During the COVID-19 pandemic, telemedicine quickly expanded. Broadband speeds may impact equitable access to video-based mental health (MH) services.To identify access disparities in Veterans Health Administration (VHA) MH services based on broadband speed availability.Instrumental variable difference-in-differences study using administrative data to identify MH visits prior to  and after COVID-19 pandemic onset  among 1176 VHA MH clinics. The exposure is broadband download and upload speeds categorized as inadequate , adequate , or optimal (download and upload  ≥100/100 Mbps) based on data reported to the Federal Communications Commission at the census block and spatially merged to each veteran’s residential address.All veterans receiving VHA MH services during study period.MH visits were categorized as in-person or virtual . By patient, MH visits were counted quarterly by broadband category. Poisson models with Huber-White robust errors clustered at the census block estimated the association between a patient’s broadband speed category and quarterly MH visit count by visit type, adjusted for patient demographics, residential rurality, and area deprivation index.P < 0.001) and decreased in-person visits .Over the 6-year study period, 3,659,699 unique veterans were seen. Adjusted regression analyses estimated the change after pandemic onset versus pre-pandemic in patients’ quarterly MH visit count; patients living in census blocks with optimal versus inadequate broadband increased video visit use (incidence rate ratio (IRR) = 1.52, 95% CI = 1.45–1.59; This study found patients with optimal versus inadequate broadband availability had more video-based and fewer in-person MH visits after pandemic onset, suggesting broadband availability is an important determinant of access-to-care during public health emergencies requiring remote care.The online version contains supplementary material available at 10.1007/s11606-023-08120-8. Predictors of reduced adoption include age, income, education, rurality, and establishing care as a new patient.13 The availability of adequate broadband Internet speeds needed for streaming video may also be a critical factor.In the last decade, technology advancements allowed consistent delivery of face-to-face  care via streaming video. Further, the equivalence of tele-MH services to in-person care is well-established across outcomes, including symptom improvement, adherence, and patient satisfaction.14 but depending on the number of devices simultaneously streaming content, latency, and other factors, higher download and upload speeds may be needed. Combined, these factors contribute to a “digital divide,” or the gap between those who do and do not have ready Internet availability and Internet-capable devices. VHA has attempted to bridge this divide by supplying patients Internet-connected devices, and negotiating with telecommunication companies to provide free unlimited data to veterans while using VHA video telemedicine,17 but such programs may be limited in rural or other inadequate broadband connectivity areas.17 Although the COVID-19 pandemic offered the opportunity to adopt new technologies, it also highlighted and potentially exacerbated existing care disparities, including between individuals with and without broadband speeds adequate for video-based telemedicine.18For this study, broadband refers to the connection between the patient’s home to a VHA provider using streaming video. According to the Federal Communications Commission (FCC), video telemedicine requires minimum download/upload speeds of 25/3 Megabits per second (Mbps), In this study, we evaluate whether access to tele-MH services differed between veterans living in areas with optimal versus inadequate broadband speeds. We hypothesized that in the transition from in-person care to telemedicine at the onset of the COVID-19 pandemic, patients residing in inadequate broadband speed areas would have lower video telemedicine use. In these areas, we further hypothesized telephone care would supersede video and overall MH visits would be reduced. Identifying veterans with a measurable disparity in broadband availability may help evaluate the impact of unequal access to and use of tele-MH and inform health system policy initiatives to reduce the digital divide.19 The study was approved by the University of Iowa Institutional Review Board and the Iowa City VA Healthcare System Research and Development Committee. We conducted this work without direct patient contact using data routinely collected in the electronic health record and deemed of minimal risk; therefore, a waiver of informed consent was obtained.This is an instrumental variable difference-in-differences analysis using a retrospective cohort of VHA MH outpatient visits from October 1, 2015, to December 31, 2021. We followed the Strengthening the Reporting of Observational Studies in Epidemiology reporting guideline.20 and census block-based broadband availability using FCC Fixed Broadband data.21Data were obtained from the Veterans Informatics and Computing Infrastructure, an integrated system including all VHA electronic health records and administrative data. Patient-level data, including demographics, date, and outpatient delivery method, was obtained from the Corporate Data Warehouse. The 2010 Census Bureau TIGER/Line shapefile contains geographic entity codes. These data were spatially merged with the fiscal year-specific latitude and longitude of each Veteran’s home address to identify their census block group-based area deprivation index (ADI), a measure of neighborhood socioeconomic disadvantageThe study cohort included all veterans with an outpatient VHA MH visit between October 2015 and December 2021. Using 500-series stop codes, we included all in-person, telephone, or video-based MH encounters, as well as all specialty, non-specialty, and primary care-embedded MH encounters. We excluded care received at residential rehabilitation centers or nursing homes, and domiciliary care.22 broadband technology speed capabilities, BroadbandNow quarterly reports,23 and senatorial calls to update broadband speed minimums to 100/100 Mbps.24 For each census block, the number of fixed Internet providers offering broadband at these speed thresholds was identified using December 2019 FCC Form 477.21 Broadband categories were assigned based on the highest broadband speed combination available, with at least one provider reporting such speeds. Fixed wireless and satellite Internet were excluded because these technologies, though available virtually everywhere, have low subscription rates, high costs, and less reliability compared to other broadband technologies.25 We note though FCC data is available biannually throughout our study period, variability in this definition over time was minimal.Our primary exposure included census block broadband speeds at the patient’s residence, categorized as the availability of (1) inadequate , (2) adequate , or (3) optimal (download and upload  ≥100/100 Mbps) broadband speeds. These speed thresholds are derived according to the FCC adequate speeds definitions,We assessed MH clinic visits by clinic stop codes and classified into mutually exclusive categories: in-person, telephone, or video-to-home via VA Video Connect. Once categorized, we calculated the number of MH visits per quarter by visit modality by patient and total MH visits per patient per quarter were enumerated. Visits were categorized as being pre- (October 2015–February 2020) or post-pandemic onset (March 2020–December 2021).26 Race and ethnicity were self-reported. Race was categorized as Black or African American, other , and White. Ethnicity was reported as being Hispanic, Not Hispanic, or other .Patient demographics included age, sex, race, ethnicity, and patient rurality identified using the geocoded location of the patient’s home using Rural Urban Commuting Area codes and dichotomized into urban and rural .We performed a difference-in-difference analysis evaluating the differences in MH visit count and MH visit modality in the period prior to and after onset of the COVID-19 pandemic. The dependent variable was a patient’s number of MH visits per quarter, by visit modality from October 2015 thru December 2021. Independent variables included a binary indicator for time before and after pandemic onset, a categorical variable of broadband speed category, and their interaction. The model was adjusted for patient characteristics, rurality, ADI, and quarter-year fixed effects using the Poisson model structure with Huber-White robust standard errors clustered at the census block. We report incidence rate ratios (IRRs). All hypothesis tests were two-sided with an a priori 0.05 level of significance. We plotted quarterly visit rates by modality and overall, from October 2017 to December 2021, as well as by broadband category. All analyses were conducted using SAS Enterprise Guide, version 8.2, and SQL Server Management, version 18.8.Video visits are most impacted by broadband availability. Thus, we conducted subgroup analyses to determine whether there was varying association between video visit rates and broadband availability based on demographic factors by running the regression model for each demographic sub-group.During the 6-year study period, 3,659,699 unique veterans were seen by VHA MH clinicians, of which 87.9% were male; 66.6% White; 70.8% urban residing, with a mean age of 57.4 SD = 16.9) years; 35.8% lived in an optimal broadband census block; 57.0% lived in an adequate broadband census block; and 7.2% lived in an inadequate census block   and universally higher after pandemic onset . In adjusted analyses, patients living in optimal versus inadequate broadband census blocks exhibited a greater increase in the rate of video MH visits post- versus pre-pandemic (IRR = 1.52 95% CI = 1.45–1.59); increases were less but still significantly different when comparing adequate versus inadequate broadband categories .P < 0.001); decreases were similar for adequate versus inadequate broadband categories .Telephone MH visits per 100 patients per quarter varied based on broadband speeds pre-pandemic  and were higher in all categories after pandemic onset . In adjusted analyses, patients living in optimal versus inadequate broadband census blocks experienced a smaller increase in the rate of telephone MH visits over the study period 27 and developing innovative telemedicine solutions should be considered.The COVID-19 pandemic required a rapid transition from in-person visits to telemedicine. We examined whether this adjustment was associated with MH utilization among veterans by broadband speeds. Overall, MH visits have not recovered to pre-pandemic levels regardless of broadband category. For veterans living in inadequate broadband service areas, MH visit rates were significantly lower before the pandemic began. This disparity widened as in-person visits were restricted, despite the growth of telephone and video visits. With VHA’s continued commitment to provide care where and how veterans need it, and the amenability of MH services to telemedicine,28 In many treatment contexts, MH services delivered by video or telephone have been noninferior to in-person care.4 Because visual cues may provide useful clinical information and improve patient-clinician rapport among other benefits, access to video-based care becomes a quality-of-care issue. Nonetheless, telephone-based access is preferable to no access and may even be favored in some instances. For example, in a study of 25 primary care, MH, and pediatric clinicians in community health centers, Chang et al.29 reported although MH clinicians acknowledged issues reading body language and facial expressions during telephone psychotherapy visits, telephone allowed greater privacy and at times increased sharing. Although most patients preferred video-based encounters, some preferred telephone underscoring the importance of patient preferences when evaluating treatment delivery options.29Telephone-based visits increased in all groups after pandemic onset. Those with optimal (or adequate) versus inadequate broadband were less likely to use telephone, aligning with recent research.30. These programs represent valuable alternatives while residential broadband expands in areas of greatest need. These include Clinical Resource Hubs (CRH), which use team-based, technology-facilitated care to increase access to primary care, MH, clinical pharmacy, and other specialties;31 MH CRHs were established in 2019 in all 18 VHA Veterans Integrated Service Networks.32 These “hubs” serve medically underserved “spoke” sites through telemedicine or in-person care, allowing veterans to receive care at their local VA clinic if broadband adequacy precludes home tele-MH encounters. In over 450 sites nationally, CRHs served over 680,000 veterans between September 2019 and September 2020.33VHA has invested considerable resources in tele-MH services and developed a digital divide consult to overcome infrastructure-related barriers, including tablet distribution to eligible veterans and resources for discounted Internet access34 and experience larger unadjusted suicide rates.35 In previous research, although video-based MH care increased for rural and urban populations, rural veterans received a smaller proportion of their care via video during the pandemic.37 However, a recent study found rural versus urban residents were more interested in tele-MH services38 and take advantage of mental health services as they become available39 underscoring the need for educational and exposure opportunities  for telemedicine at key points in the access trajectory.40 According to our study, despite improvements,42 this may be due in part to broadband coverage limitations, which are more prevalent among rural populations and will not be quickly resolved. To overcome this issue, VHA could expand clinical video telehealth, which connects a veteran at a VHA community-based clinic to a provider elsewhere. This may require a continuation of the clinic-based broadband upgrades that took place in 2018–2021. Additionally, as eligible veterans obtain community-based care thru VHA due to drive time and access standards43, opportunities for collaboration across healthcare systems extending tele-MH access may exist. In a recent pilot study, eligible rural veterans were connected to VHA telemedicine appointments following clinic appointments at federally qualified health centers, mitigating issues with home broadband connectivity.45 The VHA should also work with infrastructure partners, like the FCC and telecommunications companies, to prioritize broadband Internet development based on the greatest community-level impact.These results should be considered specifically among rural populations, who often live in MH professional shortage areasThis research has limitations. First, we did not account for patient comorbidities, clinician familiarity, or other factors affecting telemedicine demand including digital literacy or socioeconomic status. Second, we were unable to distinguish when a video visit reverted to telephone thereby possibly overcounting video visits when broadband was inadequate. Understanding the technology barriers affecting video-based telemedicine should be considered. Finally, FCC data inadequacies, including our inability to jointly account for cellular service, which is reported by technology types (versus speeds) and coverage areas (instead of census blocks) and imprecise reporting standards , may affect the estimation of broadband availability. We acknowledge individual barriers may exist to accessing the maximum broadband speed available within the census block, including cost, infrastructure changes, veteran preferences, digital literary, or other reasons. Despite these limitations, this work is the first we are aware of using FCC data by varying speed thresholds to triangulate the impact of broadband availability and disparities in VHA tele-MH services.The COVID-19 pandemic dramatically expanded tele-MH in VHA. Though MH services are well-suited to video-based telemedicine, disparities based on broadband availability are a growing equity concern. This study adds to the growing literature about MH visits, video-based telemedicine, and the impact of broadband availability on both.Supplementary file1 (DOCX 40 KB)Below is the link to the electronic supplementary material.


Forty-nine children who started wearing cartilage conduction hearing aids (CC-HAs) before completing elementary school  were followed-up and examined. The wearing and utilization status of the CC-HA and its progress to date were evaluated. In addition, 33 participants who purchased the CC-HAs were interviewed to assess the wearing effect. Eleven of seventeen children with bilateral hearing loss and 25 of 32 children with unilateral hearing loss continued to use the CC-HAs. In terms of wearing effect, a good wearing effect was reported, even by those with unilateral hearing loss. In cases where it was difficult to wear CC-HAs stably with pasting or ear tips, it was possible to fix them stably using commercially available hair bands and eyeglass vines. In two cases, the CC-HAs were worn from infancy. With ingenuity and appropriate educational and medical support, it is possible to wear CC-HAs from infancy. Acoustic energy traveling from a cartilage conduction transducer to the cochlea reportedly occurs via three different pathways . The firThe third pathway, first reported in 2004, involves bone and cartilage conduction via the skull from the transducer to the cochlea (cartilage–bone pathway) . Unlike Air and cartilage–bone pathways are common routes that operate based on the same principles that pertain to regular air and bone conduction hearings, respectively. AC and BC hearing aids (HAs) use the first two types of sound transmission pathways. In contrast, the cartilage–air pathway is not a common sound conduction route. Applying vibrations generated by gently placing a transducer on the auricular cartilage can transmit audible sounds with clarity similar to that of AC or BC, leading to the development of a new type of hearing aid called a cartilage conduction hearing aid (CC-HA) ,4. HowevCC-HAs can amplify and transmit sound signals to the inner ear by simply attaching a vibration generator to the skin of the auricular cartilage ,6. In coSince the release of CC-HAs, the attachment-only method has become the preferred option and has gained popularity as an alternative to BC-HAs ,15,16,17Since 2020, safety measures such as battery boxes have been fully integrated, allowing the use of the device even for children under three age of 3 years . In the This study enrolled 49 children , including 28 boys and 21 girls, in whom trial hearing was initiated using the CC-HA before primary school age at our hospital. The guardians/parents of these children requested the use of CC-HAs. Trial hearing was initiated between the ages of 0 (3 months) and 11 years in children with bilateral hearing loss and between 0 (6 months) and 10 years in those with unilateral hearing loss. The mean age of the participants was 5.02 ± 2.71 (SD) years.Among the participants with bilateral hearing loss, eight had conductive hearing loss, eight had mixed hearing loss, and one participant could not undergo bone conductometry. Among the participants with unilateral hearing loss, 29 had conductive hearing loss, one had mixed hearing loss, and two could not undergo bone conductometry. Among the participants with bilateral hearing loss, two had chromosome 21 trisomy, and the remaining participants each had Treacher Collins syndrome, chromosome 18 trisomy, FOXP1 syndrome, and Primrose syndrome.The presence of a history of HA use was not observed in cases of unilateral hearing loss, and it was only observed in five of the 17 cases of bilateral hearing loss .Auditory thresholds were assessed by an experienced audiologist in a standard soundproof room using a commercially available audiometer . Pure-tone thresholds were determined using over-ear headphones (125 Hz to 8 kHz) to assess the air conductance thresholds and a calibrated bone-conducting transducer (500 Hz to 4 kHz) to assess the bone conductance thresholds. The sound field (SF) thresholds were evaluated to assess the effects of the CC-HAs. Complementary and non-complementary hearing thresholds were assessed by introducing an azimuthal angle of 0° and transmitting warble tones from a loudspeaker positioned 1 m away from the participant. As the CC-HAs were fitted on only one side in participants with unilateral hearing loss, noise masking was provided to the other ear through headphones such that the test tone could not be heard. The complementary hearing threshold for CC-HAs could not be accurately assessed in participants with unilateral hearing loss; therefore, the hearing threshold was used as the reference value. Behavioral hearing tests, such as behavioral observation audiometry (BOA) and visual reinforcement audiometry (VRA) were used to assess the hearing ability if the participant was too young to undergo the hearing tests described above. Behavioral hearing tests were performed in a manner similar to those used in previous reports from Japan .The devices were fitted at the Sugiuchi Clinic. Participants or guardians were provided explanations regarding the CC-HAs. Concurrently, ENT examinations, hearing tests, and imaging were conducted to confirm HA history and indications prior to initiating the trial hearing. Trial hearing with the fitted CC-HAs was continued for 1–3 months free of charge, and the participants were instructed to assess the usefulness and comfort of using the CC-HA in their daily lives during the trial hearing period. We provided the participants with the option to extend their trial period until a satisfactory agreement was reached, which could be approximately 6 months.The initial adjustment of the HAs was performed using the sedation level version 5 (DSL v5) procedure . This prThe vibration terminal (transducer) of the CC-HA was attached to the skin overlying the tragus cartilage and fixed with a double-sided adhesive tape. As the morphology and location of the tragus and auricular cartilage were not well mapped in patients with microtia or congenital aural atresia, the transducer was carefully applied to the skin overlying the cartilage near the assumed location of the tragus, with a subtle concavity . The souIn principle, the hearing test was initiated as described above. CC-HAs were attached to the posterior parts of both the auricles in participants with bilateral hearing loss. The CC-HAs were fitted to the affected ear in participants with unilateral hearing loss, similar to those with unilateral congenital auricular atresia. The two CC-HAs were fitted for participants with bilateral hearing loss, similar to those with bilateral congenital auricular atresia. The hearing test conditions were the same for participants with one and two CC-HAs.Explanations regarding the indicated HAs, such as bone-conduction HAs, BAHAs , and the ADHEAR system , were provided, and demonstrations via test hearing were also provided, if possible, upon request. Furthermore, the staff at the rehabilitation institution provided information regarding the need for HAs, and the model and adjustment of HAs. The final decision regarding the purchase of HAs was made by the parents based on the HA use thresholds and the combined observations and evaluations of the parents and caregivers.This study was conducted in accordance with the “Ethical Principles for Medical Research Involving Human Subjects”  as stateThe overall purchase rate was evaluated and the participants were divided into two groups based on whether the CC-HA was purchased: purchase and non-purchase groups. Information regarding age, sex, condition of the ear fitted with the HA (affected or good ear), and mean hearing thresholds  of the participants were collected and used for comparison. Participants who were too young to undergo hearing assessments such as sound field thresholds were excluded from the study.The following methods were used when the HAs could not be stabilized by attaching CC-HA transducers and sound processors.Use of hairband: In this method, a silicone rubber was sewn onto a commercially available flat rubber-like hairband to which the hearing aid body was fixed. The transducer was subsequently attached to double-sided adhesive tape .Use of eyeglasses: In this method, the sound processor of the CC-HA was fixed to the temple of the glass using rubber or silicone rubber, and the transducer was subsequently attached .The participants or their guardians who purchased the CC-HAs were interviewed during the consultation to understand their post-purchase status, and the participants were evaluated. The questions included the duration and effectiveness of HA use and requests for HA use. Questions and options regarding the duration and effectiveness of HA use were determined in advance.Among the 17 participants with bilateral hearing loss, 11 (64.7%) had purchased a CC-HA. Among the 32 patients with unilateral hearing loss, 25 (78.1%) had purchased CC-HAs. We examined the average hearing thresholds according to age, bilateral hearing loss, and unilateral hearing loss and divided the participants into purchase and non-purchase groups; however, no significant difference was observed between the purchasing and non-purchasing groups in terms of any of the measured characteristics . Among tThere were various reasons for not purchasing the CC-HAs. Among the five participants with bilateral hearing loss in the non-purchase group, the parents of a 3-month-old infant selected the BC-HA because of its ease of attachment and detachment. The parents of the 6-month-old infant started using the BC-HA at a different hospital. The parents of a 7-year-old patient with bilateral microtia who was currently using a BC-HA (with a fabric headband) wished to continue using the BC-HA until ear reconstruction surgery. A child with right external auditory canal stenosis and a left middle ear anomaly was found to have an enlarged right external auditory canal during the process of making an ear impression for CC-HA ear tip fabrication; thus, AC-HA was selected.Furthermore, a 4-year-old child with chronic otitis media and immunodeficiency with selective IgG2 deficiency (Primrose syndrome ) had theSeven participants with unilateral hearing loss in the non-user group refrained from purchasing HAs because of their personal reluctance to use it.Some participants were too young and it was very difficult to measure the hearing thresholds, even at the sound field threshold, and a few participants, especially in the non-purchase group, chose not to wear the HAs early and did not undergo measurement. Hearing aids other than the CC-HA, that is, the BC-HA or AC-HA, could only be auditioned in the binaural hearing loss group. Of the cases with this comparative hearing loss, the SF thresholds for each HA were measured in eight cases (five with the CC-HAs and three without it). All these patients had better thresholds with the CC-HA than without HAs, with the CC-HA being better than or equal to other HAs in all cases except for one in the non-purchased group . The AC-A questionnaire survey was conducted during the post-purchase evaluation of 36 cases, and responses were obtained from 33 participants. All participants with bilateral hearing loss (100%) and 22 of 25 participants with unilateral hearing loss (88.0%) responded to the survey . Three pRegarding the effectiveness of wearing, among the statements “noticed voices from behind more easily”, “easier understanding of conversations in noisy places, such as parks or restaurants”, “better understanding of the direction of sounds and voices”, and “easier understanding of conversations with multiple people”, participants with bilateral hearing loss and unilateral hearing loss responded with “strongly agree” or “agree” in over 50% of the cases . HoweverThe wearing behaviors of the participants are shown in Among the 22 participants with unilateral hearing loss, one participant reported wearing CC-HA from “morning, upon waking up” to “night, before going to bed”, one participant reported wearing CC-HA until “returning home”, and the majority of 15 participants (68.2%) reported wearing CC-HAs from “when going to nursery school/school” to “returning home”. One participant reported wearing CC-HA “only at nursery school/school” and the remaining four participants reported wearing CC-HAs only when spoken to .The requests for HA usage were classified into six categories (n = 46): “concerns regarding adhesives (tape)”, “issues with wearing and handling”, “concerns regarding shape and structure”, “waterproofing concerns”, “concerns regarding background noise”, and “concerns regarding social acceptance”. Among these categories, “concerns regarding adhesives (tape)” were the most common (34.8%), with noticeable responses indicating that the tape tended to become less adhesive over time, owing to sweat. The second most common category was “issues with wearing and handling”, accounting for 23.9% of the responses, with difficulties mentioned in children independently using and putting on the device .Case 1 was a 3-year-2-month-old girl born at 37 weeks and 1 d of gestation, weighing 2690 g. The patient had multiple malformations (Treacher Collins syndrome), including micrognathia, ptosis, down slanted palpebral fissures, and cleft palate. Tracheotomy was performed after 9 days. The patient required medical care and attended school for the deaf and Kotoba-no-mori.The first visit was at the age of 6 months. Trial hearing with the CC-HA with both the transducer and attached body was initiated, and the clinical course was mostly favorable. Trial hearing with the BC-HA (with a fabric headband) was initiated for comparative listening purposes. Both HAs had similar wearing efficacies . HoweverCase 2 was of a child aged 1 year and 11 months who was born at 38 weeks of gestation and weighed 2398 g. Chromosomal abnormalities (chromosomes 18 and 3) and FOX P1 syndrome were identified. The patient is currently receiving education at a municipal development facility. Significant stenosis was observed in both the external auditory canals during the initial visits at the age of 1 year and 1 month. The possibility of conductive hearing loss was indicated by the auditory steady-state response (ASSR). Following the experience in Case 1, the HA was attached to a commercially available cloth headband, with the transducer placed outside the band for testing purposes . By the This study aimed to evaluate the effectiveness and fitting/wearing status of the CC-HA in children with hearing loss, and to examine the indications for HAs in children as they grow older. The primary finding of this study was that it is possible to continuously and stably wear HAs from infancy by devising a fitting method while monitoring developmental status and wearing conditions. The discovery of cartilage conduction pathways has uncovered new possibilities for auditory function.Continuous monitoring should be accompanied with specific strategies for children with unilateral hearing loss and latent disabilities . HearingWe initiated a trial hearing of the CC-HA in 49 cases, ranging from infants to elementary school students, and 36 patients proceeded to decide on and utilize the device. While promoting the suitability of CC-HAs for infants and young children, particularly those with developmental disorders, we encountered difficulties in achieving stable attachment using the recommended methods of adhesion or ear tips alone. Initially, we proposed attaching the transducer using a double-sided tape and securing it further with tape ; howeverTreacher Collins syndrome (as seen in Case 1), also known as mandibulofacial dysostosis, is an autosomal dominant inherited genetic disorder with an incidence of 1 in 50,000 ,28. CommFOXP1 syndrome (Case 2) is associated with intellectual disability, language impairment, autism spectrum disorder, myotonia, mild dysplasia, and congenital abnormalities of the brain, heart, and urinary system. Hearing loss has also been reported in patients with this syndrome. Lozano et al.  reportedIn this study, five participants with bilateral hearing loss had a history of HA use prior to the CC-HA trial. Four participants used bilateral BC-HAs, and one participant used AC-HA on the side without external auditory canal stenosis. The preference for switching to the CC-HA primarily came from caregivers because of limited wearing time, concerns regarding esthetic aspects, and discomfort caused by the pressure of the BC transducer in the BC-HA. Among the three participants with bilateral microtia and external auditory canal atresia, all participants except one, who was awaiting transition to CC-HA after auricular reconstruction surgery, immediately transitioned to CC-HA. In one participant with unilateral microtia, external auditory canal stenosis, and contralateral ear ossicular malformation, external auditory canal enlargement was observed while making a near impression of the CC-HA, resulting in the selection of the AC-HA. In cases of bilateral hearing loss with microtia, external auditory canal closure, or stenosis since birth, conventional BC-HAs (with cloth headbands) are commonly used by both medical professionals and caregivers because they are easy to wear and readily available. However, CC-HAs offer the potential for stable use from infancy by adapting the wearing method as the child grows and are expected to have wider applications. This adaptation requires repeated prototyping. Moreover, collaboration with parents, especially the mother, is essential, as the mother observes the child’s behavior and experiences the benefits of wearing a HA. The support and involvement of healthcare professionals and caregivers are crucial in increasing the motivation for wearing HAs and encouraging their active utilization.An evaluation of the post-purchase experience revealed that HAs were used almost throughout the day by participants with bilateral hearing loss. Moreover, both individuals and their surroundings experience the positive effects of their usage. Similar results were observed in the participants with unilateral hearing loss; however, there were some instances of shorter wearing times. Educational and medical support are crucial for the effective use of HAs, particularly in cases of unilateral hearing loss. Additionally, a higher proportion of individuals with unilateral hearing loss reported perceiving the benefits of wearing a HA compared to those with bilateral hearing loss, which may be attributed to the presence of non-usage periods, making the effects of the HA more noticeable. This is believed to reflect the binaural hearing effects reported by Kagaet al. . RegardiIt is assumed that, in the case of bilateral hearing loss, patients are more open to wearing HAs, irrespective of the type, to improve their quality of life and learning abilities. On the other hand, if the child has hearing loss on only one side from birth, caregivers are not keen on providing HAs. In this context, the high rate of device purchase by children with unilateral hearing impairment demonstrated the perceived utility of binaural hearing. The findings also suggested that CC-HAs are one of the most comfortable HAs to wear, and provide reliable and adequately amplified speech.Participants with unilateral hearing loss had no history of using HAs, and the CC-HA was the first HA selected for these participants because there were limited options available in terms of other models, as they required surgical intervention. In recent years, implants such as the BAHA Attract System (Cochlear Limited), Bonebridge , and Sophono  have been developed. In the case of children, the decision to undergo surgery is primarily made by caregivers (parents). Considering the currently available evidence, identifying one type of HA  over others is not justified. When deciding on a particular HA, the cases that are more adaptable should be defined. Furthermore, patients’ perceived functional gains, specific hearing status, extent of hearing loss in individual patients, and the cost of HAs should be considered. In pediatric cases, it is also important to consider the developmental status. However, the use of CC-HAs as a policy until the age when the child’s own will can be taken into consideration is also an important option.Even in cases where it is challenging to use AC-HAs, such as in patients with external auditory canal closure, the ability to consistently use HAs from infancy is crucial for the development of language and communication skills in children with hearing loss. The CC-HA allows for continuous and stable usage from infancy to early childhood by adjusting the fitting method according to a child’s growth. The use of CC-HAs involves utilizing options such as headbands or attaching the HAs to glass frames. The device is likely to reduce the physical and psychological burden on the infant, as well as on parents or caregivers. Parents of a high percentage of children with unilateral hearing loss in this study purchased and used HAs, indicating positive sentiments toward the device. Collaboration with caregivers is necessary for implementing these adaptations, and an effective use of HAs requires educational and medical support.


Hearing loss is the most common sensory deficit experienced by humans and represents one of the largest chronic health conditions worldwide. It is expected that around 10% of the world's population will be affected by disabling hearing impairment by 2050. Hereditary hearing loss accounts for most of the known forms of congenital deafness, and over 25% of adult-onset or progressive hearing loss. Despite the identification of well over 130 genes associated with deafness, there is currently no curative treatment for inherited deafness. Recently, several pre-clinical studies in mice that exhibit key features of human deafness have shown promising hearing recovery through gene therapy involving the replacement of the defective gene with a functional one. Although the potential application of this therapeutic approach to humans is closer than ever, substantial further challenges need to be overcome, including testing the safety and longevity of the treatment, identifying critical therapeutic time windows and improving the efficiency of the treatment. Herein, we provide an overview of the recent advances in gene therapy and highlight the current hurdles that the scientific community need to overcome to ensure a safe and secure implementation of this therapeutic approach in clinical trials. Severe or profound deafness in children impacts on the development of spoken language and the ability to read, which has consequences for academic performance and ultimately employability. In cases where hearing loss occurs later in life, such as with progressive hearing loss, people tend to become socially isolated, leading to feelings of loneliness and depression. When untreated, midlife-acquired hearing loss represents the largest modifiable risk factor for cognitive decline and dementia ,2.https://hereditaryhearingloss.org/). Much less is known about the genetics underlying progressive, late-onset hearing loss, since it is influenced by environmental factors such as noise, drugs and past infection ). 2Otof gene, has facilitated the development of the first adeno-associated virus (AAV) vector for OTOF-mediated deafness in human patients. In late 2022, three separate clinical trials have been approved for DFNB9: OTOF-GT by Sensorion (https://www.sensorion.com/en/our-approach/restore-treat-prevent/), DB-OTO by Decibel Therapeutics (https://www.decibeltx.com/pipeline/) and AK-OTOF by Akouos (https://akouos.com/our-focus/).Gene therapy is primarily aimed at either replacing, suppressing or editing faulty genes to treat disease ,30. The Tmc1 [Vglut3 [Otof [Pjvk [Eps8 or those causing Usher syndrome when mutated . Thig. Gjb6: ,47). In g. Gjb6: . Therefoin utero. In mice, the cochlea is immature at birth and requires at least another two–three weeks to reach full maturity [Another important consideration is the different developmental timelines between mice and humans. In humans, the auditory system is fully functional at birth, with auditory startle reflexes appearing from around 24 weeks gestation . Therefomaturity . The conAn additional solution would be to identify the forms of congenital deafness that would be amenable to gene therapy at later stages, once the cochlea has fully developed (curing hearing loss rather than preventing it). This could also include the identification of deafness genes that, when defective, cause a more progressive deterioration of cochlear function, such as those involved in ARHL. In both cases, the gene therapy approach would benefit from a longer therapeutic window for intervention. The success of this approach will depend on further fundamental and pre-clinical research being carried out, including the identification of novel AAV variants that can efficiently target inner ear hair cells, as well as the optimization of their delivery into both neonatal and adult mice. Moreover, further development is required in the use of cell-specific promoters, which will also help to reduce the ectopic expression of genes in off-target cell types. Finally, more research is required to determine the possible side effects of the therapy in the cochlea in terms of inflammation and immunotoxicity. The immune response to AAVs in humans is still largely unknown , but ong. 3OTOF gene. Given current knowledge and progress, AAV gene therapy represents a promising prospect for ameliorating, preventing or even curing hereditary hearing loss that affects millions of people worldwide. However, we have to remain aware that several challenges need to be overcome before any gene therapy for hearing loss can be applied to patients, which could take several years after the successful completion of clinical trials . Some o


Maintaining independence in activities of daily living (ADL) is essential for the well-being of older adults. This study examined the relationship between demographic and living situation factors and ADL independence among community-dwelling older adults in Norway.p < 0.05.Data was collected in Norway between 2017 and 2019 as part of the fourth wave of the ongoing Trøndelag Health Study (HUNT) survey, sent to all citizens in Trøndelag county over 20 years of age, which is considered representative of the Norwegian population. Included in the current cross-sectional study were 22,504 community-living individuals aged 70 years or older who completed the survey and responded to all items constituting the ADL outcome measure. Group differences in ADL independence were examined with Chi Square tests, while crude and adjusted associations with ADL independence were examined with logistic regression analyses. Statistical significance was set at The participants reported a high degree of independence in primary ADL and slightly lower in instrumental ADL. In the fully adjusted analyses, ADL independence was associated with lower age, female gender, higher levels of education and income, higher subjective well-being, having no chronic or disabling disease, and having someone to talk to in confidence. Surprisingly, women who were married had higher likelihood of ADL independence than unmarried women, whereas married men had lower likelihood of ADL independence than unmarried men.In addition to known demographic and disease-related factors, the social context affects independence in ADL even in a society that offers advanced health and homecare services to all older adults equally. Furthermore, the same social setting can have differential effects on men and women. Despite the healthcare system in Norway being well-developed, it does not completely address this issue. Further improvements are necessary to address potential challenges that older adults encounter regarding their social connections and feelings of inclusion. Individuals with limited education and income are especially susceptible to ADL dependency as they age, necessitating healthcare services to specifically cater to this disadvantaged demographic. In Norway, as well as globally, the older adult population is increasing due to a rise in life expectancy . The curAging in place refers to older adults living independently in their own homes, alone or with family . This idA relevant model for aging in place is the Competence-Press Model of aging that was introduced by Lawton and Nahemow , which eGaugler et al.  reportedSeveral studies have reported that aging is generally associated with a decrease in ADL independency . Higher Although older adults living in the community generally have sufficient levels of ADL abilities, demographic and living situation factors may play a crucial role in sustaining these abilities and preventing institutionalization , 29. ThiPrior research has investigated several factors within individuals that may impact their performance in ADL, including factors such as physical, spiritual, cognitive, and emotional aspects . In addin = 56.042, 54.0% in North Trøndelag and n = 107.711, 42.6% in South Trøndelag), indicating small risk of selection bias. However, participation was slightly higher among people aged 40–79 years, and lower among those who were unmarried and living in urban areas. The sample was ethnically homogeneous, limiting generalizability to people with non-European backgrounds , which is one of the world’s largest and most comprehensive ongoing population-based health surveys . The popkgrounds .n = 10,003, 44.4%). Approximately a third of the sample had higher education , and 12,619  were married.Of the 26,668 adults aged 70 years or older that completed the HUNT4 survey, 22,504 (84.4%) lived in their own home and responded to all items constituting the ADL outcome measure used in this study. These individuals were included in the data analyses. The sample consisted of 10,905 (48.5%) men and 11,599 (51.5%) women, with the larger proportion aged 70–74 years (Participants filled out the questionnaires at the field station or their (nursery) home, after they had been informed about the study and provided consent. Study assessors were available in case of questions .ADL independence was assessed on 16 discrete activities of daily living. Seven of the items were primary ADL  and the remaining nine items were instrumental ADL . On each item, the participants indicated whether they were able or unable to perform the activity independently. A dichotomous variable was constructed based on the ADL items, where participants were classified according to their ability to perform all ADL independently (1) or not (0), and used as outcome variable in the analyses.Age was collected as a continuous variable and categorized into 70–74 years, 75–79 years, 80–84 years, and 85+ years of age. Information was also collected about gender . For this study, educational level was categorized as elementary school, high school or vocational training, and higher education. Household annual income (in NOK) was categorized as less than 250,000, between 251,000 and 450,000, between 451,000 and 750,000, and above 750,000.Perceived health was assessed with one item: “How is your health at the moment?” Response options were “poor,” “not so good,” “good,” and “very good.” Higher scores indicated better perceived health. The participants were also asked whether they had a chronic and disabling disease or injury, with response options “yes” and “no.”The participants indicated whether they were married, unmarried, widow(er), separated, divorced, or did not want to respond. Subsequently, a dichotomous marital status variable was created by distinguishing between those reporting to be married and those who reported otherwise.Social support was measured with the question: “Do you have someone who can provide help when you need it?” Response options were “yes” and “no.” Closeness was measured with the question: “Do you have someone you can talk to in confidence?” Response options were “yes” and “no.”No secondary data was used in the current study.Individuals with missing scores on variables other than the ADL measures were removed casewise. Missing values constituted between 0 and 12.6% of the total amount of data, with only two variables containing more than 3% missing values . ADL independence was defined as having an ADL score of 16, indicating the ability to perform all specified activities independently.r = 0.25, p < 0.001), otherwise correlations were between 0.09 and 0.10.ADL independence was cross tabulated with all independent variables, and group differences in proportions with full ADL independence were examined with Pearson’s Chi Square coefficient. We checked for multicollinearity among the explanatory variables by examining bivariate correlations between conceptually related variables . Social support and closeness were associated with a small to medium effect size  for the unadjusted and adjusted associations between each of the independent variables and ADL independence. Thus, each OR indicates the change (increase or decrease) in likelihood for being classified as ADL independent by each increase in the relevant independent variable. Possible interactions were examined post-hoc in logistic regression analyses. Statistical significance was set at n = 4,403, 19.6%), the mean ADL score was 13.2 (SD 2.7).The number and proportions of the sample being independent in each of the ADL are displayed in Independence in all ADL was reported among larger proportions of individuals in the younger age groups, among women, and among those with higher levels of education and household income. Similarly, independence in all ADL was more frequently reported among individuals with better perceived health, and among those who reported no chronic or disabling disease or injury during the past year. Independence in all ADL was also more frequently reported among individuals who were married and individuals who had someone they could talk to in confidence see .p < 0.001) with pseudo R2 ranging between 0.18 (Cox & Snell) and 0.29 (Nagelkerke). Individuals of higher age were significantly less likely to report ADL independence compared to their younger counterparts, whereas females were more likely ADL independent than men. Individuals with higher levels of education had higher likelihood of being ADL independent, compared to individuals with elementary education. Higher levels of household income were associated with ADL independence. Similarly, better perceived health and reporting not having a chronic or disabling disease or injury were associated with higher likelihood of ADL independence.Results from the univariate and multivariate logistic regression analyses are displayed in Of the living situation variables, being married was associated with higher likelihood of ADL independence in the unadjusted analysis, while this association was reversed in the multivariate analysis. Reporting having social support was unrelated to ADL independence in both unadjusted and adjusted analyses. Having someone to talk to in confidence was related to higher likelihood of ADL independence.The effect of gender on ADL independence was larger in the adjusted model compared to the unadjusted model, whereas the association between marital status and ADL independence was reversed when adjusting for all variables. To explore a possible explanation for these results, we examined the interaction between gender and marital status in explaining ADL independence.p < 0.05). In contrast, among women, being married was associated with higher odds of ADL independence .A logistic regression model including gender and marital status as the only independent variables revealed a statistically significant association between female gender and ADL independence, and also between being married and ADL independence. When included in the second step, the interaction term gender × marital status was significant, suggesting that the association between marital status and ADL independence was dependent on gender. Hence, we examined the associations between marital status and ADL independence separately for men and women. Among men, being married was associated with lower odds of ADL independence  can affect morbidity to a larger extent than marital status. An earlier study found that individuals living with a partner had lower morbidity rates compared to those living alone, and that excess risk of illness among the never married, widowed, and divorced was reduced by 40–70% for most health measures after controlling for living arrangement . These fWhile the results of the current study confirm and further validate previously established scientific understanding, the present study provides several insights to existing knowledge. Firstly, despite the evidence that social surroundings impact ADL and IADL, there is a scarcity of large-scale studies conducted in Europe, and none has been conducted in Norway , 31, 32.Older adults place high importance on maintaining ADL independence. Therefore, it is crucial to identify modifiable factors that contribute to the onset of ADL disability and can inform the development and employment of support mechanisms.As longevity increases, home care services need to be designed to meet increasing needs for support from community-dwelling older individuals, especially those who are 85 years or older.Special attention should be paid to supporting independence in ADL for community-dwelling individuals with lower education and income, as this can contribute to an active and longer independent life, lower demands for home care services, and lower expenditures. A recommendation from this study involves directing special attention toward aiding independence in ADL for those who lack confidants. Furthermore, these findings indicate that even in a fully established homecare system within an egalitarian welfare state such as Norway, there is a requirement for additional development to tackle the potential challenges faced by older adults concerning their relationships and sense of belonging. In turn, this enhancement may serve to maintain older people’s independence in ADL.The main strengths of this study are a large and representative sample of Norwegian older adults and access to a wide range of variables that may be relevant for ADL functioning.The outcome measure (ADL independence) might be challenging to define as it encompasses large variation; some individuals may have difficulty with one activity while others struggle with multiple activities. At the same time, what one is capable of doing is rarely a fixed capacity across different situations, and factors such as daily form and context may affect independence but were not taken into account. Furthermore, while “marital status” most often implies living with a partner, “not married” can obscure whether people are in fact living in a paired relationship with another person. Thus, results related to marital status should be treated with some caution. Social support, closeness, and perceived health status were all measured using single-item scales. Thus, the constructs underpinning these measures may be somewhat loosely defined and subject to the respondents’ interpretation.Generally, missing data is a threat to the validity of results, and sophisticated methods for overcoming problems with missing data have been developed in recent years . HoweverAs our study is cross-sectional, we are unable to identify factors that may impact ADL independency over time. In addition, we cannot establish the direction of statistical relationships. Nevertheless, this study identified focus areas that can be examined longitudinally across multiple HUNT surveys in future research.This study has highlighted several demographic and living situation factors that are significantly associated with independence in ADL among community-dwelling older people in Norway, namely age, gender, education, household income, perceived health, marital status and having someone to talk to in confidence. People with lower levels of education and income are at particular risk of experiencing ADL dependency in older age, and policymakers and healthcare services should target this disadvantaged group. Additionally, the study’s most intriguing results indicate that the social context holds influential and enduring impacts on independence in ADL even in a society where advanced health- and homecare services are provided to all older adults in need. Furthermore, similar social environments can exert varying influences on men and women. Even though health services in Norway are highly developed, they might not fully tackle this concern. Taking proactive measures, such as selecting, compensating, and optimizing interactions with relationship partners, can have a favorable influence on the aging process and on effectively managing the challenges associated with growing older.http://www.ntnu.edu/hunt/data). The following licenses/restrictions apply: the data are stored in the HUNT Databank and biological material are stored in the HUNT Biobank. The HUNT Research Centre has permission from the Norwegian Data Inspectorate to store and handle these data. The key identification in the data base is the personal identification number given to all Norwegians at birth or immigration, while de-identified data are sent to researchers upon approval of a research protocol by the Regional Ethical Committee and the HUNT Research Centre. To protect participants’ privacy, the HUNT Research Centre aims to limit storage of data outside of the HUNT Databank, and cannot deposit data in open repositories. The HUNT Databank has precise information on all data exported to different projects and are able to reproduce these on request. There are no restrictions regarding data export given approval of applications to the HUNT Research Centre. Requests to access these datasets should be directed to the HUNT Research Centre, kontakt@hunt.ntnu.no.The data analyzed in this study was obtained from the Trøndelag Health Study .SR, BV, and TB contributed substantially to the conceptualization and design of the study. TB performed the statistical analysis and reported the findings. All authors contributed to the interpretation of the data. SR wrote the first draft. BV and TB revised it critically for important intellectual content. All authors contributed to the article and approved the submitted version.


In patients with bilateral asymmetrical hearing loss (AHL), where only one hearing aid is available, it is difficult to decide which ear to amplify. The aim of this study was to evaluate the outcomes of hearing aid use for AHL patients fitted with a hearing aid in their worse ear only. One-hundred-two adults with asymmetrical-mixed or sensorineural hearing loss were retrospectively included. AHL was classified into three subgroups: unilateral hearing loss (UHL) and AHL type 1 (AHL1) and type 2 (AHL2). The main outcome measures were (1) the time spent wearing a hearing aid, (2) the hearing in a noise test (HINT), (3) the sound localization test and (4) the Korean version of the International Outcome Inventory for Hearing Aids (IOI-HA). The 1 kHz-hearing threshold of the better ear was significantly better in the successful users than in the intermittent users for UHL. Younger age was associated with significantly better outcomes than older for AHL1 and AHL2. Among the etiologies of AHL, sudden hearing loss was associated with significantly better outcomes of hearing aid use for AHL, UHL and AHL1 patients. In this study, the success rate and usage rates were 43.1% and 67.6% in AHL patients wearing a hearing aid in the worse ear. This study identified the hearing threshold of 1 kHz from the better ear, age and etiology of sudden hearing loss as audiometric and non-audiometric factors that affected the outcomes of hearing aid use. For a long time, there have been many studies to find out the factors which are good enough to consistently differentiate successful from unsuccessful hearing aid candidates ,4,5,6,7.Although it is well-known that two hearing aids are the best for bilateral hearing loss, we often encounter a lot of cases where patients can only afford one hearing aid for bilateral hearing loss for economic reasons. If only one hearing aid is affordable, selecting which ear to amplify in cases with bilateral symmetrical hearing loss is not difficult. However, approaches in selecting which ear to amplify are quite different between unilateral and bilateral hearing aids. We often encounter AHL cases in which binaural symmetry cannot be accomplished with hearing aid(s). In some situations where only one hearing aid is permissible to patients with AHL, the 60 dB HL rule has been a simple, practical guideline but is inadequate when deciding which ear should be fitted with a hearing aid. Because only a few researchers have reported the choice of either ear (better or worse) for monaural amplification in patients with AHL, we have frequently struggled to determine which ear should be fitted for a hearing aid. In many cases of AHL, we have empirically prescribed a hearing aid to the worse ear, based on audiometric data, surveys and patient interviews, and found that our choice was not wrong in most cases. However, we have often encountered cases in which the side fitted with a hearing aid changed from the worse ear to the better ear during the process of counseling and fitting. This discrepancy between the clinician’s recommendation and patient acceptance has been a big problem in real situations.Our alternative hypothesis was that empirical prescription of a hearing aid to the worse ear in cases with AHL could reduce the interaural difference in the hearing and contribute to better satisfaction for a hearing aid. To prove this hypothesis, we analyzed cases with AHL in which a hearing aid was prescribed to the worse ear. In addition, the secondary objective of this study was to identify any predictable factors that might influence hearing aid outcomes.This retrospective observational study recruited Korean adults with AHL who purchased a hearing aid at one secondary-referral, university-based hospital. The inclusion criteria were as follows: (1) 19 years old or above; (2) asymmetrical hearing loss; (3) sensorineural or mixed-type HL; (4) ear anatomy compatible with wearing a conventional hearing aid; and (5) hearing aid fitted to the worse ear. The exclusion criteria were (1) conductive hearing loss; (2) fluctuating hearing loss; (3) observed neurological or psychiatric disorder; (4) inadequate cognitive competence for responding to questionnaires; and (5) self-reported physical or mental health unsuitable for hearing aid fitting and use. Patients with some visual problems, those with tinnitus and those with balance problems were not excluded, but patients belonging to the deaf community and users of sign language were excluded.The degree and type of hearing loss were classified using the four-frequency  pure-tone average thresholds (PTA4) and the criteria set by the World Health Organization . AHL is At 1, 2, 3, 6 and 12 months after the purchase, a hearing aid fitting was performed by one author (H.N.) using the National Acoustic Laboratories (NAL) formula. The hearing aid setting was modified and fitted using Noah software (Hearing Instrument Manufacturers’ Software Association (HIMSA)) or the manufacturer’s fitting programs. The fine-tuning procedure was primarily performed to solve the patient’s subjective discomfort. To avoid interference with the better ear, we did not force it to reach the target gain. The real ear-aided response (REAR) was checked with a FONIX FP35 Portable Hearing Aid Analyzer  to verify the proper gain only in case of unusual discomfort. Twelve months post-fitting, the performance of hearing aid use were evaluated and classified into three groups: (1) successful users, (2) intermittent users and (3) failed users. Successful users met all of the following criteria: (1) wearing the hearing aid for more than four hours per day; (2) wearing the hearing aid for twelve months or longer after purchase; (3) showing improved speech discrimination score more than 2% in the hearing in noise test (HINT); (4) showing improved sound localization; and (5) scoring 21 points or more in the International Outcome Inventory for Hearing Aids (IOI-HA) . PatientThe clinical files of 102 patients were included in the analysis (37 men and 65 women with an average age of 63 ± 14 years). The demographic data of the participants in this study are presented in This study classified the etiologies of AHL into sudden hearing loss, central nervous system (CNS) problems and other unspecified (or unidentified) etiology. The former two were grouped as retrocochlear/neural causes. Twenty-seven patients  experienced AHL resulting from sudden hearing loss. Their PTA4s were 65 ± 12 dB HL for the worse ear and 27 ± 14 dB HL for the better ear. Among those 27 patients, 19 were successful users, 3 were intermittent users, and 5 were failed users. Among all 102 patients, three cases resulted from a CNS problem . Their PTA4s were 68 ± 10 dB HL for the worse ear and 31 ± 10 dB HL for the better ear. One patient was a successful user, and two were intermittent users.This study defined the success rate of a hearing aid as the percentage of successful users who bought a hearing aid and the usage rate as the percentage of successful and intermittent users to patients who bought a hearing aid.Patient selection, interviews for amplification, choice of the aided ear and hearing aid selection and fitting were performed by one author (H.N.). The interview was simply structured, and two questions were developed for AHL. In the beginning, the routine hearing aid counseling styles were similar, putting hearing aids in both ears or to the worse ear. Whoever thinks that their better ear has a normal hearing range and decides to have one hearing aid for the worse ear only, we asked them if the amplified worse ear hears similar loudness compared to the better ear. After the final fitting reached the target gain, the second question was if the client perceived the binaural symmetry. The first question focused on loudness, and the second was focused on space perception or stereo. Most of the clients could express the loudness differences or similarities. Some had difficulties expressing symmetry at first. However, during the follow-up periods, most patients perceived and expressed that they had gained some symmetry.After 12 months post-fitting, four main outcomes were administered: (1) the time wearing a hearing aid, which was investigated using IOI-HA as well as data-logging, (2) the HINT at a fixed intensity at SNR 0 dB, (3) sound localization test at a fixed level of 50 dB and (4) the Korean version of the IOI-HA.The HINT and sound localization were performed in unaided and aided conditions. The HINT was performed in a double-walled, sound-treated booth, and 50 recorded Korean monosyllables were presented using presentation levels from 40 dB in 5 dB steps at a 1 m distance in the sound field while speech spectrum noise was presented with a fixed intensity at SNR 0 dB. The aided–unaided difference in speech discrimination score of more than 2% was a criterion of meaningful difference. The sound localization test was performed in a double-walled, sound-treated booth, and the spondee was presented at a fixed level of 50 dB at 1 m in azimuth of the front, right and left sides in the sound field while the presented azimuth was randomly selected, and the speech was presented during 5 s with a silent interval of 5 s. The examinee answered the direction of a sound source. If the examinee responded to all three directions correctly, we decided that he or she would receive a sound localization. This study defined improved sound localization in which a test result was positive in aided condition regardless of an unaided result.p < 0.05 was considered to be statistically significant. All statistical analyses were performed using IBM®-SPSS® statistics . The data are expressed as the mean ± standard deviation. Differences in numerical values  were examined using the Kruskal–Wallis test for the three outcomes of hearing-aid use and the Mann–Whitney U test for comparing two outcomes (successful and intermittent users versus failed users) in multiple independent samples separated by age, the threshold at each frequency and PTA4. Differences in ordinary values  among the three outcomes for hearing aid use were tested using the chi-squared test in subgroups separated by sex, aided side, type of hearing loss, the subtype of AHL and etiology of hearing loss. A discriminant analysis was performed as a multivariate test of differences among the three outcomes (successful versus intermittent versus failed users) and between two outcomes (successful and intermittent users versus failed users).The probability value of Forty-four patients were successful users, twenty-five patients were intermittent users and thirty-three patients were failed users. The success rate of a hearing aid worn in the worse ear in cases with AHL was 43.1% (=44/102) in this study. The usage rate was 67.6% (=69/102).p = 0.041; 59 ± 13 years old for successful users; 67 ± 12 years old for intermittent users; and 65 ± 15 years old for failed users). No other frequencies significantly differed with three outcomes  , only age and etiology significantly differed among the three or two outcomes of hearing aid use. Successful users were younger than intermittent users (outcomes a or two outcomes b. Compar= 0.006) e.For three outcomes (successful users versus intermittent users versus failed users), the discriminant function was D = −2.886 + . For two outcomes (successful-intermittent users versus failed users), the discriminant function was D = −3.797 + .p = 0.046; 13 ± 6 dB HL for successful users; 19 ± 7 dB HL for intermittent users; and 17 ± 8 dB HL for failed users) (p = 0.021) (The hearing threshold at 1 Hz for the better ear was lower for successful users than for intermittent users (d users) a,b. Comp= 0.021) c.For three outcomes (successful user versus intermittent user versus failed users), the discriminant function was D = −3.637 + .p = 0.040) (p = 0.040)  c. Compar= 0.040) d. No sigp = 0.007; successful users, 63 ± 11 years old; intermittent users, 76 ± 4 years old; and failed users, 73 ± 8 years old). For the AHL2 subgroup, no specific frequency significantly differed with three outcomes  Should we recommend unilateral or bilateral hearing aids to them? (2) If only one hearing aid is preferable or feasible, should the better or worse ear be fitted? In South Korea, many patients with symmetrical or asymmetrical hearing loss buy only one hearing aid, and the second question is a serious dilemma in real clinical situations. For monaural amplification in AHL, two self-questions are useful in selecting the ear to be aided. (1) If the better ear is aided, can aided hearing improve speech detection as well as understanding for the AHL patient? (2) If the worse ear is aided, can the patient understand better in quiet as well as in noisy environments and obtain the advantages of binaural hearing? Actually, these two questions address the same issue: which ear sends higher-quality signals to the brain when aided? In answering that question, the 60 dB HL rule offers a simple, practical principle for fitting a monaural hearing aid to an AHL patient. Briskey  stated tOnly the hearing threshold at 1 kHz in the better ear in the UHL group was significantly lower (better) for those who continued hearing aid use. Why is the hearing threshold on the better ear (not wearing a hearing aid) significantly lower? This is not a common-sense result, but it is interesting. The possible explanation comes from the main role of a patient’s better ear in hearing and listening. In many patients with AHL who are monaurally fitted in the worse ear, aided hearing in the worse ear may remain supplementary, especially in situations in which the sound of interest is soft and comes from the side of the aided ear. While speaking in a group conversation or where there are multiple talkers or noises, the better ear can still play the main and crucial role . Our finA second interesting finding was that age influenced hearing-aid use for all cases and patients classified as AHL2 cases. Three subgroups of UHL, AHL1 and AHL2 are quite distinct from each other. UHL seems to be suitable for monaural amplification, but AHL1 is likely to be a candidate for binaural amplification. AHL2 seems to be a dilemma for the selection of which ear to amplify monaurally; if the worse ear is amplified, binaural symmetry can be accomplished, but both ears’ hearing is more likely to be handicapped. If the better ear is amplified, the patient may only receive one serviceable hearing ear. The heterogeneity of both hearing thresholds in cases with AHL2 could explain why younger patients with AHL2 showed better hearing aid use outcomes than older patients. The influence of age may be explained by younger patients’ lifestyles and listening environments, but this study did not analyze them. Because younger patients are likely to have better binaural central processing and better plasticity of the CANS , they maA major limitation of this study was its retrospective design. Because this study included only AHL cases wearing a hearing aid in the worse ear, we cannot present any evidence to determine which ear, better or worse, should be fitted with a unilateral hearing aid in AHL. The second limitation is the subgrouping of AHL. We defined them based on the degree of hearing loss. Many authors have stated that the shape of hearing loss  should be considered because the amplification range of hearing aids can be limited according to the frequency range. This study analyzed the parameters among three subgroups but did not consider the differences in demographics . For example, some patients only needed to wear their hearing aid for less than 4 h per day while at work or in a classroom but managed well otherwise, therefore making them not necessarily ‘intermittent’ users. Other issues to consider might include which environment the patient spent most of their day. If they worked in a very noisy factory, it would make sense that they remove the hearing aid while working to avoid amplification of noise. This was why this study analyzed the parameters between two outcomes (successful-intermittent users and failed users). Considering this limitation, we also restricted ‘failed users’ to cases in which a patient returns his or her hearing aid or gives up wearing it. In this study, the etiologies of AHL were classified into three groups . For an individual, the exact specific etiology of hearing loss cannot be easily evaluated because many causes have been mixed, including aging, noise, head trauma, ototoxic drug and so forth. So, we had to focus on specific etiology, which could be sorted quite exactly based on the history taken and the past imaging studies. When evaluating the outcome of a hearing aid, the time of use with the hearing aids is an important factor, as is the frequency of a hearing aid use or the contexts of use. Although the frequency of hearing aid use is also important, this parameter may be too difficult to be used as a comparison variable because of too-large individual variation and too much recall bias. The contexts of hearing aid use are very important, but we did not analyze them because of too much recall bias, and it was too difficult to classify and standardize them as a comparison variable. This study included IOI but not specific instruments to evaluate the outcomes of satisfaction with hearing aid use, such as Expected Consequences of Hearing Aid Ownership (ECHO), Satisfaction with Amplification in Daily Life (SADL), Quebec User Evaluation of Satisfaction with assistive Technology (QUEST) or Psychosocial Impact of Assistive Devices Scale (PIADS). We hope that future study considers these two limitations of this study.There are too many factors influencing hearing/listening as well as hearing aid performance, such as, for example, audiometric factors , personal factors , demographic factors  and external factors  ,5,36. A Unfortunately, we failed to find any specific hard-and-fast fitting rules for AHL in this study. It means that the only way to judge whether patients with AHL can successfully use a hearing aid in their worse ear is to fit a hearing aid, give them time to adapt, and then make appropriate adjustments. We hope that our results may provide further evidence supporting the efficacy of unilateral hearing aid fitting to the worse ear in patients with AHL.In this study, the success and usage rates were 43.1% and 67.6% in AHL patients wearing a hearing aid in the worse ear, which was much higher than those of previous data in South Korea.This study found audiometric and non-audiometric factors as predictable factors affecting the outcomes of hearing aid use. Only one audiometric factor in AHL affected the outcomes of hearing aid use: the hearing threshold of 1 kHz of the better ear had statistically significant effects on the success of hearing aid use in UHL. As the non-audiometric factor, age was statistically significant in AHL2. The etiology of sudden hearing loss was another non-audiometric factor that had statistically significant effects on the outcome for patients with AHL, especially in UHL.


Hearing results after chronic ear surgery encompass recurrence, localization and extent of cholesteatoma, type of surgery, ossiculoplasty methods, but rarely interpret intraoperative findings. This study aimed to analyze the impact of intraoperative findings in revision tympanomastoidectomy in predicting postoperative hearing.This was a retrospective non-randomized cohort of 101 patients treated for recurrent chronic otitis media by tympanomastoidectomy. The patients’ demographics, localizations of disease recurrence and perioperative hearing results were analyzed.Logistic regression showed that presence of tympanic perforation (p=0.036), ossicular chain damage (p=0.006), were negatively associated with improved hearing postoperatively. Attic cholesteatoma was associated with better postoperative hearing (p=0.045). Presence of tympanic perforation (p=0.050), alongside perifacial localization of imflammation (p=0.021) and ossicle destruction (p=0.013) were associated with worse postoperative hearing results. Multivariate analysis confirmed that tympanic perforation , and ossicular chain involvement , were consistent negative predictors of hearing improvement, while postoperative deterioration of hearing was associated with tympanic perforation  and facial nerve dehiscence .Comparison of postoperative revision tympanomastoidectomy hearing outcomes revealed significant positive reductions in air-bone gap values, primarily at low and mid frequencies. Postoperative hearing results at high frequencies are not affected by revision surgery. Revision canal-wall-up (CWU) and canal-wall-down (CWD) tympanomastoidectomy represent strategies aimed at eliminating recurrent or residual pathological processes from the tympanic cavity and reconstructing the ossicles and tympanic membrane ,2. The pattern of cholesteatoma spread is determined by the place of its origin, involving and eroding surrounding structures and causing intratemporal and intracranial complications ,4. WhileMany papers compare hearing outcomes after primary CWU and CWD procedures, listing recidivism and disease patterns, surgery type and hearing restoration methods as factors influencing postoperative hearing outcomes -9. HowevThe aim of this study was to analyze localization of disease in revision tympanomastoidectomy procedures and link them to postoperative hearing outcomes. It is our hypothesis that localization of disease recurrence may be helpful in assessing postoperative hearing outcomes.Data of 101 chronic otitis media patients that underwent tympanomastoidectomy for recurrent disease were enrolled in this retrospective comparative cohort study. The study protocol received IRB approval according to relevant ethical Helsinki principles . Inclusion criteria included the following: patients that underwent revision tympanomastoidectomy  from January 1st, 2010 to May 1st, 2019 in a high-volume otologic center, if the procedures were carried out by the same otologist, with available surgical data and preoperative and postoperative hearing outcomes recorded. Our follow-up concept was scheduling bi-monthly exams and performing planned second-look surgery in all suspect patients 6 months after the initial surgery. Non EPI-diffusion MRI was not routinely used. Indications for revision surgery were constant otorrhea with suspected recurring disease. Variables included demographics, type and number of surgeries, intraoperative findings, pure tone average air-bone gap (ABG) values (dB) concerning speech discriminating frequencies (500 Hz - 4000 Hz), in accordance with Committee on Hearing and Equilibrium recommendations. Average ABG was calculated from bone conduction (BC) – air conduction (AC) difference at frequencies of 500 - 4000 Hz, following American Academy of Otolaryngology, Head and Neck Surgery (AAO-HNS) recommendations, using an AC40  audiometer with TDH-39 earphones . InformeExclusion criteria were: absent surgical details, deafness and absent audiometric data. This excluded 32 patients from the initial cohort . In the cohort with complete follow-up (69 patients), twelve anatomical sites and extent of disease were noted, and analyzed with regard to postoperative hearing outcomes. Postoperative hearing threshold gain in decibels was labeled as the primary outcome. The follow-up PTA was performed 6 months after surgery. A postoperative ABG change of > 10 dB was considered to be significant. Statistics were calculated using SPSS . Associations between variables were analyzed using binary logistic regression and a general linear model multivariate analysis of variance (MANOVA). All tests of were performed using a two-sided 5% type I error rate.Preoperative findingsMean age of patients was 39,91 years, from 7 to 81 years. The study included 33 male and 36 female patients. There were 41 patients with defects in the tympanic membrane, while 33 had suspected cholesteatoma on otoscopy. Out of 69 patients, 39 were surgically treated only once, while 30 had multiple procedures, with 1,47 surgeries per patient on average, and average time since last surgery was 8,44 years. Of the 69 patients in the study, 13 had been previously treated in our otologic center. There were 47 CWU tympanomastoidectomies and 22 CWD tympanomastoidectomies. In the CWD group, seven patients were previously treated by a CWU surgery, and 15 had disease that required a CWD surgery outright. Intraoperative findings and hearing outcomesThe tympanic membrane was perforated in 59,42% cases, and was affected by cholesteatoma-related retraction pockets in approximately half of the patients. Recurrent disease and inflammation were the ossicles in 55,07%. This area was followed by erosion of the posterior and superior external auditory canal wall in 52,17% patients, high facial ridge in 50,72% and attic recurrent disease in 42,03%, mastoid recurrence in 36,23% and 36,23% patients .Cholesteatoma recurred in 33  patients. According to the ChOLE classification in patients with cholesteatoma, there were 18 patients in stage I , twelve patients in stage II  and three patients in stage III .The average preoperative and postoperative PTA values and postoperative ABG shifts were analyzed at 500 Hz, - 4000 Hz frequencies, depending on surgery type . The average ABG reduction at 500 Hz was 9.06 dB (±11.94), at 1000 Hz it was 11.41 dB , at 2000 Hz it was 8.28 dB (±13.051), and at 4000 Hz, it was 8.28 dB . The average total postoperative reduction of the ABG across all speech discriminating frequencies was 37.34 dB (±26.089).Logistic regression dependent variables were twofold - improvement of postoperative hearing (reduction of air-bone gap) and deterioration of postoperative hearing (increase of air-bone gap) -6.The logistic regression model did not identify ChOLE stage as a predictor of hearing outcome. However, when individual anatomical sites of residual disease and cholesteatoma were compared, the presence of tympanic perforation , and ossicular chain involvement , were identified as the strongest negative predictors of hearing improvement (air-bone gap reduction). Attic involvement was identified as a positive predictor of hearing improvement (air-bone gap reduction) . When analyzing intraoperative sites at risk for the deterioration of hearing (increased air-bone gap), tympanic perforation , perifacial residual disease  and ossicular chain involvement  were singled out as the most accurate predictor variables of hearing deterioration.In order to control for potential sources of bias and confirm our results, a multivariate analysis using a general linear model multivariate analysis of variance (MANOVA) was used. It confirmed that tympanic perforation , and ossicular chain involvement , were consistent negative predictors of hearing improvement. When analyzing factors correlated with postoperative deterioration of hearing, tympanic perforation  and facial nerve dehiscence  were the strongest predictors of hearing deterioration postoperatively.After analyzing the regression model for correlation of intraoperative sites, PTA hearing thresholds and the type of revision surgery, CWU patients had a significantly lower postoperative PTA values in all frequencies , but no postoperative ABG reduction was identified among the CWU and CWD patients. In contrast, the intraoperative presence of recurring cholesteatoma was correlated with a lower postoperative PTA hearing threshold affecting 500 Hz, 1000 Hz, but not the 2000 Hz and 4000 Hz frequencies in both CWU and CWD surgeries . In patients that demonstrated a postoperative ABG reduction >10 dB, it was statistically significantly demonstrated in the 500 Hz  and 1000 Hz frequencies , while the 2000 Hz and 4000 Hz frequencies remained unchanged postoperatively. Both canal-wall up and canal-wall down techniques represent two strategies for chronic otitis media management. Literature has discussed the advantages and disadvantages of these techniques extensively -15. We aCholesteatoma was found in 47,83% revision cases, forming a retraction pocket (recurrent disease) or left behind after the previous surgery . If the patient has undergone CWU previously, a more radical CWD procedure may be required in order to eradicate the disease . The preAssociating recurrence sites and hearing outcomes has significant prognostic value. Conductive hearing loss following chronic otitis media surgery can be anticipated by analyzing ossicular and acoustic coupling ,20. PostSome localizations of the recurrent/residual disease are associated with hearing improvement, while others with hearing deterioration, indicating that likely and probable postoperative hearing outcomes have to be discussed in a realistic and data-reliant way .Positive predictors of hearing deterioration in our study were tympanic perforation, perifacial residual disease and involvement of the ossicles, all contributing to defective sound transmission, with tympanic perforation and facial nerve canal dehiscence confirmed as significant predictors by multivariate analysis. Facial nerve dehiscence is a frequent anatomical landmark in all patients, especially in those with longstanding disease, and may be associated with adjoining difficulties in ossicular defect reconstruction in recurring disease and revision surgery ,25A tympanic membrane reperforation was found in 59,42 % cases. It causes persistent otorrhea and conductive hearing loss and those are symptoms that reduce the quality of life and represents an important etiological factor in cholesteatoma formation since squamous epithelial cells can migrate from the external ear to the tympanic cavity. Recurrent perforation and ossicle involvement were identified as the most important negative predictors of hearing improvement. When comparing the outcomes of primary tympanoplasties with revision cases with ossicular destruction, primary surgeries provide better results, both with regard to closing the perforation of the tympanic membrane and hearing improvement . In our There are many factors affecting the choice of the adequate surgery technique. CWD procedure provides better visualization and the complete removal of cholesteatoma. Kerckhoff et al. claim that the risk of cholesteatoma recurrence and residual cholesteatoma is lower in CWD procedures 0-13,2%) comparing to CWU 16,7-61%) ,25. Howe,7-61% ,2,2% compaOur data show that the majority of patients with cholesteatoma have poor preoperative hearing (ABG >20 dB). Patients who have had CWU surgery showed significantly lower preoperative and postoperative PTA values at all frequencies , with no difference in postoperative ABG reduction was noted among the CWU and CWD groups, confirming that both types of surgeries are suitable for achieving hearing improvement, which is not significantly different in terms of total ABG reduction, but with inferior preoperative hearing thresholds in CWD patients. fenestra rotunda and cochlear promontory, which is crucial for the perception of high frequency sounds (In patients that demonstrated a significant postoperative ABG reduction, it mostly involved 500 Hz and 1000 Hz frequencies, which is consistent to previous studies . In normy sounds ,26. No dy sounds . The canThe main limitations of this study are a small, heterogeneous sample, retrospective data collection and a short postoperative follow-up interval. Hearing results had precedence over reconstructive materials or techniques in our analysis. Analyzing hearing outcomes between CWU and CWD procedures might pose a risk of bias, due to differences in operating technique, indication and extent of surgery.In revision chronic otitis media surgery, the type of procedure can significantly affect postoperative hearing. Air-bone-gap shifts indicated that improvements are possible, primarily at low and middle frequencies, with a sustained hearing loss occuring at high frequencies. Sites of recurrence of the disease can be linked to the postoperative hearing outcome which is helpful in determining the prognosis. Careful surgical planning using extrapolated data on anatomical pitfalls is important to reduce the need for further revision surgeries.