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Association Between Cardiovascular Health and Hearing Function: Pure-Tone and Distortion Product Otoacoustic Emission Measures

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A reduction in hearing sensitivity is often considered to be a normal age-related change. Recent studies have revisited prior ways of thinking about sensory changes over time, uncovering health variables other than age that play a significant role in sensory changes. In this cross-sectional study, cardiovascular (CV) health, pure-tone thresholds at 1000 to 4000 Hz, and distortion product otoacoustic emissions (DPOAEs), with and without contralateral noise, were measured in 101 participants age 10-78 years. Persons in the "old" age category (49-78 years) had worse pure-tone hearing sensitivity and DPOAEs than persons in the younger age categories (p < .05), affirming an age effect. Although hearing decline occurred in all persons in all CV fitness categories of every age group, those with low CV fitness in the old age group had significantly worse pure-tone hearing at 2000 and 4000 Hz (p <.05). Otoacoustic emission measurements were better for the old high-fit group but not significantly influenced by CV fitness level across age groups. Results of the current study elucidate the potentially positive impact of CV health on hearing sensitivity over time. This finding was particularly robust among older adults.
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Association Between Cardiovascular
Health and Hearing Function: Pure-Tone
and Distortion Product Otoacoustic
Emission Measures
Kathleen M. Hutchinson
Helaine Alessio
Miami University, Oxford, OH
Rachael R. Baiduc
Northwestern University, Evanston, IL
Purpose: A reduction in hearing sensitivity is
often considered to be a normal age-related
change. Recent studies have revisited prior ways
of thinking about sensory changes over time,
uncovering health variables other than age
that play a significant role in sensory changes.
Method: In this cross-sectional study, cardio-
vascular (CV) health, pure-tone thresholds at
1000 to 4000 Hz, and distortion product oto-
acoustic emissions (DPOAEs), with and without
contralateral noise, were measured in 101
participants age 1078 years.
Results: Persons in the oldage category
(4978 years) had worse pure-tone hearing
sensitivity and DPOAEs than persons in the
younger age categories (p< .05), affirming an
age effect. Although hearing decline occurred
in all persons in all CV fitness categories of
every age group, those with low CV fitness in
the old age group had significantly worse pure-
tone hearing at 2000 and 4000 Hz ( p<.05).
Otoacoustic emission measurements were bet-
ter for the old high-fit group but not significantly
influenced by CV fitness level across age groups.
Conclusions: Results of the current study
elucidate the potentially positive impact of
CV health on hearing sensitivity over time.
This finding was particularly robust among
older adults.
Key Words: distortion product otoacoustic
emissions, suppression, cardiovascular fitness,
pure-tone thresholds
Adecline in hearing sensitivity is considered a likely
consequence of age (Gates & Cooper, 1991; Hull,
1989). However, some initial signs of auditory ag-
ing start long before senescence. Early evidence of nerve
degeneration in the cochlea secondary to hair cell degener-
ation was reported by early adolescence nearly 40 years
ago (Johnsson & Hawkins, 1972). Numerous studies have
reported deterioration of hearing levels at 4550 years of age
and then a notable acceleration above 70 years (Gates &
Cooper, 1991; Robinson & Sutton, 1978; Ross, Fujioka,
Tremblay, & Picton, 2007; Shuknecht, 1955, 1964, 1974).
However, aging is only one of many factors that contribute
to a decline in hearing sensitivity. Hearing ability is also
commonly compromised by otologic and cardiovascular
(CV) disease and exposure to noise.
Previous studies have provided evidence that CV fit-
ness has a protective role in hearing preservation (Alessio,
Hutchinson, Price, Reinart, & Sautman, 2002; Cristell,
Hutchinson, & Alessio, 1998; Hutchinson et al., 2000; Ismail
et al., 1973; Kolkhorst et al., 1998; Manson, Alessio, Cristell,
& Hutchinson, 1994). CV fitness was the main health com-
ponent associated with hearing, with peak oxygen consump-
tion (VO
2
peak) as the basis for comparison. Other health
and fitness determinantsbody composition, blood pressure,
and blood lipidsdisplayed no significant relation to hearing
sensitivity (Hutchinson et al., 2000; Kolkhorst et al., 1998),
whereas muscle strength was inversely related to hearing
sensitivity (Hutchinson et al., 2000). Research in cellular
mechanisms in the cochlea revealed that cells under stress
from noise, ototoxic drugs, and aging generate proteins to
protect surviving cells. Several laboratories have demon-
strated positive protective pharmacological effects of specific
proteins against cochlear damage (Henderson, Bielefeld, Harris,
& Hu, 2006). Antioxidant research has allowed researchers
Research and Technology Paper
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to better understand the effects of certain nutrients on co-
chlear microcirculation. The results of one randomized
controlled trial demonstrated that participants who supple-
mented their diet with folic acid (an antioxidant that scavenges
free radical molecules) for 3 years evidenced improvement
in low-frequency behavioral thresholds (Durga, Verhoef,
Anteunis, Schouten, & Kok, 2007).
A common explanation of how CV fitness may influence
hearing sensitivity is through the effect on blood circulation,
especially to the organs and muscles of the inner ear, in
particular, the stria vascularis in the cochlea. Metabolism and
blood flow are directly related to the vascular pattern of
the cochlea. Reduction in blood circulation through the inner
ear can also cause reduced hearing sensitivity over time.
Variations in cochlear blood flow may affect the availability
of oxygen and glucose, which is more rapidly metabolized
during sound stimulation (Brant et al., 1996). This hypothesis
is difficult to assess in vivo; therefore, knowledge about
these interactions is based on descriptive and animal studies.
Any decrease in blood flow causes a disruption of the phys-
ical and chemical processes by which metabolic energy is
created in the cochlea (Cruickshanks et al., 1998).
There is evidence that regular exercise may play a role
in hearing conservation via improvements in circulation and
VO
2
peak. Ismail et al. (1973) had participants complete a
20-week-long physical fitness program, which improved
their CV fitness as measured by VO
2
peak, as well as their
baseline pure-tone thresholds (PTTs). A more recent in-
vestigation revealed improved pure-tone and temporary
threshold shifts in healthy, young adults with low-average
fitness levels who improved their VO
2
peak following
8 weeks of twice-weekly aerobic exercise (Cristell et al.,
1998). Hutchinson et al. (2000) and Alessio et al. (2002)
found PTTs to be specifically related to CV fitness, the prem-
ise being that high CV fitness levels are associated with
enhanced circulation within the vascular system. Neverthe-
less, two studies found no consistent pattern between fit-
ness level, exercise, and evoked otoacoustic emission (OAE)
amplitudes (Alessio et al., 2002; Engdhal, 1996).
A growing body of evidence has demonstrated the value
of evoked OAEs in addition to standard PTTs in revealing
the acute effects of noise and ototoxic agents (Engdhal &
Kemp, 1996; Ress et al., 1999). OAE testing has been
shown to reflect alterations in the cochlea and outer hair
cells before a significant hearing loss is present (Arnold,
Lonsbury-Martin, & Martin, 1999; Lonsbury-Martin &
Martin, 1990; Marshall & Lapsley Miller, 2007; Negley,
Katbamna, Crumpton, & Lawson, 2007). OAEs are useful
experimentally for evaluating the status of cochlear func-
tion in experimental models. They have proven valuable in
monitoring the effects of ototoxins and noise on cochlear
function. Furthermore, OAEs also provide a means to assess
the efferent system.
Though a number of studies have investigated the inter-
connection between CV health and hearing sensitivity (Alessio
et al., 2002; Hutchinson et al., 2000), there is no consensus
on the topic. This evidence to date prompts us to examine
more closely the relationship of CV fitness level and hear-
ing. The present study evaluated both pure-tone levels and
distortion product otoacoustic emission (DPOAE) measures
in a representative sample of more than 100 participants
categorized by age and fitness abilities. In this cross-sectional
study, data were gathered from participants who had been
screened for otologic disorders and evidence of noise-induced
hearing loss prior to assessment, thus reducing bias due to
underlying hearing disorders. It is hypothesized that a healthy
CV system attenuates the effects of age on hearing processes,
thus maintaining hearing sensitivity and cochlear function.
Design and Method
Participants
A total of 102 participants were volunteer members from
the central Midwest area, including Ohio and Indiana. All
potential participants reported good general health and hear-
ing ability. None reported smoking. The participants were
screened for middle ear disease with an otoscopic exam
and tympanometry demonstrating Type A tympanograms
(Jerger, Jerger, & Mauldin, 1972). No exclusions were made
for abnormal gradient or pressure. Participants with a uni-
lateral hearing loss or any evidence of noise-induced hearing
loss were excluded. One participant was excluded because
of his report of occupational noise exposure. As Table 1
shows, the participants comprised 67 women and 34 men.
Table 2 shows the mean PTTs across the audiometric fre-
quencies by age.
Procedure
PTTs at 1000, 2000, 3000, and 4000 Hz were obtained
by the standard Hughson-Westlake method using pulsed
tones generated by a diagnostic, clinical audiometer (Grason-
Stadler Model GSI 33) through insert earphones. Participants
were seated in a double-walled sound booth (Industrial
Acoustics Company) suitable for threshold testing (Ameri-
can National Standards Institute [ANSI], 2004). Participants
were then instructed to respond using a push button. Thresh-
old was determined as the softest level obtained two out
of three times on an ascending presentation run. Thresholds
at octave frequencies were obtained at 1000, 2000, 3000,
and 4000 Hz, in order of presentation. One ear of each par-
ticipant was selected randomly for testing.
Annual calibration of audiometric equipment was per-
formed according to ANSI (2004) guidelines. A listening
check was performed daily on audiometric equipment.
DPOAEs were recorded using an Otometrics Madsen
Capella 503 Cochlear Emissions Analyzer coupled to an
IBM personal computer with RS232 cables to present the
primary tones and record DPOAEs. Participants were seated
quietly and instructed to keep movement to a minimum.
Table 1. Sex and age with standard deviations.
Sex nAge (years) ± SD
Women 67 34.88 ± 18.9
Men 34 31.68 ± 15.3
Total 101
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The DPOAEs were recorded with the input/output (I /O)
function at an audiometric frequency of 4000 Hz by insert-
ing an adult ear probe into the test ear of each participant.
Good reliability has been found for DPOAE measurement
at 4000 Hz; DPOAEs in the midfrequency range are sen-
sitive to changes caused by aging and noise factors. The
I /O function of the 2f1-f 2 DPOAE (f1 = 3649 Hz) was
recorded. Briefly, I/O curves were obtained at 4000 Hz using
equilevel stimuli between 70 and 55 dB SPL in 5-dB incre-
ment steps. Because the growth of the distortion product
(DP) varies by primary tone level differences (Kummer,
Janssen, & Arnold, 1998), the growth of the DPs was mea-
sured at equal levels. A limitation of this DPOAE instrument
is its inability to vary tone levels continuously instead of
in discrete steps. A measurement was considered valid if the
signal-to-noise ratio was +3 dB SPL or better (Cilento, Norton,
& Gates, 2003). Response amplitude at the four intensity
levels was assessed both with and without contralateral white
noise.
To assess efferent suppression, the DPOAE was recorded
in both the presence and absence of contralateral suppression
supplied by white noise (bandwidth of 1600 to 8000 Hz) pre-
sented continuously at 84.1 dB SPL by a Beltone 2000 audio-
meter using an insert earphone in the opposite meatus. Prior
to stimulation, the check probe fitprocedure was performed
to ensure accurate fit of the DPOAE probe as well.
The amplitude of the DPOAE responses in relation to
the noise floor was noted for each of the eight test conditions;
those with a +3-dB SPL signal-to-noise ratio were accepted
as valid DPOAEs. The proportions of valid DPOAEs at
55 dB SPL without and with contralateral noise were .96
and .95, respectively; the proportions of valid DPOAEs at
70 dB SPL in the same two conditions were .97 and .98, re-
spectively. The DPOAE data collected at 60 and 65 dB SPL
were not included in this report because they paralleled
the findings at 55 and 70 dB SPL; additional analyses of re-
peated measures at all SPLs might reduce the power to detect
differences without additional contribution to the experi-
mental questions.
VO
2
peak was determined using either a maximal or
a submaximal graded exercise test protocol on a Monark
Bicycle ergometer. Participants began by pedaling at
50 revolutions/min against a 1-kg resistance for 2 min.
Thereafter, resistance was increased 0.5 kg every 2 min.
Heart rate response, blood pressure, and respiratory gases
were monitored continuously throughout the test. Oxygen
uptake was measured by the open-circuit method using a
low-resistance, two-way breathing valve. Respiratory gases
were analyzed for CO
2
and O
2
concentrations on Ametek gas
analyzers. Modified regulations that required a physician to
be present when administering maximum graded exercise
tests to participants age 35 years and older forced a switch
to use of submaximal exercise tests for most of the partic-
ipants in this study (American College of Sports Medicine,
2000). The VO
2
peak was calculated using a standard Young
Mens Christian Association (YMCA) submaximal graded
exercise test (Sanders & Duncan, 2006). No test had to be
terminated due to participant report of angina or any other
abnormal exercise response.
Statistical Analyses
Analyses were done with SPSS Version 16.0. The data
were first summarized and examined for outliers and con-
sistency. Multivariate analyses of variance (MANOVAs)
were done for four age categories and three fitness levels
using PTTs and DPOAE amplitudes as dependent variables.
Participants were divided into four age categories containing
22 to 27 participants for analysis purposes: youth = 10 to
19 years; young adult = 20 to 27 years; middle-aged adult =
28 to 48 years; old adult = 49 to 78 years. Dividing participants
into four groups for initial analysis enabled large enough
samples (n=2226) to avoid single participants overwhelming
an average across-aged adult responses. The old age par-
ticipants were lowest in number (n= 22) and spanned the
widest age range. The VO
2
peak was also analyzed as a
categorical variable to represent an individuals CV fitness
level (high, medium, or low). In other words, the VO
2
peak
parameters indicated whether an individuals fitness level
acted as a buffer for age-related hearing decrement. Low-fit
individuals had an aerobic capacity equal to the least fit 20%
of the population for that age group and sex (Sanders &
Duncan, 2006). Moderately fit participants had an average
aerobic capacity equal to 20%59% of the population for that
age group and sex. The high-fit group had an aerobic capac-
ity equal to the most fit 60%100% of the population for
each age group and sex.
It has been shown that the individuals in the highest
fitness level should show less of an age-related impact on
pure-tone and DPOAE amplitude test results than those
individuals in the lowest fitness level (Alessio et al., 2002).
A value of p< .05 was set as the level of statistical sig-
nificance for all tests reported here. Because significant
Table 2. Mean pure-tone thresholds by frequency and age groups with standard deviations.
Age classification n
1000 Hz 2000 Hz 3000 Hz 4000 Hz
M SD M SD M SD M SD
Youth 26 3.65 4.80 2.31 6.81 3.65 6.09 3.85 6.05
Young adult 27 3.89 5.43 2.22 5.93 4.63 8.42 4.63 7.32
Middle-aged adult 26 10.38 9.04* 8.08 8.49* 12.12 8.38* 17.12 10.50*
Old adult 22 11.82 7.95* 10.23 9.1* 14.09 10.3* 15.00 12.53*
*p< .05.
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interactions were present, separate MANOVAs were done for
age and fitness variables.
Amplitude measurements obtained at 55 dB and 70 dB SPL
and PTTs for the same ear were compared by participants
CV fitness level by age group. Previous research has detailed
no effect of sex on DPOAE results (Sheppard, Brown, &
Russell, 1996); therefore, no separate sex analyses were done.
Results
Participant Information
Table 1 illustrates the demographic characteristics of
the participants. Audiometric and DPOAE test results for
67 women and 34 men were analyzed. The mean age of the
women was 34.88 years (SD = 18.9; range = 1078), and
the mean age of the men was 31.68 years (SD = 15.3; range =
1056). The sex age difference was not significant, F(1, 100) =
0.73, p> .05.
Table 2 illustrates the means of the PTTs by age group;
pure-tone levels increased with age, with more variability
in the middle and old age groups. Ninety-four percent of
the participants had normal PTTs (i.e., 25 dB HL) at all
audiometric frequencies. Examination of Table 2 shows
mean thresholds at 1000, 2000, 3000, and 4000 Hz were
worse for the middle and old age groups compared with the
two younger age categories.
Table 3 shows the mean DPOAE amplitudes both with-
out and with contralateral noise at two intensity levels. The
DPOAE amplitudes show a similar pattern to PTTs, with
values worsening with increasing age among the middle and
old age groups at both intensity levels. Table 3 also illustrates
better DPOAE thresholds at 70 dB SPL without noise in
comparison to two mean thresholds at 55 dB SPL (with and
without contralateral noise).
Suppressive effects did not increase with emissions evoked
at lower levels. In fact, some ears exhibited an enhance-
ment of amplitudes with contralateral noise. However, mean
DPOAE magnitude did not change as systematically with
age compared to the PTTs with age; much more variability
was found at both intensity levels and age classifications.
Testretest changes have been found in the magnitude of
DPOAEs with multiple measurements (Kim, Frisina, &
Frisina, 2002).
Values of the VO
2
peak measurements ranged from
17.2 to 78.6 ml/kg /min, with a mean of 37.6 (SD = 11.4;
see Table 4). Because the three fitness categories were de-
termined by participant age and sex, both classification
values are listed. Although absolute mean levels appear
consistent across age classifications, analysis of variance
(ANOVA) follow-up test results show that the values for the
youth group classification were significantly better than the
old age group, F(3, 100) = 3.78, p<.05.
MANOVA Results
Considering age as a categorical variable, a MANOVA
model tested using the age category as a factor and PTTs
measured at 1000 to 4000 Hz as dependent variables. Figure 1
illustrates better hearing levels across frequencies in the two
younger groups compared with the old group, in which the
pure tones were worse, F(3, 100) = 13.14, p< .05. Dunnetts
post hoc tests point to a significant drop-off in pure-tone
hearing sensitivity in the middle-aged group and continued
in the old age group at 1000, 2000, 3000, and 4000 Hz (see
Table 2).
A MANOVA using fitness level as a factor (i.e., VO
2
peak) and pure-tone responses as dependent variables in-
dicated significantly better thresholds for the high- versus
low-fit participants at 1000 Hz, F(2, 100) = 2.01, p< .05.
Although hearing decline occurred in persons in all CV
fitness categories of all age groups, a MANOVA performed
using both age and fitness level as factors showed that
those with low CV fitness in the old age group had sig-
nificantly worse pure-tone hearing at 2000 Hz, F(6, 100) =
2.30, p< .05, and 4000 Hz, F(6, 100) = 4.56, p< .05. The old
Table 3. Mean distortion product otoacoustic emission amplitudes (dB SPL) by intensity and age groups with standard deviations.
Age classification n
55 dB 70 dB 55 dB suppressed 70 dB suppressed
M SD M SD M SD M SD
Youth 26 4.77 7.68 15.2 8.29 5.82 7.84 17.33 5.55
Young adult 27 0.078 7.16 11.72 8.54 0.004 7.85 13.23 6.17
Middle-aged adult 26 7.283 9.74 0.185 10.3 7.88 8.95 9.22 5.82
Old adult 22 12.110 10.79 0.108 12.6 11.55 10.51 4.64 12.80
Table 4. Mean oxygen consumption values by age group and
gender with standard deviations.
Age classification n
VO
2
peak
MSD
Youth
Female 16 40.24 9.77
Male 10 43.49 14.81
Young adult
Female 20 39.10 10.52
Male 7 42.00 5.83
Middle-aged adult
Female 14 32.34 8.76
Male 12 41.36 11.92
Old adult
Female 17 30.09 11.03
Male 5 36.51 12.87
Total 101
Female 67 35.67 10.82
Male 34 41.40 11.77
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high-fitness levels hearing values were consistently better
than the mean thresholds of the low-fitness levels in the same
age group.
The two-factor ANOVA model was repeated to assess
the factors of CV fitness and fitness level on DPOAE am-
plitudes at 4000 Hz at two intensity levels, with and without
contralateral noise. Figure 2 illustrates the mean DPOAE
thresholds categorized by age and fitness categories. The
DPOAE thresholds at 55 dB and 70 dB SPL were signifi-
cantly better in the youth and young groups in comparison to
the two elder age groups, F(3, 100) = 9.26, p< .05. Similarly,
the DPOAE level with contralateral noise at 55 dB SPL
was also significantly better in the youth group (1019 years)
compared with the middle-age and old age groups, F(3, 100) =
8.11, p< .05. There was no statistical separation of the fit-
ness level factor on DPOAE amplitude in any test condition
across age groups ( p> .05).
Multivariate regressions of PTT and DPOAE amplitude
on age were done at each frequency for each fitness level.
Linear regression estimated the coefficients of the linear
equation involving the two continuous independent variables,
VO
2
peak and age, that best predicted PTTs and DPOAE
amplitudes. For each value of the independent variables,
the distribution of the PT and DPOAE variables was normal.
The mean rates of change and the slope coefficient (b) with
age and fitness are displayed in Table 5. As expected, the
slopes of the pure-toneage functions increased with increas-
ing frequency. That is, pure-tone levels increase with increas-
ing age, representing age-associated hearing loss. These
differences were significant (p< .05) for all comparisons by
frequency and age. The pvalue of each predictor measures
the unique effect of age and fitness on the variance of the
PTTs after the effects of each of the other predictors on PTTs
have been accounted for. Therefore, the pvalue of VO
2
peak
(range =.00.23) measures the amount of unique variance
it explained for the PTT after accounting for the effects of age.
PTTs systematically increased, indicating compromised
hearing, with decreasing fitness levels.
In Table 5, the rate of change (b) with age in the DPOAE
amplitudes is shown at the two intensity levels; the slopes
varied only slightly by intensity, and values also deteriorated
with age. The slopes of the DPOAEage functions were
statistically significant ( p< .05). The pvalue of VO
2
peak
(p= .03) illustrates the significant positive impact of fitness
Figure 1. Mean pure-tone (PT) threshold at 1000, 2000, 3000, and 4000 Hz (±SD) by fitness level and age classification. The population
was separated into 4 age groups with similar numbers of people in each group.
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level on DPOAE amplitude at 55 dB SPL accounting for the
effects of age.
Table 5 also displays the slope coefficient (b) for the effect
of age and fitness on DPOAE at the two intensity levels
when amplitude values were adjusted for hearing threshold
level at 4000 Hz; the decline in DPOAE amplitude was
attributable to the worsening auditory thresholds. Patterns
of DPOAE amplitudes measured with contralateral noise
were similar to results found in Table 5. The unique variance
of fitness level did not significantly account for DPOAE
Figure 2. Mean distortion product otoacoustic emission (DPOAE) thresholds by age and
intensity level (±SD).
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amplitudes after accounting for the effects of the PTT at
4000 Hz. Multivariate regression findings were consistent
with the MANOVA results.
Discussion
Of the various age, genetic, environmental, and lifestyle
interactions that affect hearing sensitivity, there is one var-
iable, CV fitness, that is potentially modifiable. The main
result reported in this article was a significant positive impact
of fitness level on PTTs among old adults. Previous stud-
ies have reported benefits to PTTs in young adults who
participated in regular exercise. However, there has not
been a systematic study of hearing sensitivity using both
pure-tone and DPOAE in young and old persons of differ-
ing CV fitness levels. This information may contribute to
understanding the role of CV fitness in protecting and pre-
serving hearing at different ages. Clinicians may benefit from
gathering a more detailed CV history from their patients,
including presence of hypertension, blood pressure, hyper-
lipidemia, and physical activity each week.
In our cross-sectional design, mean pure-tone hearing
level was most sensitive in the younger age groups. Figure 1
illustrates better hearing levels in the younger groups com-
pared with the old group (age 4978 years). Hearing levels
for the 1027-year-old participants primarily ranged be-
tween 5 and 15 dB HL, whereas the participants age 28
and older ranged between 0 and 40 dB HL across fitness
categories. Variability within categories is more evident in
the mid- and low-fit levels, showing more dramatic changes
between the teen years and early 20s versus middle to old age
groups. The PTT range of the high-fit category indicated a
narrower range of hearing levels and more consistent, sen-
sitive levels.
Nevertheless, the cross-sectional snap shots(see Figure 1)
indicate that pure-tone hearing sensitivity is not consistently
associated with better CV health at all frequencies. Hear-
ing levels were similar in teens and 20-year-olds within all
fitness levels; an increase in pure-tone hearing sensitivity,
indicating worse hearing, was observed in the middle and old
age range. For the study participants, however, mean PTTs
at 2000 and 4000 Hz were significantly better within the
high-fit compared with the low-fit old adult group.
Earlier reports have observed significant associations be-
tween CV fitness and hearing sensitivity (Alessio & Hutchinson,
1991; Cristell et al., 1998; Hutchinson et al., 2000; Manson
et al., 1994). Other laboratories have reported similar re-
sults using criteria such as VO
2
peak, blood pressure, and
percentage body fat to distinguish persons with low and
high CV health (Axelsson & Lindgren, 1985; Ismail et al.,
1973). Alessio et al. (2002) illustrated better hearing thresh-
olds among high CV health fitness participants compared
to the low and medium fitness level groups only at the older
ages (i.e., over 55 years). Age 50 appeared to be a separa-
tion point, after which fitness level and age were related in
a statistically significant direction, with high fitness being
positively related to better hearing levels (Alessio et al.,
2002). In the current study, primary changes were most prom-
inent for individuals over 60, especially at 4000 Hz or above.
Figure 2 illustrates the decrease of DPOAE amplitude
across the age groups by fitness categories. Results show
highest amplitudes for all younger participants at both the
55- and 70-dB SPL stimulus levels. CV fitness, as an isolated
variable, resulted in stabilization of amplitudes as the par-
ticipants increased in age over 49 years at both intensity
levels. This demonstrated a protective effect of CV fitness on
hearing; participant age and 4000-Hz PTT appeared to drive
the decrease in levels. Similarly, DPOAE amplitudes with
contralateral noise did not exhibit sensitivity to CV health
status. In some ears, a small enhancement of DPOAEs
created by contralateral stimulation was observed. Similar
findings have previouslybeen reported (Grazyna, Smurzynski,
Morawski, Namyslowski, & Probst, 2002). With lower and
higher levels of fitness, the clinical performance of DPOAEs
did not separate groups for early identification for suscep-
tibility to hearing loss. The DPOAE results are consistent
with Hutchinson et al.s (2000) findings; no association was
found between fitness and muscle strength measures and
DPOAE measures. Cilento et al. (2003) examined the effects
of age and PTT shift and also found much variability in
DPOAE findings.
Measurement of DPOAEs exhibits properties of sup-
pression, tuning, and vulnerability closely paralleling the
properties of hearing. Gains in CV fitness result in changes
in underlying physiological mechanisms such as cerebral
structure and both cerebral and cochlear blood flow (Colcombe
& Kramer, 2003; Torre, Cruickshanks, Klein, Klein, &
Nondahl, 2005). CV improvements have led to improved
visuospatial and executive control processes. Corticofugal
activity has been shown to influence efferent suppression
of OAEs (Perrot et al., 2006). Ipsilateral sound stimulation
suppresses the contralateral sound-evoked excitation of
almost half of inferior colliculus neurons (Faingold, Gehlbach,
& Caspary, 1989; Rose, Gross, Geisler, & Hind, 1966). If
cortical function is a beneficial consequence of CV fitness
training, then subcortical modulation of the evoked OAEs
measured from the contralateral ear could also be influenced.
The present DPOAE suppression results exhibited much
variability and were not sensitive to differences in the func-
tion of the efferent system between fitness levels.
Current results support the statistical inferential associa-
tion between CV fitness and pure-tone hearing ability pres-
ervation across a 68-year time period. Moderate and high
CV fitness levels have protected against temporary hearing
loss caused by noise (Hutchinson et al., 2000; Manson et al.,
1994). Current concepts in auditory physiology include
an active mechanism that serves to counteract the effects
of trauma and stress (Campbell et al., 2003; Henderson,
Table 5. Slope (bcoefficients) and significance ( pvalues) at
55 and 70 dB SPL accounting for pure-tone hearing threshold at
4 kHz.
Value 55 dB SPL 70 dB SPL
b(pvalue) Age .215* .218*
VO
2
peak .092 .093
4 kHz .455* .417*
*p< .05.
32 American Journal of Audiology Vol. 19 2635 June 2010
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Subramaniam, & Boettcher, 1993; Patuzzi, 1992). The
observations that hair cells contain specific proteins that
undergo changes in expression with slight edema suggest
that active elements exist to protect tissue from damage.
Suchproteinsmayalsoplaykeyrolesinprotectingthe
hair cell from metabolic and aging changes, as has been
suggested as the function of stress-induced proteins (Campbell
et al., 2003; Lindquist, 1986). Other studies have also raised
the possibility that stress proteins could protect the auditory
periphery from damage due to noise, ototoxic drugs, or trauma
(Patuzzi, 1992).
A limitation of this study is that it was a cross-sectional
analysis of the relation between fitness and hearing func-
tion. Directionality associations cannot be inferred from this
investigation, as cochlear and brainstem function preceded
fitness level achievement or the measured fitness level pre-
ceded auditory function. Another limitation of this study
was self-reported history of lifestyle factors (i.e., smoking,
noise exposure, medication use, activity, and alcohol). Some
participants may have misrepresented their health history
during the questionnaire interview. Misinformation may
bias the association either in favor or away from the null
hypothesis. An evaluation of the pure-tone levels and DPOAE
levels of participants in a 5-year follow-up study may help
clarify whether cochlear hearing function is influenced by
CV health. Despite the adequate sample size, comparison of
these results with otherCVanalysesof age-related hearing loss
will be an important next step to confirm the long-term effects
of health on cochlear function.
Accumulating evidence has pointed to a large number
of physiological, psychological, and sociological risk factors
that are either directly or indirectly related to late-onset
hearing loss (Gates & Cooper, 1991). Although different
mechanisms underlie these various types of stressors, com-
monalities exist including free radical formation and alter-
ations in the bodys antioxidant activity (Wang, Puel, &
Bobbin, 2007). The current state of knowledge regarding the
interaction of risk factors for hearing loss is still limited.
Genetics, nutrition, and pharmacological factors have been
shown to play a role in the susceptibility to hearing loss
(Campbell & Rybak, 2007; Gates, Schmid, Kujawa, Nam,
&DAgostino, 2000; Wang et al., 2007). It is generally
accepted that antioxidative mechanisms in the vasculature
protect the auditory system from excessive free radical
formation. An imbalance favoring free radicals over anti-
oxidant activity results in oxidative stress and may result in a
suppressed ability to repair cellular function (Cruickshanks
et al., 1998). Antioxidant levels can be increased from nu-
tritional supplementation as well as with regular exercise. A
large number of exercise studies, both acute and chronic
(Alessio & Blasi, 1997), indicate a protective role of regular
exercise in boosting antioxidants, especially during exer-
tion or stress, when free radicals are elevated. In this way,
physical activity positively affects cellular mechanisms
related to oxidative stress.
In summary, although hearing sensitivity and age were
negatively related, considerable variability existed among
hearing levels for the old adult cohorts as well as within the
different fitness categories. High CV fitness was associated
with the best PTTs in the old adult participants, suggesting
that high CV fitness protected and preserved hearing in
high-fit persons regardless of other factors. In the teens and
20s, persons with moderate and low CV fitness displayed
good hearing between 5 and 15 dB HL, experienced worse
hearing as they became older, and demonstrated high var-
iability in hearing threshold levels. The DPOAE thresholds
appeared at higher amplitudes among the younger partici-
pants and stabilized among the most fit participants as they
aged.
Most certainly, the dedicated and steady accumulation
of scientific knowledge about the processes that protect hear-
ing decrement lay the basis for developing successful clinical
applications for incorporation of remediation approaches.
The ways regular physical activity affect health and longev-
ity have, in the past, focused on improved CV health and
cancer prevention. Another explanation is that physically
active individuals may be better equipped to handle acute
oxidative stress associated with disease or other metabolic
stressors (Colcombe & Kramer, 2003). While a general mea-
sure of physical fitness using maximum oxygen consumption
may be less sensitive to subclinical circulation patterns, the
current study points to the beneficial influence of CV health
on hearing function, especially as one ages.
Conclusions
Multiple pathophysiological factors participate in wors-
ening auditory sensitivity. Three conclusions can be drawn
from the present cross-sectional study:
1. Hearing sensitivity is at its peak in the teens and 20s,
regardless of fitness level. PTTs decline over time;
however, compared to the low CV fit persons, the high
CV fit persons have more sensitive thresholds after 50 years
of age.
2. After age 49, persons with low CV fitness had worse
hearing levels than persons with high CV fitness from
1000 to 4000 Hz.
3. The DPOAE amplitudes were stronger among the
younger age cohorts and were observed to stabilize
among the old age participants with high-fitness level.
Acknowledgments
The authors acknowledge support from Miami Universitys
Undergraduate Summer Scholars program and the College of Arts
and Science Deans Scholar program.
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Received April 9, 2009
Revision received July 3, 2009
Accepted December 21, 2009
DOI: 10.1044/1059-0889(2009/09-0009)
Contact author: Kathleen M. Hutchinson, Department of Speech
Pathology and Audiology, Miami University, 2 Bachelor Hall,
Oxford, OH 45056. E-mail: hutchik@muohio.edu.
Hutchinson et al.: Cardiovascular Health and Hearing 35
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Reproducedwithpermission ofthecopyrightowner.Furtherreproductionprohibitedwithoutpermission.
... 1 The pathophysiology of noise-induced hearing loss (NIHL) is associated with a range of factors including age, smoking, health-related fitness, poor glycemic content and blood lipids, atherosclerosis, oxidative stress, heat shock protein response, cellular adhesion molecule accumulation, C-reactive protein, damage to cochlear outer hair cells, and auditory nerve degeneration. [2][3][4][5][6][7] Hearing loss may also be caused by physical dislodging of hair cells during acoustic trauma or detachment of the basilar membrane as a result of rapid acceleration rates. 8 In 2015, WHO estimated that over a billion young people are at risk of developing hearing loss due to their habit of listening to music at loud levels and for prolonged periods of time. ...
... 13,14 The synergistic interaction of healthy cardiovascular and auditory systems has been affirmed by many studies over time. 3,5,12,15 Previous research has established a significant protective effect on hearing sensitivity for persons with healthy cardiovascular systems, as measured by maximum oxygen consumption (VO 2 max), 5,16-18 blood pressure, cholesterol, 19,20 and body composition. 18,21 Persons with healthy cardiovascular fitness and body composition indices are likely to have lower blood pressure, higher oxygen uptake, and healthier blood lipid profiles, all of which are associated with unobstructed blood flow, oxygen, and nutrient delivery to the organs and muscles of the inner ear, in particular, the stria vascularis in the cochlea. ...
... 18,21 Persons with healthy cardiovascular fitness and body composition indices are likely to have lower blood pressure, higher oxygen uptake, and healthier blood lipid profiles, all of which are associated with unobstructed blood flow, oxygen, and nutrient delivery to the organs and muscles of the inner ear, in particular, the stria vascularis in the cochlea. 5,15 In a study of 101 participants ranging in age from 10 to 78 years, those with low cardiovascular fitness in the older age group had significantly greater pure tone hearing levels measured at 2 k and 4 kHz compared with age-matched moderate and high fit individuals. 5 NHANES data show that during teenage and young adult years, hearing sensitivity peaks relative to persons age 50 years and older. ...
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Objectives This study examined the association between pure tone hearing sensitivity and music listening behaviors among traditional college-aged students and sought to determine factors that mediate hearing sensitivity, including health and fitness levels, gender, and personal listening device (PLD) use. Methods A convenience sample of college students (N = 182; 133 females, 49 males, mean age = 19.8 ± 1.4 year, average PLD use = 1.52 ± 7.1 hours•day ⁻¹ ) completed hearing assessments, music listening behavior questionnaires, and health and fitness tests. Results Most students listened to music at safe intensity levels (<80 dBA), though 18% had higher hearing levels (≥25 dB HL at one of the measured frequencies). Longer listening duration behavior approached but did not reach a statistical association with compromised hearing sensitivity. Of all variables measured, including cardiovascular health, fitness, and music listening, two variables: total cholesterol: triglycerides (TC:TG) and total cholesterol: high-density lipoproteins (TC:HDL) significantly associated with hearing sensitivity at 2 kHz. The odds hearing loss occurring at 4 kHz was 59% lower in females compared with males. Conclusion The majority of college students had healthy music listening behavior and fitness, contributing to normal hearing sensitivity in most. In cases where greater hearing threshold levels at one or more frequencies was detected, TC:HDL and TC:TG were statistically related and at 2 kHz, males were more likely to demonstrate higher listening levels compared with females of similar health and fitness level.
... Indeed, there is seemingly converging evidence that auditory functions and CV health are associated. [34][35][36][37][38][39] Furthermore, a causal relationship between CV health and auditory functions has been demonstrated by improvements in CV health following a physical-exercise program, resulting in better peripheral hearing functions. [40] However, not all studies investigating CV health and auditory functions found evidence in favour of the existence of a link between the two. ...
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... Regular physical activity has been associated with better weight control, reduction in the risk for cardiovascular disease (CVD), Type 2 diabetes, and some cancers [28]. A connection has been noted between low cardiovascular fitness and reduced hearing levels in individuals over the age of 49 in specific frequency ranges [29]. The direction of this relationship was not established though. ...
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... U źródeł problemów sercowo-naczyniowych można doszukiwać się czynników podobnych do tych, które wywołują równocześnie uszkodzenie słuchu. Dwa odrębne zespoły badawcze -pod kierunkiem Petera Torre'a (2005) oraz Kathleen Hutchinson (2015) zwróciły uwagę na czynniki ryzyka wpływające na powstawanie chorób sercowo-naczyniowych i uszkadzające komórki zmysłowe w ślimaku: nadciśnienie, palenie tytoniu oraz wysoki poziom cholesterolu. Wyniki badań prowadzonych w wielu ośrodkach na świecie nie są jednoznaczne. ...
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Celem publikacji był opis trudności, z jakimi na co dzień zmagają się osoby starsze z uszkodzeniem słuchu, oraz zaproponowanie rozwiązań, które mogą być pomocne w codziennym funkcjonowaniu tych osób. Do przedstawienia uniwersalnych trudności związanych z niedosłuchem wykorzystano najnowszą literaturę przedmiotu, w szczególności raport fundacji Hear-It Hearing Loss: Numbers and Costs Evaluation of the Social and Economic Costs of Hearing Impairment (Shield, 2019) oraz raport EuroTrak Poland by EHIMA (Anovum, 2019). Książka zawiera także wyniki badań pilotażowych przeprowadzonych na grupie 144 Polaków w wieku powyżej 65 roku życia. Przesiewowy test Hearing Handicap Inventory Screening Questionnaire for Adults (HHISQA) pozwolił na rozeznanie, jaka jest samoocena słyszenia i poziomu satysfakcji z życia badanych. Analiza obejmowała osoby korzystające i niekorzystające z aparatów słuchowych. Założeniem było ustalenie, ile osób zgłasza trudności w zakresie percepcji słuchowej oraz ocena rodzajów, sytuacji i miejsc pogarszających ich słyszenie.
... Several studies in developed countries have been conducted to find out whether hypertension is one of the risk factors for hearing loss. The results have been contradictory with some showing positive correlation 6-8 while others have shown no relation between hearing loss and hypertension 9,10 with that in mind this study was conducted to ascertain whether hypertension is a risk factor for hearing loss in our setup where such data is not available. As to the methodological characteristics of this study, the case is taken in outline with the age factor, focusing on the age range of middle aged individuals, between 45 and 65 years, all being hypertensive patients. ...
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Background: The impact of adult nutrition on hearing acuity is poorly researched. This study was designed to examine relationship between nutritional status (using body mass index [BMI]) and hearing impairment. Methods: Data from the Bayero University Ear and Hearing Health Examination Survey 2017 were used. This was a community-based, cross-sectional descriptive survey of a sample of Tofa community in Kano State. Out of 650 participants, only 103 fulfilled the criteria designed for this study. Pure tone audiometric testing was performed to assess for hearing impairment. Analysis was conducted for associations between hearing impairment and BMI. Results: Prevalence of hearing impairment among adults in this population is 26.2%. Mean documented age of the participants was 41.6 years (standard deviation: ±18.55). Majority of the participants had low BMI, signifying underweight (n = 89; 86.4%) out of which 21 (23.5%) had a moderate-to-profound hearing loss. Conclusion: These findings provide some evidence that adults with a low BMI (underweight) may also be at a risk of hearing impairment; however, more research is required. Adult malnutrition also deserves more attention. Keywords: Adults, body mass index, community survey, hearing acuity, Kano
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Objective: Distortion product otoacoustic emissions (DPOAEs) are sensitive to early indices of cochlear pathology. Pathology to the cochlea is in part mediated by ischaemic related mechanisms. We propose that DPOAEs may provide an objective measure of cardiovascular risk. Design: Cross-sectional. Study sample: The relationships between stroke risk and DPOAEs of 1,107 individuals from the Jackson Heart Study (JHS), an all-African-American cohort, were assessed. Linear regression models were used for analysis among all participants and delimited to normal hearing, defined as either a pure-tone threshold average of 500, 1000, 2000, and 4000 Hz (PTA4) ≤ 25 dBHL or pure-tone thresholds for all individual tested frequencies for each ear (500, 1000, 2000, 4000, and 8000 Hz) ≤ 25 dBHL. Results: We observed a significant inverse relationship between DPOAE amplitudes and stroke risk scores in the pooled cohort and in the subgroups with normal hearing defined by pure tone thresholds. Participants in the high-risk group had significantly lower DPOAE amplitudes than those in the low stroke risk group. Conclusions: Our results indicate that auditory dysfunction as measured by DPOAEs are related to stroke risk. Further prospective studies are needed to determine if DPOAEs could be used as a predictive tool for cardiovascular disease.
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Objectives: To evaluate the relationships among the overall cardiovascular health scoring tool, Life's Simple 7 (LS7), and hearing in an African-American cardiovascular study cohort. Methods: Using the Jackson Heart Study's cohort of African Americans, the relationships between the LS7 scoring metric and hearing of 1314 individuals were assessed. Standard audiometric data was collected and hearing loss was defined as a four-frequency average of 500, 1000, 2000, and 4000 Hz greater than 25 dBHL (PTA4). Measures of reported tinnitus and dizziness were also collected. The LS7 scoring tool, which consists of seven individual categories (abstinence from smoking, body mass index, physical activity, healthy diet, total cholesterol <200 mg/dL, normotension, and absence of diabetes mellitus), was used as measure of overall cardiovascular health. Each category of the LS7 was broken down into poor, intermediate, and ideal subgroups as in accordance with the American Heart Association Strategic Planning Task Force and Statistics Committee. Unadjusted and adjusted gamma regression and logistic regression models were constructed for determining relationships between LS7 and hearing loss. Results: Higher total LS7 scores (per 1-unit increase) were associated with lower PTA4 in gamma regression analyses (RR = 0.942, 95% CI, 0.926-0.958, P < .001). This held true even after adjustments for age, sex, education, and history of noise exposure. Using logistic regression analyses to compare LS7 scores to presence of hearing loss, tinnitus, and vertigo; only hearing loss showed a statically significant relationship after adjustments for age, sex, education, and history of noise exposure. Conclusions: This study shows a significant, graded association between higher life's simple seven scores and lower incidence of hearing loss. Level of evidence: 2b. Laryngoscope, 2019.
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OBJECTIVE: We sought to demonstrate the rate of change in distortion product otoacoustic emission (DPOE) amplitude with age in relation to hearing loss in an unselected adult population. STUDY DESIGN AND SETTING: We conducted a cross-sectional observation study involving the Framingham Offspring Cohort. Age changes in DPOE amplitude for frequencies of f2 from 1 to 8 kHz adjusted for pure-tone threshold level were assessed by multivariate linear regression. RESULTS: The women showed a mean hearing threshold-adjusted loss in high-frequency DPOE amplitude of 0.6, 2.1, 2.6, and 1.1 dB/per decade at the f2 frequencies of 1, 2, 4, and 8 kHz, respectively. In contrast, the men showed no effect of age on the DPOE amplitude independent of hearing loss. Emissions were reduced or absent in the noise notch frequencies. The rate of change with age in DPOE amplitude was significantly less than the rate of change in pure-tone thresholds in both the men and the women. CONCLUSION: Women lose DPOE amplitude from both age and hearing threshold loss. Men lose more DPOE amplitude than do women, and the loss is proportional to the degree of loss of hearing threshold sensitivity. The differential effect whereby age-related hearing loss affects thresholds more than emissions suggests that strial atrophy may be a pathophysiologic factor. SIGNIFICANCE: The use of DPOE measures for screening and monitoring cochlear status of adult women should take into account the age, pure-tone thresholds, and noise exposure status of the subjects. ( Otolaryngol Head Neck Surg 2003;129:382–9.)
Article
To develop an objective, fast, and simply performed screening protocol for cis-platinum (CP) ototoxicity, we compared the efficacy of screening with distortion-product otoacoustic emissions (DPOAEs) with the outcome of both conventional and ultra-high-frequency (UHF) audiometry. Baseline audiometric and DPOAE testing was performed in 66 patients, 33 of whom met criteria for inclusion in the final database. Comparisons were made between baseline measurements and those recorded before subsequent CP infusions. Outcomes were analyzed clinically and with paired repeated-measures analysis of variance. Results indicated that DPOAEs and UHF were better measures than conventional audiometry. Further, DPOAEs may be better suited for screening older patients receiving CP chemotherapy because DPOAEs are as sensitive as UHF and are present in a greater number of these patients. Screening with DPOAEs may be enhanced by testing only in the 3- to 5.2-kHz range, thus decreasing testing time. Higher time averages to increase the signal-to-noise ratio and use of this narrower bandwidth might also allow for accurate bedside testing.
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Context.— Clinical studies have suggested that cigarette smoking may be associated with hearing loss, a common condition affecting older adults.Objective.— To evaluate the association between smoking and hearing loss.Design.— Population-based, cross-sectional study.Setting.— Community of Beaver Dam, Wis.Participants.— Adults aged 48 to 92 years. Of 4541 eligible subjects, 3753 (83%) participated in the hearing study.Main Outcome Measures.— The examination included otoscopy, screening tympanometry, and pure-tone air-conduction and bone-conduction audiometry. Smoking history was ascertained by self-report. Hearing loss was defined as a pure-tone average (0.5, 1, 2, and 4 kHz) greater than 25-dB hearing level in the worse ear.Results.— After adjusting for other factors, current smokers were 1.69 times as likely to have a hearing loss as nonsmokers (95% confidence interval, 1.31-2.17). This relationship remained for those without a history of occupational noise exposure and in analyses excluding those with non–age-related hearing loss. There was weak evidence of a dose-response effect. Nonsmoking participants who lived with a smoker were more likely to have a hearing loss than those who were not exposed to a household member who smoked (odds ratio, 1.94; 95% confidence interval, 1.01-3.74).Conclusions.— These data suggest that environmental exposures may play a role in age-related hearing loss. If longitudinal studies confirm these findings, modification of smoking habits may prevent or delay age-related declines in hearing sensitivity.
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Data from the literature on presbyacusis, in the form of pure tone hearing threshold levels as a function of age, were subjected to a critical numerical evaluation. A formula was derived for generating the age effect for otologically screened groups of males and females for tone frequencies from 125 Hz to 12 kHz inclusive. The results are expressed as medians, with quartiles and deciles, and as a simple rule for determining other points of the distribution. For each frequency, only two parameters are required to determine the complete distribution with the aid of an elementary algebraic formula.
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Persons with healthy cardiovascular (CV) fitness have more acute hearing than persons with below-average CV fitness. Possible mechanisms include enhanced circulation, healthier blood lipid profiles, and different sympathetic activity. Muscle strength (MS) and conditioning programs may influence hearing acuity via similar proposed mechanisms. But studies have only examined the relationship of cardiovascular fitness and hearing. This study compared pure tone hearing levels and otoacoustic emissions for 4 groups categorized as high CV-high MS (n = 11), high CV-low MS (n = 10), low CV-high MS (n = 7), and low CV-low MS (n = 15). Twenty-four women and 19 men, mean (+/-SD) age = 21 +/- 4 years underwent hearing tests at 3 frequencies: 2, 3, and 4 kHz. Each group's Vo2max; strength by leg curl, leg extension, bench press, and hand grip; blood lipid profile; body composition; and diet recall were assessed. Pure tone hearing results showed that at 2 kHz, the high CV-high MS group had better hearing than the low CV-high MS group (F = 4.31, p = .04). Otoacoustic emission results demonstrated similar patterns. The fitness-hearing relationship appears to be specifically related to cardiovascular fitness. High MS has an additive effect with CV on hearing. (C) 2000 National Strength and Conditioning Association
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In a survey of more than 1500 current users of hearing instruments, half of which were digital, overall customer satisfaction was measured at 71% for hearing instruments 0-5 years old. Customer satisfaction with 1-year-old instruments was 78%, which placed hearing instruments in the top third of all products and services in the United States as measured by the University of Michigan. Hearing care professionals received stellar ratings approaching perfection. Overall they achieved a 92% satisfaction rating. Eighty-five percent of consumers are satisfied with the ability of their instruments to improve their hearing, meaning they are deriving tremendous benefit. In 15 listening situations, customer satisfaction ranges from 90% (one-on-one) to 59% (cell phone). Six out often consumers are satisfied with their instruments in 80% of the listening situations measured in this study. Hearing instruments are beneficial all along the hearing loss continuum. However, ratings are significantly lower for the severe-to-profound hearing loss population (i.e., the 20% of people with the most severe hearing loss). Significant opportunity remains to meet the needs of people with the greatest hearing losses. For example, fewer than 1% of consumers own an FM assistive listening system and only 25% use directional microphones or telecoils. The use of digital hearing instruments is associated with significantly higher ratings on overall satisfaction and benefit, improved sound quality, reduction in feedback, improved performance in noisy situations, and greater utility in a number of important listening situations.
Article
The aim of this study was to determine normative values for minimal response levels (MRLs) for normal-hearing young infants using insert earphone visual reinforcement audiometry (VRA). The subjects were 46 normally developing infants aged between 33 and 50 weeks who had hearing sensitivity assumed to be within normal limits and no evidence of middle ear dysfunction. VRA was carried out using insert earphones with warble tone stimuli, generated from an AC33 audiometer and calibrated to ISO 389–2 for insert earphones in adults. The frequencies assessed were 500 Hz, 1 kHz, 2 kHz and 4 kHz. In total, 102 MRLs were obtained, with an approximately equal number of MRLs per frequency. Mean MRLs for 500 Hz, 1 kHz, 2 kHz and 4 kHz were 16 dB HL, 13 dB HL, 7 dB HL and 6 dB HL, respectively. Standard deviations were close to 6 dB for all frequencies. Mean MRLs at the lower frequencies were significantly greater than MRLs at the two higher frequencies. MRLs did not vary significantly with age. The results obtained from this study suggest significant infant-adult differences when testing hearing using VRA with insert earphones, particularly at lower frequencies. Possible reasons for this and the clinical use of these normative values arc discussed.