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ORIGINAL ARTICLE Table of Contents  
Ahead of print publication
Changes in the audiometric patterns in presbycusis with ongoing medical upgradation


1 Department of ENT, Government Medical College, Jammu, Jammu and Kashmir, India
2 Department of Anaesthesia, Maharishi Markandeshwar Institute of Medical Science and Research, Ambala, Haryana, India
3 Department of Neurosurgery, Maharishi Markandeshwar Institute of Medical Science and Research, Ambala, Haryana, India

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Date of Submission20-May-2022
Date of Decision20-Sep-2022
Date of Acceptance20-Sep-2022
Date of Web Publication31-Oct-2022
 

  Abstract 


Background: Presbycusis or age-related hearing loss. Nowadays, age-related hearing impairment is recognized as a disorder with environmental and genetic factors, use of ototoxic medication, hypertension with increasing age, i.e., longevity of life the burden of presbycusis is increasing. Aims: This study aims to identify patterns based on audiometric data collected from a sample with a clinical indication of presbycusis and to quantify hearing loss at the time of presentation. Materials and Methods: One hundred and forty-five participants were studied, and tuning fork tests, pure-tone audiometry, and speech audiometry were performed. Conclusion: It concluded that hearing loss increased with increasing age and speech discrimination scores decreased with increasing age. The hearing loss associated with presbycusis seen in the elderly was essentially symmetrical. The most common audiogram configuration seen in the study of presbycusis was the Flat type, followed by the high-frequency gently sloping and high-frequency steeply sloping types.

Keywords: Audiological assessment, hearing loss, presbycusis, pure-tone audiometry, speech discrimination scores


How to cite this URL:
Sharma S, Thakur G, Kour A, Singh A. Changes in the audiometric patterns in presbycusis with ongoing medical upgradation. Apollo Med [Epub ahead of print] [cited 2022 Nov 28]. Available from: https://apollomedicine.org/preprintarticle.asp?id=359910





  Introduction Top


Presbycusis is the loss of hearing that gradually occurs in individuals as they grow old due to physiological and degenerative processes associated with aging (Fransen et al., 2003)[1]. One stated it as the most common sensory impairment associated with aging. According to the WHO estimates, by 2025, there will be approximately 1200 million people over 60 years of age, with more than 500 million individuals suffering from presbycusis.[2] According to Gates and Mills,[3],[4] presbycusis leads to social isolation, loss of autonomy, depression, and anxiety. Presbycusis is characterized by decreased speech understanding in a noisy environment, slowed central processing of acoustic information, impaired localization of sound sources, and natural deterioration in hearing.[5] described it as an elevation of hearing thresholds above 2 kilohertz (kHz), with speech perception deterioration under strenuous conditions. Elderly persons with hearing loss have higher rates of hospitalization,[6] death (Fisher et al., 2014),[6],[7] dementia (Fisher D el al., 2012)[8],[9] and depression[10] even when known risks for these disorders are taken into account (Lin et al., 2011).[9] Noise exposure is the most studied environmental factor causing hearing loss. Another possible cause of hearing loss is the use of ototoxic medication. Hypertension and systolic blood pressure were also related to hearing thresholds.[11] A causal relationship between high-frequency sensorineural hearing (SNH) impairment and diabetes mellitus (DM) has been found.[12] Another study that has been remarkable in the field of presbycusis was that of Demeester et al.[13] They categorized the audiogram into six different types using audiometric configuration classification.[14]

Aims and objectives

  • To identify presbycusis patterns with audiometric data collected from a sample of the elderly population
  • To quantify hearing loss at the time of presentation.



  Materials Top


Source of data

The present prospective study was conducted in the Department of ENT in the Territory Centre for 1 year, commencing from November 1st, 2020, to October 31st, 2021, after approval from the Institutional Ethics Committee.

Subjects

Patients attending the otorhinolaryngology department were included in the study (n = 145). The participantswere patients with the clinical diagnosis of presbycusis.

  • A detailed history of the participantswas taken, including otological symptoms, systemic diseases (such as Type 2 DM, hypertension, chronic renal disease, heart disease, and dyslipidemia), drug history (ototoxic drugs such as aminoglycosides, diuretics, salicylates, cisplatin), personal history (alcohol, smoking), family history (hereditary hearing loss), and incidental or occupational exposure to noise
  • The participantswere then subjected to routine systemic and ENT examinations
  • Routine blood investigations were performed
  • Otoscopy was done, and any ear wax, if present, was removed. Participantswith healthy tympanic membranes were subjected to audiological assessment listed below
  • Participants had auditory functions tested by tuning fork tests, followed by pure-tone audiometry (PTA) and speech audiometry in the audiology unit attached to the department.


Inclusion criteria

  • Age >60 years
  • Bone conduction levels above 20 decibels (dB) in the right or left ear for average thresholds of 0.5, 1, 2, and 4 kHz.


Exclusion criteria

  • Otitis media (chronic) and with effusion
  • Hearing loss congenital
  • Meniere syndrome
  • Previous idiopathic sudden SNH loss
  • Ear surgery
  • Cranial trauma and surgery
  • Cranial
  • Labyrinthitis viral/bacterial
  • Previous acoustic trauma
  • Ototoxic drug usage
  • Occupational noise history.



  Methods Top


A detailed history of the participantswas taken, including otological symptoms, systemic diseases (such as Type 2 DM, hypertension, chronic renal disease, heart disease, and dyslipidemia), drug history (ototoxic drugs such as aminoglycosides, diuretics, salicylates, and cisplatin), personal history (alcohol and smoking), family history (hereditary hearing loss), incidental or occupational exposure to noise. Otoscopy was done, and any ear wax, if present, was removed. Participantswith healthy tympanic membranes were subjected to the audiological assessment listed below. Participants had auditory functions tested by tuning fork tests, followed by PTA and speech audiometry in the audiology unit attached to the department.

Procedure

The audiological assessment was conducted in a sound-treated room which was confirmed by the American National Standards Institute (1977) and International Organization for Standardization standards for maximum permissible noise level.

Pure-tone audiometry

Pure-tone hearing thresholds were tested (Audiolite (Lobat) diagnostic audiometer at speech frequencies between 0.25 and 8 kHz with TDH39P headphones). Pure tone hearing threshold were tested using Audiolite diagnostic audiometer at speech frequency between 0.25 and 8KHz with TDH39 head phones. Air conduction (AC) thresholds in the right and left ears were marked as standard. Bone conduction threshold was obtained using bone vibrator B71 as per standards and marked with signs, respectively. Masking was employed when the difference between left and right ears' unmasked AC threshold was 40 dB or more. With the help of PTA, the followings were determined:

The average hearing threshold grading was done per Clark (Clark, 1981)[15] and described as hearing loss:

  • 0–25 dB – Normal
  • 26–40 dB – Mild
  • 41–55 dB – Moderate
  • 56–70 dB – Moderately severe
  • 71–90 dB – Severe
  • >90 dB – Profound.


The shape of the audiogram thus obtained was categorized into one of the three based on the criteria devised by Demeester et al.:[13]

  • Flat audiogram configuration (trial presbycusis)
  • High-frequency gently sloping (HFGS) audiogram configuration (cochlear conductive presbycusis)
  • High-frequency steeply sloping (HFSS) audiogram configuration (sensory presbycusis).


The mean pure-tone AC thresholds for the higher frequencies (4 and 8 kHz) were calculated.

Speech audiometry

Speech reception threshold and speech discrimination score (SDS) were done per standards.

  • Standard D score – Ability to understand speech
  • 90%–100% – Normal
  • 76%–88% – Slightly difficult
  • 60%–74% – Moderately difficult
  • 40%–58% – Poor
  • <40% – Very poor


Statistical analysis

The Chi-square test or Fisher's exact test was applied for comparing categorical variables, whichever was appropriate. A P < 0.05 was considered statistically significant.


  Observations Top


The study comprised 145 participantsaged 60 years and above, as shown in [Table 1]. Ninety-nine were male, and 46 were female. The male: female ratio was 2.15:1.
Table 1: Distribution of age (years) of study subjects

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The Pure tone AV (Average) threshold every where of the participantsin the present study for the frequencies of 500, 1000, and 2000 Hz lay in the range of 36.67–85 dB for the right ear and 31.67–80 dB for the left ear with the mean ± SD being 46.95 ± 12.3 dB for the right ear and 46.16 ± 12.22 dB for the left ear as evident in [Table 2]. The air-bone (AB) gap in the present study lies in the range of 3.33–15 dB for the right ear and 1.6–15 dB for the left ear. The SDS ranged from 60% to 100% in both ears.
Table 2: Descriptive statistics of pure-tone average air conduction (dB), air-bone gap (dB), and speech discrimination score (%) of study participants

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[Table 3] shows that 48.28% of the participantshad mild hearing loss at the time of presentation. Only 2.76% had severe hearing loss. None of the participantsreported profound hearing loss at the time of presentation.
Table 3: Distribution of grades of hearing loss of study subjects

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The study participants most commonly occurring type of audiogram was the Flat type, consistent with the metabolic or trial type of presbycusis. It was seen in 57 (39.31%) participants. HFGS type (cochlear conductive) was a close second, occurring in 52 (35.86%) participants. HFSS type corresponding to the sensory type of Schuknecht's typology was the least common and observed in only 36 (24.83%) subjects.

[Table 4] shows that the mean PTAv AC rose from 43.06 ± 9.69 dB to 42.58 ± 10.1 dB for the right and left ears, respectively, in the 60–70 years of age group to the values of 77.5 ± 10.6 dB and 70 ± 14.14 dB for right and left ears in the age group of 91–100 years. The difference in the value of PTAv AC for both ears when compared with the age groups was found to be statistically significant (P < 0.001). The AB gap was comparable between the age groups. The mean AB gap for the present study was 10.93 ± 3 dB for the right and 10.82 ± 3.09 dB for the left ear. The SDS showed a decline as the age increases being 85.86% ± 8.95% and 86.12% ± 9.39% for the right and left ears, respectively, in the age group of 60–70 years to 63% ± 4.24% for both ears in the age group of 91–100 years. The P value was statistically significant for SDS in both ears.
Table 4: Association of pure-tone average air conduction (dB), air-bone gap (dB), and speech discrimination score (%) with age group

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In our study, the participantsin the 91–100 years of age group had the higher grades of hearing loss, with 50% being each in the moderately severe and severe categories. More than 80% of participantsin the 81–90 years of age group had moderate hearing loss or above. The participantsin the 71–80 years of group had more than 70% participantswith moderate hearing loss or above. Participants in the 60–70 years of group were more in the lower groups of hearing loss, with roughly 90% of participants being in the mild and moderate groups, as tabulated in [Table 5]. Statistically, a significant difference was observed in the hearing loss grades compared to the different age groups.
Table 5: Association of grades of hearing loss with age group

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[Table 6] shows the mean averages of pure-tone thresholds at three frequencies (PTAv AC) and SDS were compared between the three types of the audiogram. The mean PTAv AC values for the right and the left ears for the Flat configuration of the audiogram were 50.02 ± 11.51 dB and 49.59 ± 11.50 dB, respectively, which were higher than those for HFGS type and HFSS type (P = 0.038 for right ear and 0.023 for left ear). When comparison was drawn based on mean SDS values among the three audiogram types, it was seen that SDS values were significantly lower for the Flat type (79.64% ± 9.61% and 79.82% ± 9.83% for right and left ear, respectively) as compared to HFGS type and HFSS type (P = 0.019 for right and 0.015 for left ear).
Table 6: Comparison of pure-tone average air conduction (dB) and speech discrimination score (%) between different types of an audiogram

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PTAv AC and SDS differences were statistically significant when compared to the audiogram types.


  Discussion Top


With advances in medical care and betterment of living standards which have led to an overall increase in life expectancy, presbycusis has become a major contributor to the disease burden in the elderly, second only to hypertension and arthritis.[16] The present study aimed to learn more about the same by analyzing the audiogram shape. The grading of hearing loss was it was seen that 48.28% of participantshad mild hearing loss at the time of presentation. Only 2.76% had severe hearing loss. 31.03% of participantshad moderate hearing loss, and 17.93% had moderately severe hearing loss. None of the participantsreported profound hearing loss. Thus, it was seen that the maximum number of issues had mild hearing loss. The most prevalent grade of hearing loss was of a moderate degree, similar to Guerra et al.[17] Sogebi et al.[18] (26.1% moderate loss in his study). Similar results were from Mohammad and Muhammad (2017).[19]

The mean PTAv AC for the right was 46.95 ± 12.32 dB, and for the left ear, it was 46.16 ± 12.22 dB. The present study's mean ± SD for PTAv BC in the left and the right ears was 35.33 ± 11.24 dB and 36 ± 11.27 dB, respectively. The mean AB gap of the present study was 10.82 ± 3.09 dB for the right ear and 10.93 ± 3 dB for the left ear. All these values were comparable as no statistically significant difference was seen when a comparison was drawn based on the side involved (left or right). It was observed that PTAv increased with increasing age groups (P < 0.001), while the AB gap had no statistically significant difference when compared amongst the age groups. The present study was similar to that of Arlinger,[20] who tested 40 elderly with a mean age of 68. Their mean PTA average was 40 dB, and the mean AB gap was 3 dB. Megighian et al.,[21] in their study of 1370 participants, concluded that the hearing threshold rose progressively with age in both sexes. A similar positive correlation between increasing age and hearing loss was demonstrated by various studies in the past, such as those of Brant et al. (1996)[11] and Homans et al.[22] Kim et al. (2019).[23]

In our study, the mean value of SDS for the right ear was 82.72% ± 10.64% and 83.01% ± 10.9% for the left ear, ranging from 60% to 100% for both ears. These values were statistically not significant when compared between the two sides. When the SDS was compared with the age groups, it declined with each subsequent higher age group with a statistically significant difference (P < 0.001). The present study's findings were consistent with those of Baraldi et al.,[24] who tested 211 patients and revealed a significant performance difference in age groups where discrimination values significantly declined with age. Their study's average SDS was 75.73% for the right and 75.50% for the left ear. Arlinger[20] found that the SDS ranged from 20% to 98%, with an average of 83% and a median of 88% in their study of 40 elderly. Gimsing[25] also, when compared SDS with age in 269 participantsaged 60–89 years, found that SDS loss was much greater in those aged 70 years and above.

In our study, three types of audiometric configurations, namely Flat type, HFGS type, and HFSS type, were described when the pure-tone thresholds were plotted on the audiogram. These could be attributed to the three main types of Schuknecht's typology: trial or metabolic, cochlear, and sensory types of presbycusis, respectively. Flat-type (trial) audiogram was the most common, accounting for 39.31% of all audiogram shapes. HFGS (cochlear) was the second-most common type comprising 35.86% of all audiogram types. HFSS (sensory) type was the least commonly occurring, seen only in 24.83% of participants.

Similarly, Ogunleye and Labaran,[26] in their study of presbycusis, found the trial to be the most common type (29.9%) of presbycusis, followed by mechanical (22.4%), neural (20.9%), and sensory (10.4%) types. The results from the longitudinal studies of Vaden et al.[27] demonstrated that metabolic and metabolic + sensory phenotypes were more likely with increasing age.

Kaya et al. (2015),[28] in their study of 1134 subjects, deduced contrary results, HFSS configuration was the most commonly occurring at 48.5%, followed by the HFGS configuration at 26.9%, and the Flat configuration was 24.5%. Flat configurations were significantly more common in females, whereas HFSS configurations were standard in males. Sarafraz et al.[29] also gave contrasting results in their study on 560 with sensory patterns most frequent, detected in 360 (64.29%) of patients, followed by neural, conductive, and metabolic patterns in 16.25%, 59.54%, and 2.68% of patients, respectively. Forty participants (7.14%) showed a combination of sensory and neural patterns in audiometry. A sensory-neural pattern was more frequent among females (55%), while the four other patterns (sensory, neural, conductive, and metabolic) showed a higher frequency in men.

The PTAv values and SDS values were also compared for the different audiogram shapes in the present study, and it was found that mean of pure-tone thresholds for the Flat audiogram type was significantly higher than those for the HFSS and HFGS types. Thus, in the present study, it was seen that participantswith the Flat audiogram shape type had more hearing loss and poorer SDSs as compared to the HFGS and HFSS configurations.


  Conclusions Top


  1. The mean ± SD value for PTAv AC was 46.16 ± 12.22 dB for the left ear and 46.95 ± 12.32 dB for the right ear. The mean ± SD value for PTAv BC was 35.33 ± 11.24 dB for the left and 36 ± 11.27 dB for the right ear. The mean ± SD value for the AB gap was 10.82 ± 3.09 dB for the left ear and 10.93 ± 3 dB for the right ear. The SDS values were 83.01% ± 10.9% and 82.72% ± 10.64% for the left and right ears, respectively
  2. The present study also compared the PTAv AC, SDS, and AB gap between each age group and the values of PTAv AC values were found to increase with age. These values were statistically significant, and hence, it was seen that hearing loss increased with increasing age. When the AB gap was compared between the age groups, the difference was not statistically significant. And when a comparison of SDS was drawn between the age groups, it was seen to decline with each subsequent age group, with minimum values of 63% ± 4.24% for both ears being seen in the age group of 91–100 years. The difference in values of SDS was statistically significant, and it was seen that the ability to speech discrimination decreased with advancing age
  3. The grade of hearing loss was quantified at the time of examination of the participantsby using the value of PTAv AC in the better ear. The maximum number of participantshad mild hearing loss (48.28%)
  4. The audiogram shape was categorized into one of the following configurations: Flat, HFGS, and HFSS representing trial, cochlear conductive and sensory presbycusis. Overall, Flat configuration was the most commonly occurring (39.31%)
  5. The PTAv AC and SDS were compared between the three audiogram configurations. It was observed that the PTAv AC values were higher in the Flat configuration than in the remaining two configurations. The SDS values were lower for the Flat configuration) than those for the HFGS and the HFSS type. When compared between the audiogram shapes, the differences in the values of PTAv AC and SDS were statistically significant.


It was concluded that hearing loss increased with increasing age and SDSs decreased with increasing age. The hearing loss associated with presbycusis seen in the elderly was essentially symmetrical, with no significant differences being seen when audiometric parameters were compared between the two sides. The most common audiogram configuration seen in the study of presbycusis was the Flat type, followed by the HFGS and HFSS types. The audiogram configurations also varied significantly with the gender of the subjects. The Flat type showed a female preponderance, and the HFGS type showed a male preponderance. There was no significant association established between age and the audiogram configuration. Furthermore, participantswith Flat audiogram configurations corresponding to the trial type of presbycusis had more hearing loss (seen by higher mean values of PTAv) and poorer SDSs than the other two audiogram configurations.

Conflicts of interest

There are no conflicts of interest.

Ethics approval

Institute Ethics Committee GMC Jammu – IEC/GMC/2020/211.

Funding

Nil.

Author's contributions

Dr. Sugandha Sharma and Girja Thakur collected the data and did observations. Dr. Arvinpreet, your helped compile, arrange, proofread, search, and make final data into paper form, checking for plagiarism. Dr. Ajaydeep Singh is the one who assimilated the data, did all formatting and statistical analysis as well, and made conclusions.



 
  References Top

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Clark JG. Uses and abuses of hearing loss classification. ASHA 1981;23:493-500.  Back to cited text no. 15
    
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Correspondence Address:
Ajaydeep Singh,
Flat No. 22, I Block, Maharishi Markandeshwar University Campus, Mullana, Ambala - 133 207, Haryana
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/am.am_80_22




 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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    -  Thakur G
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