Audiovestibular disturbance in patients with systemic lupus erythematosus

Audiovestibular Dysfunction in Systemic Lupus Erythematosus Patients: A Systematic Review

Audiovestibular dysfunction in patients with systemic lupus erythematosus has been underestimated for decades. Systemic lupus erythematosus can affect both the auditory and vestibular systems simultaneously. Several potential pathophysiological mechanisms behind systemic lupus erythematosus-related audiovestibular dysfunction have been proposed, including antibody-mediated immune responses, cell-mediated cytotoxicity, immune complex deposition in microvessels, central involvement in the audiovestibular pathway, and ototoxicity from medications used in systemic lupus erythematosus treatment. Currently available tests to evaluate audiovestibular function in systemic lupus erythematosus patients are neither specific nor sensitive. Nevertheless, there is no consensus regarding the efficacy of treatments for audiovestibular dysfunction in such patients. In this systematic review, we electronically searched the PubMed, Embase, ClinicalKey, Web of Science, and ScienceDirect platforms to find eligible articles. The first inspection date was on 29 December 2023 and the final update search date was on 11 June 2024. Further, we rated the quality of the included articles with Newcastle-Ottawa Scale. Based upon the aforementioned systematic review process, we have summarized the currently available evidence on the characteristics, pathophysiology, examination, and treatment of audiovestibular dysfunction related to systemic lupus erythematosus. Furthermore, we have proposed a specific steroid treatment protocol to manage audiovestibular dysfunction related to systemic lupus erythematosus. Audiovestibular dysfunction related to systemic lupus erythematosus may be responsive to adequate treatments, potentially allowing for reversibility if the disease is recognized and managed in a timely manner. Therefore, to provide clinically relevant evidence to clinicians, we have organized this literature review article to summarize the available evidence on the characteristics, pathophysiology, examination, and treatment of audiovestibular dysfunction in patients with systemic lupus erythematosus. Finally, based on our modified steroid treatment protocol, we would like to provide a new treatment strategy to clinicians to manage systemic lupus erythematosus-related audiovestibular dysfunction.

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

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

Ear, Nose, and Throat Manifestations of Vasculitis and Other Systemic Autoimmune Diseases: Otologic, Sinus, and Airway

Auricular, nasal, and laryngeal manifestations occur frequently in rheumatic diseases. Inflammatory ear, nose, and throat (ENT) processes often result in organ damage and have profound effects on quality of life. Herein, we review the otologic, nasal, and laryngeal involvement of rheumatic diseases, focusing on their clinical presentation and diagnosis. ENT manifestations generally respond to treatment of the systemic disease, which is outside the scope of this review; however, adjunctive topical and surgical treatment approaches, as well as treatment of idiopathic inflammatory ENT manifestations will be reviewed.

Sensorineural Hearing Loss in Sjögren’s Syndrome

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

Hearing disorders in lupus patients: correlation with duration and severity of the disease

Background

Hearing loss can greatly affect the overall quality of life. Several studies have reported that patients with SLE may suffer from audio-vestibular manifestations. The aim of this study is to evaluate the influence of systemic lupus erythematosus (SLE) on hearing and association of hearing impairment with severity and duration of SLE.

Results

Pure-tone audiometry (PTA) (air conduction and bone conduction) thresholds showed significant elevation in SLE group than controls (P ≤ 0.05). It was observed also that there is a significant association between SLE severity and duration with sensorineural hearing loss (SNHL) and its degree.

Conclusion

SLE can lead to hearing loss, and there is a positive association of SLE severity and duration with degree of hearing loss.

Hearing loss in patients with systemic lupus erythematosus: A systematic review and meta-analysis

OBJECTIVE

To determine the prevalence of hearing loss (HL) in patients with systemic lupus erythematosus (SLE), describe frequency-specific hearing threshold changes in this patient population as compared to age-matched control, and compare the clinical and serological profiles of patients with SLE with and without HL.

METHODS

A systematic review querying four databases (PubMed, Web of Science, Scopus, and Cochrane) was performed. Meta-analysis of available data was performed to determine the overall prevalence and odds ratio (OR) of HL, and compare mean differences in frequency-specific hearing thresholds between patients with SLE and control. Additionally, meta-analysis of proportions allowed for comparison of disease features present in patients with SLE with and without sensorineural HL.

RESULTS

This review included 17 studies reporting on 1326 patients (635 with SLE and 691 control). The pooled prevalence of HL in patients with SLE was 27%. In comparison to control, patients with SLE had a significantly higher odds of HL (OR 14.6, 95% CI: 8.5 to 25.0). Mean air-conduction hearing thresholds in patients with SLE were significantly elevated relative to control at 125 and 250 Hz. Mean bone-conduction hearing thresholds were significantly elevated in patients with SLE across all measured frequencies except at 3000 and 6000 Hz compared to control. Disease features did not significantly differ between patients with SLE with and without HL.

CONCLUSION

Compared to age-matched control, patients with SLE have increased odds of HL, which primarily manifests at low frequencies. Therefore, this patient population requires greater audiologic attention.

Association of systemic lupus erythematosus with hearing loss: a systemic review and meta-analysis

Systemic lupus erythematosus (SLE) is a systemic autoimmune disease that can affect virtually any organ, including middle and/or inner ear. The objective of the current systematic review and meta-analysis was to investigate the association of SLE with the different subtypes of hearing loss. This systematic review and meta-analysis was conducted in agreement with the PRISMA guidelines. The review protocol was registered in the PROSPERO international prospective register of systematic reviews ( https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=216353 ). A random effects model meta-analysis was carried out while heterogeneity was appraised by I². Subgroup analysis and sensitivity analysis were also performed. Nine studies comprising 7,654 SLE patients and 37,244 controls were included in this systematic review. Four of them were rated to a moderate rate of bias, while five of them were rated to a low rate of bias. SLE patients had significantly increased odds of sensorineural hearing loss (SNHL) compared with controls (OR 2.31; 95%CI 1.48-3.60; I² = 0). SLE patients did not have significantly increased odds of Conductive Hearing Loss (CHL) (OR 1.30; 95% CI 0.23-7.45; I² = 0). Only one study reported on the outcome of Mixed Hearing Loss (MHL) (3 events in SLE group vs. 0 events in control group). Subgroup analysis, based on study design and detection method of hearing loss also showed significantly increased odds of SNHL in SLE patients. The significantly increased odds of SNHL in SLE persisted even after sensitivity analysis. In conclusion, SLE is significantly associated with SNHL; SLE is not associated with CHL, while, due to lack of data, we could not reach a conclusion regarding the odds of MHL in SLE patients. Pure tone audiometry as a screening test and follow-up test in SLE patients could be of essence. Management and prognosis of hearing loss in SLE patients should be discussed.

Chloroquine, Hydroxychloroquine and Hearing Loss: A Study in Systemic Lupus Erythematosus Patients

Objectives/Hypothesis

Antimalarial drugs (chloroquine and hydroxychloroquine) are widely used for the treatment of systemic lupus erythematosus (SLE). However, these drugs may have side effects such as hearing loss. This study aimed to describe the hearing function in SLE patients using antimalarials. Secondarily, this study aimed to investigate whether SLE causes hearing loss and if there are any serological or clinical aspects of this diseases associated with inner ear damage.

Study Design

Cross‐sectional study.

Methods

This study included 84 individuals (43 SLE patients and 41 controls) with audiometry and tympanometry tests. Epidemiological, clinical, serological, and treatment profiles of SLE patients were extracted from the charts.

Results

SLE patients had more sensorineural hearing loss than controls (23.2% vs. 0; P = .001). Pure‐tone averages in SLE patients using antimalarials and not using antimalarials were similar (8.75 vs. 8.75; P = .63). At 8,000 Hz, antimalarial dug nonusers performed worse than users (10.00 vs. 22.50; P = .03). Tympanometry was normal in all participants. SLE serological and clinical profiles in patients with and without hearing loss were the same (all P = nonsignificant).

Conclusions

There is a high prevalence of hearing loss in SLE that is not affected by antimalarial drug use.

Level of Evidence

3b Laryngoscope, 131:E957–E960, 2021

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.

Update on Vertigo in Autoimmune Disorders, from Diagnosis to Treatment

The prevalence of autoimmune diseases has been increasing over the last 20 years. The clinical presentation of this large and heterogeneous group of disorders depends on whether the involvement is organ-specific or non-organ-specific. Dizziness, vertigo, and disequilibrium are common symptoms reported by patients with vestibulocochlear involvement. The association of vertigo and autoimmune diseases has been largely documented, suggesting that autoimmune disorders could be overrepresented in patients with vertigo in comparison to the general population. The aim of this review is to present the recent literature findings in the field of autoimmune-mediated diseases with cochleovestibular involvement, focusing on the clinical presentation, diagnosis, and treatment of immune-mediated inner ear diseases including autoimmune inner ear disease (AIED), Meniere's disease, and bilateral vestibulopathy, as well as of systemic autoimmune diseases with audiovestibular disorders, namely, Behçet's disease, Cogan's syndrome, sarcoidosis, autoimmune thyroid disease, Vogt-Koyanagi-Harada syndrome, relapsing polychondritis, systemic lupus erythematosus, antiphospholipid syndrome, IgG4-related disease, and ANCA-associated vasculitides.

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.

Alteraciones auditivas en artritis reumatoide, lupus eritematoso sistémico y síndrome de Sjögren

Introducción. En la actualidad no hay cifras sobre las personas que padecen artritis reumatoide (AR), lupus eritematoso sistémico (LES) o síndrome de Sjögren (SS) ni información sobre las alteraciones auditivas que puede causar el tratamiento farmacológico utilizado para controlar dichas enfermedades.Objetivo. Evidenciar las posibles afectaciones y alteraciones audiológicas y vestibulares producidas por AR, LES y SS o su tratamiento farmacológico.Materiales y métodos. Se analizaron los hallazgos clínicos de herramientas diagnósticas y procedimientos de prevención e intervención de alteraciones auditivas en artículos de investigación publicados en español, inglés, francés y portugués en bases de datos científicas entre los años 2000 y 2016.Resultados. Se extrajeron 62 artículos de investigación (31 de AR, 5 de LES, 12 de SS, 5 de Hipoacusia inmunomediada, 9 de medicamentos ototóxicos), 1 tesis doctoral sobre AR, 1 tesis doctoral sobre AR y LES y 1 guía de práctica clínica para la detección temprana, diagnóstico y tratamiento de AR. Se evidenció que las pérdidas auditivas con mayor reporte son hipoacusia neurosensorial, lesiones en cadena osicular y vestíbulo-coclear.Conclusiones. Se confirmó la relación entre las lesiones audiológicas y AR, LES y SS, pero aun no es claro el desarrollo de los ototóxicos.

Diagnosing and attributing neuropsychiatric events to systemic lupus erythematosus: time to untie the Gordian knot?

Neurological and psychiatric syndromes, collectively referred to as NPSLE, occur frequently in SLE. The frequency of NPSLE varies from 21 to 95%; however, only 13-38% of neuropsychiatric (NP) events could be attributable to SLE in the NPSLE SLICC inception cohort. This variability in the frequency of NPSLE is attributable to the low specificity of the ACR case definitions for SLE-attributed NP syndromes, inclusion of minor NP events in the ACR nomenclature, difficulty in ascertainment of NP events and diverse experience of rheumatologists in the clinical assessment of NP events. Making the correct and early attribution of NP events to SLE is important to institute appropriate immunosuppressive treatment for favourable outcomes. Various attribution models using composite decision rules have been developed and used to ascribe NP events to SLE. This review will focus on the various clinical presentations, diagnostic work-up and attributions of the common NPSLE syndromes, including other NP events not included in the ACR nomenclature but which have come to attention in recent years.

Systemic Lupus Erythematosus and hearing disorders: Literature review and meta-analysis of clinical and temporal bone findings

Objective

This literature review and meta-analysis was performed to evaluate the correlations among hearing and vestibular clinical symptoms, temporal bone findings, and pathological mechanisms in patients with systemic lupus erythematosus (SLE).

Study design

Relevant papers in the literature were retrospectively reviewed. Clinical hearing aspects in patients with SLE and relevant temporal bone studies in the same field were analyzed.

Methods

PubMed and Google Scholar searches were performed using the following keywords: “auto-immune disease,” “systemic lupus erythematosus (SLE),” “hearing loss,” “temporal bone study,” “vertigo,” “dizziness,” “tinnitus,” “ear symptoms,” “treatment,” “diagnosis,” “symptoms,” “etiopathogenesis,” “Wegener granulomatosis,” “Sjogren,” “polyarteritis nodosa,” “Cogan syndrome,” and “granulomatosis.” Also included were reviews in which the following terms were present: “SLE,” “temporal bone,” and “hearing symptoms.”

Review and conclusion

This literature review and meta-analysis focused on the pathological mechanisms through which SLE can damage inner ear structures and determinate hearing and vestibular symptoms. The main mechanisms involved in inner ear damage include the autoimmune response, deposition of immune complexes in the vessels and, to a lesser extent, cytotoxic damage.

Extended high frequency audiometry can diagnose sub-clinic involvement in a seemingly normal hearing systemic lupus erythematosus population

CONCLUSIONS

Sensorineural hearing loss must be considered within the clinical picture of systemic lupus erythematosus. The results confirm the usefulness of extended high-frequency audiometry in the audiologic testing of these patients, enabling the possibility of modifying or applying a preventive treatment for a possible hearing loss.

OBJECTIVES

Hearing involvement is usually under-diagnosed with routine auditory examination. This study proposes the use of extended high-frequency audiometry to achieve a correct detection of a possible asymptomatic hypoacusis in early stages of the disease. The aim of this study is to analyze the hearing levels in extended high-frequencies in these patients and to correlate the hearing loss with the severity of the disease and the immunological parameters.

METHODS

A descriptive cross-sectional study was performed. Fifty-five patients with systemic lupus erythematosus were included in the study. The control group consisted of 71 patients paired by age and sex with the study population. Both a pure tone audiometry and an extended high-frequency audiometry (8-18 KHz) were performed.

RESULTS

In total, 70% were diagnosed with sensorineural hearing loss with extended high-frequency audiometry, overcoming the results obtained with pure tone audiometry (30.9%). Statistically significant correlations were found within the patients regarding sensorineural hearing loss related with age, disease activity and cryoglobulinemia.

Neuropsychiatric Lupus in clinical practice

ABSTRACT Systemic lupus erythematosus (SLE) is a chronic autoimmune disease involving multiple organs, characterized by the production of autoantibodies and the development of tissue injury. The etiology of SLE is partially known, involving multiple genetic and environmental factors. As many as 50% of patients with SLE have neurological involvement during the course of their disease. Neurological manifestations are associated with impaired quality of life, and high morbidity and mortality rates. Nineteen neuropsychiatric syndromes have been identified associated with SLE, and can be divided into central and peripheral manifestations. This article reviews major neuropsychiatric manifestations in patients with SLE and discusses their clinical features, radiological findings and treatment options.

Histopathologic Findings in Peripheral Vestibular System From Patients With Systemic Lupus Erythematosus: A Human Temporal Bone Study

HYPOTHESIS

We hypothesized that a pathologic condition exists in vestibular hair cells in human temporal bones from patients with systemic lupus erythematosus (SLE).

BACKGROUND

A significant association between sensorineural hearing loss and autoimmune disease has been reported. Patients with SLE also frequently have vestibular symptoms whose pathophysiologic mechanism is unclear.

METHODS

We examined 15 temporal bone samples from 8 patients with SLE, along with 21 samples from 17 age-matched healthy control patients. The samples were serially sectioned in the horizontal plane and stained with hematoxylin and eosin. Using differential interference contrast microscopy, we counted the number of type I and type II hair cells in the saccular macula, the utricular macula, and the cristae of the three semicircular canals; then, we calculated the hair cell density (cells per 0.01 mm).

RESULTS

The mean density of type I hair cells in our SLE group was significantly lower than in our control group in the saccular macula, in the utricular macula, and in the superior, lateral, and posterior semicircular canals. But in all five vestibular sensory epithelia, the mean density of type II hair cells did not significantly differ between our two groups. In our SLE group, the mean density of vestibular hair cells did not significantly correlate with the patient's age at death or with the duration of SLE.

CONCLUSION

Type I hair cells in peripheral vestibular organs are affected in patients with SLE. Our findings could provide a pathologic basis for the difficulty with balance experienced by patients with SLE.

Evaluation of Hearing and Outer Hair Cell Function of Cochlea in Patients With Psoriatic Arthritis

Objectives

The aim of this study was to investigate hearing and outer cells function in patients with psoriatic arthritis. Our investigation was a prospective case control study.

Methods

A total of 31 psoriatic arthritis patients (62 ears) and 31 healthy control subjects (62 ears) were enrolled in the study. We investigated hearing changes of patients and controls via pure tone audiometry, speech discrimination scores, tympanometry, acoustic reflex, and transient product otoacoustic emission.

Results

The mean age of psoriatic arthritis patients was 36.1±8.5 years (range, 14 to 62 years). The average age of the control group was 37.9±8.1 years (range, 16 to 62 years). There were statistically significant differences between pure tone audiometry in all frequencies and right and left emission at the 4.0 and 1.0 in psoriatic arthritis patients versus controls (P<0.05). This difference was evident, especially at high frequencies. There was no statistically significant difference between the ages and genders of the patient and control groups (P>0.05). Both audiological and otoacoustic emissions were not significantly different between right and left ear (P>0.05).

Conclusion

Based on the audiological and otoacoustic findings; it is likely that the cochlear outer hair cells become subtly damaged in psoriatic arthritis patients, consequently leading to changes in hearing thresholds. These data suggest that it is important to screen psoriatic arthritis patients for hearing changes with otoacoustic emissions and audiologic tests regularly.

Function of the audiovestibular system in children with systemic lupus erythematosus

Systemic lupus erythematosus can affect inner ear by disrupting either the hearing or balance system. Affection of hearing can be anatomically categorized into conductive and sensorineural hearing loss, while affection of the equilibrium system manifests either as an isolated manifestation like vertigo or as a part of a spectrum like Meniere's disease. Most cases show asymptomatic affection requiring an objective audiovestibular assessment. More focus should be given to routine evaluation especially with disease flares and for proper treatment. In pediatric patients, more concern should be given owing to the added effect of ototoxicity with several drugs and the educational impact of such comorbidity.

Study of audiovestibular dysfunction in children with systemic lupus erythematosus

OBJECTIVE

Inner ear dysfunction in systemic lupus erythematosis patients has been reported but audiovestibular involvement is not well documented especially in pediatrics. This study was designed to evaluate silent audiovestibular dysfunction among SLE children.

METHODS

Case control study examined in allergy and immunology clinic; pediatrics hospital and audiovestibular clinic; Ain Shams University from January 2009 to December 2010. Thirty-five systemic lupus erythematosus children (diagnosed according to American College of Rheumatology); age group 8-16 years, were randomly selected. Five of them were excluded due to one or more exclusion criteria (previous otitis media, stroke, lupus cerebritis, meningitis or encephalitis, audiovestibular symptom). Ten of them refused enrollment or could not complete full battery. Seventeen females and three males, mean age 12.9 ± 2.6 years, completed the study. Control group included 20 normal subjects, age and sex matched. Full clinical assessment, basic audiological evaluation and vestibular testing (videonystagmography VNG and computerized dynamic posturography CDP) were conducted for children included in the study.

RESULTS

Five systemic lupus erythematosus patients had sensorineural hearing loss strongly associated with +ve antiphospholipid antibody and two had conductive hearing loss. Two children in control group had conductive hearing loss (p=0.05). Abnormal VNG findings was significantly higher among systemic lupus erythematosus children (40%) compared to controls (0%) and associated with +ve antiphospholipid antibodies (χ(2)=10, p=0.002, Fisher exact test=0.003). Twenty-five percentage of systemic lupus erythematosus children had abnormal CDP findings reflecting impaired balance function associated with positive antiphospholipid antibodies showing significant statistical difference compared to controls (0% affection) (χ(2)=5.7, p=0.017, Fisher exact test=0.047).

CONCLUSION

Silent audiovestibular dysfunction is prevalent among systemic lupus erythematosus children especially those positive for antiphospholipid antibodies necessitating routine regular evaluation.

Hearing loss in patients with systemic lupus erythematosus

Objectives:

Systemic lupus erythematosus has its unique complications which warrant careful examination and assessment during follow/up visits of patients. The present study was conducted to evaluate prevalence of hearing loss in patients with SLE.

Materials & Methods:

At present a case- control study has been performed on 45 patients with SLE in a clinic of a teaching university hospital, Qazvin city, Iran. The patients were examined and evaluated for auditory and hearing problems as well as parameters related to their disease severity and progression. The control group was selected from the same clinic.

Results:

Five patients (11.1%) complained from hearing loss, 4 patients (8.9%) complained from otorrhea, 3 patients (6.7%) had tinnitus in research group, moreover twelve patients (26.7%) in case group and 4 patients (8.9%) in control group had sensorineural hearing loss. The difference was found to be statistically significant. No statistical significant relationship was found between severity, age of onset, and duration of the disease, and the lab tests of the patients with hearing loss.

Conclusion:

The present study implies that patients with systemic lupus erythematosus may develop sensorineural hearing loss during their course of the disease. It is recommended that audiology examination and/or audiometry become a part of routine follow/up studies of the patients.

Hearing and vestibular disorders in patients with systemic lupus erythematosus

OBJECTIVES

Systemic lupus erythematosus (SLE) is associated with several comorbidities, including hearing and vestibular disorders. We recently described an increase of SLE prevalence in patients with Menierés disease (MD). The aim of this study is to explore if a subset of SLE patients may have a common inner ear disorder and determine the potential relationship with migraine. METHODS; Eighty-nine patients with SLE (according to the American College of Rheumatology criteria for the diagnosis of SLE) were evaluated for audiovestibular symptoms by a telephone interview carried out by two experienced otoneurologists. Twenty-one patients with SLE were referred to the otoneurology clinic for a detailed clinical history for criteria assessment for MD and a complete audiovestibular examination (audiogram, oculomotor, and caloric testing with video-oculography).

RESULTS

Recurrent headache was found in 50/89 patients, and 26 of them had diagnostic criteria for migraine. Twenty-four percent of patients reported sensorineural hearing loss (SNHL) or episodic vertigo. Among the eight patients (9%) with episodic vertigo, one had criteria for definite MD and another two patients had criteria for possible MD. SNHL was found to be associated with a history of episodic vertigo (Fisher's test, p=0.02), but not with headache or migraine. SLE and episodic vertigo were not associated with tinnitus, migraine, lupus nephritis, antinuclear antibodies or antiphospholipid syndrome.

CONCLUSIONS

Migraine, SNHL and episodic vertigo are comorbid conditions in patients with SLE, but migraine is not associated with SNHL or vertigo in these patients. However, SNHL and vertigo are associated conditions in SLE, suggesting a common audiovestibular dysfunction.

Young systemic lupus erythematosus patients with no hearing involvement: 10-year follow up

Objective:

To evaluate patients with systemic lupus erythematosus and normal hearing over 10 years, compared with healthy controls.

Methods:

Thirty patients diagnosed with systemic lupus erythematosus were evaluated in a prospective, descriptive study. Eight patients fulfilled the inclusion criteria, i.e. normal otoscopy, normal hearing, normal imaging and disease duration of less than one year. Eleven healthy companions of ENT patients were recruited as controls.

Results:

At study commencement, the mean patient age was 32.75 years (range, 15–49 years) and there were no statistically significant audiometric differences between patients and controls. No statistically significant audiometric changes were found either within or between the patient and control groups at 10-year follow up.

Conclusion:

These results supply no evidence for progressive hearing loss in systemic lupus erythematosus patients with no hearing involvement at study commencement. Therefore, we recommend audiometric tests only for systemic lupus erythematosus patients complaining of hearing loss, or for other clinical purposes. It is conceivable that asymptomatic hearing loss could be observed over a more extended follow-up period (i.e. more than 10 years).

[Vestibular system in patients with systemic sclerosis]

OBJECTIVES

In systemic sclerosis (SSc) there may occur hearing and balance disorders as a result of the immune-mediated inner ear damage, the etiology being vasculitis and fibrosis. The objective is the vestibular organ evaluation in patients with SSc regarding their prevalence and relationship to duration of the disease and Raynaud phenomenon and also to type and severity of SSc.

MATERIAL

Twenty unselected, consecutive patients with diagnosed SSc, complying with international diagnostic criteria of the American Rheumatism Association (1982), were enrolled into the study. The control group consisted of 26 otologically healthy persons matched to the SSc group for age and sex.

METHODS

In all patients the questionnaire about audiovestibular history, otolaryngological examination, static and dynamic vestibular tests and the electronystsgmography (ENG) were performed. The patients were investigated with the electronystsgmography (ENG) for spontaneous, positional and caloric-induced nystagmus. Also visual ocular-motor tests were performer.

RESULTS

In the anamnesis 65% of patients reported vertigo, 55% - headaches, 50% - tinnitus, 40% - hyperacusis, 40% - hearing loss and 30% - ear fullness. Vertigo, dizziness balance disturbance and uncorrect results of Romberg and Utenberger tests were more frequent in patients with vestibular organ lesion. Abnormalities in vestibular organ in SSc patients were fund in 14 (70%) persons - the central type of lesion - 8 (40%), mixed type in 3 (15%) and peripheral in 3 (15%).

CONCLUSIONS

Ear involvement is frequent in systemic sclerosis and should be taken into consideration during diagnostic and therapeutic procedures.

Auditory function in patients with systemic lupus erythematosus

OBJECTIVE

Patients with systemic lupus erythematosus (SLE) may develop hearing and balance disorders as a result of the immune-mediated inner ear damage due to vasculitis or ototoxicity of drugs used in SLE treatment. The aim of the study was evaluation of the hearing organ disorders in patients with SLE with particular regard to their prevalence and relationship to duration and severity of disease. The severity was assessed from involvement of organs that resulted in poorer SLE outcome, i.e. kidneys and central nervous system (CNS), and from the presence of antibodies associated with unfavourable SLE prognosis.

METHODS

Thirty-five unselected, consecutive patients (33 women, two men, mean age 47.8 years) with SLE diagnosed in compliance to the international diagnostic criteria of the American Rheumatism Association (1982) were enrolled into the study. The control group consisted of 30 otologically healthy persons matched to the SLE group for age and sex. Case history was recorded for all patients from questionnaire data and laryngological examinations were performed, followed by pure-tone, speech and impedance audiometry and auditory brainstem response audiometry (ABR).

RESULTS

In the anamnesis 71.4% of patients reported vertigo, 62.9% headaches, 40% tinnitus, 25.7% hyperacusis, 17.1% hearing loss and 2.9% ear fullness. It was found that SLE patients had a significantly poorer mean hearing thresholds than the control group for all frequencies, except for 500; 2000 and 4000 Hz. Longer ABR latency averages were observed in the group of SLE patients compared to control. Ten patients (28.6%) developed high-frequency and symmetric sensorineural hearing loss (SNHL). Significant positive correlation between mean air-conduction hearing thresholds and SLE duration (r = 0.46, p < 0.001) was found. After taking age into consideration, hearing acuity in SLE was related to duration of disease in younger patients. Furthermore, no relation was seen between hearing level and severity of disease.

CONCLUSIONS

Auditory system involvement ought to be considered as one of elements of the clinical picture of systemic lupus erythematosus while determination of its character, original or secondary, requires further research.

Hearing organ disorders in patients with systemic sclerosis

In systemic sclerosis (SSc), there may develop hearing and balance disorders as a result of the immune-mediated vasculitis and fibrosis in the inner ear. The objective of the study was evaluation of the hearing organ function in patients with SSc with relationship to duration of the disease and Raynaud phenomenon and also to type and severity of the disease. Twenty unselected, consecutive patients with SSc diagnosed in compliance with the international diagnostic criteria of the American Rheumatism Association (1982), were enrolled into the study. The control group consisted of 26 otologically healthy persons matched to the SSc group for age and sex. Case history was recorded for all patients from questionnaire data. Otolaryngological examination and battery of audiological tests (pure tone audiometry, speech audiometry, impedance audiometry and auditory brainstem response-ABR) were performed. In the anamnesis 60% of patients reported vertigo, 55% headaches, 50% tinnitus, 40% hyperacusis, 40% hearing loss and 30% ear fullness. It was found that patients with SSc had significantly poorer mean hearing thresholds than the control group for 0.5, 1, 6 and 8 kHz. In ABR there were no differences between SSc and control groups although an increase of latency averages in the group of limited patients with SSc compared with the diffuse patients with SSc was observed. In eight patients (40%) sensorineural hearing loss, mostly bilateral and symmetrical was found. Furthermore, no relation was seen between hearing level and duration, type and severity of the disease. Ear involvement is frequent in systemic sclerosis and should be taken into consideration during diagnostic and therapeutic procedures.

Cranial nerve VI palsy as a rare initial presentation of systemic lupus erythematosus: case report and review of the literature

A 48-year-old woman presented with isolated sixth cranial nerve palsy. She subsequently developed systemic lupus erythematosus (SLE) based on clinical and laboratory parameters. Three years later, she presented again with sixth cranial nerve palsy affecting the contralateral eye. Within 2 weeks of steroid initiation, complete recovery occurred. The unusual rare presentation of SLE in the current patient, as well as the pathogenesis and treatment of cranial neuropathy in SLE are discussed. Lupus (2010) 19, 201—205.

Results for audiology and distortion product and transient evoked otoacoustic emissions in patients with systemic lupus erythematosus

The aim of the current study was to investigate hearing loss and cochlear function in patients with systemic lupus erythematosus, using audiology, distortion product otoacoustic emissions and transient evoked otoacoustic emissions.

STUDY DESIGN

Prospective, case-control study.

METHODS

The study included 26 randomised patients with systemic lupus erythematosus (52 ears) and 30 healthy control subjects (60 ears). Pure tone audiometry was performed at 250 and 500 Hz and at 1, 2, 4, 6, 8, 10, 12, 14 and 16 kHz. Distortion product otoacoustic emissions and transient evoked otoacoustic emissions were measured using Biologic System equipment with Scout Acoustic Emissions System software.

RESULTS

The distortion product otoacoustic emission signal responses were significantly different only at 750 Hz, while the distortion product otoacoustic emission signal-noise ratios were significantly different at 750 Hz and 6 kHz (p < 0.05), comparing patients and controls. The transient evoked otoacoustic emission signal-noise ratios were significantly different at 2 and 3 kHz, comparing patients and controls (p < 0.05). The transient evoked otoacoustic emission total signal-noise ratios were significantly different, comparing patients and controls (p < 0.05). In addition, the pure tone audiometry thresholds were significantly different at 250 and 500 Hz and at 1, 2, 10 and 12 kHz, comparing patients and controls (p < 0.05).

CONCLUSION

Our findings do not completely agree with those of previous temporal bone histopathological studies. However, our results do support a general picture of low frequency hearing loss in systemic lupus erythematosus patients. We consider these results to be related to endolymphatic and cochlear hydrops, and we suggest that electrocochleography could be performed in further studies for clarification of this subject.

Sensorineural Hearing Loss in Patients with Mixed Connective Tissue Disease: Immunological Markers and Cytokine Levels

Objective.

To investigate the frequency of sensorineural hearing loss (SNHL) in patients with mixed connective tissue disease (MCTD).

Methods.

The study population consisted of 71 patients with MCTD (69 female; 2 male), with a mean age of 57.1 ± 7.9 years and a mean disease duration of 14.5 ± 8.0 years. All patients underwent audiological evaluation that included pure tone and speech audiometry. In addition, the systemic manifestations of the disease and drug therapy were recorded. All patients were tested for presence of autoantibodies. Fifty-one age-matched healthy subjects served as controls.

Results.

SNHL was found in 33 (46.4%) of the 71 patients with MCTD. There was no correlation between SNHL and age and disease duration. An association was found between Raynaud’s phenomenon (p < 0.03), secondary antiphospholipid syndrome (APS) (p < 0.05), and SNHL. MCTD patients with SNHL had higher serum levels of anti-U1RNP (p < 0.05), antiendothelial cell antibodies (p < 0.001), and IgG type anticardiolipin antibodies (p < 0.0001) than patients without SNHL. Serum levels of interferon-γ and tumor necrosis factor-α were increased in MCTD patients with SNHL compared to patients without SNHL. The absolute number of natural (CD4+CD25highFoxP+) regulatory T cells (Treg) was lower compared to patients without SNHL.

Conclusion.

In MCTD, SNHL is a specific organ manifestation and appears frequently. We have found that pathogenic autoantibodies, decreased levels of regulatory T cells, and overexpression of proinflammatory cytokines may play a role in the pathogenesis of immune mediated inner ear disorders in MCTD.

Sensorineural hearing loss in systemic lupus erythematosus: case report and literature review

OBJECTIVES

We present a case of systemic lupus erythematosus with symptomatic sensorineural hearing loss which was successfully treated with azathioprine, as assessed both clinically and radiologically. We also present a review of the relevant literature.

CASE REPORT

A woman with systemic lupus erythematosus presented with sensorineural hearing loss, initially on the right and subsequently developing on the left over several months. An audiogram revealed profound neurosensory hearing loss bilaterally. The patient was treated with prednisone 60 mg daily and azathioprine 200 mg daily. An improvement on the left was noted on follow-up audiography as well as on magnetic resonance imaging of the internal auditory canals and surrounding structures.

CONCLUSION

Sensorineural hearing loss has been described in autoimmune disorders but is rare. Aural symptoms have been described, with varying incidences (0-57.5 per cent), in systemic lupus erythematosus. However, symptomatic sensorineural hearing loss is rare in systemic lupus erythematosus. Prednisone appears essential when an immunological or vasculitic cause is found. The use of azathioprine should be considered, as well as follow-up with magnetic resonance imaging to detect improvement.