title: Prospective study of inner ear radiation dose and hearing loss in head-and-neck cancer patients.
abstract: OBJECTIVE
  To determine the relationship between the radiation dose to the inner ear and long-term hearing loss.
  
  
  METHODS
  Eligible patients included those receiving curative radiotherapy (RT) for head-and-neck cancer. After enrollment, patients underwent three-dimensional conformal RT planning and delivery (180-200 cGy/fraction) appropriate for their disease site and stage. The inner ear was contoured on axial CT planning images. Dose-volume histograms, as well as the mean and maximal dose for each structure, were calculated. Patients underwent pure tone audiometry at baseline (before treatment) and 1, 6, 12, 24, and 36 months after RT. The threshold level (the greater the value, the more hearing loss) in decibels was recorded for 250, 500, 1000, 2000, 4000, and 8000 Hz. For patients receiving predominantly unilateral RT, the contralateral ear served as the de facto control. The differences in threshold level between the ipsilateral and contralateral ears were calculated, and the temporal pattern and dose-response relation of hearing loss were analyzed using statistical methods that take into account the correlation between two ears in the same subject and repeated, sequential measurements of each subject.
  
  
  RESULTS
  Of the 40 patients enrolled in this study, 35 qualified for analysis. Four patients who received concurrent chemotherapy and RT were analyzed separately. The 31 unilaterally treated patients received a median dose of 47.4 Gy (range, 14.1-68.8 Gy) to the ipsilateral inner ear and 4.2 Gy (range, 0.5-31.3 Gy) to the contralateral inner ear. Hearing loss was associated with the radiation dose received by the inner ear (loss of 210dB was observed in ears receiving >/=45 Gy) and was most appreciable in the higher frequencies (>/=2000 Hz). For a 60-year-old patient with no previous hearing loss in either ear, after receiving 45 Gy, the ipsilateral ear, according to our clinical model, would have a 19.3-dB (95% confidence interval [CI], 15.5-23.0) and 5.4-dB (95% CI, 3.5-7.5) hearing decrement compared with the contralateral ear for 8000 Hz and 1000 Hz, respectively. Age and an initial hearing difference within an ear pair also affected hearing loss. The baseline hearing threshold was inversely related to radiation-induced hearing loss. The degree of hearing loss was dependent on the frequency tested, age, baseline hearing, and baseline difference in hearing between a patient's two ears.
  
  
  CONCLUSIONS
  High-frequency (>/=2000 Hz) hearing acuity worsens significantly after RT in a dose-dependent fashion. A larger number of patients needs to be studied to validate these results. This knowledge can be applied to create guidelines regarding future dose limits to the auditory apparatus for patients undergoing head-and-neck RT.
authors.affiliation: Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA.
authors.forename: Charlie C
authors.initials: CC
authors.lastname: Pan
authors.forename: Avraham
authors.initials: A
authors.lastname: Eisbruch
authors.forename: Julia S
authors.initials: JS
authors.lastname: Lee
authors.forename: Rhonda M
authors.initials: RM
authors.lastname: Snorrason
authors.forename: Randall K
authors.initials: RK
authors.lastname: Ten Haken
authors.forename: Paul R
authors.initials: PR
authors.lastname: Kileny
mesh_terms: D000367:Age Factors; D000368:Aged; D016001:Confidence Intervals; D007758:Ear, Inner / Q000528:radiation effects*; D005260:Female; D006258:Head and Neck Neoplasms / Q000532:radiotherapy*; D006309:Hearing / Q000528:radiation effects; D034381:Hearing Loss / Q000209:etiology*; D006320:Hearing Tests; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D011829:Radiation Dosage; D011880:Radiotherapy Planning, Computer-Assisted; D020266:Radiotherapy, Conformal / Q000009:adverse effects*