Pure tone audiometry in children

Our purpose was to evaluate performance of the children on pure tone audiometry (PTA), and role of age, concentration level (CL) and otitis media with effusion (OME) in testing process.This study was prospectively performed on 100 consecutive
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  Pure tone audiometry in children Yusuf Kemal K emalog˘lu a, *, Bu¨lent Gu¨ndu¨z b , Selda Go¨kmen b ,Metin Yilmaz a a Department of ENT-HNS, Ankara, Turkey  b Gazi University, Prof. N. Akyildiz Hearing, Speech, Voice and Balance Disorders Center, Ankara, Turkey  Received 12 May 2004; accepted 29 August 2004 International Journal of Pediatric Otorhinolaryngology (2005)  69 , 209— KEYWORDS Pure tone audiometry;Bone and airthresholds;Concentration;Hearing loss;Otitis media witheffusion Summary Objective:  Our purpose was to evaluate performance of the children on pure toneaudiometry (PTA), and role of age, concentration level (CL) and otitis media witheffusion (OME) in testing process. Methods:  This study was prospectively performed on 100 consecutive childrenreferred for PTA between 24 and 120 months of age. After the audiologists’ decisionon test technique, the followings were noted: CL (by using a visual analog scale), testduration, test convenience (TC) and the problems (interruption, delay, crying) duringthe test. By using pure tone averages (PTAv), mean hearing level (MHL) and mean gap(MG) were calculated. Results:  PTAwas achieved in 90% of the children and PTAv of bone and air conductionin the both ears were obtained in 86% (play audiometry with earphones (PAE): 73%,conventional audiometry (CA): 22%). These ratios were not different between thechildren with and without OME. About 55% of the younger children than 36 monthswere failed in PTA, while this ratio was 4.5% in the children between 36 and 120months. Only difference between PAE and CA tests was in MHL. In OME group, only TCwas found to be lower. Correlation analysis showed that CL was correlated with age.TestdurationwascorrelatedwithMGandMHL,butfoundtobedependentononlyMG.Further, it was found that test choice of the audiologist was correlated with age andCL, but dependent on only CL. Conclusions:  PTA is available in children depending on their age and particularly CL;hence, performance in PTA is directly related with audiologists’ assessment thechildren and cooperation before starting the test. Meanwhile, test duration appearsto be directly associated with the work on detection of the gap between air and boneconduction thresholds. # 2004 Elsevier Ireland Ltd. All rights reserved. * Corresponding author. Tel.: +90 312 2150589l; fax: +90 312 2230528. E–mail address: (Y.K. Kemalog˘lu).0165-5876/$ — see front matter # 2004 Elsevier Ireland Ltd. All rights reserved.doi:10.1016/j.ijporl.2004.08.018  1. Introduction Although objective assessment of hearing in new-borns and infants has improved recently [1 — 3], puretone audiometry (PTA) is still an important tool inolder children, particularly in those with otitismedia.In children older than 24 months, frequency-spe-ci fi c thresholds (PTA) may be obtained by playaudiometry with earphones (PAE) or without ear-phones (free  fi eld audiometry, FFA) until the agethat they could be tested with PTA as in the adults(conventional audiometry, CA) [3,4]. In PTA assess-ment, the requirement to comprehend and concen-trate to the task of responding is essential.Therefore, assessment of hearing of children byPTA improves by age [4,5]. However, as stated byMRC (Multi-center Otitis MediaStudy) Group [6], ourknowledgeaboutthefactorsthatcouldaffectPTAinchildren is limited. In addition to age, some otherfactors likedegree of hearing loss, presenceof otitismedia, concentration of the child and test methodcan affect assessment of pure tone thresholds inchildren [3 — 10].Our purpose in this paper was to evaluate per-formance of children older than 24 months on PTAtesting (CA, PAE and FFA), and role of age, concen-tration level and presence of otitis media in testingprocess. 2. Materials and methods This study was prospectively performed in Hearing,Speech, Voice and Balance Disorders Center of theUniversity. We prospectively analyzed 100 consecu-tive children referred for PTA assessment from thedepartments of ENTand pediatrics according to thefollowing criteria. The exclusion criteria were pre-sence of any craniofacial or neurological handicap,chronic systemic illness, hospitalization due to anyacute or chronic illness, and children referred fordelayed speech. Only outpatient children agedbetween 24 and 120 months whose ear examinationwas clearly noted in the  fi le were included to thestudy.All of the tests were performed in an acousticallyshielded sound unite which was designed for chil-dren by using an Interacoustic (AC40) audiometry.All PTAs were conducted by two experiencedaudiologists (second and third authors of the study),who were not informed about content of the study.Before starting the test, the child was taken to thetest unit and pre-test evaluation was performed; inthis process, initial task of the audiologists was toassess his or her ability to concentrate on the test,to attenuate his or her fear and to establish a goodworking relationship. After this, decision on testtype (CA, PAE or FFA) was made by the audiologist.Then, the test was started and the followingpoints were noted:(a) Concentration of the children during PTA: It wasmeasured by using 10 cm visual analogue scale(VAS). The audiologists recorded the degree of concentration level of each child on this scale.While a score of 0 represented no concentrationduring the test and a score of 10 indicated thathe or she was fully concentrated to all steps of the test.(b) Fearfromthesound:Itwasnotedas ‘ present ’ or ‘ absent ’ .(c) Test duration: It was noted as minutes andmeasured after earphones were put on, whenthe test was done by using earphones.(d) Test interruption: It was noted as  ‘ present ’  or ‘ absent ’ .(e) Test cessation and delay to another day: It wasnoted as  ‘ present ’  or  ‘ absent ’ .(f) Test change: When the audiologist needed tochange test method after starting the test, itwas noted.At the end of the study, means of both bone andair conduction thresholds at 500, 1000, 2000 and4000 Hz were noted to calculate pure tone averages(PTAv) of bone and air conduction for each ear se-parately, and mean of air conduction PTAv found inboth ears in each child was calculated as mean h-earing level (MHL) of the child. The differences b-etween PTAv of air and bone conduction wascalculated as  ‘ gap ’  for each ear separately, and t-hen, mean of the values in both ears was calculatedas mean gap (MG).These data were evaluated according to type of the test and presence of otitis media with effusion(OME),andeffectsofageandtypeanddegreeofthehearing loss were also evaluated. Presence of OMEwas decided according to type of the tympanogramsand otoscopical  fi ndings. The ears with tympano-grams with no-peak, and peaked ones with pressurevalue lower than   199 mmH 2 O were accepted asthose with OME when otoscopical  fi ndings of thesecases were in accordance OME (dullness, retractionand vascularisation).Group differences in age, MHL, MG, concentra-tion level and test duration were statistically com-pared by Student ’ s  t -test. Presence of OME andproblems occurred during the test (test interrup-tion, test cessation, test change and fair from thesound) were tested by  x 2 test. Pearson correlationanalysiswasdonetoassessrelationshipbetweenthe210 Y.K. Kemalog ˘ lu et al.  following parameters: age, MHL, MG, concen-tration level and test duration. Further, step-wiseregression analysis was performed to understandwhich parameter(s) (MHL, MG, CL and age wasentered as independent variables) affected testduration.To understand the parameter affecting selectionof the test type by audiologists, PTA tests werescored as CA= 3, PAE = 2 and FFA= 1, and a correla-tionofthesescoreswithageandconcentrationlevelwasmadebyPearsontest,andthenstepwiseregres-sion analysis was done (dependent variable: testscore; independent variables: age and concentra-tionlevel).Forallstatisticalanalyses,  p -valuelowerthan 0.05 was accepted as signi fi cant. 3. Results It was found that audiologists could perform PTAtesting in 90 of 100 children whose mean age was73.5  54.08 months. OME was present in 60 chil-dren (unilateral: 16, bilateral: 44), and PTA testingcould be performed in 52 of them (86.67%) ( x 2 test,  p > 0.1). The mean age of the children who couldnotadapttoanyofPTAmethods(CA,PAEorFFA)was43.50  18.83 months, and 5 of them were under 36months while 3 were older than 48 months. It wasfound that audiologists could not obtain pure tonethresholds in 55.56% (5/9) of the children who wereyounger than 36 months, while 20% (2/10) of thechildren between 36 and 48 months of age failed inPTAtesting( x 2 test,  p > 0.1).Thisratiowasfoundtobe3.70%(3/81) inthechildrenolder than 48monthsof age. The difference between three age groups(24 — 36, 37 — 48 and 48 — 120 months) were statisti-cally signi fi cant ( x 2 test,  p < 0.001).In Table 1a, methods of PTA are shown. In  fi vechildren in which CA was decided, the test wasturned to PAE (5/25, 20%), while PAE was changedto FFA in two children (2/63, 3.17%) ( x 2 test,  p < 0.001). Altogether, PAE was performed in themajority of children (73.33%). CA was achieved in22.22% of the children in which pure tone thresholdswere obtained. These ratios were 69.23 and 25% inthose with OME, respectively ( x 2 test,  p > 0.1). Theoverall achievement of the audiologists to obtainpure tone thresholds from both ears were 86%. Thisratio was 84.48% in the children with OME ( x 2 test,  p > 0.1) (Table 1b).The children whose CA could be performed wereolder than PAE group; but the difference was notstatisticallysigni fi cant(Table1a).Testduration,VASvalues of concentration level and MG were notPure tone audiometry in children 211 Table 1a  Mean age, mean hearing level (MHL), mean gap (MG), test duration and concentration level vs. test typeCA PAE FFA No PTA n  20 66 4 10 n (OM) 13 36 3 8Age 98.50  19.74 73.08  62.01 31.00  9.56 43.50  18.83PTAv (dB)Left 20.94  19.40 14.04  13.54 42.17  32.92  — Right 24.52  26.00 14.67  15.88 42.17  32.92  — MHL * 22.73  20.30 14.35  12.69 42.17  32.92  — Gap (dB)Left 11.44  10.79 9.39  11.84  — — Right 12.59  13.13 10.51  14.97  — — MG ** 12.01  9.94 9.95  11.83  — — Test duration (min) ** 18.95  6.95 21.18  6.55 16.50  5.07  — Concentration (VAS) ** 6.83  2.01 6.83  2.01 5.00  1.63  — n : number of the children;  n (OM): number of the children with OM. *  p < 0.02. **  p > 0.1. Table 1b  Mean age, mean hearing level (MHL), meangap (MG), test duration and concentration level in thechildren with or without OME, in which PTA wasachievedOME (+) OME (  ) n (OM) 52 38Age 68.86  22.74 86.63  71.01MH 20.71  11.11 10.81  17.75MGL *,a 17.43  8.57 1.57  7.77Test duration (min) 21.79  6.88 19.16  6.14Concentration (VAS) 6.90  2.20 7.30  1.74 a Thestatisticalanalysisforthisparameterwasdoneonthedata of 49 and 37 children in which bone and air conductionthresholds were separately obtained in each study group. * Student ’ s- t  test,  p  = 0.003.  different between CA and PAE groups, while MHLwas signi fi cantly higher in CA group (Student ’ t -test,  p < 0.02) (Table 1a). The percentage of the childrenwith OME was not statistically different betweenPAE and CA groups ( x 2 test,  p > 0.1) (Table 1a).While there was no signi fi cant difference in age,MHL, test duration and concentration level betweenthechildrenwithandwithoutOME(Student ’ s t -test,  p > 0.1), MG was signi fi cantly higher in those withOME (Student ’ s  t -test,  p  = .0.003).The problems occurred during PTA are pre-sented in Table 2a. The ratio of the children inwhich no problem was detected was not differentbetween CA and PAE tests ( x 2 test,  p > 0.1) (Table2a). Major problem faced during CA or PAE was testinterruption. While test was postponed in 1 of 2children in which CA was interrupted, 8 of 10 chil-dren who interrupted PAE was persuaded to returnand complete to the test ( x 2 test,  p > 0.1). Theconvenience of the pure tone thresholds was notdifferent between CA and PAE tests ( x 2 test,  p > 0.1).When the children with and without OMEwere compared regarding test problems and con-venience of the thresholds (Table 2b), only differ-ence was found in the number of children in whichpure tone thresholds were not convenient; it wassigni fi cantly higher in children with OME ( x 2 test,  p < 0.05).The correlation analysis showed that therewas a signi fi cant positive correlation betweenage and concentration level; further, test durationpositively correlated with MG and MHL (Table 3a).Then, stepwise regression analysis was performedfor test duration, and only MG was found asdependent variable of the test duration (  p  = 0.002).As seen in Table 3b, test type score was found tobe positively correlated with both age and concen-tration level, and stepwise regression analysisshowed that concentration level was only depen-dent variable of test type score (  p < 0.0001). 4. Discussion Our data supported that, particularly by PAE,obtaining left and right ears ’  pure tone air andbone thresholds separately was more feasible inchildren older than 36 months and its applicationbecame higher in the ones older than 48months. While 14% of all children aged between24 and 120 months could not be tested forpure tone thresholds, it was only 6% in the childrenaged between 36 and 120 months. MRC groupreported that they did not obtain pure tone thresh-olds either by PAE or CA in 4.5% of the childrenbetween the ages of 3 and 7 years [7]. It was statedthat the test technique which is considered to beassociated with age and concentration level, shouldbe chosen according to child ’ s cooperation[3,4,7,10]. In this study, our data clearly demon-strated that audiologists ’  decision on either PAE orCA were associated with age and concentrationlevel, and it was found to be particularly dependenton concentration level of the child. We observedthat audiologists changed their decision in 20% of children in which CA was considered as the test of choice for PTA after initial observation, and per-formed PAE instead of CA. Initial observation shouldbe focused on which test method would providebetter concentration of the child for a convenient212 Y.K. Kemalog ˘ lu et al. Table 2a  The problems occurred in children during pure tone audiometryCA PAE FFA Total n  20 66 4 90Problems in PTANo problem (%) 18 (90.00) 56 (84.85) 3 (75.00) 77 (85.56)Crying and afraid (%) 1 (5.00) 3 (3.03) 0 (0.00) 4 (4.44)Test interruption (%) 2 (10.00) 10 (15.15) 1 (25.00) 13 (14.44)Test cessation and delay (%) 1 (5.00) 2 (3.03) 0 (00.00) 3 (3.33)Convenient thresholds (%) 19 (95.00) 62 (93.94) 4 (100) 85 (94.44) n : number of the subjects; PTA: pure tone audiometry. Table 2b  Comparison of the problems during the testin children with and without otitis media with effusionin which pure tone audiometry (PTA) was achievedOME (+) OME (  ) n  52 38No problem 42 35Crying and afraid 2 2Test interruption 10 3Test cessation and delay 2 1Convenient thresholds 47 38 * * x 2 test,  p < 0.05.  pure tone thresholds. When making decision on thispoint, the majority of tests were completedwithoutany problem (84.85 and 90% by PAE and CA, respec-tively) within a similar duration (21.18 and18.95 min, respectively). We also found that testduration was not associated with concentrationlevel and age. Instead, it was associated with typeand level of the hearing loss. We observed thatparticularly level of gap between air and bone con-duction thresholds was the main determinant of thetest duration.Inthisstudy,presenceofOMEinchildrenchangedonly the mean gap value, but no difference wasfound in MHL and age. Further, test choice did notpresent any difference in children with OME. Onlydifference was related with number of the childrenin which pure tone thresholds were found to beconvenient; it was smaller in OME group. Probably,this  fi nding explains the association between testduration and level of the gap between air and boneconduction. It may be speculated that efforts toobtain convenient thresholds in children increasedtest duration.It was reported that PAE group was youngerthan CA group and prevalence of OME was lowerin CA group [7]. However, we found that agedifference between PAE and CA groups, if any,was not signi fi cant, and the ratio of children withOME was similar between them. Further, in oppositeto the previous papers [7,10], PTAv was signi fi cantlyhigher in CA group than PAE group. This was due tothe fact that the children in our study group werereferred for PTA from the departments of ENT orpediatrics mainly due to any otologic or neurooto-logic disease, while previous researchers ’  studygroupsweretakenfromotitismediasurveys.Hence,while most of the children in non-OME group in theprevious papers wereprobably healthychildren, ournon-OME group included the children with otologicdiseases.We conclude that PTA is available in childrendepending on their age and particularly con-centration level; hence, performance in PTA isdirectly related with audiologists ’  assessment thechildren before starting the test. After this initialafford, PTA is completed without any problem in themajority although 10 — 15% of children interruptedthe test. Meanwhile, test duration appears to bedirectly associated with the work on detection of the gap between air and bone conduction thresh-olds. References [1] Y.S. Sininger, B. Cone-Wesson, Thereshold prediction usingauditory brainstem response and steady-state evokedpotentials with infants and young children, in: J. Katz(Ed.), Handbook of Clinical Audiology,  fi fth ed., LippincottWilliams & Wilkins, Philadelphia, 2002, pp. 298 — 322.[2] N.T.Shepard,Otoacoustic emissions, in: J.Katz(Ed.),Hand-book of Clinical Audiology,  fi fth ed., Lippincott Williams &Wilkins, Philadelphia, 2002, pp. 440 — 466.[3] A.O. Diefendorf, Detection and assessment of hearing loss ininfants and children, in: J. Katz (Ed.), Handbook of ClinicalAudiology,  fi fth ed., Lippincott Williams & Wilkins, Philadel-phia, 2002, pp. 469 — 480.[4] W.R. Hodgson, Evaluating infants and young children,in: J. Katz (Ed.), Handbook of Clinical Audiology,  fi fthed., Lippincott Williams & Wilkins, Philadelphia, 1994, pp.465 — 475.[5] A.F.Roche,R.M.Siervogel,J.H.Himes,Longitudinalstudyof hearing in children: baseline data concerning auditorythresholds, noise exposure and biological factors, J. Acoust.Soc. Am. 64 (1978) 1593 — 1601.[6] D.J. Orchik, W.F. Rintelmann, Comparison of pure-tone,warble-tone and narrow-band noise thresholds of young normal children, J. Am. Acad. Audiol. 3 (1978)214 — 220.[7] MRC Multi-centre Otitis Media Study Group, MRC Institute of Hearing Research (Notthingham, UK), In fl uence of age, typeof audimoetry and child ’ s concentration on hearing thresh-olds, Br. J. Audiol. 34 (2000) 231 — 240.[8] G. Thompson, B.A. Weber, Responses of infants and youngerchildren to behavioral observation audiometry (BOA), J.Speech Hear. Disord. 39 (1974) 140 — 147. Pure tone audiometry in children 213 Table 3a  Correlation analysis between mean age, concentration level (CL), mean hearing loss (MHL) and mean gap(MG)  AgeCL r  : 0.29,  p  = 0.004  CLTest duration p > 0.1  p > 0.1  Test durationMHL p > 0.1  p > 0.1  r  : 0.24,  p < 0.05  MHLMG p > 0.1  p > 0.1  r  : 0.35,  p  = 0.001  r  : 0.63,  p < 0.001 Table3b  Correlation of test type score with age, testduration, mean hearing loss (MHL), mean gap (MG) andconcentration level (CL) of the childTest type scoreAge  r  : 0.30,  p  = 0.003CL  r  : 0.60,  p < 0.0001Test duration  p > 0.1MHL  p > 0.1MG  p > 0.1
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