The Relationship between Endolymphatic Hydrops Features and Hearing Loss in Bilateral Meniere's Disease

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Methods A retrospective analysis was conducted on 77 patients diagnosed with Bilateral Meniere's Disease. The features of endolymphatic hydrops in the affected ear were evaluated through gadolinium-enhanced inner ear Magnetic resonance imaging. The Spearman correlation coefficient, paired t-tests, and Wilcoxon signed-rank tests were employed for data analysis. Results The analysis revealed a significant correlation between the degree of endolymphatic hydrops and hearing loss across all frequencies(0.125-8 kHz), including the cochlear, vestibular, and overall degree of endolymphatic hydrops. The strongest correlation between the overall degree of endolymphatic hydrops and hearing loss was observed at low frequencies (r = 0.571, p < 0.05), followed by mid-frequencies (r = 0.508, p < 0.05), and high-frequencies (r = 0.351, p < 0.05), with a correlation of r = 0.463, p < 0.05 for the staging of Meniere's disease. Affected Ears with endolymphatic hydrops both in the cochlea and vestibule exhibited more severe hearing loss and Meniere's disease staging compared to those with isolated endolymphatic hydrops within the same patient. Conclusions The features of endolymphatic hydrops in patients with Bilateral Meniere's Disease were found to correlate with the severity of hearing loss and the staging of Meniere's disease. Endolymphatic Hydrops Bilateral Meniere’s Disease Hearing Loss Inner Ear Gadolinium-enhanced MRI Figures Figure 1 Figure 2 1. Background Meniere's Disease (MD) is recognized as a prevalent otological disorder, characterized by episodic vertigo, fluctuating hearing loss, tinnitus, and a sensation of aural fullness. Endolymphatic hydrops(EH) has been long identified as the primary pathological feature of MD, though its pathogenesis remained elusive ( 1 ). The prevailing consensus among researchers is that MD constitutes a syndrome initiated by diverse etiologies, necessitating the subdivision of MD into distinct subtypes. This stratification aims to facilitate the investigation into the clinical manifestations and underlying causes of different subtypes, thereby promoting the development of tailored treatment strategies( 2 , 3 ). Unilateral Meniere's Disease (UMD) encompasses the majority of MD cases, with the prevalence of Bilateral Meniere's Disease (BMD) reported variably across studies, ranging from 2–78%, most commonly estimated between 20%-30%. Diagnosing BMD requires individual assessment of each ear; however, once MD advanced in one ear, pinpointing the ear responsible for vertigo episodes becomes challenging. It is widely accepted among scholars that the diagnosis of BMD can be established upon the manifestation of contralateral ear symptoms such as hearing loss, tinnitus, and ear fullness( 4 ). BMD distinguishes itself by a pronounced sense of imbalance due to bilateral vestibular hypofunction and communication challenges stemming from bilateral hearing loss. Additionally, patients with BMD often exhibit a reduced tolerance for vertigo, and then a heightened rate of disability, thus significantly diminishing their quality of life. The management and treatment of BMD necessitate a more meticulous and conservative approach compared to UMD, especially when employing interventions that risk further hearing and/or vestibular damage( 5 ). Despite the acknowledged significance of precise diagnosis and treatment of BMD, research dedicated to its clinical characteristics remains limited, underlining the need for further investigation to enhance its treatment and management. Endolymphatic hydrops, a cardinal pathological hallmark of Meniere's Disease, was first visualized by MRI in patients by Nakashima et al( 6 ). The correlation between the degree of endolymphatic hydrops and hearing loss has been central to academic inquiry, albeit with inconsistent outcomes. One study identified a significant correlation between Pure Tone Audiometry (PTA) thresholds at low to mid-frequency and the degree of endolymphatic hydrops across all cochlear turns, excluding vestibular hydrops, whereas average high-frequency hearing thresholds did not demonstrate a significant correlation with the degree of endolymphatic hydrops either in the vestibule or cochlea( 7 ). The other study revealed that patients presenting with both vestibular and cochlear hydrops experienced more severe hearing loss and staging of MD than those with isolated cochlear or vestibular hydrops. Nonetheless, no significant correlation was found between vestibular hydrops and hearing loss or disease staging ( 8 ). Conversely, the degree of endolymphatic hydrops both in the vestibule and cochlea were significantly correlated with PTA thresholds( 9 ) ( 10 ). Moreover, disparate cochlear grading methods resulted in varying correlation coefficients between the degree of cochlear hydrops and hearing loss( 11 ). The inconsistency among study findings may be attributed to variations in the methods employed for visualizing endolymphatic hydrops via inner ear Magnetic resonance imaging (MRI), differences in criteria for assessing hydrops severity, individual variances among study populations, and potentially due to the lack of strict classification of Meniere's disease subtypes in previous research. Such factors might lead to conclusions that do not accurately reflect the specific context. Current investigations into the correlation between the degree of endolymphatic hydrops and hearing loss have not differentiated between bilateral and unilateral Meniere's Disease, possibly failing to capture the clinical nuances of BMD accurately. Thus, this study aims to explore the relationship between endolymphatic hydrops features and hearing loss in Bilateral Meniere's Disease, endeavoring to elucidate further the clinical features of BMD and provide a foundation for its diagnosis and treatment. 2. Materials and Methods 2.1 Patient Cohort and Clinical Examination Protocol 2.1.1 Participants Inclusion Criteria: Individuals diagnosed with bilateral Meniere's Disease by our team from March 1st, 2016, to March 1st, 2023, following the diagnostic criteria( 12 ) for MD were enrolled. Each ear of the patient was assessed individually. A diagnosis of bilateral Meniere's disease is made if gadolinium-enhanced MRI confirms bilateral endolymphatic hydrops and both ears present with symptoms such as hearing loss, tinnitus, and ear fullness( 13 ). All participants underwent gadolinium-enhanced inner ear magnetic resonance imaging (Gd-enhanced MRI) and Pure Tone Audiometry (PTA). Exclusion Criteria: Patients whose MRI images were of insufficient quality for assessing the degree of endolymphatic hydrops, as well as those whose hearing loss was too severe to yield responses to the PTA test, were excluded from the study. 2.1.2 Ethics: The ethical committee of the Eye and ENT Hospital at Fudan University granted approval for this study (#2023128). Given its retrospective nature and the absence of adverse effects on de-identified subjects, the requirement for patient consent forms was waived. 2.1.3 MRI Protocol Participants received an intravenous injection of a double dose (0.4 ml/kg body weight) of Gd-HP-DO3A. Four hours following the injection, MRI scans were conducted using a 32-channel phased-array coil (Verio; Siemens Healthcare, Erlangen, Germany) exclusively for reception. Imaging utilized T2 SPACE and three-dimensional real inversion recovery (3D-real-IR) sequences, with parameters for the 3D-real-IR sequence set as follows: voxel size = 0.2 × 0.2 × 0.6 mm; scan duration = 15 minutes and 20 seconds; repetition time = 6000 milliseconds; echo time = 181 milliseconds; inversion time = 1850 milliseconds; slice thickness = 0.6 mm; field of view = 160 × 160 mm; matrix size = 768 × 768. 2.1.4 PTA Protocol Pure Tone Audiometry (PTA) thresholds across all frequencies (0.125-8 kHz) were assessed for participants. Affected ears demonstrated varying degrees of sensorineural hearing loss, with the mean pure tone thresholds at 0.5, 1, 2, and 4 kHz reflecting the average level of hearing loss. 2.2 Data 2.2.1 Data Collection Air conduction hearing thresholds, at 0.125-8 kHz, were recorded for participants. The average thresholds at 125, 250, and 500 Hz were considered as the low-frequency hearing level (LH), at 1 kHz and 2 kHz as the mid-frequency hearing level (MH), and at 4 kHz and 8 kHz as the high-frequency hearing level (HH). The overall hearing level (PA) was calculated from the average thresholds at 500 Hz, 1 kHz, 2 kHz, and 4 kHz. Additionally, participants' 3D-real-IR sequences of inner ear gadolinium-enhanced MRI were collected. 2.2.2 Data Evaluation Grading of Endolymphatic Hydrops: Based on the 3D-real-IR sequence of inner ear gadolinium-enhanced MRI, cochlear hydrops (CL) was classified into four grades according to the criteria described by Gürkov et al( 14 ), as shown in Fig. 1 , Grade 0: No expansion of the endolymphatic dark areas(1A); Grade I: The endolymphatic dark areas are round(1B); Grade II: The endolymphatic dark areas are semicircular(1C); Grade III: The endolymphatic dark areas are expanded and flattened, with the disappearance of the vestibular scale(1D). Vestibular hydrops (VL), as the criteria proposed by Bernaerts et al( 15 ), was also classified into four grades as Fig. 2 indicated: Grade 0: The saccule and utricle are normal, their combined area is less than half of the vestibular region(2A); Grade I: The saccule is expanded with the saccule area ≥ utricle area, and the saccule/utricle ratio is inverted(2B); Grade II: The endolymphatic areas of the saccule and utricle are expanded, with their delineation becoming blurred or disappearing, yet the peripheral perilymphatic high signal areas remain visible(2C); Grade III: The peripheral perilymphatic high signal areas are no longer visible, leaving only the endolymphatic dark areas(2D). The overall degree of c in the affected ear was represented by summing the grades of cochlear and vestibular hydrops. Staging of Meniere’s Disease: The Meniere's disease staging (MDS)for affected earswas determined based on the average hearing threshold at 0.5, 1.0, 2.0, and 4.0 kHz, as follows: Stage I: Average hearing threshold ≤ 25 dBHL; Stage II: Average hearing threshold 26–40 dBHL; Stage III: Average hearing threshold 41–70 dBHL; Stage IV: Average hearing threshold > 70 dBHL. 2.3 Statistical Methods The Spearman correlation coefficient was employed to analyze the relationship between the degree of endolymphatic hydrops and hearing loss or the staging of Meniere's disease. The differences in hearing loss between the affected ear with both vestibular and cochlear hydrops and that with isolated cochlear or vestibular hydrops within the same patient was analyzed by paired t-tests, and that of Meniere's disease staging was analyzed by Wilcoxon signed-rank tests. 3. Results 3.1 Baseline As shown in Table 1, 77 patients diagnosed with Bilateral Meniere’s Disease, encompassing 154 ears, were included in the study. The cohort had an average age of 50.9 years, comprising 44 males and 33 females. In terms of vestibular hydrops (VL), 27 ears were classified as Grade 0, 29 as Grade I, 85 as Grade II, and 13 as Grade III. For cochlear hydrops (CL), classifications were as follows: 13 ears at Grade 0, 66 at Grade I, 67 at Grade II, and 8 at Grade III. The overall degree of endolymphatic hydrops (EHL) was determined to be Grade I in 25 ears, Grade II in 27 ears, Grade III in 45 ears, Grade IV in 39 ears, Grade V in 16 ears, and Grade VI in 2 ears. Table 1: This table summarizes the demographic and clinical characteristics of the study cohort Table 1 details the distribution of male and female patients (44 males and 33 females), the average age (51 years), the classification of vestibular hydrops (VL) and cochlear hydrops (CL) into grades 0 to 3, and the overall degree of endolymphatic hydrops (EHL) categorized into grades 1 to 6. Additionally, the overall hearing level (PA) is presented with a 95% confidence interval (46.4 dB [95% CI: 43.5-49.3]). Male/Female 44/33 Age 51 VL(0/1/2/3) 27/29/85/13 CL(0/1/2/3 13/66/67/8 EHL(1/2/3/4/5/6) 25/27/45/39/16/2 PA 46.4 dB(95%CI[43.5-49.3]） 3.2 Audiometric Findings Relative to Hydrops Severity From Table 2, it was observed that hearing thresholds across all frequencies progressively elevated with the advancement of vestibular and cochlear hydrops in the affected ears. Specifically, in cases where the vestibular hydrops in the affected ear was graded from 0 to 3, the average PA( the mean pure tone thresholds at 0.5, 1, 2, and 4 kHz ) values for affected ears were 37 dB, 40 dB, 53 dB, and 61 dB, respectively. Correspondingly, for cochlear hydrops levels from 0 to 3, the average PA values for affected ears were 38 dB, 43 dB, 52 dB, and 68 dB, respectively. Table 2: The hearing thresholds of different grades of vestibular and cochlear hydrops 150 250 500 1k 2k 4k 8k LH MH HH PA VL=0 33 34 35 35 36 43 51 34 35 47 37 VL=1 32 35 36 36 39 48 59 34 38 53 40 VL=2 44 48 51 51 51 57 67 48 51 62 53 VL=3 51 55 60 63 58 62 73 56 60 67 61 CL=0 34 36 36 38 35 40 47 35 37 43 38 CL=1 34 37 39 41 43 51 61 37 42 56 43 CL=2 45 48 51 51 50 57 68 48 51 63 52 CL=3 66 70 73 69 64 64 69 70 67 67 68 Table 2 presents the hearing thresholds at different frequencies (150 Hz, 250 Hz, 500 Hz, 1 kHz, 2 kHz, 4 kHz, and 8 kHz) according to the grades of vestibular and cochlear hydrops. The low-frequency hearing level (LH), the mid-frequency hearing level (MH), the high-frequency hearing level (HH), and the overall hearing level (PA) for vestibular hydrops grades (VL=0 to VL=3) and cochlear hydrops grades (CL=0 to CL=3). 3.3 Impact of Endolymphatic Hydrops Site on Hearing Loss The analysis included patients with varying numbers of endolymphatic hydropic sites in bilateral ears. Hearing thresholds of bilateral ears within the same patient were compared using a paired t-test. As shown in Table 3, ears with hydrops in both the cochlea and vestibule exhibited more severe hearing loss compared to those with isolated hydrops ( cochlear or vestibular hydrops) in the same patient. It was found that ears exhibiting both vestibular and cochlear hydrops demonstrated an average low-frequency hearing threshold difference of 17 dB(95%CI 8-26dB), a mid-frequency difference of 13 dB(95%CI 4-22dB), a high-frequency difference of 10 dB(95%CI 1-20dB), and a PTA threshold difference of 14 dB(95%CI 5-23dB), with all p-values less than 0.05. Additionally, the Meniere’s Disease (MD) staging of bilateral ears was compared using a paired Wilcoxon test, revealing a statistically significant difference (p < 0.05, z=2.973), indicating more severe MD staging in ears with both vestibular and cochlear hydrops compared to ears with isolated hydrops. Table 3. The hearing level of the ear with different Endolymphatic Hydrops Site d p 95%CI LH 17dB 0.002 (8 -26） MH 13dB 0.003 (4-22) HH 10dB 0.02 (1-20) PA 14dB 0.002 (5-23) MDS / 0.003 / Table 3 compares the low-frequency hearing level (LH), the mid-frequency hearing level (MH), the high-frequency hearing level (HH), the overall hearing level (PA), and the staging of Meniere's disease (MDS), between one ear with both vestibular and cochlear hydrops versus the other with isolated hydrops in the same patient. The differences (d), p-values (p), and 95% confidence intervals (95%CI) are provided, demonstrating statistically significant differences in the severity of hearing loss and MDS between the two groups. 3.4 Correlations Between Endolymphatic Hydrops Severity and Audiological Outcomes 3.4.1 Cochlear Hydrops and Hearing Loss As indicated in Table 4. A significant correlation was identified between the severity of cochlear hydrops and hearing threshold levels across all frequencies, with all p-values less than 0.05. The correlation was most pronounced with low-frequency average hearing levels (0.15-0.50 KHz) (r=0.462, p < 0.05), and least pronounced with high-frequency average hearing levels (4-8KHz) (r=0.261, p < 0.05). Significant correlations were also observed with the PA (0.5-4KHz) (r=0.383) and Meniere’s disease staging (MDS) (r=0.307). Table 4. The relationship between the degree of cochlear hydrops and hearing loss 150 250 500 1k 2k 4k 8k LH MH HH PA MDS r 0.433 0.453 0.443 0.379 0.316 0.242 0.252 0.462 0.368 0.261 0.383 0.307 p 0.000 0.000 0.000 0.000 0.000 0.002 0.001 0.000 0.000 0.001 0.000 0.000 Table 4 outlines the Spearman correlation coefficients (r) and p-values (p) assessing the relationship between the degree of cochlear hydrops(CL) and hearing loss across various frequencies (150 Hz to 8 kHz), also including low-frequency (LH), mid-frequency (MH), high-frequency (HH) hearing levels, the overall hearing level (PA), and he degree of CL and Meniere’s disease staging (MDS). Significant correlations indicate a strong relationship between CL and hearing impairment across all tested frequencies and MDS. 3.4.2 Vestibular Hydrops and Hearing Loss As indicated in Table 5, significant correlation was noted between the severity of vestibular hydrops and hearing threshold levels across all frequencies, with all p-values less than 0.05. The strongest correlation was observed with low-frequency average hearing levels (0.15-0.50KHz) (r=0.468, p < 0.05), and the weakest with high-frequency average hearing levels (4-8KHz) (r=0.314, p < 0.05). Significant correlations were further noted with PA (0.5-4KHz) (r=0.464) and Meniere’s disease staging (MDS) (r=0.436). Table 5. The relationship between the degree of vestibular hydrops and hearing loss 150 250 500 1k 2k 4k 8k LH MH HH PA MDS R 0.393 0.453 0.495 0.482 0.368 0.304 0.277 0.468 0.455 0.314 0.464 0.436 p 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 Table 5 details the Spearman correlation coefficients (r) and p-values (p) evaluating the association between the degree of vestibular hydrops(VL) and hearing loss at different frequencies (150 Hz to 8 kHz), also encompassing including low-frequency (LH), mid-frequency (MH), high-frequency (HH) hearing levels, the overall hearing level (PA). And the association between the CL and Meniere’s disease staging (MDS). Significant correlations indicate strong relationships between VL and hearing impairment and MDS. 3.4.3 The Overall Endolymphatic Hydrops and Hearing Loss As shown in Table 6, significant correlation was established between the comprehensive degree of endolymphatic hydrops and hearing threshold levels across all frequencies, with all p-values less than 0.05. The most substantial correlation was with low-frequency average hearing levels (0.15-0.50KHz) (r=0.571, p < 0.05), and the least substantial with high-frequency average hearing levels (4-8KHz) (r=0.351, p < 0.05). Significant correlations were also seen with PA (0.5-4KHz) (r=0.522) and Meniere’s disease staging (MDS) (r=0.463). Table 6. The relationship between the degree of endolymphatic hydrops and hearing loss 150 250 500 1k 2k 4k 8k LH MH HH PA MDS R 0.503 0.555 0.579 0.532 0.418 0.333 0.324 0.571 0.508 0.351 0.522 0.463 P 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 Table 6 presents the Spearman correlation coefficients (r) and p-values (p) illustrating the correlation between the overall degree of endolymphatic hydrops (EHL) and hearing loss at various frequencies (150 Hz to 8 kHz), also including assessments of low-frequency (LH), mid-frequency (MH), high-frequency (HH) hearing levels, the overall hearing level (PA). And the association between the EHL and Meniere’s disease staging (MDS). Statistically significant correlations underscore the profound impact of EHL on hearing across and MDS. 4. Discussion This study was undertaken to elucidate the association between the features of endolymphatic hydrops and hearing loss in patients diagnosed with Bilateral Meniere's Disease (BMD), a disorder that significantly undermines the quality of life through bilateral vestibular dysfunction and hearing loss. The findings from our investigation revealed a robust correlation between the severity of the overall endolymphatic hydrops, cochlear hydrops, and vestibular hydrops in bilateral Meniere's disease with hearing loss across all frequencies, particularly pronounced in the low to mid-frequency ranges. Existing literature on the correlation between the severity of endolymphatic hydrops and hearing loss has yielded inconsistent results. While a consensus exists among several studies that the severity of cochlear and vestibular hydrops is correlated with hearing loss ( 9 , 10 , 16 – 19 ), this concurs with our findings. However, certain studies posit that the severity of vestibular hydrops bears no relation to the extent of hearing loss( 7 , 8 ), a conclusion at odds with our findings. Such disparities may be attributable to the limited sample sizes in various studies, individual variances among patients, and the disparities in MRI imaging techniques and grading methodologies for vestibular and cochlear hydrops across different clinical settings( 19 ). For example, disparities in cochlear hydrops grading methods were noted to produce varied correlation coefficient with hearing loss( 11 ). This study found that the severity of bilateral Meniere's Disease (MD) endolymphatic hydrops and MD staging are correlated, which partially diverges from the conclusions of the study( 20 ). That study posited that traditional MD staging does not correlate with the degree of endolymphatic hydrops (EH) visible on MRI, although advanced staging of MD may indicate increased severity of cochlear and vestibular EH. Furthermore, it was observed that, within the same patient, ears afflicted with both vestibular and cochlear hydrops manifested more severe hearing loss and MD staging compared to those with isolated cochlear hydrops or vestibular hydrops, suggesting that isolated vestibular or cochlear hydrops may represent an earlier stage of the disease. This underscores the importance of continuous follow-up in clinical practice for such patients to monitor disease progression and identify influencing factors. The novelty of our study lies in its focus on BMD to enhance the extant body of evidence on the correlation between the severity of endolymphatic hydrops and hearing loss in bilateral Meniere's disease. Moreover, a distinguishing feature of our study is the employment of novel methodologies for determining the grades of cochlear and vestibular hydrops. Utilizing the latest grading method proposed by Gürkov et al ( 14 ) for cochlear hydrops, which classifies the condition into grades 0 through 3, which demonstrated the highest correlation with the degree of hearing loss in this study compared other grades methods( 11 ). For vestibular grading, following the criteria outlined by BERNAERTS et al( 15 ), vestibular hydrops was categorized into grades 0 through 3, with grade 1 identified as saccular expansion surpassing the utricle's area, thereby facilitating the early diagnosis of vestibular hydrops( 21 ). The findings from our study underscored a strong correlation between the severity of vestibular hydrops and hearing loss, thereby validating the scientific robustness of the grading method mentioned above. Finally, by amalgamating the grades of vestibular and cochlear hydrops, the overall severity of endolymphatic hydrops in the affected ear was represented. It was concluded that the aggregate severity of hydrops, encompassing both endolymphatic and cochlear hydrops, exhibited a stronger correlation with hearing loss. This suggests that such an approach enhances the accuracy in assessing the correlation between endolymphatic hydrops and hearing loss, considering the impact of both vestibular and cochlear involvement on hearing. The limitations of this study include its reliance on specific imaging techniques for assessing endolymphatic hydrops, which may not be universally accessible or standardized across healthcare facilities. Additionally, the retrospective design of the study precludes the direct inference of causality. Future research should endeavor to standardize imaging protocols for the diagnosis of endolymphatic hydrops and conduct prospective studies to gain a more comprehensive understanding of the progression of BMD and the factors influencing hearing loss. Such endeavors aim to refine treatment modalities for patients afflicted with this condition. In conclusion, the findings of this research into the correlation between the characteristics of endolymphatic hydrops and hearing loss in BMD contribute to an enhanced comprehension of the syndrome, particularly by focusing on the distinct clinical features of BMD. This lays the foundation for subsequent research directed at improving the quality of life for those affected by this debilitating condition. 5. Conclusion The degree of endolymphatic hydrops in affected ears of patients with Bilateral Meniere's Disease was found to correlate with the severity of hearing loss and the staging of Meniere's disease. The degree of endolymphatic hydrops positively correlated with hearing loss across all frequencies, with the strongest correlation observed in low-frequency hearing loss and the weakest in high-frequency hearing loss, and the overall degree of endolymphatic hydrops and hearing loss has the strongest correlation between hearing loss. Patients with both vestibular and cochlear hydrops exhibited more severe hearing loss and staging of MD than those with isolated hydrops. Abbreviations Meniere's Disease (MD) Endolymphatic hydrops(EH) Unilateral Meniere's Disease(UMD) Bilateral Meniere's Disease (BMD) Pure Tone Audiometry (PTA) Magnetic resonance imaging (MRI) gadolinium-enhanced inner ear magnetic resonance imaging (Gd-enhanced MRI) three-dimensional real inversion recovery sequences (3D-real-IR) low-frequency hearing level (LH) mid-frequency hearing level (MH) high-frequency hearing level (HH) overall hearing level (PA) cochlear hydrops (CL) Vestibular hydrops (VL) endolymphatic hydrops (EHL) Meniere's disease staging (MDS) Declarations Ethical Approval ： The ethical committee of the Eye and ENT Hospital at Fudan University approved this study (#2023128). Consent for Publication ： I confirm that I have obtained consent from all participants for the publication of the content of this paper. Availability of data and materials ： The data in this study are clinical in nature and therefore cannot be publicly disclosed. Conflicts of Interest and Source of Funding ： The authors declare no financial interests in the present study and have no potential conflicts of interest to disclose.This study received support from the National Natural Science Foundation of China (Nos. 82101222) and the Natural Science Foundation of Shanghai (No. 20ZR1409600). Contribution ： XL contributed to the conceptualization, methodology, and supervision of the study. DW was responsible for data curation, formal analysis, and writing the original draft. Yue-Lin Hsieh conducted the investigation, validation, and visualization of the results. SS managed resources, and project administration, and contributed to the writing, review, and editing of the manuscript. WW provided software support, secured funding for the study, and contributed to the writing, review, and editing of the manuscript. References Rizk HG, Mehta NK, Qureshi U, Yuen E, Zhang K, Nkrumah Y, et al. 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Endolymphatic hydrops imaging and correlation with clinical characteristics, audiovestibular function and mental impairment in patients with Meniere's disease. Eur Arch Otorhinolaryngol. 2023;280(9):4027–36. 10.1007/s00405-023-07899-w . Epub 20230227. Kahn L, Hautefort C, Guichard JP, Toupet M, Jourdaine C, Vitaux H, et al. Relationship between video head impulse test, ocular and cervical vestibular evoked myogenic potentials, and compartmental magnetic resonance imaging classification in menière's disease. Laryngoscope. 2020;130(7):E444–52. 10.1002/lary.28362 . Epub 20191119. Zhang W, Xie J, Li S, Zhang B. Correlation Between Quantitative Value of Endolymphatic Hydrops and Hearing Threshold Using Magnetic Resonance Imaging. Ann Otol Rhinol Laryngol. 2023;132(10):1149–55. Epub 20221122. doi: 10.1177/00034894221134729. PubMed PMID: 36412145. de Pont LMH, van Steekelenburg JM, Verhagen TO, Houben M, Goeman JJ, Verbist BM, et al. Hydropic Ear Disease: Correlation Between Audiovestibular Symptoms, Endolymphatic Hydrops and Blood-Labyrinth Barrier Impairment. Front Surg. 2021;8:758947. 10.3389/fsurg.2021.758947 . Epub 20211104. Yan HY, Young YH. Role of conventional MD staging in modern era of hydrops MR imaging. Laryngoscope Investig Otolaryngol. 2024;9(1):e1213. 10.1002/lio2.1213 . Epub 20240115. Jasińska A, Lachowska M, Wnuk E, Pierchała K, Rowiński O, Niemczyk K. Correlation between magnetic resonance imaging classification of endolymphatic hydrops and clinical manifestations and audiovestibular test results in patients with definite Ménière's disease. Auris Nasus Larynx. 2022;49(1):34–45. 10.1016/j.anl.2021.03.027 . Epub 20210415. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 16 Sep, 2024 Read the published version in Head & Face Medicine → Version 1 posted Editorial decision: Revision requested 02 Aug, 2024 Reviews received at journal 02 Aug, 2024 Reviews received at journal 02 Aug, 2024 Reviews received at journal 30 Jul, 2024 Reviewers agreed at journal 25 Jul, 2024 Reviewers agreed at journal 24 Jul, 2024 Reviewers agreed at journal 23 Jul, 2024 Reviewers invited by journal 06 Jul, 2024 Editor assigned by journal 03 Jul, 2024 Submission checks completed at journal 03 Jul, 2024 First submitted to journal 30 Jun, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4665048","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":331340294,"identity":"cb9b6e2a-e776-498e-b74f-0e50fb69da77","order_by":0,"name":"XU Liu","email":"","orcid":"","institution":"ENT Institute and Department of Otorhinolaryngology, Eye \u0026 ENT Hospital, Fudan University, Shanghai 200031, China","correspondingAuthor":false,"prefix":"","firstName":"XU","middleName":"","lastName":"Liu","suffix":""},{"id":331340295,"identity":"9b45f0f3-c507-48fe-96fd-47494f3af7f8","order_by":1,"name":"Dan Wang","email":"","orcid":"","institution":"ENT Institute and Department of Otorhinolaryngology, Eye \u0026 ENT Hospital, Fudan University, Shanghai 200031, China","correspondingAuthor":false,"prefix":"","firstName":"Dan","middleName":"","lastName":"Wang","suffix":""},{"id":331340296,"identity":"1dd53374-12d8-409b-aa37-f454ef04100b","order_by":2,"name":"Yue-Lin Hsieh","email":"","orcid":"","institution":"ENT Institute and Department of Otorhinolaryngology, Eye \u0026 ENT Hospital, Fudan University, Shanghai 200031, China","correspondingAuthor":false,"prefix":"","firstName":"Yue-Lin","middleName":"","lastName":"Hsieh","suffix":""},{"id":331340297,"identity":"29fd252f-addc-4025-94e3-485742062587","order_by":3,"name":"Suming Shi","email":"","orcid":"","institution":"ENT Institute and Department of Otorhinolaryngology, Eye \u0026 ENT Hospital, Fudan University, Shanghai 200031, China","correspondingAuthor":false,"prefix":"","firstName":"Suming","middleName":"","lastName":"Shi","suffix":""},{"id":331340298,"identity":"87126fbf-41d6-4884-890d-6e5e69e4f6f7","order_by":4,"name":"Wuqing Wang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA80lEQVRIiWNgGAWjYLCCBAYGOSjzAJiUIEaLMZBibCBeCxAkNhCtxeBGjuGNhztq0/vZe48/YPhzJ9rgAPPB2zwMdnl4tBhbJJ45njuz51xiA2Pbs9wNB9iSrXkYkotxaTG7nWMmkdh2LHcD0LoGxobDQC08ZtI8DAdATsWrJd3+/hvDBoY/IC3834jRUpNgIMED1MIGtoUNrxb7+8+KLRLbDhjOOJNjOCOx7XDuzMNsxpZzDJJxapHsObzx5s+2Onn+9jMGHz4AHdZ3vPnhjTcVdji1gAAwFg5DWAkgghlEGOBRD9FSh1/FKBgFo2AUjGwAAJ7nYEOuY8niAAAAAElFTkSuQmCC","orcid":"","institution":"ENT Institute and Department of Otorhinolaryngology, Eye \u0026 ENT Hospital, Fudan University, Shanghai 200031, China","correspondingAuthor":true,"prefix":"","firstName":"Wuqing","middleName":"","lastName":"Wang","suffix":""}],"badges":[],"createdAt":"2024-07-01 03:37:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4665048/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4665048/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13005-024-00455-9","type":"published","date":"2024-09-16T15:57:46+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":61183895,"identity":"cbd45629-217e-4577-a662-edf19ff0342e","added_by":"auto","created_at":"2024-07-26 17:09:36","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":130540,"visible":true,"origin":"","legend":"\u003cp\u003eIllustrations of the Classification method of Cochlear Hydrops degree,1A: Grade 0 - No visible cochlear hydrops, indicating normal cochlear condition.1B: Grade I - Mild cochlear hydrops, showing slight expansion of the endolymphatic space.1C: Grade II - Moderate cochlear hydrops, with significant enlargement of the endolymphatic compartment.1D: Grade III - Severe cochlear hydrops, characterized by extensive dilation of the endolymphatic space, indicative of advanced pathological changes.\u003c/p\u003e","description":"","filename":"Figure1300DPI.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4665048/v1/878278dfaa80ce374fe6eb15.jpeg"},{"id":61183185,"identity":"15bda38a-f845-4c8c-b1cf-38bb07e7749b","added_by":"auto","created_at":"2024-07-26 17:01:36","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":142497,"visible":true,"origin":"","legend":"\u003cp\u003eIllustrations of the Classification method of Vestibular Hydrops degree,2A: Grade 0 - No evidence of vestibular hydrops, representing a normal vestibular appearance 2B: Grade I - Mild vestibular hydrops, with slight distension of the saccule.2C: Grade II: The endolymphatic areas of the saccule and utricle are expanded, with their delineation becoming blurred or disappearing, yet the peripheral perilymphatic high signal areas remain visible. 2D: Grade III: The peripheral perilymphatic high signal areas are no longer visible, leaving only the endolymphatic dark areas.\u003c/p\u003e","description":"","filename":"Figure2300DPI.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4665048/v1/4a8c8807cfbf5531a51bf54f.jpeg"},{"id":65104266,"identity":"9ded7a32-ee6e-444d-b6a6-cc2d6144476a","added_by":"auto","created_at":"2024-09-23 16:13:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":832822,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4665048/v1/7bc31c24-9642-425a-993a-4560d510e8ba.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Relationship between Endolymphatic Hydrops Features and Hearing Loss in Bilateral Meniere's Disease","fulltext":[{"header":"1. Background","content":"\u003cp\u003eMeniere's Disease (MD) is recognized as a prevalent otological disorder, characterized by episodic vertigo, fluctuating hearing loss, tinnitus, and a sensation of aural fullness. Endolymphatic hydrops(EH) has been long identified as the primary pathological feature of MD, though its pathogenesis remained elusive (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). The prevailing consensus among researchers is that MD constitutes a syndrome initiated by diverse etiologies, necessitating the subdivision of MD into distinct subtypes. This stratification aims to facilitate the investigation into the clinical manifestations and underlying causes of different subtypes, thereby promoting the development of tailored treatment strategies(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Unilateral Meniere's Disease (UMD) encompasses the majority of MD cases, with the prevalence of Bilateral Meniere's Disease (BMD) reported variably across studies, ranging from 2\u0026ndash;78%, most commonly estimated between 20%-30%. Diagnosing BMD requires individual assessment of each ear; however, once MD advanced in one ear, pinpointing the ear responsible for vertigo episodes becomes challenging. It is widely accepted among scholars that the diagnosis of BMD can be established upon the manifestation of contralateral ear symptoms such as hearing loss, tinnitus, and ear fullness(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). BMD distinguishes itself by a pronounced sense of imbalance due to bilateral vestibular hypofunction and communication challenges stemming from bilateral hearing loss. Additionally, patients with BMD often exhibit a reduced tolerance for vertigo, and then a heightened rate of disability, thus significantly diminishing their quality of life. The management and treatment of BMD necessitate a more meticulous and conservative approach compared to UMD, especially when employing interventions that risk further hearing and/or vestibular damage(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Despite the acknowledged significance of precise diagnosis and treatment of BMD, research dedicated to its clinical characteristics remains limited, underlining the need for further investigation to enhance its treatment and management.\u003c/p\u003e \u003cp\u003eEndolymphatic hydrops, a cardinal pathological hallmark of Meniere's Disease, was first visualized by MRI in patients by Nakashima et al(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). The correlation between the degree of endolymphatic hydrops and hearing loss has been central to academic inquiry, albeit with inconsistent outcomes. One study identified a significant correlation between Pure Tone Audiometry (PTA) thresholds at low to mid-frequency and the degree of endolymphatic hydrops across all cochlear turns, excluding vestibular hydrops, whereas average high-frequency hearing thresholds did not demonstrate a significant correlation with the degree of endolymphatic hydrops either in the vestibule or cochlea(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). The other study revealed that patients presenting with both vestibular and cochlear hydrops experienced more severe hearing loss and staging of MD than those with isolated cochlear or vestibular hydrops. Nonetheless, no significant correlation was found between vestibular hydrops and hearing loss or disease staging (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Conversely, the degree of endolymphatic hydrops both in the vestibule and cochlea were significantly correlated with PTA thresholds(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Moreover, disparate cochlear grading methods resulted in varying correlation coefficients between the degree of cochlear hydrops and hearing loss(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe inconsistency among study findings may be attributed to variations in the methods employed for visualizing endolymphatic hydrops via inner ear Magnetic resonance imaging (MRI), differences in criteria for assessing hydrops severity, individual variances among study populations, and potentially due to the lack of strict classification of Meniere's disease subtypes in previous research. Such factors might lead to conclusions that do not accurately reflect the specific context. Current investigations into the correlation between the degree of endolymphatic hydrops and hearing loss have not differentiated between bilateral and unilateral Meniere's Disease, possibly failing to capture the clinical nuances of BMD accurately. Thus, this study aims to explore the relationship between endolymphatic hydrops features and hearing loss in Bilateral Meniere's Disease, endeavoring to elucidate further the clinical features of BMD and provide a foundation for its diagnosis and treatment.\u003c/p\u003e"},{"header":"2. Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Patient Cohort and Clinical Examination Protocol\u003c/h2\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003ch2\u003e2.1.1 Participants\u003c/h2\u003e \u003cp\u003eInclusion Criteria: Individuals diagnosed with bilateral Meniere's Disease by our team from March 1st, 2016, to March 1st, 2023, following the diagnostic criteria(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) for MD were enrolled. Each ear of the patient was assessed individually. A diagnosis of bilateral Meniere's disease is made if gadolinium-enhanced MRI confirms bilateral endolymphatic hydrops and both ears present with symptoms such as hearing loss, tinnitus, and ear fullness(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). All participants underwent gadolinium-enhanced inner ear magnetic resonance imaging (Gd-enhanced MRI) and Pure Tone Audiometry (PTA).\u003c/p\u003e \u003cp\u003eExclusion Criteria: Patients whose MRI images were of insufficient quality for assessing the degree of endolymphatic hydrops, as well as those whose hearing loss was too severe to yield responses to the PTA test, were excluded from the study.\u003c/p\u003e \u003cp\u003e 2.1.2 Ethics: The ethical committee of the Eye and ENT Hospital at Fudan University granted approval for this study (#2023128). Given its retrospective nature and the absence of adverse effects on de-identified subjects, the requirement for patient consent forms was waived.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003ch2\u003e2.1.3 MRI Protocol\u003c/h2\u003e \u003cp\u003eParticipants received an intravenous injection of a double dose (0.4 ml/kg body weight) of Gd-HP-DO3A. Four hours following the injection, MRI scans were conducted using a 32-channel phased-array coil (Verio; Siemens Healthcare, Erlangen, Germany) exclusively for reception. Imaging utilized T2 SPACE and three-dimensional real inversion recovery (3D-real-IR) sequences, with parameters for the 3D-real-IR sequence set as follows: voxel size\u0026thinsp;=\u0026thinsp;0.2 \u0026times; 0.2 \u0026times; 0.6 mm; scan duration\u0026thinsp;=\u0026thinsp;15 minutes and 20 seconds; repetition time\u0026thinsp;=\u0026thinsp;6000 milliseconds; echo time\u0026thinsp;=\u0026thinsp;181 milliseconds; inversion time\u0026thinsp;=\u0026thinsp;1850 milliseconds; slice thickness\u0026thinsp;=\u0026thinsp;0.6 mm; field of view\u0026thinsp;=\u0026thinsp;160 \u0026times; 160 mm; matrix size\u0026thinsp;=\u0026thinsp;768 \u0026times; 768.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003e2.1.4 PTA Protocol\u003c/h2\u003e \u003cp\u003e Pure Tone Audiometry (PTA) thresholds across all frequencies (0.125-8 kHz) were assessed for participants. Affected ears demonstrated varying degrees of sensorineural hearing loss, with the mean pure tone thresholds at 0.5, 1, 2, and 4 kHz reflecting the average level of hearing loss.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Data\u003c/h2\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003e2.2.1 Data Collection\u003c/h2\u003e \u003cp\u003eAir conduction hearing thresholds, at 0.125-8 kHz, were recorded for participants. The average thresholds at 125, 250, and 500 Hz were considered as the low-frequency hearing level (LH), at 1 kHz and 2 kHz as the mid-frequency hearing level (MH), and at 4 kHz and 8 kHz as the high-frequency hearing level (HH). The overall hearing level (PA) was calculated from the average thresholds at 500 Hz, 1 kHz, 2 kHz, and 4 kHz. Additionally, participants' 3D-real-IR sequences of inner ear gadolinium-enhanced MRI were collected.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003e2.2.2 Data Evaluation\u003c/h2\u003e \u003cp\u003eGrading of Endolymphatic Hydrops: Based on the 3D-real-IR sequence of inner ear gadolinium-enhanced MRI, cochlear hydrops (CL) was classified into four grades according to the criteria described by G\u0026uuml;rkov et al(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e), as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, Grade 0: No expansion of the endolymphatic dark areas(1A); Grade I: The endolymphatic dark areas are round(1B); Grade II: The endolymphatic dark areas are semicircular(1C); Grade III: The endolymphatic dark areas are expanded and flattened, with the disappearance of the vestibular scale(1D). Vestibular hydrops (VL), as the criteria proposed by Bernaerts et al(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), was also classified into four grades as Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e indicated: Grade 0: The saccule and utricle are normal, their combined area is less than half of the vestibular region(2A); Grade I: The saccule is expanded with the saccule area\u0026thinsp;\u0026ge;\u0026thinsp;utricle area, and the saccule/utricle ratio is inverted(2B); Grade II: The endolymphatic areas of the saccule and utricle are expanded, with their delineation becoming blurred or disappearing, yet the peripheral perilymphatic high signal areas remain visible(2C); Grade III: The peripheral perilymphatic high signal areas are no longer visible, leaving only the endolymphatic dark areas(2D). The overall degree of c in the affected ear was represented by summing the grades of cochlear and vestibular hydrops.\u003c/p\u003e \u003cp\u003eStaging of Meniere\u0026rsquo;s Disease: The Meniere's disease staging (MDS)for affected earswas determined based on the average hearing threshold at 0.5, 1.0, 2.0, and 4.0 kHz, as follows: Stage I: Average hearing threshold\u0026thinsp;\u0026le;\u0026thinsp;25 dBHL; Stage II: Average hearing threshold 26\u0026ndash;40 dBHL; Stage III: Average hearing threshold 41\u0026ndash;70 dBHL; Stage IV: Average hearing threshold\u0026thinsp;\u0026gt;\u0026thinsp;70 dBHL.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Statistical Methods\u003c/h2\u003e \u003cp\u003eThe Spearman correlation coefficient was employed to analyze the relationship between the degree of endolymphatic hydrops and hearing loss or the staging of Meniere's disease. The differences in hearing loss between the affected ear with both vestibular and cochlear hydrops and that with isolated cochlear or vestibular hydrops within the same patient was analyzed by paired t-tests, and that of Meniere's disease staging was analyzed by Wilcoxon signed-rank tests.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003e\u003cstrong\u003e3.1 Baseline\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs shown in Table 1, 77 patients diagnosed with Bilateral Meniere\u0026rsquo;s Disease, encompassing 154 ears, were included in the study. The cohort had an average age of 50.9 years, comprising 44 males and 33 females. In terms of vestibular hydrops (VL), 27 ears were classified as Grade 0, 29 as Grade I, 85 as Grade II, and 13 as Grade III. For cochlear hydrops (CL), classifications were as follows: 13 ears at Grade 0, 66 at Grade I, 67 at Grade II, and 8 at Grade III. The overall degree of endolymphatic hydrops (EHL) was determined to be Grade I in 25 ears, Grade II in 27 ears, Grade III in 45 ears, Grade IV in 39 ears, Grade V in 16 ears, and Grade VI in 2 ears.\u003c/p\u003e\n\u003cp\u003eTable 1: This table summarizes the demographic and clinical characteristics of the study cohort\u003c/p\u003e\n\u003cp\u003eTable 1 details the distribution of male and female patients (44 males and 33 females), the average age (51 years), the classification of vestibular hydrops (VL) and cochlear hydrops (CL) into grades 0 to 3, and the overall degree of endolymphatic hydrops (EHL) categorized into grades 1 to 6. Additionally, the overall hearing level (PA) is presented with a 95% confidence interval (46.4 dB [95% CI: 43.5-49.3]).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eMale/Female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e44/33\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e51\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eVL(0/1/2/3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e27/29/85/13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eCL(0/1/2/3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e13/66/67/8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eEHL(1/2/3/4/5/6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e25/27/45/39/16/2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003ePA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e46.4 dB(95%CI[43.5-49.3]）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e3.2 Audiometric Findings Relative to Hydrops Severity\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFrom Table 2, it was observed that hearing thresholds across all frequencies progressively elevated with the advancement of vestibular and cochlear hydrops in the affected ears. Specifically, in cases where the vestibular hydrops in the affected ear was graded from 0 to 3, the average PA( the mean pure tone thresholds at 0.5, 1, 2, and 4 kHz )\u0026nbsp;values for affected ears were 37 dB, 40 dB, 53 dB, and 61 dB, respectively. Correspondingly, for cochlear hydrops levels from 0 to 3, the average PA values for affected ears were 38 dB, 43 dB, 52 dB, and 68 dB, respectively.\u003c/p\u003e\n\u003cp\u003eTable 2: The hearing thresholds of different grades of vestibular and cochlear hydrops\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"520\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.302681992337165%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\" valign=\"top\"\u003e\n \u003cp\u003e150\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\" valign=\"top\"\u003e\n \u003cp\u003e250\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\" valign=\"top\"\u003e\n \u003cp\u003e500\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\" valign=\"top\"\u003e\n \u003cp\u003e1k\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\" valign=\"top\"\u003e\n \u003cp\u003e2k\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\" valign=\"top\"\u003e\n \u003cp\u003e4k\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\" valign=\"top\"\u003e\n \u003cp\u003e8k\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\" valign=\"top\"\u003e\n \u003cp\u003eLH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.237547892720306%\" valign=\"top\"\u003e\n \u003cp\u003eMH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\" valign=\"top\"\u003e\n \u003cp\u003eHH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\" valign=\"top\"\u003e\n \u003cp\u003ePA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.302681992337165%\" valign=\"top\"\u003e\n \u003cp\u003eVL=0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e33\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e34\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e35\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e35\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e36\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e43\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e51\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e34\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.237547892720306%\"\u003e\n \u003cp\u003e35\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e47\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e37\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.302681992337165%\" valign=\"top\"\u003e\n \u003cp\u003eVL=1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e32\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e35\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e36\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e36\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e39\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e48\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e59\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e34\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.237547892720306%\"\u003e\n \u003cp\u003e38\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e53\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e40\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.302681992337165%\" valign=\"top\"\u003e\n \u003cp\u003eVL=2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e44\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e48\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e51\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e51\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e51\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e57\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e67\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e48\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.237547892720306%\"\u003e\n \u003cp\u003e51\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e62\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e53\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.302681992337165%\" valign=\"top\"\u003e\n \u003cp\u003eVL=3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e51\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e55\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e60\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e63\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e58\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e62\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e73\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e56\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.237547892720306%\"\u003e\n \u003cp\u003e60\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e67\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e61\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.302681992337165%\" valign=\"top\"\u003e\n \u003cp\u003eCL=0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e34\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e36\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e36\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e38\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e35\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e40\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e47\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e35\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.237547892720306%\"\u003e\n \u003cp\u003e37\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e43\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e38\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.302681992337165%\" valign=\"top\"\u003e\n \u003cp\u003eCL=1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e34\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e37\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e39\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e41\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e43\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e51\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e61\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e37\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.237547892720306%\"\u003e\n \u003cp\u003e42\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e56\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e43\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.302681992337165%\" valign=\"top\"\u003e\n \u003cp\u003eCL=2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e45\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e48\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e51\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e51\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e50\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e57\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e68\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e48\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.237547892720306%\"\u003e\n \u003cp\u003e51\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e63\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e52\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.302681992337165%\" valign=\"top\"\u003e\n \u003cp\u003eCL=3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e66\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e70\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e73\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e69\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e64\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e64\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e69\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e70\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.237547892720306%\"\u003e\n \u003cp\u003e67\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e67\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.045977011494253%\"\u003e\n \u003cp\u003e68\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 2 presents the hearing thresholds at different frequencies (150 Hz, 250 Hz, 500 Hz, 1 kHz, 2 kHz, 4 kHz, and 8 kHz) according to the grades of vestibular and cochlear hydrops. The low-frequency hearing level (LH), the mid-frequency hearing level (MH), the high-frequency hearing level (HH), and the overall hearing level (PA) for vestibular hydrops grades (VL=0 to VL=3) and cochlear hydrops grades (CL=0 to CL=3).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.3 Impact of Endolymphatic Hydrops Site on Hearing Loss\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe analysis included patients with varying numbers of endolymphatic hydropic sites in bilateral ears. Hearing thresholds of bilateral ears within the same patient were compared using a paired t-test. As shown in Table 3, ears with hydrops in both the cochlea and vestibule exhibited more severe hearing loss compared to those with isolated hydrops ( cochlear or vestibular hydrops) in the same patient. It was found that ears exhibiting both vestibular and cochlear hydrops demonstrated an average low-frequency hearing threshold difference of 17 dB(95%CI 8-26dB), a mid-frequency difference of 13 dB(95%CI 4-22dB), a high-frequency difference of 10 dB(95%CI 1-20dB), and a PTA threshold difference of 14 dB(95%CI 5-23dB), with all p-values less than 0.05. Additionally, the Meniere\u0026rsquo;s Disease (MD) staging of bilateral ears was compared using a paired Wilcoxon test, revealing a statistically significant difference (p \u0026lt; 0.05, z=2.973), indicating more severe MD staging in ears with both vestibular and cochlear hydrops compared to ears with isolated hydrops.\u003c/p\u003e\n\u003cp\u003eTable 3. The hearing level of the ear with different Endolymphatic Hydrops Site\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.853211009174313%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.238532110091743%\" valign=\"top\"\u003e\n \u003cp\u003ed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.954128440366972%\" valign=\"top\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.954128440366972%\" valign=\"top\"\u003e\n \u003cp\u003e95%CI\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.853211009174313%\" valign=\"top\"\u003e\n \u003cp\u003eLH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.238532110091743%\" valign=\"top\"\u003e\n \u003cp\u003e17dB\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.954128440366972%\" valign=\"top\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.954128440366972%\" valign=\"top\"\u003e\n \u003cp\u003e(8 -26）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.853211009174313%\" valign=\"top\"\u003e\n \u003cp\u003eMH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.238532110091743%\" valign=\"top\"\u003e\n \u003cp\u003e13dB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.954128440366972%\" valign=\"top\"\u003e\n \u003cp\u003e0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.954128440366972%\" valign=\"top\"\u003e\n \u003cp\u003e(4-22)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.853211009174313%\" valign=\"top\"\u003e\n \u003cp\u003eHH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.238532110091743%\" valign=\"top\"\u003e\n \u003cp\u003e10dB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.954128440366972%\" valign=\"top\"\u003e\n \u003cp\u003e0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.954128440366972%\" valign=\"top\"\u003e\n \u003cp\u003e(1-20)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.853211009174313%\" valign=\"top\"\u003e\n \u003cp\u003ePA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.238532110091743%\" valign=\"top\"\u003e\n \u003cp\u003e14dB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.954128440366972%\" valign=\"top\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.954128440366972%\" valign=\"top\"\u003e\n \u003cp\u003e(5-23)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.853211009174313%\" valign=\"top\"\u003e\n \u003cp\u003eMDS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.238532110091743%\" valign=\"top\"\u003e\n \u003cp\u003e/\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.954128440366972%\" valign=\"top\"\u003e\n \u003cp\u003e0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.954128440366972%\" valign=\"top\"\u003e\n \u003cp\u003e/\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 3 compares the low-frequency hearing level (LH), the mid-frequency hearing level (MH), the high-frequency hearing level (HH), the overall hearing level (PA), and the staging of Meniere\u0026apos;s disease (MDS), between one ear with both vestibular and cochlear hydrops versus the other with isolated hydrops in the same patient. The differences (d), p-values (p), and 95% confidence intervals (95%CI) are provided, demonstrating statistically significant differences in the severity of hearing loss and MDS between the two groups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.4 Correlations Between Endolymphatic Hydrops Severity and Audiological Outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e3.4.1 Cochlear Hydrops and Hearing Loss\u003c/p\u003e\n\u003cp\u003eAs indicated in Table 4. A significant correlation was identified between the severity of cochlear hydrops and hearing threshold levels across all frequencies, with all p-values less than 0.05. The correlation was most pronounced with low-frequency average hearing levels (0.15-0.50 KHz) (r=0.462, p \u0026lt; 0.05), and least pronounced with high-frequency average hearing levels (4-8KHz) (r=0.261, p \u0026lt; 0.05). Significant correlations were also observed with the PA (0.5-4KHz) (r=0.383) and Meniere\u0026rsquo;s disease staging (MDS) (r=0.307).\u003c/p\u003e\n\u003cp\u003eTable 4. The relationship between the degree of cochlear hydrops and hearing loss\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"567\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.964539007092198%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.1914893617021276%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.624113475177305%\" valign=\"top\"\u003e\n \u003cp\u003e150\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.801418439716312%\" valign=\"top\"\u003e\n \u003cp\u003e250\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.801418439716312%\" valign=\"top\"\u003e\n \u003cp\u003e500\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.624113475177305%\" valign=\"top\"\u003e\n \u003cp\u003e1k\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.624113475177305%\" valign=\"top\"\u003e\n \u003cp\u003e2k\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.624113475177305%\" valign=\"top\"\u003e\n \u003cp\u003e4k\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.624113475177305%\" valign=\"top\"\u003e\n \u003cp\u003e8k\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.624113475177305%\" valign=\"top\"\u003e\n \u003cp\u003eLH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.624113475177305%\" valign=\"top\"\u003e\n \u003cp\u003eMH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.624113475177305%\" valign=\"top\"\u003e\n \u003cp\u003eHH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.624113475177305%\" valign=\"top\"\u003e\n \u003cp\u003ePA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.624113475177305%\" valign=\"top\"\u003e\n \u003cp\u003eMDS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.964539007092198%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.1914893617021276%\" valign=\"top\"\u003e\n \u003cp\u003er\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.624113475177305%\" valign=\"top\"\u003e\n \u003cp\u003e0.433\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.801418439716312%\" valign=\"top\"\u003e\n \u003cp\u003e0.453\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.801418439716312%\" valign=\"top\"\u003e\n \u003cp\u003e0.443\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.624113475177305%\" valign=\"top\"\u003e\n \u003cp\u003e0.379\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.624113475177305%\" valign=\"top\"\u003e\n \u003cp\u003e0.316\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.624113475177305%\" valign=\"top\"\u003e\n \u003cp\u003e0.242\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.624113475177305%\" valign=\"top\"\u003e\n \u003cp\u003e0.252\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.624113475177305%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.462\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.624113475177305%\" valign=\"top\"\u003e\n \u003cp\u003e0.368\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.624113475177305%\" valign=\"top\"\u003e\n \u003cp\u003e0.261\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.624113475177305%\" valign=\"top\"\u003e\n \u003cp\u003e0.383\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.624113475177305%\" valign=\"top\"\u003e\n \u003cp\u003e0.307\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"3.3582089552238807%\" valign=\"top\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.022388059701493%\" valign=\"top\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.208955223880597%\" valign=\"top\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.208955223880597%\" valign=\"top\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.022388059701493%\" valign=\"top\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.022388059701493%\" valign=\"top\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.022388059701493%\" valign=\"top\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.022388059701493%\" valign=\"top\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.022388059701493%\" valign=\"top\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.022388059701493%\" valign=\"top\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.022388059701493%\" valign=\"top\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.022388059701493%\" valign=\"top\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.022388059701493%\" valign=\"top\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 4 outlines the Spearman correlation coefficients (r) and p-values (p) assessing the relationship between the degree of cochlear hydrops(CL) and hearing loss across various frequencies (150 Hz to 8 kHz), also including low-frequency (LH), mid-frequency (MH), high-frequency (HH) hearing levels,\u0026nbsp;the overall hearing level\u0026nbsp;(PA), and he degree of CL and Meniere\u0026rsquo;s disease staging (MDS). Significant correlations indicate a strong relationship between CL and hearing impairment across all tested frequencies and MDS.\u003c/p\u003e\n\u003cp\u003e3.4.2 Vestibular Hydrops and Hearing Loss\u003c/p\u003e\n\u003cp\u003eAs indicated in Table 5, significant correlation was noted between the severity of vestibular hydrops and hearing threshold levels across all frequencies, with all p-values less than 0.05. The strongest correlation was observed with low-frequency average hearing levels (0.15-0.50KHz) (r=0.468, p \u0026lt; 0.05), and the weakest with high-frequency average hearing levels (4-8KHz) (r=0.314, p \u0026lt; 0.05). Significant correlations were further noted with PA (0.5-4KHz) (r=0.464) and Meniere\u0026rsquo;s disease staging (MDS) (r=0.436).\u003c/p\u003e\n\u003cp\u003eTable 5. The relationship between the degree of vestibular hydrops and hearing loss\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"566\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.761904761904762%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.821869488536155%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.583774250440917%\" valign=\"top\"\u003e\n \u003cp\u003e150\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.583774250440917%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e250\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.583774250440917%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e500\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.583774250440917%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e1k\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.583774250440917%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e2k\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.583774250440917%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e4k\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.583774250440917%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e8k\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.583774250440917%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eLH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.583774250440917%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eMH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.583774250440917%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eHH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.583774250440917%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003ePA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.583774250440917%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eMDS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"1.4109347442680775%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.728546409807356%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.8021015761821366%\" valign=\"top\"\u003e\n \u003cp\u003eR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.705779334500876%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.393\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.705779334500876%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.453\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.705779334500876%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.495\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.705779334500876%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.482\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.705779334500876%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.368\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.705779334500876%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.304\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.705779334500876%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.277\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.705779334500876%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.468\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.705779334500876%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.455\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.705779334500876%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.314\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.705779334500876%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.464\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.705779334500876%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.436\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"2.9411764705882355%\" valign=\"top\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.088235294117647%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.088235294117647%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.088235294117647%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.088235294117647%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.088235294117647%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.088235294117647%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.088235294117647%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.088235294117647%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.088235294117647%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.088235294117647%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.088235294117647%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.088235294117647%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.432624113475177%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"3.900709219858156%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"7.446808510638298%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"0.1773049645390071%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"7.446808510638298%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"0.1773049645390071%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"7.2695035460992905%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"0.3546099290780142%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"7.092198581560283%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"0.5319148936170213%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"7.092198581560283%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"0.5319148936170213%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"6.914893617021277%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"0.7092198581560284%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"6.73758865248227%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"0.8865248226950354%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"6.73758865248227%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"0.8865248226950354%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"6.560283687943262%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"1.0638297872340425%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"6.382978723404255%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"1.2411347517730495%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"6.382978723404255%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"1.4184397163120568%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"6.205673758865248%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"1.4184397163120568%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 5 details the Spearman correlation coefficients (r) and p-values (p) evaluating the association between the degree of vestibular hydrops(VL) and hearing loss at different frequencies (150 Hz to 8 kHz), also encompassing including low-frequency (LH), mid-frequency (MH), high-frequency (HH) hearing levels, the overall hearing level (PA). And the association between the CL and Meniere\u0026rsquo;s disease staging (MDS). Significant correlations indicate strong relationships between VL and hearing impairment and MDS.\u003c/p\u003e\n\u003cp\u003e3.4.3 The Overall Endolymphatic Hydrops and Hearing Loss\u003c/p\u003e\n\u003cp\u003eAs shown in Table 6, significant correlation was established between the comprehensive degree of endolymphatic hydrops and hearing threshold levels across all frequencies, with all p-values less than 0.05. The most substantial correlation was with low-frequency average hearing levels (0.15-0.50KHz) (r=0.571, p \u0026lt; 0.05), and the least substantial with high-frequency average hearing levels (4-8KHz) (r=0.351, p \u0026lt; 0.05). Significant correlations were also seen with PA (0.5-4KHz) (r=0.522) and Meniere\u0026rsquo;s disease staging (MDS) (r=0.463).\u003c/p\u003e\n\u003cp\u003eTable 6. The relationship between the degree of\u0026nbsp;endolymphatic\u0026nbsp;hydrops and hearing loss\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"567\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"3.368794326241135%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.0141843971631204%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.801418439716312%\" valign=\"top\"\u003e\n \u003cp\u003e150\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.801418439716312%\" valign=\"top\"\u003e\n \u003cp\u003e250\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.801418439716312%\" valign=\"top\"\u003e\n \u003cp\u003e500\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.801418439716312%\" valign=\"top\"\u003e\n \u003cp\u003e1k\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.801418439716312%\" valign=\"top\"\u003e\n \u003cp\u003e2k\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.801418439716312%\" valign=\"top\"\u003e\n \u003cp\u003e4k\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.801418439716312%\" valign=\"top\"\u003e\n \u003cp\u003e8k\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.801418439716312%\" valign=\"top\"\u003e\n \u003cp\u003eLH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.801418439716312%\" valign=\"top\"\u003e\n \u003cp\u003eMH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.801418439716312%\" valign=\"top\"\u003e\n \u003cp\u003eHH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.801418439716312%\" valign=\"top\"\u003e\n \u003cp\u003ePA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.801418439716312%\" valign=\"top\"\u003e\n \u003cp\u003eMDS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"3.368794326241135%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.0141843971631204%\" valign=\"top\"\u003e\n \u003cp\u003eR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.801418439716312%\" valign=\"top\"\u003e\n \u003cp\u003e0.503\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.801418439716312%\" valign=\"top\"\u003e\n \u003cp\u003e0.555\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.801418439716312%\" valign=\"top\"\u003e\n \u003cp\u003e0.579\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.801418439716312%\" valign=\"top\"\u003e\n \u003cp\u003e0.532\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.801418439716312%\" valign=\"top\"\u003e\n \u003cp\u003e0.418\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.801418439716312%\" valign=\"top\"\u003e\n \u003cp\u003e0.333\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.801418439716312%\" valign=\"top\"\u003e\n \u003cp\u003e0.324\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.801418439716312%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.571\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.801418439716312%\" valign=\"top\"\u003e\n \u003cp\u003e0.508\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.801418439716312%\" valign=\"top\"\u003e\n \u003cp\u003e0.351\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.801418439716312%\" valign=\"top\"\u003e\n \u003cp\u003e0.522\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.801418439716312%\" valign=\"top\"\u003e\n \u003cp\u003e0.463\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"3.1192660550458715%\" valign=\"top\"\u003e\n \u003cp\u003eP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.073394495412844%\" valign=\"top\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.073394495412844%\" valign=\"top\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.073394495412844%\" valign=\"top\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.073394495412844%\" valign=\"top\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.073394495412844%\" valign=\"top\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.073394495412844%\" valign=\"top\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.073394495412844%\" valign=\"top\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.073394495412844%\" valign=\"top\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.073394495412844%\" valign=\"top\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.073394495412844%\" valign=\"top\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.073394495412844%\" valign=\"top\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.073394495412844%\" valign=\"top\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 6 presents the Spearman correlation coefficients (r) and p-values (p) illustrating the correlation between the overall degree of endolymphatic hydrops (EHL) and hearing loss at various frequencies (150 Hz to 8 kHz), also including assessments of low-frequency (LH), mid-frequency (MH), high-frequency (HH) hearing levels, the overall hearing level (PA). And the association between the EHL and Meniere\u0026rsquo;s disease staging (MDS). Statistically significant correlations underscore the profound impact of EHL on hearing across and MDS.\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis study was undertaken to elucidate the association between the features of endolymphatic hydrops and hearing loss in patients diagnosed with Bilateral Meniere's Disease (BMD), a disorder that significantly undermines the quality of life through bilateral vestibular dysfunction and hearing loss. The findings from our investigation revealed a robust correlation between the severity of the overall endolymphatic hydrops, cochlear hydrops, and vestibular hydrops in bilateral Meniere's disease with hearing loss across all frequencies, particularly pronounced in the low to mid-frequency ranges. Existing literature on the correlation between the severity of endolymphatic hydrops and hearing loss has yielded inconsistent results. While a consensus exists among several studies that the severity of cochlear and vestibular hydrops is correlated with hearing loss (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan additionalcitationids=\"CR17 CR18\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e), this concurs with our findings. However, certain studies posit that the severity of vestibular hydrops bears no relation to the extent of hearing loss(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e), a conclusion at odds with our findings. Such disparities may be attributable to the limited sample sizes in various studies, individual variances among patients, and the disparities in MRI imaging techniques and grading methodologies for vestibular and cochlear hydrops across different clinical settings(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). For example, disparities in cochlear hydrops grading methods were noted to produce varied correlation coefficient with hearing loss(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis study found that the severity of bilateral Meniere's Disease (MD) endolymphatic hydrops and MD staging are correlated, which partially diverges from the conclusions of the study(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). That study posited that traditional MD staging does not correlate with the degree of endolymphatic hydrops (EH) visible on MRI, although advanced staging of MD may indicate increased severity of cochlear and vestibular EH. Furthermore, it was observed that, within the same patient, ears afflicted with both vestibular and cochlear hydrops manifested more severe hearing loss and MD staging compared to those with isolated cochlear hydrops or vestibular hydrops, suggesting that isolated vestibular or cochlear hydrops may represent an earlier stage of the disease. This underscores the importance of continuous follow-up in clinical practice for such patients to monitor disease progression and identify influencing factors.\u003c/p\u003e \u003cp\u003eThe novelty of our study lies in its focus on BMD to enhance the extant body of evidence on the correlation between the severity of endolymphatic hydrops and hearing loss in bilateral Meniere's disease. Moreover, a distinguishing feature of our study is the employment of novel methodologies for determining the grades of cochlear and vestibular hydrops. Utilizing the latest grading method proposed by G\u0026uuml;rkov et al (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) for cochlear hydrops, which classifies the condition into grades 0 through 3, which demonstrated the highest correlation with the degree of hearing loss in this study compared other grades methods(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). For vestibular grading, following the criteria outlined by BERNAERTS et al(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), vestibular hydrops was categorized into grades 0 through 3, with grade 1 identified as saccular expansion surpassing the utricle's area, thereby facilitating the early diagnosis of vestibular hydrops(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). The findings from our study underscored a strong correlation between the severity of vestibular hydrops and hearing loss, thereby validating the scientific robustness of the grading method mentioned above. Finally, by amalgamating the grades of vestibular and cochlear hydrops, the overall severity of endolymphatic hydrops in the affected ear was represented. It was concluded that the aggregate severity of hydrops, encompassing both endolymphatic and cochlear hydrops, exhibited a stronger correlation with hearing loss. This suggests that such an approach enhances the accuracy in assessing the correlation between endolymphatic hydrops and hearing loss, considering the impact of both vestibular and cochlear involvement on hearing.\u003c/p\u003e \u003cp\u003eThe limitations of this study include its reliance on specific imaging techniques for assessing endolymphatic hydrops, which may not be universally accessible or standardized across healthcare facilities. Additionally, the retrospective design of the study precludes the direct inference of causality. Future research should endeavor to standardize imaging protocols for the diagnosis of endolymphatic hydrops and conduct prospective studies to gain a more comprehensive understanding of the progression of BMD and the factors influencing hearing loss. Such endeavors aim to refine treatment modalities for patients afflicted with this condition.\u003c/p\u003e \u003cp\u003eIn conclusion, the findings of this research into the correlation between the characteristics of endolymphatic hydrops and hearing loss in BMD contribute to an enhanced comprehension of the syndrome, particularly by focusing on the distinct clinical features of BMD. This lays the foundation for subsequent research directed at improving the quality of life for those affected by this debilitating condition.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eThe degree of endolymphatic hydrops in affected ears of patients with Bilateral Meniere's Disease was found to correlate with the severity of hearing loss and the staging of Meniere's disease. The degree of endolymphatic hydrops positively correlated with hearing loss across all frequencies, with the strongest correlation observed in low-frequency hearing loss and the weakest in high-frequency hearing loss, and the overall degree of endolymphatic hydrops and hearing loss has the strongest correlation between hearing loss. Patients with both vestibular and cochlear hydrops exhibited more severe hearing loss and staging of MD than those with isolated hydrops.\u003c/p\u003e"},{"header":"Abbreviations","content":" \u003cp\u003eMeniere's Disease (MD)\u003c/p\u003e \u003cp\u003eEndolymphatic hydrops(EH)\u003c/p\u003e \u003cp\u003eUnilateral Meniere's Disease(UMD)\u003c/p\u003e \u003cp\u003eBilateral Meniere's Disease (BMD)\u003c/p\u003e \u003cp\u003ePure Tone Audiometry (PTA)\u003c/p\u003e \u003cp\u003eMagnetic resonance imaging (MRI)\u003c/p\u003e \u003cp\u003egadolinium-enhanced inner ear magnetic resonance imaging (Gd-enhanced MRI)\u003c/p\u003e \u003cp\u003ethree-dimensional real inversion recovery sequences (3D-real-IR)\u003c/p\u003e \u003cp\u003elow-frequency hearing level (LH)\u003c/p\u003e \u003cp\u003emid-frequency hearing level (MH)\u003c/p\u003e \u003cp\u003ehigh-frequency hearing level (HH)\u003c/p\u003e \u003cp\u003eoverall hearing level (PA)\u003c/p\u003e \u003cp\u003ecochlear hydrops (CL)\u003c/p\u003e \u003cp\u003eVestibular hydrops (VL)\u003c/p\u003e \u003cp\u003eendolymphatic hydrops (EHL)\u003c/p\u003e \u003cp\u003eMeniere's disease staging (MDS)\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Approval\u003c/strong\u003e：\u0026nbsp;The ethical committee of the Eye and ENT Hospital at Fudan University approved this study (#2023128).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e：\u0026nbsp;I confirm that I have obtained consent from all participants for the publication of the content of this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e：\u0026nbsp;The data in this study are clinical in nature and therefore cannot be publicly disclosed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest and Source of Funding\u003c/strong\u003e\u003cstrong\u003e：\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eThe authors declare no financial interests in the present study and have no potential conflicts of interest to disclose.This study received support from the National Natural Science Foundation of China (Nos. 82101222) and the Natural Science Foundation of Shanghai (No. 20ZR1409600).\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContribution\u003c/strong\u003e：\u0026nbsp;XL contributed to the conceptualization, methodology, and supervision of the study. DW was responsible for data curation, formal analysis, and writing the original draft. Yue-Lin Hsieh conducted the investigation, validation, and visualization of the results. SS managed resources, and project administration, and contributed to the writing, review, and editing of the manuscript. WW provided software support, secured funding for the study, and contributed to the writing, review, and editing of the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eRizk HG, Mehta NK, Qureshi U, Yuen E, Zhang K, Nkrumah Y, et al. Pathogenesis and Etiology of M\u0026eacute;ni\u0026egrave;re Disease: A Scoping Review of a Century of Evidence. 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Correlation between magnetic resonance imaging classification of endolymphatic hydrops and clinical manifestations and audiovestibular test results in patients with definite M\u0026eacute;ni\u0026egrave;re's disease. Auris Nasus Larynx. 2022;49(1):34\u0026ndash;45. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.anl.2021.03.027\u003c/span\u003e\u003cspan address=\"10.1016/j.anl.2021.03.027\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 20210415.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"head-and-face-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"hafm","sideBox":"Learn more about [Head \u0026 Face Medicine](http://head-face-med.biomedcentral.com)","snPcode":"13005","submissionUrl":"https://submission.nature.com/new-submission/13005/3","title":"Head \u0026 Face Medicine","twitterHandle":"@HeadNeckMed","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Endolymphatic Hydrops, Bilateral Meniere’s Disease, Hearing Loss, Inner Ear Gadolinium-enhanced MRI","lastPublishedDoi":"10.21203/rs.3.rs-4665048/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4665048/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThis study aimed to investigate the relationship between the features of endolymphatic hydrops and hearing loss in patients with Bilateral Meniere's Disease.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA retrospective analysis was conducted on 77 patients diagnosed with Bilateral Meniere's Disease. The features of endolymphatic hydrops in the affected ear were evaluated through gadolinium-enhanced inner ear Magnetic resonance imaging. The Spearman correlation coefficient, paired t-tests, and Wilcoxon signed-rank tests were employed for data analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe analysis revealed a significant correlation between the degree of endolymphatic hydrops and hearing loss across all frequencies(0.125-8 kHz), including the cochlear, vestibular, and overall degree of endolymphatic hydrops. The strongest correlation between the overall degree of endolymphatic hydrops and hearing loss was observed at low frequencies (r\u0026thinsp;=\u0026thinsp;0.571, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), followed by mid-frequencies (r\u0026thinsp;=\u0026thinsp;0.508, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), and high-frequencies (r\u0026thinsp;=\u0026thinsp;0.351, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), with a correlation of r\u0026thinsp;=\u0026thinsp;0.463, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 for the staging of Meniere's disease. Affected Ears with endolymphatic hydrops both in the cochlea and vestibule exhibited more severe hearing loss and Meniere's disease staging compared to those with isolated endolymphatic hydrops within the same patient.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe features of endolymphatic hydrops in patients with Bilateral Meniere's Disease were found to correlate with the severity of hearing loss and the staging of Meniere's disease.\u003c/p\u003e","manuscriptTitle":"The Relationship between Endolymphatic Hydrops Features and Hearing Loss in Bilateral Meniere's Disease","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-26 17:01:31","doi":"10.21203/rs.3.rs-4665048/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-08-02T16:44:43+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-02T15:43:16+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-02T14:57:28+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-30T18:37:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"297226248704163081058409087366664236437","date":"2024-07-25T15:01:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"117390789485759040508506876286071502841","date":"2024-07-24T16:17:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"75494866773006147557439727907521450658","date":"2024-07-23T14:24:28+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-07-06T07:46:07+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-03T06:57:14+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-03T06:55:56+00:00","index":"","fulltext":""},{"type":"submitted","content":"Head \u0026 Face Medicine","date":"2024-07-01T03:36:04+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"head-and-face-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"hafm","sideBox":"Learn more about [Head \u0026 Face Medicine](http://head-face-med.biomedcentral.com)","snPcode":"13005","submissionUrl":"https://submission.nature.com/new-submission/13005/3","title":"Head \u0026 Face Medicine","twitterHandle":"@HeadNeckMed","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"949748bf-ac68-466e-a13a-aeec0b552bfd","owner":[],"postedDate":"July 26th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-09-23T16:08:37+00:00","versionOfRecord":{"articleIdentity":"rs-4665048","link":"https://doi.org/10.1186/s13005-024-00455-9","journal":{"identity":"head-and-face-medicine","isVorOnly":false,"title":"Head \u0026 Face Medicine"},"publishedOn":"2024-09-16 15:57:46","publishedOnDateReadable":"September 16th, 2024"},"versionCreatedAt":"2024-07-26 17:01:31","video":"","vorDoi":"10.1186/s13005-024-00455-9","vorDoiUrl":"https://doi.org/10.1186/s13005-024-00455-9","workflowStages":[]},"version":"v1","identity":"rs-4665048","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4665048","identity":"rs-4665048","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}