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NITROBID THERAPY IN SUDDEN SENSORIINE URAL HEARING LOSS N. K. Panda q Y. N. Mehra q S. H. S. Mann
S
udden sensorineural hearing loss (SHL) can be a frightening experience for the patient and quite frustrating for the physician. It may occur due to many causative factors such as in'ections, vascular, metabolic, traumatic, neoplastic, by pregnancy and last but not the least idio—pathic. It is never easy to discover the exact cause but the virovascular theory has been recognised widely as an important aetiological factor. In otological paractice, idiopathic sudden sensorineural hearing loss is not uncommon. There has been no treatment proved effective for idiopathic sudden hearing loss even though many drugs including vasodilators, anticoagulants, plasma expanders. steroids and recently diatriazoate meglumine have been reported as possibly beneficial. The labyrinthine and the coronary artery both being= end arteries, their response to nitroglycerine may be similar. The rationale for trying nitroglycrine (Nitrobid) ointment was with the presumption that beneficial vasodilatation would be produced in labyrinthine vasculature akin to the effects on the coronary artery. We tried application of Nitrobid ointment in the management of idiopathic sudden hearing loss. The purpose of this paper is to report the results of our Panda. Assistant Prof.. Y. N. Mehra, Prof. & head. (ex) S. B. S. Mann, Prot. &lead, Department of Ototaryngotogy Postgraduate Institute of Medical Education Research. Ch:atdigarh. India N. K.
Address for Reprints
Dr. S. 11. S Main. Prot A Ilead of the Deptt, of EN]' 1'. G. 1. M. ti. K. Chaudigarh —I(i(1012
treatment and its efficacy in cases of idiopathic sudden sensorineural hearing loss. Material and Methods
'Twenty two cases of sudden idiopathic sensorineural hearing loss were treated with local application of Nitrobid ointment in the Department of Otolaryngology, Nehru Hospital, Postgraduate Institute of Medical Education & Research, Chandigarh. The age of the patient varied from 5 to 25 years with a mean age of 13 years. Work up of the patients included a detailed history and a thorough Ear, Nose and Throat emamination. Only those patients in whom no causative factors could be attributed for the sudden hearing loss were included in the study. A preliminary audiovestibular work—up was carried out in all these patients which included pure tone audiometry, special tests of hearing like tone decay, short increment sensitivity index, discrimination scores and cold caloric test. The hearing acuity was evaluated at 0. 5 KHz, 2 KHz 4 Kliz and 8 KI-Iz. X—ray perorbital view for internal auditory meatus was routinely obtained to rule out acoustic neuroma. All these patients were admitted in the hospital prior to application of Nitrobid ointment on the forearm in all these patients. Nitrobid ointment comes with a tube and an appliruler pad which is used
to measure and apply the ointment. To start with
2 an inch of Nitrobid was, measured
by means of the appliruler and applied daily. This was followed by daily or alternate day increments of
inch to a
maximum of 2" of that dose which induced a persistent mild headache. The dosage was reduced in cases of transient headache, flushing, faintness, tachycardia or dizziness. Serial audiograms were done daily for consecutive 10 days. Evaluation of treatment was based on comparison of an audiogram conducted prior to a starting the Nitrobid therapy with the audiogram done after attaining a maximum dose of Nitrobid. We chose to rank the recovery of sudden hering loss in one of four categories i. e. good, fair, poor and none as shown in 'fable I similar to those used previously (Sheehy, 1900). Statistical analysis with the graded recovery criteria was done with a chi—square test. Observations and Results
There were twenty two patients in this series. Eleven had unilateral deafness and the same number had bilateral hearing loss. The age of patients ranged from 5 to 25 years with a mean age of 13 years. Trinnitus was noted by 13 patients (59. 09%), vertigo in 3 patients (13. 6%). Half (11/22) of our patients presented within the
fable I
Graded Recovery Scale improvement A Good B Fair C Poor D None
Affected ear More than 30 dB improvement 10 — 30 dB improvement o— 10 d13 improvement only
No improvement in hearing
Indian Journal of OtoIar'.'ngo/ogv and Head and Neck Surgery, Volume 2, Na. 3, September 1993 — 125
Nitrobid Therapy in Sudden Sensorineural Hearing Loss—Panda et al.
100 -t
80 >- 60 w 0 w
40
LL
o 20
0
11/2, (4 5%) 1/22 FR C
4/22
S
3/22
A
(1B'/.)
(4 5/.)
(13.6'/.)
½2—c 2/22 B 9•/
HEARING LOSS LESS THAN 60dB
FIG, 1,
Mild hearing loss was defined at 30-50 d13 loss, 51 - 70 d13 as moderate, 71-90 dB as severe and 90 or more dB was considered to be profound hearing loss. Out of 22 patients, 4 had mild, 9 had severe and 9 had profound hearing loss at the time of presentation. Over all recovery : The recovery with nitrobid application is shown in Fig.] . 3 patients (13. 6%) had good recovery and 6 (27%%x) had a fair recovery. 2 patients had poor response to nitrobid therapy. 11 patients i. e. (50%) fell in category of no
HEARING LOSS MORE THAN 60 dB
FIG.2 RECOVERY RELATED TO SEVERITY OF INITIAL
THE RESULT OF NITROBID APPLICATION AFTER 2
first two weeks of the onset of hearing loss.
D
(50'/.)
HEARING LOSS.
recovery. Recovery related to severity of initial hearing loss is shown in Fig. 2. Patients having an initial hearing loss less than 60 dB were found to have responded better to nitrobid application compared to those having hearing loss more than 60 dB. The difference was significant X 2 = 6. 497 (P < 0. 05). Recovery related to age : We found on analysis of the data that younger the patient at the time of presentation, the better is the response. 9 patients had good to fair response to nitrobid applications, 7 of these patients were younger than I5 years.
However, the correlation between age and response was not significant X 2 = 0. 042 (P. 0. 05). hearing status of the opposite ear and recovery : The importance of hearing status of the opposite ear is reflected in Fig. 3. 11 patients had a normal audiogram of the opposite ear. 9 of them had good to fair recovery (81%). In contrast, 50% patients (11/22) who did not have any recovery had bilateral hearing loss. The difference was statistically significant X 2 = 4. 90 (P< 0. 05) Recovery related to time of initial visit: S out of 9 patients with good recovery had
100
80
80 U 0
U w
^
LL
o
60
60 2/22 UU
(9/)
D
6/22 (272/.)
B
9R (40.91
A
2/22 (9/)
40
20
3/22 (1367.)
UNILATERAL HEARING
LOSS
RESPONSE
40
D
20
8/22 (36V.)
8
V/A
C 0t
BILATERAL HEARING
POOR RESPONSE
8/:
0D0 ^r
1/22[111 GOOD RESPONSE
viii
w.^i...^.
AFTER
WITHIN 15 DAYS 15 DAYS
LOSS
FIG.3 HEARING STATUS OF THE OPPOSITE EAR, AND
RECOVERY
5/22 qp POOR
(22'/.)
L
FIG.4 RECOVERY RELATED TO TIME OF INITIAL VISIT.
126 - Indian Journal of OtoloryngoIo v and Head and Neck S,ngerv, Volume 2, No. 3, S'epteinlxr1993
Nitrobid Therapy in Sudden Sensorineu al Hearing Loss—Panda et al,
presented within 15th days of onset of deafness. 8 out of 11 patients who eventually had no improvement with nitrobid therapy had presented after 15 days of onset of deafness. The difference was however not statistically significant X 2 = 0. 42 (P> 0. 05) (Fig. 4).
Byl (1984) reported that those patients less than 15 and more than 60 years of age did not recover as well, compared to those in the mid decades. There are other studies to support the concept that older the patients, the poorer the prognosis for recovery (Byl, 1978). On analysis of our data, we also found that the younger the patient, better
Discussion
are the chance of recovery. Out of 9
Treatment of idiopathic sudden sensorineutal loss remains controversial and no regimen has been clearly demonstrated as effective. Saunders (1972) sent _ a questionnarie to 130 otolaryngologists in America and Europe and found that one third offered no treatment or believed that treatment was ineffective. Vasodilators have been one of the most commonly used treatments for sudden hearing loss (Sheehy, 1960). The rationale for using vasodilators is to promote blood flow and reverse presumed vasospasm. Shaia and Sheehy (1979) reported that 380 (40%) patients had improved hearing after receiving intravenous histamine and nicotinic acid. Haug et al. (1976) reported 75% good results in a series of 76 patients, . having stellate ganglion block. Suga and Snow (1969) demonstrated experimentally that vasodilators had little effect on cochlear blood flow and might in fact reduce it by shunting. They postulated that in sensorineural hearing loss, toxic local metabolic products accummulate causing maximal vasodilatation. It has been emphasized again and again in the literature by supporters of one treatment or another that it is important to institute treatment early in the course of the disease Byl 1978. Our data suggest a trend for imnproved outcome for those seen within first 14 days. 8 out of 9 patients with good recovery had presented within 15 days of onset of deafness.
)
patients, who had good to fair recovery, 7 were younger than 15 years. I-Iowever, this relationship between age and response was not statistically significant. As regards the overall recovery, 3 patients (13. 6%) had good recovery with local application of nitrobid ointment. This study discloses a direct relationship between the severity of initial hearing loss and potential recovery. Patients with initial hearing loss less than 60 dB responded better compared to those with hearing loss more than 60 dB. The difference was statistically signilican (p < 0. 05). Wilson et al. (1980) in their study had 34 patients who had hearing loss greater than 90 dB in all frequencies, only 24% had recovery with systemic steroids.
The hearing in the opposite ear is important in predicting recovery. Patients having a normal audiogram in the opposite ear were more likely to recover compared to those with an abnormal audiogram in the opposite ear. !The difference was statistically significant. ' Decreased hearing in the opposite ear may indicate a weakness in the entire auditory system and a pre existing decreased recovery potential.
Overall good to fair recovery occurred in 40% of patients. Important prognostic indicators were found to be severity of initial hearing loss, time from onset to initial visit, age of the patient, and•bearing status of the opposite ear. It is however, difficult to infer if the nirtobid therapy had any significant discernible
effect on the hearing since if any treatment is to be judged effective, it must significantly improve the results beyond the spontaeneous recovery late (40-78%) reported in the literature when no treatment is given (Wilson 1980, Mattox 1977). References 1.
Saunders, W. H. (1972) : Sudden
deafness and its several treatments. Jayngoscope 82 : 1206-1213.
2.
Sheehy, J. L (1960) : Vasodilators therapy in sensorineural hearing loss. Larvngoscope 70 : 885-914.
3.
Shaia F. T., Sheehy, J. L. (1979) sensorineural hearing Sudden impairment — A report of 1220 cases. Larvngoscopc 86 : 389-98.
4.
Haug, 0., Draper, W. L and Haug S.
A. (1979) : Stellate ganglion blocks for idiopathic sensorineural hearing loss — A review of 76 cases. Arch. Otolmyngo! 102, 5-8.
5.
Suga F., Snow, J. B. JR (1969) Cochlear blood flow in response to vasodilating drugs and some related agents. Laryngoscope 79 : 1956-1979.
6.
Byl, F. M. (1984) : Sudden hearing loss. and years experience Eight suggested prognostic table. Laryngoscope 94 : 647-61.
7.
Byl. F. M. (1978) : Sudden hearing loss. Research Clinic Otolarvng Clinic North Am. 11 : 71 —9.
8.
Wilson W. R., Byl F. M., Larid N (1980) : The efficacy of steroids in the treatment of idiopathic sudden hearing loss. Arch Orolaryng 106 772-6.
9. Mattox D. E., Simmons F. B. (1977) Natural history of sudden sensorineural hearing loss. Am Otol Rhino! Laryngol, 86 : 463-80.
Indian Journal of Utolarvngologv and bead ana I vecK .urgery, volume t, tva. 1, .^cpremaerlrr, - ici
