Abnormal electronystagmography in rheumatoid arthritis

OBJECTIVE: Although sensorineural hearing loss has been widely investigated in those with rheumatoid arthritis, studies assessing the vestibular system in patients with rheumatoid arthritis are limited. The aim of this study was to assess the vestibular system in patients with rheumatoid arthritis. METHODS: The study consisted of 43 patients with rheumatoid arthritis and 30 healthy controls. Otorhinolaryngologic and neurotologic examinations, pure-tone audiometry, impedancemetry, electronystagmography including smooth pursuit, saccade, positional, and caloric tests were performed in all patients with rheumatoid arthritis and in controls. The erythrocyte sedimentation rate, C-reactive protein level, and rheumatoid factor level were evaluated in all patients with rheumatoid arthritis. RESULTS: Audiograms revealed sensorineural hearing loss in 12 patients (27.9%) with rheumatoid arthritis and in two controls (6.6%); the difference was statistically significant (P=.033). In those with rheumatoid arthritis, the results of electronystagmography revealed central abnormalities in nine patients (20.9%), peripheral abnormalities in three (6.9%), and mixed abnormalities in three (6.9%). Smooth pursuit and saccade tracing impairments were significantly higher in patients with rheumatoid arthritis (P>.05). Canal paresis in patients with rheumatoid arthritis were significantly higher than those in the control group (P=.039). No association was found between electronystagmographic abnormalities in patients with rheumatoid arthritis and age, sex, duration of disease, the results of laboratory testing, sensorineural hearing loss, or medication use. CONCLUSION: Our results suggest an association of rheumatoid arthritis with vestibular system dysfunction as well as auditory impairment.     

Extended high-frequency hearing loss in children with cleft palate

Hearing sensitivity for frequencies 250 through 20 000 Hz was compared between children with repaired cleft palate and a history of otitis media, and children without cleft palate or middle ear disease. All subjects were clear of middle ear effusion during the evaluation. Although children in the cleft palate group had consistently poorer hearing throughout the auditory range, statistical analysis demonstrated significant differences in hearing levels above 9 000 Hz only. No statistical difference was observed for the standard clinical audiometric frequencies. Extra-high-frequency hearing loss appears to be associated with cleft palate and its sequelae.     

Hearing loss and middle ear involvement in patients with juvenile idiopathic arthritis

OBJECTIVE: Evaluation of the hearing status and middle ear function of patients with juvenile idiopathic arthritis. METHODS: The study group was comprised of 38 ears of 19 patients (6 males, 13 females) aged between 5 and 23 years. The control group was comprised of 30 ears of 15 healthy subjects (5 males, 10 females) aged between 5 and 22 years. All subjects were examined audiologically using tympanometry, stapedial reflex, acoustic reflex decay, pure-tone audiometry, high frequency audiometry and transient evoked otoacoustic emission tests. RESULTS: There were statistically significant (p<0.05) number of ears (32%) with abnormal tympanograms in the patient population while all tympanograms were normal, type A in the control group. Seven type As, 2 type Ad, and 3 type C tympanograms were seen in the patient population. In pure tone audiometry tests there was no subject having neither a conductive nor sensorineural hearing loss individually in both groups. But as a group, patients with juvenile idiopathic arthritis showed statistically significant elevation of air conduction thresholds at frequencies of 250, 500, 6000, 14,000 and 16,000 Hz for right ears; and at 500, 2000, 12,500 and 16,000 Hz for left ears; and larger air-bone gaps at 500 and 2000 Hz for right ears; and at 500 Hz for left ears (p<0.05). Comparison of bone conduction thresholds and otoacoustic emission tests between both groups did not reveal any statistically significant difference (p>0.05). CONCLUSION: This study suggests a dual effect of disease on both the middle and inner ear of patients with juvenile idiopathic arthritis. Presence of abnormal tympanograms together with worse air conduction thresholds at lower frequencies as well as larger air bone gaps at frequencies of 500 and 2000 Hz suggest subclinical middle ear involvement; while hearing losses at 6000 Hz and very high frequencies of 12,500, 14,000 and 16,000 Hz suggest inner involvement at an early stage.     

High-frequency hearing loss and middle ear involvement in rheumatoid arthritis

PURPOSE: We aimed to evaluate the possible changes in the middle ears of patients with rheumatoid arthritis (RA) and to measure their hearing functions by eleven different test frequencies including standard and high frequencies. MATERIALS AND METHODS: The study group was comprised of 74 patients with RA. The control group was comprised of 45 healthy subjects. We performed speech test, tympanometry, acoustic reflex test, and standard and high-frequency pure tone audiometric tests in the study and the control groups. RESULTS: It was observed that significant increases in the thresholds of pure tones in all test frequencies for the study group versus the controls (P <.0001). In terms of the duration of the disease, hearing loss of the patients with disease duration of 1 to 5 years was higher than that of the controls and exceeded beyond the level of 20 dB especially in high frequencies starting from 10,000 Hz. In patients with disease duration of 6 to 10 years, the beginning point for hearing loss was 4,000 Hz. The patients with disease duration of 11 to 15 years and of above 16 years had high hearing thresholds in all frequencies. We found normal pressure in the middle ears of the study and the control groups. CONCLUSION: Sensorineural type hearing loss developed in patients with RA especially in high frequencies. We also determined a diminished compliance in the middle ears of those patients, but this was not in a level of a conducting type hearing loss.     

Hearing in patients with Paget’s disease

Paget’s disease has been reported in several uncontrolled studies to cause hearing loss, either sensorineural, conductive or mixed in type. No study has established convincing evidence of a connection between Paget’s disease of the skull and hearing loss. The aim of this study was to compare the hearing in patients with Paget’s disease and controls, and to identify any link between hearing loss and skull involvement. Patients with biochemically confirmed Paget’s disease (n = 100) were examined and had pure-tone audiometry and a skull radiograph. A group of hospital controls (n = 50) was recruited from a physiotherapy department. The hearing in the Paget’s patients was also compared with population controls from the MRC National Study of Hearing. Analysis of co-variance was performed to control for age, gender, occupational group and noise exposure. The results show a significant effect of Paget’s disease at all frequencies (maximal at 2000, 4000 and 8000 Hz), in both better (effect size 6.8 dB, SE 1.2) and poorer (effect size 7.4 dB, SE 1.6) ear, on bone conduction as well as air conduction thus showing the hearing loss to be sensorineural. Sub-division of the Paget’s patients into those with and those without radiological evidence of Paget’s in the skull showed that the group with skull involvement were statis tically different (P < 0.01) from both clinic and population controls, while the group with no evidence of skull involvement showed no such effects. Patients with Paget’s disease of the skull show evidence of sensorineural but not conductive hearing loss, while those without demonstrable skull involvement have hearing thresh olds similar to control groups.     

Audiovestibular functions in rheumatoid arthritis

Audiologic, middle ear impedance and vestibular function tests were administered to 25 patients with classical or definite rheumatoid arthritis and 25 normal control subjects of 30 to 50 years age group. Any possible influence of other common causes of hearing loss was avoided by carefully selecting the patients. Six patients had mild sensorineural hearing loss and another had bilateral mixed hearing loss. Results of tone decay test, speech reception threshold, speech discrimination score and short increment sensitivity index tests suggested cochlear pathology being responsible for the sensorineural hearing loss. There was no statistical correlation between hearing loss or otoadmittance abnormality and duration or activity of rheumatoid arthritis or positivity of rheumatoid factor. Electronystagmographic recording of saccades and bithermal caloric induced nystagmus revealed no significant abnormality.     

保留乳突的改良完壁式鼓室成形术的临床疗效观察

目的 探讨局限于上鼓室区病变的慢性化脓性中耳炎、中耳胆脂瘤行上鼓室径路保留乳突的改良完壁式鼓室成形术的长期临床疗效.方法 诊断慢性化脓性中耳炎、中耳胆脂瘤47例(47耳)患者,结合患者专科检查,依据手术方式不同分A、B两组,A组行上鼓室径路保留乳突的改良完壁式鼓室成形术,B组行完壁式乳突切开+鼓室成形术.术后随访5～7...     

Peripheral audition of children on the autistic spectrum

OBJECTIVE: To determine whether the peripheral audition of a group of children comprehensively diagnosed as being on the autistic spectrum was quantitatively different from that of a matched group of typically developing children. METHODS: Thirty-seven children with autism and an equal number of control participants matched for chronological age within 6 mo were examined by means of behavioral and physiologic measures of auditory function. All participants had normal hearing (thresholds <15 dB HL; 0.25 to 8 kHz) and normal middle ear function by quantitative tympanometry. Conventional behavioral audiometry, a computer-assisted threshold assessment procedure, acoustic middle ear muscle reflex thresholds, and evoked otoacoustic emissions (both transient and distortion product) tests were administered to both groups. RESULTS: No significant differences between children with autism and those developing typically on any behavioral or physiologic measure of peripheral auditory function were found. CONCLUSIONS: There was no evidence of intrinsic differences in the peripheral auditory mechanism of children with autism that would account for the auditory processing disorders and sound sensitivity that are commonly reported in this population.     

Outcome prediction for Bonebridge candidates based on audiological indication criteria

ObjectiveTo re-evaluate current indication criteria and to estimate the audiological outcomes of patients with Bonebridge bone conduction implants based on preoperative bone conduction thresholds.MethodsWe assessed the outcome of 28 subjects with either conductive or mixed hearing loss (CMHL) or single-sided deafness (SSD) who were undergoing a Bonebridge implantation. We used linear regression to evaluate the influence of preoperative bone conduction thresholds of the better/poorer ear, indication group, and language (German- and French-speaking patients) on aided sound field thresholds. In addition, aided word recognition scores at 65 dB sound pressure level were fit with a logistic model that included preoperative bone conduction thresholds of the better/poorer ear, indication group, and language as effects.ResultsWe found that both aided sound field thresholds and word recognition were correlated with the preoperative bone conduction thresholds of the better hearing ear. No correlation between audiological outcomes and the preoperative bone conduction thresholds of the poorer ear, language, or indication group was found.ConclusionBone conduction thresholds of the better hearing ear should be used to estimate the outcome of patients undergoing Bonebridge implantation. We suggest the indication criteria for Bonebridge candidates considering maximal bone conduction thresholds of the better ear at 38 dB HL to achieve an aided sound field threshold of at least 30 dB hearing level and an aided word recognition score of at least 75% for monosyllabic words.     

Hörgerätanpassung bei Kleinkindern mit Hilfe der elektrischen Reizantworten des Hirnstammes

Summary Hearing thresholds in newborn and little babies are routinely investigated by BSER in all cases of possible hearing impairment. No sedation was needed for measurement of air and bone conducted thresholds for click and 4 kHz. In case of normal hearing threshold, 20 dB (HL) or better, the development of latency-changings due to maturity of the auditory pathway was analysed. The results of 121 babies with jaundice, congenital, infectious or metabolic disturbances of brain function and middle ear malformation are presented and compared with later audiometric findings.     

Speech recognition in patients after successful surgery for unilateral congenital ear anomalies

It is generally assumed that auditory stimulation since birth is important for the proper development of the central auditory nervous system. Whether auditory deprivation occurs in man and, therefore, whether it may be considered as a contraindication to surgery in unilateral congenital middle ear anomalies and atresias is the subject of the present study. Speech recognition during both monaural and binaural presentation was studied in patients who had successful surgery for a unilateral congenital ear anomaly. In binaural speech recognition tests, the average results of the patient group (N = 13) and a group of subjects with normal hearing proved to be comparable. The average speech recognition score using monaurally presented band-pass filtered speech was 84% ± 8% and 77% ± 10% for the unoperated (normal) and operated ears, respectively (statistically significant). Speech-to-noise ratios of -5.6 ± 0.7 dB and -3.9 ± 1.6 db were found in the normal and operated ears, respectively (statistically significant). It is concluded that, in general, the speech recognition scores of the operated ears were satisfactory, but poorer than those of the normal ears.     

TNFα blockers do not improve the hearing recovery obtained with glucocorticoid therapy in an autoimmune experimental labyrinthitis

The effectiveness of etanercept [tumour necrosis factor-alpha (TNFα) blocker] and corticoids in treating immuno-mediated inner ear disease (IMIED) was compared in an animal model of autoimmune labyrinthitis. IMIED is one of the few forms of sensorineural hearing loss that is reversible with proper medical treatment. While the effectiveness and usefulness of immunomodulating agents (corticosteroids) in treating IMIED have been demonstrated, TNFα antagonists, which inhibit granuloma formation in rheumatoid arthritis and other autoimmune diseases, have been considered as an alternative therapy. The efficacy of etanercept (anti-TNFα) was evaluated in a guinea pig model of experimental autoimmune labyrinthitis in which 25 guinea pigs were divided in a control group, which was used to document the rise in hearing thresholds following immunisation, and two experimental groups, which were treated with steroids (6-methylprednisolone) and anti-TNFα (etanercept), respectively, after the immunisation. Comparison of the auditory thresholds obtained by means of auditory brainstem response (ABR) revealed that the auditory thresholds of the two experimental groups were not statistically different (6-methylprednisolone: 41.5 dB, SD: 8.51; etanercept: 37.5 dB, SD: 7.91) and that both compared favourably with that of the control group (60 dB, SD: 7.91) at p=0.001. We therefore conclude that etanercept is as effective as glucocorticoids in an animal model of autoimmune labyrinthitis; however, the potential adverse effects and high price of the former advise against its use as an initial therapy for IMIED.     

Subjective audiological tests and transient evoked otoacoustic emissions in patients with rheumatoid arthritis: analysis of the factors affecting hearing levels

We investigated hearing functions in patients with rheumatoid arthritis (RA) using audiological tests and transient evoked otoacoustic emissions (TEOAEs). The study group consisted of 20 adult patients with RA (7 males, 13 females); 20 adult healthy subjects without RA (7 males, 13 females) were recruited as controls. All patients were evaluated by pure tone audiometry, high frequency audiometry, tympanometry and TEOAEs. There were no statistical differences between the study and control groups with respect to the pure tone and high frequency audiometries. TEOAE results of 1.0–2.0 kHz % and of 1.5 and 3.0 kHz amplitude values were significantly lower, and ipsilateral stapes reflex threshold value at 1.0 kHz was significantly higher in the study group when compared to respective values in the control group. In elderly patients and those with longer disease duration, RA nodules and higher methotrexate cumulative doses, hearing thresholds increased and TEOAE values decreased. In active stage of the disease, hearing thresholds diminished and in higher Brinkman Index values, TEOAE values decreased. Compliance values decreased in patients with higher Ritchie Articular Index, C-reactive protein, erythrocyte sedimentation rate and platelet counts, and longer disease duration. Sensorineural hearing loss is generally observed in patients with RA, and this condition may be detected by TEOAEs in an early period of the disease. Inflammation during the active stage of the disease and the subsequent fibrosis may cause conductive hearing loss of varying degrees. In those patients detected as having initiation of TEOAE decrease, vasodilator treatment and antioxidant drugs may be useful in protecting the inner ear.     

Distortion product otoacoustic emission findings in Behçet's disease and rheumatoid arthritis

BACKGROUND AND OBJECTIVE: This study aimed to assess cochlear functions in Beh?et's disease and rheumatoid arthritis (RA) using otoacoustic emission testing (OAE), which objectively assesses outer hair cells in the cochlea. METHODS: Patients with Beh?et's disease (n = 16) and RA (n = 11) as well as 20 controls were tested using pure tone audiometry and transiently evoked (TEOAEs) and distortion product OAEs (DPOAEs). RESULTS: Pure tone results in the Beh?et's group were not significantly different from controls (p > 0.05). Pure tone results in the RA group were significantly different than in controls at 250, 500 and 6,000 Hz (p < 0.05). TEOAEs could be obtained in all participants. DPOAE amplitudes in the RA group and controls were similar (p > 0.05). DPOAE amplitudes were significantly higher in the Beh?et's group than in controls at 1 and 2 kHz (p < 0.05). CONCLUSION: A subtle deterioration in hearing can be seen at low and high frequencies in RA, which is not related to outer hair cell dysfunction as detected by DPOAE testing. In the patients with Beh?et's disease who have hearing thresholds within the normal limits, outer hair cell functions seem spared with an increased activity in the apical regions of the cochlea.     

Binaurality in middle ear implant recipients using contralateral digital hearing AIDS.

OBJECTIVE: For some patients, conventional hearing aids might have disadvantages that clearly limit the benefit of using them. The middle ear implant, Vibrant Soundbridge hearing prosthesis offers an approach to help such patients. Our study's objective was to identify the binaurality in a well-fitted digital hearing aid worn in the contralateral ear in recipients experienced with use of the Vibrant Soundbridge middle ear implant device. STUDY DESIGN: In a prospective study, warble-tone thresholds and stereophony were evaluated for the following conditions: (1) binaural unaided-with the middle ear implant inactive and the behind-the-ear hearing aid removed; (2) middle ear implant alone-middle ear implant active, behind-the-ear hearing aid removed; (3) middle ear implant plus behind-the-ear omnidirectional-middle ear implant active, behind-the-ear active; and (4) behind-the-ear omnidirectional alone-middle ear implant inactive, behind-the-ear omnidirectional active. Behind-the-ear omnidirectional and behind-the-ear is defined as the behind-the-ear active in the omnidirectional or directional response, respectively. Behind-the-ear is a contralateral digital hearing aid to the middle ear implant. Benefits such as improved sound detection, speech perception in quiet and in noise, and sound quality were investigated. The evaluation of subjective hearing benefit was based on the Abbreviated Profile of Hearing Aid Benefit (APHAB) test. Paired t tests (subject) were used to analyze the differences between mean thresholds for the different test conditions. SETTING: Tertiary referral center. PATIENTS: Eight adults (aged 45-68 yr) had undergone implantation with a single Vibrant Soundbridge at least 12 months before starting the study. These eight subjects presented no contraindication for contralateral hearing aid use. Patients were fitted 5 weeks before testing with a Siemens Signia digital behind-the-ear hearing aid in the side contralateral to the Vibrant Soundbridge. RESULTS: Five weeks after use of the contralateral hearing aid together with the middle ear implant, mean differences in warble-tone thresholds between Conditions 2 and 3 and between Conditions 3 and 4 were both statistically significant. The mean differences in speech reception thresholds were in line with the mean differences in average warble-tone thresholds. The mean speech reception threshold for the middle ear implant plus behind-the-ear omnidirectional condition was slightly worse (3 dB) than that for the middle ear implant alone condition; however, this difference was not statistically significant. Whereas speech reception threshold difference between Condition 1 and Condition 4 was not statistically significant (60 dB and 61 dB, respectively). The mean difference for the 0-degree azimuth alone was statistically significant (p < 0.05) for the conditions middle ear implant alone and middle ear implant plus behind-the-ear omnidirectional. The middle ear implant alone appears to give good sensitivity at 2 kHz for any direction. Increasing scores indicate greater percentages of problems. Percentages of problems were on average lower for the middle ear implant when used with the contralateral digital hearing aid based on the global score. CONCLUSION: The use of a middle ear implant Vibrant Soundbridge together with a contralateral digital hearing aid improved functional gain and speech perception thresholds in quiet, especially for the sound coming from the front of the patient. The use of a middle ear implant together with a contralateral digital hearing did not significantly improve hearing in noise.     

Hearing in the elderly: the Framingham cohort, 1983-1985. Part I. Basic audiometric test results

Many studies have documented the decline in auditory function with age. We broaden that data base in this the first of a series of reports emanating from the auditory testing of the Framingham cohort during biennial exam 18. The results of the auditory questionnaire, hearing sensitivity, acoustic compliance measures, and word recognition tests obtained from 1662 men and women in their 60th through 90th decades are presented. Pure-tone thresholds increased with age but the rate of change with age did not differ by gender even though men had poorer threshold sensitivity. Maximum word recognition ability declined with age more rapidly in men than in women and was poorer in men than in women at all ages. Acoustic compliance and middle ear pressure did not vary with gender or age. Acoustic reflex thresholds to a contralateral stimulus at 1 kHz increased slightly with age, more in women than in men; ipsilateral acoustic reflex thresholds did not vary with age or gender. Hearing aids were being used in only 10% of subjects likely to benefit from amplification.     

Audiological findings in patients with ankylosing spondylitis

Ankylosing spondylitis (AS) is a chronic inflammatory disease. The aim of this investigation was to study the relationship between AS and hearing loss. This study compared 28 patients with AS with 23 age-matched controls. All subjects underwent ENT examination, audiological and acoustic immittance measurements, and auditory brainstem response (ABR) tests. Sensorineural hearing loss was found in 28.6 per cent of the AS patients and in 4.35 per cent of the control group. For hearing levels at 250-500 Hz and 4000-8000 Hz, there was a statistically significant difference between the two groups. Acoustic reflex was not obtained in both ears of four patients and the left ear of one patient. There was a correlation between increase of tympanic volume and limitation in neck movement, between extension of 1-3 interpeak latency and limitation in the neck movement. In conclusion, AS affects the inner ear more than the middle ear.     

Middle ear injury through the external auditory canal: a review of 44 cases

We performed a retrospective review of 44 patients with middle ear injury incurred through the external auditory canal. Twenty-two of the 44 patients had presented to our center within 1 month of their injury (early group), and 22 presented later (delayed group); the mean interval from the time of the trauma to presentation was 6 days in the early group and 7 years in the delayed group. The causes of injury were penetrating trauma (70% of cases), thermal insults (20%), and explosive and nonexplosive blasts (9%). Purulent otorrhea, cholesteatoma, and ossicular discontinuity were more common in the delayed group. Otologic surgery was required in 9 early-group patients (41%) and in all 22 delayed-group patients (100%). Two patients in the early group developed a dead ear. The mean pure-tone averages (PTAs) at presentation were 30.7 and 52.2 dB in the early and delayed groups, respectively; after management, the corresponding mean PTAs were 21.0 and 42.5 dB. The respective mean air-bone gaps in the two groups were 14.6 and 28.2 dB at presentation and 8.0 and 17.2 dB after management. We conclude that middle ear injury incurred as a result of trauma sustained through the external auditory canal is associated with considerable morbidity. Patients who present in a delayed fashion have significantly poorer hearing at presentation and after management. Patients who do not develop a dead ear generally derive benefit from reconstruction of the middle ear sound-conduction mechanism.     

Auditory investigations in hypothyroidism

Twenty patients with thyroprivic hypothyroidism with a mean age of 34.8 years (range: 15-50 years) were investigated. Peripheral/central functions of the auditory system were assessed in the hypothyroid state and they were re-evaluated in the euthyroid state after treatment with levothyroxine. The mean observation period for re-evaluation was 3.7 months (range 3-7 months). Sixteen patients with hypothyroidism (80%) demonstrated hearing loss when compared with randomly selected age- and sex-matched normal subjects. Twelve of the hypothyroid patients had sensorineural hearing loss and 4 had mixed loss. Special hearing tests revealed a cochlear type of hearing loss. The tympanogram curve was of Type B in one ear of each of the 4 patients. Brainstem electric response audiometry showed prolonged, absolute latency of wave V and interpeak latencies I-III and I-V. The amplitudes of waves I, II and V were reduced. Following treatment with levothyroxine a statistically significant improvement in hearing thresholds was observed by pure-tone audiometry. Tympanogram curves returned to normal in 3 out of 4 patients. Brainstem electric response parameters did not show significant reversibility to normalcy following treatment. The results of auditory investigations suggest a causal relationship between hypothyroidism and hearing loss. The site of lesion in the auditory system is probably at several levels, viz. in the middle ear, and at cochlear and retrocochlear sites.     

Effect of intratympanic dexamethasone on noise-induced temporary threshold shift

OBJECTIVE: To evaluate the effects of intratympanic treatment of dexamethasone (IT-DEX) and combination of DEX and hyaluronic acid (DEX/HA) for noise-induced temporary threshold shift (NITTS). MATERIALS AND METHODS: NITTS was experimentally performed in 60 rats. Electrophysiologic hearing thresholds of the rats were measured before and right after noise exposure. Then, the rats were placed into two groups, the first 30 rats in an IT-DEX group and the second in an IT-DEX/HA group. Treatments were performed in the two subgroups (30 ears in one subgroup) of each group. In the IT-DEX group, one ear of each rat was treated with 0.02 mL IT-DEX, and the other ear was treated with IT 0.02 mL physiologic solution of serum saline. In the IT-DEX/HA group, one ear of each rat was treated with combination of 0.01 mL IT-DEX and 0.01 mL HA, and the other ear was treated with IT 0.02 mL of physiologic solution of serum saline. One week after the treatments, electrophysiologic hearing thresholds of all rats were measured again. RESULTS: No statistically significant difference was observed in recovery values of electrophysiologic hearing thresholds between IT-DEX and serum saline (P = .641) in the IT-DEX group. Also, we found no statistically significant difference in the recovery values of electrophysiologic hearing thresholds between IT-DEX/HA and serum saline (P = .344) in the IT-DEX/HA group. CONCLUSION: There is no effect of either IT-DEX and DEX/HA for NITTS.