An Evaluation of the Cross-Check Principle Using Visual Reinforcement Audiometry, Otoacoustic Emissions, and Tympanometry

Abstract

Early intervention to reduce the effects of congenital hearing loss requires accurate description of hearing loss. In pediatric audiology, a cross-check principle is used to compare behavioral and physiological tests. The purpose of this study was to investigate the correspondence of visual reinforcement audiometry (VRA) minimal response levels (MRLs), otoacoustic emissions (OAEs), tympanometry, and VRA test reliability to determine the odds of obtaining the expected cross-check results. We hypothesized that (1) when MRLs were within normal limits (WNL), OAEs would be present; (2) in the event of normal MRLs and absent OAEs, tympanograms would be abnormal; and (3) in the event of elevated MRLs and present OAEs, the tester's confidence in the MRLs would be judged to be only fair, rather than good. This was a retrospective study. A previous study provided data from 993 infants who had diagnostic audiologic evaluations at 8-12 mo of age. The data were analyzed to compare VRA MRLs with OAE signal-to-noise ratios at 1, 2, and 4 kHz. Odds ratios and 95% confidence intervals were calculated to test the three hypotheses related to the correspondence among MRLs, OAEs, tympanometry, and the reliability of MRLs. The probability that OAEs would be present when MRLs were WNL varied from 12 to 26 to 1, depending on the test frequency. When OAEs were absent in the presence of normal MRLs, the odds of abnormal tympanometry varied from 5 to 10 to 1, depending on the test frequency. When MRLs were elevated (>20 dB HL), the odds suggested that examiners judged the MRLs at 1 and 2 kHz to lack reliability. The results suggest that the cross-check principle is effective when employing VRA, OAE, and tympanometry to rule out or determine the degree, type, and configuration of hearing loss in infants.