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Key words: adult, audiology, auditory dysfunction, blast injuries, brain injuries, hearing, hearing loss, mTBI, tinnitus, Veterans, wounds and injuries. A dramatic increase in the use of explosive devices in Operation Enduring Freedom and Operation Iraqi Freedom is responsible for a significant shift in the types of injuries experienced among soldiers.
In conjunction with the increase in mild TBI, blast-related injuries also result in auditory and vestibular issues. Ear and hearing injuries may significantly affect the daily lives of soldiers, both in and out of combat.
A retrospective chart review of 250 Veterans with mild TBI was performed at a single, midwestern Department of Veterans Affairs (VA) medical center. Veterans with mild TBI and hearing problems were identified using the VA’s comprehensive second-level TBI evaluation.
Detailed data were collected from electronic medical records by using a data collection tool developed for this study. At the time of the comprehensive second-level evaluation, the average age of the 240 Veterans was 27.9, with 73 percent of the population under the age of 30. Table 1.Demographics for patients overall (N = 240) and for those receiving hearing examination (n = 37).
More than half the cohort, or 64.2 percent (n = 154), reported at least one blast exposure, 106 of whom were injured solely from blast injuries. CAPD = central auditory processing disorder, DPOAE = distortion product otoacoustic emissions.
Of the 37 Veterans who had audiology clinic visits, hearing loss occurred in varying degrees (Table 4).
Of particular interest, 50.7 percent (n = 38) of Veterans who were referred did not attend their audiology clinic appointment.
Unexpectedly, Veterans who did attend their audiology appointment received about 25 percent more referrals at the comprehensive second-level examination than those who did not attend.
To better assist patients, physicians need to be aware of the services that are provided by audiologists; otherwise, referrals will not be made. The use of additional testing, such as CAPD testing that helps to identify CAP deficits, allows for patient-specific management [22]. When hearing loss occurs, the VA offers premium amplification choices and has many assistive listening devices available to suit nearly all hearing impaired Veterans.
When people think about hearing loss, they think about the effect it has on communications and relationships. When we think about being aware of our surroundings to keep our families and ourselves safe, we often think of being on the lookout for any dangers. Hearing Loss Affects Your SafetyWhen you are crossing a street or walking across a parking lot, it’s not just the sight of other cars that you are aware of, but also the sound. Hearing Loss Leads To AccidentsWhen your hearing is compromised, your safety, and the safety of your loved ones, is compromised because you can’t hear many of these sounds.
Hearing Loss and Smoke DetectorsEar and Hearing published a study in February, 2009 which found that the sound made by the standard smoke detectors used by most people (3000 to 4000 Hz) was not sufficient to wake a person with hearing loss. Test Your Hearing, Save Your LifeThe study tested multiple types of smoke detectors to wake people with hearing loss, and it found that the best type of detector for those with mild to moderate hearing loss was one with a low-frequency (520 Hz) was the best at waking them from sleep. MARYLAND: Montgomery County, Bethesda, Rockville, Gaithersburg, Germantown, Olney, Kensington, Potomac, Chevy Chase, and Silver Spring. Key words: auditory impairment, dual sensory impairment, hearing impairment, hearing loss, legal blindness, prevalence, rehabilitation, veterans, vision impairment, vision loss. Hearing and vision impairments are common chronic conditions in older adults that have been studied extensively as single sensory disabilities. Although the evidence is not conclusive, some literature suggests that DSI is more debilitating than a single sensory impairment, whereas other literature suggests that the vision impairment component of DSI is the sensory impairment that has the main impact on the individual.
As a result of the foreseeable growing population of older veterans, VHA is increasingly interested in DSI, as evidenced by the recent conference hosted by the Department of Veterans Affairs (VA) Rehabilitation Research and Development (RR&D) Center of Excellence National Center for Rehabilitative Auditory Research [15]. DSI can be modeled schematically as a two-channel continuum with an auditory channel and a vision channel.
The three cases of individuals with DSI (A, B, and C in Figure 1) illustrate the complexities of combining both hearing impairment and vision impairment in a single individual.
Hearing and vision impairment definitions, overall dual sensory impairment prevalence rates, and ages studied from several published studies.
In the prevalence studies summarized in Table 1, the degree of each single sensory impairment used to establish the DSI definitions also varied.
The different prevalence rates and the mixed evidence associated with the impact of DSI demonstrate that DSI is multifaceted and complex.
For years, hearing impairment typically has been defined by the unaided pure tone average (PTA) of the air-conduction thresholds at 500, 1,000, and 2,000 Hz. The present study estimated the prevalence of DSI in a population of veterans receiving healthcare from the VA and described their clinical hearing and visual characteristics. To estimate the prevalence of DSI in our veteran sample, we formulated an operational definition of DSI by using previously described categories of each sensory impairment. A retrospective chart review was completed to obtain data on veterans who sought treatment in both the optometry and audiology outpatient clinics at the VA medical center in Mountain Home, Tennessee, between June 1, 2004, and May 31, 2005. The following data were obtained from the medical charts to determine the prevalence and clinical characteristic of veterans with DSI: (1) age at the time of the visit, (2) best-corrected distance visual acuity in the better eye, (3) etiology of the vision impairment, (4) pure tone, air-conduction thresholds from 250 to 8,000 Hz in the better ear, (5) word-recognition performance in quiet in the better ear, and (6) hearing aid possession. Audiologists and optometrists collected the clinical data obtained from the medical charts. We calculated the prevalence data to estimate the proportion of veterans with hearing impairment alone, with vision impairment alone, and with DSI for each age group.
The overall prevalence collapsed across age groups, termed Poverall, of the sensory impairments and of DSI also was calculated. The mean pure tone, air-conduction thresholds in the better ear for each age group are listed in Table 2, along with the mean values for the traditional PTA and the word-recognition score for the better ear.
Mean ± standard deviation pure tone thresholds, pure tone average (PTA) in decibels hearing level (ANSI, 2004), and word-recognition score (WRS) in percent correct are listed for four age groups. Degree of hearing impairment (decibels hearing level; ANSI, 2004) displayed as % (95% confidence interval) for participants in four age groups. Data related to best-corrected hearing thresholds were unavailable; however, the number of participants who possessed hearing aids was available and is listed in Table 4 for each hearing impairment category.
Number of participants with hearing aids (HAs) in each hearing impairment category collapsed across all age groups. Normal hearing sensitivity is depicted by the shaded region in Figure 2 with thresholds <25 dB HL at each frequency.
Because the traditional PTA was misleading in characterizing hearing impairment, we reclassified the pure tone data by using the HFPTA of the thresholds at 1,000, 2,000, and 4,000 Hz.
Mean ± standard deviation pure tone thresholds, pure tone average (PTA) (500, 1,000, 2,000 Hz), and high-frequency PTA (HFPTA) (1,000, 2,000, 4,000 Hz) in decibels hearing level, and word-recognition score (WRS) in percent correct are listed for six categories of hearing impairment as determined by traditional PTA and HFPTA. This presentation will examine the effects of hearing preservation for cochlear implant outcomes, by a review of recent key research articles on the topic. This article discusses issues surrounding hearing preservation with cochlear implantation surgery. This article discusses new research regarding newest applications of implantable hearing technology that combines electric and acoustic stimulation (EAS) in the same ear via hearing preservation using a conversational 20-question format.
This course will review pertinent journal articles on the topic of hearing loss and the risk for cognitive impairment, with implications for audiology clinical practice.
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Key words: compensation, hearing disorders, loudness matching, loudness perception, malingering, pitch matching, pitch perception, rehabilitation, reliability of results, tinnitus, tinnitus diagnosis.
Abbreviations: ANOVA = analysis of variance, HL = hearing level, LM = loudness match, PM = pitch match, PVAMC = Portland VA Medical Center, SD = standard deviation, SL = sensation level, SPL = sound pressure level, TES = Tinnitus Evaluation System, VA = Department of Veterans Affairs, VHA = Veterans Health Administration. Chronic tinnitus is the persistent sensation of hearing a sound that exists only inside the head.
Special audiological tests are effective in detecting deliberate exaggeration of hearing loss [10-11], but no documented test exists that is capable of detecting the presence or absence of tinnitus. Any type of audiometric test for tinnitus diagnosis may rely at least partly upon the demonstration of response reliability. We completed a pilot study to investigate the potential for LM functions to detect differences between 12 subjects with tinnitus versus 12 subjects without tinnitus [16]. Study inclusion criteria were intended to identify two groups of individuals: those who experienced chronic tinnitus (tinnitus subjects) and those who did not experience tinnitus (nontinnitus subjects). Candidates who passed telephone screening were invited to make an appointment to determine whether they met the audiometric criteria for study entry. After signing informed consent, subjects had their hearing evaluated manually by an audiologist (conventional hearing threshold evaluation that obtained results in decibel hearing level [HL]).
Following the conventional hearing threshold evalua-tion, subjects completed a baseline questionnaire that asked their age, sex, veteran status, and tinnitus status.
To ensure that the tinnitus and nontinnitus groups exhibited approximately the same degree of hearing loss, we matched subjects by hearing loss with respect to both their low (0.5, 1, 2 kHz) and high (3, 4, 6 kHz) frequency average hearing thresholds (in decibel HL).
Audiometric testing was conducted in a double-walled sound-attenuated suite (Acoustic Systems Model RE-245S, ETS Lindgren; Cedar Park, Texas). The TES Module also serves as a control device (user interface), enabling patients to easily control stimulus parameters and respond to tests. All-new programming was required to support the new platform and to create new testing capabilities. All testing data are stored via connectivity to a Microsoft Access database (Microsoft Corp; Redmond, Washington). The management interface is used to manage patient information, create and configure test session templates (preconfigured test scenarios), launch test sessions, and report on test results.
As a single integrated device with earphones (ER-4B, Etymotic Research, Inc; Elk Grove Village, Illinois) permanently attached, the TES Module is calibrated independently in the laboratory and then sent out to a testing site.
Prior to conducting the tinnitus matching tests, we carefully instructed the nontinnitus subjects to ensure that they responded to all testing as if they were attempting to prove that they did in fact experience chronic tinnitus.
Tinnitus matching requires patients to make a clear distinction between the tinnitus perception and the matching tones. For the nontinnitus subjects, if one ear had better hearing sensitivity, then that ear was selected as the stimulus ear. Following the general instructions, we provided specific instructions for obtaining hearing thresholds (in decibel sound pressure level [SPL]) with the TES.
After a threshold was obtained at 1 kHz, we then obtained an LM (in decibel SPL) at the same frequency. This sequence of testing (average hearing threshold followed by average LM) was then repeated at the next higher test frequency (1,260 Hz) followed by the remainder of the test frequencies in ascending order.
When hearing thresholds and tinnitus LMs had been obtained at all 13 test frequencies, on-screen instructions were shown to explain the PM task.
The previously described testing was conducted during two sessions that were at least 3 days apart. Within- and between-session correlations were computed for the dB SPL LMs and compared between the tinnitus and nontinnitus subjects.
Within-subject PM variability (five observations for each of the two tests within the two test sessions) was pooled within and across subjects and compared between the tinnitus and nontinnitus subjects on the premise that subjects with tinnitus would exhibit less variability in pitch matching. Demographic and audiometric characteristics of tinnitus subjects (n = 36) and nontinnitus subjects (n = 36).
Tables 2 and 3 show the LM means (and standard errors) in decibel SPL and decibel SL, respectively, for the sessions and runs in the tinnitus and nontinnitus subjects for 1 to 16 kHz.
Across-subject mean loudness matches (dB sound pressure level) for tinnitus subjects (n = 36) and nontinnitus subjects (n = 36). Across-subject mean loudness matches (decibel sensation level) for tinnitus subjects (n = 36) and nontinnitus subjects (n = 36). Table 4 shows the within-session LM correlations (between two test runs on the same day) for the tinnitus and nontinnitus subjects for 1,000 to 12,700 Hz.
Within-session loudness-match correlations (decibel sound pressure level) for tinnitus subjects (n = 36) and nontinnitus subjects (n = 36). Telehealth provides Veterans access to health care that is timely, more convenient and easier to access through the use of new health care technology including video conferencing and health monitoring devices that can connect patients to their health care team. Telehealth uses video conferencing which provides a patient a real-time interactive medical visit with their provider using a computer screen; store and forward which allows patient information and diagnostic images to be forwarded to another provider and home care which provides a Veteran with a chronic disease to be monitored at home using a variety of home health care technologies.
Because the human ear is designed to be sensitive to changes in pressure, it is the most susceptible organ to damage from the pressure created by a blast wave [6].
Permanent hearing loss has been reported to contribute to psychosocial and physical health problems, such as depression, decreased social and emotional function, personal relationships, and decreased cognitive function [9-11].
Individuals with a confirmed diagnosis of mild TBI between June 15, 2007, and July 15, 2009, were identified by local physicians based on TBI reports to the Veterans Health Administration (VHA) Support Service Center and considered for inclusion. Veterans are referred for a comprehensive second-level evaluation after receiving an initial positive mild TBI screening. Information was extracted from the comprehensive second-level TBI evaluation and from subsequent referrals to audiology (including all audiology follow-up appointments). However, the average NSI hearing difficulty score did not differ statistically among these groups. In our study, 87 percent of Veterans with mild TBI reported some level of hearing difficulty while more than 64 percent of Veterans reported at least a moderate level of hearing difficulty.
In support of this, our study found that a significantly greater percentage of men were involved in blast-related mild TBI. One possibility for low attendance at audiology appointments is the stigma attached to both hearing loss and hearing aids. This result was not consistent with our hypothesis that patients with many health concerns may prioritize their visits.
We were unable to find any previous studies that examined the mild TBI population; however, our results are similar to previous studies that found TBI patients (TBI injury severity unreported) to have decreased hearing sensitivity on audiograms [7,20]. Blast-related auditory deficits can occur throughout the auditory system, from the outer ear to the cortex, which can result in a variety of complex symptoms [23]. Once the nature and severity of specific deficits are identified, appropriate guidance for management can be offered. In the current study, 20 percent of the Veterans with hearing loss exhibited a mild sensorineural hearing loss. Many options for tinnitus management are currently available, including counseling, sound generators, hearing aids, and other devices.
But people don’t realize the extent that they use their hearing to keep themselves and their loved ones safe.
People may call out to you saying, “Look out!” or “Heads up!” to alert you to things going on around you. Even the simple honk of a horn to let you know that a car is approaching could be missed, resulting in an unnecessary collision. For the millions of people who are walking around asking people to speak up, and turning the volume up on the television – without getting their hearing checked and, if necessary, corrected – this could be a matter of life and death. People who are hard-of-hearing are 7 times more likely to be woken by a low-frequency alarm than a standard high-frequency alarm. This study determined the prevalence and clinical characteristics of DSI in a veteran population receiving healthcare from the Department of Veterans Affairs (VA). Dual sensory impairment (DSI), or concurrent hearing and vision impairments, also occurs in older adults but is less well understood.
The consensus from this conference was that scientific evidence about DSI is lacking in many areas, including but not limited to diagnostics, rehabilitation, psychosocial implications, and cognitive functioning. In this DSI model, which is illustrated in Figure 1, channel one is the auditory channel (top) and channel two is the vision channel (bottom).
Person A has a mild hearing impairment combined with a severe vision impairment, person B has moderate impairments in both senses, and person C has a severe hearing impairment and a mild vision impairment. Another complication is that the population with DSI is largely older, adding further heterogeneity. Historically, this three-frequency PTA has been recognized as highly correlated with the auditory threshold for speech stimuli [18-19].
To accomplish this goal, we formulated an operational definition based on standardized definitions of the single sensory impairments and on available objective data.


Because patients seen in these two clinics had standardized clinical data on their vision and hearing status in their medical charts, a query from a computerized hospital database generated a list of all unique patients seen in these two clinics (N = 1,472). This study was approved by the local institutional review board and the local research and development committee before its initiation.
The prevalence rate is a single value calculated from a sample that provides the best estimation of the population value [34].
Additionally, the prevalences and CIs for the four age groups were determined for each sensory impairment and for DSI.
As expected with this sample of older participants, the mean audiogram and PTA illustrate a high-frequency hearing impairment for each age group that increases with increasing age. Recall that the degree of hearing impairment, which was defined by the PTA of thresholds at 500, 1,000, and 2,000 Hz in the better ear, is categorized as normal, mild, moderate, moderate-severe, severe, and profound [20].
Hearing impairment category was based on pure tone average at 500, 1,000, and 2,000 Hz in better ear.
Consider first only the data in the two columns associated with the 500, 1,000, and 2,000 Hz PTA (the data in the two columns associated with the HFPTA will be considered in a subsequent section). Impairment category based on traditional pure tone average (PTA) (500, 1,000, 2,000 Hz) and high-frequency PTA (HFPTA) (1,000, 2,000, 4,000 Hz) in decibels hearing level. The remaining pure tone thresholds in Figure 2 represent the mean hearing sensitivity of the participants for each of the five remaining categories of hearing impairment.
The HFPTA gives more weight to the higher frequencies and, as several studies suggest, is a better indicator of hearing function than the traditional PTA [21-23,38]. Topics such as how postoperative hearing may affect outcome, programming of devices, working with patients with potential dead regions, bilateral EAS, who to refer and more are discussed.
Ascertaining the presence of tinnitus in individuals who claim tinnitus for compensation purposes is very difficult and increasingly becoming a problem. That is, the validity of any response depends upon its reproducibility; thus, response reliabili-ty is expected to be an important component of any test developed to assess the presence of tinnitus for claims purposes. Testing was done using a computer-automated program that had recently been modified to allow more patient control of test stimuli (through the use of a handheld control pad device). Essentially the same protocol was used, except this study used a computer-automated testing system that was completely redesigned for improved functionality. Subjects were recruited by a local newspaper advertisement, by flyers posted around the Portland Department of Veterans Affairs (VA) Medical Center (PVAMC), and from other auditory investigations that were being conducted at the National Center for Rehabilitative Auditory Research.
As part of the informed consent process at the start of the appointment, all candidates were told that the study was being conducted to determine the effectiveness of a new technique for measuring various aspects of tinnitus. Subjects with tinnitus completed a written tinnitus questionnaire in which they reported the length of time they had had tinnitus, whether their tinnitus was tonal or nontonal, and whether their tinnitus was binaural or unilateral. Collection of data from human subjects was approved by the PVAMC institutional review board committee. We used the latest version of our computer-automated testing system that has undergone several revisions over a period of 10 years [16-19]. This was accomplished by constructing the TES Module enclosure to also serve as a handheld control pad for patients to control the auditory stimuli.
They were instructed to "Imagine a sound in your head or ears and try to match that sound consistently to the sounds that you will hear through earphones. This is done most easily if the stimulus in one ear is compared to the tinnitus in the contralateral ear [21-22].
Before testing began, the program presented a series of screens describing the general testing procedures, followed by specific instructions for hearing threshold testing. Each test frequency was presented at the output level previously selected as a tinnitus LM during the threshold and LM testing. Two test runs (thresholds, loudness matching, and pitch matching) were conducted within each session. A repeated measures analysis of variance (ANOVA) was used to assess the difference in LMs (dB SPL and dB SL) between the tinnitus and nontinnitus subjects across the four tests.
This analysis was motivated by the expectation that the correlations between the two tests within a session and the correlations between sessions would be greater for the tinnitus subjects than for the nontinnitus subjects and would represent more consistent responses for the tinnitus subjects. With one exception (10,080 Hz), mean SPL LMs were consistently greater for nontinnitus than for tinnitus subjects. Results of a comprehensive second-level mild TBI evaluation and subsequent visits to audiology were evaluated.
Head and neck injuries have increased in proportion relative to previous conflicts, and 78 percent of these injuries were consequential to explosions caused by devices such as improvised explosive devices (IEDs), land mines, mortars, bombs, or grenades [2]. Previous studies have found that 62 percent of blast-related TBI patients admitted after the onset of Operation Iraqi Freedom complained of hearing loss and 38 percent reported tinnitus [7].
While studies have examined the link between TBI and hearing loss, the mild TBI population specifically has not been widely studied. The initial screening is administered by a healthcare provider and consists of four questions regarding exposure to a mild TBI event(s), immediate symptoms, and current symptoms.
Data elements collected from the medical record of audiology encounters included family history, demographics, hearing complaints, number of visits, noise exposure, examinations received, diagnoses, and treatment.
A total of 75 Veterans received an audiology referral, with 37 presenting for an examination (Figure). The average reported NSI hearing difficulty and percentage reporting hearing difficulty did not differ by degree of blast exposure (primary, secondary, tertiary) among patients incurring a blast-only mild TBI (n = 106) or by number of visits to audiology (Table 2). White Veterans were also found to report significantly greater hearing difficulty and increased percentages of hearing complaints than non-white Veterans for unknown reasons. Previous studies have found that perceived stigma has an influence on decision-making processes that occur during initial acceptance of hearing loss, testing, and use of hearing aids [18]. Instead, some of these patients may be more likely to visit all their appointments because they are already spending a greater amount of time at the healthcare facility.
Pure sensorineural hearing loss was found to be the most common type of hearing loss among Veterans, as in previous studies [7]. Yet, the high prevalence of testing beyond the audiogram in our cohort found abnormalities in a significant number of these Veterans.
Audiologists can offer a variety of treatment and management options for audiological and vestibular dysfunction. Education and counseling on deficit-specific compensatory and communication strategies should also be offered. Open-fit devices are ideal for mild to moderate high frequency hearing losses and are appealing to a younger population because of cosmetics and Bluetooth compatibility. The method currently endorsed by the VA is progressive tinnitus management, developed at the National Center for Rehabilitative Auditory Research, which is located at the Portland VA Medical Center in Portland, Oregon [25-26]. When walking down the street or driving in your car, a siren will alert you to an emergency vehicle that is approaching, and a telephone call or fire alarm could save your life by waking you in the middle of the night in case of an emergency. And though an accident like this may not be life threatening, it could still lead to a lot of avoidable hassle, confusion and expense. But unless you know you have hearing loss, how will you know which smoke detector will save your life? A retrospective review was conducted on 400 charts randomly selected from a database of 1,472 unique veterans enrolled in the audiology and optometry outpatient clinics during a 1-year period. Older adults with DSI also are more likely than individuals with single sensory impairments to exhibit depressive symptoms [8-9].
Interest in DSI also is evidenced by the recent addition of a DSI diagnosis code, V49.85, effective October 1, 2007, to the International Classification of Diseases-9th Revision, Clinical Modification (ICD-9-CM) manual. The problems with defining DSI are exacerbated by the difficulties involved in integrating the single sensory impairments into a unified definition of DSI.
Table 1 summarizes the hearing and vision impairment definitions and the overall DSI prevalence rate from the just-mentioned studies. Surveillance for sensory impairment, activity limitation, and health-related quality of life among older adults-United States, 1993-1997.
Concurrent visual and hearing impairment and risk of mortality: The National Health Interview Survey. Association between vision and hearing impairments and their combined effects on quality of life. Visual and hearing impairment in elderly patients hospitalized for rehabilitation following hip fracture. Combined hearing and visual impairment and depression in a population aged 75 years and older. The complexity associated with defining and understanding DSI, however, is determined primarily by the definitions used to define the respective single sensory impairments.
Perhaps because of this relation between pure tone and speech thresholds, the three-frequency PTA has become the gold standard by which hearing impairment is described.
Although the goal of the present study was not to develop a standard definition of DSI via an interactive process, the operational definition used represents a starting place in the process of estimating the prevalence of DSI in a veteran sample.
The pure tone thresholds were measured with use of the modified Hughson-Westlake procedure [32]. Table 3 lists the percentage of participants and 95% CIs for each hearing impairment category by age group. The data associated with the traditional PTA show that the majority of the 400 participants had hearing aids (n = 357, 89%).
The pure tone configuration of hearing impairment is high frequency in nature, which is typical with age-related hearing impairment. Table 5 lists the age, pure tone thresholds, traditional PTA, HFPTA, and word-recognition scores for each hearing impairment category that was based on the traditional PTA (top portion) and on the HFPTA (bottom portion). The Vanderbilt Audiology Journal Club is presented four times a year on AudiologyOnline, and this is our fourth year.
Just since this article has been published, there are some very recent developments in EAS research at the University of Iowa. This study examined the potential to observe differences in loudness and pitch matches between individuals who experience tinnitus versus those who do not. Epidemiology studies reveal that between 10 and 15 percent of all adults experience chronic tinnitus [2-7]. Because so many parameters of tinnitus are capable of being measured, any of those parameters could potentially be used for repeated testing to evaluate a tinnitus claim. Candidates with tinnitus were told that they had been invited to participate in the study because they had tinnitus that was constant and therefore could be measured. The system enabled direct patient control of certain stimulus parameters during testing to make testing more efficient. For most of the tests, the computer presents a starting sound and the patient turns a dial on a peripheral hardware device (TES Module) to control output level, frequency, or bandwidth of the sound. The peripheral hardware device (TES Module) was developed to enable specialized auditory tests. The TES control pad includes a continuous rotating encoder dial that provides a single-point adjustment of a parameter of interest (programmable and determined according to the particular test or test phase).
Information about test parameters is stored in an Access database, which also determines which tests to run for each session and provides parameters to control the hardware behavior. The TES uses decibel SPL because normative hearing threshold levels have not been established for frequencies above 8 kHz and because the earphones used with the TES have not been documented for conventional audiometric testing of hearing sensitivity.) Testing started when a hearing threshold was obtained at 1 kHz. It is critical for them to clearly understand the difference between these two psychological attributes of sound for us to obtain well-informed, and therefore accurate, matching measurements [21,23]. These differences were significant at frequencies of 2 kHz and below and diminished in the higher frequencies. The nontinnitus group had a similar distribution of correlations, except that half the frequencies had correlations that were below 0.90. We found the vast majority (87%) of Veterans reported some level of hearing disturbance and those involved in blast injuries reported a higher incidence of hearing disturbance than those with other injury etiologies. Mild traumatic brain injury (TBI) can result from these types of blast-related injuries [3], and their prevalence in modern combat has increased dramatically.
Hearing problems were also found to be present in TBI patients who had not experienced a blast, with 44 percent complaining of hearing loss and 18 percent reporting tinnitus [7]. A previous study of 36 American adults with a history of mild TBI found that when compared with the normative values, these individuals performed significantly worse on the Dichotic Word Listening Task [12].
Further information regarding the VHA’s mild TBI screening process is described by Donnelly et al. Degree of hearing loss was measured as decibels hearing loss (dBHL) on an audiogram, where any threshold above 25 dBHL at any frequency was considered a hearing loss. No significant associations were found between age, marital status, education, or employment and reported hearing difficulty disturbance.
Additionally, this stigma is not exclusive to men and is perceived by younger women as well [19].
While previous studies have found that tympanic membrane perforation is the most common ear-related blast injury, we found no tympanic membrane perforations in this mild TBI population [6,21]. DPOAE testing within our sample also produced a large group diagnosed with subclinical hearing loss.
Additionally, audiologists must be aware that although a patient who complains of hearing loss in this population may present a normal audiogram, further testing may result in identifying auditory dysfunction.
Unfortunately, the results of a 2007 questionnaire given to randomly selected members of the American Academy of Audiology found that audiologists have very limited knowledge of this additional testing [24]. For those with more severe atypical losses, many VA centers offer cochlear implants and bone-anchored hearing devices.
This is a hierarchal program designed to be maximally efficient and address the needs of all tinnitus patients [27]. Clinicians in these disciplines are aware of the importance of auditory and vision function for activities of daily living and communication; however, joint rehabilitation programs for individuals with DSI are few. One study reported that hearing impairment did not increase depressive symptoms in participants with vision impairment [10]. The area between the dashed vertical lines represents a segment of the continuum that includes individuals who retain some degree of sensory function with both senses or individuals who potentially have DSI, which is the most likely case of veterans seeking services from VHA. For example, the functional and psychosocial impacts of a moderate impairment in each sense in person B are unknown but may be considered less than additive, additive, or in some instances, compounded. The top portion of the table summarizes prevalence rates obtained from studies that used self-report techniques, which are Likert-type response scales, to define hearing and vision impairments.
Within VHA, the degree of hearing impairment for each ear is described with the three-frequency PTA [20].
The final goal of this project was to generate a discussion about DSI within VHA so that appropriate preparations could be made to identify and better manage the foreseeable growing veteran population affected by DSI [30]. Vision impairment is categorized based on the better eye, whereas hearing impairment is defined for each ear. This interval provides a range of values in which the population proportion of veterans with the sensory impairments in each age group falls with 95 percent certainty. The numbers in the parentheses to the left of each function indicate the number of participants who were defined as having the corresponding category of hearing impairment. As age increases, pure tone thresholds increase and word-recognition scores decrease, which are expected relations among these three variables. In the last three months, they have been given FDA approval to conduct two feasibility trials to study preservation of hearing with Nucleus hybrid cochlear implants in those with severe hearing loss and will be implanting children between the ages of 5 and 15 years of age. Gifford will review recent research journal articles regarding cochlear implantation in children under 12 months of age, and Dr.
This study follows a previous pilot study we completed that included 12 subjects with and 12 subjects without tinnitus. The basis for awarding a tinnitus disability is that the tinnitus is (1) at least recurrent (intermittent) and (2) related to military service [8-9]. Jacobson et al., however, reported results from an experiment that showed test-retest reliability of LMs to be similar between individuals with and those without tinnitus [13]. The key is to determine which test, or combination of tests, will be most effective in accomplishing this purpose.
No other screening criteria were applied because the intent was to simulate real-life individuals who might be attempting to claim the presence of tinnitus. Candidates who did not have tinnitus were told that they could represent individuals who might want to claim tinnitus when they do not actually experience it. The present fifth-generation system is referred to as the Tinnitus Evaluation System (TES). The TES Module brings various capabilities together in one small device that connects to a personal computer.


In addition, four push buttons are included on the TES control pad to facilitate patient responses. Patient responses made with the TES Module encoder dial and response buttons are recorded to the same database from which the test session parameters are read. The management interface presents configuration options through the test session configuration dialogs, in which tests and their parameters can be preset into session templates to allow an operator to easily run many patients through the same battery of tests. A testing interface program checks the device's calibration time stamp and compares it with the one already stored in the database.
Subjects determined on their own how they would respond in a consistent manner in spite of their nonexistent tinnitus. They were queried to ensure that they understood that they would be matching tones in one ear to an imagined tinnitus in the contralateral ear. To ensure that the subjects understood pitch and loudness, we included a series of instruction screens that explained the concepts prior to performing tinnitus loudness matching. Tinnitus and nontinnitus subjects were similar in age, sex, veteran status, and mean hearing thresholds (Table 1). SL LMs were essentially equal between the tinnitus and nontinnitus subjects across the frequencies. An estimated 20 percent, or 300,000 of the 1.6 million soldiers deployed to Iraq and Afghanistan, have mild TBI [4].
Additionally, more than one-third of individuals with a mild TBI were found to fail at least one condition of a dichotic word recall task [13]. Because of the complicated medical needs of those with mild TBI, the significant percentage of Veterans experiencing hearing difficulties may not have received a referral because more pressing issues presented at the time of their comprehensive second-level examination. Efforts to reduce the stigma surrounding hearing loss may increase the number of Veterans who return for follow-up visits after the comprehensive evaluation.
This finding suggests that blasts and other mild TBI etiologies may cause damage that is not detected by an audiogram and strongly indicates that audiological testing should not stop after the audiogram. Hence, it is not surprising that many VA audiology clinics are not providing these services [22]. Counseling on hearing conservation and preservation as well as various auditory training exercises may be offered.
For the audiologist, individuals with vision impairment pose unique challenges in the audiological rehabilitative process [1]. In comparison with a single sensory impairment, DSI is associated with lower health-related quality of life [11] and increased risk of mortality [12]. Current estimates predict that between 2002 and 2020, the 85+ veteran population will increase by 58 percent and the 90+ veteran population will increase by 235 percent [14].
The main issue is that the functional and psychosocial impacts of DSI created by the combination of various degrees of single sensory impairment are unknown. For person B, therefore, the degree of DSI may be moderate or worse, but functionally, the combined effect of the sensory impairments is unknown. Some definitions of hearing impairment were based on thresholds obtained without hearing aids being worn [11], whereas other definitions were based on thresholds obtained with hearing aids being worn when available [17]. This standard measurement determines, for example, eligibility for rehabilitative programs (such as VHA Blind Rehabilitation Center) or Social Security disability benefits [25-26]. For consistency with the vision definitions and for practical reasons, the hearing impairment component of DSI is defined only for the ear with the better pure tone thresholds.
This number may seem alarmingly high for individuals with normal hearing; however, recall that hearing impairment was based on the traditional PTA of 500, 1,000, and 2,000 Hz, which emphasizes the low and mid frequencies.
Based on the traditional PTA, these numbers suggest that the majority of participants had mild or moderate hearing impairments and a few participants had severe or profound hearing impairments. For each hearing-impairment category, the HFPTA is on average 12 dB poorer than the traditional PTA. This new information about the Iowa-sponsored feasibility trials contradicts two points within questions 15 to 18 of the article: Adults with greater hearing impairment than those in the clinical trial described in the article are eligible for implantation with a Nucleus Hybrid L24 implant through the Iowa-sponsored feasibility trial, and the S12 and L24 devices are available to children through the feasibility study at the University of Iowa.
The number of tinnitus disability claims has increased dramatically during this decade (Figure 1). The only difference was that individuals without tinnitus generally provided LMs at higher levels. Tinnitus loudness matching has been shown to be very reliable with tinnitus patients, but the Jacobson et al. Reliability of the LMs was at least as good for the nontinnitus group as for the tinnitus group, both within and across sessions. Any screening criteria other than the presence or absence of tinnitus might have introduced bias to the samples. These capabilities include signal genera-tion (pure tones and noise bands) and signal processing (mixing, switching, muting, attenuation, and headphone buffering). Testing sessions can then be launched by selecting a patient record and preconfigured template.
If newer calibration data are available, they are downloaded from the TES Module, saved in the database, and used in testing to provide calibrated stimulus levels. If the tinnitus was perceived to be symmetrical, then the stimulus ear was determined randomly. Subjects rotated the encoder dial to find the point of minimum audibility for the tone and then selected the threshold level by pressing the response button.
In session 2, the tinnitus subjects showed significantly greater correlations in 4 of the 12 frequencies. Individuals with mild TBI can present clinically with cognitive, physical, or behavioral problems [5]. Of these, Veterans who experienced blast-related injuries were found to have the highest rate of self-reporting both auditory and visual impairment [8]. The comprehensive TBI evaluation [14-15] is designed to identify the presence or absence of mild TBI and examines items such as demographics, injury etiology, number and degree of blasts exposed to, distance from blasts, and the Neurobehavioral Symptom Inventory (NSI) [16]. Previous studies have found that in such patients, ear and balance deficits are commonly overlooked [1].
Although the effect of hearing loss on the Veteran population is lesser known, its effects in the general population and the elderly are well documented. More training is needed for audiologists with regards to this type of testing, and more research is needed on CAP and management in the adult TBI population [22].
Auditory training may take several forms, including clinician-directed (Auditory Process Training), self-directed (Auditory Process Training 3), and computer-based (Listening and Communication Enhancement). Often hearing impairment is treated via small amplification devices such as hearing aids, auditory perception training, communication strategies training, and counseling. Interestingly, one report found that individuals with vision impairment also may have poorer hearing sensitivity than individuals without vision impairment, suggesting an underlying biological contribution to impairments with both senses [11].
Inevitably, DSI will have a growing impact on future health care trends in the Veterans Health Administration (VHA). The development of a standardized DSI definition is fundamental to a full understanding of the impact of DSI. The middle portion of the table summarizes two studies that used objective standard clinical results to classify the two sensory impairments. Although these PTAs have limitations in characterizing hearing impairment, we used this metric in the initial analysis of the study data as a starting point for the definition of hearing impairment. Typically, word recognition was evaluated at two levels 20 dB apart, with the lower level minimally at 60 dB HL.
A test of significance of difference in the prevalence across the age groups was performed with an omibus chi-square test [36]. Participants defined as having normal hearing could have a PTA <25 dB HL but have a high-frequency hearing impairment that warranted hearing aid intervention.
The effect of this 12 dB shift is reflected in the distribution of participants in the categories of hearing impairment. Results of this study revealed no significant differences between groups with regard to decibel sensation level (SL) loudness matches and within-session loudness-match reliability.
As of October 2008, 558,232 veterans had been awarded tinnitus service-connection disability.* Among veterans returning from the Iraq and Afghanistan wars, tinnitus is the most common service-connected disability (67,689 veterans in 2008).
In addition, pitch matches (PMs) were obtained from each subject, which involved subject selection of the frequency that most closely matched the pitch of the tinnitus from the different test frequencies.
The pure tone quality, output linearity, frequency accuracy, pulse characteristics, and signal cross talk of the TES Module conform to the American National Standards Institute specification for audiometers across the standard frequency range from 125 to 8,000 Hz [20]. The operator can override the template tests' default values of some parameters on a per-session basis.
Following the instructions, we presented the tone at a randomized output level above the level of the hearing threshold that had just been established. Nearly half (48.6%) of Veterans were diagnosed with conductive hearing loss, sensorineural hearing loss, or central auditory dysfunction. Individuals also often present with complaints of anxiety, depression, apathy, and mood swings [5]. The NSI consists of 22 TBI symptoms, including hearing difficulty, and asks patients to rate the degree to which the symptom disturbs them. In instances where otoacoustic emissions (OAEs) were performed, one of two methods was used.
An additional nine Veterans (23.7%) did not schedule or attend an appointment for unknown reasons. Because hearing loss increases with aging, these Veterans may also experience symptomatic hearing loss at younger ages than expected. The complexities encountered in defining DSI are discussed and suggestions are made for determining standardized definitions. A better understanding of the impact that DSI has on individuals is necessary to assist the rehabilitative process for older veterans.
One reason is that standardized definitions of the hearing and vision impairment components are not used to determine DSI. Finally, the bottom portion of the table summarizes two studies that combined objective and subjective clinical results to classify the impairments. Subsequently, we investigated a second PTA weighted more with high-frequency information as an alternative pure tone metric.
Distance visual acuity was measured with a projected Snellen chart with the best spectacle correction in place. To better understand why a high percentage of participants in the study had hearing aids, the mean audiogram for each hearing impairment category is illustrated in Figure 2. For example, when we used the traditional PTA, 139 participants were in the mild category; this number decreased to 65 participants when we used the HFPTA. As new advances are made in this exciting area of research and practice, we will try our best to keep you informed! Between-group differences revealed that the tinnitus subjects had (1) greater decibel sound pressure level loudness matches, (2) better between-session loudness-match reliability, (3) better pitch-match reliability, and (4) higher frequency pitch matches. These concerns have prompted our overall effort to develop tests that can help ensure that a tinnitus disability is accurately rated and that allow for reexamination whenever a need exists to verify the continued existence of tinnitus. These PMs were performed multiple times after loudness matching and the multiple PMs were averaged.
A special test template was devised to enable the device to be calibration-checked on-site at regular intervals. Diagnostic testing was performed with the Bio-logic Scout OAE device (Natus Medical Inc; San Carlos, California) from 750 to 8,000 Hz using Boys Town criteria (65 and 55 dB for level 1 and level 2, respectively).
These findings highlight the need for clinicians to pay particular attention to hearing complaints among mild TBI patients and for more comprehensive screening methods and proper referral methods to be developed. Conceivably, the Veteran population, with an active role both in the workplace and home life, may also experience a significant loss of quality of life because of unmanaged hearing loss.
More research is needed to determine the unique characteristics of individuals with DSI and their impact on VA resources.
Likewise, individuals with hearing impairment may produce unique challenges in low-vision and blind rehabilitation programs.
A second reason is that the various combinations of the two sensory impairments may affect individuals differently. In these final two studies, the vision impairment was classified based on standard clinical results, whereas the hearing impairment was defined based on substandard clinical measures or self-reported data.
This high-frequency PTA (HFPTA) included the thresholds at 1,000, 2,000, and 4,000 Hz and has been shown to have a stronger relationship to the understanding of speech signals presented in background noise than traditional PTA [21-23].
Notice that the participants defined as having normal hearing (filled circles) based on the traditional PTA had a moderate hearing impairment at 4,000 and 8,000 Hz, which are above the frequency range used with the PTA. These findings support the data from our pilot study with the exception that decibel SL loudness matches were greater for the tinnitus subjects in the pilot study.
The result of pitch matching was that the mean PMs for the tinnitus group were significantly higher in frequency than for the nontinnitus group. The reporting module of the management interface uses preformatted reports for presenting test results from the response database. A screening test was performed with the Bio-logic AuDX Pro (Natus Medical Inc), from 1,500 to 6,000 Hz. When we used the HFPTA, ~30 percent more participants were categorized with at least a moderate hearing impairment when compared with the prevalence rate of 41.6 percent when we used the traditional PTA. Tinnitus loudness and pitch matching may have some value in an overall battery of tests for evaluating tinnitus claims. All calibration procedures are conducted in a double-walled sound-attenuated suite (Acoustic Systems Model RE-245S). Strategies to address perceived stigma associated with hearing loss may increase attendance at follow-up visits. For diagnostic testing, results were deemed to be abnormal if an emission was absent at any or all frequencies. Furthermore, the effects of hearing loss are only further compounded by the effect of mild TBI on an individual’s health overall. Effective rehabilitation of individuals with DSI, therefore, may be hindered by the inability of the individual to use alternate sensory input in a compensatory fashion. These communication difficulties in participants defined as having normal hearing would be perceived as substantial enough to warrant hearing aid intervention.
Additionally, while only a third of audiograms were found to be abnormal, advanced testing resulted in a significant percentage of our population being diagnosed with auditory dysfunction. An absent response was defined as less than 6 dB emission to noise-floor ratio, as well as an emission amplitude greater than −10 dB, replicated.
Rehabilitation efforts also might be enhanced if more were known about the functional and psychosocial impact of DSI as compared with those of a single sensory impairment.
Classifying hearing impairment based on the traditional PTA is misleading and beyond the original intended use of the PTA. Tertiary blast injuries are the result of people being thrown into the ground or a fixed object. For acoustic reflex thresholds, findings were abnormal if they were unexpectedly absent or elevated based on pure tone findings. There is ongoing discussion about how much steroid should be administered preoperatively, postoperatively and perioperatively. Speech recognition tests were most often CID-W22 recorded word lists, but sometimes may have been performed with a monitored live voice. Descriptive statistics used include chi-square for dichotomous variables and analysis of variance for continuous variables.
Cochlear implantation with hearing preservation yields significant benefit for speech recognition in complex listening environments. Speech perception with combined electric-acoustic stimulation and bilateral cochlear implants in a multisource noise field. The role of preoperative, intratympanic glucocorticoids for hearing preservation in cochlear implantation: A prospective clinical study.
Effects of hearing preservation for cochlear implant outcomes - Vanderbilt audiology’s journal club.



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