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Research and Development at the Audiology Department

In October, we hosted a Research Workshop with our patients to gain an insight for project ideas.

The Audiology Department benefits from a close working relationship with the Research and Development (R&D) department at RSCH, and the researchers at University of London, University of Surrey, and University of Cambridge. Research Ethics Committees and NHS R&D departments review and oversee the ethical aspect of all research projects conducted by the Audiology Department.

The Audiology Department supports research studies relevant to audiological diagnosis and rehabilitation, tinnitus and hyperacusis, paediatric audiology, balance and vestibular rehabilitation and other related topics.

PhD and MSc students who are keen to undertake research studies in the above mentioned areas should contact Dr. Hashir Aazh (the audiology R & D lead) via hashir.aazh@nhs.net in order to express their interest and discuss supervisory arrangements.

Tinnitus under the Spotlight at Royal Surrey

Over 180 people attended the ‘Tinnitus and Hearing Impairment Seminar’  which  showcased new research from Royal Surrey specialists who treat the painful and distressing hearing condition.  Up to 15% of the UK population is believed to suffer from persistent Tinnitus which is commonly described as a persistent ‘ringing’ in the ears.

In the first session of the seminar, Royal Surrey Tinnitus team lead Dr Hashir Aazh explored the relationship between the severity of hearing loss and the loudness of tinnitus. Drawing from new research from over 400 patient studies he outlined a number of key findings:

  • Tinnitus will generally get louder as hearing loss worsens but not by a large factor
  • using hearing protection to try and mitigate further hearing loss and related  ‘safety- seeking’ behaviours are likely to contribute to tinnitus related anxiety
  • ‘Safety-seeking’ behaviours that restrict a patient’s life experience are likely to make the patient feel that the tinnitus ‘sound’ gets louder
  • there are a wide range of rehabilitative approaches that can minimise the annoyance that tinnitus causes and its impact on the patient’s life

In the second part of the seminar,  Consultant  Audiovestibular Physician, Dr R Srinivasa Raghavan looked at medical Evaluation and treatments for tinnitus combined with hearing loss.  A question and answer session which addressed patient experience was led by Jemma Hatton, a specialist in Tinnitus and Hyperacusis Rehabilitation.

“Tinnitus currently affects about 10-15% of the UK population  and up to 30% of the population may experience it at some time in their lives,” said Hashir. “It can be an extremely debilitating condition but there is not enough public understanding of its causes or the treatments that are available.

“Many people with tinnitus are worried that if their hearing worsens for any reason it may lead to an increase in the loudness of their tinnitus to a level that they would not be able to cope with.  The seminar was a great opportunity to reassure patients and inform audiology professionals of the latest developments in tinnitus therapy.”

If you want to know more about Tinnitus listen to Hashir’s informative description of the condition here.

Below are the topics and abstracts of the recent studies conducted at the Audiology Department:

Am J Audiol. 2017 Sep 18;26(3):226-232.

Incidence of Discomfort During Pure-Tone Audiometry and Measurement of Uncomfortable Loudness Levels Among People Seeking Help for Tinnitus and/or Hyperacusis.

Aazh H(1), Moore BCJ(2).

Author information: (1)Audiology Department, Royal Surrey County Hospital NHS Foundation Trust, Guildford, United Kingdom. (2) Department of Psychology, University of Cambridge, United Kingdom.

PURPOSE: The aim of this study was to assess the proportion of patients seen in a tinnitus and hyperacusis therapy clinic for whom presentation levels based on the British Society of Audiology (BSA)-recommended procedures for pure-tone audiometry and determination of uncomfortable loudness levels (ULLs) exceed ULLs, leading to discomfort during administration of these procedures.

METHOD: This was a retrospective cross-sectional study of 362 consecutive patients who attended a National Health Service audiology clinic for tinnitus and/or hyperacusis rehabilitation.

RESULTS: For 21% of the patients, presentation levels based on the BSA procedure for pure-tone audiometry exceeded the ULL for at least 1 of the measured frequencies (excluding the first frequency tested, 1 kHz): 0.25, 0.5, 2, 3, 4, 6, and 8 kHz. For 24% of patients, the starting presentation level of 60 dB hearing level recommended for determination of ULLs exceeded the ULL for at least 1 frequency.

CONCLUSION: The starting presentation levels used for pure-tone audiometry and measurement of ULLs should be lower than those recommended by the BSA for people with tinnitus and hyperacusis.

Int J Audiol. 2017 Sep;56(9):677-684.


Factors related to tinnitus and hyperacusis handicap in older people.

Aazh H(1), Lammaing K(1), Moore BCJ(2).

Author information: (1) Audiology Department, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK. (2) Department of Experimental Psychology, University of Cambridge, Cambridge, UK.

OBJECTIVE: The aim was to assess factors related to tinnitus and hyperacusis handicap in older people.

DESIGN: Retrospective cross-sectional.

STUDY SAMPLE: Data were gathered for 184 patients with an average age of 69 years.

RESULTS: Tinnitus handicap as measured via the Tinnitus Handicap Inventory (THI) was significantly predicted by tinnitus annoyance as measured via the visual analogue scale (VAS) (regression coefficient, b = 2.9, p < 0.001) and the effect of tinnitus on the patient’s life as measured via the VAS (b = 3.9, p < 0.001). Hyperacusis handicap as measured via the Hyperacusis Questionnaire (HQ) was significantly predicted by the score on the depression subscale of the Hospital Anxiety and Depression Scale (HADS) (b = 0.8, p < 0.001) and to a small extent by the THI score (b = 0.07, p = 0.048). Insomnia scores as measured via the Insomnia Severity Index (ISI) were significantly predicted by scores on the depression subscale of the HADS (b = 0.46, p = 0.007).

CONCLUSIONS: Since tinnitus annoyance significantly predicts tinnitus handicap, it is important to explore factors associated with annoyance that may be useful in designing appropriate rehabilitative interventions aimed at reducing tinnitus handicap in older people. Future studies should explore whether hyperacusis and insomnia in older people with tinnitus need to be managed in conjunction with treatment for depression.

 Int J Audiol. 2017 Oct;56(10):793-800


Factors related to uncomfortable loudness levels for patients seen in a tinnitus and hyperacusis clinic.

Aazh H(1), Moore BCJ(2).

Author information: (1) Audiology Department , Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK and (2) Department of Experimental Psychology, University of Cambridge, Cambridge, UK.

OBJECTIVES: The aims were as follows: (1) to explore patterns of uncomfortable loudness levels (ULLs) across frequency and their associated factors for patients with tinnitus and hyperacusis, and (2) to re-evaluate the criteria for diagnosing hyperacusis based on ULLs and scores for the Hyperacusis Questionnaire (HQ).

DESIGN: This was a retrospective cross-sectional study.

STUDY SAMPLE: 573 consecutive patients for whom ULLs had been measured were included.

RESULTS: A good correspondence between the diagnosis of hyperacusis based on the across-frequency average ULL for the ear with the lowest ULLs (ULLmin) and hyperacusis handicap based on HQ scores was obtained with cut-off values of ULLmin ≤77 dB HL and HQ score ≥ 22. A regression model showed significant relationships between ULLmin and the score on the HQ and age. The mean HQ score for patients with a large interaural asymmetry in ULLs was significantly higher than for the remainder. Hyperacusis handicap was associated with strong across-frequency variations in ULLs.

CONCLUSIONS: Appropriate cut-off values for diagnosing hyperacusis are ULLmin ≤77 dB HL and HQ score ≥22. Large interaural asymmetry and large across-frequency variations in ULLs are associated with higher HQ scores.

Int J Audiol. 2017 Jul;56(7):489-498.


Usefulness of self-report questionnaires for psychological assessment of patients with tinnitus and hyperacusis and patients’ views of the questionnaires.

Aazh H(1), Moore BCJ(2).

Author information: (1) Audiology Department, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK. (2) Department of Experimental Psychology, University of Cambridge, Cambridge, UK.

OBJECTIVE: The objective was to determine the relevance and applicability of psychologica questionnaires to patients seeking help for tinnitus and/or hyperacusis.

DESIGN: This was a questionnaire-based survey. The following questionnaires were administered: Generalised Anxiety Disorder (GAD-7), Short Health Anxiety Inventory (SHAI), Mini-Social Phobia Inventory (Mini-SPIN), Obsessive Compulsive Inventory-Revised (OCI-R), Panic Disorder Severity Scale-Self Report (PDSS-SR), Patient Health Questionnaire (PHQ-9) and Penn State Worry Questionnaire-Abbreviated version (PSWQ-A). In addition, a patient feedback questionnaire was completed asking about the extent to which each questionnaire was relevant to them and how strongly they would recommend its use in the assessment of patients with tinnitus and hyperacusis.

STUDY SAMPLE: A total of 150/402 consecutive patients seen in a one-year period completed the questionnaires.

RESULTS: 65% of patients had abnormal scores for one or more of the questionnaires. All questionnaires except the PDSS-SR were rated as relevant and recommended for use.

CONCLUSIONS: The GAD-7, SHAI, Mini-SPIN, OCI-R, PSWQ-A and PHQ-9 are recommended for evaluation of psychological problems for patients seeking help for tinnitus and/or hyperacusis. Abnormal results on these questionnaires may indicate the need for referral for possible treatment of psychological problems.

J Am Acad Audiol. 2017 Mar;28(3):248-260.


Audiological Rehabilitation for Facilitating Hearing Aid Use: A Review.

Aazh H(1)(2), Moore BC(3).

Author information: (1)Audiology Department, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK. (2)London School of Hygiene & Tropical Medicine, University of London, London, UK. (3)Department of Psychology, University of Cambridge, Cambridge, UK.

PURPOSE: This article reviews and critically analyzes the design of studies on the effect of audiological rehabilitation (AR) programs on hearing aid (HA) outcomes, in order to guide future research.

RESEARCH DESIGN: The design of this study was a narrative review. Studies were included in the review if they were randomized controlled trials that investigated the effects of AR on HA use and outcome between 2000 and 2016.

RESULTS: Seven articles that met the inclusion criteria were included in the review. Most used educational rather than counseling approaches. Although educational AR programs seem to be useful in enhancing the use of communication strategies, there is limited evidence for their effect on HA use and self-perceived hearing handicap.

CONCLUSIONS: More research is needed in this field. Future studies should (1) investigate the efficacy of AR interventions based on counseling and empathetic listening as opposed to or in addition to educational interventions, (2) use stricter criteria to include only a subpopulation of patients who do not get on well with their HAs, (3) measure the amount of HA use via data-logging and self-report questionnaires, and (4) use a matching comparison intervention for patients in the control group.

Int J Audiol. 2016 Sep;55(9):514-22


Tinnitus and hyperacusis therapy in a UK National Health Service audiology department: Patients’ evaluations of the effectiveness of treatments.

Aazh H(1), Moore BC(2), Lammaing K(1), Cropley M(3).

Author information: (1) Audiology Department , Royal Surrey County Hospital NHS Foundation Trust Guildford, UK. (2)b Department of Experimental Psychology, University of Cambridge, UK. (3) School of Psychology, University of Surrey, Guildford, UK.

OBJECTIVE: To assess patients’ judgements of the effectiveness of the tinnitus and hyperacusis therapies offered in a specialist UK National Health Service audiology department.

DESIGN: Cross-sectional service evaluation questionnaire survey. Patients were asked to rank the effectiveness of the treatment they received on a scale from 1 to 5 (1 = no effect, 5 = very effective).

STUDY SAMPLE: The questionnaire was sent to all patients who received treatment between January and March 2014 (n = 200) and 92 questionnaires were returned.

RESULTS: The mean score was greatest for counselling (Mean = 4.7, SD = 0.6), followed by education (Mean = 4.5, SD = 0.8), cognitive behavioural therapy – CBT (Mean = 4.4, SD = 0.7), and hearing tests (Mean = 4.4, SD = 0.9). Only 6% of responders rated counselling as 3 or below. In contrast, bedside sound generators, hearing aids, and wideband noise generators were rated as 3 or below by 25%, 36%, and 47% of participants, respectively.

CONCLUSION: The most effective components of the tinnitus and hyperacusis therapy interventions were judged by the patients to be counselling, education, and CBT.

Int J Audiol. 2016;55(3):149-56.


Feasibility of conducting a randomized controlled trial to evaluate the effect of motivational interviewing on hearing-aid use.

Aazh H(1).

Author information: (1)a Audiology Department, Royal Surrey County Hospital, Guildford, UK.

OBJECTIVES: The aim of this study was to evaluate the feasibility of conducting a randomized controlled trial (RCT) on the effect of motivational interviewing (MI) on hearing-aid use.

DESIGN: This was a pilot single-blind, randomized parallel-group study conducted in the UK.

STUDY SAMPLE: Thirty-seven adult patients who reported using their hearing aid(s) less than four hours per day were randomized to MI combined with Standard Care (MISC) (n = 20), and Standard Care only (SC) (n = 17).

RESULTS: Of 220 patients invited, 37 were enrolled giving the recruitment rate of 17%. One participant withdrew giving the retention rate of 97%. It was feasible to combine MI with SC for facilitating hearing-aid use and deliver the intervention with high fidelity in an audiology setting. The measure on hearing-aid use (data logging) one month after interventions favoured the MISC group.

CONCLUSIONS: This pilot study suggests that conducting an RCT on using MI for facilitating hearing-aid use in people who do not use their hearing aids is feasible, and that MI combined with SC may have more positive effects on hearing-aid use compared to SC only.

Int J Audiol. 2015 Mar;54(3):152-61.


Hearing-aid use and its determinants in the UK National Health Service: a cross-sectional study at the Royal Surrey County Hospital.

Aazh H(1), Prasher D, Nanchahal K, Moore BC.

Author information: (1) Audiology Department, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK.

OBJECTIVES: The aim of this study was to investigate the rate of and factors contributing to non-adherence to hearing-aid use in the UK National Health Service.

DESIGN: A cross-sectional postal questionnaire survey.

STUDY SAMPLE: A questionnaire, including the International Outcome Inventory for Hearing Aids, was sent to all patients fitted with hearing aids at the Royal Surrey County Hospital between 2011 and 2012 (N = 1874). A total of 1023 questionnaires were completed and returned (response rate of 55%).

RESULTS: A total of 29% of responders did not use their hearing aids on a regular basis (i.e. used them less than four hours per day). Non-regular use was more prevalent in new (40%) than in existing patients (11%). Factors that reduced the risk of non-regular use included bilateral versus unilateral amplification, and moderate or severe hearing loss in the better ear. 16% of responders fitted with bilateral amplification used only one of their hearing aids.

CONCLUSIONS: The level of non-regular use of hearing aids in NHS found in this study was comparable to those for other countries. Additional support might be needed for patients at a higher risk of non-regular use.

 Noise Health. 2014 Mar-Apr;16(69):123-6.


Insights from the First International Conference on Hyperacusis: causes, evaluation, diagnosis and treatment.

Aazh H(1), McFerran D, Salvi R, Prasher D, Jastreboff M, Jastreboff P.

Author information: (1)Department of Audiology, Royal Surrey County Hospital, Guildford; Department of Social and Environmental Health Research, London School of Hygiene & Tropical Medicine, London, United Kingdom.

The First International Conference on Hyperacusis gathered over 100 scientists and health care professionals in London, UK. Key conclusions from the conference included: (1) Hyperacusis is characterized by reduced tolerance of sound that has perceptual, psychological and social dimensions; (2) there is a growing awareness that children as well as adults experience symptoms of hyperacusis or misophonia; (3) the exact mechanisms that give rise to hyperacusis are not clear, but the available evidence suggests that functional changes within the central nervous system are important and in particular, hyperacusis may be related to increased gain in the central auditory pathways and to increased anxiety or emotional response to sound; (4) various counseling and sound therapy approaches seem beneficial in the management of hyperacusis, but the evidence base for these remains poor.

Am J Audiol. 2012 Dec;21(2):175-80.


The accuracy of matching target insertion gains with open-fit hearing aids.

Aazh H(1), Moore BC, Prasher D.

Author information: (1)Royal Surrey County Hospital National Health Service Foundation Trust, UK.

PURPOSE: To assess the accuracy with which target insertion gains were matched for a single type of open-fit hearing aid, both on initial fitting and after adjustment.

METHOD: The hearing aids were fitted using the first-fit setting in the programming software and the target formula was selected as NAL-NL1. The difference between the real ear insertion gain (REIG) and the NAL-NL1 target REIG was recorded. The initial fitting was considered acceptable if the difference was less than 10 dB at all frequencies. If an initial fitting was not acceptable, the frequency-gain response was modified. The difference between the final REIG and the NAL-NL1 target REIG was recorded as final target mismatch.

RESULTS: Of the 51 initial fittings, 36 (71%) failed to achieve a match within ±10 dB of the NAL-NL1 insertion gain target at 1 or more frequencies between 0.25 and 4 kHz. After the authors adjusted the frequency-gain response of the hearing aids, only 9 fittings (18%) failed to achieve a match.

CONCLUSION: These outcomes suggest that target insertion gains for the open-fit hearing aids used here are rarely achieved with a first fitting but can usually be achieved through adjustments based on REIG measurements.

Int J Audiol. 2012 Feb;51(2):103-7.


Real ear measurement methods for open fit hearing aids: modified pressure concurrent equalization (MPCE) versus modified pressure stored equalization (MPSE).

Aazh H(1), Moore BC, Prasher D.

Author information: (1)Audiology Department, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK.

OBJECTIVE: The aim of this study was to assess differences between real ear insertion gains (REIG) measured with the modified pressure concurrent equalization (MPCE) and modified pressure stored equalization (MPSE) methods for open fittings in a typical audiology patient population.

DESIGN: REIGs were compared for the two methods using a warble tone sweep at 65 dB SPL. The differences between the two methods at 0.25, 0.5, 1, 2, 3, 4 and 6 kHz were recorded.

STUDY SAMPLE: Eighty-three ears of a consecutive sample of 48 candidates for open-fit hearing aids were included.

RESULTS: The mean difference between MPSE and MPCE REIGs was less than 1 dB at all frequencies. Analysis of variance showed that the main effect of method was not significant, and there was no significant interaction between method and frequency.

CONCLUSIONS: The results for the MPSE and MPCE methods did not differ significantly for the patients with mild-to-moderate hearing losses tested here, for whom REIGs were generally less than 20 dB. Further research is needed to identify the REIG values at which the differences between MPCE and MPSE methods become clinically significant.

Am J Audiol. 2011 Dec;20(2):151-8.


Gabapentin for tinnitus: a systematic review.

Aazh H(1), El Refaie A, Humphriss R.

Author information: (1)Royal Surrey County Hospital NHS Foundation Trust, Guildford, United Kingdom.

PURPOSE: The main aim of this study was to assess the effect of gabapentin on tinnitus via a systematic review.

METHOD: An electronic search of literature as well as a hand search were conducted. Only double-blind randomized controlled trials (RCTs) that met all of the inclusion criteria were included in this review. The Cochrane Collaboration tool for risk of bias assessment was used to investigate the validity of the included studies. Meta-analysis was not appropriate due to inadequate details in reporting the data in the included studies. Hence, qualitative synthesis and interpretation of the data were carried out.

RESULTS: Two studies that met the inclusion criteria were included in the review. Fourteen studies were excluded. There were substantive within-study clinical heterogeneities with regard to the baseline tinnitus handicap scores, duration of tinnitus, and severity of hearing loss in the included double-blind RCTs.

CONCLUSION: The authors of both studies reported that gabapentin was not superior to placebo in their primary outcomes. However, following the assessment of risk of bias and within-study clinical heterogeneities, this review concludes that there is insufficient evidence regarding the effect of gabapentin on tinnitus.



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