Untreated age-related sensorineural hearing loss is challenged by low adoption and adherence to hearing aids for treatment. Hearing care has evolved from traditional clinic-controlled treatment to online consumer-centered hearing care, supported by the increasingly person-centered design of hearing aid technology. Greater evidence and a more nuanced understanding of the personal need for adoption versus adherence to the use of consumer hearing care devices are required. Research considering consumer hearing aid acceptance behavior rests on behavior modification theories to guide clinical approaches to increasing hearing aid adoption and adherence. However, in the context of complex chronic health management, there may be a gap in how these theories effectively align with the needs of consumers. Similarly, market data indicates evolving consumer behavior patterns have implications for hearing care theory and implementation, particularly in terms of sustained behavior change. This essay proposes that evidence, including theory and application, be strengthened by revising basic theoretical premises of personal experience with complex chronic health, in addition to considering recent changes in commercial contexts. Hearing loss has various causes and treatment options, which include the sustained use of hearing aids. The leading presentation of hearing loss in adults is age-related sensorineural hearing loss, caused by the degenerative effects of aging on the auditory system. Sensorineural hearing loss impacts the ability of auditory organs from the ear to auditory pathways in the brain  to detect (sense) and process sound effectively . Age-relHealth status is functionally and personally integral to a person’s sense of identity ,11. The “…encounter with limitation and finitude. In particular, chronic incurable conditions require a major adjustment in personal identity. Patients must assimilate the fact of imperfection, of impairment and constraint” (p. 341)Personal autonomy, agency, and independence are challenged by complex chronic conditions, such as hearing loss ,14. HearIllness identity describes how a person perceives their condition and its treatment, as well as how the person integrates their condition into their identity ,19. AcceHearing aids are intended to compensate for the diminished ability to hear and communicate. However, it is physiologically impossible to regain 100% functional hearing or a pre-condition capability . There i“Hearing loss involves change and adjustment and a changing sense of identity that threatens one’s control over one’s autonomy and independence. [Hearing loss] adds to other physiologic changes and to societal attitudes that foster dependency to reduce one’s sense of personal control” .Involuntary changes to personal identity inherently instigate an emotional process of grieving and acceptance ,27,28,29Ease of communication can be improved with hearing aid use, along with reducing the rate of further deterioration of hearing loss and associated impacts on health ,25,30,31Knowledge of the negative consequences of untreated hearing loss is insufficient to motivate sustained behavior change in hearing aid consumers, as there continues to be non-use of hearing aids, even after purchasing them ,10. The There remains a gap between the advancement of hearing technology to treat and support hearing loss and the increasing number of people who would benefit from wearing hearing aids . BehavioThe aim of this essay is to synthesize evidence and articulate current knowledge about concepts derived from behavior change theories. To identify and map concepts utilized in practice and reflected in the literature, behavior modification theories often employed in hearing care were identified. The purpose of this essay was not to perform a systematic review or to offer a comprehensive description of all existing approaches but to present evidence to debate whether the hearing care industry should reassess its approaches to hearing aid adoption and long-term hearing care. The provocative question posed in this article is, “Does the inclusion of commonly used behavioral theories in hearing care assist clinician knowledge of the requirements of individual adoption and adherence to hearing aids in today’s environment?”Analyzing behavior theories provides a benchmark to improve the adoption and adherence of behavior-dependent hearing care treatments and technologies. Traditional hearing care typically comprised seeking a hearing test and advice, which may include referral for further investigation, and purchasing a hearing aid from clinic attendance, guided by one clinician. Innovation in hearing care includes new models of service where hearing aids can be acquired online. However, to support a person using their hearing aids successfully, effectively, and to their greatest potential, it is important to realize that clinical input and guidance are not mutually exclusive to online provision of hearing aids, with such services being further offered, recommended, or required via a variety of innovative business models that uncouple service and device provided for the person to access both in a way that serves them best ,37,38. TLong-term habit modification is more than a buying choice. Behavior modification theories for long-term hearing care must account for lived experience to address the elements that drive adherence. Hearing aid users’ ultimate behavior aim is sustained behavior modification. Hearing aid adoption and adherence are essential to ensure consumer ownership and continuing person-centered support for hearing aids to be effective in treating hearing loss.To understand and discuss opportunities and obstacles regarding hearing aid adoption and adherence processes, behavior change theory applied in audiology research is explored. Hearing care literature recognizes six models for behavior change: Capability, Opportunity, Motivation Behavior (COM-B), Trans-Theoretical Model (TTM), Health Belief Model (HBM), Theory of Reasoned Action/Theory of Planned Behavior (TRA/TPB), Common-Sense model (CSM), and Self-Determination Theory (SDT) See . COM-B, The disparity between the original behavioral change context on voluntary lifestyle behaviors and behavior change theories applied in hearing care research for the complex chronic condition of hearing loss as an involuntary experience raises the question—are these theories appropriate for use with hearing loss? Wearing a hearing aid necessitates deliberately placing one in the ear or on the ear of the person in need, making their usage an active choice. Acting is a skill essential for good hearing aid use. Motivation to act is required in behavioral theories adopted in audiology ,49,50,51Voluntary behavior and involuntary experience have different contexts due to the contrast between being an active participant versus a recipient of change. The act of wearing a hearing aid is voluntary behavior. However, the lived experience of hearing loss that influences the motivation to keep wearing a hearing aid is involuntary. Behavior change research in audiology repeatedly investigates adoption and rarely adherence to the wearing of hearing aids . This ovThe emotional sense of loss of function and change of identity described as illness identity, how a person feels about their involuntary complex chronic health change experiences, is under-represented in the use of behavior change theories in hearing care research see . The TheTRA, TPB, and CSM recognize emotion is relevant to desired health behaviors or pertaining to the negative impacts of a condition. However, a person’s emotional relationship with their condition and the impact on such health behaviors is overlooked ,43,59. TIn CSM, distress caused by a health threat or condition is at the root of an emotional response ,59. The Emotional components involved in a fear-driven response relate to the condition’s immediate effect, implying an acute response rather than a chronic perspective on the impact of hearing loss on the person’s self-identity ,28,29. TThe recent revision of the CSM theory acknowledges differences that apply to the management of acute, complex, and chronic conditions . TheoretEmotional response to hearing loss is anchored to self-identity rather than the condition or treatment. Individuals recognizing a loss of their hearing, in turn, are faced with a change in self-identity ,26,27. TFor the hearing care industry, adopting hearing aids is consumer-focused purchasing behavior. Adherence to the use of hearing aids, on the other hand, is a person-centered behavior. Person-centered care is a popular discussion topic in hearing care, endorsed to improve clinical outcomes and successful behavior change ,65,66. HLack of recognition of self-identity or emotional response to involuntary change caused by health conditions is an observation across hearing care studies into behavior change. The self-determination theory (SDT) applied to hearing loss proposes internal and external processes are required to recognize the impact on motivating people to seek help ,57. InteBehavior changes theories frequently used in hearing care focus on adoption. Behavior change theories in hearing care place the adoption of treatments and technologies such as hearing aids as an outcome ,71. ThisThe following section discusses recognized behavior change factors in audiology, suggests the potential impact on improving behavior change thinking, and highlights recent changes and evidence in the field of hearing care that may contribute to a better understanding of successful, long-term behavior change in hearing care adherence.Theories of behavior change date from the 1950s ,60, befoThe concept of self-efficacy was realized in 1977 , becominRelative to market potential, hearing care continues to demonstrate low rates of adoption, along with persistent issues with adherence to hearing aid use ,9. IncreTechnology developments in hearing care enable a reduced dependence on traveling to clinics to receive services and clinician-controlled health management models and services. Instead, a shift towards empowering consumers to manage their own health and care needs is increasingly possible ,72,81. RThe importance of consumer satisfaction and perceived self-efficacy is demonstrated by its association with the adoption and adherence to hearing aid use ,73,90,91Online services and the use of self-fit products have been described as empowered hearing care models in hearing care ,96. WhilSatisfaction with hearing technology has increased in recent years due to improvements in technology design and performance; yet, there is still much to be achieved or agreed upon regarding improvements in market penetration ,97,98. MLike the theories and audiology applied research discussed so far, the market data available focuses on the adoption of hearing technology rather than adherence. In future, the specialty of hearing care would benefit from adding variables related to adherence to hearing care and technology management in future market surveys and analyses.Satisfaction is linked to potential adoption and adherence to hearing care ,95. ReseBehavioral research, seminal theories, market trends, and the construction of commercially derived research data provide opportunities to revise current thinking and identify opportunities for the implementation of new and improved learnings. Studies in hearing care research highlight the value of adoption-related factors and point to the need to address adherence considerations see . Figure Starting a successful hearing care journey is highlighted by revisiting seminal theories of behavior change alongside lived experience of chronic health; the importance of understanding consumer emotional status in accepting a personal change, rather than the condition itself. Commercially derived data that govern technology design, and business models, shaping modern changes to available sales and service models, have the potential to provide real-time data on consumer behavior and outcomes. Combined learning from research and market data indicate that consumer-centered technology is sought by consumers, sales models can enable consumers to access and adopt hearing technologies, and autonomous services models have the potential to positively impact known behavioral factors. In agreement with the Consumer Technology Associations’ recent standards for digital therapeutics, evidence of adherence and satisfaction is considered of value in improving and revising what constitutes success in hearing care . AdherenClinicians’ understanding of the requirements for adoption and adherence to hearing aid use in today’s hearing care environment are hampered by the limitations of how behavioral theories continue to be applied in hearing care research. Consideration has been given to understanding behavior change theories applied in clinical practice and the consumer market of hearing care. Understanding the personal experience of hearing loss is impacted by an involuntary loss of functionality and change to self-identity has been highlighted. Consideration of the influence of service and product design to support personal needs caused by a loss in a respectful and effective manner is a foundation upon which the new era of digital health intervention models can expand and enable changing consumer behavior in hearing care. Chronic conditions have not changed; however, if we want to see a change in consumer behavior response to them, we should adopt models of care which empower and support those with lived experience of hearing loss as a complex chronic condition.This essay has provided a stimulating rethinking of issues concerning the successful treatment of age-related sensorineural chronic hearing loss. A systematic review is still needed to further explain how existing techniques for fostering permanent sustained behavior change in persons with hearing loss should be altered or handled. Other forms of hearing loss and their management have not been included in this paper and, thus, should be investigated for additional research, as they may not be relevant to the discussion and recommendations mentioned in this essay. Ongoing research is recommended.


Additionally, performance in azimuth is further reduced for contralateral routing of signal aided localization compared to the simulated unilateral hearing loss condition. Use of the contralateral routing of signal device also results in a reduction in promptness of the listener response and an increase in response variability. Conclusions: Results suggest contralateral routing of signal hearing aids disrupt monaural spectral and level cues, which leads to detriments in localization performance in both the horizontal and vertical dimensions. Increased reaction time and increasing variability in responses suggests localization is more effortful when wearing the contralateral rerouting of signal device.Objectives: In the absence of binaural hearing, individuals with single-sided deafness can adapt to use monaural level and spectral cues to improve their spatial hearing abilities. Contralateral routing of signal is the most common form of rehabilitation for individuals with single-sided deafness. However, little is known about how these devices affect monaural localization cues, which single-sided deafness listeners may become reliant on. This study aimed to investigate the effects of contralateral routing of signal hearing aids on localization performance in azimuth and elevation under monaural listening conditions. Design: Localization was assessed in 10 normal hearing adults under three listening conditions: (1) normal hearing (NH), (2) unilateral plug (NH-plug), and (3) unilateral plug and CROS aided (NH-plug + CROS). Monaural hearing simulation was achieved by plugging the ear with E-A-Rsoft™ FX™ foam earplugs. Stimuli consisted of 150 ms high-pass noise bursts (3–20 kHz), presented in a random order from fifty locations spanning ±70° in the horizontal and ±30° in the vertical plane at 45, 55, and 65 dBA. Results: In the unilateral plugged listening condition, participants demonstrated good localization in elevation and a response bias in azimuth for signals directed at the open ear. A significant decrease in performance in elevation occurs with the contralateral routing of signal hearing device on, evidenced by significant reductions in response gain and low  Sound source localization is dependent on the ability of the listener to extract interaural timing and level cues arriving at the two ears. In binaural hearing, integration of these cues plays a critical role in the ability to localize sound and separate speech from competing signals. Unilateral hearing loss abolishes binaural hearing cues. This significantly disrupts spatial hearing abilities and leads to impaired sound source localization . One forEvidence demonstrates that listeners can adapt to the monaural hearing condition over time, relying on level and spectral cues to improve their localization abilities . SpectraContralateral routing of signal (CROS) hearing aids are a common rehabilitation solution for individuals with SSD, serving to reroute the signal of interest from the impaired ear to the better-hearing ear . StudiesDespite offering this non-invasive treatment option for individuals with SSD, CROS technology has not gained widespread adoption and acceptance, primarily due to the known acoustic limitations . It is pStudies of CROS performance have focused almost exclusively on investigating the ability of these devices to improve localization performance in individuals with SSD ,27,28,29Ten normal hearing adults  participated in this study. All participants had normal hearing bilaterally as determined by air conduction hearing thresholds of <20 dB HL across the standard audiometric test frequencies of 250–8000 Hz, and no prior history of hearing impairment. All participants were naïve to the experimental procedures. All experimental procedures have been approved by the local ethics committee of the Faculty of Social Sciences of the Radboud University (ECSW 2016-2208-41).Sound localization measurements were performed in a completely darkened sound-isolated chamber ,35. StimDuring the task, participants sat comfortably in a chair and were instructed to fixate a head-mounted light emitting diode (LED) towards the perceived sound location via a head movement. Horizontal and vertical head movements were recorded with the magnetic search coil technique to measure the head rotation of the subject in response to the stimuli. The presentation of stimuli and data acquisition were implemented using TDT3 hardware  and controlled with a custom-made software based in MATLAB .Prior to each trial, subjects had to fixate to a visual target presented straight ahead at 0° azimuth  normal hearing (NH), (b) unilateral plug (NH-plug), and (c) unilateral plug and CROS aided (NH-plug + CROS). All participants were plugged in the left ear for the NH-Plug and NH-plug + CROS conditions with E-A-Rsoft™ FX™ foam earplugs , which attenuated sounds above 3000 Hz by at least 30 dB. The three experimental conditions were performed in succession in a single experimental session lasting approximately 40 min. Note that although the unilateral plugged conditions significantly perturbed binaural hearing cues, complete monaurality could not be achieved. Some remnant ITD and ILD cues may have been available to listeners under plugged listening conditions, particularly at high presentation levels (65-dBA). When occluding one ear in normal-hearing listeners, monaural level and spectral-pinnae cues are enhanced sound localization cues ,36,37. M® CROS open fit hearing aid system. This hearing aid consists of a microphone placed on the superior portion of the pinna of the impaired ear, which wirelessly transmits acoustic information (130–6000 Hz) to a receiver hearing aid worn in the normal ear. Devices were fitted using NAL-NL prescriptive targets  = 152.67, p < 0.001), localization bias  = 63.75, p < 0.001), and r2  = 166.35, p < 0.001). The post hoc comparisons revealed that α-gain, α-bias, and α-r2 under NH-plug and NH-plug + CROS conditions were significantly poorer than the NH condition. Note that the goodness of fit of the NH-plug + CROS condition decreased significantly compared to NH-plug, evidencing poor localization  = 99.44, p < 0.001) and r2  = 133.44, p < 0.001). Post hoc comparisons revealed significant differences between all listening conditions, reflected by a systematic decrease in ε-gain and ε-r2  = 1.44, p = 0.25; The distribution of listeners’ individually fitted  response gains, biases and lization C. Responand ε-r2 D,F. Ther(α) = 1.25, p = 0.29; F(ε) = 0.45, p = 0.64), localization bias (F(α) = 0.09, p = 0.92; F(ε) = 1.47, p = 0.24), or r2 (F(α) = 0.89, p = 0.41; F(ε) = 1.45, p = 0.24). Moreover, no interaction was observed between listening conditions and presentation level for gain (F(α) = 0.73, p = 0.58; F(ε) = 0.73, p = 0.58) or bias (F(α) = 0.07, p = 0.99; F(ε) = 0.08, p = 0.99) or r2 (F(α) = 0.27, p = 0.90; F(ε) = 0.27, p = 0.89) in either the horizontal or vertical dimensions.Stimulus presentation level did not influence localization performance in either the azimuthal or vertical dimensions. Analyses revealed no effect of stimulus level  on localization gain  = 50.96, p < 0.001) and response variability  = 7.27, p = 0.003). Post hoc comparisons showed no difference between NH-plug and NH-plug + CROS on the far-left side where listeners were plugged. On the open hearing side (right), there was a main effect of conditions towards the periphery of the hemifield for both gain  = 12.33, p < 0.001) and variability  = 7.13, p = 0.003). Post hoc comparisons indicated performance with the CROS device was significantly poorer than the other listening conditions  = 0.8; NH-plug = 0.7) and low response variation  = 7.5°; NH-plug = 8.5°). However, this performance is significantly impaired when the CROS device is applied  = 0.3) and increased response variability  = 12.5). The fact that elevation gain is maintained at the open ear but significantly diminished when the CROS is applied which is concomitant with a significant increase in response variability, provides support that monaural spectral cues are disrupted by the use of a CROS device.Under plugged hearing conditions . NH-plug and NH-plug + CROS response patterns show a significant decrease on the plugged side  = 19.87, p < 0.001), reaching 3.4 s−1 on average. From the plugged to the open hearing side, there is a systematic increase in promptness (faster responses). Maximum promptness is reached at  = 3.9 s−1) compared to the plug alone  = 4.4 s−1). There was a main effect of listening condition at  = 9.08, p < 0.001), and although To further evaluate the effects of CROS devices on the use of monaural cues, the promptness of responses across azimuth was analyzed. Response promptness to the auditory stimuli is presented for all participants in Due to the loss of binaural hearing, SSD listeners suffer from poor speech perception in noisy environments and reduced sound localization. In more recent previous studies on the benefits and limitations of rehabilitative devices in monaural listeners have been limited to localization in azimuth. This approach neglects to take into account the role of spectral pinna cues in vertical sound localization. Monaural localization is well studied, but studies on the effects of ear level devices  on monaural localization performance in monaural listeners are lacking. Research has shown that listeners can learn to reweight spatial hearing cues under monaural listening conditions to improve their spatial hearing abilities ,39,40. Tr2) compared to the NH condition. Although, a closer review of the data , increased response variability, and slowed response rates (i.e., promptness, When the CROS hearing aid was applied, the good vertical localization at the open ear was obliterated . This isAs others have shown, under acute monauralization, listeners present with a biased localization response to the open ear side but maintain good vertical localization ,40,41. FThe effect of the CROS device on localization performance in the open ear is far more pronounced. With the addition of a CROS device in the intact ear , red, noOur findings offer some insight into those monaural listeners who do adapt and become reliant on monaural spectral cues, in particular young listeners with normal high-frequency hearing who reject CROS as a treatment solution for SSD. This may be of value when determining candidacy for various treatment solutions for individuals with SSD. It is possible that the hearing in noise and sound awareness benefits of CROS  do not oNormal pinna function is distorted by the CROS hearing aid which leads to detriments in localization performance in both the horizontal and vertical dimensions. Sounds are mostly perceived towards the extreme side of the functional ear on azimuth and monaural spectral cues are functionally perturbed for localization in both elevation and azimuth. Furthermore, this drop in performance comes with higher effort and yields higher uncertainty of sound location. For those monaural listeners who successfully adapt to the use of such monaural spectral cues, this may contribute to failure to adopt CROS technology. Collectively, these results demonstrate that the CROS hearing aid diminishes the access to monaural spectral cues and suggests that reweighting of monaural spectral cues may not be possible with the use of an ear level device on the better-hearing ear.


Audio-vestibular symptoms can arise from vertebrobasilar dolichoectasia (VBD) and basilar dolichoectasia (BD). Given the dearth of available information, herein we reported our experience with different audio-vestibular disorders (AVDs) observed in a case series of VBD patients. Furthermore, a literature review analyzed the possible relationships between epidemiological, clinical, and neuroradiological findings and audiological prognosis. The electronic archive of our audiological tertiary referral center was screened. All identified patients had a diagnosis of VBD/BD according to Smoker’s criteria and a comprehensive audiological evaluation. PubMed and Scopus databases were searched for inherent papers published from 1 January 2000 to 1 March 2023. Three subjects were found; all of them had high blood pressure, and only the patient with high-grade VBD showed progressive sensorineural hearing loss (SNHL). Seven original studies were retrieved from the literature, overall including 90 cases. AVDs were more common in males and present in late adulthood , with symptoms including progressive and sudden SNHL, tinnitus, and vertigo. Diagnosis was made using different audiological and vestibular tests and cerebral MRI. Management was hearing aid fitting and long-term follow-up, with only one case of microvascular decompression surgery. The mechanism by which VBD and BD can cause AVD is debated, with the main hypothesis being VIII cranial nerve compression and vascular impairment. Our reported cases suggested the possibility of central auditory dysfunction of retro-cochlear origin due to VBD, followed by rapidly progressing SNHL and/or unnoticed sudden SNHL. More research is needed to better understand this audiological entity and achieve an evidence-based effective treatment. Elongation, widening, and tortuosity of the vessels in the posterior brain circulation are defined as vertebrobasilar dolichoectasia (VBD) and basilar dolichoectasia (BD) depending on the involved anatomical structures. With a prevalence ranging from 0.06% to 5.8% and a reported male predominance, VBD is due to a deterioration of the tunica structure given by multifactorial etiologies affecting both basilar and vertebral arteries, while BD is limited to the basilar artery . The conTherefore, the possibility of VBD as a cause of audio-vestibular dysfunction must be considered, along with neurovascular conflict between the anterior inferior cerebellar artery (AICA) and the vestibulocochlear nerve and CPA masses ,4,9. CerAt the same time, specific recommendations for clinical management of VBD and BD still need to be developed, and a long-term follow-up is commonly employed as a precautionary approach even for asymptomatic cases .Given the dearth of available information, the main aim of this investigation was to report our experience with the spectrum of different audio-vestibular disorders observed in a case series of VBD diagnosed during a 7-year period. Furthermore, a literature review was performed in order to analyze the possible relationships between epidemiological, clinical, and neuroradiological findings and audiological prognosis.Data were examined in accordance with the Helsinki Declaration, the Italian privacy and sensitive data laws, and the in-house regulations of our hospital. All patients gave their written consent for clinical case publication. The electronic archive  of our tertiary referral center for audio-vestibular disorders  was consulted. The time framework evaluated ranged from 2015 to 2022. Inclusion criteria were the following: (i) diagnosis of vertebrobasilar dolichoectasia according to Smoker’s criteria ; (ii) auAudiometry was performed with Madsen Astera by GN Otometrics , in accordance with European (IEC 60645-I) and ISO (389-1) standards, in a sound-attenuating room, as previously reported . HearingDistorted product otoacoustic emission (DPOAE) was registered with the ILO 292 system , recorded at 1000, 1501, 2002, 3003, 4004, 6006, and 7996 Hz (f2). Impedance was studied using GSI TympStar Version 2 .Auditory brainstem potentials (ABRs) were recorded from scalp electrodes  for 2000 trials of alternating polarity clicks presented monaurally using a TDH-50 transducer earphone at a maximum intensity of 125 dB p.e. SPL . The filter settings of the amplifier were set between 5 and 4000 Hz.Spontaneous/positional nystagmus was registered with VisualEyes Goggles and VNG software v7, Interacoustic . The procedure was followed by a bi-thermic caloric instrument test using an Otometrics ICS AirCal  with air at 50 °C and 24 °C, 60″ of stimulation per side, and 70″ of recording .MRI protocol included T1-W and 3D T2-W sequences of the skull base and the posterior fossa. Subsequently, contrast-enhanced or time-of-flight (TOF) magnetic resonance angiography (MRA) was performed. The inclusion of a sequence covering the whole head, a T1-W, T2-W, or FLAIR sequence, needed to be considered for the evaluation of intracranial space-occupying lesions or vascular abnormalities.Multi-detector CT angiography (CTA) or CT venography (CTV) of the head and neck region was performed with detector configurations that covered the whole head with 16 cm coverage as 320 × 0.5 mm or 256 × 0.625 mm collimations, as previously described . A tempoPubMed and Scopus electronic databases were searched for papers on vertebrobasilar dolichoectasia published in the last 22 years (from 1 January 2000 to 1 March 2023). The search strings were as follows: “basilar dolichoectasia tinnitus” OR “basilar dolichoectasia hearing” OR “basilar dolichoectasia vertigo” OR “vertebrobasilar dolichoectasia tinnitus” OR “vertebrobasilar dolichoectasia hearing” OR “vertebrobasilar dolichoectasia vertigo” for PubMed; (basilar AND dolichoectasia AND tinnitus) OR (basilar AND dolichoectasia AND hearing) OR (basilar AND dolichoectasia AND vertigo) OR (vertebrobasilar AND dolichoectasia AND tinnitus) OR (vertebrobasilar AND dolichoectasia AND hearing) OR (vertebrobasilar AND dolichoectasia AND vertigo) for Scopus. The “Related articles” option on the PubMed homepage was also considered. Titles and abstracts of papers available in the English language were examined. The identified full texts were screened for original data, and the related references were retrieved and checked manually for other relevant studies. Studies were included when the following general criteria were met: (i) articles were original reports; (ii) studies included only clinically confirmed cases of audiological symptoms in patients with vertebrobasilar dolichoectasia; (iii) investigation reported detailed information about diagnostic workout and/or treatment results; (iv) study design was not editorial, letter to the editor, or review; (v) the report was written in the English language. Included studies were analyzed to extract all available data and ensure eligibility for all patients. Descriptive data of epidemiology, etiology, symptoms, diagnostic procedures, treatments, outcomes, and follow-up were considered.A 66-year-old male patient complaining of left tinnitus in the previous 7 months was referred to our Unit. The patient’s medical history was relevant for high blood pressure (HBP) under medical treatment. Otoscopy examination was bilaterally normal. The pure-tone audiometry showed bilateral mild sensorineural hearing loss (PTA 20 dB); speech audiometry was bilaterally within normal limits (SRT 30 dB). Tympanograms were normal. Acoustic reflexes were partially present. DPOAEs were present bilaterally. ABR showed increased latencies of wave V on the left ear . The Tinnitus Handicap Index score (THI) was 28/100.At 6-month follow-up, the patient reported dizziness and severe hearing loss in the left ear. The patient also reported poor blood pressure control. PTA was unchanged but SRT was absent on the left side, and ABR waves on the left side were not detectable. DPOAEs were bilaterally present. Upon vestibular examination, spontaneous nystagmus was absent, and left vestibular hyporeflexia was found in the caloric test. THI was 12/100. Brain MRI showed normal inner ear structures but revealed the presence of vertebrobasilar dolichoectasia (Smoker classification: 7/7) and postero-lateral dislocation of the left branches of VII and VIII CNs a. AccordOne-year follow-up radiological images showed unchanged conditions; the patient did not report any different symptoms. Nonetheless, pure tone audiometry revealed aggravation of hearing loss on the left side (PTA 90 dB) with unilateral absent DPOAE b.A 68-year-old male patient complaining of bilateral hearing loss and ear fullness (worse on the left side) was referred to our Unit to undergo a course of Eustachian tube insufflations. The patient also suffered from bilateral tinnitus in the previous 10 years and recurrent episodes of benign paroxysmal positional vertigo (BPPV), as previously diagnosed and treated in our clinic, according to international diagnostic criteria ,15. HBP The patient was fitted with bilateral hearing aids with subjective and objective benefit at three-year follow-up control, without significant progression of the hearing loss.An 80-year-old male patient was referred to our Unit complaining of bilateral subjective hearing loss, dizziness, and ear fullness to perform a course of Eustachian tube insufflations. Past history was relevant for renal carcinoma surgically treated three years before and HBP under medical therapy. Otolaryngological examination was within normal limits. Pure tone audiometry showed bilateral sensorineural hearing loss . Speech audiometry was consistent with tonal audiometry . ABR showed a slight delay of the fifth wave on the left side (5.56 ms on the right ear vs. 5.64 ms on the left one). Tympanograms were normal. Acoustic reflexes were bilaterally present. Videonystagmography (VNG) showed no signs of vestibular anomalies, as reported in Hearing aids were prescribed but the patient refused for personal reasons. A cardio-vascular visit found scarce control of blood pressure; its normalization brought to dizziness regression. Follow-up controls showed no significant progression of hearing loss.Following our research methods, 487 manuscripts were retrieved from the PubMed and Scopus databases from January 2000 to March 2022 see also . Seven aA total of 90 patients  have been analyzed; the mean age was 65 years (range 37–71). Predominant cochleovestibular symptoms included hearing loss, sudden hearing loss, tinnitus, and vertigo. In two cases, hemifacial spasm and facial pain were reported. The majority of patients (71%) had a medical history of hypertension, syncopal events, and cardiovascular disorders.Considered patients generally developed mild to moderate hearing loss, without significant alterations of speech recognition ,6,9,16. VBD is a vascular condition first described by the international literature in the early 20th century; the term VBD is often used to encompass both vertebral and basilar artery involvement. It is important to differentiate between VBD and BD as they can have different clinical presentations, radiological features, and potential complications . VBD andAs mentioned before, the exact mechanism by which VBD and BD can cause audio-vestibular symptoms is still debated. One of the main hypotheses is VIII CN compression, as postulated by Passero and Rossi , which mMoreover, vascular mechanisms leading to blood flow alterations in the vertebrobasilar system, resulting in a reduction in blood supply to the cochlea, have been advocated in CPA pathologies . In the Decreased cerebral perfusion of posterior circulation territory characterized by delayed time-to-perfusion in dynamic, susceptibility-weighted, contrast-enhanced perfusion cerebral MRI was shown in a study on 77 patients with VBD, resulting in an augmented risk of posterior ischemic stroke .Few studies have focused on the management of neurological symptoms related to VBD and BD . ConcernOn the other hand, in a prophylactic setting, preliminary good results have been shown by the administration of novel oral anticoagulants to prevent stroke . RegardiIn the studies included in this review, the treatment of audio-vestibular disorders was always conservative, except for one case, in which surgical microvascular decompression (MVD) was indicated, due to the coexistence of a hemifacial spasm (HFS) on the same side of the audio-vestibular symptoms . In thisIn all the considered studies, BD or VBD diagnosis was based on cerebral MRI. However, only one provided a classification of BD/VBD severity according to Smoker’s criteria .In the considered articles, the clinical evaluation of audio-vestibular signs/symptoms was based on different tests, including pure tone and speech audiometry, ABR, vHIT, and VNG see . InteresIn the present study, we reported the case series of three patients with different audio-vestibular symptoms ; all these patients developed various degrees of sensorineural hearing loss on the same side of their VBD or BD. Given the advanced age of the patients, we should not neglect the contribution of presbyacusis to the hearing decrement, especially concerning Case 3 for whom age-related hearing loss has been considered as a differential diagnosis. In such cases, we stress the need for an accurate hearing diagnosis and a consequent prompt treatment to avoid late-insufficient hearing aid fitting . RegardiRegarding possible risk factors, all three patients of our series showed HBP as a comorbidity. Interestingly, our literature review showed that HBP was present in more than half of reported cases with VBD/BD and audio-vestibular disorders. Regarding other possible epidemiological associations resulting from the literature, a slight male prevalence (109 vs. 81 cases) and a late adult mean age  were found.The size of our series did not allow us to investigate any statistical association; however, some findings deserve to be mentioned: (i) only the case with the highest Smoker’s classification score (7/7) showed progression of hearing loss see ; (ii) thThe natural history of our Case 1 may present some interesting insights into the possible pathophysiology of audiological symptoms in VBD. In the first months of clinical presentation, Case 1 developed a retro-cochlear left hearing loss as shown by normal PTA and DPOAE and the absence of SRT and ABR waves see b. This cIt is well known that certain types of hearing disorders may be due to brain dysfunction, referring as central auditory dysfunction (CAD). Models of CAD, apart from pediatric central auditory processing disorders, include acquired auditory neuropathy of the VIII CN due to retro-cochlear lesions, in its most common form due to vestibular schwannoma ,32. Our For all our audiological patients, we preferred a conservative treatment based on hearing aid fitting and long-term follow-up. In fact, in the absence of sufficient evidence supporting any kind of active treatment of VBD (except for the case of life-threatening complications), a potential surgical approach would have led to a potentially unfavorable risk–benefit balance, in particular regarding hearing outcome, as previously reported . NonetheOverall, in the present study, we reported our experience with the management of patients with audio-vestibular symptoms and VBD. The main strengths of our study are the application of a complete audiological evaluation and the long-term follow-up; the main limitations are related to the retrospective monocentric study design.Audio-vestibular manifestations of VBD and BD have been reported for many decades, but the epidemiological and clinical features, etiopathogenesis, and best management strategy are still unclear. Herein, we reported a clinical scenario in which the natural history of audio-vestibular symptoms of VBD/BD could be explained by both compressive and vascular mechanisms.Based on the small amount of available evidence, a long-term follow-up seems to be a useful approach, along with continued monitoring of the possible evolution of signs/symptoms in collaboration with neurologists and neuroradiologists and the early detection of possible complications. However, further studies  are mandatory to better understand this audiological entity with the objective of identifying an evidence-based effective therapeutic approach.


Congenital cholesteatoma is typically an expanding cystic mass of keratinizing squamous epithelium located medial to the intact tympanic membrane in patients with no prior history of perforation, otorrhea and ear. It is generally thought to be a progressive disease and is usually surgically removed upon detection as the first-choice treatment. As such, it is rare to be observed for a long term without progression. Here we report a rare case of congenital cholesteatoma that remained in an undetectable size and did not deteriorate mild hearing loss for 12 years. A seven years old boy was referred to us with right hearing impairment. Pure-tone audiometry found conductive hearing loss with an air-bone gap of 25 dB and a high-resolution computed tomography (CT) scan found the eroded long process of incus but did not detect any soft tissue density indicating congenital cholesteatoma. He initially did not wish to undergo surgery. His hearing level and image finding remained virtually unchanged during the next 12 years of the follow-up period. Twelve years later, endoscopic ear surgery was performed, which revealed a very small cholesteatoma mass, an eroded long process of the incus and ossicular chain discontinuities. We suspect that the cholesteatoma was originally larger, partially eroded the incus, then regressed to a very small size, and remained small for at least 12 years under our observation. Congenital cholesteatoma is typically an expanding cystic mass of keratinizing squamous epithelium located medial to the intact tympanic membrane in patients with no prior history of perforation, otorrhea and ear surgery ,2. CongeA seven years old boy was referred to our hospital for hearing loss in the right ear. His right ear hearing impairment was first detected during a health examination at school. The patient had no history of otitis media, otorrhea, ear trauma, otologic surgery and subjective hearing loss. Otomicroscopic examination revealed a normal tympanic membrane and outer ear canal Figure .Pure-tone audiometry revealed conductive hearing loss with an air-bone gap of 25 dB Figure . AlthougAt age 19, after 12 year follow-up period, the patient wanted to improve his right ear hearing and underwent endoscopic surgery. A preoperative audiogram found that the conductive hearing loss in his right ear with an air-bone gap of 31.6 dB was not significantly different from 12 years ago Figure . PreoperNo recurrence has been acknowledged for more than three years.We presented a rare case of CTCC which did not progress and did not deteriorate hearing for over 12 years. It is rare to observe such a long term without disease advancement, as congenital cholesteatoma is generally expected to grow and extend over time and is usually surgically removed upon detection as the first-choice treatment . AlthougWe suspect that the cholesteatoma was originally larger, partially eroded the incus, then regressed to a very small size, and remained small for at least 12 years under our observation. The intact lenticular process and partially eroded long process of incus suggested that the ossicular chain discontinuity was caused by erosion associated with cholesteatoma rather than anomalies. How and when such regression could take place is uncertain. Possible hypotheses in literature we could relate to include spontaneous regression or disappearance of cholesteatoma  especialAlthough the clinical and pathological findings were consistent with the diagnosis of CTCC, it is important to note other possibilities. We cannot rule out the possibility that the mass is a ruptured cyst and could be classified as OTCC. Slow growth may not be unusual in some OTCCs . AnotherEndoscopic ear surgery provides superior visualization in a less invasive manner afforded by 0° and angled endoscopes . It contIn this case, we were able to observe the patient with CTCC before the operation for 12 years, during which time there was no worsening of the disease. In the absence of infection or other aggravating factors, congenital cholesteatoma may not worsen but removal should be prioritized because of the possible acute exacerbation.


This case highlights the necessity to inform patients with vein ligation about the possibility of varicose vein formation in the periphery and brings awareness to emergency staff that bleeding could be caused by a ruptured peripheral varicose vein. The structure of the vein wall disrupted by a structure (▲), which appears to be a thread, and the rupture of the elastic fibers (△). This results in swollen, visible peripheral varicose veins on the skin surface, which are associated with swelling, pain, severe skin discoloration, and potential ulceration.22 was 99% . He had pallor, marked coldness, marked sweating, blood pressure of 64/55 mmHg, and pulse rate of 83 beats/min. Arterial blood gas analysis revealed a lactate level of 5.9 mmol/L. At the scene, active bleeding was not noted, and the cause could not be identified in the ambulance because of adherent blood. After docking, the peripheral venous tract was secured, fluid was administered, and a tourniquet was wrapped around the left lower leg to prevent further bleeding.An 86‐year‐old male patient suddenly began bleeding profusely from the left ankle joint while working in his restaurant. The patient was taking carvedilol 10 mg/day) for hypertension and had undergone open repair and fixation of a distal end fracture of the left tibial fibula at another hospital 10 years prior. However, he had no past medical or family history of bleeding disorders. On checking vital signs, the systolic blood pressure had dropped to 50 mmHg, and the patient was in shock. Figure 0 mg/day Upon hospital admission, the patient was somnolent; therefore, we administered crystalloid fluid (500 mL and plasma protein). His blood pressure gradually stabilized, and his consciousness improved. After cleaning the blood from his left lower leg, a 1‐cm varicose vein was found on the left dorsal surface with a 5‐mm ulcer at its apex Figure . On his 3Peripheral varicose veins are a chronic condition. However, a varicose vein of an imperceptible size can rupture and cause fatal bleeding. The legs are more prone to varicose veins, and a previous surgery can cause varicose veins to form and worsen in the same area. Therefore, patients should be informed about the possibility of varicose vein formation in the periphery of the surgical area if vein ligation is performed. Two types of ruptured varicose veins can cause fatal bleeding: the acute perforation type, in which the ulcer is less than 5 mm and is not accompanied by skin lesions, and the other type, which has the chronic ulcerative ulcers (more extensive and profound than the previous ones).The vulnerable leg veins in older people, who are more prone to varicose veins, can be exacerbated by previous surgical venous ligatures of the leg, which can lead to varicose vein formation at the same site. To date, no reports on the histopathologic features of ulcers suggest fatal variceal rupture due to previous surgical vein ligation.Therefore, patients should be informed that they might develop varicose veins in the periphery if venous ligation was performed in a previous surgery. The lack of adequate information and training related to this condition is the main reason for first aid being not performed by the patients themselves. Whenever a therapist treats a patient with varicose veins for other pathologies that may aggravate varicose veins, the possibility of harmful interactions with the pathological entity leading to fatal bleeding of the varicose veins must be considered. Additionally, patients with these risk factors must be educated regularly; the same is true for the present case.4In conclusion, we experienced a case of asymptomatic peripheral varicose vein rupture in a lower extremity that resulted in hemorrhagic shock due to sudden massive bleeding. This was a very rare case in which histopathology confirmed that previous surgery resulted in varicose veins formation. Thus, to prevent rupture, it is important to inform patients about potential fatality from a rupture. Moreover, orthopedic surgeons must be aware of this risk factor, and emergency physicians must consider this as a possible cause when handling bleeding cases.Jumpei Takamatsu: Conceptualization; data curation; project administration; writing – original draft. Hajime Nakajima: Conceptualization. Masatoshi Nakata: Conceptualization. Aya Fukuhara: Conceptualization; data curation. Jinkoo Kang: Conceptualization. Yuichi Yasue: Conceptualization.This study did not receive any grants from funding agencies in the public, commercial, or not‐for‐profit sectors.The authors declare that they have no competing interests.Ethical approval was waived by the institution.Written informed consent was obtained from the patient to publish this report in accordance with the journal's patient consent policy.


Indirect calorimetry is established as a gold standard to determine the resting metabolic rate (RMR), however, its clinical use is limited, especially in low-income settings. Thus, the use of predictive equations appear as an alternative to estimate the RMR, but its precision is debatable, especially in obese individuals and in populations without specifically developed equations. To evaluate the agreement between the RMR estimated by equations and by indirect calorimetry in low-income obese women. A cross-sectional study with adult and obese women, which estimated the RMR by indirect calorimetry and compared with 13 predictive equations using the concordance correlation coefficient, root mean square error (RMSE) and Bland-Altman methods. The maximum allowed differences were predefined as 10%. No equation presented its confidence intervals for the Bland-Altman limits of agreement inside the predefined acceptable range. The Harris-Benedict equation achieved better agreement  whereas the Henry-Rees equation achieved better precision . None of the studied equations satisfactorily estimated the RMR estimated by indirect calorimetry. In the absence of specific equations for this population, the use of the Harris-Benedict and Henry-Rees equations could be considered. Obesity is a worldwide public health problem and is associated with increased morbidity and mortality . In BrazDespite the complexity of the various physiological mechanisms and social phenomena that influence the establishment of obesity, most of them culminate in greater individual energy intake in relation to energy expenditure (EE) . Hence, An adequate evaluation of the individual EE is usually achieved by estimating the RMR, which may be calculated through the use of predictive equations or determined by indirect calorimetry (IC), which must be combined with the physical activity level to determine the total EE of the individual . AlthougTherefore, the present study aimed to determine the predictive equation of RMR that shows the highest agreement with RMR obtained by IC in socially vulnerable obese Brazilian women.The research was approved by the Research Ethics Committee of the Federal University of Alagoas (number 2 535.99). All participants were informed about the procedures and signed a written informed consent form before starting the study, marking their formal participation. The present study is a substudy of a randomized clinical trial still in progress, registered in the Registro Brasileiro de Ensaios Clínicos (ReBEC) under number RBR-387v6v.2 and < 45 kg/m2, waist circumference (WC) ≥ 88 cm, body fat percentage ≥ 35%. Women who were on chronic medications , experiencing menopause, pregnant or breastfeeding, or had undergone any surgical intervention for weight loss were not included. Sampling was non-probabilistic for convenience, and recruitment occurred through advertisements in the community or direct invitation to women who had some link with the Center for Recovery and Nutritional Education (CREN-AL), which treats malnourished children, located in the 7th administrative region of the municipality of Maceió-AL and has the lowest Human Development Index (HDI) of the municipality (0.65).Obese women, aged 19-44 years and classified as economic class “C” and “D-E”, as determined by the Critério de Classificação Econômica Brasil (CCEB), Brazil’s economic classification criteria, were included . The CCEAn anthropometric evaluation was performed with weight and height data collection. The participants’ weight was measured on a digital scale and their height was measured by means of a standardized wall stadiometer. BMI was calculated and classified according to the World Health Organization. The percentage of body fat was estimated by means of four-pole electric bioimpedance Sanny BI 1010 . For the test, 4 electrodes were fixed in the right hemibody of the patients, who were lying in the supine position, wearing light clothes, barefoot, and without metallic props . Partici2 and 5% CO2, and a 3 L syringe, with the secondary pressure gauge adjustable between 40 and 60 psi.RMR was estimated using a gas analyzer . The participants were taken by car to the Federal University of Alagoas Laboratory of Applied Sports Sciences. The collection took place in the morning (between 07:00 and 09:00), in a quiet environment, with low light and a comfortable temperature for the participants (22-26°C), following the same preparation used for bioimpedance, because the measurements were performed at the same moment. The equipment was calibrated before each test session according to the manufacturer’s specifications, with gases in the concentration of 20.9% OOn this occasion, measurements of axillary temperature using a digital thermometer and heart rate using a tensiometer were collected to avoid calorimeter measurements in individuals with signs of hyperthermia (> 37.5ºC) or tachycardia (>100 bpm). Participants were asked to wear the equipment’s silicone mask, and thus, the inspired volumes of expired oxygen and carbon dioxide were counted for 15 minutes. Measurements for the first five minutes were discarded to avoid discrepancies due to the location and use of the silicone mask, and data were collected every minute . After mThe studied equations were selected based on the clinical practice use for obese women and those specifically developed for the Brazilian public. Thirteen equations were included: those proposed by Anjos and cols. , Bernste®, Glasgow, UK), which was placed in the frontal area of the participants’ thigh, in the medium point between the inguinal line and the upper edge of the patella, with two transparent, hypoallergenic medical dressings  to avoid contact of the device with the skin of the participants. The women used the accelerometers for 3 consecutive days without removal for any activity. The data were transferred to the activPAL3™ software version 7.2.32 to yield the intensity and duration of each activity performed by the individuals. The system estimates the physical activity for the period in which the device is used, and the calculation is based on acceleration from three body axes – anteroposterior, lateral, and vertical – by means of computing the periods in which the individual was lying down/sitting down, standing, walking, and running at every tenth of a second. The activPAL software provides an indirect estimate of the Metabolic Equivalent of Tasks (METs) based on default values for sitting/lying (1.25 MET), standing (1.40 MET), and stepping at 120 steps per minute (4 MET). For cadences that differ from 120 steps per minute, the following equation is used to calculate the MET estimate: MET.h = (1.4 xd) + (4 - 1.4) x (c / 120) x d, where c is the cadence (steps per minute) and d is the duration of the activity (in hours). Software analysis of accelerometer data provides the MET value for the entire period in which individuals used the device, multiplying the MET value for each activity by the duration of the activity. MET is defined as the amount of oxygen consumed while at rest, which corresponds to 3.5 ml of O2 per kg of body weight x min, or as 1 kcal/kg/hour, and is roughly equal to the cost of sitting quietly. This concept, while simple, can express the EE of physical activity as a multiple of RMR, regardless of the individual’s characteristics and type of activity.The physical activity level was measured using a triaxial accelerometer (activPALThe methods for assessing the agreement between the equation-RMR and the IC-RMR were as follows: (a) First, the method proposed by Bland and Altman , where ta posteriori calculation, based on the equation with the lowest RMSE in the present study, and that considered the mean and the standard deviation of the differences between the estimated-RMR and the IC-RMR, a power of 80%, an alpha of 5%, and the present sample size of 59 was conducted to estimate the maximum allowed difference of the limit of agreement that should be considered in the present study.With regard to sample size, because this study used the baseline data of a randomized clinical trial, the sample size calculation was not delineated considering the present analyses. An a posteriori calculations of the maximum allowed difference, a value of 750 kcal was found, which is roughly 50% of the IC-RMR of the sample, whereas a maximum allowed difference of 10% was predefined. The Bland-Altman scatter plots can be found in Fifty-nine obese women were included, and their characteristics are presented in The present study demonstrated that among the 13 equations analyzed to estimate RMR, seven showed no significant bias when compared to IC-RMR. The Henry-Rees  equation2 (-0.5%), while the Harris-Benedict equation (2 (The Henry-Rees  equationequation  providedation (2 . Horie aation (2 , when coation (2 , while dation (2  presenteation (2 , similarThis evidence suggests that the Harris-Benedict equation  is accepThe environmental conditions may influence the biological factors of women living in socially vulnerable contexts, a fact corroborated by studies with women from the same community as the present research group , which ea priori sample size calculation. Considering the sample size of this study, the maximum allowed difference that should have been considered was 750 kcal, or roughly 50% of the IC-RMR, while we assumed a predefined maximum allowed difference of 10%. This means that with the present sample, an estimated RMR that showed limits of agreement within a range of 50% of the IC-RMR would still be considered to agree with the IC-RMR, indicating the low precision yielded by the present sample size. However, because our goal was to show which equation would perform better, considering that there is no gold-standard equation for this population, we believe that the present study may still provide useful information for clinicians and researchers working with populations similar to ours.A major limitation of the present study is due to the absence of an In conclusion, none of the studied equations satisfactorily estimated the IC-RMR, which indicates that these equations are not sufficiently precise in the context of this study. However, the Harris-Benedict  equation