u t k e b i a sa a n me r o k o k ( n = 3 6 ) . Ya (n=9) PTA awal, rata-rata (dB)±SD PTA pertama, rata-rata(dB) ±SD PTA setelah salvasi, Rata-rata (dB)±SD Delta PTA, rata-rata(dB)±SD
Ti d a k (n=27)
62.2±15 .1 54.4±15 .5 51.1±17 .8
67.9 ± 17.8 61.3 ± 16.9 45.4±1 8.1
3.3±6. 6
15.9 ±16.0
0.39 0.29 0.41 <0.05
p- v a l u e Me r okok
Pasie n SSHL yang ga gal me nda pat per baikan pendengara n de nga n tera pi sistemik prime r telah dilaporka n oleh be berapa pe nulis [16–20]. Demikian juga dalam penelitian kami pemulihan setelah terapi salvasi adalah baik dan mirip dengan apa yang telah disebutkan pada laporan. Tingkat pendengaran
10
yang tidak berubah tercatat pada pasien yang menolak terapi salvasi adalah indikasi dari peran pengbobatan intratimpani dalam memulihkan fungsi pendengaran , w a l a u p u n h a n ya se d i k i t .
Sebuah penemuan yang menarik muncul dari penelitian prospektif ini yaitu hubungan antara kebiasaan merokok dan respon terhadap pengobatan. . beberapa penelitian telah menunjukkan hubungan perokok dengan risko penurunan pendengaran yang signifikan [21,22]. Konsumsi rokok telah dilaporkan menjadi agen ototoksik (efek nikotin) dan menjadi penyebab tidak langsung iskemia di koklea melalui produksi carboxyhemoglobin , vasospasme, peningkatan kekentalan darah, dan hubungannya dengan atherosklerosis pembuluh darah [23]. Penelitian ini menunjukkan hubungan gagalnya terapi salvasi intratimpani dengan merokok, dan data ini harus diingat ketika merencanakan terapi salvasi pada pasien yang merokok selama masa pengobatan .
Lebih lanjut, analisis data menunjukkan bahwa pasien yang diobati dengan steroid sistemik sebelumnya mempunyai beberapa manfaat dalam hemostasis telinga dalam, meskipun tidak ada perbaikan . Semua pasien yang diobati dengan steroid terlebih dahulu mempunyai respon yang lebih baik terhadap terapi salvasi dengan respon yang lebih baik dibandingkan pasien yang mendapat terapi diuretik atau antiviral sebelumnya. Efek steroid dan sensivitas telinga dalam dibandingkan merokok dapat menunjukkan efek steroid intratimpani yang berhubungan dengan pasokan pembuluh darah, dan oksigenasi dalam telinga dalam.
Seperti yang ditunjukkan pada penelitian sebelumnya [2], hasil dari pengobatan tidak terlalu terkait dengan waktu dimulainya terapi setelah penurunan pendengaran. Hal ini juga dicatat oleh Parnes et al. yang mengobati 37 pasien yang mempunyai beberapa gangguan telinga dalam [10] dan oleh HO et al. pada 39 kasus [24]. Tidak adanya hubungan antara awal pengobatan dan hasil sangat penting, hal ini memungkinkan ITS sebagai terapi salvasi juga setelah penundaan beberapa hari dan pemeriksaan lebih lanjut seperti radiologi.
5.
Conclusions
Our data showed t h a t a salvage t r e a t m e n t with i n t r a t y m p a nic d e x a m e t h a s o n e should be suggested to all pa t ie nt s who failed the first systemic t r e a t m e n t . The unchanged hearing of the group of pa t i e n t s who refused salvage therapy is indicative of some important action of the steroids into the cochlear recovery process. The systemic steroid therapy d o n e before t h e s a l v a g e t r e a t m e n t s e e m s to e x e r t a protective role for the inner ear, as shown by our series. On the contrary the smoking habit is a negative prognostic factor in the hearing recovery. We agree with the last recommendation of the American Academy in the field of SSHL [25] t h a t considers the salvage intr a tympa nic steroids as a recommended therapy.
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