Hearing Status: 3- to 5-Year Olds
Audiometry was not conducted in 3- to 5-year olds (n = 555), therefore findings were based on DPOAE and tympanometry results. The prevalence of absent DPOAEs was 7.1E% (95% CI: 3.9, 12.3) and 14.5% (95% CI: 10.0, 20.4) had flat tympanometry results.
Hearing Status: 6 to 11 Versus 12- to 19-Year Olds
Qualitatively, approximately 8.1% (95% CI: 5.7, 11.4) of 6- to 11-year olds had HL for any PTA compared with 7.4E% (95% CI: 4.8, 11.2) of 12- to 19-year olds with a slightly higher HL prevalence in the younger versus older age group observed for all PTA HL categories (Tables 1–5). Among participants aged 12 to 19 years, 5.3% (95% CI: 4.1, 6.9) had flat tympanometry results. Although the prevalence of flat tympanometry could not be determined in 6- to 11-year olds due to small sample size, 5.7% (95% CI: 4.4, 7.4) of 6- to 19-year olds had flat tympanometry results.
Tympanometry and DPOAEs
“Flat” tympanometry results were found in 7.8% (95% CI: 6.0, 10.1) of youth, aged 3 to 19 years. The estimated prevalence of “flat” tympanometry results and absent DPOAEs in one or both ears among Canadians aged 3 to 19 years was less than 3.5%.
The prevalence of absent DPOAEs found in 3- to 5-year olds (7.1E%; 95% CI: 3.9, 12.3) was significantly higher (p < 0.05) than for 6- to 19-year olds (3.4E%; 95% CI: 2.1, 5.3). The “E” denotes a large CV (hence the wide confidence interval) indicating that a high sampling variability is associated with these DPOAE estimates, and signaling cautious interpretation. For 6- to 19-year olds, 49.3E% (95% CI: 26.6, 72.3) of those with absent DPOAEs had audiometric results showing HL: LFPTA, HFPTA, and or FFPTA. Correlational analysis was conducted between absent DPOAEs and measured HL and ranged from 0.62 to 0.71 using tetrachoric correlation, a statistic used for measuring the strength of the association between dichotomous variables which have a bivariate normal distribution.
Sensorineural Hearing Loss
It is estimated that less than 2.2% of Canadian youth have SNHL (data not shown).
Otoscopy was conducted on all participants eligible for the hearing evaluation (n = 2591); 16 participants were missing wax/pus data. Among the remaining 2575 participants, aged 3 to 19, 385 were found to have excessive or impacted pus or wax in one or both ears, corresponding to a weighted estimate of 17.0%. No significant differences were observed among age groups, that is, 3- to 5-year olds (M = 19.9%; 95% CI: 14.7, 26.5), 6 to 11 (M = 14.7%; 95% CI: 11.6, 18.4) or 12- to 19-year olds (M = 17.1%; 95% CI: 13.0, 22.2).
Self-Reported Survey Results
Among Canadians aged 3 to 19, (n = 2601), 65.3% (95% CI: 61.7, 68.7) indicated that they never had their hearing tested by a health professional in the past. Among the 34.8% who did report having had their hearing tested in the past, an estimated 4.4% (95% CI: 2.8, 7.0) reported being diagnosed with a hearing problem. There was no difference between 6- to 11- and 12- to 19-year olds, with regard to the percent diagnosed with a hearing problem. A reliable estimate was not available for 3- to 5-year olds due to the small sample size.
Among participants aged 6 to 19 years, 0.6E% (95% CI: 0.30, 1.24) self-reported hearing difficulty using the HUI3. Less than 2.3% (n = 33) of youth in this sample, aged 3 to 19, reported an ear infection and or pain in one or both ears on the day of testing and were excluded from all or portions of the hearing evaluation.
This is the first population-based study to provide national estimates of hearing acuity among a representative sample of Canadian children and adolescents, aged 6 to 19 years. These findings indicate that 7.7% of participants, representing 387,000 Canadians, aged 6 to 19 years, had some type of HL in one or both ears. The prevalence of FFPTA HL, known to be important in understanding speech, is estimated to be 4.7%. A slightly higher percentage was found for HFPTA HL (6.0%) and LFPTA HL (5.8%). In contrast, the prevalence of HL in adults was reported to be 19.2%, 15.4%, and 35.4% for FFPTA, LFPTA, and HFPTA, respectively (Feder et al. 2015). The HL prevalence of 7.7% for Canadian youth is likely an underestimate of the true prevalence because 167 participants were excluded from audiometric evaluation. Furthermore, a certain percentage of the sample (estimated to be less than 2.3%) had an ear infection and or pain on the day of testing and could not participate in all or some of the hearing evaluation (Fig. 1).
Nonetheless, the present study findings indicating that the majority of HL in youth is unilateral and of slight to mild magnitude (i.e., below 40 dB) are consistent with previous research by Bess et al. (1998) and Niskar et al. (1998). Unilateral HL prevalence in school-aged children varies across studies from 0.1% to over 5.0% according to Lieu (2004), with the upper limit consistent with the present study’s unilateral HL findings of 4.3% to 4.8%. There is consensus among researchers that unilateral and or mild to moderate HL loss may have negative impacts on a child’s educational, language and social/communication outcomes (Culbertson & Gilbert 1986; Bovo et al. 1988; Brookhauser et al. 1991; Lieu 2004; Most 2004; Wake et al. 2004; Moeller et al. 2007; Lieu et al. 2010). According to Archbold et al. (2015), children with mild/moderate HL are less likely to be diagnosed at early ages, if at all. As these children develop speech and language skills which are intelligible to their teachers, their HL may go unnoticed. They are also less likely to receive school or health professional support compared with children who have severe or profound hearing impairments (Russ et al. 2002; Bamford et al. 2005). Studies have found this population of late-diagnosed children to have smaller vocabularies, greater difficulties listening over distance, and in noisy or reverberant classrooms such as portables. In addition, there is evidence that a greater signal to noise ratio is required for children with unilateral or mild HL compared to normal-hearing peers to understand speech (Bess et al. 1986; Bovo et al. 1988; Lieu 2004), placing them at a disadvantage in classrooms when trying to hear a teacher's voice above background noise (Crandell 1993). These children also tend to have difficulties with pragmatic and social skills, all of which may significantly affect learning and educational achievement (Moeller et al. 2007; Cone et al. 2010; Wolters et al. 2011; Marschark et al. 2015).
Some studies have included the slight HL category (i.e., 16 to 25 dB) in addition to a mild HL category (26 to 40 dB) or have used a different mild HL definition (20 to 40 dB) applied to the better or worse ear to define HL. As Niskar et al. (1998) points out, prevalence estimates based on better ear measurements define children with unilateral HL as having normal-hearing acuity; therefore estimates using worse ear may be a more accurate indicator of the extent of the problem. The present study used a greater than 20 dB HL threshold for the worse ear to estimate HL prevalence, which is based on the American Academy of Audiology (AAA) Childhood Hearing Screening Guidelines and the ASHA Guidelines for Audiological Screening for age 5 to 18 years, and has been used in other large scale studies (ASHA 1997; Bess et al.1998; AAA 2011; Wood et al. 2015).
However, a HL threshold of greater than 15 dB may be more appropriate for young children, such as preschoolers, kindergarten or early primary school age according to Goldberg and Richburg (2004). In particular, voiceless consonants may be missed impacting communication and language learning (Northern & Downs 2002; Goldberg & Richburg 2004), which may result in attentional difficulties, mild language delays and speech problems (Northern & Downs 2002). In an Australian study (n = 6581) of elementary school children (grades 1 and 5), those identified as having slight/mild bilateral SNHL (LFPTA and or HFPTA of 16 to 40 dB HL in better ear) had poorer phonologic discrimination and short term memory compared with their normal-hearing peers, however scores on language, reading, behavior, and quality of life measures were not significantly different (Wake et al. 2006). However, as the authors have noted, due to the small percentage of affected children (0.88%), the power is reduced for drawing conclusions regarding the impact of having slight/mild bilateral SNHL (Wake et al. 2006); other limitations include wide CIs for many outcome estimates and the exclusion of subjects with unilateral HL. There are research findings highlighting the importance of identifying minimal or mild HL in children (15 to 40 dB HL) due to difficulty understanding speech under adverse conditions and to avoid erroneous labeling of learning disabled or behaviorally challenged (Crandell 1993; Bess et al. 1998; Goldberg & Richburg 2004).
The HL threshold of 16 dB used by Niskar et al. (1998) is likely a major factor in the HL prevalence being nearly double that found in the present study (14.9% versus 7.7%). However, consistent with Niskar et al.’s findings, the present study found that thresholds were significantly worse at the 6 and 8 kHz frequencies compared with lower frequencies, and there were no significant differences in HL prevalence by age group. The suggestion of a slightly higher HL prevalence in 6- to 11-year olds compared with 12- to 19-year olds may be due to the higher prevalence of CHL that is generally found in younger aged children. However, given the wide CV and small sample size of 12- to 19-year olds in this study, analysis of future CHMS cycles will be useful in contributing to this body of knowledge.
It is well known that HL estimates for children/adolescents vary considerably across studies due to differing definitions of hearing impairment, variable age ranges, small sample sizes, selection bias, and inadequate sampling procedures (Bess et al.1998; Lieu 2004; Mehra et al. 2009). In a systematic review of US studies, the prevalence of mild to worse, unilateral or bilateral hearing impairment (conductive, sensorineural, or unspecified) above 25 dB ranged from 1.7 to 5%, in subjects aged 20 and under (Mehra et al. 2009). This is in contrast to Bess et al. (1998) who reported a prevalence of 11.3% for conductive and sensorineural HL and 5.4% for SNHL in a US study of 1218 elementary school children, using thresholds of less than 20 dB for bilateral and less than or equal to 20 dB for unilateral HL. In comparison, the present study which used the same HL threshold had a somewhat lower HL prevalence (7.7%). However, if the estimates of conductive HL (less than 3.5%) were included, the prevalence may be somewhat consistent with Bess et al. (1998) despite a few salient differences. The present CHMS sample was nationally representative and included a broader age group compared with Bess et al.’s study which focused on younger children recruited from one US school district. Table 8 shows the prevalence estimates of several population-based or large scale retrospective studies involving children and or adolescents.
As noted above, precise estimates of HL are tenuous due to the disparate definitions of HL across studies (Lieu 2004; Ross et al. 2010). The importance of controlling for abnormal middle ear function, that is, “flat” tympanograms, often associated with temporary CHL was highlighted by Ross et al. (2010). In the present study, less than 3.5% of participants, aged 3 to 19 years, had “flat” tympanograms and absent DPOAEs (one or both ears). Although HL prevalence for this subgroup could not be estimated, participants with this profile were categorized as suggestive unilateral or bilateral CHL, which may be temporary. An Australian study (n = 6581) of elementary school children reported a CHL prevalence of 6.3% whereas the prevalence of slight mild bilateral SNHL was only 0.88% (defined as LFPTA and or HFPTA HL of 16 to 40 dB HL in the better ear with air bone gaps of <10 dB; Cone et al. 2010). The authors attributed this low SNHL prevalence to the rigorous exclusion of CHL cases using air and bone conduction tests (Cone et al. 2010).
There have been adult studies suggesting that otoacoustic emissions (OAEs) may be more sensitive than audiograms in detecting subtle changes in cochlear function, that is, "preclinical" signs of HL (Plinkert et al. 1999; Balatsouras 2004; Lapsley et al. 2004). Although fewer studies have been conducted in children, both Yin et al. (2009) and Georgalas et al. (2008) concluded that OAEs were a fast, efficient and feasible method for early identification of potential HL in preschool and school-aged children. In a subgroup of 2- to 6-year olds (n = 142) who underwent transient otoacoustic emission testing (TOAE) and audiometry (25 dB HL threshold), no child who passed TOAE screening had audiometric results indicating a HL (Yin et al. 2009). Similarly, Georgalas et al. reported that in their study of 6- to 12-year olds (n = 196), virtually all children with 30 dB HL or worse were identified using TOAE testing, and 90% of children with a 25 dB HL or worse were identified. In the present study, approximately half of the 6- to 19-year olds with absent DPOAEs also had HL worse than 20 to 25 dB. Similarly, other researchers have reported a strong association between absent OAEs and HL worse than 30 dB (Amedee 1995; Van Cauwenberge et al. 1995). It is likely that the majority of the preschoolers in the present study with absent DPOAEs (7.1E%) also had some degree of HL. However, approximately three-quarters of these participants had flat tympanograms indicating that HL in this proportion was likely conductive. CHL, which is usually temporary, may nevertheless lead to permanent HL if left untreated. Nonetheless, the accuracy and time efficiency (30 to 60 sec) of OAE testing (DPOAE or TOAE) makes it an ideal HL screening tool for young children.
When comparing OAE results, a study of 744 preschoolers by Yin et al. (2009) found that just over 12% had absent TOAEs in one or both ears which are higher than the present study results. However, the present study sample was smaller (n = 555) and consisted of a nationally representative cohort (aged 3 to 5) compared with 2 to 6 years olds recruited from publicly funded preschools in low income areas of Los Angeles (Yin et al. 2009). These factors may play a role in the higher percentage of absent OAEs reported by Yin et al. (2009). The higher prevalence of absent DPOAE for 3- to 5-year olds in the present study compared with 6- to 19-year olds, is consistent with findings by Georgalas et al. (2008); and was attributed to a higher prevalence of otitis media often seen in younger children. It is important to identify children with otitis media because it may cause temporary CHL, and if untreated, this condition can lead to permanent HL (Gates 1996).
Advocates of screening for HL in school-age children have pointed out that mild SNHL (20 to 40 dB) may be missed in infancy because universal newborn hearing screening methods are less sensitive to HL below 40 dB (Johnson et al. 2005). A large proportion of children with mild HL have passed newborn screenings but were later identified as having HL in the preschool or school-age period (Bamford et al. 2005; White & Muñoz 2008; Porter & Bess 2011). In 2011, the Canadian Paediatric Society Community Paediatrics Committee acknowledged the limitations of the universal newborn hearing screening and recommended that all children experiencing developmental or learning difficulties have their hearing evaluated. However, according to Wang et al. (2011), low-income or immigrant families face barriers in accessing medical services for their children including audiometric evaluation. Apart from isolated programs established by nonprofit organizations which offer routine hearing screening for inner city schools (Wang et al. 2011), there are no hearing screening programs for school-age children or adolescents being carried out across Canada.
Proxy-reported HL through a child’s parent or guardian may be carried out by family practitioners to screen for HL, however some reports have found that only 12% of physicians screened for HL during annual physical exams with about half using a questionnaire (Cohen et al. 2005; Kochkin & Trak 2005). However, among participants aged 6 to 19 years in the present study, the prevalence of reported HL (either through proxy or self-report) was less than 1%, which is substantially lower than the 7.7% that were found to have a measured HL above 20 dB. A wider discrepancy between self-reported and measured HL was reported by NHANES (Niskar et al. 1998)—3.4% compared with 14.9%, respectively. The larger discrepancy may be partially attributed to Niskar et al.’s (1998) use of a 16 dB HL threshold and or other methodological differences such as the cutoff age for proxy data. Furthermore, data collected by proxy may not reflect the child’s actual hearing status, especially when the severity of HL is mild (Stewart et al. 1999; Gates et al. 2003; Meinke & Dice 2007). In fact, some studies have reported that only 50% of children with HL are actually identified by the use of questionnaires and checklists (Watkin et al. 1990; Kittrell & Arjmand 1997). Adolescents and parents provided poor self-report of hearing status in contrast to older adults when self-reported and measured HL were studied (Stewart & Ohlms 1999; Gates et al. 2003; Meinke & Dice 2007). The lack of a high quality adolescent hearing risk assessment capable of adequately capturing high-risk noise exposure behaviors was discussed by Sekhar et al. (2014). In this US study of 282 Grade 11 students, the validity of the Bright Futures adolescent screening tool being used by physicians was examined. No association between most of the screening questions and HL above 25 dB (based on the inability to hear two or more frequencies: 0.25, 0.5, 1, 2, and 4 kHz) using audiometry was found (Sekhar et al. 2014). The discrepancy between self-reported and audiometrically measured HL in the present study is also notable.
The present study finding indicating that 17% of Canadian children and adolescents, aged 3 to 19, having excessive or impacted earwax or pus, has potential hearing health and acuity implications. HL prevalence among this subgroup could not be examined; however, these conditions can mask the detection of existing HL or result in a future HL that can range from 5 to 40 dB (Roland et al. 2008). In a study of 1000 South African children, CHL from impacted earwax accounted for 10% of children failing a hearing screening test (Bhoola & Hugo 1997); impacted earwax was the most common problem found in 5120 Karachi children, aged 5 to 15, who underwent hearing evaluations (Hussain et al. 2011). Other studies have reported a range of impacted earwax prevalences: 10% of school children (Roeser & Ballachanda 1997), 12.3% of a representative sample (n = 1119) of Latin American children/adolescents (Godinho et al. 2001); 15.7% of 802 Tanzanian school children (Minja & Machemba 1996); and 24.4% of a representative sample of Bosnian/Herzegovinan 7- to 10-year olds (n = 1344) reported by Brkic (2010). In older adults, removal of earwax improved audiometric hearing thresholds for nearly half the study subjects (Gleitman et al. 1992); however, due to limited child/adolescent research in this area, it is unknown whether this procedure would yield similar results.
It is interesting that nearly two-thirds of young Canadians, aged 3 to 19, reported they had never before had their hearing tested. At present, in Canada, a hearing evaluation for a child is more likely to be initiated when a concern by a parent or teacher is expressed, or when the child is at high risk due to a family history or an underlying medical condition. However, as Wang et al. (2011) has reported, medical access and follow-up audiology services may be limited for economically disadvantaged or immigrant families. Furthermore, as these and other study findings have shown, children and adolescents are more likely to have unilateral or mild HL, which may go undetected by the classroom teacher, the parent or even the child (Dodd-Murphy et al. 2014).
The cross-sectional design of this study allows a snapshot of hearing acuity among Canadian youth; however, conclusions about changes in HL prevalence over time cannot be made until future CHMS hearing cycles are analyzed. One limitation of the present study is that audiometry was not conducted on 3- to 5-year olds. Therefore, HL findings were based on DPOAE and tympanometry results. Second, the small sample size for specific subgroups, that is, 3- to 5-year olds with absent DPOAEs, limited the analysis that could be carried out. The population weighted estimate of these subgroups often yielded a large CV (between 16.6 and 33.3) denoted by superscript E and categorized as “marginal.” This indicates that the estimate has low precision due to the high sampling variability associated with the estimate and these findings should therefore be interpreted with caution. However this limitation is expected to be ameliorated once Cycle 4 CHMS hearing data is available for analysis.
The upper age cutoff of 19 years for this article was selected to be consistent with previous CHMS publications (Statistics Canada 2015a). The use of a >20 dB HL threshold cutpoint for 6- to 18-year olds, and ≥26 dB for 19-year olds in the present study is in accordance with the AAA guidelines and the ASHA pediatric audiologic screening guidelines which “pertain to infants and children age birth through 18 years” (ASHA 1997; AAA 2011); and was also adopted by the National Workshop on Mild and Unilateral Hearing Loss (2005) and used in several large scale studies (Bess et al. 1998; Wood et al. 2015). Nonetheless, the use of these HL threshold cutpoints instead of the >15 dB HL threshold cutpoints used by Niskar et al. (1998) and by Shargarodsky et al. (2010), which would have allowed comparison to NHANES studies that examined HL prevalence among a national sample of U.S. children, represents a limitation of this study and may have resulted in an underestimate of HL prevalence. However, as Ross et al. (2008) and others have noted, there is no standard definition of unilateral or bilateral HL, with variable definitions used among countries, states/provinces and providers. The use of two different HL thresholds in this study represents a minor limitation; however, the small number of 19-year olds in our sample (n = 104) diminishes its overall impact on the findings.
The response rate for this study was close to 50% and did not include an analysis of those who refused to participate in the physical health measures portion of the study. Therefore, potential selection bias in those who agreed to participate may be a possibility, because this group may have a higher prevalence of hearing challenges than those who refused or vice versa. Another limitation is the lack of bone conduction testing in the present study which may have led to CHL being missed in some cases; and represents a limitation insofar as it adds to the uncertainty of the true prevalence of permanent HL. In addition, the CHMS hearing evaluation scoring protocol used during otoscopic examination did not allow for differentiation between pus and wax. Although it is assumed that earwax would be more prevalent than pus, it may be beneficial to revise this particular scoring protocol so that differentiation is possible in future studies. CHMS study results are considered representative of the Canadian population; however, sampling exclusions such as residents from the three territories, First Nations Reserves, and other Aboriginal settlements as well as full-time members of the Canadian Forces, represent a limitation. However, as these exclusions represent approximately 4% of the target population, this limitation may be considered minor.
Self-reported HL was evaluated using hearing questions from the HUI3. This tool has not previously been validated with regard to self-reported HL sensitivity and objective audiometric measures. Furthermore, estimates of self-reported and measured HL based on the same respondents could not be carried out due to small age group sample sizes. Therefore, self-reported HL data, that is, HUI3 data from the 2013 Canadian Community Health Survey was used in the analysis. These factors represent a limitation in terms of the validity and reliability of self-reported HL data in the present study. The development of a robust self-report HL tool tailored to children and adolescents for use in future studies would be beneficial. Last, an assessment of participants’ exposure to leisure noise would lead to a more comprehensive understanding of HL.
The authors thank all the families and children who participated in this study.
This research was funded by Statistics Canada and Health Canada.
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Adolescents; Audiometry; Children; Distortion product otoacoustic emissions; Hearing loss; Population based
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