Hearing loss leads to impaired social functioning and quality of life. Hearing loss is also associated with sleeping disorders and cardiometabolic risk factors. Here, we determined whether subclinical hearing loss is associated with sleep duration and cardiometabolic risk factors in a cross-sectional and longitudinal study of healthy Japanese general population. 48,091 men and women aged 20–79 years who underwent medical checkups were included in a cross-sectional study, and 6,674 were included in an 8-year longitudinal study. The prevalence of audiometrically determined hearing loss (>25 dB) at 4000 and 1000 Hz increased significantly with increasing sleep duration in any age strata. Logistic regression analysis showed that compared with reference sleep duration (6 h) longer sleep duration (≥8 h) was significantly associated with hearing loss, even after adjusting for potential confounding factors. Simultaneously, hearing loss was significantly associated with male sex, diabetes, and no habitual exercise. In the longitudinal study, the risk of longer sleep duration (≥8 h) after 8 years was significantly greater in subjects with hearing loss at 4000 Hz at baseline. In conclusion, current results suggest a potential association of subclinical hearing loss with longer sleep duration and cardiometabolic risk factors in a Japanese general population. The progressive aging of society is leading to an increase in the prevalence of hearing loss worldwide. Although hearing loss is not directly life threatening, it may impair social functioning and quality of life, causing isolation, frustration, and impaired communication –6. MeanwIn this context, we focused on subclinical objective hearing loss, which is often undetected and left untreated , 6, and Because hearing loss has been shown to be associated with cardiometabolic risk factors, such as diabetes and smoking –16, we cThis study was based on a composite research program that is being conducted to identify the factors associated with cardiometabolic and atherosclerotic diseases. The design of this study is described in more detail elsewhere . This ren = 488) were excluded from the analysis because the cause and treatment received  were not available in this study. Subjects with self-reported depression and sleep apnea syndrome were also excluded because these conditions may affect sleep duration [n = 1, 396) were included because tinnitus was usually mild and was not always diagnosed by a physician in this study. Consequently, 48 091 subjects were included in the cross-sectional study.We digitally stored data from 83 286 apparently healthy subjects aged 20–79 years old who underwent medical checkups at Saitama Health Promotion Corporation between April 1, 2007, and March 31, 2008. Subjects with diagnosed or undiagnosed self-reported hearing loss  and who underwent the same checkup four times between April 1, 1999, and March 31, 2008 (8 years duration), was <1,000. Therefore, subjects included in the longitudinal study were identified from the original study population, which means the subjects included in the longitudinal study differed from those included in the cross-sectional study. However, the assessment of hearing loss and other laboratory tests were identical between the cross-sectional and longitudinal studies. After excluding subjects with incomplete data and those with known ear diseases, 6,774 subjects with normal or short sleep duration at baseline were included in the longitudinal study . During Anthropometric, laboratory, and audiometric tests were carried out in the morning. Serum parameters were measured using standard methods on Hitachi autoanalyzers  at Saitama Health Promotion Corporation. Hemoglobin (Hb) A1c was converted to national glycohemoglobin standardization program levels using a validated formula . Unfortu2). We took into consideration that WHO has proposed that BMI cutoff points for overweight and obesity for Asian populations should be lower  compared to Western populations [2) or obese  are very low  in this study, we round up the low and high BMI cutoffs to 19 and 27 kg/m2 . The influence of systemic inflammation was roughly evaluated in terms of the circulating white blood cell count, a putative risk factor for cardiovascular disease [n = 39, 691).Self-reported sleep duration per night, which was obtained as a response to the simple question about sleep, was divided into five categories  according to previous studies , 25. Theulations . Since t disease , which we i.e., ≥.0 kg/m2  disease , the useχ2 tests, respectively. The prevalence of hearing loss was first evaluated in four age groups  because advancing age is one of the main risk factors for hearing loss. In the cross-sectional study, multivariate logistic regression models were used to examine whether subclinical hearing loss was associated with lifestyle and cardiometabolic risk factors to calculate odds ratios (OR) and 95% confidence intervals (CI) with adjustment for relevant confounders. After sleep durations in five categories of sleep duration were coded as 5, 6, 7, 8, and 9 for ≤5 h, 6 h, 7 h, 8 h, and ≥9 h, respectively, associations between sleep duration as a continuous variable and hearing loss were examined. The associations between relevant confounders and hearing loss were also evaluated.Data are expressed as means (SD) or medians (interquartile range). Differences in clinical parameters and categorical variables between the five categories of sleep duration were examined by one-way analysis of variance (ANOVA) and 2 based on the proposal by the World Health Organization regarding overweight and obese classifications for Asian populations [P < 0.05 were considered statistically significant.For the longitudinal analysis, multivariate logistic regression models were also used to examine the association between baseline hearing loss and risk of longer sleep duration (8 h and ≥9 h) after 9 years to calculate relative risk (RR) and 95% confidence interval (CI) because the incidence of longer sleep duration after 9 years was <10% and the ORs are expressed as relative risks in the longitudinal study . In thisulations . StatistThe clinical characteristics of the subjects are presented in Multivariate logistic regression analyses showed that, compared with sleep duration of ≤5 h, the other categories of sleep duration were significantly associated with hearing loss at 4000 and 1000 Hz at least in one ear . Adjustm2/μL), current smoking, and daily alcohol consumption were significantly associated with hearing loss at 4000 Hz. Work duration was significantly and inversely associated with hearing loss at 1000 Hz but not at 4000 Hz. Compared with clerical work, other work types, except managerial and medical work, were significantly associated with hearing loss at 4000 Hz (ORs 1.24–4.49) and 1000 Hz (ORs 1.34–1.90), even after controlling for confounding factors, including work duration (data not shown).The baseline clinical characteristics of subjects included in the longitudinal study  are simiOur cross-sectional and longitudinal studies provide robust evidence that subclinical hearing loss, especially at high frequencies, is associated with longer sleep duration, which was particularly depicted in older age, independently of relevant lifestyle factors, cardiometabolic risk factors, and the use of organic solvents at work. These associations were not weakened when the reference sleep duration was changed to 6 h, the major sleep duration category in this study. Although several epidemiological studies have shown U- or J-shaped relationships between sleep duration and clinical disorders, such as obesity and diabetes , 33, 34,Regarding the cause-effect relationship, considering the results of our longitudinal study, it is likely that longer sleep duration may occur because of or in conjunction with hearing loss. In other words, subclinical hearing loss may be a predictor of long sleep duration, which may be related to the development of cardiometabolic disease , 33–38. 12 and antioxidants [Meanwhile, many previous studies have provided evidence that diabetes, cardiometabolic disease, and smoking are associated with hearing loss –16, plauoxidants –55, or ooxidants –58. In ooxidants , 59–62. oxidants  have shooxidants –37, our Several limitations should be mentioned. First, we assessed self-reported sleep duration but not the quality of sleep or other related factors. Nocturnal awakening, insomnia, nocturia, daytime napping, and difficulties with falling sleep may interfere with the observed associations , 63, 64.Our results suggest that subclinical hearing loss, especially at a high frequency, was independently associated with longer sleep duration and cardiometabolic risk factors in Japanese general population. Current findings remain to be warranted in further study.


Chronic inflammatory demyelinating polyneuropathy (CIDP) is a rare complication of Crohn's disease (CD), and it is uncertain whether it is associated with CD itself or with its treatment. We describe a case of CIDP-like neuropathy as an initial symptom of CD. The neurologic symptoms of the patient which responded partially to intravenous immunoglobulin (IVIG) recovered after resection of the appendiceal CD.A 17-year-old male had experienced three separate attacks of motor weakness and paresthesia of all four extremities over a period of 7 months. The electrophysiologic findings revealed a demyelinating sensory-motor polyneuropathy which was compatible with CIDP. However, repeated intravenous IVIG (2 g/kg) treatment gave only a partial response. Four days after the last discharge, he was diagnosed as appendiceal CD after surgical resection of a periappendiceal abscess. His neurologic symptoms and electrophysiologic findings recovered without any maintenance therapy.CIDP-like neuropathy can be an initial presentation of CD, and recovery of the CIDP symptoms may result from resection of the CD. Clinicians should be aware of the possibility of CD in patients with intractable CIDP symptoms. Crohn's disease (CD) is a relapsing, transmural inflammatory disease of the gastrointestinal mucosa that can affect the entire gastrointestinal tract form mouth to anus . It is cA 17-year-old male without any medical history was admitted with ascending weakness of both lower extremities that had progressed for about two weeks. He had upper respiratory infection one week ago. At the time of admission, his upper respiratory infection was improved and physical examinations in neck, chest and abdomen were unremarkable. On neurologic examination, he had symmetric weakness of both lower extremities (MRC grade 4) with paresthesia of both hands and feet. Deep tendon reflexes were absent in the upper and lower extremities. Routine laboratory findings, including serum complete blood count, biochemistry, urine analysis and C-reactive protein, were normal. Cerebrospinal fluid (CSF) protein level was elevated at 72 mg/dL without pleocytosis and immunoglobulin G levels in serum (3370 mg/dL) and CSF (13.8 mg/dL) were increased. Extensive laboratory investigations including, thyroid function, anti-nuclear antibodies, anti-ganglioside, myelin-associated glycoprotein and viral markers, were all negative. Motor nerve conduction study (NCS) of the median, ulnar, tibial and common peroneal nerves showed prolonged motor terminal latencies and F-wave latencies, and decreased compound muscle action potential (CMAP) amplitudes, sensory nerve action potential (SNAP) amplitude and nerve conduction velocity (NCV)  prompted suspicion of a periappendiceal abscess, and emergent surgical resection of the ileum, cecum and appendix was performed. Appendiceal biopsy revealed diffuse wall thickening due to transmural lymphocytic infiltration and fibrosis, with scattered non-necrotizing granulomas, which was compatible with Crohn’s disease Figure . Since iWe report the first case in which CIDP-like neuropathy was the initial presentation of concealed CD. We may assume that the CIDP-like neuropathy was the initial symptom of CD since recurrent and intractable neurological symptoms preceded the diagnosis of CD, and the symptoms recovered without maintenance therapy after surgical resection of the appendiceal CD.The origin of CIDP is still unclear, but it is widely accepted that it is an autoimmune disease with underlying immunopathology involving autoreactive T cells and B cells . BecauseIn the two other cases the CIDP and CD occurred at the same time, but the patients had only one acute progressive symptom, which was not differentiated from acute inflammatory demyelinating polyradiculoneuropathy (AIDP) ,11. In aAnother noteworthy finding in our patient is that he recovered from the CIDP symptoms after resection of the appendiceal CD. Although 3 times of IVIG treatment could have influenced the clinical course of the patient, there was only minimal responses before removal of the periappendiceal abscess. Furthermore, the symptoms and electrophysiological findings gradually improved without any treatment for CIDP. Based on our patient’s clinical courses, we believe that surgical resection may have more pronounce effect on clinical stabilization of the patient. CD confined to the appendix occurs in younger patients and is known to be less aggressive and have a low recurrence rate ,15. It cIn summary, we describe a case of CIDP as an initial presentation of CD, with recovery of the CIDP symptoms after resection of the appendiceal CD. We suggest that inflammatory bowel disease should be considered a possible underlying disease when investigating patients with CIDP.Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.


Children using unilateral cochlear implants abnormally rely on tempo rather than mode cues to distinguish whether a musical piece is happy or sad. This led us to question how this judgment is affected by the type of experience in early auditory development. We hypothesized that judgments of the emotional content of music would vary by the type and duration of access to sound in early life due to deafness, altered perception of musical cues through new ways of using auditory prostheses bilaterally, and formal music training during childhood. Seventy-five participants completed the Montreal Emotion Identification Test. Thirty-three had normal hearing (aged 6.6 to 40.0 years) and 42 children had hearing loss and used bilateral auditory prostheses . Reaction time and accuracy were measured. Accurate judgment of emotion in music was achieved across ages and musical experience. Musical training accentuated the reliance on mode cues which developed with age in the normal hearing group. Degrading pitch cues through cochlear implant-mediated hearing induced greater reliance on tempo cues, but mode cues grew in salience when at least partial acoustic information was available through some residual hearing in the contralateral ear. Finally, when pitch cues were experimentally distorted to represent cochlear implant hearing, individuals with normal hearing  switched to an abnormal dependence on tempo cues. The data indicate that, in a western culture, access to acoustic hearing in early life promotes a preference for mode rather than tempo cues which is enhanced by musical training. The challenge to these preferred strategies during cochlear implant hearing , regardless of musical training, suggests that access to pitch cues for children with hearing loss must be improved by preservation of residual hearing and improvements in cochlear implant technology. Basic components of music (mode and tempo) influence our perception of whether the music is happy or sad , 2. In tLike speech, music is used in a unique way by humans to communicate ideas and emotions . Since bHumans are known to be the only species able to obtain pleasure from aesthetically abstract or conceptually meaningful stimuli (such as listening to music), with little direct relevance for survival . It is wThere is a lack of systematic investigation of emotional processing of music in the classic literature, for it was thought to be a very personal and variable experience. More recently, however, various mechanisms have been advocated to explain how music listening may induce emotions, including brain stem reflexes, evaluative conditioning, emotional contagion, visual imagery, episodic memory, and musical expectancy . EmotionWhile tempo perception seems to be more intuitive, immediate and independent from the musical cultural context in which it develops, the discrimination between major and minor chords is based on implicit knowledge or passive exposure to pitch structures of Western music . Tempo oThe saliency of tempo cues in early life could be explained by the assumption that tempo is easier to process or that sensitivity to mode is more dependent on music learning with age . UnfortuBrain anatomy can change noticeably as a function of learning, both in adults and children , 27. ForThe degree of anatomical and functional change induced by musical experience is related to the number of years of continuous musical training , amount The scientific literature agrees about the positive and negative connotations conveyed by specific aspects of music such as tempo and mode, but to date only a few studies have investigated infants’ emotional response to music and how emotional associations to musical characteristics develop over time. Infants as young as 7 to 11 months are able to detect mode changes  but onlyThis led to the idea that the ability to attribute emotional connotation based on mode cues alone develops with cognitive maturity and exposure to the musical culture. Gerardi and Gerker described a “two-step” developmental change, in which 5 year olds’ discrimination of emotion in music based on mode clusters near chance, while by age 8 years there is a shift towards more positive affect in response to major melodies, with the greatest differentiation between modalities found in adulthood. The authors therefore hypothesized the existence of a developing sensitivity to tonal scale structure that facilitates or underlies modal differentiation , 56.Taken together, the ability to assign mode an emotional connotation takes time to develop, for it requires sufficient musical exposure and cognitive maturity . These qGiven the importance of experience to shape music perception during development, it is likely that children wearing cochlear implants use unique strategies to make judgments about the emotion conveyed in music. Indeed, access to the normally rich soundscape through a CI is restricted by its signal processing limits, which are responsible for poor pitch resolution and atypical timbre quality . In ExpeMany causes are proposed to explain poor music perception in CI users –61 incluMusical experience of child CI users has generally been limited to CI input because their deafness was from birth or very early in life. As a result, they do not compare the quality of sound through their CI(s) with a remembered sound as do adults with post-lingual deafness and they seem to enjoy and take part in musical activities to the same extent as their hearing peers , 73. ChiThus, given the technical constraints of signal transduction, which places a greater importance to the rate of stimulation rather than a faithful reproduction of the envelope of the waveforms, unilateral CI users rely more on tempo than mode cues because of the signal from the CI device itself , 75. If Thanks to broadening inclusion criteria for cochlear implantation, today there are many children receiving one implant who have considerable residual hearing in the contralateral ear. These children can therefore still benefit from hearing through a conventional hearing aid in one ear and a cochlear implant in the other ear . This emerging population has a theoretical advantage for music perception over children using unilateral or bilateral CIs because of their access to low-frequency acoustic information. A group of children using bimodal devices were included in Experiment 2 to explore whether the combined use of acoustic and electric hearing by children is of benefit for identifying emotion in music.Similar to individuals with normal hearing, training is a powerful tool proven to improve music identification and appreciation in CI users. Perceptual accuracy in pitch- and rhythm-based tasks, as well as music enjoyment, can be enhanced in CI recipients by specific music-oriented training programs . Yet it We hypothesized that CI and bimodal users would show poorer accuracy than normal hearing peers in identifying emotions conveyed by the original musical excerpts. Moreover, we hypothesized that bilateral CI users would use tempo more than mode cues when asked to identify the emotion in musical excerpts. Bimodal users would have a relatively greater reliance on mode cues than CI users due to their greater access to acoustic information. These findings would be independent of any formal musical training.In Experiment 3, we asked whether any differences in music emotion identification in children with CIs reflect developmental changes or, rather, more rapid abilities to adjust to changes in stimuli. We tested this by comparing responses of CI users with responses of children with normal hearing when mode cues were degraded by vocoded processing.While abnormal input induces plasticity in the auditory system, the normal system is able to adapt to changing acoustic environments as well. Contributing mechanisms are fast “ad-hoc” adaptive processes as well as longer term changes. Plasticity is constantly occurring in the auditory system; rapid changes in early development take place at all levels of the auditory system .Three conditions designed to degrade pitch cues were added to the quiet condition: two vocoder conditions simulating listening through a CI (MEI—vocoder) and an environmental noise condition . Vocoded conditions were created by filtering each musical item from the original MEI test using AngelSim , a free The real world noise condition was determined by comparing effects of white, pink, brown and speech babble noise on test accuracy of seven adults from Experiment 1. Keeping the primary signal (MEI) intensity fixed at 60 dB SPL, the level of each noise was increased until the accuracy of the unaltered melodies decreased to that of the children using a unilateral CI .An iPad application (Reactobutton) was specifically developed for the present study. This “app” synchronizes the musical stimulus onset, delivered through a computer, with the appearance of two buttons on the screen of an iPadMini. Drawings of a happy and sad face  were preEach melody in its original form had an assigned emotion provided by the MEI developers . AccuracExclusion criteria for all three experiments included any history of neurological difficulties , diagnosed psychiatric disorders, or developmental disorders known to impact emotion recognition skills. Parental written informed consent and participant assent were obtained from all participants and protocols were approved by the Hospital for Sick Children Research Ethics Board.Study participants were 33 native English speakers with normal hearing , and demographic details are summarized in Children with bilateral severe-to-profound sensorineural hearing loss were enrolled who received two CIs, both simultaneously and sequentially, or only one CI but continued to wear a contralateral hearing aid . For inclusion children had to be: 1) between 6 and 15 years of age; 2) implanted by age three years, except for the bimodal group who were generally older when implanted due to a progressive hearing loss; and 3) using both devices for at least four years. Only children with specific device characteristics were included in order to minimize any external processor or array-related effects see . Using tEach of the 33 normal hearing individuals recruited to participate in Experiment 1 also participated in Experiment 3. Of the 33 individuals, 22 were able to complete all test conditions; 11 individuals could only reliably complete three out of four random conditions due to the highly time- and effort-consuming nature of the complete task. Data from Experiment 1 was used in Experiment 3 (quiet condition). This avoided repeating the same test in the same condition, thus reducing potential fatigue and learning effects. Demographic details of the study groups are summarized in We enrolled a sample of five children using a right unilateral CI but no hearing aid in the non-implanted ear. These children were aged (mean ± standard deviation) 10.1 ± 12.1 years with 7.6 ± 23.0 years of electrical hearing, and met the device characteristics and inclusion criteria for Experiment 2. The MEI was completed in the original condition, and because their accuracy with our set-up was consistent to previously reported values , this vaSPSS version 22  was usedAs shown in p2 = 0.70). Mean data shown in On the other hand, when presented with manipulated melodies individuals with normal hearing tended to change their opinion of which emotion was conveyed by the tunes relative to the original versions. When either mode or tempo changed, accuracy continued to remain above chance  = 4.2, p<0.0001; Tempo change: 87.6 ± 21.2%, t(32) = 31.0, p<0.0001). In contrast, once both cues were changed concurrently, accuracy reduced to chance  = 0.21, p = 0.83). The amount of change, measured by the difference in percent responses judged based on the originally intended emotion, depended on the altered cue  = 67.5, p<0.0001, ηp2 = 0.07), children and adults reacted differently to the different manipulations  = 8.4, p = 0.002, ηp2 = 0.22). Tempo changes invoked the greatest difference in behavior across development; children were more affected by these tempo changes than adults (p = 0.004). This greater use, or weighting of mode cues into adulthood was accentuated in those individuals with musical training (age*music interaction p = 0.02). Opinion changes were significantly associated with age in musicians upon mode changes  and combined mode and tempo changes , but not in individuals without musical training . Because whether an individual had musical training affected decisions regarding the emotion of a musical excerpt when cues were changed, we explored whether the amount of training was an important factor. As shown in Although there was no overall main effect of age group  = 2.2, p = 0.15, ηChildren using CIs identified the emotion of the original musical excerpts with significantly less accuracy (-8.0 ± 2.6%) than their normal hearing peers (p2 = 0.39) occurred differently between the implanted and normal hearing groups  = 24.4, p<0.0001, ηp2 = 0.31). There were no overall effects of group  = 1.4, p = 0.25, ηp2 = 0.02) or musical experience  = 0.8, p = 0.76, ηp2 = 0.002) on opinion changes; however, there was an interaction between group and music  = 7.2, p = 0.01, ηp2 = 0.12). To explore the interaction between cue change and group further, post hoc analyses were conducted using independent t-tests with Bonferroni corrections. All children reacted similarly when mode changed (t(56) = -3.5, p = 0.27), but implanted children changed their opinion to a greater extent when tempo changed (t(56) = 4.0, p = 0.001). On the other hand, children with normal hearing were affected more by a concurrent change in mode and tempo (t(56) = -3.2, p = 0.007).As observed in experiment 1, children with normal hearing retained accuracy above chance with altered mode  = 6.4, p<0.0001) and tempo  = 23.0, p<0.0001) cues but responded at chance  = 1.8, p = 0.10) with both cues changed together. On the other hand, implanted children retained accuracy above chance regardless of whether each cue was changed separately  = 17.0, p<0.0001; Tempo change: 71.3 ± 1.9%, t(41) = 11.0, p<0.0001) or together  = 8.7, p<0.0001). Changes in opinion as mode and tempo cues were altered are shown in the top plot of p2 = 0.30), and there was a significant main effect of which cue changed  = 29.4, p<0.0001, ηp2 = 0.35). More specifically, reaction times changed significantly as each cue was changed, either independently (p = 0.049) or in conjunction (p<0.0001). When collapsed across group, changes to both cues affected reaction time the most, then tempo changes, and finally mode changes. Furthermore, there was a significant two-way interaction between cue and group  = 17.6, p<0.0001, ηp2 = 0.25). Children with normal hearing took longer to make decisions when mode was changed (t(56) = -3.5, p = 0.002) and when both cues were changed together (t(56) = -4.1, pc = 0.002), but not when tempo was changed alone (t(56) = -2.0, p = 0.14), although there was a similar trend for this cue change as well.Reaction times  or bilateral , and regardless of whether the children were bimodal or bilateral CI users .Factors related to duration of cochlear implant input were then explored for their relationship with changes in opinion . Total yDue to the difference in response to tempo cues between bilateral and bimodal users with the type of hearing experience, we focused on the potential role of residual hearing in changing opinions . OpinionBoth vocoded acoustic input and noise were used to acutely degrade acoustic musical input in order to study which musical components normal hearing individuals would use to identify emotion. Four different noise conditions were first piloted with group of normal hearing adults (n = 7). Noise was presented at the highest level which did not decrease accuracy of performance of emotion identification of music in its original condition. Of all four noise conditions, only pink noise significantly: 1) decreased accuracy when tempo cues were changed in individuals with normal hearing (p = 0.02), and 2) decreased accuracy in the tempo changed condition to the point that scores were not significantly different from that of 5 children with unilateral CI use listening to the original condition in quiet (p = 0.24). In all other noise conditions, accuracy was better than the best listening condition in children with unilateral cochlear implants . Therefore, pink noise was used along with the two vocoders to test which cues a larger group of normal hearing individuals use to identify emotion in music.p2 = 0.60) and reaction time  = 18.6, p<0.0001, ηp2 = 0.47) for the original melodies were significantly different across conditions. Pairwise comparisons using Bonferroni corrections indicated that accuracy in the presence of pink noise and in the two vocoder conditions was significantly less than in quiet (p<0.0001). Vocoder conditions resulted in similar accuracy (p = 1.0), but surprisingly, the pink noise condition generated the worst performance compared to both vocoder conditions . Furthermore, reaction time was significantly longer in the presence of pink noise than any other condition (p<0.0001), and this was the only condition in which reaction times of normal hearing individuals were different than child CI users (t(69) = 3.9, p = 0.001). As in Experiment 2, individuals with normal hearing performed better than the CI users (p<0.0001); however, this difference/advantage was lost in all three degraded conditions . An average signal to noise ratio of -12 ± 2 dB was required to degrade normal hearing individuals’ performance to that of CI users.Effects of acutely degrading acoustic input through pink noise and partial (32 channel) and more restrictive (22 channel) vocoders are shown for normal hearing groups and the comparative CI group in p2 = 0.44) and cue changed  = 24.8, p<0.0001, ηp2 = .54) on these opinion changes in individuals with normal hearing. Pairwise comparisons indicated that overall, opinion changes were similar in quiet and pink noise conditions (p = 0.49) but these two conditions were significantly different than both vocoder 32  and vocoder 22 conditions , which were similar to one another (p = 1.0). Furthermore, opinion changes were significantly greater when both cues were changed (p<0.0001) than either cue changed alone (p = 1.0). However, individuals with normal hearing still responded differently across cue changes in the different degraded conditions  = 27.1, p<0.0001, ηp2 = 0.56). When mode cues were changed independently or in combination with changes in tempo cues, normal hearing individuals changed their opinions significantly more than CI children in quiet  and pink noise , but they behaved similarly to CI children in the vocoder 32  and vocoder 22  conditions. Conversely, when tempo cues were changed, individuals with normal hearing changed their opinions significantly less than children with CIs only in quiet (tempo p<0.0001), but not in pink noise (p = 0.74) or vocoder 32 (p = 1.0) and 22 (p = 1.0) conditions. With respect to changes in reaction times with these decisions, there were also significant main effects of condition  = 7.1, p = 0.003, ηp2 = 0.25), cue  = 15.2, p<0.0001, ηp2 = 0.42), and a two-way interaction between condition and cue  = 7.2, p<0.0001, ηp2 = 0.25). Pairwise comparisons indicated that reaction times of individuals with normal hearing were significantly longer in quiet than any other condition , regardless of which cues were changed. It was only in the quiet condition that individuals with normal hearing took significantly longer than CI children to make decisions, specifically when mode cues were changed independently (p<0.0001) or in conjunction with tempo changes (p<0.0001).Changes in opinion with cues changes for each of the signal degraded conditions are shown in Effects of musical training were explored for each degraded condition as well. Individuals with musical training reacted differently as they aged  when mode cues changed than those without musical training (cue*music group interaction p = 0.02): opinions changed significantly more with age in musicians  but non-musicians responded similarly regardless of their age . Once pitch cues were masked or degraded, these associations became non-significant, with the exception of the interaction between musical experience and age when mode cues were changed in the vocoder 32 condition . Additionally, there was a trend that reaction times lengthened with age when individuals with normal hearing listened to the vocoder 32 musical excerpts with altered mode cues . In most conditions, as musical training increased  opinionsThe results from the present experiments confirmed previously reported findings that children as young as six years and adults as old as 40 years had similarly excellent accuracy identifying basic emotions in music . NeitherAn advantage of the MEI test is that it allowed for separate analyses of the relative importance of two major contributors to emotion identification in music, namely mode and tempo. The assumption was that if opinion from the original version did not change when one of the two cues was altered, it was likely that the second, fixed cue contributed more to labelling the emotion conveyed by the melody. In Musical training is known to enhance many neural networks involved in music processing. Kraus and colleagues found that training-related plasticity leads to neuroanatomical differences and improves neural encoding of sound . Both stThe unrefined spectral representation provided by currently available cochlear implants is adequate to represent speech signals, as evidenced by acquisition of oral communication in early implanted children who undergo appropriate auditory verbal rehabilitation , 97. HowOverall reaction time for the original condition was not significantly different between the two groups in the present study  and therefore likely did not significantly impact the differences noted in response times. On the other hand, unilateral auditory deprivation was limited (mean 2.5 years) in our current cohort of bilaterally implanted and bimodal users, whereas our previous cohort was unilaterally implanted and deaf in the contralateral ear. Though the MEI task does not evaluate binaural hearing, bilateral CI use has been shown to ease the increased listening effort demonstrated in unilateral CI use . GreaterAlthough reaction times to unaltered musical excerpts were similar between normal hearing children and bilateral CI and bimodal users, the change in response time with altered excerpts differed. Normal hearing children took significantly longer than children with CIs to judge the emotion of music with altered cues . This diOpinion changes in the present groups of children using cochlear implants were not associated with bilateral auditory deprivation  or unilateral deprivation (defined as no stimulation in one ear). Therefore, it appears that the length of deprivation did not affect simple emotion identification skills as it does speech perception outcomes . On the If hearing experience is an important factor for judging emotion in music, it is surprising that no significant effect of musical training was found in pediatric CI users , even whBy introducing pink noise and degrading the signal through two vocoders, we purposely and successfully decreased the accuracy of individuals with normal hearing to that of unilaterally implanted CI children . Out of In the vocoded conditions, accuracy in the normal hearing adults was similar to the unilateral CI group with similar reaction times, and their behavior mirrored CI users when cues were altered : opinionMusical experience accentuated the bias of using mode when assigning emotion to music. Participants with musical experience tried to use any available pitch information even when access to the signal declined with noise. Individuals with normal hearing and musical experience changed their opinion to a greater extent with mode changes than non-musicians, and this behavior was most evident when all available cues were present in the quiet condition. However, there was less effect of mode changes on musicians’behavior as pitch cues became distorted or masked . On the other hand, non-musicians responded similarly to mode changes across noise conditions, regardless of their age. Musicians’ opinions did not significantly change across age in pink noise, where presumably there were still some pitch cues, albeit masked to some extent. Though hearing in pink noise is a very challenging task, it is known that musicians have better speech-in-noise perception compared with non-musicians, even during pivotal childhood developmental years . This isFindings from the present study confirm that there is an increasing use of mode cues to judge emotion in western music in normal development. This strong dependency reflects the unique use of pitch in the context of music perception relative to speech perception . Indeed,The strong dependence of pitch for emotion perception in music makes the MEI an excellent tool to study effects of poor access to pitch cues. It is clear that neither unilateral  nor bilaThe combined findings of the 3 experiments suggest that with normal hearing, humans in western culture develop a predisposition toward mode cues when asked to judge simple emotions in music. This development is altered when access to pitch cues is deprived by deafness and cochlear implant use. The new cohorts of bilateral cochlear implant users and bimodal users indicate that improving access to acoustic hearing reduces the abnormal switch to tempo to judge emotion in music. The importance of access is highlighted by the immediate switch by individuals with normal hearing to use cochlear implant-like strategies of tempo upon acute degradation of pitch cues. This means that, for individuals with hearing loss, pitch cues must be preserved  and/or replaced by improvements to cochlear implant technology.S1 Dataset(XLSX)Click here for additional data file.


Cochlear implants have been used for almost 30 years as a device for the rehabilitation of individuals withsevere-to-profound hearing loss. One of the important aspects of cochlear implantation is the type of electrode selected and proper insertion of the electrode array in scala tympani to minimize cochlear damage. The HiFocus Helix™ electrode is a precurved design aimed at placing the electrode contacts close to the spiral ganglion cells in the modiolus. The prescribed insertion techniques are intended to minimize the likelihood of damage to the basilar membrane or lateral wall of the cochlea.To describe the first insertion of a HiFocus Helix™ electrode in Brazil exposing surgical particularities and device details in a patient with profound hearing loss, due to Mondini’s dysplasia.No problems were encountered during the surgical procedure. The patient experienced improvement in hearing thresholds and speech perception. The HiFocus Helix™ electrode proved easy to insert and provided expected hearing benefits for the patient. This manuscript indicates that the HiResolution™ Bionic Ear System with HiFocus Helix™ electrode comprise a cochlear implant system that is practical and beneficial for the treatment of severe-to-profound hearing loss. Cochlear implants are surgically implanted devices that provide hearing sensation to individuals with severe-to-profound hearing loss who obtain limited benefit from hearing aids. By electrically stimulating the auditory nerve directly, a cochlear implant bypasses damaged or undeveloped sensory structures in the cochlea, thereby providing usable information about sound to the central auditory nervous system. Over the last 30 years, cochlear implants have become standard treatment for adults and children with severe-to-profound profound bilateral sensorineural hearing loss.In particular, hearing impairment in very young children has a significant impact on both language and social development. The prevalence of congenital hearing loss varies from 1.2 to 2.7 per 1,000 newborns. Recent information estimates a current rate of 1.4 per 1,000 newborns in the United States, which makes it the most frequent sensory deficit present at birth [One of the important components of a cochlear-implant system is the electrode array that is inserted surgically into the cochlea. Electrode technology has evolved since the first cochlear implants were introduced in the early 1980s. Contemporary electrode designs are aimed at (1) limiting intracochlear damage during electrode insertion, and (2) reducing the current required for usable hearing .The HiFocus Helix™ electrode  . Medical records of the patient selected as well as a review of the literature were analysed.The HiResolution™ Bionic Ear cochlear implant system  was selected for this patient. It was used the HiRes 90K™ implant with HiFocus Helix™ electrode implantable components Figure . The HiFThe patient was a 17-year-old female referred to our hospital for the evaluation of candidacy for a cochlear implant. Her hearing loss was diagnosed at the age of 5 years and the patient began using bilateral hearing aid 1 year later. There were no abnormalities observed at a physical examination.High resolution temporal bone CT and MRI studies detected cochlear malformation and large vestibular aqueduct in both sides, thus characterizing Mondini dysplasia Figure .Figure 3Before surgery, the patient was informed about the surgical procedure, implant device, post-operative expectations, and possible complications.The HiRes 90K™ implant and HiFocus Helix™ electrode were surgically implanted using manufacturer-recommended techniques and procedures (Advanced Bionics). Facial nerve function was monitored during surgery using the Xomed-Treace Nerve Integrity Monitor-2 (NIM 2™). The monitoring electrodes were placed in the frontal and zygomatic areas. No problems were encountered during surgery and no complications occurred.Antisepsis of the entire face and retroauricular region;Retroauricular trichotomy, micropore tape used to isolate this region;Local anesthesia  in retroauricular area;New antisepsis of the mentioned regions;Placement of sterile sheets in retroauricular areas;Rectilinear retroauricular incision of approximately 4 cm and dissection along anatomical places; preparation of a cross-like muscle-periosteal flap;Removal of small fragments of fascia and temporal muscle to occlude the cochleostomy;Simple mastoidectomy, identifying the lateral semicircular canal, the short process of the incus, the posterior wall of the outer ear canal, tegmen tympani and the lateral sinus, gathering a small amount of bone dust;Thinning of the posterior wall of the outer ear canal, posterior tympanotomy with preservation of the incus buttress;After identification of the round window niche, a 1.5 mm cochleostomy is created antero-inferior to the round window;Placement of internal part of the device in a periosteal pocket created in the squamous part of the temporal bone;Insertion of the electrode into the cochleostomy using and electrode inserter;Positioning the muscle graft around the electrode to seal the cochleostomy; placing bone dust to close the posterior tympanotomy;Closure with Vycril 3.0 sutures on the muscle-periosteum flap and subcutaneous tissue; skin closure with Nylon 4.0;Cleaning of the patient and external compressive dressing;Impedance testing, neural response imaging (NRI) and a transorbital incidence radiograph to confirm intracochlear position of the electrode Figures , 5.FigurThe patient was under general anesthesia and placed in supine position. Antibiotic prophylaxis (Cefazolin 1 g) was administered intravenously. The surgical steps are described below:We experienced no problem during the electrode insertion and we observed an improvement in hearing thresholds and speech perception of the patient.As cochlear implantation benefits have been well established, a new focus has been directed to better performance devices combined with less trauma to the inner ear. In this concept, the Helix model was created using a perimodiolar positioning that would provide better neural stimulation –8.First perimodiolar electrodes were introduced 12 years ago, and can be either curved or designed to curve at itself during insertion. Proximity to the ganglion spiral cells is sought to provide better stimulation at lower current levels, thus leading to less cochlear damage and less energy consumption –8.A temporal bone anatomic study was conducted to analyze prototypes of models Thin Lateral™ and Helix II™ (Advanced Bionics Corporation). The study observed a medium depth of insertion of 368 and cochlear lateral wall positioning in the Thin Lateral™ model. Helix II™ was shown to have a 436 insertion and cochlear medial wall positioning. No evidence of inner ear trauma in the temporal bones was identified for both devices. The lesser diameter in these devices compared to conventional electrodes seems to contribute to performance and less cochlear trauma , 6.The curved shape and lateral flexibility of the Thin Lateral™ device allows the bundle of electrodes to follow the cochlear lateral wall curvature, therefore avoiding damage and risk of tympanic scale manipulation , 8.The Helix II™ model has an insertor that is removed during insertion allowing the bundle of electrodes to curve medially along the tympanic scale, diminishing the risk of trauma to the spiral ligament .® Freedom™ RECA (Cochlear®) and Advanced Bionics HiRes 90K™ HiFocus Helix™ (Advanced Bionics) showed a correct positioning of the electrodes through computed tomography in 95.1% of the cases. All cases were implanted via round window with or without an insertor. The radiologic confirmation of the electrode position inside the tympanic scale was obtained in 95.4% of cases fitted with Nucleus® Freedom™ device. The Helix 90k™ device showed correct placement in 100% of cases when utilizing an electrode insertor and 85.7% without the insertor [Another prospective analysis with 82 patients aged between 18 and 84 years fitted with devices NucleusThe perimodiolar HiFocus Helix™ electrode proved easy to insert in this patient. In addition, the recipient was able to experience better hearing thresholds and improved speech perception compared to pre-operatively with a hearing aid. Thus, the HiFocus Helix™ electrode is a viable and effective electrode option for patients who choose a HiResolution™ Bionic Ear.Written informed consent was obtained from the patient for publication of this Case Report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal. Ethical precepts of the institution were respected .


To outline the audiological findings of aphasic patients after cerebrovascular accidents.Universidade Federal de São Paulo. A total of 43 aphasic subjects (27 men) were referred for audiological evaluation after stroke, with mean age of 54.48 years. Basic audiological evaluation tests were performed, including pure tone audiometry, speech audiometry (speech recognition threshold and word recognition score), immittance measures , and transient otoacoustic emissions. This is a cross-sectional study performed between March 2011 and August 2012 in the Speech, Language, and Hearing Pathology Department of the  Sensorineural hearing loss was prevalent (78.6%). Speech recognition threshold and word recognition score were not obtained in some patients because they were unable to perform the task. Hearing loss was a common finding in this population. Comprehension and/or oral emission disruptions in aphasic patients after stroke compromised conventional speech audiometry, resulting in the need for changes in the evaluation procedures for these patients. In Brazil, CVAs are the main cause of death.,3Cerebrovascular accidents (CVA) refer to a group of vascular disorders that affect the brain and compromise neurological function. CVAs are one of the top three most common causes of death in a majority of developed and developing nations. Furthermore, when a patient presents with a CVA, hearing loss can impede and affect both the evaluation process and speech rehabilitation, as several linguistic skills depend on peripheral and central auditory perception. We know that comprehension is always impacted in aphasic post-CVA patients to varying degrees because it is a widely reported central component, but it is not always clear whether some component of peripheral hearing is also damaged or how this component could affect the central processing of acoustic information. However, systemic studies on how to measure peripheral auditory acuity in aphasic individuals are lacking.The risk of both hearing loss and CVAs increases with age.To investigate the occurrence of peripheral hearing loss in aphasic post-CVA patients.Universidade Federal de São Paulo (UNIFESP), and approved by the Research Ethics Committee (protocol 1272/02). After receiving full information about the study, written informed consent was obtained from all enrolled subjects.This was a cross-sectional study performed between March 2011 and August 2012 in the Speech, Language, and Hearing Pathology Department of the All of the patients who were evaluated in the acquired speech and language disorder clinic at UNIFESP and diagnosed with aphasia after a single ischemic cerebral lesion in the left hemisphere, confirmed by neuroimaging, were selected for this study. Aphasic patients who agreed to audiology examination underwent otoscopy. After otoscopy, a medical history was taken, followed by the tests that make up the basic audiologic evaluation. Individuals who referred hearing deficits prior to stroke, noise exposure, or use of drugs that could interfere in audiological results were excluded from the study. Then the patients were exposed to pure tone audiometry, speech audiometry: speech recognition threshold (SRT) and the word recognition score (WRS), acoustic immittance , and transient evoked otoacoustic emissions (TEOAE). For the SRT test, which identifies the threshold for detecting speech, a CD recording containing a list of disyllabic words was used. SRT was considered compatible when it was equal to or up to 10dB above the average of auditory thresholds at 500, 1,000 e 2,000Hz. WRS was analyzed for compatibility in relation to average auditory thresholds at frequencies of 500, 1,000, and 2,000Hz according to the following criteria: for an average between zero and 10dB, an SRT of 100% was considered compatible; between 11 and 25dB, 96% accurate or greater; between 26 and 40dB, 82% or greater; between 41 and 55dB, 66% or greater; between 56 and 70dB, 56% or greater; between 71 and 90dB, 26% or greater, and for an average over 90dB, 8% accurate or greater.Auditory sensitivity was tested for the following frequencies: 250, 500, 1,000, 2,000, 3,000, 4,000, 6,000, and 8,000Hz, using a Midimate 622 audiometer coupled to a Sony CD player. An audibility threshold of 25dB was considered normal hearing for all frequencies. and recorded on a CD. For aphasic patients who exhibited modified expression of verbal symbols, we used a picture album and instructed the patients to point to the word they heard.The WRS, which measures the patient’s auditory acuity, was assessed by providing speech stimuli organized into four listsNext, the patient’s tympanometry and the acoustic reflex threshold of their stapedius on the contralateral side were measured at 500, 1,000, 2,000, and 4,000Hz. Their acoustic reflex was considered normal when the difference between their audibility limit and reflex limit was between 70 and 90dBNA for at least three frequencies. The stimulus used was adjusted at the ear canal and delivered at 80dB.The OAE was considered normal when OAE results were positive and the signal-to-noise ratio and the overall response were greater than or equal to 3dB. The minimum value for the stability and reproducibility parameters were 70 and 50%, respectively.2 (without Yates correction) was used for categorical comparisons of the data. Differences in the means of continuous measurements were tested by Student’s t-test, followed by the Mann-Whitney test, which without exception did not identify any discrepant results (only the parametric test results will be reported). All statistical analyses were performed on a personal computer using the Statistical Package for the Social Sciences (SPSS) version 11.5.1 for Windows.The χFifty patients in the language acquired disorders outpatient clinic who were diagnosed with strokes and who presented aphasia were selected. A total of seven were excluded . The remaining 43 patients met the inclusion criteria. Therefore, 86 ears were examined.Sixteen of the 43 patients were women, and the group had a mean age of 57.6 (standard deviation − SD=13.2) years.There were no statistically significant differences between the threshold means of the right and left ears for any of the frequencies tested (data not shown).The audiogram was not performed in five ears: two individuals could not understand the test instructions, and in one ear, the external acoustic meatus was obstructed.The audiogram was abnormal in 56 ears, indicating some type of hearing loss. Of the 81 ears, 25 had normal tonal thresholds at all frequencies, and 56 ears had hearing loss for at least one frequency.The following types of hearing loss were observed: 78.6% exhibited sensorineural loss, 17.8% exhibited hearing loss at just one frequency, and 3.6% exhibited mixed loss. Of the audiograms for patients with sensorineural hearing loss, we observed a descending curve in 50% of cases, a flat curve in 19.6%, an ascending curve in 1.8%, and other types in 28.6%.The average values for the SRT were 28.6 (SD=12.6) for the right ear and 23.1 (SD=7.85) for the left ear. Pictures had to be used to obtain the SRT in 12.8% of the sample (11 ears).The WRS was consistent with the pure-tone threshold audiometry results in 42.4% of the tested ears, and 15.3% of the patients used pictures. However, the WRS was inconsistent in 57.6% of the cases because the possibility to respond to speech was much worse, considering the auditory thresholds obtained with these patients in relation to average auditory thresholds at frequencies of 500, 1,000, and 2,000Hz. The previously established criteria were: for an average between zero and 10dB, an SRT of 100% would be considered compatible; between 11 and 25dB, 96% accurate or greater; between 26 and 40dB, 82% or greater; between 41 and 55dB, 66% or greater; between 56 and 70dB, 56% or greater; between 71 and 90dB, 26% or greater; and for an average over 90dB, 8% accurate or greater.Logoaudiometry was performed using the conventional method in 63 ears (73.3%) and with pictures in 11 ears (12.8%). There was no response after repeating the words or pointing to pictures in 12 of the tested ears (14%).Acoustic immittance measurements generated type A tympanometric curves in 97.6% of the ears. Type C curves were noted in only two ears (2.4%). Type B curves were not observed.Acoustic reflex data were analyzed by measuring the difference between the auditory limit and the acoustic reflex limit at the tested frequency.Next, we classified the difference between the reflex and audibility thresholds into four categories and compared each frequency. These data are presented on The OAE values did not differ between ears. The results in both ears for all individuals, including the confidence intervals, are shown on The most significant finding in this study was the high rate of hearing loss, most commonly sensorineural, observed in this population of aphasic patients. Tonal audiometry thresholds proved to be an extremely useful procedure, but the aphasic patients’ difficulties in understanding and/or vocalizing affected the conventional logoaudiometry test and emphasized the need for alternative evaluation methods for this population.,12 although some studies have reported CVAs in patients over 60 years of age.,14The sample population had an average age of 57.48 years, similar to reports of other studies,Two individuals were unable to complete the conventional tests because they did not understand the instructions. These aphasic patients exhibited severe comprehension problems.In 94.1% of the cases, we were able to evaluate hearing using conventional tonal audiometry. Therefore, we can verify that conventional tonal audiometry is a valid method for evaluating this population and can be used to determine the degree of peripheral hearing loss that can aggravate the comprehension disorders common in patients with aphasia. Presbycusis is represented by four subtypes: sensorial (loss of hair cells), neural , metabolic (atrophy of the stria vascularis), and mechanical (thickening and stiffening of the basilar membrane). However, because multiple genetic and environmental factors cause presbycusis, most cases are of mixed pathology and affect multiple cell types.  This considered, we could hypothesize that patients with vascular problems could also be more susceptible to these mechanisms.The usual tonal thresholds for high frequencies are higher than the average for low frequencies. The cochlea is a helicoid structure with approximately 2 and 2/3 turns. The base of the cochlea tends to vibrate at high frequencies, and the apex tends to vibrate at lower frequencies. Thus, lesions begin at high frequencies. In addition, presbycusis is caused by deficiencies in blood flow to the inner ear, causing degenerative lesions in the organ of Corti. The initial lesion causes deafness for acute sounds (descending curve) and loss of word discernment. The age of the population ranged from 22 to 82 years, and although the average age of the study population was 57.48 years, part of the sample may experience this type of hearing loss simply due to age. Therefore, vascular problems could lead to compression and subsequent damage to a specific vascularized area, and the individual may exhibit some symptoms arising from the lack of blood flow to this area.In addition, because CVA involves vascular changes, it is possible that these adults with vascular problems could exhibit early blood flow deficiencies in the inner ear.Audiologic evaluation results revealed a normal audiogram in 25 ears; 56 ears exhibited some type of hearing loss. In the identified hearing loss cases, 78.6% were sensorineural, and 17.8% had an isolated decrease at a specific frequency , indicating that middle ear changes are rare in these patients. Only two ears (3.6%) exhibited mixed-type hearing loss.In the audiogram shape test, the most common result was a descending curve. This may be because part of the sample (47.72%) consisted of individuals older than 60 years of age, as mentioned previously, and these subjects may have exhibited presbycusis, which is normally characterized by sensorineural hearing loss with a descending curve.,20 These changes may affect their responses in this type of test. Therefore, pictures had to be used in 12.8% of the tests. We know that a SRT measured using a picture album is potentially easier, likely because it is a closed set (multiple choice) with a limited number of alternative responses. Thus, post-CVA aphasic patients are expected to exhibit better results than those using an open set. However, even though it is a simpler procedure, an SRT with a picture album had to be used in this population of aphasic patients whose difficulties vocalizing could potentially hinder SRT data collection.SRT measurements require the patients to repeat the words heard. We know that this population of post-CVA aphasic patients may exhibit changes in their vocalization and often exhibit specific changes in their ability to repeat.We were also unable to obtain an SRT in 14% of the tested ears because some patients did not understand the test’s instructions or the stimuli due to severe comprehension difficulties, which made it impossible to repeat or to point to a picture of the words heard.,23 Therefore, if we take the complexity of linguistic processing into account, the observed errors during repetition could have multiple sources in aphasic patients. Although the repetitions are extremely simple for some people with a cerebral lesion, repetition is extremely complex in post-CVA aphasic individuals. In summary, the task of repeating words could be altered at multiple points in linguistic processing and/or could be associated with difficulties in speech motor programming, as is often found in patients with aphasia.,25 In patients with cerebral lesions and peripheral hearing impairment, the audiogram and WRS were consistent. The inconsistency between the audibility thresholds and the WRS in aphasic patients is related to the linguistic processing that generates errors in the task of repetition. These results have led us to rethink our methods for evaluating hearing in specific patients to remove the effect of the challenges experienced by these patients. Our results also confirm the importance of pointing tests, as patients with severe comprehension disorders respond better to this type of task.A picture album was also necessary during the WRS test in 15.3% of cases (13 ears), more often than the SRT test (12.8%), possibly because monosyllabic words with and without meaning were used in the WRS, making the task more difficult. Moreover, as observed in the SRT test, 14% were unable to repeat or point to pictures of the words heard. In addition, individuals were able to repeat the words in 57.6% of the cases, but the results were below the expected results for the degree of hearing loss. Even in the 37.7% of cases in which the audiogram and WRS were consistent, 15.3% used the picture album to respond. In aphasic patients, comprehension and/or vocalization are highly variable. Thus, it is possible that the aphasic patient understands the task but is unable to repeat or paraphrase the word, which is considered an error in the WRS test. The patient may also not be able to understand the test instructions, or the patient may understand the instruction but fail during linguistic input processing .Type A tympanometric curves were the most commonly observed (97.6%), indicating that this population rarely has problems with the middle ear. The studied population includes individuals older than 60 years (47.72%), and sensorineural hearing loss accompanied by type A tympanometric curves is more common in this group, as they often arise from changes in the inner ear and/or central auditory pathways.The acoustic reflex analysis focused on the values of the difference between the acoustic reflex threshold and the audibility threshold at the tested frequencies. In this dataset, the average values for the highest frequency  are lower than the average for the other frequencies. These results can be explained by the high number of people with sensorineural hearing loss with a descending curve in this sample. Recruitment is occasionally observed in the presence of hearing loss. Recruitment is a clinical symptom of cochlear hearing loss related to the rapid and abnormal psychoacoustic sensation of intensity that accompanies an increase in the intensity of the stimulus.For all of the tested frequencies, the difference between the acoustic reflex threshold and the audibility threshold was between 70 and 90dB in most cases. At the frequencies of 500, 1,000, and 2,000Hz, there was a notable difference between this category and the others, but at 4,000Hz, we noticed a significant number of people were in the category below 70dB, indicating that recruitment was more common at 4,000Hz (a strong indicator of cochlear lesions), consistent with the fact that there was greater hearing loss at higher frequencies. Because the majority of patients exhibited decreasing curves, the thresholds at high frequencies were higher than the thresholds at lower frequencies.During the otoacoustic emission analysis, the average response at 4,000Hz was less frequent. In these tests, low responses were observed when the audibility limit for the frequency was near the limits for normality. In fact, the emission amplitude studied decreased as frequency increased.-30 have demonstrated the importance of this evaluation technique for the early detection of changes in the cochlear cells, even when there has been no change in their audibility threshold levels measured by pure-tone threshold audiometry. Therefore, we suggest that this is a highly legitimate test, as it detects early cochlear changes that may occur as a result of blood flow loss. The test is also important for providing an idea of the patient’s hearing when they are unable to perform any of the activities in the basic audiologic evaluation.A comparison of the tonal audiometry and the TEOAE tests demonstrated that 19 patients lacked a TEOAE at one or more frequencies even with normal audibility thresholds. In fact, previous studies in individuals exposed to noise and individuals who underwent cisplatin chemotherapy treatmentIn this study, we observed hearing loss at one or more frequencies in 56 ears, indicating a high prevalence of hearing loss in this population. We also observed that, of these 56 ears, 43 experienced sensorineural hearing loss, and 2 exhibited mixed-type hearing loss. The most common audiometric configuration was descendent. Individuals with high frequency hearing loss  can exhibit difficulties recognizing speech.Given the importance of hearing for developing linguistic skills and for the efficiency of communication, we conclude that audiologic evaluation in this population is indispensible, both for clinical and research reasons, as it is essential to differentiate peripheral and central deficits for the evaluation and rehabilitation of aphasic patients after a cerebral lesion.This is a cross-sectional study, so it is not possible to identify precisely the cause of hearing loss. In this study we were only able to show that the majority of aphasic patients presented with hearing loss.There was a high rate of hearing loss, most often sensorineural, in aphasic patients evaluated in this study. Changes in comprehension and/or vocalization in these patients affected their convention logo audiometry results and highlighted the need to use alternative evaluation procedures in this population in order to provide better assistance and better speech/language rehabilitation in this population.  No Brasil, os AVEs são a principal causa de morte.,3Acidentes vasculares cerebrais ou encefálicos (AVE) correspondem a um grupo de distúrbios vasculares que afetam o cérebro e comprometem a função neurológica. Os AVEs estão dentre as três causas de morte mais frequentes na maioria de países desenvolvidos e em desenvolvimento. Além disso, quando o paciente tem um AVE, a perda auditiva pode impedir e afetar tanto o processo de avaliação quanto a reabilitação da fala, já que várias habilidades linguísticas dependem da percepção auditiva periférica e central. Sabemos que a compreensão está sempre afetada em pacientes afásicos após o AVE em graus variados, estando o componente central bem descrito, mas não está claro se algum componente da audição periférica também está alterado, ou de que forma tal componente poderia afetar o processamento central de informação acústica. Apesar disso, faltam estudos sistemáticos que revelem como se encontra a acuidade periférica em indivíduos com afasia.Com o avanço da idade, há um aumento do risco tanto para o AVE como para a deficiência auditiva.Investigar a ocorrência de perda auditiva periférica em pacientes afásicos após acidente vascular encefálico.Este foi um estudo transversal conduzido entre março de 2011 e agosto de 2012, no Departamento de Fonoaudiologia da Universidade Federal de São Paulo (UNIFESP), e aprovado pelo Comitê de Ética em Pesquisa (protocolo 1272/02). Após receber todas as informações sobre o estudo, todos os pacientes assinaram o Termo de Consentimento Livre e Esclarecido.Todos os pacientes avaliados no ambulatório de distúrbios adquiridos de fala e de linguagem da UNIFESP e diagnosticados como tendo uma afasia após uma lesão isquêmica cerebral única no hemisfério esquerdo, confirmada por exame de neuroimagem, foram selecionados para este estudo. Os pacientes afásicos que compareceram para a avaliação audiológica foram submetidos à meatoscopia. Após a meatoscopia, foi feita a anamnese, seguida dos exames de compõem a avaliação audiológica básica. Os indivíduos que referiram deficits auditivos anteriores ao AVE, exposição a ruído, ou uso de drogas que poderiam interferir nos resultados audiológicos foram excluídos do estudo. Em seguida, os pacientes foram expostos à audiometria tonal liminar, logoaudiometria: limiar de reconhecimento da fala (LRF) e o índice percentual de reconhecimento de palavra (IPRF); medidas de imitância acústica ; e emissões otoacústicas evocadas transitórias (EOAT).player Sony. O limiar de audibilidade de 25dB foi considerado normal para todas as frequências. Para o LRF foi usada uma gravação em CD contendo um a lista de palavras dissilábicas. Esse teste foi considerado compatível quando era igual a ou até 10dB acima da média de limiares auditivos em 500, 1.000 e 2.000Hz. O índice de reconhecimento de palavra foi analisado quanto à compatibilidade em relação aos limiares auditivos médios, nas frequências de 500, 1.000 e 2.000Hz segundo os seguintes critérios: para uma média entre 0 e 10dB, foi considerado compatível um limiar de reconhecimento da fala de 100%; entre 11 e 25dB, 96% ou maior; entre 26 e 40dB, 82% ou maior; entre 41 e 55dB, 66% ou maior; entre 56 e 70dB, 56% ou maior; entre 71 e 90dB, 26% ou maior e, para uma média acima de 90dB, 8% ou maior.A sensibilidade auditiva foi testada para as seguintes frequências: 250, 500, 1.000, 2.000, 3.000, 4.000, 6.000 e 8.000Hz, usando um audiômetro Midimate 622 acoplado a um CD  gravadas em CD. Para pacientes afásicos que apresentavam alteração na emissão dos símbolos verbais, usamos um álbum de figuras e os instruímos a apontar para a figura da palavra ouvida.O IPRF, que mostra a acuidade auditiva do paciente, foi obtido por meio da apresentação de estímulos de fala organizados em quatro listasPosteriormente, foi realizada a timpanometria e a pesquisa do limiar de reflexo acústico do estapédio, modo contralateral nas frequências sonoras de 500, 1.000, 2.000 e 4.000Hz. O reflexo acústico foi considerado normal quando a diferença entre o limiar de audibilidade e o limiar do reflexo estava entre 70 e 90dBNA em pelo menos três frequências. Quanto ao estímulo, consideramos o nível mais próximo de 80dB.O teste de EOAT foi considerado normal quando os resultados eram positivos, e a relação sinal-ruído e a resposta geral eram maiores ou iguais a 3dB. Os valores mínimos para os parâmetros de estabilidade e reprodutibilidade foram de 70 e 50%, respectivamente.2 (sem a correção de Yates) foi usado para comparações categóricas dos dados. As diferenças nas médias de medidas contínuas foram avaliadas pelo teste t de Student, seguido do teste de Mann-Whitney, que − sem exceções − não identificou quaisquer resultados discrepantes (apenas os resultados dos testes paramétricos são relatados). Todas as análises estatísticas foram feitas em um computador pessoal usando o pacote Statistical Package for the Social Sciences (SPSS) versão 11.5.1 para Windows.O teste χCinquenta pacientes do ambulatório de distúrbios adquiridos da fala diagnosticados com AVE e que apresentavam afasia foram selecionados. Foram excluídos sete pacientes, pois dois foram incapazes de completar o protocolo e cinco estiveram ausentes. Os 43 pacientes restantes atenderam aos critérios de inclusão. Assim, 86 orelhas foram examinadas.Dezesseis dos 43 pacientes eram mulheres e o grupo tinha uma média de 57,6 anos .Não houve nenhuma diferença estatisticamente significante entre as médias dos limiares das orelhas direita e esquerda para todas as frequências testadas (dados não apresentados).O audiograma não foi realizado em cinco orelhas: dois indivíduos não conseguiram entender as instruções do teste, e em uma orelha, o meato acústico externo estava obstruído.A O audiograma foi anormal em 56 ouvidos, indicando algum tipo de perda auditiva. Das 81 orelhas, 25 apresentavam limiares tonais normais em todas as frequências, e 56 apresentavam perda auditiva para pelo menos uma frequência.Os seguintes tipos de perda auditiva foram observados: 78,6% exibiram perda neurossensorial, 17,8% perda auditiva em apenas uma frequência, e 3,6% perda mista. Em relação aos audiogramas com perda auditiva neurossensorial, observamos uma curva descendente em 50% dos casos, uma curva plana em 19,6%, uma ascendente em 1,8%, e outros tipos em 28,6%.Os valores médios do LRF foram 28,6  para a orelha direita e 23,1  para a orelha esquerda. Figuras tiveram de ser usadas para poder obter o LRF em 12,8% da amostra (11 orelhas).O IPRF foi compatível com os resultados do limiar de audiometria tonal liminar em 42,4% das orelhas avaliadas, sendo 15,3% realizado com figuras. No entanto, foi incompatível em 57,6% dos casos porque a possibilidade de responder à fala estava bem pior considerando os limiares auditivos obtidos nesses pacientes em relação à média de limiares auditivos nas frequências de 500, 1.000 e 2.000Hz. Os critérios previamente estabelecidos foram: para uma média entre 0 e 10dB, LRF de 100% seria considerado compatível; entre 11 e 25dB, 96% ou maior; entre 26 e 40dB, 82% ou maior; entre 41 e 55dB, 66% ou maior; entre 56 e 70dB, 56% ou maior; entre 71 e 90dB, 26% ou maior; e para uma média acima de 90dB, 8% ou maior não puderam ser encontrado em 57,6% dos casos.A logoaudiometria foi realizada usando o método convencional em 63 orelhas  e com figuras em 11 orelhas . Não houve resposta após a repetição de palavras ou a indicação de figuras em 12 das orelhas testadas (14%).Quanto às medidas de imitância acústica, observamos curvas timpanométricas tipo A em 97,6% das orelhas. Curvas do tipo C foram notadas em apenas duas orelhas . Curvas timpanométricas do tipo B não foram encontradas.Os dados de reflexo acústico foram analisados considerando-se a diferença entre o limiar auditivo e o limiar do reflexo acústico na frequência testada.A A seguir, classificamos a diferença entre o limiar do reflexo e os limiares de audibilidade em quatro categorias e os comparamos para cada frequência. Esses dados estão apresentados na Os valores das EOAT não diferiram entre as orelhas. Os resultados de ambas as orelhas em todos os indivíduos, incluindo o intervalo de confiança, são mostrados na O achado mais significante deste estudo foi a alta taxa de perda auditiva, mais comumente neurossensorial, observada nessa população de pacientes afásicos. A audiometria tonal limiar se mostrou um procedimento extremamente útil, mas as dificuldades de compreensão e/ou de emissão observadas nos pacientes afásicos alteraram a logoaudiometria convencional e apontaram para a necessidade de métodos alternativos de avaliação para tal população.,12 embora alguns estudos tenham relatado AVE em pacientes com mais de 60 anos de idade.,14A população de amostra tinha uma média de idade de 57,48 anos, semelhante a dos relatos de outros estudos,Dois indivíduos foram incapazes de completar os testes convencionais porque não compreendiam as instruções. Esse fato foi justificado pelo fato de pacientes afásicos poderem apresentar distúrbios graves de compreensão.Em 94,1% dos casos, foi possível avaliar a audição usando audiometria tonal convencional. Assim, pudemos verificar que a audiometria tonal convencional é um método válido de avaliação dessa população e pode ser usada para determinar o grau de perda auditiva periférica que pode agravar os distúrbios de compreensão comuns em pacientes com afasia. A presbiacusia é representada por quatro subtipos: sensorial (perda de células ciliadas), neural (perda de neurônios espirais e ganglionares), metabólica (atrofia da estria vascular), e mecânica (espessamento e enrijecimento da membrana basilar). Entretanto, já que múltiplos fatores genéticos e ambientais causam a presbiacusia, a maioria dos casos é de patologia mista e afeta múltiplos tipos celulares. Assim, poderíamos formular a hipótese de que pacientes com problemas vasculares também poderiam ser mais suscetíveis a tais mecanismos.A média dos limiares tonais das frequências altas é maior que a das frequências baixas. A cóclea é uma estrutura helicoidal com aproximadamente 2 giros e 2/3. A base da cóclea tende a vibrar em altas frequências e o ápice tende a vibrar com baixas frequências. Assim, as lesões se iniciam nas frequências mais altas. Além disso, a presbiacusia é causada por deficiências de fluxo sanguíneo para o ouvido interno, causando lesões degenerativas no órgão de Corti. A lesão inicial causa surdez para sons agudos (curva descendente) e perda de discriminação da palavra. A idade da população variou de 22 a 82 anos e, embora a média de idade da população do estudo tenha sido de 57,48 anos, parte da amostra apresentou idade superior a 60 anos de idade. Portanto, esses pacientes poderiam apresentar esse tipo de perda auditiva em decorrência da idade. Portanto, nos distúrbios vasculares, pode ocorrer compressão que prejudica determinada área vascularizada, e o indivíduo pode exibir alguns sintomas resultantes da perda de fluxo sanguíneo para essa área.Além disso, já que o AVE envolve alterações vasculares, é possível que esses adultos com problemas vasculares possam exibir deficiências precoces de fluxo sanguíneo para o ouvido interno.Os resultados de avaliações audiológicas revelaram um audiograma normal em 25 orelhas; 56 orelhas exibiram algum tipo de perda auditiva. Na identificação de casos de perda auditiva, 78,6% foram neurossensoriais, e 17,8% apresentaram uma queda isolada em uma frequência específica , indicando que alterações do ouvido médio são raras nesses pacientes. Apenas duas orelhas  apresentavam perda auditiva do tipo mista.Na configuração do audiograma, o tipo mais comum foi a curva descendente. Isto pode ter ocorrido porque parte da amostra  consistiu de indivíduos com mais de 60 anos de idade, como foi mencionado anteriormente, e esses pacientes podem apresentar presbiacusia, que é normalmente caracterizada por perda neurossensorial de configuração descendente.,20 e, com isso alterar as respostas neste tipo de teste. Por esse motivo, as figuras tiveram de ser usadas em 12,8% dos casos. Sabemos que o LRF obtido por meio do álbum de figuras pode ser mais fácil, provavelmente porque se trata de um conjunto fechado (múltipla escolha) com um número limitado de respostas. Assim, é esperado que pacientes afásicos depois do AVE tenham melhores resultados neste tipo de procedimento do que com conjunto “set” aberto. Entretanto, mesmo sendo um procedimento mais simples, foi necessário utilizá-lo na população de pacientes afásicos, cujas dificuldades de emissão oral podem dificultar a obtenção de dados do LRF.As medidas de LRF exigem que os pacientes repitam as palavras ouvidas. Sabemos que a população de pacientes afásicos após AVE pode apresentar alteração em sua emissão de fala e frequentemente exibe alterações específicas na tarefa de repetiçãoTambém não foi possível obter o LRF em 14% das orelhas testadas, já que alguns pacientes não entenderam as instruções do teste nem os estímulos em função de sérias dificuldades de compreensão, o que tornou impossível a repetição ou a indicação das figuras representativas das palavras ouvidas. buffer fonológico de entrada, léxico fonológico de entrada, e sistema semântico).,23 Assim, se considerarmos a complexidade do processamento linguístico, os erros observados durante a repetição poderiam ter múltiplas origens em pacientes afásicos. Embora a tarefa de repetição seja extremamente simples para algumas pessoas sem lesão cerebral, a repetição é extremamente complexa em indivíduos afásicos após AVE. Em suma, a tarefa de repetição pode ser alterada em diversos pontos do processamento linguístico, além da possibilidade de associação com alterações na programação motora da fala, comumente encontrada em pacientes com afasia.,25 Em pacientes sem lesão cerebral com comprometimento periférico da audição, há compatibilidade entre o audiograma e IPRF. A incompatibilidade entre os limiares de audibilidade e o IPRF em pacientes afásicos se relaciona com falhas no processamento linguístico, que geram erros na tarefa de repetição. Esses resultados nos fizeram repensar nossos métodos de avaliação da audição em pacientes especiais, a fim de tirar a influência das dificuldades apresentadas por esses pacientes. Nossos resultados também confirmam a importância do uso de tarefas em que o paciente aponte para a resposta, já que pacientes com transtornos graves de compreensão respondem melhor a esse tipo de tarefa.No IPRF, também foi necessário usar o álbum de figuras em 15,3% dos casos (13 orelhas), mais do que no LRF , possivelmente porque palavras monossilábicas com e sem significado foram usadas no IPRF, tornando a tarefa mais difícil. Da mesma forma como foi observado na obtenção do LRF, 14% foram incapazes de repetir ou apontar as figuras das palavras ouvidas. Além disso, os pacientes foram capazes de repetir as palavras em 57,6% dos casos, mas os resultados foram abaixo do esperado para o grau de perda auditiva. Mesmo nos 37,7% dos casos em que o audiograma e o IPRF foram compatíveis, em 15,3% foi utilizado o álbum para obtenção das respostas. Em pacientes afásicos, o comprometimento da compreensão e/ou da emissão é variável. Assim, é possível que o paciente afásico compreenda a tarefa, mas seja incapaz de repetir ou repita com parafasias, o que é considerado um erro no IPRF. O paciente também pode não ser capaz de entender as instruções do teste, ou o paciente pode entender a instrução, mas falhar durante o processamento linguístico de entrada , indicando que essa população raramente tem alteração de orelha média. Parte da população estudada incluiu indivíduos com mais de 60 anos de idade , e a perda auditiva neurossensorial acompanhada de curvas timpanométricas tipo A é mais comum neste grupo, já que frequentemente surgem de alterações de orelha interna e/ou nas vias auditivas centrais.Na análise do reflexo acústico, foram considerados os valores referentes a diferença entre o limiar do reflexo acústico e o limiar de audibilidade nas frequências testadas. A média dos valores na frequência mais alta (4.000Hz) foi menor que a média obtida nas outras frequências. Esse resultado pode ser explicado pelo alto número de pessoas com perda auditiva neurossensorial, com uma curva descendente nessa amostra. Sabemos que, na presença de perda auditiva, podemos encontrar o recrutamento. O recrutamento é um sintoma de perda auditiva coclear e diz respeito à sensação psicoacústica rápida e anormal que acompanha o aumento na intensidade do estímulo.Para todas as frequências testadas, a diferença entre o limiar de reflexo acústico e o limiar de audibilidade ficou, na maioria das vezes, entre 70 e 90dB. Nas frequências de 500, 1.000 e 2.000Hz, houve notável diferença entre essa categoria e as demais, porém, na frequência de 4.000Hz, observamos um número significante da categoria abaixo de 70dB, indicando que o recrutamento era mais comum em 4.000Hz (um forte indicador de lesão coclear), compatível com o fato de que houve maior perda auditiva nas frequências mais altas. Já que a maioria dos pacientes exibiu curvas descendentes, os limiares das frequências mais altas foram maiores que os limiares das frequências mais baixas.Na análise das emissões otoacústicas, a média de respostas na frequência de 4.000Hz foi menor do que nas demais frequências. Nesses testes, valores de respostas menores foram observados quando o limiar de audibilidade para a frequência estava perto dos limites de normalidade. De fato, a latência das emissões diminui com o aumento da frequência.-30 demonstraram a importância dessa técnica de avaliação para detectar precocemente alteração nas células cocleares, mesmo quando não houve alteração nos limiares de audibilidade avaliados pela audiometria de limiar tonal. Assim, sugerimos que este seja um exame de grande validade, já que detecta precocemente alterações na cóclea, que podem ocorrer como resultado de deficits na irrigação sanguínea. O teste também é importante para propiciar uma ideia da audição dos pacientes quando eles não são capazes de realizar nenhuma das atividades na avaliação audiológica básica.A comparação entre a audiometria tonal e as emissões otoacústicas transitórias demonstrou que 19 pacientes tiveram ausência de EOAT em uma ou mais frequências, mesmo com limiares normais de audibilidade. Realmente, estudos anteriores com indivíduos expostos a ruído e com indivíduos submetidos a tratamento quimioterápico com cisplatinaNeste estudo, observamos perda auditiva em uma ou mais frequências em 56 orelhas, indicando alta prevalência de perda auditiva nessa população. Também observamos que, dessas 56 orelhas, 43 tiveram perda auditiva neurossensorial e 2 exibiram perda auditiva do tipo mista. A configuração audiométrica mais comum foi descendente. Indivíduos com perda auditiva em frequências altas (acima de 2.000Hz) podem exibir dificuldades no reconhecimento da fala.Dada à importância da audição para o desenvolvimento de aptidões linguísticas e para a eficiência da comunicação, concluímos que a avaliação audiológica nessa população é indispensável, tanto para fins clínicos como para pesquisa, já que é importante diferenciar deficits periféricos de centrais na avaliação e reabilitação de pacientes afásicos após a ocorrência de uma lesão cerebral.Este é um estudo transversal, de forma que não é possível identificar, com precisão, a causa da perda auditiva. Neste estudo, apenas pudemos demonstrar que a maioria dos pacientes afásicos apresentou perda auditiva.Houve uma alta taxa de perda auditiva, na maioria das vezes neurossensorial, em pacientes afásicos avaliados neste estudo. As alterações de compreensão e/ou emissão oral, nesses pacientes, alteraram a logoaudiometria convencional e apontaram para a necessidade de usar procedimentos alternativos de avaliação, a fim de fornecer melhor assistência e uma melhor reabilitação de fala/linguagem nessa população.


The study employed a cross-sectional design. The study was conducted in United Kingdom and 90 participants completed University of Rhode Island Change Assessment (URICA) scale as well as measures of self-reported hearing disability, self-reported anxiety and depression, self-reported hearing disability acceptance, and provided additional demographic details online. As predicted, the results indicate that a high percentage of participants (over 90%) were in the contemplation and preparation stages. No statistically significant differences were observed among groups of stage with highest URICA scores and factors such as: years since hearing disability, self-reported hearing disability, self-reported anxiety and depression, and self-reported hearing disability acceptance. Cluster analysis identified three stages-of-change clusters, which were named as: decision making (53% of sample), participation (28% of sample), and disinterest (19% of sample). Study results support the stages-of-change model. In addition, implications of the current study and areas for future research are discussed.The aim of the current study was to test the hypothesis that adults experiencing hearing difficulties who are aware of their difficulties but have not taken any action would fall under  Health behaviour change refers to facilitating changes of habits and/or behaviour related to health. There are several models proposed which provide a theoretical framework when studying and understanding health behaviour change , 2, and precontemplation—not thinking seriously about changing a specific behaviour and not interested in help ; (2) contemplation—aware of the consequences of the problem and spends time thinking about the problem; (3) action—taking active steps to change their behaviour; and (4) maintenance—successfully avoiding any temptation to give up the change they have made. In some stages-of-change models, additional stages such as ‘preparation’  and ‘relapse’  have also been included  and a weak negative and statistically significant correlation with self-reported hearing disability acceptance . Although statistically significant correlation was observed, R-values are small explaining only 7% and 11% of the variability respectively in relation to committed action composite and hearing disability acceptance. For this reason, the relation between URICA score, committed action composite scores, and hearing disability acceptance measure are not very strong. However, no statistically significant correlation was observed between the readiness to change composite and other factors such as; duration of hearing disability, self-reported hearing disability and self-reported anxiety and depression. Also, no statistically significant correlation was observed between committed action composite and other factors such as; duration of hearing disability, self-reported hearing disability, self-reported anxiety and depression and self-reported hearing disability acceptance.Pearson’s correlation coefficient was performed to study the correlation among URICA composites with other factors. The readiness to change composite showed a moderate positive statistically significant correlation with the committed action composite . However, this effect was not found to be statistically significant considering the Bonferroni adjusted significance levels . Also, we found no statistically significant difference in scores among those participants with highest scores in the preparation stage and the action stage in terms of readiness to change composite.decision making; (2) participation; and (3) disinterest. Scores of the precontemplation stage did not vary among the three groups. However, differences in other stage scores  made the groups distinct.Hierarchical cluster analysis was performed using Ward’s method and standardised Z scores to identify the stages-of-change clusters in the sample participants. Cluster analysis can identify individuals who share similar characteristics in the same group when compared to other groups . Inspection of the dendogram identified three unique clusters. Decision making was the most common cluster, which represents 53% of the study population in which participants had equally high scores in contemplation and preparation stages when compared to action stage. The difference in the stage scores between contemplation and preparation were not significant. But the stage scores between contemplation and action stages t(47) = 7.18, p < 0.001, and also between preparation and action stages t(47) = 7.18, p < 0.001, were found to be statistically different. The participation cluster represents 28% of the study population in which the scores in all three stages  were almost equal and no statistically significant difference were found between mean scores. Lastly, the disinterest cluster represents 19% of the study population in which participants had equal scores on preparation and action stage but higher scores in contemplation stage. The stage scores between contemplation and preparation t(16) = 3.87, p < 0.01, were found to be significantly different but not for scores between preparation and action stages. In addition, although some differences were noticed among scores between contemplation and action , they were found not to be significant considering the Bonferroni adjusted significance levels .contemplation and preparation stages based on the transtheoretical stages-of-change model. In addition, this study presents results of a stages-of-change measure and relates this measure with additional factors of hearing disability and acceptance, as well as possible related factors of anxiety and depression among adults noticing hearing difficulties who have not taken any action.The study was aimed at testing the hypothesis that adults experiencing hearing difficulties who have not taken any action would fall under In the current study, most participants had their highest URICA scores in the contemplation or preparation stages as predicted by the stages-of-change model. These results are similar to recent study results of adults who failed online screening where 88% of participants had their highest URICA scores in contemplation and preparation stages . This suThere were some differences observed among URICA composite scores  between the current study sample and those with hearing impairment seeking help for the first time , but notThere was no linear relationship found between other factors such as duration of hearing disability, self-reported hearing disability, self-reported anxiety and depression, and self-reported hearing disability acceptance among groups based on stage with highest scores. This may be to some degree related to not having any participants in precontemplation stage and having very few participants in the action stage. However, these findings may raise some concerns about the concurrent validity of the stages-of-change measure. Further studies are necessary to evaluate if other factors have linear relationship with stages-of-change as indicated in the previous study .active change, initiation, disengagement and ambivalence. However, two clusters  had the same characteristics as reported in a recent study on adults who failed online hearing screening and hence we used the same names for them [decision making cluster . Hence, they are still probably not ready to make an action but seeking information. Approximately one fourth of the population were in the participation cluster  who would probably be close to taking action. The rest of the participants were in the disinterest cluster (significantly higher scores in contemplation stage scores when compared to preparation and action stage scores). People in this group may be thinking about the problem but not seeking information actively, and this group may take longer to make a change. However, due to the cross-sectional design of the study, no firm conclusions can be drawn about the longitudinal predictive validity of these findings.Cluster analysis identified three distinct stages-of-change clusters see , which wfor them . 81% andfor them  respectifor them , 47. MosIt has been highlighted in previous studies that the staging algorithms might be based on arbitrary time periods and may not be measuring discrete stages of change . The curThis study could have a number of applications. First, this information about stages of change characteristics could be useful information for various stakeholders such as government, hearing aid industry, hearing-related charities that could use this information while planning hearing health—awareness events, and promotion and education by developing targeted approaches to different groups of population, if these results are replicable in further studies. Second, it is also common that some people with hearing difficulties who are not motivated to seek help come to see hearing healthcare professionals due to various other reasons . For this reason, it is important to better understand the characteristics of such a population. Furthermore, it is suggested in the literature that adults with hearing impairment take about 10 years on an average to seek help after they have started to notice hearing difficulties . HoweverThe study has some limitations that were unavoidable, mainly due to the nature of study sample chosen. The data was collected using self-reported measures using the internet. This method of data collection may have eliminated some people who do not have access to internet and also those who cannot use internet due to other disabilities  and may not be representative of the general population , 59. EveComparison of our results with the previous study by Laplante-Lévesque et al.  may reveThe current study was limited in terms of the main factors included . Other factors such as attitude and motivation could have also been useful in better understanding the population characteristics. Although the cross-sectional design helped us understand the population characteristics, no predictions can be made about their help-seeking behaviour from these findings and longitudinal studies are necessary with particular emphasis to process of change. Furthermore, even though Milstein and Weinstein have reported some findings in the population who are noticing hearing difficulties but in denial , not much is known about them and further studies are necessary to better understand characteristics of that population . Moreovecontemplation and preparation stages based on the transtheoretical stages-of-change model. The study sample included both pre-clinical  and clinical  populations, but not those who were in denial. The majority of the participants (over 90%) in this study were in contemplation and preparation stage as predicted from the model. At a population level, the stages-of-change model can predict overall readiness to change and also the stage at which the people with hearing disability may be categorized. The current study results support the arguments that the change might be better represented as continuum rather than discrete stages . The potential applications of stages-of-change model in relation to hearing disability and its application to audiological rehabilitation needs to be further investigated.The study was aimed at testing the hypothesis that adults experiencing hearing difficulties who have not taken any action would fall under S1 Dataset(XLSX)Click here for additional data file.