Abstract
This study aimed to compare spatial hearing performance between adult individuals with the unilateral sensorineural hearing loss and unilateral loss of horizontal semicircular canal function (termed canal paresis/weakness) in the same ear and adults with normal hearing thresholds and normal vestibular function and to examine associated factors (duration of hearing loss and rate of canal paresis).The study participants consisted of 20 adults (aged 48±11 years) with unilateral sensorineural hearing loss and unilateral canal paresis (unilateral weakness≥25%) in the same ear. The control group comprised 25 adults (aged 45±13 years) with normal hearing and a unilateral weakness rate below 25%. Pure tone audiometry, bithermal binaural air caloric test, Turkish Spatial Hearing Questionnaire (T-SHQ), and Standardized Mini-Mental State Exam were applied to all the individuals. When the performance of the participants in T-SHQ was examined both in terms of the subscales and the total scale, there was a statistically significant difference between the two groups in relation to the scores. A statistically significant, high, negative correlation was detected between the duration of hearing loss, the rate of canal paresis and all the subscale scores and total score of T-SHQ. According to these results, as the duration of hearing loss increased, the scores obtained from the questionnaire decreased. As the rate of canal paresis increased, vestibular involvement increased, and the T-SHQ score decreased. This study showed that adults with unilateral hearing loss and unilateral canal paresis in the same ear had lower spatial hearing performance than those with normal hearing and balance.
Supplementary Information
The online version contains supplementary material available at 10.1007/s12070-022-03442-1.
Keywords: Turkish Spatial Hearing Questionnaire, Unilateral hearing loss, Canal paresis, Spatial hearing, Audio-vestibular weakness
Introduction
Spatial hearing is the ability to identify the location of sounds. It contributes significantly to the capacity to distinguish signal/speech from noise and plays a fundamental role in orienting to multisensory events [1]. In determining different sound sources and distinguishing between different sounds, information obtained from both ears is a determinant factor. Studies have shown that the interaural time difference (ITD) and interaural level difference (ILD) could be used to effectively identify the source of a sound and distinguish a target signal in the background noise. Specifically, ITD helps find the source of a sound, as its signal reaches both ears at different times. ILD allows for the determination of the location of a sound based on the higher intensity perception of the sound produced from a source closer to both ears [2, 3].
Normal-hearing listeners perform the function of separating target signals from competing sounds and sound source localization predominantly through these binaural spatial cues. Studies have shown the importance of binaural cues to improve sound source localization and perception of target sounds in the presence of other sounds. Unilateral or asymmetrical hearing loss impairs spatial hearing due to its destructive effects on spatial hearing by eliminating binaural cues [4]. Listening with one ear causes difficulty in sound localization [5]. On the other hand, there are studies reporting that different systems are also effective in spatial hearing. In addition to the auditory system, postural stability and visual and somatosensory cues affect the perception of spatial hearing. It has been reported that difficulties are encountered in following acoustic information flow, especially in studies where bilateral sensorineural hearing loss and vestibular problems occur together [6]. To determine the sources of a moving sound, the role of vestibular functions in spatial hearing is emphasized in listening environments with background noise [7]. Zhong and Yost demonstrated a link between spatial hearing and the balance system [8]. However, much less is known concerning the role of both unilateral hearing loss and vestibular loss in the same ear. Data on the underlying mechanism of spatial hearing and vestibular function interaction is limited. In our review of the literature, we found no study evaluating spatial hearing in individuals with vestibular and auditory loss in the same ear, and therefore we consider that our study will fill this gap in the literature.
This study aimed to compare spatial hearing performance between adult individuals with unilateral sensorineural hearing loss and unilateral canal paresis/weakness in the same ear and those with normal hearing thresholds and normal vestibular function and to examine associated factors (duration of hearing loss and rate of canal paresis).
Materials and Methods
The study participants consisted of 20 adults with unilateral sensorineural hearing loss, who presented to the Ear, Nose, and Throat Diseases Department of Eskisehir Osmangazi University Health, Application, and Research Hospital. The control group comprised 25 adults. A power analysis was used to determine the sample size. Effect size was analyzed using G*Power version 3.1. The power was found to be 0.809, and the effect size q was 0.6 for each of two independent sample sizes (n = 20). The exclusion criteria for the groups were as follows: (1) abnormal otorhinolaryngology findings, (2) presence of an air-bone gap in an audiogram (indicates a middle ear problem), (3) presence of cardiological, systemic, or metabolic diseases (such as diabetes mellitus and hypertension), (4) history of an ear operation, and (5) being under active medical treatment (vestibulosuppresants, etc.). The inclusion criteria were as follows: (1) presence of sensorineural hearing loss in only one ear and vestibular loss (canal paresis) on the same ear and normal hearing and normal vestibular test results on the other ear for the study group, and (2) presence of bilateral normal hearing and normal vestibular test results for the control group.
The demographic (age, gender, etc.) and medical data of all the participants were obtained using an information form. An experienced audiologist working in the audiology unit of the same hospital performed all the audiological evaluations following the otolaryngology examination. The hearing thresholds of all the participants were evaluated in a soundproof room using a clinical audiometer (AC 40 model, Interacoustics, Otometrics, Taastrup, Denmark) and supra-aural headphones (Telephonics TDH-39P). The thresholds were determined with the standard Hughson–Westlake procedure (steps: 10 decibels descending, 5 decibels ascending; two-thirds correct), air conduction thresholds at 0.5-6 kHz, and bone conduction thresholds at 0.5-4 kHz. Hearing was accepted as normal if the 500–2,000 Hz pure tone average (PTA) indicated a 20 decibels hearing level (dB HL) or better [9]. For the vestibular evaluation of the participants, the bithermal binaural air caloric test (8 L/min airflow of hot and cold air at 50 °C and 25 °C, respectively in each ear) was performed using the ICS Chart 200 VNG/ENG system (Otometrics, Denmark). The slow phase velocity of nystagmus appearing with the horizontal-vestibuloocular reflex arc obtained by the stimulation of both labyrinths with air was compared. The asymmetry of vestibular function was calculated using Jongkees’ formula [10]. The rate of unilateral weakness (UW) being ≥ 25% in one ear was evaluated as the presence of canal paresis and accepted as a pathological/abnormal response. UW < 25% was considered to indicate normal vestibular function/canal function [11, 12].
The Standardized Mini-Mental Status Exam (SMMSE) was administered by a clinician to the individuals in both the study and control groups. SMMSE has been used as a global screening tool for cognitive impairment. SMMSE consists of 19 items, and the maximum score is 30 points (10 points for orientation, 6 for verbal memory, 5 for concentration and calculation, 5 for language, 3 for praxis, and 1 for visuospatial construction). A score of 24 or higher is classified as normal. If the score is below 24, the result is usually considered to be abnormal, indicating possible cognitive impairment. Cognitive impairment can affect spatial hearing [13]. Therefore, individuals that scored between 24 and 30 on SMMSE were included in the study. Finally, the participants were asked to complete the Turkish Spatial Hearing Questionnaire (T-SHQ), which consists of a total of 24 items. This is a self-report assessment tool including eight subscales with questions pertaining to the perception of male, female, and children’s voices, music in quiet, source localization, understanding speech in quiet, and understanding speech in noise. Respondents score each question on a scale from 0 to 100, with 0 indicating that the situation is very difficult and 100 indicating that the situation is very easy. The score in this scale provides the clinician with an indication of how the patient perceives his or her spatial hearing abilities or disabilities, and the subscale scores offer details on how the patient performs in specific situations. The Spatial Hearing Questionnaire was developed by Tyler et al. [14]. The Turkish version of the questionnaire was published by Çıldır et al. [15].
All the participants were aged between 18 and 65 years. The study group included 20 participants with sensorineural hearing loss and a UW rate above 25%. Middle ear function was accepted as normal in cases without the air-bone gap on audiogram. Individuals with conductive hearing loss were excluded from the study. The control group comprised 25 participants with normal hearing thresholds and a UW rate below 25%. The duration of hearing loss and rate of canal paresis were investigated as associated factors that could have an effect on spatial hearing performance.
Statistical Analysis
SPSS IBM version 23.0 was used for statistical analyses [16]. The variables were examined with the Shapiro–Wilk test in terms of the normality of distribution, and it was determined that they did not demonstrate a normal distribution. Non-parametric tests were used for intergroup comparisons. Spearman’s correlation test was used to analyze the relationship between canal paresis, audiological evaluation, and spatial hearing. The significance level was accepted as 0.05 in all the tests.
Results
The demographic characteristics of all the individuals that participated in the study are summarized in Table 1. There was no statistically significant difference between the two groups in terms of the age distribution of the participants (p = .43). The mean age of the participants in the study group was 48 (± 11) years, and the mean age of those in the control group was 45 (± 13) years.
Table 1.
Age and Gender Distribution of the Participants in the Study and Control Groups
| Groups | ||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Study Group | Control Group | |||||||||||||||
| Female (n = 10) |
Male (n = 10) |
Female (n = 16) |
Male (n = 9) |
|||||||||||||
| Min | Mean | Max | SD | Min | Mean | Max | SD | Min | Mean | Max | SD | Min | Mean | Max | SD | |
|
Age (Year) |
18 | 47 | 64 | 14 | 33 | 49 | 63 | 8 | 27 | 41 | 56 | 10 | 23 | 51 | 64 | 14 |
Max: Maximum; Min: Minimum; SD: Standard Deviation
It was determined that the bilateral hearing thresholds of the participants in the control group were within normal limits after the audiological evaluation (PTA ≤ 20 dB HL). The participants in the study group, however, had unilateral hearing loss. Hearing loss was found in the right ear of nine (45%) and left ear of 11 (55%) of the 20 participants in the study group. After the vestibular evaluation of all the participants, the presence and rate of canal paresis were determined for both groups according to their performance in the caloric test. The average rate of unilateral weakness was 66% [range: 35–95, standard deviation (SD) = 21] in the study group and 10% (range: 3–15, SD = 7) in the control group. The study group participants had hearing loss and canal paresis in the same ear. The pure tone average, duration of hearing loss, speech discrimination, and unilateral weakness values of the study group are given in Table 2.
Table 2.
Data on the Hearing Loss, Speech Discrimination, and Unilateral Weakness of the Participants in the Study Group
| Min | Mean | Max | SD | |
|---|---|---|---|---|
| Hearing loss duration (month) | 5 | 21 | 72 | 19 |
| PTA, pathological ear | 40 | 72 | 110 | 17 |
| PTA, ear with better hearing | 0 | 10 | 20 | 6 |
| Speech discrimination, pathological ear % | 72 | 80 | 88 | 8 |
| Speech discrimination, ear with better hearing % | 92 | 96 | 100 | 4 |
| Unilateral weakness, pathological ear % | 35 | 66 | 95 | 21 |
PTA: Pure Tone Average; Max: Maximum; Min: Minimum; SD: Standard Deviation
The performances of the study and control groups in T-SHQ were examined in terms of the subscales and the total scale (Table 3; Fig. 1). The Mann-Whitney U test was used to compare the T-SHQ scores between the study and control groups. There was a statistically significant difference between the two groups in terms of all the subscale scores and the total score (Table 4). The distribution of the T-SHQ performances of the study and control groups is shown in Fig. 2.
Table 3.
Distribution of Turkish Spatial Hearing Questionnaire Performance Scores of the Participants in the Study and Control Groups
| Study Group | Control Group | |||||||
|---|---|---|---|---|---|---|---|---|
| Subscales | Min | Mean | Max | SD | Min | Mean | Max | SD |
| Male voices | 25.00 | 53.45 | 72.00 | 12.73 | 76.00 | 86.68 | 98.00 | 5.75 |
| Female voices | 31.00 | 51.20 | 70.00 | 12.21 | 74.00 | 86.16 | 98.00 | 6.02 |
| Children’s voices | 31.00 | 48.65 | 65.00 | 11.05 | 72.00 | 85.68 | 95.00 | 5.49 |
| Music | 12.00 | 49.70 | 74.00 | 14.59 | 75.00 | 85.52 | 95.00 | 6.13 |
| Sound localization | 27.50 | 51.79 | 80.42 | 14.21 | 65.42 | 80.43 | 99.17 | 7.64 |
|
Understanding speech in quiet |
45.00 | 64.12 | 80.00 | 7.98 | 88.75 | 96.05 | 100.00 | 3.84 |
| Understanding speech in noise-front | 8.75 | 45.56 | 72.50 | 17.77 | 62.50 | 84.25 | 100.00 | 8.13 |
| Understanding speech in noise-separate | 5.00 | 43.00 | 62.50 | 14.27 | 65.00 | 85.00 | 100.00 | 9.09 |
| Total score | 21.04 | 48.53 | 67.92 | 12.42 | 74.79 | 84.53 | 93.54 | 5.43 |
Max: Maximum; Min: Minimum; SD: Standard Deviation
Fig. 1.
Performance of the Study and Control Groups in the Turkish Spatial Hearing Questionnaire
Table 4.
Turkish Spatial Hearing Questionnaire Performance of the Participants in the Study and Control Groups
| Turkish Spatial Hearing Questionnaire |
Group | n | Mean Rank |
Rankings Total |
U | Z | p |
|---|---|---|---|---|---|---|---|
| Male voices | Study | 20 | 10.0 | 210.00 | |||
| Control | 25 | 33.00 | 825.00 | 0.00 | -5.91 | 0.001 | |
| Female voices | Study | 20 | 10.50 | 210.00 | |||
| Control | 25 | 33.00 | 825.00 | 0.00 | -5.88 | 0.001 | |
| Children’s voices | Study | 20 | 10.50 | 210.00 | |||
| Control | 25 | 33.00 | 825.00 | 0.00 | -5.90 | 0.001 | |
| Music | Study | 20 | 10.50 | 210.00 | |||
| Control | 25 | 33.00 | 825.00 | 0.00 | -5.98 | 0.001 | |
| Sound localization | Study | 20 | 11.40 | 228.00 | |||
| Control | 25 | 32.28 | 807.00 | 18.00 | -5.64 | 0.001 | |
| Understanding speech in quiet | Study | 20 | 10.50 | 210.00 | |||
| Control | 25 | 33.00 | 825.00 | 0.00 | -5.85 | 0.001 | |
| Understanding speech in noise-front | Study | 20 | 10.73 | 214.50 | |||
| Control | 25 | 32.82 | 820.50 | 4.50 | -5.56 | 0.001 | |
| Understanding speech in noise-separate | Study | 20 | 10.50 | 210.00 | |||
| Control | 25 | 33.00 | 825.00 | 0.00 | -5.79 | 0.001 | |
| Total score | Study | 20 | 10.50 | 210.00 | |||
| Control | 25 | 33.00 | 825.00 | 0.00 | -5.94 | 0.001 |
U: Mann-Whitney U Value; p: Significance Level; z: Standard Score
Fig. 2.
Distribution of the Spatial Hearing Questionnaire Scores in Both Groups
When the duration of hearing loss and the rate of canal paresis were examined as associated factors, there was a statistically significant, high, negative correlation between the duration of hearing loss and all the subscale scores and total score of T-SHQ (Table 5). According to these results, as the duration of hearing loss increased, the scores obtained from the questionnaire decreased. Similarly, a statistically significant, high, negative correlation was observed between the rate of canal paresis and the results of T-SHQ (Table 5). As the rate of canal paresis increased, vestibular involvement increased, and T-SHQ scores decreased. The results of Spearman’s correlation analysis are presented in Table 5. In terms of age and gender, no significant correlation was observed between the subscale scores and the total score of questionnaire.
Table 5.
Examination of the Relationship between the Turkish Spatial Hearing Questionnaire Scores and the Duration of Hearing Loss, and Rate of Canal Paresis
| Hearing Loss Duration | Canal Paresis Rate | p | |
|---|---|---|---|
| Male voices | -0.85 | -0.78 | 0.001 |
| Female voices | -0.85 | -0.78 | 0.001 |
| Children’s voices | -0.84 | -0.79 | 0.001 |
| Music | -0.85 | -0.82 | 0.001 |
| Sound localization | -0.74 | -0.66 | 0.001 |
| Understanding speech in quiet | -0.83 | -0.75 | 0.001 |
| Understanding speech in noise-front | -0.80 | -0.75 | 0.001 |
| Understanding speech in noise-separate | -0.84 | -0.74 | 0.001 |
| Total score | -0.85 | -0.78 | 0.001 |
p: Significance Level
Discussion
The purpose of this study was to compare the spatial hearing performance of adults with unilateral hearing loss and canal paresis in the same ear to individuals with normal hearing and no canal paresis. We also examined the relationship between the duration of hearing loss and rate of canal paresis as factors associated with spatial hearing. In the evaluation of the participants’ spatial hearing performance, we used T-SHQ, a self-assessment tool. Scales that evaluate performance through questionnaires and self-assessment in determining individual differences in difficult listening conditions provide information for clinicians and researchers. In the literature, one of the most frequently used questionnaires for the evaluation of spatial hearing is SHQ. In a previous study evaluating participants with normal-hearing and those with hearing loss, the correlation between SHQ and a psychophysical spatial hearing test (spatial word in noise test) was investigated. Hearing loss was found to affect spatial hearing ability, and both tests were shown to be effective in assessing spatial hearing. In addition, it was emphasized that audiometry and speech tests could not evaluate spatial hearing [17].
Hearing loss, especially unilateral loss is one of the factors affecting spatial hearing performance, since it eliminates bilateral cues. In a study by Perreau et al., the spatial hearing performance of individuals with normal hearing and those using cochlear implants were compared, and differences were found between the two groups according to SHQ. When the results of SHQ for individuals with normal hearing in the control group and unilateral and bilateral cochlear implant users were examined, the lowest performance was observed in the unilateral cochlear implant group [18]. Given that unilateral cochlear implant users did not benefit from binaural hearing, it can be assumed that individuals with unilateral hearing loss can experience similar difficulties in daily life. In a study using the Speech, Spatial, Qualities of Hearing Scale, children with sensorineural and mixt type unilateral hearing loss were determined poor localization skills than those with normal hearing [19]. In another study, spatial release masking and sound source localization were reported to be worse in adults with unilateral conductive hearing loss than in those with normal hearing [3]. Unilateral hearing loss, regardless of its type, has adverse effects on spatial hearing performance. Consistent with the literature, in the current study, the individuals with unilateral sensorineural hearing loss showed lower performance in T-SHQ than those with normal hearing. When the scores of the T-SHQ subscales were examined, there were significant differences between the study and control groups.
It is not only the auditory system that is effective in spatial hearing skills. Spatial hearing relies on systematic associations between the auditory input reaching the ears, the position of the head, and coordinates in external space [20]. In the literature, there are only few studies investigating the relationship between the vestibular system and spatial hearing. In a study evaluating individuals that had normal hearing but were diagnosed with bilateral vestibulopathy, Peetermans et al. (2022) showed a moderate correlation between Dizziness Handicap Inventory and Spatial, Speech, and Qualities Questionnaire, i.e., spatial hearing scores decreased with a dizziness handicap accompanying hearing loss [21]. Similarly, Anson et al. (2021) determined that spatial orientation was worse in individuals with vestibular dysfunction, especially in those with semicircular canal and utricle hypofunction. The authors demonstrated that spatial orientation was worse in individuals with bilateral vestibular hypofunction than in unilateral individuals. They also emphasized that individuals with vestibular weakness benefitted more from binaural processing for spatial hearing, and spatial orientation also decreased with impaired hearing [22]. In our study, the T-SHQ subscale scores and total score were significantly lower in the group with unilateral hearing loss and canal weakness compared to the healthy group. In addition, as the duration of hearing loss increased, the scores obtained from the questionnaire decreased. Similarly, as the rate of canal paresis increased, vestibular involvement increased, and the T-SHQ scores decreased. We determined that the performance of the participants with unilateral hearing loss and vestibular disorder was negatively affected according to the questionnaire evaluating the spatial characteristics of hearing. In addition, the rate of canal paresis and the duration of hearing loss had a negative effect on spatial hearing performance. This shows a significant correlation between increased vestibular involvement and the difficulty of spatial hearing in daily life. Since we did not find a similar study in the literature, we were unable to compare our data, but our results indicate that vestibular loss also affects spatial hearing. We detected no significant relationship in spatial hearing ability according to age and gender, which is consistent with the literature [23].
Studies have shown that the auditory system is related to the vestibular system, and most individuals with hearing loss have vestibular problems/loss [6]. Individuals with unilateral hearing loss commonly have vestibular dysfunction on the side of the ear with hearing loss. Since the relationship between hearing and balance systems is very complex, it is very difficult to refer to a direct interaction. It has been reported that vestibular disorder is encountered at rates ranging from 20 to 70% in cases of sensorineural hearing loss. It has been suggested that the rate of unilateral sudden hearing loss accompanied by vestibular problems is approximately 45% in the adult group. In a study with children, balance disorders were observed in the presence of unilateral hearing loss, which resulted in a significant difference compared to their peers with normal hearing. Studies have also shown that spatial hearing loss is the leading cause of central auditory processing disorder in children [17]. It should also be noted that after hearing loss is detected in children, vestibular loss may coexist, and spatial hearing skills may be more affected. In an experimental study performed by Valzolgher et al. in adults, monaural listening training was applied to adults by temporarily plugging one ear, and it was determined that spatial hearing difficulties decreased and were partially compensated after three consecutive days of multisensory active training [1]. We consider that improving spatial hearing skills with multi-sensory education/rehabilitation strategies will be beneficial, especially in children with hearing loss, as well as adults with auditory and vestibular loss.
This study has certain limitations. First, individuals with canal paresis and those without hearing loss were not evaluated as separate subgroup. Another limitation concerns the small number of participants. Therefore, the results should be interpreted by considering that they are limited to individuals taking part in the study and cannot be generalized to the entire research population. In future studies, it is recommended that research be planned with participants from different age groups to examine age-related differences in a larger sample including individuals with unilateral canal paresis and those without hearing loss.
Conclusion
It was determined that adults with unilateral sensorineural hearing loss and unilateral canal paresis in the same ear had lower spatial hearing performance than those with normal hearing and balance. Individuals with unilateral hearing loss should be clinically examined with regard to not only hearing loss but also the vestibular system. Furthermore, difficulties experienced by these individuals in different listening environments should be evaluated with questionnaires and scales, considering individual differences in order to determine appropriate rehabilitation approaches and provide effective counseling.
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Footnotes
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Arzu Kırbaç, Email: arzukirbac@gmail.com.
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