3/14/21

Terapi Intratimpani
untuk Tuli Mendadak

PENDAHULUAN
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Perbandingan terapi Intratimpani vs Sistemik

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KONSENSUS TERAPI INTRATIMPANI UNTUK TULI MENDADAK

Revisi AAO HNS 2020
First line vs First line bila pasien tidak dianjurkan
Salvage terapi steroid sistemik (DM, dll)
Lebih diutamakan sebagai salvage
terapi bila 2 minggu terapi sistemik
gagal
Konsensus Spanyol 2017
First line : Oral atau Intratimpani atau
Oral + IT sesuai pertimbangan klinik
IV bila ambang dengar > 70 dB
Gagal oral 5 hari à IT timpanik à gagal
à hiperbarik + IV

Tipe obat yang Dexametason Methylprednisolone,1cc 40mg vial

diberikan 24 mg/mL (kental) atau diencerkan menjadi 2 cc
10 mg/mL
Dexametason 8mg dalam 9 cc
Methylprednisolone
40 mg/mL or 30 mg/mL

Interval 2x perminggu selama 2 minggu 1 x perminggu untuk 3 minggu

2
 fluid-filled space communicating with perilymph when drug A schematic of the main processes and compartments under-
solution is applied there. The middle ear is lined with epithe- lying inner ear pharmacokinetics with intratympanic drug appli-
lium that on the ventral surface, leading to the Eustachian tube, cations is shown in Fig. 1. The figure shows a drug-containing
is of endodermal origin and is densely ciliated. In contrast, formulation injected through the tympanic membrane into the
dorsal surfaces of the epithelium and regions in the vicinity of middle ear cavity. Drug enters the inner ear through multiple
the round window membrane and stapes are of neural crest pathways, including through the round window (RW) membrane
origins and are not ciliated (Thompson and Tucker, 2013). The and the stapes (King et al., 2011; Salt et al., 2012a). Drug is lost from
epithelium is both highly vascularized and includes lymphatic the middle ear by multiple mechanisms, as discussed above. As the 3/14/21
drainage to the retroauricular and junctional lymph nodes (Lim drug enters perilymph it initially distributes throughout the fluid
and Hussl, 1975). Fluid and/or drug loss through the Eustachian and tissue spaces of basal turn and vestibule, with spread along the
tube, via the vasculature and via the lymphatics can all scalae towards the cochlear apex occurring more slowly. In the
contribute to the decline of middle ear concentration with time basal turn of ST, drug levels are diluted by CSF, either entering
after drug application, as can fluid or mucus secretion by the through the cochlear aqueduct as a volume flow, or as a CSF-
epithelium. An initial breakdown (metabolism) of drugs in the
A.N. Salt, S.K. Plontke / Hearing Research xxx (2018) 1e13 5
middle ear also likely occurs but only limited quantitative data
areentry
yetofavailable. The primary function of
600 molecules in humans (Daina and Zoete, 2016). the middle ear the inner ear. As discussed earlier, the middle ear has a number of
epithelium is to the
Fig. 3A shows maintain
base form the normal gas-filled
of dexamethasone state and
lies substantially powerful mechanisms to remove fluids and drugs. For intra-
FARMAKOKINETIK TERAPI
removal of applied drug solutions by these multiple
to the left of the more polar form, dexamethasone-phosphate,
occurs as a result
suggesting of that
it would be specialization.
more permeable through membranous
processes tympanic applications in humans, the patient lies in a supine po-
sition for 20e30 min with the head orientated to keep the
2) InnerINTRATIMPANI
Ear. The
barriers.
lies at endolymph
taining
inner ear
Gentamicin,
the lower right
in comprises
orside of the plot,
perilymph,
prominent
contrast is highly
but
polar and
suggesting
spaces con-
fluidhydrophilic.
gentamicin
drugs entering the would
inner
It Eustachian tube uppermost, so that drug solution applied to the RW
niche does not immediately drain towards the Eustachian tube and
earless
doreadily
not remainpass through
confined cellular
to justboundaries. Fig. 3B Most
the fluid spaces. and Cof show
the be swallowed. Also, depending on middle ear and mastoid anatomy
similar calculations
adjacent tissue spaces for are
the different
not boundedforms byof methylprednisolone
tissues with tight (e.g. pneumatization and mucosal state) fluid can easily be
ž
and triamcinolone
junctions so drugs respectively. These calculations
rapidly equilibrate with theshow that it is
extracellular disseminated through the mastoid cells or diluted by fluid in the
critically important to know the exact form of the drug being used, middle ear.
spaces of the spiral ligament, the organ of Corti, the spiral
as small differences in molecular configuration influence polarity Middle ear drug kinetics has not been extensively studied but
ganglion and of the auditory and vestibular nerves. Depending
and lipophilicity, therefore altering the pharmacokinetic properties even in anesthetized recumbent animals applied substances are
onofpermeability
the molecule.
properties, drugs may enter the intracellular rapidly lost from the middle ear. The concentration time course of
compartments of these parameters
The same physical tissues or become
also playmembrane-bound
a major role in the if drug in the middle ear, the so-called “residence time” of the drug
lipophilic. Distribution
aqueous solubility between
of different endolymph
drugs. and perilymph
Small, nonpolar lipophilic critically influences the perilymph drug level achieved with intra-
depends on where
drugs, such - the
as the basedrug
formsenters the ear, whether
of dexamethasone and by systemic
methylpred- tympanic applications (Salt and Plontke, 2009). Mikulec et al.
ornisolone,
local application, and insoluble
are relatively whether the drug as
in water, canseen
passby through
comparing the (2009) reported the decline time course of the marker TMPA
tight, cellular
solubility dataendolymph-perilymph
in Fig. 2 with propertiesbarrier.plotted In the 3.cochlea,
in Fig. Adding measured in real time in the RW niche with ion-specific micro-
polar groupsoftocharged
distribution the molecule, such asbetween
molecules the phosphate
endolymphor succinateand electrodes. Within just 30 min, concentration of marker solution in
groups forisdexamethasone
perilymph also influenced andby methylprednisolone
the endocochlearrespectively,
potential. the niche fell to 52% of that initially-measured. Fig. 4 shows the
2
greatly increase aqueous
bone solubility by capsule
increasing TPSA/A . Thewith
use normalized decline of middle ear concentration measured for
Fluid spaces -
in the of the otic also
of these polar, more soluble forms of steroids was a successful
interact Fig. 1. Schematic of drug applied intratympanically to the inner ear. Colored arrows
gentamicin (Salt et al., 2016) and for dexamethasone-phosphate in
perilymph, with incomplete bone-lining cells (Chole and indicate movements of drug; Purple: Distribution; Red: Elimination to blood; Cyan:
strategy to increase the total drug amount delivered in IV formu- our studies. In both cases, solutions were applied to the round
Tinling, 1994) and a lacuno-canalicular system in the bone in CSF-Perilymph fluid exchange; Gray: Elimination to lymphatics; Black: Elimination via
lations. When given intravenously the soluble formulation is window nichetube.
the Eustachian in experiments
Abbreviationswhere
are: CSF:perilymph wasFluid;
Cerebrospinal collected after aque-
CA: Cochlear
open fluid communication with perilymph (Zehnder et al.,
rapidly dispersed by blood flow before the polar groups are cleaved aduct;
1 h Esac:
application period.Sac;
Endolymphatic After
ES: perilymph
Endolymphatic collection,
Space; ET:the drug so-
Eustachian tube; ME:
2005).
in tissues such as the liver, forming the less-soluble active molecule. lution
Middle remaining in the
Ear; RW: Round RW niche
Window; was sampled.
SA: Saccule; SS: SigmoidFor gentamicin,
Sinus; a
ST: Scala Tympani;
3) Cranium. Perilymph
Unfortunately, thereis has
in open little communication
been fluid consideration of with how cere-
such substance that is UT:
SV: Scala Vestibuli; retained
Utricle. well in the innerof ear,
(For interpretation the middle
the references ear in this
to color
brospinal
molecular fluid (CSF). The endolymphatic
transformations sac also contacts
influence the pharmacokinetics of the
the figure legend, thewas
concentration reader is referred
found to falltotothe
anWeb versionofof46%
average this after
article.)
83 min
drug when used with local applications to the ear. (Salt et al., 2016). For dexamethasone-phosphate the decline in
It should be noted that permeability characteristics inferred concentration was even more rapid, falling to 10% of that applied at
Please cite
from this article
molecular in press
properties as: Salt,
all relate A.N., Plontke,
to passive S.K.,ofPharmacokinetic
movements small 93 min principles in the(Salt
after application inneret ear: Influence
al., 2018). of drugthat
It is notable properties
genta- on
intratympanic
molecules applications, Hearingboundaries.
across membranous Research (2018), https://doi.org/10.1016/j.heares.2018.03.002
Many small nonpolar micin was lost more slowly than dexamethasone-phosphate, in
5 lipophilic substances such as steroids which gain access to the brain accordance with its molecular properties calculated in Fig. 3. These
are actively transported out (Karssen et al., 2001; Lo €scher and studies show that applied drugs are eliminated rather rapidly from
Potschka, 2005). Such transport, superimposed on passive move- the middle ear when applied as a solution.
ments, can potentially influence and even dominate pharmacoki- In other studies, we applied dexamethasone base in its
netics for the substance. Active transport of drugs across the micronized form to the RW niche as a 4.5% suspension in
boundaries of the ear, however, has not yet been demonstrated. phosphate-buffered saline. The concentration of dexamethasone in
the aqueous supernatant of this formulation was measured to be
94.2 mg/ml, which is close to the solubility published on Pubchem
4. Middle ear kinetics (https://pubchem.ncbi.nlm.nih.gov) of 89 mg/ml. There was insuf-
Perbandingan berbagai potensi permeabilitas steroid terhadap
When drug solution is injected into the middle ear it does not
ficient volume in the RW niche to collect uncontaminated super-
natant so no measure of middle ear concentration was possible. It is

membran telinga dalam

remain “undisturbed”, waiting for the dissolved drug to diffuse into

Fig. 3. Membrane permeation-related characteristics, WLOGP (lipid solubility, Y-axis) and TPSA (topological polar surface area; X-axis) for a number of drugs calculated by the
SwissADME website (http://www.swissadme.ch). The yellow ellipse bounds the statistical range for molecules that pass through the blood-brain barrier and the white ellipse
bounds the range for molecules that permeate the gut (Daina and Zoete, 2016; Daina et al., 2017). Based on this analysis, dexamethasone and methylprednisolone would be
expected to permeate membranes more readily than dexamethasone-phosphate, methylprednisolone-hemisuccinate, and methylprednisolone-succinate. Gentamicin would be
expected to be substantially less permeable than all forms of the steroids. (For interpretation of the references to color in this figure legend, the reader is referred to the Web version
of this article.)

Salt,cite
Please A.N.,this
Plontke, S.K., Pharmacokinetic
article principles
in press as: Salt, in the
A.N., inner ear:S.K.,
Plontke, Influence of drug propertiesprinciples
Pharmacokinetic on intratympanic applications,
in the inner ear:Hearing Research (2018),
Influence of drug properties on
https://doi.org/10.1016/j.heares.2018.03.002
intratympanic applications, Hearing Research (2018), https://doi.org/10.1016/j.heares.2018.03.002

3
 3/14/21

Protokol yang saya lakukan

ž

Intratympanic
injection

4
 3/14/21

Hearing improvement

PTA improvement
32,06 + 18,6 dB

53 % get better
more than 50 %
compare to non
affected side

Hasil terapi IT steroid sebagai salvage terapi pada penelitian di

luar
ž

10

Fig. 4. Meta
ating intraty
vage ther
CI 5 confide
ure can b
5issue, whic
laryngoscop

the authors feel that the reliability of the findings of
these trials should be questioned.28,29,31 It is possible
that the meta-analysis of this category of trials is made
up of a significant number of studies that should be con-
sidered outliers.
emotional distress these patients ex
trying steroid treatment, given tha
outweigh the risk. This compassion
quently used to justify the lack of a
in trials comparing systemic versus
 3/14/21

NETWORK META-ANALYSIS PERBANDINGAN

BERBAGAI METODE TERAPI TULI MENDADAK

11

FAKTOR PENYEBAB KEGAGALAN

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12

6
 (b) patient side. On the right
side there is an additional bony
overhang ( →), while the left
side seems open

3/14/21
Fig. 4 Coronal view of a left
temporal bone in CBCT imag-
ing. The RWN (a) and the
OWN (b) are completely opaci-
fied ( →). The soft tissue extents
to the ossicular chain in (b)

PERAN PENCITRAAN DALAM TATALAKSANA TULI

MENDADAK
European Archives of Oto-Rhino-Laryngology (2020) 277:1931–1937 1935

Fig. 3 Sagittal slices of tem- showing a hollow, air-filled cavity. The middle ear also
poral bone CBCT. The RWN
( >) can be clearly identified
Roßberg
presented ‘very dkk (2020)
well’ ventilated evaluasi
without granulation tis- CBCT
sue. This was a group A-patient with no relevant effect
on the right (a) and on the left
(b) patient side. On the right koklea menunjukkan
after IT treatment variasi
(FTA improvement of 10 dB).
side there is an additional bony Three of the four group A-patients with a post-thera-
overhang ( →), while the left
side seems open
tampilan RW yang
peutic FTA improvement dapat
of 15 dB or more had radiologic
menyebabkan tidak efektifnya
imaging. The first patient presented with a bony overhang
at the RWN; the second patient with a bony overhang and
terapi intra timpani
additional soft tissue at the RWN and an ‘unsufficiently’
aerated mastoid cavity. The third patient was characterized
by additional soft tissue at the round and oval window
niche and by an opacified tympanomastoid cavity.
All group B-patients with hearing improvement of more
than 15 dB did not show pathological findings in the radio-
logic analysis.

Fig. 5 Sagittal view of a left temporal bone in CBCT imaging. The

Fig. 4 Coronal view of a left RWN ( >) can be clearly identified but seems capped by a secondary
temporal bone in CBCT imag- membrane ( →)
ing. The RWN (a) and the
OWN (b) are completely opaci-
fied ( →). The soft tissue extents 13
to the ossicular chain in (b)
Perdarahan / ruptur intra labirin
dapat diidentifikasi dengan
pemeriksaan MRI FLAIR dan T1
dengan kontras à prognosis buruk
perbaikan pendengaran

showing a hollow, air-filled cavity. The middle ear also

presented ‘very well’ ventilated without granulation tis-
sue. This was a group A-patient with no relevant effect
after IT treatment (FTA improvement of 10 dB).
13 Three of the four group A-patients with a post-thera-
peutic FTA improvement of 15 dB or more had radiologic
imaging. The first patient presented with a bony overhang
at the RWN; the second patient with a bony overhang and
additional soft tissue at the RWN and an ‘unsufficiently’
aerated mastoid cavity. The third patient was characterized
by additional soft tissue at the round and oval window
niche and by an opacified tympanomastoid cavity.
All group B-patients with hearing improvement of more
than 15 dB did not show pathological findings in the radio-
logic analysis.

Fig. 5 Sagittal view of a left temporal bone in CBCT imaging. The

RWN ( >) can be clearly identified but seems capped by a secondary
membrane ( →)
PROGNOSIS
BERBASIS KURVA
13

AUDIOGRAM
ž

14

7
 3/14/21

Plontke:
Plontke:Diagnostics
Diagnosticsand
andtherapy
therapyofofsudden
suddenhearing
hearingloss
loss

Figure 7: Staged approach to therapy of idiopathic sudden sensorinerua

[7]). *as currently applied in the Department of Otorhinolaryngology, Unive

PERKEMBANGAN TERKINI TERAPI

INTRATIMPANI
ž

Figure 7: Staged approach to therapy of idiopathic sudden sensorinerual hearing loss (modified according to Plontke (2013)
ž Rogha
[7]). *as currently applied in the Department of Otorhinolaryngology, University Medicine Halle. RWM: round window membrane.
Mühlmeier Figure 8: Obstruction of the round window niche with a “false” round win
condition after removal of the false membrane (right). P:
ž
5.2 R
Becaus
ž “small”
Figure
Figure7:7:Staged
Stagedapproach
approachtototherapy
therapyofofidiopathic
idiopathicsudden
suddensensorinerual
sensorinerualhearinghearingloss
loss(mod
(mo
ested in
[7]).
[7]).*as
*ascurrently
currentlyapplied
appliedininthe
theDepartment
DepartmentofofOtorhinolaryngology,
Otorhinolaryngology,University
UniversityMedicine
MedicineHall Ha
ively de
maceu
[113]. T
Figure 8: Obstruction of the round window niche with a “false” round window membrane (left). Endoscopic view (middle) and applica
condition after removal of the false membrane (right). P: promontory; ISJ: incudo-stapedial joint. With re
absorb
15 5.2 Recent developments a majo
trolled
Because of the high prevalence of inner ear diseases, period
“small” and large pharmaceutical companies are inter- [115], [
ested inFigure
this
Figuretopic. Besideofofstart-up
8:8:Obstruction
Obstruction the roundcompanies
theround window
windowniche that
withaexclus-
nichewith a“false”
“false”round
roundwindow
windowmembrane
membrane(le (
ively dedicate theircondition
work toafter
condition thisremoval
after ofofthe
subject,
removal false
even
the membrane
large
false phar-(right).
membrane (right).P:P:promontory;
promontory;ISJ:ISJ:inc
in
maceutical companies Figure 9: Tertiary
meanwhile therapy of sudden
invest hearing
in this fieldloss with
tympanoscopy
[113]. The current and application
developments consider ofdrugs and drug105.2
triamcinolone 5.2
mg/mlRecent on develo
Recent deve
ROUND WINDOW SEALING UNTUK TULI MENDADAK ®
Curaspon into the oval (c, d) and round window niche (a, b).
application systems alike [95], [114], [115], [116]. Because
Becauseofofthe thehigh
highprepr
Plontke: Diagnostics and therapy of sudden hearing loss
With respect to drug application systems, biocompatible, “small”
(Plontke, 2013) absorbable polymers (as gels or solids) will probably play ested
“small”and andlarge
estedininthis
largepharm
thistopic.
phar
topic.Beside
Besid
a major role in the future. They GMS allow
Currenttargeted and con- ively
Topics in Otorhinolaryngology ivelydedicate
- Head their
dedicate their
and work
work
Neck S
maceutical companies
trolled release of substances over a predefined time maceutical companies
[113].
[113].The Thecurrent
currentdevelo
devel
period outside or inside the cochlea (Figure 10) [95], application
applicationsystems
systemsalikealik
[115], [116], [117], [118]. With
Withrespect
respecttotodrugdrugappl
app
absorbable
absorbablepolymers
polymers(as (a
aamajor
majorrole
roleininthe
thefuture
futu
Figure 9: Tertiary therapy of sudden hearing loss with trolled
trolledrelease
releaseofofsubst
subs
tympanoscopy and application of triamcinolone 10 mg/ml on period
periodoutside
outsideororinside
insid
Curaspon® into the oval (c, d) and round window niche (a, b). [115],
[115],[116],
[116],[117],
[117],[118
[11

Figure
Figure9:9:Tertiary
Tertiarytherapy
therapyofofsudden
suddenhearing
hearingloss
losswith
with
tympanoscopy
tympanoscopy and
andapplication
applicationofoftriamcinolone
triamcinolone10
10mg/ml
mg/mlon on
GMS Current Topics in Otorhinolaryngology - Head and Neck Surgery
Curaspon2017,
®®
Curaspon into Vol.
intothe 16,
theoval ISSN 1865-1011
oval(c,(c,d)d)and
andround
roundwindow
windowniche 13/21
niche(a,
(a,b).
b).

GMS
GMSCurrent
CurrentTopics
TopicsininOtorhinolaryngology
Otorhinolaryngology- Head
- Headand
andNeck
NeckSurgery
Surgery2017,
2017,Vol.
Vol.16,
16

Figure 7: Staged approach to therapy of idiopathic sudden sensorinerual hearing loss (modified according to Plontke (2013)
[7]). *as currently applied in the Department of Otorhinolaryngology, University Medicine Halle. RWM: round window membrane.

16

8
Figure 8: Obstruction of the round window niche with a “false” round window membrane (left). Endoscopic view (middle) and
condition after removal of the false membrane (right). P: promontory; ISJ: incudo-stapedial joint.

5.2 Recent developments

Because of the high prevalence of inner ear diseases,
 TheThirty-seven
mean hearingpatients loss of 51presented
patients with withunilateral
unilateral SSHL idiopathic
was was observed in 8acases
and 7 with (15.7%)
hearing loss while
between11 patients
30 and(21.6%)
60 dB. had
Three of the
sensorineural
73.3 dB. The left hearing
ear was loss, whereas
affected in 2532cases of them
(49%)had anda the
severe no change of the hearing function (Table 3).
patients with a hearing loss less than 70 dB had no remission.
hearing
right in 26 loss more
cases thanThe
(51%). 70 mean
dB. Time time frominterval primary
betweentherapy
onset to A partial Three orhadcomplete decreaseremission,
a complete of the associated
and one symptoms
had a slight
surgery was 12 (range,
of first symptoms and surgery3–60) wasdays,
5 days and(range,
time 1from to 12surgery
days) to couldrecovery.
be observed in 72.8%
One patient(n=8)
withof 70the dB
patients
alsowith
hadvertigo,
no change of
improvement of hearing was 4 (range, 1–38) days.
hearing after conservative treatment. There was one young
Table Five patientsresults
2. Clinical had witha hearing
respect to level less than otologic
accompanying 70 dB (2
patient aged 16 who had an acoustic trauma on both ears
patients,
symptoms 60 dB; 2 patients, 50 dB; 1 patient, 40 dB
150
because of a rocket during a firework presenting a complete
3/14/21
downsloping to 80 dB). Twenty-six (70.3%) Completely had tinnitus
Accompanying
Worsened Same whereas Improvedsevere rotatory
recovery on one ear and a slight recovery from 90 dB to
and 15 (40.5%) patients
symptom had vertigo, recovered 100
posttherapeutic 55 dB on his other ear.
vertigo was observed in
Tinnitus (n=37) 3 (8.1%)
1 (2.7) of them.
16 (42.2) 11 (29.7) 9 (24.3) There is no difference in outcome whether a leak was
Tympanotomy
Vertigo (n=11) was 0carried 3out (27.3) after4 (36.4)
a median time of
4 (36.4) observed
50
or not in idiopathic hearing loss; of 26 patients with
12 daysof (range, 3–60 days). Retrospectively, the 3group
(100) with

dB
Feeling ear fullness 0 0 0
improved hearing levels, 3 patients with leak improved their
a hearing gain was operated on after a median interval of
(n=3)
Periauricular 0
hearing and 23 patients without a leak improved, whereas
14 days (range, 3–37 days) and0 the group 0 without 1 (100)
response
dysaesthesia (n=1) one0 patient with a leak and 10 patients without showed no
after 12 days (range, 7–60 days).
effect after surgery. From the 4 patients presented where a
Hasil beberapa penelitian RW sealing pada tuli mendadak
ValuesNine are presented
patients aswith number (%). tone hearing level more than
a pure
70 dB and 2 with less than 70 dB had no significant change
leak1288
–50
B. Loader3 et(75%)
was observed, al.R-Quadrat linear=0.083
showed recovery after
Table 3. Audiometric results after treatment of 51 patients with unilat-
tympanotomy (Table 2 ). In patients without presenting a T2
after tympanotomy.
eral sudden sensorineural hearing loss leak, 220 (71%) 5 improved 10 and15 9 (29%) 20 failed 25 to enhance The age of pati
Twenty-one patients with hearing loss more than 70 dB
hearing125level (Table 3). Days T3 was statistically si
and
Hearing5 patients
gain with hearing No.loss
(%) less than Mean70 dB gain
hearing showed(dB) an
In patients with tympanotomy and sealing of round did not improve (F
improvement
Complete recovery of hearing level.
12 (23.5) Fifteen patients
52.33 had a Fig. 1. Linear univariate regression analysis
100after barotraumas, * of duration before initial
window 5 patients with leak improved 65 years improved
recovery
Marked recovery of more than 3020dB, (39.2)9 of 10 to 3048.83 dB, and 2 had presentation and influence on the hearing gain in 51 patients with
their
unilateral hearing
sudden to a complete
sensorineural hearingresponse.
loss. Hearing gain (dB), du- who did not im
aSlight
full recovery
recovery with a resulting 8 (15.7)hearing level 20.43 of 0 dB. In the ration before initial presentation (day).(7Pearson correlation R=–0.23;
No change 11 (21.6) –6.50 Those80who had no leak patients) had levels enhanced to 65 years of age.
group with hearing improvement, 19 (73%) had tinnitus and P =0.057.
0 dB [28] and one slight and one marked recovery. Two with were younger tha
11 (42.3%) had vertigo. In the group of patients with no

PTA
Hoch dkk, 2015 (N= 51) a leak and
60 5 without a leak had no measurable improvement. showed a postope
response
Table
Rerata to surgery,
Clinical
4. ambang differences
dengar tinnitus
between
awal : was
73,3 observed
patients
dB with complete in 8 (72.7%)
versus noand
recovery of hearing function
Onset tointerapi < 12 hari
So there might be a better outcome if a leak was identified in the age of patient
vertigo
Variable 4 (36.4%) patients. Complete recovery No recovery * but not in patients
P-value with idiopathic
Clinical and Experimental Otorhinolaryngology Vol. 8, No. 1: 20-25, March 2015 patients40with barotraumas (average 61.8 ye
Sex (male:female) 75:25 hearing loss and 36:63 acoustic trauma. 0.100 higher (p = 0.004
Table 2
Mean age (year) 55.60 20 63.90 0.171
Recovery after tympanotomy with sealing of round window membrane show postoperati
Mean follow-up time (month) 12.58 12.45 0.986
Recovery
Mean hearing loss (dB) b10 dB 10–30 dB N30 dB Final 0 dB 64.70 4. Discussion 73.20 0.419
every increase of
hearing loss 0 the improvement
Duration until begin of therapy (day) 1.67 7.90
Preoperative 0.024
Postoperative
Time between start of conservative
Barotrauma 6 therapy
0 and tympanotomy
8 (day)
4 1.50 The management 1.55of idiopathic sensorineural
0.958 hearing loss (p = 0.03).
Vertigo, ntrauma
Acoustic (%) 2 0 2 0 3 (25.0) Figure
is still Loader
without 3 (27.3)
3. Pure-tone
dkk,
defined average
2013 (PTA)
(N=25)
structure [29-32]. 1.000
of bone conduction
As at 0.5, 1, 2,
the pathogenesis The median tim
Tinnitus,hearing
Sudden n (%) loss 10 9 15 2
remains Rerata
10 (83.3) and 3 kHz ambang
shows
unknown 7 (63.6) dengarcases
a statistically
in most >70 dB 0.371
significant
and postoperative improve-
the spontaneous toms and surgery
Ear fullness, n (%) 1 (8.3) ment of Onset
20.4 to
dB0terapi
acrossmed 9 hari
the complete patient
1.000 collective. In those age 37.2 dB bon
Gedlicka dkk, 2007 (N=36) patientsAmerican
whoJournal of Otolaryngology–Head and Neck Medicine and Surgery 30 (2009) 157–161
improved the average postoperative increase was
Rerata ambang dengar >70 dB average age of
37.2 dB, with a wide range of postoperative values.
Onset to terapi 3 – 60 hari unchanged posto
American Journal of Otolaryngology–Head and Neck Medicine and Surgery 30 (2009) 157–161
the median betwe
frequency ranges (Figure 4). In all, 13/25 (52%)
tion. However, th
patients exhibited improved hearing PTA thresholds
relationship betw
17 postoperatively regardless of age and time of treatment
degree of improv
(Table I). A marked recovery (> 30 dB) could be seen
a univariate regr
in 8 (32%) patients and a recovery between 10 and
regression model
30 dB could be identified in 5 (20%) patients, whereas
surgery, the adjus
12 (48%) patients showed no clinically relevant
significant (p = 0.
improvement. Of those patients who improved post-
age-adjusted relat
operatively the average audiometric gain was 37.2 dB.
degree of improv

KESIMPULAN
20

ž
0

ž
dB HL change

–20

ž –40

–60

–80

diff_250 diff_500 diff_1000 diff_2000 diff_3000 diff_4000 diff

Figure 4. Change in dB bone conduction post-tympanotomy for each measured frequency. A sta
seen across all frequencies with the emphasis on lower and middle frequency ranges.
18