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THE IMPACT OF RHEUMATOID ARTHRITIS ON MIDDLE EAR FUNCTION. Caroline Marie ... PDF

170 Pages·2007·1.98 MB·English
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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! ii 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. iii 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 iv 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 v 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 vi 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 vii

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Table 4: Bone-conduction thresholds compared between RA and NC of a laptop computer (Dell Pentium laptop), a PC card (PCMCIA card) for digital signal processing, a DPOAE probe system (Etymotic Research ER-10C),
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