Identification of Hearing Loss & Middle-Ear Dysfunction in Preschool & School-Age Children
The American Academy of Audiology believes it is important to identify children with undetected sensorineural hearing loss as well as those with hearing loss resulting from middle ear dysfunction and chronic or recurrent otitis media with effusion (OME). The selection and implementation of a screening protocol must be guided by the specific goals of an identification program. The most appropriate screening protocol will differ based on the target population, available personnel and various features unique to each program. It is the responsibility of the audiologist, in consultation with local health care providers, speech-language pathologists, and others to whom referrals will be made, to determine the most appropriate and cost-effective screening and referral criteria. The American Academy of Audiology recommends several considerations in the design, implementation, and evaluation of a program for the identification of children with hearing loss and/or middle ear dysfunction. These recommendations pertain to preschool-age children (3-4 year olds), school-age children at the early elementary grade levels, and children with developmental delays or disabilities.
Personnel, Supervision, & AdministrationSupervision and administration of the screening program must occur under the direction of an audiologist. The audiologist assumes responsibility for the selection and calibration of screening instruments, design and evaluation of the screening protocol, assessment of ambient noise conditions, training of personnel, and coordination of referral and follow-up. Screening personnel may include speech-language pathologists, volunteers, support personnel, or health care workers employed in the setting where screening is performed; however, hearing screening for children who are uncooperative or otherwise difficult to test should be performed by an audiologist.
Identification of Hearing Loss in Preschool & School-Age ChildrenAll children should be screened for hearing loss at least once during the preschool years. In addition, hearing screening should always occur when hearing loss is suspected by parents or caretakers. Hearing loss should also be ruled out whenever a child is being considered for special education services, regardless of whether a hearing loss is suspected. Individually administered, manual pure tone screening with an audiometer is currently the preferred method of screening for hearing loss in typically developing preschool and school-age children. For conventional pure tone screening in a suitable acoustic environment (ANSI S3.1, 1991), a screening level of 20dB HL at 1000, 2000 and 4000 HL is recommended. A pass requires detection of pure tone stimuli at all three frequencies in both ears.
Identification of Middle Ear Dysfunction in Preschool & School-Age ChildrenOtitis Media with effusion is highly prevalent in your children; however, certain groups are at increase risk for OME. Because of the high prevalent of undetected OME in the preschool years, middle ear screening should routinely accompany pure tone screening. However, it is particularly important to include middle ear measures when screening groups at increased risk for OME and/or those more likely to suffer harmful developmental sequelae from the conductive hearing loss that usually accompanies OME. Groups at increased risk include children with developmental delays, including learning disabilities; children with delays in speech and language development; children with known sensorineural hearing loss; children who fail pure tone screening; children with craniofacial anomalies, including cleft lip/palate and Down syndrome; children of Native American heritage; children with known histories of chronic or recurrent OME, and children in group day care.
Aural acoustic immittance measures are well-suited for middle ear screening. Instrumentation and recording should be in compliance with ANSI standards (ANSI S3.39, 1987). Otoscopic inspection should occur prior to tympanometry to identify obstruction of the ear canal, the presence of tympanostomy tubes, or any obvious signs of external or middle ear disease. Tympanometric measures should employ a low frequency probe tone (e.g., 226 HL) and include peak compensated static admittance (Peak Y) for identification of middle ear effusion. Large ear canal volume in the presence of a "flat" tympanogram suggests tympanic membrane perforation. However, normal equivalent volume may occur in patients with perforation and active middle ear disease and thus does not rule out tympanic membrane perforation. Measures of tympanometric with may improve the sensitivity of middle ear screening; however, in some populations there is like to be significant overlap with static admitance. Because the acoustic reflex is likely to be absent in the presence of middle ear effusion, screening for presence/absence of the acoustic reflex may reduce the number of flase positive medical referrals associated with "wide" tympanograms accompanied by normal static admittance. However, inclusion of the acoustic reflex in a first-tier screening protocol using currently available instrumentation for screening should be undertaken cautiously, based on the low specificity reported by several investigators.
Specific pass/fail criteria must be designed and carefully evaluated by each program. A reasonable balance between sensitivity and specificity will most likely be achieved by applying normative data obtained from study samples having age and other population characteristics similar to those of the group targeted for screening. In general, children between the ages of 3-7 years without significant history of middle ear disease will have static admittance >0.2 mmho and tynpanometric with <150 daPa; however, younger children and those with histories of middle ear disease may exhibit wider tympanograms (up to 250 daPa) even in the absence of middle ear effusion. Thus, children who exhibit static admittance <0.2 mmho and/or tympanometric with >250 daPa should be identified for re-screening. Immediate medical referral is recommended for children who present with ear pain, otorrhea, signs of external ear disease, or flat tympanograms with ear canal volume estimates >1.0cm3 (in the absence of tympanostomy tubes). For children who do not require immediate medical referral, the re-screening interval will vary based on circumstances unique to each program; however, an interval of 4-6 weeks will generally identify children most likely to have persistent conditions. Those who exhibit abnormal static admittance and/or abnormal tympanometric width on re-screening should be referred to a physician for determination of need for medical management. Whenever feasible, those who pass on re-screening should be identified as "high risk" and evaluated after another interval. If static admittance and/or tympanometric width are again abnormal, a medical referral is warranted.
Audiologic Follow-UpChildren identified by either a pure tone screening program or an acoustic immittance screening program are at increased risk for sensorineural and/or conductive hearing loss. These children should be seen for evaluation by an audiologist. Audiologic evaluation typically includes pure tone and speech audiometry as well as a battery of acoustic immittance measures.
When medical referral is made because of suspected OME, re-screening and/or audiologic evaluation should be provided upon completion of medical intervention to insure that hearing loss and/or middle ear dysfunction has resolved. Children with sensorineural hearing loss will need acoustic amplification and/or assistive devices requiring the audiologist to initiate and coordinate a plan for fitting and follow-up. Appropriate accommodations such as sound field amplification should also be considered for children with chronic hearing loss due to unresolved OME.
Referral to Other ProfessionalsChildren requiring medical evaluation should be referred to their pediatrician or family practice physician. Referral to an otolaryngologist is recommended for children with newly identified sensorineural hearing loss, persistent or recurrent otitis media lasting more that three months, or ear canal volume estimates suggesting tympanic membrane perforation.
Audiologists should be familiar with the milestones of normal speech/language development and are strongly encouraged to review the child's communication history with parents and/or caretakers. Children exhibiting evidence of speech-language delays, either through direct observation, use of developmental screening measures, or from parental report, should be referred to a speech-language pathologist. Children with sensorineural hearing loss who are not already receiving intervention services should be referred for a multidisciplinary team evaluation, as required by the Individuals with Disabilities Education Act, for evaluation and determination of need for special services.
SummaryIt is the position of the American Academy of Audiology that children with undetected hearing loss and/or persistent or recurrent middle ear disease should be identified so that appropriate audiologic and medical management can be provided. The Academy believes that a carefully designed identification program, carried out under the supervision of an audiologist and tailored to the specific needs of each setting and target population, promotes good health and improved developmental outcomes for young children.
ReferencesAmerican National Standards Institute (1987). Specifications for instruments to measure aural acoustic impedance and admittance (aural acoustic immittance) (ANSI S3.39–1987), New York ANSI.
American National Standards Institute (1991). Criteria for permissible ambient noise during audiometric testing (ANSI S3.1–1991), New York ANSI.
Berry, Q.C., Andrus, W.S., Bluestone, C.D., & Cantekin, E.I. (1975). Tympanometric pattern classification in relation to middle-ear effusions. Annals of Otology, 84,56–64.
Bluestone, C.D., Fria, T.J., Arjona, S.K., Casselbrant, M.L., Schwartz, D.M., Ruben, R.J., Gateo, G.A., Downs, M.P., Northern, J.L., Jerger, J.F. (1986). Controversies in screening for middle ear disease and hearing loss in children. Pediatrics 77: 57–70.
Boothroyd, A. (1982). Hearing impairments in young children. Englewood Cliffs, NJ: Prentice-Hall.
Cantekin, E.I., Bluestone, C.D., Fria, T.J., Stool, S.E., Berry Q.C., & Sabo, D.L. (1980). Identification of otitis media with effusion in children. Annals of Otology, Rhinology and Laryngology, 89, (Suppl. 68), 190–195.
Cantekin, E.I., Doyle, W.J., Phillips, D.C., & Bluestone, C.D. (1980). Gas absorption in the middle ear. Annals of Otology, Rhinology and Laryngology, 89, (Suppl. 68) 71–75.
Daly, K. (1991). Epidemiology of otitis media. Otolaryngol Clin N Am, 24, 775–786.
Decreten, S.J., Hanssens, K. & De Sloovere, M. (1991). Evoked otoacoustic emissions in infant hearing screening. Int. J Ped Otorhino, 21, 235–247.
Feightner, J.W., (1992). Screening in the 1990s: Some principles and guidelines. In F.H. Bess & J.W. Hall (eds.), Screening Children for Auditory Function (Chapter 1, pp. 1–16). Nashville: Bill Wilkerson Center Press.
Fiellau-Nikolajsen, M. (1983). Tympanometry and secretory otitis media. ACTA Otolaryngologica, (Stockholm) Suppl. 394, 1–73.
Finitzo, T., Friel-Patti, S., Chinn, K., & Brown, O. (1992). Tympanometry and otoscopy prior to myringotomy: Issues in diagnosis of otitis media. International Journal of Pediatric Otorhinolaryngology, 24, 101–110.
Fria, T., Cantekin, E., & Eichler, J.A. (1985). Hearing acuity of children with otitis media with effusion. Archives of Otolaryngology, 111: 10–16.
Friel-Patti, S. & Finitzo, T. (1990). Language learning in a prospectivestudy of otitis media with effusion in the first two years of life. J Speech Hear Research 33: 188–194.
Gravel, J.S., & Ellis, M.A. (1995). The auditory consequences of ototis media with effusions: the audiogram and beyond. Seminars in Hearing, 16(1), 44-59.
Gravel, J.S. & Wallace, I.F. (1992). Listening and language at four yers of age: Effects of early otitis media. Journal of Speech and Hearing Research, 35(3), 588–595.
Hall, J.W. & Grose, J.H. (1993). The effects of otitis media with effusion on the masking-level difference and the auditory brainstem response. Journal of Speech and Hearing Research, 36, 210–217.
Hall, J.W., Grose, J.H. & Pillsbury, H.C. (1990). Predicting binaural hearing after stapedectomy from presurgery results. Archives of Otolaryngology, 116, 946–950.
Haughton, P.M. (1977). Validity of tympanometry for middle ear effusions. Archives of Otolaryngology, 103 (9), 503–513.
Hosford-Dunn, H., Johnson, S., Simmons, F.B., Malachowski, N., & Low, K. (1987). Infant hearing screening: Program implementation and validation. Ear and Hearing, 8:1, 12–20.
Individuals with Disabilities Education Act (P.L., 100-476), 20 U.S.C. Secs. 1400–1485 (1990).
Karzon, R.G. (1991). Validity and reliability of tympanometric measures for pediatric patients. Journal of Speech and Hearing Research, 34 (2), 386–390.
Klein, J.O. (1978). Epidemiology of otitis media. In E.R. Hanford, F.H. Bess, C.D. Bluestone, & J.O. Klein (Eds.), Impedance screening for middle ear disease in children, pp. 11–16. New York: Grune & Stratton.
Koebsell, K.A., & Margolis, R.H. (1986). Tympanometric gradient measured from normal preschool children. Audiology, 25 (3), 149–157.
Levitt, H., McGarr, N. & Geffner, D., (Eds). (1987). Development of language and communication skill in hearing-impaired children. ASHA Monograph, No. 26, Washington, DC: American Speech-Language-Hearing Association.
Lous, J. (1983). Three impedance screening programs on a cohort of seven-year-old children. Scandinavian Audiology, Suppl. 17, 60–64.
Lucker, J.R. (1980). Application of pass-fail criteria to middle ear screening results. ASHA, 22 (10), 839–840.
Mencher, G.T., & McCulloch, B.F. (1970). Auditory screening of kindergarten children using the VASC. Journal of Speech and Hearing Disorders, 35 (3), 241–247.
NIH Consenus Statement, Early Identification of Hearing Impairment in Infants and Young Children, Volume 11, No. 1, March 1–3, 1–24, 1993.
Northern, J.L., & Downs, M.P. (1991). Hearing in Children (4th Edition). Baltimore, MD: Williams and Wilkins Co.
Nozza, R.J. (1995). Critical issues in acoustic immittance screening for middle-ear effusion. Seminars in Hearing, 16 (1), 86–98.
Nozza, R.J., Bluestone, C.D., Kardatzke, D. (1992a). Sensitivity, specificity, and predictive values of immittance measures in the identification of middle-ear effusion. In F.H. Bess & J.W. Hall (Eds.), Screening Children for Auditory Function (pp. 315–329), Nashville: Bill Wilkerson Press.
Nozza, R.J. Bluestone, C.D., Kardatzke, D., Bachman R. (1992b). Towards the validation of aural acoustic immittance measures for diagnosis of middle-ear effusion in children. Ear and Hearing, 13 (6), 442–453.
Nozza, R.J., Bluestone, C.D., Kardatzke, D., & Bachman, R. (1994). Identification of Middle Ear Effusion by Aural Acoustic Admittance and Otoscopy. Ear and Hearing, 15 (4), 310–323.
Nozza, R.J., & Sabo, D.L. (1992). Transiently evoked otacoustic emissions for screening school-age children. The Hearing Journal, 45 (11), 29–31.
Paradise, J.L., Smith, C.G., & Bluestone, C.D. (1976). Tympanometric detection of middle ear effusion in infants and young children. Pediatrics, 58, 198–210.
Roberts, J.E., Sanyal, M.A., Buchinal, M.R., Collier, A.M., Ramsey, C.T., & Henderson, F.W. (1986). Otitis media in early childhood and its relationship to later verbal and academic performance. Pediatrics, 78 (3): 423–430.
Roberts, J.E., Buchinal, M.R., Collier, A.M., Ramsey, C.T., Koch, M.A., & Henderson F.W. (1989). Otitis media in early childhood and cognitive, academic, and classroom performance of the school-aged child. Pediatrics, 83 (4), 477–485.
Roberts, J.E., Buchinal, M.R., Medley, L.P., Zeisel, S.A., Munday, M., Roush, J., Hopper, S., Bryant, D., & Henderson, F.W. (1995). Otitis media, hearing sensitivity, and maternal responsiveness in relation to language during infancy. Journal of Pediatrics, 126 (3), 481–489.
Ross, M., Brackett, D., & Maxon, A. (1991). Assessment and Management of Mainstreamed Hearing-Impaired Children, Austin, TX: Pro-Ed.
Roush, J., & Tait, C.A. (1985). Pure-tone and acoustic immittance screening of pre-school aged children: An examination of referral criteria. Ear and Hearing, 6 (5), 245–250.
Roush, J., Drake, A., & Sexton, J.E. (1992). Identification of middle ear dysfunction in yound children: A comparison of tympanometric screening procedures. Ear and Hearing, 13 (2), 63–69.
Roush, J., Bryant, K., Mundy, M., Zeisel, S., & Roberts, J. (1995). Developmental changes in static admittance and tympanometric width in infants and toddlers. Journal of the American Academy of Audiology, 6 (4), 334–338.
Schappert, S.M. (1992). Office visits for otitis media: United States, 1975-1990. Advance data from vital and health statistics, No. 214, Hyattsville, MD: National Centers for Health Statistics.
Sells, J., Hurley, R., Morehouse, C.R., & Douglas, J. (1997). Validity of the ipsilateral acoustic reflex as a screening parameter. Journal of the American Academy of Audiology, 8: 132–136.
Shanks, J.E., Stelmachowica, P.G., Beauchaine, K.L., & Schulte, L. (1992). Equivalent ear canal volumes in children pre-and post-tympanostomy tube insertion. Journal of Speech and Hearing Research, 35 (4), 936–941.
Silman, S., & Emmer, M.B. (1995). Ipsilateral acoustic reflex in middle-ear effusion. Seminars in Hearing, 16 (1), 80–85.
Silman, S., Silverman, C.A., & Arick, D.S. (1992). Acoustic immittance screening for detection of middle-ear effusion in children. Journal of the American Academy of Audiology, 3 (4), 262–268.
Silva, P.A., Kirkland, C., Simpson, A., Stewart, L.A., & Williams, S.M. (1982). Some development and behavioral problems associated with bilateral otitis media with effusion. Journal of Learning Disabilities, 15 (7), 417–421.
Simmons, F.B. (1978). Identification of hearing loss in infants and young children. Otolaryngologic Clinics of North America, 11: 19–28.
Utech-Smith, P., Wiley, T., & Pyle, M. (1993). Efficacy of ASHA guidelines for screening middle-ear function. ASHA, 35 (10), 114.
Stein, L.K., Jabaley, T., Spitz, R., Stoakley, D., & McGee, T. (1990). The hearing-impaired infant: Patterns of identification and rehabilitation revisited. Ear and Hearing, 11 (3), 201–205.
Stool, S.E., Berg, A.O., Berman, S., Carney, C.J., Cooley, J.R., Culpapper, L., Eavey, R.D., Feagsns, L.V., Vinitzo, T., & Friedman, E.M., et al. Otitis Media with Effusion in Young Children. Clinical Practice Guideline, Number 12. AHCPR Publication No. 94-0622, Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services, July, 1994.
Teele, D.W., Klein, J.O., & Rosner, B.A., and the Greater Boston Otitis Media Study Group (1989). Epidemiology of otitis media during the first seven years of life in children in greater Boston: A prospective cohort study. Journal of Infectious Diseases, 160 (1), 83–94.
Van Cauwenberge, P.B., Vinck, B.M., De Vel, E., & Dhooge, I. Tympanometry and click evoked otoacoustic emissions in secretory otitis media: Are C-EOAE really consistently absent in type B tympanograms? Sixth International Symposium on Recent Advance in Otitis Media, June, 1995, Ft. Lauderdale, FL.
Vecchio, T.J. (1996). Predictive value of a single diagnostic test in unselected populations. New England Journal of Medicine, 274: 1171–1173.
Wachtendort, C.A., Lopez, L.L., Cooper, J.C., Hearn, E.M., & Gates, G.A. (1984). The efficacy of school screening for otitis media. In D.J. Lim, C.D. Bluestone, J.O. Klein & J.D. Newlson (Eds). Recent advances in otitis media with effusion (pp. 242–246), Philadelphia: B.C. Becker.
Watkin, P., Baldwin, M., & Laoide, S. (1990). Parental suspicion and identification of hearing impairment. Archives of Disease in Childhood, 65 (8), 846–850.
Wiley, T.L., & Utech-Smith, P. (1995). Acoustic-immitance measures and middle-ear screening. Seminars in Hearing, 16 (1), 60–80.
Wright, P.F., Sell, S.H., McConnell, K.B., Sitton, A.B., Thompson, J., Vaughn, W.K., & Bess, F.H. (1988). Impact of recurrent otitis media on middle-ear function, hearing, and language. Journal of Pediatrics, 113, 581–587.
Yoshinaga-Itano, C. (1995). Universal hearing screening for infants: simple, risk-free, beneficial, and justified. Audiology Today, 7 (1), 13.