www.bjorl.org
Brazilian
Journal
of
OTORHINOLARYNGOLOGY
ORIGINAL
ARTICLE
Hearing
loss
assessment
in
primary
and
secondary
acquired
cholesteatoma
夽,夽夽
Julia
Maria
Olsen
a,∗,
Fernando
de
Andrade
Quintanilha
Ribeiro
b,
Mariana
Mieko
Mendes
Yasui
c,
Ivan
Taylor
Ribeiro
dos
Santos
caFaculdadedeSaúdePública,UniversidadedeSãoPaulo(USP),SãoPaulo,SP,Brazil
bDepartmentofOtorhinolaryngology,FaculdadedeCiênciasMédicasdaSantaCasadeSãoPaulo,SãoPaulo,SP,Brazil cDepartmentofMedicine,FaculdadedeCiênciasMédicasdaSantaCasadeSãoPaulo,SãoPaulo,SP,Brazil
Received3July2014;accepted23November2014 Availableonline8September2015
KEYWORDS Hearingloss; Cholesteatoma; Suppurativeotitis media;
Audiometry
Abstract
Introduction:Acquired middleearcholesteatomacanbeclassifiedasprimaryorsecondary. Althoughbothcanresultinhearingloss,itisstillcontroversialwhetherthereisanassociation betweenthetypeofcholesteatomaandthedegreeofhearingloss.
Objective: To analyze the association between hearing loss and the type of acquired cholesteatoma,andthestatusoftheossicularchain.
Methods:This was a cross-sectional historical cohort study involving patients diagnosed with acquiredcholesteatomawhowere surgicallytreated. Airandbone conduction thresh-olds, air---bonegaps and the statusof the ossicular chain were analyzed for both types of cholesteatoma.
Results:Eightypatientsaged5---57wereincludedinthestudy.Fifty-onepatientshadprimary cholesteatomaand29hadsecondarycholesteatoma.Bothtypesofcholesteatomadetermined greaterair---bonegapsat0.5kHz.Secondarycholesteatomadeterminedgreaterhearinglossin allanalyzedfrequenciesandhigherairconductionandair---bonegapmeans.
Conclusion: Therewasassociationbetweenhearinglossandthetypeofcholesteatoma. Sec-ondarycholesteatomaresultedingreaterhearingimpairment.
© 2015Associac¸ãoBrasileira de Otorrinolaringologiae CirurgiaCérvico-Facial. Publishedby ElsevierEditoraLtda.Allrightsreserved.
夽 Pleasecitethisarticleas:OlsenJM,RibeiroFAQ,YasuiMMM,dosSantosITR.Hearinglossassessmentinprimaryandsecondaryacquired
cholesteatoma.BrazJOtorhinolaryngol.2015;81:653---7.
夽夽Institution:DepartmentofOtorhinolaryngology,SantaCasadeMisericórdiadeSãoPaulo,SãoPaulo,SP,Brazil.
∗Correspondingauthor.
E-mail:juolsen@hotmail.com(J.M.Olsen). http://dx.doi.org/10.1016/j.bjorl.2014.11.009
PALAVRAS-CHAVE Perdaauditiva; Colesteatoma; Otitemédia supurativa; Audiometria
Avaliac¸ãodaperdaauditivanocolesteatomaadquiridoprimárioesecundário
Resumo
Introduc¸ão:Ocolesteatomaadquiridodeorelhamédiapodeserclassificadocomoprimárioe secundário.Ambos podemocasionar perdadeaudic¸ão,mas aindahácontrovérsia quantoà relac¸ãodostiposdecolesteatomacomaperdaauditiva.
Objetivo:Analisararelac¸ãodostiposdecolesteatomaedaerosãodacadeiaossicularcoma perdaauditiva.
Método: Estudodecoortehistóricacomcortetransversal,envolvendopacientesquereceberam odiagnósticodecolesteatomaadquiridoeforamsubmetidosàcirurgiaotológica.Foram anal-isadososlimiaresósseos,aéreoseadiferenc¸aaéreo-óssea,esuasassociac¸õescomostiposde colesteatomaecomapresenc¸adeerosãonacadeiaossicular.
Resultados: No estudo foram incluídos oitenta pacientes, com idade entre 5 e 57 anos, sendo 51 com colesteatoma primário e 29 com colesteatoma secundário. Ambos os tipos de colesteatoma determinaram maior diferenc¸a aéreo-óssea na frequência de 0,5 kHz. O colesteatomasecundáriodeterminouumaperdaauditivamaioremtodasasfrequências anal-isadas,emaioresmédiasdolimiaraéreoedadiferenc¸aaéreo-óssea.
Conclusão:Houve associac¸ão entre o tipo de colesteatoma e a perda de audic¸ão. O colesteatomasecundáriodeterminoumaiorcomprometimentodaaudic¸ão.
©2015Associac¸ãoBrasileira deOtorrinolaringologiaeCirurgiaCérvico-Facial.Publicadopor ElsevierEditoraLtda.Todososdireitosreservados.
Introduction
Cholesteatomaisdefinedasthepresenceofskininany air-filledareaofthetemporalbone,andcanbecongenitalor acquired.1Acquiredmiddle-earcholesteatomacanbe
clas-sifiedaccordingtoitsoriginasprimaryorsecondary.2---6The
primarytype originates frompars flaccida retractionand thesecondarytypefromtheinvolvementoftheparstensa ofthetympanicmembrane.5,7,8
Studies have shown that the incidenceand prevalence ofcholesteatomaaremuchhigherindevelopingcountries, highlightingitsassociationwithlowsocioeconomicstatus, poorhygiene,anddelayinseekinghealthcareorpoorhealth services.9,10
Cholesteatomas determine mechanical compression of adjacent structures and have cells with hyperprolifera-tivecharacteristics(cytokeratin16,KI67,andinflammatory cytokines), which maycause temporalbone and ossicular chainerosion,resultinginhearingloss.4,11,12Forthisreason
andduetothepresenceoffetidotorrhea,theyresultin psy-chosocialdamage.Astheyhaveamajorimpactonactivities ofdailyliving,theycanlimitfuturejobopportunitiesand causesocialinclusiondifficulties.9
There is no consensus in the literature regarding the influenceofthetypeofcholesteatomaonhearingloss,or concerningthefrequenciesmostaffected.11,13---17
Most studies have shown that there is an associa-tion between ossicular chain erosion and magnitude of hearing loss, and that the most affected ossicle is the incus.12,15,17
Theaimof thisstudywastoanalyzetheassociationof primaryandsecondaryacquiredcholesteatoma,aswellas ossicularchainerosionwithhearingloss.
Methods
The study was approved by the Ethics Committee of the institutionunderNo.03856512.4.0000.5479.
This was a historical cohort study with cross-sectional design, based on data obtained from medical records of patients treated at the Otorhinolaryngology Outpatient Clinic of amedical teachinginstitution, between January of2010andOctoberof2013.
Inclusion criteria: patients who were diagnosed with acquiredcholesteatomaandsubmittedtootologicalsurgery.
Exclusioncriteria:patients withother concomitantear diseases or those who had been previously submitted to otologicalsurgery.
Prior to surgery, all patients underwent pure tone audiometry with determination of air thresholds at 0.25, 0.5, 1---4, 6, and 8kHz, and bone thresholds at 0.5 and 1---4kHz.Air andbone thresholds andair---bone gapswere evaluatedseparatelyatthefrequencies0.5,1,2,and4kHz. The means were alsoevaluatedfor each patientat those frequencies.
The variables studied were: (a) age and gender; (b) type of cholesteatoma: defined according to clinical his-tory,physicalexaminationdata,andintraoperativefindings described in the standardized surgical description form, classifiedasprimarycholesteatomawhen originatingfrom parsflaccidaretractionandsecondarywhenoriginatingfrom theinvolvementofparstensaofthetympanicmembrane8;
(c)presenceofossicularchainerosion,definedbythe intra-operativefindings,notedaspresentorabsent.
Statistical analysis was performed using StataTM
chi-squared test for categorical variables, and the non-parametric Wilcoxon---Mann---Whitney test for continuous variables,consideringa95%confidenceintervaland5%level ofsignificance.
Results
The present study included 80 patients, 31 females and 49 males, aged between 5 and 57 years (mean age of 26.5±14.75). The left ear was affected in 52.5% of the patients and the right ear, 47.5%. Primary cholesteatoma was found in 51 (63.8%) patients and sec-ondarycholesteatomain29(36.2%)patients.Therewasno statisticallysignificantdifferencebetweenthetwogroups inrelationtogenderandage(Table1).
Asforthehearingimpairmentatthedifferent frequen-cies, it was observed that thebone thresholdwas higher atfrequencies2and4kHz,bothinprimaryandsecondary cholesteatoma (Table 2); the air threshold was higher at frequencies 0.5kHz and 1kHz in primary cholesteatoma andsimilarat all frequencies insecondary cholesteatoma (Table 3), whereas the gap washigher at a frequency of 0.5kHzinbothtypesofcholesteatoma(Table4).
Table 1 Distribution of demographic characteristics accordingtothetypeofcholesteatoma.
Variable Primary Secondary p
n % n %
Gender 0.187a
Female 17 33.3 14 48.3
---Male 34 66.7 15 51.7
---Meanage 27.1 22.6b 25.7 21.8b 0.706c
Total 51 63.8 29 36.2
a Chi-squaredtest. b Median.
c Non-parametricWilcoxon---Mann---Whitneytest.
As for the degree of hearing loss, it was observed that secondary cholesteatoma caused greater loss than primary cholesteatoma at all analyzed frequencies, as well as a larger gap at the frequencies of 1 and 2kHz (Tables 3 and 4). There was no statistically significant differencein mean bone threshold between primary and secondarycholesteatomas; however, themean air thresh-oldandthemeangapwerehigherinpatientswithsecondary cholesteatoma(Table5).
Table2 Meanbonethreshold(indB)atdifferentfrequencies(inkHz)accordingtothetypeofcholesteatoma.
Frequency Primary Secondary p
Mean CI Mean CI
0.5kHz 7.45 4.90---10.00 11.38 5.59---17.17 0.309
1kHz 7.05 4.07---10.05 11.96 5.52---18.41 0.172
2kHz 10.78 7.65---13.92 18.45 11.10---25.80 0.084
4kHz 10.00 7.16---12.84 16.55 9.40---23.71 0.163
CI,confidenceinterval;p,nonparametricWilcoxon---Mann---Whitneytest.
Table3 Meanairthreshold(indB)atdifferentfrequencies(inkHz)accordingtotypeofcholesteatoma.
Frequency Primary Secondary p
Mean CI Mean CI
0.5kHz 40.29 35.46---45.13 50.52 41.92---59.12 0.029
1kHz 38.43 33.23---43.62 50.71 42.03---59.39 0.008
2kHz 33.83 29.12---38.53 50.86 40.51---61.21 0.002
4kHz 23.40 23.51---39.22 50.34 40.27---60.42 0.038
CI,confidenceinterval;p,nonparametricWilcoxon---Mann---Whitneytest.
Table4 Meangap(indB)atdifferentfrequencies(inkHz)accordingtotypeofcholesteatoma.
Frequency Primary Secondary p
Mean CI Mean CI
0.5kHz 32.84 28.50---37.18 39.14 32.81---45.47 0.066
1kHz 31.37 27.04---35.70 38.75 33.54---43.96 0.017
2kHz 23.03 18.11---26.63 32.41 27.11---37.71 0.007
4kHz 28.04 24.21---31.86 33.79 28.28---39.31 0.055
Table5 Meanhearingthresholds(indB)accordingtotypeofcholesteatoma.
Threshold Primary Secondary p
Mean CI Mean CI
Bone 8.8 6.4---11.2 14.6 8.5---20.7 0.136
Air 37.6 33.4---41.9 50.6 42.0---59.2 0.006
Gap 28.8 25.2---32.5 36.0 31.3---40.7 0.019
CI,confidenceinterval;p,nonparametricWilcoxon---Mann---Whitneytest.
Onlyfive(6.25%) patientshadan intactossicularchain during surgery, two of them with primary cholesteatoma and three with secondary cholesteatoma. Patients with intact ossicular chain had a mean gap of 26.25dB (SD±7.55dB) and patients with ossicular chain erosion, 31.77dB(SD±13.54dB).
Discussion
Theaimofthisstudywastoprimarilyinvestigatethe asso-ciationofthetypesofcholesteatomawithhearinglossand, secondarily,theassociationbetweentheossicularchain sta-tusandhearingimpairment.
The twotypes of cholesteatoma caused a greater gap at the low frequencies, and 0.5kHz was affected to a greaterdegree.Thus,incommonwiththatreportedinthe literature,18,19 this study showed the preservation of the
bonethresholdandgreaterinvolvementoftheairthreshold atthesefrequencies.
The difference in hearing loss between both types of cholesteatoma is still controversial in the literature, as the different methodologies make it difficult to compare results.12,18,19 In theory, due to its location, secondary
cholesteatomawouldaffectthetensepartofthetympanic membraneto agreater extent, the incusand thestapes, causinggreaterhearingloss.Thisassumptionwasconfirmed bythisstudy,inwhichsecondarycholesteatoma was asso-ciatedwithmoreseverehearingloss.Mildhearinglosswas found associatedwith primarycholesteatoma and moder-atelosswithsecondarycholesteatoma,greaterfindingsthan thosereportedinotherstudies.17---19
Theliteratureindicatesthatthedegreeofhearinglossis notagoodpredictorofossicularchainstatus.15,16However,
recent studies have shown that hearing loss is associated with ossicular chain erosion, with the incus being most importantossicleinhearingthresholds.12,19 In thepresent
study,thelack ofinformationonthe affectedossicleand thesmallnumberofcaseswithanintactossicularchainat surgerypreventedtheanalysisofthe associationbetween hearinglossandtheossicularchainstatus.
The present study was performed in a public health service,where consultationswithspecialists, complemen-tary examinations, and surgical treatment still require considerable time.20 Thus, the interval between patient
symptomonsetandtheirdiagnosisandtreatmentislengthy. This could explain the high prevalence of ossicular chain erosionandthegreaterdegreeofhearinglossweobserved. This study has some limitations. The study includes patientstreatedatanoutpatientclinicratherthanarandom patientsample,whichreducesitsabilitytobegeneralized.
Additionally,thelackofinformationonthesocioeconomic characteristics of patients and disease duration makes it impossible to investigate possible associations of these variableswithhearinglossandthedevelopmentof explana-tionsforthehighprevalenceofossicularchainerosion.
Conclusions
Thetypeofacquiredcholesteatomaresultedinstatistically significant differences regarding hearing loss. Secondary cholesteatoma resultsin greater airthresholdimpairment and air---bone gap than the primary cholesteatoma. Addi-tionally,bothtypesofcholesteatoma resultedinagreater air---bonegapatthelowerfrequencies.
Funding
ThisstudywasfundedbythePIBICScientificInitiationGrant ---CNPq.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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