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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 24  |  Issue : 3  |  Page : 199-203

Vestibular dysfunction and glycemic control in diabetes mellitus: Is there a correlation?


Departments of Otorhinolaryngology and HNS, Smt Kashibai Navale Medical College and General Hospital, Pune, Maharashtra, India

Date of Web Publication11-Jan-2019

Correspondence Address:
Prof. Chetana S Naik
Department of Otorhinolaryngology and HNS, Smt Kashibai Navale Medical College and General Hospital, Pune - 411 041, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/indianjotol.INDIANJOTOL_70_18

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  Abstract 


Objectives: The aim of this study is to evaluate and find the proportion of patients with Type-II diabetes mellitus (DM) with sensorineural hearing loss (SNHL) and vestibular dysfunction (VD) and association with glycemic control. Materials and Methods: An observational cross-sectional study was carried out in 100 patients (age group: 30–60 years) diagnosed with Type-II DM coming to the outpatient department of our Rural Tertiary Care Teaching Hospital, fulfilling the inclusion criteria. Prior approval of the Institutional Ethics Committee and written informed consent was obtained. All patients were subjected to investigations to assess their diabetes control, hearing, and vestibular function. The findings were subjected to statistical analysis. Results: Out of 100 patients, 62 were male and 38 were female between the age group of 30 and 60 years. The mean hemoglobin A1c (HbA1c) level was 9.16 ± 2.4. The patients were divided into three groups depending on HbA1c level, to denote control, good (≤7%), moderate (>7, ≤12%), and poor (>12%). There were a total of 69 patients with SNHL and 70 patients with VD. SNHL was present in 57.6% of good control group, 66.1% of moderate control group, and 100% of poor control group. Analysis with Chi-square test for correlation between glycemic control and SNHL was statistically significant. Out of the 70 patients with VD, 51.4% had right vestibulopathy, 41.4% had left vestibulopathy, and 7.2% had a bilateral vestibulopathy. Twenty-two patients had benign paroxysmal positional vertigo. VD was present in 42.3% of good control group, 74.5% of moderate control group, and 100% of poor control group. Chi-square test was statistically significant. Conclusion: There is a significant association between Type II DM, and SNHL and VD, especially with worsening of glycemic control. Screening for these debilities should be a part of the routine workup of a diabetic patient. VD is a potential cause for imbalance and vertigo in DM.

Keywords: Diabetes mellitus, hearing loss, vestibular dysfunction


How to cite this article:
Naik CS, Tilloo R. Vestibular dysfunction and glycemic control in diabetes mellitus: Is there a correlation?. Indian J Otol 2018;24:199-203

How to cite this URL:
Naik CS, Tilloo R. Vestibular dysfunction and glycemic control in diabetes mellitus: Is there a correlation?. Indian J Otol [serial online] 2018 [cited 2019 May 26];24:199-203. Available from: http://www.indianjotol.org/text.asp?2018/24/3/199/249877




  Introduction Top


Diabetes mellitus (DM) is a multisystemic disease with variety of manifestations. The “International Diabetes Federation” estimates that the total number of diabetics in India is around 40.9 million, expected to rise to 69.9 million by 2025.[1] A variety of molecular mechanisms play a role in the pathogenesis of the complications in DM, like the formation of advanced glycation end-products, polyol formation, increased activity of protein kinase C, increased production of extracellular matrix proteins, and glycosaminoglycans.[2] All this ultimately leads to microvascular damage termed as “Microangiopathy.” Makishima and Tanaka,[3] found microangiopathy to be a significant cause of sensorineural hearing loss (SNHL) in diabetics. A similar correlation has also been established between diabetic SNHL and acoustic neuropathy,[4],[5] the latter commonly being a late complication.

All these findings led us to extrapolate similar mechanisms for vestibular dysfunction (VD) in DM. The current data regarding in diabetes are limited, especially in India and studies conducted along these lines have not associated VD with glycemic control in DM. The need to consider DM as a potential cause for SNHL and VD is important, so that timely rehabilitation of hearing and balance disorders can be performed along with management of DM. The study focuses on Type-II DM, and its association with SNHL and VD. We have used hemoglobin A1c (HbA1c), which is a sensitive parameter for the assessment of diabetic control, which has not been used in many studies.

Aims and objectives

(1) To evaluate the patients of Type-II DM for SNHL and VD. (2) To find the proportion of Type-II DM patients suffering from SNHL and VD. (3) To grade the SNHL and VD and associate it with the glycemic control in the patients.


  Materials and Methods Top


Study design: An observational cross-sectional study. Study population: Patients of Type-II Diabetes diagnosed with per diagnostic criteria of the American Diabetes Association (ADA) attending the outpatient department of our Rural Tertiary Care Teaching Hospital. Sample size: 100. Inclusion criteria: (1) Patients diagnosed with Type-II DM, (2) Age: 30–60 years. Exclusion criteria: (1) Type-I DM, (2) Pregnancy, (3) Ototoxic drug intake, (4) Ear discharge, (5) History of head injury, (6) Noise exposure, (7) Family history of deafness, (8) History of hypertension, meningitis/encephalitis, ear surgery, Meniere's disease, migraine, or metabolic disorder, (9) Patients not giving consent. The Institutional Ethics Committee approval was taken. A written informed consent was obtained. Patients fulfilling the selection criteria underwent a detailed history and oto-neurological examination. Patients were evaluated with the dizziness handicap inventory (DHI)[6] and underwent the aforementioned investigations. Investigations for diabetes included; blood sugar level–fasting and postprandial after 2 h, HbA1c levels, lipid profile, serum ketones, serum creatinine, urine sugar, and albumin. Audio-vestibular investigations included; pure-tone audiometry including Short Increment Sensitivity Index and tone decay tests, otoacoustic emissions, videonystagmography with caloric tests and subjective visual vertical.

Patients were evaluated for glycemic control status as per the criteria of ADA.[7] The criteria for ideal glycemic control are as follows: (1) HbA1c <7.0% (2) Preprandial capillary plasma glucose should be 80–130 mg/dl (3) Peak postprandial capillary plasma glucose should be <180 mg/dl. The major parameter used by us was HbA1c, to classify the patients into groups to denote their glycemic control status. The patients were divided into three groups depending on HbA1c, to denote control, good (≤7%), moderate (>7, ≤12%), and poor (>12%). Statistical analysis was performed with Microsoft Excel and SPSS software version 22, IBM, Chicago, USA.


  Observations and Results Top


Out of 100 patients, 62 were male and 38 were female between 30 and 60 years of age. Eighteen patients were between 31 and 40 years, 34 (41–50 years), and 48 (51–60 years). The mean fasting blood glucose level was 140.5 ± 70 mg/dl, and the mean postprandial blood glucose (2 h) was 231 ± 70 mg/dl. The mean HbA1c level was 9.16 ± 2.4. There were 26 patients with good control, 59 patients with moderate, and 15 patients with poor control [Figure 1]. SNHL was found in 69 patients and VD in 70 patients. Out of 69 patients with SNHL, 46.3% had slight SNHL (16–25 dB), 7.2% had mild SNHL (26–40 dB), 27.5% had moderate SNHL (41–55 dB), 14.4% had moderately severe SNHL (56–70 dB), and 4.6% had severe (71–90 dB) SNHL [Figure 2]. Out of 69 patients with SNHL based on recruitment and the tone decay tests, 24.7% had SNHL, 55.1% had sensory type and 20.2% had a neural type. Selective high-frequency SNHL (≥4000 Hz) was seen in 18.8%. There were 5 (33.33%) high-frequency SNHL cases in the good control group, 7 (17.9%) cases in the moderate control group and 1 (6.25%) case in the poor control group. Seventy-one patients had abnormal otoacoustic emissions (OAEs). Abnormal OAEs were found in 46.1% of good control, 74.5% of moderate control, and 100% of the poor control group [Figure 3]. All 100 patients were evaluated with DHI score. Out of 100 patients, 50 patients had an insignificant score, 25 had mild handicap, 16 had moderate handicap, and 9 patients, severe handicap, as per the DHI grading. Out of the 100 patients, 70 had evidence of VD. Out of these, 51.4% had right vestibulopathy, 41.4% had left vestibulopathy, and 7.2% had a bilateral vestibulopathy [Figure 4]. In addition, 22 patients were found to have benign paroxysmal positional vertigo (BPPV) on positional testing. SNHL was present in 15 (57.6%) in good control group, 39 (66.1%) in moderate control group, and 15 (100%) in poor control group [Figure 5]. Results of Chi-square test were statistically significant (χ2 = 8.525, degrees of freedom = 2, P = 0.01409 with 95% confidence limit). VD was present in 11 (42.3%) in good control group, 44 (74.5%) in moderate control group, and 15 (100%) in poor control group [Figure 6]. Results of Chi-square test were statistically significant (χ2 = 16.51, degrees of freedom = 2, P = 0.0002598 with 95% confidence limit). Out of 100 patients, 62 were male and 38 were female. Thirty-nine (62.9%) males and 30 (78.9%) females had SNHL. Results of Chi-square for sex versus SNHL: χ2 = 6.204, degrees of freedom = 1 and P = 0.01275. SNHL was found to be comparatively more in females than males, and this was statistically significant. Forty-three (69.3%) males and 27 (71%) females had VD. Results of Chi-square for sex versus VD were: χ2 = 0.06119, degrees of freedom = 1 and P = 0.8046. Sex-wise distribution of VD showed the only slight difference and this was not statistically significant.
Figure 1: Distribution of patients with diabetes mellitus as per hemoglobin A1c levels (glycemic control groups)

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Figure 2: Distribution of grades of sensorineural hearing loss among glycemic control groups

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Figure 3: Distribution of patients with abnormal otoacoustic emissions in various glycemic control groups

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Figure 4: Distribution of patients with various vestibular dysfunctions in different glycemic control groups

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Figure 5: Correlation of sensorineural hearing loss with glycemic control (X-axis: Number of patients, Y-axis: Glycemic control group)

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Figure 6: Correlation of vestibular dysfunction with glycemic control (X-axis: Number of patients, Y-axis: Glycemic control group)

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  Discussion Top


DM is a systemic disease affecting multiple organs. DM is being linked with inner ear diseases since the 19th century.[8] Knowing that DM causes peripheral neuropathy, researchers hypothesized SNHL to be linked to it. Friedman et al.[4] in 1975 evaluated 20 DM patients with peripheral neuropathy and showed that hearing thresholds were elevated in these patients. Most studies have evaluated SNHL by pure tone audiometry.[9],[10] Other modalities have also been used to assess inner ear dysfunction like OAE,[11],[12] and auditory brainstem response (ABR).[13],[14] Parving et al. found that ABR results were abnormal in 40% of patients, with long-standing DM history.[13] Histopathological studies of temporal bone have also been performed in DM patients, for evidence of cochlear microangiopathy,[15] to establish it as a cause for diabetic SNHL. Type-I and Type-II DM have been evaluated separately as well as together in different studies.[16],[17] Many studies support the association between the two, the majority of which show a significant association[16],[18],[19] which also includes the recent meta-analyses.[20],[21] However, certain inconsistency is reflected from the fact, that some of them only show a weak association,[22] whereas some of them do not show it.[23],[24]

Studies have tried to find a relationship between VD and diabetes. Klagenberg et al. found a significant association between Type-I DM and VD.[25] Detection of VD in people with diabetes often gets delayed, and patients are only referred for dizziness and instability, which is subjective and can be due to multiple causes in DM. Studies for assessing VD and SNHL have been performed, to associate them with multiple metabolic disorders together,[26],[27] without specifically focusing on Type-II DM, which is more prevalent than others. Overall consensus for DM and VD is that certain studies do not support this correlation,[28] some suggest only a weak association,[26] whereas few other studies show a strong positive relationship between the two.[25],[29] None of the studies are done in India. The study consisted of a total of 100 patients of Type-II DM, of which 62 were male and 38 were female. These patients had a mean fasting blood glucose level was 140.5 ± 70 mg/dl, and the mean postprandial blood glucose (2 h) was 231 ± 70 mg/dl. The mean HbA1c levels were 9.16% ±2.4%. After dividing patients based on HbA1c levels in 3 groups, good (≤7%), moderate (>7, ≤12%), poor (>12%) as an index of their glycemic control, we found 26 patients with good control, 59 patients with moderate control, and 15 with poor control. Out of total 100 patients, 69 patients had SNHL and 70 had VD, i.e., 69% and 70% was the prevalence rate, respectively. SNHL was seen in 15 (57.6%) of the good control group, 39 (66.1%) of the moderate control group and 15 (100%) of poor control group, thus showing an increasing trend with decline of glycemic control. Similarly, VD as present in 11 (42.3%) of good control group, 44 (74.5%) of moderate control group, and 15 (100%) of poor control group, again displaying an increasing trend with decline of glycemic control.

The prevalence of SNHL was found to be almost similar to one other previous study.[19] However other studies, especially which have been carried with a larger sample size have found a comparatively lower prevalence rate.[16],[22] Kakarlapudi et al. reported a prevalence of only 13.1%. Although this study was carried on a bigger scale, they screened patients of SNHL for DM, which is opposite to our methodology.[16] For VD, the prevalence rate is similar to what other researchers have found. Chávez-Delgado et al. have reported 89% prevalence in their study of 385 patients.[26] The difference seen in the two rates could be due to the inclusion of other risk factors such as dyslipidemia and hypertension. Comparing the SNHL levels with glycemic control of the patients, we found that the relationship between the two was statistically significant, with 95% confidence limit (P = 0.01409). Similarly, for VD and glycemic control also, the relationship was statistically significant with 95% confidence limit (P = 0.0002598).

Majority of the cases had slight or mild SNHL in our study. Our study also differentiated between the types of SNHL, showing that the majority of the patients had a sensory type of SNHL, indicating a cochlear pathology. This was also supported by abnormal OAE results pointing to outer hair cell dysfunction which showed an increasing trend with decrease in the quality of diabetic control. This reinforces the hypothesis put by studies that cochlear microangiopathy is a major cause of diabetic SNHL.[3],[15] Furthermore, neural type of hearing less which is due to acoustic neuropathy, was mainly seen in poor control group and in patients of higher age group. This correlates to the finding that acoustic neuropathy is usually a late complication.[30] Previous studies have said that DM is known to cause high-frequency SNHL, especially in the early stages,[31] this finding is similarly depicted in our study.

Majority of our patients had insignificant score with DHI, which could be attributed to the varied presentation of vertigo and subclinical vestibulopathy. As DM is a systemic disease, bilateral VD might be expected to be more common. However, we found that unilateral dysfunction was far more common than bilateral disease which was similar to one of other study.[26] BPPV which is found to be associated with diabetes[32] was found in 22% of our cases. This may be related to the ischemic insult to otoliths resulting from microangiopathy associated with DM. In our study, SNHL was more common in females than males with DM. Age largely influenced the presence of VD or SNHL, along with the quality of glycemic control. This might be because aging itself can worsen diabetic control and thus make the patient more prone to VD or SNHL.


  Conclusion Top


There is a significant association between Type II DM, and SNHL and VD. Furthermore, both are more likely to occur, with worsening of glycemic control. Cochleopathy is more common in DM than the neuropathy, but neuropathy is more likely in a patient with poor glycemic control. It is important to recognize vestibulopathy as a potential cause for imbalance and vertigo in patients with diabetes and should be considered if a patient of DM presents with dizziness. Early detection would prevent falls and morbidity. Thus, screening for SNHL and VD should be part of the routine workup of a diabetic patient. Better diabetes control would prevent these complications thus assuring a better lifestyle for these patients.

Acknowledgements

This study was funded by the Indian Council of Medical Research for short-term student project. Authors declare no conflicts of interests. Authors would like to acknowledge the support of the Dr. K.J Shinde, head of the Department of ENT, Dr. S.M. Bhat, head of Department of Medicine and Mr. Bedake, Audiology and Speech Therapy.

Financial support and sponsorship

The study was approved and funded by the Indian Council of Medical research (ICMR) as a part of short-term student project.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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