Clinical and Experimental Rheumatology 2005; 23: 701-703. BRIEFPAPER Assessment of the ear ABSTRACT nostic purposes (3-5). and otoacoustic emission O b j e c t i v e . We aimed to assess oto - The OAE findings of the patients with findings in fibromyalgia acoustic emission (OAE) findings in FM syndrome have remained unclear fibromyalgia (FM) syndrome. to date. The objective of this study was syndrome Methods. Thirty-two ears of 16 female to address this issue and assess OAE patients with FM syndrome and 30 ears findings in FM syndrome. 1 1 M. Yilmaz , E. Baysal , of 15 healthy female controls were also B. Gunduz2, A. Aksu3, included in the study. Pure tone audio - Materials and methods N. Ensari1, J. Meray3, m e t ry, speech discrimination testing, Thirty-two ears of 16 female patients Y.A. Bayazit1 t y m p a n o m e t ry and otoacoustic emis - who were diagnosed as having FM sion testing (both transiently evoked syndrome were included in the study 1Department of Otolaryngology, 2Depart- and distortion product) were perform - after informed consent was obtained. ment of Audiology, and 3Department of ed. The ages of patients ranged from 22 to Physical Medicine, Faculty of Medicine, Results. There was no significant dif - 45 years (31.5 years). Thirty ears of 15 Gazi University, Besevler, Ankara, Turkey. ference between the pure tone hearing healthy females were also included in Metin Yilmaz, MD, Assistant Professor; results of the patients and controls (p > the study and comprised of the control Elif Baysal, MD, Resident; Bulent Gunduz, PhD, Speech Language Pathologist; At i l l a 0.05). There was no significant differ - group. Their ages ranged from 21 to 42 Aksu, MD, Resident; Nuray Ensari, Resi- ence between the distort i o n - p ro d u c t - years (mean 33.2 years). dent; Jale Meray, MD, Professor and otoacoustic emission results of the The diagnosis of FM syndrome was Head, Dept. Phys. Med.; Yildirim A. patients and controls. Audiologic find - made on the basis of the criteria of the Bayazit, MD, Associate Professor. ings of the patients with and without American College of Rheumatology, Please address correspondence to: otologic symptoms were not signifi - 1990 (6). Briefly, the criteria were dif- Doc. Dr. Yildirım A. Bayazit, Mithapasa cantly different than controls (p > fuse aches and stiffness in the muscle Cad. Emek Apt. 51/12, 06640 Kizilay, 0.05). and tendon insertions on digital palpa- Ankara, Turkey. C o n c l u s i o n . Although FM patients tion with an approximate force of 4 kg E-mail: [email protected] generally have subjective symptoms (the amount of pressure required to Received on November 29, 2004; accepted related to ear, clinical or laboratory as - blanch a thumbnail) lasting for at least in revised form on June 24, 2005. sessments usually fail to find out any 3 months. To meet the diagnostic crite- © Copyright CLINICALAND EXPERIMEN- objective finding related to these sub - ria, pain must be in 11 or more out of TAL RHEUMATOLOGY 2005. jective symptoms. The otologic func - the 18 specified tender point sites. The tions seem spared in FM syndrome. FM impact questionnaire was applied Key words: Fibromyalgia syndrome, to all patients (7) (Table I). The patients audiometry, otoacoustic emissions. Introduction had no symptoms other than pain, and Fibromyalgia (FM) syndrome causes those with the objective sign of articu- chronic and disabling pain (1). This is a lar or periarticular disease, erythrocyte syndrome of unknown etiology, and is sedimentation rate more than 10 mm/h characterized by chronic widespread ( We s t e rgren), positive latex fixation pain, increased tenderness on palpa- test, elevated creatine phosphokinase tion, and some additional symptoms values, and obvious underlying disease like disrupted sleep, stiffness, fatigue, such as diabetes mellitus, chronic renal psychological disease and cold intoler- insufficiency, epilepsy, chronic psychi- ance. This syndrome is mostly seen in atric disorder, multiple sclerosis, or hy- females. There may be neuroendocrine pothyroidism were not admitted to the dysfunctions in FM syndrome (2). study. Otoacoustic emissions (OAE) are ac- Otolaryngologic assessment included oustical signals, which occur sponta- p a t i e n t ’s history, and otolaryngologic neously as narrow band tonal signals or and audiologic investigations. In the after stimulation of the ear. Both patient’s history, questions were asked TEOAEs (transiently evoked OAE) for the presence or absence of hearing and DPOAEs (distortion product OAE) loss, tinnitus, aural fullness and verti- are produced by active micromech- go. anisms of the outer hair cells (OHCs) Audiometric evaluation: Pure tone au- of the organ of Corti. The DPOAE, diometry results and speech discrimi- which is a consequence of normal non- nation scores were obtained (AC 40, linear processes in the cochlea, has Denmark). Tympanometry (Audiomet gained popularity as a clinical test for Sat 30, Germany), and TEOAE and hearing screening, research and diag- DPOAE testing (ILO, England) were

701 BRIEFPAPER Auricularfindings in fibromyalgia / M. Yilmaz et al. performed. The pure tones were ob- Table II. Frequency specific pure tone audiometry results. tained at the frequencies of 250, 500, Group Frequencies on audiometry 1000, 2000, 4000 and 6000 Hz, and Pure tone results (dB ± Standard deviation) pure tone averages were calculated at the frequencies of 500, 1000 and 2000 250 500 1000 2000 4000 6000 Hz. FM 20 ± 5 13 ± 5 11 ± 5 8 ± 5 9 ± 6 15 ± 8 The TEOAEs and DPOAEs were Control 17 ± 9 12 ± 8 9 ± 6 9 ± 8 12 ±13 21 ±15 recorded consecutively and analyzed utilizing the ILO-96 cochlear emission analyzer (Otodynamics, London). The Table III.Amplitudes recorded on DPOAE testing. TEOAEs were obtained with stimuli Group f2 frequencies on DPOAE testing consisting of clicks of 80 ms duration. Amplitudes (dB ± Standard deviation) The stimulus level in the outer ear was set at 80 ± 3 dB per SPL. The click rate 1 2 3 4 5 6 was 50 per second, and post-stimulus FM 8.1± 6.8 7.2 ±7.2 4.8 ± 7.9 7.5 ± 7.4 11.3± 8.1 0.4± 8.6 analysis was in the range of 2 to 20 ms. Control 6.2± 5.5 7.5 ±5.1 5.4 ± 5.1 9.4 ±14.9 7.7± 6.7 2.9± 4.5 A total of 260 sweeps was averaged above the noise rejection level of 47 dB. Stimuli were presented in the non- Statistics lation rather than on an acute inflam- linear mode, in which every fourth The results of patients and controls matory reactivation of the disease (10). click stimulus was inverted and three were compared using the Kruskal Wal- Although FM syndrome is mainly times greater in amplitude than the lis test, and confirmation of the results characterized by widespread pain, there three preceding clicks. A TEOAE was were made using the Chi-square test. may also be some other symptoms sug- defined as a response if its amplitude gesting involvement of the other sys- was ³ 3 dB above the level of the noise Results tems in the body. A number of otologic floor. Reproducibility percentages ³ 60 Of 16 FM patients, 11 (68.7%), 9 manifestations can be seen in FM syn- percent were taken into account as ac- (56.2%), 7 (43.7%) and 6 (37.5%) drome, which can bring the patient to ceptable for analysis at four successive complained of tinnitus, vertigo, hearing otolaryngologist initially. Almost 50% frequency bands. loss and aural fullness, respectively. of the patients have some sort of oto- DPOAEs were measured where the There was no significant difference be- neurologic symptoms despite the fact intensity levels of the primary tones tween the pure tone hearing results of that the majority of them have normal held constant. DPOAE data were re- the patients and controls (p > 0 . 0 5 ) audiovestibular test results (11). These corded for different frequency regions (Table II). The TEOAEs could be ob- findings are in parallel with the results from 1 to 6.3 kHz and plotted as a func- tained in all patients and controls. in this study. tion of f2. The frequency ratio of the There was no significant difference be- Audiologic findings of the patients and two primary tones (f2/f1) was fixed at tween the DPOAE results of the pa- controls were similar. In other words, 1.22. Stimulus levels were kept at 65 tients and controls (p>0.05) (Table III). external ear canal and tympanic mem- dB for f1 and 55 dB for f2 frequencies. Audiologic findings of the patients brane were normal on otoscopic exam- DPOAE measurement at 2f1-f2 was with and without otologic symptoms ination. Middle ear was normal on pure considered significantly different from were not significantly different than tone audiometry and tympanometry. the background noise if it exceeded it controls (p > 0.05). Finally, cochlear functions were nor- by at least 3 dB. mal as far as the results of audiometry Discussion and OAE testing are concerned. Otolaryngologic disturbances may be Some of the patients in this study had Table I. Body sites and rates of the tender- seen in a variety of autoimmune or subjective cochleovestibular symp- ness points. rheumatoid diseases like systemic lu- toms, but their otolaryngologic and au- pus erythematosus, Wegener’s granulo- diologic assessments were normal. Body site Tenderness point No. Patients (%) matosis, relapsing polychondritis, pol- There was no difference between the yarteritis nodosa, cogan’s syndrome, results of patients with and without Occiput 8 (50) S j ö g r e n ’s syndrome, Churg - S t r a u s s neurotologic symptoms. This condition Low cervical 11 (68.8) syndrome and Behçet’s disease (8, 9). may suggest that cochleovestibular Trapezius 11 (68.8) It was also reported that there is a coch- symptoms are not associated with an Supraspinatus 13 (81.3) Second rib 14 (87.5) lear impairment in rheumatoid arthritis organic ear disorder in FM syndrome. Lateral epicondyl 15 (93.8) that can be confirmed by TEOAE test- In addition to that, patients with FM Gluteal 10 (62.5) ing and that inner ear injury depends on syndrome may have an altered percep- Trochanter 13 (81.3) chronic damage to the cochlea due to tion of normal and disease states. This Knee 14 (87.5) impairment of the inner ear microcircu- contention could be supported by the

702 Auricular findings in fibromyalgia / M. Yilmaz et al. BRIEFPAPER previous study that showed a general- jective symptoms. The otologic func- 7. B U R C K H A R D T DS, CLARK SR, BENNETT ized disturbance of perceptual thresh- tions seem spared in FM syndrome. RM: The fibromyalgia impact questionnaire development and validation. J Rheumatol olds in patients with FM, which was 1991; 18: 728-33. not restricted to the perception of pain References 8. PAPADIMITRAKI ED, KYRMIZAKIS DE, KRI- (12). The patients may have reduction 1. I N A N I C I F, YUNUS MB: History of fibro- T I K O S I, BOUMPAS DT: Ear- n o s e - t h r o a t of cognitive functions, unprotected myalgia: past to present. Curr Pain Head - manifestations of autoimmune rheumatic dis- ache Rep 2004; 8: 369-78. eases. Clin Exp Rheumatol 2004; 22: 485-94. psychological functioning, and increas- 2. YUNUS BM: Fibromyalgia syndrome current 9. BAYAZIT YA, EVEREKLIOGLU C, OZER E et ed mental load, and somatic symptoms concepts of biophysiological mechanism and al.: Neurotological status in Behcet’s disease (13). management. Tibbi Rehabil Derg 1997; 8: and its ophthalmological correlates. Postgrad It was reported that there is an increase 120. Med J 2004; 80: 724-8. 3. L I U TC, HSU CJ, HWANG JH, TSENG FY, 10. S A LVINELLI F, D’ASCANIO L, CASALE M: in regional cerebral blood flow in the CHEN YS: Effects of alcohol and noise on Staging rheumatoid arthritis: what about oto- caudate nuclei as well as a reduction in temporary threshold shift in Guinea pigs. acoustic emissions ? Acta Otolaryngol 2004; the pons and cerebral cortex in FM ORL J Otorhinolaryngol Relat Spec 2004; 124: 874-5. (14). That alteration in the cerebral 66: 124-9. 11. BAYAZIT YA, GURSOYS, OZER E, KARAKU- 4. SHERA CA: Mechanisms of mammalian oto- RUM G, MADENCI E: Neurotologic manifes- blood flow may lead to changes in per- acoustic emission and their implications for tations of the fibromyalgia syndrome. J Neu - ception in the patients with FM. The the clinical utility of otoacoustic emissions. rol Sci 2002; 15: 77-80. blood circulation in the cochlea seems Ear Hear 2004; 25: 86-97. 12. DOHRENBUSCH R, SODHI H, LAMPRECHTJ, 5. K O R R E S S, NIKOLOPOULOS T, FEREKIDIS GENTH E: Fibromyalgia as a disorder of per- spared in FM as far as audiologic re- E, GOTZAMANOGLOU Z, GEORGIOU A , ceptual organization? An analysis of acoustic sults of the patients are concerned. The B A L ATSOURAS DG: Otoacoustic emissions stimulus processing in patients with wide- otologic symptoms described by the in universal hearing screening: which day spread pain. Z Rheumatol 1997; 56: 334- 41. patients may be attributed to perceptual after birth should we examine the newborns? 13. WENTZ KA, LINDBERG C, HALLBERG LR: ORL J Otorhinolaryngol Relat Spec 2003; Psychological functioning in women with fi- changes rather than an ear disorder. 65: 199-201. bromyalgia: a grounded theory study. Health In conclusion, although FM patients 6. W O L F E F, SMYTHE HA, YUNUS MB, BEN- Care Women Int2004; 25: 702-29. generally have subjective symptoms NETRM, BOMBARDIER C, GODENBERG DL: 14. GUR A, KARAKOC M, ERDOGAN S, NAS K, related to ear, clinical or laboratory as- The American College of Rheumathology C E V I K R, SARAC A J: Regional cerebral 1990 criteria for the classification of fibro- blood flow and cytokines in young females sessments usually fail to find out any myalgia. A rthritis Rheumatism 1990; 33: with fibromyalgia. Clin Exp Rheumatol objective finding related to these sub- 160-72. 2002; 20: 753-60.

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