Abstract
Introduction
Meniere’s disease is a disorder of the membranous labyrinth of the inner ear manifesting as vertigo, tinnitus, sensory neural hearing loss and aural fullness of known or unknown origin. Some patients may present after years into typical forms. The endocrine disorders, especially hypothyroidism and the factors like inflammation, trauma, otosclerosis, autoimmunity explains the multifactorial causation for the basis of Meniere’s disease. Endolymphatic hydrops is the pathologic term named for the defective regulation of endolymph volume with respect to production and absorption. However, hyper production of endolymph cannot be excluded. The cause of Meniers disease is multifactorial so clinical features of repeated attacks of variable duration cannot be explained satisfactorily based on single causation.
Aim
To study the incidence of hypothyroidism in Meniere’s disease and to assess the success rate of improvement in subjective symptoms after treatment.
Materials and Methods
The study was carried out on total 35 out patients who were clinically diagnosed of Meniere’s disease and of these 35 patients, 12 patients were found to have hypothyroidism. All patients with hypothyroidism were treated with oral thyroxin supplements and they were evaluated clinically at 3 weeks, 3 months and 6 months interval for the improvement in subjective symptoms on outpatient basis.
Results
In our study, the subjective improvement of all symptoms was seen in all cases of Meniere’s disease with hypothyroidism after 12 weeks of treatment.
Conclusion
The improvement in clinical symptoms after treatment demonstrates an association between Meniere’s disease and hypothyroidism which was found to be significant. Hence, clinicians should consider screening patients with Meniere disease for thyroid dysfunction who are not already taking supplements.
Keywords: Autoimmunity, Endolymph, Hydrops, Labyrinth, Pure tone audiometry, Tinnitus, Vertigo
Introduction
Meniere’s disease is a disorder of labyrinth with constellation of symptoms like progress of deafness, tinnitus, vertigo and aural fullness, it is most likely seen in the age group of 40-60 years, it is usually unilateral but can be bilateral [1]. The aetiology of Meniere’s disease is multifactorial like allergy, adrenal pituitary insufficiency, hypothyroidism, stenosis of the internal auditory canal, trauma, and combination of above. Available pathologic studies suggest overproduction or underproduction of endolymph [2]. There are many proposed pathophysiologic mechanisms among which many suggest an abnormal immune mechanism [3].
The symptom of vertigo is seen in 67% of patients with hypothyroidism. Attacks are usually mild and brief, and are not associated with hearing loss [4]. The unpredictable, fluctuating nature of Meniere’s disease, the lack of an objective diagnostic test, and the high incidence of spontaneous resolution of symptoms make it extremely difficult to come to valid statistical conclusions with regard to therapeutic efficacy in Meniere’s disease. The attacks frequently are associated with nausea, vomiting, and diaphoresis. After the attacks, patients usually are fatigued for 24 hours or more. The attacks of vertigo may be associated with a concomitant or preceding change in their hearing loss, tinnitus, or aural fullness. Many patients also have various combinations of dysequilibrium or motion-provoked vertigo between the classic attacks. Subtypes of Meniere’s disease are described that have only vestibular symptoms (vestibular Meniere’s) or auditory symptoms (cochlear Meniere’s). Hypothyroidism is a condition where thyroid hormone is in insufficient quantity is one of the common disorders of endocrine system. Most common cause for hypothyroidism worldwide other than iodine deficiency is autoimmune. Hypothyroidism causes many symptoms and signs like fatigue, lethargy, weight gain, cold intolerance, etc., it also causes hearing loss, vertigo, tinnitus. Approximately 40% of adults with hypothyroidism have the involvement of sensorineural hearing loss in both ears. Considerable deafness persists after thyroxine therapy in 10% of patients with congenital hypothyroidism [5]. Although it is common in primary hypothyroidism, deafness has been reported with pituitary disfunction [6].
The present study was undertaken to find out the incidence of hypothyroidism in Menieres disease. A total of 35 patients, clinically diagnosed of Menieres disease over a 6 months period were included in the study. All the patients met the criteria determined by the 1995 American Academy of Otolaryngology for Meniere’s disease [1] and were treated only on out patient’s basis.
Meniere’s disease is critical clinical condition, the medical management of which has shown poor results [7]. All patients who are clinically diagnosed with Meniere’s disease were classified as having unilateral or bilateral ears involvement (criteria described by Kitahara [8]). Patients among the study group, who were found to have hypothyroidism were prescribed thyroid hormone supplements as an add-on medication.
Aim
To study the incidence of hypothyrodisim in Meniere’s disease and the subjective symptom improvement after the treatment.
Materials and Methods
The study was carried out on a total of 35 out patients who were clinically diagnosed as Meniere’s disease and of these 35 patients, 12 patients were found to have hypothyroidism. All patients with hypothyroidism were treated with oral thyroxin supplements and they were evaluated clinically at 3 weeks, 3 months and at 6 months intervals for the improvement in subjective symptoms on outpatient basis only.
Inclusion criteria
All cases of clinically diagnosed Meniere’s disease only.
Age group 15 years and above irrespective of the sexes.
Exclusion criteria
Patients with diseases like otitis media, otosclerosis, perilymphatic fistula, vestibular neuritis, labyrinthitis, posttraumatic vertigo, or previous ear surgery were excluded. Patients with cerebro vascular accidents, and central nervous system disorders causing vertigo, psychiatric disturbances, seizure disorder, or other otologic diseases, congenital hearing loss, systemic autoimmune disorders and the patients with a history of thyroid surgery or thyroid ablation were also excluded from the study.
The selected patients were subjected to clinical, audiological, and laboratory investigations.
Results
Age distribution: In our study, maximum patients with Meniere’s disease who were found to have hypothyroidism, were in the age group of 31-45 years, however, the number of patients between the age group of 15-30 years and more than 45 years of age were found to be equal [Table/Fig-1].
[Table/Fig-1]:
Age distribution.
| Age group in years | Patients with Euthyroidism | % | Patients with Hypo Thyroidism | % |
|---|---|---|---|---|
| 15-30 | 11 | 31.4% | 3 | 8.5% |
| 31-45 | 6 | 17.4% | 6 | 17.4% |
| >45 | 6 | 17.4% | 3 | 8.5% |
The early presentation may be due to increased awareness to health issues and difficulty affecting the work efficiency, leading patients to seek early medical intervention.
Sex distribution: [Table/Fig-2]-There is female sex predilection for disease in our study out of 12 hypothyroidic patients only one patient was male and the male to female ratio was 0.08: 1.
[Table/Fig-2]:
Sex distribution.
| Sex | Patients with HypoThyroidism | % |
|---|---|---|
| Male | 1 | 8.4% |
| female | 11 | 91.6% |
Side affected: [Table/Fig-3]-In this study Bilateral ear involvement was seen in 9 patients (75%), Right ear involvement was found in 2 patients (16.6%), and only 1 patient (8.4%), had Left ear involvement who was a male.
[Table/Fig-3]:
Side affected.
| Side affected | Patients with HypoThyroidism | % |
|---|---|---|
| Right | 2 | 16.6% |
| Left | 1 | 8.4% |
| Bilateral | 9 | 75% |
Duration of symptoms & Sex distribution: [Table/Fig-4]-In our study 6 patients (50%), all females, were having the symptoms of Meniere’s disease, duration ranging between between 2 to 4 years of duration and 3 patients (25%) had symptoms for more than 4 years.
[Table/Fig-4]:
Duration of symptoms and sex distribution.
| Duration of symptoms & Sex distribution | Male | % | Female | % |
|---|---|---|---|---|
| 0-2 | 1 | 8.3 | 2 | 16.6 |
| 2-4 | 0 | 0 | 6 | 50 |
| >4 | 0 | 0 | 3 | 25 |
Hearing improvement before and after 12 weeks of treatment: [Table/Fig-5]-In our study 6 female patients (50%) had Sensory Neural Hearing Loss duration ranging between 2 to 4 years and 3 female patients (33.4%) had this symptom for more than 4 years only 2 female patients (16.6%) had hearing loss for a period of less than 2 years. Only 1 male patient had Sensory Neural Hearing Loss for less than a period of 2 years.
[Table/Fig-5]:
Hearing loss before and after 12 weeks of treatment.
| Side affected | Patients with Hypo Thyroidism | % | Avg Hearing loss Before Treatment | Avg Hearing loss After 12weeks of Treatment |
|---|---|---|---|---|
| Right | 2 | 16.6% | 50dB | 45dB |
| Left | 1 | 8.4% | 40dB | 30dB |
| Bilateral | 9 | 75% | 40dB | 23.4dB |
The average Bilateral Sensory Neural Hearing Loss was 40 dB in the involved cases and it was found to be 50dB in patients with only right ear involvement and 40dB in right and left ears. These patient showed significant improvement in hearing after 12 weeks of treatment (p<0.000).
Status of Thyroid Hormone Profile: [Table/Fig-6]-There was classical elevation in the TSH levels in 12 patients who were detected to be hypothyroidic, and reverted to Euthyroidic state after 12weeks of treatment in T3 and TSH levels (p<0.002 and p<0.006 respectively). Whereas the T4 values did not change significantly in our study. In our study, after 12 weeks of the treatment for the hypothyroidism showed significant reduction in the TSH levels which is the sensitive indicator of the hypothyroidism is what we have considered.
[Table/Fig-6]:
Status of thyroid hormone profile.
| Thyroid Functions | Mean | Std Deviation | Willcoxon Signed Ranks Test | p-value | |
|---|---|---|---|---|---|
| T3 | Before treatment | 94.68 | 31.84 | 3.06 | p<0.002 |
| After treatment | 77.5 | 10.55 | |||
| T4 | Before treatment | 8.38 | 4.54 | 1.42 | NS |
| After treatment | 7.33 | 1.09 | |||
| TSH | Before treatment | 25.03 | 43.87 | 2.75 | p<0.006 |
| After treatment | 2.92 | 1.00 | |||
However, in our study the T3 and more so the T4 levels reduction was not much appreciable and they were found within the normal range and also deriving that the TSH level is the sensitive indicator for hypothyroidism.
Mean vertigo score (SM): [Table/Fig-7]- The mean vertigo score for rotator sensation, tinnitus, hearing loss and aural fullness was found to be reduced significantly after 12weeks of oral thyroid supplement therapy.
[Table/Fig-7]:
Mean vertigo score before and after 12 weeks of treatment.
| n=12 | Mean | Std Deviation | t-value | p-value | |
|---|---|---|---|---|---|
| Sense of Rotation | Before | 1.42 | 0.67 | 3.32 | p<0.001 |
| After | 0.5 | 0.67 | |||
| Tinitus | Before | 1.5 | 0.52 | 3.46 | p<0.001 |
| After | 0.5 | 0.52 | |||
| Hearing loss | Before | 2 | 0 | 2.83 | p<0.005 |
| After | 1.33 | 0.49 | |||
| Aural Fullness | Before | 1.33 | 0.49 | 3.32 | p<0.001 |
| After | 0.5 | 0.69 | |||
N: number of hypothyroid patients, Std: Standard.
The clinical examination results of the Unterburger Test showed significant improvement after 12weeks of therapy in Angle of Deviation, Angle of Rotation, Lateral sway and in Ant-post displacement and all patient’s parameters were in the normal range (p<0.000).
In our study all hypothyroid patients scored 2 with respect to the hearing loss and the sum of scores of all subjects for hearing loss were equal to 24, hence the standard deviation came out to be zero in hearing loss.
In our study, the subjective improvement of all symptoms was seen in all cases of Meniere’s disease with hypothyroidism after 12 weeks of treatment.
The Mean Vertigo Score Improvement for Sense of rotation is 1.42 to 0.5, (p <0.001) Tinitus from 1.5 to 0.5, (p<0.001) Aural fullness from 1.33 to 0.67, (p <0.04), before and after 12weeks of treatment, and for the symptom of Hearing loss which improved from 2 to 1.33 after 12weeks of treatment, (p<0.04) for the hypothyroidism.
Discussion
The exact cause of Meniere’s disease remains unknown. However, it is considered to be a multifactorial disease. Several studies done to find the prevalence of hypothyroidism among patients with Meniere’s disease and it varied from 3% to 17%. [7–9]. The clinical examination to identify the thyroid dysfunction still remains as the key stone area in spite of the available thyroid function tests [10].
To maintain the uniformity and standard of our study with the studies already done, we selected the patients diagnosed of Meniere’s disease with respect to the involvement of the side of the ear and were classified based on the diagnostic criteria described by Kitahara [11], and the 1995 American Academy of Otolaryngology criteria for unilateral Meniere’s disease [12].
The components of Meniere disease were fluctuating vertigo, sensorineural hearing loss; tinnitus and aural fullness are the clinical presentation resulting from several different pathologic processes [12].
The association of thyroid dysfunction with age in the studies conducted show varying results, some show higher prevalence of thyroid dysfunction in the elderly population, and other studies show as low as 10% [13–16]. However in our study, 50% patients with hypothyroidism were between 31 to 45 years of age.
The studies have shown that the clinical features of Meniere’s disease are produced by the metabolic changes occurring in hypothyroidism [17–20], though other studies did not supported this finding [21–24]. The role of autoimmunity related thyroid disorders is not clear in Meniers disease and is only a susceptible entity and the metabolic changes occurring in hypothyroidism produces the symptoms of Meniers disease [24–34].
Our study did not include the autoimmune thyroid disorders; however some studies support the role autoimmune thyroid dysfunction as a causative factor for some cases of Meniere’s disease [30–34].
In our study the incidence of hypothyroidism was found to be high. There should be a high degree of suspicion in clinically examining patients diagnosed with Menieres disease, as there may be no thyroid enlargement on clinical examination as in the present study, which made it possible for the patients with less severe thyroid dysfunction to be diagnosed and treated.
Conclusion
Our study shows the possibility of a higher incidence of thyroid dysfunction in patients with Meniere’s disease, especially in middle aged patients, Hence clinicians should consider screening for thyroid dysfunction in patients with Meniere’s disease who are not already taking supplements. However, further studies with larger sample size is needed.
Financial or Other Competing Interests
None.
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