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Cost effectiveness of strategies to combat vision and hearing loss in sub-Saharan Africa and South East Asia: mathematical modelling study

BMJ 2012; 344 doi: (Published 02 March 2012) Cite this as: BMJ 2012;344:e615

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Re: Cost effectiveness of strategies to combat vision and hearing loss in sub-Saharan Africa and South East Asia: mathematical modelling study

Dear Editor,

Presbycusis, or the inevitable age related hearing loss (ARHL), is a gradually progressive, permanent sensorineural hearing loss (SNHL) with an unclear pathogenesis that’s considered multifactorial. Remediation requires amplification [1-7]. The absolute numbers requiring remediation for the age related hearing loss in the age population is very high, and with the aged population increasing worldwide, managing aged people for hearing loss will be posing an ever growing problem. It is already known that after hypertension and arthritis, it is this presbycusis that retains the third most common medical condition in the elderly [1, 3]. The total annual costs of hearing loss are pegged at approximately $50 billion per year in the U.S. alone [3].

Since we do think differently, we are writing to you, with the expectations that maybe this could usher in some new thinking and management techniques for this chronic debilitating condition. We do assume that senescence will not be targeting cochlea and hair cells selectively, while sparing other functional elements of the ear. We suppose that an interplay and superimposition of all such aspects of aging and senescence like decreasing microcirculation, myringosclerosis, atelectasis, etc, could also be occurring simultaneously and in varied proportions, which could possibly tilt a delicate and precarious balance and thereby precipitating or aggravating hearing loss. We assume that the possibility of any or all such factors getting superimposed does exist, variably in varied proportions and combinations, over the already existing cochlear and hair cell damage, and can precipitate hearing loss.

Our assumptions are based on the accidental “recovery” of hearing in one of the members of our team who is also a co-author here. He could hear the heart sounds by his new stethoscope with difficulty, and he wrongly presumed the problem to lie with his stethoscope, rather than with his own ears. Trial of other new pieces of stethoscopes was unable to help him. A sudden change occurred, with return of his normal hearing, following an insufflations test for the tympanic membranes. Thereafter, we performed this insufflations test in our team member’s wife, who also had a somewhat miraculous improvement in hearing.
Cochlear issues alone can’t be the red flags in every case of age related hearing loss (Figure 1). Now if the cochlear damage and hair cell damage attributed to excessive noise exposure during the life time, would providing further amplification in order to overcome the hearing loss by subjecting the remaining hair cells to “amplified sounds” be termed scientifically reasonable, or it is just a matter of convenience? Could the ascribed cochlear and hair cell issues be the red-herrings perhaps, jettisoning almost all such patients for remediation by either external or internal amplification.

We as a team are unable to follow this up to see the response in a large number of patients as we would certainly have wanted, and we do not have any kind of support, financial, administrative, governmental or institutional, etc. But then, we will definitely feel so happy if some better remedial measures can be developed for the aged to help them with hearing. That said, we feel that there is a need for further research in areas like improving mobility of the tympanic membrane and of the ossicles, improving microcirculation and the blood supply to the ears, etc. There will not be any improvement in cases of central presbycusis, and then maybe not every patient who suffers from presbycusis (or the age related hearing loss) would benefit, but we definitely feel as a clear hunch, that age related hearing loss can be overcome in a vast majority without having to wear hearing aids constantly, or having to resort to the costlier cochlear implants for providing amplification. Amplification can come later, as a final resort.

Finally, we may also try, deliberate, and start identifying this condition simply as “age related hearing loss” (ARHL), while discarding terms like “age-related hearing impairment” (ARHI), presbycusis, or presbyacusis.

Best regards.

Dr (Lt Col)Rajesh Chauhan

Dr. Ajay Kumar Singh Parihar

Dr. Shruti Chauhan

Shivendra Pratap Singh Chauhan


1. Parham K, McKinnon BJ, Eibling D, Gates GA. Challenges and opportunities in presbycusis. Otolaryngol Head Neck Surg. 2011; 144 (4): 491-495.

2. Sprinzl G.M., Riechelmann H. Current Trends in Treating Hearing Loss in Elderly People: A Review of the Technology and Treatment Options – A Mini-Review. Gerontology. 2010; 56: 351–358

3. Pacala JT, Yueh B. Hearing deficits in the older patient : “I didn’t notice anything”. JAMA. 2012; 307(11):1185-94.

4. Yueh B, Shapiro N, MacLean CH, Shekelle PG. Screening and management of adult hearing loss in primary care: scientific review. JAMA. 2003 Apr 16;289(15):1976-1985.

5. Meyer C, Hickson L, Khan A, Hartley D, Dillon H, Seymour J. Investigation of the actions taken by adults who failed a telephone-based hearing screen. Ear Hear. 2011 Nov-Dec; 32(6):720-731.

6. Smits C, Merkus P and Houtgast T (2006). How we do it: The Dutch functional hearing-screening tests by telephone and internet. Clinical Otolaryngology, 31:436-440.

7. Davis A, Smith P, Ferguson M, Stephens D, Gianopoulos I. Acceptability, benefit and costs of early screening for hearing disability: a study of potential screening tests and models. Health Technol Assess. 2007 Oct;11(42):1-294.

Competing interests: No competing interests

20 April 2013
Dr (Lt Col) Rajesh Chauhan
Consultant Family Medicine
Dr. Ajay Kumar Singh Parihar, Dr. Shruti Chauhan, Shivendra Pratap Singh Chauhan
Family Healthcare Centre, Awas Vikas Colony, Sikandra, AGRA
154 Sector 6B, Awas Vikas Colony, Sikandra, AGRA -282007. INDIA