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J Audiol Otol > Volume 29(1); 2025 > Article
Kim, Cho, Jo, Yun, Quilter, Kim, and Moon: Effects of Hearing Aids on Static and Subjective Balance in Patients With Hearing Loss: A Pilot Study

Abstract

Background and Objectives

This study aimed to investigate the effects of hearing aids (HAs) on reducing symptoms of dizziness in patients with hearing loss (HL) and dizziness.

Subjects and Methods

A pre- and post-intervention study was conducted between February 2022 and July 2022 at the outpatient clinic of a tertiary hospital in Seoul, South Korea. Ten participants (four males and six females) with HL and dizziness were recruited. Participants were screened using pure-tone audiometry and visual analog scale scores at baseline. Selected participants underwent the Modified Clinical Test of Sensory Interaction on Balance (mCTSIB) and Korean Dizziness Handicap Inventory (K-DHI) in the unaided state. Thereafter, participants were provided HAs and instructed to use them for at least 6 hours every day. At the 1-month follow-up, all participants were assessed in the aided state using the same tests as at baseline. All tests were performed bilaterally.

Results

In the mCTSIB, a significant difference was observed in the foam surface-eyes closed score before (median=2.35) and after (median=2.2) HA use (p=0.049). No significant differences were observed in the K-DHI scores before and after HA use.

Conclusions

HA use may improve the static and subjective perception of balance in patients with HL and dizziness. Future research should explore the benefits of HAs under various balance conditions such as dynamic balance and gait.

Introduction

Hearing loss (HL) and dizziness are common disorders in adults. The prevalence of HL and dizziness in adults >60 years of age was reportedly 20%–30% and 58%, respectively [1,2]. Furthermore, individuals commonly experience HL and dizziness simultaneously. HL and dizziness, when coexisting in a person, can diminish the quality of life and lead to adverse health outcomes, including falls. Age-related HL is associated with an increased risk of falls [3,4].
Several theories have been proposed to account for the relationship between HL and dizziness. First, both HL and dizziness are the result of a common age-related loss of both anatomical and physiological cochleovestibular functions. Human hearing and balance systems are located in the inner ear. Therefore, the structures of the inner ear that have deteriorated with aging may be responsible for postural instability [5]. Second, HL immediately affects a person’s balance due to a lack of audiological cues. Postural stability is maintained by sensory inputs, including visual, vestibular, and somatosensory. In a previous study, auditory information was shown to be potentially involved in maintaining balance by acting as auditory biofeedback [6]. Finally, patients with HL require greater resources for auditory processing, therefore, fewer resources remain for maintaining balance.
Previous research has demonstrated that auditory correcting devices, such as cochlear implants (CIs) and hearing aids (HAs), can enhance balance functions in individuals with HL. Specifically, CI recipients with severe-to-profound HL have shown significant improvements in spatial awareness and postural control. A meta-analysis further supported these findings, indicating enhanced balance capabilities in patients with severe-to-profound HL who received CIs [7]. HAs are also suggested to improve various aspects of balance in patients with HL, though the overall benefits remain somewhat ambiguous [8]. It is hypothesized that HAs might contribute to better static, dynamic, or subjective balance perceptions in adults with HL.
In the present study, the effects of HAs on dizziness in patients with both HL and dizziness were investigated. We hypothesized the use of HAs would lead to a significant reduction in the symptoms of dizziness.

Subjects and Methods

Participants

Ten participants were recruited from the Department of Otorhinolaryngology outpatient clinic between February 2022 and July 2022. The number of participants was calculated using G*Power Version 3.1.9.7 (Institute for Experimental Psychology, Dusseldorf, Germany) with the conditions of a two-tailed test, parent distribution=normal, effect size (dz)=0.93 [9], significance level (α)=0.20, and power (1-β)=0.80, resulting in a sample size of 7. Considering the dropout rate, a total of 10 participants were recruited. The inclusion criteria were as follows: 1) ≥18 and <70 years of age; 2) pure-tone averages (0.5, 1, 2, and 4 kHz) ≥25 dB HL and ≤70 dB HL in both ears; and 3) complaints of dizziness (reporting a score ≥1 point on the visual analog scale, VAS). Patients who were unable to walk independently and had a history of congenital malformations in the central and auditory nervous systems were excluded. The Institutional Review Board of Samsung Medical Center in Seoul approved this study (IRB No. 2021-09-135-004). All participants provided written informed consent form before enrollment.

Outcome measures

Screening test

Pure-tone audiometry

Pure-tone audiometry (PTA) was performed using a calibrated GSI Audio Star audiometer (Grason-Stadler, Inc., Eden Prairie, MN, USA) in a sound-proof room to screen HL. The PTA was performed in each ear at 0.25 kHz and 8 kHz frequencies according to a standard procedure. The pure-tone average was calculated for each ear at 0.5, 1, 2, and 4 kHz frequencies. The participants with a pure-tone average ≥25 dB HL and ≤70 dB HL in both ears were enrolled in the study.

Visual analog scale

The VAS was used to quantify the severity of dizziness. The VAS is a 100 mm horizontal line anchored by two extremes: 0 (no dizziness) and 100 (maximum dizziness). The participants were instructed to mark an “x” on the scale corresponding to the dizziness they were experiencing. A minimum score ≥1 point on the VAS was required for participation in the study.

Main test

Modified Clinical Test of Sensory Interaction on Balance

The Modified Clinical Test of Sensory Interaction on Balance (mCTSIB) was performed with the Bertec Portable Essential (Bertec© Corp., Columbus, OH, USA). The test is designed to objectively assess static balance. The mCTSIB included four conditions: 1) firm surface/eyes open, standing on a rigid surface with eyes open; 2) firm surface/eyes closed, standing on a rigid surface with eyes closed; 3) foam surface/eyes open, standing on a compliant surface with eyes open; and 4) foam surface/eyes closed, standing on a compliant surface with eyes closed. The participants performed the mCTSIB three times under the above four conditions. Each participant was instructed to maintain an upright position during each condition for up to 30 seconds. The mean center of gravity (COG) sway velocity was recorded for each condition. The scores were calculated as the average of the three trials for each condition.

Korean Dizziness Handicap Inventory

The Korean Dizziness Handicap Inventory (K-DHI) is a validated 25-item questionnaire for assessing physical, emotional, and functional impairment to evaluate the severity of dizziness symptoms [10]. The total score is the sum of the individual score of each item (ranging from 0–100); a higher total score indicates more severe symptoms.

Intervention

The participants were screened using PTA and VAS at baseline. The participants who passed the screening tests underwent the mCTSIB and the K-DHI during the unaided condition (without HAs). Finally, the participants were given ReSound ONE HAs (GN Hearing A/S , Ballerup, Denmark) fitted to the NAL-NL2 formula and instructed to use them for at least 6 hours every day during the intervention. After 1 month, all the participants visited the clinic and were assessed for the same tests as at baseline during the aided condition (with HAs). All tests were performed bilaterally in the aided state (Fig. 1).

Statistical analysis

Using descriptive statistical analysis, the median and interquartile range (IQR) were used for continuous variables, and numbers and percentages for categorical variables. The Wilcoxon signed-rank test was used to examine the significance of the median difference between before and after intervention outcomes. All statistical analyses were completed using SPSS version 25.0 (IBM Corp., Armonk, NY, USA).

Results

The study included ten participants suffering from HL and dizziness, with a median age of 64 years. The gender distribution was 40% male and 60% female. Diagnoses among participants included vestibular hydrops (1 patient), Meniere’s disease (6 patients), and vestibular neuritis (3 patients). The median pure-tone average was 48.13 dB HL for the right ear and 38.75 dB HL for the left ear. The median VAS score for dizziness was 28. The participant characteristics are shown in Table 1.
In the mCTSIB test, a significant difference in the foam surface-eyes closed score was observed between before (median= 2.35) and after (median=2.2) use of HAs (p=0.049). Significant differences were not observed for the other conditions between before and after use of HAs (Fig. 2).
A significant difference was not observed in K-DHI scores between before and after use of HAs. However, the scores tended to decrease after using HAs (Table 2).

Discussion

In the present study, the influence of HAs on dizziness in patients with both HL and dizziness was investigated. For the study, a before-and-after intervention was conducted. After 1 month of using HAs, a significant improvement was observed in the foam surface-eyes closed score on the mCTSIB test. A decreasing trend in the K-DHI score was observed but without statistical significance.
The mCTSIB was used to evaluate postural stability under different visual, vestibular, and somatosensory conditions. Abnormal sway or fall with eyes closed on the foam surface indicated the participants had difficulty incorporating vestibular information in balance control. In the study, a significant improvement was observed in the foam surface-eyes closed condition after 1 month of HA use, indicating auditory input may help postural stability along with visual, vestibular, and somatosensory cues. Similar results were reported in previous studies [6,9,11]. Vitkovic, et al. [6] reported auditory spatial cues might improve postural corrections to maintain balance.
The K-DHI was used to measure the subjective balance function of the participant. The score ranges from 0–100 with a higher score indicating a greater handicap. A significant difference was not observed in the K-DHI scores between before and after use of HAs. However, the scores tended to decrease in all subscales after using HAs. One reason for these results may be that most participants did not have severe dizziness (i.e., the median VAS was 28 of 100 at the initial visit). In addition, results of the previous studies regarding the effect of HAs on subjective measurements of balance were inconsistent [9,12] and further research is needed.
The present study had several limitations. First, the small sample size and the relatively short intervention period make it difficult to generalize the results. Future studies should be conducted with a larger sample size and a longer intervention period. Second, auditory stimulation was not used to evaluate the balance function. To ascertain whether auditory cues aid in postural stability, incorporating auditory stimulation during the test may be beneficial. Third, the absence of a control group in the study warrants caution in interpreting the results. Subsequent research should consider designs that compare a control group not using HAs or compare paired conditions within the experimental group, such as time slots with and without the use of HAs. Finally, the balance function in various conditions was not tested. Future research should include several balance conditions, such as dynamic balance and gait.
In conclusion, the study showed that auditory input might be considered an important contributor for maintaining postural stability and reducing symptoms of subjective dizziness. Therefore, the use of HAs improves auditory perception and might enhance postural stability in subjects with HL.

Notes

Conflicts of Interest

The authors have no financial conflicts of interest.

Author Contributions

Conceptualization: all authors. Data curation: Ga-Young Kim. Formal analysis: Ga-Young Kim. Funding acquisition: Il Joon Moon. Investigation: Ga-Young Kim, Mini Jo, Hee Jung Yun. Methodology: Ga-Young Kim, Mini Jo. Project administration: Il Joon Moon. Supervision: Il Joon Moon. Validation: all authors. Visualization: Ga-Young Kim. Writing—original draft: Ga-Young Kim. Writing—review & editing: Young Sang Cho, Il Joon Moon. Approval of final manuscript: all authors.

Funding Statement

This research was funded by the GN Resound Ltd. The sponsor only provided funding and was not involved in the design, data collection, analysis, or reporting of the research results.

Acknowledgments

None

Fig. 1.
Flowchart of the study. K-DHI, Korean Dizziness Handicap Inventory; mCTSIB, Modified Clinical Test of Sensory Interaction on Balance; PTA, pure-tone audiometry; VAS, visual analogue scale.
jao-2024-00150f1.jpg
Fig. 2.
The mCTSIB scores before and after use of hearing aids (n=10). *p<0.05. COG, center of gravity; mCTSIB, Modified Clinical Test of Sensory Interaction on Balance.
jao-2024-00150f2.jpg
Table 1.
Characteristics of the participants with hearing loss and dizziness (n=10)
No. Age (yr) Gender Diagnosis Pure-tone average (dB HL)
VAS (mm)
Right Left
1 67 Female Vestibule hydrops 58.75 37.50 85
2 46 Male Meniere’s disease 36.25 52.50 76
3 64 Female Vestibular neuritis 47.50 62.50 24
4 70 Female Meniere’s disease 42.50 33.75 27
5 55 Male Vestibular neuritis 63.75 36.25 29
6 41 Female Meniere’s disease 47.50 38.75 59
7 67 Male Meniere’s disease 48.75 37.50 26
8 64 Male Meniere’s disease 51.25 41.25 23
9 68 Female Meniere’s disease 48.75 38.75 18
10 53 Female Vestibular neuritis 45.00 40.00 50
Median (IQR) 64 (51.25-67.25) M:F=4:6 48.13 (44.38-53.13) 38.75 (37.19-51.56) 28 (23.75-63.25)

The pure-tone average was calculated for each ear at 0.5, 1, 2, and 4 kHz frequencies. IQR, interquartile range; VAS, visual analogue scale

Table 2.
K-DHI scores before and after use of hearing aids (n=10)
Domains Median (IQR)
p
Before After
Total (max=100) 48.5 (39.75-55.25) 39.5 (32.25-51.75) 0.153
Physical (max=24) 11 (7.5-16.5) 8 (4-12.5) 0.355
Emotional (max=36) 12 (9.5-16) 13 (5.5-16.5) 0.365
Functional (max=40) 13 (11.5-22) 7 (4-15.5) 0.051

IQR, interquartile range; K-DHI, Korean Dizziness Handicap Inventory

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