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An investigation into hearing loss among patients of 50 years or older

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To investigate the extent of hearing loss in an elderly sample population to estimate hearing disorders among the age–equivalent population in China and to study primary clinical characteristics of presbycusis.
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Journal of Otology 2011 Vol.6 No.1
Original Article
An investigation into hearing loss among patients
of 50 years or older
JI Fei, LEI Lei, ZHAO Su-ping, LIU Ke-fang, ZHOU Qi-you, YANG Shi-ming
Department of Otolaryngology/ Head and Neck Surgery, Chinese PLA Institute of Otolaryngology,
Chinese PLA General Hospital, 28 Fuxing Road, Beijing 100853, China
Abstract Objects To investigate the extent of hearing loss in an elderly sample population to estimate hearing dis
orders among the age-equivalent population in China and to study primary clinical characteristics of presbycusis.
Methods Clinical data from 110 hearing loss patients of both senium and pre-senium ages95 males and 15 fe
males, mean age = 74.4±12.1 yearswere reviewed. Patients aged from 50 to 59 years were accepted as the pre-seni
um control groupn=15. The 95 senium patients (> 60 years of age) were divided into 4 groups according to age:
60+ group60 to 69 years, n=25, 70+ group70 to79 years, n=26, 80+ group80 to 89 years, n=32and 90+
group90 years or older, n=12. Pure tone audiometry thresholds were measured in all 110 patients. Hearing loss se
verity of each tested ear was rated according to the Goodman classification criteria. Besides, audiometric configura
tion was examined in each ear. Results Audiometric testing showed normal hearing in 65 ears29.5%, slight to
moderately severe hearing loss in 131 ears59.5%, and severe and profound loss in 24 ears11%. Air-bone gaps
were found in 12 ears5.45%indicating conductive hearing loss. Except the 12 ears with conductive hearing loss,
audiograms showed gradually sloping loss in 99 ears45%, sharply sloping loss in 34 ears (15.45%), flat loss in 45
ears20.45%, notch pattern loss in 5 ears2.27%, trough and rising pattern loss in 2 ears0.91%, total deafness
in 2 ears0.91%, and normal hearing in 21 ears9.55%. On average, hearing thresholds increased at a rate of ap
proximately 10 dB per 10 year for subjects aged 60 and older. Conclusions Hearing thresholds tend to be stable in
presbycusis patients aged from 50 to 70 years, increase significantly between 70 and 80 years of age, and reach anoth
er stable stage at high levels after 80 years of age, especially in high frequencies. Hearing loss in middle frequencies
accounts for most of recession in loudness perception.
Key words elderly; presbycusis; hearing loss
Introduction
Presbycusis is the third most common chronic disease in
the world, which seriously affects the quality of life in el
der people. The main clinical manifestations of presby
cusis include symmetrical and slowly developing senso
rineural hearing loss, high pitched tinnitus and speech
recognition disorders. As the result of economic growth
and improved health care, China is gradually becoming
an aging society. Hearing loss is one of the most impact
ing chronic diseases on the quality of life in the Chinese
elder population.
1, 2
In clinical practice, an increasing
number of older patients complain of their communica
tion disorders induced by hearing loss. On the other
hand, there is a long way to go in epidemiological data
collection and analysis regarding presbycusis. In view of
this, we have focused on this population and conducted
systematic research. This article will report our primary
results of hearing investigation in patients who are 50
years or older and complain of hearing impairment.
Materials and Methods
Subjects
A survey was done in 110 patients95 males and 15
femalesover the age of 50 years with hearing loss as
the chief complaint. The male to female ratio was 6.3
Correspondence author: YANG Shi-ming, Department of Otolaryn⁃
gology/ Head and Neck Surgery, Chinese PLA Institute of Otolaryn⁃
gology, Chinese PLA General Hospital, 28 Fuxing Road, Beijing
100853, China Email: yangsm301@263.net
··44
Journal of Otology 2011 Vol.6 No.1
1. The age ranged from 50 to 96 years, with a mean age
of 74.4 years and a standard deviation of 12.1 years. The
subjects were divided into five groups: pre-senium con
trol group50 to 59 years, n=15. 60+ group60 to 69
years, n=25, 70 + group70 to79 years, n=26, 80 +
group80 to 89 years, n=32and 90+ group90 years or
older, n=12. History of the following diseases was ex
cluded from all the patients participating in this study:
genetic deafness, congenital deafness, drug-induced
hearing loss, sudden deafness, noise-induced hearing
loss, infections and systemic disease-related hearing
loss.
Test methods
All participants received pure tone audiometry testing
with a GSI61 audiometer in sound proof booth with am
bient noise level in compliance with national standard
GB/T 16403 AcousticsAudiometric test methodsBa
sic pure tone air and bone conduction threshold audiom
etry.
3
Both air and bone conduction thresholds were test
ed on each patient, using calibrated TDH 39 earphones
and B-71 bone vibrator respectively. Test procedures
followed GB/T16403. For each patient, the claimed bet
ter ear was tested first and then the other ear. Air con
duction threshold was measured first using Hugh
son-Westlake procedure and then bone conduction. The
frequencies testing sequences was 1 kHz, 2 kHz, 4 kHz,
8 kHz, 500 Hz and 250 Hz in air conduction, and 250
Hz, 500 Hz, 1 kHz, 2 kHz and 4 kHz in bone conduc
tion. The hearing loss severity of each ear was rated ac
cording to the classification criteria by Goodman as: to
tal deafness, profound hearing loss, severe hearing loss,
moderately severe hearing loss, moderate hearing loss,
slight hearing loss, and normal hearingTable 1.
4
The
audiometric configuration of all tested ears was charac
terized as: conductiveFigure 1-A, gradually sloping
Figure 1-B, sharply sloping (Figure 1-C), flatFigure
1-D, notchFigure 1-E, trough and risingFigure
1-F, total deafness, and normal.
Figure 1 Audiometric Configurations
AConductive hearing loss BGradually sloping CSharply sloping
DFlat loss Ftrough and risingENotch
Classification
Total deafness
Profound
Severe
Moderately severe
Moderate
Slight
Normal hearing
Criterion
average threshold at 0.5, 1, and 2 kHz
No response
>91dB
7190dB
5670dB
4155dB
2640dB
<26dB
n
2
1
21
31
65
35
65
Table 1 Distribution of hearing loss severity
Note: Classification criteria are based on those reported by Goodman1965
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Journal of Otology 2011 Vol.6 No.1
Results
Average air conduction thresholds in different age
groups for each octave frequency are listed in Table 2.
According to the Goodman criteriaTable 1, of all the
220 ears, the test showed normal hearing in 65 ears
29.5% , mild to severe hearing loss in 131 ears
59.5%and worse than severe hearing loss in 24 ears
11%Figure 3.
Hearing thresholds at each frequency were compared
among age groups using rank-sum test. The significance
was adjusted to 0.005 due to repeated use of rank-sum
test. There was no significant difference between 50 + ,
60 + and 70 + age groups at all 6 frequencies except
an age-associated deterioration at 8 kHzP < 0.005.
Thresholds in patients older than 70 years increased dra
matically at all frequenciesP < 0.005, with those in pa
tients older than 80 years significantly higher than those
in the 70+ groupP < 0.005. No significance was found
between 80 + and 90 + age groups at 250 Hz, 2 kHz, 4
kHz, and 8 kHzFigure 2.
Concerning the audiometric configuration, 12
Figure 2 Averaged Pure Tone Audiogram in Different Age Groups
Figure 3 Distribution of hearing loss severity
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Journal of Otology 2011 Vol.6 No.1
Figure 4 Proportions of different Audiometric Configurations
5.45%ears showed conductive hearing loss with obvi
ous air-bone gapFigure 1A. For the other ears, the
configuration was gradually slopingFigure 1Bin 99
ears 45%, sharply sloping Figure 1C in 34 ears
15.45% , flatFigure 1D in 45 ears20.45% ,
notch-shapedFigure 1Ein 5 ears2.27%, trough
and risingFigure 1Fin 2 ears0.91%, total deaf
ness in 2 ears (0.91% ) and normal hearing in 21 ears
9.55%Figure 4.
Discussion
Survey data have showed that there are about 130 mil
lion elderly people in China, 11% of the total popula
tion. It is expected that the elderly population will in
crease to more than 400 million around the year of
2040. Hearing impairment is a major issue the elderly
are faced with. Calculated from the results of second Na
tional Sample Survey on Disability, there are more than
13 million elderly patients suffering from presbycusis.
In people between 65 and 75 years of age, about 30%
have hearing loss, while in people older than 75 years
this proportion is higher than 50%.
1
The main clinical
manifestations of presbycusis include symmetrical and
g4 Discussion Survey data have showed that there are
about 130 million elderly people in China, 11% of the to
tal population. It is expected that the elderly population
will increase to more than 400 million around the year of
2040. Hearing impairment is a major issue the elderly
are faced with. Calculated from the results of second Na
tional Sample Survey on Disability, there are more than
13 million elderly patients suffering from presbycusis.
In people between 65 and 75 years of age, about 30%
have hearing loss, while in people older than 75 years
this proportion is higher than 50%.
1
The main clinical
manifestations of presbycusis include symmetrical and
gradually increasing sensorineural hearing loss, high fre
quency tinnitus and speech recognition disorders. These
will bring a series of psychological and emotional dis
tress to the elderly, such as depression, loneliness, anxi
ety, irritability, etc., thereby affecting quality of life in
older persons.
5, 6
Two major factors affect the incidence
control group
60+ group
70+ group
80+ group
90+ group
Mean±SD
250 Hz
17.5 ± 11.4
20.4 ± 12.0
30.4 ± 20.3
39.1 ± 16.6
49.6 ± 14.6
30.9 ± 18.7
500 Hz
18.3 ± 10.1
22.2 ± 14.1
37.0 ± 22.4
46.3 ± 17.5
58.4 ± 13.0
36.0 ± 21.2
1000 Hz
20.7 ± 11.7
27.3 ± 18.3
40.8 ± 23.1
51.3 ± 17.5
60.9 ± 9.6
40.1 ± 22.0
2000 Hz
25.3 ± 17.7
38.4 ± 22.2
46.9 ± 22.0
59.6 ± 16.9
65.0 ± 13.1
47.6 ± 22.9
4000 Hz
42.0 ± 27.8
52.2 ± 23.2
58.4 ± 16.6
71.0 ± 16.4
76.8 ± 11.3
60.3 ± 22.5
8000 Hz
32.7 ± 23.4
58.8 ± 17.8
66.1 ± 14.6
76.9 ± 11.1
80.5 ± 7.6
62.9 ± 21.8
Table 2 Mean air conduction thresholds in different age groupsdB HL
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Journal of Otology 2011 Vol.6 No.1
of presbycusis. First, industrialization and urbanization
bring about high level environmental noises which can
do chronic harm to hearing. Second, with the increase of
people's life expectancy, the impact of aging on the audi
tory system becomes increasingly prominent. There is a
strong need to investigate the status of elder people with
hearing loss in China. We have investigated into hearing
loss among Chinese elder adults who are over 50 years
old and complain of hearing impairment, in order to un
derstand general characteristics of this population. In
this paper, the preliminary results are reported.
The mechanism and inducement of presbycusis is
complex. In 1988 a work group of the Committee on
Hearing and Bioacoustics and BiomechanicsCHABA
of the National Research Council published a report on
speech-understanding problems in the elderly. In this
report, the etiology and risk factors of presbycusis were
comprehensively summarized: Understanding of presby
cusis may be flawed because physiological, pathological,
and environmental factors all undoubtedly contribute to
age-related hearing loss. Presbycusis is the sum of vari
ous types of hearing loss that result from several variet
ies of physiological degeneration. The degeneration can
result from noise exposure, exposure to ototoxic materi
als, systemic medical disorderssuch as arteriosclerosis,
hypertension, renal disease, diabetes mellitus, and
treatment of these disorders. Potential sites of disorders
have been identified as peripheral-auditory, central-au
ditory, or cognitive systems.
7
The complexity in mecha
nisms and causes of hearing loss in elderly patients
leads to a wide variety of audiometric configurations.
8
Such complexity can be seen from the results of this pa
per. In addition to conductive hearing loss with air-bone
gap, other configurations included gradually sloping,
sharply sloping, flat, notch, trough and rising curves, to
tal deafness and normal hearing. Variability in hearing
loss profiles reflects effects by various impacting factors
in different individuals.
In this paper, elderly subjects of different ages were
investigated. It can be seen from Table 2 and Figure 1
that hearing loss in elder adults generally shows a gradu
al deterioration especially in high frequencies., Hearing
loss is mild in the mid and low frequency area, but mod
erate to severe in high frequency area. Pure tone thresh
olds increase gradually along with age at a rate of about
10 dB/10year. Lee et al
9
analyzed pure-tone thresholds
in 188 elder adult human subjects to study longitudinal
changes in thresholds over a period of 3 to 11.5 years.
Subject initial ages ranged from 60 to 81 years, and
pure-tone thresholds at 0.25 to 8 kHz were measured. It
was concluded that on average, hearing threshold in
creased approximately 1 dB per year for subjects aged
60 and over, which was similar to our results. Lee et al
suggested that the rate of change in thresholds could be
affected by age, gender, and initial threshold levels.
Pure tone thresholds at 0.25 to 3, 10, and 11 kHz in fe
male subjects over 70 years changed faster than in fe
male subjects aged 60 to 69 years, while those in older
male subjects changed faster at 6 kHz than in younger
male subjects., Females had a slower rate of threshold
change at 1 kHz and faster at 6 to 12 kHz than males.
Subjects with higher initial thresholds at low and mid
frequencies tended to have faster changing rate at 0.25
to 2 kHz, and those with higher initial thresholds at mid
and higher frequencies tended to have slower changing
rate at 6 to 8 kHz in the following years.
9
From the current investigation, some preliminary con
clusions can be drawn. (1) Thresholds remain stable
from 50 to 70 years of age, except a significant deteriora
tion along with age at 8 kHz. (2) Thresholds increase dra
matically at all frequencies after 70 years of age. (3) Be
tween the 80 + and 90 + age groups, most threshold
changes are at only 500 Hz and 1 kHz but not at high
frequencies, indicating stable high-frequency hearing
sensitivity in patients over 80 years of age. The decline
in mid and low frequencies may lead to a significant de
cline in perception of loudness.
Acknowledgement
This work has been supported by the grants from
Hi-Tech Research and Development Program of China
973#2011CBA01000, National Natural Science
Foundation of ChinaNSFC#30871398, 30730040.
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4 Harrell RW. Pure tone evaluation. In: Handbook of clinical audiology
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7 Committee on Hearing. Bioacoustics and biomechanicsCHABA:
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Received May 27, 2011
··49
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Pure tone evaluation
  • R W Harrell
Harrell RW. Pure tone evaluation. In: Handbook of clinical audiology (5th Edition), Lippincott Williams & Wilkins, Philadelphia, 1997: 71-87.
CHABA) : working group on speech understanding. Speech understanding and ag• ing
Committee on Hearing. Bioacoustics and biomechanics(CHABA) : working group on speech understanding. Speech understanding and ag• ing. J Acoust Soc Am, 1988, 83 (3) : 859-895.