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Episodic vertigo is the most common reason for patients to seek and pursue treatment for Meniere’s disease. If episodes of vertigo persist despite changes in diet, medication called diuretics can be helpful. Other options are available and include transtympanic decadron or gentamicin, decadron perfusion of the inner ear, endolymphatic sac surgery, vestibular neurectomy and labyrinthectomy surgery.
Steroid treatment of the inner ear may offer beneficial effects for the symptoms of Meniere’s disease.
A powerful way of delivering steroid to the inner ear is by injection into the middle ear through the tympanic membrane. There is a 1% chance of a persistent 1 mm perforation of the eardrum at the injection site.
This form of treatment involves injection of medication through the eardrum into the middle ear. A shunt is placed in the endolymphatic sac, a reservoir for endolymph, to shuttle fluid out of the sac and into a cavity created in the mastoid.
Step 3: A mastoidectomy is done exposing the semicircular canals, venous sinus, and dura covering the brain.
Step 4: Spinal fluid is drained and the brain relaxes, exposing the trigeminal nerve (responsible for the conduction of facial sensation), the vestibulocohlear nerve (hearing and balance), and the facial nerve. This is an operation to divide the balance nerves and interrupt the connection between the inner ear and the brain.
The middle fossa approach is the least commonly used and involves an incision above the ear followed by removal of bone over the brain. Another approach is the retrolabyrinthine approach, which involves incisions behind the ear similar to the endolymphatic shunt procedure.
A third approach is the suboccipital approach, which involves an incision further behind the ear and removal of bone over the covering of the brain. Learn how Metropolitan NeuroEar Group gives back to the community through numerous philanthropic efforts. Sudden hearing loss is associated with vertigo in between 20 to 60% of patients (Rambold et al, 2005).
There is presently no convincing evidence that any oral or intravenous treatment for idiopathic SHL is better than placebo. According to Zhang et al (2015), in China, in a study of about 250 people, SHL is commonly seen in middle aged people. In our medical practice in Chicago, of the 54 SHL patients in our database, the median age was 60. Some authors maintain that vascular disease is the most likely cause (Rambold et al, 2005). Also supporting the idea that vascular causes are important, is the observation that SHL following surgery outside the inner ear, is most commonly associated with cardiopulmonary bypass surgery (Page and Peters, 2015). It is better to have a minor hearing loss, no vertigo, and rapid treatment (within 1 week). If you have experienced a SHL, you might be able to follow your hearing loss using a cell-phone hearing app. Occasionally, unfortunate persons experience hearing loss on the opposite ear, a year or more later. Bottom line: At this writing (2016) almost everything looks either ineffective or slightly effective. We presently suggest that most people start on oral steroids quickly (preferably same day), check and follow their hearing with a cell-phone hearing app, and if the hearing loss is severe, consider the more aggressive steroid regimens outlined below. Ng et al (2014) performed a metaanalysis of intratympanic steroids and reviewed 187 randomized trials, but found only 5 that met their inclusion criteria.
A slightly better recent double-blinded study of only 60 patients split into 3 groups (Battaglia et al, 2008) indicated that patients treated with a combination of intratympanic dexamethasone and high dose steroids are more likely to recover hearing than those treated with high dose steroids alone.
Dallan et al (2011) reported that intratympanic steroids had identical results to a mixture of oral steroids, pentoxifylinne, low molecular weight heparin and vitamin E.
Kim et al (2015) compared use of both IT and oral steroids to patients with either one alone -- this was an unblinded retrospective study -- thus the level of evidence is low.
Steroid injections through the ear drum are more costly (in the USA) than the alternatives of no-treatment or oral steroid treatment.
Steroid injections through the ear drum are prone to produce long lasting perforations of the ear drum. SHL is a very disturbing experience and there have been many unusual protocols and drugs advocated. There are several protocols involving increasing blood flow or oxygenation: We think that the oxygen part of these treatments is a placebo. These studies are implausible -- , is is difficult to see why this treatment should work and we would not suggest anyone go forward with this until it confirmed with a placebo-controlled and adequately powered study.
Haberkamp and Tanyeri (1999) noted that while numerous treatments have been studied aiming to improve blood flow, such as carbogen inhalation or stellate ganglion block, all remain controversial or simply lack convincing evidence of efficacy. Recently, Kim et al (2011) compared steroids +carbogen+lipoprostaglandin E1 to several other variants including steroids alone, but not including placebo, They found a small advantage for the combination group. At the University of Freiburg, exploration of the middle ear and patching is recommended for patients with SHL. Similar results are reported in another German Otolaryngology Dept, in Cologne (Kampfner et al, 2013). Lipo-prostaglandin E1 in combination with steroid therapy is effective for treatment of sudden sensorineural hearing loss in Korean patients with Type 2 diabetes. Coelho DH, Thacker LR, Hsu DW.Variability in the Management of Idiopathic Sudden Sensorineural Hearing Loss.
Ng JH1, Ho RC, Cheong CS, Ng A, Yuen HW, Ngo RY.Intratympanic steroids as a salvage treatment for sudden sensorineural hearing loss? Kampfner D, Anagiotos A, Luers JC, Hüttenbrink KB, Preuss SF Analysis of 101 patients with severe to profound sudden unilateral hearing loss treated with explorative tympanotomy and sealing of the round window membrane.
Khan AS, Sheikh Z, Khan S, Dwivedi R, Benjamin E.Viagra deafness-Sensorineural hearing loss and phosphodiesterase-5 inhibitors. Linthicum FH Jr, Doherty J, Berliner KI.Idiopathic Sudden Sensorineural Hearing Loss: Vascular or Viral? Niu X and many others.The relationship between hearing loss and vestibular dysfunction in patients with sudden sensorineural hearing loss. Samuelsson AK, Hyden D, Roberg M, Skogh T.Evaluation of Anti-hsp70 Antibody Screening in Sudden Deafness. Wang Y1, Zhang L1, Zhang J1, Zhang X1, Zhang W1, Chen X1, Tang S2.The clinical analysis of bilateral successive sudden sensorineural hearing loss. Zhang X, Xu X, Ma W, Zhang Q, Tong B, Yu H, Xu M, Ren T, Rosenhall U, Anniko M, Duan M.Acta Otolaryngol.
Objetivo: Observar a evolucao da surdez subita em pacientes incluidos em diferentes grupos de tratamento, de acordo com o tempo de evolucao da doenca e com as contra-indicacoes para uso das medicacoes.
Objective: Determine the follow-up between pacients sudden sensorineural hearing loss treated in five different groups according to duration of disease and the drugs used for treatment. INTRODUCAOA surdez subita (SS) e definida como perda auditiva (PA) neuro-sensorial, igual ou maior que 30 decibel (dB), em 3 ou mais frequencias consecutivas, instalada num periodo de ate 3 dias (1).
Sudden sensorineural hearing loss is hearing loss that results from damage to either the cochlea or the cochlear nerve.
The inflammation that develops and certain kinds of cell-releasing enzymes that break up protein are initially destructive. We recommend treatment with prednisone at a very high dose initially that gradually tapers over nine days.
A more powerful way of delivering the steroid is to inject it into the middle ear through the tympanic membrane. Reducing or eliminating smoking is not only good for Meniere’s disease but also good for your health in general.
Administration of steroids to the inner ear is an attempt to reduce the inflammation within the inner ear.
From here, the steroid diffuses through the round window (one of the two openings into the cochlea of the inner ear)membrane and enters the inner ear. The medication, which is then taken up by the inner ear, destroys the hair cells of the inner ear.
Of the surgical options, this is the most conservative operation with minimal risk to hearing. The mastoid bone is entered and the endolymphatic sac is decompressed, meaning that the bony covering is removed. The ear may protrude slightly shortly after surgery, but it should return to its original position in two to three weeks.
90-95 percent of patients who undergo this operation for Meniere’s disease will not have another spell of vertigo.

The roof of the canal through which the balance nerves run is removed and the nerves are then divided. Nearly all patients with Meniere's disease will be vertigo-free after a labyrinthectomy.
Using a high-powered drill, the mastoid bone is entered and the semicircular canals are removed. Sanjay Prasad MD FACS is a board certified physician and surgeon with over twenty years of sub-specialty experience in Otology, Neurotology, advanced head and neck oncologic surgery, and cranial base surgery.
It is very rare that hearing loss occurs in both ears within 72 hours, so generally the timing definition of SHL alone leaves this situation out.
The wide spread probably depends on what you define as vertigo -- a little bit of dizziness, or a profound sensation of rotation.
Thus people who already have ear damage -- are more likely to have more hearing loss documented going forward.
Migraine is very common (15% of the population), far more so than SHL, and even occasional SHL due to migraine could be very significant. This is surprising as pregnancy is a risk factor for another cranial nerve syndrome -- Bell's palsy. MRI testing is not always ordered -- in fact, only about half the time (Coelho et al, 2011). Two meta-analysis studies of steroid treatment (Conlin and Parnes, 2007; Labus et al, 2010) suggested there was no benefit.
Hearing outcome is not altered differentially by IV steroids administered in the first day vs. This doesn't happen very often, and there is an obvious fallacy in that if hearing tends to improve anyway, improvements cannot necessarily be attributed to steroids.
This involved 10, 90-minute sessions of breathing pure oxygen at 2.2 atmospheric pressure in a chamber. Very few placebo controlled studies have performed of treatment of SHL and for this reason, there is presently a limited ability to determine what is the optimal treatment of SHL.
Rather, there are a few unusual institutions that perform surgery in spite of the general opinion that surgery is not indicated.
First, it is difficult to follow the logic described by the authors that led them to designated fistula or no-fistula. Even if there is an additional effect of adding prostaglandin, this is a very narrow population and it seems doubtful that this experience generalizes to others. Uramoto, et al, in a paper entitled Vitamin E and vitamin C in the treatment of idiopathic sudden sensorineural hearing loss. This study from China suggests that intravenous administration of a mushroom extract improves hearing in SHL.
Practically, the US drug industry has priced these drugs in the nose-bleed range, and it seems unlikely that this information will do anyone much good until these drugs become generic and cheap.
Combinatin therapy (intratympanic dexamethosone + high-dose predisone taper) for the treatment of idiopathic sudden sensorineural hearing loss. Prognostic model for predicting hearing recoery in idiopathic sudden sensorineural hearing lossl. Experimental otoacoustic emission and auditory brainstem response changes by stellate ganglion blockage in rat. Intratympanic dexamethasone for sudden sensorineural hearing loss after failure of systemic therapy.
Potential Benefits of Combination Therapy as Primary Treatment for Sudden Sensorineural Hearing Loss. Results of exploratory tympanotomy following sudden unilateral deafness and its effects on hearing restoration. Association between the V Leiden G1691A mutation and sudden sensorineural hearing loss in Italian population: a meta-analysis. The side effects of prednisone treatment are mood disturbances, insomnia, blood sugar alterations in diabetics, and gastric hyperacidity. Close monitoring of blood pressure and potassium levels by your primary care physician is recommended. During the procedure, the eardrum is elevated and the round window (one of the two openings into the cochlea of the inner ear) membrane is perfused with high-dose steroid. The medication, Gentamicin, is an antibiotic that is toxic to the hair cells of the hearing and balance organ. Unfortunately, control of vertigo occurs in only 60 percent of patients undergoing this operation. After the operation, disequilibrium lasts until the brain learns to compensate and adapt to the lack of input from one inner ear.
He is chief surgeon and founder of the private practice, Metropolitan NeuroEar Group, located in the metropolitan Washington D.C. However, sometimes it is difficult to know -- such as someone with a preexisting unilateral hearing loss, who loses hearing in the other ear. And probably people who care enough about their hearing to get it tested in the past, are more likely to keep caring about it when they have a change.
An additional study of 11 more temporal bones in 2013 (Linthicum et al), was suggestive of a viral etiology. The author's opinion is that migraine is a much more common cause of SHL than is generally appreciated in the otolaryngologic community. However, perhaps it relates to the fact that pregnancy is often reduces Migraine substantially.
These apps might also be useful for following ones response to treatment (or no treatment as it may be). In our opinion, MRI is not always necessary as one must consider availability, severity of the situation, and followup. They suggested that the hearing impairment in this select group is more severe and outcome of treatment is worse. In a more recent evidence based review, Lawrence and Thevasagayam (2015) suggested that either oral or intratympanic steroids should generally be offered.
As of 2016, the best approach appears to be more steroids - -both systemic and intratympanic.
The steroid regimen involved prescribing 66 tablets of prednsone (10 mg) given in a dose of 6 tablets for 7 days, then 5 capsules for 2 days, then 1 less capsule per day until finished.
It seems to us that the injections themselves might have an adverse effect on hearing (compared to oral steroids given without a placebo injection). We do not recommend IT steroids otherwise -- for example, in persons with minor hearing loss. In a more recent evidenced based review, Lawrence and Thevasagayam (2015) suggested that antivirals should not generally be offered routinely. Horn et al (2005) also reported some good responses to hyperbaric treatment in an uncontrolled study of 9 patients. In a recent evidenced based review, Lawrence and Thevasagayam (2015) suggested that "Due to the variability in the vasodilator and vasoactive agents used, there is insufficient evidence to support the routine use of these agents. At this writing we do not feel that there is enough evidence for either treatment to advocate for its use. According to their article on their experience in 97 patients, surgery can be beneficial if performed within 7 days (Maier et al, 2008). Metodo: Analise de pacientes atendidos no Ambulatorio de surdez subita submetidos a tratamento padronizado de janeiro de 1996 a janeiro de 2006, divididos em cinco grupos de tratamento para receber expansor plasmatico, dexametasona, aciclovir, acido nicotinico, cloridrato de papaverina e ou vitamina A.
Method: Review of patients records included in a standardized protocol of treatment of the sudden sensorineural hearing loss outpatient unit between January 1996 and January 2006. Em cerca de um terco dos casos podem ocorrer queixas associadas como zumbido, vertigem ou tontura e plenitude aural (2,3).
During the procedure the eardrum is elevated and the round window membrane is perfused with high-dose steroid.
This is a relatively painless procedure that involves anesthetizing the tympanic membrane and then injecting the steroid thereafter. The fluid that would normally enter the sac is shunted away from the inner ear and into the cavity created by the surgery, where it is then reabsorbed. This is an operation that is recommended to patients who have no useful hearing in the dysfunctional ear.
Considering this unlikely but devastating possibility, we think it is prudent to take the more aggressive approach in treating SHL (see below).
Even more recently, Gao and Liu (2016), in another meta-analysis, suggested that combined intratympanic and systemic steroids provide better outcomes than systemic steroids alone. Another recent meta-analysis concluded that there was no significant effect (Labus et al, 2010).
There is an obvious trend for an increasing number of positive reports, albeit nearly all uncontrolled, over time.

Or perhaps this is because controlled studies show no effect, and studies that show no effect are hard to publish. We are not sure ourselves whether oral or IT steroids are superior in terms of hearing results to doing nothing, but we are certain that large amounts of oral steroids can cause significant side effects. We are very unenthused about this treatment suggestion deriving from this uncontrolled trial. Second, the natural history of SHL is such that improvement cannot be necessarily attributed to surgical exploration and patching.
It is puzzling that these patients were operated, and even more puzzling that they got better.
A audiometria foi realizada antes (inicial) e apos o inicio da terapia (30, 90, 120 e 180 dias).
Inclusion criteria were sudden sensorineural hearing loss occurring within 72 hours and 30 dB or more at three serial frequencies.
This is a relatively painless procedure that involves anesthetizing the tympanic membrane with injection thereafter. Avoiding adding salt to meals and curtailing intake of snacks high in sodium, including canned foods and fried foods, can be helpful.
Just as in vestibular neurectomy, after the operation, disequilibrium lasts until the brain learns to compensate and adapt to the lack of input from one inner ear.
High levels of cholesteral and low levels of Coenzyme Q are associated with SHL (Cadoni et al, 2007).
Another recent trial comparing oral steroids to intratympanic injections suggested that there was no difference (Nakache et al, 2015).
This study suggested a powerful treatment effect where the combination group did far better than groups with either IT dexamethasone alone or high dose steroids + placebo injections.
Concerning intravenous steroids, they are likely superior to oral steroids, but they are far more difficult to administer. Their method of judging whether or not a fistula was present was direct observation of the round window while displacing the stapes footplate. Pacients were included in five treatment groups and had received Dextran®, dexamethasone, acyclovir, nicotinic acid, papaverine chloridrate and or vitamin A. Dentre os fatores associados temos os disturbios metabolicos que sao mais frequentes entre cocleo-vestibulopatas do que na populacao geral (7).
These electrodes detect contractions of the facial muscles, and the signals are transmitted to a speaker so the surgeon may hear the responses. Of course, most of the processes that they noticed were either disorders that affected spinal fluid (such as meningitis or superficial siderosis), the body as a whole (a variety of autoimmune inner ear disease), and bilateral forms of unilateral ear disorders. They reported a statistically better effect in the IT patients, with no change in the controls.
This protocol also would be expected to have numerous steroid side effects due to the prolonged use of high-dose prednisone.
Resultados: A amostra compreende 139 pacientes com idade media de 45,4 anos, 52,5% do sexo feminino e 47,5% masculino, em 92,8% a surdez subita era unilateral e em 7,2% bilateral. Lets be clear however -- these are not big effects, and one should be careful to judge whether the risk of steroids is warranted by the small effect.
Outcome was determined by subtracting baseline PTA (first day of the medical assessment) from final PTA (after 180 days). For example, one would generally not want to use high dose systemic steroids in a diabetic, as the risk from steroid effects on diabetes might easily outweigh the small average effect on hearing. The problem with this study is that it is not a protocol likely to be helpful clinically, as it is not presently common to give 10 days of intravenous steroids in the treatment of SHL. Nao pode ser detectada diferenca significante na resposta audiometrica entre os grupos de tratamento.
Results: Complete data were collected for 139 subjects, mean age were 45,4 years, 52,5% were female and 47,5% were male, 92,8% had unilateral sudden sensorineural hearing loss and 7,2% had bilateral one. Another concern with this study is that it is implausible in that conventional thought is that treatments provided after 10 days of illness are intrinsically unlikely to work. The obvious problem here that makes interpretation impossible, is the lack of definition of what was done as well as the lack of controls. Observamos correlacao linear inversa significante entre o tempo decorrido do inicio da doenca e o primeiro atendimento e a evolucao ou resposta audiometrica. Conclusoes: O expansor plasmatico nao melhorou a eficacia da associacao entre o corticoide e o aciclovir no tratamento da surdez subita. Nevertheless, no significant difference could be noted in audiometric assessment between treatment groups. Foram incluidos neste grupo aqueles que possuiam contra-indicacao clinica ao uso do expansor plasmatico (hipertensao arterial sistemica, cardiopatia, disturbio da coagulacao e insuficiencia renal).
We observed a significant linear correlation between time from sudden sensorineural hearing loss onset to initial visit and audiometric recovery. Conclusion: Dextran® did not provide more benefit than steroid and acyclovir in the treatment of SSHL. As soon as treatment begins better will be the outcome prognosis for sudden sensorineural hearing loss. Nestes casos, a audiometria tonal limiar foi realizada em dias alternados,sendo programada a suspensao da medicacao e alta hospitalar na ausencia de melhora dos limiares auditivos apos tres dias. Nos casos de melhora audiometrica, o esquema terapeutico foi mantido por ate 10 dias.Para documentacao da variacao audiometrica foi utilizado o PTA, pure tone average ou limiar tonal puro. O PTA para frequencias graves foi determinado pela media dos limiares tonais das frequencias de 250, 500 e 1000 Hertz (Hz) e o PTA para frequencias agudas a partir da media das frequencias de 2000, 4000 e 8000 Hz. A evolucao ou resposta audiometrica dos pacientes entre os diversos grupos de tratamento foi determinada subtraindo-se o PTA inicial (primeiro dia de avaliacao medica) do final (apos 180 dias).Para analise estatistica dos resultados, foram utilizados o teste t de Student e a analise de variancia (ANOVA). O nivel de significancia considerado foi de p RESULTADOSEm 129 (92,8%) pacientes a surdez subita (SS) era unilateral e em apenas 10 (7,2%) era bilateral. Quanto a etnia 77 (55,4%) eram brancos, 35 (25,2%) eram negros e 4 (2,9%) eram da raca amarela. Assim, para as frequencias graves observamos um coeficiente de correlacao de Spearman r = - 0,45 (p Grafico 1. Correlacao entre o tempo de inicio do tratamento e a evolucao nas frequencias graves.Grafico 2. Correlacao entre o tempo de inicio do tratamento e a evolucao nas frequencias agudas.DISCUSSAOA literatura mostra que a idade media dos pacientes com surdez subita (SS) varia de 43 a 53 anos, que a distribuicao por sexo e equivalente e que o acometimento em mais 95% dos casos e unilateral, semelhante ao que observamos neste levantamento (2, 4, 13, 15, 16). O unico levantamento epidemiologico de SS publicado ate o momento foi feito no Japao em tres anos distintos, em diferentes decadas e mostra que o tempo entre o inicio da SS e o primeiro atendimento variou de 11,6 ± 12,1 dias em 1974, 9,1 ± 9,8 dias em 1987 a 8,1 ± 9,1 dias em 1993 (15). Nao podemos comparar diretamente nossa casuistica com a de NAKASHIMA et al (15), pelo tipo de desenho e por serem populacoes diferentes, porem observamos retardo ate o primeiro atendimento o que pode ser atribuido em parte a descaso dos pacientes em relacao ao sintoma ou a dificuldade de acesso ao medico.Partindo de grupos homogeneos quanto as medias iniciais do PTA e considerando-se todos os casos atendidos, houve reducao significante na media do PTA.
Esta media de melhora (PTA inicial - final) foi de 21,6dB para frequencias graves e de 16,7dB para as agudas. Apesar de nao haver grupo controle para comparacao, a literatura mostra que a melhora espontanea (sem tratamento) ocorre em 32% dos casos de SS e e em media de 15dB de PTA (3, 8), portanto menor do que a observada neste estudo.
A recuperacao audiometrica estimada com o tratamento e de aproximadamente 25dB de PTA (3), semelhante a que observamos para frequencias graves.Quanto a evolucao dos pacientes (PTA inicial - PTA final) nos cinco grupos de tratamento, a diferenca observada nao se mostrou significante, tanto para frequencias graves como para agudas. Embora nao tenhamos observado significancia estatistica, a melhora do PTA foi menor nos pacientes dos grupos IV e V, que iniciaram o tratamento apos 15 dias do inicio da SS. Os grupos I, II e III iniciaram o tratamento nos primeiros 15 dias de SS, porem o melhor PTA foi observado no grupo II, o unico a nao receber expansor plasmatico por contra-indicacao clinica. Embora algumas doencas de base sejam capazes de interferir na microcirculacao da orelha interna dificultando a melhora clinica da SS, as comorbidades apresentadas pelos pacientes do grupo II, aparentemente nao significaram fatores de pior prognostico.
Em nosso levantamento, o expansor plasmatico nao contribuiu para potencializar os efeitos do corticosteroide e do aciclovir no tratamento da SS, uma vez que o grupo que melhor respondeu a terapia nao o utilizou.Observamos uma correlacao linear inversa significante entre o tempo decorrido ate o inicio do tratamento e a resposta audiometrica apresentada pelo paciente, tanto para frequencias graves quanto para agudas. Oral steroid treatment of sudden sensorineural hearing loss: a ten year retrospective analysis.
Sudden complete or partial loss of function of the octavus system in apparently normal persons. Antiviral treatment of idiopathic sudden sensorineural hearing loss: a prospective, randomized, double-blind clinical trial. Treatment of idiopathic sudden sensorineural hearing loss with antiviral therapy: a prospective, randomized, double-blind clinical trial. Prognosis for sudden sensorineural hearing loss: a retrospective study using logistical regression analysis. Clinicoepidemiologic features of sudden deafness diagnosed and treated at university hospitals in Japan. Assistente Doutor do Setor de Otoneurologia do Departamento de Otorrinolaringologia da FMUSP.2.

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