Recommended Procedure for Hearing Testing and Treatment of Hearing Loss
The preferred method of hearing assessment is age-appropriate audiologic testing through conventional audiometry or comprehensive audiologic assessment, with subsequent treatment determined by the type and severity of hearing loss identified. 1
Initial Hearing Assessment
For Adults and Children ≥4 Years:
- Conventional audiometry is appropriate, where the patient raises their hand when a stimulus is heard 1
- Testing should be performed in a quiet environment using earphones 1
- Each ear should be tested at 500,1000,2000, and 4000 Hz 1
- A fail criterion is >20 dB HL at one or more frequencies in either ear 1
- Pure-tone audiometry remains the gold standard for hearing evaluation in adults 1, 2
For Children 6 Months to 4 Years:
- Comprehensive audiologic evaluation by an audiologist is recommended 1
- For children 6 months to 2.5 years: Visual response audiometry is used, where the child associates sound stimuli with reinforcers like lighted toys 1
- For children 2.5 to 4 years: Play audiometry is used, where the child performs tasks in response to stimulus tones 1
- Ear-specific testing using insert earphones is recommended whenever possible 1
For Infants <6 Months:
- Auditory Brainstem Response (ABR) testing is the preferred method 1
- ABR can be performed in natural sleep up to 3-6 months of age 1
- For older infants requiring ABR, sedation may be necessary 1
Comprehensive Audiologic Evaluation
A complete audiologic evaluation should include:
- Thorough hearing-specific case history 3
- Otoscopic examination 3
- Ear-specific air and bone conduction threshold measures 3
- Speech audiometry measures 3
- Tympanometry to assess middle ear function 1
- Otoacoustic emission (OAE) measures to determine cochlear function 3
Interpretation of Results
Hearing loss is categorized based on severity:
- Normal speech: 0-20 dB 1
- Soft speech/Mild loss: 21-40 dB 1
- Moderate loss: 41-55 dB 1
- Moderately-severe loss: 56-70 dB 1
- Severe or profound loss: 71 dB or higher 1
And by type:
- Conductive: Outer or middle ear problem 4
- Sensorineural: Cochlear or auditory nerve problem 4
- Mixed: Combination of conductive and sensorineural 4
Treatment Recommendations
For Conductive Hearing Loss:
- Treatment of cerumen impaction with irrigation or curettage if present 2
- Referral to an otolaryngologist for evaluation and possible surgical intervention 2
For Sensorineural Hearing Loss:
- Referral to an audiologist for hearing aid evaluation 2
- For mild to moderate hearing loss: Conventional hearing aids 5
- For severe to profound hearing loss unresponsive to hearing aids: Consider cochlear implant evaluation 2, 5
For Children with Otitis Media with Effusion (OME):
- If bilateral OME persists for ≥3 months with documented hearing difficulties, tympanostomy tube insertion should be offered 1
- Any child with hearing loss detected prior to tympanostomy tube insertion should have postoperative testing to confirm resolution 1
Special Considerations
- Sudden sensorineural hearing loss (≥30 dB loss within 72 hours) requires prompt otolaryngology referral 2
- Asymmetric hearing loss (>15 dB difference between ears) requires further evaluation, possibly including imaging 3, 4
- For patients with persistent symptoms, re-examination at 3-6 month intervals is recommended until resolution or additional intervention 3
Common Pitfalls to Avoid
- Do not rely solely on tuning fork tests for clinical screening due to insufficient accuracy 3
- Developmental abnormalities or behavioral problems may preclude accurate results on routine audiometric screening; refer these patients to specialists with appropriate equipment and expertise 1
- Do not order routine laboratory tests for sudden hearing loss unless specific risk factors are present 3
- Do not overlook the importance of post-intervention hearing testing to confirm resolution or identify persistent issues 1