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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 3  |  Issue : 3  |  Page : 618-624

Auditory function in children with vitiligo


1 Audiovestibular Unit, Audiovestibular Medicine, ENT Department, Cairo, Egypt
2 Dermatology Department, Al-Zahraa University Hospital, Al-Azhar University, Cairo, Egypt
3 Resident of Dermatology, Dermatology Department El-Zaharaa University Hospital, Cairo, Egypt

Date of Submission10-Jun-2019
Date of Decision15-Jul-2019
Date of Acceptance16-Jul-2019
Date of Web Publication10-Feb-2020

Correspondence Address:
Iman Eladawy
MD of Audio Vestibular Medicine, Lecturer of Audio Vestibular Medicine, Al-Zzhar Faculty of Medicine for Girls 6 Elkhabeer Street Elzaitoun Cairo
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sjamf.sjamf_68_19

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  Abstract 


Background Vitiligo is an acquired disorder of pigmentation affecting ∼0.1–2% of the world population and characterized by the development of well-defined white macules on the skin. Vitiligo is classified into two broad categories, segmental and nonsegmental (most common). Recent studies have suggested a direct relation between cochlear dysfunction and decreased amounts of melanin. Loss of melanocytes resulting in decreased melanin production (as occurring in vitiligo) could decrease cochlear health. Owing to the high importance of having normal hearing during the infancy and the childhood period, this study is designed to assess the cochlear function in pediatric patients with vitiligo.
Materials and methods This study involved 30 children with vitiligo and 30 apparently healthy controls; both groups were matched in age and sex. All patients included were subjected to full history taking, otological examination, and audiological evaluation. Audiologic evaluation including pure tone audiometry, extended high-frequency audiometry, immittancemetry, and transient evoked otoacoustic emission was evaluated to detect signal to noise ratio (average) for the frequency bands 1000, 1500, 2000, 3000, and 4000 Hz.
Results Children with vitiligo had high pure tone thresholds at all frequencies with a statistically significant difference on both sides in conventional and extended high-frequency audiometry. Transient evoked otoacoustic emission (TEOAEs) average signal to noise (S/N) ratio showed decreased emission in the patient group in both ears and the difference was statistically significant in comparison with the control group. The pure tone threshold in generalized and localized vitiligo is elevated, and the difference is statistically significant almost at all frequencies, but the hearing is affected more in generalized type especially at high frequencies. Moreover, there is elevation in the pure tone threshold in either positive or negative family history in vitiligo subgroups. Patients with skin type IV are more affected than other types. There is no variation in the prevalence of hearing affection regarding sex.
Conclusion Vitiligo is associated with cochlear dysfunction. Hearing loss is more common in generalized type of vitiligo.
Recommendation Hearing screening of pediatric patients with vitiligo should be done for early detection of hearing abnormalities to ensure maximum scholastic and academic performance to help them to achieve their best potentials.

Keywords: extended high frequency, otoacoustic emission, pure tone audiometry, vitiligo


How to cite this article:
Elgohary M, Darweish H, Eladawy I, Seibaei AS. Auditory function in children with vitiligo. Sci J Al-Azhar Med Fac Girls 2019;3:618-24

How to cite this URL:
Elgohary M, Darweish H, Eladawy I, Seibaei AS. Auditory function in children with vitiligo. Sci J Al-Azhar Med Fac Girls [serial online] 2019 [cited 2020 Feb 25];3:618-24. Available from: http://www.sjamf.eg.net/text.asp?2019/3/3/618/278039




  Introduction Top


Vitiligo is an acquired skin disorder characterized by milky-white macules and absence of functioning melanocytes [1]. Lesions may occur in a localized or generalized distribution [2].

Multiple theories have been proposed to explain melanocyte destruction in vitiligo. There are three major hypotheses for the pathogenesis of vitiligo: autoimmune, autocytotoxic or metabolic, and neural dysfunction [3],[4].

The hallmark of vitiligo is the disappearance of melanocytes from the skin. The presence of the melanocytes in the auditory and vestibular apparatus has been confirmed, and the involvement of these systems in vitiligo, which targets the melanocytes of the whole body, is possible, suggesting that vitiligo is a systemic disease rather than a purely cutaneous problem [5]. Cochlear melanocytes may be affected in vitiligo and interfere with the conduction of action potentials in the auditory pathway. Melanocytes are not confined to the peripheral auditory system; they are also present in the central auditory system [6]. Damage can also occur to melanocytes within the iris and retina of the eyes [7]. Sensorineural hearing loss was reported in several patients with vitiligo owing to a reduction in the number of melanocytes contained in the membranous labyrinth of the inner ear [8]. Normal hearing level is mandatory during infancy and the childhood period to ensure maximum language acquisition and academic performance; hence, this study was conducted to evaluate the auditory function in children with vitiligo.


  Aim Top


The aims of the study were as follows:
  1. To evaluate the auditory function in children with vitiligo.
  2. To study the association between vitiligo and hearing loss in a pediatric population.



  Materials and methods Top


This is a cross-sectional study that was conducted in the Audiology Unit, Al-Zahraa University Hospital. This study included 60 patients divided into two groups: the control group consisted of 30 healthy participants, and their age ranged from 6 to 16 years, and the study group consisted of 30 patients with vitiligo and their age ranged from 6 to 16 years. Regarding the type of vitiligo, there were 10 (33.3%) patients with generalized type and 20 (66.7%) with localized type. They were recruited from the Outpatient Dermatology Clinic, Al-Zahraa University Hospital, during the period from March 2015 to October 2016.

Inclusion criteria

Children between 6 and 16 years of age, of both sexes, diagnosed with vitiligo, which was confirmed by a dermatology consultant, were included.

Exclusion criteria

History of familial hearing loss; oral ototoxic drug or corticosteroid intake; chronic noise exposure; head trauma; metabolic, neurological, vascular, and autoimmune diseases; systemic diseases such as diabetes or hypertension; and any dermatological diseases other than vitiligo were the exclusion criteria.


  Materials and methods Top


After parental informed consent, all participants included were subjected to the following: history taking, dermatological examination, otological examination, and audiological evaluation using Interacoustics AC 40. Pure tone audiometry was done at frequencies of 250, 500, 1000, 2000, 4000, and 8000 Hz. Extended high-frequency audiometry was done at the frequencies of 10, 12.5, and 16 kHz. Bone conduction was tested at frequencies of 500, 1000, 2000, and 4000 Hz. Immittancemetry was performed using MiacoMi 44, tympanometry, and acoustic reflexes on 500, 1000, 2000, and 4000 Hz ipsilateral and contralateral. Transient evoked otoacoustic emission (TEOAEs) using Madsen Capella were elicited using nonlinear click stimuli at stimulus intensity of 80 dB peak equivalent sound pressure level, 80 µs duration at a rate of 50 clicks per second, and within a time window of 20 ms. TEOAEs were analyzed by recording 260 sweeps in one session and averaged within five frequency bands centered at 1, 1.5, 2, 3, and 4 kHz. An acceptable TEOAE is 3 dB above the noise floor signal to noise ratio (SNR), and the whole reproducibility percent was at least 50%.

Statistical analysis

Data were analyzed with SPSS version 16 (Interacoustics AC 40, Denimark; Miaco Mi 44: Company Mico Diagnostic, Germany). Qualitative data were described using number and percent. Association between categorical variables was tested using χ2-test. Continuous variables were presented as mean±SD. The two groups were compared with Student t-test. Analysis of variance test was used for comparison of means of more than two groups. The nonparametric Mann–Whitney test was done when quantitative variables were compared. Comparison of quantitative variables among three or more subgroups within the study groups was carried out using the nonparametric Kruskal–Wallis test.


  Results Top


This study included 30 children with vitiligo and 30 of apparently healthy control group; they were matching in age and sex. The study group consists of 15 (50%) males and 15 (50%) females, and their age range from 6 to 16 years, with mean age of 12.43±2.64 years. According to the type of vitiligo, the study group has been subdivided into two subgroups: 10 (33.3%) patients with generalized vitiligo and 20 (66.7%) patients with localized vitiligo. Positive family history was found in seven (23.3%) patients, and 23 (76.7%) patients had a negative family history. According to skin type, 28 (93.3%) patients were skin type IV and two (6.7%) patients with skin type V.

Pure tone results

Patients with vitiligo had elevated pure tone thresholds at all frequencies on both sides in conventional audiometry. Pure tone average showed statistically significant difference ([Table 1]). No statistically significant difference was found between males and females in the patient group ([Table 2]). Extended high frequency showed relative elevation in hearing thresholds at 10, 12.5, and 16 kHz in the patient group versus control, with a statistically significant difference ([Figure 1]). Hearing is affected more in generalized vitiligo than in localized type, especially at high frequencies ([Figure 2]). No statistically significant difference was found between positive and negative family history subgroups in conventional audiometry ([Figure 3]). Patients with type IV vitiligo showed elevation in hearing threshold which was statistically significant at all frequencies in comparison with the control group, and they were more affected than other types ([Figure 4]).
Table 1 Pure tone average of the patient and control groups

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Table 2 Comparison of mean and SD of pure tone thresholds in the males and females in patient group

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Figure 1 Comparison of mean and SD of extended high frequency of the patient and control groups.

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Figure 2 Comparison of mean and SD of pure tone thresholds of the control group and patient subgroups according to vitiligo type.

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Figure 3 Comparison of mean and SD of pure tone thresholds of the control group and patient subgroups according to family history.

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Figure 4 (a) Comparison of the mean and the SD of pure tone thresholds between the control group and the patients with vitiligo with different skin type. (b) Comparison of the mean and the SD of pure tone thresholds between the control group and the patients with vitiligo with different skin types.

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Otoacoustic emission results

TEOAEs average signal to noise (S/N) ratio in the patient group was significantly low in both ears, when we compare it with the control group ([Table 3]). There is no statistically significant difference between generalized and localized vitiligo types ([Table 4]), as well as between positive and negative family history subgroups. Moreover, there was no sex effect ([Table 5]). TEOAEs S/N ratio was low in type IV skin lesion when we compare it with the control and other types, and the difference is statistically significant ([Figure 5]).
Table 3 Comparison of mean and SD of TEOAES average S/N ratio of the patient and control groups

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Table 4 Comparison of mean and SD of TEOAES average S/N ratio of the control group and patient subgroups according to vitiligo type

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Table 5 Comparison of mean and SD of TEOAEs average S/N ratio of the males and females in the patient group

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Figure 5 TEOAEs S/N ratio showed decrease in average in case with type IV skin type.

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  Discussion Top


In this study, pure tone audiometry threshold was elevated at all frequencies in the patient group, and this elevation was statistically significant. These results are in agreement with Fleissig et al. [8], as they found sensory neural hearing loss in 68.8% of patients with vitiligo versus 6.3% in healthy controls. On the contrary, Shalaby et al. [9] found that patients with vitiligo had near-normal pure tone thresholds, and there was no statistically significant difference between the control and vitiligo groups in conventional audiometry.

Transient evoked otoacoustic emission average (S/N ratio) was lower in the patient group bilaterally, and this was statistically significant. The same was found by Shalaby et al. [9]. However, Aslan et al. [10] found no statistically significant difference, when they compared the value for reproducibility, stimulus intensity, stability, and average TEOAE amplitude of patients and control groups.

In this study, extended high-frequency audiometry showed relative elevation in hearing threshold at 10, 12.5, and 16 KHz in the patient group versus control. This elevation is highly statistically significant. These results agree with the results of Shalaby et al. [9], who evaluated 30 patients affected by vitiligo of various durations and distributions and 10 normal participants. They found that some subjects in the patient group showed hearing affection at extended high-frequency audiometry.

Patients with vitiligo were classified according to the type into generalized and localized type. Children with generalized type were 10 and those with localized type were 20. Pure tone hearing threshold was elevated in both groups in comparison with the control, and this difference was statistically significant almost in all frequencies. The hearing was more affected in the generalized type especially at high frequencies. These results agreed with Sharma et al. [11], who stated that generalized vitiligo can be a risk factor for sensory neural hearing loss. In contrast, Fleissing et al. [8] did not find an association between hearing affection and type of vitiligo. Extended high frequency showed elevation in hearing threshold, and this elevation is highly statistically significant in the generalized group.

In this study, TEOAEs average S/N ratio showed statistically significant decrease emission in both generalized and localized types in both ears in comparison with the control.

In this study, there were seven children with positive family history of vitiligo and the rest has had no family history of vitiligo. When comparing pure tone audiometry results in those with positive and negative family history, there was no statistically significant difference between them.

Looking at the vitiligo subgroups, type IV showed elevation in hearing threshold for conventional and extended high-frequency audiometry, as well as decreased TEOAEs S/N ratio, and the difference was statistically significant when we compare it with the control and with the other skin types. This difference may be owing to the large number of this type. Our results disagree with Sharma et al. [11], who concluded that differences in the skin color in patients of different countries may not affect the incidence of audiological abnormalities in patients with vitiligo. They found that their results of patients with vitiligo in India were similar to the results of the study carried out in Italy by Tosti et al. [12].

In this study, the participants comprised 50% male and 50% female in the patients group. Comparison of pure tone thresholds and TEOAEs average S/N ratio in the male and female in the patient group showed no significant differences. The same results were obtained by Fleissig et al. [8], who found that sex was not associated with sensory neural hearing loss. Moreover, Sharma et al. [11] found that hypoacusis was not affected by age, sex, occupation, and therapy of vitiligo. These results disagree with Sharifian et al. [13], who found that hearing loss in high frequencies occurred more in females, but the reason could have been owing to the higher number of women participating in their study.


  Conclusion Top


  1. Vitiligo is associated with cochlear dysfunction, and it is usually asymptomatic for long time.
  2. TEOAEs are sensitive tests for detecting cochlear dysfunction before symptoms become manifested, as TEOAE may be impaired in pediatric patients with vitiligo with normal hearing.
  3. Hearing loss is more common in generalized type of vitiligo, so it may be a risk factor of hearing loss.
  4. Patients with vitiligo with skin type IV have a certain amount of auditory defect more than other skin types.


Recommendations

  1. Hearing screening of pediatric patients with vitiligo should be done for early detection of hearing abnormalities to ensure the maximum scholastic and academic performance.
  2. Extended high-frequency audiometry and TEOAEs can be used for early detection of hearing loss in pediatric patients with vitiligo.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Yadav AK, Singh P, Khunger N. Clinicopathologic analysis of stable and unstable vitiligo: a study of 66 cases. Am J Dermatopathol 2016; 38:608–613.  Back to cited text no. 1
    
2.
Krüger C, Schallreuter KU. Stigmatisation, avoidance behaviour and difficulties in coping are common among adult patients with vitiligo. Acta Derm Venereol 2015; 95:553.  Back to cited text no. 2
    
3.
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4.
Iannella G, Greco A, Didona D, Didona B, Granata G, Manno A et al. Vitiligo: pathogenesis, clinical variants and treatment approaches. Autoimmun Rev 2016; 15:335–343.  Back to cited text no. 4
    
5.
Mahdi P, Amali A, Ruzbahani M, Pourbakht A, Mahdavi A. The effect of otic melanocyte destruction on auditory and vestibular function: a study on vitiligo patients. Acta Med Iran 2015; 54:96–101.  Back to cited text no. 5
    
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Ozuer MZ, Sahiner T, Aktan S, Sanli B, Bayramoğlu I. Auditory evoked potentials in vitiligo patients. Scand Audiol 1998; 27:255–258.  Back to cited text no. 6
    
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Sharma L, Dixit SN, Kant S. Eye lesion in vitiligo. Q J Surg Sci 1999; 35:49–53.  Back to cited text no. 7
    
8.
Fleissig E, Gross M, Ophir I, Elidan J, Bdolah-Abram T, Ingber A. Risk of sensorineural hearing loss in patients with vitiligo. Audiol Neurootol 2013; 18:240–246.  Back to cited text no. 8
    
9.
Shalaby MES, El-Zarea GA, Nassar AL. Auditory function in vitiligo patients. Egypt Dermatol Online J 2006; 2(1).  Back to cited text no. 9
    
10.
Aslan S, Serarslan G, Teksoz E, Dagli S. Audiological and transient evoked otoacoustic emission finding in patients with vitiligo. Otolaryngol Head Neck Surg 2010; 142:409–414.  Back to cited text no. 10
    
11.
Sharma L, Bhawan R, Jain RK. Hypoacusis in vitiligo. Indian J Dermatol Venerol Leprol 2004; 70:162–164.  Back to cited text no. 11
    
12.
Tosti A, Bardazzi F, Tosti G, Monti L. Audiologic abnormalities in cases of vitiligo. J Am Acad Dermatol 1987; 17:230–233.  Back to cited text no. 12
    
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Sharifian MR, Maleki M, Honarvar H. The correlation between vitiligo and hearing loss. Iran J Otorhinolaryngol 2006; 17:3–8.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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