eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Inner Ear

Inner Ear, Sudden Hearing Loss: Treatment & Medication

Author: Neeraj N Mathur, MBBS, MS, Professor, Department of Ear, Nose and Throat, Lady Hardinge Medical College and Associated Smt SK and Kalawati, Saran Children's Hospital, University of Delhi, India; Professor, Department of Ear, Nose and Throat, BP Koirala Institute of Health Sciences, Nepal
Coauthor(s): Michele M Carr, DDS, MD, MEd, Associate Professor, Department of Otolaryngology, Hershey Medical Center
Contributor Information and Disclosures

Updated: Feb 6, 2009

Treatment

Medical Care

No preferred treatment regimen exists for sudden hearing loss.

Treatment can be based upon a rational approach. Based on the history, physical examination findings, and laboratory results, if no definitive or treatable etiology is found, the treatment regimen should be dictated by the most likely factors involved. Remembering that all the medications used in treatment of sudden sensory hearing loss have potential adverse effects, the best course of action must be agreed upon by the physician and the patient.

The treatment regimens for ISSHL are varied, and this diversity reflects both the different etiologies that may cause sudden hearing loss and the uncertainty in diagnosis. The therapies can be grouped by mechanism of action.

Experimental outcomes for some of these therapies are discussed under Prognosis.

  • Vasodilators: Theoretically, vasodilators improve the blood supply to the cochlea, reversing hypoxia. In general, these are agents with effects on the systemic vasculature. Papaverine, histamine, nicotinic acid, procaine, niacin, and carbogen (5% carbon dioxide) have been used in attempts to improve cochlear blood flow. Carbogen inhalation has been shown to increase perilymph oxygen tension. Carbogen has also increased measured transcutaneous and subcutaneous oxygen tension without significantly affecting carbon dioxide tension. A study found that the efficiency of carbogen combined with drugs is superior to drug therapeutics in the treatment of sudden deafness.8
  • Rheologic agents: By altering blood viscosity with the use of low molecular weight dextrans, pentoxifylline, or anticoagulants (eg, heparin, warfarin), better oxygen delivery might be achieved. Dextrans cause a hypervolemic hemodilution and affect factor VIII, with both these effects influencing blood flow. Pentoxifylline affects platelet deformability, presumably improving blood flow. Anticoagulants interfere with the coagulation cascade as a mechanism to avoid formation of thrombi and emboli.
  • Anti-inflammatory agents
    • Corticosteroids are the primary anti-inflammatory agents used to treat ISSHL. The mechanism of action in sudden hearing loss is unknown, although reduction of cochlear and auditory nerve inflammation is the presumed pathway. However, the value of steroids in the treatment of idiopathic sudden sensorineural hearing loss remains unclear.9
    • In a recent randomized controlled study, intratympanic injection of dexamethasone is shown to effectively improve hearing in patients with severe or profound SSNHL after treatment failure with standard therapy and is not associated with major side effects.10 Similar results were reported in yet another recent study.11 Its trial to salvage hearing in cases where other medical therapy fails is justified.
    • A paucity of data exists on the use of nonsteroidal anti-inflammatory agents.
  • Antiviral agents: Acyclovir and amantadine have had limited use in treating ISSHL, presuming a viral etiology. Two newer agents, famciclovir and valacyclovir, have not yet been reported upon as treatment for sudden hearing loss. They are structurally similar to acyclovir, affecting viral thymidine kinase. They inhibit viral DNA polymerase, preventing viral DNA replication.
  • Diuretics: Under the assumption that some episodes of ISSHL are secondary to cochlear endolymphatic hydrops, diuretic therapy has been used as treatment. As in Ménière disease, the mechanism of action for diuretics in sudden hearing loss is not understood.
  • Triiodobenzoic acid derivatives: These agents are thought to affect the stria vascularis and assist in maintaining the endocochlear potential. Diatrizoate meglumine, an angiographic contrast agent, was rather serendipitously found to have an effect on sudden hearing loss and is the most commonly used derivative of triiodobenzoic acid.
  • Hyperbaric oxygen: Presumably by increasing oxygen tension, hyperbaric oxygen has been evaluated as therapy for sudden hearing loss. The reported series are small, but the topic has been reviewed by Lamm et al in 1998.12
    • A study by Narozny (2004) concluded that hyperbaric oxygen therapy (consisting of exposure to 100% oxygen at a pressure of 250 kPa for a total of 60 minutes) in a multi-place hyperbaric chamber with high doses of glucocorticoids improves the results of conventional sudden sensorineural hearing loss treatment; the best results are achieved if the treatment is started as early as possible.13
    • Some other authors also believe that for people with early presentation of idiopathic sudden sensorineural hearing loss, the application of hyperbaric oxygen therapy can significantly improve hearing loss. However, a beneficial effect of hyperbaric oxygen therapy on chronic presentation of idiopathic sensorineural hearing loss and/or tinnitus is not evident.14

Surgical Care

Repair of oval and round window perilymph fistulae (PLF) has been used in cases of ISSHL associated with a positive fistula test result or a history of recent trauma or barotrauma.

  • Perilymph leaks could produce sudden hearing loss in accordance with the intracochlear membrane rupture theory. Alternatively, low perilymph pressure could produce a relative state of cochlear endolymphatic hydrops.
  • Controversy exists regarding the role of surgical repair of perilymphatic fistulae because no universal standard exists for positive identification of a fistula. The tau transferrin test on perilymph fluid has not proven to be useful in the diagnosis of this entity.

Medication

No high-quality, randomized, controlled trial exists demonstrating the efficacy of any medical therapy in ISSHL. Hence, no single treatment has been unequivocally shown to be effective, but many strategies have been proposed. Carbogen (5% CO2 +95% oxygen) inhaled for 30 min, 6 times per day (q2h during the day) for 5 days has been used.15

Corticosteroids

These agents have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli.


Prednisone (Orasone, Meticorten, Deltasone, Wysolone)

May decrease inflammation by reversing increased capillary permeability and suppressing PMN activity.

Adult

60 mg PO qd for 10 d, then taper by 5 mg qd (the taper is not strictly necessary)

Pediatric

1 mg/kg PO qd for 10 d with taper if desired

Coadministration with estrogens may decrease prednisone clearance; concurrent use with digoxin may cause digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics

Documented hypersensitivity; viral infection; peptic ulcer disease; hepatic dysfunction; connective tissue infections; fungal or tubercular skin infections; GI disease

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur with glucocorticoid use


Dexamethasone (Decadron)

Intratympanic dexamethasone increases cochlear blood flow after ischemia-induced injury.
Has many pharmacologic benefits but significant adverse effects. Stabilizes cell and lysosomal membranes, increases surfactant synthesis, inhibits prostaglandin and proinflammatory cytokines (eg, TNF-alpha, IL-6, IL-2, and IFN-gamma). The inhibition of chemotactic factors and factors that increase capillary permeability inhibits recruitment of inflammatory cells into affected areas. Suppresses lymphocyte proliferation through direct cytolysis and inhibits mitosis. Breaks down granulocyte aggregates, and improves pulmonary microcirculation. Adverse effects are hyperglycemia, hypertension, weight loss, GI bleeding or perforation synthesis, cerebral palsy, adrenal suppression, and death. Most of the adverse effects of corticosteroids are dose-dependent or duration-dependent.

Adult

0.3–0.4 mL solution of dexamethasone (8 mg/mL) with hyaluronidase by intratympanic route on alternate days

Pediatric

Not established

Effects decrease with coadministration of barbiturates, phenytoin and rifampin; dexamethasone decreases effect of salicylates and vaccines used for immunization

Documented hypersensitivity; active bacterial or fungal infection

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Increases risk of multiple complications, including severe infections; monitor adrenal insufficiency when tapering drug; abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections are possible complications of glucocorticoid use

Diuretics

These agents are beneficial in the treatment of fluid retention.


Hydrochlorothiazide/triamterene (Dyazide, Maxzide)

Inhibits reabsorption of sodium in distal tubules, causing increased excretion of sodium and water as well as potassium and hydrogen ions.

Adult

25 mg (hydrochlorothiazide)/50 mg (triamterene) PO qod

Pediatric

Not established

Thiazides may decrease effects of anticoagulants, antigout agents, and sulfonylureas; thiazides may increase toxicity of allopurinol, anesthetics, antineoplastics, calcium salts, loop diuretics, lithium, diazoxide, digitalis, amphotericin B, and nondepolarizing muscle relaxants

Documented hypersensitivity; anuria; renal decompensation

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in renal disease, hepatic disease, gout, diabetes mellitus, and erythematosus

Skin and mucus membrane agents

Agents in this category may help in the dispersion and absorption of drugs.


Hyaluronidase (Hylase, Wydase Injection)

Stimulates hydrolysis of hyaluronic acid, one of the chief ingredients of tissue cement, which offers resistance to diffusion of liquids through tissues. Used to aid in absorption and dispersion of injected drugs
Intratympanic hyaluronic acid may increase permeability of membranes and influences distribution of dexamethasone within inner ear.

Adult

Administer 0.2 mg/mL with dexamethasone by intratympanic route on alternate days (1-7 injections)

Pediatric

Not established

Salicylates, cortisone, ACTH, estrogens, and antihistamines may decrease effects of hyaluronidase

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Avoid injecting into inflamed or cancerous areas; perform intradermal skin test for sensitivity before initiating infusion; discontinue if sensitivity or extravasation occur

More on Inner Ear, Sudden Hearing Loss

Overview: Inner Ear, Sudden Hearing Loss
Differential Diagnoses & Workup: Inner Ear, Sudden Hearing Loss
Treatment & Medication: Inner Ear, Sudden Hearing Loss
Follow-up: Inner Ear, Sudden Hearing Loss
References
[ CLOSE WINDOW ]

References

  1. Okamoto M, Shitara T, Nakayama M, et al. Sudden deafness accompanied by asymptomatic mumps. Acta Otolaryngol Suppl. 1994;514:45-8. [Medline].

  2. Rudack C, Langer C, Stoll W, Rust S, Walter M. Vascular risk factors in sudden hearing loss. Thromb Haemost. Mar 2006;95(3):454-61. [Medline].

  3. Simmons FB. Theory of membrane breaks in sudden hearing loss. Arch Otolaryngol. Jul 1968;88(1):41-8. [Medline].

  4. Goodhill V, Harris I. Sudden hearing loss syndromes. In: Goodhill V, ed. Ear Diseases, Deafness, and Dizziness. New York: Harper-Collins; 1979:664-681.

  5. Gussen R. Sudden hearing loss associated with cochlear membrane rupture. Two human temporal bone reports. Arch Otolaryngol. Oct 1981;107(10):598-600. [Medline].

  6. Toubi E, Ben-David J, Kessel A, Halas K, Sabo E, Luntz M. Immune-mediated disorders associated with idiopathic sudden sensorineural hearing loss. Ann Otol Rhinol Laryngol. Jun 2004;113(6):445-9. [Medline].

  7. Shaia FT, Sheehy JL. Sudden sensori-neural hearing impairment: a report of 1,220 cases. Laryngoscope. Mar 1976;86(3):389-98. [Medline].

  8. Ni Y, Zhao X. [Carbogen combined with drugs in the treatment of sudden deafness]. Lin Chuang Er Bi Yan Hou Ke Za Zhi. Jul 2004;18(7):414-5. [Medline].

  9. [Best Evidence] Wei BP, Mubiru S, O'Leary S. Steroids for idiopathic sudden sensorineural hearing loss. Cochrane Database Syst Rev. Jan 25 2006;CD003998. [Medline].

  10. Ho HG, Lin HC, Shu MT, Yang CC, Tsai HT. Effectiveness of intratympanic dexamethasone injection in sudden-deafness patients as salvage treatment. Laryngoscope. Jul 2004;114(7):1184-9. [Medline].

  11. Gouveris H, Selivanova O, Mann W. Intratympanic dexamethasone with hyaluronic acid in the treatment of idiopathic sudden sensorineural hearing loss after failure of intravenous steroid and vasoactive therapy. Eur Arch Otorhinolaryngol. Feb 2005;262(2):131-4. [Medline].

  12. Lamm K, Lamm H, Arnold W. Effect of hyperbaric oxygen therapy in comparison to conventional or placebo therapy or no treatment in idiopathic sudden hearing loss, acoustic trauma, noise-induced hearing loss and tinnitus. A literature survey. Adv Otorhinolaryngol. 1998;54:86-99. [Medline].

  13. Narozny W, Sicko Z, Przewozny T, Stankiewicz C, Kot J, Kuczkowski J. Usefulness of high doses of glucocorticoids and hyperbaric oxygen therapy in sudden sensorineural hearing loss treatment. Otol Neurotol. Nov 2004;25(6):916-23. [Medline].

  14. Bennett MH, Kertesz T, Yeung P. Hyperbaric oxygen for idiopathic sudden sensorineural hearing loss and tinnitus. Cochrane Database Syst Rev. Jan 25 2005;CD004739. [Medline].

  15. Cinamon U, Bendet E, Kronenberg J. Steroids, carbogen or placebo for sudden hearing loss: a prospective double-blind study. Eur Arch Otorhinolaryngol. Nov 2001;258(9):477-80. [Medline].

  16. Fetterman BL, Saunders JE, Luxford WM. Prognosis and treatment of sudden sensorineural hearing loss. Am J Otol. Jul 1996;17(4):529-36. [Medline].

  17. Redleaf MI, Bauer CA, Gantz BJ, Hoffman HT, McCabe BF. Diatrizoate and dextran treatment of sudden sensorineural hearing loss. Am J Otol. May 1995;16(3):295-303. [Medline].

  18. Wilson WR. The relationship of the herpesvirus family to sudden hearing loss: a prospective clinical study and literature review. Laryngoscope. Aug 1986;96(8):870-7. [Medline].

  19. Wilkins SA Jr, Mattox DE, Lyles A. Evaluation of a "shotgun" regimen for sudden hearing loss. Otolaryngol Head Neck Surg. Nov 1987;97(5):474-80. [Medline].

  20. Belal A Jr. Pathology of vascular sensorineural hearing impairment. Laryngoscope. Nov 1980;90(11 Pt 1):1831-9. [Medline].

  21. Billings PB, Keithley EM, Harris JP. Evidence linking the 68 kilodalton antigen identified in progressive sensorineural hearing loss patient sera with heat shock protein 70. Ann Otol Rhinol Laryngol. Mar 1995;104(3):181-8. [Medline].

  22. Bloch DB, San Martin JE, Rauch SD, Moscicki RA, Bloch KJ. Serum antibodies to heat shock protein 70 in sensorineural hearing loss. Arch Otolaryngol Head Neck Surg. Oct 1995;121(10):1167-71. [Medline].

  23. Byl FM Jr. Sudden hearing loss: eight years' experience and suggested prognostic table. Laryngoscope. May 1984;94(5 Pt 1):647-61. [Medline].

  24. Daniels RL, Shelton C, Harnsberger HR. Ultra high resolution nonenhanced fast spin echo magnetic resonance imaging: cost-effective screening for acoustic neuroma in patients with sudden sensorineural hearing loss. Otolaryngol Head Neck Surg. Oct 1998;119(4):364-9. [Medline].

  25. Fisch U. Management of sudden deafness. Otolaryngol Head Neck Surg. Feb 1983;91(1):3-8. [Medline].

  26. Grandis JR, Hirsch BE, Wagener MM. Treatment of idiopathic sudden sensorineural hearing loss. Am J Otol. Mar 1993;14(2):183-5. [Medline].

  27. Hultcrantz E, Stenquist M, Lyttkens L. Sudden deafness: a retrospective evaluation of dextran therapy. ORL J Otorhinolaryngol Relat Spec. May-Jun 1994;56(3):137-42. [Medline].

  28. Jackler RK, De La Cruz A. The large vestibular aqueduct syndrome. Laryngoscope. Dec 1989;99(12):1238-42; discussion 1242-3. [Medline].

  29. Kallinen J, Kuttila K, Aitasalo K, Grénman R. Effect of carbogen inhalation on peripheral tissue perfusion and oxygenation in patients suffering from sudden hearing loss. Ann Otol Rhinol Laryngol. Oct 1999;108(10):944-7. [Medline].

  30. Khetarpal U, Nadol JB Jr, Glynn RJ. Idiopathic sudden sensorineural hearing loss and postnatal viral labyrinthitis: a statistical comparison of temporal bone findings. Ann Otol Rhinol Laryngol. Dec 1990;99(12):969-76. [Medline].

  31. Kronenberg J, Almagor M, Bendet E, Kushnir D. Vasoactive therapy versus placebo in the treatment of sudden hearing loss: a double-blind clinical study. Laryngoscope. Jan 1992;102(1):65-8. [Medline].

  32. Matthies C, Samii M. Management of 1000 vestibular schwannomas (acoustic neuromas): clinical presentation. Neurosurgery. Jan 1997;40(1):1-9; discussion 9-10. [Medline].

  33. Mattox DE, Lyles CA. Idiopathic sudden sensorineural hearing loss. Am J Otol. May 1989;10(3):242-7. [Medline].

  34. Mattox DE, Simmons FB. Natural history of sudden sensorineural hearing loss. Ann Otol Rhinol Laryngol. Jul-Aug 1977;86(4 Pt 1):463-80. [Medline].

  35. McCabe BF. Autoimmune sensorineural hearing loss. Ann Otol Rhinol Laryngol. Sep-Oct 1979;88(5 Pt 1):585-9. [Medline].

  36. Moffat DA, Baguley DM, von Blumenthal H, Irving RM, Hardy DG. Sudden deafness in vestibular schwannoma. J Laryngol Otol. Feb 1994;108(2):116-9. [Medline].

  37. Nakashima T, Yanagita N. Outcome of sudden deafness with and without vertigo. Laryngoscope. Oct 1993;103(10):1145-9. [Medline].

  38. Perlman H, Kimura R, Fernandez C. Experiments on temporary obstruction of the internal auditory artery. Laryngoscope. 1959;69:591-612.

  39. Probst R, Tschopp K, Ludin E, Kellerhals B, Podvinec M, Pfaltz CR. A randomized, double-blind, placebo-controlled study of dextran/pentoxifylline medication in acute acoustic trauma and sudden hearing loss. Acta Otolaryngol. 1992;112(3):435-43. [Medline].

  40. Schuknecht HF, Donovan ED. The pathology of idiopathic sudden sensorineural hearing loss. Arch Otorhinolaryngol. 1986;243(1):1-15. [Medline].

  41. Suga F, Preston J, Snow JB Jr. Experimental microembolization of cochlear vessels. Arch Otolaryngol. Sep 1970;92(3):213-20. [Medline].

  42. Ullrich D, Aurbach G, Drobik C. A prospective study of hyperlipidemia as a pathogenic factor in sudden hearing loss. Eur Arch Otorhinolaryngol. 1992;249(5):273-6. [Medline].

  43. Wilson WR, Byl FM, Laird N. The efficacy of steroids in the treatment of idiopathic sudden hearing loss. A double-blind clinical study. Arch Otolaryngol. Dec 1980;106(12):772-6. [Medline].

  44. Yoon TH, Paparella MM, Schachern PA, Alleva M. Histopathology of sudden hearing loss. Laryngoscope. Jul 1990;100(7):707-15. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

hearing loss, sudden hearing loss, sudden deafness, sudden sensorineural hearing loss, idiopathic sudden sensory hearing loss, ISSHL, hearing problems, hearing

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Neeraj N Mathur, MBBS, MS, Professor, Department of Ear, Nose and Throat, Lady Hardinge Medical College and Associated Smt SK and Kalawati, Saran Children's Hospital, University of Delhi, India; Professor, Department of Ear, Nose and Throat, BP Koirala Institute of Health Sciences, Nepal
Neeraj N Mathur, MBBS, MS is a member of the following medical societies: Association of Otolaryngologists of India, Cochlear Implant Group of India, Indian Medical Association, National Academy of Medical Sciences, India, Neuro-Otologic and Equlibriometric Society of India, and Royal Society of Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Michele M Carr, DDS, MD, MEd, Associate Professor, Department of Otolaryngology, Hershey Medical Center
Michele M Carr, DDS, MD, MEd is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery
Disclosure: Nothing to disclose.

Medical Editor

Cliff A Megerian, MD, FACS, Medical Director of Adult and Pediatric Cochlear Implant Program, Vice-Chairman and Director of Otology and Neurotology, University Hospitals of Cleveland; Professor, Department of Otolaryngology-Head and Neck Surgery and Neurological Surgery, Case Western Reserve University School of Medicine
Cliff A Megerian, MD, FACS is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Neurotology Society, American Otological Society, Association for Research in Otolaryngology, Massachusetts Medical Society, Society for Neuroscience, Society of University Otolaryngologists-Head and Neck Surgeons, and Triological Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Peter S Roland, MD, Professor, Department of Neurological Surgery, Professor and Chairman, Department of Otolaryngology-Head and Neck Surgery, Director of Clinical Center for Auditory, Vestibular and Facial Nerve Disorders, Chief of Pediatric Otology, University of Texas Southwestern Medical Center; Adjunct Professor of Communicative Disorders, School of Human Development.
Peter S Roland, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American Auditory Society, American Laryngological Rhinological and Otological Society, American Neurotology Society, American Otological Society, North American Skull Base Society, and Society of University Otolaryngologists-Head and Neck Surgeons
Disclosure: Alcon labs Honoraria Speaking and teaching; GSK Honoraria Speaking and teaching; Advanced Bionics Honoraria Board membership; Cochlear corp Honoraria Board membership; Med El corp travel grants Speaking and teaching; Insight vision Consulting fee Consulting

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society
Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation unstricted gift unknown

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.