Hearing loss in Behçet's disease

Cervical vestibular evoked myogenic potential and high-frequency audiometry results in Behçet’s disease

Background

Hearing is commonly impaired in Behçet’s disease (BD). Also, vestibular abnormalities as well as cochlear function affection have been found. The inflammatory process which leads to BD may be the cause of vestibular frequency audiometry abnormalities in those patients. The aim of this study is to assess hearing and vestibulo-colic reflex in Behçet patients using convential pure-tone audiometry (cPTA), high-frequency audiometry (HFA), and cervical vestibular evoked myogenic potential (cVEMP).

Results

This study included 25 patients with BD (group I), whose age ranged from 21 to 45 years, with a mean age of 34.24 ± 7.07 years. The control group (group II) comprised 20 normal adults whose ages are between 21 and 45 years, with a mean age of 30.8 ± 8.02 years. The measured cVEMP parameters which include the mean peak latency of P13 and the mean peak latency of N23 were statistically significantly different between the patients suffering from BD and the control groups. All BD patients had high-frequency sensorineural hearing loss (SNHL) starting from 4 up to 12.5 kHz. The mean thresholds of the audiometry were significantly higher in the diseased group.

Conclusion

cVEMP testing can be used for the evaluation of the vestibulo-colic reflex in BD patients. The occurrence of hearing loss especially in high-frequency regions is a common finding in patients suffering from BD, and a HFA may be a valuable tool in early exploration of hearing loss in patients with BD.

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.

Behçet disease as a cause of hearing loss: A prospective, placebo-controlled study of 29 patients

We conducted a prospective, placebo-controlled study to determine the incidence and severity of inner ear involvement and hearing loss in patients with Behçet disease. Our study population was made up of 29 patients with Behçet disease and 28 healthy controls. Audiometric pure-tone thresholds and transient evoked otoacoustic emission (TEOAE) levels were determined in both groups. The main outcome measures were pure-tone audiometry (PTA) levels and TEOAE levels in the two groups. PTA detected a sensorineural hearing loss in 10 of the 29 patients (34.5%). The difference in audiometric findings between the two groups was statistically significant at 1, 2, 4, and 8 kHz (p ≤ 0.0498). A comparison of TEOAE levels revealed that the difference in sound-to-noise ratio between the two groups was not significant at 1, 1.5, 2, and 3 kHz, but it was significant in 4 kHz (p = 0.02), and the difference in reproducibility between the two groups was significant at 2 and 4 kHz (p ≤ 0.03). We conclude that all patients with Behçet disease should be screened for hearing impairment and subsequently treated if an impairment is discovered.

[Otorhinolaryngological manifestations in patients with Behçet disease]

INTRODUCTION AND OBJECTIVES

Behçet disease (BD) is a systemic immune-mediated vasculitis of unknown origin characterised by recurrent orogenital ulceration, ocular inflammation and skin lesions. The aim of our study was to identify ear, nose and throat (ENT) manifestations associated with BD.

PATIENTS AND METHODS

Retrospective review of the medical records of all patients diagnosed with BD who attended a tertiary public hospital in Cantabria (Spain) over a period of 22 years. Clinical manifestations, in particular those concerning ENT, were retrieved from medical records. A medical literature review of ENT manifestations was conducted.

RESULTS

Thirty-three patients (age range: 17-64 years) were included in the study. Most of them presented oral ulcers (97%). Eight patients (24%) presented oropharyngeal ulcers and 5 patients (15%) experienced audiovestibular symptoms (high frequency sensorineural hearing loss, vertigo and bilateral vestibular hypofunction). One patient had symptoms compatible with vestibular neuronitis as the presentation manifestation of Neuro-Behçet. In 4 patients (12%) the presence of odynophagia secondary to the presence of oropharyngeal lesions, initially interpreted as acute or recurrent tonsillitis, was the first manifestation of the disease, alone or associated with cutaneous or ocular lesions.

CONCLUSIONS

In addition to the characteristic oral ulcers present in most patients with BD, ulcers in the oropharynx, occasionally interpreted as acute pharyngitis, are also common in these patients. Audiovestibular manifestations frequently appear during the course of the disease and may be the first symptom of central nervous system involvement.

Is there a need for audiologic evaluation in patients with Behçet disease?

Behçet disease is known to be a multisystem condition. We conducted a study to determine the prevalence of hearing loss in patients with Behçet disease and to identify any associations between audiologic findings and other clinical manifestations and treatment. Our study group was made up of 41 adults with Behçet disease and 41 healthy sex- and age-matched controls. All patients and controls underwent a complete clinical otolaryngologic examination, which included pure-tone audiometry, acoustic impedance testing, and otoacoustic emissions testing. Audiology revealed that the prevalence of sensorineural hearing loss (SNHL) was significantly higher in the Behçet patients than in the controls-68.3 vs. 22.0% (p < 0.002). The duration of Behçet disease had no significant impact on whether patients did or did not experience hearing loss. Hearing loss was the fourth most common clinical finding in the Behçet group, after oral ulcers, genital ulcers, and skin lesions. We conclude that SNHL is present in a significant number of Behçet patients, and we suggest the need for an adequate investigation of hearing in the routine follow-up of these patients.

Behçet's disease initially presenting with meningitis and sudden hearing loss

We report a patient with neuro Behçet's disease (BD) initially presenting with meningitis and severe hearing loss. A 51-year-old man with no noteworthy past history was hospitalized for evaluation of non-pulsating headache and high fever. Lumbar puncture on admission only showed slight pleocytosis (6 /microL, monomorphonuclear cells predominantly) but no evidence of meningitis. However, after admission, he continued to have a fever of over 38 degrees, and he developed painful oral aphthous ulcer and pseudofolliculitis on the upper limbs and trunk. Prior to admission he had often experienced oral ulceration and had bought commercially available mouthwash for prophylaxis. Subsequently, genital ulceration appeared. A small ulcer was observed at the blood collection site, leading to the diagnosis of BD. On the seventh hospital day, the patient developed sudden hearing loss, which was diagnosed as severe sensorineural hearing loss. Lumbar puncture was performed again. Cerebrospinal fluid (CSF) analysis showed mild pleocytosis (60 /microL, predominantly monomorphonuclear cells), with high CSF IL-6 levels. Neither edematous change nor atrophy of the brainstem was noted and there were no other abnormal findings on the brain MRI/MRA. Auditory brainstem response was normal, suggesting that the patient had developed hearing loss due to peripheral neuropathy. We speculate that the hearing loss was likely due to vasculitis associated with BD. This case is considered to be a rare case of Behçet's disease caused by severe hearing loss and meningitis.

Inner ear involvement in Behçet's disease

OBJECTIVE

To assess cochlear involvement and hearing loss in patients with Behçet's disease (BD).

METHOD

Forty-two patients with BD and 24 sex and age matched healthy subjects were included in the study. pure-tone audiometry including high frequencies (250-16000Hz) and DPOAE were performed to all participants. Results of the audiological evaluation were compared and correlation between the audiologic status and clinical manifestations of the BD were investigated.

RESULTS

Bilateral sensorineural hearing loss was detected in 27 (64.3%) patients. Hearing thresholds were found to be higher in patients with BD at all of the frequencies except at 500Hz when compared to control group (p<0.05). The difference in the hearing levels tend to increase in high frequencies. Compared with control group, distortion products and SNR of the BD patients were lower in all of the tested frequencies (p<0.05) which indicates weaker outer hair cell motility. There was no correlation between the clinical manifestations and the audiological parameters.

CONCLUSION

Even having hearing levels within normal limits in speech frequencies, increased hearing thresholds in high frequencies and decreased signal-noise ratios (SNR) in distortion product otoacoustic emission (DPOAE) indicate a cochlear involvement in patients with BD.

Hearing loss in patients with Behçet's disease: an audiological and transient evoked otoacoustic emission study

Objective:

To investigate hearing loss in patients with Behçet's disease.

Materials and methods:

Twenty-four consecutive cases of Behçet's disease and 24 sex- and age-matched controls were included in this study. Pure tone and high frequency audiometric tests were performed and pure tone average hearing thresholds calculated for both groups. Transient evoked otoacoustic emission testing was also performed.

Results:

Pure tone audiometry showed a sensorineural hearing loss in 15 of the Behçet's disease ears. Hearing thresholds were significantly higher in the study group than in the control group, on both pure tone frequency (except 0.5 kHz) and high frequency audiometry. Significant reductions in transient evoked otoacoustic emission amplitude were found at 1.4 and 2 kHz in the Behçet's disease patients. There were no significant differences in reproducibility, stimulus intensity or stability, comparing the Behçet's disease patients and controls.

Conclusion:

Significantly lower mid-frequency amplitudes were found in Behçet's patients on transient evoked otoacoustic emission testing.

Ear, nose and throat manifestations of Behçet's disease: a review

OBJECTIVE

To review Behçet's disease and to describe its clinical features in the head, neck and upper respiratory tract.

METHOD

A literature review was undertaken, following a Medline search of publications over a 30-year period, and utilising the expert knowledge of one of the authors (RJM) with a specialist interest in Behçet's disease.

RESULTS

Twenty-seven articles with ENT relevance were obtained. Otorhinolaryngological manifestations included symptoms and signs in the mouth, nose, sinus, larynx and ear.

CONCLUSION

Behçet's disease is usually considered to be a condition affecting the oral cavity, eyes and genitals. This article shows that most patients will also exhibit other ENT symptoms, hearing loss in particular. Indeed, Behçet's disease may present with features other than the classic triad of symptoms. Raised awareness of the clinical features within the head and neck region will hopefully enable early diagnosis and treatment of this potentially serious condition.

Hearing loss in Behçet syndrome

OBJECTIVE

To determine the prevalence and characteristics of hearing loss in Behçet syndrome.

STUDY DESIGN AND SETTING

This study included 27 patients with Behçet syndrome and 35 sex-and age-matched controls. A complete audiological evaluation was performed.

RESULTS

The average pure-tone audiograms from both groups showed a statistically significant hearing loss in the Behçet group. Sixteen patients (59.26%) showed some degrees of sensorineural hearing loss (SNHL), with the high-frequency type (4, 8, 10, and 12 kHz) being the most common pattern (93.75%). Hearing loss was the fourth most common manifestation. Although the patient's age, sex, and the duration of the disease were not related to hearing loss, there was a significant correlation between a negative pathergy test and hearing loss in patients with Behçet syndrome.

CONCLUSION

We should consider audiovestibular involvement in Behçet syndrome as a common finding.

Distortion Product Otoacoustic Emission Findings in Behçet’s Disease and Rheumatoid Arthritis

BACKGROUND AND OBJECTIVE

This study aimed to assess cochlear functions in Behçet's disease and rheumatoid arthritis (RA) using otoacoustic emission testing (OAE), which objectively assesses outer hair cells in the cochlea.

METHODS

Patients with Behçet's disease (n = 16) and RA (n = 11) as well as 20 controls were tested using pure tone audiometry and transiently evoked (TEOAEs) and distortion product OAEs (DPOAEs).

RESULTS

Pure tone results in the Behçet's group were not significantly different from controls (p > 0.05). Pure tone results in the RA group were significantly different than in controls at 250, 500 and 6,000 Hz (p < 0.05). TEOAEs could be obtained in all participants. DPOAE amplitudes in the RA group and controls were similar (p > 0.05). DPOAE amplitudes were significantly higher in the Behçet's group than in controls at 1 and 2 kHz (p < 0.05).

CONCLUSION

A subtle deterioration in hearing can be seen at low and high frequencies in RA, which is not related to outer hair cell dysfunction as detected by DPOAE testing. In the patients with Behçet's disease who have hearing thresholds within the normal limits, outer hair cell functions seem spared with an increased activity in the apical regions of the cochlea.

Audio-vestibular disturbance in patients with Behçet's disease

OBJECTIVE

The present study prospectively investigated the frequencies and characteristics of audio-vestibular disturbance and the results of audiologic and vestibular function tests in patients with Behçet's disease.

STUDY DESIGN

A prospective study.

METHODS

Seventeen patients with Behçet's disease (mean age 41.2 [30-56] years, 5 males and 12 females), as well as age- and sex-matched healthy controls, were included in this study. All subjects satisfied the diagnostic criteria of the International Study Group for Behçet's Disease. Information on the subjects was obtained through questionnaires. Tests, including those for hearing impairment, tinnitus, ear fullness, and dizziness, pure-tone audiometry, and vestibular function, were performed.

RESULTS

Auditory symptoms were reported by 7 (41.2%) and dizziness by 14 (82.4%) of the subjects. Sensorineural hearing loss was present in four (23.5%) subjects. One was treated with a cochlear implantation because of bilateral sudden deafness. Spontaneous nystagmus was detected in two (11.8%) subjects. Abnormal findings were noted in 1 (5.9%) in saccadic movement, 5 (29.4%) in the bithermal caloric tests, and 10 (58.9%) in the rotation chair tests. In total, audiologic or vestibular disturbance were noted in 16 (94.1%) of the subjects. However, audio-vestibular abnormalities were not noted in the healthy controls.

CONCLUSION

Audio-vestibular disturbance is not rare in Behçet's disease patients compared with healthy controls. We believe that audio-vestibular assessment and management may be helpful for the diagnosis and treatment of patients with Behçet's disease.

Audio-vestibular disturbances in Behcet's patients: report of 62 cases

This study was carried out to determine the characteristics and incidence of hearing loss and vestibular disturbance in Behcet's syndrome with a large number of patients. Sixty-two patients with Behcet's syndrome were included in this study, 34 men and 28 women whose mean age was 33.7 (15-60). Sixty-two healthy normal control subjects (38 male and 24 female) were included. Patient and control groups were questioned about any history of audio-vestibular disturbance and underwent physical and ENT examination and the following audiologic tests: pure tone audiometric test (0.25, 0.5, 1, 2, 4, and 6 kHz), tympanogram, speech discrimination, short increment sensitivity index, tone-decay test, auditory brainstem response. Vestibular system was evaluated by videonistagmogram and caloric test. Cranial and brainstem magnetic resonance imagine (MRI) of patients who have vestibular disturbances were practiced to examine the central nervous system. Both the patient and the control groups were tested with the HLA-B51 antigen. Pure tone audiogram showed sensory-neural hearing loss (25 dB hearing level in at least two frequencies) in 20 of the 62 (32%) Behcet's patients while the control group were normal. There was a hearing loss involving high frequencies in the audiograms of Behcet's patients with hearing disturbances. The recruitment investigation tests and auditory brain stem response confirmed cochlear involvement in all 20 patients. Caloric stimulation tests revealed a normal vestibular function in all patient and control group. In electronystagmography, 21 (34%) patients had hypometric or hypermetric saccades and smooth pursuit tests showing that 4 (6%) patients had pathological changes while the control group was normal. HLA-B51 antigen was found positive in 15 of 20 Behcet's patient with hearing loss.

CONCLUSION

(1) The hearing and vestibular disturbances in Behcet's syndrome is more prevalent than previously recognized; (2) Hearing loss in high frequencies in Behcet's patients is an indicator of cochlear involvement in this disease; (3) There is a higher prevalence of central vestibular syndrome in Behcet's patients than it was thought before; (4) HLA-B51 antigen may be able to be a prognostic factor for sensorineural hearing loss in Behcet's patients.

Neurotological status in Behçet's disease and its ophthalmological correlates

OBJECTIVE

To assess neurotological status and its ophthalmological correlates in Behçet's disease.

STUDY DESIGN

A cross sectional study in which 17 patients with Behçet's disease and 13 healthy controls were included.

PATIENTS AND METHODS

The patients were divided into two groups: those with and without end stage ocular involvement. Neurotological status was evaluated with audiological tests (pure tone and speech audiometry, tympanometry, short increment sensitivity index, tone decay, and evoked response audiometry), and Dix-Halpike positional testing.

RESULTS

The positional test was normal. The audiological test results of the patients with and without end stage ocular involvement were not significantly different (p>0.05). A sloping audiogram with bilateral symmetric and mild sensorineural hearing loss was the main audiogram obtained. There was no relationship between the presence or absence of the end stage ocular involvement and the otological parameters studied excluding I-III interval on evoked response audiometry (p>0.05).

CONCLUSION

Although the main underlying pathogenetic factor in Behçet's disease is the autoimmune vasculitis, the mechanisms involved in the pathogenesis of neurological and ocular damage may be different. Alternatively, the differential involvement of certain organ systems may not reflect the nature of the disease process itself, but rather the manner in which each organ responds to injury.

Neuro-Behçet Disease

BACKGROUND

Behçet disease is a vasculitis with mucocutaneous, ocular, arthritic, vascular, and other manifestations. Its neurologic manifestations (neuro-Behçet disease) are relatively rare, but they must be thoroughly investigated due to their grave prognosis.

REVIEW SUMMARY

The frequency of neurologic manifestations, more common in male Behçet patients, is between 5% and 30%. Both the central and peripheral nervous systems can be involved. Central nervous system manifestations can be divided into 2 main groups: (1) parenchymal involvement, which includes brainstem involvement, hemispheric manifestations, spinal cord lesions, and meningoencephalitic presentations; (2) nonparenchymal involvement, including dural sinus thrombosis, arterial occlusion, and/or aneurysms. Peripheral neuropathy and myopathy are relatively rare. Cerebrospinal fluid analysis reveals pleocytosis and elevated protein levels. Magnetic resonance imaging is the investigation of choice which often reveals iso-/hypointense lesions in T1-weighted images and hyperintense lesions in T2-weighted images, mostly in the mesodiencephalic junction, cerebellar peduncles, and other parts of the brainstem. Corticosteroids and adjuvant immunosuppressive therapy are used for parenchymal manifestations, and corticosteroids and anticoagulants are used for treatment of dural sinus thrombosis.

CONCLUSION

Neuro-Behçet disease must be considered in the differential diagnosis of stroke in young adults, multiple sclerosis, movement disorders, intracranial hypertension, intracranial sinovenous occlusive diseases, and other neurologic syndromes.

Electrocochleographic findings in cases of autoimmune disease with sensorineural deafness

OBJECTIVES

To present electrocochleographic findings in patients with autoimmune disease (AD) with sensorineural deafness (ADSD), and to discuss the etiologies of sensorineural hearing loss (SNHL) in cases of ADSD.

METHODS

Study design is a retrospective review of electrocochleographic results of 26 patients with ADSD. To evaluate the electrocochleographic results, average SP/AP ratios were compared between ADSD and normal subjects. In the ADSD group, audiologic pattern, fluctuations in hearing and results of the glycerol test were also reviewed. Electrocochleography (ECoG) was recorded using the extratympanic method, and the SP to AP ratio (SP/AP ratio) was analyzed.

RESULTS

The mean of average SP/AP ratios in the ADSD groups (0.46) was significantly higher than that in normal subjects (0.27). Further, 17 of 29 affected ears in patients with ADSD showed fluctuating hearing loss. Eighteen ears showed low tone loss (rising and peak audiologic patterns). Only 5 of 26 ears (19.2%) showed positive results on glycerol test. There was no correlation between glycerol test results and hearing fluctuation or between glycerol test results and the SP/AP ratio on chi(2)-test. There was no tendency between audiologic pattern and glycerol test results or between audiologic pattern and the SP/AP ratio.

CONCLUSION

These results suggest the etiologies of SNHL in cases of ADSD remain unclear. However, some cases showed clinical findings similar to endolymphatic hydrops. We should bear in mind that clinical Meniere's syndrome involves ADSD. Further investigation is needed to resolve the etiology of SNHL of ADSD.

Behçet’s disease and hearing loss

OBJECTIVES

The aim of this study was to determine the incidence and severity of hearing loss in different frequencies in Behçet's patients in a Turkish population.

MATERIAL AND METHOD

Sixty-three consecutive cases with Behçet's syndrome and 63 sex- and age-matched healty subjects as control group were included in this study. A detailed history was taken, all patients underwent neuro-otolological, ophthalmologic and dermatologic examination. Audiometric pure-tone thresholds at 125-8000Hz were obtained in all subjects in both groups. The results of the two groups were statistically evaluated by Chi-square, Student's-t and McNemar tests.

RESULTS

In 35 patients (55%), a hearing loss equal or more than 30dB hearing level was detected. 24 of 35 patients (68%) showed hearing loss in the higher frequencies (6 and 8kHz). 12 of 35 patients (34%) showed hearing loss in speech frequencies (500-2000Hz). No relationship could be found between hearing loss and other system involvements in Behçet's group. Also there was no correlation between hearing loss and duration of the disease, but the mean age of Behçet's patients with hearing loss was found to be significantly higher than the mean age of the patients without hearing loss.

CONCLUSION

We suggest that presence of hearing loss in Behçet's disease is prevalent and represents a fourth clinical symptom after oral, genital ulcers and skin lesions and especially there is a statistically significant hearing loss at high frequencies when compared with the speech frequencies.

The multiple faces of Behçet's disease and its aetiological factors

Behçet's disease (BD) is a chronic, inflammatory multisystemic condition of unknown aetiology. It is clinically characterized by recurrent orogenital ulcerations and skin eruptions; ocular manifestations; arthritis; vasculitis and in some cases neurological and large vessel involvement. Aetiology has not been defined, but genetic, environmental, viral, bacterial and immunological factors have been proposed as causative agents. Treatment includes colchicine, thalidomide, steroids and immunosuppressive agents and it is based on the severity of systemic manifestations, such as central nervous system involvement, arterial aneurysms and thrombosis of the major veins. Mortality is related to major system involvement. In this article the different clinical features, the multiple faces of BD and a list of currently suspected aetiological factors of the disease are discussed, and treatment modalities summarized.

Behçet's disease and complex aphthosis

Behçet's disease is a complex multisystem disease diagnosed by means of clinical criteria. Clinical features include oral and genital aphthae, pustular vasculitic cutaneous lesions, and ocular, gastrointestinal, and vascular manifestations. We believe that complex aphthosis, characterized by oral or oral and genital ulcers, may be a forme fruste of Behçet's disease. Although the pathogenesis of both Behçet's disease and complex aphthosis remain unknown, immune factors, infectious agents, and effector mechanisms are implicated. Treatment is based on the severity of systemic involvement and includes topical therapies as well as colchicine, dapsone, thalidomide, and immunosuppressive agents.