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Table of Contents
Year : 2004  |  Volume : 6  |  Issue : 2  |  Page : 79-85

Universal new born hearing screening programme in King Fahd Military Medical Complex, Dhahran, Saudi Arabia

1 Consultant and Head of Otorhinolaryngology Department, King Fahd Military Medical Complex, Dhahran, K.S.A, Saudi Arabia
2 Physician Audiologist Otorhinolaryngology Department, King Fahd Military Medical Complex, Dhahran, K.S.A, Saudi Arabia
3 Professor and Senior Consultant, Otorhinolaryngology Department, Security Forces Hospital, Riyadh, K.S.A, Saudi Arabia

Date of Web Publication12-Jul-2020

Correspondence Address:
Saud Al-Saij
Consultant and Head of Otorhinolaryngology Department, King Fahd Military Medical Complex, Dhahran
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1319-8491.289588

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Objectives: The purpose of this study was to establish in King Fahd Military Medical Complex (KFMMC) a universal newborn hearing screening (UNHS) programme and to determine the prevalence of hearing impairment in neonates delivered at our center.
Materials and Methods: All neonates delivered normally or by cesarean section in KFMMC from i5 April to 15 September 2003 and either admitted to the Newborn Nursery (NN), Special Care Baby Unit (SCBU), or Neonatal Intensive Care Unit (NICU) were screened for hearing loss. The neonates delivered during the weekend were excluded from this study due to the fact that they were discharged before evaluation.
Results: A total of 428 neonates were screened for hearing loss. The percentage of neonates found with normal hearing TEOAE screening was 69.6% and increased to 89% by diagnostic TEOAE then to 91.6% by screening ABR and lastly to 95.7% by diagnostic ABR. The prevalence of hearing loss in KFMMC was found to be 1.3%.
Conclusion: The number of neonates with hearing loss is higher than the international record, which is 0.3%. TEOAE can be used successfully in UNHS.

Keywords: Universal Newborn Hearing Screening, Transient Evoked Otoacoustic Emissions, Auditory Brain Stem Response, Hearing loss

How to cite this article:
Al-Saij S, Shabaka T, Zakzouk S. Universal new born hearing screening programme in King Fahd Military Medical Complex, Dhahran, Saudi Arabia. Saudi J Otorhinolaryngol Head Neck Surg 2004;6:79-85

How to cite this URL:
Al-Saij S, Shabaka T, Zakzouk S. Universal new born hearing screening programme in King Fahd Military Medical Complex, Dhahran, Saudi Arabia. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2004 [cited 2023 Feb 5];6:79-85. Available from: https://www.sjohns.org/text.asp?2004/6/2/79/289588

  Introduction Top

Hearing loss is one of the most common congenital anomalies. The prevalence of hearing loss has been shown to range from one to six per 1,000 in neonates and infants [1],[2] The prevalence of hearing loss in neonatal intensive care units (NICU) is approximately 20 to 50 in 1000. [3] The risk factors for hearing loss listed by the Joint Committee on Infant Hearing (JCIH) 1994 Position Statement are as follows: family history of hereditary childhood sensorineural hearing loss, in-utero infection (eg, rubella, cytomegalovirus, syphilis, toxoplasmosis, herpes), craniofacial anomalies, low birth weight (<1500 g or 3.3 lb), hyperbilirubinemia at levels requiring exchange transfusion, bacteria] meningitis, exposure to ototoxic medications, mechanical ventilation lasting 5 days or longer, stigmata or other findings associated with a syndrome known to include a sensorineural and/or conductive hearing loss and Apgar scores of 0-4 at 1 minute or 0-6 at 5 minutes [4]. Screening only those infants who meet the risk factors for hearing loss listed by the (JCIH) is not enough, because as many as 50% of infants born with hearing loss have no known risk factors. The prevalence of hearing loss is greater than that of most other diseases and syndromes (eg, phenylketonuria) screened at birth [4]. The current goal is to screen all babies by one- month of age, confirm hearing loss by three months of age and begin treatment before six months of age. Infants who are not identified before 6 months of age have delays in speech and language development. Intervention at or before 6 months of age allows a child with impaired hearing to develop normal speech and language. UNHS screening is essential to normal speech and language development [5].

Infants identified after 6 months of age had lower receptive and expressive language quotients than infants identified by age 6 months. Moreover, Hall, 2000 [6], proved that there was no significant difference between infants identified at age 7-12 months and those children identified at age 25-30 months in receptive and expressive language. Early identification and intervention can prevent severe psychosocial, educational, and linguistic repercussions [7],[8].

There are currently two physiological measures of auditory function that are used to screen newborns; otoacoustic emissions (OAE) and auditory brain stem response (ABR). These two measures are not hearing tests per se, but are considered as physiological measures related to hearing levels [9]. OAE is used to assess cochlear integrity and is a physiologic measurement of the response of the outer hair cells to acoustic stimuli. It serves as a fast objective-screening test for preneural cochlear function. Currently, two types of evoked OAE measurements are used for newborn hearing screening: Transient Evoked (TEOAE), and Distortion Product (DPOAE). Provided that the patient’s middle ear function is normal, these measurements can be used to assess cochlear function at the 500 to 6,000 Hz frequency range. The presence of evoked OAE response indicates hearing sensitivity in the normal-to-near normal range. OAE is a fast, efficient, and frequency-specific measurement of peripheral auditory sensitivity [10]. ABR is an electro physiologic measurement that is used to assess auditory function from the eighth nerve through the auditory brainstem. ABR tests can be used to determine the degree of hearing loss. Also ABR test should be used for follow- up diagnostic procedures. OAE and ABR testing can provide valuable information about an infant’s hearing loss. Diagnostic OAE and ABR testing is recommended for any infant who does not pass the second screening session [9]. Both tests are necessary to differentially diagnose an infant’s hearing impairment. OAE tests are used to assess the outer, middle, and inner ear portion of the auditory system. ABR tests help in assessing the whole system, from the periphery to the auditory nerve and brainstem. As a result of early intervention, there is no reason why any infant born with a hearing loss should experience anything but normal speech and language development [10].

The objective of this study was to establish the universal hearing screening system (UNHS) at King Fahd Military Medical Complex (K.FMMC) and to determine the prevalence of hearing loss in neonates delivered at KFMMC.

  Materials and Methods: Top

All neonates delivered normally or by cesarean section at KFMMC from 15 April to 15 September 2003 that were either admitted to Newborn Nursery (NN), Special Care Baby Unit (SCBU) or Neonatal Intensive Care Unit (NICU) were screened for hearing loss. A total number of 828 ears (428 Neonates) were examined in this study. A questionnaire was modified from the Joint Committee on Infant Hearing (JCIH) 1994 Position Statement and completed according to information obtained from the medical record.

Appendix (1): This Questionnaire applied in the program of UNHS in KFMMC.

  Procedure Top

The procedure was divided into 4 stages according to the test used. The first stage was portable TEOAE screen. (Echochec - Otodynamics Ltd, Hatfield. UK) Neonates who failed in one or both ears were referred to second stage in the audiology clinic by the age of four weeks to be evaluated by tympanometry (Interacoustices AZ 26) and TEOAE (ILO 88). The results of diagnostic TEOAE were interpreted according to Maxon et al. [11]. Babies who failed or only partially passed according to TEOAE results were referred to third stage (Screening ABR) at the age of 4 months. Screening ABR done at 80 and 35 dBnHL, 1024 sweeps were differentially amplified through a band pass filter of 300-3000 Hz with 10-msec. analysis time. ABR was recorded using the evoked response audiometry (ICS medical CHARTAR). Infants were sleeping naturally or sedated by chlorohydrate. Acoustic rarefaction clicks were presented at a rate of 21.1 p/sec. Assessment by ABR was based on the detection of wave V at its expected latency. If babies failed at 35/80 dBnHL they were referred to fourth stage (diagnostic ABR). Diagnostic ABR was performed as screening ABR but at lowered thresholds. Also behavioral audiological evaluation was completed at the age of 6 months. Audiological intervention was initiated according to the diagnosis.

  Results: Top

Two hundred ninety eight (69.6%) of the neonates passed the screening test (right ear:312 passed and left ear:311 passed). Hundred and thirty neonates failed in one or both ears (right ear: 113 and left ear: 117). Those babies delivered over the weekend were excluded as they were discharged before evaluation but were seen within 4 weeks in the audiol- ogy clinic for their first evaluation.

The second step was done within the age of 4 weeks in a sound treated room. One hundred thirty babies were evaluated using the tympanometer and diagnostic TEOAES. According to the results of the tympanogram there were two groups, group 1 26(6.1%), with type (B) tympanogram in one or both ears and group II 104 (24.3%)with type (A) tympanogram in both ears.
Table 1: Number and percentage of passed and failed ears in the study group using screening TEOAE.

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Table 2: Mean (X), Standard deviation (SD), Range, Minimum and Maximum o number of trial (No. Tri), gestational age (Gest. Age) in weeks, birth weight (Bir. Wght.) in grams, APGAR score at 1 & 5 minuets (AP. 1 & AP. 5), use of mechanical ventilator in days (Ven.) and use of ototoxic drugs in days (Oto.) in the study group.

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Out of 8% of study group for which Screening ABR was done at 80 and 35 dBnHL, 5.4% failed (either at 35 or at 80 dBnHL) in screening ABR. 1.3% did not participate so were excluded. At age of 6 months, diagnostic ABR done for 5.4% of the study group, 4.1% were with nonnal hearing level and 1.3% were with hearing loss. The prevalence of hearing loss in this study group was 1.3%.

Neonates with syndromes associated with hearing loss form 0.9% of the study group and 3 (0.7%) with Trisomy 21.

The family history of hearing loss could not be obtained because it was not mentioned in the hospital files and a social cause was not included in our Questionnaire, None of the study group suffered from meningitis, in-utero infections and/or craniofacial anomalies.

  Discussion Top

Hearing screening programs in neonates have been established in many centers in the USA, UK, and Canada. Also, the prevalence of hearing loss differs from center to center according to the methods used and the criteria for passing and failing/The results of screening with TEOAE test revealed that 69.6% of the study group passed and 30.4% failed. The high false positive result of screening TEOAE was in agreement with Clarke P. et al. and Nada E. et al. [12],[13]. They reported that high noise levels might give false positive results with TEOAE and this high false positive result occurred during the first two days of life. They recommended that the test must be done in a quiet isolated room to overcome this problem, Gamal et al. [14] reported that sedation could be used during the test. However, in this study the neonates were tested while they were sleeping or calm. In order to further decrease the false positive results of screening TEOAE the initial test was, if possible, repeated more than once during the patientis stay in the hospital. The second step of this program was performed in a sound treated room.

Tympanometry and diagnostic TEOAE were used in 30.4% of the study group. According to the results of tympanometry, 6.1% of the study group suffered from secretory otitis media. Smurziniski et al. [15] reported simitar result (6.5%) but Veen et al., 1993 [16] reported 13.8% and Stevens et al., 1991 [17] reported 21.1%. Secretory otitis media interfered with OAE recording and increased the false positive rate and referral rate. The proper management of secretory otitis media decreases the false positive rate of TEOAE and also decreases the referral rate since all babies treated for secretory otitis media passed in TEOAE.

At age of four months screening ABR was performed at 80dBnHL and 35dBnHL for 8% of the study group. There was no response in 5.4% of the study group. Referral rate was remarkably similar to the results of Vohr et al., 2001 [18] who showed a referral rate of 4.7% but less than Mehl and Thomson, 2002[19] who reported a 8.4% referral rate. In this study, the referral rate was less than Mehi and Thomson. 2002 because tympanometry, diagnostic TEOAE and screening ABR were done for all babies who initially failed in screening TEOAE. Also the high referral rates in this study could be attributed to the time taken to establish the program.

Diagnostic ABR and behavioral audiological evaluation were completed for 5.4% of the study group. The final result was 13 out of 1000 suffered from hearing loss. Intervention was initiated according to threshold levels and the results of behavioral tests. The incidence of hearing loss in the study group was higher than the international record in other centers [1],[2]. They reported a one to six per 1000 incidence of hearing loss among their studies. This high incidence of hearing loss can possibly be explained by the high rate of consanguinity in Saudi Arabia. Zakzouk, 2002 [20] stated that higher incidence of hearing loss in developing countries is due to the custom of intermarriages. However, syndromal hearing loss can be diagnosed during pregnancy and some countries such as the USA have legalized the termination of pregnancy if congenital anomalies are diagnosed during pregnancy. This not allowed in Saudi Arabia. Maternal admission sheets were lacking many details regarding antenatal, prenatal and family history. Homer et al., 2000[21] reported similar obstacles. They found 92% of neonates with risk factors of hearing loss but the maternal admission sheets detected only 80%. Questionnaire and full history must be obtained from the parents. Also maternal admission sheets must be tailored and completed adequately.

  Conclusions and Recommendations Top

TEOAE can be used successfully in universal newborn hearing screening. Retesting seems to decrease the referral rate for ABR.

The prevalence of hearing loss in our medical facility seems to be higher than the international rate. It is important to make the public aware of the value and importance of hearing screening at the earliest possible opportunity. Universal newborn hearing screening should be made mandatory in order to allow for early detection of hearing loss and its management.

As there is recognized risk of consanguinity, this should be discouraged by education of the public. The value of genetic counseling cannot be overemphasized.

The newly implemented premarital screening in Saudi Arabia should be followed.

Training of nurses and audiology technicians to conduct the UNHS program is important in order to accommodate all neonates.

  References Top

Finitzo T., Albeight K., O Neal J. The newborn with hearing loss: Detection in the nursery. Pediatrics, 1998; 102: 1452-1460.  Back to cited text no. 1
National Center On Hearing Assessment And Management. Prevalence of congenital hearing loss. Retrieved aug. 2002; 10, 2002. From: HYPERLINK “http://www.infanthearing.org/reseearch/summary/prevelance.htmlhttp://www.infanthearing.org/reseearch/summary/prevelance.html.  Back to cited text no. 2
Northern J., Hayes D. Universal screening for infant hearing impairment: beneficial and justifiable. Audiology Today, I994;6: 10-13.  Back to cited text no. 3
Joint Committee On Infant Hearing (JC1H). Year 2000 position statement: Principles and guidelines for early hearing detection and intervention programs. Am J Aud, 2000; 9: 9-29.  Back to cited text no. 4
American Academy Of Pediatrics. Year 2000 position statement: Principles and guidelines for early hearing detection and intervention programs. Pediatrics, 2000; 106, 798-817.  Back to cited text no. 5
Hall J, Infant hearing impairment and universal hearing screening: Screening for and assessment of infant hearing impairment. J. Of Perinatology, 2000;20: 5113-5121.  Back to cited text no. 6
Shabaka T„ Tawfik S., and Abdel _ Maksoud A. The Complementary Use Of Tactile Aids In Children With Severe To Profound Hearing Loss: A Study On The Transmission Of Temporal Cues. Unpublished master thesis in audiology. Ain Shams Uni. Egypt 2001.  Back to cited text no. 7
Cunningham M., Cox E. And The Committee On Practice And Ambulatory Medicine And The Section On Otolaiyngology And Bronchoesophagology. Hearing assessment in infants and children: Recommendations beyond neonatal screening. Pediatrics, 2003; 111(2) 436-441.  Back to cited text no. 8
Judith E., Warren B. and Richard F. Newborn hearing screening what it means for providers of early intervention services. Infants And Young Children/July-Sept. 2003:249-257.  Back to cited text no. 9
Maisoun M. and Zakzouk M. Hearing screening of neonates at risk. Saudi Med J, 2003;24(l):55-7.  Back to cited text no. 10
Maxon A., White K., Vohr B. and Beharens T. Using transient evoked otoacoustic emissions for neonatal hearing screening. British J. Audiology, 1993;27: 149-53.  Back to cited text no. 11
Clarke P., Iqbal M., Mitchell S. A comparison of transient- evoked otoacoustic emissions and automated auditory brainstem responses for pre-discharge neonatal hearing screening. Inter J Aud, 2003;42:443-447.  Back to cited text no. 12
Nada E.. El-Danasoury I., Shalaby A., and Abdel _ Maksoud A. Hearing screening: A NICU project. Unpublished master thesis in audiology. Ain Shams Uni. Egypt 2003.  Back to cited text no. 13
Gamal Y., Hazaa N., Awwaad K., Reda S. and Abdel Halim O. Otoacoustic emission in high risk neonates. Egypt J Otolaryngology, 2001 ;185 (1) (suppl.): 145-155.  Back to cited text no. 14
Smurzynski J. Longitudinal measurements of distortion product and click-evoked otoacoustic emission of preterm infants: Preliminary results. Ear and Hearing, 1994;15: 210-223.  Back to cited text no. 15
Veen S., Sassen L., Schreudor M. Hearing loss in very preterm and very low birth birth weight infants at the age of 5 years in nationwide cohort. Int J Pediat Otorhinolaryngol, 1993;26(I): 11-28.  Back to cited text no. 16
Stevens C., Webb D., Hutchinson J. Evaluation of click evoked otoacoustic emissions in the newborn. British J. Audiology, 1991 ;25: 11-14.  Back to cited text no. 17
Vohr R., Oh W., Stevwart E., Bentkover D., Gabbard S. Comparison of costs and referral rates of 3 universal newborn hearing screening protocols. J. Ped. 2001; 139: 238-244.  Back to cited text no. 18
Mehl L., Thomson V. The Colorado newborn hearing screening project. 1992-1999: on the threshold of effective population-based universal newborn hearing screening. Pediatrics, 2002:109 (1), E 7.  Back to cited text no. 19
Zakzouk S. Consanguinity and hearing impairment in developing countries: A custom to be discouraged. J Laryngol Otol. 2002; 116(10): 811-6.  Back to cited text no. 20
Homer J., Linney S., Strachan, D. Neonatal hearing screening using the auditory brain stem response. Neonatal Intensive Care, 2000; 14(3): 28-32.  Back to cited text no. 21


  [Table 1], [Table 2]


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