Analysis of audiological results of patients referred from newborn hearing screening program

Conclusion: As tools of confirmation of sensorineural hearing loss in neonates who are ‘referred’ from a newborn hearing screening program, both ASSR and DPOAE have high sensitivity and specificity. In addition, ASSR can be used as a substitute for ABR. Objectives: To analyze the confirmative audiological results of patients referred from a newborn hearing screening program. Patients and method: From January 2007 to December 2013, hearing tests were performed on 474 babies (804 ears) who were ‘referred’ from the hospital or other maternity centers. Auditory brainstem response (ABR), auditory steady-state response (ASSR), and distortion product otoacoustic emissions (DPOAE) were used for hearing evaluation. Results: Of 474 babies (804 ears), 232 had normal hearing, while 242 babies (358 ears) had over 30 dB nHL threshold from ABR. Among the 156 babies (312 ears) who underwent both ABR and ASSR, the mean ASSR threshold had a strong correlation with ABR threshold (r = 0.942, p < 0.001). Assuming that ABR results were the yardstick of abnormal hearing, sensitivity and specificity of ASSR to ABR were 90.6% and 95%. DPOAE tests were performed on 180 babies (360 ears), with sensitivity of 85.9% and specificity of 84.4%.     

重症监护病房新生儿听力筛查模式初探

目的：探索重症监护病房（NICU）新生儿听力筛查模式,初步了解听力损失在此类人群的患病情况。方法：采用自动听性脑干反应（AABR）2阶段筛查方案,即NICU新生儿在出院或转入普通病房前以AABR进行听力初筛,未通过者出院1个月后门诊接受AABR复筛。复筛仍未通过者,3个月内转诊到我院儿童听力中心,进行全面的听力学诊断评估。结果：对2007—09—200808从NICU出院的824例新生儿进行了听力筛查,70例（8．5％）未通过出院前的AABR初筛,其中55例（78．6％）1个月后接受了AABR复筛,9例未通过。后者经全面的听力学诊断评估,3例确诊患不同程度的感音神经性听力损失,1例患听神经病。听力损失总患病率0．48％。结论：AABR两步法可能是NICU新生儿合适的听力筛查模式;本组新生儿听力损失患病率低于已往文献报道。     

Benefits and costs of universal hearing screening programme

Hearing loss affects 1-3 out of 1000 newborns. A programme of universal newborn hearing screening (UNHS) was implemented in our ENT department in February 2000. In 2001, the programme was extended to all the hospitals of the canton Geneva. The programme is based on the recording of transient evoked otoacoustic emissions (TEOAE) from all newborns. In addition, automated auditory brainstem responses (aABR) are recorded in high-risk neonates. In the report, we compare the mean age at which rehabilitation of hearing was undertaken during a 5-year period before and after the screening programme was instituted. We also identify some causes of delayed diagnosis and intervention and the pitfalls of universal hearing screening. The price of the UNHS programme is estimated at 26 Swiss francs (17 Euros; 21 US dollars) per infant screened, including the material required, the personal involved to run the programme, and the follow-up.     

听力筛查未通过的婴儿听力追踪检查

目的：探讨听力筛查未通过的婴幼儿的听力变化及其特点。方法：对使用ABR、DPOAE、声导抗而未通过听力筛查的新生儿分别在3月龄及6月龄时行客观听力检查,将2次检查结果进行比较和分析。结果：DPOAE在3月龄时测试假阳性率为9．6％;6月龄的复查和3月龄的初查相比较,重度或极重度听力损失者听力基本无改变,而轻-中度听力损失者转化为正常或听力改善所占的比例较高;将3月龄和6月龄2次ABR检查所得的ABR阈值,分左、右耳侧,前、后比较,左侧t=3．496,P〈0．01,右侧t=5．572,P〈0．01,差异有统计学意义。结论：未通过DPOAE筛查者不能立即作出听力损伤的结论,必须与ABR检查相互结合,相互补充;重度以上的听力损失者3月龄的早期诊断和6月龄的早期干预是可行的,而轻-中度听力损失者应进行至少2次以上的听力检测和6个月以上的追踪,并根据听觉行为测试和日常生活观察综合分析各项检查结果后才可得出正确诊断。     

Comparison of two-step transient evoked otoacoustic emissions (TEOAE) and automated auditory brainstem response (AABR) for universal newborn hearing screening programs

OBJECTIVE: Both transitory auditory otoemissions (TEOAE) and automated auditory brainstem responses (AABR) are considered adequate methods for universal hearing screening. The goal of this study was to compare the results obtained with each device, applying the same screening procedure. MATERIALS AND METHODS: From 2001 to 2003, all the newborns in our health area (2454 infants) were evaluated with TEOAE (ILO92, otodynamics) and all those born from 2004 to 2006 (3117) were evaluated with AABR (AccuScreen, Fischer-Zoth). The population studied included all well newborns and those admitted to neonatal intensive care units (NICU). The first screening was normally undertaken with well babies during the first 48h of life, before hospital discharge. Infants referred from this first step underwent a second screening after hospital discharge, before they were a month old. RESULTS: The results from each study group were compared and analyzed for significant differences. TEOAE screening yielded 10.2% fail results from the first screening step; AABR gave 2.6%. In the second screening step, 2% of the newborns screened with TEOAE were referred, whereas 0.32% of those screened with AABR were referred. These differences are statistically significant. CONCLUSIONS: Although AABR screening tests involve a slightly higher cost in time and money than TEOAE, the results obtained compensate this difference. AABR gives fewer false positives and a lower referral rate; the percent of infants lost during follow-up is consequently smaller. Therefore, in our environment, universal newborn auditory screening with AABR is more effective than that with TEOAE.     

Comparison of hearing screening programs between one step with transient evoked otoacoustic emissions (TEOAE) and two steps with TEOAE and automated auditory brainstem response

OBJECTIVE: To compare the efficacy between one step with transient evoked otoacoustic emissions (TEOAE) and two steps with TEOAE and automated auditory brainstem response (AABR) in a newborn hearing screening program. We investigated their differences in referral rate, the accurate identification rate of congenital hearing loss (HL), and cost effectiveness. METHOD: From November 1998 to December 2004, a total of 21,273 healthy newborns were screened for HL in Mackay Memorial Hospital, Taipei. In the periods from November 1998 to January 2004 and from February 2004 to December 2004, the screening tools used were TEOAE alone (n = 18,260) and TEOAE plus AABR (n = 3,013), respectively. RESULTS: A statistically significant decrease of referral rate was achieved in the group using TEOAE and AABR as screening tools when compared with TEOAE alone (1.8% vs. 5.8%). The accurate identification rate of congenital HL was 0.45% in TEOAE protocol and 0.3% in TEOAE and AABR protocol, which was not statistically significant. The total direct costs per screening were 10.1 U.S. dollars for the program using TEOAE alone and 8.9 U.S. dollars for the TEOAE plus AABR program. The intangible cost, however, was much higher in the earlier program because of the higher referral rate. CONCLUSION: In terms of the efficacy of a hearing screening program using the one step TEOAE and two step TEOAE and AABR programs, the later significantly decreased the referral rate from 5.8% to 1.8%. No significant difference was noted between the accurate identification rates of congenital HL. The total costs, including expenditures and intangible cost, were lower in the protocol with TEOAE plus AABR.     

The economics of screening infants at risk of hearing impairment: an international analysis

Objective

Hearing impairment in children across the world constitutes a particularly serious obstacle to their optimal development and education, including language acquisition. Around 0.5-6 in every 1000 neonates and infants have congenital or early childhood onset sensorineural deafness or severe-to-profound hearing impairment, with significant consequences. Therefore, early detection is a vitally important element in providing appropriate support for deaf and hearing-impaired babies that will help them enjoy equal opportunities in society alongside all other children. This analysis estimates the costs and effectiveness of various interventions to screen infants at risk of hearing impairment.

Methods

The economic analysis used a decision tree approach to determine the cost-effectiveness of newborn hearing screening strategies. Two unique models were built to capture different strategic screening decisions. Firstly, the cost-effectiveness of universal newborn hearing screening (UNHS) was compared to selective screening of newborns with risk factors. Secondly, the cost-effectiveness of providing a one-stage screening process vs. a two-stage screening process was investigated.

Results

Two countries, the United Kingdom and India, were used as case studies to illustrate the likely cost outcomes associated with the various strategies to diagnose hearing loss in infants. In the UK, the universal strategy incurs a further cost of approximately £2.3 million but detected an extra 63 cases. An incremental cost per case detected of £36,181 was estimated. The estimated economic burden was substantially higher in India when adopting a universal strategy due to the higher baseline prevalence of hearing loss. The one-stage screening strategy accumulated an additional 13,480 and 13,432 extra cases of false-positives, in the UK and India respectively when compared to a two-stage screening strategy. This represented increased costs by approximately £1.3 million and INR 34.6 million.

Conclusions

The cost-effectiveness of a screening intervention was largely dependent upon two key factors. As would be expected, the cost (per patient) of the intervention drives the model substantially, with higher costs leading to higher cost-effectiveness ratios. Likewise, the baseline prevalence (risk) of hearing impairment also affected the results. In scenarios where the baseline risk was low, the intervention was less likely to be cost-effective compared to when the baseline risk was high.     

Evoked otoacoustic emissions and auditory brainstem responses: concordance in hearing screening among high-risk children

Objective Evoked otoacoustic emissions (OAEs) and diagnostic auditory brainstem responses (ABRs) were determined in 379 high-risk children referred for hearing screening.

Material and Methods This was a retrospective, cross-sectional study. The records of 379 children referred for hearing screening between January 2002 and March 2003 at the Ear Unit of the Philippine General Hospital were evaluated.

Results Of the 379 children, 53.6% were male and 46.4% were female and the mean age was 41±47 months. The age distribution was as follows: ≤12 months, 32.2%; 12–24 months, 52.2%; and>24 months, 11%. Out of 229 right and 232 left ears, 111 (48.5%) and 112 (48.3%) had “pass” responses and 113 (49.3%) and 116 (50.5%) had “refer” responses, respectively. Five right and four left ears had “noise” responses. Out of 266 right and 209 left ears, the ABR results showed 72 (27.1%) and 30 (14.4%) with normal auditory pathways and 194 (72.9%) and 179 (85.6%) with abnormal auditory pathways, respectively. Of the 131 children whose parents gave their consent for concomitant OAE and ABR testing, agreements were observed between the two tests in terms of classifying the results as normal or abnormal of 78.9% (κ=0.51; p=0.00) in right and 78.6% (κ=0.51; p=0.00) in left ears. When the children were classified as either “with hearing loss—bilateral abnormal ABRs” or “at least one normal ABR”, there was an observed agreement of 81% (κ=0.6; p=0.00). OAEs had a sensitivity of 76.9% (95% CI 66.7–84.8%) and a specificity of 90% (95% CI 75.4–96.7%).

Conclusion There is good concordance between OAE and ABR results among high-risk children referred for hearing screening.     

1700例新生儿听力筛查结果分析

目的了解新生儿听力损失的发病情况,观察畸变产物耳声发射作为新生儿听力筛查方法的效果,分析初筛通过率的影响因素。方法应用畸变产物耳声发射仪,对2005年5月～2007年12月在我院妇产科分娩的1700例新生儿进行听力筛查。未通过初筛者,出生42天进行复查,复筛未通过者,3个月左右到指定机构行听性脑干反应测听进行诊断。结果1700例新生儿接受初次筛查,其中1582例通过,通过率为93.06%。初筛“未通过”的118例新生儿全部进行复筛,复筛通过106例,通过率为89.83%。复筛仍未通过的12例,其中3例确诊为先天性听力损失。结论我院新生儿听力障碍发病率为1.76‰,畸变产物耳声发射应用于新生儿听力筛查效果良好,初筛通过率与性别、分娩方式无关,足月儿较早产儿初筛通过率高,出生后3～5天进行筛查者通过率较出生后1～2天者通过率高。     

Cost and outcome of a community-based paediatric hearing screening programme in rural India with application of tele-audiology for follow-up diagnostic hearing assessment

Objective: This study evaluated the cost and outcome of a community-based hearing screening programme in which village health workers (VHWs) screened children in their homes using a two-step DPOAE screening protocol. Children referred in a second screening underwent tele diagnostic ABR testing in a mobile tele-van using satellite connectivity or at local centre using broadband internet at the rural location. Design: Economic analysis was carried out to estimate cost incurred and outcome achieved for hearing screening, follow-up diagnostic assessment and identification of hearing loss. Two-way sensitivity analysis determined the most beneficial cost-outcome. Study sample: 1335 children under 5?years of age underwent screening by VHWs. Results: Nineteen of the 22 children referred completed the tele diagnostic evaluation. Five children were identified with hearing loss. The cost-outcomes were better when using broadband internet for tele-diagnostics. The use of least expensive human resources and equipment yielded the lowest cost per child screened (Rs.1526; $23; €21). When follow-up expenses were thus maximised, the cost per child was reduced considerably for diagnostic hearing assessment (Rs.102,065; $1532; €1368) and for the cost per child identified (Rs.388,237; $5826; €5204). Conclusion: Settings with constrained resources can benefit from a community-based programme integrated with tele diagnostics.     

Newborn hearing screening in a South African private health care hospital

OBJECTIVE: Early Hearing Detection and Intervention (EHDI) programs are being established as part of the public health systems in increasing numbers of countries. In developing countries, however, little progress has been made towards implementing NHS programs and South Africa's public and private health care sectors is no exception. The current study presents the first report on a hospital-based UNHS program conducted in the South African private health care sector to provide preliminary results towards advocating for and guiding future programs. METHODS: A retrospective study of a UNHS program at a private hospital in urban Gauteng, South Africa over a 4 year period of time was performed. Screening was conducted with Transient Evoked Otoacoustic Emissions (TEOAE) with a rescreen recommended within 6 weeks if referred. Diagnostic audiological assessments were performed on those infants referring the rescreen. The discharge screening costs were subsidized through the hospital birthing package for the first 22 months of the program. RESULTS: Six thousand two hundred and forty-one newborns were screened from 13,799 hospital births during the first 4 years. Ninety-four percent of these infants were from the well-baby nurseries. During the initial 22 months, whilst the service was subsidized as part of the hospital birthing package, coverage of 75% was attained compared to 20% during the subsequent 26 months. The overall referral rate for the screening program across the 4 years was 11.1% but referral rates decreased by between 2 and 4% for each year of program existence with a 5% rate in year 4. Only 32% of the rescreens were completed at the hospital and no data was available for the remaining infants because parents were provided a choice of follow up centers. Referral for a diagnostic assessment after the rescreens at the hospital was predictive of sensorineural hearing loss in one-third of cases and the estimated prevalence was 3 in every 1000. CONCLUSIONS: Screening coverage in the current study was not adequately high and can be attributed to insufficient parental knowledge to make an informed decision. Improvements in program efficiency over time also suggest that pilot programs must be monitored over sufficiently long periods of time to allow observations of optimal efficiency. Initial referral rates and prevalence data indicate a large hearing loss burden and the capacity to implement increasingly efficient programs in South Africa.     

TEOAE与AABR在高危新生儿听力筛查中的联合应用

目的探讨联合应用瞬态诱发性耳声发射(TEOAE)和自动听性脑干反应(AABR)在高危新生儿听力筛查中的应用。方法对新生儿科NICU高危新生儿200例（400耳）,运用AccuScreen听力筛查仪,同时进行TEOAE和AABR联合听力筛查,根据TEOAE初次筛查结果通过与否,分为双耳TEOAE初筛均未通过组(A组)和双耳TEOAE初筛均通过组（B组）,共2组,每组100例（200耳）,其中3个月时任何一项检查未通过者均在患儿6个月时进行听性脑干反应、声导抗测试等诊断性检查。结果A组：3个月时TEOAE未通过12例（22耳）,AABR未通过2例（2耳）,联合筛查未通过22例。6月龄时确诊1例（2耳）分泌性中耳炎,该两耳均为3次TEOAE筛查未通过、AABR筛查通过者,本组高危新生儿听力损伤现患率为1.7%（2/120）;B组：3个月时TEOAE未通过2例（2耳）,AABR未通过5例（5耳）,联合筛查未通过5例（5耳）。6月龄时确诊2例（2耳）诊断为蜗后性耳聋,该两耳均为3次AABR筛查未通过、TEOAE筛查通过者,本组高危新生儿听力损伤现患率为1.4%（2/146）,每组在定期复筛时均有部分失诊患儿。结论通过TEOAE和AABR联合筛查,可以检出中耳、蜗性及蜗后听损伤,证实了TEOAE和AABR是听力筛查的有效组合方式,AABR和TEOAE联合筛查应用可以优势互补,降低漏诊、误诊率。     

Screening strategy and time points for newborn hearing re‐screening with high risk factors

ObjectiveTo compare and analyze the pass rate and screening strategy of hearing rescreening for newborns with high risk factors.MethodsRetrospective chart review of high‐risk newborns who failed their initial newborn hearing screen and subsequently underwent secondary hearing tests from June 2011 to June 2018 in Guangzhou Women and Children''s Medical Center were performed.ResultsEight hundred and sixty‐eight newborns with high risk factors were included in the study. The 57‐70 days (83.5%) and 71‐84 days (83.4%) group had the highest pass rate compared with 42‐56 days (75.8%) and < 42 days (68.3%) group. As for different screening strategies, the pass rate of OAE(otoacoustic emissions), AABR (auto auditory brainstem response) and OAE + AABR was the highest in 57–70 days group and 71‐84 days group, respectively. The OAE + AABR had the lowest pass rate compared to the other two modalities. When the pass rate was compared as different risk factors, the 57–70 days and 71–84 days group also had the highest pass rate compared with 42–56 days and < 42 days group and the pass rate had no significant differences among various risk factors group.ConclusionOur results showed that all the pass rate of OAE, AABR and OAE + AABR was the highest in 57–70 days group and 71–84 days group with significant difference, suggesting that the delayed screening time (>57 days) may increase the re‐screening pass rate and reduce anxiety of parents, which is of great significance for clinical work.     

Neonatal hearing screening: a combined click evoked and tone burst otoacoustic emission approach

OBJECTIVE: This study evaluated an alternative transient evoked otoacoustic emissions method for screening hearing in newborn babies that may reduce the referral rate of initial screening. METHODS: A total of 1,033 neonates (2,066 ears) from two hospitals were recruited. Subjects had their hearing screened in both ears using a combined approach-both click evoked OAEs (CEOAEs) and 1kHz tone burst evoked OAEs (TBOAEs). RESULTS: 1kHz TBOAEs were more robust than CEOAEs in terms of emission response level and signal-to-noise ratio (SNR) at both 1 and 1.5kHz frequency bands. The prevalence rate for CEOAE and TBOAE responses in these two frequency bands was significantly different. The combined protocol significantly reduced the referral rate-by almost 2 percentage points for first time screening. CONCLUSIONS: The implementation of a combined 1kHz TBOAE/CEOAE screening protocol is a feasible and effective way to reduce referral rates, and hence false positive rates, in neonatal hearing screening programs.     

Transient evoked otoacoustic emissions in hearing screening programs: protocol for developing countries

OBJECTIVES: To formulate a protocol for infant hearing screening in developing countries enabling it to be later incorporated into their national deafness screening programs. The screening tool should be sensitive in detecting hearing loss in infants with high specificity. METHODS: 2659 infants in the age range of 0-3 months who reported to the Department of Otolaryngology were included in the study. As 537 children were lost to follow up after the first screening, the remaining 2122 infants only were considered for the statistical analysis. These were divided into 3 groups with age range between 0-1, 1-2 and 2-3 months of age. All were subjected to transient evoked otoacoustic emission (TEOAE) for hearing screening. Those who failed first screening were followed up after 1-month. Pass rate for TEOAE was calculated for each. Infants who had failed the second screening underwent Brainstem Evoked Response Audiometry (BERA). The data collected was statistically analyzed. RESULTS: 77.5% of infants in 0-1-month age group passed the screening test whereas 83.4% and 92.8% of infants passed the screening test in 1-2 months and 2-3 month age groups, respectively. On the first follow up, the pass percentage of the infants who had failed screening earlier rose significantly high up to age of 3 months. Those who had failed the follow up were scheduled for Brainstem Evoked Auditory testing. CONCLUSION: The concept of this delayed hearing screening at 3 months of age would considerably decrease the number of false positive cases undergoing unnecessary investigations and wastage of resources making the universal neonatal hearing screening within 48 h of life impractical for developing countries. Combining this delayed hearing screening with the 3rd dose of universal immunization program would constitute a viable, feasible and universal hearing screening program, which can be drafted into national deafness programs of the developing countries.     

On a possible prognostic value of otoacoustic emissions: a study on patients with sudden hearing loss

Otoacoustic emissions (OAE) and pure tone audiogram (PTA) were examined in 26 ears of 25 patients suffering from sudden hearing loss from the 1st day to up to 505 days following the drop of hearing to test the hypothesis whether the OAEs are capable of delivering predictive information about the recovery process. The patients were selected from 50 candidates according to the following criteria: one or both ears exhibited a systematic and significant recovery of pure tone threshold in at least one frequency, OAEs were detectable and PTA available, a conductive hearing loss was excluded, and the auditory brainstem responses (ABR) yielded no signs of retrocochlear disorders. Transitory evoked otoacoustic emissions (TEOAE) and distortion product otoacoustic emissions (DPOAE) were measured under constant stimulus and recording conditions in three to nine sessions. The relation between OAE level and actual pure tone threshold was subject to a regression analysis. The correlation between both parameters is small but significant. Even smaller correlations are observed if the OAE level is related to former hearing loss, whereas the correlation improves if the OAE level is compared to the pure tone threshold measured in a later session. The slopes of individual trajectories that connect the successive results of one ear in a plane defined by hearing loss and OAE level show a remarkable accumulation around zero, i.e., in many cases the OAEs remain unchanged even if the hearing loss decreases. The comparison of the OAE levels measured at an early stage with later audiograms shows that there are only a small number of cases with small initial emissions and good final threshold or large initial emissions and bad final threshold. This means that small initial OAEs end up with a remaining final hearing deficit, whereas a high OAE level immediately after drop of threshold correlates with good outcome. The reliability of an individual prediction based on the OAE level combined with the threshold after sudden hearing loss and the consequences for the physiologic mechanisms underlying the sudden hearing loss remain to be proved in further investigations.     

听性脑干反应与畸变产物耳声发射检测在听神经病诊断中的表现和意义

目的分析听神经病患者的听性脑干反应与畸变产物耳声发射特征,探讨该类听力学检测方法在听神经病诊断中的意义。方法回顾性研究本科确诊为听神经病的患者37例,比较分析其听性脑干反应与畸变产物耳声发射检测结果,探索其诊断意义。结果本组患者中,3例5耳（双耳病变2例,单耳病变1例）可引出V波,阈值70～90dB SPL,其余患耳ABR各波均未引出（刺激声强〉100dB SPL）。无论纯音听阈损失程度轻重如何,所有患者的DPOAE均全部引出。在各个频率点上,DPOAE的DP—gram幅值左、右耳间的差异均无统计学意义（P〉0．10）。结论听神经病的主要病变部位可能位于听神经传入通路,或伴有脑干内侧橄榄耳蜗系统的传出神经通路病变。