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Contents lists available at ScienceDirect

Auris Nasus Larynx

journal homepage: www.elsevier.com/locate/anl

The protective effect of adrenocorticotropic hormone treatment

against noise-induced hearing loss$
Ahmet Mutlu a,*, Fatma Ceyda Akin Ocal b, Seyra Erbek c, Levent Ozluoglu c
a
Uskudar State Hospital, Otorhinolaryngology Department, Istanbul, Turkey
b
Gulhane Training and Research Hospital, Otorhinolaryngology Department, Ankara, Turkey
c
Baskent University Medical Faculty, Otorhinolaryngology Department, Ankara, Turkey

A R T I C L E I N F O A B S T R A C T

Article history: Objective: NIHL is a common problem, and steroids are the most effective treatment option. In this
Received 27 October 2017 study, we aimed to evaluate the protective effects of the synthetic adrenocorticotropic hormone
Accepted 13 December 2017 (ACTH) analogues, which induce endogenous steroid secretion, against noise-induced hearing loss
Available online xxx
(NIHL) and to compare their effectiveness with that of steroid treatment.
Methods: Twenty-four male Sprague–Dawley albino rats were divided into four subgroups as
Keywords:
follows: group 1 (n = 6) control, group 2 (n = 6) saline, group 3 (n = 6) dexamethasone (2 mg/kg/
Noise
Noise-induced hearing loss
day intramuscularly [IM]), group 4 (n = 6) ACTH analogue (0,4 mg/kg/day IM), respectively. Three
Acoustic trauma groups (groups 2–4) were exposed to white noise (105 dB SPL, 12 h). All the rats were evaluated for
Steroid hearing thresholds of 10 kHz, 20 kHz, and 32 kHz via acoustic brainstem responses (ABR)
Adrenocorticotropic hormone (ACTH) measurement. After the basal threshold measurements, measurements were repeated immediately
Auditory brainstem responses (ABR) after the noise and on day 7 and day 21.
Results: Both steroid and ACTH analogue groups showed significantly better hearing outcomes
than the saline group on day 7 (p < 0.001) and day 21 (p < 0.001) after the noise exposure. No
superior treatment effect was demonstrated in either the steroid or ACTH analogue group. None of
the related intervention groups reached the basal hearing thresholds.
Conclusion: Steroids were effective drugs for the treatment of NIHL. ACTH analogues also
demonstrated promising therapeutic effects for NIHL. Further studies to establish ACTH analogues
as an alternative NIHL treatment option to steroids are needed.
© 2018 Elsevier B.V. All rights reserved.

1. Introduction temporary or permanent hearing threshold shift with the

Noise-induced hearing loss (NIHL) is an ear injury, which
can occur via the exposure of a sudden or prolonged high-
decibel noise. It has become a common problem in the
modern population [1]. The intense sound may cause
$
Level of evidence: I b.
* Corresponding author at: Barbaros Mahallesi, Veysi Pasa Sokak No:14,
34672 Uskudar, Istanbul, Turkey.
E-mail addresses: ahmutlu1988@gmail.com (A. Mutlu), (F.C.A. Ocal),
(S. Erbek), (L. Ozluoglu).
https://doi.org/10.1016/j.anl.2017.12.006
0385-8146/© 2018 Elsevier B.V. All rights reserved.
macroscopic (tympanic membrane rupture, ossicular chain
dislocation, perilymph fistula, etc.) and microscopic (tector-
ial and basilar membrane rupture, hair cell loss, etc.) effects
in the ear [2]. Besides, the related effects stimulate the
metabolic cell responses to maintain the cell homeostasis.
Paradoxically, the related metabolic activity might also
disrupt the vital cochlear structures and in turn cause
apoptosis, which is relevant to permanent hearing loss. For
this reason, many studies have aimed to find an effective
treatment to treat NIHL. However, the suggested treatments
for NIHL do not recommend a specific treatment, except for

Please cite this article in press as: Mutlu A, et al. The protective effect of adrenocorticotropic hormone treatment against noise-induced hearing
loss. Auris Nasus Larynx (2018), https://doi.org/10.1016/j.anl.2017.12.006
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the use of steroids [1]. Recent studies have revealed the
promising effects of the glucocorticoids, which have been
widely used against NIHL [1–3].
Glucocorticoids are lipophilic hormones, which are synthe-
sized from cholesterol precursors and strongly associated with
maintaining homeostasis during stress-related events (e.g.,
trauma, infection, hypoglycemia, physical stress, and exercise)
[3,4]. Glucocorticoids are also released from the adrenal glands
according to the diurnal rhythm, and secretion is controlled by
the adrenocorticotropic hormone (ACTH) as a part of the
hypothalamic-pituitary-adrenal axis.
ACTH is a polypeptide hormone, which is produced by cells
of the anterior pituitary gland. It stimulates the secretion of
corticosteroid hormone (i.e., glucocorticoid, aldosterone) from
the adrenal glands and can be eliminated in minutes [3]. The
synthetic ACTH analogues are manufactured with the aim of
enhancing the blood elimination period for therapeutic
applications. Currently, the synthetic ACTH analogues are
generally preferred as a drug to demonstrate the endogenous
glucocorticoid secretion from the adrenal gland (ACTH
stimulation test) and West syndrome; in fact, it may be an
alternative option to steroid treatment for exacerbations of
multiple sclerosis and ulcerative colitis, rheumatoid arthritis,
and psoriatic arthritis [5]. The promising effects of the ACTH
analogues may shed light on new treatment protocols for
different disorders.
The aim of this present study was to evaluate the protective
effects of the synthetic ACTH analogues against NIHL. The
protective effects of the ACTH analogues against NIHL were
also compared with the effects of dexamethasone, which is a
potent steroid. To our knowledge, this study represents the first
preliminary study aimed to evaluate the synthetic ACTH
analogue effects on NIHL.
2. Methods
2.1. Animals and experimental design
This study was conducted in the Baskent University Medical
Faculty animal laboratory under the statement of the local ethic
committee (Project Number: DA16/47). Twenty-four male
Sprague–Dawley albino rats aged 12–16 weeks and weighing
280 g–320 g were included in this study. The rats were maintained
under standardized laboratory conditions (12-h light/dark cycle,
temperature 21  1  C, background noise <50 dB) with access to
food (standard rodent chow) and water ad libitum.
Ear examinations and hearing tests were performed under
general anaesthesia with a mixture of ketamine (60 mg/kg
intraperitoneal [IP]) and xylazine (6 mg/kg IP). Before the hearing
tests, all the rats were examined with an otoscope and controlled for
normal external ear canal with an intact tympanic membrane.
Twenty-four rats were divided randomly into four groups of
six rats per cage. The groups and respective interventions are
summarized in Table 1 and as follows.
- Group 1 (n = 6): This group was classified as the control
group. The rats in this group did not receive acoustic trauma
and were not administered drugs.
Please cite this article in press as: Mutlu A, et al. The protective effect of adrenocorticotropic hormone treatment against noise-induced hearing
loss. Auris Nasus Larynx (2018), https://doi.org/10.1016/j.anl.2017.12.006
- Group 2 (AT + Sal) (n = 6): This group was classified as the
saline group. The rats in this group received the acoustic
trauma and saline injections (0.2 mL/day intramuscularly
[IM] 7 days after the acoustic trauma).
- Group 3 (AT + Dex) (n = 6): This group was classified as the
dexamethasone group. The rats received the acoustic trauma
and dexamethasone injections (2 mg/kg/day IM 7 days after
the acoustic trauma) [6].
- Group 4 (AT + ACTH) (n = 6): This group was classified as
the ACTH group. The rats received the acoustic trauma and
synthetic ACTH analogue injections (Synacthen Depot1,
0.4 mg/kg/day IM 7 days after the acoustic trauma) [7].
2.2. Acoustic trauma model
After the basal trauma, all the rats (except group 1) were
placed in a quiet cabin (403-A, Industrial Acoustics Company1
GMBH, Germany). The cages were located 50 cm away
between two free-field loudspeakers. The acoustic trauma
(white noise 105 dB SPL, 12 h) was generated with a calibrated
clinical audiometer device (AC 40 Interacoustics1, Denmark).
2.3. Hearing tests
The auditory brainstem responses (ABR) was recorded using
the Smart EP high frequency device (Intelligent Hearing System-
IHS1, Miami, FL, USA) fitted with high-frequency transducers
and measurement were performed with the official software
(version 5.30). ABR waves were recorded with subdermal needle
electrodes, which are placed in the vertex (active), below the
ipsilateral pinna (reference), and below the counter-lateral pinna
(neutral). The electrode impedance was set to 0–3 kOhm and was
connected to a 0.1 kHz–3 kHz preamplifier filter.
The acoustic stimuli were presented with insert earphones,
and three different (10 kHz, 20 kHz, and 32 kHz) tone burst
frequencies (rarefaction polarity) were selected [8]. The tone
burst acoustic stimuli rate was set as 21.1/s (1562 ms in
duration; cos2-shaped; 21 Hz) with 0.1–3 kHz band pass filter
[2]. The average sweep number for each stimulus was set to
2000 sweeps. The evaluation of the hearing thresholds was
started from the 80-dB intensity, and the wave II of the ABR
patterns were used to define the thresholds. 20-dB decrements
and 10-dB increments were used to distinguish the lowest
intensity levels of the ABR wave patterns. All the measure-
ments were repeated to obtain the exact thresholds via two
investigators.
After the basal level measurements, three groups received
the acoustic trauma. The measurements were repeated
immediately in all groups to evaluate the effectiveness of the
acoustic trauma (control group was also assessed to screen the
measurement). The treatment success was evaluated by
revisiting the measurements in all groups on day 7 and day
21 of the acoustic trauma.
2.4. Statistical analysis
All the statistical data were assessed using SPSS software
(version 16.0, SPSS, Inc., Chicago, IL, USA). Descriptive
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Table 1
The experimental design of the study.
Basal Acoustic trauma Immediately
Group 1 + + +
n=6
Group 2 + + +
n=6
Group 3 + + +
n=6
Group 4 + + +
n=6
ACTH indicates synthetic adrenocorticotropic hormone; basal, basal hearing measurements; group 1, control group; group 2, saline group; group 3, dexamethasone
group; group 4, ACTH analogue group; immediately, hearing measurements immediately after the acoustic trauma.
values were expressed as the mean, standard deviation (SD),
median (med), minimum (min), maximum (max) and 25th–75th
percentile. The data distribution was evaluated with the
Kolmogorov–Smirnov test, and all the data were classified
as non-parametric. The comparison between the groups was
analysed for all the measured frequencies (10 kHz, 20 kHz, and
32 kHz) with the Kruskal Wallis test (p < 0.05). Mann–
Whitney U test was used to define which of the two groups
differed significantly (p < 0.0083 with Bonferroni correction).
The Friedman test was used to detect the significance of the
measurements in the groups (p < 0.05), and the Wilcoxon test
was applied to reveal the significance in the groups
(p < 0.0083 with Bonferroni correction).
3. Results
The audiological results of 24 rats (48 ears) were evaluated
for this study. The basal measurements of the groups at all
frequencies were not significantly different, and all the groups
(except the control group) were similarly affected by the
acoustic trauma at all frequencies. All rats which were exposed
to acoustic trauma point out a significant difference from
control group in terms of audiological results. The groups that
received the acoustic trauma (groups 2–4) did not recover to the
basal hearing threshold levels. The detailed hearing results of
the 10-kHz, 20-kHz, and 32-kHz frequencies are detailed as
follows:
- 10 kHz: The day 7 and day 21 measurements for group 3 and
group 4 were lower than group 2. However, no significant
difference was detected between the group 3 and group
4 measurements. For groups 3 and 4, the results were better
than the measurements immediately after the acoustic trauma,
day 7, and day 21 measurements (Table 2) (Fig. 1) and showed
a significant difference.
- 20 kHz: Groups 3 and 4 had shown better results than group
2 in day 7 and day 21 measurements, but the results of group
3 and group 4 were not significantly differed. In group 2, the
day 21 measurements were better than the measurements
immediately after the acoustic trauma and the day 7. The ABR
thresholds of immediately after the acoustic trauma in group
3 and group 4 were significantly higher than the day 7 and day
21 measurements (Table 3) (Fig. 2).
- 32 kHz: The ABR threshold levels of group 2 were significantly
higher than only group 3 in the day 7 measurements, but in the
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loss. Auris Nasus Larynx (2018), https://doi.org/10.1016/j.anl.2017.12.006
3
Day 7 Day 21 Saline Dexamethasone ACTH
+
+ + +
+ + +
+ + +
day 21 measurements both group 3 and group 4 were lower than
group 2. Groups 3 and 4 showed a significant difference in the
measurements immediately after the acoustic trauma and the
day 7 and day 21 measurements (Table 4) (Fig. 3). No difference
was detected between group 3 and group 4 for all measurements.
4. Discussion
NIHL has an important role in the development of hearing
impairment in the modern population. The glucocorticoids are
the preferred agents for the treatment of this condition [1–
3]. Currently, the steroid-releasing agents had new indications
where the steroids were not well-tolerated or remained
ineffective in adopted doses. The ACTH analogues are the
well-known agents and had various indications [5]. To our
knowledge, the ACTH analogues have not been used to treat
hearing loss to date. This animal study was the first study
intended to determine the protective effects of the ACTH
analogues against NIHL.
Many studies have represented various effective acoustic
trauma models, but there remained no consensus on the acoustic
trauma model of rats [2,8–10]. White noise was frequently used
as an instrument in the acoustic trauma models, and it was also
preferred for use in this study. The applied acoustic trauma was
generated at the required homogenous temporary hearing level
shift in the rats that were exposed to the acoustic trauma.
In our study, the hearing threshold levels were recovered in
all groups during this period. Both dexamethasone and ACTH
analogue groups showed a higher rate of recovery than the
saline group on day 7 and day 21 measurements at all
frequencies. The ACTH group had better hearing results at
certain frequencies, but no difference was detected between the
dexamethasone and ACTH groups. However, all the trauma-
tized rat groups showed significant progress in hearing recovery
on day 21, according to the measurements at all frequencies,
with the best hearing levels in the dexamethasone and ACTH
analogue groups. This result may be related to the steroidogenic
effect on the cessation of the acute inflammatory process. The
acute inflammation control of the steroidogenic agents may
help to maintain the cochlear homeostasis and lead to better
hearing results in the long-term.
ACTH has a secondary role in the regulation of the
inflammatory process except for the steroidogenic effects.
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Table 2
Descriptive data of the 10-kHz ABR threshold.

Basal (dB) AT (dB) Post 7 (dB) Post 21 (dB) p*** p****

Mean  SD 17.5  4.52 20  4.26 19.16  5.14 18.33  3.89 0.112
Group 1 Median 20 20 20 20
Control 25–75 per 12.5–20 20–20 20–20 20–20
n = 12 Min–max 10–20 10–30 10–30 10–20
<0.001 Bas-AT 0.002
Group 2 Mean  SD 17.5  4.52 61.66  5.77 55  6.7 50  6.03 Bas-Post 7 0.002
Saline Median 20 60 60 50 Bas-Post 21 0.002
n = 12 25–75 per 12.5–20 60–67.5 50–60 50–50 AT-Post 7 0.039
Min–max 10–20 50–70 40–60 40–60 AT-Post 21 0.004
Post 7–Post 21 0.014
<0.001 Bas-AT 0.002
Group 3 Mean  SD 18.33  3.89 62.5  8.66 44.16  7.92 38.33  5.77 Bas-Post 7 0.002
Dex Median 20 60 40 40 Bas-Post 21 0.002
n = 12 25–75 per 20–20 60–70 40–50 32.5–40 AT-Post 7 0.003
Min–max 10–20 50–80 30–60 30–50 AT-Post 21 0.002
Post 7–Post 21 0.035
<0.001 Bas-AT 0.002
Mean  SD 18.33  3.89 59.16  9.0 43.33  7.8 34.16  6.68 Bas-Post 7 0.002
Group 4 Median 20 60 40 35 Bas-Post 21 0.003
ACTH 25–75 per 20–20 50–60 40–50 30–40 AT-Post 7 0.004
n = 12 Min–max 10–20 50–80 30–60 20–40 AT-Post 21 0.002
Post 7–Post 21 0.009
p* 0.92 <0.001 <0.001 <0.001
p** Group 1–2 0.000 Group 1–2 0.000 Group 1–2 0.000
Group 1–3 0.000 Group 1–3 0.000 Group 1–3 0.000
Group 1–4 0.001 Group 1–4 0.000 Group 1–4 0.000
Group 2–3 0.871 Group 2–3 0.003 Group 2–3 0.000
Group 2–4 0.255 Group 2–4 0.002 Group 2–4 0.000
Group 3–4 0.289 Group 3–4 0.749 Group 3–4 0.138
ABR indicates auditory brainstem response; ACTH, synthetic adrenocorticotropic hormone; AT, measurements taken immediately after the acoustic trauma; Dex,
dexamethasone; post 7, measurements taken 7 days after the acoustic trauma; post 21, measurements taken 21 days after the acoustic trauma; SD, standard deviation.
*
Kruskal Wallis test is for comparison of groups (p < 0.05).
**
Mann Whitney U test is for double comparisons (p < 0.0083 with Bonferonni correction).
***
Friedman test is for comparisons in the groups (p < 0.05).
****
Wilcoxon test is for the double comparisons in the groups (p < 0.0083 with Bonferonni correction).

ACTH is a proopiomelanocortin hormone and can activate the

Fig. 1. The box-plot graph displays the distribution of the 10-kHz auditory
brainstem response (ABR) threshold means. AT indicates measurements
immediately after the acoustic trauma; post 7, measurements taken 7 days after
the acoustic trauma; post 21, measurements taken 21 days after the acoustic
trauma.
melanocortin (MC) receptors, which are situated on the immune
cells (e.g., macrophages, mast cells, neutrophils, and lympho-
cytes). MC1, MC3, and MC5 receptors are suspected in the
inhibition of the immune cell inflammatory responses, which
are leucocyte infiltration, cytokine secretion, and phagocytosis
[5]. Consequently, a MC-related mechanism may be a part of
the central control of peripheral inflammatory activity [11]. In
our study, the ACTH analogues demonstrate better hearing
outcomes than steroids, and this result may be related to the
additional anti-inflammatory effect.
Aldosterone is another hormone that is secreted from the
adrenal cortex with the stimulation of synthetic ACTH
analogues. Aldosterone has a role in the regulation of the
blood pressure with the electrolyte absorption. Various studies
have suggested the possible protective effect of the aldosterone
hormone on hearing; in fact, Song et al. have mentioned the
decreased levels of aldosterone in the rats that are exposed
acoustic trauma [12], and Tadros et al. showed similar results in
patients with presbycusis [13]. Furthermore, Halonen et al.
presented the findings on long-term aldosterone treatment,

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Table 3
Descriptive data of the 20-kHz ABR threshold.

Basal (dB) AT (dB) Post 7 (dB) Post 21 (dB) p*** p****

Mean  SD 17.5  4.52 20.83  5.14 20  6.03 19.16  5.14 0.05
Group 1 Median 20 20 20 20
Control 25–75 per 12.5–20 20–20 20–20 20–20
n = 12 Min–max 10–20 10–30 10–30 10–30
Bas-AT 0.002
Group 2 Mean  SD 17.5  4.52 63.33  7.78 60  8.52 50.83  11.64 <0.001 Bas-Post 7 0.002
Saline Median 20 60 60 50 Bas-Post 21 0.002
n = 12 25–75 per 12.5–20 60–70 52.5–60 40–57.5 AT-Post7 0.046
Min–max 10–20 50–80 50–80 40–80 AT-Post21 0.004
Post 7–Post 21 0.005
<0.001 Bas-AT 0.002
Group 3 Mean  SD 18.33  3.89 59.16  9.96 39.16  9 34.16  9.96 Bas-Post 7 0.003
Dex Median 20 60 40 40 Bas-Post 21 0.006
n = 12 25–75 per 20–20 50–70 32.5–47.5 22.5–40 AT-Post 7 0.002
Min–max 10–20 40–70 20–50 20–50 AT-Post 21 0.002
Post7–Post 21 0.109
<0.001 Bas-AT 0.002
Mean  SD 18.33  3.89 63.33  10.73 40.83  7.92 35.83  7.92 Bas-Post 7 0.002
Group 4 Median 20 60 40 40 Bas-Post 21 0.002
ACTH 25–75 per 20–20 52.5–70 40–40 30–40 AT-Post 7 0.002
n = 12 Min–max 10–20 50–80 30–60 20–50 AT-Post 21 0.002
Post 7–Post 21 0.034
p* 0.92 <0.001 <0.001 <0.001
p** Group 1–2 0.000 Group 1–2 0.000 Group 1–2 0.000
Group 1–3 0.001 Group 1–3 0.000 Group 1–3 0.001
Group 1–4 0.000 Group 1–4 0.000 Group 1–4 0.000
Group 2–3 0.371 Group 2–3 0.000 Group 2–3 0.001
Group 2–4 0.951 Group 2–4 0.000 Group 2–4 0.001
Group 3–4 0.417 Group 3–4 0.871 Group 3–4 0.755
ABR indicates auditory brainstem response; ACTH, synthetic adrenocorticotropic hormone; AT, measurements immediately after the acoustic trauma; Dex,
dexamethasone; post 7, measurements taken 7 days after the acoustic trauma; post 21, measurements taken 21 days after the acoustic trauma; SD, standard deviation.
*
Kruskal Wallis test is for comparison of groups (p < 0.05).
**
Mann Whitney U test is for double comparisons (p < 0.0083 with Bonferonni correction).
***
Friedman test is for comparisons in the groups (p < 0.05).
****
Wilcoxon test is for the double comparisons in the groups (p < 0.0083 with Bonferonni correction).

which may be effective in the progression of presbycusis

Fig. 2. The box-plot graph shows the distribution of the 20-kHz auditory
brainstem response (ABR) threshold means. AT indicates measurements taken
immediately after the acoustic trauma; post 7, measurements taken 7 days after
the acoustic trauma; post 21, measurements taken 21 days after the acoustic
trauma.
[14]. In our study, ACTH analogue showed better results at
certain frequencies. These results may be associated with the
secretion of the aldosterone hormone secondary to ACTH
stimulation and may be independent of the immune modulating-
effects of steroids.
The synthetic ACTH analogues have some disadvantages in
comparison with the synthetic glucocorticoids. The systemic
glucocorticoid drugs are widely prescribed in daily clinical
practice, and the corticosteroid-dependent adverse effects
(Cushing’s syndrome, cardiovascular, gastrointestinal, immu-
nological, metabolic, neuropsychiatric, etc.) have been previ-
ously described [15]. Besides, the ACTH analogues also show
similar steroidogenic activity and related steroid-dependent
adverse effects. Another point is the multiple administration
routes (i.e., intravenous, IM, IP, intratympanic) may be an
advantage of the glucocorticoids, and these drugs can be stored
at room temperature. The ACTH analogue (Synacthen Depot1)
must only be administered via IM injection and must be kept at
2–8  C. Moreover, the cost of synthetic glucocorticoids is

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Table 4
Descriptive data of the 10-kHz ABR threshold.

Basal (dB) AT (dB) Post 7 (dB) Post 21 (dB) p*** p****

Mean  SD 21.66  5.77 20.83  5.14 20.83  5.14 20  4.26 0.261
Group 1 Median 20 20 20 20
Control 25–75 per 20–27.5 20–20 20–20 20–20
n = 12 Min–max 10–30 10–30 10–30 10–30
<0.001 Bas-AT 0.002
Group 2 Mean  SD 20.83  5.14 9.16  9.96 62.5  12.15 55  7.97 Bas-Post 7 0.002
Saline Median 20 70 60 55 Bas-Post 21 0.002
n = 12 25–75 per 20–20 60–77.5 52.5–70 50–60 AT-Post 7 0.011
Min–max 10–30 60–90 40–80 40–70 AT-Post 21 0.004
Post 7–Post 21 0.014
<0.001 Bas-AT 0.002
Group 3 Mean  SD 21.66  3.89 67.5  9.65 46.66  7.78 39.16  6.68 Bas-Post 7 0.002
Dex Median 20 65 45 40 Bas-Post21 0.004
n = 12 25–75 per 20–20 60–70 40–50 32.5–40 AT-Post 7 0.002
Min–max 20–30 60–90 40–60 30–50 AT-Post 21 0.002
Post 7–Post 21 0.007
<0.001 Bas-AT 0.002
Mean  SD 21.66  3.89 68.33  11.14 46.16  12.40 41.66  9.37 Bas-Post 7 0.002
Group 4 Median 20 65 50 40 Bas-Post 21 0.002
ACTH 25–75 per 20–20 60–80 40–57.5 32.5–50 AT-Post 7 0.003
n = 12 Min–max 20–30 50–80 30–70 30–60 AT-Post 21 0.003
Post 7–Post 21 0.084
p* 0.967 <0.001 <0.001 <0.001
p** Group 1–2 0.000 Group 1–2 0.000 Group 1–2 0.000
Group 1–3 0.000 Group 1–3 0.000 Group 1–3 0.000
Group 1–4 0.000 Group 1–4 0.000 Group 1–4 0.000
Group 2–3 0.683 Group 2–3 0.002 Group 2–3 0.000
Group 2–4 0.683 Group 2–4 0.018 Group 2–4 0.003
Group 3–4 1 Group 3–4 0.668 Group 3–4 0.532
ABR indicates auditory brainstem response; ACTH, synthetic adrenocorticotropic hormone; AT, measurements immediately after the acoustic trauma; Dex,
dexamethasone; post 7: measurements taken 7 days after the acoustic trauma; post 21: measurements taken 21 days after the acoustic trauma; SD, standard deviation.
*
Kruskal Wallis test is for comparison of groups (p < 0.05).
**
Mann Whitney U test is for double comparisons (p < 0.0083 with Bonferonni correction).
***
Friedman test is for comparisons in the groups (p < 0.05).
****
Wilcoxon test is for the double comparisons in the groups (p < 0.0083 with Bonferonni correction).

relatively lower than the synthetic ACTH analogues. Although

Fig. 3. The box-plot graph shows the distribution of the 32-kHz auditory
brainstem response (ABR) threshold means. AT indicates measurements
immediately after the acoustic trauma; post 7, measurements taken 7 days after
the acoustic trauma; post 21, measurements taken 21 days after the acoustic
trauma.
physicians might be discouraged by the difficulties of using the
ACTH analogues, they are still vital for many patients, and the
new intravenous formulation is currently in clinical use.
In our study, we encountered some limitations that will need
to be clarified in future studies. One major limitation was the
lack of histology. The inner ear structures were not able to be
demonstrated properly in histology. Therefore, further histo-
logical studies with light and electron microscopy are needed.
Another limiting factor was that the measurements were limited
to high frequencies. This study was performed in rats, which are
strongly sensitive to high frequencies [16], and experimental
studies are needed to demonstrate these effects on the human
ear. Another important limiting factor was the absence of the
otoacoustic emission (OAE) measurements. The cochlear
emissions were not measured. The OAE tests need additional
time for the measurements, and the extended anaesthesia
durations might have increased the mortality risk in the rats.
Moreover, using the ACTH analogues for the treatment of
hearing loss is a new application in the literature, and the

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effective ACTH doses are still controversial. A comparison of
the multiple ACTH dosages is required to establish the
minimum effective dosages. We hope this first provocative
study on the probable therapeutic effects of ACTH on NIHL
may lead researchers to overcome these limitations.
5. Conclusion
NIHL is a still a challenging problem for physicians.
Systemic steroids are an efficient treatment option against
acoustic trauma. Synthetic ACTH analogues demonstrate a
potential for the patients who could not tolerate the oral
glucocorticoid therapy or benefit from standard therapeutic
doses of glucocorticoids. This study demonstrated that both
systemic steroids and ACTH analogues exert a promising
therapeutic effect against NIHL. For this reason, ACTH
analogues may be an alternative treatment to systemic steroids
against acoustic trauma. The related results need to be
confirmed with further controlled prospective studies.
Financial support
No financial support was received for this study.
Ethical statement
Compliance with ethical standards The study was performed
in accordance with the 2011 Guide for the Care and Use of
Laboratory Animals.
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