THE IMPACT OF RHEUMATOID ARTHRITIS ON MIDDLE EAR

170 Pages·2007·1.98 MB·English

by  Matthew Hill

ABSTRACT

Title of Document: THE IMPACT OF RHEUMATOID
ARTHRITIS ON MIDDLE EAR FUNCTION.

Caroline Marie Roberts,
Doctor of Clinical Audiology (Au.D.), 2007

Directed By: Assistant Professor, Tracy Fitzgerald, Ph.D.,
Department of Hearing and Speech Sciences

Rheumatoid arthritis (RA) is an autoimmune disease that causes inflammation
and swelling of the joints. Middle ear joints may be subject to rheumatic involvement
similar to other joints in the body. Results from previous studies examining
audiological characteristics in individuals with RA have varied with respect to
incidence and type of hearing loss, as well as incidence and type of middle ear
involvement (increased or decreased stiffness). The purpose of this study was to
compare audiometric, immittance, distortion-product otoacoustic emission (DPOAE),
and energy reflectance (ER) results between participants with RA and normal control
(NC) participants to further examine the effects of RA on middle ear function.
Twenty-one participants with RA (38 ears) were matched 1:1 based on age and
gender to 21 individuals (38 ears) without RA. The following measures were
completed for all participants: pure-tone air- and bone-conduction thresholds, 226-,
678- and 1000-Hz tympanograms, acoustic reflex thresholds, acoustic reflex decay,
and middle ear resonant frequency. ER and DPOAEs were measured for a subset of
16 RA (28 ears) and 16 NC (28 ears) matched participants. No significant difference
in prevalence of hearing loss was found between groups. Individuals with hearing
loss in both groups presented with sensorineural-type hearing loss, which was
typically a mild to moderate high-frequency hearing loss. No significant differences
were found between groups for air- and bone-conduction thresholds. A significantly
greater number of ears from the RA group had thresholds poorer than the 95th
percentile for their age range and gender across the audiometric test frequencies.
Generally, younger individuals with RA had poorer thresholds at 1000 and 2000 Hz
compared to normative data for age and gender. No differences were found between
groups for static admittance, the number of notched versus single-peaked 678- and
1000-Hz tympanograms, acoustic reflex thresholds, ER, and DPOAE measurements.
The RA group had a significantly lower mean resonant frequency, consistent with an
increase in the laxity or an increase in the mass dominance of the middle ear system.
These significant findings revealed the importance of considering audiological
assessment of individuals with RA.
THE IMPACT OF RHEUMATOID ARTHRITIS
ON MIDDLE EAR FUNCTION

By

Caroline Marie Roberts

Dissertation submitted to the Faculty of the Graduate School of the
University of Maryland, College Park, in partial fulfillment
of the requirements for the degree of
Doctor of Clinical Audiology
2007

Advisory Committee:
Tracy Fitzgerald, Ph.D. Chair
Carmen C. Brewer, Ph.D. Co-Chair
Sandra Gordon-Salant, Ph.D.
Monita Chatterjee, Ph.D.
David Cooper, Ph.D.
© Copyright by
Caroline Marie Roberts
2007
Dedication
This dissertation is dedicated to those individuals who have encouraged,
supported, and uplifted me through this process. I thank my husband, Chris Roberts,
for his love, encouragement, and ability to help me see the light at the end of the
tunnel. I thank Tracy Fitzgerald and Carmen Brewer for their support and extensive
time invested in this project. Additionally, I appreciate Tracy’s mentorship,
guidance, and investment in my professional development throughout my academic
career. And lastly, I would like to thank my classmates: Erin McAlister, Kelly King,
Christine Gmitter, Lauren Wisman, and Krystal Strazik. Their collaborative support,
laughter, and friendship helped guide me through not just this process but through my
graduate career. They have shared in my joys and struggles, and provided strength
and encouragement. And together – we can beat the Stenger!
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Acknowledgements
Special thanks to Dr. Raphaela Goldbach-Mansky and Mildred Wilson for
their assistance with participant recruitment at the National Institute of Arthritis and
Musculoskeletal and Skin Diseases (NIAMS). This research was made possible by
their research efforts and acceptance of our addendum to their natural history study.
Also, thanks to Carmen Brewer and Chris Zalewski for their assistance with
participant supervision and report writing at the National Institute on Deafness and
Other Communication Disorders (NIDCD). In addition, the contributions of the
committee members are greatly appreciated: Tracy Fitzgerald, Carmen Brewer,
Sandra Gordon-Salant, Monita Chatterjee, and David Cooper. Special thanks to
Tracy Fitzgerald and Carmen Brewer for their tireless efforts serving as co-chairs.
This research was partially funded by the MCM Fund for Student Research
Excellence, from the Department of Hearing and Speech Sciences at the University of
Maryland, College Park.
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Table of Contents
Dedication.....................................................................................................................ii
Acknowledgements......................................................................................................iii
Table of Contents.........................................................................................................iv
List of Tables..............................................................................................................vii
List of Figures............................................................................................................viii
Chapter 1: Introduction.................................................................................................1
Chapter 2: Literature Review........................................................................................4
Rheumatoid Arthritis (RA).......................................................................................4
Overview...............................................................................................................4
Symptoms..............................................................................................................5
Etiology.................................................................................................................6
Diagnoses..............................................................................................................7
Pharmacological Treatment...............................................................................10
Extra-articular manifestations............................................................................11
Middle Ear..............................................................................................................12
Middle Ear: Anatomy..........................................................................................12
Middle Ear: Diagnostic Tests.............................................................................14
Wideband Reflectance............................................................................................27
Normative Values in Adults................................................................................31
Energy Reflectance (ER) and Middle Ear Disorders.........................................33
Rheumatoid Arthritis (RA) and the Auditory System............................................38
RA and Hearing Loss..........................................................................................38
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RA and Middle Ear Function..............................................................................48
Summary and Purpose:...........................................................................................55
Chapter 3: Research Questions and Hypothesis.........................................................57
Chapter 4: Methods.....................................................................................................60
Participants..............................................................................................................60
Procedures...............................................................................................................66
Audiometric Measures........................................................................................68
Standard Immittance...........................................................................................69
Multi-frequency Tympanometry..........................................................................70
ER and DPOAE Measures..................................................................................71
Preliminary Data................................................................................................74
Statistical Analysis..................................................................................................75
Chapter 5: Results.......................................................................................................77
Preliminary Data: Location Differences............................................................77
Preliminary Data: Test Order............................................................................82
Audiometric Measures............................................................................................82
Standard Immittance...............................................................................................92
Multi-frequency Tympanometry...........................................................................100
Energy Reflectance (ER) Measures......................................................................108
DPOAE Measures.................................................................................................111
RA Disease Activity and Audiological Measures................................................113
Chapter 6: Discussion..............................................................................................119
Audiometric Measures..........................................................................................119
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Standard Immittance.............................................................................................123
Multi-frequency Tympanometry...........................................................................124
ER and DPOAE Measures....................................................................................129
RA Demographics.................................................................................................134
Chapter 7: Conclusions............................................................................................137
Appendix A...............................................................................................................140
Appendix B...............................................................................................................143
References.................................................................................................................145

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List of Tables
Table 1: Demographic and disease information for RA participants…….………63-64
Table 2: Number of participants and ears from each group included in
measurements………………………………………………………..…….67
Table 3: Comparisons of hearing loss at different threshold classifications……...…86
Table 4: Bone-conduction thresholds compared between RA and NC groups……...90
Table 5: Air-bone gap differences compared between RA and NC groups…………91
Table 6: Air-conduction threshold compared to age-related normative data.……….95
Table 7: 226-Hz quantitative measures compared between RA and NC groups……97
Table 8: Acoustic reflex thresholds compared between RA and NC groups………..99
Table 9: Calculated admittance for 678- and 1000-Hz tympanograms compared
between RA and NC groups……………………………………………...104
Table 10: Comparisons of ears within individuals in the RA group across
tympanometry and pure-tone audiometry measures………………..…….107
Table 11: Energy reflectance (ER) measurements compared between RA and
NC groups………………………………………………………………...112
Table 12: DPOAE level compared between RA and NC groups………………..…114
Table 13: Partial correlations accounting for age and comparing RA disease
involvement and audiological measures..……………………………..…115

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