Sordera súbita idiopática. Revisión de 58 casos
Resumen Introduccion y Objetivo: La sordera súbita (SS) se define como la hipoacusia neurosensorial de inicio brusco, en menos de 72 horas, con pérdida de 30 o más decibelios (dB) en tres frecuencias consecutivas en la audiometría tonal. En el 90% de los casos no es posible determinar su etiología dando lugar a lo que se conoce como sordera súbita idiopática (SSI). El objetivo de este estudio es describir las características de los pacientes con SSI diagnosticados en los últimos 20 años, identificar factores pronósticos y mostrar los resultados en función del tratamiento. Método: Estudio descriptivo retrospectivo de 58 pacientes diagnosticados de SSI entre 1995-2016. Se determinaron el nivel de pérdida auditiva y el grado de recuperación posterior. Se estudiaron los factores de riesgo cardiovascular, asociación con otros síntomas, inicio del tratamiento, severidad de la hipoacusia y morfología de la curva auditiva. Resultados: No se encontró relación entre la recuperación auditiva y los diferentes factores de riesgo cardiovascular. Presentaron una mejoría completa un 24,1%, parcial un 17,2% y leve el 17,2%. El 41,5% no obtuvo ninguna mejoría con un peor pronóstico auditivo en los sujetos con hipoacusia profunda. Se obtuvo un 100% de recuperaciones completas en los sujetos con morfología inclinación ascendente. El síntoma asociado más frecuente fue el acúfeno. Los síntomas vestibulares al inicio del cuadro, determinaron un peor pronóstico auditivo. El tiempo de inicio desde la aparición de la hipoacusia hasta la instauración del tratamiento intravenoso no se ha relacionado con una mejor evolución. El porcentaje “sin mejoría” es del 54% (DIT y tratamiento sistémico) frente al 75% en los tratados exclusivamente con tratamiento intravenoso, pero esta mejoría no tiene significación estadística. Conclusiones: La afectación vestibular, severidad de la hipoacusia y la morfología de la curva auditiva son determinantes como factor pronóstico. Aunque hay mejores resultados utilizando la DIT como tratamiento de rescate, nuestra experiencia no determino un beneficio evidente de su uso en sujetos con SSI.
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Ballesteros F, Alobid I, Tassies D, Reverter JC, Scharf R E, Guilemany JM, et al. Is there an overlap between sudden neurosensorial hearing loss and cardiovascular risk factors? Audiol Neurotol. 2009; 14(3): 139-145. https://doi.org/10.1159/000171475. PMid:19005247
Battaglia A, Burchette R, Cueva R. Combination Therapy (Intratympanic Dexamethasone + High-Dose Prednisone Taper) for the Treatment of Idiopathic Sudden sensorineural Hearing Loss. Otol Neurotol. 2008; 29:453- 60. https://doi.org/10.1097/MAO.0b013e318168da7a. PMid:18401285
Bennett M, Kertesz T, Yeung P. Hyperbaric oxygen therapy for idiopathic sudden sensorineural hearing loss and tinnitus: a systematic review of randomized controlled trials. J Laryngol Otol. 2005; 119:791-8. https://doi.org/10.1258/002221505774481246. PMid:16259656
Bird PA, Begg EJ, Zhang M, Keast AT, Murray DP, Balkany TJ. Intratympanic versus intravenous delivery of methylprednisoloneto cochlear perilymph. Otol Neurotol. 2007; 28:1124-30. https://doi.org/10.1097/MAO.0b013e31815aee21. PMid:18043438
Byl FM. Sudden hearing loss: eight years experience and suggested prognostic table. Laryngoscope. 1984; 94: 647-61. https://doi.org/10.1288/00005537-198405000-00014. PMid:6325838
Cadoni G, Agostino S, Scipione S, Ippolito S, Caselli A, Marchese R, Et al. Sudden sensorineural hearing loss: Our experience in diagnosis, treatment, and outcome. J Otolaryngol. 2005; 34, 395-401. https://doi.org/10.2310/7070.2005.34606. PMid:16343399
Capaccio P, Cuccarini V, Ottaviani F, et al. Prothrombotic gene mutations in patients with sudden sensorineural hearing loss and cardiovascular thrombotic disease. Ann Oto Rhino Laryngol. 2009; 118:205-10. https://doi.org/10.1177/000348940911800308. PMid:19374152
Capaccio P, Ottaviani F, Cuccarini V, Bottero A, Schindler A, Cesana B, et al. Genetic and acquired prothrombotic risk factors and sudden hearing loss. Laryngoscope. 2007; 117: 547-551. https://doi.org/10.1097/MLG.0b013e31802f3c6a. PMid:17334320
Ceylan A, Celenk F, Kemaloglu YK, Bayazit YA, Goksu N, OzbilenS. Impact of prognostic factors on recovery from sudden hearing loss. J Laryngol Otol. 2007;121:1035-40. https://doi.org/10.1017/S0022215107005683. PMid:17241495
Chang NC, Kuen-Yao Ho MD, Kuo WR. Audiometric patterns prognosis in sudden sensorineural hearing loss in Southern Taiwan. Otolaryngol Head Neck Surg. 2005;133:916-22. https://doi.org/10.1016/j.otohns.2005.09.018. PMid:16360514
Chau JK, Lin JR, Atashband S, Irvine RA, Westerberg BD. Systematic review of the evidence for the etiology of adult sudden sensorineural hearing loss. Laryngoscope. 2010; 120: 1011-21. https://doi.org/10.1002/lary.20873. PMid:20422698
Cvorovic L, Deric D, Probst R, Hegemann S. Prognostic model for predicting hearing recovery in idiopathic sudden sensorineural hearing loss. Otol Neurotol. 2008; 29:464- 9. https://doi.org/10.1097/MAO.0b013e31816fdcb4. PMid:18434930
Fujimoto C, Egami N, Kinoshita M, Sugasawa K, Yamasoba T, Iwasaki S. Involvement of vestibular organs in idiopathic sudden hearing loss with vertigo: an analysis using oVEMP and cVEMP testing. Clin Neurophysiol.2015; 126(5):1033-8. https://doi.org/10.1016/j.clinph.2014.07.028. PMid:25200460
Furuhashi A, Mastuda K, Asahi K, Nakashima T. Sudden deafness: long-term follow-up and recurrence. Clin Otolaryngol. 2002; 27:458-63. https://doi.org/10.1046/j.1365-2273.2002.00612.x. PMid:12472512
Guyot JP, Thielen K. Evolution of sudden deafness without treatment. Schweiz Med Wochenschr. 2000; 116: 93-96. https://doi.org/10.1159/isbn.978-3-318-00592-9
Ho Guan-Min, MD, PhD; Lin Hung-Ching, MD; Shu Min-Tsan, MD; Yang Cheng-Chien, MD; Tsai Hsun-Tien, MD, PhD. Effectiveness of Intratympanic Dexamethasone Injection in Sudden- Deafness Patients as Salvage Treatment. Laryngoscope. 2004; 114:1184-89. https://doi.org/10.1097/00005537-200407000-00010. PMid:15235345
Huy PT, Sauvaget E. Idiopathic sudden sensorineural hearing loss is not an otologic emergency. Otol Neurotol. 2005; 26: 896-902. https://doi.org/10.1097/01.mao.0000185071.35328.6d
Joong HA, Myung HY, Tae HY, Jong WC. Can Intratympanic Dexamethasone Added to Systemic Steroids Improve Hearing Outcome in Patients With Sudden Deafness? Laryngoscope. 2008; 118:279-82. https://doi.org/10.1097/MLG.0b013e3181585428. PMid:17989574
Kosyakov S, Atanesyan A, Gunenkov A, Ashkhatunyan E, Kurlova A. Intratympanic steroids for sudden sensorineura lhearing loss. Int Adv Otol. 2011; 7:323-32.
Lin HC, Chao PZ, Lee HC. Sudden sensorineural hearing los increases the risk of stroke: a 5-year follow-up study. Stroke. 2008; 39:2744-8. https://doi.org/10.1161/STROKEAHA.108.519090. PMid:18583554
Mamak A, Yilmaz S, Cansiz H, Inci E, Güçlü E, Dereköylü L. A study of prognostic factors in sudden hearing loss. Ear Nose Throat J. 2005; 84: 641-44.
Marcucci R, AlessandrelloLiotta A, Cellai AP, Rogolino A, Berloco P, Leprini E, et al. Cardiovascular and thrombophilic risk factors for idiopathic sudden sensorineural hearing loss. J Thromb Haemost. 2005; 3:929-34. https://doi.org/10.1111/j.1538-7836.2005.01310.x. PMid:15869586
Marx M, Younes E, Chandrasekhar SS, Ito J, Plontke S, O’Leary S, Et al. International consensus (ICON) on treatment of sudden sensorineural hearing loss. Eur Ann Otorhinolaryngol Head Neck Dis. 2018; 135(1S):S23-S28. https://doi.org/10.1016/j.anorl.2017.12.011. PMid:29396226
Mattox DE, Simmons FB. Natural history of sudden sensorineural hearing loss. Ann Otol Rhinol Laryngol. 1977;86:463-80. https://doi.org/10.1177/000348947708600406. PMid:889223
Narozny W, Kuczkowski J, Kot J, Stankiewicz C, Sicko Z,Mikaszewski B. Prognostic factor in sudden sensorineural hearing loss: our experience and a review of the literature. Ann Otol Rhinol Laryngol. 2006;115:553-8. https://doi.org/10.1177/000348940611500710. PMid:16900810
Nosrati-Zarenoe R, Arlinger S, Hultcrantz E. Idiopathic sudden sensorineural hearing loss: results drawn from the Swedish national database. Acta Otolaryngol. 2007;127:1168-75. https://doi.org/10.1080/00016480701242477. PMid:17851927
Rauch SD. Clinica lpractice. Idiopathic sudden sensorineural hearing loss. N Engl J Med. 2008; 359:833-40. https://doi.org/10.1056/NEJMcp0802129. PMid:18716300
Sakata T, Kato T. Feeling of ear fullness in acute sensorineural hearing loss. Acta Otolaryngol. 2006; 126: 828-33. https://doi.org/10.1080/00016480500527268. PMid:16846925
Samim E, Kilic R, Ozdek A, Gocman H, Eryilmaz A, UnluI. Combined treatment of sudden sensorineural hearing loss with steroid, dextran and piracetam: experience with 68 cases. Eur Arch Otorhinolaryngol. 2004; 261:187-90. https://doi.org/10.1007/s00405-003-0659-y. PMid:12937918
Schreiber BE, Agrup C, Haskard DO, Luxon LM. Sudden sensorineural hearing loss. Lancet. 2010; 375:1203-11. https://doi.org/10.1016/S0140-6736(09)62071-7
Shaia FT, Sheehy JL. Sudden sensorineural hearing impairment. A report of 1220 cases. Laryngoscope. 1976; 86: 389-98. https://doi.org/10.1288/00005537-197603000-00008. PMid:1256213
Siegel LG. The treatment of idiopathic sudden sensorineural hearing loss. Otolaryngol Clin North Am.1975; 8:467-73.
Stachler RJ, Chandrasekhar SS, Archer SM, Rosenfeld RM, Schwartz SR, Barrs DM, et al. Clinical practice guideline: sudden hearing loss. Otolaryngol Head Neck Surg. 2012. 146(3 Suppl):S1-S35. https://doi.org/10.1177/0194599812436449. PMid:22383545
Stokroos RJ, Albers FW, Tenvergert EM. Antiviral treatment of idiopathic sudden sensorineural hearing loss: a prospective, randomized, double-blind clinical trial. Acta Otolaryngol.1998; 118:488-95. https://doi.org/10.1080/00016489850154603. PMid:9726671
Teranishi M, Katayama N, Uchida Y, Tominaga M, Nakashima T. Thirty-year trends in sudden deafness from four nationwide epidemiological surveys in Japan. Acta Otolaryngol.2007;127: 1259-65. https://doi.org/10.1080/00016480701242410. PMid:17851966
Tucci DL, Farmer Jr JC, Kitch RD, Witsell DL. Treatment of sudden sensorineural hearing loss with systemic steroids and valacyclovir. Otol Neurotol. 2002; 23:301-8. https://doi.org/10.1097/00129492-200205000-00012. PMid:11981385
Weber PC, Zbar RI, Gantz BJ. Appropriateness of magnetic resonance imaging in sudden sensorineural hearing loss. Otolaryngol Head Neck Surg. 1997,116:153-6. https://doi.org/10.1016/S0194-5998(97)70317-6
Wei B, Mubiru S, O’Leary S. Steroids for idiopathic sudden sensorineural hearing loss. Cochrane Database of Systematic Reviews 2006, Issue 1. Art. No: CD003998. DOI: 10.1002/14651858.CD003998.pub2. https://doi.org/10.1002/14651858.CD003998.pub2
Wilson W, Byl F, Laird N. The efficacy of steroids in the treatment of idio-pathic sudden hearing loss a double-blind clinical study. Arch Otolaryngol.1980; 106:772-6. https://doi.org/10.1001/archotol.1980.00790360050013. PMid:7002129
Xenellis J, Karapatsas I, Papadimitriou N, Nikolopoulos T,Maragoudakis P, Tzagkaroulakis M, et al. Idiopathic sudden sen-sorineural hearing loss: prognostic factors. J Laringol otol. 2006;120:718-24. https://doi.org/10.1017/S0022215106002362. PMid:16854244
Zadeh MH, Storper IS, Spitzer JB. Diagnosis and treatment of sudden-onset sensorineural hearing loss: A study of 51 patients. Otolaryngol Head Neck Surg. 2003; 128: 92-98. https://doi.org/10.1067/mhn.2003.50. PMid:12574765
Battaglia A, Burchette R, Cueva R. Combination Therapy (Intratympanic Dexamethasone + High-Dose Prednisone Taper) for the Treatment of Idiopathic Sudden sensorineural Hearing Loss. Otol Neurotol. 2008; 29:453- 60. https://doi.org/10.1097/MAO.0b013e318168da7a. PMid:18401285
Bennett M, Kertesz T, Yeung P. Hyperbaric oxygen therapy for idiopathic sudden sensorineural hearing loss and tinnitus: a systematic review of randomized controlled trials. J Laryngol Otol. 2005; 119:791-8. https://doi.org/10.1258/002221505774481246. PMid:16259656
Bird PA, Begg EJ, Zhang M, Keast AT, Murray DP, Balkany TJ. Intratympanic versus intravenous delivery of methylprednisoloneto cochlear perilymph. Otol Neurotol. 2007; 28:1124-30. https://doi.org/10.1097/MAO.0b013e31815aee21. PMid:18043438
Byl FM. Sudden hearing loss: eight years experience and suggested prognostic table. Laryngoscope. 1984; 94: 647-61. https://doi.org/10.1288/00005537-198405000-00014. PMid:6325838
Cadoni G, Agostino S, Scipione S, Ippolito S, Caselli A, Marchese R, Et al. Sudden sensorineural hearing loss: Our experience in diagnosis, treatment, and outcome. J Otolaryngol. 2005; 34, 395-401. https://doi.org/10.2310/7070.2005.34606. PMid:16343399
Capaccio P, Cuccarini V, Ottaviani F, et al. Prothrombotic gene mutations in patients with sudden sensorineural hearing loss and cardiovascular thrombotic disease. Ann Oto Rhino Laryngol. 2009; 118:205-10. https://doi.org/10.1177/000348940911800308. PMid:19374152
Capaccio P, Ottaviani F, Cuccarini V, Bottero A, Schindler A, Cesana B, et al. Genetic and acquired prothrombotic risk factors and sudden hearing loss. Laryngoscope. 2007; 117: 547-551. https://doi.org/10.1097/MLG.0b013e31802f3c6a. PMid:17334320
Ceylan A, Celenk F, Kemaloglu YK, Bayazit YA, Goksu N, OzbilenS. Impact of prognostic factors on recovery from sudden hearing loss. J Laryngol Otol. 2007;121:1035-40. https://doi.org/10.1017/S0022215107005683. PMid:17241495
Chang NC, Kuen-Yao Ho MD, Kuo WR. Audiometric patterns prognosis in sudden sensorineural hearing loss in Southern Taiwan. Otolaryngol Head Neck Surg. 2005;133:916-22. https://doi.org/10.1016/j.otohns.2005.09.018. PMid:16360514
Chau JK, Lin JR, Atashband S, Irvine RA, Westerberg BD. Systematic review of the evidence for the etiology of adult sudden sensorineural hearing loss. Laryngoscope. 2010; 120: 1011-21. https://doi.org/10.1002/lary.20873. PMid:20422698
Cvorovic L, Deric D, Probst R, Hegemann S. Prognostic model for predicting hearing recovery in idiopathic sudden sensorineural hearing loss. Otol Neurotol. 2008; 29:464- 9. https://doi.org/10.1097/MAO.0b013e31816fdcb4. PMid:18434930
Fujimoto C, Egami N, Kinoshita M, Sugasawa K, Yamasoba T, Iwasaki S. Involvement of vestibular organs in idiopathic sudden hearing loss with vertigo: an analysis using oVEMP and cVEMP testing. Clin Neurophysiol.2015; 126(5):1033-8. https://doi.org/10.1016/j.clinph.2014.07.028. PMid:25200460
Furuhashi A, Mastuda K, Asahi K, Nakashima T. Sudden deafness: long-term follow-up and recurrence. Clin Otolaryngol. 2002; 27:458-63. https://doi.org/10.1046/j.1365-2273.2002.00612.x. PMid:12472512
Guyot JP, Thielen K. Evolution of sudden deafness without treatment. Schweiz Med Wochenschr. 2000; 116: 93-96. https://doi.org/10.1159/isbn.978-3-318-00592-9
Ho Guan-Min, MD, PhD; Lin Hung-Ching, MD; Shu Min-Tsan, MD; Yang Cheng-Chien, MD; Tsai Hsun-Tien, MD, PhD. Effectiveness of Intratympanic Dexamethasone Injection in Sudden- Deafness Patients as Salvage Treatment. Laryngoscope. 2004; 114:1184-89. https://doi.org/10.1097/00005537-200407000-00010. PMid:15235345
Huy PT, Sauvaget E. Idiopathic sudden sensorineural hearing loss is not an otologic emergency. Otol Neurotol. 2005; 26: 896-902. https://doi.org/10.1097/01.mao.0000185071.35328.6d
Joong HA, Myung HY, Tae HY, Jong WC. Can Intratympanic Dexamethasone Added to Systemic Steroids Improve Hearing Outcome in Patients With Sudden Deafness? Laryngoscope. 2008; 118:279-82. https://doi.org/10.1097/MLG.0b013e3181585428. PMid:17989574
Kosyakov S, Atanesyan A, Gunenkov A, Ashkhatunyan E, Kurlova A. Intratympanic steroids for sudden sensorineura lhearing loss. Int Adv Otol. 2011; 7:323-32.
Lin HC, Chao PZ, Lee HC. Sudden sensorineural hearing los increases the risk of stroke: a 5-year follow-up study. Stroke. 2008; 39:2744-8. https://doi.org/10.1161/STROKEAHA.108.519090. PMid:18583554
Mamak A, Yilmaz S, Cansiz H, Inci E, Güçlü E, Dereköylü L. A study of prognostic factors in sudden hearing loss. Ear Nose Throat J. 2005; 84: 641-44.
Marcucci R, AlessandrelloLiotta A, Cellai AP, Rogolino A, Berloco P, Leprini E, et al. Cardiovascular and thrombophilic risk factors for idiopathic sudden sensorineural hearing loss. J Thromb Haemost. 2005; 3:929-34. https://doi.org/10.1111/j.1538-7836.2005.01310.x. PMid:15869586
Marx M, Younes E, Chandrasekhar SS, Ito J, Plontke S, O’Leary S, Et al. International consensus (ICON) on treatment of sudden sensorineural hearing loss. Eur Ann Otorhinolaryngol Head Neck Dis. 2018; 135(1S):S23-S28. https://doi.org/10.1016/j.anorl.2017.12.011. PMid:29396226
Mattox DE, Simmons FB. Natural history of sudden sensorineural hearing loss. Ann Otol Rhinol Laryngol. 1977;86:463-80. https://doi.org/10.1177/000348947708600406. PMid:889223
Narozny W, Kuczkowski J, Kot J, Stankiewicz C, Sicko Z,Mikaszewski B. Prognostic factor in sudden sensorineural hearing loss: our experience and a review of the literature. Ann Otol Rhinol Laryngol. 2006;115:553-8. https://doi.org/10.1177/000348940611500710. PMid:16900810
Nosrati-Zarenoe R, Arlinger S, Hultcrantz E. Idiopathic sudden sensorineural hearing loss: results drawn from the Swedish national database. Acta Otolaryngol. 2007;127:1168-75. https://doi.org/10.1080/00016480701242477. PMid:17851927
Rauch SD. Clinica lpractice. Idiopathic sudden sensorineural hearing loss. N Engl J Med. 2008; 359:833-40. https://doi.org/10.1056/NEJMcp0802129. PMid:18716300
Sakata T, Kato T. Feeling of ear fullness in acute sensorineural hearing loss. Acta Otolaryngol. 2006; 126: 828-33. https://doi.org/10.1080/00016480500527268. PMid:16846925
Samim E, Kilic R, Ozdek A, Gocman H, Eryilmaz A, UnluI. Combined treatment of sudden sensorineural hearing loss with steroid, dextran and piracetam: experience with 68 cases. Eur Arch Otorhinolaryngol. 2004; 261:187-90. https://doi.org/10.1007/s00405-003-0659-y. PMid:12937918
Schreiber BE, Agrup C, Haskard DO, Luxon LM. Sudden sensorineural hearing loss. Lancet. 2010; 375:1203-11. https://doi.org/10.1016/S0140-6736(09)62071-7
Shaia FT, Sheehy JL. Sudden sensorineural hearing impairment. A report of 1220 cases. Laryngoscope. 1976; 86: 389-98. https://doi.org/10.1288/00005537-197603000-00008. PMid:1256213
Siegel LG. The treatment of idiopathic sudden sensorineural hearing loss. Otolaryngol Clin North Am.1975; 8:467-73.
Stachler RJ, Chandrasekhar SS, Archer SM, Rosenfeld RM, Schwartz SR, Barrs DM, et al. Clinical practice guideline: sudden hearing loss. Otolaryngol Head Neck Surg. 2012. 146(3 Suppl):S1-S35. https://doi.org/10.1177/0194599812436449. PMid:22383545
Stokroos RJ, Albers FW, Tenvergert EM. Antiviral treatment of idiopathic sudden sensorineural hearing loss: a prospective, randomized, double-blind clinical trial. Acta Otolaryngol.1998; 118:488-95. https://doi.org/10.1080/00016489850154603. PMid:9726671
Teranishi M, Katayama N, Uchida Y, Tominaga M, Nakashima T. Thirty-year trends in sudden deafness from four nationwide epidemiological surveys in Japan. Acta Otolaryngol.2007;127: 1259-65. https://doi.org/10.1080/00016480701242410. PMid:17851966
Tucci DL, Farmer Jr JC, Kitch RD, Witsell DL. Treatment of sudden sensorineural hearing loss with systemic steroids and valacyclovir. Otol Neurotol. 2002; 23:301-8. https://doi.org/10.1097/00129492-200205000-00012. PMid:11981385
Weber PC, Zbar RI, Gantz BJ. Appropriateness of magnetic resonance imaging in sudden sensorineural hearing loss. Otolaryngol Head Neck Surg. 1997,116:153-6. https://doi.org/10.1016/S0194-5998(97)70317-6
Wei B, Mubiru S, O’Leary S. Steroids for idiopathic sudden sensorineural hearing loss. Cochrane Database of Systematic Reviews 2006, Issue 1. Art. No: CD003998. DOI: 10.1002/14651858.CD003998.pub2. https://doi.org/10.1002/14651858.CD003998.pub2
Wilson W, Byl F, Laird N. The efficacy of steroids in the treatment of idio-pathic sudden hearing loss a double-blind clinical study. Arch Otolaryngol.1980; 106:772-6. https://doi.org/10.1001/archotol.1980.00790360050013. PMid:7002129
Xenellis J, Karapatsas I, Papadimitriou N, Nikolopoulos T,Maragoudakis P, Tzagkaroulakis M, et al. Idiopathic sudden sen-sorineural hearing loss: prognostic factors. J Laringol otol. 2006;120:718-24. https://doi.org/10.1017/S0022215106002362. PMid:16854244
Zadeh MH, Storper IS, Spitzer JB. Diagnosis and treatment of sudden-onset sensorineural hearing loss: A study of 51 patients. Otolaryngol Head Neck Surg. 2003; 128: 92-98. https://doi.org/10.1067/mhn.2003.50. PMid:12574765
Delgado-Gil, J. E., Krstulovic, C., Pérez-Guillén, V., García-Zamora, E., & Pérez-Garrigues, H. (2019). Sordera súbita idiopática. Revisión de 58 casos. Revista ORL, 10(4), 235–243. https://doi.org/10.14201/orl.20151
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