European Journal of Cardiovascular Medicine

RA or rheumatoid arthritis is a chronic multifactorial disease that has an unknown etiology having a peculiar characteristic feature of persistent inflammatory synovitis. Rheumatoid arthritis has a prevalence of nearly 0.8% globally with a higher prevalence reported in females compared to male subjects. The disease usually presents in 4^th to 5^th decade of the life and shows a significant genetic predisposition. Earlier, rheumatoid arthritis a considered as a disease that exclusively affect the joints, however, after extensive literature results, RA was considered as a systemic disease that has various extra‑articular manifestations that affects nearly 40% of the subjects with symptoms. These manifestations are seen in subjects that have high titres for rheumatoid arthritis factor or subjects with anti‑cyclic citrullinated peptide.¹ 

Rheumatoid nodule is typically seen in 20% to 30% subjects with rheumatoid arthritis with reports showing that subjects with RA have CHL (conductive hearing loss) that ahs been linked with disease activity exacerbation. Involvement of ear can result in CHL which can be attributed to synovial joint disease in the middle ear. Substantial data in previous literature has established a link between hearing loss and rheumatoid arthritis with majority of studies reporting conductive type of hearing loss in rheumatoid arthritis. Also, underlying pathology of hearing loss is attributed to middle ear disease leading to ossicular involvement.²

It has been hypothesized that incudomalleolar and incudostapedial joints are synovial joints that can be involved in the process of rheumatoid arthritis. Necrosis of ossicles and fibrosis of joints are considered as major reason for conductive hearing loss in these subjects. Autoimmune inner ear disease has been documented in the literature from earlier times. It is also reported that SNHL is associated with the risk of rheumatoid arthritis and is caused from autoimmune damage to inner ear from vasculitis or neuritis.³

The diagnostic criteria for subjects suffering from rheumatoid arthritis was given by Ropes et al and Arnett et al revised the criteria to establish diagnosis in subjects with rheumatoid arthritis which was based on various clinical and radiological findings. The classification for tympanograms is also widely used for assessment of hearing loss which is based on variation of air pressure and middle ear compliance. It is also seen that majority of subjects with hearing loss either have conductive or sensorineural hearing loss.⁴ The present study was aimed to assess the prevalence and types of hearing loss in patients with rheumatoid arthritis and to assess its associations with age, gender, and disease duration.

The present case-control clinical study was aimed to assess the prevalence and types of hearing loss in patients with rheumatoid arthritis and to assess its associations with age, gender, and disease duration. The study subjects were from Department of ENT of the Institute. Verbal and written informed consent were taken from all the subjects before study participation.

The study assessed 50 subjects with rheumatoid arthritis that were assessed against 50 controls (age and gender-matched) without rheumatoid arthritis. The inclusion criteria for the study were subjects with normal tympanic membrane, subjects diagnosed with rheumatoid arthritis following American College of Rheumatology revised criteria classification for RA, disease duration in the range of 6 months to 20 years, and subjects in the age range of 20-60 years. The exclusion criteria for the study were subjects on any ototoxic drugs, with connective tissue disorder or autoimmune disorders other than RA, history of otorrhea, middle ear effusion, Meniere’s disease, and history of ear surgery, head injury, acoustic trauma, perforated or scarred tympanic membrane, and previous history of ear diseases.

For all the subjects, NSAIDs (nonsteroidal anti‑inflammatory drugs) were discontinued 7 days prior to audiological assessment followed by comprehensive and complete ear, nose, and throat examination before hearing assessment and included mastoid X-ray, tuning fork test, and otoscopic examination.

Audiological assessment was done using impedance audiometry and PTA (pure‑tone audiometry). Clinical audiometer was used to assess hearing threshold which included assessment of bone conduction threshold and pure-tone air threshold. Stapedial reflexes and impedance audiometry was assessed with commercial impedance audiometer.

Collected data were subjected to statistical evaluation with the chi-square test, Fisher’s exact test, Mann Whitney U test, and SPSS (Statistical Package for the Social Sciences) software version 24.0 (IBM Corp., Armonk. NY, USA) using ANOVA, chi-square test, and student's t-test. The significance level was considered at a p-value of <0.05

The present case-control clinical study was aimed to assess the prevalence and types of hearing loss in patients with rheumatoid arthritis and to assess its associations with age, gender, and disease duration. The present study assessed 50 subjects with rheumatoid arthritis that were assessed against 50 controls without rheumatoid arthritis. In all subjects from both the groups, complete clinical examination was done followed by audiological assessment that included acoustic reflex, tympanometry, and PTA (pure‑tone audiometry) assessment. For hearing loss type in study subjects, normal hearing was seen in 14 and 20 subjects from right and left ear respectively. SNHL was seen in 8 right and left ear each, conductive hearing loss was noted in 28 and 22 right and left ears (Table 1).

Table 1: Hearing loss type in study subjects in right and left ear

 Table 2: Tympanogram type in study subjects in right and left ear

 Table 3: Acoustic reflexes in study subjects in right and left ear

Table 4: Hearing threshold comparison in study subjects in right and left ear

On assessing the tympanogram type in study subjects in right and left ear, the study results showed that type on tympanoplasty was seen in 18 right ears and 14 left ears, whereas, A type of recordings were seen in tympanoplasty of 32 right ears and 36 left ears respectively as shown in Table 2.

Concerning the study of acoustic reflexes in study subjects in right and left ear, it was noted that acoustic reflex was absent in 3 right and 24 left ears, was delayed in 6 right ears and 8 left ears, and was present in 14 right ears and 18 left ears respectively as summarized in Table 3.

The study results showed that for hearing threshold comparison in study subjects in right and left ear, hearing threshold in right ear was <25dB in all 50 subjects and no control group subjects reported hearing threshold reading of >25dB. Similar results were seen in control group for left ear where all subjects depicted hearing threshold reading of <25dB and no subject was shown to have hearing threshold of >25dB. However, in cases, hearing threshold of <25dB was seen in 14 subjects in right ear and 20 subjects in left ear and hearing threshold of >25dB was seen in 18 subjects in right ear and 30 subjects in left ear (Table 4).

The present study assessed 50 subjects with rheumatoid arthritis that were assessed against 50 controls without rheumatoid arthritis. In all subjects from both the groups, complete clinical examination was done followed by audiological assessment that included acoustic reflex, tympanometry, and PTA (pure‑tone audiometry) assessment. For hearing loss type in study subjects, normal hearing was seen in 14 and 20 subjects from right and left ear respectively. SNHL was seen in 8 right and left ear each, conductive hearing loss was noted in 28 and 22 right and left ears. These results were consistent with the findings of McCabe BF⁵ in 2007 and Ilham et al⁶ in 2016 where authors reported results for hearing loss in their studies confirming with the present study.

Concerning the assessment of the tympanogram type in study subjects in right and left ear, the study results showed that As type on tympanoplasty was seen in 18 right ears and 14 left ears, whereas, A type of recordings were seen in tympanoplasty of 32 right ears and 36 left ears respectively. These findings were in agreement with the results of Nasution ME et al⁷ in 2018 and El-Raheem MA et al⁸ in 2020 where A and As type on tympanogram had proportion comparable to the present study in studies by the authors.

The study results showed that for the study of acoustic reflexes in study subjects in right and left ear, it was noted that acoustic reflex was absent in 3 right and 24 left ears, was delayed in 6 right ears and 8 left ears, and was present in 14 right ears and 18 left ears respectively. These results correlated with the findings of Milisavljević D et al⁹ in 2017 and Chaitidis N et al¹⁰ in 2020 where study of acoustic reflexes reported hy the authors in their studies was comparable to the present study.

It was seen that for hearing threshold comparison in study subjects in right and left ear, hearing threshold in right ear was <25dB in all 50 subjects and no control group subjects reported hearing threshold reading of >25dB. Similar results were seen in control group for left ear where all subjects depicted hearing threshold reading of <25dB and no subject was shown to have hearing threshold of >25dB. However, in cases, hearing threshold of <25dB was seen in 14 subjects in right ear and 20 subjects in left ear and hearing threshold of >25dB was seen in 18 subjects in right ear and 30 subjects in left ear. These findings were in line with the results of Gonçalves LF et al¹¹ in 2021 and Jeong H et al¹² in 2016 where hearing threshold comparison similar to the present study was also reported by the authors in their respective studies.

The present study, considering its limitations, concludes that a large number of subjects with rheumatoid arthritis have involvement of ears presenting as hearing loss. Hence, it is vital to conduct auditory screening using PTA in subjects with rheumatoid arthritis which can help in early diagnosis and superior rehabilitation.

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