A Multisite Study to Examine the Efficacy of the Otoacoustic Emission/Automated Auditory Brainstem Response Newborn Hearing Screening Protocol

Optimisation of visual reinforcement audiometry: a scoping review

OBJECTIVE

Visual reinforcement audiometry (VRA) is a well-established behavioural test used to assess hearing in infants and young children. This scoping review aimed to summarise the evidence for different approaches to optimising and improving the effectiveness of VRA for clinical practice.

DESIGN

A pre-registered scoping review was conducted.

STUDY SAMPLE

Fifty-nine original articles were included in the review.

RESULTS

The review identified a number of factors which improved response behaviour, such as increased variety and complexity of visual reinforcers, short reinforcer durations, and providing breaks. Intermittent conditioning, where as few as 50% of conditioning trials were rewarded, did not have an impact on response behaviour, and neither did the (suprathreshold) presentation level used during conditioning. More responses were achieved for younger (around 12 months) than older (around 18-24 months) infants. Once infants were developmentally ready to condition to play audiometry, this allowed for a more comprehensive hearing evaluation.

CONCLUSIONS

VRA is a successful behavioural hearing test for most infants of developmental age around 7-24 months, with well-established protocols describing its clinical implementation. Further evidence is needed to assess potential benefits of different reinforcers, different auditory stimuli (e.g. filtered familiar sounds), and technologies to assist response detection.

Correction Factor Evaluation and Between-System Comparison of Behavioral Threshold Predictions From Auditory Brainstem Response Measures in Infants

PURPOSE

Auditory brainstem response (ABR) thresholds are corrected to estimate behavioral thresholds in infants. Corrections were validated, and a comparison of behavioral threshold estimates between systems was conducted to inform equipment transition and protocols in Ontario, Canada.

METHOD

In Study 1, a retrospective file review was conducted. ABR threshold estimates from 84 infants with hearing loss were compared to behavioral thresholds to validate the accuracy of the ABR corrections applied in the Ontario Infant Hearing Program since 2016. Study 2 examined the precision of two different ABR systems to estimate thresholds in 37 adult and 105 infant ears.

RESULTS

Corrected ABR thresholds predicted behavioral thresholds in infants to within 1.77 dB (range of mean values across frequency: 1.18-2.26 dB) on average. The average differences decreased across frequency to 0.6 dB (range: 0.14 to -1.23) when ear canal acoustics were accounted for. The average between-system difference in ABR threshold estimates was 2.40 dB (range: 1.18-2.26).

CONCLUSIONS

ABR correction factors used in Ontario's Infant Hearing Program provide accurate predictions of behavioral thresholds in infants with hearing loss. When calibration and collection parameters are similar between different ABR systems, threshold estimates are comparable and no further adjustment to correction factors was required.

Measurement of thresholds using Chirp-ABR in children with auditory neuropathy spectrum disorder and sensorineural hearing loss

AIM

This study explored the value of Chirp-auditory brainstem response (ABR) thresholds in assessing the hearing threshold of children diagnosed with auditory neuropathy spectrum disorder (ANSD).

METHODS

A total of 20 children with ANSD (40 ears, aged 1.5-7.0 years, median age 4.5 years) and 31 children with sensorineural hearing loss (SNHL) (52 ears, aged 0.9-8.0 years, median age 3.7 years) were included. Besides, 25 normal children (50 ears, aged 0.8-7.5 years, median age 4.6 years) were used as controls. Chirp-ABR and behavioral audiometry were performed simultaneously among three groups of children, allowing for a comparison of the thresholds obtained through both methods.

RESULTS

In ANSD children, the correlation (r-values) between the thresholds obtained from Chirp-ABR and behavioral audiometry at 500-4000 Hz were 0.84, 0.67, 0.59, and 0.60, respectively. The average threshold differences between two methods ranged from 9.7 to 13.3 dB at 500-4000 Hz. Notably, 20 % ears (8/40) exhibited considerable discrepancies (>30 dB) in thresholds at certain frequencies. For SNHL children, the r-values between two methods were 0.84, 0.89, 0.92, and 0.93, respectively. The average threshold differences between two methods were 5.7-8.2 dB at 500-4000 Hz. Similarly, in normal children, the average threshold differences between two methods ranged from 6.1 dB to 7.7 dB, the r-values were 0.81, 0.78, 0.80, and 0.80 at 500-4000 Hz, respectively.

CONCLUSION

Chirp-ABR threshold is not suitable to predict the behavioral audiometry threshold in ANSD children. When there is a significant discrepancy (>30 dB) between Chirp-ABR thresholds and behavioral audiometry thresholds in hearing loss, ANSD should be highly suspected.

Comparison of Otoacoustic Emission (OAE) and Brainstem Evoked Response Audiometry (BERA) in High Risk Infants and Children under 5 Years of Age for Hearing Assessment in Western India: A Modification in Screening Protocol

There are very few studies from India, which have compared Otoacoustic Emission (OAE) and Brainstem Evoked Response Audiometry (BERA) as a screening modality for detection of hearing loss in children. With the aim of establishing some guidelines regarding the protocols for hearing loss assessment and preventive measures, the present study has been undertaken to compare OAE with BERA done simultaneously, in the diagnosis of paediatric hearing loss, and also to study associated risk factors for hearing loss in children of Rural Central India. Prospective observational study was carried out on 100 children (200ears) in age group of 0-5 years. Selection was based on the inclusion and exclusion criteria. In all the 100 children detailed history was taken from the parents and were subjected to distortion product otoacoustic emissions (DPOAE). Irrespective of the pass or refer result children were subjected for BERA test. The interpretation of OAE and BERA test was as follows. Both the results of OAE refer and BERA fail were considered as confirmed HL, OAE pass and BERA fail were considered as children having Auditory Neuropathy (AN), OAE refer and BERA pass were considered as children at risk of permanent hearing loss (HL), OAE pass and BERA pass were considered as children with no evidence of HL. In the present study the male to female ratio was 1.32:1. Of the total 100 children 80% children showed presence of any one or more than one risk factors. In our study, eclampsia [7%] followed by multiparity [6%] and oligohydramnios [5%] were the most common risk factors in prenatal period. Maximum number of infants in AN profile were with Low Apgar score, children exposed to ototoxic medications, non-syndromic cardiac disorders in children [25.8% each]. Maximum number of infants in Confirmed HL profile were with congenital syndromes/ear anomalies [41.86%] followed by other risk factors. In our study, both OAE and BERA test were comparable and statistically significant with p value of 0.0001. OAE has a high specificity and positive predictive value of 93.33% and 97.22% respectively and it has a low sensitivity and negative predictive value of 67.74% and 45.65% respectively. In a developing country like India were universal screening protocols are not followed large number of children may be missed and may present late when it affects child's communication abilities. Hence, we need to modify our screening test and implement high risk screening even in the absence of any hearing or speech complaints.

Acoustic Change Complex and Visually Reinforced Infant Speech Discrimination Measures of Vowel Contrast Detection

OBJECTIVES

To measure the effect of stimulus rate and vowel change direction on the acoustic change complex (ACC) latencies and amplitudes and compare ACC metrics to behavioral measures of vowel contrast detection for infants tested under the age of 1 year. We tested the hypothesis that the direction of spectral energy shift from a vowel change would result in differences in the ACC, owing to the sensitivity of cortical neurons to the direction of frequency change. We evaluated the effect of the stimulus rate (1/s versus 2/s) on the infants' ACC. We evaluated the ACC amplitude ratio's sensitivity (proportion of ACCs present for each change trial) and compared it to perceptual responses obtained using a visually reinforced infant speech discrimination paradigm (VRISD). This report provides normative data from infants for the ACC toward the ultimate goal of developing a clinically useful index of neural capacity for vowel discrimination.

DESIGN

Twenty-nine infants, nine females, 4.0 to 11.8 months of age, participated. All participants were born at full term and passed their newborn hearing screens. None had risk factors for hearing or neurologic impairment. Cortical auditory evoked potentials were obtained in response to synthesized vowel tokens /a/, /i/, /o/, and /u/ presented at a rate of 1- or 2/s in an oddball stimulus paradigm with a 25% probability of the deviant stimulus. All combinations of vowel tokens were tested at the two rates. The ACC was obtained in response to the deviant stimulus. The infants were also tested for vowel contrast detection using a VRISD paradigm with the same combinations of vowel tokens used for the ACC. The mean age at the time of the ACC test was 5.4 months, while the mean age at the behavioral test was 6.8 months.

RESULTS

Variations in ACC amplitude and latency occurred as a function of the initial vowel token and the contrast token. However, the hypothesis that the direction of vowel (spectral) change would result in significantly larger change responses for high-to-low spectral changes was not supported. The contrasts with /a/ as the leading vowel of the contrast pair resulted in the largest ACC amplitudes than other conditions. Significant differences in the ACC presence and amplitude were observed as a function of rate, with 2/s resulting in ACCs with the largest amplitude ratios. Latency effects of vowel contrast and rate were present, but not systematic. The ACC amplitude ratio's sensitivity for detecting a vowel contrast was greater for the 2/s rate than the 1/s rate. For an amplitude ratio criterion of ≥1.5, the sensitivity was 93% for ACC component P2-N2 at 2/s, whereas at 1/s sensitivity was 70%. VRISD tests of vowel-contrast detection had a 71% hit and a 21% false-positive rate. Many infants who could not reach performance criteria for VRISD had ACC amplitude ratios of ≥2.0.

CONCLUSIONS

The ACC for vowel contrasts presented at a rate of 2/s is a robust index of vowel-contrast detection when obtained in typically developing infants under the age of 1 year. The ACC is present in over 90% of infants tested at this rate when an amplitude ratio criterion of ≥1.5 is used to define a response. The amplitude ratio appears to be a sensitive metric for the difference between a control and contrast condition. The ACC can be obtained in infants who do not yet exhibit valid behavioral responses for vowel change contrasts and may be useful for estimating neural capacity for discriminating these sounds.

Should You Follow the Better-Hearing Ear for Congenital Cytomegalovirus Infection and Isolated Sensorineural Hearing Loss?

OBJECTIVE

To describe the progression of sensorineural hearing loss (SNHL) in the better- and poorer-hearing ears in children with asymptomatic congenital cytomegalovirus (CMV) infection with isolated SNHL.

STUDY DESIGN

Longitudinal prospective cohort study.

SETTING

Tertiary medical center.

SUBJECTS AND METHODS

We analyzed hearing thresholds of the better- and poorer-hearing ears of 16 CMV-infected patients with isolated congenital/early-onset or delayed-onset SNHL identified through hospital-based CMV screening of >30,000 newborns from 1982 to 1992.

RESULTS

By 12 months of age, 4 of 7 patients with congenital/early-onset SNHL developed worsening thresholds in the poorer-hearing ear, and 1 had an improvement in the better-hearing ear. By 18 years of age, all 7 patients had worsening thresholds in the poorer-hearing ear and 3 patients had worsening thresholds in the better-hearing ear. Hearing loss first worsened at a mean age of 2 and 6 years in the poorer- and better-hearing ears, respectively. Nine patients were diagnosed with delayed-onset SNHL (mean age of 9 years vs 12 years for the poorer- and better-hearing ears), 6 of whom had worsening thresholds in the poorer-hearing ear and 1 in both ears.

CONCLUSION

In most children with congenital CMV infection and isolated SNHL, the poorer-hearing ear worsened earlier and more precipitously than the better-hearing ear. This study suggests that monitoring individual hearing thresholds in both ears is important for appropriate interventions and future evaluation of efficacy of antiviral treatment.

Universal Hearing Screening in Newborns Using Otoacoustic Emissions and Brainstem Evoked Response in Eastern Uttar Pradesh

The objectives were to determine the incidence of hearing impairment in a standardized population of neonates and to determine the significance of association of epidemiological and risk factors with neonatal hearing loss. A cohort of 600 newborns was selected for study and divided into two groups-525 in 'No Risk' group and remaining 75 in 'At Risk' group. The study protocol was carried out in three steps: (a) Screening of Hearing Loss with TOAE, done from 36 h after birth to 28 days of life, (b) Re-screening of hearing loss in newborns (of 4-12 weeks of age), who were tested positive for hearing loss in the first screening, done with DPOAE, (c) Confirmation of hearing loss with BERA, in those who were tested positive in both the first and second screening. In the study the incidence of hearing impairment in 600 infants screened was 6.67 per 1000 screened; 3.81 per 1000 screened in the Not at Risk group and 26.67 per 1000 screened in At Risk group. In At Risk group, admitted to the NICU, severe birth asphyxia and hyperbilirubinemia were found to be major risk factors. Loss to follow up was more in Not at Risk group and False Positive cases with TEOAE were more than DPOAE. BERA was found to be must for confirmation of hearing loss. Neonatal Hearing Screening of only At Risk population is likely to miss some hearing loss. Universal Hearing Screening should be the preferred strategy. Good follow up in the 'At Risk' group suggests that initial interventions in NICU had sensitized the parents for the possibility of hearing loss. This study recommends the introduction of two stage neonatal screening-rescreening protocol, using OAE and BERA, in the country in phased manner.

Quantitative and Qualitative Follow-Up Outcomes From a Preschool Audiologic Screening Program: Perspectives Over a Decade

Purpose

This investigation reports on quantitative and qualitative follow-up information obtained from a preschool audiologic screening program covering a 10-year period (1995 to 2004).

Method

The audiologic screening consisted of a hearing (pure tone) and tympanometry screening. A total of 34,979 children, 3 to 5 years of age, were screened.

Results

Eighteen percent (6,337) of the children were referred for further hearing and/or medical ear evaluation. Of 1,421 follow-up responses received, 93% complied with the follow-up recommendations while 7% did not. Of 1,316 children in the follow-up group, outer and/or middle ear disorder in one or both ears was medically confirmed for 37%. Unilateral or bilateral hearing loss was diagnosed in 18% as conductive (12%), sensorineural (1%), mixed (0.4%), or unspecified (5%). Overall, hearing loss and/or otologic disorder was confirmed in 49% of the follow-up group, suggesting a prevalence of 1.8% in a preschool-age population. A small ( n = 32) sample of unsolicited comments indicated that physicians most influenced noncompliance with hearing evaluation follow-up.

Conclusions

The quantitative hearing and otologic follow-up outcome data affirm the importance of audiologic screening in the preschool population. Qualitative data suggest that some physicians may not be advocating appropriate screening follow-up services.

A Multisite Study to Examine the Efficacy of the Otoacoustic Emission/Automated Auditory Brainstem Response Newborn Hearing Screening Protocol

Purpose: Most newborns are screened for hearing loss, and many hospitals use a 2-stage protocol in which all infants are screened first with otoacoustic emissions (OAEs). In this protocol, no additional testing is done for those passing the OAE screening, but infants failing the OAE are also screened with automated auditory brainstem response (A-ABR). This study evaluated how many infants who failed the OAE and passed the A-ABR had permanent hearing loss (PHL) at 8–12 months of age.

Method: A total of 86,634 infants were screened at 7 birthing centers using a 2-stage OAE/A-ABR hearing screening protocol. Of infants who failed the OAE but passed the A-ABR, 1,524 were enrolled in the study. Diagnostic audiologic evaluations were performed on 64% of the enrolled infants (1,432 ears from 973 infants) when they were 8–12 months old.

Results: Twenty-one infants (30 ears) who passed the newborn A-ABR hearing screening were identified with PHL when they were 8–12 months old. Most (71%) had mild hearing loss.

Conclusions: If all infants were screened for hearing loss using a typical 2-stage OAE/A-ABR protocol, approximately 23% of those with PHL at 8–12 months of age would have passed the A-ABR.

A Multisite Study to Examine the Efficacy of the Otoacoustic Emission/Automated Auditory Brainstem Response Newborn Hearing Screening Protocol

Purpose: This article examines whether changes in hearing screening practices are warranted based on the results of the recent series of studies by J. L. Johnson, K. R. White, J. E. Widen, J. S. Gravel, B. R. Vohr, M. James, T. Kennalley, A. B. Maxon, L. Spivak, M. Sullivan-Mahoney, Y. Weirather, and S. Meyer (Johnson, White, Widen, Gravel, James, et al., 2005; Johnson, White, Widen, Gravel, Vohr, et al., 2005; White et al., 2005; Widen et al., 2005) that found a significant number of infants who passed an automated auditory brainstem response (A-ABR) screening after failing an initial otoacoustic emission (OAE) screening later were found to have permanent hearing loss in one or both ears.

Method: Similar to the approach used by F. H. Bess and J. Paradise (1994), this article addresses the public health tenets that need to be in place before screening programs, or in this case, a change in screening practice (use of a 2-step screening protocol) can be justified.

Results: There are no data to suggest that a 2-step OAE/A-ABR screening protocol should be avoided.

Conclusion: Research is needed before any change in public policy and practice surrounding current early hearing detection and intervention programs could be supported.