Hearing loss associated with hyperkalemia?

[Versatil]

Here's the story of a patient complaining of a major hearing loss, especially at right.

5'9'' - 162lbs - 21 yrs
cystic fibrosis
Liver transplant
diabetes
+ lazy suprarenal glands
...
Transplanted in May 2009

he's taking the following:
tacrolimus (prograf) 3.5 bid
testim (testosterone) 5g/day alt. 7.5g
cortef 15mg 10mg 5mg = 30mg/day
TOBI (tobramycin for inhalation) 150mg each day
oxycodone 10mg prn
clonidine 0.1 bid
coumadin 2.5mg
singulair 10mg hs
desyrel 50 hs
lyrica 50 bid (stopping)
... for the least

New addition these past weeks was the clonidine to treat high pressure probably associated with tacrolimus undoubtedly.
Today, he came at the hospital for a regular appointment.
labs: Total testosterone way too high. Potassium at 5.9 just an edge under my established toxic limits (6.0). Creat 140 (tacrolimus decreasing renal fonction), not too bad and and I don't think it can explain this acute hyperkalemia. The rest is normal for him.
Then, he complained of hearing loss that has begun since 2 months or so. He has always had a small tinnitus, but it's is even more noticeable in his right ear since that time. He thinks the tinnitus is still the same, but he is hearing it more because of this hearing loss (this is logic).
Past audiograms (6 months ago) were showing a considerable loss @ 8khz, medium loss @ 7 and very small at 6, the rest is normal. This was asymmetric, the right ear was a bit more affected than the left one. We are all sure that this loss of high frequencies was caused by neurotoxic ears medication, such as tobramycin IV.
He has noticed that, some time after pain and a take of oxycodone, the tinnitus is increasing and he is earing less. I searched some information about hearing loss with the take of oxycodone, this was not proved, though Vicodin, an other codeinic, is already known for impairing ears (so it might be related to codeinics like oxycodone in some ways... or not).
Then I came with this idea (since I am an anesthesiologist student so I know a lot about opiates but nothing about ears), which sounds not that crazy after all, is the fact that most opiates are increasing K+ currents synapticly. And this, combined with a progressive hyperkalemia could perhaps lead to an hearing disorder according to his case and his symptoms because now he feels that he lost some hearing.

I need someone who can help me on that one.

Is it reversible or not? Do we need to worry? Do we need to act quickly?

How does potassium channels impact on hearing?

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[Versatil]

Am I asking this at the right place?

 

[rEliseMe]

Am I asking this at the right place?

Sorry, but this is not a medical advice thread. Consult with your supervisor or an audiologist to which you have access. Most of us are still students.

 

[Versatil]

All I am asking is this: do you know anything about hearing loss associated with hyperkalemia?
And how does potassium channels impact on hearing? Does is impact (I'm sure of it)?

 

[Dustbug10]

As Ashley said, any input here would likely be from a non-medical student, and should not be taken as absolute fact (mine included). Without potassium channels, hearing would not occur (unless the pt had a cochlear implant).

This is my understanding and best attempt at a summary of it.. The cochlea is filled with fluids called perilymph and endolymph. The latter has a high concentration of potassium, the former sodium. When a sound wave reaches the inner ear and the basilar membrane is displaced, the stereocillia on the tips of hair cells on the organ of corti are 'sheared'. This allows the ion channels to open allowing K+ to rush in from the endolymph, depolarizing the hair cell. This causes the release of a neurotransmitter, which reaches CN VIII of the brain. No clue about your theory.. I believe that neurons/muscles are depolarized by sodium.. Inner ear hair cells are depolarized by K+..

I don't know if hyperkalemia is linked with hearing loss.. Kidney failure most definitely is.. Would you want to refer for audiology to compare results to six months ago?

 

[rEliseMe]

All I am asking is this: do you know anything about hearing loss associated with hyperkalemia?

Have you considered that if he's still taking the Tobramycin, he's still at risk for damage regardless of his potassium levels?

Also, his diabetes could be contributing even if his blood sugar is well-maintained.

 

[Versatil]

Have you considered that if he's still taking the Tobramycin, he's still at risk for damage regardless of his potassium levels?

Also, his diabetes could be contributing even if his blood sugar is well-maintained.

IV tobramycin = toxic
inhalation = not

HbA1C @ 5.7 mmol/L, would be a problem?
He would not pass as a diabetic according to these results.

Audio tests have been made today: -40db @ 4 khz at right
the rest is exactly like last the last time.
He wasn't so wrong after all, not just a sensation.

We don't know yet. Audiologists have no idea.

 

[rEliseMe]

Audio tests have been made today: -40db @ 4 khz at right
the rest is exactly like last the last time.
He wasn't so wrong after all, not just a sensation.

We don't know yet. Audiologists have no idea.

Well, 4KHz is the noise notch. The specificity of that sounds significant to me, but I'm just a senior in undergrad so if audiologists have no idea, my ideas are worth even less.

 

[Versatil]

We got something, new diagnostic has dropped today: Mononucleosis .
This could lead to a... Sudden Sensorineural Hearing Loss (SSHL)
http://www.hearinglosshelp.com/articles/suddenhearingloss.htm

Sudden Sensorineural Hearing Loss (SSHL).

Sudden sensorineural hearing losses (SSHL) are medical emergencies. You need to see your ear specialist (preferably an otologist or neurotologist) immediately (not your family doctor—he is not qualified and it wastes precious time you don't have).

By definition, you have SSHL if you have a hearing loss that occurs within three days (often within minutes or an hour or two) and your hearing loss is greater than 30 dB over three adjacent octaves (test frequencies) as shown on your audiogram.

About one-third of the people with SSHL discover their hearing loss when they wake up in the morning. They go to bed with normal hearing, and in the morning they realize they are deaf in one or both ears! Fortunately, SSHL only affects both ears about 2-4% of the time. Other people discover their loss when they go to use the phone and realize they can't hear the phone with one ear any more.

SSHL may be almost instantaneous. In such cases, you may notice a loud sound or a loud "pop" just before your hearing disappears. You will also experience dizziness or vertigo 50% of the time and tinnitus (ringing in your ears) about 70% of the time. Incidentally, the intensity of your vertigo often roughly corresponds to the degree of your hearing loss. You might also have a feeling of fullness in your ear(s) and a headache.

How common is SSHL? It varies, but the average seems to be that about one person in 10,000 experiences SSHL in any given year.

Causes of SSHL
Other viruses thought to cause SSHL include adenovirus, cytomegalovirus (CMV), infectious mononucleosis, influenza, measles, mumps, parainfluenza, rubella and rubeola.

He is already on corticosteroids (cortef), but i've increased a bit the total dose of cortisone by adding prednisone 2.5mg hs so we can get all chances on our side for a complete recovery.
Corticosteroids:
Cortef 30mg /day + prednisone 2.5mg hs

Is there something else we can do to prevent/help ?

 

[DrAudio]

First place to look is with your local ENT or otology group at your hospital.

Has this resolved? If not lemme know.

-D

 

[Versatil]

Our local ENT?

I don't think we have an official otology group, I'll check.

 

[Versatil]

Audiologists don't think it's related to SSHL.

I've done my part of the job on that, I'm sure the oxycodone is involved in some way to this hearing loss. There's a lot of evidences proving it, but no studies yet to confirm it.

There's a lot of stories on it:
http://www.bluelight.ru/vb/showthread.php?t=483565

Radio talk show host and political commentator Rush Limbaugh turned half deaf after opiates (most are codeinics) use: (hydrocodone and oxycodone)
http://www.foxnews.com/story/0,2933,99731,00.html

Inner ear = hair cells?

 

[Audie2014]

IV tobramycin = toxic
inhalation = not

There is just as much evidence of inhaled tobramycin being ototoxic as there is of codeinic drugs being ototoxic.

http://www.pharma.us.novartis.com/product/pi/pdf/tobi.pdf
Here we see that inhaled tobramycin caused transient tinnitus, which suggests ototoxicity (most likely).

ETA: Btw, I don't think that a hearing loss progressing over a couple of months counts as Sudden SNHL, at least not according to your definition.

 

[Versatil]

Instructive.

Pneumologists told me there was almost zero absorption into the blood. Thanks for the tip, I'll show them.

ETA: Btw, I don't think that a hearing loss progressing over a couple of months counts as Sudden SNHL, at least not according to your definition.

Indeed, that's what the audiologists told me yesterday.

Remaining choices:
oxycodone itself
hyperkalemia

 

[DrAudio]

What's the dosing on the oxy? How long has the patient been on it?

-D

 

[Versatil]

oxycodone 10mg prn (not regular) since June 2009.

He is taking it periodically.

 

[DrAudio]

Unless you're seeing hypersensitivities to other side effects I'm doubting that's the cause. That's not a very prolonged exposure if he's taking prn.

K+ issues would lead to a more global effect in my opinion.

What is the rest of the audiologic results? Ototoxic monitoring should always have OAE's included. Is there a change there? What does high freq. audiometry show? Take off the name and post all results from the past couple testings.

rElise - noise notch is based on a center frequency and yes, 4kHz is common but it doesn't have to be there. If you're around something very noisy centered around 1kHz you'll have a 1k noise notch.

-D

 

[rEliseMe]

rElise - noise notch is based on a center frequency and yes, 4kHz is common but it doesn't have to be there. If you're around something very noisy centered around 1kHz you'll have a 1k noise notch.

But how does this reconcile with the basal turn of the cochlea? Would it be a wider dip because of damage at 1KHz and 4KHz?

 

[DrAudio]

But how does this reconcile with the basal turn of the cochlea? Would it be a wider dip because of damage at 1KHz and 4KHz?

You may have higher frequency components to the loss, abnormal high frequency OAE's (if they were there to begin with), and very likely tinnitus but the primary component of the loss will be centered around the region with highest exposure.

-D

 

[Audie2014]

Oh, I misread what you said about the 40 dB drop. So they said it was or wasn't?