Overview of Intratympanic Steroid Injection

Steroids are often given to patients suffering from disorders of the inner ear, like chronic Meniere’s disease, or sudden hearing loss with no known cause (idiopathic sudden sensorineural hearing loss or ISSNHL). Steroids can help control symptoms quickly. But for some patients, standard steroid treatments don’t work or aren’t recommended for other health reasons. In these cases, a treatment called intratympanic steroid (ITS) administration may be used instead.

ITS refers to steroids being delivered directly into the ear and it’s a method that’s becoming more commonly used for treating inner ear conditions. It’s usually well-received by patients, and studies have shown that it results in a better uptake of steroids in the inner ear fluids (perilymph) without any risk of the side effects that can come from taking steroids orally or injecting them. This makes ITS a good alternative or something to be used alongside oral or injected steroids.

One condition that might require ITS treatment is ISSNHL, which is considered a medical emergency. It’s when someone becomes deaf in either one or both ears to a significant degree, within a 72-hour period, with no apparent cause. The numbers of people affected by this condition vary, but it’s estimated to be between 5 to 20 in every 100,000 individuals each year. In the UK, health guidelines recommend using steroids as the first course of treatment for sudden hearing loss, either as an oral medication, ITS injection, or a combination of both. Similarly, doctors in America often suggest ITS treatment to those patients whose hearing loss hasn’t improved in the 2 to 6 weeks following the onset of symptoms.

Meniere’s disease is another condition where the patient might be treated with ITS. It’s a disease that affects the inner ear, causing changes in hearing and balance due to a malfunction in the inner ear mechanisms. If the first course of treatments for this disease is not successful, international guidelines suggest using ITS as the next step.

Anatomy and Physiology of Intratympanic Steroid Injection

The tympanic membrane (TM), often known as the eardrum, is a small, thin, see-through part of the ear that divides the outer ear from the middle ear. It’s about a centimeter in size and has a pearly-grey color. The membrane consists of two parts: the pars tensa, which is larger and thicker, and the pars flaccida, which is thinner. The pars tensa has three layers: an outer layer, which connects with the skin in the outer ear canal; an inner layer that connects with the lining of the middle ear; and a middle layer that contains fibers which gives the eardrum its stiffness.

The TM plays a vital role in our hearing by transmitting sound in the form of vibrations to small bones in the middle ear, called auditory ossicles. The handle of one of these bones, the malleus, is embedded in the TM and can normally be seen near the middle of the eardrum.

The middle ear contains a small, air-filled chamber within a part of the skull called the temporal bone. It also contains very tiny bones that help pass sound vibrations from the eardrum to a part of the inner ear called the cochlea. The air in the middle ear’s chamber is refreshed through the Eustachian tube, which connects the middle ear to the back of the nose.

The inner ear, also known as the internal ear, contains the cochlea and the vestibular system, which are responsible for our hearing and balance, respectively. They are contained within a series of cavities filled with a fluid called the perilymph. The cochlea, one of these cavities, help in our hearing process. Two openings, the round window and the oval window, connect the middle ear to the inner ear. The round window is important in the hearing process as it allows the fluid in the cochlear to move, enabling us to hear

The inner ear has a natural barrier, known as the blood-labyrinth barrier, protects the ear from potential damage by restricting the entry of most substances from our blood into our ear tissues, allowing only necessary components to pass. This barrier also limits the delivery of drugs to the cochlea when they are administered orally. Therefore, in many cases, drugs are administered directly into the middle ear – a method called intratympanic administration – which results in an increased concentration of the drug in the inner ear.

One common use of this method is for the treatment of sudden sensorineural hearing loss (SSNHL) and Meniere’s Disease. The role of the immune system in both diseases is increasingly recognized. Treatment with corticosteroids, often administered directly into the middle ear, can help through their protective and calming effects on the immune system and through maintaining the balance of ions in the cochlea. For Meniere’s Disease, the success of the treatment is usually dependent on the ability to control vertigo attacks, which can be achieved in up to 90% of cases with conservative intervention or medication. The remaining patients who do not respond to these methods are often treated with intratympanic drug administration to control vertigo attacks.

Why do People Need Intratympanic Steroid Injection

Sudden Hearing Loss Treatment

When it’s believed that someone has sudden hearing loss, starting treatment right away is generally the best way to help make sure the person recovers fully. A study from 2011 that monitored 250 patients found that starting treatment right away with either inner-ear injections or oral steroids (medication that reduces inflammation and pain) made no difference.

Sometimes, initial treatment doesn’t fully help, and additional treatment is necessary. If someone is still having trouble hearing after the primary treatment, then a second rescue treatment is recommended within 2 to 6 weeks of when the symptoms started. This is the most frequently used option in sudden hearing loss. One study found that when using inner-ear injections of a specific steroid after the initial therapy didn’t work, 40% of patients improved compared to just 9.1% in the group that didn’t receive this treatment.

A combination treatment, involving both steroid injections to the inner ear and oral steroids, have shown different results in different studies. Some suggest it might be beneficial, especially if the hearing loss is moderate to severe. But others didn’t find any added benefits in comparison to just standalone or systemic therapy in regaining hearing for patients with sudden hearing loss.

As for Meniere’s Disease, a condition that affects the inner ear and is known to cause vertigo (the feeling of spinning when you’re not), certain guidelines from 2018 suggest that injection treatments could be really beneficial. They can be particularly effective in reducing dizziness episodes, especially once basic medical treatment has not been successful. Excitingly, one trustworthy test from 2016 showed that steroid injections could completely control vertigo in about half of the cases for up to two years after just one treatment cycle. However, this kind of treatment is generally most effective when the basic medical treatment hasn’t worked.

Tinnitus, a condition leading to a persistent ringing or buzzing sound in the ears can sometimes be managed with inner-ear steroid injections. One theory is that the high concentration of steroids increases blood flow to the inner ear, which could reduce the ringing sensation. Most studies suggest this is more effective for tinnitus that has just started rather than for the chronic form of the condition.

In cases of autoimmune inner ear diseases, where the body’s immune system mistakenly attacks the inner ear, a corticosteroid, which is a type of steroid that reduces inflammation, is often the first choice for treatment.

When a Person Should Avoid Intratympanic Steroid Injection

There are several reasons why certain procedures might not be recommended:

If a patient isn’t willing or able to cooperate fully, the procedure might not be safe or successful.

One specific example is a patient with a working tympanostomy tube (a small tube put in the ear drum to help drain fluid). Corticosteroids (medicines that reduce inflammation) might be delivered through this tube, which could affect the procedure.

If a patient has acute otitis externa (an infection of the outer part of the ear), it might not be safe to proceed with the procedure.

The presence of an intratympanic tumor (a growth inside the ear) or abnormal blood vessels also makes the procedure risky.

Finally, the procedure might not work well if we can’t see important landmarks (identifiable features) of the tympanic membrane (eardrum) clearly.

Equipment used for Intratympanic Steroid Injection

To perform this procedure, the doctor uses several tools and medications:

A suitably-sized ear speculum is needed. This is a tool used by doctors to look inside your ear.

A binocular otology microscope is used. This is a special microscope designed to magnify the inside of your ear, enabling the doctor to see the tiny structures clearly.

The doctor also needs a syringe with a 25-gauge spinal needle. This is a thin needle that’s typically used for procedures in the ear.

Cotton wool soaked with Emla cream 5% or phenol, or xylocaine 10% spray, is applied to your eardrum for about 30 minutes to numb it. Some doctors may prefer to inject local anesthesia, such as 1% lidocaine with 1:100,000 adrenaline, under the skin near the ear. However, no one type of local anesthesia has been shown to be more effective than others.

The doctor uses a steroid called methylprednisolone (30 to 62.5mg/mL) to reduce inflammation. This is warmed to body temperature to prevent any vertigo-like symptoms, and is freshly prepared because preservatives in the drug may cause pain or irritation to the middle ear.

Preparing for Intratympanic Steroid Injection

Before having a procedure, it’s important for patients to understand what’s going to happen and agree to it. In some cases, after the procedure, you may feel a bit dizzy. Because of this, it’s a good idea to have someone available to take you home.

When getting ready for the procedure, you will be asked to sit comfortably in a chair and turn your head to the opposite side of your ear that is being examined. The doctor will use a special piece of medical equipment, called a binocular otology microscope, along with a device called a speculum to get a clear view of the area inside your ear.

Sometimes, there may be earwax or other debris that could block the doctor’s view of your eardrum, the thin layer of tissue that separates your ear canal from your middle ear. If this is the case, the doctor will carefully remove these substances to get a better look at your eardrum.

To minimize discomfort during the procedure, an anesthetic is applied to a specific section of the eardrum. Anesthetic is a type of drug that numbs the area it is applied to, helping you feel more comfortable during the procedure. The specifics of the anesthetic used may vary, but examples include a spray of Xylocaine (10 mg/dose) or a cream containing lidocaine and prilocaine (5%).

How is Intratympanic Steroid Injection performed

The procedure includes these steps:

First, a dose between 0.4 to 0.8 mL of a medication called methylprednisolone is given with a thin needle that is 25-gauge. This injection is done through the front bottom area, which has been numbed, into the middle part of your ear, until it’s full.

Next, the doctor might make a second small hole, that we also call a borehole, on the eardrum, to help relieve pressure. This is done while the medication is being put in, which also helps to avoid any potential damage to the round window, an important part of your inner ear. Instead of a borehole, some patients might be fitted with a small tube, called a pressure-equalization tube or grommet, if they need this kind of medication on a regular basis.

After the medication is given, you need to lie down on your back keeping the ear that got the injection upwards, and try to avoid moving your mouth, like swallowing, yawning, or talking, for around 20 to 30 minutes. This helps the medicine to pass into the deeper parts of your ear across the round window membrane, and also stop it from leaking into the eustachian tube, a tube that connects your ear to your throat.

Possible Complications of Intratympanic Steroid Injection

There are some potential risks or side effects associated with the procedure of injecting steroids directly into the middle part of the ear, known as intratympanic steroids. Although generally safe, it’s essential to know about and discuss these with your doctor before choosing to have this procedure.

The most common temporary side effects include dizziness just after the procedure, discomfort at the site where the injection was given, and a burning sensation in the ear. These are usually short-lived and fade away on their own.

But there could also be other side effects or complications like:

  • Pain in the ear
  • Feeling as though your ear is full or blocked
  • Vertigo, which is a sensation of feeling off balance or experiencing a spinning sensation. This is usually temporary.
  • Headache
  • Persistent dizziness
  • A continuous hole or tear in the eardrum, also known as a persistent tympanic membrane perforation
  • Tinnitus, which is the perception of noise or ringing in the ears
  • Infection in the ear
  • A sudden drop in blood pressure causing fainting spells, also known as a syncopal episode
  • Hearing loss, which can be temporary or permanent
  • Numbness in the tongue

Note, these side effects are not common, but it’s important to be aware of them since they can occur.

What Else Should I Know About Intratympanic Steroid Injection?

Intratympanic injections are a medical procedure where medication is injected directly into the ear. This treatment has many benefits, especially for patients who can’t take systemic steroids, a type of medication that can affect the entire body. Since this method doesn’t involve system-wide absorption of the steroids, it doesn’t cause side effects that can occur when the medication is taken orally or injected in other parts of the body.

The drug delivered using intratympanic injections is more concentrated in the area where it is needed most, so it could be more effective than systemic steroid therapy. In addition, a smaller amount of the drug is needed compared to oral or injectable steroids, which means less overall stress on the body’s system.

This procedure is relatively simple and can be done in a doctor’s office using a topical anesthetic that’s applied to the skin. That reduces the chances of serious complications. Plus, bypassing the body’s normal process for breaking down medications (termed ‘first-pass’ metabolism) increases the drug’s potency.

Intratympanic injections can also be more cost-effective than other treatment options. Most patients find the procedure quite tolerable, and it offers a safe and efficient way to deliver medications directly to the site where they are needed.

Frequently asked questions

1. What condition am I being treated for with the intratympanic steroid injection? 2. How does the intratympanic steroid injection work to treat my condition? 3. What are the potential risks and side effects of the intratympanic steroid injection? 4. How many injections will I need and how often will they be administered? 5. Are there any alternative treatments or therapies that I should consider alongside the intratympanic steroid injection?

Intratympanic steroid injection can have a positive effect on individuals with sudden sensorineural hearing loss (SSNHL) and Meniere's Disease. The injection, which is administered directly into the middle ear, helps by protecting and calming the immune system and maintaining the balance of ions in the cochlea. It can also be used to control vertigo attacks in patients who do not respond to other methods of treatment.

There are several reasons why someone might need an Intratympanic Steroid Injection. One possible reason is if they have a condition called sudden sensorineural hearing loss (SSNHL). This is a sudden loss of hearing in one or both ears that occurs within a few days. Intratympanic Steroid Injection is a treatment option for SSNHL and involves injecting a corticosteroid medication directly into the middle ear. This can help reduce inflammation and improve hearing.

You should not get an Intratympanic Steroid Injection if you are unable or unwilling to cooperate fully during the procedure, if you have a working tympanostomy tube, acute otitis externa, an intratympanic tumor or abnormal blood vessels in the ear, or if important landmarks of the eardrum cannot be clearly seen.

To prepare for an Intratympanic Steroid Injection, the patient should sit comfortably in a chair and turn their head to the opposite side of the ear being examined. The doctor will use a binocular otology microscope and a speculum to get a clear view of the area inside the ear. An anesthetic, such as Xylocaine spray or lidocaine and prilocaine cream, may be applied to numb the eardrum and minimize discomfort during the procedure.

The complications of Intratympanic Steroid Injection include pain in the ear, feeling of fullness or blockage in the ear, vertigo, headache, persistent dizziness, persistent tympanic membrane perforation, tinnitus, infection in the ear, syncopal episodes (fainting spells), hearing loss (temporary or permanent), and numbness in the tongue. These complications are not common but can occur.

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