Drugs affecting the inner ear. A review of their clinical efficacy, mechanisms of action, toxicity, and place in therapy.

Many drugs have a site of action within the inner ear. The list includes therapeutic, diagnostic and ototoxic agents. Therapeutic agents are most useful in cases of infections, endolymphatic hydrops, vascular insufficiency, vertigo of peripheral origin, autoimmune disease, otosclerosis (otospongiosis), sudden hearing loss and tinnitus. For infections, the most widely used anti-microbial agents are the penicillins and cephalosporins. There are no antiviral agents that have been proven useful for inner ear viral infections. However, steroids have been of some value for controlling some of the sequelae. Steroids have also been useful in conjunction with ampicillin in cases of syphilitic hearing loss. In cases of endolymphatic hydrops, the diuretics chlorthalidone, hydrochlorothiazide and acetazolamide have been useful. When diuretic and diet therapy cannot control endolymphatic hydrops, ototoxic drugs such as streptomycin have been used. In cases of vascular insufficiency within the inner ear, vasodilators such as carbon dioxide, papaverine, buphenine (nylidrin), naftidrofuryl (nafronyl) and thymoxamine have been recommended, but their true efficacy is questionable. Some success with betahistine has been achieved but the mechanism of this drug's action may be other than vasodilatation. Vertigo is best controlled with antihistamines and anticholinergics and with certain calcium channel blockers. Autoimmune inner ear disease appears to respond to a combination of steroids and cyclophosphamide. Although controversial, current pharmacotherapy for otosclerosis includes sodium fluoride. Sudden hearing loss is treated with a 'shotgun' combination of drugs and/or bed rest. There are as yet no drugs which can be used to routinely reduce tinnitus although some medications may help the patient tolerate the problem. Lignocaine (lidocaine) is useful in diagnosing, and very evanescently reducing, tinnitus. Glycerin (glycerol) is useful in diagnosing endolymphatic hydrops and may at times transiently reduce tinnitus. The drugs most noted for their ototoxicity are the aminoglycoside antibiotics, certain diuretics, non-steroidal anti-inflammatory agents, certain anticancer agents and some miscellaneous chemicals. Some new research drugs are in clinical trials for tinnitus, hearing loss and vertigo, and the rational search for new otopharmacotherapeutic agents is increasing.