An Internet-Based Hearing Test for Simple Audiometry in Nonclinical Settings: Preliminary Validation and Proof of Principle

Efficacy of virtual reality pure-tone audiometry in training of hearing test for audiologist

Background and objectives

The immersive virtual reality (VR) simulator is advantageous because it is cost-effective, realistic, can be controlled directly by the user, and can be integrated into education and training in otorhinolaryngology. The present study explored the feasibility of incorporating VR pure-tone audiometry (PTA) into an audiologist training curriculum, and assessed audiology experts' willingness to use a VR PTA.

Materials and methods

A total of 31 audiologists (16 skilled audiologists and 15 undergraduate students) participated in the study, using a developed VR PTA application with a Meta Quest 2 device. A digital twin technique was applied for a realistic environment. The study measured key components of the VR system and behavioral intention to use VR PTA and traditional PTA using a modified version of the Technology Acceptance Model survey. The survey outcomes for VR PTA and the traditional PTA were compared, using a paired t-test and W test.

Results

The general characteristics of the participants were homogeneous. In the homogeneity test, no statistically significant differences were found between the ratings of VR PTA and traditional PTA. The comparison between VR PTA and traditional PTA revealed no significant differences between skilled audiologists and undergraduate students for all variables.

Conclusions

The VR PTA and traditional PTA had no differences in of VR system characteristics and behavioral intention to use. The efficacy of the VR PTA was validated, and previous experience with traditional PTA was not affected by adopting VR PTA. Further studies are needed to assess performance enhancements in audiological testing through VR simulation.

The Hearing Test App for Android Devices: Distinctive Features of Pure-Tone Audiometry Performed on Mobile Devices

The popularity of mobile devices, combined with advances in electronic design and internet technology, has enabled home-based hearing tests in recent years. The purpose of this article is to highlight the distinctive aspects of pure-tone audiometry performed on a mobile device by means of the Hearing Test app for Android devices. The first version of this app was released a decade ago, and since then the app has been systematically improved, which required addressing many issues common to the majority of mobile apps for hearing testing. The article discusses techniques for mobile device calibration, outlines the testing procedure and how it differs from traditional pure-tone audiometry, explores the potential for bone conduction testing, and provides considerations for interpreting mobile audiometry including test duration and background noise. The article concludes by detailing clinically relevant aspects requiring special attention during testing and interpretation of results which are of substantial value to the hundreds of thousands of active users of the Hearing Test app worldwide, as well as to users of other hearing test apps.

Exploring Hearing Care Technology from Clinic to Capability

Healthcare systems are traditionally a clinician-led and reactive structure that does not promote clients managing their health issues or concerns from an early stage. However, when clients are proactive in starting their healthcare earlier than later, they can achieve better outcomes and quality of life. Hearing healthcare and the rehabilitation journey currently fit into this reactive and traditional model of care. With the development of service delivery models evolving to offer services to the consumer online and where they are predominately getting their healthcare information from the internet and the advancement of digital applications and hearing devices beyond traditional hearing aid structures, we are seeing a change in how consumers engage in hearing care. Similarly, as the range of hearing devices evolves with increasingly blended and standard levels of technology across consumer earbuds/headphones and medical grade hearing aids, we are seeing a convergence of consumers engaging earlier and becoming increasingly aware of hearing health needs. This article will discuss how the channels, service, and technology are coming together to reform traditionally clinician-led healthcare models to an earlier consumer-led model and the benefits and limitations associated with it. Additionally, we look to explore advances in hearing technologies and services, and if these will or can contribute to a behavioral change in the hearing healthcare journey of consumers.

Utilizing True Wireless Stereo Earbuds in Automated Pure-Tone Audiometry

True wireless stereo (TWS) earbuds have become popular and widespread in recent years, and numerous automated pure-tone audiometer applications have been developed for portable devices. However, most of these applications require specifically designed earphones to which the public may not have access. Therefore, the present study investigates the accuracy of automated pure-tone audiometry based on TWS earbuds (Honor FlyPods). The procedure for developing an automated pure-tone audiometer is reported. Calibration of the TWS earbuds was accomplished by electroacoustic measurements and establishing corrected reference equivalent threshold sound pressure levels. The developed audiometer was then compared with a clinical audiometer using 20 hearing-impaired participants. The average signed and absolute deviations between hearing thresholds measured using the two audiometers were 3.1 dB and 6.7 dB, respectively. The overall accuracy rate in determining the presence/absence of hearing loss was 81%. The results show that the proposed procedure for an automated air-conduction audiometer based on TWS earbuds is feasible, and the system gives accurate hearing level estimation using the reported calibration framework.

A Smartphone-Based Approach to Screening for Sudden Sensorineural Hearing Loss: Cross-Sectional Validity Study

Background

Sudden sensorineural hearing loss (SSNHL) is an otologic emergency that warrants urgent management. Pure-tone audiometry remains the gold standard for definitively diagnosing SSNHL. However, in clinical settings such as primary care practices and urgent care facilities, conventional pure-tone audiometry is often unavailable.

Objective

This study aimed to determine the correlation between hearing outcomes measured by conventional pure-tone audiometry and those measured by the proposed smartphone-based Ear Scale app and determine the diagnostic validity of the hearing scale differences between the two ears as obtained by the Ear Scale app for SSNHL.

Methods

This cross-sectional study included a cohort of 88 participants with possible SSNHL who were referred to an otolaryngology clinic or emergency department at a tertiary medical center in Taipei, Taiwan, between January 2018 and June 2019. All participants underwent hearing assessments with conventional pure-tone audiometry and the proposed smartphone-based Ear Scale app consecutively. The gold standard for diagnosing SSNHL was defined as the pure-tone average (PTA) difference between the two ears being ≥30 dB HL. The hearing results measured by the Ear Scale app were presented as 20 stratified hearing scales. The hearing scale difference between the two ears was estimated to detect SSNHL.

Results

The study sample comprised 88 adults with a mean age of 46 years, and 50% (44/88) were females. PTA measured by conventional pure-tone audiometry was strongly correlated with the hearing scale assessed by the Ear Scale app, with a Pearson correlation coefficient of .88 (95% CI .82-.92). The sensitivity of the 5–hearing scale difference (25 dB HL difference) between the impaired ear and the contralateral ear in diagnosing SSNHL was 95.5% (95% CI 87.5%-99.1%), with a specificity of 66.7% (95% CI 43.0%-85.4%).

Conclusions

Our findings suggest that the proposed smartphone-based Ear Scale app can be useful in the evaluation of SSNHL in clinical settings where conventional pure-tone audiometry is not available.

Personal Music Players Use and Other Noise Hazards among Children 11 to 12 Years Old

Exposure to loud music-due to widespread personal music players (PMPs) and noisy leisure activities-are major risk factors for noise induced hearing loss (NIHL) in adolescents. However, there is little evidence of the impact of noise on the hearing of younger children. This study aimed to explore an association between PMP use and hearing, and to identify other sources of noise among children. The study sample consisted of 1032 children aged 11-12 years old. Hearing thresholds were determined from 0.5 to 8 kHz. PMP use and other noise exposures were evaluated using a survey. We found that 82% of the children had a PMP, and 78% were exposed to noise when playing computer games. An audiometric notch was documented in 1.3% of the children. Only 11.5% of the children ever used hearing protection while engaged in noisy activities. We found no convincing evidence of an association between PMP use and hearing thresholds, although our results suggest that tinnitus may be an early sign of NIHL in young children. The study shows a need to provide children, their parents, and educators with knowledge of how to take care of hearing, including how to avoid and minimize noise exposure.

Results of hearing screening of school-age children in Bishkek, Kyrgyzstan

Aim:

To gauge the prevalence of hearing loss in school children in Bishkek, Kyrgyzstan, and refer pupils with positive results for further diagnostic testing.

Background:

According to WHO data, hearing disorders are common in school-age children. Screening for hearing loss is an important preventative tool, helping to avoid further complications. Expenditure that supports early child development can reduce future outlay on health care and social services; it can eliminate disability problems, education deficits, and social maladaptation in later adult life.

Methods:

Pure-tone air-conduction hearing thresholds were obtained at 0.5–8 kHz. The results of the hearing screening examination were regarded as positive if pure-tone thresholds were higher than 20 dB HL in one or both ears at one or more of the test frequencies. Data were also obtained from follow-up visits of children who failed the initial screening.

Findings:

This study included 452 children aged 7–13 years old. Based on audiograms, screening showed that 123 (27.2%) of the children had hearing impairment. The study has important implications for clinical practice and health policy. There is a need for systematic monitoring of hearing status among children of this age, and parents and educators need to be made aware of the significance of hearing loss.

Sensitivity and Specificity of Automated Audiometry in Subjects with Normal Hearing or Hearing Impairment

Objective

To investigate the sensitivity and specificity in an automatic computer-controlled audiometric set-up, used for screening purposes.

Design

Comparison between standardized audiometry and automated audiometry performed in the same participants.

Study Sample

In total, 100 participants (51 females and 49 males) were recruited to take part of this study the same day they visited the hearing clinic for clinical audiometry. Ages varied between 18 and 84 years (mean 45.9 in females, 52.3 in males).

Results

The participants were divided into groups, dependent of type of hearing. A total of 23 had normal hearing, 40 had sensorineural hearing loss, 19 had conductive hearing loss and 18 showed asymmetric hearing loss. The sensitivity for the automated audiometry was 86%-100% and the specificity 56%-100%. The group with conductive hearing loss showed the poorest sensitivity (86 %) and specificity (56 %). The group with sensorineural hearing loss showed the smallest variation in difference between the two methods.

Conclusions

The results show that automated audiometry is a method suitable to screen for hearing loss. Screening levels need to be selected with respect to cause of screening and environmental factors. For patients with asymmetric hearing thresholds it is necessary to consider the effect of transcranial routing of signals.

A Mobile Phone-Based Approach for Hearing Screening of School-Age Children: Cross-Sectional Validation Study

Background

Pure-tone screening (PTS) is considered as the gold standard for hearing screening programs in school-age children. Mobile devices, such as mobile phones, have the potential for audiometric testing.

Objective

This study aimed to demonstrate a new approach to rapidly screen hearing status and provide stratified test values, using a smartphone-based hearing screening app, for each screened ear of school-age children.

Method

This was a prospective cohort study design. The proposed smartphone-based screening method and a standard sound-treated booth with PTS were used to assess 85 school-age children (170 ears). Sound-treated PTS involved applying 4 test tones to each tested ear: 500 Hz at 25 dB and 1000 Hz, 2000 Hz, and 4000 Hz at 20 dB. The results were classified as pass (normal hearing in the ear) or fail (possible hearing impairment). The proposed smartphone-based screening employs 20 stratified hearing scales. Thresholds were compared with those of pure-tone average (PTA).

Results

A total of 85 subjects (170 ears), including 38 males and 47 females, aged between 11 and 12 years with a mean (SD) of 11 (0.5) years, participated in the trial. Both screening methods produced comparable pass and fail results (pass in 168 ears and fail in 2 ears). The smartphone-based screening detected moderate or worse hearing loss (average PTA>25 dB) accurately. Both the sensitivity and specificity of the smartphone-based screening method were calculated at 100%.

Conclusions

The results of the proposed smartphone-based self-hearing test demonstrated high concordance with conventional PTS in a sound-treated booth. Our results suggested the potential use of the proposed smartphone-based hearing screening in a school-age population.

Mobile Hearing Testing Applications and the Diagnosis of Sudden Sensorineural Hearing Loss: A Cautionary Tale

OBJECTIVE

Mobile hearing applications (apps) are available for hearing testing, personal sound amplification, as well as hearing aid modulation. Hearing testing apps are gaining popularity, especially in resource-limited settings. The reliability of mobile hearing testing apps, however, is not well characterized.

PATIENTS/INTERVENTIONS

A case study of a single patient with a complaint of sudden hearing loss presenting to a tertiary-care hospital.

MAIN OUTCOME MEASURE

Comparison of a mobile hearing testing app results with standard audiogram.

RESULTS

A commercially available mobile hearing testing app was used after hours to determine if a patient's hearing complaints were consistent with sudden sensorineural hearing loss. The hearing app produced a rudimentary audiogram that was consistent with unilateral SSNHL. Given contraindications to oral treatment, preparations for possible intratympanic dexamethasone after a full audiometric evaluation were completed. Confirmatory audiogram the following day demonstrated normal hearing without evidence of hearing loss. Steroid treatment was aborted and appropriate counseling provided.

CONCLUSION

While mobile hearing testing apps offer improved access to hearing screening in resource-limited settings, caution must be exercised when interpreting data and making clinical decisions based upon results. The role of professional audiologists remains critical. Further testing and validation of specific apps is required.

Hearing Tests Based on Biologically Calibrated Mobile Devices: Comparison With Pure-Tone Audiometry

BACKGROUND

Hearing screening tests based on pure-tone audiometry may be conducted on mobile devices, provided that the devices are specially calibrated for the purpose. Calibration consists of determining the reference sound level and can be performed in relation to the hearing threshold of normal-hearing persons. In the case of devices provided by the manufacturer, together with bundled headphones, the reference sound level can be calculated once for all devices of the same model.

OBJECTIVE

This study aimed to compare the hearing threshold measured by a mobile device that was calibrated using a model-specific, biologically determined reference sound level with the hearing threshold obtained in pure-tone audiometry.

METHODS

Trial participants were recruited offline using face-to-face prompting from among Otolaryngology Clinic patients, who own Android-based mobile devices with bundled headphones. The hearing threshold was obtained on a mobile device by means of an open access app, Hearing Test, with incorporated model-specific reference sound levels. These reference sound levels were previously determined in uncontrolled conditions in relation to the hearing threshold of normal-hearing persons. An audiologist-assisted self-measurement was conducted by the participants in a sound booth, and it involved determining the lowest audible sound generated by the device within the frequency range of 250 Hz to 8 kHz. The results were compared with pure-tone audiometry.

RESULTS

A total of 70 subjects, 34 men and 36 women, aged 18-71 years (mean 36, standard deviation [SD] 11) participated in the trial. The hearing threshold obtained on mobile devices was significantly different from the one determined by pure-tone audiometry with a mean difference of 2.6 dB (95% CI 2.0-3.1) and SD of 8.3 dB (95% CI 7.9-8.7). The number of differences not greater than 10 dB reached 89% (95% CI 88-91), whereas the mean absolute difference was obtained at 6.5 dB (95% CI 6.2-6.9). Sensitivity and specificity for a mobile-based screening method were calculated at 98% (95% CI 93-100.0) and 79% (95% CI 71-87), respectively.

CONCLUSIONS

The method of hearing self-test carried out on mobile devices with bundled headphones demonstrates high compatibility with pure-tone audiometry, which confirms its potential application in hearing monitoring, screening tests, or epidemiological examinations on a large scale.

Cigarette- and snus-modified association between unprotected exposure to noise from hunting rifle caliber weapons and high frequency hearing loss. A cross-sectional study among swedish hunters

Aim:

To investigate in this cross-sectional study among Swedish hunters if tobacco use modifies the previously observed association, expressed as prevalence ratio (PR), between unprotected exposure to impulse noise from hunting rifle caliber (HRC) weapons and high-frequency hearing impairment (HFHI).

Settings and Design:

A nationwide cross-sectional epidemiologic study was conducted among Swedish sport hunters in 2012.

Materials and Methods:

The study was Internet-based and consisted of a questionnaire and an Internet-based audiometry test.

Results:

In all, 202 hunters completed a questionnaire regarding the hearing test. Associations were modeled using Poisson regression. Current, daily use of tobacco was reported by 61 hunters (19 used cigarettes, 47 moist snuff, and 5 both). Tobacco users tended to be younger, fire more shots with HRC weapons, and report more hunting days. Their adjusted PR (1–6 unprotected HRC shots versus 0) was 3.2 (1.4–6.7), P = 0.01. Among the nonusers of tobacco, the corresponding PR was 1.3 (0.9–1.8), P = 0.18. P value for the interaction was 0.01. The importance of ear protection could not be quantified among hunters with HRC weapons because our data suggested that the HFHI outcome had led to changes in the use of such protection. Among hunters using weapons with less sound energy, however, no or sporadic use of hearing protection was linked to a 60% higher prevalence of HFHI, relative to habitual use.

Conclusion:

Tobacco use modifies the association between exposure to unprotected impulse noise from HRC weapons and the probability of having HFHI among susceptible hunters. The mechanisms remain to be clarified, but because the effect modification was apparent also among the users of smokeless tobacco, combustion products may not be critical for this effect.

Hearing Tests on Mobile Devices: Evaluation of the Reference Sound Level by Means of Biological Calibration

Background

Hearing tests carried out in home setting by means of mobile devices require previous calibration of the reference sound level. Mobile devices with bundled headphones create a possibility of applying the predefined level for a particular model as an alternative to calibrating each device separately.

Objective

The objective of this study was to determine the reference sound level for sets composed of a mobile device and bundled headphones.

Methods

Reference sound levels for Android-based mobile devices were determined using an open access mobile phone app by means of biological calibration, that is, in relation to the normal-hearing threshold. The examinations were conducted in 2 groups: an uncontrolled and a controlled one. In the uncontrolled group, the fully automated self-measurements were carried out in home conditions by 18- to 35-year-old subjects, without prior hearing problems, recruited online. Calibration was conducted as a preliminary step in preparation for further examination. In the controlled group, audiologist-assisted examinations were performed in a sound booth, on normal-hearing subjects verified through pure-tone audiometry, recruited offline from among the workers and patients of the clinic. In both the groups, the reference sound levels were determined on a subject’s mobile device using the Bekesy audiometry. The reference sound levels were compared between the groups. Intramodel and intermodel analyses were carried out as well.

Results

In the uncontrolled group, 8988 calibrations were conducted on 8620 different devices representing 2040 models. In the controlled group, 158 calibrations (test and retest) were conducted on 79 devices representing 50 models. Result analysis was performed for 10 most frequently used models in both the groups. The difference in reference sound levels between uncontrolled and controlled groups was 1.50 dB (SD 4.42). The mean SD of the reference sound level determined for devices within the same model was 4.03 dB (95% CI 3.93-4.11). Statistically significant differences were found across models.

Conclusions

Reference sound levels determined in the uncontrolled group are comparable to the values obtained in the controlled group. This validates the use of biological calibration in the uncontrolled group for determining the predefined reference sound level for new devices. Moreover, due to a relatively small deviation of the reference sound level for devices of the same model, it is feasible to conduct hearing screening on devices calibrated with the predefined reference sound level.

Shooting history and presence of high-frequency hearing impairment in swedish hunters: A cross-sectional internet-based observational study

The aim of this cross-sectional study among Swedish hunters was to examine the association between shooting history and presence of high-frequency hearing impairment (HFHI). All hunters registered with an e-mail address in the membership roster of the Swedish Hunters’ Association were invited via e-mail to a secure website with a questionnaire and an Internet-based audiometry test. Associations, expressed as prevalence ratio (PR), were multivariately modelled using Poisson regression. The questionnaire was answered by 1771 hunters (age 11-91 years), and 202 of them also completed the audiometry test. Subjective severe hearing loss was reported by 195/1771 (11%), while 23/202 (11%) exhibited HFHI upon testing with Internet-based audiometry. As many as 328/1771 (19%) had never used hearing protection during hunting. In the preceding 5 years, 785/1771 (45%), had fired >6 unprotected gunshots with hunting rifle calibers. The adjusted PR of HFHI when reporting 1-6 such shots, relative to 0, was 1.5 [95% confidence interval (CI) 1.1-2.1; P = 0.02]. We could not verify any excessive HFHI prevalence among 89 hunters reporting unprotected exposure to such gunshot noise >6 times. Nor did the total number of reported rifle shots seem to matter. These findings support the notion of a wide variation in individual susceptibility to impulse noise; that significant sound energy, corresponding to unprotected noise from hunting rifle calibers, seems to be required; that susceptible individuals may sustain irreversible damage to the inner ear from just one or a few shots; and that use of hearing protection should be encouraged from the first shot with such weapons.

Phoneme-based self hearing assessment on a smartphone

Phonemes provide an interesting alternative to pure tones in hearing tests.We propose a new smartphone-based method for self-hearing assessment using the four Korean phonemes which are similar to the English phonemes /a/, /i/, /sh/, and /s/. We conducted tests on 15 subjects diagnosed with mild to severe hearing loss and estimated their conventional pure-tone hearing thresholds from their phoneme hearing thresholds using regression analysis. The phoneme-based self-hearing assessment was found to be sufficiently reliable in estimating the hearing thresholds of hearing impaired subjects. The difference between the hearing thresholds obtained through conventional pure-tone audiometry and those obtained using our method was 5.6 dB HL on average. The proposed hearing assessment was able to significantly reduce the mean test time compared to conventional pure-tone audiometry.

Biological calibration for web-based hearing tests: evaluation of the methods

Background

Online hearing tests conducted in home settings on a personal computer (PC) require prior calibration. Biological calibration consists of approximating the reference sound level via the hearing threshold of a person with normal hearing.

Objective

The objective of this study was to identify the error of the proposed methods of biological calibration, their duration, and the subjective difficulty in conducting these tests via PC.

Methods

Seven methods have been proposed for measuring the calibration coefficients. All measurements were performed in reference to the hearing threshold of a normal-hearing person. Three methods were proposed for determining the reference sound level on the basis of these calibration coefficients. Methods were compared for the estimated error, duration, and difficulty of the calibration. Web-based self-assessed measurements of the calibration coefficients were carried out in 3 series: (1) at a otolaryngology clinic, (2) at the participant’s home, and (3) again at the clinic. Additionally, in series 1 and 3, pure-tone audiometry was conducted and series 3 was followed by an offline questionnaire concerning the difficulty of the calibration. Participants were recruited offline from coworkers of the Department and Clinic of Otolaryngology, Wroclaw Medical University, Poland.

Results

All 25 participants, aged 22-35 years (median 27) completed all tests and filled in the questionnaire. The smallest standard deviation of the calibration coefficient in the test-retest measurement was obtained at the level of 3.87 dB (95% CI 3.52-4.29) for the modulated signal presented in accordance with the rules of Bekesy’s audiometry. The method is characterized by moderate duration time and a relatively simple procedure. The simplest and shortest method was the method of self-adjustment of the sound volume to the barely audible level. In the test-retest measurement, the deviation of this method equaled 4.97 dB (95% CI 4.53-5.51). Among methods determining the reference sound level, the levels determined independently for each frequency revealed the smallest error. The estimated standard deviations of the difference in the hearing threshold between the examination conducted on a biologically calibrated PC and pure-tone audiometry varied from 7.27 dB (95% CI 6.71-7.93) to 10.38 dB (95% CI 9.11-12.03), depending on the calibration method.

Conclusions

In this study, an analysis of biological calibration was performed and the presented results included calibration error, calibration time, and calibration difficulty. These values determine potential applications of Web-based hearing tests conducted in home settings and are decisive factors when selecting the calibration method. If there are no substantial time limitations, it is advisable to use Bekesy method and determine the reference sound level independently at each frequency because this approach is characterized by the lowest error.

Self-test web-based pure-tone audiometry: validity evaluation and measurement error analysis

Background

Potential methods of application of self-administered Web-based pure-tone audiometry conducted at home on a PC with a sound card and ordinary headphones depend on the value of measurement error in such tests.

Objective

The aim of this research was to determine the measurement error of the hearing threshold determined in the way described above and to identify and analyze factors influencing its value.

Methods

The evaluation of the hearing threshold was made in three series: (1) tests on a clinical audiometer, (2) self-tests done on a specially calibrated computer under the supervision of an audiologist, and (3) self-tests conducted at home. The research was carried out on the group of 51 participants selected from patients of an audiology outpatient clinic. From the group of 51 patients examined in the first two series, the third series was self-administered at home by 37 subjects (73%).

Results

The average difference between the value of the hearing threshold determined in series 1 and in series 2 was -1.54dB with standard deviation of 7.88dB and a Pearson correlation coefficient of .90. Between the first and third series, these values were -1.35dB±10.66dB and .84, respectively. In series 3, the standard deviation was most influenced by the error connected with the procedure of hearing threshold identification (6.64dB), calibration error (6.19dB), and additionally at the frequency of 250Hz by frequency nonlinearity error (7.28dB).

Conclusions

The obtained results confirm the possibility of applying Web-based pure-tone audiometry in screening tests. In the future, modifications of the method leading to the decrease in measurement error can broaden the scope of Web-based pure-tone audiometry application.