The accuracy of standard audiometric hearing level thresholds in pediatric patients.

OBJECTIVES: Standard audiograms provide decibels Hearing Level (dB HL) thresholds, which are referenced to normative values specified in decibels Sound Pressure Level in an acoustic coupler. Due to variability in external ear acoustics, the actual sound levels reaching the eardrum can vary across individuals. The real-ear to coupler difference (RECD) is a frequency-specific measurement of the difference between sound levels measured at the eardrum and in a coupler. Here, we compare the standard audiogram dB HL levels to RECD corrected hearing thresholds (dB RECHL) in children. METHODS: Children who underwent standard audiometric and RECD testing were included. The dB RECHL was established and the differences between dB HL and dB RECHL (threshold error) was calculated. A threshold error >5 dB was considered significant. RESULTS: A total of 166 children were included (mean age 12 years). Overall, 14% had normal hearing, 52% had conductive hearing loss and 27% had sensorineural hearing loss. Hearing threshold levels were overestimated by the standard audiogram compared to dB RECHL, at all frequencies (250-6000 Hz). In the lower frequencies and at 6000 Hz, 33-59% of patients were overestimated, with a threshold error up to 25 dB. In the mid frequencies, 33% were overestimated with a similar threshold error. CONCLUSION: Standard audiogram thresholds overestimated hearing levels in children which may have clinical implications. This problem can be addressed by correcting thresholds with RECD. More studies are needed to assess the effect of correcting thresholds on hearing outcomes in children.

Clinician Use and Payments by Medical Specialty for Audiometric and Vestibular Testing Among US Medicare Beneficiaries.

Importance: Variations in diagnostic test use may indicate that there are opportunities for quality improvement in vestibular health care. To date, the extent to which clinician acquisition of tests varies nationwide by region and specialty of the clinician is unknown. Objective: To quantify variation in clinician use and payments for audiograms and vestibular tests across all geographic regions of the United States and by specialty of practice. Design, Setting, and Participants: This cross-sectional study used a population-based sample of 1 307 887 audiovestibular test claims from fee-for-service Medicare beneficiaries aged 65 years or older in the Medicare Provider Utilization and Payment Public Use File from January 1 through December 31, 2014. The analysis was completed from January 2 through June 1, 2019. Exposures: Diagnostic audiograms, caloric testing, and rotary chair testing. Main Outcomes and Measures: Test utilization was analyzed by hospital referral region, medical specialty, and total payments. Results: In 2014, clinicians performed 1 213 328 audiograms, 317 880 caloric tests (ie, single caloric irrigations), and 62 779 rotary chair tests, for a total of $38 647 350.21 in Medicare payments from the Centers for Medicare & Medicaid Services. No patient or clinician demographic characteristics were available. Across health care referral regions, rates of testing per 100 000 beneficiaries varied from 166 to 12 021 for audiograms, 15 to 4271 for caloric tests, and 13 to 3556 for rotary chair tests between the lowest-use and highest-use regions. Most audiograms and caloric tests were billed by audiologists (797 957 audiograms [65.8%]; 112 485 caloric tests [35.4%]) and otolaryngologists (376 728 audiograms [31.0%]; 70 567 caloric tests [22.2%]). In contrast, primary care physicians (18 933 [30.2%]) and neurologists (15 254 [24.3%]) billed the largest proportion of rotary chair tests compared with other specialists, including audiologists (7253 [11.6%]) and otolaryngologists (6464 [10.3%]). Conclusions and Relevance: Substantial geographic and clinician-level variation may have been observed in use of audiovestibular tests. Quality improvement efforts in vestibular health care may need to target a range of clinicians, including primary care physicians to be successful.

Standard Audiograms for Koreans Derived through Hierarchical Clustering Using Data from the Korean National Health and Nutrition Examination Survey 2009-2012.

Assessments of standardized region/population-specific audiological characteristics are needed for provision of effective rehabilitative services through reducing costs associated with hearing aids. This study aims to propose a set of standard audiograms representing the Korean population that were derived by analyzing data from the 2009-2012 Korea National Health and Nutrition Examination Survey (KNHANES), a nationwide epidemiologic study conducted by Korean government organizations. Standard audiograms were derived by applying a hierarchical clustering method from recorded audiologic data that were obtained independently at 6 frequencies for each ear: 0.5, 1.0, 2.0, 3.0, 4.0, and 6.0 kHz (in dB HL). To derive the optimal number of clusters of the desired standard audiograms, cubic clustering criterion, pseudo-F-, and pseudo-t2-statistics were calculated. These analyses resulted in 29 clusters representing a standard audiogram of the South Korean population. Eighteen of the clusters represented normal hearing audiograms (73.11%), while 11 represented hearing-impaired (HI) standard audiograms (27.89%). Of the 11 HI audiograms, 7 were defined as flat-type (17.81%), while the remaining 4 were defined as sloping-type (9.08%). In conclusion, 29 audiograms representing standard audiograms for the Korean population have been derived using KNHANES data. Improved understanding of the characteristics of each cluster may be helpful for development of more personalized, fixed-setting hearing aids.

Reliability of Measures of N1 Peak Amplitude of the Compound Action Potential in Younger and Older Adults.

Purpose: Human auditory nerve (AN) activity estimated from the amplitude of the first prominent negative peak (N1) of the compound action potential (CAP) is typically quantified using either a peak-to-peak measurement or a baseline-corrected measurement. However, the reliability of these 2 common measurement techniques has not been evaluated but is often assumed to be relatively poor, especially for older adults. To address this question, the current study (a) compared test-retest reliability of these 2 methods and (b) tested the extent to which measurement type affected the relationship between N1 amplitude and experimental factors related to the stimulus (higher and lower intensity levels) and participants (younger and older adults). Method: Click-evoked CAPs were recorded in 24 younger (aged 18-30 years) and 20 older (aged 55-85 years) adults with clinically normal audiograms up to 3000 Hz. N1 peak amplitudes were estimated from peak-to-peak measurements (from N1 to P1) and baseline-corrected measurements for 2 stimulus levels (80 and 110 dB pSPL). Baseline-corrected measurements were made with 4 baseline windows. Each stimulus level was presented twice, and test-retest reliability of these 2 measures was assessed using the intraclass correlation coefficient. Linear mixed models were used to evaluate the extent to which age group and click level uniquely predicted N1 amplitude and whether the predictive relationships differed between N1 measurement techniques. Results: Both peak-to-peak and baseline-corrected measurements of N1 amplitude were found to have good-to-excellent reliability, with intraclass correlation coefficient values > 0.60. As expected, N1 amplitudes were significantly larger for younger participants compared with older participants for both measurement types and were significantly larger in response to clicks presented at 110 dB pSPL than at 80 dB pSPL for both measurement types. Furthermore, the choice of baseline window had no significant effect on N1 amplitudes using the baseline-corrected method. Conclusions: Our results suggest that measurements of AN activity can be robustly and reliably recorded in both younger and older adults using either peak-to-peak or baseline-corrected measurements of the N1 of the CAP. Peak-to-peak measurements yield larger N1 response amplitudes and are the default measurement type for many clinical systems, whereas baseline-corrected measurements are computationally simpler. Furthermore, the relationships between AN activity and stimulus- and participant-related variables were not affected by measurement technique, which suggests that these relationships can be compared across studies using different techniques for measuring the CAP N1.

The Role of the Professional Supervisor in the Audiometric Testing Component of Hearing Conservation Programs.

: ACOEM believes that the functions of a professional supervisor in hearing conservation programs are part of the "core practice" of occupational medicine. This guidance emphasizes the role occupational medicine clinicians play in the supervision of audiometric surveillance conducted under the auspices of hearing conservation programs and reviews the regulatory and scientific basis and pertinent practices involved in this supervisory role.

[Acoustic conditions in open plan office - Application of technical measures in a typical room]. / Warunki akustyczne w pomieszczeniach biurowych open space ­ zastosowanie srodków technicznych w typowym pomieszczeniu.

BACKGROUND: Noise in open plan offices should not exceed acceptable levels for the hearing protection. Its major negative effects on employees are nuisance and impediment in execution of work. Specific technical solutions should be introduced to provide proper acoustic conditions for work performance. MATERIAL AND METHODS: Acoustic evaluation of a typical open plan office was presented in the article published in "Medycyna Pracy" 5/2016. None of the rooms meets all the criteria, therefore, in this article one of the rooms was chosen to apply different technical solutions to check the possibility of reaching proper acoustic conditions. Acoustic effectiveness of those solutions was verified by means of digital simulation. The model was checked by comparing the results of measurements and calculations before using simulation. RESULTS: The analyzis revealed that open plan offices supplemented with signals for masking speech signals can meet all the required criteria. It is relatively easy to reach proper reverberation time (i.e., sound absorption). It is more difficult to reach proper values of evaluation parameters determined from A-weighted sound pressure level (SPLA) of speech. The most difficult is to provide proper values of evaluation parameters determined from speech transmission index (STI). Finally, it is necessary (besides acoustic treatment) to use devices for speech masking. The study proved that it is technically possible to reach proper acoustic condition. CONCLUSIONS: Main causes of employees complaints in open plan office are inadequate acoustic work conditions. Therefore, it is necessary to apply specific technical solutions - not only sound absorbing suspended ceiling and high acoustic barriers, but also devices for speech masking. Med Pr 2018;69(2):153-165.

Phyllis M. Tookey Kerridge and the science of audiometric standardization in Britain.

The provision of standardized hearing aids is now considered to be a crucial part of the UK National Health Service. Yet this is only explicable through reference to the career of a woman who has, until now, been entirely forgotten. Dr Phyllis Margaret Tookey Kerridge (1901-1940) was an authoritative figure in a variety of fields: medicine, physiology, otology and the construction of scientific apparatus. The astounding breadth of her professional qualifications allowed her to combine features of these fields and, later in her career, to position herself as a specialist to shape the discipline of audiometry. Rather than framing Kerridge in the classic 'heroic-woman' narrative, in this article we draw out the complexities of her career by focusing on her pursuit of standardization of hearing tests. Collaboration afforded her the necessary networks to explore the intricacies of accuracy in the measurement of hearing acuity, but her influence was enhanced by her ownership of Britain's first Western Electric (pure-tone) audiometer, which she placed in a specially designed and unique 'silence room'. The room became the centre of Kerridge's hearing aid clinic that, for the first time, allowed people to access free and impartial advice on hearing aid prescription. In becoming the guardian expert and advocate of the audiometer, Kerridge achieved an objectively quantified approach to hearing loss that eventually made the latter an object of technocratic intervention.

Asynchronous interpretation of manual and automated audiometry: Agreement and reliability.

Introduction Remote interpretation of automated audiometry offers the potential to enable asynchronous tele-audiology assessment and diagnosis in areas where synchronous tele-audiometry may not be possible or practical. The aim of this study was to compare remote interpretation of manual and automated audiometry. Methods Five audiologists each interpreted manual and automated audiograms obtained from 42 patients. The main outcome variable was the audiologist's recommendation for patient management (which included treatment recommendations, referral or discharge) between the manual and automated audiometry test. Cohen's Kappa and Krippendorff's Alpha were used to calculate and quantify the intra- and inter-observer agreement, respectively, and McNemar's test was used to assess the audiologist-rated accuracy of audiograms. Audiograms were randomised and audiologists were blinded as to whether they were interpreting a manual or automated audiogram. Results Intra-observer agreement was substantial for management outcomes when comparing interpretations for manual and automated audiograms. Inter-observer agreement was moderate between clinicians for determining management decisions when interpreting both manual and automated audiograms. Audiologists were 2.8 times more likely to question the accuracy of an automated audiogram compared to a manual audiogram. Discussion There is a lack of agreement between audiologists when interpreting audiograms, whether recorded with automated or manual audiometry. The main variability in remote audiogram interpretation is likely to be individual clinician variation, rather than automation.

Comparison of threshold estimation in infants with hearing loss or normal hearing using auditory steady-state response evoked by narrow band CE-chirps and auditory brainstem response evoked by tone pips.

OBJECTIVE: The objective of this study is to compare air-conduction thresholds obtained with ASSR evoked by narrow band (NB) CE-chirps and ABR evoked by tone pips (tpABR) in infants with various degrees of hearing loss. DESIGN: Thresholds were measured at 500, 1000, 2000 and 4000 Hz. Data on each participant were collected at the same day. STUDY SAMPLE: Sixty-seven infants aged 4 d to 22 months (median age = 96 days), resulting in 57, 52, 87 and 56 ears for 500, 1000, 2000 and 4000 Hz, respectively. RESULTS: Statistical analysis was performed for ears with hearing loss (HL) and showed a very strong correlation between tpABR and ASSR evoked by NB CE-chirps: 0.90 (n = 28), 0.90 (n = 28), 0.96 (n = 42) and 0.95 (n = 30) for 500, 1000, 2000 and 4000 Hz, respectively. At these frequencies, the mean difference between tpABR and ASSR was -3.6 dB (± 7.0), -5.2 dB (± 7.3), -3.9 dB (± 5.2) and -5.2 dB (± 4.7). Linear regression analysis indicated that the relationship was not influenced by the degree of hearing loss. CONCLUSION: We propose that dB nHL to dB eHL correction values for ASSR evoked by NB CE-chirps should be 5 dB lower than values used for tpABR.

Management of lateral skull base cancer: United Kingdom National Multidisciplinary Guidelines.

This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. It provides recommendations on the work up and management of lateral skull base cancer based on the existing evidence base for this rare condition. Recommendations • All patients with more than one of: chronic otalgia, bloody otorrhoea, bleeding, mass, facial swelling or palsy should be biopsied. (R) • Magnetic resonance and computed tomography imaging should be performed. (R) • Patients should undergo audiological assessment. (R) • Carotid angiography is recommended in select patients. (G) • The modified Pittsburg T-staging system is recommended. (G) • The minimum operation for cancer involving the temporal bone is a lateral temporal bone resection. (R) • Facial nerve rehabilitation should be initiated at primary surgery. (G) • Anterolateral thigh free flap is the workhorse flap for lateral skull base defect reconstruction. (G) • For patients undergoing surgery for squamous cell carcinoma, at least a superficial parotidectomy and selective neck dissection should be carried out. (R).

Evaluation of Audiometric Test Results to Determine Hearing Impairment in Patients with Rheumatoid Arthritis: Analysis of Data from the Korean National Health and Nutrition Examination Survey.

This study aimed to evaluate the association between rheumatoid arthritis (RA) and hearing impairment in the Korean adult population. Audiometric and laboratory test data from the 2010-2012 Korean National Health and Nutrition Examination Survey (KNHANES) were used for analysis. The relationship between RA and hearing impairment was analyzed, adjusting for various known risk factors associated with hearing impairment. RA was defined in the questionnaire as "RA diagnosed by a physician (yes/no) through a standardized interview." We defined hearing impairment according to 2 categories of frequency (low/mid and high) as follows (average values in kHz): low/mid frequency, 0.5, 1.0, and 2.0, and high frequency, 3.0, 4.0, and 6.0. Of the subjects, 15,158 (weighted n = 32,035,996) completed the audiometric tests. The overall weighted prevalence of RA was 1.5%. The prevalence of hearing impairment was higher in the subjects with RA than in those without RA, in both, the low/mid- and high-frequency categories (21.1% vs 7.5%, p < 0.001 and 43.3% vs. 26.2%, p < 0.001, respectively). In the multivariable logistic analysis, RA (odds ratios [OR] 1.47, 95% confidence interval [CI] 1.05-2.06, p = 0.025) was an independent risk factor of low/mid-frequency hearing impairment along with age (OR 1.12, 95% CI 1.12-1.13, p < 0.001), current smoking (OR 1.27, 95% CI 1.03-1.56, p = 0.026), and college graduation (OR 0.53, 95% CI 0.39-0.72, p < 0.001). In the multivariable analysis of high-frequency hearing impairment, RA did not show any association with hearing impairment. This study suggests that RA is associated with low/mid-frequency hearing impairment after adjustment for various known risk factors. Further study is needed to verify the hearing impairment in RA.

Practical considerations for the application of ear simulators in the calibration of audiometers in the extended high frequency region.

OBJECTIVE: Calibration service providers for audiometric equipment often encounter impracticalities in fully implementing the International Electrotechnical Commission (IEC) guidelines for the extended high frequency region. This report evaluates some of the work-around solutions sometimes employed in practice and the implications these have for audiometer calibration results and uncertainties. DESIGN: The impact of using four different microphone configurations on the ear simulator calibration in the frequency range 125 Hz to 20 kHz, and especially in the extended high frequency range from 10 kHz to 20 kHz, was investigated, at a range of temperatures. RESULTS: Variations in the response of the ear simulator of up to 6 dB were observed with the different microphone configurations. In addition, using the microphone without its protection grid produced a dip in the high frequency response of approximately 15 dB. CONCLUSION: While deviation from the practices required in IEC standards is not recommended, replacing the microphone protection grid with a specially fabricated collar (essentially a grid with the top removed) was found to constrain deviations in response to within ±2 dB. It was also concluded that simply removing the microphone protection grid resulted in a wholly unsatisfactory performance.

[Implementation of the new quality assurance agreement for the fitting of hearing aids in daily practice. Part 2: New diagnostic aspects of speech audiometry]. / Umsetzung der neuen Qualitätssicherungsvereinbarung zur Hörgeräteversorgung im Praxisalltag. Teil 2: Diagnostische Neuerungen in der Sprachaudiometrie.

Upon review of the statutory health insurance reimbursement guidelines, a specific quality assurance questionnaire concerned with the provision of hearing aids was introduced that assesses elements of patient satisfaction within Germany's public healthcare system. APHAB questionnaire-based patient evaluation of the benefit of hearing aids represents the third pillar of audiological diagnostics, alongside classical pure-tone and speech audiometry. Another new aspect of the national guidelines is inclusion of free-field measurements in noise with and without hearing aids. Part 2 of this review describes new diagnostic aspects of speech audiometry. In addition to adaptive speech audiometry, a proposed method for applying the gold standard of speech audiometry - the Freiburg monosyllabic speech test - in noise is described. Finally, the quality assurance questionnaire will be explained as an appendix to template 15 of the regulations governing hearing aids.

Responsive parenting intervention after identification of hearing loss by Universal Newborn Hearing Screening: the concept of the Muenster Parental Programme.

BACKGROUND: Parents of newborns with hearing loss (HL) identified by Universal Newborn Hearing Screening (UNHS) programmes wish for educational support soon after confirmation and for contact with other affected families. Besides pedaudiological care, a high level of family involvement and an early start of educational intervention are the best predictors for successful oral language development in children with HL. The implementation of UNHS has made it necessary to adapt existing intervention concepts for families of children with HL to the needs of preverbal infants. In particular, responsiveness has proven to be a crucial skill of intuitive parental behaviour in early communication between parents and their child. Since infants with HL are being fitted earlier with hearing devices, their chances of learning oral language naturally in daily communication with family members have noticeably improved. OBJECTIVES: The Muenster Parental Programme (MPP) aims at empowering parents in communicating with their preverbal child with HL and in (re-)building confidence in their own parental resources. Additionally, it supplies specific information about auditory and language development and enables exchange with other affected parents shortly after the diagnosis. CONCEPT: The MPP is a responsive parenting intervention specific to the needs of parents of infants with HL identified by UNHS or through other indices and testing within the first 18 months of life. It is based on the communication-oriented Natural Auditory Oral Approach and trains parental responsiveness to preverbal (3-18 months) infants with HL. The MPP has been developed for groups of 4-6 families and comprises six group sessions (without infants), two single training sessions with video feedback, and two individual counselling sessions. At the age of 24-30 months, an individual refresher training session is offered to the parents for adapting their responsiveness to the current verbal level of the child via dialogic book reading. The programme also benefits parents of paediatric cochlear implant (CI) candidates preimplantation and postimplantation. CONCLUSIONS: The MPP is evidence-based (see Glanemann et al., this volume) and meets the current need for effective family-centred educational intervention after UNHS.

Wideband acoustic immittance: tympanometric measures.

Wideband tympanometry (WT) measurements provide a view of the acoustic response properties of the middle ear over a broad range of frequencies and ear-canal pressures. These measurements show sensitivity to trends in ear-canal/middle ear maturation and changes in middle ear status as a result of different types of dysfunction. While results from early WT work showed improvements over ambient wideband tests in terms of test performance for identifying middle ear dysfunction and conductive hearing loss (CHL), more recent studies have shown high, but similar test performance for both ambient and tympanometric wideband tests. Case study and group results presented in this article, demonstrating the sensitivity of WT to middle ear dysfunction, CHL, and maturational changes in the middle ear, are promising and suggest the need for additional investigations in individual subjects and large subject populations. Future research should focus on identifying key predictors of developmental trends, middle ear dysfunction, and CHL in an effort to develop middle ear tests with high sensitivity and specificity. Technological advances, more accessibility to equipment, and evolving data analysis techniques should encourage progress in the areas of WT research and clinical application.

Consensus statement: Eriksholm workshop on wideband absorbance measures of the middle ear.

The participants in the Eriksholm Workshop on Wideband Absorbance Measures of the Middle Ear developed statements for this consensus article on the final morning of the Workshop. The presentations of the first 2 days of the Workshop motivated the discussion on that day. The article is divided into three general areas: terminology; research needs; and clinical application. The varied terminology in the area was seen as potentially confusing, and there was consensus on adopting an organizational structure that grouped the family of measures into the term wideband acoustic immittance (WAI), and dropped the term transmittance in favor of absorbance. There is clearly still a need to conduct research on WAI measurements. Several areas of research were emphasized, including the establishment of a greater WAI normative database, especially developmental norms, and more data on a variety of disorders; increased research on the temporal aspects of WAI; and methods to ensure the validity of test data. The area of clinical application will require training of clinicians in WAI technology. The clinical implementation of WAI would be facilitated by developing feature detectors for various pathologies that, for example, might combine data across ear-canal pressures or probe frequencies.

The statistical basis for serial monitoring in audiology.

OBJECTIVES: Audiologists regularly use serial monitoring to evaluate changes in a patient's auditory function over time. Observed changes are compared with reference standards to determine whether further clinical action is necessary. Reference standards are established in a control sample of otherwise healthy subjects to identify the range of auditory shifts that one might reasonably expect to occur in the absence of any pathological insult. Statistical approaches to this seemingly mundane problem typically invoke 1 of 3 approaches: percentiles of the cumulative distribution, the variance of observed shifts, and the "standard error of measurement." In this article, the authors describe the statistical foundation for these approaches, along with a mixed model-based alternative, and identify several necessary, although typically unacknowledged assumptions. Regression to the mean, the phenomenon of an unusual measurement typically followed by a more common one, can seriously bias observed changes in auditory function and clinical expectations. An approach that adjusts for this important effect is also described. DESIGN: Distortion product otoacoustic emissions (DPOAEs) elicited at a single primary frequency, f2 of 3175 Hz, were collected from 32 healthy subjects at baseline and 19 to 29 days later. Ninety percent test-retest reference limits were computed from these data using each statistical approach. DPOAE shifts were also collected from a sample of 18 cisplatin patients tested after 120 to 200 mg of cisplatin. Reference limits established according to each of the statistical approaches in the healthy sample were used to identify clinically alarming DPOAE shifts in the cisplatin patient sample. RESULTS: Reference limits established with any of the parametric methods were similar. The percentile-based approach gave the widest and least precisely estimated intervals. The highest sensitivity for detecting clinically alarming DPOAE shifts was based on a mixed model approach that adjusts for regression to the mean. CONCLUSIONS: Parametric methods give similar serial monitoring criteria as long as certain critical assumptions are met by the data. The most flexible method for estimating test-retest limits is based on the linear mixed model. Clinical sensitivity may be further enhanced by adjusting for regression to the mean.

A free-field method to calibrate bone conduction transducers.

Bone conduction communication systems employ a variety of transducers with different physical and electroacoustic properties, and these transducers may be worn at various skull locations. Testing these systems thus requires a reliable means of transducer calibration that can be implemented across different devices, skull locations, and settings. Unfortunately, existing calibration standards do not meet these criteria. Audiometric bone conduction standards focus on only one device model and on limited skull locations. Furthermore, while mechanical couplers may be used for calibration, the general human validity of their results is suspect. To address the need for more flexible, human-centered calibration methods, the authors investigated a procedure for bone transducer calibration, analogous to free-field methods for calibrating air conduction headphones. Participants listened to1s third-octave noise bands (125-12,500 Hz) alternating between a bone transducer and a loudspeaker and adjusted the bone transducer to match the perceived loudness of the loudspeaker at each test frequency. Participants tested two transducer models and two skull locations. Intra- and inter-subject reliability was high, and the resulting data differed by transducer, by location, and from the mechanical coupler. The described procedure is flexible to transducer model and skull location, requires only basic equipment, and directly yields perceptual data.