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