The main variables were the presence of Otorhinolaryngological diseases among patients with CKD. The independent variables are age and gender, and dependent variables are duration of illness and audiometric pattern. Data collected ware collated and presented in descriptive format, tables, diagrams, graph and audiograms where appropriate. Data analyses were done using Statistical package for service solution (SPSS version 22). The mean and standard deviations was computed for all quantitative variables. Similarly, frequencies, percentages and cross tabulations was used to summarize qualitative variables. Differences between categorical variables were analyzed using chi-square test while student t test was used to analyze difference between continuous variables. Analysis of variance test (ANOVA) was used to analyze the difference between three or more continuous variables. Chi-square was used to assess the association between development of otorhinolaryngological diseases and chronic kidney disease and duration of illness. A ΄p΄ value less than 0.05 was accepted as statistically significant.
34
35
CHAPTER FIVE RESULTS 5.1 Demographics
A total of 110 patients were initially recruited for the study. However, 101 patients completed the study. Three out of the 9 patients who failed to complete the study were due to failure to present at ORL clinic for some personal reasons and 6 patients who are in stage 1 and 2 were excluded from further analysis as their renal parameters were generally normal in stage 1 and mild in stage 2 CKD. The age distribution ranged from 18 to 78 years for the subjects and 18 to 71 years for controls. There were 57 (56.4%) males and 44 (43.6%) females giving a male to female ratio 1.3:1. The control group were 53 (52.5%) males and 48 (47.5%) females giving male to female ratio of 1.1:1.
Mean age for the subjects and control group were 42.5 ± 17.6 and 40.6 ± 15.8 respectively. Table I shows detailed age and gender distribution of both patients and controls
Table I: Age and gender distribution of participants
Age group of patients (years)
Patients N(%) N=101
Controls N(%) N=101
chi-square p-value
18-27 11(10.9) 10(9.9)
4.045 0.542
28-37 20(19.8) 22(21.8)
38-47 27 (26.7) 31 (30.7)
48-57 19(18.8) 26(25.7)
58-67 12(11.9) 7(6.9)
68 and above 12(11.9) 5 (5.0)
Sex
0.498 0.480
Male
57(56.4) 53(52.5)
Female
44(43.6) 48(47.5)
36 5.2 Risk and Aetiological factors of CKD
Hypertension (46.4%) was the most common cause of CKD among the subjects studied, followed by chronic glomerulonephritis (23.6%). Among the subjects that had haemodialysis chronic glomerulonephritis accounted for 36.4%.
5.3 Stage of CKD
More than half of the patients (52/101) studied were stage 5 CKD (51.5%) (Table II).
Table II: Stage of CKD in studied population
Stage of CKD Frequency
N=101
Percentage (%)
Stage 3 20 19.8
Stage 4 29 28.7
Stage 5 52 51.5
Total 101 100%
37 5.4 Mode of treatment of CKD
Thirty subjects (29.7%) had haemodialysis during the study period and these were all stage 5 CKD patients. Most of the patients were on conservative treatment (70.3%) and these were stage 3 and 4 CKD and 22 stage 5 CKD patients who could not afford haemodialysis. (Figure I).
Figure I: Mode of treatment of CKD
70.30%
29.70%
conservative n=71 hamodialysed n=30
38
5.5 Duration of symptoms of CKD and time of diagnosis
The mean duration of symptoms and time of diagnosis were 3.8years ± 2.8 years and 2.9 (± 3.4) years, and median of 2.0 yrs and 3.0 yrs respectively. Table III shows descriptive statistics of time of diagnosis and duration of symptoms among CKD patients.
Table III: Descriptive statistics of time of diagnosis and duration of symptoms among CKD patients.
Time of diagnosis of CKD(years ago)
N(%) Duration of symptoms of CKD(years)
N(%)
1-3 58(57.4) 1-3 86(85.2)
4-6 23(22.8) 4-6 8(7.9)
7-9 15(14.9) 7-9 7(6.9)
10 and above 5(5.0) 10 and above 0
39 5.6 Base line renal function test among controls
Six controls (6/107) were found to have deranged E/U/CR result and they were thus referred to renal physician for further evaluation and management.
5.7 Otorhinolaryngologic symptoms presented by patients and controls
Subjects and control presented with various otologic, rhinologic, and laryngologic symptoms. The pattern and occurrence of otorhinolaryngological diseases among adult patients with CKD were tinnitus in 12 patients (11.9%), vertigo in 44 patients (43.6%), persistent nasal blockage in 14 patients (13.9%), snoring in 24 patients (23.8%), epistaxis in 6 patients (5.9%), multiple ORL symptoms in 19 patients (18.8%) and 27 patients (26.7%) did not have any ORL diseases while tinnitus (6.9%) was the common presenting symptoms among the control group (Table IV).
Table IV: Distribution of ORL symptoms among patients and controls Patients
N =101 N (%)
Controls N =101 N(%)
Chi-square
p-value
Otologic 9.766 0.21
Tinnitus 12(11.9) 7(6.9)
Hearing impairment 15(14.8) 5 (4.9)
Vertigo 44(43.6) 2(2.0)
Aural fullness 9(8.9) 3 (3.0)
Rhinologic 0.998 .802
Snoring 24(23.8) 4(4.0)
Epistaxis 6(5.9) 1(1.0)
Rhinorrhoea 9(8.9) 2(2.0)
Perstistent nasal obstruction 14(13.9) 1(1.0)
Laryngologic 8.139 0.087
Sore throat 9(8.9) 1(1.0)
Hoarseness 2(2.0) 0
Foreign body sensation in the throat 17(16.8) 2(2.0)
Dryness of mouth 8 (7.9) 0
Dysphonia 5 (4.9) 0
Remarks: Fisher exact test p-value was used
40
5.8 Otorhinolaryngological diseases in patients and controls
Otologic findings among patients and controls were summarized in Table V.
Sensorineural hearing loss was found in 68 patients (67.3%).
Rhinologic findings: Diagnostic nasal endoscopy (DNE) revealed CRS in 17 patients (16.8%) and 5 controls (5.0%), and CRS with nasal polyp in 2 patients (2.0%). (Table VI).
Laryngologic, head and neck findings: Oral thrush (candidiasis) in 5 patients (5.0%);
hyperaemic and oedematous oropharyngeal mucosal with mucus stained granular posterior pharyngeal wall (non-specific pharyngitis) in 4 patients (4.0%); indirect laryngoscopy with 900 endoscope revealed normal findings in 78 patients (77.2%) and 99 controls (98.0%), hyperaemic laryngeal mucosal (laryngitis) in 9 patients (8.9%) as against 2 in controls (2.0%) and oedematous mucosal (laryngeal oedema) in 5 patients (4.9%). (Table VI).
41
Table V: Otologic findings among patients and controls Patients
N (%)
Controls N (%)
chi-square P value
Otologic
Cerumen auris 18 20 0.923 0.976
Dull TM 10 9 0.958 0.998
Right Rinne’s test
positive 86 92
.999 0.998
negative 2 4
No response 13 5
Left Rinne’s test
positive 98 104
0.997 0.999
negative 7 3
no response 5 3
Weber’s test
lateralized 41 5
11.344 0.001
Central 53 91
Not perceived 7 5
Remarks: Fisher exact test p-value was used
42
Table VI: Rhinolaryngological findings among patients and control ORL DISEASES Patients
N(%)
Control N(%)
Chi-square p-value Rhinologic
15.176 .00001
CRS 17(16.8) 5(5.0)
CRS+POLYP 2(2.0) 0(0)
Septal spur 5(5.0) 0(0)
Normal DNE 77(76.2) 96(95.0) Oral
cavity/Laryngologic
Oral candidiasis 5(5.0) 0(0)
20.317 .00001 Non-specific
pharyngitis
4(4.0) 0(0)
Normal IDL 78(77.2) 99(98.0)
laryngitis 9(8.9) 2(2.0)
Laryngeal oedema 5(4.9) 0(0) Remarks: Fisher exact test p-value was used
43
5.9 Degree of hearing threshold among patients and controls
There was significant difference in the hearing threshold between patients and controls (P<0.0001). Sixty-eight patients had SNHL (67.3%) as against 17 in controls (16.8%).
Mild, moderate and moderately severe SNHL accounted for 46.9%, 8.9%, and 4.9% in patients as against 8.4%, 3.4%, and 3.9% respectively for controls. Seventy ears (34.7%) had normal hearing among the patients while 171 ears (84.6%) had normal hearing among the control group (Table VI). Conductive hearing loss was found in 2 ears (1.0%) and mixed hearing loss was also found in 2 ears (1.0%) of the subjects as against conductive hearing loss in 3 ears (1.5%) and mixed hearing loss in 2 ears (1.0%) in control group respectively. Fifty – eight patients had bilateral hearing loss while 10 patients had unilateral hearing loss.
Table VII: Degree of hearing threshold among patients and controls
Ear side Hearing threshold
Total ears Patients N=202 (%)
Total ears Control N=202 (%)
chi-square p-value
Right
normal <25 30(29.7) 89(88.1)
102.71 0.000
mild 26-40 46(45.5) 7(6.9)
moderate 41-55 11(10.9) 3 (2.9)
moderate severe
56-70
10(9.9) 3(2.9)
Severe 71-90 4(4.0) 0
profound >90 0 0
Left
normal <25 40(39.6) 82(81.2)
73.40 0.000
mild 26-40 47(46.5) 10(9.9)
moderate 41-55 7(6.9) 4(3.9) moderate
severe
56-70
5(5.0) 5(4.9)
severe 71-90 2(2.0) 0
profound >90 0 0
Remarks: Fisher exact test p-value was used
44
5.10 Mean Hearing Threshold (MHT) of patients and controls
Mean Hearing Threshold was calculated from air conduction. Table VII shows MHT among patients and controls. Figures II and III depicted the auditory pattern of both patients and controls.
Table VIII: Mean Hearing Threshold of patients and controls
Frequencies Hz
Patients MHT
Controls MHT Right ears
N=101
Left ears N=101
Right ears N=101
Left ears N=101
250 21.7273 20.0909 13.3784 12.5225
500 32.5455 29.2727 25.2703 21.9820
1000 33.9545 32.7727 26.3964 23.3333
2000 37.9545 36.0727 26.8468 27.0270
4000 41.4545 39.7727 31.9820 32.7027
8000 41.9545 39.7273 32.2784 33.3784
Table Difference between subjects and control
PTA Group N Mean Std. Deviation
t-test p-value
right ear
subject 101 36.7545 14.41532
control 101 24.8288 11.57809 6.784 0.000 left ear
subject 101 36.8636 13.91091
control 101 24.3153 9.84145 7.747 0.000
45
Figure II: Audiometric pattern of patients and control in left ear
0 5 10 15 20 25 30 35 40 45
250 500 1000 2000 4000 8000
Hearing level in dB
frequency (Heartz)
Left ear (Cases) left ear(Control)
46
Figure III: Audiometric pattern of patients and control in right ear
0 5 10 15 20 25 30 35 40 45
250 500 1000 2000 4000 8000
Hearing level in dB
Frequency (Heartz)
Right ear (cases) Right ear (control)
47
5.11 Prevalence of ORL diseases among patients and controls
There was significant difference in the prevalence of otological, rhinological, and laryngological diseases between patients and controls (Table IX).
Table IX: Prevalence of ORL diseases among patients and controls ORL diseases Subjects
(%)
Controls (%)
Chi-square
p-value
Otologic 53.7% 10.9%
22.2 0.00001
Rhinologic 18.7% 4.1%
Larygologic,head
and neck 11.9% 1.3%
ORL 28.1% 5.4%
Remarks: Fisher exact test p-value was used
48
5.12 Association of ORL diseases and stage of CKD
There were no significant association between otologic, rhinologic , and laryngologic symptoms and stage of CKD (p-value = 0.603, 0.914, and 0.73 respectively).
(Table X).
Table X: Association between ORL diseases and stage of CKD
Stage of CKD complaint N(%)
no complaints
N(%) Chi-square
test
p-value
Stage 3 3(15.0) 17(85.0)
2.214 0.603
Stage 4 11(37.9) 18(62.1)
Stage 5 14(26.9) 38(73.0)
Total 28 73
Stage of CKD Nasal
diseases
N(%)
No nasal diseases
N(%)
chi-square p-value
Stage 3 1(5.3) 18(94.7)
0.851 0.914
Stage 4 2(6.7) 28(93.3)
Stage 5 5(9.1) 41(90.9)
total 8 93
Stage of CKD Laryngeal diseases N(%)
No laryngeal diseases N(%)
chi-square p-value
Stage 3 1(5.3) 18(94.7)
1.82 0.73
Stage 4 4(13.4) 26(86.7)
Stage 5 4(7.3) 42(92.7)
total 9 92
Remarks: Fisher exact test p-values were 0.664, 0.925 and 0.75 respectively.
49
5.13 Comparism between duration of CKD and mean hearing threshold
Stage 5 CKD is specifically associated with higher mean hearing threshold (P<0.05).
The higher the stage of CKD, the worse was the hearing threshold (Table XI).
Table XI: Comparison between duration of CKD and Mean Hearing Threshold using One-way analysis of variance
duration of
symptoms of CKD (years)
N Mean Standard
deviation
f-test p-value
0-3 54 33.61 13.16
3.983 .010
4-6 27 40.81 16.82
7-9 15 37.40 10.56
>9 5 52.40 13.16
left ear
4.074 .009
0-3 47 34.08 13.38
4-6 35 40.33 13.14
7-9 14 36.80 12.01
>9 4 53.40 18.01
Descriptive Statistics
Mean Std. Deviation N
Right PTA 36.7545 14.41532 101
Left PTA 36.8636 13.91091 101
Duration of
symptoms 3.8455 2.83874 101
50 HAPTER SIX DISCUSSION 6.1 Demographic characteristics
This study found mean age to be 40.5±17.6 years and 42.6±15.8 years for patients and controls respectively. The male to female was 1.3:1 for subjects and 1.1:1 for controls respectively. This is similar to what was reported by Lasisi et al, they reported the mean age to be 45.30 years (SD 16.20).22
6.2 Treatment of CKD
Majority of the subjects (70.3%) had conservative treatment which entailed fluid and dietary regulation, medications such as diuretics, antihypertensive, and anti-lipidaemia.
Thirty subjects (29.7%) had haemodialysis. Hypertension (46.4%) was found to be most common co-existing risk factor for CKD. This agreed with reports from work done by other researchers.10,47,48
6.3 Occurrence and pattern of ORL diseases 6.3.1 Otological diseases
The prevalence of SNHL in this study was 67.3%, this is similar to what was reported by Lasisi et al, and Adekwu they reported prevalence of SNHL to be 67% and 57.2%
respectively in their studies.12,13
This was contrary to what was reported by Quick et althey reported the prevalence of SNHL among patients with CKD to be 20%-40%. The higher prevalence of SNHL in this study compared to that of Quick et al may be attributed to our larger sample size in this study.12 There was significant difference in the hearing level between the subjects and controls in this study (p=0.000) .
In this study tinnitus was reported by 12 patients (11.9%), and vertigo in 44 patients (43.6%). The finding of tinnitus in this study is comparable to what was reported by Agarwa et al who studied 50 cases of CKD and found that 5 patients (10%) had tinnitus.
51
However, they reported smaller percentages for SNHL (28%) and vertigo (4%) when compared to this study.15 These differences could be as a result of larger sample size in this study. In another similar study, Beaney et al observed deafness in 1 patient (0.30%), vertigo in 5 patients (19.5%).17 Vilayur et al found moderate CKD to be associated independently with hearing loss.16
Vertigo was the most common presenting symptom in this study with clinical diagnosis of serous labyrinthitis, this agreed with the report of other similar studies that reported high prevalence of vertigo.13,14 The exact cause of vertigo in patients with CKD is not known, it is probably due to the effect of retained toxic products on the labyrinth.18,19,21 Further research is required to assess the middle ear function by tympanometry, and brainstem evoked response (BERA) to objectively assess the hearing threshold among CKD patients.
6.3.2 Rhinological diseases
There are 17 subjects (16.8%) with clinical diagnosis of chronic rhinosinusitis and 2 subjects with CRS with nasal polyp (2.0%) and were thus referred for further evaluation and treatment. However, Garba et al reported a case of sinonasal malignancy in a patient on haemodialysis which was detected on DNE.49 In patients with CKD, blood urea is excreted through nasal secretions. The bacteria flora in nose and paranasal sinuses split this urea releasing ammonia producing chemical mucositis, the possible cause of congestion, ulceration of nasal cavity mucosa and epistaxis.3
There was snoring in 24 patients (23.8%), and epistaxis in 6 patients (5.9%). This is similar to what was reported by Agarwa et al and Beaney et al they reported 10% and 8.02% cases of epistaxis respectively.15,17
Similarly, Kumar et al studied 30 paediatrics patients with CKD; epistaxis was present in 9 subjects (30.0%), multiple ORL manifestations in 4 subjects (13.3%), whereas 3 subjects (9.9%) did not have any ORL symptoms.24 Although, this study was carried out among paediatric subjects. The findings was similar to what that has been reported in
52
adult subjects with CKD.13,22,23 These are due to biochemical derangement in patients with CKD which leads to various manifestations of otorhinolaryngological diseases.
18-20
In this study none of the subjects demonstrate evidence of ETD during diagnostic nasal endoscopy. However, Kewase et al21 found 13 out of 147 haemodialysis subjects (8.8%) to have haemodialysis related ETD. This area still requires further research with a larger sample size to demonstrate the Eustachian tube function in CKD with or without haemodialysis.
6.3.3 Laryngologic, head and neck diseases
There are 5 patients (5.0%) with candidiasis; Non-specific pharyngitis in 4 patients (4.0%); Non-specific laryngitis in 9 patients (8.9%) as against 2 in controls (2.0%) and laryngeal oedema in 5 patients (4.9%). This is smaller to what was reported by other workers.13,14 However, it agreed with the report of Kumar et al. They reported pharyngitis in 4 patients (13.3%), respiratory insufficiency in 2 (6.6%), and parotid swelling in 1 (3.3%).25 Although none of the patients in this study had parotid swelling.
In this work 5 patients (4.9%) reported dysphonia. Again, Kumar et al found that subjects with CKD exhibit a clinical evidence of voice disorders acoustically and aerodynamically.25 Similar findings was also reported by Hamdan et al.26 This may be due to palatal and pharyngeal oedema in CKD which is due to lower plasma osmotic pressure induced by kidney disease.3,12 Future study on a larger sample size is suggested to establish the prevalence of voice disorder in CKD patients in our environment.
6.3.4 Prevalence of ORL diseases
Prevalence of otological, rhinological, and laryngological diseases among CKD patients were 53.7%, 18.7% and 11.9% as against 10.9%, 4.1%, and 1.3% in controls
53
respectively. Prevalence of ORL diseases in CKD patients was 28.1% while in controls was 5.4%. This study shows that there was significant difference in the prevalence of ORL diseases among adult patients with CKD than the controls. The high prevalence of ORL diseases among CKD patients could be attributed to
biochemical derangements.
6.3.5 Mean hearing threshold
There was significant difference in the hearing threshold between patients and controls with p=0.000. Mild, moderate and moderately severe SNHL accounted for 46.9%, 8.9%, and 4.9% in subjects as against 10.9%, 4.5%, and 3.9% respectively for controls. This agreed with what was reported by Lasisi et al and Gatland et al.22,50
The higher prevalence of SNHL in patients with CKD may be due to the resemblance in the histological and biochemical pattern between the cochlea and the kidney particularly that of the stria vascularis and glomerulus, both of which are epithelial structures and intimately associated with the vascular system hence factors leading to changes in the kidney can bring about changes in the cochlea also.12
Stages 4 and 5 CKD had the highest prevalence of hearing loss with 26.7% and 48.5%
respectively. This was similar to the findings of work done by other workers.10,22,51 This could be as a result of gradual destruction of cochlear that is attributable to ureamic process.52,53 Hearing loss precipitated by CKD may not be noticeable in the early phase of the disease due to compensatory mechanisms which come to play until the late phase of the disease.12
6.3.6 Association between ORL diseases and stage of CKD
There was no significant association between the ORL diseases and stage of CKD.
Although, the higher the stage of the CKD, the worse was the hearing threshold.
54
This corroborated what was reported by Kligerman et al53 and other workers.22,54 However, stage 5 CKD had the highest number of hearing loss and other ORL diseases.
This was similar to the findings of work done by other researchers.22,49 This may be due to chronic nature of the disease as a result of non specific early symptoms and compensatory mechanism at the early phase of the disease.12 Future study on a larger sample size with more sophisticated investigative tools is suggested to establish any association between ORL diseases and stage of CKD.
6.3.7 Correlation between duration of CKD and mean hearing threshold
There was positive correlation between the duration of CKD and mean hearing threshold and the longer the durations of CKD, the worse the hearing threshold (p=0.010). This was similar to the findings of other workers such as Gatland et al50 and Kligerman et al.53 This could be as a result of gradual destruction of the cochlear that is attributable to the ureamic process.
This study shows that there was high prevalence of ORL diseases among adult patients with CKD than the controls. However, further researches still require to determine correlation between stage of CKD, biochemical derangement, and ORL diseases.
Null hypothesis was rejected, as occurrence and pattern of ORL diseases among adult patients with CKD are different from that of general population.
Locally, most of the studies done have been on hearing threshold in chronic kidney disease patients. These researchers however did not look at other ORL diseases in details. This study was extended to cover other aspects of ORL diseases among adult patients with CKD. Demonstration that there was high prevalence of Otorhinolaryngological diseases among CKD patients was an addition to the existing body of knowledge especially in our environment.
55
CHAPTER SEVEN
CONCLUSION AND RECOMMENDATIONS Conclusions
The following conclusions were drawn from this study:
1. The prevalence of otorhinolaryngologic symptoms among adult patients with CKD was 28.1% while in controls was 5.4%. The difference was statistically significant (p=0.00001).
2. The prevalence of Otological, Rhinological, and Laryngological diseases among adult patients with CKD were 53.7%, 18.7%, and 11.9% as against 10.9%, 4.1%, and 1.3% in control groups respectively. The difference was statistically significant (p=0.00001).
3. The prevalence of sensorineural hearing loss among patients with CKD was 67.3% while in controls was 16.8% (p<0.001). The higher the stage of CKD, the worse the hearing threshold.
4. There was no significant association between the ORL diseases and stage of CKD ( p> 0.05).
Recommendations
1. Health care providers should have high index of suspicions for ORL diseases in adult patients with chronic kidney disease.
2. Specific screening for sensorinueral hearing loss should be incorporated into the management protocol of adult patients with chronic kidney disease.
3. A collaboration between the renal physician and Otorhinolaryngologist is recommended to improve the care of adult patients with chronic kidney disease.
56
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