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Adv Biomed Res 2023,  12:80

Prevalence rate of hearing loss in patients with rheumatoid arthritis

1 Department of Rheumatology, Rheumatology Research Center, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran
2 Department of Rheumatology, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran
3 Department of Audiology, Rehabilitation Research Center, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran
4 Department of Otolaryngology, Firoozgar Clinical Research Development Center, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran

Date of Submission16-May-2021
Date of Acceptance27-Jun-2021
Date of Web Publication28-Mar-2023

Correspondence Address:
Dr. Fatemeh Mehrabian
Department of Rheumatology, Firoozgar Hospital, Iran University of Medical Sciences, Tehran
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/abr.abr_118_21

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Background: Rheumatoid arthritis (RA) is a common chronic inflammatory disorder that can be associated with some hearing impairments. Hence, we aimed to evaluate the prevalence rate of hearing loss (HL) in RA patients.
Materials and Methods: This study included 130 participants from February 2019 to March 2020 including 100 RA patients (78 females and 22 males) as RA group and 30 healthy cases (16 females and 14 males) as control group. All patients underwent pure tone audiometry, speech audiometry, tympanometry, acoustic reflex, and tone decay test by single operator and device. The rate of HL and contributing factors were then determined.
Results: The mean age of RA group was 53.95 ± 7.6 years, and the mean duration of disease was 12.74 years. Rheumatoid factor was positive in 54% of patients, and the frequency rates of diabetes, chronic kidney disease, hypertension, and dyslipidemia among RA patients were 14%, 1%, 26%, and 19%, respectively. These values among RA patients with HL were 18%, 1.7%, 34%, and 27.5%, respectively. HL in RA patients was related to dyslipidemia (P = 0.011) and age (P = 0.0001). Frequency rate of conductive HL in left and right ears was 2% and 5%, respectively, and these rates for sensorineural hearing loss (SNHL) were 55% and 61%, respectively. In addition, the percent of HL in low, mid, and high frequency ranges was 18%, 19%, and 57%, respectively.
Conclusions: The findings of the present research demonstrate that HL especially with SNHL and high-frequency types is common among RA patients.

Keywords: Pure tone audiometry, rheumatoid arthritis, sensorineural hearing loss, tympanometry

How to cite this article:
Almasi S, Mehrabian F, Rahbar N, Maleki Delarestaghi M. Prevalence rate of hearing loss in patients with rheumatoid arthritis. Adv Biomed Res 2023;12:80

How to cite this URL:
Almasi S, Mehrabian F, Rahbar N, Maleki Delarestaghi M. Prevalence rate of hearing loss in patients with rheumatoid arthritis. Adv Biomed Res [serial online] 2023 [cited 2023 Jun 7];12:80. Available from:

  Introduction Top

Rheumatoid arthritis (RA) is a chronic inflammatory disease affecting nearly 1% of general population[1] diagnosed by clinical, radiological, and laboratory parameters.[2] Bone and joint destruction would result in early mortality and socioeconomic burden.[2] Head-and-neck involvement is reported in RA patients including laryngeal, cervical, and temporomandibular joint.[3] The prevalence of RA in the world is very small (1% of the people). Corresponding to community-oriented program for control of rheumatic diseases prevalence rate of this disease in Iran is 0.19%.[4] Female gender[5] and older ageing[6] have higher prevalence of RA than others. In addition, the role of genetic factors is reported in 50% of cases.[7] Despite relatively favorable therapeutic outcomes, the presence of some comorbidity such as hearing problems may occur in some cases. These patients should be treated with invasive treatments and controlling risk factors such as smoking, dyslipidemia, diabetes, and hypertension.[8] The association between hearing loss (HL) and autoimmune diseases was initially described by McCabe.[9] In addition, some studies showed that the HL occurs also in other autoimmune diseases too.[10] HL (in all low, mid, or high frequencies) may be seen in more than 60% of RA patients.[11],[12] Middle ear involvement, vasculitis, neuritis, and drug-induced adverse effects are common causes for HL in the affected patients.[13] Prompt diagnosis and treatment would decrease the progression of HL in RA patients.[14] The HL problem in RA patients has been reported in many studies.[15] The most common type of HL in RA patients is sensorineural form with the rate of 25%–80%, while the other types of HL are not common.[16],[17],[18],[19],[20]

Since different rates have been reported for HL in RA patients (may be due to different types of hearing tests), the rate and type of HL in RA patients have studied here to find the effect of different hearing measurement methods on the outcomes in comparison with other studies and to better follow-up RA patients.

  Materials and Methods Top

In this study, one-hundred consecutive patients with RA attending Rheumatology Clinic in a training referral hospital in Tehran, Iran, in 2019 and 2020 were enrolled in addition to thirty healthy cases selected for control group. All the demographic data including the patient condition, gender, age, duration and background of disease, and type and severity of HL were determined by otolaryngologist. Only the patients with normal tympanic membrane have been entered to this study. The exclusion criteria were otorrhea, inner ear effusion, head trauma, noise exposure, previous drug-induced ototoxicity, chronic neurological disease, and Meniere syndrome.

Demographic and clinical data including Disease Activity Score 28 (DAS28) results for disease severity were recorded. All patients underwent pure tone audiometry (PTA), speech audiometry, tympanometry, acoustic reflex, and tone decay test by single operator and device. Furthermore, the CBC results, rheumatoid factor (RF), anticyclic citrullinated peptide (anti-CCP) status, and erythrocyte sedimentation rate (ESR) were assessed. The rate of HL and contributing factors were determined. Audiometry and tympanogram tests have been performed based on the method presented in ASHA guideline.[21] Acoustic reflex is recorded as present or absent. Type of HL based on audiometry is classified to normal, sensorineural hearing loss (SNHL), conductive hearing loss (CHL), and deafness. The threshold of PTA has been measured at different frequencies as 250, 500, 1000, 2000, 4000, and 8000 Hz and the severity of HL is determined according to [Table 1]. In addition, based on the shape of tympanogram, various middle ear dysfunctions can be classified into five types as defined in [Table 2].
Table 1: Hearing loss grading in patients based on audiometry sensitivity

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Table 2: Hearing loss grading in patients based on tympanogram

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Data analysis was done by SPSS Version 20.0 software (SPSS Inc., Chicago, IL, USA). The frequency and percent were reported for categorical data, and the mean and standard deviation were calculated for numerical variables. The utilized tests were Chi-square and independent-sample t-test. In addition, P < 0.05 was considered statistically dependent.

  Results Top

As discussed in introduction, many studies have reported more hearing impairments in RA patients than in healthy people in general population. Recent studies also confirm this finding,[22],[23],[24],[25],[26],[27],[28] for example, a recent large study in Korea found that RA people were 40% more likely to develop SNHL than others without the condition.[22] Chaitidis et al. reported that RA patients had nearly fourfold increased odds of SNHL compared with control group.[23] In another study, Huang et al. reported that the incidence density of HL was approximately twofold greater in RA than in non-RA group.[24] Since the hearing impairment in RA patients has been proved in many studies, the main concern of our study is analyzing the hearing problems only in RA patients. However, similar to the previous studies, a control group is selected at first here in addition to RA group to compare the hearing impairments between RA and non-RA persons. After a simple comparison between RA and control groups, the condition of HL in RA patients will be discussed in more details.

In this research, thirty healthy cases (53% female and 47% male) and 100 RA patients (78% female and 22% male) are selected as control and RA groups, respectively. P value of these data is 0.009 (less than 0.05) that confirms a statistically significant condition. The mean values of PTA thresholds in different frequencies are presented in [Table 3] for both RA and control groups. It is clear that these data are statistically dependent for all the frequencies in both right and left ears. As anticipated, it can be seen that the hearing thresholds in RA patients are generally higher than those of controls at all the frequencies. In addition, the hearing problem is more significant at higher frequencies and the most sever condition occurs at the frequency of 8000 Hz. This is also compatible with the previous studies.[25],[26],[27] Based on a similar finding, Gamal et al. proposed recently an extended high frequency audiometry test from 10,000–20,000 Hz to early diagnose HL in RA patients.[27]
Table 3: Mean value of pure tone audiometry threshold for different frequencies in rheumatoid arthritis and control groups

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In the selected RA group, 78% of participants were female and 22% were males. The mean age was 53.95 ± 7.6 years, and the mean duration of disease was 12.74 years. RF, CRP, ESR, and anti-CCP were positive in 54%, 35%, 65%, and 80%, respectively. Smoking, hypertension, diabetes mellitus, chronic kidney disease (CKD), and dyslipidemia were reported in 13%, 26%, 14%, 1%, and 19%, respectively. Furthermore, 4% had rheumatoid nodule. As shown in [Figure 1], the patients were in remission phase in 58%.
Figure 1: Disease activity according to Disease Activity Score 28

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Audiometry results showed abnormal hearing in 71% of patients. In the left ear, the HL was sensorineural, conductive, and deafness in 55%, 2%, and 1%, respectively, and in the right ear, the HL was sensorineural, conductive, and deafness in 61%, 5%, and 1%, respectively. The severity of HL was slight, mild, moderate, severe, and profound in 34%, 12%, 9%, 1%, and 2%, respectively, in the left ear and 46%, 12%, 8%, 1%, 0%, respectively, in the right ear. The results of other tests are shown in [Table 4].
Table 4: Percentage of other hearing tests across the rheumatoid arthritis group

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The age frequency distribution according to severity and type of HL in both sides is shown in [Table 5] that demonstrates type and severity had significant differences (P = 0.0001). The disease duration frequency distribution according to severity and type of HL in the ears are shown in [Table 6] that demonstrates type and severity had significant differences (P = 0.0001). Categorical variables according to audiometry-type are also presented in [Table 7].
Table 5: Mean age of the patients with type and grade of hearing loss in rheumatoid arthritis group

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Table 6: Mean of disease duration according to the type and grade of hearing loss

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Table 7: Categorical variables according to audiometry-type

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As shown in [Figure 2], the type of HL for the patients with positive and negative rheumatoid nodules is presented. Vertical axis in this figure shows the number of patients and the horizontal axis shows the presence of rheumatoid nodules. It can be seen that most of the patients with rheumatoid nodules has a HL problem. Furthermore, the number of the patients based on the type and severity of their HL are demonstrated in [Figure 3].
Figure 2: Number of patients based on the type of hearing loss and rheumatoid nodule

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Figure 3: Number of patients based on the type of hearing loss and disease activity

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The percentage of different variables is presented in [Table 8] for all patients and patients with HL contributed in this study. For the RA patients with HL, these values are compared with other studies in [Table 9]. In this table, the values in the parenthesis show the variable among the RA patients with HL and the values out of the parenthesis relate to all RA patients. In addition, different reported percentages for the type of HL are compared with the results of our study in [Table 10]. These results will be discussed in the next section.
Table 8: Percentage of different variables in all rheumatoid arthritis patients and patients with hearing loss

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Table 9: Comparison the percentage of variables across the studies

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Table 10: Comparison the percentage of the type of hearing loss across the studies

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  Discussion Top

Hearing problems are common among patients with RA in nearly two-third of patients.[11] Among the patients with RA, there are numerous causes for HL.[13] The presence of such comorbidities would decrease the quality of life.[14] In our study, 78% of RA patients were female, the mean age of patients was 53.95 years, and mean disease duration was 12.74 years. It is noticeable that these values are nearly compatible with the other studies referred here. For example, the mean age of RA patients in the studies done by Kastanioudakis et al., Reiter et al., Lobo et al., and Jeong et al. was 53, 58, 49, and 56.7 years, respectively, and most of the patients have been female in all of these studies.[11],[12],[13],[20] In our study, age was related to HL (P = 0.0001), but duration of disease was not related to HL (P = 0.142). In addition, the gender was not related to HL as shown in [Table 8]. Similarly, the study in Japan showed a significant association between age and HL.[16] Study by Lobo et al. showed that RF was positive in 55% of patients and the anti-CCP was positive in 80% of patients.[20] However, in our study, ESR, RF, CRP, and anti-CCP were not related to HL.

In our study, low, mid, and high-frequency HL was 18%, 19%, and 57%, respectively. In both ears, the HL was mainly SNHL. Totally, 71% of patients had HL. Kastanioudakis et al. reported that 35% of patients had bilateral SNHL.[13] In the study in Pennsylvania, 48 patients had SNHL.[11] Furthermore, Ozcan et al. reported that 35.1% of patients had SNHL.[19] The study by Lobo et al. revealed that HL was present in 46.5% of RA patients that was SNHL in 80%.[20] The study in Japan revealed that 36.1% of patients had SNHL that was bilateral in 28%.[16] More recent studies also confirm that RA is significantly associated with SNHL, and it is not associated with CHL and MHL.[23],[25],[26]

The study in Spain revealed that HL was high frequency and sensorineural in 70% of RA patients. In their study, the acoustic reflex was absent in 27% of patients.[29] In the study in Korea, the mid/low-frequency and high-frequency were seen in 21.1% and 43.3%, respectively.[12] Kastanioudakis et al. reported acoustic reflex latency in 10%.[13] It was seen in 15% in the study by Ozcan et al.[19] In our study, the tympanogram was abnormal in 14%, but they reported it in 38%. In Japanese study, the abnormal results were reported in 19.5%.[16] In 16.7% of their RA patients, the type of HL was As, and in 2.8%, it was Ad subtype, while in the control group, these rates were 1.4% and 11.1%, respectively. In our study, the HL rate was 16% and 14% according to PTA and SRT, respectively. The study by Ozcan et al. showed that PTA was abnormal in 51.4% and it was 43% in Spanish study.[19],[29]

In our study, smoking was reported by 12% of RA patients with HL, but there was no significant association. Furthermore, diabetes, CKD, and hypertension were not related to HL. However, dyslipidemia was related to HL with P = 0.011. In our study, hypertension, diabetes, CKD, dyslipidemia, rheumatoid nodule, and smoking were seen in 26%, 14%, 1%, 19%, 4%, and 13% of RA patients, respectively, as reported in [Table 8]. In the Korean study hypertension and diabetes were seen in 28% and 12%, respectively, and the GFR was under 60 in 7% with smoking rate of 10%.[12] In our study, RF, anti-CCP, ESR, CRP, and nodule were seen in 54%, 83%, 65%, 35%, and 4% of RA patients, respectively. In the study by Lobo et al., the RF was positive in 56.5% and anti-CCP was positive in 34.78%.[20] The disease was in remission in 58%, and the disease was low, moderate, and high activity according to DAS28 in 20%, 20%, and 2%, respectively. The disease activity was not related to HL. The study by Lobo et al. also showed no association between these factors.

Totally, according to the obtained results in this study, it can be concluded that HL is a common problem among patients with RA, especially with sensorineural and high-frequency types. In addition, the rate of HL in RA patients depends on different factors such as the age and gender of patients as well as the duration of disease and the method of audiometry tests. Therefore, further studies with larger sample size and multicenter samplings are required to attain more definite results in comparison with our studies.

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  References Top

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  [Full text]  
Gamal N, El-Oseily A, Mostafa H, Badawy E, Abd Elsamea M. Detection of hearing loss in rheumatoid arthritis patients using extended high frequency audiometry: Is it related to disease activity and severity? Egypt Rheumatol 2021;43:219-24.  Back to cited text no. 27
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Lasso de la Vega M, Villarreal IM, Lopez-Moya J, Garcia-Berrocal JR. Examination of hearing in a rheumatoid arthritis population: Role of extended-high-frequency audiometry in the diagnosis of subclinical involvement. Scientifica (Cairo) 2016;2016:1-7, Article ID 5713283.  Back to cited text no. 29


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10]


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