Pitfalls of Evaluating Toddlers for Unilateral Hearing Loss Given the difficulty of conducting complete hearing evaluations with young children, how can audiologists ensure an accurate, earlier diagnosis of hearing loss? All Ears on Audiology
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All Ears on Audiology  |   November 01, 2018
Pitfalls of Evaluating Toddlers for Unilateral Hearing Loss
Author Notes
  • Sara Kader, AuD, CCC-A, is a clinical consultant at The Center for Audiology at the Johnson Rehabilitation Institute at Hackensack Meridian Health. sara.kader@hackensackmeridian.org
    Sara Kader, AuD, CCC-A, is a clinical consultant at The Center for Audiology at the Johnson Rehabilitation Institute at Hackensack Meridian Health. sara.kader@hackensackmeridian.org×
  • Virginia Gural-Toth, AuD, CCC-A, is audiology manager at The Center for Audiology at the Johnson Rehabilitation Institute at Hackensack Meridian Health. virginia.toth@hackensackmeridian.org
    Virginia Gural-Toth, AuD, CCC-A, is audiology manager at The Center for Audiology at the Johnson Rehabilitation Institute at Hackensack Meridian Health. virginia.toth@hackensackmeridian.org×
  • Anne Eckert, AuD, MBA, CCC-A, is the Administrative Director of Rehabilitation at JFK Johnson Rehabilitation Institute Anne.eckert@hackensackmeridian.org
    Anne Eckert, AuD, MBA, CCC-A, is the Administrative Director of Rehabilitation at JFK Johnson Rehabilitation Institute Anne.eckert@hackensackmeridian.org×
Article Information
Hearing Disorders / All Ears on Audiology
All Ears on Audiology   |   November 01, 2018
Pitfalls of Evaluating Toddlers for Unilateral Hearing Loss
The ASHA Leader, November 2018, Vol. 23, 12-15. doi:10.1044/leader.AEA.23112018.12
The ASHA Leader, November 2018, Vol. 23, 12-15. doi:10.1044/leader.AEA.23112018.12
We know that identifying unilateral hearing loss in young children decreases their risk for language, academic, social and emotional challenges. However, young children often refuse to wear earphones during testing, so it may take multiple patient visits for us to identify that hearing loss. And unfortunately, published guidelines are vague and often fail to address appropriate follow-up recommendations.
What can the audiologist do to obtain a more complete diagnostic picture? Simple counseling strategies when working with families can help children become more familiar with wearing transducers in-lab. On the clinical side, a diagnostic otoacoustic emissions protocol of at least 12 frequencies may help assess additional frequencies. And proactively scheduling follow-up appointments can increase families’ compliance.
At times, audiologists or parents can easily distract the child while placing inserts, and then the child quickly forgets about the inserts once engaged in the testing task. Other toddlers may not tolerate inserts but willingly accept supra-aural phones for testing. However, despite repeated trials, children frequently will not accept either transducer.

Young children often refuse to wear earphones during testing, so it may take multiple patient visits for us to identify that hearing loss.

Testing realities
There are many tests in the arsenal of the pediatric audiologist. Each test presents its own challenges and limitations:
  • Sound-field thresholds require the patient to engage in a visual reinforcement or play audiometry task, and results are not ear-specific.

  • Earphone thresholds require the patient to engage in a task similar to a sound-field task—but for longer duration—and to tolerate earphones.

  • Otoacoustic emission screening requires the patient to tolerate a probe in the ear for a short duration and provides information regarding cochlear function for limited frequencies.

  • Diagnostic otoacoustic emission requires the patient to tolerate a probe in the ear for slightly longer duration than screening protocol, usually about five minutes, and provides information regarding cochlear function for more frequencies than screening protocol.

  • Diagnostic auditory brainstem response (ABR) requires the patient to be still for one to two hours, usually asleep or sedated, and estimates speech frequencies in each ear. This procedure is not available at all facilities.

Guidelines and research
A review of current publications and research provides limited guidelines for identifying unilateral hearing loss, leaving the clinician with significant room to exercise clinical judgment.
An ear-specific assessment is critical because we cannot identify unilateral hearing loss without ear-specific test results. Children with unilateral hearing loss are at increased risk for language delays, educational performance below expectations, and even social and emotional difficulties (see sources). One study also found that children with unilateral hearing loss were at risk for progressive and bilateral loss (see sources).
A new dilemma emerges when testing shows a patient’s sound-field thresholds are within normal limits and the patient passes the otoacoustic emission screen bilaterally. First, otoacoustic emissions are not a direct measure of hearing and do not rule out retro-cochlear pathologies, such as auditory neuropathy spectrum disorders. Second, emissions can be present with slight to mild losses. Finally, a passing screening does not necessarily indicate passing emissions for all frequencies.
The Joint Commission on Infant Hearing (JCIH) suggests that children with hearing loss should be monitored, but provides no specific guidelines. In a recent article on the Pediatric Minimum Speech Test Battery, follow-up visits for hearing aid users were suggested at three-month intervals for the first three years of device use, at six-month intervals between years three and five, and at 12-month intervals after five years (see sources).
Case study
Recently, a family brought their 3-year-old to our clinic to rule out hearing loss as a contributing factor to speech and language delay. Initial testing showed sound field thresholds of no worse than slight hearing loss, and otoacoustic emissions were passing on a screening protocol in each ear (see charts at left). Ear-specific testing could not be completed because the patient refused both headphones and insert phones.
Although our protocol suggests a six-month follow-up for findings like these, we recommended follow-up in three months because the thresholds were at slight levels, meaning hearing loss in even the better ear had not been completely ruled out. The second evaluation confirmed initial findings, but the patient continued to refuse transducers for ear-specific testing. At that point, we recommended re-evaluation in six months to monitor thresholds and to obtain ear-specific thresholds.
Before the six-month follow up, the patient’s pediatrician referred her to an otolaryngologist for voice concerns, and she was diagnosed with velopharyngeal insufficiency. The patient underwent repeated audiometric testing over several visits to the otolaryngologist’s office, revealing left-ear hearing loss. Ultimately, the child returned to our facility for confirmation of hearing loss.
Findings indicated slight to moderately severe sensorineural “cookie bite” hearing loss: 250–8000 Hertz in the left ear and hearing within normal limits in the right ear. We also repeated otoacoustic emission testing, which indicated that otoacoustic emissions were absent at four of 12 frequencies in the left ear, and right-ear emissions were present for all frequencies.
Audiologists counseled the family that patients with this type of unamplified hearing loss might have trouble hearing in noisy environments, particularly when speech is on the left side. Higher-level auditory processes like localization, binaural separation and binaural integration are also likely affected. The patient will now receive amplification for the left ear.

A new dilemma emerges when testing shows a patient’s sound-field thresholds are within normal limits and the patient passes the otoacoustic emission screen bilaterally.

Testing strategies and counseling
In reviewing this case, several questions arose. Was the family advised appropriately to wait for six months following testing, which indicated no worse than slight loss in at least the better ear with passing otoacoustic emission screening bilaterally? Was the patient’s development adversely affected by waiting for six months before the unilateral hearing loss was diagnosed? Alternatively, was the recommendation appropriate with diagnosis happening within six months of initial contact?
It isn’t always possible for us to conduct ear-specific testing on a child’s initial visit. When test results indicate normal thresholds across speech frequencies in the sound field and bilaterally passing otoacoustic emission screening, we may not be able to pinpoint unilateral losses at specific frequencies. With this understanding, the thorough clinician can implement the following testing strategies and protocols to minimize delayed diagnosis:
  • Counsel families that hearing loss has not been definitively ruled out.

  • Encourage the family to give their child earphones at home—for watching TV or listening to music—so that wearing the transducer becomes familiar at follow-up.

  • Consider using a diagnostic otoacoustic emissions protocol of at least 12 frequencies so that additional frequencies can be assessed.

  • Recommend re-evaluation in six months to try for ear-specific results.

  • Schedule a follow-up appointment before discharge to improve compliance with the recommendations.

Of course, the distance between recommending that a family return for follow-up and a family actually doing so may seem like a long, unattainable journey. In a 2015 ophthalmology article exploring the barriers to follow-up, the authors identify peer support, extensive patient education and improved transportation as key strategies to improve follow-up (see sources).
Take the time to counsel patients so that they understand the real risks of failure to follow-up. Strategies like information teach-back, as recommended by The Agency for Healthcare Research and Quality (AHRQ), help ensure that the patient’s family fully understands findings and recommendations.
Several “take-home” messages emerge. For speech-language pathologists reviewing audiology records, be aware that normal testing in the sound field or “in at least the better ear” does not rule out unilateral hearing loss. For audiologists, review protocols, use testing strategies and counsel parents appropriately when ear-specific behavioral testing was not completed. By identifying unilateral hearing loss earlier, we can mitigate a child’s struggles with language, academic and social development.
Sources
Bess, F., Dodd-Murphy, J., &Parker, R. (1998). Children with minimal sensorineural hearing loss: Prevalence, educational performance, and functional status. Ear and Hearing, 19(5), 339–54. [Article] [PubMed]
Bess, F., Dodd-Murphy, J., &Parker, R. (1998). Children with minimal sensorineural hearing loss: Prevalence, educational performance, and functional status. Ear and Hearing, 19(5), 339–54. [Article] [PubMed]×
Bess, F., &Tharpe, A. (1986). Case history data on unilaterally hearing-impaired children. Ear and Hearing, 7(1), 14–19. [Article] [PubMed]
Bess, F., &Tharpe, A. (1986). Case history data on unilaterally hearing-impaired children. Ear and Hearing, 7(1), 14–19. [Article] [PubMed]×
Bess, F., Tharpe, A., &Gibler, A. (1986). Auditory performance of children with unilateral sensorineural hearing loss. Ear and Hearing, 7(1), 20–26. [Article] [PubMed]
Bess, F., Tharpe, A., &Gibler, A. (1986). Auditory performance of children with unilateral sensorineural hearing loss. Ear and Hearing, 7(1), 20–26. [Article] [PubMed]×
Blair, J. C., Peterson, M. E., & Viehweg, S. H. (1985). The effects of mild sensorineural hearing loss on academic performance among young school age children. Volta Review, 87(2), 87–94.
Blair, J. C., Peterson, M. E., & Viehweg, S. H. (1985). The effects of mild sensorineural hearing loss on academic performance among young school age children. Volta Review, 87(2), 87–94.×
Brookhouser, P., Worthington, D., &Kelly, W.J. (1994). Fluctuating and/or progressive sensorineural hearing loss in children. Laryngoscope, 104(8), 958–964. [Article] [PubMed]
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Davis, J., Elfenbein, J., Schum., R., &Bentler, R. (1986). Effects of mild and moderate hearing-impairments on language, educational and psychosocial behavior of children. Journal of Speech and Hearing Disorders, 51, 53–62. [Article] [PubMed]
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Matkin, N. (1994). Strategies for enhancing interdisciplinary collaboration. In Roush J. & Matkin, N. D. (Eds.), Infants and toddlers with hearing loss, (pp.83–97). Baltimore: York Press.
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Thompson, A. C., Thompson, M. O., Young, D. L., Lin, R. C., Sanislo, S. R., Moshfeghi, D. M., & Kuldev, S. (2015). Barriers to follow-up and strategies to improve adherence to appointments for care of chronic eye diseases. Investigative Ophthalmology and Visual Science, 56(8), 4324–4331. [Article] [PubMed]
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Uhler, K., Warner-Czyz, A., Gifford, R., & Working Group, PMSTB, (2017). Pediatric minimum speech test battery. Journal of the American Academy of Audiology, 28(3), 232–247. [Article] [PubMed]
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November 2018
Volume 23, Issue 11