Intratympanic vs Systemic Corticosteroids in First-line Treatment of Idiopathic Sudden Sensorineural Hearing Loss: A Systematic Review and Meta-analysis

Abstract

Importance: To our knowledge, evidence-based recommendations on the intratympanic vs systemic administration of corticosteroids for the treatment of idiopathic sudden sensorineural hearing loss remain unestablished, and contradictory conclusions have been reported in previous meta-analyses.

Objective: To compare recovery from idiopathic sudden sensorineural hearing loss based on systemic, intratympanic, or a combined treatment with corticosteroids as first-line treatment.

Data sources: We adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. We searched PubMed, Embase, OvidSP, CINAHL, and Cochrane Library from January 1, 1966, to July 1, 2018. This study was registered in the International Prospective Register of Systematic Reviews (CRD42018109314).

Study selection: We included randomized studies. Included studies must have excluded identifiable causes. Corticosteroids must have been administered solitarily. We excluded studies that did not define hearing loss as a minimum 30 dB within 72 hours.

Data extraction and synthesis: We identified 170 titles, of which 56 (32.9%) were eligible for full-text screening. We independently extracted data. We applied a fixed-effects model to investigate our objectives.

Main outcomes and measure: We aimed to (1) estimate the difference in mean pure tone average (PTA) gain in decibels from intratympanic treatment vs systemic treatment and (2) investigate odds ratios for recovery between the different treatment groups.

Results: We included 7 eligible studies. A total of 710 patients were allocated to receive either intratympanic treatment (IT group, 235 [33%]), systemic treatment (ST group; 325 [46%]) or combined intratympanic and systemic treatment (CB group; 150 [21%]). The PTA was measured by taking the mean of 4 frequencies: 4 studies measured at 500, 1000, 2000, and 3000 Hz and 3 studies measured at 500, 1000, 2000, and 4000 Hz. The ST group had a 2.01-dB higher PTA gain (95% CI, -5.61 dB to 1.59 dB; P = .96; I2 = 0%) compared with the IT group and the odds for achieving complete recovery was not significantly different at an odds ratio of 0.94 (95% CI, 0.61 to 1.44; P = .19; I2 = 34.5%). For the CB group vs the ST group, the odds ratio was 1.11 (95% CI, 0.68 to 1.82; P = .75; I2 = 0%). The analysis of the CB group vs IT group comprised only 2 studies.

Conclusions and relevance: This study does not suggest that corticosteroid delivered intratympanically is more beneficial than systemic treatment in the case of moderate to severe idiopathic sudden sensorineural hearing loss. There were no indications that combined treatment was associated with improved hearing outcomes compared with either systemic or intratympanic treatment.

Figure 1.. Mean Hearing Gain in Decibels (dB) From Baseline (Pretreatment) Pure Tone Average (PTA) Compared With PTA at Follow-up (Between 1 to 3 Months)

The forest plot illustrates the mean difference, which is the PTA mean gain in dB of intratympanic therapy subtracted from the PTA mean gain in dB of systemic therapy. Total indicates the number of patients. ^aQ₁ = 0.01; P = .93; I² = 0%. ^bQ₁ = 0.23; P = .63; I² = 0%. ^cQ₃ = 0.30; P = .96; I² = 0%.

Figure 2.. Odds for Complete Recovery When Treated With Intratympanic Corticosteroids vs Systemic Corticosteroids

Complete indicates the proportion of patients achieving complete recovery as defined within the individual study. Not complete indicates the proportion of patients not achieving complete recovery. Total indicates number of patients in the study. OR indicates odds ratio; PTA, pure tone average. ^aQ₂ = 4.63; P = .10; I² = 56.8%. ^bQ₁ = 1.39; P = .24; I² = 28.0%. ^cQ₄ = 6.11; P = .19; I² = 34.5%.

Figure 3.. Odds for Complete Recovery Between Combined Intratympanics (Dexamethasone or Methylprednisolone) and Systemic Corticosteroids vs Systemic Corticosteroids

Complete indicates the proportion of patients achieving complete recovery as defined within the individual study. Not complete indicates the proportion of patients not achieving complete recovery. Total indicates number of patients in the study. OR indicates odds ratio; PTA, pure tone average. ^aQ₂ = 0.93; P = .63; I² = 0%. ^bQ₀ = 0; P > .99; I² = 0%. ^cQ₃ = 1.23; P = .75; I² = 0%.