Decreased hearing after combined modality therapy for head and neck cancer

Cochlear Implantation in Radiation-Induced Hearing Loss: A Systematic Review

OBJECTIVE

Cochlear implantation (CI) has been reported as a treatment modality for radiation-induced sensorineural hearing loss (SNHL). However, its efficacy is based on individual reports with no cumulative supporting evidence. Therefore, we conducted the current systematic review to provide cumulative evidence regarding the feasibility and safety of CI in this context.

DATABASES REVIEWED

An online bibliographic search was conducted in PubMed, ProQuest, Scopus, Google Scholar, and Web of Science using MeSH-based terms.

METHODS

A systematic review was conducted to retrieve both observational and interventional studies that reported the outcomes of CI for patients suffering from radiation-induced SNHL.

RESULTS

We included 12 studies that recruited 88 patients who underwent CI because of radiation-induced SNHL. All included studies reported satisfactory hearing/speech perception outcomes. No serious complications were reported, whereas some manageable adverse events were reported, such as paroxysmal facial spams (n = 1), postauricular wound dehiscence with mastoid cutaneous fistula (n = 1), dehiscence in blind sac closure (n = 1), and electrode exposure (n = 1). Four studies assessed the postoperative quality of life/patient satisfaction, showing improved outcomes.

CONCLUSION

CI could be considered to be feasible and safe in patients with irradiation-induced SNHL. The adverse events of CI in such cases are manageable. Future studies are needed to be strengthened this context.

Radiation dose to the cochlea and its association with sensorineural hearing loss in head and neck cancer-A prospective study

AIM

To determine the effect of cochlear dose on sensorineural hearing loss in patients with head and neck cancer treated by radiotherapy and chemoradiotherapy.

MATERIALS AND METHOD

A two-year longitudinal study was conducted on 130 subjects with various head and neck malignancies who were receiving radiotherapy or chemoradiation. 56 patients received only radiotherapy while 74 patients received concurrent chemoradiation five days a week at a dose of 66-70 Gy. They were categorized as having a radiation dose to the cochlea of <35 Gy, <45 Gy or >45 Gy. Pre- and post-therapy audiological evaluation was done using a Pure-tone audiogram, distortion product otoacoustic emission, and impedence. Hearing thresholds were measured at frequencies up to 16,000 Hz.

RESULTS

Out of 130 patients 56 received RT alone and 74 received CTRT. There was statistically significant (p value <0.005) difference in Pure-tone audiometry assessment in both the RT and CTRT groups between subjects who received more than and <45 Gy of radiation to the cochlea. There was no significant difference in distortion product otoacoustic emission assessment between patients who received >45 Gy and <45 Gy radiation to the cochlea. Comparison between subjects who received radiation dose of <35 Gy and >45 Gy revealed significant results in the degree of hearing loss (p value <0.005).

CONCLUSION

We observed that patients who received >45 Gy of radiation had more sensorineural hearing loss compared to patients who received <45 Gy. A cochlear dose of <35 Gy is associated with significantly lower hearing loss compared to higher doses. We would like to conclude by emphasizing the importance of regular audiological assessments prior to and post radiotherapy and chemoradiotherapy, with regular follow-ups encouraged over a longer period to improve the quality of life in patients with head and neck malignancy.

Ototoxicity in Patients of Advanced Head and Neck Malignancies Receiving Chemoradiation Versus Radiation Alone: Comparative Study

To evaluate ototoxicity in patients receiving combined cisplatin and radiotherapy in comparison to patients receiving radiotherapy alone. A prospective study was conducted in sixty (60) cases of advanced Head and Neck malignancy (stage III and IV). Patient were divided in two randomized groups (30 each), group I received chemoradiation and group II received radiation alone. Inclusion criteria were histopathologically confirmed head & neck malignancy, normal baseline audiograms. Exclusion criteria were defined as: previously treated cases with chemotherapy/radiotherapy, patients who didn't complete treatment or lost to follow up. Ototoxicity was evaluated as per criterion established by the American speech-language-hearing association. Study participants were evaluated for ototoxicity at intervals defined as per study design. Sensorineural hearing loss (SNHL) was noticed in 56.6% and 36.6% of subjects in Group I & II respectively at 6 months follow up post completion of treatment. Incidence of sensorineural hearing loss increased significantly with cumulative dosages of chemoradiotherapy in group I and radiotherapy in group II. Incidence of SNHL in both study groups was found to be higher in patients older than 50 years. Incidence of ototoxicity in chemoradiated patients was found to be higher in comparison to patients receiving radiation alone. Ototoxicity occurred more with cumulative doses, with higher speech frequencies affected earlier in comparison to middle range frequencies. Lower frequencies were spared.

Eustachian Tube Functions in Concurrent Chemoradiotherapy for Head and Neck Cancer Patients

Ototoxicity is a dose-limiting adverse event for concurrent chemoradiotherapy (CCRT) with high-dose cisplatin for locally advanced head and neck squamous cell carcinoma (HNSCC). Both irradiation to the Eustachian tube (ET) and weight loss are risk factors for patulous ET. The aim of this prospective, observational study was to elucidate the incidences of patulous ET conditions before and after CCRT in HNSCC patients by means of ET function tests. This prospective, observational study was conducted in 27 HNSCC patients who received CCRT with high-dose cisplatin, and ET function tests (sonotubometry and tubo-tympano-aerodynamic graphy) were performed before and 3 months after CCRT. Factors potentially affecting the incidence of patulous ET conditions after CCRT were evaluated. Of the 54 ears from 27 patients investigated, patulous ET conditions were observed in 12 ears (22.2%) from 9 patients (33.3%) before CCRT and 15 ears (27.8%) from 11 patients (40.7%) at 3 months after CCRT. Only patulous ET conditions before CCRT in each ear were significantly associated with patulous ET conditions after CCRT (p = 0.010). This is the first report to describe the incidences of patulous ET conditions before and after CCRT in HNSCC patients. HNSCC patients are potentially at higher risk of patulous ET.

Nonsurgical Treatment Strategies for Elderly Head and Neck Cancer Patients: An Emerging Subject Worldwide

Consistent with the increasing rate of head and neck cancers among elderly adults, there has been an increase in the rate of those receiving nonsurgical treatments to maintain their function and quality of life. However, various problems, such as poor tolerance to chemoradiotherapy-related toxicity, are of greater concern in elderly adults than in younger individuals. In this review, we describe adverse events that should be particularly noted in elderly patients and provide an overview of countermeasures in nonsurgical treatments. We mainly focus on cisplatin-based chemoradiotherapy-the primary treatment for head and neck squamous cell carcinoma (HNSCC). Furthermore, we review the molecular targeted drugs and immune checkpoint inhibitors for elderly patients with HNSCC. Although the number of older patients is increasing worldwide, clinical trials aimed at determining the standard of care typically enroll younger or well-conditioned elderly patients. There is still very little evidence for treating elderly HNSCC older patients, and the question of optimal treatment needs to be explored.

Association of hearing loss and tinnitus symptoms with health-related quality of life among long-term oropharyngeal cancer survivors

BACKGROUND

This study investigated the association of hearing loss and tinnitus with overall health-related quality of life (HRQoL) among long-term oropharyngeal cancer (OPC) survivors.

METHODS

This study included OPC survivors treated between 2000 and 2013 and surveyed from September 2015 to July 2016. Hearing loss and tinnitus were measured by asking survivors to rate their "difficulty with hearing loss and/or ringing in the ears" from 0 (not present) to 10 (as bad as you can imagine). Hearing loss and tinnitus scores were categorized as follows: 0 for none, 1-4 for mild, and 5-10 for moderate to severe. The primary outcome was the mean score of MD nderson Symptom Inventory Head & Neck module interference component as a HRQoL surrogate dichotomized as follows: 0 to 4 for none to mild and 5 to 10 for moderate to severe interference.

RESULTS

Among 880 OPC survivors, 35.6% (314), reported none, 39.3% (347) reported mild, and 25.1% (221) reported moderate to severe hearing loss and tinnitus. On multivariable analysis, mild (OR, 5.83; 95% CI; 1.48-22.88; p = 0.012) and moderate (OR, 30.01; 95% CI; 7.96-113.10; p < 0.001) hearing loss and tinnitus were associated with higher odds of reporting moderate to severe symptom interference scores in comparison to no hearing loss and tinnitus. This association of hearing dysfunction was consistent with all domains of HRQoL.

CONCLUSIONS

Our findings provide preliminary evidence to support the need for continued audiological evaluations and surveillance to detect hearing dysfunction, to allow for early management and to alleviate the long-term impact on QoL.

Chemoradiation-induced hearing loss remains a major concern for head and neck cancer patients

OBJECTIVE

Review of the literature regarding hearing loss in patients with head and neck cancer treated with chemoradiation.

DESIGN

Studies in the literature are reviewed that pertain to hearing loss sustained in head and neck cancer patients receiving cisplatin-based chemoradiation. Personal observations noted while treating these patients are also detailed.

STUDY SAMPLE

PubMed was searched for pertinent articles regarding hearing loss in head and neck cancer patients receiving cisplatin chemotherapy and/or radiation.

RESULTS

Studies on the incidence and severity of hearing loss in head and neck cancer patients are limited, but those studies suggest that the risk of hearing loss is greater with higher-dose regimens.

CONCLUSIONS

Newer cisplatin chemotherapy regimens using lower, weekly doses may be associated with a lower incidence and severity of hearing loss; however, large prospective studies are needed. Such information will be paramount to effective pre-treatment counselling of head and neck cancer patients.

Hearing and tinnitus in head and neck cancer patients after chemoradiotherapy

Head and neck cancer patients treated with high-dose cisplatin and radiotherapy will suffer from hearing deficits. The current low-dose regimen seldom causes hearing threshold decrease. Tinnitus in this patient population has not been investigated earlier. We aimed to evaluate the possible ototoxicity of low-dose (40 mg/m(2)) weekly administered cisplatin with concomitant radiotherapy. Twenty-two patients with locally advanced head and neck cancer were prospectively recruited to participate the study after treatment recommendation for chemoradiotherapy with low-dose cisplatin and intensity-modulated radiotherapy. They filled in a Tinnitus Handicap Inventory and undertook audiologic evaluations before and after treatment. Ototoxicity was determined by >10 dB threshold shift at frequencies 4 and 8 kHz or in pure tone average. A historical cohort of nine patients treated with high-dose (100 mg/m(2)) cisplatin and radiotherapy was used for comparison. After treatment, study patients demonstrated no significant changes in their hearing over frequencies 0.5-4 kHz, and the threshold shifts were minor at 4 and 8 kHz. More than 50 % of patients reported no tinnitus after treatment and the remainder only had slight to moderate tinnitus causing no interference with their daily activities. In contrast, five of the nine patients having received high-dose cisplatin reported disturbing tinnitus. Further, changes in pure tone averages were exhibited in three of these patients and six had significant threshold shifts at 4 and 8 kHz. Head and neck cancer patients treated with concomitant intensity-modulated radiotherapy and low-dose cisplatin seem to experience only minor audiological sequelae and therefore, these patients appear to require no routine audiological monitoring. Such evaluation could be performed only when needed.

Sensorineural hearing loss following induction chemotherapy plus concurrent chemoradiotherapy for advanced nasopharyngeal carcinoma

OBJECTIVE

To compare the incidence of sensorineural hearing loss between those treated with docetaxel, cisplatin and 5-fluorouracil induction chemotherapy followed by carboplatin concurrent chemoradiotherapy and those treated with conventional concurrent chemoradiotherapy for advanced nasopharyngeal carcinoma.

METHODS

Serial pure tone audiometry was conducted in 36 nasopharyngeal carcinoma patients who were randomised into 2 groups. The first group received docetaxel, cisplatin and 5-fluorouracil induction chemotherapy followed by carboplatin concurrent chemoradiotherapy. The second group received conventional concurrent chemoradiotherapy.

RESULTS

The incidence of sensorineural hearing loss at speech frequency in the first group was 10 per cent and in the second group was 50 per cent (p = 0.0027). Bone conduction thresholds were significantly increased after completion of the treatment at 2-4 kHz in the first group and at all frequencies in the second group.

CONCLUSION

The docetaxel, cisplatin and 5-fluorouracil induction chemotherapy regimen followed by concurrent chemoradiotherapy was associated with a lower incidence of sensorineural hearing loss than conventional concurrent chemoradiotherapy. This regimen may be the preferred choice of treatment for hearing preservation.

Sensorineural Hearing Loss after Treatment for Head and Neck Cancer: A Review of the Literature

BACKGROUND

Definitive cisplatin-based chemoradiation is increasingly delivered as the treatment of choice for patients with head and neck cancer. Sensorineural hearing loss is a significant long-term side effect of cisplatin-based chemoradiation and is associated with potential major quality of life issues for patients. The purpose of this article was to review the mechanism behind sensorineural hearing loss in patients treated with cisplatin-based chemoradiation, including incidence, the contributions of radiotherapy and cisplatin to sensorineural hearing loss, and the impact of the toxicity on patient quality of life.

METHODS

Database searches were conducted through PubMed (National Centre for Biotechnology Information) and OvidSP Medline via the Queensland University of Technology Library website. General article searches were conducted through the online search engine Google Scholar. Articles were excluded if the full text was unavailable, they were not in English, or if they were published before 1990. Key words included hearing loss, ototoxicity, cancer, quality of life, cisplatin, and radiotherapy.

RESULTS/DISCUSSION

The total number of journal articles accessed was 290. Because of exclusion criteria, 129 articles were deemed appropriate for review. Findings indicated that sensorineural hearing loss is a significant, long-term complication for patients treated with cisplatin-based chemoradiation. Current literature recognizes the ototoxic effects of cisplatin and cranial irradiation as separate entities; however, the impact of combined modality therapy on sensorineural hearing loss is seldom reported. Multiple risk factors for hearing loss are described; however, there are contradictory opinions on incidence and severity and the exact radiation dose threshold responsible for inducing hearing loss in patients receiving combined modality therapy. Sensorineural hearing loss creates a subset of complexities for patients with head and neck cancer and these patients face significant quality of life impairment.

CONCLUSIONS

The literature review identified that sensorineural hearing loss is a major quality of life issue for patients treated with cisplatin-based chemoradiation for head and neck cancer. Further investigation evaluating the contribution of cisplatin-based chemoradiation to sensorineural hearing loss and the subsequent effect on patient quality of life is warranted.

Distortion-product otoacoustic emission test performance for ototoxicity monitoring

INTRODUCTION

A nonbehavioral method for monitoring ototoxicity in patients treated with cisplatin is needed because patients enduring chemotherapy may not be well or cooperative enough to undergo repeated hearing tests. Distortion-product otoacoustic emissions (DPOAEs) provide a nonbehavioral measure of auditory function that is sensitive to cisplatin exposure. However, interpreting DPOAE findings in the context of ototoxicity monitoring requires that their accuracy be determined in relation to a clinically accepted gold standard test.

OBJECTIVES

Among patients receiving cisplatin for the treatment of cancer, we sought to (1) identify the combination of DPOAE metrics and ototoxicity risk factors that best classified ears with and without ototoxic-induced hearing changes; and (2) evaluate the test performance achieved by the composite measure as well as by DPOAEs alone.

DESIGN

Odds of experiencing hearing changes at a given patient visit were determined using data collected prospectively from 24 Veterans receiving cisplatin. Pure-tone thresholds were examined within an octave of each subject's high-frequency hearing limit. DPOAE were collected as a set of four response growth (input/output) functions near the highest f2 frequency that yielded a robust response at L2 = L1 = 65 dB SPL. Logistic regression modeled the risk of hearing change using several DPOAE metrics, drug treatment factors, and other patient factors as independent variables. An optimal discriminant function was derived by reducing the model so that only statistically significant variables were included. Receiver operating characteristic curve analyses were used to evaluate test performance.

RESULTS

At higher cisplatin doses, ears with better hearing at baseline were more likely to exhibit ototoxic hearing changes than those with poorer hearing. Measures of pre-exposure hearing, cumulative drug dose, and DPOAEs generated a highly accurate discriminant function with a cross-validated area under the receiver operating characteristic curve of 0.9. DPOAEs alone also provided an indication of ototoxic hearing change when measured at the highest DPOAE test frequency that yielded a robust response.

CONCLUSIONS

DPOAEs alone and especially in combination with pre-exposure hearing and cisplatin dose provide an indication of whether or not hearing has changed as a result of cisplatin administration. These promising results need to be validated in a separate sample.

Audiological findings in patients treated with radio- and concomitant chemotherapy for head and neck tumors

Objective

To evaluate the functionality of the auditory system in patients who underwent radiotherapy and chemotherapy treatment with cisplatin to treat head and neck tumors.

Study Design

Case series with planned data collection.

Setting

From May 2007 to May 2008 by the Department of Otorhinolaryngology and the Department of Oncology/Radiotherapy at Faculdade de Medicina de Marília.

Subjects and Methods

Audiological evaluation (Pure Tone Audiometry (air and bone conduction), Speech Audiometry, Tympanometry, Acoustic Reflex testing and Distortion Product Otoacoustic Emissions) was performed in 17 patients diagnosed with head and neck neoplasia and treated with chemotherapy, using cisplatin, and radiotherapy.

Results

12 left ears (70.5%) and 11 right ears (64.7%) presented bilateral decreased hearing soon after the treatment for the frequency 1 kHz (mild auditory damage) and for the frequency 8 kHz (more significant auditory damage).

Conclusion

Patients with head and neck cancer submitted to the conventional radiotherapy treatment, combined with the chemotherapy with cisplatin, presented a high incidence of decreased hearing by the end of treatment. Strong evidence was observed linking auditory alteration to the amount of radiotherapy treatment.

Prospective study of sensorineural hearing loss following radiotherapy for nasopharyngeal carcinoma

Objectives:

To investigate the severity and incidence of sensorineural hearing loss in patients with nasopharyngeal carcinoma treated with radiotherapy.

Methods:

Forty-two patients with nasopharyngeal carcinoma were treated with conventional radiotherapy. Audiological testing was performed to compare patients' hearing before and at varying stages after radiotherapy.

Results:

At one month post-radiation, a significant hearing threshold increase was seen only for high frequencies. At 12, 24 and 60 months post-radiation, significant threshold increases were observed at speech frequencies (4.0 and 8.0 kHz), compared with pre-radiation data. The mean values of wave I, III and V latencies and of the I–V interpeak latency intervals were not significantly altered at one month post-radiation, but were significantly prolonged at 12, 24 and 60 months post-radiation, compared with pre-radiation data.

Conclusion:

In patients with nasopharyngeal carcinoma treated with radiotherapy, the severity and incidence of radiation-induced sensorineural hearing loss increased with time, especially at high frequencies. This hearing impairment may be due to changes in the cochlea and/or the retrocochlear auditory pathway.

Ototoxicity in a Randomized Phase III Trial of Intra-Arterial Compared With Intravenous Cisplatin Chemoradiation in Patients With Locally Advanced Head and Neck Cancer

Purpose

Cisplatin concomitantly administered with radiotherapy is increasingly used in locally advanced head and neck squamous cell carcinoma. We aimed to compare the incidence of hearing loss between patients treated with intra-arterial high-dose cisplatin chemoradiation with sodium thiosulfate (CRT-IA) and intravenous high-dose cisplatin chemoradiation without sodium thiosulfate (CRT-IV).

Patients and Methods

We conducted a prospective analysis of hearing thresholds at low and (ultra-) high frequencies obtained before, during, and after treatment in 158 patients. Patients were randomly assigned for either CRT-IA (150 mg/m2, four courses) with sodium thiosulfate cisplatin neutralization or CRT-IV (100 mg/m2, three courses) without rescue. All patients received concomitant radiation therapy (RT; 70 Gy).

Results

CRT-IA resulted in approximately 10% less hearing loss at frequencies vital for speech perception, compared with CRT-IV (P < .001). In CRT-IA, fewer ears qualified for hearing aids (36% v 49%; P = .03). However, in both treatment arms, the incidence expressed in National Cancer Institute Common Terminology Criteria of Adverse Events (version 3) did not deviate (P > .14). Age, cumulative cisplatin dose, cumulative RT dose, and the considered frequency area determine the degree of hearing loss (P < .001). Cisplatin induced increasing hearing loss of 24% to 60% with increasing frequencies. RT induced hearing loss at speech frequencies of 9% to 12%.

Conclusion

Depending on the criteria used to assess hearing loss due to treatment, differences in ototoxicity between CRT-IA and CRT-IV were found in favor of CRT-IA. It is desirable to specify hearing loss criteria toward frequencies vital for speech perception, and to refine grading scales to reveal subtle and clinically relevant dissimilarities in ototoxicity between different treatment protocols.