Kathmandu University Medical Journal (2005) Vol. 3, No.

3, Issue 11, 230-233

Original Article
Viral infections in sudden hearing loss. Do we have enough
evidence?
Mishra B1, Panda N2, Singh MP3, Ratho RK4
1
Assistant Professor, Department of Virology, 2Additional Professor, Department of Otolaryngology, 3Senior
Resident, Department of Virology, 4Additional Professor and Head, Department of Virology, Postgraduate Institute
of Medical, Education & Research, Chandigarh, India.

Abstract
Objective: The aetiology of sudden deafness remains unknown even though some evidences suggest that it could be
viral in origin. This study aimed to find out the relationship between viral infections and sudden sensorineural
hearing loss. Methods: 32 patients presenting with sudden deafness and 10 healthy controls were included in the
study. IgM antibodies to varicella zoster virus, measles, cytomegalovirus and herpes simplex virus were detected
using micro ELISA. Results: Overall, 7(21.8%) patients showed seropositivity to one or more viruses. Virus
specific IgM antibodies against measles and varicella zoster could be demonstrated in 4 (12.5%) and 3 (9.4%)
patients respectively. None of the samples were found to be positive for herpes simplex virus (HSV) and human
cytomegalovirus (HCMV) specific IgM antibodies. Controls were negative for all the viruses tested. The difference
in seropositivity between the patient and control group was not statistically significant (p>0.05). Conclusion: Thus,
this study suggests that sudden deafness is not commonly associated with a systemic viral infection.

Key Words: Sudden deafness, viruses, serology.

T he sudden loss of hearing is a frightening

experience for the patient that can result in
definitive loss of an organ essential for
patients has shown pathological changes resembling
those encountered in viral labyrinthitis 8,9. Viral
infections implicated in acute hearing loss include
communication. In fact, it is one of the few true herpes simplex virus (HSV)10, measles, mumps,
emergencies in otology. Sudden hearing loss (SHL) rubella, influenza, varicella zoster (VZV) and
generally refers to hearing loss of sensorineural cytomegalovirus (CMV)4,11,12.
origin and has been defined as the loss of more than
30 dB of hearing in at least three contiguous All patients with sudden SNHL require thorough
frequencies over the course of less than 3 days in an evaluation to identify and treat the underlying
otherwise healthy person 1. Worldwide an estimate of disorder that could play a predisposing role. Delay in
15,000 cases of sudden hearing loss (SHL) per year is detection of impaired hearing may affect the
being reported. One in every 10,000 to 15,000 people development of skills in speech, language and social
suffer from this condition, highest incidence being in interaction.
the 5th to 6th decade of life 2. The aetiopathogenesis of
sudden hearing loss has remained as an enigma Considering the above facts, the present study was
thereby posing a challenge for its diagnosis. No planned to address the role of common viral
definite cause has been identified in most of the infections in patients with sudden sensorineural
cases. Based upon clinical and histopathologic hearing loss.
findings, either viral or vascular role has been
attributed for idiopathic sensory neural hearing loss
(SNHL) in about 10% of cases only 3.Wilson et al 4
have postulated viral cochleitis as the most common
cause. This was based upon the observation of upper
respiratory infection preceding hearing loss 5. Few
cases seroconverted against some viruses during the Correspondence
course of illness 1,4. Magnetic resonance imaging Baijayantimala Mishra
(MRI) studies of inner ear have shown the evidence Departments of Virology and Otolaryngology,
Postgraduate Institute of Medical, Education & Research,
of viral labyrinthitis 6 ,7. Post mortem cochlear Chandigarh, India 160 012.
histopathology of SNHL

230
Methodology
Patients: Thirty two patients attending Diagnostica, GmbH, Germany) and cytomegalovirus
Otorhinolaryngology (ENT) clinics at Nehru (CMV)(EIA gen, CMV IgM, Adaltis Italia, Italy). All
Hospital, Post Graduate Institute of Medical the tests were performed according to the
Education and Research, Chandigarh, India between manufacturers instructions.
July, 2001 and December, 2003 with suspected acute Statistical Analysis
hearing loss were enrolled in the study after taking Statistical analysis was done using the Fischers exact
their informed consent. Patients participating in the test and Chi square test.
study met the following inclusion criteria: a) cochlear
hearing loss of unknown aetiology b) hearing loss of Results
at least 30 dB in three contiguous frequencies over The patients ranged between 19-45 years and the
the course of <3 days. Patients suffering from male: female ratio was 5.6:1. A total of 7(21.8%)
medical conditions like diabetes mellitus and patients showed the presence of antibodies to one or
hypertension were excluded from the study. more viruses. IgM antibodies against measles and
Controls: Ten age and sex matched apparently varicella zoster virus could be demonstrated in 4
healthy individuals were included as the control (12.5%) and 3 (9.4%) patients respectively. None of
group. the samples were found to be positive for IgM
Serology: 2 ml venous blood samples were collected antibodies to HSV and HCMV. In all the 12 follow
aseptically from all the subjects at the onset of their up samples, the IgM status for the viruses tested was
symptoms (during their first hospital visit). found to be the same as in their respective first
Subsequent follow up blood samples were obtained samples. The hearing loss in seropositive patients
only from 12 patients within a interval of 1-2 weeks. was unilateral in 3 and bilateral in 4 patients. One
Sera were separated and stored at -20C till tested. patient had the history of upper respiratory infection
Specific IgM antibodies were detected using micro 5 days prior to the onset of hearing loss. The controls
ELISA system against herpes simplex virus(HSV) were negative for all the parameters tested. The
(EIA gen, HSV, IgM, Italy), varicella zoster virus difference in positivity between the patient and the
(VZV) (Nova Tec immunodiagnostica, GmbH, control group was not statistically significant
Germany), measles (Vir ELISA, Viro-Immun (p>0.05).

Table 1: Comparison of results of present study with published series in patients with sudden hearing loss
(SHL)
Studies Viral Association with SHL
seroconversion(%)
Maasab et al, 1973 62% Yes (adenovirus)
Jaffe, 1978 61.7% Yes (adenovirus)
Mercke et al, 1980 6% Yes (adenovirus)
Veltri et al, 1981 65% Yes (Influenza B, measles)
Wilson et al, 1983 63% Yes (mumps, measles, VZV, CMV, Influenza
B)
Schulz et al, 1998 100% Yes (HSV-1)
Pitkaranta et al, 1998 0% No
Gagnebin et al, 2000 0% No
Garcia et al, 2000 12.5% No
Present study 18.75% No
SHL: Sudden Hearing Loss

Discussion
There is widespread controversy concerning the role the viral aetiology of sudden hearing loss, ideally
of viruses in the onset of SNHL. Several studies identification of viruses in inner ear fluids as well as
using conventional viral diagnostic tests have refuted confirmation of viral cytopathic effect in the cochlear
the belief that viral infection is a common cause of region is required. Serological evidence cannot prove
sudden deafness 12,13,14 while others have shown the viral cause of inner ear damage and similarly
definite association 1,15,16,17,18,19 (Table I). To establish isolation of viruses from tissues and nasopharynx

231
does not necessarily imply the viral aetiology of inner References
ear disease since viruses like herpes simplex virus 1. Wilson WR, Veltri RW, Laird N, Sprinkle
and adenovirus may remain latent and are PM - Viral and epidemiologic studies of
intermittently shed in oropharynx. Identification of idiopathic sudden sensorineural hearing loss.
viral antigens in perilymph involves invasive Otolaryngol Head Neck Surg 1983; 91: 653-
procedure and is associated with risk of damage to 8.
the inner ear hence difficult to establish as a routine 2. Muller C, Vrabec J- Sudden sensorineural
diagnostic test. Thus, immunological and serological hearing loss : In Grand Rounds Presentation.
tests continue to provide presumptive diagnosis in UTMB, Dept of Otolaryngology. Series Eds
patients with sudden hearing loss. : Quinn FB. June 13, 2001
3. Fetterman BL, Sanders JE, Luxford WM-
In the present study, VZV and measles IgM was Prognosis and treatment of sudden
detected in 4 (12.5%) and 3 (9.4%) patients sensorineural hearing loss. Am J Otol 1980;
respectively. Seroconversion against VZV has been 106: 772-6.
observed in 5% and against measles in 15% of SNHL 4. Wilson WR- Sudden sensorineural hearing
cases 1. Veltri et al 18 observed significant loss. In: Cummings CW, edior-
seroconversion to measles in 16% of 77 paired serum Otolaryngology, Head and neck surgery. St.
samples of sudden hearing loss patients. Louis, MO: Mosby , 1986: 3219-24
5. Van Dishoek HAE, Bierman TH- Sudden
Role of herpes simplex virus as an aetiology of perceptive deafness and viral infection. Ann
SNHL is controversial. IgM immune response against Otol Rhinol Laryngol 1957; 66: 963-80.
HSV 1 and 2 has been demonstrated in paediatric 6. Alberts FWJ, Demuynk KMNP, Casselman
population with hearing loss 10. HSV DNA in JW- Three dimensional magnetic resonance
temporal ganglia has been detected in patients with imaging of the inner ear in idiopathic sudden
SNHL 19. However in some of the studies immune sensorineural hearing loss. ORL 1994 ;
response against HSV could not be demonstrated 14 56:1-4.
and so also the response to acyclovir 20. 7. Mark AS, Seltzer S, Nelson- Drake J,
Chapman JC, Fitzgerald DC, Gulya AJ.
CMV is thought to be the most common infectious Labyrinthine enhancement on gadolinium -
cause of congenital deafness. Bilateral sensory neural enhanced magnetic resonance imaging in
hearing loss of patients has correlated with elevated sudden deafness and vertigo: correlation
antibody titres against cytomegalovirus in serum of with audiologic and electronystagmographic
children as well as in adults 21. Wilson et al 1 and studies. Ann Otol Rhinol Laryngol 1992;
Veltri et al 18 have shown the presence of CMV in 7% 101: 459-64.
of SNHL patients. 8. Schuknecht HF, Donovan ED- The
pathology of idiopathic sudden sensorineural
The results of this study suggest that sudden deafness hearing loss. Arch Otolaryngol 1986; 243:1-
is not commonly associated with a systemic viral 15.
infection. However, the possibility of local viral 9. Sando I, Harada T, Loehr A, Sobel Hl -
involvement cannot be entirely ruled out. Hence, Sudden deafness, histopathologic
further studies need to be carried out to demonstrate correlations in the temporal bone. Ann Otol
the presence of viral antigen or nucleic acid in inner Rhinol Laryngol 1977; 86: 269-79.
ear fluids or tissues to prove the causal role of viruses 10. Muhaimeed H, Zakzouk SM- Hearing loss
in this group of patients. and herpes simplex. J Trop Pediatr 1997; 43:
20-4.
Conclusion 11. McKenna MJ- Measles, mumps and
Previous studies have suggested that viruses have a sensorineural hearing loss. Ann N Y Acad
role in causation of sudden hearing loss. In this study, Sci 1997; 830: 291-8.
viral antibody detection was evaluated in 32 patients 12. Garcia Berrocal JR, Ramirez- Camacho R,
with sudden deafness. Overall, 21.8% of patients Portero F, Vargas JA - Role of viral and
showed seroconversion to measles and varicella Mycoplasma pneumoniae infection in
zoster virus. No significant difference was observed idiopathic sudden sensorineural hearing loss.
in positivity between the patient and the control Acta Otolaryngol 2000; 120: 835-39.
group (p>0.05). Thus, the authors conclude that 13. Pitkaranta A, Julkunen I- Sudden deafness:
sudden deafness is not commonly associated with a lack of evidence for systemic viral infection.
systemic viral infection.

232
 Otolaryngol Head Neck Surg 1998; 118: primary infection or reactivation of latent
397-9. viruses? Otolaryngol Head Neck Surg 1981;
14. Gagnebin J, Maire R- Advantage for 89: 137-41.
screening for infection in sudden and 19. Schulz P, Arbusow V, Strupp M, Dieterich
progressive hearing loss. Schweiz Med M, Rauch E, Brandt T - Highly variable
Wochenschr 2000; Suppl 125: 89S-91S. distribution of HSV-1 specific DNA in
15. Maasab H- The role of virus in sudden human geniculate, vestibular and spiral
deafness. Adv Otorhinolaryngol 1973; 20: ganglia. Neurosci Lett 1998; 252: 139-42.
229-35. 20. Stokroos RJ, Albers FW, Tenvergert EM-
16. Jaffe BF- Viral causes of sudden inner ear Antiviral treatment of idiopathic sudden
deafness. Otolaryngol Clin North Am 1978; sensorineural hearing loss: a prospective,
11: 63-69. randomized, double blind clinical trial. Acta
17. Mercke U, Nordenfelt E, Sjoholm A- The Otolaryngol 1998;118: 488-95.
role of viral infection in sudden deafness. 21. Morgenstern C, Scheidt A, Kau R, Niessen
HNO 1980; 28:125-7. A- Cytomegalovirus infection and inner ear
18. Veltri RW, Wilson WR, Sprinkle PM, deafness. Laryngorhinootologie 1989; 68:
Rodman SM, Kavesh DA.- The implication 503-5.
of viruses in idiopathic sudden hearing loss:

233