Accuracy and Reliability of Smartphone Self-Test Audiometry in Community Clinics in Low Income Settings: A Comparative Study

The Emerging Future of Mobile Audiometry: A Prospective Validation Study of the Mimi Hearing Test Application

OBJECTIVE

The objective of this study is to assess the accuracy of the Mimi Hearing Test (MHT) mobile application in the detection of air conduction (AC) thresholds and in screening for moderate hearing loss.

STUDY DESIGN

Prospective clinical study.

SETTING

Tertiary care center.

PATIENTS

Participants with or without a varying degree of hearing loss, aged 18 years and over, without cognitive impairment and without active otorrhea or earwax impaction at the time of the hearing assessment were included.

INTERVENTION

Subjects with a ranging severity of hearing loss underwent a conventional in-booth audiogram as well as mobile-based screening with MHT in a quiet room (45.5 dB background noise) on the same day. Both regular over-the-ear and noise-canceling headphones were tested with MHT.

MAIN OUTCOME MEASURES

Comparisons of AC thresholds between conventional audiometry and mobile-based audiometry at discrete frequencies and with pure-tone averages (PTA) were performed.

RESULTS

A total of 75 adults (mean age: 56.2 yr, 54.7% male) were recruited and 63 used for analysis. Of the thresholds measured with MHT using regular headphones, 44.0% were within 10 dB of the conventional audiogram, compared to 39.3% using noise-canceling headphones. MHT demonstrated best accuracy at high frequencies (4-8 kHz). When screening for moderate hearing loss (PTA >40 dB HL), MHT demonstrated a sensitivity and specificity of 100.0% and 80.2%, respectively.

CONCLUSIONS

MHT is reliable for identifying moderate hearing loss but lacks precision in detecting thresholds at low frequencies. Noise canceling headphones seem to improve its precision at 4,000 Hz only.

Smartphone-Facilitated In-Situ Hearing Aid Audiometry for Community-Based Hearing Testing

OBJECTIVES

Hearing loss prevalence is increasing, with an estimated 2.5 billion people affected globally by 2050. Scalable service delivery models using innovative technologies and task-shifting are World Health Organization priorities to improve access to hearing care, particularly in low- and middle-income countries. Smartphone-facilitated audiometry in the community using hearing aids covered by noise-attenuating ear cups ("in-situ") could support more accessible hearing care when provided by less trained individuals such as community health workers (CHWs). This study aimed to determine the validity of this method for potential hearing aid fitting. Study objectives included determining the maximum permissible ambient noise level (MPANL), inter-device reliability, clinical threshold accuracy, reliability, and performance in real-world settings.

DESIGN

Experiment 1: 15 normal-hearing adult participants were evaluated to determine MPANLs for circumaural Peltor 3M earcups covering Lexie Lumen hearing aids with smartphone-facilitated in-situ audiometry. MPANLs were calculated by measuring the difference in attenuation between thresholds obtained with standard headphones and in-situ hearing aids. Experiment 2: Pure-tone frequency and intensity output of 14 same-model Lexie Lumen hearing aids were measured to determine inter-device reliability. Pure-tone stimuli were measured and analyzed to determine sound pressure levels in decibels and pure-tone frequency when connected to a test box 2cc coupler. Experiment 3: 85 adult participants were tested in a sound booth to determine the accuracy of automated in-situ pure-tone audiometry (PTA) compared to clinical PTA (500, 1000, 2000, 3000, 4000, 6000 Hz) facilitated by an audiologist. The first 39 participants were tested twice to determine test-retest reliability. Experiment 4: In a community setting, 144 adult participants were tested with automated in-situ audiometry facilitated by CHWs using a smartphone app. These participants were subsequently tested with automated mobile PTA (500, 1000, 2000, 4000 Hz). An additional 44 participants were tested twice to determine test-retest reliability.

RESULTS

Experiment 1: MPANLs of the Peltor 3M earcup-covered hearing aids were higher than standard headphones across all frequencies, ranging from 24 to 47.3 dB SPL. Experiment 2: Inter-device performance reliability was high, with all inter-device differences across all intensities and frequencies less than 3 dB. Frequency output was consistent and differed less than 0.7% between devices. Experiments 3 and 4: 85.2% and 83.3% of automated in-situ audiometry thresholds were within 10 dB of thresholds obtained in the sound booth and in a community setting, respectively. Acceptable test-retest intraclass correlation coefficient (ICC) was evident across all thresholds obtained in a sound booth (ICC = 0.85 to 0.93) and in a community setting (ICC = 0.83 to 0.97).

CONCLUSIONS

Smartphone-facilitated in-situ audiometry allows for reliable and valid community-based testing. A simple smartphone user interface and automated in-situ audiometry allow CHWs with minimal training to facilitate the testing. With the additional capability to program hearing aids via the smartphone after the initial test, this approach would have the potential to support widespread access to personalized hearing aid fittings facilitated by CHWs in low- and middle-income countries. This approach also supports self-fitting options based on in-situ thresholds, enabling testing and fitting via over the counter hearing aids.

Self-assessment of bone conduction hearing threshold using mobile audiometry: comparison with pure tone audiometry

OBJECTIVE

The aim of the research was to evaluate the feasibility of measuring the bone conduction hearing threshold using self-administered mobile audiometry.

DESIGN

A single-centre, closed, cross-over trial was carried out on patients from the ENT Department. A mobile-based, self-administered, audiologist-assisted assessment of the bone conduction hearing threshold was carried out by means of the open-access, freeware app Hearing Test using two types of bone conduction headphones: professional B71 bone transducer and commercially available AfterShokz Openmove open-ear headphones.

STUDY SAMPLE

Seventy-seven ears.

RESULTS

A test-retest examination revealed the lowest standard deviation for open-ear headphones at 3.33 dB (95% CI 2.92-3.79). When compared with pure tone audiometry, the intraclass correlations of 0.95 (95% CI 0.94-0.96) and 0.90 (95% CI 0.88-0.92) were obtained for the bone transducer and for the open-ear headphones, indicating excellent and good reliability, respectively. However, the regression slope of 0.67 was found for the air-bone gap when using open ear headphones, which was significantly different from 1 (p < 0.001).

CONCLUSIONS

Open-ear headphones provide an alternative for estimating bone conduction once the air-bone gap has been adjusted by a factor of 1/0.6 7 ≅1.5. They demonstrate improved reproducibility over the bone transducer and are much easier to use with a mobile device. Trial Registration: Wroclaw Medical University, Science Support Centre, BW60/2020.

New Age Hearing Testing at your Fingertips: Shravana Mitra App

INTRODUCTION

WHO estimated the prevalence of disabling hearing loss is 5% of the world population (430 million). People with a risk of hearing loss from noise exposure, ototoxic drugs, and comorbidities need regular hearing assessments. It is done by pure tone audiometry (PTA), requiring a skilled audiologist, special equipment, and a soundproof room. Modern technologies can help in overcoming these barriers. This study aimed to fill the lacuna by developing a new android-based application "Shravana Mitra" (Hearing companion) with features of both air conduction (AC) and bone conduction (BC) testing.

OBJECTIVES

To develop, corroborate and compare smartphone application-based audiometry with PTA.

METHODOLOGY

This study was done in three phases -(i) development of a mobile application, (ii) app validation in healthy individuals (iii) testing and comparison of results with PTA in individuals visiting OPD. The third phase was done as a cross-sectional observational study including 780 individuals visiting OPD of 10-60 years of age.

RESULTS

The mean age of the study population was 32.89 years with female preponderance (57%). In AC testing, 83% of the pure tone average of the mobile application was within 5 dB of PTA thresholds and 99% was within 10 dB and for BC testing, 81% was within 5 dB of PTA thresholds and 98% within 10 dB.

CONCLUSION

Our user-friendly mobile application- Shravana Mitra is the first Indian application available in the google play store with both AC & BC testing, multiple language options and accuracy similar to PTA. Thus, it can be used as the best hearing screening tool in camps, high-risk individuals, or any healthcare setup requiring initial hearing assessment.

Comparisons of air-conduction hearing thresholds between manual and automated methods in a commercial audiometer

Objective

To investigate the correlation of air-conduction thresholds between automated audiometry in a non-isolated environment and manual audiometry in participants with normal hearing and different degrees of hearing loss.

Methods

Eighty-three participants aged 11-88 years old underwent automated pure-tone audiometry in a non-acoustically isolated environment, and the results were compared with those of manual pure-tone audiometry performed in a standard acoustically isolated booth, with the order of testing randomised. Six frequencies of 250, 500, 1,000, 2000, 4,000 and 8,000 Hz were tested.

Results

All 166 ears were completed and 996 valid hearing threshold data were obtained, with 28 data exceeding the 95% confidence interval in the Bland-Altman plot, accounting for 2.81% of all data. The means and standard deviations of the differences for the six frequencies from 250 to 8,000 Hz were, respectively, 0.63 ± 5.31, 0.69 ± 4.50, 0.45 ± 4.99, 0.3 ± 6.2, -0.15 ± 4.8, and 0.21 ± 4.97 dB. The correlation coefficients of the two test results for normal hearing, mild, moderate, severe and above hearing loss groups were 0.95, 0.92, 0.97, and 0.96, respectively. The correlation coefficient of the automated and manual audiometry thresholds for the age groups under 40 years, 40-60 years, and 60 years above, were 0.98, 0.97 and 0.97, respectively, with all being statistically significant (p < 0.01). The response time of the three age groups were 791 ± 181 ms, 900 ± 190 ms and 1,063 ± 332 ms, respectively, and there was a significant difference between the groups under 40 years and over 60 years.

Conclusion

There was good consistency between automated pure-tone audiometry in a non-acoustically isolated environment and manual pure-tone audiometry in participants with different hearing levels and different age groups.

ISOM 2023 research Panel 4 - Diagnostics and microbiology of otitis media

OBJECTIVES

To identify and review key research advances from the literature published between 2019 and 2023 on the diagnosis and microbiology of otitis media (OM) including acute otitis media (AOM), recurrent AOM (rAOM), otitis media with effusion (OME), chronic suppurative otitis media (CSOM) and AOM complications (mastoiditis).

DATA SOURCES

PubMed database of the National Library of Medicine.

REVIEW METHODS

All relevant original articles published in Medline in English between July 2019 and February 2023 were identified. Studies that were reviews, case studies, relating to OM complications (other than mastoiditis), and studies focusing on guideline adherence, and consensus statements were excluded. Members of the panel drafted the report based on these search results.

MAIN FINDINGS

For the diagnosis section, 2294 unique records screened, 55 were eligible for inclusion. For the microbiology section 705 unique records were screened and 137 articles were eligible for inclusion. The main themes that arose in OM diagnosis were the need to incorporate multiple modalities including video-otoscopy, tympanometry, telemedicine and artificial intelligence for accurate diagnoses in all diagnostic settings. Further to this, was the use of new, cheap, readily available tools which may improve access in rural and lowmiddle income (LMIC) settings. For OM aetiology, PCR remains the most sensitive method for detecting middle ear pathogens with microbiome analysis still largely restricted to research use. The global pandemic response reduced rates of OM in children, but post-pandemic shifts should be monitored.

IMPLICATION FOR PRACTICE AND FUTURE RESEARCH

Cheap, easy to use multi-technique assessments combined with artificial intelligence and/or telemedicine should be integrated into future practice to improve diagnosis and treatment pathways in OM diagnosis. Longitudinal studies investigating the in-vivo process of OM development, timings and in-depth interactions between the triad of bacteria, viruses and the host immune response are still required. Standardized methods of collection and analysis for microbiome studies to enable inter-study comparisons are required. There is a need to target underlying biofilms if going to effectively prevent rAOM and OME and possibly enhance ventilation tube retention.

Diagnostic Accuracy of Mobile Health-Based Audiometry for the Screening of Hearing Loss in Adults: A Systematic Review and Meta-Analysis

Background: Hearing loss is one of the most prevalent chronic health conditions. Traditional pure tone audiometry (PTA) is the gold standard for hearing loss screening, but is not widely available outside specialized clinical centers. Mobile health (mHealth)-based audiometry could improve access and cost-effectiveness, but its diagnostic accuracy varies widely between studies. Therefore, we aimed to evaluate the diagnostic accuracy of mHealth-based audiometry for hearing loss screening in adults compared with traditional PTA. Methods: Ten English and Chinese databases were searched from inception until April 30, 2022. Two researchers independently selected studies, extracted data, and appraised methodological quality. The bivariate random-effects model was adopted to estimate the pooled sensitivity and specificity for each common threshold (i.e., the threshold to define mild or moderate hearing loss). The hierarchical summary receiver operating characteristic model was used to assess the area under the receiver operating characteristic curve (AUC) across all thresholds. Results: Twenty cohort studies were included. Only one study (n = 109) used the mHealth-based speech recognition test (SRT) as the index test. Nineteen studies (n = 1,656) used mHealth-based PTA as the index test, and all of them were included in the meta-analysis. For detecting mild hearing loss, the pooled sensitivity and specificity were 0.91 (95% confidence interval [CI] 0.80-0.96) and 0.90 (95% CI 0.82-0.94), respectively. For detecting moderate hearing loss, the pooled sensitivity and specificity were 0.94 (95% CI 0.87-0.98) and 0.87 (95% CI 0.79-0.93), respectively. For all PTA thresholds, the AUC was 0.96 (95% CI 0.40-1.00). Conclusions: mHealth-based audiometry provided good diagnostic accuracy for screening both mild and moderate hearing loss in adults. Given its high diagnostic accuracy, accessibility, convenience, and cost-effectiveness, it shows enormous potential for hearing loss screening, particularly in primary care sites, low-income regions, and settings with in-person visit limitations. Further work should evaluate the diagnostic accuracy of the mHealth-based SRT tests.

Validation of a tablet-based assessment of auditory sensitivity for researchers

Quantifying hearing acuity is increasingly important across a wide range of research areas in the behavioral and neurosciences. Scientists have relied on either self-reported hearing status or the availability of diagnostic hearing assessment in past studies. There remains a need for a valid and reliable assessment of auditory sensitivity that can provide estimates of the magnitude of hearing loss, if present, without requirements for professional audiologists, facilities, and equipment that are needed to conduct a diagnostic hearing assessment. The goal of this experiment was to validate the NIH Toolbox® Hearing Threshold Test (HTT), a tablet-based hearing assessment available via iPad application that uses consumer-grade headphones, on a clinical sample of children and adults with varying degrees of hearing acuity. Electroacoustic analysis of the hearing assessment application and headphones demonstrated acoustic outputs within established conformity standards for hearing assessment. Twenty-seven children and 63 adults participated in a standard diagnostic hearing assessment and the experimental tablet-based assessment. The results showed that thresholds from the tablet-based assessment were highly correlated with thresholds from the clinical hearing assessment (r = .83-.93) for children and adults for all frequencies and across a range of levels of hearing acuity. The HTT also met clinical test-retest reliability standards (Cronbach's α > .86). The tablet-based hearing assessment provides acceptable estimates of hearing levels for children and adults when diagnostic audiometric assessment capabilities are not available.

Artificial intelligence and digital health in improving primary health care service delivery in LMICs: A systematic review

AIM

Technology including artificial intelligence (AI) may play a key role to strengthen primary health care services in resource-poor settings. This systematic review aims to explore the evidence on the use of AI and digital health in improving primary health care service delivery.

METHODS

Three electronic databases were searched using a comprehensive search strategy without providing any restriction in June 2023. Retrieved articles were screened independently using the "Rayyan" software. Data extraction and quality assessment were conducted independently by two review authors. A narrative synthesis of the included interventions was conducted.

RESULTS

A total of 4596 articles were screened, and finally, 48 articles were included from 21 different countries published between 2013 and 2021. The main focus of the included studies was noncommunicable diseases (n = 15), maternal and child health care (n = 11), primary care (n = 8), infectious diseases including tuberculosis, leprosy, and HIV (n = 7), and mental health (n = 6). Included studies considered interventions using AI, and digital health of which mobile-phone-based interventions were prominent. m-health interventions were well adopted and easy to use and improved the record-keeping, service deliver, and patient satisfaction.

CONCLUSION

AI and the application of digital technologies improve primary health care service delivery in resource-poor settings in various ways. However, in most of the cases, the application of AI and digital health is implemented through m-health. There is a great scope to conduct further research exploring the interventions on a large scale.

Hearing Screening Alternative Using a Website-Based Application

BACKGROUND AND OBJECTIVES

Indonesians encounter several barriers to regular functional hearing assessment. Hearing loss screening is only provided by tertiary-care hospitals that are not reachable by people in remote regions. This study aimed to develop a website-based hearing screening application that is accessible and inexpensive. Subjects and.

METHODS

This comparative study was conducted between July and August 2022 in the Otolaryngology Clinic of Muhammadiyah Bandung Hospital with noise levels below 50 dB. The hearing screening was conducted using a website-based application (www.Screenout.id) and audiogram as the gold standard method. On ScreenOut, patients heard sounds with frequencies at 500, 1,000, 2,000, 4,000, and 8,000 Hz and sound intensity of each frequency at 35, 55, and 75 dB using earphones.

RESULTS

A total of 133 participants were enrolled in our study. ScreenOut showed high sensitivity, specificity, accuracy, positive predictive value, and negative predictive value (90.9%, 98.9%, 93.6%, 99.4%, and 84.8%, respectively). Regarding hearing threshold, a very strong correlation was found between ScreenOut and audiogram, ranging between r=0.843 and r=0.899. Aside from that, there was no significant difference in hearing threshold values between ScreenOut and audiogram.

CONCLUSIONS

Many advantages of the ScreenOut were found, including low-cost, accessibility, and easy-to-use interface, making it favorably used in low-middle-income countries such as Indonesia.

Clinical comparison of two automated audiometry procedures

Objective

Automated pure-tone audiometry has been shown to provide similar hearing threshold estimates to conventional audiometry, but lower correlations were reported at high and low frequencies in audiometric tests than those of manual tests, while the correlations were better in the middle frequencies. In this paper, we used the same equipment and different test procedures for automated testing, and compared the results with manual test results.

Design

One hundred subjects aged 18–36 years were randomly divided into two groups to perform air-conduction pure-tone audiometry (0.25, 0.5, 1, 2, 4, 8 kHz) using the ascending and shortened ascending protocols built-in to the automated audiometer, respectively. Recorded testing time, the total number of responses and the subject’s preference tests were compared with those of manual tests.

Results

Significant difference was found at 250 Hz regarding the distribution of the absolute difference between the two automated and the manual thresholds. The testing time spend in the ascending method (9.8 ± 1.4 min, mean ± SD) was significantly longer than in the shorted ascending method (5.8 ± 0.9 min). The total numbers of responses of the ascending method (90.5 ± 10.8 times) and shorted ascending method (62.0 ± 11.4 times) were significantly different. Finally, no significant difference was found in preferences between automated and manual procedures.

Conclusion

The shorted ascending method can save lots of testing time. The difference between the two automated thresholds at 250 Hz is caused by the different test procedures, and the difference at 8,000 Hz between the automated test and the manual test can be due to the transducer types and allowable differences in calibration.

Telehealth solutions for assessing auditory outcomes related to noise and ototoxic exposures in clinic and research

Nearly 1.5 billion people globally have some decline in hearing ability throughout their lifetime. Many causes for hearing loss are preventable, such as that from exposure to noise and chemicals. According to the World Health Organization, nearly 50% of individuals 12-25 years old are at risk of hearing loss due to recreational noise exposure. In the occupational setting, an estimated 16% of disabling hearing loss is related to occupational noise exposure, highest in developing countries. Ototoxicity is another cause of acquired hearing loss. Audiologic assessment is essential for monitoring hearing health and for the diagnosis and management of hearing loss and related disorders (e.g., tinnitus). However, 44% of the world's population is considered rural and, consequently, lacks access to quality hearing healthcare. Therefore, serving individuals living in rural and under-resourced areas requires creative solutions. Conducting hearing assessments via telehealth is one such solution. Telehealth can be used in a variety of contexts, including noise and ototoxic exposure monitoring, field testing in rural and low-resource settings, and evaluating auditory outcomes in large-scale clinical trials. This overview summarizes current telehealth applications and practices for the audiometric assessment, identification, and monitoring of hearing loss.

Home-Based Audiometry With a Smartphone App: Reliable Results?

PURPOSE

The aim of this study was to assess the test-retest reliability of a smartphone-based hearing test, performed without supervision of a hearing professional in an uncontrolled environment.

METHOD

The hearing application is based on an automated hearing test (DuoTone) and relies on verification procedures (ambient noise monitoring algorithm, graphical user interface) to ensure appropriate measurement conditions. Thresholds obtained with DuoTone were compared to those obtained with standard clinical audiometry for 0.5, 1, 2, and 4 kHz in 13 subjects. Subsequently, test-retest reliability was analyzed using anonymized cloud-stored data from a large group of app users (1,641 subjects) who performed multiple hearing tests. Thresholds at minimum or maximum presentation level of the hearing test (10 dB HL, 85 dB HL) were excluded to avoid floor/ceiling effects. A subset (500 subjects) was created to exclude potentially unreliable data. Test-retest thresholds were compared at 12 test frequencies, from 125 Hz to 12 kHz.

RESULTS

Thresholds determined by DuoTone and clinical audiometry did not differ significantly for each test frequency. Regarding test-retest analysis, the percentage of test-retest results within 5 dB ranged from 60% to 77% per test frequency. Results from the subset were not substantially different. Test-retest reliability for app users was comparable to results published in the literature regarding test-retest reliability of audiometry, performed in the clinic.

CONCLUSIONS

Initial validation results suggest that thresholds obtained with DuoTone are comparable to clinical audiometry (four frequencies tested). The hearing app provides reliable hearing thresholds between 15 and 80 dB HL (12 frequencies tested) with a test-retest reliability comparable to clinical audiometry.

Software Application toward Accessible Hearing Care Assessment: Gap in Noise Test

Currently, several methods are being applied to assess auditory temporal resolution in a controlled clinical environment via the measurements of gap detection thresholds (GDTs). However, these methods face two issues: the relatively long time required to perform the gap detection test in such settings and the potential of inaccessibility to such facilities. This article proposes a fast, affordable, and reliable application-based method for the determination of GDT either inside or outside the soundproof booth. The proposed test and the acoustic stimuli were both developed using the MATLAB® programming platform. GDT is determined when the subject is able to distinguish the shortest silent gap inserted randomly in one of two segments of white noise. GDTs were obtained from 42 normal-hearing subjects inside and outside the soundproof booth. The results of this study indicated that average GDTs measured inside the booth (5.12 ± 1.02 ms) and outside (4.78 ± 1.16 ms) were not significantly different. The measured GDTs were also comparable to that reported in the literature. In addition, the GDT screening time of the proposed method was approximately 5 minutes, a screening time that is much less than that reported by the literature. Data show that the proposed application was fast and reliable to screen GDT compared to the standard method currently used in clinical settings.

Accuracy of smartphone-based hearing screening tests: a systematic review

PURPOSE

To verify the accuracy of smartphone apps to identify hearing loss.

RESEARCH STRATEGIES

A systematic review followed the PRISMA-DATA checklist. The search strategies were applied across four databases (Lilacs, PubMed, Scopus and Web of Science) and grey literature (Google Scholar, OpenGrey, and ProQuest Dissertations and Thesis).

SELECTION CRITERIA

The acronym PIRD was used in review. This included populations of any gender and all age groups. The Index test is the smartphone-based hearing screening test; the Reference test is the pure-tone audiometry, which is considered the gold reference for hearing diagnostics; the diagnosis was performed via validity data (sensitivity and specificity) to identify hearing loss and diagnostic studies.

DATA ANALYSIS

Two reviewers selected the studies in a two-step process. The risk of bias was assessed according to the criteria of the QUADAS-2.

RESULTS

Of 1395 articles, 104 articles were eligible for full-text reading and 17 were included. Only four met all criteria for methodological quality. All of the included studies were published in English between 2015 and 2020. The applications Digits-in noise Test (5 articles), uHear (4 articles), HearScreen (2 articles), hearTest (2 articles) and Hearing Test (2 articles) were the most studied. All this application showed sensitivity and specificity values between 75 and 100%. The other applications were EarScale, uHearing Test, Free field hearing (FFH) and Free Hearing Test.

CONCLUSION

uHear, Digit-in-Noise Test, HearTest and HearScreen have shown significant values of sensitivity and specificity and can be considered as the most accurate methods for screening of hearing impairment.

Digital Approaches to Automated and Machine Learning Assessments of Hearing: Scoping Review

BACKGROUND

Hearing loss affects 1 in 5 people worldwide and is estimated to affect 1 in 4 by 2050. Treatment relies on the accurate diagnosis of hearing loss; however, this first step is out of reach for >80% of those affected. Increasingly automated approaches are being developed for self-administered digital hearing assessments without the direct involvement of professionals.

OBJECTIVE

This study aims to provide an overview of digital approaches in automated and machine learning assessments of hearing using pure-tone audiometry and to focus on the aspects related to accuracy, reliability, and time efficiency. This review is an extension of a 2013 systematic review.

METHODS

A search across the electronic databases of PubMed, IEEE, and Web of Science was conducted to identify relevant reports from the peer-reviewed literature. Key information about each report's scope and details was collected to assess the commonalities among the approaches.

RESULTS

A total of 56 reports from 2012 to June 2021 were included. From this selection, 27 unique automated approaches were identified. Machine learning approaches require fewer trials than conventional threshold-seeking approaches, and personal digital devices make assessments more affordable and accessible. Validity can be enhanced using digital technologies for quality surveillance, including noise monitoring and detecting inconclusive results.

CONCLUSIONS

In the past 10 years, an increasing number of automated approaches have reported similar accuracy, reliability, and time efficiency as manual hearing assessments. New developments, including machine learning approaches, offer features, versatility, and cost-effectiveness beyond manual audiometry. Used within identified limitations, automated assessments using digital devices can support task-shifting, self-care, telehealth, and clinical care pathways.

Tele-Audiology: Current State and Future Directions

The importance of tele-audiology has been heightened by the current COVID-19 pandemic. The present article reviews the current state of tele-audiology practice while presenting its limitations and opportunities. Specifically, this review addresses: (1) barriers to hearing healthcare, (2) tele-audiology services, and (3) tele-audiology key issues, challenges, and future directions. Accumulating evidence suggests that tele-audiology is a viable service delivery model, as remote hearing screening, diagnostic testing, intervention, and rehabilitation can each be completed reliably and effectively. The benefits of tele-audiology include improved access to care, increased follow-up rates, and reduced travel time and costs. Still, significant logistical and technical challenges remain from ensuring a secure and robust internet connection to controlling ambient noise and meeting all state and federal licensure and reimbursement regulations. Future research and development, especially advancements in artificial intelligence, will continue to increase tele-audiology acceptance, expand remote care, and ultimately improve patient satisfaction.

Hearing Impairment in South Africa and the Lessons Learned for Planetary Health Genomics: A Systematic Review

Hearing impairment (HI) is a silent planetary health crisis that requires attention worldwide. The prevalence of HI in South Africa is estimated as 5.5 in 100 live births, which is about 5 times higher than the prevalence in high-income countries. This also offers opportunity to drive progressive science, technology and innovation policy, and health systems. We present here a systematic analysis and review on the prevalence, etiologies, clinical patterns, and genetics/genomics of HI in South Africa. We searched PubMed, Scopus, African Journals Online, AFROLIB, and African Index Medicus to identify the pertinent studies on HI in South Africa, published from inception to April 30, 2021, and the data were summarized narratively. We screened 944 records, of which 27 studies were included in the review. The age at diagnosis is ∼3 years of age and the most common factor associated with acquired HI was middle ear infections. There were numerous reports on medication toxicity, with kanamycin-induced ototoxicity requiring specific attention when considering the high burden of tuberculosis in South Africa. The Waardenburg Syndrome is the most common reported syndromic HI. The Usher Syndrome is the only syndrome with genetic investigations, whereby a founder mutation was identified among black South Africans (MYO7A-c.6377delC). GJB2 and GJB6 genes are not major contributors to nonsyndromic HI among Black South Africans. Furthermore, emerging data using targeted panel sequencing have shown a low resolution rate in Black South Africans in known HI genes. Importantly, mutations in known nonsyndromic HI genes are infrequent in South Africa. Therefore, whole-exome sequencing appears as the most effective way forward to identify variants associated with HI in South Africa. Taken together, this article contributes to the emerging field of planetary health genomics with a focus on HI and offers new insights and lessons learned for future roadmaps on genomics/multiomics and clinical studies of HI around the world.

User-Operated Audiometry Project (UAud) - Introducing an Automated User-Operated System for Audiometric Testing Into Everyday Clinic Practice

Hearing loss is the third leading cause of years lived with disability. It is estimated that 430 million people worldwide are affected, and the number of cases is expected to increase in the future. There is therefore increased pressure on hearing health systems around the world to improve efficiency and reduce costs to ensure increased access to quality hearing health care. Here, we describe the User-Operated Audiometry project, the goal of which is to introduce an automated system for user-operated audiometric testing into everyday clinic practice as a means to relieve part of this pressure. The alternative to the existing referral route is presented in which examination is executed via the user-operated system. This route is conceptualized as an interaction between the patient, the system, and the hearing care professional (HCP). Technological requirements of the system and challenges that are related to the interaction between patients, the user-operated system, and the HCPs within the specific medical setting are discussed. Lastly, a strategy for the development and implementation of user-operated audiometry is presented, which includes initial investigations, a validation study, and implementation in a real-life clinical situation.

Diagnostic Accuracy of Smartphone-Based Audiometry for Hearing Loss Detection: Meta-analysis

Background

Hearing loss is one of the most common disabilities worldwide and affects both individual and public health. Pure tone audiometry (PTA) is the gold standard for hearing assessment, but it is often not available in many settings, given its high cost and demand for human resources. Smartphone-based audiometry may be equally effective and can improve access to adequate hearing evaluations.

Objective

The aim of this systematic review is to synthesize the current evidence of the role of smartphone-based audiometry in hearing assessments and further explore the factors that influence its diagnostic accuracy.

Methods

Five databases—PubMed, Embase, Cochrane Library, Web of Science, and Scopus—were queried to identify original studies that examined the diagnostic accuracy of hearing loss measurement using smartphone-based devices with conventional PTA as a reference test. A bivariate random-effects meta-analysis was performed to estimate the pooled sensitivity and specificity. The factors associated with diagnostic accuracy were identified using a bivariate meta-regression model. Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool.

Results

In all, 25 studies with a total of 4470 patients were included in the meta-analysis. The overall sensitivity, specificity, and area under the receiver operating characteristic curve for smartphone-based audiometry were 89% (95% CI 83%-93%), 93% (95% CI 87%-97%), and 0.96 (95% CI 0.93-0.97), respectively; the corresponding values for the smartphone-based speech recognition test were 91% (95% CI 86%-94%), 88% (95% CI 75%-94%), and 0.93 (95% CI 0.90-0.95), respectively. Meta-regression analysis revealed that patient age, equipment used, and the presence of soundproof booths were significantly related to diagnostic accuracy.

Conclusions

We have presented comprehensive evidence regarding the effectiveness of smartphone-based tests in diagnosing hearing loss. Smartphone-based audiometry may serve as an accurate and accessible approach to hearing evaluations, especially in settings where conventional PTA is unavailable.

Expanding telemedicine to reduce the burden on the healthcare systems and poverty in Africa for a post-coronavirus disease 2019 (COVID-19) pandemic reformation

The coronavirus disease 2019 (COVID-19) global public health emergency, has exposed the fragility of health systems. Access to healthcare became a scarce commodity as healthcare providers and resource-poor populations became victims of the novel corona virus. Therefore, this study focuses on Africa's readiness to integrate telemedicine into the weak health systems and its adoption may help alleviate poor healthcare and poverty after COVID-19. We conducted a narrative review through different search strategies in Scopus on January 20, 2021, to identify available literature reporting implementation of various telemedicine modes in Africa from January 1, 2011 to December 31, 2020. We summarized 54 studies according to geographies, field, and implementation methods. The results show a willingness to adopt telemedicine in the resource-poor settings and hard-to-reach populations, which will bring relief to the inadequate healthcare systems and alleviate poverty of those who feel the burden of healthcare cost the most. With adequate government financing, telemedicine promises to enhance the treating of communicable and non-communicable diseases as well as support health infrastructure. It can also alleviate poverty among vulnerable groups and hard-to-reach communities in Africa with adequate government financing. However, given the lack of funding in Africa, the challenges in implementing telemedicine require global and national strategies before it can yield promising results. This is especially true in regards to alleviating the multidimensionality of poverty in post-COVID-19 Africa.

Optimization of the Speech Test Material in a Group of Hearing Impaired Subjects: A Feasibility Study for Multilingual Digit Triplet Test Development

Background: The development of the global digit-in-noise test requires optimization of each language version on a group of normal-hearing native-speakers. An alternative solution may be an adaptive optimization during ongoing tests in a group of subjects with unknown hearing impairments. The objective of the research was to compare the optimization results between these groups. Methods: Digit triplets consisting of three pseudo-randomly selected digits were presented in speech-shaped noise at various signal-to-noise ratios (SNRs), according to the protocol of the final speech test. Digit-specific and position-specific speech reception thresholds (SRTs) were determined and compared between groups. Results: The study sample consisted of 82 subjects, 26 normal-hearing subjects and 56 patients with diverse hearing disorders. Statistically significant differences in digit-specific SRTs between the control and the investigated group were obtained for three digits in continuous noise (digits 0, 4, 6; p-value of 0.04, 0.03, 0.05) and two in modulated noise (digits 1 and 6; p-value of 0.05 and 0.01). An analysis including only ears with SRTs within the range of the normal hearing control group showed no statistically significant differences between digits. Conclusion: Optimization of speech material can be carried out in a group of subjects with unknown hearing impairments, provided the ears with scores outside normal range are rejected.

Organizational Aspects and Outcomes of a Hearing Screening Program Among First-Grade Children in the Mazovian Region of Poland

Purpose The purpose of this study is to describe and assess a hearing screening program of first-grade children in Poland. The program aimed to detect hearing disorders and increase awareness among parents of hearing problems. Method A hearing screening program was conducted in all elementary schools of the biggest region in Poland. A total of 34,618 first-graders were screened. The hearing screening protocol included video otoscopy and pure-tone audiometry. The program also included an information campaign directed to the local community and educational meetings between parents and medical staff. Results The estimated prevalence of hearing loss was 11%. Unilateral hearing loss was more common than bilateral hearing loss. Mild hearing loss was more frequent than moderate (or worse) hearing loss. In otoscopy, the most common positive result was otitis media with effusion. Parents and medical staff took part in 1,608 educational meetings, broadening the parents' knowledge of how to care for hearing. Conclusions A hearing screening program not only provides data on the prevalence of childhood hearing problems but is also an avenue for providing the local community with valuable knowledge about how to care for hearing. This study demonstrated the importance for systematic monitoring of children's hearing status and of increasing awareness among parents and teachers of the significance of hearing loss. The hearing screening of children starting school should become a standard part of school health care programs.

Development of a public audiology service in Southern Malawi: profile of patients across two years

OBJECTIVE

To describe the profile of patients attending the Queen Elizabeth Central Hospital (QECH) audiology clinic in Malawi, over a two-year period (2016-2017).

DESIGN

A retrospective patient record review.

STUDY SAMPLE

There were 2299 patients assessed at the QECH audiology department between January 2016 and December 2017. Adult patients' ages ranged from 18 to 94 years (M = 45.8, SD = 19.22). The mean age of children included in this study was 7.7 years (SD= 5.21). Overall, 45.4% of patients were female.

RESULTS

Of the 61.6% of adults and 41.7% of children found to have some degree of hearing loss, 28.3% and 15.4% were fitted with hearing aids, respectively. The number of patients seen in 2017 (n = 1385) was 34% higher than that of 2016 (n = 914).

CONCLUSION

This study found that demand for hearing services is increasing in this public sector Malawian audiology department but uptake of hearing aids for those in need is low. Future evaluation of service provision and treatment outcomes is needed. Results from this study can be used to inform the development of future audiology clinics in low resource settings.

Worldwide Prevalence of Hearing Loss Among Smartphone Users: Cross-Sectional Study Using a Mobile-Based App

Background

In addition to the aging process, risk factors for hearing loss in adults include, among others, exposure to noise, use of ototoxic drugs, genetics, and limited access to medical care. Differences in exposure to these factors are bound to be reflected in the prevalence of hearing loss. Assessment of hearing loss can easily be carried out on a large scale and at low cost using mobile apps.

Objective

This study aimed to conduct a worldwide assessment of the differences in hearing loss prevalence between countries in a group of mobile device users.

Methods

Hearing tests were conducted using the open-access Android-based mobile app Hearing Test. The app is available free of charge in the Google Play store, provided that consent to the use of the results for scientific purposes is given. This study included hearing tests carried out on device models supported by the app with bundled headphones in the set. Calibration factors for supported models were determined using the biological method. The tests consisted of self-determining the quietest audible tone in the frequency range from 250 Hz to 8 kHz by adjusting its intensity using the buttons. The ambient noise level was optionally monitored using a built-in microphone. Following the test, the user could compare his hearing threshold against age norms by providing his or her age. The user's location was identified based on the phone’s IP address.

Results

From November 23, 2016 to November 22, 2019, 733,716 hearing tests were conducted on 236,716 mobile devices across 212 countries. After rejecting the tests that were incomplete, performed with disconnected headphones, not meeting the time criterion, repeated by the same user, or carried out regularly on one device, 116,733 of 733,716 tests (15.9%) were qualified for further analysis. The prevalence of hearing loss, defined as the average threshold at frequencies 0.5 kHz, 1 kHz, 2 kHz, and 4 kHz above 25 dB HL in the better ear, was calculated at 15.6% (95% CI 15.4-15.8). Statistically significant differences were found between countries (P<.001), with the highest prevalences for Bangladesh, Pakistan, and India (>28%) and the lowest prevalences for Taiwan, Finland, and South Korea (<11%).

Conclusions

Hearing thresholds measured by means of mobile devices were congruent with the literature data on worldwide hearing loss prevalence. Uniform recruitment criteria simplify the comparison of the hearing loss prevalence across countries. Hearing testing on mobile devices may be a valid tool in epidemiological studies carried out on a large scale.

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.