See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/343513949

Effect of Diabetes on the Prognosis of Sudden Sensorineural Hearing Loss:

Propensity Score Matching Analysis

Preprint · August 2020

CITATIONS READS

0 365

5 authors, including:

Jae Ho Chung Seung Hwan Lee

Hanyang University Korea Research Institute of Bioscience and Biotechnology KRIBB
12 PUBLICATIONS   25 CITATIONS    946 PUBLICATIONS   16,143 CITATIONS   

SEE PROFILE SEE PROFILE

All content following this page was uploaded by Jae Ho Chung on 07 August 2020.

The user has requested enhancement of the downloaded file.

Original Research
Effect of Diabetes on the Prognosis of
Sudden Sensorineural Hearing Loss:
Propensity Score Matching Analysis
Hee Won Seo, MD1, Jae Ho Chung, MD, PhD1,
Hayoung Byun, MD, PhD1, Jin-Hyeok Jeong, MD, PhD1,
and Seung Hwan Lee, MD, PhD1
Sponsorships or competing interests that may be relevant to content are dis-
closed at the end of this article.
Abstract
Objective. The aim of this study was to investigate the clinical
implications of diabetes for the management of idiopathic
sudden sensorineural hearing loss (ISSNHL).
Study Design. Retrospective study.
Setting. Tertiary referral center.
Subjects and Methods. ISSNHL patients (N = 403) who re-
ceived inpatient management between January 2015 and
December 2018 were analyzed. All were managed by a
uniform treatment protocol of high-dose steroid therapy
and salvage intratympanic steroid injections. Treatment
results were evaluated according to the American Academy
of Otolaryngology—Head and Neck Surgery’s criteria 3
months after the start of treatment. We compared the clini-
cal parameters and treatment outcomes of ISSNHL with
and without diabetes. We also evaluated the influence of
diabetes on the prognosis of ISSNHL by propensity score
matching.
Results. Overall, of the 403 ISSNHL patients, 94 (23.3%) had
diabetes, and 11 were newly diagnosed with diabetes. The
patients with diabetes were older than those without dia-
betes (P \ .001), and their initial hearing threshold was sig-
nificantly higher (P \ .001). The diabetic patients were
hospitalized for a longer period, and their hearing recovery
rate was lower. However, when age, sex, and initial hearing
level were adjusted by propensity score matching, the dia-
betic patients and matched controls yielded similar treat-
ment results.
Conclusions. ISSNHL with diabetes usually presents with severe
hearing loss and requires longer hospitalization. However, dia-
betes itself may not influence the prognosis of ISSNHL. Proper
management must be provided in ISSNHL with diabetes.
Keywords
sudden hearing loss, prognosis, diabetes
Otolaryngology–
Head and Neck Surgery
1–7
Ó American Academy of
Otolaryngology–Head and Neck
Surgery Foundation 2020
Reprints and permission:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/0194599820901359
http://otojournal.org
Received July 11, 2019; accepted January 1, 2020.
I
diopathic sudden sensorineural hearing loss (ISSNHL)
is acute unexplained hearing loss and an emergency oto-
logical condition that can lead to permanent hearing dis-
ability. The incidence of ISSNHL has been reported to be 5
to 20 per 100,000 persons per year.1,2 ISSNHL can occur at
any age but is most common between 43 and 53 years of
age.2 The presumed causes of sudden sensorineural hearing
loss include microvascular abnormalities, virus infections,
autoimmune disorders, acoustic tumors, and head trauma.
However, in most cases of sudden sensorineural hearing
loss, the etiology is uncertain.3
Previous studies have postulated that hypertension, dia-
betes mellitus (DM), and cerebrovascular and cardiovascular
disease are associated with an increased incidence of
ISSNHL.4 The cochlea receives its blood supply from the
labyrinthine artery, which has no collateral circulation, so
the impaired cochlear perfusion in ISSNHL may reduce the
oxygen concentration in the cochlear endolymph and increase
blood viscosity and embolic and/or thrombotic episodes,
resulting in hearing loss.5-7 In particular, DM is known to be
related to microangiopathy and macroangiopathy, so it may
be considered a possible cause of hearing loss.
Systemic steroid therapy tends to be used as the first-line
treatment in ISSNHL, due to its anti-inflammatory effects.
However, the use of steroid in patients with diabetes may be
questionable due to the possibility of steroid-induced hypergly-
cemia, and physicians are usually concerned about the unex-
pected complications associated with steroid use in ISSNHL
with diabetes.
Several studies have suggested that diabetes is associated
with poorer recovery of hearing in ISSNHL, while other
1
Department of Otolaryngology–Head and Neck Surgery, College of
Medicine, Hanyang University, Seoul, Republic of Korea
Corresponding Author:
Jae Ho Chung, MD, PhD, Department of Otolaryngology–Head and Neck
Surgery, School of Medicine, Hanyang University, 222-Wangshimni-ro,
Seongdong-gu, Seoul 133-792, Republic of Korea.
Email: jaeho.chung.md@gmail.com
2 Otolaryngology–Head and Neck Surgery

studies have not detected a significant difference in treat-

ment outcomes.8-10 Thus, the clinical implications of dia-
betes in ISSNHL are unclear. We therefore aimed to
evaluate diabetes itself as a prognostic factor in ISSNHL
and to investigate the clinical implications of DM for the
management of ISSNHL.

Materials and Methods

Patients and Setting
We performed a retrospective medical record review of
ISSNHL patients who received inpatient management in a
tertiary referral center from January 2015 to December 2018,
and we identified 403 consecutive patients. Medical records
were carefully reviewed, including the basic characteristics of
the patients, comorbid diseases, hospitalization period, initial
hearing threshold, treatment method, and hearing recovery.
All patients were treated by a uniform protocol of high-
dose steroid therapy and salvage intratympanic steroid injec-
tions. Oral prednisolone was given at 1 mg/kg/d for 7 days
and then tapered for another 7 days. If hearing did not
improve up to ‘‘partial recovery’’ per the American Academy
of Otolaryngology—Head and Neck Surgery (AAO-HNS)
criteria after 1 week, intratympanic dexamethasone injection
was considered (dexamethasone, 5 mg/mL; a total of 4 injec-
tions for 2 weeks).
Ethical Consideration
Written informed consent was obtained from all patients.
This investigation was approved by the Institutional Review
Board (file 2019-09-028) at the Hanyang University Guri
Hospital and performed in accordance with the Declaration
of Helsinki and good clinical practice guidelines.
Assessment
All patients diagnosed with ISSNHL underwent physical
examination, clinical interview, laboratory tests, audiologic
evaluation, and radiologic tests. Based on the 2012 AAO-
HNS practice guideline, ISSNHL was defined as idiopathic
hearing loss of at least 30 dB over at least 3 test frequencies
over a 72-hour period.1
Pure tone audiometry was performed at initial presenta-
tion and then 3 months posttreatment. Hearing recovery was
classified into 3 groups according to the AAO-HNS criteria,
which consider contralateral hearing as the standard:
Complete recovery: final hearing return to within 10
dB of initial hearing or within 10 dB of the unaf-
fected ear
Partial recovery: final hearing return to within 50%
of initial hearing or improvement in pure tone
thresholds .10 dB
No recovery: \10-dB improvement1
Diagnosis of Diabetes
All patients were asked about their history of diabetes, and
random blood sugar levels were measured and urine analysis
Figure 1. A flowchart for the propensity score matching analysis.
performed to screen for diabetes. Hemoglobin A1c (HbA1c)
was checked when random blood sugar was .200 mg/dL,
and diabetes was diagnosed when HbA1c was 6.5. Insulin
therapy was based on blood sugar level, in consultation with
the endocrinology department.
Propensity Score Matching
To control covariate imbalance between diabetes and non-
diabetes patients, a propensity score was calculated in both
groups by a binary logistical regression analysis with the
parameters of age, sex, and initial hearing level (Figure 1).
Afterward, all subjects in the diabetes and nondiabetes
groups were paired 1:1 with the same or similar propensity
scores via the greedy method, and those not matched were
excluded from statistical analysis. Eventually, 94 patients
with diabetes and the same number of control patients were
analyzed.
Statistical Methods
Statistical analysis was performed with SPSS for Windows
20.0 (IBM Corp, Armonk, New York). The chi-square test
or Fisher’s exact test was used to compare categorical vari-
ables and Student’s t test to compare continuous variables.
A 2-tailed P value \.05 was considered statistically signifi-
cant. Propensity score matching analysis was performed by
a syntax and matching macro program.11
Results
Demographics and Clinical Characteristics
Of 403 patients diagnosed with ISSNHL, 174 were male
(43.2%), and the mean (6 SD) age was 54.6 6 14.2 years.
Of the total patients, 94 (23.3%) had DM; 133 (33.0%),
hypertension; and 18 (4.4%); cardiovascular disease.
ISSNHL was in the right ear in 189 (46.9%) patients.
Associated symptoms included the presence of vertigo
Seo et al 3

Table 1. Demographic and Clinical Characteristics of the Study mean age of the patients with diabetes (60.5 6 10.0 years)
Population (N = 403). was significantly higher than that of the nondiabetics (52.8
ISSNHL, n (%) or 6 14.8 years), and more diabetics had hypertension (62.4%
Variable Mean 6 SD vs 24.3%).
The mean initial hearing threshold of the affected ear
Sex was about 15 dB higher in the patients with diabetes (84.2
Male 174 (43.2) 6 24.7 vs 68.6 6 25.8). The former was also hospitalized
Female 229 (56.8) for longer (7.5 6 5.8 days), and more received additional
Age, y 54.6 6 14.2 intratympanic steroid injection (77.7% vs 65.7%). According
Underlying disease to AAO-HNS criteria, the complete recovery rate of the
Hypertension 133 (33.0) patients with diabetes was 27.7%, lower than that of the
Diabetes mellitus 94 (23.3) patients without diabetes (40.5%). The rates of no recovery
Cardiovascular disease 18 (4.4) were 16.0% and 29.8% in the diabetes group and nondiabetic
Affected side group, respectively. The hearing recovery rates between the
Right 189 (46.9) groups were significantly different (P \ .001; Table 2).
Left 214 (53.1)
Associated symptoms Comparison of Hearing Recovery Outcomes between
Vertigo 110 (27.3) Propensity Score–Matched Diabetes and Control
Tinnitus 248 (61.5) Groups
Ear fullness 163 (40.4) We subsequently matched 94 pairs of cases by propensity
Onset of treatment, d 5.3 6 11.6 score matching to minimize baseline differences between
Initial hearing threshold, dB the groups with and without diabetes. After adjustment for
Affected ear 72.2 6 26.3 age, sex, and initial hearing level, hospitalization was longer
Unaffected ear 24.7 6 21.6 in the diabetic patients, and the rates of hypertension and
Treatment method cardiovascular disease were significantly higher. However,
High dose oral steroid 127 (31.5) there was no significant difference in hearing recovery
Oral steroid 1 ITDX 276 (68.5) between the groups (Table 3). Figures 2 and 3 show pre-
Hearing gain, dB 24.2 6 23.9 and posttreatment scattergrams for the diabetic and control
Hearing recovery (AAO-HNS criteria) groups.
Complete recovery 151 (37.5)
Partial recovery 119 (29.5)
Discussion
No recovery 133 (33.0)
In the present study, we assessed the clinical implications of
Abbreviations: AAO-HNS, American Academy of Otolaryngology—Head diabetes for the management and prognosis of ISSNHL. The
and Neck Surgery; ISSNHL, idiopathic sudden sensorineural hearing loss;
ITDX, intratympanic dexamethasone injection.
core findings of the study can be summarized as follows:
(1) About one-fourth of ISSNHL patients had diabetes, and
70% of them needed insulin therapy during systemic steroid
treatment. (2) Twelve patients were newly diagnosed with
(27.3%), tinnitus (61.5%), and ear fullness (40.4%). The
diabetes during the workup for ISSNHL. (3) The patients
mean period from symptom onset to treatment was 5.3 6
with diabetes had a higher initial hearing threshold, more
11.6 days. All patients were treated with high-dose oral ster-
hypertension, and less frequent hearing recovery than those
oid, and 276 (68.5%) received additional intratympanic ster-
without diabetes. (4) After adjusting age, sex, and initial
oid injection. In response to these treatments, 270 (67.0%)
hearing level by propensity score matching, the hearing out-
patients showed partial to complete improvement (Table 1).
comes of the patients with and without diabetes were not
Characteristics of the Diabetic Patients significantly different.
Most causes of sudden hearing loss are idiopathic, but
Of the 94 diabetic patients, 12 were newly diagnosed by several factors are presumed to be the causes of ISSNHL,
laboratory tests after admission. The mean initial random including microvascular insufficiency and viral infection.12
glucose level was 226.3 6 96.6, and the HbA1c level was In our study, we focused on DM, which is a risk factor for
7.3 6 1.5. Of these 94 patients, 12 (12.8%) had previously microvascular disorders, and we examined the clinical
received insulin, and 70 required insulin for glycemic con- implications of diabetes for ISSNHL patients.
trol during the high-dose steroid therapy (74.5%; Table 2). Several studies have reported that DM increases the pre-
valence of ISSNHL. Lin et al suggested that DM is associ-
Clinical Characteristics of the ISSNHL ated with an increased risk of ISSNHL—especially in
Patients with Diabetes patients treated with triple antidiabetic medication or those
In a univariate analysis, there was no difference in sex ratio with diagnosed comorbidities of retinopathy or coronary
between patients with and without diabetes. However, the heart disease.7 Another study showed that ISSNHL with
4 Otolaryngology–Head and Neck Surgery

Table 2. Clinical Characteristics of the ISSNH Patients with and without Diabetes (N = 403).
ISSNHL, n (%) or Mean 6 SD

Variable With Diabetes (n = 94) Without Diabetes (n = 309) P Valuea

Sex
Male 40 134 .906
Female 54 175
Age, y 60.5 6 10.0 52.8 6 14.8 \.001
Underlying disease
Hypertension 58 (62.4) 75 (24.3) \.001
Cardiovascular disease 8 (8.5) 9 (2.9) .053
Associated symptom
Vertigo 33 (35.1) 77 (24.9) .064
Tinnitus 60 (63.8) 188 (60.8) .630
Ear fullness 44 (46.8) 119 (38.5) .187
Onset of treatment, d 4.3 6 9.6 5.5 6 12.2 .361
Initial hearing threshold, dB
Affected ear 84.2 6 24.7 68.6 6 25.8 \.001
Unaffected ear 28.3 6 20.8 23.6 6 21.7 .062
Treatment method
High dose oral steroid 21 (22.3) 106 (34.3) .031
Oral steroid 1 ITDX 73 (77.7) 203 (65.7)
Duration of admission, d 7.5 6 5.8 5.9 6 1.9 \ .001
Hearing gain, dB 25.5 6 22.3 23.8 6 24.3 .554
Hearing recovery (AAO-HNS criteria) \ .001
Complete recovery 26 (27.7) 125 (40.5)
Partial recovery 42 (44.7) 77 (24.9)
No recovery 26 (27.7) 107 (34.6)
Parameter of diabetes
Random glucose 226.3 6 96.6
HbA1c 7.3 6 1.5
Use of insulin 12 (12.8)
Use of insulin during steroid therapy 70 (74.5)
Newly diagnosed diabetes 12 (12.8)
Abbreviations: AAO-HNS, American Academy of Otolaryngology—Head and Neck Surgery; ISSNHL, idiopathic sudden sensorineural hearing loss; ITDX,
intratympanic dexamethasone injection.
a
Bold indicates P \.05.

diabetes was frequently accompanied by profound hearing
loss.8 Similarly, the present study revealed that diabetic
patients had a significantly higher hearing threshold than
nondiabetic patients (P \ .001).
There have been numerous studies of the prognostic fac-
tors for ISSNHL.13-15 One study reported that hearing out-
comes were poorer in subjects presenting late and in those
with associated diabetes or hypertension.9 Another study
suggested that prognostic factors were age, initial hearing
threshold, speech performance scores before treatment,
descending-type audiogram, and coexistence of tinnitus.16
Recently, metabolic syndromes including diabetes have
been considered to be poor prognostic factors in ISSNHL.17
In particular, one study suggested that the poor prognosis of
sudden deafness in diabetic patients is caused by preexisting
microvascular lesions in the inner ear, and the authors sug-
gested that postprandial glucose level could be a surrogate
indicator of cochlear dysfunction in these patients.8 Others
showed, however, that controlling blood sugar level during
treatment of ISSNHL did not improve hearing recovery and
that even ISSNHL patients with diabetes had better hearing
improvement than a nondiabetic group.18 Likewise, the
prognostic value of diabetes in ISSNHL is still in debate.
In the current study, the complete recovery rate of the
diabetic group (27.7%) was much lower than that of the
nondiabetic group (40.5%). Because the diabetic group was
older than the nondiabetic group, had more comorbidities,
and had a lower initial hearing threshold, we could not con-
clude that DM itself was a prognostic factor for ISSNHL
based on this simple comparison. Therefore, we selected a
control group at random among ISSNHL patients who were
not diagnosed with diabetes, and a patient group and control
group were matched 1:1 by age, sex, and initial hearing
level via propensity scores. After propensity score matching,
Seo et al 5

Table 3. Hearing Recovery in the Propensity Score–Matched Diabetes and Control Groups.a
Matched Group, n (%) or Mean 6 SD

Variable Diabetes (n = 94) Control (n = 94) P Valueb

Sex
Male 40 40
Female 54 54
Age, y 60.5 6 10.0 60.9 6 11.7 .805
Underlying disease
Hypertension 58 (62.4) 37 .001
Cardiovascular disease 8 (8.5)
Associated symptom
Vertigo 33 (35.1) 28 (29.8) .533
Tinnitus 60 (63.8) 49 (52.1) .139
Ear fullness 44 (46.8) 20 (21.3) \.001
Onset of treatment, d 4.3 6 9.6 5.1 6 8.3 .565
Initial hearing threshold, dB
Affected ear 84.2 6 24.7 84.2 6 26.2 .986
Unaffected ear 28.3 6 20.8 31.9 6 26.6 .295
Treatment method
High dose oral steroid 21 (22.3) 20 (21.3) ..99
Oral steroid 1 ITDX 73 (77.7) 74 (78.7)
Duration of admission, d 7.5 6 5.8 6.0 6 1.6 .013
Hearing gain, dB 25.5 6 22.3 21.7 6 24.1 .270
Hearing recovery (AAO-HNS criteria) .125
Complete recovery 26 (27.7) 29 (30.9)
Partial recovery 42 (44.7) 29 (30.9)
No recovery 26 (27.7) 36 (38.3)
Abbreviations: AAO-HNS, American Academy of Otolaryngology—Head and Neck Surgery; ITDX, intratympanic dexamethasone injection.
a
Matching (1:1) was done with propensity scores for age, sex, and initial hearing level.
b
Bold indicates P \.05.

Figure 2. Pretreatment (A) and posttreatment (B) scattergrams for the diabetic group.
6 Otolaryngology–Head and Neck Surgery
Figure 3. Pretreatment (A) and posttreatment (B) scattergrams for the matched control group.
the hearing recovery rates of the diabetic and nondiabetic
groups were not significantly different (P = .125).
Accordingly, in situations where age, sex, and initial hearing
level are the same, diabetes itself is not a poor prognostic
indicator for ISSNHL.
The first-line treatment for ISSNHL is steroid, but steroid
can cause hyperglycemia, which requires close attention
when it is used in diabetic patients. Moreover, it can cause
serious complications, such as avascular necrosis, adrenal
crisis, and diabetic ketoacidosis.19 So, the AAO-HNS prac-
tice guideline recommends intratympanic steroid injection
over oral systemic steroid in patients with poor medical con-
ditions, such as insulin-dependent or poorly controlled dia-
betes, labile hypertension, tuberculosis, and peptic ulcer
disease.1 However, in the present study, ISSNHL patients
with diabetes received systemic steroid therapy and salvage
treatment by intratympanic steroid injection. During sys-
temic steroid therapy, 58 diabetic patients who had been
previously taking oral hypoglycemic agents also received
insulin therapy. In addition, the diabetic patients required
longer hospitalization than the nondiabetic patients, due to
the additional period required for management of hypergly-
cemia. However, as most serious side effects are known to
occur in chronic use, any serious complications were not
identified in diabetic patients during treatment.1 Thus, high-
dose steroid therapy for a short time should not be a major
problem, and high-dose steroid therapy with aggressive gly-
cemic control should be recommended for diabetic ISSNHL
patients.
Another interesting finding of the current study is that
newly diagnosed diabetes was identified in 12 patients with
laboratory tests during workup of ISSNHL. The AAO-HNS
practice guideline does not recommend routine laboratory
testing because of the cost and risk of false-positive results
for etiologic causes.1 But early symptoms of diabetes, such
as thirst, fatigue, frequent urination, and weight change, can
be easily underestimated upon development. Hence, we
should take into consideration the possibility of new-onset
diabetes in the management of ISSNHL when prescribing
high-dose steroid therapy. It is therefore advisable to take
detailed histories and check random glucose levels before
starting high-dose steroid therapy.
The present study has several strengths and limitations.
On the positive side, it included a large number of patients.
However, although consecutive patients received a uniform
protocol for workup and management, the retrospective
nature of the study design may have reduced its power. The
present study used propensity score matching to adjust
major parameters related to prognosis to overcome these
issues, but not dealing with every parameter during the
matching process could be a possible limitation. A prospec-
tive study should provide further insight into the clinical
implications of ISSNHL accompanied by diabetes.
Conclusions
ISSNHL patients with diabetes were predominantly elderly
and tended to have a poor initial hearing threshold.
However, since DM itself did not affect hearing recovery, it
is important to provide the appropriate treatment for
ISSNHL patients with diabetes.
Author Contributions
Hee Won Seo, study design, data analysis, wrote article, revise
article, final approval of article agreement to be accountable for all
aspects of the work in ensuring that questions related to the accu-
racy or integrity of any part of the work are appropriately investi-
gated and resolved; Jae Ho Chung, data collection, study design,
revise article, data analysis, final approval of article, agreement to
Seo et al
be accountable for all aspects of the work in ensuring that ques-
tions related to the accuracy or integrity of any part of the work
are appropriately investigated and resolved; Hayoung Byun, study
design, data analysis, revise article, final approval of article agree-
ment to be accountable for all aspects of the work in ensuring that
questions related to the accuracy or integrity of any part of the
work are appropriately investigated and resolved; Jin-Hyeok Jeong,
study design, data analysis, revise article, final approval of article
agreement to be accountable for all aspects of the work in ensuring
that questions related to the accuracy or integrity of any part of the
work are appropriately investigated and resolved; and Seung Hwan
Lee, study design, data analysis, revise article, final approval of arti-
cle, agreement to be accountable for all aspects of the work in
ensuring that questions related to the accuracy or integrity of any
part of the work are appropriately investigated and resolved.
Disclosures
Competing interests: None.
Sponsorships: None.
Funding source: This research was supported by the Basic Science
Research Program through the National Research Foundation of
Korea funded by the Ministry of Education (NRF-2017R1D1A1B0
3033051)—no role in study.
References
1. Stachler RJ, Chandrasekhar SS, Archer SM, et al. Clinical
practice guideline: sudden hearing loss. Otolaryngol Head Neck
Surg. 2012;146:S1-S35.
2. Rauch SD. Idiopathic sudden sensorineural hearing loss.
N Engl J Med. 2008;359:833-840.
3. Lee HS, Lee YJ, Kang BS, Lee BD, Lee JS. A clinical analy-
sis of sudden sensorineural hearing loss cases. J Audiol Otol.
2014;18:69-75.
4. Aimoni C, Bianchini C, Borin M, et al. Diabetes, cardiovascu-
lar risk factors and idiopathic sudden sensorineural hearing
loss: a case-control study. Audiol Neurootol. 2010;15:111-115.
5. Fukui M, Kitagawa Y, Nakamura N, et al. Idiopathic sudden
hearing loss in patients with type 2 diabetes. Diabetes Res
Clin Pract. 2004;63:205-211.
6. Hirano K, Ikeda K, Kawase T, et al. Prognosis of sudden deaf-
ness with special reference to risk factors of microvascular
pathology. Auris Nasus Larynx. 1999;26:111-115.
7. Lin SW, Lin YS, Weng SF, Chou CW. Risk of developing
sudden sensorineural hearing loss in diabetic patients: a
View publication stats
7
population-based cohort study. Otol Neurotol. 2012;33:1482-
1488.
8. Weng SF, Chen YS, Hsu CJ, Tseng FY. Clinical features of
sudden sensorineural hearing loss in diabetic patients. Laryngoscope.
2005;115:1676-1680.
9. Arjun D, Neha G, Surinder KS, Ravi K. Sudden sensorineural
hearing loss: prognostic factors. Iran J Otorhinolaryngol.
2015;27:355-359.
10. Wilson WR, Laird N, Moo-Young G, Soeldner JS, Kavesh
DA, MacMeel JW. The relationship of idiopathic sudden hear-
ing loss to diabetes mellitus. Laryngoscope. 1982;92:155-160.
11. Painter J. SPSS syntax for nearest neighbor propensity score
matching. http://www.unc.edu/~painter/SPSSsyntax/propen.txt.
Published 2004. Accessed May 15, 2012.
12. Ryu IY, Park SH, Park EB, Kim HJ, Kim SH, Yeo SG.
Factors prognostic of season-associated sudden sensorineural
hearing loss: a retrospective observational study. J Audiol Otol.
2017;21:44-48.
13. Chung JH, Lee SH, Park CW, Kim C, Park JK, Shin JH.
Clinical significance of arterial stiffness in idiopathic sudden
sensorineural hearing loss. Laryngoscope. 2016;126:1918-1922.
14. Byun H, Chung JH, Lee SH, Park CW, Park DW, Kim TY.
The clinical value of 4-hour delayed-enhanced 3D-FLAIR
MR images in sudden hearing loss. Clin Otolaryngol. 2019;44:
336-342.
15. Chung JH, Cho SH, Jeong JH, Park CW, Lee SH. Multivariate
analysis of prognostic factors for idiopathic sudden sensori-
neural hearing loss in children. Laryngoscope. 2015;125:2209-
2215.
16. Kim JY, Han JJ, Sunwoo WS, et al. Sudden sensorineural
hearing loss in children and adolescents: clinical characteristics
and age-related prognosis. Auris Nasus Larynx. 2018;45:447-
455.
17. Jung SY, Shim HS, Hah YM, Kim SH, Yeo SG. Association
of metabolic syndrome with sudden sensorineural hearing loss.
JAMA Otolaryngol Head Neck Surg. 2018;144:308-314.
18. Min SK, Shin JH, Chang MY, et al. Impact of control of blood
glucose level during treatment of sudden deafness in diabetics:
relationship with prognosis. Eur Arch Otorhinolaryngol. 2017;
274:1339-1343.
19. Ericson-Neilsen W, Kaye AD. Steroids: pharmacology, com-
plications, and practice delivery issues. Ochsner J. 2014;14:
203-207.