Practices employed by audiologists in the management of adult patients with multidrug-resistant tuberculosis in South Africa

Figures & data

Table 1: Demographic profile (n = 93)

Characteristics	n	%
Gender
Female	83	89
Male	10	11
Age
22–30 years	67	72
31–39 years	23	25
40–41 years	3	3
Work experience
1–3 years	37	40
3–5 years	27	29
5–10 years	19	20
>10	10	11
Work setting
Community health clinic	5	5
District hospital	21	23
Regional hospital	12	13
Provincial hospital	45	48
Private hospital	3	3
Private practice	7	8

Figure 1: Awareness of the available protocols and guidelines (n = 74)

Table 2: Audiological tests used during the baseline assessment (n = 81)

Tests	n	%
An otoscopic examination, immittance audiometry, air conduction testing, bone conduction testing, high-frequency audiometry, speech reception testing, speech discrimination testing, otoacoustic emissions and auditory brainstem response	65	80
An otoscopic examination, immittance audiometry, air conduction testing, Eustachian tube function, speech reception testing, speech discrimination testing and otoacoustic emissions	10	12
An otoscopic examination, immittance audiometry, air conduction testing, high-frequency audiometry speech reception testing, otoacoustic emissions and auditory brainstem response	6	7

Figure 2: Modifications made to the international guidelines (n = 42)

Figure 3: Reasons for modifications to the international guidelines

Table

1	Age
2	Gender	Male		Female
3	The number of years working as an audiologist (excluding community service)	1–3 years	3–5 years	5–10 years	>10 years
3.1	Have you conducted multidrug-resistant tuberculosis monitoring in the last three years?	Yes		No
4	In which province are you working?	Free State		KwaZulu-Natal	Eastern Cape
		Limpopo		Northern Cape	Mpumalanga
		Gauteng		Western Cape	North West
5	The type of institution in which you work	Private practice	Private hospital	Provincial hospital
		Regional hospital	District hospital	Community health clinic
				Other: (specify)
6	Do you conduct diagnostic audiometric testing?	Yes		No
7	Do you have access to electrophysiological testing equipment?	Yes		No
7.1	If yes, please indicate which equipment	Otoacoustic emissions		Auditory brainstem response	Auditory steady-state response
		Immittance audiometry		Other (please specify):
8	Are you currently assessing patients with multidrug-resistant tuberculosis?	Yes		No
9	Do you provide ototoxicity monitoring at your institution?	Yes		No
10	Are you aware of any audiological guidelines and/or protocols for multidrug-resistant tuberculosis ototoxicity monitoring?	Yes		No
10.1	If yes, please state them in the space provided	a. South African ototoxicity monitoring guidelinesb. American Speech-Language-Hearing Association (1994) audiological management of individuals receiving cochleotoxic drug therapyc. American Academy of Audiology (2009) position statement and clinical guidelines: ototoxicity monitoringd. All of the abovee. B and C

Table

11	Do you believe that the identification of a patient at risk of hearing loss depends on a good working relationship between the audiologist, physicians and nurses?	Yes		No
12	Do you think that in-service training, with the staff involved in monitoring patients with multidrug-resistant tuberculosis, is important?	Yes		No
12.1	If yes, please select which description best conveys the aspects of multidrug-resistant tuberculosis ototoxicity monitoring that need to be addressed during in-service training	a. What ototoxicity is, what audiology is, which audiological tests must be conducted, and the need for counselling and fitting hearing aidsb. What ototoxicity is, when ototoxicity occurs, what happens to the ear and its function when there is ototoxicity, which ototoxic drugs are involved in multidrug-resistant tuberculosis, the associated auditory and vestibular problems, and the need for counselling and aural rehabilitationc. The signs and symptoms of hearing loss, the audiological battery of tests used for monitoring, and vestibular assessment and counsellingd. None of the above
12.2	Who do you think should conduct this training?	Community members	Audiologists		Doctors
		Nurses	Other (please specify):
13	Which if these drugs do you think require automatic referral for ototoxicity monitoring?	a. Dihydrostreptomycin, stilpain, asprin and gentamicinb. Tobramycin and kanamycinc. Dihydrostreptomycin, tobramycin, kanamycin, amikacin and gentamicind. None of the above
14	Do you think that if referrals were made automatically when patients undergo ototoxic drug treatment, there would be an improvement in the current referral system?	Yes		No

Table

15	Do you conduct a baseline assessment prior to the administration of multidrug-resistant tuberculosis treatment once the patient has been identified?	Yes	No
15.1	If yes, when is the patient’s baseline assessment performed?	8–12 hours	12-24 hours			24–48 hours
		48–72 hours			> 72 hours
15.2	If no, why?
16	Choose one of the statements which indicates the tests that should be performed during the baseline assessment?	a. An otoscopic examination, immittance audiometry, air conduction testing, bone conduction testing, high-frequency audiometry, speech reception testing, speech discrimination testing, otoacoustic emissions and auditory brainstem responseb. An otoscopic examination, immittance audiometry, air conduction testing, Eustachian tube function, speech reception testing, speech discrimination testing and otoacoustic emissionsc. An otoscopic examination, immittance audiometry, air conduction testing, high-frequency audiometry speech reception testing, otoacoustic emissions and auditory brainstem response
17	Do you conduct testing above 8 kHz?	Yes		No
17.1	If yes, which frequencies are tested?	9 kHz	10 kHz	11 kHz		12 kHz
		14 kHz	16 kHz	18 kHz		20 kHz
17.2	If no, please provide the reasons why this is so
18	Do you perform a re-test to confirm the results?	Yes	No
18.1	If no, why?
19	Do you conduct pre-treatment counselling advising the patient of the possible ototoxic effect of multidrug-resistant tuberculosis medication on their auditory system?	Yes	No
19.1	If no, why?
20	Choose one statement which reflects the topics covered during pre-treatment counselling?	a. Tinnitus, loss of balance, the pharmacological effects, the synergistic effect on ototoxicity and noise exposure, the occlusion effect, hearing loss and the potential impact on communication abilityb. Tinnitus, loss of balance, the synergistic effect on ototoxicity and noise exposure, the occlusion effect, hearing loss and the potential impact on communication abilityc. Tinnitus, loss of balance, the synergistic effect on ototoxicity and noise exposure, the occlusion effect, hearing loss, the potential impact on communication ability and the effects of daily living

Table

21	Do you apply specific criteria when defining ototoxic hearing loss?	Yes		No
21.1	If no, why?
22	Do you use a baseline measure to compute any changes in hearing sensitivity?	Yes		No
22.1	If no, why?
23	Choose the correct statement which indicates significant changes in hearing sensitivity	a. A 20 dB decrease at any one test frequencyb. A 10 dB decrease at any two adjacent test frequenciesc. Loss of response at three consecutive testsd. All of the abovee. A and B only
24	If there is a change in hearing sensitivity, do you conduct a full audiological evaluation?	Yes		No
24.1	If yes, please indicate which tests are conducted in the space provided
24.2	If no, why?
25	What battery of tests is used when testing a non-responsive patient?	a. An objective testb. Behavioural testsc. Testing should not be conductedd. A and B
26	Do you conduct periodical testing every 2–3 days per week for patients receiving multidrug-resistant tuberculosis treatment?	Yes		No
26.1	If no, when do you conduct periodical testing?	Weekly	Fortnightly		Monthly
27	If there is a significant shift in hearing threshold, do you report these findings to the physician?	Yes		No
27.1	If yes, select the correct statement on what possible changes the physician can make to the treatment regime	a. Scheduled timing of the dosage and a reduction in the dosageb. Reduce the dosage and increase the scheduled timingc. Temporary discontinuation, or a switch to a less ototoxic drugd. A and Ce. All of the above
27.2.	If no, why?
28	If the physician changes the drug used in the treatment of multidrug-resistant tuberculosis, are you notified or is it documented in the patient file?	Yes		No
29	If the treatment is changed, do you establish a new baseline for the patient?	Yes		No
29.1	If no, why?

Table

30	Do you conduct a full audiological evaluation after the cessation of multidrug-resistant tuberculosis treatment?	Yes		No
30.1	If no, why?
31	When should follow-up evaluations be conducted?	3 months	6 months		One year	All of the above
32	Do you think that the management of an adult is different to that of a child?	Yes		No
32.1	Choose one of the statements which focus on the management of an adult who has hearing impairment due to the effects of multidrug-resistant tuberculosis treatment	a. Hearing aids, assistive listening devices, and counselling of both the patient and familyb. Hearing aids, assistive listening devices, an audition, and counselling of both the patient and familyc. Hearing aids, assistive listening devices, counselling of both the patient and family, communication strategies, an audition, speech reading and available support groupsd. A and B
33	Do you conduct counselling after the cessation of multidrug-resistant tuberculosis treatment?	Yes		No
33.1	If no, why?
33.2	Who do you think should conduct the counselling?
33.3	If yes, which statement would you select that best suits the topics you would include in your counselling agenda?	a. What ototoxicity is, and the effect that it has on the ear, how to optimise the use of amplification, available assistive listening devices, and the use of audition and speech reading to cope with a breakdown in communicationb. The nature and aetiology of hearing loss, the impact that hearing loss has on daily living, how to optimise the use of amplification, available assistive listening devices, and the use of an audition and speech reading to cope with a breakdown in communicationc. All of the aboved. None of the above
34	When providing counselling, is it conducted in the home language of the patient?	Yes		No
35	Do you provide the patient with informational pamphlets once the counselling is complete?	Yes		No
35.1	If no, why?
36	Do you believe that ototoxicity monitoring would be easier for audiologists if a South African guideline and/or protocol was available?	Yes		No
37	Do you make modifications to the recommended guidelines?	Yes		No
37.1	If yes, please indicate the type of modifications	a. Only conduct air conduction testing for monitoringb. Do not conduct speech audiometry for the baseline testingc. Test only certain frequenciesd. All of the abovee. Other (please specify):
37.2	What are the possible reasons for modifications to the recommended guidelines?	a. Time constraintsb. Lack of resourcesc. Being understaffedd. Lack of guidelinese. Other (please specify):