Hearing impairment is a significant challenge faced by medical students and physicians, impacting their communication abilities and stethoscope use. This condition, though prevalent, remains underaddressed in medical education, with many institutions lacking explicit support systems and some even imposing exclusionary standards. This personal narrative chronicles the journey of a medical student who experienced a gradual and severe bilateral sensorineural hearing loss. This article also highlights the pivotal role of cochlear implants in significantly enhancing the author's academic and social life. Medical educators are encouraged to understand the challenges faced by hearing-impaired students and adapt their teaching methods to support them effectively. Many schools do not explicitly support accommodations, and some reject certain accommodations or have more exacting and exclusionary technical standards.2 Deafness is not a visible disability, although the hearing aids are conspicuous. Most physicians and medical students with hearing impairment want people to understand the obstacles they have to hearing, while simultaneously wanting to appear "normal."3 They become quite isolated, repeatedly failing at social engagement and finding it very difficult to understand what anyone is saying, particularly in locations with background noise.4 However, there is a lack of literature on the difficulties faced by hearing-impaired medical students and how medical educators can support them with their training.5Hearing is an important sense for medical students and physicians, making communication and stethoscope use possible.6 While facing shock, grief and fear at the same time, the phase of denial made the situation even more challenging.7 The feeling of isolation and frustration made me gradually lose the closeness with my family, friends, and relatives. However, over time I gradually accepted my condition and was resilient, determined and hopeful that some technology may surely help in future.Bilateral sudden sensorineural hearing loss was diagnosed when I was 14 years old. However, at that time, it was mild to moderate in severity. Later, my hearing capacity gradually decreased over time until I could no longer recognize words despite perceiving sounds to a satisfactory level. Further investigation showed bilateral auditory neuropathy spectrum disorder (ANSD), a hearing condition where the ear receives sounds normally, but the signals to the brain get scrambled, making it difficult for a person to understand speech or other sounds clearly.By the time I entered my first year in medical school, I was nearly deaf bilaterally. With the fear of being noticed as a hearing-impaired student, understanding lectures were the most challenging and even minor noises were irritating. While having a hard time listening to people in groups, I preferred studying alone. As a result, my speaking frequency decreased which affected my speech in comparison to others and was painful in itself. My hearing loss made my learning very slow and difficult, but I made the decision to never give up.8During my early clinical year, my friends would write everything the professor and patients would say. I completely relied on them and it was tiresome and stressful. Besides, COVID-19 made everything difficult with everyone wearing face masks as recognizing facial expressions and lip reading was impossible. During the lockdown phase, I relied on auto-captioning of Microsoft Teams applications as Zoom had no captioning feature. My experience on Zoom was limited to reading slides and taking screenshots at that time as a general public.During my first year, I was donated a pair of hearing aids. I was excited about listening to everything, having conversations, sharing knowledge and having to laugh together with friends, family and relatives. I was hard working and also thought I would enjoy learning medicine. That did not happen. My hearing aids just amplified sounds but speech recognition was very poor. So, the first 3 years of my medical school were the same with lots of challenges on the way. Still, the amplification of sounds proved to be a great help for me.At the end of my third clinical year, I had right-sided cochlear implant surgery. I did a lot of practice with an implant device. Although its performance depends on whatever social situation I am in, it brought significant improvement in my academics as well as social life. I could hear lectures, phone calls and group conversations. Although background noises were still a problem during conversations with patients as well as professors in the ward, I would just request them to take their masks out and speak louder so that it could be audible that way. I thrived my remaining medical school years successfully and until now.I avoided approaching patients during the beginning of my clinical years for fear of being judged. Repeating was stressful for them like listening was for me. As a result, practical exams were challenging to tackle. In addition, the background noises inwards made it almost impossible to have conversations with patients.After my cochlear implant surgery, my hearing was relatively better. My confidence to approach patients increased by introducing myself and my difficulties first. It became quite easier that way by gradually increasing my visits with different patients to ask about their conditions and do relevant clinical examinations properly. As a result, once painful practical exams became easier during my fourth and final year as I used a Thinklabs digital stethoscope for auscultation. I could hear all the heart, lung and bowel sounds. In this way, I learned how to have a good doctor-patient relationship despite being hearing impaired.The number of hearing-impaired students and doctors within medicine will likely increase in the future. This type of problem necessitates the inclusion of targeted preventive medicine modules in medical curricula regarding modern technology and its health effects. As this type of hearing impairment once established, is irreversible but completely preventable and medical educators need to learn and adapt to these student's needs. Medical educators must become familiar with the challenges faced by hearing-impaired students and be aware of what they can do to enhance their learning experience and support them to achieve to the best of their ability. Furthermore, hearing-impaired students should disclose their disability, and ask people to make reasonable adjustments to help them hear.


This study aimed to investigate the efficacy and safety of intratympanic or postauricular subperiosteal glucocorticoid injection combined with systemic glucocorticoid in the treatment of sudden sensorineural hearing loss (SSNHL).This study is a prospective randomized controlled study. This study included unilateral SSNHL patients who were hospitalized in our department between January 2020 and June 2021. Patients were randomly divided into three groups . Patients in group A were treated with an intratympanic corticosteroid injection combined with systemic corticosteroid treatment, and patients in group B received a postauricular corticosteroid injection combined with systemic corticosteroid treatment. Patients in group C (control group) were treated with systemic corticosteroid alone. The case number of groups A, B, and C was 311, 375, and 369, respectively.P > 0.05). However, there were significant differences in their average age, distribution of audiogram type, and hearing loss levels among them (P < 0.01). Our study shows that there was no significant difference in average hearing threshold improvement before and after treatment in the three groups (P > 0.05). Regarding the complications, in group A, 33 patients (10.6%) had a transient vertigo attack during tympanic injection, which lasted for ~1–3 min. In group B, 20 patients (6.43%) complained of pain at the injection site, which disappeared after 1–3 days. No other complications occurred in all the other patients.There was no significant difference in gender distribution, the proportion of left and right affected ears, and the average interval from onset to treatment among the three groups (The addition of intratympanic or postauricular corticosteroid to systemic steroids did not result in a significant effect on hearing recovery in SSNHL. No obvious complications occur in SSNHL patients treated with intratympanic injection or postauricular injection of corticosteroid.chictr.org.cn], registration number: ChiCTR2100048762.[ Sudden sensorineural hearing loss (SSNHL) is an idiopathic emergency disease. The recommended treatments for SSNHL do not target the etiology of SSNHL specifically. As a result, a large number of patients cannot be cured completely despite comprehensive treatments. Therefore, it is an urgent challenge for clinicians to improve the treatment efficacy of SSNHL.The adopted treatments of SSNHL by clinicians include systemic and local application of corticosteroids, vasodilators, defibrinogenating agents, thrombolytics, neurotrophic drugs, antioxidants, antivirals, and hyperbaric oxygen therapy. Currently, the widely accepted effective treatments are systemic and local use of corticosteroids, which are recommended by the latest Chinese and American SSNHL diagnosis and treatment guidelines , 2. The Intratympanic corticosteroid injection for treating SSNHL was used for the first time in 1996 by Silverstein et al. . Since tvia postauricular capillaries and lymphatic capillaries and transported to the inner ear via its arterial supply, and may also be transported to the inner ear through the bone suture of the auditory vesicle. The drug enters the outer lymph and consequently forms the osmotic gradient between the endolymph and perilymph to exert effects. Currently, the postauricular subperiosteal corticosteroid injection procedure is not mentioned in the American guideline. Therefore, further studies with large sample sizes are needed to evaluate the efficacy of this treatment regimen.Although the effects of corticosteroid tympanic injection alone for treating SSNHL are controversial, there is some evidence that this technology could be used as a salvage treatment for SSNHL patients whose hearing do not restore after 14-day systematic treatment , 12. TheCurrently, few reports focus on the treatment effect of local combined with systemic corticosteroid therapy for SSNHL, and most studies have focused on the efficacy of local corticosteroid administration as a salvage treatment for treating SSNHL. However, it is difficult for many patients to return to the hospital several times to receive salvage treatment, and they expect to achieve the best curative effect in the shortest time during hospitalization. In order to evaluate the efficacy of this combined treatment regimen as an initial treatment for SSNHL, we conducted this prospective randomized study. All enrolled SSNHL patients were divided into three groups: intratympanic corticosteroid injection combined with a systemic corticosteroid, postauricular subperiosteal corticosteroid injection combined with a systemic corticosteroid, and systemic corticosteroid treatment alone (control group). Since the prognostic factors of SSNHL include age, the interval from onset to treatment, type of audiometric curve, and degree of hearing loss, we first compared the baseline of clinical characteristics and pre-treatment hearing results of the patients. Then, we compared the hearing efficacy between the patients of the three groups with different audiometric-type SSNHL.In this randomized controlled study, we enrolled SSNHL patients hospitalized in the Second Affiliated Hospital of Nanchang University from January 2020 to June 2021. All patients underwent routine physical examination, general otorhinolaryngological examination, nervous system physical examination, pure tone audiogram and tympanometry, laboratory examination, and brain magnetic resonance imaging (MRI) examination.The study was performed in accordance with the ethical principles and approved by the Second Affiliated Hospital of Nanchang University Institutional Review Board. Written informed consent was obtained from all patients and/or their guardians.Inclusion criteria were as follows: (1) A diagnosis of unilateral SSNH. The diagnostic criteria were based on the latest guidelines revised by the American Academy of Otolaryngology-Head and Neck Surgery in 2019 (Exclusion criteria were as follows: (1) patients with hearing loss due to other causes such as otitis media, Meniere's disease, otosclerosis, congenital deafness, presbycusis, vestibular schwannoma, and inner ear malformation. (2) The interval from onset to treatment was more than 1 month. (3) Patients who did not undergo standard treatment for 14 days and were discharged without restoring to normal hearing. (4) Patients who had previously received other treatment. (5) Patients with bilateral SSNHL. (6) Patients with contraindications of systemic corticosteroids, such as diabetes, gastrointestinal ulcers, mental disorders, and epilepsy. (7) Patients who dropped out of the study or were lost in follow-up. (8) Patients with insufficient medical record data were also excluded.Patients who met the inclusion criteria were randomly divided into three groups. The patients of group A underwent intratympanic corticosteroid injection combined with systemic corticosteroid treatment; patients of Group B received postauricular subperiosteal corticosteroid injection combined with systemic corticosteroid treatment; and patients of group C were treated only with systemic corticosteroid. Due to the loss of follow-up or lack of complete clinical data, 311, 375, and 369 patients were included in groups A, B, and C, respectively .All patients underwent a detailed clinical interview. Clinical data, demographic information, past medical history, and personal history were obtained. Routine physical examination, otolaryngology examination, and audiological and laboratory tests were conducted in all subjects. MRI scanning of the ear and the brain was performed in all patients.All patients received standard 14-day systemic treatment, which was based on the treatment recommended by the Chinese guidelines for SSNHL diagnosis and treatment revised in 2015  of methylprednisolone was injected at the postauricular site. The injection site was located 0.5 cm behind the posterior sulcus of the affected ear and was level with the posterosuperior part of the external auditory meatus . After tAll patients' hearing was evaluated with pure tone audiogram and tympanometry. All hearing tests were carried out by the same audiologist. Air and bone conduction was assessed at frequencies of 250 Hz, 500 Hz, 1 kHz, 2 kHz, 4 kHz, and 8 kHz.Pure tone audiogram (PTA) was calculated by averaging air conduction thresholds at 0.5, 1, 2, and 4 kHz . The heaIn addition to calculating patients' PTA, we evaluated patients' hearing by calculating the average air conduction hearing threshold at hearing impairment frequency. The patients' hearing of the affected ear was assessed by referring to the unaffected ears' hearing or their affected ears' initial hearing. Referring to the 2015 Chinese guidelines  was performed for the data conforming to normal distribution and homogeneity, while a Kruskal–Wallis test was conducted for those not conforming to normal distribution or homogeneity. Categorical data were shown as percentages and compared using the chi-square test. The Fisher exact test was used when expected counts in the chi-square test were insufficient. All analyses were conducted using SPSS version 25 for Windows. All statistical tests were two-sided, and statistically significant levels were set at a P < 0.01). However, no significant difference existed in patients' gender distribution, the proportion of affected left or right ears, and the average interval from onset to treatment between the three groups (P > 0.05).P < 0.01). The pre- and post-treatment PTA and the PTA gap of the patients in the three groups were also significantly different (P < 0.05). The biggest pre- and post-treatment PTA gap existed in group B, followed by group A and group C. In addition, the pre- and post-treatment average hearing thresholds at the impairment frequency in patients of the three groups were significantly different (P < 0.05). As for the pre- and post-treatment gap of hearing thresholds at hearing impairment frequency, the largest one existed in group B (23.479 ± 21.740 dB HL), followed by group A  and group C . This gap was statistically significant (P < 0.05). In terms of grading of hearing efficacy, the highest one was in patients of group C (66.8%), followed by group B (61.9%) and group A (52.7%)  .The baseline of patients in the three groups including the average age, gender distribution, and the distribution of auditory types and hearing degrees was inequivalent, which may affect the post-treatment hearing effect. Therefore, we analyzed the efficacy of SSNHL patients with different audiogram-type SSNHL.P > 0.05). In terms of hearing results, a significant difference existed in the pre- and post-treatment average hearing threshold at the hearing impairment frequency among the patients in the three groups (P < 0.05), but no significant difference was observed in the gap between pre- and post-treatment average hearing threshold at the hearing impairment frequency (P > 0.05), which were 17.454 ± 15.166 dB, 22.296 ± 14.959 dB, and 18.91 ± 13.142 dB, respectively. However, there was a significant difference in the proportion of patients with different hearing efficacy grading in the three groups (P < 0.05). Furthermore, the hearing recovery rate of patients in group C was higher than those in the other two groups . In addition, no significant difference existed in the pre- and post-treatment average hearing threshold at the hearing impairment frequency among patients of the three groups (P > 0.05), as well as in the gap of the pre- and post-treatment average hearing threshold at the hearing impairment frequency between them (P > 0.05). Similarly, there was no significant difference in the proportion of patients with different hearing efficacy grading among patients in the three groups (P > 0.05)  .P > 0.05), but there was a significant difference in the degree of hearing loss before treatment and pre- and post-treatment average hearing threshold at the hearing impairment frequency among patients in the three groups (P < 0.05). However, no significant difference was observed in the gap between the pre- and post-treatment average hearing threshold at the hearing impairment frequency (P > 0.05). Moreover, there was no significant difference in the proportion of patients with different hearing efficacy grading among patients in the three groups (P > 0.05)  .P > 0.05). Regarding the hearing result, there was a significant difference in the pre-treatment average hearing threshold at the hearing impairment frequency (P < 0.05), but no significant difference in the post-treatment average hearing threshold at the hearing impairment frequency, as well as the pre- and post-treatment gap at the hearing impairment frequency between the three groups (P > 0.05). Moreover, there was no significant difference in the proportion of patients with different hearing efficacy grading among patients in the three groups (P > 0.05)  .In group A, 33 patients (10.6%) had a transient vertigo attack during tympanic injection, which lasted for ~1–3 min; 20 patients felt earache, lasting for 1–3 days. In group B, 18 patients (4.8%) complained of swelling and pain at the injection site, which disappeared within 2 days. No obvious complications such as tympanic membrane perforation or acute and chronic otitis media occurred in patients of group A during follow-up. In addition, there were no complications in all other patients during follow-up.The possible prognostic factors of SSNHL include the patient's age, the audiogram type, the degree of hearing loss, and the interval from onset to treatment , 16. TheThe pathogenesis of SSNHL with various audiogram types may be different, which may explain this discrepancy. For example, the proposed pathogenesis of low-frequency hearing loss may be inner ear hydrops; the high-frequency hearing loss may be due to hair cell injury; the flat-type hearing loss is mostly caused by stria vascularis dysfunction or inner ear vasospasm; and the etiology of profound hearing loss is inner ear vascular embolism or thrombosis .The effectiveness of intratympanic injection combined with systemic corticosteroids for treating SSNHL is still controversial. Several researchers showed that the effect of intratympanic combined with systemic corticosteroid therapy was better than that of systemic corticosteroid administration alone , 20. ForIntratympanic corticosteroid injection has its own advantages. The first one is that it can avoid the side effects of systemic corticosteroid administration, which is contraindicated in patients with diabetes, hypertension, tumor, infection, and acute stage of peptic ulcer. Second, intratympanic injection is easy to operate. However, this technology is an invasive operation and may result in some local complications, such as pain, dizziness, and secondary acute or chronic otitis media. Therefore, it is necessary to select treatment strategies according to the patient's own circumstances. For example, for patients with contraindications of systemic administration of corticosteroids, local administration of corticosteroids can be taken as a priority.Regarding the type of corticosteroid selected for intratympanic injection, dexamethasone, methylprednisolone, and prednisone are most used by medical institutions. Animal experiment results demonstrated that methylprednisolone has the highest permeability after intratympanic injection compared with dexamethasone and prednisone . HoweverAs a new treatment scheme for SSNHL, postauricular corticosteroid injection has been more and more valued by otologists. This scheme is recommended by the 2015 Chinese guideline for the diagnosis and treatment of SSNHL  exploredThe limitation of this study is that after stratification, the sample size of subjects in each subgroup is limited, although our study has a large sample size. Therefore, it is difficult to ensure the equivalence of the baseline such as age or pre-treatment hearing level between each group, which may generate methodological bias and affect the accuracy of the results. Nevertheless, since the baselines of most subgroups are equivalent, our results are convincing. In contrast, in order to ensure the treatment effect, patients received a combination of multiple therapies such as antioxidants, neurotrophic agents, and defibrinogen, which may also result in heterogeneity. In addition, a randomized blind placebo control multicenter study is necessary before we make a clear conclusion.The exact role of intratympanic and postauricular corticosteroids requires additional trials. The addition of intratympanic or postauricular corticosteroid to systemic steroids did not result in a significant effect on hearing recovery in SSNHL. However, for patients with contraindications to systemic corticosteroid administration, intratympanic corticosteroid or postauricular corticosteroid may be safe and efficacious alternatives.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by the Second Affiliated Hospital of Nanchang University Institutional Review Board. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.MD and YL conceived and designed the study. WX, NK, JL, and HP performed the experiments. CL and ZZ collected data. WX, NK, and MD wrote the manuscript. All authors contributed to the writing and final approval of the manuscript.


Background: The prevalence of cigarette smoking is a significant public health challenge in Saudi Arabia, as it is a known risk factor for many health problems. Hearing problems are also a major concern, as they are invisible disabilities that can negatively impact an individual's perception, communication, and social interactions. Studies have identified various risk factors for hearing loss, including genetics, diseases, infection, exposure to noise, and demographic factors such as age and gender. Smoking has been found to be associated with hearing loss, tinnitus, and vertigo, but the results of studies investigating this association have been inconsistent. It is crucial to understand the impact of smoking on hearing problems and tinnitus in the Saudi Arabian population to protect individual and societal health.Aim: We aim to investigate whether smoking is related to tinnitus, hearing loss, or other hearing difficulties.Methods: A cross-sectional study was established from March to August 2022 among adults in the Kingdom of Saudi Arabia to determine whether smoking can affect hearing.Results: It has been observed that smokers experience hearing issues or trouble hearing more frequently than non-smokers. Additionally, as the number of cigarette smoking grows or as smoking persists for longer periods of time, there is a rise in hearing problems/hearing difficulty. In contrast, there is no conclusive evidence associating smoking and tinnitus.Conclusion: These results should encourage more investigation into the impact of demographic factors on hearing problems/hearing difficulty, or tinnitus. Cigarette smoking is a major public health challenge in the Kingdom of Saudi Arabia, as it is a prevalent lifestyle factor and a well-known risk factor for various health issues . BesidesResearch has indicated that different risk factors for hearing loss may be genetic or related to complications or negative consequences of diseases, infections, the use of ototoxic drugs, exposure to noise, etc. In addition, several studies have explored the impact of demographic factors such as gender, aging, and smoking on hearing loss ,5. Age-rTherefore, it is essential to investigate the relationship between smoking and hearing problems while paying attention to demographic factors such as age and gender, as well as smoking habits, the duration of time, and the number of cigarettes smoked per day. A study revealed that women who have smoked in the past or present are more likely to suffer from moderate or severe hearing loss, with the magnitude of risk increasing with the number of years smoked . StudiesConsidering the impact of smoking and hearing problems, including tinnitus, on the quality of life of individuals and society, it is crucial to reveal the effect of smoking on hearing problems or tinnitus in the general population of the Kingdom of Saudi Arabia to safeguard people's health. Thus, a comprehensive understanding of the relationship between smoking and hearing problems is necessary to develop effective strategies to prevent and manage these conditions. In addition, according to the researchers' knowledge, there is a lack of studies conducted in Saudi Arabia that aim to measure the relationship between smoking and hearing, as well as tinnitus. Therefore, this study aims to measure the prevalence of smoking, hearing problems, and tinnitus and also assess the effect of smoking on hearing, or tinnitus, as well as investigate the potential role of covariates (sociodemographic factors and chronic diseases) as determinants of risk for hearing problems or tinnitus, among a large population sample, 18-60 years of age, who represents that population group at the national level.A cross-sectional study was conducted from March to August 2022 to assess the effect of smoking on hearing among the adult population of Saudi Arabia.The sample size was calculated using the Raosoft sample size calculator, taking into account a total adult population of 25,777,851 (aged 18-60), an expected response rate of 50%, a margin of error of 5%, and a standard deviation of 1.96 for the 99% confidence interval (CI). According to the General Authority for Statistics' yearly statistics for the current mid-2020s, a minimum sample size of 664 was required. We doubled the sample size to 1,328 and added a 65% increase to create a more representative sample of survey participants and decrease bias. After applying the exclusion criteria, 2,209 participants from the western, northern, southern, central, and eastern parts of the Kingdom participated in the study.The inclusion criteria were the general adult population, ages 18-60, in all administrative districts within the Kingdom, while participants under the age of 18 and over the age of 60 were excluded. The questionnaire was self-administered and took between five and eight minutes to complete, consisting of 15 items categorized as follows: (1) sociodemographic characteristics, including age, gender, residency region, nationality, marital status, occupation, and level of education; (2) smoking status and presence of chronic diseases; (3) Hearing Handicap Inventory Screening Questionnaire for Adults; and (4) Tinnitus Handicap Inventory (THI).Statistical analyses were conducted using Statistical Package for the Social Sciences (SPSS) version 25.0 . Descriptive statistics, including frequency and proportions, were used to analyze all quantitative variables, including demographic characteristics. Chi-square tests were performed to determine the association between the smoking index and hearing problems/difficulty and tinnitus, as well as to evaluate the demographic characteristics related to these conditions. Logistic regression analysis was also used to predict the presence of hearing problems/difficulty and tinnitus (dependent variable), where odds ratios (OR) and 95% confidence intervals (CIs) were calculated for each independent variable. The statistical significance level was set at p < 0.05, and the results were presented using tables and graphs.The study was granted ethical approval with the number H-2022-310 by the Hail University Medical Research Ethics Committee on December 9, 2022. Before participating, every participant received the questionnaire with their explicit permission and consent, and any ethical concerns were addressed beforehand.A total of 1,939 individuals in the Kingdom of Saudi Arabia were enrolled in the study, including 1,061 men and 878 women, with ages ranging from 18 to 60. The majority (55.2%) were between the ages of 18 and 30. Of those who participated in the study, 1,014 (45.9%) were smokers, while 308 (13.5%) used e-cigarettes. The remaining 617 (31.9%) were non-smokers  participants had mild to moderate hearing impairments with a 50% likelihood of experiencing hearing difficulties, and 156 (7.1%) participants had severe hearing impairments with an 84% probability of experiencing hearing difficulties, as shown in Figure According to the results of the Tinnitus Handicap Inventory shown in Figure Investigation of hearing problems/difficulty of hearingWhen considering the influence of social and demographic factors on the occurrence of hearing problems/difficulty of hearing, the majority of individuals did not express concern about hearing issues or difficulties; however, 338 (15.3%) participants did Figure .After comparing the ages of participants who experienced hearing problems/difficulty hearing, the majority of those were in the age range of 18-30 years, while 4.9% were aged 31-40 years, and 2.3% were aged 41-50 years. The age group of 51 years and over had the lowest percentage of participants who experienced hearing problems/difficulty hearing at 1.4%. There was a significant association between age and hearing problems/difficulty hearing (p = 0.000), as the majority of individuals with these issues were in the age group of 18-30 years.As for gender differences, participating males experienced greater hearing problems/difficulty than participating females, and there was a significant association between gender and suffering from hearing problems/difficulty hearing (p = 0.000). Regarding marital status, there was a significant association between marital status and hearing problems/difficulty (p = 0.000), with 4.9% of unmarried participants and 10.4% of married participants experiencing hearing problems/difficulty hearing, but married people experience these issues more frequently. There was no significant association between Saudi and non-Saudi participants with hearing problems/difficulty (p = 0.467). However, there was a significant association (p = 0.000) between regional differences in Saudi Arabia and hearing problems/difficulty hearing, as individuals in the southern region had a higher risk of experiencing these issues.The majority of individuals with hearing problems/difficulties of hearing were found to be in high school/diploma and bachelor's stages, indicating a significant association between education level and these conditions (p = 0.000). When comparing occupation and the presence of hearing problems/difficulty hearing, it was found that both public and private sector workers suffered from the presence of these issues, with a higher frequency among workers in the private sector. This indicates a significant association between occupation and hearing problems/difficulty hearing (p = 0.000).Similarly, when comparing participants who had chronic diseases with those who did not, an association was observed between the presence of chronic diseases and the occurrence of hearing problems/difficulty hearing (p = 0.000) Table .When investigating the relationship between smoking and its specific factors as risk factors for hearing problems/difficulty hearing, it was found that there is a significant association between smoking and suffering from hearing problems/difficulty hearing (p = 0.000). Smokers were observed to suffer from hearing problems/difficulty hearing more frequently than non-smokers. Additionally, smokers who smoke more than 20 cigarettes a day have a higher frequency of hearing problems/difficulty hearing than those who smoke less than that or use e-cigarettes. Similarly, smokers who have smoked cigarettes for more than five years have a higher frequency of hearing problems/difficulty hearing than those who have smoked recently or for less than five years. This indicates that as the number of cigarettes smoked increases, there is an increase in hearing problems/hard of hearing, and if cigarette smoking continues for a longer period of time, the frequency of hearing problems/difficulty hearing also increases Table .Investigation of tinnitusWhen considering the influence of sociodemographic factors on the incidence of tinnitus, the majority of individuals did not express that they had tinnitus, but 393 (17.8%) participants did Figure .After comparing the ages of participants with tinnitus, the majority of those were in the age group of 18-30 years (9.2%), followed by 4.5% in the age group of 31-40 years, and 3% in the age group of 41-50 years. The age group of 51 years and over had the lowest percentage of participants who reported experiencing tinnitus at 1.1%. However, there was no significant association between age and tinnitus (p = 0.115).Regarding gender differences, male participants were observed to suffer from tinnitus more frequently than female participants, and there was a significant association between gender and suffering from tinnitus (p = 0.018). As for differences in marital status, there was no significant association between marital status and tinnitus (p = 0.100). Similarly, there was no significant association between Saudi and non-Saudi participants with tinnitus (p = 0.976). However, there was a significant association (p = 0.000) between regional differences in Saudi Arabia and tinnitus, with individuals in the southern region having a higher risk of developing these problems, despite the proportions being similar in all regions of the Kingdom.Regarding educational level and its relationship to tinnitus, there was no significant association between educational level and tinnitus (p = 0.760). On the contrary, in terms of the difference in occupation and the presence of tinnitus, it was found that students were more likely to suffer from tinnitus compared to workers, retirees, and non-workers. This indicates an association between occupation and tinnitus (p = 0.019).When comparing participants who suffered from chronic diseases with those who did not but suffered from tinnitus, an association was observed between chronic diseases and tinnitus (p = 0.000). Participants who did not suffer from chronic diseases were found to be the most vulnerable group to tinnitus Table .When investigating the relationship between smoking and its factors specifically, as risk factors for tinnitus, there is no significant association Table .When using binary logistic regression to predict smoking habit as an independent variable associated with hearing problems/difficulty hearing, it was found that 221 (10%) smokers suffered from hearing problems/difficulty hearing. The odds ratio and 95% confidence interval for hearing problems/difficulty hearing in smokers were 0.908 (0.886-0.929) (p < 0.05), indicating that smoking was a significant predictor of hearing problems/difficulty hearing in smokers Table .Our study's goals are to determine the prevalence of smoking habits along with each hearing problem/hearing difficulty and tinnitus, as well as investigate how smoking habits affect these conditions.Smoking in the Kingdom of Saudi ArabiaUpon considering the prevalence of smoking, our study found a significant prevalence of smoking in Saudi society, with almost half of the participants  being current smokers, resulting in a 45.9% smoking rate. Additionally, 13% of the participants were ex-smokers. This indicates an increase in smoking habits compared to a previous local survey, which showed a smoking prevalence of 12.8% among the Saudi population . This stHearing problems/difficulty hearing in the Kingdom of Saudi ArabiaFirst, upon considering the prevalence of hearing problems/difficulty of hearing, our study found that hearing problems are not as prevalent in Saudi society as smoking is.However, this study found a significant association between smoking and hearing issues such as difficulty hearing and hearing loss. This association has been reported in several other studies -21. It iSecond, when investigating the role of sociodemographic factors in hearing problems of hearing, this study found a significant association between sociodemographic factors and hearing difficulties. Age, gender, marital status, region, education, occupation, and chronic illness were all linked to hearing problems. Specifically, married, middle-aged men from the southern region with a bachelor's or diploma degree, working in the private sector, and with chronic diseases were more likely to have hearing issues. The National Institute on Deafness and Other Communication Disorders also reported that men are more likely to experience hearing problems than women . In addiTinnitus in the Kingdom of Saudi ArabiaUpon considering the prevalence of tinnitus, the findings of our study revealed a non-significant prevalence of tinnitus in Saudi society, in the same context as hearing problems.Our investigation found no significant association between smoking and tinnitus. However, we did find that gender, regional differences, educational level, chronic disease, and suffering from tinnitus were significantly associated. Specifically, males, students, participants from the southern region, and those with chronic diseases were more likely to suffer from tinnitus. A previous study revealed that males had higher disability measures than females, particularly in emotional and functional measurements, with 76% of patients experiencing tinnitus-related hearing loss. Male patients also experienced higher severity scores for the disease, 15.3 points higher than female patients . In contTo the best of our knowledge, this was the first study to investigate the association between smoking, tinnitus, and hearing problems in Saudi Arabia. However, our study was limited by its cross-sectional design, which may have resulted in retrieval inaccuracies and imprecise results. Additionally, we excluded pediatric and senior age groups to focus on specific age ranges. Therefore, we recommend further experimental and prospective research with larger, multicenter samples to better understand the link between smoking, tinnitus, and hearing issues.The study found that there is an association between smoking and hearing problems, and unlike tinnitus, there was no clear evidence of an association. The results also indicated a significant influence of demographic factors, as these factors showed differences in the hearing health status of smokers compared to non-smokers.Based on the conclusion, several recommendations can be made to further investigate the link between smoking and hearing problems. Firstly, more studies should be conducted to determine the specific types of hearing problems associated with smoking, such as reduced hearing sensitivity or difficulty understanding speech. Secondly, demographic factors that impact hearing problems and tinnitus should be further specified, with larger sample sizes and more detailed data collection methods. Thirdly, health awareness and promotion specialists should develop targeted educational materials and resources for patients who smoke or have hearing problems to highlight the link between smoking and hearing problems. Fourthly, ear, nose, and throat (ENT) doctors should routinely screen patients for smoking and hearing problems and provide smoking cessation counseling as part of their practice. Fifthly, awareness campaigns and smoking cessation sessions should be tailored to specific populations, such as adolescents or pregnant women, who may be more vulnerable to the negative effects of smoking on hearing. Lastly, longitudinal studies should be conducted to determine whether quitting smoking can improve hearing outcomes over time. By following these recommendations, it is hoped that a better understanding of the link between smoking and hearing problems can be established, and effective interventions can be developed to improve hearing outcomes in smokers.


Hearing loss is a prevalent health concern, and dietary factors, such as fatty acid intake, may play a role in its development. The current study aimed to investigate the association between the intake of dietary fatty acids and hearing thresholds among U.S. adults.The researchers examined data from the National Health and Nutrition Examination Survey (NHANES), including 7,623 participants with available dietary fatty acid intake and audiometry data. Dietary fatty acid intake was assessed using dietary recalls, and hearing thresholds were measured using pure-tone audiometry. Multivariate linear regression models and smoothing curve fitting were utilized to explore the associations between dietary fatty acid intake and hearing thresholds, adjusting for relevant covariates.This study reveals a direct association between both low and high frequency pure tone average (PTA) hearing thresholds and the dietary intake of total saturated fatty acids (SFAs) and total polyunsaturated fatty acids (PUFAs). Conversely, the intake of total monounsaturated fatty acids (MUFAs) demonstrates an inverted U-shaped correlation with low-frequency and high-frequency PTA hearing thresholds, having inflection points at 11.91 (energy (%)) and 10.88 (energy (%)), respectively.Dietary intake of certain fatty acids may influence hearing thresholds in adults.The online version contains supplementary material available at 10.1186/s12944-023-01896-y. Hearing loss is a widespread public health issue that affects millions of people worldwide , 2. HearFatty acids are one type of dietary component that has received a lot of attention in recent decade because of their numerous implications in human health –15. FattWhile previous investigations have addressed the connection between dietary patterns, nutrient intake, and hearing loss, few studies have specifically focused on the connection between individual fatty acids intake and hearing threshold. Furthermore, existing research largely focuses on specific subtypes of fatty acids, like omega-3 and omega-6 PUFAs, giving less consideration to the wider range of fatty acids that are part of the human diet.The hypothesis of this study is that dietary intake of certain fatty acids is associated with hearing thresholds in adults. Hence, this study sought to explore the correlation between consumption of various dietary fatty acids and hearing thresholds, utilizing data from the National Health and Nutrition Examination Survey (NHANES). The study considered a total of 19 dietary fatty acids, encompassing saturated, monounsaturated, and polyunsaturated fatty acids.This study employed cross-sectional data from NHANES, a multistage survey that is nationally representative and designed to evaluate the health and nutritional status of adults and children in the United States –27. ThisDietary information were collected using two days dietary recalls, administered in-person and via telephone, respectively . For theAll statistical procedures were conducted using R software and Empowerstats. The demographic traits of the study participants were assessed via chi-square tests for categorical variables and t-tests for continuous variables, differentiated by gender. A univariate logistic regression was leveraged to investigate the relationship between covariates and hearing thresholds. In order to probe the linear association between dietary fatty acids and hearing thresholds, multivariate linear and logistic regression models were put to use. For curve smoothing, the penalized spline method was adopted, and a two-segment linear regression model was implemented to study the possible nonlinear correlation between fatty acid intake and hearing thresholds –33. The The research included 7,623 participants, with a mean age (SD) of 44.15 ± 12.98 years, composed of 3,652 (47.91%) males and 3,971 (52.09%) females. The low and high-frequency PTA hearing thresholds were recorded at 7.51 ± 6.75 dB and 21.56 ± 17.43 dB, respectively. The average proportions of energy derived from saturated fatty acids (SFAs), monounsaturated fatty acids (MUFAs), and PUFAs were 11.55%, 12.60%, and 9.25%. Male participants were observed to have a higher MUFA intake and a higher high-frequency PTA in comparison to female participants (Table Table A comparable link was found between high-frequency PTA and total SFA and total PUFA, while no statistically significant association was observed with total MUFA Tables  and 4. EGiven the absence of a significant linear association between total MUFA intake and both low-frequency PTA and high-frequency PTA, a further exploration of the non-linear relationship between total MUFA intake and hearing thresholds was undertaken Table . Figure This research provide evidence of a positive relationship between both low and high-frequency PTA and the intake of total SFA and PUFA. It is important to clarify that a positive association in this context indicates that higher intake of these fatty acids is associated with higher hearing thresholds, which signifies poorer hearing ability. In light of theses findings, higher intake of SFA and PUFA are associated with higher hearing thresholds, suggesting a potential detrimental effect. While these are preliminary findings lacking causality, they suggest that adjusting the intake of these specific fatty acids could influence hearing thresholds. However, it is important to stress that these findings should not be directly used to make clinical recommendations without further investigation. Furthermore, a non-linear, inverted U-shaped association between low and high-frequency PTA and MUFA consumption were observed. The curves suggest that moderate intake of MUFAs may be associated with poorer hearing ability, while both low and high intakes may be beneficial. Specifically, the bottom end of the curve, representing low and high intake levels, was associated with better hearing thresholds, indicating a potential beneficial effect. The top of the U-curve represents moderate intake levels, which are associated with the highest hearing thresholds, indicating potential adverse effects on hearing. However, these are preliminary findings and should be interpreted with caution.This study builds on previous population-based studies that have examined the relationship between the intake of different types of dietary fatty acids and hearing loss –39. GopiFew research have looked at the relationship between dietary SFAs and MUFAs and hearing . A recenThe current study’s outcomes are in agreement with prior research highlighting the advantageous impacts of certain fatty acids on hearing levels –43. It’sThe current investigation possesses several strengths, encompassing the extensive, nationally representative sample and the thorough evaluation of a broad array of dietary fatty acids , 50. NevThe findings from the present study suggest that dietary intake of certain fatty acids may influence hearing thresholds in adults. If confirmed by future studies, these findings could lead to new dietary recommendations for the prevention or management of hearing loss.Below is the link to the electronic supplementary material.Supplementary Material 1Supplementary Material 2


Hearing health is a critical part of people's overall wellbeing . In addiPublic hearing health: challenges and opportunities in the aftermath of the COVID-19 pandemic” aims to enhance awareness and provide support to the hearing loss-affected community by identifying opportunities to increase access to and equity of better hearing healthcare, while addressing existing evidence gaps in hearing assessment, management, and prevention. The four selected articles in this Research Topic offer their respective authors' views, encompassing the factors, barriers, and challenges found mainly in low- and middle-income countries.This Research Topic titled “Grados-Espinoza et al. captures the mental health burden effect of the pandemic in terms of virtual education-related dissatisfaction among Peruvian medical students. Non-virtual and partial adaptation to such modalities, as well as stress levels, were found to be highly associated with students' satisfaction with virtual education, factors that should be considered as a future reference in the event of similar situations.The first article from Nyarubeli et al. to assess the use of hearing protection devices among noise-exposed workers in manufacturing factories in Tanzania. The resulting questionnaire was preliminarily validated to reflect the real working environment, work culture, and traditions, and to accommodate the current technological situation in manufacturing factories in developing countries.The second article refers to the development of a 24-item questionnaire derived by Oosthuizen et al. identifies limited research evidence in terms of combined hearing and vision screening programs, even after the pandemic event. There are still challenges to be addressed in terms of combined screening in hearing and vision, in an age-agnostic manner, where more feasibility and implementation research is required, especially in low- and middle-income countries.The final article, a systematic review by Grados-Espinoza et al.), Tanzania , and beyond . Hearing loss poses a considerable economic burden globally, estimated at $980 billion annually in terms of healthcare, education, loss of productivity, and societal costs (The main interest in the selected articles is the focus on low- and middle-income countries, which are deemed to be of research interest. Gaps in terms of universal access and socio-economic and healthcare facility levels are a common factor identified across Peru (PK: conceptualization, writing, editing, and review.


Despite normal hearing in one ear, individuals with congenital unilateral aural atresia may perceive difficulties in everyday listening conditions typically containing multiple sound sources. While previous work shows that intervention with bone conduction devices may aid spatial hearing for some children, testing conditions are often arranged to maximize any benefit and are not very similar to daily life. The benefit from amplification on spatial tasks has been found to vary between individuals, for reasons not entirely clear. This study has sought to expand on the limited knowledge on how children with unilateral aural atresia recognize speech masked by competing speech, and how horizontal sound localization accuracy is affected by the degree of unilateral hearing loss and by amplification using unilateral bone conduction devices when fitted before 3 years of age. In a within-subject, repeated measures design, including 11 children (mean age = 7.9 years), bone conduction hearing device (BCD) amplification did not negatively affect horizontal sound localization accuracy. The effect on speech recognition scores showed greater inter-individual variability. No benefit from amplification on a group level was found. There was no association between age at fitting and the benefit of the BCD. For children with poor unaided sound localization accuracy, there was a greater BCD benefit. Unaided localization accuracy increased as a function of decreasing hearing thresholds in the atretic ear. While it is possible that low sound levels in the atretic ear provided access to interaural localization cues for the children with the lowest hearing thresholds, the association has to be further investigated in a larger sample of children. Treatme2.The aim of the present study was to quantify the effect of early access to unilateral bone conduction amplification on sound localization accuracy and recognition of speech in symmetrically separate competing speech in a cohort of children with UAA fitted with a BCD before 3 years of age.3.3.1.n = 4); sensorineural hearing loss (n = 1); contralateral air conduction pure-tone average across 500, 1,000, 2,000, and 4,000 Hz (PTA4) >20 dB hearing level (HL) (n = 4); and surgical ear canal repair (n = 1). Investigations took place during January 2018, November 2020, and spring 2021. Four individuals that were not able to come in for testing in 2018 had grown too old for inclusion in 2020. One subject had moved abroad and could not be contacted. Thirteen individuals declined or could not attend any of the visits for different reasons. One subject repeatedly did not show up for measurements. One subject did not fulfill any aided measurements due to lack of time and was excluded from analysis . Aided and unaided pure-tone hearing thresholds were also measured. The children used their own BCD, either a Cochlear or an Oticon processor , for all3.3.4, based on recordings in adults (n = 8) with normal hearing according to ISO 4869-1 (1990) (n = 8) were 34.7 dB (6.3 dB) at 0.5 kHz, 35.1 dB (6.0 dB) at 1 kHz, 40.5 dB (2.9 dB) at 2 kHz, 47.2 dB (5.6 dB) at 3 kHz, 49.4 dB (4.4 dB) at 4 kHz, and 46.2 dB (6.4 dB) at 6 kHz.Unaided air- and bone conduction hearing thresholds were measured according to ISO 8253-1 2010) using TDH39 supra-aural headphones and the Radioear B71 bone transducer. Masking of the non-test ear was applied as appropriate. To estimate the degree of amplification provided by the BCD, aided hearing thresholds were quantified by measuring frequency-modulated tone thresholds in sound field using a fixed-frequency Békèsy technique. While the reliability of this technique is not quantified in children, it is characterized by high reliability and reproducibility in adults , 18. DurO 4869-1 90 , respectively]. Twelve active loudspeakers each coupled to a 7-inch video display (LD pairs) were placed equidistantly in a 110° arc in the frontal horizontal plane, resulting in loudspeaker positions at ±55°, ±45°, ±35°, ±25°, ±15°, and ±5° relative to the subject who was seated facing the loudspeaker array. The distance from the LD pairs to the head of the study participant was approximately 1.2 (loudspeaker) and 1.1 m (screen). The LD pairs were vertically adjusted to the height of the study participant using a motorized stand, situating the loudspeakers at ear level . The coordinates of the LD pairs were defined in three dimensions in the eye-tracking system, resulting in areas of interest AOIs , 24]. Tw. Tw24)].3.4.2.The visual stimulus was a colorful children's cartoon. The auditory part of the stimulus consisted of a broadband musical melody with a long-term frequency spectrum similar to that of a female voice and naturally occurring amplitude modulations. The stimulus was presented at 63 dB sound pressure level (SPL) (A). The rationale for using this stimulus was that it allows comparison with previous findings in children and adults with normal hearing , with ch3.4.3.Study participants were familiarized with the auditory–visual stimulus during a gaze-calibration procedure in which the stimulus was presented from different azimuths. The test started by presenting the stimulus from the LD pair at −5°. After approximately 7 s, the visual stimulus was stopped, and the sound immediately shifted to a randomized loudspeaker. After 1.6 s, the visual stimulus was reintroduced at the azimuth of the sounding loudspeaker. Azimuthal shifts were repeated 24 times following a beforehand generated order of randomized shifts.Children were allowed to move their head freely. They were instructed to look where they perceived the sound was coming from and informed that they would be guided by audition only during sound-only presentation and that the visual part of the stimulus would reappear at the same azimuth as the sound.The position of the study participant's pupil relative to the LD pairs was sampled at 20 Hz during the 1.6 s sound-only periods. The median pupil position from the last 500 ms of the sound-only period was defined as the perceived sound source location. SLA was quantified as an error index (EI)  ranging3.5.Measurements of SRT were performed in a setup resembling a challenging everyday listening situation , 22, 26 Study participants were instructed to face the loudspeaker presenting target speech and asked to repeat the sentences from three lists (one training list), each containing 10 sentences. This resulted in the presentation of 30 sentences per listening condition (aided and unaided). No sentence was repeated. Oral responses were recorded and scored by an audiologist outside the test room. Both the aided and unaided assessments started by presenting the first sentence of the training list at a signal-to-noise ratio (SNR) of +10 dB. For the following training sentences, the target speech level decreased up to three times in 5 dB steps, then up to three times in 3 dB steps, and then in 2 dB steps until the number of correct words in a sentence was ≤2. When the number of correct words in a sentence was ≤2, or the training list ended, the training was terminated. Subsequently, two lists  were presented. The level adjustment of the target speech aimed at a threshold of 40% words correctly repeated according to the following scheme: the target speech level was changed +2 dB for zero correctly identified words, +1 dB for one correctly identified word, 0 dB for two correctly identified words, −1 dB for three correctly identified words, −2 dB for four correctly identified words, and −3 dB for five correctly identified words. The 40% threshold and the adaptive scheme for level adjustment were based on computer simulations and analysis of the maximum steepness of the psychometric function –29. The 3.6.The PEACH score is a questionnaire consisting of 13 questions assessing auditory behaviors of the child in different situations and is to be filled in by the caregiver. It is divided into two domains, quiet and noise. The questionnaire was developed from the more extensive PEACH diary  and is v3.7.4 were calculated as the mean of hearing thresholds at 500, 1,000, 2,000, and 4,000 Hz. Statistical calculations were conducted using GraphPad Prism 9.3.1 (350). Correlations with age, age at first fitting of the BCD, mean time of usage per day, duration of device use, and unaided PTA4 as predictor variables and SLA and SRT as dependent variables were performed using non-parametric tests (Spearman correlation) due to skewed distribution of the data. Paired comparisons (unaided vs. aided listening) were also performed using non-parametric tests (Wilcoxon signed rank).PTA4.The final sample comprised 11 children aged 5.3–10.8 years . All study participants had a normal eardrum on the non-atretic side. Background data are presented in 4.1.4 of the atretic ear was 64.3 (4.9) dB HL (4 of 24.9 (8.8) dB HL. Six of the study participants  reached aided hearing thresholds <25 dB HL.The mean (SD) PTA9) dB HL . All stuIndividual results from the sound localization test and speech recognition are summarized in 4.2.p = 0.078, n = 9, Wilcoxon matched pairs).SLA data from two study participants could not be interpreted and were excluded from further analysis . The mean (SD) of unaided EI was 0.48 ± 0.17, whereas the mean (SD) of aided EI was 0.37 ± 0.05; individual results are plotted in p < 0.05).Based on previous calculations on test–retest reliability for the localization task, and an estimate of the 95% confidence interval for a single error index value based on this reliability , we analyzed intra-individual performance differences (unaided vs. aided) in localization accuracy. The three study participants who showed the poorest unaided SLA  showed intra-individual statistically significant improvements when tested with the BCD (±0.12)  . The two youngest participants had the worst unaided SLA performance, as well as the most benefit from amplification. Age at first fitting did not correlate with SLA performance in listening condition , time of usage per day , or duration of device use . The participant with the lowest time of usage performed worse in the aided compared to the unaided setting. Unaided SLA was found to be correlated to unaided PTA4 of the atretic ear  .Age at testing did not have a statistically significant effect on SLA performance on a group level (unaided elation) , or on telation) , indicatelation)     or time of usage per day . Aided SRTs were found to improve with increased duration of use in years ; however, duration of use in years also correlate with the age of the study participants. Correlation of duration of use was not found in the unaided performance . There was a trend toward a correlation between unaided PTA4 of the atretic ear to unaided performance . No correlation was found between aided hearing thresholds and aided SRT .One subject did not finish the speech recognition test due to tiredness and was not included in the analysis, i.e., 10 children provided data for this test. Data are presented in d pairs) . SRTs imelation)  but was formance ; this waided SRT  (ρ = −0.4.4.n = 11). The caregiver of one child could not fill in the unaided part of the questionnaire as the study participant used its BCD “during all waking hours.” One subject had not been well during the last week, and one had not been using the BCD during the last week. These questionnaires were excluded from analysis. The total score and the scores for the quiet and noise domains are presented in p < 0.05, Wilcoxon matched pairs) and aided  conditions, indicating that the study participants might have greater difficulties listening in noisy than in quiet environments. There was no significant difference between unaided and aided scores in any of the domains .Caregivers of all participating subjects filled out the PEACH questionnaire . Two of these individuals  improved their SLA performance and all three improved their SRTs in the aided condition. Subjects 6 and 9 also had the worst unaided PTAg et al.  suggesten = 12, mean (SD) −10.9 dB (1.4 dB), p = 0.008, unpaired t-test]  and interaural level differences (ILDs) are known to be important for localizing sound in the horizontal plane . For ind65 dB HL  and the 65 dB HL . Second,with UAA  using thwith UAA , 42. An When comparing the localization results of the present study to those of adults with UAA , the aduSimilar to scores from children with moderate unilateral sensorineural hearing loss, results from the overall PEACH scores were lower in the aided and unaided condition than those for normal hearing children in the same age group , 31. Par6.The statistical power of this study is limited. The authors were only able to present a small sample as only 11 out of 31 individuals that met inclusion criteria decided to take part in the study. Several of the predictor variables co-varied making it difficult to draw conclusions from the results. Aided hearing thresholds also varied in the studied cohort, where five study participants had aided hearing thresholds within the range of mild-to-moderate hearing loss. However, the studied cohort was homogenous regarding hearing thresholds of the non-atretic ear and all study participants had normal BC thresholds in the atretic ear. There was no formal procedure to ensure that the device was fully functioning prior to testing, but since all participants of the study improved their hearing thresholds in the aided setting, we assumed that the BCD was functional. Information on longitudinal device use was not available to the authors.7.Collectively, the results from the current pilot study indicate that the introduction of BCD amplification before 3 years of age in children with UAA does not seem to affect horizontal sound localization accuracy and might result in benefit for horizontal sound localization for some individuals. The effect of early access to amplification on recognition of speech in spatially and symmetrically separated competing speech is more diverse. While there is no significant effect on a group level, some individuals might perform worse in the aided setting. In the future, it would desirable to be able to predict which individuals might benefit more from amplification. The effects of early fitting of a BCD in UAA on spatial hearing needs to be evaluated in a larger sample.


Current estimates suggest that nearly half a billion people worldwide are affected by hearing loss. Because of the major psychological, social, economic, and health ramifications, considerable efforts have been invested in identifying the genes and molecular pathways involved in hearing loss, whether genetic or environmental, to promote prevention, improve rehabilitation, and develop therapeutics. Genomic sequencing technologies have led to the discovery of genes associated with hearing loss. Studies of the transcriptome and epigenome of the inner ear have characterized key regulators and pathways involved in the development of the inner ear and have paved the way for their use in regenerative medicine. In parallel, the immense preclinical success of using viral vectors for gene delivery in animal models of hearing loss has motivated the industry to work on translating such approaches into the clinic. Here, we review the recent advances in the genomics of auditory function and dysfunction, from patient diagnostics to epigenetics and gene therapy. Sound wThe intricacy of the inner ear provides multiple possibilities for damage that leads to hearing loss, including environmental accidents, such as prematurity; infections, such as meningitis, rubella, cytomegalovirus, mumps, and chicken pox; head trauma; and ototoxicity . Alterna2.2.1.Nankin nezumi (Nanjing mice) for their vestibular dysfunction phenotypes. It is important to note that in the early days, research on hereditary deafness in humans, like research on other hereditary conditions, became part of the eugenics movement in Europe and the United States, a phenomenon that culminated in the sterilization and murder of deaf people in Germany during the 1930s.Research into hereditary hearing loss began during the late nineteenth century with descriptions of syndromic hearing loss . At the POU3F4  classification for hearing impairment defined as 25 decibels (dB) or better for no impairment, 26–40 dB for mild impairment, 41–55 dB for moderate impairment, 56–70 dB for moderately severe impairment, 71–90 dB for severe impairment, and 91 dB or greater for profound impairment, referred to as deafness . Exome s2.4.Approximately 30% of genetic deafness cases are syndromic, where another organ or system is also affected. The best-known forms of syndromic hearing loss are Usher syndrome, which affects both the auditory and visual systems with varying degrees of severity and a range of ages of onset depending on the mutated gene; Pendred syndrome, which is characterized by hearing loss, enlarged vestibular aqueduct, and thyroid dysfunction; and Waardenburg syndrome, which presents with hearing loss and pigmentation defects in various organs, including the skin, eyes, and hair. Syndromic forms of hearing loss further underscore the importance of genetic testing of individuals with hearing loss. A classic example of the potential ramifications of genetic testing in this context is the case of Jervell and Lange-Nielsen syndrome, in which patients present with hearing loss and a long QT interval on an electrocardiogram, which dramatically increases the risk of sudden cardiac death . In addi2.5.GJB2, coding for connexin 26, are responsible for up to 50% of genetic deafness cases in many countries in Europe and in the United States  are noncoding RNA molecules with 22–25 nucleotides that were initially described in eviously .In the inner ear, RNA-sequencing experiments have led to the identification of hundreds of miRNAs . Global 4.3.Xist) gene  are a category of noncoding RNA molecules that are more than 200 base pairs long. In every other aspect they behave in the same ways as the mRNAs of protein-coding genes  . Importast) gene . It is wing gene . Hence, recently . Howevered state .Malat1, while others, such as Xloc_012867, are novel lncRNAs that are apparently restricted to the inner ear  provides a centralized portal that aggregates all multiomic data from the ear research field and provides seamless access for data visualization, analysis, and sharing  data are deposited in the National Center for Biotechnology Information’s Gene Expression Omnibus database . While c sharing   is that the identification of a gene or a genetic variant is followed by the development of targeted therapy. Gene therapy involves the use or manipulation of DNA or RNA for therapeutic purposes . ResearcThere are a number of strategies for developing gene therapy for genetic hearing loss, with gene replacement by viral vectors being the most straightforward and common approach for loss-of-function variants, where cellular dysfunction is due to lack of a certain protein. Alternatively, adeno-associated virus gene editing may be designed to correct a variant and restore the wild-type sequence. By contrast, some form of gene silencing is preferred for variants that create a dominant-negative effect, where the presence of the mutated protein harms the cell by disrupting the function of the wild-type protein. This may be accomplished either by transcriptional or translational repression or by gene editing. Lastly, alteration of the splicing pattern can be a viable strategy for variants that cause splicing defects. Notably, some types of genetic hearing loss may be treated by more than one strategy, as we discuss further below. The pharmaceutical industry has not ignored these achievements, and numerous companies are currently active in this field . Notable6.1.1.TMC1 was one of the first genes identified as involved in human deafness and was found to be mutated in several murine deafness models (Transmembrane channel-like protein 1 (TMC1) is a protein expressed by hair cells, which together with additional proteins forms the mechanosensitive ion channel complex . As alres models , 171. Ins models . The auts models . This waTMC1 can also manifest as recessive. Tmc1−/− mice were used as a model of TMC1 recessive deafness in a study in which the Tmc1 coding sequence was delivered by injection of AAV at P1 to alleviate hearing loss , several alternative approaches have been undertaken to circumvent this limitation. Two independent studies used a dual-AAV approach to deliver the Otof coding sequence into the inner ears of Otof−/− mice (trans-splicing approach, in which the 5´ and 3´ halves of the coding sequence assemble in vivo and the intervening inverted terminal repeats are spliced out by incorporating artificial splice donor and splice acceptor sequences. Other options that were examined by other groups involved overloading the AAV beyond its capacity or, conversely, delivering a cut-down version of otoferlin (Otof−/− mice injected with the dual AAV-Otof at P30, well after the onset of hearing in mice, exhibited wild-type-like ABR thresholds, indicating that Otof−/− inner hair cells retain the potential for function for an extended period of time. This finding is compelling because humans are thought to begin to respond to auditory stimuli during the first trimester of pregnancy, and the feasibility of postnatal intervention in many forms of congenital deafness in humans is still not clear (The ir cells . Variantdeafness . Since O−/− mice , 3. Bothtoferlin , 161. Unot clear .6.2.Otoprotection refers to the protection of the auditory system from external insults such as noise, aging, ototoxins, and drugs. The use of genomic technologies has the potential to elucidate the molecular mechanisms underlying noise- or drug-induced hearing loss and lead to the development of targeted otoprotective therapeutics. For example, the complement pathway has been implicated in noise-induced hearing loss . AnotherInformation about the molecular pathways involved in common forms of hearing loss is already being translated to therapeutics, as in the example described in 6.3.As the organ of Corti is postmitotic at birth, any insult that results in hair cell loss leads almost invariably to impaired auditory function. For this reason, a vast body of literature has focused on studying the development of the inner ear in the hope of identifying pathways and targets that can be manipulated to induce regeneration of hair cells and recovery of auditory function . Two preRecent gene delivery technologies, specifically AAV-mediated gene delivery, have enabled targeted manipulation of transcription factors involved in hair cell differentiation, such as Atoh1 . Overexp7.The past decades have seen a revolution in the field of auditory function and hearing loss. A major contribution to this transformation has been provided by the development of genomic sequencing technologies, including exome sequencing, RNA sequencing, and epigenetic profiling technologies such as ATAC-seq and CUT&RUN. These technologies have dramatically increased the number of genetic variants known to be associated with hearing loss and have enabled the identification of key factors and pathways involved in the development of the inner ear and in common forms of hearing loss, thereby opening up avenues for therapeutic interventions. In addition, gene delivery and gene editing tools—primarily AAV and CRISPR-Cas9, respectively—have facilitated the emergence of gene therapy as a new field in the search for hearing solutions. As always, open questions remain regarding the ethical use of genetic data and, in particular, of genetic manipulations. Nonetheless, these scientific strides and the collaborative efforts of scientists in the field to share data and combine forces are currently advancing this field by leaps and bounds.


In this paper, we present the solvolysis reaction of dipeptide analogues of fluorinated aminophosphonates with simultaneous quantitative deprotection of the amino group. To the best of our knowledge, this work is the first reported example of the application of fluorinated aminophosphonates in cathepsin C inhibition studies. The new molecules show moderate inhibition of the cathepsin C enzyme, which opens the door to consider them as potential therapeutic agents. Overall, our findings provide a new avenue for the development of fluorinated aminophosphonate-based inhibitors. Cathepsin C, also known as dipeptidyl peptidase I (DPPI) belongs to the family of lysosomal cysteine proteases encompassing 11 human enzymes  .2 , which, however, has not been used as a therapeutic substance due to the instability of the diazomethylketone group  = concentration of the substrate, [I] = concentration of the inhibitor.In conclusion, we demonstrated the solvolysis reaction of dipeptide analogues of fluorinated aminophosphonates with the simultaneous deprotection of the amino group. The resulting acids were converted into the corresponding salts. All the reactions proceeded quantitatively. Obtained compounds were subjected to kinetic studies against cathepsin C, and the results indicated that they are moderate competitive inhibitors of this enzyme. This study presented the first kinetic investigation of fluorinated dipeptide derivatives of aminophosphonic acid salts against cathepsin C, thus contributing to the development of the novel cathepsin C inhibitors. We are currently working on the development of more effective fluorinated inhibitors of cathepsin C in our laboratory.File 1Experimental procedures, biological protocol, NMR data.


Analyze maternal and child predictors associated with loss to follow-up in the newborn hearing screening program at maternity hospitals in northeastern Brazil.Retrospective cohort study, including secondary data from infants (n=604) referred to the newborn hearing screening program in two maternity hospitals for monitoring and/or diagnosis. The predictors evaluated included socioeconomic factors, such as maternal age, marital status, income, schooling, place of residence, number of children and number of prenatal visits. In addition, maternal and child health factors, such as smoking and drug intake during pregnancy, consanguinity, congenital infections, craniofacial malformations, use of ototoxic drugs, syndromes and a history of hearing loss in the family. Statistical analysis was performed based on binary logistic regression models, using the stepwise method.The logistic regression model containing the number of prenatal visits and the history of hearing loss in the family was significant . The number of prenatal visits  and family history of hearing loss  were significant predictors. The other predictors were not significant.The results reveal that newborns whose mothers had ≤ 5 prenatal visits and those with a family history of hearing loss increased their likelihood of loss to follow-up by 2.3 and 2.1 times, respectively. It is important to provide subsidies for public health improvements in order to help advise, guide and educate mothers, especially during prenatal care. The sooner children with hearing loss receive special care, the more likely they are to reach their full potential,2.The newborn hearing screening program (NHSP) in Brazil is part of a set of measures recommended by the Ministry of Health for comprehensive hearing healthcare in childhood, and is responsible for the early detection of hearing loss in newborns (NBs) and increasing by up to 10-fold when those with risk factors for hearing loss (RFHL) are included.It is estimated that the prevalence of congenital hearing loss is between 1.7-11/1000 in live births reports in the World Report on Hearing (WRH), untreated hearing loss represents an annual cost of over USD 980 billion. This includes expenses related to health, education, lost productivity, and social costs. Many of these expenditures could be mitigated using cost-effective interventions.According to World Health Organization (WHO)-6, with adaptations according to their social sanitary situation. The main recommendations that guide NHSPs are from the Multiprofessional Committee on Auditory Health (COMUSA), which discusses and endorses actions aimed at the hearing health of newborns, infants, preschoolers, schoolchildren, adolescents, adults and older adults, in addition to the national guidelines proposed by the Ministry of Health.NHSPs in Brazil follow the recommendations, guidelines and updates proposed by the Joint Committee on Infant Hearing (JCIH)-10. The JCIH proposes different quality indicators for these programs over time, one of which is related to the rate of adherence and losses of families at any stage of the program,6. COMUSA always endorses and recommends quality indicators for the implementation and evaluation of comprehensive care actions for hearing health in childhood,7. Although existing programs seek to comply with these, research has shown that they face significant difficulties due to the high dropout rates of families in the different phases of the NHSP-13.Reports on the effectiveness of NHSPs demonstrate disparity between developed and developing countries, low socioeconomic level, unmarried parents and mothers with several children.The literature describes several predictors for loss to follow-up in hearing screening programs, such as newborns who failed the newborn hearing test, younger mothers, remaining 5 days or more in the NICU, use of ototoxic medication, hearing loss in the family,4. In this respect, it is important to analyze the causes of loss to follow-up, covering every phase of the NHSP, which includes monitoring and diagnosis, providing assistance and information to create new strategies aimed at reducing these losses.Hearing Health Programs depend on the interrelationship of several factors, including support and public research policy, follow-up and monitoring of children, training of professionals at all levels of health care and the existence of centers of excellence for diagnosis and interventionDetermine whether there is an association between maternal and/or child variables and loss to follow-up in the NHSP in maternity hospitals in the city of Natal/Brazil.The retrospective cohort study model was adopted, limited to the NHSP developed by two maternity hospitals in northeastern, Brazil, in the city of Natal, Rio Grande do Norte state. At the time of the study, these were the only maternity hospitals available for vaginal deliveries and low-risk pregnancies in the municipality. Free and informed consent was signed by all participants. The mean of all live births delivered in a hospital from 2007-2009 in Natal was 11.329,66., based on evidence found in studies on universal NHSPs,11,15,16.Loss to follow-up in the NHSP is the outcome variable. Maternal and child predictors described below were included to investigate this variable. The inclusion criteria, social economic factors and risk indicators for hearing loss of all the variables selected were established by the Joint Committee on Infant Hearing (JCIH)The present study was approved by the Research Ethics Committee of the Universidade Potiguar (UNB) under protocol number 107/2007.In order to characterize the maternal and child variables, the database was systematized by extracting secondary data from the medical records of the maternity hospitals. The records contained information found on the prenatal medical charts.All social economic and maternal and child health data were stratified to simplify analyses, as follows: socioeconomic data, such as maternal age, into two age groups: ≤ 25 years and > 25 years; marital status: married/common law or not; schooling: ≤ 4th grade and > 4th grade; family income, based on the monthly minimum wage at the time: up to 1 and more than 1; place of residence, categorized as those living in Natal or outside the city; number of children, classified as first-born, yes (only child) and no ; prenatal visits, divided into: ≤ 5 and >5 s; and maternal and child health data, stratified into nominal categorical variables, with yes or no answers.The subjects of this study are mothers and infants born between July 2007 and March 2009. This cohort was accompanied until 2018.In the database, live births (n=3822) at these maternity hospitals during the study period were analyzed. All newborns with life-threatening conditions transferred to intensive care units were excluded from the study, due to the assumption that health problems made them ineligible for the NHSP. All infants who underwent newborn hearing screening tests and who, based on the results, needed to be referred to the monitoring and/or diagnosis phase of the NHSP (n=604) were included ..Monitoring in the NHSP refers to those newborns and infants with risk indicators who responded satisfactorily during screening and who were referred for hearing evaluation every six months in he Specialized Rehabilitation Centers (SRC) by the Hearing Rehabilitation Service and in the High-Complexity Hearing Health Care Service of the Ministry of Health With respect to diagnosis, every newborn or infant who did not respond adequately during screening, was referred and diagnosed in the SRC as well. These individuals were excluded from the study, as well as follow-up losses during the program that occurred before the monitoring and/or diagnosis phase. The term ‘loss to follow-up’ was specifically used for losses that occurred in the monitoring and diagnosis phases.Newborns and infants without risk indicators who exhibited satisfactory responses during screening underwent monthly monitoring of hearing and language development in primary care,5, namely Brainstem Auditory Evoked Potential (BAEP), Transient and distortion product evoked Otoacoustic Emissions, Immittance measures and Visual Reinforcement Audiometry, in addition to follow-up with otolaryngologists and speech therapists. When hearing loss was identified, newborns were referred for auditory rehabilitation which included selection and adaptation of personal sound amplification devices (PSAD) and auditory speech language therapy.The infants underwent audiological monitoring or diagnosis at the SUVAG  specialized care center, in the same state and municipality as the maternity hospitals under study. The SUVAG center is a philanthropic institution that has been promoting hearing health for 35 years, aimed at the prevention, diagnosis and rehabilitation of people with hearing and speech impairment, favoring their inclusion in society. The center provides weekly vacancies for newborns referred for hearing screening, thereby enabling early diagnosis. All the infants were submitted to the audiological diagnosis protocols recommended by international guidelines2 association test, with Yates’ correction. All variables considered relevant for analysis were described using odds ratio (OR) values with respective confidence intervals (95%CI), evaluating the risks in relation to the independent variable of interest. Values were estimated by binary logistic regression models using the Stepwise method and p ≤ 0.05 was considered statistically significant. Prerequisites to apply binary logistic regression were the absence of both outliers and multicollinearity in the sample. Goodness of fit was assessed using the Hosmer-Lemeshow test. Statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS), version 23.0.In order to identify maternal and child predictors of loss to follow-up in the NHSP, descriptive statistical analysis and the association with variables of interest were performed for comparison with the outcome variable, using the χAfter hearing screening, 604 of the 3822 newborns were referred for follow-up care, 60.4% (n=365) of whom were lost to follow-up and 39.6% (n=239) monitored and/or diagnosed . 34.6% fDescriptive analysis of social economic factors  demonstrIn regard to maternal and child health factors , family , COMUSA and Azevedo.In the relationship between the dependent variable and covariables, bivariate analysis of socioeconomic, maternal and child health factors demonstrated that the number of prenatal visits  with estimated risk  and family history of hearing loss (HL)  with estimated risk  were statistically significant and included in the logistic regression models, while the remaining factors were not statistically significant. Risk factor selection was based on JCIHLogistic regression analysis was conducted to determine whether the number of prenatal visits and family history of hearing loss  are predictors of loss to follow-up in the hearing screening program.The independent variables analyzed met the prerequisite of multicollinearity with tolerance > 1 and VIF (Variance Inflation Factor) < 10.The model  containiThe Hosmer - Lemeshow test (p=0.902) was used to determine the degree of accuracy and whether there were significant differences between the classifications predicted by the model and those observed in practice. Since no significance was found, the alternative hypothesis was rejected, where observations would be different, and the null hypothesis accepted, where there are no significant differences between reality and the model, indicating reliability of the model.Thus, the results reveal that a variable number of prenatal visits is a risk factor for loss to follow-up in the NHSP, where the likelihood of mothers who had up to 5 prenatal visits abandoning the program is 2.3 times greater than that of mothers with more than 5 visits.A variable family history of hearing loss is also a risk factor for loss of follow-up, where the chances of an infant not adhering to the program are 2.1 times greater than those with no such history.-20. When these families do not adhere to hearing follow up programs the prevalence of hearing loss in newborns may be widely underestimated. A recent study shows that the improvement of early identification of hearing loss in newborns, increased the prevalence from 0.9 to 1.7/1000 infants screened. Hearing loss triples in school aged children due to lost cases in NHS as well as late onset hearing loss.The quality of a newborn hearing screening programs depends substantially on the number of babies who attend follow-up visits, whether for diagnosis or hearing monitoring. Loss to follow up still occurs in all stages of NHSPs, although an improvement in screening coverage and methods can be observed. Family history of hearing loss and craniofacial anomalies are risk factors for congenital hearing loss in neonates from well being nurseries.Factors that contribute to non-attendance are educational disparities, uninformed parents, distance between home and a hearing health care center, setbacks at work, unfavorable attitudes and not prioritizing the issue. The creation of a database and education and information for parents may reduce these problems. As described by parents from a community in South Africa, contributing factors for the family to return with the baby to the program are the friendly attitude of the audiologist and effective communication between the audiologist and the family. A reminder of the day and time to return was also considered positive reinforcement.Socioeconomic factors such as income and low schooling levels were also obstacles to parent participation in the hearing screening program.The presence of a full-time coordinator in the NHSP also helps achieve greater adherence of babies who need follow-up compared to programs without a coordinator. Few studies report this as a maternal predictor for loss to follow-up, but one study that used logistic regression identified lower maternal age, more than one child, mothers without prenatal care or few prenatal visits, and the use of illegal substances as risk factors.Our study did not find that income, schooling level or place of residence were predictors of non-attendance to audiological follow-up, unlike most literature reports. The fact that the program takes place in a municipal reference center may explain the lack of discrepancy between the economic and educational levels of families. As such, these variables do not elucidate the non-commitment to follow-up. However, the number of prenatal visits was a risk predictor for not adhering to the NHSP. Mothers with ≤ 5 prenatal visits are twice as likely to be lost to follow-up compared to those with 5 or more visits; this predictor is related to socioeconomic status,23. Our study indicates that there is twice as much risk for a baby with a family history of hearing loss for adhering to the follow-up. This seems contradictory, since a risk indicator should reinforce the need for constant assessment of hearing status. One explanation may be that parents do not perceive this risk as threatening, specially if the baby has passed the child hearing screening and if the speech therapist has not explained the importance of this finding.There are no literature reports that associate high risk indicators for hearing loss with loss to follow-up in hearing screening programs. Prolonged stay in the newborn intensive care unit (NICU) is the most cited risk indicatorOur analyses allows for reflection on NHSPs to ensure that no child is left uncared for. Health services should carry out rigorous monitoring and guidance for mothers, since the association between maternal and child predictors  increases the chances of loss to follow-up in the NHSP. Studies aimed at identifying the reasons for the low number of prenatal visits and for dropping out of the NHSP, despite the presence of a risk indicator for hearing loss, require robust quantitative and qualitative analyses, which are essential to solving the problems underlying non-participation in a Brazilian context.. This database could make it easier to track program development and provide valuable information on the effects that changes may have on the participation rate. A comprehensive database could also identify children who, for unknown reasons, were lost to follow-up.The results demonstrate the need for greater involvement of professionals who work in NHSPs. They are often in direct contact with the families that this study identified as at risk of non-participation. The program would also benefit from a national database that would allow for monitoring, as seen in other countriesThe main strength of this study is the population-based study design, which makes it less vulnerable to selection bias because it reached the entire sample within the surveyed locations. However, as with all record-based data, we cannot rule out inaccurate information and missing data, which could have affected the results. Data quality is considered reliable; however, the present study retrospectively evaluated a sample of newborns in two maternity hospitals in northeastern Brazil, which means it does not represent the entire region and that other evidence is needed to confirm these predictors as risk factors. Thus, it is not possible to generalize the findings to the newborn population referred for follow-up at Brazilian NHSPs.The results reveal that newborns whose mothers had ≤ 5 prenatal visits and those with a family history of hearing loss increased their likelihood of loss to follow-up by 2.3 and 2.1 times, respectively. It is important to provide subsidies for public health improvements in order to help advise, guide and educate mothers, especially during prenatal care.