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J Am Acad Audiol 2023; 34(05/06): 100-113
DOI: 10.1055/a-2095-7002
Research Article

Defining Hearing Loss Severity Based on Pure-Tone Audiometry and Self-Reported Perceived Hearing Difficulty: National Health and Nutrition Examination Survey

Joseph Alexander de Gruy 
1   Department of Otolaryngology – Head and Neck Surgery, University of Mississippi Medical Center, Jackson, Mississippi
,
Samuel Hopper
2   University of Mississippi School of Medicine, Jackson, Mississippi
,
William Kelly
3   University of South Carolina School of Medicine, Columbia, South Carolina
,
Ryan Witcher
4   Lake Erie College of Osteopathic Medicine, Erie, Pennsylvania
,
Thanh-Huyen Vu
5   Northwestern University Feinberg School of Medicine, Chicago, Illinois
,
Christopher Spankovich
1   Department of Otolaryngology – Head and Neck Surgery, University of Mississippi Medical Center, Jackson, Mississippi
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Abstract

Background There is a well-known metric to describe average/normal vision, 20/20, but the same agreed-upon standard does not exist for hearing. The pure-tone average has been advocated for such a metric.

Purpose We aimed to use a data-driven approach to inform a universal metric for hearing status based on pure-tone audiometry and perceived hearing difficulty (PHD).

Research Design This is a cross-sectional national representative survey of the civilian noninstitutionalized population in the United States.

Study sample Data from the 2011–2012 and 2015–2016 cycles of the National Health and Nutrition Examination Survey (NHANES) were used in our analysis. Of 9,444 participants aged 20 to 69 years from the 2011–2012 and 2015–2016 cycles, we excluded those with missing self-reported hearing difficulty (n = 8) and pure-tone audiometry data (n = 1,361). The main analysis sample, therefore, included 8,075 participants. We completed a subanalysis limited to participants with “normal” hearing based on the World Health Organization (WHO) standard (pure-tone average, PTA of 500, 1000, 2000, 4000 Hz < 20 dBHL).

Analysis Descriptive analyses to calculate means and proportions were used to describe characteristics of the analysis sample across PHD levels relative to PTA. Four PTAs were compared, low frequency (LF-PTA, 500, 1,000, 2,000 Hz), four-frequency PTA (PTA4, 500, 1,000, 2,000, 4,000 Hz), high frequency (HF-PTA, 4,000, 6,000, 8,000 Hz), and all frequency (AF-PTA, 500, 1,000, 2,000, 4,000, 6,000, 8,000 Hz). Differences between groups were tested using Rao–Scott χ2 tests for categorical variables and F tests for continuous variables. Logistic regression was used to plot receiver operating characteristic curves with PHD as a function of PTA. The sensitivity and specificity for each PTA and PHD were also calculated.

Results We found that 19.61% of adults aged 20 to 69 years reported PHD, with only 1.41% reporting greater than moderate PHD. The prevalence of reported PHD increased with higher decibel hearing levels (dBHL) categories reaching statistical significance (p < 0.05 with Bonferroni correction) at 6 to 10 dBHL for PTAs limited to lower frequencies (LF-PTA and PTA4) and 16 to 20 dBHL when limited to higher frequencies (HF-PTA). The prevalence of greater than moderate PHD reached statistical significance at 21 to 30 dBHL when limited to lower frequencies (LF-PTA) and 41 to 55 dBHL when limited to higher frequencies (HF-PTA). Forty percent of the sample had high-frequency loss with “normal” low-frequency hearing, representing nearly 70% of hearing loss configurations. The diagnostic accuracy of the PTAs for reported PHD was poor to sufficient (<0.70); however, the HF-PTA had the highest sensitivity (0.81).

Conclusion We provide four basic recommendations based on our analysis: (1) a PTA-based metric for hearing ability should include frequencies above 4,000 Hz; (2) the data-driven dBHL cutoff for any PHD/“normal” hearing is 15 dBHL; (3) when considering greater than moderate PHD, the data-driven cutoffs were more variable but estimated at 20 to 30 dBHL for LF-PTA, 30 to 35 dBHL for PTA4, 25 to 50 dBHL for AF-PTA, and 40 to 65 dBHL for HF-PTA; and (4) clinical recommendations and legislative agendas should include consideration beyond pure-tone audiometry such as functional assessment of hearing and PHD.

Keywords

hearing loss - epidemiology - screening issues

Supplementary Material



Publication History

Received: 06 February 2023

Accepted: 12 May 2023

Accepted Manuscript online:
17 May 2023

Article published online:
29 October 2024

© 2024. American Academy of Audiology. This article is published by Thieme.

Thieme Medical Publishers
333 Seventh Avenue, New York, NY 10001, USA.

 

  • References

  • 1 Carter HA. Review of methods used for estimating percentage loss of hearing. Laryngoscope 1942; ;(November): 879-890
    CrossrefGoogle Scholar
  • 2 Snellen H. . Snellen Chart. Probebuchstaben zur Bestimmung der Sehschärfe. Utrecht; 1862
  • 3 Nixon CW. A Glimpse of History: The Origin of Hearing Conservation Was in the Military?. Technical Report AFRL-HE-WP-SR-1998-0005; 1998
    Google Scholar
  • 4 Beck DL, Danhauer JL, Abrams HB. et al. Audiologic considerations for people with normal hearing sensitivity yet hearing difficulty and/or speech-in-noise problems. Hear Rev 2018; 25 (10) 28-38
    Google Scholar
  • 5 International Organization for Standardization. Acoustics: Estimation of Noise Induced Hearing-Loss (ISO-1999). Geneva, Switzerland: 2013
    Google Scholar
  • 6 Gatlin AE, Dhar S. History and lingering impact of the arbitrary 25-dB cutoff for normal hearing. Am J Audiol 2021; 30 (01) 231-234
    CrossrefPubMedGoogle Scholar
  • 7 American National Standards Index. Methods for Calculation of Speech Intelligibility Index. ANSI/ASA S3.5-1997 (R2020)
    Google Scholar
  • 8 Hunter LL, Monson BB, Moore DR. et al. Extended high frequency hearing and speech perception implications in adults and children. Hear Res 2020; 397: 107922
    CrossrefPubMedGoogle Scholar
  • 9 Léger AC, Moore BCJ, Lorenzi C. Abnormal speech processing in frequency regions where absolute thresholds are normal for listeners with high-frequency hearing loss. Hear Res 2012; 294 (1–2): 95-103
    CrossrefPubMedGoogle Scholar
  • 10 Motlagh Zadeh L, Silbert NH, Sternasty K, Swanepoel W, Hunter LL, Moore DR. Extended high-frequency hearing enhances speech perception in noise. Proc Natl Acad Sci U S A 2019; 116 (47) 23753-23759
    CrossrefPubMedGoogle Scholar
  • 11 Stelmachowicz PG, Pittman AL, Hoover BM, Lewis DE, Moeller MP. The importance of high-frequency audibility in the speech and language development of children with hearing loss. Arch Otolaryngol Head Neck Surg 2004; 130 (05) 556-562
    CrossrefPubMedGoogle Scholar
  • 12 Monson BB, Hunter EJ, Lotto AJ, Story BH. The perceptual significance of high-frequency energy in the human voice. Front Psychol 2014; 5: 587
    CrossrefPubMedGoogle Scholar
  • 13 Fletcher H. Speech and Hearing in Communication. Van Nostrand; 1929
    Google Scholar
  • 14 Dobie RA. Medical-Legal Evaluation of Hearing Loss. 3rd ed.. San Diego, CA: Plural Publishing; 2015
    Google Scholar
  • 15 Kryter KD, Williams C, Green DM. Auditory acuity and the perception of speech. JASA 1962; 34 (9, pt 1): 1217-1223
    CrossrefGoogle Scholar
  • 16 Levy SC, Freed DJ, Nilsson M, Moore BCJ, Puria S. Extended high-frequency bandwidth improves speech reception in the presence of spatially separated masking speech. Ear Hear 2015; 36 (05) e214-e224
    CrossrefPubMedGoogle Scholar
  • 17 Council on Physical Therapy. Tentative standard procedure for evaluating the percentage of useful hearing loss in medicolegal cases. JAMA 1942; 119: 1108-1109
    Google Scholar
  • 18 Suter AH. The Ability of Mildly Hearing-Impaired Individuals to Discriminate Speech in Noise. United States: Environmental Protection Agency; 1978
    Google Scholar
  • 19 AAO. Guide for the evaluation of hearing handicap. JAMA 1979; 241 (19) 2055-2059
    CrossrefPubMedGoogle Scholar
  • 20 Harris JD, Haines HL, Myers CK. A new formula for using the audiogram to predict speech hearing loss. AMA Arch Otolaryngol 1956; 63 (02) 158-176
    CrossrefPubMedGoogle Scholar
  • 21 Ryan AF, Kujawa SG, Hammill T, Le Prell C, Kil J. Temporary and permanent noise-induced threshold shifts: a review of basic and clinical observations. Otol Neurotol 2016; 37 (08) e271-e275
    CrossrefPubMedGoogle Scholar
  • 22 Lough M, Plack CJ. Extended high-frequency audiometry in research and clinical practice. J Acoust Soc Am 2022; 151 (03) 1944
    CrossrefPubMedGoogle Scholar
  • 23 Lowe DA, Moore BCJ. Audiometric assessment of hearing loss sustained during military service. J Acoust Soc Am 2021; 150 (02) 1030
    CrossrefPubMedGoogle Scholar
  • 24 Liberman MC. Noise-induced hearing loss: permanent versus temporary threshold shifts and the effects of hair cell versus neuronal degeneration. Adv Exp Med Biol 2016; 875: 1-7
    CrossrefPubMedGoogle Scholar
  • 25 Arvin B, Prepageran N, Raman R. “High frequency presbycusis”-is there an earlier onset?. Indian J Otolaryngol Head Neck Surg 2013; 65 (3, Suppl 3): 480-484
    CrossrefPubMedGoogle Scholar
  • 26 Jordan J, Baiduc RR, Spankovich C. Hearing screening age considerations for adults: National Health and Nutrition Examination Survey. J Am Acad Audiol 2022; 33 (02) 58-65
    Article in Thieme ConnectPubMedGoogle Scholar
  • 27 Clark JG. Uses and abuses of hearing loss classification. ASHA 1981; 23 (07) 493-500
    PubMedGoogle Scholar
  • 28 Stevens G, Flaxman S, Brunskill E, Mascarenhas M, Mathers CD, Finucane M. Global Burden of Disease Hearing Loss Expert Group. Global and regional hearing impairment prevalence: an analysis of 42 studies in 29 countries. Eur J Public Health 2013; 23 (01) 146-152
    CrossrefPubMedGoogle Scholar
  • 29 Olusanya BO, Davis AC, Hoffman HJ. Hearing loss grades and the International classification of functioning, disability and health . Bull World Health Organ 2019; 97 (10) 725-728
    CrossrefPubMedGoogle Scholar
  • 30 Hearing Conservation Amendment. Guidelines. OSHA; 1983
    Google Scholar
  • 31 American Academy of Opthalmology and Otolaryngology Committee on Conservation of Hearing. Guide for the evaluation of hearing impairment. Trans Am Acad Ophthalmol Otolaryngol 1959; 63: 236-238
    Google Scholar
  • 32 Humes LE. The World Health Organization's hearing-impairment grading system: an evaluation for unaided communication in age-related hearing loss. Int J Audiol 2019; 58 (01) 12-20
    CrossrefPubMedGoogle Scholar
  • 33 Glorig A. Audiometry: Principles and Practices. Baltimore, MD: The Williams and Wilkins Co; 1965
    Google Scholar
  • 34 Dragon JM, Grewal MR, Irace AL, Garcia Morales E, Golub JS. Prevalence of subclinical hearing loss in the United States. Otolaryngol Head Neck Surg 2023; 169 (04) 884-889
    CrossrefPubMedGoogle Scholar
  • 35 Hannula S, Bloigu R, Majamaa K, Sorri M, Mäki-Torkko E. Self-reported hearing problems among older adults: prevalence and comparison to measured hearing impairment. J Am Acad Audiol 2011; 22 (08) 550-559
    Article in Thieme ConnectPubMedGoogle Scholar
  • 36 National Health and Nutrition Examination Survey. Analytic Guidelines, 2011-2014 and 2015-2016. Centers for Disease Control and Prevention; 2018
    Google Scholar
  • 37 Bhatt JM, Lin HW, Bhattacharyya N. Prevalence, severity, exposures, and treatment patterns of tinnitus in the United States. JAMA Otolaryngol Head Neck Surg 2016; 142 (10) 959-965
    CrossrefPubMedGoogle Scholar
  • 38 Merluzzi F, Hinchcliffe R. Threshold of subjective auditory handicap. Audiology 1973; 12 (02) 65-69
    CrossrefPubMedGoogle Scholar
  • 39 Martin FN, Champlin CA. Reconsidering the limits of normal hearing. J Am Acad Audiol 2000; 11 (02) 64-66
    Article in Thieme ConnectPubMedGoogle Scholar
  • 40 Hussain DM, Gorga MP, Neely ST, Keefe DH, Peters J. Transient evoked otoacoustic emissions in patients with normal hearing and in patients with hearing loss. Ear Hear 1998; 19 (06) 434-449
    CrossrefPubMedGoogle Scholar
  • 41 Gorga MP, Neely ST, Dorn PA. Distortion product otoacoustic emission test performance for a priori criteria and for multifrequency audiometric standards. Ear Hear 1999; 20 (04) 345-362
    CrossrefPubMedGoogle Scholar
  • 42 Bramhall N, Ong B, Ko J, Parker M. Speech perception ability in noise is correlated with auditory brainstem response wave I amplitude. J Am Acad Audiol 2015; 26 (05) 509-517
    Article in Thieme ConnectPubMedGoogle Scholar
  • 43 Parker MA. Identifying three otopathologies in humans. Hear Res 2020; 398: 108079
    CrossrefPubMedGoogle Scholar
  • 44 Luo L, Jiang J, Huang SL, He J, Li JM. Analysis on characteristics of hearing loss in occupational noise-exposed workers in automotive manufacturing industry [in Chinese]. Zhonghua Lao Dong Wei Sheng Zhi Ye Bing Za Zhi 2018; 36 (06) 445-448
    PubMedGoogle Scholar
  • 45 Herman C. What makes a screening exam “good”?. Virtual Mentor 2006; 8 (01) 34-37
    PubMedGoogle Scholar
  • 46 Curti SA, DeGruy JA, Spankovich C. et al. Relationship of overall cardiovascular health and hearing loss in the Jackson Heart Study population. Laryngoscope 2020; 130 (12) 2879-2884
    CrossrefPubMedGoogle Scholar
  • 47 Wiley TL, Cruickshanks KJ, Nondahl DM, Tweed TS. Self-reported hearing handicap and audiometric measures in older adults. J Am Acad Audiol 2000; 11 (02) 67-75
    Article in Thieme ConnectPubMedGoogle Scholar
  • 48 Humes LE, Weinstein BE. The need for a universal hearing metric-is pure-tone average the answer?. JAMA Otolaryngol Head Neck Surg 2021; 147 (07) 588-589
    CrossrefPubMedGoogle Scholar
  • 49 McManus B, Harbarger C, Grillis A. et al. Otoscopy and tympanometry outcomes from the National Health and Nutrition Examination Survey (NHANES). Am J Otolaryngol 2022; 43 (02) 103332
    CrossrefPubMedGoogle Scholar
  • 50 Pearson J. A method for the assessment of hearing impairment. Br J Prev Soc Med 1972; 26 (01) 60
    PubMedGoogle Scholar
  • 51 Lin FR, Reed NS. The pure-tone average as a universal metric-knowing your hearing. JAMA Otolaryngol Head Neck Surg 2021; 147 (03) 230-231
    CrossrefPubMedGoogle Scholar
  • 52 McPherson B, Knox E. Test-retest variability using the Liverpool screening audiometer in a field environment. Br J Audiol 1992; 26 (02) 139-141
    CrossrefPubMedGoogle Scholar
  • 53 Lo AHC, McPherson B. Hearing screening for school children: utility of noise-cancelling headphones. BMC Ear Nose Throat Disord 2013; 13 (01) 6
    CrossrefPubMedGoogle Scholar