To verify the relationship between hearing handicap and frailty in community-dwelling older adults.A cross-sectional study was carried out with 238 older adults (aged ≥ 60 years) in 2018. The Hearing Handicap Inventory for the Elderly – Screening version – HHIE-S was applied to assess the hearing handicap. To assess frailty, the Frailty Phenotype proposed for Fried and co-workers was adopted, objectively evaluating 5 criteria: unintentional weight loss, reported fatigue, reduced grip strength, reduced walking speed and low physical activity. It was investigated whether the hearing handicap were related with frailty using Kruskal-Wallis and Spearman test.Worse perception of the hearing handicap was found in pre-frail and frail individuals, compared to non-frail individuals. In addition, hearing handicap showed a positive and statistically significant correlation with frailty.Hearing handicap is related to frailty in community-dwelling older adults. Despite being a physiological change resulting from cochlear aging, many factors favor its occurrence, such as genetic, environmental (exposition to intense noise and ototoxic substances), or individual (ear infection pre-pathways and systemic diseases or comorbidities) components, which explains its prevalence in the population of older adults. Regarding the older adults population, international studies have pointed to a prevalence of self-reported hearing complaint in around 20 to 30% of older individuals,4, a scenario that is not different in Brazil. However, studies based on audiometric measures have found higher prevalence, above 80%, in the older population. Although the symptoms are not noticed at first, hearing loss has a slow, gradual, and irreversible progression, leading to the impairment of hearing perception and speech understanding along the years, severely compromising the verbal communication process in the older person, and affecting their life quality.According to the Global Burden of Disease Study of 2021, hearing loss affects around 26% of the world population, thus characterizing as a high-prevalence disease and the third main cause of coping with deficiency. Therefore, it is crucial to detect not only hearing impairment, but hearing handicap as well.Nonetheless, in addition to changes in the communication process, other problems also result from hearing impairment in older individuals, such as social isolation, feelings of devaluation, decreased self-esteem, depression, and difficulties in family relations and in using means of communication. According to the IFC, an hearing deficiency leads to an hearing impairment and consequent handicap, which may either limit or restrict the individual’s participation in daily life activities. Thus, it can be said that an hearing loss may prevent or limit the older person to fully perform their activities, therefore being regarded as one of the most frustrating sensory deprivation and disabling chronic disorders that affect both the functionality and life quality of older adults.According to the WHO, a deficiency is an abnormality in the organs, systems, or body structures, while an impairment is the implication of a deficiency from the functional point of view. Handicap, in turn, reflects the adaptation of an individual to their deficiency or impairment. In light of this, the International Functional Classification (IFC) describes both the nature and severity of functionality limitations.For such reasons, as the population ages, associated hearing losses become a common concern to public health, as well as frailty. Many instruments have been elaborated to assess the restriction of participation, including the widely used HHIE-S, aimed at the older adults population. The instrument was proposed to assess handicap in the older adults population, that is, the individual’s own perception of their hearing limitation and how it affects their lifestyle, family relations, and social and emotional situation. These questionnaires are also important to assess the promotion of hearing health services for allowing to monitor the influence of impairments and handicaps on the life quality of older individuals. Frailty implies loss of homeostatic capacity to resist stressors, causing vulnerability in the systems. Nonetheless, the loss of reserve in multiple systems may lead to a decreased capacity of the organism to tolerate stressors, thus increasing the risk of negative outcomes associated with frailty, such as hospitalization, early institutionalization, falls, functional loss, and death. Fried et al. proposed five criteria to detect frailty that indicate energy impairment, like muscle weakness, fatigue or exhaustion, slow walking speed, reduced physical activity, and unintentional weight loss.Frailty, in turn, is a clinical syndrome resulting from declines in the physiological reserve associated to the impairment, in addition to reduced neurological control, mechanical performance, and energy metabolism,12,13. Early results, published in 2014, showed an association between self-reported hearing loss and frailty in older women, which did not apply to men. Hearing loss has been associated with risk of developing frailty and falls along the years, and the risk of frailty progression was corroborated in subsequent studies,14.Recent studies have suggested that hearing loss is related to frailty and its implications,12 or results from audiometric assessments to investigate hearing issues. Nonetheless, there are no studies that applied the HHIE-s, an instrument validated and consolidated in the international literature for measuring handicap or restricted hearing participation, as well as social and emotional damages resulting from the hearing loss. Therefore, our goal is to verify whether there is a relationship between hearing handicap and the presence of frailty in older adults of the community.Although it is a topic of great interest in the field of aging, it is noteworthy that studies addressing the relationship between hearing loss and frailty are still recent and scarce in the literature. Background studies used a single question regarding hearing self-perceptionThis study used data derived from the project “Monitoring tool for frailty levels in older individuals served by the basic health care: assessment of effectiveness and efficiency”, conducted by the research group Aging Management – GEnv. The project was authorized by the Municipal Secretariat of Health and approved by the Research Ethics Committee of the Federal University of São Carlos (CAAE:861067418.4.0000.5504 and Decision nº 3.101.282), in accordance with the ethical expectations in the Resolution 466/2012 regulated by the National Health Council.Cidade Aracy”, in the city de São Carlos-SP. The research took place between 2017 and 2018 through home assessments of older adults registered in five units of the Family Health Units (USFs – abbreviation in Portuguese) supported by the regional health administrations (ARES – abbreviation in Portuguese).This is a cross-sectional, observational study of quantitative approach carried out in the context of a large community of high social vulnerability, “Cidade Aracy” served by the family health center, able to understand and communicate verbally, and acceptance of participating in the study and signature of the Informed Consent Form. The following exclusion criteria were applied: conditions that would prevent the tests from being performed, such as severe motor deficits, lack of communication or terminally ill status. The final sample included 238 older adults who met all eligibility criteria.The following inclusion criteria were applied: individual aged 60 years or more, registered in the USFs of the ARES “Our research protocol is constituted of sociodemographic characterization data, frailty test, and hearing handicap inventory. The sociodemographic and health data were collected by means of a questionnaire elaborated by the researchers encompassing information on sex, age, race, marital status, education, income, and comorbidities., which assesses frailty according to the following five components: 1) Unintentional weight loss – assessed based on the following question: “Over the last twelve months, do you consider having lost weight without undergoing any diet?” In case of affirmative answer, if the weight loss is equal or higher than 4.5 kg or 5% of body weight over a year, the criterion was met. (2) Fatigue – assessed through self-reported based on the following two questions: “Have you felt the need to make any effort to cope with your daily tasks?” and “Have you felt unable to perform your tasks?”. If the older adults individual answered “always” or “mostly” for any of the two questions, the criterion was met. (3) Low strength of palm grip – measured by instructing the older adults individual to squeeze the device as strong as possible. Before that, the individual would receive the command “attention, get ready, now!” and was stimulated during the test by “go, stronger, go!”. For this criterion, the result was reached in the arithmetic mean of three measures and adjusted according to the Body Mass Index and sex, considering the weakest 20%in the sampling distribution. (4) Low level of caloric expenditure – assessed through self-report based on the following question “Do you consider doing fewer physical activities than twelve months ago?” In case of affirmative answer, the criterion was met. (5) gait slowness – assessed by the average time spent to walk 4.6 meters of distance, with adjustment according to sex and height. Three measures of walking speed were performed using the arithmetic mean as response considering the slowest 20% in the sampling distribution. According to the score achieved in the five criteria, the older adults individual would be classified according to frailty as: non-frail (no score in none of the five criteria), pre-frail (score in one or two criteria), or frail (score in three or more criteria).For frailty data, we used the phenotype proposed by Fried et al. questionnaire, an instrument translated and validated to the Brazilian context since 1997. It is an instrument of hearing screening for older adults individuals that assesses the perception of hearing handicap (impairment or restriction to hearing participation), as well as social and emotional impact resulting from the perceived hearing loss. Composed of ten questions and divided between social and emotional scales, each item has the following response options: yes (4 points), sometimes (2 points), or no (0 points). Total scoring varies from 0 to 40 points, classified into three categories: 0-8 points – no perception of hearing handicap, 10-22 points – slight or moderate perception, and 24-40 points – significant perception of hearing handicap.To assess the hearing handicap, we applied the Hearing Handicap Inventory for the Older adults – Screening version (HHIE-S)The protocols were checked before typing the data of the main study. Data were then typed in two different spreadsheets by different researchers blindly on the MS Excel XP software and further imported and analyzed using the IBM SPSS Statistics 20 statistical package.. All analyses considered p≤ 0.05 as statistical significance.For the sampling profile description, we performed descriptive statistics with measures of position and dispersion  for the continuous variables. Tables of absolute and relative frequencies were elaborated for the category variables. Data normality was assessed through a Komogorov Smirnov test, followed by Kruskal-Wallis non-parametric tests to assess the relationship between hearing handicap and frailty using the mean values of the HHIE-S to compare the groups according to frailty based on Spearman Correlation to assess the correlation between hearing handicap and frailty (continuous variables) by adopting the following scale to interpretate statistically significant values: weak <0.29, moderate de 0.3 a 0.59, strong de 0.6 a 0.9, and optimum 1.0The sample included 238 older adults aged between 60 and 100 years, average of 71.9 years, out of which 85.7% were aged below 80 years. It is a low-income population with poor educational level, residents of a community regarded as to be highly socially vulnerable. The conditions of frailty and pre-frailty appeared in most of the sample, while 26.9% of the population studied reported some perception of hearing handicap .We applied the Spearman correlation test to verify whether there was statistically significant correlation between hearing handicap and frailty. The outcome showed a positive correlation between the variables both for the social and emotional scales since the increase in the HHIE-S test score was followed by a higher frailty score  .This research aims to investigate the relationship between hearing handicap and frailty in 238 older adults individuals of the community. The results demonstrate that frail and pre-frail older adults reported restricted participation in daily life activities according to the questionnaire HHIE-S. Such result is ratified by the positive correlation found between frailty score, according to Fried Phenotype, and the HHIE-S score.. Like the presence of self-reported hearing complaint, hearing handicap research is a subjective approach to hearing assessment commonly used in international and national population studies with household collections aimed at investigating restrictions due to hearing problems. The questions have been validated in previous studies whose accuracy has been tested in relation to other objective assessment approaches,18.The HHIE-S instrument used herein aims to quantify the social and emotional impacts of hearing loss and is useful for hearing screening and measurement of treatment responses and follow-up, both in the clinical scope and research,19. Despite their unique relevance, Tonal Threshold Audiometry and other hearing sensitivity measures are not sufficient to measure hearing handicap since they do not address how the individual adapts to their deficiency or the impact on life quality. Thus, investigating hearing handicap and its relationship with frailty in older adults individuals implies more than a mere hearing loss detection but regards the individual as a biopsychosocial being within a specific environmental context, with skills to adapt to their deficiency/impairment, thus justifying the relationship found between restriction of hearing participation and frailty in older adults.With the publication of the IFC in 2001 and its larger use along these past two decades, hearing loss now has a biopsychosocial approach focused on health and welfare promotion, with the impairment developed within the individual-environment interaction. Tools proposing the assessment of hearing self-perception in daily life activities gained higher relevance for allowing to assess the restriction to hearing participation pointing to a high number of pre-frail and frail older adults, numbering 76.10% of the sample – a similar prevalence to other studies in both the national and international literature based on the same frailty assessment instrument in the community,20.Frailty was investigated through the instrument proposed by Fried et al.,12,14.By investigating the relationship between the HHIE-S and frailty, we found that pre-frail and frail individuals have higher restriction of participation in daily life activities than non-frail individuals . However, the pre-frail and frail groups did not differ when compared to the HHIE-S mean. It is noteworthy that longitudinal studies have pointed to higher incidence risk of hearing loss and frailty progressionAccordingly, the results show a statistically significant positive correlation between the HHIE-S score and frailty score (r=0.218 and p=0.001) both in the social and emotional scales of the HHIE-S. Although the correlations had weak magnitude, these findings suggest that the greater the restriction in participation in daily life activities the higher the score for frailty, thus showing the strength of this similar correlation in social and emotional scales.,12,13,21, thus demonstrating the relevance of the research question. We found no national studies or in Portuguese addressing the topic. The oldest study detected in the literature directly addressing the topic of frailty and hearing loss was published in 2014 followed by a publication in 2015 and another in 2017. All these studies, despite based on different methodologies, found an association between hearing loss and frailty. However, the authors highlight the adverse health conditions involved, such as diabetes, cardiovascular diseases, or history of falls as factors associated with frailty and/or hearing losses,22. Potential causes of such an association include a shared neuropathological etiology (like microvascular disease and inflammation) contributing both to hearing deficiency and frailty.Our study shows to be very up to date since the literature has very few publications on the topic of hearing loss and frailty and our results are aligned with background findings,22,23.Hearing loss has also been associated with higher death risk by cardiovascular diseases, in addition to an even higher death risk by all causes when associated with other sensorial deficiencies, such as visual, possibly because it is common for older individuals to have multiple sensorial deficiencies, which may cause adverse health conditions and increases frailty risk and consequently death, and the conclusion is that hearing loss in older adults may be associated with an increase by 20% in the death risk, which can be explained by shared pathological processes like mitochondrial dysfunction, generalized inflammation, or microvascular disease potentially evolving to hearing loss and death risk.The association between hearing loss and death was also investigated.Other sociodemographic variables such as age, sex, income, education, and social support were also considered in earlier studies on hearing loss and frailty. A cross-sectional study with 2,1010 older adults individuals over 70 years considered a stratification by sex found that the hearing was significantly associated with frailty in women, but not in men based on a self-assessment question for detecting hearing loss, and Fried phenotype for frailty, therefore a pioneer study. The research monitored 2,836 older adults individuals whose hearing was self-assessed by means of a single question to be answered as excellent, very good, good, reasonable, or poor. The responses were arranged in order to constitute two analysis groups: good hearing  and poor hearing (reasonable or poor response). The research analyzed baseline data cross-sectionally and reassessed the older adults individuals after four years. To establish the association between hearing loss and frailty, the researchers considered adjustments of sex, age, income, education, diseases cardiovascular, cognition, depression, and socialization and found an association of hearing loss with frailty and pre-frailty in the base study . Such an association was confirmed by the longitudinal analysis showing a relationship between hearing loss in pre-frail older adults individuals with higher risk of frailty progression, regardless of covariables. For the authors, hearing loss in older adults individuals may be a frailty risk, suggesting that hearing deficiency accelerates frailty progression.A cohort study on the topic was published in 2017. Thus, it is crucial to consider the necessary interventions, such adapting the Individual Sound Amplification Device (ISAD) for hearing recovery seeking to improve self-perception of handicap and life quality of older adults.The communication limitations imposed by hearing loss cause social and family isolation due to a restriction of hearing participation and in daily life activities, like going for groceries, to the church, meetings etc. Such a scenario not only generates impacts on social activities but also reduces the levels of physical activity and life qualityFinally, we found that the most prevalent comorbidities were hypertension (71%) and diabetes mellitus (29.4%). Sociodemographic features as age, sex, education, income, and ethnicity were also addressed in this study, although not considered for analyzing the factors associated with hearing loss or frailty, thus implying a research limitation.,12.Therefore, although previous studies have shown that the relationship between hearing loss and frailty persists even after the adjustments of the associated factors, our results do not allow us to state that the relations found between the two variables are not masked by sociodemographic factors or health conditions that interfere both with hearing and frailty in older adults individuals. Accordingly, the cross-sectional nature of our study could not indicate any causality relationship between the two variables, as cohort studies do. Thus, our research proves relevant for corroborating the relationship between hearing and frailty losses – a latest, very little explored topic –revealing the relevance of hearing monitoring in older adults individuals. The restricted participation in daily life activities associated with hearing loss can also represent an important assessment component when identifying individuals with frailty risk.Nevertheless, it is suggested that such a relation may result from the negative outcomes of hearing loss, like restricted participation in daily life activities, communication difficulty, and consequent social isolation, leading to the onset and progression of frailtyThese findings provide many research routes for exploration. We suggest analyzing how the five components included in the frailty phenotype according to Fried are individually related to hearing..The results analyzed herein are based on hearing self-assessment, more specifically regarding the detection of hearing handicap, that is, restricted participation in daily life activities and related social and emotional impacts resulting from the perceived hearing deprivation. However, the Tonal Threshold Audiometry is considered a gold standard hearing assessment that detects hearing loss and measures its degree. Prior studies point to a lower prevalence of self-declared hearing losses in population studies than hearing losses analyzed through audiometric assessmentsDespite the promising results, we do not really know the hearing features that are in fact related to frailty regarding speech degree and understanding. We also did not know how hearing recovery, more specifically the use of hearing aids, could interfere with this relationship. Thus, further research should explore the relationship between frailty and different hearing configurations, as well as how hearing rehabilitation could influence the frailty condition. Prospective studies could deepen the research on the topic by targeting control strategies for frailty progression.Our results demonstrate the presence of a relationship between subjective perception of hearing handicap and frailty in older population of the community. The relevance of this study is its innovation in correlating hearing loss, more specifically the restricted participation in daily activities, with frailty in vulnerable older adults registered in the basic care service. Another leverage of this research is enabling the health service to use our findings to develop a health monitoring of the older adult individuals aimed at integral care assurance. .A perda auditiva relacionada ao envelhecimento caracteriza-se pelo comprometimento neurossensorial do órgão da audição e vias auditivas. Apesar de ser uma alteração fisiológica em decorrência do envelhecimento coclear, vários fatores contribuem para sua ocorrência como fatores genéticos, ambientais (exposição a ruídos intensos e a substâncias ototóxicas) e individuais (infecções prévias de ouvido e doenças sistêmicas ou comorbidades), o que torna a perda auditiva prevalente na população idosa. Na população idosa, estudos internacionais apontam prevalência da queixa auditiva autorrelatada em cerca de 20 a 30% dos idosos,4 e no Brasil não é diferente. No entanto, estudos que utilizaram medidas audiométricas encontraram prevalência maior, acima de 80% em idosos mais velhos. Apesar dos sintomas não serem percebidos no início, a perda auditiva possui progressão lenta, gradual e irreversível, levando à incapacidade de percepção auditiva e também da compreensão da fala ao longo dos anos, o que compromete gravemente o processo de comunicação verbal do idoso, afetando sua qualidade de vida.De acordo com o Global Burden of Disease Study, de 2021, a perda auditiva atinge cerca de 26% da população mundial, encontrando-se entre as doenças com maior prevalência, sendo a terceira principal causa de anos convividos com deficiência. Por este motivo, é fundamental verificar não somente a incapacidade auditiva, mas também a desvantagem auditiva (handicap).Porém, além das alterações no processo comunicativo, existem outros problemas decorrentes da incapacidade auditiva em idosos, tais como isolamento social, sentimentos de desvalorização, diminuição da autoestima, depressão e ainda, dificuldades de relacionamento familiar e de utilização dos meios de comunicação. À luz da CIF, a deficiência auditiva leva à incapacidade auditiva e consequente desvantagem, o que pode limitar ou restringir a participação do indivíduo em atividades de vida diária. Assim, pode-se dizer que a deficiência auditiva pode impedir ou limitar o idoso a desempenhar plenamente suas atividades, sendo considerada, uma das mais frustrantes privações sensoriais e um dos mais incapacitantes distúrbios crônicos que afetam a funcionalidade e a qualidade de vida dos idosos.Segundo a OMS, a deficiência refere-se à anormalidade nos órgãos, sistemas e estruturas do corpo, enquanto a incapacidade refere-se à consequência da deficiência do ponto de vista funcional. Já a desvantagem reflete a adaptação do indivíduo frente à deficiência e à incapacidade. A partir deste conceito, a Classificação Internacional de Funcionalidade (CIF) descreve a natureza e a gravidade das limitações de funcionalidadePor esses motivos, à medida que a população envelhece, as perdas auditivas advindas do envelhecimento tornam-se uma preocupação comum à saúde pública, assim como a fragilidade.handicap da população idosa, ou seja, a percepção do próprio indivíduo a respeito de sua limitação auditiva, e como esta afeta seu estilo de vida, relação familiar, sua situação social e emocional. Esses questionários também são importantes na avaliação dos serviços de promoção da saúde auditiva, pois, por meio de sua aplicação, é possível monitorar como as incapacidades e desvantagens afetam a qualidade de vida dos idosos.Vários instrumentos já foram desenvolvidos para avaliar a restrição da participação, sendo um dos mais utilizados o HHIE-S, desenvolvido para a população idosa. Este instrumento foi proposto para avaliar o . A fragilidade envolve perda de capacidade homeostática para a resistência de estressores, resultando em vulnerabilidade dos sistemas. Contudo, a perda da reserva em múltiplos sistemas pode levar a um declínio na capacidade do organismo em tolerar estressores aumentando o risco de desfechos negativos associados a fragilidade, tais como, hospitalização, institucionalização precoce, quedas, perda funcional e óbito. Fried et al. propuseram, para identificar a fragilidade, cinco critérios que indicam comprometimento energético como fraqueza muscular, fadiga ou exaustão, lentidão na velocidade da marcha, redução na atividade física e perda de peso não intencional.A fragilidade, por sua vez, é uma síndrome clínica decorrente de declínios da reserva fisiológica associada à incapacidade e redução do controle neurológico, desempenho mecânico e metabolismo energético,12,13. Os primeiros resultados, publicados em 2014, demonstraram associação entre a perda auditiva autorreferida e fragilidade em mulheres idosas, porém esta associação não foi encontrada em homens. A perda auditiva foi associada ao risco de desenvolvimento da fragilidade e quedas ao longo dos anos, sendo que o risco de progressão da fragilidade foi confirmado nos estudos posteriores,14.Estudos recentes sugerem que a perda auditiva está relacionada com fragilidade e suas consequências,12 ou resultados de avaliações audiométricas, contudo nenhum utilizou o HHIE-s, instrumento validado e consolidado na literatura internacional para mensurar a desvantagem ou restrição à participação auditiva e os prejuízos sociais e emocionais decorrentes do déficit auditivo. Portanto, o objetivo deste estudo foi verificar a relação entre o handicap auditivo e a presença de fragilidade em idosos da comunidade.Apesar da temática ser de extremo interesse na área do envelhecimento, ressalta-se que os estudos que mostram a relação entre a perda auditiva e a fragilidade ainda são recentes e escassos na literatura. Os estudos prévios utilizaram, como forma de investigação auditiva, pergunta única a respeito da autopercepção auditivaO estudo utilizou dados oriundos do projeto “Ferramenta de monitoramento de níveis de fragilidade em idosos atendidos na atenção básica de saúde: avaliação de sua efetividade e eficiência” realizado pelo grupo de pesquisa Gestão em Envelhecimento-GEnv. O projeto foi autorizado pela Secretaria Municipal de Saúde do município e aprovado pelo Comitê de Ética em Pesquisa da Universidade Federal de São Carlos (CAAE:861067418.4.0000.5504 e Parecer nº 3.101.282), respeitando os aspectos éticos previstos pela Resolução 466/2012 regulamentada pelo Conselho Nacional de Saúde.Trata-se de um estudo transversal, observacional, de abordagem quantitativa, realizado em uma extensa comunidade de alta vulnerabilidade social “Cidade Aracy”, localizada no município de São Carlos-SP. A pesquisa foi desenvolvida no período entre 2017 e 2018, sendo avaliados em seus domicílios idosos cadastrados em cinco unidades da Unidade de Saúde da Família (USFs) assistidas pelas administrações regionais de saúde (ARES).Os critérios de inclusão foram: possuir idade igual ou superior a 60 anos, ser cadastrado na USFs das ARES “Cidade Aracy” assistidas pelo núcleo de atendimento à saúde da família, ter capacidade de compreensão e comunicação verbal, aceitar participar do estudo e assinar o Termo de Consentimento Livre e Esclarecido. Os critérios de exclusão foram: possuir condições que impedissem a realização dos testes como déficits motores graves, falta de comunicação e doenças em estado terminal. A amostra final foi composta por 238 idosos que preencheram os critérios de elegibilidade para esse estudo.handicap auditivo compuseram o protocolo de pesquisa. Os dados sociodemográficos e de saúde foram coletados por meio de questionário construído pelos pesquisadores, com informações sobre sexo, idade, raça, estado civil, escolaridade, renda e comorbidades.Neste estudo os dados de caracterização sociodemográfica, teste de fragilidade e avaliação do , que avalia a fragilidade segundo cinco componentes: 1) Perda de peso não intencional: este critério foi avaliado por meio da seguinte pergunta: “Nos últimos doze meses o (a) senhor (a) acha que perdeu peso sem fazer nenhuma dieta? ” Em caso afirmativo, se essa perda de peso fosse igual ou superior a 4,5 kg ou 5% do peso corporal em um ano, o idoso pontuava neste critério. (2) Fadiga: avaliada por meio do autorrelato evocado por duas questões: “O (a) Sr (a) sentiu que teve que fazer algum esforço para dar conta de suas tarefas do dia-a-dia?” e “O(a) Sr (a) sentiu que não conseguiria levar adiante as suas tarefas?”. Se o idoso respondesse “sempre” ou “na maioria das vezes” para qualquer uma das duas questões, pontuava nesse critério. (3) Baixa força de preensão palmar: foi medida com dinamômetro hidráulico portátil na mão dominante e o idoso foi orientado a apertar o aparelho o mais forte que conseguia. Antes, recebia o comando “atenção, prepara, já! ”, e era estimulado durante o teste com “força, força, força! ”. Para esse critério, o resultado foi obtido pela média aritmética de três medidas, sendo o resultado ajustado segundo o Índice de Massa Corporal e sexo, considerando os 20% mais fracos da distribuição amostral. (4) Baixo nível de dispêndio calórico: este critério foi avaliado por meio de autorrelato a partir da pergunta “O (a) senhor (a) acha que faz menos atividades físicas do que há doze meses atrás? ” Caso a resposta fosse afirmativa, o idoso pontuava neste critério. E (5) lentidão da marcha: avaliada pelo tempo médio gasto para percorrer 4,6 metros de distância, com ajuste segundo sexo e altura. Foram realizadas três medidas da velocidade da marcha, utilizando-se como resposta a média aritmética, considerando os 20% mais lentos da distribuição amostral. De acordo com a pontuação obtida nos cinco critérios, o idoso foi classificado segundo a Fragilidade sendo: Não Frágil (ausência de pontuação nos cinco critérios); Pré-frágil (pontuação em um ou dois critérios); e frágil (pontuação em três ou mais critérios).Para os dados da fragilidade foi utilizado o fenótipo proposto por Fried et al.handicap auditivo aplicou-se o questionário Hearing Handicap Inventory for the Elderly - Screening version (HHIE-S), instrumento traduzido e validado para o Brasil em 1997. Este é um instrumento de triagem auditiva para idosos que avalia a percepção do handicap auditivo (desvantagem ou restrição à participação auditiva), e o impacto social e emocional decorrente da perda auditiva percebida. Composto por dez perguntas e dividido entre escala social e escala emocional, as respostas de cada item eram sim (4 pontos), algumas vezes (2 pontos) ou não (0 pontos). As pontuações totais variam de 0 a 40 pontos, sendo classificada em três categorias: 0-8 pontos ausência de percepção do handicap auditivo, de 10-22 pontos percepção leve ou moderada e de 24-40 pontos percepção significativa do handicap auditivo.Para avaliar o Statistics 20.Antes da digitação dos dados do estudo principal, os protocolos foram conferidos. Os dados foram digitados em duas planilhas diferentes por pesquisadores diferentes e de forma cega no programa MS Excel XP e posteriormente importados e analisados com apoio do pacote estatístico IBM SPSS handicap auditivo e a fragilidade, utilizando os valores médios do HHIE-S para comparar os grupos segundo a fragilidade e Correlação de Sperman, para avaliar a correlação entre o handicap auditivo e a fragilidade (variáveis contínuas) e adotou-se a seguinte escala para interpretação dos valores estatisticamente significantes: fraca <0,29; moderada de 0,3 a 0,59; forte de 0,6 a 0,9 e perfeita 1,0. Em todas as análises adotou-se p≤ 0,05 para atribuir significância estatística.Para descrever o perfil da amostra, foi realizada estatística descritiva, com medidas de posição e dispersão  para as variáveis contínuas. Tabelas de frequências absoluta e relativa foram confeccionadas para as variáveis categóricas. A normalidade dos dados foi avaliada por meio do teste Komogorov Smirnov, seguido dos testes não paramétricos de Kruskal-Wallis, para avaliar a relação entre o handicap auditivo   .handicap auditivo e a fragilidade em 238 idosos da comunidade. Os resultados demonstraram que idosos frágeis e pré-frágeis relatam restrição de participação em atividades de vida diária segundo o questionário HHIE-S. Tal resultado foi ratificado pela correlação positiva entre a pontuação da fragilidade, segundo o Fenótipo de Fried, e a pontuação do HHIE-S.Este estudo se propôs investigar a relação entre o follow-up, tanto na clínica quanto em pesquisas. Assim como a presença de queixa auditiva autorrelatada, a pesquisa do handicap auditivo é uma forma de avaliação subjetiva da audição comumente utilizada nos estudos populacionais nacionais e internacionais que realizam coletas domiciliares que visam investigar as restrições decorrentes de problemas auditivos. Tratam-se de questões previamente validadas em estudos anteriores que tiveram sua acurácia testada quando comparada a outras formas de avaliação objetiva,18.O instrumento HHIE-S utilizado neste estudo tem o objetivo de quantificar o impacto social e emocional advindo da perda auditiva, sendo um instrumento útil para rastreio auditivo e mensuração de respostas a tratamentos e ,19. A audiometria tonal liminar dentre outras medidas da sensibilidade auditiva, apesar de sua importância ímpar, não são suficientes para mensurar a desvantagem auditiva, ou seja, como o indivíduo se adapta a sua deficiência, ou qual o impacto na qualidade de vida. Assim, a opção de se estudar o handicap auditivo e sua relação com a fragilidade em idosos transcende a mera constatação da perda auditiva e considera o indivíduo como um ser biopsicossocial, inserido num contexto ambiental próprio, com habilidades para se adaptar à sua deficiência/incapacidade, o que justifica a relação encontrada entre a restrição da participação auditiva e a fragilidade em idosos.Com a publicação da CIF em 2001 e a ampliação de seu uso ao longo destas duas décadas, a perda auditiva passou a ter uma abordagem biopsicossocial focada na promoção de saúde e bem-estar, com a incapacidade construída dentro da interação pessoa-ambiente. Ferramentas que se propunham a avaliar a autopercepção auditiva em atividades em vida diária, ganharam maior relevância uma vez que possibilitam a avaliação da restrição à participação auditiva que apontou elevado número de idosos pré-frágeis e frágeis, totalizando 76,10% da amostra, prevalência similar a outros estudos da literatura nacional e internacional que utilizaram o mesmo instrumento de avaliação da Fragilidade na comunidade,20.A fragilidade foi investigada por meio do instrumento proposto por Fried et al.,12,14.Ao investigar a relação entre o HHIE-S e a fragilidade foi possível verificar que indivíduos pré-frágeis e frágeis possuem maior restrição de participação em atividades de vida diária comparados aos não frágeis . No entanto, os grupos pré-frágil e frágil não diferiram entre si, quando se comparou a média do HHIE-S. É importante destacar que em estudos longitudinais foi observado que a perda auditiva aumenta o risco de incidência e progressão da fragilidadeHHIE-S. Embora as correlações tenham sido de fraca magnitude, tais achados sugerem que quanto maior a restrição de participação em atividades de vida diária maior a pontuação indicativa de fragilidade, sendo a força dessa correlação semelhante nas escalas social e emocional.Da mesma forma, os resultados demonstram que a pontuação do HHIE-S apresentou correlação positiva estatisticamente significante com a pontuação da fragilidade , sendo essa correlação demonstrada tanto na escala social quanto na emocional do ,12,13,21, demonstrando a pertinência da pergunta de pesquisa. Não foram encontrados estudos nacionais ou realizados na língua Portuguesa que abordassem o tema. O estudo mais remoto identificado na literatura que tratou diretamente do tema fragilidade e perda auditiva foi publicado em 2014 seguido de uma publicação em 2015 outra em 2017, sendo que, nestes estudos, apesar de utilizarem metodologias diferentes, houve associação entre perda auditiva e fragilidade. No entanto, os autores destacaram as condições de saúde adversas como diabetes, doenças cardiovasculares ou história de quedas como fatores associados à fragilidade e/ou perdas auditivas,22. As explicações potenciais para esta associação incluem uma etiologia neuropatológica compartilhada  contribuindo tanto para a deficiência auditiva, quanto para a fragilidade.O estudo aqui apresentado se mostra bastante atual pois publicações sobre o tema perda auditiva e fragilidade são escassas na literatura e os resultados apresentados são condizentes com os achados anteriores,22,23.A deficiência auditiva também já foi associada com maior risco de mortalidade por doenças cardiovasculares, sendo que quando associada a outras deficiências sensoriais, como a visual, aumentou-se o risco de mortalidade por todas as causas, possivelmente porque é comum pessoas mais velhas terem deficiências sensoriais múltiplas, podendo haver condições de saúde adversas o que aumenta o risco de fragilidade e consequente morte, concluindo que a perda auditiva em idosos pode estar associada ao aumento de até 20% no risco de mortalidade, podendo ser explicado pelos processos patológicos compartilhados como disfunção mitocondrial, inflamação generalizada ou doença microvascular podendo contribuir potencialmente para uma perda auditiva e risco de mortalidade.A associação entre perda auditiva e mortalidade também foi estudada. Um estudo de coorte sobre o tema foi publicado em 2017, utilizando uma pergunta de autoavaliação para identificação da perda auditiva e o fenótipo de Fried, para identificação da fragilidade, o que caracterizou o estudo como inédito. Foram acompanhados 2.836 idosos que tiveram a audição autoavaliada por meio de uma única questão em que os idosos deviam classificá-la como excelente, muito boa, boa, razoável ou ruim. As respostas foram organizadas compondo dois grupos de análise: audição boa  e audição ruim (resposta razoável e ruim). A pesquisa analisou os dados basais de forma transversal e reavaliou os idosos após quatro anos. Para estabelecer a associação entre perda auditiva e fragilidade, o estudo levou em consideração ajuste de sexo, idade, renda, educação, doenças cardiovasculares, cognição, depressão e socialização e revelou que a perda auditiva foi associada com fragilidade e pré-fragilidade no estudo de base . Tal associação foi confirmada na análise longitudinal no qual a perda auditiva em idosos pré-frágeis foi associada ao maior risco de progressão da fragilidade, independentemente das covariáveis. Para os autores, perda auditiva em idosos pode ser um risco para fragilidade, sugerindo que a deficiência auditiva acelera a progressão da fragilidade.Outras variáveis sociodemográficas como idade, sexo, renda, educação e suporte social também foram consideradas nestes estudos prévios de perda auditiva e fragilidade. Em um estudo transversal realizado com 2.1010 idosos acima de 70 anos, quando feita a estratificação por sexo, a audição foi significativamente associada à fragilidade em mulheres, porém não em homens. Assim, é fundamental considerar as intervenções necessárias, como a adaptação de Aparelho de Amplificação Sonora Individual (AASI), para a reabilitação auditiva, com vistas a melhorar a autopercepção do handicap e qualidade de vida do idoso.As limitações comunicativas impostas pela perda auditiva provocam isolamento social e familiar, com restrição à participação auditiva e nas atividades de vida diária, como ir ao supermercado, igrejas, reuniões. Tal situação impacta não somente nas atividades sociais, mas também provoca redução dos níveis de atividade física e qualidade de vidaPor fim, observou-se que as comorbidades mais prevalentes foram hipertensão arterial (71%) e diabetes mellitus . As características sociodemográficas como idade, sexo, escolaridade, renda e etnia também foram levantadas neste estudo, porém não foram consideradas para análise de fatores associados a perda auditiva ou fragilidade, sendo essa uma limitação do presente estudo.,12.Assim, apesar dos estudos prévios demonstrarem que a relação entre perda auditiva e fragilidade se mantém mesmo após os ajustes dos fatores associados, os resultados da presente pesquisa não permitem afirmar que as relações demonstradas entre as duas variáveis não estejam mascaradas por fatores sociodemográficos ou condições de saúde que interferem tanto na audição quanto na fragilidade de idosos. Por se tratar de um estudo transversal, também não se pode indicar a relação de causalidade entre as duas variáveis, como pôde ser demonstrado nos estudos de coorte. Assim, este estudo se mostra importante uma vez que vem ratificar a relação entre perdas auditivas e fragilidade, uma temática tão recente e pouco explorada, que demonstra a importância do monitoramento auditivo em idosos. A restrição da participação em atividades de vida diária, em decorrência da perda auditiva, também pode ser um importante componente de avaliação quando se objetiva identificar indivíduos com risco de fragilidade.Apesar disso, aventa-se a possibilidade desta relação ser decorrente dos desfechos negativos da perda auditiva, como a restrição de participação em atividades de vida diária, dificuldade de comunicação e consequente isolamento social, levando ao desencadeamento e progressão da fragilidadeA partir desses achados, vários caminhos da pesquisa podem ser explorados. Sugere-se analisar como os cinco componentes incluídos no fenótipo de fragilidade segundo Fried se relacionam individualmente com a audição.handicap auditivo, ou seja, restrição de participação em atividades de vida diária e seus impactos sociais e emocionais decorrentes da privação auditiva percebida. No entanto, a avaliação auditiva considerada padrão ouro é a Audiometria Tonal Liminar, exame que detecta a perda auditiva e mensura seu grau. Pesquisas anteriores apontam que a prevalência de perdas auditivas autodeclaradas nos estudos populacionais é inferior às perdas auditivas aferidas por meio de avaliações audiométricas.Os resultados analisados nesta pesquisa foram baseados em autoavaliação da audição, mais especificamente na identificação do Apesar dos resultados promissores, não conhecemos as características auditivas que de fato se relacionam com a fragilidade, no que diz respeito ao grau e compreensão de fala. Também não sabemos como a reabilitação auditiva, mais especificamente o uso de próteses auditivas, pode interferir nesta relação. Assim, pesquisas futuras poderão explorar a relação da fragilidade com as diferentes configurações auditivas e como a reabilitação auditiva pode impactar no quadro de fragilidade. Mais pesquisas poderiam auxiliar no aprofundamento do tema e direcionamento de estratégias de controle da progressão da fragilidade.handicap auditivo e a fragilidade em idosos da comunidade.Os resultados apresentados neste estudo demostram que há relação entre a percepção subjetiva do O presente estudo se faz relevante perante sua inovação em correlacionar a perda auditiva, mais especificamente a restrição da participação em atividades diárias, com a fragilidade de idosos cadastrados na atenção básica e em contexto vulnerável. Outra potencialidade do estudo é a sua contribuição para o serviço de saúde com a utilização dos achados para a elaboração de estratégias de monitoramento de saúde da pessoa idosa com vistas à garantia do cuidado integral.


Hearing loss is a multifaceted condition with many etiologies, among which genetic mutation is. Therefore, it is important to connect audiological investigation to etiological diagnosis.this study aims to establish the audiological and genetic profiles of three non-syndromic children with sensorineural hearing loss.three brothers aged 3, 5 and 16 were enrolled in this study. They were submitted to behavioral and electrophysiological hearing tests and molecular studies.the hearing tests showed moderate to moderately severe bilateral symmetric sensorineural hearing loss and an accentuated descending slope. Transient and Distortion Product Otoacoustic emissions were absent in the two younger children. ABR showed a bilateral moderately severe to severe sensorineural hearing loss. P300 showed bilateral normal latencies in the older brother. Molecular tests showed that the two younger children were heterozygote for mutation 35delG on gene GJB2.The combination of speech and hearing tests and genetic analysis allows for the etiologic diagnosis of seemingly similar hearing loss cases, which however display different genetic backgrounds. Molecular studies must be comprehensive enough to avoid precipitated diagnosis which may impair genetic counseling. Hearing loss (HL) is the most frequently diagnosed sensorial deficit. This condition impairs the exertion of communication skillsBehavioral and electrophysiological tests are available to assist with the audiological diagnosis, and may be used as part of the assessment procedureCongenital sensorineural hearing loss may or not have a genetic background. Within the genetically-originated cases, there are those in which HL is part of a syndrome (30%) and those in which it is an isolated condition - non-syndromic sensorineural HL (70%)Within the cases of non-syndromic recessive autosomal inheritance HL are the ones occurring from mutations on gene GJB2, in charge of encoding protein conexin 26. One of these mutations, 35delG, accounts for about 70% of the mutant alleles in European and North-American Caucasians, with 2.3% to 4% heterozygotesIn developing countries environmental factors such as congenital infections and perinatal disorders are still quite common28.In cases of genetically-acquired hearing loss, additionally to early auditory stimulation and use of hearing aids, genetic counseling must also be considered to allow individuals and their families to make well-informed decisions on procreationGenetic counseling for cases of inherited non-syndromic HL relies heavily on accurate diagnosis of the inheritance mechanism. The introduction in Brazil of tests to check for mutation 35delG on gene GJB2, among other exams required to clarify the etiology of the condition has been fundamental for effective genetic counseling. Indeed, its detection is highly relevant in tracking the origins of HL, thus reinforcing the relevance of having comprehensive molecular to avoid precipitated diagnosis and unnecessary stress for the families.This paper aims to report on the audiological profiles and genetic test results of a family from the municipality of São Paulo, emphasizing the genetic heterogeneity of HL patients and the complexity of genetic counseling.This study was approved by the Research Ethics Committee at CEFAC under permit 172/05.The index-case II.5, , male, HAudiological examination included both behavioral and electrophysiological tests, conducted based on the needs of each participant considering their ages and presence of hearing impairment.Tone audiometry (TA), speech audiometry (SA), impedance tests (IT), acoustic reflex measurements (ARM), distortion product otoacoustic emission (DPOAE) tests, and transient-evoked otoacoustic emission (TEOAE) tests were conducted at the IEAA.Brainstem auditory evoked potential (BAEP), middle-latency auditory evoked potential (MLAEP), and P300 tests were conducted at the CDP at FMUSP. Genetic tests were carried out at the Center for Molecular Biology and Genetic Engineering at UNICAMP. Presence of mutation 35delG on gene GJB2 was investigated using *AS-PCR  to discriminate normal from mutant alleles, thus telling normal homozygotes from 35delG homozygotes and mutated heterozygotes; this gene was also completely sequenced.Deletions involving the conexin 30 gene (GJB6-Cx30) were also analyzed - del (GJB6 - D13S1830) and del (GJB6 - D13S1854) - using multiplex PCR; mutation A1555G on mitochondrial gene 12SrRNApor was searched through restriction analysis with digestion of enzyme Bsm AI.Audiological evaluation of the index-case (II.5) and siblings (II.6 and II.7) showed an audiometric curve with sensorineural bilateral symmetric hearing loss, with an accentuated descending configuration. Individuals II.5 and II.7 had moderately severe bilateral hearing impairment and II.6 had moderate hearing loss in the right ear and moderately severe HL on the left ear. The parents (I.2 and I.3), sister (II.4), half-sister (II.2) and nephews (III.1 and III.2) had normal hearing thresholds. DPOAEs were absent on II.6 and TEOAEs were absent on subject II.7.BEAP test results were consistent with severe bilateral hearing loss for clicks on subjects II.5 and II.7 and moderately severe on II.6. P300 showed latencies within normal range bilaterally for subject II.5.In terms of molecular tests, none of the analyzed individuals had deletions in the conexin 30 gene or mutations on gene 12SrRNA. Mutation 35delG in heterozygosis was found in the index-case mother’s (I.2) gene GJB2, in the older sister (II.4) with normal hearing and in the two siblings with hearing impairment (II.6 and II.7). The father (I.3), the index-case (II.5) and the half-sister’s daughter (III.1) are normal homozygotes, and thus did not have mutation 35delG; unfortunately it was not possible to perform molecular tests on the half-sister (II.2) and the nephew (III.2). Molecular findings can be seen in the inheritance patterns shown in Hearing impairment introduces a series of restrictions and difficulties into the lives of those affected by itThe thorough audiological examination performed with the core of the family (parents and siblings) added to the tests done with the half-sister and the nephews revealed that the three siblings had practically the same kind of hearing loss, and that their parents, sister, half-sister and nephews had normal hearingThe study also showed that the identified hearing impairment was of the sensorineural prelingual non-syndromic typeMany are the possible inheritance mechanismsIt is still possible to consider dominant autosomal inheritance, with incomplete penetrance in one of the parents or consequent to germinative tissue mutation in one of themThe limitations related to the diagnosis of patients with non-syndromic sensorineural hearing loss through molecular tests pose an interesting challenge. If the genetic tests had been limited to one of the siblings carrying mutation 35delG (II.6 and II.7) and one of the parents, we would have looked at explaining the presence of the mutation in heterozygosis in individuals with hearing loss. Indeed, one of the biggest difficulties in offering genetic counseling to individuals carrying mutations in the conexin 26 gene - including mutation 35delG - is the fact that in 10% to 40% of the cases these mutations are detected only in one of the alleles, but still result in hearing loss. In some cases these mutations segregate with deletions in gene GJB6, i.e., the individual is heterozygote for mutations in gene GJB2 and in the other allele he or she presents one of the two deletions involving gene GJB6Still in reference to the scenario in which subject II.5 did not undergo molecular testing, any geneticist would see as the best possibility a situation in which the interaction occurred in the other allele is not explained, and thus mutation 35delG would be connected to the hearing loss phenotype presented by the family.Therefore, recessive inheritance connected to chromosome X could be excluded and thus the risk of the sister (II.4) and the half-sister (II.2) having male children with hearing loss would not be considered, as nor would mitochondrial inheritance, thus also discarding the risk for the offspring of the sister and that of the half-sister.However, as the core of the family was entirely studied, we could verify that the hearing loss phenotype is independently segregated from genotype 35delG. Indeed, there were two individuals carrying the mutation with yet normal hearing (I.2 and II.4) and one with hearing loss but without mutation 35delG (II.5).Mutation 35delG can thus be considered to be a casual finding, given the fact that this mutation in heterozygosis is quite common within the unaffected, getting to as much as 4% in some populationsThis paper stresses the importance of multidisciplinary diagnosis and the need of establishing closer ties between speech and hearing therapy and genetics to enhance the etiologic diagnosis and genetic counseling offered to hearing loss cases.


This paper presents an assistive hearing smartphone app mimicking the two main functions of hearing aids, consisting of compression and noise reduction. The app is designed to run in real time on smartphones or tablets. Appropriate levels of amplification or gain are activated by selecting a filter from a filter bank for six audio environment situations covering three sound pressure levels of speech and two sound pressure levels of noise. The results of this smartphone app for real-world audio environments are provided, indicating its effectiveness as a real-time platform for studying compression and noise reduction algorithms in the field or in realistic audio environments. According to the World Health Organization (WHO), the number of people with hearing loss will grow to nearly 2.5 billion people by 2050, with 700 million of them suffering from severe hearing loss . To copeConsidering the widespread utilization of smartphones all around the world, hearing aid manufacturers have introduced smartphone apps such as Signia, Starkey Thrive Hearing Control, and Oticon ON  for adjuHumans have a roughly 120 dB dynamic range of hearing. In people with hearing loss, this range is narrowed or reduced, and it is thus necessary to map the above wide range of sound into a narrower range. This process is referred to as wide dynamic range compression (WDRC). WDRC provides more gain for low-SPL (sound pressure level) signals and less gain for high-SPL signals. The compression can be represented graphically by an input/output compression function or curve for each frequency band. Speech sounds with SPL values of less than 55 dB are regarded as soft speech. Speech sounds with SPL values between 55 dB and 75 dB are regarded as moderate speech, while speech sounds with SPL values greater than 75 dB are regarded as loud speech [For operation in real-world audio environments, a voice activity detector (VAD) module is needed ,9. In thThe VAD module used in the app is based on the VAD approach described in ,13, provIn the filter selection part, the VAD value is used to separate noise-only frames from noisy speech frames. When a frame is pure noise and does not contain any speech, a variable called ‘NR_flag’ is updated for the purpose of deciding whether to enable the noise reduction module or not. When a frame contains speech with noise or no noise, a variable called ‘WDRC_flag’ is updated to see whether the speech SPL is soft, moderate, or loud. Then, based on ‘NR_flag’ and ‘WDRC_flag’, a so-called temporary filter selection is made for each frame. All temporary filter selections are saved in a buffer depending on the decision rate. The filter selection is performed by taking majority voting within the buffer.Six filters were designed for the three settings of WDRC_flag and two settings of NR_flag, as indicated in The WDRC or compression gain values are then generated based on a prescriptive compression fitting ,19. In oThe app has two main graphical user interfaces: one is the operation interface, and the other is the settings interface see . In the The code for the entire signal processing pipeline is written in C within a project shell described in , based oExperiments were conducted by running the app with a frame size of 256 samples at a sampling frequency of 48 kHz on an Android phone with a Snapdragon processor. To obtain the quantitative results reported in this section, audio files of real-world noisy audio environments were captured and stored on the phone’s storage. By running the app on the audio files, the filtered audio and a text file were generated, which contained the VAD, SPL, and selected filter values in the same folder where the audio file was stored. The filtered audio and text files were then used to report the results discussed next.Real-world audio files were captured at a 48 kHz sampling frequency in the presence of commonly encountered noisy environments, such as dining halls, lecture rooms, machinery, cars, streets, etc. To verify that the filter bank could perform the compression (WDRC) and the noise reduction (NR) properly, an experiment was conducted by considering only a single filter and by speaking the numbers 1 through 10 in a counting order with washing machine noise in the background. This allowed an easy separation between speech and background noise. As expected, the SPL of the audio signal increased because of the gain applied by the WDRC, and the noise level was decreased when the NR was activated.Furthermore, by comparing the effects of Filters 1 and 2, Filters 3 and 4, and Filters 5 and 6, which corresponded to situations with the noise reduction on and off, it can be seen that the SPL of the noise-only part was suppressed when the noise reduction was enabled. For the soft-speech audio, even though the speech was amplified by the WDRC, the SPL of the noise part was kept around the original level. For the loud-speech audio, due to the very small gain applied by the WDRC, the SPLs for both the speech and the noise were reduced considerably, which naturally impacted the quality of the speech signal. In all of the experiments carried out in various realistic audio environments, it was found that the compression and noise reduction were carried out according to the designed filters for those audio environments.For typical hearing improvement smartphone apps, the latency needs to remain below 20 ms ,24 in orIn this paper, a real-time smartphone app was developed to mimic the two key functions of hearing aids, consisting of compression and noise reduction. The developed app allows a smartphone to be used as a virtual hearing aid for the purpose of studying the compression and noise reduction functions of hearing aids in the field, or in realistic audio environments, noting that hearing aid manufacturers do not allow access to these signal processing modules on their hearing aids. The open-source nature of this app allows researchers and audiologists to study and experiment with different compression and noise reduction algorithms.


Charcot-Marie-Tooth disease (CMT) is one of a group of clinically and genetically heterogeneous polyneuropathies. The prevalence is 1:2,500. It is characterized by peripheral nerve degeneration, which results in distal muscle atrophy, loss of sensitivity, and hand and foot deformities; deep reflexes are also affected.A clinically distinct condition is the association of this disease with hearing loss, suggesting an abnormal expression on the PMP22 gene.The purpose of this study was to report a case of a patient with Charcot-Marie-Tooth disease, highlighting its importance in the differential diagnosis of hearing loss.A female patient aged 42 years complained of difficulties in understanding speech, especially in noise environments, developing within the last 2 years. An electromyography was done in 1992 because of pain associated with absent deep reflexes in the lower limbs, and valgus knees; this test revealed marked chronic mixed peripheral axonal-demyelinating polyneuropathy (sensitive and motor) in the four limbs, which suggested type 1 CMT disease.The pain progressed and affected the upper limbs and right shoulder; lower limb hypoesthesia, paresthesia and weakness were also present.The otorhinolaryngological physical examination was normal. Auditory thresholds were within normal limits. Acoustic immittance testing demonstrated type A tympanograms, and bilaterally absent ipsilateral and contralateral acoustic reflexes. Responses were bilaterally absent in the brainstem auditory evoked potential (BAEP) test. Otoacoustic emissions were altered, and an assessment of auditory processing revealed decoding disorders and non-verbal deficits.DNA studies of the patient and her parents (PCR and Southern blot methods) found no duplication or mutation on the PMP22 gene in the chromosome 17 (which explains most cases of type 1 CMT); these studies, however, do not preclude another form of CMT disease.Musiek et al.There is no single reported feature for hearing loss in CMT disease. Kovach et al.4 described sensorineural tests of limbs in a family, which ranged from normal results to profound losses. Papadakis et al.3 described a case of sudden hearing loss with profound bilateral sensorineural loss associated with CMT disease.As with our patients, several authors reported altered acoustic reflexes and abnormal BAEP, in which wave latencies were increased or absent.6Kovach et al.As our case had altered otoacoustic emissions, the diagnosis of auditory neuropathy did not apply; however, BAEP and otoacoustic emissions changes were probably due to demyelinated auditory pathways because of CMT disease.CMT disease is relevant in the differential diagnosis of sensorineural hearing loss, particularly if hereditary hearing loss is suspected. Specialists should be aware of the possible association between hearing loss and CMT disease, to support appropriate treatment for patients.


TCOF1 gene is mainly responsible for this condition. Here, we present a case of a 13-year-old adolescent girl with complaints of maligned teeth with conductive deafness. On clinical examination, she had retrognathia, a broad nose, maligned teeth, a high arch palate, and midfacial hypoplasia. On the basis of the clinical findings, a diagnosis of a mild-variant TCS was made as eyes were not involved and supportive treatment was given to the patient. The symptoms of the disease have a varying range of severity. Early diagnosis and supportive treatments, which include multidisciplinary treatment involving pediatrics, otolaryngologists, audiologists, orthodontists, and psychologists, are very important for the management of such cases.Treacher Collins syndrome (TCS) is a rare genetic disorder that affects craniofacial development due to malformation of the first and second branchial arches. The  TCOF1 as autosomal dominant, POLR1C as autosomal recessive, POLR1D as either autosomal dominant or autosomal recessive, and POLR1B as autosomal dominant. In 95% of the cases, TCOF1 is responsible for it. The diagnosis mainly depends on the clinical features, but confirmation can be made by genetic screening. Patients with less severe TCS are asymptomatic and rarely face any problems. They are retrospectively diagnosed after the birth of a child who has more severe TCS and is symptomatic [Treacher Collins syndrome (TCS) is a rare genetic disease, with 40% family history and 60% de novo mutations. The incidence rate is about 1 in 50,000 live births worldwide . Some ofptomatic .Here, we report a 13-year-old adolescent girl who was diagnosed with a case of TCS based on clinical examination when she consulted us for malaligned teeth.A 13-year-old adolescent girl who was born out of nonconsanguineous marriage was presented to the hospital with complaints of forward-placed teeth of the upper jaw along with mild hearing loss Figure . When thTCOF1, which is located on chromosome 5q31.3 32 and codes for the protein serine or alanine-rich nucleolar phosphoprotein necessary for the development of craniofacial, is the critical gene causing this condition [TCS is a very uncommon developmental disorder affecting 1 in 50,000 live births. Of the total cases, 60% take place as de novo mutation, whereas 40% as familial [Franceschetti and Klein explained some of the features associated with this syndrome as a downward slanting of the palpebral fissure with either a notch or coloboma of the lower eyelid; hypoplasia of malar, mandibular, and zygomatic bones; abnormal formation of the external, middle, and internal ear; high palate and malposition of the teeth; and some other features such as cleft palate and ears . HypodonTCS is a developmental disorder with characteristic features of craniofacial malformation. The patient typically presents with facial deformities, which range in severities. Early diagnosis of the disease is essential to treat the patient and conduct genetic counseling. Although there is no exact treatment for this condition, symptomatic relief can be provided with a multidisciplinary approach and supportive treatment.


Created in 2007, COMUSA is a multiprofessional committee comprising speech therapy, otology, otorhinolaryngology and pediatrics with the aim of debating and countersigning auditory health actions for neonatal, lactating, preschool and school children, adolescents, adults and elderly persons. COMUSA includes representatives of the Brazilian Audiology Academy (Academia Brasileira de Audiologia or ABA), the Brazilian Otorhinolaryngology and Cervicofacial Surgery Association , the Brazilian Phonoaudiology Society (Sociedade Brasileira de Fonoaudiologia or SBFa), the Brazilian Otology Society (Sociedade Brasileira de Otologia or SBO), and the Brazilian Pediatrics Society (Sociedade Brasileira de Pediatria or SBP). Because more hospital units are implementing universal neonatal auditory screening programs (UNAS), because state and city laws are being approved, because questions have been sent to entities by their associate members, and because of federal and state funded research in neonatal auditory health, the abovementioned entities have decided to publish advice on UNAS as a guideline for professionals.Hearing develops in increasingly complex stages from intrauterine life onwards. For a child to acquire language and develop speech, he or she should be able to detect, locate, discriminate, memorize, recognize, and finally understand sounds.The central nervous system is very plastic when stimulated early, before 12 months of age, which increases the number of nerve connections and improves the results of auditory rehabilitation and language development in children with hearing loss.There are several causes of congenital hearing loss, which is acquired prenatally of within the first days following birth. Genetic recessive inherited auditory system damage, which causes hearing loss not associated with any syndrome, is the most frequent cause of hearing loss reported in developed countries; it generally is expressed early, before language develops. Other than heredity, the most common causes of congenital hearing loss are due to very low birth weight , hyperbilirubinemia, congenital infection such as rubella, toxoplasmosis, cytomegalovirus, syphilis, and neonatal use of ototoxic drugs. Children with head and neck malformations and and/or syndromes that include hearing loss may also be affected. It is common for such hearing loss risk factors to be associated among neonates, especially if they remain in neonatal ICUs for over five days.It is not uncommon for the cause of hearing loss to remain unclear; hearing loss is idiopathic is about half of neonates. As such, selective neonatal auditory screening done only in children selected for hearing loss risk factors identifies about 50% of hearing loss patients.In developed countries, sensorineural hearing loss affects one in every 1,000 newborns; 40% are due to hereditary factors, 30% are due to a variety of acquired conditions, and 20% are of unknown etiology.A study of 200 children and adolescents by the Sao Paulo Federal University (UFSP) in 1998 revealed that diagnostic confirmation of hearing loss within the optimal neuronal plasticity phase – up to age 2 years – was made in only 13% of cases, even though parents had suspected hearing loss in 56% of cases in this age group. Time wasted – over two years – between suspected and confirmed hearing loss occurred in 42% of cases, underlining the need for rethinking our health care model.Early functional and etiological diagnosis of hearing loss and prompt medical, phonoaudiological or surgical interventions minimize the effects of hearing loss in children.Guidelines published in the US by the National Institutes of Health•Permanent hearing loss is a major public health issue; satisfactory results may be attained with treatment if interventions take place within the first months of life;•Effective methods are available in clinical practice to identify hearing loss; these methods include recording evoked otoacoustic emissions (EOAE) and the brainstem auditory evoked potential (BAEP);•Neonatal auditory screening only of newborn babies at risk of hearing loss has been suggested as a lower cost strategy; it may, however, not identify about 40–50% of children with permanent hearing loss;•UNAS is only the first step of a neonatal auditory health program; diagnostic and rehabilitation measures should ensue.UNAS was recommended in Europe in 1998 in a consensus signed by several countries at a scientific event for this purpose. Below are the justifications for implementing UNAS:In Brazil, the first multiprofessional guidelines on auditory health in children were published in 1995, the result of a workgroup that was organized in the X International Audiology Meeting . The debate forum on “Hearing in Children” made recommendations for auditory healthcare in children, focusing on joint and multiprofessional actions in the public and private spheres to promote and protect auditory health. This document suggests early identification, diagnosis and rehabilitation according to the principles of integral healthcare for children.The Universal Neonatal Auditory Screening Support Group (GATANU) was created in Brazil in 1998; its aim was to disseminate and sensitize society to the need for an early diagnosis of deafness.In 1999, the Brazilian Committee on Hearing Loss in Infancy (CBPAI), composed of speech therapists, otorhinolaryngologists and pediatricians, published guidelines on the need for identifying hearing loss in neonates and implementing the UNAS, preferably before the children were discharged from hospital. Auditory screening was recommended within three months of age for those born at home.o 05/00, which suggested implementing auditory screening in neonates using objective methods published in medical literature, such as evoked otoacoustic emissions (EOAE) and the brainstem auditory evoked potential (BAEP). The recommendation also points out the required steps and the need for multiprofessional teams if a further diagnosis is required.In 2000, the Federal Board of Phonoaudiology published the Recommendation CFFa. nThus one can state that Brazil, for over the past 10 years, has carried out actions to underline the importance of identifying and treating hearing loss at an early age.Several city and state laws making UNAS compulsory in maternity hospitals have been passed in Brazil. However, it is clear that few public maternity hospitals have a systematic UNAS program.By screening we mean a simple, quick and low cost process to identify children at a higher probability of having altered auditory function. Children that do not pass the screening tests should be referred for more complex diagnostic procedures.The following principles should be applied during screening procedures: the prevalence of the disorder being tested should justify universal screening; screening procedures should be sensitive and specific; diagnostic and treatment resources should be available; cost should be compatible with the desired effectiveness; this actions should be accepted by healthcare professionals and the population.1All neonates should have priority access to UNAS with physiological measures within the first month of life;2All children with unsatisfactory test and retest UNAS results should have access to diagnostic measures to confirm hearing loss within three months of life;3All children with confirmed permanent hearing loss should start treatment and intervention measures after diagnosis within six months of life;4Interventions should include family and caretaker participation, respecting the rights of child and family, confidentiality, and the current ethical and legal requirements;5Children and their families should have prompt access to high quality and high complexity technology, such as sound amplification hearing aids and cochlear implants, as well as other support devices, whenever applicable;6All normal hearing children should have their hearing, language development and communication ability monitored, even in the absence of hearing loss risk factors, by duly trained professionals:7Children with permanent hearing loss and their families should be followed-up by experienced interdisciplinary teams in the care of children with hearing loss:8Computer database systems should be generated to monitor the results and effectiveness of identification, diagnosis and early intervention measures for hearing loss in neonates.The most recent international publication containing guidelines for UNAS was published in 2007 by the Joint Committee On Infant Hearing;The Joint Committee on Infant HearingThe Joint Committee on Infant Hearing (2007)For neonates with hearing loss risk factors, especially those admitted to neonatal ICUs, the Joint Committee on Infant HearingProfessionals who implement, coordinate or work, teach and research the UNAS are encouraged to read the Joint Committee on Infant Hearing (2007)The US Preventive Services Task Force published similar guidelines in July 2008 for carrying our UNAS with EOAE or BAEP-A testing to identify 30–40 dB hearing losses; in this case, the process may include two steps (EOAE followed by BAEP-A) to improve sensitivity (0.92) and specificity (0.98). Auditory screening in neonates should be done on the first day of life, preferably before the newborn is discharged from hospital. This particular North-American publication describes studies showing the strong contribution of UNAS for early diagnosis and intervention and the reliability of objective tests. Further publications on studies demonstrating the results for language development in children identified by applying the UNAS.Recent published studies have attempted answer language developmental issues in children with identified, diagnosed and treated conditions within the first months of life; it appears that such evidence is being demonstrated.Authors who have shown that this population group had a higher rate of retrocochlear hearing loss – not identifiable with EOAE recordings – have suggested using BAEP-A in the UNAS of higher risk children. The auditory neuropathy spectrum falls within this situation. Thus, low birth weight children, which generally present other associated risk factors, and those admitted to neonatal ICUs, may require BAEP-A in the UNAS, because of increased synergy among risk indicators. Studies have shown that hearing needs to be monitored in these children because of the possibility of late onset hearing loss or the progression of hearing losses diagnosed at this initial point.The techniques and protocols are being described to reduce the number of false positives in UNAS. Use of EOAE and BAEP-A recording in different steps has shown a positive effect. Studies have shown that using EOAE as a first step, followed by BAEP-A as a second step, significantly decreases the number of neonates referred for diagnosis when there is initial failure of hearing.Although genetic congenital hearing losses are important, particularly those involving ConexinThe epidemiology of hearing loss in children in Brazil requires further study in order to put in effect preventive measures. There are few data on the determining factors and prevalence of hearing loss in neonates. UNAS may help provide prompt interventions in children with hearing loss and foster appropriate public policies for this age group.The National Policy for Auditory Healthcare is available in most of the country; there are 127 auditory health reference centers, of which 80 are high complexity units able to care for neonates with specialized diagnostic needs and to select and provide sound amplification hearing aids and speech therapy. Maternity hospitals with auditory health reference units for diagnosis and medical and phonoaudiological interventions may already implement neonatal auditory screening.1•Promote the health of pregnant women, neonates and lactating children;•Prevent hearing loss by applying specific measures to be put in place following epidemiological prevalence and determinant factor studies on hearing loss in neonates;•Identify hearing loss by auditory screening with sensitive and specific methods; electrophysiological measures are recommended  and/or electroacoustic methods (recording evoked otoacoustic emissions – EOAE – by transient or distortion product stimuli);•Make available referral for medical and audiological diagnosis and laboratory tests, as needed; imaging and genetic evaluation may be required;•Make available medical treatment and speech therapy, including the selection and indication of individual sound amplification hearing aids, cochlear implants, and family support, as needed;•Make available high quality technology, assuring adequate treatment for a good development of hearing, language acquisition, and consequently, educational and social development in children with hearing loss;•Medical care and speech therapy should respect the needs and choices of parents or caretakers of neonates, offering different scientifically and technologically supported approaches and methods.A neonatal auditory health program with all prevention, diagnosis and hearing loss rehabilitation measures should be implemented, as follows:2Implanting a universal neonatal auditory screening program (UNAS), for all neonates preferably before being discharged from hospital.3For home births, out of hospital environments, or in maternity hospitals that are still implementing universal auditory screening, tests should be one within the first month of life.4It is suggested that strategies for implementing UNAS in all maternity hospitals be written. Meanwhile, sites for carrying out auditory screening within the first months should be defined.5Implementation of a UNAS program may be gradual in order to better organize the necessary actions. The goal for implementing auditory screening universally, however, is three years.6It is suggested that a dissemination/information plan about this action for neonates be written during implementation of neonatal auditory screening, for both healthcare professionals and the general population, so that the importance of UNAS and its methods be widely known among the population.7It is suggested that every hospital with a neonatal auditory screening program should elect a maternity hospital coordinator for this action, such as a neona-tologist, or otorhinolaryngologist or speech therapist with proven experience or specialization in audiology. In smaller municipalities or hospitals that are unable to elect such a coordinator, it is recommended that implementation of a neonatal auditory screening program be carried by a healthcare professional supervised and supported by a coordinator from another hospital with experience in implementing UNAS. Scientific societies that undersign this document are ready to provide further information to their associate members about implementing a UNAS, helping supervise and legitimatize these programs.8It is suggested that parents/caretakers receive explanations about the importance of UNAS, and that they be asked to sign a free informed consent form for the test, or a term of responsibility if they refuse the test. Furthermore, it is suggested that parents/caretakers sign upon receiving the results of tests and orientation before the neonate is discharged from hospital, for both normal and altered tests. All test results (test and retest) should be provided in printed form to parents/ caretakers.9For neonates with no indicated risk of hearing loss, the recommended method for UNAS is the transient or distortion product stimuli evoked otoacoustic emissions (EOAE) test. Its purpose is to identify cochlear hearing loss up to 35 dBHL. It is a low cost easily applied test, added to which this neonate population group has a low prevalence of auditory neuropathies.10Because of false negatives due to vernix in the outer ear in the first days of life, a second evaluation is recommended within 30 days of hospital discharge in all cases of absent  EOAE, even if in one ear only. At this visit, both ears should be retested, even in test failure occurred in only one ear during the first test.11Cases where EOAE testing fails should undergo automatic BAEP (BAEP-A) before being discharged from hospital and/or when being retested. This measure aims to reduce the number of unnecessary referrals for diagnosis. Normal BAEP-A responses in both ears should be considered as satisfactory screening results. However, parents or caretakers should be informed that if hearing difficulties arise or are suspected, an auditory healthcare reference unit should be sought immediately.12If within 30 days screening tests fail, the patient should immediately be referred for a full otorhinolaryngological medical and phonoaudiological diagnosis. A diagnostic team consisting of otorhinolaryngologists and speech therapists should have experience in evaluating neonates and lactating children.13For neonates with normal tests, orientation on the care of auditory health should be given, as well as a table for monitoring the development of hearing abilities and language, so that these may be observed within the family.14A copy of the test and relevant annotations should be annexed to the child's records, including the data and signature of the healthcare professional in charge of the UNAS process, in the case of normal or altered tests, and with their referrals, if applicable.15For neonates with risk indicators of hearing loss, BAEP-A testing at 35 dBHL is recommended as the initial screening method. This method makes it possible to diagnose cochlear, retrocochlear, and sensorineural conditions, including the auditory neuropathy spectrum, which are more prevalent in the higher risk population. EOAE testing may be associated with BAEP-A, given the risk of more unsatisfactory results because of middle ear changes, but not because of permanent sensory hearing loss.16If BAEP-A recording are absent in the initial test of neonates at risk for hearing loss, it is recommended that these patients be referred to diagnostic units immediately, without retesting, as described for other neonates.17All test results should be given to parents or caretakers, and annotated in the child's health report and hospital records; parents or caretakers should sign an appropriate form or terms upon receiving the referrals, results and orientation.18For neonates with risk indicators of hearing loss and satisfactory BAEP-A testing during screening, auditory function should be monitored by a trained professional until the third year of life.19•Parental concern with child development with regards to hearing, speech or language;•History of permanent deafness cases in the family starting during infancy, and therefore considered a hereditary risk. Consanguinity cases should be included here;•ICU stay for over five days, or the occurrence of any of the following conditions, regardless of the duration of ICU stay: extracorporeal ventilation, assisted ventilation; exposure to ototoxic drugs such as aminoglicoside antibiotics and/or loop diuretics; hyperbilirubinemia; severe perinatal anoxia; neonatal Apgar score from 0 to 4 in the first minute or 0 to 6 in the fifth minute; birth weight below 1,500 grams; preterm birth, or low weight for the gestational age;•Congenital infections ;•Craniofacial anomalies involving the ear and temporal bone.•Genetic syndromes that usually express hearing loss ;•Neurodegenerative disorders ;•Postnatal bacterial or viral infections such as cytomegalovirus infection, herpes, measles, smallpox, and meningitis;•Cranial trauma;•Chemotherapy.The main hearing loss risk factors described in the specialized literature included any of the following factors, and are therefore listed in these guidelines:20It is suggested that a computerized database on auditory neonatal auditory screening be made so that the coordinator may monitor the results monthly, and as a tracking tool for cases that may be lost to follow-up, or that did not conclude all the necessary retest or diagnostic steps. Software is available, and other computer programs may be written by the information technology teams of states and municipalities.21•Screening indices over 95% of live births, with attempts to reach 100% of live births;•Screening tests should be carried out within the first month of life;•A less than 4% rate of neonates referred for diagnosis;•Quality indicators in the diagnosis phase are the visit rates upon referral for diagnosis; 90% of referred neonates should be present and the diagnostic visit, and should have been diagnosed by three months of life;•It is suggested that 95% of lactating babies with confirmed permanent bilateral hearing loss should initiate use of sound amplification within one month of the diagnosis.Monthly, quarterly and annual reports should be made to help monitor the development of the neonatal auditory screening program, quality control, and tracking information. The same quality control metrics used in the auditory screening program of the Joint Committee on Infant Hearing (2007) are recommended:After analyzing the literature of data showing evidence on the identification, diagnosis and early intervention in neonates and lactating children with hearing loss, COMUSA recommends:COMUSA DOES NOT RECOMMEND including genetic screening to identify hearing loss-related genetic abnormalities at this point in time, because of the need to investigate the cost, effectiveness and feasibility of genetic studies in maternity hospitals.Implementing a UNAS program is only meaningful if after its completion a correct diagnosis is made and auditory rehabilitation processes and language development are implemented in sequence.


When we hear a song, when we attend a class or when we talk to someone, countless processes are triggered in order to enjoy the melody, understand what is being explained by the speaker or listen to a conversation and developing an answer. Over the full 24-hour period we are exposed to multiple auditory informations most of them happen simultaneously and our auditory system is responsible for identifying the messages we are interested in, reducing or canceling the interferences which only serves to prevent the comprehension. The performance of these tasks count on central nervous system activity and it is called auditory processing (AP), which refers to the efficiency and effectiveness by which the central nervous system is able to use auditory information. In other words, AP is a specific set of skills a person depends on to understand what he/she is hearing.These abilities include sound localization, speech recognition in noise, auditory performance with degraded or distorted acoustic speech signals, auditory performance in competing acoustic signals (including dichotic listening), temporal aspects of audition such as identification of brief and rapidly successive acoustic changes in frequency, intensity or duration.These skills are extremely important in a classroom, for example, where the student must focus attention on what is been said by the teacher and ignore any stimulus that may negatively interfere with listening: conversations between colleagues, chair dragging sounds, steps in the hallway, the fan noise, horns in the street or yelling in the schoolyard. The child with proper functioning of the central auditory nervous system will easily understand the teacher; while those with AP disorders may have difficulties to understand what is being said - which can negatively impact the learning process.In normal speech, auditory information reaches the nervous system in a very quick succession. Each information processing must happen in few milliseconds in order that we can understand the meaning. A child with temporal AP disorder may have developmental language disorders and learning disabilities. This happens because the discrimination of syllables such as /ba/, /da/, /ga/, /pa/, /ta/, /ka/ should occur in the first 40 milliseconds, which is a period of time too short for those who have difficulties to detect brief acoustic stimuli.These difficulties can occur at any age and it is assumed that long standing hearing loss is one of the main causes. Much has been published about AP changes due to otitis media, mainly when it occurs during the first two years of life, but we cannot forget that the elderly, as they lose their hearing slowly as they age, may also have difficulties to understand speech, even while using an appropriate hearing aid, if they were fitted long after the hearing loss onset.Over the past 20 years there has been a huge progress in neurosciences, which has also been reflected in a better understanding of the AP. Knowledge of the location of the regions involved in the processing of speech, language and learning became more accurate thanks to positron emission tomography and functional magnetic resonance imaging. These new technologies, used primarily by researchers, have also identified areas that decode auditory information, the areas that make the phonological, lexical and semantic analysis, as well as the areas that produce the answers. Electrophysiological tests such as ABR, EEG, P300 and magnetoencephalography can measure the time of transmission and processing of such information in the range of milliseconds.A battery of behavioral tests with high sensitivity and high specificity helps identify the skills affected and program specific management strategies geared to the problem of each patient.Conventional audiologic evaluation does not reflect the daily life of a classroom, an office, a business meeting, a conference or a party. This may have been the reason for the difficulty we still have to date to help patients who report difficulties in understanding speech and who have normal, or very close to normal, audiometric values. Whenever a patient has complaints which do not match his hearing thresholds, we should consider expanding our investigation using the available diagnostic methods.