Rheumatoid arthritis (RA) is a systemic disease characterized by inflammation of the synovial tissue with anatomical and functional repercussion in the articulations [
RA is a pathology that causes musculoskeletal disability and probably auditive involvement. The aim of this study was to establish the prevalence and type of auditive involvement in patients with RA, and to correlate this auditive disfunction with disease activity and duration.
We carried out a descriptive and observational study of paired cases and controls in a cohort. Cases were consecutive patients at the out-patient consulting office of the Rheumatology Department who fulfilled the following inclusion criteria: classification of RA according to the American College of Rheumatology (ACR) [
We collected demographic data on patients by means of a predesigned questionnaire and evaluated RA activity with the Disease Activity Score (DAS) 28 [ tonal audiometry with AC 40 audiometry-type equipment from Interacoustics, by air conduction test, to obtain the auditive threshold, considering auditive loss with a threshold >20 dB in one or more frequencies [ bone conduction test, performed in patients with some alteration in the air conduction test, for later auditive loss classification in conductive (air-bone gap >15 dB), sensory (gap <15 dB), or mixed conductive as well as sensory frequencies [ logoaudiometry (LG), obtaining the word detectability threshold, intelligibility threshold, and maximum comprehension by means of the average threshold in speech frequencies (500 Hz and 1 and 2 KHz) [ impedanciometry: to evaluate middle ear function with the Ampliad brand model 775 (regulated by ANSI 3.39) impedanciometry, 226-Hz tympanometry, classifying the results according to Jerger based on compliance and pressure in the following curves: type A (normal compliance and pressure), type As (diminished compliance and normal pressure), type Ad (increased compliance and normal pressure), type B (flat tympanogram), and type C (displaced to negative pressures) [ high-frequency tympanometry, classifying results according to the model of Vanhuyse in patterns 1B1G and 3B1G (characteristics of rigidity) and of 3B3G and 5B3G (characteristics of mass) [
We conducted a descriptive analysis of the demographic variables utilizing parametric statistics: student
We screened 53 patients with a diagnosis of RA: eight of these patients were excluded due to Meniere's syndrome, eustachian tube dysfunction, and being aged >65 years. A total of 45 patients with RA were studied; these patients were paired with 45 healthy subjects, who made up the control group. In total, we studied 90 ears in each study group. In Table
Demographic characteristics of the populations under study.
Characteristic | Cases | Controls |
---|---|---|
45 | 45 | |
Gender | 41 (91.1%) | 41 (91.1%) |
Age (years) | 44.1 (11.9) | 44.4 (12) |
Comorbilidity ( | Dyslipidemia (1) | Dyslipidemia (1) |
Systemic high blood pressure (4) | Systemic high blood pressure (2) | |
Diabetes mellitus (2) | ||
Categorization by age (years), | ||
<35 | 12 (27) | 13 (28.9) |
>35 | 33 (73) | 32 (71.1) |
DAS 28, | ||
Inactive | 8 (18) | |
Slight activity | 9 (20) | |
Moderate activity | 19 (42) | |
Severe activity | 9 (20) | |
RA evolution (years), | ||
<2 | 10 (22) | |
2–5 | 14 (31) | |
5–10 | 10 (22) | |
>10 | 11 (25) | |
Drugs utilized, | ||
Methotrexate | 35 (78) | |
Hydroxychloroquine/ | 24 (53) | |
Anti-TNF | 7 (15) | |
Leflunomide | 6 (13) | |
Sulfasalazine | 6 (13) | |
Rituximab | 5 (11) | |
Steroids | 11 (24) | |
NSAID | 33 (73) |
*Age difference between groups (
In the group of patients with RA, we found 19 subjects (42.2%) with normal air conduction, 18 patients (40%) with bilateral alteration, and eight patients with unilateral alteration versus the control group, in which we detected 33 subjects (73.3%) without alterations, 10 subjects (22.2%) with bilateral alteration, and only two (4.4%) with unilateral alteration (
Audiological results.
Cases 45 | Controls 45 | ||||
---|---|---|---|---|---|
Age (years) of patients with hypoacousia Mean ± SD | .02 | ||||
Audiometry | Normal | 19 (42.2) | 33 (73.3) | .008 | |
Bilateral alteration | 18 (40) | 10 (22.2) | |||
Unilateral alteration | 8 (17.8) | 2 (4.4) | |||
Audiometric alteration | Right ear | 21 (46.7) | 12 (26.6) | .049 | |
Left ear | 23 (51.1) | 10 (22.2) | .004 | ||
Bone conduction | Sensory hypoacousia | Right ear | 19 (42.2) | 12 (26.6) | >.05 |
Left ear | 22 (48.8) | 10 (22.2) | >.05 | ||
Conductive hypoacousia | Right ear | 1 (2.2) | 0 | >.05 | |
Left ear | 1 (2.2) | 0 | >.05 | ||
Mixed hypoacousia | Right ear | 1 (2.2) | 0 | >.05 | |
Left ear | 0 | 0 | >.05 | ||
Logoaudiometry | 2 (4.4) | 0 | >.05 | ||
Tympanometry 226 Hz | Right ear | Curve A | 23 (51.1) | 29 (64.4) | .2 |
Curve As | 22 (48.8) | 16 (35.5) | |||
Left ear | Curve A | 19 (42.2) | 25 (55.5) | .2 | |
Curve As | 26 (57.7) | 20 (44.4) | |||
High-frequency tympanometry | Right ear | 1B1G | 32 (71.1) | 43 (95.5) | .002 |
3B1G | 13 (28.8) | 2 (4.4) | |||
Left ear | 1B1G | 33 (73.3) | 42 (93.3) | .01 | |
3B1G | 12 (26.6) | 3 (6.6) |
Air conduction test in study groups. Prevalence of hypoacusia was higher in RA patients compared with controls (
Patients with RA tend to have deterioration in high- and low-frequency auditive thresholds compared with the controls, with this being statistically significant at frequencies of 0.125, 0.250, and 8 KHz (
Mean audition threshold obtained by frequency in both study groups. The mean threshold in frequencies of 0.125, 0.250 and 8 KHz showed higher decrease in RA patients versus control group. (
On categorizing results by age, in individuals aging <35 years, patients with RA had greater deterioration in low-frequency auditive thresholds in comparison with controls, reaching statistical significance in RE at the frequency of 0.125 (
Mean hearing levels obtained by frequency by age group of both groups of subjects. In RA patients younger 35 years old in frequencies 0.125 KHz (
In inactive patients according to the DAS 28, we found elevation in mean auditive thresholds in LE; in an analysis of only patients >35 years of age, these differences were maintained. We found no difference in RE.
No statistical significant differences were observed when air conduction test alterations were correlated with mean disease duration.
The proportion of sensory hypoacousia was that which was most frequently found in both groups, with the proportion of patients with RA at 45.5% versus 24.4% in the control group; conductive- or mixed-type hypoacousia was only found in some patients of the group with RA (Table
Only two patients (4.4%) of the group with RA had maximum phonemic discrimination threshold displacement.
A total of 53.2% of patients with RA had As-type curve (rigidity of the tympano-ossicular complex) compared with control subjects (39.9%); although we observed a tendency for ossicular-chain rigidity, we found no statistically significant difference (
In both groups, the most frequently encountered pattern was 1B1G, although the group of patients with RA presented the 3B1G pattern with greater frequency (27.7%) compared with the control group (5.5%) (
The objective of the study was to compare the prevalence of auditive alterations in patients with RA versus a control group. In our study, we found that patients with RA had a greater prevalence of hypoacousia compared with healthy subjects, this is similar to that reported previously by Takatsu et al., Raut et al., and García Callejo et al. [
The prevalence of neurosensory hypoacousia was the most frequent in our patients, this is similar to that reported by Takatsu et al., Halligan et al., and Raut et al. Probably, the cause of greater neurosensory hypoacousia can be due to autoimmune-type etiologies, as well as to the use of ototoxic drugs. The prevalence of conductive- or mixed-type hypoacousia has been reported less frequently. In our study, we found no healthy subject with these hypoacousia types, probably because our inclusion and exclusion criteria were strict; this is different from other studies [
On analyzing thresholds obtained by frequency, we observed that patients with RA tend to present auditive threshold deterioration; frequencies of 0.125 and 0.250 KHz are those that consistently have been affected in our study as well as in previous reports [
With the exception of the study conducted by Murdin et al. in which the study subjects were <50 years of age [
In earlier studies, attempts were made to relate hypoacousia and RA disease activity; reports only included greater auditive involvement in patients with active RA in comparison with patients with inactive RA in the study performed by Salvinelli et al. [
In the LG, we only found displacement of maximum phonetic discrimination thresholds at greater intensities in two patients with RA and in no healthy subject, this is because speech frequencies (500, 1,000, and 2,000 Hz) were found to be generally conserved in our study group.
In conventional tympanometry (226-Hz), we found that patients with RA presented A-type curves more frequently than the control group, this is compatible with greater rigidity at the ossicular-chain level, as reported by Salvinelli et al. [
In high-frequency tympanometry in both groups, we found patterns of normality (1- and 3B1G), both characteristic of rigidity. However, it is evident that the 3B1G pattern is more characteristic of patients with RA in comparison with subjects in the control group.
In our study, we did not carry out an otoacoustic emissions study, and the results in the previous studies are controversial. The group of Halligan et al. [
The strengths of our study include the number of patients evaluated and the diminution of the degenerative factor on possessing a lower age range, as well as the subanalysis we performed between individuals >35 and <35 years of age and exclusion of middle ear and/or inner ear pathology. However, in future studies, a sample calculation should be made, taking into account the information available for finding an association of hypoacousia in patients with RA and conducting all of the systematic studies in the patients, such as bone conduction test, because we only performed this on finding auditive threshold deterioration, so as to be able to evaluate the air-bone gap in the study groups, in order to carry out prospective and longitudinal-type designs and to include patients with early-onset RA, as well as to be able to know the incidence of audiological involvement in patients with RA, to evaluate risk factors, and to control variables such as medical treatment and comorbidities.
In the present study, we found a prevalence of >57% air conduction involvement in patients with RA, with sensory-type hypoacousia being the most frequently encountered; however, we also found conductive- and mixed-type hypoacousia. These two hypoacousia types were exclusive findings in patients with RA. Auditive thresholds in patients with RA exhibit deterioration in relation to the control group. In the 226-Hz tympanometry studies, there was diminished compliance with greater frequency in patients with RA, which can be translated into rigidity at the ossicular chain level. In high-frequency tympanometries, we found that the 3B1G was the most prevalent pattern in patients with RA.
We found no relationship between RA disease evolution time and disease activity with alteration in audiological studies.
The authors would like to thank Leticia Hernández-González for her assistance in coordinate schedule patients.