Hearing Loss Screening Tests for Adults

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Acta Otorrinolaringol Esp. 2013;64(3):184---190
www.elsevier.es/otorrino
ORIGINAL ARTICLE
Hearing Loss Screening Tests for Adults夽
Perla B. Becerril-Ramírez,∗ Dina F. González-Sánchez, Angélica Gómez-García,
Rafael Figueroa-Moreno, Gerardo A. Bravo-Escobar, Miguel A. García de la Cruz
División de Otorrinolaringología y cirugía de cabeza y Cuello, Secretaría de Salud, Hospital General Dr. Manuel Gea González,
Ciudad de México, Distrito Federal Mexico, Mexico
Received 4 July 2012; accepted 10 November 2012
KEYWORDS
Hearing loss;
Adults;
Ageing;
Screening
PALABRAS CLAVE
Hipoacusia;
Adultos;
Abstract
Introduction: The early detection of hearing loss has been studied widely in newborns due to
the emerging technologies for diagnosis and treatment. There are detailed protocols for this
goal. Nonetheless, hearing loss screening in adults has become more important lately with
the increase of the life expectancy, an expected change in the Mexican population pyramid
towards a rectangular shape in the next 50 years (with increased hearing loss prevalence) and
the creation of public policies for social security such as the ‘‘Seguro Popular’’. There are no
Mexican studies about hearing loss screening in adults.
The aim of this work was to assess a tone emission and a questionnaire as screening tools for
hearing loss in adults.
Methods: A sample size of 500 individuals without otology pathology from the outpatient clinics
at a general hospital. An otoscopy, 2 screening tests (tone emission and questionnaire) and tonal
audiometry were performed on all subjects.
Results: The questionnaire turned out to be a sensitive test but with low specificity, whilst the
tone emission was less sensitive but more specific with a higher rate of precision. In this study,
the best result was achieved by a combined strategy using the two tests above, with a precision
of 90%.
Conclusions: The best screening strategy proposed by this study for hearing loss in adults is
a questionnaire and tone emission test, which guarantees complete hearing assessment in
objective and subjective manners, performed quickly and without special training.
© 2012 Elsevier España, S.L. All rights reserved.
Pruebas de despistaje auditivo en adultos
Resumen
Introducción: La detección temprana de hipoacusia ha sido ampliamente estudiada en recién
nacidos gracias a las nuevas tecnologías en pruebas diagnósticas y tratamiento; existen
夽 Please cite this article as: Becerril-Ramírez Perla B., et al. Pruebas de despistaje auditivo en adultos. Otorrinolaringol Esp. 2012.
http://dx.doi.org/10.1016/j.otoeng.2013.06.001.
∗ Corresponding author.
E-mail address: [email protected] (P.B. Becerril-Ramírez).
2173-5735/$ – see front matter © 2012 Elsevier España, S.L. All rights reserved.
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Hearing Loss Screening Tests for Adults
Envejecimiento;
Despistaje
185
protocolos bien establecidos de despistaje universal en esta población. Sin embargo, en adultos, el despistaje auditivo es un tema que también cobra importancia debido al aumento en la
esperanza de vida, al cambio en la pirámide poblacional mexicana, que se estima que en los
siguientes 50 años se transformará hacia una forma rectangular (con un aumento en la prevalencia de presbiacusia), y al establecimiento de programas de protección social en salud como
el Seguro Popular. No se cuenta con investigaciones mexicanas sobre despistaje auditivo en
adultos.
El objetivo de este trabajo es evaluar una prueba de emisión tonal y un cuestionario como
estrategias de despistaje en adultos.
Métodos: Se tomó una muestra de 500 personas sin antecedente de patología otológica en la
consulta externa de un hospital general. Se realizó otoscopia, 2 pruebas de despistaje auditivo
(emisión tonal y cuestionario) y audiometría a todos los sujetos.
Resultados: El cuestionario es una prueba sensible pero poco específica, mientras que la prueba
de emisión de tono fue menos sensible pero más específica con tasa mayor de exactitud. La
mejor estrategia resultó la combinación de ambas pruebas que alcanzó una exactitud del 90%.
Conclusiones: Se propone como la mejor estrategia de despistaje en adultos un cuestionario y
una prueba de emisión tonal que garantiza de forma rápida, sin necesidad de entrenamiento
especial, una evaluación completa del estado de audición en lo objetivo y subjetivo.
© 2012 Elsevier España, S.L. Todos los derechos reservados.
Introduction
The decrease in hearing sensitivity or hypoacusis (hearing
loss) is defined by a hearing threshold (pure tone average
at 0.5, 1, 2 and 4 kHz) of 25 dB or more.1 The World Health
Organisation (WHO) defined disabling hearing weakness as a
permanent hearing threshold of 41 dB or more in the better
ear.2 Age-related hearing loss is known as presbycusis and
is the most common sensory deficit in older adults. It has
become a severe social and health problem. It is estimated
that 1 in 5 adults suffers a bilateral hearing problem that
affects their hearing and communication.1
In the United States, it is estimated that over 28 million people are affected, but a large number of cases go
undetected and therefore remain untreated, thus affecting productivity, functioning and quality of life for those
individuals.3 People who develop hearing impairments as
adults face different problems from those who grew up deaf,
since they must adjust to many new circumstances. From
the social and emotional standpoint, the onset of hearing
impairment in the life of a person with normal hearing represents a need for re-adaptation at the social, and in some
cases work, level. Nevertheless, it has been reported that
treatment can reverse depressive symptoms and social isolation and improve quality of life.4 The subtle and gradual
onset of hypoacusis, as well as the lack of visible symptoms
contribute to its underdiagnosis.5
Audiometry is the standard for evaluating hearing loss. It
is a behavioural study used to assess hearing sensitivity. This
measurement includes the central and peripheral auditory
systems. The pure tone threshold is defined as the softest
sound which a person can hear on 50% of the times it is presented. Hearing sensitivity is defined through a graph, called
an audiogram, which displays the intensity of the sound,
the decibels on the vertical axis (y), as a function of frequency, measured in Hertz, on the horizontal axis (x). This
study has a sensitivity of 96% and a specificity of 92%, and is
inexpensive and useful. Unfortunately, it cannot be considered as a screening test because it requires about 1 h to be
performed by a trained audiologist in a soundproofed cabin
and with specialised equipment.6
Screening tests for hearing loss should be precise and
practical. According to the WHO, screening procedures
should include: a short questionnaire, otoscopy and a
hearing test whose characteristics are known and proven.
Subjects in whom a hearing problem is detected should be
referred for a full otological and auditory evaluation.2
Two tests have shown accurate detection and have
been recommended as useful tools; one is hearing evaluation with an otoscope that emits tones, and the other
is a self-assessment questionnaire for hearing impairment.
Both studies can be performed quickly and without special
training.7
A positive test result for hearing loss is considered when
patients do not hear a tone of 40 dB at a frequency of 2000 Hz
in either ear. Screening through the questionnaire is performed with the validated Spanish version of the ‘‘Hearing
impairment inventory for the elderly’’, which consists of 10
questions measuring the degree of social and emotional disability caused by hearing loss. Its scores range from 0 (no
disability) to 20 (maximum disability). The questionnaire
can be completed within 5 min. Patients with scores over
10 are considered positive for hearing loss. These tools can
be complementary, since each identifies different aspects
of hypoacusis.6---10
In several developed countries, such as the United
Kingdom, United States and Canada, healthcare prevention organisations have recommended routine screening for
hearing loss in adults. The WHO has published guidelines
for the implementation of diagnostic strategies and hearing aid provision in developing countries, pointing to the
importance of programmes with a wide coverage, optimising
resources for diagnosis and treatment.2,11
The availability of precise and practical auditory
screening methods enables an early diagnosis of hearing
impairment which facilitates the referral of identified individuals for further evaluation or adequate intervention, as
appropriate.
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186
P.B. Becerril-Ramírez et al.
In addition to accuracy and practicality, there are other
criteria which justify the implementation of screening programmes. These include the fact that the impact of the
disease is significant enough to justify the screening effort.
In addition, there are treatments available for detected
cases and the natural history usually allows time for
intervention.12
In Mexico there are no studies assessing auditory
screening tests, which are becoming increasingly important due to the creation of social healthcare protection
programmes, such as the Seguro Popular (‘‘general insurance’’), which will require strategies that benefit the
greatest number of people, whilst optimising available
resources.
General Objective
• To determine the sensitivity and specificity of 3 auditory
screening tools (questionnaire, tone emission and both
tests together).
Specific Objectives
• To determine the number of subjects with hearing loss
identified through each of the tests.
• To determine differences between female and male gender in the outcome of the tests.
• To describe the results of the 3 tests in subjects with
comorbidities.
• To establish mean audiometric curves according to age
groups, for healthy subjects and for those with comorbidities.
Methods
Design
The current study was analytical observational, open,
prospective and transversal.
Sample Size
The sample size was calculated using the following formula:
n=
z 2 pq
B2
where z=1.96 for a 95% confidence interval; P=expected frequency; q=1−p; B=admitted error or precision.
The expected prevalence was 20%, with a 5% margin of
error and a 95% confidence level. The required sample size
was 246 subjects.
Selection Criteria
Inclusion Criteria
Patients or carers, aged between 40 and 75 years, who consulted at the outpatient clinic of a general hospital, with
no history of otological disease or any other disease interfering with the sense of hearing, who agreed to participate
in the study by signing the informed consent form and who
completed all the required tests.
Exclusion Criteria
We excluded those patients with ages outside the accepted
range or with a known history of otological pathology.
Elimination Criteria
We eliminated those subjects who did not complete the 3
evaluation tests (tone emission, questionnaire and audiometry).
Definition of Variables
• Hearing threshold: mean pure tone threshold at frequencies of 0.5, 1 and 2 kHz.
• Hearing loss by audiometry: hearing threshold greater
than 25 dB.
• Positive tone emission test for hearing loss: a tone of 40 dB
at 2 kHz is not perceived by one or both ears.
• Positive questionnaire for hearing loss: the sum of the
response scores is equal to or greater than 10.
• Comorbidities considered: systemic arterial hypertension, diabetes mellitus (DM), dyslipidemia and rheumatoid
arthritis.
• Speech audiometry: a test that aims to assess the ability
of a subject to understand language. It was considered
abnormal when 100% comprehension of words at 40 dB was
not reached.
Description of Procedures
1. At the outpatient consultation of the General Hospital,
we identified patients or caretakers who met the inclusion criteria and asked them to sign the informed consent
form.
2. We asked about the presence of previously diagnosed
comorbidities, of which we considered the following for
the study: arterial hypertension, type 2 DM, dyslipidemia
and rheumatoid arthritis.
3. We performed otoscopy to rule out the presence of
earwax blockages (which were removed, if present) or
otological pathology which, if detected, eliminated the
subject from the study.
4. We conducted a questionnaire on auditory weakness.
The tool used was the validated Spanish version of the
‘‘Hearing impairment inventory for the elderly’’,9 which
consists of 10 questions measuring the degree of social
and emotional disability caused by hearing loss. ‘‘Yes’’
responses were scored with 2 points, ‘‘Sometimes’’
responses with 1 point and ‘‘No’’ responses with 0 points.
Scores ranged from 0 (no disability) to 20 (maximum
disability). Patients with scores greater than 10 were
considered positive for hearing impairment (Annex 1).
5. We conducted a tone emission test. Subjects were given
headphones through which a 40 dB tone at a frequency
of 2 kHz was emitted independently for each ear. It was
considered a positive test for auditory weakness when
patients did not hear the tone.
6. Patients were referred to the Audiology Service to
undergo an audiometry, which is the gold standard for
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Hearing Loss Screening Tests for Adults
Table 1
187
Number of Subjects per Age Group.
Age group, Years
40---49
50---59
60---69
70---75
Table 3
Number of Subjects, %
150
292
234
124
(18.8)
(36.5)
(29.3)
(15.5)
the assessment of hearing sensitivity. It consists of a
pure tone threshold test (audiometry) and a speech discrimination test (speech audiometry). It takes place in a
soundproofed cabin and is conducted by an audiologist.
7. Subjects with hearing impairment confirmed by audiometry were referred for a complete ENT evaluation which
determined the best treatment according to each case.
We used the software package SPSS 10.0 to conduct the
statistical analysis. We calculated the basic measurements
(mean, standard deviation, and frequency) and odds ratio.
Results
Table 2
Characteristics
Females
(n=239)
Males
(n=161)
Mean age
58 years
Mean threshold right ear, dB
Mean threshold left ear, dB
Bilateral hypoacusis by audiometry
Abnormal speech audiometry
Positive questionnaire for hypoacusis
Mean score of the questionnaire
Positive tone test for hypoacusis
25.4
24.3
30%
20.2%
63.1%
11
21.3%
56.5
years
29.3
31
45%
32.9%
69.5%
12
37.5%
Table 4 Result of Tests Conducted on Subjects With and
Without the Studied Comorbidities.
Statistical Analysis
The study was completed over a period of 4 months (July to
October 2011) with 400 subjects who met the inclusion criteria. They underwent otoscopy, answered the questionnaire
and underwent the tone emission test and tone audiometry.
A total of 239 subjects were female and 161 were male.
Their mean age was 58.57 years (SD=9.68). Table 1 shows
the distribution by age groups.
The sensitivity, specificity and predictive values of the
tests are shown in Table 2. The combination of the questionnaire and the tone emission test as a single screening
strategy took into account a positive result for both tests.
The audiometry showed that 45% of subjects suffered unilateral hearing loss (n=360), whilst 36.7% suffered bilateral
hearing loss (n=147). In total, 40.5% of females and 51.5% of
males suffered unilateral hearing loss by audiometry. In the
speech audiometry test, 25.4% of subjects had an abnormal unilateral result (n=203). In the questionnaire, 65.8%
(n=526) of subjects were positive for hypoacusis. The tone
emission test identified 27.9% positive cases (n=223).
Table 3 shows the characteristics studied in subjects
divided by gender. Males were more affected in all tests.
In total, 29% of subjects (n=116) presented some of
the comorbidities studied. In this group, 55% of subjects
presented hearing loss according to their hearing threshold and 34.9% presented a unilateral, abnormal speech
audiometry. In addition, 69.8% of subjects presented
Result of Tests Conducted According to Gender.
Characteristics
Without
comorbidities
(n=284)
With
comorbidities
(n=116)
Mean age
Mean threshold right ear,
dB
Mean threshold left ear,
dB
Bilateral hypoacusis by
audiometry
Abnormal speech
audiometry
Positive questionnaire for
hypoacusis
Mean score of the
questionnaire
Positive tone test for
hypoacusis
57.3 years
26.2
61.4 years
29
24.3
30.3
32%
48.2%
21%
34.9%
64%
69.8%
11
12.36
28.8%
25.4%
positive questionnaires for hearing loss, and 25.4%
presented positive tone emission tests. Table 4 shows
the results of tests comparing those subjects who
reported any of the comorbidities studied against
those who did not have this variable. In all tests,
except for the tone emission test, subjects with
comorbidities had a higher percentage of positive
cases for hypoacusis and presented worse hearing
thresholds.
Graph 1 shows the mean audiometric graphs for each
age group in subjects without comorbidities. Graph 2 shows
subjects with comorbidities.
Sensitivity and Specificity of Screening Tests.
Questionnaire
Tone emission
Combined test (both positive)
Sensitivity
Specificity
Accuracy
PPV
NPV
80
68
88
58
78
75
66
71
82
50
89
80
85
49
85
NPV, negative predictive value; PPV, positive predictive value.
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188
P.B. Becerril-Ramírez et al.
Graph 1 Mean audiometric graphs of subjects without comorbidities, divided by age group.
Group 1: 40---49 years; group 2: 50---59 years; group 3: 60---69
years; group 4: 70---75 years.
(sensitivity) and exclude those who are not (specificity).
The more sensitive a screening method is, the more it
increases the likelihood of false positives. Therefore, there
is an inherent and inevitable equilibrium between sensitivity and specificity. The objective of a screening programme
is an approach that allows this exchange to be managed.
In our study, the questionnaire showed good sensitivity but
low specificity, whereas the tone emission test showed low
sensitivity but good specificity. However, by combining the
positive results of both tests we obtained the best result,
with a sensitivity of 88% and a specificity of 75%, as well as
an accuracy of 82%. This strategy enables a comprehensive
assessment of the objective and subjective hearing condition of individuals in a quick manner which does not require
special training. It also makes it possible to identify individuals who could benefit from treatment to reverse the impact
of hearing loss in communication, quality of life and in the
workplace.
Discussion
Prevalence of Hypoacusis Among Adults
Sensitivity and Specificity of Screening Tests
The prevalence of hearing loss among adults is considerable.
According to the WHO, an estimated 413 million people globally suffer a slight hearing loss, 187 million suffer a moderate
loss and 46 million suffer a severe to profound loss.14
Studies conducted in the United Kingdom reported that
approximately 20% of adults suffered a hearing problem
which affected their communication.15 The incidence in our
sample was higher, with 45% of subjects presenting unilateral hypoacusis and 36.7% bilateral hypoacusis. These figures
alert us about the need to implement diagnostic tools that
can identify a significant, potentially affected fraction of
the population which would otherwise remain underdiagnosed and suffer a delay of approximately 10---15 years in the
establishment of a treatment, which could, in turn, become
increasingly complex and less effective.12
db
Hz
500
1
2
4
8
0
10
4
20
3
30
2
40
1
50
60
70
There have been several studies evaluating various hearing screening tests. Gates et al. compared the full hearing
disability questionnaire vs performing a single overall question and the combination of both as a screening test. They
found that the full questionnaire had a sensitivity of 35%
and a specificity of 94%. The overall question had a sensitivity of 71% and specificity of 71%. Combining both tests
failed to improve the sensitivity of the questionnaire and
the specificity of the overall question. In their conclusions
they recommend the use of the overall question as part of
the initial clinical history of elderly patients.13
In a screening study conducted with veterans, Yueh et al.
mentioned a sensitivity of 63%---80% and a specificity of
67%---77% for the questionnaire, and a sensitivity of 94% and
a specificity of 69%---80% for the tone emission test. They
also mentioned that there are no data available on the use
of both tests in combination.12
Conducting a screening for any disorder attempts
to increase the likelihood of identifying those affected
dB
Hz
500
1
2
4
8
0
10
20
4
30
3
40
2
50
1
60
Differences Between Females and Males
In a study using screening tests and audiometry to detect
hypoacusis, Gates et al. reported that males met the criteria for hearing loss in 35% of cases, whereas females did
so in 22%.13 In our study, males presented hearing loss by
threshold in 51.5% of cases, compared to females in 40.5%.
After conducting a study with 224 subjects, Sharashenidze et al. reported that males presented age-related
hypoacusis at earlier ages than females, and that their loss
progressed more quickly than that of females. They also
mentioned that, for all decades studied, females presented
better hearing than males and that these differences may
reflect different dynamics in the onset of age-related hearing loss.16
This trend towards a more severe involvement among
males was also observed in our study. Males presented a
higher prevalence of hearing loss in all our tests.
70
Graph 2 Mean audiometric graphs of subjects with comorbidities, divided by age group.
Group 1: 40---49 years; group 2: 50---59 years; group 3: 60---69
years; group 4: 70---75 years.
Comorbidities
Agrawal et al. conducted a study on the association between
cardiovascular risk and hearing level at specific frequencies
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Hearing Loss Screening Tests for Adults
and found a difference with worse hearing levels among subjects with DM and hypertension. Diabetes doubled the risk
of suffering hypoacusis.17
Uchida et al. found an adverse effect of DM on hearing.
This effect varied according to age at high frequencies.18
Huang and Tang reported that several medical conditions, some related to age, could be determining factors for
hearing loss (cardiovascular risk, metabolic diseases, DM).
Nevertheless, they also stated that more research focused
on this field was needed.19
In our study, subjects with comorbidities showed a higher
prevalence of hearing loss in all tests, except for the tone
emission test, as well as a worse hearing threshold at
different frequencies. It is probable that, in this group,
audiometric curves are affected at younger ages and are
influenced by the duration and effectiveness of the treatment for the underlying disease.
In the light of these results, we consider that suffering any of the studied comorbidities (DM, systemic arterial
hypertension, dyslipidemia and rheumatoid arthritis) places
subjects at an increased risk of hearing loss. In this group
it is especially relevant to consider a screening test which
identifies hearing impairment from the time of diagnosis and
which is part of a comprehensive monitoring.
The mean audiometric charts represent a reference of
the threshold expected for each age group. Schuknecht proposed 4 types of presbycusis after studying the audiograms
and histopathology of elderly patients. In his classification,
type 1 referred to a sensory hypoacusis with a loss of external ciliated cells which is reflected by an audiometry with
a sharp drop at high frequencies, below the frequencies of
speech (0.5, 1, and 2 kHz).20 The audiometric pattern was
the same as that observed in our sample in all age groups
and in subjects with and without comorbidities.
Conclusions
• Based on the results of this study, we recommend a combination of the questionnaire and the tone emission test
as the best screening strategy.
• Our population suffered a higher prevalence of hearing
loss than that reported in the literature.
• Males presented a higher frequency of hearing loss in all
tests conducted.
• Subjects with presence of any of the studied comorbidities
presented a higher frequency of hearing loss in all tests
(except tone emission) compared with those who did not
have this factor. Therefore, in this group it is especially
important to consider a hearing screening test as a routine
test at the time of initial diagnosis.
• Early identification of hearing loss is important to minimise the impact on the daily lives of subjects, both of
working age and older adults.
• Social healthcare protection programmes can benefit
from this study, as it proposes a strategy for a simple,
fast, reliable and inexpensive method to identify subjects
suffering hypoacusis.
Conflict of Interests
The authors have no conflict of interests to declare.
189
Annex 1. Questionnaire on Hearing
Impairment
Question
Yes
Sometimes
No
Score
Have you noticed that you
need people to repeat things
because you do not manage to
hear them properly?
For that reason, have you at
some point answered
something different from what
you were being asked?
Further, have you felt
uncomfortable because you
had to ask to have things
repeated to you several times?
Have you noticed that you have
trouble hearing a conversation
when you are in a restaurant or
in other noisy places?
Do you experience difficulty
understanding words when
several people speak to you at
the same time?
Do you find it difficult to
understand words when people
whisper?
Do you find it difficult to
understand the radio or
television at the intensity
which other people normally
set?
Have you noticed that you do
not manage to hear everything
you are told when you are in
the theatre, in a conference or
in church?
Do you have trouble hearing
when you speak on the
telephone?
Have you noticed that loud
noises make you more
uncomfortable than before?
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