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Correlation between sensorineural

hearing loss and chronic otorrhea
| Reprints

November 3, 2017 by Fernanda Martinho Dobrianskyj, MS; Ísis Rocha Dias Gonçalves,
DO; Yumi Tamaoki, DO; Edson Ibrahim Mitre, MD; Fernando A. Quintanilha Ribeiro, PhD

Abstract
Many studies have attempted to correlate chronic otorrhea in children and in
adults with the sensorineural hearing loss in the affected ear, with
contradictory results. This loss might be the result of the likely toxicity of the
bacteria involved, effects of inflammatory cytokines, or constant use of
ototoxic antibiotics. All studies evaluated to date compared the affected ear
with the normal contralateral ear. From the digitized archive of otologic
surgery files of the Department of Otorhinolaryngology at Santa Casa de
São Paulo School of Medical Sciences, the ears of patients with chronic
otorrhea were evaluated visually and compared with the normal contralateral
ears. Ears with otorrhea were also compared with ears of other patients with
dry tympanic perforation. Ears with suppuration were evaluated for
cholesteatoma. The duration of otorrhea was considered. The sensorineural
hearing threshold was evaluated for the frequencies of 500, 1,000, 2,000,
and 4,000 Hz. A total of 98 patients with chronic otorrhea and 60 with dry CURRENT ISSUE
tympanic membrane perforation were evaluated. A correlation between
sensorineural hearing loss and chronic otorrhea was observed when
compared with both contralateral normal ears and dry perforated ears of
other patients. No relationship between hearing loss and the duration of
suppuration or cholesteatoma was found. Sensorineural hearing loss occurs
in ears with chronic otorrhea. The duration of otorrhea and the etiology of
suppuration did not influence the hearing loss.

Introduction
Studies examining the correlation between chronic otorrhea and ipsilateral
September
sensorineural hearing loss in large numbers of patients have mostly been 2017
conducted in countries with populations that have low purchasing power,
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where chronic otitis media is endemic, as in Brazil. The data are conflicting
and correlation still has not been proved, perhaps because of inadequate View The Digital
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Many patients suffer from otorrhea during the years after an initial episode
due to diseases that begin insidiously during childhood, such as secreting
otitis media or undiagnosed or poorly treated dysfunction of the auditory tube WEBINARS &
that evolves to chronic suppurative otitis media. The causes of sensorineural WHITEPAPERS
hearing loss are thought to relate to the toxicity of the infectious condition,
the associated inflammatory cytokines, or the local ototoxic drugs that are Salivary Endoscopy
usually used. Through the permeability of the oval and round windows, these Applications and Advanced
potential precipitating factors would compromise the ciliated cells of the Techniques
organ of Corti of the cochlea. 4,5
Optimizing Your Rooming
Studies have sought to correlate the sensorineural hearing thresholds of the Process to Generate
compromised ear with those of the contralateral ear without otorrhea. Many Ancillary Revenue
took into consideration the time involved, 5-8 and some considered the The Science of Biologic
causative disease and whether cholesteatoma was involved. 1,4,6 Among the Grafts in CSF Leak Repair
studies surveyed, only one was conducted in Brazil. 6 and Skull Base
Reconstruction
If sensorineural hearing loss really occurs and is related to the duration of
the otorrhea, diagnosing and treating it at an early stage might avoid the Smart Growth: Three Ways
need for hearing aids to complement hearing even after surgical cure of the
to Boost Your Ancillary
Revenue Generation
disease. 7,8
Modern Use of Biologic
The objective of this article is to evaluate whether a correlation exists Grafts in Endoscopic Ear
between the duration of otorrhea and sensorineural hearing loss and Surgery
whether the duration of the disease or its etiology interferes with this hearing
MORE WEBINARS AND
loss.
WHITEPAPERS

Patients and methods

This was a cross-sectional study. It was approved by the Research Ethics
Committee under the number 634.869 on April 30, 2014.

A total of 98 ears with chronic otorrhea and 60 ears with dry tympanic
perforation were evaluated. Data on the ears of patients with unilateral
chronic otorrhea (chronic suppurative otitis media for many years) obtained
from the digitized files of the Department of Otorhinolaryngology of an
academic institution in the municipality of São Paulo were selected, and the
hearing thresholds were evaluated using the frequencies of 500 Hz, 1 kHz, 2
kHz and 4 kHz in presurgical audiometry.

Only the sensorineural thresholds were considered; conductive losses

relating to lesions in the middle ear caused by the disease were not
included. These thresholds were subtracted from the respective thresholds
of the contralateral normal ears (taking the patient's otoscopic results and
history into account), with the aim of eliminating any other type of bilateral
compromise, such as presbycusis.

The same procedure was performed in patients who had had dry
perforations of the tympanic membrane for many years. In the case of
chronic otorrhea that for any reason had ceased for some time, as reported
by the patient, the lengths of time during which otorrhea was active were
added together. The correlation between patient age and hearing loss was
also evaluated, and the etiology of the otorrhea was considered (i.e.,
whether the suppuration was caused by cholesteatoma).

Inclusion criteria. Patients with unilateral suppurative otitis media for more
than 1 year and a contralateral normal ear, and patients with dry tympanic
perforation, were included. The evaluation was performed using digitized

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otoscopy and patient history.

Exclusion criterion. Patients with any other type of otologic compromise,

such as previous surgery, otologic or cephalic trauma, and exposure to
noise, were excluded.

Statistical analysis. The statistical analysis was performed by means of the

Statistical Package for the Social Sciences software (v. 13). We used the
Student t test for paired samples to analyze occurrences of otorrhea in
patients with one ear presenting suppuration and a normal contralateral ear.
We used the Student t test for independent samples to analyze
neurosensory loss in patients with otorrhea and in patients with dry
perforation of the tympanic membrane.

Because of nonparametric data, with the presence of outliers that distorted

the mean values of the sample, we applied the Kruskal-Wallis and
Mann-Whitney test to compare suppurated ears with and without
cholesteatoma. Lastly, we used Pearson correlation to analyze the length of
time with otorrhea and neurosensory loss.

Results
A total of 98 patients presenting with one ear with otorrhea and a
contralateral normal ear, and 60 patients in a control group with dry tympanic
perforation, were evaluated. Thus, 158 patients were evaluated. Among the
patients with otorrhea, 39 were <18 years old and 20 reported that their
symptoms had started during childhood but that they had only sought
medical care in adulthood. Therefore, 60.2% of the cases of chronic otorrhea
media had begun during childhood. The average age of patients with
otorrhea was 32.2 years (median: 26.5). The average duration of the
otorrhea was 11.6 years (median: 6.0 years).

Figure 1 shows a comparison of hearing loss between a dry ear and an ear
with otorrhea at the four prespecified frequencies in one of our patients. A
difference in sensorineural hearing loss between the normal and affected
ears was observed at all frequencies, with statistical significance using the
Student t test (p < 0.001).

Figure 1. Graph depicts hearing loss at four

frequencies in a patient's normal ear vs. the
ear with chronic otorrhea.

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A comparison between the ears of patients with dry tympanic perforations

and the ears of patients with chronic otorrhea appears in figure 2. A
difference in sensorineural hearing loss between ears with dry perforation
and ears with chronic otorrhea was again observed at all frequencies, with
statistical significance using the Student t test (p < 0.001).

Figure 2. Graph shows hearing loss vs.

frequencies in ears with perforation without
otorrhea and those with chronic otorrhea.

Figure 3 shows a comparison between suppurated ears without

cholesteatoma and suppurated ears with cholesteatoma. The Mann-Whitney
test revealed no difference in sensorineural hearing loss between those with
and without cholesteatoma in patients with chronic otorrhea.

Figure 3. Graph depicts hearing loss vs.

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frequencies in ears with suppurative chronic

otitis media with and without cholesteatoma.

The Pearson correlations between the duration of the otorrhea and the
sensorineural loss at each frequency appear in figure 4.

Figure 4. Plots show hearing loss at each

frequency vs. duration of otorrhea (PC =
Pearson correlation).

Discussion
The relationship between chronic otorrhea and sensorineural hearing loss is
controversial and is often studied in a poorly defined manner. Whether the
duration of the otorrhea interferes with hearing loss and its etiology and
whether the etiology derives from cholesteatoma to aggravate the
sensorineural loss has not been examined. 1-3

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In the present study, many patients (N = 98) were evaluated, first comparing
the chronic otorrhea ear with the normal contralateral ear, as most previous
authors have done, 4,5,9,10 and then examining the correlation between the
suppurated ears of these patients with 60 ears of patients with dry
membrane perforation. The duration of the otorrhea was also taken into
consideration in addition to whether it was continuous. If it was not
continuous, we summed the lengths of time for which this symptom was
present (suppurative chronic otitis media). To remove possible bilateral
sensorineural losses among older patients with presbycusis, the values of
the respective contralateral ears were subtracted from the values at each
frequency in the affected ears, thus defining the real loss value.

In figure 1, a threshold of approximately 15 dB can be seen in the normal

ears, compared with a hearing loss of 40 dB in the suppurated ears. At the
frequencies evaluated, there was no progressive loss in the higher pitches,
which would have been expected if this loss had been due to continuity of
the infected middle ear through the oval and round windows with the base of
the cochlea, where these sounds are processed.

Figure 2 shows a comparison between the suppurated ears and the dry
perforated ears of other patients. The average threshold of the dry ears was
practically 0 dB, compared with 40 dB in the suppurated ears. Thus, ears
with dry perforations and sporadic otorrhea did not interfere with the
sensorineural thresholds.

As seen in figure 3, no correlation was observed between the etiology of the

suppuration (i.e., whether caused by cholesteatoma) and the sensorineural
hearing loss. 6 Thus, the loss was evidently caused by the suppuration itself,
without interference from any other factor present in the cholesteatoma.

The images in figure 4 show that the duration of the otorrhea did not
influence the increase in sensorineural hearing loss. These losses occur
during the first years of the disease and last throughout the patients' lives.
This finding was unexpected because the duration of the disease should
interfere with the hearing loss. Perhaps the duration of the chronic
inflammatory process somehow protects the oval and round windows from
possible contamination of the inner ear.

Over the duration of the otorrhea, treatment with ear drops generally
containing ototoxic antibiotics is often instituted. Thus, it was possible to
confirm that chronic otorrhea gives rise to sensorineural hearing loss but not
that the cause was the infectious process itself (rather than indiscriminate
use of ear drops for long periods of time).

These diseases begin insidiously during childhood because of tube

problems consequent to rhinitis, sinusitis, or hypertrophy of the tonsils and
adenoids, thereby leading to secretory otitis, aspirations, and tympanic
perforations. Early treatment of the disease or its causes may avoid not only
the inherent conductive loss, for which surgical treatment is sometimes only
partially successful, but also the irreversible sensorineural hearing loss
deficiency. Thus, otorrhea of the middle ear gives rise to neurosensory
auditory deficiency that is processed equally at all frequencies but does not
worsen with increasing length or evolution of the disease.

In our sample, we found no evidence to show that cholesteatoma influences

hearing loss. We also demonstrated that dry perforation does not cause
neurosensory loss. Most of the patients with chronic infection start to show
symptoms during childhood. 9

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loss in chronic suppurative otitis media with and without cholesteatoma.
Braz J Otorhinolaryngol 2007; 73 (5): 671-4.
7. Kolo ES, Salisu AD, Yaro AM, Nwaorgu OG. Sensorineural hearing loss
in patients with chronic suppurative otitis media. Indian J Otolaryngol
Head Neck Surg 2012; 64 (1): 59-62.
8. Noordzij JP, Dodson EE, Ruth RA, et al. Chronic otitis media and
sensorineural hearing loss: Is there a clinically significant relation? Am J
Otol 1995; 16 (4): 420-3.
9. Yehudai N, Most T, Luntz M. Risk factors for sensorineural hearing loss
in pediatric chronic otitis media. Int J Pediatr Otorhinolaryngol 2015; 79
(1): 26-30
10. Luntz M, Yehudai N, Haifler M, et al. Risk factors for sensorineural
hearing loss in chronic otitis media. Acta Otolaryngol 2013; 133 (11):
1173-80.

From the Department of Otorhinolaryngology of Santa Casa de Sao Paulo

School of Medical Sciences (Dr. Gonçalves, Dr. Tamaoki, Dr. Mitre, and Dr.
Ribeiro); student (Miss Dobrianskyj).

Corresponding autor: Dr. Fernando Ribeiro, MD, Santa Casa de Sao Paulo
School of Medical Sciences, São Paulo, Brazil. Rua Itapeva 366 cj 74, CEP
01332-000 - São Paulo, Brazil. Email: quintanilha.f@uol.com.br

Ear Nose Throat J. 2017 October-November;96(10-11):E43

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