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Dr Udai Bhan Yadav MBBS,DMCH .Senior Medical officerGeneral hospital alwar rajasthan, india.
Dr Udai Bhan Yadav 1
IntroductionDefinition
Damage to the cochlea or vestibular apparatus from exposure to a chemical source.
Drug ototoxicity is defined as a temporary or permanent inner ear dysfunction after drug exposure, resulting in a hearing and/or balance disturbance. It represents one of the main preventable causes of deafness, an outcome that can perhaps be most directly influenced by healthcare professionals. Although the use of ototoxic drugs in humans should be avoided, this is not always possible because the benefits of these drugs in combating life-threatening diseases often outweigh the risks.
Dr Udai Bhan Yadav 2
Outer Ear, Middle Ear & Inner Ear
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Ototoxic Drugs
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Antibiotics Loop diuretics Nonsteroidal anti-inflammatory drugs Antimalarial drugs Antineoplastic drugs Miscellaneous
AminoglycosidesStreptomycin, kanamycin, neomycin, amikacin,
gentamicin, tobramycin, sisomycin, netilmicinEnter into inner ear by unknown mechanism
Secreted into the perilymph by spiral ligament or endolymph by stria vascularis
Diffuse through round window membraneEliminated by kidney
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AminoglycosidesCochlear toxicity
Amikacin, kanamycin, neomycin, netilmicinVestibular toxicity
Streptomycin, gentamicin, sisomycinCan occur simultaneously
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AminoglycosidesCochlear toxicity
Increase of 10-20 dB in thresholds of one or more frequencies
Incidence (6-13%), netilmicin lowestRisk factors
Diuretics, renal failure, prolonged treatment, old age, preexisting SNHL
Infants less affected, once daily dosing
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AminoglycosidesCochlear toxicity
Outer hair cell loss first in basal turn then to apex
Inner hair cell loss later
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AminoglycosidesCochlear toxicity presentation
High frequency Sensorineural hearing loss (SNHL) first, then lower frequencies to profound loss
Not reversibleDamage usually heralded by tinnitus
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AminoglycosidesVestibular toxicity
Assessment is difficultDynamic posturography can detectPathologically
Type I hair cells more sensitive Cristae ampullaris then utricle and saccule
Clinically (ambulatory vs. bedridden) Ataxic gait, lose balance when turning
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AminoglycosidesPrevention
PharmacologicalClinical
Consider less ototoxic drugs (netilmicin) Identify “high-risk” patients
Audiogram before and weekly after starting ENG prior if possible History and physical exam daily (Romberg, VA) Adjust doses or switch drugs if toxic
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Risk factors for ototoxicity
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Impaired renal function Intrinsic ototoxic potential of the drug Combination with other ototoxic drugs Total dose and duration of therapy Prior exposure to aminoglycosides Prolonged exposure of inner-ear
tissues to the aminoglycoside
How to avoid ototoxicity ??
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Renal, auditory, and vestibular function Assessed before, during, and following
therapy Aminoglycoside serum concentrations
Avoiding prolonged therapy and ototoxic
agents
Maintain hydration, urine output, and normal serum electrolytes
Recommend : stop the aminoglycoside at the
first sign of vestibulotoxicity
MacrolidesDiscovered erythromycin 1952
(McGuire)Mintz (1972) first report of ototoxicity
Reversible 50-55 dB losses in two casesClinically
Hearing loss with/without tinnitus– 2 daysAll frequencies, recovery after stoppingRarely permanent (hepatic)Incidence unknown
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MacrolidesMechanism
unknownAzithromycin and
clarithromycin can cause similar findings in animals
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Other antibioticsVancomycin
Believed to be ototoxic (no data)Penicillin, sulfonamides, cephalosporins
May have topical toxicity in middle earNucleoside analog reverse transcriptase
inhibitorsPoor study
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Loop DiureticsEthacrinic acid, furosemide, bumetasideClinically (6-7%)
Usually tinnitus, temporary and reversible SNHL, rare vertigo within minutes
High doses can cause permanent SNHLHighest risk– coadministration of
aminoglycosides
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Loop DiureticsPathologically
Edema of stria vascularis
Ionic gradient changes
Inhibition of adenylate cyclase and G-proteins
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Salicylates and NSAIDSMost common OTC drugsMechanism
Normal histology (no hair cell loss)Decreased blood flow, decreased enzymes
ClinicallyTonal, high frequency tinnitus (7-9 kHz)Reversible mild to moderate SNHL (usually
high frequency)– rarely permanent
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QuinineSimilar clinical findings with aspirinUsage up for leg crampsClinically
High-pitched tinnitusReversible, symmetric SNHLOccasional vertigo
MechanismDecreased perfusion, direct damage to outer
hair cells, biochemical alterations
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Antineoplastic AgentsCisplatin
Incidence is high (62%-81%)Pathologically
Outer hair cell degenerationClinically
Bilateral symmetric SNHL, usually high frequency– not reversible, cumulative
Risks factors– age extremes, cranial irradiation, high dose therapy, high cumulative dose
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Antineoplastic DrugsCisplatin
Prevention Probenecid, WR 2721, DDTC, diuretics, calcium
supplements– not effective L-N-acetyl-cysteine– protective in vitro
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Topical AntimicrobialsCommonly prescribed for otorrhea after
tubes and CSOMControversial subject
Agents may enter middle ear and gain access to membranous labyrinth
Animal testing reveals irrefutable evidence of severe ototoxicity
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Topical AntimicrobialsPolymixin B (Brummett)Chloramphenicol (Patterson)Neomycin (Brummett)Gentamicin (Webster)Ticarcillin (Jakob)Vasocidin (Brown)Ciprofloxacin (Lenarz)
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Topical AntimicrobialsRemains a possibility in humansPatient education importantPrescribe for only necessary durationAvoid in healthy earCaution with prexisting vestibular defects
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Case PresentationPatients presents to clinic with complaint of
“ringing in my ears”Described as high pitched in both ears, onset was
5 days prior and worsening, not able to sleepLong history of mild hearing loss, now worsening
alsoDenies vertigo or dysequilibriumHas prior history of significant noise exposure
(worked in factory)No recent or prior antibiotic useNo prior otologic history except mild HL
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.Referrence ms Ekta yadav project on drugs
induced ototoxicity .
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Thank YouThank You
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