What Are the Current Audiological Practices for Ototoxicity Assessment and Management in the South African Healthcare Context?

The use of tele-audiology in ototoxicity monitoring: A scoping review

INTRODUCTION

Due to the growing burden of disease in South Africa, encompassing conditions such as tuberculosis, human immunodeficiency virus, and cancer, the holistic management of affected patients incorporating ototoxicity monitoring is a necessity. However, ototoxicity monitoring in developing countries may be limited due to a lack of resources and inadequate healthcare facilities. Subsequently, the use of tele-audiology may be a revolutionary technique with the potential to provide audiology services to under-served populations with limited access.

METHODS

The study aimed to describe the use of tele-audiology services in ototoxicity monitoring through a scoping review of English peer-reviewed articles from June 2009 to June 2020. Seventeen articles were purposively selected from the following databases: PubMed, Science Direct, Taylor and Francis Online, WorldCat, and Google Scholar. Data was extracted as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses diagram and results were analyzed using deductive thematic analysis.

RESULTS AND DISCUSSION

While a minority of the studies indicated that the cost of implementation and network connectivity within a South African context pose as barriers, most researchers reported that tele-audiology provides a reliable, time-efficient, cost-effective, and easily accessible alternative for ototoxicity monitoring. Hardware including the WAHTS, KUDUwave, and OtoID, along with software such as the TabSINT, Otocalc, uHear, and the hearTest, have proven to be useful for ototoxicity monitoring. A need for further investigations regarding the feasibility of tele-audiology implementation in South Africa is evident. Despite this, it provides audiologists with an opportunity to offer contact-less services during COVID-19, thus, confirming its versatility as an augmentative method for ototoxicity monitoring.

South African adolescents' lived experiences of acquired hearing loss following multidrug-resistant tuberculosis treatment

Objective

The impact of acquiring hearing loss might be exacerbated during adolescence, as this normal transition from childhood to adulthood is characterised by identity construction and social intensity. This study aimed to describe the lived experiences of South African adolescents with acquired hearing loss following aminoglycoside treatment for multidrug resistant tuberculosis.

Design

The study adopted a descriptive phenomenological design and in-depth, semi-structured interviews were conducted in English, isiZulu and Afrikaans. The data was managed and analysed according to a modified version of Hycner's framework.

Study sample

Six participants aged 16-24 years with bilateral, mild to profound hearing loss acquired from aminoglycoside treatment were recruited from two South African provinces.

Results

Three themes emerged which created a triple burden for participants. They endured socio-economic hardship encompassing limited economic and emotional support. Participants battled the consequences of life-threatening MDR-TB including illness, hospitalisation, stigma, and other challenges. Finally, participants were left with life-changing hearing loss.

Conclusion

The findings indicate the necessity of holistic management of adolescents with aminoglycoside-related acquired hearing loss and serves as motivation to improve ototoxic monitoring practices and patient uptake of monitoring services and calls for the cessation, or at least cautious use, of aminoglycosides.

Cisplatin-associated ototoxicity: perspectives from a single institution cervical cancer cohort and implications for developing a locally responsive monitoring programme in a public healthcare setting

Background

Ototoxicity monitoring is uncommon in South Africa, despite the increased use of ototoxic medication to manage the burden of disease in the country. The successful implementation of such a protocol requires cognisance of contextual realities and multiple dimensions for consideration from both patients and service providers. As part of an ongoing cohort study on cisplatin-associated ototoxicity and efforts to better inform the implementation of such programmes, the perspectives of cervical cancer patients and healthcare workers towards ototoxicity monitoring were assessed.

Methods

This concurrent-triangulation mixed-methods study was conducted at a tertiary hospital in South Africa. Self-reported questionnaires from patients (n = 80) and healthcare personnel comprising clinicians, oncology nurses, pharmacists, and radiotherapists (n = 32), results of audiological evaluations, researcher field notes, and estimated patient and service provider costs contributed to data for this study. Data analysis included descriptive statistics, comparison of test characteristics and deductive thematic analysis.

Results

The ototoxicity monitoring programme was positively received by the participants, with 90.6% of healthcare personnel and 89% of patients reporting it to be beneficial. The clinicians (76.6%) were identified as the main providers of information on the effects of chemotherapy medication and made the necessary referrals for audiological evaluation. The approximate cost of setting up such a programme included purchase of equipment (US56 700) and the appointment of an audiologist (US 26 250). The approximate costs to patients included transport costs (US$ 38) and the loss of income for the day (US 60), calculated at the minimum wage per hour, if employed. Creative appointment scheduling, easy facility access and detailed locally comprehensible couselling improved patient compliance to the programme. Whilst the sequential use of American Speech-Language-Hearing Association (ASHA) and National Cancer Institute Common Terminology Criteria for Adverse Events (NCI-CTCAE) criteria aided in an evidence-informed approach to aural rehabilitation, DPOAEs and speech discrimination displayed low sensitivity (range 1.45% – 22.39%) but high specificity (range 77.78% – 100%) when identifying ototoxic change.

Conclusion

This novel study, through a ‘real-world’ experience, has revealed that an ototoxicity monitoring programme is feasible in South Africa, through meaningful engagements with- and considerations from- patients and service providers regarding planning, delineation of responsibilities and cost implications. The findings can potentially serve as a roadmap for other limited resource environments.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08099-8.

A longitudinal community-based ototoxicity monitoring programme and treatment effects for drug-resistant tuberculosis treatment, Western Cape

Background

South Africa has a high burden of drug-resistant tuberculosis (DRTB) and until recently, ototoxic aminoglycosides were predominant in treatment regimens. Community-based ototoxicity monitoring programmes (OMPs) have been implemented for early detection of hearing loss and increased patient access.

Objectives

A longitudinal study was conducted to describe the service delivery characteristics of a community-based OMP for DRTB patients facilitated by CHWs as well as observed ototoxic hearing loss in this population.

Method

A descriptive retrospective record review of longitudinal ototoxicity monitoring of 194 DRTB patients undergoing treatment at community-based clinics in the city of Cape Town between 2013 and 2017.

Results

Follow-up rates between consecutive monitoring assessments reached as high as 80.6% for patients assessed by CHWs. Few patients (14.2% – 32.6%) were assessed with the regularity (≥ 6 assessments) and frequency required for effective ototoxicity monitoring, with assessments conducted, on average, every 53.4–64.3 days. Following DRTB treatment, 51.5% of patients presented with a significant ototoxic shift meeting one or more of the American Speech-Language-Hearing Association (ASHA) criteria. Deterioration in hearing thresholds was bilateral and most pronounced at high frequencies (4 kHz – 8 kHz). The presence of pre-existing hearing loss, human immunodeficiency virus co-infection and a history of noise exposure were significant predictors of ototoxicity in patients.

Conclusion

DRTB treatment with kanamycin resulted in significant deterioration of hearing longitudinally, predominantly at high frequencies. With ongoing training and supportive supervision, CHWs can facilitate community-based ototoxicity monitoring of DRTB patients. Current protocols and guidelines may require reassessment for appropriate community-based ototoxicity monitoring.

Investigation of the Interaction between Hearing Function and Comorbidities in Adults Living with Human Immunodeficiency Virus

Adults living with the human immunodeficiency virus (HIV) have a high prevalence of co-existing comorbidities. While research indicates that adults living with HIV are at risk of developing hearing impairment, limited research exists on the interaction between hearing function and comorbidities in this population. The objective of this study was to determine and compare the hearing function of a group of adults living with HIV and comorbidities and those without comorbidities. A sample of 132 adults living with HIV underwent a basic audiological test battery to assess their hearing function. Participants with comorbidities were 1.23 times more likely to develop hearing loss, with crude odds of 1.236 (95%CI 0.5467 to 2.795), while those with three comorbidities were 2.52 times more likely to develop hearing loss. Participants with hypertension were 93% more likely to develop hearing loss when compared to nonhypertensive participants (OR = 1.928; 95%CI: 0.7856 to 4.7345). There was only a marginal association between hypercholesterolemia and sensorineural hearing loss (SNHL), with no association between other comorbidities and the type of hearing loss. The current findings raise a need for prioritizing patients with comorbidities in audiological assessment and monitoring in resource-constrained contexts, where capacity versus demand challenges might prevent the provision of audiological services to all adults living with HIV. These findings also highlight the importance of preventive care in this population with regard to the burden of the disease, as it may lead to worse ear and hearing outcomes for affected individuals.

Community-Based Ototoxicity Monitoring for Drug-Resistant Tuberculosis in South Africa: An Evaluation Study

In response to the drug-resistant tuberculosis (DRTB) ototoxicity burden in South Africa, ototoxicity monitoring has been decentralised, with community health workers (CHWs) acting as facilitators. This study describes a community-based ototoxicity monitoring programme (OMP) for patients with DRTB. Findings are compared to the recommended guidelines for ototoxicity monitoring, the OMP protocol and published studies. This was a retrospective study of longitudinal ototoxicity monitoring of 831 patients with DRTB, using data collected at community-based clinics in the City of Cape Town between 2013 and 2017. Approximately half (46.8%) of the patients had an initial assessment conducted in accordance with the OMP protocol recommendations, and follow-up rates (79.5%) were higher than those of a similar DRTB programme. However, patients in this study were not monitored within the timeframes or with the regularity recommended by the guidelines or the OMP protocol. Extended high-frequency pure-tone audiometry (27.5%) was underutilised by testers and data recording was inconsistent (e.g., 37.7% of patient gender was not recorded by testers). Community-based OMP using CHWs to facilitate monitoring showed improvement over previous hospital-based reports, with more accessible services and higher follow-up rates. However, to improve OMP outcomes, OMP managers should reassess current protocols and data recording practices.

A Randomized Controlled Trial Using Automated Technology for Improving Ototoxicity Monitoring in VA Oncology Patients

Purpose Determine the efficacy of ototoxicity monitoring (OM) administered as automated protocols with the Oto-ID mobile audiometer (automated ototoxicity monitoring [A-OM]), compared with usual care (UC) OM in cancer patients receiving cisplatin. Method Participants were patients (n = 46, mean age 64.7 years; range: 30-78 years) receiving cisplatin-based chemotherapy at the Department of Veterans Affairs Portland Health Care System. A randomized controlled trial contrasted A-OM and UC at up to three program evaluations (PEs) conducted by the study audiologist who was blinded to arm through PE1. PE1 occurred before randomization or oncology treatment; PE2 and PE3 occurred during and/or after treatment at 35 and 365 days postrandomization. The A-OM group (n = 24) used Oto-ID to screen their hearing before each cisplatin dose. Oto-ID results were sent to the study audiologist for interpretation, follow-up, and care coordination. The UC group (n = 22) received a consult for OM services through the audiology clinic. Outcomes included hearing shift near each patient's high-frequency hearing limit, revised hearing-handicap inventory score, and survival time from the start of treatment. Adherence to OM protocols, patients' use of aural rehabilitation services, and oncologists' treatment decisions were also examined. Results Ototoxicity was identified at a high overall rate (46% and 76% at 35 and 365 days, respectively, postrandomization). Adherence to monitoring prior to each cisplatin dose was 83.3% for those randomized to A-OM compared with 4.5% for UC. Randomization to A-OM was not associated with reduced ototoxic hearing shifts or self-reported hearing handicap relative to UC; neither did it compromise participants' survival. Half of participants in each arm accessed aural rehabilitation services. One in each arm had a documented ototoxicity-related cisplatin dose reduction. Conclusions Auditory impairment was an actionable concern for the participants and their oncology providers. A dedicated surveillance program using the Oto-ID's automated protocols improved adherence to OM recommendations over a traditional UC service delivery model. Supplemental Material https://doi.org/10.23641/asha.16649602.

Acoustic immittance measures and middle ear assessment: Current practice by South African audiologists

BACKGROUND

Limited research exists regarding South African audiologists' practice with acoustic immittance. This study was part of a bigger study titled 'Wideband acoustic immittance in adults living with human immunodeficiency virus'.

OBJECTIVES

The purpose of the study was to explore current practice of South African audiologists regarding acoustic immittance measures, and to explore their perceived knowledge and views on acoustic immittance advancements.

METHOD

A quantitative survey with a cross sectional design was employed. An electronic questionnaire was distributed to participants via professional associations of audiologists. Data was analysed through descriptive and inferential statistics.

RESULTS

Most audiologists worked in private practice and conducted tympanometry with 226Hz probe tone and ipsilateral acoustic reflexes. There was no association between clinical setting, levels of qualification, and the use of tympanometry. None of the participants included multifrequency and multicomponent tympanometry (MFT) and/or wideband acoustic immittance (WAI) in their test battery. Most of the participants were not familiar with MFT and WAI. Familiarity with MFT and WAI were only associated with the level of qualification. Limited training and lack of equipment were major barriers to conducting some of the acoustic immittance measures. Most participants believed that they would include MFT and/or WAI in their test battery if they had access to the equipment.

CONCLUSION

Current findings raise training and clinical implications for the South African audiologists, including training institutions. These findings provide motivation for strategic resource allocation, planning and distribution of audiology clinics in the country if positive preventive audiology outcomes are to be achieved.

Factors influencing speech language pathologists' and audiologists' decision to pursue postgraduate studies in South Africa

BACKGROUND

Factors that influence various professionals to pursue postgraduate studies have been investigated. However, there is a dearth of evidence of factors that influence South African speech language pathologists (SLPs) and audiologists (As) to pursue their postgraduate studies.

OBJECTIVE

Therefore, this study aimed to determine factors that influence the decision of South African SLPs and As to pursue postgraduate studies and potential barriers to this pursuit.

METHOD

A quantitative survey research methodology with a cross-sectional research design was adopted, where a 21-item web-based survey was used to survey 127 speech therapists, As and speech therapists and As from across the country. All participants were qualified and registered with the Health Professionals Council of South Africa (HPCSA). Ethical clearance and permission from relevant stakeholders were obtained. Data were analysed descriptively.

RESULTS

The findings suggested that over half of the participants pursued their postgraduate studies to fulfil a personal goal and improve their knowledge, whilst others did it to develop expertise and for job opportunities. Participants highlighted that a lack of time and funding, heavy workloads and bad experiences during their undergraduate studies were the main barriers to pursuing postgraduate studies. Whilst community service was not a barrier per se, participants felt that it delayed them from beginning their postgraduate studies immediately.

CONCLUSION

The findings of this study highlighted the urgent need for institutions of higher learning, government and other stakeholders to provide the necessary support for SLPs and As in South Africa to pursue postgraduate studies.

Impact of drug-resistant tuberculosis treatment on hearing function in South African adults: Bedaquiline versus kanamycin

Background

Ototoxicity linked to medications used to treat tuberculosis (TB) remains a global challenge.

Objectives

The aim was to describe the audiological function in a group of adults with drug-resistant tuberculosis (DR-TB) on bedaquiline (G-BDQ) treatment attending a TB hospital in South Africa and compare this with patients on kanamycin (G-KCIN).

Methods

A quantitative paradigm was adopted within a non-experimental retrospective record review design. The sample consisted of 30 records of adults with DR-TB between the ages of 18 and 50 years, recruited from a Tropical Diseases Hospital in South Africa. Data were analysed through both descriptive and inferential statistical measures.

Results

Clear and statistically significant differences in the audiological function were found between the two groups. The group receiving G-KCIN presented with ototoxicity that was clearly demonstrated by sensorineural hearing loss of high-frequency worsening of thresholds in over 73% of the records, which was statistically (p < 0.05) and clinically significant, over the three testing sessions, demonstrating the cumulative effects of dosage. Increased evidence of tinnitus was also found in this group. The group receiving G-BDQ presented with neither statistically (p > 0.05) nor clinically significant changes in hearing thresholds across all frequencies over the same monitoring timeframe. Additionally, only one report (7%) of tinnitus was found in this group.

Conclusion

The results indicating that bedaquiline does not cause hearing loss when compared with G-KCIN highlight the need for increased availability of bedaquiline for the treatment of DR-TB within the South African context, to preserve both the quantity and quality of life of those infected.