Hearing screening in the newborn intensive care nursery: Comparison of methods

Patients in the neonatal intensive care unit were tested by hearing screening tests including auditory brain stem response (ABR), transient and distortion-product otoacoustic emissions (TEOAEs and DPOAEs), and acoustic stapedius reflex (ASR), and by middle ear function tests including multifrequency tympanometry and pneumatic otoscopy. Pass rates on hearing tests were 75% to 89%. TEOAEs produced the lowest pass rate, and DPOAEs the highest. TEOAE, DPOAE, or ASR testing followed by ABR testing of initial failures produced pass rates of about 90%. The most efficient combination was DPOAEs followed by ABR. Pass rates tended to decrease with age. Of patients who failed 226-Hz and 678-Hz tympanometry, 30% to 67% passed hearing tests, suggesting a high false-positive rate for these immittance tests. The 3 ears that failed the 1000-Hz tympanogram failed all hearing tests. Many ears were abnormal by pneumatic otoscopy but passed hearing tests, suggesting that the usual ear examination criteria may not apply to infants.     

Changes in otoacoustic emissions and auditory brain stem response after cis-platinum exposure in gerbils

Ototoxicity associated with cis -platinum administration commonly presents as hearing loss and tinnitus. The hearing loss is usually an irreversible, high-frequency sensorineural loss. Histologic studies in humans and animals suggest that the outer hair cells (OHCs) are most susceptible to cis -platinum. Evoked otoacoustic emissions (EOAE), as a measure of outer hair cell function, are potentially useful in following ototoxic insults involving OHCs. Distortion-product otoacoustic emission (DPOAE) test frequency-specific regions of the cochlea and therefore may be particularly well suited for monitoring ototoxic injuries. We measured distortion product otoacoustic emissions, at f2 = 2, 4, 6, 8, 10, and 12 kHz, in gerbils after a single large dose of cis -platinum. Animals treated with saline served as controls. The findings were compared to auditory brain stem evoked response (ABR) thresholds, using tone pipe of the same frequencies. The DPOAE and ABR thresholds were measured before treatment and again 2, 5, and 14 days after drug administration. The changes in DPOAE were compared with the changes in ABR. No treatment effect was noted in the 2-day group. Animals treated with cis -platinum demonstrated significant elevation of DPOAE and ABR thresholds compared with control animals at 5 and 14 days. There was no significant difference between the threshold changes in the 5-and 14-day groups. (Otolaryngol Head Neck Surg 1997; 116:585-92.)     

Hearing disorders screening in neonates at risk

The present report concerns a three year, eight month hearing screening in 1 531 high-risk neonates by means of two successive transient evoked otoacoustic emissions (TEOAE) recordings followed, cin cases of suspected hearing loss, by brainstem auditory evoked potential (BAEP) recording and otolaryngology (ORL) consultation. After TEOAE1 and 2 and BAEP testing, 1 361 infants (88.9%) were declared normal, and 170 (11%) suspected of hearing loss. Of these 170, 58 showed bilateral and 26 unilateral impairment. Definite hearing loss on ORL consultation was diagnosed in 14 infants (0.9% of the screened population as a whole); 22 are still followed, while 86 (5.6%) failed to consult for diagnosis. The mean age on diagnosis of definite hearing loss on ORL consultation was 9.9 +/- 4.9 (range 4-20) months. Several auditory function risk factors have been proved to be more frequent in deaf than in normal children. Our results show that early hearing loss screening in at-risk neonates needs to be pursued.     

Cost and cost-effectiveness of universal screening for hearing loss in newborns.

OBJECTIVE: To estimate the cost and cost-effectiveness of universal newborn hearing screening. STUDY DESIGN AND SETTING: Decision analysis model utilizing the hospital perspective. This model evaluated 4 distinct protocols for screening a fixed and defined hypothetical cohort of newborn infants. OUTCOME MEASURES: Cost of screening and the number of infants with hearing loss identified through universal screening. RESULTS: Otoacoustic emissions testing at birth followed by repeat testing at follow up demonstrated the lowest cost ($13 per infant) and had the lowest cost-effectiveness ratio ($5100 per infant with hearing loss identified). Screening auditory brainstem evoked response testing at birth with no screening test at follow-up was the only protocol with greater effectiveness, but it also demonstrated the highest cost ($25 per infant) and highest cost-effectiveness ratio ($9500 per infant with hearing loss identified). These findings were robust to sensitivity analysis, including best-case and worst-case estimation. The prevalence of hearing loss and the fraction of infants returned for follow-up testing had a large impact on the absolute level, but not relative level of protocol cost and cost-effectiveness. CONCLUSION: The otoacoustic emissions testing protocol should be selected by screening programs concerned with cost and cost-effectiveness, although there are certain caveats to consider. SIGNIFICANCE: The most significant barriers to implementation of universal newborn hearing screening programs have been financial, and this study compares the most common protocols currently in use. This study can assist program directors not only in the decision to initiate universal screening but also in their choice of screening protocol.     

Absence of sensorineural hearing loss in treated infants and children with congenital toxoplasmosis.

Educationally significant hearing loss has been reported in 10% to 15% of children with congenital toxoplasmosis. As part of a pilot study to assess feasibility and safety of prolonged therapy for congenital toxoplasmosis, 30 congenitally infected infants and children were evaluated for auditory function. Serial testing, beginning within 2 months of birth, was performed. Availability of auditory brainstem response (ABR) testing made evaluation at an earlier age than previously possible. Six (20%) of the 30 infants had mild to moderate conductive type hearing loss associated with otitis media. No infant or child had sensorineural hearing loss. The better outcome we observed compared to previous reports of a 15% to 26% incidence of sensorineural hearing loss and 10% to 15% incidence of educationally significant, bilateral hearing impairment may be related to early initiation and/or prolonged institution of antimicrobial therapy. Continued followup to exclude progressive hearing impairment and study of larger numbers of children are needed to verify these preliminary findings.     

Etiology and one-year follow-up results of hearing loss identified by screening of newborn hearing in Japan

Objective

To evaluate the incidence of newborn hearing loss in a Japanese population and to elucidate etiological factors and one-year prognosis.

Study Design

Screening of newborn hearing.

Setting

Children's tertiary referral center.

Subjects and Methods

Between 1999 and 2008, 101,912 newborn infants were screened, with 693 infants (0.68%) referred. Etiology investigation included CT, detection of cytomegalovirus (CMV) DNA, and connexin 26 mutation.

Results

Abnormal results (auditory brainstem response [ABR] threshold ≥ 35 normal hearing level [dB nHL] in either side) were observed in 312 infants (0.31%), and 133 subjects (0.13%) with ABR thresholds ≥ 50 dB nHL on both sides were classified into the habilitation group. In this group, inner ear/internal auditory meatus anomalies were detected in 20 of 121 subjects (17%) tested, middle/external ear anomalies in 14 of 121 subjects (12%), CMV DNA in 13 of 77 subjects (17%), and connexin 26 mutation in 28 of 89 subjects (31%). In 68 subjects undergoing all three investigations (CT, CMV, and connexin 26), 41 (60%) had positive results in at least one test. With inclusion of otitis media with effusion and perinatal problems, this rate amounted to 78% (53 subjects). Of the 97 infants in the habilitation group successfully followed up to one year, 36 (37%) showed a threshold change of 20 dB or more in either ear: 11 (11%) progression and 25 (26%) improvement, and 15 infants (15%) were reclassified into a less severe classification.

Conclusion

Considering that 26 percent of infants with bilateral moderate to severe hearing loss showed improvement in one year, habilitation protocols, especially very early cochlear implantation within one year of birth, should be reconsidered.     

Usefulness of 1000 Hz tone-burst-evoked responses in the diagnosis of acoustic neuroma

The auditory brain stem response (ABR) has become widely recognized as a sensitive and cost-effective screening modality in neuro-otologic diagnosis. However, the audiometric characteristics of the test ear may obscure the interpretation of the click-evoked ABR, particularly in the face of high-frequency hearing loss. It is often unclear whether latency delays or absent responses are attributable to retrocochlear disease or simply to the magnitude of the patient's hearing loss. The acoustic click stimulus commonly used in ABR testing activates predominantly the basilar membrane in the 2000 to 4000 Hz range. Because many cochlear and retrocochlear processes are associated mainly with hearing loss in this range, we have found it helpful in selected cases to use 1000 Hz tone-burst stimuli to circumvent the effects of elevated hearing thresholds on the ABR. In this article, our experience with the use of 1000 Hz nonlinearly gated tonebursts in 17 patients with acoustic neuroma is presented.     

Neonatal hearing screening with otoscopy, auditory brain stem response, and otoacoustic emissions

A study was performed to investigate the relationship between external and middle ear factors and hearing screening results by auditory brain stem response (ABR) and transient evoked otoacoustic emissions (EOAEs). The ears of 200 well newborns aged 5 hours to 48 hours underwent screening by ABR and EOAEs, followed by otoscopic examination. The pass rates for ABR and EOAE screening were 88.5% and 79%, respectively. On otoscopic examination, 13% (53 of 400) ears had occluding vernix obscuring the view of the tympanic membrane. Cleaning of vernix was attempted in ears that failed ABR or EOAE screening. Seventeen ears that failed ABR were cleaned, and 12 (71%) of them passed repeat ABR. Thirty-three ears that failed EOAE screening were cleaned, and 22 (67%) of them passed repeat emissions testing. Cleaning vernix increased the pass rates for ABR and EOAE screening to 91.5% and 84%, respectively. Decreased tympanic membrane mobility was found in 9% of ears that could be evaluated otoscopically. Increased failure rates for both ABR and EOAE screening were found in infant ears with decreased tympanic membrane mobility, but significance testing could not be performed because of inadequate sample size. Prevalence of occluding external canal vernix and middle ear effusion as a function of increasing infant age were studied. Implications for newborn hearing screening are discussed. (Otolaryngol Head Neck Surg 1997;116:597-603.)     

Experience of the ENT clinic--rehabilitation hospital of Iaşi in the diagnosis of hearing loss in children between 1 and 5 years of age

The aim of this study is to asses the average age of diagnosis of congenital hearing loss in children up to 5 years old. A group of 48 children aged between 1-5 years old were admitted in our clinic in 2005 because of hearing impairment, noticed in most cases by their parents. All cases were investigated in our clinic by transient evoked oto-acoustic emission test, threshold auditory brainstem response, impedance-metry and, whenever possible, audiometry. Sensori-neural hearing loss of variable gravity was diagnosed in 30 cases, most of them in the 2-3 yrs group of age (9 cases). The etiology of hearing loss could be established in 9 cases only. 19 patients (63%) were hearing aided, but follow-up was not possible. The average age of congenital hearing loss diagnosis may be reduced by applying universal neonatal hearing screening and a well established modality of confirmation of deafness in infants identified by the universal screening.     

根因分析法联合流程优化降低外出检查早产儿低体温的研究

目的 探讨根因分析法联合流程优化对新生儿重症监护室早产儿外出检查体温的影响.方法 成立根因分析小组,应用根因分析法对2020年1～7月67例新生儿重症监护室外出检查早产儿进行追踪,调查导致外出检查低体温发生的原因,寻找近端原因、剖析根本原因,制订改进措施,包括对早产儿外出检查流程进行重排、合并、优化等.并于2020年8月至2021年2月在58例外出检查早产儿中实施,比较改善措施实施前后低体温发生率.结果 改善措施实施后,早产儿腹部B超、全腹B超及听诱发检查时体温显著改善(均P＜0.01);早产儿外出检查低体温发生率由实施前的37.31％下降至实施后的10.34％,差异有统计学意义(P＜0.01).结论 根因分析法联合优化早产儿外出检查流程,可有效降低早产儿外出检查低体温发生率.     

The diagnosis and management of neonatal hip instability: results of a clinical and targeted ultrasound screening program

This article reports the results of a neonatal hip screening program comprising clinical screening and targeted ultrasound performed by orthopaedic surgeons. Over 7 years, from 1995 to 2001, there were 15,397 live births in the authors' region. Seven hundred thirty-three babies (4.8% of births) were referred for hip ultrasound: 80% for risk factors and 20% for instability. Eighty-three babies (5.4/1,000) were splinted in a Pavlik harness. Three of these subsequently required surgery (1.9/1,000). Ten patients (0.65/1000) presented with hip dislocation after 12 weeks of age, nine of whom required open or closed reduction (0.56/1,000). From 1978 to 1985, when neonatal pediatricians clinically screened all babies, 18 babies presented late from 13,707 births (1.3/1000). Since the introduction of orthopaedic screening and targeted ultrasound, there has been a significant reduction in late diagnosis in the authors' institution.     

Acoustic-distortion products: separation of sensory from neural dysfunction in sensorineural hearing loss in human beings and rabbits

Because distortion-product otoacoustic emissions (DPOAEs) provide a noninvasive measure of outer hair-cell (OHC) activity, they should provide a unique and sensitive indicator of the effects of agents that damage hearing. Using DPOAE methods, the present study was designed to assess the relative contributions of the cochlea's outer hair cells to some common sensorineural diseases, including Meniere's disease, acoustic neuroma, and noise-induced, hereditary, and sudden idiopathic sensorineural hearing loss. Parallel evaluations of DPOAEs were performed under essentially identical conditions in rabbit models of several of the human disorders, including noise-induced hearing loss, endolymphatic hydrops, and cochlear neurectomy. Animal studies were performed to assess the proficiency of DPOAEs to track a developing sensorineural deficit as well as to compare patterns of DPOAE dysfunction between clinical and experimental forms of peripheral hearing loss. Detailed measures of DPOAEs were collected in the stimulus-frequency and intensity domains as "audiograms" and response/growth or input/output functions, respectively. The outcome of analyses of both human beings and animals supported the notion that DPOAE testing is sensitive to sensory-cell disease. Thus, in combination with conventional audiometry, DPOAE measures permit a distinction between the relative contribution sensory and neural components of the cochlea make to hearing deficits.     

Cost-effective initial screening for vestibular schwannoma: auditory brainstem response or magnetic resonance imaging?

OBJECTIVE: Our goal was to determine the cost-effectiveness of including auditory brainstem response (ABR) testing in a screening protocol for the diagnosis of vestibular schwannoma (VS) in patients with asymmetric auditory symptoms at the Christian Medical College and Hospital, Vellore, India, where, commonly, patients with VS have tumors greater than 2 cm at the time of diagnosis. METHODS: Ninety patients with asymmetric audiovestibular symptoms were investigated prospectively with both ABR and gadolinum-enhanced magnetic resonance imaging (GdMRI). RESULTS: Of these 90 patients, 6 were diagnosed with VS on GdMRI. On ABR testing, 4 patients with VS had retrocochlear pathology and 2 with profound sensorineural hearing loss had no responses. ABR was found to have a sensitivity of 100% and specificity of 61.9%. A protocol involving screening of all patients with asymmetric audiovestibular symptoms using ABR and only subjecting those patients with no responses or retrocochlear pathology to GdMRI would effect a savings of $1200 for every patient detected to have a VS. CONCLUSIONS: In our hospital setting, including ABR as the preliminary screen for patients with asymmetric audiovestibular symptoms is a cost-effective strategy.     

Aminoglycoside ototoxicity in pediatric patients receiving long-term peritoneal dialysis

We evaluated 14 children on long-term peritoneal dialysis for ototoxicity associated with aminoglycoside (AG) therapy. Baseline evaluation of all patients and 7 controls included pure-tone audiometry (PTA) and click-evoked auditory brain stem response (ABR). Nine patients had repeat PTA and ABR evaluations and vestibular testing 1 year after study entry. Five patients had an additional assessment following intraperitoneal AG therapy. The baseline auditory function of the patients was significantly poorer than controls at 6.0 and 8.0 kHz by PTA (p<0.05), whereas the results of ABR testing were not different. Of the 14 patients, 4 (28%) had hearing loss, 3 of whom had a history of intravenous AG therapy. In contrast, none of the patients who received intraperitoneal AG therapy only, or without a history of AG therapy, had hearing loss (P<0.005). There was no evidence of progressive loss of hearing acuity with time or associated with intraperitoneal AG therapy. One patient had findings of vestibular dysfunction. We conclude that children receiving peritoneal dialysis are at risk of AG ototoxicity. While intraperitoneal administration of AG may be associated with less ototoxicity than intravenous administration, further study is necessary to verify this finding and close monitoring of AG levels remains mandatory irrespective of the route of administration. PTA rather than click-evoked ABR appears to be the best indicator of abnormal hearing acuity in this population.     

External and middle ear effects on infant hearing screening test results.

This study investigated the relationship between external and middle ear factors and hearing screening results by automated auditory brain stem response (ABR) and transient-evoked otoacoustic emissions (EOAEs). The ears of 200 healthy newborns aged 5 to 48 hours underwent screening by ABR and EOAE, followed by otoscopic examination. The pass rates for ABR and EOAE were 91% and 58.5%, respectively. On otoscopic examination, 28% (112/400) ears had occluding vernix obscuring the view of the tympanic membrane. Cleaning of vernix was successfully performed in all but 2 ears that had occluding vernix. Cleaning of vernix significantly increased the pass rates of all 400 ears for ABR and EOAE to 96% and 69%. Decreased tympanic membrane mobility was found in 22.7% (90/396) of ears that were evaluated otoscopically. Decreased tympanic membrane mobility had a significant effect on EOAE screening; only 33.4% of ears passed EOAE testing. Decreased tympanic membrane mobility did not significantly affect pass rates for ABR screening; 95% of these ears passed the automated ABR screen. Implications for newborn hearing screening are discussed.     

A comparison of screening methods in school-aged children

OBJECTIVE: We sought to compare the findings of 3 different hearing screening methods in school-aged children. STUDY DESIGN AND SETTING: Prospective testing of second- and third-grade students in their schools was carried out. METHODS: Three hundred children (599 ears) were screened by using 3 test modalities, pure-tone audiometry, distortion product otoacoustic emissions (DPOAE), and tympanometry. RESULTS: All of the tests were normal in 532 ears (89%), and all were abnormal in 12 ears (2%). Tympanometry yielded the most abnormalities (8.3%), and pure-tone testing demonstrated the fewest (3.3%), with a positive rate of 6.3% for DPOAE testing. False-positive rates were 1.2%, 4.2%, and 6.4% for pure tones, DPOAE, and tympanometry, respectively, when normal results on pure-tones or DPOAE were taken to represent true hearing. CONCLUSION/SIGNIFICANCE: We continue to recommend pure-tone testing as an effective screening method, with follow-up by using otoacoustic emissions in those who fail the pure-tone test.     

DPOAE-grams in patients with acute tonal tinnitus.

OBJECTIVE: To investigate cochlear outer hair cell function in patients with acute tonal tinnitus and normal or near-normal hearing threshold. STUDY DESIGN AND SETTING: Prospective controlled study in an academic tertiary health center. Distortion products of otoacoustic emissions (DPOAE)-grams of 32 ears with acute tonal tinnitus and normal hearing or minimal hearing loss were compared with those of 17 healthy nontinnitus ears. RESULTS: Tinnitus ears exhibited relatively increased amplitudes of DPOAE at high frequencies (4-6.3 kHz) when compared with the group of healthy ears and relatively decreased DPOAE amplitudes at middle frequencies (1650-2400 Hz). Statistically significant ( P < 0.01) increased mean values of DPOAE amplitudes were observed only at a frequency of f2 equal to 4.9 kHz. CONCLUSIONS AND SIGNIFICANCE: These findings suggest an altered functional state of the outer hair cells at a selected high-frequency region of the cochlea in ears with acute tonal tinnitus and normal or near-normal hearing threshold.     

Survival results in patients with screen-detected prostate cancer versus physician-referred patients treated with radical prostatectomy: early results

OBJECTIVE: Screening using a standardized protocol may improve outcomes of patients undergoing treatment for prostate cancer. We compared the 7- year progression-free survival rates after radical retropubic prostatectomy in patients whose prostate cancer was detected through a formal screening program with those of patients referred for treatment by other physicians who did not use a standardized screening/referral protocol. METHODS: A single surgeon (W.J.C.) performed radical retropubic prostatectomy in 3,177 consecutive patients between 1989 and 2003. Of these patients, 464 had cancer detected in a screening study, and 2,713 were referred from outside institutions. We compared the screened and referred cohorts for age at surgery, clinical stage, pathologic stage, Gleason sum, preoperative prostate-specific antigen (PSA) levels, and adjuvant radiation therapy. Kaplan-Meier product limit estimates were used to calculate 7-year progression-free probabilities, and Cox proportional hazards models were used to determine the clinical and pathologic parameters associated with cancer progression in each group. RESULTS: The overall 7-year progression-free survival rates were 83% for the screened patients compared with 77% for the referred patients (P = 0.002). Preoperative PSA, Gleason sum, clinical stage, pathologic stage, and adjuvant radiotherapy were all significantly associated with cancer progression. There was a significantly higher proportion of referred patients with a preoperative PSA > or =10, Gleason sum > or =7, and nonorgan-confined disease. CONCLUSIONS: Patients with screened-detected prostate cancer have more favorable clinical and pathologic features, and 7-year progression-free survival rates than referred patients. On multivariate analysis, including other clinical variables, screening status was a significant independent predictor of biochemical outcome.     

The Brainstem Auditory Evoked Responses in Alport's Syndrome

Alport's syndrome is a "hereditary nephritis" associated withstructural defects of basement membranes in kidneys, ears andeyes, with variable clinical expression. As the acoustic abnormalitiesare often subclinical, we studied the brainstem auditory evokedresponses (ABR) and tonal audiometry in 12 patients (7 males,5 females, mean age 32.50±16.70 years) with histologicallydocumented renal lesions consistent with Alport's syndrome.ABR were used to document the altered acoustic-nerve conductionand transmission typical of the early stage of Alport's syndrome. In 11 patients (seven males, four females), we found bilateraldelayed latency (I dx: 2.50±0.80 msec; III dx: 4.24±0.68msec; V dx: 7.02±0.94 msec) and altered waveform I, III,V by ABR. By audiometry eight patients (six males, two females)showed a loss of medium-high tones, and this group includedthe patients with a negative ABR study. Therefore, the ABR isabnormal in Alport's syndrome; it may be positive in patientswith normal tonal audiometry, usually all cochlear functionsare grossly intact; the acoustic-nerve lesions in Alport's syndromemay precede the cochlear involvement and clinical hearing loss;the electrophysiological analysis does not identify the particularnervous structures involved in the acoustic pathways.     

Ultrasound screening for hips at risk in developmental dysplasia. Is it worth it?

Between May 1992 and April 1997, there were 20,452 births in the Blackburn District. In the same period 1107 infants with hip 'at-risk' factors were screened prospectively by ultrasound. We recorded the presence of dislocation and dysplasia detected under the age of six months using Graf's alpha angle. Early dislocation was present in 36 hips (34 dislocatable and 2 irreducible). Of the 36 unstable hips, 30 (83%) were referred as being Ortolani-positive or unstable; 25 (69%) of these had at least one of the risk factors. Only 11 (31%) were identified from the 'at-risk' screening programme alone (0.54 per 1000 live births). Eight cases of 'late' dislocation presented after the age of six months (0.39 per 1000 live births). The overall rate of dislocation was 2.2 per 1000 live births. Only 31% of the dislocated hips belonged to a major 'at-risk' group. Statistical analysis confirmed that the risk factors had a relatively poor predictive value if used as a screening test for dislocation. In infants referred for doubtful clinical instability, one dislocation was detected for every 11 infants screened (95% confidence interval (CI) 8 to 17) whereas in infants referred because of the presence of any of the major 'at-risk' factors the rate was one in 75 (95% CI 42 to 149). Routine ultrasound screening of the 'at-risk' groups on their own is of little value in significantly reducing the rate of 'late' dislocation in DDH, but screening clinically unstable hips alone or associated with 'at-risk' factors has a high rate of detection.