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08.12.2015
Definitions of sudden sensorineural hearing loss (SSHL) vary widely, depending on severity, time course, audiometric criteria, and frequency spectrum of the loss.
Only about 10 to 15 percent of people with SSHL will ever know what actually caused their loss. Sudden sensorineural hearing loss most often occurs a week or so after a person has experienced a viral or bacterial infection, such as a head cold or the flu. Estimates of the annual incidence of sudden sensorineural hearing loss range from five to 20 cases per 100,000 people. Objective: The purpose of this study was to observe the effectiveness of immune modulator –Inosine Pranobex (Isoprinosine) in the treatment of sudden sensorineural hearing loss of suspected viral origin. Setting: This study was performed in the Clinic of Otorhinolaryngology in the Medical Institute of Ministry of Interior, Sofia.
Patients: The study included 28 patients with sudden hearing loss of suspected viral origin, divided randomly into two groups.
Intervention: The first group of 14 patients was treated with corticosteroids and vasodilators.
Main Outcome Measures: The patients passed precise otorhinolaryngological examination, pure tone audiometry, speech audiometry, stapedial reflex testing, ABR, CT scan, hematological testing –complete blood count (CBC) and sedimentation rate, biochemistry and serologic testing for syphilis. Results: We compared the two groups before and after the treatment regarding mean hearing level at each frequency, speech reception threshold improvement, and tinnitus and balance complaints.
Conclusions: Administration of a combination of corticosteroids, vasodilators and immune-modulator should be recommended for treatment of patients with sudden sensorineural hearing loss. Sudden sensorineural hearing loss is defined as 30 dB or more sensorineural hearing loss over at least three contiguous audiometric frequencies occurring within 3 days or less. The vascular courses include vasospasm, thrombosis, embolism, hemorrhage, hypercoaguability and rheologic abnormalities. The viral-vascular combination theory suggests that a viral infection initiates a hypercoagulable state secondary to the effect of viruses on the vascular system. The therapy that has been proven to be effective in the treatment of sudden sensorineural hearing loss is the etiologic based one.
28 patients of either gender (24 male and 4 female), aged between 12 and 47 years with sudden hearing loss were enrolled in the study.
Pure tone audiometry was performed weekly during the first 14 days of the treatment, 4 weeks after the onset of the disease and 2 months later.
After 14 days of the treatment in the Clinic of Otorhinolaryngology and 2 weeks more at home, the results were as following in Table 2. We compared the two groups before and after treatment regarding mean hearing level at each frequency, speech reception threshold improvement, and tinnitus and balance complaints.
It is not surprising that the cochleovestibular blood supply may be affected by circulatory disorders such as embolic phenomenon, thrombosis, vasospasm and hypercoagulable or high viscosity states resulting in sudden sensorineural hearing loss. Administration of a combination therapy of corticosteroids, vasodilators and immune-modulator should be recommended for treatment of patients with sudden sensorineural hearing loss of suspected viral origin. Over 360 million people (5% of the world’s population) suffer from disabling hearing loss, of which 32 million are children, states WHO. Hearing loss is classified according to the degree of deafness in the person, say ENT specialists.
ENT specialists claim that acquired hearing loss can occur due to viral infections, allergies, accidents, impacted earwax etc.
According to the American Speech-Language Hearing Association there are three basic types of hearing loss: conductive hearing loss, sensorineural hearing loss and mixed hearing loss.
The first step towards diagnosing hearing loss is a physical examination of the affected ear when the doctor checks for possible inflammation from an infection or earwax accumulation. Depending upon the person’s lifestyle, listening needs, hearing concerns and hearing aid evaluation report, an appropriate hearing aid is advised. Hearing aids or cochlear implants need to be followed by auditory training to help maximise hearing abilities.
Indian corporate hospitals have been providing the latest treatment options for hearing loss. Indian corporate hospitals also have specialised clinics for hearing loss that are equipped with full-fledged ENT equipment and specialised operation theatres. Importance Can be a sign of serious diseases Can be seen in other specialties Hard to diagnose because it integrates several organs and systems together and the underlying cause is not clear. INTRODUCTION Dizziness is a common symptom that accounted for more than 5.6 million clinic visits in the United States 15% to 30% of patients, most often women and the elderly, will experience dizziness severe enough to seek medical attention at some time in their life.
Physiology Function of vestibular system: “Input” resulting from a stimulus that needs to be corrected through the vestibular system such as falling down. It is not surprisingly that vestibular lesion cause: Imbalance posture and gait imbalance visual distortion (oscillopsia ). VERTIGO The word "vertigo" comes from the Latin "vertere", to turn + the suffix "-igo", a condition = a condition of turning about).
Vestibular Neuritis Viral infection of vestibular organ Affect all ages but rare in children – mostly adults Affected patient presents acutely with spontaneous nystagmus,vertigo and nausea &vomiting stays for hours and sometimes days. BPPV The most common cause of vertigo in patient > 40 years Repeated attacks of vertigo usually of short duration less than a minute. BPPV Diagnosis History Dix-Halpike maneuver : putting the patient in a certain position to stimulate the attack, and to look at the eye (causes nystagmus) to see which canal is mostly affected by trying to push the particles inside the canal and inducing the sense of dizziness.
Migraine associated vertigo (MAV): common in females between the ages of 20 to 35 Classical presentation, preceded by aura or without aura then headache followed by couple of hours of dizziness. Acoustic tumor Benign tumor Arise from vestibular division of VIII Clinical presentation: Unilateral tinnitus Hearing loss Dizziness The only way to differentiate between Meniere's disease and the Acoustic tumor is by MRI. A commonly used criterion to qualify for this diagnosis is a sensorineural hearing loss of greater than 30 dB over three contiguous pure-tone frequencies occurring within a three-day period. When they see their family physician, it is often mistakenly confused with a common middle-ear infection and treated thusly. No single treatment has been shown to be unequivocally effective in treating patients with SSHL. The second group of 14 patients was treated with corticosteroids, vasodilators and immune modulator - Isoprinosine.


The patients with vertigo passed observation for nystagmus, static and kinetic tests, posturography and electronystagmography (ENG). 4 patients recovered totally, 19 patients improved their hearing with 20 dB and 5 patients showed no improvement. The phylogenetically newer portion of the inner ear, which includes the cochlea and saccule, is relatively more susceptible to various agents than the pars superior.
Experimental studies have shown that the ganglion cells are the most sensitive to ischemia, while the pathologic data indicates that the organ of Corti, stria vascularis and tectorial membrane are the predominant structures affected in cases of sudden sensineural hearing loss (7). One of the mechanism by which hearing loss develops is through changes in cellular immunity.
We used a combination of medicines, according to the viral-vascular etiologic theory (8-10).
8 patients noted their hearing loss upon first awakening in the morning, 2 patients – after stress situation, 18 patients had in their history a viral upper respiratory infection as 2 patients were in contact with varicella – infected persons, 1 woman was with rubeolla and 15 patients had in their history symptoms of influenza.
Ophthalmologic, neurological and rheumatologic consultations were carried out to rule out systemic vasculitic diseases. The vascular etiologic theory is favored because of the sudden nature of the onset of hearing loss. This type of treatment result in earlier hearing recovery and less extensive cochlear destruction compared to steroids and vasodilators.
Therapy of idiopathic sudden sensorineural hearing loss: antiviral treatment of experimental herpes simplex virus infection of the inner ear.
Oral steroid treatment of sudden sensorineural hearing loss: a ten-year retrospective analysis.
Treatment of idiopathic sudden sensorineural hearing loss with antiviral therapy: a prospective, randomized, double blind clinical trial. Recovery of hearing: results of delayed medical treatment in patients with idiopathic sudden hearing loss. A person who is not able to hear as well as someone with normal hearing – hearing thresholds of 25 dB (decibels) or better in both ears – is said to have hearing loss.
It needs to be treated at the earliest to lead a quality life,” said Dr Mohan Jagade, head of the ENT department at Sir JJ Group of Hospitals, Mumbai.
Damage can occur with long-term exposure to loud noises, or from a short blast of noise, such as a gunshot.
Other recreational activities with dangerously high noise levels include snowmobiling, motorcycling or listening to loud music. Temporary effects on hearing — ringing in the ear (tinnitus) or hearing loss — can occur if the person takes very high doses of aspirin, other pain relievers, anti-malarial drugs or loop diuretics.
This is followed by general screening tests where the response of the patient to certain sound volumes is monitored. It is a small electronic device generally used for people with severe, irreversible hearing loss.
Dr Marfatia said that India has a large population of people with hearing loss and therefore research is being conducted to help these patients lead a quality life.
In the private sector, the cost is around Rs 6 lakh,” said Dr Rajeev Nerurkar, ENT surgeon at Bombay Hospital, Mumbai.
An “output” results from responses of the vestibular system to the input such as the eyes, cerebellum.. B) central vestibular loss – above the level of the vestibular nerve and towards the brain. Patient requires only symptomatic treatment It takes 3 weeks to recover from vestibular neuritis Diagnosis – no other tool other than history. Pathophysiology: Calcium carbonate particles shear off and enter the canal leading to brief episodes of vertigo.
Provoked by cert" title="BPPV The most common cause of vertigo in patient > 40 years Repeated attacks of vertigo usually of short duration less than a minute.
Treatment: repositioning of the head to get particles out of the canal (Epley or particle repositioning maneuver). Fortunately, the vast majority of cases of sudden hearing loss are unilateral, and the prognosis for some recovery of hearing is good.
Early treatment for SSHL can save your hearing, so it’s important to see a hearing healthcare professional for immediate evaluation. However, the anti-inflammatory properties of corticosteroids make them a common treatment option. The findings in animal models of hearing loss of vascular origin are of extensive cochlear fibrosis and ossification. The otorhinolaryngologic examination included otoscopy, anterior rhinoscopy and pharyngoscopy. The treatment of sensorineural hearing loss often proves to be frustrating to the clinician as, in the majority of cases, the etiology is unknown and the underlying disease process is irreversible. The underlying pathophysiology can be explained by the occurrence of sudden anoxic injury to the cochlea. The recovery is significantly related, as well, to onset of hearing loss and audiogram type.
The other confirmatory tests include tuning fork tests and audiometer tests to evaluate which part of the ear is affected. The centres also offer the latest auditory verbal therapy to hearing impaired children, to help them learn to listen and speak,” added Dr Marfatia.
More frequently the patient might complain of nausea when smelling something in the car or while driving around. Although spontaneous recovery does occur, SSHL is a medical emergency and requires immediate medical evaluation. Evaluation should include a careful history and physical examination, including diagnostic audiometric testing. Most people do recover at least some of the hearing lost, but about 15 percent have symptoms that continue to worsen. Sudden hearing loss may be idiopathic but also significant differential diagnoses must be considered.


Additional evidence of that type of etiology is indicated by the fact that patients had substantial hearing improvement with mono steroid treatment. Otorhinolaryngologists make efforts to treat the sudden sensorineural hearing loss according to the established etiologic courses as viral, vascular or viral-vascular combination (11-15). Effects of anoxia result in changes in the cochlea microphonics with loss of the action potential. So the combination of immune-mediator (Isoprinosine), corticosteroid (Methylprednisolon) and vasodilator (Cavinton) proved to be effective in treatment of sudden sensorineural hearing loss. Treatment aimed at the possible etiologic agent might be beneficial only in the very early phase of the hearing loss.
It has little receptors that are implanted inside the skin, near the ears, to make it possible for the patient to hear,” said Dr Marfatia.
People need hard surfaces to get the full effect of their proprioception or it will feel like they are walking on sand “ shaky grounds”. The physical stimulus (input) will be transformed into a biological stimulas in the brain stem which will in turn be sent afterwards to the corresponding areas in the vestibular system. For those patients with resultant permanent hearing loss, hearing technologies such as hearing aids and implantable devices can often help. The audiometric patterns from the pure tone audiometry were variable with mild to profound hearing losses.
Support for a viral theory is the antecedent history of a viral upper respiratory infection and epidemic of viral diseases, such as parainfluenza, mumps, varicella, rubeola, and adenovirus infections.
Despite restoration of the cochlea blood flow, loss of endocochlear potentials may be irreversible after 30 minutes (4). The person has to undergo a hearing aid evaluation and consultation by an audiologist,” said Dr Hetal Marfatia, ENT surgeon at KEM Hospital, Mumbai.
Transform of the forces associate with head acceleration and gravity into a biological signals that the brain can use to develop subjective awareness of head position in space (orientation) produce motor reflexes that will maintain posture and ocular stability to prevent the feeling of dizziness.
The patients, included in our study, did not have in their history any of these well-established courses or mentioned upper diseases.
The entire examined group had tinnitus, which preceded the hearing loss by several hours with usually a roaring quality.
Patients treated by the same course of corticosteroids and vasodilators and in addition immune-modulator – Isoprinosine – 3g per day (3x2 tabl.) for a period of 5 days. Histological analyses of temporal bones from patients who suffered from sudden sensorineural hearing loss displayed atrophy of the organ of Corti, stria vascularis and tectorial membrane. Hearing recovery in profound losses tends to occur in the low tones, which correlates with involvement at the apex of the cochlea rather than the basal end. Being pushed from behind will lead to all the previous systems to work together to maintain balance.
If there is a defect in the input and output processes the patient will present with vertigo, defects in the gait or ocular distortions. Etiology of the sudden sensorineural hearing loss includes as well viral, vascular and viral-vascular combination.
The arterial supply to the cochlea is such that the basal turn is fed first by the main cochlear artery with the cochlear apex fed last. Patients in our study reported antecedent history of upper respiratory infection within a month or less of onset of the hearing loss. Haemaglutination and slaging of blood may occur when virus particles attach to erythrocytes. The findings in animal models of hearing loss of vascular origin prove extensive cochlear fibrosis and ossification. The viruses of mumps, measles, herpes simplex, herpes zoster, adenoviruses and influenza deserve particular attention in view of their clearly demonstrated etiologic role in sudden sensineural hearing loss.
In the histological findings the organ of Corti was absent throughout the cochlea; the stria vascularis was atrophic throughout.
The spiral ganglion cells were considerably decreased in the basal turn and somewhat decreased in the apical turn.
Patients with measurable speech discrimination scores on presentation uniformly improved with treatment, even if their pure tone-average was profound. The cutaneus lesions associated with herpes zoster infections make this form of viral neurinitis and ganglionitis relatively easy to diagnose clinically and to relate etiologically the sudden sensorineural loss to the virus (6). Presence of vertigo is associated with more severe losses and represents a greater insult to the labyrinth and those patients recover worse.
The patients with vertigo passed observation for nystagmus, static and kinetic tests, posturography and ENG. The vascular endothelium is invaded and inclusion bodies may be seen in the endothelial cells in viral diseases. Application of combination of steroid, vasodilator and immunostimulater significantly improves the recovery outcomes in cases of sudden sensorineural hearing loss.
There is, however, overall hyperemia at the site of inflammation and total effective blood flow may not be altered.
Infiltration of lymphocytes, plasma cells, macrophages and polymorphonuclear leukocytes occurs. Necrosis of neuroepithelium may occur and is indicated by hyperchromatism, fragmentation and lysis of nuclei (5).
The most common route of access of viral particles to the inner ear is a viremia in the early phase of viral illness in which virions are deposited within the membranous cochlea. Isoprinosine was used to support the mechanism of immune answer to the foreign agent – the virions and to reduce the damage of the cochlea structures.
Medications like Acyclovir may be unhelpful when the cause is a virus that is not in the herpes family, that’s why Isoprinosine is favored. The corticosteroids, as well, have an anti-inflammatory effect on the organ of Corti and the microvasculature.




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