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Characterization of Vertigo and Hearing Loss in Patients with Fabry

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Characterization of Vertigo and Hearing Loss in Patients with Fabry Köping et al. Orphanet Journal of Rare Diseases (2018) 13:137 https://doi.org/10.1186/s13023-018-0882-7 RESEARCH Open Access Characterization of vertigo and hearing loss in patients with Fabry disease Maria Köping1* , Wafaa Shehata-Dieler1, Dieter Schneider1, Mario Cebulla1, Daniel Oder2, Jonas Müntze2, Peter Nordbeck2, Christoph Wanner2, Rudolf Hagen1 and Sebastian P. Schraven3 Abstract Background: Fabry Disease (FD) is an X-linked hereditary lysosomal storage disorder which leads to a multisystemic intralysosomal accumulation of globotriaosylceramid (Gb3). Besides prominent renal and cardiac organ involvement, patients commonly complain about vestibulocochlear symptoms like high-frequency hearing loss, tinnitus and vertigo. However, comprehensive data especially on vertigo remain scarce. The aim of this study was to examine the prevalence and characteristics of vertigo and hearing loss in patients with FD, depending on renal and cardiac parameters and get hints about the site and the pattern of the lesions. Methods: Single-center study with 57 FD patients. Every patient underwent an oto-rhino-laryngological examination as well as videonystagmography and vestibular evoked myogenic potentials (VEMPs) and audiological measurements using pure tone audiometry and auditory brainstem response audiometry (ABR). Renal function was measured by eGFR, cardiac impairment was graduated by NYHA class. Results: More than one out of three patients (35.1%) complained about hearing loss, 54.4% about vertigo and 28. 1% about both symptom. In 74% a sensorineural hearing loss of at least 25 dB was found, ABR could exclude any retrocochlear lesion. Caloric testing showed abnormal values in 71.9%, VEMPs were pathological in 68%. A correlation between the side or the shape of hearing loss and pathological vestibular testing could not be revealed. Conclusions: Hearing loss and vertigo show a high prevalence in FD. While hearing loss seems due to a cochlear lesion, peripheral vestibular as well as central nervous pathologies cause vertigo. Thus, both the site of lesion and the pathophysiological patterns seem to differ. Keywords: Fabry disease, Vertigo, VEMP, Cardiomyopathy, Chronic kidney disease, Lysosomal storage disorder Background males are usually affected more seriously than heterozy- Fabry disease (FD) is an X-linked lysosomal storage gous women [10, 11]. The accumulation of Gb3 in disorder which is characterized by a reduced or absent kidneys, heart and the nervous system lead to progres- enzyme activity of α-galactosidase A. This leads to an sive kidney failure, cardiomyopathy and Fabry-associated intralysosomal accumulation of globotriaosylceramid pain or stroke [12–14]. Consequently, life expectancy is (Gb3), which results in tissue damage of kidneys, heart reduced by 15–20 years due to end-stage complications and the nervous system [1–4]. The incidence of FD was as sudden cardiac death or renal failure [10, 11]. previously stated at 1:40.000 to 1:117.000 [5, 6], whereas Another, yet poorly understood, organ involvement is of recent studies assumed a much higher occurrence with the cochleovestibular system leading to progressive demographic and ethnical correlation as newborn asymmetric hearing loss, tinnitus and vertigo [15–17]. screenings in Taiwan or Italy suggest [7–9]. Hemizygous Histological temporal bone findings showed hyperplastic mucosa and seropurulent effusion in the middle ear, * Correspondence: [email protected] strial and spiral ligament atrophy and loss of outer hair 1Department of Oto-Rhino-Laryngology, Plastic, Aesthetic and Reconstructive cells. A Gb3-storage in spiral ganglia could not be found. Head and Neck Surgery, Comprehensive Hearing Center (CHC) and Fabry Center for Interdisciplinary Therapy (FAZIT), University Hospital Würzburg, There were no pathological findings in sacculus, utricu- Josef-Schneider-Straße 11, Haus B2, D-97080 Würzburg, Germany lus or semicircular canals [18]. Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Köping et al. Orphanet Journal of Rare Diseases (2018) 13:137 Page 2 of 9 Since the introduction of enzyme replacement (Rostock, Germany) as potential indicator for disease therapy (ERT) in 2001, a reduction of Gb3 storage in severity [26]. kidneys and the heart could be shown [19–22]. Furthermore, clinical data suggest a beneficial effect Audiological measurements of ERT in stabilizing hearing loss and improving ves- Audiological measurements were performed with tibular function [16, 17, 23]. calibrated instruments in a sound-proofed room (DIN Despite the profound impact of hearing loss and ver- EN ISO 8253). The audiological evaluation included tigo on patients’ individually experienced health-related standard pure-tone audiometry (air conduction AC: 0.25 quality of life, comprehensive data supporting the devel- through 8 kHz; bone conduction BC: 0.5 through opment of new guidelines for the monitoring and treat- 6 kHz), conducted with a clinical audiometer in 5-dB ment of Fabry disease remain scarce due to prognostic steps. Hearing thresholds were then averaged in 4-pure domination of other organs. The aim of this current tone average (4-PTA: 0.5, 1, 2, 4 kHz) and a modified study was to evaluate the prevalence and characterize 6-pure tone average (6-PTA: 0.5, 1, 2, 4, 6, 8 kHz), the patterns of vertigo and hearing loss in dependence summarizing all values and dividing by 4 resp. 6, so of other Fabry-typical organ manifestations and to get every threshold carries equal weight. Values 10 dB above hints about the site and the pattern of the lesions. normative hearing thresholds were considered abnormal (calculation based on [27]). Otoacoustic emissions (Etymotic ER10, Illinois, USA) Methods were performed in each patient. Furthermore, auditory Subjects brainstem response audiometry (ABR) was performed Fifty-seven FD patients (27 male, 30 female; 46,2 +/− using Eclipse - ASSR EP15/EP25 (Interacoustics, Mid- 13,8 years, range 19–77 years), who attended the Depart- delfart, Denmark) in 56/57 patients. Click stimuli were ment of Oto-Rhino-Laryngology, Plastic, Aesthetic and presented at intensities between 10 and 100 dB HL and Reconstructive Head and Neck Surgery in Würzburg, responses were then averaged and the ABR threshold were investigated between 04/2012 and 11/2016. was visually determined where wave V showed the Informed oral and written consent had been obtained smallest response amplitude. appropriate to the decision of the institutional review board of the medical department Würzburg (20,170,904 Vestibular measurements 01; 220/15_z). All patients were recruited from the Videonystagmography (VNG) with recording of Würzburg Fabry Center for Interdisciplinary Therapy spontaneous nystagmus (SPN) and caloric testing with (FAZIT) within the scope of routine check-ups irrespect- warm (44 °C) and cold (30 °C) water or air (Videonys- ive of any ENT symptoms or comorbidities. Inclusion tagmograph VNG ULMER, Synapsys SA, Marseille, criteria were age ≥ 18 years and confirmed diagnosis of France) were performed. Results were considered abnor- FD by DNA testing and α-galactosidase A assay. mal when canal paresis factor (CP) was above 25%. Cervical Vestibular Evoked Myogenic Potentials (cVEMPs) Clinical examination were recorded ipsilaterally from the tonically activated Medical history was taken of all patients before a sternocleidomastoid muscle by surface electrodes. Ocular complete oto-rhino-laryngological examination. Espe- VEMPs (oVEMPs) were detected contralaterally by surface cially, they were asked about hearing loss, tinnitus and electrodes inferior the eye, while the patient was vertigo as well as ototoxic medication, noise exposure or looking upward. Stimulation was carried out with infections. monaural clicks of 100 dB and a rate of 5,1 Hz each Glomerular filtration rate (CKD-EPI equation) was via insert tips. Each measurement was performed measured to estimate renal function with following twice and results averaged. graduation: ≥90, 60–89, 30–59 and ≤ 29 ml/min/1.73 m2 [24]. Cardiac function was classified by NYHA score Statistical significance (class 1: no limitation of physical activity; class 2: slight A normal distribution was not found using Shapiro-Wilk limitation, ordinary physical activity results in fatigue, test, so Kruskal-Wallis test and pairwise Wilcoxon’s rank palpitation or dyspnea; class 3: marked limitation, com- sum test were applied. Statistical significance was set at fortable at rest, less than ordinary activity causes fatigue, the 95% confidence level and above (p < 0.05). palpitation or dyspnea; class 4: unable to carry out any physical activity without discomfort, symptoms of heart Results failure at rest) [25]. Patients with no structural cardiac All 57 patients had normal otoscopy results. Two pa- disease were distributed to class 0. Serum lyso-Gb3 tients were wearing hearing protection at work because (reference: < 0.9 ng/mL) were
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