Introduction: Cochlear implantation is a fully accepted method of treating individuals with profound hearing loss. Since the indications for cochlear implantation have broadened and include patients with low-frequency residual hearing, single-sided deafness, or an already implanted ear , the emphasis now needs to be on vestibular protection.Materials and Methods: The research group was made up of 107 patients operated on in the otorhinolaryngosurgery department: 59 females and 48 males, aged 10.4–80.2 years  with hearing loss lasting from 1.4 to 56 years . The patients underwent cVEMP, oVEMP, a caloric test, and vHIT assessment preoperatively, and, postoperatively, cVEMP and oVEMP at 1–3 months and a caloric test and vHIT at 4–6 months.Results: After cochlear implantation, there was postoperative loss of cVEMP in 19.2% of the patients, oVEMP in 17.4%, reduction of caloric response in 11.6%, and postoperative destruction of the lateral, anterior, and posterior semicircular canal as measured with vHIT in 7.1, 3.9, and 4% respectively.Conclusions: Hearing preservation techniques in cochlear implantation are connected with vestibular protection, but the risk of vestibular damage in never totally eliminated. The vestibular preservation is associated with hearing preservation and the relation is statistically significant. Informed consent for cochlear implantation must include information about possible vestibular damage. Since the risk of vestibular damage is appreciable, preoperative otoneurological diagnostics need to be conducted in the following situations: qualification for a second implant, after otosurgery , having a history of vestibular complaints, and when there are no strict audiological or anatomical indications on which side to operate. Cochlear implantation (CI) is a well-known method of treating individuals with profound hearing loss. Despite its great effect in restoring hearing, after a CI procedure there is the risk of traumatization of the inner ear causing residual hearing loss or vestibular damage –4. PreviWith recent advances in technology, in otosurgical techniques, and in our understanding of hearing electrophysiology, the population eligible for cochlear implantation has been broadened. Not only patients with bilateral profound sensorineural hearing loss but also those with unilateral deafness  or partiPatients with low-frequency residual hearing  achieve statistically better preoperative results in vestibular tests than do standard implantees, but their vestibular performance may be compromised after a CI procedure . ElderlyIn the 1990s and into this century, the first steps toward “soft surgery” in cochlear implantation began to be implemented , 11, 12.Many papers have assessed vestibular function following cochlear implantation done via cochleostomy or the round window approach. However, they show a big discrepancy in the incidence of postoperative vestibular deterioration: for cochleostomy, the figures are 31–86% for cervical Vestibular Evoked Myogenic Potentials (cVEMPs), 6–50% for caloric tests, and 4–9% for video Head Impulse Test (vHIT); for the round window approach, the comparable figures are 0–76% for cVEMPs, 5–37% for ocular Vestibular Evoked Myogenic Potentials (oVEMPs), and 0–93% for caloric tests –28. MoreThe aim of this study was to assess the safety of cochlear implantation in partial deafness in terms of vestibular preservation, with hearing preservation (HP) techniques and range of electrode types.In total, 149 patients qualified for PDT-EAS, PDT-EC, or PDT-ES cochlear implantation  were enrThe exclusion criteria included reimplantation cases and the presence of complete vestibular damage prior to implantation—demonstrated by the absence of cVEMP and oVEMP, areflexia in a caloric test with a slow-component velocity (SCV) <12°/s, or covert or overt saccades in all three planes of the vHIT. Additionally, cVEMP and oVEMP were not performed if there were superior semicircular canal dehiscence syndrome (SSCD), inner ear malformation (including large aqueductus vestibule syndrome LVAS), retrocochlear pathology, central nervous system (CNS) pathology affecting the reflex arc , conductive hearing loss, or highly probable conductive hearing loss. Caloric tests were not done if there was a history of canal wall down tympanoplasty, tympanic membrane perforation, inner ear malformation, or cerebellar pathology. The RWA implantation was carried out according to a six-step procedure for Partial Deafness Treatment (PDT): (1) antrotomy; (2) posterior tympanotomy to allow for visualization of the round window niche; (3) puncture of the round window membrane; (4) insertion of the electrode array, approaching the scala tympani directly through the round window membrane; (5) electrode fixation in the round window niche with fibrin glue ; and 6) fixation of the device in a well-created in the temporal bone . The patients were stimulated with a 500-Hz tone burst 2:2:2 at 97 dB nHL using an insert tip , 32. TheIn cVEMP, patients were asked to turn their head 45° away from the examined ear and to tension the sternocleidomastoid muscle (SCM) at a contraction level of 50–150 μV with the assistance of visual feedback from the software. The right and left electrodes were placed at the midpoint between the termination of the muscle at the mastoid and its origin at the sternum on the right and left sides, respectively, with the vertex electrode situated between the sternoclavicular joints, the ground electrode at the forehead. Averaging of 200 stimulus repetitions was done, and two repeated wave patterns were accepted as a positive response. Results were determined based on the amplitude asymmetry ratio (norm <36%) , responsFollowing oVEMP standards, the recording electrodes were placed infraorbitally in the midline of the contralateral eye to the side they refer to, with the ground electrode at the forehead and the vertex on the chin. Signal averaging was increased to 500. The patient was instructed to fix their gaze at a point 35° upward . The resDuring the examination, the patient lay recumbent with the head elevated by 30°. Bilateral caloric stimulation used water at 30°C and 44°C for 30 s into the ear canal with each trial preceded by an 8-min break . Unilateral weakness (UW) and slow component velocity (SCV) on both sides before and after cochlear implantation were compared. The degree of canal paresis (UW) was calculated based on Jongkees' formula. A difference of UW > 25% between pre- and postoperative measurements toward the implanted ear was judged as a weakened response. The examination was carried out 4–6 months after the operation.vHIT was performed using an ICS Impulse type 1085 (GN Otometrics). The patient was seated and asked to focus on a spot 1.5 m away. Then abrupt, unpredictable, small-angle (10–20°) head movements were done in three planes: horizontal, LARP (left anterior–right posterior), and RALP (right anterior–left posterior). In each case, 20 impulses were delivered with a minimum peak head velocity of 150°/s. Normal gain (the quotient of head movement speed and eye movement speed) ranged from 0.6 to 1.2. A gain below 0.6 or the appearance of covert or overt saccades was considered as damage to the particular semicircular canal. The test was conducted preoperatively and 4–6 months postoperatively.*100%, where PTApre is the pure tone average measured preoperatively, PTApost is the pure tone average measured postoperatively, and PTAmax is the maximum level generated by the audiometer. The HP (hearing preservation) values were divided into total loss of hearing (no detectable hearing), minimal HP (range 1–25%), partial HP (26–75%), and complete HP (>75%) (We measured the hearing preservation 3 and 6 months after cochlear implantation using the following formula : HP = [1P (>75%) .U-test was used to examine the relationship between age and postoperative vestibular preservation as well as between hearing preservation (in percent) and vestibular preservation. A Chi-square test was used to investigate the relation between sex, type of electrode, its length, and the postoperative test results and the relation between the postoperative affiliation of the HP group and postoperative vestibular function. A paired-sample t-test was applied to assess the latency of the VEMP before and after cochlear implantation. In all cases, p <0.05 was considered statistically significant.Statistical analysis was performed using IBM SPSS Statistics v.24. A Mann–Whitney n = 1; or an incomplete partition, n = 1) or those with other factors affecting the postoperative function of the labyrinth: recurrent vertigo attacks due to possible delayed Meniere's disease within 9 months after cochlear implantation, n = 1; the need for reimplantation due to inflammation of the implant bed, n = 1; head injury within a few months after cochlear implantation, n = 1; the need for reimplantation due to failure of the internal part of the implant, n = 1; and Meniere's disease on the implanted side existing preoperatively and active postoperatively, n = 1. Additionally, subjects were excluded after a non-standard course of the CI procedure: traumatic electrode insertion (n = 2), with the need to apply a trial electrode in one patient, and a narrow round window niche demanding an extended round window approach (n = 2).From the initially enrolled group of 149 patients (153 ears), 32 patients (34 ears) were excluded due to complete damage of the vestibulum before implantation according to the criteria described in “Material and methods.” The study did not include people who had inner ear malformation  with hearing loss lasting from 1.42 to 56 years . The implanted ear was right in 56 cases and left in 51.n = 4), soft/straight (n = 23), and ultrasoft (n = 80). The range of inserted electrodes included Advanced Bionics HiRes 90k Advantage Mid-scala (n = 4), Cochlear Nucleus CI422 (n = 5), Cochlear Nucleus CI522 (n = 4), Med-El Sonata Standard (n = 6), Advanced Bionics HiRes Hi Focus Slim J (n = 1), Med-El Sonata Medium (n = 3), Med-El Concerto Medium (n = 3), Med-El Sonata Form24 (n = 1), Med-El Concerto Form24 (n = 1), Med-El Sonata Compressed (n = 1), Med-El Sonata Flex soft (n = 10), Med-El Concerto Flex soft (n = 2), Med-El Concerto Flex28 (n = 8), Med-El Sonata Flex28 (n = 20), Med-El Synchrony Flex28 (n = 3), Med-El SonataTi100 Flex28 (n = 1), Med-El Concerto Flex24 (n = 8), Med-El Sonata Flex24 (n = 17), Med-El Synchrony Flex24 (n = 2), Med-El Concerto Flex20 (n = 5), and Med-El Sonata Flex20 (n = 2).Of the 107 patients, 103 were implanted with soft lateral wall electrodes and four with precurved electrodes. Among the 103 patients implanted with soft electrodes, 80 were implanted with ultrasoft Flex electrodes. That is, in terms of inserted electrodes, there were three groups: precurved (n = 103), oVEMP (n = 69), caloric test (n = 43), vHIT horizontal semicircular canal (n = 28), vHIT anterior semicircular canal (n = 26), and vHIT posterior semicircular canal (n = 25).The tests performed included cVEMP . The rate of saccular loss was not affected by sex (p = 0.554). However, it depended on age . A preserved cVEMP response was present in 31 women and 28 men aged 10.4 to 68.2 y.o.  and a lost cVEMP response by nine women and five men aged 30–67.3 years . The causes of hearing loss in patients with an abnormal cVEMP response postoperatively were head injuries , autoimmune inner ear disease , sudden idiopathic deafness , viral infection , and unknown origin . The etiology of hearing loss in patients with a preserved VEMP response was much wider: acoustic trauma  cholesteatoma , TORCH infection , genetic mutation , head injury , effect of ototoxic drugs , prematurity , barotrauma , sudden idiopathic deafness , unknown origin , and viral infection . Due to the wide diversity of hearing loss causes, no statistical analysis of its effect on test results was undertaken. No statistically significant differences were found regarding the effect of electrode type on postoperative vestibular function , although the incidence of saccular damage was lowest in the group of ultrasoft electrodes. In the three groups implanted with the ultraflex, straight, and precurved electrodes, elicitable cVEMPs were found postoperatively in 49 of 57 patients (86.0%), 9 of 14 patients (64.3%), and 1 of 2 patients (50%), respectively. In a further analysis of the effect of electrode length on postoperative cVEMP responses, two patients with incomplete electrode insertion were excluded. Maintenance of saccular responses was seen in 4/6 (66.7%) using 20-mm electrodes, 23/27 (85.2%) using 24-mm electrodes , 18/20 (90%) using 28-mm electrodes, and 8/11 (72.7%) using 31-mm electrodes . A similar analysis restricted to the four subgroups of the Flex group  showed retained cVEMP in 4/6 patients (66.7%), 19/21 patients (90.5%), 18/20 patients (90%), and 6/8 patients (75%), respectively. There was no significant effect of electrode length either by analyzing within the Flex electrodes (p = 0.367) or by pairing different types of lateral wall electrodes into groups of the same length (p = 0.437). All the postoperative cVEMP results are summarized in Of the 103 people who underwent a preoperative examination, responses were recorded in 73 cases. We found a postoperative loss of cVEMPs in 14 of 73 patients (19.2%). The preoperative and postoperative latency of P1 and N1 peak did not differ significantly . The loss of response was not influenced by gender (p = 0.999) or age , although the mean age of people with oVEMP loss was higher than the mean age of people with preserved oVEMP responses, and the youngest person with loss of utricular function was 34 years old.Among the 69 oVEMP tests performed on the patients preoperatively, positive responses were recorded in 46 of them. Of the 46 patients, postoperative losses were found in 8 (17.4%). The difference between preoperative and postoperative N1 and P1 latency was not statistically significant , head injury , idiopathic sudden deafness , and autoimmune inner ear disease . Patients with recorded postoperative utricular responses had the following hearing loss etiology: acoustic trauma , cholesteatoma , TORCH infection , genetic defect , ototoxic drugs , post labyrinthitis , sudden idiopathic deafness , viral infection , and unknown . Due to the multiplicity of etiological factors, their effect on oVEMP responses after CI was not analyzed.oVEMP responses were preserved in 21 women and 17 men, while no response was recorded in four women and four men. The age of the patients with retained oVEMPs ranged from 11.08 to 68.17 y.o. , and the age of those with newly postoperative absent oVEMPs ranged from 34.50 to 64.25 y.o. . Among patients with oVEMP loss, the etiology of hearing loss was unknown (p = 0.421). When considering the effect of electrode length on the maintenance of oVEMP responses, two patients with incomplete electrode insertion were excluded from the calculations. The results for preserved oVEMPs after CI were 3 out of 4 (75%) for 20 mm, 18 out of 20 (90%) for 24 mm, 9 out of 12 for 28 mm (75%), and 5 out of 5 (100%) for the 31-mm electrode length recipients. If one only takes into consideration electrode length within the Flex group, the percentage of postoperatively recorded oVEMPs was 75% (3 out of 4) for the Flex 20, 86.7% (13 out of 15) for the Flex 24, 75% (9 out of 12) for the Flex 28, and 100% (3 out of 3) for the Flex soft group. Similarly to the cVEMP responses, no statistically significant relationship was found between electrode length and the risk of possible postoperative oVEMP loss, either for the Flex electrodes alone (p = 0.698) or when comparing groups of electrodes of the same length (p = 0.462). The postoperative prevalence of oVEMPs is shown in In terms of the impact of electrode type  on postoperative oVEMPs, we found retained responses in one of two (50.0%), eight of nine (88.9%), and 29 of 35 (82.9%), respectively. There was no significant correlation between the frequency of oVEMP loss and the type of electrode  with the weakness on the implanted side, and in one other there was only a slight change in this index (0.19) with a correct value in the postoperative examination (0.30 with a predominance of the implanted side). Among 37 subjects with a preserved oVEMP response after CI, 34 presented cVEMP responses simultaneously and 3 patients lost cVEMPs. All six subjects with postoperative oVEMP loss did present cVEMP loss. In summary, maintenance of the cVEMP response (an indicator of saccule function) was always associated with a preserved oVEMP response (which assesses utricle function), whereas loss of oVEMP response was always associated with a loss of cVEMP response.The caloric test was performed pre- and postoperatively in 43 patients, five of whom (11.6%) had a postoperative change in unilateral weakness UW >25% toward the implanted ear.U-test . Due to the small size of the group with weakened responses in the caloric sample, no further statistical analysis was undertaken. The CI recipients with weakened caloric response were implanted with Flex28 (n = 2), Flex28 (n = 1), Flex soft (n = 1), and Medium (n = 1), and their hearing losses were caused by ototoxic drugs (n = 1), Meniere's disease (n = 1), viral infection (n = 1), sudden idiopathic deafness (n = 1), and unknown factor (n = 1). Patients with preserved caloric responses received the following electrodes: CI 422 , CI 522 , Compressed , Flex 20 , Flex 24 , Flex 28 , Form 24 , Medium , Mid-scala , Standard , and SlimJ . Their hearing loss etiology was as follows: idiopathic sudden deafness , acoustic trauma , cholesteatoma , genetic , head trauma , otosclerosis , postinflammatory , Meniere's disease , autoimmune inner ear disease , and unknown .The group with maintained caloric response consisted of 20 females and 18 males aged 12.3–80.2 years , and those with a weakened response after CI were represented by three females and two males aged 26.0 to 74.8 years . The results were not affected by the age of the patients according to a Mann–Whitney Among five subjects with weakened caloric responses postoperatively, two of them also showed a loss of cVEMP response, in two cVEMPs were not done, and one patient had a preserved response (with a change in the amplitude asymmetry index by 0.36 with weakness of the implanted ear). oVEMP response in the group with weakened caloric response was as follows: absent in one patient postoperatively, absent in one patient already preoperatively, preserved in one patient (with a change in the amplitude asymmetry index of 0.59 showing weakness of the implanted side), and two patients not tested. The results of caloric tests after CI are shown in Postoperative damage to the lateral semicircular canal was found in 2 of 28 patients (7.1%), the anterior semicircular canal in 1 of 26 (3.9%), and the posterior semicircular canal in 1 of 25 (4.0%) patients. One of the patients had damage to all semicircular canals . The second patient lost function in the lateral canal, while the anterior and posterior canals presented responses within the normal range .vHIT was preserved in 15 women and 11 men, aged 12.3 to 77.3 years .n = 3; 30%), partial HP , or total hearing loss . There were 49 patients with retained cVEMPs who presented HP of 31–100%  and were classified as partial HP  or complete HP . The difference in HP between both groups (lost vs. maintained cVEMPs) was statistically significant in both percentage of preserved hearing  and affiliation to the particular group (p = 0.001). There were six people who lost oVEMPs after CI who had preserved hearing postoperatively consisting of two patients (33.3%) with complete HP, one patient (16.7%) with partial HP, and three patients (50%) with hearing loss . Maintained postoperative oVEMP responses (n = 33) together with hearing preservation ranged from 31 to 100% , and there were 25 CI recipients (75.8%) with complete HP and eight (24.2%) with partial HP. The difference in HP between the patients with and without maintained oVEMPs postoperatively was on the border of statistical significance  and statistical significance (p < 0.001) if one considers the percentage and affiliation to each group, respectively. In case of the caloric tests, three patients with weakened responses after CI achieved hearing preservation  6 months postoperatively  and were consequently classified as partial HP  or total hearing loss . In contrast, among 25 people with maintained postoperatively caloric responses, hearing preservation was 0 to 100% , and so 10 patients (41.7%) were classified as having complete HP, 12 patients (50%) with partial HP, and two patients (8.4%) with total hearing loss. Due to the small numbers, a statistical analysis was not undertaken.Hearing preservation (HP) was assessed 3 and 6 months postoperatively in 79 CI recipients who had significant preoperative low-frequency residual hearing and so had undergone PDT-EC and PDT-EAS cochlear implantation. cVEMP and oVEMP results were compared with HP at 3 months and with the caloric test, and vHIT results were compared with HP at 6 months after CI, matching the timeline of vestibular tests. Of 10 patients who had postoperative loss of cVEMP responses, hearing preservation ranged from 0 to 100%  and was described as complete HP (n = 14) was characterized by HP of 0 to 100%  and their group affiliations were eight complete HP (57.1%), four partial HP (28.6%), and three total hearing loss (21.4%).In one case of lateral, anterior, and posterior semicircular canal loss in vHIT, hearing loss of 0% was measured. However, in the group of 16 patients with correct vHIT in the horizontal plane after CI, it was found that seven (43.8%) had complete HP, five (31.3%) had partial HP, and four (25.0%) had total hearing loss (HP ranged from 0 to 100% with M = 58.3 and SD = 36.1). Similarly, in 15 cases of preserved vHIT for the anterior semicircular canal after CI, HP ranged from 0 to 100%  with three patients (20.0%) having total hearing loss, seven (46.7%) with complete HP, and five (33.3%) with partial HP. Finally, the group with correct postoperative vHIT responses for the posterior semicircular canal  –28. A reIn addressing the problem of vestibular damage after a CI, there is first a need to define the criteria of how to analyze and compare otoneurological tests  pre- and postoperatively, since there is a definite lack of uniformity in the literature. These criteria should specify which change in response represents definite vestibular damage rather than just say that the test is within or beyond norms.In the case of the caloric test, the slow component velocity (SCV) may depend on many factors such as the patient's alertness or small differences in performing the exam. It is possible that day-to-day changes in this parameter can be observed even when there are no vestibular changes. UW  is a much more reliable parameter to compare. Nevertheless, only specifying a change between categories  may falsely lead one to say that there is vestibular damage among patients with borderline Unilateral Weakness (UW), even though the UW change is not significant. Proctor et al. and Piker et al. investigated the minimum detectable change in UW in test–retest exams and found that it was 24%  and 23% Interpreting vHIT exams is more clear-cut, and detecting new overt or covert saccades in the postoperative period, or drop in the gain of head movement/eye movement to <0.6, should be recognized as vestibular damage. However, the sensitivity of vHIT is a matter for further research and many papers indicate that, among patients with vestibular neuritis or other symptoms suggestive of impairment, a lower percentage have vestibular damage detected by vHIT than by the caloric test –41. The cVEMP and oVEMP are thought to be the most sensitive tools to detect post-CI changes in the vestibulum as they represent the most fragile organs, the saccule and the utricle. The loss of cVEMPs or oVEMPs should be treated as vestibular damage unless there is conductive hearing loss. However, vestibular damage may lead not only to total loss but also to a decrease in amplitude, making analysis more complicated. Comparing the corrected P1–N1 amplitude in cVEMPs, or N1–P1 amplitude in oVEMPs, between pre- and postoperative exams may be erroneous, although some good test–retest reliability has been reported . No striOur study has shown that, based on a wide range of electrodes, partial deafness treatment is protective in terms of vestibular preservation. However, the risk of postoperative vestibular damage is not eliminated. It gives a rate of saccular damage of 19.2% and utricular damage of 17.4% measured by VEMP loss. A reduction in horizontal semicircular canal response was noticed in 11.6% if measured by the caloric response, and damage to the horizontal, anterior, and posterior semicircular canals, as measured by vHIT, of 7.1, 3.9, and 4%, respectively. Hearing preservation was associated with maintenance of vestibular function, and the relation was statistically significant. Patients with elicitable VEMP responses after a CI had at least partially preserved hearing, but never total hearing loss. Weakened caloric tests postoperatively were always associated with at least partial hearing loss.To properly discuss the counseling of CI candidates, certain facts about central compensation of the unilateral and bilateral vestibular damage need to be recalled. Unilateral vestibular damage can be treated with vestibular rehabilitation including Cawthorne–Cooksey exercises, optokinetic training, virtual reality games, or posturographic training. Such exercises are effective and end with full recovery unless additional comorbidities exist . With bilateral vestibular damage, many functions are affected: postural stability, visual stability during head movements, autonomic cardiovascular reaction of the lower part of the body while standing, cognitive abilities like spatial orientation, navigation abilities, and impairment in dual tasking , 42. OnlOur PDT implantation strategy involves applying “soft surgery”: the use of a round window approach via scala tympani which lowers the risk of misinsertion, the administration of postoperative steroids, micropuncture of the round window membrane, insertion of soft electrodes, and reduced insertion angles.Histological studies have found that vestibular damage is significantly reduced when the electrode is inserted into scala tympani , 49. TemTo avoid intracochlear trauma by deep electrode insertion, a flex electrode is used. It has special features such as the five most apical electrode contacts being single, whereas the basal seven electrodes are paired, reducing the diameter of the electrode tip.Despite the above anatomical facts, we did not find any strong relationship between either electrode type or length and postoperative vestibular function. However, the multiple types of electrodes used restrict the statistical power of being able to see the effect of electrode type on the incidence of vestibular damage. This also agrees with other reports. Nordfalk et al.  measuredHearing preservation techniques in cochlear implantation are connected with vestibular protection, but the risk of vestibular damage is never totally eliminated. The vestibular preservation is associated with hearing preservation, and the relation is statistically significant. Special care and counseling are recommended when qualifying a patient for implantation when that ear has the only (or better) vestibulum, since there is then the risk of bilateral hypofunction or areflexia. Similarly, caution is needed for a patient with comorbidities affecting central nervous system compensation. Therefore, preoperative otoneurological diagnostics are necessary in the following situations: qualification for a second implant, after otosurgery , with a history of vestibular complaints, with comorbidities that may result in impairment of central compensation mechanisms, and in those who do not have any strict audiological and anatomical indication about which side to operate.m.sosna@ifps.org.pl.The datasets generated for this article are not readily available because the patients did not agree to share their data publicly. The datasets are stored on an internal server and are only available to co-workers. All data related to people in the European Union (EU) is protected by law of the General Data Protection Regulation (GDPR). Requests to access the datasets should be directed to The studies involving human participants were reviewed and approved by Institutional board's ethics committee–Institute of Physiology and Pathology of Hearing, Warsaw, Poland. Written informed consent to participate in this study was provided by each participant or the participants' legal guardian .MS-D: study design, data collection, data interpretation, preparation of manuscript, literature analysis. GT: data interpretation, preparation of manuscript. EG: data analysis/statistics. AK: data collection, preparation of manuscript. PS and HS: study design, data collection. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


FGFR3 gene, affecting endochondral bone growth, including the craniofacial anatomy. Recurrent otitis media infections, chronic middle ear effusion, and hearing loss are common in children with achondroplasia, but few studies have investigated hearing loss in adults with this condition.Achondroplasia is the most common form of disproportionate skeletal dysplasia. The condition is caused by a mutation in the This population-based study investigated the prevalence, severity, and type of hearing loss in Norwegian adults with achondroplasia.We collected data on 45 adults with genetically confirmed achondroplasia: 23 men and 22 women, aged 16–70 years. All participants underwent a comprehensive audiologic assessment, including medical history, pure-tone audiometry, speech audiometry, and impedance audiometry. According to the Global Burden of Disease classification, pure-tone average ≥ 20 decibel hearing level (dB HL) was considered clinically significant hearing loss.Insertion of ventilation tubes had been performed in 44% (20/45) of the participants, 49% (22/45) had a history of adenoidectomy, while 20% (9/45) used hearing aids. Hearing loss in at least one ear was found in 53% (24/45) of the participants; in 57% (13/23) of the men and 50% (11/22) of the women. In the youngest age group (age 16–44 years), 50% (14/28) had hearing loss, although predominantly mild (20–34 dB HL). An abnormal tympanometry (Type B or C) was found in 71% (32/45) of the participants. The majority (15/24) had conductive hearing loss, or a combination of conductive and sensorineural hearing loss (8/24).Adults with achondroplasia are at increased risk of early hearing loss. Our findings underline the importance of a regular hearing assessment being part of standard care in achondroplasia, including adolescents and young adults. In adult patients diagnosed with hearing loss, an evaluation by an otolaryngologist should be considered, and the need for hearing aids, assistive listening devices, and workplace and educational accommodations should be discussed.Clinical trial registration ClinicalTrials.gov identifier NCT03780153. FGFR3) gene, affecting endochondral bone growth, including the craniofacial anatomy [Achondroplasia is the most common form of disproportionate skeletal dysplasia, affecting more than 250,000 individuals worldwide . The con anatomy –9. Prior anatomy , giving  anatomy . Hearing anatomy , 9, 13.  anatomy , 14.Tunkel et al. reported that 55% out of 28 adults with achondroplasia screened at a patient support meeting failed hearing screening in one or both ears, and 39% had abnormal tympanometry . Hunter According to the Global Burden of Disease Study 2019, hearing loss was the third largest cause of disability worldwide, with an overall global prevalence of 19% . In EuroCurrently, there are no widely accepted recommendations for hearing assessment in adolescents or adults with achondroplasia. In the recently revised recommendations on Health Supervision for People with Achondroplasia (2020), provided by the American Academy of Pediatrics, the recommendation of a formal routine hearing assessment in children, ideally on an annual basis, has been extended to also include adolescents and adults . Other gIn the present study, we conducted a comprehensive audiologic assessment to investigate the prevalence, severity, and type of hearing loss in Norwegian adults with achondroplasia.This cross-sectional study was part of The Norwegian Adult Achondroplasia Study, a population-based study conducted between 2017 and 2019 on community-dwelling, Caucasian adults, aged 16 years or older, living in Norway . DetailsA medical history was obtained in a face-to-face interview, including history of otitis media, upper airway infections, prior upper airway surgery, prior diagnosis of impaired hearing, and the use of hearing aids. Participants were also asked whether they received any regular follow-up for hearing loss. Demographic and anthropometric data were collected from The Norwegian Adult Achondroplasia Study . All heaBetter ear refers to the subject’s better ear when comparing the pure tone average (PTA) of the frequencies 0.5, 1, 2 and 4 kHz of the left and the right ear (BE PTA4).Air- and bone-conducted pure-tone thresholds were obtained to measure hearing sensitivity, and provide diagnostic information regarding severity, type and configuration of hearing loss. Pure-tone thresholds were measured separately for the left and right ear and in accordance with the International Organization for Standardization (ISO 8253-1:1989). Pure tones for the frequencies 0.25, 0.5, 1, 2, 3, 4, 6 and 8 kHz were obtained for the air conduction test, and the frequencies 0.25, 0.5, 1, 2, 3 and 4 kHz for the bone conduction test. Speech audiometry was carried out to assess speech intelligibility and discrimination, and to crosscheck the results obtained by pure-tone audiometry. A Norwegian Speech Audiometry set (“HiST speech audiometry”) was used for speech recognition measurement . The tesImpedance audiometry (tympanometry and stapedius reflex test) was conducted to determine the pressure in the middle ear, evaluate acoustic reflex pathways and tension of the tympanic membrane. The test was also used to distinguish a conductive from a sensorineural hearing loss.The tympanometry results were displayed as a graph showing compliance, gradient and pressure according to normative values, and was categorized as Type A , Type B  or Type C  . For furStapedius reflex test was measured both ipsilateral and contralateral. We measured the contraction and thresholds for activation of the stapedius in response to stimuli of 0.5, 1, 2, and 4 kHz, at intensities of 70–115 decibel (dB) sound pressure level. The outcome was dichotomized to normal or abnormal for one or both ears .Type of hearing loss was categorized as (a) normal hearing/no hearing loss, (b) conductive hearing loss, (c) sensorineural hearing loss, or (d) mixed hearing loss. A conductive hearing loss was defined as air-bone gaps larger than ≥15 dB at one frequency or ≥10 dB at two frequencies . A sensoSeverity of hearing loss was defined according to the Global Burden of Disease classification: normal hearing: < 20 dB HL; mild hearing loss: 20.0–34.9 dB HL; moderate hearing loss: 35.0–49.9 dB HL; moderately severe hearing loss: 50.0–64.9 dB HL; severe hearing loss: 65.0–79.9 dB HL; profound hearing loss: 80–94.9 dB HL; complete or total hearing loss: ≥ 95 dB HL , 29. DisDescriptive statistics are presented as frequencies (n) with percentages (%) for proportions, or means with standard deviation (SD) for continuous variables. Independent sample t-tests were used to compare differences between continues variables. Continuity corrected chi-squared tests were used for comparing proportions (using the “prop. Test” R function). Confidence intervals for proportions was found using the Exact Binominal Test (applying the “binom.test” R function). Statistical significance was set to p < 0.05 (two-sided). Statistical analyses was performed using the Statistical Package for Social Sciences (SPSS) version 26 , and R version 3.6.1.Out of the 50 participants in The Norwegian Adult Achondroplasia Study, 45 were included in the present study: 23 men and 22 women. Those five not included were all visited in their homes due to impaired health , making Hearing loss ≥ 20 dB HL) in at least one ear was found in 53% (24/45) of the participants: in 57% (13/23) of the men and 50% (11/22) of the women . Unilateral hearing loss was found in 11% (5/45), while 42% (19/45) had bilateral hearing loss (Table 0 dB HL iHearing loss in the better ear (BE PTA4 ≥ 20 dB HL) was found in 42% (19/45) of the participants: in 32% (9/28) of the youngest age group, and 50% (7/14) of those aged 45–64 year. The majority (15/19) had mild hearing loss, while four had disabling hearing loss (hearing threshold ≥ 35 dB HL).An abnormal tympanometry (Type B or C) in at least one ear was found in 71% 32/45) of the participants  had a conductive hearing loss, 4% (1/24) had a sensorineural hearing loss, and 33% (8/24) had a mixed hearing loss  in at least one ear, including half of the youngest age group (age 16–44 years). There was no considerable difference between men and women. The majority had conductive hearing loss. An abnormal tympanogram (Type B or C) in at least one ear was found in over 70% of the participants.To our knowledge, this is the largest clinical study to date investigating hearing loss in adults with achondroplasia and performed under standardized conditions. Our findings are consistent with prior studies, having reported a prevalence of hearing loss of about 55–60% in adults with achondroplasia , 15.We compared our data to the Norwegian HUNT4 Hearing study, both based on BE PTA4 . The preHearing loss may have a considerable negative impact on the ability to participate in social activities, and may cause social isolation and reduce educational attainments and employment opportunities , 18, 31.More than 80% of our study participants reported having had at least one episode of acute otitis during childhood, and almost half had a history of adenoidectomy. These findings are consistent with a recent US study by Okenfuss et al., where 74% of the participants reported recurrent episodes (≥ 3) of otitis media infection, and 40% had undergone adenoidectomy . In a stThe majority of those diagnosed with hearing loss in our study had conductive hearing loss, consistent with prior studies in achondroplasia , 11, 15.In average statured persons, hearing loss is usually more prevalent in men than in women, across all age groups , 33. In While over half of the participants in our study had hearing loss, only 20% were currently using hearing aids. This proportion is comparable to studies conducted on average stature populations . In the The present study demonstrated a high prevalence of hearing loss in adults with achondroplasia. Of particular notice was the high prevalence of hearing loss observed in young persons with achondroplasia, consistent with prior studies , 9, 11. Our findings indicate that hearing loss might be underdiagnosed and undertreated in adults with achondroplasia, underlining the importance of a formal hearing assessment being conducted also in adolescents and young adults with this condition . FurtherHearing loss may have a negative effect on work participation and educational achievements, and compensating strategies are strenuous and can cause tiredness . In adulStrengths of this study are the population-based study sample, all having genetically confirmed achondroplasia, and a comprehensive audiologic assessment conducted in all participants. Other strengths are that all hearing assessments were conducted by an experienced investigator and in accordance with current international reference standards.There are also limitations to this study. First, there were few participants in the oldest age group over 64 years of age. In the general population, hearing loss increases with age , 21. ASecond, the exact prevalence of achondroplasia within Norway is uncertain. We have estimated the population of adults (16 years or older) with achondroplasia in Norway to be between 66 and 101 adults . As thisFinally, our study population consisted only of Caucasian participants, although this was not an inclusion criterion. Prevalence rates of hearing loss might be different in achondroplasia populations of other ethnicity, although the medical complication rates, including otitis media infections, seem to be relatively consistent across achondroplasia study populations of different geographical origin , 41, 42.This population-based study has demonstrated that adults with achondroplasia are at increased risk of early hearing loss, in contrast to the general population where hearing loss largely is caused by ageing. The high prevalence of early hearing loss underlines the importance of a regular hearing assessment being part of standard care in achondroplasia, including adolescents and young adults. In adult patients diagnosed with hearing loss, an evaluation by an otolaryngologist should be considered, and the need for hearing aids, assistive listening devices, and workplace and educational accommodations should be discussed. New precision therapies aimed at restoring normal endochondral ossification are now in final clinical development for children with achondroplasia , 43, and


Colorectal polyps are precursor lesions of colorectal cancer and are known to be associated with obesity, low physical activity, and unhealthy behavior. This cross-sectional study analyzed the prevalence of colorectal polyps based on cardiorespiratory fitness (CRF), muscle strength, and health behavior in older adults. Participants were asymptomatic and included 1024 men and 472 women aged 65–80 years who visited the health care center. Colonoscopy was performed under conscious sedation, and cardiorespiratory fitness was measured as the maximum oxygen uptake using gas analysis. Muscle strength was determined using isokinetic equipment, and physical activity, alcohol consumption, and smoking status were investigated using questionnaires. Waist circumference was measured at the thickest part of the middle of the abdomen. Logistic regression analysis was used to calculate the prevalence of colorectal polyps using odds ratios (ORs) based on the variables. The incidence of colorectal polyps was 65.2% in men and 48.5% in women. The ORs of colorectal polyps for obesity were 1.151  and 1.178  in men and women, respectively. The OR for colorectal polyps in male current smokers was 1.884. The ORs for low CRF were 1.985 and 1.841 in men and women, respectively, compared with high CRF. The prevalence of polyps increased with low muscle strength (men’s OR 1.343 women’s OR 1.440) and physical activity in both men (OR 1.693) and women (OR 1.861). In conclusion, lower CRF and muscle strength were associated with an increased prevalence of colorectal polyps in men and women. In both sexes, high waist circumference and low physical activity increased the prevalence of colorectal polyps. Cancer is a leading cause of mortality worldwide, and according to the Global Cancer Statistics 2018 report, colorectal cancer is the fourth leading cause of death, with a mortality rate of 6.1% [‘Colorectal polyp’ refers to a lesion consisting of neoplastic tissue protruding above the intestinal mucosa. The adenoma corresponding to the highest rate among polyps is known as a precursor of colorectal cancer . ExpertsRisk factors for colorectal polyps and cancer include non-modifiable factors—such as age, sex, and genetics—with a high incidence of polyps being reported in older adults and men . In addiPrevious research suggests that high physical fitness reduces the incidence of colorectal polyps. In a cardiorespiratory fitness (CRF) analysis in young adult men, the prevalence of colorectal polyps was reduced by 31.3% in individuals in the upper quartile group compared to those in the lower quartile group . HoweverTherefore, this study cross-sectionally analyzed the prevalence of colorectal polyps according to cardiorespiratory fitness, leg muscle strength, obesity, and health behavior among older adults in Asian countries where the incidence of colorectal cancer is increasing. We hypothesized that lower fitness levels, reduced frequency of physical activity, and negative health behavior would be associated with a higher prevalence of colorectal polyps.n = 560), (2) had not completed the questionnaire (n = 146), (3) had a history of colorectal cancer, and (4) were diagnosed with cancer through biopsy of polyps at colonoscopy (n = 30)  were analyzed. The participants were asymptomatic and visited for disease prevention and care. Healthcare center visitors were generally informed through brochures or bulletin boards, and participate voluntarily. Patients were excluded if they (1) were unable to complete the fitness test due to physical and psychological discomfort or refusal ((n = 30) .The participants fasted from 6:00 p.m. the day preceding the test. All tests were performed in the morning, and the order of inspection was designed to prevent inter-influence. Center visits were made before 8 a.m. During the visit, a health questionnaire was completed, and physician consultations were conducted. The doctor consulted the medical history and determined the patient’s current condition; if there was no abnormality, medical examinations were performed. The first medical examination included electrocardiography, blood pressure measurements. The body height, body weight, and waist circumference of participants were also measured. Subsequently, CRF, muscle strength, and colonoscopy were performed. After all the tests were completed, the doctor evaluated patients for safety and health issues before being discharged.Participants signed informed consent, and all data was de-identified in conformance with ethical guidelines. The study was conducted in compliance with the Declaration of Helsinki and was approved by the institutional review board of institutional review board of Zhengzhou University .The questionnaire was self-completed, and the staff provided assistance only if the participant did not understand a question or requested help. Physical activity, alcohol consumption, and smoking status were measured using questionnaires published by the WHO. Physical activity was investigated using the International Physical Activity Questionnaire (IPAQ), and the weekly frequency of moderate and high intensity was used for analysis . Alcohol2 was classified as normal, BMI of 23.0–24.9 kg/m2 as overweight, and BMI ≥ 25.0 kg/m2 as obese. A tape measure was used to determine the waist circumference by measuring at the thickest part between the last lip and above the iliac crest. The participant stood with the upper body upright and breathed naturally; the examiner adjusted the tape measure horizontally and recorded the value obtained immediately after the participant exhaled. Care was taken to avoid placing pressure on the skin when using the tape measure. A waist circumference >90 cm in men or >80 cm in women was classified as obesity according to the WHO adult Asian classification [The WHO Asia–Pacific standards were applied for obesity . BMI ≤ 2fication .CRF was measured using gas analysis . The BRUCE protocol was selected and initiated with light walking; the speed and inclination were gradually increased every 3 min . The exa2 and CO2 ventilated through the sensor were measured in real time, and the test was continued until the participant stopped. The maximum oxygen uptake obtained during this process was recorded in mL/kg/min. During the test, a 12-lead electrocardiogram  was used to evaluate heart function, and all tests were conducted under the supervision of a cardiologist.OAn isokinetic dynamometer (CSMi) and HUMAC software  were used to measure leg muscle strength. Before the test, participants were asked to confirm their physical condition, whether they had injuries other than the knee, and if they could exert maximum strength. The participants performed 15 min of warm-up exercises including cycling, walking, and stretching. The examiner explained what the test entailed and conducted appropriate practice sessions. Before initiating the actual test, participants performed several movements at low, medium, and high speeds to adapt to and gain familiarity with the test equipment. After sufficient practice, the actual test was performed.−1).Concentric knee extension and flexion were measured at 60°/s. The test range was 0° (knee extension) to 90° (flexion), and the starting posture was 90°. The participant fixed his or her body with a strap while sitting on a chair and used both hands to grip the handle. When the examiner provided the start signal, extension was performed first, followed by flexion. The peak torque (N·m) of extension and flexion were recorded, and the values were summed . Muscle For colonoscopy, the participants fasted from 6:00 p.m. the day preceding the examination, and antiplatelet and anticoagulant drugs were discontinued 3 days before the examination. Polyethylene glycol electrolyte  and water were orally administered to clean the colorectal. The ingredients are as follows: (A) Each pack (56.402 g) consisted of polyethylene glycol 3350 (50 g), potassium chloride (0.5075 g), sodium chloride (1.3455 g), and anhydrous sodium sulfate (3.75 g). (B) Each pack (5.3 g) contained ascorbic acid (2.35 g) and sodium ascorbate (2.95 g). For the first dose, from 8:00 p.m. to 9:00 p.m. the day before the test, packs A and B were taken twice with 500 mL of water. The second dose was taken twice from 4:00 a.m. to 5:00 a.m. on the day of the medical test. For endoscopy, conscious sedation colonoscopy was performed by a gastroenterologist. For participants with colorectal polyps, the type, location, and size were measured, polyps were removed using biopsy forceps or polypectomy, and tissue analysis was performed to identify malignant or benign polyps.Analyses were performed using SPSS . CRF was recorded and analyzed in mL/kg/min, and muscle strength (Nm) was recorded. Muscle strength is affected by body weight (BW); therefore, relative values (kg/BW and Nm/BW) were used in the analyses. The groups were divided into tertiles and classified as high, middle, or low.General characteristics were expressed as medians and standard error, and normality tests were performed for both sexes using the Kolmogorov–Smirnov test. For both men and women, the variables did not follow a normal distribution and the Mann–Whitney U test was performed for between-group comparisons. Furthermore, polyp and non-polyp groups were compared using a nonparametric method for non-normal distribution.p < 0.05.Relationships between categorical variables, physical activity, alcohol consumption, smoking, and colorectal polyps were examined using the chi-square test, and the prevalence of colorectal polyps was analyzed using logistic regression to calculate the odds ratios (ORs). Multiple regression and stepwise analyses were conducted to select adjustment variables, including CRF, muscle strength, smoking status, and waist circumference. Statistical significance was set at p < 0.001), weight (p < 0.001), BMI (p = 0.009), waist circumference (p < 0.001), CRF (p < 0.001), and muscle strength (p < 0.001). There were also significant differences between men and women in terms of smoking, alcohol consumption, and physical activity (p < 0.05).p = 0.006), CRF (p < 0.001), muscle strength (p = 0.004), smoking (p < 0.001), alcohol consumption (p = 0.046), and physical activity (p = 0.021) among individuals with and without polyps. In women, there were also significant differences in waist circumference (p < 0.001), CRF (p < 0.001), muscle strength (p = 0.038), and physical activity (p = 0.044) in the polyp and non-polyp groups.p < 0.05), whereas in women, they were 1.841 and 1.440, respectively (p < 0.05)  .p = 0.014) in men. The OR for smoking was 1.884 . The OR for physical activity was 1.693  after age adjustment; however, no significant value was derived in the multivariate adjustment . Smoking did not significantly increase the OR compared to non-smokers. Compared to daily physical activity, the OR for lack of physical activity was 1.861 .Globally, cancer has a high mortality rate, and colorectal cancer has the third-highest incidence among the different types of cancers . AlthougThis study analyzed the prevalence of colorectal polyps in the elderly based on CRF, muscle strength, and abdominal obesity, as well as health behaviors—particularly smoking status, alcohol consumption, and physical activity.The results of this study indicated that colorectal polyps were more prevalent in men and women with lower CRF. A previous study similarly reported that a high CRF reduced the incidence of colorectal polyps in men by 31.3% . NakamurAlthough the exact biological mechanisms supporting the association between CRF and colorectal cancer or polyps have not been clearly established, several hypotheses exist. Cardiorespiratory function is inversely proportional to fasting insulin levels and positively related to insulin sensitivity. Thus, high CRF blocks the pathway that contributes to the formation of neoplastic tumors . Next, tThe results of muscle strength shown in this study were also approached in a similar context to CRF. Recently, research on sarcopenia has been actively conducted, and this condition is regarded as a general phenomenon associated with aging. Sarcopenia is diagnosed based on muscle mass and grip strength. A study conducted in Korea reported a significant relationship between colorectal neoplasia and sarcopenia. There was a significant difference in the incidence of sarcopenia (51.1%) compared to that in the healthy group (41.1%) . In a stIn this study, the results showed that the prevalence of colorectal polyps was lower in men and women with high physical activity. This fact was also mentioned in the representative health benefits of physical activity published by the American College of Sports Medicine . MoreoveThe probable mechanisms of colorectal cancer prevention through physical activity are related to insulin levels, inflammation, myokine levels, and immune responses. In particular, physical activity can potentially reduce toxins generated during food digestion by decreasing the time that food remains in the large intestine; however, these mechanisms are still being debated . Some stInsulin has been implicated in colorectal tumor cell development; therefore, physical activity may reduce the risk of cancer by reducing insulin resistance and insulin levels, which impacts the insulin-like growth factor pathway . InflammIn this study, the prevalence of colorectal polyps in men was higher than that in women. Similar results have been reported in other studies. In a study conducted in Japan, the incidence of adenomatous polyps was 55.0% in men and 38.3% in women , and a sMore clearly, men have higher tobacco use and alcohol intake than women ; these rDrinking alcohol is considered a major activity affecting health, along with smoking and physical activity; however, this study did not identify any significant relationship between alcohol consumption and polyp occurrence in women, similar to the results of other studies. Shrubsole et al.  reportedIt has been reported that alcohol influences neoplasia through various pathways. Typically, metabolites such as acetaldehyde are produced, and these metabolites can promote carcinogenesis. These mechanisms induce genetic, acquired, biochemical, and immunological abnormalities, leading to chronic inflammation and the formation of neoplastic lesions . There aAbdominal obesity has traditionally been widely applied in cardiovascular disease research and is considered a major risk factor. In this study, the relationship with colorectal polyps was investigated, and the prevalence of polyps was increased in both men and women with obesity. These results are similar to those of various studies. Kim et al.  reportedThis study emphasizes the need for physical activity, physical fitness, and active health care for the prevention of colorectal polyps and extension of colorectal cancer. Therefore, the greatest strength of this study is that the prevalence of colorectal polyps was evaluated by examining muscle strength, physical activity, and health habits. Despite these strengths, this study has several limitations. Since this was a cross-sectional study, there was a limit to determining a causal relationship. Diverse types of polyps—such as adenoma, hyperplastic, serrated, and hamartomatous polyps—have been analyzed in another study . HoweverSeveral studies have examined the incidence of CRC based on the socioeconomic status of the participants. Those with low education and low income exhibited 42% and 31% increased risk of colorectal cancer compared to those with higher education and higher income, respectively . This inIn addition to the risk factors investigated in this study, various other factors influence the prevalence of colorectal polyps. For example, diabetes was associated with colorectal polyps , and shiFor the prevention of colorectal health, lifestyle modification in terms of health behaviors is important, and experts recommend regular colonoscopy, even for asymptomatic individuals . TherefoIn this cross-sectional study, the incidence of colorectal polyps in the elderly was higher in men than in women. Low cardiorespiratory fitness increased the prevalence of colorectal polyps 1.985- and 1.841-fold in men and women, respectively. Moreover, abdominal obesity, low physical activity, and low muscle strength also increased the prevalence of colorectal polyps in both men and women. Older men with current tobacco use and high alcohol consumption frequency increased the risk of polyp formation. Therefore, high CRF, high physical activity, and normal abdominal circumference may have a role in preventing colorectal polyps in the elderly.


The temporal association of mucormycosis with coronavirus disease 2019 (COVID-19) has been termed COVID-19-associated mucormycosis (CAM). Because of its poor prognosis, early diagnosis and treatment are crucial. Although tissue samples for culture and histological evaluation are the cornerstones of diagnosis, the role of fine-needle aspiration cytology (FNAC) and cytologic findings are also significant. Here, we report a case of mucormycosis in a COVID-19-positive 34-year-old male diagnosed by FNAC and confirmed by fungal culture. To our knowledge, this is possibly the first and only case report of CAM diagnosed by FNAC. Coronavirus disease 2019 (COVID-19)-associated mucormycosis (CAM) is the term used to describe the association of mucormycosis in COVID-19 patients that was rampant during the second wave of the pandemic. Indiscriminate use of corticosteroids, uncontrolled blood sugar levels, and viral lymphopenia are some key factors implicated in the development of mucormycosis in COVID-19 patients [2 of 82% on room air. The reverse transcription-polymerase chain reaction test for severe acute respiratory syndrome coronavirus 2 was positive. Chest examination showed bilateral air entry. Additionally, cardiovascular system examination and abdominal examination were normal. His routine blood investigations showed hemoglobin of 15.3 g/dL, total leukocyte count of 8,300/mm3 with 81% neutrophils, and platelet count of 112,000/mm3. His C-reactive protein (CRP) level was 18.93 mg/dL, and his lactate dehydrogenase level was 725 U/L. His blood sugar levels were monitored in the ward and were not elevated. Serum ferritin level was 1,929 ng/mL. The radiological findings on chest X-ray and non-contrast-enhanced computerized tomography (CT) are shown in Figure A 34-year-old male patient was admitted to our hospital with complaints of fever and difficulty in breathing for the past seven days. He was not a known diabetic or hypertensive. On presentation, he was conscious and afebrile, with SpOThe patient’s chest X-ray Figure  showed bMay-Grunwald-Giemsa (MGG) stain showed some loose aggregates of basophilic amorphous material resembling calcification Figure , inset. In light of the above cytological and culture findings, the HRCT findings were reviewed. There were focal areas of the reverse halo sign in the right middle lobe region, which is specific for pulmonary mucormycosis Figure . There wOne of the most dreaded opportunistic infections associated with COVID-19 that has ravaged the world is mucormycosis which caused significant morbidity and mortality in India during the second wave of the pandemic. Mucormycosis is an angioinvasive fungal infection caused by a fungus of the order Mucorales. It is usually present in the environment and grows on wet surfaces and dead and decaying vegetable matter. Predisposing risk factors for mucormycosis include immunosuppression, chronic kidney disease, malignancy, neutropenia, increased serum iron, and, most importantly, diabetes mellitus with ketoacidosis [Mucormycosis is classified into the following five forms depending on the site of infection: rhinocerebral, pulmonary, cutaneous, gastrointestinal, and disseminated type . PulmonaThe first case of pulmonary CAM in a COVID-19 patient was reported by Pasero et al.  in DecemThe identification of fungal elements in histological sections and fresh clinical specimens, such as bronchoalveolar lavage and biopsy, confirm infection. Although site-specific biopsy and culture are important for the diagnosis of mucormycosis, guided FNAC also plays a crucial role in pulmonary CAM . The utiThe morphological differences between Mucor and Aspergillus in the cytological and histopathological examination are important for accurate diagnosis and guiding the choice of treatment. On cytology, the hyphae of Mucor are quite variable in size, averaging 15-20 µm in diameter, are aseptate, and show right-angle branching. However, Aspergillus hyphae, measuring 3-6 µm, are septate and show regular, dichotomous, acute angle (45 degrees) branching. The tendency of the Mucor hyphae to fold and wrinkle gives them a ribbon-like appearance which is very helpful in identification. Another cytological finding seen in our patient was the presence of bluish calcific material on the MGG stain, possibly representing calcium oxalate crystals Figure ; inset; We performed an extensive search of PubMed and Medline but did not come across any study reporting post-COVID-19 mucormycosis diagnosed on FNAC; hence, this case probably represents the first case of pulmonary CAM to be diagnosed by FNAC and confirmed by fungal culture. Pulmonary mucormycosis presenting with a neck mass is very uncommon, and the literature review revealed only one such uncommon case reported by Ukoha and Nguyen in 2021 . The facThis case highlights the utility of FNAC in providing an early and accurate diagnosis of mucormycosis, especially in a critical situation like CAM, where the timely diagnosis is key to the successful management of a potentially serious and fatal condition. Although tissue biopsy confirmation is recommended, FNAC is very useful to obtain adequate diagnostic material, especially in pulmonary mucormycosis. The characteristic appearance of the fungal hyphae on aspirate smears and confirmation by fungal culture helps establish the diagnosis of mucormycosis in any suspected patient of CAM. The possibility that mucormycosis can also present as a soft tissue swelling, especially in COVID-19 patients, should be kept in mind and needs urgent attention.


The present study reviews our experience with children with white matter disturbances and the benefits they get from rehabilitation post cochlear implantation.It is a retrospective cohort study of 7 cochlear implanted children with white matter disturbances. Preoperatively all the subjects had undergone a complete Audiological test battery for confirmation of hearing thresholds. Post assessment, a digital hearing aid trial was followed by three months’ therapy. Unilateral cochlear implant surgery and monitored auditory-verbal therapy sessions were the next line of treatment for at least one year. The therapist regularly monitored hearing and communication outcomes on an Auditory verbal ongoing scale, revised CAP, MAIS, word, and sentence discrimination scores.The age range of Implantation was between 48 to 60 months. 5 out of 7 participants showed remarkable improvement with regular therapy. Their Meaningful Auditory Integration Scale (MAIS) scores were greater than 35 indicating good auditory integration and Categories of Auditory Performance (CAP) revealed scores of even 9 and higher indicating good telephone conversation. Speech Intelligibility Rating (SIR) showed a rating of 4 meaning thereby that an unfamiliar Listener could understand Speech without additional cues. However, all of them reported difficulty perceiving speech in noisy environments. Two cochlear implantees needed speech reading cues in conjunction with the audition.Our experience with cochlear Implantation in children with white matter abnormalities has been positive and satisfactory. The presence of white matter abnormalities on MRI should not be a contraindication for Implantation. Successful outcomes can be expected with regular and dedicated auditory-verbal therapy sessions.  Cochlea002 has rin India -6. With in India -9. Perivin India . White matter disturbances have been associated with gait and postural defects, ophthalmological disorders, learning problems and attention abnormalities . The disA cochlear implant is an invasive and expensive procedure; identification of appropriate candidacy is the primary goal. Successful outcomes with cochlear Implantation are comparable to regular hearing counterparts in Hearing, Speech, and Language performance . Early iThis study retrospectively analyzed data from cochlear implanted subjects with white matter disturbances. The study sample consisted of prelingual cochlear implantees who had attended regular auditory-verbal therapy at a tertiary care hospital. All the subjects had undergone free field audiometry, Immittance Audiometry, Auditory Brainstem Response (ABR), and Otoacoustic Emissions (OAE) to confirm severe to profound hearing loss. The study sample comprises five males and two females, age range 7-17 years .A thorough case history was acquired that included patient demographics, chronological age, gender, the age at which fitted with a hearing aid, the age of cochlear Implantation and pre-peri- and post-natal medical history. All the subjects had undergone regular Speech and language therapy for six months to 1 year with hearing aids before Implantation.A retrospective chart review showed that a detailed pediatric and neurologic examination had been conducted before Implantation. None of the subjects had any neurologic deficits other than white matter changes in the brain. The patients with features of leukodystrophy on MRI were assessed by the pediatric Neurologists and Intensivists. All the subjects reporting white matter changes were classified into three categories: mild – showing periventricular temporal, anterior and posterior horn or body involvement, moderate – showing two or three lesions and severe – showing 3 or more lesions. Most of them had associated bilateral profound hearing loss for which they were being considered for Cochlear Implantation. Additionally, some of them had features of attention deficit hyperactivity disorder. One of the subjects had motor difficulty, one patient had features of mild athetoid Cerebral palsy and developmental delay. However, none of them had any seizure disorder. Imaging dataHigh-resolution HRCT and MRI of temporal bone and brain had confirmed the presence of white matter disturbances in all seven subjects. MRI scans of two patients are shown below for illustration , and 3 tSpeech and language assessment was conducted through various scales and tests, viz; Auditory verbal ongoing scale (AVOS), categories of auditory performance (CAP), Meaningful auditory integration scale (MAIS), Speech intelligibility rating scale (SIR), and Speech discrimination ability (using a Punjabi PB word list)The purpose of presenting this case study was to characterize the long-term speech and language outcomes in implantees with white matter disturbances.Case 1 The subject is a 16-year-old male, implanted on the right ear at the age of 4. He was diagnosed at 2years with a bilateral profound sensorineural loss with the absence of ABR waves at 99dBnHL and absent OAEs. Digital hearing aids were accepted quickly by the subject, and his parents regularly attended therapy sessions. Due to the limited benefit even after three months of regular hearing aid usage, the child was worked up for Cochlear Implantation. Detailed radiological examination revealed mild to moderate peri-ventricular and deep white matter changes. The psychological evaluation revealed above average intellectual functioning with no behavioral issues. The radiological study further showed that the cochlear anatomy was normal in structure. He was implanted with CI 24 RE (ST) cochlear implant at 4 years of age using a round window approach with more than 270-degree insertion. The post-surgery subject underwent intensive Speech and language therapy for two years. His mother attended two sessions (each lasting for 45 minutes) per week for the first six months and one session per week after that. The mother of the child was very enthusiastic and she actively participated during the sessions. She carried out all the home training tasks religiously. The subject attained complex language and pragmatic skills with a sprint processor (Cochlear), which he has been satisfactorily wearing for the past 12 years. He demonstrates excellent listening skills, such as open set listening, auditory memory and auditory sequencing. He listens to music, talks on the telephone, and his speech intelligibility is good. However, he reports intermittent difficulty articulating a few consonants, especially the blends -4.Case 2The subject reported to the tertiary care hospital at the age of 4.5 years, with severe bilateral loss. He was using a digital hearing aid and had attended regular speech therapy for five months at a private clinic, but with a limited benefit. The child was already using gestures along with a few words for communication needs. The workup for cochlear Implantation included a thorough medical and radiological examination which confirmed the absence of inner ear malformations. Neurological examination findings confirmed normal central nervous system functioning. The preoperative psychological assessment showed average intelligence with no significant behavioral concerns. MRI showed increased T2 signals in the medial temporal lobe region and changes in the right frontal lobe. At 5years of age, a round window surgical technique was employed to achieve complete electrode insertion of Nucleus CI 24 RE (ST). The auditory-verbal therapy continued for 2years post-implantation with a freedom processor. The most challenging part was to reduce reliance on gestures for communication and increase auditory comprehension. The parents were very much inclined towards speech rehabilitation and attended speech therapy at a center near their home as well as at the rehabilitation unit of the tertiary care center. The subject presented with a few behavioral issues in the first few sessions of auditory verbal therapy. Time out, along with contingent reinforcement techniques helped to achieve the desired goals at a regular pace. The subject can currently discriminate words and sentences in noise at 60% and 50%, respectively. Connected Speech is intelligible to the Listener with a little concentration -4.Case 3 The subject was the younger brother of the case 2, so he reported very young (at the age of 1 year). He also presented with bilateral profound sensorineural hearing loss. Despite being fitted with digital aids at 1.5 years of age, the subject could attain no optimum benefit in auditory, speech and language domains. The cochlear implant surgery was expedited and a detailed neurological, pediatric, radiological, and psychological evaluation followed thereon. After attaining a neurological and pediatric clearance, radiological examination results showed no dysplasia of the Inner ear canal. MRI showed scattered white matter changes indicative of underlying leukodystrophy. The psychologist's observation indicated no cognitive issues. At two years the subject was implanted with Nucleus CI 24 RE (ST) without any complications. The electrode insertion was complete with the round window technique and the Neural Response Telemetry could be obtained on all the electrodes. Post-switch-on the verbal interactions between the siblings started increasing drastically. However, being the youngest child of the family, the subject had many issues relating to behavior and discipline. He was not cooperative for auditory verbal therapy sessions during initial sittings. Gradually, with a cumulative effort of parents as well as grandparents followed by strenuous therapy, the child showed considerable progress. The subject's mother had attained a great deal of confidence post AVT sessions of the elder sibling. She very keenly took the initiative and carried out many group tasks at home to facilitate speech and language development.As a result, the subject has attained audition and language goals much faster -4. The sCase 4 The Pediatrician referred the child with suspected hearing loss and associated mild motor and visual difficulties at eight months for audition and language goals to the tertiary care. The wave V could not be identified on auditory brainstem response even at 99dBnHL and OAEs were also absent. The audiologist fitted him with Naida Q 30 Phonak hearing aids in both ears. The parents were very motivated and regularly brought the child for therapy. However, consistent responses could be observed during auditory training sessions only for low-frequency sounds like that of the drum. She did not respond even to name call after four months of regular therapy. At 1.5 years of age, the cochlear implant team reevaluated the subject's performance and planned for cochlear implant surgery. The neurologist and pediatrician did their preliminary workup, and no contraindications for surgery were reported. The radiological investigations showed white matter changes in Frontal –anterior and middle cerebral, parieto occipital, and posterior cerebral areas. The psychologist mentioned that the child was shy and took time to build rapport. However, the social quotient (SQ) was age-appropriate. Nucleus CI 24 RE (CA) with a freedom processor was implanted at 1.5 years. The round window surgical technique led to an uneventful surgery, and Intraoperative NRT confirmed the same. She slowly adjusted to her implanted device.Regular mapping sessions ensured a full range of hearing. Parents shifted their base near tertiary care hospital for almost six months for intensive auditory-verbal therapy sessions. The mother worked tirelessly with the daughter, using various auditory-verbal strategies like acoustic highlighting and focused attention to develop listening skills. She is now six years of age; her mean length of utterance is 4-5 words and articulatory errors are frequent. Speech intelligibility is fair; the Listener can comprehend with few repetitions -4. She iCase 5 The subject is a 17-year-old female. She was diagnosed with bilateral sensorineural hearing loss at the chronological age of 4. She was fitted with digital aids (Danavox aid) and she attended regular therapy for six months. However, even after intensive auditory training with hearing aids, she could only detect the low-frequency Ling sounds at a distance of five feet. Her responses to even simple verbal instructions were minimal. She had associated Gait disturbances (mild athetoid movements) and orthodontic anomalies as assessed by the pediatrician. MRI of the brain showed bilateral nearly symmetrical white matter T2 and fluid-attenuated inversion recovery (FLAIR) hyper intensities with diffuse involvement. The radiologist's reports did not indicate any cochlear deformities or underlying diseases. The psychological assessment did not suspect any intellectual disability. At the age of 5, she was implanted with nucleus CI 24 RE (ST), using a round window surgical technique. All the electrodes were active, and within weeks, the cochlear implant was used for all waking hours. Her aided audiogram with a sprint processor was within speech banana, post one month of the switch-on. She continued auditory-verbal therapy for 1.5 years; however, her verbal comprehension and expression were limited despite excellent aided thresholds. Her mother was highly motivated and would continuously expand the child's language through meaningful interaction and encouraged her to progress from simple to complex sentences. The therapist incorporated many techniques during auditory-verbal therapy sessions like auditory bombardment, imitation, expansion, and adding meaning to sound. The subject could identify items from closed set tasks but demonstrated decreased performance in the open set. Presently the child is using both oral and manual modes for communication -4. She iCase 6 The subject was the twin brother of case 5, referred by the pediatric neurology department at 4 years of age with suspected hearing loss. He also presented with orthodontic and facial deformities. The subject's medical records were summarized as having white matter changes within the right parietal region suggestive of underlying leukodystrophy. The parents did not proceed with genetic testing and were keen on initiating the management. Bilateral profound sensorineural hearing loss was confirmed after detailed audiological assessment through Auditory brainstem response, otoacoustic emissions, pure tone audiometry, followed by Immittance audiometry etc. He did not benefit from digital and analog hearing aids. Hence, he was referred for cochlear implant surgery. He was fitted with binaural strong class hearing aids and he underwent language therapy during the preimplant candidacy assessments. By this time, the child had adopted lip-reading skills and manual signs as a mode of communication. Preimplant radiological evaluation ruled out any other brain or cochlear anomalies. At the chronological age of 5, Implantation was completed with Nucleus CI 24 RE (ST). The surgeon used round window insertion with a soft surgical approach. Sprint processor gave him excellent access to verbal stimuli in an extremely stimulating and language enriched environment. The therapist gave them a family-based program where the emphasis was on natural child-centered communication. The parents trained subjects 5 and 6 (twins) for 3-4 hours per day in natural settings. Partnership with professionals and his immediate and extended family's keen involvement fostered the subject's way towards the processing of even complex spoken language. He is currently 17 years and using an N6 speech processor. Speech is intelligible with a little effort, inconsistent use of grammatical markers and inappropriate repair strategies -4. He ocCase 7 The subject was referred from the psychiatry department with mild global developmental delay, attention deficit hyperactivity disorder and inability to speak. His mother was also undergoing psychiatric treatment for depression. There was no other history of seizures, impaired vision, night blindness, or ataxia. Magnetic resonance imaging (MRI) of the brain indicated global hypomyelination. However, the brainstem and basal ganglia were normal. Pure tone and free field assessments were not conclusive about his hearing sensitivity. Objective tests viz  confirmed the diagnosis of bilateral severe to profound hearing loss. During the hearing aid fitting sessions, optimum responses were not observable with any analog or digital aid. Hence, the subject had been enrolled for diagnostic therapy sessions with digital hearing aids. He would frequently throw his hearing aids, and his parents had to shell out a lot of money to repair and maintain the aids. The psychiatrist's opinion helped to manage ADHD (Methylphenidate was prescribed). At the age of 5, a senior surgeon carried out a successful cochlear implant surgery with Nucleus CI 24 RE (ST) using a round window technique. Intraoperative NRT documented on electrodes 1-18 only. Following "switch on," frequent mapping sessions were required to establish conditioned MAPs. Only the father of the subject attended regular sessions and was highly cooperative. The child accepted the cochlear implant and wore it for approximately 5-6 hours a day. He started comprehending 2-3 word meaningful verbal commands and expressed himself through a few words and phrases along with rudimentary gestures -4. HowevThis study is novel in elaborating long-term speech and language outcomes in cochlear implantees with white matter changes. The present research typically evidenced satisfactory results (71.42% subjects), except for a few cases. There is a paucity of literature on long-term outcomes with cochlear implants in white matter disturbances. Most researchers have emphasized cochlear implants' role in malformed ears and compared them with deaf counterparts . NeverthPerlman JM (1998) commented that white matter changes may have an adverse impact on neurodevelopmental outcomes and may act as deterrents in managing cochlear implant subjects . AdditioThe findings of these studies did not agree with those of ours, as 5 out of 7 cases showed significant improvement. MAIS scores with > 35 (showing good auditory integration) and CAP score of >9 (good perception on telephone conversations) implied optimum aural skills. Speech intelligibility rating (SIR) of > 4 in these five subjects indicated reasonably good outcomes. Furthermore, they also demonstrated satisfactory word and sentence discrimination scores in quiet settings.Busi et al. studied the outcome in subjects with brain anomalies and subjects with both inner ear malformations and brain abnormalities. They reported significant differences after 2-3 year follow-up in favor of subjects having only brain abnormalities. The subjects with brain anomalies reportedly had better performances .Researchers have also emphasized significant differences in long term outcome scores after cochlear implantation in subjects with brain anomalies, implanted at older than 3 years of age . Robbins and colleagues observed that IT-MAIS results were favorable for children under 19 months of age with comorbidities . Gears (Despite having limitations, i.e., retrospective case study and small sample size, our study provides positive evidence towards cochlear Implantation in white matter disturbances. Our results reflect an assessment of the extensive case series and support the earlier notion that Cochlear Implant surgery is a successful intervention technique with favorable long-term benefits in subjects with white matter abnormalities.Periventricular white matter injury remains a significant problem in almost 15-20% of infants. The current research reported positive outcomes of cochlear implanted children with white matter abnormalities. We believe that an experienced team of professionals and an early intervention would be the two critical factors for attaining successful implantation outcomes. Therefore, children showing demyelination on MRI are potential candidates for cochlear Implantation.


Even before the COVID-19 pandemic, there was mounting interest in remote testing solutions for audiology. The ultimate goal of such work was to improve access to hearing healthcare for individuals that might be unable or reluctant to seek audiological help in a clinic. In 2015, Diane Van Tasell patented a method for measuring an audiogram when the precise signal level was unknown . In this method, the slope between pure-tone thresholds measured at 2 and 4 kHz is calculated and combined with questionnaire information in order to reconstruct the most likely audiograms from a database of options. An approach like the Van Tasell method is desirable because it is quick and feasible to do in a patient's home where exact stimulus levels are unknown. The goal of the present study was to use machine learning to assess the effectiveness of such audiogram-estimation methods. The National Health and Nutrition Examination Survey (NHANES), a database of audiologic and demographic information, was used to train and test several machine learning algorithms. Overall, 9,256 cases were analyzed. Audiometric data were classified using the Wisconsin Age-Related Hearing Impairment Classification Scale (WARHICS), a method that places hearing loss into one of eight categories. Of the algorithms tested, a random forest machine learning algorithm provided the best fit with only a few variables: the slope between 2 and 4 kHz; gender; age; military experience; and self-reported hearing ability. Using this method, 54.79% of the individuals were correctly classified, 34.40% were predicted to have a milder loss than measured, and 10.82% were predicted to have a more severe loss than measured. Although accuracy was low, it is unlikely audibility would be severely affected if classifications were used to apply gains. Based on audibility calculations, underamplification still provided sufficient gain to achieve ~95% correct (Speech Intelligibility Index ≥ 0.45) for sentence materials for 88% of individuals. Fewer than 1% of individuals were overamplified by 10 dB for any audiometric frequency. Given these results, this method presents a promising direction toward remote assessment; however, further refinement is needed before use in clinical fittings. Several factors have been pushing audiologists toward telehealth, the most obvious of which is the COVID-19 pandemic. The pandemic closed the physical doors of audiology clinics around the world, requiring healthcare professionals to come up with alternatives to traditional in-person clinical approaches. Regardless of the pandemic, a shift to telehealth is necessary to reach underserved communities and individuals far away from audiology clinics.One way to provide more convenient, accessible care for patients is to have them complete hearing tests in their own home. Testing hearing in the home is not a new concept. Computer-based or cellular phone-based hearing screenings  have been used successfully e.g., –3]. Howe. Howe3)]It is difficult to devise at-home hearing testing when the patient uses their own home computer or cell phone with earphones because that equipment will produce unknown presentation levels . A methA similar in-home test would also be useful for experimental procedures. A large, diverse pool of subjects can be recruited and tested quickly by using remote testing. If the population of interest for a study is people with hearing impairment, it may be important to apply gain to the stimuli being tested. In this case, an estimate of the participant's hearing loss is necessary. Because a precise threshold cannot be guaranteed to be measured in the home for the reasons listed above, a remote testing solution that does not rely on precise threshold measurements is desirable.Put plainly, the problem that needs to be solved is this: how can a person's audiometric thresholds be accurately predicted with limited information? Machine learning excels when using a set of features (variables) to categorize an unseen case. In order to do this, a machine learning algorithm is trained on a set of sample data, then it is asked to categorize a set of test data. By way of example, suppose a machine learning algorithm were trained to categorize objects as either an animal, a plant, or a mineral based on the object's features . If the algorithm was asked to categorize a strawberry, it would use the features it was trained on to make its best guess. Then the algorithm would—hopefully—correctly categorize the strawberry as a plant. The accuracy of any given machine learning algorithm is dependent on the particular cases it receives when it is being trained and how generally the algorithm is able to apply what it “learned” during the training phase. A large, diverse dataset tends to provide strong fits for a machine learning approach.Fortunately, a large, diverse dataset of audiologic information exists in the public domain: the National Health and Nutrition Examination Survey (NHANES). NHANES is a complex survey that is collected biennially in the United States. Each survey cycle examines roughly 10,000 individuals from the United States civilian non-institutionalized population. Participants in the survey are given questionnaires, some are interviewed, and some receive medical examinations including audiometric tests. The NHANES database provides a rich source of pure tone audiometric and demographic data from individuals in the United States.Audiometric data were categorized in order to facilitate most machine learning approaches . There aThe goal of the present study was to determine how accurately a machine learning algorithm can predict a person's audiometric configuration given limited information about that person's demographics, hearing loss, and self-reported difficulty hearing. An additional goal was to apply this approach in a hypothetical speech test remotely administered, and to quantify the degree to which mismatches between the observed and predicted audiometric configurations would affect speech intelligibility. Three machine learning algorithms were trained using the following features: age, gender, previous military experience, the slope between 2,000 and 4,000 Hz pure tone thresholds, and self-reported amount of hearing difficulty.All data preprocessing and analysis was done in R  using thhttps://www.cdc.gov/nchs/nhanes/index.htm). NHANES is a complex survey that studies the United States civilian non-institutionalized population. As a part of this survey, participants in most survey cycles receive audiometric evaluations. The large sample size and diverse population make NHANES an excellent dataset for examining audiometric patterns within the population surveyed. Because pure-tone thresholds were necessary for the present analysis, sample sets that did not include audiometric measurements were excluded. The sample sets that included audiometric data are those from 1999–2012 and 2015–2016. This span of years resulted in 71,963 cases.Data were downloaded from the National Health and Nutrition Examination Survey (NHANES) database . Therefore, the MEC weights were used for the present study. Eight NHANES cycles were combined for this dataset. Based on the guidelines laid out in the NHANES tutorials, a combined weight was created by multiplying the weights from 1999–2002 by 0.25 and the weights for all other years by 0.125. These new weights were saved and used in analysis.The survey questions asked of participants also changed over the years. The question of “General condition of hearing” (Which statement best describes your hearing (without a hearing aid)?) had six possible answers from 1999–2004 (AUQ130), eight possible answers from 2005–2010 (AUQ131), and was given a new designation starting in 2011 (AUQ054). The data needed to be adjusted for these changes. From 1999–2004, participants could answer: “Good,” “Little trouble,” “Lot of trouble,” “Deaf,” “Don't know,” or by refusing to answer the question. Starting in 2005, participants were given two new answers to the question: “Excellent,” and “Moderate hearing trouble.” When the data were merged, the class of answer from 1999–2004 was unchanged, though it should be noted that some number of participants that responded “Good” from 1999–2004 may have chosen “Excellent” if it were an option for them. A similar argument applies to the “Moderate hearing trouble” response added in 2005. For ease of reading, all three versions of this question  will be referred to as “the question regarding hearing condition.”Next, data were cleaned to ensure all cases had the following data: audiological thresholds for both ears at audiometric frequencies between 0.5 and 8 kHz, military experience, age, gender, and a response to the question regarding hearing condition. Of those 72,509 cases, 62,087 cases (85.6%) did not have audiological data because they did not participate in the MEC portion of their NHANES cycle. In addition to those missing audiological data, 1,164 cases (1.6%) were missing military status data. Two cases were missing answers to the question regarding hearing condition. All of these cases were dropped from the analysis resulting in 9,256 individuals with complete data for the variables listed above . Wisconsin Age-Related Hearing Impairment Classification Scale (WARHICS) classes were calculated for each ear for each person and saved as a separate variable for the two ears (WARHICS left and WARHICS right). The WARHICS subcategories were not included in this analysis because the subclasses were subsumed by the major classes in a previous study  were male and 5,100 cases (55.1%) were female. Eight hundred seventy-seven cases had military experience (9.5%), 8,377 cases had no military experience (90.5%), one refused to answer the question and one responded “I don't know.” Age ranged from 17 to 85 years. The distribution of ages is plotted in Three machine learning algorithms were trained on the dataset to predict WARHICS class: random forest (RF), support vector machines with a radial kernel , and k-nearest neighbors (KNN). Accuracy was used to assess the efficacy of the algorithms.N = 9,256) were used for a second round of validation and testing.The 9,256 data points for the left ears were split into two sub-datasets: one for training  and one for validation . Only three cases were classified as WARHICS class 8, so one of these cases was forced into the validation dataset. The other two cases classified as WARHICS class 8 were used in the training dataset. The right ear data . Cohen's kappa was calculated as 0.35 which signifies a fair agreement between the reference and prediction . Cohen's kappa showed fair agreement between the machine learning algorithm and the reference classifications (Cohen's kappa = 0.3573). The confusion matrix from which these values were calculated is shown in Right ear data were used to test the RF algorithm. The same model trained on 80% of the left ear data was used to predict the classification for all 9,258 cases of right ear data. Again, accuracy was significantly greater than the no information rate , or by devising a threshold test at the outset of the experiment to identify those that were underamplified. Such methods are speculative here and would need to be refined further in the future.User-operated tests could be applied inside and outside of the clinic. In the clinic, it could be used to improve efficiency. An audiologist that needs to only measure two or three air conduction thresholds in conjunction with a short questionnaire would save a substantial amount of time, improving the efficiency of clinic operations. The saved time could then be used for other diagnostic tests or counseling. This is consistent with calls to action for audiologists to focus on more sophisticated measures, expert interpretation, and patient counseling, vs. spending a majority of their appointment time manually adjusting the levels produced by a pure-tone audiometer , 20. WitAs a caution, if in-home testing becomes a broadly accepted option in the future, careful steps will need to be taken to make sure that patients have a pathway for follow-up likely including a full audiogram, medical care, and that treatable audiologic disorders are not missed. One questionnaire, the Consumer Ear Disease Risk Assessment (CEDRA), effectively screens for serious audiologic disorders . CEDRA oFor research studies, a researcher using the approach described here might be able to administer in-home speech tests to individuals with hearing loss without needing detailed knowledge of the participant's computer, headphones, or sound card. Although environmental factors  cannot be controlled for using this method, the experimenter can coarsely estimate the class of a participant's loss and apply the appropriate gain. In view of the known difficulties in accurately predicting loudness perception from pure-tone thresholds , it woulhttps://wwwn.cdc.gov/nchs/nhanes/default.aspx National Health and Nutrition Examination Survey (NHANES) years 1999-2012 and 2015-2016.Publicly available datasets were analyzed in this study. This data can be found here: GE: responsible for data processing, analysis, figures, tables, and Discussion. PS: responsible for Introduction, Discussion, framing, and editing. Both authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.