Hearing loss can be caused by a number of different pathological conditions. Some of them can be successfully treated, mainly by surgery, depending on the individual’s disease process. However, the treatment of chronic sensorineural hearing loss with damaged cochlear structures usually needs hearing rehabilitation by means of technical amplification. During the last two decades tremendous improvements in hearing aid technology led to a higher quality of the hearing rehabilitation process. For example, due to sophisticated signal processing acoustic feedback could be reduced and hence open fitting options are available even for more subjects with higher degrees of hearing loss. In particular for high-frequency hearing loss, the use of open fitting is an option. Both the users’ acceptance and the perceived sound quality were significantly increased by open fittings. However, we are still faced with a low level of readiness in many hearing impaired subjects to accept acoustic amplification. Since ENT specialists play a key-role in hearing aid provision, they should promote early hearing aid rehabilitation and include this in the counselling even in subjects with mild and moderate hearing loss. Recent investigations demonstrated the benefit of early hearing aid use in this group of patients since this may help to reduce subsequent damages as auditory deprivation, social isolation, development of dementia, and cognitive decline. For subjects with tinnitus, hearing aids may also support masking by environmental sounds and enhance cortical inhibition. The present paper describes the latest developments of hearing aid technology and the current state of the art for amplification modalities. Implications for both hearing aid indication and provision are discussed. Up to now it is not possible to curatively treat the causes of (chronic) inner hear hearing loss and the associated impairment regarding communication and thus also reduced quality of life and participation in social life. So rather rehabilitative approaches are available for therapy.Hearing loss can be compensated, even corrected, but only rarely hearing can be completely restored. At best, recovery – often also complete – is possible after an acute stage of sudden hearing loss or after noise-induced trauma. However, it can only be expected if therapeutic steps are undertaken to enhance this recovery; the current data situation does not confirm this assumption . So the According to a current review article from Singapore , causal A conceivable option would also be a therapy of inner ear hearing loss with stem cells in order to increase the population of functional neurons that are often reduced in cases of longer-lasting hearing loss and only allow moderately successful cochlear implantation .Only for the application of stem cells in the treatment of hearing loss, a review article  found 45In their current review of 2014, Géléoc and Holt  try a veSoberly speaking, most of the articles on gene therapy only describe possibilities and discuss research projects. Actually, the development of therapeutic approaches that might be applied protectively for noise exposition or support cochlear implantation, seems to be more probable than the possibility to completely replace the damaged structures of the inner ear.Even if causal therapy of inner ear hearing loss cannot be expected for the near future, there are several possibilities have been developed to compensate hearing loss and they have been definitely improved due to new technologies. Furthermore, there are extensive publications on hearing aids  an) an9]) aStill 15 or 20 years ago, most of the adapted (better) hearing aids were products to be used in the ear with the claim to be mostly invisible and to thus avoid stigmatization. Nowadays, modern hearing aids are openly adapted behind-the-ear versions with a visible device and an integrated microphone. This makes wearing hearing aids more comfortable because the “occlusion effect” caused by the closure of the auditory canal, is avoided and especially the high frequencies are effectively amplified. Since most of the inner ear hearing impairments, especially in older patients, start in the high-frequency ranges, an effective high-quality regeneration is possible. Only in cases of more severe hearing loss or hearing impairment in the deep frequencies, individually adapted otoplastics are required to achieve sufficient amplification. However, even for those devices the wearing comfort can be significantly increased via vents due to available modern noise suppression.Nonetheless, the care for hearing impaired people is rather poor – and not only in Germany Figure 1 . Often, Nevertheless, hearing aids should be recommended and prescribed as early as possible in order to prevent deprivation of the hearing pathway and especially of the auditory cortex (for further information see chapter 12. Excursion: Hearing loss and dementia).In the context of a large epidemiologic study in the USA (Beaver Dam Offspring Study) performed between 2005 and 2008, 3285 patients with an average age of 49 years were questioned about hearing aids and their usage : 34% hadA very interesting study from Giessen  evaluateIn a study from Florida, a new test battery could again demonstrate the superiority of binaural provision of hearing aids that – according to the applicable regulation from 2012 – is the general rule in Germany . SignalsIn an evaluation study from Israel on the use of hearing aids, the superiority of modern digital hearing devices was described. 177 hearing impaired adults were provided with such a hearing system and questioned about their satisfaction. 74% participated in the interviews, 83% of them used their hearing aids regularly, 17% did not. Among the users, 92% were satisfied. The patients who did not wear their hearing aids, complained about too high amplification of background noises and only poor hearing gain. The authors require better information about a usage of the hearing aids as regular as possible and training of special hearing situations . Furthermore, good information improves the acceptance of hearing aids, as confirmed by an investigation from Portland, Oregon. For this study, 60 first users of hearing aids were randomly assigned to 3 groups. They received information and consultation of different intensity and elaboration. The more intensive the consultation was with regard to specific hearing situations, the better was the acceptance of the hearing device. It was also important to discuss unrealistic expectations to hearing aids and to emphasize positive aspects .Patients should be informed very realistically with regard to what can be achieved with hearing aids and where the limits are. Hearing and audio-therapy should ideally accompany hearing aid provision and train specific hearing situations with the hearing device .For the statutory health insurances, the indications of hearing aids is based on the respective paragraph dated April 1, 2012, of the Federal Ministry of Health, that was lastly revised on December 17, 2015. According to those regulationssurgical hearing improvement should not be possible,the tone audiometric hearing loss in the better hearing ear should be at least 30 dB in at least one of the test frequencies between 500 and 4000 Hz, andspeech audiometry should reveal an understanding in the better hearing ear with headphones in the Freiburg monosyllabic test of not more than 80% at 65 dB,the patient should be sufficiently cooperative.Also the treatment of unilateral hearing loss is possible according to the current guideline; the same criteria apply for hearing loss and speech understanding (in the Freiburg monosyllabic test) as for bilateral hearing loss.The new guideline provides that the statutory health insurances pay for such hearing devices that are able to compensate the functional deficit of the hearing impairment based on the most recent stage of medical engineering. If possible, speech understanding even with background noise and larger groups of people should be achieved. This decision is based on a decision of the Federal Social Court of Germany dated December 17, 2009, emphasizing the objective that hearing aids have to ensure in the context of an entitlement of benefit.Another modification of the guideline came into effect on October 29, 2014 . Since tchildrenhearing loss close to deafness (WHO-4)newly occurring tinnitusFrom an ENT-specific point of view as well as from the point of view of associations of affected people, these facts are certainly unsatisfactory because even hearing deteriorations of 5 or 10 dB have to be examined medically and not only be cared for with new hearing aids by hearing care professionals.Finally, those modifications rather have the purpose – as often observed in healthcare – to limit costs, which generally cannot be in the sense of the patients.In this context, a recent study was published that evaluates the effect of this “reform” on the quality of care: 859 insured people of a statutory health insurance (HHK) were questioned before the reform and 622 were interviewed afterwards. The percentage of those who had to pay own contributions, decreased by 6% (from 80.6 to 74.1%), however, still 40% of the patients paid a contribution of more than 1000 Euro. No improvement of the subjective hearing quality could be assessed, neither of the individual duration of usage. According to the authors’ opinion, the “reform of the hearing aid provision” did not change the lack of compliance of the patients .In an extensive educational article, Löhler et al. describe in 2 parts the current and newly developed process of hearing aid prescription in the German healthcare system , 19]. W. W19]. WFor patients suffering from recognized noise-induced hearing loss with and without tinnitus who are insured via the professional associations, the hearing aid provision has significantly improved due to a new contract between the German Statutory Accident Insurance  and the Federal Guild of Hearing Care Professionals . It exceeds also the regular services of the statutory health insurances. Furthermore, there are 3 categories while the (expensive) category 3 should be the absolute exception. In this contract, also the individual hearing protection is defined. Details have been described by Michel, Wolf, and Brusis .In comparison to most of the other European countries as well as the USA, there is the particular situation in Germany that hearing aids are  prescribed by ENT specialists, but the concrete fitting is performed by hearing care professionals, in rare cases also in ENT departments (mainly in children). The profession of hearing care professional is learned in an apprenticeship (apprentice – assistant – foreman) with an excellent education regarding technique and hearing aid setting, however, completely without therapeutic aspects or authorization. In other countries, hearing aids are either issued and adapted directly by ENT specialists or – even more frequently – by audiologists, which means professionals who are specially trained for the therapy of hearing impaired patients. An advantage of the German proceeding is certainly the high competence in technical equipment and the – at least theoretical – usage of the whole multitude of products even if they are increasingly limited by mechanisms of concentration and market control finally even of the hearing aid manufacturers themselves. In particular forced by the professional association of ENT specialists and accompanied with special courses and additional trainings, the above-mentioned quality control systems are thus very important to control and to verify the provision of hearing aids. Efforts of hearing care professionals to present themselves for example by issuing own “guidelines” as competent also regarding the treatment of hearing impaired and tinnitus affected people, are certainly a wrong and inacceptable way.With regard to the still missing and insufficient care for hearing impaired people, associated with poor acceptance, social stigmatization, and often too high expectations in hearing aids, it is only possible to improve the situation of the increasing number of hearing impaired people by competent and quality-oriented efforts of ENT specialists, of course in constructive cooperation with hearing care professionals.In other countries, however, the possibility of hearing aid provision via internet is already investigated. A study from New Zealand enrolled 18 people who were all experienced hearing aid users. They were cared for in this way and then interviewed . The onlOften sweating causes problems for hearing aid users. Skin reactions may develop, the devices may fail because of increased sweat production; in summary, the wearing comfort is impaired. This is also a reason why hearing aids are often not used during sports. A possible solution regarding those side effects of hearing aid usage is reported from Göttingen : Two casAstonishingly, a retrospective study including 164 patients of several audiological departments from England and India came to the conclusion that there is no correlation between cerumen production and density in hearing aid users compared to patients without hearing aids .The data situation on the assessment of hearing aid usage especially in older hearing impaired people is rather poor, as confirmed by a meta-analysis from England. 1933 studies were found of which only 64 were selected and evaluated. Only 5 articles were considered as having a sufficient quality, a total of 15 different assessment methods were found for the usage of hearing aids. The authors urgently request better methods for data collection regarding the use of hearing aids .A survey of 1,000 hearing impaired patients in Harvard revealed that only 22% of them used hearing aids. Patients who could achieve an improved speech understanding with hearing aids, had a device in 50% of the cases. Only 0.3% of the patients who did not achieve better understanding used hearing aids. The authors postulate that the word understanding is the crucial argument for purchasing hearing aids . It is noteworthy that standardized instruments for assessment of hearing aid use and satisfaction are missing. So each study group develops its own procedure in all different parts of the world, really reliable investigations revealing high evidence are rare.New epidemiological data still show a poor acceptance of hearing aids, in particular for older people. In the USA, data were compared from 2005 to 2006 with those from 2009 to 2010. A representative sample of 1,636 hearing impaired people older than 70 years were interviewed regarding the provision of hearing aids and the actual usage. Only one third of the hearing aid candidates regularly used the device. In the group that was evaluated later (2009–2010) this percentage was higher. A higher income was related to an increased number of patients who actually used their hearing aids. Regarding gender and further age differentiation, no significant differences were found .In a population-related prospective evaluation from 1993 to 2005 , 718 parA comparable study from Australia , also poHereby, older bilaterally hearing impaired people often used only one hearing aid, even if the binaural provision should be the general rule. As a consequence of this unilateral deprivation, the ability of dichotic hearing significantly decreased. 30 older users of hearing aids (60–81 years) who used only 1 hearing aid, mostly on the right side, could not fulfill the dichotic test items at 100%. 94% only used one hearing aid because 2 devices were perceived as too loud and disturbing, 6% had esthetical reasons . HoweverAnother study interviewed and examined 30 older and socially active persons on the same topic. 63% had an audiometric hearing loss but only 32% were aware of it. 93% found that hearing aids were too expensive. The authors conclude that socially active older people are frequently aware of their hearing loss but do not want to use hearing aids .In England, 1,874 hearing aid users were asked to fill out a questionnaire; 29% did not regularly wear the hearing aid, especially first users tended to a rather temporary use of their hearing device. Partly only one hearing aid was used despite binaural provision .5,172 older hearing impaired people were evaluated in an investigation from Iceland; only 23% of the male and 15.9% of the female patients used hearing aids. One positive aspect was observed that when people admitted to have a hearing loss, they usually used hearing aids. Women more frequently used hearing aids when they were physically and communicatively more active .The age reduces the hearing improvement in speech understanding. Among 188 patients, the understanding of speech and monosyllables was clearly poorer in 20% of the group of the older people .In this context, directional microphones may help in particular older hearing aid users (n=15) to improve sentence recognition in noise. An efficient suppression of background noise, however, is not sufficiently achieved, as confirmed by a study from Texas .The significance of the age in hearing aid provision was evaluated in 59 patients who had digital hearing aids because of their hearing loss. Hereby, the speech intelligibility and the discrimination were improved in the 65 to 80 year-old people as well as in patients older than 80 years .An interesting article from Toronto evaluated the ability of older patients to operate a hearing device considering especially their dexterity. 20 patients of each age group  were asked to operate a BTE hearing aid. Additionally 28 older patients suffering from arthritis and 28 older patients without joint problems were compared regarding the handling of different controls of the hearing aid. In the first comparison, relevant differences were observed in the age groups but also the test persons with arthritis managed rather well the second experiment and their basic performance regarding the handling was not poorer compared to patients without arthritis. In summary, also older patients were able to operate the hearing aid adequately after training .In a study from Norway, 174 patients of a waiting list of 193 persons for hearing aid provision were asked about their expectancies regarding the hearing aid . The patAn investigation from Switzerland evaluated 4,979 male and 3,410 female hearing aid users in order to find out how and how long they used their hearing aids per day . Women uIn Germany, only about 10–15% of the people who actually would need hearing aids (percentage taken from the report of the Green Cross ) are proOne reason for this poor situation regarding hearing aids for compensation of hearing loss  might beEspecially because hearing in noise is most severely impaired , an optiENT-specific diagnostics are obligatory in Germany at least before first fitting of hearing aids. In general, it ends up with the above-mentioned indication for hearing aid provision and the prescription of one or two hearing aids. The main objectives of hearing diagnostics are the determination of the severity, i.e. the quantification of an existing hearing loss, and the identification of the origin, i.e. the localization of the hearing impairment.The most important examination methods in this context are tone and speech audiometry measured with the Freiburg monosyllabic and number test. For both aspects, the measurement results have to be noted in a form issued by the statutory healthcare services. In this way, the type of damage (sensory hearing loss or conductive hearing loss) and the severity of the hearing impairment can be directly identified as frequency-related hearing threshold. The statutory health insurances refer to the above-mentioned indication criteria regarding tone and speech audiogram. Exceptions – for example low-grade hearing impairments – require extensive explanations and justifications.To confirm and objectify subjective audiometry, objective measurements such as impedance audiometry (tympanometry and stapedius reflexes), the measurement of otoacoustic emissions (OAE) and the electric response audiometry  may be applied. They are highly relevant for pediatric audiological hearing diagnostics, but also in the context of aggravation, simulation, and dissimilation and in patients who do not sufficiently speak the (German) language. Objective audiometric measurements are furthermore important tools for the localization of hearing disorders. So they should always be performed in cases of suspected retrocochlear damage or central lesions. Another differential diagnostic questions concerns the confirmation of auditory synaptopathy/auditory neuropathy . Hereby, regular OAE may be measured even in cases of high-grade hearing loss while the brainstem potentials in BERA completely miss or are suspect. The prevalence was estimated as rather low in the past, but recent evaluations especially of high-grade hearing losses in children confirm case numbers in a range of some percent .The quantification of the hearing impairment can be assessed by questionnaire inventories. The severity of the impairment by hearing loss gives first hints to the later usage of hearing aids and can thus be applied to answer the question if the patient is ready to use the device as it is explicitly required by the guideline on hearing aids. Beyond basic care, the provision of hearing aids for minimal hearing losses is increasingly discussed , 49]. D. D49]. DAlready a hand held behind the ear amplifies sound signals in the frequency range of 1–2 kHz and 6–8 kHz of up to 16 dB . Beside th century, the first pocket hearing aids were developed on the basis of electronic tube amplifiers. The implementation of transistor technology in the 1950ies and later of the integrated circuits (IC) rapidly led to further improvement of the amplificatory performance and the size reduction of the devices . T. T68]. THNO ..83].In summary, the statements about the benefit that hearing impaired people have from hearing aids, are rather contradictory. From the high number of the studies of the last 2 years that were presented here, the evaluations and results show again the necessity to assess the data in a more systematic and exact way. With the APHAB questionnaire applied in Germany, we have an excellent base that will certainly generate new knowledge due to the increasing database. Already now it can be stated that the provision can and must still be significantly optimized, but that also control and follow-up have to be intensified. It is especially important to inform hearing aid users before fitting in order to assess and correct the individual expectations, in particular when they are unrealistic after concrete hearing loss. Perhaps, also the technology of hearing aids may be more efficiently improved by the assessment of always more patient feedback.During the last years, another really important research branch came up regarding the clarification of hearing loss especially in higher ages: the correlation between cognitive abilities and losses and hearing impairment. The provision of hearing aids probably becomes more important in terms of prophylaxis and intelligence preservation .It is well known that hearing loss impairs the ability of older people in road traffic, especially in cases of distraction, as a study group from Australia found out . It inveAlso the psychosocial health is influenced by hearing loss, which could be confirmed in a study of 1,178 older people from the Netherlands; hearing impaired people were mostly more lonesome .Already in 1989, Uhlmann and co-workers  comparedIn a recent population-related evaluation in Utah, USA, more than 4,400 persons who were more than 65 years old and had no dementia at the time of first examination, were examined exhaustively . The aveHowever, the problem of coincidence and direct causal correlation seems to be very important for future research; actually, the increasing age of society leads to a higher incidence of dementia, especially in the industrial nations. Hereby, the interrelationship of dementia and hearing loss is various. Because of the missing mental stimulation, hearing impaired people develop dementia possibly earlier, at the same time, however, the interaction with dement patients who are hearing impaired is clearly more difficult and also leads to increased agitation of dementia patients. Finally, it is also possible that people are considered as being dement even if they are “only” hearing impaired and cannot participate in normal conversations or react inadequately.So it will become very important to perform audiometric examinations also in dementia patients in order to identify hearing deficits and to introduce rehabilitation. Even if such an audiometric examination is not always easy and according to an investigation in a US-American retirement home with dementia patients (n=307) only 5% tolerated the complete examination procedure, at least 70% could be partially examined . In an oFirst studies on the effect of hearing aids on mental abilities have meanwhile been presented, however, with low evidence. So 3,670 patients who were older than 65 years, were re-examined after 25 years. Initially, 137 had severe hearing loss, 1,139 had a moderate hearing impairment; after 25 years, significantly better mental state result were observed in those who used hearing aids . Good hearing aid provision led to restructuring and measurable changes of the brain with regard to the processing of complex and in particular amplified signals .In an investigation with 16 adult hearing impaired people, it could be confirmed that they mentally tire quickly. By means of clinically well adjusted hearing aids, this fatigue can be reduced and the effort of hearing decreased . In a study from Nashville, USA, 16 hearing impaired people underwent a concentration test with and without hearing aids that took one hour . The fatA study from Korea  evaluateEven in older patients, expectations regarding hearing aids are very high when they finally decide to use them. But then hearing aids cannot only improve the communication skills but the increased sensory stimulation even improves the cognitive, of course especially speech-related functions. Conversely, if not treated, hearing loss leads to the development of mental impairment. Further research activities on the significance of hearing aids regarding the reduction of mental abilities and the development of dementia are planned and will certainly be published. According to the definition, hyperacusis is normal hearing but the patients seem to hear even “better than normal”. Because of the loud noise, they often develop typical vegetative anxiety reactions. In single cases, the habituation to noise is indicated with so-called noisers, however, there are currently no reliable studies on this topic. These devices are applied in the context of tinnitus retraining therapy (TRT) and also for hyperacusis, apparently with success, which cannot be explained by the noisers alone. An overview about this topic and a summary can be found in the articles published by Jastreboff , 96]. . 96]. Hearing aids may be a very useful therapy for other types of noise sensitivity, such as especially the quasi physiological recruitment as result of inner ear hearing loss in the sense of functional loss of the outer hair cells. Also in this context, no reliable evaluations are found, only the clinical experience reveals that a compensation of an existing hearing loss by well and flexibly adjusted hearing aids reduces among others the central amplification effects for this frequency range and thus also the sensitivity for those frequencies .Since much more than 90% of the patients suffering from tinnitus are hearing impaired, nearly always in the frequency range of the tinnitus , the treUnfortunately, there are only few studies that examine the effectiveness of hearing aids on the tinnitus alone. Nearly always, the hearing aids are part of a combined therapy and cannot be evaluated in an isolated and solitary way. A recent Cochrane analysis confirms this aspect: One single study was found that compared the effect of hearing aids with noisers. It revealed the same (positive) effect for both approaches. All other studies mentioned a high effect of hearing aids but they were embedded in multimodal therapy concepts . So alsoIndeed, this observation is a great problem: In up to 95%, tinnitus is associated with hearing loss and thus a symptom of impaired hearing perception. With hearing aids, many patients experience effective relief of their complaints, but studies on hearing aids as solitary therapy do not exist because they are always embedded in an audio-therapeutic concept. Nonetheless, hearing aids are essential in the tinnitus therapy because they nearly always include and compensate the existing hearing loss. As a consequence, cortical compensation reaction and a decrease of the inhibition are reduced.Single studies emphasize this fact: In a retrospective tinnitus analysis , 58 tinnA group from Marseille reported about 74 tinnitus patients who received hearing aids with a linear frequency transposition . Those hIn Auckland, a special hearing aid feature was tested in 25 tinnitus patients to find out the influence on the tinnitus. Single frequencies were reduced and others were amplified . Most suThe principle of frequency transposition turned out to be effective in the hearing aid fitting for high frequency hearing loss with steep drop. Some manufacturers of hearing aids pursue this concept for many years, especially regarding children in order to enhance the speech level. Hereby, high frequencies are transposed and shifted to the middle frequencies and then provided via the hearing aid. Other manufacturers try to maximally amplify the high frequencies. Interestingly, a suppression of the tinnitus is successful in particular in tinnitus patients with high-frequency ear noise, however, it cannot be predicted for all patients. The French study confirms this phenomenon in all of their patients. Our own clinical experience shows similar effects also for the other approach. The reactivation of the tonotopic map of the auditory cortex leads to plastic changes that also influence the tinnitus, either by direct re-stimulation or a mediated gate effect.A group from Berlin and London examined 15 tinnitus patients and found out that improvement of the tinnitus by hearing aids can only be achieved when the tinnitus frequency is located in the range of the actual transmission properties of the hearing aid, i.e. <6 kHz .An overview from Netherland evaluated 786 articles, but only 10 could be identified as valid. Improvement was shown in 25–72% of the patients, the tinnitus was eliminated in 8–45% of the patients. Up to 25%, however, even mentioned deterioration, new additional tinnitus developed in up to 10%. But in summary, a high rate of improvements could be confirmed . AnotherOften also combination devices are used for tinnitus therapy. Hereby, an additional noise or sound for relaxation may be added beside an amplification of the missing frequencies and thus compensation of the existing hearing loss is achieved. Those tinnitus devices may generally be prescribed , but there are no studies confirmed the usefulness of these devices. Further it must be questioned if a compensation of the existing hearing loss should be coupled with an additional noise because in this way central amplification effects are again activated especially because hearing is masked by the additional noise . The useAn article from Iran reported about 974 war veterans that hearing aids are clearly better accepted than noise generators . All patFinally it is the tinnitus itself that influences relevantly the course of the patients with tinnitus, as was confirmed by a group from Mannheim, Germany. They followed-up 28 patients with “fresh” tinnitus for 6 months . At the Also implantable hearing aids and cochlear implantations for severe hearing loss or deafness with tinnitus may have a positive effect on the tinnitus treatment. An overview of studies about the use of different hearing aids in the tinnitus therapy emphasized the particular importance of hearing loss compensation . For heaA study including 79 CI patients from Korea diagnosed tinnitus in 59 patients (74.7%). After cochlear implant surgery, the tinnitus was eliminated in 10 patients (25%), in 16 (40%) it was clearly improved. In summary, the results of the according questionnaires (THI and BDI) were significantly better 6 months after CI .Meanwhile modern digital hearing aids are very important in tinnitus therapy. Especially since an open, well tolerable provision of an external receiver, good feedback and noise suppression is also available for patients with high frequency hearing loss and high frequent tinnitus, a decisive progress was made. Those hearing aids also influence higher-frequency tinnitus because the transmission of those frequencies (up to 10 kHz) is now more effective. The use of additional noise for normal amplification should be well considered because the amplification is reduced or the patient is distracted which may lead to a reduced inhibition in the cortex and the auditory pathway and thus to increased tinnitus. All this must be taken into account in every single case.Satisfactory hearing aids and thus rehabilitation of the hearing loss reduces the stress of hearing processing and leads to cortical re-structuring that may reduce tinnitus and also hyperacusis. Cochlear implantation for high-grade hearing loss and deafness is also useful especially because the hearing pathway is adequately stimulated which often reduces the tinnitus perception. But also in cases of unilateral deafness, the directional hearing may be optimized and tinnitus improvement is achieved. This development showed new ways because in particular unilateral deafness with torturing tinnitus could only be treated insufficiently with CROS or BAHA devices; generally the tinnitus could not be influenced. It is fascinating how cortical plasticity succeeds in integrating normal hearing in one ear with CI in the other and thus achieving a good hearing impression. Of course the extremely high costs must be considered but the improvement of the quality of life of the patients is a very high benefit.In the broadest sense, also hearing protection is part of the group of hearing devices. This is especially true in the context of active hearing protection since many workers in noise and patients with (acknowledged) noise-induced hearing loss depend on hearing aids for improved communication or elimination of tinnitus. At the same time they have to protect themselves from noise exposure to avoid further deterioration of their hearing abilities. This aspect concerns working in noise and the necessary, even obligatory protection as well as noise to which people are exposed in their spare time, e.g. listening to music  or other activities such as hunting, shooting, or loud motor noise. A particularly difficult situation arises for orchestra musicians who might need hearing aids as well as good hearing protection.People who are regularly exposed to more than 85 dB (A) at their working place, have to use hearing protections that has to be provided by the employer. The requirements of hearing protection are defined by the DIN EN 352-2 regulation for Europe. Since there are different sensitivities of the skin of the auditory canal, hygienically well cleanable hearing protectors are available, either made of acryl or – even better tolerable – of silicone. The reduction of the environmental noise amounts to 22–26 dB according to the filter, while high frequencies are clearly more filtered (>30 dB). For special requirements, also differentiated filters may be adapted to the hearing protection. Another hearing protection that is even more effective (30 dB on the average) is achieved by the use of earmuffs. Nowadays they are less heavy (around 200 g), however, the worker has to get used to them and they are less tolerated in high temperatures. It is a particular problem for tinnitus patients to wear hearing protection because the tinnitus is perceived more loudly with the acoustic shielding. When they use hearing protection devices, hearing impaired patients will understand even less. For those persons, only an active hearing protection is appropriate even if it is more complex and of course expensive.Such an active earmuff is equipped with 2 adjustable microphones, an internal electronic system reduces every noise exposure from 82 dB onwards; weak noise is amplified by 10, loud noise is reduced to the admitted measure. Such a hearing protection would also be recommended for musicians. Especially musicians in electronically amplified bands are exposed to significant noise levels but also orchestra musicians have to cope with high loudness levels in narrow and acoustically poorly isolated rehearsal rooms or orchestra pits. For those persons, individually adjusted (with otoplasty) hearing protection is available that is provided with several attenuation features . The above-mentioned active hearing protection could then be used in an even more effective and better way, however, because of the optic effect it will not prevail. But it was tested and primarily developed for rock bands.Unfortunately, the general readiness of musicians to effectively protect their hearing organ that is so important for their profession, is only small, which could be shown by Richter et al. in a large survey from 2011 . PerhapsRegarding the numerous noise exposures in the leisure sector, such as for example music in loud concerts, discos, certain sports events, and especially motor sport, but also for hunters and shooters, appropriate hearing protections are available, starting with very simple ones up to individually adjusted ones with possible attenuations of 15–30 dB. It is necessary that a conscious desire develops to really protect the own hearing and to avoid damage – this consciousness, however, sometimes only matures when already damage has occurred. This necessity exists especially for small children and infants when they are exposed to high loudness levels; it is recommended to use specially designed earmuffs designed for children with soft-touch materials, which can achieve a high attenuation without completely shielding from the environment.In addition to hearing aid provision, hearing training programs have been developed in the last years, some of them have turned out to be useful, others, however, were less effective.Generally, a review article in the context of geriatrics showed that the fitting of hearing aids always has to be individual and with particular consideration of the hearing habits, abilities, and special circumstances of the hearing impaired people . This alFrom 26 older hearing aid users (average age of 79 years) who were not satisfied with their device, 80% benefitted from hearing training and targeted comparing adjustment .Especially, spatial hearing with hearing aids can be significantly improved by targeted training, which could be shown in a controlled study from Illinois. 15 participants were allotted to 3 groups and examined regularly for 3 months by means of special tests for spatial resolution; 2 groups underwent training at home and in the hospital in alternating sequence, the third group did not receive training. The groups with hearing training had significantly better results in the tests compared to those without training .A study from Australia suggested several methods for rehabilitation to 153 hearing impaired persons of a total of 289 examined patients: Besides hearing aid fitting, it was either communication training or no measure. 6 months after this consultation, 43% had received hearing aids, 18% had absolved the communication training program, and 39% had not undergone any measure. Predictors of successful rehabilitation were a higher socio-economic status, a severer initial impairment, and a higher willingness to change the situation. Physician should well support their patients in the decision of good hearing rehabilitation .In the hearing and audio-therapies, often musical examples are applied successfully, however, there is a problem with regard to the use of hearing aids. Modern hearing aid technology focuses mainly on an improved speech understanding. Improved perception of music is taken less into consideration. An article from Cambridge asked (via internet) 523 hearing aid users regarding their hearing loss and their hearing habits. Most of them used the hearing aids also for listening to music, but often distortions, feedbacks, and override occurred Figure 5 . The autOf course, an improved speech understanding is a relevant and important task of good hearing aid provision. Already for the quality of life and also for audiotherapies that accompany hearing aid fitting, enjoying music is essential; however, often hearing aids fail in this context or they are not suitably adjusted. Nonetheless, special programs and settings of current technology may lead to very good results also with regard to music, assuming that hearing care professionals and patients work on it together.Recent studies on the effectiveness of hearing therapies are presented for example from a group from Korea: 20 older hearing aid users were evaluated, 10 of them underwent a 4-level training for 4 weeks (meaningless words) and 10 received a normal fitting. With the special hearing training, a significant improvement of the consonant and sentence test was revealed .In a randomized and controlled study from Nottingham, 103 hearing aid users were trained by means of video-assisted interactive training units, 100 did not undergo additional therapy. The training took one hour every day for 6 weeks (on a voluntary basis), especially first users wore their device more frequently and benefitted significantly from this training .In contrast, compared to a control group without training, no statistically significant difference regarding speech understanding in noise could be found in first hearing aid users who underwent hearing training via internet (USA). The conclusion of the authors was that such an internet-mediated training would be an interesting and cheap alternative comparable to expensive clinical training programs  .In Germany, partly very offensively promoted hearing training programs such as “Terzo” could not confirm the evidence of an additional effect. This is aggravated by the fact that the program was not allowed to be published due to patent protection and thus could not be verified even if it consisted of simplest hearing and writing items.Beside an improved and quality-controlled hearing aid provision, an accompanying hearing training is important. This fact is taught in the education of audio-therapists of the German association of hearing impaired people . Such therapy programs are available as manuals for everyone . They deIn the last years, hearing aid technology has progressed enormously and the possibilities of hearing rehabilitation have been clearly improved. Nonetheless, the provision of hearing aids is complex and not always satisfactory. It must be taken into account that device-related hearing care can never replace the normal hearing function and cannot lead to hearing improvement in every acoustic situation of life of a hearing impaired individual. Furthermore, hearing aid adjustment requires a habituation phase of up to several weeks in order to get used to a new hearing perception.ENT specialist should not forget to undertake the tasks of good hearing rehabilitation. Neither hearing care professionals nor general practitioners, nor psychologists are in a position to responsibly and objectively fulfil these requirements. Compared to other European countries, the situation in Germany is better regarding the at least partial financing of hearing aids by the statutory health insurances, but the devices are sometimes very expensive, are associated with high financial expenses for the patient, and often consultation is not really adapted to the needs of the individual patient. That is why a good verification by the ENT specialist is absolutely necessary; it should be performed in a quality-controlled way as it is for example validated and published by the APHAB procedure.Actually, it should no longer happen that ENT specialist tell their hearing impaired patients that they needed no hearing aid or were too young. In this way, a suitable care is shifted to a higher age and at the same time it becomes more and more difficult.The authors declare that they have no competing interests.


Phytolacca americana L.) plants. The genome of the PkMV-NJ (New Jersey) isolate was cloned by PCR and sequenced by the Sanger sequencing method. The sequence comparison indicates that PkMV-NJ is more divergent from the other two sequenced isolates, PkMV-MD and PkMV-PA.Pokeweed mosaic virus (PkMV) causes systemically mosaic symptoms on pokeweed ( Phytolacca americana L.) causing mosaic symptoms (Potyvirus in the family Potyviridae (Pokeweed mosaic virus (PkMV), first described in 1969  and high-speed  centrifugations. The PkMV-NJ viral particles were further purified and collected with an Amicon 100K MWCO centrifugal filter. Viral RNA was isolated with the Trizol Reagent (Ambion), and used to produce first strand cDNA with the High Capacity cDNA synthesis kit (Applied Biosystems) and the oligo d(T) primer. After comparing the sequences of PkMV-MD and PkMV-PA, five sets of PCR primers were designed based on their most-conserved sequences to amplify the PkMV-NJ genome in five fragments. The PCR amplicons were cloned into pGEMT-easy (Promega) and sequenced by the Sanger sequencing method (Genewiz). New primers were designed within the amplicons to re-clone and sequence the fragments flanked by the first five sets of primers. The complete PkMV-NJ cDNA sequence was obtained and aligned to the sequences of PkMV-MD (JQ609096) and PkMV-PA (JQ609095) , 0.15% thioglycolic acid, and 0.01 M sodium diethylthiocarbonate. After stirring in 0.5 vol of chloroform, PkMV-NJ was purified from the juice by PEG (MW 6000) and NaCl precipitation and alternate low-speed (6000 × KU133475. The version described in this paper is the first version.The complete genome sequence of PkMV-NJ has been deposited in GenBank under the accession no.


P=0.017, P<0.001, P =0.038, P <0.001 and P =0.008, respectively). Logistic regression analysis showed that the dynamic enhancement pattern (P=0.012), and the metastasis-to-liver ratios on hepatic artery phase (P=0.009) were independent CT predictors for liver metastases of GEP NETs. The sensitivity and specificity of combing the two predictors in differentiation of liver metastases of GEP adenocarcinomas from GEP NET were 82.6% (19 of 23) and 91.3% (21 of 23), respectively. CT features are helpful in differentiating liver metastases of well-differentiated GEP NETs from that of GEP adenocarcinomas.This study proposed to evaluate the feasibility of dynamic enhanced CT in differentiation of liver metastases of gastroenteropancreatic well-differentiated neuroendocrine tumors (GEP NETs) from GEP adenocarcinomas based on their characteristic features. CT images of 23 well-differentiated (G1 or G2) GEP NETs and 23 GEP adenocarcinomas patients with liver metastases were retrospectively reviewed. The distribution type, shape, intra-tumoral neovascularity, enhancement on hepatic artery phase, dynamic enhancement pattern and lymphadenopathy were subjective analyzed. Meanwhile, the size, number, CT value of tumor and adjacent normal liver parenchyma were measured and the metastasis-to-liver ratios were calculated objectively. Compared with GEP adenocarcinomas, the liver metastases of GEP NETs more frequently demonstrated a hyper enhancement on hepatic artery phase, washout dynamic enhancement pattern, absence of lymphadenopathy and higher metastasis-to-liver ratios on both hepatic artery phase and portal venous phase ( Gastroenteropancreatic neuroendocrine tumors (GEP NETs) arise from the diffuse endocrine system of gastro-intestinal tract and pancreatic islet cells . AccordiAs the first line imaging modality, the dynamic enhanced computed tomography (CT) play an important role in the assessment of the stage of GEP NETs. Besides lesion detecting, several previous studies have addressed the values of CT findings, including shape and enhancement features, in the pathological differentiation of GEP NETs , 11. As P = 0.637). The mean size of the maximum liver metastases of GEP NETs was 44.57±41.37mm, and that of GEP adenocarcinomas was 50.35±39.40mm. Differences in tumor sizes were not statistically significant . Both of the metastasis-to-liver ratios on hepatic artery phase and portal venous phase were higher in the GEP NETs liver metastases  compared with GEP adenocarcinomas  with statistically significant differences . (Table There was no significantly differences in tumor numbers between patients with liver metastases of GEP NETs 13.48±9.56) and those with GEP adenocarcinomas (12.61±10.30) , dynamic enhancement pattern (P<0.001) and presence of lymphadenopathy (P=0.038) were significantly different between liver metastases from GEP NETs and from GEP adenocarcinoma , the metastasis-to-liver ratios on hepatic artery phase (Exp (B) < 0.001, 95.0 % CI = 0.000–0.067, P = 0.009) were independent CT predictors for liver metastases of GEP NETs. In ROC analysis, metastasis-to-liver ratios on hepatic artery phase had an AUC of 0.856 (95%CI=0.749-0.963) in distinguishing GEP adenocarcinomas from GEP NET, with a cutoff value of 0.898 and 78.3% (18 of 23), respectively  = 0.113, 95.0 % CI = 0.020–0.622, According to the results of the present study, two CT criteria were statistically significant predictors capable of differentiating liver metastases of GEP adenocarcinomas from NETs: present of plateau enhancement dynamic enhancement pattern and a metastasis-to-liver ratios <0.898 on hepatic artery phase. Moreover, when the two features were used in combination, better differentiation of liver metastases of GEP adenocarcinomas from that of NETs could be acheved, with a sensitivity of 82.60% and specificity of 91.30%. This finding indicates that the CT features of liver metastases may be helpful in establishing an accurate diagnosis when distinguishing GEP adenocarcinomas from NETs.Generally, hyper-enhancement has been considered as the common character of NETs , 13. TheAnd to the pattern of enhancement, most of liver metastases of GEP NETs demonstrated as washout pattern (15/23), followed by plateau pattern(6/23), contrarialy majority of the liver metastases from adenocarcinomas were plateau pattern21/23). The pattern of enhancement of liver NETs have been reported in the study of Kim et al. , 16 of 3/23. The In the present study, the present ratio of lymphadenopathy of GEP NETs was lower than that of adenocarcinomas (30.4% vs. 60.9%). The GEP NETs mainly demonstrated a better biology with less lymph node metastases. In the previous studies, lymphadenopathy were found in up to 22.2% of gastric NETs , 34.5% oThe present study had some limitations. First, the number of patients in our study was limited by the relatively low incidence of NETs, rendering stratified comparison of patients of different primary location. Second, this was a retrospective study; the start of dynamic enhanced CT used fixed delay time. To eliminate the incoordination of scanning phase, we excluded the cases with insufficient image quality and used enhancement ratio in analysis. Third, pathology result could not be obtained for each of the liver metastases lesions. In some cases, clinical diagnosis were applied, which was also acceptable in previous studies . Our resIn conclusion, the subjective and objective features of dynamic enhanced CT are helpful to differentiate liver metastases of well-differentiated GEP NETs from that of GEP adenocarcinomas.This retrospective study was approved by our institutional review board and the requirement for informed consent was waived. Patients’ records of the radiology and pathology departments of our institute from January 2009 through February 2016 were reviewed and cross-referenced. To create a study group of liver metastases of GEP NET, the following inclusion criteria were used: (a) pathological diagnosis of GEP NET, (b) available dynamic enhanced CT images within 4 weeks of pathology, and (c) liver metastases were confirmed on pathology or based on a combination of CT findings and serial imaging or multi-modality imaging such as somatostatin receptor scintigraphy, Gallium-68 positron emission tomography (PET)/CT, determined by a consensus of two experienced abdominal radiologists . In this study, we excluded patients whose primary tumor was not from the GEP, or who had prior treatment before the current CT scan, or insufficient image quality. Finally, 23 patients with pathologically proven GEP NET were enrolled in this study Figure . To servCT was performed with a 64 multidetector CT (MDCT) scanner  or a 256 MDCT . Each patient fasted for 6 hours before undergoing CT. After the initial non-enhanced scan, about 100-150 ml (600 mg iodine/kg body weight) of iopromide  or iohexol  through an angiographic catheter inserted into an antecubital vein was administered at a rate of 3 ml/sec by using an automatic power injector. Dynamic enhanced CT scans were obtained 25-30 seconds (hepatic artery phase), 70-75 seconds  and 150 seconds (equilibrium phase) after the initiation of the intravenous contrast material injection. The scanning range included the upper part of the abdomen from the level of the hepatic dome to the iliac crest. The main scanning parameters of the three scanners were uniform included the following: 120 kVp, automatic tube current modulation, and a tube rotation time of 0.5-0.75 second. Images were displayed in the axial plane with a slice thickness of 5 mm, and multiplanar reformatted images were available for all patients.Subjective image analyses were performed by two experienced abdominal radiologists  using a PACS workstation. Individual reviews were done, and few discrepancies pointed out were resolved by consensus. The radiologists were blinded to patient pathology information. All patients were assessed of the following subjective features: distribution type; lesion shape; intra-tumoral neovascularity; enhancement on hepatic artery phase; dynamic enhancement pattern; and lymphadenopathy were also evaluated. In this study, the distribution type of lesions was described as restricted metastases, which was the metastases confined to one liver lobe or limited to two adjacent segments, or diffuse metastases, that was multifocal lesions located diffuesly in both liver lobes. The lesion shape was assessed as round-oval or irregular. The intra-tumoral neovascularity was defined as the presence of increased, irregular vessels in the tumor. The enhancement on hepatic artery phase was described as hyper enhancing and hypo-enhancing, referencing the adjacent normal liver parenchyma. The dynamic enhancement patterns were recorded as: plateau pattern, the enhancing degree of tumor was similar between the portal venous phase and hepatic artery phase, progressive enhancement pattern, the enhancing degree of tumor on portal venous phase were higher than that of hepatic artery phase, or a washout enhancement pattern, the enhancing degree of tumor on portal venous phase were lower than that of hepatic artery phase. The lymphadenopathy was defined as the presence of lymph node(s) with short axis diameter more than 1cm.Two observers (Y.C. and S-Y.G.) performed objective measurement independently, including the size, number, CT value of tumor and adjacent normal liver parenchyma. The longest diameter of the biggest metastasis of a patient was measured for the size comparison. The tumor number was counted if liver metastases of a patient less than 20, or else the tumor number of the patient was defined as uncountable. The mean CT value at the maximum level of the biggest liver metastasis and adjacent normal liver parenchyma were measured by using an operator-defined region of interest (ROI), which was specified as a round or oval area including most possible tumor. We took ROI readings from one area of the tumorous lesion and from the other area of adjacent normal liver parenchyma devoid of necrosis or vascular structures. Thereafter, the metastasis-to-liver ratios on hepatic artery phase and portal venous phase were calculated using the following equation: Metastasis-to-liver ratios = CT values of liver metastasis/ CT values of normal liver parenchyma.All the pathological diagnoses were confirmed by a pathologist (Z-W.L.) with 10 years of experience in gastrointestinal pathology, who was blinded to all clinical information and imaging findings. Pathological tumor grades were determined according to the WHO classification  by count2 tests or the Fisher's exact test was used for comparison of the subjective interpretation and the independent t-test was used to compare the objective measurement between the two groups. Independent factors for differentiating were evaluated using the logistic regression model with backward selection. Receiver operating characteristic (ROC) curves were employed to evaluate the performance of CT features above in the discrimination of the two groups, and area under ROC(AUC) was calculated. An AUC>0.75 suggested clinically useful. The cut-off value was determined by using the maximum Youden's index method. We performed a simple κ analysis to assess inter-observer agreement for subjective variables and calculated intra-class correlation coefficient(ICC) for objective variables. A kappa or ICC of 0.81-1.0, 0.61-0.80, 0.41-0.60, 0.21-0.40 or 0.0-0.20 suggested perfect, substantial, moderate, fair or poor agreement. For all tests, a P value <0.05 was considered to indicate statistical significance in all analyses.The analysis was performed using SPSS software . The χ


POU4F3 gene encodes a transcription factor which plays an essential role in the maturation and maintenance of hair cells in cochlea and vestibular system. Several mutations of POU4F3 have been reported to cause autosomal dominant nonsyndromic hearing loss in recent years. In this study, we describe a pathogenic nonsense mutation located in POU4F3 in a four-generation Chinese family. Target region capture sequencing was performed to search for the candidate mutations from 81 genes related to nonsyndromic hearing loss in this family. A novel nonsense mutation of POU4F3, c.337C>T (p. Gln113⁎), was identified in a Chinese family characterized by late-onset progressive nonsyndromic hearing loss. The novel mutation cosegregated with hearing loss in this family and was absent in 200 ethnicity-matched controls. The mutation led to a stop codon and thus a truncated protein with no functional domains remained. Transient transfection and immunofluorescence assay revealed that the subcellular localization of the truncated protein differed markedly from normal protein, which could be the underlying reason for complete loss of its normal function. Here, we report the first nonsense mutation of POU4F3 associated with progressive hearing loss and explored the possible underlying mechanism. Routine examination of POU4F3 is necessary for the genetic diagnosis of hereditary hearing loss in the future.  WFS1 [http://hereditaryhearingloss.org/). A large proportion of sensorineural hearing loss remains genetically unexplained. The traditional Sanger sequencing method is highly expensive and time-consuming in identifying the pathogenic variants when there are hundreds of candidate genes. In contrast, next-generation sequencing can overcome these shortcomings through its ability to perform parallel sequencing of billions of nucleotides at a low cost and high speed. It has been proven as a powerful tool in identification of novel mutations and genes associated with hereditary hearing loss in recent years.Hearing loss is one of the most common sensory disorders in human. Genetic factors account for about 50% of these cases. Nonsyndromic hearing loss has four hereditary patterns: autosomal dominant, autosomal recessive, X-linked, and mitochondrial. Although hundreds of genes have been reported to be associated with nonsyndromic hearing loss, GJB2, SLC26A4, and mtDNA12SrRNA are the major contributors. Sometimes, one deafness gene can exhibit both autosomal dominant and recessive patterns in different mutations, such as WFS1 . To date (POU4F3), also known as BRN3C, is a POU-domain transcription factor exclusively expressed in both nascent and adult hair cells of cochlear and vestibular system in the inner ear [ POU4F3, Brn-3c−/−, manifested severe defects in hearing and balance, and they showed a rapid and progressive loss of hair cells during late gestation and early postnatal period. In contrast, the heterozygous littermates Brn-3c+/− mice represented normal behaviors. Histological examinations revealed that hair cells were totally absent in the auditory and vestibular systems of Brn-3c−/− adult mice. Loss of hair cells also resulted in a large decrease in the number of neurons and myelinated fibers in the spiral ganglion [ POU4F3 was expressed in postmitotic cells committed to hair cell phenotype but not in mitotic progenitors [ POU4F3 kept high in both inner and outer hair cells till adulthood in mice [ POU4F3 was essential for the maturation and maintenance, but not the fate determination of hair cells. The vital role of POU4F3 in the development of hair cells indicated that it might be related with some kind of hereditary hearing loss.POU class 4 transcription factor 3nner ear . Brn-3c ganglion . Other sgenitors  and the  in mice , which m POU4F3 was confirmed to be a causative factor of autosomal dominant nonsyndromic deafness 15 (DFNA15). Thus far, several POU4F3 mutations were involved in DFNA15 and mapped to 5q31-33 [The search for pathogenic mutations involved in hereditary hearing loss never ceases. Mutation of 5q31-33 –16. The  5q31-33 , 12–15.  5q31-33 . Vestibu 5q31-33 , 18. POU4F3, c.337C>T (p. Gln113∗), was identified to be the causative factor using the method of target region capture sequencing.In this study, we reported a Chinese family suffering from ADNSHL. All affected members experienced a late-onset progressive hearing loss. A new nonsense mutation inA four-generation Chinese family suffering from hereditary hearing loss was reported here. All 12 patients in this family had a putative autosomal dominant pattern of inheritance according to the participating patient statements. Because of some objective reasons and out of the patients' privacy, we were not able to contact and examine all the members in this family. Only 4 members with impaired hearing  and 8 members with normal hearing  participated in our research . They alhttp://dx.doi.org/10.1155/2016/1512831) related to nonsyndromic hearing loss in the genome of the proband. This work was done by BGI  using a standardized next-generation capture sequencing platform. This method can cover all exons and nearby ±10 base pairs of introns of the 81 candidate genes. Data analysis was conducted according to the analysis process for next-generation sequencing, BGIv0.1.0. Reads were aligned to the human reference genome UCSC hg19 Feb.2009 by BWA 0.6.2-r126 software. Mutation detection software was GATK. dbSNP (snp137) was used as a reference for recorded SNPs. The databases including 1000 genome database (phase I), HapMap database (combined data from phases II and III), and own databases of BGI  were used as references to investigate the novelty and possible pathogenicity of the variations detected in the sequencing approach. Guideline of American College of Medical Genetics and Genomics was used as the reference of data interpretation [In order to identify the pathogenic mutation underlying the hearing loss in this family, the genomic DNA was extracted from peripheral blood of all the subjects using DNA extraction kit . Target region capture sequencing was employed to screen possible mutations of 81 genes  and corresponding protein sequence (NP_002691.1).Sanger sequencing was performed in all the family members participating in our research and 200 ethnicity-matched control subjects. The primers used to amplify the exons and intron-exon boundaries by polymerase chain reaction were as follows: (1) forward 5′-GCAGGCTGCTTGTAAGATGAG-3′ and reverse 5′-AGACAGCGGCGATTGTTC-3′; (2) forward 5′-CTCGGTTGCTTGAAAATGTG-3′ and reverse 5′-GGGGATCTTGAGATTAGCC-3′; (3) forward 5′-AGCTGGAAGCCTTCGCC-3′ and reverse 5′-GGAAAGTCTGTGGCTTCGG-3′. The first pair of primers was for the amplification of exon 1, while the other two were for exon 2. Sequencing reactions were performed by BGI . Data was analyzed using Lasergene-SeqMan software. The sequences were compared with the sequence ofhttp://www.mutationtaster.org/) [ POU4F3 protein was carried out using I-TASSER, an automated homology modeling program (http://zhanglab.ccmb.med.umich.edu/). The wild-type POU4F3 protein includes 338 amino acids (NP_002691.1) and the mutant protein includes 112 amino acids. Data obtained from the homology models were visualized using Swiss-Pdb Viewer 4.1 software.Mutation Taster was used to predict the possible pathogenic effect of the candidate mutation (er.org/) . Three-d2 at 37°C. HEI-OC1 auditory cells, which were given by Dr. Federico Kalinec  as a present, were cultured in DMEM  containing 10% FBS in a sterile environment with 10% CO2 at 33°C [HEK293 cells were originally stored in Shandong Provincial Key Laboratory of Otology and then cultured in MEM  containing 10% FBS  in a sterile environment with 5% CO at 33°C . POU4F3 cDNA was purchased from Cusabio Biotech . Sanger sequencing of this cDNA clone confirmed that it is totally consistent with that of POU4F3 cDNA (accession number: BC112207). We then used this to generate the wild-type expression plasmid. Primers used to amplify the cDNA region were 5′-ATGCAGGATCCATGATGGCCATGAACTCCAAGCAGCCTTTCG-3′ and 5′-ACGCAGAATTCGTGGACAGCCGAATACTTCA-3′. After digestion by restriction enzymes BamH I and EcoR I, the amplified PCR products were then subcloned into the expression vector, pCMV-Tag 2B . To construct the mutant expression vector, we used the QuikChange site-directed mutagenesis kit  to introduce the mutation (c.337C>T) which we identified from targeted next-generation sequencing into the wild-type vector following the manufacturer's protocol.The vector containing human4/well and 10 × 104/well, respectively, and were then transfected with either wild-type or mutant expression plasmid using Lipofectamine® 3000 transfection reagent . Immunofluorescence analysis was performed after 72-hour transfection. Cells were fixed in 4% paraformaldehyde for 15 min, permeabilized in PBS containing 0.3% Triton X-100 for 10 min and then blocked in PBS containing 10% donkey serum for 1 h at 37°C in a humid atmosphere. Subsequently, the cells were incubated for 12–14 h at 4°C with primary anti-FLAG antibody  at a concentration of 1 : 800 diluted and then stained with secondary goat-anti-mouse antibody  and DAPI for 1 h at a concentration of 1 : 1000. Finally, the cells were visualized under confocal microscope for image acquisition.HEK 293 and HEI-OC1 cells were cultured on glass coverslips in 24-well plates with the densities of 25 × 10A four-generation Chinese family suffered from hereditary progressive hearing loss with an autosomal dominant pattern. The pedigree of this Chinese family was drawn in The proband (IV-20) developed bilateral hearing loss at the age of 14 and after then, the hearing loss became more and more severe. So he received PTA in our hospital at 17 and 18 years old, respectively. The results showed moderate sensorineural hearing loss of both ears shown in  and an oTinnitus was a common symptom among these patients. Tinnitus examination revealed a 3 kHz binaural consistent tinnitus in IV-20  and a 6 kHz binaural tinnitus in III-19 . Speech recognition scores (SRS) of IV-20 were 88% in left and 80% in right. SRS of III-19 were 52% in left and 48% in right. Results of vestibular bithermal caloric test and VEMP showed no obvious dysfunction although IV-20 mentioned he experienced vertigo sometimes. Tympanometry results of all participants were completely normal. ABR results of those affected members were consistent with results of PTA, showing moderate to severe sensorineural hearing loss. All affected members failed to pass DPOAE test in most or all frequencies bilaterally. Results of all the unaffected members were normal.  were detected to be possible candidates. By considerations of the autosomal dominant pattern and clinical manifestations in this family, five genes were excluded. Sanger sequencing was performed in all the participating members to confirm the remaining four genes . Only one heterozygous nonsense mutation, c.337C>T (p. Gln113∗), in exon 2 of POU4F3 was confirmed  ( POU4F3 (residues 1–338). The sequence identity between the target and template was 53%, higher than the average 25%. The constructed model of mutant protein matched the target sequence of POU4F3 (residues 1–112). The sequence identity between the target and template was 25%. We analyzed the wild and mutant structure of POU4F3 proteins with Swiss-Pdb Viewer 4.1 software. Compared with the wild-type Pou4f3 structure, the mutant protein structure is incomplete.Prediction made by Mutation Taster about whether this mutation was pathogenic showed a probability value of 1 . A molecular model ofd 1jvrA) . The conPOU4F3 is a transcription factor and is exclusively located in the nuclei as previously reported [ POU4F3. These two constructs were transfected into HEK 293 and HEI-OC1 cell lines, respectively. HEI-OC1 cell line is a conditionally immortalized organ of Corti-derived epithelial cell line [ POU4F3 proteins expressed by these two constructs were fused with N-terminal FLAG-tag, we used anti-FLAG antibody to detect its localization by immunofluorescence analysis under confocal microscopy. Similar results were observed in both cell lines. The normal POU4F3 protein was exclusively located in the cell nuclei while most of the mutant POU4F3 protein was located in the cytoplasm. Even though there was still some mutant POU4F3 protein in the nuclei, the signal was much weaker than that in the cytoplasm  led to the loss of both NLSs which in turn caused the change of localization. Some earlier studies reported that mutant protein produced by transfection could also locate only in nuclei and the difference between normal and mutant protein was the proportion of cells with POU4F3 protein outside nuclei [In order to investigate the effect of this novel mutation, we examined the subcellular localization of mutant protein in comparison to a wild-type protein control. The immunofluorescence staining revealed that normal protein was exclusively located in nuclei while mutant protein was located predominantly in cytoplasm in both HEK293 cells and HEI-OC1 cells. Nuclear localization signal (NLS) is an amino acid sequence which plays a key role in guiding transcription factors to cell nucleus and loss of NLS would result in cytoplasmic localization. There are two NLSs inus study . One is e nuclei , 13. We  POU4F3 is important for understanding its function and the mechanism of POU4F3-related hearing loss. There have been several genes verified to be its downstream targets. Growth factor independence 1 (Gfi1), a zinc-finger transcription factor, was the first-identified target gene of POU4F3 and its loss of expression was presumed to be the main cause of outer hair cell degeneration in POU4F3 mutant individuals [ POU4F3 was capable of activating both BDNF and NT-3 promoters and might be an important regulator of neurotrophic gene expression [ POU4F3 in auditory but not in vestibular system of hair cells [ POU4F3-related mechanism of differentiation and maintenance of hair cells is largely unknown.Identification of targets ofividuals . Clough pression . Later, ir cells . In 2014ir cells . But sti POU4F3 for the first time in a four-generation Chinese family suffering from autosomal dominant nonsyndromic hearing loss. Functional defects of this truncated protein were revealed by structural analysis and in vitro cellular experiments. Thus far, 10 variants of POU4F3 related to DFNA15 have been reported. Mutation of POU4F3 may not be a rare cause in ADNSHL and routine examination of POU4F3 is necessary for the genetic diagnosis of hereditary hearing loss in the future.In this study we identified a new nonsense mutation c.337C>T inSummary of 81 Genes related to non-syndromic hearing loss in target region capture sequencing. Name, inheritance pattern, GenBank accession number and exon count of each gene are shown in the table. AR: Autosomal Recessive; AD: Autosomal Dominant; MT: Mitochondrial Inheritance.


In the publication of this article , there wThe error:‘5′-Quasar 670–CTCAAGTTGGAAACCACGAGTAAGAGTGATGAA-3′-BHQ-2’.Should instead read:‘5′-Quasar 670– CAAGCTTCCCGTTCTCAGCC-3′-BHQ-2 ‘.This has now been included in this erratum.


Supplemental Digital Content is available in the text CTSK). Medullary thyroid carcinoma (MTC) is also a relatively rare type of primary thyroid carcinoma.Pycnodysostosis is a rare autosomal recessive skeletal dysplasia caused by a mutation in the cathepsin K encoded by cathepsin K gene  but no mutation associated with the familial forms of MTC.The patient's clinical examination revealed short stature, underweight, a prominent forehead, stubby fingers, and a fixed nodule in the right thyroid lobe. Intraoral examination revealed multiple clinically malposed and missing teeth, as well as chronic periodontitis with a narrow and grooved palate. Radiographic examination revealed typical widely separated cranial sutures and an open anterior/posterior fontanel with an obtuse gonial angle, acroosteolysis, and osteosclerosis with narrowed medullary cavities. Ultrasonography of the thyroid gland showed a marked hypoechoic solid nodule in the right lobe in which tumor cell clusters were confirmed by ultrasound-guided fine needle aspiration biopsy and was suspected to be MTC. Laboratory tests revealed dramatically elevated serum calcitonin >2000 pg/L (reference range: 0–5 pg/L) and carcinoembryonic antigen (CEA) 134.37 ng/mL (reference range: 0–5 ng/mL). Genotypic screening revealed compound heterozygous mutations in the The patient underwent a total thyroidectomy with right-sided functional neck dissection.CEA and serum calcitonin decreased significantly postthyroidectomy, and no further fracture has been reported by the patient so far.CTSK gene mutation and sporadic MTC. Radiological techniques and gene analysis play key roles in the definitive diagnosis.The present study is the first to report a rare case of the coexistence of pycnodysostosis with a compound  This disorder is caused by a homozygous or compound heterozygous mutation in the cathepsin K gene (CTSK), which encodes a lysosomal cysteine protease highly expressed in osteoclasts. Medullary thyroid carcinoma (MTC) is also a relatively rare type of primary thyroid carcinoma originating from the parafollicular C cells. MTC accounts for only 5% to 10% of all thyroid carcinomas; however, it exhibits a more aggressive behavior, which increases the difficulty of treatment. MTC can be either sporadic or familial, which is defined as part of the cancer syndrome known as multiple endocrine neoplasia type 2 (MEN2). To our knowledge, no case of pycnodysostosis coexisting with MTC has been reported. Herein, we describe a case of coexistence of these 2 rare diseases.Pycnodysostosis (OMIM 265800) is a rare inherited osteosclerotic skeletal disease first described and named by Lamy and Maroteaux in 1962.2A 31-year-old woman was referred to our department with a history of short stature and a palpable nodule in the front of her neck that had gradually increased in size during the last 2 years. She experienced minor falls twice at the age of 24 and 28 and was diagnosed with multiple fractures of the lower limbs, which were treated conservatively. Upon admission, a routine clinical examination revealed that the patient's standing height was 132 cm with the upper segment at 70 cm and the lower segment at 62 cm , free triiodothyronine, free thyroxine, growth hormone, insulin-like growth factor 1, and cortisol were normal. Notably, dramatically elevated serum calcitonin >2000 pg/L (reference range: 0–5 pg/L) and carcinoembryonic antigen (CEA) 134.37 ng/mL (reference range: 0–5 ng/mL) were detected. Radiographic examination revealed widely separated cranial sutures and open anterior and posterior fontanels. The paranasal sinuses were nonpneumatized with an obtuse angle of the mandible   proto-oncogene associated with familial forms of MTC. A further evaluation was performed postthyroidectomy, revealing that CEA and calcitonin deceased significantly – serum calcitonin at 862 pg/L and CEA at 6.33 ng/mL. One year after total thyroidectomy, laboratory test showed calcitonin at 1149 pg/L and CEA at 8.52 ng/mL, as well as swollen lymph nodes in the neck revealed by ultrasonography. Thus, lymph node metastases consequent to MTC was considered. This patient has been referred to the Department of Oncology for further treatment. Key milestones of the diagnoses and interventions were depicted in timeline figure .Genotypic screening of the whole blood revealed compound heterozygous mutations in the Based on the characteristic clinical, radiological, and histopathological features and DNA analysis, the patient was diagnosed with pycnodysostosis accompanied with sporadic MTC.3 Because short stature is an essential feature of the disease, many patients are usually referred to the pediatric unit with failure to thrive or to dentists because of oral deformities that severely affect their daily life. Thus, radiological techniques to confirm osteosclerosis and acroosteolysis combined with genetic analysis are required for diagnostic purposes. The patient presented in this report was diagnosed with typical pycnodysostosis as described in the literature; however, her case is the first exhibiting pycnodysostosis accompanied by MTC, which is also a rare neuroendocrine tumor.Pycnodysostosis is a rare autosomal-recessive disease causing osteosclerosis due to decreased bone resorption. It is characterized by reduced stature, osteosclerosis, acroosteolysis of the distal phalanges, frequent fractures, hypoplasia of the clavicle, skull deformities with delayed suture closure, as well as oral abnormalities including malposed teeth, proneness to dental caries, a highly arched bone palate, and a long soft palate with a long uvula. There may also be trunk deformities, for instance, kyphosis, lordosis, or a narrow chest. Occasionally, exophthalmos and blue sclera are present.RET proto-oncogene. In this reported case, possibilities of parathyroid hyperplasia or adenoma were excluded based on an ultrasound examination of the parathyroid and laboratory tests revealing normal serum calcium, phosphate, and parathyroid hormone levels. It was also less likely to be pheochromocytoma, based on the normal blood pressure and computed tomography examination of the adrenal gland, or mucosal neuroma, according to the physical examination. Further DNA sequencing of the RET proto-oncogene did not detect any mutation. Therefore, a sporadic MTC was diagnosed.MTC, which is further categorized into sporadic MTC and MEN2, originates from the parafollicular C cells and exhibits histopathologic and clinical characteristics that differ from papillary or follicular carcinomas of thyroid origin. A solitary thyroid nodule is the most common feature of MTC. Clinically, patients with MEN2 may also develop parathyroid hyperplasia, pheochromocytoma, parathyroid adenoma, mucosal neuroma, or pheochromocytoma. Moreover, most MEN2 cases derive from a variation in the  In this reported case, multiple metastases were also detected in the extrathyroidal extension and lymph nodes in the right-sided neck (7 out of 9 nodes). Consistently, 1 year after total thyroidectomy, lymph node metastases consequent to MTC was considered based on laboratory test on calcitonin and CEA as well as ultrasonography examination. So far, this patient has been referred to the Department of Oncology for further treatment.Although MTC accounts for only 5% to 10% of thyroid carcinomas, its prognosis is severer than more-well-differentiated thyroid carcinomas. Moreover, in most patients, the disease is always diagnosed accompanied with metastases to regional lymph nodes or even to the lungs, liver, and bone tissue.CTSK gene located on chromosome 1q21 encoding a lysosomal cysteine protease, cathepsin K, which is widely expressed in bone, ovary, heart, placenta, lung, skeletal muscle, colon, and small intestine. As a member of the papain-cysteine protease family, it is responsible for degrading bone matrix proteins, type I/type II collagen, osteopontin, and osteonectin and for bone remodeling. Cathepsin K is synthesized as an inactive precursor protein that requires removal of its N-terminal pro-region for activation. To date, at least 35 different mutations have been reported in the CTSK locus leading to nonsense, missense, frameshift, and splicing mutations, as well as small deletions or insertions. The majority of the mutations are located in the mature active domain of cathepsin K protein.,6 Our patient exhibited compound heterozygous mutations in the CTSK gene . The C830T mutation is a missense mutation located in the mature region and causes loss of function, which has been reported previously. The C158delA is a novel mutation leading to a reading frameshift and a truncated form of only 54 amino acids at the N-terminus. Indeed, compound heterozygous mutations of the CTSK gene have been frequently reported in patients with pycnodysostosis diseases , which accounts for approximately 24.73% of the included patients.Pycnodysostosis is caused by mutations in the ,7,8 Thus, it will be difficult to speculate whether CTSK-deficiency or loss of function is directly affecting in the pathogenesis of MTC. Indeed, apart from its well-confirmed involvement in bone disease, cathepsin K is also highly expressed in gastric cancer, squamous cell carcinoma, basal cell carcinoma, breast tumors, lung cancer, melanomas, prostate tumors, and renal tumors and appears to have a positive role in promoting tumor progression.,10 Other cathepsins  also have the potential to accelerate tumorigenesis by promoting extracellular matrix (ECM) degradation. These lines of evidence appear to be controversial to what we have seen in this case report. However, Friedrichs et al proposed a compensatory role of cathepsin L for cathepsin K deficiency, in which case the cathepsin L protein level is enhanced when cathepsin K is absent. Therefore, it will be of interest to further evaluate the expression pattern of cathepsins K and L in thyroid tissue. Furthermore, cathepsin K is closely related to osteoclast function (being primarily responsible for bone matrix degradation by osteoclasts) and acts as a potential regulator of apoptosis and senescence to control osteoclast numbers in vivo.,13 Considering that bone destruction in skeletal metastases may result from osteoclast-induced bone resorption, a CTSK mutation, in this case, will potentially affect the extent of MTC skeletal metastases. In particular, based on the clinical observation and the phenotypes of CTSK-deficient mice, cathepsin K loss of function may also lead to changes in the immune and hematopoietic systems. For example, a low-grade anemia was observed in this patient. Thus, there may be a potential correlation between the immune or hematopoietic system and MTC progression. The consideration of these findings will encourage us to further investigate the structure and function of this mutated cathepsin K protein, as well as its potential involvement in the pathogenesis of MTC, either directly or indirectly.To date, an increasing number of patients acquire multiple primary carcinomas because of environmental modifications or genetic predispositions. Under this particular circumstance, the possible association between the pathogenesis of pycnodysostosis and MTC is unclear. Although it may only be an unfortunate coincidence, this case still leads us to further consider any potential association between these 2 rare diseases. Both in vivo and in vitro studies show that cathepsin K protein is predominantly found within the thyroid follicular lumen and involved in liberating thyroxine from thyroglobulin; however, research on cathepsin K in para-follicular cells is absent. Cathepsin K, intensively expressed in osteoclasts, is essential for normal bone resorption. Recently, a large multinational, randomized, double-blind phase III study of odanacatib (a cathepsin K inhibitor) in postmenopausal women with osteoporosis was completed. Both thyroid hormone and cathepsin K were closely related to bone maintenance and disease, for example, osteoporosis. Certain findings have indicated the direct correlation of thyroid hormones and cathepsin K but are limited and controversial. Mikosch et al reported high cathepsin K levels detected in patients on suppressive L-thyroxine therapy. By contrast, Zhang et al have shown that TSH inhibits cathepsin K expression and osteoclastogenesis in RAW264.7 cells. Nerveless, in the present case, the CTSK gene was mutated and presumably underwent loss of function. Additionally, the serum TSH, free triiodothyronine, and free thyroxine levels were all in the normal range, which indicated that thyroid hormone likely did not affect the pathogenesis of pycnodysostosis. In addition, calcitonin was intensively secreted by MTC in this case. Calcitonin may protect against skeletal calcium loss by directly inhibiting bone resorption or indirectly inhibiting prolactin released from the pituitary gland. Therefore, theoretically, increased calcitonin and a mutated cathepsin K possibly have a synergistic effect on bone resorption.Notably, mounting evidence has revealed that thyroid hormones have profound effects on bone development, linear growth, and adult bone maintenance, including the inhibition of osteoclast formation and function. To date, no specific treatments have been developed for pycnodysostosis. It is critical to emphasize and promote supportive management and prophylactic measures to prevent fracture occurrence and maintain oral hygiene.In sporadic MTC cases, total thyroidectomy and central lymph node dissection should be performed. Lateral lymph node dissection is further required when invasion is identified. Few chemotherapeutic options are available for patients with metastatic MTC that cannot be cured by surgery.4CTSK gene mutation and sporadic MTC. Radiological techniques and genetic analysis played key roles in the definitive diagnosis.In conclusion, the present study is the first to report a rare case of the coexistence of pycnodysostosis with novel


The severity of hearing loss was most frequently mild (pure tone average of ≤40 decibel hearing level). In 22.5% of ears, otitis media with effusion was observed at time of most recent audiogram. Age was not related to mean air conduction hearing thresholds or to otitis media with effusion . In conclusion, hearing loss and otitis media are frequently present in patients with 22q11.2 deletion syndrome. Moreover, our results suggest that children with 22q11.2 deletion syndrome remain susceptible for otitis media as they age.Hearing loss is frequently present in the 22q11.2 deletion syndrome. Our aim was to describe the audiologic and otologic features of patients with 22q11.2 deletion syndrome. We conducted a retrospective cohort study in a single tertiary referral center. We reviewed medical files of all patients with 22q11.2 deletion syndrome who visited an otolaryngologist, plastic surgeon or speech therapist, for audiologic or otologic features. Hearing loss was defined as a pure tone average  of >20 decibel hearing level. Audiograms were available for 102 of 199 included patients, out of which 163 ears were measured in the required frquencies (0.5–4 kHz). Median age at time of most recent audiogram was 7 years (range 3–29 years). In 62 out of 163 ears (38%), hearing loss was present. Most ears had conductive hearing loss ( First identified in 1983 and later confirmed in the 1990s, patients with velocardiofacial syndrome, DiGeorge syndrome, and conotruncal anomaly face syndrome were found to have a microdeletion in the same genetic region, the 22q11.2 region . This leTbx1, a gene located on the 22q11.2 region (the same region where the microdeletion in 22q11DS is located), is suggested to be required for inner ear development , grommet insertion, tympanic membrane perforation, cholesteatoma, adenoidectomy, adaptation of hearing aids (air or bone conducted) and history of otologic surgery. In addition, we collected all available conventional pure tone audiograms and we reviewed otoscopic reports specifically at time of the most recent audiogram. If these reports were lacking, information on tympanic membrane perforations and grommets could be reasoned if there was a tympanic membrane perforation or grommet in place before and after the most recent audiogram. Then we assumed that those findings were also present during the most recent audiogram.We defined hearing loss as a pure tone average (PTA)  of more than 20 decibel hearing level (dB HL), in concordance with the AAO-HNS 1995 guidelines (apart from 3 kHz where we used 4 kHz) . ConductDue to various practical reasons, in some audiograms, not all hearing thresholds were measured for every frequency. Those missing data were assumed to be missing at random, implying that the missing at random (MAR) assumption was applicable. Therefore, multiple imputation was used to handle missing hearing thresholds . We geneU test to analyze the relation between age and otologic pathology. Linear regression was used to evaluate the effect of age on hearing thresholds. In this evaluation, we did one sensitivity analysis where we excluded outliers. We employed SPSS version 21 for statistical analysis.We used the Mann–Whitney BC hearing thresholds were not measured in 79 ears in the most recent audiogram. Earlier measurements were evaluated in 28 ears, and the BC thresholds from the contralateral ear were adapted in 41 ears. In five patients and ten ears, the BC was never measured, nor was there a BC threshold measured of the contralateral ear. All these ears had AC conduction thresholds in the normal range. In these cases, since they had normal hearing, we assumed that there was no ABG. In 49 ears, where there were at least two audiograms with an interval of at least 1 year, BC thresholds were not measured in the first audiogram. Later measurements were evaluated in 38 ears, and the BC thresholds that form the contralateral ear were adapted in 11 ears. Next, in the most recent and first pure tone audiogram, there were 16% and 25.5% missing hearing thresholds, respectively.We included a total of 199 patients, 102 males, and 97 females. Audiometric measurements were available for 102 patients and 204 ears. Characteristics are shown in Table Considering otoscopic reports at time of the most recent audiograms, a tympanic membrane perforation was present in 31 of 196 ears (15.8%). Grommets were present and patent in 29 of 185 ears (15.7%), otitis media with effusion (OME) was present in 32 of 142 ears (22.5%), and 22 of these 32 ears had a history of grommet insertion. In addition, 2 of 142 ears (1.4%) had acute otitis media (OMA) while a grommet in place (purulent otorrhoea).There were two ears with immeasurable BC thresholds with measurable AC thresholds. In one of those two ears, there was an immeasurable BC threshold at 4 kHz, where the AC threshold at 4 kHz was 100 dB HL, the frequencies 0.5–2 kHz showed an ABG of 10–30 dB, and we interpreted this audiogram as mixed hearing loss. The other ear had immeasurable BC thresholds at 0.5 and 1 kHz with AC thresholds of 60 and 65 dB HL, interpreted as a pure sensorineural hearing loss in the low frequencies, but overall as a mixed hearing loss, because the ABG was 20 dB at 2 and 4 kHz.Overall, patients had received their most recent audiogram between 1995 and 2015. The median PTA AC threshold was 17.5 dB HL (range −1.3 to 57.5 dB HL), and the median of PTA BC threshold was 2.4 dB HL (range −9.4 to 46.3 dB HL). There were 163 ears where every frequency  was measured and hearing loss was found in 62 of these ears (38%)  scan .In four ears (three patients), a sensorineural component in combination with a conductive hearing loss (mixed hearing loss) was observed. In all of these ears, the severity of hearing loss was moderate with a median of PTA AC threshold of 50.6 dB HL (range 46.3–56.3 dB HL) and a median of PTA BC threshold of 37.5 dB HL (range 33.8–46.3 dB HL). CT scanning of one patient (out of three) with bilateral mixed hearing loss revealed soft tissue opacification of the right middle ear, but no malformations. Another patient with unilateral mixed hearing loss had an anterior inferior cerebellar artery loop on the same side (left) as the ear with mixed hearing loss, shown on magnetic resonance imaging of the petrous bone including the cerebellopontine angle. However, no specific cause for the hearing loss could be found. The last patient with unilateral mixed hearing loss was diagnosed with a tympanic membrane perforation in both ears, but no other pathology potentially causing the mixed hearing loss was identified.p = 0.43). However, age was significantly related to  the average BC thresholds (p = 0.03), and the slope for this linear regression line was very small (0.27). There were two outliers (two ears from one patient), aged 29 years with poor hearing. In the sensitivity analysis without these outliers, there was no significant relation between age and AC or BC hearing thresholds . The median age of patients with OME during the most recent audiogram was 7 years (range 3–14 years). Age at time of the most recent audiogram was not related to the presence of OME (p = 0.11).Figure In 104 ears, at least two audiograms were available with an interval of at least 1 year Fig. . 31 of tIn 23 of 104 ears, at least 20 dB difference was shown (range 20–50 dB) between the first and most recent AC thresholds at 1 kHz. Nine of these 23 ears showed worsening (median 20 dB), whereas the remaining 14 ears showed improvement (median 27 dB). Out of those 23 ears, 13 ears were diagnosed with an otologic abnormality during otoscopy at time of the first or most recent audiogram, four had a tympanic membrane perforation, six ears had  OME, and two ears had OMA in combination with a grommet in place. One ear had a recurrent stenosis of the external auditory canal, not present at time of the first audiogram.For BC at 1 kHz, 37 of 104 ears had the same hearing level over time, 40 ears showed improvement [median improvement was 5 dB (range 4–20 dB)], and 27 ears (24 ears before multiple imputation) showed worsening [median decrease 9 dB (range 4–26 dB)]. Seven of 104 ears showed a difference of ≥20 dB in BC at 1 kHz between the first and most recent audiograms. Evaluation of other frequencies shows a roughly similar trend (Fig. We described the otologic features of 199 patients and the audiometric results of 163 ears in patients with 22q11DS. Hearing loss was frequently present in our study population and was predominantly conductive with a mild severity. Previous studies regarding 22q11DS report similar results , 16–18. At time of the most recent audiogram, 22.5% of all ears had OME. This number is higher compared to the normal population, where the reported prevalence of children aged 7.5–8 years is around 6% . In anotAC hearing thresholds seemed not to change with aging in our population. Moreover, age was not related to OME during the most recent audiogram. This suggests that children with 22q11DS continue to be at risk for otitis media with effusion as they age. This is consistent with Reyes et al. who found the same prevalences of OME in age younger than 3, 4–7 years and older than 7 years . In the Surprisingly, none of our patients had a pure sensorineural hearing loss and mixed hearing loss was only seen in four ears. This prevalence is considerably lower compared to other studies , 15–18. The main limitation of this study was that it was performed in a tertiary referral center. Some of the more regular pathology such as otitis media or tympanic membrane perforation will presumably be treated in primary or secondary care. Our number of tympanic membrane perforations, a history of ventilation tubes or adenoidectomy could therefore be underestimated. Another limitation is the fact that audiograms were available in 51%; selection bias is likely since patients with assumed normal hearing are less likely to undergo audiometric evaluation. In addition, patients with OME or other otologic anomalies are more likely to receive an audiogram; therefore, our results for otologic manifestations at time of most recent audiogram are likely overestimated.In conclusion, hearing loss and otitis media are frequently present in patients with 22q11DS. Moreover, our results suggest that children with 22q11DS remain susceptible for otitis media as they age. Although conductive hearing loss is presumably largely caused by otitis media, future studies are needed to assess the cause of sensorineural and conductive hearing loss.