HomeAnswersOtolaryngology (E.N.T)sensorineural hearing lossWhat is the best treatment for asymmetric hearing loss and tinnitus?

Intratympanic steroid injection shows no improvement in my hearing loss and tinnitus. Why?

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The following is an actual conversation between an iCliniq user and a doctor that has been reviewed and published as a Premium Q&A.

Medically reviewed by

Dr. Vinodhini J.

Published At August 21, 2020
Reviewed AtAugust 17, 2023

Patient's Query

Hello doctor,

I am 56-year-old male and have been diagnosed with asymmetrical hearing loss and tinnitus of the left ear. I did not notice any ongoing hearing problems. Four months back I had my ears cleaned. After having them cleaned, I felt that the left ear is still plugged. About a week or so later, I woke up to horrible tinnitus. By two months back, my hearing was tested and confirmed hearing loss. An MRI with contrast showed no acoustic neuroma. I was also given a Methylprednisone pack for a week which was poorly tolerated and the dosage had to be lowered. About two weeks later, the hearing returned to normal but then about two weeks after it went back to hearing loss with tinnitus and the feeling of clogging on and off. My doctor is now giving me intratympanic injections of Dexasone steroids. I have had two injections so far. But the results have not been great. I am worried about what could be causing this. Nobody seems to know other than perhaps from an infection that got into the inner ear. I am afraid that something is wrong and I hope it would not affect my other ear or vision. I have never had anything like this before.

Hi,

Welcome to icliniq.com.

Hearing loss of sudden onset can be due to various causes. The most common of them being termed sudden sensorineural hearing loss. There are various theories to the different causes of this type of hearing loss and there is no evidence to prove all of them. The most important aspect of this entity is its initiation of the treatment. If there is clinical evidence of sudden sensorineural deficit through pure tone audiometry, the treatment has to be initiated within the first 48 hours of the diagnosis. It has been observed that any form of treatment given after this time frame is not as efficient and the degree of hearing loss may be irreversible. The guidelines for treatment of sudden sensorineural hearing deficit varies depending upon the protocols of the institution. We usually give a course of oral antivirals, plasma expanders, low molecular weight heparin, i.v steroids, hyperbaric oxygen therapy all initiated on the same day. Intratympanic injections are also an alternative and can be considered having equal results as far as efficiency is concerned. Usually patients who have been initiated with intratympanic steroids after 48 hours have a less than 30 percent chance of getting back 50 percent of their hearing. Around 70 % of patients who have been given timely treatment within the first 48 hours of onset have got back 80 % of hearing, but the status are not consistent. I would advice you to wait until a total of six sessions are over and then get a repeat audiogram done to see where we stand and then things can be managed accordingly. There is no temporal association of the hearing loss to the other uninvolved ear or vision for that matter.

I hope this helps.

Patient's Query

Hello doctor,

I do not think perhaps the response was quick enough with respect to enough treatment. However, I did take Medrol dose pretty quickly after the actual severe tinnitus and initial hearing loss occurred. I just could not handle the higher levels of the oral dose. None of the other treatments you mentioned were done. The hearing got back to normal then dropped off. And now I am on the injections and my ENT doctor wants to do four. I just do not understand why the hearing is getting back to normal and dropped off again? Methylprednisone is very hard on me. It is increasing my resting pulse upto 90s and also increasing the BP. Even the injections cause similar but less severe side effects. Some days, I hear better than others. Some days there is more tinnitus or clogging. It changes from day to day and sometimes throughout the day. It is uncomfortable and make me feel imbalanced with different pressure and hearing in the two ears.

Hi,

Welcome back to icliniq.com.

High dosage of oral steroids can be taken, but they create a lot of tummy upsets and many people cannot handle them. At the same point of time, lower dosage of steroids are not found to be very effective. It should be understood that there is no specific head-on treatment for this particular condition and hence so many medications are given at a time. It is almost impossible to ascertain the possible cause of the hearing loss as well. Please also note that eustachian tube dysfunction can also be somewhere involved contributing to the conductive component of hearing in addition to the already existing sensorineural deficit. The use of steroids usually temporarily masks the conductive component and transiently one starts hearing better for a while after which the problem starts again. If there are ongoing nasal allergies, it has to be treated accordingly, as at least the eustachian tube dysfunction and its conductive component can be treated which will results in a 20 percent hearing advantage. Four doses of intratympanic steroids are not going to do too much good and you might require a few more doses as well. It is the fluid in the middle ear which can be the reason for the unsteadiness as increased middle ear pressure gets transmitted to the vestibule causing feeling of vertigo in some patients. As the steroids get absorbed, the fullness and vertigo should reduce with time. Let us wait and watch how much improvement has been thereafter four doses of intratympanic steroids and get a hearing assessment done. Even if there is a 10 percent improvement, I would advice you to go ahead for two more sessions with the hope that the hearing might improve.

I hope this helps.

Patient's Query

Hello doctor,

I had my third intratympanic steroid injection to my left middle ear yesterday. Several hours after the injection my ear started feeling better. Much less tinnitus, no clogged feeling, and better hearing. However, by the evening and today all the bad symptoms are back. It seems like shortly after I am injected things get better then fall off again. Even my right ear feels a little full but the ent said my hearing was normal in my right ear and it could be allergy. My hearing test revealed that my left ear improved by 5 decibels from last week which was my second injection. I must say that I was excited after my last injection which was yesterday because it seemed like things were improving but now have fallen off again. I do not know what to expect or why it gets somewhat better than falling off so quickly.

Hello,

Welcome back to icliniq.com.

Apologies for the late reply. There is absolutely nothing that you need to worry about. This transient increase in hearing is something that gives a fall feeling of hearing well and is present in all patients who have undergone injections with dexa. I would suggest you to wait for at least 3 months, and I would also suggest you to take at least 6 sessions of intra-tympanic steroid injections. I would also want to consider a eustachian tube catarrh in your case which could have been responsible for the recurrent conductive hearing loss. It would be better if you start nasal sprays containing fluticasone propionate and azelastine hydrochloride 2 puffs in each nostril 2 times a day for the next 3 months. Along with the nasal spray plz take an Allegra 120 mg one tab in the morning and evening after food for the next 20 days. I have hopes that there will be hearing improvement of at least 70 percent in the affected ear. If you can request your doctor to give a total of 6 sessions of intra tympanic steroids. Besides this, you can also go for acupuncture. Their temporal association towards the improvement of the problem is not known, I do not have facts and figures, but yes I have had a few patients who did improve taking this modality of therapy as well.

Please let me know if there is anything more I can help you with.

Patient's Query

Hello doctor,

I know I have been out of contact for a while. I had my steroid injections and about two weeks after the last injection my hearing in my left ear was normal and almost as good as my right ear. Everything seemed like a great success. A few weeks later, my ear started having episodes of fullness and not hearing as well. I went to my ENT a couple of days ago. He found my hearing in the left ear was off by 15 decibels. However, he said while allergies could be causing some of it, the hearing test shows nerve damage. He suggested we start the injections again. I have an appointment to start injections if my hearing is not better. The doctor does not really know why this repeats. He asked about autoimmune disease symptoms throughout my life but I really do not have any and he said often bloodwork is not a reliable indicator because some people show markers and have no issues and some show no markers and have symptoms. The dexamethasone injections are not great for me because hours after I always get a rapid heartbeat for several hours but my doctor said there are not really any other medically proven treatments. Oral steroids make me feel even worse. I am very nervous about what is causing this and I cannot have steroid shots all the time to help it. I use Flonase and Allegra and sometimes it seems to help and other times it does not.

Hi vincent!Wonderful to hear from you again.Yes, most of what you have been told by your ent is right and query regarding autoimmune conditions is very much valid. As far as your sensorineural hearing loss is concerned, steroids are the main stay of the treatment, but there is a catch here. Considering that its been a while since the onset, this deficit of 15 db corresponding to the neural component, according to me will most likely persist for life and giving steroids now is not going bring a major benefit to the hearing improvement. Yes, initially you might feel that the hearing has gone back to normal as steroids are very potent anti inflammatory medications which transiently do show some effect. However, the this small deficit usually persists in many of the patients i have seen. Considering the pros and cons as far as steroids are concerned, my opinion would be not to continue any more steroids as it can cause other short term and long term side effects as well. We need to consider those aspects as well and if the side effects outway the benefits, giving steroids wont be my choice in the current scenario. An auto immune condition involving can also be present which you may not be aware of, but i would want to consider this entitiy id you find that the hearing loss has been slowly detiorating and there has been clinical and audiological evidence of further increase in the hearing loss. Furthermore, the conductive component (due to eustachian tube dysfuction secondary to nasal allergies which has caused the aural fullness) contributing to the hearing loss should not due ignored and nasal sprays (atleast) should be used regularly atleast for a total of 6 months. Intermittent usage of the nasal spray is not going to bring desired effect. I personally do not advice any systemic medication (allegra) on a long term basis considering its side effects (ecg changes that fexofenadine creates). Dont worry too much about that 15db loss as this amount of sensorineural loss can also be related to age onset hearing loss as well. I hope this answers your query. Please do let me know regarding any query that you have. Warm regards

Same symptoms don't mean you have the same problem. Consult a doctor now!

Dr. Bhadragiri Vageesh Padiyar
Dr. Bhadragiri Vageesh Padiyar

Otolaryngology (E.N.T)

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