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ORIGINAL ARTICLE
Year : 2022 | Volume
: 28
| Issue : 3 | Page : 194-197
Intratympanic treatment in chronic subjective tinnitus
Derya Mendes1, Kemal Koray Bal2, Onur Ismi1, Yusuf Vayisoglu1
1 Department of Otorhinolaryngology, Faculty of Medicine, University of Mersin, Mersin, Turkey
2 Lecturer Otorhinolaryngology Specialist, Mersin University Medicine Faculty Otorhinolaryngology Department, Meü Çiftlikköy Kampüsü 33343 Yenişehir-Mersi, Turkey
Correspondence Address:
Dr. Kemal Koray Bal
Lecturer Otorhinolaryngology Specialist, Mersin University Medicine Faculty Otorhinolaryngology Department, Meü Çiftlikköy Kampüsü 33343 Yenişehir-Mersi
Turkey
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/indianjotol.indianjotol_58_21
Aims: The aim of our study was to determine the efficacy of this treatment by evaluating the results of pure-tone audiometry, tinnitus rating scale, and tinnitus handicap questionnaire performed before and after intratympanic (IT) steroid treatment in patients with chronic subjective tinnitus who were not treated despite receiving medical treatment. Settings and Design: Twenty-three patients between 27 and 79 years of age who had normal physical examination had tinnitus complaints at least 3-month duration and who had been treated with IT steroid treatment were enrolled to the current study. Patients smaller than 18 years of age, patients with mental, neurological and psychological pathology, patients who had used any kind of medical treatment for tinnitus in the past 3 months, were excluded from the study. Subjects and Methods: The study included patients who were admitted to Mersin University Medicine Faculty Otorhinolaryngology Department, Department with tinnitus and were treated with IT steroid treatment. Written informed consent was obtained from all patients participating in the study. Statistical Analysis Used: All analyses were performed using IBM SPSS 22 package software trial version. The normal distribution of the data was examined with Shapiro–Wilk test. Frequency and percentage were calculated for categorical values. Results: In the tinnitus grading scale, a significant decrease in before and after treatment was determined for 17 patients with tinnitus complaints and was found statistically significant (P < 0.001). The results of tinnitus handicap questionnaires were rated between 21.4 and 69.6 for before treatment and between 11.4 and 63.6 for after treatment and were found statistically significant (P < 0.001). Conclusion: In this study, we found that IT steroid treatment decreased both tinnitus rating scale and tinnitus handicap scores for patients with chronic idiopathic tinnitus without hearing loss.
Keywords: Dexamethasone, otolaryngology, steroids, therapeutics, tinnitus
Tinnitus, from the Latin tinnire meaning to ring, is a heterogeneous diagnosis that may occur alone, in the presence of hearing loss, or as a component of other disorders, and can be quite disabling.[1] When the causes of tinnitus are examined, the most common cause of tinnitus is idiopathic tinnitus (62%). The cause of known tinnitus was reported as exposure to noise (20%), head-and-neck injuries (9%), ear problems (7%), ototoxic drug use, and Meniere's disease (2%).[2] Tinnitus is generally divided into two groups as objective and subjective. According to objective tinnitus, which can also be heard by people other than the patient, subjective tinnitus is more common than can be heard only by the patient.[3] According to the duration of tinnitus, “acute” and “chronic” tinnitus are divided into two groups. Chronic tinnitus is long-lasting, clinically more than 3 months of tinnitus.[4]
In addition to accepted treatment modalities for tinnitus such as hearing aid amplification, masking techniques, tinnitus retraining therapy, or certain oral medications, the option of managing certain forms of tinnitus with intratympanic (IT) therapies should be considered in selected cases.[1]
Meyer wrote a short report on the IT treatment of tinnitus with morphine.[5] Sakata et al. reported a retrospective study with IT dexamethasone for tinnitus in 109 patients (138 ears). Tinnitus was abolished in 63% of patients, ameliorated in 27%, and remained unchanged in 10%.[6]
Limited number of studies were published on the use of IT steroids in subjective tinnitus.[7],[8],[9],[10],[11],[12],[13] In the Shim study, IT steroids were administered to patients with acute tinnitus and idiopathic tinnitus. Tinnitus handicap inventory and a subjective instrument, the visual analog scale, were used during the evaluation.[7]
The aim of our study was to determine the efficacy of this treatment by evaluating the results of pure-tone audiometry, tinnitus rating scale, and tinnitus handicap questionnaire performed before and after IT steroid treatment in patients with chronic subjective tinnitus who were not treated despite receiving medical treatment.
Subjects and MethodsThe study included patients who were admitted to Mersin University Medicine Faculty Otorhinolaryngology Department Department with tinnitus and were treated with IT steroid treatment. Written informed consent was obtained from all patients participating in the study.
Twenty-three patients between 27 and 79 years of age who had normal physical examination, had tinnitus complaints at least 3-month duration, and who had been treated with IT steroid treatment were enrolled to the current study. Patients smaller than 18 years of age, patients with mental, neurological and psychological pathology, patients who had used any kind of medical treatment for tinnitus in the past 3 months, were excluded from the study.
Complete blood count, blood biochemistry parameters (sodium, potassium, urea, creatinine, liver function tests), serum cholesterol and triglyceride levels, thyroid function, ferritin, transferrin, serum iron-binding capacity, Vitamin B12, folic acid levels were measured. Temporal magnetic resonance imaging was performed in all cases. No abnormalities were found in the results. All cases had idiopathic tinnitus.
The patients were asked to complete the tinnitus handicap questionnaire and tinnitus rating scale which were prepared for tinnitus patients.[14],[15],[16] As described, Handicap questionnaire results were evaluated by Hand comb without any handicap from 0 to 16, mild handicap between 18 and 36, moderate handicap between 38 and 56, and severe handicap between 58 and 100.[17]
IT dexamethasone was administered to the posterior inferior quadrant of the tympanic membrane at a dose of 8 mg\2 cc each time by the same otolaryngologist (all injections were made by otorhinolaryngologist). In the supine position, under the microscope, cotton soaked with lidocaine hydrochloride was placed on the tympanic membrane and left for 10 min. Then, cotton was taken and dexamethasone in the dental injector was applied to the patients slowly for about 1 min. After the application, the patients did not get up, talk, or swallow for 30 min. Patients received three doses of IT dexamethasone every other day.
One month after the treatment, the patients were called back to the control, and again, pure-tone audiometry was performed with tinnitus severity rating scale and tinnitus handicap questionnaire. Pretreatment and posttreatment results were compared to assess the efficacy of IT steroid dexamethasone treatment for chronic subjective tinnitus patients.
All analyses were performed using IBM SPSS 22 (IBM® SPSS®, USA) package software trial version. The normal distribution of the data was examined with Shapiro–Wilk Test. Frequency and percentage were calculated for categorical values. The variables were summarized as median (25P.–75P.) (P. = Percentile) since the data could not be determined by normal distribution and the Wilcoxon test was applied for two dependent group comparisons. The data were tested at a significance level of P ≤ 0.05.
Written consent form and consent were obtained from all patients before the procedure. Ethics committee approval was obtained from Mersin University Medicine Faculty Otorhinolaryngology Department, University Ethics Committee. Ethics committee decision number was 2017/85; ethics committee protocol number was 78017789/050.01.04/377855.
ResultsTwelve (52.2%) of the 23 patients included in the study were female and 11 (47.8%) were male. These patients were between the ages of 27 and 79 and the mean age was 57.5 ± 12.3 years. Thirteen (56.5%) of these patients underwent IT steroid treatment in the left ear and 10 (43.5%) in the right ear. Patients in the study had no hearing loss. None of the patients had bilateral tinnitus.
According to the tinnitus rating scale scores, 6 patients' tinnitus rating scale scores did not change after IT steroid treatment. After treatment, three patients gave 1 point, four patients gave 2 points, seven patients gave 3 points, and three patients gave 5 points. For overall patients, there was a statistically significant decrease in tinnitus rating scale scores after treatment (P < 0.001) [Table 1] and [Table 2].
Table 1: The statistical value of tinnitus rating scale before and after treatmentThe handicap questionnaire given before and after the IT steroid treatment of the patients was evaluated with a score of 100 points. In this survey, yes, no, and sometimes 3 answers were found, and yes or some patients were asked to give a value of at least 1 and 10, and each increase was calculated according to the increase of 0.2 points. Calculation results were evaluated with Hand comb no handicap between 0 and 16, mild handicap between 18 and 36, moderate handicap between 38 and 56, and severe handicap between 58 and 100.
According to tinnitus handicap questionnaire, IT steroid values were calculated between 21.4 and 69.6 before treatment and 11.4–63.6 after treatment. Accordingly, 6 (26.1%) patients had mild handicap, 9 (39.1%) patients had moderate handicap, 8 (34.8%) patients had severe handicap, before treatment. After treatment, there was no handicap in 6 (26.1%) patients, mild handicap in 14 (60.9%) patients, moderate handicap in 1 (4.3%) patient, and severe handicap in 2 (8.7%) patients [Figure 1].
Results of handicap questionnaire revealed a statistically significant difference between the values before and after treatment (P < 0.001) [Table 3].
Table 3: Statistical value of tinnitus handicap questionnaire before and after treatmentTemporary ear pain was seen in 11 (47.8%) patients during injection. Self-limited vertigo lasting maximum 10 min was seen in 7 (30.4%) of patients.
None of the patients had complications such as permanent perforation or otorrhea during and after treatment. No patient had any change in hearing tests after treatment.
DiscussionIn this study, we found that IT steroid treatment decreased both tinnitus rating scale and tinnitus handicap scores for patients with chronic idiopathic tinnitus without hearing loss.
Tinnitus is one of the most common symptoms of the hearing system, which affects the quality of life of the individual and can cause social and psychological problems. Tinnitus is seen in approximately 20% of the population and for 5%, it is a serious problem. The goal of tinnitus treatment is to completely eliminate tinnitus or to provide the patient with minimal discomfort.[18]
In 1956, Schuknecht first introduced IT aminoglycosides (streptomycin) for the treatment of Meniere's disease.[1],[19] Gentamicin as a treatment for Meniere's disease was later reported by Beck and Schmidt in 1978 and quickly gained popularity because vertigo control was achieved with acceptable preservation of hearing.[20] IT lidocaine has been tried in the treatment of tinnitus. In 1960, Kroath reported on the use of IT lidocaine in German literature.[21] Sakata used IT lidocaine in 168 patients (220 ears) to eliminate tinnitus in 34% of patients.[6]
Inner ear steroid receptors have been demonstrated in animal models and in human temporal bones.[22],[23] Increased cochlear blood flow has also been proposed as a mechanism by which corticosteroids act upon the inner ear.[24],[25] Factors influencing the passage of medication across the round window include mechanical obstruction within the middle ear, integrity and inflammation of the round window membrane, and the molecular weight, concentration, liposolubility, and electrical charge of the medication.[26],[27]
Regarding the effect of IT steroid treatment for idiopathic tinnitus, the results are challenging. Nearly 25 years ago, Sakata et al. found the efficacy of IT dexamethasone treatment for tinnitus patients as high as 72% and 75% in a large (1214 and 3041 patients) population, but very minority of these patients included idiopathic tinnitus, most patients had an underlying cause such as Meniere's disease, noice-induced hearing loss, sudden hearing loss, drug intoxicity, and others.[28] In 1992, Coles et al. administered dexamethasone to 6 patients with tinnitus, none had benefit from the therapy, but only one of them had idiopathic tinnitus.[29] Lee et al., Topak et al., Choi et al., and Araujo et al. found no significant effect of IT steroid treatment for idiopathic tinnitus.[8],[9],[12],[30] On the other hand, Shim et al. found that IT steroid treatment was effective for both patients with idiopathic tinnitus and acute noise-induced tinnitus.[7] She et al. demonstrated that IT steroid treatment was as effective as oral carbamazepine treatment for patients with subjective tinnitus.[13] Elzayat et al. presented that adding lidocaine to dexamethasone increased the effectiveness of IT treatment for patients with idiopathic tinnitus.[10],[11] In the Shim study, 4 doses of IT dexamethasone were administered every other day.[7] According to our study results, we found a statistically significant decrease in posttreatment tinnitus rating scale scores and tinnitus handicap questionnaire for all patients treated with IT dexamethasone therapy.
IT injection methods seem to be safe treatment modalities for control of tinnitus. According to a review, most commonly seen complications are ear pain (as much as 57%) and transient vertigo (as much as 100% of patients). More severe complications such as eardrum perforation or otitis media are seen in 0.1% of patients.[5] In our study, temporary ear pain was seen in 47.8% of patients and self-limited vertigo was seen in 30.4% of patients. Eardrum perforation, decrement in hearing levels, or otitis media was not seen in any patient. IT steroid treatment can be safely used for patients with chronic tinnitus. This treatment protocol decreases both tinnitus rating scale scores and handicap scores for patients with chronic idiopathic tinnitus patients. Further diagnostic methods and studies with more patients are needed to evaluate the effects of IT steroid treatment on tinnitus more objectively.
ConclusionIn conclusion, IT steroid treatment can be safely used for patients with chronic tinnitus. This treatment protocol decreases both tinnitus rating scale scores and handicap scores for patients with chronic idiopathic tinnitus patients. Further diagnostic methods and studies with more patients are needed to evaluate the effects of IT steroid treatment on tinnitus more objectively.
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Conflicts of interest
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References
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