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ChildhoodHearingScreeningGuidelines
September2011
ThechargeoftheSubcommitteeonChildhoodHearingScreeningwastodevelopevidencebased
recommendationsforscreeninghearingofchildrenage6monthsthroughhighschool.
Committeemembersandcontributors
Chair:KarenL.Anderson,PhD,KarenL.AndersonAudiologyConsulting,Minneapolis,MN
Members:CandiBown;NeboSchoolDistrict,SpringvilleUT;MelissaR.Cohen,AuD.,CobbCounty
PublicSchools,AtlantaGA;SusanDilmuthMiller,AuD.,EastStroudsburgUniversity,EastStroudsburg,
PA;DonnaFisherSmiley,PhD,ArkansasChildrensHospital,LittleRock,AR;DebraGwinner,AuD.Cherry
CreekSchools,GreenwoodVillage,CO;BarbaraLambright,AuD,CherryCreekSchools,Greenwood
Village,CO;BarbNorris,Ed.D,Consultant;ErinPlyler,AuD.,UniversityofTennesseeHealthScience
Center,Knoxville,TN;AparnaRao,PhD,UniversityofMinnesota,Minneapolis,MN;JaneSeaton,MS.,
SeatonConsultants,Athens,GA;VictoriaWalkupPierce,AuD,OrangeCountyPublicSchools,Orlando,
FL;
Contributors:KathrynBright,PhD.,UniversityofNorthernColorado,Greeley,CO;JohnEichwald,MS;
CDC/EHDI,Atlanta,GA;JayHallIII,PhD,UniversityofFlorida,GainesvilleFL;WendyD.Hanks,Ph.D.,
GallaudetUniversity,WashingtonDC;BradIngrao,AuD.,SoundAdviceHearingSolutions;PatMauceri,
AuD.,NortheasternUniversityinBoston,MAKimberlyMiller,AuD.,ThompsonR2JSchoolDistrict,
Loveland,CO;GailTanner,Au.D.,IllinoisDepartmentofPublicHealth;
EXECUTIVESUMMARY
TheAmericanAcademyofAudiologyendorsesdetectionofhearinglossinearlychildhoodand
schoolagedpopulationsusingevidencebasedhearingscreeningmethods.Hearinglossisthemost
commondevelopmentaldisorderidentifiableatbirthanditsprevalenceincreasesthroughoutschool
ageduetotheadditionsoflateonset,lateidentifiedandacquiredhearingloss.Underidentification
andlackofappropriatemanagementofhearinglossinchildrenhasbroadeconomiceffectsaswellasa
potentialimpactonindividualchildeducational,cognitiveandsocialdevelopment.Thegoalofearly
detectionofnewhearinglossistomaximizeperceptionofspeechandtheresultingattainmentof
linguisticbasedskills.Identificationofneworemerginghearinglossinoneorbothearsfollowedby
appropriatereferralfordiagnosisandtreatmentarefirststepstominimizingtheseeffects.Informing
educationalstaff,monitoringchronicorfluctuatinghearingloss,andprovidingeducationtowardthe
preventionofhearinglossareimportantstepsthatareneededtofollowmassscreeningiftheimpactof
hearinglossistobeminimized.
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SummaryofHearingScreeningRecommendations*
*RefertothefullGuidelinesdocumentformoredetailontheserecommendations.Notethat
thefollowingguidelinesareconsideredtobetheminimumstandardforeducationalsettings.
Programsareencouragedtofollowamoreintensiverescreeningandreferralprotocolwherestaffing
patternspermit.
Puretonescreening
1. Performbiologicalcheckonpuretonescreeningequipmentpriortodailyscreening.
2. Screenpopulationsage3(chronologicallyanddevelopmentally)andolderusingpuretone
screening.
3. Performapuretonesweepat1000,2000,and4000Hzat20dBHL.
4. Presentatonemorethanoncebutnomorethan4timesifachildfailstorespond.
5. Onlyscreeninanacousticallyappropriatescreeningenvironment.
6. Lackofresponseatanyfrequencyineitherearconstitutesafailure.
7. Rescreenimmediately.
8. Usetympanometryinconjunctionwithpuretonescreeninginyoungchildpopulations(i.e.,
preschool,kindergarten,grade1).
9. Screenforhighfrequencyhearinglosswhereeffortstoprovideeducationonhearingloss
preventionexist.
10. Minimumgradestobescreened:preschool,kindergarten,andgrades1,3,5andeither7or9.
Tympanometryscreening
1. Calibratetympanometryequipmentdaily.
2. Tympanometryshouldbeusedasasecondstagescreeningmethodfollowingfailureofpure
toneorotoacousticemissionsscreening.
3. Usedefinedtympanometryscreeningandreferralcriteria:a250daPatympanometricwidthis
therecommendedcriterion.Ifitisnotpossibletousetympanometricwidththen0.2mmhos
staticcompliancecanbeusedasthecriterion.Afinalchoiceforfailurecriterionisnegative
pressureof>200daPato400daPahoweveritisnotappropriateforthiscriteriontostand
alonetoelicitareferral.
4. Youngchildpopulationsshouldbetargetedfortympanometryscreening.
5. UseresultsofpuretoneorOAEandtympanometryrescreeningtoinformnextsteps.
Rescreening
1. Rescreenwithtympanometryafteradefinedperiod:afterfailingtheimmediatepuretone
rescreeningandin810weeksforchildrenfailingpuretoneorOAEscreeningand
tympanometry.
2. Donotwaittoperformasecondstagescreeningonchildrenwhofailpuretonescreeningonly.
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OAE
1. Useonlyforpreschoolandschoolagechildrenforwhompuretonescreeningisnot
developmentallyappropriate(abilitylevels<3years).
2. CalibrateOAEequipmentdaily.
3. MaintainprimaryDPOAElevelsat65/55dBSPL.
4. SelectDPOAEorTEOAEcutoffvaluescarefully.
5. Defaultsettingsmaynotbeappropriate.
6. ScreeningprogramsusingOAEtechnologymustinvolveanexperiencedaudiologist.
7. ChildrenfailingOAEshouldbescreenedwithtympanometry.
Acousticreflextesting,reflectometryandhearingscreeningusingspeechmaterialsarenot
recommended.
TABLEOFCONTENTS
I. INTRODUCTION
a. Backgroundandphilosophy
b. Prevalenceofchildhoodhearingloss
c. Economicimpactofhearingloss
d. Educationalimpactofhearingloss
i. Definitionofnormalhearing
ii. Minimalsensorineuralhearingloss
iii. Unilateralhearingloss
iv. Highfrequencyhearingloss
v. Hearinglossduetootitismediawitheffusion
e. Populationofchildrentobescreened
i. Earlychildhood
ii. Preschool
iii. Schoolaged
iv. Targetedgradelevels
II. METHODOLOGY
a. Evidencedbasedreview
b. SensitivityandSpecificity
c. BritishNationalInstituteforHealthResearchAssessment
d. TestProcedureandProtocolreview
i. Puretonescreening
1. Intensity
2. Frequency
3. Numberofpresentations
4. Screeningenvironment
ii. Immittance
1. Tympanometry
a. Middleearpressure
b. Tympanometricwidth
c. Staticadmittance(compliance)
2. Acousticreflexandreflectometry
iii. Screeningwithspeechstimulimaterials
iv. Otoacousticemissions
1. Measurementparameters
2. Screeningconsiderations:environmentandtime
3. TransientevokedOAEs
4. DistortionproductOAEs
5. Researchsummary
6. OAElimitations
7. OAEFutureneeds
v. Rescreening
III. DISCUSSION/RESULTS/RECOMMENDATIONS
a. Protocolrecommendations
i. Puretonescreening
ii. Immittance
1. Tympanometry
2. Acousticreflexandreflectometry
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iii. ScreeningwithSpeechStimuliMaterials
iv. OtoacousticEmissions
v. Rescreening
b. Referralandfollowup
c. Programmanagement
i. Personnelandstafftraining
ii. Scheduling
iii. Equipmentselection
1. Puretonescreeningequipment
2. Immittancescreeningequipment
3. Otoacousticemissionsscreeningequipment
iv. Equipmentmaintenance
v. Infectioncontrol
vi. Accountability
vii. Evaluation
IV. CONCLUSION/SUMMARY
V. REFERENCES
VI. APPENDICES
AmericanAcademyofAudiology
ChildhoodHearingScreeningGuidelines
INTRODUCTION
BackgroundandPhilosophy
Hearinglossisthemostprevalentdevelopmentalabnormalitypresentatbirth(White,1997).
Identificationofhearinglossby6monthsofageincombinationwithqualityearlyinterventionservices
isassociatedwithlanguagedevelopmentatornearthetypicalrateofdevelopment(YoshinagaItano,
1995;YoshinagaItano,1998;YoshinagaItano,etal.2000;YoshinagaItano,etal.2004).Age
appropriatelanguagedevelopmentandliteracyoutcomesrequireearlyandongoingattentiontoskill
development,andfortheeffectsofhearinglossonskilldevelopmentandsocializationtobeprevented,
itfirstisnecessaryforchildhoodhearinglosstobeidentified.Thisdocumentprovidesareviewofthe
currentstateoftheartinpediatrichearingscreeningandrecommendsevidencedbasedprotocolsfor
theidentificationofhearinglossinthepreschoolandschoolagedpopulation.
Needforhearingscreeningguidelines
Thepresumptionthathearinglosscanbereliablyidentifiedbasedonachildsbehaviorin
everydaysituationshasbeenshowntobefaultybyseveralstudiesdocumentingoutcomesfromtheuse
ofparentquestionnaires(Olusanya,2001;GomesandLichtig2005;Loetal.2006).TheJointCommittee
onInfantHearing(2007)identifiedtenriskfactorsfordelayedonsetorprogressivehearinglossin
children.Evidencesuggeststhatfor9yearoldswitheducationallysignificanthearingloss,upto50%
willhavepassednewbornhearingscreening(Fortnumetal.2001).Finally,itisestimatedthat910per
1000childrenwillhaveidentifiablepermanenthearinglossinoneorbothearsbyschoolage
(Sharagorodsky,Curhan,CurhanandEavey,2010;White,2010).
TheAmericanAcademyofPediatrics(AAP)endorseshearingscreeningthroughoutinfancy,early
childhood,middlechildhoodandadolescenceinitsRecommendationsforPreventivePediatricHealth
Care(AmericanAcademyofPediatrics2007).Allnewbornsaretobescreenedinaccordancewiththe
JointCommitteeonInfantHearing(JCIH)Year2007PositionStatementwithadditionalhearing
screeningtobeperformedduringroutinewellchildvisitsatages4,5,6,8,and10.Wellchildcareplays
animportantroleintheprovisionofqualityhealthcareforchildren;however,manychildrenhavefar
fewerwellchildvisitsthanarerecommendedbytheAAP(Selden2006).Evenwhenachildisseenfora
wellchildvisit, pediatricianstypicallyneitherrecheckhearingnorrefermorethanhalfoftheten
percentofchildrenwhofailtheirhearingscreening(Halloranetal.2006).
ItisthepositionoftheAmericanAcademyofAudiology(AAA)thatchildrenwithundetected
hearinglossand/orpersistentorrecurrentmiddleeardiseasebeidentifiedsothatappropriate
audiologicandmedicalmanagementcanbeprovided(AAA,1997).TheAmericanSpeechLanguage
HearingAssociation(ASHA)GuidelinesforAudiologicScreeningendorsestheidentificationofschool
childrenatriskforhearingimpairmentthatmayadverselyaffecteducation,health,developmentor
communicationasanexpectedoutcomeforhearingscreeningprograms(ASHA,1997).
Finally,thecriteriaforappraisingtheviability,necessity,effectivenessandappropriatenessof
screeningprogramsarebasedontenprinciplesfromtheWorldHealthOrganizationthatserveasthe
basisforrecommendingorplanningscreeningforearlydetectionofsignificanthealthconditions.
(Wilson&Jungner,1968)(SeeTable1).Hearinglossanditspotentialconsequencesunquestionably
meetthesecriteriatoqualifyasahealthconditionthatmeritsscreening.
Table1.Tenprinciplesforappraisingtheappropriatenessofscreeningprograms
1.
Theconditionsoughtshouldbeanimportanthealthproblem.
2.
Thereshouldbeanacceptedtreatmentforpatientswithrecognizeddisease.
3.
Facilitiesfordiagnosisandtreatmentshouldbeavailable.
4.
Thereshouldbearecognizablelatentorearlysymptomatic stage.
5.
Thereshouldbeasuitabletestorexamination.
6.
Thetestshouldbeacceptabletothepopulation.
7.
Thenaturalhistoryofthecondition,includingdevelopmentfromlatenttodeclared
disease,shouldbeadequatelyunderstood.
8.
Thereshouldbeanagreedpolicyonwhomtotreataspatients.
9.
Thecostofcasefinding(includingdiagnosisandtreatmentofpatientsdiagnosed)should
beeconomicallybalancedinrelationtopossibleexpenditureonmedicalcareasawhole.
10.
Casefindingsshouldbeacontinuingprocessandnotaonceandforallproject.
Table1:WorldHealthOrganizationScreeningPrinciples(developedbyWilson&Jungner,1968)
PrevalenceofHearingLossinChildren
Theprevalenceofcongenitalhearinglossinnewbornshaslongbeenthoughttorangefrom1to
over3infantsper1,000,orapproximately13,000babiesbornintheUnitedStateseachyearwithsome
degreeofpermanenthearingloss(Finitzoetal.1998;VanNaardenetal.1999).).Mostrecent
informationindicatesthatthecurrentprevalenceis1.4per1,000(USCentersforDiseaseControland
Prevention2009).EarlyHearingDetectionandIntervention(EHDI)programshavebecomethestandard
ofcareinthiscountry,andscreeningforhearinglossnowoccursformorethan95%ofinfantsbornin
theUnitedStates.Diagnosticfindingsfor43.3%ofinfantsidentifiedbyhearingscreeningwerereported
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asunknownduetolackofdocumentationatastatelevel,andmorethanonequarter(28.1%)ofinfants
whowereidentifiedashavingconfirmedhearinglosscouldnotbedocumentedasreceiving
interventionservices(USCentersforDiseaseControlandPrevention2008).Notallcasesofhearingloss
inearlychildhoodareidentifiedthroughEHDIprogramsduetothefollowingfactors:1)universal
newbornhearingscreening(UNHS)programsutilizescreeningdevicesprimarilydesignedtotarget
hearinglossaveraging30to40dBormore;2)allinfantsnotpassingtheirnewbornhearingscreeningdo
notreceiveneededdiagnosticservices;and3)UNHSdoesnotidentifylateonset,acquired,ormany
casesofprogressiveloss(JointCommitteeonInfantHearing,2007).
Grote(2000)reportedthatneonatalhearingscreeningprogramswouldnotdetectthe10to20
percentofcasesofpermanentchildhoodhearinglossthatstartlaterinlife.Prevalencecomparisons
suggestasignificantlyhigherprevalenceofhearinglossintheschoolagepopulationrelativetothe
prevalenceidentifiedinthenewbornperiod.PrevalencestudiesintheUnitedKingdomindicatedthat
forevery10childrenwithpermanentbilateralhearingimpairmentofgreaterthan40dBHLdetectedby
universalnewbornhearingscreening,another5to9childrenwouldmanifestsuchahearingimpairment
bytheageof9years(Fortnumetal.2001). Analysisofschoolhearingscreeningresultsfromalmost
100,000studentsrevealedthat2.9%requiredmanagementsuchasadvicetoparents,referralto
educationservices,watchfulwaiting,medicalandsurgicaltreatment,andamplification,andofthe
childrenscreened,2.2%werenewlyidentifiedashearingimpaired(Fonsecaetal.2005).
TheUnitedStatesCentersforDiseaseControlandPrevention(CDC)hashadthelegislative
authoritytoconducttheNationalHealthandNutritionExaminationSurveysince1970toprovide
currentstatisticaldataontheamount,distribution,andeffectsofillnessanddisabilityintheUnited
States(CDC2010).Threesurveyshavebeenconducted:NHANESIfrom19711975;NHANESIIfrom
19761980;andNHANESIIIfrom19941998.NHANESdatahavebeencollectedannuallysince1999.
Eachofthesesurveysreportedpuretoneaverageairconductionresultsfor(500,1000,2000,and4000
Hz)ofmorethan5000schoolagedchildren.NHANESIIIdatasuggest14.9%ofschoolagedchildrenin
theUnitedStates (morethan7millionchildreninthe6to19yearagerange) havesomedegreeof
hearingloss(Niskaretal.,1998).ItshouldbenotedthatNHANESfindingsdonotseparatetemporary
frompermanenthearingloss.ThesuccessofEHDIprogramsislikelytoreducethenumberofnewcases
ofpermanenthearinglossidentifiedinschoolbasedhearingscreeningprogramsHowever,the
importanceofidentifyinglateonset,acquired,andprogressivehearingloss,aswellascasesof
congenitallossesnotidentifiedthroughnewbornhearingscreening,underscorestheneedfor
identificationpracticesbeyondthenewbornperiodtoensuretheprovisionoftimelyintervention
servicesandreduceorminimizeeducationalandbehavioralsequelaeforallpreschoolandschoolaged
childrenandyouthwithhearingloss.
Insummary,ithasbeenestimatedthatthe3/1000prevalenceofpermanenthearinglossin
infantscanbeexpectedtoincreaseto910/1000childrenintheschoolagepopulation(White,2010)
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andpermanentand/ortransienthearinglossinoneorbothearsaffectsmorethan14% (oneinseven)
ofschoolagedchildren.Asaresult,severalstudentsineveryclassroompotentiallywillhavedifficulties
perceivingspeechclearlyintheeducationalenvironment.Hearinglosscancontributetodifficultieswith
attention,learning,andsocialfunction.Theprevalenceofhearinglossinchildrenisgreatenoughto
affectindividualandstandardizedschooltestscoresifthesestudentsarenotidentifiedandprovided
themedicaland/oreducationalassistanceneeded(Sarff,Ray,&Bagwell,1981;Ray,1992).
EconomicImpactofHearingLoss
Oneoftheacceptedprinciplesofscreeningisthatitshouldbeeconomicallybalancedinrelation
topossibleexpendituresofresources.Thecostsofrehabilitation,specialeducation,andunderandun
employmentduetodisordersofhearing,voice,speech,andlanguagehavebeenprojectedas$154186
billion,approximately3%ofthegrossnationalproductoftheUSAin1999(Ruben,2000).RTI
International(ResearchTrianglePark,NorthCarolina)andtheCDCanalyzeddatafrommultiplesurveys
andreportedestimatesforthedirectandindirecteconomiccostsassociatedwithhearingloss,aswell
asotherdevelopmentaldisabilitiesintheUnitedStates(CDC,200406.).Theirestimatedlifetimecosts
(in2003dollars)were$383,000foreachpersonwithhearingloss,totalingaprojected$1.9billionforall
personswithhearingloss.Totaldirectcosts(i.e.,directmedicalplusdirectnonmedical)amountedto
approximately$601million.Economiccostestimatesclearlydonotreflecttheimpactofhearinglosson
intangiblesthatcannotbedirectlymeasured(e.g.,qualityoflife).
Theretentionrate(repeatingagrade)amongstudentswithunilateralhearingloss(UHL)has
beenestimatedat30%(Bess&Tharpe,1986;Oyler,Oyler,&Matkin,1986)andslightlyhigher,37%,
amongtheirsubjectswithminimalsensorineuralhearingloss(MSHL)(Bess,DoddMurphy,&Parker,
1998).Thecostofretainingastudentisaneconomicburdentotheeducationalsystem.For56million
schoolagedchildrenintheUnitedStates(UnitedStatesDepartmentofEducation,2006),slightlyover3
million(5.4%)willhaveMSHL,and37%(approximately1million)canbeprojectedtorepeatagrade.
Withanaveragecostof$9,200toeducateachildforoneyear(UnitedStatesDepartmentofEducation,
2006),thetotalexpenditureforarepeatedgradeisinexcessof10billiondollars.
Thepresentcalculatedlifetimeeducationalcostofhearingloss(greaterthan40dBpermanent
losswithoutotherdisabilities)is$115,600perchildandtheidentification,diagnosisandinterventionfor
infantswithpermanenthearinglossresultingfromnewbornhearingscreeningreducesspecial
educationcostsbyanestimated36%orareductionof$44,200perchild(Grosse,2007).Thisassumes
thatchildrenwhoaredeaforhardofhearingreceive12yearsofspecialeducation,thatallchildrenwith
hearinglossarediagnosedasaresultofnewbornscreeningandreceiveinterventionservicesby6
monthsofage,andthatchildrenwhohavemultipledisabilitieswillhavesimilarreductionsineducation
costsasthosewithisolatedhearinglosses.Theseeconomicfiguresalsosuggestthatschooldistricts
spend2.4timesmoreonaverageforeachstudentenrolledinaprogramforthedeafandhardof
hearingthanforachildwhodoesnotreceivespecialeducationservices.
Historically,unidentifiedchildhoodhearinglosshasaffectededucationalachievement,limited
choicesforhighereducationandultimatelydecreasedvocationaloptions(HoldenPitt&Diaz,1998).
Holt,TraxlerandAllen(1997)foundthatchildrenwhoaredeafattainedmedianreadingscoresatthe
4.0gradelevelbytheageof17or18years.Thisinformationpredatestheimpactofearlyidentification
ofhearinglosssecondarytouniversalnewbornhearingscreening.Ofstudentswhoaredeaforhardof
hearingwhoareacceptedintohighereducation,70%withdrawfromcollegebeforeearningacollege
degree(Stinson&Walter,1992).Datafromthe2000U.S.censusindicatethetotalunemploymentrate
for1664yearsis60%forpersonswithseveresensorydisabilities,andlessthanonethirdofadultswho
aredeafandundertheageof35whowanttoworkcanfindajob.Wagesearnedbymaleswhoaredeaf
are77%ofthenationalwageaverage,whereasthewagesearnedbyfemaleswhoaredeafare88%of
thenationalwageaveragewithineveryoccupationalgrouping(USDepartmentofLabor,1990).
Insummary,evenwithahighschooldiploma,anindividualwithlateidentifiedhearinglossis
likelytohavepoorerlanguageandreadingachievement,belesscompetitivewithotherhighschool
graduatesforjobs,andislesslikelytoattainacollegedegree.Moreover,thejobsthatareheldby
personswhoaredeafoftencarryareduced salary.Similardatadonotexistforindividualswhoarehard
ofhearingandlateidentified;however,theyareathighriskfordelayedlanguage,educational
challengesandunderemployment,althoughtheytypicallywouldbeaffectedtoalesserdegreethan
individualswhoaredeaf.Thegreatercoststosocietyduetolateidentifiedcongenitalhearingloss
includeexpensivespecialeducationservices,alessproductivesubgroupoftheworkforceresultingin
fewerdollarsinlifetimetaxcontributions,andtheindividualcoststhatarebothmonetaryandpersonal.
Ifearlyidentificationofchildhoodhearinglossandprovisionofappropriatehighqualityearly
interventionservicesresultinimprovedlanguageabilities,lowereducationalandvocationalcosts,and
increasedlifetimeproductivity,thenlongtermcostsavingscanbepredicted(Keren,Helfand,Homer,
McPhillips,&Lieu,2002).
EducationalImpactofHearingLoss
Thetypicalclassroomisanauditoryverbalenvironmentwhereaccuratetransmissionand
receptionofspeechbetweenteachersandstudents,andfromstudenttostudent,iscriticalforeffective
learningtooccur(Smaldino&Flexer,2008).Hearingloss,whetherconsistentorfluctuating,interferes
withtheaccuratereceptionofspeech,especiallyundernoisyandreverberantclassroomconditionsand
whenspeechispresentedatadistancefromthestudent(Blumsack&Anderson,2004).Thebehavioral
effectsofhearinglossareoftensubtleandresembleeffectssimilartothoseofchildrenwhoexperience
attentiondeficitdisorders,learningdisabilities,languageprocessingproblemsorcognitivedelays.
Examplesofcommonlycitedbehaviorsincludethefollowing(Johnson&Seaton,2011):
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1.Hasdifficultyattendingtospokenorotherauditoryinformation.
2.Frequentlyrequestsrepetition.
3.Fatigueseasilywhenlistening.
4.Givesinappropriateanswerstosimplequestions.
5.Appearsisolatedfrompeers.
6.Hasdifficultywithreadingskills.
7.Hasdifficultywithspokenand/orwrittenlanguage.
8.Iseasilyfrustrated.
Inasurveyofparentsofchildrenwithidentifiedhearingloss,3outof4respondingparents
reportedtheirchildrenhadexperiencedproblemsduetohearingloss(Kochkinetal.2007).Themost
seriousproblemswerenotedtooccurintheareasidentifiedinTable2.
Percentofreportingparents
Table2.Percentofparentsofchildrenwithhearinglossreportingproblemsrelatedtothehearingloss.
Definitionofnormalhearing
Becausethisdocumentfocusesonscreeningforeducationallysignificanthearingloss,itis
importanttoconsiderthecriterionfornormal.TheAmericanAcademyofOphthalmologyand
Otolaryngology(AAOO,1965)established26dBasanallowablelimitofhearingdamagewithreference
11
toworkerscompensationregardingearningpower.Theseguidelineswererevisedin1973and1979
(Moller,2006).Inthecontextofvocationalperformance,26dBwassetasanacceptablehearingloss
becausethiswasthehearinglevelatwhichanindividualbeginstoexperiencedifficultyunderstanding
everydayspeechinaquietenvironment.TheAAOOguidelinesstatetheabilitytounderstandnormal
everydayspeechatadistanceofabout5feetdoesnotnoticeablydeteriorateaslongasthehearingloss
doesnotexceedanaveragevalueof25dBat500,1000and2000Hz.Thisamountofhearinglosswas
regardedasajustnoticeablehandicapforwhichaworkerintheUnitedStateswasentitledtoreceive
workmenscompensationforlossofearningpower.TheAmericanAcademyofOtolaryngologyhasnot
updatedtheseearlyrecommendationsbytheAAOO.AlthoughtheAmericanMedicalAssociation
releasedthe6theditionoftheGuidestotheEvaluationofPermanentImpairmentin2007,theyfollow
theAAO1979guidelinesintheiruseof26dBasthedemarcationforhearingloss.
BavosiandRupp(1984)describedtheuseof26dBasacutoffbetweennormalandmild
hearinglossasantiquatedbecausethisapproachmaycauseindividualstoconcludethatnohearing
problemexistsbelowthiscutoffintensitylevel.Asreportedearlier,morethan7millionchildrenfrom6
to19yearsofage(14.9%ofschoolagedchildrenintheUnitedStates)havesomedegreeofhearingloss
(Niskaretal.,1998).Eventhoughthemajorityofhearinglossinthisreportwasidentifiedasunilateral
andofminimaldegree,evidencesuggeststhesehearingdeficitscanadverselyaffectachilds
development,overallwellbeing,orboth(Rossetal.,2008).AccordingtoFrankenberg(1971),the
outcomesofscreeningincludeidentificationasearlyaspossibleofthoseindividualswhohaveadefined
disorder,thosewhowouldotherwisehavenotbeenidentified,andthoseforwhomtreatmentwill
amelioratetheeffectsofthedisorder.Theforemostpurposeinanyhearingscreeningprogramisto
identifythechildreninthepopulationwhohavehearingdeficitsthatcouldadverselyimpacttheir
educationandwhowouldnototherwisebeidentified.Thelinguisticandeducationalimpactofminimal
hearinglossisfurtherdescribedinthesectionsthatfollow.
MinimalSensorineuralHearingLoss
Beginninginthemid1980sresearchbegantofocusonmilderdegreesofhearingloss.Theterm
minimalsensorineuralhearingloss(MSHL)wasusedtoincludethreedifferenthearinglosscategories:
bilateralsensorineuralhearingloss(averageairconductionthresholdsbetween20and40dBinboth
ears),highfrequencysensorineuralhearingloss(meanairconductionthresholds>25dBattwoormore
frequenciesabove2kHzinoneorbothears),andunilateralsensorineuralhearingloss(meanair
conductionthresholds>20dBintheimpairedear)(Bess,1982;Bess&Tharpe,1984;Bess&Tharpe,
1986;Culbertson&Gilbert,1986;Klee&DavisDansky,1986).A5.4%prevalenceofMSHLinagroupof
3rd,6th,and9thgradechildrenwasreportedbyBess,DoddMurphy,&Parker(1998),andtheyfound
lowereducationaltestperformancefor3rdgradechildrenwithMSHLcomparedwithtypicalhearing
peersandgreaterdysfunctioninareassuchasbehavior,energy,stress,socialsupportandselfesteem
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forsixthandninthgradechildrenwithMSHL. AdditionalstudiesreportchildrenwiththisMSHLareat
higherriskforacademicstruggles(37%repeatingagrade),speechlanguagedeficits(4.3timesmore
likelytoexperiencetroubleincommunication)andsocialemotionaldifficulties(poorerselfesteemand
lessenergy)(Tharpe&Bess,1991;Bessetal.,1998;Bess,1999;McKay,Gravel&Tharpe,2008).
UnilateralHearingLoss
Bess(1982)andhiscolleagues(Bess&Tharpe,1984;Bess&Tharpe,1986;Culbertson&Gilbert,
1986;Klee&DavisDansky,1986)alsohighlightedthesignificanceofunilateralhearingloss(UHL)and
classroomchallengesrelatedtohearinglossofgreaterthan20dBinoneear.Althoughdifferencesin
languageskillsandintelligencewerenotfoundbetweenthosewithUHLandnormalhearingchildren,a
slightlyhigherincidenceofbehaviorproblemswasnotedforthegroupwithUHL.Inaddition,37%ofthe
childrenwithUHLwerefoundtohaverepeatedagrade.
HighFrequencyHearingLoss
Blairetal(1996)reportedthat97%of273thirdgraderssurveyedhadbeenexposedto
hazardoussoundlevels,andChermakandPetersMcCarthy(1991)foundthat43%ofelementary
studentsroutinelylistentoapersonalstereoorTVataloudvolume). Evidenceofincreasedprevalence
ofhearinglossinstudentswasobtainedbyMontgomery&Fujikawa(1992)whofoundthatoveraten
yearperiod,2ndgraderswithhearinglossincreased2.8times,andhearinglossin8thgradershad
increased4times.Cone,Wake,Tobin,Poulakis,andRickards(2010)reportedtheassociationbetween
slightmildsensorineuralhearinglossandparentreportofpersonalstereouse.
UsingdatafromthethirdNationalHealthandNutritionExaminationSurvey(NHANESIII),Niskar
etal.(1998)reportedalowfrequencyhearingloss(LFHL)prevalenceof7.6%for611yearoldstudents
and6.6%forthe1219yearagegroup.Highfrequencyhearingloss(HFHL)prevalencewas12.2%for6
11yearoldsand13.0%fortheoldergroup.Thedegreeofhighfrequencyhearinglossreportedinthese
studiesisgenerallymildinnatureandsometimesnotevennoticedbythechildrenthemselves.The
prevalenceofhighfrequencyhearinglosswashighestinthepoorerearat6000Hz(24.7%)and8000Hz
(27.3%).NHANESIIIdataalsosuggestthat14.9%ofschoolagedchildrenintheUnitedStates havesome
degreeofhearingloss(Niskaretal.1998).DifferencesbetweentheNHANESIIIandNHANES20052006
datawererecentlyanalyzed,andthemorerecentdatasuggestanoverallhearinglossprevalence
increasefrom14.9%to19.5%(Shargorodsky,Curhan,Curhan,&Eavey,2010),.Moredetailedanalysis
indicated1in5adolescentsintheUnitedStates12to19yearsofagedemonstratedhearingloss(most
commonlyunilateral(14%)andinvolvinghighfrequencies(16.4%).Althoughthemajorityofthehearing
losswasslight,theprevalenceofanyhearingloss25dBorgreaterincreasedsignificantlyfrom3.5%to
5.3%,or1in20childreninthisagegrouphavemildorgreaterdegreesofhearingloss.
13
Henderson,Testa,andHartnick(2010)alsoinvestigatedNHANESresultsfor19881994and
20052006,andfoundnosignificantincreaseinnoiseinducedthresholdshifts(30006000Hz)
betweenthesurveyperiodsandsimilarexposuretorecreationalnoisebetweenmaleandfemale
youths.Inthisinvestigationfemalesreportedlowerusageofhearingprotectionpossiblyresultinginan
increaseinhighfrequencyhearinglossamongfemales.SchlauchandCarney(2010)alsoinvestigated
NHANESresultsfor19881994and20052006,applyingcomputerprotocolsforestimatingfalsepositive
rates.TheyconcludedthattheNHANESIIIaudiometricdatahadunacceptablyhighfalsepositiverates
andrecommendedeliminatingcalibrationerrors,repeatingandaveragingthresholdmeasurements,and
usingearphonesthatyieldlowervariabilityat6000and8000Hztoreducefalsepositiveresponseswhen
testingthesehighfrequencies.HoodandLamb(1974)notedresponsevariabilityof6000Hz.
Insummary,thereisstrongevidencethatexposuretorecreationalnoisehasresultedin
increasesinhighfrequencyhearinglossofadolescents.Thereisalsoevidenceofpotentialerrorsin
identificationduetoinstabilityintestingthehigherfrequencies.Thisinformationlendssupportfor
screeningstudentsintheirearlyadolescencewithafocusonidentifyingpreviouslyunidentifiedhigh
frequencyhearingloss;however,caremustbetakentopreventhighfalsepositiverates.TheNational
InstitutesofHealthConsensusDevelopmentConference(NIH,1990)specifiedthatstrategiestoprevent
damagefromsoundexposureshouldincludetheuseofindividualhearingprotectiondevicesand
educationprogramsbeginningwithschoolagechildren.Furthersupportforconsiderationofscreening
forhighfrequencyhearinglossintandemwithimplementinginteractiveeducationalhearingloss
preventionprogramscanbefoundinChermak,CurtisandSeikel(1996),BennettandEnglish(1999),and
Folmer(2003).
HearingLossduetoOtitisMediawithEffusion
Otitismediawitheffusion(OME)isdefinedasfluidinthemiddleearwithoutsignsorsymptoms
ofacuteearinfection,whereasacuteotitismedia(AOM),usuallylastingtwotothreeweeks,isamiddle
earinfectionofrecentonsetwithsymptomsandsignsofinfectionsuchasfever,painandirritability
(AAP,2004;Flexer,1994).OMEmayoccurspontaneouslyduetoEustachiantubedysfunctionorasan
inflammatoryresponsetoAOM.Middleeareffusionmayaccountformorethan90%ofallmiddleear
pathologyinchildren(Brooks,1978).Approximately90%ofchildrenhaveOMEatsometimebefore
enteringschool,mostoftenbetweensixmonthsandfouryearsofage(Tos,1984).Fiftypercentof
childrenwillexperienceOMEintheirfirstyearoflife,andmorethan60%willhaveexperiencedthe
diseasebytwoyearsofage(AAP,2004).Casselbrandt,etal.(1985)examinedpreschoolchildrenat
regularintervalsforayearandfound5060%ofchildcarecenterattendeesexperiencedamiddleear
effusionsometimeduringtheyear.LousandFiellauNikolajsen(1981)reportedthat25%ofschoolage
childrenhadeffusionsometimeduringtheyear.
14
Otitismediawitheffusionischaracterizedbydecreasedmobilityofthetympanicmembrane
thatcanserveasabarriertosoundconduction.TheconductivehearinglossassociatedwithOMEis
variable,fluctuating,andtypicallymildindegree(1550dBHLacrossthefrequenciesof5004000Hz)
(Daly,etal.,1999).Thediseaseprocessaltersthestructureoftheliningofthemiddleearcavity,and
spontaneousrecoveryoccursmoreslowlywitheachadditionalepisode(Tos,HolmJensen,Sorensen,&
Morgensen,1982).Earlyidentificationofabnormalmiddleearfunctionallowsinitiationofappropriate
treatment,followupandpossiblepreventionofthedevelopmentofconductivehearinglossandother
adversesequelaesuchasrecurrentacutesuppurativeotitismedia,adhesiveotitismedia,
cholesteatoma,tympanosclerosis,ossiculardiscontinuity,andcholesterolgranuloma(McCurdy,etal.,
1976).
Theresearchonunilateralandminimalsensorineuralhearinglossaddedanewperspectiveon
theidentificationandmanagementofchildrenwithothertypesofminimal/mildhearingloss,including
OMEanditsimpactondevelopmentandeducationalperformance.Inthe1990s,theliterature
reportedalinkbetweenOMEandspeechandlanguagedelays(Klein,Teele,&Pelton,1992),reading
problems(Updike&Thornburg,1992),andattentionproblems(Feagans,Kipp,&Boyd,1994).Studies
werecriticizedbecausetheyoftenfocusedonthenumberofepisodesofOMEandnotthehearingloss
associatedwiththediseasethevariablehypothesizedtoaffectdevelopment.Robertsetal.(2004)
providedareviewoftheliteraturesummarizedinTable3.
Table3.SummaryofOMEandresultingeducationaleffectsasreviewedbyRoberts:et.al(2004).
OMEand
Difficulttoconcludeor
Folsom,Weber,&Thompson,(1983);Anteby,Hafner,Pratt,&Uri,(1986);
Auditory
refutealinkbetweenOME
Gunnarson&Finitzo,(1991);Moore,Hutchings,&Meyer,(1991);Pillsbury,
Processing
andcentralauditory
Grose,&Hall,(1991);Hall&Grose,(1993);Hall&Grose,(1994)Hall,Grose,
processing.p.113
&Pillsbury,(1995);Hogan,Meyer,&Moore,(1996);Hall,Grose,Dev,&
Ghiassi,(1998);Hall,Grose,Dev,etal.(1998);Moore,Hine,Jiang,etal.
(1999);King,Parsons,&Moore,(2000);Hogan&Moore,(2003);Knudsen,
(2002);
OMEand
NotanindicationthatOME Shriberg,&Smith,(1983);Eimas&Clarkson,(1986);Roberts,Burchinal,
Speech
representsasignificantrisk
Koch,etal.(1988);Paden,Matthies&Novak,(1989);Nittrouer,(1996);
tospeechproductionin
Mody,Schwartz,Gravel,&Ruben,(1999);Paradise,Dollaghan,Campbell,
otherwisehealthychildren. etal.(2000);Shriberg,FrielPatti,Flipsen,&Brown,(2000);Shriberg,
p.114
Flipsen,Thielke,etal.(2000);Paradise,Feldman,Campbell,etal.(2001);
Campbell,Dollagahan,Rockette,etal.(2003);Paradise,Dollaghan,
Campbell,etal.(2003)
OMEand
OMElanguagelinkage
VernonFeagans,Manlove,&Volling,(1996);VernonFeagans,Emanuel,&
Language
continuestobeopento
Flood,(1997);Feldman,Dollaghan,Campbell,eal.(1999);Maw,Wilks,
15
somedebate.p.115
Haarvey,etal.(1999);Rovers,Straaatman,Ingels,etal.(2000);Paradise,
Dollaghan,Campbell,etal.(2000);Paradise,Feldman,Campbell,etal.
(2001);Casby,(2001);AHRQ,(2002);Roberts,Burchinal,&Zeisel,(2002);
VernonFeagans,Hurley,&Yont,(2002);Feldman,Dollaghan,Campbell,et
al.(2003);Paradise,Feldman,Campbell,etal.(2003);Paradise,Dollaghan,
Campbell,etal.(2003)
OMEand
Datalinkingahistory
Roberts,Sanyal,Burchinal,etal.(1986);Feagans,Sanyal,Henderson,etal.
Academics,
ofOMEtolateracademic
(1987);Roberts,Burchinal,Collier,etal.(1989);Teele,Klein,Chase,etal.
Attention,
skills,attentionand
(1990);Arcia&Roberts,(1993);Lous,(1993);Feagans,Kipp,&Blood,
andBehavior
behaviorcontinuetobe
(1994);Gravel&Wallace,(1995);Paradise,Feldman,Colborn,etal.(1999)
mixed.p.116
Roberts,Burchinal,Jackson,etal.(2000);Minter,Roberts,Hooper,etal.
(2001);Roberts,Burchinal,&Zeisel,(2002);
Roberts,etal.(2002)andZumach,etal.(2010)conductedprospectivestudiesinvestigatingthe
longtermeffectofearlyOMEonlanguageandacademicskillsatage7.Bothstudiesfoundthatthe
deficitsidentifiedattwoandthreeyearsofagehadresolvedbysecondgrade.Gravel&Ruben(1996)
suggestedthatOMEmaybeaformofauditorydeprivation,andplasticityofdevelopingauditory
systemscanfacilitaterecoveryfromearlyauditorydeficits.Gravel,etal.(2006)examinedtheeffectof
conductivehearinglosssecondarytoOMEinthefirstthreeyearsoflifeonperipheralandhigherorder
auditorymeasuresatschoolage.Theyreportedthatextendedhighfrequencyhearing(12.5,14and16
kHz)andbrainstemauditorypathwaymeasureswereassociatedwithOME/hearinglossinearly
childhood.Yilmaz,Karasalihoglu,Tas,YagizandTas(2006)foundthatsignificantlyfewerotoacoustic
emissionsweredetectedinyoungadultswithOMEhistoriesthaninsubjectswithoutahistoryofOME,
suggestingthatOMEinchildhoodmaycauseminorbutirreversibledamagetothemiddleearor
cochlea.At4yearsofage,childrenwithpositivehistoriesofOMEduringtheirfirstyearrequiredamore
advantageoussignaltonoiseratiothandidotitisnegativepeerstoachievethesamelevelofspeech
perceptionaccuracy(Gravel&Wallace,1992).Theseauthorsspeculatedthatthedelays/disorders
identifiedintheearlierstudiesofyoungchildrenwererelatedtoinadequateorinconsistentaccessto
auditoryinformationduringaperiodofrapiddevelopment.Roberts,etal.(2002),Zumach,etal.(2010),
andGravel,etal.(2006)furtheracknowledgedthatthehomeenvironment,irregularmedical
management,andlowsocioeconomicstatuswereprobablymoreinfluentialonoutcomesthanOMEor
theassociatedfluctuatinghearingloss,makingitdifficulttopredicttheimpactofOMEonfuture
educationalperformance.
ThediagnosisofOMEisamedicalratherthananaudiologicalprerogative.Theasymptomatic
natureofthediseasecontributestothedifficultyinitsdiagnosis.Manychildrenhavefarfewerwell
childcarevisitsthanarerecommendedbytheAAP(Seldon,2006)andin4060%ofcasesofOME
16
neitherchildrennortheirparentsreportsignificantcomplaintsrelativetothedisease(Burkeyetal.,
1994;Rosenfeld,Goldsmith,Tetlus,&Balzano,1997).Thus,parentreportishighlyinaccuratein
identifyingchildrenexperiencingnonacuteOME,withorwithoutsubstantialhearingloss(Burkeyetal.,
1994;Olusanya,2001;Loetal.2006;Gomes&Lichtig2005).Manyepisodesresolvespontaneously
within3months,butapproximately3040%ofchildrenhaverecurrentOME,and510%ofepisodeslast
oneyearorlonger(Stool,Berg,Berman,et.al,1994;Tos,1984;Williamson,Dunleavy,Baine,&
Robinson,1994).Tos(1984)foundthatalthough55%ofchildrenwithOMEimprovedbythreemonths,
onethirdhadanOMErelapsewithinthesubsequentthreemonths.Thesesamestudiesreportedthatif
middleeareffusionispresentlongerthanthreemonths,therewillbelittlechanceofrecoverywithout
medicaltreatment.
Thereisnoclearconsensusamongeducators,speechlanguagepathologists,andaudiologists
regardingtheimpactofOMEondevelopment.Bluestone(1978)statedthatthedegreeanddurationof
hearinglossassociatedwithotitismediaandthecomplicationsandsequelaerequiredtoproduce
impairmentinthecognitive,linguistic,andemotionaldevelopmentofchildrenwerenotdefined.More
than30yearslaterthisisstilltrue.AlthoughashorttermcorrelationbetweenOMEanddevelopment
hasbeenestablished,acausalrelationshiphasnot.Itisdifficulttodocumentthedurationanddegree
ofhearinglossassociatedwithOME,andethicalstandardspreventcontrolofthisvariableinorderto
providetheparadigmneededtostudythephenomenon;thus,investigatorsmuststudyOMEinits
naturalcourse.Itisreasonabletopostulatethatchildrenwithminimalconductivehearinglossmight
experiencesomeofthesamedifficultiesasTharpe&Bess(1991)identifiedforstudentswithminimal
sensorineuralhearingloss.OnecannotdrawtheconclusionthatoutcomesforMSHLchildrenarethe
sameasthoseforchildrenwithmild/minimalhearinglossduetoOME;however,MSHLresearchmay
helpusbetterunderstandallstudentswithminimal/mildhearingloss.Inrecognitionofthenoisyverbal
environmentinwhichchildrenareeducated,itisreasonabletoassumethatanydegreeofhearingloss,
whetherstableorfluctuating,canactasabarriertocompleteperceptionofverbalcommunication
withinaschoolsettingandultimatelymayimpactlinguisticandacademicperformance.
POPULATIONOFCHILDRENTOBESCREENEDFORHEARINGLOSS
LegislativeMandates
Althoughthereisnosinglefederalmandateforchildhoodhearingscreening,thegoaltoidentify
childrenmostlikelytohaveahearinglossthatmayinterferewithcommunicationandfutureschool
performanceissupportedbycurrentfederallegislation.TheIndividualswithDisabilitiesEducationAct
(IDEA)2004requiresschooldistrictstoidentify,locate,andevaluateallchildrenwithdisabilities[20
U.S.C.1412(a)(3)],andstatesthat"eachpublicagencymustconductafullandindividualinitial
evaluation"toidentifyadisabilityandsubsequenteligibilityforspecialeducationservices[34CFR
300.301(a)].Inaddition,IDEA2004,requiresstatestohaveacomprehensivechildfindsystemthat
17
ensuresrigorousstandardsforappropriatelyidentifyinginfantsandtoddlerswithdisabilitiesthatwill
reducetheneedforfutureservices[20U.S.C.1435(a)(5)].HeadStartPerformanceStandardsspecify
thatahearingscreeningbeconductedwithinthefirst45daysofenrollment([45CFR1304.20(b)(1)]
Childhealthanddevelopmentalservices).Arequirementtoofferannualhearingscreeningforchildren
frombirthtoentryintokindergartenwhenneededisalsoincludedintheHeadStartstandardsfor
training,qualificationsandconductofhomevisits(PublicLawNo:110134).Finally,theU.S.Department
ofHealthandHumanServices(2005)suggestedthatthereisaneedtoidentifyandreducethe
proportionofadolescentswhohaveelevatedhearingthresholdsinthehighfrequenciesinbothears,
signifyingnoiseinducedhearingloss.
Onastateandlocallevel,procedurestoidentifyhearinglossinchildrenhaveexistedinmost
publicschoolsystemsintheUnitedStatesfordecades(Anderson,1991).OveradecadeagoPenn(1999)
reportednearly90%ofthestateshadenactedhearingscreeninglegislationorconductedsometypeof
coordinatedstatewidescreeningactivityforschoolagechildren.Mosteducationaljurisdictionshave
requiredhearingscreening,buttherearesignificantdifferencesintheauthorityandspecificationsof
thestatelawsgoverningthesescreeningactivities(NationalAssociationofStateBoardsofEducation,
2010).
.
EarlyChildhood
Evenmildalterationsofauditoryinputduringinfancymayresultinsignificantdevelopmental
speechdelays,lendingsupportforearlyidentificationofminimaldegreesofhearingloss(Nozza,1994).
Childrenwithmildhearinglossmaypassnewbornhearingscreening,andmanydonotreceivefollowup
rescreeningordiagnosticswhentheydonotpass.Mildhearinglossmaybeanearlyindicatorforthose
withprogressiveorlateonsethearingloss.Theeducationalimpactofminimalormildhearinglosscan
beincreasedsignificantlywhenaccompaniedbyotherdisabilities.
Earlydetectionofpermanenthearinglosshasbeengreatlyimprovedthroughnewbornhearing
screening,(CommissiononEducationoftheDeaf,1988;Harrison,Roush,&Wallace,2003).However,
childrennotscreenedatbirth,thoselosttofollowupafterfailingnewbornscreening,andchildrenwho
presentwithlateronsethearinglossmaystillbeidentifiedtoolatetopreventseriousdevelopmental
problemsassociatedwithuntreatedhearingloss(Niskar,et.al,2001).Datagatheredonscreeningand
followupofEarlyHeadStartchildren(birth3yearsofage)suggestthatapproximately2ofevery1000
childrenscreenedinearlychildhoodsettingsarebeingidentifiedwithapermanenthearingloss,andan
additional18childrenper1,000arebeingidentifiedandtreatedfortransientconductivehearingloss
(Eisermanetal.,2008).Ithasbeenestimatedthatapproximately67per1000childrenhavepermanent
hearinglossinadditiontothe3per1000likelytobediagnosedshortlyafterbirth(NationalInstituteon
DeafnessandOtherCommunicationDisorders,2005;Bamfordetal.,2007).Anestimated35%ofpre
schoolchildrenexperienceintermittenthearinglosssecondarytorepeatedoruntreatedepisodesofear
18
infections(AmericanSpeechLanguageHearingAssociation(2007).TheJointCommitteeonInfant
Hearing(2007)recommendedregularsurveillanceofdevelopmentalmilestones,auditoryskills,parental
concerns,andmiddleearstatusforallinfantstobeperformedinthemedicalhome,consistentwiththe
AmericanAcademyofPediatrics(AAP)pediatricperiodicityschedule(Hagan,Shaw,&Duncan,2008).
Fortheearlychildhoodpopulation,avalidatedglobalscreeningtoolistobeadministeredtoallinfants
at9,18,and24to30monthsoratanytimethereisphysicianorparentalconcernabouthearingor
language.JCIHfurtherrecommendedthatinfantsnotpassingthespeechlanguageportionofamedical
homeglobalscreeningorforwhomthereisaconcernregardinghearingorlanguagebereferredfor
speechlanguageevaluationandaudiologyassessment.
Preschool
Duetoinjury,illness,orgenetics,childrenwhopasshearingscreeningatbirthcanstillbeatriskfor
hearinglossthatisprogressiveoracquiredafternewbornhearingscreeningoccurs.Itisestimatedthat
byschoolage,approximately6to7percentper1,000childrenareexpectedtohaveapermanent
hearingloss(Bamfordet.al,2007).Onepurposeofperforminghearingscreeningsinthepreschoolage
populationistoidentifyearlierscreeningfailuresthatwerelosttofollowup.Basedon2008Centersfor
diseaseControlEHDIdata,atotalof48statesreportedthat62,246infantsdidnotpassthefinal
screeningbeforereferralfordiagnostics.Outoftheseinfants,46.6%werenotdocumentedtohavea
diagnosis(CDC2009).Anotherpurposeofhearingscreeningistoidentifylateronsethearinglossthat
mayinterferewithlanguagedevelopmentandfuturesuccessinschool.
SchoolAgeChildren
Theresponsetointervention(RtI)processwasdesignedtoincreasesupportsundertheNoChild
LeftBehind(NCLB)Act(2001)forstudentswithspecificlearningandbehaviordisabilitiesandtoprevent
academicfailurefortheseschoolagestudentsthroughinterventionwithingeneraleducation.RtIcalls
foraperiodofinformationanddatagathering,evidencebasedacademicandbehavioralstrategiestobe
putintoplace,andongoingmonitoringoftheeffectivenessofthosestrategies.Itisprudentto
immediatelyruleoutthepresenceofhearinglossinanystudentwhoisintheRtIreferralprocess.With
thisinmind,thefollowingthreegroupsaretypicallytargetedforschoolagedhearingscreening:
1. Allstudentsinspecificgrades(studentsintargetedgradelevelsselectedbyormandatedfor
schooldistrictstoscreenannually).Schooldistrictsthatchoosetoidentifystudentswithhearing
lossand/orOMEtypicallytargetpreschoolandearlyelementarygradelevelsformassscreening
duetothehighprevalenceofOMEinyoungchildrenandthedesiretoidentifyhearinglossas
earlyaspossible.Oneormorehigherelementarygrades(e.g.4thor5thgrade)maybeselected
toidentifylateonsethearingloss.Becausesecondarystudentsaremoreatriskfornoise
19
2. ReferralStudents(studentsnotingradeswithmassscreeningwhoarereferredbyateacheror
parentforconcernsregardinghearing).ThiscategorywouldalsoincludeanystudentintheRtI
orspecialeducationeligibilityprocess,especiallythosestudentswhoarebeingreferredfora
psychoeducationaland/orspeech/languageevaluation.Inthesesituationsitiscriticaltorule
outhearinglossasanunderlyingcauseorcontributingfactorforeducationaldifficulties.
3. NewStudents(anystudentenrollingforthefirsttimeintheschoolsystem).Thiscategory
includesstudentswhomaybetransferringfromanothersystemandstudentswhohavenot
beenenrolledinschoolpreviously.ItcannotbeassumedthatstudentstransferringwithIEP's
havehadtheirhearingadequatelyscreened,andunfortunately,discoveringastudentbeing
servedinaspecialeducationprogramwithunidentifiedsignificanthearinglosscontinuesto
occur.Studentswhotransferfrequentlymaymissopportunitiestoparticipateinrequiredmass
screeningsandshouldbeincludedinanewstudentreferralgroupaspartoftheirenrollment
process.
TargetedGradeLevels
Aspreviouslynoted,itisimportanttoperformhearingscreeningonyoungchildpopulationsin
ordertoidentifythosewithlateonsetorprogressivehearingloss.Inmanystatestherealsocontinuesto
beasignificantproportionofinfantswhofailnewbornhearingscreeningthatarelosttofollowup.Only
bymethodicallyscreeninginearlychildhoodeducational,childcare,andmedicalsettingswillpreviously
undiagnosedchildrenwitheducationallysignificanthearinglossbeidentified.
Althoughschoolhearingscreeningprocedureshavebeeninplaceinschooldistrictsformore
than50years,thereisminimalresearchspecifyingagesorgradeswhenscreeningwillmostefficiently
identifystudentswitheducationallysignificanthearingloss.TheAmericanAcademyofPediatricsand
BrightFuturespublishedRecommendationsforPreventiveHealthCare(2008).Theserecommendations
weredevelopedtoguidepediatriciansforscreeningsandriskassessmentsofthewellchildandspecify
hearingscreeningsforschoolagedchildrenat4,5,6,8,and10years.Sarafraz&Ahmadi(2009)
identifiedasignificantlyhighernumberofstudentswithhearinglossinthesecondgradethaninthe
firstgrade,datathatsupportshearingscreeningbeyondschoolentrance. Informationonhigh
frequencyhearinglossprovidessupportfortheneedtoscreenforhearinglossbeyondtheelementary
schoolyears(Montgomery&Fujukawa,1992;Niskaretal,1998;Sargorodsky,etal,2010).
20
Additionaldatatofacilitateselectionoftargetedgradesforhearingscreeningisprovidedin
AppendicesA,B,andC.Screeningprotocolsandactualscreeningresultsoverathreeyearperiodfor
threeschooldistrictsinColoradoandFloridawerecompiledandanalyzed.TwodistrictsinColorado
screenedforhighfrequencyhearinglossinsecondaryschool,andallschooldistrictsused
tympanometrywhenrescreeningstudentswhodidnotpasspuretonescreening.Audiologistswere
integralinthescreeningprogramforalldistricts.Therangeofnewlyidentifiedstudentspergradelevel,
expressedinpercentofthetotal,wascombinedindifferentgradecombinationsinAppendixC.Twoof
thedistrictsscreenedforhearinglossingrades7and9resultingintheirtotalnumberofnewly
identifiedstudentsbeingspreadoverawiderrangethanthethirddistrictthatscreenedsixinsteadof
eightgrades.Thesummarystatementsbelowarebasedondatafromthethreeschooldistrictsincluded
inAppendixA,B,C:
Schoolentryhearingscreeningatpreschoolandkindergartenwillidentifylessthantoless
thanofstudentswithnewlyidentifiablehearingloss
ScreeningpertheAAPguidelines(aged4,5,6,8and10years),specificallypreschool,
kindergarten,andgrades1,3,and5,resultsinidentifyingoverbutlessthanofpreviously
unidentifiedstudents(excludingonedistrictsdataforgrade6).
Approximately90%ofnewhearinglosseswillbeidentifiedifgradesPS3arescreened;the
remaining10%thatwillbemissedbynotscreeninghighergradesarelikelytohavealarge
proportionofemerginghighfrequencyhearingloss,asevidencedinthetwodistrictsthatdid
screenforhighfrequencyhearinglossingrades5andhigher.
Screeningatgrades5or6andgrade7,ORscreeningatgrades7and9yieldverysimilarresults.
Ifscreeningonlyonesecondarygrade,7thand9thhavesimilaryields,althoughidentifying
hearinglossearlierincombinationwithaneducationalpreventioneffortmaybemoreeffective
priortohighschool.
Toidentifyapproximately70%ofpreviouslyunidentifiedhearinglosses,preschool,
kindergarten,andgrades1,3,5and7or9shouldbescreenedataminimum.Sincethesedata
reflectscreeningimplementedover2or3years,studentswhomayhavehadidentifiable
hearinglossinthegradesthatwerenotscreened(e.g.,grade4)wereidentifiedoneyearlater.
Thetrendforidentificationofnewhearinglossesdecreasesingrades1,2and3andincreasesin
grade5,suggestingapossibleincreasedprevalenceofhighfrequencyhearinglossinupper
elementaryschool.
Inadditiontotheminimumgradesscreenedabove,morestudentswithpreviouslyunidentified
hearinglosswillbefoundifgrade2isaddedratherthananothersecondarygrade.
III.METHODOLOGY
EvidenceBasedReview
21
Thereareavarietyofwaysinwhichthelevelofevidenceisratedforindividualstudies.TheUS
PreventativeServicesTaskForceproposedthefollowinglevelsofevidenceratingforqualitywhen
reviewingindividualscreeningstudies:
LevelI:randomizedcontrolledtrial
LevelII:nonrandomizedcontroltrial
LevelIII:cohortorcasecontrolstudy
LevelIV:ecologicalordescriptivestudies(e.g.internationalpatterntimeseries)
LevelV:opinionsofrespectedauthoritiesbasedonclinicalexperience,descriptivestudiesor
reportsofexpertcommittees(USPSTF1996).
TheBritishHealthTechnologyAssessmentconcludedthattherewasonlylevelIIIevidencefor
theeffectivenessofpreschoolhearingscreening(Bamford,Fortnum,Bristowetal.2007).Theyprovided
thefollowingsummaryrelatedtohearingscreeningtechniquesusingthepuretoneaverage(PTA)
criteriasetfrom15to30dBdependingonthestudyasthereferencetest:
Studiescomparingvariousscreenprotocolsofpuretonesweepaudiometryreporthigh
sensitivityandspecificityforfullPTAandthereforeappeartobesuitabletestsforscreening.
Spokenwordtestsarereportedtobeaviableoptionbecauseoftheirpotentialacceptable
levelsofspecificityandsensitivity.
Dependingonreferralcriteria,transientevokedotoacousticemissions(TEOAEs)have
potentiallyhighspecificity,butsomewhatlowersensitivity.
Tympanometryandacousticreflectometryhavevariablesensitivityandspecificity.
Parentalquestionnaireandotoscopyhavepoorsensitivityandspecificity.Therefore,these
testsarelikelytobelesssuitableforscreening.
Itisadisadvantagetobasepracticeguidelinesoninformationthatdoesnotmeetthehighest
evidencelevel.However,untilhigherqualityevidencebasedresearchbecomesavailable,thecurrent
GuidelinesforChildhoodHearingScreeningarebasedonthefollowing:(1)thesensitivityandspecificity
oftherelevantstudiesidentifiedbytheBritishHealthTechnologyAssessment,and(2)additionalstudies
thatprovideevidencebasedinformationonspecifictestmeasuresorprotocols.
SensitivityandSpecificity
Thevalidityofascreeningprotocolisthedegreetowhichresultsareconsistentwiththeactual
presenceorabsenceofthedisorder.Sensitivityandspecificityareusedtoidentifythevalidityofa
screeningtest.Thesensitivityofatestisitsaccuracyincorrectlypredictingindividualswiththe
conditionyouarelookingfor(inthiscase,childrenwhohavepotentiallyeducationallysignificant
hearingloss).Thespecificityofatestisitsaccuracyincorrectlyidentifyingindividualswhodonothave
thecondition,orforourpurposes,childrenwhodonothaveauditoryacuityissuesthatarelikelyto
22
interferewitheducationalperformance.Forahearingscreeningprotocoltobeacceptable,itshould
correctlyidentifyatleast9095%ofindividualswithexistinghearingloss(sensitivity)andfailnomore
than510%ofindividualswhowouldbeconsideredtohaveacceptablehearing(specificity)(Roeser&
Downs,1981).Overorunderreferralduringthehearingscreeningprocesshasliabilitiesorcostsin
time(staffingcosts),effort,orcooperativegoodwilloffamilies.Medicaland/oraudiologicalfollowup
costsassociatedwithoverreferralincludetimeforretrievingeveryoveridentifiedchildforfurther
screeningfromtheirclassroomsetting,expensesassociatedwithadditionalscreeningand/ordiagnostic
teststoconfirmahearingloss,andmentalanguishoftheparentandchild(Frankenberg,1971).
BritishNationalInstituteforHealthResearchAssessmentonSchoolHearingScreening
TheBritishNationalInstituteforHealthResearchpublishedadetailedHealthTechnology
Assessmentonthecurrentpractice,accuracy,efficiencyandcosteffectivenessofschoolhearing
screeningproceduresthatincludedperformingasystematicreviewoftheliteratureregardingthe
effectivenessofschoolhearingscreening(Bamford,Fortnum,Bristowetal.,2007).Anextensivesearch
ofthemajorrelevantelectronicdatabasesfrom1966throughMay,2005,soughttoidentifyhearing
screeningtestaccuracyviasensitivityandspecificity,specificallyforstudiesthatincluded46yearold
children.Atotalof998studieswereidentifiedviaelectronicsearches,themajorityfromMedline(464),
EMBASE(252),andERIC(172).Ofthetotalidentified,899studieswereexcludedlargelydueto
irrelevanceforhearingscreening.Theremaining99articlesweresubjectedtosystematicqualityreview
usingtheQualityAssessmentofStudiesofDiagnosticAccuracy(QUADAS)tool(Whiting,2003)that
consistsof14questions.Thequalityofeacharticlewasscoredbytwoexperiencedreviewersonthe
basisofthetotalnumberofyesresponses,rangingfromzero(poorestpossiblequalityscore)to14
(highestpossiblequalityscore).BasedonQUADASreview,threesystematicmetaanalysisreviewsand
25primaryresearcharticleswereconsideredtomeetinclusioncriteriaspecifictostudydesign,
comparator,screeningtest,population,andoutcomes.Ofthese,23studieswereidentifiedfrominitial
screeningbaseddatasearchesandtwofromfollowupsearchesrelatedtotestaccuracy.The
assessmentreportedgoodagreementontheselectionofthisgroupofstudiesbetweenthetwo
reviewers(weightedkappa0.67,95%CIfrom0.60to0.75).RefertoTable7forasummaryofthe
specificityandsensitivitydataforsevenofthesestudies.Sensitivity/specificityinformationiscalculated
intermsofthetotalpopulationwhereasoverandunderreferralsarecalculatedintermsofthose
havingthecondition.Roeser&Downs(1981)recommendedthatoverreferralsshouldbebetween5
10%.NoneoftheprotocolsorcombinationofprotocolsevaluatedbyFitzZaland&Zinkmeetsthose
criteria.
Table7.Sensitivityandspecificityof7studiespertheBritishAssessmentonSchoolHearingScreening
(2007).
23
Test
Sensitivity
Specificity
51%
96%
59%
93%
87%
96%
93.4
98.8
26%
6.6%
92.7
91.1
92.7
94.6
91.2
97.8
100
97
85%
91%
71%
65%
34%
95%
87%
80%
97%
86%
97%
83%
98.5%
75%
DPOAE(SNR5dBat1.9kHzORSNR11dBat3.8kHz) 95.7%
95%
VASCscreen(protocol1)vs.puretone
VASCscreen(protocol2)vs.puretone
VASCvs.puretone
Puretonevs.combinedtests
Boneconductionvs.impedanceaudiometry
TympanometryTypeBor150mm
TympanometryTypeBor175mm
TympanometryTypeBor200mm
Puretone+TypeBor200mm+
Tympanometryvs.puretone
Tympanometry+stapediusreflexvs.puretone
Questionnairevs.puretone
TEOAEvs.puretone
DPOAE(SNR5dBat1.9kHz)vs.tympanometry+
puretone
5
DPOAE(SNR11dBat3.8kHz)vs.tympanometry+
puretone
5
DPOAE(SNR5dBat1.9kHzANDSNR11dBat
3.8kHz)vs.tympanometry+puretone
5
vs.tympanometry+puretone
Ritchie&Merklein,19721,FitzZaland&Zink,19842,Hamill,19883,Sabo,Winston,Macias,20004,Lyons,
Keri,&Driscoll,20045,McCurdy,Goldstein,&Gorski,19766,Olusanya,20017.
TestProcedureandProtocolReview
Puretonescreening
Historically,themostwidelypreferredhearingscreeningprocedureandtheonethathasbeen
consideredthegoldstandardisthepuretoneaudiometricsweeptestthatwasfirstdescribedin1938by
Newhart(Krueger&Ferguson,2002).PuretoneaudiometricsweepcanbeconductedusinganANSI
calibratedportableaudiometer(AmericanNationalStandardsInstitute,2004)withTDHsupraaural
earphones.Puretonesignalsarepresentedacrossdifferentfrequencies,and responses tothesignals
typicallyinclude ahandraiseoraconditionedresponse(e.g. droppingablockinabucket).Meinkeand
24
Dice(2007)surveyedstatesregardingtheirhearingscreeningprotocols,andtheirresultsforpuretone
proceduresaresummarizedinTable8.
Table8.Hearingscreeningprotocols.FromMeinkeandDice,2007.
Screeningfrequenciesandintensities
Referenceduseofprotocol
1000,2000,4000Hz@20dBHL
FL,IN,KY,LA,MD,MO,NY,OH,OK,
RI,SC,TN,UT,WA,WY(ASHA,AAA)
1000,2000,4000Hz@25dBHL
CA,ME,NH,SD
1000&2000Hz@20dBHL&4000Hz@20or25dBHL
AR,TX,WI
500,1000,2000,4000Hz@20dBHL
NJ,OR,VA(AAP)
250,500,1000,2000,4000,&8000Hz@20dBHL
NV,NM
500,1000,2000Hz@(a)20or(b)25dBHL
AL,DE
500,1000,2000,4000Hz@(a)20or(b)25dBHL
AK,MA
500Hz@25dB,1000,2000,4000Hz@20dBHL
AZ,MN
500,1000,2000,4000Hz@25dBHL
GA,IL,MS
1000,2000Hz@20dBHL,4000Hz@25dBHL
CT,MT
500,1000,2000,4000,6000Hz@20dBHL
KS
500Hz@25dBHL,1000,2000,4000Hz@20dBHL,6000
CO
Hz@25dBHL
500,1000,2000,&4000Hz@15or20dBHL&8000Hz
IA
@15,20,or25dBHL
1000,2000,&4000Hz@20,25,or30dBHL
ID
1000,2000,4000Hz@(a)20or(b)25dBHL
MI
Noinformationreported
HI,ND,WV,DC,NB,NC,PA,VT
Intensity
Puretonescreeningpresentationlevels arereportedto varyfrom20dBto30dB(ANSI,1969).
Niskaretal.(1998)andSarafrazandAhmadi(2009)identifiedstudentswithhearinglossbyusing15dB
HLcriteria.Theresultingprevalencedatasupporttheuseofa20dBHLscreeninglevelasopposedto25
dBHL.MeinkeandDice(2007)providedevidenceofthegreatersensitivityofa20dBHLscreeninglevel
whencomparedtoa25dBHLscreeninglevelintheidentificationofhighfrequencynotches.Usinga
screeninglevelof20dBHLhasbeenshowntoincreasethesensitivityinidentifyingminimalhearingloss
(MHL)(DoddMurphy&Murphy2008).
25
DoddMurphy,Murphy,andBess(2003)investigatedtheuseofa20versus25dBHLscreening
levelat1000,2000,and4000Hzforidentifyingeducationallysignificanthearingloss(ESHL)inagroupof
1219studentsingrades3,6and9forwhomthresholdswereknown.Sensitivity/specificityrateswere
100/92.2fora20dBHLscreeningleveland97.5/97.4forthe25dBHLscreeninglevel.Whenthesedata
wereanalyzedforidentificationofminimalhearingloss,sensitivity/specificityratesfora20dBHL
screeninglevelwere61.5/94.4and35.4/98.3when25dBHLwasused.
InalaterstudyDoddMurphyandMurphy(2006)screened82studentsat20and25dBHLfor
1000,2000,and4000Hz,andcompletedfollowupthresholdtestingforthosewhofailed.Both
screeningprotocolsyieldeda2.4%prevalenceofESHLwith100%sensitivity.Specificitywaspoor(50%)
forthe20dBHLlevel,andonly78%forthe25dBHLlevel.WhentheMHLcriterionwasapplied,both
screeninglevelsfounda6.1prevalence,sensitivity/specificityof100/53forthe20dBHLlevel,and
60/81forthe25dBHLprotocol.Theauthorsconcludedthatpuretonescreeningat25dBHLhadthe
bestcombinedsensitivity/specificityratesforESHLbutunacceptablesensitivitywhenscreeningfor
MHL.Theyfurtheracknowledgedthesmallsamplesizeandcommentedthatreducingtimebetween
screeninganddiagnosismayimprovespecificityofascreeningprogram.
TheAmericanSpeechLanguageHearingAssociationGuidelinesforAudiologicalScreeningfor
age518years recommends aprotocolthatusesa20dBHLscreeninglevelandincludesthe
frequencies1000,2000and4000Hz(ASHA,1997).AsstatedbyRoeserandNorthern(1981),By
decreasingthelevelatwhichthetestisperformed,thesensitivityofthetestcanbeincreasedand
childrenwithevenminimalhearinglosscanbeidentified.Sinceaudiologistsfeelthatevenslighthearing
lossesaffectthedevelopmentofspeechandlanguagethegoalofmanyprogramsistoreducethe
screeningleveltoidentifythesechildren.However,weareforcedintoacceptingscreeninglevelsof20
to25dBHLbecauseoftheconditionsunderwhichmostscreeningisperformed(pg135).
Anydiscussionofintensitylevelsforhearingscreeningpurposesmustincluderecognitionthatthevast
majorityofschoolhearingscreeningdoesnotoccurinasoundtreatedsetting.FitzZalandandZink
(1984)screened3510students,and123wereidentifiedbyaudiologicalandmedicalexaminationswith
conductiveimpairments.Ofthoseidentified,115failedpuretonescreeningeventhough81(70%)had
clinicallyestablishedthresholdsbetterthanthescreeninglevelsatallscreeningfrequencies.The
authorsacknowledgedthathearingscreeningisoftenconductedinlessthanidealsettingsand
suggestedthatthereasonisprimarilyineffectiveplanningandnegotiationwithschooladministrators
whocanensureadequateenvironmentsiftheyconsiderscreeningahighpriority.Theseauthorsalso
foundthatfrequentandthoroughscreenertraining,controlofinstrumentcalibration,andrigidambient
noisecontrolreducedfalsepositiveratesfromarangeof4090%downtoamoreacceptablelevelof
2030%.AsapartofaninvestigationofhearinghealthneedsindevelopingcountriesbytheWorld
HealthOrganizationPreventionofBlindnessandDeafness(WHO)2001,astudyof240subjectswas
undertakentomeasurethevalidityoftestinginconditionswith4045dBAofambientnoise.Hearing
26
screeningresultswerecomparedwiththoseonthesamesubjectsinasoundproofroomtogivea
"goldenstandard."Whenthe5dBdifference"normal"variationwasacknowledged,theresultwasthat
71.5%hadthesamethresholdsbut28.5%haddifferentthresholds.
Frequency
Aspreviouslystated,screeningimpliesthataspecificpass/failcriterionisappliedtoallresults.It
ispreferablethatasinglefailureatanyfrequencyscreenedineitherearwillconstituteafailureofthe
hearingscreeninginordertomaximizethenumberofchildrenwithnewlyidentifiedoremerging
hearinglosses.Requiringfailureatmorethanonefrequencyineitherorbothearswilldecreasethe
numberofchildrenwhorequirehearingrescreen(i.e.increasethenumberwhopass),butwillalso
potentiallyincreasefalsenegatives(i.e.thenumberofchildrenwithhearinglossesthataremissed).
Moststatesperformscreeningbetween1000Hzthrough4000Hz,withthesecondhighest
numberofstatesalsoperforminghearingscreeningat500Hz(Meinke&Dice,2007).Therearelimited
datatosupportscreeningatjustoneortwofrequencies(House&Glorig,1957;Norton&Lux,1961);
however,theworkofSiegenthalerandSommer(1959)andStevensandDavidson(1959)refutedlimited
frequencyscreeninginfavorofapuretonesweepatthreeorfourfrequencies.TheASHA(1997)
screeningguidelines recommend aprotocolthatusesa20dBHLscreeninglevelandincludesthe
frequencies1000,2000and4000Hz.ThisisachangefrompreviousASHAguidelinesthatincluded500
Hzata25dBlevelasameanstoimproveidentificationoftemporaryhearinglossduetoOME(ASHA,
1990).Screeningat500Hzhassincefallenintodisfavorduetoquestionablevalidityasameansto
identifyOME,identifyingonlyabouthalfofchildrenexperiencingOME(Melnick,Eagles,&Levine,1964;
Brooks,1971).The500Hzfrequencyisalsomoreeasilymaskedbyroomnoise,thusreducingthe
specificityofscreeningresults(ANSIS3.11999(R2003);Minnesota,DepartmentofHealth,2006).
FitzZaland&Zink(1984)investigatedapuretonescreeningprotocolsabilitytoidentify
conductivehearinglosswhenusing25dBHLat500and4000Hzand20dBHLat1000and2000Hz.
Theyfoundthatreferredchildrenwhofailedonlythe500Hztoneaccountedfor15%ofthechildren
withconfirmedconductiveimpairment,andthatnoneofthemhadnormalhearing.Theauthors
acknowledgedconcernabouttheimpactofambientnoiseonscreeningat500Hzandstatedthat
effectiveplanningwithschoolofficialsiscriticaltoensureanadequatescreeningenvironment.
Meinke&Dice(2007)evaluatedadatabaseof6419thand12thgraderswithidentifiedhigh
frequencyhearinglossusingfourdifferentintensityandfrequencycombinations.Theirfindingsare
summarizedinTable9.Theauthorsperformedfurtheranalysisof45ofthe641audiogramsandfound
that48.8%ofthediagnosedhearinglossesinvolvedthefrequencyof4000Hz,46.1%involved6000Hz,
and5.1%involved3000Hz.
Table9:Percentofstudentswithknownhighfrequencyhearinglosswhowouldhavebeenidentifiedby
fourhearingscreeningprotocols(Meinke&Dice,2007).
27
ScreeningProtocol
PercentageofKnown
HFHearingloss
Identified(HitRate)
20dBHLat1000Hz,2000Hzand4000Hz
22.2
25dBat1000,2000,and4000Hz
6.7
Protocolsthatincludescreening6000Hzat20dB
44.4
15dBat500,1000,2000,4000,and8000Hz
44.4
Numberofpresentations
Screeningimpliesthataspecificpass/failcriterionisappliedtoallresults.Itisnotunusualfor
childrentofailtorespondtoasinglepuretonepresentationwhenhearingscreeningisperformedinthe
presenceofvaryinglevelsofambientnoise,whenyoungchildrenhavelimitedattentionspans,orwhen
theintensityofthepuretoneisclosetothreshold.Becauseofthis,itisassumedthatapuretonewillbe
presentedmorethanonceifachildfailstorespond.Cautioniswarrantedtopreventpresentingso
manyrepetitionsofthetonethattheeventualfalsepositiveresponsesfromachildwillbeconsidereda
pass.Therefore,itisreasonablethatmorethanone,butnomorethanseveral(i.e.4)puretone
presentationsoccurifachilddoesnotrespondtothefirstpuretonepresentation.Otherthanfor
trainingpurposes,itisimportantthatthechosendecibellevelscreeningcriterionbeadheredto
throughoutthehearingscreeningandthatthelevelisnotincreasedifachildfailstorespond.
Screeningenvironment
Basedona20dBHLscreeninglevel,theallowableambientnoiseifanindividualhas0dBHL
hearingthresholdsis50,58,and76dBSPLrespectivelyfor1000,2000,and4000Hz(ANSIS3.11999
(R2003).Ambientnoisesourcesfromventilation,adjacenthallorclassroomnoise,childrenmoving
abouttheroomandscreeningpersonnelgivinginstructionsallcontributetodifficultyscreeningatlevels
lessthan20dBHL.Mostschoolsystemsdonothavetheequipmentorexpertisetotakeambientnoise
measurementsintheareastobeusedforscreening.Analternateapproachistouseabiologicnoise
levelcheckpriortothecommencementofhearingscreening.Thishasbeendefinedastheabilityto
establishhearingthresholdsatleast10dBbelowthescreeninglevel(e.g.10dBHLforscreening
conductedat20dBHL)atallfrequenciesforapersonwithknownnormalhearing.Ifthesethresholds
cannotbeestablished,theareamustnotbeusedforscreening(Minnesota,DepartmentofHealth,
2006).
28
Schooldistrictsshouldbecautiouswhenconsideringaddinghighfrequencytonestothe
hearingscreeningprotocolassensitivityofthescreeningprogrammaydecreaseduetoresponse
variabilityat6000Hz(Hood&Lamb,1974).SchlauchandCarney(2010)recommendedthatprecisionof
audiometricresultscouldbeimproved by (1) eliminatingsystematiccalibrationerrors,includinga
possibleproblemwithreferencelevelsforTDHstyleearphones;(2)repeatingandaveragingthreshold
measurements;and(3)usingearphonesthatyieldlowervariabilityfor6000and8000Hz(two
frequenciescriticalforidentifyingnoisenotches).
ImmittanceScreening
Tympanometry
Sinceitsdevelopmentinthe1970stympanometryhasbeenusedtoassessmiddleearfunction
intheclinicalsetting(Margolis,Hunter&Goeboml,1994).Tympanometryputsvariedairpressureinto
theearcanalandthenmeasurestheacousticenergythatistransmittedthroughthemiddleearsystem.
Theearcanalpressureinrelationtothemeasuredacousticadmittanceisthenplottedonagraphcalled
atympanogram.Tympanometryisnotatestofhearingsinceitdoesnottestauditorypathwaysbeyond
themiddleear.Krueger&Ferguson(2002)identifiedahighrateoffalsepositives(6.4%)forstudents
failingtympanometryscreeningascomparedtopuretonescreeningat35dBHL.Theseauthorsfound
thattwoproblemswereapparent.First,puretonescreeningandtympanometryassessdifferent
aspectsoftheauditorysystem.Becausetympanometryisnotameasureofacuity,comparingittopure
toneresultsthatdomeasureacuityisflawed.Secondly,tympanometryisamoresensitivetoolthanthe
useofa35dBscreeningleveltoidentifystudentswithmiddleeareffusion.
Inthe1970s,muchresearchwasfocusedontheuseofimmittance(thenknownasimpedance
audiometry)toidentifypoormiddleearfunctionthatistypicallyassociatedwithotitismediawith
effusion.ThequestionatthattimewasnotifweshouldidentifyOMEbutratherhowbesttodoso.
Entireconferencesweredevotedtothetopic,andimpedanceaudiometrywasestablishedasaviable
toolforscreeningchildrenforthepresenceofmiddleearfluid(Harford,Bess,Bluestone,&Klein,
1978;TaskForceoftheSymposiumonImpedanceScreeningforChildren,1978).Tympanometry
hasbeenusedclinicallyfordecades,anditisanacceptedclinicalstandardforidentifyingthelikely
presenceofOME(Watters,Jones,&Freeland,1997).
Middleearpressure
Whenaerationofthemiddleearspaceisinterruptedbypartialorcompleteobstructionofthe
Eustachiantube,theairinthemiddleearspacebecomesstaticandisabsorbedbythemucosallining.
Negativemiddleearpressure(MEP)causesthetympanicmembranetobecomeretractedandifthis
conditionpersistsoveraperiodoftime,fluidmayfillthemiddleearspace.ThelongernegativeMEP
29
exists,thegreaterdegreeoflossoftheimmunoprotectivepropertiesofthemiddleear.This,in
combinationwithaninflammatoryprocess,createsaviciouscyclewithrecoveryoccurringmoreslowly
witheachepisodeespeciallyatyoungerages(Northern,Rock,&Frye,1976;Tos,1982).Because
negativeMEPisaprecursortotheformationofmiddleeareffusion(MEE),itisoftenstudiedinyoung
childrenwheretheprevalenceofOMEisgreater.
Bluestone,Beery,&Andrus(1974)statedthattympanometryasameasureofMEPisan
effectivetooltoidentifyEustachiantubedysfunctionbutacknowledgedthatidentifyingthepresenceof
anabnormalconditionisnotsynonymouswithidentifyingthosethatshouldbereferredformedical
evaluation.OtherreportsdonotrecommendtheuseofMEPinisolationfordeterminingwhetherornot
amedicalreferralshouldbemade(Paradise&Smith,1975;Hopkins,1978).Roeser,Soh,Dunckel,&
Adams(1978)foundpooragreementbetweenotoscopyandMEPintheidentificationofMEE.They
reexaminedtheirdatatoseeifraisingthecutoffforMEPwouldimproveagreementandfoundthatit
didnot.FindingsbyLewis,Dugdale,Canty,andJerger(1975)weresimilar.
TheuseofMEPhasbeencriticizedasascreeningtoolduetotheoverreferralsitgenerates
(Bluestone,Fria,Arjona,Casselbrant,Schwartz,Ruben,Gateo,Downs,Northern,&Jerger,1986;Page,
Kramer,Novak,Williams,&Symen,1995),andtheASHAGuidelinesforAudiologicScreening(1997)
recommendthattympanometricpeakpressure(TPP)notbeusedtoscreenformiddleeardisordersin
childrenbirthage18.Althoughfluctuationsinmiddleearstatuscanbereflectedinothercomponents
oftympanometry,greatvariabilityexistsinnormalMEPofyoungchildren.Liden&Renvall(1978)and
Renvall&Liden(1978)foundthat90%of7yearoldsubjectshadnegativeMEP<150.Margolisand
Heller(1987),Nozza,Bluestone,Kardatzke,andBachman(1992),Nozza,SaboandMandel,(1997),and
Lyons,Kei,andDriscoll(2004),allfoundasimilarlargerangefornormalmiddleearresponses.To
evaluatetheuseoftympanometricvariablesintheidentificationofMEE,Nozza,Bluestone,Kardatzke,
andBachman(1992)studied61subjectsundergoingmyringotomyandtubesurgery.ThosewithMEEat
thetimeofsurgeryhadMEPrangingfrom375to67decaPascals(daPa),whereasthosewithoutfluid
hadarangeof458to+18daPa.Duetothelargevariabilityfoundinbothgroups,theuseofMEPdid
notappeartobeaneffectivetooltoidentifymiddleeareffusion.
FitzZalandandZink(1984)screened3510kindergartenand1stgradestudentsfollowedby
audiologicalandmedicalexamswithin2daysofscreening.Whencombiningpuretonescreeningwith
tympanometryscreeningusingaflat(TypeB)tympanogramorMEPinexcessof200mmH2Oasrefer
criteria,sensitivitywas100%andspecificitywas97%.Althoughtheoverreferralratewas42%,the
underreferralratewas0%.Resultsofuseof150and175mmH2OarereportedinTable3.
Roeser,JinSoh,DunkelandAdams(1978),Schwartz,Schwartz,Rosenblatt,Berry,andSweisthal
(1978)andKonkle,Potsic,Rintelmann,Keane,Pasquaariello,andBaumgart(1978)studied
tympanometricchangeovertimeandsuggestedthatchildrenwhoseMEPwasbetween100and200
daPaberetestedin6weeksbecauseitisthedynamictrendofMEPratherthanastaticstatethatis
30
mostimportantindeterminingifamedicalreferralshouldbemade.Asameanstomoreclearlyidentify
childrenwithnegativeMEPwhoshouldbereferredfromthosewhomightbenefitfromfurther
monitoring,ParadiseandSmith(1975)suggestedtheadditionaluseofgradient(sharpversusgradual)as
ameanstoreducefalsepositives.
Tympanometricwidth
AnalternativeclassificationsystemtotheearlierABCsystemdevisedbyJerger(1970)was
offeredbyParadiseandSmith(1975)asameanstomoreclearlyseparatethosewhoshouldbereferred
formedicalmanagementfromthosewhomightbenefitfromfurtheraudiologicalmonitoring.They
proposedtheuseofwidthandgradient(sharpvs.gradual)inthisclassificationsystemandfoundthatby
usingtympanometricshape(width,gradient)inconjunctionwithmiddleearpressure,thenumberof
falsepositivescouldbereducedby44%.
Thetermgradienthasbeenusedinseveralstudiesbutisdefineddifferentlyineach(Nozzaetal,
1992;Roush,Bryant,Mundy,Zeisel,&Roberts,1995;DeJonge,1996).Ontheotherhand,
tympanometricwidthisalwaysclearlydefinedasthedistanceindaPabetweenthesidesofthe
tympanogramatonehalfofthepeakadmittance.AccordingtoNozzaetal(1992),widthisconsidered
thebestsinglevariablefordiscriminatingbetweenearswithorwithoutmiddleeareffusion,witha
negativepressurecutoffofgreaterthan275daPabeingpositiveformiddleeareffusioninchildrenage
1to12years.Whenincludingonlychildrenage3to12years,acutoffgreaterthan250daPacanbe
used.Whenconsideringtympanometricwidthinrelationtochildrensages,theyoungerthechild,the
greatertheacceptablewidthtopredictnormaloreffusionfreeears(Roushet.al,1995).Larger
tympanometricwidthhasalsobeenassociatedwithearshavingarecenthistoryofmiddleeareffusion
(Henderson&Roush,1997).Thus,tympanometricwidthcanbeconsideredabetterpredictorofmiddle
eareffusionthanmiddleearpressure,althoughmedicalpractitionersreceivingreferralsfromhearing
screeningmaybemorefamiliarwithinterpretationofMEPandstaticcompliancethanwiththe
implicationsoftympanometricwidth.
Staticadmittance(compliance)
Staticadmittanceisameasureofmiddleearmobilitythatrepresentsthetransmissionofenergy
throughthemiddleearspaceinitsrestingstate.Onceatympanogramhasbeencompleted,thestaticor
restingadmittanceofthemiddleeariscomputedfromtwovalues:thecompliance(C2)obtainedat+200
daPaintheearcanalandthecompliance(C1)atthetympanometricpeak.Staticcomplianceofthe
middleearisthencalculatedbysubtractingthefirstcompliancefromthesecondcompliance[(C)=C2
C1](Zwislocki,1963).
Inastudyof280subjects,Paradise,SmithandBluestone(1976)foundthatlowtympanic
membranecompliancewashighlycorrelatedwithotitismediawitheffusion.Nozza,etal.(1992),found
31
thattympanometricpeakheightandtympanometricwidth,independentlyaswellasincombination,
stronglyinfluencedtheprobabilityofmiddleeareffusion,whereastympanometricpeakpressurehad
onlyminorinfluence.Inastudythatwasundertakentoacquirenormativedataforstaticadmittance
andtympanometricwidthinchildrenunder3years,Roush,etal.(1995)foundthat90%ofchildrenin
thestudywithoutmiddleeareffusionhadstaticadmittancewithintherangeof0.2and0.7mmhos
(millimhos).Itiscommontofindshallowtympanograms(i.e.,0.2mmhos)thatdonotindicatea
compromisedmiddleearsystemintheAsianAmericanpopulation(Wan&Wong,2002).Becausestatic
admittancevaluescanvarywidelywithage,ethnicity,andmiddleearpathology,thismeasureshould
onlybeusedinconjunctionwithothermeasurestoassessmiddleearfunctioning.
AcousticReflexandReflectometry
Acousticreflextestingmeasuresthemovementofthetympanicmembraneasanindirect
measurementofthecontractionofthestapediusmuscleinthemiddleearinresponsetoaloudsound.
Itisfrequencyspecific,objective,andtestsuptothelevelofthebrainstemandcanbeusedonstudents
whoareunabletoperformapuretonehearingscreening.Themaindrawbackofcontralateralacoustic
reflexisthatithasanextremelyhighfalsepositiverate.AstudyperformedbyFitzZalandandZink
(1984)on3,510studentsfoundthat30.4%ofthechildrenwithnormalhearingandnormalmiddleear
statushadabsentcontralateralreflexes.StudiesbyRenvallandLiden(1980)andBrooks(1974)found
similarresults.Duetotheunacceptablefalsepositiverate,contralateralacousticreflexcanberuledout
asanacceptablescreeningmeasure.Asearchoftheliteratureregardingtheuseofipsilateralacoustic
reflexforscreeningpreschoolandschoolagedchildrenwasunsuccessful.
Acousticreflectometrywasintroducedin1984asamethodofimprovingthediagnosisofotitis
mediawitheffusion(OME),particularlyinchildren.EarlyresearchassummarizedbyHolmesetal.
(1989)suggestedgoodspecificitybutwidelyvaryingsensitivityforthisscreeningprocedure.More
recentstudies(Babbetal.2004;Chianeseetal.2007)reportonuseofnewertechnologythatprovides
measuresofreflectivityintermsofspectralgradientlevelsandangledata.Theirresultssuggestagain
thatthistechniquehasgoodspecificitybutvaryingsensitivitythatappearsdependentonthepass/fail
cutoffpointsusedforinterpretation.Allstudiesreviewedconcludedthatacousticreflectometrywas
notasefficientinidentifyingOMEaseithertympanometryorpneumaticotoscopywhenscreeningthe
normalpopulation.
ScreeningwithSpeechStimuliMaterials
RitchieandMerklein(1972)studiedtheeffectivenessofusingtheVerbalAuditoryScreeningfor
Children(VASC)withpreschoolersasameanstoidentifyhearingloss.TheVASCusesataperecording
ofspondaicwordsatprogressivelyattenuatedlevelswithapicturepointingidentificationresponse
(Mencher&McCulloch,1970).Inthisstudy,162childrenweretestedwithpuretonesandtheVASC,
32
andofthe41studentswhofailedthepuretonethresholdtests,48.8%weremissedusingtheVASC.The
authorsconcludedthattheVASCisamuchlessefficientmethodofidentifyinghearingimpairment
whencomparedtousingapuretonetestwithpreschoolchildren.
OtoacousticEmissionsScreening(EarlyChildhoodandSchoolAge)
Successfulcompletionofpuretonescreeningcanbechallengingwhenscreeningyoungchildren
orthosewithspecialneeds.Ananalysisofpuretonehearingscreeningresultsfromwellchildvisitsat
thepediatriciansofficefoundthat3yearoldsare33timesmorelikelythanolderchildrentobe
recordedascouldnottestforpuretonescreening(Halloranetal.,2005).Fortyfivepercentof3year
oldsdidnotcompletethescreening,comparedwith7%ofthe4yearolds,andthispercentage
decreasedwithincreasingage.Thesechallengessuggesttheneedforconsideringanalternativetopure
tonescreeningforyoungchildren.
MeasurementofOtoacousticemissions
Otoacousticemission(OAE)assessmentistechnicallynotatestofhearing,butrathera
reflectionofinnerearmechanics.OAEsaresoundsdetectedintheexternalearcanalthatare
generatedbytheouterhaircellswithinthecochlea.OAEsrecordedintheabsenceofstimulationare
knownasspontaneousOAEs.OAEsthatarerecordedinresponsetoauditorysignalsareknownas
evokedotoacousticemissions.Whenclicksortoneburstsareusedtostimulatetheear,transientOAEs
(TEOAEs)areelicited.Twopuretones,alsoknownasprimaries(f1=lowfrequencyprimaryandf2=high
frequencyprimary),areusedtogeneratedistortionproductOAEs(DPOAEs).Clicksstimulateamajority
ofthebasilarmembrane,whilestimulationwithtonesisrestrictedtoadiscreteregion.OAEsare
measureableinearswithnormalhearingsensitivityandinearswithabnormalhearingsensitivityofup
to3040dBHL(Gorgaetal.,1997;Hussainetal.,1998).Both,TEOAEsandDPOAEshavebeenusedto
screenforhearinglossininfantsandchildren.OAEsarealsousedtodocumentouterhaircellfunction
inpersonswithauditoryneuropathy/auditorydyssynchrony(Starretal.,1996;Berlinetal.,2005).
WhenperformingOAEscreening,asmallprobeisplacedintheearcanalandisusedtopresentthe
stimuliandrecordtheresponse.Itisimportantthatthestatusoftheouterandmiddleearsiswithin
thenormalrangeasthesestructuresformthepathwayforstimulitotheinnerearandforreverse
transmissionofresponsestotheearcanal.
OAEscreeningconsiderations:environmentandtime
OAEsarelowamplitudesignalsthattravelfromtheinnerearbacktotheearcanal.An
importantvariableinthevalidityofOAEscreeningresultsisthelevelofnoiseintherecording.Validand
reliableOAEresultsdependonthescreeningenvironmentbeingasfreefromnoiseandvibrationas
possible.Properselectionandplacementoftheprobetipresultinginagoodacousticsealcanmitigate
theeffectsofbackgroundnoisesignificantly.Disposabletipsarepreferredforoptimalhygieneand
33
infectioncontrol.Ifreusabletipsareused,systematicproceduresareneededtoensuredisinfectionof
tipsbetweenuses.AllstudiesonOAEscreeningreviewedherewerecompletedintypicalschool
screeningsettingsorinhomes,thusillustratingthatitispossibletomeasureOAEsinscreening
environmentsinschoolfacilities,withoutasoundattenuatingbooth.Driscoll,KeiandMacpherson
(2001)reportedambientnoiselevelsbetween34dBAand51dBA,thusprovidinganacceptablerange
tocompleteOAEscreening.TesttimesreportedforTEOAEscreeningrangefrom25secondsto330
seconds(Richardsonetal.,1995;Driscoll,Kei&Macpherson,2001;Sideras&Glattke,2006).Eiserman
etal(2008)reportedanaverageof4.8minuteswitharangebetween1minuteand30minutesto
completevisualinspectionandDPOAEscreeningonpreschoolchildren.Assumingaquietenvironment
andastillchild,thescreeningproceduretakeslessthanaminute.Longerscreeningtimeswere
associatedwithtechnicaldifficulties,noisyenvironments,increasedphysiologicalnoise(e.g.,heavy
breathingorswallowing),excessivechildmovement,noncomplianceofsubjects,andpresenceof
hearingloss.
Transientevokedotoacousticemissions
ResearchexploringthepotentialroleofTEOAEsinscreeningpreschoolersandschoolage
childrenissummarizedinTable10.AllstudiesreportedutilizingclickstoobtainTEOAEs.Themajority
ofmeasuresofscreeningperformancecharacteristics(i.e.,sensitivityandspecificity)werebasedon
resultsofpuretonescreeningorpuretonescreeningandtympanometry.Onlytwostudiesused
diagnosticaudiologicresultsasthegoldstandardtocalculatesensitivityandspecificity.Itisimportant
tonotethatpuretonescreeningalsohasitslimitations,andusingtheseresultsasthegoldstandardis
notasstringentasusingdiagnostictestresults.
MoststudiesusedthedefaultsettingontheTEOAEequipmentforstimulusintensity(i.e.85dB
peSPLor80dBpeSPL).Arangeofvariableswasusedtosetpass/failcriteriaforTEOAEscreening
results.Sensitivityrangedfrom0.65to1.0.Lowersensitivityvalueswereassociatedwiththeuseof(1)
adiagnostictestasthestandard,(2)multiplevariablesforpass/failcriteria(e.g.,OAE<7dBandOAE/N
0dB),and(3)resultsofbothpuretonescreeningandtympanometry.Areductioninsensitivitywhen
comparedwithbothpuretonescreeningandtympanometryindicatesthatTEOAEsarenotsensitiveto
middleearpathologiesidentifiedusingtympanometry.Whencriteriausedfornewborns(3dBSNR
acrossthefrequencybandsof20003000Hzand30004000Hz),wasusedontheschoolagepopulation,
sensitivitywas68%andspecificitywas90%(Driscoll,Kei&Macpherson,2001).Thus,32%ofchildren
withidentifiablehearinglossweremissedbyTEOAEscreeningusingnewbornscreeningcriteria.This
wasattributedtothelowsensitivityofTEOAEstoidentifymiddleeardysfunctioninthispopulation.
GiventhedevelopmentalchangesseenwithTEOAEs,useofnewborncriteriaforolderchildrenmaynot
beappropriate,andconsiderationshouldbegiventousingdifferentTEOAEpass/failcriteriaforschool
agechildren.
34
TEOAEsarereducedinamplitude(orpotentiallyabsent)inthepresenceofmiddleear
conditions,especiallyinthelowfrequencies(Naeveetal.,1992;Trine,Hirsch&Margolis,1993;Norton,
1994).Hoetal.,(2002)foundthatthegreatestcorrelationbetweenTEOAEfailureandtympanometry
occurredwhentympanometricwidth>300daPawasusedasthecriterionforfailure.Theyalsofound
that68%ofthechildrenbetween2weeksand5yearsfailedtheTEOAEscreeningduetoanabnormal
tympanogram.TEOAEfailurehasalsobeendocumentedinthepresenceofnegativemiddleearpressure
(Hoetal.,2002)andincreasedadmittance(Nozzaetal.,1997).WhenTEOAEtestperformancewas
comparedwithpuretonescreeningandtympanometry,sensitivityandspecificitywerereduced(Nozza
etal.,1997;Driscoll,Kei,&McPherson,2001).ComparisonofTEOAEandtympanometryresults
revealedsensitivityvaluesofonly60%(Taylor&Brooks,2000)and69%(Georgalasetal.,2008).Nozza
etal.(1997)revealedpoorcorrelationsbetweenTEOAEvariablesandtympanometricvariablesinears
thatwereinthenormalrangeontympanometry.Reproducibilityat2000Hzwasaffectedbyscarringon
thetympanicmembranethatwasreflectedontheadmittancemeasure.Duetolackofa
straightforwardrelationshipbetweenTEOAEvariablesandtympanometricvalues,TEOAEscannotbe
usedtopredictmiddleearstatus.IfTEOAEsareusedtoscreenpreschoolandschoolagechildren,itis
prudenttouseitalongwithtympanometrygiventhehighincidenceofmiddleearpathologyinthis
populationandthelowsensitivityofTEOAEstodetecttheseconditions.
ReferralrateswithTEOAEscreeningrangefrom9%(Yinetal.,2009)to13%(Saboetal.,2000)in
thenormalpopulationwithagerangesbetween26yearsand59years.Referralratesareashighas
40%forspecialpopulations(Driscoll,Kei,Bates,&McPherson,2002).ResearchconductedbySideris
andGlattke(2006)comparedtheresultsofconventionalpuretonebehavioralscreeningandtransient
otoacousticemissions(TEOAEs)for200childrenages2years1monthto5years10months.The
referralratesobtainedwiththetwoproceduresweresimilar;21.5%referredfrompuretonescreening
and21%referredfromTEOAEscreening.However,themajorityofthereferrals(>50%)fromthepure
tonescreeningwereduetotheinabilitytoconditionthechildrentorespond,whereasonly10%ofthe
referralsfromTEOAEswereduetolackofcooperation.Nearlytwothirds(62%)ofthechildrenwho
werereferredbyTEOAEscreeningalsofailedimmittancescreening.
Table10.SummaryofscreeningstudiesusingTEOAEs.
Study
Authors
Protocol
Subjects
Protocolfor
Pass/fail
Test
TEOAEs
criteria
performance
goldstandard
=puretone
screeningor
diagnostictest
35
Richardson
Standard
52
85dBpe
SPLclicks
diagnostic
children
Williamson
audiometry
(104
Quickscree
ears)
nonILO
,Lenton,
TEOAEs
Tarlowand
Rudd,
Wavefor
Sensitivitywas
1.0forall
correlatio
criteriaused
n50%
Specificity
0.215
Weighted
rangedfrom
years
response
0.47to0.82
level2dB
1995
Highest
Corrected
specificityfor
response
bandwidth
level0dB
S/Nratioof3
Rhode
Island
dB
criteria
(S/Nratio
of3dBat
anythree
frequenci
es
between
1KHzand
4KHz)
Bandwidt
h
waveform
reproduci
bility60%
Bandwidt
hS/N
ratio3dB
Nozza,
Saboand
TEOAEs
Puretone
66
students
Manel,
screening(20 510
1997
dBHLat1
yearsof
83.5dBpe Wavefor
SPL
Default
modeon
Sensitivity
rangedfrom
reproduci
0.67to1.0(by
bility
ears)
36
KHz,2KHz,
age
(50%and Highest
ILO88
40%)*
4KHzand25
OAE
dBat0.5
sensitivity
seenfor*
amplitud
pass/fail
Pneumatic
es(68
values
otoscopy
dBSPL)
KHz)
OAE/N(0
Tympanomet
ry
Specificity
rangedfrom
dBand1
0.8to0.97(by
dB*)
ears)
Reproduc
Highest
ibilityat
specificity
2KHz
seenforOAE<
(50%)*
7andOAE/N
OAE<7
dBor
0
Sensitivity
OAE/N
rangedfrom
0*
0.6to1.0(by
OAE<7
children)
and
Specificity
OAE/N
rangedfrom0.7
to0.96(by
children)
*seenext
column
Sabo,
Winston
TEOAEs
Puretone
583
children
Default
S/Nratio
settingson
of3dB
and
screening(25 59years
Echoport
and
Macias,
dBHLat0.5k
ILOV5
reproduci
2000
Hzand20dB
system
bilityof
Sensitivityof
65%
Specificity
was91%
Compared
HLat1,2,4
70%and
withresultsof
kHz)
stability
audiometric
of90%
assessment
Audiometric
assessment
37
Taylorand
Brooks
2000
TEOAEs,
Tympanomet
ry
Puretone
75dB85
S/Nratio
dBpeSPL
of3dBin
(297
Otodynami
atleast3
ears)
cILO88
frequency
152
children
screening(20 38years
Sensitivityof
81%
Specificityof
94%
bands
dBHLat1,2,
4kHz)
Driscoll,
Otoscopy,
940
80dBpe
S/Nratios Sensitivity
Keiand
TEOAEs
children
SPL
of1,2,3,
rangedfrom
Macpherso
Puretone
(1880
Quickscree
4,7,9,15
0.7to0.89
ears)
nonILO
dBat
292
2.4,3.2,4
sensitivitywas
kHz
atS/Nratioof
n(2001)
screening(20
dBat0.5,1,
2,4KHz)
6years
old
Highest
Tympanomet
15dB
Specificity
ry
rangedfrom
0.84to0.96
Highest
specificitywas
atS/Nratioof
1dB
Yin,
Bottrell,
TEOAEs
Puretone
744
preschoo
80dBpe
SPL
enon
frequenc
was0.94
ILO288
yranges
lchildren Quickscre
Shasksand
dBHLat1,2,
complet
Poulsen,
4KHz)
ed
142
was1.0
Specificity
screening(25
TEOAEs
of5dB
for3of5
Clark,
2009
S/Nratio Sensitivity
(presetat
factory)
children
complet
edboth
TEOAEs
andpure
38
26years
DistortionproductOtoacousticemissions
UseofDPOAEsasascreeningmeasurewasinvestigatedintwomajorstudiessummarizedin
Table12.Bothofthesestudiesusedthesamestimulusparameterstoelicitthe2f1f2DPOAE(f2/f1
ratioof1.22,L1/L2=65/55dBSPL).Pass/failcriteriaweredependentonfrequencyoff2.Lyon,Driscoll
andKei(2004)used3differentS/Nratiosforpass/failcriteria.DPOAEsalongwithtympanometryand
puretonescreeningresultswereobtained,andthebesthitrateswereobtainedwithaSNRof5dBat
1.9kHzand11dBat3.8kHz.At1.1kHz,hitrateswerelowandfalsealarmrateswerehighowingto
increasedambientandphysiologicalnoisecontaminatingtheresponse.Inchildrenwhofailed
tympanometry,DPOAEamplitudeswerereduced,leadingtoareductionintheSNRaswell.Hitrates
reducedandfalsealarmratesincreasedwhenDPOAEresultswerecomparedwiththebatteryofpure
toneandtympanometryresults.ThesetwostudiesareinagreementthatDPOAEsarenotsensitiveto
thoseconditionsdetectedusingtympanometry.OthershavealsoreportedthatDPOAEsareknownto
beaffected(especiallyinthelowfrequencies)inthepresenceofmiddleearconditions(Owensetal.,
1993;Akdogan&Ozkan,2006)
Table11.SummaryofscreeningstudiesusingDPOAEs.
Study
Protocol
Subjects Protocolfor
Authors
1003
Pass/fail
DPOAEs
criteria
F2
S/Nratios
Testperformance
Besthitrates
Lyons,
Otoscopy
Kei&
DPOAEs,
school
frequencies
of4,5,and
obtainedwith5
Driscoll,
Tympanometry
childre
at1.1,1.9,
11dBat
dBSNRat1.9
2004
Puretone
3.8kHz
1.1,1.9
kHz(0.89),and
and3.8
11dBSNRat3.8
kHz,
kHz(0.90).
screening(20
dBHLat0.5,1,
4.17.9 F1/f2=65/55
years
2,4kHz)
dBSPL
F2/f1ratio
of1.21
frequency
Highfalsealarm
specific
rate.
analysis
conducted
Eiserman DPOAEs(upto 4519
F2
Frequency
Sensitivityand
39
etal.,
3OAE
childre
frequencies
specific
Specificitycould
2008
screeningsina
at2,3,4,5
pass/fail
notbe
kHz,
criteria
calculated.
24week
period)
3
years
Otoscopy
Diagnostic
assessments
F1/f2=
old
65/55dB
minimum
SPL,
DPof6dB
F2/f1ratio
of1.22
with
at5kHz,5
at4kHz,8
at3kHz,7
at2kHz
withaS/N
ratioof6
dB.
Eisermanetal(2008)describedamultistepstrategytoscreenmigrantchildrenenrolledin
HeadStartprograms.TheprotocolincludedvisualexaminationanduptothreeDPOAEscreensovera
24weekperiod.Thescreeningstookplaceinclassroomplaysettingsandhomes.Thereferralratefor
thefirststageofDPOAEscreeningwas18%,and6%ofthechildrenwereclassifiedascanttestdueto
excessiveinternalorexternalnoise.Afterthethreescreenings,5.7%ofthechildrenwerereferred,
resultscomparabletothosereportedbyKruegerandFerguson(2002),whopublishedareferralrateof
6.3%intheirDPOAEscreeningstudy.Themajordrawbackofamultistepscreeningprotocolislossto
followup.FifteenpercentofthechildrendidnotreceivethesecondDPOAEscreening,and20%ofthe
childrendidnotreceivethethirdstepscreening.Althoughthescreeningsweretooccurina24week
period,thisperiodwasnotstrictlyadheredtoduetoparentcomplianceissuesandscreenerschedules.
SummaryofResearchonOAEandChildhoodScreening
TEOAEandDPOAEscreeningcanbecompletedsuccessfullyinregularearlychildhoodand
schoolenvironmentswhenextraneousnoiseiskepttoaminimum.
Pass/failcriteriaforTEOAEsneedtobechosencarefullytomaximizesensitivityandspecificity.
OptimumSNRsforpass/failcriteriaforDPOAEsarefrequencydependent.
Duetocompromisedsensitivityandspecificity,TEOAEsorDPOAEscannotreplacethepreferred
batteryofpuretonescreeningandtympanometry.
MiddleearstatuscannotbeinferredbyOAEmeasurementsaloneandshouldbeverifiedif
OAEsareabsenttoruleouttransitorymiddleeareffusionasacauseoffindingsabsentor
reducedinamplitude.
40
ReferralratesforTEOAEscreeningrangefrom9%to21%inpreschoolandschoolagechildren,
andtheratemaybehigherwhenscreeningspecialpopulations.ReferralratesforDPOAE
screeningarearound6%.
Multistepscreeningprotocolsmaybeusedtoreducereferralrates;however,itisimportantto
notethatlosstofollowupisaconcernwhenusingthisprotocol.
Althoughnotmentionedinanyofthescreeningstudiesreviewedearlier,itisusefultonotethat
OAEscanbemeasuredinearswithpatentpressureequalizationtubes,althoughresponse
amplitudemaybereduced(Owens,McCoy,LonsburyMartin,&Martin,1993).
LimitationsofOAEscreening
TEOAEsandDPOAEsarerecordablefrommostearswithnormalperipheral(outerhaircell)
function.However,TEOAEsmayberecordedinsomeearswithhearingsensitivityinthemildrange(20
30dB),andDPOAEsmaybeseeninsomeearswithhearingsensitivityinthemildtomoderaterange
(2050dBHL).AsTEOAEsandDPOAEsmayberecordedinsomeearswithmildormildtomoderate
hearingloss,thesecasesmaybemissedinascreeningprogramthatutilizesOAEsonly.
ItmaynotbepossibletocompleteOAEscreeningonchildreninthelowfrequencyrange(<1000
Hz)eveninasoundtreatedroomduetocontaminationfromphysiologicalnoise.Ifacousticconditions
areunfavorableinschoolenvironments,itmaynotbepossibletoscreenbelow2000Hz.Although
TEOAEandDPOAEprotocolscanbemodifiedtonotemphasizelowfrequencymeasurement(e.g.,
shorteningthetimewindowforTEOAEsortestingDPOAEsat1000Hzandabove),appropriatepass/fail
criteriaforthe<1000Hzfrequencyrangehavenotbeenestablished.Atthistime,lowfrequency
hearingstatuscanbescreenedonlyusingpuretonesandcannotbeinferredusingOAEs.
AlthoughOAEscanbeanimportanttoolinscreeningprograms,itissignificanttonotethatasmany
as10%ofchildrenwithnormalOAEsmayhaveanauditorysynchronyproblem(Berlin,Morlet&Hood,
2003).Auditoryneuropathy/dyssynchrony(AN/AD)orauditoryneuralhearinglossisdefinedasa
formofhearingimpairmentwhereouterhaircellfunctionisnormalbutneuraltransmissioninthe
auditorypathwayisimpaired(Rance,2005).Mostnotably,individualswithAN/ADwilltypicallyhavethe
followingaudiologicalprofile:
Normaltympanometry
Abnormalacousticreflexes
NormalOAEs
Absentorgrosslyabnormalauditorybrainstemresponse(ABR)(arecordablemeasureofneural
synchronyfollowinganauditoryclickortoneburststimuli)
Variablepuretoneaudiometricresults
Significantlypoorerspeechperceptionabilitiesthanexpected
41
Althoughtheabovefactorsaretypical,itmustbenotedthatsomechildrenwithAN/ADhaveabsent
OAEswithevidenceofcochlearfunctionbasedonthepresenceofcochlearmicrophonics(Deltenreet
al,1999;Ranceetal,1999;Starretal,2001).Therehavebeensomeriskfactorsthatareassociatedwith
AN/ADincludingchildrenwithahistoryofhyperbilirubinemia,prematurity,perinatalasphyxiaand
familyhistory.However,manychildrenidentifiedwithAN/AD,donothaveanyriskfactors(Hood,
2002).Itisbeyondthescopeofthispaper,todiscussetiology,identificationandmanagementof
childrenwithAN/AD,otherthantonotethatthisauditorydisorderwillbemissedbyscreening
programsusingOAEsalone.
OAEFutureNeeds
MoreresearchisneededinordertoestablishtestandequipmentparametersifTEOAEor
DPOAEscreeningistobeconsideredareplacementforpuretonescreeninginthetypicalschoolaged
population.BlindedstudiesareneededtovalidateTEOAEandDPOAEtestperformancewiththe
goldstandardfordiagnosis,currentlyacomprehensiveevaluationforhearingloss.Also,OAEtest
performancecannotbecompareddirectlywithtympanometricresults,asthegoldstandardfor
identifyingmiddleeardiseaseispneumaticotoscopyandconfirmationviamyringotomy.Reflectance
measuresofmiddleearfunctionandOAEsmayhelpusdevelopmoreefficientprotocolsforscreening
forhearinglossandmiddleeardiseaseinthefuture.Additionaldataareneededregarding
developmentalnormsandappropriatepass/failcriteriausingTEOAEsandDPOAEs.Beforefirm
guidelinescanappropriatelybeestablishedforOAEasamassscreeningtoolforchildhoodpopulations,
trainingonhowtoconsistentlyattainaccurateresponsesrequiresstudyandreplication.Moredataare
neededregardingtheappropriateageatwhichscreeningcanbeaccomplishedforpreschoolersand
schoolagechildren.VerylittledataareavailableoncostsassociatedwithOAEscreeningprogramsin
preschoolandschoolagechildren.TechnicalchallengeswithOAEsincludedevelopingnewstrategiesto
reducenoiseinrecordingsandpossiblyevendevelopingstrategiestoscreenwiththeouterearpressure
equaltotympanometricpeakpressuretomitigatetheeffectsofnegativemiddleearpressureonOAEs
(Nozza,2001).
Rescreening
Thetermmassscreeningmeansthatallindividualswithinapopulationorlargesampleof
peoplewillbeexaminedinanidenticalmannertodeterminetheprobabilityofpresenceorabsenceof
sometrait,condition,orbehavior.Effectivemassscreeningprogramswillhaveoptimalsensitivityand
specificityrates.Duetovariationsinearphoneplacement,childbehaviorandhearingfluctuationsfrom
transientmiddleearconditions,a2tieredhearingscreeningprogramisrecommendedtoreducefalse
positiveresults.Thisprotocolwouldincludetheinitialscreenandsamedayrescreenforfailureswitha
secondtierrescreencompletedapredeterminednumberofweeksafterthedateofinitialscreeningfor
thosewhodonotpassthesamedayrescreen.Rescreening,preferablywithinthesamesession,has
42
beenfoundtoreducethenumberoffailuresbyapproximatelyonehalfduetorepositioningof
earphonesandreinstruction(Ayukawa,Lejeune,&Proulx,2003).ThedataavailablefromoneFlorida
schooldistrict(seeTable5)revealedthatimmediaterescreenreducedthetotalnumberoffailuresby
25%.
Becauseofthetransientcharacteristicsofmiddleeareffusionandtheneedtominimizeover
referral,screeningprotocolsformiddleeardisordershaverecommendedarescreeninresponseto
abnormaltympanometricresultsbeforerecommendingamedicalreferral(ASHA,1997;USDept.of
HealthandHumanServices,1997).Therationaleforthelengthoftheperiodbetweeninitialmass
hearingscreeningandrescreeningisbasedoninformationknownaboutspontaneousresolutionof
transientmiddleeareffusion.Theprevalenceofmiddleeareffusioninchildrenwithinthepreschool
populationisextremelyhighbutoftenresolvesspontaneouslywithouttreatment.Bluestone(2004)
foundthat80percentofmiddleeareffusionresolvedonitsownintwomonths.FiellauNikolajsen
(1983)foundthat36percentofcaseshadresolvedinfourweeks,anadditional23percenthadresolved
ineightweeks,and9percentmoreresolvedafteranotherfourweeks.Tos(1980)found50percentofa
populationof2yearoldsresolvedinthreemonthswithouttreatment.
Inordertoreducethehighoverreferralrates,theASHA(1997)guidelinesrevisedthetime
betweentheinitialscreenandtherescreento68weeks.TheAmericanAcademyofPediatrics(2004)
recommendedwatchfulwaitingofthechildwithOMEfor3monthsfromthedateofeffusiononsetor
diagnosisbeforeprovidingtreatment.Additionalreportsoftimebetweentheinitialscreenandthe
rescreenrangefrom2weeksinHeadStartprograms(USDept.ofHealthandHumanServices,1997),to
16weeksinaNewZealandprogram(Claridge,Schluter,Wild,&Macleod,1995).SerpanoandJarmel
(2007)lookedat34,979childrenthroughtheLongIslandHearingScreeningProgram,andreported18
percentofchildrenweremedicallyreferredformiddleeardysfunctionaftertheinitialscreenusing
ASHA(1997)criteria.Norescreenswereperformed.Of1,462preschoolersscreenedinaNorthCarolina
HeadStart,29percentofthechildrenreferredfollowingtheinitialscreenusingASHAcriteria,and8.5
percentofthechildrenstillhadabnormalresultsontherescreenwhichoccurredtwoweekslater(a
71%reduction)(Allenet.al.,2004).DataavailablefromoneColoradoschooldistrict(seeTable5)
revealedthatrescreenafter812weeksreducedthetotalnumberofchildrenrequiringreferralby
almost75%.Thetrendfromthereporteddataisthelongerthetimebetweentheinitialscreenandthe
rescreen,thelowerthenumberofchildrenfailingrescreenandrequiringreferral.
The2004AAPguidelinesrecommendthreemonthsofwatchfulwaitingforotherwisehealthy
childrendiagnosedwithOMEandfurtherstatethatantimicrobialsshouldnotbeusedforroutine
management.TheAAPguidelineswereestablishedforthemedicalcommunity,butbecauseschool
screeningprogramsoftenreferhearingscreeningfailurestothemedicalhome,theseguidelinesare
relevanttotheestablishmentofschoolprogramgoalsandprotocolsforrescreeningandreferral.
Vergisonetal.(2010)discussthedifficultydiscriminatingbetweenacuteotitismedia(AOM)andotitis
43
mediawitheffusion(OME),aswellasthechallengesindeterminingonsetandduration.Theseauthors
speculatethatlackofinformationregardingdocumentationofthedisorderisrelatedtothecontinued
systematicuseofantimicrobialdrugsforthetreatmentofotitismedia.WhenthedurationofOMEis
unknown,physiciansmustusewhateverevidenceisavailableandmakeareasonableestimate(AAP,
2004).
Hearingscreeningbyschoolsystemsthatincludesidentificationofchildrenwithmiddleear
malfunction,togetherwithsubsequentrescreeningormonitoringofhearingandtympanometryovera
23monthperiodcanprovidethemedicalcommunitywithimportantinformationonthedurationof
OMEsothatappropriatemanagementoptionscanbedetermined.Becauseofthelargenumberof
childrenroutinelyparticipatinginschoolhearingscreeningprograms,itislikelythattheinitialsuspicion
ofOMEwillbetheresultofschoolhearingscreeningratherthanfromthemedicalhome.Forthis
reasonacoordinatedeffortamongschoolscreeningprogramsandthemedicalcommunitywillresultin
theoptimummanagementforstudentswithOME.
Becausetheprimarypurposeofhearingscreeningprogramsistoidentifychildrenwith
previouslyundiagnosedpermanenthearingloss,itisimportantthattheprocessattemptstominimize
thetimebetweenhearingscreeningfailureanddiagnosisforthesechildren.Therefore,itwouldbe
appropriatetoimmediatelyreferchildrenwhofailpuretonehearingscreeningandasamedayhearing
rescreenbutpasstympanometry.Hearingscreeningprogramsmayalsochoosetorescreenchildren
failingpuretonescreeningatasinglefrequencyinoneorbothears,withpassingtympanometryresults,
ratherthanseekimmediatereferraldependinguponlocalcircumstances(interferenceofnoisein
screeningenvironment,availabilityofscreeningstaff,availabilityofindistrictaudiologicalevaluation,
etc.).
DISCUSSION/RESULTS/RECOMMENDATIONS
Aspreviouslydiscussed,childrenwithunilateral,minimalandfluctuatingconductivehearing
lossareallathigherriskforschoolproblemsthanchildrenwithnormalhearing.Therefore,identifying
childrenwithmild,highfrequency,conductiveorunilateralhearinglossusingcosteffective,stringent
screeningprotocolsinearlychildhood,preschoolorschoolsettingsarewarranted,asisthe
identificationofemerginghighfrequencyhearinglossinearlyadolescence.Evidencebasedhearing
screeningpracticestoidentifyallpotentiallyeducationallysignificanthearinglosscanbejustified;
however,districtlevelresources(e.g.screeningprogrambudget,personnel,educationalaudiologystaff)
andthewillinginvolvementofmedicalandclinicalaudiologyprofessionalsinthecommunitytoaccept
anddocumentoutcomesforhearingscreeningreferralswillultimatelyshapethepopulationstobe
identifiedandthestrengthofthefollowuppractices.
44
ProtocolRecommendations*
*Notethatthefollowingguidelinesareconsideredtobetheminimumstandardforeducational
settings.Programsareencouragedtofollowamoreintensiverescreeningandreferralprotocolwhere
staffingpatternspermit.
Puretonescreening
Table12.Summaryofpuretonescreeningrecommendationsforfrequencyandintensity
Pure
500Hz*
1000Hz
2000Hz
3000Hz 4000Hz
6000Hz** 8000Hz**
Rightear
No
20dB
20dB
No
20dB
No
No
Leftear
No
20dB
20dB
No
20dB
No
No
tonescreening
1. Performbiologiccheckonpuretoneequipmentpriortodailyscreening.
2. Screenusingpuretonesforpopulationsage3(chronologicallyanddevelopmentally)and
older.
3. Performapuretonesweepat1000,2000,and4000Hzat20dBHL.
4. Presentatoneatleasttwicebutnomorethan4timesifachildfailstorespond.
5. Screeninanacousticallyappropriatescreeningenvironment.Thescreeningenvironment
shouldnotexceed50,58,and76dBSPLrespectivelyfor1000,2000,and4000Hzasmeasured
byasoundlevelmeter.Ifnosoundlevelmeterisavailable,thescreeningenvironmentshould
bequietenoughforanormalhearingadulttoperceive1000,2000,and4000Hztones
presentedat10dBHL.Ifthisisnotpossiblethentheeffectivenessofhearingscreeningwillbe
compromisedduetohigherthanacceptablefailurerates.
6. Lackofresponseatanyfrequencyineitherearconstitutesafailureinordertomaximizethe
numberofnewlyidentifiedoremerginghearinglossesthatwillbeidentified.
7. Rescreenimmediately.Anychildthatfailstorespondatanyfrequencyineitherearshouldbe
rescreenedimmediately,preferablybyadifferenttesterandwithadifferentaudiometerto
includeremovingearphonesfromthechildsheadandcarefullyreplacingthemovertheears.
8. Gradesrecommendedforstandardprotocolsincludepreschool,kindergarten,andgrades1,3,
5andeither7or9ataminimumtoidentifyapproximately70%ofcasesofnewlyidentifiable
hearingloss(basedonthedataavailable).Ifidentificationofagreatproportionofchildrenwith
newhearinglossesisdesired,addinggrade2willresultinagreateryieldthanaddingahigher
45
gradelevel.Considerationshouldbegiventoscreeningforhighfrequencyhearinglossstarting
ingrade5.
9. *Usetympanometryinconjunctionwithpuretonescreeninginyoungchildpopulationsin
communitieswheremedicalprofessionalsandschoolsystemsjointlytargetidentifyingchildren
withotitismediawitheffusioninadditiontothosewithpermanenthearingloss.Screeningat
500Hzdoesnoteffectivelyidentifythispopulation.
10. **Screenforhighfrequencyhearinglossinschooldistrictsthatintendtoimplementnoise
inducedhearinglosspreventioneducationalefforts.Twoprotocolsarerecommended(a)
including6000Hzat20dBHL,or(b)screeningat15dBat500,1000,2000,4000and8000Hz.
Stepstopreventhighfalsepositiveratesinthehighfrequenciesshouldbeimplemented(per
SchlauchandCarney,2010).
Immittance
Tympanometry
Table13.Summaryoftympanometryrecommendations.
Perform
CutoffCriteria
Negativepressure
Initialscreening
No
Aspartofanimmediatefollowupor
Yes
TympanometricWidth250daPa
secondtierscreening(rescreening)
OR
(preferredcriteriauponwhichtobasereferral
decisions)OR
OR
Aspartofanimmediatefollowupor
Yes
secondtierscreening
Aspartofanimmediatefollowupor
secondtierscreening
NA
StaticAdmittanceFlator<0.2mmhos
OR
Yes
MiddleEarPressure>200daPato400daPaor
(donotreferbasedonthiscriteriaalone)
1. Calibratedaily.Priortouseeachday,tympanometryequipmentshouldbecalibratedper
manufacturerinstructions.
2. Tympanometryshouldbeusedasasecondstagescreeningmethod.Tympanometry
shouldbeusedasanimmediatenextscreeningstep,and/orsecondstagescreening,
followingfailureofpuretonehearingorotoacousticemissionsscreeningtohelpclarifythe
natureofthefailureandmostefficientreferralprotocol.Withthisstep,thestudentswith
activemiddleeareffusionandhearinglossversusthosewithpossiblesensorineuralhearing
losscanbedifferentiated.
46
3. Usedefinedtympanometryscreeningandreferralcriteria.Itisrecommendedthatfailure
beidentifiedastympanogramtracingsinexcessof250daPatympanometricwidth(255
daPato400daPa).Asecondarychoiceoffailurecriteriaiftympanometricequipmentdoes
notallowsettingfailurecriteriatotympanometricwidthisstaticadmittancelessthan0.2
mmhos(flattracingor0mmhosto0.19mmhos).Atertiarychoiceoffailurecriteriawould
benegativepressure>200daPato400daPa,howeverfailureofMEPcriteriaalonewould
notresultinamedicalreferral.Thiscriteriawouldbeappliedtoallchildrenwiththe
exceptionofthosewithlargeearcanalvolumeswhoareknowntohavepressure
equalizationtubes(thelatterwhowouldbeconsideredtopassscreeningwhenaflat
tympanogramandlargeearcanalvolumeispresent).Asecondexceptionwouldbefor
childrenofAsianheritagewithtympanometricpeakswithstaticadmittancelessthanthan
0.2mmhos.
4. Youngchildpopulationsshouldbetargetedfortympanometryscreening.Youngerchildren
(preschool,kindergarten,grade1)areathigherriskforhearingscreeningfailuresecondary
tomiddleeareffusion.Asthisisalsoaperiodofrapidlanguageandliteracydevelopment
forwhichgoodauditionisfoundational,itisrecommendedthatschooldistrictsconsider
includingtympanometryatleastforchildrenintoddler,preschool,kindergartenandfirst
gradepopulations.Ifthescreeningprogramhasthesupportofthelocalmedical
communityandthecapacityforfollowup,initialscreeningusingpuretone(orOAEfor<3
yearolds)andtympanometryfortheseyoungchildpopulationsshouldbeconsidered.
5. Useresultsofpuretoneandtympanometryrescreeningtoinformnextsteps.Theresults
ofthesecondhearingscreeningincombinationwithtympanometrycanhelpdeterminethe
needforperiodichearingmonitoringofthosechildrensuspectedofhavingrecurrentmiddle
eareffusion,referraltoaudiologyand/ormedicalevaluations,andcanbeusedasguidance
forschoolstaff(e.g.,teacherinservice,deferringeducationalevaluations).
Acousticreflexandreflectometry
Basedonthecurrentevidence,neitheracousticreflexscreeningnoracousticreflectometryare
recommendedforuseinmasshearingscreeningprogramsforpreschoolorschoolagedchildren.
SpeechMaterials
Useofspeechmaterialsformassscreeningofchildrenforhearinglossisnotrecommended.
OtoacousticEmissions
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1. Useonlyforpreschoolandschoolagechildrenforwhompuretonescreeningisnot
developmentallyappropriate(abilitylevels<3years).
2. Calibratedaily.Priortouseeachday,OAEequipmentshouldbecalibratedpermanufacturer
instructions.
3. DPOAElevelsat65dBSPL.ItisbesttomaintainprimarylevelsforDPOAEsatorbelow65dB
SPL(forexample,65/55or65/65)tomaximizetheresponse.
4. TEOAElevelsat80dBSPL.StimuluslevelsforTEOAEsshouldbemaintainedat80dB3dBto
avoidcontaminationoftheearcanalresponse.Atveryhighintensities,astimulusartifactsare
seentheearcanalresponse.FalseTEOAEresponsesmaybeseenwithclickspresentedathigh
intensities(e.g.,90dBpeSPL).
5. SelectDPOAEorTEOAEcutoffvaluescarefully.Pass/failcriteriashouldbechosencarefullyto
maximizesensitivityandspecificity.BasedoninformationsummarizedinTable10,a
combinationofparameters(e.g.waveformreproducibility,TEOAEamplitude,andTEOAEsignal
tonoiseratio)maybeusedascriteria.ForDPOAEs,criteriamaybebasedonminimumDPOAE
amplitudeandSNR.Thesecutoffvaluesmaybefrequencyspecific(seeTable11).Clinicians
areencouragedtocollectnormativedataandestablishcutoffcriteriawiththeirown
equipment.
6. Defaultsettingsmaynotbeappropriate.Itisimportanttounderstandthedefaultsettingson
equipmentusedfornewbornscreeningforstimulusparametersandpass/failcriteriabefore
thesesettingsareusedinnoninfantscreeningprograms.Performancespecificationsand
functionstobeprovidedbymanufacturersarespecifiedintheIECstandardsforOAEscreening
equipment(IEC60645,2009).
7. ScreeningprogramsusingOAEtechnologymustinvolveanexperiencedaudiologist.An
audiologistfamiliarwithOAEtechnologyshouldbeinvolvedindecisionmakingregarding
screeningtechnologyandintrackingprogramoutcomes.
8. ChildrenfailingOAEtestingshouldbescreenedwithtympanometry.Performing
tympanometryinconjunctionwithOAEscreeningwithsubsequentreferralforaudiological
evaluationforchildrenfailingOAEonlyandrescreeningforchildrenfailingbothOAEand
tympanometrymayreducetheneedformultistagescreeningandimprovelosstofollowup.
Rescreening
Table14.Summaryofrescreeningrecommendations.
Perform
Followinginitial
Yes
Immediateorsamedayrescreenofpuretones.Conduct
48
screeningfailure
tympanometryscreeningifchildfailstheimmediatepuretone
rescreenorinitialOAEscreen.
Rescreeningasasecond
Yes
Minimumof8weeks,maximumof10weeks.Rescreen
childrenfailingpuretoneand(or*)tympanometryscreening
tierscreening
OR
Rescreenchildrenfailingonlyasinglefrequencyinoneorboth
earsandpasstympanometryscreen
Rescreeningasasecond
No
Childrenwhofailpuretonescreeningandpasstympanometry
tierscreening
screening**
OR
Childrenwhohavemorethanasinglefrequencyfailureinone
orbothearswhopasstympanometryscreening**
*refertopuretonescreeningrecommendations#6,tympanometryrecommendations#3
**Referforaudiologicalevaluation
1. Rescreenwithtympanometryafteradefinedperiod.
a. Followinginitialpuretonescreeningfailureandimmediaterescreen,childrenstillnot
passingshouldbescreenedwithtympanometry.
b. Followingfailureofpuretoneandtympanometryscreeningonthedayofmass
screening,childrenwhodonotpasstympanometry*orchildrenwhodonotpassboth
tympanometryandpuretonescreeningshouldberescreened.Therescreeningperiod
willataminimumbe8weeksaftertheinitialscreeningdateandnolaterthan10weeks
afterfailingmasshearingscreening.
2. Donotwaittoperformasecondstagescreeningonchildrenwhofailpuretonescreening
only.
a. Inordernottodelaydiagnosisofpermanenthearingloss,isitstronglysuggestedthat
screeningprogramsdonotrescreenchildrenwhofailpuretonehearingscreeningand
immediaterescreeningandpasstympanometry.Theyshouldbereferredfor
audiologicalevaluationafterthemassscreeningdateratherthanwaitfor8to10weeks
torescreen.
b. Hearingscreeningprogramsmaychoosetoperformsecondstagescreeningonchildren
failingasinglefrequencyonlyinoneorbothears.Childrenwhofailtwoormorepure
tonefrequenciesinoneorbothearswithpassingtympanometryscreeningresults
shouldbeimmediatelyreferredforaudiologicalevaluation.
49
c. Schooldistrictsthatemployaudiologiststoprovideclinicalevaluationsmaychooseto
immediatelyreferforaudiologicevaluationthosechildrenfailingtympanometryand
twoormorepuretonefrequenciesinordertoassistindeterminingneedfor
educationalaccommodations.Insettingswherenoinhouseaudiologicalevaluationcan
beperformed,referralbytheprimaryphysicianforhearingevaluationmayberequired.
Physicianreferralstoaudiologymaybemorelikelytooccurfollowingfailureofhearing
andtympanometryrescreening810weeksafterinitialmassscreening,withnoaccess
tohearingrelatededucationalaccommodationsduringthisperiod.
REFERRALANDFOLLOWUP
Whenmakingresponsiblereferralstothemedicalcommunity,itisimportantforaudiologiststo
recognizehowtreatmentforconditionswithmiddleeareffusionhaschanged.Clinicalpractice
guidelinesonOMEresultingfromthejointeffortsoftheAmericanAcademyofFamilyPhysicians(AAFP),
theAmericanAcademyofOtolaryngologyHeadandNeckSurgery(AAO/HNS)andtheAmerican
AcademyofPediatrics(AAP)concludedthatOMEmedicaltherapiesshouldonlybeusedifOMEis
persistentorprovidessignificantbenefitbeyondthenaturalcourseofOME.Itwasfurther
recommendedthatchildrenwithOMEwithoutriskfactorsshouldbemonitoredforthreemonthsfrom
thedateofonsetordiagnosis.Whenareferralismadefromthehearingscreeningprogramtothe
medicalcommunitythefollowinginformationshouldbeincludedifknown:durationofOME,laterality
ofOME,resultsofpriorhearingevaluationsortympanometry,evidenceorconcernofany
speech/languagedifficulties,andanyconditionsthatwouldexacerbatetheimpactofOME(AAP,2004).
Massscreeningisonlyeffectiveifitresultsinthechildrenidentifiedreceivingevaluationsto
determineiftheconditionofconcernistrulypresentorabsent.Accomplishingthisforeverychild
identifiedviaschoolhearingscreeningisoftenchallengingasitcanrequirecaregiverstodevotetime,
healthcareresourcesand/orprivatefundingtosetupandtransporttheirchildrentomedicalor
audiologicalevaluationappointments.Flanary,Flanary,ColomboandKloss(1999)evaluatedthemass
hearingscreeningprogramofamajormetropolitanareaandconcludedthatthere was very poor follow-up
by the families of those students needing referrals following the screening program. In the three school districts
from which data were collected, information following referral was returned to the school in only 10-20% of
cases. OneColoradoschooldistrictdocumentedthatapproximately40%oftheinformationreturned
followinghearingscreeningwasbyfamiliesofpreschoolchildren,withreturnratesdecreasingin
numberaschildrenbecameolder.Increasingfamilyfollowupformedicalevaluationfollowingachilds
hearingscreeningfailureischallenging.Itisimportantthatscreeningresultsandreferralinformationbe
presentedtothefamilyintheirnativelanguage.Includingaphotofromvideootoscopy,serialpuretone
andtympanometryscreeningresults,andapamphletdescribingpotentialeffectsofundiagnosed
hearinglossaresuggestedconsiderations.Itremainscriticalfortheindividual(s)coordinatingtheschool
50
hearingscreeningprogramtodeveloprelationshipswiththelocalmedicalcommunity,informthemof
thescreeningprotocolsusedandencouragetheircollaborationinreturningresultsofmedicalor
audiologicalevaluationfollowingahearingscreeningreferral.
Someofthechildrenidentifiedbypuretonescreeningandtympanometrymayhavepersistent
orrecurrentmiddleeareffusionsthatplacethemathigherriskfordevelopmental,medical,and
subsequenteducationalconsequences.Ashasbeenillustrated,feedbackontheresultoftheevaluation
followingthereferralfromscreeningisrelativelyrare.Someschooldistrictsmonitorthemiddleearand
hearingstatusofchildrenwithapparentmiddleeareffusionaftermasshearingscreeningandreferrals
havebeencompleted.OneFloridaschooldistrictreferred61%(Table5)ofchildrenfailinghearing
screenandchosetofollow39%totheresolutionofmiddleeareffusionoridentificationofstudents
witheffusionandepisodichearinglossfor3monthsormore.Theothertwoschooldistrictsroutinely
followedchildrenreferredwithabnormaltympanometryscreeningresultsuntilthechildwasableto
passhearingandtympanometryscreeningthreetimesconsecutively.Monitoringhearingandmiddle
earstatusmayalsobejustifiedforchildrenwithventilationtubes,afamilyhistoryofpermanenthearing
loss,syndromicpopulationsathighriskforhearinglossandannualrecheckofpermanenthearingloss
thatdoesnotmeetcriteriaforhearingimpairmentunderspecialeducation.Basedonthesmallsample
ofdatagathered,schooldistrictswithwelldevelopedhearingscreeningprogramsandeducational
audiologyservicesmayroutinelymonitor1%ormoreoftheschooldistrictpopulationannuallyor
semiannually.
Itisveryimportanttorecognizethattherecommendationsinthisdocumentrepresent
minimumpracticeguidelinesformasshearingscreeninginschoolsettings.Ifaschooldistrictemploys
educationalaudiologistswhoprovideclinicalhearingevaluationsthenumberofstudentsreceiving
referralsforbothmedicalandaudiologicalevaluationoraudiologicalevaluationsonly,islikelyto
increase.Inmanycaseschildrencannotbeevaluatedbyanaudiologistinacommunityclinicsetting
withoutreferralfromtheirprimaryphysician,andtheserealitiesarelikelytoinfluencereferralpatterns.
HEARINGSCREENINGPROGRAMMANAGEMENT
PersonnelandStaffTraining
RichburgandImhoff(2008)studiedthetrainingofhearingscreeningpersonnelinschool
systems.Theyreportedthatwithnocommonsourceoftrainingorsupervision,theprotocolsusedby
personsperformingthehearingscreeningsvariedgreatly.Theseauthorsalsofoundthatwhenaschool
systemhadaneducationalaudiologistasasinglesupervisorthemethodsusedfortestingweremuch
moreconsistent.Theirresultsindicatedthatitwasbeneficialforidentifyingstudentswithundiagnosed
hearingloss(includingminimalhearingloss)tohaveaneducationalaudiologisttrainandsupervise
hearingscreeningpersonnel,andthiswasespeciallytruewhentheaudiologistwasonsiteduringthe
51
screeningprocess.Asaresultoftheirsurvey,theauthorsconcluded,supervisionbyaneducational
audiologistcanleadtomoreuniformscreeningprotocolsthat,inturn,shouldresultinmoreaccurate
screeningresults,abettersystemforreferrals,andproperdiagnoses(pg.41).
TheWorldHealthOrganizationreportedresultsof240subjectsthatreceivedhearingscreening
byminimallytrainedjuniortestersthatwerecomparedwithresultsforthesamesubjectswhen
screenedbyspecialisttestersinidealconditionsinasoundproofroom.Testsofinterandintra
observervariationrevealedavarietyofsignificantdifferencesamongresultsobtainedbyexperienced
andjuniortesters.Itwasrecommendedthatscreeningprogramshaveanexperiencedtester(atleast
oneyearexperienceinaudiometry)forhearingtestinginthefield.Wherenewlytrainedtestersare
used,interintraobservervalidationshouldbemeasuredbeforemasshearingscreeningbeginsto
determinethegoodandpoortesters(WHO2001).
Manystateshavelicensurerequirementsforaudiologyassistantswhosejobdescription
includeshearingscreening.Schoolpersonnel,includingaudiologists,whoareresponsibleforhearing
screeningprogrammanagement,shouldbefamiliarwiththeirstatesrequirements.Additional
informationonthetraining,use,andsupervisionofaudiologyassistantscanbefoundinguidelines
developedbyASHAandAAAthatweredevelopedcollaborativelyasaConsensusPanelonSupport
PersonnelinAudiologyin1997(AAA1997).InadditionAAAhasrecentlypublishedanupdatedposition
statementthatspecificallyaddressesaudiologyassistants(AAA,2010).
ItisrecognizedthatmanyofthethousandsofschooldistrictsintheU.S.neitheremploynor
contractwithanaudiologist,andtheirhearingscreeningprogramsaremanagedbyanonaudiologist
whoistypicallyaschoolhealthprofessional.Duetotheimportanceoffollowupwithinthemedical
community,itisverystronglyrecommendedthatthenonaudiologistmanagersofschoolhearing
screeningprogramsutilizeasingleorsmallgroupofrepresentativeaudiologistsfromtheircommunities
asanadvisorybodyforhearingscreeningprograms.Thisassistanceistoensuretheappropriatenessof
thetechnicaldetailsofequipment,training,andprotocols,aswellastofacilitatebuyinbycommunity
audiologiststhatwillultimatelyimprovecollaborativereferrals,recommendations,andfollowup.
Scheduling
Schedulingmassorschoolwidehearingscreeningsmustbeacollaborativeprocessbetweenthe
audiologistorotherprogrammanager,personscompletingthescreenings,volunteerassistants,and
relevantschoolpersonnel(e.g.principal,schoolnurse).Amongthefactorstoconsiderarenumberof
studentsandgradestobescreened,gradelevelorschoolwideassessmenttimeperiods,scheduled
vacationdays,availabilityofsupportpersonnelandvolunteerstoassistonsitewiththescreening
process,weatherrelatedfactors,andadequatetimeforfollowupscreeningandevaluations.
Consultationwiththeschoolprincipalisneededtoprovideayearlyscheduleofgradelevel
academicassessments,aswellasanyotherscheduledactivitiesthatmightimpactefficient
52
implementationofschoolwidehearingscreening.Screeninginthefallismostadvantageousforfollow
upoffailures,butinservicetimefortrainingpersonneltoassistmustbeimplementedpriortotheactual
screening.Forthesereasons,itmightbemoreefficienttostaggergradelevelsscreenedthroughoutthe
schoolyearespeciallyfordistrictsthathavelargenumbersofstudentstobescreened.Oftenschool
administratorswillprefertohavethescreeningcompletedforallgradesinonebuildingonthesame
day,sincethattypicallyislessdisruptivetotheschoolroutineandworksefficientlyforschoolswith
smallerstudentpopulations.Ifschoolvolunteersarebeingused,asingledesignatedscreeningdayis
alsomorepractical.Weatherrelatedissuesandtimesofhigherabsenteeismmayalsoneedtobe
factoredinforsomeschoolsordistricts,andahigherscreeningfailureratecanbeexpectedduring
periodswhenchildrenaremorepronetohavemiddleearproblems(i.e.winterorallergyseasons).
EquipmentSelection
Thetypesofequipmentusedforhearingscreeningwillvarydependingontheresources
availabletotheprogram,theenvironmentinwhichthescreeningwilloccur,thetargetpopulationtobe
screened,andtheexpertiseofthescreeningpersonnel.Inadditiontotheactualscreeninginstruments
used,someequipmentmayrequireadditionalsupplies,suchasprobetipsforotoacousticemissions
testingandimmittancescreening,insertearphonesforpuretonescreening,andspeculaforvisual
inspectionsusinganotoscope.Probetips,specula,andfoaminsertsmaybedisposableorreusable,but
caremustbetakentoensuretheyareproperlysanitizedbeforetheyareusedagain(seesectionthat
followsoninfectioncontrol).
Puretonescreeningequipment
Puretonescreeningrequirestheuseofapuretoneaudiometer.Althoughscreening
audiometerswithlimitedfrequenciesandintensitylevelsthatmaybepresetareavailable,thecost
benefitofusingasinglechannelportableaudiometerwithtwoearphones(eithercircumauralorinsert
style)thatproducesaminimumofoctavefrequenciesbetween250and8000Hzatlevelsrangingfrom0
toatleast90dBHLshouldbeconsidered.Themoneythatwillbesavedwhenpurchasingalimited
frequency/intensityaudiometermaynotbeworththeflexibilitythatislostwiththistypeofequipment.
Withastandardpuretoneaudiometer,thescreeninglevelandthefrequenciestobescreenedcanbe
determined,ratherthanusingthepredeterminedlevelsandfrequenciessetbyascreeningaudiometer.
Additionally,thestandardpuretoneaudiometercanbeusedforbothscreeningandthreshold
procedures,whereasthescreeningaudiometercanbeusedonlyforscreening.
Apuretoneaudiometerusedforscreeningshouldbeportable,lightweight,anddurable.Most
audiometersincorporateuseofanelectricalplugforpower,butsomeaudiometersarepoweredbya
rechargeablebattery.Ifbatterypowered,avisualindicatorforlowbatterychargeshouldbeincluded.
Olderschoolfacilitiesmayincludescreeningenvironmentswitholderelectricalwiringwhereoutletsare
incompatiblewiththreeprongedplugsfoundonmanyaudiometers.Theuseofadapterstypicallydoes
53
notmeetelectricaland/orfirecoderequirements,soscreeningaudiometerswiththreeprongedplugs
maybeasafetyhazardandthushavelimiteduseintheseschoolfacilities.Schoolsafetydirectorsshould
beconsultedtodetermineanyspecialelectricalrequirementsbeforepurchasinghearingscreening
equipment.Audiometersshouldbecalibratedtothecurrentstandardsdevelopedandadoptedbythe
AmericanNationalStandardsInstitute(ANSI3.62004).Specificationsandappropriatecorrections
shouldbemadewhenusinginsertearphones.
Immittancescreeningequipment
Thereareanumberofautomatedacousticimmittanceinstrumentsthatareusefulfor
screening.Theaudiologistshouldbecertainthattheequipmentcanquicklyandeasilyprovide
measurementsofthecomponentsthatwillbeconsideredinthescreening,e.g.,gradient,earcanal
volume,andpeakpressure,andthattheinstrumentmeetstheANSIS3.39(1987)standardsfor
instrumentstomeasureacousticimmittance.Althoughsomeinstrumentsarecapableofmulti
frequencymeasures,a226Hzprobetoneisappropriateforscreeningpreschoolandschoolaged
children.Aswithpuretoneaudiometers,animmittancescreeninginstrumentthatislightweightand
durableispreferred.Instrumentsthatcontainbothapuretoneaudiometerandacousticimmittance
reducethenumberofpiecesofequipmentthatmustbetransportedandsetup,butasignificant
disadvantageisthatwhenonecomponentmalfunctions,bothareoutofcommissionwhilerepairs
occur.
Ifimmittancescreeningisincluded,avisualinspectionoftheearcanalandtympanicmembrane
usinganotoscopemustbecompletedpriortoinsertingtheprobetip.Themainrequirementforan
otoscopeisthattherebesufficientlighttoviewtheearcanaladequately.Halogenbulbsnowavailable
inmanyotoscopesprovidethenecessarybrightness.Caremustbetakentofollowinfectioncontrol
strategieswhenusinganotoscope,andselectionshouldincludeconsideringpurchaseofdisposable
and/orlatexfreespecula.
Otoacousticemissionsscreeningequipment
Otoacousticemissionsscreenersareautomatedandcanincorporateseveraltypesofstimuli.
SomescreenersperformDPOAE,TEOAEorbothtypesoftests.Theycomewithanassortmentof
disposableorreusableprobetipinserts(again,careshouldbetakentoincludeavisualinspectionofthe
earcanalandtympanicmembranepriortoinsertingprobetips).Handheldscreenershaveeasytoread
screens,menuoptionsandgiveapass/refertestresultrequiringnointerpretation.Theywillalsogive
errormessagessuchaswhenapoorsealisobtainedorifthebackgroundnoiselevelistooloudforthe
testtorun.OAEscreenerscanrunonbatterypower,ACorboth.Theycanholdanywherefrom50to
100testsorrunfor3hoursbeforeneedingtorechargeifrunningonbatteries.Thecostofgeneral
maintenance,calibration,batteryreplacement,softwareupgrades,andreplacementprobesshouldbe
considered.Somescreenershaveportableprintersthatallowthetestresultstobeprintedatthetest
site.OAEscreenerscanalsocomewithtrainingmanuals,quickreferenceguidesandtrainingvideos.
54
Theycometypicallysetwithadefaultpass/refercriteria(e.g.,4outof4frequencies,3outof4
frequenciesor2outof4frequencies).However,manyunitshaveoptionsforchangingthedefault
pass/refercriteria.
EquipmentMaintenance
Regardlessofthetypeofequipmentusedinascreeningprogram,itiscriticalthatitbeworking
properlyonthedayofthescreening.Unlesstheequipmentisperformingasintended,thescreeningwill
notbeaccurate,resultingeitherinpassingsomechildrenwhohaveahearingproblemorinexcessive
failures.Abackupplanwithloanerequipmentshouldbedevelopedforemergencies.Allequipment
shouldbecalibratedtotherequiredstandardsatleastannually,andscreenersshouldbetrainedto
performadailylisteningandvisualcheckpriortotheuseoftheequipment.Screenersshouldbealertto
excessivereferralsduringthescreeningprocess,andequipmentshouldbecheckedanytimeitseemsto
befunctioningimproperly.Mostmanufacturersortheirlocalrepresentativesofferannualcalibration
andrepaircontracts.Thesecontractsmayprovetobecosteffectiveforlargerdistrictsormultisystem
schoolcooperativesthatareresponsibleforalargestockofhearingscreeningequipment,sincemany
providerswillnegotiatecostbasedonnumbersofinstrumentpiecesthatrequirerecalibration.Backup
loanerunitsmayalsobeavailableunderacontractualrepairagreement.
InfectionControl
Thepurposeofinfectioncontrolistominimizetheexposureofpeopleandtheenvironmentto
microorganismsthatmaymakethetestersorthestudentsbeingtested,sick(Kemp&Roeser,1998;
Kemp&Bankaitis,2000a;Kemp&Bankaitis,2000b).Theamountofriskfromexposureto
microorganismscandependonthetypeofscreeningtestsperformedandtheopportunitiesfortransfer
ofmicroorganismsfrompersontopersoneitherdirectlyorindirectly.Tympanometryorotoacoustic
emissionsscreeningprovideopportunitiesforcontactwithandexposuretocerumen.Cerumenitselfis
notconsideredtobeaninfectiousmaterial,butitcancontainsubstancesthatcanbeinfectious(Kemp,
Roeser,Pearson,&Ballachandra,1996).Becauseofcerumenscolorandconsistencyitmaybedifficult
todetermineiftherearecontaminationsfrombloodorotherinfectioussubstances,and,therefore,
cerumenshouldalwaysbetreatedasifitcontainsaninfectiousmaterial(Kempetal.,1996).
Probetipsusedfortympanometryorotoacousticemissionstestingandinsertearphonesfor
puretonetestingshouldeitherbedisposableorcleanedandsterilizedaftereachuse(Bankaitis,2005;
Clark,Kemp,&Bankitis,2003).Surfacessuchassupraauralheadphonesandtoysorobjectsusedduring
screeningshouldbecleanedanddisinfectedbeforeeachreusebyusingaproductsuchasawipeor
spray.Finally,itisalwaysagoodideatochecktoseeiftherehasbeenaliceoutbreakinthepopulation
ofstudentsbeingscreened.Ifso,amodificationofthescreeningscheduleisrecommended.Although
liceareunlikelytopreferthesurfaceoftheheadphonestoascalp,theactofbendingovertoproperly
55
seattheheadphonesovertheearspotentiallyplacestheadultperformingthescreeningatriskforlice
transmission.
Eachhearingscreeningprogramshouldincludeasectiononstrategiesandtechniquestobe
usedtominimizethepotentialforspreadofinfectioninthescreeningprotocol,andpersonsresponsible
forthistaskshouldbeidentified (ASHA,1991;Ballachanda,Roeser,&Kemp,1996;JointCommissionon
AccreditationofHealthCareOrganizations,1995;U.S.DepartmentofLabor,OccupationalSafetyand
HealthAdministration,1991).
Accountability
Programmanagementresponsibilitiesforahearingscreeningprogrammusttargetthefollowing
threeprimaryareas:accountability,riskmanagementandprogramevaluation.Theaudiologistor
designatednonaudiologyprogrammanagerisaccountablefordeveloping,supervising,and
implementinganyhearingscreeningprogram.Nonaudiologypersonnelmayperformtheactual
screening,butanaudiologisttypicallyisultimatelyresponsibleforthetrainingandsupervisionofthe
personneladministeringthescreening.Asstatedinthesectionabovecoveringpersonnelandstaff
training,manystateshavelicensureand/orcertificationrequirementsforsupervisingpersonnelin
hearingscreeningprograms,andtheprogrammanagershouldensurethattheserequirementsaremet.
Programmanagementresponsibilitiesalsoincludeimplementingaprotocolthatensurespatient
confidentiality,parentalnotificationand/orpermissionwhenrequired,appropriatereferral,and
counseling.Itisstronglyrecommendedthatasingleschoolbasedstaffmemberbedesignatedfor
trackingreferralsthatarisefromeachschoolshearingscreeningprogramtofacilitatefollowupof
individualstudentrecommendations.However,itmaybemoreefficienttodevelopandmaintaina
systemwidedatabaseforaccountabilityandprogramevaluationpurposes.
Managementofriskfactors,includingthepotentialforinfection,invalidscreeningresultsbased
onequipmentmalfunctionorerrorsincalibration,anderrorsinpatientreferralandfollowupshould
alsobeunderthesurveillanceofanaudiologist.Qualityassuranceactivitiesincludeonsitesupervision,
writtendocumentation,andreviewonanannualbasisataminimum.Followingthisannualreview,any
revisionsinprotocols,toincluderecommendationsformodificationsinthereferralsystemshouldbe
made.
Programmanagersmustbeknowledgeableabouttherequirementsforparentalconsentunder
thelaw.Theneedforparentalnotificationand/orpermissionforachildtoparticipateinhearing
screeningwhenparentsarenotpresentmayvaryunderlocal,state,andfederalrequirementsforeach
populationscreened,andschooldistrictsareresponsibleforensuringthattheirhearingscreening
protocolscomplywithcurrentregulations.Typically,iftheprogramisoneofscreeningeverychild,
parentsmustbegivennoticeandallowedtorefusetohavetheirchildincluded.Thisnoticecanbe
completedeasilyandefficientlybytheprovisionofwritteninformationduringtheschoolenrollment
56
process.Followuptestingwherethechildissingledoutandgivenarescreeningorfollowupevaluation
requiresinformedwrittenparentalconsentunlessrescreeningisspecificallyincludedintheinitial
parentalnotice.Parentsshouldalwaysbeprovidedwithacopyofresultsandrecommendations.
Evaluation
Programevaluationreferstotheresponsibilityoftheprogrammanagertoevaluate
theeffectivenessofthescreeningprogram.Thisinvolvesdevelopingmechanismsto(a)quantifythe
passandreferrates,(b)estimatethefalsepositiveandfalsenegativerates(i.e.sensitivityand
specificity),and(c)assuretheeffectivenessoffollowupprotocolsforpatientswhoneedrescreeningor
arereferredfromthescreeningprocess.Programevaluationshouldoccuronanongoingbasisto
identifyandadjustfactorsthathinderoptimumscreeningprogramperformanceandpatientcare.
Carefulconsiderationofcomponentssuchasprofessionalliability,riskmanagementandquality
assuranceasintegralpartsofprogramaccountabilityandevaluationmustbecompletedpriorto
implementationofanyscreeningprogram.Appropriatedevelopmentofthesecomponentsassiststhe
audiologistinensuringoverallprogramqualityandeffectiveness.
Typesofinformationneededtodeterminetheprogramseffectivenessincludethefollowing
(adaptedfromJohnsonandSeaton,2011):
Totalnumberofchildrenscreened;
Numberand/orpercentageofchildrenwhodidnotpasstheinitialscreening
Numberand/orpercentageofchildrenwhomissedtheinitialscreeningduetoabsence,
parentalrefusalorotherreasons
Numberand/orpercentageofchildrenwhodidnotpassarescreening
Numberand/orpercentagereferredonforfollowup(audiological,medical,educational)
Numberand/orpercentageseenforfollowupevaluations(audiological,medical,educational)
Numberand/orpercentagewithdiagnosedhearingproblems
Numberand/orpercentageprovidedwithmedicaltreatmentand/oreducationalservicesfor
hearingproblems(includingamplificationorhearingassistivedevices)
Thesedatacanhelpdocumentneedforthehearingscreeningprogram,identifyoverorunder
referralsthatcantargetequipmentortrainingneeds,helptracklosstofollowup,andclarifyother
issuesthatimpacttheefficiencyandeffectivenessofahearingscreeningprogramIntheschools.
Costeffectivenessisacriticalaspectofhearingscreeningprogramevaluation.Thetotalcostof
personnel,equipment,equipmentmaintenance,andformsforeachyearcanbecomparedtothe
numberofchildrenscreenedtodeterminethecostofscreeningeachchild.Additionally,thenumberof
childrenidentifiedashavingahearingproblem(whetherpermanentortransient)canbecomparedto
thetotalcostoftheprogramtodeterminethecostofidentifyingeachchildwithahearinglossthatmay
haveeducationalimpact.
57
SUMMARY
Theevidencereviewedsupportshearingscreeninginearlychildhoodandschoolaged
populationstofacilitateidentificationoflateonsetoracquiredpermanenthearinglossand
longstandingorfrequentlyrecurringconductivehearinglossthatmayimpactlinguisticdevelopment
andschoolperformance.Itisimperativethatevidencebasedpracticesbeusedbyschoolhearing
screeningprogramstothemaximumextentpossible.Annualhearingscreeninginearlychildhood,
monitoringhearingofhighriskpopulationsandeducationaleffortstargetingpreventionofnoise
inducedhearinglossarecriticalstrategiesforachievingoptimalacademicandeconomicoutcomes.
Theseguidelinesarebasedoncurrentresearchandproviderecommendationsforeducationandpublic
healthagenciesinvolvedinimplementinghearinghealthinitiatives.Advocatingforstudentneedsand
empoweringparentswithinformationabouttheirchildrensear/hearingstatusandrelatededucational
risksarenecessaryforfamilyfollowupofhearingscreeningreferrals.Equallyimportantare
collaborativerelationshipsbetweentheschoolhearingscreeningprogram,districtstudenthealth
program,educationalaudiologyandthemedicalcommunitytoachievethegoalofoptimalhearing
healthforeverydevelopingchild.
58
REFERENCES
Acuin,J.2004.Chronicsuppurativeotitismedia:Burdenofillnessandmanagementoptions.
Geneva:WorldHealthOrganization,
http://www.who.int/pbd/deafness/activities/hearing_care/otiis_media.pdf
Akdogan,O.andS.Ozkan.2006.Otoacousticemissionsinchildrenwithotitismediawith
effusion.InternationalJournalofPediatricOtorhinolaryngology70(11):19411944.doi:S0165
5876(06)002308[pii]
Alberti,P.andR.Kristensen.1970.Theclinicalapplicationofimpedanceaudiometry.
Laryngoscope,80:735746.
AmericanAcademyofAudiology.1997.IdentificationofMiddleEarDysfunctioninPreschool&
SchoolAgeChildren.AmericanAcademyofAudiology,
http://www.audiology.org/resources/documentlibrary/Pages/HearingLossChildren.aspx
AmericanAcademyofAudiology.1997.PositionStatementandGuidelinesofthe
ConsensusPanelonSupportPersonnelinAudiology.AudiologyToday9(3):2728.
AmericanAcademyofAudiology.2010.PositionStatement:AudiologyAssistants.American
AcademyofAudiology,http://www.audiology.org
AmericanAcademyofPediatrics.2004.Clinicalpracticeguideline:Otitismediawitheffusion.
Pediatrics,113(5),14121429.Accessedat
http://aappolicy.aappublications.org/cgi/content/full/pediatrics;113/5/1412
AmericanAcademyofPediatrics.2007.RecommendationsforPreventivePediatricHealthCare
CommitteeonPracticeandAmbulatoryMedicineandBrightFuturesSteeringCommittee.
Pediatrics120(6):1376
AmericanMedicalAssociation.2008.GuidestotheEvaluationofPermanentImpairment,6thEd.
Chicago:AMAPublications.
AmericanNationalStandardsInstitute.1999.Americannationalstandardspecificationsfor
maximumambientnoiselevelsforaudiometrictestrooms.ANSIS3.11999.NewYork:
AcousticalSocietyofAmerica.
AmericanNationalStandardsInstitute.(2004).Specificationsforaudiometers(ANSIS3.62004).New
York:Author.
AmericanSpeechLanguageHearingAssociation.CausesofHearingLossinChildren.
http://www.asha.org/public/hearing/disorders/causes.html(AccessedMarch6,2007).
59
AmericanSpeechLanguageHearingAssociation.1995.AdHocCommitteeonScreeningfor
HearingImpairment,Handicap,andMiddleEarDisorders:Reportonaudiologicscreening.
AmericanJournalofAudiology.4:2440
AmericanSpeechLanguageHearingAssociation1975.CommitteeonAudiometricEvaluation
GuidelinesforIdentificationAudiometry.ASHA,17:9499.
AmericanSpeechLanguageHearingAssociation.2002.Guidelinesforaudiologyservice
provisioninandforschools.Availablefromwww.asha.org
AmericanSpeechLanguageHearingAssociation1997.Guidelinesforscreeninginfantsand
childrenforouterandmiddleeardisorders,birththrough18years.InGuidelinesforaudiologic
screening,1522.Rockville,MD:Author.
AmericanSpeechLanguageHearingAssociation1997.GuidelinesforAudiologicalScreening.
RockvilleMD:Author.
Anderson,K.1991.Hearingconservationinthepublicschoolsrevisited.SeminarsinHearing
12(4):340364.
Ayukawa,H.,Lejeune,P.,andJ.Proulx,.2003.HearingscreeningoutcomesinInuitchildrenin
Nunavik,Quebec,Canada.Circumpolarhealth.309311,Accessedat
http://ijch.fi/issues/63suppl2/ICCH12_Ayukawa_1.pdf
Babb,M.,Hillsinger,R.Jr.,Korol,H.,andR.Eilcox.2004.Modernacousticreflectometry:
Accuracyindiagnosingotitismediawitheffusion.Ear,NoseandThroatJournal83(9):622624.
Bamford,J.,Fortnum,H.,Bristow,K.,Smith,J.,Vamvakas,G.,Davies,L.,Taylor,R.,
Watkin,P.,Fonseca,S.,Davis,A.,andS.Hind.2007.Currentpractice,accuracy,
effectivenessandcosteffectivenessoftheschoolentryhearingscreen.Health
TechnologyAssessment11(32):1168.Accessedat
http://www.hta.ac.uk/pdfexecs/summ1132.pdf
Bankaitis,A.1996.AudiologicalchangesattributabletoHIV.AudiologyToday8(6):79.
Bankaitis,A.2005.FAQsaboutinfectioncontrol.AudiologyToday17(5):1719.
Bavosi,R.andR.Rupp.1984.Whennormalhearingisnotnormal.HearingInstruments35(9):
910.
BennettJ.andK.English.1999.Teachinghearingconservationtoschoolchildren:comparing
theoutcomesandefficacyoftwopedagogicalapproaches.JournalofEducationalAudiology,
7:2933.
60
Berlin,C.,Hood,L,Morlet,T.,Wilensky,D.,StJohn,P.,Montgomery,E.andM.Thibodaux.
2005.Absentorelevatedmiddleearmusclereflexesinthepresenceofnormalotoacoustic
emissions:auniversalfindingin136casesofauditoryneuropathy/dyssynchrony.Journalofthe
AmericanAcademyofAudiology16(8):546553.
Berlin,C.,Morlet,T.,andL.Hood.2003.Auditoryneuropathy/dyssynchrony:Itsdiagnosisand
management.PediatricClinicsofNorthAmerica50(2):331340,viiviii.
Bess,F.1982.Childrenwithunilateralhearingloss.JournaloftheAcademyofRehabilitative
Audiology15:131144.
Bess,F.1999.Schoolagedchildrenwithminimalsensorineuralhearingloss.TheHearing
Journal52:5.
Bess,F.andA.Tharpe.1984.Unilateralhearingimpairmentinchildren.Pediatrics74:206216.
Bess,F.andA.Tharpe.1986.Anintroductiontounilateralsensorineuralhearinglossin
children.EarandHearing7:313.
Bess,F.,DoddMurphy,J.,andR.Parker.1998.Minimalhearinglossinchildren:Prevalence,
educationalprogressandfunctionalstatus.EarandHearing19:339354.
BlairJ.,HardegreeD.,andP.Benson.1996.Necessityandeffectivenessofahearing
conservationprogramforelementarystudents.JournalofEducationalAudiology4:1216.
Bluestone,C.,Beery,Q.,andW.Andrus.1974.Mechanicsoftheeustachiantubeasit
influencessusceptibilitytoandpersistenceofmiddleeareffusionsinchildren.Annalsof
Otology,Rhinology,andLaryngology83:2734.
Blumsack,J.andK.Anderson.2004.Backtoschool!13factsrevisited.HearingReview,11(10),
1416,6263.
Brooks,D.1969.Theuseoftheelectroacousticimpedancebridgeintheassessmentofmiddle
earfunction.InternationalAudiology8:563569.
Brooks,D.1971.Anewapproachtoidentificationaudiometry.Audiology10:334339.
Brooks,D.1974.Theroleoftheacousticimpedancebridgeinpediatricscreening.Scandinavian
Audiology,3:99104.
Brooks,D.1978.Impedancescreeningforschoolchildren:Stateoftheart.InImpedance
ScreeningforMiddleEarDiseaseinChildren,editedbyE.Harfordandothers.NewYork:Grune
&Stratton,Inc.
61
Burkey,J.,Hamilton,M.,Schatz,K.,andS.Sylvester.1994.Studyfindsmostparentsoverlook
otitismedarelatedhearingloss.TheHearingJournal,47(6):3942.
Cash,S.2003.Hearingscreeningassessmentininfantsandchildren:Recommendationsbeyond
neonatalscreening.Pediatrics.111:436440.
Casselbrandt,M.,Brostoff,L.,Cantekin,E.,andothers.1985.Otitismediawitheffusionin
preschoolchildren.Laryngoscope95:428436.
ChermakG,CurtisL,andJ.Seikel.1996.Theeffectivenessofaninteractivehearing
conservationprogramforelementaryschoolchildren.LangSpeechHearingServicesinSchools
27:2939.
Chianese,J.,Hoberman,A.,Paradise,J.,Colborn,K.,Kearney,D.,Rockette,H.,andM.Kurs
Lasky.2007.SpectralGradientAcousticReflectometryComparedWithTympanometryin
DiagnosingMiddleEarEffusioninChildrenAged6to24Months.ArchivesofPediatric
AdolescentMedicine161(9):884888.
Clark,J.,Kemp,R.,andA.Bankaitis.2003.InfectionControlinAudiologyPractice.American
AcademyofAudiologyGuideline.AudiologyToday15(5):1219.
CommissiononEducationoftheDeaf.1988.TowardEquality:EducationoftheDeaf.
Washington,DC:U.S.GovernmentPrintingOffice.Author.
Culbertson,J.andL.Gilbert.1986.Childrenwithunilateralsensorineuralhearingloss:
Cognitive,academic,andsocialdevelopment.EarandHearing,7:3842.
Daly,K.,Hunter,L.,andG.Giebink.1999.Chronicotitismediawitheffusion.Pediatricsin
Review,20(3):8593.
Davis,H.1965.Guidefortheclassificationandevaluationforhearinghandicapinrelationto
internationalaudiometriczero.TransactionsoftheAmericanAcademyofOphthalmologyand
Otolaryngology69:740751.
Deltenre,P.,Mansbach,A.L.,Bozet,C.,Christiaens,F.,Barthelemy,Pl,Paulissen,D.,&T.
Renglet.1999.Auditoryneuropathywithpreservedcochlearmicrophonicsandsecondaryloss
ofotoacousticemissions.Audiology,38,187195.
DoddMurphy,J.&Murphy,W.(2006March).SchoolhearingscreeningreferralandDPOAEs.
presentedattheannualmeetingoftheAmericanAuditorySociety,Scottsdale,AZ.
DoddMurphy,J.,andW.Murphy.2009.Predictivevalueofschoolhearingscreenings.
(Manuscriptinpreparation).
62
DoddMurphy,J.D.,Murphy,W.,&Bess,F.H.(2003April).Doschoolscreeningsidentify
minimalhearingloss?posterpresentedattheannualmeetingoftheAmericanAcademyof
Audiology,SanAntonio,TX.
Downs,M.,Doster,M.,andM.Weaver.1965.Dilemmasinidentificationaudiometry.Journalof
SpeechandHearingDisorders,30:360364.
Driscoll,C.,Kei,J.,Bates,D.,andB.McPherson.2002.Transientevokedotoacousticemissions
inchildrenstudyinginspecialschools.InternationalJournalofPediatricOtorhinolaryngology
64(1):5160.doi:S0165587602000435[pii]
Driscoll,C.,Kei,J.,andB.McPherson.2001.Outcomesoftransientevokedotoacousticemission
testingin6yearoldschoolchildren:acomparisonwithpuretonescreeningand
tympanometry.InternationalJournalofPediatricOtorhinolaryngology,57(1):6776.doi:S0165
5876(00)004456[pii]
Eiserman,W.andL.Shisler.Earlychildhoodhearingscreening:Notjustfornewbornsanymore.
InAResourceGuideforEarlyHearingDetectionandIntervention.NationalCenterforHearing
AssessmentandManagementeBook.Accessedathttp://www.infanthearing.org/ehdi
ebook/ebook_docs/Chapter13.pdf
Eiserman,W.,Shisler,L.,Foust,T,Buhrmann,J.,Winston,R.,andK.White.2007.Screeningfor
hearinglossinearlychildhoodprograms.EarlyChildhoodResearchQuarterly,22(1),105117.
Eiserman,W.,Hartel,D.,Shisler,L.,Buhrmann,J.,White,K.,andT.Foust.2008.Using
otoacousticemissionstoscreenforhearinglossinearlychildhoodcaresettings.
InternationalJournalofPediatricOtorhinolaryngology,72:475482.
Feagans,L.,Kipp,E.,andI.Blood.1994.Theeffectsofotitismediaontheattentionskillsofday
careattendingtoddlers.DevelopmentalPsychology,30(5):701708.
FinitzoT,AlbrightK,andJ.O'Neal.1998.Thenewbornwithhearingloss:Detectioninthe
nursery.Pediatrics102:14529.
FitzZaland,R.andG.Zink.1984.Acomparativestudyofhearingscreeningprocedures.Earand
Hearing5:205210
Flanary,V.,Flanary,C.,Colombo,J.,andD.Kloss,D.1999.Masshearingscreeningin
kindergartenstudents.InternationalJournalofPediatricOtorhinolaryngology,50(2):9398.
Flexer,C.1994.FacilitatingHearingandListeninginYoungChildren.Singular,SanDiego,CA
Folmer,R.2003.Theimportanceofhearingconservationinstruction.TheJournalofSchool
Nursing19(3)140148;
63
Fonseca,S.,Forsyth,H.andW.Neary,2005.Schoolhearingscreeningprogrammeinthe
UK:Practiceandperformance.ArchivesofDiseaseinChildhood.90:154156;
doi:10.1136/adc.2003.046979
Fortnum,H.,Summerfield,A.,Marshall,D.,Davis,A.,Bamford,J.,YoshinagaItano,C.andS.
Hind.2001.PrevalenceofpermanentchildhoodhearingimpairmentintheUnitedKingdomand
implicationsforuniversalneonatalhearingscreening:questionnairebasedascertainment
study.BritishMedicalJournal323(7312),536542.
Frankenberg,W.1974.Selectionofdiseasesandtestsinpediatricscreening.Pediatrics,54(5),
612616.
Georgalas,C.,Xenellis,J.,Davilis,D.,Tzangaroulakis,A.,andE.Ferekidis.2008.Screeningfor
hearinglossandmiddleeareffusioninschoolagechildren,usingtransientevokedotoacoustic
emissions:Afeasibilitystudy.JournalofLaryngologyandOtology122(12):12991304.doi:
S0022215108002156[pii]
Gomes,M.andI.Lichtig.2005.Evaluationoftheuseofaquestionnairebynoonspecialiststo
detecthearinglossinpreschoolBrazilianchildren.InternationalJournalofRehabilitation
Research28(2):1714.
Gorga,M.,Neely,S.,Ohlrich,B.,Hoover,B.,Redner,J.,andJ.Peters.1997.Fromlaboratoryto
clinic:alargescalestudyofdistortionproductotoacousticemissionsinearswithnormal
hearingandearswithhearingloss.EarandHearing18(6):440455.
Gravel,J.,Roberts,J.,Roush,J.,Grose,J.,BESING,J.,BURCHINAL,M.,NEEBE,E.,Wallace,I.and
S.Zeisel.2006.Earlyotitismediawitheffusion,hearingloss,andauditoryprocessesatschool
age.EarandHearing27(4):353368.
Gravel,J.andR.Ruben.1996.Auditorydeprivationanditsconsequences:Fromanimalmodels
tohumans.InClinicalAspectsofHearing:SpringerSeriesinAuditoryResearch.Volume6,edited
byR.Fay,A.Popper,andT.VanDeWater,86115.NewYork:SpringerVerlag
GrosseS.2007.Educationcostsavingsfromearlydetectionofhearingloss:Newfindings.Volta
Voices14(6):384
GroteJ.2000.Neonatalscreeningforhearingimpairment.Lancet355(9203):513514.
Hagan,J.,Shaw,J.,andP.Duncan.Eds.2008.BrightFutures:GuidelinesforHealthSupervision
ofInfants,Children,andAdolescents.3rdEd.ElkGroveVillageIL:AmericanAcademyof
Pediatrics.Availableat
http://brightfutures.aap.org/pdfs/AAP%20Bright%20Futures%20Periodicity%20Sched%201011
07.pdf
64
Halloran,D.,Wall,T.,Evans,H.,Hardin,J.andA.Woolley.2005.Hearingscreeningatwellchild
visits.ArchivesofPediatricsandAdolescentMedicine159(10):949955.doi:159/10/949[pii]
HalloranD.,WallT.,EvansH.,HardinJ.andA.Woolley.2006.Hearingscreeningatwellchild
visits.ArchivesofPediatricsandAdolescentMedicine,160(2):156.
HamillB.1988.Comparingtwomethodsofpreschoolandkindergartenhearingscreening.
JournalofSchoolHealth58:957.
HammondP.,GoldM.,WiggN.andR.Volkmer.1997.Preschoolhearingscreening:evaluation
ofaparentalquestionnaire.JournalofPaediatricsandChildHealth33:52830.
Harford,E.,Bess,F.,Bluestone,C.andJ.KleinEds..1978.Impedancescreeningformiddleear
diseaseinchildren.NewYork:Grune&Stratton
HarrisonM,RoushJ.andJ.Wallace.2003.Trendsinageofidentificationandinterventionin
youngchildrenwithhearingloss.EarandHearing,24:8995.
HendersonE,,TestaM.andC.Hartnick.2011.PrevalenceofNoiseInducedHearingThreshold
ShiftsandHearingLossAmongUSYouths.Pediatrics.127.E39e46.
Henderson,F.andJ.Roush.1997.Diagnosisofotitismedia.InOtitisMediainYoungChildren:
Medical,DevelopmentalandEducationalConsideration,editedbyJ.Roberts,I.WallaceandF.
Henderson.Baltimore:PaulHBrooksPublishingCo.
Hernando,F.,Cailliez,J.,Trinel,P.,Faille,C.,Mackenzie,D.andD.Poulain.1993.Qualitativeand
quantitativedifferencesinrecognitionpatternsofcandidaalbicansproteinandpolysaccharide
antigensbyhumansera.JournalofMedicalandVeterinaryMycology,31(3):219226.
Ho,V.,Daly,K.,Hunter,L.andC.Davey.2002.Otoacousticemissionsandtympanometry
screeningamong05yearolds.Laryngoscope,112(3):513519.doi:10.1097/00005537
20020300000020
HoldenPittL.andJ.Diaz.1998.Thirtyyearsoftheannualsurveyofdeafandhardofhearing
childrenandyouth:aglanceoverthedecades.AmericanAnnalsoftheDeaf143:7276.
Holmes,A.,JonesMuir,K.andF.Kemker.1989.Acousticreflectometryversustympanometry
inpediatricmiddleearscreenings.Language,Speech,andHearingServicesintheSchools20:
4149.
Holt,J.,Traxler,C.andT.Allen.1997.Interpretingthescores:Auser'sguidetothe9thedition
StanfordAchievementTestforeducatorsofdeafandhardofhearingstudents.Gallaudet
ResearchInstitituteTechnicalReport971.Washington,D.C.:GallaudetUniversity.
65
Hood,B.andL.Lamb.1974.Identificationaudiometry.InDetectionofHearingLossandEar
DiseaseinChildren,editedbyK.GerwinandA.Glorig.Springfield,IL:CharlesC.Thomas.
Hood,L.2002.Auditoryneuropathy/auditorydyssynchrony:Newinsights.TheHearingJournal
55(2):10,14,1718.
Hopkins,N.1978.Effectsofage,sex,raceonmiddleearpressuresinpreschoolchildren.In
ImpedanceScreeningforMiddleEarDiseaseinChildren,editedbyE.
Harford,F.Bess,C.BluestoneandJ.Klein.NewYork:Grune&Stratton,Inc.
House,H.andA.Glorig.1957.Anewconceptinauditoryscreening.Laryngoscope,67:661668.
Hussain,D.,Gorga,M.,Neely,S.,Keefe,D.andJ.Peters.1998.Transientevokedotoacoustic
emissionsinpatientswithnormalhearingandinpatientswithhearingloss.EarandHearing,
19(6):434449
Jerger,J.1970.Clinicalexperiencewithimpedanceaudiometry.ArchivesofOtolaryngology,
92:311324.
Johnson,D.andJ.Seaton.2011.EducationalAudiologyHandbook,2ndEd.CliftonNJ:Cengage
Learning.
Johnson,J.,White,K.,Widen,J.,Gravel,J.,Vohr,B.,James,M.,Kennalley,T.,Maxon,A.,Spivak,
L.,SullivanMahoney,M.,Weirather,Y.andS.Meyer.2005.Amultisitestudytoexaminethe
efficacyoftheotoacousticemission/automatedauditorybrainstemresponsenewbornhearing
screeningprotocol:IntroductionandoverviewofthestudyAmericanJournalofAudiology,14:
S178S185.
JointCommitteeonInfantHearing.2007.Year2007PositionStatement:Principlesand
GuidelinesforEarlyHearingDetectionandInterventionPrograms.Pediatrics,120(4):898921
(doi:10.1542/peds.20072333).
Kei,J.,Robertson,K.,Driscoll,C.,Smyth,V.,McPherson,B.,Latham,S.,andJ.Loscher.2002.
Seasonaleffectsontransientevokedotoacousticemissionscreeningoutcomesininfantsversus
6yearoldchildren.JournaloftheAmericanAcademyofAudiology,13(7):392399.
Kemp,R.,Roeser,R.,Pearson,D.,andB.Ballachandra.1996.Infectioncontrolforthe
professionsofaudiologyandspeechlanguagepathology.Olathe,KS:IlesPublications
Kemp,R.andA.Bankaitis.2000a.Infectioncontrolforaudiologists.InAudiologydiagnosis,
treatment,andpracticemanagement,Vol.III,editedbyH.HosfordDunn,R.RoeserandM.
Valente,257279.NewYork:ThiemePublishingGroup.
Kemp,R.andA.Bankaitis.2000.Germinationofinfectioncontrolintheaudiologyclinic.The
AudiologyJournal.[Online}.Available:www.audiologyjournal.com.
66
Kemp,R.andR.Roeser.1998.Infectioncontrolforaudiologists.SeminarsinHearing,19(2):
195204.
Keren,R.,Helfand,M.,Homer,C.,McPhillips,H.,&T.A.Lieu.2002.Projectedcosteffectiveness
ofstatewideuniversalnewbornhearingscreening.Pediatrics110,855864.
Klee,T.andE.DavisDansky.1986.Acomparisonofunilaterallyhearingimpairedchildrenand
normalhearingchildrenonabatteryofstandardizedlanguagetests.EarandHearing,7:2737.
Klein,J.,Teele,D.andS.Pelton.1992.Newconceptsinotitismedia:Resultsofinvestigationsof
theGreaterBostonOtitisMediaStudyGroup.AdvancesinPediatrics,39:127156.
Kochkin,S.,Luxford,W.,Northern,J.,Mason,P.,andA.Tharpe,.2007.MarkeTrakVII:Are1
milliondependentswithhearinglossinAmericabeingleftbehind?HearingReview14(10):10
36.
Konkle,D.,Potsic,W.,Rintelmann,W.,Keane,W.,Pasquariello,P.,andS.Baumgart.1978.A
comparisonofacousticimpedanceandotoscopicfindingsinotorhyinolaryngologicand
pediatricpractice.InImpedanceScreeningforMiddleEarDiseaseinChildren,editedbyE.
Harford,F.Bess,C.BluestoneandJ.Klein.NewYork:Grune&Stratton,Inc.
Krueger,W.andL.Ferguson.2002.Acomparisonofscreeningmethodsinschoolagedchildren.
OtolaryngologyHeadandNeckSurgery,127(6):516519.doi:10.1067/mhn.2002.129734
S0194599802002528[pii]
Lewis,N.,Dugdale,A.Canty,A.,andJ.Jerger,J.1975.Openendedtympanometricscreening:A
newconcept.ArchivesofOtolaryngology,101:722725.
Liden,G.andU.Renvall.1978.Impedanceaudiometryforscreeningmiddleeardiseasein
schoolchildren.InImpedanceScreeningforMiddleEarDiseaseinChildren,editedbyE.
Harford,F.Bess,C.BluestoneandJ.Klein.NewYork:Grune&Stratton,Inc.
Lo,P.,Tong,M.,Wong,E.,andC.vanHasselt.2006.Parentalsuspicionofhearinglossinchilren
withotitismediawitheffusion.EuropeanJournalofPediatrics165(12):8517
Lous,J.andM.FiellauNikolajsen.1981.Epidemiologyofmiddleeareffusionandtubal
dysfunction.Aoneyearstudycomprisingmonthlytympanometryin387nonselectedseven
yearoldchildren.InternationalJournalofPediatricOtorhyinolaryngology3:303317.
LyonsA,KeiJ,andC.Driscoll.2004.Distortionproductotoacousticemissionsinchildrenat
schoolentry:acomparisonwithpuretonetympanometryresults.JournaloftheAmerican
AcademyofAudiology15:70215.
67
MargolisR.andJ.Heller.1987.Screeningtympanometry:Criteriaformedicalreferral.
Audiology26:197208.
McCurdy,J.,Goldstein,J.andD.Gorski.1976.Auditoryscreeningofpreschoolchildrenwith
impedanceaudiometryAcomparisonwithpuretoneaudiometry.ClinicalPediatrics15(5):
436441.
McKay,S.,Gravel,J.andA.Tharpe.2008.Amplificationconsiderationsforchildrenwith
minimalormildbilateralhearinglossorunilateralhearingloss.TrendsinAmplification12:43
54.
Meinke,D.andN.Dice.2007.Comparisonofaudiometricscreeningcriteriaforthe
identificationofnoiseinducedhearinglossinadolescents.AmericanJournalofAudiology16:
190202.
Melnick,W.,Eagles,E.,andH.Levine.1964.Evaluationofarecommendedprogramof
identificationaudiometrywithschoolagechildren.JournalofSpeechandHearingDisorders29:
313.
Mencher,G.T.,andB.F.McCulloch.1970.Auditoryscreeningofkindergartenchildrenusing
theVASC.JournalofSpeechandHearingDisorders35,241247.
MinnesotaDepartmentofHealth.2006.Hearingscreeningtrainingmanual,32.St.Paul,MN:
Author.
Moller,A.2006.Hearing:Anatomy,physiology,anddisordersoftheauditorysystem,2ndEd.,
296297.Burlington,MA:AcademicPress.
Montgomery,J.andS.Fujikawa.1992.Hearingthresholdsofstudentsinthesecond,eighth,
andtwelfthgrades.Language,Speech,andHearingServicesinSchools23:6163.
Naeve,S.,Margolis,R.,Levine,S.andE.Fournier.1992.Effectofearcanalairpressureon
evokedotoacousticemissions.JournaloftheAcousticalSocietyofAmerica91(4Pt1):2091
2095.
NationalAssociationofSchoolNurses(NASN).1998.Theearandhearing:Aguideforschool
nurses.Scarborough,ME:Author.
NationalAssociationofStateBoardsofEducation.2010.StateSchoolHealthyPolicyDatabase.
ScreeningforHealthConditions.Accessedat
http://www.nasbe.org/healthy_schools/hs/bytopics.php?topicid
4100&catExpand=acdnbtm_catD
68
NationalInstituteofHealth.1990.NoiseandHearingLoss.NIHConsensusStatement
1990;8(1):124.
NationalInstituteonDeafnessandOtherCommunicationDisorders.2005.NIDCD
outcomesresearchinchildrenandhearingloss,statisticalreport:Prevalenceofhearinglossin
U.S.children.RetrievedApril29,2009,from
http://www.nidcd.nih.gov/funding/programs/hb/outcomes/
Newhart,H.1938.Apuretoneaudiometerforschooluse.ArchivesofOtolaryngology28:777
779.
NiskarA.,KiezakS.,HolmesA.,EstebanE.,RubinC.andD.Brody.1998.Prevalenceofhearing
lossamongchildren6to19yearsofage.JournaloftheAmericanMedicalAssociation279:
10711075.
NiskarA.,KieszakS.,HolmesA.,EstebanE.,RubinC.andD.Brody.2001.Estimatedprevalence
ofnoiseinducedhearingthresholdshiftsamongchildren6to19yearsofage:theThird
NationalHealthandNutritionExaminationSurvey,19881994,UnitedStates.Pediatrics108:
403.
NorthernJ.,Rock,E.andD.Frye.1976.Atechniqueforidentifyingeardiseaseinchildren.In
SelectedReadingsinImpedanceAudiometry,editedbyJ.Northern.DobbsFerry,NY:Morgan
Press.
Norton,M.andE.Lux.1961.Doublefrequencyauditoryscreeninginpublicschools.Journalof
SpeechandHearingDisorders26:293299.
Norton,S.1994.Emergingroleofevokedotoacousticemissionsinneonatalhearingscreening.
AmericanJournalofOtology15:412.
Nozza,R.1994.Theeffectsofmildhearinglossoninfantauditoryfunction.InfantToddler
Intervention:TheTransdisciplinaryJournal4(4):28598.
Nozza,R.2001.Screeningwithotoacousticemissionsbeyondthenewbornperiod.Seminarsin
Hearing22(4):415425.
Nozza,R.,Bluestone,C.,Kardatzke,D.andR.Bachman.1992.Towardsthevalidationofaural
acousticimmittancemeasuresfordiagnosisofmiddleeareffusioninchildren.EarandHearing
13(6):442453
Nozza,R.,Sabo,D.andE.Mandel.1997.Aroleforotoacousticemissionsinscreeningfor
hearingimpairmentandmiddleeardisordersinschoolagechildren.EarandHearing18(3):
227239.
69
OlusanyaB.2001.Earlydetectionofhearingimpairmentinadevelopingcountry:what
options?Audiology40:1417.
Owens,J.,McCoy,M.,LonsburyMartin,B.andG.Martin.1993.Otoacousticemissionsin
childrenwithnormalears,middleeardysfunction,andventilatingtubes.AmericanJournalof
Otology14(1):3440.
Paradise,J.andC.Smith.1978.Impedancescreeningforpreschoolchildren:Stateoftheart.In
ImpedanceScreeningforMiddleEarDiseaseinChildren,editedbyE.Harford,F.Bess,C.
BluestoneandJ.Klein.NewYork:Grune&Stratton,Inc.
Patterson,C.1995.JointCommissiononAccreditationofHealthcareOrganizations.Infection
ControlandHospitalEpidemiology.16(1):3642.
http://www.ncbi.nlm.nih.gov/pubmed/7897172
PennT.1999.SchoolbasedhearingscreeningintheUnitedStates.AudiologyToday11(6):20
21.
Poulain,D.,Faille,C.,Delaunoy,C.,Jacquinot,P.,Trinel,P.andD.Camus.1993.Probable
presenceofbeta(12)linkedoligomannosidesthatactashumanimmunoglobulinG3epitopes
andaredistributedoveraCandidaalbicans14to18kilodaltonantigen.InfectionandImmunity
61(3):11641166.
Rance,G.2005.Auditoryneuropathy/dyssynchronyanditsperceptualconsequences.Trendsin
Amplification9(1):143.
Ray,H.1992.SummaryofMARRSadoptiondatavalidatedin1992.NorrisCity,IL;Wabash&
OhioValleySpecialEducationDistrict.
Renvall,U.andG.Liden.1978.Clinicalsignificanceofreducedmiddleearpressureinschool
children.InImpedanceScreeningforMiddleEarDiseaseinChildren,editedbyE.Harford,F.
Bess,C.BluestoneandJ.Klein.NewYork:Grune&Stratton,Inc.
Renvall,U.andG.Liden.1980.Screeningprocedurefordetectionofmiddleearandcochlear
disease.AnnalsofOtology,RhinologyandLaryngology(Suppl.68)89:214216.
Ritchie,B.andR.Merklein.1972.Anevaluationoftheefficiencyoftheverbalauditory
screeningforchildren(VASC).JournalofSpeechandHearingResearch15:280286.
Richardson,M.,Williamson,T.,Reid,A.,Tarlow,M.andP.Rudd.1998.Otoacousticemissionsas
ascreeningtestforhearingimpairmentinchildrenrecoveringfromacutebacterialmeningitis.
Pediatrics102(6):13641368.
70
Richardson,M.,Williamson,T.,Lenton,S.,Tarlow,M.andP.Rudd.1995.Otoacousticemissions
asascreeningtestforhearingimpairmentinchildren.ArchivesofDiseaseinChildhood72(4):
294297.
Richburg,C.andL.Imhoff.2008.Surveyofhearingscreeners:Trainingandprotocolsusedin
twodistrictschoolsystems.JournalofEducationalAudiology14:3141.
Roberts,J,Burchinal,M.,andS.Zeisel.2002.Otitismediainearlychildhoodinrelationto
childrensschoolagelanguageandacademicskills.Pediatrics110(4):696706.
Roberts,J.,Hunter,L.,Gravel,J.,Rosenfeld,R.,Berman,S.,Haggard,M.,Hall,J.,Lannon,C.,
Moore,D.,VernonFeagans,L.,andI.Wallace.2004.Otitismedia,hearingloss,andlanguage
learning:Controversiesandcurrentresearch.DevelopmentalandBehavioralPediatrics25(2):
110122.
Rosenfeld,R.,Goldsmith,A.,Tetlus,L.andA.Balzano.1997.Qualityoflifeforchildrenwith
otitismedia.ArchivesofOtolaryngoogyandHeadandNeckSurgery123:10491054.
Roeser,R.andJ.Northern.1981.Screeningforhearinglossandmiddleeardisorders.In
AuditoryDisordersinSchoolChildren,editedbyR.RoeserandM.Downs.NewYork:Thieme
Stratton.
Roeser,R.,JinSoh,D.,Dunckel,C.,andR.Adams.1978.Comparisonoftypanometryand
otoscopyinestablishingpass/failreferralcriteria.InImpedanceScreeningforMiddleEar
DiseaseinChildren,editedbyE.Harford,F.Bess,C.Bluestone,andJ.
Klein.NewYork:Grune&Stratton,Inc.
Ross,D.,Gaffney,M.,Green,D.,andW.Holstrum.2008.Prevalenceandeffects.Seminarsin
Hearing29(2):141148
Roush,J.,Bryant,K.,Mundy,M.,Zeisel,S.,andJ.Roberts.1995.Developmentalchangesin
staticadmittanceandtympanometricwidthininfantsandtoddler.JournaloftheAmerican
AcademyofAudiology6(4),334338.
RubenR.2000.Redefiningthesurvivalofthefittest:Communicationdisordersinthe21st
century.Laryngoscope11:241245
SaboM.,WinstonR,andJ.Macias.2000.Comparisonofpuretoneandtransientotoacoustic
emissionsscreeninginagradeschoolpopulation.AmericanJournalofOtology21:8891.
Sarafraz,M.andK.Ahmadi.2009.ApracticalscreeningmodelforhearinglossinIranianschool
agedchildren.WorldJournalofPediatrics(5):4650.
Sarff,L.,Ray,H.,andC.Bagwell.1981.Whynoamplificationineveryclassroom?HearingAid
Journal,34(10):11,4752.
71
SchlauchR,andE.Carney.2010.AreFalsePositiveRatesLeadingtoanOverestimationof
NoiseInducedHearingLoss?JournalofSpeech,LangandHearingResearch.Publishedonline
Sep15.
Shargorodsky,J.,Curhan,S.G.,Curhan,G.C.,andR.Eavey.2010.Changeinprevalenceof
hearinglossinUSadolescents.JournaloftheAmericanMedicalAssociation304(7):7728.
Schwartz,D.,Schwartz,R.,Rosenblatt,M.,Berry,G.,andP.Schweisthal.1978.Variabilityin
tympanometricpatterninchildrenbelowfiveyearsofage.InImpedanceScreeningforMiddle
EarDiseaseinChildren,editedbyE.Harford,F.Bess,C.Bluestone.andJ.Klein,J.NewYork:
Grune&Stratton,Inc.
SeldenT.2006.Compliancewithwellchildvisitrecommendations:Evidencefromthemedical
expenditurepanelsurvey,20002002.Pediatrics118(6):176678.
Sideris,I.andT.Glattke.2006.Acomparisonoftwomethodsofhearingscreeninginthe
preschoolpopulation.JournalofCommunicationDisorders39(6):391401
Siegenthaler,B.andR.Sommers.1959.Abbreviatedsweepcheckproceduresforschoolhearing
testing.JournalofSpeechandHearingDisorders24:249257.
Smaldino,J.,andC.Flexer,.2004.Classroomacoustics:PersonalandsoundfieldFMandIR
systems.InPediatricAudiology:Diagnosis,Technology,andManagement,editedbyJ.Madell
andC.Flexer.NewYork:Thieme.
Starr,A.,Picton,T.,Sininger,Y.,Hood,L.,andC.Berlin.1996.Auditoryneuropathy.Brain119
(Pt3):741753.
Stevens,D.,andG.Davidson.1959.Screeningtestsofhearing.JournalofSpeechandHearing
Disorders24:258261.
Stinson,M.,Scherer,M.,andG.Walker.1987.Factorsaffectingdeafcollegestudents.Research
inHigherEducation27(3):244258.
Stool,S.,Berg,A,Berman,S.,etal.Otitismediawitheffusioninyoungchildren:Clinical
practiceguidelines,Number12.AHCPRPublicationNo.940622,Rockville,MD:Agencyfor
HealthCarePolicyandResearch,PublicHealthService,USDepartmebtofHealthandHuman
Services,1994
TaskForceoftheSymposiumonImpedanceScreeningforChildren.1978.Useofacoustic
impedancemeasurementinscreeningformiddleeardiseaseinchildren.Pediatrics62,570
573.
72
Taylor,C.andR.Brooks.2000.Screeningforhearinglossandmiddleeardisordersinchildren
usingTEOAEs.AmericanJournalofAudiology9(1):5055.
Teasdale,T.andM.Sorenson.2007.Hearinglossinrelationtoeducationalattainmentand
cognitiveabilities:apopulationstudy.InternationalJournalofAudiology46(4):172175.
Tharpe,A.andF.Bess.1991.Identificationandmanagementofchildrenwithminimalhearing
loss.InternationalJournalOfPediatricOtorhinolaryngology21:4150.
Tos,M.1984.Epidemiologyandnaturalhistoryofsecretoryotitis.AmericanJournalofOtology
5:459462.
Tos,M.,HolmJensen,S.,Sorensen,C.andC.Morgensen.1982.Spontaneouscourseand
frequencyofsecretoryotitisinfouryearoldchildren.ArchivesofOtolaryngology108:411.
Trine,M.,Hirsch,J.andR.Margolis.1993.Theeffectofmiddleearpressureontransient
evokedotoacousticemissions.EarandHearing14(6):401407.
Updike,C.,andJ.Thornburg.1992.Readingskillsandauditoryprocessingabilityinchildren
withchronicotitismediainearlychildhood.AnnalsofOtology,Rhinology,andLaryngology
101(6):530537.
U.S.CentersforDiseaseControlandPrevention.2004,2006.Economiccostsassociatedwith
mentalretardation,cerebralpalsy,hearingloss,andvisionimpairmentUnitedStates,2003.
MMWR.2004;53(3):579.Errata:Vol.53,No.3.MMWR2006;55(32):881
U.S.CentersforDiseaseControlandPrevention.2008.EarlyHearingDetectionand
Intervention(EHDI),2006AnnualEHDIData[cited2008Dec01].Accessedat
www.cdc.gov/ncbddd/ehdi/data.htm
USCentersforDiseaseControlandPrevention.2008.Summaryof2008NationalCDCEHDI
Data,VersionA.Accessedatwww.cdc.gov/ncbddd/hearingloss/2008
data/2008_EHDI_HSFS_Summary.pdf
USCentersforDiseaseControlandPrevention.2009.Summaryof2008NationalCDCEHDI
Data,VersionA.Accessedathttp://www.cdc.gov/ncbddd/hearingloss/2009
Data/2009_EHDI_HSFS_Summary_508_OK.pdf
USCentersforDiseaseControlandPrevention(2010).NationalHealthandNutrition
ExaminationSurvey.Availableathttp://www.cdc.gov/nchs/nhanes/history.htm
USCodeofFederalRegulations1998[45CFR1304.20].Childhealthanddevelopmental
services.Availableathttp://cfr.vlex.com/vid/130420childdevelopmentalservices19937851
73
USDepartmentofLabor.1990,April.BureauofLaborStatistics,FirstQuarter1990.NEWS:
UDSL90197.
U.S.DepartmentofLabor,OccupationalSafetyandHealthAdministration,1991.
Availablefromhttp://www.osha.gov/SLTC/healthcarefacilities/index.html
USPreventiveServicesTaskForce(1996).USPSTFRecommendations:Qualityofevidence.
Availableathttp://www.fpnotebook.com/prevent/epi/UsPrvntvSrvcsTskFrcRcmndtns.htm
VanNaardenK.,DecoufleP.andK.Caldwell.1999.Prevalenceandcharacteristicsofchildren
withserioushearingimpairmentinmetropolitanAtlanta,19911993.Pediatrics103:5705.
Vergison,A.,Dagan,R.,Argueda,A.,Bonnoeffer,Cohen,R.,DHooge,I.,Hoverman,A.,Liese,J.,
Marchisio,P.,Palmu,A.,Ray,G.,Sanders,E,Simoes,E.,Uhari,M.,vanEldere,J.andS.Pelton.
2010.Otitismediaanditsconsequences:beyondtheearache.LancetInfectiousDiseases10:
195203.
Watters,G.,Jones,J.andA.Freeland.1997.Thepredictivevalueoftympanometryinthe
diagnosisofmiddleeareffusion.ClinicalOtolaryngology22:343345.
White,K.1997.Thescientificbasisfornewbornhearingscreening:Issuesandevidence.Invited
keynoteaddresstotheEarlyHearingDetectionandIntervention(EHDI)Workshopsponsored
bytheCentersforDiseaseControlandPrevention,Atlanta,GA.
White,K.(October,2010).Twentyyearsofearlyhearingdetectionandintervention(EHDI):
Wherewevebeenandwhatwevelearned.ASHAAudiologyVirtualConference.
WhitingP.2003.ThedevelopmentofQUADAS:atoolforthequalityassessmentofstudiesof
diagnosticaccuracyincludedinsystematicreviews.BMCMedicalResearchMethodology3:25.
Williamson,I.,Dunleavy,J.,Baine,J.,andD.Robinson,1994.Thenaturalhistoryofotitismedia
witheffusionathreeyearstudyoftheincidenceandprevalenceofabnormaltympanograms
infourSouthWestHampshireinfantandfirstschools.JournalofLaryngologyandOtology
108:930934.
Wilson,J.andG.Jungner.1968.Principlesandpracticeofscreeningfordisease.PublicHealth
PaperNumber34.Geneva:WorldHealthOrganization22(11):473
WorldHealthOrganization(2001).HearingAidsForDevelopingCountries:Informal
Consultation.Geneva,1112.Accessedat
http://whqlibdoc.who.int/hq/2001/WHO_PBD_PDH_01.2.pdf
Yilmaz,S.,Karasalihoglu,A.,Tas,A.,Yagiz,R,andM.Tas.2006.Otoacousticemissionsinyoung
adultswithahistoryofotitismedia.JournalofLaryngologyandOtology120:103107.
74
Yin,L.,Bottrell,C.,Clarke,N.,Shacks,J.andM.Poulsen.2009.Otoacousticemissions:Avalid,
efficientfirstlinehearingscreenforpreschoolchildren.JournalofSchoolHealth79(4):147
152.doi:DOI10.1111/j.17461561.2009.00383.x
Yokel,N.2002.Acomparisonofaudiometryandaudiometrywithtympanometrytodetermine
middleearstatusinschoolagechildren.JournalofSchoolNursing18(5)):287292.
YoshinagaItano,C.1995.Efficacyofearlyidentificationandearlyintervention.Semininarsin
Hearing16:115123.
YoshinagaItanoC.2004.Levelsofevidence:universalnewbornhearingscreening(UNHS)and
earlyhearingdetectionandinterventionsystems(EHDI).JournalofCommunicationDisorders
37:451465.
YoshinagaItano,C.,SedeyA.,CoulterD.andA.Mehl.1998.Languageofearlyandlater
identifiedchildrenwithhearingloss.Pediatrics102:11611171.
YoshinagaItanoC,.CoulterD,andV.Thomson.2004.TheColoradonewbornhearingscreening
project:Effectsonspeechandlanguagedevelopmentforchildrenwithhearingloss.Journalof
Perinatology20(8,pt2):S132S137.
Zumach,A.,Gerrits,E.,Chenault,M.andL.Anteunis.2010.Longtermeffectsofearlylifeotitis
mediaonlanguagedevelopment.JournalofSpeech,Language,andHearingResearch53:34
43.
Zwislocki,J.(1963).Anacousticmethodforclinicalexaminationoftheear.JournalofSpeech
andHearingResearch6:303314.
75
AppendixA:SummaryofScreeningProtocolsofThreeLargeSchoolDistrictHearingScreeningPrograms
i
HearingScreeningProtocols
Frequenciesscreened
OrangeCo
CherryCreek
DouglasCounty
(Orlando)
(Denversuburb)
(Denverarea)
500,1000,2000,
PSK:1k,2k,4k+
KGr6:.5,1,2,4KHz
4000Hz
tympanogram;
Gr712:1,2,4,6KHz
1:500,1k,2k,4k+
tympanogram;
Gr25:.5,1,2,4KHz
Gr612:1,2,4,6KHz
Respectivedecibellevelsforeach
frequency
30dB500Hz
20dB500,1000,
25dB500,6000Hz
20dB1000,2000,
2000,4000,6000Hz
20dB1000,2000,
4000Hz
4000Hz
Puretonescreeninitialscreenofall
YES
YES
YES
NO
PreschoolGrade1
K1only
students
Tympanometryscreeninitialscreenof
allstudents
Tympanometryusedinimmediate
Presch.whenseen
YES
YES
YES
Puretoneplustympanometryfor
Iftympswere
Generally,unless
YES
rescreen
abnormalon
highHzhearingloss
rescreen(samedayoffailedpuretone)
immediate
rescreen
Puretone,tympanometryonlyifPTnot
YES
YES
>150daPa
>200daPa
>275daPaor<0.2
NO
YES
YES
3monthsfor
AnnuallyforSN/HL;
Monitoruntilpass3
medicalreferrals,6
monitortubesat
consecutive
monthsfornew
least2x/yr;monitor
tympanometryand
permanentloss,
middleearproblems
thresholdchecks
annualforstable
eachvisittobldg.
passed
Failurecriteriafortympanometry:Flat
plus?
Screeningprotocolforsecondary
different
Recheckprotocol
76
hearinglosses
Staffusedinscreeningprocess
Volunteers,
Audiologist,
Volunteersforfirst
audiologists,Techs
sometimeswith
linescreening;
forinitialscreen;
assistanceofTech;
Techs/Audiologist
Audiologist/Tech
Audiologistfor
forrescreen
forimmediateand
rescreens
rescreens
AppendixB:SummaryofResultsofThreeLargeSchoolDistrictHearingScreeningPrograms
Averagemasshearingscreeningresultsfor3years
OrangeCo
CherryCreek
DouglasCo
(2007/2008,2008/2009,2009/2010)
(Orlando)
(Denversuburb)
(Denver)
Totalnumberstudentsscreened20072010(3yrs)
187,987
37,503(2yrs)
101,931
PS,K,1,2,3,6
PS,K,1,2,3,5,
K,1,2,3,5,7,9
Gradesmassscreenedeachyear
7,9
%failinginitialscreen
8%
notavailable
notavailable
%failingimmediaterescreenoftotalscreened
6%
8.8%
3.7%
810weeks
812weeks
812weeks
notavailable
notavailable
25.9%
Percentoftotal#screenedthatwerereferred
6%
4%
3.16%
ReferraltoMedicalpercentoftotalreferred
25%
63%
33%
ReferraltoAudiologypercentoftotalreferred
23%
37%
61.5%
Referraltobothpercentoftotalreferred
13%
5.5%
20%(medical
20%
12.6%
hearinglosspergradePreschool(3to5)
12%
1%
9%
Kindergarten
28%
25%
10%
25%
21%
12%
16%
13%
7%
9%
9%
11%
*Denotesgradenotincludedinmassscreen4
13%
15%
7%
13%
22%
5%
14%
Rescreenedafterwhatperiod(weeks)?
%failingrescreen
Percentoftotalreferredforwhichevaluation
resultsarereportedbacktoschool(verbal/written)
%oftotalnumberofnewlyidentifiedpermanent
refers)
77
Passrateforelementary(PS5)initialscreening
10
11
12
91%
89%
96.5%
93%
91%
96.1%
23%
notavailable
15%
Passrateforsecondary(612)initialscreening
Percentofnewlydiagnosedhearinglossdueto
unilateral/bilateralhighfrequencyhearingloss
AppendixC.Percentoftotalgroupofstudentswithnewlyidentifiedhearinglossinspecifiedgrade
combinationsformasshearingscreeningbasedonresultsfrom3schooldistricts.
Grade
combinations
OCPS
CCSD
DCSD
PS,K
40%
26%
19%
PS,K,1
65%
49%
31%
PS,K,1,2
81%
63%
38%
PS,K,1,3
74%
58%
42%
PS,K,1,5or6
72%
62%
53%
PS,K,1,3,5or6
81%
71%
57%
PS,K,1,2,3
90%
72%
49%
PS,K,1,2,3,5or6
97%
90%
72%
PS,K,1,5,7
75%
68%
PS,K,1,5,9
67%
60%
PS,K,1,3,5,7
71%
64%
PS,K,1,3,5,9
76%
71%
PS,K,1,2,3,5,7
84%
71%
PS,K,1,2,3,5,9
89%
78%
AppendixACcontainunpublisheddataprovidedbyOrangeCountyFL,CherryCreekCO,and
DouglasCountyCOschooldistrictsforthe20072008,20082009,and20092010schoolyears.
78