THROMBOSIS RESEARCH 66; 787-791,1992 0049-3848/92 $5.00 + .OO Printed in the USA. Copyright (c) 1992 Pergamon Press Ltd. All rights reserved.
BRIEF SOME
HEMOSTATIC
AND
CONMUNICATION
HEMORHEOLOGICAL DISORDERS VESTIBULAR IMPAIRMENTS
IN AUDITORY
AND
M.C. Lalanne",
C. Doutremepuich", F. Boj'", L. Traissac**, F. Quichaud*'. "Laboratoire d'Hematologie, 3 Place de la Victoire F33076 Bordeaux cedex France Fax: (33) 56 94 61 28 ""Centre des Specialites, Hopital des Enfants, 89 rue des Sablieres, F33800 Bordeaux France
(Received
8.1.1992;
accepted
in revised form 19.51992
by Editor I.P. Baskova)
The ear is a complex organ: one part of them is the labyrinth, a structure localized in the inner ear. It enclosed a canalicular system full of liquid and send to the brain several stimuli, involved in audition and equilibrium. Alterations of labyrinth provokes vertigo, sudden deafness and tinnitus. Mechanical causes joint, of such disorders exist, like a faulty temporo-mandibular an artery rubbing against the auditory nerve and other one, but they can also be drug-related (9), noise-related, of central origin, or due to cochlear deterioration (1,7). Vascular disorders including the vessels (5, 6, 8) and the blood is another possibility. In fact, audiologic cells suffering can be a consequence of occlusion of irrigating microvessels, produced after modification of blood functions (hyperviscosity, These modifications can easily be blood cells hyperactivity..). explored by the current hemostatic tests. So the aim of this study was to determine which modification in patients suffering from auditoxy and could be observed vestibular impairments and, if this hemostatic disturbancels could be linked to audiologic disorders. MATERIAL
AND METHODS
1. Patients Seventy-nine patients audiologic disorders were 61.04 ? 14.06 years. Key Words:
hemostasis,
(45 men, 34 women) suffering from included in the study. Mean age was
audiologic 787
disorders
788
HEMOSTASIS AND AUDIOLOGY
2. Clinical
and paraclinical
Vol. 66, No. 6
observations
Patients were investigated by doppler, electrocochleographia and audiograms. Four kinds of pathologies were determined using these observations and selected for the study. They were: sudden deafness, presbycousis, tinnitus and vertigo. 3. Biological
analyses
. Blood collection and treatment Blood was collected by venopuncture. The first milliliters were discarded for avoiding coagulation. Blood was then drawn into plastic tubes containing trisodium citrate 3.8 % (1:9 V/V) for coagulation and aggregation tests or EDTA, for blood filtration. A part of titrated blood was then centrifugated 20 minutes at 1000 rpm to obtain platelets-rich- plasma (PRP) and platelets-poorthen, 10 minutes again at 5000 rpm to obtain plasma (PPP). Blood on EDTA was conserved in mild warm bath system Several parameters of the hemostatic were (37OC). using primary hemostasis explored 3 check-up: coagulation, (platelet aggregation) and red cells deformability. . Coagulation
check-up
Common tests of coagulation were used. They were: Prothrombin A.P.T.T PrestR, time (NeoplastineR, Stag0 Stago), (CE Laboratories, France), thrombin clotting time (Houde LaboraFrance), fibrinogen level (FibritestR, Stag0 tories, by the thromboelastogram potential Laboratories, France) and index (or TPI) determined on whole blood . . Platelet aggregation Two kinds of protocol
were performed: on plasma using the Born device. method and on whole blood following the Cardinal's Aggregation were always performed on an aggregometer (VS 500, Chronolog" Coultronics SA - France). - Aggregation on whole blood: The model chosen was an electrical model (4).The aggregating reagents were collagen (20 pg/ml final concentration) and ADP (10 I.~Mfinal concentration, Stago Laboratories, France). Changes of conduction were recorded and analyzed using the MERAPR software (Coultronics SA, France). - Aggregation on plasma: The model chosen was the optical method described by Born (2). The temperature of the aggregation module was set at 37OC and a stirring bar was introduced into the test of the tube. Stirring speed was 1100 r/min. Upon addition aggregating reagent collagen (40 pg/ml final concentration) and ADP (1 and 2 PM final concentration, Stago Laboratories, France) the platelets aggregated and light transmission increased. The changes in light transmission were recorded and the data were automatically analyzed using the MERAP= software (Coultronics SA, France). . Viscosity
determination
Red cells functions were estimated using the Reid- Dormandy apparatus by their ability to be bent. One ml of whole blood was filtered through a MilliporeR membrane, under 20 cm water pressure and determined the filtration time.
Vol. 66, No. 6
HEMOSTASIS AND AUDIOLOGY
4. Definition
789
of normal and abnormal values
Were taken as normal, the values defined as follows: Platelets: Normal values for platelets count were between 200,000 - 400,000 /mm". For platelet aggregation, they were as in table 1. .
Table 1 Normal values ranges of aggregation parameters inducting agents Amplitude ADP 10 j.fM Collagen 20 pg/ml ADP 1 PM ADP 2 PM Collagen 40 pg/ml . Viscosity:
Filtration
7 - 14 8 - 14 15 - 35 25 - 70 20 - 70
Ohms Ohms % % %
according
to
Velocity 3 3 12 15 15
-
6 Ohm/min 6 Ohm/min 30 %/min 40 %/min 50 %/min
time was compared to a control
. Coagulation: Normal fibrinogen level was between 2-'4 g/l. Normal Thromboplastin Time was 100 % and normal TPI was between 6 and 10. All other coagulation tests were compared to controls. Were taken as abnormal, values which differ for more than 20% of the normal values or the controls.
5. Statistical
analysis
Statistical analysis allows to determine means and standard deviation of the mean in each type of pathology. Analysis between normal and disturbed hemostatic groups was performed by using the of Chi, test (PCSM Deltasoft software, France). Determination correlation was performed using a linear regression. A ~~0.05 was considered significant. RESULTS 1. Audioloqic
observations
deafness study were observed in the Audiologic defects (presbycousis and sudden deafness) alone or associated (82 %), tinnitus alone or associated (43 %), vertigo alone or associated (21 %) and other disturbances (7 %). 2. Biological
evaluations
Patients were setted into two groups according to the biological observations made : in group A, patients presented no hemostatic disorder, while, in qroup 2_, they have one or more defects (table 2).Frequency of abnormal biological check-ups increased according to the number of clinical defects. They was a very good correlation (~~0.01) between the number of audiologic defects and the number of biological disturbances.
790
HEMOSTASIS AND AUDIOLOGY
Vol. 66, No. 6
Table 2 Frequencies
Clinical
(in %) of biological observations according number of audiologic abnormalities.
Defects
Biology
-___-----------___--~~__ One defect Association of 2 defects Association of 3 defects Association of 4 defects Agg.: aggregation;
Vise.:
(%)
to the
Group 2 Abnormal Biology Agg. 1 Vise. 1 Coag. alone or in association (%) (%) (%)
41 20 11 0
18 26 26 0
viscosity;
21 23 10 100
14 31 53 0
Coag.: coagulation
No statistical variation was observed in platelet count, hematocrit, fibrinogen level or all other coagulation tests excepted evaluation in these patients of biological TPI. Examination showed that biological defects were observed in 70 % of the patients studied. The women (37 %) presented a greater frequency than the men (33 %). DISCUSSION The cause of hearing impairement is unknown in a high number of patients. Alterations of labyrinth provokes vertigo, sudden deafness and tinnitus. However, vascular modifications are also involved. So, ectopia of the jugular dome provokes venous forms of tinnitus, while abnormalities on the internal carotid course (following stenosis, tumor...) give arterial forms of such symptom. As far as vessels abnormalities causes hearing losses and associated disorders, it could be assumed that qualitative modifications of blood components (erythrocytes, platelets or coagulation factors) associated with trophies insufficiencies will take an active part in these pathologies. Only, few works have tackled this hypothesis, demonstrating a possible effect of has been blood viscosity or hyperlipidemia (3). Since ischaemia factor, the relation between hearing thinked as a possible parameters and blood viscosity, platelet aggregation, platelets and coagulation has been explored in this count, hematocrit takes into account the sex, age and treatment of 79 study. It show that 70 % of the patients presented patients. Results biological check-ups partially or totally disturbed. There was a good correlation between modifications of vascular system and correlation clinical observations. This was even increasing according to the number of clinical defects. The most observed disorders was hypercoagulability, determined by thromboelastogram in whole blood, alone or in association. This observation is quite new owing to that only blood viscosity has been demonstrated as responsible of hearing impairement. No changes in hematocrit, platelet number or fibrinogen level could explain these results. Therefore, absence of hematocrit changes in such type of defects has already been described in the literature (3).
Vol. 66, No. 6
HEMOSTASIS AND AUDIOLOGY
791
Interest of such results is that they offers new perspective in the treatment of audiological and vetibular impairements, mainly by vascular drugs like low molecular weight heparins or aspirin. This study has to be continue by the determination of clinical changes according to the treatment done and will be monitored by F1+2 fragments or TAT complex. So, it appears that a good correlation exists between clinical and hemostatic defects, which could open the field of new search of treatment of audiologic disorders by vascular drugs. REFERENCES
1.
ALLEVA M., LOCH W., 17(2), 289-297, 1990
2.
BORN G., CROSS M. The aggregation of blood Physiol. London, 168, 176-195, 1963.
3.
BROWNING G., GATEHOUSE S., LOWE G. Blood viscosity as a impairment. Lancet, hearing factor in sensorineural 1(8473), 121-123, 1986.
4.
aggregometer: a CARDINAL D., FLOWER R. The electronic novel device for assessing platelet behaviour in blood. J. Pharmacological methods, 135-158, 1980.
5.
COURTENEY-HARRIS R., FORD G., INNES A., COLIN J. (1990). fistula Pulsatile tinnitus: three cases of arteriovenous treated by ligation of the occipital artery. J. Laryngol. oto1., 104(5), 421-422, 1990.
6.
de la DOUTREMEPUICH C. A propos de l'etude biologique note maladie de Meniere et du syndrome menieriforme: preliminaire. Rev. Larynq., 95(1-2), 45-48, 1975.
7.
HAZELL J., JASTREBOFF P. Tinnitus I: Auditory mechanisms: impairment. J. tinnitus and hearing for model a Otolarynqol., 19(l), l-5, 1990.
8.
C., BEBEAR PORTMANN M., DOUTREMEPUICH sur l'etude de complementaires Donnees menieriformes. Meniere et des syndromes 96(5-6), 45-48, 1975.
9.
STYPULKOWSI P. Mechanisms of salicylate Res., 46(1-2), 113-145, 1990.
PAPARELLA
M.
Tinnitus.
Prim.
Care,
platelets.
J. -
P. J.P, VAZEL la maladie de Rev. Larynq.,
ototoxicity.
Hear.
BRIEF SOME
HEMOSTATIC
AND
CONMUNICATION
HEMORHEOLOGICAL DISORDERS VESTIBULAR IMPAIRMENTS
IN AUDITORY
AND
M.C. Lalanne",
C. Doutremepuich", F. Boj'", L. Traissac**, F. Quichaud*'. "Laboratoire d'Hematologie, 3 Place de la Victoire F33076 Bordeaux cedex France Fax: (33) 56 94 61 28 ""Centre des Specialites, Hopital des Enfants, 89 rue des Sablieres, F33800 Bordeaux France
(Received
8.1.1992;
accepted
in revised form 19.51992
by Editor I.P. Baskova)
The ear is a complex organ: one part of them is the labyrinth, a structure localized in the inner ear. It enclosed a canalicular system full of liquid and send to the brain several stimuli, involved in audition and equilibrium. Alterations of labyrinth provokes vertigo, sudden deafness and tinnitus. Mechanical causes joint, of such disorders exist, like a faulty temporo-mandibular an artery rubbing against the auditory nerve and other one, but they can also be drug-related (9), noise-related, of central origin, or due to cochlear deterioration (1,7). Vascular disorders including the vessels (5, 6, 8) and the blood is another possibility. In fact, audiologic cells suffering can be a consequence of occlusion of irrigating microvessels, produced after modification of blood functions (hyperviscosity, These modifications can easily be blood cells hyperactivity..). explored by the current hemostatic tests. So the aim of this study was to determine which modification in patients suffering from auditoxy and could be observed vestibular impairments and, if this hemostatic disturbancels could be linked to audiologic disorders. MATERIAL
AND METHODS
1. Patients Seventy-nine patients audiologic disorders were 61.04 ? 14.06 years. Key Words:
hemostasis,
(45 men, 34 women) suffering from included in the study. Mean age was
audiologic 787
disorders
788
HEMOSTASIS AND AUDIOLOGY
2. Clinical
and paraclinical
Vol. 66, No. 6
observations
Patients were investigated by doppler, electrocochleographia and audiograms. Four kinds of pathologies were determined using these observations and selected for the study. They were: sudden deafness, presbycousis, tinnitus and vertigo. 3. Biological
analyses
. Blood collection and treatment Blood was collected by venopuncture. The first milliliters were discarded for avoiding coagulation. Blood was then drawn into plastic tubes containing trisodium citrate 3.8 % (1:9 V/V) for coagulation and aggregation tests or EDTA, for blood filtration. A part of titrated blood was then centrifugated 20 minutes at 1000 rpm to obtain platelets-rich- plasma (PRP) and platelets-poorthen, 10 minutes again at 5000 rpm to obtain plasma (PPP). Blood on EDTA was conserved in mild warm bath system Several parameters of the hemostatic were (37OC). using primary hemostasis explored 3 check-up: coagulation, (platelet aggregation) and red cells deformability. . Coagulation
check-up
Common tests of coagulation were used. They were: Prothrombin A.P.T.T PrestR, time (NeoplastineR, Stag0 Stago), (CE Laboratories, France), thrombin clotting time (Houde LaboraFrance), fibrinogen level (FibritestR, Stag0 tories, by the thromboelastogram potential Laboratories, France) and index (or TPI) determined on whole blood . . Platelet aggregation Two kinds of protocol
were performed: on plasma using the Born device. method and on whole blood following the Cardinal's Aggregation were always performed on an aggregometer (VS 500, Chronolog" Coultronics SA - France). - Aggregation on whole blood: The model chosen was an electrical model (4).The aggregating reagents were collagen (20 pg/ml final concentration) and ADP (10 I.~Mfinal concentration, Stago Laboratories, France). Changes of conduction were recorded and analyzed using the MERAPR software (Coultronics SA, France). - Aggregation on plasma: The model chosen was the optical method described by Born (2). The temperature of the aggregation module was set at 37OC and a stirring bar was introduced into the test of the tube. Stirring speed was 1100 r/min. Upon addition aggregating reagent collagen (40 pg/ml final concentration) and ADP (1 and 2 PM final concentration, Stago Laboratories, France) the platelets aggregated and light transmission increased. The changes in light transmission were recorded and the data were automatically analyzed using the MERAP= software (Coultronics SA, France). . Viscosity
determination
Red cells functions were estimated using the Reid- Dormandy apparatus by their ability to be bent. One ml of whole blood was filtered through a MilliporeR membrane, under 20 cm water pressure and determined the filtration time.
Vol. 66, No. 6
HEMOSTASIS AND AUDIOLOGY
4. Definition
789
of normal and abnormal values
Were taken as normal, the values defined as follows: Platelets: Normal values for platelets count were between 200,000 - 400,000 /mm". For platelet aggregation, they were as in table 1. .
Table 1 Normal values ranges of aggregation parameters inducting agents Amplitude ADP 10 j.fM Collagen 20 pg/ml ADP 1 PM ADP 2 PM Collagen 40 pg/ml . Viscosity:
Filtration
7 - 14 8 - 14 15 - 35 25 - 70 20 - 70
Ohms Ohms % % %
according
to
Velocity 3 3 12 15 15
-
6 Ohm/min 6 Ohm/min 30 %/min 40 %/min 50 %/min
time was compared to a control
. Coagulation: Normal fibrinogen level was between 2-'4 g/l. Normal Thromboplastin Time was 100 % and normal TPI was between 6 and 10. All other coagulation tests were compared to controls. Were taken as abnormal, values which differ for more than 20% of the normal values or the controls.
5. Statistical
analysis
Statistical analysis allows to determine means and standard deviation of the mean in each type of pathology. Analysis between normal and disturbed hemostatic groups was performed by using the of Chi, test (PCSM Deltasoft software, France). Determination correlation was performed using a linear regression. A ~~0.05 was considered significant. RESULTS 1. Audioloqic
observations
deafness study were observed in the Audiologic defects (presbycousis and sudden deafness) alone or associated (82 %), tinnitus alone or associated (43 %), vertigo alone or associated (21 %) and other disturbances (7 %). 2. Biological
evaluations
Patients were setted into two groups according to the biological observations made : in group A, patients presented no hemostatic disorder, while, in qroup 2_, they have one or more defects (table 2).Frequency of abnormal biological check-ups increased according to the number of clinical defects. They was a very good correlation (~~0.01) between the number of audiologic defects and the number of biological disturbances.
790
HEMOSTASIS AND AUDIOLOGY
Vol. 66, No. 6
Table 2 Frequencies
Clinical
(in %) of biological observations according number of audiologic abnormalities.
Defects
Biology
-___-----------___--~~__ One defect Association of 2 defects Association of 3 defects Association of 4 defects Agg.: aggregation;
Vise.:
(%)
to the
Group 2 Abnormal Biology Agg. 1 Vise. 1 Coag. alone or in association (%) (%) (%)
41 20 11 0
18 26 26 0
viscosity;
21 23 10 100
14 31 53 0
Coag.: coagulation
No statistical variation was observed in platelet count, hematocrit, fibrinogen level or all other coagulation tests excepted evaluation in these patients of biological TPI. Examination showed that biological defects were observed in 70 % of the patients studied. The women (37 %) presented a greater frequency than the men (33 %). DISCUSSION The cause of hearing impairement is unknown in a high number of patients. Alterations of labyrinth provokes vertigo, sudden deafness and tinnitus. However, vascular modifications are also involved. So, ectopia of the jugular dome provokes venous forms of tinnitus, while abnormalities on the internal carotid course (following stenosis, tumor...) give arterial forms of such symptom. As far as vessels abnormalities causes hearing losses and associated disorders, it could be assumed that qualitative modifications of blood components (erythrocytes, platelets or coagulation factors) associated with trophies insufficiencies will take an active part in these pathologies. Only, few works have tackled this hypothesis, demonstrating a possible effect of has been blood viscosity or hyperlipidemia (3). Since ischaemia factor, the relation between hearing thinked as a possible parameters and blood viscosity, platelet aggregation, platelets and coagulation has been explored in this count, hematocrit takes into account the sex, age and treatment of 79 study. It show that 70 % of the patients presented patients. Results biological check-ups partially or totally disturbed. There was a good correlation between modifications of vascular system and correlation clinical observations. This was even increasing according to the number of clinical defects. The most observed disorders was hypercoagulability, determined by thromboelastogram in whole blood, alone or in association. This observation is quite new owing to that only blood viscosity has been demonstrated as responsible of hearing impairement. No changes in hematocrit, platelet number or fibrinogen level could explain these results. Therefore, absence of hematocrit changes in such type of defects has already been described in the literature (3).
Vol. 66, No. 6
HEMOSTASIS AND AUDIOLOGY
791
Interest of such results is that they offers new perspective in the treatment of audiological and vetibular impairements, mainly by vascular drugs like low molecular weight heparins or aspirin. This study has to be continue by the determination of clinical changes according to the treatment done and will be monitored by F1+2 fragments or TAT complex. So, it appears that a good correlation exists between clinical and hemostatic defects, which could open the field of new search of treatment of audiologic disorders by vascular drugs. REFERENCES
1.
ALLEVA M., LOCH W., 17(2), 289-297, 1990
2.
BORN G., CROSS M. The aggregation of blood Physiol. London, 168, 176-195, 1963.
3.
BROWNING G., GATEHOUSE S., LOWE G. Blood viscosity as a impairment. Lancet, hearing factor in sensorineural 1(8473), 121-123, 1986.
4.
aggregometer: a CARDINAL D., FLOWER R. The electronic novel device for assessing platelet behaviour in blood. J. Pharmacological methods, 135-158, 1980.
5.
COURTENEY-HARRIS R., FORD G., INNES A., COLIN J. (1990). fistula Pulsatile tinnitus: three cases of arteriovenous treated by ligation of the occipital artery. J. Laryngol. oto1., 104(5), 421-422, 1990.
6.
de la DOUTREMEPUICH C. A propos de l'etude biologique note maladie de Meniere et du syndrome menieriforme: preliminaire. Rev. Larynq., 95(1-2), 45-48, 1975.
7.
HAZELL J., JASTREBOFF P. Tinnitus I: Auditory mechanisms: impairment. J. tinnitus and hearing for model a Otolarynqol., 19(l), l-5, 1990.
8.
C., BEBEAR PORTMANN M., DOUTREMEPUICH sur l'etude de complementaires Donnees menieriformes. Meniere et des syndromes 96(5-6), 45-48, 1975.
9.
STYPULKOWSI P. Mechanisms of salicylate Res., 46(1-2), 113-145, 1990.
PAPARELLA
M.
Tinnitus.
Prim.
Care,
platelets.
J. -
P. J.P, VAZEL la maladie de Rev. Larynq.,
ototoxicity.
Hear.
