Review and management of children identified with a transient conductive hearing loss within the context of a newborn hearing screening program Alison Collins Senior Audiologist, Healthy Hearing Program, Children’s Health Queensland PhD Candidate, University of Queensland

Universal Newborn Hearing Screening (UNHS) Aim: Identify infants and children with bilateral moderate or greater permanent childhood hearing loss (PCHL). Infant HEARING SCREEN Provide rehabilitation to reduce the long-term impacts on speech and language. There is currently work looking at the identification and management of unilateral and mild hearing loss in the context of a universal newborn hearing screening program. There has been little to no work examining conductive hearing loss. Few policies or pathways exist that guide the management of these children in the context of a universal screening program. Unilateral Hearing Loss Mild Hearing Loss Conductive Hearing Loss

Conductive Hearing Loss Otitis Media (OM) is highly prevalent in children <3 years of age. OM is a major cause of a conductive hearing loss (CHL). Neonatal episodes of CHL may indicate chronic recurrence. Auditory processing problems Speech and language delay Social and emotional challenges Anxiety and depression disorders Poor social, educational and vocational outcomes Many of the risks of long-standing conductive hearing loss mirror those of a mild to moderate permanent hearing loss. Why are we then not looking at this closely?

Conductive Hearing Loss within UNHS Identification and management is varied with little guidance provided in the literature. Research is beginning to suggest CHL may be more prevalent than PCHL within a UNHS (e.g. Aithal, Aithal, Kei, & Driscoll, 2012)

Review Aims Question 1: What is the prevalence of CHL within UNHS? Question 2: What is the classification of CHL within UNHS? Question 3: What is the Audiological Management of CHL within UNHS? Question 4: What is the ENT management of CHL within UNHS?

Inclusion/Exclusion Criteria Search Strategy 601 68 Duplicates 533 Title Review 292 Abstract Review 42 PubMed 10 CINHAL 41 Embase Inclusion/Exclusion Criteria Some of the inclusion criteria included: Children referred through universal newborn hearing screen. Some of the exclusion criteria: Children not referred fro audiology assessment under UNHS 19 +5 Reference List 24

Quality Assessment Evidence Quality Internal Validity External Validity One article excluded due to poor external and internal validity Adequate evidence quality Adequate external and internal validity ratings. USPSTF = First an overall measure of evidence strength was determined from the research design to yield high quality studies with minimum risk of error (Jones & Evans, 2002). McMaster = This form was selected as it can be used as an appraisal of both qualitative and quantitative studies and has application in reviews of comparable health care programs, including newborn hearing screening, thereby increasing its application to the research question (Beswick et al., 2012; Ducat & Kumar, 2015; Letts et al., 2007). External Validity the plausibility of the study, similarities in study population, test conditions and social and/or environmental factors

Question 1: What is the prevalence of CHL within UNHS? 18 Articles 13 3 2 UNHS Population Ranged from 0.38 – 64.47%. Larger samples = lower prevalence of CHL. Conductive Hearing Loss within UNHS Ranged from 13 – 22.7%. Samples ranged from 173 – 1,696. Higher prevalence of CHL than PCHL. NICU Population Ranged from 31.58 – 36.84%. Small sample sizes (n=38). Screened Population: These were incidental findings from a screened population Signification variation of prevalence of CHL from 0.38 – 64.47% - this pretty much tells us nothing. Significaiton variation on partipant numbers Often compared to prevalence of Permanent Hearing Loss. Conductive Hearing Loss within UNHS Three articles specifically looked at conductive hearing loss within a universal screening program. All three reported considerably greater prevalence of CHL, particularly on comparison to PCHL. The sample sizes of these articles can be seen below. I kept these separate as the results were remarkable on comparison to the screened population and raises questions as to the testing and classification of CHL in these articles. (does the purpose of the article have an influence on prevalence? CHL is typically not considered so could be underreported or could be overresported in these articels?)

Question 2: What is the classification of CHL within UNHS? 5 Articles 2 1 1 A pattern of audiological results A permanent hearing loss False positive from hearing screen 1 A permanent hearing loss if hearing amplification is prescribed

Question 3: What is the Audiological Management of CHL within UNHS? 18 Articles 15 1 3 Tests Conducted Otoscopy TEOAEs Tympanometry DPOAE ABR (Click and/or TB) A-ABR ASSR Behavioural assessment Pneumatic Otoscopy Audiological Follow up 6-8 weeks review Onward Referral Medical Physician Onward specialist referral (ENT).

Question 4: What is the ENT management of CHL within UNHS. 3 Articles 1 1 3 1 Oral antibiotics Watch and wait Visual Inspection (including pneumatic otoscopy) Surgical Drainage (with or without ventilation tubes) Very much incidental findings.

Future Considerations Further investigation into the prevalence of CHL. Clear classification of CHL. Guidelines and protocols for audiology assessment are required. Further investigation into the role of ENT in the early identification of conductive hearing loss within a universal screening program. Further investigation (this may warrant review of definition of CHL) Classification (at which point on the screening care pathway is this needed) High agreement (91%) between tymp and pneumatic otoscopy – Doyle, kon, Stribel, Dallare and Ray, 2004).

How is conductive hearing loss managed within a UNHS? 1 Systematic Literature Review: Prevalence of CHL Classification of CHL Audiological Management ENT Management 2 Prevalence of CHL within QLD Healthy Hearing Program: Risk Factors GA Indigenous Status 3 Audiological Management within QLD Healthy Hearing Program: Tests conducted Onward referral Number of Appointments 4 ENT Management within QLD Healthy Hearing Program: Chart Review Assessment/treatment Onward referral Number of Appointments 5 Policies, Pathways and Recommendations for the identification and management of CHL within UNHS

Review and management of children identified with a transient conductive hearing loss within the context of a newborn hearing screening program Alison Collins, PhD candidate, University of Queensland Senior Audiologist, Healthy Hearing Program, Children’s Health Queensland Alison.collins2@health.qld.gov.au