sudden sensorineural hearing loss ( ssnhl ) is commonly defined as a loss of at least 30 db in three contiguous frequencies occurring within 3 days.1 ) lack of knowledge of the specific causes of idiopathic ssnhl limits our ability to implement effective treatment . although it is possible that a number of different pathological processes result in sudden hearing loss , it is widely believed that viral infection and vascular occlusion account for the majority of these cases.2 - 4 ) systemic steroid administration is the most widely accepted treatment option for ssnhl.5 ) since viral infection and vascular compromise are considered specific causes of ssnhl , antiviral agents , anticoagulants , and stellate ganglion block have been used for its treatment , although the evidence of their effectiveness is weak.2 - 4,6 ) in our hospital , one author used a combination therapy consisting of systemic steroids , an antiviral agent , anticoagulants , and stellate ganglion block for the treatment of ssnhl , while two authors employed systemic steroids only to determine whether there is a difference in hearing recovery rate between the two treatment options . the present study evaluated the hearing recovery rate in the combination therapy group ( systemic steroids , an antiviral agent , anticoagulants , and stellate ganglion block ) in comparison with the group treated with systemic steroids alone . a total of 85 patients diagnosed with ssnhl were treated with either combination therapy ( group a , 46 patients ) or systemic steroids only ( group b , 39 patients ) . the study population consisted of 43 females and 42 males ranging in age from 14 to 77 years , with a mean age of 49.2 years . all patients were treated with a 10-day course of systemic steroids ( 10 mg of dexamethasone for 5 days , followed by tapering for 5 days ) . the treatment regimen of group a included acyclovir ( 250 mg , 3 times daily , 5 days ) , heparin ( low molecular weight heparin 10000 u daily , 10 days ) , and stellate ganglion block ( daily by anesthesiologist , 5 - 10 days ) . auditory function was determined by pure tone audiometry , and mean hearing levels were expressed as the average of hearing thresholds at 500 , 1000 , 2000 , and 3000 hz . auditory measurements were performed before and 2 months after treatment using siegel 's hearing improvement criteria ( table 1 ) . hearing improvement was defined as a hearing gain of more than slight improvement using siegel 's criteria . the following prognostic factors were taken into consideration in the analysis of hearing recovery rates : 1 ) initial hearing level ( > 70 db hl ) , 2 ) audiogram shape ( ascending , descending , and flat type ) , 3 ) treatment onset ( within 7 days ) , 4 ) age ( > 40 years ) , and 5 ) presence of dizziness . statistical evaluations were performed using the chi - square test , fisher 's exact test , and logistic regression . the overall rate of hearing improvement was 60.9% ( 28/46 patients ) in group a , which was significantly higher than that ( 38.5% , 15/39 patients ) in group b ( p=0.039 ,  test)(fig . group a included nine patients ( 19.6% ) with complete hearing recovery , seven ( 15.2% ) with partial recovery , and 12 ( 26.1% ) with slight improvement . group b included 10 patients ( 25.6% ) with complete hearing recovery , three ( 7.7% ) with partial recovery , and two ( 5.1% ) with slight improvement ( fig . the distribution of prognostic factors was not significantly different between the two groups , with the exception of degree of initial hearing loss , which was more severe in group a ( fig . hearing improvement was analyzed according to the prognostic factors , and the results indicated a better recovery rate in group a compared to group b among patients with hearing loss > 70 db , age > 41 years , dizziness , and early start of treatment ( < 1 week)(p<0.05 ,  test , fisher 's exact test)(table 2)(fig . 3 ) . multivariate analysis of potential prognostic factors , including treatment option ( group a or b ) , indicated a significant association between an ascending audiogram shape and good clinical outcome . the level of hearing loss , the pres ence of dizziness , delay of treatment , age > 40 years , and treatment options showed no associations with hearing recovery ( table 3 ) . the current standard treatment for ssnhl is a tapered course of systemic steroids.7 ) however , data to support this recommendation are limited . a 2006 cochrane database review concluded that the value of steroids in the treatment of ssnhl remains unclear.8 ) the mechanism of action of steroids in the inner ear is incompletely understood . the actions attributed to steroids in the inner ear include ion homeostasis , antioxidant activity , inhibition of apoptosis , downregulation of local proinflammatory cytokines , and promotion of cochlear blood flow.5 ) the potential success of antiviral medication for treatment of ssnhl is based on the suggestion that many cases of such hearing impairment have a viral etiology.3 ) herpes virus may be involved in the etiology of ssnhl by one of several mechanisms , including labyrinthitis secondary to viremia , labyrinthitis or neuritis secondary to meningitis , cranial neuropathy , reactivation of a latent ganglion cell infection , or alteration of the immune response.9 ) it is possible that the viral damage to the ear is completed within a relatively short time and that inflammatory and other effects of the virus are most effectively treated thereafter with steroids.3 ) this may explain the observed better recovery rate in group a than group b among patients treated within 1 week in the present study . the use of heparin and stellate ganglion block is based on the suggestion that impairments in microcirculation of the inner ear may be involved in the pathophysiology of ssnhl.2,4,6 ) the blood flow disturbance theory , including thromboembolism or vasospasm , has been proposed based on the etiology of ssnhl , because the blood supply within the inner ear is its termination and intraosseous position and symptoms of ssnhl develop abruptly.10,11 ) heparin as a treatment for ssnhl was described by fisch , et al.2 ) and it has an anticoagulant effect on intracranial blood vessels . however , mattox and simmons12 ) reported no significant difference between patients with and without general heparin therapy . since the introduction of low - molecular - weight heparin in the early 1990s , its use and indications have been greatly expanded.13 ) low - molecular - weight heparin can prevent venous thrombosis and shows greatly reduced side reactions compared with general heparin . yue , et al.4 ) suggested that hearing improvement is significantly greater in patients treated with low - molecular weight heparin than in those treated with the commonly used therapeutic regimen alone . stellate ganglion block induces an increased blood supply via sympathetic blockade and vasodilation.14 ) the eventual involvement of internal ear circulatory disturbance causes metabolic disturbance of the inner ear cells , decreases in oxidation of metabolic substrates , and edema , resulting in irreversible changes . the resorption of edema is promoted by arterial relaxation from sympathetic blockade.6,15 ) takinami15 ) reported that stellate ganglion block favorably affected outcomes in patients with unilateral ssnhl given a prior or concomitant course of systemic corticosteroids . the combination therapy showed a beneficial effect in the present study ; however , the analysis was performed in a retrospective manner . especially in patients with poor prognosis , the combined therapy resulted in a higher recovery rate than steroids alone , although the complete recovery rate was not different between the two treatment methods . the efficacy of combination therapy can not be established definitively in a retrospective analysis with a small sample size . therefore , our results indicate only a trend toward a beneficial effect of combination therapy as a component of ssnhl treatment . the results of this study suggest that ssnhl patients treated with the combination therapy have a higher likelihood of hearing improvement than those treated with systemic steroids alone .
background and objectivessudden sensorineural hearing loss ( ssnhl ) is commonly defined as a loss of at least 30 db in three contiguous frequencies occurring within 3 days . 
 systemic steroid administration has become the most widely accepted treatment option for ssnhl . since viral infection and vascular compromise are considered specific causes of ssnhl , antiviral agents , anticoagulants , and stellate ganglion block have been used for its treatment , although the evidence of their effectiveness is weak . 
 the present study evaluated the hearing recovery rate in the combination therapy group ( systemic steroids , antiviral agent , anticoagulants , and stellate ganglion block ) in comparison with patients treated with systemic steroids alone.subjects and methodsa total of 85 patients diagnosed with ssnhl were treated with combination therapy ( group a , 46 patients ) or systemic steroids only ( group b , 39 patients ) . 
 hearing improvement was defined as a hearing gain of more than slight improvement using siegel 's criteria . 
 all patients were treated with a 10-day course of systemic steroids ( 10-mg dexamethasone for 5 days , followed by tapering for 5 days ) . 
 acyclovir , heparin , and stellate ganglion block were included in the group a treatment regimen.resultsthe overall rate of hearing improvement was 60.9% ( 28/46 patients ) in group a , which was significantly higher than that ( 38.5% , 15/39 patients ) in group b. the distribution of prognostic factors was not significantly different between the two groups with the exception of the degree of initial hearing loss , which was more severe in group a. upon analysis according to prognostic factors , group a showed a better hearing improvement recovery rate than group b in patients with hearing loss > 70 db , age > 41 years , dizziness , and early treatment ( < 1 week).conclusionsthus ssnhl patients treated with combination therapy have a higher likelihood of hearing improvement than those treated with systemic steroids alone .