Role of Obesity on the Prognosis of Sudden Sensorineural Hearing Loss in Adults

Original Research

Role of Obesity on the Prognosis ofSudden Sensorineural Hearing Loss inAdults

OtolaryngologyHead and Neck Surgery16 American Academy ofOtolaryngologyHead and NeckSurgery Foundation 2015Reprints and permission:sagepub.com/journalsPermissions.navDOI: 10.1177/0194599815584599http://otojournal.org

Juen-Haur Hwang, MD, PhD1

No sponsorships or competing interests have been disclosed for this article.

Abstract

Objective. To investigate the role of obesity/overweight onthe prognosis of sudden sensorineural hearing loss (SSHL).

Study Design. Retrospective cohort study.

Setting. Outpatient department of a community hospital.

Subjects and Methods. We collected 254 adult patients withSSHL from a community hospital. The odd ratios of bodymass index (BMI) or obesity/overweight (BMI 25 kg/m2)on the recovery of SSHL were evaluated with multivariatelogistic regression analysis.

Results. There were 120 (47.2%) patients in the nonobesitygroup (BMI\25 kg/m2) and 134 (52.8%) patients in the obe-sity/overweight group (BMI 25 kg/m2). The complete andpartial recovery rates were 10.0% and 49.2% in the non-obesity group and 9.7% and 47.0% in the obesity/overweightgroup, respectively. Univariate logistic regression showedthat BMI had no significant association with recovery ofSSHL (odds ratio [OR] of complete and partial recoveryversus no recovery = 1.04, 95% confidence interval [CI] =0.965-1.113, P = .327). Multivariate logistic regression analy-sis also showed that BMI (OR = 1.04, 95% CI = 0.964-1.131,P = .292) was not significantly associated with the recoveryof SSHL for all subjects, after adjusting for all consideredvariables. Also, obesity/overweight (BMI 25 kg/m2) had nosignificant association with the recovery of SSHL.

Conclusion. Obesity/overweight would appear to have no sig-nificant effect on the prognosis of SSHL.

Keywords

Body mass index, obesity, overweight, sudden sensorineuralhearing loss, prognosis, auditory function

Received September 23, 2014; revised March 3, 2015; accepted April

8, 2015.

Sudden sensorineural hearing loss (SSHL) is defined

as a loss of greater than 30 dB in 3 contiguous fre-

quencies in less than 3 days.1 Estimates of the annual

incidence range from 5 to 20 cases per 100,000 persons.

The median age at presentation ranges from 40 to 54 years.

There is an equal distribution of female-to-male cases and

between ears.1 The etiology and pathogenesis of SSHL

remain unknown.2,3 Some risk factors are associated with

the onset of SSHL.4 For example, diabetes mellitus (DM),

hypercholesterolemia, cardiovascular risk factors,5 chronic

kidney disease (CKD) with DM,6 and migraine7 are associ-

ated with an increased risk of developing SSHL. However,

the predictive factors for the recovery of SSHL are still lim-

ited and controversial.

In addition to obesity-related comorbidities or sequelae,

obesity per se was reported to be a novel independent risk

for peripheral and central types of age-related hearing

impairment (ARHI).8-10 Body mass index (BMI) was

reported to correlate with hearing loss across all frequency

ranges, with a higher BMI correlating with more severe

hearing loss.8 Our study group had also demonstrated that

waist circumference (WC), which may be a better surrogate

marker of obesity and obesity-related morbidity and mortal-

ity,11 was an independent risk factor for elevated hearing

thresholds in adults after adjusting for age, gender, BMI,

and other clinical factors.9 However, the impact of obesity

on the prognosis of SSHL is still unknown.

Initial severe hearing loss, vertigo, and downward audio-

metric pattern are negative prognostic factors of hearing

recovery.12 The poor prognosis has also been observed in

patients with concurrent microvascular diseases, such as

hypertension (HTN), DM, and hyperlipidemia.13-15 The

youngest and the oldest patients might have a lower recovery

rate.16 Inflammatory signs in the laboratory workup are a

good indicator for recovery from SSHL-treated steroids.17

Higher neutrophil-to-lymphocyte ratio is a poor indicator for

occurrence and recovery of SSHL.18

1Department of Otolaryngology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi

Medical Foundation, Chiayi, Taiwan; the School of Medicine, Tzu Chi

University, Hualien, Taiwan

Corresponding Author:

Juen-Haur Hwang, MD, PhD, Department of Otolaryngology, Dalin Tzu Chi

Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan; the School

of Medicine, Tzu Chi University, No. 2 Minsheng Road, Dalin, Chiayi,

62247, Taiwan.

Email: [email protected]

at IMSS on May 26, 2015oto.sagepub.comDownloaded from

However, there are still many reports against these positive

findings. For example, there were no differences in remission

rates for SSHL patients with preexisting sensorineural hearing

loss, previous episode of SSHL, or chronic otitis media.19

Vertigo,20 audiogram type, cardiovascular and thromboembolic

risk factors, time elapsed from onset of SSHL to hospitaliza-

tion,20,21 or routine laboratory parameters22 were not associated

with recovery of SSHL. Lionello et al21 concluded that only

age was significantly and independently related to hearing out-

come among all known factors.

The role of obesity on the recovery of SSHL has never

been reported, but it might be supposed to be positive with

the knowledge of obesity-related inflammation and patho-

physiology of SSHL. In this study, therefore, we aimed to

investigate the effect of BMI on the outcome of SSHL in

adults using a retrospective cohort study with detailed and

complete chart review.

Methods

From 2000 to 2010, well-recorded clinical and audiometric

data of 254 consecutive adult patients with unilateral SSHL

were collected for analysis from the outpatient department

of Dalin Tzu Chi Hospital, Chiayi, Taiwan. The data were

acquired by clinical chart review, and SSHL was documen-

ted by clinical diagnosis. Those charts should be maintained

for at least 15 years in Taiwan for legal and medical pur-

poses. The study was approved by the institutional review

board of the Dalin Tzu Chi Hospital, Taiwan (No.

B09902015). Since all of the files contain only de-identified

secondary data, the review board waived the requirement

for obtaining informed consent from the patients.

All patients were treated by 4 physicians with a standard

treatment protocol. The decision to admit or not admit was

based on the patients will but was not based on age,

gender, disease severity, and so forth. Age, gender, BMI,

presenting symptoms, time elapsed from onset of SSHL to

initial treatment, admission or not, and medical history,

including coronary artery disease (CAD), HTN, DM, dysli-

pidemia, and CKD, were recorded. In addition, data of

pure-tone audiometry were collected.

All included patients were divided into 2 groups based

on BMI as defined by the World Health Organization in

2014. The nonobesity group was defined as patients with a

BMI\25 kg/m2, whereas the obesity/overweight group wasdefined as patients with a BMI 25 kg/m2. Those patientswho were not admitted for treatment received the outpatient

protocol: oral prednisolone (1 mg/kg per day for 7 days, and

then tapered within 14 days), nicametate (50 mg, 3 times a

day), and aspirin (100 mg, once a day). In addition, those

patients who were admitted for treatment received the inpa-

tient protocol: intravenous dexamethasone (10 mg per day

for 7 days, and then tapered within 14 days by oral predni-

solone), intravenous 10% dextran 40 (twice a day for 7

days), oral nicametate (50 mg, 3 times a day), and aspirin

(100 mg, once a day).

Exclusion criteria included age younger than 18 years,

external or middle ear diseases, conductive hearing loss

(presenting with an air-bone gap on audiogram), acoustic

trauma (presenting with a 3- to 6-kHz dip in audiogram),

brain tumor or vestibular schwannoma, or head and neck

radiation exposure. Patients whose time elapsed from onset

of SSHL to initial treatment longer than 30 days were

excluded. Besides, to avoid confounding from other optional

treatment, also excluded were the patients who received

intratympanic steroid (ITS) injection as primary or salvage

treatment for SSHL.

All patients were followed up once per month, and the

endpoint for outcome measurement was set at 6 months

after initial treatment at the outpatient department or admis-

sion in the hospital. We averaged the thresholds at 500 Hz,

1 kHz, 2 kHz, and 4 kHz to obtain the averaged pure-tone

hearing threshold (PTA) for each subjects. According to the

clinical practice guideline for sudden hearing loss,23 the

initial hearing loss severity was that the audiometric dif-

ference between the affected ear and nonaffected ear. In

addition, the outcomes of SSHL were divided into 3 groups

based on the status of recovery by treating the unaffected

ear as the standard. A complete recovery requires return to

within 10 dB HL of the unaffected ear. Anything less than a

10-dB HL improvement was classified as no recovery.

Partial recovery was defined as the status other than com-

plete recovery or no recovery conditions.

Second, the recovery of SSHL was also categorized as

none (0 dB HL), moderate (1-10 dB HL), or good (.10 dBHL) recovery relative to baseline hearing level, as shown in

the report of Weiss et al.24

Statistical Analysis

The data were presented as means 6 standard deviation(SD), unless indicated otherwise. Continuous variables were

compared by Student t test, whereas categorical variables

were compared by x2 test. The odds ratio (OR) and BMI onthe recovery of SSHL, which was shown as complete and

partial recovery versus no recovery, or good and mod-

erate recovery versus no recovery, were first evaluated

with univariate a logistic regression analyses for all subjects.

Then, we included the variables whose P value was .4 inthe univariate logistic regression into the multivariate logis-

tic regression model for all ages, age younger 65 years, and

age older than 65 years, because the prognosis might vary

in different age groups.16 In addition, in each analysis, age

was regarded as a continuous variable. P values\.05 wereconsidered statistically significant. All analyses were per-

formed using STATA 10.0 software (Stata Corp, College

Station, Texas). The power calculation was performed by

the free software G-Power (http://www.gpower.hhu.de/).

Results

There were 109 (42.9%) female patients and 145 (57.1%)

male patients in this study. The mean age was 54.9 6 14.2years (range, 18-88 years) for all 254 patients. The mean

BMI was 24.9 6 4.1 kg/m2 (range, 15.8-42.1 years).Table 1 showed the general characteristics of all subjects

by BMI. There were 120 (47.2%) patients in the nonobesity

2 OtolaryngologyHead and Neck Surgery


group (BMI \25 kg/m2) and 134 (52.8%) patients in theobesity/overweight group (BMI 25 kg/m2). The completeand partial recovery rates were 10.0% and 49.2% in the

nonobesity group and were 9.7% and 47.0% in the obesity/

overweight group, respectively. The ratio of admission was

significantly higher in the nonobesity group than in the obe-

sity/overweight group. But, age, gender, time elapsed from

onset of SSHL to initial treatment, initial or treated hearing

loss severity, outcome of SSHL treatment, and all other

variables were not significantly different between both

groups.

Table 2 shows the results of univariate logistic regres-sion analysis for the relationship between all considered

variables and the recovery (combined complete and partial

recovery versus no recovery) of SSHL for all subjects. Only

age (OR = 0.98, 95% confidence interval [CI] = 0.959-

0.995, P = .014) and initial hearing loss (OR = 1.02, 95%

CI = 1.006-1.029, p = 0.002), but not BMI (OR = 1.04,

95% CI = 0.965-1.113, P = .327) and other variables, were

significantly associated with the recovery of SSHL.

Table 3 shows the results of multivariate logistic regres-sion analysis for the relationship between BMI and the

recovery (combined complete and partial recovery versus no

recovery) of SSHL in different ages. BMI (OR = 1.04, 95%

CI = 0.964-1.131, P = .292) was not significantly associated

with the recovery of SSHL for all subjects, after adjusting

for age, gender, initial hearing loss severity, admission,

CAD, and HTN. The post hoc power calculation showed

that the power was 72% under the number of predictors = 7,

observed R2 = 0.047, probability level = .05, and sample

size = 254. Also, the association between BMI and the

recovery of SSHL was not significant in the subjects

younger than 65 or older than 65 years.

When we used obesity/overweight (BMI 25 kg/m2)instead of BMI in the multivariate logistic regression model,

we still found that obesity/overweight was not significantly

associated with the recovery of SSHL after adjusting for the

considered variables. Also, when a further subanalysis based

on admission was performed, BMI did not show a significant

association with the recovery of SSHL in patients without

admission (OR = 0.91, 95% CI = 0.576-1.450, P = .701) or

with admission (OR = 1.04, 95% CI = 0.936-1.151, P = .485).

When the recovery was alternatively categorized as none,

moderate, or good recovery, the good and moderate recov-

ery rates were 59.2% and 22.5% in the nonobesity group

and 56.7% and 20.9% in the obesity group, respectively.

Multivariate logistic regression showed that BMI (OR =

0.95, 95% CI = 0.695-1.309, P = .771) still did not have a

significant association with the recovery (combined good

and moderate recovery) of SSHL after adjusting for age,

gender, admission, initial hearing loss level, CAD, and HTN

for all subjects.

Discussion

In this retrospective cohort study, we have provided new

evidence about the role of obesity/overweight on the recov-

ery of SSHL in adults. In SSHL patients without receiving

ITS, BMI or obesity/overweight was not significantly and

Table 1. General Characteristics of Subjects in the Nonobesity and Obesity/Overweight Groups.

Nonobesity Group

(BMI\25 kg/m2)Obesity/Overweight

Group (BMI 25 kg/m2) P Value

Case number, n (%) 120 (47.2) 134 (52.8)

Age (mean 6 SD), y 55.2 6 14.7 54.7 6 13.8 .7888

Gender, F/M, % 42.5/57.5 43.3/56.7 1.000

Time elapsed from onset of SSHL to initial treatment (mean 6 SD), d 6.0 6 4.6 5.9 6 5.8 .9674

Initial hearing loss severitya (mean 6 SD), dB HL 55.4 6 23.7 52.6 6 23.1 .3414

Treated hearing loss severitya (mean 6 SD), dB HL 39.1 6 25.4 36.8 6 25.6 .4755

Outcome, %

No recovery 40.8 43.3 .949

Partial recovery 49.2 47.0

Complete recovery 10.0 9.7

Admission, n (%) 74 (61.7) 61 (45.5) .012

CAD, n (%) 3 (2.5) 5 (3.7) .726

HTN, n (%) 43 (35.8) 47 (35.1) 1.000

DM, n (%) 36 (30.0) 38 (28.4) .784

Dyslipidemia, n (%) 16 (13.3) 19 (14.2) .858

CKD, n (%) 9 (7.5) 6 (4.5) .425

Vertigo, n (%) 28 (23.7) 43 (32.2) .248

Headache, n (%) 8 (6.7) 18 (13.6) .200

Abbreviations: BMI, body mass index; CAD, coronary artery disease; CKD, chronic kidney disease; DM, diabetes mellitus; F, female; HTN, hypertension; M,

male; SD, standard deviation; SSHL, sudden sensorineural hearing loss.aThe initial or treated hearing loss severity was the audiometric difference between the affected ear and nonaffected ear.

Hwang 3


independently associated with the prognosis of SSHL in

adults.

The complete and partial recovery rates were 10.0% and

49.2% in the nonobesity group and 9.7% and 47.0% in the

obesity/overweight group, respectively. These data were

very similar to those of other studies.12-22 The role of HTN

on the prognosis of SSHL in our study was different from

that of Hirano et al,13 Nagaoka et al,14 and Shikowitz15 but

was similar to that of Mosnier et al20 and Lionello et al.21

As for the role of age, our current result was slightly differ-

ent from that of Wang et al16 and Lionello et al.21

Statistically, hearing level was in fact a continuous vari-

able but was arbitrarily defined into a category variable for

outcome calculation. Second, treatment protocols might

contribute variably to the treatment outcomes. Thus, the

contradictory results between these articles mentioned

above and ours might be due to the differences in the out-

come definition and/or treatment protocols.12-24 In addi-

tion, the merit of this study over other published similar

studies is that we have proposed a novel possible factor

(obesity/overweight) on the prognosis of SSHL, although a

negative result was shown.

Table 2. Univariate Logistic Regression Analysis for the Recovery of SSHL for All Subjects.

OR SE Z P Value 95% CI

Age, y 0.98 0.009 2.46 .014 0.959-0.995

Gender (males vs females) 1.31 0.336 1.05 .295 0.791-2.163

BMI, kg/m2 1.04 0.038 0.98 .327 0.965-1.113

Time elapsed from onset of SSHL to initial treatment, d 1.00 0.028 0.17 .862 0.942-1.051

Initial hearing loss severity, dB HL 1.02 0.006 3.03 .002 1.006-1.029

Admission 1.37 0.350 1.24 .215 0.832-2.262

CAD 5.30 5.707 1.55 .121 0.642-43.734

HTN 0.65 0.173 1.61 .107 0.388-1.096

DM 1.10 0.308 0.33 .743 0.633-1.900

Dyslipidemia 0.84 0.309 0.46 .644 0.412-1.730

CKD 1.49 0.839 0.71 .480 0.494-4.490

Vertigo 1.01 0.340 0.02 .982 0.520-1.953

Headache 3.18 2.089 1.76 .078 0.877-11.528

Abbreviations: BMI, body mass index; CAD, coronary artery disease; CI, confidence interval; CKD, chronic kidney disease; DM, diabetes mellitus; HTN,

hypertension; OR, odds ratio; SE, standard error; SSHL, sudden sensorineural hearing loss.aOR was calculated from the odds of the combined complete and partial recovery versus no recovery.

Table 3. Multivariate Logistic Regression Analysis for the Recovery of SSHL.

All Subjects 18 age\ 65 y Age 65 yOR (95% CI) P OR (95% CI) P OR (95% CI) P

Age, y 0.99 (0.965-1.013)

.345

0.97 (0.937-1.010)

.148

1.06 (0.949-1.181) .308

Gender 1.25 (0.684-2.276)

.471

1.39 (0.676-2.866)

.370

1.13 (0.330-3.861) .846

BMI, kg/m2 1.04 (0.964-1.131)

.292

1.01 (0.911-1.120)

.852

1.15 (0.981-1.352) .084

Initial hearing loss severity, dB HL 1.01 (0.999-1.027)

.065

1.01 (0.996-1.028)

.160

1.02 (0.985-1.048) .317

Admission 0.88 (0.462-1.674)

.696

0.71 (0.318-1.589)

.406

1.43 (0.428-4.757) .563

CAD 3.92

.227

Omitted 1.54 .750

(0.427-36.000) (0.106-22.416)

HTN 0.63 (0.327-1.231) .178 0.63 (0.275-1.445) .276 0.63 (0.182-2.173) .464

Abbreviations: BMI, body mass index; CAD, coronary artery disease; CI, confidence interval; HTN, hypertension; OR, odds ratio; SSHL, sudden sensorineural

hearing loss.aOR was calculated from the odds of the combined complete and partial recovery versus no recovery.



Adipose tissue is now considered to be an endocrine

tissue. It secretes hormones and cytokines and influences

insulin resistance, energy metabolism, and atherosclero-

sis.25 Further, obesity-induced inflammation may exacer-

bate end-organ damage. Therefore, in addition to the

contribution to peripheral hearing degeneration indirectly

via its comorbidities-related angiopathy and/or neuropa-

thy,26 obesity itself might also make hearing worse directly

via lipotoxicity and related oxidative stress.27 This hypothesis

was proved by some recent animal28 and human studies.8-

10,29,30 Meanwhile, inflammation was one of important under-

lying mechanisms9-11 and prognosis indictors17,18 for SSHL.

Thus, we could also suppose obesity to be associated with

treatment outcome of SSHL. However, we could not show a

positive relationship between obesity/overweight and out-

come of SSHL.

The negative result of this study might be mainly due to

the low OR, case number, and subsequent lower power. The

result might also be weakened by a lack of WC data, which

was a better indicator for obesity-related problems, in this

retrospective chart review study. Otherwise, the negative

results of this study might be also due to the different etiol-

ogy or underlying mechanisms of SSHL and ARHI. The

etiology and pathogenesis of SSHL remain unknown,9,10 but

Chau et al4 reported that the percentages of the possible

etiologies for SSHL were 71.0% for idiopathic cause, 12.8%

for infectious diseases, 4.7% for otologic diseases, 4.2% for

trauma, 2.8% for vascular or hematologic problems, 2.3%

for neoplastic diseases, and 2.2% for other causes.

However, ARHI might be caused by obesity and its comor-

bidities.8-10,28-30 Thus, our negative result has just enforced

the difference between SSHL and ARHI.

As for the relationship between admission and prognosis

of SSHL, this study raised the issue regarding the effi-

ciency of the treatment protocol and the cost of medical

care. Considering the differences in both treatment proto-

cols, our results could also indicate that oral steroid treat-

ment did not have a significantly poorer or better effect on

the recovery of SSHL than intravenous steroid and dextran

did. Thus, there is no need to suggest that adult patients

with SSHL be admitted for treatment, pay more money, or

spend much time. Furthermore, there is much evidence

showing that a new outpatient treatment protocol could be

as effective as conventional treatment with oral steroids.

For example, 3 different outpatient treatment protocols

(oral steroid, ITS injection, or the combination of both)

resulted in similar hearing recovery rates.31,32 Therefore,

outpatient departmentbased systemic and/or local steroid

therapy can be recommended as an initial treatment for

SSHL, although oral prednisolone was once reported to

have no benefit on the recovery of SSHL.17

Conclusion

In this retrospective cohort study, we found that BMI or

obesity/overweight was not significantly associated with the

recovery of SSHL without ITS. Additional prospective,

well-designed studies about WC and the prognosis of SSHL

with a greater number of cases should be conducted in the

future.

Acknowledgment

I thank Dr Jin-Cherng Chen and Associate Professor Malcolm Koo

at Dalin Tzu Chi Hospital for data analysis and for providing sta-

tistical consultation for this study.

Author Contributions

Juen-Haur Hwang, accountability for all aspects of the work.

Disclosures

Competing interests: None.

Sponsorships: None.

Funding source: None.

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