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11th clinical conference 2011-2012
Guided byMs
Sreena.E.N
“Nasopharyngeal Carcinoma and Hearing Loss”
A Case Report Presented by
Neelima Chellappan
Hemy Elsa Abraham
HEARING……..
Among five basic senses, hearing is one of the most important sense as it not only help us in hearing all sounds in our surrounding world but it is also a prerequisite for the development of normal speech and language…
• .
Outer ear
Ability to perceive sound by detecting vibrations through ear
Senses Sound
Equilibrium
Hearing loss???“Generic term referring to any organic hearing problem regardless of etiology or degree…”
Hearing Loss
Congenital Hearing LossAcquired Hearing Loss
Types of hearing loss
Conductive
Sensori-neural
Mixed
Conductive Hearing Loss AtresiaWaxOtitis externaOtitis mediaCholesteatomaOtosclerosisOssicular discontiunityGlomus Tumor
Mixed Hearing LossConductive
Sensorineural
Mixed
Sensorineural Hearing Loss Congenital birth
defects Hereditary/genetic
factors Noise trauma Head injury Ototoxicity
Aging Measles Mumps Meningitis Meniers Tumors
uncontrollableirreversible
independent
uncoordinated autonomous
unlimited abnormal
Characterised by
WHAT IS CANCER ???
over growth of tissues.
Cancer spreads…
By invasion to the
surrounding tissues
By metastasi
s to distant
sites
Malignant
Benign
Types of
Cancers
CANCER & HEARING LOSS
How both are related????
Direct Effect
IndirectEffect
Treatment of cancer
Tumor within or outside the
auditory system
Hearing Loss Resulting from Cancer
Sensorineural Hearing Loss
Conductive Hearing Loss
Reversible
Progressive &
Irreversible
INDIRECT EFFECTS
Treatment
Radiation
therapy
Chemo-
therapy
Radiation damages sensory hair cells of the inner ear
Sensorineural hearing loss
Chemotherapy
Damage the hair cells
Sensorineural Hearing loss
Chemotherapy drugs used for
Head & neck cancer
Cervical carcinoma
Lung cancer
Neurologic cancer
Breast cancer
leukimia
Brain tumour
Neuroblastoma
Nasopharyngeal carcinoma
Results in Hearing
loss
Oto-toxic Chemotherapy
Drugs
Nitrogen mustard
Carboplatin
Cisplatin
Perspective studies show evidence of irreversible high frequency hearing loss in patients receiving chemotherapy drugs…
Out of 32 patients (aged 30-59yrs), hearing loss was confirmed in 23%of patients
Out of 67 patients (aged 8 months to 23 years), 61% developed hearing loss following onset of treatment
[Annuals of Oncology,2002]
[Oregon health & science center,2005]
Within the auditory system
Glomus Tumors
• Most common benign neoplasm of the middle ear.
• Patients present with conductive hearing loss, pulsatile unilateral tinnitus & a middle ear mass
• A type tympanogram with tiny saw-tooth variations
Cerebellopontine angled Tumors
• 80% 0f tumors are acoustic neuromas
• Patients present with a progressive, unilateral, sensorineural hearing loss
• Reduced SDS scores, Roll over will be present,absent reflexes
• ABR will demonstrate an increased wave I to V interpeak latency
DIRECT EFFECTS
Acoustic neuroma
Cerebellopontine Angle Lesions
Outside the Auditory System
Nasopharyngeal Cancer
Cancer that occurs in the nasopharynx, which is located behind the nose and near the Eustachian Tube Conductive hearing loss is the most common symptom Sometimes leads to sensorineural hearing loss also
Nasopharyngeal Carcinoma
31
• It occurs in the nasopharynx, which is located behind the nose and above the back of the throat.
• The nasopharynx is the upper portion of the pharynx — a 5-inch tube that extends from behind the nose to the top of the windpipe and esophagus.
• NPC is the most common neoplasm to cause unilateral ET obstruction.
Malignant tumors of nasopharynx
Squamous Cell Carcinoma
Lymphoma
Large Miscellaneous Group
INCIDENCE & PREVALENCE
Age
40-50 years
Well known to ENT specialist but not
familiar to audiologist
neck mass
head ac
he
ear pain
nasal o
bstructi
on
facial
pareath
esia
dysphag
ia
diplopia
eye pain
exopthalm
os0
10203040506070
Symptom from NPC found in Siriraj hospital 2532
Clinical manifestations
0102030405060
Symptom & sign of NPC frequency at diagnostic in Mayo clinic series Kuala Lumpur 1983
Causes
Genetic factors
Environmental
factorsmicroele
ment nickel(Ni
)
Epstein barr virus
Ear involvement
•Resulting from eustachian
tube involvement
•Sensation of ear blockage
•Serous otitis media
•Conductive hearing loss
•Tinnitus
A Study……
Beth McLeod & Glen Croxson (2004 )
Subject:52 year old manPresent
complaints
a blocked feeling in the
left ear, & tinnitus
Test results
PTA :Rt ear-normalLt ear-38 dB
Lt ear:-Flat tympanogram
with absent reflexes
Rt ear:- normal
Diagnosed as mild to moderate conductive HL for the left ear
On further evaluation the case was diagnosed as NPC
Post treatment assessment
Both PTA & tympanometry
indicated symmetrical
normal hearing
The case study is offered to illustrate the necessity for audiologists to be aware that unilateral effusions are associated with NPC
Treatment
First by radiation therapy
surgery
Chemotherapy
Pathophysiology of hearing loss from treatment..
Chemo therapy and radiation Results in ototoxicity
Free radicals
•They are very reactive & unstable substances which cause damage to the cell walls
How are free radicals produced??
They are formed from exposure to elements in chemotherapy & radiation therapy.
How are they harmful???
Other StudiesYupa &Vasana,2007
• Clinicians should inform patients of the risk of hearing loss, particularly the treatment with cisplatin. • Hearing test should be a routine test after chemotherapy.
Ling, Wen-Rei Kuo, Kuen-Yao Ho, Ka-Wo Lee,2003
• The pre- and post-therapeutic hearing levels were recorded in a previously published study of 20 patients receiving radiotherapy for NPC
• The incidence of SNHL increased significantly with increasing dose of radiation.
Henriette B. Honore, Soren M. Bentzenb, Kitty Mollerc, Cai Graud,2002
• After RT, at least a 10 dB loss in bone conduction threshold at speech frequency• effect of radiation on hearing tended to be chronic and progressive.
KWONG,WEI&YUEN,1996
• BC Thresholds at 0.5,1,2,4 kHz kHz were compared with pretreatment thresholds at respective frequencies.• SNHL occurred after radiotherapy, more commonly affecting high frequency.
CASE PRESENTATION
Present Complaints.. Came on 09-07-2011
Reduced hearing
since 2 years
C/O Tinnitus (continous low
frequency)
H/o ear discharge from
both ears for the past 6 months
Case name: XAge/sex: 42yrs/F
R/O progress in hearing sensitivity
No C/o vertigo
No C/o Speech discrimination
in noisy situations
Giddiness while hearing loud sounds
Medical History…
Nasopharyngeal Tumor
Underwent Medication
for 4 Months
Took 33 Radiation and
5 Chemo-therapy
Follow-up in every 3 months
Test Results
PTA • Right Ear: 70 dB HL• Left Ear : 63.3 dB HL
ImmittanceAudiometry• Bilateral ‘B’ type
tympanogram with absent reflex
Speech Audiometry
Ear SAT SRT SDSRight 55 dB HL 75 dB HL 90%Left 55 dB HL 70 dB HL 100%
Masking could not done since Nautons dilemma was present.
Audiological Interpretation
•Bilateral moderately severe conductive hearing loss
Recommendations
•ENT Consultation•Re-evaluation after ENT Consultation •Follow Up
Follow up evaluation was not done as the client didn’t turn up
Through telephonic conversation the
patient reported that she is not having the ear discharge after
the treatment
But reported of having difficulty in
hearing and tinnitus in both
ear
Discussion…• Nasopharyngeal cancer results in
hearing loss which can be conductive or sensorineural hearing loss..
• Unilateral conductive hearing loss with a flat tympanogram indicates a middle ear effusion which can be one of the symptom of NPC..
• NPC is the most common neoplasm to cause unilateral Eustachian tube obstruction..
• Bilateral or unilateral ear discharge could be a sign of nasopharyngeal cancer..
It is important to obtain a baseline
audiogram, prior to beginning treatment
or soon after..
Hearing should be monitored at regular
intervals during treatment..
Researchers found that intake of the drug NAC
(N- acetylcysteine) prior to chemotherapy did not suffer from ototoxicity..
Research is going on about Proton beam
therapy which helps in reduced ototoxicity..
Limitations of the study..
Single case report
Improvement in hearing could not be evaluated
Future directions..
Audiometric profile of patient
undergoing cancer
treatment to be developed..
Pre & Post treatment
assessment of hearing must
be done in clinical practice
for future research..
References
Diseases of the ear(6th edition);Harold Ludman & Tony Wright
Auditory Diagnosis(2nd edition);Ross J Roeser
Journal of Medical Association,Thai 2010; 93 (3): 324-9
Journal of Radiotherapy and Oncology 65 (2002) 9–16
• The Australian & New Zealand Journal of audiology, vol 26, 2, 2004, 139-141)
• American Journal of Roentgenology,June 2003 vol. 180
• Journal of Clinical Oncology,1998; 16: 1310–1317.
• Journal of Clinical Oncology,2001; 19: 1105–1110.
Open for
discussion