Enhancing audiometric surveillance in head and neck cancer patients undergoing cisplatin-based chemoradiation

Cisplatin-based chemoradiation remains a cornerstone in the treatment of head and neck cancers (HNCs), but its use is frequently associated with ototoxicity, a significant and frequently irreversible adverse event, characterized by high-frequency sensorineural hearing loss, tinnitus, and occasionally vestibular dysfunction (1,2). These impairments negatively affect quality of life, communication, social integration, and emotional well-being, and may contribute to increased healthcare utilization (3,4).

Cisplatin-induced ototoxicity raises safety concerns, impairs communication ability, and is associated with increased rates of depression, anxiety, social isolation and hospital admission. Despite these known risks, audiometric monitoring protocols are inconsistently implemented across oncology centres and are often limited to cases in which symptoms have already developed. Audiometric surveillance programs should aim to detect early, subtle threshold shifts and facilitate timely interventions that preserve patients’ hearing and quality of life. Cisplatin-induced hearing loss is dose-dependent and cumulative, typically affecting high-frequency hearing first (4). Hearing loss has considerable quality of life implications, with notable effects on a patient’s social and emotional need. Early identification of audiometric shifts enables clinicians to consider dose adjustments, treatment modifications, or otoprotective strategies without compromising oncologic efficacy (5). Despite the well-established risks, analysing cisplatin-treated HNC patients between 2018 and 2023 revealed that fewer than 5% underwent full audiometric monitoring as recommended by American Speech-Language-Hearing Association (ASHA) and the American Academy of Audiology (AAA) guidelines, which assess baseline audiometry prior to initiation of cisplatin therapy, with regular monitoring during and after treatment (6). Post-treatment follow-up beyond 6 months is rarely achieved, particularly in adult cohorts (7).

Lee et al. recently reported that although initial audiological evaluations are frequently performed, sustained follow-up is limited. Only a minority of patients diagnosed with hearing loss eventually receive rehabilitative support such as hearing aids, pointing to a gap in survivorship care (5). This represents a deficiency in survivorship care, particularly as hearing loss has been linked to cognitive decline and social withdrawal and underscore the need to integrate audiological monitoring as a routine component of comprehensive HNC management.

However, logistical constraints, variable team composition, and limited access to audiological services hinder full implementation in clinical practice.

Recent data show that fewer than 5% of adult patients receiving cisplatin adhere to these protocols fully. Recent years have seen advances in both ototoxicity prevention and monitoring:

• Pharmacologic otoprotection: intratympanic administration of N-acetylcysteine (NAC) has demonstrated safety and efficacy in preventing cisplatin-induced hearing loss, as supported by a 2025 meta-analysis of clinical trials in both adult and pediatric populations (8).
• Novel protective compounds: berberrubine, a plant-derived alkaloid, has shown protective effects in preclinical models by enhancing folate biosynthesis and reducing hair cell apoptosis (9).
• Technological solutions: particularly in mobile health (mHealth), offer new opportunities. Extended high-frequency audiometry administered via portable or smartphone-connected devices has proven feasible and effective for monitoring ototoxicity in outpatient settings, enabling broader coverage and reduced patient burden (10,11).
• Implementation of ototoxicity monitoring programs (OMPs) has also proven effective in increasing baseline audiometric assessments (up to 66.1% post-intervention vs. 34.4% prior) but remains insufficient to ensure long-term follow-up, particularly in resource-limited centers (12).
• In addition, Pedmark (sodium thiosulfate) has received Food and Drug Administration approval for otoprotection in pediatric patients receiving cisplatin for certain solid tumors, providing a valuable precedent for future adult clinical trials.

These findings underscore a broader issue: in many centers, audiological care is reactive rather than proactive, often initiated only after symptomatic complaints arise.

Nevertheless, cisplatin ototoxicity should not be accepted as an inevitable trade-off for oncologic efficacy. With appropriate surveillance, emerging preventive strategies, and timely rehabilitation, clinicians can preserve auditory function, protect neurocognitive development, and support long-term survivorship. To truly support survivorship in patients undergoing cisplatin-based therapy, audiological care must become an integrated, proactive aspect of multidisciplinary oncology management. The inclusion of audiologists or audiometrists in tumor boards and care teams is not a luxury but a necessity (Figure 1).

Figure 1 Conceptual framework of cisplatin-induced ototoxicity and monitoring strategies in head and neck cancer patients. mHealth, mobile health; NAC, N-acetylcysteine; OMP, ototoxicity monitoring program.

Structured, timely audiometric surveillance ensures that hearing loss is detected early, addressed effectively, and managed comprehensively, thereby preventing irreversible damage, enabling clinicians to balance oncologic efficacy with long-term quality of life.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Chinese Clinical Oncology. The article has undergone external peer review.

Peer Review File: Available at https://cco.amegroups.com/article/view/10.21037/cco-25-89/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://cco.amegroups.com/article/view/10.21037/cco-25-89/coif). R.A. serves as an unpaid editorial board member of Chinese Clinical Oncology from August 2024 to July 2026. The other author has no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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References

1. Frisina RD, Wheeler HE, Fossa SD, et al. Comprehensive Audiometric Analysis of Hearing Impairment and Tinnitus After Cisplatin-Based Chemotherapy in Survivors of Adult-Onset Cancer. J Clin Oncol 2016;34:2712-20. [Crossref] [PubMed]
2. Sheth S, Mukherjea D, Rybak LP, et al. Mechanisms of Cisplatin-Induced Ototoxicity and Otoprotection. Front Cell Neurosci 2017;11:338. [Crossref] [PubMed]
3. AlJasser A. Monitoring Ototoxicity in Cancer Patients Undergoing Platinum-Based Chemotherapy and Radiation in Saudi Arabia: Challenges and Solutions. J Multidiscip Healthc 2025;18:7159-73. [Crossref] [PubMed]
4. Landier W. Ototoxicity and cancer therapy. Cancer 2016;122:1647-58. [Crossref] [PubMed]
5. Lee DS, Travis EY, Wong SK, et al. Audiologic Follow-up in Patients With Head and Neck Cancer Treated With Cisplatin and Radiation. Laryngoscope 2023;133:3161-8. [Crossref] [PubMed]
6. American Speech-Language-Hearing Association (ASHA). Guidelines for the audiologic management of individuals receiving cochleotoxic drug therapy. ASHA 1994;36:11-9.
7. Patel J, Beiriger J, Liu K, et al. Ototoxicity Monitoring: The Evolution of a Protocol for Head and Neck Cancer Patients. OTO Open 2025;9:e70070. [Crossref] [PubMed]
8. Tawalbeh M, Ibrahim RM, Al-Saraireh T, et al. Intratympanic NAC for prevention of cisplatin-induced ototoxicity: a meta-analysis. BMC Pharmacol Toxicol 2025;26:26. [Crossref] [PubMed]
9. Miao Z, Chang D, Du X, et al. Berberrubine protects cochlear hair cells via folate biosynthesis. Front Pharmacol 2025;15:1496917. [Crossref] [PubMed]
10. Wang M, Ai Y, Han Y, et al. Extended high-frequency audiometry in healthy adults with different age groups. J Otolaryngol Head Neck Surg 2021;50:52. [Crossref] [PubMed]
11. Stuijt DG, Radanovic I, Kos M, et al. Smartphone-Based Passive Sensing in Monitoring Patients With Cancer: A Systematic Review. JCO Clin Cancer Inform 2023;7:e2300141. [Crossref] [PubMed]
12. Gambacorta V, Orzan E, Faralli M, et al. Practice of Monitoring Cisplatin-Induced Ototoxicity by Audiology, ENT, and Oncology Specialists: A Survey-Based Study in a Single Italian Medical Center. Audiol Res 2023;13:779-90. [Crossref] [PubMed]