Search

Objectives: To determine the impact of age, electrode array, and time on impedance patterns in cochlear implant (CI) patients. Methods: A retrospective case review was performed on 98 patients implanted with the CI24RE perimodiolar (PM) and CI422 lateral wall (LW) arrays between 2010 and 2014 to assess impedances at the 1 week and 3-6 month visit after initial stimulation (IS). Results: With respect to age, impedances were higher in young patients compared to older patients in the middle and apical turns. With time, there were significant reductions in impedances across most electrodes. Electrode array type also had a significant impact on impedance measurements with PM and LW arrays having higher impedances in the basal turn and apical turns, respectively. Furthermore, PM arrays demonstrated significantly lower impedances in the middle and apical turn with time, when compared to LW arrays. Conclusions: Age, electrode array, and time can independently affect CI impedances. Moreover, we show that PM arrays may be advantageous to LW arrays, due to demonstrated lower impedances in the middle and apical turns long term. Understanding the impact of impedance on speech discrimination and determining the intracochlear processes that contribute to differences in impedance are future research directions.

Objectives: Conservative treatments are usually the preferred choices for newly diagnosed adult otitis media with effusion (OME). This study was performed to explore the efficacy of conservative treatments, including medication and eustachian tube auto-inflation (ETA), for treating OME in adults and to analyze its predictors., Materials and Methods: A total of 107 adult patients with OME were included. All patients completed two weeks of conservative treatments including medication alone or the combination of medication and ETA., Results: The numbers of patients with only one and both ears affected were 79 and 28, respectively, and therefore, 135 affected ears were included. After treatment, 75 affected ears were classified as responders (55.6%), while 60 ears were classified as nonresponders (44.4%). Four predictive factors, including age, air-bone gap (ABG), tubomanometry value (TMM), and the treatment plan (all p<0.05) were found in treatment outcomes. Patients with age ≤50 years (vs. age>50 years), ABG <17 dB (vs. ABG≥17dB), TMM values of 2-6 (vs. TMM values of 0-1), and patients who received combined treatments, including medication and ETA (vs. patients who received medication only), were more likely to be responders (all p<0.05)., Conclusion: For OME in adult patients, younger age, smaller ABG, higher TMM value, and combined treatment including medication and ETA are good predictors for treatment success.

Objective: Otitis media with effusion (OME) is a common disease among children that can lead to grave sequelae with respect to hearing. Thus, when treating OME, appropriate hearing care should be provided; ventilation tube insertion (VTI), a standard approach for treating OME, is no exception. This study examined hearing care for VTI and its associated factors, especially at the national level., Design: Retrospective database analysis., Setting: Taiwan's National Health Insurance Research Database., Participants: One thousand one hundred and fifty-nine patients who received VTI (age ≤12 years; 2011-12)., Intervention: No intervention., Main Outcome Measures: Compliance to guidelines: sufficient observation time (OBS), tympanogram before VTI (TYM-B) and hearing tests before and after VTI (HEAR-B and HEAR-A, respectively)., Results: The national proportions of completion for each procedure were 30.1% for OBS, 84.4% for TYM-B, 74.3% for HEAR-B and 36.0% for HEAR-A; those of OBS and HEAR-A were extremely low. Age, nasal allergy and even geographic area were associated with differences across completion patterns. Regression revealed some notable patterns. Compared with non-teaching hospitals, teaching hospitals administered HEAR-B most successfully (odds ratio [OR: 3.20, 95% CI: 1.06-9.63) and the smallest hospital group performed HEAR-B most successfully (OR: 2.92, 95% CI: 1.14-7.46)., Conclusion: Several findings surfaced concerning VTI-related hearing care and its association with many clinical and socioeconomic factors in this national study. These findings could serve as a map for improving hearing care quality among children with OME., (© The Author(s) 2019. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objectives: This study aimed to assess absorbance using a thorough analysis of individual points of its plot in ears with intraoperatively confirmed otosclerosis. To the best of our knowledge, until recently no analyses have been performed that concerned the shape of an absorbance plot and a detailed analysis of its individual points. This study is the first to undertake such an issue., Methods: A total of 77 otosclerotic ears were included in the study. Pure tone audiometry, low frequency tympanometry, and wide band tympanometry including absorbance were performed preoperatively. The average patients' age in the group was 43.49 years (standard deviation = 10.44). Individual points of absorbance plot were thoroughly analyzed. Parameters were analyzed, such as resonance frequency; number of peaks; maximum absorbance (Height); and plot Width at the following Heights: 1/3, 1/2, and 2/3 (Width1/3, Width1/2, Width2/3, respectively), as well as associated absorbance parameters and frequencies., Results: Data analysis revealed five different types of absorbance plots. Numerous statistically significant differences regarding the parameters of individual points of the plots were found among the distinguished types., Conclusions: There are five types of absorbance plots in otosclerotic ears: type I, characterized by two distinct peaks, closely resembling normal ear absorbance plot; type II with a single distinct peak reaching high values of absorbance; type III with reduced absorbance for frequencies <2000 Hz; type IV with reduced absorbance for all frequencies; and type V with reduced absorbance for frequencies >2000 Hz. Absorbance measurements may play an important role in the diagnostics of otosclerosis; however, further research is necessary in this area., Levels of Evidence: 4 Laryngoscope, 129:E365-E376, 2019., (© 2018 The American Laryngological, Rhinological and Otological Society, Inc.)

Background: The reported rates of tympanostomy tube insertion (TTI) in children vary significantly internationally. Lack of adherence to evidence-based clinical guidelines may contribute to these differences., Objectives: To study the rates of TTI in South Africa (SA) in children ≤18 years old in the private healthcare sector, both nationally and regionally, to compare these with international TTI rates, and to determine the use of preoperative audiometry and tympanometry., Methods: A retrospective analysis was done of data obtained from the Discovery Health database. Rates of TTI were analysed nationally and regionally and in different age groups, as was the use of tympanometry and audiograms., Results: The SA TTI rates were much higher than published international rates except for the 0 - 1-year age group in Canada and Denmark and the 0 - 15-year age group in Denmark. There was a statistically significant regional variation in TTI rates as well as in the use of preoperative audiometry and tympanometry., Conclusions: SA private sector TTI rates are high by international standards. Significant regional variations may indicate over- or underservicing in certain regions. Further investigation of causes for the high TTI rate and regional variations is recommended. Education of healthcare professionals on recognised indications for TTI may improve patient selection.

Objective: Adenoidectomy is a surgical procedure with potential adverse events. Effective nonsurgical therapy could reduce patient risk and harm. The aim of this study was to evaluate the role of bacteriotherapy to reduce the necessity of adenoid surgery., Patients and Methods: This experimental study was conducted as an open study in 44 children (30 males and 14 females, mean age 4.9 years) who were candidates for adenoidectomy and tympanocentesis as treatment for adenoidal hypertrophy and otitis media with effusion. Twenty-two children were treated with Streptococcus salivarius 24SMB and Streptococcus oralis 89a nasal spray, administered as 2 puffs per nostril twice a day for a week for 3 months (study group). The other half of the children was treated with hypertonic saline nasal lavage on the same schedule (control group). Tympanometry and adenoid size assessment were evaluated throughout the intervention period., Results: In the study group, 6/22 children required surgery, compared to 20/22 children in the study group (p<0.0001). The clinical change in the treated children was a significant reduction of adenoid size (p<0.0001) and improvement of middle ear effusion measured with tympanometry (p<0.0001)., Conclusions: Bacteriotherapy with Streptococcus salivarius 24SMB and Streptococcus oralis 89a nasal spray could significantly reduce the need for adenoid surgery.

Objectives: To test the hypothesis that bipolar electrical impedance measurements in perimodiolar cochlear implants (CIs) may be used to differentiate between perimodiolar insertion technique favoring proximity to the modiolus or lateral wall., Study Design and Methods: Bipolar impedances are a measure of electrical resistance between pairs of electrode contacts in a CI. Stimulation is through biphasic pulses at fixed frequency. Impedance measurements were made in real time through sequential sampling of electrode pairs. Perimodiolar electrodes were inserted in temporal bones using one of two techniques: 1) In the standard insertion technique (SIT), the electrode array slides along the lateral wall during insertion. 2) In the Advance Off Stylet (Cochlear Ltd. Sydney) technique (AOS), the electrode maintains modiolar contact throughout the insertion process. A set of 22 insertions were performed in temporal bone specimens using perimodiolar electrode arrays with both AOS and SIT. Buffered saline was used as a substitute for natural perilymph based on similar electrical conductivity properties. Impedance with and without stylet removal were recorded with a 30-second sampling window at final insertion depth., Results: There is a significant difference in bipolar impedance measures between AOS and SIT, with impedances rising in measurements with stylet removal. Evaluation was based on two-sided analysis of variance considering technique and electrode with P < 0.025., Conclusion: Bipolar electrical impedance can be used to detect relative motion toward the modiolus inside the cochlea. This detection method has the potential to optimize intraoperative placement of perimodiolar electrode arrays during implantation. We anticipate that this will result in lower excitation thresholds and improved hearing outcome., Level of Evidence: NA. Laryngoscope, 127:1413-1419, 2017., (© 2016 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: This study aimed to develop a simple and accurate method to diagnose paediatric obstructive sleep apnoea hypopnea syndrome., Methods: A total of 311 children with suspected paediatric obstructive sleep apnoea hypopnea syndrome were included in the study. Multiple clinical parameters, including sex, age, body mass index, history of snoring or gasping, history of nasal obstruction, history of running nose, palatine tonsil size, adenoid to nasopharynx ratio, and tympanogram type, were compared with polysomnography results using relevant correlation and regression analyses. A diagnostic scale was established using the regression equation and the correlation between the polysomnography result and scale result was determined., Results: The apnoea-hypopnea index correlated significantly with a history of snoring or gasping, palatine tonsil size, and tympanogram type. Stepwise logistic regression analysis revealed that the polysomnography result correlated significantly with a history of snoring or gasping, palatine tonsil size, and the adenoid to nasopharynx ratio. The percentage correlation between the scale and polysomnography results was 77.8 per cent., Conclusion: The diagnostic scale can be used to diagnose paediatric obstructive sleep apnoea hypopnea syndrome for clinical application when polysomnography cannot be performed. However, it is not suitable for assessing the severity of paediatric obstructive sleep apnoea hypopnea syndrome.

Background: It is a known fact that bacterial or viral acute otitis media occurs more frequently in the winter months. Only a few older studies on seasonal differences in middle ear findings are available. These studies are based solely on tympanography, without correlation to intraoperative middle ear findings. This study addresses the question of whether seasonal differences can be found in the preoperative tympanogram and in the corresponding intraoperative findings in children with chronic middle ear problems., Patients and Methods: This retrospective study included patients who had undergone myringotomy with or without tympanostomy tube insertion at the Charité-Universitätsmedizin Berlin between January and December 2011. Corresponding to the catarrhal phases, winter months were defined as those from November to April; summer months from May to October. The preoperative tympanogram and the documented intraoperative middle ear finding were statistically analyzed for seasonal differences., Results: A total of 654 ears from 206 male and 127 female patients with mean age 3.7 ± 2.5 years were analyzed. In the majority of cases, a type B tympanogram was found (n = 376; 57.5%), whereas the middle ear was filled with air in 19.1% of cases. No significant seasonal differences were found for either the intraoperative middle ear findings or the preoperative tympanograms (p > 0.05)., Conclusion: For children with a typical history of chronic otitis media without effusion and chronic tube ventilation dysfunction, myringotomy with or without tympanostomy tube insertion is indicated independently of the season. The results indicate that a wait-and-see approach with hope of improvement during the summer months is not rational.

Objective: Studies on the use of wideband tympanometry (WBT) for the evaluation of middle ear pathologies have been increasing gradually in recent years. However, studies regarding normative data of WBT are not sufficient. The aim of this study was to determine normative values of WBT for different age groups in Turkish population., Materials and Methods: One hundred fifty volunteers from five age-related groups were included in this study. Values of resonance frequency (RF), absorbance percentage according to frequency, maximum absorbance ratio, and maximum absorbance frequency were obtained using WBT. Measurements were recorded at a pressure of 0 decapascal (daPa) using a sound stimulus given at 90±3 decibel sound pressure level (dB SPL)., Results: The RF was detected to be significantly lower only in the group of subjects in the age range of 0-1 month. The absorbance value at 250 Hz was detected to be significantly higher in the age groups of 0-1 month and 1 month-2 years than in the other groups., Conclusion: We believe that the findings obtained in this study would be helpful in determining normative data regarding WBT; by the determination of this normative data, the clinical use of WBT would become widespread.

Objective: To investigate the effect of consecutive 1000-Hz tympanometry testing on admittance measures, and examine test-retest reliability., Design: Repeated measures with eight trials of 1000-Hz Y(a) and B(a)/G(a) tympanometry, respectively, in two ears of each subject, followed by repeated 226-Hz tympanometry., Study Sample: Twenty-seven normal-hearing young adults., Results: For single-peak tympanograms, peak Y(tm) and G(tm) systematically increased across trials with a mean change of 8% and 15% at Trial 8, respectively, whereas B(tm) increased marginally. For notched tympanograms, peak Y(tm) and B(tm) decreased by 23% and 162% at Trial 8, and G(tm) in two cases also decreased (10% on average). Trial 2 and 3 contributed 50% to 70% of the total changes. Test-retest differences of subsequently acquired 1000- and 226-Hz tympanograms were smaller than previously reported., Conclusions: Consecutive testing significantly alters middle-ear admittance in 1000-Hz tympanometry. The outcome is contingent on tympanogram pattern and admittance component: Increase of peak Y(tm) and G(tm) in single-peak tympanograms and decrease of all measures in notched tympanograms. The present results complement previous studies on our understanding of the mechanism underlying this effect: a decrease of middle-ear stiffness. The effect of repetitive tympanometry should be accounted for in research involving sequential testing.

Objective: To explore the law of wide band tympanometry energy reflectance (WBTER) in Chinese infants of Han nationality with normal outer and middle ears, and to provide the normal values for the clinical application of WBTER., Methods: Ninety four infants (170 ears) of Han nationality with normal outer and middle ears evidenced by temporal bone CT, and 226 Hz and 1 000 Hz tympanometry at the ages between three and 48 months (median age: 14 months) were selected and divided into four groups: 3-6 months (32 ears), 7-12 months (53 ears), 13-24 months (46 ears) and 25-48 months (39 ears). WBTER was conducted on these infants, and the basic law of energy reflectance under different frequencies, as well as the influence of age on energy reflectance were analyzed using SPSS 15.0., Results: The normal value of energy reflectance was higher at low frequency, gradually decreased with the increase of frequency, reached the minimum near 4 000 Hz , followed by constantly increased till 8 000 Hz. In the scope of frequency below 1 000 Hz and above 6 350 Hz, the energy reflectance values of infants in the group of 3-6 months were significantly lower than those of infants in other age groups (P < 0.05). In comparison to the group below six months, the groups over six months generally had higher energy reflectance and lower fluctuation., Conclusions: The pattern of energy reflectance across frequency range for Chinese infants and children was consistent with that of other races reported in foreign countries. The WBTER changes with the growing of age, which tends to be stable after the first six months of birth.

Objectives: Otitis media has been a serious disease and can be that even today. The diagnosis of otitis media is often difficult. Pneumatic otoscopy, otomicroscopy, and tympanometry can improve the diagnostic quality by indication of fluid in the middle ear and thereby improve the quality of treatment. The aim of this ongoing study is to analyze the use of tympanometry in Denmark after reimbursement for doing tympanometry (November 2006) when clinically indicated. Our research questions were: How many clinics were using tympanometry? How frequent was it used? Is the use increasing? Has the number of GPs in the clinic any relation to the use of tympanometry?, Method: We used information in The Danish National Health Service in three Regions to analyze the use of tympanometry in general practice during the years 2007-2009. The coverage of the GPs is 100% in the regions., Results: The three regions counted about half of Danish population. In 2009 the material was 902 different clinics with more than 1700 GPs. In 2007 55% of the clinics did tympanometry, in 2009 the figure was 60%. In the clinics doing tympanometry the median value was 28 tympanometries per year (inter-quartile range 13-53) per GP. The variation in the use of tympanometry was surprisingly high, from none or a few per GP per year to a maximum of more than 500 tympanometric examinations per GP a year. This huge variation has to be discussed., Discussion: Many answers can be given. Some of the explanation was problems in doing correct tympanometry, and problems understand the clinical implications of curves and the figures., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Objective: We sought to further examine the relationship between tympanometry and mortality after noting an unexpected association on assessment of baseline data of a study whose primary aim was to investigate the utility of noninvasive tympanic membrane displacement measurement for monitoring intracranial pressure in childhood coma., Methods: We recruited children who presented with acute nontraumatic coma to the high-dependency unit of Kilifi District Hospital on the rural coast of Kenya. We excluded children with sickle cell disease, epilepsy, and neurodevelopmental delay. We performed tympanometry on the right ear before tympanic membrane displacement analyzer measurements. All children were managed according to standard World Health Organization guidelines., Results: We recruited 72 children with a median age of 3.2 years (interquartile range [IQR]: 2.0-4.3 years); 31 (43%) were female. Thirty-eight (53%) had cerebral malaria, 8 (11%) acute bacterial meningitis, 4 (6%) sepsis, and 22 (30%) encephalopathy of unknown etiology. Twenty (28%) children died. Tympanometry was normal in 25 (35%) children. Adjusting for diagnosis and clinical features of increased intracranial pressure, both associated with death on univariable analysis, children with abnormal tympanometry had greater odds of dying than did those with normal tympanometry (adjusted odds ratio: 17.0; 95% confidence interval: 1.9-152.4; P = .01). Children who died had a lower compliance (0.29 mL; IQR: 0.09-0.33 mL) compared with those who survived (0.48 mL; IQR: 0.29-0.70 mL) (P < .01)., Conclusions: Abnormal tympanometry appears to be significantly associated with death in children with acute nontraumatic coma. This finding needs to be explored further through a prospective study that incorporates imaging and intensive physiologic monitoring.

Wideband immittance measures can be useful in analyzing acoustic sound flow through the ear and also have diagnostic potential for the identification of conductive hearing loss as well as causes of conductive hearing loss. To interpret individual measurements, the variability in test–retest data must be described and quantified. Contributors to variability in ear-canal absorbance–based measurements are described in this article. These include assumptions related to methodologies and issues related to the probe fit within the ear and potential acoustic leaks. Evidence suggests that variations in ear-canal cross-sectional area or measurement location are small relative to variability within a population. Data are shown to suggest that the determination of the Thévenin equivalent of the ER-10C probe introduces minimal variability and is independent of the foam ear tip itself. It is suggested that acoustic leaks in the coupling of the ear tip to the ear canal lead to substantial variations and that this issue needs further work in terms of potential criteria to identify an acoustic leak. In addition, test–retest data from the literature are reviewed.

Objective: To analyze the judgement standard and evaluate the diagnostic value of the low frequency and high frequency tympanometry in infants with otitis media., Method: Tympanograms for admittance with 226 Hz and 1 000 Hz probe tones and resonant frequency were obtained from normal infants (195 cases, 321 ears) and infants with otitis media(122 cases, 171 ears). The mean, standard deviation, median, 5% quantile, 95% quantile and 95% confidence interval of peak admittance, gradient and resonant frequency were measured and calculated in different age groups. The significant differences of 1000 Hz peak admittance, 226 Hz peak admittance and gradient between normal infants and infants with otitis median were analyzed using SPSS 11.0. The false positive rate and the false negative rate of different age groups in infants with otitis media were evaluated according to such judgement standards as 1000 Hz peak admittance, 226Hz peak admittance or gradient., Result: The false positive rate and the false negative rate of the 1000 Hz probe tone tympanometry in infants with otitis media unter one year of age were 3.07% and 1.84% as the normal range of positive peak was more than 0.2 mmho. The false positive rate and the false negative rate of the 1000 Hz probe tone tympanometry in infants with otitis media aged 1-2 years and aged 2-3 years were 3.26%, 5.26% and 1.52%, 0.00% respectively,as the normal range of positive peak was more than 0.3 mmho. These was no significant difference in the gradient with 226 Hz probe tone between normal infants and infants with otitis median under one year of age. The false positive rate and the false negative rate of the 226 Hz probe tone tympanometry in infants with otitis media aged 1-2 years and aged 2-3 years were 44.57%, 31.58% and 16.67%, 6.67% respectively, as the gradient with 226 Hz probe tone was a judgement standard., Conclusion: (1) The diagnostic accuracy of tympanometry with 1000 Hz probe tone for otitis media in infants younger than 3 years of age exceeded 226 Hz probe tone tympanometry, the 1000 Hz probe tone tympanometry is suggested to the evaluation of middle ear function in infants before 3 years. (2) It is reasonable that the normal range of positive peak is more than 0.2 mmho in infants unter one year of age and the normal range of positive peak is more than 0.3 mmho in infants aged 1-3 years.

Objectives: The diagnosis in children with middle ear symptoms is often difficult. Tympanometry is recommended as a supplementary diagnostic tool with a high predictive value for fluid or no fluid in the middle ear. The aim of this study was to examine how tympanometry was used in Danish general practice in 2009, to report common problems general practitioners (GPs) and GP nurses encounter in tympanometry and to evaluate the effect of a practical and theoretical course., Methods: A 1-year registration of the use of tympanometry in the Danish National Health Service Register in two regions with 40% of all Danish GPs and a survey among 197 participants in a course on diagnosis of otitis media and tympanometry in children were used. The Danish National Health Insurance covers 100% of GPs because they administer reimbursement for their activities, including tympanometry., Results: During the year 2009, 1433 GPs in 702 clinics were on the list. A total of 417 clinics performed 35 529 tympanometries. Some 285 clinics (40.6%) did not perform tympanometry in 2009. The active clinics performed 42 tympanometries per GP. A 1-day course improved the knowledge and practical skills of the participating GPs and nurses. A majority (70%) stated in a self-reported questionnaire that tympanometry often provided important information, especially about middle ear fluid, and 48% reported that tympanometry several times during the past 2 weeks had changed their management of a middle ear problem. Few had not used their tympanometer during the 2 weeks preceding the survey. The response rate was 72%., Conclusions: The use of tympanometry is very skewed. A 6-hour course could improve GPs' care of patients with middle ear problems by using tympanometry.

Purpose: The purpose of this study was to examine current immittance practices and trends over time, reasons why multifrequency (MF) and multicomponent (MC) tympanometry have been underused, and the prevalence of negative patient reactions to acoustic reflex (AR) testing., Method: Two audiological practice surveys were conducted regarding tympanometry (2008, n = 156) and AR (2009, n = 90)., Results: Most respondents conduct tympanometry and AR threshold (ART) testing. MF and MC tympanometry were rarely reported, generally due to a lack of equipment and training. ART testing was reported most often using both ipsilateral and contralateral presentation. Contralateral testing has decreased over time. Patient complaints of discomfort following AR testing were common. Complaints of tinnitus or hearing loss were present, although rare., Conclusion: Tympanometry and ART tests have remained popular for the past 30 years, whereas acoustic reflex decay (ARD) testing has decreased in popularity. MF and MC tympanometry are conducted infrequently. AR is frequently associated with discomfort but rarely associated with other symptoms. However, one respondent reported that AR testing had caused permanent tinnitus and hearing loss.

Background: Adenotonsillar hyperplasia is considered as a possible cause for two frequent ENT disorders in children: pediatric obstructive sleep apnea syndrome (OSAS) and otitis media with effusion (OME). The present study analyzes whether a link between pediatric OSAS and OME can also be presumed., Methods: Polysomnographic data of 186 children with suspected OSAS were correlated to middle ear ventilation assessed by tympanometry. Tympanograms were classified according to Jerger., Results: In a Kruskal Wallis test, children with an apnea-hypopnea index  < 1 (exclusion of OSA by tight criteria), 1-5 or  > 5 (definitively pathological value) did not statistically significantly differ in the prevalence of normally ventilated ears and OME. Accordingly, the Mann-Whitney U test showed that children with normally ventilated ears did not have a statistically different apnea-hypopnea, apnea, hypopnea or snoring index or varying minimal oxygen saturation to children suffering from OME., Conclusions: In the present study, no link was detected between pediatric OSAS and OME.

Aim: Previous research has shown that general practitioners (GPs) rarely use pneumatic otoscopy or tympanometry as recommended by best practice guidelines for diagnosing otitis media. The purpose of this study was to determine whether a multimodal, interactive training workshop on the techniques of pneumatic otoscopy and tympanometry would improve the confidence of GPs for the diagnosis of otitis media with effusion (OME) and acute otitis media (AOM), and for using pneumatic otoscopy and tympanometry. Additionally, we sought to determine whether this training could change GPs' intentions for using pneumatic otoscopy and tympanometry in their practices., Methods: Twenty-three GPs participated in a three-hour training workshop led by an ear, nose and throat (ENT) surgeon, a paediatrician and an audiologist. Prior to and following the workshop, GPs completed questionnaires indicating their previous use and beliefs about the usefulness of pneumatic otoscopy and tympanometry, confidence for diagnosing AOM and OME, confidence for using pneumatic otoscopy and tympanometry, and intention to use pneumatic otoscopy and tympanometry in the future., Results: There were no differences (P > 0.05) from pre- to post-workshop in GP confidence for diagnosing AOM. There were increases in GP confidence for diagnosis of OME (pre: 4.5 ± 0.9, post: 4.9 ± 0.4, P < 0.01) and confidence for using pneumatic otoscopy (pre: 3.6 ± 1.6, post: 4.8 ± 1.0, P < 0.01) and tympanometry (pre: 3.3 ± 1.5, post: 5.0 ± 0.7, P < 0.01), but no change (P > 0.05) in intention to use pneumatic otoscopy or tympanometry in their practices in the future., Conclusion: These results suggest that a multimodal, interactive workshop can significantly increase the confidence of GPs for diagnosis of OME and also for using pneumatic otoscopy and tympanometry. It is likely, however, that GPs will need follow-up and further practice with these techniques to implement them in their practices.

Purpose: To gain an understanding of practice patterns for infant diagnostic hearing services at pediatric audiology facilities., Method: The authors used a cross-sectional survey design. From August to November of 2009, surveys were mailed to 1,091 facilities in 28 states and the District of Columbia. One survey was completed per facility, and responses were anonymous., Results: The return rate was 33% (356 surveys). The results revealed that the comprehensiveness of the test batteries used varied among facilities. Over half of the respondents, 146 (55%), reported using a limited test battery, 94 facilities reported using a comprehensive test battery but lacked at least 1 component recommended by the Joint Committee on Infant Hearing, and 25 facilities reported using a test battery that met Joint Committee on Infant Hearing recommendations. The wait time for an appointment varied between facilities (range = 3 days-5 months) and was affected by the test condition (i.e., natural sleep, sedation, or operating room)., Conclusions: The results suggest that it is difficult for stakeholders to identify pediatric audiology facilities that serve infants less than 6 months of age and that there is variability among facilities in test batteries and wait times for an appointment. Implications exist for diagnostic accuracy and timeliness of diagnosis.

Objectives: The development of acoustic reflectance measurements may lead to noninvasive tests that provide information currently unavailable from standard audiometric testing. One factor limiting the development of these tests is that normal-hearing human ears show substantial intersubject variations. This work examines intersubject variability that results from measurement location within the ear canal, estimates of ear-canal area, and variations in middle-ear cavity volume., Design: Energy reflectance (ER) measurements were made on nine human-cadaver ears to study three variables. (1) ER was measured at multiple ear-canal locations. (2) The ear-canal area at each measurement location was measured and the ER was calculated with the measured area, a constant area, and an acoustically estimated area. (3) The ER was measured with the middle-ear cavity in three conditions: (1) normal, (2) the mastoid widely opened (large air space), and (3) the mastoid closed off at the aditus ad antrum (small air space)., Results: Measurement-location effects are generally largest at frequencies below about 2000 Hz, where in some ears reflectance magnitudes tend to decrease systematically as the measurement location moves away from the tympanic membrane but in other ears the effects seem minimal. Intrasubject variations in reflectance due to changes in either measurement location within the ear canal or differences in the estimate of the ear-canal area are smaller than variations produced by large variations in middle-ear cavity air volume or intersubject differences. At frequencies below 2000 Hz, large increases in cavity volume systematically reduce the ER, with more variable changes above 2000 Hz., Conclusions: ER measurements depend on all variables studied: measurement location, ear-canal cross-sectional area, and middle-ear cavity volume. Variations within an individual ear in either measurement location or ear-canal cross-sectional area result in relatively small effects on the ER, supporting the notion that diagnostic tests (1) need not control for measurement location and (2) can assume a constant ear-canal area across most subjects. Variations in cavity volume produce much larger effects in ER than measurement location or ear-canal area, possibly explaining some of the intersubject variation in ER reported among normal ears.

The impedance of a simple artificial ear occluded with an earplug and bypassed with narrow air leaks was measured along with the attenuation of sound through the air leaks. A lumped element model is suggested for the simple occluded artificial ear with an air leak. The suggested model was adapted to the impedance measurements and the attenuation was predicted from the model. The attenuation predictions were compared to the attenuation measurements and were found to be within [-3.5,+3] dB of the measured attenuation over the frequency range of 50-1000 Hz and an attenuation range of -2-38 dB. The average difference between the measured and predicted attenuation for four different leaks in the frequency range of 50-1000 Hz was -0.7 dB, indicating a very slight underestimation of the attenuation.

Objectives: To investigate the tympanometric characteristics of Chinese school-aged children with normal middle ear function., Design: Measurements were made for four tympanometric variables [peak, compensated static acoustic admittance (peak Ytm); equivalent ear canal volume (Vec); tympanometric width (TW); and tympanometric peak pressure] from 278 Chinese children aged between 6 and 15 yrs. Data from the right ear were compared across age groups with those of Chinese young adults and with Western children of comparable ages. Data from the left ear were used to examine specificity using tympanometric screening criteria suggested in the present study., Results: The developmental pattern in tympanometric variables found with the Chinese school-aged children in the study was similar to that found with white children in Western studies. Increasing age was accompanied by an increase in peak Ytm and Vec values, a decrease in TW values, and less negative and less varied tympanometric peak pressure values. The lower limit of peak Ytm 90% range of the Chinese school-aged children in the study was lower and their TW values were wider than those of white children. Age-specific data also suggested that the upper Vec limits of children between 6 and 7 yrs of age differed from those of older children. Racial differences in peak Ytm and TW values were noted, in that the Chinese school-aged children had a lower peak Ytm limit and wider TW values than white children. The use of ASHA 1997 guidelines for identifying ears for referral with respect to Chinese school-aged children may therefore not be highly sensitive and specific. Gender differences noted in peak Ytm and Vec values were too small to be of clinical significance., Conclusions: To increase the accuracy of tympanometry in determining ears to be referred for further assessment, the use of the tympanometric characteristics observed in the Chinese school-aged children in the present study (i.e., peak Ytm lower limit < 0.2 mmhos and Vec upper limit > 1.5 cm3) should be considered in addition to ASHA 1997 tympanometric screening guidelines.

Because of its anatomic and functional connections, middle ear disorders frequently occur in sinusitis. Its prevalence, however, is likely to be underestimated. We evaluated the prevalence of Eustachian tube dysfunction in children with chronic sinusitis, in a large group of patients with chronic respiratory symptoms and its possible relationship with respiratory allergy. From a population of 1810 children with respiratory symptoms referred to our Pediatric Allergy Center, subjects with chronic sinusitis diagnosed by clinical criteria were selected. The children underwent testing of Eustachian tube function by tympanometry and of allergy by skin tests with common environmental allergens. Patients were divided into three groups according to age: group 1, <3 yr; group 2, between 3 and 6 yr, group 3, older than 6 yr. Overall 402 children (22.2%) had clinical diagnosis of chronic sinusitis according to the established criteria. Thirty-three patients were in group 1, 299 in group 2, and 70 in group 3. Altered middle ear pressure was found in 69.1% of patients, with a significantly higher rate of altered tympanograms in younger children (p=0.001). A positive skin-prick test was found in 29.8% of children, with a significantly higher rate of positivity in older children (p=0.015). The decrease in the rate of Eustachian tube dysfunction with age is likely to be associated with the anatomic development of the upper airways, while the presence of atopy does not seem to play a role in their occurrence.

Objective: To discuss the multiple-frequency probe tones tympanograms and the normal ranges of admittance, susceptance and conductance in normal newborns., Method: Tympanometries with 226 Hz, 678 Hz and 1000 Hz probe tones were obtained from newborn infants with normal TEOAE and DPOAE(55 infants, 110 ears), analysed multiple-frequency prone tones tympanograms and values of admittance, susceptance and conductance by using GSI-33 middle ear analyzer., Result: 226 Hz tympanograms for admittance, susceptance and conductance main were W-shaped, the percentages were 90.0%, 99.1% and 85.5%. 678 Hz tympanograms for admittance, susceptance and conductance main were single-peaked, the percentages of single-peaked type were 62.7%, 77.3% and 62.7%, and the percentages of W-shaped type were 34.6%, 20.9% and 31.8%, had a little three-peaked type. 1000 Hz tympanograms for admittance, susceptance and conductance main were single-peaked, and percentages were 96.4%, 99.1% and 97.3%, and had a little W-shape type but no three-peaked type. There were significant differences between admittance and susceptance, susceptance and conductance in 226 Hz and 678 Hz probe tones tympanogram. There were significant differences between admittance and susceptance, susceptance and conductance, admittance and conductance in 1000 Hz probe tones tympanogram., Conclusion: Multiple-frequency probe tones tympanograms and the normal ranges of admittance, susceptance and conductance of normal newborn infants is obtained, and 1000 Hz probe tone tympanometry is a sensitive test for function of middle ear in newborn infants.

Recent implementations of binaural synthesis have combined high-frequency pinna diffraction data with low-frequency acoustic models of the head and torso. This combination ensures that the salient cues required for directional localization in the horizontal plane are consistent with psychophysical expectations, regardless of the accuracy or match of the high-frequency cues, or the fidelity of experimental low-frequency information. This paper investigates the effect of a nonrigid boundary condition on the surface pressure and the resulting interaural cues used for horizontal localization. These are derived from an analytical single sphere diffraction model assuming a locally reacting and uniformly distributed impedance boundary condition. Decreasing the magnitude of a purely resistive surface impedance results in an overall decrease in the sphere surface pressure level, particularly in the posterior region. This produces nontrivial increases in both the interaural level and time difference, especially for sound source directions near the interaural axis. When the surface impedance contains a reactive component the interaural cues exhibit further changes. The basic impedance characteristics of human hair and their incorporation into the sphere diffraction model are also discussed.

We consider studies in which an enrolled subject tests positive on a fallible test. After an intervention, disease status is re-diagnosed with the same fallible instrument. Potential misclassification in the diagnostic test causes regression to the mean that biases inferences about the true intervention effect. The existing likelihood approach suffers in situations where either sensitivity or specificity is near 1. In such cases, common in many diagnostic tests, confidence interval coverage can often be below nominal for the likelihood approach. Another potential drawback of the maximum likelihood estimator (MLE) method is that it requires validation data to eliminate identification problems. We propose a Bayesian approach that offers improved performance in general, but substantially better performance than the MLE method in the realistic case of a highly accurate diagnostic test. We obtain this superior performance using no more information than that employed in the likelihood method. Our approach is also more flexible, doing without validation data if necessary, but accommodating multiple sources of information, if available, thereby systematically eliminating identification problems. We show via a simulation study that our Bayesian approach outperforms the MLE method, especially when the diagnostic test has high sensitivity, specificity, or both. We also consider a real data example for which the diagnostic test specificity is close to 1 (false positive probability close to 0).

Hypothesis: Tympanometric measurements of middle ear pressure in children with secretory otitis media are overestimated in a dose-response manner because of increased hysteresis explained by the viscosity and amount of middle ear fluid., Background: Tympanometric middle ear pressure is important in evaluating children with secretory otitis media. These measurements are influenced by hysteresis appearing as a peak pressure difference in bidirectional tympanometry. This represents an inaccuracy of 0.5 x peak pressure difference, which is only 5 to 25 daPa in normal ears. However, previous experiments found increased hysteresis, suggesting an inaccuracy of 225 daPa in secretory otitis media ears., Materials and Methods: In 56 patients with secretory otitis media, bidirectional tympanometry was performed; Type B curves were excluded. The middle ear fluid was semiquantified subsequently at surgery according to viscosity (serous, seromucoid, or mucoid) and amount (small, medium, or large). A control group included 28 normal children. Peak pressure difference was calculated by the difference between middle ear pressure determined by a positive and negative pressure sweep., Results: Mean peak pressure difference was 10 and 69 daPa in the normal and secretory otitis media groups, respectively (p <0.001). However, peak pressure difference ranged to 205 daPa in the secretory otitis media group and showed a significant positive correlation to viscosity and amount of the fluid (both p <0.0001)., Conclusion: Peak pressure difference is significantly increased in secretory otitis media because of additional damping explained by the viscosity and amount of the fluid. The mean error was 5 daPa in normal ears and 35 daPa in secretory otitis media ears, but ranged to greater than 100 daPa. These results were only a low estimate of the inaccuracy, because patients with Type B tympanograms could not be included, and errors of more than 100 daPa can be anticipated.

Background: Pneumatic otoscopy is believed to be helpful in optimally assessing the presence or absence of middle ear effusion (MEE). Although expert clinicians teach the importance of this diagnostic skill to trainees, evidence exists that many pediatric providers do not typically perform pneumatic otoscopy., Objective: To determine if the otoscopic accuracy within a group of clinicians improves with the pneumatic assessment when compared with the static assessment using videotaped otoendoscopic examinations (VOEs)., Methods: Residents and faculty from 2 pediatric training programs served as subjects. All viewed a set of 50 video otoscopic examinations of tympanic membranes (TMs) from a validated VOE developed previously for training purposes. The video displays each TM in a static presentation and then in a pneumatic (mobile) presentation, followed by a final static presentation. Each subject first viewed the initial static presentation of each TM and responded "yes/no" to the presence of MEE, and then viewed the pneumatic presentation of the same TM and again responded "yes/no" to the presence of MEE. We compared the accuracy of assessment for both the static and the pneumatic tests., Results: Thirty-four pediatric residents and 6 clinical faculty participated. Accuracy (percent of total test items correct) on the pneumatic test was uniformly greater than accuracy on the static test. The mean absolute improvement in the accuracy from the static test (61%) to the pneumatic test (76%) was 15% (95% confidence interval [CI] = 12%-18%). The mean relative improvement in accuracy from the static test to the pneumatic test was 26% (95% CI = 19%-32%). Higher accuracy on the VOE was associated with greater absolute (r = 0.57) and greater relative (r = 0.47) improvement. The mean relative improvement in sensitivity and specificity from static viewing to pneumatic viewing was 24% (95% CI = 15%-33%) and 42% (95% CI = 27%-58%), respectively., Conclusions: Using a video otoendoscopic test, we found that accurate identification of both the presence and the absence of MEE improved after pneumatic assessment of TM mobility. Providers who were more accurate at otoscopy, defined by higher video total test scores, benefited more from the pneumatic component than providers with lower scores.

Objective: To obtain tympanometric norms in Southern Chinese young adult population and compare the results with data obtained for a Caucasian population., Design: Ear canal volume (Vea), tympanometric compensated static acoustic admittance (Peak Ytm), tympanometric width (TW) and tympanometric peak pressure (TPP) were obtained on 100 Southern Chinese young adults. Results were compared with findings from Roup et al. (1998). Inter-tester reliability was established., Results: Compared with the results obtained by Roup et al. (1998) on non-Hispanic Caucasian population, Southern Chinese subjects were found to have lower Peak Ytm, wider TW and more positive TPP values. No gender difference was noted for Peak Ytm, TW and TPP values in Chinese subjects. Inter-tester reliability was good., Conclusion: The tympanometric norms obtained in this study are recommended when evaluating middle ear function among Southern Chinese young adults.

Background and Objectives: Although otitis media is a common problem in primary care, little is known about the use of diagnostic tools such as pneumatic otoscopy, tympanometry, acoustic reflectometry, or tympanocentesis by family physicians in training., Methods: This was a self-reported observational study of family practice residents' use of otitis media diagnostic tools. Twenty-three family practice programs in Texas and Oklahoma were surveyed during November and December 2000. Residents were asked about their use of diagnostic tools, and, if tools were not used, they were asked the reason for not using them. Residents were also asked about the criteria they used to diagnose otitis media, and their responses were compared to criteria recommended by national guideline panels., Results: The response rate was 61% (n = 316). The percentage of residents using pneumatic otoscopy was 66%, tympanometry 29%, acoustic reflectometry 2%, and tympanocentesis 0%. The most common reasons cited for not using tools were lack of training or unavailability of equipment. Fifty-five percent of family practice residents do not report pneumatic otoscopy for diagnosing otitis media and thus did not use recommended criteria. Faculty training of residents in the use of diagnostic tools was associated with a higher rate of using these tools., Discussion: Few residents believed that diagnostic tools had no value in the diagnosis of otitis media, but lack of training or equipment problems were reported as contributing to their not using these tools. Half of family practice residents may be inadequately diagnosing middle ear problems since they did not report that pneumatic otoscopy was necessary for diagnosing otitis media. Because training was associated with higher rates of using appropriate diagnostic tools, family medicine faculty can play a significant role in improving the residents' diagnostic skills.

Objective: To evaluate the effect of uncomplicated viral respiratory infections (colds) on middle ear pressure in healthy school-aged children., Methods: Children (ages 2-12) with normal tympanograms before onset of illness had bilateral tympanometry daily except weekends for 2 weeks after the onset of a cold. Nasopharyngeal secretion obtained at onset of illness was cultured for bacterial pathogens of otitis media using selective agars and tested for rhinovirus, coronavirus, respiratory syncytial virus, influenza A and B, and parainfluenza 1-3 by reverse transcriptase polymerase chain reaction technology. Tympanometry was designated as abnormal with peak pressure of < or =-100 daPa or > or =50 daPa and/or a compliance peak of < 0.2 cm(3)., Results: Eighty-six colds were studied, 82 in schoolchildren (5-12 years old) and 4 in 2- to 3-year-olds. Abnormal negative middle ear pressure occurred at least once during the 2 weeks after onset in 57 (66%) of the 86 colds. Tympanometry was abnormal in the first week after onset in 50 (88%) of the 57 colds and was abnormal on a single day in 17 (30%) of the 57. The middle ear pressure abnormalities were intermittent and shifted from one ear to the other ear from day to day. Reverse transcriptase polymerase chain reaction was positive for a respiratory virus in 56 (65%) of the 86 illnesses. Rhinovirus was found in 48% and respiratory syncytial virus in 14%. Pathogenic bacteria (Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis) were detected in nasopharyngeal secretion in 29 (34%) of the 86 colds; the bacteria were in high titer (> or =10(3) cfu/mL) in 26 of the 29 positive specimens. None developed illness that required a visit to a physician. Age, detection of a respiratory virus, and presence of bacterial pathogen in the nasopharyngeal secretion had a negligible effect on the occurrence of abnormal tympanometry. Occurrence of negative middle ear pressure in winter-spring colds was significantly greater than in fall colds for unexplained reasons., Conclusions: Transient negative middle ear pressure occurred in two thirds of uncomplicated colds in healthy children. This negative pressure, which may facilitate secondary viral or bacterial otitis media, seems to result from viral infection of the nasopharynx and distal tube causing bilateral eustachian tube dysfunction. Tympanometry provides an objective measure of the potential beneficial effects of investigational treatments on the risk of eustachian tube dysfunction/otitis media.

A flat tympanogram predicts a middle ear effusion in about 90% of cases. This paper describes how to perform tympanometry, some common problems when doing it and how to classify the curves in normal (type A), middle ear effusion (type B) or negative pressure (type C). The theoretical background of impedance audiometry is outlined. The stapedius reflex, pneumatic otoscopy, reflexometry and otomicroscopy are described as supplements or alternatives in diagnosing fluid in the middle ear. Tympanometry is recommended as a diagnostic modality for general practitioners.

Two-hundred and forty-two tympanograms of infants were interpreted according to a standard operating procedure independently by an audiologist and ten study doctors from the Finnish Otitis Media Vaccine Trial. The interrater agreement among the study doctors according to Kappa index was excellent (kappa = 0.80). The agreement was significantly better on curves taken during pre-scheduled healthy visits than during sick visits due to respiratory infection (p < 0.001). In addition concurrent knowledge of the clinical ear status significantly improved the agreement on abnormal curves (flat B-curves and failed F-curves, p < 0.001). The clinical differences between the groups were minor. The age of the infant had no effect on interpretation. The agreement between the audiologist and the study doctors was also excellent (kappa = 0.77). Excellent agreement can be achieved in infant tympanometry through adequate instruction and training.

To determine the value of different otoscopic findings in diagnosing otitis media with effusion, 3,780 otological examinations of 250 infants at ages 0-2 years were compared with tympanometric findings. Otoscopy was performed by an experienced otologist and research-audiologist prior to tympanometry. The following success rates for these procedures were found: otoscopy, 85-91%, tympanometry, 74-94%, either otoscopy or tympanometry, 89-99%. "Glue" was noted as the most frequent abnormal otoscopic feature, i.e., depending on age, 6-32%. Fluid line/ bubbles, bulging/hyperaemia or otorrhoea were rarely (0-5%) observed and contributed little to the diagnosis of otitis media with effusion. No structural changes of the tympanic membrane were observed. Analysis of tympanometric data revealed that the prevalence of tympanogram types B (21-44%), C1 (0.5-16%) and C2 (0-8%) was age-dependent. Comparison of otoscopic and tympanometric findings indicated sufficient diagnostic agreement (Cohen's kappa between 0.41 and 0.74) at age 6-24 months. In conclusion, otoscopy appears to be a valid instrument for diagnosing otitis media with effusion, at least from 6 to 24 months of age. In addition, the results of our study suggest that tuba-dysfunction and otitis media with effusion are age-dependent disorders during infancy, without structural effects on the tympanic membrane.

Objective: In this study, researchers evaluated the otologic and audiologic status of 112 children with repaired cleft lip and palate who had received primary palatal repair by means of Frolova palatoplasty, a surgical technique developed by Dr. Larisa Y. Frolova, founder and director of the National Pediatric Center for Congenital Maxillofacial Pathology, Moscow, Russia., Design: Results of hearing thresholds and tympanograms for these Russian children were compared with data previously reported from a group of 48 children and adults with repaired cleft lip and palate at the University of Florida Craniofacial Center, Gainesville, Florida., Results: There were no substantial differences in hearing thresholds between the two groups, which was surprising in view of the vast differences between middle ear management techniques used in Russia and the United States., Conclusions: Considering these findings and the growing body of literature favoring a more conservative approach to the management of middle ear effusion in infants with cleft lip and palate, a reexamination of otologic strategies in the United States seems advisable.

Distortion product otoacoustic emissions (DPOAE) are generated undoubtedly in the region of overlap between the two travelling waves of primaries f1 and f2 (the "primary" generator). Since DPOAE lead to a psychoacoustic perception, it is suspected that the cochlear amplifier is additionally activated at place 2f1-f2 (the "secondary" generator) leading to a stimulus frequency emission (SFOAE). In suppression experiments we demonstrated that a suppressor tone 25 Hz above the frequency of the postulated secondary generator alters DP-amplitude depending (1) on the DP-gram fine structure and (2) the sound pressure level of the suppressor (-20 to 80 dB SPL). At a maximum of the fine structure, low suppressor levels (< 50 dB SPL) reduced the DP-amplitude, whereas an increase occurred at a minimum. Intermediate suppressor levels (50-60 dB SPL) always clamped the DP-amplitude and extinguished the DP-gram fine structure. Our results support the hypothesis that conventional DPOAE, which are measured in the external ear canal, are the result of an interference of the primary and secondary generator. Depending on the relative phase between the two emissions, a constructive and a destructive interference of the two signals results in an emission pattern which closely resembles the DP-gram fine structure. When the secondary generator is suppressed by intermediate suppressor levels, DPOAE amplitude depends only on the status of the cochlear amplifier near f2. These emissions we call "single generator" DPOAE (sgDPOAE).

The evaluation of the temporal characteristics of the acoustic stapedius reflex is one the fundamental aspects of the impedance audiometry, since significant biological information to be used as sensitive indicators of distinctive pathologies can be obtained. At the Audiology Service of the E.N.T. Department of Parma four parameters of the acoustic stapedius reflex have been studied (onset latency, latency at 10% of the maximum amplitude, rise time, offset latency) in a group of people having normal ears without previous otological problems, with the aim to establishing some rules. The equipment used is the Madsen Impedenzometro ZO 174 which enables to obtain an average among a desired number of reflex responses. The report shows the value of the four parameters of the stapedius reflex obtained from the study of 10 normoacusic patients totalling 20 ears. The resulting guidelines can make up the basis for further research in pathological cases with cochlear, neural and central lesions.

Conventional behavioral testing of hearing shows that children with Down syndrome have a high prevalence of hearing deficits. However, most young (< 3.5 years of age) children with Down syndrome are unable to cooperate in this type of testing. We evaluated auditory brain-stem responses of 47 unselected patients 2 months to 3 1/2 years of age. Thirty-four percent had normal hearing, 28% had unilateral loss, and 38% had bilateral loss. Type of loss was conductive in 19 ears, mixed in 14, and sensorineural in 16. Degree of loss was mild in 33 ears, moderate in 13, and severe to profound in 3. Language quotients and degree of hearing loss were compared and an association was not found. Because of the high prevalence of hearing loss in children with Down syndrome, we recommend evaluation of auditory brain-stem responses in the first 6 months of life.

The purpose of the present study was to test a fully automated screening impedance tympanoscope against a clinical impedance audiometer. Previous studies have indicated a relatively high incidence of type B tympanograms when using the tympanoscope and in addition shown a surprisingly large number of type B curves of one day's duration. The present study was based on 51 otherwise healthy children attending kindergartens (100 ears) who underwent daily tympanometric screening with both the impedance tympanoscope ZS331 and the impedance audiometer AZ7. The tympanoscope indicated a significantly larger number of type B tympanograms, and in 16 cases the type B curves could be demonstrated on only one day, resulting in significantly higher point and period prevalences of type B tympanograms. The difference is mainly attributable to the different ways in which a type B tympanogram is defined by the two instruments. On the basis of the present study we conclude that the impedance tympanoscope is not well suited for this type of study.

In order to select hearing aids with a highly predictable real ear gain, in situ gain and compliance through the individual ear mould were measured on 8 normal-hearing subjects. The latter were chosen in order to reduce gain variation caused by various pathological conditions of the ear. All behind-the-ear aids commonly used in Sweden and one in-the-ear aid were studied. One sample of each hearing aid type was tested and the subjects had identical ear moulds. Hence, the variables were hearing aid type and subject. The study showed wide intra-subject coupler-related real ear gain variation (30 dB). Most of the aids showed a distinct correlation between coupler-related overall gain, and mould compliance. Some of the aids gave more uniform real ear gain, i.e. low interaction between subject and frequency-dependent gain. These results are elucidated by measuring the aid's acoustic output impedance.

The diagnosis and treatment of diseases of the ear in general practice could be rendered optimal by employing tympanometry (measurement of the pressure in the middle ear) which is already known from specialist practice. This was investigated by means of a controlled investigation with cooperation between general practice, otologists and the health services in the County of Vejle. Following randomizing among 20 general practitioners, ten were trained in tympanometry (the test group) while ten did not change their principles for diagnosis and treatment (control group). The criteria for inclusion in the investigation were the findings of indications for otoscopy in children under the age of 16 years. During a period of 12 months, parallel registrations of the data were made in the two groups and 3,166 children with an average age of 3.4 years were included. The clinical course showed statistically significant differences (p less than 0.05) between the groups as regards diagnosis and treatment: acute otitis media was found in 8.4% in the control group and 2.6% in the test group. Secretory otitis media (glue ear) was found in 14.2% in the control group and in 25% in the test group. Correspondingly, penicillin was prescribed for 7.6% in the control group and 4.1% in the test group. The otologists performed tubulation of the tympanic membrane in 0.9% in the control group and 3.2% in the test group. Continued investigations are necessary to elucidate whether tympanometry should be part of the daily routine in general practice.