James W. Hall

Telehealth in audiology: The need and potential to reach underserved communities

Abstract Permanent hearing loss is a leading global health care burden, with 1 in 10 people affected to a mild or greater degree. A shortage of trained healthcare professionals and associated infrastructure and resource limitations mean that hearing health services are unavailable to the majority of the world population. Utilizing information and communication technology in hearing health care, or tele-audiology, combined with automation offer unique opportunities for improved clinical care, widespread access to services, and more cost-effective and sustainable hearing health care. Tele-audiology demonstrates significant potential in areas such as education and training of hearing health care professionals, paraprofessionals, parents, and adults with hearing disorders; screening for auditory disorders; diagnosis of hearing loss; and intervention services. Global connectivity is rapidly growing with increasingly widespread distribution into underserved communities where audiological services may be facilitated through telehealth models. Although many questions related to aspects such as quality control, licensure, jurisdictional responsibility, certification and reimbursement still need to be addressed; no alternative strategy can currently offer the same potential reach for impacting the global burden of hearing loss in the near and foreseeable future. Sumario La pérdida auditiva permanente es una importante carga para los cuidados de la salud a nivel mundial, con 1 de cada 10 personas afectadas en grado ligero o mayor. La escasez de profesionales entrenados en cuidados de la salud y de infraestructura asociada y la limitación de recursos determina que los servicios de salud auditiva no estén disponibles para la mayoría de la población mundial. La utilización de información y tecnología de la comunicación para los cuidados de la salud auditiva o teleaudiología, combinada con la automatización, ofrece oportunidades únicas para mejorar los cuidados clínicos, ampliar el acceso a los servicios y tener cuidados de salud auditiva costoefectivos y sustentables. La Teleaudiología ha demostrado un potencial significativo en áreas como las de educación y adiestramientio de profesionales de la salud auditiva, profesionales afines, padres y adultos con problemas auditivos; tamiz de problemas auditivos; diagnóstico de pérdidas auditivas y servicios de intervención. La conectividad global está creciendo rápidamente y ha aumentado de manera generalizada su distribución en comunidades con pocos servicios, en donde los servicios audiológicos pueden facilitarse a través de modelos de telesalud. No obstante, existen muchas dudas que deben resolverse y que están relacionadas con aspectos como control de calidad, regulación del ejercicio profesional, responsabilidad jurisdiccional, certificación y reembolso de servicios, pero no existe como alternativa ninguna otra estrategia que pueda ofrecer actualmente el mismo potencial, para impactar el peso global de las pérdidas auditivas en el futuro cercano o previsible.

Multiple benefits of personal FM system use by children with auditory processing disorder (APD)

Children with auditory processing disorders (APD) were fitted with Phonak EduLink FM devices for home and classroom use. Baseline measures of the children with APD, prior to FM use, documented significantly lower speech-perception scores, evidence of decreased academic performance, and psychosocial problems in comparison to an age- and gender-matched control group. Repeated measures during the school year demonstrated speech-perception improvement in noisy classroom environments as well as significant academic and psychosocial benefits. Compared with the control group, the children with APD showed greater speech-perception advantage with FM technology. Notably, after prolonged FM use, even unaided (no FM device) speech-perception performance was improved in the children with APD, suggesting the possibility of fundamentally enhanced auditory system function.

Evidence of hearing loss in a “normally-hearing” college-student population

Abstract We report pure-tone hearing threshold findings in 56 college students. All subjects reported normal hearing during telephone interviews, yet not all subjects had normal sensitivity as defined by well-accepted criteria. At one or more test frequencies (0.25–8 kHz), 7% of ears had thresholds ≥25 dB HL and 12% had thresholds ≥20 dB HL. The proportion of ears with abnormal findings decreased when three-frequency pure-tone-averages were used. Low-frequency PTA hearing loss was detected in 2.7% of ears and high-frequency PTA hearing loss was detected in 7.1% of ears; however, there was little evidence for ‘notched’ audiograms. There was a statistically reliable relationship in which personal music player use was correlated with decreased hearing status in male subjects. Routine screening and education regarding hearing loss risk factors are critical as college students do not always self-identify early changes in hearing. Large-scale systematic investigations of college students’ hearing status appear to be warranted; the current sample size was not adequate to precisely measure potential contributions of different sound sources to the elevated thresholds measured in some subjects. Sumario Reportamos los hallazgos de umbrales auditivos con tonos puros en 56 estudiantes universitarios. Todos los sujetos reportaron audición normal durante entrevistas telefónicas, aunque no todos tenían sensibilidad auditiva normal, conforme se define por criterios bien aceptados. En una o más de las frecuencias evaluadas (0.25-8 kHz), el 7% de los oídos tuvieron umbrales >25 dB HL y el 12% tuvieron umbrales >20 dB HL. La proporción de oídos con hallazgos anormales disminuyó cuando se usaron promedios tonales puros de tres frecuencias. Se detectaron hipoacusias con PTA en las frecuencias bajas en 2.7% de los oídos, e hipoacusias con PTA en altas frecuencias fueron detectadas en un 7.1% de los oídos; sin embargo, hubo poca evidencia de audiogramas con “muescas”. Existió una relación estadísticamente confiable en la que el uso de dispositivos para escuchar música se correlacionó con una disminución en la condición auditiva de sujetos varones. El tamiz de rutina y la educación en relación con los factores de riesgo para la hipoacusia se vuelven críticos, dado que los estudiantes universitarios no siempre auto-identifican cambios en su audición. Parecen justificadas las investigaciones sistemáticas a gran escala en estudiantes universitarios sobre su condición auditiva; el tamaño actual de la muestra no fue adecuado para medir con precisión las contribuciones potenciales de diferentes fuentes de sonido en la elevación de los umbrales medidos.

Validity of diagnostic pure-tone audiometry without a sound-treated environment in older adults

Abstract Objective: To investigate the validity of diagnostic pure-tone audiometry in a natural environment using a computer-operated audiometer with insert earphones covered by circumaural earcups incorporating real-time monitoring of environmental noise. Design: A within-subject repeated measures design was employed to compare air (250 to 8000 Hz) and bone (250 to 4000 Hz) conduction pure-tone thresholds, measured in retirement facilities, with thresholds measured in a sound-treated booth. Study sample: One hundred and forty-seven adults (average age 76 ± 5.7 years) were evaluated. Pure-tone averages were ≥ 25 dB in 59%, mildly (> 40 dB) elevated in 23%, and moderately (> 55 dB) elevated in 6% of ears. Results: Air-conduction thresholds (n = 2259) corresponded within 0 to 5 dB in 95% of all comparisons between the two test environments. Bone-conduction thresholds (n = 1669) corresponded within 0 to 5 dB in 86% of comparisons. Average threshold differences (− 0.6 to 1.1) and standard deviations (3.3 to 5.9) were within typical test-retest reliability limits. Thresholds recorded showed no statistically significant differences (paired samples t-test:p > 0.01) except at 8000 Hz in the left ear. Conclusion: Valid diagnostic pure-tone audiometry can be performed in a natural environment with recently developed technology, offering the possibility of access to diagnostic audiometry in communities where sound-treated booths are unavailable.

Efficacy of a community-based infant hearing screening program utilizing existing clinic personnel in Western Cape, South Africa

OBJECTIVE Screening programs at primary health care immunization clinics have been proposed as an alternative to hospital-based programs in South Africa. The objective of this study was to evaluate the first systematic community-based infant hearing screening program in a developing South African community in the Western Cape. METHODS A community-based universal infant hearing screening program initiated at eight primary health care clinics in the Cape Metropolitan area was evaluated over a 19-month research period. During this time 6227 infants that were candidates for screening attended their 6, 10 or 14-week immunization visit at the relevant clinic. Clinic nurses were trained as screening personnel. A two-stage distortion product otoacoustic emissions screening protocol was utilized. The target disorder was uni- or bilateral hearing loss and infants referring the first screen were scheduled for a 4-week follow-up visit at the clinic. Diagnostic audiological and medical evaluations were scheduled at referral hospitals when indicated. The study evaluated the efficacy of the program based on coverage, referral and follow-up rates and diagnostic outcomes according to guidelines specified by the Health Professions Council of South Africa 2007 Position Statement. RESULTS Overall coverage rate across the eight clinics was 32.4% with 2018 infants (aged 0-14 weeks) screened. The mean age of the sample at first stage screen was 3.9 weeks of age and 13.5 weeks of age for first hospital visit. Overall first stage screen referral rate was 9.5% with 62 subjects (3%) referred for diagnostic services at hospital level after a follow-up screen. The average follow-up rate for rescreens at clinic level was 85.1% and for initial diagnostic assessments at hospital level it was 91.8%. Prevalence rates were 4.5/1000 with significant hearing loss, including sensorineural (1.5/1000) and conductive (3/1000) losses, and 12.9/1000 for subjects with middle ear effusion. CONCLUSIONS The community-based infant hearing screening program was valuable in attaining high follow-up return rates but reaching sufficient coverage may require dedicated screening personnel as opposed to existing nursing personnel.

Vuvuzela - good for your team, bad for your ears

Vuvuzela is synonymous with the vibrant atmosphere at South African soccer matches. The intensity of the sound however, is dangerously loud according to occupational noise exposure standards. Preventative measures, such as public awareness and hearing protection, should be prioritized, especially in lieu of the upcoming World Cup in 2010.

Outcomes with OAE and AABR screening in the first 48 h—Implications for newborn hearing screening in developing countries

OBJECTIVE Early discharge of newborns (<24h after birth) from birthing centres is an important barrier to successful newborn hearing screening (NHS) in developing countries. This study evaluated the outcome of NHS within the first 48 h using an automated auditory brainstem response (AABR) device without the need for costly disposables typically required, and transient evoked otoacoustic emissions (TEOAE). METHODS NHS was performed on 150 healthy newborns (300 ears) with TEOAE and AABR techniques before discharge at a hospital. A three-stage screening protocol was implemented consisting of an initial screen with TEOAE (GSI AUDIOscreener+) and AABR (BERAphone(®) MB 11). Infants were screened at several time points as early as possible after birth. Infants were only re-screened if either screening technique (TEOAE or AABR) initially yielded a refer outcome. The same audiologist performed all TEOAE and AABR screenings. RESULTS Over the three-stage screen AABR had a significantly lower refer rate of 16.7% (24/144 subjects) compared to TEOAE (37.9%; 55/145 subjects). Screening refer rate showed a progressive decrease with increasing age. For both TEOAE and AABR, refer rate per ear screened 24h post birth was significantly lower than for those screened before 24h. For infants screened before 12h post birth, the AABR refer rate per ear (51.1%) was significantly lower than the TEOAE refer rate (68.9%). Overall AABR refer rate per ear was similar for infants screened between 24 to 36 h (20.2%) and 36 to 48 h (18.9%) but significantly lower than for TEOAE (40.7% and 41.9%, respectively). Lowest initial refer rates per ear (TEOAE 25.8%, AABR 3.2%) were obtained after 48 h post birth. CONCLUSION In light of the early post birth discharge typical in developing countries like South Africa, in-hospital screening with AABR technology is significantly more effective than TEOAEs. AABR screening with a device like the MB 11 is particularly appropriate because disposable costs are negligible.

Tele-ABR using a satellite connection in a mobile van for newborn hearing testing

Summary We assessed the feasibility of conducting Auditory Brainstem Response (ABR) testing in a mobile van with satellite connectivity, with the help of trained health workers. ABR recordings in newborn babies made by telemedicine were compared with recordings made face to face. The auditory evoked response equipment was controlled by an audiologist at a nearby hospital. Videoconferencing was used during the testing process to monitor patient preparation by the village health worker. A total of 24 newborns (13 male and 11 female) aged 8–30 days underwent ABR in face-to-face and tele-mode. There was no significant difference between peak V latency measured at three intensity levels in the two modes. Agreement between the two methods of measurement was examined with a Bland-Altman plot. Almost all points were within the limits of agreement, suggesting no bias in the telemedicine measurements. Real-time tele-ABR testing as a component of newborn hearing screening is feasible in a mobile van using satellite link with the assistance of village health workers.

Effect of prolonged contralateral acoustic stimulation on transient evoked otoacoustic emissions

Although the suppressive effect of the medial olivocochlear system (MOCS) on peripheral auditory active mechanisms is well documented in humans, the effect of efferent inhibition over prolonged periods of acoustic stimulation is less well documented, especially as observed by transient evoked otoacoustic emission (TEOAE) suppression. The present study evaluated the relationship between the duration of contralateral acoustic stimulation and the suppression of TEOAE in 10 normal-hearing adults. TEOAE recordings with linear clicks (60 dB SPL) were measured at four intervals during 15 min of continuous contralateral white noise (45 dB SL), followed by two post-noise recordings. An identical within-subject control condition was recorded without contralateral noise. Experimental and control measurements were repeated three times, on separate days. Results revealed significant and sustained TEOAE amplitude reduction for the entire duration of contralateral stimulation. Suppression increased gradually for the duration of contralateral noise presented, but not sufficiently to be statistically significant. Three minutes after noise termination, TEOAE amplitudes increased to values significantly above control recordings. The MOCS is able to sustain suppression over a prolonged duration of contralateral stimulation, supporting its role as an active modulator of outer hair cell mechanics during ongoing stimuli.

Football match spectator sound exposure and effect on hearing : a pretest-post-test study

OBJECTIVES To determine (i) noise exposure levels of spectators at a FIFA 2010 designated training stadium during a premier soccer league match; and (ii) changes in auditory functioning after the match. METHODS This was a one-group pretest-post-test design of football spectators attending a premier soccer league match at a designated FIFA 2010 training stadium in Gauteng, South Africa. Individual spectator noise exposure for the duration of the football match and post-match changes in hearing thresholds were measured with pure-tone audiometry, and cochlear functioning was measured with distortion product oto-acoustic emissions (DPOAEs). RESULTS The average sound exposure level during the match was 100.5 LAeq (dBA), with peak intensities averaging 140.4 dB(C). A significant (p=0.005) deterioration of post-match hearing thresholds was evident at 2 000 Hz, and post-match DPOAE amplitudes were significantly reduced at 1,266, 3,163 and 5,063 Hz (p=0.011, 0.019, 0.013, respectively). CONCLUSIONS Exposure levels exceeded limits of permissible average and peak sound levels. Significant changes in post-match hearing thresholds and cochlear responsiveness highlight the possible risk for noise-induced hearing loss. Public awareness and personal hearing protection should be prioritized as preventive measures.