Hearing Screening

Without intervention, hearing loss in adults may contribute to higher rates of unemployment (or lower levels of employment), social isolation, loneliness, and social stigma (Shan et al., 2020; Shukla et al., 2020; World Health Organization, 2021b). Age-related hearing loss is significantly associated with cognitive decline, and it increases the risk for cognitive difficulties and/or dementia? (Lin et al., 2011; Liu & Lee, 2019; Loughrey et al., 2018). Adults with hearing loss also experience a greater incidence of annual hospitalizations (Genther, Betz, Pratt, Martin, et al., 2015), a greater risk for falls (Lin & Ferrucci, 2012), and increased mortality (Genther, Betz, Pratt, Kritchevsky, et al., 2015).

Despite the burdens associated with untreated hearing loss, the average adult waits 8.9 years before taking action to address their hearing (Simpson et al., 2019). Asking older patients about hearing difficulties during routine medical exams significantly increases the identification of (and subsequent audiological referral for) individuals at risk for hearing loss (Zazove et al., 2020). Implementing routine hearing screenings may increase the identification, diagnosis?, and treatment of hearing loss in adults (Bennett et al., 2020; Yueh et al., 2003). There is guidance for establishing measures to screen individuals with increased hearing loss risk due to factors such as noise exposure, ototoxic chemical exposure, and/or increasing age (World Health Organization, 2021a).

Roles and Responsibilities

Roles and Responsibilities of Audiologists

Audiologists, by academic degree, clinical? training, and license to practice, are qualified to provide guidance, development, implementation, and oversight of hearing screening programs. Professional roles and activities in audiology include clinical services (e.g., screening); prevention and advocacy; and education, administration, and research.

Appropriate roles and responsibilities for audiologists include the following:

• Maintaining knowledge of the anatomy?, physiology, and pathophysiology of the auditory and balance systems.
• Remaining informed of research around hearing loss and related disorders.
• Providing oversight to hearing screening programs.
• Selecting screening protocols appropriate for the given setting, population, and screening personnel.
• Selecting, upgrading, and calibrating screening equipment and applicable software.
• Completing hearing screenings.
• Training and supervising screening personnel (e.g., audiology assistants).
• Selecting and/or developing educational materials for patients, families, and the public.
• Developing and implementing written policies and procedures on issues such as infection? control, screening process, and documentation.
• Communicating screening results to patients and their families, appropriate program representatives, primary care physicians, and diagnostic audiology centers.
• Providing counseling and education in a comprehensive, person-centered, and health-literate format.
• Completing rescreening and comprehensive diagnostic evaluations of hearing, auditory function, balance, and related systems.
• Referring to appropriate professionals to rule out other conditions, to determine the etiology of hearing loss, and to facilitate access to comprehensive services.
• Collaborating with other professionals to ensure appropriate follow-up and outcomes.
• Providing prevention information, promoting hearing wellness, and monitoring? acoustic environments.
• Educating medical professionals about the importance of hearing screening and the impact of chronic? diseases and ototoxic medications on hearing.
• Advocating for the communication needs of all individuals, including advocating for the rights to and funding of services for those with hearing loss and/or related disorders.

Roles and Responsibilities of Speech-Language Pathologists

Speech-language pathologists (SLPs) play a role in the hearing screening process. Professional roles and activities in speech-language pathology include clinical services; prevention and advocacy; and education, administration, and research.

Appropriate roles and responsibilities for SLPs include the following:

• Maintaining general knowledge of anatomy, physiology, and pathophysiology of the auditory system and the impact of hearing loss on communication.
• Educating the public and other professionals on the communication needs of individuals with hearing loss and/or related disorders.
• Completing hearing screenings.
• Communicating screening results to patients and their families.
• Reviewing a patient’s auditory status and their use of any communication devices, amplification devices, and/or hearing assistive technology in advance of speech, language, and cognitive assessment.
• Providing counseling and education in a comprehensive, person-centered, and health-literate format.
• Referring to appropriate professionals (e.g., audiologist, physician) to facilitate access to comprehensive services.
• Collaborating with other professionals to ensure appropriate follow-up and outcomes.
• Providing prevention information and promoting hearing wellness.
• Advocating for the communication needs of all individuals, including advocating for the rights to and funding of services for those with hearing loss and/or related disorders.

Hearing Loss Risk Factors and Associated Conditions

Hearing loss risk factors and associated conditions include

• chronic health conditions (e.g., diabetes?, cardiovascular disease, kidney? disease);
• disorders of the ear (e.g., Ménière’s disease, otosclerosis, autoimmune? inner ear disease);
• exposure to ototoxic and vestibulotoxic medications, such as those prescribed for the treatment of cancer, infection, and pain?;
• exposure to recreational noise (e.g., personal listening devices) and/or occupational noise;
• genetic? factors;
• head trauma?/traumatic brain injury;
• history of ear infections;
• history of falls;
• increasing age;
• speech, language, and cognitive impairments (e.g., dementia);
• stroke?; and
• tinnitus?.

Hearing Screening Settings and Situations

While there is no one agreed-upon hearing screening schedule for adults, there are various factors to consider when deciding when and how often to get screened. These factors include age, comorbidities, risk factors (e.g., history of noise exposure), and access to routine screening (e.g., as part of an annual health appointment). Hearing screenings for adults may take place at or during

• health fairs,
• memory care clinics (McDonough et al., 2021; Reed et al., 2022),
• occupational hearing conservation programs,
• remote access hearing screening (e.g., phone-based and online tools and applications),
• research studies,
• residential facilities (e.g., skilled nursing, long-term care) per protocols for hearing screening or assessment (e.g., Centers for Medicare & Medicaid Services: Long-Term Care Facility Resident Assessment Instrument 3.0 [PDF]; Centers for Medicare & Medicaid Services, 2019),
• routine primary care or post-hospitalization medical visits,
• speech-language pathology visits, and
• telepractice visits.

Screening Components

A comprehensive protocol for adult hearing screening may include several components (Schow, 1991; Ventry & Weinstein, 1983; World Health Organization, 2021c):

• A brief case history (e.g., review of chronic diseases, medications, and family history?) and a visual and/or otoscopic inspection facilitate screening for pertinent and/or related health conditions.
• The use of calibrated pure-tone signals (and/or otoacoustic emissions [OAEs]) facilitates screening for loss or abnormality? in body structure and function (e.g., auditory system).
• The use of self-report tools facilitates screening for perceived hearing disability and impact on activities and participation.

Completing each step of this process allows for more targeted and appropriate referrals and recommendations as well as patient-centered counseling.

Screening for Health Conditions

Case History

A brief case history should include questions designed to identify individuals with possible hearing and/or related disorders. Participation of significant others in the case history process can be valuable.

A case history may include, but not be limited to, the following questions:

• Do you have a known or suspected hearing loss? If so, is it in one ear or both ears?
• Do you have difficulty understanding speech?
• Have you ever had a sudden or rapid progression? of hearing loss?
• Do you hear ringing and/or other noises in your ears and/or head?
• Do you have pain, discomfort, and/or fullness in your ear(s)?
• Have you had any recent drainage from your ear(s)?
• Have you had problems with dizziness? and/or an impaired balance?
• Do you have any chronic diseases?
• What medications (including prescription? and over-the-counter) are you currently taking?
• Do you have a family history of hearing loss?
• Do you have a history of ear infections or ear surgery?
• Do you have a history of head injury or concussion?
• Have you ever been exposed to loud sounds or noises through occupational and/or recreational activities?

Otoscopy/Visual Inspection

Otoscopy completed by a trained examiner (e.g., audiologist, audiology assistant) allows for visualization of the tympanic membrane? and inspection of the external ear canal for drainage, foreign bodies, impacted cerumen, infection, fluid, or structural abnormalities. A screener who is not trained in otoscopy can perform a general visual inspection of the outer portion of the ear and make note of any anomalies or obvious anatomic abnormalities. The information obtained during visual inspection or otoscopy may have an important impact on screening results and/or referral to medical personnel for further evaluation.

Pass/Refer Criteria: Screening for Health Condition

• A pass or an unremarkable result is documented if ­no concerns are reported during the case history that has not been previously evaluated (e.g., by a physician or an audiologist), and no abnormal findings are observed during otoscopy.
• A referral is documented if concerns are reported from the case history for which the individual has not received medical/audiological consultation or if otoscopy identifies outer ear, ear canal, or tympanic membrane abnormality or cerumen impaction.

Screening for Body Structure and Function

Pure-Tone Screening

Pure-tone screening is a behavioral test of hearing sensitivity that is typically completed with the use of a pure-tone audiometer that enables results to be plotted on an audiogram. Pure-tone stimuli are routed through either supra-aural earphones or inserted earphones. If a pure-tone audiometer is not available or convenient, other options (e.g., laptop-based audiometers) allow for increased portability. Handheld audio scopes allow for otoscopic visualization and pure-tone screening, and some devices will utilize tones at a variety of presentation levels (e.g., 20 dB HL, 25 dB HL, 40 dB HL).

There are also a growing number of online and smartphone applications for a hearing screening. These tools may use tone frequency testing and/or other methods (e.g., digits in noise). Advancements in technology allow for self-testing as an alternative method of monitoring hearing status and may help address unmet needs in hearing health care for adults (Wasmann et al., 2022). Many professionals advocate for self-screening. However, caution is warranted when using these tools due to variability in the applications, requirement for device calibration (Masalski et al., 2018), method of test administration, and other factors that may impact the accuracy of the results obtained.

An otoacoustic emission (OAE) is a sound generated from the cochlea in response to auditory stimulation (e.g., from a handheld OAE screening device). OAE testing can be particularly useful in screening for hearing loss in individuals who are difficult to test and/or who cannot reliably perform behavioral hearing screenings, as OAE test results do not rely on behavioral responses to sound stimuli (Jupiter, 2009). OAEs may also be used for monitoring cochlear damage due to noise or ototoxicity (Shetty et al., 2020).

Pass/Refer Criteria: Screening for Body Structure and Function

• A pass result is documented if responses are obtained in both ears to pure-tone air-conduction stimuli at 25 dB HL at 1000 Hz, 2000 Hz, and 4000 Hz.
• A referral is documented if there is an absent response to pure-tone air-conduction stimuli at 25 dB HL at any screening test frequency in either ear.

The incidence of hearing loss increases with age, and some adults will not pass a pure-tone screening at 25 dB HL, particularly at 4000 Hz. Hearing loss over 25 dB HL is clinically significant, as it can negatively affect communication. Some clinicians have advocated for the use of higher screening levels (i.e., 30 dB HL or 35 dB HL) when screening adults of increasing age. While higher screening levels may result in lower referral rates, milder degrees of hearing loss may be missed, along with opportunities for further assessment, counseling, and education.

Screening for Hearing Disability

Self-Assessment Tools

Self-assessment tools (e.g., questionnaires/inventories) for disability screening can be used in conjunction with other screening components to help identify those who would benefit from a more comprehensive audiological evaluation, counseling, and management (Louw et al., 2018; Ventry & Weinstein, 1983; World Health Organization, 2021c). These tools may identify an individual’s perceived difficulties related to hearing as well as changes in participation in activities. Hearing disability screening measures can be administered in a verbal, written, or computerized format. Some measures can be completed by family members or significant others. In the absence of an audiometer or other screening technology, these questionnaires can be useful in the identification of individuals at risk for hearing loss and those who may require audiologic follow-up.

Examples of hearing screening self-assessment tools include the following:

• Hearing Handicap Inventory for the Elderly–Screening Version (Lichtenstein et al., 1988)
• Speech, Spatial, and Qualities of Hearing Scale (Gatehouse & Noble, 2004)
• Self-Assessment of Communication (Schow & Nerbonne, 1982)
• Significant Other Assessment of Communication (Schow & Nerbonne, 1982)

Pass/Refer Criteria: Screening for Disability (Activities and Participation)

Before using a self-assessment questionnaire, it is important to review the background publications related to the administration, scoring, and interpretation associated with that specific tool.

Referrals and Recommendations

Referrals and recommendations resulting from adult hearing screening may involve counseling and education, comprehensive audiology assessment, and/or other examinations or services as indicated. Examples include the following:

• Positive findings on the case history and/or otoscopic inspection indicate a recommendation for an audiologist and/or medical evaluation.
• A result of a referral on the pure-tone screening is an indication? for a comprehensive audiological evaluation.
• When hearing disability scores fall outside the normal range, recommendations may include counseling, referral for an audiology assessment (especially if pure-tone screening also results in a referral), and/or other examinations or services.

Follow-Up

There is limited information in the literature about how often adults follow recommendations after a hearing screening and the long-term outcomes of those referrals (Meyer et al., 2011; Thodi et al., 2013; Zazove et al., 2020). Some adults may appreciate the hearing screening opportunity but may choose not to act on the referrals or recommendations. Hearing screenings offer the opportunity to educate adults about the full range of rehabilitative options available to those with hearing loss (e.g., environmental modifications, auditory training, amplification). Knowledge of a wide range of options may increase the chance that an individual will pursue some follow-up services.

Program Management

Equipment Calibration

Audiometric equipment must meet applicable specifications of the American National Standards Institute (ANSI)/Acoustical Society of America S3.6-2018 (ANSI, 2018b, or current standard) and/or manufacturer recommendations to ensure accurate results. Calibration should be performed annually using instrumentation traceable to the National Institute of Standards and Technology. Functional inspection, performance checks, and biologic listening checks should be conducted to verify equipment performance before each use (ANSI, 2018b). All calibration activities should be conducted by a trained audiologist or an external company or individual properly trained in performing such tasks.

Screening Environment

A clinical or natural environment that is conducive to obtaining reliable hearing screening results will be free from auditory and visual distractions and interruptions and will allow for privacy and confidentiality.

Performing daily listening checks can rule out defects in major pure-tone screening components. Ambient noise levels may exceed ANSI standards for pure-tone threshold testing in audiometric test rooms S3.1-1999 (ANSI, 2018a, or current standard) but must be sufficiently low to allow the accurate screening. A sound level meter, if available, may be used to establish maximum permissible noise levels at 25 dB HL for the earphone to be used during screening (i.e., supra-aural, circumaural, or insert). There are some smartphone-based sound level meters available that can be used to measure ambient noise; however, these applications may require calibration, and results may vary. When a sound level meter is not available, a biological check is typically suitable.

Universal Precautions

It is important to follow universal precautions and appropriate infection control procedures during screenings.

Personnel Training

Audiologists overseeing screening personnel can ensure proper screening skills by providing both initial and refresher training and validating the initial results of new screeners.

Documentation

Documentation typically includes the date of screening, patient demographics, positive concerns from the case history, screening results, and recommendations and referrals. Any educational resources should be provided in a health-literate and person-centered format. For an example of a hearing screening template for adults,

Reimbursement

For information on audiology and speech-language pathology services as well as issues related to Medicare, Medicaid, private health plans, and billing codes,

References