Costen’s syndrome and COPD
Foundation Don Carlo Gnocchi IRCCS, Department of Cardiology, Institute of Hospitalization and Care with Scientific Address, Milan 20100, Italy
I read with great interest the article of systematic review and meta-analysis of Bayatet al,1 which shows a close relationship between loss of hearing and COPD. The article reminds us that the doctor should always make an accurate medical history, because the clinical evaluation is the foundation of what will be the therapy of the patient.
View original paper by Bayat et al.
I read with great interest the article of systematic review and meta-analysis of Bayat et al,1 which shows a close relationship between loss of hearing and COPD. The article reminds us that the doctor should always make an accurate medical history, because the clinical evaluation is the foundation of what will be the therapy of the patient.
The text does not give explanations on the possible causes that induce hearing loss in patients diagnosed with COPD.
There is a close embryological and functional relationship between the temporomandibular joint (TMJ) and the middle ear.2 The structure of union between these two anatomical areas is the discomalleolar ligament or Pinto’s ligament, which connects the medial retrodiscal portion of TMJ and the malleus of the middle ear.2 Studies show that an altered ligament tension due to an abnormal opening of the mouth leads to dysfunction of the middle ear with risk of hearing loss.3–5
The patient with COPD suffers from many comorbidities, including musculoskeletal disorders, arthritis, arthrosis, with degeneration of the joint functions (as for TMJ), as well as obstructive sleep apnea syndrome (OSAS).6,7
OSAS causes an abnormal opening of the mouth during the night, with a structural and functional alteration of the neck; there is a close relationship between this syndrome and the decrease in hearing.8,9
From a clinical point of view, signs such as hearing loss, functional impairment of the neck and TMJ disorders lead to Costen’s syndrome.10
The latter alters the internal pressure of the middle ear and subsequent decrease in hearing, through muscular (neck), articular (TMJ) and ligament dysfunction (Pinto’s ligament).10
We can strongly hypothesize that one of the most important causes of hearing loss in patients with COPD is the secondary presence of Costen’s syndrome.
The author reports no conflicts of interest in this communication.
Bayat A, Saki N, Nikakhlagh S, et al. Is COPD associated with alterations in hearing? A systematic review and meta-analysis. Int J COPD. 2019;14:149–162.
Mérida-Velasco JR, de la Cuadra-Blanco C, Pozo Kreilinger JJ, Mérida-Velasco JA. Histological study of the extratympanic portion of the discomallear ligament in adult humans: a functional hypothesis. J Anat. 2012;220(1):86–91.
Loughner BA, Larkin LH, Mahan PE. Discomalleolar and anterior malleolar ligaments: possible causes of middle ear damage during temporomandibular joint surgery. Oral Surg Oral Med Oral Pathol. 1989;68(1):14–22.
Kusdra PM, Stechman-Neto J, Leão BLC, Martins PFA, Lacerda ABM, Zeigelboim BS. Relationship between otological symptoms and TMD. Int Tinnitus J. 2018;22(1):30–34.
Kitsoulis P, Marini A, Iliou K, et al. Signs and symptoms of temporomandibular joint disorders related to the degree of mouth opening and hearing loss. BMC Ear Nose Throat Disord. 2011;11(1):5.
Bordoni B, Marelli F, Morabito B, Castagna R. Chest pain in patients with COPD: the fascia’s subtle silence. Int J Chron Obstruct Pulmon Dis. 2018;13:1157–1165.
Smith MC, Wrobel JP. Epidemiology and clinical impact of major comorbidities in patients with COPD. Int J Chron Obstruct Pulmon Dis. 2014;9:871–888.
Spinosi MC, D’Amico F, Passali G, Cingi C, Rodriguez H, Passali D. Hearing loss in mild OSAS and simple snoring patients. Otolaryngol Pol. 2017;71(2):11–15.
Ando E, Shigeta Y, Nejima J, et al. Assessment of the calcification of the nuchal ligament and osteophytes of the cervical spine in obstructive sleep apnoea subjects and snorers. J Oral Rehabil. 2016;43(2):96–102.
Effat KG. Otological symptoms and audiometric findings in patients with temporomandibular disorders: Costen’s syndrome revisited. J Laryngol Otol. 2016;130(12):1137–1141.
1Department of Audiology, Hearing Research Center, Imam Khomeini Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran; 2Department of Otorhinolaryngology, Hearing Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran; 3Department of Biostatistics and Epidemiology, School of Health, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran; 4Department of Internal Medicine, Air Pollution and Respiratory Diseases Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran; 5Department of Molecular Medicine, Health Research Institute, Thalassemia and Hemoglobinopathies Research Centre, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
Correspondence: Fakher Rahim, Department of Molecular Medicine, Health Research Institute, Thalassemia and Hemoglobinopathies Research Center, Ahvaz Jundishapur University of Medical Sciences, PO Box 61537-15794, Ahvaz, Iran, Tel +98 613 336 7652, Email email@example.com
We wish to emphasize some issues concerning our study. Actually, among the well-studied reasons that lead to hearing loss in patients with COPD, we discussed those that have been observed in most studies. The reason which is conflicting is the impact of smoking status or the type of smoking on the degree of impairment in auditory measures, which some studies reported a significant correlation,1–3 whereas other evidence demonstrated no association.4,5 The first possible reason that received special attention is the effect of COPD and chronic hypoxemia or hypoxia on the auditory function.6 Moreover, numerous studies have documented another possible reason that locally accompanied by loss of hearing sensitivity due to the high dependence of the transduction mechanism of the inner ear to the change in cochlear oxygen supply such as hypoxia.7–9
Another research suggested poorer central auditory function during hypoxemia in patients with COPD.10 Besides, some researchers introduced infection as a symptom that needs special consideration in patients with COPD; so, this leads researchers to use antibiotics in COPD patients as a prophylactic treatment to reduce exacerbations as well as to improve quality of life.11,12
Besides, infection is one of the different factors that can cause a type of hearing loss called conductive hearing loss.13 Although it is interesting to hypothetically consider secondary change in internal pressure of the middle ear and subsequent hearing impairment through temporomandibular joint (TMJ) as a cause of hearing loss in patient with COPD, this will require more research to be done. So far, up to 90% of the individuals with tinnitus suffer from some level of noise-induced hearing loss.14 A group of evidence reported that tinnitus associated with a TMJ falls under this second category.15,16
Another important suggestion is that functional impairment of the neck and TMJ, and consequently Costen’s syndrome, can lead to dysfunctional breathing such as mouth breathing syndrome, respiratory mechanics changes, diaphragmatic muscular dystonia and overuse of accessory inspiratory muscles.17 Consequently, such breathing dysfunction may induce hypoxia through various mechanisms,18 but not necessarily COPD.
The authors report no conflicts of interest in this communication.
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Herath SC, Normansell R, Maisey S, Poole P. Prophylactic antibiotic therapy for chronic obstructive pulmonary disease (COPD). Cochrane Database Syst Rev. 2018;10:CD009764.
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Leal MC, Muniz LF, Ferreira TS, et al. Hearing loss in infants with microcephaly and evidence of congenital Zika virus infection – Brazil, November 2015–May 2016. MMWR Morb Mortal Wkly Rep. 2016;65(34):917–919.
Le TN, Straatman LV, Lea J, Westerberg B. Current insights in noise-induced hearing loss: a literature review of the underlying mechanism, pathophysiology, asymmetry, and management options. J Otolaryngol Head Neck Surg. 2017;46(1):41–41.
Algieri GMA, Leonardi A, Arangio P, Vellone V, Paolo CD, Cascone P. Tinnitus in temporomandibular joint disorders: is it a specific somatosensory tinnitus subtype? Int Tinnitus J. 2017;20(2):83–87.
Attanasio G, Leonardi A, Arangio P, et al. Tinnitus in patients with temporo-mandibular joint disorder: proposal for a new treatment protocol. J Craniomaxillofac Surg. 2015;43(5):724–727.
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Tanaka E, Detamore MS, Mercuri LG. Degenerative disorders of the temporomandibular joint: etiology, diagnosis, and treatment. J Dent Res. 2008;87(4):296–307.
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