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Drug-Induced Ototoxicity


Mickie Hamiter

, MD, New York Presbyterian Columbia

Reviewed/Revised May 2023

A wide variety of drugs can be ototoxic. Medication-related factors affecting ototoxicity include

  • Dose

  • Duration of therapy

  • Concurrent renal failure

  • Infusion rate

  • Lifetime dose

  • Coadministration with other medications that have ototoxic potential

  • Genetic susceptibility

Ototoxic medications should not be used for otic topical application when the tympanic membrane is perforated because the medications might diffuse into the inner ear.

Aminoglycosides, including the following, can affect hearing:

  • Streptomycin tends to cause more damage to the vestibular portion than to the auditory portion of the inner ear. Although vertigo and difficulty maintaining balance tend to be temporary, severe loss of vestibular sensitivity may persist, sometimes permanently. Loss of vestibular sensitivity causes difficulty walking, especially in the dark, and oscillopsia (a sensation that the environment is bouncing with each step). About 4 to 15% of patients who receive 1 g/day for > 1 week develop measurable hearing loss, which usually occurs after a short latent period (7 to 10 days) and slowly worsens if treatment is continued. Complete, permanent deafness may follow.

  • Neomycin has the greatest cochleotoxic effect of all antibiotics. When large doses are given orally or by colonic irrigation for intestinal sterilization, enough may be absorbed to affect hearing, particularly if diffuse mucosal lesions of the colon are present. Neomycin should not be used for wound irrigation or for intrapleural or intraperitoneal irrigation because massive amounts of the medication may be retained and absorbed, causing deafness.

  • Kanamycin and amikacin are close to neomycin in cochleotoxic potential and are both capable of causing profound, permanent hearing loss while sparing balance.

  • Gentamicin and tobramycin have vestibular and cochlear toxicity, causing impairment in balance and hearing.

  • Vancomycin can cause hearing loss, especially in patients with renal insufficiency.

Some mitochondrial DNA mutations predispose to aminoglycoside ototoxicity.

Azithromycin, a macrolide, causes reversible or irreversible hearing loss in rare cases.

Viomycin, a basic peptide with antituberculous properties, has cochlear and vestibular toxicity.

Chemotherapeutic (antineoplastic) medications, particularly those containing platinum (cisplatin and carboplatin), can cause tinnitus and hearing loss. Hearing loss can be profound and permanent, occurring immediately after the first dose, or it can be delayed until several months after completion of treatment. Sensorineural hearing loss occurs bilaterally, progresses decrementally, and is permanent.

Ethacrynic acid and furosemide given IV have caused profound, permanent hearing loss in patients with renal failure who had been receiving aminoglycoside antibiotics.

Salicylates in high doses (> 12 325-mg tablets of aspirin a day) cause temporary hearing loss and tinnitus.

Quinine and its synthetic substitutes can cause temporary hearing loss.

Prevention of Drug-Induced Ototoxicity

Ototoxic antibiotics should be avoided during pregnancy because they can damage the fetal labyrinth. Older adults and people with preexisting hearing loss should not be treated with ototoxic medications if other effective medications are available. The lowest effective dosage of ototoxic medications should be used and levels should be closely monitored, particularly for aminoglycosides (both peak and trough levels).

If possible before treatment with an ototoxic medication, hearing should be measured and then monitored during treatment; symptoms are not reliable warning signs.

Risk of ototoxicity increases with the use of multiple medications that have ototoxic potential and the use of ototoxic medications excreted through the kidneys in patients with renal compromise; in these cases, closer monitoring of medication levels is advised. In patients known to have mitochondrial DNA mutations Mitochondrial DNA Abnormalities Each cell has 1000 to 2500 mitochondria in its cytoplasm. Mitochondria contain DNA in a single circular chromosome containing 37 genes that code for 13 proteins, various RNAs, and several regulating... read more that predispose to aminoglycoside toxicity, aminoglycosides should be avoided.

Key Points

  • Drugs may cause hearing loss, dysequilibrium, and/or tinnitus.

  • Common ototoxic medications include aminoglycosides, platinum-containing chemotherapy medications, and high-dose salicylates.

  • Symptoms may be transient or permanent.

  • Use the lowest possible dose of ototoxic medications and closely monitor levels of the medication (particularly aminoglycosides); measure medication levels during treatment to help prevent hearing loss caused by ototoxic medications.

  • Medications that cause or risk ototoxicity are stopped if possible, but there is no specific treatment.

Drugs Mentioned In This Article

Drug Name Select Trade
No brand name available
Amikin, Amikin Pediatric, ARIKAYCE
Garamycin, Genoptic, Genoptic SOP, Gentacidin, Gentafair, Gentak , Gentasol, Ocu-Mycin
AK-Tob, BETHKIS, Kitabis Pak, Nebcin, Tobi, TOBI Podhaler, Tobrasol , Tobrex
FIRVANQ, Vancocin, Vancocin Powder, VANCOSOL
Azasite, Zithromax, Zithromax Powder, Zithromax Single-Dose , Zithromax Tri-Pak, Zithromax Z-Pak, Zmax, Zmax Pediatric
Platinol, Platinol -AQ
Delone , FUROSCIX, Lasix
Anacin Adult Low Strength, Aspergum, Aspir-Low, Aspirtab , Aspir-Trin , Bayer Advanced Aspirin, Bayer Aspirin, Bayer Aspirin Extra Strength, Bayer Aspirin Plus, Bayer Aspirin Regimen, Bayer Children's Aspirin, Bayer Extra Strength, Bayer Extra Strength Plus, Bayer Genuine Aspirin, Bayer Low Dose Aspirin Regimen, Bayer Womens Aspirin , BeneHealth Aspirin, Bufferin, Bufferin Extra Strength, Bufferin Low Dose, DURLAZA, Easprin , Ecotrin, Ecotrin Low Strength, Genacote, Halfprin, MiniPrin, St. Joseph Adult Low Strength, St. Joseph Aspirin, VAZALORE, Zero Order Release Aspirin, ZORprin
NOTE: This is the Professional Version. CONSUMERS: View Consumer Version
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