Middle Ear Disease Research Articles

Ear disease and hearing loss: a descriptive study of Aboriginal children living in metropolitan South Australia

ObjectiveThis article aims to describe the rates of middle ear disease in Aboriginal children living in metropolitan Adelaide. MethodsData from the Under 8s Ear Health Program (population-based outreach screening) were analysed to identify rates of ear disease and the referral outcomes for children identified with ear conditions during screening. ResultsIn total, 1598 children participated in at least one screening between May 2013 and May 2017. Males and females were equally represented; 73.2% had one or more abnormal findings on otoscopy at the first screening visit, 42% had abnormal tympanometry, and 20% registered a “fail” on otoacoustic emission testing. The referral pathway for children with abnormal findings included referrals to their GP, Audiology, and Ear Nose Throat (ENT) Departments. Also, 35% (562/1598) of the children screened required referral either to a GP or Audiology, and 28% of those referred (158/562) or 9.8% (158/1598) of the total number of children screened required further ENT management. ConclusionsHigh rates of ear disease and hearing problems in urban Aboriginal children were detected in this study. Existing social, environmental, and clinical interventions need to be evaluated. Closer monitoring including data linkage may assist to better understand the effectiveness, timeliness, and challenges of public health interventions and follow-up clinical services to a population-based screening program. Implications for Public HealthAboriginal-led population-based outreach programs such as the Under 8s Ear Health Program augmented by seamless integration with education, allied health and tertiary health services should be prioritised for expansion and continued funding.

Comparative study of quality of life and surgical outcome in open mastoid cavity and mastoid cavity obliteration in canal wall down mastoidectomy

Background: Canal wall down mastoidectomy is a surgical technique used for the eradication of middle ear disease. The remaining large mastoid bowl is associated with a number of issues; one of the techniques that have been developed in order to avoid such problems is the obliteration of the mastoid cavity. Mastoid obliteration resulted in a decrease in the complications associated with the open mastoid cavity. The materials used for this reason are either biological or synthetic. Mastoid obliteration with synthetic materials is a valuable and safe surgical technique for patients who undergo canal wall down mastoidectomy. Methods: This is a prospective study carried out in the department of otorhinolaryngology. Sample size: 30 patients out of which 15 were operated by Modified Radical Mastoidectomy with obliteration (Group A) and 15 were operated by Modified Radical Mastoidectomy without obliteration (Group B). Study design: single centre, longitudinal, prospective, two group, parallel, follow-up, randomly allocated statistical method and tools: Fischer’s Exact Test. Study period: August 2017 to August 2020. Results: Study was divided in two groups, group A (modified radical mastoidectomy with obliteration) & group B (modified radical mastoidectomy without obliteration). Conclusions: The incidence of pain, discharge, giddiness and wax formation was markedly reduced in obliterated cavities as compared to open cavities. Healing of the cavity as evidenced by epithelialization, at the end of 3 months, was better in obliterated ears. Patients with obliterated mastoid cavity required less cavity care, doctor dependence, frequent OPD visits.

High Frequency Tympanometry in Early Infancy and Its Effect on Oto Acoustic Emissions.

The present study was conducted to study the benefit of high frequency tympanometry (HFT) in detecting middle ear pathologies in infants. This study also aims to find the effect of middle ear diseases on absent otoacoustic emissions (OAE). Our study was a prospective study which included 123 healthy neonates below 1 month of age. The babies were referred for the new born hearing screening programme. They were subjected to DPOAE followed by tympanometry with a 1000z probe tone (HFT). The study was approved by the institutions ethical committee. "Present" OAE result was obtained for 202 ears, while "absent" OAE result was obtained for 44 ears. High frequency tympanometry was also performed on all the participants, where a normal tympanogram was obtained in 170 ears and 76 ears showed an abnormal tympanogram. The following parameters were studied: peak pressure, ear canal volume and compliance. Descriptive statistics were obtained for the same. Association of OAE with HFT was studied. Out of the 44 ears with refer OAE, 34 ears had an abnormal tympanogram and among 202 ears with a present OAE, 160 ears had a normal tympanometric peak indicating a sensitivity and specificity of 77.3% and 79.2% respectively. High frequency tympanometry not only helps in early detection of middle ear pathologies but also to find the effect of middle ear diseases on absent otoacoustic emissions.

Structure-constrained deep feature fusion for chronic otitis media and cholesteatoma identification.

Chronic suppurative otitis media (CSOM) and middle ear cholesteatoma (MEC) were two most common chronic middle ear disease(MED) clinically. Accurate differential diagnosis between these two diseases is of high clinical importance given the difference in etiologies, lesion manifestations and treatments. The high-resolution computed tomography (CT) scanning of the temporal bone presents a better view of auditory structures, which is currently regarded as the first-line diagnostic imaging modality in the case of MED. In this paper, we first used a region-of-interest (ROI) network to find the area of the middle ear in the entire temporal bone CT image and segment it to a size of 100*100 pixels. Then, we used a structure-constrained deep feature fusion algorithm to convert different characteristic features of the middle ear in three groups as suppurative otitis media (CSOM), middle ear cholesteatoma (MEC) and normal patches. To fuse structure information, we introduced a graph isomorphism network that implements a feature vector from neighbourhoods and the coordinate distance between vertices. Finally, we construct a classifier named the "otitis media, cholesteatoma and normal identification classifier" (OMCNIC). The experimental results achieved by the graph isomorphism network revealed a 96.36% accuracy in all CSOM and MEC classifications. The experimental results indicate that our structure-constrained deep feature fusion algorithm can quickly and effectively classify CSOM and MEC. It will help otologist in the selection of the most appropriate treatment, and the complications can also be reduced.

Correlation between chronic suppurative otitis media and deviated nasal septum of the ipsilateral side

Background: Chronic suppurative otitis media (CSOM) is a long standing infection of middle ear with permanent defect in tympanic membrane with or without ear discharge, frequently have an underlying nasal pathology, which can worsen the middle ear disease secondary to Eustachian tube dysfunction, leading to negative middle ear pressure, tympanic membrane retraction, chronic otitis media with effusion and/or cholesteatoma. Present study was conducted to study the correlation of a etiopathogenesis, bacteriology of CSOM with the deviation of the nasal septum (DNS) of the ipsilateral side. Methods: Study was conducted in ENT department, AJ institute of medical science, Mangalore, Karnataka. Study group included 120 patients having CSOM, selected randomly from outpatient department (Time bound cross-sectional study). Predesigned proforma was used. Detailed history taken, followed by a thorough ENT examination. Relevant investigations were performed. Results: In this study, the prevalence of nasal disease (DNS) in patients with CSOM was 73.33%. Out of 120 CSOM patients, 88 patients had co-existent nasal disease (DNS). Among the 88 cases; 71 (59.2%) patients showed direct correlation with CSOM. Culture swabs showed similar bacterial isolates in aural and nasal swabs indicating, there may be retrograde spread of pathogens from nasopharynx to middle ear via Eustachian tube. Conclusions: A significant correlation was established between CSOM and DNS of the ipsilateral side. DNS played a key role in persistence of CSOM. A conscientious evaluation of nose and paranasal sinuses diseases is essential and we thus endorse management of nasal disease prior to the surgical treatment of ear disease, for meritful postoperative results.

First reports of primary ciliary dyskinesia caused by a shared DNAH11 allele in Canadian Inuit.

Primary ciliary dyskinesia (PCD) is typically an autosomal recessive disease characterized by recurrent infections of the lower respiratory tract, frequent and severe otitis media, chronic rhinosinusitis, neonatal respiratory distress, and organ laterality defects. While severe lower respiratory tract infections and bronchiectasis are common in Inuit, PCD has not been recognized in this population. We report a case series of seven Inuit patients with PCD identified by genetic testing in three Canadian PCD centers. Patients ranged from 4 to 59 years of age (at time of last evaluation) and originated in the Qikiqtaaluk region (Baffin Island, n = 5), Nunavut, or Nunavik (northern Quebec, n = 2), Canada. They had typical features of PCD, including neonatal respiratory distress (five patients), situs inversus totalis (four patients), bronchiectasis (four patients), chronic atelectasis (six patients), and chronic otitis media (six patients). Most had chronic rhinitis. Genetic evaluation demonstrated that all had homozygous pathogenic variants in DNAH11 at NM_001277115.1:c.4095+2C>A. The discovery of this homozygous DNAH11 variant in widely disparate parts of the Nunangat (Inuit homelands) suggests this is a founder mutation that may be widespread in Inuit. Thus, PCD may be an important cause of chronic lung, sinus, and middle ear disease in this population. Inuit with chronic lung disease, including bronchiectasis or laterality defects, should undergo genetic testing for PCD. Consideration of including PCD genetic analysis in routine newborn screening should be considered in Inuit regions.

Ear and hearing care programs for First Nations children: a scoping review

BackgroundEar and hearing care programs are critical to early detection and management of otitis media (or middle ear disease). Otitis media and associated hearing loss disproportionately impacts First Nations children. This affects speech and language development, social and cognitive development and, in turn, education and life outcomes. This scoping review aimed to better understand how ear and hearing care programs for First Nations children in high-income colonial-settler countries aimed to reduce the burden of otitis media and increase equitable access to care. Specifically, the review aimed to chart program strategies, map the focus of each program against 4 parts of a care pathway (prevention, detection, diagnosis/management, rehabilitation), and to identify the factors that indicated the longer-term sustainability and success of programs.MethodA database search was conducted in March 2021 using Medline, Embase, Global Health, APA PsycInfo, CINAHL, Web of Science Core Collection, Scopus, and Academic Search Premier. Programs were eligible or inclusion if they had either been developed or run at any time between January 2010 to March 2021. Search terms encompassed terms such as First Nations children, ear and hearing care, and health programs, initiatives, campaigns, and services.ResultsTwenty-seven articles met the criteria to be included in the review and described a total of twenty-one ear and hearing care programs. Programs employed strategies to: (i) connect patients to specialist services, (ii) improve cultural safety of services, and (iii) increase access to ear and hearing care services. However, program evaluation measures were limited to outputs or the evaluation of service-level outcome, rather than patient-based outcomes. Factors which contributed to program sustainability included funding and community involvement although these were limited in many cases.ConclusionThe result of this study highlighted that programs primarily operate at two points along the care pathway—detection and diagnosis/management, presumably where the greatest need lies. Targeted strategies were used to address these, some which were limited in their approach. The success of many programs are evaluated as outputs, and many programs rely on funding sources which can potentially limit longer-term sustainability. Finally, the involvement of First Nations people and communities typically only occurred during implementation rather than across the development of the program. Future programs should be embedded within a connected system of care and tied to existing policies and funding streams to ensure long term viability. Programs should be governed and evaluated by First Nations communities to further ensure programs are sustainable and are designed to meet community needs.

Adenoids-diagnosis and treatment: the new German S2k guideline

Hyperplasia of the pharyngeal tonsils is to be considered pathologic when nasopharyngeal symptoms of mechanical obstruction and/or chronic inflammation occur. Chronic Eustachian tube dysfunction can result in various middle ear diseases such as conductive hearing loss, cholesteatoma, and recurrent acute otitis media. During examination, attention should be paid to the presence of adenoid facies (long face syndrome), with apermanently open mouth and visible tip of the tongue. In the case of severe symptoms and/or failure of conservative treatment, adenoidectomy is usually performed on an outpatient basis. Conventional curettage remains the established standard treatment in Germany. Histologic evaluation is indicated for clinical evidence of mucopolysaccharidoses. Due to the risk of hemorrhage, the preoperative bleeding questionnaire, which is obligatory before every pediatric surgery, is referred to. Recurrence of adenoids is possible despite correct adenoidectomy. Before discharge home, otorhinolaryngologic inspection of the nasopharynx for secondary bleeding should be performed and anesthesiologic clearance obtained.

Audiometric Variability of the Carhart Effect in Middle Ear Diseases - Pretreatment Analysis.

The assessment of bone conduction thresholds in patients with conductive hearing loss is not a full measure of the function of the inner ear due to the weakening of the influence of middle ear components on bone conduction. This relationship has been called the 'Carhart effect'. The retrospective analysis covered 977 patients diagnosed and treated for middle ear diseases from 2010 to 2020. The Carhart effect was considered to be an increase in the bone conduction threshold by a minimum of 10dB relative to adjacent frequencies. The study was performed with the aim of assessing the presence of the Carhart effect in the course of middle ear diseases in pretreatment analysis. The Carhart effect was observed in 532 cases, most often in patients with chronic otitis media and otosclerosis. It was least often observed in patients with otitis media with effusion. In otitis media with effusion, the Carhart effect was more often noted for the frequency of 4000Hz, in otosclerosis for the frequency of 2000Hz. In patients with chronic otitis media, this effect for the frequency of 4000Hz was correlated with the location of inflammatory changes in the attic area. The presence of inflammatory lesions in the oval window area was associated with the presence of the Carhart effect for the frequency of 2000Hz. 1. The frequency of the Carhart effect observed in diseases of the middle ear does not depend on the disease entity but on the type and location of abnormalities in the middle ear. 2. The Carhart effect observed for the frequency of 4000Hz coexists with the localization of lesions in the range of the malleus and incus, and for the frequency of 2000Hz, it is partially associated with abnormalities in the range of stapes and oval window.

Micro RNAs and Circular RNAs in Different Forms of Otitis Media.

The aim of this comprehensive review was to present the current knowledge on the role of microRNAs (miRNAs) in acute, recurrent, and chronic forms of otitis media. Special attention was focused on cholesteatoma of the middle ear. MicroRNAs modulate gene expression, which, in turn, influences the development and likelihood of the recurrence of acute and aggressive chronic middle ear inflammatory processes. Moreover, this study discusses the modulating role of a specific subgroup of noncoding RNA, circular RNA (circRNA). Recognizing the precise potential pathways and the mechanisms of their function may contribute to a better understanding of the molecular bases of middle ear diseases and identifying novel methods for treating this demanding pathology. Articles published between 2009 and 2022 were used in this analysis. In this review, we provide a complete overview of the latest progress in identifying the role and mechanisms of particular miRNAs and circRNAs in acute, recurrent and chronic forms of otitis media.

Evaluating the generalizability of deep learning image classification algorithms to detect middle ear disease using otoscopy

To evaluate the generalizability of artificial intelligence (AI) algorithms that use deep learning methods to identify middle ear disease from otoscopic images, between internal to external performance. 1842 otoscopic images were collected from three independent sources: (a) Van, Turkey, (b) Santiago, Chile, and (c) Ohio, USA. Diagnostic categories consisted of (i) normal or (ii) abnormal. Deep learning methods were used to develop models to evaluate internal and external performance, using area under the curve (AUC) estimates. A pooled assessment was performed by combining all cohorts together with fivefold cross validation. AI-otoscopy algorithms achieved high internal performance (mean AUC: 0.95, 95%CI: 0.80–1.00). However, performance was reduced when tested on external otoscopic images not used for training (mean AUC: 0.76, 95%CI: 0.61–0.91). Overall, external performance was significantly lower than internal performance (mean difference in AUC: −0.19, p ≤ 0.04). Combining cohorts achieved a substantial pooled performance (AUC: 0.96, standard error: 0.01). Internally applied algorithms for otoscopy performed well to identify middle ear disease from otoscopy images. However, external performance was reduced when applied to new test cohorts. Further efforts are required to explore data augmentation and pre-processing techniques that might improve external performance and develop a robust, generalizable algorithm for real-world clinical applications.

Artificial Intelligence and Telehealth as Diagnostic Approach to Middle Ear Disease- Advances in Otology

As with other subspecialities, remote otoscopy commonly regarded as telehealth is being studied as a new approach for diagnosis of middle ear diseases. As in covid-19 pandemic, otolaryngologists were the most affected health care professionals as aerolized particles were a hurdle to conduct routine upper airway and ear canal examination, telehealth gain popularity, also to justify shortage of PPE. Beside this, reduction in post operative follow up visits, and cost savings in terms of greater access for rural populations were the major attractions to adopt remote otoscopy in ENT.

International experience and recommendations on audiological screening of schoolchildren: review.

Permanent childhood hearing loss is crucial for speech development and restricts learning abilities. Universal newborn hearing screening programs are well established to detect congenital hearing loss and address the need of hearing-impaired babies. Progressive or acquired permanent hearing loss can manifest later due to genetic causes, intrauterine or postnatal infections, middle ear diseases and excessive exposure to noise when listening the personal audio devices. The hearing loss prevalence in the population of 9 year-olds three times higher compared with newborns. School hearing screening is a part of hearing across the lifespan conception. The article presents international experience and recommendations for the organization of school hearing screening programs. A school-entry hearing test is mandatory, other grades might be screened also. The basic method is pure tone audiometry at frequencies of 500, 1 000, 2 000, 4 000 Hz at 20 dB. Otoscopy and tympanometry can be performed also, while whisper voice speech test is of low sensitivity. The main hearing screening issue is low follow-up of referrals to ascertain audiological assessment. Modern approaches to the prevention of hearing loss in schoolchildren and management of hearing impairements are described. Planning of hearing screening programs requires sufficient human and logistical resources, monitoring of results and quality improvement, all stakeholders engagement.

Research and application progress in deep learning in otology.

With the optimization of deep learning algorithms and the accumulation of medical big data, deep learning technology has been widely applied in research in various fields of otology in recent years. At present, research on deep learning in otology is combined with a variety of data such as endoscopy, temporal bone images, audiograms, and intraoperative images, which involves diagnosis of otologic diseases (including auricular malformations, external auditory canal diseases, middle ear diseases, and inner ear diseases), treatment (guiding medication and surgical planning), and prognosis prediction (involving hearing regression and speech learning). According to the type of data and the purpose of the study (disease diagnosis, treatment and prognosis), the different neural network models can be used to take advantage of their algorithms, and the deep learning can be a good aid in treating otologic diseases. The deep learning has a good applicable prospect in the clinical diagnosis and treatment of otologic diseases, which can play a certain role in promoting the development of deep learning combined with intelligent medicine.

The Rate of Eustachian Tube Dysfunction in Adult Patients With Chronic Inflammatory Middle Ear Disease Is Low.

To assess the rate of dilatory (chronic obstructive) eustachian tube dysfunction (ETD) in adult patients scheduled for surgery for chronic inflammatory middle ear disease. We included adult patients with chronic inflammatory middle ear disease (chronic suppurative otitis media, adhesive otitis media [middle ear atelectasis], cholesteatoma). We excluded patients with pathologies that do not stem from ETD (e.g., noninflammatory chronic middle ear disease [e.g., otosclerosis], tumors, solely external auditory canal conditions), patients scheduled for implantable electronic hearing devices independent of disease, patients with otitis media with effusion and scheduled paracentesis or ventilation tubes only, patients with previous radiotherapy or previous balloon eustachian tuboplasty, and children and patients unable to complete questionnaires. We evaluated ETD with Valsalva maneuver and in case of negative or unclear Valsalva with the eustachian tube score (ETS). A negative Valsalva maneuver and an ETS score of 5 or lower were used to define dilatory (chronic obstructive) ETD. Rate of ETD in the included patients. From a total of 482 consecutive patients, 350 patients had positive Valsalva maneuver or ETS score higher than 5. From the 193 patients with negative or unclear Valsalva maneuver, 77 patients had an ETS score of 5 or lower, and 55 rejected further diagnostics with ETS. Based on a large cohort of adult patients with chronic inflammatory middle ear disease scheduled for middle ear surgery, the majority (82%) seems to have no dilatory (chronic obstructive) ETD that can be detected with current routine clinical methods and tubomanometry. Common pathophysiological explanations should be questioned critically, especially in the context of communication with patients.

Microbiology of Chronic Suppurative Otitis Media amongst Children Attending a Tertiary Health Facility in North-Western Nigeria

Background: Chronic suppurative otitis media (CSOM) is a global middle ear disease worst in developing nations of the world. The burden in our environment of repeated episodes of childhood CSOM, and the resultant difficulty in the management of these patients because of improper or inadequate treatment is quite worrisome.
 Aim: The aim of this study was to prospectively analyze the aspirated middle ear exudates of paediatric patients with CSOM for both facultative aerobic bacteria and fungi, with their antimicrobial sensitivity patterns.
 Materials and Methods: A total of 166 children clinically diagnosed with CSOM were enrolled in the study, of which 219 middle ear discharge samples were obtained using sterile disposable plastic Pasteur pipettes and cultured for microbial flora. Drug susceptibility testing for the isolated microbes was conducted using the Kirby‑Bauer disc diffusion method.
 Results: The ratio of facultative aerobic bacteria to fungi was 2.1: 1, while the ratio of Gram-positive to Gram-negative aerobic bacteria was 1: 1.7. The most common causative aerobic organisms isolated were Staphylococcus aureus 41/202 (20.3%), Pseudomonas aeruginosa 30/202 (14.9%), Klebsiella pneumonia 23/202 (11.4%), and Proteus mirabilis 21/202 (10.4%). Aspergillus species 47/202 (23.3%) and Candida albicans 21/202 (10.4%) were the commonest fungal isolates. The antimicrobial profile of aerobic isolates revealed maximum sensitivity to gentamycin (91.1%), ceftriaxone (90.1%), and ciprofloxacin (85.6%); while the isolated fungi were completely sensitive to all the antifungals.
 Conclusion: The main isolates were Gram-negative aerobic bacteria, though Gram-positive aerobes and fungi were also isolated. Their varying antimicrobial susceptibility brings to the fore, the therapeutic significance of these drugs in CSOM management.

Inhibition of TGF-β signaling enables long-term proliferation of mouse primary epithelial stem/progenitor cells of the tympanic membrane and the middle ear mucosa

The surface of the middle ear is composed of the tympanic membrane (TM) and the middle ear mucosa (MEM). A number of diseases and conditions such as otitis media, middle ear cholesteatoma, and perforation of the TM have been reported to cause dysfunction of the middle ear, ultimately leading to high-frequency hearing loss. Despite its importance in repairing the damaged tissues, the stem/progenitor cells of the TM and the MEM epithelia remains largely uncharacterized due, in part, to the lack of an optimal methodology to expand and maintain stem/progenitor cells long-term. Here, we show that suppression of TGF-β signaling in a low Ca2+ condition enables long-term proliferation of p63-positive epithelial stem/progenitor cells of the TM and the MEM while avoiding their malignant transformation. Indeed, our data show that the expanded TM and MEM stem/progenitor cells respond to Ca2+ stimulation and differentiate into the mature epithelial cell lineages marked by cytokeratin (CK) 1/8/18 or Bpifa1, respectively. These results will allow us to expand epithelial stem/progenitor cells of the TM and MEM in quantity for large-scale analyses and will enhance the use of mouse models in developing stem cell-mediated therapeutic strategies for the treatment of middle ear diseases and conditions.

Ear Portal: An urban-based ear, nose, and throat, and audiology referral telehealth portal to improve access to specialist ear health services for children

Introduction Shortage of ear, nose, and throat specialists in public hospitals can result in delays in the detection and management of otitis media. This study introduced a new hospital-based telehealth service, named the Ear Portal, and investigated its role in improving access to specialist care. Methods The study included 87 children (aged 6 months to 6 years) referred to a tertiary children's hospital due to otitis media-related concerns. A specialist multidisciplinary team met fortnightly to review pre-recorded data and provide care plans. Results The service resulted in a median waiting time of 28 days to receive a diagnosis and care plan by the multidisciplinary team, compared to a mean waiting time of 450 days for a reference group receiving standard healthcare services. Most children (90.3%) received bilateral ear diagnosis. Normal findings were found in 43.9%. However, the majority required further ear, nose, and throat with or without audiology face-to-face follow-up due to a diagnosis of middle-ear disease, unknown hearing status, or concerns not related to ears. The mean time required for clinical assessments completion by research assistants and multidisciplinary team review was 37.6 and 5.1 min per participant, respectively. Discussion Children in the Ear Portal service received a diagnosis and care plan in a median of 28 days, which is within the clinically recommended timeframes. With sufficient clinical information, this service can provide faster access to specialist care than the standard healthcare pathway. The service can reduce the time required by the specialist to provide a diagnosis and care plan which may help increase the specialists’ capacity.

Changing the Paradigm for School Hearing Screening Globally: Evaluation of Screening Protocols From Two Randomized Trials in Rural Alaska.

Diagnostic accuracy was evaluated for various screening tools, including mobile health (mHealth) pure-tone screening, tympanometry, distortion product otoacoustic emissions (DPOAE), and inclusion of high frequencies to determine the most accurate screening protocol for identifying children with hearing loss in rural Alaska where the prevalence of middle ear disease is high. Hearing screening data were collected as part of two cluster randomized trials conducted in 15 communities in rural northwest Alaska. All children enrolled in school from preschool to 12th grade were eligible. Analysis was limited to data collected 2018 to 2019 (n = 1449), when both trials were running and measurement of high frequencies were included in the protocols. Analyses included estimates of diagnostic accuracy for each screening tool, as well as exploring performance by age and grade. Multiple imputation was used to assess diagnostic accuracy in younger children, where missing data were more prevalent due to requirements for conditioned responses. The audiometric reference standard included otoscopy, tympanometry, and high frequencies to ensure detection of infection-related and noise-induced hearing loss. Both the mHealth pure-tone screen and DPOAE screen performed better when tympanometry was added to the protocol (increase in sensitivity of 19.9%, 95% Confidence Interval (CI): 15.9 to 24.1 for mHealth screen, 17.9%, 95% CI: 14.0 to 21.8 for high-frequency mHealth screen, and 10.4%, 95% CI: 7.5 to 13.9 for DPOAE). The addition of 6 kHz to the mHealth pure-tone screen provided an 8.7 percentage point improvement in sensitivity (95% CI: 6.5 to 11.3). Completeness of data for both the reference standard and the mHealth screening tool differed substantially by age, due to difficulty with behavioral testing in young children. By age 7, children were able to complete behavioral testing, and data indicated that high-frequency mHealth pure-tone screen with tympanometry was the superior tool for children 7 years and older. For children 3 to 6 years of age, DPOAE plus tympanometry performed the best, both for complete data and multiply imputed data, which better approximates accuracy for children with missing data. This study directly evaluated pure-tone, DPOAE, and tympanometry tools as part of school hearing screening in rural Alaskan children (3 to 18+ years). Results from this study indicate that tympanometry is a key component in the hearing screening protocol, particularly in environments with higher prevalence of infection-related hearing loss. DPOAE is the preferred hearing screening tool when evaluating children younger than 7 years of age (below 2nd grade in the United States) due to the frequency of missing data with behavioral testing in this age group. For children 7 years and older, the addition of high frequencies to pure-tone screening increased the accuracy of screening, likely due to improved identification of hearing loss from noise exposure. The lack of a consistent reference standard in the literature makes comparing across studies challenging. In our study with a reference standard inclusive of otoscopy, tympanometry, and high frequencies, less than ideal sensitivities were found even for the most sensitive screening protocols, suggesting more investigation is necessary to ensure screening programs are appropriately identifying noise- and infection-related hearing loss in rural, low-resource settings.

Tubomanometry in measurement of velopharyngeal closure: A pilot study.

To investigate the differences in velum closure pattern in people with and without a history of middle ear disease using intranasal pressure curves recorded with the tubomanometer, a Eustachian tube (ET) testing device. Case control study. Tertiary referral center. Tubomanometry nasopharyngeal pressure curves from 20 controls (Group 1) and 20 people with history of otitis media (OM) and possible ongoing ET dysfunction (ETD) (Group 2 or OM/ETD group) were compared. The variables included in the analysis were: (a) ratio of signal amplitude relative to the delivered nasal pressure (C2/delivered pressure x10); (b) time (s) to achieve maximal signal amplitude (C2-C1); (c) duration of velum closure (s) and (d) plateau decay during the isometric contraction of the velum (C3-C2) and (e) swallow duration (s) (C4-C1). Statistical analysis was conducted using mixed models for the normalized values of individual characteristics. Age, race and sex distribution in each group was as follows: 24 ± 8 years, 15 whites and 12 females in Group 1; 20 ± 10 years, 19 whites and 15 females in Group 2. Group 2 demonstrated a greater velopharyngeal pressure decay (p= .13), longer swallow duration (p= .10), and longer duration of velum closure (p= .14). This is the first study using tubomanometry to investigate differences in velopharyngeal closure between controls and individuals with OM/ETD. Although not statistically significant, our results showed that those with OM/ETD demonstrated a longer swallow and velum closure duration, and a higher degree of leakage during velum contraction compared to controls.