Blood Pressure, 2015; 24: 199–205

REVIEW ARTICLE

Hypertension and cochlear hearing loss

TOMASZ PRZEWOŹNY1, ANNA GÓJSKA-GRYMAJŁO2, MARIUSZ KWARCIANY2,

DARIUSZ GĄSECKI2 & KRZYSZTOF NARKIEWICZ3

Departments of 1Otolaryngology, 2Neurology of Adults, and 3Hypertension and Diabetology,

Medical University of Gdańsk, Gdańsk, Poland
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Abstract
This paper presents a review of experimental and clinical research on the contribution of hypertension to cochlear hearing
loss. Hypertension is one of the crucial risk factors underlying pathophysiological processes taking place in the cochlea.
Several mechanisms explaining these processes have been described, mainly in animal models, such as the disturbance
of the inner ear potassium recycling process due to the detrimental action of natriuretic hormone, and the decrease in
the cochlear oxygen partial pressure. Current evidence linking hypertension to sensorineural high-frequency cochlear
hearing loss in humans may be confounded by other concomitant diseases or risk factors such as age, coronary artery
disease, diabetes, obesity, hyperlipidemia, smoking and noise exposure. Therefore, further research in this field is clearly
needed.
For personal use only.

Key Words: Cochlear hearing loss, hypertension, inner ear diseases

Introduction Clinical studies

Hypertension is one the most common chronic dis-
eases in adults. In the year 2000, it was found in
26.4% of the world’s adult population, and the per-
centage is predicted to rise to 29.2% by 2025. The
incidence of hypertension, similarly to hearing def-
icit, increases with age (1,2). Impairment of
cochlear function is mentioned among other com-
plications of hypertension such as myocardial
infarction, stroke, retinopathy and nephropathy
(3–5). It is assessed that there are 360 million
people in the world with disabling hearing loss
(5.3% of the world’s population) (6). In the USA
there were 29 million people (16.1% of the adult
population) with hearing loss in 2004. In 2006, this
number was assessed to reach 36 million and the
main risk factors mentioned were smoking, noise
exposure and cardiovascular risk factors (7,8). In
this paper, we review the most important experi-
mental and clinical studies that have reported on
the influence of hypertension on hearing loss in the
past 50 years.
Hearing loss and hypertension
A hypothesis on the detrimental effect of hyperten-
sion on cochlear and vestibular systems in humans
was developed early in the twentieth century (3,9–
11). Since then, many studies have been conducted,
with contradictory results. In a study by Baraldi et al.
(12), conducted in elderly people, the degree of hear-
ing loss was similar in the normotensive and the
hypertensive groups; however, the audiometric con-
figuration in the hypertensive group was different
from the non-hypertensive group. Torre et al. (13)
evaluated the relationship between self-reported
cardiovascular disease and cochlear function in
1501 older adults. Cochlear function was measured
using distortion product otoacoustic emissions
(OAEs). The only statistically significant correlation
found was that women with a self-reported history
of myocardial infarction were twice as likely to have
cochlear impairment as women without such a
history. No other cardiovascular risk factors were

Correspondence: Tomasz Przewoźny, Department of Otolaryngology, Medical University of Gdańsk, Smoluchowskiego 17 Str., 80-214 Gdańsk, Poland.
Tel. ⫹ 48 58 349 31 10. E-mail: tprzew@gumed.edu.pl

(Received 5 February 2015 ; accepted 17 April 2015)

ISSN 0803-7051 print/ISSN 1651-1999 online © 2015 Scandinavian Foundation for Cardiovascular Research
DOI: 10.3109/08037051.2015.1049466
 200 T. Przewoźny et al.
associated with cochlear impairment. On the other
hand, de Moraes Marchiori et al. (14) studied pure-
tone audiometry results and blood pressure measure-
ments in middle-aged people (45–64 years of age).
In a group of subjects with hearing loss, 46.8% had
hypertension, which was found in only 29.9% of sub-
jects with normal hearing. The type of hearing loss
(mild sensorineural) was similar in both groups.
Regression analysis showed arterial hypertension,
advanced age and male gender to be independent
risk factors for the hearing loss. Similarly, Agarwal
et al. (15) compared the hearing of 150 hypertensive
patients with that of 124 healthy volunteers. They
concluded that hypertensive patients with blood
pressure over 180/110 mmHg had worse hearing
thresholds in high frequencies. Similar findings were
obtained by Gates et al. (16). Moreover, they found
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a correlation between hypertension and low-fre-
quency hearing loss in women. Tan et al. (17) studied
the influence of hypertension on hearing in patients
with hypertensive retinopathy. They confirmed statis-
tically significant impairment of hearing thresholds
in hypertensive patients for 2, 4 and 8 kHz frequen-
cies in comparison with the control group. Further-
more, they found worse results for the hearing
threshold for 4 and 8 kHz frequencies in patients
For personal use only.
with grade I retinopathy in comparison with hyper-
tensive patients without retinal pathology and with a
control group. The authors suggested that it is the
hypertensive microangiopathy in the cochlear and
retinal vessels that causes hearing and eyesight loss,
respectively. Similarly, Esparza et al. (18) compared
inner ear and retinal function in hypertensive patients
(29–64 years of age) and in healthy subjects. Hyper-
tensive subjects had worse hearing for 8 kHz and
worse evoked OAE results. Over 60% of the hyper-
tensive patients had retinopathy that correlated pos-
itively with worse hearing threshold and with lack of
response from the hair cells in OAE for frequencies
of 4–8 kHz. From these results, it seems reasonable
to refer a hypertensive patient with retinal angiopathy
for audiometric tests. Results of the clinical studies
on hearing loss due to hypertension alone are incon-
sistent, although it seems significant that high-fre-
quency sensorineural hearing loss is predictable
among patients with hypertension.
Impact of other cardiovascular risk factors
Hypertension often coexists with other risk factors
such as type 2 diabetes and dyslipidemia. These mul-
tifactorial inheritance chronic disorders (MICDs)
develop through the interaction of environmental
and epigenetic factors. Moreover, each of the dis-
eases increases the risk of the other conditions, and
their effect on target organs seems to be synergistic.
The effect of MICDs on cochlear and vestibular dys-
function was assessed by Chávez-Delgado et al. (19),
who studied a group of 385 patients with MICDs
with use of the tone audiometry and electronystag-
mography. Hearing loss was as common in the group
of hypertensive patients as in the group with hyper-
tension, type 2 diabetes and dyslipidemia. It was also
found that cochlear dysfunction was more common
than cochleovestibular impairment in all of the
MICD patients.
Chen and Ding (20) found that hypertension
together with hyperlipidemia worsens the hearing of
elderly people. Friedland et al. (21) planned to con-
firm the correlation between cardiovascular risk fac-
tors and hearing loss in low frequencies by means
of tone audiometry. A group of 1168 smoking
patients with hypertension, diabetes and hyperlipi-
demia was studied. In this study, slope type hearing
loss, which begins in 0.5–2 kHz frequencies and is
more profound in high frequencies, was inade-
quately reported as low-frequency hearing loss. This
can be misleading since most scientists associate
these comorbidities with high-frequency hearing
loss. In multivariate regression analysis, hyperten-
sion correlated with the above-mentioned hearing
loss and with another type of audiometric configu-
ration called “strial”, i.e. ⱖ 25 dB hearing loss
between 0.5 and 2 kHz with ⱕ 15 dB variability,
combined with disturbance of the stria vascularis.
The authors recommended that patients with these
two types of audiogram should be followed up for
cardiovascular risk factors.
Agrawal et al. (7) assessed the effect of microvas-
cular risk factors on hearing in a large group of 3853
American subjects. Hypertension was found in 27%
of the subjects and turned out to be a weak risk fac-
tor, and hearing loss was found only in the range
around 1 kHz. A larger population of 26,917 men
(40–74 years of age) including 3488 cases of hearing
loss was studied by Shargorodsky et al. (22), who did
not find statistically significant correlations between
hypertension, diabetes, obesity and hearing impair-
ment. In this study, the multivariate regression
analysis proved statistically significant only hyperc-
holesterolemia and smoking. In another study, hear-
ing loss was assessed in 12 patients with hypertension
and diabetes (average blood pressure 146/78 mmHg)
and in 10 normotensive patients with diabetes (23).
All patients were tested with tonal audiometry includ-
ing air and bone conduction, speech reception
threshold and speech discrimination score. In each
frequency (0.25–8 kHz), there was a significant
increase in the hearing loss between the normotensive
and the hypertensive insulin-dependent diabetics.
However, patients with hypertension and diabetes
were 15 years older than those with normal blood
pressure. When age was taken into consideration
and the results were re-evaluated, a weak, although
statistically significant, difference was found only
in frequencies of 4–8 kHz (p ⫽ 0.048). The average
speech reception threshold of the normotensive
insulin-dependent diabetics was 11 ⫾ 2.69 dB and

that of the hypertensive insulin-dependent diabetics
was 26.67 ⫾ 4.48 dB (23).
In people above 60 years of age, hearing loss is
often accompanied by tinnitus. Sometimes it is the
tinnitus that prompts patients with unrecognized
hypertension to visit their general practitioner or
otolaryngologist. Gibrin et al. (24) studied tinnitus
in patients with hypertension and diabetes, and
found that only the comorbidity of diabetes mellitus
and hypertension was an independent risk factor for
tinnitus. In hypertensive patients with other cardio-
vascular risk factors such as diabetes and hyper-
lipidemia, high-frequency sensorineural hearing
loss spreads also to medium and low frequencies.
This has a crucial influence on understanding
speech.
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Hearing loss and age
Age is the most important risk factor for hearing loss.
Many authors emphasize that presbyacusis has the
same audiometric characteristics as hearing loss due
to hypertension: high-frequency bilateral and sym-
metrical sensorineural hearing loss. Some authors
introduce corrections on age in their analyses of
For personal use only.
hearing loss; however, changes caused by aging can
be individually different (25–29). Thus, it is very
difficult to discriminate the hearing loss component
dependent on hypertension in elderly people. How-
ever, certain studies have shown that cochlear dys-
function is too profound to be caused only by aging
in hypertensive patients (18,19). In addition, in
another study of elderly people, low cardiovascular
fitness was correlated with lower hearing threshold
in frequencies of 2 kHz and 4 kHz (30). In a study
on patients with ischemic stroke, the pathophysiol-
ogy of which is strictly related to vascular risk factors
such as hypertension, age above 60 years was a
crucial risk factor for sensorineural hearing loss (5).
Figure 1. Pure-tone audiometry of a 45-year-old patient with a 7 year history of hypertension: (A) right ear; (B) left ear. Bilateral
sensorineural, high-frequency and symmetric hearing loss is present. ⚪, ⫻, air conduction; ⬎, ⬍, bone conduction.
Hypertension and cochlear hearing loss 201
Cochlear presbyacusis is symmetrical high-
frequency sensorineural hearing loss caused by
physiological aging of the cochlea. Hypertension
seems to augment this process, as illustrated in
Figure 1, which presents an audiogram of a 45-year-
old patient with hypertension.
Hearing loss and noise
Since a multifactorial etiology of hearing loss seems
to be most probable, many studies have been con-
ducted to determine the possible correlations and/or
additive effects of hypertension and noise. Transient
noise exposure causes reversible changes in the vas-
cular system and in the cochlea, and chronic expo-
sure intensifies these changes significantly (31–34).
It has also been found that deaf–mute children have
lower blood pressure than their normal hearing age-
mates (35). Multiple regression analysis revealed that
body mass index, age and hearing ability explained
a significant amount of the variation in blood pres-
sure range in these children. On the basis of these
results, it was suggested that noise exposure is asso-
ciated with higher systolic and diastolic blood pres-
sure. A surprising finding of Malinow et al. (36) was
an increase in blood pressure in deaf people who
sign. This study suggests independence of this com-
munication method from vocalization, which has a
substantial influence on the cardiovascular system.
The evidence linking chronic noise exposure to
human hypertension (16,27,29,32,37,38) is consis-
tent with previous reports from animal studies
(39,40). However, Hirai et al. (41), who conducted
a study on a large group of 2124 factory workers,
could not find a correlation between increased blood
pressure and noise exposure at work. The authors
explained that their observations could be due to
adaptation of workers to chronic noise. They also
suggested that stress caused by noise might induce
 202 T. Przewoźny et al.
hypertension only if a genetic predisposition for
hypertension was present. Several other studies also
failed to find an independent correlation between
noise exposure and elevated blood pressure (42–45).
Results of a study by Zhao et al. (46) in 1101 female
workers in a textile mill in Beijing, China, indicated
that cumulative exposure to noise, as measured by
years worked in a particular noise environment, did
not predict the risk of hypertension. Belli et al. (47)
studied hypertension in over 400 textile factory
workers exposed to noise of over 100 dB and in
workers not exposed to noise. No difference was
found in the number of subjects with hypertension
between the two groups; however, hypertension was
more advanced in noise-exposed workers.
Other studies have investigated the combined
effect of hypertension and noise on hearing loss. In
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a study by Ni et al. (48), an increased risk of high-
frequency hearing loss was found in noise-exposed
women with low artery compliance. Tarter and
Robins (49) reported correlations between hyperten-
sion, 4 kHz hearing loss and long-term (minimum
5 years) work in noise of over 85 dB, only in African-
Americans. This correlation was not found in Cau-
casian workers. Industrial and environmental noise
can simultaneously cause damage to the organ of
For personal use only.
Corti and increase blood pressure through the mech-
anism of stress. In a study comparing long-distance
and city bus drivers, hypertension was three times
more common in the former group, and was associ-
ated with 0.25–2 kHz hearing loss, especially in the
left ear. These differences were attributed to higher
stress levels in the long-distance bus drivers, but the
contribution of noise exposure on the side of the
usually opened window of the driver’s cab was not
ruled out (50).
Idiopathic sudden sensorineural hearing loss
Two of the authors of this review (TP and DG)
proved in multivariate stepwise linear regression that
hypertension is a crucial risk factor in sensorineural
hearing loss in patients with ischemic cerebral stroke
(5). However, this seems not to be true for idiopathic
sudden sensorineural hearing loss (ISSHL), as
studied by Chang et al. (51). In that study, ISSHL
was not associated with an increased stroke risk,
although both disorders have similar vascular etiol-
ogy. In another study, ISSHL was statistically more
common in patients with diabetes and hypercholes-
terolemia; however, hypertension alone was not
linked to an increased risk of this type of hearing loss
(52). Duck et al. (23) observed cerebral microan-
giopathy in patients with ISSHL and hypertension;
however, these patients also had diabetes and hyper-
lipidemia and were of older age. Similarly, Nagaoka
et al. (53) found that ISSHL correlates with higher
rates of cerebral microangiopathy (85%) and slower
improvement of speech understanding in older
patients with hypertension, diabetes and hyper-
lipidemia. Hirano et al. (54) found that the results of
treatment of ISSHL in patients with coexisting
microangiopathic diseases (hypertension, diabetes
and hyperlipidemia) were worse than in patients
without these comorbidities; however, the latter group
was younger. In the study by Mosnier et al. (55),
hypertension, diabetes, hyperlipidemia and cigarette
smoking were not related to the risk of ISSHL. While
hypertension causes bilateral sensorineural hearing
loss, ISSHL is commonly connected with unilateral
sensorineural hearing loss. However, there are some
single reports on ISSHL observed after a sudden
reduction in blood pressure (56,57). The possible
cause of hearing loss in such cases could be an asym-
metrical cochlear ischemia. Chao (56) reported a
case of a 46-year-old woman with malignant hyper-
tension who presented “cookie bite” low-frequency
hearing loss when her blood pressure was lowered
from 237/144 mmHg to 155/85 mmHg with an
infusion of sodium nitroprusside.
Animal studies
In the early 1960s, a new strain of genetically modi-
fied rats with many similarities to humans was
created, named spontaneously hypertensive (SH)
rats (58,59). In the 1980s, Borg (60) documented a
deterioration in high-frequency hearing sensitivity in
older SH rats in comparison with normotensive
animals. Because of the physiology of the rodents’
hearing and the difference in frequencies of hearing
tested, direct transposition of the results to humans
is difficult. However, Borg (61) showed that exposure
to high-frequency noise of 100 dB causes much
greater loss of cochlear hair cells in SH rats than in
normotensive ones. Moreover, he compared the
influence of noise on SH rats with rats with hyperten-
sion induced by renal artery occlusion and with a
control group (62). SH rats had significantly larger
hearing loss in comparison with other strains. The
duration of induced hypertension was too short to
cause substantial vascular damage in rats with renal
artery occlusion. Axelsson et al. (63) also studied
noise exposure in SH rats. It was reported that 100
dB noise lasting for 10 h caused constriction of pre-
capillary sphincters in radial arterioles and thus a
reduction in blood flow. This phenomenon took place
in both hypertensive and normotensive animals, but
was more pronounced in the hypertensive group.
One possible explanation given for this difference
was vascular damage due to the preceding presence
of vascular factors such as hypertension. Pillsbury
(64) studied the synergistic influence of hyperten-
sion, atherogenic diet and noise exposure on hearing
in rats. Hypertension and atherogenic diet alone did
not cause substantial hearing loss of 4, 8 and 20 kHz

frequencies. However, SH rats that were exposed to
95 dB noise and were fed an atherogenic diet had
worse hearing than SH rats exposed to noise but
which received a normal diet. Thus, it was concluded
that diet does not cause hearing loss alone, but it
causes cochlear damage when associated with hyper-
tension and chronic noise exposure. The additive
effect of these various factors is supported by studies
linking noise to blood pressure increase in rats
(39,40). Thus, the influence of hypertension on the
inner ear causes the cochlea to be more vulnerable
to noise. Atherogenic diet seems to augment this
detrimental effect.
The relationship between hypertension and
hearing loss may be affected by glucose metabolism.
Duck et al. (23) studied the detrimental effects on
hearing of diabetes and hypertension. No significant
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differences were found in the loss of hair cells between
diabetic rats with and without hypertension.
The mechanisms underlying the relationship
between cochlear damage and hypertension are
poorly understood. In 1984, Tachibana et al. (65)
suggested that the primary target of hypertensive
damage in the rat cochlea is the vascular stria feeding
the organ of Corti. Oxygen diffuses to the organ of
Corti through the endolymph from the vascular stria
For personal use only.
and from the middle ear through the round and oval
windows (66–68). Normally, the partial pressure of
oxygen (pO2) differs in various parts of the cochlear
duct, but it is always lowest near the organ of Corti
(67–71). Thus, even a small decrease in pO2 can
cause cochlear damage.
McCormick et al. (72) reported a positive cor-
relation between cochlear potentials in hypertensive
Figure 2. Pathophysiological mechanisms of hypertensive high-tone sensorineural hearing loss. Black dashed line: part of the cochlea
affected in arterial hypertension; black dotted line: part of the cochlea additionally affected in the presence of other comorbidities
(hyperlipidemia, diabetes) or addictions (smoking). EAC, external auditory canal; TC, tympanic cavity; SV, scala vestibuli; ST, scala
tympani; CD, cochlear duct; OC, organ of Corti; K⫹, potassium ion concentration; pO2, partial pressure of oxygen.
Hypertension and cochlear hearing loss 203
rats and systolic blood pressure. Similarly to
Tachibana et al. (65), they postulated that natriuretic
hormones may accelerate the development of sen-
sorineural hearing loss by inhibiting the potassium
pump in the cochlear stria vascularis. Flexion of the
stereocilia of the hair cells causes opening of K⫹
canals and an influx of potassium from the endo-
lymph to the hair cells. The influx causes depolariza-
tion and activation of calcium canals, which in turn
causes outflow of K⫹ ions, resulting in repolarization.
Extracellular K⫹ ions are then transported through
junctions between the supporting cells to the stria
vascularis and then back to the endolymph (ionic K⫹
recycling). Inhibiting the potassium pump in the stria
vascularis stops the K⫹ influx to the hair cells and
thus stops their depolarization (73). The disturbance
of the concentration of ions, mainly K⫹ in the endo-
lymph and in the hair cells, was observed in an SH
rat model of age-related hearing loss in the study by
Rarey et al. (74).
Taken together, previous studies indicate that
malfunction of the stria vascularis seems to be the
most important factor in hypertension-related
cochlear damage. Subclinical damage to the vascular
stria includes the decrease in the cochlear oxygen
partial pressure and disturbance of the ionic K⫹
recycling.
Summary
The results of the clinical studies, although not
unequivocal, indicate that hypertension may be an
important risk factor in sensorineural high-frequency
hearing loss. This link is affected by confounding
 204 T. Przewoźny et al.
factors such as diabetes, noise exposure, stress,
advanced age and gender. Hearing loss in hyperten-
sive patients with comorbidities, besides high tones,
also affects middle and low tones. These complex
relationships, including potential underlying mecha-
nisms, are summarized in Figure 2. It should be
noted that our current pathophysiological knowledge
comes primarily from animal studies. Clearly, we
need more human studies based on novel methods
assessing both hearing loss and cardiovascular func-
tion and structure. These studies should clarify the
current doubts on whether hearing loss should be
listed among other forms of hypertension-related
target organ damage, such as left ventricular hyper-
trophy, increased carotid intima–media thickness or
brain white matter lesions. Better understanding of
the relationship between high-frequency hearing loss
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and hypertension may have important clinical impli-
cations. Early referral of patients with hypertension
to audiometric testing may become one of the early
disability prevention strategies.
Declaration of interest: The authors report no
conflicts of interest.
For personal use only.
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