The Mediterranean Journal of

ORIGINAL ARTICLE

Relationship between Acoustic Trauma and Serum Level of Vitamin B12, Folic Acid, Zinc, Magnesium and Malondialdehyde

Bilal Çetin, Engin Çekin, Hakan C›nc›k, Atila Güngör

Sivas Military Hospital, Department of Otolaryngology (B. Çetin) INTRODUCTION: In our study, relationship between due to Gulhane Military Medical Academy acoustic trauma and serum levels of vitamin B12, folic acid, zinc, Department of Otolaryngology, magnesium and malondialdehyde were investigated. Haydarpasa Training Hospital, ‹stanbul; (E. Çekin, H. C›nc›k, MATERIAL AND METHODS: The study was carried out on 135 healthy male A. Güngör) individuals who were subjected to 138 dB sound intensity level. The mean age was 22 years. Pure-tone tests including high frequencies Correspondent Author: were performed to all individuals at one day before, same day and one Dr. Bilal ÇET‹N month later with reference to the time of acoustic trauma. One day and Sivas Asker Hastanesi Otolaryngology Dept. Sivas-Turkey four days after acoustic trauma, serum levels of vitamin B12, folic acid, zinc, magnesium and malondialdehyde were measured. Tel : 903462212038 RESULTS: After acoustic trauma, notch type hearing loss at 4000 Hz Fax : 903462249971 frequency was observed in 83 of the participants. However there was no Email: [email protected] significant difference among high frequency audiometry thresholds (p>0.05). There was a statistically significant difference between serum Submitted: June 3, 2008 Revised: September 10, 2008 levels of malondialdehyde before and after acoustic trauma in all subjects Accepted: September 24, 2008 (p<0.05). There was no significant relationship between hearing loss due to acoustic trauma and serum levels of vitamin B12, folic acid, zinc and Mediterr J Otol 2008; 164-169 magnesium (p>0.05). CONCLUSION: These results indicate that free oxygen radicals play a role in

Copyright 2005 © The Mediterranean the pathophysiology of acoustic trauma even though it is not directly Society of Otology and related to the serum levels of vitamin B12, folic acid, zinc and magnesium.

164 Relationship between Acoustic Trauma and Serum Level of Vitamin B12, Folic Acid, Zinc, Magnesium and Malondialdehyde

Noise-induced hearing loss (NIHL) is one of the most levels and hearing loss if it is present. For this purpose common ten occupational diseases. It causes both we investigated hearing loss and serum levels of manpower and financial loss [1]. vitamin B12, folic acid, zinc, magnesium and The most common reason for NIHL is loss of outer malondialdehyde (MDA) in individuals subjected to hairy cells in organ of Corti. At first stereocilia of high intensity noise. outer hairy cells become stiff and dysfunction. After cessation of noise, stereocilias renew themselves. This MATERIAL AND METHODS condition is defined as temporary threshold shift. If noise continues, stereocilias adhere to each other and it may lead to permanent hearing loss. At further period This study is performed on 135 healthy male of time inner hairy cells injury and secondary neural military personnel with normal hearing levels. Their degeneration may develop. Pathology occurring at ages were 21 to 24 years old (mean age 22). All basal turn of leads to hearing loss of high individuals were subjected to acoustic trauma during frequencies at first. In due course, injury happens at Habitable Place Battle Training (HPBT). This training apical part, and low frequencies are affected. At noise is a routine for Infantry School Commandership levels of more than 85 decibels (dB), hearing loss training program. A G3 A3 automatic infantry rifle begins and it affects first high frequencies rather than with 7.62 mm caliber was used in training, and shoots low frequencies [2]. An intense and short term sound were sequentially repeated for 21 times. This process stimulation may cause permanent threshold shift takes about 3 minutes at most. All subjects were without a period of temporary threshold shift and if exposed to acoustic trauma with intensity between 134 this occurs it is called as “acoustic trauma”. This to 142 dB Sound Pressure Level (average 138 dB) trauma may lead to damage of organ of Corti, rupture according to our measurements. They were all of the membranes and flow of the perilymph and informed for the risk of the blast injury by trainers but endolymph to each other. As a result, acoustic trauma because of training standards, protection against the may cause much more hearing loss compared to sound was not an obligation. Almost all of the chronic noise. There is no single degenerative participants did not used ear plug or goggle during mechanism taking part in noise-induced cell injury. As training. The volunteers among individuals were a result of more than one stimulus such as free oxygen accepted to the study. Before being drafted, all the radicals (FORs) and calcium increase may play role in participants without protection against sound were noise-induced cell injury. The most important injury examined and informed. Sound intensity was caused by FORs is mutations in DNA component of measured by “Radio Shack Sound level meter (Texas, nucleus and mitochondria. The greatest resource of USA)” device. Examination and laboratory study of toxic oxygen radicals is electron transport chain. That participants were made in GATA Haydarpasa Training is why mitochondrial DNA is injured much more by Hospital, Biochemistry and Audiology Laboratories. FORs and that leads to mutations affecting energy The study program was approved by the ethics metabolism. As a consequence of mitochondrial committee of our hospital, and each participant damage that exhibits electromechanical differential provided signed informed consent after receiving and within other cells, ATP production is broken down. extensive explanation of the examination. Finally cellular necrosis and apoptosis occur then Complete blood count, blood and urine biochemical [3,4] hearing loss becomes . analyses (fasting blood glucose, AST, ALT, alkaline In our study, we tried to explain role of oxidative stress phosphatase, lipid profile, urea, creatinine, T3, T4, in pathogenesis of hearing loss in NIHL and we aimed TSH) were done before acoustic trauma. Individuals to investigate relationship between serum electrolyte with abnormal results are excluded from study.

165 The Mediterranean Journal of Otology

Neuro-otological examination and pure tone analyze the non-parametric data. Student t-test was audiometry including high frequencies were used to analyze the parametric data. Statistical performed to all participants one day before acoustic significance was considered at P < 0.05. trauma. Audiometry was done by the same audiometrist with “Interacoustic AC-40 (Denmark)” RESULTS model audiometer. Participants with abnormal results, those with ear and/or mastoid surgery history and those with hearing loss were excluded from study. Those Taking into consideration that American Academy with hearing loss more than 24 dB at high frequencies of Otolaryngology and Head & Neck Surgery and those using ototoxic medications were also Foundation’s suggestion; “It should be accepted as excluded from study. Pure tone audiometry was acoustic trauma depending on hearing loss when a repeated 24 hours and one month after acoustic trauma change of 15 dB or more at 500, 1000, or 2000 Hz; or in order to avoid temporary threshold shift. 20 dB or more at 3000,4000 or 6000 Hz frequencies in consecutive audiograms”. These values were accepted All participants’ serum level of vitamin B12, folic as standard in our study [5]. acid, zinc, magnesium and MDA were measured We have detected permanent hearing loss more before and 4 days after acoustic trauma. than 20 dB (37.5±17.5) at 2000-6000 Hz in 83 Measurement of serum vitamin B12, folic acid, participants (62 %) (Paired Sample T Test p<0.05). No zinc, and magnesium were performed by means of significant difference was found between high microparticle enzyme immunoassay method with frequency audiometer thresholds (8000-20,000 Hz) “Abbott Axsym System (Germany)” automatized (Mann-Whitney U Test, p<0.05). analysator. MDA levels were measured by Shinmadzu There was no significant relationship between RF 5000 spectroflorophotometer (Spain). In the hearing loss and serum levels of vitamin B12, folic existence of antioxidant, MDA hydrolyzing itself in acid, zinc and magnesium measured before and after acid environment at 95 0C reacts with 1,3-diethyl-2- acoustic trauma (Mann-Whitney U Testi, p<0.05). thiobarbituric acid (DETBA). After this reaction recent After acoustic trauma, serum levels of MDA have formed complex can be measured with synchronized increased, and this increment was statistically florophotometer and MDA level can be detected. significant (Paired Samples T Test, p<0.05). However Statistical test were made using SPSS (Statistical there was no statistically significant difference in Package for the Social Sciences for Windows 11.0). serum MDA levels between those with hearing loss Descriptive statistics were calculated for individuals and those with no hearing loss (Mann-Whitney U Test, demographics. Mann-Whitney U Test was used to p<0.05) (Table 1).

Table-1: Average values of biochemical tests (n=patients’number) Group with hearing loss Group without hearing loss Normal (n: 83) (n: 52) Laboratory

Before After Before After value trauma trauma P trauma trauma P (mg/dl) (mg/dl) (mg/dl) (mg/dl) (mg/dl)

B12 257,3 269,6 p>0.05 189,7 242,7 p>0.05 220-914 Folic Acid 4,6 4,9 p>0.05 4,6 4,9 p>0.05 3,1-17,5 Zinc 106,5 101,9 p>0.05 105,9 105,1 p>0.05 73-140 Magnesium 2,6 2,5 p>0.05 2,6 2,5 p>0.05 1,9-2,5 MDA 112,9 451,2 p<0.05 111,9 462,7 p<0.05 80-284

166 Relationship between Acoustic Trauma and Serum Level of Vitamin B12, Folic Acid, Zinc, Magnesium and Malondialdehyde

DISCUSSION hearing loss (p<0.05). Since high oxidative parameters have been found in all participants subjected to acoustic trauma and hearing loss has been observed in While cochlea transforms acoustic energy into only 83 participants (%62), there should be some other neural signals, some FORs appear and intracellular searches delving into factors causing hearing loss or defense mechanisms against FORs protect inner ear. limiting hazardous effects of oxidative stress However at acoustic trauma these mechanisms fail and (antioxidant enzyme levels, trophic factor levels). hearing loss happens irreversibly. Reinforcement of natural defense mechanisms prevent or lessens hearing Magnesium plays an important role in energy loss [6]. turnover of . In magnesium deficiency, noise FORs are products of routine aerobic cellular has more destructive effect. Attias et al. exposed 90 dB metabolism and they disrupt structure of lipids, sensational level noise to 20 healthy individuals with proteins and nucleic acids [7]. Lipid peroxidation mean age 21 and administered 122 mg magnesium per products caused by FOR can be measured. day during 10 days. They have shown that magnesium Measurement of serum MDA level can be used in administration protects cochlear function and [4] order to indicate oxidative stress [8]. accelerates recovery of hearing . In another study, 300 individuals with normal hearing have been After exposing 4 kHz octave 115 dB SPL noise for administered 167 mg magnesium per day during 2 5 hours to guinea pigs, Ohinata et al demonstrated that month- period of military training. Individuals not lipid peroxidation increases directly proportional to having magnesium intake have experienced noise duration of noise exposure. In the wake of lipid induced hearing loss at the end of training [11]. peroxidation, apoptosis become stimulated then apoptotic cell death occur [7]. Experimental studies have shown that NIHL Liu showed that after acoustic trauma in cochlea, increased in case of magnesium deficiency. Protective MDA level elevates in first hours, reaches peak level mechanism of magnesium in NIHL has not been at third to sixth day, returns to normal level at eighth proven. Magnesium is physiologic antagonist of day, then makes a second peak at twelfth day. They calcium. Its protective effect attributed to this concluded that MDA level increases as a result of antagonism. In conclusion it is thought that NIHL [9]. magnesium shows protective effects by decreasing oxidative stress, vasospasm, neurotransmitter release, Derekoy applied acoustic trauma at 100 dB SPL vasoconstriction and calcium intoxication [12]. intensity for one hour to guinea pigs, then showed that serum MDA level increased and glutathione level After increasing mononuclear magnesium level, decreased. They concluded that there is a relationship hearing thresholds due to acoustic trauma decreased [12] between noise and body antioxidant system, and noise . Scheibe et al. claimed that taking more magnesium induces oxidative stress not only in cochlea but also in in diet may increase blood flow to inner ear, and thus whole body [10]. provides more oxygenation and hinders NIHL [13]. In our study, serum MDA level is measured for the However in our study there was no significant purpose of indicating oxidative stress resulting from relationship between serum level of magnesium and acoustic trauma. After acoustic trauma, serum levels hearing loss (p<0.005). of MDA have increased and this was statistically Gok et al. investigated serum Vitamin B12 and significant when compared to the levels of MDA folic acid levels in patients working in hydroelectric before acoustic trauma (p<0.05). However there was plant and found that level of vitamin B12 in patients no statistically significant difference in MDA level with acoustic trauma was 199,87±75,25 pmol/L and between those with hearing loss and those with no was 323,62±121,91 pmol/L in control group

167 The Deflation (Passive) Opening Pressure of The Eustachian Tube

(p<0.001). Level of folic acid in patients with acoustic in serum levels of malondialdehyde between before trauma was 10,71±4,16 µmol/L and was 12,69±3,61 and after acoustic trauma in all subjects (p<0.05). µmol/L in control group (p<0.05). In the view of these These results indicate that free oxygen radicals play an findings they recommended that people working in noisy important role in the pathophysiology of acoustic place should be checked regularly with measurement of trauma, and acoustic trauma causes stress by serum level of Vitamin B12 and folic acid [14]. increasing free oxygen radicals in whole body. Harada et al. treated 52 patients with acute acoustic However every participant with increased MDA level trauma. 60 mg prednisolone, low molecular weight %10 did not suffer from hearing loss. This finding tells us dextran and 1,5 mg vitamin B12 have administered in that more potent antioxidant defense mechanisms may 42 patients and 10 patients after seven and ten days be playing roles in oxidative stress. respectively. It has been found that early beginning of treatment have good affect for hearing recovery but no REFERENCES significant relationship between age, ear plug usage and medication of prednisolone, low molecular weight dextran and vitamin B12 (p<0.05) [15]. 1. Konig O, Winter E, Fuchs J, Haupt H, Mazurek B, Shemesh et al. found vitamin B12 deficiency Weber N. Gross protective effect of magnesium (<250pg/ml) in 47% of 113 soldiers with mean age 39. and MK 801 on hypoxia-induced hair cell loss in After vitamin B12 treatment, 12 soldiers recovered new-born rat cochlea. J Magnes Res 16: 98-105; from their . Authors recommend measurement 2003. of serum B12 level for patient with chronic tinnitus in 2. Chan E, Suneson A, Ulfendahl M. Acoustic [16] a routine fashion . trauma causes reversible stiffness changes in Quaranta revealed protective effect of vitamin B12 auditory sensory cells. Neuroscience 83: 961-8; in guinea pigs to which he exposed 112 dB SPL noise 1998. [17] for 10 minutes . Patients with low serum level of 3. Devlin MT. Textbook of Biochemistry with vitamin B12 and folic acid were more prone to hearing Clinical Correlations. Wiley-Liss Inc.Publication: loss due to acoustic trauma [18,19]. However in our study New York,1054-1075; 2002. there was no significant relationship between hearing loss and vitamin B12 -folic acid level (p< 0.05). 4. Kopke RD, Coleman JK, Liu J, Campbell KC, Riffenburg RH. Enhancing intrinsic cochlear Zinc has protective effect against oxidative stress [20] stress defensess to reduce noise-induced hearing and prevents free radical formation . Since oxidative stress has a role in pathogenesis of acoustic trauma [21,22] loss. Laryngoscope. 112: 1515-32; 2002. there were no significant difference in serum zinc level 5. Liu Z. Experimental study on the mechanism of of patients with hearing loss between before and after free radical in blast trauma induced hearing loss. acoustic trauma (p< 0.05). Zhonghua Er Bi Yan Hou Ke Za Zhi 27, 24-26; 1992 (Abstract). CONCLUSION 6. Kaygusuz I, Ozturk A, Ustundag B, Yalcin S. Role of free oxygen radicals in noise-related hearing There was no significant relationship between impairment. Hear Res 162: 43-7; 2001. hearing loss due to acoustic trauma and serum level of 7. Ohinata Y, Miller JM, Schacht J. Protection from vitamin B12, folic acid, zinc, magnesium (p>0.05). noise-induced lipid peroxidation and hair cell loss However there was a statistically significant difference in the cochlea Brain Res 21;966: 265-73; 2003.

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