management of ototoxicity outline history examination investigations diagnosis differential...
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MANAGEMENT OF OTOTOXICITY OUTLINE• History• Examination • Investigations• Diagnosis• Differential diagnosis• Prevention and monitoring• Treatment• Prognosis• Follow up• Recent advances• Conclusion
HISTORY
Detailed history is required to - Establish a diagnosis - Ascertain severity of the condition - Identify those at risk
Bio data - AgeThe following symptoms are looked out for and
evaluated > Tinnitus – most often the first symptom > Hearing loss > Imbalance or vertigo
> History of intake of ototoxic drugs (type, dose & duration).
> History of risk factors -- impaired renal function -- impaired liver function --history of previous intake of ototoxic
agents -- family history of ototoxicity Recent organ transplantation.
Examination General examination Ear examination -- otoscopy- usually normal except in pre existing
pathology like csom – TM perforation ± discharge etc -- Tuning fork test -SNHL -Rhinne test –positive - Weber test – lateralized to better ear
Vestibular function test – for those who present with vertigo or sense of imbalance.
- Hallpike manoeuvre - Romberg testR/o other causes of vertigo -fistula test
Investigations• Pure tone audiometry – High frequency• Otoacoustic emissions• Brainstem evoked response audiometry• Electrocochleography – measures the signals
produced by the cochlea and cochlear nerve in response to acoustic stimulus
• Caloric test - canal paresis - unilateral preponderance
Diagnosis
From history - reveals intake of ototoxic medication
• Diagnosis is by exclusion• OAEs, high frequency PTA, BERA &
electrocochleography reveal cochlear damage but not specifically ototoxicity
Differential diagnosis
I. Sudden hearing lossII. PresbyacusisIII.Acoustic neuroma.
Prevention and monitoring• Ototoxicity is preventable• Ototoxic damage is often times irreversible • Treatment poses a great challenge• Prevention is therefore highly advocated
Measures• Avoidance of ototoxic drugs• Awareness – clinicians should be aware of drugs with
ototoxic potentials
• Recognition of at risk groups e.g. - previous history of ototoxicity - family history of ototoxicity - elderly - impaired kidney or liver function - patients already on ototoxic medication. Recent organ transplantation
Recognition of at risk group allows the modification of therapeutic regimen.
• Protection against ototoxicity.• - Co-administration of antioxidants or iron
chellators. • - otoprotective agents; vitamin A, alpha
lipoic acid, gingko biloba.• - study by Kocyigit et al suggested that the
antioxidant N-acetyl- cysteine can protect against Amikacin toxicity
• Avoidance of noisy environment.• Monitoring of serum levels of ototoxic agents.• Audiologic monitoring. - Pure tone audiometry - Otoacoustic emissions - Brain stem evoked response audiometry. - Electrocochleography• No official guideline for audiologic monitoring.• Routine monitoring is unnecessary unless patient is
at risk of ototoxicity.• Interval of testing should decrease with the first sign
of ototoxic damage.
TREATMENT• Medical - labyrinthine vasodilators. - labyrinthine sedatives - tinnitus maskers - vestibular rehabilitation exercises.• Amplification – use of hearing aids.• Surgical - Cochlea implants.
PROGNOSIS• Depends on ; - the ototoxic agent. - nature of ototoxicity- reversible,
irreversible, progressive. - severity of the toxicity.• For those that can benefit from amplification,
prognosis is good.• Cochlear implant where available and
affordable increases prognosis.
RECENT ADVANCES.Hair cell regeneration. - Possibility of hair cell recovery is recently an
area of active interest. -Avian inner ear has demonstrated regenerative
capacity of hair cells after gentamicin exposure. - Role of regenerated hair cell in relation to
functional recovery is yet to be clearly defined. -Further studies needed.• Otoprotection. - another area that requires further study.
• CONCLUSION.• Ototoxicity is a preventabe cause of
severe morbidity which is usually difficult to manage.
• The emphasis should be on prevention.