A newer method of corticosteroid administration is by the intra-drum route. The treatment of patients who have failed to respond to systemic glucocorticoid therapy with intra-drum administration will be covered in another section of this guideline; intra-drum injection of glucocorticoids as initial therapy will be described here. parnes et al. published the first animal data and clinical series declaring higher inner ear hormone concentrations after intra-drum injection, which favors 1/3 of patients with certain otologic conditions in which higher efficiency was obtained. A subsequent series of laboratory data supported this statement by stating that ectolymphatic hormone concentrations were higher after intra-drum hormone injection. Following this, a large number of small uncontrolled and usually reviewed studies have shown the opposite results with intra-dural administration of hormones. To improve the poor prognosis, 25 patients with profound deafness were initially treated with a combination of oral and intra-drum administration, and only 3 had positive results. However, intra-dural injection of high doses of prednisone with gradual taper resulted in full or partial recovery of hearing in 14 of 16 patients. Another study combining oral and intra-implantation glucocorticoids did not show more effective hearing restoration than alone. A recent study recommended intra-dural administration alone as the initial treatment regimen, which consisted of early continuous injection for 3 days, and only 3 of 34 subjects did not recover their hearing. A systematic review summarizes that intra-thalamic hormone infusion is a valuable approach for patients suffering from idiopathic sensorineural deafness who either cannot tolerate systemic dosing or who do not persist. Intratympanic infusion of glucocorticoids may be a revolutionary approach. Intratympanic injection of hormones is usually done with dexamethasone or succinyl prednisolone. Laboratory studies have shown that histamine and hyaluronic acid act as mediators to facilitate the transfer of glucocorticoids across the round window membrane. Intra-drum infusion of glucocorticoids has shown immunosuppressive and ion balancing effects. The concentration of glucocorticoids used varies widely from study to study; most studies have used 10-24 mg/mL dexamethasone and 30 mg/mL succinyl prednisolone or higher for intra-drum chamber glucocorticoid infusion. Higher concentrations have been shown to give better results. The frequency of hormone infusion in the tympanic chamber also varies greatly from study to study. From patients self-administering several times a day via a pressure pump, to physicians administering once a day, and in some cases once a week or less. Moreover, intra-drum chamber dosing is reported to be either initial therapy, subsequent therapy, or remedial therapy. In this way, these varied studies of intra-drum chamber drug administration are difficult to evaluate uniformly, but more rigorous studies are cited for reasons of success in justifying initial treatment. Although potentially much less toxic than systemic glucocorticoid administration, intra-drum chamber administration of glucocorticoids can also have side effects. These include infrequent but present pain, transient vertigo, infection, permanent tympanic membrane perforation, vasovagal neurological reactions or syncopal episodes during drug injection, high costs, and multiple visits to the doctor. The only randomized controlled study of oral contrast tympanic chamber injection of hormones in idiopathic sensorineural deafness was conducted at 16 medical centers and included 250 patients. All patients were enrolled within 14 days of the onset of sensorineural deafness. As initial treatment, the effects of prompt medical attention and equivalent doses of oral and intra-dural administration appeared to be approximately equal, with hearing improvement in more than 75% of the patients treated. Since the hearing improvement results were the same for both groups, physicians judged that the choice of treatment regimen could and should be based on other considerations, such as the risk of side effects and cost. Side effects such as increased blood sugar, increased thirst, and changes in eating and sleeping habits occurred in 88% of the oral group and transient pain during injection and transient fever and dizziness occurred in 90% of patients in the intra-drum injection group. These side effects were predictable and manageable in advance, with most recovering after 1-2 weeks and very few permanent tympanic membrane perforations for up to 6 months.