Asymptomatic Sensorineural Hearing Loss 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.

Relationship Between Chloroquine or Hydroxychloroquine Use and Hearing Disorders: A Systematic Review and Meta-Analysis

BACKGROUND AND OBJECTIVES

Chloroquine and its analog hydroxychloroquine are derivatives of 4-aminoquinoline and are regularly used in the treatment of malaria and autoimmune diseases. Among the side effects of these drugs, alterations associated with the auditory system are frequently mentioned. Thus, the aim of this systematic review is to systematically review publications on hearing disorders and chloroquine or hydroxychloroquine use.

MATERIALS AND METHODS

Inclusion criteria were observational or interventional studies on audiological assessment in participants who were using chloroquine or hydroxychloroquine. The methodological quality was independently assessed by two reviewers using the Meta-Analysis of Statistics: assessment and review Instrument. The certainty of the evidence was assessed using the GRADE tool.

RESULTS

A total of 1,372 non-duplicate papers were screened, out of which 17 were included in the final qualitative synthesis, and 5 studies in the meta-analysis. The odds ratio for the two subgroups evaluated did not show significance with no heterogeneity between the effects observed between the different diseases (I2=0%) and obtaining the global estimate of 0.76 (95% confidence interval [CI]=0.41-1.39; p>0.05). Despite the inclusion of papers with different disease samples, the heterogeneity observed in the analysis was low (I2= 0%) and prediction interval (95% PI=0.32-1.80; p>0.05) remained close to that estimated by the CI (95% CI=0.41-1.39; p>0.05). The certainty of the evidence assessed by the GRADE tool was considered very low due to the risk of bias, indirect evidence, and imprecision.

CONCLUSIONS

The findings of this study suggest that the use of chloroquine/hydroxychloroquine is not associated with hearing disorders.

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.

[Immune-mediated sensorineural hearing loss: prevalence and treatment strategies]

Autoimmune sensorineural hearing loss is a rare clinical entity which accounting for less than 1% in all cases with hearing loss. The prevalence of hearing loss in immune-mediated inner ear diseases, as shown in case reports or single-center statistics, varies widely. We reviewed the current literatures on the association between sensorineural hearing loss and autoimmune diseases, focused on the prevalence of hearing loss in different autoimmune diseases, treatments and challenges.

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

Ascorbic acid prevents chloroquine-induced toxicity in inner glial cells

Ototoxicity is a collateral effect of prolonged treatment with chloroquine which is a widely utilized as an anti-lupus and anti-malarial drug. Glial cells of inner ear are responsible for maintenance of neuronal cells homeostasis in auditory system. In the current study we have evaluated chloroquine-induced toxicity and protective effect of ascorbic acid treatment on Schwann glial cell cultures of inner ear. Glial cells were cultured from organ of Corti of mice cochlear structure. Purity of Schwann glial cell was confirmed by S100 protein staining. Cell viability was evaluated in control and cultures treated with different concentrations of chloroquine. Glutamate uptake and ROS production were measured by HPLC and DCFH-DA probe fluorescence, respectively. Results have shown that chloroquine treatment evoked concentration and time -dependent toxicity (LC50 = 70 μM) as well as significant decrease on glutamate uptake and high production of ROS in glial cell cultures. Co-treatment with ascorbic acid has prevented both chloroquine-induced ROS production and chloroquine toxicity on glial cell cultures. This pre-clinical study is the first one to demonstrate chloroquine-induced ROS production by glial cells of inner ear as well as the protective effect exerted by ascorbic acid on these cells.

Audiovestibular Symptoms in Systemic Autoimmune Diseases

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

Hearing loss in autoimmune disorders: Prevalence and therapeutic options

The objective of this study was to review our current knowledge relative to the correlation between sensorineural hearing loss (SNHL) and autoimmune diseases, focusing on the prevalence of hearing loss in different pathologies and possible therapeutic approaches. A review of the literature on hearing loss in different forms of autoimmune disease has been carried out, with emphasis on incidence and prevalence of SNHL. Therapeutic protocols have been assessed including both conservative medical and rehabilitative methods. Cochlear implant outcomes have been investigated. The prevalence of hearing loss in autoimmune and immune-mediated inner ear diseases, as referred by case reports or single-center statistics, is widely variable. More difficult is the evaluation of severe/profound SNHL, usually reported in relation to cochlear implantation. Though these patients represent ideal candidates for cochlear implantation, as they become deaf after years of hearing; the associated systemic disease, the specific damage on inner ear structures and the medication taken may influence the result of cochlear implantation. The main problem is the cochlear fibrosis or ossification that has been found to affect 50% of implanted ears in patients suffering from autoimmune and immune-mediated SNHL. Hence, in the presence of severe/profound SNHL earlier implantation may be indicated before post-inflammatory obliterative changes to the cochlea.

Azathioprine reduces the risk of audiometric relapse in immune-mediated hearing loss

INTRODUCTION

Current schemes for treatment of immune-mediated hearing loss with sporadic short-course, low-dose corticosteroids, are insufficient.

METHODS

To determine the role of azathioprine in the control of auditory impairment, a longitudinal, observational, descriptive study was performed with 20 patients treated with azathioprine (1.5-2.5mg/kg/day into two doses) for 1year. The loss of 10dB on two consecutive frequencies or 15dB on an isolated frequency was considered as relapse.

RESULTS

The mean age of the patients was 52.50years (95%CI: 46.91-58.17), half were women. Bilateral affectation was 65%. 75% had organ specific disease and 25% had systemic autoimmune disease. The difference between baseline PTA (46.49dB; DS18.90) and PTA at 12months (45.47dB; DS18.88) did not reach statistical significance (P=.799). There was a moderate positive correlation between female sex and the presence of systemic disease (R=.577). By applying Student's t for paired data, a significant difference (P=.042) was obtained between the PTA in frequencies up to 1000 Hz (PTA125-1000Hz). The relative incidence rate of relapse per year was .52 relapses/year (95%CI: .19-1.14]). The median time to audiometric relapse-free was 9.70months (DS1.03).

CONCLUSIONS

Azathioprine maintains the hearing threshold, decreases the risk of relapse, and slows down the rate at which patients relapse, altering the course of immune-mediated inner ear disease.

Cochlear Histopathologic Findings in Patients With Systemic Lupus Erythematosus: A Human Temporal Bone Study

HYPOTHESIS

We hypothesized that, in archived human temporal bone samples from patients with systemic lupus erythematosus (SLE), a pathologic condition exists in the stria vascularis and cochlear hair cells.

BACKGROUND

Sensorineural hearing loss is a common feature in SLE patients. However, the pathophysiologic mechanism of cochlear dysfunction is unclear.

METHODS

We examined 15 temporal bone samples from 8 SLE patients, along with 17 samples from 10 age-matched healthy control patients. The samples were serially sectioned in the horizontal plane and stained with hematoxylin and eosin. We determined the area of the stria vascularis in a midmodiolar section of each cochlear turn. Then, we made cytocochleograms and calculated the percentage of missing inner and outer hair cells.

RESULTS

The area of the stria vascularis in our SLE group was significantly smaller than in our control group. The number of remaining inner hair cells in our SLE group was smaller than in our control group; however, the difference did not reach statistical significance. The loss of outer hair cells in our SLE group was significantly higher than in our control group. There was a tendency toward a positive correlation between the loss of cochlear hair cells and the duration of SLE.

CONCLUSION

The stria vascularis and cochlear hair cells are affected in SLE patients. Our findings could provide the histopathologic basis for the cochlear dysfunction, including sensorineural hearing loss, experienced by SLE patients.

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.

Congenital heart block and immune mediated sensorineural hearing loss: possible cross reactivity of immune response

Immune-mediated sensorineural hearing loss may complicate systemic autoimmune diseases. We have previously reported the presence of antibodies directed against inner ear antigens in patients with Cogan syndrome, a disease characterized by sudden hearing loss and interstitial keratitis. Such autoantibodies cross-react with an epitope of SSA/Ro60 protein. Anti-Ro/SSA antibodies in pregnant women cross the placenta and reach the fetal tissues inducing an immune-mediated damage of the cardiac conduction system. We wanted to evaluate whether mothers with anti-Ro/SSA antibodies who gave birth to children with congenital heart block have antibodies directed against inner ear antigens and whether these antibodies are connected with the presence of immune-mediated sensorineural hearing loss. We did not find anti-inner ear antibodies in the majority of the mothers. On the contrary a 13-year-old boy with congenital heart block and sensorineural hearing loss was positive for the presence of anti-inner ear antigens antibodies. Moreover his serum was positive for the presence of anti-Ro60 peptide antibodies but did not recognize the entire protein Ro60 (TROVE2), a behaviour similar to that of sera from patients with Cogan syndrome. In conclusion the data obtained so far show that anti-inner ear antibodies do not recognize the entire protein TROVE2 and do not support the hypothesis that such antibodies may be involved in the pathogenesis of congenital heart block.

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.

[Hydroxychloroquine-induced hearing loss: First case of positive rechallenge and analysis of the French pharmacovigilance database]

INTRODUCTION

Several cases of hearing loss induced by hydroxychloroquine have been reported in the literature but the role of hydroxychloroquine still remains debated.

CASE REPORT

We report the first case, to our knowledge, of hearing loss induced by hydroxychloroquine with a positive re challenge in a woman treated for systemic lupus. An analysis of the French pharmacovigilance database allowed to identify 23 additional cases of hearing loss in patients treated with hydroxychloroquine and, among them, 8 had systemic lupus.

CONCLUSION

Despite an excellent tolerance and high efficacy-side effect ratio, this case report adds some evidence for an otoxicity of hydroxychloroquine.

Bilateral sudden sensorineural hearing loss as a presenting feature of systemic lupus erythematosus: Case report and brief review of other published cases

INTRODUCTION

Sudden sensorineural hearing loss is an unusual presenting clinical feature of systemic lupus erythematosus.

CASE REPORT

We report the case of a young woman who was admitted to hospital for sudden sensorineural hearing loss and hemophagocytic syndrome which was attributed to systemic lupus erythematosus on the basis of specific renal involvement, thrombocytopenia, and consistent autoantibodies. Favorable outcome was obtained on high-dose corticosteroids, and the hearing fully recovered.

DISCUSSION

Sudden sensorineural hearing loss in systemic lupus erythematosus is seemingly more frequently associated with severe systemic involvement and antiphospholipid antibodies may be present. Although management remains empirical, the high risk of permanent hearing impairment seems to justify emergency treatment with high-dose corticosteroids. When the clinical and laboratory criteria of antiphospholipid syndrome are met, antiplatelets agents or anticoagulation therapy shall be considered.

Evaluation of hearing loss in pediatric celiac patients

OBJECTIVES

Celiac disease (CD) is a chronic immune-mediated enteropathy caused by the ingestion of gluten in genetically predisposed individuals. In some reports, sensorineural hearing loss (SNHL) has been identified as an extraintestinal symptom of CD. We aimed to further investigate the possible association between CD and SNHL by examining a greater number of pediatric CD patients.

METHODS

The study was carried out from March to September 2014 and included 110 pediatric patients with biopsy-confirmed CD (220 ears) and 41 age- and sex-matched controls (82 ears); participants were evaluated by tympanometry and pure tone audiometry (frequency, 250-8000Hz frequency).

RESULTS

Audiometric bone conduction thresholds were significantly different between the CD patients and the controls (p<0.05), but there were no significant differences in pure tone averages for air conduction (p>0.05). When the results for CD patients were analyzed according to duration of disease (≤36 months and >36 months), a significant difference in bone conduction thresholds (p<0.05) was noted, with significant increments at the later stages of disease. However, this difference was not sufficient to define clinical hearing loss, as the pure tone average thresholds remained below 20dB.

CONCLUSION

These results indicate that subclinical hearing loss may be present in children with CD, which could presage more serious hearing impairments at older ages and later stages of the disease. Hearing screenings should be recommended for children with CD in order to prevent the potentially unfavorable effects of hearing loss on the emotional, behavioral, cognitive, and sensorimotor development of these patients.

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.

Risk of sudden sensorineural hearing loss in patients with systemic lupus erythematosus: a population-based cohort study

Sudden sensorineural hearing loss (SSHL) may be a manifestation of systemic vascular involvement in systemic lupus erythematosus (SLE) and may have an important impact on the health of patients with SLE. To investigate the risk of developing SSHL in patients with SLE, we conducted a population-based, retrospective cohort study from the Taiwan National Health Insurance Research Database. A total of 7168 patients diagnosed with SLE and 35840 control subjects without SLE were selected from claims made from 2001 to 2006. The incidence of SSHL was assessed and determined at the end of 2010. The incidence of SSHL was 2.22-fold higher in the SLE group than in the non-SLE group (6.52 vs. 2.93 per 10000 person-years), with an adjusted hazard ratio (HR) of 2.253 (95% confidence interval, CI=1.407-3.608) calculated using a Cox proportional hazard regression model. Age was an independent risk factor for SSHL, with adjusted HRs of 2.103 for individuals aged≥35 years compared with those 0-34 years. In the 0-34 age range, the incidence of developing SSHL was 4.27-fold (95% CI=2.11-8.67) higher in the SLE group compared with the non-SLE group. In female patients, the incidence of developing SSHL was 2.19-fold (95% CI=1.73-3.50) higher in the SLE group than in the non-SLE group. Systemic lupus erythematosus was significantly associated with an increased risk of developing SSHL. Scheduled auditory examinations for patients with SLE to assess the presence of chronic hearing impairment are advised to enable the early detection of SSHL.

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).

Corticosteroid therapy for hearing and balance disorders

This review addresses the current status of steroid therapies for hearing and vestibular disorders and how certain misconceptions may be undermining the efficacy in restoring normal ear function, both experimentally and clinically. Specific misconceptions addressed are that steroid therapy is not effective, steroid-responsive hearing loss proves an underlying inflammatory problem in the ear, and steroids only have application to the hearing disorders listed below. Glucocorticoid therapy for hearing and balance disorders has been employed for over 60 years. It is recommended in cases of sudden hearing loss, Meniére's disease, immune-mediated hearing loss, and any vestibular dysfunction suspected of having an inflammatory etiology. The predominant steroids employed today are dexamethasone, prednisone, prednisolone, and methylprednisolone. Despite years of use, little is known of the steroid responsive mechanisms in the ear that are influenced by glucocorticoid therapy. Furthermore, meta-analyses and clinical study reviews occasionally question whether steroids offer any benefit at all. Foremost in the minds of clinicians is the immune suppression and anti-inflammatory functions of steroids because of their efficacy for autoimmune hearing loss. However, glucocorticoids have a strong binding affinity for the mineralocorticoid (aldosterone) and glucocorticoid receptors, both of which are prominent in the ear. Because the auditory and vestibular end organs require tightly regulated endolymph and perilymph fluids, this ion homeostasis role of the mineralocorticoid receptor cannot be overlooked in both normal and pathologic functions of the ear. The function of the glucocorticoid receptor is to provide anti-inflammatory and antiapoptotic signals by mediating survival factors.

Vascular Pathophysiology in Hearing Disorders

The inner ear vasculature is responsible for maintenance of the blood-labyrinth barrier, transport of systemic hormones for ion homeostasis, and supplying nutrients for metabolic functions. Unfortunately, these blood vessels also expose the ear to circulating inflammatory factors resulting from systemic diseases. Thus, while the inner ear blood vessels are critical for normal function, they also are facilitating pathologic mechanisms that result in hearing and vestibular dysfunction. In spite of these numerous critical roles of inner ear vasculature, little is known of its normal homeostatic functions and how these are compromised in disease. The objective of this review is to discuss the current concepts of vascular biology, how blood vessels naturally respond to circulating inflammatory factors, and how such mechanisms of vascular pathophysiology may cause hearing loss.

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.

Sudden sensorineural hearing loss

Sudden sensorineural hearing loss is usually unilateral and can be associated with tinnitus and vertigo. In most cases the cause is not identified, although various infective, vascular, and immune causes have been proposed. A careful examination is needed to exclude life threatening or treatable causes such as vascular events and malignant diseases, and patients should be referred urgently for further assessment. About half of patients completely recover, usually in about 2 weeks. Many treatments are used, including corticosteroids, antiviral drugs, and vasoactive and oxygen-based treatments. Although no treatment is proven, we recommend a short course of oral high-dose corticosteroids. There is much to learn about pathogenesis of sudden sensorineural hearing loss, and more clinical trials are needed to establish evidence-based management.

Sensorineural hearing loss in pediatric patients with inflammatory bowel disease

OBJECTIVES

Sensorineural hearing loss as an extraintestinal manifestation of inflammatory bowel disease has been reported in several studies, including adult patients. The aim of this study is to determine the presence of subclinical sensorineural hearing loss associated with inflammatory bowel disease in pediatric patients.

METHODS

Otoscopy, tympanometry, and pure tone audiometry were performed in 24 patients with disease and 20 healthy age- and sex-matched controls.

RESULTS

Pure tone audiometry did not show significant sensorineural hearing loss over all frequencies in patients with inflammatory bowel disease compared with controls (P > 0.05).

CONCLUSIONS

Subclinical sensorineural hearing loss was demonstrated in adult patients with inflammatory bowel disease; therefore we recommend performing audiometric examinations in pediatric patients to recognize hearing loss early during the course of the disease.

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 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.

Chloroquine ototoxicity

Chloroquine (CQ), a 4-aminoquinoline drug, has been largely used for the treatment of rheumatoid arthritis and other connective tissue diseases. Besides the well-known retinal toxicity, its use has been suspected of be associated to ototoxicity. Some reports have described mainly sensorineural hearing loss, tinnitus, sense of imbalance, and cochleovestibular manifestations. Differently from what occurs in retinopathy, in which there is a predominance of CQ toxicity, there are reports of alterations in hearing related to either CQ or hydroxychloroquine. Brain-evoked response audiometry seems to be the most sensitive test in detecting early manifestations of cochlear injury caused by CQ when still in a reversible stage. The reversibility of CQ ototoxicity has been debatable, but there is suggestion that such complication can be corrected if the medication is stopped and appropriate therapy, with steroids and plasma expanders, is instituted.