Hearing Screening: Procedures

Hearing Screening Procedures

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Risk Assessment

Risk Assessment and Hearing History

You may download Risk Assessment and Hearing History in printable format.

Ages
One month through 20 years

Purpose
To assess risk factors for lost to follow-up, delayed onset, progressive and acquired hearing loss

Equipment
C&TC, Early Childhood Screening hearing work sheet, School hearing worksheet or other documentation form

Procedure
Review the following:

  • For infants zero to one months of age or any initial C&TC visit of a child up to the age of three years:
    • Universal newborn hearing screening is required for all newborns by one month of age using either otoacoustic emissions (OAE) or auditory brainstem response (ABR) technology.
    • If an infant did not receive newborn hearing screening, it is recommended that an objective screening, OAE or ABR as appropriate, be performed as soon as this gap in screening is identified.
  • For all children:
  • For youth 11 to 21 years, review Indicators of Noise Induced Hearing Loss.

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Risk Assessment: JCIH Risk Indicators

You may download Risk Assessment: JCIH Risk Indicators in printable format.

Ages
One month through 20 years

Purpose
To assess risk factors for delayed onset, progressive and acquired hearing loss

Procedure
For initial interviews review all the following risk indicators (JCIH, 2007) which are associated with permanent congenital, delayed onset or progressive hearing loss in childhood. For subsequent visits review interim hearing history indicated by an *. Refer to the JCIH Position Statement (2007) in the appendix of this manual for more information on each indicator.

  1. Caregiver concern regarding hearing, speech, language, or developmental delay.*
  2. Family history of permanent childhood hearing loss.
  3. Neonatal intensive care for more than 5 days, or any of the following: extra-corporeal membrane oxygenation (ECMO), assisted ventilation, exposure to ototoxic medications (gentamycin and tobramycin) or loop diuretics (furosemide also known as Lasix) and hyperbilirubinemia that requires exchange transfusion.
  4. In utero infections such as cytomegalovirus (CMV), herpes, rubella, syphilis, and toxoplasmosis.
  5. Craniofacial anomalies, including those that involve the pinna, ear canal, ear tags, ear pits, and temporal bone anomalies.
  6. Physical findings, such as a white forelock that are associated with syndrome, known to include sensorineural or permanent conductive hearing loss.
  7. Syndromes associated with congenital hearing loss or progressive or late onset hearing loss such as neurofibromatosis, osteoporosis, and Usher syndrome; other frequently identified syndromes include Alport, Pendred, and Jervell and Lange-Nielson.
  8. Neurodegenerative disorders such as Hunter syndrome, or sensory motor neuropathies such as Friedreich ataxia and Charcot-Marie-Tooth Syndrome.
  9. Culture positive postnatal infections associated with sensorineural hearing loss including confirmed bacterial and viral (especially herpes virus and varicella) meningitis.
  10. Head trauma, especially basal skull or temporal bone fractures that required hospitalization.*
  11. Chemotherapy.*

PASS
Children for whom no risk factors for hearing loss are identified do not require referral.

REFER
Children who pass their newborn hearing screen but have a risk factor for hearing loss should be referred to an audiologist (ideally one specializing in pediatrics) for at least one diagnostic audiology assessment by age 24 to 30 months or as soon as a concern is identified. Infants and children with specific risk factors, such as those who received ECMO therapy and those with CMV infection, have a higher risk of delayed onset or progressive hearing loss require ongoing monitoring by an audiologist as soon as a concern is identified.

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Risk Assessment: Parent, Caregiver, Teacher, and Child Observation of Complaints and Behavior

You may download Risk Assessment: Parent, Caregiver, Teacher, and Child Observation of Complaints and Behavior in printable format.

Ages
All ages, especially in younger children

Purpose
To assess for indicators of potential hearing loss

Procedure
Ask the child to report any complaints about his or her ears. Ask the parents, caregivers or teachers to report any abnormal listening behaviors.

Complaints

  • Pain in the ear(s)
  • Fullness in the ear(s)
  • Noise in the ear(s)
  • Drainage from the ear(s)
  • Cannot hear

Behaviors

  • Tugs at the ear(s)
  • Asks to have things repeated
  • Turns side of head towards the speaker
  • Is inattentive to conversation
  • Watches speaker's lips
  • Shows strain when listening
  • Has difficulty with phonics
  • Tends to isolate
  • Talks too loudly or softly
  • Has a speech problem
  • Is not working to capacity in school
  • Makes frequent mistakes in following directions
  • Tends to be passive

PASS
Children for whom no hearing loss indicators are identified do not require referral.

REFER
Children with any complaints or concerns should be referred to their primary care provider to determine appropriate treatment or referrals.

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Risk Assessment: Indicators of Noise-Induced Hearing Loss

You may download Risk Assessment: Indicators of Noise-Induced Hearing Loss in printable format.

Ages
11 through 20 years of age

Purpose
To assess for the presence of noise induced hearing loss indicators

Procedure

Review the following hearing history questions with the caregiver or child

  1. Do you have a problem hearing over the telephone?
  2. Do you have trouble following the conversation when two or more people are talking at the same time?
  3. Do people complain that you turn the TV volume up too high?
  4. Do you have to strain to understand conversation?
  5. Do you have trouble hearing in a noisy background?
  6. Do you find yourself having to ask people to repeat themselves?
  7. Do people you talk to seem to mumble (or not speak clearly)?
  8. Do you misunderstand what others are saying and respond inappropriately?
  9. Do you have trouble understanding the speech of women and children?
  10. Do people get annoyed with you because you misunderstand what they say?
    (Buz Harlor & Bower, 2009)

PASS
Children for whom no hearing loss indicators are identified do not require immediate rescreening or referral.

Rescreen/ REFER
Children with one or more risk factors should have ongoing hearing screening. Refer if there is a positive response to one or more of the history questions and the child cannot be screened.

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Visual Inspection

You may download Visual Inspection in printable format.

Ages
All ages

Purpose
To check for signs of ear disease or abnormal development

Description
A systematic inspection of the external ear canal, surrounding tissue, ear canal, and tympanic membrane

Equipment
External inspection: Adequate lighting
Internal inspection: Otoscope*

Procedure
External: Inspect the pinna, the external auditory canal and the area around it for any abnormalities such as preauricular sinuses, skin tags, or atresia; check for position (set or tilt)of the ears, tenderness, redness or edema, signs of drainage, foul odor, wax build-up in the outer ear canal, or dermatitis. Refer to the Otoscopy and Tympanometry Manual for pictures and more information.

Internal: With the otoscope*, inspect the ear canal and tympanic membrane for signs of drainage, wax buildup, foreign bodies, redness of the ear canal, and other abnormalities; note presence or absence of normal tympanic membrane landmarks.

PASS
Children with normal appearance of all structures and no complaints of pain in the pinna or the tissue around the ear do not require referral.

REFER
Refer children with any abnormality to a medical provider. Do not proceed with audiometer screening if tenderness, signs of drainage, or foul odor is present; this should be an automatic referral. *If the screener has training and experience in using an otoscope. If the screener lacks training and experience in using an otoscope, the visual inspection should be limited to the external aspect of the ears.

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Pure Tone Audiometry Screening

You may download Pure Tone Audiometry Screening in printable format.

For information on the audiometer, refer to Audiometer Use, Care and Calibration.

Ages
3 through 20 years of age

Purpose
To identify children with suspected hearing loss

Description
A standard series of pure tones at set decibels presented to the child using pure tone audiometry

Equipment
Pure tone audiometer (for operating instructions refer to Audiometer Use, Care, and Calibration)

Facilities
Quiet room or area free from visual distractions

Procedure set-up

  1. Identify the child by name.
  2. Explain the procedure.
  3. Avoid using the term fail when speaking to the child; for terminology guidelines refer to Communicating results and follow-up.
  4. Position the child so they cannot see the front of the audiometer.
  5. Lay headphones on the table, facing the child. Set audiometer to 2000 Hz and maximum volume, and have the child practice raising either hand when a tone is heard.
  6. Refer any child who is unable to hear the tone at maximum volume to their primary care provider.
  7. Perform a visual inspection of the ears.
  8. Set decibel dial to 40dB and frequency dial to 1000 Hz.
  9. Place the red headphone on the child's right ear and the blue headphone on the left ear and ensure the headphones fit snugly on the child's head.

Screening children ages 3 through 10 years

  1. Set selector switch to "Right" and present 40dB at 1000 Hz.
  2. Turn dial to 20dB and present tones at 1000, 2000, and 4000 Hz.
  3. Turn selector switch to "Left" and present tones at 4000, 2000, and 1000 Hz.
  4. Set dial to 25dB and present tone at 500 Hz *; next, turn selector switch to "Right" and present tone at 500 Hz *.
  5. Present tones for one to two seconds; you may present the tone twice consecutively if needed for each screening frequency.
  6. If the child did not hear one or more tones in either ear, perform an immediate rescreen by repeating the entire pure tone series, preferably with a different screener and audiometer.
  7. Document screening results.

Screening children ages 11 through 20 years

  1. Set selector switch to "Right" and present 40dB at 1000 Hz.
  2. Turn dial to 20dB and present tones at 1000, 2000, 4000, and 6000 Hz.
  3. Turn selector switch to "Left" and present tones at 6000, 4000, 2000, and 1000 Hz.
  4. Set dial to 25dB and present tone at 500 Hz *; next, turn selector switch to "Right" and present tone at 500 Hz *.
  5. Present tones for one to two seconds; you may present the tone twice consecutively if needed for each screening frequency.
  6. If the child did not hear one or more tones in either ear, perform an immediate rescreen by repeating the entire pure tone series, preferably with a different screener and audiometer.
  7. Document screening results.

Considerations

  • Pure tone audiometry screening should take place in a very quiet room.
  • Perform an Environmental noise level check before performing screenings in any setting.
  • Pause the screening if any distracting noise occurs.
  • If the child does not appear to understand the directions, stop, take the head phones off, and reinstruct the child.
  • If the child did not hear one or more tones in either ear, perform an immediate rescreen by repeating the entire pure tone series, preferably with a different screener and audiometer.
  • If the child is unable to screen due to issues such as behavior or equipment malfunction, stop and document "unable to screen."
  • For children who are difficult to screen, refer to play audiometry on the next page.

PASS
A child who responds to all tones required for their age in each ear does not require rescreening or referral.

Rescreen Procedure
If you work in a clinic setting:

When the child does not respond to one or more tones on the immediate rescreen, refer to health care provider for immediate evaluation of the middle ear. 

  • If the child has factors which might impact hearing (fluid in middle ear, ear infection, etc.), then rescreen after middle ear condition is cleared or in 8-10 weeks. 
  • If the child has no visible middle ear condition, refer to audiology for immediate evaluation of hearing.

If you work in a community setting:

When the child does not respond to one or more tones on the immediate rescreen, schedule the child for pure tone audiometry rescreening in 14 to 21 days; refer to Rescreen and REFER criteria for further information.

*The 500 Hz tone may be eliminated from the screening procedures when the environmental noise level is too high based on the Environmental Noise Level Check.

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Play Audiometry

You may download Play Audiometry in printable format.

Ages
Children who are difficult to screen due to age or developmental level

Purpose
To obtain valid results with very young children (ages three to four years) or those children who have difficulty with standard pure tone audiometric methods

Description
Is a modification of standard pure tone screening; play audiometry conditions the child to respond to the sound by placing a toy in a container, rather than raising their hand

Equipment
Pure tone audiometer, stickers, and small child-safe toys such as animals, airplanes, cars, clothes pins, nested boxes, or pegs and pegboard

Facilities
Appropriate size table and chairs in a quiet, comfortable setting with limited distractions

Procedure

  1. First, practice without the headphones on.
  2. Lay headphones on the table, facing the child, with audiometer set at 2000 Hz and maximum dB level to ensure tone is audible.
  3. Hold the toy near your ear; assume a "listening" attitude and present tone.
  4. Indicate through facial expression the sound was heard and then drop the toy in a container, such as a pail; repeat as often as necessary until the child shows interest.
  5. Offer the toy to the child and place your hand on theirs to guide the first responses; encourage the child to wait until they hear the sound.
  6. When the child appears ready, present the sound and guide the child's hand to put the toy in the container.
  7. The child may give consistent responses after only one demonstration or may need several demonstrations to respond on their own.
  8. Once the child understands the play audiometry technique use the audiometric procedure as described in the pure tone audiometry screening section.
  9. Reward the child with praise after initial responses. If this is not effective, a tangible reward like a sticker may be given.
  10. If the child still is unable to do the screening after re-instruction, stop and document "unable to screen."

Considerations

  • The tone to response time varies between children; some children will drop the toy as soon as they hear the tone; others will wait until the sound goes off before dropping the toy.
  • If the child does not accept the headphones, the screener should try putting them on for only one or two seconds, removing and rewarding the child. Slowly increase the time with the headphones on.
  • A timid child will often benefit from watching other children successfully complete the screening.
  • If the child is unable to screen, refer to Rescreen and REFER criteria.

PASS
Same recommendations as pure tone audiometry screening: a child who responds to all four tones in each ear (25dB at 500 Hz; 20dB at 1000, 2000, and 4000 Hz) does not require rescreening or referral.

Rescreen
Same recommendations as pure tone audiometry screening: if the child does not respond to one or more tones on the immediate rescreen, schedule the child for pure tone audiometry rescreening in 14 to 21 days; refer to Rescreen and REFER criteria for further information.

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Pure Tone Threshold Screening* (Optional)

You may download Pure Tone Threshold Screening in printable format.

Ages
3 through 20 years of age

Purpose
To provide more detailed information on the child's hearing status, and to inform further referral and follow-up; does not provide a diagnosis

Description
A series of pure tones presented at decreasing decibel (dB) levels so that the softest dB level that the child consistently responds to at each frequency may be recorded

Equipment
Pure tone audiometer (for operating instructions refer to Audiometer Use, Care, and Calibration)

Facilities
Quiet room, free from visual distractions

Procedure
Set-Up

  1. Identify the child by name.
  2. Explain the procedure.
  3. Avoid using the term "fail" when speaking to the child; for terminology guidelines refer to Communicating results and follow-up.
  4. Position the child so they cannot see the front of the audiometer.
  5. Lay headphones on the table, facing the child, set audiometer to 2000 Hz and maximum volume, and have the child practice raising either hand when a tone is heard.
  6. Perform a visual inspection of the ears.
  7. Set the decibel dial to 40dB, set frequency dial to 1000 Hz.
  8. Place the red headphone on the child's right ear and the blue headphone on the left ear, and ensure the headphones fit snugly on the child's head.

Threshold Determination

  1. Screen right or better ear first.
  2. Present 1000 Hz tone at 40dB; decrease incrementally by 10dB until there is no response, or down to 0dB.
  3. At the level where there is no response, increase in 5dB increments until there is a response.
  4. Decrease 10dB until there is no response.
  5. Increase in 5dB increments until there is a response again.
  6. Repeat until there are two responses at the same dB level; record this as the threshold level.
  7. Repeat the same process for 2000, 4000, 8000, and 500 Hz.
  8. Switch ears and repeat.

Considerations

  • Pure tone audiometry screening should take place in a very quiet room.
  • Perform an Environmental noise level check before performing screenings in any environment.
  • Pause the screening if any distracting noise occurs.
  • Perform thresholds only when there are hearing concerns or a child does not pass pure tone audiometry.
  • Thresholds are solely to provide more information for referral.
  • Referrals are based on pure tone audiometry screening results regardless of threshold results.
  • Thresholds should not take the place of a medical or audiological evaluation.
  • Threshold screening requires advanced training.

PASS
A child who qualifies for threshold screening has not passed pure tone audiometry and should be managed per Rescreen and REFER criteria.

Rescreen/ REFER
Rescreens and referrals should be based on pure tone audiometry screening results regardless of threshold screening results.
*Performing threshold screening requires advanced training that may be beyond the skill of some screeners.

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Environmental Noise Level Check

You may download Environment Noise Level Check in printable format.

Ages
All ages

Purpose
To ensure the environment is quiet enough to perform pure tone audiometry screening.
An environmental noise level check is a recommended substitution in lieu of performing ambient noise level measurements as most local agencies and schools do not have such equipment.

Description
Perform pure tone audiometry threshold screening on another person with known normal hearing.

Equipment
Pure tone audiometer

Facilities
Quiet room or area free from visual distractions, where you are planning to perform hearing screening

Procedure

  1. Establish thresholds at 10dB below the screening level, 1000, 2000, 4000, and 6000 Hz at 10dB and 500 Hz at 15dB.
  2. Screeners who do not have training and skills to perform threshold screening can perform this check with pure tone sweep screening instead.
    • If a screener is performing pure tone sweep screening in lieu of threshold screening, they should complete the process twice.
  3. Do not use the area for screening if a person with normal hearing is unable to detect 1000 ,2000, 4000 Hz, 6000 Hz at 10dB and 500 Hz at 15dB.
  4. If the only frequency not audible in the screening environment is 500 Hz, then omit the 500 Hz level from today's screening protocol.

Considerations
The screener should maintain awareness of noise level throughout the screening procedure and avoid excess noise within the screening area including:

  • Talking.
  • Paper shuffling.
  • Movement of desks and furniture.
Avoid areas near:
  • Fans or air conditioners.
  • Hall traffic (reroute if possible).
  • Playground or street traffic.
  • Group activities (i.e. music, free play).
  • Bathrooms.
  • Lunchrooms.
  • Office equipment (i.e. copy machines).
  • Soft drink machines.
  • Refrigerators.
  • Open windows.
Keep the screening room uncluttered and free of visual distractions:
  • Avoid facing the child toward windows or open doors.
  • Avoid mirrors or other reflective surfaces.

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