Most Common Causes of Failed OAE Testing
The most common causes of failed OAE screening are transient outer and middle ear conditions—specifically debris in the external ear canal (vernix caseosa, amniotic fluid, cerumen) and middle ear effusion—which produce false-positive failures in infants with normal cochlear function.
Primary Causes: Outer and Middle Ear Dysfunction
External Ear Canal Obstruction
- Debris in the ear canal is the leading cause of OAE failure, accounting for the majority of false-positive results 1
- Specific obstructing materials include 2, 3:
- Vernix caseosa (most common in newborns)
- Collapsed ear canal
- Cerumen
- Amniotic fluid residue
- Cleaning the external ear canal improves OAE pass rates from 76% to 91% in one study, demonstrating that debris is often the sole reason for initial failure 2
- Most newborns (84%) who failed OAE had external ear canal obstruction on otoscopic examination 3
Middle Ear Effusion
- Otitis media with effusion (OME) is present in 64.5% of infants referred for failed OAE screening 4
- Both OAE and ABR technologies are affected by middle ear dysfunction, as these transient conditions prevent sound transmission to the cochlea 1
- Middle ear effusion resolves spontaneously in 65.3% of affected infants, while 34.7% require tympanostomy tubes 4
- OAEs are particularly sensitive to middle ear effusions because the acoustic signal must travel through the middle ear space in both directions 1
Secondary Causes and Risk Factors
Maternal Factors
- Maternal tobacco use is significantly associated with OAE failure (95% CI of odds ratio: 0.04,0.59, p = 0.0078) 5
- Maternal drug use shows borderline significance for OAE failure (95% CI of odds ratio: 0.0065,0.72, p = 0.058) 5
- Amniotic fluid index in the third trimester is NOT associated with OAE failure 5
Infant Activity and Testing Conditions
- Motion artifacts interfere with test results, requiring the infant to be relatively inactive during testing 1
- The acoustic and electrical environment must be suitable for testing 1
- Repeated screening increases the likelihood of obtaining a pass outcome by chance alone when statistical probability is used for pass/fail decisions 1
True Hearing Loss (Less Common in Initial Failures)
Sensory Hearing Loss
- Among infants without middle ear disease who fail OAE, 78.9% have confirmed hearing loss on ABR 4
- However, 11% of infants with OME are subsequently found to have sensorineural hearing loss after effusion resolution 4
- OAE testing will miss mild or isolated frequency region losses 1
Neural Hearing Loss (Not Detected by OAE)
- OAE cannot detect auditory neuropathy/dyssynchrony because OAEs are generated within the cochlea and do not assess neural function 1
- Neural conduction disorders affecting the eighth nerve or auditory brainstem pathway will not be detected by OAE testing 1
Critical Clinical Pitfalls
Common Errors in Interpretation
- Do not assume permanent hearing loss without first ruling out external canal obstruction and middle ear effusion 2, 4, 3
- Perform otoscopic examination and clean debris before repeating OAE or proceeding to ABR 2, 3
- Consider tympanometry to assess middle ear status, which shows good correlation with otoscopy 3
Timing Considerations
- Retesting 3 days postpartum increases pass rates to 98% (at least one ear), as transient conditions resolve 3
- Many well-infant screening protocols incorporate outpatient rescreening within 1 month of discharge to minimize unnecessary referrals 1