A wide variety of medications can be ototoxic. Medication-related factors affecting ototoxicity include the following:
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:
StreptomycinStreptomycin causes more damage to the vestibular portion than to the auditory portion of the inner ear. Although vertigo and difficulty maintaining balance are usually 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). Some 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 (1). Complete, permanent deafness may follow.
NeomycinNeomycin 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. 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 amikacinKanamycin and amikacin are close to neomycin in cochleotoxic potential and are both capable of causing profound, permanent hearing loss while sparing balance. are close to neomycin in cochleotoxic potential and are both capable of causing profound, permanent hearing loss while sparing balance.
Gentamicin and tobramycinGentamicin and tobramycin cause primarily vestibular and cochlear toxicity, respectively, causing impairment in balance and hearing.
VancomycinVancomycin can cause hearing loss, especially in patients with renal insufficiency.
Some mitochondrial DNA mutations (eg, variants in the mitochondrial 12S rRNA gene [MT-RNR1]) predispose to aminoglycoside ototoxicity (2).
AzithromycinAzithromycin, 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.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 furosemideEthacrynic 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 (eg, approximately 2 grams of aspirin daily) induce typically reversible loss and tinnitus (in high doses (eg, approximately 2 grams of aspirin daily) induce typically reversible loss and tinnitus (3, 4).
QuinineQuinine and its synthetic substitutes can cause temporary hearing loss.
(See also Hearing Loss.)
References
1. Selimoglu E. Aminoglycoside-induced ototoxicity. Curr Pharm Des. 2007;13(1):119-126. doi:10.2174/138161207779313731
2. Gaafar D, Baxter N, Cranswick N, Christodoulou J, Gwee A. Pharmacogenetics of aminoglycoside-related ototoxicity: a systematic review. J Antimicrob Chemother. 2024;79(7):1508-1528. doi:10.1093/jac/dkae106
3. Kyle ME, Wang JC, Shin JJ. Ubiquitous aspirin: a systematic review of its impact on sensorineural hearing loss. . Ubiquitous aspirin: a systematic review of its impact on sensorineural hearing loss.Otolaryngol Head Neck Surg. 2015;152(1):23-41. doi:10.1177/0194599814553930
4. Sheppard A, Hayes SH, Chen GD, Ralli M, Salvi R. Review of salicylate-induced hearing loss, neurotoxicity, tinnitus and neuropathophysiology. Acta Otorhinolaryngol Ital. 2014;34(2):79-93.
Prevention of Drug-Induced Ototoxicity
Ototoxic antibiotics should be avoided during pregnancy because they can damage the developing 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 assessed and then monitored during treatment; symptoms are not reliable warning signs.
The risk of ototoxicity increases with the use of multiple medications that have ototoxic potential, especially in patients with renal impairment who are taking ototoxic medications that are excreted through the kidneys; in these cases, closer monitoring of medication levels is advised. In patients known to have mitochondrial DNA mutations that predispose to aminoglycoside toxicity, aminoglycosides should be avoided.
Key Points
Ototoxic medications may be vestibulotoxic and/or cochleotoxic; they 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 increase the risk of ototoxicity are stopped if possible, but there is no specific treatment once ototoxicity occurs.
Drugs Mentioned In This Article
