Emerging options in immune-mediated hearing loss

Cogan's syndrome. A comprehensive review

Cogan Syndrome (CS) is a rare autoimmune systemic vasculitis affecting the inner ear and the eye with systemic manifestations affecting mainly young adults. The clinical presentation is historically classified in two subtypes. Typical CS associated interstitial keratitis with audio-vestibular symptoms with a 2-year maximum delay between these 2-organ involvements. Atypical CS subgroup associated inflammatory ocular disease in the absence of interstitial keratitis, audio-vestibular impairment, and systemic manifestations in a delay longer than 2 years between different organ manifestations. Neither diagnostic criteria nor specific biomarkers could lead to definite diagnosis. Cogan syndrome is a diagnosis of exclusion after a meticulous appropriate investigation to rule out other conditions. Disease prognosis is related to the risk of deafness and/or blindness as well as complications related to systemic vasculitis. Early recognition of this condition and early intervention can minimize disabling and irreversible damage. Treatment of CS is challenging, and the only available data comes from case reports and series. The aim of this review is to describe the clinical spectrum and outcome of CS through a summary of published case series, the differential diagnosis, and the therapeutic approaches with a special focus on the recent novel therapeutic options in the biological era.

Current and emerging approaches to cochlear immunosuppression with translation to human inner ear stem cell therapy: A systematic review

Hearing loss is a significant health burden across all stages of life. One in 5 people suffer hearing loss, with 5% of the world's population experiencing disabling hearing loss. A large proportion of this loss is the consequence of damage or loss of neurosensory structures, termed "sensorineural" hearing loss. A recent advance in the treatment of sensorineural hearing loss has occurred, with the advent of inner ear stem cell therapy. Focus has pivoted from augmenting existing neural structures to regenerating neural frameworks. To date, stem cell therapy is limited by the host immune system and rejection of donor cells. A better understanding of immunity in the inner is ear required to progress stem cell therapy for hearing loss. This review outlines a contemporary understanding of the inner ear immune system. We discuss concepts of immune dysregulation that may lead to common inner ear pathologies, and, in doing so, review the efficacy of current pharmacotherapies that mitigate end organ damage through a process of immunosuppression. Current literature is appraised through a systematic review exploring two areas of focus; immunosuppression therapies for the treatment of inner ear pathology associated immune dysregulation, and, subsequently, the efficacy of immunosuppressive agents in translational models of inner ear stem cell therapy. Through greater understanding of these concepts, and systematic appraisal of the literature, this review summarises the literature for contemporary immunosuppressive regimes that may facilitate stem cell accommodation in the cochlea and auditory nerve.

Infliximab in Autoimmune Inner Ear Disease: A Case Report

Autoimmune inner ear disease (AIED) is characterized by bilateral, asymmetric, and fluctuating sensorineural hearing loss (SNHL) with no identifiable cause that responds to immunosuppressive therapy. Diagnosis can be challenging due to a lack of standardized diagnostic criteria and pathognomonic tests. The mainstay of treatment is corticosteroids; however, only a small number of patients remain responsive after prolonged use. There are no agreed treatment protocols for AIED following corticosteroids, as there is limited data from randomized controlled trials. We report a case of a 27-year-old man with secondary AIED on a background of ulcerative colitis (UC) who experienced frequent relapses and deterioration in his hearing despite multiple courses of high-dose corticosteroids. He received methotrexate and azathioprine but did not show clinical or audiometric improvement. After the commencement of infliximab infusions, his symptoms of AIED and UC improved, and his hearing remained stable without further use of oral corticosteroid therapy. The available studies on the efficacy of biologic therapy are limited and have produced variable results, with the majority of the data relying mainly on case reports and case series. Large, multicenter randomized controlled trials are required to confirm its efficacy in the management of AIED.

Prevalence and Intriguing Clinical Profiles of Autoimmune Inner Ear Diseases in Sudden Sensorineural Hearing Loss

INTRODUCTION

Sudden sensorineural hearing loss (SSNHL) is idiopathic in 70-90% of cases with 10-30% linked to vascular injuries, viral infections, or autoimmune inner ear disease (AIED). AIED contributes to less than 1% of all hearing losses, categorized into primary, affecting only the inner ear, and secondary, associated with systemic autoimmune diseases (SAID). This study examines the prevalence and features of AIED in SSNHL in a tertiary referral center.

MATERIALS AND METHODS

We conducted a prospective study from November 2021 to December 2022 including SSNHL patients who exhibited symptoms like hearing loss or tinnitus. Evaluations included tympanometry, pure tone audiometry, and blood tests, with suspected AIED cases further assessed by rheumatologists using Lobo's diagnostic criteria. Treatment responses were monitored through regular audiometry updates.

RESULTS

Out of 694 SSNHL patients, 43 (6.2%) were diagnosed with AIED, of which 36 (83.7%) had primary AIED and 7 (16.3%) had secondary AIED linked to conditions like Sjögren's syndrome and systemic lupus erythematosus. Treatment response was seen in 19.4% of primary and 42.9% of secondary AIED cases.

CONCLUSION

The prevalence of AIED in SSNHL patients was found to be 6.2%, with a notable fraction also suffering from SAID. Responses to treatment were positive in about a third of these cases, highlighting the importance of interdisciplinary management for this rare yet significant cause of SSNHL.

Brazilian Society of Otology task force - cochlear implant ‒ recommendations based on strength of evidence

OBJECTIVE

To make evidence-based recommendations for the indications and complications of Cochlear Implant (CI) surgery in adults and children.

METHODS

Task force members were educated on knowledge synthesis methods, including electronic database search, review and selection of relevant citations, and critical appraisal of selected studies. Articles written in English or Portuguese on cochlear implantation were eligible for inclusion. The American College of Physicians' guideline grading system and the American Thyroid Association's guideline criteria were used for critical appraisal of evidence and recommendations for therapeutic interventions.

RESULTS

The topics were divided into 2 parts: (1) Evaluation of candidate patients and indications for CI surgery; (2) CI surgery - techniques and complications.

CONCLUSIONS

CI is a safe device for auditory rehabilitation of patients with severe-to-profound hearing loss. In recent years, indications for unilateral hearing loss and vestibular schwannoma have been expanded, with encouraging results. However, for a successful surgery, commitment of family members and patients in the hearing rehabilitation process is essential.

Investigating the Process of Autoimmune Inner Ear Disease: Unveiling the Intricacies of Pathogenesis and Therapeutic Strategies

Autoimmune inner ear disease (AIED) is a rare condition characterized by immune-mediated damage to the inner ear, leading to progressive sensorineural hearing loss (SNHL) and vestibular symptoms such as vertigo and tinnitus. This study investigates the pathogenesis and therapeutic strategies for AIED through the analysis of three cases with different underlying autoimmune disorders: rheumatoid arthritis, relapsing polychondritis, and IgG4-related disease. The etiology of AIED involves complex immunopathological mechanisms, including molecular mimicry and the "bystander effect," with specific autoantibodies, such as those against heat shock protein 70 (HSP70), playing a potential role in cochlear damage. Diagnosis remains challenging due to nonspecific symptoms and the lack of distinct biomarkers, emphasizing the need for comprehensive clinical evaluation and exclusion of other hearing loss causes. Treatment primarily involves immunosuppressive therapies, with glucocorticoids as the first line, effective in 70% of cases. However, resistance or partial response necessitates the use of additional agents like methotrexate and biologics such as anti-TNF and IL-6 receptor antagonists. Early intervention is crucial for favorable outcomes, as demonstrated in the studied cases, where timely corticosteroid and immunosuppressive treatments led to significant hearing improvement. The study underscores the importance of personalized treatment strategies based on individual immunologic profiles and comorbidities. Our findings highlight the heterogeneity of AIED and the potential for biologic therapies in refractory cases.

Audiovestibular outcomes in adult patients with cogan syndrome: a systematic review

PURPOSE

To determine factors associated with steroid responsiveness and efficacy of biologic disease-modifying anti-rheumatic (DMARD) use in patients with Cogan Syndrome (CS).

METHODS

A systematic search of Cochrane Library, PubMed, CINAHL, and Scopus was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Any study describing audiometric or vestibular data and pharmacologic treatment in patients with CS was included. Due to limited literature, only case reports/case series were included.

RESULTS

Seventy case reports or case series studies comprising 79 individual cases of CS were included. A difference in vestibular symptoms with a higher prevalence in the steroid-resistant group than the steroid-responsive group was found (79.5% vs 57.9%, p = 0.04). Eighteen (60.0%) patients treated only with oral steroids had no audiological improvement, while twelve (n = 12; 85.7%) patients treated with biologic DMARD showed audiological improvement. The steroid-responsive group had an overall better response to DMARDs than the steroid-resistant group (62.1% vs 45.0%; 100.0% vs 77.8%).

CONCLUSIONS

Our study synthesized the available literature to better characterize steroid resistance in patients with Cogan syndrome and treatment outcomes. Vestibular symptoms were noted to be more prevalent in patients who were eventually labeled as steroid resistant. There were higher rates of audiological improvement in patients given biologic DMARDs rather than conventional DMARDs or steroids only. Further studies are needed to characterize each individual vestibular symptom and investigate the utility and timing of biologic DMARDs in managing patients with Cogan syndrome.

Increasing Utilization of Intratympanic Injections among Medicare Fee-for-Service Providers

OBJECTIVE

To characterize national practice patterns and geographic variations in intratympanic injections among Medicare providers.

STUDY DESIGN

Retrospective cross-sectional analysis of intratympanic injections performed in the Medicare fee-for-service population from 2013 to 2021.

SETTING

Center for Medicare & Medicaid Services Physician and Other Practitioners database.

PARTICIPANTS

Providers performing outpatient intratympanic injections, documented by Current Procedural Terminology code 69801.

INTERVENTIONS

Intratympanic injections.

MAIN OUTCOME MEASURES

The number of intratympanic injections performed by individual providers, states, and geographic regions, as well as reimbursements, was analyzed annually.

RESULTS

A total of 159,236 in-office intratympanic injections were performed. The Center for Medicare & Medicaid Services reimbursed $25,407,086; out-of-pocket patient costs were $6,591,514. The mean Medicare reimbursement rate and out-of-pocket cost per injection were $159.56 and $41.38, respectively. From 2013 to 2021, the number of intratympanic injections increased from 13,117 to 20,711 injections, representing a 57.9% increase. On linear regression, an additional 989.9 injections were performed each year (95% CI 766.4-1,213.4, p < 0.001). The number of providers performing injections also increased from 1,828 to 2,834 from 2013 to 2021 ( b = 125.6 [95% CI 111.3-140.0], p < 0.001). The population-controlled annual mean number of injections varied substantially across the United States, ranging from 12.0 injections per 100,000 beneficiaries in Oklahoma to 255.2 injections per 100,000 beneficiaries in Alabama.

CONCLUSIONS

The number of intratympanic injections administered in the Medicare population has increased from 2013 to 2021. There is variability in practice patterns and utilization of intratympanic injections among otolaryngologists in the United States.

A Retrospective Study of Clinical Profile of Patients with Autoimmune Inner Ear Disease

Bilateral sensorineural hearing loss can be a very distressing symptom and can affect the efficiency of a person and one's quality of life. Conditions causing bilateral hearing loss are very few and autoimmune aetiology is one of them. Autoimmune ear disease is characterised by bilateral, mostly fluctuating audiovestibular symptoms and symptoms which respond to steroids. Diagnosis of AIED presents a unique challenge to clinicians due to the lack of standardized diagnostic criteria or reliable pathognomonic tests. The purpose of the study is to evaluate the patients who fit into criteria of autoimmune inner ear disease and understand the clinical features and response to medications for the same. A retrospective chart review of patients presenting with rapidly progressive bilateral hearing loss was done. The clinical presentation including detailed history and examination findings along with the blood investigation reports and audiograms were recorded in a tabular form. The study included 6 patients - 3 male and 3 female patients. Age of the patients at onset of hearing loss varied between 24-35 years. 3 of 6 patients presented with primary autoimmune ear disease and other 3 had hearing loss secondary to systemic autoimmune disease. All patients were treated with systemic steroids, but however showed a varied response. Patients with primary AIED were administered inner ear steroid therapy as well. AIED is thus a diagnosis of exclusion done with high index of suspicion. Patients with bilateral progressive sensorineural hearing loss should be evaluated for autoimmune etiology. Oral steroids with intratympanic steroids are currently the mainstay of treatment for AIED. Guarded prognosis of hearing improvement is noted in these patients. Hence, emphasis should be placed on early hearing rehabilitation for better quality of life.

Secondary autoimmune immune ear disease (AIED): a systematic review and meta-analysis on vestibular manifestations of systemic autoimmune and inflammatory disorders

Secondary autoimmune inner ear disease (AIED) is often bilateral and asymmetric in patients presenting with audiovestibular symptoms due to a systemic autoimmune disease. This systematic review and meta-analysis are aimed at identifying and highlighting patterns in prevalence of vestibular dysfunction, symptom presentation, and diagnostic methods in extant literature by combining clinical context from case reports with quantitative analyses from cohort studies. Screening of articles by title, abstract, and full text was completed by four reviewers (K.Z., A.L., S.C., and S.J.). In this study, we grouped secondary AIED and systemic autoimmune diseases by pathophysiologic mechanism: (1) connective tissue disease (CTD), (2) vasculitides (VAS), (3) systemic inflammatory disorders (SID), and (4) other immune-mediated disorders (OIMD). The search for AIED disease identified 120 articles (cohorts and case reports) that met the final inclusion criteria. All 120 were included in the qualitative review, and 54 articles were included for meta-analysis. Of these 54 articles, 22 included a control group (CwC). Ninety individual cases or patient presentations from 66 articles were included for analysis in addition to the 54 cohort articles. Secondary AIED does not have a diagnostic algorithm for managing vestibular symptoms. The management of audiovestibular symptoms requires close collaboration between otolaryngologists and rheumatologists to preserve end-organ function of the ear. To improve our ability to understand the impact on the vestibular system, vestibular clinicians need to develop a standardized reporting method. Clinical presentation should frequently be paired with vestibular testing to contextually investigate symptom severity and provide higher quality care.

Paediatric Cogan´s syndrome - review of literature, case report and practical approach to diagnosis and management

BACKGROUND

Cogan´s syndrome is a rare, presumed autoimmune vasculitis of various vessels characterized by interstitial keratitis and vestibular impairment accompanied by sensorineural hearing loss. Due to the rarity of Cogan´s syndrome in children, therapeutic decision making may be challenging. Therefore, a literature search was performed to collect all published paediatric Cogan´s syndrome cases with their clinical characteristics, disease course, treatment modalities used and their outcome. The cohort was supplemented with our own patient.

MAIN TEXT

Altogether, 55 paediatric Cogan´s syndrome patients aged median 12 years have been reported so far. These were identified in PubMed with the keywords "Cogan´s syndrome" and "children" or "childhood". All patients suffered from inflammatory ocular and vestibulo-auditory symptoms. In addition, 32/55 (58%) manifested systemic symptoms with musculoskeletal involvement being the most common with a prevalence of 45%, followed by neurological and skin manifestations. Aortitis was detected in 9/55 (16%). Regarding prognosis, remission in ocular symptoms was attained in 69%, whereas only 32% achieved a significant improvement in auditory function. Mortality was 2/55. Our patient was an 8 year old girl who presented with bilateral uveitis and a history of long standing hearing deficit. She also complained of intermittent vertigo, subfebrile temperatures, abdominal pain with diarrhoea, fatigue and recurrent epistaxis. The diagnosis was supported by bilateral labyrinthitis seen on contrast-enhanced magnetic resonance imaging. Treatment with topical and systemic steroids was started immediately. As the effect on auditory function was only transient, infliximab was added early in the disease course. This led to a remission of ocular and systemic symptoms and a normalization of hearing in the right ear. Her left ear remained deaf and the girl is currently evaluated for a unilateral cochlear implantation.

CONCLUSIONS

This study presents an analysis of the largest cohort of paediatric Cogan´s syndrome patients. Based on the collected data, the first practical guide to a diagnostic work-up and treatment in children with Cogan´s syndrome is provided.

Immunohistochemical localization of glucocorticoid receptors in the human cochlea

In the present study we investigated the localization of glucocorticoid receptors (GCR) in the human inner ear using immunohistochemistry. Celloidin-embedded cochlear sections of patients with normal hearing (n = 5), patients diagnosed with MD (n = 5), and noise induced hearing loss (n = 5) were immunostained using GCR rabbit affinity-purified polyclonal antibodies and secondary fluorescent or HRP labeled antibodies. Digital fluorescent images were acquired using a light sheet laser confocal microscope. In celloidin-embedded sections GCR-IF was present in the cell nuclei of hair cells and supporting cells of the organ of Corti. GCR-IF was detected in cell nuclei of the Reisner's membrane. GCR-IF was seen in cell nuclei of the stria vascularis and the spiral ligament. GCR-IF was found in the spiral ganglia cell nuclei, however, spiral ganglia neurons showed no GCR-IF. Although GCRs were found in most cell nuclei of the cochlea, the intensity of IF was differential among the different cell types being more intense in supporting cells than in sensory hair cells. The differential expression of GCR receptors found in the human cochlea may help to understand the site of action of glucocorticoids in different ear diseases.

[Autoimmune hearing loss and a chance of its development in children: literature review and own observations]

Autoimmune sensorineural hearing loss (AiSNHL) is an uncommon auditory disorder characterized by rapidly progressive bilateral hearing loss and a positive clinical response to treatment with corticosteroids and cytostatics. The prevalence of the disease in the adult population is less than 1% among all cases of subacute and permanent sensorineural hearing loss (precise data are unknown), it is even rarer in children. AiSNHL can be primary (isolated, organ-specific) or secondary (manifestation of another systemic autoimmune disease). The pathogenesis of AiSNHL is based on the proliferation of autoaggressive T cells and the pathological production of autoantibodies to the protein structures of the inner ear, which leads to damage to various parts of the cochlea (possibly also to the retrocochlear parts of the auditory system), less frequently to the vestibular labyrinth. Pathologically, the disease is most often represented by cochlear vasculitis with degeneration of the vascular stria, damage to hair cells and spiral ganglion cells, and endolymphatic hydrops. In 50% of cases, the result of autoimmune inflammation may be fibrosis and/or ossification of the cochlea. The most characteristic symptoms of AiSNHL at any age are episodes of sudden progression of hearing loss, fluctuations of hearing thresholds, and bilateral, often asymmetric impairments. The article presents contemporary ideas of the clinical and audiological manifestations of AiSNHL, the possibilities of diagnosing and treating the disease, and highlights the current approaches to (re)habilitation. Along with literature data, two own clinical cases of an extremely rare pediatric AiSNHL are given.

Sensorineural Hearing Loss in Sjögren’s Syndrome

Sjögren’s syndrome is a chronic autoimmune disease characterized by systemic dysfunction of exocrine glands, mainly the salivary and lachrymal glands. Sjögren’s syndrome consists of two forms: primary Sjögren’s syndrome, which is characterized by dry eyes and dry mouth without autoimmune diseases; and secondary Sjögren’s syndrome, which is characterized by symptoms associated with other autoimmune diseases, such as systemic lupus erythematosus. Disease severities vary considerably from mild glandular dryness to severe glandular involvement with numerous extraglandular and systemic features. Sensorineural hearing loss is sometimes observed in both primary and secondary Sjögren’s syndrome. This review article consists of (1) Pathology of Sjögren’s syndrome, (2) Clinical manifestation of Sjögren’s syndrome, (3) Autoimmune inner ear disease, (4) Histoanatomical features of the inner ear, (5) Immunological characteristics of the inner ear, (6) Pathophysiology of autoimmune inner ear disease, (7) Treatment for sensorineural hearing loss in Sjögren’s syndrome, and (8) Future direction. Finally, we introduce a recently developed disease model of salivary gland inflammation and discuss future expectations for the treatment of sensorineural hearing loss in Sjögren’s syndrome.

Association of sleep duration and noise exposure with hearing loss among Chinese and American adults: two cross-sectional studies

OBJECTIVES

To examine the associations of sleep duration (SPD) and noise exposure with hearing loss (HL) among Chinese and American adults.

DESIGN

Two cross-sectional studies.

SETTING

The National Health and Nutrition Examination Survey (2011-2012), and Zhejiang Chinese participants between 1 January 2018 and 1 November 2021.

PARTICIPANTS

3322 adults from the USA and 4452 adults from Zhejiang, China.

MAIN OUTCOME MEASURES

HL was defined as a pure-tone average >20 dB in the better ear at low frequency (500, 1000 and 2000 Hz), speech frequency (500, 1000, 2000 and 4000 Hz) or high frequency (3000, 4000, 6000 and 8000 Hz). Binary logistic regression analysis quantified the associations between SPD, noise exposure (at work or off-work) and HL.

RESULTS

SPD ≥8 hours/night had an OR of 0.71 (95% CI 0.59 to 0.84) for high-frequency HL vs. an SPD of 6-8 hours/night among the Chinese participants but had an OR of 1.28 (95% CI 1.03 to 1.58) among American participants. Noise exposure (both at work and off-work) was associated with poorer low-frequency (OR 1.58, 1.43; p<0.05), speech-frequency (OR 1.63, 1.29; p<0.05) and high-frequency (OR 1.37, 1.23; p<0.05) hearing among the Chinese participants; and it was associated with worse high-frequency hearing (OR 1.43, 1.66; p<0.05) among the American participants. The negative relationship between SPD ≥8 hours/night and HL was mainly observed in the Chinese participants with noise exposure (OR <1, p<0.05), and SPD ≥8 hours/night associated with poorer HF hearing was only identified in the American participants without noise exposure (OR >1, p<0.05).

CONCLUSIONS

Noise exposure was associated with poorer hearing. SPD ≥8 hours/night was negatively associated with HL in the Chinese participants especially when exposed to noise. SPD ≥8 hours/night was related to poorer high-frequency hearing in the American participants when they had no noise exposure.

Hearing restoration and the stria vascularis: evidence for the role of the immune system in hearing restoration

PURPOSE OF REVIEW

This article reviews the current literature regarding the pathogenesis of immune-mediated sensorineural hearing loss, utilizes previously published single-nucleus transcriptional profiles to characterize cytokine and cytokine receptor expression in the adult stria vascularis cell types to support immune system interaction with the stria vascularis and reviews the current literature on immunomodulatory agents currently being used for hearing-restoration treatment.

RECENT FINDINGS

The literature review highlights recent studies that elucidate many cytokines and immune markers, which have been linked to various immune-mediated disease processes that have been observed with sensorineural hearing loss within the stria vascularis and highlights recent publications studying therapeutic targets for these pathways.

SUMMARY

This review highlights the current literature regarding the pathogenesis of immune-mediated hearing loss. The role of cochlear structures in human temporal bones from patients with immune-mediated sensorineural hearing loss are highlighted, and we review cytokine signalling pathways relevant to immune-mediated sensorineural hearing loss and localize genes encoding both cytokine and cytokine receptors involved in these pathways. Finally, we review immunomodulatory therapeutics in light of these findings and point to opportunities for the application of novel therapeutics by targeting these signalling pathways.

Autoimmune inner ear disease: A systematic review of management

OBJECTIVES

The study systematically reviewed the existing literature on the management of autoimmune inner ear disease (AIED).

STUDY DESIGN

Systematic review.

METHODS

We performed a literature search of Embase, NCBI, Cochrane, and Web of Science databases from April 1990 to April 2020. Inclusion criteria included studies that were retrospective or prospective in nature evaluating the treatment of AIED with audiometric data measuring hearing outcomes during treatment. Hearing improvement was the primary study outcome and improvement in vestibular symptoms was the secondary study outcome.

RESULTS

Sixteen of 412 candidate articles were included in our study. Systemic steroid treatment is most commonly described. Alternative treatment modalities included intratympanic steroid treatment, methotrexate, cyclophosphamide, azathioprine, infliximab, etanercept, adalimumab, golimumab, methylprednisolone, rituximab, and anakinra.

CONCLUSION

Systemic corticosteroids are the first line treatment of AIED. Intratympanic steroids are a potential adjuvant or alternative treatment for patients who cannot tolerate or become refractory to steroid treatment. Steroid nonresponders may benefit from biologic therapy. Alternative treatment modalities including nonsteroidal immunosuppressants and biologics have been studied in small cohorts of patients with varying results. Prospective studies investigating the efficacy of biologic and nonsteroidal therapy are warranted.

LEVEL OF EVIDENCE

2.

[Syncope, pain in the large joints, and painful swelling of the right eye in a 51-year-old patient : Pitfalls in the diagnosis and treatment of a rare disease]

In the present case we report on a 51-year-old patient diagnosed with Cogan syndrome. This vasculitis of variable vessel size is a rare disease that poses a major challenge for the correct diagnostics and therapy. In the classic setting, it comprises a triad of non-syphilitic interstitial keratitis as well as hearing loss with vestibular dysfunction. A vascultis-related aortitis, an uncertain, more likely degenerative structure in combination with strongly elevated inflammation parameters was misinterpreted as infective endocarditis for a long time and treated with anti-infective medications. After diagnosis the patient recovered following treatment with high-dose steroids and in the further course cyclophosphamide and tumor necrosis factor‑α blockers.

The Role of Anti-Endothelial Cell Autoantibodies and Immune Response in Acute Low-Tone Hearing Loss

OBJECTIVE

Immunity is associated with acute low tone hearing loss. However, the exact pathophysiology of immunity-mediated acute low tone hearing loss remains unknown. In this study, we evaluated the presence, therapeutic effectiveness, and immunopathological mechanisms of anti-endothelial cell autoantibodies (AECEs) in patients with acute low-frequency hearing loss.

MATERIAL AND METHODS

Forty-nine patients who were treated as inpatients having acute low-frequency hearing loss and additional symptoms, such as ear fullness, tinnitus, dizziness, or hyperacusis, were enrolled in this study. Serum samples from these patients were collected for laboratory serum autoimmunity detection, including AECAs, antinuclear antibodies, immunoglobulin, and circular immune complex. Therapeutic responses to combination therapy in short-term outcome and serum cytokine levels were compared between AECA-positive and AECA-negative patients.

RESULTS

Anti-endothelial cell autoantibodies-positive patients tended to show significantly less response to standard therapy compared with AECAs controls (P < .05). Moreover, some serum cytokine levels elevated in both AECAs- and AECAs+ groups. Positive ratio of interleukin-8 and concentrations of macrophage inflammatory protein-1α were found higher in AECAs+ groups (P < .05).

CONCLUSION

The results supported that AECAs might wield influence on the short-term outcome of acute low-tone hearing loss (ALHL) treatment. Furthermore, AECA-mediated acute low-frequency hearing loss possibly involved dysregulation of inflammation process and release of cytokines.

Cogan's Syndrome: Clinical Presentations and Update on Treatment

PURPOSE OF REVIEW

Cogan's syndrome (CS) is a rare systemic vasculitis that can severely affect vision and hearing, which may also have significant systemic effects. Early recognition of this autoimmune disorder and intervention can minimize disabling and irreversible damage.

RECENT FINDINGS

This article will review the varying clinical presentations of CS and emerging information of systemic disease associated with CS. We will also review recently published promising treatment outcomes using immune modulating medications. As our framework for recognizing the markers of CS and the associated systemic disorders expands, more effective guidelines and treatment options may emerge.

Pediatric Autoimmune Inner Ear Disease: A Rare, But Treatable Condition

Autoimmune inner ear disease (AIED) is a rare, but treatable cause of sudden sensorineural hearing loss in children. Most cases present acutely and involve both ears. The precise mechanism of hearing loss in AIED is not known. Many suspected etiologies have been proposed including infections, vascular abnormalities, and trauma. However, 70% of cases are defined as idiopathic. There are no standardized diagnostic criteria for AIED, and the diagnostic process may be challenging. Positive auto antibodies and response to immunosuppressive therapy support the diagnosis. Treatment may include corticosteroids and steroid-sparing immunosuppressive medications. A high index of suspicion is recommended as the hearing loss may be stabilized or even reversed with early treatment. Long-term medical treatment failures generally have good outcomes with cochlear implantation. [Pediatr Ann. 2019;48(10):e391-e394.].