Functional outcomes in the Cleft Care UK study - Part 3:oral health and audiology

OBJECTIVES: To compare oral health and hearing outcomes from the Clinical Standards Advisory Group (CSAG, 1998) and the Cleft Care UK (CCUK, 2013) studies. SETTING AND SAMPLE POPULATION: Two UK-based cross-sectional studies of 5-year-olds born with non-syndromic unilateral cleft lip and palate undertaken 15 years apart. CSAG children were treated in a dispersed model of care with low-volume operators. CCUK children were treated in a centralized, high volume operator system. MATERIALS AND METHODS: Oral health data were collected using a standardized proforma. Hearing was assessed using pure tone audiometry and middle ear status by otoscopy and tympanometry. ENT and hearing history were collected from medical notes and parental report. RESULTS: Oral health was assessed in 264 of 268 children (98.5%). The mean dmft was 2.3, 48% were caries free, and 44.7% had untreated caries. There was no evidence this had changed since the CSAG survey. Oral hygiene was generally good, 96% were enrolled with a dentist. Audiology was assessed in 227 of 268 children (84.7%). Forty-three per cent of children received at least one set of grommets--a 17.6% reduction compared to CSAG. Abnormal middle ear status was apparent in 50.7% of children. There was no change in hearing levels, but more children with hearing loss were managed with hearing aids. CONCLUSIONS: Outcomes for dental caries and hearing were no better in CCUK than in CSAG, although there was reduced use of grommets and increased use of hearing aids. The service specifications and recommendations should be scrutinized and implemented.

Measuring the impact of illness perception on NHS audiology service usage in presbycusis patients – a feasibility study

Objective: Coping behaviour in adult hearing loss is still not well understood. Despite the high prevalence of hearing loss in those over 65, many people do not seek help for hearing loss. The common sense model of illness perceptions suggests that illness perceptions are a strong predictor of adapted coping behaviours, including help-seeking and take-up of treatments. This study aimed to determine the feasibility of using the brief illness perceptions questionnaire (bIPQ) to measure the impact of illness perception in predicting usage of NHS audiology services. Study design: Twenty-four volunteers were recruited from a standard NHS audiology outpatient clinic and illness perception was measured using the bIPQ. Two different recruitment strategies were explored and compared in terms of recruitment and retention rates. Comprehensibility of the questionnaire was assessed by Think Aloud Analysis in a subset of participants, while possible risks and burdens were monitored in structured telephone interviews. Results: The questionnaire is a comprehensive and quick tool to measure individual illness perception at minimal cost. We suggested minor adaptations of three questionnaire items to increase comprehension. Participants preferred to complete the questionnaire after their appointment at the clinic facilities rather than at home prior to their hearing assessment appointment. There were no identified risks or burdens to participants in this study. Conclusions: This approach met our criteria for feasibility. Understanding the impact of illness perception on patients’ coping behaviour in presbycusis could improve treatment outcomes and increase patient satisfaction, while promoting a more efficient and individualized audiology service.

Childhood auditory processing disorder as a developmental disorder:the case for a multi-professional approach to diagnosis and management

Auditory processing disorder (APD) is diagnosed when a patient presents with listening difficulties which can not be explained by a peripheral hearing impairment or higher-order cognitive or language problems. This review explores the association between auditory processing disorder (APD) and other specific developmental disorders such as dyslexia and attention-deficit hyperactivity disorder. The diagnosis and aetiology of APD are similar to those of other developmental disorders and it is well established that APD often co-occurs with impairments of language, literacy, and attention. The genetic and neurological causes of APD are poorly understood, but developmental and behavioural genetic research with other disorders suggests that clinicians should expect APD to co-occur with other symptoms frequently. The clinical implications of co-occurring symptoms of other developmental disorders are considered and the review concludes that a multi-professional approach to the diagnosis and management of APD, involving speech and language therapy and psychology as well as audiology, is essential to ensure that children have access to the most appropriate range of support and interventions.

The role of volunteer support in the community for adults with hearing loss and hearing aids

Objectives: To explore interactions between audiology patients and volunteers, to describe encounters and define the role of volunteers. Methods: Qualitative ethnographic and interview study of volunteer-patient interactions. Ten volunteer participants from two volunteer schemes in South West England were observed and interviewed. Three patient participants were interviewed. Results: Analysis of observational data showed that volunteers provided support relating to local services and hearing aids, but did not engage in discussions about hearing loss. Interviews with volunteers identified gaps in audiology provision, including accessible services and clear information and highlighted a need for more support from audiology services to enable them to fulfil their role. Volunteer interactions with patients mimicked a clinician-patient encounter and volunteers employed strategies and behaviours used by professional audiologists. Conclusions: Audiology volunteers could provide an accessible bridge between health services and the community but their care is limited to focus on hearing aids. Practice implications: Volunteers enable patients to use hearing aids appropriately and are a core element of current care arrangements. However, volunteers express a need for adequate support from audiology services. Volunteers have the potential to increase service capacity and to bridge the gaps between community and audiology healthcare services.

Causal attributions in King-Kopetzky syndrome

At least 10% of people who present for help with hearing difficulties will be found to have normal hearing thresholds. These cases are clinically categorized as King-Kopetzky syndrome (KKS), obscure auditory dysfunction (OAD), or auditory processing disorder (APD). While recent research has focussed on the possible mechanistic basis for these difficulties, the perceptions of the hearing difficulties that lead people to seek help have not hitherto been identified. This study presents findings from an observational survey of causal attributions of hearing difficulties from 100 people with KKS. The findings suggest that participants regard immunity and risk related causes of hearing difficulties as pre-dominant. Psychological factors were not considered to be causal for hearing difficulties. These factors were not affected by diagnostic classification. These findings inform audiologists about their patient beliefs for the first time. The authors suggest that clinicians take care to ensure that their counselling is responsive to these beliefs. © 2010 British Society of Audiology, International Society of Audiology, and Nordic Audiological Society.

Illness perceptions and hearing difficulties in King-Kopetzky syndrome:what determines help seeking?

The present study explored illness perceptions of hearing difficulties amongst one hundred participants who reported experiencing hearing difficulties despite normal audiometric thresholds. This experience is referred to as King-Kopetzky syndrome (KKS), obscure auditory dysfunction (OAD), or auditory processing disorder (APD). Logistic regression was used to consider the associations between help-seeking and a range of audiological and illness perception measures. Results indicate that help-seekers present with poorer speech in noise thresholds than non help-seekers, and that coherent illness perceptions and a negative belief in the consequences of hearing difficulties are associated with help-seeking status, regardless of hearing sensitivity.

Emotional responses to King-Kopetzky syndrome:a qualitative study

The objective of the study was to identify the effects of King-Kopetzky syndrome on emotional well-being and the effects of emotional well-being on the condition itself. The study was designed as a qualitative study using semi-structured interviews, using six patients with long-standing hearing problems and exposure to a range of interventions. Participants were recruited from Audiology and Hearing Therapy Services, Bath and the Welsh Hearing Institute, Cardiff. Interviews were conducted in participants' homes and work places. King-Kopetzky syndrome was perceived to result in a change in level of anxiety, distress and depression. The determining factor in whether the change was positive (e.g. reduction in anxiety, distress or depression) or negative (e.g. increase in anxiety, distress or depression) was the person's interpretation of the experience of not hearing. This process of interpretation was based on feeling different towards other people, the relationship with the communicant person, and the confidence to employ strategies and the types of strategies chosen. Participants associated an increase in distress, anxiety or depression with an increase in mishearing or not hearing, and a reduction in hearing difficulties with a reduction in anxiety, distress and depression. It is hypothesised that emotional response to King-Kopetzky syndrome affects the degree of hearing difficulty experienced. Interventions aimed at the process of interpretation may be a means of empowering individuals in managing their own hearing difficulties.

Help-seeking for medically unexplained hearing difficulties:a qualitative study

Aims - Up to 10% of audiology patients report diffi culties hearing speech in noise even though clinical investigation reveals normal hearing thresholds, in other words, no evidence of physical pathology. The diagnostic category applied to these patients is known as King-Kopetzky Syndrome (KKS). This study aimed to gather descriptions of patients' experiences of the clinical encounter involving their KKS diagnosis and analyse the themes of help-seeking, as part of a larger study into the process of coping with medically unexplained hearing diffi culties. Method - A qualitative approach was employed, comprising unstructured interviews in the homes of 25 patients who had attended audiology services (and received a diagnosis of KKS) in Bath and Cardiff. Thematic analysis of transcripts was undertaken, infl uenced by grounded theory techniques. Findings - Informants characterized the clinical encounter as either negative or positive. Negative consultations were those in which patients' illness claims were dismissed and as such not validated. Positive encounters were typifi ed by the provision of meaningful information that reconciled clinical information with the patients' experiences of hearing loss. Conclusion - Successful management of medically unexplained illnesses requires the adoption of a patient-centred approach, rather than focusing on the absence of observable pathology

Auditory training and adult rehabilitation:a critical review of the evidence

Auditory Training (AT) describes a regimen of varied listening exercises designed to improve an individual’s ability to perceive speech. The theory of AT is based on brain plasticity (the capacity of neurones in the central auditory system to alter their structure and function) in response to auditory stimulation. The practice of repeatedly listening to the speech sounds included in AT exercises is believed to drive the development of more efficient neuronal pathways, thereby improving auditory processing and speech discrimination. This critical review aims to assess whether auditory training can improve speech discrimination in adults with mild-moderate SNHL. The majority of patients attending Audiology services are adults with presbyacusis and it is therefore important to evaluate evidence of any treatment effect of AT in aural rehabilitation. Ideally this review would seek to appraise evidence of neurophysiological effects of AT so as to verify whether it does induce change in the CAS. However, due to the absence of such studies on this particular patient group, the outcome measure of speech discrimination, as a behavioural indicator of treatment effect is used instead. A review of available research was used to inform an argument for or against using AT in rehabilitative clinical practice. Six studies were identified and although the preliminary evidence indicates an improvement gained from a range of AT paradigms, the treatment effect size was modest and there remains a lack of large-sample RCTs. Future investigation into the efficacy of AT needs to employ neurophysiological studies using auditory evoked potentials in hearing-impaired adults in order to explore effects of AT on the CAS.

A qualitative investigation of decision making during help-seeking for adult hearing loss

Objective: The Any Qualified Provider framework in the National Health Service has changed the way adult audiology services are offered in England. Under the new rules, patients are being offered a choice in geographical location and audiology provider. This study aimed to explore how choices in treatment are presented and to identify what information patients need when they are seeking help with hearing loss. Design: This study adopted qualitative methods of ethnographic observations and focus group interviews to identify information needed prior to, and during, help-seeking. Observational data and focus group data were analysed using the constant comparison method of grounded theory. Study sample: Participants were recruited from a community Health and Social Care Trust in the west of England. This service incorporates both an Audiology and a Hearing Therapy service. Twenty seven participants were involved in focus groups or interviews. Results: Participants receive little information beyond the detail of hearing aids. Participants report little information that was not directly related to uptake of hearing aids. Conclusions: Participant preferences were not explored and limited information resulted in decisions that were clinician-led. The gaps in information reflect previous data on clinician communication and highlight the need for consistent information on a range of interventions to manage hearing loss.

Prevalence and characteristics of spontaneous tinnitus in 11-year-old children

OBJECTIVE: To estimate the prevalence of spontaneous tinnitus in 11-year-old children. DESIGN: A prospective UK population-based study. STUDY SAMPLE: A total of 7092 children from the Avon longitudinal study of parents and children (ALSPAC) who attended the hearing session at age 11 years and answered questions about tinnitus. RESULTS: We estimated the prevalence of any spontaneous tinnitus as 28.1% (95% CI 27.1, 29.2%), and the prevalence of 'clinically significant' tinnitus as 3.1% (95% CI 2.7, 3.5%). Children were less likely to have clinically significant tinnitus if the tinnitus was 'soft' rather than 'loud' and if continuous rather than intermittent. Clinical significance was more likely if the tinnitus occurred more than once a week. Neither pitch nor length of history were important determinants of clinical significance. Small increases in mean hearing threshold (of up to 2.3 dB HL) were associated with clinically significant tinnitus. CONCLUSIONS: Although the prevalence of any tinnitus in 11-year-old children appears high, the small proportion in which this was found to be clinically significant implies that this does not necessarily indicate a large unmet clinical demand. We would expect approximately one child per class of 30 to have clinically significant tinnitus which is, by definition, problematic.

Prevalence and risk factors for reduced sound tolerance (hyperacusis) in children

OBJECTIVE: To estimate the prevalence of reduced sound tolerance (hyperacusis) in a UK population of 11-year-old children and examine the association of early life and auditory risk factors with report of hyperacusis. DESIGN: A prospective UK population-based study. STUDY SAMPLE: A total of 7097 eleven-year-old children within the Avon longitudinal study of parents and children (ALSPAC) were asked about sound tolerance; hearing and middle-ear function was measured using audiometry, otoacoustic emissions, and tympanometry. Information on neonatal risk factors and socioeconomic factors were obtained through parental questionnaires. RESULTS: 3.7% (95% CI 3.25, 4.14) children reported hyperacusis. Hyperacusis report was less likely in females (adj OR 0.64, 95% CI 0.49, 0.85), and was more likely with higher maternal education level (adj OR 1.72, 95% CI 1.08, 2.72) and with readmission to hospital in first four weeks (adj OR 1.98, 95% CI 1.20, 3.25). Report of hyperacusis was associated with larger amplitude otoacoustic emissions but with no other auditory factors. CONCLUSIONS: The prevalence of hyperacusis in the population of 11-year-old UK children is estimated to be 3.7%. It is more common in boys.

The effect of notch filtering on the waveform of the newborn auditory brainstem response

OBJECTIVE: To identify whether the use of a notch filter significantly affects the morphology or characteristics of the newborn auditory brainstem response (ABR) waveform and so inform future guidance for clinical practice. DESIGN: Waveforms with and without the application of a notch filter were recorded from babies undergoing routine ABR tests at 4000, 1000 and 500 Hz. Any change in response morphology was judged subjectively. Response latency, amplitude, and measurements of response quality and residual noise were noted. An ABR simulator was also used to assess the effect of notch filtering in conditions of low and high mains interference. RESULTS: The use of a notch filter changed waveform morphology for 500 Hz stimuli only in 15% of tests in newborns. Residual noise was lower when 4000 Hz stimuli were used. Response latency, amplitude, and quality were unaffected regardless of stimulus frequency. Tests with the ABR stimulator suggest that these findings can be extended to conditions of high level mains interference. CONCLUSIONS: A notch filter should be avoided when testing at 500 Hz, but at higher frequencies appears to carry no penalty.