Can corticosteroids affect hearing, and what are the risks in patients with diabetes, hypertension, infection, or osteoporosis?

Can Steroids Affect Hearing?

Corticosteroids do not cause hearing loss; rather, they are the primary treatment for sudden sensorineural hearing loss (SSNHL) and can actually improve hearing outcomes in specific inner ear conditions. 1, 2

Therapeutic Effects on Hearing

Steroids are beneficial for hearing in several conditions:

• Sudden sensorineural hearing loss: Oral corticosteroids (prednisone 1 mg/kg/day, maximum 60 mg daily) for 10-14 days result in hearing improvement in more than 75% of treated patients 1
• Autoimmune inner ear disease: Patients with immune-mediated hearing losses show the best results with intratympanic corticosteroids 3
• Meniere's disease and inflammatory inner ear conditions: Intratympanic steroid treatment produces improvement in cochlear function, with 41% of patients showing significant improvement 4

Mechanism of Hearing Improvement

Steroids work through multiple pathways in the inner ear:

• Higher inner ear concentrations: Intratympanic administration achieves much higher penetration into cochlear fluids compared to systemic administration, with methylprednisolone showing the best profile 3
• Anti-inflammatory and antiapoptotic effects: Glucocorticoids bind to mineralocorticoid and glucocorticoid receptors in the ear, providing survival signals and maintaining ion homeostasis critical for auditory function 5
• Restoration of cochlear function: Treatment addresses cochlear inflammation and can result in significant recovery even from severe hearing loss (>120 dB to 85 dB) 6

Risks in Patients with Comorbidities

Diabetes

• Hyperglycemia is the most common adverse effect: Among non-diabetic patients receiving high-dose systemic steroids (>1,499 mg cumulative prednisolone), 67% developed diabetic levels of fasting blood glucose 7
• Diabetic patients are at higher risk: 100% of diabetic patients receiving high-dose steroids developed hyperglycemia, with a strong correlation (r = 0.51) between blood glucose levels and glucocorticoid dose 7
• Intratympanic steroids are preferred: For patients with diabetes who cannot tolerate systemic corticosteroids, intratympanic steroids provide an effective alternative without systemic glucose effects 1

Hypertension

• Short-term courses are generally manageable: Most serious side effects occur with chronic use rather than the 10-14 day courses recommended for SSNHL 1
• Monitor blood pressure: Hypertension is listed among documented side effects, with dose-response relationships established 1
• Consider intratympanic route: Patients with labile hypertension may not be able to receive systemic corticosteroids but can receive intratympanic injections with equivalent efficacy 1

Infection Risk

• Minimal with short courses: Adverse events are rare and manageable for short 10-14 day courses 1
• Intratympanic administration risks: Transient otitis media can occur (3 of 37 patients in one series) but is easily controlled with antibiotics 3
• Other intratympanic complications: Infrequent adverse effects include pain, transient dizziness, infection, and persistent tympanic membrane perforation 1

Osteoporosis

• Fracture risk increases with dose and duration: Vertebral fractures occur at 21-30% incidence with prolonged use, with dose-response relationships documented 1
• Short courses pose lower risk: Recent (within 12 months) and prolonged (≥90 days) glucocorticoid use is associated with reduced bone mineral density, but 10-14 day courses carry acceptable risk 1
• Preexisting bone disease increases risk: Osteonecrosis and fractures occur more commonly in patients with preexisting bone or joint problems such as systemic lupus erythematosus and rheumatoid arthritis 1

Clinical Decision-Making Algorithm

For patients requiring steroid treatment for hearing loss:

1. Assess contraindications to systemic steroids: Insulin-dependent or poorly controlled diabetes, labile hypertension, glaucoma, tuberculosis, peptic ulcer disease, prior psychiatric reactions 1

2. If systemic steroids are contraindicated: Offer intratympanic steroid injections, which are equally effective (>75% improvement rate) without systemic adverse effects 1

3. If systemic steroids are appropriate: Use prednisone 1 mg/kg/day (maximum 60 mg daily) for 7-14 days, followed by taper over similar period 1, 2

4. Monitor high-risk patients closely:

   • Diabetic patients: Check blood glucose levels, as hyperglycemia occurs in majority of patients 7
   • Hypertensive patients: Monitor blood pressure during treatment 1
   • Osteoporotic patients: Consider intratympanic route to minimize systemic exposure 1

5. Timing is critical: Initiate treatment within 14 days of symptom onset for optimal outcomes, though benefit has been reported up to 6 weeks 1, 2

Common Pitfalls to Avoid

• Underdosing: The commonly prescribed methylprednisolone dose pack provides significantly less than the recommended total dose of 540 mg prednisone over 14 days for a 60-kg adult 2
• Delayed treatment: Greatest recovery occurs when treatment starts within the first 2 weeks of symptom onset 2, 6
• Assuming steroids cause hearing loss: Steroids are therapeutic, not ototoxic; any hearing symptoms during treatment likely reflect the underlying condition rather than drug effects 8