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Original Article

Vestibular Dysfunction and Glycemic Control in Diabetes

Mellitus: Is there a Correlation?
Chetana S. Naik, Raviraj Tilloo
Departments of Otorhinolaryngology and HNS, Smt Kashibai Navale Medical College and General Hospital, Pune, Maharashtra, India

Abstract
Objectives: The aim of this study is to evaluate and find the proportion of patients with Type‑II diabetes mellitus (DM) with sensorineural
hearing loss (SNHL) and vestibular dysfunction (VD) and association with glycemic control. Materials and Methods: An observational
cross‑sectional study was carried out in 100 patients (age group: 30–60 years) diagnosed with Type‑II DM coming to the outpatient department
of our Rural Tertiary Care Teaching Hospital, fulfilling the inclusion criteria. Prior approval of the Institutional Ethics Committee and
written informed consent was obtained. All patients were subjected to investigations to assess their diabetes control, hearing, and vestibular
function. The findings were subjected to statistical analysis. Results: Out of 100 patients, 62 were male and 38 were female between the age
group of 30 and 60 years. The mean hemoglobin A1c (HbA1c) level was 9.16 ± 2.4. The patients were divided into three groups depending
on HbA1c level, to denote control, good (≤7%), moderate (>7, ≤12%), and poor (>12%). There were a total of 69 patients with SNHL and
70 patients with VD. SNHL was present in 57.6% of good control group, 66.1% of moderate control group, and 100% of poor control group.
Analysis with Chi‑square test for correlation between glycemic control and SNHL was statistically significant. Out of the 70 patients with
VD, 51.4% had right vestibulopathy, 41.4% had left vestibulopathy, and 7.2% had a bilateral vestibulopathy. Twenty‑two patients had benign
paroxysmal positional vertigo. VD was present in 42.3% of good control group, 74.5% of moderate control group, and 100% of poor control
group. Chi‑square test was statistically significant. Conclusion: There is a significant association between Type II DM, and SNHL and VD,
especially with worsening of glycemic control. Screening for these debilities should be a part of the routine workup of a diabetic patient. VD
is a potential cause for imbalance and vertigo in DM.

Keywords: Diabetes mellitus, hearing loss, vestibular dysfunction

Introduction All these findings led us to extrapolate similar mechanisms

Diabetes mellitus (DM) is a multisystemic disease with variety
of manifestations. The “International Diabetes Federation”
estimates that the total number of diabetics in India is around
40.9 million, expected to rise to 69.9 million by 2025.[1] A
variety of molecular mechanisms play a role in the pathogenesis
of the complications in DM, like the formation of advanced
glycation end‑products, polyol formation, increased activity
of protein kinase C, increased production of extracellular
matrix proteins, and glycosaminoglycans.[2] All this ultimately
leads to microvascular damage termed as “Microangiopathy.”
Makishima and Tanaka,[3] found microangiopathy to be a
significant cause of sensorineural hearing loss  (SNHL) in
diabetics. A  similar correlation has also been established
between diabetic SNHL and acoustic neuropathy,[4,5] the latter
commonly being a late complication.
for vestibular dysfunction  (VD) in DM. The current data
regarding in diabetes are limited, especially in India and
studies conducted along these lines have not associated VD
with glycemic control in DM. The need to consider DM as
a potential cause for SNHL and VD is important, so that
timely rehabilitation of hearing and balance disorders can be
performed along with management of DM. The study focuses
on Type‑II DM, and its association with SNHL and VD. We
have used hemoglobin A1c  (HbA1c), which is a sensitive
parameter for the assessment of diabetic control, which has
not been used in many studies.
Address for correspondence: Prof. Chetana S. Naik,
Department of Otorhinolaryngology and HNS, Smt Kashibai Navale
Medical College and General Hospital, Pune ‑ 411 041, Maharashtra, India.
E‑mail: drchetana71@gmail.com

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DOI: How to cite this article: Naik CS, Tilloo R. Vestibular dysfunction and
10.4103/indianjotol.INDIANJOTOL_70_18 glycemic control in diabetes mellitus: Is there a correlation? Indian J Otol
2018;24:199-203.

© 2019 Indian Journal of Otology | Published by Wolters Kluwer - Medknow 199

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Naik and Tilloo: Vestibular dysfunction and glycemic control in diabetes mellitus: Is there a correlation?
Aims and objectives
(1) To evaluate the patients of Type‑II DM for SNHL and
VD. (2) To find the proportion of Type‑II DM patients suffering
from SNHL and VD.  (3) To grade the SNHL and VD and
associate it with the glycemic control in the patients.
Materials and Methods
Study design: An observational cross‑sectional study. Study
population: Patients of Type‑II Diabetes diagnosed with per
diagnostic criteria of the American Diabetes Association (ADA)
attending the outpatient department of our Rural Tertiary Care
Teaching Hospital. Sample size: 100. Inclusion criteria:
(1) Patients diagnosed with Type‑II DM, (2) Age: 30–60 years.
Exclusion criteria: (1) Type‑I DM, (2) Pregnancy, (3) Ototoxic
drug intake,  (4) Ear discharge, (5) History of head injury,
(6) Noise exposure, (7) Family history of deafness, (8) History
of hypertension, meningitis/encephalitis, ear surgery, Meniere’s
disease, migraine, or metabolic disorder, (9) Patients not giving
consent. The Institutional Ethics Committee approval was
taken. A  written informed consent was obtained. Patients
fulfilling the selection criteria underwent a detailed history
and oto‑neurological examination. Patients were evaluated
with the dizziness handicap inventory (DHI)[6] and underwent
the aforementioned investigations. Investigations for diabetes
included; blood sugar level–fasting and postprandial after 2 h,
HbA1c levels, lipid profile, serum ketones, serum creatinine,
urine sugar, and albumin. Audio‑vestibular investigations
included; pure‑tone audiometry including Short Increment
Sensitivity Index and tone decay tests, otoacoustic emissions,
videonystagmography with caloric tests and subjective visual
vertical.
Patients were evaluated for glycemic control status as per
the criteria of ADA.[7] The criteria for ideal glycemic control
are as follows:  (1) HbA1c  <7.0%  (2) Preprandial capillary
plasma glucose should be 80–130 mg/dl (3) Peak postprandial
capillary plasma glucose should be <180 mg/dl. The major
parameter used by us was HbA1c, to classify the patients into
groups to denote their glycemic control status. The patients
were divided into three groups depending on HbA1c, to denote
control, good (≤7%), moderate (>7, ≤12%), and poor (>12%).
Statistical analysis was performed with Microsoft Excel and
SPSS software version 22, IBM, Chicago, USA.
Observations and Results
Out of 100 patients, 62 were male and 38 were female between
30 and 60 years of age. Eighteen patients were between 31 and
40 years, 34 (41–50 years), and 48 (51–60 years). The mean
fasting blood glucose level was 140.5  ±  70  mg/dl, and the
mean postprandial blood glucose (2 h) was 231 ± 70 mg/dl.
The mean HbA1c level was 9.16 ± 2.4. There were 26 patients
with good control, 59 patients with moderate, and 15 patients
with poor control [Figure 1]. SNHL was found in 69 patients
and VD in 70  patients. Out of 69  patients with SNHL,
46.3% had slight SNHL (16–25 dB), 7.2% had mild SNHL
200
Figure 1: Distribution of patients with diabetes mellitus as per hemoglobin
A1c levels (glycemic control groups)
(26–40 dB), 27.5% had moderate SNHL (41–55 dB), 14.4%
had moderately severe SNHL  (56–70  dB), and 4.6% had
severe  (71–90  dB) SNHL  [Figure  2]. Out of 69  patients
with SNHL based on recruitment and the tone decay tests,
24.7% had SNHL, 55.1% had sensory type and 20.2% had
a neural type. Selective high‑frequency SNHL  (≥4000  Hz)
was seen in 18.8%. There were 5 (33.33%) high‑frequency
SNHL cases in the good control group, 7  (17.9%) cases in
the moderate control group and 1 (6.25%) case in the poor
control group. Seventy‑one patients had abnormal otoacoustic
emissions (OAEs). Abnormal OAEs were found in 46.1% of
good control, 74.5% of moderate control, and 100% of the poor
control group [Figure 3]. All 100 patients were evaluated with
DHI score. Out of 100 patients, 50 patients had an insignificant
score, 25 had mild handicap, 16 had moderate handicap, and
9 patients, severe handicap, as per the DHI grading. Out of
the 100 patients, 70 had evidence of VD. Out of these, 51.4%
had right vestibulopathy, 41.4% had left vestibulopathy,
and 7.2% had a bilateral vestibulopathy  [Figure  4]. In
addition, 22 patients were found to have benign paroxysmal
positional vertigo (BPPV) on positional testing. SNHL was
present in 15  (57.6%) in good control group, 39  (66.1%)
in moderate control group, and 15  (100%) in poor control
group [Figure 5]. Results of Chi‑square test were statistically
significant (χ2 = 8.525, degrees of freedom = 2, P = 0.01409
with 95% confidence limit). VD was present in 11 (42.3%) in
good control group, 44 (74.5%) in moderate control group,
and 15  (100%) in poor control group  [Figure  6]. Results
of Chi‑square test were statistically significant  (χ2  =  16.51,
degrees of freedom = 2, P = 0.0002598 with 95% confidence
limit). Out of 100 patients, 62 were male and 38 were female.
Thirty‑nine (62.9%) males and 30 (78.9%) females had SNHL.
Results of Chi‑square for sex versus SNHL: χ2  =  6.204,
degrees of freedom = 1 and P = 0.01275. SNHL was found
to be comparatively more in females than males, and this
was statistically significant. Forty‑three  (69.3%) males and
27 (71%) females had VD. Results of Chi‑square for sex versus
VD were: χ2 = 0.06119, degrees of freedom = 1 and P = 0.8046.
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Naik and Tilloo: Vestibular dysfunction and glycemic control in diabetes mellitus: Is there a correlation?
Figure 2: Distribution of grades of sensorineural hearing loss among
glycemic control groups
Figure 4: Distribution of patients with various vestibular dysfunctions in
different glycemic control groups
Sex‑wise distribution of VD showed the only slight difference
and this was not statistically significant.
Discussion
DM is a systemic disease affecting multiple organs. DM is
being linked with inner ear diseases since the 19th century.[8]
Knowing that DM causes peripheral neuropathy, researchers
hypothesized SNHL to be linked to it. Friedman et al.[4] in
1975 evaluated 20 DM patients with peripheral neuropathy
and showed that hearing thresholds were elevated in these
patients. Most studies have evaluated SNHL by pure tone
audiometry.[9,10] Other modalities have also been used to assess
inner ear dysfunction like OAE,[11,12] and auditory brainstem
response  (ABR).[13,14] Parving et  al. found that ABR results
were abnormal in 40% of patients, with long‑standing DM
history.[13] Histopathological studies of temporal bone have
also been performed in DM patients, for evidence of cochlear
microangiopathy,[15] to establish it as a cause for diabetic
SNHL. Type‑I and Type‑II DM have been evaluated separately
as well as together in different studies.[16,17] Many studies
Indian Journal of Otology  ¦  Volume 24  ¦  Issue 3  ¦  July-September 2018
Figure 3: Distribution of patients with abnormal otoacoustic emissions
in various glycemic control groups
Figure 5: Correlation of sensorineural hearing loss with glycemic
control (X‑axis: Number of patients, Y‑axis: Glycemic control group)
support the association between the two, the majority of which
show a significant association[16,18,19] which also includes the
recent meta‑analyses.[20,21] However, certain inconsistency is
reflected from the fact, that some of them only show a weak
association,[22] whereas some of them do not show it.[23,24]
Studies have tried to find a relationship between VD and
diabetes. Klagenberg et  al. found a significant association
between Type‑I DM and VD.[25] Detection of VD in people
with diabetes often gets delayed, and patients are only referred
for dizziness and instability, which is subjective and can be
due to multiple causes in DM. Studies for assessing VD and
SNHL have been performed, to associate them with multiple
metabolic disorders together,[26,27] without specifically focusing
on Type‑II DM, which is more prevalent than others. Overall
consensus for DM and VD is that certain studies do not support
this correlation,[28] some suggest only a weak association,[26]
whereas few other studies show a strong positive relationship
between the two.[25,29] None of the studies are done in India.
The study consisted of a total of 100 patients of Type‑II DM, of
which 62 were male and 38 were female. These patients had a
mean fasting blood glucose level was 140.5 ± 70 mg/dl, and the
mean postprandial blood glucose (2 h) was 231 ± 70 mg/dl. The
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Naik and Tilloo: Vestibular dysfunction and glycemic control in diabetes mellitus: Is there a correlation?
Figure 6: Correlation of vestibular dysfunction with glycemic
control (X‑axis: Number of patients, Y‑axis: Glycemic control group)
mean HbA1c levels were 9.16% ±2.4%. After dividing patients
based on HbA1c levels in 3 groups, good (≤7%), moderate
(>7, ≤12%), poor  (>12%) as an index of their glycemic
control, we found 26 patients with good control, 59 patients
with moderate control, and 15 with poor control. Out of total
100 patients, 69 patients had SNHL and 70 had VD, i.e., 69%
and 70% was the prevalence rate, respectively. SNHL was seen
in 15 (57.6%) of the good control group, 39 (66.1%) of the
moderate control group and 15 (100%) of poor control group,
thus showing an increasing trend with decline of glycemic
control. Similarly, VD as present in 11 (42.3%) of good control
group, 44 (74.5%) of moderate control group, and 15 (100%)
of poor control group, again displaying an increasing trend
with decline of glycemic control.
The prevalence of SNHL was found to be almost similar to
one other previous study.[19] However other studies, especially
which have been carried with a larger sample size have found
a comparatively lower prevalence rate.[16,22] Kakarlapudi et al.
reported a prevalence of only 13.1%. Although this study was
carried on a bigger scale, they screened patients of SNHL
for DM, which is opposite to our methodology.[16] For VD,
the prevalence rate is similar to what other researchers have
found. Chávez‑Delgado et al. have reported 89% prevalence
in their study of 385  patients.[26] The difference seen in the
two rates could be due to the inclusion of other risk factors
such as dyslipidemia and hypertension. Comparing the SNHL
levels with glycemic control of the patients, we found that
the relationship between the two was statistically significant,
with 95% confidence limit (P = 0.01409). Similarly, for VD
and glycemic control also, the relationship was statistically
significant with 95% confidence limit (P = 0.0002598).
Majority of the cases had slight or mild SNHL in our study.
Our study also differentiated between the types of SNHL,
showing that the majority of the patients had a sensory type
of SNHL, indicating a cochlear pathology. This was also
supported by abnormal OAE results pointing to outer hair cell
dysfunction which showed an increasing trend with decrease in
the quality of diabetic control. This reinforces the hypothesis
put by studies that cochlear microangiopathy is a major cause
202
of diabetic SNHL.[3,15] Furthermore, neural type of hearing
less which is due to acoustic neuropathy, was mainly seen in
poor control group and in patients of higher age group. This
correlates to the finding that acoustic neuropathy is usually a
late complication.[30] Previous studies have said that DM is
known to cause high‑frequency SNHL, especially in the early
stages,[31] this finding is similarly depicted in our study.
Majority of our patients had insignificant score with DHI,
which could be attributed to the varied presentation of vertigo
and subclinical vestibulopathy. As DM is a systemic disease,
bilateral VD might be expected to be more common. However,
we found that unilateral dysfunction was far more common
than bilateral disease which was similar to one of other study.[26]
BPPV which is found to be associated with diabetes[32] was
found in 22% of our cases. This may be related to the ischemic
insult to otoliths resulting from microangiopathy associated
with DM. In our study, SNHL was more common in females
than males with DM. Age largely influenced the presence of
VD or SNHL, along with the quality of glycemic control. This
might be because aging itself can worsen diabetic control and
thus make the patient more prone to VD or SNHL.
Conclusion
There is a significant association between Type II DM, and
SNHL and VD. Furthermore, both are more likely to occur,
with worsening of glycemic control. Cochleopathy is more
common in DM than the neuropathy, but neuropathy is more
likely in a patient with poor glycemic control. It is important to
recognize vestibulopathy as a potential cause for imbalance and
vertigo in patients with diabetes and should be considered if a
patient of DM presents with dizziness. Early detection would
prevent falls and morbidity. Thus, screening for SNHL and
VD should be part of the routine workup of a diabetic patient.
Better diabetes control would prevent these complications thus
assuring a better lifestyle for these patients.
Acknowledgements
This study was funded by the Indian Council of Medical
Research for short‑term student project. Authors declare no
conflicts of interests. Authors would like to acknowledge
the support of the Dr. K.J Shinde, head of the Department of
ENT, Dr.  S.M. Bhat, head of Department of Medicine and
Mr. Bedake, Audiology and Speech Therapy.
Financial support and sponsorship
The study was approved and funded by the Indian Council
of Medical research (ICMR) as a part of short‑term student
project.
Conflicts of interest
There are no conflicts of interest.
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