Common causes of hearing loss in adults

Nurses can help reduce potential loss of quality

of life. By Tamara Link, DNP, RN, FNP-BC

26 American Nurse Journal Volume 16, Number 8 MyAmericanNurse.com APPROXIMATELY 16% of U.S. adults age 18 clearing, but occlusion can occur if cerumen years and older report hearing loss, according doesn’t naturally clear or if the patient pushes to the Centers for Disease Control and Preven- it deeper into the canal. With marked im- tion. Symptoms range from temporary and in- paction, sound can’t conduct to the middle ear. convenient, to permanent and disabling. Pa- According to Yang and colleagues, cerumen tients wait an average of 10 years before impaction is common, affecting 1 in 20 adults actively seeking treatment for hearing loss, ac- and up to 57% of nursing home residents. Pa- cording to a report from the National Institute tients at particular risk include those who use on Deafness and Other Communication Disor- ear plugs or hearing aids, which may stimulate ders (NIDCD). Lack of treatment can lead to cerumen production and block outflow. For social isolation, depression, impaired commu- reasons that aren’t completely clear, others at nication, neurological decline, and decreased risk include those who live in nursing homes quality of life. Nurses may be the first to rec- or are institutionalized for developmental dis- ognize hearing loss and have an opportunity abilities, possibly due to cognitive deficits or, in to start a conversation with the patient. the case of some forms of intellectual disability, To understand the causes of hearing loss, anatomical differences within the ear canal. nurses must have knowledge of hearing physi- Patients with cerumen impaction frequently ology. Sound is a vibration that funnels through report hearing loss, ear discomfort, tinnitus, the outer ear to the middle ear via the eardrum and a feeling of fullness in the ear. Blockage (tympanic membrane) and the three bones, or can cause difficulty hearing normal conversa- ossicles (malleus, incus, and stapes), in the tion. Cerumen impaction should be treated middle ear. Vibration of the ossicles transmits only by experienced clinicians via manual re- sound waves to the cochlear sensory hair cells moval with specialized instruments, irrigation, in the inner ear. These cells convert the waves or cerumenolytics. into an electrical signal that travels via the au- ditory nerve to the brain where it’s perceived Acute otitis externa as sound. (See Anatomy of the ear.) Acute otitis externa (AOE)—sometimes called Hearing loss, which can originate any- “swimmer’s ear”—is a painful infection of the where along this pathway, is classified by type external ear canal caused predominantly by (conductive, sensorineural, and mixed [any bacterial pathogens. Symptoms present acute- combination of conductive and sensorineur- ly and include external ear pain, redness and al]) in relation to ear anatomy and physiology. swelling of the ear canal, ear discharge, itch- This review will familiarize nurses with the ing, fullness, and possibly hearing loss. causes of conductive and sensorineural hear- Common risk factors for AOE include fre- ing loss in adults and the implications for quent self-removal of cerumen, warm and nursing practice. Autoimmune, vascular, neu- moist climates, hearing aid use, chronic skin rogenic, oncological, and congenital hearing conditions, diabetes, immunodeficiency disor- loss are beyond the scope of this review. (See ders, and swimming. Severe AOE may cause Causes of hearing loss.) marked inflammation and discharge, which prevent sound conduction through the ear Conductive hearing loss canal. Uncomplicated AOE is treated with Conductive hearing loss occurs when sound analgesics and topical agents such as antibi- can’t be transmitted from the environment otics, steroids, and acetic acid drops. through the external or middle ear to the cochlea. It can result from a blockage of the ex- Acute otitis media ternal or middle ear from substances such as Acute otitis media (AOM) is a bacterial infec- earwax (cerumen), swelling, fluid, pus, a tumor, tion of the middle ear characterized by an or a foreign body. Abnormalities of the ossicles acute onset of ear pain with middle ear in- also can cause conductive hearing loss. Most flammation and fluid, which prevent adequate causes can be medically or surgically managed. sound transmission to the inner ear. Accord- ing to Rijk and colleagues, the incidence of Cerumen impaction AOM in adults is only 5/1,000 person-years. Cerumen is a naturally occurring, protective The most common symptoms are unilateral substance in the ear canal. Typically, it’s self- earache, discharge, and hearing loss. Sponta-

MyAmericanNurse.com August 2021 American Nurse Journal 27 Anatomy of the ear Hearing loss can result from conditions in the external, middle, or inner ear.

neous rupture of the tympanic membrane tract infection, barotrauma from pressure (TM) may occur more frequently in adults changes associated with flying or scuba diving, than in children, further complicating the con- and allergic rhinitis. It affects children more dition. Common AOM treatment for adults is frequently than adults. The incidence of OME an oral antibiotic; watchful waiting usually is in adults hasn’t been established, but it may be indicated for children. Barring any complica- a symptom of an underlying nasopharyngeal tions, hearing should return to normal after carcinoma that damages the eustachian tube. the infection is cleared. Uncomplicated OME typically resolves spontaneously, but recurring or persistent Otitis media with effusion OME requires otolaryngology consultation. Similar to AOM, otitis media with effusion Treatment in adults hasn’t been well studied (OME) can cause conductive hearing loss as a but may include inserting tympanostomy result of fluid and inflammation in the middle tubes to drain the fluid and equalize pressure. ear. The middle ear mucosa becomes in- flamed, causing negative air pressure in the TM perforation middle ear. This negative pressure, coupled Holes in the TM reduce the surface area of the with the inability of the eustachian tube to eardrum, decreasing sound transmission to open properly, causes fluid to flow (effuse) the ossicles. Perforation can occur as a result from the mucosa and fill the middle ear cavity. of AOM, head or ear trauma, barotrauma, and Unlike AOM, OME isn’t an infectious process self-inflicted punctures during ear cleaning. and usually is painless. However, it may result Symptoms depend on the cause but may in- from fluid accumulation caused by AOM or clude ear pain, bleeding, discharge, tinnitus, predispose the patient to infection because of and hearing loss. Significant hearing loss is as- trapped fluid and bacteria. OME is associated sociated with larger holes. with eustachian tube dysfunction. Patients with large perforations, perforations OME can develop after an upper respiratory that don’t heal within 2 months, or vertigo are

28 American Nurse Journal Volume 16, Number 8 MyAmericanNurse.com at greater risk for damage to the ossicles and years and presents as gradual hearing loss, ear require otolaryngology consultation. Treatment discharge, and eventual discomfort. Untreated depends on the cause and severity of the de- cholesteatoma may advance into the inner ear, fect and may include surgical reconstruction or causing permanent sensorineural hearing loss. grafting. Early detection and surgical excision are key to restoring normal hearing. Otosclerosis Otosclerosis occurs as a result of abnormal os- Nursing implications sicles remodeling, which prevents sound waves To decrease the risk of infection, TM perfora- from vibrating the bones normally. According tion, and cerumen impaction, discourage pa- to the American Hearing Research Foundation, tients from cleaning their ears with cotton the condition is most common in Whites. About tipped swabs, candling, or daily olive oil 1 in 10 White adults develop otosclerosis, and drops. Pain, cerumen impaction, and persist- White women are affected twice as frequently ent ear discharge should be evaluated by a as men. Onset is between ages 10 and 45 years, provider. but most common in the twenties. Although the Persistent hearing loss that lasts more than etiology is unclear, otosclerosis has a hereditary 1 to 2 weeks after treatment of the underlying component. Someone who has a parent with condition, including hearing loss after head the condition has a 25% chance of developing trauma, should be re-evaluated for complica- otosclerosis. tions. Assess patients for a family history of Symptoms start with unilateral, low-fre- hearing loss and refer those with gradual, pro- quency hearing loss, tinnitus, and possibly gressive conductive hearing loss to an oto- vertigo. Hearing loss gradually progresses in laryngologist to rule out serious causes such severity and eventually affects both ears. as otosclerosis and cholesteatoma. Hearing aids can help, but surgical treatment that replaces the bone with a prosthesis is the Sensorineural hearing loss most effective intervention for improving Sensorineural hearing loss (SNHL) occurs hearing and reducing tinnitus. when the mechanical sound that passes through the middle ear can’t be processed in Traumatic ossicular chain disruption the inner ear. It’s more complex than conduc- The ossicular chain (malleus, incus, and tive hearing loss, and normally involves dam- stapes) is subject to fracture or dislocation by age to the sensory nerve cells in the cochlea, direct head trauma from falls, blows to the the auditory nerve, or a combination of both. head, or blast injuries. Damage to these bones—which can prevent adequate sound Presbycusis conduction to the inner ear—may be over- Age is the most significant factor associated looked because of other more demanding in- with hearing loss in adults. According to the juries associated with the trauma. Temporal NIDCD, one in three adults age 65 to 75 years bone fractures have a high association with have age-related hearing loss; nearly half of ossicular chain disruption. Treatment includes those older than 75 report difficulty hearing. reconstruction of the ossicular chain. Approximately 15% of adults age 18 and older report some hearing loss, with the greatest Cholesteatoma amount of loss in those between 60 to 69. A cholesteatoma is a noncancerous tumor made Presbycusis (age-related hearing loss) is a form up of keratinizing squamous epithelium in the of sensorineural hearing loss that can be middle ear. According to Jackson and col- caused by noise exposure, ototoxins (such as leagues, the condition in children commonly aminoglycoside antibiotics and the chemother- originates at birth (congenital cholesteatoma); apeutic agent cisplatin), smoking, family histo- however, acquired cholesteatoma affects 9 to 12 ry, and chronic illness. Presbycusis is thought adults annually. Risk factors include recurrent to result from degenerative changes to the AOM and TM perforation. Cholesteatoma cochlear hair cells and auditory neurons from pathogenesis isn’t well defined, but it is locally cumulative environmental insults. invasive and can erode the TM and ossicles. Because symptoms start gradually and Typically, cholesteatoma grows slowly over progress slowly, they may be overlooked. The

MyAmericanNurse.com August 2021 American Nurse Journal 29 Causes of hearing loss — Conductive

Hearing loss is classified as conductive, sensorineural, or mixed (a combination of any of the conductive and sensorineural conditions). These tables describe causes and typical presentations.

CONDUCTIVE

Condition Causal associations Typical presentation

Cerumen impaction • Ear plugs • Unilateral or bilateral hearing loss • Hearing aids • Gradual onset • Nursing home or developmental • Ear discomfort disability institutionalization • Tinnitus • Feeling of ear fullness • Itching

Acute otitis externa • Frequent cerumen removal • Unilateral hearing loss • Moisture in ear • Acute onset • Chronic skin conditions • External ear pain • Diabetes • Redness and swelling of ear canal • Immunodeficiency disorders • Ear discharge

Acute otitis media (AOM) • Eustachian tube dysfunction • Unilateral hearing loss • Immunosuppression • Acute onset • Ear pain • Discharge if tympanic membrane ruptures

Otitis media with effusion • Upper respiratory infection • Unilateral hearing loss • Barotrauma • Gradual onset • Allergic rhinitis • Feeling of ear fullness • No pain or mild discomfort

Tympanic membrane perforation • Ear/head trauma • Unilateral hearing loss • Barotrauma • Acute onset • Self-cleaning of ears • Ear pain • Bleeding • Discharge • Tinnitus

Otosclerosis • Family history • Unilateral hearing loss that progresses to bilateral • Female • Gradual onset • White • Progressive • Low-frequency hearing loss • Tinnitus

Traumatic ossicular chain disruption • Head trauma from falling or • Unilateral or bilateral hearing loss blow to head • Acute onset • Blast injuries • Other injuries from trauma • Temporal bone fracture

Cholesteatoma • Recurrent AOM • Unilateral hearing loss • Tympanic membrane perforation • Gradual onset • Foul-smelling ear discharge • Discomfort

hearing loss is symmetrical, bilateral, and most 70% of patients who can benefit don’t use pronounced at high frequencies. As it pro- them, according to NIDCD data. Barriers to gresses, patients have more difficulty under- hearing aid use include cost, social stigma, standing conversations, especially with back- lack of insurance coverage, and difficulty ma- ground noise. Patients also may have more nipulating and adjusting to the device. For trouble understanding women and children more profound hearing loss, surgically insert- than men as a result of high frequency loss. ed cochlear implants, which bypass severely Presbycusis is linked to cognitive and physical damaged hair cells to directly stimulate the decline, social isolation, depression, demen- auditory nerve, are an option. Hearing aids tia, and decreased quality of life. and cochlear implants can improve hearing, Adverse effects of presbycusis can be miti- speech perception, social function, and over- gated with hearing aids; however, more than all well-being.

30 American Nurse Journal Volume 16, Number 8 MyAmericanNurse.com Causes of hearing loss — Sensorineural

Hearing loss is classified as conductive, sensorineural, or mixed (a combination of any of the conductive and sensorineural conditions). These tables describe causes and typical presentations.

SENSORINEURAL

Condition Causal associations Typical presentation

Presbycusis • Aging • Bilateral hearing loss • Noise • Gradual onset • Ototoxins • High-frequency hearing loss • Smoking • Genetics • Chronic illness

Noise-induced hearing loss • Chronic recreational or • Bilateral hearing loss occupational noise exposure • Gradual onset • Progressive • High-frequency hearing loss

Ménière’s disease • Unknown • Unilateral hearing loss • Fluctuating hearing loss • Low- and mid-frequency hearing loss • Tinnitus • Vertigo • Feeling of ear fullness

Sudden sensorineural hearing loss • No precipitating event • Unilateral • Acute onset • Feeling of ear fullness • Tinnitus • Sometimes vertigo

Acoustic neuroma • Neurofibromatosis • Unilateral • Childhood radiation to head • Gradual onset • Progressive • May have tinnitus, unsteadiness, facial weakness, headache, visual disturbance

Noise-induced hearing loss to 200 per 100,000 adults annually and is most Noise-induced hearing loss, which affects one prevalent in adults between age 40 and 60 in four adults, is the second most common years, according to a clinical practice guide- form of SNHL. Although presbycusis involves line from the American Academy of Otolaryn- noise exposure, noise-induced hearing loss is gology-Head and Neck Surgery (AAO-HNSF). considered a separate entity and may be the Hearing loss, tinnitus, and recurring “attacks” result of recreational exposure (loud music, of vertigo are the most common symptoms, firearms, motorcycles) or occupational expo- but patients also may experience aural full- sure (aircraft, machinery, power tools). Both ness, similar to a plugged ear. Hearing loss the intensity of the noise and duration of ex- fluctuates from low to mid frequency and usu- posure create the risk for damage to the sen- ally is unilateral. Vertigo may stabilize over sory hair cells in the cochlea. Louder sounds time, but hearing loss tends to worsen; 82% of may be harmful with less duration, and even those with Ménière's disease experience per- sounds that are “comfortably” loud may cause sistent moderate to severe hearing loss. damage with longer durations. Management to reduce acute and long-term Symptoms, which can be temporary or per- symptoms include lifestyle modifications (re- manent, affect the higher frequencies and of- duced salt, alcohol, stress) and medication ten include tinnitus. Noise-induced hearing (such as antihistamines, oral or intratympanic loss can be treated with hearing aids. steroids, and diuretics). Hearing aids may im- prove hearing and quality of life. Ménière’s disease Ménière’s disease results from increased fluid Sudden sensorineural hearing loss in the vestibular system of the inner ear, Sudden sensorineural hearing loss (SSNHL) which is responsible for balance. It affects 50 may affect only 5 to 20 per 100,000 adults an-

MyAmericanNurse.com August 2021 American Nurse Journal 31 Screening for hearing loss

These hearing screens can be performed without specialized equipment.

What it does How to perform and interpret results

Hum test Helps differentiate conductive • Instruct the patient to hum and ask if they hear the hum louder in from sensorineural hearing loss the affected ear. • If they do, hearing loss is more likely to be conductive (from wax or fluid) rather than sensorineural.

Finger rub Assesses for hearing loss • Rub your fingers together 6 inches from the patient’s ear. • Inability to hear the finger rub in at least three of six attempts may indicate hearing loss.

Whisper test Assesses for hearing loss • Have the seated patient block one ear. • Stand behind the patient, exhale before whispering, then whisper a combination of three numbers and letters (such as S-4-G) into the unblocked ear. • Test the other ear in the same way, using a different combination. • If all three numbers and letters are repeated correctly, the patient passes. If the patient can’t repeat any numbers or letters correctly, perform the test again using a different combination. Correctly repeating at least half of the numbers and letters the second time is considered passing. • Inability to repeat any number and letter combinations may indicate hearing loss.

nually, according to a clinical practice guide- also may be sudden. Other symptoms may in- line from AAO-HNSF, but it’s an otologic clude tinnitus, unsteadiness, facial weakness, emergency that requires an urgent referral to headache, and visual disturbance. Large tu- an otolaryngologist. SSNHL etiology is un- mors may compress the brain stem, causing known, but viral, autoimmune, and vascular gait abnormalities. Childhood cancer treatment causes have been suggested. The condition radiation of the head is a risk factor. presents as acute, unilateral hearing loss with Refer patients with suspected acoustic neu- symptom onset in less than 72 hours with no roma to an otolaryngologist. Treatment options precipitating event. Patients frequently report include radiotherapy, surgery, and watchful ear fullness and tinnitus. Vertigo also may oc- waiting. The best treatment depends on multi- cur, leading to misdiagnosis of Ménière’s dis- ple factors, such as tumor size, symptoms, pa- ease. In addition, aural fullness may be erro- tient age, and underlying health conditions. neously attributed to fluid in the middle ear. To conserve hearing, specialist treatment Nursing implications should be initiated urgently and may include Encourage patients to use appropriate hearing oral or intratympanic steroids and hyperbaric protection to minimize the risk of SNHL. As- oxygen therapy. Time from symptom onset to sess patients for potentially hazardous noise initial treatment should be no more than 2 exposure with the “shout test,” where a pa- weeks, although the exact time frame is de- tient states they must shout to a person who batable. Spontaneous recovery can occur; is only an arm’s length away to be heard over however, even with treatment, hearing loss background noise. The most common types and tinnitus may be permanent. of SNHL are gradual, bilateral, progressive, and high frequency, which means that symp- Acoustic neuroma toms initially may go unnoticed by the patient. An acoustic neuroma (vestibular schwannoma) Although presbycusis and noise-induced hear- is a slow-growing benign tumor of the myelin- ing loss are the most common types of SNHL, producing Schwann cells of the eighth cranial be aware of more serious causes and their as- nerve. According to Goshtasbi and colleagues, sociated symptoms. this rare but serious tumor affects 1.1 to 1.7 per To help distinguish SNHL from more in- 100,000 people, mostly adults between 40 and nocuous conductive causes (such as fluid or 63 years. Patients typically present with a pro- wax), perform a quick screening with the gressive, unilateral SNHL, but the hearing loss “hum test.” Instruct the patient to hum and ask

32 American Nurse Journal Volume 16, Number 8 MyAmericanNurse.com if they hear the hum louder in the affected ear Goshtasbi K, Abouzari M, Moshtaghi O, et al. The (such as you would if you plugged your ear). changing landscape of vestibular schwannoma diagnosis If so, the hearing loss is most likely conductive and management: A cross-sectional study. Laryngo- scope. 2020;130(2):482-6. doi:10.1002/lary.27950 rather than sensorineural. All unilateral hearing loss thought to be sensorineural requires audi- Jackson R, Addison AB, Prinsley PR. Cholesteatoma in children and adults: Are there really any differences? J ology and specialty referral to rule out serious Laryngol Otol. 2018;132(7):575-8. doi:10.1017/S002221 causes. Sudden SNHL is an otologic emer- 5118000890 gency. (See Screening for hearing loss.) Kühn AL, Chang Y-M. Traumatic incudomalleolar disar- ticulation. J Clin Neurosci. 2019;62:242-3. doi:10.1016/ Take the opportunity j.jocn.2018.12.017 Hearing loss, whether it’s conductive or sen- Michaudet C, Malaty J. Cerumen impaction: Diagnosis sorineural, can affect a patient’s quality of life. and management. Am Fam Physician. 2018;98(8):525-9. Nurses have an opportunity to identify and Michels TC, Duffy MT, Rogers DJ. Hearing loss in adults: screen patients, educate them about hearing Differential diagnosis and treatment. Am Fam Physician. conservation, offer treatment as ordered by a 2019;100(2):98-108. provider, coordinate referrals, and support Mills R, Hathorn I. Aetiology and pathology of otitis me- long-term management, including hearing aid dia with effusion in adult life. J Laryngol Otol. 2016; 130(5):418-24. doi:10.1017/S0022215116000943 use when appropriate. AN National Institute on Deafness and Other Communica- Tamara Link is board-certified family nurse practitioner and assis- tion Disorders. Age-related hearing loss. July 17, 2018. tant professor at the University of North Carolina Wilmington. www.nidcd.nih.gov/health/age-related-hearing-loss National Institute on Deafness and Other Communica- References tion Disorders. NIDCD working group on accessible and Alzhrani F, Mokhatrish MM, Al-Momani MO, Alshehri H, affordable hearing health care for adults with mild to Hagr A, Garadat SN. Effectiveness of stapedotomy in im- moderate hearing loss. June 23, 2016. www.nidcd.nih.gov/ proving hearing sensitivity for 53 otosclerotic patients: research/workshops/accessible-and-affordable-hearing- Retrospective review. Ann Saudi Med. 2017;37(1):49-55. health-care/2009 doi:10.5144/0256-4947.2017.49 Nguyen T, Pulickal G, Singh A, Lingam R. Conductive American Hearing Research Foundation. Otosclerosis. hearing loss with a “dry middle ear cleft”—A compre- american-hearing.org/disease/otosclerosis/ hensive pictorial review with CT. Eur J Radiol. 2019; 110:74-80. doi:10.1016/j.ejrad.2018.11.024 Basura GJ, Adams ME, Monfared A, et al. Clinical prac- tice guideline: Ménière’s disease executive summary. Nooni K, Sreekanth G. Otitis media with effusion: Com- Otolaryngol Neck Surg. 2020;162(4):415-34. doi:10.1177/ parative effectiveness of treatments. IOSR J Dent Med Sci. 0194599820909439 2016;15(7):29-34. doi:10.9790/0853-150722934 Bennett RJ, Fletcher S, Conway N, Barr C. The role of Pagrani M, Srivastava A, Mohan C. Adult onset acute oti- the general practitioner in managing age-related hearing tis media—A preliminary report. J Evol Med Dent Sci. loss: Perspectives of general practitioners, patients and 2014;3(19):5094-9. doi:10.14260/jemds/2014/2559 practice staff. BMC Fam Pract. 2020;21(1):87. doi:10.1186/ Rijk MH, Hullegie S, Schilder AGM, et al. Incidence and s12875-020-01157-2 management of acute otitis media in adults: A primary Centers for Disease Control and Prevention. QuickStats: care-based cohort study. Fam Pract. Published online Percentage of adults Aged ≥18 years with any hearing January 28, 2021:cmaa150. doi:10.1093/fampra/cmaa150 loss, by state — National Health Interview Survey, 2014– Rosenfeld RM, Schwartz SR, Cannon CR, et al. Clinical 2016. MMWR Morb Mortal Wkly Rep. 2017;66(50):1389. practice guideline: Acute otitis externa. Otolaryngol doi:10.15585/mmwr.mm6650a7 Head Neck Surg. 2014;150(suppl 1):S1-24. doi:10.1177/ Chandrasekhar SS, Tsai Do BS, Schwartz SR, et al. Clini- 0194599813517083 cal practice guideline: Sudden hearing loss (update). Schwartz SR, Magit AE, Rosenfeld RM, et al. Clinical Otolaryngol Head Neck Surg. 2019;161(suppl 1):S1-45. practice guideline (update): Earwax (cerumen im- doi:10.1177/0194599819859885 paction). Otolaryngol Head Neck Surg. 2017;156(suppl Cunningham LL, Tucci DL. Hearing loss in adults. N Engl 1):S1-29. doi:10.1177/0194599816671491 J Med. 2017;377(25):2465-73. doi:10.1056/NEJMra1616601 Wu H, Zhang L, Han D, et al. Summary and consensus Foley RW, Shirazi S, Maweni RM, et al. Signs and symp- in 7th International Conference on Acoustic Neuroma: toms of acoustic neuroma at initial presentation: An ex- An update for the management of sporadic acoustic ploratory analysis. Cureus. 2017;9(11):e1846. doi:10.7759/ neuromas. World J Otorhinolaryngol Head Neck Surg. cureus.1846 2016;2(4):234-9. doi:10.1016/j.wjorl.2016.10.002 Fortunato S, Forli F, Guglielmi V, et al. A review of new Yang EL, Macy TM, Wang KH, Durr ML. Economic and insights on the association between hearing loss and demographic characteristics of cerumen extraction cognitive decline in ageing. Acta Otorhinolaryngol Ital. claims to Medicare. JAMA Otolaryngol Head Neck Surg. 2016;36(3):155-66. doi:10.14639/0392-100X-993 2016;142(2):157-61. doi:10.1001/jamaoto.2015.3129

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