Rheumatoid Arthritis Involved in the Ear Drum

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It is commonly known that hearing can be affected by rheumatoid arthritis (RA), a systemic inflammatory disease which can affect multiple organ systems. However, it remains controversial whether RA can affect the ossicular joints and cause a conductive hearing loss, as has been reported in isolated cases. Most studies of hearing in patients with RA show sensorineural hearing loss but either transitory or minimal conductive hearing loss from ossicular problems. Some have suggested that RA might affect the middle ear not by impairing conduction but rather by reducing the ear's protective mechanisms (1). We report here a possible direct cause for conductive hearing loss in patients with RA and provide an explanation for secondary inner ear conditions due to inflammation.CASE REPORTClinical NotesA 59-year-old woman with a 20-year history of RA consulted for the first time at the ENT Department with otalgia, hearing loss, and dizziness. She was also having a disabling RA crisis. Before the consultation, numerous RA treatments had been prescribed, some of which were no longer effective.On examination, her external ear canals were inflamed and sensitive; the tympanic membranes were gray without any light reflex, and the audiogram showed mixed hearing loss with air conduction pure-tone average thresholds of 38.5 and 22.5 dB and air-bone gaps of 23 and 10 dB for the right and left ear, respectively. She was diagnosed with bilateral serous otitis. Treatment for her RA crisis consisted of a corticosteroid bolus, which was also effective for her hearing. In the following months, she presented with several similar episodes (without systematic audiometric examination), which were again successfully treated with corticosteroids.One year later, after a further episode of severe conductive hearing loss (>30-dB air-bone gap), a ventilation tube was placed in her right ear. Despite this intervention, both conductive and sensorineural hearing loss continued to progress. A computed tomographic scan showed a total invasion of the right middle ear and a partial invasion of the left ear by a dense tissue mass. A surgical exploration of the right ear was conducted and revealed nonspecific inflammatory tissue invading the entire eardrum.Over time, the patient continued to present with RA disorders, developing extra-articular symptoms such as episcleritis, peripheral neuropathies, and spontaneous fracture of the odontoid process. Two years after the first ENT examination, the patient was profoundly deaf in the right ear. Currently, 4 years since the initial examination, her RA is stable, and her left ear has a mixed hearing loss of 25 dB, with an air-bone gap of 10 dB.HistopathologyThe resected mass consisted of fibrous tissue riddled with inflammatory elements, primarily mononucleates. Capillary neogenesis was apparent in some fragments, whereas another fragment revealed a necrosis pocket surrounded by epithelioid histiocytes with acidophile cytoplasm and stretched nucleus (Fig. 1). As it is rare to find such rheumatoid histological features in the ear, the diagnosis of a rheumatoid nodule could not have been made without previous knowledge of the patient's RA condition.DISCUSSIONRheumatoid nodules, the predominant lesions of subcutaneous periarticular soft tissue, also can be found in different ENT sites such as the pharynx, larynx, nose, or external ear (2) as well as the temporal bone. We find only 1 previous report in the literature of RA nodules in the temporal bone (3). RA nodules are reported to appear in approximately 20% of advanced seropositive RA cases (1). Therefore, it may be beneficial to perform a magnetic resonance imaging when serous otitis is suspected in patients with RA.

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