[Hyperacusis: a mini review].

Hyperacusis refers to the experience of the sound environment being perceived as overwhelmingly loud or painful, and this can severely affect the patient's quality of life. In China little attention has been paid to hyperacusis, and there has been little research undertaken on the topic. Therefore, this article summarizes the recent research on hyperacusis regarding definition, epidemiology, etiology, mechanism, evaluation and treatment to give directions for future research.

The prevalence of tinnitus in China: a systematic review of the literature.

OBJECTIVE: The aim of the present study was to identify reports of the prevalence of tinnitus in China and to present these findings in a review format. METHOD: This study assessed and collated published prevalence estimates of tinnitus and tinnitus severity, creating a narrative synthesis of the data from publications identified from a combination of Chinese and English language databases. RESULTS: A total of 23 studies were included. Tinnitus prevalence ranged from 4.3 per cent to 51.33 per cent but varied with age and gender. The highest increase in prevalence from previous decade in age occurs during the fifth and sixth decades, and the highest prevalence was in the seventh decade at 32.47 per cent. There is also evidence that tinnitus prevalence is related to certain risk factors including comorbid disorders. CONCLUSION: The prevalence of tinnitus in mainland China in this study is consistent with global data. With increasing awareness of the prevalence of tinnitus in China, the development of epidemiological standards is a priority.

An audit of UK audiological practice in specialist paediatric oncology centres regarding hearing assessment of children at risk of ototoxicity due to chemotherapy.

OBJECTIVE: Platinum-based chemotherapy drugs are associated with substantial ototoxicity. The hearing of children treated with these drugs should be closely monitored. METHOD: A questionnaire was sent out to the 19 audiology departments associated with national paediatric cancer specialist centres in the UK looking at current practice in ototoxicity monitoring. RESULTS: Responses were received from 17 of 19 centres (89 per cent). All offered some form of audiometric monitoring service. Extended high-frequency testing (9-20 kHz) was only utilised by 7 services (29 per cent). A majority of respondents were reluctant to consider self-test devices in paediatric ototoxicity monitoring (n = 9; 53 per cent). Provision of long-term audiological follow up is sporadic with only 4 (23 per cent) respondents keeping all children with normal hearing under review once treatment is completed. CONCLUSION: While some good practice in paediatric ototoxicity was identified, opportunities exist to improve clinical practice and protocols, promote multidisciplinary team working and to utilise technologies such as extended high frequency and self-test audiometry.

Aural fullness and transtympanic ventilation tubes in Ménière's disease: a scoping review.

BACKGROUND: Ménière's disease often presents with aural fullness, for reasons that are currently not well understood. Transtympanic ventilation tube insertion has been historically used for the management of this symptom, though the nature and mechanism of effectiveness is unclear. OBJECTIVE: To give an overview of the data available on the effects of ventilation tube insertion on aural fullness in Ménière's disease. METHODS: The databases PubMed, Embase, Medline, Scopus, Web of Science, Central and Google Scholar were searched to identify relevant records. Records were subsequently analysed and data extracted. RESULTS: Only two studies directly measured the effect of ventilation tube insertion on aural fullness, while three others measured it as a placebo to assess another treatment. Considerable heterogeneity was found amongst the studies, including conflicting conclusions. CONCLUSION: There is a paucity of evidence investigating the effect of grommet insertion on aural fullness in Ménière's disease. This work directs future research into this topic.

Hyperacusis: major research questions.

BACKGROUND: Hyperacusis is a troublesome symptom that can have a marked negative impact on quality of life. OBJECTIVES: To identify major research questions in hyperacusis. MATERIALS AND METHODS: Review of gaps in knowledge regarding hyperacusis, and where opportunities may lie to address these. RESULTS: Eight major research questions were identified as priorities for future research. These were: What is the prevalence of hyperacusis in adults and children? What are the risk factors associated with hyperacusis? What is the natural history of hyperacusis? How is 'pain hyperacusis' perceived? What mechanisms are involved in hyperacusis? What is the relationship between hyperacusis and tinnitus? Can a questionnaire be developed that accurately measures the impact of hyperacusis and can be used as a treatment outcome measure? What treatments, alone or in combination, are effective for hyperacusis? CONCLUSION: This clinical/researcher-led project identified major research questions in hyperacusis. A further development to identify patient-prioritized research will follow.

Positive experiences related to living with tinnitus: A cross-sectional survey.

OBJECTIVE: The aim of this study was to gain insights related to positive experiences reported by adults with tinnitus living in the United Kingdom. DESIGN: A cross-sectional survey design was used in a sample of adults with tinnitus who were interested in undertaking an Internet-based intervention for tinnitus. SETTING: The study was UK wide and data collection was online. PARTICIPANTS: Participants consisted of 240 adults (137 males, 103 females), with an average age of 48.16 years and average tinnitus duration of 11.52 years (SD: 11.88). MAIN OUTCOME MEASURES: Tinnitus severity was measured by means of the Tinnitus Functional Index. To evaluate the secondary effects of tinnitus, the Insomnia Severity Index, the Hearing Handicap Inventory for Adults-Screening Version and the Cognitive Failures Questionnaires were administered. Positive experiences related to tinnitus were explored using an open-ended question format. RESULTS: Around a third of participants (32.5%) reported positive experiences associated with tinnitus. The number of positive responses ranged from one to eight responses per participant, although there were fewer participants with more than one positive response. The predominant themes concerned for (i) coping; (ii) personal development; (iii) support, and to a lesser extent (iv) outlook. Younger participants, those with a lower hearing disability and those with fewer cognitive failures were more likely to report positive experiences associated with having tinnitus. CONCLUSIONS: This study has identified that personal development and a positive outlook are possible despite experiencing tinnitus. Ways to facilitate positive experiences related to tinnitus should be promoted, as these may reduce the negative consequences associated with tinnitus. The most prevalent positive theme was the ability to cope with tinnitus. Positive experiences were also drawn from having clinical and other support networks. This highlights the importance of providing tinnitus interventions that can assist people in coping with tinnitus, particularly to those less likely to relate tinnitus to any positive experiences. Those most likely to be helped include those who are older with greater cognitive difficulties and a greater hearing disability.

Functional auditory disorders.

There are a number of auditory symptom syndromes that can develop without an organic basis. Some of these, such as nonorganic hearing loss, affect populations similar to those presenting with functional somatosensory and motor symptoms, while others, such as musical hallucination, affect populations with a significantly different demographic and require different treatment strategies. Many of these conditions owe their origin to measurably abnormal peripheral sensory pathology or brain network activity, but their pathological impact is often due, at least in part, to overamplification of the salience of these phenomena. For each syndrome, this chapter briefly outlines a definition, demographics, investigations, putative mechanisms, and treatment strategies. Consideration is given to what extent they can be considered to have a functional basis. Treatments are in many cases pragmatic and rudimentary, needing more work to be done in integrating insights from behavioral and cognitive psychology to auditory neuroscience. The audiology literature has historically equated the term functional with malingering, although this perception is, thankfully, slowly changing. These disorders transcend the disciplines of audiology, otorhinolaryngology, neurology and psychiatry, and a multidisciplinary approach is often rewarding.

Attitudes towards and personal use of complementary and alternative medicine amongst clinicians working in audiovestibular disciplines.

OBJECTIVE: Literature indicates that complementary and alternative medicine is used by patients with auditory and vestibular symptoms. This study sought to determine the prevalence of complementary and alternative medicine uptake, and examine attitudes towards complementary and alternative medicine in clinicians working with audiovestibular disorder patients. METHOD: The Holistic Complementary and Alternative Medicine Questionnaire and a devised questionnaire about recent and lifetime use of complementary and alternative medicine were used. RESULTS: Fifty-four individuals, including audiologists, ENT surgeons, nurses and rehabilitationists, completed the questionnaires (67 per cent response rate). Lifetime prevalence of complementary and alternative medicine uptake was 44 per cent, and 12-month prevalence was 22 per cent. Uptake was more common in females, but there was no significant difference in use when comparing age, seniority or profession. Attitudes towards complementary and alternative medicine were mildly adverse, but sizeable standard deviation indicates wide-ranging attitudes. CONCLUSION: Clinicians working with patients with audiovestibular disorders have a range of attitudes towards complementary and alternative medicine. Personal uptake of complementary and alternative medicine was lower than that of the general UK population, but remains sizeable.

Images of otoscopy: rate and extent of non-compliance with good practice standards.

BACKGROUND: The British Society of Audiology has produced clear guidelines as to how otoscopy should be undertaken; however, no nationally recognised guidelines exist for the wider clinical community. Images of otoscopy appear in many books, journals, magazines and websites. OBJECTIVE: This study aimed to determine the rate of non-compliance with good practice in images of otoscopy, the seriousness of the breach, and whether this is more common in sites for professionals or the general public. METHOD: Google Images was searched using the terms 'otoscopy' and 'ear examination'. A total of 200 images were identified and collated. The images were reviewed for compliance with good practice standards. RESULTS: Only 12.75 per cent of the images were graded as having no breach of good practice standards. CONCLUSION: Professional websites have a responsibility to show best practice. When choosing an image, the source of the image needs to be carefully considered.

Current oxygenation practice in ventilated patients-an observational cohort study.

Oxygen therapy is a mainstay of critical care medicine, yet its optimal therapeutic use has not been systematically evaluated. A detailed understanding of current practice in oxygen therapy in intensive care is required to enable future interventional studies. We aimed to describe current oxygenation practice in patients requiring ≥48 hours of mechanical ventilation (MV) at an academic tertiary referral centre. We collected longitudinal arterial blood gas and hourly oxygenation data from intensive care unit charts in a consecutive cohort of 40 trauma, 41 medical and 20 surgical patients for their first seven MV days, analysed data for 14,063 MV hours, and derived time-weighted averages (TWA) of variables for each 24-hour interval on MV for all patients.The TWA-FiO2 was 0.42 (95% CI 0.41 to 0.44) and TWA-SpO2 was 97.1% (95% CI 96.8 to 97.4) for the first seven MV days. TWA-PaO2 was >80 mmHg on 80% of MV days. TWA-FiO2 of ≥0.35 was used to achieve TWA-SpO2 >95% on 61% of MV days. Of 58 MV days with TWA-FiO2 ≥0.60, TWA-SpO2 ≥96% occurred on 28 (48%) days. Mean SpO2 and PaO2 in patients with severe acute lung injury (ALI) scores were higher than recommended targets. Wide variability in the mean SpO2 and PaO2 was observed in patients with comparable ALI scores. Inspired oxygen therapy in these MV patients was 'liberal', with PaO2 and SpO2 values generally above 80 mmHg and 96% respectively. An interventional study comparing current practice to more conservative targets (PaO2≍60 to 65 mmHg and/or SpO2≍90 to 92%) appears possible.

Identifying and treating persistent tinnitus in CI users.

The study was undertaken within an established cochlear implant (CI) centre, in conjunction with a tertiary Tinnitus Clinic. The primary aim was to identify more readily which CI recipients experience significant tinnitus, by introducing the Tinnitus Handicap Inventory (THI). A secondary aim was to pilot a specialist joint clinic for CI users with tinnitus, involving clinicians from both the implant and the tinnitus teams. This paper reports principally on the level of agreement between the centre's established tinnitus self-report measure and the THI.

Bone-anchored hearing aids for people with bilateral hearing impairment: a systematic review.

BACKGROUND: Bone-anchored hearing aids (BAHAs) are indicated for people with conductive or mixed hearing loss who can benefit from amplification of sound. In resource limited health care systems, it is important that evidence regarding the benefit of BAHAs is critically appraised to aid decision-making. OBJECTIVE OF REVIEW: To assess the clinical effectiveness of BAHAs for people with bilateral hearing impairment. TYPE OF REVIEW: Systematic review. SEARCH STRATEGY: Nineteen electronic resources were searched from inception to November 2009. Additional studies were sought from reference lists, clinical experts and BAHA manufacturers. EVALUATION METHOD: Inclusion criteria were applied by two reviewers independently. Data extraction and quality assessment of full papers were undertaken by one reviewer and checked by a second. Studies were synthesised through narrative review with tabulation of results. RESULTS: Twelve studies were included. Studies suggested audiological benefits of BAHAs when compared with bone-conduction hearing aids or no aiding. A mixed pattern of results was seen when BAHAs were compared to air-conduction hearing aids. Improvements in quality of life with BAHAs were found by a hearing-specific instrument but not generic quality of life measures. Issues such as improvement of discharging ears and length of time the aid can be worn were not adequately addressed by the studies. Studies demonstrated some benefits of bilateral BAHAs. Adverse events data were limited. The quality of the studies was low. CONCLUSIONS: The available evidence is weak. As such, caution is indicated in the interpretation of presently available data. However, based on the available evidence, BAHAs appear to be a reasonable treatment option for people with bilateral conductive or mixed hearing loss. Further research into the benefits of BAHAs, including quality of life, is required to reduce the uncertainty.

Bone-anchored hearing aids (BAHAs) for people who are bilaterally deaf: a systematic review and economic evaluation.

BACKGROUND: A bone-anchored hearing aid (BAHA) consists of a permanent titanium fixture, which is surgically implanted into the skull bone behind the ear, and a small detachable sound processor that clips onto the fixture. BAHAs are suitable for people with conductive or mixed hearing loss who cannot benefit fully from conventional hearing aids. OBJECTIVES: To assess the clinical effectiveness and cost-effectiveness of BAHAs for people who are bilaterally deaf. DATA SOURCES: Nineteen electronic resources, including MEDLINE, EMBASE and The Cochrane Library (inception to November 2009). Additional studies were sought from reference lists and clinical experts. REVIEW METHODS: Inclusion criteria were applied by two reviewers independently. Data extraction and quality assessment were undertaken by one reviewer and checked by a second. Prospective studies of adults or children with bilateral hearing loss were eligible. Comparisons were BAHAs versus conventional hearing aids [air conduction hearing aid (ACHA) or bone conduction hearing aid (BCHA)], unaided hearing and ear surgery; and unilateral versus bilateral BAHAs. Outcomes included hearing measures, validated measures of quality of life (QoL), adverse events and measures of cost-effectiveness. For the review of cost-effectiveness, full economic evaluations were eligible. RESULTS: Twelve studies were included (seven cohort pre-post studies and five cross-sectional 'audiological comparison' studies). No prospective studies comparing BAHAs with ear surgery were identified. Overall quality was rated as weak for all included studies and meta-analysis was not possible due to differences in outcome measures and patient populations. There appeared to be some audiological benefits of BAHAs compared with BCHAs and improvements in speech understanding in noise compared with ACHAs; however, ACHAs may produce better audiological results for other outcomes. The limited evidence reduces certainty. Hearing is improved with BAHAs compared with unaided hearing. Improvements in QoL with BAHAs were identified by a hearing-specific instrument but not generic QoL measures. Studies comparing unilateral with bilateral BAHAs suggested benefits of bilateral BAHAs in many, but not all, situations. Prospective case series reported between 6.1% and 19.4% loss of implants. Most participants experienced no or minor skin reactions. A decision analytic model was developed. Costs and benefits of unilateral BAHAs were estimated over a 10-year time horizon, applying discount rates of 3.5%. The incremental cost per user receiving BAHA, compared with BCHA, was £ 16,409 for children and £ 13,449 for adults. In an exploratory analysis the incremental cost per quality-adjusted life-year (QALY) gained was between £ 55,642 and £ 119,367 for children and between £ 46,628 and £ 100,029 for adults for BAHAs compared with BCHA, depending on the assumed QoL gain and proportion of each modelled cohort using their hearing aid for ≥ 8 or more hours per day. Deterministic sensitivity analysis suggested that the results were highly sensitive to the assumed proportion of people using BCHA for ≥ 8 hours per day, with very high incremental cost-effectiveness ratio values (£ 500,000-1,200,000 per QALY gained) associated with a high proportion of people using BCHA. More acceptable values (£ 15,000-37,000 per QALY gained) were associated with a low proportion of people using BCHA for ≥ 8 hours per day (compared with BAHA). LIMITATIONS: The economic evaluation presented in this report is severely limited by a lack of robust evidence on the outcome of hearing aid provision. This has lead to a more restricted analysis than was originally anticipated (limited to a comparison of BAHA and BCHA). In the absence of useable QoL data, the cost-effectiveness analysis is based on potential utility gains from hearing, that been inferred using a QoL instrument rather than measures reported by hearing aid users themselves. As a result the analysis is regarded as exploratory and the reported results should be interpreted with caution. CONCLUSIONS: Exploratory cost-effectiveness analysis suggests that BAHAs are unlikely to be a cost-effective option where the benefits (in terms of hearing gain and probability of using of alternative aids) are similar for BAHAs and their comparators. The greater the benefit from aided hearing and the greater the difference in the proportion of people using the hearing aid for ≥ 8 hours per day, the more likely BAHAs are to be a cost-effective option. The inclusion of other dimensions of QoL may also increase the likelihood of BAHAs being a cost-effective option. A national audit of BAHAs is needed to provide clarity on the many areas of uncertainty surrounding BAHAs. Further research into the non-audiological benefits of BAHAs, including QoL, is required.

Heart rate and blood pressure effects during caloric vestibular testing.

OBJECTIVES: To determine whether the caloric vestibular test causes significant changes in heart rate and mean arterial blood pressure. MATERIALS AND METHODS: Changes in heart rate and mean arterial blood pressure before and after caloric irrigation were compared with the degree of nystagmus (as measured by maximum slow phase velocity) and the patient's subjective dizziness (scored from 0 to 10). A cardiologist reviewed each patient's heart rate and mean arterial blood pressure changes. Patients' anxiety levels were also assessed. RESULTS: Eighteen patients were recruited. There were no adverse events in any patient. There were no overall significant differences between the heart rate and mean arterial pressure before and after each irrigation. There was a significant correlation between the maximum slow phase velocity and patients' subjective dizziness scores. CONCLUSION: Heart rate and mean arterial blood pressure are not significantly influenced by the caloric vestibular test. This preliminary study will enable patients with stable cardiovascular disease to be recruited for further risk determination.

Is musical hallucination an otological phenomenon? a review of the literature.

BACKGROUND: Musical hallucination is the subjective experience of hearing music, or aspects of music, when none is being played, and as such is a disorder of the processing of complex sounds. OBJECTIVE OF REVIEW: To determine the extent to which the otological system is responsible for musical hallucination, and to evaluate approaches to clinical management. TYPE OF REVIEW: A review of all studies and literature reviews pertaining to musical hallucination, supplemented by inclusion of informative case reports. SEARCH STRATEGY: A systematic search of multiple databases carried out on 22nd March 2009 was complemented by referral to the reference lists of included manuscripts. RESULTS: Although not always troublesome in itself, musical hallucination can be a marker of underlying pathology in the ear or brain, or indicate obsessive-compulsive traits or social isolation, and is likely to be clinically underreported. Associations have been reported with hearing loss, female gender, social isolation and being over 60 years of age, although it is rare even in this group, and these may well not be independent risk factors. Robust comparative analysis of these factors with controls has yet to be undertaken. Underlying causes include neurovascular pathology, psychiatric disorders and opioid medications, however these are absent in the majority of cases. CONCLUSIONS: This review supports the proposal that the otological system plays a role in the pathogenesis of musical hallucination. Hearing impairment may act as an initiating factor, and the primary dysfunction is overactivity of auditory association cortex, although an impairment of higher-level inhibition does also seem necessary. Once underlying sinister causes have been excluded, first line treatment should be explanation of the condition and optimisation of hearing. Medications have a role only in selected patient groups.

The role of magnetic resonance imaging in the identification of suspected acoustic neuroma: a systematic review of clinical and cost effectiveness and natural history.

OBJECTIVE(S): To evaluate the clinical effectiveness and cost-effectiveness of a range of diagnostic strategies for investigating patients with unilateral hearing loss and/or tinnitus, with a view to confirming or eliminating a diagnosis of acoustic neuroma, and to describe the natural history of acoustic neuroma. DATA SOURCES: Major electronic databases were searched from January 1980 to August 2008. REVIEW METHODS: Selected studies were assessed and subjected to data extraction and quality assessment using standard methods. RESULTS: Studies comparing auditory brainstem response (ABR) with magnetic resonance (MR) imaging were highly heterogeneous. ABR has high sensitivity compared with MR imaging for acoustic neuromas greater than 1 cm in size but not for smaller neuromas. The sensitivities of T2-weighted (T2W) and T2-star-weighted (T2*W) imaging strategies compared with gadolinium-enhanced T1-weighted (GdT1W) MR imaging (gold standard) were high and relatively homogeneous. The specificity of T2W and T2*W studies ranged from 90% to 100% and from 86% to 99% respectively. The review of cost-effectiveness showed that GdT1W MR imaging immediately or in conjunction with ABR appears to be more cost-effective than 'traditional' protocols; ABR/GdT1W MR imaging protocols were more cost-effective than going directly to GdT1W MR imaging. Non-contrast-enhanced MR imaging was found to be a more cost-effective test for acoustic neuroma than GdT1W MR imaging. The incidence of acoustic neuroma has increased over the last 30 years, with the median age at diagnosis remaining at 55 years. Most patients present with insidious symptoms of unilateral hearing impairment, tinnitus and/or vertigo. The pattern and rate of growth of acoustic neuroma are highly variable and currently unpredictable. At least 50% of tumours do not grow, at least for some years after diagnosis. Some studies have found large initial size to be a determinant of later growth, with the opposite also being reported. The mean growth rate for all tumours varies between 1 and 2 mm/year, with a rate of 2-4 mm/year for only those that grow; however, there are cases with significant regression (5%) or exceptional growth (which may exceed 18 mm/year). CONCLUSIONS: The majority of the evidence reviewed was poorly reported and there is therefore an inherent risk of bias. Given the recent improvement in resolution and reduction in cost of MR imaging, ABR can no longer be considered appropriate as the primary test used to screen for acoustic neuroma. T2W or T2*W sequences enable accurate evaluation of the VIIIth and VIIth cranial nerves within the cerebellopontine angle and internal auditory canal as well as evaluation of the cochlea and labyrinth, and inclusion of GdT1W sequences is unlikely to contribute information that would alter patient management in the screening population. The quality of the imaging chain and experience of the reporting radiologist are key factors determining the efficacy of a non-contrast screening strategy. Based on a cost-effectiveness model developed to reflect UK practice it was concluded that a diagnostic algorithm that deploys non-contrast MR imaging as an initial imaging screen in the investigation of acoustic neuroma is less costly than and likely to be as effective as available contrast MR imaging.