The countless methods available to analyze hearing recovery in idiopathic sudden sensorineural hearing loss (ISSHL) cases hinder the comparison of the various treatments found in the literature.This paper aims to compare the different criteria for hearing recovery in ISSHL found in the literature.This is an observational clinical cohort study from a prospective protocol in patients with ISSHL, treated between 2000 and 2010. Five criteria were considered for significant hearing recovery and four for complete recovery by pure tone audiometry, using non-parametric tests and multiple comparisons at a significance level of 5%. After determining the stricter criteria for hearing recovery, vocal audiometry parameters were added.p < 0.001) as they were analyzed together. Mild auditory recovery occurred in only 35 (27.6%) patients. When speech audiometry was added, only 34 patients (26.8%) showed significant improvement.There was a significant difference between the criteria (There is a lack of consistency among the criteria used for hearing recovery. The criterion of change of functional category by one degree into at least mild hearing recovery was the stricter. Speech audiometry did not prove essential to define significant hearing recovery. Sudden sensorineural hearing loss (SSHL) was originally described by DeKleynIncidence rates range between 5 and 20 cases for every 100,000 individuals per yearHearing progress analysis in SSHL patients is more challenging to do than in patients with other inner ear diseases, as various other factors may be present such as vertigo and/or tinnitus, multiple compromised audiometric frequencies, previously established hearing loss or comorbidity, and varying degrees of hearing loss. Additionally, there is a limited number of patients suffering from SSHL, a disease that scarcely ever stems from one single pathologic process.et al.Aside from the challenges listed above, there is no universally accepted standard for hearing recovery in the studies carried out on SSHL. Plontke et al.et al.et al.One of the various parameters used to assess hearing recovery is 10-dB improvements on PTA at 0.5, 1, and 2 kHz described by Stakroos et al.et al.et al.Other forms of assessment have been proposed: Wilson et al.The lack of consistency between the analytical methods used in trials on idiopathic sudden sensorineural hearing loss hinders the establishment of a proper comparison between the various treatments described in the literature. Berliner This study aims to compare the various criteria for hearing recovery described in the literature for patients with sudden sensorineural hearing loss seen at a university hospital.This is a cohort observational trial based on a prospective protocol that included patients from the sudden hearing loss ward of a university hospital affected by idiopathic sudden sensorineural hearing loss seen between 2000 and 2010. This study was approved by the institution's Ethics Committee and given permit number 1540/08.The protocol included patients with unilateral ISSHL of at least 30 dB in at least three consecutive frequencies occurring within up to 72 hours seen at the Sudden Hearing Loss Ward for at least two months or who recovered completely before the end of these two months. All patients included signed a free informed consent form. They were treated with oral prednisone 1 mg/kg/day (maximum daily dosage of 60 mg) for at least one week, and then had their dosages reduced on a weekly basis for up to 21 days. Patients with contraindication for the prescribed prednisone dosages had their dosages reduced or, in a few rare occasions took deflazacort instead.Patients with history of otological disease and cases with a confirmed etiology for sudden hearing loss, i.e., patients showing conditions that may evolve together with SSHL such as trauma, infection, exposure to ototoxic drugs, barotrauma, and suspected for endemic parotitis, were excluded from the study. Patients with retrocochlear disease or malformation in the inner or middle ear detected by inner ear MRI, patients with defined Ménière's disease as per the criteria of the American Academy of Otolaryngology-Head and Neck Surgery FoundationThe sample was analyzed for gender, involved side, and type of audiometric curve. Curves were deemed ascending when reductions were greater than 15 dB in the worst low frequency in relation to the other frequencies; U curves were the ones in which reductions greater than 15 dB were seen in the worst medium frequencies in relation to the worst low and high frequencies; inverted-U curves occur when there are reductions greater than 15 dB in the worst high and low frequencies in relation to medium frequencies; descending curves show reductions of 15 dB in average values from 4 to 8 kHz in relation to the averages seen at 250 and 500 kHz; and flat curves occur when there are differences smaller than 15 dB between the average values seen at 250 and 500 Hz, 1 and 2 kHz, and between 4 and 8 kHz.The auditory assessments of included patients were done by the same speech and hearing therapist. Auditory assessment was made up by pure-tone audiometry at 0.25, 0.5, 1, 2, 3, 4, 6, and 8 kHz, speech audiometry along with speech recognition threshold analysis, and impedance tests for stapedial reflexes. Initial and final audiometric parameters were analyzed, the latter being obtained at least two months after the initial audiometric assessment or earlier in cases where full recovery was observed.Initial and final average values for pure-tone audiometry tests of every patient were collected for the sets of frequencies covered. For low and medium frequencies, average values were gathered for 0.25, 0.5, 1, and 2 kHz; for medium and high frequencies, average values were gathered for 1, 2, 3, 4, 6, and 8 kHz; for high frequencies alone, average values were gathered for 3, 4, 6, and 8 kHz; for low, medium, and high frequencies combined, average values graves of all eight frequencies were collected. Low frequencies were 250 and 500 Hz; medium frequencies were 1 and 2 kHz; high frequencies were 3, 4, 6 and 8 kHz.When hearing thresholds for profound hearing loss were not detected, the upper limit of the device (120 dB) was considered.et al.Tucci PTA recovery (dB) = (PTAII- PTAIH)- (PTAFI-PTAFH).PTA-related percent hearing recovery was calculated as follows:PTA recovery (%)= (PTAII- PTAIH)- (PTAFI-PTAFH)X 100/ (PTAII- PTAIH).Where: PTAII is the initial PTA value in the involved ear; PTAIH is the initial PTA value of the healthy ear; PTAFI is the final PTA value of the involved ear; and PTAFH is the final PTA of the healthy ear.•Criterion A: significant recovery - improvement of at least 10 dB between the initial and final PTA as described by Stokroos et al.•Criterion B: significant improvement - improvement of at least 30 dB between the initial and final PTA or when final hearing thresholds are under 20 dB or the thresholds of the healthy ear have been reached; and full recovery - final hearing thresholds are under 20 dB or the thresholds of the healthy ear have been reached as described by Suzuki et al.•Criterion C: significant recovery - recovery above 20% of the potential improvement; full recovery - recovery above 90% of the potential improvement as described by Penido et al.•Criterion D: significant recovery - improvement greater than 50% on PTA or when final hearing thresholds are up to 10 dB higher than the thresholds of the healthy ear; full recovery - final hearing thresholds are up to 10 dB higher than the thresholds of the healthy ear as described by Wilson et al.•Criterion E: significant recovery - occurrence of change in functional class and mild/normal final hearing loss; full recovery - hearing thresholds are back to normal levels. Patients with pure-tone averages below 25 dB were not considered to have hearing loss; mild hearing loss was diagnosed for PTA values ranging between 26 and 40 dB; moderate hearing loss for the 41-70 dB range; severe for the 71-90 dB range; and profound for PTA values above 90 dB as described by Dallan et al.In order to compare the criteria to assess hearing recovery in ISSHL patients, this paper contemplates five sets of parameters described in the literature to characterize significant hearing improvement and four used to substantiate full recovery based on pure-tone audiometry. All patients categorized as fully recovered were included in the group for significant recovery cases. See below the five criteria:Cochran's non-parametric test was used to compare the five criteria for significant hearing recovery altogether with a significance level of 5%. In order to identify which of the criteria would stand out from others, multiple comparisons were carried out using the Student-Newman-Keuls test with a significance level of 5%. These tests helped pick the stricter hearing recovery criterion.et al.et al.Statistical analysis indicated that the stricter PTA-based criterion was E (see discussion for details). Speech audiometry parameters were added to criterion E, defining that significant hearing recovery occurs when there is an improvement of at least 50% on speech recognition thresholds or when SRT was up to 10 dB above that of the healthy ear and when the initial PB max was under 50% and moved to above 50% or when the initial PB max was above 50% and improved by at least 12%. The speech recognition threshold had to be up to 10 dB lower than that of the healthy ear and the PB max above 90% or equal to that of the healthy ear to consider that full hearing recovery had occurred. These parameters for SRT were based on the paper by Wilson This study looked into 277 patients with sudden sensorineural hearing loss. Eight patients did not meet the standard of having hearing loss of at least 30 dB in at least three consecutive frequencies. Ten were bilateral cases and in 33 the cause of hearing loss could be established. Seventy-five patients were lost during the first two months of follow-up. Twenty-four patients declined to sign the free informed consent term. The final sample stood at 127 patients. Within the valid sample 50.4% were females and 49.6% were males. As to involved ear, 46.5% had their right ear involved and 53.5% had hearing loss in their left ears. Low, medium, and high frequencies were reached in 83.5% of the patients; low and medium in 6.3% of the cases; medium and high in 7.1%; and high alone in 3.1% of the patients. Audiometric curves were categorizes as descending in 40.2% of the cases, flat in 40.9%, ascending in 14%, U-shaped in 3.9%, and inverted-U in 0.8%. Systemic steroids were administered to 100 (78.8%) patients. The absolute average rate of recovery stood at 25.3 dB. When compared to the involved ear, the rate dropped to 23.6 dB. The average relative percent recovery was 37.2%.As we looked at the outcomes based on each criteria analyzed, we could see that when criterion A was used, 89 (70.1%) patients were categorized as presenting hearing recovery. When adopting criterion B, significant recovery was seen on 49 (38.6%) patients and full recovery in 20 (15.7%). By the standards set in criterion C, significant improvement was seen in 82 (64.6%) patients and full recovery in 15 (18.8%). According to criterion D, 44 (34.6%) patients had partial recovery while 24 (18.8%) recovered fully. Based on criterion E, significant recovery was seen in 35 (27.6%) and full recovery in 20 (15.7%) patients.p-value < 0.001 was found in the comparison made between hearing recovery criteria A, B, C, D, and E. Therefore, the criteria were statistically different from each other  patients and full recovery in 20 (15.7%). On average, speech audiometry parameters showed improvements of 36% in auditory discrimination and 33.2 dB in speech recognition thresholds or 37.2% of the potential recovery.Numerous criteria for hearing recovery were utilized in the analysis of our patients in an attempt to cover most of the parameters found in the literature, ranging from pure-tone audiometry to speech audiometry, the latter in terms of speech recognition thresholds and auditory discrimination. The criteria were adjusted to allow for comparisons between them.et al.No significant difference was found in the comparison made between criteria A and C and criteria B and D. Nonetheless, differences were found in all other comparison, thus showing the lack of consistency between the criteria for hearing recovery published in the literature. BylCriteria A and C showed higher hearing improvement percentages than the others. However, they fail to demonstrate the reality of hearing recovery as observed in the clinical setting, once an increase of a meagre 10 dB or even of 20% on pure-tone average values will not amount to anything significant for patients with severe to profound hearing loss.et al.Criterion B used by Suzuki et al.Wilson et al.et al.Criteria B and D showed hearing recovery rates different from the ones seen in their original studies. Wilson et al.et al.Dallan Considering pure-tone audiometry assessment, it is our opinion that criterion E is the one closest to matching the clinical expectations around what significant hearing recovery means. The functional characterization of this criterion includes speech audiometry parameters. Yet, very little difference was observed, as only one patient who moved to mild hearing loss had an auditory discrimination score under 50%. This probably happened because criterion E has stricter hearing recovery parameters than the other methods. It might be that if the pure-tone audiometry criteria are less strict, the importance of speech audiometry as a whole will be greater. Therefore, we recommend that Criterion E be used to assess hearing recovery in ISSHL patients.Despite our findings, we believe that all pure-tone and speech audiometry parameters should be an integral part of the assessment of sudden sensorineural hearing loss patients. Future detailed analyses of this topic will allow us to define the prognostic profile of each patient so as to offer them customized care, bearing in mind that his is an idiopathic disease with myriad etiologies. Thus, the characteristics of initial hearing loss may guide us in the adoption of specific therapeutic approaches as we are better able to tell which patients will not evolve satisfactorily from the clinical and functional standpoints.•There is a lack of consistency in the criteria used to verify hearing recovery in sudden sensorineural hearing loss patients; such inconsistencies hinder the comparison between research findings on the topic. Standardization is urgently required.•The criterion that uses changes in auditory functional class to at least mild hearing loss was the one that had lower rates of significant hearing recovery of all criteria analyzed, and was thus elected the stricter of the lot.•Speech audiometry parameters were not required to define significant hearing recovery.


Hearing thresholds are not always predictive of performance in environments with reduced extrinsic redundancy.To investigate the communication disorders reported by adults with normal hearing, and to assess their underlying conditions through behavioral and electrophysiological testing.This case control study enrolled 20 adults with normal hearing thresholds and divided them into two groups: a case group with 10 adults with hearing impairment-related communication disorders and a control group with 10 adults with normal hearing. The frequency of occurrence of communication difficulties was recorded during speech recognition tests run in quiet and noisy conditions, audiometry, and auditory evoked brainstem potential testing.Case group subjects differed statistically from controls only in self-reported scores of hearing impairment. The groups did not differ in the other ratings. A positive correlation was found between hearing thresholds and scores on self-reported impairment.The combination of hearing complaints and unaltered audiograms was not correlated with differences in performance in speech recognition testing in noisy conditions or in the remaining evaluations. Correlation analysis showed that the higher the pure tone thresholds, the greater were the reported communication difficulties, even in thresholds between 0 and 25 dB. An important factor that leads patients without peripheral auditory disorder to be referred to central auditory processing assessment is difficulty understanding speech in noisy or reverberative environmentsAuditory processing disorder is not the only hearing alteration that may be missed in an audiogram. Alterations arising from the inner hair cells, the auditory nerve, and the efferent system  may not result in disordered pure-tone sensitivity or speech recognition in quiet conditions, but can compromise speech recognition in noisy environmentsMany studies have attempted to understand the conditions underlying central auditory processing disorders. Although hearing difficulty was the reason for patients to have their auditory processing assessed, many individuals submitted to these tests ended up having results within normal range and no further explanation for their complaints.This study aimed to investigate self-reported hearing-related communication difficulties and compare pure-tone thresholds, speech recognition in quiet and noisy conditions, and brainstem auditory evoked potentials (BAEP) of adult subjects with normal audiograms and communication disorders and individuals with normal audiograms and no communication disorders.Twenty patients aged between 16 and 49 years without specific middle-ear complaints and with A-sha-ped tympanogram tracings in both ears were enrolled in the study. This study was approved by the institution's Ethics Committee and given permit 046/2010. All patients signed an informed consent term.Participants were divided into two groups: 1) case group - ten subjects  with hearing thresholds of 25 dBNA and under in all tested frequencies who sought ENT care due to speech recognition impairment; 2) control group - ten subjects  with hearing thresholds of 25 dBNA and under in all tested frequencies with no hearing complaints.Abbreviated Profile of Hearing Aid Benefit). Subjects in the case group had their complaints confirmed through the same protocol.Case group subjects were referred to the study by ENTs and speech and hearing therapists. Sixteen subjects were referred within ten months. They were pre-selected based on their charts, and two were excluded for not meeting the enrollment criteria. The remaining 14 patients were contacted, but one refused to join the study while three were excluded due to altered audiometry results. Control subjects were paired for gender and age against case group individuals. At the time of enrollment they were asked about the presence of hearing complaints. Absence of complaints on the control group was confirmed through a specific protocol  and another group with mean hearing thresholds at 250 and 500 Hz of 15 dB and above (G ≥ 15 dB).The tool used to quantify hearing complaints was the APHAB (Abbreviated Profile of Hearing Aid Benefit) self-assessment scaleSubject self-reports can be assessed based on four different situations represented in four APHAB sub-scales: EC (ease of communication), BN (background noise), RV (reverberation), and AV (aversiveness). The scores in the APHAB scale account for how often patients experience the issues related to each sub-scale as a percentage. Higher scores signify higher incidence of the issues related to each sub-scale. The global score of the APHAB scale is calculated as the mean value of the scores obtained in the EC, BN, and RV sub-scales. Sub-scale AV is not included in the APHAB global score as it is not related to communication situations. Thus, sub-scales EC, BN, and RV were considered to verify the presence of communication-related difficulties in case and control group subjects. The individual scores on each sub-scale were compared to APHAB scores of young adults subjectively deemed normal to characterize the complaints manifested by the subjects enrolled in the study.Hearing thresholds were analyzed for frequencies ranging between 250 and 8000 Hz, with the subjects inside an acoustic booth wearing TDH-39 earphones. A Madsen Electronics Midimate 622 audiometer calibrated as per standard ANSI 1969 was used. Speech recognition tests in quiet and noise were carried out with the same device.The tests were carried out with the subjects wearing TDH-39 earphones, and by playing the LSPDuring the test, subjects were instructed to repeat whatever they could understand from the sentences played to them. They were not trained to cope with the sentences played in noise, and the groups' performances were compared in both situations: first in a test session in which they had not had previous contact with noise (right ear) and in a second session (left ear) after they had undergone the first test session with noise.Subjects' right ears were initially presented the 10 sentences on list 1A at 65 dB without noise. Then list 1B was presented to the same ear at 65 dB with ipsilateral noise at 65 dB (S/N = 0 dB). Finally, list 2B was presented at 65 dB and ipsilateral noise at 70 dB (S/N = −5 dB). The same procedure was carried out for left ears, and the following sentence lists were presented in the same respective order: 3B, 4B, and 6B. A sentence recognition ratio was calculated based on the number of right answers, according to the instruments' instruction manual. Each correctly repeated sentence accounted for 10% of the ratio.Potentials were measured using a Contronic Masbe ATC Plus device. Auditory pathway integrity was assessed by the onset and reproducibility of waves I, III, V, and interpeak intervals I-III, I-V, III-V at 80 dBNA. Tests were carried out in an electrically and acoustically insulated room. Subjects had electrodes placed in their left and right ear mastoids. Click stimuli with altered polarity were presented at a rate of 17.1 clicks per second with an intensity of 80 dBNA to subjects wearing TDH-39 earphones.p< 0.05.As the samples were small and the data did not follow a normal distribution, the Mann-Whitney test was performed to verify the existence of in-group statistical differences. Correlation analysis was done using Pearson's r. Statistical analyses were done using the Statistical Package for the Social Sciences, version 17.0. Statistical significance was attributed when th percentile of the scale's normative values. In this group, eight (80%) individuals had scores above the 95th percentile in sub-scale BN, seven (70%) in sub-scale RV, and six (60%) in sub-scale EC. Two participants (20%) had above normal scores in sub-scale AV (aversiveness). Control group participants had results below the 95h percentile in sub-scales EC, BN, and RV, but two (20%) individuals had scores above the 95th percentile in sub-scale AV.All case group members had scores in at least one of the sub-scales related to communication situations  above the 952 = 12.45; p = 0.002), RV , BN , and AV . The Mann-Whitney test indicated that case group subjects had higher incidence rates of communication disorder in environments favorable to communication (p = 0.002), environments with reverberation (p = 0.000), and in noise (p = 0.009) than controls; no significant differences were seen in situations of aversive sound (p = 0.218).The incidence of communication difficulties varied between case and control subjects, as seen in scales EC .All participants had 100% PRSQ in both ears  and left ears , or both ears were compared . At a signal to noise ratio of −5 dB, the percent recognition rates among controls ranged from 0% to 10%, while case group individuals presented a rate of 0%. The Mann-Whitney test revealed no differences between groups in PRSN at a S/N ratio of −5 dB (p = 0.435) (High levels of variability were observed in PRSN (N/S = 0 dB). The percentage of right answers in the control group ranged from 30% to 100%, and from 0% to 90% among case group subjects. The difference between groups was not statistically significant, either when right (c= 0.435) .Figure 5The differences in the pure-tone thresholds of case and control group individuals were not statistically significant .Figure 6p-value was 0.609.Latencies in the onset of waves I , III (generated in the cochlear nuclei), and V  from the introduction of acoustic stimuli, and interpeak intervals I-III, I-V, and III-V of case and control group members were within normal range. The Wilco-xon signed-rank test showed no statistically significant differences between the latency and interpeak interval values of case and control group subjects. The lowest observed p-value of 0.417). The Kolgomorov-Smirnov test confirmed the absence of differences between case and control groups .Given the lack of difference between ears, the Mann-Whitney test was used to check whether in-group differences were statistically significant, only to find they were not , i.e., the lower the I-V interpeak interval the higher the AV score.BAEP vs. APHAB. Greater thresholds were correlated to higher scores in sub-scales related to communication situations. The thresholds at 250 and 500 Hz were within normal range (≤ 25 dB), but were correlated to sub-scales ease of communication, reverberation, background noise, and global APHAB scores. Thresholds at 1000 Hz were correlated to ease of communication, and thresholds at 2000 Hz were correlated to ease of communication and reverberation. All correlations were positive, i.e., higher thresholds at 250, 500, and 1000 Hz were correlated to higher incidence rates of communication difficulties (p = 0.047).Pure-tone thresholds iculties . AV-relaThe analyses of test results based on pure-tone thresholds showed, according to the Mann-Whitney test, that individuals with thresholds of 15 dB and above reported statistically more communication difficulties than subjects with thresholds under 15 dB . The groThe APHAB scale has been successfully used as an instrument to verify the subjective benefit offered by hearing rehabilitation, including hearing aids, cochlear implants, and auditory trainingth percentile in at least one of the sub-scales related to contexts of communication. Case and control group subjects were statistically different in relation to their auditory complaints. Despite the confirmation of the difference in hearing complaints, the results of the tests run in noise were not statistically different between the groups.Comparisons against the scale's normative values indicated that all case group individuals had scores above the 95The enormous variability observed in the performance of case and control group subjects in recognition of sentences in noise may explain the absence of statistical differences between the groups. The variability seen in the case group was due to sample heterogeneity, a factor that could have been greatly reduced by more stringent enrollment criteria to eliminate the interference of other variables that affect speech recognition in noise, such as memory and attention disorders.,Statistical analysis pointed to the existence of significant differences between ears in the sentence recognition tests in noise of case and control group individuals, with left ears performing better than right ears. This difference may be related to the fact that right ears were tested first for sentence recognition in noise, and left ears may have benefitted from a learning effect. Other authors have also seen improved performance in the second ear tested, regardless of side,This study did not aim to verify the differences in performance between right and left ears. If that were the case, the study would have to be designed in a way to eliminate or mitigate the interferences of the learning effect by, for example, including bilateral ear training before running the tests. Dichotic tests carried out in studies that looked into differences between left and right ears have suggested that right ears perform betterThe significant variability in the performance of individuals from both groups may explain the absence of statistical differences between them. Therefore, correlation analysis was carried out on the combined results of case and control group subjects in the sentence recognition test in noise and their scores in the APHAB scale, in order to verify whether participants who performed better in speech recognition in noise also has lower APHAB scores. However, the analysis confirmed that self-reports were not correlated to performance in speech recognition tests in noise. Not even the BN sub-scale scores were correlated to speech recognition tests in noise when both groups were analyzed.An explanation for the absence of a correlation is the lack of awareness from control group members of the possible hearing impairments they may have. Several studies have analyzed the accuracy of hearing loss complaints and absence of complaints and found that approximately 20% of the individuals with hearing claim not to have hearing impairmentAuthors assessed the efficiency of central auditory function in elderly subjects who reported they could hear well and found that - despite the self-reports of good hearing − 60% of the studied individuals had hearing loss and significant incidences of impaired central auditory functionBoth false negatives and false positives are possible in patient complaints. Psychosocial matters may be at play in the genesis of the complaint, as in chronic complaint disorders, in which patients go to various physicians complaining of multiple symptoms -none of which supported by examination and testingThis study did not aim to see whether subjects had central auditory processing disorders. Once the standard for normal results in audiological examination is based in criteria that may not be sensitive to capture minor alterations, we tried to verify if, even in the presence of normal test results, the groups with statistical differences in their complaints would perform differently in speech recognition tests in noise - and they did not. It is worth pointing out that one cannot state, based on the tests carried out in this study alone, that individuals reporting hearing impairment do not really experience auditory difficulties in their lives. One may only conclude that the reported difficulty was not confirmed in a structured setting. Tests were monaural , in a situation that differs greatly from the everyday life of the subjects enrolled in the study, in which dichotic hearing is used more frequently. Given the variety of environments and noises associated with different types of discourse, one cannot assume that the ability to understand speech in all circumstances can be measured by one single speech recognition test in noiseThe same logic may be applied to the interpretation of the absence of a correlation between hearing complaints related to communication contexts and the sentence recognition rate in quiet conditions. Can self-report reflect the actual difficulty subjects experience? Can one single test measure individual performance? Authors indicate that questionnaires usually fail to describe a given situation with the same level of control and precision obtained in lab experimentsMany authors have used absence of auditory complaints as an enrollment criteria, but there are no published validated instruments to analyze this criterion. Analysis is usually done by questions such as ‘Do you have any hearing complaints?' The findings in this study suggest the APHAB scale is an appropriate instrument to capture the presence and absence of hearing complaints, principally as it allows for comparisons against normative values based in subjectively normal hearing adults.Considering the comparison of hearing thresholds, no differences were found between case and control group subjects. Even with the enrollment criterion of thresholds of 25 dBNA and under, statistical differences could have been found between the groups.Sentence recognition tests in noise failed to detect the underlying conditions related to the reported hearing difficulties in communication situations. However, a positive correlation was found between pure-tone thresholds and scores in the scales connected to self-reported difficulties, i.e., higher thresholds meant higher scores in everyday life hearing difficulties, although they were within normal range.This finding shows how broad the range of normality can be, as also indicated by other authors in a study that compared thresholds between 250 and 1600 Hz of young adults and elderly subjects with hearing thresholds of 25 dB and below in frequencies between 250 and 8000 HzIn this study, although the thresholds of case and control groups at 250 and 500 Hz were within normal range, there was a positive correlation between thresholds and sub-scales EC, RV, BN, and the global APHAB score. Control group subject thresholds were inversely and significantly correlated to the AV sub-scale. Thus, self-reported hearing difficulty in communication contexts was associated with higher thresholds, while greater difficulty hearing aversive sounds was correlated with lower thresholds (greater sensitivity).The data from both groups were rearranged based on low-frequency tone sensitivity. One of the groups featured individuals with mean thresholds at 250 and 500 Hz under 15 dB (G < 15 dB) while the other included subjects with mean thresholds of 15 dB and above (G ≥ 15 dB). The group with less low-frequency sensitivity reported difficulties in communication situations more frequently than the group with thresholds under 15 dB.The indication that higher pure-tone thresholds at lower frequencies correlate to higher scores of self-reported difficulty calls for reflections on the standard of normality. Despite the excessive flexibility of this criteria, the fact that outer hair cell alterations lessen auditory sensitivity more frequently at higher frequencies makes one wonder why a positive correlation between thresholds and self-report of hearing difficulty was not observed at higher frequencies. People with altered sensitivity at higher frequencies combined with normal sensitivity at lower frequencies usually report normal sensitivity along with difficulty understanding speechThresholds at 1000 Hz were also correlated with sub-scale EC, while thresholds at 2000 Hz were correlated to sub-scales EC and RV. Higher thresholds at 250, 500, 1000 and 2000 Hz meant higher incidence of communication difficulties, thus reinforcing the predictive value of the APHAB scale.Bureau Internacional d'Audio Phonologie(BIAP), an institution that congregates several European associations with the main purpose of guiding health care workers in the region, considers that individuals with normal hearing have mean thresholds of 20 dBNS and under at frequencies between 500 and 4000 HzIn Brazil, the classification proposed by Lloyd & Kaplan is the most widely used scheme to assess the degree of hearing loss in adult subjects. Normal hearing in this classification is assigned to subjects whose mean air conduction thresholds at 500, 1000 and 2000 Hz is of 25 dBNA and underAuthors using the APHAB scale reported inconsistencies in the data related to sub-scale AVth percentile being equal to 2 and the 95th percentile equal to 54 - the highest value in the 95th percentile of the normal distribution. The 95th percentiles of the other sub-scales are: 21 (EC), 29 (RV), and 34 (BN).Normative values in the AV scale present the higher levels of variation in subject responses, with the 5In this study, sub-scale AV was the only not to present differences between case and control group subjects. However, when analyzing the correlation between this sub-scale and the other tests, we found that lower I-V interpeak intervals meant higher scores in the AV sub-scale. The analysis of interpeak intervals allows the identification of possible alterations in the trajectory of the acoustic stimulus along the auditory pathway. As wave I is generated in the distal portion of the auditory nerve and wave V starts at the inferior colliculus, increased I-V interpeak intervals suggest differences in case and control group auditory processing. This finding is worthy of further investigation.Indeed, in addition to the variables analyzed in this study, others have been indicated by a number of authors. Caporali & Silva, for instance, observed that speech recognition in noise is a task that requires the use of memory and selective attention, as individuals need to focus their attention to the sound of interest and evoke information while they ignore irrelevant information (noise)Future research could, therefore, look into the auditory pathways after the brainstem and compare the results of case and control groups in terms of medium and long latency evoked potentials to present evidences on the neural substrate connected to communication difficulties.Case group subjects reported statistically more communication difficulties than their control group counterparts. However, when group test results were compared, no statistically significant differences were found in the latencies of waves generated in the distal portion of the cochlear nerve, in the cochlear nuclei, and in the lateral lemniscus.There certainly are many variables involved in speech recognition, specifically in environments with reduced extrinsic redundancy. The differences in pure-tone thresholds within normal range affect the self-report of communication difficulties. However, the differences in complaint self-reporting were not reproduced statistically in pure-tone thresholds. Thus, it was not possible to correlate the variables connected to auditory function from the cochlear nerve to the brainstem with differences in complaint self-reporting of case and control group subjects.


The activities of daily living (ADL) score is a widely used index to establish the degree of independence from any help in everyday life situations. Measuring ADL accurately is time-consuming and costly. This paper presents a framework to approximate ADL via variables usually collected in comprehensive geriatric assessments. We show that the selected variables serve as good indicators in explaining the physical disabilities of older patients.Our sample included information from a geriatric assessment of 326 patients aged between 64 and 99 years in a hospital in Tyrol, Austria. In addition to ADL, 23 variables reflecting the physical and mental status of these patients were recorded during the assessment. We performed least absolute shrinkage and selection operator (LASSO) to determine which of these variables had the highest impact on explaining ADL. Then, we used receiver operating characteristic (ROC) analysis and logistic regression techniques to validate our model performance. Finally, we calculated cut-off points for each of the selected variables to show the values at which ADL fall below a certain threshold.Mobility, urinary incontinence, nutritional status and cognitive function were most closely related to ADL and, therefore, to geriatric patients’ functional limitations. Jointly, the selected variables were able to detect neediness with high accuracy (area under the ROC curve (AUC) = 0.89 and 0.91, respectively). If a patient had a limitation in one of these variables, the probability of everyday life disability increased with a statistically significant factor between 2.4  and 15.1 .Our study highlights the most important impairments of everyday life to facilitate more efficient use of clinical resources, which in turn allows for more targeted treatment of geriatric patients. At the patient level, our approach enables early detection of functional limitations and timely indications of a possible need for assistance in everyday life.The online version contains supplementary material available at (10.1186/s12877-022-03368-x). Many countries around the world are faced with rapidly aging societies. This demographic shift not only poses capacity problems for health care providers but also changes the quality-related requirements for health services. Early detection of diseases and impairments of everyday life is therefore an indispensable task to maintain the sustainability of the healthcare system.This study addresses the mental and physical impairments of older people who underwent geriatric screening to assess their health status and potential limitations to participation in daily life. Such assessments typically rely on formal tools such as questionnaires and tests to evaluate the physical and mental dimensions of older adults’ health –3. A keyPrevious research has adopted three major approaches to approximate ADL . A firstHowever, the participants did not suffer from an ADL disability at baseline and only 22.3% developed one in the following three years. One possible reason for this could be the fact that only participants younger than 75 years were included in the study. The authors concluded that additional research with adults above 75 years was required .This paper is related to the third strand of literature and extends the existing research in two ways. First, using clinical data from a comprehensive assessment of 326 geriatric patients, we focused on the age group between 64 and 99 years. Hence, we were particularly able to detect ADL for older-aged patients. Second, we propose a framework that allows us to not only identify the most important explanatory variables of ADL but also to estimate the cut-off values at which ADL falls below a certain threshold. Monitoring the selected explanatory variables together with their derived cut-off values could be interesting from a clinical perspective as it supports more efficient use of medical resources, which in turn allows for more targeted treatment of geriatric patients. In addition, it facilitates early detection of functional limitations and the potential need for daily assistance, which might be particularly useful in outpatient care.To explain ADL of older patients, we conducted a cross-sectional study in the hospital of Hochzirl, Tyrol (Austria). This hospital has its own geriatric ward and is accordingly specialised in the care of geriatric patients. Patients are referred either by an outpatient centre , by clinics  or by emergency departments of related hospitals, as the hospital of Hochzirl does not have its own emergency department. A medical report was prepared for each patient at the time of registration. This report was based on the medical history provided by the referring facility, a medical admission interview and a physical examination. In addition, older adults underwent a comprehensive geriatric assessment, including a variety of screening tests and the elicitation of anthropometric data. Overall, information was gathered on general health status, mobility, cognitive ability, nutritional status, urinary incontinence, sensory functions and psychological situation. Furthermore, ADL data were collected for each patient.Our sample included 326 patients aged between 64 and 99 years who underwent geriatric assessment between July 2019 and February 2020 at the hospital of Hochzirl. Within the first three days after admission, every patient older than 64 years was assigned to the geriatric assessment by the doctor in charge. The assessment was waived if a patient had the following contraindications: (i) lack of consent, (ii) complete independence and no need for assistance in daily living, (iii) stable need for assistance with no prospect of rehabilitation, (iv) terminal illness, or (v) severe dementia and (vi) the current report was not older than 12 weeks. The information on (ii), (iii), (iv) and (v) was obtained from the medical report, produced for each patient on admission to hospital.The geriatric assessment took approximately 30 to 60 minutes and was performed by a trained graduated nurse following a prespecified procedure (more details are provided below). A test could be skipped if the patient was not able to perform it due to physical or a mental dysfunction. In addition, further information was gathered from the nurse team on the ward in the form of a patient-related questionnaire to collect all the necessary information for ADL. Finally, a document with the results of the geriatric assessment (including ADL) was handed over to the attending physician. The results of the geriatric assessment were gathered by the doctors’ team, and data were collected manually in Microsoft Excel.Our main variable of interest was ADL, which measures in a standardized way physical independence and, hence, a patient’s need for assistance in everyday life . In partseven categories (number of variables in parentheses):1Mobility (3): Falling is often caused by mobility problems [∘ and wrist in neutral position. Three measurements were taken with the dominant hand and the mean value was reported.Mobility : Fallingproblems , 18, theproblems , and a pproblems . TMT conproblems . TUG is problems . GS is iproblems , 22 in sCognitive function (3): Recognition and information processing issues may indicate cognitive deficits. In geriatric assessments, cognitive performance was screened with the Mini Mental State Examination (MMSE) [n (MMSE) , the clon (MMSE) , and then (MMSE) . The MMSn (MMSE) .Nutritional status (3): Older adults often suffer from vitamin and mineral deficiencies [l status : Older aciencies , body maciencies  and fat ciencies . Guigoz ciencies .Incontinence Screening (4): Urinary incontinence has a negative impact not only on physical health due to an increased risk of infections, falls and death but also on mental health as self-esteem suffers and affected people isolate themselves more often [1), stress (ICD2) or mixed urinary incontinence (ICD3). ICD4 indicates uncertainty about the presence of urinary incontinence, and ICD0 suggests no urinary incontinence [re often , 29. Furre often . Furtherntinence .Sensory function (2): Carabellese et al. showed that sensory impairments in older people have a negative impact on their social relationships and self-sufficiency [ficiency . To captficiency .Psychological situation (1): The most common psychological illness in older people is depression, which is screened for with the Geriatric Depression Scale (GDS) [le (GDS) . The GDSClinical admission status (7): To account for a patient’s general health status, we included the patient’s age (AGE) and sex (SEX), whether and which type of diabetes mellitus (DM) was diagnosed, and whether medication for diabetes mellitus therapy (DMT), arterial hypertension (AH) or cerebrovascular diseases (CVD) were prescribed prior to the assessment or polypharmacy (PP) occurred.To determine the driving impairments behind ADL, we relied on all test procedures of the geriatric assessment. These included the general health status  of the patients as well as information on their mobility, cognitive abilities, nutritional status, urinary incontinence, sensory functions and general psychological situation. In total, our sample included 23 geriatric variables which we divided into Table A.1 of Additional file Our sample included information on the assessments of 326 geriatric patients. This information included ADL along with 23 covariates collected in these assessments  was applied to identify the most influential geriatric covariates on the numeric ADL. In the second step, as we were solely interested in whether a person was independent from everyday assistance, we transformed ADL to a binary variable and performed logistic regression techniques and receiver operating characteristic (ROC) analysis to evaluate the variable selection of the first step. More specifically, we calculated the area under the ROC curve (AUC) as a measure of discriminatory power. In addition, to easily identify patients with a potential ADL disability, we derived optimal cut-off values for the selected geriatric variables. To test their strength, we used odds-ratios. Finally, an out-of-sample exercise was performed to validate the robustness of our results.λ). As a result, less important coefficients are shrinked to zero, i.e., are excluded from impacting the model. Since optimal selection of the regularization parameter is critical, we used 100-fold cross-validation to detect optimal values of λ based on the resulting regression errors. We chose two different λ-specifications in the variable selection process [λmin), and the second one is the largest value of λ such that the error is within one standard error of the cross-validated errors for λmin. We refer to this as λse1.To identify the most relevant geriatric covariates driving ADL, we applied LASSO . This me process . The firλ-specifications.Based on our definition of neediness in everyday life, we examined the extent to which our geriatric covariates were able to explain our indicator variable ADL* , 12, 13.Furthermore, one might be interested in the univariate effects of the selected variables on ADL* and in the cut-off values of these geriatric covariates as they are essential for clinical decision-making. In medical practice, for example, cut-off values support the diagnosis of an impairment and thus the initiation of appropriate therapies or assistance . Of the In order to validate the robustness of our results, we performed a 100-fold out-of-sample validation exercise. For this purpose, we assigned to each observation a probability of 0.2 of belonging to the out-of-sample subsample and, therefore, a probability of 0.8 to be part of the in-sample data. We performed variable selection (LASSO) and logistic regression based on the observations on the in-sample-group and obtained predictions accuracy’s  on ADL* disability for the out-of-sample subsample. The same approach was applied for the univariate analysis. We repeated this procedure 100 times. In doing so, we got a distribution on both the inclusion of the single variables from LASSO procedure and the cut-off values, which served as robustness measures for variable selection and their optimal cut-off value for estimating an ADL* disability. Furthermore, resulted out-of-sample distributions for AUC were used to assess the reliability and robustness of our results.The statistical analysis was conducted with R version 4.1.1 . For theIn this section, we first describe which variables were selected to explain ADL. Then, we derive the underlying cut-off values and present the evaluation of the selected variables based on their detection accuracy. Finally, we check the out-of-sample robustness of our results.λ.We applied LASSO to detect the geriatric covariates that serve as appropriate explanatory variables to describe ADL and cross-validation to estimate the penalty term λse1, nine variables, TUG, TMT, MMSE, MNA, ICD4, ICS, and the dummy variables for missing values on TUG (1TUG), TMT (1TMT), and MC (1MC), were selected to explain ADL. In the case of λmin, five additional geriatric covariates were entered into the model: ICD3, PC, GDS, AGE and 1GS. Hence, we included 14 variables to explain ADL in this specification . Using the 14 explanatory variables, selected under λmin, functional limitations in everyday life were identified with high accuracy (AUC = 0.91). Therefore, the potential of the joint use of the data-driven selected variables to capture ADL disability was supported by these higher detection accuracies compared to previous literature [Table AUC = 0.8. Using tterature , 46 whenλse1, since in the case of Guralnik et al. or Prasitsiriphon and Weber the joint use of variables was only partially able to outperform individual explanatory variables [We were also interested in the univariate performance of the variables selected under ariables , 8. Furtariables . We compariables , 13 or aTable TUG and 1TMT) and 0.85 (TUG). As expected, the cut-off values of the dummy variables were 1, so it was assumed that patients who were unable to perform the corresponding tests  or whose incontinence status was unclear (ICD4) needed help in everyday life. The cut-off values we calculated for the metric variables were also supported by the literature as patients who were indicated to have an ADL disability also had an impairment in the respective geriatric covariate. The only exception was the cut-off value of the MMSE, according to which patients with a score below 27 already needed help in everyday life, whereas in the literature a cognitive deficit is only assumed at less than 25 points [Overall, on a univariate level, the AUC varied between 0.57 . None of the estimated CI intervals overlapped with the null value (OR=1). This can be used as a proxy of statistical significance of the estimated cut-off values.The odds ratios quantified the strength of these cut-off values, which showed that for a patient with a limitation in one of these explanatory variables, the probability of needing assistance in daily living increased by a statistically significant factor between 2.4  and 15.1 , cognitive function , nutritional status (MNA) and urinary incontinence . Wojtusiak et al., despite relying on a different methodological approach and using large-scale rather than clinical data, used a very similar variable choice, i.e., emphasizing the role of cognitive functions, age and urinary incontinence for ADL [Focusing on single dimensions of ADL, Gobbens and van Assen, Duchowny et al. and Prasitsiriphon and Weber used a test of balance, usual walking speed, GS, physical activity, BMI or fatigue to examine functional limitations , 12, 13. ICS, ICD. WojtusiWhen evaluating the selected variables for their ability to detect an ADL disability, the highest accuracy was achieved when our selected variables were used jointly . Regarding the detection power of single influencing dimensions, only the mobility measures (TUG and TMT) indicated functional limitations with good accuracy. This is in line with Guralnik et al. and Jonkman et al., who also examined the detection accuracy of joint use rather than univariate use of their explanatory variables , 9. HoweThe cut-off values we obtained from our analysis were broadly in line with the literature. One notable exception was the MMSE, for which previous papers suggested a cognitive deficit at scores below 25 –49, whilThe robustness of our results was validated using an out-of-sample exercise. We found that the AUC values presented in Table We used data from a comprehensive geriatric assessment to explain the activities of daily living (ADL) index, which is used to measure functional impairment and older patients’ needs for assistance in everyday life. Empirically, we proposed a data-driven approach that allowed us to employ all patient-related information typically recorded in a geriatric assessment. In particular, we identified nine variables belonging to four groups of impairments that are most influential for ADL: mobility, urinary incontinence, nutritional status and cognitive function. For each of the underlying variables, we derived cut-off values indicating functional impairment and the need for support in everyday tasks. Jointly, these selected variables were able to indicate ADL disability with high accuracy.Our findings might be of interest for clinical purposes. First, determining ADL requires a comprehensive observation of patients. In some cases, additional information must be obtained from the referring physicians, and the writing of test protocols is time-consuming and causes high administrative costs. Our study proposes a method of approximating ADL based on limited patient information that is typically easy to obtain. Using this information rather than the ADL score may lead to significant cost savings for a hospital. Second, and perhaps more importantly, ongoing monitoring of the main drivers of ADL allows for early detection of limitations in daily living. This seems particularly interesting for general practitioners and physicians in outpatient care, where information on ADL is usually not collected.Additional file 1. Variables of the geriatric assessment by health category.


Aims: to verify difficulties related to device use, batteries and ear molds handling, the very characteristics of sound amplification, and to discuss factors that impact audiological rehabilitation in this group of patients.Hearing aid fitting involves numerous issues that must be investigated - from the device supply all the way to results achieved with it in order to improve its results in planning Auditory Health Care. 31 individuals, from 12 to 77 years age, with bilaterally symmetrical hearing losses, sensorineural or mixed, from moderate to moderately severe degrees and hearing aid users of digital or hybrid hearing aids. We carried out an interview approaching topics related to device use, battery handling, ear molds and hearing aids, as well as sound amplification characteristics.12.90%, 58.06% and 67.74% of the interviewees presented difficulties related to battery, ear molds or capsules and amplification characteristics, respectively.the majority of the individuals presented some kind of complaint related to hearing aids characteristics, and difficulties related to users' expectations, communication skills and monetary cost and the Municipal Health Care Network, which all interfered in the audiological rehabilitation. How one defines hearing loss varies according to different educational, social and audiological aspects, as well as the physician involved. Notwithstanding, it is a highly disabling disorder, considering its impact on communication, cognitive, psychosocial, oral and written language.With the development of medicine and technological progress, it became possible to improve quality of life, including people with hearing loss. Thus, sound amplification systems have been developed and are constantly improved in order to minimize the limiting effects caused by such disabilitySound amplification is not restricted only to help with warning signs, but mainly to make audible the sounds of speech, a tool used to facilitate education and the psychosocial and intellectual development of the hearing impairedIn Brazil, according to estimates from the World Health Organization, there are about 2.25 million people with hearing impairment. In order to guarantee specialized care to everyone, the Ministry of Health created the National Policy of Hearing Health Care. Two ordinances associated with the Secretary of Health Care standardized this new policy: ordinance 587, from October 07, 2004, and ordinance 589, October 08, 20043.According to the strategies of this new policy, the audiologic rehabilitation process involves a much broader work, aiming at providing continuous flow hearing aids with medical and audiologic follow up, both for adjustments and for periodic inspections of the device and the benefit brought about by it; and whenever necessary, speech and hearing therapy and social and psychological care.Although the new ordinances were only created in 2004, this issue of an Auditory Health Care had already been discussed. Thus, based on Ordinance 432 from the Ministry of Health, the State Health Secretary of Rio Grande do Sul, in order to establish joint actions to provide hearing aids, established a consortium with the Federal University of Santa Maria in order to care for the users of the Sistema Único de Saúde , for people with hearing impairment, signed on 12/29/2000 and published in the Federal Gazette on 02/08/2001, which was put into effect by 2005.1.Checking the difficulties associated with the use and handling of batteries and ear molds, and sound amplification characteristics;2.Discuss the many aspects involved in the hearing aid fitting processes, education and follow up of this study group.In the area of audiology, many surveys are being carried out with users of hearing aids, however, no studies were found involving users of the Public Health Care System in Brazil. Thus, the first part of this paper aimed at:This study was carried out at the Audiology Outpatient Ward of the Speech and Hearing Care Center (SAF) of the Federal University of Santa Maria (UFSM), from July of 2004 to July of 2005, after being approved by the Ethics Committee, under protocol # 112/2004 - UFSM. We evaluated only those individuals who agreed to participate in the project, after they were fully educated about the objective and methodology of our study and, after they signed the Informed Consent Form.The individuals evaluated in this study were fitted in the Hearing Aid Laboratory of the Federal University of Santa Maria by means of a consortium established between the State Health Secretary and the Federal University of Santa Maria.–Age equal to or above 12 years;–Hearing aid in both ears;–Patients of mild to moderately severe sensorineural or mixed hearing loss4;–Symmetrical hearing loss, considering a maximum difference of 10dB between the same frequencies in both ears;–Minimum time of three months of hearing aid use–Users of hearing aids with digital signal processing or computer programmable analogue signal.To form the group, we established the following criteria:Coming from different locations of the Midwest of Rio Grande do Sul State, the individuals in this investigation, part of the low income population, were selected based on personal and audiologic data which were previously surveyed at the time of hearing aid selection and fitting. Of the 224 individuals fitted from April of 2003 to July of 2005, according to the study criteria, 37 individuals were selected.Most of the appointments were scheduled through the Municipal Health Secretariat. Of the 76 appointments scheduled, only 31 individuals came to 46 of them.Thus, the study involved 31 individuals, 51.61% (N = 16) males and 48.39% (N = 15) females, at an age range between 12 and 77 , all with symmetrical bilateral sensorineural or mixed hearing loss, of moderate to moderately-severe level, users of miniretroauricular and intracanal hearing devices, digital or computer-programmable analogue type.We established a minimum time of three months ofATTACHMENT IFEDERAL UNIVERSITY OF SANTA MARIAHEALTH SCIENCES CENTERSPEECH AND HEARING DEPARTMENTMASTER'S PROGRAM IN HUMAN COMMUNICATIONS DISORDERS SCIENCESFIELD OF INTEREST: HEARING - CLINICAL AUDIOLOGYQUESTIONNAIREEvaluation Date: ______________Name: _____________________________________ DB: ______________ Age: _______Address: _____________________________________1.Background associated with the initial interview at the time of selection and fitting of the hearing aid (s): __________________________________________________________________________________________________________________________2.For how long have you been wearing a hearing aid? _____________________________3.What is the type of fitting?  monoaural  binaural4.What is the make and model of the hearing aid (s)? _______________________5.Wear the hearing aid full time?  yes  no ___________6.Had any battery-related difficulty? ___________________________________________________________________7.Had any type of difficulty associated with the ear mold (s)? ____________________________________________________8.Had any difficulty associated with the settings of the hearing aid (s)? _______________________________________________________________9.If the hearing aid (s) requires any fixing, do you authorize it and would you be able to afford it? ________________________________________10.If the ear mold (s) needs to be remade, would you be able to afford it? _________________11.Is there any place in your town to buy hearing aid batteries?  yes  no12.Is there an otorhinolaryngologist in your city for consultation?  yes  no13.Is there an audiologist in your city for consultation?  yes  no14.Is there any doubt in relation to battery use and handling, ear mold and/or hearing device?hearing aid use, because clinical experience has shown that this is a reasonable time span for the person to get used to wearing the hearing aid, when it is possible to assess the real results of the intervention, since the benefits provided by the amplification do not come immediatelyTelephone:  __________ Occupation: ______________ Gender:  F  MIntegral use of hearing aid was considered when the user reported that he/she used the hearing aid the entire time, in all activities of his/her daily lives; partial use when it was used everyday, but only during part of the time; and sometimes; when it was used in specific or eventual situations; alternate when it was used sometimes on the right and sometimes on the left ear; and no use, when the person reported not using it because of technical problems or the need for adjustment. Of the 31 individuals, 18 used it full time, while the other 13 used it irregularly; 3 used it partially, 3 in an alternate fashion; 4 used it sometimes and 4 did not use it at all.The evaluations carried out during the selection and initial fitting process for hearing aids were not considered because they were not part of the goal of this study.The first part of this study was an interview with topics prepared by the examiner, related to the experience and use of hearing aids, complaints related to the use and handling of batteries, ear molds, amplification characteristics and support, as well as access to specialists of the region (Annex I). By the same token, in this first time, we checked the technical conditions of the hearing aids.Depending on the needs of each case, we adjusted the amplification characteristics and, in the case in which the problem could not be solved in the first session, new appointments were scheduled.In For the patient who could use sound amplification, the auditory prosthesis although representing only one of the components, plays a fundamental role in the auditory rehabilitation process, providing to the hearing impaired an acoustic environment similar to the original environment. Notwithstanding, only the user of the hearing aid can define which were the difficulties encountered with the systematic use of sound amplification during the rehabilitation process. For that reason, we interviewed patients with the goal of investigating the aspects related to the use and handling of batteries, ear molds or capsules, and also in relation to the amplification characteristics.As far as the batteries are concerned, the users were asked whether they had any difficulty in handling or accessing them. We could notice that 87.10% (27) of them did not have any complaints or doubt in relation to the batteries. Nonetheless, 6.45% (2) said they could not afford them, and one of them said he did not use the aid in full time in order to save batteries; and 6.45% (2) of them had difficulties to buy batteries because they were not sold in his city (Chart 1).According to the report of some interviewees, the batteries were purchased in other cities of the region, and in some cases they were supplied by the Health Secretariat of the Municipality. One must consider factors like this, in other words, the monetary costs involved with the rehabilitation process, even in the cases fitted by the Public Health Care System - Sistema Único de Saúde (SUS), when technical support and maintenance often times are paid for by the user, interfering in different aspects such as: acceptance, performance, benefit and satisfaction with the use of hearing aidRegarding the use and handling of ear molds or capsules, 12.40% (4) of the users reported handling difficulties. The discomfort associated with fitting the ear mold to the pinna or the capsule in the external acoustic meatus was reported by 12.40% (4) of them. Only 3.23% (1) of the individuals reported they did not know how to clean the molds (Chart 1).Moreover, as we inspected the molds and capsules, we noticed that in 16.13% (5) of the cases, the wax filter was ruptured or obstructed, and only one of them made a regular use of the device, two did not do it for over six months, one for more than 11 years, and another wore only to watch TV or attend classes. We also noticed that 12.90% (4) of the cases had tube in the rigid molds or were cracked and 3.22% (1) had a broken capsule, and only one used the hearing aid irregularly. We noticed the presence of noise or feedback in only 3.22% (1) of the cases (Chart 1).Although all individuals were educated and instructed during the fitting process, regarding the use and handling of batteries, molds and hearing aids, as well as long term follow up, we found some problems that were not properly solved. It is believed that although satisfaction and use are also associated with the quality of service that the user receives, intellectual and social level, as well as the emotional aspects and motivation involved at the time of fitting, were some of the factors that remained throughout the rehabilitation process.No complaints and/or observations associated with the amplification characteristics and hearing aid circuit for 10 (35.26%) of the 31 individuals interviewed in the post-fitting period. Nonetheless, one of them said he was not wearing the hearing aid for 14 months, because he did not feel any benefit from it and the mold hurt him, then he decided to return it. Nine others used it full time and one of them used it three times a week, alternatively (Chart 2).The remaining, 64.74% (21) of the users presented one or more complaints and/or problems associated with the hearing aid devices, namely 28.57% (6) reported strong intensity; 28.57% (6) weak intensity, and two used it at maximum volume; 28.57% (6) discomfort was most of the times associated with binaural use; 19.05% (4) frequent headaches; 9.52% (2) with difficulties caused by the noise; 4.76% (1) could hear, but did not understand; and 4.76% (1) could not hear from far sources. Of these individuals, 10 remained using their hearing aids in full time and the other 11 used them irregularly (Chart 2).We stress that 33.33% (7) of the individuals had their hearing aids not working or with distorted sound. Despite these occurrences, three of them remained using them, two used them irregularly, one had not used it for more than 6 months and the other hadn't used it for more than 11 months.Although many of the users had some complaint and/or technical problem, there was not direct association with the time or frequency of use, by the same token, none of them sought help for their problems, justifying it with aspects such as: financial difficulties, accessibility or availability. Nonetheless, we noticed they were not very interested in solving the problems; neither the user nor the municipal health care network, which was often times communicated about the problems found among their users. It is very likely that this is due to the fact that often times communication difficulties remained despite the use of amplification1. By the same token, it is very likely that the perspectives of these users were associated with a curative treatment and not enabling or rehabilitatingOf the 31 individuals who came to the appointments, 12.90% (4) had neurological issues, three of them had some complaint, and only one of them did not use the hearing aid regularly. Other 6.45% (2) apparently had some depression, used the hearing aid wrongly, both with some type of complaint. We also noticed that 12.90% (4) of the users strongly denied their hearing impairment, and only one of them wore his hearing device the entire time.In light of the problems found, it was necessary to change amplification characteristics in 25.80% (8) of the cases. Moreover, nine devices needed to be fixed 22.58% (7), and of them, only five were re-fitted during the investigation period. By the same token, another one was re-fitted because it was not used in the last months before the study (Chart 3).To begin with, these users had restricted access, most of the time needing the aid of the Municipal Secretaries of Health, 76 appointments were scheduled and 46 of them actually happened. With this, we can see the enormous difficulty of bringing awareness, considering the user and the health care network as to the importance of follow up and advice throughout the fitting process. Thus, studies like the present one must be constantly held, not only with a scientific goal, but also to bring awareness to the system and its users that the preferential health care model is not curative, but rather of full health care, in such a way that the user himself would be responsible for his own healthAnother issue of major relevance considered by the members of this study are the monetary costs involved with the process, because although they were adapted by means of a consortium for providing hearing aids through the Public Health Care System (SUS), it is also necessary to have resources for providing technical support and maintenance for these devices, just as there is the need for transportation availability to the health care facility for follow up. These are some aspects that also justify the delay in seeking to solve the complaints and/or problems found.It is known that the audiologic rehabilitation results depend on the active desire by the user, however, the perceived benefit of using amplification is directly associated with the user's expectationsThese aspects must receive special attention during hearing aid fitting process, especially during the stage of advice and guiding, which must be revised also after fitting, when there are less variables involved, because then better results may be seen and validated along the process1.difficulties in relation to the molds or ear capsules and the amplification characteristics were reported by most individuals;2.the results of this intervention are directly associated, especially to the expectations, communication needs and financial concerns of the user himself, and also to the support provided to this group of patients by the municipal health care network.As we analyze qualitatively the results of the fitting process in this group, we can conclude that:


Auditory plasticity refers to the possibility of anatomical and/or functional changes in the system where transmission of auditory information takes place. The auditory system is often required in communication; it is important to learn how the auditory system reacts to stimuli in order to improve performance in individual communication of subjects with impaired hearing.To review the literature on auditory plasticity and the possibility and ability of plastic responses in the auditory system; also to review the evidence of auditory plasticity.A review of the Brazilian and international literature  was carried out. The MEDLINE, SCIELO, BIREME, PUBMED, and LILACS data bases were consulted, as well as 24 papers from the 1990s to the present date; each paper was assessed for relevance to the topic.The findings showed that the auditory system is able to reorganize itself if there is variation, whether by by reducing, increasing, or conditioning of sound stimuli. This is evidence of plasticity in the auditory system. Neuroplasticity is the ability of the central nervous system to adapt to different stimuli - it is a current object of study. The ability that the auditory system has to change anatomically or functionally is named auditory plasticityHearing loss decreases the ability to perceive sounds, which causes several limitations in individual, social, and emotional developmentSeveral studies have investigated the ability of the auditory sensory system to respond with plasticity to different types of injuryScientific data on the evidences of plasticity in the auditory system were reviewed because of the importance of hearing, the number of individuals in all age groups being diagnosed with hearing loss, and the relevance of this topic.A review of the Brazilian and international literature  was made. The following databases were consulted: MEDLINE, SCIELO, BIREME, PUBMED, and LILACS. The key words were: “audition, hearing loss, neuronal plasticity”. As the review progresses, important references cited in the databases above were also consulted. After reading and analysis, this review comprised 24 published papers from the 1990s to the current date, taking into account the relevance of each document for the study topic.The hearing system consists of auditory sensory organs, nervous system auditory pathways, and brain structures that receive, analyze, and interpret sound information - it is used in communication contextsHowever, the auditory system is not always whole. The impact of hearing loss is significant; it affects not only the ability to understand information contained in sound but also the way in which an individual may related with the environment and culture. Additionally, hearing loss may have biological, psychological, and social effects“Plastic” derives from the Greek “plastikós”, which means molded. According to the Oxford English Dictionary, plasticity is the ability to undergo a change in shapeAccording to Pascual-Leone et al.Behavior and experience equate with the activity of all neurons in the brain. These consist of neuronal networks that are an efficient, spatially compact, and precise medium for processing input signals and generating responsesKaasSome authorsIn the past it was thought that plasticity did not take place in older individuals, and that it was limited in adult nervous systems. However, adult brains have been shown to be able to change and adapt to circumstances. Plasticity is expected to be less efficient with age; however, plastic mechanisms do not end at this or that age, and also take place in the elderly. Thus, it is incorrect to set limits to age groups before beginning treatmentDuring the 1950s, it was stated that language learning was only possible until the age 10 to 12 years; in other words, plasticity was generally associated with critical windows. This was based on the idea that the nervous system had a limited time to develop, and that certain abilities did not develop beyond a specific growth period in children. These ideas are currently being questionedMusiek et al.The hearing system is not fully developed at birth; it matures slowly after the inner ear starts to function. Sensory neuron plasticity is fundamental at the beginning of intrauterine and neonatal life, to consolidate hearingSensory system plasticity occurs in both peripheral receptor neurosensory tissues and central pathwaysMecklenburg & BabighianMusiek & BergeChanges in the anatomical or physiological properties of the central auditory system may be induced by sensorineural hearing loss (primary plasticity), by reintroducing auditory stimuli (secondary plasticity), or by conditioningAccording to WillotInteraction plasticity (excitatory or inhibitory) that is evoked by binaural stimuli should also impact perception. This is particularly relevant for deprivation associated with monaural use of hearing aids. An example is the weakened ability of unaided ears - and the strengthened ability of stimulated ears - to evoke central responses. This would lead to unbalanced neural responses where the aided ear would be supported by binaural neurons at the cost of the less stimulated ear. With time, this could result in deprivation. Thus, the term deprivation would not be the most correct word; an association between plasticity and deprivation would cause hearing loss in unaided earsSome authors have given much value to early fitting of hearing aids and balanced stimulation of ears, and have suggested that symmetrical bilateral hearing loss with monaural hearing aid adaptation may become asymmetric because of unequal stimulationStudies on the effects of deprivation and auditory stimulation on hearing perception have shown conclusively that the development and function of the auditory system is related with the quantity and quality of auditory inputIf the central auditory system is able to reorganize itself following injury, the question is whether reintroduction of auditory stimuli by hearing aids or cochlear implants has the potential of provoking auditory plasticity.Studies on plasticity have suggested that increased auditory stimulation because of amplification may induce secondary plasticity, which facilitates acclimationMunro & LutmanIf beneficial primary plasticity occurs in an individual, sound amplification may have a negative effect, at least initially, due to distortion between acoustic stimuli and auditory responses that were initially used advantageously by the hearing system. Frequencies that used to go unheard start to be heard again because of hearing aids, and the result is a competition for the old neurons. Thus, neural coding of sounds may raise new problemsChanges may occur in the organization of the central auditory system between the onset of hearing loss and the moment when hearing aids are used. These should be fitted before the auditory system reorganizes and the opportunity for improving hearing passes. Sound amplification increases auditory stimuli, which may induce secondary plasticity, thereby contributing to aclimationThe true purpose of hearing aids should be to use stimulus reintroduction to induce secondary plasticity, returning representation maps to the due places. Hearing aids could have two effects if plasticity were used as a clinical tool: to restore sensitivity, and to change the central nervous systemMecklenburg & BabighianBoéchatAmorim & AlmeidaSome authorsStudies have shown that hearing improved after auditory training. Ambient influences - such as auditory training - stimulated neural structures involved with the performance of trained hearing abilities, thereby benefiting individuals. Neural plasticity, therefore, is essential for improvements gained in auditory trainingProfessionals involved in habilitation and/or rehabilitation of patients with hearing loss need to understand plasticity in the auditory system, and consider it an important clinical tool. Thus, the possibility of primary, secondary, and/or conditioned plasticity should be taken into account in clinical practice. Future studies will be very helpful to add knowledge about plasticity in the auditory system. Our review of the literature showed that the auditory system is able to reorganize itself when the input of auditory stimuli increases or decreases. So, subjects with hearing loss who require hearing aids or cochlear implants may benefit in their social, emotional, and intellectual aspects, and enjoy an improved quality of life.


In general, hearing loss is sensorineural, which is sometimes confused with presbycusis, mainly because it develops in patients older than 40 years of age. Angiopathy and neuropathy caused by diabetes mellitus have been considered important factors for the vestibular-cochlear disorders found in these patients. However, there is controversy regarding the etiopathogenesis of hearing loss, as some researchers support that it develops due to neuropathy, others say it is due to angiopathy, or even a combination of both. Yet, some researchers believe diabetes mellitus and hearing loss are part of a genetic syndrome. We have conducted an extensive bibliographic review to determine whether there is cause-effect relationship between diabetes mellitus and hearing loss. We were able to verify that, despite the large number of studies performed, there is still a great deal of controversy, and new approaches are being studied, for example in the field of genetics, which shows that new paths can be followed to reach a conclusion on this issue.Patients with  The most frequent causes of vestibular and auditory abnormalities are attributed to dysfunctions in the metabolism of carbohydrates, thyroid affections, supra adrenal, and other different metabolic disorders. Among glucose metabolism disorders, diabetes mellitus is the affection most commonly related with auditory disordersDiabetes mellitus is a genetically determined metabolic disorder associated with absolute or relative impairment of insulin and in complete clinical manifestation is characterized by metabolic affections, vascular and neuropathic complications. The main objective of treating patients with diabetes is the prevention of chronic complications because the disease is not curable but only controllable. In Brazil, the incidence of chronic complications of diabetes is quite high. It is estimated that there are five million subjects with diabetes and half of them are not aware of the diagnosis. A large number of subjects, especially children and adolescents, have diagnosis of diabetes made in face of complications, especially infectionsOne of the morphological aspects more constant in diabetes mellitus is diffuse thickness of basal membrane, which may also happen with vascular endothelium, and it is named diabetic microangiopathy. It is more evident in skin capillaries, skeletal muscles, retina, renal glomeruli, and renal medulla. Its pathogenesis is still obscure, but it is clearly associated with hyperglycemia. Other morphological affections refer to impairment of both motor and sensorial nerves of lower limbs, characterized as Schwann cell lesions, degeneration of myelin and axon damage. The cause of neuropathy is still very controversial, and it may be related with diffuse microangiopathy that would affect nourishment of peripheral nervesNeuropathy and angiopathy are common affections in diabetes mellitus. Angiopathy has been observed in small arteries and skin capillaries, muscle, kidney, retina and peripheral nerves. The factors that may cause neuropathy are metabolic disorders . Some researchers referred to the fact that vascular affections in interfascicular or intrafascicular branches of vasonbervorum contribute to neuropathy. Atherosclerosis, however, very common in diabetes mellitus, can also contribute to neuropathy, owing to interference in rate of nutrient transferAngiopathy may occur both in direct way, interfering with supply to the cochlea by reducing transport through the thickened walls of capillaries, and indirectly by the reduction of flow in vascular pathways, or still, because of secondary degeneration of 8th cranial nerveConcerning diabetes mellitus, there are different opinions about the pathological affections caused in the auditory system.According to Nageris et al., the association between hearing loss and diabetes mellitus has been debated since it was first reported by Jordao in 1857In the literature, there are many different types of hearing loss found in diabetic patients. One of them is progressive, gradual bilateral sensorineural loss, affecting especially high frequencies and the elderly. It would be similar to presbyacusis, but with more severe losses than those expected by agingAs to incidence of hearing loss in patients with diabetes mellitus, we observed that there is no consensus in the literature either, ranging from zero to 93%In view of the reported data, we decided to perform a literature review to check whether there is really a hearing loss inherit to diabetes mellitus and to which factors it is related.A)Diabetic angiopathy has been characterized by endothelial proliferation, accumulation of glucoprotein in the intima and thickness of basal membrane of capillaries and small blood vessels. We can also observe fibrotic thickness of the wall and narrowing of internal auditory artery lumen. We confirmed accumulation of positive PAS substance  on the artery wall, as well as on the modiolus vessels and vascular stria capillariesA1)The effects of diabetes in the inner ear can be studied in experimental model by using diabetogenic drugs , in genetically modified animals with diabetes (such as Sabra line rats) by means of total or subtotal pancreatectomy and still by extraction of anterior hypophysis.CostaSmith et al.Raynor et al.The use of alloxan or intraperitoneal streptozocin to induce diabetes in experimental models has been contested because it did not reflect the real physiological mechanism of diabetes in human beings because it has genetic origin. Thus, Nageris et al.Triana et al.A2)Willianson & KilloJorgensen & BuchCostaMakishima and TanakaAfter these initial data on diabetes mellitus and hearing, most researchers agreed that primary lesions are angiopathic14B)B1)Makishima & TanakaB2)There are other authors that believe that neuropathy is the primary lesion of hearing loss, arguing that positive PAS material found in the vessel wall is very nonspecific, found also in other diseases. They conducted an audiometric study in 20 patients with diabetic peripheral neuropathy using the control of 32 patients with diabetes mellitus. They observed that the thresholds of peripheral neuropathy subjects were also worse than the control group, in all frequencies. And also that patients aged over 60 years were worse than both groups. Hearing loss found by them was normally sensorineural, progressive and more intense when over the age of 60 yearsC)D)It is known that hearing loss can also have its origin from genetic mutations, which can be congenital or acquired, occur in nuclear genes and mitochondria and present syndromic or non-syndromic episodes. DNA mitochondrial mutations are transmitted by maternal line, but there may be spontaneous mutations. As to physiopathogenesis of hearing loss, there are still many issues and theoriesIn 1989, a specific genealogical tree was studied by Lemkes et al.Authors have observed a coinciding loss of variable severity in each diabetic patients. When the third-generation line was considered, they detected diabetes and hearing loss present only in children of affected mothers. This observation has strongly suggested that heritage is exclusively maternal, which is a particular characteristics of diseases associated with mitochondrial DNA mutation.Leu(uur). They also pointed out that this syndrome was originally identified as a cause of MELAS syndrome  and that sensorineural hearing loss was an additional symptom in about 70% of the cases.Newkirk et al.leu, a substitution of nucleotide adenine for guanine in locus 3243, which may cause three different phenotypes: progressive chronic external ophthalmoplegia, diabetes, maternal-originated deafness and MELAS syndrome. Clinically, diabetes mellitus and maternal inherited deafness are characterized by insulin-dependent diabetes, which can be non-insulin dependent at first, but normally evolves to it because the mitochondrial affection modifies insulin secretion by the pancreas; patients are thin and less than 40 years of age and hearing loss is normally sensorineural progressiveIn some cases, the same mutation may cause different phenotypes such as in the case of gene tRNAFowler et al.As presented in the literature review, there is not enough evidence to solidly define diabetes mellitus as a cause of hearing loss. There is no consensus on any aspect of this topic, either audiologically or histopathologically. Clinical experience, in many studies, showed direct correlation between hearing loss and diabetes, as reported in Affection of blood vessels that irrigate the inner ear and affections that occur in stria vascularis of diabetic patients are unquestionable facts confirmed by different authors that believe in the correlation between hearing loss and diabetes, and these affections are strong evidences that diabetes may cause hearing lossSome studies indicate that decrease in hearing acuity, similarly to the one presented in presbyacusis, is greater than what is expected for the age in elderly and diabetic patientsUp to 1960, there were 3 theories about the pathogenesis of hearing loss caused by diabetes mellitus: neuropathy, angiopathy and association of both. Currently, there are significant reasons to believe that the angiopathy found in diabetic patients contributes to greater evidences of hearing loss. In favor of this hypothesis we can rely on histopathological findings of microvascular lesions of the inner ear, such as thickness of basal membrane of stria vascularis capillaries, as well as the fact that diffuse vascular affections caused by diabetes mellitus are well knownIt is known that the main difficulty to conduct inner ear study is related with difficulty to access histological assessment, especially in human beings. Moreover, the steps to preparation of material can also have artifacts, provoking misinterpretations. The localization of inner ear circulation makes it difficult to study homeostasis, as well as the consequences of metabolic disorders. Other factors that can induce misinterpretation of statistical data are use of different populations for comparison purposes, lack of good control group, need to conduct longitudinal studies . Other important aspect is size of studied group and the huge universe of variables such as other diseases, use of drugs, noise exposure, genetic affections. It is possible that these are the reasons for discrepancy in results detected among similar studies conducted by different authors.Finally, we observed growing interest in hearing loss caused by genetic affections, many of them related to mitochondrial DNA mutations. They correspond to 0.5% to 1% of all genetically-based hearing losses, which may be associated with syndromic presentations. One of the syndrome presentations is diabetes mellitus associated with maternal-inherited hearing loss, amounting to 1.5% of all cases of diabetes in Japan and The NetherlandsThe investigation of genetic causes has been the answer to many questions and disagreeing results.In view of current knowledge, there is evidence that diabetes mellitus may cause hearing loss, but we can not state that there is clear cause-effect correlation. It is known that a series of variants may favor the association between both diseases, but it is necessary to conduct more careful studies to define the true role of these factors. As seen before, diabetes mellitus and hearing loss can be dependent components, or even components of a genetic syndrome and not dependent one on the other.According to the analyzed studies, we can conclude that many questions will be answered by multicenter longitudinal studies with large populations and strict inclusion and exclusion criteria.