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Wideband Reflectance in Newborns: Normative Regions and Relationship to Hearing-Screening Results

Hunter, Lisa L.1; Feeney, M. Patrick2; Lapsley Miller, Judi A.3; Jeng, Patricia S.3; Bohning, Susie4

doi: 10.1097/AUD.0b013e3181e40ca7
Research Articles

Objectives: To develop normative data for wideband middle-ear reflectance in a newborn hearing-screening population and to compare test performance with 1-kHz tympanometry for prediction of otoacoustic emission (OAE) screening outcome.

Design: Wideband middle-ear reflectance (using both tone and chirp stimuli from 0.2 to 6 kHz), 1-kHz tympanometry, and distortion-product (DP) OAEs were measured in 324 infants at two test sites. Ears were categorized into DP pass and DP refer groups.

Results: Normative reflectance values were defined over various frequency regions for both tone and chirp stimuli in ambient pressure conditions, and for reflectance area indices integrated over various frequency ranges. Receiver operating characteristic analyses showed that reflectance provides the best discriminability of DP status in frequency ranges involving 2 kHz and greater discriminability of DP status than 1-kHz tympanometry. Repeated-measures analyses of variance established that (a) there were significant differences in reflectance as a function of DP status and frequency but not sex or ear; (b) tone and chirp stimulus reflectance values are essentially indistinguishable; and (c) newborns from two geographic sites had similar reflectance patterns above 1 kHz. Birth type and weight did not contribute to differences in reflectance.

Conclusions: Referrals in OAE-based infant hearing screening were strongly associated with increased wideband reflectance, suggesting middle-ear dysfunction at birth. Reflectance improved significantly during the first 4 days after birth with normalization of middle-ear function. Reflectance scores can be achieved within seconds using the same equipment used for OAE screening. Newborns with high reflectance scores at stage I screening should be rescreened within a few hours to a few days, because most middle-ear problems are transient and resolve spontaneously. If reflectance and OAE are not passed upon stage II screening, referral to an otologist for ear examination is suggested along with diagnostic testing. Newborns with normal reflectance and a refer result for the OAE screen should be referred immediately to an audiologist for diagnostic testing with threshold auditory brainstem response because of higher risk for permanent hearing loss.

Wideband middle-ear power analysis (also known as reflectance) is better able than 1- kHz tympanometry to detect middle-ear dysfunction in newborns, aiding interpretation of referrals from otoacoustic emissions-based (OAE) screening. These babies are likely to pass re screening after a brief waiting period to allow middle-ear aeration. Detecting middle-ear problems could enhance second-stage screening as well as diagnostic testing for infants referred from newborn screening. Normative data are presented for reflectance and the reflectance area index (RAI) for newborns who received a pass or a refer for the OAE screen, for tone and chirp reflectance stimuli and a variety of frequencies/frequency ranges.

1Audiology Division, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; 2Otolaryngology, Head and Neck Surgery, V. M. Bloedel Hearing Research Center, University of Washington, Seattle, Washington; 3Mimosa Acoustics, Inc., Champaign, Illinois; and 4University of Utah Hospital, Salt Lake City, Utah.

Address for correspondence: Lisa L. Hunter, CCHMC, 3333 Burnet Avenue, Cincinnati, OH 45229-3039. E-mail:

Received September 27, 2009; accepted April 16, 2010.

© 2010 Lippincott Williams & Wilkins, Inc.