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The Evaluaton of Audtory System in Obstructve Sleep Apnea Syndrome
(Osas) Patents
Mahmut Deniz M.D., Zafer C iftci M.D., Tolga Ersozlu M.D., Erdogan
Gultekin M.D., Recep Alp M.D.
PII: S0196-0709(16)00065-X
DOI: doi: 10.1016/j.amjoto.2016.03.004
Reference: YAJOT 1702
To appear in: American Journal of OtolaryngologyHead and Neck Medicine and Surgery
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Mahmut Deniz1, Zafer ifti1, Tolga Erszl1, Erdoan Gltekin1, Recep Alp2
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: Namk Kemal University Medical Faculty Otorhinolaryngology Department
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2
: Namk Kemal University Medical Faculty Neurology Department
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Mahmut Deniz, Assist Prof, M.D. (drmahmutdeniz@hotmail.com)
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Tolga Erszl, Assist Prof, M.D. (tolga76@hotmail.com)
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Erdoan Gltekin, Associate Prof, M.D. (erdogangultekin@hotmail.com)
Please address all correspondence to: Assist. Prof. Mahmut Deniz, M.D
E mail: drmahmutdeniz@hotmail.com
Degirmenalt Kampus
59000 Tekirdag
Turkey
Phone: +905325059507
ABSTRACT
Objective: The authors of the present study aimed to investigate the impact of hypoxemia on
the auditory functions of OSAS patients and discussed their findings under the scope of the
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existing literature.
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Materials and Methods: 160 patients who underwent a polysomnographic analysis for the
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diagnosis of possible sleep disordered breathing between Jan 2015 and December 2015 were
enrolled in this study. Polysomnography tests were conducted at the sleep laboratory of the
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department of neurology at the same institute. Comprehensive otorhinolaryngological
designated according to the severity of the apnea hypopnea index (AHI) and blood oxygen
saturation values of the participants. All participants underwent pure tone auditometry and
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otoacoustic emission testing (OAE). Statistical data analysis was performed using SPSS for
Results: Audiological assessment of the patients revealed that all patients in the control group
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and in mild OSAS group had normal hearing thresholds (lower than 26 dB). However, the
patients who had moderate and severe OSAS had varying degrees of sensorineural hearing
losses. As far as body mass indexes are concerned, statisitically significant differences were
Conclusion: There is convincing evidence that the risk of progressive dysfunction in vascular
and neural structures of the body is inevitable for the patients who suffer from a chronic
hypoxemic condition secondary to OSAS. The findings of the present study indicated auditory
transduction and transmission mechanisms may also be affected in moderate and severe
OSAS patients. Therefore, via taking necessary steps in preventing hypoxemia at the outset,
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OSAS patients may be protected from the long term detrimental effects of chronic hypoxemia
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loss, polysomnography test.
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INTRODUCTION
hemodynamical regulatory mechanisms located in the central and peripheral nervous system.
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dysfunctions in neural mediator turnover and a decrease in the adenosine levels in the central
nervous system can be observed (1-3). Furthermore, repetitive oxidative stress secondary to
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chronic hypoxemia was found to be associated with endothelial dysfunction in
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microcirculation. This condition, in turn, was proposed to compromise the vascular supply of
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the peripheral nerves and lead to an inevitable loss in neural function (4, 5).
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From an otorhinolaryngological point of view, patients with obstructive sleep apnea
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syndrome (OSAS) usually suffer from such a serious hypoxemic state as a consequence of
repetitive apneic episodes (6- 8). Patients are known to exhibit decreased oxygen (02)
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concentrations in the bloodstream during their sleep. In addition, significant fluctuations in 02
levels may persist even during the day time in OSAS patients (9).
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OSAS patients may be detrimental for the auditory transduction and transmission
mechanisms. The sense of hearing is accomplished by the peripheral and central auditory
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mechanisms, which are both vulnerable to the effects of hypoxemia. Flawlesss generation
and conduction of the neural signals from the cochlea to the auditory cortex necessitate the
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presence of an adequate and uninterrrupted supply of oxygen to the components of this neural
circuit (9). The authors of the present study aimed to investigate the impact of hypoxemia on
the auditory functions of OSAS patients and discussed their findings under the scope of the
existing literature.
The study was conducted in a tertiary referral center in Turkey. Approval was granted
from the local ethics committee (2015/72/06/04) and all patients were asked to fill in an
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informed consent form. Patients who underwent a polysomnographic analysis for the
diagnosis of possible sleep disordered breathing between Jan 2015 and December 2015 were
enrolled in this study. Polysomnography tests were conducted at the sleep laboratory of the
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department of neurology at the same institute. Comprehensive otorhinolaryngological
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examinations of all participants were conducted by the same senior otorhinolaryngologist.
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Patients who had an acute or chronic otorhinolaryngological disease which may have a
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negative impact on hearing mechanism (otitis media, eustachian tube problems, sino-nasal
disorders and etc.) and other co-morbid chronic systemic conditions that are well known to be
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associated with hypoxemia and disturbances in the microvascular circulation, including
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diabetes mellitus (DM), hypertension (HT) and chronic obstructive pulmonary disease
(COPD) were excluded from the study. Three study groups and a control group were
designated in the study. Each study group was designated according to the severity of the
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apnea hypopnea index (AHI) and blood oxygen saturation values (SpO2) of the participants.
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The blood oxygen saturation levels were measured by a pulse oximeter (Beijing Safe Heart
Technology Ltd, China). The first, second and third groups were comprised of patients having
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mild (AHI: 5-15, SpO2 > 85%), moderate (AHI: 15-30, SpO2 = 65-84%) and severe OSAS
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(AHI > 30, SpO2<65%), respectively. Each group consisted of randomly selected 40 patients.
The control group was comprised of individuals who had an AHI < 5.
All participants also underwent pure tone auditometry and otoacoustic emission testing
(OAE). Pure tone audiometry (PTA) was conducted by the same audiometrist in accordance
to the international standards using a two channel audiometer (Interacoustics A/S, Denmark).
Hearing thresholds at 250 to 8 kHz for each ear were determined. Average PTA thresholds
was calculated by using threshold levels at 500, 100, and 2000 Hz. Patients who had a hearing
threshold greater than 25 dBHL were accepted to have auditory dysfunction. The degree of
hearing loss was accepted as mild (26 to 40 dBHL), moderate (41 to 55 dBHL), moderately
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severe (56 to 70 dBHL), severe (71 to 90 dBHL), and profound (91+ dBHL). For OAE
testing, Madsen AccuScreen TE device was used (Otometrics, Denmark). Normal outer hair
cell function was determined by a Pass/Clear Response result. Individuals with a Refer/No
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Clear Response result were re-tested. Upon retesting, individuals with a persistent Refer/No
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Clear Response result were accepted as having a sensorineural hearing loss.
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Statistical data analysis was performed using SPSS for Windows, version 17 (SPSS
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Inc., Chicago, IL, USA). The chi-square (2) test was used to compare qualitative data. The
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Kruskal-Wallis test (KW) was used to compare the groups. Dunns multiple comparison test
and the Tukeys range test were used to compare the subgroups. Results were considered
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significant for p<0.05.
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RESULTS
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The ages of the 160 participants (120 OSAS patients and 40 control subjects) were
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found to range between 23 and 55 years (mean age= 42.4 years). Of these, 76 were female
and 84 were male. The mean age for mild, moderate, and severe OSAS groups, and the
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control group was 42.6413.8, 41.3513.7, 43.14 11.6 and 42.3212.4 years, respectively.
As far as body mass indexes (BMI) are concerned, statisitically significant differences
were observed among the groups (p=0.038, odds ratio 1.52; 95% confidence intervals 1.11
2.39). In the control group and the first study group, BMI was within the normal range (18.5
24.9 kg/m2) while it was found to be >30 kg/m2 in the second and third study groups (Figure
1).
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5
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Control group (BMI Group 1(mild OSAS) Group 2 (moderate Group 3 (severe
kg/m2) (BMI kg/m2) OSAS) (BMI kg/m2) OSAS)(BMI kg/m2)
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Audiological assessment of the patients revealed that all patients in the control group
and in mild OSAS group had normal hearing thresholds (lower than 26 dB). Mean hearing
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thresholds for control group, mild (AHI: 5-15, SpO2 > 85%), moderate (AHI: 15-30, SpO2 =
65-84%) and severe OSAS (AHI > 30, SpO2<65%) groups were 16.356.7 dBHL, 17.244.8
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25 Control group
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20 Mild OSAS
15 Moderate OSAS
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10 Severe OSAS
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Control group Mild OSAS Moderate Severe OSAS
OSAS
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Figure 2: Hearing thresholds in all groups (dBHL).
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However, the patients who had moderate and severe OSAS had varying degrees of
sensorineural hearing losses. 9 of 40 patients in the second group and 16 of 40 patients in the
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third goup had mild sensorineural hearing loss (hearing levels were more than 25 dB) (Figure
3). Moderate and severe OSAS patients showed statistically significant difference with
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control group in terms of hearing levels (KW = 22.34, p = 0.0416, p < 0.05). Despite a slight
increase in the hearing thresholds of the patients at higher frequencies, the difference between
the hearing thresholds across the frequencies in all groups (i.e. lower vs. middle vs. high
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Control group
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Group 1
Group 2
Group 3
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Figure 3: Number of patient having sensorineural hearing loss more than 25 dB
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Otoacoustic emission testing results revealed that all patients in the control and mild
OSAS groups have passed the test. On the contrary, 9 of 40 patients in the moderate OSAS
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group and 16 of 40 patients in the severe OSAS group have failed the OAE testing.
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DISCUSSION
The findings of the present study pointed out that moderate and severe OSAS may be
associated with a mild sensorineural hearing loss. This finding was in consistence with the
previous literature proposing that OSAS induced hypoxemia may have a negative impact on
Despite the abundance of the studies analyzing the impact of OSAS on certain aspects
of human functions including memory (11) cognition (12) and cardiac aoutonomic functions
(13, 14), OSAS induced alterations in the auditory system and their mechanisms of action yet
OSAS induced hypoxemia falls into one of the two broad patterns of hypoxemia
described in the literature. The first pattern is low frequency or sustained hypoxemia and
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obstructive pulmonary disease. The second pattern of hypoxemia is characterized by short
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episodes of intermittent and high frequency hypoxemia that is encountered in OSAS patients.
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The decreases in oxygen saturation usually last for 15-60 seconds and this cyclic pattern may
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occcur during the sleep period. The episodic hypoxemia is followed by a reoxygenation or
reperfusion state after each episode (15). Literature review revealed that, the negative impacts
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of OSAS on vascular function and tissue oxygenation were extensively studied. Hypoxemia
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induced chemoreflex stimulation and consequent vasoconstriction which persists even during
Although there is satisfying evidence that points out the association between OSAS
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and decreased tissue oxygenation, the literature review revealed that there are conflicting
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studies regarding the role of OSAS in auditory dysfunction. In a recent study, the authors
concluded that OSAS does not seem to affect the cortical processing of auditory afferent
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stimuli during sleep (18). However, the results of another study showed that severe OSAS
patients had abnormal auditory evoked potentials which persisted despite having an optimal
continuous positive airway pressure treatment for three months (19). Another issue that needs
to be further investigated is the possible association between the degree of hearing loss and
the severity of OSAS. In one study an apnea-hypopnea index value equal or greater than 10
was found to be associated with impaired cochlear function (20), whereas others proposed
that auditory dysfunction could be observed only in severe OSAS patients (10).
The findings of the present study indicated that OSAS patients with an AHI value less
than 15 did not have an auditory dysfunction. On the contrary, a mild sensorineural hearing
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loss was observed in both moderate and severe OSAS patients. Comparison of these two
groups of patients in terms of the severity of the hearing loss, however, yielded that the
difference between the groups was statistically insignificant. Further clinical researches
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should be conducted to delineate the association between AHI value and the degree of hearing
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loss in OSAS patients.
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Obesity and increased body mass index were reported to be important risk factors for
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OSAS in the literature (21-23). In our study a similar correlation between the increased body
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mass index and severity of OSAS was found. The body mass indices of the patients in
moderate and severe OSAS groups in which a mild sensorineural hearing loss was observed
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were greater than 30/m2. As the body mass index increased, the severity of OSAS seemed to
be increased. Therefore, weight gain control should be recommended for these patients for the
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vascular and neural structures of the body is inevitable for the patients who suffer from a
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chronic hypoxemic condition secondary to OSAS. The findings of the present study indicated
auditory transduction and transmission mechanisms may also be affected in moderate and
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severe OSAS patients. The authors of this research are of the opinion that, via taking
necessary steps in preventing hypoxemia at the outset, OSAS patients may and should be
protected from the long term detrimental effects of chronic hypoxemia on the auditory
system.
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