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How accurate are bedside hearing tests? D. F. Boatman, D. L. Miglioretti, C. Eberwein, M. Alidoost and S. G. Reich Neurology 2007;68;1311-1314 DOI: 10.1212/01.wnl.0000259524.08148.16 This information is current as of April 30, 2007 The online version of this article, along with updated information and services, is located on the World Wide Web at: http://www.neurology.org/cgi/content/full/68/16/1311 Neurology is the official journal of AAN Enterprises, Inc. A bi-monthly publication, it has been published continuously since 1951. Copyright © 2007 by AAN Enterprises, Inc. All rights reserved. Print ISSN: 0028-3878. Online ISSN: 1526-632X. Downloaded from www.neurology.org at Johns Hopkins University on April 30, 2007 How accurate are bedside hearing tests? D.F. Boatman, PhD, CCC-A; D.L. Miglioretti, PhD; C. Eberwein, MS, CCC-A; M. Alidoost, MS; and S.G. Reich, MD Abstract—The accuracy of five bedside hearing tests was evaluated in 107 consecutive adults, using pure-tone audiometry as the standard reference. Bedside tests had poor sensitivity (ⱕ0.60), relatively good specificity (ⱖ0.74), and variable positive predictive value (0.24 to 1.0) for detecting hearing loss. Sensitivity improved when bedside tests were combined with case history. The diagnostic utility of bedside tests routinely administered by neurologists to detect hearing loss in adults requires further study. NEUROLOGY 2007;68:1311–1314 Hearing loss affects 23% to 40% of individuals aged older than 65 years,1,2 impacting adversely on physical, cognitive, and social functioning.3,4 To screen for hearing loss, neurologists traditionally use bedside tests such as finger rub, whispered speech, watch tick, tuning forks, and self-report.5 Evidence-based reviews have questioned the reliability of screening measures, citing lack of test standardization and validation.6,7 For this study, we sought to determine the sensitivity, specificity, and positive predictive value of bedside hearing tests and a self-assessment questionnaire, using pure-tone audiometry as the standard reference. Methods. We studied 107 consecutive adults, aged 50 to 88 (mean 66) years, over 2 months. Fifty-four were patients attending a movement disorders clinic, and 53 were spouses or family members (table 1). We excluded subjects with known hearing loss, stroke, or clinically diagnosed dementia. All participants provided written informed consent. Tests included finger rub, whispered speech, watch tick, and the Rinne and Weber tuning fork tests. The same neurologist (S.G.R.) performed the testing, with subjects seated in an examination room (mean ambient noise 58 dB SPL). Each ear was tested while subjects occluded the nontest ear. Finger rub and watch tick were administered six times each, 6 in from the ear. Results were abnormal if subjects did not respond to more than one sound presentation. For whispered speech, two sets of three words were whispered 2 ft from each ear (soup, pen, apple; soap, pot, orange).7 More than one error (incorrect, no response) was considered abnormal. The Weber and Rinne tests used tuning forks of 128, 256, and 512 Hz.5 For the Weber test, the vibrating tuning fork was placed midline on the forehead. Normal listeners detect no interaural loudness differences. Lateralizing responses indicate unilateral hearing loss. For the Rinne test, the tuning fork was alternately placed on the mastoid and at the ear. Normal listeners and individuals with sensorineural hearing loss hear the sound louder at the ear (positive Rinne test result) because air conduction is more effective than bone conduction. A negative Rinne test result occurs when sound is heard louder at the mastoid, consistent with conductive hearing loss. Subjects completed an eight-item, self-assessment questionnaire about their hearing (table 2). Questions were developed as a potential screening tool and not to elicit perceived social or emotional handicap secondary to hearing loss, as in other questionnaires including the Hearing Handicap Inventory for the Elderly.8 An audiologist (C.E.), blinded to the bedside test results, performed pure-tone audiometry the same day. Hearing thresholds were established for each ear at four octave frequencies (500 to 4,000 Hz) under headphones using a two-channel audiometer. Hearing loss was defined as thresholds ⬎ 25 dB at one or more frequency in either ear and classified as mild (26 to 40 dB), moderate (41 to 55 dB), or severe (⬎55 dB).9 Three-frequency puretone averages (500 to 2,000 Hz) were computed. Otoscopy and tympanometry were performed to identify external or middle ear abnormalities. Statistical analyses. Rate of hearing loss was compared by sex and patient status using 2 tests. Test sensitivity and specificity were estimated using logistic regression fitted with generalized estimating equations assuming an exchangeable correlation structure to account for possible within-subject correlations between ear measurements.10 Sensitivity was not calculated for the Rinne test because audiometry did not differentiate conductive vs sensorineural hearing loss. Positive predictive values were determined from test sensitivity and specificity and published estimates of the minimum prevalence of hearing loss in the ages tested: 45 to 64 years (13.7%), 65 to 74 years (22.9%), and ⬎74 years (31.9%).1 Positive predictive values were not calculated for the Weber test because unilateral hearing loss rates in these ages are unknown. Results. Pure-tone audiometry identified 52 of 107 subjects (48%) with either unilateral (10) or bilateral (42) hearing loss. Of these, 37 (71%) had only high-frequency hearing loss (⬎1,000 Hz) and 34 (65%) had moderate or greater hearing loss. More men (67%) than women (31%) had hearing loss (p ⫽ 0.0002), likely reflecting the older ages of our male subjects. Rate of hearing loss did not differ for patients vs nonpatients (p ⫽ 0.29). Twenty-six subjects (24%) had pure-tone averages ⬎ 25 dB in their From the Departments of Neurology and Otolaryngology, Johns Hopkins School of Medicine, Baltimore, MD (D.F.B., C.E., M.A.); Center for Health Studies, Group Health Cooperative, Seattle, WA (D.L.M.); and Department of Neurology, University of Maryland, Baltimore, MD (S.G.R.). Supported by NIH grants R01-DC005645 and R21-DC007490. Disclosure: The authors report no conflicts of interest. Received March 21, 2006. Accepted in final form December 19, 2006. Address correspondence and reprint requests to Dr. Dana Boatman, Department of Neurology, 600 North Wolfe Street/Meyer 2-147, Baltimore, MD 21287; e-mail: [email protected] Copyright © 2007 by AAN Enterprises, Inc. Downloaded from www.neurology.org at Johns Hopkins University on April 30, 2007 1311 Table 1 Subject demographics Participants Number Age, years Male 52 51 to 88 (mean 67) Female 55 50 to 81 (mean 65) Patient 54 50 to 88 (mean 66) Nonpatient 53 51 to 88 (mean 66) 50 to 64 years 40 NA 65 to 74 years 52 NA ⬎74 years 15 NA Sex Status Age NA ⫽ not applicable. better ear. Of the 214 ears tested, 135 (63%) had hearing loss at 4,000 Hz. Otoscopy was normal in 87 subjects (81%); tympanometry was normal (0 ⫾ 1,000 daPa) in 89 subjects (83%). Test sensitivity for detecting hearing loss ranged from 0.05 to 0.60 (table 3). Watch tick had the highest sensitivity: 0.44 for hearing loss ⬎ 25 dB and 0.60 for hearing loss ⬎ 40 dB. The Weber test for unilateral hearing loss had the lowest sensitivity (0.05 to 0.30). Combining tests improved sensitivity slightly (0.64). In contrast, bedside tests showed good specificity (0.74 to 1.0) with positive predictive values varying from 0.24 to 1.0. Subjects’ assessment of their hearing abilities by questionnaire had poor sensitivity (0.01 to 0.51) for detecting hearing loss (table 2). Combining questions about hearing in background noise (Question 7, 0.51) and the perceptions of others (Question 3, 0.30) with non–tuning fork tests yielded the highest sensitivity: 0.80 for hearing loss ⬎ 25 dB and 0.87 for hearing loss ⬎ 40 dB. However, this combination had lower specificity (0.53) than individual tests (0.74 to 1.0). Reported difficulty hearing women’s or children’s voices (Questions 4 and 6) and perceived benefits of hearing aids (Question 8) had good specificity and positive predictive value (1.0). Discussion. Our results demonstrate that bedside hearing tests have poor sensitivity for detecting hearing loss in older adults, yielding a high rate of false negatives. Test sensitivity was greatest (0.64) when bedside tests were combined, although still below acceptable levels (i.e., ⱖ0.80). Conversely, bedside tests have good specificity, suggesting that false positives are not a limitation. Using audiometric pure-tone averages for comparison, the prevalence of hearing loss in our subjects is consistent with epidemiologic studies.1,2 The most common hearing loss identified was moderate or greater bilateral, and high frequency. Individuals with this pattern of hearing loss typically have communication difficulties, especially in noisy environments, 3,4 and are candidates for hearing aids.4,5,9 Given the high prevalence of hearing loss in older adults, referral for audiologic testing is recommended if hearing loss is suspected, even if bedside tests are normal. A limitation of this study is the inclusion of only one examiner. Although this allowed us to control for interexaminer variability,6,7 our results cannot be generalized across examiners. Other neurologists performing the same bedside hearing tests might obtain different levels of test accuracy due to variations in the quality and loudness of their voices, finger rubs, or watch ticks. Nonetheless, these results are relevant to neurologists who learn to administer bedside hearing tests during clinical training, using recommended procedures from standard textbooks, and who administer these tests as part of a neurologic examination. Observed intertest differences likely reflect acoustic properties of the sounds used. Watch ticks are brief, low-intensity, clicklike sounds covering a wide frequency range, increasing sensitivity to hearing loss. Conversely, whispered speech has attenuated low-frequency components, due to absence of vocal cord vibration (voicing), Table 2 Self-assessment questionnaire Sensitivity (95% CI) Specificity (95% CI) Positive predictive value 1. Do you think you have difficulty hearing? 0.27 (0.19–0.37) 0.89 (0.66–0.97) 0.29 2. Do you hear better in one ear than the other? 0.23 (1.6–0.32) 0.92 (0.72–0.98) 0.30 3. Do family members or friends think you have difficulty hearing? 0.30 (0.21–0.40) 0.74 (0.50–0.89) 0.15 4. Do you have difficulty hearing women’s voices? 0.05 (0.02–0.11) 1.0 1.0 5. Do you have difficulty hearing men’s voices? 0.01 (0.00–0.08) 0.95 (0.71–0.99) 0.03 6. Do you have difficulty hearing children’s voices? 0.02 (0.01–0.09) 1.0 1.0 7. Do you have difficulty hearing in noisy environments, such as a restaurant or a party? 0.51 (0.41–0.61) 0.79 (0.55–0.92) 0.28 8. Do you think you would benefit from hearing aids? 0.19 (0.12–0.29) 1.0 1.0 Question 1312 NEUROLOGY 68 April 17, 2007 Downloaded from www.neurology.org at Johns Hopkins University on April 30, 2007 Table 3 Diagnostic accuracy of five bedside tests for detecting hearing loss Bedside hearing test Sensitivity (95% CI) Specificity (95% CI) Positive predictive value HL ⬎ 25 dB 0.27 (0.20–0.36) 0.98 (0.85–1.00) 0.68 HL ⬎ 40 dB 0.35 (0.26–0.46) 0.97 (0.90–0.99) 0.62 HL ⬎ 25 dB 0.44 (0.35–0.53) 1.0 1.0 HL ⬎ 40 dB 0.60 (0.50–0.69) 0.99 (0.92–1.00) 0.89 HL ⬎ 25 dB 0.40 (0.32–0.49) 0.83 (0.68–0.91) 0.24 HL ⬎ 40 dB 0.46 (0.36–0.56) 0.78 (0.68–0.86) 0.25 HL ⬎ 25 dB NA 1.0 1.0 HL ⬎ 40 dB NA 1.0 1.0 HL ⬎ 25 dB NA 1.0 1.0 HL ⬎ 40 dB NA 1.0 1.0 HL ⬎ 25 dB NA 1.0 1.0 HL ⬎ 40 dB NA 1.0 1.0 HL ⬎ 25 dB 0.20 (0.05–0.54) 0.79 (0.70–0.86) NA HL ⬎ 40 dB 0.21 (0.08–0.45) 0.80 (0.70–0.87) NA HL ⬎ 25 dB 0.30 (0.10–0.62) 0.74 (0.65–0.82) NA HL ⬎ 40 dB 0.26 (0.11–0.50) 0.74 (0.64–0.82) NA HL ⬎ 25 dB 0.30 (0.10–0.62) 0.87 (0.78–0.92) NA HL ⬎ 40 dB 0.05 (0.007–0.29) 0.83 (0.74–0.89) NA Finger rub Watch tick Whispered speech Rinne test 128 Hz 256 Hz 512 Hz Weber test 128 Hz 256 Hz 512 Hz HL ⫽ hearing loss; NA ⫽ not applicable. better suited for detecting low-frequency hearing loss. The poor diagnostic accuracy of tuning fork tests is consistent with previous reports.6,7 The Rinne and Weber tests are often used incorrectly to screen for any type of hearing loss, whereas they were designed to identify low-frequency (ⱕ512 Hz) unilateral (Weber) or conductive (Rinne) hearing loss. These tests would likely have missed subjects with highfrequency, bilateral, and presumably sensorineural hearing loss, based on normal tympanometry and otoscopy. Case history and self-assessment are poor screening tools.2,7 Sensitivity increased by combining questions about difficulty hearing in noise and concerns raised by others, together with non– tuning fork tests. In contrast to recommendations that older adults be screened for hearing loss by first asking whether they have difficulty hearing and then administering one bedside test (whispered speech),7 our results suggest that hearing loss is more likely to be identified if multiple bedside tests are combined with questions about difficulty hearing in noise and the perceptions of others. Additional studies are needed to compare newer screening tools, including the audioscope April 17, 2007 NEUROLOGY 68 1313 Downloaded from www.neurology.org at Johns Hopkins University on April 30, 2007 (pure-tone screener) and otoacoustic emissions (cochlear function test), and to develop more sensitive bedside hearing tests. Acknowledgment The authors thank Ms. Jenna Los for assistance and Dr. William J. Weiner for helpful comments. References 1. Cruickshanks KJ, Wiley TL, Tweed TS, et al. Prevalence of hearing loss in older adults in Beaver Dam, Wisconsin, Am J Epidemiol 1998:148: 879 – 886. 2. Sindhusake D, Mitchell P, Smith W, et al. Validation of self-reported hearing loss: the Blue Mountains Hearing Study. Int J Epidemiol 2001; 30:1371–1378. 3. Herbst KG, Humphrey C. Hearing impairment and mental state in the elderly living at home. BMJ 1980;281:903–905. 4. Mulrow CD, Aguilar C, Endicott JE, et al. Quality-of-life changes and hearing impairment. Ann Intern Med 1990;113:188–194. 5. Nuwer MR, Sigsbee B. The Health Care Financing Administration’s new examination documentation criteria: minimum auditing standards for the neurologic examination to be used by Medicare and other payors: report from the American Academy of Neurology Medical Economics and Management Subcommittee. Neurology 1998;50:497–500. 6. Yueh B, Shapiro N, MacLean CH, Shekelle PG. Screening and management of adult hearing loss in primary care: scientific review. JAMA 2003;289:1976–1985. 7. Bagai A, Thavendiranathan P, Detsky AS. Does this patient have hearing impairment? JAMA 2006;295:416–428. 8. Weinstein BE. Validity of a screening protocol for identifying elderly people with hearing problems. ASHA 1986;28:41–45. 9. American Speech-Language-Hearing Association. Guidelines for manual pure-tone audiometry. ASHA 1978;20:297–301. 10. Liang KY, Zeger SL. Longitudinal data analysis using generalized linear models. Biometrika 1986;73:13–22. RESIDENT AND FELLOW PAGE Call for teaching videos The Neurology Resident section is featured online at www.neurology.org. The Editorial Team of this section is seeking teaching videos that will illustrate classic or uncommon findings on movement disorders. Such videos will aid in the recognition of such disorders. Instructions for formatting videos can be found in the Information for Authors at www.neurology.org. 1314 NEUROLOGY 68 April 17, 2007 Downloaded from www.neurology.org at Johns Hopkins University on April 30, 2007 How accurate are bedside hearing tests? D. F. Boatman, D. L. Miglioretti, C. Eberwein, M. Alidoost and S. G. Reich Neurology 2007;68;1311-1314 DOI: 10.1212/01.wnl.0000259524.08148.16 This information is current as of April 30, 2007 Updated Information & Services including high-resolution figures, can be found at: http://www.neurology.org/cgi/content/full/68/16/1311 Related Articles A related article has been published: http://www.neurology.org/cgi/content/full/68/16/1243 Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Audition http://www.neurology.org/cgi/collection/audition All Clinical Neurology http://www.neurology.org/cgi/collection/all_clinical_neurology Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.neurology.org/misc/Permissions.shtml Reprints Information about ordering reprints can be found online: http://www.neurology.org/misc/reprints.shtml Downloaded from www.neurology.org at Johns Hopkins University on April 30, 2007