What is the recommended treatment for inner ear conditions?

Treatment of Inner Ear Conditions

For sudden sensorineural hearing loss (SSNHL), initiate systemic corticosteroids immediately—ideally within 14 days of symptom onset—using prednisone 1 mg/kg/day (maximum 60 mg daily) for 7-14 days followed by a taper, as this represents the primary evidence-based treatment with documented efficacy. 1

Primary Treatment: Corticosteroids for SSNHL

Systemic Steroid Therapy (First-Line)

• Prednisone 1 mg/kg/day as a single dose (maximum 60 mg daily) for 7-14 days, then taper over a similar period 2, 1
• Alternative agents include methylprednisolone 48 mg/day or dexamethasone 10 mg/day 2, 1
• Treatment offers greatest recovery when started within the first 2 weeks, though benefit has been reported up to 6 weeks after onset 2, 1, 3
• Avoid underdosing—the commonly prescribed methylprednisolone dose pack provides significantly less than the recommended total dose 3

Intratympanic (IT) Steroid Therapy

IT steroids serve two critical roles: as initial therapy for patients who cannot receive systemic steroids, and as salvage therapy for incomplete recovery. 1

As Initial Therapy:

• Use dexamethasone 24 mg/mL (compounded) or 10 mg/mL (stock) 1
• Alternative: methylprednisolone 40 mg/mL or 30 mg/mL 1
• Inject 0.4-0.8 mL into middle ear space, up to 4 injections over 2 weeks 1
• Higher concentrations achieve better outcomes 1
• IT steroids achieve higher perilymph concentrations than systemic administration 1

As Salvage Therapy:

• Offer IT steroids when patients have incomplete recovery 2-6 weeks after symptom onset 2, 1
• This applies after failure of any initial treatment (systemic steroids, HBOT, or observation) 2
• Studies show 37.5-47.6% improvement rates with IT salvage therapy versus 0-16% in control groups 2
• Initiate within 7 days of completing systemic treatment for optimal results 2

Contraindications and Side Effects

• Systemic steroids: hyperglycemia, hypertension, insomnia, weight gain 1
• Patients with diabetes, hypertension, or glaucoma may not be suitable candidates 1
• IT steroids: pain, transient dizziness, infection, tympanic membrane perforation, vasovagal episodes 1

Treatments NOT Recommended for SSNHL

Avoid Routine Use of These Agents:

Do not prescribe antivirals, thrombolytics, vasodilators, vasoactive substances, or antioxidants routinely for SSNHL—these have potential side effects with no documented efficacy. 2

• Multiple RCTs comparing antiviral therapy plus steroids versus placebo plus steroids showed no statistically significant benefit 2
• Antiviral side effects include nausea, vomiting, photosensitivity, and rarely neurologic reactions 2
• Vasodilators and vasoactive agents (prostaglandin E1, naftidrofuryl, calcium antagonists, Ginkgo biloba, pentoxifylline) lack proven efficacy 2
• These agents carry risks including allergic reactions, bleeding, hypotension, arrhythmias, seizures, and circulatory collapse 2

Hyperbaric Oxygen Therapy (HBOT)

• HBOT may be considered as adjuvant therapy with steroids within 2 weeks of onset for primary therapy, or within 4 weeks for salvage therapy 2
• Potentially more benefit in severe to profound hearing loss 2
• However, substantial cost, potential adverse effects (barotrauma), and uncertain clinical significance limit routine recommendation 2

Treatment of Ménière's Disease

Stepwise Approach:

Begin with dietary sodium restriction (1500-2300 mg daily) and lifestyle modifications, then progress to pharmacotherapy with diuretics, reserving intratympanic therapies for refractory cases. 4

First-Line: Dietary and Lifestyle Modifications

• Sodium restriction to 1500-2300 mg daily to reduce endolymphatic fluid accumulation 4
• Limit alcohol and caffeine intake as potential triggers 4
• Identify and manage allergies (contribute to symptoms in up to 30% of patients) 4
• Stress management through relaxation techniques, regular exercise, adequate sleep 4
• Maintain symptom diary to identify personal triggers 4

Acute Attack Management:

• Offer limited course of vestibular suppressants ONLY during acute vertigo attacks 4
• Options include antihistamines (dimenhidrinato, meclizine) 4
• Benzodiazepines for associated anxiety (use with caution due to dependence risk) 4

Maintenance Therapy:

• Diuretics (chlorthalidone, hydrochlorothiazide, acetazolamide) to alter endolymph electrolyte balance 4, 5
• Betahistine: Cannot make definitive recommendation due to questionable efficacy—the BEMED trial found no significant difference versus placebo 4

Intratympanic Therapies for Refractory Disease:

• IT steroids may be offered when patients fail non-invasive treatment, showing 85-90% improvement in vertigo symptoms 4
• Risks include hearing loss, tympanic membrane perforation, persistent imbalance 4
• IT gentamicin for persistent vertigo after failed conservative therapy, with 73.6% complete vertigo control rate 4
• Risk of hearing loss varies by administration method 4

Vestibular Rehabilitation:

• Offer vestibular rehabilitation for chronic imbalance between attacks or following ablative therapy 4
• Benefits include improved symptom control and reduced fall risk 4
• NOT recommended for acute vertigo attacks 4

NOT Recommended:

• Do not use positive pressure therapy (Meniett device)—systematic reviews show no significant difference versus placebo 4

Bacterial Ear Infections

Upper Respiratory Tract Infections of the Ear:

• Amoxicillin is indicated for infections due to susceptible (β-lactamase-negative) isolates of Streptococcus species, S. pneumoniae, Staphylococcus spp., or H. influenzae 6
• For infections with tympanostomy tubes, prefer antibiotic-steroid combination ear drops (e.g., ciprofloxacin-dexamethasone) over oral antibiotics 1

Critical Monitoring and Follow-Up

• Obtain audiogram before treatment, after each subsequent IT injection, at completion of treatment, and at delayed intervals 2
• Document resolution, improvement, or worsening of vertigo, tinnitus, and hearing loss after treatment 4
• Adjust treatment based on symptom evolution 4
• Monitor patients with diabetes or hypertension more closely during steroid therapy 3

Common Pitfalls to Avoid

• Do not delay treatment—spontaneous recovery is highest in first 2 weeks, matching the window for optimal steroid efficacy 2, 3
• Do not underdose steroids—ensure full 1 mg/kg/day dosing, not inadequate dose packs 3
• Do not use vestibular suppressants chronically—reserve for acute attacks only to avoid dependence 4
• Do not pursue unproven therapies (antivirals, vasodilators) that add cost and side effects without benefit 2