1 Introduction
With the rapid aging of the population, age-related declines in auditory and vestibular function have become increasingly prevalent among community-dwelling older adults
[1,
2]. Hearing loss and dizziness or vertigo impair communication, social participation, and mental health, and are associated with an increased risk of falls, fractures, and cognitive decline
[3,
4]. Previous studies suggest that self-reported symptoms alone are insufficient for the timely identification of functional impairment
[5,
6]. Therefore, an “objective assessment → early referral → individualized intervention” pathway is essential to reduce disability burden. However, rural settings face systemic gaps at multiple points along this pathway. In many rural areas, the diagnosis and treatment of hearing and vestibular disorders are still limited by service capacity and available equipment. Many primary healthcare facilities are only able to conduct basic hearing screenings and lack the personnel and equipment necessary for comprehensive assessments. Additionally, poor transportation infrastructure and complex referral pathways further hinder access to continuous care. Additionally, some older adults perceive hearing loss and dizziness as part of normal aging, which may delay timely and objective evaluation and intervention. These factors affect the effectiveness of early detection and timely intervention, hindering the improvement of healthcare services in rural areas.
At the pathophysiological level, the comorbidity of auditory and vestibular dysfunctions is biologically plausible. The auditory and vestibular sensory receptors of the inner ear originate from the same membranous labyrinth and share a highly specialized microcirculatory and metabolic environment
[7]. Age-related degeneration of hair cells, alterations in the basilar membrane and supporting cells, mitochondrial dysfunction, and oxidative stress may collectively impair both cochlear and vestibular function
[8,
9]. Furthermore, vascular and metabolic risk factors—including hypertension, dyslipidemia, abnormal glucose metabolism, smoking, noise exposure, and ototoxic medication use—may exacerbate damage to both systems through microvascular hypoperfusion and the promotion of a pro-inflammatory microenvironments
[10,
11]. At the central level, age-related declines in neuroplasticity within the multisensory integration network—encompassing vestibular, visual, and proprioceptive inputs—further amplify the cumulative burden across peripheral and central pathways
[12,
13]. Clinically, such comorbidity often manifests as concurrent hearing loss with intermittent or persistent dizziness, postural instability, and an increased risk of falls
[7]. When diagnosis relies primarily on subjective symptom reporting, sensitivity and grading accuracy are frequently suboptimal, leading to missed opportunities for targeted rehabilitation or assistive interventions.
Building upon the aforementioned contextual and mechanistic considerations, it is particularly crucial to establish a “objective, reproducible, and community-friendly” bimodal assessment pathway within primary healthcare settings. This approach integrates pure-tone audiometry (PTA) to characterize graded hearing thresholds and video head impulse testing (vHIT) to quantitatively evaluate vestibulo-ocular reflex (VOR) gain and pathological corrective saccades, thereby constructing an integrated “auditory–vestibular” objective screening framework
[14]. Compared with self-reported symptoms or single-scale screening tools, bimodal objective testing is expected to enhance the precision of high-risk case identification among rural populations and to provide an evidence base for tiered referral, individualized rehabilitation, and fall prevention strategies. However, systematic epidemiological evidence regarding the prevalence, comorbidity spectrum, and subjective–objective concordance of auditory and vestibular dysfunctions in rural communities remains scarce
[13,
14]. In particular, whether specific symptom combinations—such as concurrent hearing loss with dizziness or tinnitus—can serve as clinical indicators of vestibular dysfunction has rarely been validated in real-world primary care populations. These evidence gaps constrain evidence-informed decision-making among policymakers and primary care teams in designing screening strategies, defining referral thresholds, and allocating healthcare resources.
To address these gaps, the present study targeted adults aged 55–65 years in a rural community, conducting concurrent PTA and vHIT assessments while collecting self-reported data on hearing, dizziness, and tinnitus symptoms. The study aimed to: (1) estimate the community prevalence and comorbidity rates of auditory and vestibular impairments; (2) evaluate the concordance and reclassification patterns between subjective self-reports and objective measurements; and (3) explore the diagnostic performance of symptom combinations in predicting vestibular dysfunction (abnormal vHIT results), thereby providing actionable evidence for bimodal screening and tiered referral frameworks in rural primary care.
By establishing a reproducible workflow for measurement and interpretation under resource-limited conditions, this study seeks to support a paradigm shift in primary care screening—from symptom-driven to evidence-driven practice—through practical data and methodological exemplars.
2 Materials and Methods
2.1 Study design and participants
Participants in this study were recruited from the Taizhou Imaging Study (TIS), an ongoing community-based neuroimaging cohort nested within the Taizhou Longitudinal Study (TZL), which aims to monitor risk factors and the progression of dementia and cerebrovascular diseases in rural Chinese populations. The TIS was approved by the Ethics Committee of the School of Life Sciences, Fudan University, and Fudan University Taizhou Institute of Health Sciences (institutional review board approval number: 496 and B017, respectively). The study design of TIS has been previously described
[15]. Briefly, from 2013 onwards, TIS recruited individuals aged 55–65 years without a history of physician-diagnosed stroke, dementia, cancer, or other severe diseases. Participants underwent a range of baseline assessments as part of the parent Taizhou Imaging Study. For the present cross-sectional analysis, we used demographic and clinical information, otologic symptom questionnaires, pure-tone audiometry results, and video head impulse test results.
2.2 Procedure
All study procedures were completed during a single half-day visit for each participant. Upon arrival at the examination site, participants first underwent a series of standardized health assessments, including the collection of medical history regarding chronic conditions such as hypertension, evaluation of physical activity levels, and documentation of lifestyle behaviors including smoking and alcohol consumption. These were followed by standardized clinical assessments according to the protocol of the parent cohort. The present study focused on the otolaryngology-related assessments, including structured symptom questionnaires, pure-tone audiometry, and video head impulse testing.
Subsequently, participants were referred to a dedicated otolaryngology examination unit, where licensed audiology and vestibular technicians conducted comprehensive sensory assessments. These included the vHIT to evaluate semicircular canal function, a computerized posturography test using a balance board to assess equilibrium control, and pure-tone audiometry (PTA) in a soundproof booth to determine auditory thresholds. While we collected data from all these assessments, the present study mainly analyzes the results of the vHIT test to evaluate vestibular dysfunction. All assessments adhered to manufacturer guidelines and international consensus standards to ensure procedural consistency and diagnostic validity.
2.3 Data collection
2.3.1 Vestibular function assessment
(1) Objective vestibular function assessment
Objective vestibular function was assessed using the binocular vHIT, performed with the Verti-Goggles ZT-VNG-II (Shanghai ZEHNI Medical Technology Co., Ltd., Shanghai, China). Device calibration was conducted prior to testing. The examination evalusted three pairs of semicircular canals (SCCs): (1) bilateral lateral canals, (2) left posterior-right anterior canals, and (3) right posterior-left anterior canals. Seated participants were positioned 1.2 m from a visual target in ambient lighting, with goggles securely fitted to prevent slippage artifacts. For lateral SCC testing, the examiner stabilized the mandible while delivering unpredictable, rapid head impulses (10°–20° amplitude) as subjects maintained visual fixation. Vertical SCC testing required 30°–40° head rotation from midline, with the examiner applying impulses while supporting the vertex and mandible. Each canal pair received at least 15 valid head impulses that met the velocity criteria (150–250°/s horizontal, 100–200°/s vertical). According to international consensus criteria, abnormal findings were defined as: VOR gain below the normal reference range in any tested plane (lateral SCCs < 0.8, vertical SCCs < 0.7), or the presence of pathological corrective saccades in more than 50% of trials, indicating dysfunction of the corresponding semicircular canal
[16].
(2) Self-reported vestibular symptoms questionnaire
Before undergoing vHIT testing, each participant completed a balance function questionnaire. This questionnaire assessed the history of vertigo (“In the past year, have you experienced vertigo or unsteady walking?”) and falls (“In the past year, have you fallen due to vertigo or unsteady walking?”). Additionally, it included subjective descriptions of the participant’s vertigo symptoms (“If you have experienced vertigo, please describe the sensation”; “How long did the vertigo last?”; “In the past year, have you reduced your daily activities due to vertigo, dizziness, or falls?”).
2.3.2 Auditory function assessment
(1) Objective auditory function assessment
Pure-tone audiometry (PTA), a standardized audiological procedure, was used to objectively assess auditory function. Testing was performed in a soundproof booth with background noise levels maintained below 30 dB. A calibrated audiometer (Interacoustics, Model 1066, Denmark) was used to determine auditory thresholds across a range of frequencies. Air conduction thresholds were measured at frequencies from 250 Hz to 8000 Hz, and bone conduction thresholds from 500 Hz to 4000 Hz. The modified Hughson-Westlake procedure was employed with 5-dB step increments to establish thresholds. Air-bone gaps were analyzed to differentiate conductive from sensorineural hearing loss, with results graphically displayed as audiograms. In the analysis, the better ear hearing threshold level (BEHL), defined as the mean pure-tone air conduction thresholds at 0.5 kHz, 1 kHz, 2 kHz, and 4 kHz, was used. Participants were classified as having at least mild hearing impairment if the BEHLat 0.5–4 kHz exceeded 20 dB. The severity of hearing impairment was classified according to the World Health Organization (WHO) 2021 criteria.
(2) Subjective auditory history and symptom questionnaire
Prior to formal audiometric testing, participants underwent structured interviews and completed a standardized questionnaire to collect self-reported auditory histories. The questionnaire included items assessing perceived hearing difficulties, episodes of tinnitus lasting longer than five minutes, incidents of sudden hearing loss that did not recover within several hours, and the intensity and duration of occupational noise exposure. In this study, otologic symptoms were defined as the presence of vertigo, tinnitus, and/or hearing loss, based on self-reported responses. These subjective data were used to complement objective findings from pure-tone audiometry and to evaluate the accuracy of self-perceived auditory function, as well as to identify potential risk factors for auditory and vestibular impairment.
2.4 Statistical analysis
Descriptive statistics were used to summarize the demographic and clinical characteristics of the study participants. Group comparisons for continuous variables were performed using the t-test for normally distributed data and the Wilcoxon rank-sum test for non-normally distributed data. Differences in categorical variables were assessed using the chi-square test. To explore the association between different symptom combinations and vestibular dysfunction, univariate logistic regression analyses were conducted with abnormal video head impulse test results as the dependent variable. Given the relatively limited number of abnormal vHIT events, these analyses were considered exploratory and hypothesis-generating rather than confirmatory. No multivariable model was constructed in the primary analysis to avoid model instability and potential overfitting. The consistency between subjective symptoms and objective assessments was evaluated using sensitivity, specificity, and positive predictive value (PPV) for vertigo, and Cohen’s kappa coefficient for the agreement between self-reported hearing and pure-tone audiometry (PTA) results. A P-value of less than 0.05 was considered statistically significant. All statistical analyses were performed using R software (version 4.3.2).
3 Results
3.1 Characteristics of the study population
A total of 670 middle-aged and older adults residing in rural communities were included in the final analysis (Table 1). The median age of the sample was 58 years, and 54.03% were female. Regarding educational attainment, 43.58% had completed primary school or less, reflecting the low educational background common in rural populations. Occupational noise exposure was reported by 17.91% of participants, and 30.45% had a history of smoking, while 23.13% reported alcohol use. The prevalence of hypertension and diabetes was 40.30% and 11.19%, respectively. A history of ear-related conditions—including ear discharge, sudden hearing loss, tinnitus lasting longer than 5 minutes, or the use of ototoxic medications—was reported by 31.19% of participants. Notably, only 9.85% reported engaging in regular physical exercise, highlighting a low level of health-promoting behaviors in this rural cohort.
3.2 Prevalence of auditory and vestibular dysfunction
Among the 670 participants, 57 individuals (8.51%) exhibited abnormal findings on the vHIT, indicative of vestibular dysfunction (Table 2). A comparative analysis of demographic and clinical characteristics was performed between participants with normal and abnormal vHIT results.
The median age of those with vestibular dysfunction was significantly higher than that of the normal group (Z = 0.144, P = 0.015), suggesting an age-related decline in vestibular function. No statistically significant differences were observed between the groups in terms of sex distribution, educational attainment (≤ primary school), or prevalence of chronic conditions, including hypertension, diabetes, stroke, or transient ischemic attack (TIA), and cardiovascular disease.
Similarly, the proportion of participants reporting a history of ear-related disorders did not differ significantly between groups. However, it is notable that 479 participants (71.49%) were found to have hearing loss, among whom 48 (10.02%) also exhibited vestibular dysfunction, indicating a degree of comorbidity. Further subgroup analysis revealed that the prevalence of hearing loss was significantly higher in the vestibular dysfunction group compared to the normal group (84.21% vs. 70.31%; χ2 = 4.286, P = 0.038), suggesting a potential association between auditory and vestibular impairment.
3.3 Consistency between subjective symptoms and objective assessments
In the analysis of vertigo complaints versus vHIT findings, 164 participants reported experiencing vertigo, yet only 13 of them (7.9%) demonstrated abnormal vHIT results (Table 3). Conversely, among the 57 participants with abnormal vHIT findings, 44 did not report any vertigo symptoms. The calculated sensitivity of self-reported vertigo for detecting vHIT abnormalities was 0.228, with a specificity of 0.754, a positive predictive value of 0.079, and a negative predictive value of 0.913. These results indicate that while self-reported vertigo has low sensitivity, it exhibits relatively high specificity for identifying vestibular dysfunction.
For auditory function, comparison between self-reported hearing status and pure-tone audiometry (PTA) results revealed poor consistency (Kappa = 0.173) (Table 4). Notably, 39.7% of individuals with hearing loss underestimated their condition. This highlights the need for objective assessments in community screening, as self-reported symptoms may significantly underestimate the actual prevalence of sensory impairments.
3.4 Association between otologic symptom combinations and vestibular dysfunction
To further investigate the predictive value of different symptom combinations for vestibular dysfunction (as indicated by abnormal vHIT results), a univariate logistic regression analysis was performed. Vertigo, tinnitus, hearing loss, and their various combinations were included as independent variables, with vHIT outcome serving as the dependent variable (Table 5). The results showed that the presence of vertigo alone was not significantly associated with vHIT abnormalities （Z = −0.307, P = 0.759）. When vertigo co-occurred with tinnitus, the association approached but did not reach statistical significance (Z = −1.673, P = 0.094), indicating a potential trend.
In contrast, the combination of vertigo and hearing loss (Z = 2.163, P = 0.030), as well as the presence of all three symptoms—vertigo, tinnitus, and hearing loss—simultaneously (Z = 2.284, P = 0.022), demonstrated significant predictive value for vHIT abnormalities. Moreover, hearing loss alone—even in the absence of vertigo—was also significantly associated with abnormal vHIT results (Z = 4.467, P < 0.01). These findings suggest that the accumulation of otologic symptoms, particularly hearing loss, may indicate underlying vestibular dysfunction and has potential value in clinical screening.
4 Discussion
This study is among the first community-based investigations in rural China to simultaneously assess vestibular and auditory function using both standardized objective measures (vHIT and PTA) and structured self-reported symptoms. The research was motivated by the notable gap in empirical data on the concordance between perceived and objectively measured sensory impairments in underserved populations, where access to diagnostic resources is often limited. Our findings demonstrate a high prevalence of sensory impairment in this rural cohort, with 71.5% experiencing hearing loss and 8.5% exhibiting vestibular dysfunction. Notably, comorbidity between these two sensory deficits was common, and hearing loss—either alone or in combination with vertigo and tinnitus—was significantly associated with vestibular hypofunction. These results suggest the potential utility of symptom clustering as a simple and accessible clinical marker for the early identification of vestibular dysfunction.
Firstly, regarding the prevalence of hearing loss, we observed that 71.5% of participants had hearing loss, a finding consistent with, and slightly exceeding, previous community-based studies in China and other countries
[16,
17]. This may reflect population-specific factors, such as age structure, occupational noise exposure, or underreporting in previous self-assessments, reinforcing the recognition of age-related hearing loss (ARHL) as a major public health issue. Our study highlights that hearing loss is a prevalent and significant public health concern in rural aging populations.
Secondly, vestibular dysfunction was observed in 8.5% of participants, which falls within expected ranges for aging populations
[18,
19], reaffirming the relevance of semicircular canal degeneration as a key contributor to balance impairment
[21]. The vHIT method, offering specificity for canal-level function and practical field applicability, provides a feasible alternative to caloric or rotary chair testing, particularly in low-resource settings
[22].
Regarding comorbidity between hearing loss and vestibular dysfunction, we found that participants with vestibular dysfunction had a significantly higher prevalence of hearing loss (84.21% vs. 70.31%,
P = 0.038). This suggests that auditory and vestibular impairments often co-occur, indicating potential shared pathophysiological mechanisms. Prior histological and imaging studies have demonstrated age-related degeneration of cochlear and vestibular hair cells, as well as compromised inner ear microcirculation, supporting the hypothesis of a common neurodegenerative or vascular basis for dual-sensory decline
[23].
In terms of the diagnostic utility of subjective symptoms, we analyzed the consistency between self-reported vertigo and vHIT results. Self-reported vertigo showed limited sensitivity for detecting vestibular dysfunction and a low positive predictive value, indicating that symptom-based screening alone may miss many participants with objective vHIT abnormalities. This suggests that although self-reported vertigo has low sensitivity, it is relatively specific for detecting vestibular dysfunction, indicating its potential use in identifying those at risk, though many cases may still be missed. This finding confirms previous reports that many older adults with vestibular deficits remain asymptomatic or fail to recognize their symptoms, emphasizing the importance of objective functional testing over symptom-based triage alone
[24].
For hearing loss, we observed poor concordance between self-reported hearing status and PTA results, with a Kappa coefficient of 0.173. This reflects the significant gap in self-awareness, with 39.7% of individuals underestimating the severity of their hearing impairment. These findings underscore the need for objective assessments in community screenings, as self-reported symptoms may significantly underestimate the true prevalence of sensory impairments.
Finally, in terms of the association between symptom combinations and vestibular dysfunction, we found that the combination of vertigo and hearing loss was associated with abnormal vHIT findings (OR = 2.41, 95% CI: 1.67–3.14, P = 0.030). Additionally, the presence of all three symptoms—vertigo, tinnitus, and hearing loss—was also associated with abnormal vHIT findings (OR = 1.74, 95% CI: 1.01–2.48, P = 0.022). Notably, hearing loss was associated with abnormal vHIT findings even among participants without vertigo. This finding suggests that reliance on vestibular symptoms alone may overlook a subset of individuals with objective vestibular dysfunction. These results suggest that hearing loss, particularly when accompanied by other otologic symptoms, may serve as a practical clinical indicator of multisensory degeneration, supporting early intervention and referral decisions.
This study has several limitations. The cross-sectional design limits causal inference and our ability to determine the temporal relationship between symptom onset and functional decline. In addition, the number of participants with abnormal vHIT findings was relatively limited, with only 57 abnormal cases, which may have reduced the precision of the association estimates and limited the feasibility of stable multivariable modeling. Age also differed between participants with and without vestibular dysfunction, and residual confounding by age cannot be fully excluded. Additionally, while PTA and vHIT effectively assess peripheral function, they do not evaluate central auditory processing or otolith-related vestibular pathways, which may also affect balance and cognitive outcomes. Participants with abnormal vHIT results or positive vestibular symptoms may therefore require further comprehensive vestibular evaluation. Moreover, while our sample represents rural adults in Taizhou, caution is warranted when generalizing these findings to urban populations, other regions, or older age groups. Future longitudinal studies should further evaluate the relationships among auditory–vestibular dysfunction, falls, activity limitation, and quality of life.
Despite these limitations, the study provides valuable insights for both research and clinical practice. It supports the use of combined vestibular and auditory screening as an effective strategy to identify at-risk individuals in rural aging populations. Our findings also suggest that hearing loss, particularly when accompanied by other otologic symptoms, could serve as an early indicator of multisensory degeneration, guiding intervention and referral decisions. Overall, this study provides strong evidence for the prevalence, co-occurrence, and diagnostic challenges of vestibular and auditory dysfunction in rural older adults, and emphasizes the importance of integrating objective testing and symptom clustering to enhance sensory health screening and promote healthy aging in underserved populations.
5 Conclusion
This study highlights the high prevalence of hearing loss and the co-occurrence of auditory and vestibular dysfunction among rural middle-aged and older adults in China. The observed mismatch between subjective symptoms and objective findings reinforces the need for integrated screening of both auditory and vestibular function in primary care. Hearing loss accompanied by vertigo or tinnitus may help identify individuals who warrant further vestibular evaluation. These findings support incorporating objective auditory–vestibular assessment and sensory symptom clustering into community-level screening strategies to enhance early detection and referral.
The Author(s). This article is published by Higher Education Press at journal.hep.com.cn.
This is an open access article distributed under the Creative Commons Attribution License 4.0 (CC BY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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