DEVELOPMENT AND STANDARDIZATION OF TINNITUS HANDICAP INVENTORY IN BANGLA

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1 DEVELOPMENT AND STANDARDIZATION OF TINNITUS HANDICAP INVENTORY IN BANGLA Pinaki Dutta 1, Indranil Chatterjee 1, Sujoy Kumar Makar 1, Craig W. Newman 2, Arpita Chatterjee 1 1 Department of Audiology Ali Yavar Jung National Institute of Speech and Hearing Disabilities, Eastern Regional Centre, Kolkata-90 2 Cleveland Clinic, USA ABSTRACT The aim of the study was to develop and standardize a Bangla version of the Tinnitus Handicap Inventory (THI) and to determine the validity, internal consistency reliability and test-retest reliability of the Bangla version of the Tinnitus Handicap Inventory (THI-Bangla) for clinical and research purposes in Bengali population. The THI-Bangla was administered to thirty patients suffering from tinnitus, aged between 30 to 45 years. The clients were selected from the audiological department of AYJNISHD, ERC Kolkata. The client having tinnitus without any medical problem was included in the group. The correlation between THI- Bangla scores and matched loudness of tinnitus showed acceptable correlation (r=0.614). In case of correlation of THI- Bangla and matched pitch of the participants the result showed r=0.621 which indicates an acceptable correlation. Inter item correlation was calculated using the Cronbach s alpha test indicated the inter item correlation of total THI was the inter-item correlation of functional, emotional and catastrophic sub scale were, 0.850, and 0.637, respectively. The Pearson productmoment correlation was done among the sub scales. The association between functional and emotional sub-scale was high (r=0.951). The association between the emotional and catastrophic sub-scale were good (r= 0.889). Internal association was observed between functional and catastrophic sub-scale were also high (r= 0.987) Kendall s tau_b test was administered to identify the test-retest reliability. The correlation coefficient was 1.000, which indicates, correlation is significant at 0.01 levels. This study demonstrated that the Bangla version of THI (THI- Bangla) is a valid and reproducible tool to assess the psychosocial complaints of tinnitus sufferers. Key Words : Tinnitus, Handicap, INTRODUCTION Tinnitus is a subjective symptom making its assessment a challenging task for the audiologists. A number of measures have been developed to assess tinnitus-related distress, coping strategies, and cognitive reactions to tinnitus (Hallam, Jakes & Hinchcliffe, 1988; Wilson & Henry, 1998). In this connection self-reporting tinnitus questionnaires are one of the most commonly used tools for assessing the way patients experience tinnitus (Wilson & Henry, 2000). Currently, there exist numerous questionnaires that are available to assess the quality of life of tinnitus in such manner. One of the most widely used questionnaires is Tinnitus Handicap Inventory (THI) (Newman, Jacobson & Spitzer, 1996). The degree of distress, annoyance, emotional discomfort, sleep problems and interference with day-to-day activities are factors that differentiate people who simply experience tinnitus from those who need help and clinical attention (i.e., have clinically significant tinnitus) (Jastreboff & Hazell, 2004). Most of the instruments that evaluate the Quality of Life were developed in English and were intended to be used in English speaking countries. There is a need to develop instruments to be used in countries where English is not spoken because; such questionnaires when used with the native speakers of Bangla will not yield exact results if the psychometric adequacy of the tool is not investigated. In other words when such questionnaires are used with the native speakers of Bangla, they may not provide reliable and valid estimation of the psychosocial consequences of tinnitus. Therefore, a new instrument may be developed or an 10

2 existing one may be translated into another language (Guillemin, Bombardier & Beaton, 1993), by which, tinnitus related activity limitation and participate restriction of an individual speaking Bangla could be measured appropriately. In this study the major challenge was to assess the handicap impact of the Bangla speaking person having tinnitus through a quality of life questionnaire. The THI was selected for adaptation because it is a brief and easy-to-administer questionnaire that is suitable for use in busy clinical settings (Newman, Jacobson & Spitzer, 1996). Harris and Mc Ghee-Nelson, 1992 had stated that, bilingualism and multilingualism are the norm rather than the exception in today s world. India, not being an exception is also a multilingual and multicultural country, where only 5-10% of population can understand English (Bharati & Kulkarni, 2005). However there is no known self-rating questionnaire in Bangla language available to assess the handicapping impact due to tinnitus. Accordingly, there a need to develop and standardize such a well-designed questionnaire translated into an Indian language (Bangla), which can assess quickly and accurately the trouble of the person experiencing tinnitus. The overall aim of the study was to develop the Bangla Tinnitus Handicap Inventory (THI-Bangla). More specifically, the study was undertaken to standardize the THI- Bangla by determining its validity, internal consistency reliability and test-retest reliability. METHOD Participant Selection: Thirty native Bangla speaking individuals having tinnitus was taken for the study. The individuals had a history of permanent and spontaneous, unilateral or bilateral subjective tinnitus experiencing from at least last six months. These subjects also had mild to moderately severe sensorineural hearing loss. The age range was from 30 to 45 years (mean age: 40.43years, standard deviation of age: 13.77). This study group included participants who were able to speak and read both Bangla and English adequately and the minimum educational qualification was matriculation. All the participants hailed from similar socio-economic background. Inclusion criteria: This was determined through case history and audiological evaluation. Information was obtained on- whether the clients had history of diabetes, presence of any type of noise exposure/ acoustic trauma or use of ototoxic drugs. The presence of hearing loss and the type of hearing loss was assessed by pure tone audiometry. To rule out the middle ear pathology of the client having tinnitus, tympanometry was done. Otoacoustic emission (OAE) and auditory brainstem response (ABR) were used to rule out the auditory neuropathy. Loudness discomfort level (LDL) testing was also done to identify the discomfort level of the client. The client having tinnitus without middle ear pathology, cardiovascular diseases, neurologic diseases, diabetes, Menniere s disease, noise exposure or acoustic trauma, hyperacusis was included in the group. To ascertain whether the client really had tinnitus, Tinnitus characteristics were recorded using Tinnitus Psychoacoustic Assessment (Vernon & Meikle, 1981) using following steps: identification of the tinnitus ear, understanding of the terms loudness and pitch, pitch matching, loudness matching. Instrumentation: The clinical evaluation was conducted using a diagnostic audiometer (MAICO MA53) with TDH 39 earphones, and calibrated (according to manufacturer s standards), immittance audiometer (GSI-39 AUTO TYMP), otoacoustic emission system (MAICO ERO SCAN), and auditory brainstem response instrumentation (RMS Medulla AD). Procedure to Develop Bangla Tinnitus Handicap Inventory Material: Phase 1: Development of test material by linguistic validation The linguistic validation (Guillemin, Bombardier & Beaton, 1993) of the original version of the Tinnitus Handicap Inventory (THI-US) (Newman, Jacobson & Spitzer, 1996) into the Bangla version of Tinnitus Handicap Inventory (THI-Bangla) and its psychometric specification was completed using the following steps: (a) Translation: In the first step THI questionnaire (appendix 1) was translated by ten native speakers of Bangla, with high level of proficiency in English and Bangla. These ten native speakers translated the original instrument into Bangla language individually. (b) Back Translation: As the second step of linguistic validation, the services of another set of ten translators with high level of proficiency in Bangla and English languages were utilized. Back translation of the pooled Bangla version to English was done to measure the homogeneity of the original version of THI. Phase 2: Pilot testing The pooled back translation was compared with the original version of THI by three linguists and three audiologists. Finally, the initial Bangla version of the THI instrument (appendix 2) was formulated with proper and satisfactory translation and after item analysis. To establish construct validity, the total score and each subscale score (i.e. Functional, Emotional and catastrophic) was correlated with matched mean pitch and mean loudness of the subjects. This questionnaire was used as an initial instrument for gathering data from tinnitus subjects. Phase 3: Participant selection The participants were selected from the audiological department of AYJNIHH, ERC and different hearing clinics of Kolkata, India. Participants fulfilling the inclusion criteria for the study were selected randomly. Phase 4: Administering the developed test on participants with tinnitus and obtaining the test score 11

3 The validated THI- Bangla material was given to each participant who was ask to respond to each item on the questionnaire by indicating a choice of "Yes", "No" and "Sometimes". The score of "Yes" is 4, "No" is 0 and "Sometimes" is 2. Finally, the total THI score was measure by (number of Yes responses x 4) + (number of Sometimes responses x 2). Phase 5: Evaluating the reliability of the test (a) Internal consistency: To measure the homogeneity of three sub scale items, in terms of within subscales correlations. (b) Test-retest reliability: To evaluate its test-retest reliability, after one week from completing the first THI-Bangla, the questionnaire was re-administered to the same patients. The retest was done without informing the patients of the score of the previous test. There were no intervening treatment between test and retest conditions, e.g., fitting of hearing aid or noise generator devices, drug trials or any psychological management. The data obtained from the participants entered into a Microsoft office excel 2007 database, and was subsequently subjected to statistical analysis conducted using Statistical Package for Social Sciences (SPSS), version 16.0 include:- Cronbach s alpha, b)pearson s product moment correlation, c) Kendall s tau b correlation RESULTS Validity: The six judges consisted of three linguists and three audiologists. A three point rating scale (1= Not valid, 2= Valid, 3= Most valid) was used for validating the THI- Bangla. The pictorial representation of the judges response for 25 items of Tinnitus Handicap Inventory to validate the assessment tool is given in appendix 3. After validation of the twenty five items of THI- Bangla questionnaire (appendix 2), internal consistency and reliability of this questionnaire were examined. For standardizing THI- Bangla detailed results of construct validity, internal consistency and reliability measures are documented below. Construct validity: as shown in Table 1, the result of Pearson s product moment correlation among the THI- Bangla, matched loudness and pitch of tinnitus subject were high. Table 1: Correlation of Tinnitus Handicap Inventory Bangla with matched pitch and loudness of tinnitus sufferers THI- Bangla score Loudness matching Pitch matching THI- Bangla score r: Loudness matching r: r: 1 - Pitch matching r: r: r: 1 The correlation between THI- Bangla scores and matched loudness of tinnitus shows acceptable correlation (r: 0.614). In case of correlation of THI- Bangla and matched pitch of the participants the value obtained was r: which again indicates an acceptable correlation. Reliability: To evaluate the inter-item correlation of the full THI - Bangla, inter item correlation was done among the twenty-five questionnaire of THI- Bangla using Cronbach's Alpha test (Table 2). The result of the Cronbach's Alpha is 0.845, which indicates the questionnaires have good inter-item correlation as may be seen in table 2. Table 2: Inter-item correlation of Tinnitus Handicap Inventory Bangla (THI - Bangla) Cronbach's Cronbach's Alpha Based on Mean Variance Std. No. of Items Alpha Standardized Items Deviation Inter-item correlations of three sub-scales of Tinnitus Handicap Inventory were done using Cronbach's alpha. The results of interitem correlation of each sub-scale are displayed in table 3, 4 and 5. Table 3: Inter-item correlation of functional sub-scale of Tinnitus Handicap Inventory Bangla (THI - Bangla) Cronbach's Cronbach's Alpha Based on Mean Variance Std. No. of Items Alpha Standardized Items Deviation The functional scale of THI Bangla, includes twelve questionnaires. Inter-item correlation among the twelve questionnaires was calculated using Cronbach s alpha to identify the internal consistency of functional sub-scale. Cronbach s alpha value of was obtained which indicates good inter-item correlation among the twelve questionnaires of the functional sub-scale. 12

4 Table 4: Inter-item correlation of emotional sub-scale of Tinnitus Handicap Inventory Bangla (THI - Bangla) Cronbach's Cronbach's Alpha Based on Mean Variance Std. No. of Items Alpha Standardized Items Deviation The emotional sub-scale consists of eight questionnaires. To identify the inter-item correlation of emotional sub-scale, Cronbach s alpha was done. The result of internal consistency of eight questionnaire shows Cronbach s alpha value is indicating good internal consistency of emotional sub-scale. Table 5: Inter-item correlation of catastrophic sub-scale of Tinnitus Handicap Inventory Bangla (THI - Bangla) Cronbach's Cronbach's Alpha Based on Mean Variance Std. No. of Items Alpha Standardized Items Deviation Five questionnaires are included in catastrophic sub scale. The internal consistency was checked among the questionnaire of catastrophic sub-scale using Cronbach s alpha. The Cronbach s alpha value computed was which indicates acceptable interitem correlation of catastrophic sub-scale. In this study the Cronbach s alpha score for the catastrophic sub-scale is less. It can be happened due to less item (Questionnaire) is included in the catastrophic sub-scale. The Pearson product-moment correlation between sub-scales of Tinnitus Handicap Inventory Bangla (THI- Bangla) indicates excellent internal consistency reliability between the sub-scales. The internal consistency between functional and emotional subscale shows excellent correlation (r= 0.951). The p value was 0.201, which also supports that there is a correlation between the functional and the emotional sub-scale. The internal consistency reliability of emotional and catastrophic sub-scale shows good correlation (r= 0.889). The p value was an indication of more or less good correlation. Internal consistency reliability between functional and catastrophic sub-scale shows an excellent correlation (r= 0.987) between the two sub-scales. The p value also supports the excellent correlation between this two sub-scale (p= 0.102). Table 6: Inter-subscale correlation of Tinnitus Handicap Inventory Bangla (THI - Bangla) Functional Emotional Catastrophic Functional r : 1 Emotional r : r : 1 _ Catastrophic r : r : r : 1 For better precision in terms of reliable estimate test retest reliability was further done to re-confirm internal consistency measures which have been already mentioned. The result of the test-retest reliability is given below. Table 7: Test retest responses for the sub-scales of Tinnitus Handicap Inventory- Bangla (THI- Bangla) Responses on initial test Responses on retest after 7 days Yes Occasionally No Yes Occasionally No Functional Emotional Catastrophic To check the test retest reliability, Kendall's tau_b test was administered. The result shows the correlation coefficient is 1.000, which indicates, correlation is significant at 0.01 levels. That indicates there is a high correlation between the responses of clients having tinnitus on the initial and the subsequent administration of the test. DISCUSSION The phenomenon of tinnitus extends across several psychosocial domains that affect the everyday function of patients with tinnitus. The THI focuses on three domains of the clients having tinnitus, namely functional, emotional and catastrophic domain. The THI is used worldwide and has been adapted and developed in various languages. The internal consistency of the total scores as well as scores of functional sub-scale, scores of emotional sub-scale and the scores of the catastrophic sub-scale are represented in Table 8. From the table the difference between the inter-item correlations of various languages may be appreciated as reported in various studies. 13

5 Table 8: Cronbach s alpha scores of Tinnitus Handicap Inventory for various languages Total Functional Emotional Catastrophic THI- US α= α= α= α=0.680 THI- Danish α= α= α= α= THI- Brazilian α= THI- Turkish α= α= α= α= THI- Italian α= α= α= α= THI- Chinese (Cantonese) α= α= α= α= THI- Persian α= THI- Chinese (Mandarin) α= α= α= α= THI- Filipino α= α= α= α= THI- Thai α= α= α= α= THI- Tamil α=0.960 α= α= α= THI- Bangla α= α= α= α= From table 8, the difference between Cronbach s alpha scores of Tinnitus Handicap Inventory Bangla to main version of Tinnitus Handicap Inventory (US) and Tinnitus Handicap Inventory developed in other languages is apparent. This supports the notion that, the inter item correlation between the questionnaire are quite good in Tinnitus Handicap Inventory Bangla. The table indicates that, there are very less difference between the internal consistency for Tinnitus Handicap Inventory Bangla and the Tinnitus Handicap Inventory developed in other languages. Table 9: The inter sub-scale correlation of Tinnitus Handicap Inventory in different languages Functional-Emotional Emotional-Catastrophic Functional- Catastrophic THI- US r= r= r= THI- Danish r= r= r= THI- Turkish r= r= r= THI- Italian r= r= r= THI-Chinese (Cantonese) r= r= r= THI- Tamil r= r= r= THI- Bangla r= r= r= Pearson correlation was done to identify the correlation between the sub-scales. From table 9, it is clear that the correlation between functional and emotional sub-scale is 0.951, which indicates an excellent correlation between functional and emotional sub scale. Emotional and catastrophic sub-scale showed good correlation (r= 0.889). The internal consistency of functional and catastrophic sub scale indicates an excellent correlation (r= 0.987). This type of good correlation indicated the correlation among three sub-scales of Tinnitus Handicap Inventory Bangla is much more reliable than the Tinnitus Handicap Inventory developed in other languages. Kendall's tau_b test was administered to determine the test retest reliability. Correlation coefficient obtained was 1.000, which was significant at 0.01 levels. There was thus high correlation between the responses of clients on the test administered on two occasions separated by a week. Kam et al. (2009) identified the test retest reliability of the Chinese (Cantonese) version of Tinnitus Handicap Inventory which indicated a good correlation (r= 0.88) between test and retest score. The test-retest score of Chinese (Mandarin) version of Tinnitus Handicap Inventory (Meng et al., 2012) indicated an excellent correlation (r= 0.98) between test and retest score. Mahmoudian et al. (2011) found an excellent test-retest reliability (r= 0.96) between test and retest score of Persian version of Tinnitus Handicap Inventory (Mahmoudian et al., 2011). CONCLUSION This study demonstrated that the Bangla version of THI (THI- Bangla) is a valid and reproducible tool to assess the psychological complaints of tinnitus sufferers. Also, THI- Bangla could be administered as a standard measuring instrument for patients who are native speakers of Bangla. 14

6 REFERENCE 1. Bharati, L., & Kulkarni, A. (2005). English from hindi viewpoint: A paaninian perspective. Paper presented at platinum jubilee conference of linguistic society of India, University of Hyderabad: India. 2. Guillemin, F., Bombardier, C., & Beaton, D. (1993). Cross-cultural adaptation of health-related quality of life measures: literature review and proposed guidelines. Journal of Clinical Epidemiology, 46(12), Hallam, R. S., Jakes, S. C., & Hinchcliffe R. (1988). Cognitive variables in tinnitus annoyance. British Journal of Clinical Psychology, 27(3), Harris, R. J., & McGhee Nelson, E. M. (1992). Bilingualism: Not the exception any more. In R. J. Harris & E. M. McGhee Nelson (Eds.), Cognitive processing in bilinguals, (pp. 3-14). North Holland: Elsevier. 5. Jastreboff, P. J., & Hazell, J. W. P. (2004). Tinnitus Retraining Therapy: Implementing the Neurophysioloigical Model (1st ed.). New York: Cambridge University Press. 6. Kam, A. C. S., Cheung, A. P. P., Chan, P. Y. B., Leung, E. K. S., Wong, T. K. C., Hasselt C.A., & Tong, M. C. F. (2009). Psychometric properties of the Chinese (Cantonese) Tinnitus Handicap Inventory. Clinical Otolaryngology, 34(4), Mahmoudian, S., Shahmiri, E., Rouzbahani, M., Jafari. Z., Keyhani, M., Rahimi, F., Mahmoudian, G., Akbarvand, L., Barzegar, G., & Farhadi, M., (2011). Persian language version of the "Tinnitus Handicap Inventory": translation, standardization, validity and reliability. International Tinnitus Journal, 16(2), Meng, Z., Zheng, Y., Liu, S., Wang, K., Kong, X., Tao, Y., Xu, K., & Liu, G., (2012). Reliability and Validity of the Chinese (Mandarin) Tinnitus Handicap Inventory. Clinical Exp Otorhinolaryngology, 5(1), Newman, C. W., Jacobson, G. P., & Spitzer, J. B. (1996). Development of the tinnitus handicap inventory. Arch Otolaryngology Head Neck Surgery, 122 (2), Tobias, C. A., Llanes, E., Gonzalo, D. V., & Chiong, C. (2012). Validity of a Filipino translation of the Tinnitus Handicap Inventory. International Tinnitus Journal, Vol. 17(1),

7 APPENDIX- I TINNITUS HANDICAP INVENTORY US Name: Case no: Age: Sex: INSTRUCTIONS: The purpose of this questionnaire is to identify difficulties that you may be experiencing because of your tinnitus. Please answer every question. Please do not skip any questions. No. Questions Yes Sometimes No 1. Because of your tinnitus, is it difficult for you to concentrate? 2. Does the loudness of your tinnitus make it difficult for you to hear people? 3. Does your tinnitus make you angry? 4. Does your tinnitus make you feel confused? 5. Because of your tinnitus, do you feel desperate? 6. Do you complain a great deal about your tinnitus? 7. Because of your tinnitus, do you have trouble falling to sleep at night? 8. Do you feel as though you cannot escape your tinnitus? 9. Does your tinnitus interfere with your ability to enjoy your social activities (such as going out to dinner, to the movies)? 10. Because of your tinnitus, do you feel frustrated? 11. Because of your tinnitus, do you feel that you have a terrible disease? 12. Does your tinnitus make it difficult for you to enjoy life? 13. Does your tinnitus interfere with your job or household responsibilities? 14. Because of your tinnitus do you find that you are often irritable? 15. Because of your tinnitus, is it difficult for you to read? 16. Does your tinnitus make you upset? 17. Do you feel that your tinnitus problem has placed stress on your relationships with members of your family and friends? 18. Do you find it difficult to focus your attention away from your tinnitus and on other things? 19. Do you feel that you have no control over your tinnitus? 20. Because of your tinnitus, do you often feel tired? 21. Because of your tinnitus, do you feel depressed? 22. Does your tinnitus make you feel anxious? 23. Do you feel that you can no longer cope with your tinnitus? 24. Does your tinnitus get worse when you are under stress? 25. Does your tinnitus make you feel insecure? 16

8 ন ম নম বর APPENDIX- II TINNITUS HANDICAP INVENTORY BANGLA ক ননর শব দ ব কল ঙ গত প রশ নম ল য়স বলঙ গ বননদ শ অন র ক ননর শনব দর জনয অন র য স ব ধ গ নল হন, যসগ নল ব ব ত কর আ হল এআ প রশ ন ল র উন শয, দয় কনর প রবতট প রনশ নর উত তর যদন ন, দয় কনর যক ন প রশ ন দ যদন ন ন ন প রশ ন হয ন কখনন ১ অন র ক ননর শনব দর জনয বক অন র মনন ন গ বদনত অস ব ধ হয়? হয ন কখনন ২ অন র ক ননর শনব দর প র নলযর জনয বক অন র যল কজননর কথ শ ননত স ব ধ হয়? হয ন কখনন ৩ অন র ক ননর শনব দর জনয বক অন র র গ হয়? হয ন কখনন ৪ অন র ক ননর শব দ বক অন নক উদ ভ র ন ত কনর? হয ন কখনন ৫ অন র ক ননর শনব দর জনয বক অবন মবরয় উনত তবজত হন? হয ন কখনন ৬ অন র ক ননর শনব দর ক রনন অবন বক ননক ব ন গ কনরন? হয ন কখনন ৭ অন র ক ননর শনব দর জনয অন র বক র নত ঘ ম নত স ব ধ হয়? হয ন কখনন ৮ অন র বক মনন হয়, অবন অন র ক ননর শনব দর যথনক ম ব ন ন ন? হয ন কখনন ৯ অন র ক ননর শনব দর জনয বক স ম বজক ন ষ ঠ ন উন গ করনত স ব ধ হয়? (য মন, বসননম যদখনত) হয ন কখনন ১০ অবন বক ক ননর শনব দর জনয হত শ ন কনরন? হয ন কখনন ১১ অন র ক ননর শনব দর জনয অন র বক মনন হয় য, খ ড় অস নখ নড়ন ন? হয ন কখনন ১২ অন র ক ননর শব দ বক অন র জ ননর অনন দ উন গ কর নক কঠ ন কনর যদয়? হয ন কখনন ১৩ অন র ক ননর শব দ বক অন র কম ন ন ড় র দ বয়ত ব লনন হস তন কনর? হয ন কখনন ১৪ অন র ক ননর শনব দর জনয অবন বক প র য়আ ব র য ধ কনরন? হয ন কখনন ১৫ অন র ক ননর শনব দর জনয বক ড়নত স ব ধ হয়? হয ন কখনন ১৬ অন র ক ননর শনব দর জনয বক অবন বনর শ হনয় নড়ন? হয ন কখনন ১৭ অন র ক ননর শনব দর জনয বক অন র বর নরর নয নয সদসয ন ধ নদর সনঙ গ অন র সম পনক যক ন স ব হয়? ১৮ অন র বক মনন হয় য অন র ক ননর শনব দর যথনক মনন ন গ সবরনয় বননয় নয বদনক মনন ন গ বদনত স ব ধ হয়? হয ন কখনন হয ন কখনন ১৯ অবন বক মনন কনরন য অন র ক ননর শনব দর ওর অন র যক ন বনয়ন ত রন যনআ? হয ন কখনন ২০ অন র ক ননর শনব দর ক রনন অবন বক ক ল বন ত য ধ কনরন? হয ন কখনন 17

9 ২১ অন র ক ননর শনব দর জনয অবন বক স দ ন কনরন? হয ন কখনন ২২ অন র ক ননর শব দ বক অন নক উব গ ন কনর যত নল? হয ন কখনন ২৩ অবন বক মনন কনরন য অন র ক ননর অওয় জ অবন অর সহয করনত রন ন ন? হয ন কখনন ২৪ অবন খন নর মনধয থ নকন তখন বক ক ননর শব দ অনর য নড় য়? হয ন কখনন ২৫ অন র ক ননর শব দ বক অন নক স রব ত ন কর য়? হয ন কখনন 18

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