**4. Discussion**

In this study, the treatment of sudden deafness and acute tinnitus with intratympanic corticosteroids after failure of oral therapy (rescue) was effective. The findings were consistent with the study in which the THI and VAS scores were significantly reduced after intratympanic steroids injections, and it was concluded that these scores were useful for assessing tinnitus patients, as well as it [15].

The intratympanic therapy is currently in use for ISSHL, Meniere's disease, tinnitus associated with these disorders and idiopathic tinnitus [15]. In previous studies, positive results of intratympanic steroids injections were reported for chronic subjective tinnitus [2, 16, 17], but they did not use the control group. Statistic significant difference between saline and dexamethasone solution when a control group was used regarding tinnitus improvement measured with visual analog scale (VAS).

A systematic review was conducted to determine the efficacy of intratympanic steroids treatment. It emphasized that this treatment should be considered as an adjuvant one in sudden deafness [18] consistent with the findings of this study.

The analysis of the characteristics of sudden deafness in 105 patients pointed out that there are individual differences in clinical characteristics between patients with tinnitus and ISSHL hindering a single treatment line [19]. We emphasize that both groups of this study were homogeneous, showing no statistical difference in age, sex, and affected ear.

By examining variables such as gender, age, and laterality in relation to changes in the level of tinnitus after the start of ISSHL, our results corroborate previous studies in which patients requiring rescue therapy were those in which oral therapy had not been sufficient to improve the hearing thresholds. Some patients improved hearing thresholds but remained with residual tinnitus [20].

Overall good results were reported in 77% of patients with tinnitus and various diseases immediately after the intratympanic dexamethasone treatment [21] and found that the best results of intratympanic therapy for tinnitus are obtained in patients with a shorter duration of tinnitus, especially when treatment was initiated within 3 months of symptom onset [17]. The effectiveness of intratympanic injection of prednisolone or dexamethasone to treat subjective tinnitus was reported to be 48.6 and 37.5%, respectively [22].

Similar results were found by other researchers that recommended intratympanic therapy as a possible option in the treatment of tinnitus to a certain group of patients [3, 23]. No difference in results was observed in patients between 3 and 6 months after treatment [23].

The shorter the period from onset of sudden deafness to the start of intratympanic treatment with dexamethasone, the greater the improvement in tinnitus that could be expected after treatment [24]. There is no significant difference after 3 months [6].

In this study, we chose to use intratympanic corticosteroid as rescue after failure of oral corticosteroids. We found that this association was particularly effective in relation to tinnitus. In Group 2, VAS and THI showed a significant reduction of tinnitus annoyance after intratympanic steroids therapy. Probably, these results are due to the fact that the rescue treatment was initiated immediately after the oral treatment did not show the desired results.

**4. Discussion**

182 Up to Date on Meniere's Disease

ual tinnitus [20].

patients, as well as it [15].

measured with visual analog scale (VAS).

deafness [18] consistent with the findings of this study.

In this study, the treatment of sudden deafness and acute tinnitus with intratympanic corticosteroids after failure of oral therapy (rescue) was effective. The findings were consistent with the study in which the THI and VAS scores were significantly reduced after intratympanic steroids injections, and it was concluded that these scores were useful for assessing tinnitus

The intratympanic therapy is currently in use for ISSHL, Meniere's disease, tinnitus associated with these disorders and idiopathic tinnitus [15]. In previous studies, positive results of intratympanic steroids injections were reported for chronic subjective tinnitus [2, 16, 17], but they did not use the control group. Statistic significant difference between saline and dexamethasone solution when a control group was used regarding tinnitus improvement

A systematic review was conducted to determine the efficacy of intratympanic steroids treatment. It emphasized that this treatment should be considered as an adjuvant one in sudden

The analysis of the characteristics of sudden deafness in 105 patients pointed out that there are individual differences in clinical characteristics between patients with tinnitus and ISSHL hindering a single treatment line [19]. We emphasize that both groups of this study were

By examining variables such as gender, age, and laterality in relation to changes in the level of tinnitus after the start of ISSHL, our results corroborate previous studies in which patients requiring rescue therapy were those in which oral therapy had not been sufficient to improve the hearing thresholds. Some patients improved hearing thresholds but remained with resid-

Overall good results were reported in 77% of patients with tinnitus and various diseases immediately after the intratympanic dexamethasone treatment [21] and found that the best results of intratympanic therapy for tinnitus are obtained in patients with a shorter duration of tinnitus, especially when treatment was initiated within 3 months of symptom onset [17]. The effectiveness of intratympanic injection of prednisolone or dexamethasone to treat subjec-

Similar results were found by other researchers that recommended intratympanic therapy as a possible option in the treatment of tinnitus to a certain group of patients [3, 23]. No difference

The shorter the period from onset of sudden deafness to the start of intratympanic treatment with dexamethasone, the greater the improvement in tinnitus that could be expected after

In this study, we chose to use intratympanic corticosteroid as rescue after failure of oral corticosteroids. We found that this association was particularly effective in relation to tinnitus. In Group 2, VAS and THI showed a significant reduction of tinnitus annoyance after intratympanic

in results was observed in patients between 3 and 6 months after treatment [23].

homogeneous, showing no statistical difference in age, sex, and affected ear.

tive tinnitus was reported to be 48.6 and 37.5%, respectively [22].

treatment [24]. There is no significant difference after 3 months [6].

It is significant the correlation between the degree of hearing recovery and subjective improvement of tinnitus after treatment. It was suggested that the hearing improvement may be a prognostic factor for tinnitus improvement, but the presence of tinnitus was not a prognostic factor for the recovery of hearing [25]. These findings are similar to those of the present study.

In this study, Group 2 had increase in the amplitude of DPOAE in all frequencies. There are studies in the literature that demonstrate a prognostic role for OAEs in the ISSHL [21, 26]. Other studies do not agree with this [27, 28].

The DPOAE is detectable in three of five patients whose hearing had significantly improved. It is suggested that the presence of DPOAE can be a useful prognostic factor that positively correlates with the recovery of the SHL [29].

It is reported a significant increase in the amplitude of DPOAE among patients who regained their hearing and also found significant correlations between improvement in DPOAE and improved hearing. It was stated that the presence of DPOAE predicted improvement in hearing [28, 30]. Our study is in agreement with these previous studies.

The detection of OAE during the first 15 days after starting treatment, even with no improvement in hearing, would suggest the high sensitivity of this test to detect improvement changes in the activity of outer hair cells [31].

The sudden deafness factors that predict a favorable prognosis are still controversial. Clinical recovery was estimated by the difference between the audiometric results on admission and the audiometric results 10 days later. Only two factors were significantly associated with improved hearing: tinnitus (*p* < 0.04) and the configuration of ascending audiometric curve at admission (*p* < 0.045) [32]. In this study, most subjects had flat audiometric curve.

Tinnitus was cured in 43 of 114 patients (37.7%) within 3 months. In our study, THI was significantly reduced after intratympanic dexamethasone, and this cure rate was significantly higher in patients with symptoms lasting 2 weeks or less. The authors concluded that the duration of symptoms affected the intratympanic dexamethasone cure rate for acute subjective tinnitus [33].

The feeling of ear fullness and tinnitus in ISSHL was compared in one study that found they were primarily associated with poorer hearing thresholds at high frequencies. They concluded that tinnitus is probably originated in the region where the hair cells are damaged [34]. Steroid intratympanic therapy for acute tinnitus was found effective. SSHL patients were excluded from that study. Our study is about ISSNHL patients with tinnitus that is necessarily acute.

Steroids were likewise effective for these patients. Probably, the short time from onset of tinnitus is the determinant factor to predict the effectiveness of steroids therapy.

Our study has some limitations that should be pointed out: we did not have a control group, as this group would be composed of patients who failed on oral therapy and were not treated with rescue therapy, which would not be correct from the point of view ethics and the number of patients is small in preliminary studies. Therefore, to confirm our results, we should consider a larger number of patients in future studies.

## **5. Conclusions**

Our results as well as other studies seem to point out to the effectiveness of steroids for the treatment of acute tinnitus. Both oral and intratympanic steroids were effective in our study. Intratympanic steroids improved tinnitus further in patients that did not respond well to oral steroids. The higher concentration of steroids in inner ear fluids after intratympanic injection probably explains this result.

Why steroids are effective to treat acute tinnitus and not to treat chronic tinnitus? We believe tinnitus start in the cochlea almost always. Later the cochlea lesion causes changes in central pathways that in some patients make the symptom permanent and extremely annoying‐severe disabling tinnitus (SDT) [2]. If tinnitus is treated before it sets foot in the central pathways (acute tinnitus), steroid therapy is effective.
