By Marcello Cherchi, MD PhD
For patients
Rheumatoid arthritis (RA) can cause problems in joints and in other parts of the body. Sometimes a patient with RA notices ear symptoms (such as hearing loss) or balance problems, and in some cases, those symptoms may be due to RA itself. To figure out if RA is the cause of those symptoms, your doctor may consider checking several tests of hearing and balance function. If no other cause (besides RA) is identified, then continue treatment for RA (usually by your rheumatologist) is sensible; patients with hearing loss may want to consult with an audiologist; and patients with balance problems may want to consult with a vestibular rehabilitation physical therapist.
For clinicians
Overview
Rheumatoid arthritis (RA) is a chronic autoimmune disorder of unknown etiology that can affect multiple organ systems. Some RA patients experience audiologic and vestibular symptoms, though the mechanism by which this occurs is unknown. Compared to healthy controls, among RA patients there is a greater rate of hearing loss (predominantly sensorineural), delayed latencies in cervical vestibular evoked myogenic potentials, abnormal ocular motor findings (including caloric asymmetry) and abnormalities on computerized dynamic posturography. Such results are also found in many other diseases, so in an RA patient with otovestibular symptoms it is medically reasonable to undertake a screening workup for more common causes of such findings. If no other cause is found, then treatment of RA (under the supervision of a rheumatologist) should be undertaken, though consultation with an audiologist (for amplification in RA patients with hearing loss) or a vestibular rehabilitation physical therapist (in RA patients with disequilibrium) is medically reasonable.
Introduction
Rheumatoid arthritis (RA) is a chronic autoimmune disorder of unknown etiology. The articular manifestations tend to be the most prominent, but the disease can affect multiple organ systems (cardiac, pulmonary, ophthalmologic, integumentary and others).
Epidemiology
The global prevalence of RA has been estimated at 0.24% (Cross et al. 2014). Compared to the global prevalence, the rates in the United States may be higher, with the overall age-adjusted prevalence in 2005 was 0.72% (Myasoedova et al. 2010), and the prevalence appears to have increased from 2004 – 2014 (Hunter et al. 2017). RA affects females more than males.
Genetics
Dozens of genes have been associated with RA, particularly in genes encoding HLA (human leukocyte antigens). As with many autoimmune diseases, RA probably results from a combination of genetic predisposition and environmental exposures.
Pathophysiological mechanism of disease
The mechanism by which RA affects the audiovestibular system is unknown.
Clinical presentation
Effat and Berty (Effat and Berty 2023) conducted a questionnaire and examination based study in 141 RA patients and 141 control subjects, and reported that otologic symptoms (otalgia, hearing loss, tinnitus, vertigo) “all had a significantly higher incidence in RA patients compared to control subjects.”
Zonzini and colleagues (Zonzini Gaino et al. 2019) report a higher prevalence of falls in RA patients.
Ocular motor examination
As of this writing there were no published studies regarding face-to-face ocular motor examination in RA patients.
Testing: audiologic
Kakani and colleagues (Kakani et al. 1990) studied audiometry in 25 RA patients and 25 healthy controls, and reported that 6 patients had mild sensorineural hearing loss and one had bilateral mixed hearing loss on audiometry.
Ozkiris and colleagues (Özkırış et al. 2014) conducted a prospective study of 81 RA patients and 81 healthy controls using low frequency and high frequency audiometry. They reported that, “The mean air conduction threshold values at high frequencies (4 kHz, 6 kHz and 8 kHz) in RA group were lower than control groups.”
Yilmaz and colleagues (Yilmaz et al. 2007) studied audiometry 43 RA patients and 30 healthy controls. They reported that 12 RA patients (28%) and 2 controls (7%) had sensorineural hearing loss.
Testing: cervical vestibular evoked myogenic potentials
Heydari and colleagues (Heydari et al. 2015) studied cervical vestibular evoked myogenic potentials in 25 RA patients and 20 healthy controls. They reported that compared to controls, in RA patients the mean peak latency of p13 was significantly higher in both ears, and the mean peak latency of n23 was significantly higher in the left ear. There were no significant differences in mean peak-to-peak amplitude or in amplitude ratios between the groups.
Kent and colleagues (Kent et al. 2023) studied cervical vestibular evoked myogenic potentials in 34 patients with rheumatoid arthritis (RA), 24 patients with ankylosing spondylitis (AS) and 20 healthy controls. They reported that compared to healthy controls, “n1” latencies were prolonged on the right side in RA patients, and the amplitude asymmetry ratio was higher in RA patients.
Testing: ocular motor function
Some, though not all, investigators report abnormal ocular motor findings in RA.
Ozkiris and colleagues (Özkırış et al. 2014) conducted a prospective study of 81 RA patients and 81 healthy controls using videonystagmography. They reported that, “VNG testing revealed central abnormalities in twenty patients (25%), peripheral abnormalities in five patients (6%), and mixed abnormalities in six patients (7%).”
Yilmaz and colleagues (Yilmaz et al. 2007) studied electronystagmography in 43 RA patients and 30 healthy controls. They reported that, “the results of electronystagmography revealed central abnormalities in nine patients (20.9%), peripheral abnormalities in three (6.9%), and mixed abnormalities in three (6.9%). Smooth pursuit and saccade tracing impairments were significantly higher in patients with rheumatoid arthritis (P>.05). Canal paresis in patients with rheumatoid arthritis were significantly higher than those in the control group (P=.039).”
Kakani and colleagues (Kakani et al. 1990) studied audiometry in 25 RA patients and 25 healthy controls, and reported that electronystagmography found no abnormalities in saccades or in bithermal caloric stimulation in RA patients.
King and colleagues (King et al. 2002) studied several ocular motor functions in RA patients compared to controls. They reported no statistically significant differences between the two groups in gaze holding, vestibulo-ocular reflex gain or phase, optokinetic slow phase belocity or quick phase amplitude, optokinetic after-nystagmus slow phase velocity or duration, or latency to the illusion of circular vection.
Testing: computerized dynamic posturography
De Lorenzis and colleagues (De Lorenzis et al. 2021) studied computerized dynamic posturography in 30 ERA (“early rheumatoid arthritis”) patients and 30 age- and sex-matched controls. They found that compared to controls, ERA patients exhibited lower composite equilibrium scores, lower somatosensory ratio, lower visual ratio and lower vestibular ratios — in short, ERA patients performed more poorly across the board.
Testing: other
A rheumatologist may monitor RA disease activity through blood tests, but these results do not appear to correlate with otovestibular manifestations of the disease.
Differential diagnosis
The audiologic and vestibular abnormalities described above (high frequency sensorineural hearing loss, abnormalities in cervical vestibular evoked myogenic potentials and in ocular motor studies) are found in many other diseases as well.
In an RA patient complaining of audiologic or vestibular symptoms, it is medically reasonable to undertake a screening otovestibular workup to assess for more common causes of such symptoms. If this reveals no compelling evidence for an alternative explanation, then by exclusion, RA is reasonable to consider.
Treatment
Logically, treatment of audiologic and vestibular symptoms attributed to RA should probably be the same as treatment for RA itself, and is usually overseen by a rheumatologist.
However, in RA patients with hearing loss it is reasonable to consult audiology to be evaluated for amplifications. Similarly, in RA patients with disequilibrium it is reasonable to consider a trial of vestibular rehabilitation therapy in an attempt to reduce fall risk.
Prognosis
Curiously, of the studies that report otovestibular abnormalities in RA patients, most explicitly comment that these abnormalities did not correlate in any statistically significant way with disease duration (Kakani et al. 1990; Özkırış et al. 2014; Yilmaz et al. 2007).
References
Cross M, Smith E, Hoy D, Carmona L, Wolfe F, Vos T, Williams B, Gabriel S, Lassere M, Johns N, Buchbinder R, Woolf A, March L (2014) The global burden of rheumatoid arthritis: estimates from the global burden of disease 2010 study. Ann Rheum Dis 73: 1316-22. doi: 10.1136/annrheumdis-2013-204627
De Lorenzis E, Crudo F, Fedele AL, Fiorita A, Bruno D, Paludetti G, Alivernini S, Giraldi L, Picciotti PM, Zoli A, Cadoni G (2021) Postural control and disability in patients with early rheumatoid arthritis. Clin Exp Rheumatol 39: 1369-1377. doi: 10.55563/clinexprheumatol/hkfeur
Effat KG, Berty A (2023) Otological symptoms in patients with rheumatoid arthritis of the temporomandibular joint. Cranio: 1-8. doi: 10.1080/08869634.2023.2260281
Heydari N, Hajiabolhassani F, Fatahi J, Movaseghi S, Jalaie S (2015) Vestibular evoked myogenic potentials in patients with rheumatoid arthritis. Med J Islam Repub Iran 29: 216.
Hunter TM, Boytsov NN, Zhang X, Schroeder K, Michaud K, Araujo AB (2017) Prevalence of rheumatoid arthritis in the United States adult population in healthcare claims databases, 2004-2014. Rheumatol Int 37: 1551-1557. doi: 10.1007/s00296-017-3726-1
Kakani RS, Mehra YN, Deodhar SD, Mann SB, Mehta S (1990) Audiovestibular functions in rheumatoid arthritis. J Otolaryngol 19: 100-2.
Kent AE, Gürses E, Karabekiroğlu F, Genç A (2023) Balance Impairment in Patients with Rheumatoid Arthritis and Ankylosing Spondylitis. Curr Rheumatol Rev. doi: 10.2174/1573397119666230828162611
King J, Young C, Highton J, Smith PF, Darlington CL (2002) Vestibulo-ocular, optokinetic and postural function in humans with rheumatoid arthritis. Neurosci Lett 328: 77-80. doi: 10.1016/s0304-3940(02)00219-7
Myasoedova E, Crowson CS, Kremers HM, Therneau TM, Gabriel SE (2010) Is the incidence of rheumatoid arthritis rising?: results from Olmsted County, Minnesota, 1955-2007. Arthritis Rheum 62: 1576-82. doi: 10.1002/art.27425
Özkırış M, Kapusuz Z, Günaydın İ, Kubilay U, Pırtı İ, Saydam L (2014) Does rheumatoid arthritis have an effect on audiovestibular tests? Eur Arch Otorhinolaryngol 271: 1383-7. doi: 10.1007/s00405-013-2551-8
Yilmaz S, Erbek S, Erbek SS, Ozgirgin N, Yucel E (2007) Abnormal electronystagmography in rheumatoid arthritis. Auris Nasus Larynx 34: 307-11. doi: 10.1016/j.anl.2006.11.003
Zonzini Gaino J, Barros Bértolo M, Silva Nunes C, de Morais Barbosa C, Sachetto Z, Davitt M, de Paiva Magalhães E (2019) Disease-related outcomes influence prevalence of falls in people with rheumatoid arthritis. Ann Phys Rehabil Med 62: 84-91. doi: 10.1016/j.rehab.2018.09.003
