In the office setting, those children who refer on OAE screening should have an in-office tympanometry test (or screening with acoustic otoscope, see below) to exclude middle-ear effusion as a cause of the hearing loss. As OAE screeners generate a pass or refer result, pediatricians should consider performing a pure tone audiogram to determine the hearing threshold for the child. Be aware that 20% of 3- to 5-year-old children will not be able to be screened by pure tone audiometry and those unable to be screened should be evaluated by an audiologist.
Hearing screeners such as the Bio-logic AuDX PRO and Bio-logic AuDX PRO FLEX from Natus Medical (Pleasanton, California) are modular devices that facilitate screening in the primary care office. The Bio-logic AuDX PRO can be configured to display a cartoon to distract a child during the brief OAE screen. Additionally, it can be used to perform pure tone audiometry on children who refer on OAE screen or for those suspected as having auditory neuropathy. The Biologic AuDX PRO FLEX provides all the capabilities of the AuDX PRO as well as providing tympanometry capability. In the latter situation, one device provides all the hearing screening capability a practice needs.
Every child with hearing loss should have a visual inspection of the tympanic membrane and ear canal. Cerumen impaction, serous otitis, acute otitis, tympanic membrane perforation, otosclerosis, and cholesteatoma can contribute to conductive hearing loss. The inspection can be done with a standard otoscope using pneumatic otoscopy to check the mobility of the ear drum. In the real world, pneumatic otoscopy is rarely employed by pediatricians. Otoscopy also can be difficult in an uncooperative child or when cerumen obscures the view of canal and tympanic membrane.
The Wispr Digital Otoscope from WiscMed (Madison, Wisconsin) allows one to insert a small speculum into the ear canal while guiding insertion by looking at the viewing screen. One can then capture images or select images from a video and share with parents. These videos can be imported into the medical record and shared with audiologists and otolaryngologists (ENTs), and used for comparison purposes when one decides to monitor the resolution of a perforation or otitis.
Per the guidelines issued by the AAP in 2013, one needs to visualize a bulging tympanic membrane or intense erythema of the tympanic membrane in addition to documenting the presence of fluid in the middle ear space to diagnose otitis media.10 Assessment of fluid in the middle-ear space can be done with pneumatic otoscopy or with tympanometry. Both require a cooperative child in order to obtain and maintain a seal between the speculum or probe and the wall of the ear canal.
1. Joint Committee on Infant Hearing. Year 2019 position statement: principles and guidelines for early hearing detection and intervention programs. JEHDI. 2019;4(2):1-44.
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3. Centers for Disease Control and Prevention. 2017 Annual Data Early Hearing Detection and Intervention (EHDI) Program. Last reviewed December 5, 2019. Accessed April 8, 2020. https://www.cdc.gov/ncbddd/hearingloss/ehdi-data2017.html
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