Previous longitudinal studies indicate that hearing loss and cognitive impairment are associated in non-tonal language-speaking older adults. This study aimed to investigate whether there is a longitudinal association between hearing loss and cognitive decline in older adults who speak a tonal language.Chinese-speaking older adults aged 60 years and above were recruited for baseline and 12 month follow-up measurements. All participants completed a pure tone audiometric hearing test, Hearing Impaired-Montreal Cognitive Assessment Test (HI-MoCA), and a Computerized Neuropsychological Test Battery (CANTAB). The De Jong Gierveld Loneliness Scale was used to measure loneliness, and the 21-item Depression Anxiety Stress Scale (DASS-21) was used to measure aspects of mental health. Associations between baseline hearing loss and various cognitive, mental and psychosocial measures were evaluated using logistic regression.A total of 71 (29.6%) of the participants had normal hearing, 70 (29.2%) had mild hearing loss, and 99 (41.2%) had moderate or severe hearing loss at baseline, based on mean hearing thresholds in the better ear. After adjusting for demographic and other factors, baseline moderate/severe audiometric hearing loss was associated with an increased risk of cognitive impairment at follow-up . When pure-tone average (PTA) was modeled continuously, an average difference of 0.24 in HI-MoCA scores for every 10 dB increase in BE4FA existed, and an average difference of 0.07 in the change of HI-MoCA scores in a 12 month period.The results revealed a significant longitudinal relationship between age-related hearing loss and cognitive decline in this cohort of tonal language-speaking older adults. Steps should also be taken to incorporate hearing assessment and cognitive screening in clinical protocols for older adults 60 years and above in both hearing and memory clinics. Hearing loss is considered the fourth greatest cause of disability in the world, according to the measured years lived with disability (YLDs) . In ChinThe state of cognitive impairment covers a wide range of disorders, from subjective memory complaints and mild cognitive impairment to dementia . Those wDifferences between the structure of tonal and non-tonal languages may result in different associations between hearing loss and cognitive decline. Changes in pitch (tone) at the monosyllabic level transmit the different lexical meanings of a word in tonal languages. Psychophysiological data suggests that a tonal language background is associated with enhanced overall cognitive ability . FurtherThe association between untreated age-related hearing loss and cognitive impairment in Mandarin-speaking older adults has been supported by data from cross-sectional  and caseMost of the cross-sectional and longitudinal cohort studies of cognition and hearing loss conducted with Chinese older adults have a few limitations regarding methods used to assess hearing and/or cognitive function. For example, self-reported hearing loss, not the audiometric measures of hearing, was utilized in most of the longitudinal studies to date . EvidencFurthermore, most of the cognitive assessments included verbally loaded scales or questionnaires that rely on the hearing ability of participants, e.g., the Mini-Mental State Examination (MMSE), and Montreal Cognitive Assessment (MoCA). As hearing loss can influence participants’ performance during cognitive assessments, it is essential to adopt non-verbal cognitive test materials when assessing the cognitive functions of elderly participants with hearing loss . FurtherWhen compared to people with normal hearing, those with impaired communication abilities brought on by untreated hearing loss have a higher risk of experiencing negative mental and psychosocial effects. Hearing loss has been linked to depression , anxietyThis study explored the potential links between hearing loss and cognitive decline in a tonal language-speaking adult population based on data from a longitudinal study, utilizing both a non-verbal computer-based assessment battery for the different domains of cognitive functions (CANTAB) and a modified Montreal Cognitive Assessment for hearing impairment (HI-MoCA). We aimed to quantify the association between baseline hearing loss categories and cognitive impairment at follow-up, and also the association between audiometric hearing level and various domain-specific cognitive functions at follow-up.This study’s protocol was previously published as part of a report of a cross-sectional study on hearing loss and cognitive performance in an adult Chinese population . These aParticipants were recruited through social media notices and community activities. Participants were native Mandarin speakers and at least 60 years of age when enrolled. Those who were not in general good health, unable to complete tasks necessary for the cognition evaluation tasks due to an underlying medical or mental illness, or who had previously worn or were using hearing aids or a hearing implant at the time of the study were excluded from the study.The University of Western Australia-Human Research Ethics Committee (RA/4/20/5538) and Beijing Tongren Hospital, Capital Medical University (TRECKY2019-090) approved this study. Permission was also obtained from MoCA officials. All procedures were carried out in compliance with these approvals, and all participants signed informed consent forms.Hearing loss was assessed by pure-tone audiometry with an audiometer . For all participants, bilateral air-conduction thresholds were measured at 0.25, 0.5, 1, 2, 4, 6, and 8 kHz through a standard audiometric assessment conducted by a qualified audiologist in a soundproof booth at the audiology center of the Beijing Institute of Otolaryngology.Two different methods were used to classify the hearing loss: the traditional average of the four mid-frequency hearing thresholds at 0.5, 1, 2, and 4 kHz in the better ear, and the average of the three high-frequency hearing thresholds at 4, 6, and 8 kHz in the better ear, noted respectively, as BE4FA and BE3HFA. Hearing thresholds at the higher frequencies were included because these frequencies contribute to the clarity of speech, whereas hearing in lower frequencies is necessary for speech comprehension. Furthermore, hearing loss in adults usually starts in the higher frequencies which may not be captured by summarizing the mid-frequencies. The hearing thresholds were also classified into a categorical variable, normal hearing (BE4FA ≤ 25 dB HL), mild hearing loss (26 to 40 dB HL), and moderate or above hearing loss (>40 dB HL) .HI-MoCA was used to assess the individuals’ overall cognitive abilities. A Mandarin version of the MoCA (Version 7) was adapted, which was converted into a timed PowerPoint  presentation with all the verbal instructions replaced with visual instructions, here named HI-MoCA . To accoThe evaluation of cognitive function for this study was focused on working and episode memory, processing speed, and special information processing. CANTAB is a neuropsychological test battery that was used to measure four non-verbal cognitive functions : Motor Screening (MOT), delayed matching to sample (DMS), paired associates learning (PAL), and spatial working memory (SWM).Motor screening screens visual, movement, and comprehension issues that could limit the data collection. The DMS test assesses both simultaneous visual matching ability and short-term visual recognition memory for non-verbalisable patterns . The perThe Mandarin version of the 6-item De Jong Gierveld Loneliness Scale (DJGLS) was used to measure loneliness, a validated tool to assess overall, emotional, and social loneliness . In thisThe validated Chinese version  of the 2Demographic information, including age (years), sex, and education , was collected in 2019/2020 using a self-report questionnaire. Lifestyle characteristics, including longest occupation in life, residential arrangements , marital status , and drinking and smoking habits , were obtained.Participants reported their history of diabetes mellitus and cardiovascular-related diseases . These were chosen as covariates because they may increase the risk of hearing loss  and cognLeisure activities, which constitute a major portion of daily living and provide cognitive stimulation for older adults, were classified into recreational, intellectual, physical, and social categories . The parContinuous variables at both baseline and follow-up were described as the mean ± standard deviation, and the categorical variables were described as numbers (percentage). A further series of comparisons of hearing thresholds, cognitive performance, loneliness, and mental health scores were analyzed among these two waves by chi-square test or Wilcoxon rank-sum test.Associations between baseline hearing loss and outcome cognition impairment at follow-up were evaluated using the odds ratio (OR) and its corresponding 95% confidence intervals (95% CI) by multiple logistic regression, adjusting for confounding variables, including age, sex, education level, smoking, drinking, marital status, chronic disease, and leisure activities. Odds ratios (OR) > 1.00 indicated increased odds of cognitive impairment with every unit increase in HL across participants and other variables, whereas OR < 1.00 indicated lower odds of those variables.As a longitudinal study, the linear mixed-effect model (LME) was used, including the covariates listed above, to study the time to incident cognitive decline. The LME model is designed to analyze longitudinal data. This model offers the advantage of considering multiple observations within a subject and intrasubject correlation. It also allows for adjusting numerous potential confounding variables . An intep ≤ 0.05 based on two-sided tests.Multivariate linear regression (forward stepwise) analyses were used to assess the associations between cognition and hearing loss, loneliness and DASS-21 (continuous variables). A regression coefficient and its 95% CI were calculated. The different CANTAB modules  and HI-MoCA scores were entered as dependent variables, respectively. The collinearity tests were examined during each stepwise regression analysis. All statistical analyses were performed using Stata version 17 . The significance level was Of the 293 patients recruited in 2018/2019 at baseline, 39 did not attend the 12 month follow-up and 14 had incomplete covariate information. These 53 were excluded, leaving 240 participants who participated in both baseline and follow-up waves.Z = 6.713, p < 0.001). The mean progression of hearing loss was 0.68 and 1.58 dB/year for BE4FA and BE3HFA, respectively. Regarding the mental health and loneliness scores, we also observed significant changes over the follow-up period. The average change of depression, anxiety and stress scores were 0.83, 1.19, and 0.9, respectively  had normal hearing, 70 (29.2%) had mild hearing loss, and 99 (41.2%) had moderate or greater hearing loss at baseline . Compareectively . Mean chectively .Participants with hearing impairment at baseline had a higher incidence of developing mild cognitive impairment based on HI-MoCA cutoff scores, than those with normal hearing. The 12 month unadjusted OR of developing mild cognitive impairment was 3.23 (95% CI = 1.69−6.17) in subjects with moderate or above hearing loss , but forB = −0.04, P < 0.001) and 12 month follow-up period . Model 2 examined the association between hearing loss and cognitive decline, adjusted for age, sex, and educational level. The strength of the association between HI-MoCA scores and BE4FA and time decreased but was still significant . Finally, Model 3 assessed the same relationship as Model 2, with additional adjustments for several factors . After controlling for these factors, the coefficients of cognitive decline with hearing loss and the follow-up period were still significant . When BE3HFA was used as the independent variable, it was also significantly associated with the coefficients of cognitive decline in the three models.These results were confirmed when HI-MoCA scores were analyzed as a continuous variable. p = 0.041 and 0.037), but not for SWM scores (p = 0.082). However, no significant changes in any of the specific CANTAB cognitive domain scores during the 12 month period were observed to be associated with hearing loss .We conducted additional analyses to investigate the association between hearing loss and specific cognitive domains . When pure-tone average (PTA) was modeled continuously, we estimated an average change of 0.24 in HI-MoCA scores for every 10 dB increase in BE4FA and an average change of 0.07 in the change of HI-MoCA scores in a 12 month period for every 10 dB increase in BE4FA. As shown in Our results demonstrate that baseline hearing loss is associated with an increased risk of cognitive impairment at 12 months, as assessed by specific and general cognitive tests. However, the findings from this tonal language-speaking cohort do not appear to be significantly different from similar studies with non-tonal language speakers. Baseline moderate or severe hearing loss is associated with a greater risk of cognitive impairment after a 12 month follow-up period , compared with participants with normal hearing, after adjusting demographic and other factors, including mental health, loneliness status, behavior factors, and health conditions. Besides the general cognitive performance, an association was also observed between hearing loss and some specific baseline cognitive functions, including simultaneous visual matching ability and short-term visual recognition memory (DMS module in CANTAB) and episodic visuospatial memory (PAL module in CANTAB). This finding is consistent with previous longitudinal studies on the relationship between hearing loss measured by pure tone audiometry and cognitive impairment , and cogBaseline hearing loss was demonstrated to be a predictor of the change in overall cognitive performance (HI-MoCA) over 12 months, regardless of whether the continuous or categorical values were used. Furthermore, an association in the baseline scores of DMS and PAL with every 10 dB change of hearing loss was observed. These findings accord with those of previous studies, suggesting that these participants are at risk of developing dementia . HoweverOur findings are in general agreement with the findings in studies with non-tonal language speakers. Therefore, we provide no evidence to support the notion that speaking a tonal language provides an advantage over non-tonal language speakers over a 12 month period.There is only a limited number of longitudinal studies in this field in tonal language speaking populations . Most ofIn this study, we also observed a significant decrease in HI-MoCA scores over 12 months, with a mean change of 0.35 points in the cognitive impairment group and 0.21 points in the cognitively intact group. A previous study on the changes in MoCA scores over time, reported that a group with mild cognitive impairment at baseline showed a decline of 0.47 points/year over 3.5 years, while the cognitively intact group showed a decline of 0.18 points/year, but there was no significant difference between the two groups . We alsoSignificant changes were observed in the mental health and loneliness scores over the follow-up period. One potential explanation for the significant changes in DASS-21 and loneliness scales, could be related to the impact of COVID-19. China was the first country that identified the coronavirus disease in the world at the end of 2019, and Beijing reported the first cases in February 2020 , just afNon-verbal materials were utilized in this study, both for the general cognitive performance and in specific domains, which may be a better estimation of the association between hearing loss and cognitive impairment than achieved when using verbal materials that are based on verbal materials. It is possible that age-related hearing loss and cognitive impairment share a common etiology, such as vascular disease. Furthermore, this study provides further evidence that the link between hearing loss and cognitive decline may also be mediated by depressive disorders and social isolation. This study attempted to control for these covariates and showed that the associations remained robust.Two limitations have already been noted above. The short follow-up period may underpower the potential association between audiometric hearing loss and cognitive declines at the scale of general and specific domains. Furthermore, the participants experienced the COVID-19 pandemic between the baseline (2019/2020) and the 12 month follow-up session (2020/2021). At this stage, it is difficult to distinguish to what extent the pandemic impacted the mental health and also cognitive function of these older adults.Another limitation is that as a volunteer cohort, older adults with high self-awareness of health concerns may have tended to be enrolled; therefore, extrapolating the findings from this current study must be done with caution. More extensive studies with more representative and community-based participants will be required to confirm the results.Central auditory processing function was not measured in this study. There is evidence that central auditory processing impairment is the primary impairment associated with cognitive impairment and dementia . Future Finally, the recommended cutoff score for the MoCA, 26, was adopted for cognitive impairment in this study, which may result in a higher rate of identification of those at risk of cognitive impairment and dementia, and increase the odds ratio between hearing loss and cognitive impairment . RecentlThis study contributes to the growing but still limited body of evidence that hearing loss and cognitive impairment, and decline are significantly associated in tonal language-speaking older adults in China. Hearing loss may be a modifiable solution for health problems associated with cognitive impairment. As hearing aids are the primary management option for hearing loss, it is important to conduct a clinical trial to investigate whether hearing aids can delay cognitive decline, especially in a randomized controlled trial .Given the high occurrence of dementia, actions to reduce these concerns for seniors may have considerable public health implications. Steps should also be taken to incorporate hearing assessment and cognitive screening in clinical protocols for older adults 60 years and above in both hearing and memory clinics. Clinicians should start thinking about incorporating objective electrophysiological measurements as part of the hearing test battery, considering their advantage in evaluating hearing acuity in older adults with cognitive impairment, who are unable to complete behavioral pure tone audiometry . FurtherIn summary, this study found that moderate or above hearing loss at baseline was associated with cognitive decline during 12 months of follow-up in a Chinese language-speaking population aged 60 years and above. This finding supplied evidence that hearing loss may be a risk factor for cognitive impairment in older adults. Given that more than 50 per cent of adults older than 60 years in China are affected by hearing impairment, hearing intervention may be a target to prevent or at least delay cognitive decline in older adults.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 University of Western Australia-Human Research Ethics Committee (RA/4/20/5538) and Beijing Tongren Hospital, Capital Medical University (TRECKY2019-090). The patients/participants provided their written informed consent to participate in this study.DJ and XF designed the experiments. XF carried out the experiments. XF, RE, DJ, SW, and BL analyzed the experimental data. XF wrote the manuscript. RE and DJ revised the manuscript. RE, DJ, SW, and BL reviewed the manuscript. All authors contributed to the article and approved the submitted version.


To analyse the natural course of infants with otitis media with effusion who failed universal newborn hearing screening and to explore the appropriate observation period.This retrospective cohort analysis included infants with otitis media with effusion who failed universal newborn hearing screening every 3 months for 12 months.The average recovery time of the 155 infants was 7.08 ± 0.32 months after diagnosis. Multivariate Cox regression analysis confirmed that frequent reflux, maxillofacial deformities and initial hearing status were independent factors affecting recovery. Moreover, the cumulative recovery of most infants with mild hearing loss and infants with moderate hearing loss accompanied by frequent reflux was significantly higher at six months after diagnosis than at three months.For most infants with mild hearing loss, as well as those with moderate hearing loss accompanied by frequent reflux, the observation period can be extended to six months after diagnosis. In China, the timing of hearing screening, diagnosis and intervention is consistent with this standard.2Universal newborn hearing screening protocols have been widely applied worldwide in recent decades. The Joint Committee on Infant Hearing has established benchmarks recommending that all neonates be screened for hearing loss before the age of one month.3 According to the American Clinical Practice Guideline: Otitis Media with Effusion (Update),4 two recommendations apply to these infants. For infants aged six months or older with documented bilateral OME for at least three months and documented hearing difficulties, clinicians should offer a tympanostomy tube. For those who decline this procedure, follow-up appointments should be continued until the effusion is no longer present or until surgical intervention. At present, the surgical treatment timing for these infants mostly adheres to this guideline, with an operation rate of about 50 per cent.5 One study even suggested that a diagnostic microscopic examination with myringotomy, with or without placement of a ventilation tube, should be performed.6In neonates who failed universal newborn hearing screening, 15–65 per cent of cases were caused by otitis media with effusion (OME).7 Therefore, they tend to prolong the observation time. A small pilot study conducted by our institute found that infants with OME had a high rate of self-healing, and long-term observation did not affect post-operative outcomes.8As a leading institution for the treatment of children with ENT diseases in Wuhan, China, we provide clinical services for a large number of children with OME. Our observations indicate that few parents are willing to approve surgery after a three-month observation period because of concerns over the adverse effects of general anaesthesia and complications of myringotomy with or without ventilation tube placement.Currently, however, there is limited research on the natural course of infants with OME. This study retrospectively analysed the natural course of infants with OME who failed universal newborn hearing screening and who were observed at follow up, in order to provide guidance for determining the most suitable period for observation and follow up.This retrospective cohort study enrolled infants referred to our hospital's otolaryngology hearing centre because of failed universal newborn hearing screening during the period from 2009 to 2019. Initially, 170 children were included in the study; 15 children were excluded because of incomplete data and other reasons, and 155 children were finally included in the study. The research proposal and process are displayed in Infants who failed universal newborn hearing screening and who were previously diagnosed with otitis media with effusion (OME) before three months of age were included in the study. Follow up was conducted every 3 months, for a duration of 12 months, until the effusion had resolved or surgery was performed. Auditory function tests were conducted at each follow-up appointment, and any accompanying symptoms were documented.4 and the physicians’ clinical diagnoses, the associated symptoms were grouped into major symptom clusters, such as recurrent respiratory infections ,9 maxillofacial deformities , frequent nasal congestion  and frequent reflux10 . Patients with no obvious accompanying symptoms were classified as ‘uncertain’. Furthermore, symptomatic treatment with medication was not restricted.Based on the main causes of secretory otitis mediaThe exclusion criteria were as follows: (1) sensorineural hearing loss; (2) deformity of the pinna, external auditory canal or middle ear; (3) history of ear trauma; and (4) history of ear canal effusion.4The diagnostic criteria for OME were as follows: (1) presence of middle-ear effusion on pneumatic otoscopy; (2) abnormal results of higher-frequency probe tone (1 kHz) tympanometry; (3) failed distortion-product otoacoustic emission responses; and (4) abnormal air conduction auditory brainstem response (ABR) thresholds and normal bone conduction ABR thresholds.11 Classes I and II are mild, and classes III and IV are moderate. Normal clinical and audiological examination findings for both ears was designated ‘recovery’.There is no clear classification of hearing loss in infants. In this study, the hearing levels were classified by the air conduction ABR threshold of the worse hearing ear: class I (25–30 dB nHL), class II (35–40 dB nHL), class III (45–50 dB nHL) and class IV (55–60 dB nHL).Continuous variables with normal distribution, such as age at diagnosis and average recovery time, are presented as mean ± standard deviation. Patients were allocated to different subgroups based on discrete variables , which are presented as frequency and constituent ratio . The cumulative recovery rates at different follow-up timepoints, average recovery time and median recovery time were documented for the overall group and each subgroup. Survival curve analysis was used to describe differences in the cumulative recovery rates among the overall group and each subgroup at different follow-up timepoints.4 infants with recurrent respiratory infections were used as controls in regression analysis of influencing factors. The chi-square test was used to analyse the changes in recovery rate between different follow-up timepoints for patients with different initial characteristics and their combinations.The Kaplan–Meier method and Breslow test were used for comparison of recovery status between subgroups. Univariate and multivariate Cox regression analyses were applied to analyse recovery according to the hazard ratio for different initial features. Because respiratory infections can affect the resolution time of middle-ear effusion,p-value of less than 0.05 was the criterion for statistical significance.All statistical analyses were performed using R software  and GraphPad Prism . A two-tailed Among the 155 infants with otitis media with effusion (OME), 102 were male (65.8 per cent) and 53 were female (34.2 per cent), and the average age at initial diagnosis was 2.83 ± 0.28 months. As shown in The mean recovery time of the total infant group was 7.08 ± 0.32 months in this study, and the median recovery time was 6  months. The cumulative recovery rate reached 39.4 per cent, 58.7 per cent, 65.8 per cent and 69.7 per cent at the 3-month, 6-month, 9-month and 12-month follow-up timepoints, respectively. Thirty-five cases (22.6 per cent) were not yet healed after follow up, and in 12 cases (7.7 per cent) surgery was opted for.vs 6.45 ± 0.52 months, p = 0.31), while the results for infants with different main accompanying symptom clusters varied significantly (p < 0.01). Mean recovery times of infants with frequent reflux (4.61 ± 0.38 months) and no obvious accompanying symptoms  were lower than those of infants with frequent nasal congestion, recurrent respiratory infections or maxillofacial deformities. Infants with maxillofacial deformities had the longest mean time to recovery (11.83 ± 0.16 months).The analysis of mean recovery time for different characteristics showed no significant difference between male and female patients (7.41 ± 0.40 months p < 0.01), as shown in Mean recovery time for infants with different initial hearing levels showed an upward trend with the aggravation of hearing loss  and ‘uncertain’ symptoms (64.5 per cent) were higher than those of the other three groups at the three-month follow up, and the recovery rate of those with frequent reflux increased significantly at the six-month follow up and exceeded that of asymptomatic patients. It is noteworthy that the recovery rate among subgroups was ranked in descending order as frequent reflux, ‘uncertain’ symptoms, recurrent respiratory infections, frequent nasal congestion and maxillofacial deformities, and this order of ranking persisted from this point until the end of follow up. Infants with maxillofacial deformities had the lowest recovery rate, and there was no change except in one case, which was resolved at nine months and throughout the subsequent follow-up period .This section concerns the regression analysis of the influence of risk factors on hearing recovery. Based on the results displayed in p < 0.05). Results from the multivariate Cox regression model stratified by age and sex further confirmed frequent reflux, maxillofacial deformities and initial hearing status as independent factors affecting recovery.As shown in This section concerns the variation in cumulative recovery rates for infants with OME at different timepoints. Independent risk factors affecting hearing recovery  were recp < 0.05). However, the change between the six- and nine-month follow-up assessments was not statistically significant (p > 0.05), as the infants with level II initial hearing loss had all recovered at the nine-month follow up. For infants with other initial symptoms and class I or II initial hearing loss, the cumulative recovery at the six-month follow up was significantly higher than at the three-month follow up (p < 0.05); the recovery rate change between the six- and nine-month follow-up appointments was not statistically significant. Moreover, comparisons of the cumulative recovery rates at the 3-month versus 6-month, 6-month versus 9-month, and the 9-month versus 12-month follow-up timepoints all showed no significant differences for infants with level III initial hearing loss. None of the infants with OME accompanied by maxillofacial deformities healed throughout follow up, except for one case that was resolved at the nine-month follow up. For children with class IV hearing loss, the conclusion was not statistically significant because of insufficient sample size in this study  and failed universal newborn hearing screening, our study found that the total cumulative recovery rate increased to varying degrees with the extension of follow-up time, and the range of hearing loss was mainly mild to moderate. Considering that the age of 12–18 months is a critical period for speech development,12 Therefore, such infants may appear to have failed the universal newborn hearing screening and then receive a diagnosis of OME if effusion remains after audiological diagnosis within three months after birth. According to the resolution time of the amniotic fluid cellular content in the middle-ear cavity and the self-healing time of children with OME, the clinical practice guidelines suggest that observation for three months after diagnosis is reasonable. Our study reported a recovery rate of 39.4 per cent at three months of observation, indicating that middle-ear effusions of most of the infants were not completely resolved.It is necessary to first analyse the aetiology of OME. In research on the source of neonatal middle-ear effusion, previous evidence has shown amniotic fluid cellular content in the middle-ear cavity of newborns; although most of it practically resolved around 5 months after birth, tiny remnants of amniotic fluid cellular content appeared as late as 15 months after birth.4 Resolution of middle-ear effusion after acute infection can be prolonged, with 50 per cent of cases resolved within one month and about 80 per cent after three months.13In our study, infants with different concomitant symptoms showed different recovery times and recovery rates. Respiratory tract infection is the main risk factor for acute otitis media, and OME may occur during or after an upper respiratory tract infection.14 Reflux will develop in 70–80 per cent of infants within two months of age; most cases will resolve after seven months of age, and 95 per cent will be eliminated by the age of one year.10 In our study, the hearing recovery rate was greater than 60 per cent and greater than 90 per cent at the follow-up periods of three months and six months, respectively. This was consistent with the natural course that Rosenfeld and Kay reported for untreated otitis media, in which children with reflux reached a 60 per cent symptom resolution rate within three months and a 75 per cent resolution rate within six months.13Studies have confirmed that fluid can pass through the Eustachian tube into the middle ear during swallowing.15 In this study, the improvement in recovery rate for children with OME after six months of follow up may be related to the improvement of nasal congestion in some such infants. However, the self-healing rate of infants with long-term nasal obstruction is lower than that of infants with recurrent respiratory infections and reflux, and this may be due to frequent recurrence of rhinitis, poor symptom control and other factors such as adenoid hypertrophy.16In addition to respiratory tract infection, long-term nasal congestion in infants is mostly related to allergies. Antihistamines can be used after six months of age, according to the clinical practice guidelines for allergic rhinitis developed by the American Academy of Otolaryngology–Head and Neck Surgery Foundation.4 It has been reported that more than 20 per cent of middle-ear effusions resolved after the repair of maxillofacial deformities.17 However, other studies suggest early or exceptionally early tympanostomy tube placement.18Compared with recurrent respiratory infections, maxillofacial deformities serve as a risk factor for recovery. Infants with maxillofacial deformities are prone to OME, which is not only closely related to gastroesophageal reflux but also to Eustachian tube dysfunction and poor resistance.4 The ABR thresholds of the infants in this study ranged from 25 to 60 dB nHL, which is consistent with the study findings of Boudewyns et al.19 Studies have shown that the average hearing loss in OME is 18–35 dB HL,20 and the degree of hearing loss is highly positively correlated with effusion volume. This study's results revealed that infants with mild hearing loss had higher recovery rates and shorter recovery times. Initial hearing status was one of the independent factors affecting recovery. Therefore, assessment of initial hearing levels is another important indicator used to guide decisions to continue observation.Regular audiological evaluation is also valuable.4 the maximum period of observation in children with hearing loss should not exceed this.In infants who fail universal newborn hearing screening, 15–65 per cent of cases are due to otitis media with effusion (OME)At present, the surgical treatment rate of infants aged six months or older is approximately 50 per centIn this study, most infants with OME who failed universal newborn hearing screening recovered within 12 months of diagnosisObservation duration in follow up can be determined based on degree of hearing loss and accompanying symptomsFor most infants with mild hearing loss, or moderate hearing loss accompanied by frequent reflux, the observation period can be extended to six months after diagnosisInfants with maxillofacial deformities and most infants with moderate hearing loss were less likely to self-healIn this study, the recovery rates at each timepoint were compared according to different combinations of initial symptoms and degrees of hearing loss. Except for those with maxillofacial deformities, the cumulative recovery of all infants with mild hearing loss and those with reflux accompanied by moderate hearing loss was significantly higher at six months after diagnosis than at three months. Therefore, the observation period can be extended up to six months after diagnosis for these infants; however, ventilation tubes can be placed in a timely way for infants with maxillofacial deformities and most with moderate hearing levels. Because the age of 12–18 months is a critical period for speech development,4 As a retrospective analysis, this study mainly analysed the possible aetiologies through the main accompanying symptoms documented in the case records, which may be limited. In addition, infants with recurrent respiratory infections were used as controls in regression analysis of influencing factors. Further controlled studies will provide more evidence for the analysis of risk factors in infants with OME.Therefore, clinicians must comprehensively analyse the relevant causes of OME, predict the possibility of early recovery, and guide the feeding, nursing and disease observation methods for these infants.


Tropical cyclones (TCs) are one of the most dangerous hazards that threaten U.S. coastlines. They can be particularly damaging when they occur in densely populated areas, such as the U.S. Northeast. Here, we investigate seasonal-scale variations in TC genesis and subsequent first landfall locations of > 37,000 synthetic TCs that impact the U.S. Northeast from the pre-industrial era (prior to 1800) through a very high emissions future . TC genesis in the Main Development Region decreases across all parts of the season from the pre-industrial to the future, with the greatest decreases in the proportion of genesis (up to 80.49%) occurring in the early and late seasons. Conversely, TC genesis in a region near the U.S. southeast coast increases across all parts of the season from the pre-industrial to the future, with the greatest increases in the proportion of genesis (up to 286.45%) also occurring in the early and late seasons. Impacts of changing TC genesis locations are highlighted by variations in where TCs make their first landfall over the same time periods, with an increase in landfalls along the mid-Atlantic seaboard from Delaware to North Carolina during all parts of the season from the pre-industrial to the future. From 2017 to 2022, the U.S. was impacted by four of the costliest TCs on record in the U.S.—Hurricanes Harvey (2017), Maria (2017), Ida (2021), and Ian (2022). These four storms cumulatively cost the U.S. over $453.3 billion and caused over 3000 casualties5. TC genesis requires warm sea surface temperatures, low wind shear, ample humidity, adequate influence from the Coriolis force, and a pre-existing low-pressure disturbance in the atmosphere7. For these reasons, TCs have often historically formed in a region of the tropical North Atlantic known as the Main Development Region, where conditions are often ideal for TC development. In a warmer future, however, evolving TC characteristics-including their genesis, tracks, termination, and landfall patterns–may change. In particular, it is plausible that environmental changes caused by planetary warming could alter when and where TC genesis takes place, impacting where storms travel and eventually make landfall13.The Atlantic hurricane season officially spans from 1 June until 30 November, with the greatest number of TCs expected between the months of August and October16, primarily due to increases in sea surface temperatures in the North Atlantic Main Development Region. However, these studies tend to focus exclusively on TCs that form in the North Atlantic Main Development Region, and/or focus on relatively short  time scales. For instance, Ref.16 found that under a warming climate, tropical North Atlantic TC genesis from 1950 to 2010 shifted eastward, contributing to an increase in open ocean storm tracks. Similarly, Ref.12 found that an eastward shift in TC genesis results in changing TC activity along the U.S. Gulf and East coasts in the 2030s. At least one long-term study has also found significant changes to the tracks of TCs that impact the U.S. Northeast, including broad spatial shifts to genesis, translation speed, and track location over time, causing storms to not only reach coastal communities more quickly, but also linger longer over key coastal locations17. While findings from Ref.17 suggest broad long-term changes to TC behavior that will be critical for the U.S. East coast, the work does not consider how seasonal-scale variation in TC behavior—including landfall locations—may evolve in a warmer climate. Here, we aim to fill this knowledge gap by performing an in-depth assessment of long-term changes to seasonal patterns of both TC genesis and landfall that may impact the crowded coastlines of the U.S. Northeast. We find changes in both spatial and temporal TC genesis trends from the pre-industrial era to the future that impact TC landfall locations and the hazard that these storms pose to U.S. Atlantic and Gulf coast communities.Many previous TC modeling and observational studies have found that TC genesis in the North Atlantic shifts eastward under warmer climate conditions18; 2080–2100). To evaluate changes to seasonal patterns of TC genesis and subsequent landfall locations, we consider variations during three different times throughout and surrounding the Atlantic hurricane season: early season (April through July), peak season (August through October), and late season (November and December). Note that since the peak of the Atlantic TC season is temporally skewed to the later half of the full season5, the length of time covered during each part of the season is not evenly distributed.We consider changes in genesis patterns in three distinct regions, including the main development region , the Caribbean Sea , and a region north of the MDR near the coast of the southeastern U.S. . We evaluate changes in TC genesis and landfall patterns for three separate eras: the pre-industrial era (850–1800), the modern era (1970–2005), and a future era under a very high emissions scenario  could also play a role in TC genesis behavior. Changes in the distributions of vertical wind shear at the time of genesis indicate a general decrease in wind shear for all three of our main regions in the future relative to the pre-industrial era Fig. . This su29, which is consistent with the decrease in early-season MDR genesis demonstrated here. Relative humidity is also expected to decrease in the lower latitudes of the North Atlantic basin in some models31, which agrees with results of a general northwestern shift in genesis.Relative humidity distributions indicate higher relative humidity values in the SE US and Caribbean during all parts of the season in the future, relative to the pre-industrial era Fig. , which s33, which has been indicated as a driver of elevated TC activity in the western North Atlantic when it shifts to higher latitudes34. Similarly, a weakening of the Atlantic Meridional Overturning Circulation is associated with changes in the location of the ITCZ, SSTs, vertical wind shear, and mid-level humidity that could all contribute to more favorable TC genesis conditions at relatively higher latitudes and less favorable conditions in the MDR31. Future analyses should particularly consider not only the profile of environmental variables throughout the atmosphere , but also in-depth assessments of the broader environmental variable fields from global climate models used to downscale TC tracks.Although variations in shear and relative humidity may contribute to some variations in TC genesis, neither comprehensively explains all of the spatial or temporal variations in TC genesis for storms that impact the U.S. Northeast coast. Additional research that takes a broader look at environmental variables is therefore warranted in order to better understand the role of not only vertical wind shear and relative humidity in driving changes to TC genesis climatology patterns, but also other environmental variables that could contribute to such variations, such as SSTs, or possible changes to the location of the Intertropical Convergence Zone (ITCZ)38, particularly in the MDR30. There is also evidence that ENSO influences TC genesis locations39 and the number of landfalling TCs in the U.S41. Notably, vertical wind shear and relative humidity have a substantial impact on the reduction in Atlantic TC genesis during El Niño years42. However, the response of ENSO to anthropogenic climate change is not well understood, so it is unclear how great a role it may play in Atlantic TC genesis patterns in a warmer future44. Future work is necessary to further our comprehension of both the effect of a warmer climate on ENSO and how these shifts may impact Atlantic TC climatology.In addition to a broader analysis of environmental variables, future work may also focus on the El Niño Southern Oscillation (ENSO) and its potential to influence genesis variations such as those we identify here. ENSO has been shown to heavily influence Atlantic TC climatology. Generally, there are fewer Atlantic TCs during El Niño years and more Atlantic TCs during La Niña years45), and increase the likelihood of TCs taking a more northward trajectory  as they travel towards the U.S. Northeast, potentially resulting in more landfalls and greater impacts along the mid-Atlantic coast in a warmer climate35.Despite lingering uncertainty in the environmental mechanisms driving TC genesis changes throughout the hurricane season, there are critical impacts for U.S. coastlines that arise from such changes in genesis over time. Coinciding with changes to where TCs that impact the U.S. Northeast form, there are variations in the location where these TCs first make landfall. In general, increases in TC genesis in the SE US and decreases in MDR genesis across all parts of the season Fig. A,C,E dep38. This affected stretch of U.S. coastline includes a number of critically important locations spanning interests from national security to cultural history. For example, the U.S. Naval Station in Norfolk, Virginia, is the largest naval base in not only the U.S., but also the world47. An increase in TC activity and impacts here could therefore pose national security risks48. Additionally, areas with increased landfalls also include hundreds of miles of coastlines that host popular tourist destinations, important ecosystems, and cultural and historical landmarks. For instance, results suggest that the Outer Banks in North Carolina, which is home to some of the oldest resort towns in the U.S. as well as critical ecosystems49, will see consistent increases in TC landfalls, creating an elevated hazard for these fragile barrier islands50.There are persistent increases in first landfalls along the mid-Atlantic seaboard from Delaware through North Carolina during all parts of the season and across all eras Fig. B,D,F36–352. Our results demonstrate that seasonal scale shifts in TC genesis locations will have a substantial impact on the hazard these storms pose to U.S. coastal communities by potentially influencing the locations where these TCs make their first landfall. This creates an increasing TC hazard for portions of the U.S. East coast–a hazard that may be compounded by other factors, such as the fact that SLR in this region is rising faster than the global average35, and that TCs are becoming more damaging upon landfall52. These results for a high emissions future therefore illustrate not only the importance of coastal resiliency planning for U.S. coastal communities, but also the importance of mitigation measures to limit potential future TC impacts.The hazard that TCs present to U.S. coastlines combined with the many ways that TCs may vary in a warming climate has created an ongoing and growing need to understand exactly how such variations may impact our coastal communities54, this work relies upon synthetic TCs downscaled from global climate models (GCMs). Large numbers of synthetic TCs under a range of plausible past and future climates are generated using the statistical/deterministic approach described in Refs.56. These large datasets of simulated TCs are well-suited for evaluating long-term TC genesis and landfall behavior for the various climate scenarios and time periods we consider.To overcome the challenges of a short and potentially biased observational record of TCs in the North Atlantic57: MPI—Max Planck Institute for Meteorology, CCSM4—Community Climate System Model version 4, and IPSL—Institut Pierre Simon Laplace. The use of the MPI, CCSM4, and IPSL models allows us to perform a seasonal-scale analysis of the long-term implications of TC genesis variations originally suggested in Ref.17. In addition to their use in previous studies, the MPI, CCSM4, and IPSL models are also chosen because they are the only models available that contain all necessary variables to downscale TCs for the pre-industrial, modern, and future eras, thus providing historical context for modern and future changes to TC genesis in the Atlantic. We note, however, that future studies focusing on TC genesis shifts that may exist in the newer suite of CMIP6 models would also be useful.Datasets of simulated TCs are based upon both kinematic and thermodynamic state variables from three different Coupled Model Intercomparison Project Version 5 (CMIP5) global climate models56, which involves placing (or “seeding”) warm-core vortices with peak wind speeds of 12 m/s and minimal mid-level humidity anomalies in their cores throughout the Atlantic basin at all locations north of 2° latitude during all times of the year. The majority of these “seeds” fail to form TCs, due to environmental conditions that are not conducive for development, such as low potential intensity or large wind shear. However, some vortices will evolve, developing winds of at least 21 m/s (40 kts), at which point they are designated a TC60, and are included in our downscaled datasets. The genesis point for these TCs is simply the first point along the TC’s track .Genesis of downscaled TCs is accomplished using a random seeding process56. First U.S. landfall points are determined by interpolating the 2-hourly track points to 15-min time steps, and finding the first point at which a TC crosses a U.S. state boundary.TC tracks are simulated using a beta-and-advection model, which relies upon the wind fields from the GCMs (850 and 250 hPa)56, with the only exception being that relative humidity values are not available for the pre-industrial and modern eras of the MPI model. These variables provide an instantaneous description of the environmental and atmospheric conditions surrounding the storm for each point along its track, including the genesis point.Environmental variables for TCs are obtained from GCM fields characterizing the 600 hPa atmospheric temperature, the 850–250 hPa vertical wind shear, and the 600 hPa relative humidity of the TC’s surroundings. These variables are provided within our downscaled TC datasets17, ensuring that all TCs in our datasets will impact the U.S. Northeast. Our three eras of focus are defined as in Ref.17:The pre-industrial era (850–1800) Climatological conditions prior to major anthropogenic influence.The modern era (1970–2005) Recent climatological conditions.The future era (2080–2100) Climatological conditions under additional warming due to anthropogenic greenhouse gas emissions. TCs are generated for a very high-emissions scenario , which we expect to provide an upper bound on potential changes to future TC genesis and landfall locations18.TCs used in this work are filtered to travel within 250 km of NYC, as in Ref.56.Datasets contain ~ 5000 TCs per model for pre-industrial and modern simulations, and over 12,000 TCs per century per model for future simulations, resulting in ~ 3000 TCs per model during 2080–2100. Such large datasets allow for meaningful statistical analyses of long-term changing TC genesis and landfall characteristics on a seasonal scale. The ratio of all simulated TCs to the total number of seeded TCs is used to determine the overall frequency in each datasetBecause TCs used here are designed to travel within 250 km of The Battery in NYC, these results are not necessarily representative of basin-wide TC genesis and landfall patterns in the Atlantic basin, but are extremely pertinent for the subset of TCs that impact the crowded U.S. Northeast coast. Additionally, many of the downscaled TCs make landfall and thus impact a wide range of other locations along the U.S. coastline, as illustrated in Figs. 57. Particular caveats for this work may relate to our choice of models (reasons for which are described above), particularly since this subset of models form a relatively small ensemble that could increase uncertainty in our findings. This is especially true for relative humidity values in earlier time periods, where the variable is not available within the MPI model. Additionally, our downscaled datasets include relatively few storms in certain regions/seasons , providing somewhat limited sample sizes for analyses, that again increases uncertainty within our results. We nonetheless feel it prudent to include these analyses for completeness, and to gain as much insight as possible into changes in genesis and landfall throughout the hurricane season. Finally, it should also be noted that since seeded TC vortices have an initial peak wind speed of 12 m/s, any outside factors that may affect the development of these vortices prior to this point are not accounted for with the downscaling technique used here56. However, this downscaling method has nonetheless been shown to capture many aspects of observed TC variability quite well, including the global spatial distribution genesis and track density59, allowing the process to be highly useful for our goal of understanding temporal and spatial variability of TC formation and landfall on long time scales.As with any modeling study, there are certain caveats associated with our approach. Many caveats related to the downscaled datasets or CMIP5 experiment design and individual models are provided elsewhere in the literatureMaps illustrating spatial variations in TC genesis Figs. A,C,E andPercentages of TC genesis are calculated using Eq. :1\documeEssentially, this calculation provides the amount of TC genesis that occurs in each region during a particular season and era. We first determine the total number of TCs generated during a specific part of the season, in a particular region, in each era , and then divide that value by the basin-wide total number of TCs in that era and part of the season  are determined by bootstrapping the original dataThe “Other” region shown in Figs. Probability density functions (PDFs) are used to assess the distribution of TC genesis in various regions throughout the season Fig. A,C,E andTemperature, relative humidity, and vertical wind shear anomalies shown in Figs. Supplementary Figures.


The global epidemiological data on congenital hearing loss in children is sparse. We aimed to analyse the trends in the burden of complete hearing loss caused by congenital birth defects in children younger than five years from 1990 to 2030.Using data from the Global Burden of Disease (GBD) Study 2019, we reported the counts and rates of prevalence and years lived with disability (YLD) by age, sex, and sociodemographic index (SDI). We also forecasted the prevalence rates until 2030 through the autoregressive integrated moving average (ARIMA) and Bayesian age-period-cohort (BAPC) models.We observed a global prevalence rate of 15.4  = 5.8 to 33.8) and a YLD rate of 3.3 (95% UI = 1.1 to 7.1) per 100 000 population in 2019, with both showing downward trends from 1990 to 2019. Regionally, Oceania had the highest prevalence  and YLD  rates, while Central Europe had the lowest rates. Nationally, the prevalence  and YLD  rates were highest in Myanmar and lowest in Peru. Only the United States of America  and Norway  showed upward trends. Compared to girls, the prevalence and YLD rates were higher for boys at global, regional, and five SDI quintile levels, except for Eastern Sub-Saharan Africa. At the global level, downward trends were predicted in prevalence rates from 2019 to 2030 between boys and girls.Although the global burden of childhood congenital complete hearing loss showed inequalities across locations, sexes, and age groups, we found decreases in the global prevalence rates between 1990 and 2019 and predicted decreases from 2019 to 2030. Better prevention of infectious aetiologies, improving genetic diagnoses, and hearing restoration could alleviate this burden. Congenital hearing loss can become a chronic condition and progressively worsen if untreated. Children with the condition have difficulties with language and speech acquisition , as wellThe importance of studying congenital hearing loss is increasingly being recognised. The Joint Committee on Infant Hearing published position statements in 2000 and 2007 to establish guidelines for early hearing detection and intervention ,7. DespiTo the best of our knowledge, this is the first study to use estimates from the GBD Study 2019 to provide a retrospective and predictive assessment of the prevalence and years lived with disability (YLD) of complete hearing loss caused by congenital birth defects in children younger than five years from 1990 to 2030 and to stratify the analysis by age group, sex, and sociodemographic index (SDI), as well as to estimate global downward trends from 2019 to 2030 by autoregressive integrated moving average (ARIMA) and Bayesian age-period-cohort (BAPC) models.We extracted data on the burden of complete hearing loss caused by congenital birth defects through an online query tool from the Institute for Health Metrics and Evaluation (IHME) website . During We used counts and rates per 100 000 population with 95% uncertainty intervals (UIs) to estimate the burden of hearing loss. We measured the burden of hearing loss via prevalence and YLD and analysed it by age, sex, year, location, and SDI. We also calculated the percentage change in counts and rates between 1990 and 2019.We applied the ARIMA and BAPC models (details available elsewhere ) to predP-values <0.05 were considered statistically significant.We conducted all analyses in R, version 4.2.2  and SPSS, version 25.0 . There were 101 907  complete hearing loss prevalent cases caused by congenital birth defects among children younger than five years and 21 615  YLD globally in 2019, resulting in a prevalence rate of 15.4  and a YLD rate of 3.3  per 100 000 population  and Australasia  had the highest and lowest numbers of prevalent cases in 2019, respectively, as well as the highest and lowest number of YLD  , while Andorra had the lowest   as well as the highest and lowest YLD rates   and Norway , showed upward trends. In contrast, Equatorial Guinea  showed the largest decreases in prevalence and YLD rates during this period  for males and by -59.7% (from 12.4 in 2019 to 5.0 in 2030) for females. For both sexes, the rate decreased by -59.1% (from 13.2 in 2019 to 5.4 in 2030) (Figure S28 in the Predicted by the BAPC model, the prevalence rates for males are predicted to increase from 2019 to 2030 in four regions, including Andean Latin America, high-income North America, Western Europe, and tropical Latin America (For females, the prevalence rates are predicted to decrease from 2019 to 2030 in 14 regions, while five regions, including the Caribbean, Central Sub-Saharan Africa, Southern Sub-Saharan Africa, tropical Latin America and Western Europe, showed upward trends (Predicted by the BAPC model, the prevalence rates for males in 25 countries failed to be predicted due to the predicted absolute prevalence counts being lower than 1. The prevalence rates from 2019 to 2030 are predicted to increase in 29 countries (For females, the prevalence rates of 27 countries failed to be predicted due to the predicted absolute prevalence counts being lower than 1. The prevalence rates from 2019 to 2030 are predicted to increase in 23 (Notably, the prevalence rates showed contrasting trends between males and females in 12 countries, including Bolivia, Cyprus, Ecuador, Greece, Ireland, Israel, Italy, Malta, Pakistan, the Republic of Korea, Tonga and Venezuela, which presented upward trends for males and downward trends for females from 2019 to 2030. The prevalence rates in five countries, including the Democratic Republic of the Congo, Estonia, North Macedonia, Slovenia and South Africa, presented downward trends for males and upward trends for females from 2019 to 2030.We used the ARIMA model in our study to predict the prevalence rate of complete hearing loss caused by congenital birth defects in children younger than five years from 2019 to 2030 for males, females, and both sexes. Overall, the prevalence rates predicted by the ARIMA model were generally consistent with those predicted by the BAPC model at the global, regional, and national levels (Figures S35-S41 in the To the best of our knowledge, this is the first study to describe the prevalence and YLD of congenital complete hearing loss among children younger than five years from 1990 to 2019. We found an an overall decrease in the global prevalence and YLD between 1990 and 2019 and predicted ongoing downward trends from 2019 to 2030. This change is in contrast with the trends in the number of people with moderate-to-complete hearing loss, which increased between 1990 and 2019 , probablWe found that the global prevalence and YLD counts of congenital complete hearing loss showed upward trends from the 0-6-day age group to the 1-4-year age group. In countries with universal hearing screening, the estimated prevalence of perpetual bilateral hearing loss were 13.3 per 10 000 neonates , with a Consistent with previous findings on sex-related variations in hearing loss ,24, we fPrevalence and YLD rates decreased in most regions among males and females from 1990 to 2019, except for high-income North America, which might be due to four North American epidemics caused by Toxoplasma gondii infection  and periNationally, Myanmar, Madagascar, and Somalia had the highest burden of congenital hearing loss among developing countries due in part to inadequate immunisation, increased exposure to ototoxic agents, and consanguinity . In mostOur study has several limitations, such as the sparsity of data from low-income countries and insufficient data on the causes of congenital hearing loss, such as mutations in GJB2, congenital cytomegalovirus infection, and congenital rubella infection. Additionally, while we used the SDI to describe socioeconomic differences among countries, further classification could provide further information for understanding congenital hearing loss, such as ethnicity.We found that the burden of congenital complete hearing loss in children under five years varied widely across locations, sexes, and age groups from 1900 to 2030. Cost-effective, preventive treatment strategies, including newborn hearing screening, enhanced prenatal care, improved sanitation, immunisation, and reduction of exposure to ototoxic drugs, are needed to alleviate the adverse effects of congenital hearing loss.


BackgroundSensorineural hearing loss (SNHL) is a common complication of diabetes, but the underlying mechanisms and risk factors are not fully understood. This study investigated the relationship between several potential risk factors and SNHL in 118 individuals previously diagnosed with diabetes mellitus type 2 (DM2).MethodsWe did a cross-sectional analysis of data collected from 118 patients with diabetes mellitus at multiple tertiary hospitals in the Jordanian Royal Medical Services (JRMS). The mean age was 60.57 ± 12.8 years, with 56.8% males. Demographic and clinical data were collected, including age, gender, duration of diabetes, presence and duration of hypertension, diabetic retinopathy (DR) severity, tinnitus, and comprehension inability. In addition, a hearing assessment for SNHL was performed using pure-tone audiometry at 0.5, 1, 2, 4, and 8 kHz frequencies. Goodman and Kruskal’s γ test and cumulative odds ordinal logistic regression were used to analyze the relationship between these factors and hearing assessment results for SNHL.ResultsGoodman and Kruskal’s γ test showed a statistically significant moderate and positive association between diabetic retinopathy severity and sensorineural hearing loss. Further analysis using logistic regression revealed that retinopathy severity, age, and gender were all significant predictors of hearing loss level in this population. The odds of having a higher level of hearing loss increased by 9.1% for each additional year of age and were higher for males than females. In terms of DR severity, a worsening SNHL had lower odds in individuals with no DR or mild nonproliferative DR compared to those with proliferative DR.ConclusionOur findings have important implications for managing SNHL in individuals with diabetes. They indicate that healthcare providers must closely monitor and manage the risk factors in patients with diabetes. Further research is needed to generalize better the relationship between these risk factors and SNHL, including the potential role of other factors, such as exposure to loud noise or certain medications. Hearing loss is a common condition that affects individuals of all ages and can significantly impact their quality of life. It is estimated that hearing loss currently affects more than 1.5 billion people or 20% of the global population, with approximately 430 million of them having moderate or higher levels of hearing loss in the better hearing ear, and this number is expected to rise to over 700 million by 2050 [Diabetes mellitus is a chronic condition characterized by high blood sugar levels, which can lead to complications such as diabetic retinopathy (DR) and neuropathy. DR is a condition in which the blood vessels in the retina are damaged, leading directly or indirectly to vision loss. At the same time, neuropathy is nerve damage that can lead to sensory and motor deficits. Previous research has shown that individuals with DM are at an increased risk of developing SNHL . HyperteGiven the potential relationship between DM, HTN, and SNHL, it is crucial to investigate the association between these conditions. This study examined the relationship between retinopathy severity, DM duration, HTN status, and duration, along with other factors like age, gender, and patient hearing-related symptoms and SNHL in a sample of individuals with DM. It was hypothesized that individuals with more severe retinopathy, a longer duration of DM, and a history of HTN would have worse SNHL.Study designThis study was a cross-sectional analysis of data collected from patients having DM at multiple tertiary hospitals in the Jordanian Royal Medical Services . The data was collected from two time periods, from April to August 2018 and from March to December 2022. Data collection started after obtaining Institutional Review Board (IRB) approval from the ethical committee at Jordanian Royal Medical Services. We assigned a case number to each patient so that no personal identifiers were used in the data for statistical analysis. All included patients signed a written statement of informed consent. The study was conducted in accordance with the Declaration of Helsinki.Study participantsA total of 118 patients with DM were included in the study. Inclusion criteria were as follows: age 18 years or above, diagnosis of DM based on the American Diabetes Association criteria, and presence of retinopathy  ,6. ExcluData collectionRecruitment was done through multiple avenues, including referrals from primary care physicians and internists within the medical center and patients attending their appointments for diabetic retinopathy examination checks in the ophthalmology specialty clinics. An ophthalmology specialist did a thorough history taking and anterior and posterior eye examination and then filled in the demographic and clinical data, and examination results as follows: age, gender, duration of DM, presence of HTN, duration of HTN, retinopathy severity , maculopathy status , symptoms of decreased hearing, inability to comprehend speech at normal speaking levels, and tinnitus.Patients were then sent to do a hearing assessment for SNHL by a trained audiologist in a soundproof room using a calibrated audiometer. Pure-tone audiometry was performed at frequencies of 0.5, 1, 2, 4, and 8 kHz. The average hearing loss for each ear was calculated by summing the hearing thresholds at 500, 1000, 2000, 4000, and 8000 Hz, and then dividing the result by 5. SNHL was classified as normal, mild, moderate, or severe based on the World Health Organization criteria [Statistical analysisData from the two periods were combined and were analyzed using SPSS Statistics, version 28.0 . Descriptive statistics were used to summarize the demographic and clinical characteristics of the study population. The relationship between retinopathy severity and hearing assessment for SNHL was assessed using Goodman and Kruskal’s γ test. Cumulative odds ordinal logistic regression was used to determine the independent predictors of hearing assessment for SNHL. A p-value of <0.05 was considered statistically significant, and a confidence interval of 95% was used.This study included 118 individuals with type 2 diabetes. The mean age was 60.6±12.8 years, and the mean duration of diabetes was 13.9±8.8 years. In addition, 58.5% of the sample had a history of hypertension, and the mean duration of hypertension was 6.96 years. In terms of gender, the sample was somewhat evenly split, with 56.8% males and 43.2% females.The majority of the sample 77.1%) did not report symptoms of decreased hearing, while 22.9% reported having symptoms. Similarly, 79.7% did not report any symptom of an inability to comprehend, while 20.3% did. On the other hand, a relatively large proportion of the sample (41.5%) reported tinnitus symptoms. Considering retinopathy severity, 28.8% of the sample had no diabetic retinopathy, 14.4% had mild nonproliferative DR, 14.4% had moderate NPDR, 5.9% had severe NPDR, and 36.4% had proliferative DR. Figure % did notMoreover, 37.3% of the sample had no maculopathy, 57.6% had maculopathy, and 5.1% had clinically significant macular edema at the time of examination.The hearing assessment for sensorineural hearing loss revealed that 28.8% of the sample had normal hearing, 40.7% had mild SNHL, 22.9% had moderate SNHL, and 7.6% had severe SNHL. Figure Table When grouping the diabetic retinopathy as “no DR and mild NPDR” and “moderate NPDR, severe NPDR, and PDR” and calculating the odds ratio to have moderate or severe SNHL versus milder forms of SNHL, the odds ratio was 1.725.Goodman and Kruskal’s γ was used to determine the association between diabetic retinopathy severity level (from “no DR” to “PDR”) and sensorineural hearing loss level . It showed a moderate, positive association that was statistically significant . An omnibus test was conducted to evaluate the model's cumulative odds ordinal logistic regression overall fit. The likelihood ratio chi-square was 108.992 , indicating that the model fit the data well.Table The Wald chi-square for retinopathy severity was 9.410 , indicating a significant relationship between retinopathy severity and the level of hearing loss.The odds of experiencing a worse sensorineural hearing loss compared to patients with proliferative diabetic retinopathy varied based on retinopathy severity. For patients with no diabetic retinopathy, the odds of worse SNHL were 0.121 (95% CI: 0.022 to 0.675), with a chi-square value of 5.795. Among individuals with mild NPDR, the odds increased to 0.166 (95% CI: 0.039 to 0.716), corresponding to a chi-square value of 5.804. In the case of moderate NPDR, the odds of worse SNHL were 0.344 (95% CI: 0.097 to 1.220), with a chi-square value of 2.727. For those with severe NPDR, the odds stood at 0.142 (95% CI: 0.023 to 0.858), and the associated chi-square value was 4.520.2(1) = 13.917, p < .001. The estimate for the effect of age on hearing loss level was .087, indicating that for each additional year of age, the odds of having a higher hearing loss increased by 9.1%. The Wald chi-square for gender was 10.415 , indicating a significant relationship between gender and hearing loss level, where females were found to have a lower risk of severe hearing loss compared to males by an odds ratio of 0.240, 95% CI 0.101 to 0.571.The Wald chi-square for age was 13.917 , indicating a significant relationship between age and hearing loss level with an odds ratio of 1.091, 95% CI 1.042 to 1.142; χ2(1) = 7.915, p = 0.005. Similarly, the odds of encountering worse hearing test results were 3.542 times greater (95% CI: 1.270 to 9.879) for patients with tinnitus than those without this symptom. This association was statistically significant with a χ2(1) = 5.840, p = 0.016.The odds of observing worse hearing test results were 10.917 times higher (95% CI: 2.065 to 57.716) among patients who reported the symptom of inability to comprehend compared to those who did not report this symptom. This effect reached statistical significance, as indicated by χ2(1) = 0.418, p = 0.518), DM duration (χ2(1) = 0.080, p = 0.777), maculopathy stage (χ2(2) = 0.960, p = 0.619), and symptoms of decreased hearing (χ2(1) = 0.901, p = 0.342) were not significant predictors of hearing loss level.The presence of HTN  of having poorer hearing assessment scores. This was evident among patients with moderate non-proliferative diabetic retinopathy or more severe retinopathy, who were more likely to experience moderate SNHL or worse. This finding is consistent with the previous research on the relationship between diabetic retinopathy and hearing loss ,14.Following the results in the previous section, a significant relationship between age and hearing loss level was found. The Wald chi-square statistic of 13.917  indicated that this relationship was strong, with an odds ratio of 1.091. This relationship was further supported by the estimate for the effect of age on the hearing loss level, which indicated that the odds of having a higher level of hearing loss increased by 9.1% for each additional year of age. The 95% confidence interval of 1.042 to 1.142 further supports the reliability of these results. This finding aligns with previous research that found a strong relationship between age and hearing loss. A systematic review and meta-analysis by Lin et al. found that the prevalence of hearing loss increases with every decade of age . SimilarConsidering the gender of the patients and its relation to their hearing assessment scores, the study results showed a significant relationship, as indicated by the Wald chi-square statistic of 10.415 . This suggests that gender is a strong predictor of hearing loss level. Furthermore, females were found to have a lower risk of severe hearing loss compared to males, as indicated by the odds ratio of 0.240. This means that the odds of females having severe hearing loss are approximately 76% lower than the odds of males having severe hearing loss. The 95% confidence interval of 0.101 to 0.571 further supports the reliability of these results. This finding is supported by a previous research conducted in the mid-1990s that found that males are more than twice more likely to experience hearing loss compared to females , as oppo2(1) = 0.418, p = 0.518). However, when the study was split into hypertensive and non-hypertensive groups, the relationship between the HTN duration and the severity of SNHL was found to be significant with a Wald chi-square value of 7.129  and an odds ratio of 1.136 and 95% CI 1.035 to 1.248. The estimate for the effect of duration (in years) on hearing loss level was 0.128, indicating that for each additional year of age, the odds of having a higher level of hearing loss increased by 12.8%. This might suggest that hypertension may be a risk factor for hearing loss. Furthermore, as the duration of HTN increases, the severity of hearing loss (as measured by the hearing assessment for SNHL) also tends to increase. This finding is consistent with a previous research that found a relationship between hypertension and hearing loss [It is worth noting that this study did not show a significant relationship between the presence of HTN as a comorbidity and SNHL severity (χ2(1) = 38.295, p < 0.001, Exp(B)= 1.164) in the study group. Furthermore, the relationship between DM duration and SNHL severity was not statistically significant, with a significance of χ2(1) = 0.080, p = 0.777. A literature review showed different and inconsistent results; some studies found a positive correlation between DM duration and SNHL severity [The duration of diabetes was calculated from the year of diagnosis, which might underestimate the actual number of years the patient had diabetes. Nevertheless, in the multinomial cumulative logit model, there was a significant relationship between this calculated DM duration and DR severity  = 0.960, p = 0.619).Patients were assessed for the presence and severity of diabetic maculopathy and were grouped into three groups: no diabetic maculopathy, diabetic maculopathy, and clinically significant macular edema. The provided data showed no significant relationship with hearing loss severity (χ2(1) = 7.915, p = .005), and patients with tinnitus were more likely to have the severe form of SNHL by 3.542 times (95% CI 1.270 to 9.879) as compared with patients not complaining of tinnitus (χ2(1) = 5.840, p = .016). This suggests that individuals who reported experiencing these symptoms were more likely to have SNHL. On the other hand, decreased hearing was not significantly associated with SNHL (χ2(1) = 0.901, p = 0.342). It is important to note that these symptoms may be a consequence of SNHL rather than a contributing factor. Still, the results of this study highlight the importance of considering the presence of symptoms in the evaluation and management of SNHL in diabetic patients.We gathered information about hearing loss symptoms from patients. This data was collected through questions, in a yes/no format, asking about symptoms like tinnitus, decreased hearing, and inability to comprehend. Data analysis showed that two of these symptoms were significantly associated with hearing assessment for SNHL. In particular, the inability to comprehend had an odds ratio of 10.917, 95% CI 2.065 to 57.716 (χIt is worth noting that the present study had several limitations. First, the sample size was relatively small, which may have limited the power of the study to detect associations between variables. Additionally, using some self-report measures may aid in inaccurately capturing specific characteristics or experiences that are difficult to quantify or describe. Finally, the study was cross-sectional, so it is impossible to establish a causal relationship between retinopathy severity and hearing assessment for SNHL. Longitudinal studies will be needed to confirm the present study’s findings and further explore the potential mechanisms underlying the relationship between DR and hearing loss. Despite these limitations, the present study provides important insights into the relationship between DR and hearing loss. Moreover, further research is needed to understand this relationship and develop interventions to prevent or mitigate hearing loss in individuals with DR.In conclusion, the results of this study provide important insights into the relationship between several variables and hearing assessment for sensorineural hearing loss. The data analysis revealed that diabetic retinopathy severity, age, and male gender were significantly associated with worse SNHL; this finding is essential to consider when evaluating and managing SNHL in individuals with diabetes. Further research is needed to fully understand the mechanisms behind the relationship between diabetes and hearing loss and to develop effective strategies for preventing and mitigating hearing loss in individuals with diabetes.


In the monaural condition, total rotation and discrimination in noise were negatively correlated with difficulty . Subjects’ behaviors were different in optimizing their hearing in noise via head rotation. The evaluation of head movements seems to be a significant parameter in predicting the difficulty of monaural hearing in noisy environments.There is a discrepancy between the hearing test results in patients with single-sided deafness (SSD) and their reported outcome measures. This is probably due to the presence of two elements in everyday situations: noise and head movements. We developed a stereo-audiometric test in noise with free head movements to evaluate movements and auditory performance in monaural and binaural conditions in normal hearing volunteers with one occluded ear. Tests were performed in the binaural condition (BIN), with the left ear (LEO) or the right ear occluded (REO). The signal was emitted by one of the seven speakers, placed every 30° in a semicircle, and the noise (cocktail party) by all speakers. Subjects turned their head freely to obtain the most comfortable listening position, then repeated 10 sentences in this position. In monaural conditions, the sums of rotations  were higher (LEO 255 ± 212°, REO 308 ± 208° versus BIN 74 ± 76,  As the population ages and standards of living improve, deafness has become a real public health issue, with 1.5 billion people affected by hearing loss, according to the WHO in 2021 .Binaural hearing is crucial in everyday life, providing improved hearing comfort for soft sounds, enhanced speech discrimination in noise, and the capacity to localize the sound source . These bThese functions are impaired not only in single-sided deafness (SSD), but more extensively in asymmetric hearing losses  . DegradeAs objective factors in rehabilitation success are difficult to individualize, it is worthwhile carrying out more specific assessments for SSD/AHL patients and estimating the prognosis for success as closely as possible . Today, Disposing of a method to evaluate the hearing handicap in SSD patients in conditions close to those of real life would potentially improve the selection of candidates for rehabilitation. Even if trials in real-life conditions can be organized for bone-anchored or CROS devices, such a test enhances the selection and reduces the cost. In the case of cochlear implantation, preoperative real-life trials are impossible, and predicting the functional outcome and patient satisfaction using an audiometric test is even more important. Moreover, the exploration of SSD in noisy and dynamic environments will probably reveal different coping strategies useful to adapt therapeutic education and hearing device designs or settings.We hypothesized that the discrepancy between the routine audiometric tests and the patient’s reported outcome was probably due to the dynamic aspect of everyday life situations: noise fluctuating in intensity and azimuth, and head movements in search of the best position in relation to the signal source. Including these two elements in stereoaudiometry tests would enhance concordance with the patient’s outcome. We also hypothesized that SSD not only reduces speech discrimination in noise, but also increases head movements for sound source exploration.The objective of this study was to develop a test combining free-field speech in noise audiometry and the recording of free head rotations in the search of the optimal position and to evaluate the test in normal-hearing subjects in binaural and monaural conditions.We conducted a prospective monocentric study in an otology tertiary referral center from June to July 2022, including 20 healthy adult subjects with normal hearing (no hearing difficulties and PTA < 20 dB on both ears). The participants were all French native speakers. Subjects with hearing symptoms, a neurological, rheumatological or orthopedic disorder preventing head and/or torso rotation movements, or a condition disrupting neurosensory abilities (including communication disorders) were excluded.®, Champigny sur Marne, France) placed every 30° in a semicircle and numbered 1 to 7 from left to right. The subject was placed in the center, 1.0 m from the speakers, on a stool that could rotate freely but not translate. The speakers were located at the ear level.We used a soundproof audiometry booth, measuring 3 × 3 m, with 7 loudspeakers  .Statistical tests were carried out using Prism software . Comparisons of these different positional parameters  or auditory performance parameters  between the different conditions  were performed using an ANOVA test or a mixed model with a correction for the absence of sphericity according to Geisser–Greenhouse and a correction for multiple comparisons according to Tukey.Parameters related to head position and auditory performance did not follow a normal distribution  for the same parameter were carried out using a non-parametric Friedmann repeated-measures test, followed by Dunn multiple-comparison correction.p > 0.05: non-significant; p < 0.05: significant; p < 0.01: highly significant; p < 0.001: very highly significant.Significance levels were defined as follows: The correlation between different series of the same condition for head position or auditory performance parameters was estimated using Pearson’s r: r < 0.40: poor correlation; 0.40 < r < 0.59: moderate correlation; 0.6 < r < 0.74: good correlation; 0.75 < r < 1: excellent correlation .All 20 subjects completed the tests. The sex ratio was 1, with an average age of 28.4 ± 5.1 years . As evaluated via pure-tone audiometry, the mean hearing threshold was 9.9 ± 2.9 dB  on the right, and 10.5 ± 3.6 dB  on the left. The mean interaural difference was 2.8 ± 2.1 dB . The mean SNR50 was 58.5 ± 2.3 dB , and the mean SNR was −1.6 ± 2.3 dB  with the normalized cocktail party noise set at 60 dB.The parameters describing the head position showed significant dispersion, even in the binaural condition . This sup < 0.001, ANOVA, As expected, during the exploration phase, total rotations were greater with one occluded ear than those in the binaural condition  in the same condition shows no learning effect. Indeed, there was no decrease in the total rotation or amplitude with the repetition of the series . HoweverIt should be noted that, in the LEO condition, the left limit angle is lower than the one measured in the REO and BIN conditions, and, symmetrically, in the REO condition, the right limit angle is higher than that in the LEO and BIN conditions . This suMeanwhile, during the exploration phase, the number of presentations was higher in the LEO  or REO  conditions in comparison to that in the BIN condition , while there was no difference between the LEO and REO conditions .p < 0.001 versus BIN) and REO  conditions. There was no difference in scores between LEO and REO conditions . We found a moderate test–retest correlation in BIN, but no correlation in LEO or in REO conditions , with an offset of one speaker in only two occasions (mean offset: 0.03 ± 0.18 speaker). In contrast, in the LEO condition, the signal source was correctly identified in only 26 cases , with an error of one to three speakers in the remaining 34 cases (mean offset: 0.65 ± 0.66 speaker). Similarly, in the REO condition, the signal source was correctly identified 31 times , with an error of one to three speakers in the remaining 29 cases, (mean offset: 0.63 ± 0.78 speaker). Mean localization errors in the LEO and REO groups were higher than those in the BIN condition . Offsets were not significantly different between the LEO and REO conditions, .In the BIN condition and in all three test replicates, the speaker delivering the voice material was correctly identified 58 times .The direction of the shift between the presumed speaker and the actual source of the voice was indifferent and did not differ between the LEO and REO situations , indicating the randomness of source detection .In the monaural condition, localization errors were not correlated with discrimination scores  or total rotation .p < 0.01).Subjects rated the difficulty of the test at 5.20 ± 1.54  and the effortfulness at 3.40 ± 2.28  out of 10. There was a good correlation between these two scores  but not in the BIN condition , suggestFurthermore, the difficulty score was negatively correlated with the discrimination score in the monaural condition , while tGiven the low relative prevalence of unilateral deafness , and theIn this study, we showed that a stereoaudiometric test performed in noise with free head movements can discriminate between monaural and binaural situations. No ceiling or floor effect was observed for any of the parameters studied. We showed that in monaural situations, head movements in search of the optimal listening position were greater, and the discrimination score was lower, than those in binaural situations. These two parameters appeared to be independent, but were both correlated with test difficulty, suggesting that a combined score adding parameters related to head movements and those pertaining to speech discrimination in noise might better account for the day-to-day difficulties of patients with unilateral deafness.When measuring binaural prosthetic gain, the improvement in SNR cannot remain the only objective element in monitoring the hearing in noise conditions of rehabilitated patients . Indeed,The study of head movements during a free-field audiometric test with several sound sources is an original and innovative approach, as most existing audiometric tests are performed with the head fixed, and with varying loudspeaker configurations and volume . These tAn important aspect of testing monaural hearing or hearing in noise is the effect of training. Several authors have shown that the capacity of pure-tone azimuth localization improves with training ,26,27. ADuring the exploration phase, when subjects sought the optimal head position, we could imagine that subjects with smaller rotations would express less difficulty and effortfulness, because they had a greater ability to find the optimal position quickly. On the contrary, we were surprised to find that subjects with greater head movements found the test easier and less arduous. This reduction in the ability to find a comfortable hearing position in a monaural situation could explain the reported discomfort and the motivation for hearing aid fitting in the case of unilateral deafness, yet this ability is not explored in current tests .In a binaural situation, even in the presence of noise, subjects had excellent signal source localization performances and a near-zero error rate, whereas in a monaural position, errors were frequent, as predicted in multiple previous studies ,32,33. HIn order to measure only the auditory performance of subjects and improve the sensitivity of measurements, some authors suggest carrying out tests in the dark or blindfolded ,36. ThisAmong the objective factors predictive of rehabilitation success, age is often mentioned . As the For the same level of deafness, the extent of hearing impairment depends not only on audiological factors, but also on non-auditory criteria  . Thus, tIn conclusion, the strategy of head movements to optimize hearing in noisy environment varies between subjects and is probably a significant factor in patient-reported outcomes in SSD. The combination of the two parameters identified in our study, discrimination score and head rotation, in a composite score, would be an interesting avenue through which to predict the outcome of rehabilitation in SSD patients.