Original Research

Role of Obesity on the Prognosis of

Sudden Sensorineural Hearing Loss in
Adults

Otolaryngology
Head and Neck Surgery
16
American Academy of
OtolaryngologyHead and Neck
Surgery Foundation 2015
Reprints and permission:
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DOI: 10.1177/0194599815584599
http://otojournal.org

Juen-Haur Hwang, MD, PhD1

No sponsorships or competing interests have been disclosed for this article.

Abstract
Objective. To investigate the role of obesity/overweight on
the prognosis of sudden sensorineural hearing loss (SSHL).
Study Design. Retrospective cohort study.
Setting. Outpatient department of a community hospital.
Subjects and Methods. We collected 254 adult patients with
SSHL from a community hospital. The odd ratios of body
mass index (BMI) or obesity/overweight (BMI 25 kg/m2)
on the recovery of SSHL were evaluated with multivariate
logistic regression analysis.
Results. There were 120 (47.2%) patients in the nonobesity
group (BMI \25 kg/m2) and 134 (52.8%) patients in the obesity/overweight group (BMI 25 kg/m2). The complete and
partial recovery rates were 10.0% and 49.2% in the nonobesity group and 9.7% and 47.0% in the obesity/overweight
group, respectively. Univariate logistic regression showed
that BMI had no significant association with recovery of
SSHL (odds ratio [OR] of complete and partial recovery
versus no recovery = 1.04, 95% confidence interval [CI] =
0.965-1.113, P = .327). Multivariate logistic regression analysis also showed that BMI (OR = 1.04, 95% CI = 0.964-1.131,
P = .292) was not significantly associated with the recovery
of SSHL for all subjects, after adjusting for all considered
variables. Also, obesity/overweight (BMI 25 kg/m2) had no
significant association with the recovery of SSHL.
Conclusion. Obesity/overweight would appear to have no significant effect on the prognosis of SSHL.
Keywords
Body mass index, obesity, overweight, sudden sensorineural
hearing loss, prognosis, auditory function
Received September 23, 2014; revised March 3, 2015; accepted April
8, 2015.

udden sensorineural hearing loss (SSHL) is defined

as a loss of greater than 30 dB in 3 contiguous frequencies in less than 3 days.1 Estimates of the annual

incidence range from 5 to 20 cases per 100,000 persons.

The median age at presentation ranges from 40 to 54 years.
There is an equal distribution of female-to-male cases and
between ears.1 The etiology and pathogenesis of SSHL
remain unknown.2,3 Some risk factors are associated with
the onset of SSHL.4 For example, diabetes mellitus (DM),
hypercholesterolemia, cardiovascular risk factors,5 chronic
kidney disease (CKD) with DM,6 and migraine7 are associated with an increased risk of developing SSHL. However,
the predictive factors for the recovery of SSHL are still limited and controversial.
In addition to obesity-related comorbidities or sequelae,
obesity per se was reported to be a novel independent risk
for peripheral and central types of age-related hearing
impairment (ARHI).8-10 Body mass index (BMI) was
reported to correlate with hearing loss across all frequency
ranges, with a higher BMI correlating with more severe
hearing loss.8 Our study group had also demonstrated that
waist circumference (WC), which may be a better surrogate
marker of obesity and obesity-related morbidity and mortality,11 was an independent risk factor for elevated hearing
thresholds in adults after adjusting for age, gender, BMI,
and other clinical factors.9 However, the impact of obesity
on the prognosis of SSHL is still unknown.
Initial severe hearing loss, vertigo, and downward audiometric pattern are negative prognostic factors of hearing
recovery.12 The poor prognosis has also been observed in
patients with concurrent microvascular diseases, such as
hypertension (HTN), DM, and hyperlipidemia.13-15 The
youngest and the oldest patients might have a lower recovery
rate.16 Inflammatory signs in the laboratory workup are a
good indicator for recovery from SSHL-treated steroids.17
Higher neutrophil-to-lymphocyte ratio is a poor indicator for
occurrence and recovery of SSHL.18

1
Department of Otolaryngology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi
Medical Foundation, Chiayi, Taiwan; the School of Medicine, Tzu Chi
University, Hualien, Taiwan

Corresponding Author:
Juen-Haur Hwang, MD, PhD, Department of Otolaryngology, Dalin Tzu Chi
Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan; the School
of Medicine, Tzu Chi University, No. 2 Minsheng Road, Dalin, Chiayi,
62247, Taiwan.
Email: G120796@tzuchi.com.tw

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OtolaryngologyHead and Neck Surgery

However, there are still many reports against these positive

findings. For example, there were no differences in remission
rates for SSHL patients with preexisting sensorineural hearing
loss, previous episode of SSHL, or chronic otitis media.19
Vertigo,20 audiogram type, cardiovascular and thromboembolic
risk factors, time elapsed from onset of SSHL to hospitalization,20,21 or routine laboratory parameters22 were not associated
with recovery of SSHL. Lionello et al21 concluded that only
age was significantly and independently related to hearing outcome among all known factors.
The role of obesity on the recovery of SSHL has never
been reported, but it might be supposed to be positive with
the knowledge of obesity-related inflammation and pathophysiology of SSHL. In this study, therefore, we aimed to
investigate the effect of BMI on the outcome of SSHL in
adults using a retrospective cohort study with detailed and
complete chart review.

Methods
From 2000 to 2010, well-recorded clinical and audiometric
data of 254 consecutive adult patients with unilateral SSHL
were collected for analysis from the outpatient department
of Dalin Tzu Chi Hospital, Chiayi, Taiwan. The data were
acquired by clinical chart review, and SSHL was documented by clinical diagnosis. Those charts should be maintained
for at least 15 years in Taiwan for legal and medical purposes. The study was approved by the institutional review
board of the Dalin Tzu Chi Hospital, Taiwan (No.
B09902015). Since all of the files contain only de-identified
secondary data, the review board waived the requirement
for obtaining informed consent from the patients.
All patients were treated by 4 physicians with a standard
treatment protocol. The decision to admit or not admit was
based on the patients will but was not based on age,
gender, disease severity, and so forth. Age, gender, BMI,
presenting symptoms, time elapsed from onset of SSHL to
initial treatment, admission or not, and medical history,
including coronary artery disease (CAD), HTN, DM, dyslipidemia, and CKD, were recorded. In addition, data of
pure-tone audiometry were collected.
All included patients were divided into 2 groups based
on BMI as defined by the World Health Organization in
2014. The nonobesity group was defined as patients with a
BMI \25 kg/m2, whereas the obesity/overweight group was
defined as patients with a BMI 25 kg/m2. Those patients
who were not admitted for treatment received the outpatient
protocol: oral prednisolone (1 mg/kg per day for 7 days, and
then tapered within 14 days), nicametate (50 mg, 3 times a
day), and aspirin (100 mg, once a day). In addition, those
patients who were admitted for treatment received the inpatient protocol: intravenous dexamethasone (10 mg per day
for 7 days, and then tapered within 14 days by oral prednisolone), intravenous 10% dextran 40 (twice a day for 7
days), oral nicametate (50 mg, 3 times a day), and aspirin
(100 mg, once a day).
Exclusion criteria included age younger than 18 years,
external or middle ear diseases, conductive hearing loss

(presenting with an air-bone gap on audiogram), acoustic

trauma (presenting with a 3- to 6-kHz dip in audiogram),
brain tumor or vestibular schwannoma, or head and neck
radiation exposure. Patients whose time elapsed from onset
of SSHL to initial treatment longer than 30 days were
excluded. Besides, to avoid confounding from other optional
treatment, also excluded were the patients who received
intratympanic steroid (ITS) injection as primary or salvage
treatment for SSHL.
All patients were followed up once per month, and the
endpoint for outcome measurement was set at 6 months
after initial treatment at the outpatient department or admission in the hospital. We averaged the thresholds at 500 Hz,
1 kHz, 2 kHz, and 4 kHz to obtain the averaged pure-tone
hearing threshold (PTA) for each subjects. According to the
clinical practice guideline for sudden hearing loss,23 the
initial hearing loss severity was that the audiometric difference between the affected ear and nonaffected ear. In
addition, the outcomes of SSHL were divided into 3 groups
based on the status of recovery by treating the unaffected
ear as the standard. A complete recovery requires return to
within 10 dB HL of the unaffected ear. Anything less than a
10-dB HL improvement was classified as no recovery.
Partial recovery was defined as the status other than complete recovery or no recovery conditions.
Second, the recovery of SSHL was also categorized as
none (0 dB HL), moderate (1-10 dB HL), or good (.10 dB
HL) recovery relative to baseline hearing level, as shown in
the report of Weiss et al.24

Statistical Analysis
The data were presented as means 6 standard deviation
(SD), unless indicated otherwise. Continuous variables were
compared by Student t test, whereas categorical variables
were compared by x2 test. The odds ratio (OR) and BMI on
the recovery of SSHL, which was shown as complete and
partial recovery versus no recovery, or good and moderate recovery versus no recovery, were first evaluated
with univariate a logistic regression analyses for all subjects.
Then, we included the variables whose P value was  .4 in
the univariate logistic regression into the multivariate logistic regression model for all ages, age younger 65 years, and
age older than 65 years, because the prognosis might vary
in different age groups.16 In addition, in each analysis, age
was regarded as a continuous variable. P values \.05 were
considered statistically significant. All analyses were performed using STATA 10.0 software (Stata Corp, College
Station, Texas). The power calculation was performed by
the free software G-Power (http://www.gpower.hhu.de/).

Results
There were 109 (42.9%) female patients and 145 (57.1%)
male patients in this study. The mean age was 54.9 6 14.2
years (range, 18-88 years) for all 254 patients. The mean
BMI was 24.9 6 4.1 kg/m2 (range, 15.8-42.1 years).
Table 1 showed the general characteristics of all subjects
by BMI. There were 120 (47.2%) patients in the nonobesity

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Hwang

Table 1. General Characteristics of Subjects in the Nonobesity and Obesity/Overweight Groups.

Case number, n (%)

Age (mean 6 SD), y
Gender, F/M, %
Time elapsed from onset of SSHL to initial treatment (mean 6 SD), d
Initial hearing loss severitya (mean 6 SD), dB HL
Treated hearing loss severitya (mean 6 SD), dB HL
Outcome, %
No recovery
Partial recovery
Complete recovery
Admission, n (%)
CAD, n (%)
HTN, n (%)
DM, n (%)
Dyslipidemia, n (%)
CKD, n (%)
Vertigo, n (%)
Headache, n (%)

Nonobesity Group
(BMI \25 kg/m2)

Obesity/Overweight
Group (BMI 25 kg/m2)

P Value

120 (47.2)
55.2 6 14.7
42.5/57.5
6.0 6 4.6
55.4 6 23.7
39.1 6 25.4

134 (52.8)
54.7 6 13.8
43.3/56.7
5.9 6 5.8
52.6 6 23.1
36.8 6 25.6

.7888
1.000
.9674
.3414
.4755

40.8
49.2
10.0
74 (61.7)
3 (2.5)
43 (35.8)
36 (30.0)
16 (13.3)
9 (7.5)
28 (23.7)
8 (6.7)

43.3
47.0
9.7
61 (45.5)
5 (3.7)
47 (35.1)
38 (28.4)
19 (14.2)
6 (4.5)
43 (32.2)
18 (13.6)

.949

.012
.726
1.000
.784
.858
.425
.248
.200

Abbreviations: BMI, body mass index; CAD, coronary artery disease; CKD, chronic kidney disease; DM, diabetes mellitus; F, female; HTN, hypertension; M,
male; SD, standard deviation; SSHL, sudden sensorineural hearing loss.
a
The initial or treated hearing loss severity was the audiometric difference between the affected ear and nonaffected ear.

group (BMI \25 kg/m2) and 134 (52.8%) patients in the

obesity/overweight group (BMI 25 kg/m2). The complete
and partial recovery rates were 10.0% and 49.2% in the
nonobesity group and were 9.7% and 47.0% in the obesity/
overweight group, respectively. The ratio of admission was
significantly higher in the nonobesity group than in the obesity/overweight group. But, age, gender, time elapsed from
onset of SSHL to initial treatment, initial or treated hearing
loss severity, outcome of SSHL treatment, and all other
variables were not significantly different between both
groups.
Table 2 shows the results of univariate logistic regression analysis for the relationship between all considered
variables and the recovery (combined complete and partial
recovery versus no recovery) of SSHL for all subjects. Only
age (OR = 0.98, 95% confidence interval [CI] = 0.9590.995, P = .014) and initial hearing loss (OR = 1.02, 95%
CI = 1.006-1.029, p = 0.002), but not BMI (OR = 1.04,
95% CI = 0.965-1.113, P = .327) and other variables, were
significantly associated with the recovery of SSHL.
Table 3 shows the results of multivariate logistic regression analysis for the relationship between BMI and the
recovery (combined complete and partial recovery versus no
recovery) of SSHL in different ages. BMI (OR = 1.04, 95%
CI = 0.964-1.131, P = .292) was not significantly associated
with the recovery of SSHL for all subjects, after adjusting
for age, gender, initial hearing loss severity, admission,
CAD, and HTN. The post hoc power calculation showed
that the power was 72% under the number of predictors = 7,

observed R2 = 0.047, probability level = .05, and sample

size = 254. Also, the association between BMI and the
recovery of SSHL was not significant in the subjects
younger than 65 or older than 65 years.
When we used obesity/overweight (BMI 25 kg/m2)
instead of BMI in the multivariate logistic regression model,
we still found that obesity/overweight was not significantly
associated with the recovery of SSHL after adjusting for the
considered variables. Also, when a further subanalysis based
on admission was performed, BMI did not show a significant
association with the recovery of SSHL in patients without
admission (OR = 0.91, 95% CI = 0.576-1.450, P = .701) or
with admission (OR = 1.04, 95% CI = 0.936-1.151, P = .485).
When the recovery was alternatively categorized as none,
moderate, or good recovery, the good and moderate recovery rates were 59.2% and 22.5% in the nonobesity group
and 56.7% and 20.9% in the obesity group, respectively.
Multivariate logistic regression showed that BMI (OR =
0.95, 95% CI = 0.695-1.309, P = .771) still did not have a
significant association with the recovery (combined good
and moderate recovery) of SSHL after adjusting for age,
gender, admission, initial hearing loss level, CAD, and HTN
for all subjects.

Discussion
In this retrospective cohort study, we have provided new
evidence about the role of obesity/overweight on the recovery of SSHL in adults. In SSHL patients without receiving
ITS, BMI or obesity/overweight was not significantly and

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OtolaryngologyHead and Neck Surgery

Table 2. Univariate Logistic Regression Analysis for the Recovery of SSHL for All Subjects.

Age, y
Gender (males vs females)
BMI, kg/m2
Time elapsed from onset of SSHL to initial treatment, d
Initial hearing loss severity, dB HL
Admission
CAD
HTN
DM
Dyslipidemia
CKD
Vertigo
Headache

OR

SE

P Value

95% CI

0.98
1.31
1.04
1.00
1.02
1.37
5.30
0.65
1.10
0.84
1.49
1.01
3.18

0.009
0.336
0.038
0.028
0.006
0.350
5.707
0.173
0.308
0.309
0.839
0.340
2.089

2.46
1.05
0.98
0.17
3.03
1.24
1.55
1.61
0.33
0.46
0.71
0.02
1.76

.014
.295
.327
.862
.002
.215
.121
.107
.743
.644
.480
.982
.078

0.959-0.995
0.791-2.163
0.965-1.113
0.942-1.051
1.006-1.029
0.832-2.262
0.642-43.734
0.388-1.096
0.633-1.900
0.412-1.730
0.494-4.490
0.520-1.953
0.877-11.528

Abbreviations: BMI, body mass index; CAD, coronary artery disease; CI, confidence interval; CKD, chronic kidney disease; DM, diabetes mellitus; HTN,
hypertension; OR, odds ratio; SE, standard error; SSHL, sudden sensorineural hearing loss.
a
OR was calculated from the odds of the combined complete and partial recovery versus no recovery.

Table 3. Multivariate Logistic Regression Analysis for the Recovery of SSHL.

18  age \ 65 y

All Subjects
OR (95% CI)
Age, y

0.99 (0.965-1.013)

OR (95% CI)

1.25 (0.684-2.276)

1.39 (0.676-2.866)

1.04 (0.964-1.131)

1.01 (0.911-1.120)

1.01 (0.999-1.027)

1.01 (0.996-1.028)

0.88 (0.462-1.674)

0.71 (0.318-1.589)

3.92

HTN

.227
(0.427-36.000)
0.63 (0.327-1.231)
.178

.308

1.13 (0.330-3.861)

.846

1.15 (0.981-1.352)

.084

1.02 (0.985-1.048)

.317

1.43 (0.428-4.757)

.563

1.54

.750

.160

.696
CAD

1.06 (0.949-1.181)

.852

.065
Admission

.370

.292
Initial hearing loss severity, dB HL

OR (95% CI)

.148

.471
BMI, kg/m2

0.97 (0.937-1.010)
.345

Gender

Age 65 y

.406
Omitted

0.63 (0.275-1.445)

.276

(0.106-22.416)
0.63 (0.182-2.173)
.464

Abbreviations: BMI, body mass index; CAD, coronary artery disease; CI, confidence interval; HTN, hypertension; OR, odds ratio; SSHL, sudden sensorineural
hearing loss.
a
OR was calculated from the odds of the combined complete and partial recovery versus no recovery.

independently associated with the prognosis of SSHL in

adults.
The complete and partial recovery rates were 10.0% and
49.2% in the nonobesity group and 9.7% and 47.0% in the
obesity/overweight group, respectively. These data were
very similar to those of other studies.12-22 The role of HTN
on the prognosis of SSHL in our study was different from
that of Hirano et al,13 Nagaoka et al,14 and Shikowitz15 but
was similar to that of Mosnier et al20 and Lionello et al.21
As for the role of age, our current result was slightly different from that of Wang et al16 and Lionello et al.21

Statistically, hearing level was in fact a continuous variable but was arbitrarily defined into a category variable for
outcome calculation. Second, treatment protocols might
contribute variably to the treatment outcomes. Thus, the
contradictory results between these articles mentioned
above and ours might be due to the differences in the outcome definition and/or treatment protocols.12-24 In addition, the merit of this study over other published similar
studies is that we have proposed a novel possible factor
(obesity/overweight) on the prognosis of SSHL, although a
negative result was shown.

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Hwang

Adipose tissue is now considered to be an endocrine

tissue. It secretes hormones and cytokines and influences
insulin resistance, energy metabolism, and atherosclerosis.25 Further, obesity-induced inflammation may exacerbate end-organ damage. Therefore, in addition to the
contribution to peripheral hearing degeneration indirectly
via its comorbidities-related angiopathy and/or neuropathy,26 obesity itself might also make hearing worse directly
via lipotoxicity and related oxidative stress.27 This hypothesis
was proved by some recent animal28 and human studies.810,29,30
Meanwhile, inflammation was one of important underlying mechanisms9-11 and prognosis indictors17,18 for SSHL.
Thus, we could also suppose obesity to be associated with
treatment outcome of SSHL. However, we could not show a
positive relationship between obesity/overweight and outcome of SSHL.
The negative result of this study might be mainly due to
the low OR, case number, and subsequent lower power. The
result might also be weakened by a lack of WC data, which
was a better indicator for obesity-related problems, in this
retrospective chart review study. Otherwise, the negative
results of this study might be also due to the different etiology or underlying mechanisms of SSHL and ARHI. The
etiology and pathogenesis of SSHL remain unknown,9,10 but
Chau et al4 reported that the percentages of the possible
etiologies for SSHL were 71.0% for idiopathic cause, 12.8%
for infectious diseases, 4.7% for otologic diseases, 4.2% for
trauma, 2.8% for vascular or hematologic problems, 2.3%
for neoplastic diseases, and 2.2% for other causes.
However, ARHI might be caused by obesity and its comorbidities.8-10,28-30 Thus, our negative result has just enforced
the difference between SSHL and ARHI.
As for the relationship between admission and prognosis
of SSHL, this study raised the issue regarding the efficiency of the treatment protocol and the cost of medical
care. Considering the differences in both treatment protocols, our results could also indicate that oral steroid treatment did not have a significantly poorer or better effect on
the recovery of SSHL than intravenous steroid and dextran
did. Thus, there is no need to suggest that adult patients
with SSHL be admitted for treatment, pay more money, or
spend much time. Furthermore, there is much evidence
showing that a new outpatient treatment protocol could be
as effective as conventional treatment with oral steroids.
For example, 3 different outpatient treatment protocols
(oral steroid, ITS injection, or the combination of both)
resulted in similar hearing recovery rates.31,32 Therefore,
outpatient departmentbased systemic and/or local steroid
therapy can be recommended as an initial treatment for
SSHL, although oral prednisolone was once reported to
have no benefit on the recovery of SSHL.17

Conclusion
In this retrospective cohort study, we found that BMI or
obesity/overweight was not significantly associated with the
recovery of SSHL without ITS. Additional prospective,
well-designed studies about WC and the prognosis of SSHL

with a greater number of cases should be conducted in the

future.
Acknowledgment
I thank Dr Jin-Cherng Chen and Associate Professor Malcolm Koo
at Dalin Tzu Chi Hospital for data analysis and for providing statistical consultation for this study.

Author Contributions
Juen-Haur Hwang, accountability for all aspects of the work.

Disclosures
Competing interests: None.
Sponsorships: None.
Funding source: None.

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