|Year : 2015 | Volume
| Issue : 2 | Page : 119-123
Auditory alterations following radiotherapy in patients with head and neck malignancy: A prospective study
Anirudh Kaul, Rohan Gupta, Nitika Gupta, Sunil Kotwal
Department of ENT and Head and Neck Surgery, SMGS Hospital, Government Medical College, Jammu, Jammu and Kashmir, India
|Date of Web Publication||20-Apr-2015|
Dr. Rohan Gupta
Department of ENT and Head and Neck Surgery, SMGS Hospital, Government Medical College, Shalamar Road, Jammu - 180 001, Jammu and Kashmir
Source of Support: None, Conflict of Interest: None
Aims and Objectives: The objective is to study the auditory alterations following radiotherapy (RT) in patients with head and neck (H and N) malignancy. Materials and Methods: Patients reporting to ENT OPD and those admitted, with histologically proved H and N malignancy, undergoing RT, as the treatment modality, were included in the present study, after complete ENT and general physical examination, excluding patients with previous history of ear disease, diabetes and hypertension. Results: A total 120 patients were enrolled for the present study and were examined for otological complications following RT. It was found that the patients had hearing loss, tinnitus, ear fullness and serous otitis media. Hearing loss was mainly sensorineural and was mostly seen in carcinoma of the oral cavity, oropharynx, and nasopharynx. The patients with carcinoma of esophagus, thyroid, and occult primary did not show any significant change in hearing. Conclusion: As radiation field descends down from nasopharynx to esophagus, the effect on otological structures decreases.
Keywords: Auditory, Hearing loss, Malignancy, Radiotherapy
|How to cite this article:|
Kaul A, Gupta R, Gupta N, Kotwal S. Auditory alterations following radiotherapy in patients with head and neck malignancy: A prospective study. Indian J Otol 2015;21:119-23
|How to cite this URL:|
Kaul A, Gupta R, Gupta N, Kotwal S. Auditory alterations following radiotherapy in patients with head and neck malignancy: A prospective study. Indian J Otol [serial online] 2015 [cited 2020 Jan 25];21:119-23. Available from: http://www.indianjotol.org/text.asp?2015/21/2/119/155298
| Introduction|| |
The head and neck (H and N) malignancies constitute 5% of all the cancers worldwide. In India, the most common H and N cancers are those of oral cavity and pharynx. Incidence of H and N squamous cell carcinoma increases with age and usually presents in patients older than 50 years while nasopharyngeal carcinoma and salivary gland tumors are exceptions and may occur in the younger age group. 
Majority of the patients present as locally advanced disease while the presence of distant metastasis at diagnosis is rare. The standard loco-regional therapy of H and N carcinoma remains surgery, followed by postoperative radiotherapy (RT). RT, as single-modality, is also a common treatment for H and N cancers.  Various therapeutic modalities are being tried to improve the long-term prognosis, out of which different fractionation schedule and use of chemotherapy are worth mentioning. 
Radiotherapy (hereinafter called RT) refers to the treatment of neoplastic diseases with ionizing radiation, here in addition to destructive effect on cancer cells, RT effects the normal tissues and passes through all the tissues of the body as well. The unwanted effects of RT on various tissues depend upon the structure involved, rapidity of treatment, total dose and type of radiation, age of the patient at treatment, length of survival after treatment and variations in the individual tolerance to the therapeutic modality. Most of the complications subside after cessation of RT but in some cases, the late sequelae of the radiation do occur as unavoidable and undesirable consequences of treatment. As both the ears and Eustachian tubes are included in the radiation field, in case of cancers of H and N, the otological complications are quite common following RT. Serous otitis media (SOM), started during 2 nd week of RT and continued up to 4 th week, has been reported in 16% of the cases, with patients of complaining of conductive hearing loss (CHL). Occasional aural fullness is also complained by some patients during the follow-up period. 
During radiation treatment planning for several H and N sites, the cochlea, and temporal bone are included at the margins or within the treatment field. As a result, sensorineural hearing loss (SNHL) is a known complication following RT for H and N cancers with a recent systematic review reporting the incidence of SNHL to be 42 ± 3% after RT. ,
Therefore, the present study was thus carried to study the various auditory alterations in patients of H and N cancer undergoing RT in our setup.
| Materials and Methods|| |
The present study was conducted in the Department of Otorhinolaryngology and Head and Neck Surgery, SMGS Hospital, Government Medical College, Jammu, in collaboration with the Department of Radiotherapy, Government Medical College, Jammu for a period of 2 years, on 120 patients, with histopathologically proven head, neck, and esophageal malignancies.
Subjects excluded were those who had:
- History of hearing or vestibular disturbances previous to the diagnosis of H and N malignancy
- Risk of occupational otological disease (external noise exposure)
- Diabetes or other metabolic diseases
- Hypertension and other cardiovascular diseases
- External or middle ear pathologies on clinical examination.
Cases included in the study were the cases with World Health Organization (WHO) performance status of 0 and 1.
Patients attending/admitted in the Department of Otorhinolaryngology and Head and Neck Surgery, with cancers of H and N, were assessed thoroughly before starting, during and at completion of treatment on the following pattern: That is, history, examination, investigations, otology, and neuro-otologic assessment. PTA was done before the start of treatment, during mid-treatment, at the end of treatment and once a month for next 3 months.
Hearing loss was classified according to WHO Classification: 0-25 dB not significant, 26-40 dB mild, 41-55 dB moderate, 56-70 dB moderately severe, 71-90 dB severe and >91 dB profound. However, hearing loss of >10 dB either in a speech frequency or high frequency was considered significant. 
Neuro-otology examination was done at the start of treatment and after finishing the treatment, which included Romberg test, cerebellar function, cranial nerves, nystagmus, and vestibular testing-caloric test, fistula test, rotatory chair, Dix Hallpike. Impedance audiometry if required was done at the start/during/at completion of treatment . If required tests such as Tone decay test, recruitment, short increment sensitivity index, etc., were also done.
All the patients included in the study underwent radical RT. The radical doses given were from 60 to 70 Gy. The treatment was given on the Co-60 teletherapy machine. None of the patients received neoadjuvant or adjuvant chemotherapy.
| Results|| |
A total of 120 patients of head neck cancer, undergoing RT were enrolled for the present study. The age of the patients ranged from 21 to 80 years with the mean age being 53.06 ± 11.4 years and 81% of the patients being present in the age group of 41-70 years. Of the total of 120 patients, 78 (65%) patients were male with maximum number of patients being in the age group of 41-50 years females formed the remaining 35% of the total patients, with maximum number, that is, 14 (11.67%) patients being in 51-60 years age group. In the present study, only 6.67% females and 3.33% males were below 40 years of age [Table 1].
Of the total of 120 patients, maximum number of patients, that is, 32 (16.67%) had hypopharyngeal carcinoma. It was, followed by laryngeal, oral cavity and oropharyngeal carcinoma, with 24 (20%) patients of each. 16 (13.33%) patients had salivary gland malignancy while 12 (10%) patients had paranasal sinus and nasopharynx as the site of carcinoma. Esophageal carcinoma, thyroid malignancy and occult primary were present in 12 (10%) patients, with 4 (3.33%) patients of each [Table 2].
|Table 2: Distribution of patients according to sites and subsite of malignancy|
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Symptoms of aural fullness were present in 40 (33.33%) patients, and it was, followed by alteration in hearing and tinnitus, with each being present in 24 (20%) patients [Table 3].
|Table 3: Distribution of patients according to symptoms (subjective complaints pertaining to the ear)|
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Of the total of 120 patients enrolled for the present study, 18 (15%) patients showed significant hearing loss in high frequencies, 10 (8.3%) patients showed significant hearing loss in speech frequencies and 6 (5%) patients showed significant hearing loss in both (speech + high) the frequencies [Table 4].
A total of 10 out of the 12 patients with paranasal sinus and nasopharyngeal carcinoma had hearing loss. High frequency hearing loss and hearing loss involving both high frequencies and speech frequencies were present in 4 patients each while in 2 patients the hearing loss was restricted to speech frequencies only. 14 out of the 16 patients with salivary gland malignancy also showed the presence of hearing loss. Patients of oral cavity and oropharyngeal cancer also had a decrease in hearing following RT with 4 patients having hearing loss in the speech frequencies only and a high frequency hearing loss being present in 2 patients. Patients of esophageal and thyroid carcinoma undergoing RT did not show any significant hearing loss [Table 5].
Serous otitis media developed in 23.33% of patient undergoing RT with 4 (3.33%) patients developing it during the early phases of treatment while 24 (20%) more patients developing it during the mid-treatment. Of these 23.33% patients, 16 (13.33%) patients were treated without surgical intervention by end of treatment, while the remaining 12 (10%) patients got cured subsequently with medication only with none of the patients having SOM on follow-up after 1-month [Table 6].
|Table 6: Distribution of SOM in patients based on the duration of treatment|
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There was a typical characteristic of increase in severity of SNHL with treatment, reaching maximum by the end of treatment and declining thereafter to normal hearing or mild loss, on follow-up after 1-month [Table 7].
|Table 7: Change in degree of hearing threshold with the duration of treatment|
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| Discussion|| |
In the current treatment of H and N malignancies, strategies for organ preservation using RT and/or chemotherapy have been introduced. In radiation therapy, techniques have been adopted to minimize the radiation exposure to the sensitive structures such as the brain stem, spinal cord, cornea, optic chiasma and pituitary gland. Whenever radiation therapy is given, it is difficult to avoid side effects to the normal surrounding structures. Thus, we conducted a study of 120 patients having histopathologically proved H and N cancer and evaluated the otological effects of RT.
In the present study of 120 patients, 65% were males, with majority being in the age group of 41-50 years, while females were 35%, with majority in 51-60 years age group. Site and sub-site wise distribution of lesions showed that maximum number of patients, that is, 32 (26.66%) had hypopharyngeal carcinoma, which was followed by laryngeal carcinoma and oral cavity and oropharyngeal carcinoma in 24 (20%) patients each. Similar results were also observed by Bhagat et al.,  and Pandey, et al.,  but with the predominance of laryngeal cancer and oral cavity and oropharynx cancer in their respective studies.
In the present study of patients undergoing RT, ear fullness was the complaint in 33.33% patients while SOM was found in 23.33% patients and hearing alterations and tinnitus being present in 20% patients each. Bhagat et al.,  in their study reported SOM in 8-16% of patients undergoing external radiation therapy (XRT) and observed fullness of the ear in early stages of RT while Pandey et al.,  observed alteration in hearing (deterioration) and tinnitus in patients undergoing RT. Chen et al.,  in their study reported, 33% of patients to be suffering from alteration in hearing following >60 G radiation dose.
In the present study, most of the patients of hearing loss had SNHL, and few developed mixed hearing loss (both SNHL and CHL] during treatment. However, CHL resolved by the 1 st month following completion of treatment. CHL was mainly due to SOM, which developed in cases of nasopharyngeal carcinoma, oral cavity and oropharyngeal carcinoma and cases of carcinoma parotid undergoing treatment by XRT. Diagnosis of SOM was made on clinical examination and by impedance audiometry. These findings in the present study were not consistent with those reported in the literature by Pandey et al.  Chen et al.,  had reported findings similar to the present study, with mainly SNHL in 43% and mixed type hearing loss in some patients. They also observed reduction in static compliance of TM (type B tympanogram) in the irradiated ear in 38% patients.
Significant hearing loss in high frequencies was seen in 18 (15%) patients, out of which 10 (8.3%) patients had both the ears affected while 8 (6.6%) patients had only ipsilateral ear (to the side of malignancy) affected, 10 (8.3%) and 6 (4.9%) patients had significant hearing loss in speech frequency and in both (speech and high) frequencies, respectively. These findings are in dehiscence with Pandey et al.  who in their study reported significant hearing loss in 13% of the patients in high frequencies but in only 3 patients in speech frequencies and in only 2 patients in both high as well as speech frequencies. Our findings are akin to the study of Sharma and Agarwal  who found that there was a detrimental effect of RT on cochleovestibular functions.
Most of the cases of nose and nasopharyngeal carcinoma showed significant hearing loss, majority having high-frequency hearing loss. These cases of nasopharyngeal carcinoma developed SOM (and mixed hearing loss, henceforth) during the course of treatment which resolved with medication and hearing loss changed to SNHL as air-bone gap disappeared. These findings are consistent with those of Pandey et al.  Kwong et al.,  reported a high incidence of postirradiation SOM (46.9%), and SNHL. The pathogenesis of postirradiation SOM is quite different from that of non-irradiation related SOM, which is commonly caused by Eustachian tube dysfunction. ,, In postirradiation SOM, the generally acknowledged etiologies are associated with direct radiation damage, , including scarring of the Eustachian tube opening, poor mucociliary function of the Eustachian tube, and fibrosis of the tensor veli palatini muscle. However, an important but frequently ignored cause is radiation-compromised inflammation of the middle ear. ,,
In the present study, 40 patients of oral cavity, oropharynx and salivary glands were studied, out of which 20 patients showed hearing loss, 12 of whom had hearing loss in higher frequency while Pandey et al.,  observed 6 cases of hearing loss out of 35 study patients.
Of 24 patients of laryngopharyngeal malignancy, only 2 patients developed high frequency hearing loss, whereas no hearing loss was seen in patients of esophagus, unknown secondary and thyroid. Pandey et al.,  reported a high frequency hearing loss in 2 cases with laryngopharyngeal malignancy (n = 28) and 2 cases out of 40 patients with esophagus malignancy.
This suggests that as our radiation field descends down from nasopharynx to esophagus, the effect on otological structures decreases.
| Conclusion|| |
As radiation field descends down from nasopharynx to esophagus, the effect on otological structures decreases. RT does not affect the hearing apparatus as far as the speech frequencies are concerned.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]