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AmericanAcademyofAudiology

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.
1

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.
2

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
12

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

47

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

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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