Intra or transtympanic corticosteroids can result in significant systemic absorption so consider weaning them in a similar way to oral prednisone to avoid an adrenal crisis, advises nephrologist Professor Simon Roger.
By Professor Simon Roger
Sensorineural deafness or hearing loss is caused by damage to the cochlea or the auditory nerve. The onset can be sudden or gradual. The hearing loss can occur on one side or both. Symptoms can be very debilitating. It is the commonest type of permanent hearing loss.
The hearing loss can relate to a range of issues including a concurrent illness including infections, loud noise, diabetes, trauma to the head and some medications such as gentamycin and cisplatin.
The use of corticosteroids can be controversial as discussed in both a Cochrane review and clinical practice guidelines. The evidence has been described as low or very low certainty. These can be administered orally, intra or transtympanic, or a combination of both as primary therapy.
Oral corticosteroids, eg prednisone or dexamethasone, are used in a wide range of medical conditions whether it be treating autoimmune diseases such as systemic lupus erythematosus or rheumatoid arthritis, vasculitis or exacerbation of airways disease.
Avoiding Addisonian crisis
It is well recognised by the medical profession that oral steroid dosages need to be weaned over a period of time (depending on the initial dose and duration of therapy) to allow the adrenal glands, which produce endogenous steroid (cortisol) to recover after a period of suppression. Failure to do that can result in an Addisonian crisis, also known as an adrenal crisis.
The steroids can also be administered directly into the middle ear, using drops via a grommet or transtympanic injection 3x/week or on alternate days. Relatively large doses of steroids are administered via this route.
The transtympanic method is typically but probably incorrectly prescribed to reduce absorption in patients with diabetes mellitus, unstable hypertension, propensity to gastric ulcer disease, glaucoma or prior psychiatric reactions (steroid psychoses), who may not be able to receive corticosteroids orally. There is a propensity for the absorption, either through the middle ear or from drainage down the eustachian tube, to be swallowed and absorbed in the stomach.
Personal experience
I have worked as a renal physician for more than 30 years and have a history of type I diabetes dating back 45 years. During 2023-2024, I suffered two episodes of sensorineural hearing loss, affecting both ears.
Initial management was oral prednisone and transtympanic steroid injections. The second episode, rather than injections, involved the insertion of a grommet and administration of dexamethasone drops.
Dexamethasone is a more concentrated steroid preparation with 0.5mL (24mg/mL) on alternate days for two weeks, equating to 75mg prednisone. This followed four weeks of oral prednisone 50mg/day, titrated over that time period.
Not surprisingly, the systemic and intra-tympanic steroids caused significant side effects. These included increasing insulin dosages by 250%, insomnia, anger management issues and tremor.
The sudden withdrawal of the intratympanic steroids resulted in an Addisonian crisis with a blood pressure of 90/72mmHg. A random cortisol taken at the time came back very low at 44nmol/L; normal range is 130-650nmol/L. The hypotension responded within an hour to oral prednisone 5mg.
Teaching points
It is well recognised that oral prednisone dosages need to be titrated over time. However, it is not well recognised that intra or transtympanic corticosteroids, as they are absorbed, can markedly suppress the body’s production of cortisol. Therefore, the prescribing otolaryngologist should be aware of this phenomenon and consider weaning that route of administration of corticosteroids, in the same way that oral dosages are titrated downwards.
Appropriate discussion needs to occur between the otolaryngologist and the patient and may also involve the general practitioner to help with supervision of the process.
*Prof Roger and Dr Thomas Kertesz from the Sydney Adult and Children’s Ear Nose and Throat Surgery Centre, Randwick, first wrote a letter to the editor of the Australian Journal of Otolaryngology in May outlining this case. It aimed to create awareness among ENT specialists about the importance of titrating down transtympanic corticosteroids, rather than abrupt cessation.
ABOUT THE AUTHOR: Prof Simon D Roger MD FRACP was director of Gosford Hospital’s Department of Renal Medicine and is current director of Renal Research Gosford NSW. He has more than 30 years of clinical experience and is principal investigator for more than 100 clinical drug trials.
