Use of Corticosteroids in Otology

Educational Objectives

The goal of this program is to discuss the use of corticosteroids for the treatment of common otologic conditions. After hearing and assimilating this program, the clinician will be better able to:

1. Review recent data about the use of corticosteroids and antiviral therapy for the treatment of Bell palsy.
2. Determine the appropriateness of using intratympanic steroids for the treatment of Meniere disease.
3. Counsel patients about treatment options for sudden sensorineural hearing loss and tinnitus.

Summary

Corticosteroids: supranormal doses of steroids are often used in conditions in which there is no corticotropin or hydrocortisone deficiency; presentation of side effects usually indicates overdosage; consider contraindications

Bell palsy: an idiopathic acute unilateral paresis or paralysis of the facial nerve with an onset within 72 hr; risk factors include herpes simplex virus infection, ischemia, and autoimmune or hereditary factors; most patients recover back to baseline within 6 mo even without treatment; some patients may develop synkinesis, crocodile tears syndrome, or other cosmetic deformities; evidence — steroids show benefit for the treatment of Bell palsy and reduce incomplete recovery at 6 mo; steroids have been shown to reduce motor synkinesis and crocodile tears; typical regimen — give a high-dose burst (eg, 60 mg/day for 1 wk), then taper off over the next few days; antiviral therapy — a combination of antiviral therapy (eg, acyclovir) and steroids is better than placebo or no treatment; clinical practice guidelines recommend using oral steroids within 72 hr of onset of Bell palsy; antiviral monotherapy is not recommended

Meniere disease: an inner ear disorder characterized by recurrent vertigo associated with fluctuating hearing loss, tinnitus, and aural fullness; this disease might be partly immune-mediated and respond to corticosteroid therapy since glucocorticoid receptors are present in the inner ear; it is believed that steroids affect the inner ear fluid equilibrium and have anti-inflammatory benefits; advantages of intratympanic therapy — bypasses the blood-labyrinth barrier and avoids systemic side effects associated with oral steroids; can achieve therapeutic drug levels in the inner ear; evidence — small studies showed statistically significant improvement at the functional level (eg, vertigo, hearing class) with the use of intratympanic dexamethasone; other studies suggest that intratympanic steroids are well tolerated and safe; a systematic review from 2019 that looked at intratympanic steroids vs placebo concluded that intratympanic steroids may reduce frequency of vertigo, but the evidence was not strong; intratympanic gentamicin and labyrinthectomy are recommended for selected patients

Sudden sensorineural hearing loss: characterized by a rapid onset (within 72 hr); audiometric criteria include a 30-dB drop across 3 consecutive frequencies; mostly idiopathic, but sometimes accompanies eg, tumor or stroke; negative prognostic factors include extremes of age, vertigo, severe hearing loss, and delayed treatment; treatment — steroids and hyperbaric oxygen therapy; the value of oral steroids for idiopathic sudden hearing loss is still unclear due to the lack of properly conducted randomized trials; a network meta-analysis that included 1527 patients in six treatment groups found that the best change or improvement in pure tone audiometry occurred with the combination of intratympanic steroids and systemic steroids, followed by the combination of oral and intravenous steroids, then intratympanic steroids alone; all active treatments were better than no treatment and placebo

Tinnitus: there are no recommended treatments; antidepressants, anticonvulsants, and anxiolytics are not recommended for the treatment of persistent, bothersome tinnitus; red flags — unilateral tinnitus; asymmetric hearing loss, pulsatile tinnitus; focal neurologic symptoms

Readings

Ahmadzai N, Kilty S, Cheng W, et al. A systematic review and network meta-analysis of existing pharmacologic therapies in patients with idiopathic sudden sensorineural hearing loss. PLoS One. 2019;14(9):e0221713. Published 2019 Sep 9. doi:10.1371/journal.pone.0221713; Froehlich MH, Lambert PR. The physiologic role of corticosteroids in Menière's disease: An update on glucocorticoid-mediated pathophysiology and corticosteroid inner ear distribution. Otol Neurotol. 2020;41:271-276; doi: 10.1097/MAO.0000000000002467; Fujiwara T, Namekawa M, Kuriyama A, Tamaki H. High-dose Corticosteroids for Adult Bell's Palsy: Systematic Review and Meta-analysis. Otol Neurotol. 2019;40(8):1101-1108. doi:10.1097/MAO.0000000000002317; Mirian C, Ovesen T. Intratympanic vs systemic corticosteroids in first-line treatment of idiopathic sudden sensorineural hearing loss: a systematic review and meta-analysis. JAMA Otolaryngol Head Neck Surg. 2020;146:421-428; doi: 10.1001/jamaoto.2020.0047; Tunkel DE, Bauer CA, Sun GH, et al. Clinical practice guideline: tinnitus. Otolaryngol Head Neck Surg. 2014;151(2 Suppl):S1-S40. doi:10.1177/0194599814545325.

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Chan was recorded at the Annual Michigan Ear Institute Spring Conference, held virtually on June 5, 2021, and presented by the Michigan Ear Institute. For future CME activities from this presenter, please visit http://www.michiganear.com/. Audio Digest thanks the speakers and meeting presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

OT541902

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.