Eur Arch Otorhinolaryngol (2014) 271:199–201 DOI 10.1007/s00405-013-2763-y

CASE REPORT

Sudden hearing loss associated with methylphenidate therapy Ugur Karapinar • Omer Saglam • Engin Dursun Bilal Cetin • Nergis Salman • Murat Sahan



Received: 16 July 2013 / Accepted: 3 October 2013 / Published online: 19 October 2013 Ó Springer-Verlag Berlin Heidelberg 2013

Abstract An 8-year-old child diagnosed with attention deficit/hyperactivity disorder presented to our Department of Otolaryngology 4 days after suffering hearing loss, loss of balance, tinnitus, and fullness sensation of the left ear. Her symptoms occured with the first dose of methylphenidate. The medical history and physical examination revealed no other diseases associated with sudden hearing loss. The audiogram revealed a total hearing loss on the left ear. Stapedial reflexes, distortion product and transient-evoked otoacoustic emissions were absent in left ear. The absence of clinical, laboratory and radiological evidence of a possible cause for complaints, an association between methylphenidate and sudden hearing loss was suggested. The patient received a standard course of oral corticosteroid and hyperbaric oxygen therapy. Weekly otological and audiological examinations were performed. Conservative and

U. Karapinar Department of Otorhinolaryngology, Agri Military Hospital, Agri, Turkey O. Saglam (&)  E. Dursun Department of Otorhinolaryngology, Kasimpasa Military Hospital, Beyoglu, Istanbul, Turkey e-mail: [email protected] B. Cetin Department of Otorhinolaryngology, Gumussuyu Military Hospital, Istanbul, Turkey N. Salman Divisions of Otorhinolaryngology, TCSB Ankara Children’s Hematology Oncology Training and Research Hospital, Ankara, Turkey M. Sahan Department Of Otorhinolaryngology, Mugla Sitki Kocman University School of Medicine, Mugla, Turkey

medical treatments offered no relief from hearing loss. Sudden hearing loss is a serious and irreversible adverse effect of methylphenidate. Therefore, the risk of hearing loss should be taken into consideration when initiating methylphenidate therapy. Keywords Methylphenidate  Sudden hearing loss  Attention deficit/hyperactivity disorder  Steroid treatment  Ototoxicity  Vertigo  Hyperbaric oxygen

Introduction Attention deficit/hyperactivity disorder (ADHD) or attention deficit disorder is one of the most common mental disorders characterized by inattention, hyperactivity and impulsivity in children and adults [1]. Methylphenidate (MPH) is the most frequently prescribed drug for the children with ADHD [2]. MPH is a generally safe drug, available for many years for children and adolescents [3]. The most common side effects of MPH are: insomnia, loss of appetite and weight, hallucination, dysphonic symptoms, digestive problems, sleep disturbances and headache [4–7]. These adverse events disappear when the treatment is decreased or stopped. In present case, we describe the case of an 8-year-old girl who had underwent a treatment for ADHD with the use of 5 mg/twice a day of MPH (RitalinÒ) and who presented with sudden unilateral hearing loss and was treated with high dose steroids, antiviral agents and hyperbaric oxygen.

Case report An 8-year-old child presented to our Department of Otolaryngology 4 days after suffering hearing loss, loss of

123

200

balance, tinnitus, and fullness sensation of the left ear. Earlier in the day, she had noticed a slight decrease in hearing ability in her left ear. Initially, she was brought to the emergency unit of the local hospital and treated for vomiting and vertigo. After resolution of the symptoms, patient was referred to our ENT clinic for consultation by family physicians for the evaluation of dizziness and hearing loss. At presentation, her main manifestations were feeling faint, intermittent sensation of loss of balance, nausea, vomiting, non-pulsatile and continuous tinnitus (a ringing in the ears) and hearing loss on left side. Her right ear appeared to be unaffected. Prior to physical examination, her medical history was taken and revealed that the patient had undergone a treatment for ADHD about 4 days ago. She was prescribed 5 mg/twice a day of MPH (RitalinÒ), but about 24 h after taking the medication, she began to develop mild, feeling faint, intermittent sensation of loss of balance, nausea, vomiting. Patient was kept taking the medication as prescribed. After third dose of drug was administered, her symptoms became more severe and disabling. This medical condition necessitated her going to the emergency department. There was no history of use of any other ototoxic drugs and no history of hearing loss, trauma, or any other auditory disease. Family history was negative. Overall, the medical history was significant only for ADHD. Our patient presented no other associated symptoms. Her parents thought that it might have been associated with the medical treatment. Vital signs were as follows: temperature, 36.5 °C; pulse, 72 BPM; blood pressure, 141/92 mmHg. An otological investigation revealed normal ear canal and tympanic membrane in both ears with no evidence of external or middle ear disease. She failed the hearing whisper test on left side. Results of a Weber test lateralized to her right ear. Rinne test was positive bilaterally. There was no sign of meningeal irritation. The results of a neurological examination were normal. The other physical examinations were also normal. We then performed an audiometric test to confirm hearing loss including pure-tone audiometry, tympanometry, acoustic reflex tests and otoacoustic emission test. Audiometric analysis with pure-tone audiometry confirmed sensorineural hearing loss (SNHL) across all frequencies of about 70 dB in the left ear. The result of pure-tone audiometry was normal in the right ear. Tympanometric analysis showed normal middle ear pressure and tympanic membrane compliance on both sides with no evidence of ear disease. Stapedial reflexes were absent in left ear. The distortion product otoacoustic emission (DPOAEs) and transient-evoked otoacoustic emission (TEOAEs) responses were not detected on the left side. Routine blood tests

123

Eur Arch Otorhinolaryngol (2014) 271:199–201

including complete blood count, erythrocyte sedimentation rate, glucose, urea, liver transaminases (SGOT/SGPT), albumin, and electrolytes were all within normal limits. Magnetic resonance imaging (MRI) was performed to evaluate the head structures for causes of hearing loss. MRI of the brain and ear resulted in normal anatomical structure. All these clinical findings suggested SNHL associated with drug ototoxicity in the left ear. Oral corticosteroid therapy with prednisone 60 mg daily to be tapered with a dose of 10 mg reduction every 3 days over the next 18 days. Along with hyperbaric oxygen therapy 12 sessions of 60 min each at two bars of pressure with 100 % oxygen was administered with the additional therapeutic intervention (use of antiviral agents, antioxidant vitamins, gastro-protective agents). Three days after the introduction of treatment there was complete regression of vomiting, tinnitus and vertigo symptoms. However, our patient continued to complain of left-ear hearing loss. Mild hearing loss was progressively worsening. The audiogram revealed a total hearing loss on the left ear. The patient was followed for 2 months with repeat hearing assessment every 1–2 weeks. Unfortunately, at the end of the 2-month follow-up period, her hearing in the affected ear showed no significant improvement.

Discussion ADHD is a neurobehavioral problem in school-age children, with prevalence at 3–5 %, and is more common in males [8]. The etiology and pathophysiology of ADHD remain unknown. Many authors believed that there is a close relationship between ADHD and environmental, biological and also genetic factors. The majority of evidence for ADHD pathophysiology points to dysfunctions of the prefrontal cortex and the striatum. The most common recommended therapy for patients with ADHD is psychostimulant medication, primarily MPH. MPH is very closely related to amphetamine and has similar chemical structure, metabolization and clinical effects. The exact mechanism of MPH is still unknown but is thought to affect catecholamines and the neurotransmitter system. It has been shown that MPH improves all symptoms of ADHD in 73–77 % of cases [9, 10]. MPH is a relatively safe drug, but long-term MPH use has not been well studied. The majority of the short-term side effects of MPH are dose related and resolve within 1–2 weeks of the drug use [10]. Common side effects of MPH include nervousness, abdominal pain, agitation, anxiety, sleep problems, loss of appetite and weight, nausea, vomiting, loss of balance, palpitations, headache, tachycardia, hypertension, hypersensitivity reactions (skin rash, etc.) and psychosis [11].

Eur Arch Otorhinolaryngol (2014) 271:199–201

The diagnosis of drug-induced hearing loss is based upon the patient’s history, symptoms, and test results. We report a patient with SNHL during therapeutic use of MPH for ADHD. The hearing loss was attributed to MPH use, in the absence of noise exposure, history of the use of certain ototoxic drugs, trauma, certain neurologic disease, otological disorders or any other possible causes. Many drugs as a potential ototoxic drug have been reported to cause SNHL [12, 13]. Hearing impairment caused by ototoxic medications that damage the inner ear or the vestibulocochlear nerve typically have an immediate onset and are usually associated with other otologic symptoms like tinnitus, vertigo, ear fullness, vomiting and nausea [14]. Many treatments have been used for SNHL including antiviral agents, hyperbaric oxygen, blood-viscosity reducing agent (pentoxifylline, heparin etc.), vasodilator drugs (verapamil, etc.), systemic/intratympanic corticosteroid therapy and vitamins. The only recommended treatments for SNHL shown in most studies are systemic/ intratympanic corticosteroid therapy, antiviral agents and hyperbaric oxygen [15–17]. The success rate with these treatments is 50–80 %, whereas the spontaneous recovery rate is 30–60 % during the natural course of the disease [18].

Conclusion SNHL that occurred after the introduction of MPH is a serious complication of the treatment, without resolution after discontinuation of the drug and administration of several treatments. Treatment with antiviral agents, steroid and hyperbaric oxygen treatment has not shown benefit. It causes much anxiety to the patient and clinicians alike. The possibility of the development of irreversible sudden hearing loss should be borne in mind when patients are undergoing medical treatment of ADHD with MPH.

References 1. Polanczyk G, de Lima MS, Horta BL, Biederman J, Rohde LA (2007) The worldwide prevalence of ADHD: a systematic review and metaregression analysis. Am J Psychiatry 164(6):942–948

201 2. Ferguson JH (2000) The consensus development panel. National Institutes of Health Consensus Development Conference Statement: diagnosis and treatment of attention-deficit/hyperactivity disorder (ADHD). J Am Acad Child Adolesc Psychiatry 39(2):182–193 3. Klein R, Wender P (1995) The role of methylphenidate in psychiatry. Arch Gen Psychiatr 52:429–433 4. Lee J, Grizenko N, Bhat V, Sengupta S, Polotskaia A, Joober R (2011) Relation between therapeutic response and side effects induced by methylphenidate as observed by parents and teachers of children with ADHD. BMC Psychiatry 11:70 5. Abalı O, Mukaddes NM (2007) Methylphenidate induced hallucinations: case report. Klinik Psikofarmakoloji Bu¨lteni: Bull Clin Psychopharmacol 17:195–197 6. Yalcin O, Aslan AA, Sari BA, Turkbay T (2012) Possible methylphenidate related hoarseness and disturbances of voice quality: two pediatric cases. Klinik Psikofarmakoloji Bu¨lteni: Bull Clin Psychopharmacol 22:3 7. Clenet F, Bourin M (2002) Methylphenidate in attention deficit hyperactivity disorder. Klinik Psikofarmakoloji Bu¨lteni: Bull Clin Psychopharmacol 12:2 8. American Psychiatric Association (1994) Diagnostic and statistical manual of mental disorders, 4th edn. American Psychiatric Association, Washington, DC, pp 78–85 9. Barkley RA (1996) Attention deficit hyperactivity disorder: a handbook of diagnosis and treatment. The Guilford Press, New York, pp 3–38 (573–612 pp) 10. Kaminester DD (1997) Attention deficit hyperactivity disorder and methylphenidate: when society misunderstands medicine. MJM 3:105–114 11. Ritalin-SR (2007) Medication guide, rev. 4/2007: www.fda.gov/ downloads/Drugs/DrugSafety/ucm089095.pdf 12. Dursun E, Akpinar A, Battal B (2009) Sudden hearing loss associated with mirtazapine therapy: a case report. Klinik Psikofarmakoloji Bu¨lteni: Bull Clin Psychopharmacol 19:4 13. Dursun E, Dogru S, Cincik H, Cekin E, Gungor A, Poyrazoglu E (2007) Iloprost-induced sudden hearing loss. J Laryngol Otol 121:609–610 14. Zadeh MH, Storper IS, Spitzer JB (2003) Diagnosis and treatment of sudden-onset sensorineural hearing loss: a study of 51 patients. Otolaryngol Head Neck Surg 128(1):92–98 15. Haynes DS, O’Malley M, Cohen S, Watford K, Labadie RF (2007) Intratympanic dexamethasone for sudden sensorineural hearing loss after failure of systemic therapy. Laryngoscope 117(1):3–15 16. Feri E, Frisina A, Fasson AC, Armato E, Spinato G, Amadori M (2012) Intratympanic steroid treatment for idiopathic sudden sensorineural hearing loss after failure of intravenous therapy. ISRN Otolaryngol 2012:647271 (6 p) 17. Murphy-Lavoie H, Piper S, Moon RE, Legros T (2012) Hyperbaric oxygen therapy for idiopathic sudden sensorineural hearing loss. Undersea Hyperb Med 39(3):777–792 18. Chen CY, Halpin C, Rauch SD (2003) Oral steroid treatment of sudden sensorineural hearing loss: a ten year retrospective analysis. Otol Neurotol 24:728–733

123

Sudden hearing loss associated with methylphenidate therapy.

An 8-year-old child diagnosed with attention deficit/hyperactivity disorder presented to our Department of Otolaryngology 4 days after suffering heari...
138KB Sizes 0 Downloads 0 Views