What is the rational use of steroids, such as prednisolone (corticosteroid) or dexamethasone (corticosteroid), in the treatment of ear conditions?

Rational Use of Steroids for Ear Conditions

Systemic and intratympanic corticosteroids are strongly recommended for sudden sensorineural hearing loss (SSNHL), with treatment ideally initiated within the first 14 days of symptom onset, though benefit has been reported up to 6 weeks after onset. 1, 2

Systemic Corticosteroid Therapy

Dosing and Administration

• For SSNHL, prednisone should be administered at 1 mg/kg/day as a single dose (maximum 60 mg daily) for 7-14 days, followed by a taper over a similar time period 1, 2
• Methylprednisolone (48 mg/day) or dexamethasone (10 mg/day) are alternative options 1
• Do not divide doses; administer as a single daily dose 1
• Early treatment at appropriate starting doses is crucial as underdosing should be avoided to ensure optimal outcomes 2

Monitoring and Safety

• Monitor audiograms at completion of treatment course and at delayed intervals 1
• Most serious side effects occur with chronic steroid use rather than short courses, with adverse events being manageable for the recommended 10-14 day course 1, 3
• Common side effects include hyperglycemia, hypertension, insomnia, and weight gain 1
• Patients with certain conditions (insulin-dependent or poorly controlled diabetes, labile hypertension, glaucoma, tuberculosis, peptic ulcer disease) may not be suitable candidates for systemic corticosteroids 1

Intratympanic (IT) Corticosteroid Therapy

Indications

• IT steroids are recommended as:
  • Initial therapy option for SSNHL (particularly for patients who cannot receive systemic steroids) 1
  • Salvage therapy when patients have incomplete recovery from SSNHL 2-6 weeks after onset of symptoms 1

Dosing and Administration

• Dexamethasone: 24 mg/mL (compounded) or 10 mg/mL (stock) if compounded concentration unavailable 1
• Methylprednisolone: 40 mg/mL or 30 mg/mL 1
• Inject 0.4 to 0.8 mL into middle ear space up to 4 injections over a 2-week period 1
• Keep head in otologic position (affected ear up) for 15-30 minutes after injection 1
• Higher concentrations appear to have better outcomes 1

Technique and Monitoring

• Fill the middle ear with steroid solution 1
• Inspect tympanic membrane to ensure healing at completion of treatment course 1
• Consider interval audiograms between injections to help direct early termination of therapy if hearing loss resolves 1
• May insert pressure-equalizing tube if planning multiple injections, though this increases risk of tympanic membrane perforation 1

Comparative Efficacy

Systemic vs. Intratympanic Steroids

• IT steroids achieve higher perilymph steroid concentrations compared to systemic administration 1
• For SSNHL, post-treatment outcomes are comparable between oral prednisone and IT methylprednisolone when administered within 2 weeks of symptom onset 4
• IT steroids are a reasonable alternative to systemic therapy for patients who cannot receive systemic corticosteroids 1

Dexamethasone vs. Methylprednisolone

• For refractory SSNHL, IT methylprednisolone shows significantly better hearing improvement (84%) compared to IT dexamethasone (64%) 5
• One meta-analysis showed significantly better outcomes with dexamethasone compared to methylprednisolone, though study designs varied considerably 1

Special Considerations

Timing of Treatment

• Treatment with corticosteroids offers greatest recovery when started within the first 2 weeks of symptom onset 2
• For salvage therapy with IT steroids, treatment should be initiated within 2-6 weeks after onset of symptoms 1

Potential Adverse Effects

• IT steroids: Pain, transient dizziness, infection, persistent tympanic membrane perforation, and possible vasovagal or syncopal episode during injection 1
• Systemic steroids: Acne, blurred vision, cataracts/glaucoma, easy bruising, insomnia, hypertension, increased appetite, weight gain, lower resistance to infection, muscle weakness, osteoporosis, gastric irritation 1
• Severe complications are rare (0.9% in one study) but can include peptic ulcer and avascular necrosis of the femoral head 3

Important Caveats

• The exact molecular form of the steroid (e.g., dexamethasone vs. dexamethasone-phosphate) has significant implications for entry into perilymph and elimination from perilymph 6
• Lack of precision in steroid nomenclature can lead to inconsistent clinical results 6
• For ear infections with tympanostomy tubes, antibiotic-steroid combination ear drops (e.g., ciprofloxacin-dexamethasone) are preferred over oral antibiotics 7, 8