Initial Audiologic Assessment of Infants Referred From Well Baby, Special Care, and Neonatal Intensive Care Unit Nurseries

Potencial evocado auditivo de tronco encefálico por condução óssea: uma revisão integrativa

O objetivo deste estudo foi de realizar uma revisão de forma integrativa sobre os procedimentos utilizados nos critérios de aquisição do exame de Potenciais Evocados Auditivos de Tronco Encefálico por condução óssea com fins ao auxílio no diagnóstico de problemas auditivos. Foi realizada uma busca nas seguintes bases de dados: Literatura Latino-Americana e do Caribe em Ciências da Saúde (Lilacs), Medical Literature Analysis and Retrieval System Online (Medline) e Scientific Eletronic Library Online (SciELO). Utilizaram-se as seguintes palavras-chave: Potencial Evocado Auditivo, Eletrofisiologia e Condução Óssea, encontrados por meio de Descritores em Ciências da Saúde (DeCS). Os resultados apresentados são referentes aos 35 estudos selecionados. A maioria dos estudos optou pelo uso do estímulo clique, com transdutores por condução aérea os fones supra-aurais, como o TDH-39, para o estímulo por condução óssea, o vibrador Radioear B-71, com pressão de 425+/-25g. Observou-se que a mastoide foi à região onde mais se posicionou mais o vibrador ósseo. A maioria dos estudos refere usar polaridade alternada, com taxa de apresentação diversificada, sendo 57,7/s a mais utilizada e filtro de 30-3000 Hz, com uma janela de 15 ms de duração. Para taxa do estímulo a maioria dos estudos utilizou de 2048, e um total de estímulos de 2 registros. O Potencial Evocado Auditivo de Tronco Encefálico é um exame que vem sendo pesquisado há muitos anos e muito se tem descrito na literatura sobre seus aspectos de aquisição e analise, além de destacar a importância da sua utilização na população neonatal.

Utility of the Vivosonic Integrity™ auditory brainstem response system as a hearing screening device for difficult-to-test children

OBJECTIVE

Inability to complete a behavioral hearing screening is a challenge for children with developmental disorders or who are otherwise difficult to test, defined here as unable or unwilling to complete a behavioral screening. The study compared referral rates from screenings that used behavioral methods alone, with screenings that added a screen with the Vivosonic Integrity™ auditory brainstem response (ABR) device.

DESIGN

Behavioral screening was performed first. Those children who failed were re-screened with the Vivosonic Integrity ABR device. Changes in referral and screening completion rates after the second screening were calculated and analysed.

STUDY SAMPLE

The participant population (n = 43) consisted of children with diagnosed developmental disorders.

RESULTS

Adding the Vivosonic Integrity to the screening protocol significantly increased the proportion of children who completed the screening, from 57% after behavioral screening to 81% after behavioral and ABR screening. The addition of the ABR screen did not change that overall pass/refer rate, in part because four participants who did not complete the behavioral screen received a 'Refer' outcome on the ABR screen.

CONCLUSIONS

The results indicate that the Vivosonic Integrity device could be a useful tool for hearing screening of children who are difficult to screen using behavioral procedures.

Evaluating a prediction model for infant hearing loss

OBJECTIVES/HYPOTHESIS

The objective of this study was to determine whether a prognostic model using risk factors for hearing loss could predict the chance that infants who failed a newborn hearing screen would subsequently be found to have hearing loss diagnosed by auditory brainstem response testing.

STUDY DESIGN

Individual retrospective case-control study.

METHODS

We studied 229 infants with hearing loss compared with 458 infants with normal hearing. All infants had undergone natural sleep or sedated auditory brainstem response, predominantly for not passing a newborn hearing screen. Risk factors, birth history, and other information were extracted via medical record review. Multiple logistic regression analyses identified independent predictors of hearing loss.

RESULTS

Four risk factors were independently predictive of hearing loss diagnosed by sleep or sedated auditory brainstem response: prematurity, 5-minute APGAR score ≤ 6, intracranial complication, and craniofacial abnormality. A prognostic model developed from these risk factors was associated with a 15% rate of hearing loss in stage I, 52% rate of hearing loss in stage II, and 96% rate of hearing loss in stage III.

CONCLUSIONS

The presence of any one of four independently predictive risk factors in infants who did not pass newborn hearing screen was associated with a 50% rate of hearing loss; having three or more was associated with a 90% rate of hearing loss. Knowing that an infant is at high risk of hearing loss can motivate parents to follow up with diagnostic auditory brainstem response testing so that early identification can lead to early intervention.

Auditory brainstem responses to bone-conducted brief tones in young children with conductive or sensorineural hearing loss

The bone-conduction (BC) tone ABR has been used clinically for over 20 years. The current study formally evaluated the test performance of the BC tone-evoked ABR in infants with hearing loss. Method. By comparing BC-ABR results to follow-up behavioural results, this study addressed two questions: (i) whether the BC tone ABR was successful in differentiating children with conductive versus sensorineural hearing loss (Study A; conductive: 68 ears; SNHL: 129 ears) and (ii) the relationship between BC ABR and behavioural hearing loss severity (Study B: 2000 Hz: 104 ears; 500 Hz: 47 ears). Results. Results demonstrate that the "normal" BC-ABR levels accurately differentiated normal versus elevated cochlear sensitivity (accuracy: 98% for 2000 Hz; 98% for 500 Hz). A subset of infants in Study A with elevated BC-ABR (i.e., no response at normal level) had additional testing at higher intensities, which allowed for categorization of the degree of cochlear impairment. Study B results indicate that the BC ABR accurately categorizes the degree of cochlear hearing loss for 2000 Hz (accuracy = 95.2%). A preliminary dBnHL-to-dBHL correction factor of "0 dB" was determined for 2000 Hz BC ABR. Conclusions. These findings further support the use of BC tone ABR for diagnostic ABR testing.

Prognostic validity of dichotic multiple frequencies auditory steady-state responses versus distortion product otoacoustic emissions in hearing screening of high risk neonates

OBJECTIVE

To determine the validity of dichotic multiple frequencies auditory steady-state responses (ASSR) as a hearing screening technique versus using distortion product otoacoustic emissions (DPOAEs) among high-risk neonates.

METHODS

A cross sectional study was performed on 118 high-risk neonates by means of dichotic multiple frequencies ASSR and DPOAE for hearing screening. DPOAE results were used as the standard for hearing screening in parallel with ASSR. Dichotic multiple frequencies ASSR results were analyzed by means of F-value of less or greater than 0.05 criteria as a pass-fail for the responses. Dichotic multiple ASSR hearing screening technique was considered in two intensity levels at 40 and 70 dB HL. The ASSRs thresholds were measured in high risk neonates with and without hearing deficits as determined by DPOAES. The results of ASSR and DPOAE were compared to be gathered by contingency table in order to obtain sensitivity, specificity and other different statistical values. Average performing times for the tests were analyzed.

RESULTS

The specificity of dichotic multiple ASSR was 92.6%, 93.8% and the sensitivity was 71.6%, 62.2% at the 70 and 40 dB hearing levels, respectively. Mean ASSR thresholds for normal-hearing infants at an average corrected age of 6 days were 32.2 ± 12.2, 29.8 ± 10.2, 26.2 ± 11.4 and 30.4 ± 10.8 dB HL for 0.5, 1, 2 and 4 kHz, respectively. The average times for performing the tests were 18.7 and 32.9 min respectively.

CONCLUSIONS

ASSR with this special paradigm is a fairly desirable method for hearing screening of high-risk neonates. There is good concordance between ASSRs and DOPAEs results among high risk neonates referred for hearing screening. The sensitivity and specificity of this test is sufficient for hearing screening in high risk neonates. This test could be valuable for rapid confirmation of normal thresholds. As long as further research have not been conducted on ASSR, great caution should be made to interpret the results of ASSR as a hearing screening technique in young infants and also additional techniques such as the tone-evoked ABRs should be used to cross-check results. It's still too soon to recommend ASSRs as a standalone electrophysiologic measure of hearing thresholds in infants.

Early hearing detection and intervention: diagnostic hearing assessment practices

PURPOSE

To gain an understanding of practice patterns for infant diagnostic hearing services at pediatric audiology facilities.

METHOD

The authors used a cross-sectional survey design. From August to November of 2009, surveys were mailed to 1,091 facilities in 28 states and the District of Columbia. One survey was completed per facility, and responses were anonymous.

RESULTS

The return rate was 33% (356 surveys). The results revealed that the comprehensiveness of the test batteries used varied among facilities. Over half of the respondents, 146 (55%), reported using a limited test battery, 94 facilities reported using a comprehensive test battery but lacked at least 1 component recommended by the Joint Committee on Infant Hearing, and 25 facilities reported using a test battery that met Joint Committee on Infant Hearing recommendations. The wait time for an appointment varied between facilities (range = 3 days-5 months) and was affected by the test condition (i.e., natural sleep, sedation, or operating room).

CONCLUSIONS

The results suggest that it is difficult for stakeholders to identify pediatric audiology facilities that serve infants less than 6 months of age and that there is variability among facilities in test batteries and wait times for an appointment. Implications exist for diagnostic accuracy and timeliness of diagnosis.

Animated Toys Versus Video Reinforcement in 16–24-Month-Old Children in a Clinical Setting

Purpose

To compare the clinical efficacy of visual reinforcement audiometry (VRA) with animated toy animal reinforcement (AVRA) to the efficacy of VRA with video reinforcement (VVRA) in children age 16 to 24 months in a fast-paced medical practice.

Method

The 145 participants (age 16 to 24 months) were referred by either their primary care physician or an otolaryngology practitioner (physician or nurse practitioner) for audiologic assessment. Children were assigned in a counterbalanced manner to either the AVRA or VVRA group.

Results

Significantly more threshold estimates were obtained with AVRA ( M = 5.52) than with VVRA ( M = 3.47). There were no significant differences in performance based on age, hearing status, or gender.

Conclusions

Number and relative strength of the visual reinforcers used are posited as the main reasons for the disparate outcomes. Clinical practices that test large numbers of children with VRA would be well-served to have both AVRA and VVRA available to meet the needs of individual patients.

Initial Audiologic Assessment of Infants: Comments on Karzon and Lieu (2006)

Purpose

To comment on a recently published article titled “Initial Audiologic Assessment of Infants Referred From Well Baby, Special Care, and Neonatal Intensive Care Unit Nurseries” by R. K. Karzon and J. E. C. Lieu (2006).

Method

Comments are directed specifically at the sequence of testing described in the article.

Conclusions

This letter challenges the efficiency of beginning infant audiologic evaluations with the auditory brainstem response evoked by high-intensity, unmasked click stimuli. Reasons as well as alternatives favored by the author and other researchers are presented and summarized.

Response to Sauter (2007)

Purpose

To respond to the companion letter by T. B. Sauter (2007) commenting on “Initial Audiologic Assessment of Infants Referred From Well Baby, Special Care, and Neonatal Intensive Care Unit Nurseries” by R. K. Karzon and J. E. C. Lieu (2006).

Method

Sauter states that he is in agreement with the article by Karzon and Lieu with respect to the 2-hr time for the initial diagnostic appointment and the reliance on auditory brainstem response (ABR) as the primary method for threshold estimation in young infants. However, he questions the order of test stimuli within the ABR protocol and the order of tests within the test battery. Our comments reflect the clinical experience of the authors and are supported by evidence from the literature.

Conclusions

Development of a protocol for the initial evaluation of infants referred from newborn screening poses diagnostic challenges. A 2-hr appointment with a battery of tests works well with this population.