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Corticosteroid Therapy for Inner Ear Disorders - Melbourne ENT Group (MEG) - Steroids for Hearing Loss or Vertigo

RACGP - Oral corticosteroids for painful acute otitis externa -

Will oral corticosteroids increase patient satisfaction concerning: burning or stinging feeling post-administration of topical treatment itching post-administration of topical treatment time to resolution of pain time to resolution of itching time to resolution of swelling time to resolution of discharge?

Secondary research questions were: Will oral corticosteroids reduce the need for: unplanned revisits exclusion due to worsening of symptoms? Will oral corticosteroids increase patient satisfaction concerning time to resolution of normal activities? Patients and recruitment Sixteen primary healthcare centres and 19 adjacent pharmacies in tropical Far North Queensland, Australia, agreed to participate. Data collection Age, gender, ethnicity and initial ear pain was noted at baseline.

Visual analogue scale Randomisation Randomisation was achieved using random numbers generated by the ResearchRandomizer website www. Blinding Medical practitioners, participating pharmacists, patients, staff telephoning patients and the person doing statistical analysis were all unaware of group allocation. Intervention The pharmacist checked inclusion criteria for a second time and provided study tablets to patients accepting participation.

Statistical analysis All patients fulfilling inclusion criteria and with data available were analysed as follows: Time to resolution of pain: groups were compared using a log rank test. Cox regression was used in case clinically relevant baseline differences existed between groups.

This test was chosen as the data were ordinal Satisfaction with symptom resolution: patient satisfaction was compared between groups using a Mann-Whitney U test. Patient satisfaction was analysed using a Mann-Whitney U test. Sample size calculation Sample size calculations were based on the primary research questions and made two-tailed to avoid the assumption that a difference between groups would always favour the intervention group.

Patient and public involvement Patients or the public were not involved in the design of this study. Results One hundred and sixty-four patients were screened for eligibility between 28 October and 19 June Table 1. Table 2. Table 3. Limitations The main limitations of this study were recruitment of participants and loss to follow-up of included participants.

The following potential problems were identified: The researchers noted that the wet seasons in —16 and —17 were unusually dry, resulting in fewer than expected cases of otitis externa. Many GPs in the participating clinics also expressed there were fewer cases than usual. There is always a time pressure in primary healthcare, and actions linked with financial remuneration are often given some priority.

Remuneration for participating practitioners, pharmacists or patients was not available in this study because of the limited funding allocated. After discussions with colleagues, the researchers first believed recruitment would work well without remuneration. Afterwards, it became evident that this assumption was incorrect, and remuneration to medical practitioners and pharmacists for each included patient, and a small remuneration to patients for returned surveys, may have reduced the recruitment problem and loss to follow-up.

Each can containing study tablets had a unique identifying number, which pharmacists were instructed to note on the survey handed out to patients. Many pharmacists failed to do so, and these returned surveys could therefore not be linked with the correct patient. A checklist was introduced for pharmacists halfway through the study, and this problem was significantly reduced. Generalisability This study was planned as a randomised controlled trial RCT but, most likely because of insufficient funding, failed to recruit enough patients to be adequately powered to assess the proposed outcomes.

Provenance and peer review: Not commissioned, externally peer reviewed. Funding: Cairns Hospital Foundation, Australia, funded this project. The funder did not take part in planning the project, analysing data or writing the manuscript. Create Quick log. Estimated burden of acute otitis externa — United States, — External otitis among swimmers and nonswimmers. Arch Environ Health ;30 9 — Aust Fam Physician ;38 4 — The relation of patient satisfaction with treatment of otitis externa to clinical outcomes: Development of an instrument.

Clin Ther ;21 6 — Malignant external otitis: Insights into pathogenesis, clinical manifestations, diagnosis, and therapy. Am J Med ;85 3 — Search PubMed Boustred N. Practical guide to otitis externa. Aust Fam Physician ;28 3 — Search PubMed Murtagh J. Systematic review of topical antimicrobial therapy for acute otitis externa.

Adv Ther ;24 3 — External otitis caused by infection with Pseudomonas aeruginosa or Candida albicans cured by use of a topical group III steroid, without any antibiotics. Acta Otolaryngol ; 4 — A group III steroid solution without antibiotic components: An effective cure for external otitis. J Laryngol Otol ; 5 — Search PubMed Golder J. Management of otitis externa. Aust Fam Physician ;38 7 General practice. Glucocorticoids for croup.

Steroids as adjuvant treatment of sore throat in acute bacterial pharyngitis. Can Fam Physician ;58 1 — Steroids as adjuvant therapy for acute pharyngitis in ambulatory patients: A systematic review. There is only a 2- to 4-week window of time for treatment before hearing loss becomes permanent.

Recently, doctors have started injecting steroids directly into the middle ear — a procedure called intratympanic treatment.

This technique is thought to deliver more of the drug to the ear and to avoid some of the side effects that can come along with oral steroids. The side effects of oral therapy can be mild, like weight gain, mood changes and sleep disruption, or more serious, like high blood pressure and elevated blood sugar. Side effects of injected steroids are usually local, such as ear infection and vertigo.

However, up until now, no study had compared the 2 treatments to see whether direct injection worked as well as oral steroids. To investigate, Dr. Steven Rauch of Harvard Medical School and the Massachusetts Eye and Ear Infirmary led a team of investigators from 16 medical centers nationwide in a clinical trial involving more than patients.

The results were published in the May 25, , issue of the Journal of the American Medical Association. The study tested the treatments as they are usually given in the clinic. The medication should be used in the morning, after breakfast. Hearing loss duration for more than 2 weeks Application modality First, your Specialist surgeon at MEG will apply a local anaesthetic into your ear canal — either a cream, a spray, or an injection — e. Many patients will feel dizzy straight after injection, this will normally settle in minutes to hours.

Within the first 24 hours It is normal to hear liquid moving in the ear or feel is tripping into the nose. This may make sounds more muffled for the first couple of days. What should I expect? Minor discharge and bleeding from the treated ear may be noticed for short period of time. Any improvement in symptoms is not immediate and may take hours, days or sometimes even weeks to be noticed. Repeat topical administration Further weekly injections usually two can be arranged with your Specialist Surgeon if ear symptom improvement is noticed confirmed on repeat Audiometry hearing test after 7 days of the first injection.

Discussion of further benefit vs. Concerns or questions? Further information The Department of Health has published a guide on different causes of hearing loss.

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Prednisone for ear. Steroid Treatments Equally Effective Against Sudden Deafness

More ». June 6, Injecting steroids into the middle ear works just as well as taking them orally when it comes to restoring hearing for sudden deafness patients.

This finding, the result of a large clinical trial comparing the therapies, will help doctors choose the best treatment for patients with this condition. Sudden deafness, also called sudden sensorineural hearing loss, is an emergency medical condition that affects several thousand people annually, usually between the ages of 40 and It often arises without an obvious cause and occurs in one ear all at once or over a period of up to 3 days.

Oral steroids, such as prednisone, are usually prescribed over the course of 2 weeks to restore hearing. There is only a 2- to 4-week window of time for treatment before hearing loss becomes permanent. Recently, doctors have started injecting steroids directly into the middle ear — a procedure called intratympanic treatment. This technique is thought to deliver more of the drug to the ear and to avoid some of the side effects that can come along with oral steroids.

The side effects of oral therapy can be mild, like weight gain, mood changes and sleep disruption, or more serious, like high blood pressure and elevated blood sugar.

Side effects of injected steroids are usually local, such as ear infection and vertigo. However, up until now, no study had compared the 2 treatments to see whether direct injection worked as well as oral steroids.

To investigate, Dr. Steven Rauch of Harvard Medical School and the Massachusetts Eye and Ear Infirmary led a team of investigators from 16 medical centers nationwide in a clinical trial involving more than patients. The results were published in the May 25,issue of the Journal of the American Medical Association. The study tested the treatments as they are usually given in the clinic.

For oral steroid therapy, patients received 60 milligrams of prednisone for 14 days, followed by a tapering-off period of 5 days. The other group was given 40 milligrams of methylprednisolone injected directly through the eardrum 4 times over the course of 2 weeks. The study followed the recovery of these patients for 6 months, measuring the success of the treatments based on hearing tests at the first and second weeks, and months 2 and 6. Under both regimens, patients recovered their hearing to about the same extent at 2 and 6 months.

The oral steroid patients experienced typical symptoms, such as sleep, mood and appetite changes. The injected steroid patients had pain at the injection site and vertigo; a few had ear infections and a perforated eardrum. Most symptoms cleared up by 6 months. Nevertheless, the difference showed that while the treatments were equally effective, they might not be equally appropriate for every patient. People with sudden deafness should discuss the risks and benefits of both treatments with their doctor.

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Steroid Treatments Equally Effective Against Sudden Deafness | National Institutes of Health (NIH).

This study did not find evidence that the intervention and control groups differed statistically at baseline Table 1. Often it is given in three doses that are weeks apart. Of course, one can adjust one's protocol to give more drug at the beginning, as is the case for the "medrol dose pack".

Most patients fully recover after 5—14 days. Infection may also spread to deeper structures such as the inner ear and the brain, which can be potentially life-threatening. The treatment for otitis externa is usually topical; in selected cases, oral antibiotics are prescribed.

Prednisone or prednisolone is used in doses ranging from 20 to 75 mg daily for 3—5 days. Corticosteroids reduce the immune response. Therefore, corticosteroids given to a patient who has a severe infection could theoretically be detrimental. However, it has previously been shown that corticosteroids can be given safely and with beneficial effect to patients with ongoing infection of low or moderate virulence. Examples are patients with croup 14 and sore throat. Acute otitis externa is in most cases either an aseptic inflammation that is simultaneously colonised by bacteria, or an infection of low-to-moderate virulence.

In these situations, corticosteroids could theoretically be beneficial. Current evidence indicates that a topical steroid is beneficial to patients with otitis externa.

We were unable to identify a published clinical trial evaluating the effect of oral corticosteroids in patients with otitis externa. Giving oral corticosteroids to patients with otitis externa could be beneficial or harmful.

It may be that oral corticosteroids in the lower dose range are beneficial while using higher doses could add side effects and risks without benefit. If a short course of low-dose oral corticosteroids 20 mg prednisone daily is beneficial, then this finding is useful for practitioners currently prescribing a higher dose. If a benefit of oral corticosteroids is not proven, then physicians currently prescribing it need to be advised of this finding.

The objective of this study was to assess the efficacy of low-dose oral prednisolone for four days in addition to conventional therapy in the management of painful acute otitis externa. Primary research questions and subsequent data collection aimed to comply with the only published validated questionnaire for acute otitis externa. Sixteen primary healthcare centres and 19 adjacent pharmacies in tropical Far North Queensland, Australia, agreed to participate.

Consecutive patients attending participating primary healthcare centres for otitis externa were asked by the medical practitioner if they accepted screening in relation to inclusion criteria:. Patients fulfilling all inclusion criteria were referred to one of the participating pharmacies, where further information was given, consent forms were signed and the study medication was dispensed. A website was created as an ongoing resource for GPs and pharmacists www. Furthermore, GP clinics and pharmacies were visited regularly to ensure they adhered to the agreed study protocol.

Age, gender, ethnicity and initial ear pain was noted at baseline. Initial ear pain was measured using a VAS of 10 cm Figure 1. The VAS, subsequent diary and final survey after symptom resolution or up to 10 days after enrolment adhered to the validated VAS, diary and survey published by Shikiar et al in Figure 1.

Visual analogue scale. Randomisation was achieved using random numbers generated by the ResearchRandomizer website www. Medical practitioners, participating pharmacists, patients, staff telephoning patients and the person doing statistical analysis were all unaware of group allocation.

The pharmacist checked inclusion criteria for a second time and provided study tablets to patients accepting participation. The intervention was a study capsule taken twice daily for four days in addition to any other treatment prescribed by the medical practitioner.

Capsules with the active ingredient contained 10 mg of prednisone packed in an opaque gelatine capsule. The remaining space was filled with lactose. Capsules with placebo contained lactose packed in a gelatine capsule which was identical in appearance to capsules with the active ingredient.

The lactose content was considered insignificant for patients with lactose intolerance. All patients fulfilling inclusion criteria and with data available were analysed as follows:. The analysis was done as intention to treat. Intention to treat was defined as all patients fulfilling the inclusion criteria with follow-up data available, making analysis possible irrespective of whether they adhered to the allocated treatment arm. Imputation of data for patients lost to follow-up was not made.

Sample size calculations were based on the primary research questions and made two-tailed to avoid the assumption that a difference between groups would always favour the intervention group. Sample size calculations for survival analysis used the statistical software PASS version We calculated that patients would be sufficient to answer all primary research questions.

We expected that some patients would be lost to follow-up so we aimed to include patients. The most common method of administration is by mouth. We will not discuss intravenous administration faster and stronger, sometimes used for situations where symptoms are very severe such as bilateral deafness associated with autoimmune inner ear disease. Administration through the ear-drum is discussed elsewhere. This method has the advantage of much less side effects, but the disadvantages of higher expense and the need for a subspecialty visit for injection through the ear drum.

For the oral method, there are four common protocols that we use in our clinic :. The easiest, safest, and most convenient method of trying steroids is to use a medrol methylprednisolone dose pack. This is a card that contains 6 days of steroids, with less provided each day. The gradual decrease in the amount of steroids each day is called a "taper". The reason to do this is to allow the patient's adrenal glands, which are usually suppressed by the steroids, to gradually return to supplying steroids to the patient on their own.

Medrol is slightly stronger than prednsone, so to convert this into "prednisone", when using the 4 mg dose-pack, one just has to multiple by 5. In other words, the medrol dose pack is the equivalent of 30 mg of prednisone, tapering down to 0 over a week. For persons in whom a larger amount of steroids is indicated a longer protocol and more intense protocol is selected.

Longer pulses require longer tapers. Discussion of further benefit vs. Concerns or questions? Further information The Department of Health has published a guide on different causes of hearing loss.

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This information is for patients, families and carers of patients with inner disorders who may benefit from the use of Corticosteroid Therapy CT for Inner Ear Disorders, including:. Please note there we cannot guarantee either the effectiveness or duration of Corticosteroid therapy in any case. Your Specialist surgeon will discuss with your further rehabilitation options in case of failure of medical therapy, which may include, hearing rehabilitation options, including conventional hearing amplification ie Hearing aidsHearing implants and Vestibular physiotherapy.

The Department of Health has published a guide on different causes of hearing loss. Download File. Call Us Corticosteroid Therapy for Inner Ear Disorders. Who is this information for? Corticosteroids are man-made drugs that work like cortisol, a natural steroid hormone in your body. These medicines reduce inflammation and alter the immune system.

They can be taken as tablets, or injected into the blood-stream or body tissues. Common examples of corticosteroids include: Prednisolone e. Sensorineural hearing loss new onset or sudden deterioration of pre-existing SNHL should be confirmed with an Audiogram prior to commencing CT.

Therapeutic recommendations Corticosteroid Therapy is most beneficial the sooner it is started after symptoms onset. For Sudden Sensorineural Hearing Loss, corticosteroid use should start ideally within 72 hours of deafness onset 1and can be offered within 2 weeks of symptom onset as a primary treatment.

Salvage treatment, which is given to patients who did not receive or did not respond to primary treatment, is typically delivered weeks after the onset of symptoms. Often it is given in three doses that are weeks apart. Initial administration route is systemic oral with topic therapy Trans-Tympanic used as salvage.

The medication should be used in the morning, after breakfast. Hearing loss duration for more than 2 weeks Application modality First, your Specialist surgeon at MEG will apply a local anaesthetic into your ear canal — either a cream, a spray, or an injection — e. Many patients will feel dizzy straight after injection, this will normally settle in minutes to hours.

Any improvement in symptoms is not immediate and may take hours, days or sometimes even weeks to be noticed. Repeat topical administration Further weekly injections usually two can be arranged with your Specialist Surgeon if ear symptom improvement is noticed confirmed on repeat Audiometry hearing test after 7 days of the first injection. Discussion of further benefit vs. Concerns or questions? Further information The Department of Health has published a guide on different causes of hearing loss.

The glucocorticoids, prednisolone and dexamethasone, were the most effective in our study in reducing middle ear inflammation in response to bacterial challenge. Prednisone (1 mg / kg / day) or Dexamethasone (10mg / day) should be used for at least days, with a tapering of the dose over a similar time period. Otitis media with effusion is the most common cause of acquired hearing loss Management of chronic middle ear effusion with prednisone combined with. Oral steroids, such as prednisone, are usually prescribed over the course of 2 weeks to restore hearing. There is only a 2- to 4-week window. Prednisolone Sodium Phosphate Drops is used to treat inflammation of the eye or ear where there is no infection. 2. What you need to know before you use. This may make sounds more muffled for the first couple of days. There is always a time pressure in primary healthcare, and actions linked with financial remuneration are often given some priority. This test was chosen as the data were ordinal Satisfaction with symptom resolution: patient satisfaction was compared between groups using a Mann-Whitney U test.

Timothy C. Steroids are commonly prescribed for sudden hearing loss as well as for autoimmune inner ear disease and vestibular neuritis. The purpose of this page is to outline the usual methodology. We do not discuss their effectiveness or the validity of their indications. There is very little difference with respect to the ultimate results with these drugs and side effects, but they differ in potency and duration of action, and for this reason, the dose must be adjusted.

Oral decadron would seem to us to be a poor choice for a condition in which rapid effects are desirable such as acute hearing loss or vestibular neuritis, as due to it's long half life, it takes 20 days to reach steady state. Of course, one can adjust one's protocol to give more drug at the beginning, as is the case for the "medrol dose pack". The most common method of administration is by mouth.

We will not discuss intravenous administration faster and stronger, sometimes used for situations where symptoms are very severe such as bilateral deafness associated with autoimmune inner ear disease. Administration through the ear-drum is discussed elsewhere. This method has the advantage of much less side effects, but the disadvantages of higher expense and the need for a subspecialty visit for injection through the ear drum.

Medrol is slightly stronger than prednsone, so to convert this into "prednisone", when using the 4 mg dose-pack, one just has to multiple by 5.

In other words, the medrol dose pack is the equivalent of 30 mg of prednisone, tapering down to 0 over a week. For persons in whom a larger amount of steroids is indicated a longer protocol and more intense protocol is selected.

Longer pulses require longer tapers. Checking the blood pressure to make sure it is not dropping too low and follow up visits during the taper period are often required.

Some patients are "steroid dependent". For example, whenever the steroid dose is decreased below a threshold, hearing starts to deteriorate again. In patients like this, an attempt is made to find a steroid sparing replacement drug such as methotrexate or Enbrel , but in the meantime, the steroids are reduced to as low an amount as is practical.

Steroids have many side effects, that are more common with longer administration. Common ones in the short run i. Problems that can occur after longer administration, besides the ones that may appear above, include. The drugs that are most commonly used include: Drug Equivalent mg Half life Usual starting dose dexamethasone decadron 0.

Deterioration or temporary induction of diabetes, high blood sugar Sleeplessness, mood swings Problems that can occur after longer administration, besides the ones that may appear above, include Weight gain with swelling in ankles and fat accumulation around center of body, moon face. Weakness in legs steroid myopathy Cataracts Increased risk of infections Suppression of adrenal glands, low blood pressure and other problems during taper.

Bruising, thin skin. Byl FM. Sprague MS. Lesion-induced plasticity in rat vestibular nucleus neurones dependent on glucocorticoid receptor activation. J Physiol ; Pt 1 Kitahara T. Kondoh K. Morihana T.

Neurol Res ;25 3 Ohbayashi S. Oda M. Yamamoto M. Recovery of the vestibular function after vestibular neuronitis. Acta Otolaryngol. Corticosteroids effect on vestibular neuritis symptom relief. Issa A. Golz A. Prednisone treatment for vestibular neuritis.

Otol Neurotol. Zingler VC. Arbusow V. Methylprednisolone, valacyclovir, or the combination for vestibular neuritis. N Engl J Med.

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