- Email: [email protected]
Hearing screenings for preschool children: A comparison between whispered voice and pure tone audiogram tests
International Journal of Pediatric Otorhinolaryngology 130 (2020) 109798
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Hearing screenings for preschool children: A comparison between whispered voice and pure tone audiogram tests
T
Lukas Skoloudika, Jan Mejzlika,∗, Michal Janoucha, Jakub Drsataa, Jan Vodickab, Viktor Chroboka a
Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital Hradec Kralove, Charles University, Faculty of Medicine in Hradec Kralove, Czech Republic b Department of Otorhinolaryngology and Head and Neck Surgery, Hospital of Pardubice, Faculty of Health Studies, University of Pardubice, Czech Republic
A R T I C LE I N FO
A B S T R A C T
Keywords: Hearing screening Pure tone audiometry Whispered voice test Five-year old children
Introduction: This prospective study compares the efficiency of two hearing screening tests performed on preschool children. These tests are known as whispered voice test and pure tone audiometry. Methods: Standard hearing screenings were performed on five-year old children using a whispered voice test followed by ENT examination with pure tone audiometry. Results: A total of 827 children were included in the study. Hearing loss (> 25 dB) was observed in 5.8% of the evaluated children (n = 48), being bilateral in only 1.6% (n = 13) of these cases. Slight hearing impairment (hearing loss of 16–25 dB) was observed in 25.4% (n = 210) of the children, with 14.5% bilateral cases (n = 120). Interestingly, 62 children (7.5%) were under suspicion of hearing loss by their parents; however, an audiogram revealed the poor consistency of this diagnosis (sensitivity 20.8%, Cohen's kappa coefficient of 0.048). The whispered voice test (6 m distance) throwed a hearing impairment diagnosis in 807 (48.8%) of examined ears; however, its sensitivity was of only 56.5%, with a specificity of 51.6% and Cohen's kappa coefficient of 0.0254 (poor). Conclusion: The hearing loss incidence in preschool children coupled with the low efficacy of whispered voice tests and the parents’ unreliability during the hearing impairment survey advocate for a more efficient audiometric hearing screening before beginning school attendance.
1. Introduction Hearing screenings are often focused on newborns because the early identification of hearing impairments is essential for the optimal development of speech and language capabilities, which in turn provide the best conditions for a child's education [1]. Neonatal hearing screenings have been designed to identify congenital hearing impairments; however, the prevalence of hearing loss increases proportionally with age and, as such, cannot be identified by these screenings. Approximately 9–10 per every 1,000 children present a detectable and permanent hearing loss by school age [2,3]. Further, it is worrying that children with unrecognized unilateral, or minimal bilateral, hearing loss will have a significant speech and language delay resulting in a negative educational experience for the afflicted child, in addition to behavioral problems [4]. The European Consensus on hearing, vision and speech screenings in preschool and school aged children was established thanks to the 10th Congress of the European Federation of Audiology Societies
∗
(EFAS), encouraging the implementation of the preschool hearing screening program. Regrettably, less than half of EU countries perform these hearing tests as part of regular health screening programs in preschool or early school aged children [5]. Moreover, no consensus has been reached on which hearing test would be optimal for preschool children. Therefore, the main goal of the present study was to evaluate the accuracy of the screening tests used in the Czech Republic and thus determine the current prevalence of hearing loss in five-year old children [2]. 2. Methods This prospective study included children from three cities in the Czech Republic (Hradec Kralove, Pardubice, and Chrudim) each of which underwent the standard follow up from May 2016 to May 2017. The inclusion criteria were: 5 years of age, permanent residence in one of the three defined cities, and compliance with the whispered voice
Corresponding author. Sokolska 581, Hradec Kralove, 50005, Czech Republic. E-mail address: [email protected] (J. Mejzlik).
https://doi.org/10.1016/j.ijporl.2019.109798 Received 29 September 2019; Received in revised form 23 November 2019; Accepted 23 November 2019 Available online 27 November 2019 0165-5876/ © 2019 Elsevier B.V. All rights reserved.
International Journal of Pediatric Otorhinolaryngology 130 (2020) 109798
L. Skoloudik, et al.
test and audiometric examinations.
Table 1 Hearing loss (HL) prevalence in five-year old children.
2.1. Parent observation The suspicion of hearing loss was an obligatory data entry in the personal history of the children, with their parents stating whether they had observed signs of hearing loss during the day to day activities of their child.
Threshold (0.5–4 kHz)
Total
Single side HL
Bilateral HL
0–15 dB 16–25 dB > 25 dB
569/827 (68.8%) 210/827 (25.4%) 48/827 (5.8%)
90 (10.9%) 35 (4.2%)
120 (14.5%) 13 (1.6%)
3.1. Parent observation 2.2. Whispered voice test
A total of 62 (7.5%) children were under suspicion of hearing loss by their parents; however, these suspicions were inconsistent with the audiograms, which confirmed hearing loss in only 10 (16.1%) cases. In contrast, the parents of 38 children were unaware of their hearing loss. Therefore, the sensitivity of the parents' observations was only of 20.8%, with a Cohen's kappa coefficient of 0.048 (poor) in the > 15 dB HL group and of 0.058 (poor) in the > 25 dB HL group.
The compulsory screening visits included a whispered voice test performed by pediatricians trained in its application by a qualified otorhinolaryngologist. The results represent the distance, measured in meters, from which a child could correctly hear and repeat two whispered syllabic words. A distance of 6 m was considered as normal [2]. Each ear was examined separately, masking the contralateral ear by plugging the ear canal with a finger. If the first test failed another was performed at a distance of 5 m, progressively reducing this distance until the child responded. The obtained results were evaluated through statistical analyses.
3.2. Whispered voice test and audiometry A total of 807 (48.8%) ears were diagnosed as hearing impaired by the pediatricians based on the inability of the children to accurately repeat the words whispered from a distance of 6 m. The sensitivity of the whispered voice test was of 56.5%, with a specificity of 51.6% and Cohen's kappa coefficient of 0.0254 (poor) when using an audiometric level of 25 dB HL. On the other hand, the sensitivity of the whispered voice test was of 44.5%, specificity of 59.5%, and a Cohen's kappa coefficient of 0.0438 (poor) using a level of 15 dB HL (slight hearing impairment). Further, 227 (13.7%) of the examined ears failed to accurately hear two syllabic words from a distance of 5 m. The sensitivity of the whispered voice test was of 36.1%, with a specificity of 87.4% and a Cohen's kappa coefficient of 0.1048 (poor) using an audiometric level of 25 dB HL. Under a 15 dB HL level, however, the sensitivity was of 12.4%, a specificity 86.1%, and a Cohen's kappa coefficient of 0.0177 (poor).
2.3. Audiometric test Pure tone audiometry tests were conducted using a clinical audiometer (Interacoustics AC40; Middelfart, Denmark). The audiologic nurse examined both bone and air conduction with standard masking of the contralateral ear. Hearing loss was estimated over frequencies of 0.5, 1, 2, and 4 kHz, set by an average threshold of > 25 dB; on the other hand, slight hearing impairment was set by a threshold of > 15 dB. 2.4. Tympanometry Tympanometry tests were performed using a Siemens SD30 tympanometer (Copenhagen, Denmark). The test included the estimated tympanometric peak pressure (daPa), peak compliance (mL), and equivalent volume of the external ear canal (cm3). Tympanometry results were categorized as follows: Type A, tympanometric peak pressure (TPP) ≤100 daPa; Type B, no identifiable peak with normal external ear canal volume; and Type C, TPP > 100 daPa.
3.3. Tympanometry A type A tympanogram was obtained from 1,168 (70.6%), type B from 101 (6.1%) and type C from 395 (23.2%) of the examined ears. A bilateral type A tympanogram was observed in 532 (64.3%) of children, whereas that a bilateral type B tympanogram with flat curve and normal canal volume was observed in 31 (3.7%), being unilateral only in 37 (4.5%) of the examined children. The median hearing threshold was of 10 dB HL in the group with type A tympanogram, 25 dB in type B and 15 dB HL in type C tympanograms. The median air-bone gap was of 0 dB HL in the group with type A tympanogram, 18 dB HL in type B and 3 dB HL in type C tympanograms (Table 2).
2.5. Statistical methods The obtained data was analyzed through Pearson's Chi-Square and Fisher Exact Tests using the software SAS v9.2 (SAS Institute Inc.; North Carolina, USA) (P < 0.05). Inter-rate reliability between the whispered voice tests and pure tone audiograms was determined with the Cohen's kappa coefficient, where Kappa values of < 0.2 were considered as poor, 0.21–0.4 as fair, 0.41–0.6 as moderate, 0.61–0.8 as good, and 0.81–1.0 as very good.
Table 2 Hearing loss and air-bone gap in children with A, B and C tympanometry type curves.
3. Results A total of 827 children were included in this study, involving a total of 1,654 evaluated ears. The hearing threshold over the frequencies of 0.5, 1, 2 and 4 kHz was of 12 dB HL (median = 10 dB) for air conduction and of 10 dB (median = 10 dB) for bone conduction. Hearing loss (> 25 dB) was detected in 48 (5.8%) children, being bilateral in 13 (1.6%) children, conductive hearing loss was in 41 (5.0%) and permanent sensorineural hearing loss in 7 (0.8%) cases, finding unilateral deafness in only one child. We observed slight hearing impairments (16–25 dB HL) in 210 (25.4%) children, being bilateral in 120 (14.5%) children (Table 1).
Tympanometry
A
B
C
Number of ears
1168/1654 (70.6%)
101/1654 (6.1%)
385/1654 (23.2%)
10 10/12 0 0/0
24 17/34 18 10/10
14 10/19 4 0/0
Hearing loss (dB) ABG (dB)
Median Q1/Q3 Median Q1/Q3
ABG = air-bone gap; Q1 = first quartile; Q3 = third quartile. 2
International Journal of Pediatric Otorhinolaryngology 130 (2020) 109798
L. Skoloudik, et al.
4. Discussion
children, being bilateral in 3.7% of them. A dysfunctional Eustachian tube was suspected in 35.7% of the children (Type B or C tympanograms). The importance of the early identification of children with OME cannot be understated, as it is essential for disease management, hearing improvement, speech and language development, and optimal conditions for education.
The auditory screenings of 5-year old children are not nearly as well structured as that of newborns, where the early detection of auditory impairments is critical for the child's psychosocial development [5]. Children with slight hearing impairments (16–25 dB HL) may have trouble with soft speech, soft sounds, or distant speech. Interestingly, the prevalence of unilateral slight hearing impairments in our group was of 31.0%, being bilateral in only 16.0% of the examined children. A similar conclusion was reached by Niskar et al. during the evaluation of a pediatric population [3] where 14.9% of the evaluated children had a hearing capability worse than 16 dB. It has been concluded that the learning capacity for these children is, in some aspects, demonstrably slower than for children with no hearing impairments [4]. Further, this difference would be more prominent if focused on children with a greater handicap [6]. Children suffering from a > 25 dB hearing loss consistently miss some spoken words and their speech capacity and language development may also be affected. It is essential that these children be diagnosed before school age to prevent its negative impact on education as well as in social interaction [1]. We detected a hearing loss of > 25 dB in 48 (5.8%) children, being bilateral in 13 (1.6%) of them. Notably, most of these children suffered from conductive hearing loss 41 (5.0%). On the other hand, permanent sensorineural hearing loss was observed in 7 (0.8%) children, being bilateral in one child. Single side deafness was observed in one child only. In the Czech Republic, the standard hearing screenings for preschool children is based on a basic whispered voice test, which is performed by pediatricians on a compulsory checkup [7,8]. Our study shows that slight hearing impairments, as well as > 25 dB hearing loss, are not so easily discovered by this test. Moreover, the reliability of the whispered voice tests and audiometric hearing evaluations is poor (Cohen's kappa coefficient < 0.2). The sensitivity of the whispered voice test for > 25 and > 15 dB hearing loss is > 60 and > 45% of the affected children, respectively. If the distance limit during the whispered voice test is switched from 6 to 5 m the sensitivity decreases to 36.1% and Cohen's kappa coefficient is still poor. Although all of the pediatricians participating in our study were trained in the application of these whispered voice tests, their examinations still failed to successfully detect hearing loss in the evaluated children. It must be highlighted that the early detection of an auditory impairment leads to a faster re-socialization by the child [9]. The question then becomes if the parents' suspicion of hearing loss is reliable. In this regard, our study shows that the parents' suspicions are not consistent with the audiometric evaluations. In our study group, the parents recognized a > 25 dB hearing loss in less than 25% of the affected children. The sensitivity of the parents' observations was only of 20.8%, having an even lower value (10.2%) for slight hearing impairments. Accordingly, the reliability coefficient was poor. The inability of the parents to evaluate the hearing capacity of their children was also proven by Findlena et al. [10]. Interestingly, the assessment of their own hearing impairment and diminished speech understanding during adulthood corresponds to the results of the questionnaire's audiometric results [11]. The function of the Eustachian tube is often compromised in preschool children; however, this hearing impairment is usually temporary, adjusting spontaneously without the need for medication or surgical intervention [12]. On the other hand, a mild disorder is manifested by middle ear negative pressure (Type C tympanogram), which is a longer lasting disorder leading to the development of chronic secretory otitis. (Type B tympanogram) [13–15]. The relation between the hearing threshold and tympanometric evaluations is shown in Table 2. Our study confirms that the most common cause of hearing loss in preschool children is chronical otitis media with effusion (OME) [12,16]. In this regard, we obtained Type B tympanograms with flat curve and normal canal volume in 8.2% of the
5. Conclusion The present study demonstrates the unsuitability of whispered voice tests in hearing screenings for preschool children. This is mostly due to its low sensitivity and poor inter-rate reliability in comparison with pure tone audiograms. Therefore, the latter has proven to be a more reliable method to determine the occurrence of hearing loss in five-year old children and should be used in these screenings. It must be highlighted that the data obtained from this study has become the basis for preschool auditory screenings in the Czech Republic. As of 2018, the Ministry of Health of the Czech Republic issued a Methodological Guideline for the Implementation of Auditory Screenings in 5-year old children (Ministry of Health Bulletin 11/2018). As a result, nationwide hearing screenings have been applied through tone audiometry in the Czech Republic since 2019. Ethicals approval and consent to participate The manuscript has been approved by the Ethical Committee of University Hospital in Hradec Kralove, number 201912 S11P and by the Ethical Committee of the General Insurance Company of the Czech Republic number 12012016. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki declaration and its later amendments. Formal consent is not required for this type of study, because only standard procedures were used for hearing screening. Funding This work was supported by grant project of Vseobecna Zdravotni Pojistovna Ceske Republiky (VZP), Auditory examination in preschool children, number 4100041931 and by the project of the Ministry of Health, Czech Republic for conceptual development of research organization, number MH CZ-DRO UHHK, 00179906. Declaration of competing interest All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript. Acknowledgements We thank Dr. Eva Cermakova for statistical analysis. Thanks also to the pediatricians, otorhinolaryngologists and audiologists that participated in the screening project. Thanks also to Dr. Daniel Diaz for English language proofreading. References [1] J. Bamford, A. Davis, J. Boyle, J. Law, S. Chapman, S.S. Brown, T.A. Sheldon, Preschool hearing, speech, language, and vision screening, Qual. Health Care 7 (1998) 240–247, https://doi.org/10.1136/qshc.7.4.240.
3
International Journal of Pediatric Otorhinolaryngology 130 (2020) 109798
L. Skoloudik, et al. [2] V. Chrobok, L. Školoudík, M. Hloušková, L. Bilinová, Hearing screening in children of first class of elementary schools in Hradec Králové, Otorinolaryng. a Foniat./ Prague/ 63 (2014) 212–215. [3] A.S. Niskar, S.M. Kieszak, A. Holmes, E. Esteban, C. Rubin, D.J. Brody, Prevalence of hearing loss among children 6 to 19 years of age: the third national health and nutrition examination survey, J. Am. Med. Assoc. 279 (1998) 1071–1075, https:// doi.org/10.1001/jama.279.14.1071. [4] C. Yoshinaga-Itano, A.L. Sedey, M. Wiggin, W. Chung, Early hearing detection and vocabulary of children with hearing loss, Pediatrics 140 (2017), https://doi.org/10. 1542/peds.2016-2964. [5] N. Verhaert, M. Willems, E. Van Kerschaver, C. Desloovere, Impact of early hearing screening and treatment on language development and education level: evaluation of 6 years of universal newborn hearing screening (ALGO) in Flanders, Belgium, Int. J. Pediatr. Otorhinolaryngol. 72 (2008) 599–608, https://doi.org/10.1016/j.ijporl. 2008.01.012. [6] C. Williams, Promoting vocabulary learning in young children who are d/Deaf and hard of hearing: translating research into practice, Am. Ann. Deaf 156 (2012) 501–508, https://doi.org/10.1353/aad.2012.1597. [7] J. Bamford, H. Fortnum, K. Bristow, J. Smith, G. Vamvakas, L. Davies, R. Taylor, P. Watkin, S. Fonseca, A. Davis, S. Hind, Current practice, accuracy, effectiveness and cost-effectiveness of the school entry hearing screen, Health Technol. Assess. 11 (2007) 1–168 iii-iv. [8] W. Wu, J. Lu, Y. Li, A.C. Kam, M.C. Fai Tong, Z. Huang, H. Wu, A new hearing screening system for preschool children, Int. J. Pediatr. Otorhinolaryngol. 78 (2014) 290–295, https://doi.org/10.1016/j.ijporl.2013.11.026. [9] J.E. Stewart, J.E. Bentley, Hearing loss in pediatrics: what the medical home needs to know, Pediatr. Clin. N. Am. 66 (2019) 425–436, https://doi.org/10.1016/j.pcl. 2018.12.010.
[10] U.M. Findlen, P.S. Malhotra, O.F. Adunka, Parent perspectives on multidisciplinary pediatric hearing healthcare, Int. J. Pediatr. Otorhinolaryngol. 116 (2019) 141–146, https://doi.org/10.1016/j.ijporl.2018.10.044. [11] S. Alhanbali, P. Dawes, S. Lloyd, K.J. Munro, Hearing handicap and speech recognition correlate with self-reported listening effort and fatigue, Ear Hear. 39 (2018) 470–474, https://doi.org/10.1097/AUD.0000000000000515. [12] R.M. Rosenfeld, J.J. Shin, S.R. Schwartz, R. Coggins, L. Gagnon, J.M. Hackell, D. Hoelting, L.L. Hunter, A.W. Kummer, S.C. Payne, D.S. Poe, M. Veling, P.M. Vila, S.A. Walsh, M.D. Corrigan, Clinical practice guideline: otitis media with effusion executive summary (Update), Otolaryngology-Head Neck Surg. (Tokyo) 154 (2016) 201–214, https://doi.org/10.1177/0194599815624407. [13] L. Skoloudik, D. Kalfert, T. Valenta, V. Chrobok, Relation between adenoid size and otitis media with effusion, Eur. Ann. Otorhinolaryngol. Head Neck Dis. 135 (2018) 399–402, https://doi.org/10.1016/j.anorl.2017.11.011. [14] K. Akazawa, H. Doi, S. Ohta, T. Terada, M. Fujiwara, N. Uwa, M. Tanooka, M. Sakagami, Relationship between Eustachian tube dysfunction and otitis media with effusion in radiotherapy patients, J. Laryngol. Otol. 132 (2018) 111–116, https://doi.org/10.1017/s0022215118000014. [15] P.P. Liu, K.M. Su, B.J. Zhu, Y.Q. Wu, H.B. Shi, S.K. Yin, Detection of eustachian tube openings by tubomanometry in adult otitis media with effusion, Eur. Arch. OtoRhino-Laryngol. 273 (2016) 3109–3115, https://doi.org/10.1007/s00405-0163938-0. [16] A. Kaspar, O. Newton, J. Kei, C. Driscoll, D. Swanepoel, H. Goulios, Prevalence of ear disease and associated hearing loss among primary school students in the Solomon Islands: otitis media still a major public health issue, Int. J. Pediatr. Otorhinolaryngol. 113 (2018) 223–228, https://doi.org/10.1016/j.ijporl.2018.08. 004.
4
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Hearing screenings for preschool children: A comparison between whispered voice and pure tone audiogram tests
T
Lukas Skoloudika, Jan Mejzlika,∗, Michal Janoucha, Jakub Drsataa, Jan Vodickab, Viktor Chroboka a
Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital Hradec Kralove, Charles University, Faculty of Medicine in Hradec Kralove, Czech Republic b Department of Otorhinolaryngology and Head and Neck Surgery, Hospital of Pardubice, Faculty of Health Studies, University of Pardubice, Czech Republic
A R T I C LE I N FO
A B S T R A C T
Keywords: Hearing screening Pure tone audiometry Whispered voice test Five-year old children
Introduction: This prospective study compares the efficiency of two hearing screening tests performed on preschool children. These tests are known as whispered voice test and pure tone audiometry. Methods: Standard hearing screenings were performed on five-year old children using a whispered voice test followed by ENT examination with pure tone audiometry. Results: A total of 827 children were included in the study. Hearing loss (> 25 dB) was observed in 5.8% of the evaluated children (n = 48), being bilateral in only 1.6% (n = 13) of these cases. Slight hearing impairment (hearing loss of 16–25 dB) was observed in 25.4% (n = 210) of the children, with 14.5% bilateral cases (n = 120). Interestingly, 62 children (7.5%) were under suspicion of hearing loss by their parents; however, an audiogram revealed the poor consistency of this diagnosis (sensitivity 20.8%, Cohen's kappa coefficient of 0.048). The whispered voice test (6 m distance) throwed a hearing impairment diagnosis in 807 (48.8%) of examined ears; however, its sensitivity was of only 56.5%, with a specificity of 51.6% and Cohen's kappa coefficient of 0.0254 (poor). Conclusion: The hearing loss incidence in preschool children coupled with the low efficacy of whispered voice tests and the parents’ unreliability during the hearing impairment survey advocate for a more efficient audiometric hearing screening before beginning school attendance.
1. Introduction Hearing screenings are often focused on newborns because the early identification of hearing impairments is essential for the optimal development of speech and language capabilities, which in turn provide the best conditions for a child's education [1]. Neonatal hearing screenings have been designed to identify congenital hearing impairments; however, the prevalence of hearing loss increases proportionally with age and, as such, cannot be identified by these screenings. Approximately 9–10 per every 1,000 children present a detectable and permanent hearing loss by school age [2,3]. Further, it is worrying that children with unrecognized unilateral, or minimal bilateral, hearing loss will have a significant speech and language delay resulting in a negative educational experience for the afflicted child, in addition to behavioral problems [4]. The European Consensus on hearing, vision and speech screenings in preschool and school aged children was established thanks to the 10th Congress of the European Federation of Audiology Societies
∗
(EFAS), encouraging the implementation of the preschool hearing screening program. Regrettably, less than half of EU countries perform these hearing tests as part of regular health screening programs in preschool or early school aged children [5]. Moreover, no consensus has been reached on which hearing test would be optimal for preschool children. Therefore, the main goal of the present study was to evaluate the accuracy of the screening tests used in the Czech Republic and thus determine the current prevalence of hearing loss in five-year old children [2]. 2. Methods This prospective study included children from three cities in the Czech Republic (Hradec Kralove, Pardubice, and Chrudim) each of which underwent the standard follow up from May 2016 to May 2017. The inclusion criteria were: 5 years of age, permanent residence in one of the three defined cities, and compliance with the whispered voice
Corresponding author. Sokolska 581, Hradec Kralove, 50005, Czech Republic. E-mail address: [email protected] (J. Mejzlik).
https://doi.org/10.1016/j.ijporl.2019.109798 Received 29 September 2019; Received in revised form 23 November 2019; Accepted 23 November 2019 Available online 27 November 2019 0165-5876/ © 2019 Elsevier B.V. All rights reserved.
International Journal of Pediatric Otorhinolaryngology 130 (2020) 109798
L. Skoloudik, et al.
test and audiometric examinations.
Table 1 Hearing loss (HL) prevalence in five-year old children.
2.1. Parent observation The suspicion of hearing loss was an obligatory data entry in the personal history of the children, with their parents stating whether they had observed signs of hearing loss during the day to day activities of their child.
Threshold (0.5–4 kHz)
Total
Single side HL
Bilateral HL
0–15 dB 16–25 dB > 25 dB
569/827 (68.8%) 210/827 (25.4%) 48/827 (5.8%)
90 (10.9%) 35 (4.2%)
120 (14.5%) 13 (1.6%)
3.1. Parent observation 2.2. Whispered voice test
A total of 62 (7.5%) children were under suspicion of hearing loss by their parents; however, these suspicions were inconsistent with the audiograms, which confirmed hearing loss in only 10 (16.1%) cases. In contrast, the parents of 38 children were unaware of their hearing loss. Therefore, the sensitivity of the parents' observations was only of 20.8%, with a Cohen's kappa coefficient of 0.048 (poor) in the > 15 dB HL group and of 0.058 (poor) in the > 25 dB HL group.
The compulsory screening visits included a whispered voice test performed by pediatricians trained in its application by a qualified otorhinolaryngologist. The results represent the distance, measured in meters, from which a child could correctly hear and repeat two whispered syllabic words. A distance of 6 m was considered as normal [2]. Each ear was examined separately, masking the contralateral ear by plugging the ear canal with a finger. If the first test failed another was performed at a distance of 5 m, progressively reducing this distance until the child responded. The obtained results were evaluated through statistical analyses.
3.2. Whispered voice test and audiometry A total of 807 (48.8%) ears were diagnosed as hearing impaired by the pediatricians based on the inability of the children to accurately repeat the words whispered from a distance of 6 m. The sensitivity of the whispered voice test was of 56.5%, with a specificity of 51.6% and Cohen's kappa coefficient of 0.0254 (poor) when using an audiometric level of 25 dB HL. On the other hand, the sensitivity of the whispered voice test was of 44.5%, specificity of 59.5%, and a Cohen's kappa coefficient of 0.0438 (poor) using a level of 15 dB HL (slight hearing impairment). Further, 227 (13.7%) of the examined ears failed to accurately hear two syllabic words from a distance of 5 m. The sensitivity of the whispered voice test was of 36.1%, with a specificity of 87.4% and a Cohen's kappa coefficient of 0.1048 (poor) using an audiometric level of 25 dB HL. Under a 15 dB HL level, however, the sensitivity was of 12.4%, a specificity 86.1%, and a Cohen's kappa coefficient of 0.0177 (poor).
2.3. Audiometric test Pure tone audiometry tests were conducted using a clinical audiometer (Interacoustics AC40; Middelfart, Denmark). The audiologic nurse examined both bone and air conduction with standard masking of the contralateral ear. Hearing loss was estimated over frequencies of 0.5, 1, 2, and 4 kHz, set by an average threshold of > 25 dB; on the other hand, slight hearing impairment was set by a threshold of > 15 dB. 2.4. Tympanometry Tympanometry tests were performed using a Siemens SD30 tympanometer (Copenhagen, Denmark). The test included the estimated tympanometric peak pressure (daPa), peak compliance (mL), and equivalent volume of the external ear canal (cm3). Tympanometry results were categorized as follows: Type A, tympanometric peak pressure (TPP) ≤100 daPa; Type B, no identifiable peak with normal external ear canal volume; and Type C, TPP > 100 daPa.
3.3. Tympanometry A type A tympanogram was obtained from 1,168 (70.6%), type B from 101 (6.1%) and type C from 395 (23.2%) of the examined ears. A bilateral type A tympanogram was observed in 532 (64.3%) of children, whereas that a bilateral type B tympanogram with flat curve and normal canal volume was observed in 31 (3.7%), being unilateral only in 37 (4.5%) of the examined children. The median hearing threshold was of 10 dB HL in the group with type A tympanogram, 25 dB in type B and 15 dB HL in type C tympanograms. The median air-bone gap was of 0 dB HL in the group with type A tympanogram, 18 dB HL in type B and 3 dB HL in type C tympanograms (Table 2).
2.5. Statistical methods The obtained data was analyzed through Pearson's Chi-Square and Fisher Exact Tests using the software SAS v9.2 (SAS Institute Inc.; North Carolina, USA) (P < 0.05). Inter-rate reliability between the whispered voice tests and pure tone audiograms was determined with the Cohen's kappa coefficient, where Kappa values of < 0.2 were considered as poor, 0.21–0.4 as fair, 0.41–0.6 as moderate, 0.61–0.8 as good, and 0.81–1.0 as very good.
Table 2 Hearing loss and air-bone gap in children with A, B and C tympanometry type curves.
3. Results A total of 827 children were included in this study, involving a total of 1,654 evaluated ears. The hearing threshold over the frequencies of 0.5, 1, 2 and 4 kHz was of 12 dB HL (median = 10 dB) for air conduction and of 10 dB (median = 10 dB) for bone conduction. Hearing loss (> 25 dB) was detected in 48 (5.8%) children, being bilateral in 13 (1.6%) children, conductive hearing loss was in 41 (5.0%) and permanent sensorineural hearing loss in 7 (0.8%) cases, finding unilateral deafness in only one child. We observed slight hearing impairments (16–25 dB HL) in 210 (25.4%) children, being bilateral in 120 (14.5%) children (Table 1).
Tympanometry
A
B
C
Number of ears
1168/1654 (70.6%)
101/1654 (6.1%)
385/1654 (23.2%)
10 10/12 0 0/0
24 17/34 18 10/10
14 10/19 4 0/0
Hearing loss (dB) ABG (dB)
Median Q1/Q3 Median Q1/Q3
ABG = air-bone gap; Q1 = first quartile; Q3 = third quartile. 2
International Journal of Pediatric Otorhinolaryngology 130 (2020) 109798
L. Skoloudik, et al.
4. Discussion
children, being bilateral in 3.7% of them. A dysfunctional Eustachian tube was suspected in 35.7% of the children (Type B or C tympanograms). The importance of the early identification of children with OME cannot be understated, as it is essential for disease management, hearing improvement, speech and language development, and optimal conditions for education.
The auditory screenings of 5-year old children are not nearly as well structured as that of newborns, where the early detection of auditory impairments is critical for the child's psychosocial development [5]. Children with slight hearing impairments (16–25 dB HL) may have trouble with soft speech, soft sounds, or distant speech. Interestingly, the prevalence of unilateral slight hearing impairments in our group was of 31.0%, being bilateral in only 16.0% of the examined children. A similar conclusion was reached by Niskar et al. during the evaluation of a pediatric population [3] where 14.9% of the evaluated children had a hearing capability worse than 16 dB. It has been concluded that the learning capacity for these children is, in some aspects, demonstrably slower than for children with no hearing impairments [4]. Further, this difference would be more prominent if focused on children with a greater handicap [6]. Children suffering from a > 25 dB hearing loss consistently miss some spoken words and their speech capacity and language development may also be affected. It is essential that these children be diagnosed before school age to prevent its negative impact on education as well as in social interaction [1]. We detected a hearing loss of > 25 dB in 48 (5.8%) children, being bilateral in 13 (1.6%) of them. Notably, most of these children suffered from conductive hearing loss 41 (5.0%). On the other hand, permanent sensorineural hearing loss was observed in 7 (0.8%) children, being bilateral in one child. Single side deafness was observed in one child only. In the Czech Republic, the standard hearing screenings for preschool children is based on a basic whispered voice test, which is performed by pediatricians on a compulsory checkup [7,8]. Our study shows that slight hearing impairments, as well as > 25 dB hearing loss, are not so easily discovered by this test. Moreover, the reliability of the whispered voice tests and audiometric hearing evaluations is poor (Cohen's kappa coefficient < 0.2). The sensitivity of the whispered voice test for > 25 and > 15 dB hearing loss is > 60 and > 45% of the affected children, respectively. If the distance limit during the whispered voice test is switched from 6 to 5 m the sensitivity decreases to 36.1% and Cohen's kappa coefficient is still poor. Although all of the pediatricians participating in our study were trained in the application of these whispered voice tests, their examinations still failed to successfully detect hearing loss in the evaluated children. It must be highlighted that the early detection of an auditory impairment leads to a faster re-socialization by the child [9]. The question then becomes if the parents' suspicion of hearing loss is reliable. In this regard, our study shows that the parents' suspicions are not consistent with the audiometric evaluations. In our study group, the parents recognized a > 25 dB hearing loss in less than 25% of the affected children. The sensitivity of the parents' observations was only of 20.8%, having an even lower value (10.2%) for slight hearing impairments. Accordingly, the reliability coefficient was poor. The inability of the parents to evaluate the hearing capacity of their children was also proven by Findlena et al. [10]. Interestingly, the assessment of their own hearing impairment and diminished speech understanding during adulthood corresponds to the results of the questionnaire's audiometric results [11]. The function of the Eustachian tube is often compromised in preschool children; however, this hearing impairment is usually temporary, adjusting spontaneously without the need for medication or surgical intervention [12]. On the other hand, a mild disorder is manifested by middle ear negative pressure (Type C tympanogram), which is a longer lasting disorder leading to the development of chronic secretory otitis. (Type B tympanogram) [13–15]. The relation between the hearing threshold and tympanometric evaluations is shown in Table 2. Our study confirms that the most common cause of hearing loss in preschool children is chronical otitis media with effusion (OME) [12,16]. In this regard, we obtained Type B tympanograms with flat curve and normal canal volume in 8.2% of the
5. Conclusion The present study demonstrates the unsuitability of whispered voice tests in hearing screenings for preschool children. This is mostly due to its low sensitivity and poor inter-rate reliability in comparison with pure tone audiograms. Therefore, the latter has proven to be a more reliable method to determine the occurrence of hearing loss in five-year old children and should be used in these screenings. It must be highlighted that the data obtained from this study has become the basis for preschool auditory screenings in the Czech Republic. As of 2018, the Ministry of Health of the Czech Republic issued a Methodological Guideline for the Implementation of Auditory Screenings in 5-year old children (Ministry of Health Bulletin 11/2018). As a result, nationwide hearing screenings have been applied through tone audiometry in the Czech Republic since 2019. Ethicals approval and consent to participate The manuscript has been approved by the Ethical Committee of University Hospital in Hradec Kralove, number 201912 S11P and by the Ethical Committee of the General Insurance Company of the Czech Republic number 12012016. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki declaration and its later amendments. Formal consent is not required for this type of study, because only standard procedures were used for hearing screening. Funding This work was supported by grant project of Vseobecna Zdravotni Pojistovna Ceske Republiky (VZP), Auditory examination in preschool children, number 4100041931 and by the project of the Ministry of Health, Czech Republic for conceptual development of research organization, number MH CZ-DRO UHHK, 00179906. Declaration of competing interest All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript. Acknowledgements We thank Dr. Eva Cermakova for statistical analysis. Thanks also to the pediatricians, otorhinolaryngologists and audiologists that participated in the screening project. Thanks also to Dr. Daniel Diaz for English language proofreading. References [1] J. Bamford, A. Davis, J. Boyle, J. Law, S. Chapman, S.S. Brown, T.A. Sheldon, Preschool hearing, speech, language, and vision screening, Qual. Health Care 7 (1998) 240–247, https://doi.org/10.1136/qshc.7.4.240.
3
International Journal of Pediatric Otorhinolaryngology 130 (2020) 109798
L. Skoloudik, et al. [2] V. Chrobok, L. Školoudík, M. Hloušková, L. Bilinová, Hearing screening in children of first class of elementary schools in Hradec Králové, Otorinolaryng. a Foniat./ Prague/ 63 (2014) 212–215. [3] A.S. Niskar, S.M. Kieszak, A. Holmes, E. Esteban, C. Rubin, D.J. Brody, Prevalence of hearing loss among children 6 to 19 years of age: the third national health and nutrition examination survey, J. Am. Med. Assoc. 279 (1998) 1071–1075, https:// doi.org/10.1001/jama.279.14.1071. [4] C. Yoshinaga-Itano, A.L. Sedey, M. Wiggin, W. Chung, Early hearing detection and vocabulary of children with hearing loss, Pediatrics 140 (2017), https://doi.org/10. 1542/peds.2016-2964. [5] N. Verhaert, M. Willems, E. Van Kerschaver, C. Desloovere, Impact of early hearing screening and treatment on language development and education level: evaluation of 6 years of universal newborn hearing screening (ALGO) in Flanders, Belgium, Int. J. Pediatr. Otorhinolaryngol. 72 (2008) 599–608, https://doi.org/10.1016/j.ijporl. 2008.01.012. [6] C. Williams, Promoting vocabulary learning in young children who are d/Deaf and hard of hearing: translating research into practice, Am. Ann. Deaf 156 (2012) 501–508, https://doi.org/10.1353/aad.2012.1597. [7] J. Bamford, H. Fortnum, K. Bristow, J. Smith, G. Vamvakas, L. Davies, R. Taylor, P. Watkin, S. Fonseca, A. Davis, S. Hind, Current practice, accuracy, effectiveness and cost-effectiveness of the school entry hearing screen, Health Technol. Assess. 11 (2007) 1–168 iii-iv. [8] W. Wu, J. Lu, Y. Li, A.C. Kam, M.C. Fai Tong, Z. Huang, H. Wu, A new hearing screening system for preschool children, Int. J. Pediatr. Otorhinolaryngol. 78 (2014) 290–295, https://doi.org/10.1016/j.ijporl.2013.11.026. [9] J.E. Stewart, J.E. Bentley, Hearing loss in pediatrics: what the medical home needs to know, Pediatr. Clin. N. Am. 66 (2019) 425–436, https://doi.org/10.1016/j.pcl. 2018.12.010.
[10] U.M. Findlen, P.S. Malhotra, O.F. Adunka, Parent perspectives on multidisciplinary pediatric hearing healthcare, Int. J. Pediatr. Otorhinolaryngol. 116 (2019) 141–146, https://doi.org/10.1016/j.ijporl.2018.10.044. [11] S. Alhanbali, P. Dawes, S. Lloyd, K.J. Munro, Hearing handicap and speech recognition correlate with self-reported listening effort and fatigue, Ear Hear. 39 (2018) 470–474, https://doi.org/10.1097/AUD.0000000000000515. [12] R.M. Rosenfeld, J.J. Shin, S.R. Schwartz, R. Coggins, L. Gagnon, J.M. Hackell, D. Hoelting, L.L. Hunter, A.W. Kummer, S.C. Payne, D.S. Poe, M. Veling, P.M. Vila, S.A. Walsh, M.D. Corrigan, Clinical practice guideline: otitis media with effusion executive summary (Update), Otolaryngology-Head Neck Surg. (Tokyo) 154 (2016) 201–214, https://doi.org/10.1177/0194599815624407. [13] L. Skoloudik, D. Kalfert, T. Valenta, V. Chrobok, Relation between adenoid size and otitis media with effusion, Eur. Ann. Otorhinolaryngol. Head Neck Dis. 135 (2018) 399–402, https://doi.org/10.1016/j.anorl.2017.11.011. [14] K. Akazawa, H. Doi, S. Ohta, T. Terada, M. Fujiwara, N. Uwa, M. Tanooka, M. Sakagami, Relationship between Eustachian tube dysfunction and otitis media with effusion in radiotherapy patients, J. Laryngol. Otol. 132 (2018) 111–116, https://doi.org/10.1017/s0022215118000014. [15] P.P. Liu, K.M. Su, B.J. Zhu, Y.Q. Wu, H.B. Shi, S.K. Yin, Detection of eustachian tube openings by tubomanometry in adult otitis media with effusion, Eur. Arch. OtoRhino-Laryngol. 273 (2016) 3109–3115, https://doi.org/10.1007/s00405-0163938-0. [16] A. Kaspar, O. Newton, J. Kei, C. Driscoll, D. Swanepoel, H. Goulios, Prevalence of ear disease and associated hearing loss among primary school students in the Solomon Islands: otitis media still a major public health issue, Int. J. Pediatr. Otorhinolaryngol. 113 (2018) 223–228, https://doi.org/10.1016/j.ijporl.2018.08. 004.
4