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Hearing Loss and Rheumatic Disease

Audiologic, Cognitive Manifestations in Inflammatory Rheumatic Disease

Dillmuth-Miller, Susan AuD; Batson-Magnuson, LuAnn PhD, CCC-SLP

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doi: 10.1097/01.HJ.0000654920.33807.df
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Inflammatory rheumatic diseases (IRDs) are characterized by inflammation in the joints, muscles,1 and, for some, organs of the body, including the brain.2 Many are considered immune-mitigated diseases.3,4 Audiological manifestations have been found in patients with IRDs, although they vary considerably.5–8 Because the middle ear is composed of muscles, joints, and cartilage, IRDs have the potential to affect middle and inner ear functions due to inflammation, reduced vascularity, and ototoxic medications used to treat the condition itself.9 These variations in results can be explained not only by methodological differences but also a lack of consistency in hearing evaluation protocols.7,8,10,11 Cognitive-linguistic effects are also prevalent in this population. For the past two years, our clinic has been conducting a study examining the audiologic and cognitive effects of IRD.12 Notably, we have found that many of the published studies do not involve hearing and speech-language professionals.

Shutterstock, rheumatic disease, hearing loss, cognition.
Table 1
Table 1:
Cognitive and Audiologic Symptoms Across IRDs. Rheumatic disease, hearing loss, cognition.
Figure 1.
Figure 1.:
Hearing loss among women with IRD. Rheumatic disease, hearing loss, cognition.


Inflammation in IRD impacts the joints, tendons, ligaments, bones, and muscles of the body, as well as the organs, depending on the specific diagnosis.1 Helmick, Felson, and Lawrence2 reported that over seven million individuals in the United States are living with IRD. More than 30 specific diseases fall under the umbrella of IRD,4,13 and 8.4 percent of women14 and five percent of men15 will be diagnosed with IRD during their lifetime. In addition to the primary symptoms of each of these diseases, individuals with IRD are at increased risk of cardiovascular and cerebrovascular diseases.16 Recent research provides evidence that the inflammatory process associated with IRD affects the brain for the most prevalent diseases, including systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), fibromyalgia (FM), and Lyme disease.

The presence of inflammatory markers and proteins associated with an inflammatory process has been identified in the blood serum of patients with IRD. Serum evidence supports the presence of high levels of antiphospholipid antibodies in SLE.17 When persistently high, antiphospholipids impact vascular function, resulting in decreased blood flow and cognitive decline.16 Higher concentrations of secreted pro-inflammatory proteins have been found in individuals with RA, SLE, and Lyme disease,18–20 and individuals with RA, SLE, and FM have been found to have high levels of cytokines, chemokines, and prostaglandins,21–25 which are secreted as part of the immune response and associated with systemic inflammation. Elevated levels of cytokines are associated with decreased blood flow and reduced cognitive abilities,26 while elevated levels of chemokines are seen in patients with Alzheimer's disease.27 High levels of prostaglandins have been associated with deficits in memory.22

Imaging has provided additional evidence of brain changes resulting from chronic inflammation. EEGs of patients with SLE showed the presence of prolonged P300 latencies and reductions in P300 amplitudes, which are neuro-physiological analogues for cognitive dysfunction and indicate possible demyelination.18 MRI studies include evidence of the activation of glial cells,22 white matter lesions,28 cortical atrophy,28 ventricular dilation,28 hypoperfusion of lobes of the brain,29,30 and decreased gray matter volume,31 while a review of SPECT and PET scan evidence supports the presence of hypometabolism and decreased perfusion.28,30 These inflammatory brain changes are associated with cognitive dysfunction.


Research into the cognitive correlates of rheumatic disease has focused mostly on RA, SLE, FM, and more recently, Lyme disease. The prevalence of negative cognitive effects in IRDs varies greatly, with 30 to 70 percent of RA patients exhibiting cognitive deficits.32–34 In studies on patients with SLE, 50 to 80 percent of patients reported or displayed cognitive deficits, while 81 to 87 percent of patients with neuropsychiatric lupus exhibited cognitive deficits.35 Approximately 50 to 90 percent of individuals with FM36 and 48 percent of individuals with Lyme disease report having cognitive deficiencies.37 Individuals with IRDs may experience deficits in short-term, working, and episodic memory,17,23,31,38–42 verbal comprehension,15 attention,17,31,37,39,40,42–44 verbal fluency,14 cognitive response times,29,45 and executive functioning.46,47 These cognitive deficits often result in a reduced quality of life48 and early retirement.49

Preliminary findings from our study looked at word-finding and memory performance for subjects with RA, SLE, and Lyme disease.12 Out of 32 subjects, 33 to 53 percent had below-average word-finding abilities, and 25 to 50 percent of subjects fell below average for memory based on standardized assessments. No correlation was found between pain, sleepiness, emotional state or disease activity, and cognitive performance.


Studies examining IRDs and audiological manifestations are few and show varied results. The incidence of hearing loss in those with RA and SLE ranges between 24 and 89 percent.5–8,50–52 Mostly bilateral high-frequency sensorineural hearing loss is reported, which seems to develop within the first five years of diagnosis.5,8,10,52–54 Using age-matched controls, decreased thresholds were found in younger patients with SLE, and older patients had decreased thresholds in both the lower and higher frequencies.52 Although RA has the potential to affect joints and muscles, conductive hearing loss in this population is a lot less common.5,8,53,55 During flare-ups, bilateral and fluctuating sensorineural hearing loss has been observed in those with RA11 and unilateral hearing loss in those with SLE.50,51 In people with FM, the most common complaint was hyperacusis,56 and audiometric tests showed high-frequency sensorineural hearing loss,56,57 with auditory evoked potentials showing delayed P300s, suggesting possible auditory processing difficulties (APD).58 In those with chronic Lyme disease, hypersensitivity to sound was reported in 48 percent,59 and in another study, all five subjects were found to have mild-to-moderate auditory processing deficits.37 See Table 1 for symptoms across IRDs.

Our study conducted full audiological evaluations, tympanometry testing, and APD screenings on patients with IRDs.12 Of the 25 women aged 18 to 76 (x=45.1) who were tested, 84 percent had high-frequency sensorineural hearing loss, of which 81 percent had hearing loss that notched at 6 kHz (Fig. 1). Conductive component and tympanometric abnormalities were only observed in one person who had a history of otitis media. Of the 21 who could complete the SCAN-A, a screener for APD, 76 percent did not pass, notably in those with SLE, FM, and Lyme. Contralateral and ipsilateral acoustic reflexes were present at expected levels. All subjects with FM and Lyme reported having sensitivity to sound. Our data found no correlation between medications (methotrexate, NSAIDs, Plaquenil, and prednisone), disease state, or fatigue level, and hearing loss. Although our study is preliminary, our results show that people with IRD need the care of an audiologist and a speech-language pathologist.


  1. Based on the findings of our literature review and research, these suggestions can help best serve those with IRD:
  2. Talk to local physicians regarding the need to refer patients with IRD for hearing and cognitive-linguistic evaluations shortly after diagnosis.
  3. Monitor hearing levels throughout the course of the disease.
  4. Add questions about IRDs when discussing a patient's medical history. For example: “Do you see a rheumatologist? What medications do you take?”
  5. Include interoctaves 3 and 6 kHz.
  6. Conduct an APD screening if hearing thresholds are better than 25 dB at 1, 2, and 4 kHz.
  7. Consider that deficits in memory, word-finding, and attention may negatively impact APD testing and the validity of test outcomes.
  8. Refer those with IRD to a speech-language pathologist.


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