J Int Adv Otol 2017; 13(1):61-4 DOI: 10.5152/iao.2017.

3185

Original Article

Hyperbaric Oxygen Therapy as Salvage Therapy for

Sudden Sensorineural Hearing Loss
Terapi Oksigen Hiperbarik Sebagai Terapi (Tindakan)
Penyelamatan Bagi Kehilangan Pendengaran Sensorineural
Tiba-Tiba
Jakov Ajduk, Mihael Ries, Robert Trotic, Ivana Marinac, Kovacic Vlatka, Vladimir Bedekovic
Department of Ear Nose Throat Head and Neck Surgery, Sestre Milosrdnice University Hospital Centre, Zagreb, Croatia

OBJECTIVE: To measure the effect of hyperbaric oxygen (HBO) therapy as salvage therapy after the
failure of steroid therapy for sudden sensori- neural hearing loss (SSNHL). TUJUAN: Mengukur efek terapi
oksigen herbarik (HBO) sebagai terapi (tindakan) penyelamatan sesudah kegagalan terapi steroid bagi kehilangan
pendengaran senorineural tiba-2 (SSNHL)
MATERIALS and METHODS: Ninety-three patients with SSNHL were unsuccessfully treated with systemic
steroid therapy. Following steroid ther- apy, 43 patients received additional HBO therapy while 50 did
not. Hearing levels at 0.25, 0.5, 1, 2, 4, and 8 kHz before and after therapy were measured. BAHAN-2 &
METODE: 93 orang pasien SSNHL tidak berhasil diobati dengan terapi seroid systemik. Mengikuti terapi steroid,
43 orang pasien menerima terapi HBO tambahan sementara 50 orang lainnya tidak. Level pendengaran pada
0,25-0,5-1-2-4- dan 8 kHz sebelum dan sesudah terapi diukur.
RESULTS: A significant difference in hearing thresholds after HBO therapy was found at all frequencies
in patients with a hearing loss of >61 dB. The group of patients with a hearing threshold of 60 dB had
a significant improvement only at 250 and 500 Hz, while group of patients without additional therapy
control group showed no hearing improvement. HASIL: Ditemukan suatu perbedaan yang signifikan
dalam hal pendengaran sesudah terapi HBO dalam semua frekwensi pada para pasien dengan
kehilangan pendengaran >61 Db. Kelompok pasien dengan threshold < 60 dB mengalami
meningkatan yang signifikan hanya pada 250 dan 500 Hz, sementara kelompok pasien dalam
kelompok kontrol tanpa terapi tambahan menunjukkan tidak adanya peningkatan.
CONCLUSION: Hyperbaric oxygen therapy therapy as salvage therapy for SSNHL showed some benefits
in hearing improvement. Better results could be expected in patients with severe hearing loss, while in
patients with mild-or-moderate hearing loss, recovery should be expected only at low frequencies.
KESIMPULAN : Terapi HBO (terapi oksigen herbarik) sebagai terapi (tindakan) penyelamatan bagi SSNHL
menunjukan beberapa keuntungan bagi peningkatan kemampuan mendengar. Hasil yang lebih baik
diharapkan pada pasien2 yang menderita kehilangan pendengaran berat, sedangkan pada pasien yang
kehilangan pendengaran ringan penyembuhan diharapkan hanya pada frekwensi yang rendah.
KEYWORDS: Hearing loss, sudden, hyperbaric oxygen therapy, salvage therapy. Katakunci: Kehilangan
pendengaran, mendadak, terapi oksigen hiperbarik, terapi penyelamatan.

61
INTRODUCTION
Sudden sensorineural hearing loss (SSNHL) is defined as hearing loss of greater than 30 dB over three
contiguous pure-tone fre- quencies occurring within a three-day period[1] . Diverse pathologic processes have
been suggested as possible causes of SSNHL: viral infections, circulatory disorders, and autoimmune
reactions[2] . However, in most cases, the real cause of SSNHL remains un- known. Different therapeutic agents
such as vasodilator, anticoagulant, plasma expander, steroid, and hyperbaric oxygen (HBO) therapies have
been used[3-7] . PENDAHULUAN
SSNHL didefinisikan sebagai kehilangan pendengaran lebih > 30 dB atas tiga frekwensi suara murni yang
berdekatan yang terjadi di dalam periode 3 hari. Berbagai macam proses patologis yang diperkirakan
menjadi penyebab SSNHL : infeksi virus, circulatory disorder, dan reaksi autoimmune. Namun demikian,
dalam kebanyakan kasus, penyebab sebenarnya dari SSNHL belum diketahui. Agen2 terapik yang berbeda,
sesperti terapi vasodilator, anticoagulant, plasma expander, steroid, dan HBO telah digunakan.

Although limited evidence on their effects is available, clinical trials for most of these therapies
are rare. Although results regarding their efficacy are inconsistent, steroid therapy is mostly used
and is one of the few therapies shown to be successful[7, 8] . While some randomized, double-blind,
placebo-controlled studies have reported that steroid therapy is suc- cessful, other studies have
not confirmed these results[8-10] .
Meskipun terdapat bukti terbatas mengenai efek mereka, percobaan klinis untuk kebanyakan dari terapi2 ini jarang. Meskipun
hasil yang berkenaan dengan kemanjurannya tidak konsisten, terapi steroid yang paling sering dipakai dan merupakan salah
satu dari beberapa terapi yang kelihatannya berhasil. Sementara beberapa penelitian yang dilakukan secara acak, double-blind
(kebutaan ganda), placebo-controlled telah melaporkan bahwa terapi steroid berhasil, penelitian2 lain belum mengkonfirmasi
hasil ini.

The success rate of the initial steroid therapy depends on many factors such as the severity of the
initial hearing loss and time when the therapy is intiated time of the onset of therapy. These factors
could be the reason for discrepancies in results. In cases where initial therapy has no result,
salvage therapy is used. HBO and intratym- panic steroid therapies are mostly used as salvage
therapy after the failure of initial steroid therapy.
Tingkat keberhasilan dari terapi steroid awal tergantung kepada banyak factor seperti tingkat penderitaan dari
kehilangan pendengaran awal dan waktu pada saat terapi yang merupakan waktu dimulainya terapi permulaan.
Fakltor2 inilah yang bisa jadi alasan untuk terjadinya ketidaksesuaian dalam hasilnya. Dalam kasus2 di mana terapi
awal tidak ada hasilnya, maka digunakanlah terapi (tindakan) penyelamatan. HBO dan terapi2 steroid intratym-
panic yang paling banyak digunakan sebagai terapi penyelamatan sesudah kegagalan dari terapi steroid
sebelumnya.

Hyperbaric oxygen therapy for sudden hearing loss SSNHL was first introduced in the 1970s.[11]
It was found that perilymphatic oxygen tension decreased in patients with SSNHL, while under
hyperbaric conditions, oxygen tension in the perilymphatic fluid increased by 450%[12, 13] . These
days, HBO therapy is used as primary or as salvage therapy for sudden haring loss[14-16] .
Terapi oksigen herbarik untuk SSNHL pertama kali diperkenalkan pada tahun 1970-an. Didapati bahwa tensi
oksigen perylimpatik berkurang pada pasien dengan SSHNL sementara dibawah kondisi hiperbarik, tensi oksigen
dalam cairan perylimphatik meningkat sebesar 450%. Sekarang ini terapi HBO digunakan sebagai terapi primer
atau terapi penyelamatan bagi SSNHL.

However, the results of salvage HBO therapy for SSNHL vary among studies, and its efficacy is still
unclear. The aim of this study was to compare the effect of HBO therapy as salvage therapy and
compare it to patients not receiving additional therapy.
Bagaimanapun juga hasil dari terapi penyelamatan HBO bagi SSNHL bervariasi diantara penelitian2 yang ada dan
kemanjurannya masih belum jelas. Tujuan dari study ini adalah membandingkan efek terapi HBO sebagai terapi
penyelamatan dan membandingkannya kepada para pasien yang tidak menerima terapi tambahan.
MATERIALS and METHODS
This retrospective study included data obtained from patients admitted to a hospital between 2009
and 2015 for SSNHL treatment. A total of 93 patients with SSNHL were enrolled. Forty-three patients
underwent HBO therapy after the failure of steroid therapy.
BAHAN dan METODE
Penelitian retrospektif ini termasuk data yang diperoleh dari para pasien yang diberikan ke rumah sakit
antara tahun 2009 dan 2015 untuk pengobatan SSNHL. Ada 93 orang pasien SSNHL yang dilibatkan.
Sebanyak 43 orang pasien diberikan terapi HBO setelah gagal diterapi steroid.

Fif- ty patients were unsuccessfully treated with steroid therapy and did not undergo HBO therapy
as it was unavailable or they refused it. All patients met the criteria for the diagnosis of sudden
hearing loss: sudden onset of sensorineural hearing loss, unknown cause of hearing loss, and
average hearing level of greater of 30 dB at 250, 500, 1000, 2000 and 4000 Hz.
Ada 50 orang pasien yang tidak berhasil diterapi dengan steroid dan tidak diterapi dengan terapi HBO karena tidak ada atau
mereka menolaknya. Semua pasien memenuhi kriteria untuk diagnosis kehilangan pendengaran mendadak: kehilangan
pendengaran sensorineural mendadak, kehilangan pendengran tanpa penyebab, dan rata-rata level pendengaran lebih besar
dari 30 dB pada 250, 500, 1000, 2000, dan 4000 Hz.

Therapy was initiated within 20 days of the onset of hearing loss. The pure-tone average was
calculated prior to and after corticosteroid therapy; a hearing gain of less than 10 dB was
considered as therapy failure. All patients received steroid therapy [intravenous
methylprednisolone sodium succinate, 240 mg (Solu-Medrol, Pfizer Manufacturing, Puurs, Bel-
gium) for 2 days;
Terapi diberikan dalam 20 hari serangan kehilangan pendengaran. Rata-rata pure-tone (nada murni) dihitung
terlebih dahulu sebelum dan sesudah terapi corticosteroid; pendengaran yang kurang dari 10dB diangap terapinya
gagal. Semua pasien menerima terapi steroid [Intravenous Methylprednisolone sodium succinate, 240 mg selama
2 hari (Solu-Medrol, Pfizer Manufacturing, Puurs, Bel- gium) ].
Corresponding Address: Jakov Ajduk E-mail: jakov.ajduk@gmail.com
Submitted: 30.10.2016 Revision received: 11.01.2017 Accepted: 28.01.2017
Copyright 2017 by The European Academy of Otology and Neurotology and The Politzer Society - Available online at www.advancedotology.org
J Int Adv Otol 2017; 13(1): 61-4

Table 1. Clinical characteristics of patients with SSNHL Ciri2 klinis pasien SSNHLTable 3. Mean hearing levels before and after HBO therapy at six frequencies
in patients with a hearing loss of 60 dB (21 patients)
HBO therapy Group without
Patients group additional therapy hearing levels levels after HBO
No. of patients 43 50
Frequency Initial mean
(dB) Mean
therapy
hearing
(dB) p
Age, years (mean) 53.219.4 55.522.2
250 Hz 47.221.29 29.422.61 0.01*
Sex (male/female) 21/32 23/25
500 Hz 48.320.72 31.620.72 0.03*
Initial mean hearing level (dB) 80.575.14 75.529.42
1000 Hz 44.728.67 31.921.08 0.13
Days from onset of SSNHL to the 11.48.12 13.26.52
intiation of steroid therapy 2000 Hz 29.412.89 32.520.81 0.05
4000 Hz 31.918.79 32.719.49 0.88
Days from the end of steroid therapy to 2319.1
the intiation of HBO therapy 8000 Hz 33.619.98 36.925.67 0.63
HBO: hyperbaric oxygen therapy; SSNHL: sudden sensorineural hearing loss *Statistically significant
HBO: hyperbaric oxygen therapy
Table 2. Mean hearing levels before and after HBO therapy at six frequencies
(43 patients) Rata2 level pendengaran sebelum & ssdh terapi HBO Table 4. Mean hearing levels before and after HBO therapy at six frequencies
in patients with a hearing loss of >60 dB (22 patients)
hearing levels levels after HBO
hearing levels levels after HBO
Frequency Initial mean
(dB) Mean
therapy
hearing
(dB) p
Frequency Initial mean
(dB) Mean
therapy
hearing
(dB) p
250 Hz 64.327.52 42.329.17 0.0003*
250 Hz 71.723.04 48.529.24 0.0007*
500 Hz 66.129.11 46.229.26 0.0008*
500 Hz 79.123.04 56.630.38 0.001*
1000 Hz 49.435.23 48.531.92 0.828
1000 Hz 82.622.35 57.632.36 0.0002*
2000 Hz 47.631.94 47.534.12 0.97
2000 Hz 77.222.71 63.233.35 0.004*
4000 Hz 51.236.72 51.433.51 0.97
4000 Hz 84.3419.21 72.230.44 0.006*
8000 Hz 43.130.71 55.232.91 0.04*
8000 Hz 88.4818.95 75.130.61 0.002*
*Statistically significant
HBO: hyperbaric oxygen therapy *Statistically significant
HBO: hyperbaric oxygen therapy
the dose was then tapered till 80 mg, and oral ste- roid therapy was
continued for 6 days]. The 43 patients were treated in a hyperbaric
chamber at a pressure of 2.5 atm for 60 min daily for 4 weeks (a total
of 20 sessions). The study was approved by the ethics committee of
our institution and was conducted in accordance with the ethical
principles stated in the Declaration of Helsinki. Written informed
consent was obtained from patients who participated in this study.
Dosisnya berangsur-angsur dikuranggi hingga 80 mg,
dan terapi steroid oral diteruskan selama 6 hari].
Ke-43 orang pasien di-treat dalam sebuah ruang hyperbaric
pada tekanan 2,5 atm selama 60 menit setiap hari
selama 4 minggu (total 20 sesi). Penelitian ini disetujui
oleh komite institusi kami dan dilaksanajan sesuai dengan
prinsip2 etis yang dinyatakan dalam Deklarasi Helsinski.
Informasi tertulis diperoleh dari para pasien yang
Berpartisipasi dalam penelitian ini.

Statistical Analysis
Statistical differences were analyzed using the 2 test and a two
tailed Students t test. Statistical analysis was performed using Med-
Calc software (Version 11.2.1 1993-2010. MedCalc Software bvba
Software, Mariakerke, Belgium).
Analisa Statistik
Perbedaan statistik dianalisa menggunakan tes X2 dan uji two-
tailed mahasiswa. Analisa statistik dilakukan menggunakan
software Med- Calc software (Version 11.2.1 1993-2010. MedCalc
Software bvba Software, Mariakerke, Belgium).
RESULTS
Forty three patients with SSNHL after the failure of primary steroid herapy received HBO therapy (Table 1). The second
group of 50 patients with SSNHL after the failure of the primary therapy did not receive additional therapy (Table 1). The
mean hearing thresholds at 0.25, 0.5, 1, 2, 4, and 8 kHz were calculated before and after HBO therapy, while in the control
group, mean thresholds were calculated after the failure of primary therapy and 1 month later.
HASIL
43 pasien dengan SSNHL menerima terapi HBO setelah terapi steroid primer gagal (Tabel1 Kelompok kedua terdiri atas 50
orang pasien dengan SSNHL sesudah terapi sebelumnya gagal tidak menerima terapi tambahan (Tabel 1). Rata2 batas
pendengaran 0.25, 0.5, 1, 2, 4, dan 8 kHz dihitung sebelum dan sesudah terapi HBO, sementara di kelompok kontrol, ambang
rata2 dihitung sesudah kegagalan terapi primer dan sebulan kemudian.
After HBO therapy, significant improvement in mean hearing thresholds was found at 0.25 and 0.5 kHz (Table 2). There were no
significant differences at 1, 2, and 4 kHz, while at 8 kHz, there was a small decrease in the mean hearing threshold (Table 2). Patients were
divided in those with severe hearing loss (>61 dB) and those with moderate hearing loss (60 dB). Patients with a hearing loss of 60
dB had significant improvement only at 0.25 and 0.5 kHz (Table 3), while those with a hearing loss of >61 dB had signifi- cant
improvement at all six frequencies (Table 4). Two patients had Eustachian tube dysfunction during HBO therapy, and myringoto- my and
ventilation tube installation were required. No other side effects were noticed during HBO therapy. In the patients in the group not
receiving additional therapy, there were no significant differences in hearing thresholds 1 month after the failure of pri- mary therapy.

Sesudah terapi HBO terjadi peningkatan signifikan pada ambang rata2 pendengaran pada 0.25 dan 0.5 kHz (Tabel 2).
Tidak ada perbedaan signifikan pada 1,2 dan 4 kHz, sementara pada 8kHz terdapat sedikit pengurangan dalam rata2
ambang pendengaran (Tabel 2). Para pasien dibagi ke dalam mereka dengan kehilangan pendengaran parah (>61 dB)
dan mereka dengan kehilangan pendengaran menengah (< 60 dB).

DISCUSSION PEMBAHASAN
The most commonly used salvage therapies for sudden hearing loss are HBO therapy and intratympanic steroid
therapy[17-21] . A compar- ison of these two methods was recently described[22, 23] . Both meth- ods have been
successful. Although a positive result was shown us- ing both therapies, there is no consensus on which therapy is
better. While previous studies showed that younger patients had better response after HBO therapy, in our study,
we found no hearing im- provement related to age.
Terapi2 penyelamatan yang paling banyak digunakan untuk kehilangan pendengaran mendadak adalah
terapi HBO dan terapi steroid intratympanic. Sebuah perbandingan antara kedua metode ini baru2 ini
digambarkan. Kedua metode ini dua-duanya berhasil. Meskipun sebuah hasil positif ditunjukkan
menggunakan kedua terapi ini, tidak ada kesepakatan terapi mana yang lebih baik dari keduanya.
Sementara itu penelitian2 sebelumnya menunjukkan bahwa para pasien yang lebih muda memiliki
respons yang lebih baik sesudah terapi HBO- dalam penelitian kami didapati tidak ada peningkatan
pendengaran pada usia yang sama ini.

Our study showed that HBO therapy as salvage therapy significantly improves the outcome in patients with a hearing
loss of >61 dB, while some previous studies have found the benefit of HBO therapy only among patients presenting
with pro- found hearing loss (>80 or >90 dB)[19, 21, 22] . In the group of patients with a hearing loss of 60 dB,
improvement was noticed only at low frequencies (0.25 and 0.5 kHz), which is consistent with a previous study on
SSNHL that showed that the apical part of the cochlea re- cover better than the basal parts[24] . Spontaneous recovery
of hearing has been described in the first few weeks form the onset of SSNHL, but hearing recovery after the failure of
primary therapy is very low.
Penelitian kami menunjukkan bahwa tearpi HBO sebagai terapi penyelamatan secara signifikan meningkatkan
pendengaran pasien >61dB, sementara beberpa penelitian sebelumnya menemukan keuntungan dari terapi HBO
hanya diantara para pasien yang kehilangan pendengaran >80 atau > 90dB. Dalam kelompok pasien dengan kehilangan
pendengaran < 60dB, peningkatan terlihat hanya pada frekwensi rendah (0.25 dan 0.5 kHz) yang konsisten dengan
penelitian sebelumnya terhadap SSNHL yang menunjukkan bahwa bagian apical dari Cochlea sembuh lebih baik dari
pada bagian basal. Penyembuhan pendengaran spontan digambarkan dalam minggu2 pertama dalam penanganan
SSNHL, tetapi pendengaran pulih sesudah kegagalan terapi sebelumnya,sangat rendah.

We used a control group of 50 patients who did not receive addition- al therapy after the failure of steroid therapy.
One month after the initial therapy, hearing levels were measured and no improvement was observed. We are aware
that our control group did not receive HBO therapy for the real comparison; however, because of ethical reasons
and technical difficulties, it is difficult to perform this kind of research. We used patients who did not receive HBO
therapy after the failure of the primary therapy as it was unavailable at that time or they refused the treatment. The
high costs of HBO therapy and a lack of randomized studies are the main reason for not using it as the primary
therapy for patients with sudden hearing loss. It is very important to start primary and salvage therapies as soon as
possible because salvage therapy has no effect if it is used 4 months after the initial hearing loss[7]
Kami menggunakan kelompok control yang terdiri atas 50 orang pasien yang tidak menerima terapi tambahan sesudah
kegagalan terapi steroid. Satu minggu sesudah terapi awal, leve pendengaran diukur dan tidak ada peningkatan yang
diamati. Kami menyadari bahwa kelompok control kami tidak menerima terapi HBO untuk pembanding yang riil; namun
demikian, oleh karena alasan etis dan kesulitan tekhnis, maka sulit untuk melakukan penelitian seperti ini. Kami
menggunakan pasien yang tidak menerima terapi HBO sesudah kegagalan terapi primer karena ketiadaannya saat itu atau
mereka menolak tindakan/treatment. Tingginya biaya terapi HBO dan kurangnya penelitian2 acak merupakan alasan utama
untik tidak menggunakan terapi HBO ini sebagai terapi primer bagi pasien kehilangan pendengaran mendadak. Penting
sekali untuk memulai terapi2 primer dan penyelamatan secepat mungkin karena terapi penyelamatan tidak memiliki efek
jika digunakan 4 bulan setelah kehilangan pendengaran awal.

Intratympanic steroid therapy as salvage therapy is more effective at low frequencies than at high frequencies[19] . Our
results suggest that HBO therapy is also more effective at low frequencies in patients if the hearing loss is less severe.
An explanation for better hearing re- covery at low frequencyis that hearing cells in the apical part of the cochlea are
more resistant to ischemia than those in other parts of the cochlea.
Terapi steroid intratimpanik sebagai terapi penyelamatan lebih efektif pada frekwensi rendah dari pada frekwensi tinggi.
Hasil kami menyarankan bahwa terapi HBO juga lebih efektif pada frekwensi rendah dari penderita kehilangan pendengaran
mendadak. Sebuah penjelasan untuk penyembuhan pendengaran yang lebih baik pada frekwensi rendah adalah bahwa sel2
pendengaran pada bagian apical dari cochlea lebih resisten terhadap ischemia dari pada yang di bagian lai dari cochlea.

Hyperbaric oxygen therapy is used for primary and salvage therapy. Combination of HBO and steroid therapy compared
to steroid thera- py alone significantly improved hearing outcome[25] .The addition of HBO therapy to
primaryconventional therapy improved the results when started early after the onset of SSNHL and was more successful
in patients with a hearing loss greater than 60 dB[15] . A recent study compared four primary therapy protocols for
patients with SSNHL: oral steroid therapy, intratympanic steroid therapy, HBO therapy, and HBO therapy combined
with oral steroid therapy[19] . The results showed that the combination of oral steroid therapy and HBO thera- py was
the most effective.
Terapi oksigen herbarik digunakan untuk terapi primer dan penyelamatan. Kombinasi dari HBO dan terapi steroid
dibandingkan dengan terapi steroid saja secara signifikan meningkatkan pendengaran. Penambahan terapi HBO kepada
terapi konvensional primer meningkatkan hasil pada waktu dimulai lebih awal sesudah penanganan SSNHL dan lebih
berhasil pada pasien dengan kehilangan pendengaran lebih besar dari pada 60dB. Study belakangan ini membandingkan
protokol 4 terapi primer untuk pasien dengan SSNHL: terapi steroid oral, terapi steroid intratympanik, terapi HBO, dan
kombinasi terapi HBO dengan terapi steroid oral. Hasilnya menunjukan bahwa kombinasi terapi steroid oral dan terapi
HBO yang paling efektif.
 A high rate of spontaneous recovery, up to 65%, has been described within the first two weeks after the intiation of
steroid therapy[23] . This natural course of the disease could be attributed to the success of primary therapy.
Hyperbaric oxygen therapy is a safe and successful salvage therapy for patients with sudden hearing loss. Our results
indicate that HBO therapy as salvage therapy for SSNHL is effective and should be used, particularly in patients with
severe hearing loss. Without salvage ther- apy, no significant changes in the hearing threshold can be expected. We could
not have divided the group of patients with a hearing loss of >60 dB into even more groups because the number of
patients is small and statistical analyses would be inadequate. Further studies with a larger number of patients and
comparison with other types of salvage therapy are needed.
Suatu laju penyembuhan spontan lebih dari 65% digambarkan dalam 2 minggu pertama sesudah inisiasi terapi steroid. Natur
penyakit ini dapat dikaitkan dengankeberhasilan terapi primer, Terapi oksigen hyperbarik merupakan terapi penyelamatan
yang aman dan berhasil bagi pasien kehilangan pendengaran mendadak. Hasil penelitian kami menunjukkan bahwa terapi
HBO sebagai terapi penyelamatan bagi SSNHL sangat efektif dan harus digunakan, terutama pada para pasien dengan
kehilangan pendengaran parah. Tanpa terapi penyelamatan, tidak ada perubahan yang signifikan dalam ambang pendengaran
yang bisa diharapkan. Kita tidak bisa membagi kelompok pasien dengan kehilangan pendengaran >60dB ke dalam kelompok
lain karena jumlah pasien yang sedikit dan analisa statistik menjadi tidak memadai. Penelitian lebih lanjut diperlukan dengan
jumlah pasien yang lebih banyak dan dengan jenis terapi penyelamatan yang lain.

Ethics Committee Approval: Ethics committee approval was received for this study from the ethics committee of University Hospital Centre Sestre Milosrd- nice, Zagreb,
Croatia.

63
 J Int Adv Otol 2017; 13(1): 61-4

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2016; doi: 10.1016/j.bjorl.2016.10.013. [CrossRef] apeutic results in sudden sensorineural hearing loss with/without addition-
Conflict of Interest: No conflict of interest was declared by the authors.
21. Pezzoli M, Magnano M, Maffi L, Pezzoli L, Marcato P, Orione M, et al. Hy- al hyperbaric oxygen therapy: a retrospective review of 465 audiologically
perbaric oxygen therapy as salvage treatment for sudden sensorineural controlled cases. Clin Otolaryngol 2011; 36: 121-8. [CrossRef]
Financial Disclosure: The authors declared that this study has received no
financial support.

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