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The paediatric otological caseload resulting from improved screening in the first year of life
M P Haggard1, B McCormick, M M Gannon
1MRC Institute of Hearing Research, University of Nottingham, UK.
Insights
Improved hearing screening accurately detects hearing loss but increases referrals for otitis media with effusion (OME). The enhanced screen identifies more true cases of hearing impairment, not due to lower referral criteria, but improved sensitivity.
Area of Science:
- Audiology
- Pediatric Otolaryngology
- Public Health Screening
Background:
- Improved hearing screening techniques enhance detection of prelingual sensorineural deafness.
- However, these improvements lead to a significant increase in referrals for otitis media with effusion (OME) in infants.
Purpose of the Study:
- To evaluate the impact of enhanced hearing screening on referral rates for both sensorineural hearing impairment and otitis media with effusion.
- To determine if referral criteria for otolaryngology (ENT) changed with improved screening sensitivity.
Main Methods:
- Two child samples (n=29, n=61) were tested before and after screening improvements in a dedicated hearing assessment clinic.
- Children were categorized into referral (severe/persistent impairment) and discharge groups.
- Audiometric criteria for ENT referral were analyzed in relation to screening outcomes.
Main Results:
- Despite increased screening detections, the average audiometric referral criterion for ENT remained largely unchanged.
- The proportion of the screened population with true hearing impairment requiring referral increased from 0.4% to 1.3%.
- Enhanced screening significantly increased the caseload for otological assessment, primarily due to OME.
Conclusions:
- Improvements in hearing screening sensitivity and positive predictive value primarily increase the detection of otitis media with effusion requiring concern.
- The study highlights that effective hearing screening in young children is predominantly focused on identifying OME, not prelingual sensorineural hearing impairment.
- There is an urgent need for consensus on the otological management of young children diagnosed with OME through screening.
Abstract:
Improved test technique by health visitors has been shown to lead to higher accuracy in the screen of hearing aimed traditionally at prelingual sensorineural deafness. However, it gives greatly increased referrals of children having otitis media with effusion (OME) around the end of the first year of life. Two samples of children (n = 29 and 61) were tested in a children's hearing assessment clinic with properly documented testing techniques and trained personnel. The samples were each formed on a fixed population base, one before and one after screen improvements. This enabled characterization of two outcome groups within each sample (severe/persistent enough to refer to ENT vs discharged, despite slight hearing impairment). The average audiometric criterion for onward referral to ENT rose only very little, despite the increased assessment caseload resulting from more detections by the screen. This usefully permitted the conclusion that the number of true cases found due to the screen and assessed as lying beyond a specifiable degree of severity (average cut-off approximately 47 dB(A) or 35 dBHTL) had increased not through lower criteria for referral to ENT, but through the improvements to the screen. The increase was from approximately 0.4% to 1.3% of the base population screened. Thus a change materially enhancing the sensitivity and positive predictive value of a screen considerably enlarges the eventual otological caseload of children with middle-ear disease thought to justify concern at around the end of their first year. If done properly, screening is hence in practical terms about OME, not about prelingual sensorineural hearing impairment. This conclusion presses the urgency of evaluation and consensus on the otological management of the young child with OME.