Hearing loss in autoimmune disorders: Prevalence and therapeutic options

Examining the Relationship Between Hearing Health Beliefs and Social Determinants of Health in Black Adults

OBJECTIVES

Hearing loss is a highly prevalent condition; however, it is widely under-treated, and Black Americans have been found to have significantly lower rates of hearing aid utilization than other ethnic/racial groups. In this exploratory study, we aimed to identify hearing health beliefs among Black adults, guided by the Health Belief Model, with social determinants of health, and examine individual differences in these perspectives.

DESIGN

The Hearing Beliefs Questionnaire (HBQ) was administered online to measure constructs of the Health Belief Model among 200 Black adults aged 18 to 75 (M = 39.14, SD = 14.24). Approximately 13% reported hearing difficulty. In addition, 11 social determinants of health questions were included. Participants were recruited from a university otolaryngology clinic and local Black congregations, meeting inclusion criteria of being 18 or older and Black/African American. Mean scores and SDs for HBQ subscales were calculated. Analysis included analysis of variance and t tests to explore relationships with demographic variables and social determinants of health. Multiple regression analyses predicted HBQ subscale scores from sociodemographic variables.

RESULTS

Mean HBQ subscale scores ranged from 3.88 (SD = 2.28) for Perceived Barriers to 6.76 (SD = 1.93) for Perceived Benefits. Positive correlations were observed between Perceived Severity, Perceived Benefits, and Perceived Self-Efficacy scores and participant educational attainment. Lower economic stability was correlated with poorer scores in Perceived Self-Efficacy, Perceived Severity, and Perceived Benefits. Black adults' willingness to purchase a hearing aid was heavily influenced by their Perceived Benefit, Perceived Severity, and Perceived Self-Efficacy scores, with lower scores correlating with unwillingness to purchase devices. Higher frequency of racism/discrimination and financial hardship correlated with increased Perceived Barriers scores for accessing hearing healthcare. In addition, hearing health beliefs between participants with self-reported hearing difficulty and those without trouble only exhibited differences in the Perceived Susceptibility subscale, with those experiencing hearing difficulty having higher scores in this subscale; no other distinctions were identified.

CONCLUSIONS

The Health Belief Model, used with social determinants of health, revealed associations, and variations, in the hearing health beliefs held by Black adults. The present investigation reveals heterogeneity within this group and pinpoints individuals at higher risk for untreated hearing loss, stemming from their negative perceptions about hearing healthcare. These beliefs are influenced by demographics and social determinants of health, underscoring areas ripe for intervention.

Clinical Practice Guideline: Age-Related Hearing Loss

OBJECTIVE

Age-related hearing loss (ARHL) is a prevalent but often underdiagnosed and undertreated condition among individuals aged 50 and above. It is associated with various sociodemographic factors and health risks including dementia, depression, cardiovascular disease, and falls. While the causes of ARHL and its downstream effects are well defined, there is a lack of priority placed by clinicians as well as guidance regarding the identification, education, and management of this condition.

PURPOSE

The purpose of this clinical practice guideline is to identify quality improvement opportunities and provide clinicians trustworthy, evidence-based recommendations regarding the identification and management of ARHL. These opportunities are communicated through clear actionable statements with explanation of the support in the literature, evaluation of the quality of the evidence, and recommendations on implementation. The target patients for the guideline are any individuals aged 50 years and older. The target audience is all clinicians in all care settings. This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group (GDG). It is not intended to be a comprehensive, general guide regarding the management of ARHL. The statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experience and assessment of individual patients.

ACTION STATEMENTS

The GDG made strong recommendations for the following key action statements (KASs): (KAS 4) If screening suggests hearing loss, clinicians should obtain or refer to a clinician who can obtain an audiogram. (KAS 8) Clinicians should offer, or refer to a clinician who can offer, appropriately fit amplification to patients with ARHL. (KAS 9) Clinicians should refer patients for an evaluation of cochlear implantation candidacy when patients have appropriately fit amplification and persistent hearing difficulty with poor speech understanding. The GDG made recommendations for the following KASs: (KAS 1) Clinicians should screen patients aged 50 years and older for hearing loss at the time of a health care encounter. (KAS 2) If screening suggests hearing loss, clinicians should examine the ear canal and tympanic membrane with otoscopy or refer to a clinician who can examine the ears for cerumen impaction, infection, or other abnormalities. (KAS 3) If screening suggests hearing loss, clinicians should identify sociodemographic factors and patient preferences that influence access to and utilization of hearing health care. (KAS 5) Clinicians should evaluate and treat or refer to a clinician who can evaluate and treat patients with significant asymmetric hearing loss, conductive or mixed hearing loss, or poor word recognition on diagnostic testing. (KAS 6) Clinicians should educate and counsel patients with hearing loss and their family/care partner(s) about the impact of hearing loss on their communication, safety, function, cognition, and quality of life (QOL). (KAS 7) Clinicians should counsel patients with hearing loss on communication strategies and assistive listening devices. (KAS 10) For patients with hearing loss, clinicians should assess if communication goals have been met and if there has been improvement in hearing-related QOL at a subsequent health care encounter or within 1 year. The GDG offered the following KAS as an option: (KAS 11) Clinicians should assess hearing at least every 3 years in patients with known hearing loss or with reported concern for changes in hearing.

The Importance of Lassa Fever and Its Disease Management in West Africa

Lassa virus (LASV) is a zoonotic pathogen endemic throughout western Africa and is responsible for a human disease known as Lassa fever (LF). Historically, LASV has been emphasized as one of the greatest public health threats in West Africa, with up to 300,000 cases and 5000 associated deaths per year. This, and the fact that the disease has been reported in travelers, has driven a rapid production of various vaccine candidates. Several of these vaccines are currently in clinical development, despite limitations in understanding the immune response to infection. Alarmingly, the host immune response has been implicated in the induction of sensorineural hearing loss in LF survivors, legitimately raising safety questions about any future vaccines as well as efficacy in preventing potential hearing loss. The objective of this article is to revisit the importance and prevalence of LF in West Africa, with focus on Nigeria, and discuss current therapeutic approaches and ongoing vaccine development. In addition, we aim to emphasize the need for more scientific studies relating to LF-associated hearing loss, and to promote critical discussion about potential risks and benefits of vaccinating the population in endemic regions of West Africa.

Sex differences in autoimmune inner ear disease treatment and audiological outcomes

OBJECTIVE

The primary objective of this study was to assess possible sex-related differences in AIED treatment. The secondary aim was to assess the long-term outcomes of treatment using pre- and post-treatment audiometry and speech discrimination scores.

METHODS

Adult patients with a diagnosis of AIED who were treated for their condition at the senior author's (RTS) practice from 2010 to 2022 were included in this study. Patients were grouped as males or females for further analysis and comparison. Data included past medical history, medication use, surgical history and social history. Air-conduction thresholds (500 to 8000 Hz) were collected and averaged into discrete variables for pre- and post-treatment. The change (∆) and percent change (%∆) of these variables following therapy were analyzed. Speech discrimination score (SDS) testing results were taken at the same time points as pure tone averages, and patients were sub-stratified based on evidence of improvement in SDS and compared accordingly.

RESULTS

One hundred eighty-four patients (78 male/106 female) were included in this study. The mean age of the male participants was 57.18 ± 15.92 years, and the mean age of the female participants was 53.49 ± 16.04 years (p = 0.220). Comorbid autoimmune disease (AD) was more prevalent in females than in males (38.7 % vs. 16.7 %, p = 0.001). Of the patients treated with oral steroids, females received significantly more courses than males (2.554 ± 2.078 vs. 1.946 ± 1.301, p = 0.020). However, the average duration of oral steroids used per trial did not differ significantly between males and females (21.02 ± 18.05 vs. 20.62 ± 7.49, p = 0.135). Audiological results demonstrated that the change (∆) in pure tone average (PTA) at 0.5, 1, 2, and 3 kHz (-4.21 ± 6.394 vs. -3.91 ± 6.105) and high-frequency pure tone average (HFPTA) at 4, 6, and 8 kHz (-4.55 ± 6.544 vs. -2.19 ± 6.842) was not significantly different between the sexes following treatment (p = 0.376 and p = 0.101, respectively). Similarly, the percentage change (%∆) in PTA (-13.17 % vs. -15.01 %) and HFPTA (-8.50 % vs. -6.76 %) also did not differ significantly between males and females (p = 0.900 and p = 0.367, respectively). One hundred-five (57.1 %) patients qualified for the SDS improvement subgroup for analysis, with 50 (47.6 %) being male and 55 (51.9 %) being female (p = 0.159). The change (∆) in SDS (15.12 ± 21.159 vs. 10.62 ± 19.206) and the percentage change (%∆) in SDS (16.71 % vs. 12.40 %) also showed no significant difference between male and female patients (p = 0.312 and p = 0.313, respectively).

CONCLUSION

AIED is not a uniform condition regarding clinical presentation, audiological findings or progression, nor is its treatment straightforward. The utilization and duration of cytotoxic medications, as well as PTA and SDS findings, did not differ between the sexes. However, significantly more courses of oral steroids were prescribed to females than males. Sex as a biological variable and its implications in the pathogenesis and treatment of AIED warrant further study.

[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.

Assessment of Hearing and Vestibular Functions in a Post-COVID-19 Patient: A Clinical Case Study

SARS-CoV-2 infection may cause such complications as post-COVID-19 syndrome, which includes chronic fatigue, myalgia, arthralgia, as well as a variety of neurological manifestations, e.g., neuropathy of small fibers, hearing and vestibular dysfunction, and cognitive impairment. This clinical case describes a 41-year-old patient suffering from post-COVID-19 syndrome and chronic fatigue syndrome. A detailed examination was performed, including an in-depth study of peripheral and central hearing and vestibular functions, as well as small nerve fibers length and density in the skin and cornea of the eye. Contrary to expectations, no peripheral nervous system dysfunction was detected, despite the presence of dizziness and gait instability in the patient. Hearing tests (gap detection test and dichotic test) showed central auditory processing disorders. The evaluated lesion in the processing of temporal and verbal auditory information can be a significant factor contributing to additional overload of the neural activity and leading to chronic fatigue when performing daily activities in patients with CFS and post-COVID-19 complications.

Assessment of hearing loss in patients with rosacea

OBJECTIVES/AIMS

Rosacea is not only a skin condition but a systemic inflammatory disease that includes chronic inflammation, vascular alterations, and autoimmunity in pathogenesis. We aimed to evaluate the presence of a sensorineural hearing loss in the patients with rosacea in comparison with the healthy control group and, also to compare the audiometric results according to the severity of disease among the patient group.

METHODS

Fifty-three patients with erythematelangiectatic or papulopustular type of rosacea and 105 age- and sex-matched healthy controls were included. Each participant had audiometric measurements after a complete ear-nose-throat examination by the same otorhinolaryngologist.

RESULTS

The results of air and bone conduction thresholds showed statistically significant differences in particularly high frequencies between the groups in both the right and left ear (for all p < 0.05), but there was no correlation between audiometric measurements and the severity or the type of rosacea (p > 0.05).

CONCLUSIONS

Regardless of disease severity or type, rosacea patients are likely to have sensorineural hearing loss, and it is important to refer these patients in the early period.

Advancements in prevention and intervention of sensorineural hearing loss

The inner ear is a complex and difficult organ to study, and sensorineural hearing loss (SNHL) is a multifactorial sensorineural disorder with characteristics of impaired speech discrimination, recognition, sound detection, and localization. Till now, SNHL is recognized as an incurable disease because the potential mechanisms underlying SNHL have not been elucidated. The risk of developing SNHL is no longer viewed as primarily due to environmental factors. Instead, SNHL seems to result from a complicated interplay of genetic and environmental factors affecting numerous fundamental cellular processes. The complexity of SNHL is presented as an inability to make an early diagnosis at the earliest stages of the disease and difficulties in the management of symptoms during the process. To date, there are no treatments that slow the neurodegenerative process. In this article, we review the recent advances about SHNL and discuss the complexities and challenges of prevention and intervention of SNHL.

Idiopathic Inflammatory Arthritis in the Auditory Canal in a Patient With Hearing Impairment: A Case Report and Literature Review

Inflammatory arthritis can affect the auditory system during the disease course. Although most cases show asymptomatic hearing impairment, it can result in hearing loss. Here we describe the case of a 70-year-old female with hearing impairment associated with idiopathic inflammatory arthritis in her auditory system. She had suffered from hearing difficulties for decades; however, the causes of her hearing impairment had not been evaluated. Pure tone audiometry showed severe sensorineural hearing loss requiring a cochlear implant. The workup for the cochlear implant revealed erosive changes in the incudomalleolar and incudostapedial joints with soft tissue swelling on temporal bone computed tomography. Bone pathology revealed plasmacytic infiltration and granulomatous inflammation. Laboratory examinations showed elevated levels of inflammatory markers; otherwise, she had negative results for all autoantibodies. In patients with idiopathic hearing loss, inflammatory arthritis of the middle ear without peripheral arthritis can provide a clue regarding the cause of the hearing loss.

Autoimmune Vestibulopathy—A Case Series

Autoimmune inner ear disease (AIED) is a rare clinical entity. Its pathogenicity, heterogenous clinical presentation in the context of secondary systemic autoimmune disease and optimal treatment avenues remain poorly understood. Vestibular impairment occurring in the context of AIED is rarely subject to detailed investigation given that the auditory symptoms and their responsiveness to immunosuppression are the focus of the few proposed diagnostic criteria for AIED. We present three cases of vestibulopathy occurring in the context of autoimmune inner ear conditions, including the first known report of autoimmune inner ear pathology arising with a temporal association to administration of the Pfizer-BioNTech SARS-CoV2 vaccination. We review the available literature pertinent to each case and summarise the key learning points, highlighting the variable presentation of vestibular impairment in AIED.

[Triggers and predictors of development and formation of sensorineural hearing loss]

The purpose of the study is to review the results of scientific researches in recent years in an expanded interdisciplinary view of the problem of etiopathogenesis of sensorineural hearing loss, as well as the role of comorbidities and triggers in the formation of persistent changes in the audio-receiving part of the auditory analyzer.

Cochlear implant in immune mediated inner ear diseases: Impedance variations and clinical outcomes

OBJECTIVE

Immune-mediated inner ear disease (IMIED) might cause severe/profound hearing loss and these patients are considered ideal candidates to cochlear implant (CI) surgery. The aim of the study was to evaluate impedance changes over time.

METHOD

The Study Group (SG) was composed of CI IMIED patients (31 ears) and a Control Group (CG) of CI patients with hearing loss not related to their immune system (31 ears). Audiological performance and impedance values were measured and compared amongst groups at 3, 6, 12 and 18 months following the fitting sessions.

RESULTS

Speech perception was significantly better for SG in word and sentence recognition in quiet. Impedance values were, on average, significantly higher for apical and middle electrode segments in SG compared to CG at the 3- month follow-up and were maintained over time. Additionally, a subset of SG patients (active patients) experienced significantly greater impedance fluctuation corresponding to clinical symptom reactivation.

CONCLUSION

IMIED patients achieve good audiological performance. However, the relapsing inflammation could change the inner ear environment, causing impedance fluctuations and, consequently, more frequent CI fittings. Additionally, impedance evaluation could be utilized as an early warning sign of IMIED recurrence and as an aid to therapeutic decision-making.

Evidence of Hearing Loss and Unrelated Toxoplasmosis in a Free-Ranging Harbour Porpoise (Phocoena phocoena)

Simple Summary

Evidence of hearing impairment was identified in a female harbour porpoise (Phocoena phocoena) on the basis of inner ear analysis. The animal live stranded on the Dutch coast at Domburg in 2016 and died a few hours later. Ultrastructural examination of the inner ear revealed evidence of sensory cell loss, which is compatible with noise exposure. In addition, histopathology also revealed multifocal necrotising protozoal encephalitis. A diagnosis of toxoplasmosis was confirmed by positive staining of tissue with anti-Toxoplasma gondii antibodies; however, T. gondii tachyzoites were not observed histologically in any of the examined tissues. This is the first case of presumptive noise-induced hearing loss and demonstration of T. gondii cysts in the brain of a free-ranging harbour porpoise from the North Sea.

Abstract

Evidence of hearing impairment was identified in a harbour porpoise (Phocoena phocoena) on the basis of scanning electron microscopy. In addition, based on histopathology and immunohistochemistry, there were signs of unrelated cerebral toxoplasmosis. The six-year old individual live stranded on the Dutch coast at Domburg in 2016 and died a few hours later. The most significant gross lesion was multifocal necrosis and haemorrhage of the cerebrum. Histopathology of the brain revealed extensive necrosis and haemorrhage in the cerebrum with multifocal accumulations of degenerated neutrophils, lymphocytes and macrophages, and perivascular lymphocytic cuffing. The diagnosis of cerebral toxoplasmosis was confirmed by positive staining of protozoa with anti-Toxoplasma gondii antibodies. Tachyzoites were not observed histologically in any of the examined tissues. Ultrastructural evaluation of the inner ear revealed evidence of scattered loss of outer hair cells in a 290 µm long segment of the apical turn of the cochlea, and in a focal region of ~ 1.5 mm from the apex of the cochlea, which was compatible with noise-induced hearing loss. This is the first case of concurrent presumptive noise-induced hearing loss and toxoplasmosis in a free-ranging harbour porpoise from the North Sea.

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.

The use of gene-modified bone marrow mesenchymal stem cells for cochlear cell therapy

BACKGROUND

The aim of this study was to investigate the potential of using bone marrow mesenchymal stem cells (BMSCs) for treatment of inflammation and autoimmune sensorineural hearing loss.

METHODS

Fifty-five immunized guinea pigs were divided into five groups. Group A received BMSCs expressing IL-4, group B received BMSCs expressing an empty carrier vector, group C received recombinant lentivirus expressing IL-4, group D received recombinant lentivirus expressing an empty carrier vector, and group E received phosphate-buffered saline. Auditory function was monitored using brain stem responses (ABRs) to evaluate the auditory changes. The distribution of implanted BMSCs in the inner ear was estimated using fluorescence microscopy. The distribution and expression of IL-4 gene products in the inner ear were detected via immunohistochemistry.

RESULTS

After transplantation, the ABR III wave threshold decreased significantly in BMSCs expressing exogenous IL-4 group (group A), BMSCs expressing empty carrier vector group (group B), and recombinant lentivirus expressing IL-4 group (group C) (P < 0.001), which means the auditory functions of the experimental guinea pigs were improved. Further statistical analysis revealed that BMSCs expressing exogenous IL-4 group (group A) and BMSCs expressing empty carrier vector group (group B) were able to improve the auditory function more obviously (P < 0.05). Lentivirus-infected BMSCs were able to migrate to the inner ear. Fluorescence-positive BMSCs were scattered in the scala tympani and vestibule.

CONCLUSIONS

These results demonstrated that BMSCs expressing exogenous IL-4 successfully migrated into the inner ear in an in vitro study. BMSCs expressing exogenous IL-4 and BMSCs can be used to treat inflammatory injury in autoimmune inner ear diseases.

Evaluation of inner ear and hearing functions in lichen planus patients

BACKGROUND

Lichen planus (LP), which affects skin, nails, hair, and mucosal surfaces, is a chronic, autoimmune, and inflammatory disease, and autoimmune diseases may affect the inner ear.

AIMS

This study aims to investigate hearing and inner ear functions of the LP patients.

PATIENTS/METHODS

The present study was formed by 49 patients who were clinically and histopathologically diagnosed with LP and did not receive any treatment. The healthy group consisted of 52 healthy individuals. Pure tone audiometry (PTA) and distortion product otoacoustic emission tests were used in the hearing evaluation.

RESULTS

At frequencies of 1, 2, 4, 6, and 8 kHz in the right ear and 0.5, 1, 2, 4, 6, and 8 kHz in the left ear in PTA, the lichen group's hearing thresholds were higher than the healthy group's. Upon comparing the hearing thresholds of LP patients with oral mucosa involvement and LP patients without oral mucosa involvement, there were significant differences between the groups at 1, 4, and 8 kHz in the right ear and at 0.25, 0.5, 2, 4, 6, and 8 kHz in the left ear.

CONCLUSION

Because of the increasing hearing thresholds, we think that hearing and inner ear functions of LP patients, particularly with oral mucosal involvement, are negatively affected.

Sensorineural Hearing Loss and Systemic Autoimmune Disease: The Experience of a Systemic Immune-Mediated Diseases Unit

Background

Autoimmune inner ear disease (AIED) represents less than 1% of all cases of sensorineural hearing loss (SNHL) but its frequency may be underestimated due to lack of specific clinical and laboratory criteria. AIED can be associated with a systemic autoimmune disease (SAID) in 15%-30% of the cases. The objective of the present study was to characterize the clinical and prognostic factors of a cohort of patients with AIED.

Materials and methods

The authors conducted a retrospective descriptive analysis of a cohort of patients with AIED referred from the otorhinolaryngology department to a systemic immune-mediated diseases unit between March 2013 and November 2020. A consecutive sample of 39 patients with suspected AIED was referred. SNHL was defined as a fall of the hearing threshold of at least 30 decibels in three consecutive frequencies. Eight patients were excluded for not meeting the audiometric criteria or having confounding factors. The remaining 31 patients were included with a total of 50 affected ears. To classify the intensity of hearing loss, an arithmetic mean of pure tone was calculated. Normal hearing or mild hearing loss at the last pure tone audiometry of the follow-up were an indicator of good prognosis and were considered the outcome of interest.

Results

Thirty-two percent of the patients had an associated SAID. There were no differences regarding demographic and clinical characteristics when comparing patients with AIED alone and patients with AIED and a SAID, except for the positivity of antinuclear antibodies (ANA). ANA positivity was superior in patients with the association of AIED and a SAID when compared with patients with AIED alone (90% vs 50%; p=0.037). The SAID was diagnosed after the AIED in 70% of the patients, in which diagnosis of the SAID occurred a median of 4,2 (IQR 0.8-5.1) years after the diagnosis of the AIED. Normal audiometric evaluation or a mild hearing loss was achieved in 31% of the ears at the last audiometric evaluation. A normal audiometry or a mild hearing loss at the time of diagnosis was independently associated with a better outcome (31%, 14%, CI 1.71-273.69; p=0.018). Bilateral hearing loss was independently associated with a worse outcome (54%, 79%, CI 0.01-0.84; p=0.035). The use of systemic corticosteroids (p=0.941), transtympanic corticosteroids (p=0.700) and non-steroid immunomodulator drugs (p=0.986) did not affect prognosis. The presence of a SIAD did not affect the prognosis (p=0.986).

Conclusions

In this cohort, SAID was present in one-third of the patients with AIED. A good prognosis was achieved in one-third of the patients. A normal audiometry or mild disease at presentation was associated with a good outcome, whilst bilateral involvement was associated with a bad one. Association of a SAID did not seem to influence the hearing-related prognosis. Positivity of ANA antibodies may justify performing a complementary investigation to determine the presence of a SAID.

The Pathogenesis of secondary forms of Autoimmune Inner Ear Disease (AIED): advancing beyond the audiogram data

INTRODUCTION

Autoimmune Inner Ear Disease (AIED) can be of a primary or secondary type. To date, a clear pathogenesis of the disease is still not available. Focusing on the secondary forms of AIED, the aim of this review is to (i) assess and describe the hearing involvement in patients affected by autoimmune diseases, (ii) describe the possible association between clinical features (among serological/laboratory data and disease activity/duration) and hearing impairment, (iii) show evidence connecting the AIED types with various etiopathogenetic mechanisms.

AREAS COVERED

A PRISMA-compliant systematic review was performed. Medline, Cochrane, Embase, and Cinahl were searched from 1 January 2015 through to 5 August 2020. Overall, 16 studies (involving 1043 participants) were included in the review. The data in the literature suggested that bilateral mild-to-moderate sensorineural hearing loss is a commonly reported clinical symptom of AIED.

EXPERT OPINION

Patients with systemic autoimmune disorders present a cochlear injury which might be associated with the humoral and/or cellular immune response against the inner ear. To date, AIED pathogenesis remains an open issue, due to the rarity of these clinical entities and due to the difficulties in investigating the inner ear immunology, considering the inner ear inaccessibility for tissue sampling.

Hearing Loss in Patients With Ankylosing Spondylitis: A Systematic Review and Metaanalysis

OBJECTIVE

To determine the prevalence of hearing loss (HL) in patients with ankylosing spondylitis (AS) and to describe frequency-specific hearing threshold changes in this patient population compared to patients without AS.

METHODS

A systematic review querying 4 databases (PubMed, OVID Medline, Scopus, Cochrane) was performed to identify studies evaluating HL in patients with AS. Metaanalysis was performed to identify overall prevalence rate and OR of HL, as well as to compare mean differences in frequency-specific hearing thresholds between patients with and without AS.

RESULTS

Our metaanalysis included 14 studies and 1083 patients (598 with AS vs 485 without AS). The pooled prevalence of HL in patients with AS was 42.4% (95% CI 29.2-56.2). Patients with AS had a significantly higher OR of HL than patients without AS (OR 4.65, 95% CI 2.73-7.91). Mean differences in pure-tone hearing thresholds ranged from 0-5 decibels (dB) for frequencies of 0.25-4 kHz, and from 5-15 dB for frequencies of 6-16 kHz.

CONCLUSION

Patients with AS have higher odds of having HL than patients without AS. The AS population also presents with significantly impaired hearing thresholds across all conventional and extended pure-tone frequencies. This may manifest as slight to moderate HL. Results of this systematic review might justify increased attention to audiologic manifestations of patients with AS.

Head-Shaking Nystagmus in the Early Stage of Unilateral Meniere's Disease

OBJECTIVES

The aim of the present study was to evaluate the ability of head-shaking nystagmus (HSNy), evoked after the resolution of a vertigo spell, to predict an imminent crisis in the early stage of Meniere's disease (MD).

MATERIALS AND METHODS

A total of 20 patients in the early stage of MD were included in the study. The head-shaking test (HST) was performed twice, during the first visit within 24 h of vertigo spell (T0) and 48 h later (T1). The onset of a new vertigo episode during the 2 weeks following the first visit was recorded in each patient's medical record. The sensitivity and specificity of HSNy toward predicting a new vertigo episode were calculated.

RESULTS

At T0, an evoked ipsilesional HSNy in 15 (75%) patients was observed; in four of them, the HSNy had a biphasic component. The HSNy was present and persistent at T1 in 8 (42.1%) patients; among these cases, 6 patients had ipsilesional HSNy, and 2 patients a contralesional HSNy. None of the patients presented with a biphasic HSNy at T1. Seven (36.8%) patients experienced the recurrence of a vertigo crisis. Among these, 6 patients had ipsilesional HSNy at T1. Only 8 patients with ipsilesional HSNy at T0 did not have recurrence. The sensitivity of the ipsilesional HSNy in predicting the recurrence of vertigo in patients with MD was 100% at T0 and 85.7% at T1. The specificity was 46.6% and 100% at T0 and T1, respectively.

CONCLUSION

The HST can be a useful test in the early stages of MD to predict a new vertigo attack.

Does celiac disease cause autoimmune sensorineural hearing loss?

BACKGROUND/AIMS

The primary aim of this study is to identify whether an autoimmune sensorineural hearing loss is an extraintestinal neurological manifestation in adult CD patients. The secondary aim is to identify whether the duration of a gluten-free diet has an effect on the hearing levels of CD patients.

MATERIALS AND METHODS

This prospective study consisting of 103 adult CD patients and 79 healthy controls between May 2012 and August 2018 at the University of Gaziantep Gastroenterology and Otorhinolaryngology Departments. CD patients were divided into two groups as remission or active, according to their gluten-free diet duration and serum levels of anti-t-TG. The control group was checked both for CD symptoms and anti-t-TG serum levels. Both participants performed a pure tone audiometry after detailed ear nose and throat examination.

RESULTS

Only 4 of 103 CD patients showed sensorineural hearing loss. There was no statistically significant difference between hearing levels of the CD patients and the control group in both measurements of air and bone conductions. The hearing levels comparing the remission and active CD patients did not show any difference in air and bone conduction frequencies.

CONCLUSION

In this study with a higher number of CD patients when compared with the previous studies, it has been shown that CD does not appear to cause autoimmune sensorineural hearing loss. In addition, the status of the patients regarding the activeness or the remission of CD did not display a differ between the CD patients in terms of hearing levels.

Inner-Ear Disorders Presenting with Air-Bone Gaps: A Review

Air-bone gaps (ABGs) are commonly found in patients with conductive or mixed hearing loss generally due to outer- and/or middle-ear diseases such as otitis externa, tympanic membrane perforation, interruption or fixation of the ossicular chain, and chronic suppurative otitis media. ABGs can also be found in correlation with inner-ear disorders, such as endolymphatic hydrops, enlarged vestibular aqueduct syndrome, semicircular canal dehiscence, gusher syndrome, cochlear dehiscence, and Paget disease's as well cerebral vascular anomalies including dural arteriovenous fistula. The typical clinical presentation of inner-ear conditions or cerebral vascular anomalies causing ABGs includes audiological and vestibular symptoms like vertigo, oscillopsia, dizziness, imbalance, spinning sensation, pulsatile or continuous tinnitus, hyperacusis, autophony, auricular fullness, Tullio's phenomenon, and Hennebert's sign. Establishing a definitive diagnosis of the underlying condition in patients presenting with an ABG is often challenging to do and, in many patients, the condition may remain undefined. Results from an accurate clinical, audiological, and vestibular evaluation can be suggestive for the underlying condition; however, radiological assessment by computed tomography and/or magnetic resonance imaging is mandatory to confirm any diagnostic suspicion. In this review, we describe and discuss the most recent updates available regarding the clinical presentation and diagnostic workup of inner-ear conditions that may present together with ABGs.

Autoimmune vertigo: an update on vestibular disorders associated with autoimmune mechanisms

The role of the immune system in mediating cochleovestibular pathologies has received increasing attention in recent years. Autoimmune vertigo may be an invalidating condition and may worsen the quality of life of affected patients, especially in the cases of delayed diagnosis. Since the etiopathogenesis is still not clear, also the treatment is not yet completely delineated. According to the clinical presentation, autoimmune vertigo can present as an isolated disorder or in association with systemic autoimmune diseases. The main feature in autoimmune vertigo is the presence of an abnormal immune response, in either absence or presence of systemic autoimmune disease, directed against delicate components of the inner ear. This may determine a functional or anatomical alteration, with an inflammatory reaction often devastating for hearing and balance. Being the exact pathogenesis unknown, the diagnosis of autoimmune vertigo is based either on clinical criteria or on a positive response to steroids. The earlier the diagnosis is made, the sooner the therapy can be installed, giving a chance to the recovery of inner ear damages. Corticosteroids represent the most effective and universally accepted treatment, even if other immunomodulatory drugs are now having a more extensive use. HIGHLIGHTS: Vertigo is relatively frequent in autoimmune diseases; however, it is often misdiagnosed or attributed to central nervous system alterations rather to specific inner ear involvement. Vertigo and other audiovestibular symptoms may be the first manifestation of an autoimmune disease and if correctly addressed could significantly contribute to early diagnosis of the underlying autoimmune disease. Early diagnosis of immune-related vertigo can lead to prompt initiation of targeted therapy with elevate chances of preventing irreversible damages to the inner ear. The presence of alternating phases of well-being and disabling symptoms in patients with vertigo should always been considered, as they could suggest an underlying autoimmune condition.

Is there a relation between sudden sensorineural hearing loss and white matter lesions?

PURPOSE

Sudden sensorineural hearing loss (SSNHL) has similarities to conditions with vascular etiologies such as myocardial infarction and cerebral stroke. Thus, it could be considered as an early sign of a vascular disease and not only a specific local condition. Chronic hypoperfusion in the brain districts leads to a chronic ischemic damage, called cerebral small vessel disease (CSVD), detectable with brain magnetic resonance imaging (MRI).

METHODS

The authors used CSVD to establish the presence of vascular risk factors in individuals with SSNHL and used the Fazekas score scale to classify them.

RESULTS

Our study showed that individuals with SSNHL aged between 48 and 60 years have 26% more probability to have a Fazekas score higher than 1 compared to the general population. Individuals younger than 28 years showed a statistically significant negative correlation to have a Fazekas score higher than 0. The higher is the Fazekas score, the less is the probability of hearing recovery. The medium hearing-recovery probability is 46%. This decreases by 16% for every increase of score in the Fazekas scale. In the present study, the recovery probability decreased from 80% in individuals younger than 48 years with a score of 0 to 14% in individuals with a Fazekas scores of 3 and 4.

CONCLUSIONS

The authors assessed a higher prevalence of CSVD compared to the general population in patients aged between 48 and 60 years with SSNHL. Moreover, they assessed that the presence of CSVD is related to a decreased probability of recovery, as it has already been demonstrated for stroke.

Vitamin D and autoimmune diseases

The prevalence of autoimmune diseases (ADs) has increased over the past few decades. Vitamin D deficiency is a common factor in many of these diseases, whose etiology remains poorly understood. The objective of this study was to review published data on the role of vitamin D in ADs. Vitamin D insufficiency has been described as an important factor in the development of some ADs, generally attributed to the key role of this vitamin in the immune system. Most studies show that adequate supplementation can prevent and improve the development of some of these diseases, although the optimal vitamin D dose remains controversial. We highlight the importance of measuring serum vitamin D levels of the population and developing strategies to improve and maintain levels with no health risks.

Evaluation of hearing loss and tinnitus in Behcet's disease

OBJECTIVE

The aim of this study is to evaluate sensorineuralhearing loss (SHNL) and tinnitus in patients with Behcet's disease (BD), while also determining the association between the clinical symptoms of BD and the disease duration with the development of hearing loss.

MATERIALS AND METHODS

The study included 44 patients with BD and 42 healthy volunteers as the control group. The level of tinnitus-induced annoyance and the effects of tinnitus on daily life were evaluated with Visual Analog Scale (VAS) and the Tinnitus Reaction Questionnaire (TRQ). The hearing levels of all participants were measured with high-frequency audiometry and transient auto-acoustic emission tests.

RESULTS

The patients with BD were significantly more affected by SNHL and tinnitus than the controls (p < 0.05). The correlation between disease duration and age among those with SNHL was statistically significant (p < 0.05). No association was found between the clinical findings and SNHL and tinnitus (p > 0.05) in the BD patients.

CONCLUSION

In the present study, high-frequency SNHL was found to be common in among the patients with BD. SNHL in BD is positively correlated with the patients' age of the and the disease duration.

A Nationwide, Population-based Cohort Study on Potential Autoimmune Association of Ménière Disease to Atopy and Vitiligo

Ménière disease (MD), an idiopathic disorder of sensorineural hearing loss and vertigo, shares many similarities with two common skin conditions, atopic dermatitis (AD) and vitiligo. Recent studies have suggested that MD may be related to or triggered by autoimmune conditions, notably Hashimoto thyroiditis and alopecia areata. These evidences led to the authors contemplating the possibility of immunological bridge between MD and the two skin conditions. The authors have tested this hypothesis with population-based cohort from the National Health Insurance Service Database of Korea. A cohort of 1.1 million patients was extracted from the database. Using χ² tests, prevalence of the two skin disorders in relation to MD status was analysed. In MD patients, the odds ratios for having concurrent AD and vitiligo were 0.717 (95% CI, 0.535–0.962, p = 0.026) and 2.149 (95% CI, 1.396–3.308, p = 0.001), respectively. Females and older patients were more than twice likely to be affected by the two skin conditions. The relationship between vitiligo and MD was significant in younger subgroup only. Socio-economic subgroup analysis revealed the observed patterns are primarily a middle-upper class phenomenon. Uncertainty regarding temporal sequence of onset, and lack of detail on disease severity and subtype kept the study from more refined conclusion. In concluding, AD and vitiligo might be linked to MD through T_reg-driven action of cellular immunity, but further big data-based investigations must follow.

Audiovestibular Symptoms in Systemic Autoimmune Diseases

Immune-mediated inner ear disease can be primary, when the autoimmune response is against the inner ear, or secondary. The latter is characterized by the involvement of the ear in the presence of systemic autoimmune conditions. Sensorineural hearing loss is the most common audiovestibular symptom associated with systemic autoimmune diseases, although conductive hearing impairment may also be present. Hearing loss may present in a sudden, slowly, rapidly progressive or fluctuating form, and is mostly bilateral and asymmetric. Hearing loss shows a good response to corticosteroid therapy that may lead to near-complete hearing restoration. Vestibular symptoms, tinnitus, and aural fullness can be found in patients with systemic autoimmune diseases; they often mimic primary inner ear disorders such as Menière's disease and mainly affect both ears simultaneously. Awareness of inner ear involvement in systemic autoimmune diseases is essential for the good response shown to appropriate treatment. However, it is often misdiagnosed due to variable clinical presentation, limited knowledge, sparse evidence, and lack of specific diagnostic tests. The aim of this review is to analyse available evidence, often only reported in the form of case reports due to the rarity of some of these conditions, of the different clinical presentations of audiological and vestibular symptoms in systemic autoimmune diseases.

Hearing loss in patients with scleroderma: associations with clinical manifestations and capillaroscopy

Systemic sclerosis is a multi-systemic disease with widespread small-vessel vasculopathy and fibrosis. Involvement of the middle and inner ear and hearing loss has been reported as an uncommon manifestation of scleroderma in some studies. In this study, we evaluated hearing problems in scleroderma patients and determined its association with clinical manifestations and capillaroscopy. We evaluated 54 patients with scleroderma referred to Hafez Hospital clinic of scleroderma related to Shiraz University of Medical Science; they fulfilled the LeRoy and ACR/EULAR criteria for scleroderma. Control group consisted of 60 normal individuals. All clinical manifestations, nail fold capillaroscopy, pure tone audiometry, speech reception threshold, and speech audiometry were recorded during evaluation. Subjective hearing loss and objective hearing loss were seen in 10 and 36 patients of the case group (18.5%, 66.7%) and 6 and 10 of the control group (10%, 28.3%) (P values 0.03, < 0.001). Sensorineural hearing loss, abnormal pure tone audiometry, and abnormal speech reception threshold were more common in scleroderma patients compared to the control group (P values of < 0.001, < 0.001, and < 0.001). There was no correlation between objective hearing loss and type of scleroderma, duration of disease, skin score, interstitial lung disease, digital ulcer, gastrointestinal involvement, or nail fold capillaroscopy patterns (all P values > 0.05). In our study, subjective and objective hearing loss were higher in patients with scleroderma compared to the control group and also sensorineural hearing loss, abnormal pure tone audiometry, and abnormal speech reception threshold. There was no correlation between objective hearing loss and clinical manifestations or capillaroscopy findings.