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Chakkanova M. B., Assistant Makhkamova N. E., doctor of sciences Department of ENT Tashkent State Dental Institute E-mail: luna1088@mail.ru
TRANSTUBARISTIC ADMINISTRATION OF DEXAMETHASONE IN THE TREATMENT OF ACUTE SENSORINEURAL HEARING LOSS
Abstract. Sudden sensorineural hearing loss (SSNHL) is commonly encountered in audiologic and otolaryngologic practice. SSNHL is most commonly defined as sensorineural hearing loss of 30dB or greater over at least three contiguous audiometric frequencies occurring within a 72-hr period. Although the differential for SSNHL is vast, for the majority of patients an etiologic factor is not identified. Treatment for SSNHL of known etiology is directed toward that agent, with poor hearing outcomes characteristic for discoverable etiologies that cause inner ear hair cell loss. Steroid therapy is the current mainstay of treatment of SSNHL in the Uzbekistan. The prognosis for hearing recovery for SSNHL is dependent on a number of factors including the severity of hearing loss, age, presence of vertigo, and shape of the audiogram.
Keywords: hearing loss, sudden sensorineural hearing loss, evaluation, treatment, transtubaristic administration.
Introduction: There is a huge amount of research on the etiology and pathogenesis of the disease, as well as on the treatment of acute (sudden) sensorineural hearing loss
(SSNHL).
For the treatment of SNHL, a huge number of different drugs, methods and treatment regimens have been proposed. These include: various vasoactive and hemodilution drugs, hyperbaric oxygenation, sedatives, diuretics, prostaglandin E1, vitamins B, E and C, extracorporeal methods, steroid drugs, etc.
Abroad for the treatment of SNHL treatment with steroid drugs is adopted as the "gold standard".
There are a huge number of studies on the treatment of SNHL, among them only a few are randomized controlled studies (RCS).
In the CIS, vascular therapy, aimed at improving the blood circulation of the inner ear, is still the main treatment method.
Many authors evaluated the effect of different vasoac-tive and hemodilution drugs, such as pentoxifylline, dextran, ginkgo biloba, nifedipine, and their different combinations [3; 6; 8; 11]. There was no significant difference between the main and control groups.
Interesting facts is provided by A. Conlin, L. Parnes, who analyzed 20 RCTs devoted to the study of different types of treatment in patients with SNHL. The following results were obtained: there was no difference between patients receiving steroids systemically and placebo, between antiviral therapy in combination with steroids and placebo in combination with steroids, and there was no difference between steroids and other different types of treatment [4].
With systemic use of steroids, the optimal dose and duration of treatment are unknown and therefore often chosen empirically and are inaccurate. In addition, the therapeutic effect of steroids upon systemic administration may not be ideal in low doses, since they have a limited ability to penetrate the hematoperilymphatic barrier. So, in the work of M. Buhrer et al. It has been demonstrated that after intravenous administration of prednisolone, its concentration in the cerebrospinal fluid is about 1/3 of its concentration in plasma [2]. L. Parnes et al. measured the concentration of methylprednisolone in perilymph guinea pigs an hour after intravenous administration. The authors indicate that this indicator is only 1/6 of the entered concentration [7].
Previously, patients who did not respond to systemic steroid therapy or who had not fully recovered hearing after systemic therapy, did not have an alternative to further treatment.
With the recent appearance of numerous publications on the effectiveness of intra-imperial steroid therapy after systemic therapy, the situation has changed. Intratimpanal therapy can also be used as the main and primary method of treatment in patients who cannot receive systemic steroid therapy for medical reasons (in patients with gastric ulcer and duodenal ulcer, osteoporosis, Itsenko - Cushing syndrome, renal failure, severe arterial disease). hypertension, glaucoma, tuberculosis, etc.).
Intratimpanal administration of drugs into the inner ear was first applied by R. Barany in 1936; he used lidocaine to treat tinnitus [1].
Intratimpanal administration has two theoretical advantages. Firstly, it becomes possible for steroids to directly pen-
TRANSTUBARISTIC ADMINISTRATION OF DEXAMETHASONE IN THE TREATMENT OF ACUTE SENSORINEURAL HEARING LOSS
etrate the round window membrane (MCO), which leads to a high concentration of the drug in the perilymph. Secondly, with intra-implantation administration, in contrast to the systemic administration, it is possible to avoid the toxic effects and absorption of steroids.
L. Parnes et al. concentrations of methylprednisolone, dexamethasone, and hydrocortisone were determined in plasma, endolymph, perilymph after oral, intravenous, and intratimpanal administration. The highest concentrations of steroids in the fluids of the inner ear were detected by intratimpanal administration of drugs. At the same time, the highest concentration that lasted longer than that of hydrocortisone and dexamethasone was found in methylprednisolone [7].
Recently, a large number of clinical and review studies have been conducted to assess the effectiveness of intratimpanal steroid administration in SNHL. However, most of them are only descriptive, there are no control groups or a sample of patients is too small, therefore, the results of these studies cannot be evaluated unambiguously, additional double-blind, randomized, placebo-controlled studies are needed.
In 2011, a systematic review of studies on the effectiveness of intratimpanal steroid therapy in SNHL from 1970 to 2010 was published. The review included 176 studies, of which 32 were representative studies of the effectiveness of intratimpa-nal steroid therapy, primary or post-systemic therapy, which included 6 randomized studies and only 2 RCTs. The authors concluded that, despite the small number of well-performed studies, the vast majority of studies of intratimpanal therapy after systemic therapy showed the advantage of intratimpanal therapy. steroids can potentially improve hearing to a certain degree after systemic therapy, but it is still not clear how clinically significant this difference is. therapy as a primary treatment is equivalent to standard therapy with high doses of oral prednisolone [10].
Side effects with intratimpanal administration of steroids are minimal. So, L. Parnes et al. treated 37 patients by intraimplantation steroids. The authors indicate that 3 patients developed acute otitis media, which resolved after antibiotic therapy. No cases of hearing impairment or the formation of perforation were recorded [7]. B. Herr, S. Marzo indicate the following side effects: perforation of the eardrum, the formation of chronic suppurative otitis media, balance disorder and taste disturbances [5]. W. Slattery et al. observed several cases of perforation of the eardrum and nausea after intratimpanal administration [9].
The goal of our study is to determine the effectiveness of transtubar steroids in the treatment of SNHL.
Material and methods: 49 patients with SNHL (patients aged 22 to 65 years; observation periods ranged from 1 to 6 months) were observed on the basis of Clinic III TMA, who
underwent transtubar steroids for the treatment of this pathology. Studies of the efficacy of transtubar steroids in the treatment of SNHL and comparison with the intravenous administration of steroids and the traditional treatment regimen of SNHL have been carried out.
From the moment of the onset of the disease before the start of treatment, 3 days passed in 8 patients, 5 days in 4, over 5 days in 11, and 8 patients diagnosed with sensorineural hearing loss after previous ineffective traditional therapy. The comparison group included 18 patients, all patients of this group received intravenous steroids and traditional treatment. The duration of treatment of patients in the hospital was 20 days. The examination of patients included general clinical studies, audiometry (tonal and speech), and impedancometry.
A transtubar injection is performed using a catheter through an Eustachian tube. Dexamethasone is administered in a dose of 4 mg / ml depending on the degree of hearing loss every day, every other day. With the introduction of the drug into the tympanic cavity, the patient's head must be oriented so that the solution covers the niche of the round window for 30 minutes. The patient should not swallow, if possible, to reduce the loss of the drug through the auditory tube.
Transtubar therapy should be carried out until there is a positive trend, for example, until 2 identical audiograms are obtained with an interval of 2 weeks.
In the study of hearing after 1 month, 7 out of 8 patients who started treatment 3 days after the onset of the disease (group 1a) showed an improvement in hearing by 23.6 dB, in 1 patient by 19.5 dB; and in 4 patients who started treatment after 5 days (group 1b), hearing improved by 14 dB; over 5 days (group 1) - in 9 patients by 9.1 dB, of which in 2 patients - by 5 dB.
After 3 months - in the 1a group, 8 patients had a partial restoration of hearing by 37.3 dB; in 1b group, in 3 patients the hearing improved by 34 dB, in 1 patient - by 21.5 dB; in patients of group 1, in 9 patients by 17.5 dB, ofwhich in 2 patients by 12.4 dB; and after 6 months, all patients of the group and 3 patients of the 1b group showed a complete restoration of hearing, in 1 patient of the 1b group and in 11 patients of the 1st group a partial restoration of hearing.
Patients with a diagnosis of "sensorineural hearing loss" after the previously ineffective traditional therapy, which were included in the main group, underwent a continuous course of transtubar therapy with dexamethasone during the entire period of treatment. The treatment lasted until a positive trend was observed and was discontinued in the absence of dynamics in the next audiogram. In 3 of 8 patients, improvement in hearing was noted.
According to the research, the following conclusions were made:
- The effectiveness of the administration of steroids for - With long-term therapy for 6 months by the route of 1 month does not differ from traditional therapy and therapy administration of steroids, the effectiveness of this type of only with steroids. treatment is higher than that of conventional therapy and ther-
- In the study of the effect of therapy on different apy with steroids only. It was revealed that after 6 months the frequency ranges after 1 month, a higher effect of steroid greatest differences between the groups are in the frequency administration on the high frequency range was detected of complete restorations of hearing.
compared to traditional therapy and systemic steroid mono- - The timing of local therapy by the administration of
therapy. steroids is individual for each patient.
References:
1. Barany R. Die Beeinflussung des Ohrensausens durch intraveous injizierte Localnasthetica. Acta Otolaryngol 1936; 23: 201-7.
2. Buhrer M., Frey F. J., Frey B. M. Prednisolone concentrations in cerebrospinal fluid after different prednisolone prodrugs. Br J Pharmacol 1991; 31 (1): 111-3.
3. Burschka M. A. et al. Effect of treatment with Ginkgo biloba extract EGb 761 (oral) on unilateral idiopathic sudden hearing loss in a prospective randomized double-blind study of106 outpatients. Eur Arch Otorhinolaryngol 2001; 258 (5): 213-9.
4. Conlin A. E., Parnes L. S. Treatment of sudden sensorineural hearing loss. I. A systematic review. Arch Otolaryngol Head Neck Surg 2007; 133 (6): 573-81.
5. Herr B. D., Marzo S.J. Intratympanic steroid perfusion for refractory sudden sensorineural hearing loss. Otolaryngol Head Neck Surg 2005; 132 (4): 527-31.
6. Kronenberg J. et al. Vasoactive therapy versus placebo in the treatment of sudden hearing loss: a double-blind clinical study. Laryngoscope 1992; 102 (1): 65-8.
7. Parnes L. S., Sun A. H., Freemann D. J. Corticosteroids pharmacokinetics in the inner ear fluids: an animal study followed by clinical application. Laryngoscope 1999; 109 (7 Pt 2): 1-17.
8. Reisser C. H., Weidauer H. Ginkgo biloba extract EGb 761 or pentoxifylline for the treatment of sudden deafness: a randomized, reference-controlled, double-blind. ActaOtolaryngol 2001; 121 (5): 579-84.
9. Slattery W. H. et al. Intratympanic steroid injection for treatment of idiopathic sudden hearing loss. Otolaryngol Head Neck Surg 2005; 133 (2): 251-9.
10. Spear S., Schwartz S. Intratympanic Steroids for Sudden Sensorineural Hearing Loss: A Systematic Review. Otolaryngol Head and Neck Surg 2011; 145 (4): 534-43.
11. Wei-Che Lan et al. Pentoxifylline versus Steroid Therapy for Idiopatic Sudden Sensorineural Hearing Loss with Diabetes. J. Int Adv Otol 2018. Aug 14(2): 176-180.
