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Poor reception?
Case Report
Poor reception? Constantine Alifrangis, Jonny P Harcourt, Ondrej Gojis, Carlo Palmieri Lancet 2009; 374: 948 Department of Medical Oncology (C Alifrangis MRCP, O Gojis MD, C Palmieri MRCP), and Ear, Nose and Throat (ENT) Department (J P Harcourt FRCS), Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK Correspondence to: Dr C Palmieri, Department of Medical Oncology, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London W6 8RF, UK [email protected]
A
In September, 2008, while on holiday in France, a 58-year-old woman had loss of hearing in her left ear. This was first noticed when she tried answering a phone-call; she initially thought her mobile phone was defective. She felt otherwise well and had no other symptoms. She had been diagnosed with breast cancer in 1998, and developed a local recurrence in 2004 (currently treated with letrozole with which there has been a complete clinical and radiological response). She sought immediate medical attention in France and was referred to an ENT specialist. An audiogram showed equal loss of air and bone conduction in the left ear, most pronounced in the range 500–5000 Hz, consistent with sensorineural hearing loss (figure A). She was started immediately on a 5-day course of high dose prednisolone 60 mg once a day. A repeat audiogram done 7 days later in France and subsequently 6 weeks later in the UK by us showed improved thresholds in the affected frequencies (figure B). A gadolinium-enhanced magnetic resonance imaging (MRI) scan of the brain was normal. When last seen in January, 2009, hearing in her left ear had almost become normal with only mild subjective muffling in low
Right ear
Left ear Frequency (Hz)
Hearing in decibels (dB)
250
1000
2000
Frequency (Hz) 4000
8000
250
500
1000
2000
4000
8000
0 10 20 30 40 50 60 70 80
B Hearing in decibels (dB)
500
Right ear
Left ear
0 10 20 30 40 50 60 70 80 Air conduction, masked if necessary, right ear Bone conduction, not masked, either ear
Air conduction, masked if necessary, left ear Bone conduction, masked, left ear
Figure: Audiogram on presentation in France (A) and 6 weeks later in the UK (B) (A) Arrow shows area where thresholds are increased in the left ear. (B) The thresholds to air and bone conduction have decreased, particularly in the higher frequencies (arrow, left ear).
948
frequencies, and her breast cancer remains well controlled. Idiopathic sudden sensorineural hearing loss affects 5–20 people per 100 000 per year and is defined as unilateral unexplained hearing loss over a period of less than 72 h. In less than 15% of cases there is a defined cause, such as a cerebrovascular accident, trauma, perilymph fistula, infective process (syphilis or Lyme disease), autoimmune disease, or a demyelinating disorder. The disorder could be virally mediated, although current evidence suggests this to be an uncommon cause. Alternatively, activation of cellular stress pathways within the cochlea could be responsible.1 MRI is mandatory to exclude an intracranial lesion. While high dose corticosteroids for 5–7 days are considered the treatment of choice, preferably given early within 72 h of onset of symptoms, the evidence base to support this regimen is limited. One study showed that steroids increased the chance of recovering 50% or more of the original hearing loss compared with placebo (61% vs 32%, p<0·05).2 A follow-up trial failed to show a benefit for steroids, although this study was underpowered.3 A Cochrane review has concluded that because of the small number and varying quality of studies, the evidence remains unclear for the efficacy of steroids in idiopathic sudden sensorineural hearing loss.4 Repeat audiometry over the course of a year after onset is advised.3 Prognosis is variable and hearing can recover spontaneously without treatment.3 Poor prognostic indicators of recovery include severity of hearing loss, the presence of vertigo, advanced age, elevated erythrocyte sedimentation rate, delayed treatment, and lack of improvement with corticosteroid treatment.3,5 It is crucial for the nonspecialist who sees a patient with sudden onset of hearing loss to appreciate that this requires urgent specialist referral and audiological assessment. Contributors JH and CP were responsible for the care of the patient. All authors were involved in writing the report References 1 Merchant SN, Durand ML, Adams JC. Sudden deafness: is it viral? ORL J Otorhinolaryngol Relat Spec 2008; 70: 52–60. 2 Wilson WR, Byl FM, Laird N. The efficacy of steroids in the treatment of idiopathic sudden hearing loss. A double blind clinical study. Arch Otolaryngol 1980; 106: 772–76. 3 Rauch SD. Idiopathic sudden sensorineural hearing loss. N Eng J Med 2008; 359: 836–42. 4 Wei BP, Mubiru S, O’Leary S. Steroids for idiopathic sudden sensorineural hearing loss. Cochrane Database Syst Rev 2006; 1: CD003998. 5 Cvorović L, Deric D, Probst R, Hegemann S. Prognostic model for predicting hearing recovery in idiopathic sudden sensorineural hearing loss. Otol Neurotol 2008; 29: 464–49.
www.thelancet.com Vol 374 September 12, 2009
Poor reception? Constantine Alifrangis, Jonny P Harcourt, Ondrej Gojis, Carlo Palmieri Lancet 2009; 374: 948 Department of Medical Oncology (C Alifrangis MRCP, O Gojis MD, C Palmieri MRCP), and Ear, Nose and Throat (ENT) Department (J P Harcourt FRCS), Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK Correspondence to: Dr C Palmieri, Department of Medical Oncology, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London W6 8RF, UK [email protected]
A
In September, 2008, while on holiday in France, a 58-year-old woman had loss of hearing in her left ear. This was first noticed when she tried answering a phone-call; she initially thought her mobile phone was defective. She felt otherwise well and had no other symptoms. She had been diagnosed with breast cancer in 1998, and developed a local recurrence in 2004 (currently treated with letrozole with which there has been a complete clinical and radiological response). She sought immediate medical attention in France and was referred to an ENT specialist. An audiogram showed equal loss of air and bone conduction in the left ear, most pronounced in the range 500–5000 Hz, consistent with sensorineural hearing loss (figure A). She was started immediately on a 5-day course of high dose prednisolone 60 mg once a day. A repeat audiogram done 7 days later in France and subsequently 6 weeks later in the UK by us showed improved thresholds in the affected frequencies (figure B). A gadolinium-enhanced magnetic resonance imaging (MRI) scan of the brain was normal. When last seen in January, 2009, hearing in her left ear had almost become normal with only mild subjective muffling in low
Right ear
Left ear Frequency (Hz)
Hearing in decibels (dB)
250
1000
2000
Frequency (Hz) 4000
8000
250
500
1000
2000
4000
8000
0 10 20 30 40 50 60 70 80
B Hearing in decibels (dB)
500
Right ear
Left ear
0 10 20 30 40 50 60 70 80 Air conduction, masked if necessary, right ear Bone conduction, not masked, either ear
Air conduction, masked if necessary, left ear Bone conduction, masked, left ear
Figure: Audiogram on presentation in France (A) and 6 weeks later in the UK (B) (A) Arrow shows area where thresholds are increased in the left ear. (B) The thresholds to air and bone conduction have decreased, particularly in the higher frequencies (arrow, left ear).
948
frequencies, and her breast cancer remains well controlled. Idiopathic sudden sensorineural hearing loss affects 5–20 people per 100 000 per year and is defined as unilateral unexplained hearing loss over a period of less than 72 h. In less than 15% of cases there is a defined cause, such as a cerebrovascular accident, trauma, perilymph fistula, infective process (syphilis or Lyme disease), autoimmune disease, or a demyelinating disorder. The disorder could be virally mediated, although current evidence suggests this to be an uncommon cause. Alternatively, activation of cellular stress pathways within the cochlea could be responsible.1 MRI is mandatory to exclude an intracranial lesion. While high dose corticosteroids for 5–7 days are considered the treatment of choice, preferably given early within 72 h of onset of symptoms, the evidence base to support this regimen is limited. One study showed that steroids increased the chance of recovering 50% or more of the original hearing loss compared with placebo (61% vs 32%, p<0·05).2 A follow-up trial failed to show a benefit for steroids, although this study was underpowered.3 A Cochrane review has concluded that because of the small number and varying quality of studies, the evidence remains unclear for the efficacy of steroids in idiopathic sudden sensorineural hearing loss.4 Repeat audiometry over the course of a year after onset is advised.3 Prognosis is variable and hearing can recover spontaneously without treatment.3 Poor prognostic indicators of recovery include severity of hearing loss, the presence of vertigo, advanced age, elevated erythrocyte sedimentation rate, delayed treatment, and lack of improvement with corticosteroid treatment.3,5 It is crucial for the nonspecialist who sees a patient with sudden onset of hearing loss to appreciate that this requires urgent specialist referral and audiological assessment. Contributors JH and CP were responsible for the care of the patient. All authors were involved in writing the report References 1 Merchant SN, Durand ML, Adams JC. Sudden deafness: is it viral? ORL J Otorhinolaryngol Relat Spec 2008; 70: 52–60. 2 Wilson WR, Byl FM, Laird N. The efficacy of steroids in the treatment of idiopathic sudden hearing loss. A double blind clinical study. Arch Otolaryngol 1980; 106: 772–76. 3 Rauch SD. Idiopathic sudden sensorineural hearing loss. N Eng J Med 2008; 359: 836–42. 4 Wei BP, Mubiru S, O’Leary S. Steroids for idiopathic sudden sensorineural hearing loss. Cochrane Database Syst Rev 2006; 1: CD003998. 5 Cvorović L, Deric D, Probst R, Hegemann S. Prognostic model for predicting hearing recovery in idiopathic sudden sensorineural hearing loss. Otol Neurotol 2008; 29: 464–49.
www.thelancet.com Vol 374 September 12, 2009