The Laryngoscope C 2015 The American Laryngological, V
Rhinological and Otological Society, Inc.
Multivariate Analysis of Prognostic Factors for Idiopathic Sudden Sensorineural Hearing Loss in Children Jae Ho Chung, MD; Seok Hyun Cho, MD; Jin Hyeok Jeong, MD; Chul Won Park, MD; Seung Hwan Lee, MD Objectives/Hypothesis: To evaluate clinical characteristics and possible associated factors of idiopathic sudden sensorineural hearing loss (ISSNHL) in children using univariate and multivariate analyses. Study Design: A retrospective case series with comparisons. Methods: From January 2007 to December 2013, medical records of 37 pediatric ISSNHL patients were reviewed to assess hearing recovery rate and examine factors associated with prognosis (gender; side of hearing loss; opposite side hearing loss; treatment onset; presence of vertigo, tinnitus, and ear fullness; initial hearing threshold), using univariate and multivariate analysis, and compare them with 276 adult ISSNHL patients. Results: Pediatric patients comprised only 6.6% of pediatric/adult cases of ISSNHL, and those below 10 years old were only 0.7%. The overall recovery rates (complete and partial) of the pediatric and adult patients were 57.4% and 47.2%, respectively. The complete recovery rate of the pediatric group (46.6%) was higher than that of the adult group (30.8%, P 5.040). According to multivariate analysis, absence of tinnitus, later onset of treatment, and higher hearing threshold at initial presentation were associated with a poor prognosis in pediatric ISSNHL. Conclusions: The recovery rate of ISSNHL in pediatric patients is higher than in adults, and the presence of tinnitus and earlier treatment onset is associated with favorable outcomes. Key Words: Hearing loss, sudden, children. Level of Evidence: 4 Laryngoscope, 00:000–000, 2015
INTRODUCTION Sudden sensorineural hearing loss (SSNHL) is an otologic emergency defined as rapidly developed hearing loss with an increased pure-tone threshold over 30 dB affecting at least three consecutive frequencies. When the cause of hearing loss is unidentified despite adequate investigation, hearing loss is considered to be idiopathic SSNHL (ISSNHL).1–3 A recent study reported that the annual incidence of SSNHL was 27 per 100,000 population in the United States.4 Incidence is known to increase with age: incidence of ISSNHL is 77 per 100,000 for patients >65 years old, and 11 per 100,000 for patients younger than 18 years.4 The ratio of pediatric patients to overall SSNHL patients varies from 3.5% to 10%.5,6 Although many studies have been carried out to uncover the causes, pathogenesis, treatment, and progno-
From the Departments of Otolaryngology–Head and Neck Surgery, School of Medicine, Hanyang University, Seoul, South Korea. Editor’s Note: This Manuscript was accepted for publication January 15, 2015. This work was supported by the research fund of Hanyang University (HY-2013). The authors have no conflicts of interest to disclose. Send correspondence to Seung Hwan Lee, MD, Department of Otolaryngology–Head and Neck Surgery, School of Medicine, Hanyang University, 222-Wangshimni-ro, Seongdong-gu, Seoul 133-792, South Korea. E-mail: [email protected] DOI: 10.1002/lary.25196
Laryngoscope 00: Month 2015
sis of SSNHL, there is a lack of understanding about the prevalence and treatment outcomes of SSNHL in children. Most SSNHL is idiopathic and has suspected vascular, viral, or multiple etiologies. The cause of sudden hearing loss, such as vestibular schwannoma, stoke, or malignancy can be established in just 10% of patients.7 In children, infections with cytomegalovirus (CMV), Epstein-Barr virus, and mumps virus are important causative factors8; however, the majority of children with SSNHL have normal serologic results for these viruses.2 In children, possible causes of SSNHL are somewhat different from those in adults.8 Congenital anomalies of the inner ear should be considered in children.8 In addition, nonorganic hearing loss is an interesting causative factor of SSNHL in children aged 10 to 14.9 Patient age, presence of vertigo at onset, configuration of audiogram, late onset of treatment, and decreased speech discrimination score are considered to be poor prognostic indicators in SSNHL.10,11 However, these parameters are drawn from studies of adult patients. In addition, there is no clear understanding of treatment results and factors affecting prognosis in pediatric ISSNHL due to its low incidence, and diagnosis can be challenging owing to difficulty in ruling out other causes of hearing loss, such as hereditary hearing loss and congenital anomaly.8,12 The aim of the present study was to investigate clinical characteristics associated with prognosis in pediatric ISSNHL using univariate and multivariate analysis. Chung et al.: Sudden Sensorineural Hearing Loss in Children
1
MATERIALS AND METHODS Patients and Setting We performed a retrospective medical record review of ISSNHL patients in a tertiary referral center from January 2007 to December 2013, and identified 37 patients under 18 years old. Medical records of 276 adult patients (19 years old) diagnosed with ISSNHL from January 2010 to December 2013 were included as a control group. Written informed consent was obtained from all patients. This investigation was approved by the local ethics review board, and performed in accordance with the Declaration of Helsinki and Good Clinical Practice guidelines.
through continuous intravenous infusion for 5 days.14 Intratympanic steroid injection was not considered in the current study.
Statistical Analysis After examining variance equivalence and normal distribution, two-tailed Student t- tests were applied to continuous variables, whereas v2 tests were used for categorical variables. Parameters that were statistically significant in the univariate analysis were included in the multivariate analysis. As profound hearing loss might indicate the specific hearing level, we used only initial hearing level in the multivariate analysis. All statistical processing was conducted with SPSS version 19.0 for Windows (IBM, Armonk, NY). A P value
Rhinological and Otological Society, Inc.
Multivariate Analysis of Prognostic Factors for Idiopathic Sudden Sensorineural Hearing Loss in Children Jae Ho Chung, MD; Seok Hyun Cho, MD; Jin Hyeok Jeong, MD; Chul Won Park, MD; Seung Hwan Lee, MD Objectives/Hypothesis: To evaluate clinical characteristics and possible associated factors of idiopathic sudden sensorineural hearing loss (ISSNHL) in children using univariate and multivariate analyses. Study Design: A retrospective case series with comparisons. Methods: From January 2007 to December 2013, medical records of 37 pediatric ISSNHL patients were reviewed to assess hearing recovery rate and examine factors associated with prognosis (gender; side of hearing loss; opposite side hearing loss; treatment onset; presence of vertigo, tinnitus, and ear fullness; initial hearing threshold), using univariate and multivariate analysis, and compare them with 276 adult ISSNHL patients. Results: Pediatric patients comprised only 6.6% of pediatric/adult cases of ISSNHL, and those below 10 years old were only 0.7%. The overall recovery rates (complete and partial) of the pediatric and adult patients were 57.4% and 47.2%, respectively. The complete recovery rate of the pediatric group (46.6%) was higher than that of the adult group (30.8%, P 5.040). According to multivariate analysis, absence of tinnitus, later onset of treatment, and higher hearing threshold at initial presentation were associated with a poor prognosis in pediatric ISSNHL. Conclusions: The recovery rate of ISSNHL in pediatric patients is higher than in adults, and the presence of tinnitus and earlier treatment onset is associated with favorable outcomes. Key Words: Hearing loss, sudden, children. Level of Evidence: 4 Laryngoscope, 00:000–000, 2015
INTRODUCTION Sudden sensorineural hearing loss (SSNHL) is an otologic emergency defined as rapidly developed hearing loss with an increased pure-tone threshold over 30 dB affecting at least three consecutive frequencies. When the cause of hearing loss is unidentified despite adequate investigation, hearing loss is considered to be idiopathic SSNHL (ISSNHL).1–3 A recent study reported that the annual incidence of SSNHL was 27 per 100,000 population in the United States.4 Incidence is known to increase with age: incidence of ISSNHL is 77 per 100,000 for patients >65 years old, and 11 per 100,000 for patients younger than 18 years.4 The ratio of pediatric patients to overall SSNHL patients varies from 3.5% to 10%.5,6 Although many studies have been carried out to uncover the causes, pathogenesis, treatment, and progno-
From the Departments of Otolaryngology–Head and Neck Surgery, School of Medicine, Hanyang University, Seoul, South Korea. Editor’s Note: This Manuscript was accepted for publication January 15, 2015. This work was supported by the research fund of Hanyang University (HY-2013). The authors have no conflicts of interest to disclose. Send correspondence to Seung Hwan Lee, MD, Department of Otolaryngology–Head and Neck Surgery, School of Medicine, Hanyang University, 222-Wangshimni-ro, Seongdong-gu, Seoul 133-792, South Korea. E-mail: [email protected] DOI: 10.1002/lary.25196
Laryngoscope 00: Month 2015
sis of SSNHL, there is a lack of understanding about the prevalence and treatment outcomes of SSNHL in children. Most SSNHL is idiopathic and has suspected vascular, viral, or multiple etiologies. The cause of sudden hearing loss, such as vestibular schwannoma, stoke, or malignancy can be established in just 10% of patients.7 In children, infections with cytomegalovirus (CMV), Epstein-Barr virus, and mumps virus are important causative factors8; however, the majority of children with SSNHL have normal serologic results for these viruses.2 In children, possible causes of SSNHL are somewhat different from those in adults.8 Congenital anomalies of the inner ear should be considered in children.8 In addition, nonorganic hearing loss is an interesting causative factor of SSNHL in children aged 10 to 14.9 Patient age, presence of vertigo at onset, configuration of audiogram, late onset of treatment, and decreased speech discrimination score are considered to be poor prognostic indicators in SSNHL.10,11 However, these parameters are drawn from studies of adult patients. In addition, there is no clear understanding of treatment results and factors affecting prognosis in pediatric ISSNHL due to its low incidence, and diagnosis can be challenging owing to difficulty in ruling out other causes of hearing loss, such as hereditary hearing loss and congenital anomaly.8,12 The aim of the present study was to investigate clinical characteristics associated with prognosis in pediatric ISSNHL using univariate and multivariate analysis. Chung et al.: Sudden Sensorineural Hearing Loss in Children
1
MATERIALS AND METHODS Patients and Setting We performed a retrospective medical record review of ISSNHL patients in a tertiary referral center from January 2007 to December 2013, and identified 37 patients under 18 years old. Medical records of 276 adult patients (19 years old) diagnosed with ISSNHL from January 2010 to December 2013 were included as a control group. Written informed consent was obtained from all patients. This investigation was approved by the local ethics review board, and performed in accordance with the Declaration of Helsinki and Good Clinical Practice guidelines.
through continuous intravenous infusion for 5 days.14 Intratympanic steroid injection was not considered in the current study.
Statistical Analysis After examining variance equivalence and normal distribution, two-tailed Student t- tests were applied to continuous variables, whereas v2 tests were used for categorical variables. Parameters that were statistically significant in the univariate analysis were included in the multivariate analysis. As profound hearing loss might indicate the specific hearing level, we used only initial hearing level in the multivariate analysis. All statistical processing was conducted with SPSS version 19.0 for Windows (IBM, Armonk, NY). A P value
