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Routine hearing screening in primary care for adult populations using Distortion Product Otoacoustic Emissions testing

Patterson, Beverly M. DNP, FNP-BC (Family Nurse Practitioner)1; Renaud, Michelle PhD, RN (Faculty)1

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Journal of the American Academy of Nurse Practitioners: July 2012 - Volume 24 - Issue 7 - p 400-404
doi: 10.1111/j.1745-7599.2012.00718.x
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Hearing loss is a common condition affecting over 40% of the adult population (Pirozzo, Papinczak, & Glasziou, 2003). Hearing loss has been associated with depression and suicide (Turner, Windfuhr, & Kapur, 2007). Low self-esteem, decreased social activity, and social isolation have also been implicated as symptoms of hearing loss (Turner et al., 2007). Crews and Campbell (2004) identified hearing loss to be associated with disappointment in self and frustration. As the population ages, the prevalence of hearing loss is expected to increase (Zhan et al., 2009). Despite the negative implications of hearing loss, currently, there is no standard of practice for the routine screening of hearing loss in the primary care setting for adults (National Guidelines Clearinghouse, 2010).

Hearing loss is detrimental to quality of life; however, because hearing loss can occur gradually over years, individuals may not be aware of the worsening of hearing loss. Therefore, the current practice standards, of screening for hearing loss only if the patient requests it, are greatly outdated. Hearing loss is the second most prevalent impairment in the United States (Lee, Gomez-Marin, & Lee, 1996). Although there is an increase in frequency of self-reported hearing loss, there have not been many studies on the prevalence of hearing loss (Cruickshanks et al., 1998).

Screening guidelines and tools

The American Academy of Family Physicians (AAFP) recommends screening all newborns (National Guidelines Clearinghouse, 2010). In addition to newborn hearing screening, school-aged children are also screened during school physicals and by the school nurse. However, for the other large portion of the population, those 21 years of age and older, the AAFP recommends hearing screening only for those who complain or question hearing loss (National Guidelines Clearinghouse, 2010). Unfortunately, many with hearing loss are not aware of their hearing loss and thus would not consider hearing loss as a problem and therefore would not bring this to the primary care provider's attention (Hsin-Pin, Chin-Yu, & Pesus, 2009).

There are various screening tools used for hearing loss; however, there is no standardization of these tools for use in primary care settings. A screening tool that can be used is a self-questionnaire. This is a commonly used tool, and further hearing evaluation is performed if the findings on the questionnaire recommend the need for further screening (National Guidelines Clearinghouse, 2010). Unfortunately, the self-questionnaire screening tool has a low sensitivity of 71% (Pirozzo et al., 2003). Hsin-Pin and colleagues (2009) found that 45.5% of study participants actually had hearing loss; however, only 11.6% self-reported a hearing problem. Therefore, it is important to investigate other screening methods and put in place a standard for primary care hearing screening.

The Whispered Voice Test is a screening tool that may be used by primary care providers for screening hearing loss. The provider stands behind the patient and whispers a word at varying distances (Yueh, Shapiro, MacLean, & Shekelle, 2003). This screening tool has its limitations because voices vary from provider to provider; standardizing this tool is difficult (Yueh et al., 2003). Furthermore, the Whispered Voice Test requires the participation of the person being tested, which can be an issue if dementia or developmental delay is present.

Another screening tool that can be used is Distortion Product Otoacoustic Emissions (DPOAE) testing. When sound is transmitted to the cochlea, the outer hair cells of the cochlea produce otoacoustic emissions (OAEs), which are low-level sounds (Dille, Glattke, & Earl, 2007). These OAEs are the byproducts of hearing (Dille et al., 2007). It is these emissions that can be measured, and as such, this type of screening method is easy and reliable. DPOAEs used for predicting auditory status is a reliable option for hearing screening (Dorn, Piskorski, Gorga, Neely, & Keefe, 1999). DPOAEs will correctly identify normal hearing and hearing impairment in adults (Lyons, Kei, & Driscoll, 2004). DPOAE testing does not require participation by the person being tested, which makes this a good screening method for any patient.

The purpose of this study was to assess the prevalence of undiagnosed hearing loss in two rural primary care settings and to determine if there is a relationship between hearing loss and patient demographics. Because DPOAE testing is an appropriate hearing-screening tool in the primary care setting, DPOAE testing was used for this study.


Study sites

This study was a nonexperimental, correlational design conducted at two study sites located in two rural counties in Virginia. There is cultural and socioeconomic diversity of the clientele within the serving area of both centers. Both centers serve both insured and uninsured patients; 27% of the centers' patient population consists of Virginia Medicaid, 15% Medicare, 23% third-party payers, and 35% self-pay. The centers serve many different ethnic groups, including White, African American, Hispanic, and Asian. Together, both centers combined serve approximately 11,000 patients per year.


Participants for the study were all those presenting to either primary care site who met the study inclusion criteria of 19 years of age and older with no previous history of hearing loss and no previous history of ear problems. All English- and Spanish-speaking patients were included in the study and all other languages were excluded as a result of availability of bilingual staff. The final convenience sample included 86 participants. Excluded were those who presented to the primary care provider with complaints of hearing loss or ear problems.

Institutional Review Board (IRB) approval and confidentiality

Old Dominion University Human Subjects IRB granted approval to conduct the study. There were no identifiers on the patient demographics questionnaire. The result of the hearing screening was recorded at the bottom of the demographics questionnaire and the questionnaire then remained with the researcher and placed in a folder to be used at a later time for data entry. The informed consent was the only data that identified the participants; therefore, this was kept separate from the demographic survey and DPOAE results.


As patients entered the health center for their scheduled appointments, they were asked to participate in the study by the researcher. The researcher gave the informed consent to each participant in the waiting room. There was a consent form written in both English and Spanish to include Spanish-speaking participants in the study. After the informed consent was obtained, the researcher gave each participant a demographic questionnaire. This was completed while the participant was in the waiting room waiting to be seen by the provider. After the provider's nurse called the participant back to the exam room, the researcher entered the exam room and discussed the informed consent with the participant and answered any questions the participant had. The participant then signed the informed consent if agreeable to participating in the study. The research team member then entered the exam room and performed DPOAE testing. This hearing screening took approximately 60 s. The results were recorded on the demographic questionnaire. The participant was given the option of getting a free audiometric test to be done at a local otolaryngology practice. The free audiometric test was offered after completion of the hearing screening so as not to coerce the participants into the study. These audiometric tests were donated by the local otolaryngology practice. This practice charges an uninsured patient $12.00 for audiometric testing.

Instruments/data collection tools

A researcher-developed instrument was used to collect the demographic data for this study (Figure S1). Sociodemographic variables included age, gender, ethnicity, education, and income. Hearing screening was assessed using a hand-held DPOAE device (ERO-SCAN OAE Test System by MAICO Diagnostics, Berlin, Germany [see Figure 1]). Although this instrument has the ability to provide frequency testing, for the purpose of this study, only the pass/fail readings were used. The last calibration was performed 8 months prior to the study and thus the instrument was not due for calibration at the time of the study. Calibration of this particular device should be completed once every 12 months.

Figure 1
Figure 1:
Hearing screening device: ERO-SCAN OAE Test System by MAICO Diagnostics, Berlin, Germany.

Beattie, Kenworthy, and Luna (2003) stated that an individual's true DPOAEs are within 5 decibels (a standardized measurement of sound levels) of obtained DPOAEs with a 95% probability. Other researchers have found that DPOAEs have a high reliability as well (Parthasarathy & Klostermann, 2001). DPOAEs have been found to be reliable for the pass/fail needed in a screening hearing test; however, they are not considered valid for a true measure of hearing loss in adults (Scudder, Culbertson, Waldron, & Stewart, 2003).


A power analysis was performed indicating that a sample size of 83 was needed for an alpha of .05 and a moderate effect of .30 (Munro, 2001). There were 86 people who agreed to participate in the study and underwent DPOAE testing. Of the 86 participants, 51.2% were found to not have hearing loss. Almost half of the study participants (48.8%) were found to have undiagnosed hearing loss using DPOAE testing. This finding is quite significant given that those who participated in the study had no knowledge or symptoms of hearing loss. Age is moderately correlated with adult hearing loss; this was statistically significant in our sample using Spearman's rank-order correlation with an alpha level of .05. There were no correlations between hearing loss and gender, socioeconomic status, level of education, and ethnicity. Demographic information is presented in Table 1.

Table 1
Table 1:
Demographic findings

Discussion and implications for practice

This research demonstrates the need for routine hearing screening at the primary care level in the adult population. Of the 86 participants screened, 48.8% failed DPOAE testing, indicating some degree of undiagnosed hearing loss. There was a moderate correlation between age and hearing loss. Past research studies have shown that hearing loss is related to advancing age; however, the average age of the participants in this study was 49.3 years, yet nearly half of the participants had hearing loss. This finding makes hearing screening in the adult population, other than the elderly, an important issue.

Hearing loss is typically associated with advancing age and, although there are no life or death risks associated with undiagnosed hearing loss, there are many detrimental side effects that affect quality of life. Routine hearing screening at the primary care level, treated much the same as taking vital signs, would identify those with hearing loss and increase the chances that proper referrals can be made in a timely fashion. There are standards of care regarding routine screening for hypertension, hypercholesterolemia, hyperglycemia, and various other disease processes; however, there are no standards for hearing loss screening. This may be because hearing loss is deemed less important and less detrimental if untreated. Practice guidelines for primary care should be developed to include routine hearing screening in adults. We found no correlation between hearing loss and socioeconomic status, ethnicity, gender, or education. Although more research should be done, it appears that hearing loss affects individuals of any ethnicity, socioeconomic status, or gender. Thus, there is no population that can be easily identified for the development of hearing loss; therefore, everyone should be screened.

Community-based programs to screen for undiagnosed hearing loss can take place at free health centers or fairs. However, to begin a program a proper screening tool and protocol will need to be established. Most self-report questionnaires are not sensitive enough or are subject to errors by the screener. DPOAE testing works well, but the device is costly (approximately $4,000.00) and the free health clinics may not be able to purchase or justify the expense as there is no way to recover the expense. Members of professional organizations, such as the Society of Otolaryngology Head and Neck Nurses or the American Academy of Otolaryngology/Head and Neck Surgeons, would be good resources to approach regarding the use of DPOAE devices. The possibility of a donated device from these resources may be an option for many underserved areas. Federal grants to start a screening program in underserved areas may also be an option. Healthy People 2020 included a goal to reduce the prevalence of hearing disorders, and with this in mind, government-funded screening programs will compliment this goal (Healthy People, 2020).

Although there have been many studies that confirm there is a relationship between hearing loss and age, our study demonstrates that hearing loss affects more age groups than just the elderly. Future research needs to be done to further investigate the middle age group to confirm that this is an age group that may be at risk. Additionally, with the increased use of electronic technology using headphones, the younger population may also be at risk and this requires further investigation as well.

Our findings may have a direct impact on the care administered by nurse practitioners (NPs) and other healthcare providers in the primary care setting. Hearing screening should be treated as another set of vital signs and should be performed during each visit to the healthcare provider. This can be accomplished by DPOAE testing at the primary care level and will provide reliable and valid results.


Hearing health is an issue that is not always addressed in primary care, yet some underlying disease processes that affect hearing may be present. Poor hearing health may affect the overall wellness of the individual and thus the importance of hearing screening is important for quality of life and even safety. NPs traditionally are advocates for the holistic care of patients and thus are positioned to become a voice for those with hearing loss and to develop a much needed routine hearing screening program that would be cost-effective and easy to perform. Doing so may increase the quality of life for many.


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Supporting Information

Additional Supporting Informationmay be found in the online version of this article.

Figure S1. Demographic collection tool.

Please note: Wiley-Blackwell is not responsible for the content or functionality of any supplementary materials supplied by the authors. Any queries (other than missing material) should be directed to the corresponding author for the article.


Adults; health screening; hearing loss; otoacoustic emission; advanced practice nurse (APN); health policy; health promotion

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