Stellate Ganglion Blocks for Idiopathic Sensorineural
Hearing Loss
A Review of 76 Cases Olaf
Haug, PhD;
W. Leonard
Draper, MD; Scott A. Haug,
\s=b\ Fifty-six patients, treated with a series of anesthetizing blocks of the stellate ganglion for idiopathic sudden sensorineural loss, were compared with 20 patients of similar diagnosis who were treated by other means as to amount of pure-tone gain, speech discrimination improvement, nature of symptoms, and delay in start of therapy. Seventy percent of the stellate-ganglion-block-treated patients achieved substantial hearing improvement. Only 15% to 20% of the non\x=req-\
stellate-ganglion-block-treated patients achieved substantial hearing improve-
ment in discrimination or pure-tone levels. The delay time from onset of symptoms to start of stellate block therapy appears to be important. The type of tinnitus, presence or absence of vertigo, and fullness in the ear may be useful prognostic signs.
(Arch Otolaryngol 102:5-8, 1976)
MA
Otolaryngologists treating patients
often feel a sense of frustration and futility in with idiopathic sudden sensorineural hearing loss. The typical patient is one who suddenly becomes hard of hearing, more hard of hearing (if a previous unrelated loss was present), or deaf in one ear, usually associated with tinnitus, quality distortion of sound, recruitment, loud sound intolerance, and, at times, fullness in the ear and vertigo without apparent cause. Conditions that are known to produce abrupt, usually unilateral sensorineural losses such as
measles, meningitis, encephalitis, acoustic tumors, ear surgery, skull fracture, ototoxic drugs, and mumps,
perilymphatic fistula from exertion or
barotrauma are excluded from this review. The cause of idiopathic sudden losses is thought to be vascular or viral in origin, resulting in a reduced blood supply to the cochlea. Generally, there does not seem to be any agreement among otolaryngologists regarding treatment for idiopathic sudden deafness. Saunders1 reported that answers to a questionnaire received from 130 otolaryngologists in the United States and Europe case
Accepted for publication Aug 15, 1975. From the Department of Otorhinolaryngology, Baylor College of Medicine and the Medical Center Ear, Nose and Throat Associates, Houston. Reprint requests to the Medical Center Ear, Nose and Throat Associates, 540 Hermann Professional Bldg, Houston, TX 77025 (Dr Haug).
Downloaded From: http://archotol.jamanetwork.com/ by a University of Manitoba User on 06/17/2015
showed that
one
treatment at all to
third offered
diagnosis, or else felt that ment
was
useless.
no
patients with this any treat-
Twenty-seven drugs were reported used by the physicians who did treat these patients, with vasodilators, anticoagulants, vitamins, adrenocorticotropic hormone, steroids, sedatives, tranquilizers, diuretics, and even repeated smallpox vaccinations being listed. Stellate ganglion blocks as
not even mentioned in the questionnaire responses. We report results of treatment of a series of anesthetizing blocks of the stellate ganglion on 56 patients, together with a comparison of 20 patients who were treated by other means. The stellate ganglion block procedure for sudden deafness appears to be little known even among otolaryngologists. Some of the earliest descriptions of its use in the therapy of sudden hearing loss were that of Schubert2 in 1949 and Hilger3 in 1950. More recently, Kessler,4 reporting on a total of 94 patients, indicated symptomatic improvement in 79% of the cases in which stellate ganglion blocks were used. Cocks,5 in a brief were
Table 1.—Improvement of Seven Patients After Stellate Ganglion Block Treatment Discrimination Pure-Tone Before Treatment
Patient
After Treatment 30 30 23 33
! 2 3 4 5
98 90
~. 68 73 98
6" 7
Average
(PB Max Scores) Before Treat- After Treat-
Gain (dB)
ment(%)
>80 68 67 >77 63 61 80
5
Ï2
Ï8
(%)
ment
Gain (%)
(3
96"
Ö
92 96 96
92 96 96
TOO TOO ÏÔ0
TOO
0 0
Ö 28
Ö
96"
72
TÖÖ
Table 2.—Characteristics of Improved and Nonimproved Patients Following Stellate Ganglion Block Treatment Improved Patient Characteristics
or
Sex
Less Than 10 db or 10% PB Max Gain
or
44
40
M,49%; F, 51%
M, 60%; F, 40%
Sudden loss
Sensorineural-type
10% PB Max More Gain
10 db PTA
Age, average
Nonimproved
39(100%) 39 (100%) 39(100%) 34(86%) 16(40%) 7(17%) 11 (29%) 5(14%) 12(32%)
17(100%) 17 (100%) 16(96%) 15(93%) 2(13%) 7(40%) 7 (40%) (7%) _11 (67%) (68%)_6 (33%)
loss
Unilateral Loud tinnitus
High frequency ring, whine, whistle Low frequency roar, buzz, hum Unknown type No tinnitus Vertigo
~_1
vertigo_27 (29%)_8(47%)_ Fullness_11 No fullness 9 28(71%)~ No
(53%)_
Fig as
1 .—Pure-tone average improvement in patients treated with stellate ganglion blocks in whom stellate ganglion blocks were not used.
compared with those
clinical account of 20 patients treated with stellate ganglion blocks, stressed the importance of early treatment. The stellate ganglion is made up of the inferior cervical ganglion and the superior thoracic ganglion of the sympathetic nerve trunk. The func¬ tion of this nerve trunk, along with the rest of the autonomie nervous sys¬ tem, is to assist in preparing the body (along with the adrenals) to meet emergency, ie, to prepare the body for fight or flight. The system accom¬ plishes this by constricting blood ves¬ sels, increasing blood pressure, en¬ larging pupils, and increasing heart rate.
Destructive disease or trauma of the sympathetic nerve produces Horner syndrome, characterized by vasodilation and increased blood flow. The same effect can be achieved by anesthetizing the sympathetic nerve trunk. This procedure has been used for some years, chiefly for ischemia of the arms. In a personal communica¬ tion about ten years ago, Plester de¬ scribed his use of stellate ganglion blocks in the treatment of sudden sensorineural losses, with good re¬ sults (D. Plester, MD, oral communi¬ cation, 1966). Guilford, formerly of our staff, began using it in 1967 as the treatment of sudden sensorineurol loss. Our only change in the procedure from that used by Plester was the substitution of 2% lidocaine (Xylo-
caine) (with 1:100,000 epinephrine) for procaine. METHOD
\
I Patients Treated With Stellate Ganglion Blocks
I
—
Patients Not Treated With Stellate
BUE 10-19db
20-39db
40-59db
Pure-Tone
Ganglion
Blocks
m
Over60db
Total Gain
Average Improvement
Downloaded From: http://archotol.jamanetwork.com/ by a University of Manitoba User on 06/17/2015
The procedure is done with the patient under local anesthesia. Briefly, the tech¬ nique consists of making an injection lat¬ eral and inferior to the thyroid gland to the C-7 vertebra, and then backing off slightly to the area of the stellate ganglion, injecting 3 to 5 ml of lidocaine and observ¬ ing the patient for the onset of Horner
syndrome, ie, hyperemia, enophthalmos, anhydrosis, ptosis, miosis of the pupil, drooping of the corner of the mouth, con¬ gested nose, and nasal secretion. Rou¬ tinely, the blocks are administered twice daily for three to five days, at which time the patient is reevaluated audiologically. Moore" gives a detailed description of the procedure. RESULTS
Of the 56 patients who received
stellate
ganglion blocks,
29
(30%). There was no increase in loss of hearing noted in any of the patients. Seventy percent had over 10 dB of average pure-tone improvement, with 59% obtaining gains of more than 20
(52%)
and 27 (48%) were women. The average age of the patients was 43 years. All patients had a sudden onset of the disease, and a sensorineural-type hearing loss, with 55 (98%) having a unilateral loss. Fortynine (87%) had tinnitus, 25 (44%) had vertigo, and 29 (51%) had fullness in the ear. The pure-tone average improve¬ ments following stellate ganglion blocks were as follows: over 60 dB, 12 patients (21%); 40 to 59 dB, five pa¬ tients (9%); 20 to 39 dB, 16 patients (29%); 10 to 19 dB, six patients (11%), and less than 10-dB gain, 17 patients were men
I I
dB. The phonetically balanced max¬ imum (PB Max) improvements after stellate ganglion blocks were as fol¬ lows: 80% to 100% gain, 11 patients (20%); 60% to 79% gain, four (7%); 40% to 59%, seven (12.5%); 20% to 39%, eight (14%); and 10% to 19%, seven pa¬ tients (12.5%). A total of 37 (66%) pa¬ tients improved. Nineteen patients (34%) had less than a 10% gain. No de¬ crease in PB Max scores was noted in
Ganglion Blocks Stellate Ganglion Blocks
Patients Treated With Stellate
| Patients Not Treated With
as
JBffîi
20%-39% 40%-59% 60%-79% 80%-100% Total Gain Discrimination (PB Max) Improvement discrimination improvement of patients with stellate ganglion blocks Fig 2—Speech compared with patients who did not receive treatment with ganglion blocks. 10%-19%
from onset to start of blocks who showed improvement.
Fig 3.—Days
therapy
in
patients treated
with stellate
as
ganglion
_ _ _ 0-4
5-9
Days
10-14
15-19
From Onset to Start of
20-24
25-29
Therapy
Downloaded From: http://archotol.jamanetwork.com/ by a University of Manitoba User on 06/17/2015
any of the
patients. Thirty-seven (66%) had more than a 10% gain in discrimination, with 30 (53.5%) hav¬ ing more than a 20% gain. Averaging blunts some of the amazing gains on individual cases, Table 1. In seven
pure-tone
averages
as
illustrated in
patients, gains in were
found rang¬
ing from 63 to 80 dB, and discrimina¬ tion improvement ranged from 92% to 100% in some patients. Of the 20 patients who did not re¬ ceive therapy with stellate ganglion blocks, nine (45%) were men and 11 (55%) were women. The average age of these patients was 55 years. All pa¬
tients had a sudden onset of their dis¬ ease and had a unilateral sensorineural-type loss. Sixteen (80%) had tinnitus, 12 (60%) had vertigo, and four (20%) had fullness of the ear. The primary reason for not using the blocks was patient refusal to enter the hospital for therapy. The patients were treated in the office, using niacin, isoxsuprine hydrochloride, histamine, and Lipotriad. The pure-tone average improvements for these pa¬ tients are as follows: over 60 dB, no patient; 40 to 59 dB, one patient (5%); 20 to 39 dB, one patient (5%); and 10 to 19 dB, two patients (10%). Four patients (20%) showed improvement, and 16 (80%) had less than a 10-dB
gain.
The PB Max improvements for the patients who did not receive therapy with stellate ganglion blocks are as follows: 80% to 100% gain, one patient (5%); 60% to 79%, no patient; 40% to 59%, one patient (5%); 20% to 39%, no patient; and 10% to 19%, one patient (5%). Three patients (15%) showed im¬ provement, with 17 patients (85%) having less than a 10-dB gain. Figure 1 shows a comparison of stellate ganglion block patients and non- stellate- ganglion- block- treated patients as to improvement in aver¬ age pure-tone levels. The percentage of patients who obtained more than a 10-dB gain is substantially better for the stellate block group (70%) as com¬ pared with the non-stellate-ganglionblock-treated group (20%). Figure 2 demonstrates the comparison be¬ tween stellate-block-treated and non-
stellate-block-treated patients,
improvement
in
as
to
speech discimination
(PB Max)
age of
scores.
The total percent¬
patients achieving more than 10% discrimination improvement is much larger for the stellate ganglion block group (66%) as compared with
the non-stellate-block-treated group (15%). Table 2 indicates the symptoms for the improved cases versus the nonimproved cases following stellate blocks. Figure 3 shows the improved stel¬ late ganglion treatment patients who achieved these gains according to days of delay in treatment following onset of symptoms. Eighteen (47%) of the improved cases were treated within four days, 11 (28%) were treated from five to nine days follow¬ ing onset of symptoms, and six (16%) were treated from 10 to 14 days after onset. Therefore, 35 (91%) of the im¬ proved cases were treated within the first two weeks after symptoms were noted. Certain characteristics, such as sud¬ den onset, sensorineural-type loss, unilateral involvement, and presence of tinnitus are common to both the improved and nonimproved groups. However, it will be noted in Table 2 that three factors distinguish the im¬ proved group from the nonimproved group, ie, nature of the tinnitus, the presence of vertigo, and the presence of fullness. Sixteen (40%) of the im¬ proved group had a high-pitched ring-
ing tinnitus, while seven (40%) of the nonimproved group had low-frequen¬ cy hum, buzz, or roaring tinnitus pre¬ dominantly. Only 12 (32%) of the im¬ proved cases had vertigo, while 11 (67%) of the nonimproved patients
showed this symptom. Fullness was present in only 11 (29%) of those who
obtained improvement and in eight (47%) of the patients who did not show improvement. COMMENT
Our study shows that there is a 70% chance for a patient to receive a 10dB or over average pure-tone gain and over 10% gain in speech discrimi¬ nation with the stellate ganglion block procedure. However, there is only a 20% chance of a patient get¬ ting more than a 10-dB pure-tone gain or 10% PB Max improvement if receiving drug therapy that does not involve stellate ganglion blocks. It would appear from the results of therapy in the improved group, as compared with the unimproved group, that high-frequency tinnitus, no vertigo, and no fullness in the ear may be prognostic signs for success¬ ful treatment. Low frequency tin¬ nitus, vertigo, and fullness, as found in the unimproved group, may be in¬ dicative of a poor prognosis. The delay in time from the onset of symtoms to the institution of stellate
Downloaded From: http://archotol.jamanetwork.com/ by a University of Manitoba User on 06/17/2015
ganglion block therapy would seem to be an important factor in the even¬ tual outcome of an individual patient. Thirty-five (91%) of the improved cases were
treated within the first
two weeks after Symptomatologie features were noted. Complications of stellate ganglion blocks include pneumothorax, tempo¬ rary loss of voice due to trauma of the recurrent laryngeal nerve, and tem¬ porary dysphagia from trauma of the vagus nerve. In this series of
patients, the only complication
countered
en¬
that of one case of pneumothorax, which was promptly diagnosed and treated. was
References 1. Saunders WH: Symposium on ear diseases: I. Sudden deafness and its several treatments. Laryngoscope 82:1206-1213, 1972. 2. Schubert K: Zur diagnostik und therapie des M\l=e'\ni\l=e`\re.Arzneim Forsch 3:45, 1949. 3. Hilger JA: Vasomotor labyrinthine ischemia. Ann Otol Rhinol Laryngol 59:1102-1116, 1950. 4. Kessler L: Die stellatumanasthesic in der halsnasen-ohren-heilkunde: Ihre anwendungs\x=req-\ moglichkeiten und gafahren. Z Aerztl Fortbild (Jena) 62:106-108, 1968. 5. Cocks DB: Sudden deafness treated by stellate ganglion block. J Otolaryngol Soc Aust 2:25\x=req-\ 27, 1967. 6. Moore DC: Anterior approach for block of the stellate ganglion, in Regional Block Anesthesia, ed 4. Springfield, Ill, Charles C Thomas Publisher, 1965.
Hearing Loss
A Review of 76 Cases Olaf
Haug, PhD;
W. Leonard
Draper, MD; Scott A. Haug,
\s=b\ Fifty-six patients, treated with a series of anesthetizing blocks of the stellate ganglion for idiopathic sudden sensorineural loss, were compared with 20 patients of similar diagnosis who were treated by other means as to amount of pure-tone gain, speech discrimination improvement, nature of symptoms, and delay in start of therapy. Seventy percent of the stellate-ganglion-block-treated patients achieved substantial hearing improvement. Only 15% to 20% of the non\x=req-\
stellate-ganglion-block-treated patients achieved substantial hearing improve-
ment in discrimination or pure-tone levels. The delay time from onset of symptoms to start of stellate block therapy appears to be important. The type of tinnitus, presence or absence of vertigo, and fullness in the ear may be useful prognostic signs.
(Arch Otolaryngol 102:5-8, 1976)
MA
Otolaryngologists treating patients
often feel a sense of frustration and futility in with idiopathic sudden sensorineural hearing loss. The typical patient is one who suddenly becomes hard of hearing, more hard of hearing (if a previous unrelated loss was present), or deaf in one ear, usually associated with tinnitus, quality distortion of sound, recruitment, loud sound intolerance, and, at times, fullness in the ear and vertigo without apparent cause. Conditions that are known to produce abrupt, usually unilateral sensorineural losses such as
measles, meningitis, encephalitis, acoustic tumors, ear surgery, skull fracture, ototoxic drugs, and mumps,
perilymphatic fistula from exertion or
barotrauma are excluded from this review. The cause of idiopathic sudden losses is thought to be vascular or viral in origin, resulting in a reduced blood supply to the cochlea. Generally, there does not seem to be any agreement among otolaryngologists regarding treatment for idiopathic sudden deafness. Saunders1 reported that answers to a questionnaire received from 130 otolaryngologists in the United States and Europe case
Accepted for publication Aug 15, 1975. From the Department of Otorhinolaryngology, Baylor College of Medicine and the Medical Center Ear, Nose and Throat Associates, Houston. Reprint requests to the Medical Center Ear, Nose and Throat Associates, 540 Hermann Professional Bldg, Houston, TX 77025 (Dr Haug).
Downloaded From: http://archotol.jamanetwork.com/ by a University of Manitoba User on 06/17/2015
showed that
one
treatment at all to
third offered
diagnosis, or else felt that ment
was
useless.
no
patients with this any treat-
Twenty-seven drugs were reported used by the physicians who did treat these patients, with vasodilators, anticoagulants, vitamins, adrenocorticotropic hormone, steroids, sedatives, tranquilizers, diuretics, and even repeated smallpox vaccinations being listed. Stellate ganglion blocks as
not even mentioned in the questionnaire responses. We report results of treatment of a series of anesthetizing blocks of the stellate ganglion on 56 patients, together with a comparison of 20 patients who were treated by other means. The stellate ganglion block procedure for sudden deafness appears to be little known even among otolaryngologists. Some of the earliest descriptions of its use in the therapy of sudden hearing loss were that of Schubert2 in 1949 and Hilger3 in 1950. More recently, Kessler,4 reporting on a total of 94 patients, indicated symptomatic improvement in 79% of the cases in which stellate ganglion blocks were used. Cocks,5 in a brief were
Table 1.—Improvement of Seven Patients After Stellate Ganglion Block Treatment Discrimination Pure-Tone Before Treatment
Patient
After Treatment 30 30 23 33
! 2 3 4 5
98 90
~. 68 73 98
6" 7
Average
(PB Max Scores) Before Treat- After Treat-
Gain (dB)
ment(%)
>80 68 67 >77 63 61 80
5
Ï2
Ï8
(%)
ment
Gain (%)
(3
96"
Ö
92 96 96
92 96 96
TOO TOO ÏÔ0
TOO
0 0
Ö 28
Ö
96"
72
TÖÖ
Table 2.—Characteristics of Improved and Nonimproved Patients Following Stellate Ganglion Block Treatment Improved Patient Characteristics
or
Sex
Less Than 10 db or 10% PB Max Gain
or
44
40
M,49%; F, 51%
M, 60%; F, 40%
Sudden loss
Sensorineural-type
10% PB Max More Gain
10 db PTA
Age, average
Nonimproved
39(100%) 39 (100%) 39(100%) 34(86%) 16(40%) 7(17%) 11 (29%) 5(14%) 12(32%)
17(100%) 17 (100%) 16(96%) 15(93%) 2(13%) 7(40%) 7 (40%) (7%) _11 (67%) (68%)_6 (33%)
loss
Unilateral Loud tinnitus
High frequency ring, whine, whistle Low frequency roar, buzz, hum Unknown type No tinnitus Vertigo
~_1
vertigo_27 (29%)_8(47%)_ Fullness_11 No fullness 9 28(71%)~ No
(53%)_
Fig as
1 .—Pure-tone average improvement in patients treated with stellate ganglion blocks in whom stellate ganglion blocks were not used.
compared with those
clinical account of 20 patients treated with stellate ganglion blocks, stressed the importance of early treatment. The stellate ganglion is made up of the inferior cervical ganglion and the superior thoracic ganglion of the sympathetic nerve trunk. The func¬ tion of this nerve trunk, along with the rest of the autonomie nervous sys¬ tem, is to assist in preparing the body (along with the adrenals) to meet emergency, ie, to prepare the body for fight or flight. The system accom¬ plishes this by constricting blood ves¬ sels, increasing blood pressure, en¬ larging pupils, and increasing heart rate.
Destructive disease or trauma of the sympathetic nerve produces Horner syndrome, characterized by vasodilation and increased blood flow. The same effect can be achieved by anesthetizing the sympathetic nerve trunk. This procedure has been used for some years, chiefly for ischemia of the arms. In a personal communica¬ tion about ten years ago, Plester de¬ scribed his use of stellate ganglion blocks in the treatment of sudden sensorineural losses, with good re¬ sults (D. Plester, MD, oral communi¬ cation, 1966). Guilford, formerly of our staff, began using it in 1967 as the treatment of sudden sensorineurol loss. Our only change in the procedure from that used by Plester was the substitution of 2% lidocaine (Xylo-
caine) (with 1:100,000 epinephrine) for procaine. METHOD
\
I Patients Treated With Stellate Ganglion Blocks
I
—
Patients Not Treated With Stellate
BUE 10-19db
20-39db
40-59db
Pure-Tone
Ganglion
Blocks
m
Over60db
Total Gain
Average Improvement
Downloaded From: http://archotol.jamanetwork.com/ by a University of Manitoba User on 06/17/2015
The procedure is done with the patient under local anesthesia. Briefly, the tech¬ nique consists of making an injection lat¬ eral and inferior to the thyroid gland to the C-7 vertebra, and then backing off slightly to the area of the stellate ganglion, injecting 3 to 5 ml of lidocaine and observ¬ ing the patient for the onset of Horner
syndrome, ie, hyperemia, enophthalmos, anhydrosis, ptosis, miosis of the pupil, drooping of the corner of the mouth, con¬ gested nose, and nasal secretion. Rou¬ tinely, the blocks are administered twice daily for three to five days, at which time the patient is reevaluated audiologically. Moore" gives a detailed description of the procedure. RESULTS
Of the 56 patients who received
stellate
ganglion blocks,
29
(30%). There was no increase in loss of hearing noted in any of the patients. Seventy percent had over 10 dB of average pure-tone improvement, with 59% obtaining gains of more than 20
(52%)
and 27 (48%) were women. The average age of the patients was 43 years. All patients had a sudden onset of the disease, and a sensorineural-type hearing loss, with 55 (98%) having a unilateral loss. Fortynine (87%) had tinnitus, 25 (44%) had vertigo, and 29 (51%) had fullness in the ear. The pure-tone average improve¬ ments following stellate ganglion blocks were as follows: over 60 dB, 12 patients (21%); 40 to 59 dB, five pa¬ tients (9%); 20 to 39 dB, 16 patients (29%); 10 to 19 dB, six patients (11%), and less than 10-dB gain, 17 patients were men
I I
dB. The phonetically balanced max¬ imum (PB Max) improvements after stellate ganglion blocks were as fol¬ lows: 80% to 100% gain, 11 patients (20%); 60% to 79% gain, four (7%); 40% to 59%, seven (12.5%); 20% to 39%, eight (14%); and 10% to 19%, seven pa¬ tients (12.5%). A total of 37 (66%) pa¬ tients improved. Nineteen patients (34%) had less than a 10% gain. No de¬ crease in PB Max scores was noted in
Ganglion Blocks Stellate Ganglion Blocks
Patients Treated With Stellate
| Patients Not Treated With
as
JBffîi
20%-39% 40%-59% 60%-79% 80%-100% Total Gain Discrimination (PB Max) Improvement discrimination improvement of patients with stellate ganglion blocks Fig 2—Speech compared with patients who did not receive treatment with ganglion blocks. 10%-19%
from onset to start of blocks who showed improvement.
Fig 3.—Days
therapy
in
patients treated
with stellate
as
ganglion
_ _ _ 0-4
5-9
Days
10-14
15-19
From Onset to Start of
20-24
25-29
Therapy
Downloaded From: http://archotol.jamanetwork.com/ by a University of Manitoba User on 06/17/2015
any of the
patients. Thirty-seven (66%) had more than a 10% gain in discrimination, with 30 (53.5%) hav¬ ing more than a 20% gain. Averaging blunts some of the amazing gains on individual cases, Table 1. In seven
pure-tone
averages
as
illustrated in
patients, gains in were
found rang¬
ing from 63 to 80 dB, and discrimina¬ tion improvement ranged from 92% to 100% in some patients. Of the 20 patients who did not re¬ ceive therapy with stellate ganglion blocks, nine (45%) were men and 11 (55%) were women. The average age of these patients was 55 years. All pa¬
tients had a sudden onset of their dis¬ ease and had a unilateral sensorineural-type loss. Sixteen (80%) had tinnitus, 12 (60%) had vertigo, and four (20%) had fullness of the ear. The primary reason for not using the blocks was patient refusal to enter the hospital for therapy. The patients were treated in the office, using niacin, isoxsuprine hydrochloride, histamine, and Lipotriad. The pure-tone average improvements for these pa¬ tients are as follows: over 60 dB, no patient; 40 to 59 dB, one patient (5%); 20 to 39 dB, one patient (5%); and 10 to 19 dB, two patients (10%). Four patients (20%) showed improvement, and 16 (80%) had less than a 10-dB
gain.
The PB Max improvements for the patients who did not receive therapy with stellate ganglion blocks are as follows: 80% to 100% gain, one patient (5%); 60% to 79%, no patient; 40% to 59%, one patient (5%); 20% to 39%, no patient; and 10% to 19%, one patient (5%). Three patients (15%) showed im¬ provement, with 17 patients (85%) having less than a 10-dB gain. Figure 1 shows a comparison of stellate ganglion block patients and non- stellate- ganglion- block- treated patients as to improvement in aver¬ age pure-tone levels. The percentage of patients who obtained more than a 10-dB gain is substantially better for the stellate block group (70%) as com¬ pared with the non-stellate-ganglionblock-treated group (20%). Figure 2 demonstrates the comparison be¬ tween stellate-block-treated and non-
stellate-block-treated patients,
improvement
in
as
to
speech discimination
(PB Max)
age of
scores.
The total percent¬
patients achieving more than 10% discrimination improvement is much larger for the stellate ganglion block group (66%) as compared with
the non-stellate-block-treated group (15%). Table 2 indicates the symptoms for the improved cases versus the nonimproved cases following stellate blocks. Figure 3 shows the improved stel¬ late ganglion treatment patients who achieved these gains according to days of delay in treatment following onset of symptoms. Eighteen (47%) of the improved cases were treated within four days, 11 (28%) were treated from five to nine days follow¬ ing onset of symptoms, and six (16%) were treated from 10 to 14 days after onset. Therefore, 35 (91%) of the im¬ proved cases were treated within the first two weeks after symptoms were noted. Certain characteristics, such as sud¬ den onset, sensorineural-type loss, unilateral involvement, and presence of tinnitus are common to both the improved and nonimproved groups. However, it will be noted in Table 2 that three factors distinguish the im¬ proved group from the nonimproved group, ie, nature of the tinnitus, the presence of vertigo, and the presence of fullness. Sixteen (40%) of the im¬ proved group had a high-pitched ring-
ing tinnitus, while seven (40%) of the nonimproved group had low-frequen¬ cy hum, buzz, or roaring tinnitus pre¬ dominantly. Only 12 (32%) of the im¬ proved cases had vertigo, while 11 (67%) of the nonimproved patients
showed this symptom. Fullness was present in only 11 (29%) of those who
obtained improvement and in eight (47%) of the patients who did not show improvement. COMMENT
Our study shows that there is a 70% chance for a patient to receive a 10dB or over average pure-tone gain and over 10% gain in speech discrimi¬ nation with the stellate ganglion block procedure. However, there is only a 20% chance of a patient get¬ ting more than a 10-dB pure-tone gain or 10% PB Max improvement if receiving drug therapy that does not involve stellate ganglion blocks. It would appear from the results of therapy in the improved group, as compared with the unimproved group, that high-frequency tinnitus, no vertigo, and no fullness in the ear may be prognostic signs for success¬ ful treatment. Low frequency tin¬ nitus, vertigo, and fullness, as found in the unimproved group, may be in¬ dicative of a poor prognosis. The delay in time from the onset of symtoms to the institution of stellate
Downloaded From: http://archotol.jamanetwork.com/ by a University of Manitoba User on 06/17/2015
ganglion block therapy would seem to be an important factor in the even¬ tual outcome of an individual patient. Thirty-five (91%) of the improved cases were
treated within the first
two weeks after Symptomatologie features were noted. Complications of stellate ganglion blocks include pneumothorax, tempo¬ rary loss of voice due to trauma of the recurrent laryngeal nerve, and tem¬ porary dysphagia from trauma of the vagus nerve. In this series of
patients, the only complication
countered
en¬
that of one case of pneumothorax, which was promptly diagnosed and treated. was
References 1. Saunders WH: Symposium on ear diseases: I. Sudden deafness and its several treatments. Laryngoscope 82:1206-1213, 1972. 2. Schubert K: Zur diagnostik und therapie des M\l=e'\ni\l=e`\re.Arzneim Forsch 3:45, 1949. 3. Hilger JA: Vasomotor labyrinthine ischemia. Ann Otol Rhinol Laryngol 59:1102-1116, 1950. 4. Kessler L: Die stellatumanasthesic in der halsnasen-ohren-heilkunde: Ihre anwendungs\x=req-\ moglichkeiten und gafahren. Z Aerztl Fortbild (Jena) 62:106-108, 1968. 5. Cocks DB: Sudden deafness treated by stellate ganglion block. J Otolaryngol Soc Aust 2:25\x=req-\ 27, 1967. 6. Moore DC: Anterior approach for block of the stellate ganglion, in Regional Block Anesthesia, ed 4. Springfield, Ill, Charles C Thomas Publisher, 1965.
