Sudden Sensorineural Hearing Loss
SOURCE: Grand Rounds Presentation, UTMB, Dept. of Otolaryngology
DATE: June 13, 2001
RESIDENT PHYSICIAN: Christopher Muller, MD
FACULTY PHYSICIAN: Jeffrey Vrabec, MD
SERIES EDITOR: Francis B. Quinn, Jr., MD
"This material was prepared by resident physicians in partial fulfillment of educational requirements established for the Postgraduate Training Program of the UTMB Department of Otolaryngology/Head and Neck Surgery and was not intended for clinical use in its present form. It was prepared for the purpose of stimulating group discussion in a conference setting. No warranties, either express or implied, are made with respect to its accuracy, completeness, or timeliness. The material does not necessarily reflect the current or past opinions of members of the UTMB faculty and should not be used for purposes of diagnosis or treatment without consulting appropriate literature sources and informed professional opinion."
Sudden hearing loss (SHL) is a medical emergency for which definitive diagnosis and treatment is still largely unknown. It was first described in the literature by De Klevn in 1944. SHL generally a refers to hearing loss of sensorineural origin. It has been defined for research purposes and has been accepted by most authorities as 30 dB or more sensorineural hearing loss over at least three contiguous audiometric frequencies occurring within 3 days or less.
Estimates report approximately 15,000 reported cases of SHL per year worldwide with 4000 of those occurring in the United States. One in every 10,000 to 15,000 people will suffer from this condition, with the highest incidence occurs between 50 and 60 years of age. The lowest incidence is between 20 and 30 years of age. Of the patient suffering from SHL, 2% are bilateral. In most series, the incidence was nearly equal in men and women.
There are many potential causes of SHL, but despite extensive evaluation, the majority of cases elude definitive diagnosis and therefore, remain idiopathic. Reports estimate that the etiology of SHL is diagnosed in only 10% of cases. Suggested causes of idiopathic sudden sensorineural hearing loss (ISSNHL) include viral infections, immunologic, vascular compromise, and intracochlear membrane breaks. It is unlikely that any single one of these pathophysiologic processes explains all cases of ISSNHL. Treatment regimens aimed at addressing the underlying problem in each of these states have been suggested including decreasing cochlear inflammation, improving inner ear blood flow and oxygenation, and reestablishing the endocochlear potential.
The etiology of SHL can be broken down into broad categories: (1) viral and infectious, (2) autoimmune, (3) labyrinthine membrane rupture/traumatic, (4) vascular, (5) neurologic, and (6) Neoplastic. There are multiple conditions within each of these categories that have been associated with sudden hearing loss. The following is a partial list of reported causes of SHL:
Herpesvirus (simplex, zoster, varicella, cytomegalovirus0
Human immunodeficiency virus
Autoimmune Autoimmune inner ear disease (AIED)
Traumatic Perilymph fistula
Inner ear decompression sickness
Temporal bone fracture
Inner ear concussion
Otologic surgery (stapedectomy)
Surgical complication of nonotologic surgery
Vascular Vascular disease/alteration of microcirculation
Vascular disease associated with mitochondriopathy
Red blood cell deformability
Sickle cell disease
Neurologic Multiple sclerosis
Focal pontine ischemia
Neoplastic Acoustic neuroma
Metastasis to internal auditory canal
Contralateral deafness after acoustic neuroma surgery
Evaluation and management of SHL should be considered medically urgent, if not an emergency. The primary goal is to rule out any treatable causes.
Diagnostic evaluation of the patient with sudden hearing loss begins with a thorough history and physical exam. Details of the circumstances surrounding the hearing loss and the time course of its onset should be elicited. Associated symptoms, such as tinnitus, vertigo or dizziness, and aural fullness should also be asked about. Clinical experience has shown that about one-third of patients note their hearing loss upon first awakening in the morning, and that about one- half the cases will have associated vertigo. Patients should also be questioned about previous otologic surgery, ototoxic drug use, and previous or concurrent viral or upper respiratory tract infections. Any history of trauma, straining, diving, flying, and intense noise exposure should be noted. Past medical history of other diseases associated with sudden hearing loss should also be obtained such as diabetes, autoimmune disorders, malignancies, neurologic conditions (multiple sclerosis), and hypercoagulable states. African-Americans should be asked about sickle cell disease.
A complete head and neck exam should be performed on all patients with sudden hearing loss. More often than not, the exam will be unremarkable, however, any processes such as middle ear effusions, infections, cholesteatoma, and cerumen impaction should be excluded. A thorough neurological exam including Weber and Rinne, cerebellar and vestibular testing should be performed.
An audiogram (pure tone, speech, tympanometry, including stapedial reflex testing) should be performed on all patients with sudden hearing loss. The audiogram is the foundation of the diagnosis and provides prognostic information. Serial testing provides documentation of the progression or resolution of the hearing loss and response to treatment. In addition it may help exclude patients with secondary gain or with pseudohypacusis.
The following is a list of laboratory studies that can be ordered. Initial screening tests should be directed based on history and suspected conditions.
1) Complete blood count (CBC)
2) Erythrocyte sedimentation rate (ESR)
5) T3, T4, TSH
6) PT, PTT
7) VDRL, RTA-ABS (MHA-TP)
9) Lyme titer
Magnetic resonance imaging (MRI) is recommended by the majority of authors for patients with asymmetric hearing loss. In one survey of 79 otolaryngologists, 38% would order imaging on the patient’s initial visit. MRI is useful in evaluating for acoustic tumors, multiple sclerosis and cerebrovascular accidents. There are some proponents of following these patients and imaging only if asymmetric hearing persists. However, Berg et al., in a series of acoustic neuromas showed that 13% presented with sudden hearing loss, and of these 23% recovered auditory function.
Cogan's syndrome (CS) is an autoimmune disease of the cornea and vestibuloauditory apparatus that was first described by Cogan, an ophthalmologist, in the 1940s. It occurs primarily in young adults (average age of onset 22-29 years) and typically presents with interstitial keratitis (IK) and Meniere's-like attacks of vertigo, ataxia, tinnitus, nausea, vomiting, and hearing loss which develop within several months of each other. CS may also be associated with other systemic manifestations of the inflammatory process such as Takayasu's-like or medium-sized vessel vasculitis. Approximately 10% of patients develop aortitis within weeks to years after the onset. Hearing fluctuation in CS coincides with disease exacerbations and remissions. Its course often culminates in deafness. One series reported that 12 out of 18 patients (67%) developed bilateral deafness.
The cause of CS is unknown. Microbial etiology has been suggested by some as URTI precede nearly 40% of patients who present with this disease. Clinical parallels between syphilis and CS have led some to belief that CS may be caused by Borrelia burgdorferi. However, evidence so far has been inconclusive. There have also been links to Chlamydia species with CS and is an area of ongoing investigation. Temporal bone histopathologic studies done at autopsy of patients with CS are characterized by chronic inflammation including: infiltration of the spiral ligament with lymphocytes and plasma cells, endolymphatic hydrops, degenerative changes in the organ of Corti, and demyelination and atrophy of the vestibular and cochlear branches of the eight cranial nerve.
There is no criteria currently established for the diagnosis of CS. The general thinking is that the diagnosis requires clinical signs of both eye and inner ear inflammation. Work-up should include an audiogram and laboratory tests including CBC, ESR, and RPR. Imaging including MRI and/or CT should be done primarily to rule out cerebropontine angle tumors and other disorders. MRI may show enhancement of vestibular and cochlear structures with gadolinium.
The cornerstone of therapy is corticosteroids: topical for IK and oral for vestibuloauditory involvement. Most authors suggest using prednisone 1mg/kg for 2-4 weeks with a subsequent rapid taper for cases of complete resolution and slow taper for those with incomplete response. The best outcome is in patients in whom therapy begins shortly after the onset of symptoms. For patients who have failed steroid treatment and developed bilateral deafness, cochlear implantation should be considered and has been approved by the FDA in these patients.
Traumatic breaks in the membranous labyrinth are accepted causes of sudden hearing loss. Cochlear membrane breaks may be either intracochlear, as is thought to occur in Meniere’s disease, or involve the labyrinthine oval and/or round windows with a resultant perilymph fistula. The patients history will usually elicit an inciting event such as a blow to the head, sneezing, bending over, lifting a heavy object, exposure to sudden changes in barometric pressure (such as during flying or diving), or exposure to a loud noise. Patients who are theoretically at high risk for fistulization are those who have undergone anatomical alterations such as stapedectomy patients and in children with inner ear anomalies, such as the Mondini malformation and large vestibular aqueducts where increases in CSF pressure may be transmitted to the inner ear more easily. In clinical practice, however, patients who have undergone stapedectomy who return to their normal lifestyles including scuba diving and flying have not resulted in an obvious increase in development of symptoms of perilymphatic fistulas.
Currently there is no definitive test to diagnose perilymph fistulae other than intraoperative observation of leakage of perilymph. Diagnosis is made by the clinical history of sudden or rapidly progressive hearing loss after one of the above listed inciting events. Inflammation, granuloma, or neoplasia disorders that can mimic a perilymph fistula should be ruled out (i.e. with MRI, MHATP, and ESR). Kohut proposes that two of the following vestibular symptoms are required for diagnosis: constant dysequilibrium, a positive fistula test (Hennebert’s sign), and a positional nystagmus. Testing for Tullio’s phenomenon should also be done.
Initial treatment should include 5 days of strict bed rest with the head of bed elevated thirty degrees. The patient should avoid straining or hard nose blowing. Stool softeners may be given. Some suggest daily audiograms. If the patient has improvement, 6 more weeks of modified physical activity should be followed. If no improvement is seen after five days, surgical therapy including middle ear exploration with patching of the perilymphatic fistula should be performed.
Acoustic neuromas are usually associated with gradually progressive hearing loss. However, the increasingly widespread use of CT and MRI imaging of patients has indicated that nearly 10% to 19% of patients with acoustic tumors may present with SHL. The rationale for imaging patients with unilateral hearing loss, accepted by most authorities is that, although uncommon, their symptoms may be due to neoplasm. It has been estimated that 1% of patients with asymmetric SHL will have an acoustic tumor. In addition, these imaging studies can pick other neurologic disorders such as multiple sclerosis and ischemic changes which may be associated with SHL.
Direct identification of viruses or viral antigens from the perilymph of a affected patients provides some of the strongest evidence for the involvement of viruses in hearing loss. Also, animal studies that demonstrate the ability of viruses to infect the inner ear lend further support. Davis and Johnson demonstrated the ability of rubeola and mumps to infect the inner ears of animal models using immunofluorescent antigen studies. Westmore et. al. subsequently cultured the mumps virus from the perilymph of a patient suffering from SHL and in 1979, Davis and co-workers cultured CMV from the perilymph of infant with congenital CMV infection. In 1981, further studies using immunofluorescence showed CMV antigens on the stria vascularis, dark cells and Reissner’s membrane of an infant who died of a CMV infection.
The diagnosis of AIED is based for the most part on the presence of bilateral progressive sensorineural hearing loss and response to therapy. Hughes proposes that the two most clinically helpful tests for diagnosing AIED are the lymphocyte transformation test (LTT) and the Western blot immunoassay, however, these are rarely used by most practitioners because of availability. The sensitivity and specificity for LTT are estimated to be 50-80% and 93% respectively with positive predictive values ranging from 56-73% depending on the disease prevalence in the tested population. When applied to high risk populations (patients with bilateral rapidly-progressive SNHL), the Western blot has a sensitivity of 88%, a specificity of 80%, and an overall positive predictive value of 92%. The natural history of AIED is not known, however, clinical experience reveals that the disease waxes and wanes. Testing of patients should, therefore, be performed during periods of disease activity and before treatment is initiated.
Currently, tests for AIED are not routinely used except at certain centers (Cleveland Clinic and the Massachusetts Eye and Ear Infirmary) and in experimental trials. The major drawback to these studies is the lack of availability. If testing is desired, samples of whole blood from patients can be mailed to the Cleveland Clinic Foundation Regional Laboratory by overnight carrier for LTT. The test costs $120.00 and results take approximately seven days.
The best theoretical test for AIED would be a test for marker specific for AIED. Attempts have been made in this area and are promising. In 1990, Harris and colleagues published the results of studies which discovered, using Western blot, an anti-68kd autoantibody in the sera of patients with rapidly progressive SNHL. Since then, other studies have confirmed these findings. Overall 22% to 58% of sera of patients with rapidly progressive SNHL will contain this antibody. Harris has subsequently reported a 94% specificity for test correlating results with responsiveness to therapy and disease activity. Studies by Billings and Harris are now searching for the specific antigen involved in AIED. So far they have isolated a 68kd protein that is ubiquitous in the inner as well as other areas of the body, and have recently reported evidence that links the 68kd antigen with heat shock protein 70 (hsp 70), a highly inducible stress protein. Further research is needed in this are to determine the exact relationship of hsp 70 to AIED and whether it plays an important etiologic role or whether it is just a bi-product of the disease itself. Theories proposed are that (1) human hsp 70 may have a similar amino acid sequence to an infecting agent resulting in cross-reactivity or (2) that there may be a hsp 70 specific to the inner ear that is seen as foreign when it is over-expressed during times of chronic inflammation from an outside agent.
Treatment for AIED is controversial and widely varied from practitioner to practitioner. This is largely due to the lack of double-blind, prospective clinical trials on the matter. The general consensus is that steroids are effective and should be used. Most sources recommend prednisone 1mg/kg/day for 4 weeks followed by a slow taper if the patient responds. If the patient relapses on the taper, Harris recommends instituting high dose prednisone and if continued recurrence occurs with tapering, a cytotoxic agent such as methotrexate (MTX) at a dosage of 7.5-15 mg weekly with folic acid, or cyclophosphamide (Cytoxan) should be instituted. If MTX is used, the steroids should be continued after starting the MTX as it takes one to two months for the prednisone sparing affects of MTX to begin. Most physicians begin with MTX as it has fewer side-effects than Cytoxan. If both prednisone and MTX are ineffective, cytoxan should be used. It is important to monitor for side effects of both MTX and Cytoxan with routine monitoring of complete blood counts, platelets, LFTs, UA, and electrolytes. Those on Cytoxan should keep well-hydrated to prevent hemorrhagic cystitis.
Other authors such as McCabe are more in favor of starting cytotoxic drugs at the onset of the illness. He believes that Cytoxan is the preferred treatment of AIED rather than steroids because there is a higher response rate to this drug. Because the diagnosis of AIED is based partially on response to therapy, fewer patients with this diagnosis would be missed.
It is not surprising that the cochleovestibular blood supply may be affected by circulatory disorders such as embolic phenomenon, thrombosis, vasospasm, and hypercoagulable or high viscosity states resulting in SSNHL. The underlying pathophysiology can be explained by the occurrence of sudden anoxic injury to the cochlea. The cochlea is extraordinarily intolerant of blood supply disruptions. Early studies by Kimura and Perlman in the1957 revealed that vascular occlusion of the labyrinthine artery in guinea pigs for greater than thirty minutes led to irreversible loss of cochlear function. Suga and co-workers performed experimental embolizations of cochlear vessels and showed loss of cochlear action potentials within 60 seconds.
Much of the hard evidence for a vascular etiology of SHL comes from histopathologic comparison of a few human temporal bones with those of animal models. Belal, in 1980, looked at two temporal bones from patients suffering from SHL. He found similar histologic findings to those of animal models of vascular occlusion to the cochleovestibular apparatus including extensive fibrosis and new bone formation.
The blood supply of the membranous labyrinth is predominantly derived from he labyrinthine (internal artery) which is branch of the anterior inferior cerebellar artery. It may less commonly be a direct branch from the basilar artery. The labyrinthine artery enters the internal auditory canal and subsequently divides into the common cochlear artery and the anterior vestibular artery. The common cochlear artery divides to form the main cochlear and vestibulocochlear branches. Division of the vestibulocochlear artery results in the posterior vestibular artery and the cochlear ramus. The arterial supply to the cochlea is such that the basal turn is fed first by the main cochlear artery with the cochlear apex fed last. Based on this anatomy one would expect occlusion of the labyrinthine artery to cause both vestibular and auditory symptoms which is supported by histopathologic findings as describe above. In addition, one would expect temporary occlusion in blood flow to affect low frequency areas of the cochlea first as these areas are the most distal in terms of blood supply.
SHL can develop as a result of a number abnormal circulatory states. Patients with diseases such a sickle cell anemia and Waldenstrom's macroglobulinemia have been shown to have a higher risk of developing SHL than the normal population. Hearing loss in these individuals is usually reversible with treatment: Oxygen for sickle cell disease and plasmapheresis for Waldenstrom's. Strokes involving the anterior inferior cerebellar artery are associated with auditory and vestibular symptoms but often also affect cerebellar function. SHL following cardiopulmonary bypass has also been reported, most likely resulting from embolic phenomenon.
The majority of cases of SHL treated by otolaryngologist are for those with no definable cause. The treatments for cases with known etiologies involve addressing the underlying condition (i.e. treatment of: acoustic neuroma with excision, ototoxicity with cessation of ototoxic drugs, multiple sclerosis with medical therapy, embolic disease with anticoagulants, sickle-cell crisis with oxygen, bacterial meningitis with antibiotics and so on). This discussion will be limited to the treatments which have been proposed for patients with no underlying cause for their hearing loss based on the previous mentioned theories addressing the etiology of ISSNHL.
Antiviral agents Acyclovir
carbon dioxide with 95% oxygen
Volume expanders/hemodilutors Hydroxyethyl starch
Calcium antagonists Nifedipine
Other agents and procedures Amidotrizoate
A review of the literature confirms that the level of evidence for treating this condition is limited and consequently there is a wide disparity in consultant’s practices.
In 1987, Wilkins and associates treated 109 with a “shotgun” regimen that included dextran, histamine, Hypaque, diuretics, steroids, vasodilators, and carbogen inhalation. They found no statistically significant difference in outcome between patients treated and those who were not treated. In this study there was no control group and treatment was defined as receiving the drug for at least three days. Prospective, randomized, double-blind studies have been done looking at the dextran 40, pentoxifylline, low-molecular-weight dextran, and intravenous procaine. None of these have shown significant differences in recovery compared to placebo.
Despite the disappointing results in early trials of steroid therapy in which low doses were used for short duration, later studies using higher doses for longer periods of time have been more promising in the treatment of ISSNHL. In 1980, Wilson and colleagues performed double-blind studies for the treatment of ISSNHL with oral steroids. Their treatment consisted of a Decadron taper over 10-12 days. They stratified their patients based on audiogram and found that steroids had a significant effect on the recovery of hearing in patients with hearing loss between 40 and 90 db. Moskowitz et al. confirmed Wilson’s findings in 1984. He demonstrated an overall 89% recovery rate for those treated with a twelve day Decadron taper compared with 44% recovery for those not treated with steroids. Again, these results were found in a patients with audiograms in the so called "steroid effective zone". In both of these studies, they found that patients with profound hearing loss did not benefit significantly from steroid use. They concluded that steroid appear to be of benefit only if the injury is partial and reversible. In a recent review by Hughes, he recommended treating with prednisone 1mg/kg/day for at least ten days and up to one month.
Hughes also advocates treatment with diuretics and low salt diet. Athough there is no data to support this treatment, his rationale is based on histopathologic studies of temporal bones in patients with autoimmune SHL (mostly Cogan's syndrome) which have shown endolymphatic hydrops. He prescribes Maxide (Hydrochlorthiazide 25mg and triamterene) once a day.
Carbogen, which is a combination of 95% oxygen and 5% carbon dioxide has been used, and is still used by some physicians in patients in whom a vascular etiology is suspected for their hearing loss. Studies have shown that carbogen increases the partial pressure of oxygen in perilymph. In addition carbon dioxide is a known potent vasodilator of the vestibulocochlear vasculature, resulting in increased blood flow. Administration of Carbogen must be done in-hospital over three days to monitor blood pressure which may increase. Insurance companies currently do not cover this treatment because it is considered experimental. No conclusive data has shown Carbogen inhalation to be of any benefit over spontaneous recovery .
Finally, antivirals have recently come into favor in the treatment of ISSNHL. Animal models of viral labyrinthitis treated with prednisone and acyclovir combined have shown significantly higher rates of hearing recovery compared to either drug alone. This combination therapy has already proven its effectiveness in Ramsay Hunt syndrome and herpes zoster oticus and has also been proposed for the treatment of Bell's palsy. Studies are now ongoing to look at the efficacy of acyclovir in the treatment of patients with ISSNHL. In general, many authorities treat patients empirically with acyclovir usually for ten days.
Recently, a survey was sent to 100 consultant otolaryngologists in the United Kingdom inquiring about their assessment and management of patients presenting with SHL. Results showed that 78% would perform routine blood tests including CBC, ESR, and syphilis serology. 38% would order an MRI at the first presentation. 98.5% of the consultants would treat with steroids alone or as part of a combination. 41% treat with Carbogen, 31% with acyclovir and 35% with betahistine.
Sudden hearing loss is a medical condition which can be particularly devastating to patients and frustrating for the otolaryngologist to diagnose and treat. Despite extensive investigation, only minimal data has been generated in the past thirty years to improve our understanding of the etiology and appropriate treatment of this disease. Most authorities agree that all patients should undergo audiometry, and imaging with MRI for those patients with asymmetric hearing loss, however the etiology for the majority of patients will go undiagnosed. Treatment is more controversial. Steroids have been shown to significantly improve hearing recovery in patients with moderate to severe hearing loss and seem to be favored for the treatment of autoimmune and idiopathic forms of SSNHL. The remainder of proposed treatments for this disease are based, for the most part, on theory and will require further investigation to confirm or disprove their efficacy.
Adour, K. K., Ruboyianes J. M., Von doersten P. G. et al.: Bell's palsy treatment with
acyclovir and prednisone compared with prednisone alone: a double-blind,
randomized, controlled trial. Ann Otol Rhinol Larngol 1996; 105:371-8.
Berg, H. M., Cohen, N. L., Hammerschlag, P. E., Waltzman, S. B.: Acoustic neuroma
presenting as sudden hearing loss with recovery. Otolaryngology Head and Neck Surgery 1986; 94:15-22
Billings, P. B., keithley, E. M., Harris, J. P.: Evidence linking the 68 kilodalton antigen
identified in progressive sensorineural hearing loss patient sear with heat shock protein 70. Ann Otol Rhinol Laryngol 1995; 104:181-188
Byl, F. M.: 76 cases of presumed sudden hearing loss occurring in 1973: Prognosis and
incidence. Laryngoscope 87:817, 1977
Byl, F. M.: Sudden hearing loss: eight years experience and suggested prognostic table.
Laryngoscope 1984; 94:647-61
Cole, Randolph R. and Jahrsdoerfer, Robert A.: Sudden hearing loss: an update. The
American Journal of Otology 1988; 9:211-215 (May)
De Kleyn, A.: Sudden complete or partial loss of function of the octavus system in
apparently normal persons. Acta Otolaryngol 1944; 32:407-29
Fetterman, B. L., Saunders J. E., Luxford, W. M.: prognosis and treatment of sudden
sensorineural hearing loss. American Journal of Otology 1996; 17:529-36
Gerwin, John M. and LaCoste, Pat: The acoustic stapedial reflex as a prognostic indicator
in sudden onset sensorineural hearing loss. Otolaryngology Head and Neck Surgery 1982; 90:857-861 (Nov-Dec)
Gulya, A. Julianna: Sudden sensorineural hearing loss: an otologyic emergency.
Comprehensive Therapy 1996; 22(4):217-221
Harris, J. P., Fan J. T., Keithley E. M.: Immunologic responses in experimental
cytomegalovirus labyrinthtis. American Journal of Otolaryngology 1990; 11:304-308.
Harris, J. P., Sharp, P.: Inner ear autoantibodies in patients with rapidly progressive
sensorineural hearing loss. Laryngoscope 1990;100:516-24
Hughes, Gordon B. et. al.: Sudden sensorineural hearing loss. Otolaryngology clinics of
North America 1996; 29:393-405 (June)
Jaffe B: Clinical studies in sudden deafness. Adv Otorhinolaryngol 20:221-228, 1973
Kohut, Robert I.: Perilymph fistula. In: Bailey, B. J., ed. Head and neck surgery-
otolaryngology. Philadelphia, PA: JB Lippincott 1998; 20972106
Laird, Nan and Wilson, William R.: Predicting recovery from idiopathic sudden hearing
loss. American Journal of Otolaryngology 1983; 4:161-164 (May)
Mattox, D. E., Simmons, F. B.: Natural history of sudden sensorineural hearing loss.
Ann Otol Rhinol Laryngo 1977; 86:463-480
Mattox, Douglas E. and Lyles, C. Alan: Idiopathic sudden sensorineural hearing loss.
The American Journal of Otology 1989; 10:242-247 (May)
McCabe, Brian F.: Autoimmune inner ear disease: results and therapy. Adv
Otorhinolaryngol 1991; 46:78-81
Moskowitz, Dan, Lee, K. J., and Smith, Howard W.: Steroid use in idiopathic sudden
sensorineural hearing loss. Laryngoscope 1984; 94:664-666 (May)
Pappas, Dennis G. et al: Ultrastructural findings in the cochlea of aids cases. The
American Journal of Otology 1994; 15:456-465
Perlman, H. B. and Kumura, R.: Experimental obstruction of the venousdrainage and
arterial supply of the inner ear. Ann Otol Rhinol Laryngol 1957; 66:537-46
Sismanis, A. et. al.: Methotrexate therapy fo autoimmune hearing loss: A preliminary
report. Laryngoscope 1994; 104:932-934
Scheweitzer, Vanessa Gayl and Shepard, Neil: Sudden hearing loss: An uncommon
manifestation of multiple sclerosis. Otolaryngology Head and Neck Surgery 1989; 100:327-332 (April)
Shikowitz, Mark J.: Sudden sensorineural hearing loss. Medical Clinics of North
America 1991; 75:1239-1250 (Nov.)
Schuknecht, H. F., Donovan, E. D.: The pathology of idiopathic sudden sensorineural
hearing loss. Archives of Otolaryngology 1986; 243:1-15
St. Clair, E. William and McCallum, Rex M.: Cogan’s Syndrome. Current Opinion in
Rheumatology 1999; 11:47-52
Vasama, J., Linthicum, F. H.: Idiopathic sudden sensorineural hearing loss: Temporal
bone histopathologic study. Ann Otol Rhinol Laryngol 2000; 109:527-532
Veldman, Jan E., Hanada, Takehiro, and Meeuwsen, Frits: Diagnostic and therapeutic
dilemmas in rapidly progressive sensorineural hearing loss and sudden deafness. Acta Otolaryngol 1993; 113:303-306
Veltri, R.W. et. al.: The implication of viruses in idiopathic sudden hearing loss:
Primary infection or reactivation of latent viruses? Otolaryngology Head and Neck Surgery 1981; 89:137-41
Wilkins, S. A. Jr., Mattox, D. E., Lyles, A.: Evaluation of a “shotgun” gegimen for
sudden hearing loss. Otolaryngology Head and Neck Surgery 1987; 97:474-480
Wilson, William R. et. al.: The relationship of idiopathic sudden hearing loss to diabetes
mellitus. Laryngoscope 1982; 92:155-159 (Feb.)
Wilson, W. R. et. al.: Viral and epidemiologic studies of idiopathic sudden hearing loss.
Otolaryngology Head and Neck Surgery 1983; 91(6):653-8
Wilson, Willimam R., Byl, Frederick M., and Laird, Nan: The efficacy of steroids in the
treatment of idiopathic sudden hearing loss. Archives of Otolaryngology 1980; 106:772-776 (Dec.)