Hearing Loss in Pediatric Cancer Survivors Treated With Cisplatin

Cisplatin is effective in treating several types of childhood cancers (eg, CNS tumors, osteosarcoma, hepatoblastoma, neuroblastoma, germ cell tumors). It is the most ototoxic drug used clinically, and hearing loss is a well-recognized toxicity of cisplatin(Drug information on cisplatin) therapy.

The effects of untreated hearing loss are significant in terms of a child’s communicative, educational, and social development. Audiologic assessment should be incorporated into a child’s medical care before, during, and after cisplatin chemotherapy.

Cisplatin ototoxicity initially presents as a loss of high-frequency hearing; it is typically bilateral and permanent and may be accompanied by tinnitus.[1] With continued treatment, it progresses in severity and spreads to affect hearing at lower frequencies. The reported incidence of hearing loss varies with differences in treatment protocols and patient variables, but hearing loss generally occurs in 20% to 70% of cisplatin recipients.[2–5]

Hearing loss can progress after treatment is completed,[2,6] and children and adolescents treated with ototoxic therapy should have long-term audiologic monitoring.

Patient Overview

DK was diagnosed with standard-risk medulloblastoma at 13 years of age. He presented with headache, double vision, disconjugate gaze, and vomiting. He underwent surgical resection, 6 weeks of craniospinal radiation (2,340 cGy to the spine and whole brain with a 3,240 cGy boost to the posterior fossa), and eight cycles of chemotherapy with CCNU (lomustine), vincristine, and cisplatin.

Before beginning radiation and chemotherapy treatment in February 2001, DK had a baseline audiologic evaluation, which showed normal hearing sensitivity in both ears. He was monitored in conjunction with his cisplatin chemotherapy treatments.

He began to exhibit hearing loss after the third cisplatin cycle, with mild (40 dB HL) hearing loss at 8,000 Hz in the left ear and 6,000–8,000 Hz in the right ear.

Evaluation after the fourth cisplatin cycle revealed mild to moderate (30–50 dB) hearing loss at 4,000–8,000 Hz in both ears. Subsequent cisplatin doses were decreased 50% for ototoxicity.

DK completed treatment in October 2001 after receiving a cumulative cisplatin dose of 450 mg/m2. At the end of treatment he had a mild sloping to severe hearing loss (40–60 dB HL) in both ears at 4,000–8,000 Hz. He noted that he had difficulty hearing in settings with noise and sometimes struggled when conversing in a group.

Now 20 years of age, DK has been without evidence of tumor recurrence. He has continued to have annual hearing evaluations, and his hearing loss has progressed over the past 6 years. His most recent evaluation in October 2007 revealed a mild sloping to severe (30–70 dB) hearing loss at 2,000–8,000 Hz in the left ear and at 1,000–8,000 Hz in the right ear.

As his hearing loss progressed, DK had increasing difficulty hearing and understanding speech, particularly during classroom lectures and discussions. He was fit with bilateral hearing aids about 4 years after completing chemotherapy treatment. He is currently attending a community college.

Nursing Management in Monitoring Ototocicity and Late Effects

When children are treated with ototoxic therapy, the risk for hearing loss should be anticipated and managed as part of the treatment plan. When hearing loss is identified, information and support is needed regarding hearing intervention and management. Families need assistance in coordinating services with audiologists, otolaryngologists, speech-language pathologists, educational providers, and community resources.

Oncology nurses are instrumental in educating families about the risk for hearing loss and the need for ongoing evaluation, and in assisting in coordination of care. Early detection of ototoxicity requires audiologic monitoring. One purpose of monitoring is to identify hearing loss before communication is significantly affected.

When hearing loss is detected, treatment may be modified to avoid further hearing loss, such as reducing the medication dose or changing to medication with less risk for ototoxicity.