NIHR Nottingham Hearing Biomedical Research Unit

INTRODUCTION: There is no standard diagnostic criterion for tinnitus, although some clinical assessment instruments do exist for identifying patient complaints. Within epidemiological studies the presence of tinnitus is determined primarily by self-report, typically in response to a single question. Using these methods prevalence figures vary widely. Given the variety of published estimates worldwide, we assessed and collated published prevalence estimates of tinnitus and tinnitus severity, creating a narrative synthesis of the data. The variability between prevalence estimates was investigated in order to determine any barriers to data synthesis and to identify reasons for heterogeneity. METHODS: and analysis: A systematic review included all adult population studies reporting the prevalence of tinnitus from January 1980 to July 2015. We searched five databases (Embase, Medline, PsychInfo, CINAHL and Web Of Science), using a combination of medical subject headings (MeSH) and relevant text words. Observational studies including cross-sectional studies were included, but studies estimating the incidence of tinnitus (e.g. cohort studies) were outside the scope of this systematic review. RESULTS: The databases identified 875 papers and a further 16 were identified through manual searching. After duplicates were removed, 515 remained. On the basis of the title, abstract and full-text screening, 400, 48 and 27 papers respectively were removed. This left 40 papers, reporting 39 different studies, for data extraction. Sixteen countries were represented, with the majority of the studies from the European region (38.5%). Publications since 2010 represented half of all included studies (48.7%). Overall prevalence figures for each study ranged from 5.1% to 42.7%. For the 12 studies that used the same definition of tinnitus, prevalence ranged from 11.9% to 30.3%. Twenty-six studies (66.7%) reported tinnitus prevalence by different age groups, and generally showed an increase in prevalence as age increases. Half the studies reported tinnitus prevalence by gender. The pattern generally showed higher tinnitus prevalence among males than females. There were 8 different types of definitions of tinnitus, the most common being "tinnitus lasting for more than five minutes at a time" (34.3%). Only seven studies gave any justification for the question that was used, or acknowledged the lack of standard questions for tinnitus. There is widespread inconsistency in defining and reporting tinnitus, leading to variability in prevalence estimates among studies. Nearly half of the included studies had a high risk of bias and this limits the generalisability of prevalence estimates. In addition, the available prevalence data is heterogeneous thereby preventing the ability to pool the data and perform meta-analyses. Sources of heterogeneity include different diagnostic criteria, different age groups, different study focus and differences in reporting and analysis of the results. Heterogeneity thus made comparison across studies impracticable. CONCLUSION: Deriving global estimates of the prevalence of tinnitus involves combining results from studies which are consistent in their definition and measurement of tinnitus, survey methodology and in the reporting and analysis of the results. Ultimately comparison among studies is unachievable without such consistency. The strength of this systematic review is in providing a record of all the available, recent epidemiological data in each global region and in making recommendations for promoting standardisation.

OBJECTIVE: Age-related hearing loss is an increasingly important public health problem affecting approximately 40% of 55-74 year olds. The primary clinical management intervention for people with hearing loss is hearing aids, however, the majority (80%) of adults aged 55-74 years who would benefit from a hearing aid, do not use them. Furthermore, many people given a hearing aid do not wear it. The aim was to collate the available evidence as to the potential reasons for non-use of hearing aids among people who have been fitted with at least one. DESIGN: Data were gathered via the use of a scoping study. STUDY SAMPLE: A comprehensive search strategy identified 10 articles reporting reasons for non-use of hearing aids. RESULTS: A number of reasons were given, including hearing aid value, fit and comfort and maintenance of the hearing aid, attitude, device factors, financial reasons, psycho-social/situational factors, healthcare professionals attitudes, ear problems, and appearance. CONCLUSIONS: The most important issues were around hearing aid value, i.e. the hearing aid not providing enough benefit, and comfort related to wearing the hearing aid. Identifying factors that affect hearing aid usage are necessary for devising appropriate rehabilitation strategies to ensure greater use of hearing aids.

Hearing loss is associated with poor cognitive performance and incident dementia and may contribute to cognitive decline. Treating hearing loss with hearing aids may ameliorate cognitive decline. The purpose of this study was to test whether use of hearing aids was associated with better cognitive performance, and if this relationship was mediated via social isolation and/or depression. Structural equation modelling of associations between hearing loss, cognitive performance, social isolation, depression and hearing aid use was carried out with a subsample of the UK Biobank data set (n = 164,770) of UK adults aged 40 to 69 years who completed a hearing test. Age, sex, general health and socioeconomic status were controlled for as potential confounders. Hearing aid use was associated with better cognition, independently of social isolation and depression. This finding was consistent with the hypothesis that hearing aids may improve cognitive performance, although if hearing aids do have a positive effect on cognition it is not likely to be via reduction of the adverse effects of hearing loss on social isolation or depression. We suggest that any positive effects of hearing aid use on cognition may be via improvement in audibility or associated increases in self-efficacy. Alternatively, positive associations between hearing aid use and cognition may be accounted for by more cognitively able people seeking and using hearing aids. Further research is required to determine the direction of association, if there is any direct causal relationship between hearing aid use and better cognition, and whether hearing aid use results in reduction in rates of cognitive decline measured longitudinally.

BACKGROUND: Auditory training involves active listening to auditory stimuli and aims to improve performance in auditory tasks. As such, auditory training is a potential intervention for the management of people with hearing loss. OBJECTIVE: This systematic review (PROSPERO 2011: CRD42011001406) evaluated the published evidence-base for the efficacy of individual computer-based auditory training to improve speech intelligibility, cognition and communication abilities in adults with hearing loss, with or without hearing aids or cochlear implants. METHODS: A systematic search of eight databases and key journals identified 229 articles published since 1996, 13 of which met the inclusion criteria. Data were independently extracted and reviewed by the two authors. Study quality was assessed using ten pre-defined scientific and intervention-specific measures. RESULTS: Auditory training resulted in improved performance for trained tasks in 9/10 articles that reported on-task outcomes. Although significant generalisation of learning was shown to untrained measures of speech intelligibility (11/13 articles), cognition (1/1 articles) and self-reported hearing abilities (1/2 articles), improvements were small and not robust. Where reported, compliance with computer-based auditory training was high, and retention of learning was shown at post-training follow-ups. Published evidence was of very-low to moderate study quality. CONCLUSIONS: Our findings demonstrate that published evidence for the efficacy of individual computer-based auditory training for adults with hearing loss is not robust and therefore cannot be reliably used to guide intervention at this time. We identify a need for high-quality evidence to further examine the efficacy of computer-based auditory training for people with hearing loss.

OBJECTIVES/HYPOTHESIS: To evaluate the existing level of evidence for tinnitus management strategies identified in the UK Department of Health's Good Practice Guideline. STUDY DESIGN: Systematic review of peer-reviewed literature and meta-analyses. METHODS: Searches were conducted in PubMed, Cambridge Scientific Abstracts, Web of Science, and EMBASE (earliest to August 2010), supplemented by hand searches in October 2010. Only randomized controlled trials that used validated questionnaire measures of symptoms (i.e., measures of tinnitus distress, anxiety, depression) were included. RESULTS: Twenty-eight randomized controlled trials met our inclusion criteria, most of which provide moderate levels of evidence for the effects they reported. Levels of evidence were generally limited by the lack of blinding, lack of power calculations, and incomplete data reporting in these studies. Only studies examining cognitive behavioral therapy were numerous and similar enough to perform meta-analysis, from which the efficacy of cognitive behavioral therapy (moderate effect size) appears to be reasonably established. Antidepressants were the only drug class to show any evidence of potential benefit. CONCLUSIONS: The efficacy of most interventions for tinnitus benefit remains to be demonstrated conclusively. In particular, high-level assessment of the benefit derived from those interventions most commonly used in practice, namely hearing aids, maskers, and tinnitus retraining therapy needs to be performed.

BACKGROUND: Healthy hearing depends on sensitive ears and adequate brain processing. Essential aspects of both hearing and cognition decline with advancing age, but it is largely unknown how one influences the other. The current standard measure of hearing, the pure-tone audiogram is not very cognitively demanding and does not predict well the most important yet challenging use of hearing, listening to speech in noisy environments. We analysed data from UK Biobank that asked 40-69 year olds about their hearing, and assessed their ability on tests of speech-in-noise hearing and cognition. METHODS AND FINDINGS: About half a million volunteers were recruited through NHS registers. Respondents completed 'whole-body' testing in purpose-designed, community-based test centres across the UK. Objective hearing (spoken digit recognition in noise) and cognitive (reasoning, memory, processing speed) data were analysed using logistic and multiple regression methods. Speech hearing in noise declined exponentially with age for both sexes from about 50 years, differing from previous audiogram data that showed a more linear decline from <40 years for men, and consistently less hearing loss for women. The decline in speech-in-noise hearing was especially dramatic among those with lower cognitive scores. Decreasing cognitive ability and increasing age were both independently associated with decreasing ability to hear speech-in-noise (0.70 and 0.89 dB, respectively) among the population studied. Men subjectively reported up to 60% higher rates of difficulty hearing than women. Workplace noise history associated with difficulty in both subjective hearing and objective speech hearing in noise. Leisure noise history was associated with subjective, but not with objective difficulty hearing. CONCLUSIONS: Older people have declining cognitive processing ability associated with reduced ability to hear speech in noise, measured by recognition of recorded spoken digits. Subjective reports of hearing difficulty generally show a higher prevalence than objective measures, suggesting that current objective methods could be extended further.

Noise-induced cochlear synaptopathy has been demonstrated in numerous rodent studies. In these animal models, the disorder is characterized by a reduction in amplitude of wave I of the auditory brainstem response (ABR) to high-level stimuli, whereas the response at threshold is unaffected. The aim of the present study was to determine if this disorder is prevalent in young adult humans with normal audiometric hearing. One hundred and twenty six participants (75 females) aged 18-36 were tested. Participants had a wide range of lifetime noise exposures as estimated by a structured interview. Audiometric thresholds did not differ across noise exposures up to 8 kHz, although 16-kHz audiometric thresholds were elevated with increasing noise exposure for females but not for males. ABRs were measured in response to high-pass (1.5 kHz) filtered clicks of 80 and 100 dB peSPL. Frequency-following responses (FFRs) were measured to 80 dB SPL pure tones from 240 to 285 Hz, and to 80 dB SPL 4 kHz pure tones amplitude modulated at frequencies from 240 to 285 Hz (transposed tones). The bandwidth of the ABR stimuli and the carrier frequency of the transposed tones were chosen to target the 3-6 kHz characteristic frequency region which is usually associated with noise damage in humans. The results indicate no relation between noise exposure and the amplitude of the ABR. In particular, wave I of the ABR did not decrease with increasing noise exposure as predicted. ABR wave V latency increased with increasing noise exposure for the 80 dB peSPL click. High carrier-frequency (envelope) FFR signal-to-noise ratios decreased as a function of noise exposure in males but not females. However, these correlations were not significant after the effects of age were controlled. The results suggest either that noise-induced cochlear synaptopathy is not a significant problem in young, audiometrically normal adults, or that the ABR and FFR are relatively insensitive to this disorder in young humans, although it is possible that the effects become more pronounced with age.

The importance of psychological factors in tinnitus distress has been formally recognized for almost three decades. The psychological understanding of why tinnitus can be a distressing condition posits that it becomes problematic when it acquires an emotive significance through cognitive processes. Principle therapeutic efforts are directed at reducing or removing the cognitive (and behavioral) obstacles to habituation. Here, the evidence relevant to a new psychological model of tinnitus is critically reviewed. The model posits that patients' interpretations of tinnitus and the changes in behavior that result are given a central role in creating and maintaining distress. The importance of selective attention and the possibility that this leads to distorted perception of tinnitus is highlighted. From this body of evidence, we propose a coherent cognitive-behavioral model of tinnitus distress that is more in keeping with contemporary psychological theories of clinical problems (particularly that of insomnia) and which postulates a number of behavioral processes that are seen as cognitively mediated. This new model provides testable hypotheses to guide future research to unravel the complex mechanisms underpinning tinnitus distress. It is also well suited to define individual symptomatology and to provide a framework for the delivery of cognitive-behavioral therapy.

BACKGROUND: There is no evidence-based guidance to facilitate design decisions for confirmatory trials or systematic reviews investigating treatment efficacy for adults with tinnitus. This systematic review therefore seeks to ascertain the current status of trial designs by identifying and evaluating the reporting of outcome domains and instruments in the treatment of adults with tinnitus. METHODS: Records were identified by searching PubMed, EMBASE CINAHL, EBSCO, and CENTRAL clinical trial registries (ClinicalTrials.gov, ISRCTN, ICTRP) and the Cochrane Database of Systematic Reviews. Eligible records were those published from 1 July 2006 to 12 March 2015. Included studies were those reporting adults aged 18 years or older who reported tinnitus as a primary complaint, and who were enrolled into a randomised controlled trial, a before and after study, a non-randomised controlled trial, a case-controlled study or a cohort study, and written in English. Studies with fewer than 20 participants were excluded. RESULTS: Two hundred and twenty-eight studies were included. Thirty-five different primary outcome domains were identified spanning seven categories (tinnitus percept, impact of tinnitus, co-occurring complaints, quality of life, body structures and function, treatment-related outcomes and unclear or not specified). Over half the studies (55 %) did not clearly define the complaint of interest. Tinnitus loudness was the domain most often reported (14 %), followed by tinnitus distress (7 %). Seventy-eight different primary outcome instruments were identified. Instruments assessing multiple attributes of the impact of tinnitus were most common (34 %). Overall, 24 different patient-reported tools were used, predominantly the Tinnitus Handicap Inventory (15 %). Loudness was measured in diverse ways including a numerical rating scale (8 %), loudness matching (4 %), minimum masking level (1 %) and loudness discomfort level (1 %). Ten percent of studies did not clearly report the instrument used. CONCLUSIONS: Our findings indicate poor appreciation of the basic principles of good trial design, particularly the importance of specifying what aspect of therapeutic benefit is the main outcome. No single outcome was reported in all studies and there was a broad diversity of outcome instruments. PROSPERO REGISTRATION: The systematic review protocol is registered on PROSPERO (International Prospective Register of Systematic Reviews): CRD42015017525 . Registered on 12 March 2015 revised on 15 March 2016.

In Brief Objectives: To report population-based prevalence of hearing impairment based on speech recognition in noise testing in a large and inclusive sample of U.K. adults aged 40 to 69 years. The present study is the first to report such data. Prevalence of tinnitus and use of hearing aids is also reported. Design: The research was conducted using the UK Biobank resource. The better-ear unaided speech reception threshold was measured adaptively using the Digit Triplet Test (n = 164,770). Self-report data on tinnitus, hearing aid use, noise exposure, as well as demographic variables were collected. Results: Overall, 10.7% of adults (95% confidence interval [CI] 10.5–10.9%) had significant hearing impairment. Prevalence of tinnitus was 16.9% (95%CI 16.6–17.1%) and hearing aid use was 2.0% (95%CI 1.9–2.1%). Odds of hearing impairment increased with age, with a history of work- and music-related noise exposure, for lower socioeconomic background and for ethnic minority backgrounds. Males were at no higher risk of hearing impairment than females. Conclusions: Around 1 in 10 adults aged 40 to 69 years have substantial hearing impairment. The reasons for excess risk of hearing impairment particularly for those from low socioeconomic and ethnic minority backgrounds require identification, as this represents a serious health inequality. The underuse of hearing aids has altered little since the 1980s, and is a major cause for concern. This study reports population-based prevalence of hearing impairment based on speech in noise recognition testing in a large and inclusive sample of U.K. adults aged 40 to 69 years. Prevalence of tinnitus and use of hearing aids are also reported. Odds of hearing impairment increased with age, history of work- and music-related noise exposure, lower socioeconomic status, and ethnic minority background. The reasons for excess risk of hearing impairment particularly for those from low socioeconomic and ethnic minority backgrounds require identification. The underuse of hearing aids has altered little since the 1980s and is a cause for concern.

Acute otitis media and otitis media with effusion are common childhood disorders, a source of significant morbidity, and a leading cause of antibiotic prescription in primary health care. Although effective treatments are available, some shortcomings remain, and thus better treatments would be welcome. Recent discoveries within the field of otitis media research relating to its etiology and pathogenesis have led to further investigation aimed at developing novel treatments. This article provides a review of the latest evidence relating to the understanding of acute otitis media and otitis media with effusion, current treatment strategies, their limitations, new areas of research, and novel strategies for treatment.

Tissue fibrosis is a core pathologic process that contributes to mortality in ~45% of the population and is likely to be influenced by the host genetic architecture. Here we demonstrate, using liver disease as a model, that a single-nucleotide polymorphism (rs12979860) in the intronic region of interferon-λ4 (IFNL4) is a strong predictor of fibrosis in an aetiology-independent manner. In a cohort of 4,172 patients, including 3,129 with chronic hepatitis C (CHC), 555 with chronic hepatitis B (CHB) and 488 with non-alcoholic fatty liver disease (NAFLD), those with rs12979860CC have greater hepatic inflammation and fibrosis. In CHC, those with rs12979860CC also have greater stage-constant and stage-specific fibrosis progression rates (P<0.0001 for all). The impact of rs12979860 genotypes on fibrosis is maximal in young females, especially those with HCV genotype 3. These findings establish rs12979860 genotype as a strong aetiology-independent predictor of tissue inflammation and fibrosis.

BACKGROUND: Tinnitus is described as the perception of sound or noise in the absence of real acoustic stimulation. In the current absence of a cure for tinnitus, clinical management typically focuses on reducing the effects of co-morbid symptoms such as distress or hearing loss. Hearing loss is commonly co-morbid with tinnitus and so logic implies that amplification of external sounds by hearing aids will reduce perception of the tinnitus sound and the distress associated with it. OBJECTIVES: To assess the effects of hearing aids specifically in terms of tinnitus benefit in patients with tinnitus and co-existing hearing loss. SEARCH METHODS: We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the search was 19 August 2013. SELECTION CRITERIA: Randomised controlled trials and non-randomised controlled trials recruiting adults with subjective tinnitus and some degree of hearing loss, where the intervention involves amplification with hearing aids and this is compared to interventions involving other medical devices, other forms of standard or complementary therapy, or combinations of therapies, no intervention or placebo interventions. DATA COLLECTION AND ANALYSIS: Three authors independently screened all selected abstracts. Two authors independently extracted data and assessed those potentially suitable studies for risk of bias. For studies meeting the inclusion criteria, we used the mean difference (MD) to compare hearing aids with other interventions and controls. MAIN RESULTS: One randomised controlled trial (91 participants) was included in this review. We judged the trial to have a low risk of bias for method of randomisation and outcome reporting, and an unclear risk of bias for other criteria. No non-randomised controlled trials meeting our inclusion criteria were identified. The included study measured change in tinnitus severity (primary measure of interest) using a tinnitus questionnaire measure, and change in tinnitus loudness (secondary measure of interest) on a visual analogue scale. Other secondary outcome measures of interest, namely change in the psychoacoustic characteristics of tinnitus, change in self reported anxiety, depression and quality of life, and change in neurophysiological measures, were not investigated in this study. The included study compared hearing aid use to sound generator use. The estimated effect on change in tinnitus loudness or severity as measured by the Tinnitus Handicap Inventory score was compatible with benefits for both hearing aids or sound generators but no difference was found between the two alternative treatments (MD -0.90, 95% confidence interval (CI) -7.92 to 6.12) (100-point scale); moderate quality evidence. No negative or adverse events were reported. AUTHORS' CONCLUSIONS: The current evidence base for hearing aid prescription for tinnitus is limited. To be useful, future studies should make appropriate use of blinding and be consistent in their use of outcome measures. Whilst hearing aids are sometimes prescribed as part of tinnitus management, there is currently no evidence to support or refute their use as a more routine intervention for tinnitus.

OBJECTIVE: This study explored the psychosocial experiences of adults with hearing loss using the self-regulatory model as a theoretical framework. The primary components of the model, namely cognitive representations, emotional representations, and coping responses, were examined. DESIGN: Individual semi-structured interviews were conducted. The data were analysed using an established thematic analysis procedure. STUDY SAMPLE: Twenty-five adults with mild-moderate hearing loss from the UK and nine hearing healthcare professionals from the UK, USA, and Canada were recruited via maximum variation sampling. RESULTS: Cognitive representations: Most participants described their hearing loss as having negative connotations and consequences, although they were not particularly concerned about the progression or controllability/curability of the condition. Opinions differed regarding the benefits of understanding the causes of one's hearing loss in detail. Emotional representations: negative emotions dominated, although some experienced positive emotions or muted emotions. Coping responses: engaged coping (e.g. hearing aids, communication tactics) and disengaged coping (e.g. withdrawal from situations, withdrawal within situations): both had perceived advantages and disadvantages. CONCLUSIONS: This novel application of the self-regulatory model demonstrates that it can be used to capture the key psychosocial experiences (i.e. perceptions, emotions, and coping responses) of adults with mild-moderate hearing loss within a single, unifying framework.

PURPOSE: Parental reports of communication, listening, and behavior in children receiving a clinical diagnosis of specific language impairment (SLI) or auditory processing disorder (APD) were compared with direct tests of intelligence, memory, language, phonology, literacy, and speech intelligibility. The primary aim was to identify whether there were differences between these characteristics in children with SLI or APD. METHOD: Normally hearing children who were clinically diagnosed with SLI (n = 22) or APD (n = 19), and a quasirandom sample of mainstream school (MS) children (n = 47) aged 6-13 years, underwent tests of verbal and nonverbal IQ, digit span, nonsense word repetition, Spoonerisms, reading, grammar, and sentence and VCV nonword intelligibility. Parents completed questionnaires on the children's communication, listening, and behavior. RESULTS: There was generally no difference between the performance of the children with SLI and the children with APD on the questionnaire and test measures, and both groups consistently and significantly underperformed compared with the children in the MS group. Speech intelligibility in both noise and quiet was unimpaired in the SLI and APD groups. CONCLUSION: Despite clinical diagnoses of SLI or APD, the 2 groups of children had very similar behavioral and parental report profiles, suggesting that the children were differentially diagnosed based on their referral route rather than on actual differences.

Aminoglycoside antibiotics are a central component of the treatment of pulmonary exacerbations of cystic fibrosis (CF) and slow the decline in lung function which ultimately causes the death of most patients. The prognosis of CF has improved, and thus side effects of treatments have become increasingly important. Observational studies suggest that the morbidity from side effects of aminoglycosides is disturbingly common, and that aggressive treatment may lead to more side effects. This review of the current literature on side effects of aminoglycosides considers the pathophysiological mechanisms, epidemiology and risk factors, investigation of side effects and preventative strategies. Treatments which have shown early promise are identified and areas of future research are discussed.

How the brain extracts words from auditory signals is an unanswered question. We recorded approximately 150 single and multi-units from the left anterior superior temporal gyrus of a patient during multiple auditory experiments. Against low background activity, 45% of units robustly fired to particular spoken words with little or no response to pure tones, noise-vocoded speech, or environmental sounds. Many units were tuned to complex but specific sets of phonemes, which were influenced by local context but invariant to speaker, and suppressed during self-produced speech. The firing of several units to specific visual letters was correlated with their response to the corresponding auditory phonemes, providing the first direct neural evidence for phonological recoding during reading. Maximal decoding of individual phonemes and words identities was attained using firing rates from approximately 5 neurons within 200 ms after word onset. Thus, neurons in human superior temporal gyrus use sparse spatially organized population encoding of complex acoustic-phonetic features to help recognize auditory and visual words.

In this paper, we review studies that have investigated brain morphology in chronic tinnitus in order to better understand the underlying pathophysiology of the disorder. Current consensus is that tinnitus is a disorder involving a distributed network of peripheral and central pathways in the nervous system. However, the precise mechanism remains elusive and it is unclear which structures are involved. Given that brain structure and function are highly related, identification of anatomical differences may shed light upon the mechanism of tinnitus generation and maintenance. We discuss anatomical changes in the auditory cortex, the limbic system, and prefrontal cortex, among others. Specifically, we discuss the gating mechanism of tinnitus and evaluate the evidence in support of the model from studies of brain anatomy. Although individual studies claim significant effects related to tinnitus, outcomes are divergent and even contradictory across studies. Moreover, results are often confounded by the presence of hearing loss. We conclude that, at present, the overall evidence for structural abnormalities specifically related to tinnitus is poor. As this area of research is expanding, we identify some key considerations for research design and propose strategies for future research.

OBJECTIVES: The aims of this study were to (1) develop a series of short interactive videos (or reusable learning objects [RLOs]) covering a broad range of practical and psychosocial issues relevant to the auditory rehabilitation for first-time hearing aid users; (2) establish the accessibility, take-up, acceptability and adherence of the RLOs; and (3) assess the benefits and cost-effectiveness of the RLOs. DESIGN: The study was a single-center, prospective, randomized controlled trial with two arms. The intervention group (RLO+, n = 103) received the RLOs plus standard clinical service including hearing aid(s) and counseling, and the waitlist control group (RLO-, n = 100) received standard clinical service only. The effectiveness of the RLOs was assessed 6-weeks posthearing aid fitting. Seven RLOs (total duration 1 hr) were developed using a participatory, community of practice approach involving hearing aid users and audiologists. RLOs included video clips, illustrations, animations, photos, sounds and testimonials, and all were subtitled. RLOs were delivered through DVD for TV (50.6%) and PC (15.2%), or via the internet (32.9%). RESULTS: RLO take-up was 78%. Adherence overall was at least 67%, and 97% in those who attended the 6-week follow-up. Half the participants watched the RLOs two or more times, suggesting self-management of their hearing loss, hearing aids, and communication. The RLOs were rated as highly useful and the majority of participants agreed the RLOs were enjoyable, improved their confidence and were preferable to written information. Postfitting, there was no significant between-group difference in the primary outcome measure, overall hearing aid use. However, there was significantly greater hearing aid use in the RLO+ group for suboptimal users. Furthermore, the RLO+ group had significantly better knowledge of practical and psychosocial issues, and significantly better practical hearing aid skills than the RLO- group. CONCLUSIONS: The RLOs were shown to be beneficial to first-time hearing aid users across a range of quantitative and qualitative measures. This study provides evidence to suggest that the RLOs may provide valuable learning and educational support for first-time hearing aid users and could be used to supplement clinical rehabilitation practice.

AIM: To undertake a systematic review of the literature on acoustic neuroma growth. Predictors of growth were also explored. MATERIALS AND METHODS: A comprehensive search was conducted to identify the relevant literature. The search yielded 2,455 papers. All titles were reviewed by 2 of the authors, and finally, 41 papers were found reporting data pertinent to growth. RESULTS: The percentage of acoustic neuromas exhibiting growth ranges widely from 18 to 73%. The percentage of tumors reported not to grow for some years after diagnosis ranges from 9 to 75%. Some (usually less than 10%, but up to 22%) may get smaller. No reliable predictors of growth have been identified. The mean growth rate for all tumors varies between 1 and 2 mm/yr, and for only those that grow, between 2 and 4 mm/yr. However, there are cases with significant regression or exceptional growth (exceeding 18 mm/yr). There are various patterns of growth, and a tumor that shows growth may stop doing so and vice versa. Finally, some tumors that have been stable for many years can exhibit tumor growth. CONCLUSION: The growth pattern of acoustic neuromas is variable and incompletely understood. As much as 75% of tumors have been reported to show no growth, supporting a "wait and rescan" policy in many patients, although there are no reliable predictors of tumor behavior, and some tumors may grow rapidly. Primary longitudinal studies are needed to better define the natural history and limit unnecessary interventions.