Associations between medical conditions and auditory dysfunction in US Veterans.

OBJECTIVE: To examine associations between non-otologic medical conditions and auditory dysfunction. DESIGN: Cross-sectional analysis of baseline data from the Noise Outcomes in Service members Epidemiology (NOISE) study. Logistic regression was used to estimate the association between medical conditions (0, 1, and 2 or more conditions) and auditory dysfunction (hearing loss pure tone average ≥20 dB HL and tinnitus), adjusting for key confounders including noise exposure. Secondarily, the association between specific medical conditions and auditory dysfunction was examined. All variables were self-reported. STUDY SAMPLE: United States military Veterans (n = 580) with mean age 34.1 years (standard deviation = 9.2), who were within approximately 2.5 years of separation from service. RESULTS: Compared to Veterans reporting no medical conditions, Veterans reporting two or more had increased odds on low-frequency hearing loss and on tinnitus but not on high or extended-high frequency hearing loss. Furthermore, specific conditions sleep disorder and arthritis were associated with auditory dysfunction. CONCLUSIONS: Non-otologic medical conditions were associated with low-frequency hearing loss and tinnitus in this sample of young Veterans. This suggests medical conditions may play a role in Veterans' hearing health. Whether management of medical conditions earlier in life reduces the risk of hearing loss and tinnitus requires further study.

Auditory Brainstem Response Altered in Humans With Noise Exposure Despite Normal Outer Hair Cell Function.

OBJECTIVES: Recent animal studies demonstrated that cochlear synaptopathy, a partial loss of inner hair cell-auditory nerve fiber synapses, can occur in response to noise exposure without any permanent auditory threshold shift. In animal models, this synaptopathy is associated with a reduction in the amplitude of wave I of the auditory brainstem response (ABR). The goal of this study was to determine whether higher lifetime noise exposure histories in young people with clinically normal pure-tone thresholds are associated with lower ABR wave I amplitudes. DESIGN: Twenty-nine young military Veterans and 35 non Veterans (19 to 35 years of age) with normal pure-tone thresholds were assigned to 1 of 4 groups based on their self-reported lifetime noise exposure history and Veteran status. Suprathreshold ABR measurements in response to alternating polarity tone bursts were obtained at 1, 3, 4, and 6 kHz with gold foil tiptrode electrodes placed in the ear canal. Wave I amplitude was calculated from the difference in voltage at the positive peak and the voltage at the following negative trough. Distortion product otoacoustic emission input/output functions were collected in each participant at the same four frequencies to assess outer hair cell function. RESULTS: After controlling for individual differences in sex and distortion product otoacoustic emission amplitude, the groups containing participants with higher reported histories of noise exposure had smaller ABR wave I amplitudes at suprathreshold levels across all four frequencies compared with the groups with less history of noise exposure. CONCLUSIONS: Suprathreshold ABR wave I amplitudes were reduced in Veterans reporting high levels of military noise exposure and in non Veterans reporting any history of firearm use as compared with Veterans and non Veterans with lower levels of reported noise exposure history. The reduction in ABR wave I amplitude in the groups with higher levels of noise exposure cannot be accounted for by sex or variability in outer hair cell function. This change is similar to the decreased ABR wave I amplitudes observed in animal models of noise-induced cochlear synaptopathy. However, without post mortem examination of the temporal bone, no direct conclusions can be drawn concerning the presence of synaptopathy in the study groups with higher noise exposure histories.

Formative evaluation of a multimedia self-administered computerized hearing loss prevention program.

OBJECTIVE: To determine which features make a computer-based hearing health education intervention effective, easy to use, and enjoyable. The study examined which features of a multimedia self-administered computerized hearing loss prevention program, developed by the National Center for Rehabilitative Auditory Research (referred to as the NCRAR-HLPP), users liked and disliked, and the reasons why. DESIGN: A formative evaluation was conducted in which participants completed a questionnaire to assess knowledge and attitudes towards hearing and hearing loss prevention, used the NCRAR-HLPP, completed the questionnaire for a second time, and were interviewed to learn their opinions about the NCRAR-HLPP. STUDY SAMPLE: Twenty-five male and four female Veterans recruited from the Portland VA Medical Center who were aged between 25 and 65 years. RESULTS: Participants reported that using the NCRAR-HLPP was a positive experience. Ease of use, multimedia content, personal relevance, and use of emotion were positive features of the program. The questionnaire showed increased knowledge and improved attitude scores following use of the program. CONCLUSION: This formative evaluation showed changes designed to target user preferences and improve user instructions will be made in future versions of the program.

Development and evaluation of a questionnaire to assess knowledge, attitudes, and behaviors towards hearing loss prevention.

OBJECTIVE: To develop and evaluate a questionnaire assessing knowledge, attitudes, and behaviors (KAB) as they pertain to hearing conservation, using the constructs of the health belief model (HBM). DESIGN: The KAB was completed by 235 participants. Relationships between knowledge and attitudes about hearing and hearing conservation, participation in noisy activities, and use of hearing protection were examined. STUDY SAMPLE: 117 males and 118 females aged between 18 and 80 years (mean = 42.3, SD = 4.1) recruited from the Portland VA Medical Center, local universities, and a community college. RESULTS: Knowledge scores ranged from 15.6% to 93.8%. Factor analyses revealed six attitude factors, interpreted as measuring perceived susceptibility, perceived severity, perceived benefits, perceived barriers, perceived self-efficacy, and cues to action. Over 95% of participants routinely participated in at least one noisy activity but few used hearing protection while doing so. The attitude scores of individuals who used hearing protection differed significantly from the scores of those who did not. CONCLUSIONS: Significant relationships between use of hearing protection and scores on the KAB provide validation that the HBM is a valuable framework for understanding hearing health behaviors, and evidence that the KAB is a valid tool for assessing these attitudes and behaviors.

Randomized trial of four noise-induced hearing loss and tinnitus prevention interventions for children.

OBJECTIVE: To evaluate the effectiveness of four NIHL prevention interventions at improving knowledge, attitudes, and intended behaviors regarding sound exposure and appropriate use of hearing protective strategies in children. DESIGN: A randomized trial of the four interventions with a non-intervention comparison group. Questionnaires were completed prior to, immediately after, and three months after each intervention. STUDY: Interventions included: (1) A classroom presentation by older-peer educators, (2) A classroom presentation by health professionals, (3). Exploration of a museum exhibition, and (4). Exploration of an internet-based virtual museum. A comparison group received no intervention. STUDY SAMPLE: Fifty-three fourth grade classrooms (1120 students) participated in the study. RESULTS: All interventions produced significant improvements but the number of improvements decreased over time. In terms of effectiveness, the classroom programs were more effective than the internet-based virtual exhibit, which was more effective than the visit to the museum exhibition. Self-reported exposures indicated that as many as 94.5% of participants were at risk for NIHL. CONCLUSIONS: Interpersonal, interactive educational interventions such as the classroom program are more effective and have longer impact than self-directed learning experiences for NIHL and tinnitus prevention, however each may have an important role in promoting hearing health in elementary school students.

The tinnitus functional index: development of a new clinical measure for chronic, intrusive tinnitus.

OBJECTIVES: Chronic subjective tinnitus is a prevalent condition that causes significant distress to millions of Americans. Effective tinnitus treatments are urgently needed, but evaluating them is hampered by the lack of standardized measures that are validated for both intake assessment and evaluation of treatment outcomes. This work was designed to develop a new self-report questionnaire, the Tinnitus Functional Index (TFI), that would have documented validity both for scaling the severity and negative impact of tinnitus for use in intake assessment and for measuring treatment-related changes in tinnitus (responsiveness) and that would provide comprehensive coverage of multiple tinnitus severity domains. DESIGN: To use preexisting knowledge concerning tinnitus-related problems, an Item Selection Panel (17 expert judges) surveyed the content (175 items) of nine widely used tinnitus questionnaires. From those items, the Panel identified 13 separate domains of tinnitus distress and selected 70 items most likely to be responsive to treatment effects. Eliminating redundant items while retaining good content validity and adding new items to achieve the recommended minimum of 3 to 4 items per domain yielded 43 items, which were then used for constructing TFI Prototype 1.Prototype 1 was tested at five clinics. The 326 participants included consecutive patients receiving tinnitus treatment who provided informed consent-constituting a convenience sample. Construct validity of Prototype 1 as an outcome measure was evaluated by measuring responsiveness of the overall scale and its individual items at 3 and 6 mo follow-up with 65 and 42 participants, respectively. Using a predetermined list of criteria, the 30 best-functioning items were selected for constructing TFI Prototype 2.Prototype 2 was tested at four clinics with 347 participants, including 155 and 86 who provided 3 and 6 mo follow-up data, respectively. Analyses were the same as for Prototype 1. Results were used to select the 25 best-functioning items for the final TFI. RESULTS: Both prototypes and the final TFI displayed strong measurement properties, with few missing data, high validity for scaling of tinnitus severity, and good reliability. All TFI versions exhibited the same eight factors characterizing tinnitus severity and negative impact. Responsiveness, evaluated by computing effect sizes for responses at follow-up, was satisfactory in all TFI versions.In the final TFI, Cronbach's alpha was 0.97 and test-retest reliability 0.78. Convergent validity (r = 0.86 with Tinnitus Handicap Inventory [THI]; r = 0.75 with Visual Analog Scale [VAS]) and discriminant validity (r = 0.56 with Beck Depression Inventory-Primary Care [BDI-PC]) were good. The final TFI was successful at detecting improvement from the initial clinic visit to 3 mo with moderate to large effect sizes and from initial to 6 mo with large effect sizes. Effect sizes for the TFI were generally larger than those obtained for the VAS and THI. After careful evaluation, a 13-point reduction was considered a preliminary criterion for meaningful reduction in TFI outcome scores. CONCLUSIONS: The TFI should be useful in both clinical and research settings because of its responsiveness to treatment-related change, validity for scaling the overall severity of tinnitus, and comprehensive coverage of multiple domains of tinnitus severity.

Tinnitus: An Epidemiologic Perspective.

Tinnitus is commonly referred to as "ringing in the ears." Epidemiologic studies highlight challenges associated with clinical determination of tinnitus and ascertainment of its etiology, functional effects, temporal characteristics, psychoacoustic parameters, and risk factors. Because no standards exist for capturing these factors as measures, direct comparison of data between studies is not possible. This report suggests terminology and definitions to promote standardization, with a brief overview of findings from selected population-based epidemiologic studies. Tinnitus-specific data are presented from the Noise Outcomes in Servicemembers Epidemiology study. Further epidemiologic studies are needed to develop tinnitus treatment and a cure for this chronic condition.

Hearing loss in veterans and the need for hearing loss prevention programs.

Currently, there are more than 445,000 veterans receiving compensation for hearing loss associated with military service, and 395,000 receiving compensation for service-related tinnitus. In addition to compensation payments, service-related hearing disorders cost the US Department of Veterans Affairs in terms of provision of hearing aids, hearing aid-related services, and clinical services at its 220 facilities nationwide. It is imperative that hearing conservation among military personnel and veterans be addressed. In this paper, we describe the rationale for and the development of a multimedia Hearing Loss Prevention Program aimed at preventing the progression of hearing loss among veterans associated with social, recreational, and nonmilitary occupational noise exposure. The program was developed based on the principles outlined in the Health Belief Model of Rosenstock (1966) and the Health Promotion Model of Pender et al. (2002).

Decreased sound tolerance associated with blast exposure.

Current research on blast and other injuries sustained by United States Service members and Veterans of the Iraq and Afghanistan Wars reveals a multitude of auditory complaints linked to exposures experienced during these conflicts. Among these complaints is decreased sound tolerance, which refers to a class of auditory-related problems including physical and/or psychological reactions to aspects of everyday sounds. Limited attention has been given to the possible relationship between blast exposure and decreased sound tolerance in Service members and Veterans, which is the purpose of this report. Baseline data were gathered and analyzed from 426 Service members (n = 181) and Veterans (n = 245) who participated in the Noise Outcomes in Servicemembers Epidemiology (NOISE) Study. Logistic regression analyses were performed to generate odds ratios (ORs) with 95% confidence intervals (CIs) for each group, adjusted for age and sex. Of those who reported blast exposure, 33% of Service members (adjusted OR = 1.4; CI = 0.7-2.8) and 48% of Veterans (adjusted OR = 1.9; CI = 1.1-3.3) reported decreased sound tolerance. Among Service members and Veterans who did not report blast exposure, 28% and 34% respectively, also reported decreased sound tolerance. Overall, blast exposure increased the likelihood of participants reporting decreased sound tolerance. The strength of this association was significant in Veterans.

Impact of Tinnitus on Military Service Members.

OBJECTIVES: The Noise Outcomes in Servicemembers Epidemiology (NOISE) Study is obtaining longitudinal data to evaluate the effects of noise and other exposures on auditory function in military personnel. A gap in the literature is the lack of studies concerning how active-duty Service members might be impacted by having tinnitus. The present study reports NOISE Study data that address this gap. METHODS: Data are reported from current Service members and recently-separated (within 2.5 years) Veterans, enabling a direct comparison of results between active and post-military samples. Data were collected from two sites: VA Portland Health Care System, Portland, OR and Department of Defense Hearing Center of Excellence, San Antonio, TX. Participants completed comprehensive audiometric testing and numerous questionnaires. RESULTS: Results are presented from n = 428 participants across the two sites, including 246 Veterans and 182 Service members. The data reveal that, for both Service members and Veterans, the presence of tinnitus has effects on job performance, concentration, anxiety, depression, and sleep. CONCLUSIONS: This study has revealed that, for these samples of study participants, tinnitus has an impact on military Service members that is comparable to how it affects Veterans who have completed their military service within the previous 2.5 years.

Tinnitus outcomes assessment.

Over the past two decades, recognition has grown that measures for evaluating treatment outcomes must be designed specifically to have high responsiveness. With that in mind, four major types of tinnitus measures are reviewed, including psychoacoustic measures, self-report questionnaires concerning functional effects of tinnitus, various rating scales, and global outcome measures. Nine commonly used tinnitus questionnaires, developed in the period 1980-2000, are reviewed. Because of many similarities between tinnitus and pain, comparisons between pain and tinnitus measures are discussed, and recommendations that have been made for developing a core set of measures to evaluate treatment-related changes in pain are presented as providing a fruitful path for developing a core set of measures for tinnitus. Finally, the importance of having both immediately obtainable outcome measures (psychoacoustic, rating scales, or single global measures) and longer term measures (questionnaires covering the negative effects of tinnitus) is emphasized for further work in tinnitus outcomes assessment.

Obsessive-compulsiveness in a population of tinnitus patients.

The purpose of this study was to use the Maudsley Obsessional-Compulsive Inventory (MOCI) to assess obsessive-compulsiveness in a population of 196 tinnitus patients and to correlate MOCI scores with measures of anxiety, depression, and tinnitus severity. Tinnitus severity was positively correlated with measures of anxiety and depression. Depression was positively correlated with MOCI and anxiety scores. MOCI scores exhibited weaker positive correlations with tinnitus severity and anxiety. Effective management of tinnitus requires identification of psychological disorders or symptoms when they are present so that patients can receive appropriate treatment as soon as possible. The MOCI can be used to assess obsessive-compulsiveness in tinnitus patients.

Effectiveness of "Dangerous Decibels," a school-based hearing loss prevention program.

PURPOSE: To evaluate the effectiveness of the "Dangerous Decibels" educational program in increasing students' knowledge and positively changing their attitudes and intended behaviors related to hearing and hearing loss prevention. METHOD: Baseline questionnaires were completed by 478 4th-grade students and 550 7th-grade students. Approximately half of the students in each grade received a 35-min interactive classroom presentation on hearing and hearing loss prevention. The remaining students served as comparison groups. Students who received the curriculum filled out questionnaires immediately after the presentation. All students filled out follow-up questionnaires 3 months after baseline. RESULTS: Fourth-grade students who participated in the Dangerous Decibels presentation exhibited significant improvements in knowledge and attitudes related to hearing and hearing loss prevention. These improvements were maintained 3 months after the presentation. Seventh-grade students also experienced long-term improvements in their knowledge base. However, attitudes and intended behaviors in 7th graders returned to baseline levels 3 months postpresentation. CONCLUSION: The Dangerous Decibels hearing loss prevention program was effective at producing long-term improvements in the knowledge base of 4th- and 7th-grade students. Future studies should include components on peer pressure and should incorporate repeated, multimodality interventions to increase the likelihood of long-term improvement in adolescents.

Transcranial magnetic stimulation for tinnitus: using the Tinnitus Functional Index to predict benefit in a randomized controlled trial.

BACKGROUND: Identifying characteristics associated with transcranial magnetic stimulation (TMS) benefit would offer insight as to why some individuals experience tinnitus relief following TMS treatment, whereas others do not. The purpose of this study was to use the Tinnitus Functional Index (TFI) and its subscales to identify specific factors associated with TMS treatment responsiveness. METHODS: Individuals with bothersome tinnitus underwent 2000 pulses of 1-Hz TMS for 10 consecutive business days. The primary outcome measure was the TFI which yields a total score and eight individual subscale scores. Analyses were performed on baseline data from the active arm (n = 35) of a prospective, double-blind, randomized placebo-controlled clinical trial of TMS for tinnitus. RESULTS: Baseline total TFI score and three of the eight TFI subscales were useful in differentiating between responders and nonresponders to TMS intervention for tinnitus. These findings are not definitive, but suggest potential factors that contribute to perceived benefit following TMS. CONCLUSIONS: Overall, the main factor associated with TMS benefit was a higher tinnitus severity score for responders at baseline. The TFI subscales helped to clarify the factors that contributed to a higher severity score at baseline. Large-scale prospective research using systematic approaches is needed to identify and describe additional factors associated with tinnitus benefit following TMS. TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT01104207 . Registered on 13 April 2010.

Program Sustainability: Hearing Loss and Tinnitus Prevention in American Indian Communities.

INTRODUCTION: An important goal of any health promotion effort is to have it maintained in delivery and effectiveness over time. The purpose of this study was to establish a community-based noise-induced hearing loss and tinnitus prevention program in three different types of American Indian communities and evaluate them for evidence of long-term sustainability. METHODS: The target population was fourth- and fifth-grade students from three different models of American Indian communities. The evidenced-based Dangerous Decibels® program was adapted to include local media, classroom education, family and community outreach, and web-based activities. Sustainability was attempted by promoting funding stability, political support, partnerships, organizational capacity, program adaptation, program evaluation, communications, public health impacts, and strategic planning. RESULTS: Currently, there is evidence suggesting that the hearing health promotion program is self-sustaining in all three American Indian communities. The intervention was effective at changing knowledge, attitudes, beliefs, and behaviors in the target population, but program adoption and self-sustenance faced challenges that required patience, persistence, and creativity by the program team. Components of the intervention continue to be delivered by local members of each community. CONCLUSIONS: Critical factors that led to self-sustaining programs included approval of community leaders and engagement of community members in the design, administration, and evaluation of the effort; use of a well-developed, evidence-based intervention; and high-level training of local participants who could confidently and effectively continue delivering the program following a gradual transition to independence.

Chronic tinnitus resulting from head or neck injuries.

OBJECTIVES: The main objectives were 1) to determine the percentage of cases of chronic tinnitus in a specialized clinic that resulted from head or neck injuries; 2) to describe the characteristics of this population; and 3) to compare patients with head or neck trauma with patients whose tinnitus onset was not associated with head or neck injuries. STUDY DESIGN: Retrospective analysis of tinnitus clinic patient data. METHODS: Detailed questionnaires were mailed to 2400 patients before their initial appointment at the Oregon Health and Science University Tinnitus Clinic (Portland, OR). All of the patients experienced and received treatment for chronic tinnitus. Patient data were entered into a database and later analyzed. RESULTS: Two hundred ninety-seven patients (214 male and 83 female patients) reported that their chronic tinnitus started as a result of head or neck injuries. Compared with patients whose tinnitus onset was not associated with trauma, patients with tinnitus associated with head or neck trauma were younger; had better hearing thresholds; experienced headaches more frequently; reported greater difficulties with concentration, memory, and thinking clearly; were more likely to experience current depression, but not lifetime depression; rated their tinnitus as louder on a 1-to-10 scale; matched their tinnitus to louder sounds on the right side; and had higher Tinnitus Severity Index scores. CONCLUSIONS: Tinnitus is a significant symptom that commonly occurs as a result of head or neck trauma. The fact that tinnitus resulting from head or neck injuries tends to be more severe (and is often accompanied by a greater number of co-symptoms) than tinnitus resulting from other causes should be taken into account by clinicians treating these patients.

Radiologic correlates of symptom-based diagnostic criteria for chronic rhinosinusitis.

OBJECTIVE: In 1997, the Task Force on Rhinosinusitis (TFR) set forth symptom-based diagnostic guidelines for chronic rhinosinusitis (CRS). In the present study, we examined radiologic correlates of the TFR diagnostic criteria for rhinosinusitis. STUDY DESIGN AND SETTING: One hundred twenty-five consecutive patients undergoing computed tomography (CT) scans of the sinuses were studied at Oregon Health and Science University. Patients were evaluated prospectively with a questionnaire based on the TFR criteria, and their CT scans were graded according to the Lund-Mackay scoring system. RESULTS: Of the 125 patients, 115 met the symptom criteria for CRS. However, 40 of 115 had negative scans (Lund-McKay score, 0) despite meeting the diagnostic criteria for rhinosinusitis. Of 115, 75 had positive scans (Lund-McKay score, >1). Of the 10 patients who had negative diagnoses for rhinosinusitis, 9 had a positive CT scan. The Kappa coefficient was -0.103 (+/-95% confidence interval, -0.201 to -0.004), indicating poor agreement between CRS positivity and CT positivity. The sensitivity of TFR criteria for detecting a positive scan was 89%, but the specificity was poor at only 2%. CONCLUSION AND SIGNIFICANCE: Based on these pilot data, it appears that the specificity and predictive value of the current TFR criteria may not be adequate to serve as a diagnostic standard for rhinosinusitis. Additional validating data may provide guidance for improving the sensitivity and specificity of symptom-based diagnostic instruments for rhinosinusitis.

Hearing conservation education programs for children: a review.

Prevalence of noise-induced hearing loss (NIHL) among children is increasing. Experts have recommended implementation of hearing conservation education programs in schools. Despite these recommendations made over the past three decades, basic hearing conservation information that could prevent countless cases of NIHL remains absent from most school curricula. This paper reviews existing hearing conservation education programs and materials designed for children or that could be adapted for classroom use. This information will be useful as a resource for educators and school administrators and should encourage further development, implementation, and dissemination of hearing conservation curricula. The overall, and admittedly ambitious, goal of this review is to facilitate implementation of hearing conservation curricula into all US schools on a continuing basis. Ultimately, implementation of such programs should reduce the prevalence of noise-induced hearing loss among children and adults.