Abstract
A type-I hypersensitivity reaction of the nasal mucosa, allergic rhinitis (AR) is distinguished by nasal obstruction, watery rhinorrhea, sneezing, and throat, mouth, and nose irritation. It is assumed that allergies can affect the inner, middle, or outer ear. Many writers have studied the relationship between allergic rhinitis and otitis media. Most of them concur that bacterial infection and Eustachian tube obstruction are significant risk factors for the development of otitis media with effusion in addition to allergies. One hundred study participants had a full clinical evaluation that included an ENT history and examination. In the ENT OPD, the audiological examination was conducted using Pure Tone Audiometry (PTA) and Impedance Audiometry (IA). At frequencies of 250 and 8000 Hz, respectively, the bone and air conduction thresholds were studied. The commercially available “AT235 INTERACOUSTICS” tympanometer was used for the tympanometry procedure. With pressure variations between + 200 and − 300daPa, tympanometry was carried out employing a 226 Hz probe tone. Mean age of study population was 52.16 and 24% each in age group 51 to 60 and 61 to 70 years respectively. 73 (73%) were male and 27 (27%) were female. 46% of allergic rhinitis study population was found to have normal hearing and 43% had mild conductive hearing loss. Most common type of impedance curve was A type (47%). Patients having acute phase of allergy with symptoms less than 3 months had more ear block and secretory otitis media. Patients with duration more than 3 months had resolved secretory otitis media hence the hearing was normal in 33 cases and 11 had mild conductive hearing loss. This study was concluded that there is correlation between the severity of the hearing loss and duration of allergic rhinitis.
Keywords: Pure Tone Audiometry, Tympanogram, Eustachian Tube, Hypersensitivity
Introduction
A severe public health problem, allergic rhinitis affects between 0.8 and 39.7% of persons worldwide [1]. The type-I hypersensitivity reaction of the nasal mucosa known as allergy rhinitis has a complex aetiology and is predominantly mediated by immunoglobulin E (IgE) [1]. Allergies are thought to be able to impact the inner, middle, or outer ear. The four stages of this reaction include sensitization to allergen, early phase allergen reactivity, late phase reaction, and systemic activation. There are numerous proven ways that AR harms the middle ear, which results in conductive hearing loss. The complicated etiopathogenesis of allergic rhinitis involves many different factors, all of which interact to cause the identifiable symptoms of allergic rhinitis and non-specific hyperactivity [2]. These factors include cells, mediators, cytokines, chemokines, neuropeptides, and adhesion molecules [3].
Hearing impairments may worsen if nasal symptoms including itching, sneezing, rhinorrhea, and congestion are not properly managed. Even minor seasonal AR might cause hearing loss. Conduction hearing loss may result from severe rhinitis that is accompanied by side symptoms such sinusitis or eustachian tube dysfunction [4]. The author of the study made a clinical diagnosis of allergic rhinitis based on the presence of at least two nasal symptoms, such as frequent sneezing, watery nasal discharge, nasal obstruction, nasal itching, and conjunctivitis lasting more than a week without fever [5]. Nasal inflammation brought on by allergic reactions and viral upper respiratory infections causes eustachian tube dysfunction and reduced breathing. Tympanic membrane retraction and conductive hearing loss are the results of this [6].
The scientific basis for allergic rhinitis’ potential impact on the inner ear is unknown. The endolymphatic sac and duct appear to be the locus of immuno-activity in the inner ear, where both cellular and humoral immunity have been seen [7]. The objective of the current study is to assess patients with allergic rhinitis’ hearing status.
Materials and Methodology
Study Design
The research was a prospective observational study carried out in the department of otorhinolaryngology at the tertiary care hospital, Chettinad Academy of Research and Education (Chettinad Hospital and Research Institute), in the Chengalpet neighbourhood.
Study Duration
One year.
Sample Size Calculation
Considering 30% prevalence of allergic rhinitis, 80% power and 10% allowable error sample size was rounded off to 100 with 10% non-response rate.
Subject Selection
The study participants with allergic rhinitis were selected from out-patient department of ENT of a Tertiary Care Hospital in Chengalpattu district.
Inclusion Criteria
Patients above the age of 18.
Both sexes.
Patients who experienced nasal obstruction, runny nose, frequent sneezing, or watery eyes.
Exclusion Criteria
Those suffering from febrile illness.
A history of ear discharge, anomalies of the face, and a perforated tympanic membrane.
A history of auditory injury following the use of ototoxic drugs or exposure to noise.
A history of long-term metabolic illnesses, such as chronic kidney disease, hypertension, and diabetes mellitus.
Method
A total of 100 participants in the study got a thorough clinical evaluation, which included an ENT history and examination. Patients’ names, ages, major complaints, histories of nasal obstruction, nasal discharge, frequent episodes of sneezing, wet eyes, known allergies, histories of ear obstruction, tinnitus, hearing loss, and pertinent family histories were all noted. The exterior anatomy of the nose, nasal cavity, and septum were thoroughly examined. The nasal cavity was inspected for nasal discharge, mucosal colour, inferior turbinate hypertrophy, post nasal area, and paranasal sinuses. Along with this, we also examined the larynx, oropharynx, oral cavity, and ears. Endoscopic assessment of the ear and nose was done after that.
The patient’s hearing was assessed using Pure Tone Audiometry (PTA) and Impedance Audiometry (IA) in the soundproof room of the ENT OPD. At frequencies of 250 and 8000 Hz, respectively, the thresholds of bone conduction and air conduction were studied. “Hearing loss” is defined as a hearing threshold greater than 25 dB. The “AT235 INTERACOUSTICS” tympanometer, which is available for purchase, was used to perform tympanometry. A 226 Hz probe tone with pressure ranges of + 200 and − 300daPa was used for tympanometry.
Statistical Analysis
An Excel spreadsheet was created and filled with the collected data. For categorical variables, percentage was utilised; for continuous variables, mean and standard deviation were computed. To ascertain whether categorical variables were related, chi square analysis was utilised. The SPSS application version 21 was used; a p value of 0.05 was considered significant.
Ethical Consideration
Before the study began, it received approval from the institution’s ethical review board. In all stages of the study, the participants’ privacy was preserved.
Results
Mean age of study population was 52.16 and 24% each in age group 51 to 60 and 61 to 70 years respectively. Majority of the study participants were males (74%), 44% of the study population presented with allergic symptoms with symptoms of nose and ear (Table 1). There was no difference in the number of patients who had symptoms for more than three months and less than three months. The results of PTA revealed that 47% (N = 47) of patients with allergic rhinitis had normal hearing and 42% (N = 42) had mild hearing loss. None of them had severe or profound hearing loss. Most common type of impedance curve was found to be of A type (47%, M = 47) (Table 2). When the Chi Square test was applied to the PTA data, it was discovered that hearing loss was correlated with age (p = 0.028), the severity of AR symptoms (p = 0.001), and the length of sickness (p = 0.001) (Table 3). Additionally, impedance was substantially correlated with symptom severity (p = 0.031) and illness durations (p = 0.001), indicating that allergic rhinitis is significantly linked to hearing loss and changes in middle ear pressure (Table 4).
Table 1.
Study population characteristics (N = 100)
| Characteristics | N/% |
|---|---|
| Mean age (SD) | 52.6 ± 15.875 |
| Age | |
| 21 to 30 | 13 |
| 31 to 40 | 16 |
| 41 to 50 | 11 |
| 51 to 60 | 24 |
| 61 to 70 | 24 |
| 71 to 80 | 12 |
| Gender | |
| Male | 73 |
| Female | 27 |
| Complaints | |
| Allergic symptoms | 16 |
| Allergic symptoms and Nasal block | 40 |
| Allergic symptoms, Nasal block and Ear Symptoms | 44 |
| Duration | |
| < 3 months | 51 |
| ≥ 3 months | 49 |
Table 2.
Audiological profile in study population (N = 100)
| Characteristics | N/% |
|---|---|
| PTA * | |
| Normal | 46 |
| Mild CHL** | 43 |
| Moderate CHL** | 2 |
| Moderately Severe CHL** | 9 |
| Impedence audiometry | |
| A type | 47 |
| B type | 42 |
| C type | 11 |
*PTA – Pure Tone Audiometry, **CHL – Conductive Hearing Loss
Table 3.
Association between characteristics of the study population and PTA (N = 100)
| PTA Inference | χ2 | P value | |||||
|---|---|---|---|---|---|---|---|
| Normal hearing | Mild CHL | Moderate CHL | Moderately Severe CHL | ||||
| Age | |||||||
| 21 to 30 | 7 | 3 | 2 | 1 | 27.060 | 0.028 | |
| 31 to 40 | 9 | 5 | 0 | 2 | |||
| 41 to 50 | 8 | 3 | 0 | 0 | |||
| 51 to 60 | 12 | 9 | 0 | 3 | |||
| 61 to 70 | 8 | 14 | 0 | 2 | |||
| 71 to 80 | 2 | 9 | 0 | 1 | |||
| Gender | |||||||
| Male | 15 | 8 | 0 | 4 | 4.401 | 0.221 | |
| Female | 31 | 35 | 2 | 5 | |||
| Complaints | |||||||
| Allergic symptoms | 13 | 3 | 0 | 0 | 23.260 | 0.001 | |
| Allergic symptoms and Nasal block | 18 | 22 | 0 | 0 | |||
| Allergic symptoms, Nasal block and Ear Symptoms | 15 | 18 | 2 | 9 | |||
| Duration | |||||||
| < 3 months | 13 | 32 | 1 | 5 | 19.030 | 0.001 | |
| ≥ 3 months | 33 | 11 | 1 | 4 | |||
Table 4.
Association between characteristics of the study population and Impedance audiometry (N = 100)
| Impedance | χ2 | P value | |||
|---|---|---|---|---|---|
| A type | B type | C type | |||
| Age | |||||
| 21 to 30 | 6 | 4 | 3 | 11.540 | 0.317 |
| 31 to 40 | 8 | 7 | 1 | ||
| 41 to 50 | 7 | 3 | 1 | ||
| 51 to 60 | 14 | 8 | 2 | ||
| 61 to 70 | 9 | 14 | 1 | ||
| 71 to 80 | 3 | 6 | 3 | ||
| Gender | |||||
| Male | 34 | 29 | 10 | 2.133 | 0.344 |
| Female | 13 | 13 | 1 | ||
| Complaints | |||||
| Allergic symptoms | 13 | 1 | 2 | 10.654 | 0.031 |
| Allergic symptoms and Nasal block | 16 | 20 | 4 | ||
| Allergic symptoms, Nasal block and Ear Symptoms | 18 | 21 | 5 | ||
| Duration | |||||
| < 3 months | 15 | 31 | 5 | 15.730 | 0.001 |
| ≥ 3 months | 32 | 11 | 6 | ||
Discussion
One of the most common diagnoses made by otolaryngologists in rhinology clinics is allergic rhinitis. It is the most typical kind of rhinitis, affecting 20% of people worldwide.2 Otitis media, eustachian tube dysfunction, hearing loss, tinnitus, meniere’s disease, sinusitis, nasal polyps, allergic conjunctivitis, and atopic dermatitis have all been linked to allergy rhinitis. It may also contribute to fatigue, sleep issues, and difficulty learning [8, 9].
Poor pure-tone thresholds, especially at higher frequencies, abnormal DPOAE, abnormalities on ABR, and the absence of middle ear pathology (‘’A’’ type tympanogram), all clearly indicate the presence of cochlear involvement, which can be attributed to allergens that may have spread to the cochlea, according to Akriti Mahajan et al.‘s findings in a 2021 study of audiological evaluation in 100 patients [1]. The findings of the PTA are related to the severity of allergic rhinitis, claims the current study.
In a study that was published in 2020, Dimple Sahni and colleagues studied the hearing of 100 people who had allergic rhinitis and discovered that these patients had greater prevalence of high frequency sensorineural hearing loss and abnormal variations of OAEs [2]. The study’s participants were all affected with conductive hearing loss.
According to Sanjeev Kumar et al. (2018), who examined the otological and audiological conditions of 70 patients with allergic rhinitis, the condition of the eustachian tubes is negatively impacted by allergic rhinitis, whether it be seasonal or persistent, and it may increase the risk of middle ear effusion and otitis media. Certain middle ear diseases can be avoided by accurately detecting and treating allergic rhinitis [3].
In a 2019 study, Vikas Mysore Dwarakanath et al. randomly assigned 15 patients with allergic rhinitis and 15 healthy controls to do a battery of audiological tests and have their Eustachian tube performance assessed. They discovered that patients with AR have a higher prevalence of sensorineural hearing loss [4].
In their assessment of 30 allergic rhinitis patients and 20 controls in 2011, Satbir Singh et al.‘s audiological examination revealed that allergic rhinitis patients had a higher prevalence of hearing loss and aberrant otoacoustic emission than controls. Although the endolymphatic sac can degrade antigens and generate its own local antibody response, the inflammatory mediators and toxic byproducts that follow may have an impact on hair cell activity [10].
The current study involved 100 patients with allergic rhinitis. 46% of those with allergic rhinitis in the study population had normal hearing, whereas 43% had a mild conductive hearing loss. The majority (47%) of impedance curves were of type A. A greater frequency of secretory otitis media and ear block was seen in patients with acute allergy symptoms lasting less than three months. Thirty-three cases of patients with otitis media lasting longer than three months had cases that were resolved; as a result, 11 cases had mild conductive hearing loss, while 33 cases had normal hearing.
Conclusion
Whether it is seasonal or persistent, allergic rhinitis impairs eustachian tube function, which may raise the risk of middle ear effusion and otitis media. The key to preventing these middle ear illnesses is the accurate diagnosis and management of allergic rhinitis.
According to the current study, conductive hearing loss and allergic rhinitis are related. Hearing loss is associated with nasal symptoms and how long allergic rhinitis lasts.
Limitation and Recommendations
The current study did not evaluate the relationship between sensorineural type of hearing loss and allergic rhinitis. Future studies should be directing to the relationship of sensorineural hearing loss and allergic rhinitis. The exact mechanism for sensorineural hearing loss should be evaluated.
Declarations
Confict of interest
The authors declare that they have no confict of interest.
Ethics approval and consent to participate
The approval for the study was obtained from the Human ethical committee of the Chettinad University, Chennai.
Informed Consent
Written and informed consent was taken from all patient for participation in the study. Confdentiality of patients maintained.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.Mahajan A, Manhas M, Kalsotra P, Kalsotra G, Gul N A prospective study of audiological manifestations in patients of allergic Rhinitis. Indian J Otolaryngol Head Neck Surg 2021 Jan 7:1–6 [DOI] [PMC free article] [PubMed]
- 2.Sahni D, Verma P, Bhagat S, Sharma V Hearing Assessment in patients of allergic rhinitis: a study on 200 subjects. Indian J Otolaryngol Head Neck Surg 2020 Jun 15:1–7 [DOI] [PMC free article] [PubMed]
- 3.Kumar S, Singh HP, Kumar S, Verma V, Mishra A (2018 Jul) Assessment of otological and audiological status in patients of allergic rhinitis. Int J Otorhinolaryngol Head Neck Surg 4(4):956–960
- 4.Dwarakanath VM, Shambhu T, Jayanna VJ Assessment of hearing in individuals with allergic rhinitis. Indian Journal of Otology. 2019 Jul 1;25(3):117 – 20
- 5.Bousquet J. Allergy and asthma: from the bedside to the bench and international actions. Pol Arch Med Wewn. 2008;118:363–366. [PubMed] [Google Scholar]
- 6.Fireman P. Allergy and immunology. Annal Otol RhinolLaryngol. 1988;97(4):42–49. [Google Scholar]
- 7.Altermatt HJ, Gebbers JO, Mullar C. Human endolymphatic sac: evidence for a role in inner ear immune defense. ORL J OtorhinolaryngolRelat Spec. 1990;52:143–148. doi: 10.1159/000276124. [DOI] [PubMed] [Google Scholar]
- 8.Fireman P. Otitis media and eustachian tube dysfunction: connection to allergic rhinitis. J Allergy Clin Immunol. 1997;99(2):S787–S79716. doi: 10.1016/S0091-6749(97)70130-1. [DOI] [PubMed] [Google Scholar]
- 9.McColley SA, Carroll JL, Curtis S, Loughlin GM, Sampson HA. High prevalence of allergic sensitization in children with habitual snoring and obstructive sleep apnea. Chest. 1997;111(1):170–173. doi: 10.1378/chest.111.1.170. [DOI] [PubMed] [Google Scholar]
- 10.Singh S, Nagarkar AN, Bansal S, Vir D, Gupta AK. Audiological manifestations of allergic rhinitis. J Laryngol Otol. 2011;125:906–910. doi: 10.1017/S0022215111001137. [DOI] [PubMed] [Google Scholar]