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International Journal of Pediatric Otorhinolaryngology 76 (2012) 1366–1369 Contents lists available at SciVerse ScienceDirect International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl The performance of distortion product otoacoustic emissions and automated auditory brainstem response in the same ear of the babies in neonatal unit Siti Noor Hidayah Abdul Wahid a, Mohd Khairi Md Daud b,*, Dinsuhaimi Sidek b, Normastura Abd Rahman c, Suzana Mansor d, Mohamad Normani Zakaria a a School of Health Sciences, Health Campus, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia Department of Otorhinolaryngology Head and Neck Surgery, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia c School of Dental Sciences, Health Campus, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia d Audiology Clinic, Hospital Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia b A R T I C L E I N F O A B S T R A C T Article history: Received 22 March 2012 Received in revised form 12 June 2012 Accepted 15 June 2012 Available online 6 July 2012 Objective: To identify the outcomes of hearing screening using different protocols of both Distortion Product Otoacoustic Emissions (DPOAE) and Automated Auditory Brainstem Response (AABR) tests in the same ear of the babies in a neonatal unit population. Methods: A cross-sectional study was carried out on babies who were admitted into a neonatal unit. By using a formula of single proportion and considering 20% drop out, the number of sample required was 114. The subjects were chosen by using a systematic random sampling. The infants selected were subjected to DPOAE followed by AABR tests screening at the same setting before discharge. Results: There were 73 newborns (61.6% male and 38.4% female) participated in this study with a total of 146 ears screened. Ototoxic medication was the most common risk factor followed by hyperbilirubinaemia and low birth weight. AABR had higher passing rate (82.9%) as compared to DPOAE (77.4%). The highest passing rate was achieved if the protocol of either passed DPOAE or AABR was used (90.4%). The rate was lower when auditory neuropathy spectrum disorder (ANSD) has been considered (82.9%). Hyperbilirubinaemia, prematurity, craniofacial malformation and ototoxic drugs seem to be the high risk factors for auditory neuropathy. Conclusion: AABR has a higher passing rate as compared to DPOAE. However, the use of both instruments in the screening process especially in NICU will be useful to determine the infants with ANSD who may need different approach to management. Therefore, a protocol in which newborns are tested with AABR first and then followed by DPOAE on those who fail the AABR is recommended. ß 2012 Elsevier Ireland Ltd. All rights reserved. Keywords: Hearing tests Neonatal screening Auditory neuropathy 1. Introduction Hearing is necessary to learn language and speech. The abnormal functioning auditory system will affect the social, emotional and intellectual development of the children. Early detection and intervention will help minimising such effects. Therefore, newborn hearing screening programme has been advocated. It is known that the prevalence of significant hearing loss appears to be one to three in a thousand child births [1–5]. Therefore it is considered as the most common congenital deficit in humans. This value could become one to five in 100 if only babies in the neonatal intensive care unit (NICU) and infants selected from at-risk registers are considered [6–11]. Otoacoustic emissions (OAE) and automated auditory brainstem response (AABR) are the two types of screening technologies commonly used in newborn hearing screening programme. Both procedures are quick and painless and have been demonstrated practical and effective. Depending on the protocols used, either type can be used alone or in sequence. This study was aimed to identify the outcomes of hearing screening using different protocols of both DPOAE and AABR in a neonatal unit population which caters for the graduates of Neonatal Intensive Care Unit (NICU) and the infants who are unwell that need admission to the ward. 2. Methodology * Corresponding author. Tel.: +60 9 7676413; fax: +60 9 7664093; mobile: +61 2 9286091. E-mail address: [email protected] (M.K. Md Daud). 0165-5876/$ – see front matter ß 2012 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijporl.2012.06.008 A cross-sectional study was carried out on the children who were admitted into a neonatal unit, Hospital Universiti Sains S.N.H. Abdul Wahid et al. / International Journal of Pediatric Otorhinolaryngology 76 (2012) 1366–1369 3. Results There were 73 newborns (61.6% male and 38.4% female) participated in this study with a total of 146 ears screened. The majority of the participants were Malays (98.6%) and only 1 (1.4%) was Chinese. This reflects the actual racial composition of the population. Table 1 shows the risk factors for the infants involved in this study. Ototoxic medication was the most common risk factor followed by hyperbilirubinaemia and low birth weight. Fig. 1 shows the number of risk factors per child. Nearly half of the babies in the neonatal unit did not have any risk factors for hearing impairment. Forty one percent of the infants had at least one risk factor, 12 percent had two risk factors while about 1 percent had three, four and five risk factors. Table 2 shows the outcomes of hearing screening by ears according to different protocols used. AABR had a higher passing rate (82.9%) as compared to DPOAE (77.4%). The highest passing rate was achieved if the protocol of either passed DPOAE or AABR Table 1 Risk factors for hearing loss. Risk factor n (%) Significant family history In utero infection Craniofacial anomalies Birth weight < 1500 g Hyperbilirubinaemia Ototoxic medication Bacterial meningitis Low Apgar score (0–4 at 1 min, 0–6 at 5 min) Mechanical ventilation lasting 5 days or more Congenital anomalies (with risk of deafness) 1 1 1 4 7 37 1 2 1 3 (1.4) (1.4) (1.4) (5.5) (9.6) (50.7) (1.4) (2.7) (1.4) (4.1) 45 42.5 Case 41.1 40 35 30 Percentage Malaysia. The neonatal unit receives almost all the NICU graduates who are stable enough while waiting to be discharged. The unit also receives the problematic infants who do not need NICU treatment such as mild to moderate neonatal jaundice. The sample size was calculated using single proportion formula based on the prevalence of babies who were at risk for hearing loss at 44% [12]. The calculation indicated that minimum sample size of 95 subjects would be sufficient to obtain the 0.1 precision in calculating the prevalence of babies who were at risk for hearing loss with 95% confidence interval (CI). With anticipation of 20% non-response rate, it was decided to take 114 subjects. All infants in the neonatal unit were included in this study. They were chosen by using a systematic random sampling. The conditions of the ears were assessed by using an otoscope. The infants with impacted ear wax, middle ear effusion and persistent mesenchyme or amniotic fluid in the external ear were excluded from the study. The infants selected were subjected to DPOAE (Eclipse OAE, Interacoustic, German) with the frequencies used at 2, 3, 4 and 5 kHz followed by AABR (ABRis, Interacoustic, Germany) screening tests at the same setting as near to discharge as possible. The tests were done in their bassinets in the neonatal unit itself. No sedation was given and whenever possible neonates were tested in sleeping/ quiet state, after feeding and/or bathing. Both instruments produced a ‘‘pass’’ or ‘‘refer’’ result and did not require any special skills for the interpretation of the results. The tests were repeated two times in cases with ‘‘refer’’ result. Data were entered and analysed using SPSS version 12.0. Descriptive statistics such as frequency and percentages were calculated for all the categorical variables. Ethical approval was obtained from Research Ethics Committee (Human), Universiti Sains Malaysia (Ref.: USMKK/PPP/JEPeM (219.3.(14.1)). 1367 25 20 15 12.3 10 5 1.4 1.4 3 4 1.4 0 0 1 2 5 Fig. 1. The percentage of risk factors found per child. was used (90.4%). The rate was lower when auditory neuropathy spectrum disorder (ANSD) has been considered (82.9%). Table 3 shows the high risk factors in the patients with the possibility of having ANSD. Except in one case (case no. 2), hyperbilirubinaemia, prematurity, craniofacial malformation and ototoxic drugs seem to be the high risk factors for auditory neuropathy. 4. Discussion Universal newborn hearing screening is becoming a standard programme in many centres nowadays. Early identification of hearing loss with early medical and educational interventions has been demonstrated to significantly improve communication skills and cognitive ability. Most of the centres are using AABR and OAE for the screening as they are sensitive and specific to the identification of hearing losses but with no standard protocols. In this study, the prevalence of passing rate using DPOAE test was 77.4 percent. The passing rates for the first screening using OAEs vary depending on the different centres and group of the neonates studied. They were ranging from 66.7% to 93.5% [13–19]. In NICU babies, the different aetiologies have different referral rates [20]. Their failure rate was usually higher than the well babies’ resident [21]. The presence of OAEs provides direct evidence of the existence of an active mechanism in the cochlea. However, OAEs will be absent if there is a significant external and/ or middle ear problems. Besides that, DPOAE test must be done in environment where it is quiet, infants are in calm condition and the probe tip is snugly fitted in order to get the reliable results. In the present study, the passing rate can be considered low as compared Table 2 The outcomes of hearing screening on each ear according to different protocols. Protocol n % Passed DPOAE Passed AABR Either passed DPOAE or passed AABR Either passed DPOAE or passed AABR excluding passed DPOAE with failed AABR (auditory neuropathy) Passed both DPOAE and AABR 113 121 132 77.4 82.9 90.4 121 82.9 102 69.9 S.N.H. Abdul Wahid et al. / International Journal of Pediatric Otorhinolaryngology 76 (2012) 1366–1369 1368 Table 3 High risk factors related with auditory neuropathy. Case Sex Ear affected Risk factor (associated conditions) 1 2 3 4 5 6 7 8 Male Male Male Female Male Male Male Female Bilateral Right Right Bilateral Bilateral Left Left Left Ototoxic drugs None Ototoxic drugs, neonatal jaundice Neonatal jaundice Cleft palate and lip, ototoxic drugs Premature, neonatal jaundice, ototoxic drugs Premature, ototoxic drugs Neonatal jaundice concentration at which exchange transfusion is indicated had audiological findings of ANSD [32]. Coenraad et al. showed a significant association between vancomycin administration and ANSD compared to controls [33]. Among 37 children diagnosed with ANSD, Beutner et al. found 2 cases whom related to complex syndromal diseases [34]. Maris et al. demonstrated aplasia/ hypolasia of the cochlear nerve in MRI of the infants with ANSD [35]. In contrast to acquired causes, congenital ANSD has been found to be associated with genetic abnormality [36]. 5. Conclusion to many other centres. Since the study was done in the neonatal unit itself, the background noise in the ward may have contributed to its lower rate. In our finding, the passing rate of using AABR test was 82.9%. It was higher than the passing rate using DPOAE. Vohr et al. and Benito-Orejas et al. have shown that AABR gave significantly better passing rates as compared to TEOAEs [13,15]. The AABR test measures the electrical activity beyond the cochlea until the lower brainstem level and in contrast to OAEs test, it is less affected by the outer, middle and/or inner ear disorders. Therefore, the utilisation of AABR technology rather than OAE will further improve the values of passing rate and false positive. However, similarly to OAEs, the results of AABR test is also subjected to the influence of factors such as the environmental noise, child condition and equipment condition during the testing. The prevalence of passing rate using either passed DPOAE or AABR test was 90.4%. As expected, it was higher than the passing rate using single test such as DPOAE only and AABR only. For this combination protocol, the failures could be either passed DPOAE but failed AABR or failed DPOAE but passed AABR or failed both of the tests. The result of passed DPOAE but failed AABR may suggest ANSD while the result of failed DPOAE but passed AABR may be due to the external factors involved in the DPOAE test which suggests the possibility of false positive. When the passing of both DPOAE and AABR was considered as passed, the passing rate became 69.9%. Olusanya and Bamigboye labelled this group of infants as true-negatives [22]. In their study, the passing rate was even lower at 60.7%. Therefore, the use of such a protocol will result in a very high referral rates. Another important issue on hearing screening especially in those babies in NICU is ANSD. In our study, there were 7.53% ears were suspected to have ANSD. Further auditory evaluations are very important to confirm and differentiate it from sensorineural hearing loss (SNHL) as it may need different approach to management. The prevalence of ANSD were ranging from 1.42% to 24.0% in different groups of patients of hearing impaired children and those with at risk for hearing impairment [23–28]. All of these hearing-impaired children were not detected using TEOAE alone and therefore necessitate the used of AABR. The Joint Committee on Infant Hearing (JCIH) in its year 2007 position statement has recognised that neural conduction disorders results in adverse communication outcomes [29]. Because this disorder typically occurs in children who require NICU care, the committee recommends screening on this group with AABR. Nevertheless, since ANSD shows normal oto-acoustic emissions, the combined use of DPOAE and AABR testing will lead to the recognition of the disorder easier. As far as the risk factors for ANSD are concerned, hyperbilirubinaemia, prematurity, the use of ototoxic drugs and craniofacial malformation seem to be related with it. Sanyelbhaa Talaat et al. reported hyperbilirubinaemia as the most common cause of ANSD [30] while Foerst et al. found it to be the second commonest after prematurity with postpartal complications [31]. Saluja et al. reported that 6 out of 13 neonates with total serum bilirubin AABR has a higher passing rate as compared to DPOAE. However, the use of both instruments in the screening process especially in NICU will be useful to determine the infants with ANSD who may need different approach to management. 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