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Abstract

We evaluated the validity of remote pure tone audiometric testing conducted from North America on subjects in South Africa. Desktop-sharing computer software was used to control an audiometer in Pretoria from Dallas, and PC-based videoconferencing was employed for clinician and subject communication. Thirty adult subjects were assessed, and the pure tone audiometric thresholds (125-8000 Hz) obtained through conventional face-to-face and remote testing were compared. Face-to-face and remote audiometry thresholds differed by 10 dB in only 4% of cases overall. The limits of agreement between the two techniques were -8 and 7 dB with a 90% confidence interval of -5 to 5 dB. The average reaction times to stimulus presentations were similar, within -108 and 121 ms. The average test duration was 21% longer for remote testing (10.4 vs. 8.2 min). There were no clinically significant differences between the results obtained by remote intercontinental audiometric testing and conventional face-to-face audiometry. It may therefore be possible to expand the reach of audiological services into remote underserved regions of the world.
RESEARCH/Original article
Intercontinental hearing assessment - a study in tele-audiology
De Wet Swanepoel 1,3, Dirk Koekemoer 2 and Jackie Clark 3,4
1 Department of Communication Pathology, University of Pretoria, South Africa
2 Research and Development Department, GeoAxon, South Africa
3 Callier Center for Communication Disorders, University of Texas at Dallas, USA
4 Department of Speech and Hearing Therapy, University of the Witwatersrand, South Africa
Correspondence:
Dr De Wet Swanepoel,
Department of Communication Pathology,
University of Pretoria,
Pretoria 0002,
South Africa
(Fax: +27 12 420 3517; Email: dewet.swanepoel@up.ac.za)
Summary
We evaluated the validity of remote pure-tone audiometric testing conducted from North America
on subjects in South Africa. Desktop-sharing computer software was used to control the
audiometer in Pretoria from Dallas, and PC-based videoconferencing was employed for clinician
and subject communication. Thirty adult subjects were assessed, comparing the pure tone
audiometric thresholds (125-8000 Hz) obtained through conventional face-to-face and remote
testing. Face-to-face and remote audiometry thresholds differed by 10 dB in only 4% of cases
overall. The limits of agreement between the two techniques were -8 and 7 dB with a 90%
confidence interval of -5 to 5 dB. The average reaction times to stimulus presentations were
similar, within -108 and 121 ms. The average test duration was 21% longer for remote testing
(10.4 vs. 8.2 min). There were no clinically significant differences between the results obtained
by remote intercontinental audiometric testing and conventional face-to-face audiometry. It may
therefore be possible to expand the reach of audiological services into remote underserved regions
of the world.
Introduction
Hearing loss is the most common chronic disabling condition globally and in 2005 was estimated
to affect 642 million people to some degree.[1,2] A range of interventions can reduce the
consequences of hearing loss,[1] but the basis for intervention is early identification and accurate
diagnosis.
Except in the case of very young infants or other difficult-to-test populations (e.g. people who are
severely handicapped) who cannot provide reliable behavioural responses, the gold standard for
describing hearing sensitivity is pure tone audiometry. This procedure determines behavioural
thresholds to pure tone acoustic signals of various frequencies (i.e. 250, 500, 1000, 2000, 4000
and 8000 Hz). Thresholds represent the lowest intensity where the patient responds to the
acoustic signal providing information on hearing sensitivity (i.e. degree and configuration of
hearing loss). When combined with bone conduction testing, in which the cochlea is stimulated
directly by presenting sound vibrations to the forehead or mastoid, the type of hearing loss can
also be distinguished. The findings of this test procedure form the basis for clinical decisions
regarding audiological treatment, referrals and intervention.
Unfortunately these diagnostic test procedures are not available to the majority of those with
hearing loss. The reasons include a shortage of staff trained to conduct audiometric tests and
limited infrastructure such as the audiometers and sound booths necessary for diagnostic pure tone
testing.[3,4] Telemedicine offers the possibility of extending hearing assessments to underserved
communities. New generation audiometers are portable, highly flexible devices that are
compatible with telemedicine and some include features that could reduce the need for expensive
sound booths for testing. Such features include live monitoring of environmental noise, double
sound-attenuation with insert and circumaural earphones, and active noise-cancellation.[5]
Initial reports of pure tone audiometry conducted via telemedicine have revealed promising
results, which indicate essentially equivalent findings when compared to conventional face-to-
face testing.[6-9] However, the initial studies have been limited in the distance at which the
remote testing was conducted (between 1 and 1100 km). Cross-continent or transatlantic
telemedicine hearing assessments have not been reported.
Healthcare professionals in industrialized countries (i.e. the US) may be able to provide hearing
healthcare services via telemedicine in countries where no such professionals are available (i.e.
most countries in Africa). In underserved areas like Africa, Internet connectivity is becoming
increasingly available although it may have to rely on mobile phone networks.[5] The present
investigation therefore utilized a telemedicine compliant computer-based audiometer, connected
to the Internet through a mobile phone network, to determine the validity of synchronous pure
tone audiometry conducted from North America on subjects in sub-Saharan Africa.
Methods
The study was approved by the appropriate ethics committee. Thirty subjects (with 60 ears)
between 18 and 65 years of age were recruited for the study (18 women and 12 men). The
subjects were volunteers living in Pretoria. Most volunteers (80%) had hearing thresholds that all
fell within the range commonly specified as normal hearing (≤25dB). According to more recently
proposed criteria [10] for normal hearing thresholds (≤15dB), 50% of the volunteers had normal
hearing across all frequencies.
Equipment
A portable audiometer with insert earphones (KUDUwave 5000, GeoAxon, South Africa) was
used to measure pure tone air conduction thresholds. The audiometer is software controlled and
connected to a netbook computer (Acer Aspire One PC, Windows XP) via a USB port and to the
Internet through a 3G mobile modem. The audiometer’s circumaural earphones are placed over
insert earphones to increase the attenuation of environmental sound. Environmental noise levels
are monitored by the device with an external and internal microphone to measure noise levels for
test compliance.
At the test site, a physician acted as facilitator to ensure that the audiometer software operated
properly and that the insert earphone probes and circumaural earphones were placed correctly on
the subject's ears. A 3G cellular network was used to connect to the Internet at the test site in
South Africa and a broadband wireless or LAN network was used to connect to the Internet at the
remote clinician site in the US. The computers at both sites were configured with
videoconferencing software (Skype Video call version 4, Luxembourg) and hardware
(microphone and webcam). Remote computing was performed through application sharing
software (TeamViewer 4, Göppingen, Germany) so that the clinician in Dallas could control the
computer in Pretoria to facilitate the remote testing (Figure 1). Information privacy was ensured
through a unique identification number and password sent from the computer at the test site to the
computer at the remote site through Skype. All the information collected was stored on the
computer in Pretoria. The remote clinician was in audiovisual contact with the patient through the
videoconference.
Measurements
All subjects were tested with pure tone air conduction audiometry in both ears across octave-
interval frequencies from 125 to 8000 Hz in two test configurations scheduled in the same sound
treated room. In conventional mode the clinicians tested the subject’s hearing face-to-face. In
telemedicine mode the subject was tested in the same room but by a clinician 14,680 km away in
Dallas. The remote testing was facilitated through desktop application-sharing and interactive
videoconferencing software (Figure 1). During the remote testing, an on-site physician positioned
the earphones for testing and the remote clinician instructed patients regarding the test procedure.
The test order (face-to-face first, or remote first) was alternated and clinicians were kept blind to
each other's results. The local clinician was either outside the test room or seated at the back of
the computer screen during the remote testing. The remote clinician saved data once the test was
completed and notified the local clinician via the videoconference. All testing (one face-to-face
and one remote test) was conducted on the same day.
The test protocols and procedure were identical between local and remote clinicians. A
conventional 10 dB down and 5 dB up bracketing method was used to determine hearing
thresholds. The frequency testing started at 1000 Hz and proceeded to higher frequencies. After
testing at 8000 Hz the lower frequencies were evaluated, starting at 500 Hz and reducing to 125
Hz. Subjects indicated responses to the stimulus by using a hand-held response switch. When
pressed, a visual response was indicated on the computer screen and the reaction time was
documented. The subject's responses appeared on the audiogram and were colour-coded: a green
mark indicated that the response fell within the allowed time frame and a yellow mark indicated
that the response fell outside the allowed timeframe or that there was no response to the stimulus
presentation.
The average reaction time from stimulus presentation to the subject pressing the response button
was recorded in a sub-group of 9 patients to compare the reaction times between the face-to-face
and remote audiometric assessment conditions.
Recording time was also documented for conducting the conventional and remote audiometric
tests on 22 of the subjects. The recording was initiated with the first stimulus presentation to the
first ear tested and was terminated after the last patient response was recorded for the last ear
tested.
Data analysis
Limits of agreement (mean difference ±2 SD) between the two techniques, and 90% confidence
intervals, were determined according to the method of Bland & Altman [11] for assessing
agreement between two methods. A t-test across frequencies (125-8000 Hz) was conducted to
determine if there was a significant difference between the results obtained with the conventional
face-to-face and remote test conditions.
Results
The average thresholds observed during face-to-face (FTF) and remote (RT) audiometry are
shown in Table 1. The average absolute difference between thresholds was 2.4 dB (SD 2.9) and
varied between 2 and 2.9 dB across frequencies. There were no significant differences between
test conditions across frequencies (P>0.05).
Face-to-face and remote audiometry thresholds differed by 10 dB in only 4% of cases overall, see
Figure 2. The limits of agreement between the two techniques (FTF-RT) were -8 and 7 dB with a
90% confidence interval of -5 to 5 dB. Figure 3 illustrates the difference between face-to-face
and remote audiometry thresholds for two of the seven octave frequencies assessed.
A separate analysis of correspondence between face-to-face and remote audiometry was
conducted, for thresholds outside the range of normal hearing (≤15dB), representing 13% of all
thresholds (54 of 420 threshold comparisons). Correspondence was within 5 dB or less in 98% of
comparisons. The remaining normal hearing thresholds (≤15dB), representing 87% of all
thresholds, corresponded within 5 dB or less in 95% of cases.
The average reaction time from stimulus presentation to response is shown in Table 2, as recorded
in 9 of the 30 subjects for all threshold measurements in both ears. The mean values for the
average reaction times differed by less than 2 ms. The average difference between the average
reaction times with face-to-face and remote audiometry was 2 ms (ranging between -108 and 121
ms) and the limits of agreement between the two techniques (FTF-RT) were -135 and 139 ms
with a 90% confidence interval of -96 to 97 ms.
The time required to complete an audiogram for both ears of a subject was recorded for 22 of the
30 subjects. The average time for the conventional face-to-face test was 8.2 min (SD 2.1)
compared to 10.4 min (SD 2.1) for remote testing, which is a 21% longer average test duration.
Discussion
Apart from an anecdotal report of a patient in the USA being tested from Brazil [12], the longest
distance for remote synchronous audiometric threshold testing previously reported in a group
study was 1100 km and was within the same country.[9] The present study demonstrates the
feasibility of remote audiometric testing from North America to Africa. The intercontinental
assessment revealed no significant difference between pure tone hearing thresholds when
compared to conventional face-to-face testing. The average reaction times recorded with face-to-
face compared to remote testing were similar, within -108 and 121 ms, but the average test
duration was slightly longer for remote-testing although it varied with a 90% confidence interval
of -0.5 and 5.9 minutes. This may have been due to delays caused by the mobile phone network
Internet connection, but did not have any effect on the test results.
The results of the present study are in close agreement with previous reports comparing pure tone
audiometry thresholds obtained remotely and conventional face-to-face tests.[6-9] The first
studies were conducted in the USA by Givens and colleagues.[6,7] The mean threshold
differences between the remote and conventional test procedures employed by these authors
varied between 0.0 and 1.3 dB across frequencies (250 to 8000 Hz) compared to differences of
between -1 and 0.1 dB across frequencies (125 to 8000 Hz) in the current study. In another report
by Choi and colleagues [8] the remote versus conventional pure tone hearing thresholds varied by
less than 5 dB in 89% of threshold comparisons compared to 96% in the present study. A similar
report for 30 normal hearing subjects tested with pure tone audiometry in a remote and a face-to-
face configuration, revealed threshold correspondence within 5 dB in 97% of cases compared to
96% in the present study.[9]
The variability observed in threshold correspondence within 5 dB (90% confidence interval of -5
to 5 dB) for remote and face-to-face audiometry corresponds to normal clinical variability (test-
retest variability) in determining hearing thresholds with pure tone audiometry. Typical test-retest
variability in pure tone audiometry is ±5 dB in individual subjects, whether children or
adults.[13,14] The investigations by Choi and colleagues [8] and Krumm and colleagues also
included an evaluation of test-retest reliability for conventional face-to-face audiometry.[9]
Although the test-retest variability was reported as slightly less than that of remote compared to
face-to-face thresholds, there was no significant difference between either comparison.
Although the majority of comparisons (87%) in the present study were for normal hearing
thresholds (≤15 dB), some (n=54) elevated thresholds (≥20 dB) which indicate hearing loss were
also included. The correspondence for these elevated thresholds obtained with face-to-face and
remote test conditions was very close, with 98% within 5 dB or less of each other. This was
slightly better than the correspondence for the remaining normal hearing (≤15 dB) thresholds
(95%). Validation in more cases of hearing loss, especially with more severe degrees of hearing
loss must, however, still be performed.
The present threshold findings for remote intercontinental audiometric testing indicate that there
is no clinically significant difference when compared to conventional face-to-face audiometry.
The possibility of testing hearing accurately at long distance opens the possibility of expanding
the reach of audiological services into remote underserved regions of the world. Although much
work remains to be done, including monitoring remote sites for compliance and determining
patient and clinician acceptance of such tests, the initial findings appear very promising.
References
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Table 1. Average thresholds for face-to-face (FTF) and remote (RT) audiometry
125 Hz 250 Hz 500 Hz 1000
Hz 2000
Hz 4000
Hz 8000 Hz Overal
l
Mean FTF threshold
(SD) 9.2 (8.8) 7.6
(7.7) 8.6
(8.7) 8.7
(10.5) 8.5
(8.7) 5.3
(10.5) 10.1
(17.1) 8.3
(10.7)
Mean RT threshold
(SD) 10.2 (8.9) 8.1
(8.5) 9.3
(8.5) 8.9
(10.5) 8.4
(8.1) 6.1
(10.4) 10.9
(17.0) 8.8
(10.7)
Table 2. Average reaction times (ms) and number of presentations for face-to-face and remote
audiometry (9 subjects)
Mean SD No of presentations
Face-to-face audiometry
596 191 93
Remote audiometry
594 189 75
Mean difference (FTF-RT)
2 69 18
Figure legends
1. Remote audiometric test configuration with interactive videoconferencing. The clinician is
visualized in the top right corner with the subject being evaluated visualized in the bottom right
corner. The left and right ear thresholds are visualized on the audiogram on the left side of the
figure (There is a video recording of a test session from Dallas to South Africa at:
http://www.youtube.com/watch?v=HDfjuvP0Dh0).
2. Distribution of threshold differences between face-to-face and remote audiometry (420
threshold comparisons). 0 dB represents perfect correspondence; ± 5 dB represents normal test-
retest variability.
3. Difference between thresholds measured in face-to-face and remote audiometry (60
comparisons) versus the average of the two measurements. (a) at 125 Hz and (b) at 8 kHz
... For the qualitative synthesis of this review, four cross-sectional studies 10-13 , a case-control study 14 , a case study 15 , a validation study 16 , and two accuracy studies 17,18 were analyzed. The sample size of the studies included in this review ranged from 2 15 to 42,697 14 . ...
... The research by Swanepoel et al. 16 evaluated the validity of PTA tests. The study was carried out in individuals from South Africa. ...
... Swanepoel et al. 16 , 2010, South Africa ...
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... Developing countries are challenged by limited resources in the hearing health care sector, such as scarcity of specialist clinicians and appropriate audiological infrastructure such as sound-treated booths. Many advances have been made to increase accessibility of hearing health care through boothless audiometry, tele-audiology, and automated diagnostic audiometry (Swanepoel et al., 2010(Swanepoel et al., , 2015. An automated computer-based audiometer (KUDUwave, eMoyo) with increased passive attenuation and the potential to be incorporated into tele-audiology practices has been validated to provide access to diagnostic audiometry in underserved environments with a shortage of audiologists and audiological equipment such as sound booths (Swanepoel et al., 2015). ...
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Purpose: This study aimed to investigate the accuracy of bilateral simultaneous tympanometric measurements using a tympanometer with two pneumatic systems inside circumaural ear cups. Method: Fifty-two adults (104 ears), with a mean age of 32 years (SD = 12.39, range: 18–60 years) were included in this study. A within-subject repeated-measures design was used to compare tympanometric measurements yielded with the investigational device in unilateral and bilateral simultaneous conditions compared with an industry-standard tympanometer. Results: No significant bias (p > .05) was found between the mean of the differences of tympanometric measurements yielded by the two devices, except for a significant bias (p < .05) of the mean of the differences for ear canal volume measurements (0.05 cm3). The Bland–Altman plots showed overall good agreement between the tympanometric measurements between the two instruments. In all 104 ears, the tympanogram types of the KUDUwave TMP were compared with the reference device. The results were highly comparable with a sensitivity and specificity of 100% (95% CI [86.8%, 100%]) and 92.3% (95% CI [84.0%, 97.1%]), respectively. Conclusions: The investigational device is a suitable instrument for unilateral or bilateral simultaneous tympanometric measurements in adults and demonstrates the potential of decentralized and accessible tympanometry services.
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Objective: The primary objective of the current study was the validation of a cloud-centralized audiometry system for clinical practice. Design: A cross-sectional study design was used. Study sample: A convenience sample of patients (>10 years old) booked for follow-up appointments were invited to participate. Participants completed both conventional and online digital audiometry in a standard sound treated clinic space during a single clinic visit; tests were completed in random order. Data for both ears were included. Patients were from one of three audiological practices. Results: A total of 41 participants completed both audiometric tests. Validation study results showed that the mean difference between the two audiometric test results remained within 5 dB HL for both air and bone conduction thresholds at all tested frequencies. Conclusions: Online digital audiometry has been demonstrated as a clinically accurate method for hearing assessment.
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Objective Telemedicine and telementoring have had a significant boost across all medical and surgical specialties over the last decade and especially during the COVID-19 pandemic. The aim of this scoping review is to synthesize the current use of telemedicine and telementoring in otorhinolaryngology and head and neck surgery. Data Sources PubMed and Cochrane Library. Review Methods A scoping review search was conducted, which identified 469 articles. Following full-text screening by 2 researchers, 173 articles were eligible for inclusion and further categorized via relevant subdomains. Conclusions Virtual encounters and telementoring are the 2 main applications of telemedicine in otolaryngology. These applications can be classified into 7 subdomains. Different ear, nose, and throat subspecialties utilized certain telemedicine applications more than others; for example, almost all articles on patient engagement tools are rhinology based. Overall, telemedicine is feasible, showing similar concordance when compared with traditional methods; it is also cost-effective, with high patient and provider satisfaction. Implications for Practice Telemedicine in otorhinolaryngology has been widely employed during the COVID-19 pandemic and has a huge potential, especially with regard to its distributing quality care to rural areas. However, it is important to note that with current exponential use, it is equally crucial to ensure security and privacy and integrate HIPAA-compliant systems (Health Insurance Portability and Accountability Act) in the big data era. It is expected that many more applications developed during the pandemic are here to stay and will be refined in years to come.
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Tele-audiology practice is sometimes portrayed or practiced as an extension of conventional audiology practice, but in reality, it should be considered as a more flexible and innovative way of delivering hearing healthcare. It is likely to continue expanding beyond the bounds of conventional audiology into the future. This has far-reaching implications for clinical utility and client satisfaction. One important consequence is that tele-audiology is changing the way individuals are approaching their hearing health. In a connected economy, people are becoming more empowered in managing their health and are metamorphosing from patients, whose only option is to visit a clinical facility, to consumers with choices. There will still be a need for conventional audiology practices to manage more complex cases where medical diagnosis and intervention are involved, or where clients prefer face-to-face service, but this will be as part of a hearing health ecosystem where the consumer makes the choices drawing on a range of influencing factors. There is now substantial evidence from large-scale studies and clinical data that aspects of tele-audiology are prevalent within different service models and that the outcomes are at least as beneficial to the recipients as the outcomes from delivery of conventional audiology services in conventional audiology clinics. In addition to potential improvements to client outcomes, tele-audiology is already starting to improve access to hearing health services, reduce costs, and deliver social and economic benefits to society.
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The Telehealth program at East Carolina University has developed a system for real-time assessment of auditory thresholds using computer driven control of a remote audiometer via the Internet. The present study used 45 adult participants in a double-blind study of 2 different systems: a conventional audiometer and an audiometer operated remotely via the Internet. The audiometric thresholds assessed by these 2 systems varied by no more than 1.3 dB for air conduction and 1.2 dB for bone conduction. The results demonstrated the feasibility of this new "telehearing" audiometric system. With the rapid development of Internet-based applications, telehealth has the potential to provide important healthcare coverage for rural areas where specialized audiological services are lacking.
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The purpose of this study was to examine test-retest reliability of in situ unaided thresholds measured using a handheld hearing aid programmer coupled to a hearing aid transducer in adults with normal hearing. Randomized in situ thresholds at 4 octave frequencies were established in 1 ear of 43 adults twice using the Widex Diva SP3 device with the stimulus generated by and transduced through a Widex Diva SD-9 behind-the-ear hearing aid. Insert earphone tips were used in each of the measures to couple the hearing aid/transducer to the ear canal. Mean decibel differences between the test and retest thresholds were less than 1 dB at each frequency. Using an 80% statistical test criterion, results revealed test-retest reliability within 5 dB for all frequencies: 98% at 500 Hz, 100% at 1000 and 2000 Hz, and 93% at 4000 Hz. Test-retest reliability of in situ unaided thresholds using the SP3/SD-9 device is equivalent to that of currently accepted audiometric procedures.
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Various real-time telemedicine applications have been investigated in audiology, including pure tone audiometry, otoacoustic emission testing, auditory brainstem response recordings, hearing aid fitting and video-otoscopy. Store-and-forward applications have usually been used to transmit basic patient data including case history information and hearing screening results, although both video-nystagmography and video-otoscopy have been piloted. Remote access to computerized equipment is relevant to audiology telemedicine, although there have been few reports of the use of application sharing using computerized audiology equipment. In a pilot trial of real-time telemedicine, both pure tone and speech audiometry measures were provided remotely through application sharing. Audiology telemedicine appears promising, but it is at an early stage of development and many areas such as its cost effectiveness, patient acceptance and test efficacy require systematic investigation.
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This paper describes the international education and practice of audiology with the broader aim of proposing possible cost-effective and sustainable education models to address the current situation. Major audiology organizations worldwide were surveyed from February 2005 to May 2007, and organizations from 62 countries (78% of the world population) returned a completed survey. Overall, the results suggested a wide range of professionals providing hearing health care, and 86% of the respondents reported a need for more audiologists. There was also considerable variation in the scope of practice among the different hearing health care professionals, and the minimum education levels of audiologists with similar scopes of practice. The countries surveyed fell into four broad categories in terms of professional resources, and the results highlighted the urgent need for forward planning at both national and international levels. The study highlights options for addressing some of the challenges in educating audiologists and the provision of hearing health care services globally.
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A proposal is made that 15 dB HL, rather than 25 dB HL, be considered the upper limit of normal hearing sensitivity. This recommendation is based on an explanation of the change from an earlier philosophy and the fact that so many people with hearing levels that average less than 25 dB HL consider themselves to have hearing difficulty. Such reclassification of people with slight to mild hearing losses would dignify their clinical complaints and aid in counseling that would assist them with their hearing difficulties.