THE ROLE OF HYPERBARIC OXYGEN THERAPY IN

SUDDEN SENSORINEURAL HEARING LOSS :

A RETROSPECTIVE REVIEW OF 50 PATIENTS
R . I FA N A R I E F FA H R U R O Z I

HIPERBARIK

DEFINISI
Pengobatan oksigenasi menggunakan ruang
udara bertekanan tinggi dan pemberian oksigen
murni 100% pada tekanan lebih dari satu atm
dalam jangka waktu tertentu

SARANA
Ruang Udara Bertekanan Tinggi / RUBT (Hyperbaric
Chamber)
Tipe RUBT

RUBT Ruang Tunggal / Monoplace

Tekanan < 3 ATA, Individual, Infeksi, Intensif

Mudah di operasikan, mudah ditempatkan, tidak perlu masker, mudah
dilakukan observasi.

RUBT Ruang Ganda / Walk in Chamber

Tekanan > 3 6 ATA, Kelompok, Emboli udara, Dekompresi

Pernafasan dengan masker menutupi hidung dan mulut

RUBT Pengangkut / Mobile

Untuk operasional militer

RUBT Latihan Penyelam

Untuk uji coba penyelam

Small Hyperbaric Chamber

Untuk Neonatus dan Hewan percobaan.

SARANA
Peralatan tambahan untuk RUBT
Masker oksigen
Respirator dan Ventilator
Peralatan untuk terapi
Peralatan RJP, Tabung endotrakeal, Suction, Infus

Peralatan diagnostik
Alat diagnostik kedokteran, alat monitor oksigen, EKG, EEG, Alat
ukur AGD, Alat monitor TIK

Alat neurologi ofthalmoskop

Alat latihan treadmill
Alat terapi traksi servikal

TEKANAN DAN INDIKASI

Tipe Tekanan

Tipe Ruang

Indikasi

1,5 ATA

RUBT Ruang Tunggal

dan Ruang Ganda

Iskemia cerebri
Iskemia jantung
Iskemia peripheral vaskular
Kebugaran
Kedokteran olahraga
Skin Flaps
Trauma Akustik

2,5 ATA

Non portable dan

portable

Gas gangren
Luka bakar
Crush injury pada ujung lengan / kaki

3 ATA

Non portable dan

portable

Kondisi darurat penyakit

dekompresi

6 ATA

RUBT Ruang Ganda

Emboli udara
Dekompresi

INDIKASI

Dekompresi
Emboli udara
Keracunan gas
Gas gangren
Morbus hansen
Penyakit jamur sistemik
Luka bakar
Ulkus dan gangren diabetikum
Penyembuhan pasca bedah plastik dan rekontruksi
Crush injury
Bedah ortopedi
Penyakit vaskular shock, iskemik
Neurologi stroke, multipel sclerosis, migrain, edema cerebral
Hematologi sickle cell anemia
Ofthalmologi oklusi arteri sentralis retina
THT sudden deafness, penyakit meniere, radang telinga menahun
Paru abses paru

KONTRAINDIKASI
Absolut

Pneumothorax yang belum diterapi

Keganasan yang belum diterapi
Hamil

Relatif

ISPA
Sinusitis kronik
Kejang
Emfisema
Febris tidak terkontrol
Riwayat pneumothorax spontan
Riwayat bedah thorax
Riwayat operasi telinga

KOMPLIKASI
Berat

Barotrauma telinga, sinus, gigi dan paru

Keracunan oksigen
Temporer myopia
Kejang

Ringan

Mual, muntah
Berkeringat
Batuk kering
Sakit dada
Berkedut / muscle twitching
Tinitus

MEKANISME TERAPI
Aktifitas koklea tergantung dari suplai energi yang dibentuk
oleh metabolisme oksigen.
Stria vaskularis dan organ Corti dengan aktifitas metabolisme
yang tinggi membutuhkan konsumsi oksigen yang sangat
besar.
Tekanan oksigen pada perilimfe menurun secara signifikan
pada pasien dengan tuli mendadak.
Tindak lanjut dari keadaan ini adalah rusaknya neuroepitelium
sensori karena adanya anoksia sehingga suplai oksigen
merupakan kunci utama terjadinya disfungsi pada telinga
dalam.
Rasionalitas terapi tuli mendadak yaitu peningkatan kelarutan
oksigen yang masif, vasokontriksi yang dapat mengurangi
edema, memperbaiki aliran darah dan sel darah.

 Koklea sangat dipengaruhi oleh dua mekanisme

metabolisme yaitu oksidatif aerobik pada stria vaskularis
dan glikolitik anaerobik pada organ Corti.
HBO mempunyai dua efek yaitu membangkitkan
kembali metabolisme oksidatif pada stria vaskularis serta
melindungi sel neurosensori yang telah menjadi lambat
Untuk oksigenasi telinga dalam, HBO berperan
meningkatkan potensial transmembran dan sintesis
adenosine triphosphate (ATP) serta aktifitas metabolisme
sel dan pompa natrium kalium yang mengakibatkan
terjadinya keseimbangan ion dan fungsi elektrofisiologi
pada labirin.

THE ROLE OF HYPERBARIC OXYGEN THERAPY IN

SUDDEN SENSORINEURAL HEARING LOSS :
A RETROSPECTIVE REVIEW OF 50 PATIENTS

BACKGROUND
Sudden Sensorineural Hearing Loss (SSNHL) is hearing impairment of more than 30
dB of three consecutive pure tone frequencies developing within 3 days or less.
It is a clinical manifestation with proposed diverse etiologies such as viral infection,
vascular compromise, intra-cochlear membrane rupture or inner ear disease
among others.
It is more common in young and middle aged people with unilateral ear
involvement in more than 90% cases.
Due to lack of definite cause of SSNHL, its treatment is largely empirical and
includes use of a wide variety of therapies like systemic and intratympanic steroids,
vasodilators, osmotic drugs, antiviral and anticoagulants to counteract possible
inflammatory mechanism, modify hydrostatic pressure and improving cochlear
blood flow.
The possible final goal of any treatment modality of SSNHL has been the restoration
of oxygen tension in the cochlea to encourage healing and return of hearing to
normal levels.
Hyperbaric oxygen therapy (HBOT) is a treatment modality involving the
intermittent inhalation of 100% oxygen in chambers pressurized above 1
atmosphere absolute (ATA). HBOT has been used as an adjunctive therapy for
SSNHL as it raises the amount of oxygen in the inner ear by diffusion which activates
cell metabolism leading to restoration of ionic balance and electrophysiological
functions of cochlea

PROBLEMS
How is the efficacy of addition of HBOT to
conventional treatment in patients with SSNHL?

OBJECTIVES
To evaluate the efficacy of addition of HBOT to
conventional treatment in patients with SSNHL
To identify specific groups of patients likely to
benefit from the addition of this therapy.

METHODS

DESIGN
Retrospective study

TIME & PLACE

Time
6 year from 2006 to 2011

Place
Department of Internal and Hyperbaric Medicine and
Department of ENT of Indraprastha Apollo Hospital

SAMPLE
150 patients with SSNHL who presented to our unit
during the period 2006 to 2011.
50 Patients who met the following inclusion criteria
were taken for the study

CRITERIA
Unilateral onset of SSNHL of 30 dB or greater in at
least three contiguous frequencies
Unknown cause of hearing loss
No previous surgery in the affected ear

SAMPLING METHODS
The patients received HBOT in addition to
conventional treatment as prescribed by the
referring ENT Surgeon.
The conventional treatment however was not
standardized for patients.
HBOT was administered in a multi place chamber at
2.40 ATA for 90 min once daily for at least 10 days.
The data collected included

Demographics
Initial symptoms of hearing loss, tinnitus, vertigo
Coexisting symptom
Pure tone audiogram (PTA)
Duration of onset of hearing loss from starting of HBOT.

SAMPLING METHODS
The patient's audiograms were reviewed before starting
treatment and after 10 sessions of HBOT.
If the audiogram showed improvement after 10 treatments,
patients were advised for additional 10 sessions of HBOT, this
process was repeated after further 10 sessions and a maximum of
30 sessions were given if they continuously showed improvement.
All patients were assessed with PTA at 500, 1000, 2000, 4000 and
6000 Hz and hearing gain at these frequencies was calculated
separately.
The level of hearing loss at these 5 frequencies was evaluated in 3
groups: <40 dB (mild), between 41 and 70 dB (moderate), >70 dB
(severe).
The average of mean hearing gain of patients according to age
group and therapeutic delay along with presence of associated
complaints as contributory factors to prognosis of SSNHL was
assessed.
Data of study was evaluated using descriptive statistical methods
i.e. mean and standard deviation.

RESULTS

CLINICAL PROFILE
The 50 subjects in our study were
in the age range of 18 to 75.
Proportion : 28 males and 22
females.
The co-morbid factors :
Hypertension (8%).
Diabetes Mellitus (16%).
Coronary artery disease (8%).
There was history of smoking in
22% of cases and 34%
additionally complained of
tinnitus and vertigo.

MEAN HEARING LEVELS

AT DIFFERENT FREQUENCIES

The initial and final mean hearing levels at 500, 1000,

2000, 4000 and 6000 Hz of patients are presented in
Table 2.
The mean hearing gain was highest at frequencies
above 1000 Hz.

MEAN HEARING GAIN

BASE ON INTENSITY

The mean hearing gain after treatment is shown in Table

3.
The average hearing gain at the five frequencies was
significantly higher in patients with initial level of >70 dB in
comparison to patients with hearing levels of <70 dB.

MEAN HEARING GAIN

BASE ON THERAPEUTIC DELAY

Table 4 shows the mean hearing gain according to

therapeutic delay of starting HBOT.
Time of presentation ranged between 1 and 60 days.
The patients who received treatment within 14 days had
higher hearing gain (76 20.06 dB - 51.9 17.1 dB) as
compared to patients with therapeutic delay of 15 - 30
days (77.85 29.12 dB - 59.85 22.50 dB) and in patients
who started therapy after 30 days (77.8 23.81 dB - 64.5
21.82 dB).

CORRELATION BETWEEN TIME LAG & SEVERITY

ON THE HEARING IMPROVEMENT

Table 5 shows a correlation between the time lag and

severity on the improvement in mean hearing gain in
patients.
82% patients presenting within 14 days showed
maximum improvement as compared to other subset of
patients.

MEAN HEARING GAIN

BASE ON AGE GROUP

Average hearing gain of patients according to age

group is presented in Table 6 and was significantly high
in patients younger than 50 years.

 No statistically significant difference was found among

patients with coexisting complaints of hypertension,
diabetes, smoking and presence of tinnitus or vertigo.
The hearing gain were 30 dB or more in 40%, between 20
and 30 dB in 20% and up to 20 dB in 34% of patients.
There was no response to HBOT in 6% patients (n = 3).
The average number of hyperbaric sessions ranged from
10 to 25 with maximum number of patients showing
improvement after 10 exposures.
Only one patient was given 25 sessions of HBOT, however
the patient did not show additional improvement.
In all patients the treatment was well tolerated and no
patient complained of any side effects. Hearing loss did
not worsen in any case.

DISCUSSION

 SSNHL is considered as a clinical manifestation of

possible several underlying causes such as viral
infection, vascular compromise, intra-cochlear
membrane rupture or inner ear disease.
This diversity demonstrates the prevailing
uncertainty in etiologies and an inability to predict
the prognosis.

 The high spontaneous recovery rate of SSNHL and its

low incidence make validation of empirical
treatment modalities difficult. Many treatment
regimens have been proposed such as antiviral
agents, vasodilators, anti-inflammatory and oral
and intratympannic steroids.
Hyperbaric oxygen therapy in recent years has
gained relevance for treating SSNHL in combination
with other agents. The Undersea & Hyperbaric
Medicine Society (UHMS) has approved the use of
HBOT in SSNHL in October 2011.

 HBOT increases oxygen tension (pO2) in blood by dissolving in

the plasma and diffuses into tissue fluids such as those
surrounding the sensory and neural elements of the cochlea.
Gills showed oxygen induced osmosis as the mechanism for
healing property of HBOT in such cases.
Aslan et al and Bennett et al demonstrated that earlier the
treatment received, better is the prognosis. This was confirmed
in our study. The maximum recovery was in the cases which
received HBOT within 14 days after onset. They showed
significant mean hearing gain from 75.93 20.06 dB to 51.90
17.19 dB.
Topuz et al reported HBOT as more effective in severe hearing
loss. In our study, 64% cases had hearing loss of >70 dB and
81% of these patients showed improvement of >30 dB with
mean hearing gain of 86 11.9 dB - 58.75 13.0 dB.
We observed a significant correlation between patients with
severe hearing loss presenting to us within 2 weeks of onset.
82% of patients in this subset showed maximum improvement.

 Presence of tinnitus and vertigo has been reported to

affect reversibility of hearing loss in various studies. In our
study, 34% cases (n =17) with hearing loss had
accompanied tinnitus and vertigo but no significant
difference was observed between cases with and
without these complaints.
Age has been found to be a prognostic factor for
improvement. In our study, patients in <50 year age
group showed better hearing gain as compared to
patients with age of >50 years.
Presence of diabetes, hypertension and other
associated complaints in this age group might have
been the contributory factors to poor prognosis; however
we were not able to establish any correlations.

 There is no consensus on the right number of treatments with HBOT

in the treatment of SSNHL. While some cases show improvement
within a few days other cases might need it longer to achieve
good results, however few studies report the optimum number of
sessions. In our study, maximum patients showed improvement
after 10 exposures and maximum improvement was seen on an
average of 20 sessions. We recommend that 20 sessions of HBOT
may be optimum for recovery in a majority of patients.
While the number of cases in this study is small, 94% of patients in
the study group showed statistically significant improvement in
hearing, when HBOT was administered along with conventional
therapy. While all patients were on oral steroids the conventional
treatment was not standardized in our patients.
There appears to be a scientific rationale for use of HBOT in SSNHL
and our results are encouraging. We recommend additional
multicentric, prospective trials be carried out with a standardized
protocol to establish role of HBOT in SSNHL patients.

CONCLUSION

 This retrospective study reveals that the addition of

HBOT to conventional therapy significantly improves
outcome in patients of SSNHL if started within 14
days.
Improvement is best at frequencies above 500 Hz
and in hearing loss of above 70 dB. HBOT was more
effective in patients younger than 50 years of age.