Study of systemic lupus erythematosus in temporal bones

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.

Evaluation of Hearing Functions in Children with Celiac Disease and the Effect of Gluten-free Diet on these Functions

OBJECTIVE

The present study aims to investigate the potential impact of celiac disease (CD) on hearing functions and assess the effect of a gluten-free diet (GFD) on this condition.

MATERIALS AND METHODS

The study included 55 children with CD (110 ears) and 25 healthy controls (50 ears) matched for age and gender. The CD group was divided into adherent (n = 31) and nonadherent (n = 24) to GFD. Participants underwent tympanometry and pure tone audiometry assessments covering frequencies from 500 to 4000 Hz.

RESULTS

Patients with CD showed significantly higher air and bone conduction hearing averages compared to the control group at frequencies of 500, 1000, 2000, and 4000 Hz for air conduction, and at 500 Hz for bone conduction (P < 0.05). Celiac patients, those who fully adhered to GFD, had notably higher air conduction hearing averages at 500, 2000, and 4000 Hz compared to healthy controls (P < 0.05). However, there was no difference in bone conduction hearing averages between the two groups. In contrast, celiac patients who did not comply with GFD had statistically significantly higher air and bone conduction hearing averages than the control group (P < 0.05), at frequencies of 500, 1000, and 4000 Hz for air conduction, and at 500 and 1000 Hz for bone conduction (P < 0.05).

CONCLUSIONS

The study suggests that nonadherence to GFD may elevate the risk of hearing loss in children with CD. As a result, it is recommended to conduct hearing screenings for children with CD and underscore the importance of complying with GFD to mitigate further detrimental effects on hearing functions.

The role of the stria vascularis in neglected otologic disease

The stria vascularis (SV) has been shown to play a critical role in the pathogenesis of many diseases associated with sensorineural hearing loss (SNHL), including age-related hearing loss (ARHL), noise-induced hearing loss (NIHL), hereditary hearing loss (HHL), and drug-induced hearing loss (DIHL), among others. There are a number of other disorders of hearing loss that may be relatively neglected due to being underrecognized, poorly understood, lacking robust diagnostic criteria or effective treatments. A few examples of these diseases include autoimmune inner ear disease (AIED) and/or autoinflammatory inner ear disease (AID), Meniere's disease (MD), sudden sensorineural hearing loss (SSNHL), and cytomegalovirus (CMV)-related hearing loss (CRHL). Although these diseases may often differ in etiology, there have been recent studies that support the involvement of the SV in the pathogenesis of many of these disorders. We strive to highlight a few prominent examples of these frequently neglected otologic diseases and illustrate the relevance of understanding SV composition, structure and function with regards to these disease processes. In this study, we review the physiology of the SV, lay out the importance of these neglected otologic diseases, highlight the current literature regarding the role of the SV in these disorders, and discuss the current strategies, both approved and investigational, for management of these disorders.

Hearing restoration and the stria vascularis: evidence for the role of the immune system in hearing restoration

PURPOSE OF REVIEW

This article reviews the current literature regarding the pathogenesis of immune-mediated sensorineural hearing loss, utilizes previously published single-nucleus transcriptional profiles to characterize cytokine and cytokine receptor expression in the adult stria vascularis cell types to support immune system interaction with the stria vascularis and reviews the current literature on immunomodulatory agents currently being used for hearing-restoration treatment.

RECENT FINDINGS

The literature review highlights recent studies that elucidate many cytokines and immune markers, which have been linked to various immune-mediated disease processes that have been observed with sensorineural hearing loss within the stria vascularis and highlights recent publications studying therapeutic targets for these pathways.

SUMMARY

This review highlights the current literature regarding the pathogenesis of immune-mediated hearing loss. The role of cochlear structures in human temporal bones from patients with immune-mediated sensorineural hearing loss are highlighted, and we review cytokine signalling pathways relevant to immune-mediated sensorineural hearing loss and localize genes encoding both cytokine and cytokine receptors involved in these pathways. Finally, we review immunomodulatory therapeutics in light of these findings and point to opportunities for the application of novel therapeutics by targeting these signalling pathways.

Selected Otologic Disorders Causing Dizziness

PURPOSE OF REVIEW

This article details updated clinical presentations and current treatment paradigms of the common otologic disorders that may present to the neurologist for vertigo, including Ménière disease, superior semicircular canal dehiscence syndrome, perilymphatic fistula, barotrauma, cholesteatoma, Ramsay Hunt syndrome, enlarged vestibular aqueduct syndrome, and autoimmune inner ear disease including Cogan syndrome.

RECENT FINDINGS

The recent data on modern imaging techniques with three-dimensional delayed IV contrast in Ménière disease, findings on the clinical and testing parameters to diagnose semicircular canal dehiscence and barotrauma, and clinical findings in Ramsay Hunt syndrome, cholesteatoma, and enlarged vestibular aqueduct syndrome are discussed in the article. The most recent findings on the treatment and evaluation of autoimmune inner ear disease and Cogan syndrome are also covered.

SUMMARY

This article discusses the common clinical otologic entities in patients who may present to the neurologist for vertigo, and it can be used as a guide in the diagnosis of these conditions with the use of auditory, vestibular, and imaging results.

Sudden Sensorineural Hearing Loss in Systemic Lupus Erythematosus and Antiphospholipid Syndrome: A Clinical Review

BACKGROUND

Sudden sensorineural hearing loss (SSNHL) is defined as a sudden loss of hearing, usually unilateral, of more than 30 dB in 3 contiguous frequencies of the tonal audiometry. SSNHL estimates an incidence ranging from 5 to 20 per 100.000 people per year. In approximately 75% of cases, a cause cannot be identified. However, it could be a clinical manifestation of Systemic lupus erythematosus (SLE) and Antiphospholipid Syndrome (APS).

OBJECTIVE

This review will focus on the clinical presentation, diagnosis, and management of the SLE and APS associated SSNHL.

METHODS

We searched in PubMed, Scopus, Lilacs, and Cochrane reviewing reports of Sudden sensorineural hearing loss in SLE and/or APS. Articles written in English and Spanish, and were available in full text, were included.

RESULTS

In patients with SLE, bilateral involvement was frequent. Antiphospholipid antibodies were positive in the majority of the patients. Corticosteroids were the mainstay of the treatment. The auditory prognosis was poor with total hearing loss recovery reached in only 22% of patients. On the other hand, most of the patients with SSNHL and APS were males and presented associated symptoms such as vertigo, tinnitus and/or headache, 75% had bilateral disease. Lupus anticoagulant and aCL were found in equal proportions, all patients were anticoagulated, and aspirin was associated in 25% of the cases. Complete resolution or improvement of symptoms was observed in 25% of the patients.

CONCLUSION

Sudden sensorineural hearing loss, can be a clinical feature of SLE and APS. Treating physicians should be aware of this devastating complication, especially when bilateral involvement occurs.

Emerging options in immune-mediated hearing loss

Objective

AIED (autoimmune inner ear disease) is an autoimmune process that leads to the dysfunction of the inner ear, resulting in fluctuating, audiovestibular symptoms. Although the pathogenesis is likely heterogeneous, immune processes within the inner ear ultimately lead to histopathologic changes and sensorineural hearing loss. This review will discuss the latest evidence on treatment options.

Methods

A literature search on articles pertaining to the treatment of autoimmune inner ear disease was performed on PubMed.

Results

Corticosteroid treatment continues to remain as first line therapy for AIED but long-term responsiveness is poor. Cytotoxic chemotherapies can be effective alternatives for steroid nonresponsive patients, but significant side effects may limit their use. Intratympanic steroid injections are beneficial and although there is not enough evidence currently to supplant oral steroid trial they may be a useful adjunct if steroid toxicity is an issue. The efficacy of biologic agents has been variable. Compared to placebo, etanercept does not improve the hearing improvement already attained by steroids alone. However, open pilot studies of other biologic agents show hearing improvements, improvements in tinnitus/aural fullness/vertigo, ability to wean steroid dependency, or benefits in steroid-resistant AIED.

Conclusion

There is currently not enough evidence that alternative treatments supersede the use of initial steroid treatment. Biologic agents and intratympanic steroid injections are relatively well tolerated and should be considered as adjunctive therapy. More studies on the efficacy of various biologics and more studies on the treatment of steroid resistant disease especially after initial benefit are still needed. For those who eventually lose their hearing, cochlear implantation remains as a viable option.

Level of Evidence

expert opinion.

Intratympanic gadolinium magnetic resonance imaging supports the role of endolymphatic hydrops in the pathogenesis of immune-mediated inner-ear disease

Objective

To evaluate the presence of endolymphatic hydrops in patients with immune-mediated inner-ear disease.

Methods

The presence of endolymphatic hydrops was prospectively evaluated in 17 patients clinically diagnosed with secondary (n = 5) or primary (n = 12) immune-mediated inner-ear disease, who attended the ENT department of a tertiary care centre for evaluation or treatment over the previous year. All patients underwent magnetic resonance imaging of the temporal bone.

Results

Intratympanic gadolinium three-dimensional magnetic resonance imaging diagnosed hydrops in 11 of 12 patients with primary immune-mediated inner-ear disease (92 per cent). Of these, seven patients (64 per cent) presented only cochlear (n = 5) or predominantly cochlear (n = 2) hydrops. A positive magnetic resonance imaging result was observed in only one of five patients with secondary immune-mediated inner-ear disease (20 per cent).

Conclusion

This study confirms the presence of endolymphatic hydrops in immune-mediated inner-ear disease patients. The virtual absence of hydrops in patients with secondary immune-mediated inner-ear disease is remarkable, although firm conclusions cannot be drawn; this should be explored in a multicentre study with a larger sample of patients. A different immune reaction without development of endolymphatic hydrops should not be ruled out in secondary immune-mediated inner-ear disease patients.

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.

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.

Endolymphatic hydrops in Ménière's disease: cause, consequence, or epiphenomenon?

OBJECTIVE

To determine the relationship of endolymphatic hydrops to Ménière's disease.

DATA SOURCES

Comprehensive review of articles from 1938 through 2012 via Medline and Index Medicus.

STUDY SELECTION

Articles discussing Ménière's disease and/or endolymphatic hydrops that include temporal bone autopsy data.

DATA EXTRACTION

Fifty-three case reports and series were studied containing examination of 541 hydropic temporal bones and including 276 patients with Ménière's disease. These were divided into those meeting the 1995 American Academy of Otolaryngology-Head and Neck Surgery criteria for Ménière's disease and those that failed to meet these criteria.

CONCLUSION

An individual meeting the 1995 criteria for Ménière's disease has a near certain probability of having endolymphatic hydrops in at least 1 ear. Autopsy data do not support the view that the association of MD and EH is an epiphenomenon or that MD causes EH; this leaves us with the probability that EH causes MD. If it is causative, hydrops alone is insufficient to cause Ménière's disease, indicating that there must be one or more additional cofactors that cause asymptomatic hydrops to become symptomatic Ménière's disease. Vascular risk factors should be studied as possible cofactors.

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).

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

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

Temporal bone histopathology and immunoglobulin deposition in Sjogren's syndrome

HYPOTHESIS

The histopathology of Sjogren's syndrome (SS) in the human inner ear correlates with mouse models of autoimmune inner ear disease.

BACKGROUND

SS is an autoimmune disease in which 25% of patients have sensorineural hearing loss (SNHL). The inner ear histology in a SS mouse model has shown degeneration of the stria vascularis (SV) and immunoglobulin G deposition on the basement membrane of SV blood vessels. Correlation with human temporal bone histopathology has not been addressed.

METHODS

The histopathology and immunohistochemistry of the inner ear in 4 patients with SS is described and compared with SS mouse models.

RESULTS

The histopathology of the inner ear in 3 patients with SS and SNHL showed severe loss of the intermediate cells of the SV and immunoglobulin G deposition on the basement membrane of SV blood vessels. These results parallel those of known SS mouse models. Additionally, there was shrinkage of the spiral ganglia neurons in 2 patients, whereas vestibular ganglia neurons were preserved. The fourth patient with SS and normal hearing showed only mild SV atrophy.

CONCLUSION

This is the first study describing the pathologic changes in the inner ear of 4 patients with SS. The 3 SS specimens with SNHL showed pathologic changes in the SV similar to the mouse model of autoimmune inner ear disease. Additionally, we propose that spiral ganglia neurons may be directly affected by SS pathology. These results highlight the importance of correlating the histopathology of human temporal bones with animal models to better understand inner ear disease in future research.

A method for MS(E) differential proteomic analysis of archival formalin-fixed celloidin-embedded human inner ear tissue

Proteomic analysis of cadaveric formalin-fixed, celloidin-embedded (FFCE) temporal bone tissue has the potential to provide new insights into inner ear disorders. We have developed a liquid chromatography-mass spectrometry (LC-MS) method for tissue sections embedded with celloidin. Q-TOF (Quadrupole-time of flight mass spectrometry) MS(E) (mass spectrometry where E represents collision energy) and Identity(E)™ were used in conjunction with nano-UPLC (capillary ultrahigh pressure liquid chromatography) for robust identification and quantification of a large number of proteins. Formalin-fixed paraffin-embedded (FFPE) mouse liver sections were used to evaluate formalin de-cross-linking by five different methods. Unfixed fresh mouse liver tissue was used as a control. Five different methods for preparation of FFPE tissue for MS analysis were compared, as well as four methods for celloidin removal with FFCE mouse liver tissue. The methods judged best were applied to FFCE 20 μm sections of mouse inner ear samples, and FFCE 20 μm human inner ear and human otic capsule bone sections. Three of the five-tissue extraction methods worked equally in detecting peptides and proteins from FFPE mouse liver tissue. The modified Liquid Tissue kit protocol was chosen for further studies. Four different celloidin removal methods were compared and the acetone removal method was chosen for further analysis. These two methods were applied to the analysis of FFCE inner ear and otic capsule sections. Proteins from all major cellular components were detected in the FFCE archival human temporal bone sections. This newly developed technique enables the use of FFCE tissues for proteomic studies.

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.

Techniques of celloidin removal from temporal bone sections

OBJECTIVES

We sought to determine whether the technique of celloidin removal influences the results of immunostaining in celloidin-embedded cochleae.

METHODS

We compared four protocols of celloidin removal, including those using clove oil, acetone, ether-alcohol, and methanol saturated with sodium hydroxide. By optimally fixing our tissue (perfused mice), and keeping constant the fixative type (formalin plus acetic acid), fixation time (25 hours), and decalcification time (ethylenediaminetetraacetic acid for 7 days), we determined whether the technique of celloidin removal influenced the immunostaining results. Six antibodies were used with each removal method: prostaglandin D synthase, sodium, potassium adenosine triphosphatase (Na+,K(+)-ATPase), aquaporin 1, connective tissue growth factor, tubulin, and 200 kd neurofilament.

RESULTS

Clove oil, acetone, and ether-alcohol resulted in incomplete removal of the celloidin, thereby negatively affecting the results of immunostaining. The methanol-sodium hydroxide method was effective in completely removing the celloidin; it produced the cleanest and most reproducible immunostaining for all six antibodies.

CONCLUSIONS

Freshly prepared methanol saturated with sodium hydroxide and diluted 1:2 with methanol was the best solvent for removing celloidin from mouse temporal bone sections, resulting in consistent and reproducible immunostaining with the six antibodies tested.

[Auto-immune sensorineural deafness: physiopathology and therapeutic approach]

Sensorineural hearing loss may be due to an autoimmune mechanism. The mechanisms that could induce autoimmune inner ear damage are now better understood, but are not exclusive. Moreover, there is no specific immunologic test available for the diagnosis of autoimmune sensorineural hearing loss, which could also complicate the disease course of other autoimmune systemic diseases. Thus, the incidence of sensorineural autoimmune hearing loss is probably underestimated. The aim of this study was to review the experimental immunologic data in favour of an autoimmune mechanism in this subgroup of sensorineural hearing loss: humoral specific response against inner ear (autoantibodies against a transmembrane transporter) and also cellular response (against cochlin: one of the major proteins expressed in the inner ear). The aim of this review was also to focus on clinical and epidemiological human data that provide evidence for an autoimmune etiopathogeny of some sensorineural hearing loss. Therapeutic options such as immunosuppressive treatments (oral corticosteroids and other immunosuppressive drugs, such as methotrexate and anti-TNFalpha) are also discussed.

Sensorineural dysacusis in patients with systemic lupus erythematosus

The objective of this study was to establish the frequency of involvement of the auditory apparatus in 45 female patients with systemic lupus erythematosus (SLE) submitted to general clinical and laboratory assessments, and tone and vocal audiometry accompanied by a questionnaire evaluating auditory symptoms. The control group consisted of 45 healthy women, matched by age. Auditory symptoms were present in 25 (55.5%) patients, with a diagnosis of sensorineural hearing loss in seven (15.6%) patients. A significant correlation with hypoacusis (P < 0.001), ear fullness (P = 0.012) and tinnitus (P = 0.017) was observed in patients with hearing loss. None of the clinical or laboratory parameters showed an association with sensorineural hearing loss. In the control group, three women (6.7%) presented audiometric alterations, including two with altered tympanometry results and one with mild sensorineural hearing loss. In conclusion, an adequate investigation of auditory symptoms is important during the follow-up of patients with SLE, since manifestations of the auditory apparatus and sensorineural hearing loss can affect a significant proportion of patients.

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.

Audiovestibular disturbance in patients with systemic lupus erythematosus

OBJECTIVE

The aim of this study was to evaluate the audiovestibular disturbance in patients with systemic lupus erythematosus (SLE).

STUDY DESIGN AND SETTING

Twenty-eight patients with SLE and 28 healthy control subjects were included. Pure-tone audiometry, impedance audiometry, and electronystagmography (ENG) were used for baseline evaluation. Laboratory tests were carried out. Cranial and brain stem magnetic resonance imagings (MRI) were undertaken.

RESULTS

Nineteen (67%) patients reported audiovestibular symptoms. Sensorineural hearing loss was found in 6 (21%) patients. Abnormal results on ENG were significantly higher (50%) (P < 0.01). Abnormal laboratory data were available from 26 patients (P < 0.05). MRI did not show any pathosis.

CONCLUSION

The audiovestibular disturbances in SLE are more prevalent than previously recognized. Although no cause and effect relationship can be established by this type of study, it appears that a relationship exists.

SIGNIFICANCE

Audiologic research should be directed toward routine, pure tone audiometry, and ENG assessment for patients with SLE to enable crucial treatment.

Bone marrow transplantation as a strategy for the treatment of autoimmune hearing loss in MRL/Mp-lpr/lpr mice

Sensorineural hearing loss (SNHL) has been reported to develop as a main part of or in combination with systemic and organ-specific autoimmune diseases. The aim of the current study is to treat autoimmune SNHL in MRL/Mp-lpr/lpr (MRL/lpr) mice, a murine model of systemic autoimmune disease, using allogeneic bone marrow transplantation (BMT), which replaces recipient bone marrow cells with bone marrow cells from a non-autoimmune-prone donor. The results indicate that BMT can be used to treat SNHL; cochlear pathology, serum autoantibodies and lupus nephritis are ameliorated. Therefore, it is conceivable that the autoimmune SNHL in the MRL/lpr mice results not from defects in the cochlea, including the stria vascularis, but from defects in the bone marrow, and BMT would therefore provide a curative effect on inner ear autoimmune dysfunction associated with systemic autoimmune diseases.

Sudden sensorineural hearing loss in lupus erythematosus associated with antiphospholipid syndrome: case report and review

Systemic lupus erythematosus is a disease of unknown cause that manifests with tissue and cellular alterations due to the deposition of antibodies and pathogenic immune complexes. The disease can be associated with anticardiolipin antibody syndrome, a disorder of recurrent vascular thrombosis and thrombocytopenia associated with a persistent anticardiolipin test positivity. In this report, we describe the case of a young woman affected by lupus erythematosus and positive for anticardiolipin antibodies who was brought to our observation for a sudden sensorineural hearing loss in the right ear. The patient was successfully treated with osmotic therapy and, 13 months after the initial symptom, is now in good clinical condition with no recurrence of the hearing loss and normal bilateral hearing. Together with a critical review of the pertinent literature, this rare clinical case led us to formulate some original comments.

Autoimmune inner ear disease

PURPOSE OF REVIEW

The role of the immune system in mediating inner ear pathology has received considerable attention over the past two decades. The purpose of this paper is to summarize recent basic science research into the pathogenesis of autoimmune inner ear disease (AIED), review the current diagnostic work-up for patients with suspected AIED, and delineate treatment strategies.

RECENT FINDINGS

Basic science and clinical studies have been performed to delineate the mechanisms by which autoimmune processes may affect the ear and to develop treatment strategies to reverse this pathology. AIED refers to a rapidly progressive (over a course of weeks to months) sensorineural hearing loss that responds to the administration of corticosteroids. In addition, systemic autoimmune diseases (eg, vasculitides, lupus, Wegener granulomatosis) can secondarily affect the inner ear. Although a number of diagnostic tests for AIED have been advocated, the diagnosis of this entity is still predicated on a positive therapeutic response to corticosteroid administration. Alternate immunosuppressive regimens, designed to be used in patients who cannot be weaned off corticosteroids or whose disease becomes refractory to treatment, have proven to be difficult to develop. Methotrexate, which initially showed promise, has recently been shown to be ineffective in preventing progression of hearing loss. Further research is required to better delineate the pathophysiologic mechanisms involved in AIED and to establish more effective and better tolerated treatment regimens.

SUMMARY

The original enthusiasm that was generated by the concept that immune-mediated mechanisms may mediate reversible forms of inner ear pathology has been tempered by the realities conveyed by scientific research. The pathophysiology of AIED is still not well understood. Multiple potential mechanisms have been identified that can result in immune-mediated inner ear pathology. The diagnosis of AIED is based on clinical presentation and response to the administration of corticosteroids. Diagnostic testing may support the diagnosis, and the results of a recent multicenter study should clarify the role of immunologic testing in the diagnosis of this entity. Treatment options are limited, with corticosteroids being the only validated treatment option, and methotrexate offering no significant benefit to patients. The role of cyclophosphamide is restricted to patients willing to endure the attendant risks. With the advent of cochlear implants, the administration of toxic medications to preserve hearing at all costs is a less desirable option.

Autoimmune sensorineural hearing loss: Clinical course and treatment outcome

BACKGROUND

Autoimmune sensorineural hearing loss (ASHL) originally was defined both by the presence of progressive hearing loss (with or without vertigo) and a positive response to glucocorticoid therapy. Subsequently, antibodies to a 68-kd inner-ear antigen were identified in a high percentage of patients with ASHL.

OBJECTIVE

To analyze the disease progression and treatment outcome of ASHL.

METHODS

Retrospective chart review of 30 patients with a diagnosis of ASHL referred to Texas Tech Rheumatology Clinic. All subjects were tested for anti-68-kd antibody, had audiometric evidence of hearing loss, and were treated with glucocorticoids.

RESULTS

The median duration from onset of symptoms to audiometric testing was 25.5 weeks (mean, 144 weeks; range, 3-1,040 weeks), and to testing for anti-68-kd antibody was 40 weeks (mean, 157.3; range, 4-1,092 weeks). Ninety percent of subjects tested positive for anti-68-kd antibodies. By audiometric testing, 50% of subjects were steroid-responsive; minimal improvement or no change was recorded in 12%, and worsening occurred in 39% after steroid therapy. The 3 subjects who were anti-68-kd antibody-negative were steroid-unresponsive, and 1 progressed to complete deafness.

CONCLUSIONS AND RELEVANCE

This series of patients with ASHL suggests a more variable and benign course with a better prognosis than previously reported. Immunosuppressive therapy other than steroids rarely was required, and rapid progression to complete hearing loss was very uncommon in this cohort.

Perda auditiva sensorioneural no lúpus eritematoso sistêmico: relato de três casos

INTRODUÇÃO: O Lúpus Eritematoso Sistêmico (LES) é uma doença sistêmica do tecido conectivo, de etiologia desconhecida, provavelmente multifatorial. Acomete principalmente o sexo feminino podendo afetar múltiplos órgãos, dentre eles o sistema auditivo. A orelha interna pode ser lesada por diversos mecanismos auto-imunes, sendo a manifestação mais freqüente a disacusia sensorioneural flutuante, geralmente bilateral, rapidamente progressiva e com boa responsividade a imunossupressores. OBJETIVO: O objetivo deste trabalho é relatar três casos de disacusia de etiologia auto-imune, enfocando formas de acometimento e manifestações clínicas, bem como correlacionando o efeito ototóxico da cloroquina - droga empregada no controle do LES - com a perda auditiva. CONCLUSÃO: As perdas auditivas sensorioneurais súbitas, rapidamente progressivas ou flutuantes, podem ocorrer em pacientes com doença auto-imune e devem ser sempre lembradas nos casos de disacusia sem causa aparente.

Electrocochleographic findings in cases of autoimmune disease with sensorineural deafness

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Autoimmune sensorineural hearing loss

Autoimmune sensorineural hearing loss has been increasingly recognized as a clinical entity since its description by McCabe in 1979. Recognition and proper management of this condition is important, as it is one of the very few forms of sensorineural hearing loss that can be successfully treated by medical therapy. Recent studies have provided experimental evidence to suggest that immune processes can cause sensorineural hearing loss in animals and humans. However, antigenic targets within the inner ear are diverse and as a result conclusive evidence for specific autoimmune damage to the inner ear has been elusive. This review focuses on the recent progress in understanding of the aetio-pathogenesis of autoimmune hearing loss along with a description of the various clinical conditions in which they occur. Recent advances in the laboratory diagnosis and management of this interesting condition are also described.

Autoimmune inner ear disorders

There is considerable evidence to suggest that hearing and vestibular function can be influenced by autoimmune processes. A number of systemic autoimmune disorders include hearing loss and vertigo as part of their constellation of symptoms. Although classic evidence for a specific autoimmune etiology mediated by immune response directed solely at the inner ear is elusive, it appears that autoimmune damage can also exist as an entity confined to the labyrinth. Antigenic targets of autoimmunity within the labyrinth seem to be diverse. Partly because of this, the condition is difficult to diagnose. However, autoimmune disorders of the inner ear are of special interest since they are among the few forms of hearing loss that are amenable to medical treatment. Recent progress in understanding the etiology, diagnosis and treatment of autoimmune damage to the inner ear is reviewed.

Abnormal cochlear connective tissue mineralization in the palmerston north autoimmune mouse

Inner ear fibrosis and osteogenesis are common features of human autoimmune disease, although the cellular mechanisms are unknown. The Palmerston North (PN) autoimmune strain mouse has been shown to develop modiolar sclerotic lesions with progression of its systemic disease. Therefore, lesion development was studied in the cochleas of PN mice to gain insight into potential autoimmune osteogenic processes in the human ear. Cochleas from PN mice were examined with electron microscopy to characterize the cellular and extracellular matrix changes that lead to abnormal mineralization. Initially, activated fibroblasts produced extracellular matrix fibers, ranging in size from fine fibrils to larger collagen-like fibers. These proliferating fibers appeared to 'seed' the mineralizing lesions by serving as the framework for mineral deposition. As mineralization continued, the foci grew in size and fused to form large sclerotic masses within the connective tissue. However, the lesions never invaded nor degraded the normal modiolar bone. These observations of abnormal mineralization of cochlear connective tissue fibers show some parallels with human cochlear autoimmune osteogenesis, suggesting similar molecular processes may be involved.