TNF and ischemia: The main roles of steroids in the treatment of ISSHL are: (i) the protection of cochlea from the harmful effects of inflammatory mediators, such as the tumor necrosis factor (TNF-α and NF-κB) and cytokines (interleukin 1 and 6), which is elevated in infection and flogosis [16, 19]; (ii) increasing cochlear blood flow [20] thereby avoiding cochlear ischemia [21]; (iii) avoiding noise-induced hearing loss [22]; (iv) regulating protein synthesis in the inner ear [23].