Review

Audiology
Audiol Neurotol 2018;23:1–7 Received: June 8, 2017
Neurotology Accepted after revision: December 13, 2017
DOI: 10.1159/000486274
Published online: June 22, 2018

Effect of Antioxidant Vitamins as Adjuvant

Therapy for Sudden Sensorineural Hearing Loss:
Systematic Review Study
Iman Ibrahim a Anthony Zeitouni b Sabrina Daniela da Silva c
a
Department of Otolaryngology, Head and Neck Surgery, McGill University, b Department of Otolaryngology, Head
and Neck Surgery, Royal Victoria Hospital, McGill University, and c Department of Otolaryngology, Head and Neck
Surgery, Jewish General Hospital, McGill University, Montréal, QC, Canada

Keywords SSNHL. Quality assessment was performed using the Co-

Antioxidant · Vitamin A · Vitamin C · Vitamin E · Sudden chrane Collaboration Tool for Assessing Risk of Bias. Data
sensorineural hearing loss · Adjuvant therapy · Idiopathic Extraction: Each study had a control group (conventional
sensorineural hearing loss · Oxidative stress · Reactive treatment + placebo) and a trial group (antioxidant vita-
oxygen species · Reactive nitrogen species min(s) + conventional treatment). Results: From 446 manu-
scripts identified in the literature, 3 studies were included in
the review with 279 patients. The most common vitamins
Abstract used to treat SSNHL were the 3 major antioxidant vitamins
Importance: Sudden sensorineural hearing loss (SSNHL) is A, C, and E, combined sometimes with other antioxidants
an otological emergency of unknown etiology. Recent re- such as selenium. Conclusions and Relevance: The success
ports showed that antioxidant drugs can benefit patients of the treatment is increased in patients who received anti-
with SSNHL. This study attempted to evaluate the effect of oxidant vitamins in combination with conventional therapy.
adding antioxidant vitamins as an adjuvant therapy along- © 2018 S. Karger AG, Basel
side with corticosteroids. Objective: To evaluate the effects
of the 3 major antioxidant vitamins (A, C, and E) as an adju-
vant therapy, administered with corticosteroids, for the Introduction
treatment of SSNHL in adult patients (≥18 years). Data
Sources: MEDLINE, EMBASE, PubMed, Web of Science and Sudden sensorineural hearing loss (SSNHL) is a rela-
Cochrane electronic databases from January 1, 1995, through tively common complaint in otological and audiological
September 25, 2017. Study Selection: Published studies of practices (1.5–1.7 per 100 new patients presenting in our
adult patients who received antioxidant vitamins (A, C, E, or practice). The estimated annual incidence of SSNHL is
any combination of these vitamins) as an adjuvant therapy 5–30 cases per 100,000 populations, with 15,000 new cas-
in addition to the regular treatment (corticosteroids) for es reported annually worldwide and about 4,000 new cas-

© 2018 S. Karger AG, Basel Dr. Iman Ibrahim

Department of Otolaryngology, Head and Neck Surgery, McGill University
307-201 Metcalfe Avenue, Westmount
E-Mail [email protected]
Montreal, QC H3Z 2H7 (Canada)
www.karger.com/aud
E-Mail iman.ibrahim @ mail.mcgill.ca
es reported annually in the USA [Alexander and Harris, venting damage. Our study systematically reviewed and
2013]. The incidence of SSNHL increases with age, espe- analyzed the effect of antioxidant vitamins (A, C, and E)
cially between 50 and 60 years old for men and women impacting in the treatment outcomes for patients with
equally. SSNHL.
The majority of patients with SSNHL has no identifi-
able cause for hearing loss and is classified as “idiopathic.”
The diagnostic criteria for SSNHL are (a) a hearing loss Methods
of 30 dB (or more) over 3 contiguous pure-tone frequen-
Data Sources
cies, occurring within (b) a 3-day period. This is a frus-
A thorough search of MEDLINE, EMBASE, PubMed, Web of
trating entity appearing usually unilaterally but in some Science and Cochrane Review was conducted, using the keywords
cases bilaterally where patients are overwhelmed by the “sudden hearing loss” or “SSNHL” or “vitamin” or “antioxidant”
sudden loss of hearing [Hatano et al., 2008; Joachims et or “vitamin A” or “vitamin C” or “vitamin E” or “ascorbic acid,”
al., 2003; Kaya et al., 2015]. Despite the extensive research, or “retinol.” This systematic review included published studies
from January 1, 1995, to September 25, 2017.
controversy remains in the etiology and appropriate care
of these patients. Some of the known risk factors include Data Extraction
viral and bacterial infections, trauma, neoplasia, vascular A total of 446 potential manuscripts were identified using the
disease/alteration, and side effects of drug administra- keywords mentioned above. Only articles in English and French
tion, such as those of aminoglycosides and cisplatin [Lan- were included. Individual abstracts were screened to select the
studies that followed the criteria for this review. Full texts of se-
vers-Kaminsky et al., 2017]. Evidence suggests that there
lected articles were then retrieved, rescreened for possible inclu-
is an association between SSNHL and long-term risk of sion in the current review by two different observers indepen-
stroke [WHO, 2017]. dently.
Numerous agents have been investigated for the treat-
ment of SSNHL including anti-inflammatory agents, an- Data Presentation
Randomized case-control studies were evaluated in order to
timicrobials, calcium antagonists, vitamins, essential
investigate the effect of adding antioxidant vitamins to the tradi-
minerals, vasodilators, volume expanders, defibrinoge- tional therapy of SSNHL. Controls received placebo treatments
nators, diuretics, hyperbaric oxygen, and bed rest. Cur- associated with conventional therapy (corticosteroid). The results
rently, the regimen for SSNHL treatment consists of ste- of treatment of SSNHL are reported as: complete recovery, where
roids (prednisone or methylprednisone, at an initial dose hearing thresholds return back to their normal values before the
onset of SSNHL; marked recovery, where more than 30 dB recov-
of 1 mg/kg of body weight per day for 5–14 days [Conlin ery in mean hearing level is reported; partial recovery, a recovery
and Parnes, 2007]). For SSNHL, 45–65% of patients will of 10–29 dB in mean hearing, and no response (<10 dB in mean
regain their pre-loss hearing thresholds even without hearing level). Only patients showing complete recovery were in-
therapy, with average gains of 35 dB. Spontaneous recov- cluded in the current review. Then, the effect of adjuvant antioxi-
ery without treatment can occur within 2 weeks (30– dant vitamin therapy was compared to placebo adjuvant therapy
considering 100% recovery rates for both treatments.
80%), but the complete recovery occurs only in 35% of
patients [Ryu et al., 2017]. Data Synthesis
The benefits of antioxidants are currently the focus of The outcome was obtained by comparing the number of pa-
SSNHL as an adjuvant to the treatment. Recent reports tients who had a complete recovery from SSNHL in both groups
suggested that free radicals, reactive oxygen species, and (with vs. without adjuvant therapy with antioxidant vitamins). The
effect size was measured using the log relative risk because out-
nitric oxide have toxic effects on the auditory system, comes are reported in a dichotomous manner. Both random and
particularly the outer hair cells. During normal mito- fixed-effect models were used. Since the heterogeneity was very
chondrial respiration, reactive oxygen species (ROS) are trivial (I2 = 0.01%), using the fixed-effect model was acceptable;
produced, which can cause cell damage when generated however, both model results did not contradict.
in excess. During normal functioning they are converted
to nonreactive molecules by endogenous antioxidants
[Darrat et al., 2007]. However, disruption of this nor- Results
mally balanced system can result in overproduction of
ROS, thus overwhelming the natural intrinsic defense Searching the databases screened the total of 446 stud-
and resulting in cell injury and death [Krämer et al., ies. From these, 436 articles were excluded at abstract
2006] Administration of exogenous antioxidants may level because they were either animal studies, duplicates,
protect cells by scavenging the excess ROS, thereby pre- or they tested other drugs or antioxidants (not vitamins)

2 Audiol Neurotol 2018;23:1–7 Ibrahim/Zeitouni/da Silva

DOI: 10.1159/000486274
 446 citations found on database search:
MEDLINE: 355
PubMed: 76
Cochrane; 9
Web of Science: 6
436 studies excluded at abstract level:
‡ Animal studies
‡ Duplicates
‡Other drugs/antioxidants
(not vitamins) used for treatment
10 studies retrieved for full-text review

7 studies excluded:
no extractable/usable data

3 studies selected for inclusion in this

systematic review
Fig. 1. Flow diagram of the search and
study selection process.

Table 1. Summary of results of all studies included in the systematic review (n)

Study Vitamin Vitamin Controls Controls Vitamin Controls

(improvement) (no improvement) (improvemnet) (no improvement) (total) (total)

Joachims et al. [2003], Israel, vitamin E 13 20 11 22 33 33

Hatano et al. [2008], Japan, vitamins E, C 18 31 4 34 49 38
Kaya et al. [2015], Turkey, vitamins A, C, E, 26 44 16 40 70 56
selenium

(Fig. 1). Full texts of 10 publications were recovered, and not significant in some studies. Details of each study re-
then 6 of them were excluded because it was not possible sult are discussed below.
to extract complete data (such as the number of patients Joachims et al. [2003] found that 39.39% of patients in
who reached full recovery after administration of anti- the vitamin group (13 out of 33) experienced full recov-
oxidant vitamins). The remaining 3 studies were includ- ery, compared to 33.33% of patients in the control group
ed for the systematic review. A summary of these 3 stud- (11 out of 33). Joachims et al. set a success of treatment
ies is presented in Table  1. For quality assessment, we criterion, which is an improvement of 75% or more at the
used the Cochrane Collaboration tool for assessing risk time of discharge (achieved by dividing hearing gain by
of bias [Higgins et al., 2011]. The results are presented in the difference in hearing level between the affected and
Table 2. healthy ear). This criterion was achieved in 78.78% of pa-
The number of subjects with complete recovery in tients in the vitamin group who experienced a success of
both vitamin versus placebo groups is shown in Table 1. treatment (26 out of 33), compared to 45.45% (15 out of
It was difficult to pool the data from the 3 studies due 33) of patients in the control group. This difference was
to lack of consistency. While Joachims et al. [2003] inves- statistically significant. Joachims et al. [2003] discussed
tigated the effect of adding vitamin E, Hatano et al. [2008] some factors that can affect the results of treatment. They
looked at the effect of both vitamins E and C, and Kaya et reported that the severity of initial hearing loss can affect
al. [2015] also added vitamin A to vitamins E and C. All the recovery rate, which was also worse in patients who
3 studies found an improvement in the study group, had vertigo and/or tinnitus at the time of the sudden loss
which received the adjuvant vitamin therapy, compared of hearing as compared to those who did not experience
to the control group, which received merely the standard those symptoms; however, the difference was not statisti-
corticosteroid therapy. However, this improvement was cally significant.

Antioxidant Vitamins for SSNHL Audiol Neurotol 2018;23:1–7 3

DOI: 10.1159/000486274
Table 2. Risk of bias assessment for all studies included in the systematic review

Study, year Random Allocation Blinding of the Blinding of Incomplete Selective Any other Summary
sequence sequence participants the outcome outcome data reporting? potential assessment
generation concealment assessors reporting sources of of risk of
bias? bias

Joachims Low Low Unclear Unclear High Low Low Low

et al., 2003 Authors stated Authors stated Measured, not Measured, not Not all end points None None
that the study is that the study is explained explained were complete; 8
randomized double-blind patients in the
study group were
not reported in
the results section
Hatano Unclear Unclear Unclear Unclear n.a. (retrospective Low Low Unclear
et al., 2008 A retrospective A retrospective A retrospective A retrospective study) None None
chart review – chart review – chart review – chart review –
no details no details no details no details
provided provided provided provided
Kaya et High High High High Low Low Low High
al., 2015 The authors The authors The authors The authors Outcome data None None
clearly stated clearly stated clearly stated clearly stated were complete; no
that the study that the study that the study that the study exclusions/
was not was not was not was not attritions were
randomized or randomized or randomized or randomized or reported
blinded blinded blinded blinded

n.a., not applicable.

Hatano et al. [2008] reported a significant difference 2007; Kaya et al., 2015]. This systematic review evaluated
in final pure-tone average, hearing gain and recovery rate the effect of antioxidant vitamins (A, C, and E) impacting
between the vitamins (C and E) group and the control the treatment outcomes for patients with SSNHL.
group (Table 3). 36.7% of patients in the vitamin group Although the underlying mechanism of SSNHL re-
(18 out of 49) experienced a complete recovery compared mains unknown, ROS and reactive nitrogen species may
to 10.5% of the control group (4 out of 38). The vitamin contribute to the pathogenesis of SSNHL in the same way
group had a better final pure-tone average (41.1 dB com- as in cases of ototoxicity, noise-induced hearing loss and
pared to 52.6 dB in the control group). The recovery rate presbyacusis. ROS generation starts with rapid uptake of
was 63.3% in the vitamin group compared to 44.0% in the oxygen, activation of NADPH oxidase, and the produc-
control group. tion of superoxide anion radical. In the ear, the cochlea,
Finally, Kaya et al. [2015] found that the complete re- the organ of Corti which contains numerous hair cells,
covery rate was 37.1% (26 out of 70) in the vitamin (A, C, the vestibular organ, and neurons are the most suscepti-
E) group compared to 28.5% (16 out of 56) in the control ble structures to oxidative stress. Antioxidants are con-
group. They reported that the mean final hearing level was sidered to be important radical scavengers to neutralize
36.6 ± 26.7 dB in the vitamin (A, C, E) group compared to the oxidative stress by enhancing cellular defenses and
49.9 ± 34.5 dB in the control group. The total recovery rate then protect the cell membranes [Young and Woodside,
was also significantly better in the vitamin group (52.4 ± 2001].
24.0% compared to 39.7 ± 28.1% in the control group). Animal models showed that antioxidants ameliorate
idiopathic SSNHL. Despite the fact that only a few studies
investigated the effect of antioxidants on SSNHL, most of
Discussion them reported a significant improvement in the group of
patients who receive antioxidants as an adjuvant treat-
The cause and appropriate treatment of SSNHL re- ment for SSNHL. The current analysis focused on vita-
main unclear. Over the last few years, many protocols mins (A, C, and E), because these are the major antioxi-
have been suggested in the literature [Conlin and Parnes, dant vitamins. Each vitamin has a different mechanism of

4 Audiol Neurotol 2018;23:1–7 Ibrahim/Zeitouni/da Silva

DOI: 10.1159/000486274
Table 3. Treatment regimens and audiometric results of all studies included in the systematic review

Study, year Treatment protocol Treatment protocol Number Number Audiometric Audiometric
(study group) (control group) and age and age results results
(study (control (study group), (control group),
group) group) n (%) n (%)

Joachims In addition to the Bed rest, steroids n = 33 n = 33 Initial PTA Initial PTA
et al., 2003 control group (prednisone at a dosage of Age Age 67.6 ± 19.8 dB 70.3 ± 12.4 dB
regimen, the study 1 mg/kg/day), intravenous 42.2 ± 15.62 38 ± 16.17 Final PTA Final PTA
group received oral magnesium sulfate 4 g/day, years years 37.1 ± 28.8 dB 47.6 ± 25.2 dB
vitamin E (D-α- and carbogen (95% O2 + Complete recovery Complete recovery
tocopherol acetate), 5% CO2) by mask, 30 min (39.39%) (33.33%)
400 mg twice daily 4 times a day Good recovery (39.39%) Good recovery (12.12%)
Moderate recovery Moderate recovery
(15.15%) (36.36%)
None (6.06%) None (18.18%)
Hatano In addition to the Prednisolone at an initial n = 49 n = 38 Initial PTA 70.1 ± 18.4 dB Initial PTA
et al., 2008 control group dosage of 1 mg/kg/day Age Age Final PTA 71.2 ± 24.0 dB
regimen, oral tapered over 7 days, ATP 55.5 ± 16.6 57.4 ± 13.1 41.1 ± 23.8 dB Final PTA
administration of and vitamin B12 were given years years Complete recovery 52.6 ± 24.8 dB
vitamin E in both groups. Alprostadil, 18 (36.7%) Complete recovery
(tocopherol 10 mg lipo-PGE1 for Marked recovery 4 (10.5%)
nicotinate, 600 mg/ 7 days, was administered in 6 (12.2%) Marked recovery
day) and vitamin C cases with poor recovery Slight recovery 7 (18.4%)
(1,200 mg/day) was after steroid therapy 12 (24.5%) Slight recovery
performed for at No response 13 (26.5%) 13 (34.2%)
least 4 weeks No response
14 (36.8%)
Kaya Same as control Methylprednisolone n = 56 n = 70 Initial PTA Initial PTA
et al., 2015 group plus: at an initial dose of Age Age 72.9 ± 24.8 dB HL 77 ± 24.5 dB HL
vitamin A (natural 1 mg/kg body weight per 42.4 ± 14.1 42.8 ± 14.9 Final PTA 36.6 ± 26.7 dB HL Final PTA 49.9 ± 34.5 dB
β-carotene, 26,000 day, tapered over 14 days years years Complete recovery HL
IU) Rheomacrodex® 26 (37.1%) Complete recovery
vitamin C (ascorbic ([10 g of dextran and Marked recovery 16 (28.5%)
acid, 200 mg) 0.9 g of NaCl]/100 mL) 26 (37.1%) Marked recovery
vitamin E (D-α- 500 mL daily for 5 days Slight recovery 11 (19.6%)
tocopherol, 200 IU) Vastarel® 20-mg tablet 8 (11.4%) Slight recovery
selenium (50 μg) (20 mg of trimetazidine No response 13 (23.2%)
twice daily for dihydrochloride) 3 times 10 (14.2%) No response
30 days + control daily for 30 days 16 (28.5%)
group idiopathic Ten 60-min HBO sessions
SSNHL treatment (2.5 absolute atmospheres
regimen of 100% O2), once daily,
starting on the day of
hospitalization

IU, international unit; PTA, pure-tone average; dB HL, decibel hearing level; PGE1, prostaglandin E1; ATP, adenosine triphosphate disodium; HBO,
hyperbaric oxygen.

action, e.g. vitamin A can reduce the concentration of sin- is negligible (0.01%) strengthens the results, and the sig-
glet oxygen and repair damaged hair cells, vitamin E can nificance of the current review pointed to a homogeneous
reduce peroxyl radicals in the cell membrane, and vita- population, with minimal variability among them. How-
min C can detoxify free radicals in the aqueous phase. ever, and due to the different vitamin combinations used,
Hence, those vitamins can significantly improve the out- it was not possible to pool the results in a meta-analysis
come of the management of SSNHL [Hatano et al., 2008; study.
Kaya et al., 2015]. Although the vitamin group showed better results in
The 3 studies retrieved for review found higher com- the recovery progress, only the complete recovery pa-
plete recovery rates in the vitamin group compared to the tients were of interest to discuss to have a more robust
placebo group; the fact that heterogeneity among studies conclusion.

Antioxidant Vitamins for SSNHL Audiol Neurotol 2018;23:1–7 5

DOI: 10.1159/000486274
 There are a few postulated pathophysiologies for Conclusion
SSNHL: (1) labyrinthine viral infection – there is a moder-
ate prevalence of recent viral-type illness in SSNHL pa- Our systematic review investigated the effect of adding
tients; about 17–33% of SSNHL patients recall a recent vi- antioxidant vitamins such as vitamin A (retinol), vitamin
ral illness; however, 25% of patients without hearing loss C (ascorbic acid), and vitamin E (either used individually
visiting an otolaryngology clinic had experienced a viral- or in combination) as adjuvant therapy to the current
like illness within a month [Okamoto et al., 1994]; (2) lab- standard treatment (corticosteroids) for SSNHL. Based
yrinthine vascular compromise – the cochlea is an end or- on the reviewed data, we cannot recommend to add anti-
gan with no collateral vasculature; thrombosis, embolus, oxidant vitamins to corticosteroids. The percentage of
vasospasm, or any pathology that results in reduced blood patients with complete recovery was highest in individu-
flow to the cochlea is a possible etiology for idiopathic als who used vitamins associated with the conventional
SSNHL [Rudack et al., 2006]; (3) intracochlear membrane treatment. However, the evidence so far is inconclusive
ruptures – rupture of either the membranes that separate with regard to which vitamin or vitamin combination(s)
the inner ear from the middle ear, or the delicate mem- is more effective, and in what dosage. Further studies are
branes within the cochlea that separate the perilymphatic required to test the effect of each vitamin individually, as
and endolymphatic spaces could result in SSNHL, by creat- well as giving different combinations of these vitamins in
ing a state of relative endolymphatic hydrops or altering order to find the most effective vitamin and/or combina-
the endocochlear potential, respectively [Chung et al., tion of vitamins to be routinely administered as an adju-
2014; Goodhill et al., 1973; Simmons, 1968]; (4) immune- vant therapy alongside with corticosteroids for the treat-
mediated inner ear disease – the occurrence of SSNHL in ment of SSNHL.
autoimmune diseases, such as Cogan syndrome and sys-
temic lupus erythematosus, is well documented, and (5)
iron deficiency anemia [Chung et al., 2014]. Iron, in addi- Acknowledgments
tion to zinc and copper, is essential to break down the free
The authors would like to thank the McGill Medical librarians
radicals for the enzymatic antioxidants.
for their valuable assistance in building the search strategy and re-
It is possible that any pathological condition resulting trieving the articles from the various databases. Funding was
from one or more of these postulated mechanisms can granted by the Canada Graduate Scholarship Master’s (CGS-M)
result in idiopathic SSNHL, because no one mechanism Award – Canadian Institutes of Health Research (CIHR).
could individually explain all cases of idiopathic SSNHL.
Since vascular compromise of the cochlea is one of the
postulated mechanisms for SSNHL, the protective role of Disclosure Statement
antioxidant vitamins in treating SSNHL can be under-
The authors declare that there is no conflict of interest regard-
stood. Maintaining a good balance between oxidative by- ing the publication of this paper.
products, such as free radicals, and protective substances,
such as antioxidants, is important to prevent ischemia
and reperfusion injury [Hatano et al., 2008].
The current study has some limitations. There is a lack
of available data about which antioxidant vitamin is more
effective, what is the therapeutic dosage and for what du- References Alexander TH, Harris JP: Incidence of sudden
sensorineural hearing loss. Otol Neurotol
ration. In addition, some studies investigated the effect of 2013;34:1586–1589.
multiple vitamins, and some looked at 1 vitamin. This Chung S-D, Chen P-Y, Lin H-C, Hung S-H: Sud-
would make the conclusion of the current study less ac- den sensorineural hearing loss associated
with iron-deficiency anemia: a population-
curate, since not enough studies were performed on each based study. JAMA Otolaryngol Head Neck
vitamin separately, and they did not compare the results Surg 2014;140:417–422.
with various vitamin combinations. It should be men- Conlin AE, Parnes LS: Treatment of sudden sen-
sorineural hearing loss. I. A systematic re-
tioned too that 1 study [Kaya et al., 2015] was not ran- view. Arch Otolaryngol Head Neck Surg
domized or blinded, and hence it had a high risk of bias. 2007;133:573–581.
In sum, more studies are required in order to find out Darrat I, Ahmad N, Seidman K, Seidman MD:
Auditory research involving antioxidants.
which specific vitamin or which combination of vitamins Curr Opin Otolaryngol Head Neck Surg 2007;
can yield the best outcome. 15:358–363.

6 Audiol Neurotol 2018;23:1–7 Ibrahim/Zeitouni/da Silva

DOI: 10.1159/000486274
Goodhill V, Harris I, Brockman SJ, Hantz O: Sud- Kaya H, Koç AK, Sayın İ, et al: Vitamins A, C, and Rudack C, Langer C, Stoll W, Rust S, Walter M:
den deafness and labyrinthine window rup- E and selenium in the treatment of idiopathic Vascular risk factors in sudden hearing loss.
tures: audio-vestibular observations. Ann sudden sensorineural hearing loss. Eur Arch Thromb Haemost 2006;95:454–461.
Otol Rhinol Laryngol 1973;82:2–12. Otorhinolaryngol 2015;272:1119–1125. Ryu IY, Park SH, Park EB, Kim HJ, Kim SH, Yeo
Hatano M, Uramoto N, Okabe Y, Furukawa M, Krämer OH, Baus D, Knauer SK, et al: Acetylation SG: Factors prognostic of season-associated
Ito M: Vitamin E and vitamin C in the treat- of Stat1 modulates NF-kappaB activity. Genes sudden sensorineural hearing loss: a retro-
ment of idiopathic sudden sensorineural Dev 2006;20:473–485. spective observational study. J Audiol Otol
hearing loss. Acta Otolaryngol 2008;128:116– Lanvers-Kaminsky C, Zehnhoff-Dinnesen A, 2017;21:44–48.
121. Parfitt R, Ciarimboli G: Drug-induced oto- Simmons FB: Theory of membrane breaks in sud-
Higgins JPT, Altman DG, Gotzsche PC, et al: The toxicity: mechanisms, pharmacogenetics, and den hearing loss. Arch Otolaryngol 1968; 88:
Cochrane Collaboration’s tool for assessing protective strategies. Clin Pharmacol Ther 41–48.
risk of bias in randomised trials. BMJ 2011; 2017;101:491–500. WHO: Deafness and hearing loss. http://www.
343:d5928. Okamoto M, Shitara T, Nakayama M, et al: Sud- who.int/mediacentre/factsheets/fs300/en/
Joachims HZ, Segal J, Golz A, Netzer A, Golden- den deafness accompanied by asymptomatic (accessed March 27, 2017).
berg D: Antioxidants in treatment of idio- mumps. Acta Otolaryngol Suppl 1994; 514: Young IS, Woodside JV: Antioxidants in health
pathic sudden hearing loss. Otol Neurotol 45–48. and disease. J Clin Pathol 2001;54:176–186.
2003;24:572–575.

Antioxidant Vitamins for SSNHL Audiol Neurotol 2018;23:1–7 7

DOI: 10.1159/000486274