Auris Nasus Larynx 43 (2016) 155160

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Auris Nasus Larynx

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Hearing loss in postmenopausal women with low bone mineral

density
Ji Yoon Kim, Sun Bin Lee, Chang Ho Lee, Hyoung-Mi Kim *
Otorhinolaryngology Department, CHA University, Seongnam, Republic of Korea

A R T I C L E I N F O

A B S T R A C T

Article history:
Received 25 November 2014
Accepted 22 July 2015
Available online 12 August 2015

Objective: Several studies suggested the possible relationship between decreased bone mineral density
(BMD) of the temporal bone and hearing loss, primarily of the sensorineural type. The aim of the present
study is to determine the relationship between BMD and hearing loss and to evaluate the systemic Ca2+
and vitamin D status with relation to hearing sensitivity in the postmenopausal women who were
diagnosed with primary osteoporosis.
Methods: The study involved a total of 324 patients who were referred between 2008 and 2013. Based
on BMD scores, the subjects were divided into three groups: normal BMD (n = 102), osteopenia (n = 106)
and osteoporosis (n = 116). Hearing sensitivity was evaluated with audiometric tests along with serum
Ca2+ and vitamin D level.
Results: The age distribution among 3 groups was similar. Mean serum Ca2+, phosphate, 25(OH)D and
creatinine clearance were within the standard laboratory reference ranges in all patients. There was no
difference in the proportion of vitamin D deciency among groups. The typical type of hearing loss was
sensorineural hearing loss (SNHL) and the patients with reduced BMD showed higher prevalence of
SNHL than the patients with normal BMD. Pure-tone thresholds average was signicantly higher in all
frequencies in women with osteopenia/osteoporosis than women with normal BMD. Multiple logistic
regression analyses showed that age and lumbar BMD were associated with the presence of hearing loss
(>25 dB).
Conclusion: Our ndings suggest that the presence of decreased BMD in postmenopausal women might
be associated with the higher prevalence of age-related SNHL.
2015 Elsevier Ireland Ltd. All rights reserved.

Keywords:
Hearing loss
Postmenopause
Osteoporosis
Vitamin D
Calcium
Bone mineral density

1. Introduction
Age-related hearing loss, also known as presbycusis, is one of
the most prevalent chronic conditions affecting older population.
Hearing loss is usually bilateral, symmetrical and slowly progressive sensorineural hearing loss (SNHL), starting in high frequencies. As life expectancy has increased, an increasing number of
individuals would be forced to endure hearing impairment in their
senior years. Hearing loss in old ages has a signicant impact on
everyday living and can lead to the communication difculties,
social withdrawal and depression. In addition, unrecognized and
untreated hearing loss is also common in geriatric population until
speech communication is impaired [1].

* Corresponding author at: Otorhinolaryngology Department, CHA Bundang

Medical Center, CHA University, 351 Yatap-dong, Bundang-gu, Seongnam-si,
Gyeonggi-do 463-712, Republic of Korea. Tel.: +2 31 780 2963;
fax: +82 31 780 3449.
E-mail address: hyoungkim@cha.ac.kr (H.-M. Kim).

The prevalence of age-related hearing loss is in approximately

30% of persons over 65 years old and 50% of persons over 75 years
old [2,3]. The high incidence of SNHL in elderly subjects is
previously assumed to be related with age-related progressive
degenerative change of the peripheral auditory system as well as
the plasticity of central neural processing [4]. However, agerelated hearing loss is a multifactorial process in which there are
wide individual variations in the expression of each factor. Various
predisposing factors throughout the lifespan that could eventually
damage the hair cells, such as genetic susceptibility, noise
exposure, ototoxic medication, head trauma and ear-related
diseases, could play the multiplicative or additive confounding
effects on the development of hearing loss.
Demineralized petrous temporal bone including otic capsule
and/or internal auditory canal, in conjunction with age-related
bone mass loss, might also contribute to hearing loss in older
population, which has been explored primarily through studies
with Pagets disease of the bone and cochlear otosclerosis [5,6].
Demineralization of the otic capsule was primarily associated
with SNHL and the degree of cochlear demineralization

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J.Y. Kim et al. / Auris Nasus Larynx 43 (2016) 155160

corresponded directly to the severity of hearing loss with

secondary neuronal degeneration in later stage of disease [7,8].
Osteoporosis, which is characterized by generalized reduced
bone mass and increased bone turnover, does not spare the bone of
the skull [9], and abnormal bone remodeling of otic capsule
affected by osteoporosis might share the mechanism of hearing
loss of Pagets disease or cochlear otosclerosis [10]. Several studies
have investigated the possible relationship between reduced bone
mineral density (BMD) regarding osteoporosis and hearing loss in
old age. An epidemiological study showed almost 2-fold increase
in the risk of hearing loss among the postmenopausal women aged
6085 years who have a low BMD in the femoral neck [11].
Auditory thresholds in the frequencies higher than 4 kHz were
signicantly increased in osteoporotic women than the postmenopausal women with normal BMD [12,13]. Large-scale epidemiologic study revealed that older people aged over 65 years with
lower total BMD tended to report signicant higher hearing
complaints [14]. However, another study showed that there was
no relationship between hearing sensitivity and hip BMD in aged
White and Black women, while hearing loss was associated with
hip BMD in Black men [15]. Limited number of studies and
inconsistencies of existing data eventually need a further
investigation. Since epidemiologic studies usually adopted a
screening audiometer at particular frequency for hearing assessment, the results might not represent the exact type or level of
hearing loss associated with osteoporosis. Frequency-specic full
audiometric assessment including bone-conduction thresholds
would be necessary to clarify the contribution of age-related bone
mass loss to hearing impairments. In addition, low serum Ca2+ and
vitamin D deciency, which are often associated with osteoporosis
by enhancing bone metabolism, should be analyzed as the
independent risk factor for hearing loss. Vitamin D deciency
might lead to decrease in the hearing sensitivity through the
changed Ca2+ metabolism and microcirculation in the cochlea, and
supplementation with vitamin D could result in hearing improvement [1618].
The aim of the present study is to determine the relationship
between BMD and hearing loss and to evaluate the systemic Ca2+
and vitamin D status with relation to hearing sensitivity in the
postmenopausal women who were diagnosed with primary
osteoporosis.
2. Methods
2.1. Subjects
A total of 324 postmenopausal women who referred to
Otolaryngology Clinic at CHA University Bundang Hospital
between August 2008 and October 2013 were enrolled. The data
were retrospectively reviewed. The patients who have clear cause
other than presbycusis such as labyrinthitis, otologoc surgery,
Menieres disease and work in noisy environments without
adequate auditory protection were excluded. Inclusion criteria
were: (1) no evidence with active outer and/or middle ear disease;
(2) availability of BMD and actual 25-hydroxy vitamin D (25(OH)D)
value within 3 months from the hearing evaluation; (3) the
patients without a history of head trauma or ototoxic drug therapy;
and (4) the patients without any systemic or chronic disease
inuencing BMD results, such as chronic renal failure, liver or bile
duct disease and hormonal disorders. The study was approved by
the CHA University Bundang Hospital ethics committee.
2.2. Measurements of BMD and serum Ca2+ and vitamin D
Height and body weight were measured by standard method in
light clothes. Body mass index (BMI) was calculated as weight

divided by height squared (kg/m2). A dual X-ray absorptiometry

(DXA) scan (Discovery-W, Hologic Inc.) was obtained for all
subjects. BMD (g/cm2) was measured at central skeletal sites
(lumbar spine (L1L4), femoral neck and total hip). A T-score,
derived from the DXA measurement, expresses an individuals
BMD in standard deviations calculated from manufacturerprovided references. Diagnosis of osteopenia or osteoporosis
was made using World Health Organization (WHO) T-score
criteria; T-score  1 is considered normal BMD; osteopenia is
diagnosed with
2.5 < T-score < 1; and osteoporosis with
T-score  2.5.
The laboratory investigations included serum total calcium,
phosphate, total cholesterol, low-density lipoprotein (LDL)
cholesterol, transaminase activities (GOT and GPT), creatinine
and albumin, which were measured by automated standard
laboratory methods. Serum ionized calcium level (iCa2+) was
evaluated to identify calcium abnormality when serum total
calcium corrected for albumin [19] was not within normal ranges.
Actual 25(OH)D was measured by radioimmunoassay (CLIA,
DiaSorin). The serum vitamin D deciency was dened as a
25(OH)D  20 ng/mL [20]. Creatinine clearance was calculated
from plasma creatinine [21]. Serum thyroid-stimulating hormone
(TSH), free thyroid hormone (fT4) and level of parathyroid
hormone were also evaluated.
2.3. Audiological evaluation
Audiometric tests were conducted by one trained audiologist
using a GSI 61
audiometer (Grason Stadler Instruments,
Madison, Wisconsin) and TDH-39 cushioned headphones.
Prior to testing, an otoscopic examination was completed on
each subject to identify possible external canal obstructions or
tympanic membrane abnormalities. Pure-tone audiometry at
0.25, 0.5, 1.0, 2.0, 3.0, 4.0, and 8.0 kHz was performed in all
participants. Hearing thresholds were determined following the
guidelines of the American Speech-Language-Hearing Association (ASHA) [22]. Pure-tone averages (PTAs) across the
frequencies of 500, 1000
and 2000 Hz were calculated
separately for each ear. Averaged pure-tone hearing thresholds
were also evaluated for the better ear and worse ear. The better
ear was the ear with the lower PTA. If the PTAs were equal, the
right ear was designated as the better ear. The high-frequency
PTA was calculated as the averaged thresholds across the 4.0
and 8.0 kHz. The low-frequency PTA was calculated as the
average across 0.25, 0.5 and 1.0 kHz thresholds. SNHL was
dened as having a bone-conduction average higher than 25 dB
HL with no air-bone gap. Conductive hearing loss was
conservatively dened as having a normal bone-conduction
threshold average, but an air-bone gap more than 15 dB HL.
Mixed hearing loss was dened as having bone and airconduction threshold averages higher than 25 dB HL with an airbone gap more than 15 dB HL.
2.4. Statistics
The data were analyzed using IBM SPSS Statistics Version 22
for windows. Multiple means were compared among groups as
indicators of discriminant validity by one-way ANOVAs,
followed by pair wise post hoc tests. Two group comparisons
were made using Students t-test. A chi-square test was applied
to analyze the signicance of the multiple comparison of
frequencies among three groups. Odds-Ratios were calculated.
Multiple logistic regression analysis was used for estimating
odds ratios for the association of hearing loss and the various
factors. Test results with P < 0.05 were regarded as statistically
signicant.

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157

There was no difference in the overall prevalence rate of vitamin D

deciency among the three groups.

3. Results
3.1. Clinical characteristics of patients

3.3. Hearing sensitivity in relation to reduced BMD

The mean age of the total 324 patients was 62.1  10.0 years
(range, 4979 years). Demographic and clinical characteristics of the
324 patients are summarized in Table 1. Based on DXA results, the
patients were divided into three groups: group 1, normal BMD (Tscore  1, n = 102); group 2, osteopenia ( 2.5 < T-score < 1,
n = 106); and group 3, osteoporosis (T-score  2.5, n = 116). There
was no signicant difference among the three groups regarding the
age. The duration of the postmenopausal period in each group was
10  9.2 years, 11.9  8.4 years and 12.5  8.4 years, respectively.
BMI results were similarly distributed in all groups, and 5 (4.9%)
patients in group1, 3 (2.8%) patients in group 2 and 6 (5.2%) patients
in group3 had low BMI below 18.5 kg/m2. Overall, there was no
statistical difference among the three groups in the presence of
various risk factors including hyperlipidemia, diabetes and hypertension. The history of smoking and current alcohol consumption
were similar regardless of BMD results. All patients had normal
thyroid hormone levels.
3.2. Systemic calcium and vitamin D status in relation to reduced
BMD
The biochemical characteristics of each group are presented in
Table 2. In all three groups, mean serum calcium, phosphate,
albumin, creatinine clearance and the level of parathyroid
hormone (intact PTH) were within the standard laboratory
reference range and there were no signicant differences. Low
serum calcium levels corrected for albumin binding were found in
7 (6.9%) patients in group 1, 6 (5.7%) patients in group 2 and 10
(8.7%) patients in group 3, without statistical differences among
groups. Hypocalcemia was mild for these patients with mean iCa2+
of 1.07  0.02 mM/L. Mean serum 25(OH)D level was similarly
distributed among groups without statistical signicance. The
prevalence of vitamin D deciency was 37.3% (38/102) in group 1,
36.8% (39/106) in group 2 and 30.2% (35/116) in group 3, respectively.

First, the type and degree of hearing loss in both ears of the
patients were investigated as shown in Table 3. SNHL was found in a
total of 131 ears (56.5%, n = 232 ears) of osteoporotic patients, 101
ears (47.6%, n = 212 ears) of osteopenic patients and 61 ears (29.9%,
n = 204 ears) of the patients with normal BMD. The prevalence rate
of SNHL in the patients with osteoporosis/osteopenia was signicantly higher than the patients with normal BMD. However, there
was no signicant difference between the patients with osteopenia
and those with osteoporosis in the prevalence of SNHL. Conductive
hearing loss (CHL) or mixed hearing loss was found in relatively
small number of patients without the statistical signicance among
3 groups. The degrees of SNHL were classied as mild to moderate in
the majority of the patients regardless of BMD scores (Table 4).
There was no signicant difference among groups for the degree of
hearing impairment.
The mean air-conduction hearing thresholds at different
frequencies in better ear and poorer ear are shown in Fig. 1 The
air-conduction pure-tone thresholds in all frequencies (250
8000 Hz) were measured signicantly higher in the patients with
osteoporosis/osteopenia than the patients with normal BMD. The
mean bone-conduction hearing thresholds at different frequencies
in better ear and poorer ear are presented in Table 5. The boneconduction pure-tone thresholds in 5004000 Hz were signicantly increased in the patients with osteoporosis/osteopenia than
the patients with normal BMD. High-frequency thresholds tended
to be signicantly higher than low frequency thresholds in all ears
regardless of BMD scores (P < 0.05). For instance, high-frequency
PTA (48 kHz) for poorer ear was 34.1  22.7 for group 1,
49.4  23.1 for group 2, and 55.3  23.7 for group 3, respectively.
Low-frequency PTA (0.251 kHz) was 21.9  14.3 for group 1,
33.9  20.4 for group 2, and 37.1  20.6 for group 3, respectively.
Multiple logistic regression analyses were used to evaluate the
association of the presence of hearing loss (PTA > 25 dB) and

Table 1
Demographic data of the patients (N = 324).

Age (years)
BMI (kg/m2)
Lumbar BMD (g/cm2)
T-score
Femur neck BMD (g/cm2)
T-score
Years since menopause (y)
Smoking (%)
Alcohol (%)
Hyperlipidemia (%)
Diabetes (%)
Hypertension (%)

Normal BMD (N = 102)

Osteopenia (N = 106)

Osteoporosis (N = 116)

60.4  10.0
23.5  3.7
0.979  0.139
0.2  0.7
0.783  0.082
0.4  1.1
10.0  9.2
5 (4.9)
8 (7.8)
19 (18.6)
20 (19.6)
35 (34.3)

60.7  9.0
23.7  3.9
0.835  0.084
1.7  0.6
0.680  0.103
1.4  0.8
11.9  8.4
4 (3.8)
10 (9.4)
20 (18.9)
24 (22.6)
38 (35.8)

62.3  9.0
23.6  3.7
0.663  0.103
3.2  0.8
0.534  0.137
2.5  0.9
12.5  8.4
5 (4.3)
11 (9.5)
22 (19.0)
26 (22.4)
42 (36.2)

NS
NS

NS
NS
NS
NS
NS
NS

Data are presented as mean  SD. Signicant differences are marked, NS, not signicant. BMI, Body mass index; BMD, Bone mineral density.

Table 2
Biochemical parameters (N = 324).
Mean score  SD

Calcium (mg/dL)
Phosphate (mg/dL)
ALP (IU/L)
Creatinine clearance (mL/min)
25-(OH) vitamin D (ng/mL)
iPTH

Normal

Osteopenia

Osteoporosis

9.1  0.6
3.7  0.6
176.5  39.3
80.3  9.2
32.2  16.0
34.6  7.9

9.2  0.5
3.7  0.5
169.6  37.9
79.0  8.1
31.4  23.4
35.9  7.4

9.0  0.6
3.6  0.7
187.5  86.2
78.1  8.3
30.5  18.7
32.6  7.1

Data are presented as mean score  SD. Signicant differences are marked, NS, not signicant. ALP, total alkaline phosphatase; iPTH, intact parathyroid hormone.

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NS
NS
NS
NS
NS
NS

J.Y. Kim et al. / Auris Nasus Larynx 43 (2016) 155160

158
Table 3
Type of hearing loss presented by the patients (N = 324).

Osteopenia

Normal

Hearing thresholds within normal standards

Sensorineural HL
Conductive HL
Mixed HL

Osteoporosis

Right (%)

Left (%)

Right (%)

Left (%)

Right (%)

Left (%)

72(70.6)
30(29.4)
0(0)
0(0)

71(69.6)
31(30.4)
0(0)
0(0)

52(49.0)**
50(47.2)*
1(0.9)
3(2.9)

54(50.9)**
51(48.2)*
0(0)
1(0.9)

46(39.7)**
68(58.6)**
0(0)
2(1.7)

48(41.4)**
63(54.3)**
1(0.9)
4(3.4)

Signicant differences are marked, *P < .05; **P < .01, for the comparison with normal group. HL, hearing loss.

Table 4
Degree of sensorineural hearing loss presented by the patients.
Normal

Osteopenia

Osteoporosis

Right (%)

Left (%)

Right (%)

Left (%)

Right (%)

Left (%)

Mild (2640 dB)

Moderate (4155 dB)
Moderately severe (5670 dB)
Severe (7190 dB)
Profound (>90 dB)

17(56.7)
7(23.3)
3(10.0)
2(6.7)
1(3.3)

11(35.5)
12(38.7)
5(16.1)
2(6.5)
1(3.2)

22(44.0)
20(40.0)
4(8.0)
2(4.0)
2(4.0)

30(58.8)
13(25.5)
4(7.9)
2(3.9)
2(3.9)

17(25.0)
39(57.4)
9(13.2)
2(2.9)
1(1.5)

18(28.6)
28(44.4)
10(15.9)
5(7.9)
2(3.2)

Total

30

31

50

51

68

63

Signicant differences are marked, *P < .05; **P < .01.

variables including age, lumbar BMD, femoral neck BMD, serum

vitamin D and serum calcium (Table 6). The regression analyses
demonstrated that lumbar BMD was associated with the presence
of hearing loss with the odds ratios of 2.8 (95% condence
interval = 0.978.28, P = 0.047). As expected, the age of patients
was also risk factor for the hearing loss.
4. Discussion
The most salient ndings of this study are 1) the majority of
type of hearing loss was SNHL and the higher prevalence of SNHL
was found in women with osteoporosis/osteopenia than women
with normal BMD, 2) hearing thresholds were signicantly higher
in all frequencies in women with osteopenia/osteoporosis than
women with normal BMD, and 3) Multiple logistic regression
analyses revealed that age and lumbar BMD were signicantly
associated with the hearing loss.
The term presbycusis literally means old hearing and has been
regarded as the aging process of the auditory system. However,
age-related hearing loss is a multifactorial disease with the
accumulated effects of aging and environmental factors such as
everyday noise exposure, trauma, concurrent metabolic diseases
and any other factors that could affect the auditory system over
time. Therefore, establishing a specic etiology for age-related

hearing loss would be a more complex process than previously

assumed. Likewise, demineralized petrous temporal bone, in
conjunction with age-related bone mass loss, might contribute
to the development of age-related hearing loss. Demineralization
of the cochlear bone as the common manifestation has been known
to be associated with hearing loss in individuals with Pagets
disease of the bone and cochlear otosclerosis, although the exact
mechanisms behind this remain to be elucidated [5,6]. The
severity of demonstrable pathological changes appear to be
correlated with the degree of hearing loss [7,8], and decreased
BMD at specic locations on bony capsule was associated with
diminished hearing sensitivity for specic frequencies in patients
with cochlear otosclerosis [23].
Bone demineralization of the skull also has been documented in
the patients with severe osteoporosis [9]. Osteoporosis characterized by generalized reduced bone mass, increased bone turnover,
and increased susceptibility to fracture is one of the common
complications of aging and becoming a major public health
concern due to the aging of the global population. The reported
prevalence of osteoporosis in women older than 50 years of age
varies from 7.9% to 22.6% depending on the study population
and adoptive reference standard [24,25]. The relationship of
osteoporosis with decreased hearing sensitivity has been previously evaluated by a limited number of studies. However, the

125250500 1k 2k 3k 4k 8k
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10

10

20
30
40

*
**

*
**

**
**

**
**

*
**

50

80

**

**
**

60
70

**

Normal, N=102
Osteopenia, N=106
Osteoporosis, N=116

Better ear

Hearing thresholds (dB)

Hearing thresholds (dB)

125250500 1k 2k 3k 4k 8k
0

20
30
40

**

**

**

**

**

**

**

50

*
**

**
**

**

60

**

70
80

Poorer ear

Fig. 1. Comparison of air-conduction hearing thresholds among groups, normal bone mineral density (BMD) (n = 102), osteopenia (n = 106) and osteoporosis (n = 116).
Signicant differences are marked, *P < .05; **P < .01.

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J.Y. Kim et al. / Auris Nasus Larynx 43 (2016) 155160

Table 5
Comparison of bone conduction hearing thresholds among groups, normal bone
mineral density (BMD) (n = 102), osteopenia (n = 106) and osteoporosis (n = 116).
Bone conduction thresholds (dB)
Normal

Osteopenia

Osteoporosis

Better ear
250 Hz
500 Hz
1 kHz
2 kHz
3 kHz
4 kHz

17.6  7.4
17.6  7.7
18.4  10.2
21.0  11.7
23.1  13.6
25.2  16.5

22.6  11.8
25.2  16.5*
26.5  17.1**
30.4  19.4**
35.5  20.9**
36.4  20.2**

27.1  12.3**
29.2  14.7**
29.8  14.9**
33.1  16.5**
37.8  17.6**
40.6  18.4**

<.001
<.001
<.001
<.001
<.001
<.001

Poorer ear
250 Hz
500 Hz
1 kHz
2 kHz
3 kHz
4 kHz

22.4  9.3
21.9  11.2
19.9  12.1
22.5  14.9
26.7  18.6
26.7  18.6

27.8  17.9
32.6  20.1**
31.8  20.3**
32.9  22.1*
40.8  26.0*
41.3  24.6**

31.1  15.1**
34.5  18.2**
33.6  18.2**
37.2  19.1**
42.8  22.5**
43.1  20.4**

<.001
<.001
<.001
<.001
<.001
<.001

Data are presented as mean  SD. Signicant differences are marked, *P < .05;
**P < .01, for the comparison with the normal group.

Table 6
Association of age, BMD results, serum vitamin D and serum Ca2+ with hearing loss
analyzed by multiple logistic regression analyses.

Age
Lumbar BMD
Femur neck BMD
Serum vitamin D
Serum calcium

OR

P value

95% CI

1.1
2.8
0.4
1.0
2.2

.019
.047
>.05
>.05
>.05

1.02,
0.97,
0.13,
0.93,
0.61,

1.27
8.28
1.20
1.03
8.15

BMD, bone mineral density; OR, odds ratio; CI, condence interval.

studies have the limitations of small sample size, the issues of

clinical validity of hearing screening or the adaptation of BMD in
different regions; therefore, the effect of reduced BMD over hearing
sensitivity remained inconclusive due to the contradictory results.
First, several epidemiologic studies were summarized as follows.
The risk of hearing loss has been signicantly increased in the older
subjects who have a low BMD in the femoral neck [11] or total or
head BMD [18]. However, another study showed that there were
no relationships between the hearing loss (>40 dB) and BMD in
aged women [26], while hearing loss was associated with lower hip
BMD in black men, but not in whites or black women in the other
study [14]. Second, recent clinical studies revealed that auditory
thresholds were signicantly increased in osteoporotic aged
women than the women with normal BMD [12,13]. However,
the differences in hearing thresholds between osteoporotic
patients and controls tend to be relatively small with around
10 dB. Audiometric screening for hearing loss including bone
conduction thresholds provided frequency-specic results in the
present study, and demonstrated the similar results with 1020 dB
differences in hearing thresholds at all frequencies for the
osteoporotic women than the women with normal BMD.
Although middle ear ossicles could be affected by osteoporosis,
manifesting as CHL, typical hearing impairment of osteoporotic
patients was bilateral SNHL, often worse in the high frequencies in
the present study. This result was consistent with others, and it
might be explained by that the middle ear ossicles containing a
higher proportion of cortical bone and would have slower bone
resorption. The prevalence of SNHL was found as 56.5% in the
osteoporotic women in the present study. Given that this rate was
substantially higher than expected prevalence of disabling hearing
loss in the same population, the association between the
osteoporosis and SNHL appears to be strengthened.
In order to better understand the complicated relationships
between BMD and hearing sensitivity, the present study has also

159

focused on the inuence of systemic Ca2+ and vitamin D status on

hearing sensitivity in osteoporotic women. It has been observed
that there are associations between low serum 25(OH)D levels and
SNHL [16,17].
Proposed mechanism is dysfunctional Ca2+
metabolism and impaired microcirculation in the cochlea [18].
However, our ndings failed to show an association between low
vitamin D level and hearing loss in osteoporotic women and it
might suggest that the loss of BMD of cochlear capsule is directly
related with SNHL in osteoporotic patients.
BMD measurements often are discordant across various bone
sites, and these discrepancies most likely are related to differences
in trabecular vs. cortical bone compartments [27]. We found a
signicant association between lumbar BMD and hearing loss
after the adjustments age and by other factors. Although direct
measurement of BMD of temporal bone was limited in the present
study, there has been a signicant positive relationship between
age-related demineralization of the maxilla and mandible and
BMD of the lumbar spine [28,29]. Since estrogen deciency affects
trabecular bone rst and vertebral bone consists predominantly of
trabecular bone than total hip or femoral neck, lumbar spine
might better represent the primarily cancellous temporal bone
[30].
It has been postulated that the pathologies in the cochlear
lateral wall affect the hearing of individuals with Pagets disease or
cochlear otosclerosis. Abnormal focus of bone remodeling has been
theorized to alter ion and uid homeostasis in the spiral ligament
through perilymphatic space of the cochlea at the endosteumspiral ligament interface [31]. Distinct histopathologic changes,
which were more prominent in the basal turn, include brous
thickening and loss of blood vessels in areas of cochlear endosteal
invasion, spiral ligament hyalinization and subsequent atrophy of
the stria vascularis in the patients with cochlear otosclerosis [10].
For normal auditory function, ion concentrations and membrane
potential at endolymphatic uid are strictly controlled [32]. It is
conceivable that the loss of balance between bone formation and
bone resorption with aging or menopause might contribute to high
prevalence of SNHL by dysfunctional ionic metabolism in the
osteoporotic patients.
The present study must be interpreted within the limitations.
The results may not generalize to other medical settings or nontreatment-seeking subjects. Moreover, the study was based on the
assumption that temporal bone BMD would be reected by other
skeletal site. We do not attempt to dene the pathophysiological
relationship between reduced BMD and hearing impairments
through direct measurement of BMD of temporal bone. Instead,
our results suggest that the presence of decreased BMD might play
a role as possible risk factor of hearing loss in postmenopausal
women and major type of hearing loss is SNHL. It is therefore
important to properly identify individuals with hearing loss in the
osteoporotic patients and supply appropriate hearing aids or
assistive listening devices, which could have a positive impact on
quality of life for older people. Further longitudinal studies
employing adequate sample size and controlling for potential
confounders are needed to clarify the direct contribution of low
BMD to the risk of age-related hearing loss.
In conclusion, the present study demonstrates that the high
prevalence of SNHL in the postmenopausal women with osteoporosis/osteopenia is associated with decreased BMD in the lumbar
spine, which is not affected by the systemic Ca2+ and vitamin D
status.
Conict of interest
There are no known conicts of interest associated with this
publication and there has been no signicant nancial support for
this work.

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J.Y. Kim et al. / Auris Nasus Larynx 43 (2016) 155160

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