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Key words: audiometry, epidemiology, hearing loss, NHANES, noise exposure, prevalence, rehabilitation, thresholds, tinnitus, veterans. Abbreviations: HL = hearing level, MEC = mobile examination center, NCHS = National Center for Health Statistics, NHANES = National Health and Nutrition Examination Survey, NHIS = National Health Interview Survey, PTA = pure tone average, VA = Department of Veterans Affairs, VAMC = VA medical center, VBA = Veterans Benefits Administration, VHA = Veterans Health Administration. Hearing loss and tinnitus are the two most prevalent service-connected disabilities for U.S. The statistics just stated reflect numbers of veterans who received hearing healthcare services from VA medical centers (VAMCs) or compensation payments from the Veterans Benefits Administration (VBA).
NHANES is a program of studies that assess the health and nutritional status of adults and children in the United States. Because many veterans were exposed to loud sounds during military service, we anticipated that they would exhibit higher (that is, poorer) pure tone thresholds than age-matched groups of nonveterans. Audiological data collected in NHANES are divided into questionnaire and examination components.
Subjects were selected for NHANES according to a complex survey-design algorithm for the questionnaire and examination components. Outcomes for this study included pure tone air conduction audiometric thresholds (NHANES 1999-2006) and prevalence of tinnitus (NHANES 1999-2004). We estimated the chronic tinnitus prevalence and mean pure tone thresholds at each audiometric test frequency using the proper survey weights. Our primary objective of this study was to evaluate differences in audiometric configurations and the prevalence of tinnitus between the U.S. From 1999 to 2004, NHANES collected usable audiometric data from 5,742 individuals aged 20 through 69 years.
We analyzed audiometric data collected from 2,931 males who participated in NHANES between 1999 and 2006.
Numbers of male participants in each category who provided pure tone audiometric data for analysis (National Health and Nutrition Examination Survey, 1999-2006).
For this analysis, pure tone thresholds obtained at each frequency tested for the left and right ears were averaged for each male participant.
Figure 1.Audiograms for National Health and Nutrition Examination Survey respondents (1999–2006) by age category.
Figure 2 shows average pure tone thresholds for each test frequency and age group for veterans and nonveterans who reported a history of significant noise exposure. Figure 2.Audiograms for noise-exposed National Health and Nutrition Examination Survey respondents (1999–2006) by age category. Figure 3 shows average pure tone thresholds for each test frequency and age group for veterans and nonveterans who did not report histories of significant noise exposure.
Figure 3.Audiograms for National Health and Nutrition Examination Survey respondents (1999–2006) reporting no significant noise exposure by age category. From 1999 to 2004, NHANES collected questionnaire data from 31,126 participants, 7,169 of whom were males 20 years and older with valid data.
Table 2 contains tinnitus prevalence data for 7,169 male participants (20 years and older) in NHANES from 1999 to 2004, 2,174 (30.3%) of whom were veterans.
Prevalence of tinnitus among males, from National Health and Nutrition Examination Survey, 1999-2004.
Izabella Vince Garcia Pedriali1, Maurico Buschle2, Rita de Cassia Mendes3, Andre Luiz Ataide4, Rodrigo Pereira5, Trissia Maria Farah Vassoler6, Jose Fernando Polanski7, Angela Ribas8, Claudia Mittelmann Stumpf9, Raquel Alves Nobre10, Roberta Daroit11.
Introduction: The implantable prosthesis of osseous conduction (BAHA) is deemed to be an excellent option in the auditory rehabilitation of patients with conductive and mixed hearing loss, unilaterally or bilaterally, and unilateral sensorineural hearing loss. INTRODUCTIONThe osseointegrated implants were firstly introduced to clinical practice in Sweden in the 1970's, and they have ever since been widely accepted in such areas as dentistry, maxillofacial surgeries, and reconstructing and orthopedic surgeries (1).
However, the majority of veterans in the United States do not use VAMCs or VA clinics for healthcare and do not receive VBA compensation [3]. Designed and conducted by the National Center for Health Statistics (NCHS-a center within the Centers for Disease Control and Prevention), the survey combines interviews and physical examinations.
Furthermore, we predicted that males with histories of loud noise exposure would exhibit higher pure tone thresholds than age-matched males who reported less noise exposure. The examination component consists of medical, dental, and physiological measurements, as well as laboratory tests administered by trained medical personnel.
The questionnaire includes questions about tinnitus and noise exposure and is completed by all subjects. Questions include whether the subject has ear tubes, a current cold or ear problem, or recent loud noise exposure. The exam[ination] screened for excessive or impacted ear cerumen (wax), physical abnormalities, or collapsing external ear canals. A Quest Model BA-201-25 Bioacoustic Simulator and Octave Band Monitor [Quest Technologies; Oconomowoc, Wisconsin] was used to continuously measure the background noise levels in the audiometric test room during audiometric examinations. Briefly stated, the design involves randomly selecting counties, neighborhoods, households, and household members. Females were excluded from these analyses because the numbers of female veterans in each age category were too small to allow meaningful statistical comparisons with nonveteran females in the samples.
Statistical comparisons were made between veteran and nonveteran male participants and between groups of participants who did or did not report a significant history of noise exposure. We based the standard error of each estimate on a Taylor's series linearization using the complex design features [6].
Table 1 lists the number of participants in each age category and the numbers of male veterans and nonveterans in each age category.
The majority of thresholds for each test frequency are similar for participants within the same age group. Again, most thresholds for each test frequency are similar for participants within the same age group. Most excluded subjects were under the age of 20 (n = 15,794); of the remainder, a large number were women (n = 8,109) and a small number (n = 54) had invalid data for tinnitus, veteran status, or noise exposure. It has been a good advantage over the conservative bone conduction apparatus and those of individual sound-amplifier apparatus (ISAA), when their usage becomes unfeasible because of chronic otitis externa, which has a hard clinic control.
The Bone Anchored Hearing Aid (BAHA) system, which was originally used by Tjellstrom and his team in Sweden in 1977 (2), made the prospect of osseointegrated implants renowned in the area of otology.
The number of veterans receiving compensation and services from the Department of Veterans Affairs (VA) for these conditions continues to increase annually. Finally, we hypothesized that the chronic tinnitus prevalence would be significantly greater among male veterans than the prevalence among male nonveterans and that tinnitus prevalence among males with histories of loud noise exposure would be greater than that among age-matched males with less noise exposure. During the 1999 to 2004 survey cycles, additional noise exposure data were recorded in the Occupational History Questionnaire.

Pure tone audiometric testing was not performed if ambient noise levels in the test booth exceeded maximum permissible levels .
Complex survey designs such as that used in NHANES result in each participant assigned strata, clusters, and survey weights that must be accounted for during data analysis. Nonoccupational noise exposure was defined as unprotected exposure to firearms, loud music, or power tools for an average of at least once a month for at least 1 year.
Tests of the null hypothesis of no difference in chronic tinnitus prevalence between veterans and nonveterans are based on the Rao-Scott Likelihood Ratio chi-square test. Most of the remaining participants were women (n = 3,068), and some (n = 129) of the remaining men had invalid data related to survey weights, veteran status, noise exposure, or audiometric results. Note that the percentage of veterans in each age category increases with the age of participants. As expected, thresholds for each test frequency tended to be higher (that is, poorer) in successively older age groups of both veterans and nonveterans. However, one set of statistical differences is apparent in Figure 2: veterans aged 80 years or older with histories of noise exposure exhibited higher (poorer) thresholds for 4,000, 6,000, and 8,000 Hz tones than those thresholds of nonveterans in the same age group who also reported higher levels of noise exposure.
Exceptions include higher thresholds at most test frequencies for nonveterans in the 20 to 29 age category with low-noise exposure than those for veterans in the same age range with histories of low-noise exposure. Objective: To introduce the first BAHA case performed in Brazil, as duly authorized by ANVISA (National Agency for Sanitary Surveillance), to rehabilitate the mixed hearing loss with occurrences of chronic otitis externa.
BAHA system is comprised of two major parts: a titanium screw with an abutment implanted in the cortical part of the mastoid bone and one external unit named processor, which is connected to the abutment.
However, the majority of veterans in the United States do not use VA medical centers or clinics for healthcare and do not receive VA compensation payments. Tinnitus is the perception of ringing, buzzing, hissing, or other noises in the ears or head in the absence of external sources for these sounds.
These questions were revised in the 2005 to 2006 NHANES and were included in the audiometry questionnaire. Similar tests for pure tone thresholds at each audiometric test frequency are based on the Wald F statistic. In standard statistical analysis, ineligible subjects are ignored and attention is focused on those respondents within the eligible ranges.
The 2005 to 2006 NHANES yielded data on 10,348 participants, of whom 386 were men aged 70 and older with valid audiometric data.
Some subjects did not have measurable thresholds for certain frequencies, so sample sizes for certain frequencies might be slightly lower than those sizes shown in Table 1.
Only 14 veterans were in this subgroup, and this small sample of veterans had exceptionally good hearing at all frequencies tested. Method: 50-year-old female patient with right-ear moderate and left-ear severe hearing loss, bilateral tinnitus derived from otosclerosis, was submitted to 04 surgeries of stapedotomy and unable to use ISAA as a result of otorrhea and bilateral otalgia. The processor is intended to receive the environmental sounds and convert them into a mechanical energy, what is turned into vibration and transmitted to the abutment, which, in turn, shall stimulate the cortical part of the temporal bone. The cost for hearing aids, accessories, assistive devices, and associated clinical services exceeded $393 million that year alone [2].
This study used National Health and Nutrition Examination Survey (NHANES) data to estimate the prevalence of these auditory conditions among male veterans. These participants are selected from counties across the country, with 15 counties visited by NHANES each year. The NHANES Audiometry Examination Component consists of four parts and was administered to a subsample of participants in the MEC. NHANES questionnaires do not differentiate noise exposure during military service from other types of occupational noise exposure, so current noise exposure data were used for our analysis.
This procedure is not possible when complex survey data are analyzed because survey weights were defined for the entire sample of NHANES respondents. The majority of exclusions for 2005 to 2006 were participants under 70 years old (n = 9,466), of which the remainder were women (n = 431) or individuals with invalid data (n = 65).
The number of veterans receiving VA compensation and services for hearing loss and tinnitus continues to increase annually. Weights are derived from numerous variables and estimation procedures that are described in the NHANES documentation. This methodology is appropriate, since NHANES sampling does not include Active Duty military personnel. Since thresholds are likely to be correlated across frequencies, it is not surprising that statistically significant results are observed over the range of test frequencies in this age group. In general, the prevalence of tinnitus increases from the 20 to 29 through the 60- to 69-year-old age categories, then decreases for the 70- to 79- and 80+-year-old categories. Having surgery been performed and BAHA implemented, the patient showed a significant improvement in audiometric thresholds, speech perception and distinction, as well as she declared to be extremely satisfied with the esthetic factor. In some special occasions, such as surgeries on small children, the surgery can be performed in two different times: firstly, by placing the titanium screw and, secondly, by coupling the abutment with this osseointegrated screw. This study used National Health and Nutrition Examination Survey data to estimate the prevalence of these auditory conditions among male veterans. Like sensorineural hearing loss, chronic tinnitus more likely occurs in middle-aged and older people, especially those who have been repeatedly exposed to loud sounds without using hearing protection devices. Health measurements are performed in specially-designed and equipped mobile [examination] centers [MECs], which travel to locations throughout the country. Our analysis of the 1999 to 2004 data uses a 6-year weighting scheme, while the 2005 to 2006 data are analyzed separately using 2-year survey weights. Therefore, combining or comparing tinnitus prevalence data for these different NHANES questionnaires is not feasible. Accordingly, we used domain analysis [6] to compute proper subgroup statistics for both eligible and ineligible subjects in the sample. Pure tone thresholds for nonveterans in the 20 to 29 age category with low noise exposure (n = 300) are statistically similar to thresholds obtained from 20- to 29-year-old nonveterans who reported higher levels of noise exposure (n = 224). Final commentaries: BAHA surgical process is safe, simple and swift, thus providing excellent audiological results and a higher degree of satisfaction to patients. The titanium screw is surgically implemented, and this procedure can be performed by way of a local anesthesia. Between 1999 and 2006, pure tone audiometric data collected from 845 male veterans were compared with pure tone thresholds collected from 2,086 male nonveterans.
To produce reliable statistics, NHANES oversamples persons 60 and older, African Americans, and Hispanics. The study team consists of a physician, medical and health technicians, as well as dietary and health interviewers.

Pure tone audiograms were not accepted if there was more than a 10 dB difference between them.
For more information on the use of sample weights in NHANES data analysis, refer to the current NHANES Analytic and Reporting Guidelines [5]. The processor shall be inserted only after the osseointegration period, which is three months for adults and six months for children. We used questionnaire data collected between 1999 and 2004 to calculate and compare the prevalence of tinnitus for 2,174 veterans and 4,995 nonveterans. In general, pure tone thresholds did not differ significantly between veterans and nonveterans for most frequencies tested (500-8,000 Hz). Although it has been long used in Europe and the United States, in Brazil BAHA system has been recently used, and it has a scarce national publication and only a few surgical cases. The team at the Audiological Diagnostic Center of Iguacu Hospital (CDAH) in Curitiba has been the first one to implant BAHA after it has been authorized by the National Agency for Sanitary Surveillance.In the meantime, the team faced some difficulties with respect to methodology of audiological evaluation of the different hearing loss cases on BAHA candidates. This fact led to understanding that it is urgent to develop a protocol to audiologically evaluate and follow-up with patients who are candidates to the procedure.
The present study intends to show the first case of BAHA performed in Brazil, as duly approved by ANVISA, having the surgery been performed by Hospital Iguacu's team, as well as to describe the protocol used during the service. Depending upon the age of the participant, the rest of the examination includes tests and procedures to assess various aspects of health . A more recent indication is for patients with unilateral sensorineural hearing loss or Single Sided Deafness (SSD), presenting contralateral ear with an average bone conduction equal to or above 20 dBNA (3). Conductive and mixed hearing losses are highly prevailing disorders that can be either treated with surgical techniques or rehabilitated by an individual sound-amplifier apparatus (ISAA).
BAHA can overcome all these hassles because it does not place any pressure on skin, but it is discreet and esthetically well-accepted instead, besides being safely tightened to the implant, always in the right place of stimulation (5). BAHA system presents some outstanding results in cases of conductive and mixed hearing disorders, despite having some restraints on the gain provided to the sensorial component of mixed hearing loss (6).CASE REPORTVLVM, 50-year-old female, presented a moderate left-ear and severe right-ear mixed hearing loss, both of which with ascending configurations and progressive characteristics, caused by bilateral osteosclerosis.
The patient appeared at CDAHI after being submitted to three surgeries of stapedotomy on the right ear and one surgery on the left one, all of which were unsuccessful, and subsequent worsening of the hearing thresholds.
She mentioned a continual tinnitus in the right ear, which was more noticeable during silence, deemed to have a medium impact according to the visual analogue scale (VAS) and vertigo when placing and using ISAA.She did not actually use ISAA, due to showing chronic otitis externa associated with otorrhea and otalgia. The image test found permeable cochleas and a medium metallic prosthesis in the right vestibule.The evaluation with BAHA tester was performed with the arch-coupled processor, providing the patient with a hearing sensitivity caused by the processor vibration (3). By way of an open-field audiometry, pure-tones thresholds issued by a lateral acoustic box were evaluated, and a 60-dBNA monosyllable word-distinction test was performed with a concurring 55-dBNA speech noise before the patient. An external test has also been performed, in which the patient stayed with the tester for one day, using it on the right side during the morning and on the left side during the afternoon. After the patient's exams were analyzed, she has been indicated to use BAHA Cochlear Divine on her left ear, which is the ear with best bone conduction thresholds and the side preferred by the patient during the external test. The evaluation results were explained and the patient was guided with respect to the risks and benefits of the surgery.
The patient signed both a term of consent and an authorization for the images to be used in this work. The surgeryThe surgery was performed on February 28, 2008 by a one-time method, in which the screw and the abutment are connected and placed in the same surgical time. Processor placement and post-surgical evaluationAfter three months after surgery, the patient has attended the phonoaudiological session to adapt the process and be guided how to handle and take care of BAHA.
Open-field audiometry with pillar-coupled BAHA, external test and use of telephone were performed.
Pre-surgical pure-tone threshold audiometry - Better bone conduction in the left ear, side preferable to use BAHA, according to the patient.Figure 2. Flap repositioning by drilling its central area to exteriorize the external implant area.Figura 5.
Abutment-coupled BAHA processor.DISCUSSION OF RESULTSIn the cases of chronic otitis externa and open mastoid cavity, for occluding MAE, using ISAA mold can induce or worsen the infectious feature, leading to continual otorrhea (7). This advantage was observed in this case, mainly in 4,000-Hz frequency, where there was a 15-dBNA difference when using BAHA in comparison with ISAA. Additionally, an improvement occurred when distinguishing words, being 92% of right answers with ISAA and 100% of right answers with BAHA. In our evaluation, we observed it did not occur only in the 500-Hz frequency, we had a worse 10 dBNA threshold with implant-coupled BAHA. In the 1,000 and 3,000 Hz frequencies, there was no difference between them both, and at 2,000 and 4,000 Hz, our findings agree with the cited authors, as we observed better 5 dBNA thresholds with pillar-coupled BAHA, in comparison with the arch-coupled tester. Maybe we could have better thresholds with an implanted BAHA, if the adjustments used in the processor were the same as those in the pre-surgical evaluation, however it did not occur because the patient was discomforted when we adjusted the processor at a maximum gain, and we accordingly chose a lower gain adjustment, which would give her more comfort in the post-surgical evaluation.If we should analyze the average between the frequencies 50, 1,000, 2,000 and 3,000 Hz, the pre-surgical and post-surgical thresholds are the same, what makes us trust the pre-surgical evaluation as a preview of the result that shall be achieved in the post-surgical period. It has been observed that the airway thresholds on open-field audiometry with BAHA have exceeded the patient's best pre-surgical bone conduction, what LUSTIG and colleagues (5) refer to as 'overclosure'. Since it is a breakthrough in the Brazilian practice, a few difficulties were faced regarding this patient's audiological evaluation, for there is not a standardization of the methodology to be used. We suggest the exchange of experiences between the centers providing this service, so that by standardizing the audiological evaluation, we can compare results and pursue a better quality of service. The reliability in the pre-surgical audiological evaluation as a preview of the post-surgical result, the outstanding audiological results achieved, as well as the patient's high degree of satisfaction provided by BAHA system, turns it into an advantageous option to rehabilitate conductive and mixed hearing losses when ISAA is not possible to be used.BIBLIOGRAPHICAL REFERENCES1.
Bone Anchored Hearing Aids in patients with sensorioneural hearing loss and persistrent otitis externa.
A comparison of the audiometric performance of bone anchored hearing aids and air conduction hearing aids. Lustig LR, Arts HA, Brackmann DE, Francis HF, Molony T, Megerian CA, Moore GF, Moore KM, Morrow T, Potsic W, Rubenstein JT, Srireddy S, Syms CA 3rd, Takahashi G, Vernick D, Wackym PA, Niparko JK. Assistant Professor at UFPR's Department of Ophthalmology-Otorhinolaryngology (OFT-ORL).3 Master in Surgical Clinics - UFPR's.
Predecessor in Otology in Residence at Santa Casa de Curitiba's ORL and President of Fisch Foundation in Brazil.5 Post-Graduation Coordinator in Otorhynolaryngology at Pequeno Principe Hospital.
Post-Graduation Coordinator at Otorhinopediatrics at Pequeno Principe Hospital.6 Specialized in Otorhinolaryngology from the Brazilian Society of Otorhinolaryngology and Cervicofacial Surgery.
Otorhinolaryngologist Doctor.7 Master in Otorhinolaryngology from Federal University of Sao Paulo. Predecessor in Medical Residence in Otorhynolaryngology at Evangelical Hospital of Curitiba.8 Doctor in Environment and Urban Development.

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