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Journal of Otology 11 (2016) 18e23
www.journals.elsevier.com/journal-of-otology/

A comparison of effects of systemic and intratympanic steroid therapies for

sudden sensorineural hearing loss: A meta-analysis
Dan Zhao a,1, Busheng Tong a,1, Qiang Wang a, Sten Hellstrom b, Maoli Duan a,b,*
a
Department of Otorhinolaryngology-Head and Neck Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, PR China
b
Department of Audiology and Neurotology, Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
Received 5 January 2016; revised 25 February 2016; accepted 29 February 2016

Abstract

Objective: To evaluate the efficacy and safety of intratympanic and systemic steroid therapies in the initial treatment of Sudden Sensorineural
Hearing Loss (SSNHL) patients.
Methods: A comprehensive search of PubMed, Wanfang database and CNKI (China National Knowledge Infrastructure) was performed covering
the period from January 1990 to July 2014. A meta-analysis was conducted after filtering by the criteria of Cochrane Collaboration. Three
hundred fifty six subjects in nine studies allocated to the group of intratympanic steroid therapies and 343 controls receiving systemic steroid
therapies met the criteria for meta-analysis. The data were extracted and analyzed using the RevMan 5.3 meta-analysis software.
Results: The total effectiveness rate in SSNHL patients receiving intratympanic steroid therapies did not differ statistically from patients
receiving systemic therapies (RR ¼ 1.08, 95％CI ¼ 0.99e1.99, P ¼ 0.10), although the rate of full hearing recovery in this group differed
significantly from patients receiving systemic therapies (RR ¼ 1.29, 95％CI ¼ 1.00e1.66, P ¼ 0.05).
Conclusion: Local steroid therapy appears to generate higher rate of complete hearing recovery than systemic steroid treatment as an initial
treatment for SSNHL, which may be especially useful for patients in whom systemic steroids are contraindicated.
Copyright © 2016, PLA General Hospital Department of Otolaryngology Head and Neck Surgery. Production and hosting by Elsevier
(Singapore) Pte Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Keywords: Sudden sensorineural hearing loss; Intratympanic steroids; Systemic steroid; Meta-analysis

1. Introduction et al., 2010; Arastou et al., 2013). Although a number of

theories regarding the cause have been suggested, the etiol-
Sudden Sensorineural Hearing Loss (SSNHL), first re- ogies and pathogenesis of SSNHL are still unclear. The overall
ported by De Kleyn (Seggas et al., 2010) in 1944, is an oto- incidence of diagnosed SSNHL ranges from 5 to 20 per
logic event that needs urgent intervention. SSNHL is 100,000 persons per year (Seggas et al., 2010; Arslan et al.,
commonly defined as hearing loss greater than 30 dB and 2011; Battaglia et al., 2008). The rate of spontaneous recov-
involving at least 3 consecutive audiometric frequencies, ery without treatment ranges 32e65% (Seggas et al., 2010;
occurring within 3 days without any identifiable cause (Seggas Arastou et al., 2013; Battaglia et al., 2008), and the rate of
full recovery in treated patients ranges 49e79% (Arastou
et al., 2013; Battaglia et al., 2008).
* Corresponding author. Department of Clinical Science, Intervention and The cause of SSNHL has been the subject of debate for many
Technology, Karolinska Institutet, 171 76 Stockholm, Sweden years and has been widely studied. The suggested theories
E-mail address: maoli.duan@ki.se (M. Duan). include vascular compromise, viral infection, and immune-
Peer review under responsibility of PLA General Hospital Department of
mediated reactions (Seggas et al., 2010; Arslan et al., 2011).
Otolaryngology Head and Neck Surgery.
1
Dan Zhao and Busheng Tong contributed equally to this work. The condition may well have a multifactorial etiology and each

http://dx.doi.org/10.1016/j.joto.2016.02.002
1672-2930/Copyright © 2016, PLA General Hospital Department of Otolaryngology Head and Neck Surgery. Production and hosting by Elsevier (Singapore)
Pte Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
 D. Zhao et al. / Journal of Otology 11 (2016) 18e23 19

of the above mentioned mechanisms may be responsible for a (intratympanic steroids), as well as a clear description of the
proportion of the total number of observed cases. steroid treatment regimen; (3) the age and sex in the treatment
A number of treatments have been reported, such as and control groups were not limited, but with no significant
vasoactive substances, hyperbaric oxygen, antivirals and vi- difference at baseline.
tamins (Crane et al., 2014; Koltsidopoulos et al., 2013). Each Data fulfilling the following criteria were excluded: (i) ar-
approach has, however, been debated with no standard pro- ticles that were reviews, expert commentaries, case reports or
tocol universally accepted until the introduction of steroid other non-clinical research literature, (ii) trials that had
therapy. Administration of steroids, systemically or intra- incomplete reporting of pre- and post-treatment PTA results,
tympanally, alone or in combination, is considered to be the (iii) trials that did not evaluate steroids as a primary treatment
mainstay of treatment for SSNHL (Arslan et al., 2011; of SSNHL, and did not evaluate systemic steroids alone or
Battaglia et al., 2008; Crane et al., 2014). Systemic steroid intratympanic steroids alone as the primary treatment.
therapy, however, has serious adverse effects and contraindi- Nine studies met the criteria and were included for analysis
cations and therefore local use of steroids has attracted (Table 1). The following information was extracted from each
popularity among otology centers during the last decade article: sample size of each study arm, type and dose of ste-
(Koltsidopoulos et al., 2013). roids, methods of steroid administration, duration of therapy,
In the present study we performed a review of randomized outcomes, major complications and follow-up time.
controlled trials (RCTs) involving the use of intratympanic After identifying the reports, the abstract and full text were
steroid therapy (IST) or systemic steroid therapy (SST) for carefully read and the publication's quality was screened and
initial treatment in SSNHL patients. The aim of the meta- evaluated according to the Handbook of System Quality
analysis was to evaluate the efficacy and safety of IST and Evaluation of Cochrane criteria. Pre- and post-treatment pure-
determine whether this treatment is more effective as a pri- tone audiometry (PTA) results were noted. Treatment efficacy
mary treatment for SSNHL than SST. was determined in accordance to the sudden deafness diag-
nosis and treatment standards by the Chinese Medical Asso-
2. Materials and methods ciation Otolaryngology Head and Neck Surgery Branch,
Ji'nan, 2005. A change of hearing thresholds within the
2.1. Strategy and criteria 250e4000 Hz frequency range back to within normal range, or
to the level of the healthy ear, or back to the level before
Literature search was performed using a combination of the SSNHL was considered to represent a full recovery (cured);
keywords “sudden hearing loss”, “hearing loss”, ‘‘steroid’’, and a threshold recovery of 15 dB or greater was considered to
“transtympanic” and ‘‘intratympanic’’. PubMed, Wanfang indicate significant improvement (Spear and Schwartz, 2011).
database and CNKI were searched to yield all possible rele- The rates of full recovery and significant improvements were
vant results. Articles limited to human subjects and published calculated.
in the English or Chinese languages between January 1990 and
July 2014 were included. All RCTs based on the use of ste- 2.2. Statistical analysis
roids and the efficacies of intratympanic and systemic steroid
treatments in patients with SSNHL were assessed. Two au- Data analysis was performed with the RevMan5.3 software.
thors collected and extracted the data independently. Dis- Tests of heterogeneity were conducted with the chi-square test,
agreements were solved through discussion. RCTs fulfilling as an x2 variate. Between-study heterogeneity was assessed
the following criteria were included: (1) the RCT was designed using the I2, as the percentage of variability among effect
to study the efficacy and safety of SST and IST as initial estimates beyond that expected by chance (Ng et al., 2014). As
treatment of SSNHL; (2) SSNHL was reliably diagnosed, a reference, I2 values of 25% were considered low, 50% as
excluding other causes, and the RCT presented with a control moderate, and 75% as high (Ng et al., 2014). If the result did
arm (systemic steroid treatment) and a treatment arm not show heterogeneity (i.e. I2 < 50%, P > 0.10), the fixed-

Table 1
Characteristics of the included research.
Included literature Intratympanic therapy Systemic therapy Follow-up
(author, published time) Drug Usage and dosage Time Drug Usage and dosage Time time

Lim et al. (2013) Dexamethasone Intratympanic injection, 1.5e2 mg 2w Prednisone Oral, 60 mg/d 10d 3w
Rauch et al. (2011) Methylprednisolone Intratympanic injection, 40 mg 2w Prednisone Oral, 60 mg/d 19d 6m
Dispenza et al. (2011) Dexamethasone Intratympanic injection, 4 mg 4w Prednisone Oral, 6 mg/d 14d 6m
Zhou et al. (2006) Dexamethasone Intratympanic injection, 2.5 mg 8d Prednisone Oral, 30 mg/d 8d 20d
Peng et al. (2008) Dexamethasone Intratympanic injection, 5 mg 10d Dexamethasone Intravenous, 10 mg 10d 20d
Deng (2011) Dexamethasone Intratympanic injection, 1 mg 10d Dexamethasone Intravenous, 10 mg 10d 30d
Yi et al. (2011) Dexamethasone Auditory tube injection, 5 mg 10d Dexamethasone Intravenous,10 mg 7d 30d
You et al. (2008) Dexamethasone Intratympanic injection, 1e1.5 mg 10d Dexamethasone Intravenous, 10 mg 10d 15d
Mao et al. (2005) Methylprednisolone Auditory tube injection, 5 mg 10d Methylprednisolone Intravenous, 40 mg 7d 20d
20 D. Zhao et al. / Journal of Otology 11 (2016) 18e23

effect model was used for calculation. If a clinical heteroge- indicate statistically significant difference between the rates of
neity existed, the random-effects mode was used. The Man- total effectiveness for local and systemic steroids therapies.
teleHaenszel method was used to summarize the results, by Fig. 2 presents the funnel plots of local and systemic steroids
calculation of the combined Risk Ratio (RR) and 95% confi- treatments. In the funnel plot, each point is distributed sym-
dence intervals (95% CI), and forest plots were generated. metrically, indicating low publication bias. Fig. 3 compares the
rates of full recovery for local and systemic steroids treatments.
3. Results The forest plot results are x2 ¼ 5.19, p ¼ 0.64, I2 ¼ 0%. The
figure shows I2 ¼ 0% < 50%, P ¼ 0.64 > 0.10, again indicating
Nine studies met the inclusion criteria and revealed rates of no heterogeneity and justification for using the fixed-effect
significant improvement and full recovery. The nine studies model. The ManteleHaenszel method showed that the total
were published from 2005 to 2013. For intratympanic therapies, RR was 1.29 and the 95% CI was 1.00e1.66. The overall effect,
dexamethasone (Lim et al., 2013; Dispenza et al., 2011; Zhou Z ¼ 1.95, P ¼ 0.05 ¼ 0.05, showed a statistically significant
et al., 2006; Peng et al., 2008; Deng, 2011; Yi et al., 2011; difference. Fig. 4 presents a funnel plot of the number of patients
You et al., 2008) and methylprednisolone (Rauch et al., 2011; with full recovery. Each point in the funnel plot is distributed
Mao et al., 2005) were used, either through the tympanic symmetrically, indicating low publication bias.
membrane (Lim et al., 2013; Rauch et al., 2011; Dispenza et al., Side effects of intratympanic and systemic steroid therapies
2011; Zhou et al., 2006; Peng et al., 2008; Deng, 2011; You et al., were reported in six (Rauch et al., 2011; Dispenza et al., 2011;
2008) or via the auditory tube (Yi et al., 2011; Mao et al., 2005). Deng, 2011; Yi et al., 2011; You et al., 2008; Mao et al., 2005)
The drugs administered systemically were prednisone (Lim of the nine studies. Complications of transtympanic steroid
et al., 2013; Rauch et al., 2011; Dispenza et al., 2011; Zhou therapy included vertigo, otalgia, nystagmus, otitis media,
et al., 2006), dexamethasone (Peng et al., 2008; Deng, 2011; tinnitus, injection site pain, and persistent tympanic membrane
Yi et al., 2011; You et al., 2008) and methylprednisolone perforations. Of the 269 patients in these studies, 4 developed
(Mao et al., 2005), via oral (Lim et al., 2013; Rauch et al., 2011; vertigo (Deng, 2011), of whom 3 resolved spontaneously, one
Dispenza et al., 2011; Zhou et al., 2006) or intravenous (Peng was unable to stand upright and discontinued the treatment.
et al., 2008; Deng, 2011; Yi et al., 2011; You et al., 2008; Mao Persistent tympanic membrane perforation was seen in 5
et al., 2005) routes. Data from the nine studies were pooled
for meta-analysis.
A forest plot was created to depict the results of individual
studies along with the summary results derived from the meta-
analyses. Results showed that patients who received intra-
tympanic steroids therapies demonstrated a statistically signif-
icant improvement in the hearing threshold as compared to those
receiving systemic steroids therapies, reflecting that local ste-
roids treatments for SSNHL was more effective than systemic
therapies. Fig. 1 presents the rate of total effectiveness for local
steroids treatments in comparison to systemic steroids treat-
ments. The forest plot results are: x2 ¼ 12.15, p ¼ 0.14,
I2 ¼ 34%. As can be seen from the figure, I2 ¼ 34% < 50%,
P ¼ 0.14 > 0.10, indicates no heterogeneity and justification for
using the fixed-effect model. The ManteleHaenszel method
was used to summarize the results. The total Risk Ratio (RR)
was 1.08 and the 95% confidence intervals (95% CI) was Fig. 2. Meta-analysis funnel plot of local and systemic glucocorticoid treat-
0.99e1.19. The overall effect, Z ¼ 1.67, P ¼ 0.10 > 0.05, did not ment for SSNHL.

Fig. 1. Meta-analysis forest map of the rate of significant improvement for local and systemic glucocorticoid treatments for SSNHL.
 D. Zhao et al. / Journal of Otology 11 (2016) 18e23 21

Fig. 3. Meta-analysis forest map of the rate of full recovery for local and systemic glucocorticoid treatments for SSNHL.

In the nine randomized controlled trials, the total effective-

ness of local steroids in treating SSNHL was similar to that of
systemic steroid therapies. In contrast, the rate of full recovery in
local steroid treatment was higher than that in systemic thera-
pies. Systemic steroids may increase the risks of important
adverse effects, such as femoral head necrosis, gastrointestinal
and endocrine problems, and weight gain. In the systemic ste-
roid group, a total of 29 patients suffered side effects. By com-
parison, 17 people had side effects in the local glucocorticoid
group. Systemic administration of steroids may have broad ef-
fects on body functions, including numerous adverse reactions,
especially in long-term use. Due to side effects from systemic
administration of steroids, intratympanic administration of
steroids has been utilized (Kakehata et al., 2006; Hong et al.,
Fig. 4. Meta-analysis funnel plot of articles of local and systemic glucocor- 2009). Local administration of steroids via the middle ear cav-
ticoid treatments for SSNHL depicting the number of patients with full ity may act directly on the inner ear at a higher concentration,
recovery. without risks of systemic complications or cochlear dysfunc-
tions e advantages that may make it an ideal choice for SSNHL
patients (Rauch et al., 2011), and 6 patients suffered from in certain patient groups. Intratympanic steroid treatment has
otitis media (Rauch et al., 2011). Two patients in the intra- been used in patients in whom systemic steroids are contra-
tympanic treatment group withdrew consent due to injection indicated; i.e., in patients with immunocompromising distur-
site pain (Rauch et al., 2011). No infectious complications bances, diabetes, hypertension, peptic ulcer, and tuberculosis.
occurred. Adverse reactions of systemic steroids use were The number of clinical trials, meta-analyses and reviews
cardiovascular, gastrointestinal, neurologic, and endocrine concerning steroid therapy for SSNHL is large world-wide with
problems. Of the 256 patients in these studies, 13 developed no consistent conclusions. Studies on SSNHL patients have
gastrointestinal problems (Deng, 2011; Yi et al., 2011; Mao shown efficacy for intratympanic steroids as an initial treatment
et al., 2005), 2 had insomnia (You et al., 2008), 6 had and as a salvage therapy for refractory patients (Hong et al.,
elevated blood sugar levels (Deng, 2011; Yi et al., 2011), 3 2009; Koltsidopoulos et al., 2013; Lee et al., 2011; Wu et al.,
showed elevated blood pressure levels (Deng, 2011; Yi et al., 2011), and when combined with systemic steroids (Arastou
2011), and 1 developed weight gain (You et al., 2008). Otitis et al., 2013; Arslan et al., 2011; Gundogan et al., 2013;
media occurred in 1 patient (Rauch et al., 2011) and 1 patient Kakehata et al., 2011). Seggas et al. (2010) carried out a study
suffered right femoral head necrosis (Mao et al., 2005), the to seek the most effective technique and optimal administration
latter being the most serious complication showed in Fig. 5). schedule by examining the published literature regarding the
No other serious complications occurred in the two groups. therapeutic value of each method of treatment. They concluded
that topical steroids can be a valuable solution for SSNHL pa-
4. Discussion tients who either cannot tolerate systemic steroid therapy or are
refractory to it. Ding et al. (2013) stated, in studies on SSNHL
Treatment strategies for SSNHL vary widely and remain a patients with diabetes, that local steroids should be the first
challenge for otologists. Since 1980, administration of cortico- treatment of choice. Thus, local steroid treatment has been
steroids (systemic and/or intratympanic) has been the mainstay assumed to be a suitable alternative when there are medical
therapy for SSNHL (Battaglia et al., 2008; Koltsidopoulos contraindications to oral prednisone administration. In another
et al., 2013; Stachler, 2012). However, there is a limited study, Arastou et al. (2013) evaluated the efficacy of combined
amount of clinical data and the efficacy and safety of steroids intratympanic and systemic steroid therapies compared with
for treatment in SSNHL remain controversial. systemic steroid therapy alone in SSNHL patients with poor
22 D. Zhao et al. / Journal of Otology 11 (2016) 18e23

choosing combined intratympanic and systemic steroid thera-

5 patients: Persistent
pies. Ng et al. (2014) conducted a meta-analysis to evaluate the
tympanic membrane efficacy of intratympanic steroids as a salvage treatment for
perforation patients who have initial treatment failure with systemic ste-
roids. They showed salvage intratympanic steroids to be supe-
rior to no further treatment in patients who have failed systemic
steroids.
Complications of
In the present meta-analysis, we systematically scrutinized
2 patients: 6 patients: otitis
transtympanic English and Chinese literature on systemic and local admin-
injection site pain media istration of corticosteroids in SSNHL patients. The systemic
steroid therapy

in 269 patients.
corticosteroids administered in all trials by oral or intravenous
routes were prednisone, dexamethasone, and methylprednis-
olone at a dose of 30e60 mg/d (oral) or 10 mg/d (intravenous)
for 7e10 days. Intratympanic administration of steroids was
4 patients: vertigo performed about four times during a 1 month treatment period,
at a dose of 1e40 mg/injection (dexamethasone) or 5 mg/in-
jection (methylprednisolone). Our meta-analysis showed that
the dose in intratympanic steroid treatment was considerably
lower compared to that in systemic administration.
3 patients: healed 1 patient: unable to
The purpose of our meta-analysis was to evaluate the effi-
spontaneously stand upright cacy and safety of intratympanic and systemic steroid therapies
in the initial treatment for patients with SSNHL. The study
a: side effects of intratympanic steroid therapy showed that the two different treatment protocols, systemic and
local steroids, resulted in similar rates of hearing improvement
but were different in the rate of complete recovery. Moreover,
13 patients: local steroids carried lower risks of side effects as compared to
gastrointestina systemic treatments. We therefore recommend transtympanic
steroid administration as an initial treatment for those in whom
l problems
2 patients: initial systemic steroid treatment has failed.
insomnia Our meta-analysis has limitations. The type of steroids used
1 patient: varied as well as the duration and dose of treatment (Table 1).
For example, dexamethasone was used in 8 studies and
femoral head
methylprednisolone in the remaining study. The dose of
necrosis Complications of
dexamethasone ranged from 1 to 5 mg, and the administration
systemic steroid 6 patients:
schedule varied from once a week for 4 consecutive weeks to
therapy in 256 elevated blood daily administration for 8 or 10 consecutive days. Because of
patients sugar levels the limited number of trials and the variability regarding
1 patient: otitis duration and dose, subgroup analyses, such as comparisons
media between dexamethasone and methylprednisolone or between
3 patients: transtympanic injections and administration via the auditory
1 patient:
tube, could not be performed.
elevated blood
Some trials contained a small number of patients. Despite
weight gain pressure levels
that most of these studies showed a statistically significant
benefit, it cannot be excluded that studies with a similar
sample size but with negative results did not reach enough
priority for publication. Furthermore, publication bias cannot
b: side effects of systemic steroid therapy
be completely ruled out, although the funnel plots showed a
Fig. 5. Side effects from intratympanic and systemic steroid therapies. low publication bias. However, larger RCTs are required to
definitely confirm this conclusion.
The present study showed a statistically significant differ-
prognostic factors (age greater than 40 years, hearing loss of ence between intratympanic and systemic steroid treatments
more than 70 dB, and a greater than 2-week delay between the for SSNHL. Intratympanic steroid treatment is an effective
onset of hearing loss and initiation of therapy). It was concluded procedure that allows focused treatment of the ear of the
that combined intratympanic and systemic steroid therapy affected side only, a factor which can reduce pharmacological
showed a higher efficacy than systemic prednisolone alone in interactions. Despite the risks for adverse effects such as
the treatment of SSNHL patients with poor prognosis. So infection, residual tympanic perforation and vertigo, compli-
SSNHL patients with poor prognostic factors can consider cations are less frequent than with systemic treatment.
 D. Zhao et al. / Journal of Otology 11 (2016) 18e23 23

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