Rheumatoid arthritis (RA) is a chronic autoimmune disease primarily targeting the joints, causing pain, swelling, and eventual damage. RA is also a systemic condition, meaning the underlying inflammation can affect various other body systems beyond the musculoskeletal structure, including the eyes, lungs, heart, and the auditory system. Because of this systemic nature, individuals with RA may experience manifestations seemingly unrelated to joint health, such as hearing impairment.
The Confirmed Link: Types of Hearing Loss Associated with RA
Research consistently shows that patients with rheumatoid arthritis have a significantly higher risk of developing hearing loss compared to the general population. A substantial proportion of RA patients experience some degree of auditory impairment, sometimes reported to be as high as 72%. This impairment often presents as one of two main types: sensorineural or conductive hearing loss.
Sensorineural Hearing Loss (SNHL) is the most common form observed in RA patients, often affecting both ears and primarily impacting high-frequency sounds. This loss originates from damage to the delicate sensory hair cells within the inner ear’s cochlea or the auditory nerve itself. People with RA are approximately four times more likely to develop SNHL than those without the disease.
Conductive Hearing Loss (CHL)
Conductive Hearing Loss (CHL) is less frequent but still occurs, resulting from an issue that prevents sound from effectively passing through the outer or middle ear. In RA patients, this can arise from the disease process affecting the tiny joints of the middle ear—the incudomalleolar and incudostapedial joints. Inflammation and damage to these ossicles, the small bones that transmit sound vibrations, can lead to stiffness or discontinuity, impairing sound conduction to the inner ear. When both sensorineural and conductive components are present, the impairment is classified as mixed hearing loss.
Pathophysiological Mechanisms of Damage
The underlying mechanisms linking RA to auditory damage are rooted in the systemic inflammation and autoimmune activity characteristic of the disease. The inner ear, particularly the cochlea, is highly sensitive to changes in blood supply and immune-mediated injury.
Systemic inflammation, often manifesting as vasculitis, can affect the blood vessels supplying the inner ear structures. Restricted blood flow to the cochlea and auditory nerve causes oxygen deprivation and nutrient deficiency, leading to the gradual dysfunction and destruction of the sensory hair cells. This localized microcirculatory disturbance is a significant driver of the sensorineural component of hearing loss.
The autoimmune attack itself can directly target inner ear tissues. The immune system may mistakenly deposit immune complexes—clusters of antibodies and antigens—within the cochlea, triggering a local inflammatory response that damages the sensitive structures. This process is similar to Autoimmune Inner Ear Disease (AIED), which is more frequently associated with systemic autoimmune disorders like RA.
The Role of RA Medications
While the disease itself can cause auditory damage, a secondary cause of hearing issues in RA patients is the ototoxicity induced by some common treatments. Several drug classes used to manage RA carry a risk of damaging the auditory system.
Non-steroidal anti-inflammatory drugs (NSAIDs) and high doses of salicylates, such as aspirin, are frequently used for pain and inflammation management in RA. These medications can cause temporary or, in some cases, permanent hearing changes, often manifesting as tinnitus or subjective hearing loss. The risk of ototoxicity tends to increase with the frequency and dosage of these pain relievers.
Certain Disease-Modifying Antirheumatic Drugs (DMARDs) also have ototoxic potential. The antimalarial drug hydroxychloroquine, a common RA treatment, has been linked to cases of sensorineural hearing loss and tinnitus, although this is considered rare. The hearing damage from drug-induced ototoxicity can range from temporary and reversible upon discontinuation of the medication to permanent damage to the inner ear’s hair cells.
Screening and Management Strategies
Given the established connection, proactive screening for hearing impairment is an important part of comprehensive RA management. Early detection can prevent further deterioration and allow for timely intervention.
Audiometric testing, including a baseline assessment at the time of RA diagnosis, is often recommended, especially for patients starting on potentially ototoxic medications. Using extended high-frequency audiometry, which tests frequencies above 8,000 Hz, can be useful for detecting subclinical hearing loss at an earlier stage than standard tests. Regular follow-up testing can then monitor for any progression of hearing impairment.
Management strategies focus on controlling the underlying RA and mitigating medication-related risks. Intensifying the use of non-ototoxic DMARDs or supplementing with steroids may be considered if the hearing loss is attributed to active disease-related inflammation. If ototoxicity from a specific drug is suspected, a specialist may adjust the dosage or switch the medication to a safer alternative, which can sometimes reverse temporary hearing changes. For established, permanent hearing loss, hearing assistance devices remain the standard of care to improve communication and quality of life.