An Empowerment Model for Individuals with Chronic Tinnitus.

OBJECTIVE: This qualitative study sought to construct a model of empowerment for clinical implementation, based on the first-hand experience of a sample of individuals with chronic tinnitus. DESIGN: The study was conducted in accordance with the inductive approach to data in classic grounded theory (GT). GT aims to build a model of behavior that accounts for the main concern of individuals and how they strive to resolve it. Twenty-one participants with chronic tinnitus (10 females, 11 males, age 31-85, mean: 57.6 years, mean duration of tinnitus: 12 years) were recruited through the patient association France Acouphènes and ENT consultations. Open-ended, tape-recorded interviews addressed the variation in the intrusiveness of tinnitus in daily life. A constant comparison analysis was undertaken to identify a core category and to distinguish stages in behavioral changes toward the tolerance of tinnitus. RESULTS: Participants' main concern was to limit the intrusiveness of tinnitus day in, day out. They continuously had to handle tinnitus-induced frustration, which was found to be the core category of the analysis accounting for how all the participants tried to deal with the condition. The more they managed to handle their frustration, the better they coped with the condition. Three behavior patterns were identified as facilitating the ongoing management of tinnitus-induced frustration: (1) searching for perspective upon tinnitus; (2) maintaining order in perception despite its interference; and (3) alleviating conflict arising from social interactions. A model of empowerment is presented that is based on four stages toward tolerance of tinnitus. They are dominated by lack of perspective upon tinnitus (circuit 1), preservation of energy through attempts to control its intrusiveness (circuit 2), attempts to detach oneself from the interference of tinnitus through constant activities (circuit 3), and self-induced relief through the fulfillment of meaningful goals (circuit 4). CONCLUSION: Tolerance of tinnitus requires finding balance between limiting one's social participation and spontaneity in carrying out meaningful activities. Tolerance can be enhanced by the preservation of one's energy and the mediating role of enjoyment through the fulfillment of gratifying goals. In patient counseling, it is essential to address the individual's desire for direct relief from tinnitus through its elimination. Individuals should be made aware that such a desire will likely be thwarted, resulting in the worsening of intrusiveness. Improvement in tolerance is accompanied by the attenuation of niggling self-awareness, a change that is typical of full commitment with valued goals and that helps in alleviating the interference of tinnitus. By understanding the role of frustration, individuals may develop a sense of responsibility in dealing with disabling tinnitus.

Exploring Tinnitus-Induced Disablement by Persistent Frustration in Aging Individuals: A Grounded Theory Study.

Background: Qualitative research can help to improve the management of patients, meet their expectations and assist physicians in alleviating their suffering. The perception of moment-to-moment variability in tinnitus annoyance is an emerging field of exploration. This study sought to enlighten variability in tinnitus-induced disablement using a qualitative approach. Methods: Twelve participants (six females, six males, aged 51-79) were recruited via the French Tinnitus Association Journal for participation in recorded semi-structured interviews. Each participant had three interviews lasting 1 h, the sessions being separated one from the other by 2 weeks. Following recommendations of Charmaz (2014), the second and third interviews were aimed at gathering rich data, by enhancing the participants' reflexivity in the circumstances of distress caused by tinnitus. After transcription, the data (n = 36 interviews) were analyzed using the approach to Grounded Theory proposed by Strauss and Corbin (1998). Results: Tinnitus as persistent frustration emerged as being the core category uniting all the other categories of the study. Hence, the core category accounted for the broader scope in participants' experience of chronic tinnitus. It is suggested that tinnitus-induced disablement varied according to the degree of frustration felt by the participants in not being able to achieve their goals. The implications of this were analyzed using the following categories: "Losing body ownership," "Lacking perspectives," and "Persevering through difficulties." Based on these findings, we draw a substantive theory of tinnitus tolerance that promotes an active, disciplined and individualized approach to tinnitus-induced disablement. The model distinguishes pathways from sustained suffering to reduced annoyance (i.e., emerging tolerance). It accounts for difficulties that the participants experienced with a perceived unchanged annoyance over time. Furthermore, this model identifies a set of new attitudes toward oneself and others that tinnitus tolerance would entail. Conclusion: The subjective experience of frustration enlightens tinnitus-induced disablement, offering new perspectives for long-term self-management. Modulation of frustration, rather than moderation of tinnitus interference, is suggested as a new approach to the clinical management of tinnitus-related distress.

The Effect of Cochlear Damage on the Sensitivity to Harmonicity.

OBJECTIVES: A sum of simultaneous pure tones with harmonic relationships (i.e., simple frequency ratios) is normally heard as a single sound, with a single pitch, even when its components are fully resolved in the auditory periphery. This perceptual phenomenon called "harmonic fusion" is thought to play an important role in auditory scene analysis as listeners often have to segregate simultaneous harmonic sounds with different fundamental frequencies. The present study explored the consequences of mild or moderate cochlear hearing loss for the sensitivity to harmonicity and the detection of inharmonicity. DESIGN: The subjects were 12 normal-hearing (NH) listeners and 8 listeners with cochlear hearing loss amounting to 30 to 50 dB (mean: 42 dB) from 0.25 to 3 kHz. In each subject, thresholds for the detection of a change in the frequency ratio of simultaneous pure tones were measured with an adaptive forced-choice procedure. The standard frequency ratio was either harmonic (2:1, i.e., one octave) or inharmonic (0.8 or 1.2 octaves). The tones were presented at a low sensation level (at most 15 dB) within broadband noise, to minimize their cochlear interactions. In the main experimental conditions, the frequency register of the stimuli varied randomly within each trial, so that subjects were forced to process frequency ratios to achieve good performance; frequency discrimination was not sufficient. In other conditions, by contrast, frequency discrimination was sufficient to perform the task optimally. RESULTS: For both groups of subjects, thresholds in the main experimental conditions were lower (i.e., better) when the standard frequency ratio was harmonic than when it was inharmonic. This effect, revealing sensitivity to harmonicity, was weak for some members of the hearing-impaired group, but could be observed even in subjects showing a very poor frequency discrimination ability. The two groups, however, differed from each other with respect to the detection of inharmonicity: for the NH group, in agreement with previous results, negative deviations from one octave (i.e., compressions of this frequency ratio) were better detected than positive deviations (stretchings); for the hearing-impaired group, on the other hand, the sign of the deviations had no effect on performance. CONCLUSIONS: Sensitivity to harmonicity appears to be remarkably robust. However, it can be reduced in some listeners with mild or moderate cochlear damage. Moreover, as inharmonicity detection is asymmetric for NH listeners but apparently becomes symmetric in case of cochlear damage, it may be that listeners with cochlear damage do not detect inharmonicity in the same manner as NH listeners do. In some circumstances, inharmonicity can be detected on the basis of "beat" cues available in single frequency channels; however, the subjects tested here were unlikely to use cues of this type.

Harmonic fusion and pitch affinity: Is there a direct link?

Simultaneous pure tones approximately one octave apart tend to be fused perceptually and to evoke a single pitch sensation. Besides, sequentially presented pure tones show a subjective "affinity" or similarity in pitch when their frequency ratio is close to one octave. The aim of the study reported here was to determine if these two perceptual phenomena are directly related. Each stimulus was a triplet of simultaneous or successive pure tones forming frequency ratios varying across stimuli between 0.96 and 1.04 octaves. The tones were presented at a low sensation level (15 dB) within broadband threshold-equalizing noise, in order to prevent them from interacting in the cochlea when they were simultaneous. A large set of stimulus comparisons made by 18 listeners indicated that: (1) when the tones were simultaneous, maximal fusion was obtained for a mean frequency ratio deviating by less than 0.2% from one octave, and fusion decreased less rapidly above this frequency ratio than below it; (2) when the tones were presented successively, maximal pitch affinity was obtained for a mean frequency ratio significantly larger than one octave, and pitch affinity decreased more rapidly above this frequency ratio than below it. The differences between the results obtained for simultaneous and successive tones suggest that harmonic fusion and pitch affinity are unrelated phenomena.

Effect of chronic cortical stimulation on chronic severe tinnitus: a prospective randomized double-blind cross-over trial and long-term follow up.

BACKGROUND: Chronic severe tinnitus can be greatly detrimental to quality of life. Some authors have reported benefit of repetitive transcranial magnetic stimulation, others of electrical cortical stimulation by stimulating the Heschl's gyrus or secondary auditory areas. OBJECTIVE: To evaluate the efficacy of chronic electrical epidural stimulation of the auditory cortex on severe and disabling tinnitus. METHOD: In this double-blind randomized cross-over, patients with chronic (at least 2 years), severe (Strukturierte Tinnitus-Interview, STI score > 19), unilateral or strongly lateralized tinnitus were included. After open-phase stimulation for 4 months, patients were randomized into 2 groups for double-blind stimulation with cross-over between significant and non-significant phases and wash-out in between. Each of the 3 phases was 2 weeks in duration. Patients were chronically stimulated and followed if not explanted. A decrease of STI score >35% was considered as clinically significant. RESULTS: None of the 9 patients included achieved significant improvement during the double-blind phase. Four were explanted, 2 owing to lack of effect, one for breast cancer under the stimulator, and another for psychiatric decompensation. Five are still stimulated. Three felt slight to great subjective effectiveness, the remaining 2 reported benefits and still requested stimulation. CONCLUSIONS: This study did not find an objective efficiency of chronic cortical stimulation for severe and resistant tinnitus. The discordance between the results in double-blind and open evaluations could be related to a placebo effect of surgery, but may also be explained by a poorly defined target, a too short randomized phase, or inappropriate outcome measures. Clinical trial reference: NCT00486577.

Comparison between bilateral cochlear implants and Neurelec Digisonic(®) SP Binaural cochlear implant: speech perception, sound localization and patient self-assessment.

An alternative to bilateral cochlear implantation is offered by the Neurelec Digisonic(®) SP Binaural cochlear implant, which allows stimulation of both cochleae within a single device. The purpose of this prospective study was to compare a group of Neurelec Digisonic(®) SP Binaural implant users (denoted BINAURAL group, n = 7) with a group of bilateral adult cochlear implant users (denoted BILATERAL group, n = 6) in terms of speech perception, sound localization, and self-assessment of health status and hearing disability. Speech perception was assessed using word recognition at 60 dB SPL in quiet and in a 'cocktail party' noise delivered through five loudspeakers in the hemi-sound field facing the patient (signal-to-noise ratio = +10 dB). The sound localization task was to determine the source of a sound stimulus among five speakers positioned between -90° and +90° from midline. Change in health status was assessed using the Glasgow Benefit Inventory and hearing disability was evaluated with the Abbreviated Profile of Hearing Aid Benefit. Speech perception was not statistically different between the two groups, even though there was a trend in favor of the BINAURAL group (mean percent word recognition in the BINAURAL and BILATERAL groups: 70 vs. 56.7% in quiet, 55.7 vs. 43.3% in noise). There was also no significant difference with regard to performance in sound localization and self-assessment of health status and hearing disability. On the basis of the BINAURAL group's performance in hearing tasks involving the detection of interaural differences, implantation with the Neurelec Digisonic(®) SP Binaural implant may be considered to restore effective binaural hearing. Based on these first comparative results, this device seems to provide benefits similar to those of traditional bilateral cochlear implantation, with a new approach to stimulate both auditory nerves.

Auditory discrimination of frequency ratios: the octave singularity.

Sensitivity to frequency ratios is essential for the perceptual processing of complex sounds and the appreciation of music. This study assessed the effect of ratio simplicity on ratio discrimination for pure tones presented either simultaneously or sequentially. Each stimulus consisted of four 100-ms pure tones, equally spaced in terms of frequency ratio and presented at a low intensity to limit interactions in the auditory periphery. Listeners had to discriminate between a reference frequency ratio of 0.97 octave (about 1.96:1) and target frequency ratios, which were larger than the reference. In the simultaneous condition, the obtained psychometric functions were nonmonotonic: as the target frequency ratio increased from 0.98 octave to 1.04 octaves, discrimination performance initially increased, then decreased, and then increased again; performance was better when the target was exactly one octave (2:1) than when the target was slightly larger. In the sequential condition, by contrast, the psychometric functions were monotonic and there was no effect of frequency ratio simplicity. A control experiment verified that the non-monotonicity observed in the simultaneous condition did not originate from peripheral interactions between the tones. Our results indicate that simultaneous octaves are recognized as "special" frequency intervals by a mechanism that is insensitive to the sign (positive or negative) of deviations from the octave, whereas this is apparently not the case for sequential octaves.

Comparison of three types of French speech-in-noise tests: a multi-center study.

OBJECTIVE: To compare results on the everyday sentence test 'FIST', the new closed-set sentence test 'FrMatrix', and the digit triplet screening test 'FrDigit3'. DESIGN: First, the FrMatrix was developed and normative values were obtained. Subsequently, speech reception thresholds (SRTs) for the three types of tests were gathered at four study centers representing different geographic regions in Belgium and France. STUDY SAMPLE: Fifty-seven normal-hearing listeners took part in the normative study of the FrMatrix, and 118 subjects, with a wide range of hearing thresholds, participated in the comparative study. RESULTS: Homogenizing the individual words of the FrMatrix with regard to their intelligibility resulted in a reference SRT of -6.0 (±0.6) dB SNR and slope at the SRT of 14.0 %/dB. The within-subject variability was only 0.4 dB. Comparison of the three tests showed high correlations between the SRTs mutually (>0.81). The FrMatrix had the highest discriminative power, both in stationary and in fluctuating noise. For all three tests, differences across the participating study centers were small and not significant. CONCLUSIONS: The FIST, the FrMatrix, and the FrDigit3 provide similar results and reliably evaluate speech recognition performance in noise both in normal-hearing and hearing-impaired listeners.

Is behavioral audiometry achievable in infants younger than 6 months of age?

BACKGROUND AND GOAL: When carried out in addition to objective tests, behavioral audiometry performed in children with the so-called "Delaroche protocol" [IJORL 68 (2004) 1233-1243] enables to determine hearing thresholds by air and bone conduction over the whole auditory frequency range. In the present report, seventy-three hearing-impaired infants with different levels of motor and cognitive development were tested behaviorally before 6 months of age. Reliability of these early determined behavioral thresholds was then after analyzed using: (a) cross-sectional study, and (b) longitudinal study. METHODS: Cross-sectional study compared click-evoked ABR thresholds in the better ear with binaural high-frequency hearing thresholds. In longitudinal study, early measured binaural hearing thresholds from 500 through 4000 Hz were reassessed at 18 months. RESULTS: In 13% of babies behavioral testing was not fully completed by 6 months of age. Nevertheless, both cross-sectional and longitudinal studies yielded intraclass correlation coefficients above 0.80, suggesting that behavioral testing is applicable to this very young population. CONCLUSIONS: Assessment of hearing after newborn screening should not be restricted to objective tests before 5 ½ months. It should also include bone- and air-conduction behavioral tests adjusted to developmental stage and performed in presence of parents.

Pitch comparisons between electrical stimulation of a cochlear implant and acoustic stimuli presented to a normal-hearing contralateral ear.

Four cochlear implant users, having normal hearing in the unimplanted ear, compared the pitches of electrical and acoustic stimuli presented to the two ears. Comparisons were between 1,031-pps pulse trains and pure tones or between 12 and 25-pps electric pulse trains and bandpass-filtered acoustic pulse trains of the same rate. Three methods-pitch adjustment, constant stimuli, and interleaved adaptive procedures-were used. For all methods, we showed that the results can be strongly influenced by non-sensory biases arising from the range of acoustic stimuli presented, and proposed a series of checks that should be made to alert the experimenter to those biases. We then showed that the results of comparisons that survived these checks do not deviate consistently from the predictions of a widely-used cochlear frequency-to-place formula or of a computational cochlear model. We also demonstrate that substantial range effects occur with other widely used experimental methods, even for normal-hearing listeners.

[Pathophysiology of auditory and speech perception]. / Physiopathologie de la surdité, entendre et comprendre.

Auditory perception or hearing can be defined as the interpretation of sensory evidence, produced by the ears in response to sound, in terms of the events that caused the sound. We do not hear a window but we may hear a window closing. We do not hear a dog but we may hear a dog barking. And we do not hear a person but we may hear a person talking. Hearing impairment can result in anxiety or stress in everyday life. Pure-tone hearing loss (or threshold shift) is a measure of hearing impairment. Aging and excessive noise are the main causes of hearing impairment. Speech perception is another concept. The difference with the former is best illustrated by the disabled individual declaring "I can hear that someone is talking to me, but I don't understand what she says". Being unable to understand easily and clearly significant others, especially in understanding speech in a noisy environment, can give rise to considerable psychosocial and professional consequences (disability). Presbycusis is the decline in hearing sensitivity caused by the aging process at different levels of the auditory system. However, it is difficult to isolate age effects from other contributors to age-related hearing loss such as noise damage, genetic susceptibility, inflammatory otologic disorders, and ototoxic agents. Therefore, presbycusis and age-related hearing loss are often used synonymously. In this report pathophysiology is mostly described with regard to presbycusis, and the main peripheral types of presbycusis (sensory or Corti organ-related, strial, and neural) are summarized. An original experimental model of strial presbycusis, based on chronic application of furosemide at the round window, is further described. Central presbycusis is mainly determined by degeneration secondary to peripheral impairment (concept of deafferentation). Central auditory changes typically affect speed of processing and result in poorer speech understanding in noise or with rapid or degraded speech. Last, age-related cognitive factors can be associated to peripheral hearing impairment and increase disability in speech understanding in noise.

Screening to detect permanent childhood hearing impairment in neonates transferred from the newborn nursery.

OBJECTIVES: The focus of this report is hearing screening of newborns transferred from the regular nursery to a specialized area. The purpose of the study undertaken was: (1) to determine whether screening coverage in this population was achieved; (2) to establish whether the linkage between neonatal screening and the diagnostic follow-up was carried out correctly; (3) to better determine the incidence of permanent childhood hearing impairment (PCHI) in this at-risk population. METHODS: Six population centres averaging 12,000 births annually participated (Bordeaux, Lille, Paris, Marseille, Toulouse and Lyon). Automated auditory brainstem response (AABR) (Natus ALGO 3i) screening was performed in two stages: i.e. infants with initial "positive" results were screened a second time using the same technique. Of the 117,103 babies born during the study period, 4972 neonates were "transferred" and comprised the population for this report (4.2% of the total births). RESULTS AND DISCUSSION: Screening results for 4972 "transferred" neonates were compared with those of non-transferred neonates (N=112,131). Screening coverage of eligible infants was significantly lower (75.4%) in "transferred" neonates (3750 infants screened) compared to 97.5% coverage of non-transferred neonates (109,349 infants screened). The rate of positive results after the first stage AABR was higher in the "transferred" population (11.1%) than in the non-transferred population (6.5%). Of the 415 "transferred" newborns with initial positive screens, 91.3% were rechecked as stipulated in the project protocol. The second pre-discharge AABR ascertained that in half of the cases auditory function had normalized in the day. Of the 183 "transferred" infants whose result remained suspect at the conclusion of both stages of the neonatal screen (4.9% of the tested population), only 70.5% returned to the audiology centre for diagnostic follow-up. The incidence of bilateral PCHI was markedly higher (4/1000) in "transferred" infants than in the non-transferred population (1.08/1000). CONCLUSIONS: The difficulty of obtaining universal screening coverage in "transferred" infants was, unfortunately, verified in this prospective, multicentre study. Further, the diversity of our "transferred" population was not much greater than that revealed by careful analysis of published hearing screening studies in neonatal intensive care unit (NICU) infants. The influence of risk factors and their more or less complex combinations is apparent.

Behavioral audiometry: validity of audiometric measurements obtained using the "Delaroche protocol" in babies aged 4--18 months suffering from bilateral sensorineural hearing loss.

OBJECTIVE: Evaluation of the validity of the audiometric measurements obtained in babies aged from 4 to 18 months suffering from bilateral sensorineural hearing loss (SNHL) using an original behavioral audiometry (BA) protocol called the "Delaroche protocol" [IJPORL 68 (2004) 1233-1243]. METHODS: (1) We compared the auditory brainstem (ABR) threshold in the better ear with the mean of the BA thresholds obtained, bilaterally, at 2000 and 4000 Hz, both measurements being performed in the diagnostic phase. (2) We compared the BA thresholds obtained prior to the age of 18 months, bilaterally, at the frequencies of 500,1000, 2000 and 4000 Hz, with the thresholds of the better ear obtained at the same frequencies at the age of 3--4 years by BA. RESULTS: (1) Cross- sectional study (78 children). When there was no ABR at 100 db, there was no BA response at 100 dB in 84.2% of cases, resulting in a kappa coefficient of 0.72. When there were ABR, the difference between the ABR and the BA thresholds was equal to or less than 10 dB in 67% of cases and equal to or less than 20 dB in 95% of cases. (2) Longitudinal study (50 children). The difference between the behavioral thresholds obtained within 4 and 18 months (median age=12 months) and those obtained at 3 or 4 years old in the same children (median age=39 months) was equal to or less than 10 dB in 94% of cases at the frequencies of 1000, 2000 and 4000 Hz and in 78% of cases at 500 Hz. CONCLUSION: The two analysis evidence the validity of the behavioral measurements obtained at an early age using the protocol described.

Assessment and amelioration of hyperacusis in tinnitus patients.

CONCLUSIONS: Tinnitus can be bothersome even without hyperacusis. The good correlation found in this study between the multiple-activity scale for hyperacusis (MASH) score and the overall annoyance of hyperacusis score supports the reliability of self-rating of hyperacusis. Objectives. A prospective study was undertaken to investigate the relationships between hyperacusis and tinnitus and to determine whether hyperacusis can be rapidly controlled over time. MATERIAL AND METHODS: All tinnitus patients seen over a period of 16 months with surnames beginning with the letters A L (n = 249) were assessed during a structured interview using (i) a scale ranging from 0 to 10 for assessing the annoyance of tinnitus and the overall annoyance of hyperacusis and (ii) the newly introduced MASH. RESULTS: The annoyance of tinnitus was greater in females. The prevalence of hyperacusis was high (79%). The annoyance of hyperacusis varied. Patients were categorized into five groups according to the hyperacusis annoyance score, as follows: no hyperacusis; mild hyperacusis (< or = 3); moderate hyperacusis (3.1-5.0); substantial hyperacusis (5.1-7.0); and severe hyperacusis (> or = 7.1). Individuals with severe hyperacusis were younger than those in the other groups. The correlation between the annoyance of tinnitus and the annoyance of hyperacusis was poor (r = 0.35). No audiometric difference was found between categories, whereas self-rated hearing deficiency increased with the annoyance of hyperacusis. A good correlation (r = 0.89) was found between the overall annoyance of hyperacusis and the MASH score. Changes over time, assessed in 32 patients investigated at least 3 times, showed more frequent improvement in hyperacusis (63%) than tinnitus (47%).

Behavioral audiometry: protocols for measuring hearing thresholds in babies aged 4-18 months.

OBJECTIVE: This paper provides the first report in English of original behavioral audiometry protocols for measuring hearing thresholds in very young children, including the multiply handicapped. METHODS: Based on reactions to one or two well-calibrated acoustic stimulations delivered in the sound field, the protocol first involves the use of a vibrator to measure hearing levels by bone conduction. This measurement technique, which is not affected by middle ear infections, is the key diagnostic step. Moreover, in profoundly hearing loss children, it triggers reactions through vibratory stimulation and sets the scene for the conditioning of responses. Next, hearing levels are assessed by air conduction with the aid of headphones, in order to measure hearing levels in each ear as early as possible. A unique set-up is used to facilitate the emergence of reliable "surprise reactions", which may be interpreted by a sole examiner. Classical visual reinforcement is replaced by a highly interactive, dynamic and playful exchange between child and examiner, which gives meaning to the perception of stimuli and heralds the learning of hearing. RESULTS: The results concern 105 babies suffering from bilateral sensorineural hearing loss and aged 4-18 months at the first behavioral test. Group 1 comprised 91 babies with no other handicap, in whom full bilateral air conduction was obtained in 82.4% before 12 months and in 98.9% before 18 months. In this group, air conduction in each ear was obtained in 47.0% before 12 months and in 70.3% before 18 months. In Group 2, which included 14 multiply handicapped babies, full bilateral air conduction was obtained in 37.5% before 12 months and in 78.6% before 18 months. Air conduction in both ears was obtained in 28.6% before 18 months. CONCLUSION: The protocols described make it possible, in a minimum number of sessions, to measure hearing thresholds early over the whole range of hearing frequencies, even in multiply handicapped babies and those suffering from developmental retardation.

Further validation of the Iowa tinnitus handicap questionnaire.

The ease of use of the French version of the Tinnitus Handicap Questionnaire was assessed in a group of 100 unselected individuals with tinnitus, 57 of whom agreed to take part in the survey. In addition to the instructions commonly used with this inventory, participants were invited to make any comments they wished about each item and to give their opinion of the content and presentation of the questionnaire. Nineteen subjects (33.3%) experienced difficulties with assigning a score to at least one item and one particular item was largely responsible for this problem. Increased systematic use of quantitative and qualitative data with this type of questionnaire is advocated.

Pharmacological strategies for preventing cochlear damage induced by noise trauma.

Hearing loss induced by noise, as well as in combination with other environmental factors, is a significant health problem throughout the world. Although most structures in the inner ear can be harmed by excessive sound exposure, the sensory cells are the most vulnerable. Damage to the stereocilia bundle is often the first structural alteration noted. Once a large number of hair cells are lost, the nerve fibres to that region also degenerate resulting in an irreversible hearing loss. At present, the underlying mechanism for cochlear damage induced by noise is not fully understood. The failure of the adult peripheral auditory system to regenerate after injury is a major clinical problem. However, a number of experimental applications have recently become available and are effective in reducing the damaging effects of noise. Current experimental designs include strategies for protecting against injury and are primarily based on the fact that the metabolic state of the cochlea can determine the overall degree of hearing loss induced by noise. The purpose of the present article is to review the current literature dealing with strategies for protecting against noise trauma.