Reporting of auditory symptoms over time: (in)consistencies, expectations and the nocebo effect.

Objective: Consistent symptom reporting for conditions like tinnitus that do not have an associated sign is critical for evaluating severity and intervention effectiveness, and for interpreting research findings. There is little research examining reporting of tinnitus and hearing difficulty over time. We address this here by comparing reported hearing difficulty and tinnitus at two time-points.Design: A cross-sectional study comparing symptom reporting in March 2019 and August/September 2021 using data from two online surveys of the same cohort. Although each survey was designed to address a different question, both asked about symptoms of tinnitus and hearing difficulties and enabled this exploratory analysis.Study sample: 6881 members of the UK general public aged 18+ years.Results: Inconsistent reporting was evident - many participants who reported experiencing tinnitus and/or hearing difficulties in 2019, said in 2021 that they had never had such symptoms before. Additionally, reports of new tinnitus/hearing difficulties in 2021 were unexpectedly high, equating to 18-month incidence rates of 13.6% and 11.7%, respectively.Conclusions: Psychosocial factors, expectations and context impact symptom reporting. This should be considered when treating patients and interpreting research findings. Using real-time data collection methods could thus provide a better understanding of experiences of tinnitus and hearing.

Association between hearing loss and deprivation among Welsh adults: a cross-sectional observational study.

OBJECTIVE: To index levels of hearing loss with respect to area-level indices of deprivation in a Welsh population. DESIGN: A cross-sectional observational study of all adults (aged >18) that attended Abertawe Bro Morgannwg University (ABMU) Health Board audiology services between 2016 and 2018. Service access, first hearing aid fitting appointment rates and hearing loss at time of first hearing aid provision were used to index population hearing loss versus area-level indices of deprivation based on patient postcode. SETTING: Primary and secondary care. PARTICIPANTS: 59 493 patient entries met the inclusion criteria. Patient entries were grouped by age (18-30, 31-40, 41-50, 51-60, 61-70, 71-80, >80 years) and deprivation decile. RESULTS: The interaction between age group and deprivation decile predicted access rate to ABMU audiology services (b=-0.24, t(6858) = -2.86, p<0.01) with audiology services accessed more frequently by the most deprived versus the least deprived decile in every age group (p<0.05), except the >80 years. First hearing aid fitting rates were highest among the most deprived in the four youngest age groups (p<0.05). Severity of hearing loss at the time of first hearing aid fitting was worse among the most deprived in the five oldest age groups (p<0.01). CONCLUSIONS: Hearing health inequalities are prevalent among adults accessing ABMU audiology services. Our findings suggest that deprivation increases the likelihood of developing hearing loss, brings earlier onset of hearing loss and is linked to delays in getting help for hearing problems. However, it is not possible to know the true scale of these disparities without knowing the hearing health of the Welsh adult population including those who do not seek help for hearing problems.

Shedding Light on SARS-CoV-2, COVID-19, COVID-19 Vaccination, and Auditory Symptoms: Causality or Spurious Conjunction?

There are reports of associations between SARS-CoV2, COVID-19, COVID-19 vaccines, and auditory symptoms (hearing difficulty, tinnitus). However, most studies have relied on self-report and lack baseline and/or non-COVID control groups. This makes it problematic to differentiate if symptoms are associated with SARS-CoV2, COVID-19, the vaccine, psychosocial factors or recall bias. In this study, we differentiate these by comparing hearing and tinnitus survey data collected pre- and during the pandemic. The survey conducted during the pandemic asked about the onset and change in three types of symptom. Type One-known association (loss of smell, memory/concentration issues, persistent fatigue), Type Two-indeterminate association (auditory symptoms), and Type Three-no established association with COVID-19 (toothache). We hypothesized that if auditory symptoms are directly associated with COVID-19, their onset and change would be similar to Type One symptoms, but if indirectly associated (reflecting psychosocial factors and/or recall bias) would be more similar to Type Three symptoms. Of the 6,881 individuals who responded, 6% reported confirmed COVID-19 (positive test), 11% probably had COVID-19, and 83% reported no COVID-19. Those with confirmed or probable COVID-19 more commonly reported new and/or worsened auditory symptoms than those not reporting COVID-19. However, this does not imply causality because: (1) new auditory symptoms coincided with COVID-19 illness among just 1/3 of those with confirmed or probable COVID-19, and another 1/3 said their symptoms started before the pandemic-despite reporting no symptoms in the pre-pandemic survey. (2) >60% of individuals who had COVID-19 said it had affected their Type 3 symptoms, despite a lack of evidence linking the two. (3) Those with confirmed COVID-19 reported more Type 1 symptoms, but reporting of Type 2 and Type 3 symptoms did not differ between those with confirmed COVID-19 and those without COVID-19, while those who probably had COVID-19 most commonly reported these symptom types. Despite more reports of auditory symptoms in confirmed or probable COVID-19, there is inconsistent reporting, recall bias, and possible nocebo effects. Studies that include appropriate control groups and use audiometric measures in addition to self-report to investigate change in auditory symptoms relative to pre-COVID-19 are urgently needed.

Does coronavirus affect the audio-vestibular system? A rapid systematic review.

Objective: This rapid systematic review investigated audio-vestibular symptoms associated with coronavirus.Design: The protocol for the rapid review was registered in the International Prospective Register of Systematic Reviews and the review methods were developed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Risk of bias was assessed using the National Institute of Heath quality assessment tools.Study sample: After rejecting more than 2300 records, there were five case reports and two cross-sectional studies that met the inclusion criteria.Results: No records of audio-vestibular symptoms were reported with the earlier types of coronavirus (i.e. severe acute respiratory syndrome [SARS] and Middle East respiratory syndrome [MERS]). Reports of hearing loss, tinnitus, and vertigo have rarely been reported in individuals who tested positive for the SARS-CoV-2.Conclusion: Reports of audio-vestibular symptoms in confirmed COVID-19 cases are few, with mostly minor symptoms, and the studies are of poor quality. Emphasis over time is likely to shift from life-threatening concerns to longer-term health-related consequences such as audio-vestibular dysfunction. High-quality studies are needed to investigate the acute effects of COVID-19, as well as for understanding long-term risks, on the audio-vestibular system. Review registration: Prospective Register of Systematic Reviews (PROSPERO; registration number CRD42020184932).

Subclinical Auditory Neural Deficits in Patients With Type 1 Diabetes Mellitus.

OBJECTIVES: Diabetes mellitus (DM) is associated with a variety of sensory complications. Very little attention has been given to auditory neuropathic complications in DM. The aim of this study was to determine whether type 1 DM (T1DM) affects neural coding of the rapid temporal fluctuations of sounds, and how any deficits may impact on behavioral performance. DESIGN: Participants were 30 young normal-hearing T1DM patients, and 30 age-, sex-, and audiogram-matched healthy controls. Measurements included electrophysiological measures of auditory nerve and brainstem function using the click-evoked auditory brainstem response, and of brainstem neural temporal coding using the sustained frequency-following response (FFR); behavioral tests of temporal coding (interaural phase difference discrimination and the frequency difference limen); tests of speech perception in noise; and self-report measures of auditory disability using the Speech, Spatial and Qualities of Hearing Scale. RESULTS: There were no significant differences between T1DM patients and controls in the auditory brainstem response. However, the T1DM group showed significantly reduced FFRs to both temporal envelope and temporal fine structure. The T1DM group also showed significantly higher interaural phase difference and frequency difference limen thresholds, worse speech-in-noise performance, as well as lower overall Speech, Spatial and Qualities scores than the control group. CONCLUSIONS: These findings suggest that T1DM is associated with degraded neural temporal coding in the brainstem in the absence of an elevation in audiometric threshold, and that the FFR may provide an early indicator of neural damage in T1DM, before any abnormalities can be identified using standard clinical tests. However, the relation between the neural deficits and the behavioral deficits is uncertain.

Recording Obligatory Cortical Auditory Evoked Potentials in Infants: Quantitative Information on Feasibility and Parent Acceptability.

OBJECTIVES: With the advent of newborn hearing screening and early intervention, there is a growing interest in using supra-threshold obligatory cortical auditory evoked potentials (CAEPs) to complement established pediatric clinical test procedures. The aim of this study was to assess the feasibility, and parent acceptability, of recording infant CAEPs. DESIGN: Typically developing infants (n = 104) who had passed newborn hearing screening and whose parents expressed no hearing concerns were recruited. Testing was not possible in 6 infants, leaving 98, age range 5 to 39 weeks (mean age = 21.9, SD = 9.4). Three short duration speech-like stimuli (/m/, /g/, /t/) were presented at 65 dB SPL via a loudspeaker at 0° azimuth. Three criteria were used to assess clinical feasibility: (i) median test duration <30 min, (ii) >90% completion rate in a single test session, and (iii) >90% response detection for each stimulus. We also recorded response amplitude, latency, and CAEP signal to noise ratio. Response amplitudes and residual noise levels were compared for Fpz (n = 56) and Cz (n = 42) noninverting electrode locations. Parental acceptability was based on an 8-item questionnaire (7-point scale, 1 being best). In addition, we explored the patient experience in semistructured telephone interviews with seven families. RESULTS: The median time taken to complete 2 runs for 3 stimuli, including preparation, was 27 min (range 17 to 59 min). Of the 104 infants, 98 (94%) were in an appropriate behavioral state for testing. A further 7 became restless during testing and their results were classified as "inconclusive." In the remaining 91 infants, CAEPs were detected in every case with normal bilateral tympanograms. Detection of CAEPs in response to /m/, /g/, and /t/ in these individuals was 86%, 100%, and 92%, respectively. Residual noise levels and CAEP amplitudes were higher for Cz electrode recordings. Mean scores on the acceptability questionnaire ranged from 1.1 to 2.6. Analysis of interviews indicated that parents found CAEP testing to be a positive experience and recognized the benefit of having an assessment procedure that uses conversational level speech stimuli. CONCLUSIONS: Test duration, completion rates, and response detection rates met (or were close to) our feasibility targets, and parent acceptability was high. CAEPs have the potential to supplement existing practice in 3- to 9-month olds.

Parents' perspectives on the dilemmas with intervention for infants with auditory neuropathy spectrum disorder: A qualitative study.

OBJECTIVE: This paper explores parental experiences of choices surrounding auditory management and language and communication development for infants and children with auditory neuropathy spectrum disorder (ANSD) in the light of the heterogeneity of condition, a poor evidence base for best outcomes in relation to management options, and the scarcity of data rooted in parent and family experience. DESIGN: Qualitative narrative study. STUDY SAMPLE: Twenty-five parents of 21 children (aged four months to six years) identified with ANSD through the newborn hearing screening programme. RESULTS: Families identify barriers to early management due to conflicting expert opinions and ANSD-specific challenges with diagnosis and prognosis in infants, and share their accounts on their own evaluations of intervention benefit in their children. CONCLUSIONS: The results are of relevance to the clinicians and other professionals involved in early intervention, management, and support of infants with ANSD.

Auditory neuropathy spectrum disorder in the wider health context: experiences of parents whose infants have been identified through newborn hearing screening programme.

OBJECTIVE: This paper presents an insight into the parental experiences of how parents made sense of having their child identified with auditory neuropathy spectrum disorder (ANSD), given the broader context of their child's other health issues. DESIGN: Qualitative narrative study. STUDY SAMPLE: Twenty-one families participated whose children had been identified with ANSD through the newborn hearing screening programme. RESULTS: The majority of parents in the sample were overwhelmed with perinatal health issues and initially gave the diagnosis of ANSD very low priority. CONCLUSIONS: An understanding of parents' perspective is particularly relevant to everyone involved in early support and management of infants with ANSD.

Why don't health professionals check patient understanding? A questionnaire-based study.

Checking patient understanding, by asking questions about information presented in a medical consultation, is a core communication skill but its use is not frequently assessed. The newborn hearing screening commenced in England with a pilot of its implementation in January 2002. Because it is a new screening test, it provided an opportunity for studying the effective communication of novel information. A randomized controlled trial of training newborn hearing screeners to present information about the screening test and to ask questions to check understanding was commenced but had to be prematurely ended as the majority of the screeners did not ask the questions. The aim of this study was to understand why the screeners did not ask questions to check understanding of the information provided. Questionnaires were sent to screeners who participated in the study to elicit their responses to the use of the questions to check understanding. A response rate of 87% (26/30) was achieved. Screeners who reported not asking the questions were more likely to express a lack of confidence in their ability to ask questions, and to perceive asking questions as an ineffective way of increasing patient understanding. The study suggests that the ability and willingness of healthcare professionals to use simple communication skills may have been overestimated and training needs to target skills as well as beliefs about the effectiveness of using them.

Effectiveness of population-based newborn hearing screening in England: ages of interventions and profile of cases.

OBJECTIVE: The objective of this study was to determine the effectiveness in routine practice of the first phase of a national population-based newborn hearing screening and follow-up program that seeks to identify infants with bilateral permanent hearing loss of > or =40-dB hearing loss. METHODS: The study was a part of the independent evaluation of the 23 first phase sites (annual birth population approximately 120,000) of the national newborn hearing screening program in England. For each infant identified with the defined hearing loss, the measures of interest were degree and type of hearing loss, presence of risk factors, age of first audiologic assessment, age of identification of hearing loss, age of enrollment in an early support program, and age of hearing aid fitting. Data collection took place over the first 2 years of the program. RESULTS: Data were provided on 169 infants with permanent bilateral moderate or greater hearing loss identified through screening 169487 infants. Fifty-four percent of all cases were from an "at-risk" population. Three fourths of these "at-risk" infants spent > or =48 hours in the NICU. For the whole sample, the median age at first audiologic assessment was 5 weeks; the median age of identification of the hearing loss and of enrollment in early support program was 10 weeks irrespective of the degree of hearing loss; and the median age at hearing aid fitting was 16 weeks. Infants with moderate hearing loss were fitted with hearing aids significantly later than those with severe and profound hearing loss. CONCLUSIONS: Properly implemented, a newborn hearing screening program based on whole populations and routine service provision can deliver satisfactory outcomes in terms of age of referral, identification, and intervention. The distribution of degree and type of hearing loss and proportion with risk factors was similar to that expected. The numbers identified were such as to suggest that very few cases were missed by the screening program.

Maternal anxiety following newborn hearing screening: the moderating role of knowledge.

OBJECTIVES: To describe the impact upon maternal anxiety of newborn hearing screening and examine the Possible moderating role of knowledge. METHODS: Questionnaires assessing maternal state anxiety, worry and certainty about the baby's hearing, and knowledge about screening, were sent to four groups of mothers three weeks after screening: Group 1 consisted of mothers whose babies had clear responses on a first or second screening test (n=103); Group 2 consisted of mothers whose babies had clear responses on the third screening test (n=81); Group 3 consisted of mothers whose babies did not have clear responses in one ear at the third screening test and were referred for audiological assessment (n=105); and Group 4 consisted of mothers whose babies did not have clear responses in either ear at the third hearing test and were referred for audiological assessment (n=55). RESULTS: Although mean anxiety levels were in the normal range, there was a significant trend for anxiety to rise as testing increased (F(1,327)=4.280, P<0.05). Worry increased significantly (F(1,337)=70.432, P<0.001) and certainty decreased significantly (F(1,339)=27.474, P=0.001) as the number of tests increased. Although total knowledge did not significantly moderate anxiety (R(2)=0.016, P=0.096), there was a significant interaction between mothers' group and one knowledge item, understanding that receipt of no clear responses was unlikely to mean that the baby had a hearing loss: mothers in Group 4 who understood this had lower anxiety (F(3,323)=4.791, P<0.01) and lower worry (F(3,332)=3.565, P<0.01) compared with mothers who did not. CONCLUSIONS: Understanding the meaning of being recalled following screening may avoid some of the anxiety associated with this.

Neonatal hearing screening: modelling cost and effectiveness of hospital- and community-based screening.

BACKGROUND: Children with congenital hearing impairment benefit from early detection and management of their hearing loss. These and related considerations led to the recommendation of universal newborn hearing screening. In 2001 the first phase of a national Newborn Hearing Screening Programme (NHSP) was implemented in England. Objective of this study was to assess costs and effectiveness for hospital and community-based newborn hearing screening systems in England based on data from this first phase with regard to the effects of alterations to parameter values. DESIGN: Clinical effectiveness analysis using a Markov Model. OUTCOME MEASURE: quality weighted detected child months (QCM). RESULTS: Both hospital and community programmes yielded 794 QCM at the age of 6 months with total costs of 3,690,000 pound sterling per 100,000 screened children in hospital and 3,340,000 pound sterling in community. Simulated costs would be lower in hospital in 48% of the trials. Any statistically significant difference between hospital and community in prevalence, test sensitivity, test specificity and costs would result in significant differences in cost-effectiveness between hospital and community. CONCLUSION: This modelling exercise informs decision makers by a quantitative projection of available data and the explicit and transparent statements about assumptions and the degree of uncertainty. Further evaluation of the cost-effectiveness should focus on the potential differences in test parameters and prevalence in these two settings.

Screening for hearing loss in childhood: issues, evidence and current approaches in the UK.

Until recently, screening for childhood hearing loss in the UK was based on two universal (i.e. whole population) screens: the infant distraction test screen at age eight months and the school entry hearing screen at age four to five years. Evidence reviewed in the 1990s indicated that the infant distraction test screen was seriously underperforming, but that (based on technology that had become available in the 1980s and 1990s) universal newborn hearing screening could be efficacious. At the same time, evidence was emerging on the importance and value of very early identification and intervention for permanent congenital childhood hearing loss. This led to the decision to implement a national newborn hearing screening programme (NHSP) in England and to phase out the distraction test at eight months. The initial implementation of the programme will be completed in 2005, and we summarize the evidence on the effectiveness of the first phase of the programme here. A number of important issues concerning childhood hearing loss and its management remain unresolved: the burden of late-onset and temporary childhood hearing losses, the most effective approaches to intervention and management, the case for screening for mild and/or unilateral hearing loss, and the role of the School entry screen. Some of the current research efforts to address these are outlined.

Maternal anxiety and satisfaction following infant hearing screening: a comparison of the health visitor distraction test and newborn hearing screening.

BACKGROUND: Newborn hearing screening is currently replacing the health visitor distraction test (HVDT) conducted at eight months. Our previous research indicates that recall for further tests following newborn hearing screening can have a negative impact on the emotional well being of mothers, but it is not known if this is greater than that caused by recall following the distraction test. OBJECTIVE: To compare the impact on maternal anxiety and satisfaction of recall following newborn hearing screening and the HVDT. METHODS: Four groups participated: 27 mothers of babies receiving a satisfactory result and 21 mothers of babies recalled after the HVDT 26 mothers of babies receiving a satisfactory result and 16 mothers of babies recalled after newborn hearing screening. Questionnaires assessing maternal anxiety, worry and certainty about the babies' hearing, satisfaction with and attitudes towards the screening test were sent to mothers three weeks and six months following screening. RESULTS: Comparison of the effects of receipt of different results showed no significant differences in maternal anxiety, worry and certainty between the two tests. Those mothers whose babies had a newborn hearing screening test were significantly more satisfied, regardless of the result received. Those who received a satisfactory result on the newborn hearing screening programme also had more positive attitudes towards that screening test than those receiving a satisfactory result following the HVDT. CONCLUSION: These results suggest that newborn hearing screening does not have a more negative emotional impact than the HVDT.

Readiness of paediatric audiology services for newborn hearing screening: findings and implications from the programme in England.

As well as evaluating the newborn hearing screen itself, the government-funded evaluation of the implementation of a Newborn Hearing Screening Programme (NHSP) in England is assessing the impact of the screen on follow-up services. In the UK context, these are principally paediatric audiology, education, and social services. This article presents results from a mixed method research study involving paediatric audiology services specifically. Results demonstrate significant variety in current practice with regard to routine tests and procedures, considerable variability in number of current referrals and time allocated to caseloads, and considerable variability in expectations of how the numbers will change following newborn screening implementation. The challenges of and opportunities afforded by NHSP which were identified by respondents, highlight the urgent need for further training. The study has implications for paediatric audiology services that are yet to start NHSP in the UK, as well as for services and professionals in other countries.

To what extent do the characteristics of the object of evaluation influence the choice of epistemological framework? The case of universal newborn hearing screening.

In this article, the authors explore the role that characteristics and circumstances attendant on the object of an evaluation might play in the choice of epistemological framework underpinning research design. They consider examples from the consumer-focused evaluation of the introduction of universal newborn hearing screening in England. In particular, they look at how screen- and program-specific issues exerted influence at the levels of epistemology and method, arguing that these choices are not simply a product of values and questions that underpinned one kind of approach to knowledge production in comparison with another.

Increasing knowledge about a screening test: preliminary evaluation of a structured, chart-based, screener presentation.

The provision and understanding of good quality information is one of the key characteristics of an informed choice. However, written materials alone often fail to achieve good understanding of screening tests. The present study describes the preliminary evaluation of a structured, chart-directed presentation, aimed at increasing knowledge of a screening test. Forty mothers of babies undergoing a newborn hearing test received either a standard, or a standard plus structured, presentation of the screening test. Standard presentation was a leaflet and short verbal explanation of the test. Structured presentation comprised an illustrated chart explaining the process and possible outcomes of screening, followed by screeners checking mothers understanding of key points and, if necessary, giving further explanation. After screening, maternal knowledge of the test was assessed using seven multiple choice items. Overall knowledge was high. For women with lower levels of education, the structured presentation resulted in significantly higher levels of knowledge than the standard presentation only.