Cortisone for ear disorders

Cortisone in Otology: Oral and Intratympanic Use

Corticosteroids are among the most impactful medications we use in inner ear disease. Used correctly, they can preserve hearing, reduce vertigo, and sometimes reverse potentially devastating symptoms.

But they must be used appropriately. Understanding when to use oral steroids and when to inject them into the ear is critical.

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What Do We Mean by “Cortisone”?

“Cortisone” is a lay term. In clinical practice, we use the term corticosteroids — synthetic versions of cortisol, a hormone produced by the adrenal glands of the body.

There are two types of steroid formulations in otology. Steroids are anti-inflammatory agents, but their pharmacokinetics (how they move through the body) are different depending on how they are administered. We will discuss them separately in the article.

1. Oral Steroids

These are pills that are taken orally (by the mouth). The are then absorbed in your blood circulation and reach the inner ear through blood vessels. Examples include:

• Prednisone
• Prednisolone
• Dexamethasone

2. Intratympanic Steroids

These are injected through the eardrum with a long but thin needle, and will accumulate in the middle ear space. From there, they are absorbed in the inner ear through the round window primarily, and to a certain extent via the oval window. Once the medication is injected into the ear, it takes about 30 to 45 minutes to be absorbed into the inner ear. During this time, you will need to stay lying down so the medication can work effectively. Because it stays local and does not enter the blood circulation, it affects only the inner ear and not the rest of the body. Examples include: 

• Dexamethasone
• Methylprednisolone

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How Steroids Work in the Inner Ear

To understand steroid therapy, we need to review basic inner ear physiology.

The inner ear contains two different compartments:

• The cochlea (hearing organ)
• The vestibular labyrinth (balance organs)

These structures are filled with specialized fluids:

• Endolymph (high potassium fluid)
• Perilymph (similar to cerebrospinal fluid)

The hair cells inside the cochlea and vestibular organs are extremely sensitive. They depend on precise balance of minerals in those fluids and a constant amount of blood supply.

Most inner ear disorders involve one or more of the following damage mechanisms:

• Inflammation (swelling of inner ear cells that can cause those cells to die)
• Immune-mediated injury (the immune system of the body attacking ear structures)
• Blood flow compromise
• Abnormal fluid regulation

Steroids work by:

• Suppressing inflammatory molecules called cytokines (chemical inflammatory signals)
• Stabilizing blood vessel leakage (called permeability)
• Reducing autoimmune activity
• Preventing the death of inflamed and swollen cells

In short, steroids reduce inflammation and stabilize the delicate biochemical environment of the inner ear.

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Differences between Oral and Intratympanic steroids

1. Oral Steroids: Systemic treatment ("whole body") 

When taken orally, steroids are absorbed into the blood and reach the inner ear through the blood vessel circulation (and therefore the cortisone reaches the entire body).

Advantages

• Treat both ears at the same time
• Broad anti-inflammatory effect
• Easy to administer
• No need for repeated visits to an ENT specialist to get repeat doses 
• Painless administration
  
  

Disadvantages

• Systemic (whole body) side effects because they are absorbed in the blood:
  • Elevated blood sugar
  • Mood changes
  • Insomnia
  • Gastric irritation
  • Suppresses the immune system

Oral steroids reach the inner ear in lower concentrations compared to intratympanic injection. But they affect the entire body and both ears.

Oral steroids are often first-line in acute inner ear emergencies.

2. Intratympanic Steroids: Targeted Local Therapy

Intratympanic injection involves placing steroid directly into the middle ear through the eardrum (using a long needle). From there, the medication reaches the inner ear by diffusing across the round and oval window membranes, thin membranes separating the middle ear from the inner ear.

This allows very high steroid concentrations in the cochlea without significant exposure in the rest of the body.

Advantages

• High local drug concentration
• Minimal systemic (whole body) side effects
• Useful in diabetic patients or those intolerant to oral steroids

Disadvantages

• Requires repeat office procedures (usually up to three)
• Mild discomfort
• Rare risks:
  • Persistent tympanic membrane perforation
  • Temporary dizziness

This is not a painful (although there is discomfort) or complex procedure in experienced hands. It is done under local anesthesia in the office.

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Oral vs Intratympanic: Which Is Better?

Oral and intratympanic steroids are not competing treatments; they are complementary medical tools. Each route delivers cortisone to the inner ear in a different way and is chosen for different reasons  : 

• Oral steroids are often first-line.
  
  
• Intratympanic steroids are used:
  • As salvage ("rescue") therapy when oral steroids did not work
  • When oral steroids are contraindicated (for example a severely diabetic patient)
  • As combination therapy in severe cases

Evidence supports both approaches depending on the condition. We will explain more below.

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Indications for Steroid Use in Otology

Steroids are not a cure-all. They are used in specific, evidence-based scenarios.

1. Sudden Sensorineural Hearing Loss (SSNHL)

This is the most urgent indication. You can learn more about sudden hearing loss in this article.

Steroids are the standard of care for sudden hearing loss.

• Oral steroids as first-line therapy in the first two weeks
• Intratympanic steroids as:
  • Primary therapy (if systemic contraindications exist)
  • Salvage therapy if oral treatment fails

Timing is critical. Treatment should begin as soon as possible.

2. Ménière’s Disease

In Ménière’s disease (inner ear fluid dysregulation disorder):

• Oral steroids do not cure Ménière’s disease but can reduce attacks in a period of acute flare-up. It also helps stabilize and improve hearing.
• Intratympanic steroids reduce vertigo frequency and improve hearing also during acute flare-ups, usually as a second line when oral treatment fails. 

Both types are particularly useful when:

• Medical therapy (salt restriction, diuretics) fails
• Patients want to avoid ablative treatments (like gentamicin)

3. Autoimmune Inner Ear Disease (AIED)

This is an inner ear condition where the body's immune system attacks the inner ear (which is why it's called "autoimmune"). Steroids are the mainstay of treatment.

• Oral steroids are given initially (in the flare-up)
• Long-term immunosuppressive therapy (another class of medication, not covered in this article) is usually needed 
• There is usually no role for intratympanic steroids.

Response to steroids helps confirm the diagnosis.

4. Vestibular Neuritis

Vestibular neuritis is the inflammation of the vestibular (balance) nerve.

Evidence suggests that:

• Oral steroid used early in the course may reduce the intensity of the vertigo, but they do not dramatically shorten acute vertigo symptoms. For that reason, they are not always prescribed.
• There is usually no role for intratympanic steroids.

5. Cochlear Implant Surgery (Perioperative Use)

Some surgeons use steroids perioperatively (before and after the surgery) to:

• Preserve residual hearing
• Reduce inflammatory response from electrode insertion

This is protocol-dependent and surgeon-dépendant, and something that is evolving.

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What Steroids Do NOT Treat

Steroids are not effective for:

• Conductive hearing loss
• Chronic noise-induced hearing loss
• Long-standing stable sensorineural hearing loss

They are not a general hearing enhancer.

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Complications and Safety Considerations

Oral Steroid Risks

• Hyperglycemia (elevated blood sugar), especially in diabetics
• Mood disturbance
• Hypertension
• Gastritis (irrigation of the stomach lining)

Intratympanic Risks

• Persistent perforation (5-10%)
• Temporary discomfort
• Temporary vertigo

In experienced hands, intratympanic therapy is safe and well tolerated.

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Practical Clinical Pearls

• "Time is hearing" in sudden sensorineural hearing loss : start treatment ASAP!
• If oral steroids fail, do not delay salvage intratympanic therapy.
• Diabetic patients are often better candidates for intratympanic therapy.
• Always confirm true sensorineural loss with an audiogram before initiating treatment..

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Final Thoughts

Steroids remain one of the most powerful and effective medical therapies in otology when used appropriately. Oral and intratympanic formulations each have a defined role, and selecting the right approach requires careful clinical judgment.

Early recognition, proper diagnosis, and timely treatment are what preserve hearing — not the medication alone.

If there is any suspicion of sudden hearing change or acute inner ear dysfunction, prompt evaluation by an otolaryngologist is essential.