Criteria for detection of transiently evoked otoacoustic emissions in schoolchildren

https://doi.org/10.1016/j.ijporl.2015.06.028Get rights and content

Abstract

Objectives

The aim was to compare, on the same dataset, existing detection criteria for transiently evoked otoacoustic emissions (TEOAEs) and to select those most suitable for use with school-aged children.

Methods

TEOAEs were recorded from the ears of 187 schoolchildren (age 8–10 years) using the Otodynamics ILO 292 system with a standard click stimulus of 80 dB peSPL. Pure tone audiometry and tympanometry were also conducted. Global and half-octave-band (at 1, 1.4, 2, 2.8, 4 kHz) values of OAE signal-to-noise ratio (SNR), reproducibility, and response level were determined. These parameters were used as criteria for detection of TEOAEs. In total, 21 criteria based on the literature and 3 new ones suggested by the authors were investigated.

Results

Pure tone audiometry and tympanometry screening generated an ear-based failure rate of 7.49%. For TEOAEs, there was a huge variability in failure rate depending on the criteria used. However, three criteria sets produced simultaneous values of sensitivity and specificity above 75%. The first of these criteria was based only on a global reproducibility threshold value above 50%; the second on certain global reproducibility and global response values; and the third involved exceeding a threshold of 50% band reproducibility. The two criteria sets with the best sensitivity were based on global reproducibility, response level, and signal-to-noise ratio (with different thresholds across frequency bands).

Conclusions

TEAOEs can be efficiently used to test the hearing of schoolchildren provided appropriate protocols and criteria sets are used. They are quick, repeatable, and simple to perform, even for nonaudiologically trained personnel. Criteria with high sensitivity (89%) were identified, but they had relatively high referral rates. This is not so much a problem in schoolchildren as it is in newborns because with schoolchildren pure tone audiometry and tympanometry can be performed immediately or at a follow-up session. Nevertheless, high referral rates lead to increased screening cost; for that reason, three less rigorous criteria with high values of both sensitivity and specificity (75% and above) are recommended.

Introduction

Universal newborn hearing screening (UNHS) programs are nowadays performed in many countries and are usually based on otoacoustic emission (OAE) testing [1], [2], [3]. Some organizations recommend extending hearing screening to young children, especially schoolchildren [4]. Although pure tone audiometry may be effectively used as a method for auditory screening of children older than 4 [5] (i.e. schoolchildren), there are several limitations. The idea behind hearing screening is that it is performed by nonaudiological staff. However, screening by pure tone audiometry performed by nonaudiological personnel has low sensitivity and low specificity, and can be time-consuming [6]. Also, some groups of subjects (e.g. noncooperating) cannot be tested this way. In such cases, fast, objective, and easy-to-use methods such as OAEs might be a better option. Furthermore, some authors have suggested that OAEs can indicate an increased risk of hearing loss [7], [8] and the method is more sensitive to the early stages of hearing damage from noise exposure than is pure tone audiometry [9], [10]. The screening procedure usually has several steps, involving at least two OAE tests or sometimes a combination of OAE and auditory brainstem responses (ABRs), depending on country. One of the crucial steps in such a procedure is the criterion used for detection of the signal.

Because of the great success of UNHS, OAE equipment and detection criteria are prepared specifically with newborns in mind. However, it is known that OAE properties change with age [11], [12]: OAE amplitude decreases with age and there is also a change in the dominant response frequency. In the case of transiently evoked OAEs (TEOAEs) in newborns, the major peak is at 2–4 kHz [13], [14], [15]; in schoolchildren it is more uniformly spread over 1–4 kHz [16], [17]. This means that criteria prepared for newborns might not be effective in schoolchildren. In addition, there are many different criteria for detecting TEOAEs: different systems usually have different default settings for pass/refer, and sometimes it is impossible to change the settings. This high variability in system performance may explain the controversy about which method is more effective for screening the hearing of schoolchildren, OAEs [18] or pure tone audiometry [19].

The properties of TEOAEs in schoolchildren have been studied by several researchers and some normative values are available, e.g. [20], [21]. Nevertheless, schoolchildren are a population that is not very easy to test. TEOAEs can be influenced by seasonal disease [22], and schoolchildren are very active and find it difficult to sit still. This can introduce additional noise and affect the test result.

The rationale for the present study is that most researchers test the whole screening procedure, not the process of detecting OAEs [23], [24], [25], [26]. Moreover, criteria for newborns are usually compared with auditory brainstem responses (ABRs) as the gold standard, whereas in schoolchildren pure tone audiometry can be used (in combination with impedance audiometry) [18], [27]. There are only a few studies that have examined TEOAEs in this group using pure tone audiometry as the reference standard. Also, it is unlikely that neonatal criteria for TEOAEs deliver the same test performance as in school-age children.

This study aims to compare, on the same dataset, existing detection criteria for TEOAEs and picks out those that are most suitable for identifying hearing impairment in schoolchildren.

Section snippets

Material and methods

TEOAEs from both ears of 187 schoolchildren (117 male, 70 female) aged 8–10 years old (8 years, 48; 9 years, 70; 10 years, 69) were measured under low-noise ambient conditions with the ILO 292 apparatus (Otodynamics Ltd, Hatfield) running software version 5.6. Middle ear function was evaluated by impedance audiometry (using a Madsen Zodiac 901 tympanometer, GN Otometrics, Denmark), since middle ear status may significantly influence OAE properties [28]. Pure tone audiometry was evaluated at

Tympanometry and audiometry

Tympanometric tests were performed for all subjects for both ears. The tympanogram classification used was a modified version of Jerger's system [33], presented in Appendix A. Type B tympanograms were obtained in 18 ears (4.81%), type C2 in 10 ears (2.67%), and type C1 in 25 ears (6.68%). Type A tympanograms were found in 265 ears (70.86%), As in 54 ears (14.44%), and Ad in 2 ears (0.53%). Overall, 28 ears (tympanograms type B and C2, 7.49%) failed tympanometry.

A total of 28 ears (7.49%) had

Discussion

In summary, 24 criteria sets based on TEOAE responses have been tested. The highest sensitivity was 89.47% (set 21, Table 1; and set 24, Table 3) and the highest specificity was 91.07% (set 3, Table 1). Unfortunately there is an inevitable tradeoff between hit rates and false alarm rates. Three of the criteria sets (6, 10, and 20) had simultaneously high sensitivity and specificity values, with all three sets having both factors above 75%. A criterion set 6 is based on a global reproducibility

Conclusions

The use of TEOAEs, based on an appropriate protocol and criteria set, can be an efficient tool in school-age hearing screening. It is brief, repeatable, and simple for nonaudiological personnel to perform. The present study showed that a particular criteria set (set 24) based on global reproducibility, response level, and signal-to-noise ratio, and using different thresholds across frequency bands, had the lowest number of false negatives. On the other hand it had a relatively high false alarm

Acknowledgments

Preliminary results of this study were presented at the EFAS 2015 meeting. The authors wish to thank A. Piotrowska for help with organization of the measurements and A. Bell and K. Kochanek for comments on earlier versions of the manuscript.

References (41)

  • N.K. Apostolopoulos et al.

    Otoacoustic emission-based hearing screening of a Greek NICU population

    Int. J. Pediatr. Otorhinolaryngol.

    (1999)
  • A.R. Thornton et al.

    Methodological factors involved in neonatal screening using transient-evoked otoacoustic emissions and automated auditory brainstem response testing

    Hear. Res.

    (2003)
  • S.G. Korres et al.

    Success rate of newborn and follow-up screening of hearing using otoacoustic emissions

    Int. J. Pediatr. Otorhinolaryngol.

    (2006)
  • S. Bansal et al.

    Transient evoked otoacoustic emissions in hearing screening programs: protocol for developing countries

    Int. J. Pediatr. Otorhinolaryngol.

    (2008)
  • S.G. Korres et al.

    The effect of the number of averaged responses on the measurement of transiently evoked otoacoustic emissions in newborns

    Int. J. Pediatr. Otorhinolaryngol.

    (2006)
  • V.W. Zhang et al.

    Neonatal hearing screening: a combined click evoked and tone burst otoacoustic emission approach

    Int. J. Pediatr. Otorhinolaryngol.

    (2008)
  • V. Smyth et al.

    Otoacoustic emission criteria for neonatal hearing screening

    Int. J. Pediatr. Otorhinolaryngol.

    (1999)
  • R. Uribe-Escamilla et al.

    Transient evoked otoacoustic emissions and cochlear dysfunction

    Egypt. J. Ear Nose, Throat Allied Sci.

    (2013)
  • S.J. Norton et al.

    Identification of neonatal hearing impairment: summary and recommendations

    Ear Hear.

    (2000)
  • D.R. Halloran et al.

    Validity of pure-tone hearing screening at well-child visits

    Arch. Pediatr. Adolesc. Med.

    (2009)
  • Cited by (7)

    • Evaluation of transient-evoked otoacoustic emissions in a healthy 1 to 10 year pediatric cohort in Sub-Saharan Africa

      2017, International Journal of Pediatric Otorhinolaryngology
      Citation Excerpt :

      The specific circumstances on site however (i.e. lack of trained personnel to perform pure tone audiometry, reduced cooperation due to physical ailment of hospital recruited children, large distance between recruitment sites) may justify this approach. Although some authors argue that TEOAEs are an efficient, objective and repeatable hearing test also for school children aged more than 5 years [13], pure-tone audiometry is believed to be more sensitive in these children and remains the reference method [2]. Perhaps the present observations would have differed, if additional full auditory testing had been performed.

    • Spontaneous otoacoustic emissions in schoolchildren

      2016, International Journal of Pediatric Otorhinolaryngology
      Citation Excerpt :

      TEOAEs were recorded with a nonlinear protocol and a 20 ms recording window at a click rate of 50 clicks/s. Half-octave-band values of TEOAE response levels and signal to noise ratios (SNRs) over the range 1–4 kHz were used for analysis. All ears analyzed had TEOAEs that fulfilled the following criteria: global reproducibility parameter ≥50%, global response level ≥7 dB, signal-to-noise ratio ≥3 dB in half-octave frequency bands centered at 1 and 1.4 kHz, and signal-to-noise ratio ≥6 dB in 1 of 3 half-octave frequency bands centered at 2, 2.8, and 4 kHz [22]. These criteria ensured high quality recordings, as they give the lowest number of false negatives, particularly in school-age children [22].

    • Assessment of the hearing status of school-age children from rural and urban areas of mid-eastern poland

      2021, International Journal of Environmental Research and Public Health
    • Methods of Partial Deafness Treatment

      2021, Methods of Partial Deafness Treatment
    View all citing articles on Scopus
    View full text