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Three Part Question

In [an adult with sudden idiopathic hearing loss] is [early steroid therapy better than no steroids] at improving [time to recovery and outcome]?

Clinical Scenario

A 35 year old man presents to the emergency department with an 18 hour history of a right sided sudden hearing loss. Examination does not reveal a cause. A diagnosis of idiopathic sensorineural deafness is made. Your consultant suggests that a course of prednisolone might be of benefit. You discuss this with the registrar in audiological medicine who does not support this approach. You wonder who is right.

Search Strategy

Medline OVID 1966-June week 4 2005.
Embase OVID 1980- 2005 week 27
Cochrane Library Issue 2 2005.
Medline: [{exp hearing loss, sudden/ OR sudden$ adj deaf$.mp. OR sudden adj hearing adj loss.mp.}] AND [{exp steroids/ OR steroid$.mp. OR exp glucosteroids/ OR glucosteroid$.mp. OR corticosteroid$.mp }]. LIMIT to human, English language and all adult.
Embase: [{exp sudden deafness/ OR sudden$ adj deaf$.mp. OR sudden adj hearing adj loss.mp] AND [{exp steroid/ OR steroid$.mp OR exp glucocortcoide/ OR glucosteroid$.mp. OR exp corticosteroid/ OR corticosteroid$.mp.}] LIMIT to human, English language and adult <18 to 64 years> or aged <65+ years>)
Cochrane: Steroids [MeSH all fields] AND hearing loss, sudden [Mesh all fields]

Search Outcome

175 unique papers were found papers were found of which 5 directly answered the question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Wilson WR and Byl FM, 1980, USA	Patients attending within 10 days of a 30 decibel sudden sensorineural hearing loss in at least 3 contiguous frequencies for whom no cause could be found.	Prospective double-blind trial, combining the results from two centres	Recovery of 50% of the original hearing loss	20/33 (61%) in steroid group and 11/34 (32%) in placebo group: significant 0.01	Not randomised Poor design Not analysed with intention to treat Short follow-up Different steroids used
Moskowitz D et al, 1984, USA	Patients attending a private ENT clinic over a 10 year period with idiopathic sensorineural hearing loss (n=36)	Prospective cohort	Recovery of 50% of the original hearing loss	24/27 (89%) with steroids and 4/9 (44%) without: statistically significant 0.005	Not randomised No power study Sample size not calculated Not blinded Small numbers
Cinamon U et al, 2001, Israel	41 patients with unilateral sensorineural hearing loss. Randomised to prednisoloneo placebo tablets, carbogen inhalation or room air	PRCT	Early audiometric outcome	No difference
			Late audiometric outcome	No difference
Kitajiri S et al, 2002, Japan	78 patients with sudden sensiorineural hearing loss. Normal therapy vs normal therapy plus steroids	Controlled trial	Recovery rate	81% vs 79%	Non randomised before and after design
			Time from start of therapy to improvement	3.9 days vs 3.7 days
Chen CY et al, 2003, Taiwan	318 patients presenting with sudden unilateral sensorineural hearing loss over ten years Steroid therapy vs none (patients who refused)	Observational study	Recovery of hearing (pure tone average) in severe cases	Better in those on steroids	Non randomised study describing outcomes in a centre committed to steroid therapy
			Recovery of hearing (pure tone average) in milder cases	No difference

Comment(s)

Idiopathic sudden sensorineural hearing loss has a high (50-70%) spontaneous partial or complete recovery rate. Therefore for a given treatment to be considered effective a very high success rate must be demonstrated. The studies shown are all small and offer no convincing evidence of recovery rates above those expected.

Clinical Bottom Line

Current evidence does not support the early use of high dose steroids in idiopathic sensorineural hearing loss.

References

1. Wilson WR, Byl FM, Laird N. The efficacy of steroids in the treatment of idiopathic sudden hearing loss. A double blind clinical study. Arch Otolaryngol 1980:106(12);772-776.
2. Moskowitz D, Lee KJ, Smith HW. Steroid use in idiopathic sudden sensorineural hearing loss. Laryngoscope 1984:94(5Pt1);664-6.
3. Cinamon U, bendet E, Kronenberg J. Steroids, carboden or placebo for sudden hearing loss: a prospective double-blind study. European Arch Oto-Rhino-Laryngol 2001;258:477-80.
4. Kitajiri S, Tabuchi K, Hiraumi H et al. Is corticosteroid therapy effective for sudden-onset sensorineural hearing loss al lower frequencies. Arch Otolaryngol Head Neck Surg 2002;128:365-7.
5. Chen CY, Halpin C, Rauch SD. Oral steroid treatment of sudden onset sensorineural hearing loss: a ten tear retrospective analysis. Otology and Neurotology 2003;24:728-33.