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RA Hearing Loss — SCE Rheumatology MCQ

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ModerateRheumatoid ArthritisRA Hearing LossSCE Rheumatology

A 48-year-old woman with seropositive rheumatoid arthritis develops fluctuating bilateral hearing impairment over 12 weeks. Her rheumatoid arthritis is clinically well controlled on methotrexate 15 mg once weekly, which has been unchanged for 5 years. Otoscopy and tympanometry are normal. Serial pure-tone audiometry confirms asymmetric sensorineural hearing loss, and MRI of the internal auditory meati is normal. She has no significant noise exposure or family history of hearing loss. Which mechanism best accounts for this presentation?

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Correct answer: B — RA-associated immune-mediated cochlear injury, including immune-complex vasculopathy

The answer is B. RA is associated with sensorineural hearing loss, with proposed mechanisms including immune-complex deposition, cochlear vasculopathy, autoantibody-mediated injury and neuritis. The subacute, fluctuating and asymmetric course is characteristic of immune-mediated inner-ear disease; normal otoscopy and tympanometry also argue against middle-ear pathology. Cholesteatoma and stapes fixation usually produce conductive rather than sensorineural loss. Low-dose methotrexate is not an established typical cause of this presentation, particularly after several years on an unchanged dose. Presbycusis is usually slowly progressive, symmetrical and predominantly high-frequency, making it less consistent with fluctuation over 12 weeks in a 48-year-old. Well-controlled articular RA does not exclude immune-mediated extra-articular cochlear involvement.

Reference: Chen JJ et al. Audiological Features in Patients with Rheumatoid Arthritis: A Systematic Review. International Journal of Molecular Sciences. 2024;25:13290. https://pubmed.ncbi.nlm.nih.gov/39769062/