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. 2024 Aug 3;11(5):1085–1099. doi: 10.1007/s40744-024-00701-1

Ear Complaints in Fibromyalgia: A Narrative Review

Thelma Larocca Skare 1, Jozélio Freire de Carvalho 2,
PMCID: PMC11422319  PMID: 39096417

Abstract

Introduction

Patients with fibromyalgia (FM) have innumerable complaints due to the central amplification of somatic stimuli. The aim of this paper was to review the ear complaints in patients with FM.

Methods

A review of articles published in PubMed/MEDLINE, Embase, Web of Science, and Scopus from 1966 to June 2023 was performed.

Results

Seventeen papers were included in the review. They showed that patients with FM have a higher hearing loss rate, mostly at high frequencies, and hyperacusis. The prevalence of vestibular symptoms (tinnitus, dizziness) and hyperacusis was higher than in the general population, reaching 87.0% of the sample. Subjective findings did not always correspond to objective results. In some studies, the degree of FM severity was associated with ear symptoms; in others, it was not.

Conclusions

Ear complaints in patients with FM are linked to subjacent disease and may be related to stimuli central amplification.

Keyword: Hearing loss, Hyperacusis, Tinnitus, Dizziness, Fibromyalgia

Key Summary Points

Ear complaints are part of spectrum of symptoms in fibromyalgia (FM).
This article reviewed ear complaints in FM and observed that hyperacusis and a high hearing loss rate are frequent in FM.
The prevalence of vestibular symptoms (87.0%) (tinnitus, dizziness) was higher than in the general population.

Introduction

Fibromyalgia (FM) is a complex and poorly understood syndrome that affects from 0.4% to 8.8% of the general population, with an estimated mean prevalence of 2.7% [1]. It affects mainly women, and the most common symptom is generalized and chronic musculoskeletal pain [1, 2]. Although the pathophysiological mechanisms of this disease are unknown, it is considered that altered central sensitization plays a vital role as well as genetic predisposition and influence of traumatic life events [1].

Generalized pain is the most prominent clinical finding, but many other symptoms, such as fatigue, sleep disturbance, cognitive impairment, and mood disorders, may be seen. Among them, ear involvement may be found [3]. Rosenhall et al. [3] observed abnormal brainstem responses, altered oculomotor tests, and sensorineural hearing loss (SNHL) in these patients. Others found that patients with FM may have greater sensitivity to auditory stimuli when compared to healthy individuals [4, 5]. Tinnitus and other vestibular symptoms, such as vertigo and imbalance, are also part of patients’ complaints [2].

This paper summarizes the primary literature findings on ear involvement (audiologic and vestibular) in patients with FM as well as epidemiological and clinical factors that may influence their prevalence.

Methods

Articles published in PubMed/Medline, Embase, Web of Science, and Scopus from 1966 to June 2023 were located using the following MeSH terms: “ear” OR “hearing” OR “vestibular” and “fibromyalgia”. The search had no language restriction and was performed by both authors. The reference lists of the selected articles were examined to identify other potentially relevant publications.

To be included articles should study vestibular and cochlear function in adult patients of both sex with FM. Articles studying patients with secondary FM, reviews, meta-analyses, and opinion papers were excluded.

A standardized form to extract the data from relevant articles was designed, including authors, year of publication, number of patients studied, demographic data, disease duration, study aims, instruments used to evaluate ear involvement, and study outcomes (prevalence of auditory and vestibular symptoms and tests abnormalities in patients with FM or in patients with FM in comparison with controls, and influence of associated factors/drugs).

This article is based on previously conducted studies and does not contain any new studies with human participants or animals performed by any of the authors.

Results

The review included 17 papers: nine case–control studies, five cross-sectional studies, two retrospective, and one prospective. The main findings are in Table 1. A total of 222,341 individuals were studied in these papers (of whom 58,496 had FM). Patients age varied from 21.0 to 73.0 years old [3]. The female sex predominated (52.8–100%) with 10 papers studying only women [4, 7, 9, 11, 13, 1517, 19, 20].

Table 1.

Review of articles in ear involvement in fibromyalgia

Author/year Study Objectives Numbers Sex Disease duration Age Methods Results
Rosenhall et al., 1996 [3] Case–control To report audiological and otoneurological tests in FM

FM 168

Controls 124

83.9% female NA Range 21–73 yo

ABR

Oculomotor tests

ENG

72.0% had dizziness or vertigo

2.0% gait disturbance without dizziness/vertigo

51.0% of patients with FM had abnormal ABR

58.0% with deviant smooth pursuits (24% severely abnormal)

18.0% with abnormal saccades

45.0% had abnormal ENG

Carrillo-de-la-Peña et al., 2006 [5] Case–control To see if auditory patterns in FM suggest hypervigilance to stimulation

FM 27

Controls 25

100% female Mean pain duration 73 months Mean 48.8 yo

Pain threshold

Auditory evoked potentials

EEG

FM with shorter AEP latencies than controls

Stronger increment in N1-P2 amplitude with increasing stimuli in FM

At 105 dB, 84.0% of controls showed reduced N1-P2 amplitude vs. 52.0% of the FM group

Geisser et al., 2008 [6] Case–control To see if patients with FM are more sensitive to pressure and auditory tones than controls

FM 30

Controls 28

93.3% female NA Mean 42.1 yo

Otoscopic examination

PTA

Hyperacusis questionnaire

Pressure pain sensitivity with GBS

Auditory stimulation using LDLs at 2000 Hz

Mean pressure required to evoke pain was lower in FM than in controls

FM displayed greater sensitivity to auditory stimuli than controls

Positive correlation between auditory and pressure stimulation in FM

Zeigelboim et al., 2011 [7] Cross-sectional To study vestibular function in FM FM 25 100% female NA Mean 52.2 yo

History and physical exam

Vestibular tests, including vector electronystagmography

Symptoms

 Dizziness 84.0%

 Headache 76.0%

 Imbalance 12.0%

 Tinnitus 44.0%

Peripheral vestibular dysfunction 48% (irritative dysfunction 16.0% and deficit dysfunction in 36.0%)

Patients with imbalance and tinnitus had more vestibular dysfunction

Wolfe et al., 2012 [8] cross-sectional To see if both symptoms associated with sensory input and not associated are increased in FM and compare with other rheumatic diseases

FM 1199

RA 8533

OA 1556

Female

 FM 95.8%

 RA 80.6%

 OA 81.4%

NA

Mean

 FM 57.8 yo

 RA 62.3 yo

 OA 66.5 yo

US NDB for Rheumatic Diseases

Mailed questionnaires

3 questions

 With sensory input

  Hearing difficulties

 Without sensory input

  Easy bruising

  Hair loss

Degree of fibromyalgianess

(WPI + SSS)

Complaints of hearing difficulties: 36.2% FM 21.4% RA 24.1% in OA

Question with and without sensory input—↑in FM

Increase in 1 unit of fibromyalgianess ↑hearing difficulties by 7.0%

Iikuni et al., 2013 [9] Cross-sectional To clarify the pathogenesis of ear-related symptoms in FM FM 20 100% female Mean 45.7 yo

PTA

Eustachian tube function test

Tympanogram

Questionnaire of symptoms

Symptoms

 80.0% ear fullness

 77.5% tinnitus

 40.0% earache

Comparison of % of symptoms pre- and post- FM onset—↑ after FM diagnosis

No association between the presence of symptoms and abnormal findings at the neurotological exam

Stranden et al., 2016 [10] Retrospective Prevalence of subjective HL in individuals with WMP

FM  1483

WMP without FM 18,808

Reference 24,203

FM 85.9% female

WMP without FM 52.8% female

Reference 49% of women

NA Mean 50.2 yo

Data on HUNT2

Data on HL

Audiometry (the threshold for air conduction)

Questionnaire HADS

Results were adjusted for hearing threshold, anxiety, and depression

 21.9% of women with FM had subjective HL vs. 6.7% without FM

 33.1% of men with FM had subjective HL vs. 10.8% without FM

 FM group reported HL 5.1× (female) and 4.3× (male) more frequently than the reference group

 WMP group reported HL 3.1× (female) and 3.7× (male) more frequently than the reference

Kapusuz-Gencer et al., 2017 [11] Case–control To evaluate hearing status in FM

FM 35

Controls 25

100% female NA Mean 48.1 yo

PTA

Speech audiometry

Impedance

At low frequencies → FM = controls

At high frequencies air–bone conduction is lower in FM than in controls

Speech discrimination ↓ in FM

Koca et al., 2018 [12] Case–control Association of oxidative stress in patients with FM with audiological complaints

FM 44

Controls 44

95.4% female NA Mean 42.1 yo

Serum MPO and SOD

Serum GPx, NO

Serum MDA

FIQ and VAS of FM symptoms severity

Questionnaire on audiological complaints

PTA

Speech audiometry

Tympanogram

Stapedial acoustical reflex

Tubal residual function tests

DHI

Vertigo, tinnitus, hearing, and balance complaints were ↑ in FM

FM frequency symptoms

 Tinnitus 27.2%

 Vertigo 29.5%

 Balance problems 13.6%

 HL 13.6%

No ≠ in the presence of stabilo-acoustic reflex, intra-aural pressure, and compliance in the 2 groups

DHI was ↑ in FM

GPx, NO, and MDA ↑ in FM

SOD correlated with balance complaints

No lab results associated with FIQ and VAS

HL in FM (mainly at high frequency)

No differences in stabilo-acoustic reflex, intra-aural pressure, and compliance

Tympanograms were normal

Cil et al., 2020 [13] Prospective

Prevalence of tinnitus

Effect of drugs used for FM treatment on tinnitus

01 (FM newly diagnosed) 100% female NA Mean 51.2 yo

Audiological tests

THQ before and 2 months after treatment (duloxetine or pregabalin)

No significant HL

74.3% had tinnitus

Median degree of tinnitus ↓ with treatment

No differences between pregabalin and duloxetine treatment

Le et al., 2020 [14] Retrospective

To see if patients with FM have ↑risk of HL

To explore the relation of FM HL with comorbidities/drugs

To see the incidence rate of different types of HL in FM

FM 55,169

Controls 110,338

59.4% female NA Mainly 40.0–59.0 yo

Analysis of database- 2000 from Taiwan’s NHI system

(medical reimbursement claims)

Risk of HL in FM = 1.4× higher than controls

Patients with FM had greater SNHL

FM diabetes, dyslipidemia depression, and Meniere—↑ HL

Individuals using antidepressants and pain-relieving drugs—↑ the risk of HL

Samartin-Veiga et al., 2020 [15] Case–control To study auditory event-related potentials to stimuli of different intensities in FM considering attention mechanism and medication

Study 1

 FM 50

Controls 60

Study 2

 FM 28

 HC 30

100% female NA

Study 1

 Mean 45 yo

Study 2

 Mean 50.3 yo

Auditory event-related potentials to stimuli of several intensities:

Study 1

 Stimuli were presented randomly within the sequence

Study 2

 Stimuli were presented in blocks of the same intensity

 Analysis of Intensity of N1-P2 effect

Patients with FM tended to reduce AEP to the loudest sounds

Medication with central effect ↓ AEPs

No relationship was found between N1-P2 amplitude/intensity function and patients' symptoms

Tuncer et al., 2021 [16] Case–control To analyze the audiovestibular functions in FM

FM 33

Controls 33

100% female 4.7 yo Mean 47.0 yo

PTA

Acoustic impedancemetry

Multifrequency tympanometry

TEOAEs

oVEMP

cVEMP

PTA hearing thresholds in FM were significantly higher than in controls

Resonance frequencies were decreased in FM about controls

Signal-to-noise ratio was more ↑FM than controls

Presence of oVEMP and cVEMP were ↓ in FM to controls

Mohamed et al., 2021 [17] Cross-sectional To assess peripheral vestibular function in FM

FM 15

Controls 15

100% female NA Range 22.0–50.0 yo

PTA

Bedside tests

VNG

No differences in bedside tests or VNG in the two groups

There was a tendency for ↑ vestibular weakness in FM

Chung et al., 2021 [18] Case–control To see the influence of tinnitus in patients with FM QoL

FM with tinnitus 22

FM without tinnitus 25

93.6% female Mean 53.8 yo

THQ

FIQ

SF-36

ISI

WPI and SSS

VAS pain

No demographic differences between groups

VAS pain, WPI, → no differences between groups

SSS → higher in the group with tinnitus

ISI, SF-36 → no differences in the two groups

FM with severe tinnitus → worse FIQ, SF-36, and used more medication than those with mild

Intensity of tinnitus was not associated with WPI, SSS, or ISI

Staud et al., 2021 [19] Case–control To demonstrate hypersensitivity to stimuli (acoustic) other than pain in FM

FM 23

Controls 28

100% female NA Mean 46.2 yo

VAS pain, anxiety, and depression

Electronic VAS (pain)

The auditory threshold for air conduction

Loudness sensitivity test

Multiple random staircase method

Mechanical and heat pain sensitivity tests

MCV Pain questionnaire

CES-D questionnaire

PCS questionnaire

STAI questionnaire

Pain catastrophizing scale

2011 FM Criteria Scales

Quantitative sensory testing showed ↑ heat and mechanical pain sensitivity in FM

Sound pressures needed to report mild, moderate, and intense sound levels were↓ in FM than controls

No correlation of auditory sensitivity with clinical data, mechanical or heat pain

CES-D correlated with sound pressure for high-intensity stimuli

STAI correlated with sound pressure for moderate and high pressures used for moderate and high-intensity stimuli

Bayazit et al., 2022 [20] Cross-sectional To study otologic symptoms and vestibular findings in FM FM 24 100% female NA Mean 30.6 yo

History and physical exam

Audiometry

Bithermal caloric testing

ABR

50.0% of sample had some complaints

20.8% positional rotatory vertigo

95.8% normal audiograms

100% normal bithermal caloric test

ABR results of the patients with and without symptoms were the same

NA not available, US NDB  American National Data Bank for Rheumatic Diseases, HUTN2  The Nord-Trøndelag Health Study part 2, FM fibromyalgia, LDLs Loudness Discomfort Levels, THI tinnitus handicap questionnaire, SF-36 short-form health survey, FIQ fibromyalgia impact questionnaire, ISI insomnia severity index, ABR auditory brainstem response, AEP auditory-evoked potentials, EEG electroencephalography, WPI widespread pain index, SSS + symptom severity score, QoL quality of life, WMP widespread musculoskeletal pain, HADS Hospital anxiety and depression scale, oVEMP ocular vestibular-evoked myogenic potentials, cVEMP cervical vestibular evoked myogenic potentials, TEOAEs transient evoked otoacoustic emissions, Taiwan NHIR database Taiwan’s National Health Insurance Research Database, MCV pain questionnaire Medical College of Virginia Pain questionnaire, CES-D Center for Epidemiological Studies- Depression, GBS Gracely box scale, ENG electronystagmography, PTA pure tone audiometry, DHI dizziness handicap inventory, MCV Medical College of Virginia pain questionnaire, PCS pain coping strategies, STAI Spielberger’s state/trait anxiety inventory, yo years old, MPO myeloperoxidase, SOD superoxide dismutase, GPx glutathione peroxidase, NO nitric oxide, MDA serum malondialdehyde, VNG video nystagmography

The auditory function was studied in six papers [3, 11, 13, 14, 16, 20] and found to be compromised in four of them, while two studies [13, 20] failed to find any disturbance; two other papers registered subjective hearing loss [7, 8].

Hyperacusis was found in four papers [4, 6, 8, 19]. In one of them, it was related to mood disorders [19], but Samartin-Veiga et al. [15] found that patients with FM tended to present reduced auditory-evoked potentials (AEPs) to the loudest sounds. Wolfe et al. [8] associated the complaint of HL with the degree of fibromyalgianess (i.e., the sum of the score of widespread muscular pain or WMP and symptoms severity scale or SSS from the 2010 Fibromyalgia Classification Criteria).

Tinnitus and dizziness/vertigo were registered frequently [3, 7, 9, 12, 17, 20]. The frequency of tinnitus went from 27.2% [12] to 77.5% [9], and Chung et al. [18] found that patients with severe tinnitus had worse quality of life and used more medications. Dizziness/vertigo was present in 20.8% [20] to 84.0% [7] of the studied sample. Zeigelboim et al. [7] found objective vestibular dysfunction in 48.0% of examined individuals, while others [20] failed to document it.

Koca et al. studied audiological complaints concerning oxidative stress. Two antioxidant compounds (superoxide dismutase [SOD] and glutathione peroxidase [GPx]) and three oxidants (myeloperoxidase [MPO], malondialdehyde [MDA], and nitric oxide [NO]) were studied. One antioxidant (GPx) and two oxidants (MDA and NO) were higher in patients with FM, but only SOD correlated with imbalance problems (r = 0.49) [12].

Discussion

FM is a syndrome in which central dysregulation of the central nervous system leads to a reduced threshold to pain and several other stimuli [1]. Ear symptoms (audiological and vestibular-related) reflect this increase in sensitivity. Usually, patients with FM describe more symptoms, distress, and suffering than those with other rheumatic diseases [8].

In the study by Beyazıt et al. [20], 50.0% of the sample with FM had ear complaints, with 12.5% complaining of HL. Still, only one (1/24) had objective audiological findings showing that central sensitization may also play a role in ear symptoms. Hyperacusis and tinnitus are considered to be symptoms that reflect central stimuli augmentation [8, 13]: tinnitus is a phantom buzzing, hissing, or ringing sensation that happens without an external stimulus; hyperacusis is defined as an auditory hypersensitivity condition in which moderate to low-intensity sounds are perceived as intolerably loud or even painful [2123]. In FM, a central nervous system hypervigilant state has been identified through experimental sensory testing and supported by functional neuroimaging [2427]. The appearance of tinnitus and hyperacusis could be credited to this central nervous system dysfunction. Unaccountably, the study by Samartin-Veiga et al. [15] showed that patients with FM tended to have reduced auditory-evoked potentials to the loudest sounds compared to controls.

However, some papers did document hearing loss in patients with FM by audiometry [11, 16]. It is important to remember that HL or hearing disorders may lead to tinnitus and hyperacusis appearance in some situations [21]. Despite a reduced cochlear output, the neural activity from central auditory structures increases the neural activity to suprathreshold intensities in a compensatory mechanism called central gain enhancement [21]. Irrespective of its origin, tinnitus is influenced by emotional distress, which is modulated by personality traits, stress reactivity, and depression or anxiety [22, 28]. Psychological factors contributing to the symptom’s interpretation and probably associated with persistent health anxiety may occur [28]. Pathophysiological mechanisms other than central sensitization were demonstrated by Wolfe et al. [8]. They compared answers to three different questions among patients with FM, rheumatoid arthritis, and osteoarthritis, and found that answers not only to questions with sensory input (auditory stimuli) but also those without a sensory input (easy bruising and hair loss) were amplified in FM, supporting the idea that central sensitization is not the only one responsible for FM symptoms.

Regardless of its origin, ear symptoms are mainly hyperacusis and tinnitus, associated with poor quality of life. Cil et al. [13] found that tinnitus intensity diminished with FM treatment with duloxetine or pregabalin; the two drugs were equally effective. However, Le et al. [14] found that HL increased with antidepressants and pain medication.

Some limitations observed are the relatively low number of studies and participants. The effects of FM treatment on ear abnormalities were not evaluated.

The present review highlights that patients with FM have a high prevalence of symptoms related to auditory and vestibular apparatus, mainly tinnitus and hyperacusis. However, hearing loss was also documented. More studies are needed to understand the prevalence of such symptoms in FM.

Author Contributions

All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship for this article, take responsibility for the integrity of the work as a whole, and give their approval for this version to be published. Jozélio Freire de Carvalho: design, data collection, writing, data analysis, statistical analysis, submission. Thelma Larocca Skare: data analysis, writing, revision.

Funding

No funding or sponsorship was received for this study or publication of this article.

Data Availability

All data of our study is available from the corresponding author on reasonable request.

Declarations

Conflict of Interest

Jozélio Freire de Carvalho has no conflicts of interest. Thelma Larocca Skare has no conflicts of interest. JF Carvalho is an Editorial Board member of Rheumatology and Therapy. JF Carvalho was not involved in the selection of peer reviewers for the manuscript nor any of the subsequent editorial decisions.

Ethical Approval

This article is based on previously conducted studies and does not contain any new studies with human participants or animals performed by any of the authors.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

All data of our study is available from the corresponding author on reasonable request.


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