Steroids and the sudden hearing loss syndrome

I have read with much pleasure and major interest, the letter to the editor on 31^st May 2025 by Prof. Simon Roger (1) and my Colleague Dr Tom Kertez. Idiopathic sudden sensorineural hearing loss (ISSNHL) continues to be controversial.

The authors are to be thanked for bringing to our attention some of the real hazards of intra-tympanic steroids, some of which, I was not aware. Further, I have not seen, until recently, mention of these problems in any of the literature. It has been widely asserted that the complications of intra-tympanic therapy were minor, limited to infection and an occasional tympanic membrane perforation. The evidence offered by Roger and Kertez should lead to a thorough re-assessment of this practice.

In addition, it is well recognised that adverse effects of therapy with large doses of oral steroid are rare but occasionally there are catastrophic complications. This is discussed in a recent review (2). I have concerns for my colleagues who freely use steroids in this fashion if this treatment is not accompanied by a very careful informed consent process. Rogers and Whitaker (3) will always be with us.

If I may, I would like to make a few comments about this syndrome. As Roger and Kertez rightly say, ISSHLS indeed remains idiopathic despite the several suggested theories. I note that the case discussed was associated with diabetes. I know of no connection between the two conditions, but one wonders if this case was truly idiopathic. Further, in 40 years’ experience of Otology, I gained the impression that bilateral sudden hearing loss, whether simultaneous or serial such as discussed, is of excessive rarity.

Wilson et al. (4), indeed used the term “double-blind” in the title of this article which was, on examination, anything but double-blind. This is discussed at length in the article quoted above (2). Further, the same Dr. Wilson later co-authored an article entitled “Treatment of Sudden Hearing Loss is Illogical” (5). Mattox and Simmons (6) report a 65% spontaneous full recovery with another 10% making a partial recovery. Other authors have come to the same conclusion. In addition, several trials report that hearing recovery after intra-tympanic steroid is no better than the spontaneous rate (7,8).

It has been widely argued that “Although evidence of the efficacy of systemic steroids cannot be considered as strong enough to recommend their use, it is still the most widespread primary therapy and can be considered as the current standard of care” (9). In former times, this was the argument that was used in favour of phlebotomy.

Further, it has been claimed that “treatment efficacy will not be reduced using intratympanic steroid injections” (10). With respect to these authors, I submit that either treatment will not be shown to exceed the known rate of spontaneous recovery. Lastly, again with respect, I would have to disagree that the initial recovery that Prof. Roger experienced was due in any way to steroids. The reader will not be surprised to learn that my personal opinion, based on the evidence published (2) and many others, is that steroids are ineffectual and sometimes dangerous.

Acknowledgments

None.

Footnote

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References

1. Roger SD, Kertesz T. Administration of corticosteroids into the middle ear does not limit steroid-induced side effects. Aust J Otolaryngol 2025;8:21.
2. Murray DH, Fagan PA, Ryugo DK. Idiopathic sudden sensorineural hearing loss: A critique on corticosteroid therapy. Hear Res 2022;422:108565. [Crossref] [PubMed]
3. Rogers v Whitaker [1992] HCA 58; (1992) 175 CLR 479 (19 November 1992). Available online: https://www.paci.com.au/downloads_public/court/12_Rogers_v_Whitaker.pdf
4. Wilson WR, Byl FM, Laird N. The efficacy of steroids in the treatment of idiopathic sudden hearing loss. A double-blind clinical study. Arch Otolaryngol 1980;106:772-6. [Crossref] [PubMed]
5. Nadol J, Wilson W. Treatment of sudden hearing loss is illogical. In: Controversy in Otolaryngology. Snow J, editor. Philadelphia: W.B. Saunders Co.; 1980:22-32.
6. Mattox DE, Simmons FB. Natural history of sudden sensorineural hearing loss. Ann Otol Rhinol Laryngol 1977;86:463-80. [Crossref] [PubMed]
7. Battaglia A, Burchette R, Cueva R. Combination therapy (intratympanic dexamethasone + high-dose prednisone taper) for the treatment of idiopathic sudden sensorineural hearing loss. Otol Neurotol 2008;29:453-60. [Crossref] [PubMed]
8. Liebau A, Pogorzelski O, Salt AN, et al. Hearing Changes After Intratympanically Applied Steroids for Primary Therapy of Sudden Hearing Loss: A Meta-analysis Using Mathematical Simulations of Drug Delivery Protocols. Otol Neurotol 2017;38:19-30. [Crossref] [PubMed]
9. Marx M, Younes E, Chandrasekhar SS, et al. International consensus (ICON) on treatment of sudden sensorineural hearing loss. Eur Ann Otorhinolaryngol Head Neck Dis 2018;135:S23-8. [Crossref] [PubMed]
10. Mirian C, Ovesen T. Intratympanic vs Systemic Corticosteroids in First-line Treatment of Idiopathic Sudden Sensorineural Hearing Loss: A Systematic Review and Meta-analysis. JAMA Otolaryngol Head Neck Surg 2020;146:421-8. [Crossref] [PubMed]