Navigating Hearing Loss

Introduction

This study is about Ms Cronk, a 35-year-old woman who lives alone and had no history of a hearing loss problem until after being diagnosed with breast cancer twelve months earlier and started undergoing chemotherapy with cisplatin that she developed hearing problems accompanied with bilateral tinnitus that occurs at night. This has affected her at work, where she works in public relations, as she is not able to hear clearly during meetings performed in poorly lit rooms. Her social life, which includes frequent meal outs and quiz nights with an active group of friends, has been affected by this hearing problem. Seeking healthcare dissertation help to solve her hearing problem has become critical for Ms. Cronk. It was difficult to regain control over her both professional and social life.

The details Of Ms. Cronk’s audiological appointment together with the causes of the hearing loss, an effective holistic management plan and justification for the same will be evaluated and discussed in this study.

Cisplatin as a possible cause of hearing loss

Twelve months earlier, Ms. Cronk underwent chemotherapy with Cisplatin for breast cancer treatment. Cisplatin is a highly effective chemotherapy drug used to treat a number of life-threatening specific cancers, including testicular, gynaecological, breast, prostate, head and neck, and non-small cell lung cancers (Kros and Steyger, 2019). However, cisplatin has several adverse effects such as nephrotoxicity, ototoxicity, peripheral neuropathy and gastro intestinal reactions, among others. The drug has been known to cause severe bilateral, continuous, permanent, neuro sensory hearing loss that is dose dependent (Callejo et al., 2015). The focus here is on the ototoxicity of this particular drug.

The Mechanisms of Cisplatin Ototoxicity

Different pathways are produced in cisplatin ototoxicity (Gonçalves et al., 2013). The antioxidant model is one of these pathways and it includes the formation of reactive oxygen species in the cochlea and reduction of enzymes occurs when the cisplatin ototoxicity has happened (Rybak et al., 2007). Another mechanism of cisplatin ototoxicity includes the major contribution of phosphate oxidase 3 isoform (NOX3) nicotinamide adenine dinucleotide to the production of reactive oxygen species in the cochlea when triggered by cisplatin and the third mechanism relates to activation of vanilloid channel (TRPV1) (Campbell, Kalkanis and Glatz, 2000). Because of the these cellular pathways of cisplatin, it causes ototoxicity and damages to outer hair cells, supporting cells, marginal cells of stria vascularis, spiral ligament, and the spiral ganglion cells (Chirtes and Albu, 2014).

Clinical Presentation

Cisplatin-induced hearing loss typically occurs as permanent, progressive (Arora et al., 2009), bilateral, high frequency sensorineural hearing loss (Sakamoto, Kaga and Kamio, 2000) with tinnitus (Frisina et al., 2016). The latter may manifest with or without hearing loss (Sakamoto, Kaga and Kamio, 2000), sometimes disappearing a few hours after therapy or lasting a week after treatment (Waters et al., 1991).While most of the hearing loss in cisplatin hearing loss is permanent, sometimes, partial recovery has been occurred (Sheth et al., 2017). Furthermore, hearing loss could occur in some of patients with unilateral hearing loss, which are generally clarified on the affected side by tumorous location and procedure or therapy. Therefore, the hearing loss is not always symmetrical (Schmidt et al., 2008). A study done by (Jenkins, Low and Mitra, 2009), founded that 75 percent of women on the treatment of cisplatin displayed at least 10 dB asymmetry of hearing thresholds between ears in the post-treatment period. The degree of hearing loss varies often with the dosage of cisplatin so the more drugs accumulates, the greater ototoxic effects (Dutta, Venkatesh and Kashyap, 2005). Thus, hearing loss generally begins at high frequencies and gradually increases into midfrequencies with cumulative cisplatin dose (Tserga et al., 2019).

The Environment of Ms Cronk as a possible cause for the tinnitus and hearing loss problem

The social and business life of Ms. Cronk is a risk factor for the hearing loss problem and it worsens the condition.

According to the National Research Council (NRC, 2004), factors such as background noise, competing signals, room acoustics and situation familiarity, do affect the hearing ability of a person whether they are suffering from hearing loss problems or not. The effects are amplified if one has a hearing loss problem. A progressive hearing loss can be due to exposure to noise for a prolonges period of time. As with the social life of Ms cronk, she spends time with her friends in a noisy and crowded pub playing quiz nights. It is normal that pubs have poor lighting and use microphones and speakers to conduct various events such as the quiz night. In addition to this, there is poor lighting at the work place where meetings are usually conducted. These situations, especially the noisy pubs, could attribute to the the hearing loss and tinnitus problem of Ms Cronk and also worsen it in the process. This affects her physiologically and makes her unable to function well.

According to audiological evaluation, patient’s otoscopy examination and tympanometry results were normal and she had a bilateral symmetric high frequency hearing loss because, cisplatin-induced hearing loss initially damages outer hair cells in the basal turn of the cochlea and then progress to apical turn (Gauvin et al., 2018). Thus, the general characteristics of ototoxic hearing loss are bilaterally symmetrical sensorineural hearing loss that affects high frequencies which play a crucial role for discrimination of speech in background noise and speech perception (Kros and Steyger, 2019) and this evidence supported to her complaint about hearing in noisy environment because she had a high frequency hearing loss and these frequencies are very significant speech intelligibility in noise.

Fitting Options

Ms. Cronk had a mild hearing loss at low frequencies and moderate hearing loss at higher frequencies bilaterally. Therefore, the most suitable suggestion for her is bilateral open-fit hearing aids. First reason is that these hearing aids eliminate occlusion effect. Occlusion effect happens when the sounds at low frequency, created by hearing aid user’s own voice or other situations such a chewing, are transmitted to ear by bone-conduction (Stenfelt et al., 2003). So, Open-fit hearing aids helps to ear canal ventilate and this make it possible to low frequency sounds to enter the ear canal any further amplification. This lack of amplification leads to more comfort to the patient. Another reason for the recommendation of this hearing aids is that they improve sound localization ability. In addition to this, open-fit hearing aids have thin-tube, so I can easily fit the patient without ear-impression, it saves time and effort. However, there are some limitations for open-fit hearing aids: Combined directional and noise reduction algorithms may be a problem with the open-fitting hearing aids because of the low frequency loss; also, the available maximum gain before feedback is reduced.

I would give advice to Ms. Cronk to wear bilateral open-fit hearing aids because: it is important for horizontal localisation improvement; speech understanding in noise; good sound quality, protection of the patients from auditory deprivation and tinnitus suppression.

The patient has a mild low frequency hearing loss so open dome could be better for her.

I would like to verify open-fit hearing aid with Real-ear Measurements (REM). In addition, it will be in conjunction with REIG and NAL-NL2 prescription target. REMs, as features of hearing aid fitting verification, are known to impact the experience of a patient positively because of enhanced audibility and contentment with the general fitting encounter (Amlani et al., 2017). The approach of this feature takes REIG measurements which are compared to the target gain curves at various points in order to obtain a target that matches the recommended tolerance for the frequencies set by an audiology society (Aazh & Moore, 2007). NAL-NL2 formula targets speech intelligibility maximization while maintaining a low level of the overall loudness. The prescriptions of the formula are based on age, gender, whether patient is a new user or not, or if the audiological problem is unilateral or bilateral (Keidser et al., 2012). The combination these features makes it an effective approach to verify hearing fitting aids.

I would suggest for her different multi programmes in hearing aids including speech in quiet, speech in multi-talker noise such as pub or party.

Assistive listening devices

The patient reported that she was struggling to hear her colleagues clearly at work meetings and understanding her friends at noisy background environment. The best suggestion to the patient FM systems is one of the assistive listening devices and could be a good solution for her. The purpose of these systems to reduce negative effects of distance and noise on speech signals and to improve signal to noise ratio in noisy environments. FM systems helps to the speaker’s voice is amplified. The sounds of speakers are picked up by a microphone and transmitted to receiver.

Tinnitus Management

The patient has a tinnitus due to cisplatin induced hearing loss. The plan is to assess her tinnitus level before and after treatment with tinnitus handicap inventory. Tinnitus Handicap Inventory is developed by Newman, 1996 and it is self- administrated test for adults, and it is used to a brief diagnostic and measurement for the impact on tinnitus on daily life. After treatment, it is a good opportunity to evaluate effectiveness of given therapy.

Strategies to help the patient with tinnitus;

-Tinnitus Retraining Therapy: This therapy is combination of counselling and retraining therapy. It aims toward habituation to tinnitus by combining sound enrichment and direct counselling (Langguth et al., 2013).

-Cognitive Behavioural Therapy: CBT is currently the most common psychological approach used and studied worldwide for management of tinnitus (Nolan et al., 2020).The purpose of this therapy decreases the anxiety and distress due to tinnitus, but it does not reduce acoustic features of tinnitus such as loudness and pitch. The main principle of cognitive behavioural therapy is identifying negative thoughts and replacing them with positive thoughts.

- Sound Therapy: The major aim of this therapy is masking tinnitus to less disturbing of tinnitus sounds. Sound therapy includes both environmental and custom sound generators and these are helpful for patients with tinnitus. Environmental sounds such as sea waves, creeks, waterfalls, rain or white noise relaxes the patients to reduce the perfection of tinnitus. A custom sound generates broad band sounds and it looks like hearing aids (Hobson, Chisholm and Loveland, 2007).

- Onward referrals: This is done based on the clinical history and physical examination of a tinnitus patient. There are various symptoms that will necessitate immediate referral, referral within a day, referral within two weeks, or a referral that is not urgent (Mcferran et al., 2018). The classification of the symptoms is based on the possible effects of not referring a patient. For instance, patients who present with symptoms that include suicidal activities should be referred to a psychiatrist with immediate effect (Kilroy & EI Refaie, 2020). As for Ms. Cronk, the tinnitus presents with lack of sleep. Since this affects her overall wellbeing, a referral within 2 weeks would be suitable for the situation and aid in reducing the distress she is experiencing.

The advice to her about the essence of cognitive behavioural therapy is to reduce the patient’s sleep disorders at night due to tinnitus.

Outcome measures and evaluation

COSI: The patient before fitting was evaluated with COSI and it is one of the self-report measurements (The Client Orient Scale of Improvement) developed by the National Acoustic Laboratories(Dillon, James and Ginis, 1997). It is administered in two phases. In the first phase, the patient identifies listening situations that would like to improve and will explain any specific needs. After that, for the second phase after the hearing aid is fitted, the change in hearing function for the identified listening situation is recorded. These changes are noted among five choices from worse to much better. It is asked to patient note that her final hearing ability and a percentage score is given (between 10% to 95%).

The Glasgow Hearing-Aid Profile (GHABP): This questionnaire was developed to evaluate disability, handicap, and hearing-aid benefit for operational management, both at systematic and clinical levels (Gatehouse, 1999). The GHABP included four situations involving speech and to rate on a five-point scale their initial hearing disability, initial handicap, aided benefit, aided handicap, hearing-aid use and hearing-aid satisfaction.

There are various practical tools that have been developed by the IDA Institute to improve communication (Gali, 2012) so as to have better results in interpersonal dynamics (Flynn & Stack, 2006). These tools are designed to give audiologist a holistic approach and can be utilized to improve communication between student and preceptor (Gregory, 2012).

The IDA Institute tools also aid students in having insights into the process of audiological rehabilitation (Flynn & Stack, 2006). These tools include the Reflective Journal which simulates reflective thinking of the student by creating a preceptor-student bond and simulating patient interaction tools like: Clinical Situations, Dilemma Cards, Ethnographic tools and case library (DePlacido, 2010). There also a set of motivation tools known as ‘The Circle’ developed to give insight into an eagerness for behavioural change (Gregory, 2012). Since the main purpose of these tools is to assist audiological professionals in non-technological based techniques for having better patient outcomes, they will be the best non-device-based recommendation for Mr. Cronk to aid in her audiological problem.

Fitting Options:

If the patients are normal or nearly normal hearing thresholds in low frequencies and a mild to moderate sensorineural hearing loss in high frequencies, they are candidacy for open-fit hearing aids (Kuk et., 2005).

Advantages of Open-fit Hearing Aids;

1)According to Winkler, Latzel and Holube (2016), the benefit of the open-fit hearing aid is that reducing occlusion effects that often occurs with closed ear moulds. (Laugesen et al., 2011) found that patients were less complaint about their own voice quality with open fitting. In addition, A study done by Mackenzie (2006) investigated that the occlusion effect in different types of open-fit hearing aids models. The results showed that no differences between un-aided and aided condition in three different types of hearing aids at low frequencies and the patients reported that they were satisfied regarding same natural own voice quality with open-fit hearing aids. According to findings, the open-fit hearing aids is an effective way to eliminate occlusion effect for patient satisfaction.

2)According to Noble et al. (1998) sound localization ability was better open-fit hearing aids than non-open fit designs. Noble et al. (1998) indicated that patients having good low frequency thresholds may be more reliant on time and phase cues in sound localization.

3)The benefit of open-fit hearing aids features that make satisfied patients more than non-open fit hearing aids. In addition, invisible ear-tip changes the traditionally used ear moulds so, there is no need for ear impression before the fitting session (Kiessling et al, 2005).

4) When the open- fit hearing aids compared to non-open fit hearing aids based on patient satisfaction, Taylor (2006), Gnewikow & Moss (2006) and Christensen & Matsu (2004) evaluated the hearing aids users with self-reports. They found that in specific domains such as localization, comfort, reduction of occlusion effect, and better own voice quality are significantly superior for open fitting hearing aids than non-open fitting hearing aids.

Limitations of open-fit hearing aids;

1) Magnusson et al. (2013) indicated that open-fit hearing aids with directional microphones can significantly increase speech recognition in noise when it was compared to unaided and omnidirectional aided performance. In addition, he reported that people with normal or mild hearing loss at low frequencies and moderate hearing loss at high frequencies would receive benefit from open-fit hearing aids with directional microphones but combining noise reduction and microphone directionality speech recognition in noise would not benefit with open fitting hearing aids.

2) Another disadvantages of open fit hearing aids that feedback problem occurs near the resonance frequency of ear canal (3000 Hz), this can cause patients to hear the unamplified sound through the open fit before receiving the amplified sound from the hearing aid (Flynn, 2003). This reverberant sounds disturb the patients so appropriate feedback cancellation system is significant (Flynn, 2003).

Conrad and Rout, (2013) indicated that patients have mild to moderate hearing loss and wearing open hearing aids, and they were tested with three different dome options including open, plus and power. It was found that patients were the most comfortable with having open dome.

Assistive Listening Devices

A review done by Maidment et al. (2018) indicated that alternative listening devices improve speech intelligibility in behavioural assessments in hearing aided conditions. Chisolm et al, (2007) pointed that the satisfaction of in noisy condition listening and hearing soft sounds are greater when the hearing aids are connected to FM systems than wearing hearing aids alone. In addition, A study done by (Lewis et al., 2004) showed that FM technology greatly enhanced speech intelligibility over the hearing aids conditions both in omnidirectional and directional listening conditions.

Tinnitus Management

Since Tinnitus disorder has no standardized mode of management, choosing a clinical intervention becomes a decision that is influenced by various factors like the requirements of the patient and context of the healthcare (Marks et al., 2019).

A review done by (Zenner et al., 2017) pointed out that cognitive behavioural therapy was strongly recommended due to high level of evidence and validated-tinnitus specific. In addition, According to Aazh et al., (2019) it was investigated that cognitive behavioural therapy for tinnitus administered by physicians, clinical psychologists or specially trained audiologists can be beneficial in both individual and group environments. In addition, The patient has insomnia due to tinnitus and Marks, McKenna and Vogt, (2019) founded that cognitive behavioural therapy is beneficial for decreased insomnia and anxiety for patients with chronic and distressing tinnitus.

Outcome Measures and Evaluation

It is crucial for an outcome assessment measure to be efficient. The collection of data and analysis must be done in a time that is consistent with the significance of the information obtained.

COSI has been reported to be valid and reliable outcome measure (Dillon et al., 1999). It is helpful for the assessment of different population outcomes, in identification of the requirements of a particular patient, and recognizing patients who are experiencing issues with their hearing aids (Searchfield, 2019). This outcome measure will be relevant in evaluating M. Cronk before she proceeds to fitting the hearing aids.

The only limitation to the COSI is that it is not able to identify the difference between patients who obtain an average degree of benefit from the ones who receive benefit that is above average (Dillon et al., 1999)

The IDA Institute tools are applicable, effective and efficient, simple to implement and give a wider aspect for both the student and preceptor (Gali, 2012). These tools yield procedures that are easily understandable for expediting student reflection and perceiving education that is clinical based as a course of changes. The materials of the IDA Institute do include approaches that aid in positive clinical development, they are versatile and easily flexible to suit preceptor needs (Gregory, 2012). Therefore, Mr. Cronk will benefit from these tools as they will be customized to specifically cater for her hearing loss problem.

There is very little literature on the limitations of the IDA tools but according to Warren & Denham, (2010) these tools are not fully developed and most of the applications are in the process of growing and constantly changing. Also, not many people are confident about the effectiveness of these tools in catering for patients with hearing loss.

Bibliography

Aazh, H. et al. (2019) ‘Cognitive behavioral therapy for alleviating the distress caused by tinnitus, hyperacusis and misophonia: Current perspectives’, Psychology Research and Behavior Management, 12, pp. 991–1002.

Arora, R. et al. (2009) ‘Cisplatin-based chemotherapy: Add high-frequency audiometry in the regimen’, Indian Journal of Cancer, 46(4), pp. 311–317.

Callejo, A. et al. (2015) ‘Cisplatin-induced ototoxicity: Effects, mechanisms and protection strategies’, Toxics, 3(3), pp. 268–293

Campbell, K. C. M., Kalkanis, J. and Glatz, F. R. (2000) ‘Ototoxicity: Mechanisms, protective agents, and monitoring’, Current Opinion in Otolaryngology and Head and Neck Surgery, 8(5), pp. 436–440.

Chirtes, F. and Albu, S. (2014) ‘Prevention and restoration of hearing loss associated with the use of cisplatin’, BioMed Research International, 2014.

Chisolm, T. H. et al. (2007) ‘Evidence for the Use of Hearing Assistive Technology by Adults: The Role of the FM System’, Trends in Amplification, 11(2), pp. 73–89. doi: 10.1177/1084713807300879.

Conrad, S. and Rout, A. (2013) ‘Perceived occlusion and comfort in receiver-in-the-ear hearing aids’, American Journal of Audiology, 22(2), pp. 283–290.

Dillon, H., James, A. and Ginis, J. (1997) ‘Client Oriented Scale of Improvement (COSI) and its relationship to several other measures of benefit and satisfaction provided by hearing aids.’, Journal of the American Academy of Audiology, 8(1), pp. 27–43.

Dutta, A., Venkatesh, M. D. and Kashyap, R. C. (2005) ‘Study of the effects of chemotherapy on auditory function’, Indian Journal of Otolaryngology and Head and Neck Surgery, 57(3), pp. 226–228

Frisina, R. D. et al. (2016) ‘Comprehensive audiometric analysis of hearing impairment and tinnitus after cisplatin-based chemotherapy in survivors of adult-onset cancer’, Journal of Clinical Oncology, 34(23), pp. 2712–2720.

Gatehouse, S. (1999) ‘Glasgow Hearing Aid Benefit Profile : Derivation and Validation of a Client-centered Outcome Measure for Hearing Aid Services’, J Am Acad Audiol, 10, pp. 80–103.

Gauvin, D. V. et al. (2018) ‘Ototoxicity: The Radical Drum Beat and Rhythm of Cochlear Hair Cell Life and Death’, International Journal of Toxicology, 37(3), pp. 195–206.

Gonçalves, M. S. et al. (2013) ‘Mechanisms of cisplatin ototoxicity: Theoretical review’, Journal of Laryngology and Otology, 127(6), pp. 536–541.

Hobson, J., Chisholm, E. J. and Loveland, M. E. (2007) ‘Sound therapy (masking) in the management of tinnitus in adults’, Cochrane Database of Systematic Reviews, (1).

Jenkins, V., Low, R. and Mitra, S. (2009) ‘Hearing sensitivity in women following chemotherapy treatment for breast cancer: Results from a pilot study’, Breast. Elsevier Ltd, 18(5), pp. 279–283.

Keidser, G., Dillon, H., Carter, L., & O'Brien, A. (2012). NAL-NL2 empirical adjustments. Trends in amplification, 16(4), 211–223.

Kilroy, N., & El Refaie, A. (2020). Tinnitus management in Ireland: a pilot study of general practitioners. Irish Journal of Medical Science (1971-), 1-11.

Koehler, E. D., & Kulkarni, S. (2014). Fast and easy fitting and verification with integrated real-ear measurement. The Hearing Review, 21(10), 36-40.

Kros, C. J. and Steyger, P. S. (2019) ‘Aminoglycoside- and cisplatin-induced ototoxicity: Mechanisms and otoprotective strategies’, Cold Spring Harbor Perspectives in Medicine, 9(11), pp. 1–19.

Langguth, B. et al. (2013) ‘Tinnitus: Causes and clinical management’, The Lancet Neurology. Elsevier Ltd, 12(9), pp. 920–930.

Laugesen, S. et al. (2011) ‘Own voice qualities (OVQ) in hearing-aid users: There is more than just occlusion’, International Journal of Audiology, 50(4), pp. 226–236.

Lewis, M. S. et al. (2004) ‘Speech perception in noise: Directional microphones versus Frequency Modulation (FM) systems’, Journal of the American Academy of Audiology, 15(6), pp. 426–439. doi: 10.3766/jaaa.15.6.4.

Magnusson, L. et al. (2013) ‘Speech recognition in noise using bilateral open-fit hearing aids: The limited benefit of directional microphones and noise reduction’, International Journal of Audiology, 52(1), pp. 29–36.

Maidment, D. W. et al. (2018) ‘A systematic review and meta-analysis assessing the effectiveness of alternative listening devices to conventional hearing aids in adults with hearing loss’, International Journal of Audiology. Taylor & Francis, 57(10), pp. 721–729.

Marks, E., McKenna, L. and Vogt, F. (2019) ‘Cognitive behavioural therapy for tinnitus-related insomnia: evaluating a new treatment approach’, International Journal of Audiology. Taylor & Francis, 58(5), pp. 311–316.

National Research Council. (2004). Committee on Disability Determination for Individuals with Hearing Impairments; Dobie RA, Van Hemel S, editors. Hearing Loss: Determining Eligibility for Social Security Benefits.

Nolan, D. R. et al. (2020) ‘An Effective Treatment for Tinnitus and Hyperacusis Based on Cognitive Behavioral Therapy in an Inpatient Setting: A 10-Year Retrospective Outcome Analysis’, Frontiers in Psychiatry, 11(February), pp. 1–8. doi:

Rybak, L. P. et al. (2007) ‘Mechanisms of cisplatin-induced ototoxicity and prevention’, Hearing Research, 226(1–2), pp. 157–167.

Sakamoto, M., Kaga, K. and Kamio, T. (2000) ‘Extended high-frequency ototoxicity induced by the first administration of cisplatin’, Otolaryngology - Head and Neck Surgery, 122(6), pp. 828–833. doi: 10.1016/S0194-5998(00)70009-X.

Schmidt, C. M. et al. (2008) ‘Left-right asymmetry in hearing loss following cisplatin therapy in children - The left ear is slightly but significantly more affected’, Ear and Hearing, 29(6), pp. 830–837. doi: 10.1097/AUD.0b013e31818005a4.

Sheth, S. et al. (2017) ‘Mechanisms of Cisplatin-Induced Ototoxicity and Otoprotection’, Frontiers in Cellular Neuroscience, 11(October), pp. 1–12.

Searchfield, G. D. (2019). A client oriented scale of improvement in tinnitus for therapy goal planning and assessing outcomes. Journal of the American Academy of Audiology, 30(4), 327-337.

Stenfelt, S. et al. (2003) ‘Factors contributing to bone conduction: The outer ear’, The Journal of the Acoustical Society of America, 113(2), pp. 902–913.

Tserga, E. et al. (2019) ‘The genetic vulnerability to cisplatin ototoxicity: a systematic review’, Scientific Reports. Springer US, 9(1), pp. 1–12.

Waters, G. S. et al. (1991) ‘Ototoxicity due to cis-ziamminedichloroplatinum in the treatment of ovarian cancer: Influence of dosage and schedule of administration’, Ear and Hearing, 12(2), pp. 91–102

Winkler, A., Latzel, M. and Holube, I. (2016) ‘Open Versus Closed Hearing-Aid Fittings: A Literature Review of Both Fitting Approaches’, Trends in Hearing, 20, pp. 1–13.

McFerran, D., Hoare, D. J., Carr, S., Ray, J., & Stockdale, D. (2018). Tinnitus services in the United Kingdom: a survey of patient experiences. BMC health services research, 18(1), 110.

Zenner, H. P. et al. (2017) ‘A multidisciplinary systematic review of the treatment for chronic idiopathic tinnitus’, European Archives of Oto-Rhino-Laryngology, 274(5), pp. 2079–2091. doi: 10.1007/s00405-016-4401-y.

Warren, A. L., & Denham, S. A. (2010). Relationships between formalized preceptor orientation and student outcomes. Teaching and Learning in Nursing, 5(1), 4-11.

Flynn, J. P., & Stack, M. C. (Eds.). (2005). The role of the preceptor: A guide for nurse educators, clinicians, and managers. Springer Publishing Company.

DePlacido C. (2010) Reflective practice in audiology. Hear Rev; 17: 20-25

Gregory, M. (2012, February). A possible patient journey: A tool to facilitate patient-centered care. In Seminars in Hearing (Vol. 33, No. 01, pp. 009-015). Thieme Medical Publishers.

Amlani, A. M., Pumford, J. O. H. N., & Gessling, E. (2017). Real-ear measurement and its impact on aided audibility and patient loyalty. Hearing Review, 24(10), 12-21.

Aazh, H., & Moore, B. C. (2007). The value of routine real ear measurement of the gain of digital hearing aids. Journal of the American Academy of Audiology, 18(8), 653-664.

Dillon, H., Birtles, G., & Lovegrove, R. (1999). Measuring the outcomes of a national rehabilitation program: Normative data for the client oriented scale. Journal of the American Academy of Audiology, 10(2), 67-79.

Take a deeper dive into Navigating Ethical Dilemmas in Pandemic Surveillance with our additional resources.