Seong Jun Choi

Efficacy of 3 Different Steroid Treatments for Sudden Sensorineural Hearing Loss: A Prospective, Randomized Trial

Objectives We treated patients with idiopathic sudden sensorineural hearing loss (ISSNHL) with several protocols on an outpatient department (OPD) basis. The study compared the efficacy of 3 different steroid treatments for ISSNHL. Study Design A prospective randomized controlled study. Setting Tertiary referral center. Methods A total of 60 patients diagnosed with ISSNHL were treated through OPD. They were randomly and equally divided into 3 groups based on therapy: oral steroid for 10 days (group I), intratympanic dexamethasone injection (ITDI) 4 times (group II), and both (group III). Pure-tone average (PTA) was measured by taking 4 frequencies (0.5, 1, 2, and 3 kHz). Hearing change was evaluated by comparing pre- and posttreatment PTAs. Recovery rate was assessed by American Academy of Otolaryngology—Head and Neck Surgery (AAO-HNS) Clinical Practice Guidelines. Results The hearing gain was 12.8 ± 15.4 decibels (dB) in group I, 12.1 ± 14.6 dB in group II, and 21.9 ± 26.2 dB in group III. The recovery rate was 60% in groups I and III and 55% in group II. The overall recovery rate was 58.3% (35 of 60 patients). There was no significant difference in hearing gain and recovery rates for the 3 groups. Frequency-specific hearing gain also did not differ significantly among groups. Conclusion Three different treatment protocols (oral steroid, ITDI, or the combination) resulted in similar hearing recovery rates. Therefore, OPD-based systemic and/or local steroid therapy can be recommended as an initial treatment in ISSNHL.

Efficacy of the “bow and lean test” for the management of horizontal canal benign paroxysmal positional vertigo†‡

Horizontal semicircular canal (HSC) benign paroxysmal positional vertigo (BPPV) has been reported to have a poorer prognosis than posterior semicircular canal BPPV. Incorrect determination of the affected ear appears to be one of the causes of poorer outcome. The aim of this study was to assess the efficacy of the “bow and lean test” (BLT) for proper determination of the affected ear followed by preferable treatment outcomes of HSC‐BPPV.

Clinical Features of Recurrent or Persistent Benign Paroxysmal Positional Vertigo

Objectives To identify clinical features and causes of recurrent or persistent benign paroxysmal positional vertigo (BPPV) and to analyze the effectiveness of frequently repeated canalith repositioning procedures (CRPs). Study Design Case series with chart review. Setting Academic university hospital. Methods The authors retrospectively reviewed the clinical records of 120 patients who were diagnosed with BPPV at the Dizziness Clinic in Ajou University Hospital, Korea, between 2004 and 2008. “Persistent” and “recurrent” BPPV were respectively defined as BPPV continuing more than 2 weeks and recurring BPPV in the same canals after at least 2 weeks of a symptom-free interval following previous successful treatments. The authors treated patients with frequently repeated CRPs such as the modified Epley maneuver or a barbecue rotation every 2 or 3 days in the outpatient clinic. Results Among 120 patients with BPPV, 93 (77.5%) were typical, 15 (12.5%) were persistent, and 12 (10.0%) were recurrent. Although the most common cause was idiopathic in both recurrent and persistent BPPV, secondary causes, including trauma, were much more common in recurrent and persistent BPPV than in typical BPPV. Typical and recurrent BPPV developed most commonly in the posterior semicircular canals. Persistent BPPV was most commonly detected in the lateral semicircular canals. After frequently repeated CRPs, 91.7% and 86.7% of the patients with recurrent or persistent BPPV, respectively, had resolution of nystagmus and vertigo. Conclusion Recurrent and persistent BPPV are not rare diseases and occur with a higher incidence than expected, especially in patients with secondary causes. However, they can be successfully treated with frequently repeated CRPs.

Gingko biloba extracts protect auditory hair cells from cisplatin-induced ototoxicity by inhibiting perturbation of gap junctional intercellular communication

Gap junctional intercellular communication (GJIC) may play an important role in the hearing process. Cisplatin is an anticancer drug that causes hearing loss and Gingko biloba extracts (EGb 761) have been used as an antioxidant and enhancer for GJIC. The purpose of this study was to examine the efficiency of EGb 761 in protecting against cisplatin-induced apoptosis and disturbance of GJIC. House Ear Institute-Organ of Corti 1 auditory cells were cultured and treated with cisplatin (50 μM) and EGb (300 μg/ml) for 24h, and then analyzed by immunocytochemistry (Annexin V/propidium iodide) and Western blots. GJIC was evaluated by scrape-loading dye transfer (SLDT). Basal turn organ of Corti (oC) explants from neonatal (p3) rats were exposed to cisplatin (1-10 μM) and EGb (50-400 μg/ml). The number of intact hair cells was counted by co-labeling with phalloidin and MyoVIIa. EGb prevented cisplatin-induced apoptosis in immunostaining and decreased caspase 3 and poly-ADP-ribose polymerase bands, which were increased in cisplatin-treated cells in Western blots. EGb prevented abnormal intracellular locations of connexin (Cx) 26, 30, 31, and 43 in cells treated with cisplatin and increased quantities of Cx bands. EGb also prevented cisplatin-induced disturbance of GJIC in SLDT. In oC explants, EGb significantly prevented hair cell damage induced by cisplatin. In animal studies, EGb significantly prevented cisplatin-induced hearing loss across 16 and 32 kHz. These results show that cisplatin induces ototoxicity including hearing loss as well as down-regulation of GJIC and inhibition of Cxs in auditory cells. EGb prevents hearing loss in cisplatin-treated rats by inhibiting down-regulation of Cx expression and GJIC. The disturbance of GJIC or Cx expression may be one of the important mechanisms of cisplatin-induced ototoxicity.

Intratympanic dexamethasone injection for refractory tinnitus: Prospective placebo‐controlled study

The purpose of this study is to investigate the effectiveness of intratympanic dexamethasone injections (ITDI) for refractory tinnitus.

Green tea prevents down-regulation of gap junction intercellular communication in human keratinocytes treated with PMA

It has been suggested that connexin (Cx) gap junction proteins act as tumor suppressors and green tea has a potential to prevent tumor development, however, the studies on their association with human keratinocytes were rare. We evaluated the effects of a tumor promoter, phorbol-12-myristate-13-acetate (PMA), on the expression of Cxs and gap junction intercellular communication (GJIC) in human keratinocytes (HaCaT cells) and explored the preventive effects of green tea extracts-epicatechin (EC) and epigallocatechin-3-gallate (EGCG). We performed neutral red dye uptake assay to determine the optimal concentrations of PMA, EC, and EGCG for this study and confirmed the expression of Cx mRNAs using RT-PCR. We evaluated GJIC quantitatively using the ‘scrape-loading dye transfer (SLDT)’ technique after 24-h culture of HaCaT cells treated with agents. To analyze the expression change of Cxs, we also performed Western blot and immunocytochemistry. HaCaT cells were found to express Cx26, Cx30, Cx31, and Cx43, but not Cx29. In ‘scrape-loading dye transfer’ for functional study for GJIC, EC and EGCG significantly prevented PMA-induced down-regulation of GJIC. Western blot analyses revealed that EC and EGCG prevented down-regulation of Cx26 and Cx43 proteins in HaCaT cells treated with PMA. Immunocytochemistry showed decreased expression and abnormal location of Cx26 and Cx43 in HaCaT cells when treated with PMA, and EC and EGCG inhibited its effect. These results suggest an important role of GJIC played in carcinogenesis involving human keratinocytes and green tea as a useful anticancer diet.

Potential Benefits of Combination Therapy as Primary Treatment for Sudden Sensorineural Hearing Loss.

Objective We analyzed the effectiveness of combination therapy (CT) for idiopathic sudden sensorineural hearing loss (ISSNHL) and the utility of intratympanic dexamethasone injection (ITDI) reapplication as salvage treatment for ISSNHL refractory to CT. Study Design Case series with chart review. Setting Academic university hospital. Subjects and Methods We reviewed 229 patients with ISSNHL and divided these patients into 2 groups according to treatment: systemic steroid therapy (SST) and CT groups. The SST group received prednisolone therapy. The CT group also received ITDI daily. Patients who demonstrated no recovery (<10 dB) after initial treatment were defined as refractory and received salvage ITDI therapy: ITDI reapplication in the CT group and ITDI application in the SST group. Results Hearing recovery rates were 77.8% (77/99) in the CT group and 60.8% (79/130) in the SST group. The difference was statistically significant (P = .011). Initial pure-tone audiometry and vertigo were affective factors on hearing recovery rates in the CT group. After salvage therapy, hearing improvement of 10 dB or greater was noted in 6 of the 22 (27.3%) patients in the CT group and 16 of the 51 (31.4%) patients in the SST group. The difference in efficacy of salvage therapy between the CT and SST groups was simply not significant (P = .612). Conclusions Combination therapy was more effective for ISSNHL in achieving hearing gain than SST alone. Furthermore, ITDI reapplication for ISSNHL refractory to CT was as effective as salvage ITDI for ISSNHL refractory to SST.

Effect of low frequency on speech performance with bimodal hearing in bilateral severe hearing loss

Unilateral cochlear implantation has emerged as a widely accepted procedure to treat severe to profound hearing loss, but many studies have reported benefits in terms of speech comprehension when listeners with residual low‐frequency hearing in the nonimplanted ear use a hearing aid.

A Posterior Petrous Meningioma with Recurrent Vertigo

Meningiomas account for around 15% of all primary brain tumors with some 10% of meningiomas arising in the posterior fossa. In rare cases, a meningioma can form around the endolymphatic sac. When formed in the posterior fossa, meningioma tumors can produce vague, non-specific vertiginous symptoms. Research has observed that a subset of these lesions could produce symptoms indistinguishable from those of Menieres disease. Therefore, we described the clinical features of a case of posterior petrous meningioma with recurrent vertigo as well as the substantial resolution of symptoms after tumor removal via transmastoid approach.

In Response to Intratympanic dexamethasone injection for refractory tinnitus: Prospective placebo‐controlled study

We appreciate Dr. Chandrasekhar’s comments regarding our article entitled “Intratympanic Dexamethasone Injection for Refractory Tinnitus: Prospective Placebo-Controlled Study.” As you mentioned, we also have been concerned about the sample size in this study and in substance sufficiently discussed this point with the reviewers. Although we initially enrolled 35 patients, only 30 patients were able to complete this study due to the exclusion of five patients who failed to return for followup. In prospective study design, it would be relevant to calculate the sample size using sensitivity analysis and power calculation based on the primary outcome of interest. However, the control study of “saline injection” replacing intratympanic dexamethasone injection (ITDI) was very difficult to conduct because it was not easy to obtain the patients’ consent on intratympanic saline injection. To overcome this matter, the control study of ITDI has been commonly performed with drugs such as ginkgo biloba, alprazolam, oral carbamazepine, and so on. Until now, articles have been reported in which authors performed the control study of IT dexamethasone/methylprednisolone injection with saline injection. They enrolled 30 to 59 patients in their studies. As 30 patients were enrolled in our present study, we do not insist that ITDI in tinnitus is utterly useless. Nonetheless, we believe that the indication for ITDI in tinnitus needs careful selection. We admit that our study has limitation in sample size and further studies with larger sample sizes are necessary. Therefore, we are still in the process of studying the ITDI by various means for tinnitus. With regard to dexamethasone concentration, we used the concentration of 5 mg/ml with a commodified product. Although ITDI has been used more frequently in inner ear diseases, especially in sudden sensorineural hearing loss (SSNHL), the treatment protocols still vary among reported studies in the aspect of concentration and frequency (number and interval of injection). Moreover, ITDI protocols for patients with tinnitus were not well established when we planned and conducted this study. At that time, we recognized one study reported by Araujo et al. in which they used 4 mg/ml dexamethasone solution (once per week for 4 weeks) to severe and disabling tinnitus. In addition, ITDI (5 mg/ml, twice a week for 2 consecutive weeks) that was treated to refractory SSNHL in our clinic was considered as an effective treatment. Therefore, we expected that the protocol for refractory SSNHL used in our clinic can also be significantly effective in refractory tinnitus. As Dr. Chandrasekhar commented, the concentration range of corticosteroid considerably from 4 to 40 mg/ml for dexamethasone in inner ear diseases may produce inconsistent results. Fu Y et al. reported their clinical and laboratory data on the efficacy in ITDI as an initial combination therapy to systemic steroid in SSNHL. They concluded that 5 mg/ml concentration of dexamethasone (every other day for five times) did not accumulate the effect to systemic steroid and suggested that higher dexamethasone concentration of 10 mg and 20 mg improved the therapeutic effect, based on their animal study with a potential of clinical applications. On the other hand, Shim et al. used 5 mg/ml dexamethasone solution (4 consecutive days) for acute tinnitus and reported that the therapeutic effect of ITDI plus alprazolam is superior to that of alprazolam alone. And there are several studies that used 4 or 5 mg/ml dexamethasone solution and concluded their therapeutic effect as an initial, secondary, and salvage therapy in SSNHL. Therefore, we may presume that 5 mg/ml dexamethasone solution is not considered to be a subtherapeutic concentration in the study of intratympanic steroid injection. However, as higher dexamethasone concentration may have more possibility to improve the therapeutic effect, further study with higher concentration would be needed to find the optimal treatment protocol of tinnitus. In conclusion, we believe that it may be worthwhile to conduct further studies with larger sample sizes and various treatment protocols (the concentration, number, and interval of injection) for a more convincing conclusion in the future.