The Laryngoscope C 2014 The American Laryngological, V

Rhinological and Otological Society, Inc.

Successful Treatment of Sudden Sensorineural Hearing Loss Assures Improvement of Accompanying Tinnitus Yoon Chan Rah, MD; Kyung Tae Park, MD; Yeo-Jeen Yi, MD; Jungirl Seok, MD; Seong Il Kang, MD; Young Ho Kim, MD, PhD Objectives/Hypothesis: To investigate the long-term outcomes of accompanying tinnitus after steroid therapy for patients with sudden sensorineural hearing loss (SSNHL). Study Design: Retrospective chart review and survey. Methods: Fifty patients diagnosed with SSNHL accompanied by tinnitus were enrolled and divided into two groups— satisfied and unsatisfied—according to the degree of improvement of tinnitus after SSNHL treatment. Subjective improvement of tinnitus and hearing status were investigated before and 6 months after SSNHL treatment. Hearing improvement was assessed using criteria from our previous study and Siegel’s criteria. The change of tinnitus was assessed using a visual analogue scale for tinnitus intensity and frequency. Results: Patients with more severe initial hearing loss had less chance of hearing recovery (P 5.05). The satisfied group included significantly more cases with better hearing recovery after SSNHL treatment than the unsatisfied group (P 5.049). Pure-tone threshold and speech discrimination scores were significantly better in the satisfied group than in the unsatisfied group after SSNHL treatment (P 5.033 and P 5.018, respectively), although the two groups showed no definitive differences before treatment. Conclusions: Optimal and successful treatment of SSNHL may be an important factor in obtaining favorable long-term control of tinnitus accompanied by SSNHL. Key Words: Sudden sensorineural hearing loss, tinnitus, steroid therapy. Level of Evidence: 4. Laryngoscope, 00:000–000, 2014

INTRODUCTION Sudden sensorineural hearing loss (SSNHL) continues to be a bothersome and challenging clinical problem. Its incidence was believed to range from 5 to 20 per 100,000 population1; however, a recent study suggested a much higher incidence of up to 160 per 100,000 population.2 Although various treatment protocols have been tried, the recovery rates of patients with mild, moderate, and severe hearing loss still remain 70%, 30%, and 10%, respectively, showing remarkable differences according to the degree of initial hearing loss.3,4 About 80% to 90% of patients with SSNHL have accompanying tinnitus.5,6 Those patients reportedly have more depressive

Additional Supporting Information may be found in the online version of this article. From the Department of Otorhinolaryngology-Head and Neck Surgery, Boramae Medical Center, Seoul National University College of Medicine, Seoul, South Korea Editor’s Note: This Manuscript was accepted for publication November 7, 2014. This study was supported by the SK Chemicals Research Fund (No. 16-2013-132 to Y.H.K.). The authors have no other funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Young Ho Kim, MD, Professor, Department of Otorhinolaryngology–Head and Neck Surgery, Boramae Medical Center, Seoul National University College of Medicine, 39, Boramae-Gil, Dongjak-Gu, Seoul 156-707, Republic of Korea. E-mail: [email protected] DOI: 10.1002/lary.25074

Laryngoscope 00: Month 2014

thoughts, disruptive personal relationships, and physical symptoms than those without tinnitus.7 For these reasons, patients with SSNHL are likely to be seriously frustrated by the remaining tinnitus even after successful treatment of SSNHL. However, to the best of our knowledge, there have been no studies involving the long-term evaluation of accompanying tinnitus after SSNHL treatment. Moreover, in the actual course of SSNHL treatment, physicians usually tend to mostly concentrate on the restoration of hearing without sufficient consideration of accompanying tinnitus. Characteristics of and possible treatment strategies for acute tinnitus accompanied by SSNHL are important for reducing patients’ distress and improving their quality of life. Here, we investigated long-term outcomes of tinnitus after steroid therapy in patients with SSNHL accompanied by tinnitus.

MATERIALS AND METHODS Study Design and Patients A total of 50 patients diagnosed with SSNHL and newly developed tinnitus at Seoul National University Boramae Medical Center from September 2008 to February 2013 were enrolled in this study. SSNHL was defined as 30 dB or more sensorineural hearing deteriorations over at least three contiguous audiometric frequencies occurring within 72 hours or less. Patients with other causes of sensorineural hearing loss, such as M enie`re’s disease or autoimmune hearing loss, patients with

Rah et al.: Tinnitus Accompanied by SSNHL

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TABLE I. Criteria Used in This Study. Type

Hearing Recovery

Kim’s criteria Complete recovery Good recovery

PTA  25 dB and SDS  90% Worse than CR, but 26 dB  PTA  40 dB and 75%  SDS < 90%

Fair recovery

Worse than GR, but 41 dB  PTA  55 dB and 50%  SDS < 75%

Slight recovery No recovery

Worse than FR, but 56 dB  PTA  70 dB and 25  SDS < 50% 71 dB < PTA and/or SDS < 25%

Siegel’s criteria Complete recovery Partial recovery

Patients whose final hearing level was better than 25 dB regardless of the size of the gain Patients who showed more than 15 dB of gain and whose final hearing level was between 25 and 45 dB

Slight recovery

Patients who showed more than 15 dB of gain and whose final hearing level was poorer than 45 dB

No improvement

Patients who showed less than 15 dB of gain

PTA 5 pure-tone audiogram; SDS 5 speech discrimination score; CR 5 complete recovery; GR 5 good recovery; FR 5 fair recovery.

a previous history of psychological problems including depression, patients with insomnia, patients with any tumorous condition, pregnant patients, and patients under 15 years old were excluded. All patients underwent systemic steroid therapy, and if there was no improvement within 1 week after treatment, intratympanic steroid injection was performed a total of four times (twice a week). Assessment of hearing recovery after SSNHL treatment was primarily conducted with criteria suggested in our previous study (Kim’s criteria)8 (Table I). Subjective changes in tinnitus were evaluated by global tinnitus impact (GTI) score, which assesses changes in intensity and frequency of tinnitus after treatment on a scale of 0 (no improvement of tinnitus) to 10 (complete resolution of tinnitus). Patients were divided into satisfied (GTI score of 8 to 10) and unsatisfied (GTI score of 0 to 7) groups according to the degree of tinnitus improvement. Hearing status and GTI score were assessed before and 6 months after SSNHL treatment. The correlation between distribution of initial hearing level (categorized as mild, moderate, moderate to severe, severe, and profound hearing loss) and hearing improvement after SSNHL treatment was analyzed. The distribution of GTI scores was also analyzed according to distribution of hearing improvement after SSNHL treatment by both Kim’s criteria and Siegel’s criteria8,9 (Table I). The pure-tone threshold (PTT) and speech discrimination scores (SDS) between the satisfied and unsatisfied groups were compared. Possible contributing factors to the degree of tinnitus were also assessed, including gender, combined vertigo, shape of the audiometry curve, hearing status of the opposite side, and underlying diseases (diabetes mellitus, hypertension, heart disease, stroke, renal disease). This study was approved by the institutional review board of Seoul National University Boramae Medical Center (permit no. 16–2013-132).

STATISTICAL ANALYSIS Statistical analysis was performed using SPSS software (version 18.0; SPSS Inc., Chicago, IL). Pearson v2 and Student t tests were used to compare patients’ subjective improvement in tinnitus and hearing improvement. The logistic regression test was used to search for factors contributing to the degree of tinnitus. A value of P