Tinnitus in Sudden Sensorineural Hearing Loss

The Relationship Between Sudden Sensorineural Hearing Loss (SSHL) and Tinnitus

Sudden Sensorineural Hearing Loss (SSHL) is characterized by a sudden loss of hearing that occurs to a noticeable extent. This disease is medically defined as a neural hearing loss of at least 30 dB (unit of measurement of the loudness of a sound) in at least 3 contiguous audiometric frequencies occurring within a period of time shorter than 3 days. Almost all sudden (sensorineural) hearing loss (SSHL) cases are unilateral; and the percentage of the cases with bilateral involvement is just 2%. 70% of these patients suffer from tinnitus. Vertigo is seen in 50% them. The incidence rate of SSHL increases with age. It is seen in every 5 out of 100,000 people aged 20-30, and in every 16 out of 100,000 people aged 50-60 years of age.

A patient with sudden sensorineural hearing loss also feels humming noise, blockage, and tinnitus in the affected ear; and sometimes dizziness may occur, as well. Although 85-90% of the cases are diagnosed as sudden sensorineural hearing loss with unknown cause, there are certain factors that pave the way for it. Some of the factors for the emergence of this disease are listed as vascular and viral causes, ruptured membranes in the inner ear, autoimmunity (destruction of the body by the immune system), and tumoral causes. Although self-healing is seen in 1/3 to 2/3 of cases, it is known that the chances of recovery is lower in patients untreated in the first 2 weeks, who suffer from severe hearing loss and dizziness. For the treatment of sudden sensorineural hearing loss, it is very important to start the treatment within the first week after the identification of the symptoms. Delays constitute a disadvantage, and may cause the disorder to be a permanent hearing loss.

Tinnitus in Sudden Sensorineural Hearing Loss

If the hearing loss has not been eliminated in a sudden sensorineural hearing loss, no matter whether treated or not, the loss becomes permanent. In such cases, the only thing that can be done is to resort to hearing aids. In permanent cases, the hearing loss is accompanied by tinnitus in 70% of patients. There isa very limited number of scientific studies conducted on tinnitus that occurs in cases of sudden sensorineural hearing loss. Some studies suggest that sound transmission to the hearing nerves in the brain, beyond the inner ear, declines due to sudden sensorineural hearing loss, and then tinnitus occurs as a result of the central neural changes at higher levels. Sound echoing in the ear is usually accompanied by tinnitus; however, it is a condition that does not affect the person to a considerable extent. Regarding SSHL, it has been reported that in the treatment of tinnitus associated with hearing loss, damage and pathologies may occur at the end points extending from the ear to the brain, and that treatment procedures should be carried out accordingly. Recovery process may take up to 12 months due to the difficulties in SSHL. Additional drug treatments can be carried out for accelerating the recovery process. In some patients, the cause of SSHL can associated with metabolic disorders. In this group of patients with hearing loss and tinnitus, a nutritional program should also be recommended to control both sugar and fat metabolism, in addition to the drug treatments. In a study conducted on 12 patients with, SSHL was considered to be an important sign of anterior inferior cerebellar artery (AICA) infarction (occlusion), in addition to other findings. Audiologic studies suggest that the dysfunction of the cochlea section of the inner ear, usually caused by ischemia (vascular occlusion), is the cause of sudden sensorineural hearing loss in AICA infarction. In this patient group, improvement was seen in tinnitus after the treatment of ischemia.

If SSHL is suspected, a hearing test (audiogram) should be performed without delay. A hearing test shows the hearing loss in the affected ear, the degree of the loss, and the frequencies affected by it (low-pitched tones, high pitched tones or all tones). Certain blood tests can be performed to reveal vascular and metabolic factors in the patient. MRI (Magnetic Resonance Imaging) and CT (computed tomography) examinations should be performed to eliminate the possibility of any tumor involvement. A tumor called “ Acoustic Neurinoma” can be found in one of 100 cases of sudden sensorineural hearing loss (on an average), while a tumor may appear in company with sudden sensorineural hearing loss in about 10 in every 100 patients with Acoustic Neurinoma. In the treatment of sudden sensorineural hearing loss, we have to act very fast because we race against time. Although the stage of investigation of the cause is important, the treatment is initiated immediately without waiting for the results, if the diagnosis of sudden sensorineural hearing loss is definite. The treatment is initiated with many medications such as vasodilator agents and serums, virus killers, and circulation enhancers. Besides these medications, Cortisone therapy and Hyperbaric Oxygen therapy are very important, as well.

R-TMS treatment in Sudden Sensorineural Hearing Loss

In a study conducted in 2015, it was reported that more satisfactory results could be achieved if r-TMS therapy is carried out in conjunction with the treatment of sudden sensorineural hearing loss. The treatment is carried out in 20 sessions for a period of 4 weeks. In addition, if tinnitus has developed in SSHL, and if the cause of the tinnitus is on the pathways inside the brain, out of the retrocochlear region, the treatment becomes satisfactory in terms of tinnitus. In our treatments, we carry outr-TMS treatment in conjunction with the treatment protocols in acute phase. If permanent tinnitus has developed in late periods, we use it in the treatment of tinnitus.

Treatments in SSHL

Cortisone is usually administered in the form of pills but can also be given intravenously. Cortisone can have certain side effects such as increased blood sugar, increased blood pressure, heartburn, aggravated gastric ulcer, and osteoporosis. For this reason, it should be used with caution in people with diabetes, high blood pressure, gastric ulcer or osteoporosis. The patient should definitely limit his/her sugar and salt consumption during cortisone treatment. Stomach protective medicines are also given for the possible side effects. These treatments can be done as outpatient treatments or in some cases the patient is hospitalized. If the patient suffers from serious dizziness, he/she can be hospitalized until the dizziness is taken under control or a diabetic patient can be hospitalized if his/her blood pressure is difficult to control.

Cortisone injection into the ear is a procedure that has been added to treatments in recent years. The aim is to ensure that the cortisone given to the middle ear will be absorbed by the structure called the round window, and will then reach the inner ear, where it is expect to shows the desired effect. The process is carried out under a microscope. A fine needle passes through the eardrum and then the cortisone is injected into the middle ear. Another procedure involving the delivery of cortisone into the middle ear is carried out by placing a tube (ventilation tube) in the eardrum. In general, this process should not be preferred. Injection procedure is much better than tube insertion, in terms of the side effects. If a good result has not been achieved with the conventional treatment, cortisone should be injected into the ears, for giving a second chance to the patient to save the ear. In medical publications, it is reported that positive results can be achieved with this treatment in late periods.

Hyperbaric Oxygen Therapy (HBOT) is performed in a special cabin, where the patient inhales oxygen. A standard therapy consists of 20 sessions but maximum 40 sessions can be carried out. Although the person feels pressure in the ear during the therapy, it is at a tolerable level.

Before saying "this ear has no chance of healing anymore" to a patient, who has a full (or almost full) hearing loss in an ear, it is extremely important to encourage him/her to try everything with the treatment procedures mentioned above, in the light of scientific data. An ear that has advanced hearing loss despite the treatment can be enabled to benefit from hearing aids, by means of late-stage applications; and this can also be considered an important achievement. Of course, it should be kept in mind that some of patients with SSHL can recover from tinnitus, in cases of permanent hearing loss accompanied by tinnitus