Hyperbaric Oxygen Therapy vs Medical Therapy for Sudden Sensorineural Hearing Loss
Ahmed B. Bayoumy, BSc1; Erwin Lammet van der Veen, MD, PhD1; Jacob Alexander de Ru, MD, PhD1
Author Affiliations Article Information
JAMA Otolaryngol Head Neck Surg. Published online June 20, 2019. doi:10.1001/jamaoto.2019.0924
Sudden sensorineural hearing loss (SSNHL) occurs within 72 hours and is defined as hearing loss of at least 30 dB at 3 or more consecutive frequencies. Although steroids might be beneficial, an additional therapy is still warranted. Recently, several systematic reviews that assessed overlapping literature about the association of hyperbaric oxygen therapy (HBO) with enhancing recovery in patients with SSNHL in comparative studies have been published.1-3 The conclusion of those systematic reviews was that HBO may provide additional value to the conventional medical treatment methods with corticosteroids, especially in cases of severe hearing loss. Medical treatment was defined as standard therapy with corticosteroids (systemic and/or intratympanic) and, if applicable, combined with other drugs (eg, antiviral or vasodilator therapy). That result was as expected because those patients in general have poor recovery in the clinical setting and a larger absolute gain can be obtained. However, the methodological quality of the included studies1-3 was determined to be poor, and the risk of bias high. Furthermore, the outcome measures differed largely between studies, leading to difficulties in comparing and pooling study results. Therefore, only weak recommendations could be made.
We believe the major problem was not the methodology but the fact that HBO therapy was initiated relatively late. The cochlea is an organ with a high oxygen demand but with relatively limited vascular supply. Because of the proposed causes of SSNHL, in which oxygen shortage plays an important role, the oxygen supply should be raised by increasing the diffusion of oxygen into the inner ear. Thus, early initiation of HBO may prevent a cochlear penumbra from becoming ischemic, analogous to ischemic penumbra in the treatment of stroke.
Most studies did not honor this rationale for the therapy. Although we understand that lengthening the time frame reflects current clinical practice and is probably necessary to include enough patients in a study, early initiation of HBO remains the most crucial point in treating patients with SSNHL patients. Multiple studies have shown that early treatment with HBO is more beneficial than late treatment.4-7 Therefore, we would recommend initiation of HBO preferably within 24 or 48 hours. However, physicians should not withhold HBO if patients present after 48 hours, nor should they withhold salvage therapy.
The aim of this Viewpoint is to provide an overview for using HBO to treat SSNHL (Figure). We use the results of the 3 systematic reviews1-3 as well as 4 additional studies published in 2018. Rhee et al1 performed a meta-analysis of 14 studies regarding complete recovery. They found that 29.4% of patients who were treated with combined HBO and medical treatment had complete recovery compared with 20.7% in patients treated with medical treatment only (pooled odds ratio [OR], 1.61; 95% CI, 1.05-2.44). In the review by Erygit et al,2 HBO was found to be beneficial for patients with severe hearing loss. Saesen et al3 gave an overview of 19 studies that investigated the outcome of HBO. They found that 12 of 19 studies had clinically relevant outcomes when patients were treated with HBO; however, the definition of recovery varied considerably in those studies. The conclusion of the analysis was that there was a tendency toward a positive association of HBO with SSNHL.
Figure. View LargeDownload
Percentage of Complete Recovery
Percentage of Complete Recovery
HBO indicates hyperbaric oxygen therapy; MT, medical therapy; and SSNHL, sudden sensorineural hearing loss.
In most studies,1-3 HBO combined with medical treatment was superior to medical treatment alone. We consider it unlikely that these outcomes were caused by poor methods or bias only but rather that they constitute a genuine treatment effect. The methodological assessment of the individual studies can be found in the same systematic reviews.1-3
In studies of 3 systematic reviews,1-3 all except one compared combined HBO therapy with either systemic or intratympanic corticosteroids or both with the same therapies without HBO. Patients receiving HBO had higher absolute hearing gains in 12 of 14 studies. The absolute hearing gains were 26.9 dB in the HBO group and 18.2 dB in the medical treatment group. The mean difference between absolute hearing gains in the HBO and medical treatment groups was 11.2 dB (95% CI, 10.5-12.0 dB) in favor of combined HBO therapy.
In 14 of 16 studies, if the relative hearing gain was mentioned or calculated, HBO was superior to medical treatment. The mean relative hearing gain was 44.2% for HBO and 28.1% for medical treatment. Sixteen of 24 studies were in favor of HBO for complete recovery. Unfortunately, the definition of complete recovery varied between studies; therefore, we used the numbers for complete recovery as described within the individual studies, and these numbers do not always concur with what we considered complete recovery. Complete recovery was found in 444 of 1502 patients (29.5%) who were treated with HBO and medical treatment, whereas 338 of 1686 patients (20.0%) who were treated with medical treatment only had complete recovery (OR, 1.79; 95% CI, 1.50-2.14). This percentage seems lower than the spontaneous recovery rate of 35% to 39% expected in SSNHL; however, the studies contributing the most to this lower percentage either started HBO too late or intended HBO as salvage therapy. The specific definitions of salvage therapy may again differ from study to study, but in general it is defined as patients who were refractory to conventional corticosteroid therapy and were subsequently treated with HBO. Concerning the treatment regimen, studies differed in absolute atmospheric pressure (from 1.5-2.8 ATA), duration of the treatment session (30-120 minutes), and amount of sessions (10-25 sessions) given. No one clear regimen exists, and with the current data, it is hard to distill which regimen is preferable. We use 2.5 ATA for 90 minutes in 10 sessions.8 However, more important than differences in the treatment regimen is the time to initiation of HBO therapy.
We are convinced that early initiation of HBO therapy is the most important factor determining the outcome—both clinical and in research—and that SSNHL should be considered an otolaryngologic emergency. Future studies should focus on earlier initiation of combined HBO with corticosteroid therapy and should use uniform assessment criteria, such as those proposed by the American Academy of Otolaryngology–Head and Neck Surgery Foundation guidelines on reporting hearing outcome.
Back to top Article Information
Corresponding Author: Ahmed B. Bayoumy, BSc, Lundlaan 1 3584EZ, Utrecht, the Netherlands (a.b.bayoumy@amc.uva.nl).
Published Online: June 20, 2019. doi:10.1001/jamaoto.2019.0924
Conflict of Interest Disclosures: None reported.
References
1.
Rhee TM, Hwang D, Lee JS, Park J, Lee JM. Addition of hyperbaric oxygen therapy vs medical therapy alone for idiopathic sudden sensorineural hearing loss: a systematic review and meta-analysis. JAMA Otolaryngol Head Neck Surg. 2018;(12):1153. doi:10.1001/jamaoto.2018.2133
ArticlePubMedGoogle Scholar
2.
Eryigit B, Ziylan F, Yaz F, Thomeer H. The effectiveness of hyperbaric oxygen in patients with idiopathic sudden sensorineural hearing loss: a systematic review. European archives of oto-rhino-laryngology: official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS): affiliated with the German Society for Oto-Rhino-Laryngology, Head and Neck Surgery. Head Neck Surg. 2018;275(12):2893-2904.Google Scholar
3.
Saesen K, Loos E, Montagna C, Vanbrabant T, Goedhuys R, Lemkens N. Hyperbaric oxygen therapy in idiopathic sudden sensorineural hearing loss. B-ENT. 2017;13(2):105-112.Google Scholar
4.
Hosokawa S, Sugiyama K, Takahashi G, Takebayashi S, Mineta H. Prognostic factors for idiopathic sudden sensorineural hearing loss treated with hyperbaric oxygen therapy and intravenous steroids. J Laryngol Otol. 2017;131(1):77-82. doi:10.1017/S0022215116009725PubMedGoogle ScholarCrossref
5.
Khater A, El-Anwar MW, Nofal AA, Elbahrawy AT. Sudden Sensorineural Hearing Loss: Comparative Study of Different Treatment Modalities. Int Arch Otorhinolaryngol. 2018;22(3):245-249. doi:10.1055/s-0037-1605376PubMedGoogle ScholarCrossref
6.
Nakashima T, Fukuta S, Yanagita N. Hyperbaric oxygen therapy for sudden deafness. Adv Otorhinolaryngol. 1998;54:100-109.PubMedGoogle Scholar
7.
Xie S, Qiang Q, Mei L, et al. Multivariate analysis of prognostic factors for idiopathic sudden sensorineural hearing loss treated with adjuvant hyperbaric oxygen therapy. European archives of oto-rhino-laryngology: official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS): affiliated with the German Society for Oto-Rhino-Laryngology, Head and Neck Surgery. Head Neck Surg. 2018;275(1):47-51.Google Scholar
8.
Bayoumy AB, van der Veen EL, van Ooij PAM, et al. Effect of hyperbaric oxygen therapy and corticosteroid therapy in military personnel with acute acoustic trauma. J R Army Med Corps. 2019;(Jan):5.PubMedGoogle Scholar
Ahmed B. Bayoumy, BSc1; Erwin Lammet van der Veen, MD, PhD1; Jacob Alexander de Ru, MD, PhD1
Author Affiliations Article Information
JAMA Otolaryngol Head Neck Surg. Published online June 20, 2019. doi:10.1001/jamaoto.2019.0924
Sudden sensorineural hearing loss (SSNHL) occurs within 72 hours and is defined as hearing loss of at least 30 dB at 3 or more consecutive frequencies. Although steroids might be beneficial, an additional therapy is still warranted. Recently, several systematic reviews that assessed overlapping literature about the association of hyperbaric oxygen therapy (HBO) with enhancing recovery in patients with SSNHL in comparative studies have been published.1-3 The conclusion of those systematic reviews was that HBO may provide additional value to the conventional medical treatment methods with corticosteroids, especially in cases of severe hearing loss. Medical treatment was defined as standard therapy with corticosteroids (systemic and/or intratympanic) and, if applicable, combined with other drugs (eg, antiviral or vasodilator therapy). That result was as expected because those patients in general have poor recovery in the clinical setting and a larger absolute gain can be obtained. However, the methodological quality of the included studies1-3 was determined to be poor, and the risk of bias high. Furthermore, the outcome measures differed largely between studies, leading to difficulties in comparing and pooling study results. Therefore, only weak recommendations could be made.
We believe the major problem was not the methodology but the fact that HBO therapy was initiated relatively late. The cochlea is an organ with a high oxygen demand but with relatively limited vascular supply. Because of the proposed causes of SSNHL, in which oxygen shortage plays an important role, the oxygen supply should be raised by increasing the diffusion of oxygen into the inner ear. Thus, early initiation of HBO may prevent a cochlear penumbra from becoming ischemic, analogous to ischemic penumbra in the treatment of stroke.
Most studies did not honor this rationale for the therapy. Although we understand that lengthening the time frame reflects current clinical practice and is probably necessary to include enough patients in a study, early initiation of HBO remains the most crucial point in treating patients with SSNHL patients. Multiple studies have shown that early treatment with HBO is more beneficial than late treatment.4-7 Therefore, we would recommend initiation of HBO preferably within 24 or 48 hours. However, physicians should not withhold HBO if patients present after 48 hours, nor should they withhold salvage therapy.
The aim of this Viewpoint is to provide an overview for using HBO to treat SSNHL (Figure). We use the results of the 3 systematic reviews1-3 as well as 4 additional studies published in 2018. Rhee et al1 performed a meta-analysis of 14 studies regarding complete recovery. They found that 29.4% of patients who were treated with combined HBO and medical treatment had complete recovery compared with 20.7% in patients treated with medical treatment only (pooled odds ratio [OR], 1.61; 95% CI, 1.05-2.44). In the review by Erygit et al,2 HBO was found to be beneficial for patients with severe hearing loss. Saesen et al3 gave an overview of 19 studies that investigated the outcome of HBO. They found that 12 of 19 studies had clinically relevant outcomes when patients were treated with HBO; however, the definition of recovery varied considerably in those studies. The conclusion of the analysis was that there was a tendency toward a positive association of HBO with SSNHL.
Figure. View LargeDownload
Percentage of Complete Recovery
Percentage of Complete Recovery
HBO indicates hyperbaric oxygen therapy; MT, medical therapy; and SSNHL, sudden sensorineural hearing loss.
In most studies,1-3 HBO combined with medical treatment was superior to medical treatment alone. We consider it unlikely that these outcomes were caused by poor methods or bias only but rather that they constitute a genuine treatment effect. The methodological assessment of the individual studies can be found in the same systematic reviews.1-3
In studies of 3 systematic reviews,1-3 all except one compared combined HBO therapy with either systemic or intratympanic corticosteroids or both with the same therapies without HBO. Patients receiving HBO had higher absolute hearing gains in 12 of 14 studies. The absolute hearing gains were 26.9 dB in the HBO group and 18.2 dB in the medical treatment group. The mean difference between absolute hearing gains in the HBO and medical treatment groups was 11.2 dB (95% CI, 10.5-12.0 dB) in favor of combined HBO therapy.
In 14 of 16 studies, if the relative hearing gain was mentioned or calculated, HBO was superior to medical treatment. The mean relative hearing gain was 44.2% for HBO and 28.1% for medical treatment. Sixteen of 24 studies were in favor of HBO for complete recovery. Unfortunately, the definition of complete recovery varied between studies; therefore, we used the numbers for complete recovery as described within the individual studies, and these numbers do not always concur with what we considered complete recovery. Complete recovery was found in 444 of 1502 patients (29.5%) who were treated with HBO and medical treatment, whereas 338 of 1686 patients (20.0%) who were treated with medical treatment only had complete recovery (OR, 1.79; 95% CI, 1.50-2.14). This percentage seems lower than the spontaneous recovery rate of 35% to 39% expected in SSNHL; however, the studies contributing the most to this lower percentage either started HBO too late or intended HBO as salvage therapy. The specific definitions of salvage therapy may again differ from study to study, but in general it is defined as patients who were refractory to conventional corticosteroid therapy and were subsequently treated with HBO. Concerning the treatment regimen, studies differed in absolute atmospheric pressure (from 1.5-2.8 ATA), duration of the treatment session (30-120 minutes), and amount of sessions (10-25 sessions) given. No one clear regimen exists, and with the current data, it is hard to distill which regimen is preferable. We use 2.5 ATA for 90 minutes in 10 sessions.8 However, more important than differences in the treatment regimen is the time to initiation of HBO therapy.
We are convinced that early initiation of HBO therapy is the most important factor determining the outcome—both clinical and in research—and that SSNHL should be considered an otolaryngologic emergency. Future studies should focus on earlier initiation of combined HBO with corticosteroid therapy and should use uniform assessment criteria, such as those proposed by the American Academy of Otolaryngology–Head and Neck Surgery Foundation guidelines on reporting hearing outcome.
Back to top Article Information
Corresponding Author: Ahmed B. Bayoumy, BSc, Lundlaan 1 3584EZ, Utrecht, the Netherlands (a.b.bayoumy@amc.uva.nl).
Published Online: June 20, 2019. doi:10.1001/jamaoto.2019.0924
Conflict of Interest Disclosures: None reported.
References
1.
Rhee TM, Hwang D, Lee JS, Park J, Lee JM. Addition of hyperbaric oxygen therapy vs medical therapy alone for idiopathic sudden sensorineural hearing loss: a systematic review and meta-analysis. JAMA Otolaryngol Head Neck Surg. 2018;(12):1153. doi:10.1001/jamaoto.2018.2133
ArticlePubMedGoogle Scholar
2.
Eryigit B, Ziylan F, Yaz F, Thomeer H. The effectiveness of hyperbaric oxygen in patients with idiopathic sudden sensorineural hearing loss: a systematic review. European archives of oto-rhino-laryngology: official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS): affiliated with the German Society for Oto-Rhino-Laryngology, Head and Neck Surgery. Head Neck Surg. 2018;275(12):2893-2904.Google Scholar
3.
Saesen K, Loos E, Montagna C, Vanbrabant T, Goedhuys R, Lemkens N. Hyperbaric oxygen therapy in idiopathic sudden sensorineural hearing loss. B-ENT. 2017;13(2):105-112.Google Scholar
4.
Hosokawa S, Sugiyama K, Takahashi G, Takebayashi S, Mineta H. Prognostic factors for idiopathic sudden sensorineural hearing loss treated with hyperbaric oxygen therapy and intravenous steroids. J Laryngol Otol. 2017;131(1):77-82. doi:10.1017/S0022215116009725PubMedGoogle ScholarCrossref
5.
Khater A, El-Anwar MW, Nofal AA, Elbahrawy AT. Sudden Sensorineural Hearing Loss: Comparative Study of Different Treatment Modalities. Int Arch Otorhinolaryngol. 2018;22(3):245-249. doi:10.1055/s-0037-1605376PubMedGoogle ScholarCrossref
6.
Nakashima T, Fukuta S, Yanagita N. Hyperbaric oxygen therapy for sudden deafness. Adv Otorhinolaryngol. 1998;54:100-109.PubMedGoogle Scholar
7.
Xie S, Qiang Q, Mei L, et al. Multivariate analysis of prognostic factors for idiopathic sudden sensorineural hearing loss treated with adjuvant hyperbaric oxygen therapy. European archives of oto-rhino-laryngology: official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS): affiliated with the German Society for Oto-Rhino-Laryngology, Head and Neck Surgery. Head Neck Surg. 2018;275(1):47-51.Google Scholar
8.
Bayoumy AB, van der Veen EL, van Ooij PAM, et al. Effect of hyperbaric oxygen therapy and corticosteroid therapy in military personnel with acute acoustic trauma. J R Army Med Corps. 2019;(Jan):5.PubMedGoogle Scholar
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