Acute hearing loss in giant cell arteritis

A Giant Silence - An atypical association of sensorineural hearing loss with Giant Cell Arteritis

Giant cell arteritis (GCA) is a chronic vasculitic disorder predominantly affecting medium to large sized arteries, prevalent in the 50 plus age group. This case illustrates an atypical presentation of this disease in the form of bilateral sensorineural hearing loss (SNHL). Apart from the presence of constitutional and vertiginous symptoms, there were essentially no classical features of GCA. Differentials were broad including infection, malignancy and medication toxicity as well as brain, eye and ear syndromes such as Cogan's syndrome, all of which were eventually excluded. Her diagnosis was ultimately confirmed on positron emission tomography, which highlights the diagnostic importance of this modality. She was managed with corticosteroids then tocilizumab and is making a gradual recovery. Literature review demonstrates that SNHL is more prevalent than previously suggested in GCA, although this does not have widespread recognition. Mechanisms of SNHL in GCA include vascular occlusion, immunological mechanisms including cross reactivity with viral antigens and direct viral infection. SNHL does appear to improve with corticosteroids. This case emphasizes the importance of considering GCA as an important differential in SNHL.

[Giant cell arteritis: Ischemic complications]

GCA ischemic complications occur generally in patients with a yet undiagnosed or uncontrolled disease. When disease control is fair, ischemic complications may be due mostly to atheromatosis. Ophtalmic complications are most frequent and are dominated by anterior ischemic optic neuropathy. Vasculitic strokes occur essentially in the vertebrobasilar arterial territory. Overt vasculitic coronary disease is exceptional. The diagnosis of upper and lower limbs ischemic complications benefit from advances in echography (halo sign) and positron emission tomography imaging. Treatment relies on corticosteroids (initially 1mg/kg prednisone or more, preceded by intravenous methylprednisolone gigadoses if necessary), the control of cardiovascular risk factors and antiplatelet drugs; heparin may be indicated for threatening limbs ischemia.

Patient-reported involvement of the eighth cranial nerve in giant cell arteritis

INTRODUCTION

The frequency of eighth nerve lesions in patients with giant cell arteritis (GCA) has rarely been examined. However, sudden onset deafness has been recorded as a presenting feature of GCA on several occasions. This study sought to establish how common this and other symptoms of eighth nerve involvement are in a large retrospective survey.

METHODS

We contacted 170 patients with GCA and 250 matched PMR patients, inviting them to participate in a questionnaire survey of symptoms of eighth nerve dysfunction. We compared the presence of deafness, tinnitus, loss of balance and vertigo in both groups and examined the relationship between the onset of these symptoms and other features of GCA.

RESULTS

A total of 317 patients were recruited. The percentage of patients with symptoms of possible vestibulocochlear disease prior to commencement of steroid therapy was significantly greater among GCA patients than PMR patients for all domains. Hearing loss which was twice as common in GCA as in PMR (53% vs 26%) [p = 0.001]. Deafness was concurrent in 35% of GCA patients with other symptoms and 45% reported colocation with headache. Recovery with steroids occurred in 56% of these.

CONCLUSION

Symptoms of eighth nerve dysfunction are present in over half of patients with GCA. Recovery with steroids was predicted by concurrence with headache in terms of both timing and location. It appears that eighth nerve involvement, especially acute hearing loss, is a not infrequent feature of GCA and often responds well to steroid therapy. Clinicians should enquire about these symptoms when evaluating a patient for possible GCA.Key Points• Deafness is a frequent presenting feature of giant cell arteritis.• Vertigo, tinnitus and loss of balance are also often reported by GCA sufferers.• Steroid therapy is more likely to relieve these symptoms if they are ipsilateral and concurrent with headache.

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.

Giant Cell (Temporal) Arteritis with Persistent Bilateral Sensorineural Hearing Loss - A Likely Consequence of Delayed Institution of Glucocorticoid Therapy

Patient: Male, 66

Final Diagnosis: Giant cell arteritis

Symptoms: Hearing loss

Medication: —

Clinical Procedure: —

Specialty: Rheumatology

Audiovestibular manifestations in giant cell arteritis: a prospective study

Giant cell arteritis (GCA) is a multisystemic vasculitis of elderly people that involves large and medium-sized blood vessels with predisposition to the cranial arteries. Some cranial ischemic manifestations, in particular permanent visual loss, have been widely described. Audiovestibular manifestations have been less commonly reported. In the present study we assessed the frequency and outcome of audiovestibular manifestations in a series of GCA and isolated polymyalgia rheumatica (PMR) patients examined prospectively between June 1999 and May 2001 at the single hospital for a defined population. Patients were included in the study if a temporal artery biopsy had been performed and they were examined within a week after beginning corticosteroid treatment. Patients with abnormal otoscopy or tympanogram, history of cerebrovascular complications, syphilis, Ménière and other vestibular syndromes, infections involving the inner ear, barotrauma, or being treated with ototoxic drugs were excluded. During the study period 44 patients with GCA and 10 patients with biopsy-negative isolated PMR were examined. Patients with isolated PMR were younger. Audiovestibular dysfunction was significantly more frequent in GCA patients than in those with isolated PMR and matched controls. Almost 90% of the GCA patients had vestibular dysfunction, which was generally reversible after several days of steroid treatment; after 3 months of treatment, vestibular dysfunction was observed in only 13 (29.6%) of the 44 GCA patients. These patients with persistent vestibular dysfunction were more likely to have persistent head-shaking nystagmus. Twelve (27.3%) of the 44 GCA patients had hearing improvement after 3 months of therapy. After 6 months of therapy, only 1 of the 44 GCA patients had abnormal vestibular tests. However, no additional improvement in hearing function was observed. The present study confirms a high frequency of audiovestibular manifestations in GCA. It also suggests that audiovestibular damage may be reversible in some patients with GCA.

Temporal arteritis and sensorineural hearing loss

OBJECTIVES

The association of temporal arteritis and sensorineural hearing loss is a rare occurrence. We present four cases with both these disorders.

METHODS

A 10-year retrospective review of all cases seen at the Geisinger Medical Center showed 271 cases of temporal arteritis and four cases with concomitant sensorineural hearing loss. The four cases were identified, obtained, and extensively reviewed. Patients ranged in age from 59 to 76 years and presented with sensorineural hearing loss and signs, symptoms, and biopsy evidence of temporal arteritis. The response to therapy and clinical course of each case are discussed.

RESULTS

In three patients, the hearing loss preceded the diagnosis of giant cell arteritis by 2 days to 2 months. In one case, the hearing loss was noted concurrently with systemic features of giant cell arteritis. All cases were treated with corticosteroids and had full or partial return of hearing.

CONCLUSIONS

Sensorineural hearing loss can be a preceding or concurrent symptom of temporal arteritis. Recognition and treatment may lead to partial or full recovery. It is not certain whether the time from onset of hearing loss to diagnosis to institution of therapy influences recovery.

Progressive sensorineural hearing impairment in systemic vasculitides

OBJECTIVES

A large series of patients with various forms of systemic vasculitis were evaluated to analyze the prevalence of progressive sensorineural hearing loss (PSNHL), its characteristics and evolution, and the effects of different therapies.

METHODS

A total of 673 patients were questioned about the presence of subjective audiovestibular disturbances. Of those, 80 subjects complained of subjective audiological disturbances and underwent oto-rhino-laryngological and audiovestibular evaluation. Those patients with progressive hearing impairment were selected and studied carefully.

RESULTS

A PSNHL was observed in 14 patients. The hearing loss was bilateral and asymmetrical in most subjects. It was usually sensorineural, with a cochlear lesion. Unsteadiness was the most frequent vestibular symptom and canal paresis or palsy was noted in most patients. Systemic corticosteroids and cyclophosphamide were useful treatments; in unresponsive patients, satisfactory results were obtained with methotrexate and plasma exchange.

CONCLUSIONS

PSNHL is a rare complication of systemic vasculitis, but occasionally is one of the presenting symptoms. Its clinical evolution is variable, but timely clinical assessment and treatment can positively affect prognosis.

Recovery from sensorineural deafness in Wegener's granulomatosis

Wegener's granulomatosis may present with deafness or other aural symptoms. This report describes two patients with histological evidence of Wegener's granulomatosis who developed reversible sensorineural hearing loss during the course of their illness. The first patient showed complete recovery of a sensorineural hearing loss averaging 50 dB after ten months treatment with cyclophosphamide and high-dose prednisolone. The second patient, who was on maintenance haemodialysis, achieved a 40 dB improvement in sensorineural hearing loss within two weeks of adding cyclophosphamide to pre-existing corticosteroid therapy. These findings suggest that the prognosis of sensorineural hearing loss in Wegener's granulomatosis can be improved with suppression of the vasculitic process by early treatment with combined cytotoxic-immunosuppressive therapy.

Steroid-responsive hearing loss in temporal arteritis

An unusual case of temporal arteritis presenting with sensorineural hearing loss is presented. Deafness was improved dramatically by corticosteroid treatment. The diagnosis of temporal arteritis should be considered in elderly patients presenting with sensorineural hearing loss.