Keywords
hearing loss - protocols - hearing aids - ear diseases - chronic disease
Introduction
Although some recent studies have shown declines in the prevalence of hearing impairment
in recent generations,[1]
[2] according to World Health Organization global estimates, it still represents the
most common sensory disorder in the world, with 328 million adults having disabling
hearing loss (hearing thresholds above 40 dB), which can impair their quality of life
and potentially result in feelings of isolation, loneliness, and frustration due to
communication difficulties, economic participation, and lack of access to services.[3]
[4] However, even in developed countries, it is estimated that less than 1 in 40 people
who need hearing aids have access to them.[3]
In 2004, with the establishment of the National Hearing Health Care Policy, the Brazilian
government, through the Unified Health System (SUS), via the Organization of State
Hearing Health Networks, made it possible for the population to have access to the
service levels of basic, medium, and high-complexity audiological care.[5]
In parallel, the processes of globalization and urbanization have resulted in changes
in lifestyle. Inactivity and unhealthy diet have resulted in an epidemic of excess
weight,[6] associated with stress, smoking, and alcohol abuse. In turn, these conditions have
led to an increased prevalence of chronic diseases, the most common being cardiovascular,
which includes hypertension and hypercholesterolemia; osteoarticular; psychiatric
disorders; chronic respiratory diseases; diabetes; kidney disease; and cancer.[6]
[7]
[8]
[9] All are significantly more prevalent in women.[10] Certain chronic degenerative diseases may contribute to the onset and worsening
of hearing loss via different pathophysiological mechanisms.[7]
[8]
According to the National Sampling Policy of Households (PNAD), conducted by the Brazilian
Institute of Geography and Statistics in 2008, hypertension is the most prevalent
chronic disease in both sexes.[10]
[11]
[12] It evolves from increased blood viscosity and microcirculatory failure that can
compromise the auditory and vestibular systems at the peripheral and central levels.
This is aggravated by hypercholesterolemia, which affects one-third of individuals
over 45 years of age.[6]
[7]
[13]
Diabetes, although the seventh most prevalent chronic disease in the same PNAD statistics,
showed the strongest growth, up 37%, compared with the prevalence described in the
2003 study.[6]
[9] Although there is still no consensus on the pathophysiology of hearing damage caused
by diabetes, it is suggested that changes in the metabolism of lipids and glucides
could be related to the development and/or aggravation of not only hearing loss but
also tinnitus and balance disorders because of reduced blood flow and disability in
the transport of nutrients, due to diabetic microangiopathy and secondary degenerative
neuropathy affecting peripheral and central auditory pathways.[7]
[14]
[15]
Such situations, besides contributing to the concomitant hypoacusis with other otologic
complaints,[16]
[17]
[18] increase the progression of hearing loss and are of the utmost importance when selecting
and fitting hearing aids.
Several studies have shown the high concurrency of otologic symptoms in hearing aid
users, especially tinnitus, dizziness, itching, and ear pain. Although results vary,
tinnitus symptoms have been reported by at least 70% of the subjects in most polls,
followed by itching and/or dizziness in ∼50% of individuals.[19]
[20]
[21] Tenório et al found that 100% of a sample for hearing aid wearers had at least one
associated symptom.[12]
If on the one hand adaptation of the hearing aids has improved some of these symptoms,[20]
[21]
[22]
[23] then on the other hand, hearing aid user may be related to a worsening clinical
picture in cases of allergic contact dermatitis[24]
[25] and even worse tinnitus if the device has no ventilation or is an open mold.[22]
Such symptoms can compromise the benefits of hearing aid use. Recently, Andersson
et al found that hearing aid users with tinnitus had worse responses than the group
without tinnitus in unfavorable listening situations (low signal-to-noise ratio),
generating more complaints than improvements with the device.[26]
The impact of hearing loss in the world, the prevalence of systemic diseases and otologic
symptoms in the adult population, in addition to the increase in number of SUS users
getting hearing aids show the importance of developing protocols for integrated assessment
of candidates for fitting. Greater attention should be paid to device selection and
adaptation to better characterize and manage hearing loss and user expectations and
otolaryngologic symptoms associated with systemic comorbidities to optimize the hearing
aid fitting process.
This study aims to compare the occurrence of otologic complaints, systemic diseases,
and effective use of hearing aids in men and women with deafness.
Methods
This is an exploratory, descriptive, cross-sectional study, approved by the Research
Ethics Committee under the number CEP/027/2008. All participants signed a consent
form authorizing the use of the collected data.
Between March and September 2013, during the development of this research, 278 patients
using hearing aids were followed by the otolaryngology service at a hearing health
service center accredited by SUS in Curitiba, Brazil. For this study, individuals
were selected who fit the following criteria: over 50 years old with a diagnosis of
hearing loss, hearing aid use for at least the past 6 months, having complaints about
the adaptation and/or functioning of the device. Following this criteria the sample
was composed of 61 respondents.
All subjects were evaluated by an ear, nose, and throat (ENT) physician and audiologist.
An anamnesis, ENT evaluation, and audiological evaluation were performed.
Gender, age, otologic complaints, presence of associated systemic diseases, and otoscopy
findings were variables taken into account for the ENT assessment.
In the clinical assessment, the type, degree, and configuration of hearing loss observed
in pure tone audiometry were considered, as well as the type of hearing aid worn.
For the audiometry, an ITERA audiometer (Madsen, Denmark), calibrated in a soundproof
booth according to the standards required by the Federal Council of Speech-Language
Pathology, was used.
The subjects were divided into two groups for purposes of comparison and analysis
of results: group A, made up of women, and group B, by men. The results were statistically
analyzed using the chi-square test (to compare possible differences between observed
and expected frequencies for an event) and the difference in proportions test (to
compare differences between two populations), with 0.05 as the significance level.
Results
In the period that data were collected, 278 people presented for a follow-up visit
at an accredited clinic. Of these, 61 (21%) subjects reported otologic or operational
problems with their devices.
The sample was composed of 61 individuals, 35 (57%) women and 26 (43%) men. The age
in group A (women) ranged from 53 to 85, with a mean of 72, and in group B (male),
from 53 to 82, with a mean of 69. A family history of hearing loss was reported in
41% of subjects, 13 women and 12 men. There was a predominance of widows in group
A (51%), followed by married (37%) and single (11%), and group B was predominantly
married (81%), followed by divorced (11%) and widowers (8%). Both genders were mostly
made up of retirees or pensioners (71% of the women and 85% of the men).
When talking about hearing aids, three individuals in group A used unilateral prosthesis,
four used intracanal hearing aids, and 53 (86%) used behind-the-ear (BTE) prosthesis
with silicone molds. In the group B, two individuals used prosthesis in one ear, six
used intracanal hearing aids, and 48 (78%) used BTE prosthesis with silicone molds.
Type, degree, and configuration of hearing loss are shown in [Table 1]. The chi-square test predominantly showed mild to moderate hearing loss with descending
slopes. About 80% of subjects had comorbidities, and the data are shown in [Table 2]. Hypercholesterolemia was more significant for women and hypertension for males.
Table 1
Classification of hearing loss and gender (n = 61)
|
Variable
|
Gender
|
p
|
|
Women
|
Men
|
|
Type of loss
|
|
|
|
|
Sensorineural
|
30
|
22
|
0.9047
|
|
Mixed
|
5
|
4
|
|
Degree of loss
|
|
|
|
|
Light
|
3
|
7
|
0.0103
|
|
Moderate
|
14
|
14
|
|
|
Profound
|
6
|
–
|
|
|
Severe
|
12
|
5
|
|
|
Configuration
|
|
|
|
|
Descending
|
18
|
20
|
0.0422
|
|
Flat
|
17
|
6
|
Note: Using chi-square test, there is significant difference in the degree of loss
(p = 0.0103) and configuration (p = 0.0422).
Table 2
Morbidities by gender (n = 61)
|
Comorbidities
|
Women (n = 35)
|
Men (n = 26)
|
Total (n = 61)
|
p
|
|
Hypercholesterolemia
|
12 (34.3%)
|
3 (11.5%)
|
15 (24.6%)
|
0.0453
|
|
Diabetes
|
8 (22.9%)
|
3 (11.5%)
|
11 (18.0%)
|
0.2568
|
|
Arterial hypertension
|
26 (74.3%)
|
12 (46.2%)
|
38 (62.3%)
|
0.0289
|
|
Benign prostatic hyperplasia
|
–
|
4 (15.4%)
|
4 (6.6%)
|
N/A
|
|
Rheumatic diseases
|
2 (5.7%)
|
–
|
2 (3.3%)
|
N/A
|
|
Hypothyroidism
|
13 (37.1%)
|
1 (3.8%)
|
14 23.0%)
|
N/A
|
|
Psychiatric difficulties
|
2 (5.7%)
|
2 (7.7%)
|
4 (6.6%)
|
N/A
|
|
Others
|
2 (5.7%)
|
4 (15.4%)
|
6 9.8%)
|
N/A
|
|
No mentioned morbidity
|
4 (11.4%)
|
8 (30.8%)
|
12 (19.7%)
|
0.3187
|
Abbreviation: N/A, not applicable.
Note: The number of citations is greater than the number of respondents because some
individuals had more than one associated morbidity. Using the difference of proportions
test, there is significant difference between the number of morbidities for hypercholesterolemia
and hypertension.
The majority of the sample (92%) had bilateral fitting of hearing aids, with the same
percentage represented in both groups. The hearing aid use profile is shown in [Table 3]. Considering only the totals of continuous and discontinuous use, the chi-square
test at a significance level of 0.05 showed no significant dependence between usage
type between the two genders. Fourteen subjects (22%) reported little use of hearing
aids, either because of otologic problems associated with deafness or malfunction
of the unit itself, and the results are shown in [Table 4]. Of the 61 participants, 54% had otologic complaints related to deafness, and the
data are presented in [Table 5]; the correlation between morbidity and discontinuity of use for the hearing aid
is shown in [Table 6].
Table 3
Time and method of use for the device (n = 61)
|
Time of use (mo)
|
Women
|
Men
|
|
Continuous use
|
Discontinuous use
|
Continuous use
|
Discontinuous use
|
|
<12
|
5
|
–
|
8
|
2
|
|
13–24
|
5
|
4
|
1
|
1
|
|
25–36
|
3
|
2
|
8
|
1
|
|
37–48
|
8
|
–
|
–
|
2
|
|
49–96
|
5
|
2
|
3
|
–
|
|
≥97
|
1
|
–
|
–
|
–
|
|
Total
|
27
|
8
|
20
|
6
|
Table 4
Motives for interruption of use for the device (n = 14)
|
Variable
|
Motives
|
|
Otalgia
|
Itching
|
Noise
|
Device defect
|
Total
|
|
Women
|
1 (7%)
|
2 (14%)
|
3 (21%)
|
2 (14%)
|
8 (57%)
|
|
Men
|
3 (21%)
|
–
|
1(7%)
|
2 (14%)
|
6 (43%)
|
|
Total
|
4 (28%)
|
2 (14%)
|
4 (28%)
|
4 (28%)
|
14 (100%)
|
Table 5
Otologic complaints and improvement of symptoms with the use of hearing aids by gender
(n = 33)
|
Complaint
|
Women
|
Men
|
|
Number of complaints
|
Improvement
|
% Improvement
|
Number of complaints
|
Improvement
|
% Improvement
|
|
Wax
|
18
|
–
|
–
|
18
|
–
|
–
|
|
Itching
|
22
|
–
|
–
|
11
|
–
|
–
|
|
Dizziness
|
10
|
2
|
20
|
7
|
2
|
29
|
|
Tinnitus
|
30
|
16
|
53
|
18
|
10
|
56
|
|
Otalgia
|
6
|
–
|
–
|
2
|
–
|
–
|
|
Other
|
–
|
–
|
–
|
1
|
–
|
–
|
Note: The number of complaints is greater than the number of respondents because some
individuals had more than one complaint associated with hearing loss. Using the difference
of proportions test, there was significant difference in the two genders for itching
(p = 0.0085) and tinnitus (p = 0.0015).
Table 6
Relationship between discontinuous use of the device with comorbidities (n = 61)
|
Comorbidities
|
Discontinuous use
|
|
Women (n = 8)
|
Men (n = 6)
|
|
Hypercholesterolemia
|
4 (11.4%)
|
2 (7.7%)
|
|
Diabetes
|
1 (2.9%)
|
2 (7.7%)
|
|
Arterial hypertension
|
6 (17.1%)
|
3 (11.5%)
|
|
Benign prostatic hyperplasia
|
–
|
2 (7.7%)
|
|
Hypothyroidism
|
4 (11.4%)
|
1 (3.8%)
|
Note: The number of citations is greater than the number of respondents because some
individuals had more than one associated morbidity.
Discussion
All 61 participants had hearing loss, and of these, 80.3% reported having systemic
diseases, among which the most commonly reported were hypertension, hypothyroidism,
hypercholesterolemia, and diabetes. The study population had an average age of 69
years for men and 72 years for women; all were considered seniors. Although the appearance
of systemic diseases and hearing loss is natural, it can often be disabling and contribute
negatively to quality of life, generating increasing demands for specialized health
care services.
To improve auditory perception, the elderly population has sought out hearing health
services in SUS for evaluation of hearing and fitting of hearing aids.[27]
[28] In the present study, conducted within a hearing health clinic, most of the sample
was elderly.
A high incidence of morbidity was assessed in the sample, predominantly hypercholesterolemia
in women and hypertension in men. Investments are necessary so that medical care for
hearing health services is not restricted to ENT care. According to a published study,[8] the body of an elderly person has peculiarities that must be evaluated when dealing
with issues related to ENT disorders. The physician should consider underlying diseases,
medical history, and the drugs taken by patients.
In the study group, 62% of women reported having no life partner; only 19% of men
did not have a partner. This coincides with work that notes the feminization of old
age associated with greater longevity and independence of women compared with men.[11]
There was a balance between the two genders with regard to occupation, as most were
retired or pensioners. A study with 320 subjects in Curitiba revealed that more than
half of the sample was made up of retirees and had a minimum wage income, which explains
the use of the free, government-sponsored SUS.[27]
This study ([Table 1]) was made up of patients with predominantly sensorineural hearing loss, from mild
to moderate degree with a downward sloping audiometric curve, significant for both
groups. As most subjects were elderly, the prevalence of hearing loss caused by aging
(i.e., presbycusis) as found in other studies had been expected.[12]
[20]
[29]
The majority of the sample ([Table 3]) had been wearing a hearing aid for over 2 years, and 14 subjects (22%) reported
not using the device continuously, either because of otologic factors or functional
factors with the device. There was no significant difference between the two genders
regarding continuous or nonuse of the device. Studies point to the fact that it is
common for users to give up on wearing hearing aids for several reasons, ranging from
discomfort with the sound amplification to aesthetic considerations.[28]
[29] In this study most respondents used BTE hearing aids. Of those who discontinued
use of the device, half did so because of problems with the ear itself and half had
problems with the device. Ear pain and itching may compromise the use of the device,
because they prevent the adaptation of molds,[28] and failures in the devices are among the most common causes of abandonment of use.[27]
Hearing loss is commonly accompanied by symptoms such as tinnitus, vertigo, and aural
fullness.[1] The most common otologic complaint in both groups was tinnitus, reported by 48 subjects,
and the second most common was vertigo, reported by 17 subjects. Tinnitus is an otologic
problem that manifests itself frequently in patients with hearing loss.[19]
[20] This problem, besides compromising the proper use of the device, may reduce its
benefits and cause significant emotional and psychiatric sequelae. Vertigo also compromises
the user's adequate adaptation for the hearing aid.[21]
Contrary to the published literature[18], tinnitus was significant among women in this study.[18]
Improvement in hearing symptoms was achieved, particularly for those complaining of
tinnitus (16 women and 10 men), which confirms data from the literature.[20]
[22] This information reinforces the thesis that the hearing aid constitutes an important
resource for physicians and audiologists who engage in hearing rehabilitation.
After investigating the causes of otologic symptoms, systemic diseases should be studied
as they may be generating their own complaints and cause discontinuation of hearing
aid use because of the important relationship between hearing, metabolic, and vascular
issues.[3]
[13]
[15] In this study, 14 respondents who do not wear the device appropriately, referring
to otologic problems such as tinnitus, vertigo, ear pain and itching, mentioned the
presence of comorbidities ([Table 2)].
The literature also reports that hypertension has been shown to be a common case in
both genders, but in this study a predominance of males had this complaint.[10]
[12]
Finally, as reported in the literature,[20]
[22] use of the hearing aid was decisive for reducing some complaints, such as decreased
sensation of dizziness and tinnitus ([Table 3]) for both women and men.
Conclusion
This study showed that the incidence of systemic and otologic complaints is high in
this population. During the data collection period, 278 people had follow-up visits;
of these subjects, 61 (21%) reported otologic problems or operational problems with
their devices. Basocochlear hearing loss, a characteristic of presbycusis, was the
most prevalent both in men and women, with the majority of the subjects studied being
senior citizens. The most frequently reported comorbidities were hypercholesterolemia
(more significant in women) and hypertension (more significant in men). In 14 subjects,
use of the device had been discontinued and there was no significant difference between
genders. The reasons for discontinuation of use were itching and tinnitus, with women
complaining more often.
It is clear that this group of patients should be evaluated in its entirety, for actions
of this nature can contribute to improving the quality of life and assisting in the
process of hearing aid adaptation.
