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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 25  |  Issue : 3  |  Page : 117-120

Assessment of hearing in individuals with allergic rhinitis


1 Department of Audiology, All India Institute of Speech and Hearing, Mysore, Karnataka, India
2 Department of Prevention, All India Institute of Speech and Hearing, Mysore, Karnataka, India
3 Audiologist, Cavalier ENT & Plastic Surgery Hospital, Bengaluru, Karnataka, India

Date of Submission07-Feb-2019
Date of Decision24-Feb-2019
Date of Acceptance25-Mar-2019
Date of Web Publication18-Oct-2019

Correspondence Address:
Mr. Vikas Mysore Dwarakanath
Department of Audiology, All India Institute of Speech and Hearing, Manasagangothri, Mysore, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/indianjotol.INDIANJOTOL_12_19

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  Abstract 


Background: Allergic rhinitis is an allergic inflammation of nasal airways. It occurs when allergen, such as pollen, dust, or animal dander is inhaled by an individual with a sensitized immune system. Researchers have found that AR causes conductive hearing loss in adults. Although symptoms related to the inner ear structures were not studied till Singh et al., (2011) who reported a positive correlation between AR and sensorineural hearing loss. Aims and Objectives: The present study aimed to develop an audiologic profile in individuals with allergic rhinitis. Material and Methods: Fifteen individuals with allergic rhinitis and 15 individuals without any history of allergic rhinitis were subjected for pure-tone audiometry, distortion product otoacoustic emission, auditory brainstem response, tympanometry, auditory reflex thresholds, and Eustachian tube function tests. All these tests were repeated after 1 month on the same individuals. Results: Results indicated poorer pure-tone thresholds with reduced DP amplitude compared to normals. This can be attributed to the changes in outer hair cell function due to allergens (Singh et al., 2011). None of the individuals exhibited any middle ear or Eustachian tube dysfunction. As the pure-tone thresholds or distortion product otoacoustic emission amplitude did not improve overmedication, the effects on inner ear function might not be seasonal. Conclusion: It can be concluded from the present study that individuals with AR are more prone to sensorineural hearing loss.

Keywords: Allergens, distortion product otoacoustic emission, sensorineural hearing loss


How to cite this article:
Dwarakanath VM, Shambhu T, Jayanna VJ. Assessment of hearing in individuals with allergic rhinitis. Indian J Otol 2019;25:117-20

How to cite this URL:
Dwarakanath VM, Shambhu T, Jayanna VJ. Assessment of hearing in individuals with allergic rhinitis. Indian J Otol [serial online] 2019 [cited 2019 Dec 12];25:117-20. Available from: http://www.indianjotol.org/text.asp?2019/25/3/117/269546




  Background Top


Allergic rhinitis (AR) is an allergic inflammation of the nasal airways, nasal mucosa, primarily mediated by immunoglobulin E. The immune system has to fight against harmful substances such as bacteria and viruses. However, the immune system overreacts to harmless substances in the case of AR. Sneezing, itchy and watery eyes, swelling and inflammation of the nasal passages, and an increase in mucus production are the major symptoms of AR, but these differ in severity among individuals. Heredity and environmental exposures may contribute to a predisposition to allergies.[1] Approximately one in three people have an active allergy at any given time, and at least three in four people develop an allergic reaction at least once in their lives. In western countries between 10% and 25% of people annually are affected by AR. Prevalence of hearing loss and outer hair cell abnormalities are more in AR patients than normal individuals.[2]

A study on relation between AR and hearing, have reported that AR is the most common respiratory disorders that has been increased due to air pollution.[3] They reported a mean hearing loss of 10 ± 9.1 db in individuals with AR and 2.5 ± 2.2 db in control group (P < 0.0005) where they concluded that AR may cause conductive hearing loss in adults. Supporting findings were obtained by Dees and Lefkowitz[4] and, Rózańska-Kudelska et al.[5] where they found majority of individuals having conductive hearing loss, particularly recurrent secretory otitis media.

The anatomical and physiological relationship between the nose and the ear are known, as well as the possible involvement of the middle ear in AR. Moreover, if nasal symptoms such as itching, sneezing, rhinorrhea, and congestion are not well controlled, they may contribute to hearing problems. Even uncomplicated seasonal AR may be associated with reduced ability to hear. Severe rhinitis associated with complications such as sinusitis or  Eustachian tube More Details dysfunction can also cause conductive hearing loss. Although the above-stated studies showed eustachian tube dysfunctions which might result in conductive hearing loss, nevertheless, a sensorineural hearing loss, clearly related to cochlear involvement is stated and the adverse effect of AR on inner ear particularly outer hair cell function is least explored. Although one of the findings by Singh et al.[2] suggest a positive correlation between AR and sensorineural hearing loss, reports address the issue are scanty; thus, the present study was carried out to explore the inner ear structures through various audiological tests.

Aim

The aim of the study is to investigate the effects of AR on hearing.

Objectives

  1. To investigate the effects of AR on hearing thresholds across frequencies
  2. To investigate the effects of AR on the middle ear, outer hair cell function, and afferent pathway.



  Materials and Methods Top


Participants

The study follows a case–control study design with convenient sampling method used to select the participants for the study. Participants for the study included 15 individuals with AR with symptoms prolonging from at least 4 to 6 weeks. The individuals who were diagnosed with having AR by an otorhinolaryngologist by performing several tests were considered for the study. The age range of the participants was 18–35 years with a mean age of 25 years. Control group consisted of 15 individuals with the age range of 18–35 years with a mean age of 23 years. None of the control group reported a history of any cold, allergy for the past 4–5 months. Individuals with a history of otologic factors, use of ototoxic agents, metabolic and systemic disease causing hearing loss, noise exposure, and history of neurological factors were not included for the study. The informed consent form was obtained from individuals before the study. The research was approved from the Institutional Ethical Committee.

Procedure

All participants were subjected for pure-tone audiometry for air conduction and bone conduction testing across frequencies 250, 500, 1000, 2000, 4000, and 8000 Hz using a calibrated Maico MA 53 dual channel audiometer in an acoustically treated booth. TDH39 headphones were used for AC testing and B-71 was used for BC testing. The Modified Hughson–Westlake procedure was used to measure the hearing thresholds. Distortion product otoacoustic emission (DPOAE) was administered using OtoRead OAE instrument for frequencies 1000, 2000, 3000, 4000, 5000, 6000, and 8000 Hz. The DPAOE testing was repeated twice within 15 min, and average DP amplitude and signal to noise ratio (SNR) were considered as data.

The tympanometry, auditory reflex thresholds, and Eustachian tube function tests were administered using Maico MI-34 immittance audiometer. Auditory reflex thresholds were obtained for frequencies 500, 1000, and 2000 Hz. Valsalva test was used for assessing the eustachian tube function. This procedure is involved to introduce a positive middle ear pressure through the eustachian tube. A pretest baseline tympanogram was obtained. The individual is instructed to close off the nose and the mouth and blow followed by a posttest tympanogram.

Auditory brainstem response (ABR) evaluation was done using IHS 4 channel smart evoked potentials to assess for the presence of any retrocochlear pathology. The testing protocol was stimulus – clicks, filter settings – 150–3000 Hz, rate – 30.1/s (for threshold estimation), 90.1/s and 11.1/s (for neuro diagnosis), replications – 2, rarefaction stimuli with other settings remained same as for adult testing. Individuals were tested initially for threshold estimation and followed by neuro diagnosis using rates 90.1/s and 11.1/s. All these tests except ABR were repeated after 1 month on the same individuals to observe for any improvement in hearing as they were under medication during 1 month for AR.


  Results Top


The aim of the present study was to check the pure-tone thresholds and outer hair cell function in individuals with AR. The mean pure-tone average (500, 1000, and 2000 Hz) of individuals with AR was 19.4 dB (±4.2 dB) in the right ear and 20.8 dB (±3.9 dB). However, the average of 2000, 4000, and 8000 Hz was quite different. [Figure 1] represents the average of these frequencies (a) among individuals with AR and control group and (b) first evaluation and follow-up evaluation of individuals with AR. From the figure, it can be noted that the thresholds were higher in individuals with AR when compared with control group even after treated for rhinitis as shown in [Figure 1]b where the threshold did not show any difference.
Figure 1: Comparison of pure-tone average of 2000, 4000, and 8000 Hz (a) among individuals with allergic rhinitis and control group, (b) first evaluation and follow-up evaluation

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Independent t-test was administered across each frequencies, average of 500, 1000, and 2000 Hz (PTA1) and also average of 2000, 4000, 8000 Hz (PTA2) to investigate the effect of AR on pure tone thresholds. Results revealed significant mean effect across PTA1 of both the right ear (t = 5.675, P < 0.001) and left ear (t = 5.994, P < 0.001) and PTA2 of the right ear (t = 7.689, P < 0.001) and left ear (t = 9.339, P < 0.001). Paired t-test was administered across each frequencies, average of 500, 1000, and 2000 Hz (PTA1) and also average of 2000, 4000, and 8000 Hz (PTA2) to investigate the effect of medication on thresholds. Results revealed no statistical significant across PTA1 of both the right ear (t = −3.75, P > 0.05) and left ear (t = −3.94, P > 0.005) and PTA2 of the right ear (t = 7.689, P < 0.001) and left ear (t = 9.339, P < 0.001).

[Figure 2] represents the comparison of SNR of DPOAE across 1000–8000 Hz among individuals with AR in the first evaluation, follow-up evaluation and control group. Results of DPOAE from [Figure 2] reveals that low-DP amplitude with poorer SNR was observed in the right ear across frequencies 4000, 5000, 6000, and 8000 Hz in the right ear and 2000, 4000, 5000, 6000, and 8000 Hz in the left ear. Independent sample t-test was administered to find the significance of difference across two groups. Results revealed significant mean effect across frequencies 4000 Hz (t = −2.607, P < 0.05), 5000 Hz (t = −8.842, P < 0.001), 6000 Hz (t = −20.942, P < 0.001), and 8000 Hz (t = −44.862, P < 0.001) in the right ear and as well in the left ear across frequencies 2000 Hz (t = −3.021, P < 0.05), 3000 Hz (t = −2.244, P < 0.05), 4000 Hz (t = −4.294, P < 0.001), 5000 Hz (t = −14.145, P < 0.001), 6000 Hz (t = −34.789, P < 0.001), and 8000 Hz (t = −32.333, P < 0.001).
Figure 2: Comparison of signal to noise ratio of distortion product otoacoustic emission across 1000–8000 Hz among individuals with allergic rhinitis in the first evaluation, follow-up evaluation and control group

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Paired t-test was administered to find the significance of difference across pre medication and post medication data among individuals with AR. The post recording was done 1 month after the initiation of medicines. Results revealed no statistically significant mean difference across frequencies 2000 Hz (t = −3.021, P > 0.05), 4000 Hz (t = −2.607, P > 0.05), 5000 Hz (t = −6.294, P > 0.05), 6000 Hz (t = −5.842, P > 0.05), and 8000 Hz (t = −5.862, P > 0.05) in the right ear and as well in the left ear across frequencies 2000 Hz (t = −3.021, P > 0.05), 3000 Hz (t = −2.244, P > 0.05), 4000 Hz (t = −4.294, P > 0.05), 5000 Hz (t = −9.345, P < 0.001), 6000 Hz (t = −3.79, P > 0.05), and 8000 Hz (t = −14.333, P > 0.05).

[Table 1] represents absolute latencies and amplitude of waves I, III, and V in the right and left ear among individuals with AR. From the table, it can be seen that the ABR latencies were within the normal limits. Independent sample t-test was administered to find the significance of difference across two groups. The ABR results showed no retrocochlear involvement in any of the participants and the latency of peaks I, III, and V and also the amplitude of those peaks showed no difference between groups.
Table 1: Absolute latencies and amplitude of waves I, III, and V in the right and left ear among individuals with allergic rhinitis

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  Discussion Top


Results of the present study had few interesting findings. The pure tone audiometry of the present study reveals a higher prevalence of hearing loss in individuals with AR. Thresholds across frequencies were diminished with pure-tone average greater when compared to the control group. The present study had some salient findings, which is the thresholds at high frequencies were significantly higher than age-matched controls. Although ample of researches indicated poorer thresholds of about 10 ± 9.1 db,[6] moderate loss,[4] very fewer studies have noted significant changes across high frequencies. A study by Singhet al.[2] found that the pure-tone thresholds improved over time; hence, the effect of AR on hearing might be seasonal. However, the present study found contradicting findings to Singhet al.[2] as we found that the thresholds did not change over 1 month when actually the symptoms of AR disappeared.

Tympanometry indicated “A” type with compliance ranging between 0.3cc and 1.6cc, peak pressure between −100 daPa and +60 daPa and ear canal volume between 0.9cc and 2.0cc indicating normal middle ear functions bilaterally among all the participants. These findings are contrary to various researches where middle pathology was observed.[3],[4],[5] All the 15 individuals had acoustic reflex thresholds at 500 and 1000 Hz, whereas 12 of 15 individuals had reflex at 2000 Hz. Auditory reflex was obtained bilaterally in 10 individuals with AR, whereas unilaterally among five individuals. Similar results were obtained during the follow-up evaluation. The results of the Valsalva test revealed that none of the individuals found to have Eustachian tube dysfunction.

Results of DPOAE indicate reduced outer hair cell function. This can be attributed to the changes in outer hair cell function due to allergens.[2] The presence of an allergen will trigger the endolymphatic sac in the inner ear that can process antigens and produce its own local antibody response; the resulting inflammatory mediators and toxic products may interfere with hair cell function and thus affect the hearing.[2],[7] speculated that histamine may have protective effect on hearing by vasodilatation in cochlear artery and vein. However, the result of the present study contradicts the findings Karabulut et al.[7] The histamine might cause inflammation directly or indirectly,[8] thus by affecting the cochlea.


  Summary and Conclusion Top


AR is an allergic inflammation of the nasal airways and nasal mucosa. Research on AR concentrated more identifying the type of hearing loss and found that the conductive type of loss is more often found associated with AR. Hence, the current study was taken up to identify any cochlear involvement associated with AR and emphasize the need to evaluate hearing in individuals with AR. Results of the present study it is clear that there is sensorineural involvement in individuals with AR. Poor pure-tone thresholds reduced/absent DP amplitude, “A” type tympanogram indicating that the absence of middle ear pathology clearly indicates the presence of cochlear involvement which can be attributed the allergens which might have spread to the cochlea. It can be concluded from the present study that individuals with AR are more prone to hearing loss. The presence of allergens and inflammation of histamine affects the inner ear function, particularly on the outer hair cells.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Dykewicz MS, Hamilos DL. Rhinitis and sinusitis. J Allergy Clin Immunol 2010;125:S103-15.  Back to cited text no. 1
    
2.
Singh S, Nagarkar AN, Bansal S, Vir D, Gupta AK. Audiological manifestations of allergic rhinitis. J Laryngol Otol 2011;125:906-10.  Back to cited text no. 2
    
3.
Fireman P. Otitis media and eustachian tube dysfunction: Connection to allergic rhinitis. J Allergy Clin Immunol 1997;99:S787-97.  Back to cited text no. 3
    
4.
Dees SC, Lefkowitz D 3rd. Secretory otitis media in allergic children. Am J Dis Child 1972;124:364-8.  Back to cited text no. 4
    
5.
Rózańska-Kudelska M, Południewska B, Biszewska J, Silko J, Godlewska-Zoładkowska K. Assessment of the hearing organ in the patients with allergic perennial and seasonal allergic rhinitis. Otolaryngol Pol 2005;59:97-100.  Back to cited text no. 5
    
6.
Naini SA. Allergic rhinitis and hearing loss (a 5 year study on 800 patients). J Fac Med Shahid Beheshti Univ Med Sc Health Serv 2005;29:220-9.  Back to cited text no. 6
    
7.
Karabulut H, Acar B, Dagli M, Karadag AS, Baysal S, Karasen RM, et al. Investigation of hearing in patients with allergic rhinitis. Iran J Allergy Asthma Immunol 2011;10:29-33.  Back to cited text no. 7
    
8.
Emanuel MB. Histamine and the antiallergic antihistamines: A history of their discoveries. Clin Exp Allergy 1999;29 Suppl 3:1-1.  Back to cited text no. 8
    


    Figures

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  [Table 1]



 

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