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Page last modified:
November 28, 2007
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Figure 1A. A steroid such as dexamethasone, methylprednisolone or betamethasone can be placed into the middle ear using self-administered drops. This picture shows the tube being placed in the ear drum. |
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Figure 1B. Steroid injected into the middle ear. Multiple injections are usually required for this method. |
In extremely severe cases of episodic vertigo, such as due to Meniere's disease, treatments administered into the middle ear may be considered. This is a near last resort treatment for persons who have severe attacks of vertigo. The goal of these treatments is to affect the inner ear using medication that enters the ear through the round window. The presumption is that the mechanism of disease is immune mediated.
The author of this article is not very enthusiastic about this treatment. Nevertheless, it is rapidly growing in popularity. At the present time (2007) in his practice in Chicago, he will occasionally recommend it to a patient who is having a flare of well defined Meniere's disease, or a sudden hearing loss. The reasons for the lack of enthusiasm are given in the author's article on Meniere's disease itself, but in essence, it doesn't seem to work unless it is given over a long period, and there are alternatives (i.e. low dose gentamicin) that are much more durable, and we are skeptical that it is a good idea to give multiple injections of steroids into the middle ear over a long period of time. Still, things are changing with this treatment.
Injections of steroid can be given through the ear drum, by way of a small needle (figure 1B), or administered as drops through a ventilation tube (figure 1A). This procedure allows one to treat one side, without affecting the other. It also avoids complications of systemic steroids, may avoid surgery, and may work when other treatments fail.
| Authors | number patients treated | Protocol | response | Comment |
Silverstein et al. (1998). " |
20 | 3 injections in 3 days | None | Short duration |
Hirvonen, et al, 2000 |
17 | 3 injections over 1 week | 76% control of vertigo , no response of hearing | Short duration |
Barrs, et al. (2001). |
21 | 2 injections in 2 weeks | 43% response at 6 mo (similar to placebo) | Short duration |
| Sennaroglu et al. 2001 | 24 | drops instilled every other day for 3 months | 72% relief of vertigo, no response of hearing or tinnnitus | Long duration |
| Arriaga et al. 2003; | 15 | Single dose | None | Short duration |
| Dodson et al, 2004 | 22 | Various | Short term relief | |
| Boleas et al, 2007 | 129 | 3-4 injections/year | "Acceptable" vertigo control in 91% | Long duration |
Most practitioners use a simple protocol of an injections of steroids, delivered weekly or longer intervals. However, the most successful methods reported to date, such as the studies of Sennaroglu and Boleas, involve a longer periods of administration.
Dexamethasone has the longest half-life: 36-54 hours. We would expect that steroids in the inner ear would persist for a shorter period than in the body, because in the inner ear, steroids are not at equilibrium with the body at large. Thus, one would think that all single injection protocols would be likely to fail.
Certain steroids seem to cause more pain than others. Dexamethasone seems to be the best tolerated, in a dose of 24 mg/ml. Solumedrol was reported by Parnes to be more painful (1999)
The simplest procedure (and the least expensive) reported so far is that of Sennaroglu et al (2001). They had simply had the patient administer dexamethasone themselves through a ventilation tube. A tube is placed in the posterio-inferior quadrant of the TM. Patients are instructed to lie on their side and place 5 drops into the affected ear once every other day. After the instillation, they are to lie with the ear upright for 15 minutes. A low concentration of dexamethasone is used -- 1 mg/ml. This is far less than the amount (24 mg/ml) used when the drug is injected.
While ITS is generally thought to be safe, there are many possible (probably minor) complications (see Doyle et al, 2004).
The common risks are pain, short-lasting vertigo, otitis media, and tympanic membrane perforation.
Pain during the insertion of the drug is common. This is not unexpected as puncturing ones body needles is usually painful. Pain from the drops themselves are rare, especially if dexamethasone is used.
Otitis media was reported in only 1/24 patients using the method of Sennaroglu et al (drops through tube). It seems to be even more rare in patients who have direct injections. When otitis media occurs with a tube in place, the option of using a ear drop such as Floxin is available.
Perforation of the ear drum is a possible complication. Steroids impair wound healing and one might expect slower closure. This complication can generally be handled easily by an otologist and the perforation can be closed.
Vertigo. Temporary vertigo can occur when the solutions being used are not at body temperature or if the solutions contain lidocaine. Most patients are able to walk around unassisted after 20-30 minutes after injections. Permanent vertigo and imbalance have not been reported.
Hearing loss: most physicians using intratympanic steroids feel that there is little of any risk of hearing loss (Doyle et al, 2005).
Cost: This can be a very expensive method of treating Meniere's disease. Otologic surgeons may bill $3000 for this 30 minute procedure, possibly repeated 4 times per year. Other similar methods of treating Menieres, such as use of gentamicin instead, cost the same amount but don't need multiple repetitions. Thus, the cost to the health care system of gentamicin treatment is much lower than steroid treatment.
Failure: ITS might fail for several reasons --
ITS is an emerging treatment. Generally it is provided by ear doctors (Otologists -- a subspecialty of ENT). Variants are common, and many of the variants seem no better than placebo. We advise careful investigation of the protocol offered by your local practitioners. We favor the longer durations methods described above. Be sure that someone can monitor your treatment closely.