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Hearing loss in children with otitis media with effusion: a systematic review

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DOI: 10.1080/14992027.2016.1250960

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 International Journal of Audiology

ISSN: 1499-2027 (Print) 1708-8186 (Online) Journal homepage: http://www.tandfonline.com/loi/iija20

Hearing loss in children with otitis media with

effusion: a systematic review

Ting Cai & Bradley McPherson

To cite this article: Ting Cai & Bradley McPherson (2016): Hearing loss in children with
otitis media with effusion: a systematic review, International Journal of Audiology, DOI:
10.1080/14992027.2016.1250960

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 International Journal of Audiology 2016; Early Online: 1–11

Original Article

Hearing loss in children with otitis media with effusion: a

systematic review

Ting Cai & Bradley McPherson

Division of Speech and Hearing Sciences, Faculty of Education, The University of Hong Kong, Hong Kong

Abstract
Objectives: Otitis media with effusion (OME) is the presence of non-purulent inflammation in the middle ear. Hearing impairment is
frequently associated with OME. Pure tone audiometry and speech audiometry are two of the most primarily utilised auditory assessments
and provide valuable behavioural and functional estimation on hearing loss. This paper was designed to review and analyse the effects of
the presence of OME on children’s listening abilities. Design: A systematic and descriptive review. Study sample: Twelve articles reporting
frequency-specific pure tone thresholds and/or speech perception measures in children with OME were identified using PubMed, Ovid,
Web of Science, ProQuest and Google Scholar search platforms. Results: The hearing loss related to OME averages 18–35 dB HL. The air
conduction configuration is roughly flat with a slight elevation at 2000 Hz and a nadir at 8000 Hz. Both speech-in-quiet and speech-in-noise
perception have been found to be impaired. Conclusions: OME imposes a series of disadvantages on hearing sensitivity and speech
perception in children. Further studies investigating the full range of frequency-specific pure tone thresholds, and that adopt standardised
speech test materials are advocated to evaluate hearing related disabilities with greater comprehensiveness, comparability and enhanced
consideration of their real life implications.

Key Words: Conductive; middle ear; pure tone audiometry; speech audiometry; speech in noise; speech
perception

Introduction
Middle ear infections are common causes of paediatric visits for
medical treatment. A spectrum of inflammatory disorders affect the
middle ear cavity, with acute otitis media and otitis media with
effusion (OME) being the most prevalent in children. Acute otitis
media refers to the rapid onset of signs and symptoms of active
infection of the middle ear and OME is the presence of fluid in the
middle ear cavity without signs or symptoms of acute ear infection,
according to available clinical guidelines (National Collaborating
Centre for Women’s and Children’s Health (UK), 2008; Lieberthal
et al, 2013; Heidemann et al, 2016; Rosenfeld et al, 2016).
Eustachian tube dysfunction with or without craniofacial malfor-
mation such as Down syndrome or cleft palate, inflammatory
response following acute otitis media, and subclinical bacterial
infection are important risk factors related to the aetiology of OME
(Kubba et al, 2000; Atkinson et al, 2015). OME is especially
prevalent among infants and young children. In one Dutch study,
80% of children suffered at least one episode of OME before the age
of four based on a series of nine consecutive tympanometry
screenings (Zielhuis et al, 1990b). Several studies on the age-
specific prevalence of OME came to the conclusion that there is a
bimodal curve concerning age and prevalence of OME, showing
one prominent peak before two years of age and a smaller peak at
five to seven years of age, the latter peak coinciding with primary
school entry (Zielhuis et al, 1990a; Sadé et al, 2003; Son et al, 1998;
Zhang et al, 2011; Atkinson et al, 2015). Australian Aboriginal,
Torres Strait Islander, Inuit and preterm or very low birth weight
children are known to have a distinctively higher risk of OME, with
point prevalence rates ranging from 10% to 31% (Kramer &
McCullough, 1998; Engel et al, 1999; Morris et al, 2005; Williams
et al, 2009). Several recent studies in which pneumatic otoscopy and
tympanometry were utilised as diagnostic tools showed a preva-
lence of OME ranging from 4.3% to 6.8% in general paediatric
populations (Chen et al, 2003; Martines et al, 2011; Zhang et al,
2011). After an initial episode of OME, a child may repeatedly
suffer from it. The recurrence rate of OME can be as high as 40%
(Tos, 1983). OME imposes a great health care burden from direct

Correspondence: Ting Cai MD, Division of Speech and Hearing Sciences, Faculty of Education, Pokfulam Road, Pokfulam, Hong Kong.
Tel.: +852 5105 7206. E-mail: caiting13579@gmail.com

(Received 19 July 2016; revised 3 October 2016; accepted 11 October 2016)

ISSN 1499-2027 print/ISSN 1708-8186 online ß 2016 British Society of Audiology, International Society of Audiology, and Nordic Audiological Society
DOI: 10.1080/14992027.2016.1250960
2 T. Cai & B. McPherson
Abbreviations
AAO-HNSF American Academy of Otolaryngology-Head and
Neck Surgery Foundation
ASHA Amerian Speech-Language-Hearing Association
HL Hearing level
NICE National Institute for Health and Care Excellence
OME Otitis media with effusion
PTA Pure tone audiometry
3PTA Averaged pure tone thresholds of 500 Hz,
1000 Hz, and 2000 Hz
SAT Speech awareness threshold
SRT Speech recognition threshold
UQUEST University of Queensland Understanding
Everyday Speech Test
treatment costs as well as indirect costs such as transportation and
lost parental income. It was estimated that USD 4.1 billion was
spent on direct treatment for otitis media (both acute otitis media
and OME) in the US in 1992 (Bondy et al, 2000), CAD 470 million
in Canada in 1994 (Coyte et al, 1999), and between AUD 100 to 400
million was spend on both the direct and indirect costs of otitis
media in Australia in 2008 (Taylor et al, 2009). Note that acute
otitis media, OME and chronic suppurative otitis media are often
considered as part of an otitis media continuum (Paradise, 1987;
Giebink, 1992) in studies on the cost burden of the diseases, and the
exact proportion of the financial costs generated specifically from
OME is not clear. In addition to monetary expenses, quality of life
of children with OME and their parents/caregivers has also been
reported to be negatively impacted by the disorder (Heidemann et
al, 2015).
Accurate diagnosis of OME is the basis of clinical management
since an unremarkable clinical history may often accompany OME
and render children with a chronic condition that has unrecognised
adverse impact. Adequate sensitivity and specificity of diagnostic
tools are necessary to identify OME and to distinguish OME from
acute otitis media. Pneumatic otoscopy (Takata et al, 2003) and
tympanometry (Nozza et al, 1994; Watters et al, 1997; Kemaloğlu
et al, 1999) have been reported to have high sensitivity and
specificity in determining the reduced mobility of the tympanum
associated with the diagnosis of OME.
Conductive hearing loss is the most frequent complication of
OME, typically owing to the increased stiffness and mass of the
tympanum caused by middle ear effusion (Johansen, 1948). For
children with moderate to profound bilateral sensorineural hearing
loss, there is a consensus that significant developmental defects of
speech and language may occur as sequelae (Carney & Moeller,
1998). However, for mild to moderate OME related conductive
hearing loss, there is no consensus on the level of hearing
impairment which may trigger speech and language developmental
disorders and warrant active intervention. In the United Kingdom’s
NICE guideline, persistent bilateral OME and no less than 25–30 dB
HL in the better ear are considered criteria for surgery (National
Collaborating Centre for Women’s and Children’s Health (UK),
2008). In the AAO-HNSF guidelines, no specific hearing threshold
level is suggested (Rosenfeld et al, 2016). Moreover, hearing loss
related with OME is often persistent or recurrent and occurs in the
‘‘sensitive’’ period for child speech and language development
(Menyuk, 1986). Identification of hearing status in children with
OME is valuable for disease surveillance and management.
Advice may be provided for children with hearing loss to minimise
the effect of decreased auditory input, such as utilitising preferential
seating, during routinely advocated observational periods known as
‘‘watchful waiting’’ (Rosenfeld et al, 2016). Type and severity of
hearing loss may also be considered in determining surgical
candidacy since ventilation tube placement has shown superiority
for promoting quick recovery of pure tone hearing (Lous et al, 2005;
Rosenfeld et al, 2013). A number of national guidelines have
recommended that pure tone hearing be evaluated when OME has
persisted for three months, or before surgical intervention (National
Collaborating Centre for Women’s and Children’s Health (UK),
2008; Heidemann et al, 2016; Rosenfeld et al, 2016). However, a
US study showed that hearing assessment was only carried out for
less than one third of children with OME for longer than three
months or with risks for speech, language and academic problems
(Lannon et al, 2011). In addition, reported severity of hearing loss
may be related with the clinical settings in which data were
collected. Since surgical intervention is primarily recommended for
children with prolonged episodes of OME or poor hearing, it can be
expected that hearing loss in surgical candidates will be more
pronounced than in children visiting their general practitioners or
students enrolled in hearing screening programmes. Owing to the
significance of hearing loss in the management of children with
OME, research that has explored the peripheral hearing and speech
perception of children during episodes of OME is systematically
reviewed in the present article.
Methods
A literature search was carried out for English-language publica-
tions using PubMed, Ovid, Web of Science, ProQuest and Google
Scholar search platforms on March 9, 2016. The search terms were
‘‘otitis media with effusion’’, ‘‘otitis media’’, ‘‘child’’, ‘‘hearing’’,
‘‘hearing tests’’, ‘‘audiometry, pure tone’’, ‘‘auditory perception’’,
‘‘auditory threshold’’, ‘‘speech perception’’, ‘‘speech discrimin-
ation tests’’ and ‘‘audiometry, speech’’. The search strategy was
developed to maximise sensitivity and minimise specificity. The
initial search resulted in 652 journal articles excluding duplicated
publications. A second selection was conducted based on the full
abstracts of each article. Papers investigating acute otitis media,
chronic suppurative otitis media, or cholesteatoma were excluded.
Reports of animal studies were also excluded. Since the primary
purpose of this review was to summarise hearing and speech
performance associated with OME in general populations, rather
than in any special populations with structural abnormalities or in
which OME is one manifestation in a syndrome, papers which
explored OME in children with Down syndrome, craniofacial
abnormalities, primary ciliary dyskinesia, and Turner syndrome
were excluded. 544 articles were filtered and 108 papers then
remained. A third selection was then made on the basis of full texts.
The inclusion criteria were that frequency-specific pure tone
thresholds and/or speech perception was reported and sample size
was greater than or equal to 50 children. Articles utilising the same
participant sample as an earlier paper were also excluded. Full texts
of the remaining 10 articles were further evaluated. References of
the selected 10 articles were reviewed to search for any rele-
vant papers had been neglected in the initial search. Two
articles were added in this way and included in the final review
(Figure 1).
 Hearing loss in children 3

Results groups and their hearing thresholds were reported separately

A total of 12 studies were identified which investigated the
frequency-specific pure tone auditory profile and/or speech percep-
tion of children with OME (Kokko, 1974; Fria et al, 1985; Mandel
et al, 1989; Silman et al, 1994; Aithal et al, 1995; Sabo et al, 2003;
Haggard et al, 2004; Arick & Silman, 2005; Hall et al, 2007; Keogh
et al, 2010; Velepic et al, 2011; Yamamah et al, 2012). Figure 2
shows the age range of participants and sample size of each
reviewed article. Table 1 summarises the characteristics and pure
tone audiometric outcomes of participants in nine studies where this
information was available.
Overview of pure tone hearing threshold studies
Nine studies reported frequency-specific pure tone thresholds. In
one study, participants were divided to two differently managed
(Velepic et al, 2011). In the study of Sabo et al (2003), hearing
thresholds were reported separately according to different testing
methods and diagnosis (unilateral or bilateral OME), which resulted
in four study groups. Therefore, a total of 13 groups of children with
OME from nine studies had been investigated. Data were collected
from North America in four studies, Europe in two studies, Oceania
in two studies and Africa in one study. Although all hearing
thresholds were derived from independent right or left ear
assessment, some studies reported the results from right ears and
left ears separately (Aithal et al, 1995; Sabo et al, 2003; Arick &
Silman, 2005; Keogh et al, 2010), one study randomly selected one
ear to report (Fria et al, 1985), and some studies combined both ears
together without considering laterality (Kokko, 1974; Silman et al,
1994; Velepic et al, 2011; Yamamah et al, 2012). The air
conduction thresholds at main speech frequencies from 500 Hz to
4000 Hz were tested and reported in all articles, and thresholds from

Figure 1. Flow chart for the identification of studies included in the systematic review.

(A) = ten ears (B) = ten children

Kokko 161 Fria et al. 762

Fria et al. 540

Mandel et al. 109
Silman et al. 82

Aithal et al. 200

Silman et al. 54
Sabo et al. 169

Arick & Silman 174 Sabo et al. 709

Velepic et al. 142

Yamamah et al. 188 Keogh et al. 183

0 2 4 6 8 10 12 14 16 Age (in years) 0 2 4 6 8 10 12 Age (in years)

Figure 2. Age range of participants of studies which reported pure tone audiometric results (A) and of studies which reported speech
perception results (B). Note: The area of each rectangle bar is proportional to the relative sample size in each study. The age range was not
indicated in Keogh et al (2010), or Haggard et al (2004) for audiometric results, so they are not included in A. Age range was not applicable
for Hall et al (2007) for speech perception results as this was a longitudinal study and is not included in B.
Table 1. Summary of pure tone audiometric results in nine studies.
Air conduction thresholds, M ± SD, dB HL (bone conduction thresholds, M ± SD, dB HL)
Study (number of Mean age
patients/number (range)/ OME diagnostic Test environment/
of ears) Study group duration Laterality tools test procedure 125 Hz 250 Hz 500 Hz 1000 Hz 2000 Hz 4000 Hz 8000 Hz 3PTA
Kokko (1974) (95/161) Surgical 8.6 year Both ears Paracentesis NA/NA 28.7 ± 11.4 27.4 ± 12.4 29.6 ± 12.7 30.1 ± 13.8 23.0 ± 12.0 28.8 ± 14.5 33.8 ± 14.6 27.6
candidates (4–15 year)/ combined (4.6 ± 5.2) (4.0 ± 6.0) (3.2 ± 7.5) (1.7 ± 7.4) (3.4 ± 8.6)
8.5 month
Fria et al (1985) Hospital 5.1 year One ear ran- Otoscopy, TYM, Audiometric room/ NA NA 27.5 ± 11.6 26.5 ± 12.1 19.6 ± 12.1 26.8 ± 14.9 NA 24.5
(540/540) patients (2–12 year)/ domly acoustic reflex PA for 2–4 year (4.8 ± 5.3) (5.8 ± 5.4) (6.9 ± 6.5) (7.9 ± 7.7)
variable selected and CA for 4–12
year
Silman et al (1994)a Clinic 6.3 year Both ears Pneumatic otoscopy Audiometric room/ NA 35.1 31.5 27.2 23.5 21.8 NA 27.4
(54/82) patients (3–11 year)/ combined NA
NA
Aithal et al (1995)b Surgical 9.7 year Only right Otoscopy, TYM, Audiometric room/ NA 35.4 36.3 35.5 30.3 37.3 39.4 34.0
(100/200) candidates (4–16 year)/ ear selected PTA (ABG 410 dB NA (-2.0 ± 7.9) (-1.5 ± 7.7) (2.7 ± 6.7) (11.6 ± 7.0) (6.6 ± 7.1)
NA in two frequencies)
Sabo et al (2003)c General NA Both ears Otoscopy, TYM Audiometric room/ NA NA U: 21.7 ± 10.7 U: 18.5 ± 10.9 U: 14.2 ± 11.1 U: 17.4 ± 10.8 NA U: 18.1
(112/169) population (6–71 reported PA (27–65 month) B: 28.2 B: 27.7 B:20.9 B: 27.0 B: 25.6
month)/42 separately
month
Audiometric room/ U: 23.9 ± 11.4 U: 21.8 ± 11.8 U: 13.7 ± 8.8 U: 19.5 ± 10.1 U:
CA (39–71 month) B: 24.5 B: 24.2 B: 16.4 B: 21.7 19.8
B:21.7
Arick & Silman (2005) Clinic NA Both ears PTA 420 dB HL and NA/NA NA NA 33.4 ± 9.7 33.7 ± 10.5 23.2 ± 11.4 30.5 ± 12.2 NA 30.1
(94/174) patients (4–11 year)/ reported TYM peak
42 month separately pressure5-100
Keogh et al (2010)b Primary 7.7 ± 1.5 Both ears Otoscopy, TYM, Quiet room/NA NA NA 28.5 25.9 22.5 24.6 NA 25.6
(63/126) school year/NA reported PTA
students separately
Velepic et al (2011)d Surgical 5.5 year Both ears Microscopy NA/NA NA NA 27.6 ± 11.6 26.4 ± 11.1 20.6 ± 12.7 26.5 ± 10.4 NA 24.9
(87/142) candidates (2–12 year)/ combined
for 43 month
adenoidect-
omy and
tube
insertion
Surgical 25.9 ± 10.4 23.1 ± 8.5 18.3 ± 9.4 23.1 ± 10.1 22.4
candidates
for
adenoidect-
omy only
Yamamah et al (2012) (94/188) Primary NA Both ears Otoscopy, TYM Quiet room/NA NA 28.4 ± 4.5 28.2 ± 4.0 27.1 ± 4.9 25.2 ± 4.0 23.0 ± 4.0 21.3 ± 3.9 26.8
school (7–10 year)/ combined
students NA

M: mean;, SD: standard deviation; 3PTA: averaged pure tone thresholds of 500 Hz, 1000 Hz and 2000 Hz; NA: not indicated or not available; TYM: tympanometry; PA: play audiometry; CA:
conventional audiometry; PTA: pure tone audiometry; ABG: air-bone gap; U: unilateral OME; B: bilateral OME.
a
Pure tone thresholds of ears that passed the ASHA screening protocol and ears that failed the protocol were combined to obtain a mean in all ears. SD was not available in the combined group.
b
Pure tone thresholds of right ears and left ears were combined to obtain a mean in all ears. SD was not available for air conduction thresholds in the combined group.
c
Pure tone thresholds of right ears and left ears in children with bilateral OME were combined to obtain a mean in all ears. SD was not available in the combined group.
d
Air-bone gaps on each frequency were reported.

125 Hz to 8000 Hz were reported in one study (Kokko, 1974). Three
studies reported bone conduction thresholds. One study reported air-
bone gaps instead of air and bone conduction thresholds at each
frequency (Velepic et al, 2011). The range of mean thresholds
obtained at each frequency was from 13.7 dB HL (2000 Hz) to
39.4 dB HL (8000 Hz). Six mean frequency specific audiograms
derived from the reviewed articles are displayed in Figure 3. There
was no indication of the audiometer calibration standard used in
Kokko’s study (1974), which was carried out between 1965 and
1971. Standards on reference-equivalent threshold sound pressure
levels for audiometers adopted before 1969 differed among
countries and differed from those were adopted after 1969 and
until now (American Standards Association, 1951; British
Standards Institution, 1954; Pearl, 1968; American National
Standard Institute, 1969; American National Standard Institute,
1996; International Standards Organization, 1998; International
Organization for Standardization, 2004). Therefore, it needs to be
noted that thresholds indicated in Kokko’s study may be slightly
different from other reviewed studies owing to different reference
zero levels.
Laterality of OME
Unilateral OME and bilateral OME were reported separately in one
study (Sabo et al, 2003), and were combined on the basis of ears in
five studies (Kokko, 1974; Fria et al, 1985; Silman et al, 1994;
Arick & Silman, 2005; Velepic et al, 2011). Only bilateral OME
was involved and the thresholds of right and left ears were reported
separately in two studies (Aithal et al, 1995; Keogh et al, 2010). The
laterality of OME was not indicated in one study (Yamamah et al,
2012). The pure tone thresholds of the positive ear in children with
unilateral OME were reported to be significantly better than the
corresponding averaged (right and left) values in children with
bilateral OME when play audiometry was conducted with a 27–65
months age group (Sabo et al, 2003). However, a similar
comparison was not reported for conventional audiometry which
was conducted in children aged 39–71 months in the same study.
Audiometric configuration
The average hearing thresholds (3PTA) across all studies are in the
range of 18–35 dB HL and the weighted arithmetic 3PTA mean is
26.0 dB HL. The threshold peaks appear at 2000 Hz in 11 study
groups (Kokko, 1974; Fria et al, 1985; Aithal et al, 1995; Sabo et al,
2003; Haggard et al, 2004; Arick & Silman, 2005; Hall et al, 2007;
Keogh et al, 2010; Velepic et al, 2011), at 4000 Hz in one study
(Silman et al, 1994), and at 8000 Hz in one study (Yamamah et al,
2012). Hearing thresholds are therefore best at 2000 Hz in the
majority of cases, with a slight inverted U or trough shape. The most
prominent hearing loss occurred at 500 Hz in eight out of 13 study
groups in which 500 Hz was tested (Fria et al, 1985; Silman et al,
1994; Sabo et al, 2003; Keogh et al, 2010; Velepic et al, 2011), at
250 Hz in two out of four study groups in which 250 Hz was tested
(Sabo et al, 2003), at 8000 Hz in two out of three study groups in
which 8000 Hz was included (Kokko, 1974; Aithal et al, 1995), and
at 1000 Hz in one out of 13 study groups in which 1000 Hz was
tested (Arick & Silman, 2005). Bone conduction thresholds curves
were almost flat with the mean difference between maximum level
and minimum level across frequencies less than 5 dB in two studies
(Kokko, 1974; Fria et al, 1985). In the only other study which
Hearing loss in children 5
reported bone conduction thresholds, there was a prominent
threshold dip at 2000 Hz (Aithal et al, 1995).
Study settings and hearing loss levels
Children with OME are not inevitably symptomatic and OME may
be detected at clinics or during school entrance screening, or left
undiscovered until spontaneous resolution. School or community
based studies (Sabo et al, 2003; Keogh et al, 2010; Yamamah et al,
2012), clinic or outpatient department based studies (Fria et al,
1985; Silman et al, 1994; Arick & Silman, 2005), and surgical
candidate based studies (Kokko, 1974; Aithal et al, 1995; Velepic et
al, 2011) each account for one third of the nine reviewed articles.
Diagnostic tools in reviewed articles
The diagnosis of OME in current clinical practice usually involves
pneumatic otoscopy, tympanometry, acoustic reflex measures, or
pure tone audiometry. Invasive investigations such as paracentesis
or microscopy were used for diagnosis of OME in the three surgical
candidate based studies (Kokko, 1974; Aithal et al, 1995; Velepic et
al, 2011). Pneumatic otoscopy or tympanometry was involved in all
the remaining studies (Fria et al, 1985; Silman et al, 1994; Sabo et
al, 2003; Arick & Silman, 2005; Keogh et al, 2010; Yamamah et al,
2012). Pure tone audiometry was added to assist diagnosis in three
studies (Aithal et al, 1995; Arick & Silman, 2005; Keogh et al,
2010).
Test environments
Pure tone audiometry was conducted in an audiometric booth in
four studies (Fria et al, 1985; Silman et al, 1994; Aithal et al, 1995;
Sabo et al, 2003) and a quiet room was used in two school based
studies (Keogh et al, 2010; Yamamah et al, 2012). Test environment
was not indicated in the other three studies (Kokko, 1974; Arick &
Silman, 2005; Velepic et al, 2011).
Age and age-appropriate audiometric test procedures
The age of children in the reviewed studies ranged from two to 16
years of age (Figure 2). Conditioned play audiometry was
conducted for children between 24 and 48 months of age in Fria
et al’s study (1985) and for children aged between 27 and 65 months
in Sabo et al’s study (2003). The specific audiometric test
procedures were not mentioned in two studies in which children
younger than four years were recruited (Silman et al, 1994; Velepic
et al, 2011).
Duration of OME
Duration of OME in participants in the reviewed studies varied
according to the different data collection settings. Surgical candi-
dates often experienced a longer duration of OME than outpatient
recruited children. Children identified from schools or communities
were typically asymptomatic and without records for duration.
Duration was longer than two months in two studies (Sabo et al,
2003; Arick & Silman, 2005), longer than three months in one study
(Velepic et al, 2011), and with an average duration of 8.5 months in
another study (Kokko, 1974).
6 T. Cai & B. McPherson

Frequency (Hz) Frequency (Hz)

125 250 500 1000 2000 4000 8000 125 250 500 1000 2000 4000 8000
-20 -20
-10 -10
0 0
10 10
20 20
Hearing Level (dB)

Hearing Level (dB)

30 30
BC
40 40 AC
AC
50 50
60 60
70 70
80 80
90 90
100 100

Frequency (Hz) Frequency (Hz)

125 250 500 1000 2000 4000 8000 125 250 500 1000 2000 4000 8000
-20 -20
-10 -10
0 0
10 10
20 20
Hearing Level (dB)

Hearing Level (dB)

30 30
BC
40 40 AC
AC
50 50
60 60
70 70
80 80
90 90
100 100

Frequency (Hz) Frequency (Hz)

125 250 500 1000 2000 4000 8000 125 250 500 1000 2000 4000 8000
-20 -20
-10 -10
0 0
10 10
20
Hearing Level (dB)

20
Hearing Level (dB)

30 30
BC
40 40 AC
AC
50 50
60 60
70 70
80 80
90 90
100 100

BC: bone conduction thresholds, AC: air conduction thresholds.

Figure 3. Six mean audiograms derived from reviewed articles. A: Mean audiogram reported by Kokko (1974). B: Mean audiogram
reported by Fria et al (1985). C: Mean audiogram reported by Aithal et al (1995). D: Mean audiogram reported by Silman et al (1994).
E: Mean audiogram reported by Arick & Silman (2005). F: Mean audiogram reported by Yamamah et al (2012).
Table 2. Summary of speech audiometry in seven studies.
Mean age
Study, year Study group Diagnostic tools (range) Number Testing measurement Testing outcome Reference levela
Fria et al (1985) Clinic patients Otoscopy, TYM, acous- 14.1 month (7–24 month) 222 children SAT 24.6 ± 11.3 (dB HL) NA
tic reflex (222 ears)
5.1 year (2–12 year) 540 children (540 ears) SRT 22.7 ± 10.9 (dB HL) NA
Mandel, et al (1989) Surgical candidates TYM, acoustic reflex NA (7 month–2.5 year) 109 children in total SAT 23.6 (dB HL) NA
NA (2.5–12 year) SRT 21.8 (16.2–36.2)c (dB HL) NA
Silman et al (1994) Clinic patients Pneumatic otoscopy 6.3 year (3–11 year) 82 ears (54 children) SRT 33.2 ± 8.4 (dB HL) NA
Sabo et al (2003) General population Otoscopy, TYM NA (6–8 month) U: 32 children SAT U:17.3 ± 5.5 (dB HL) 14.0 ± 5.0 (dB HL)
B: 64 children B: 25.6 ± 11.3 (dB HL)
NA (9–35 month) U: 236 children SAT U: 11.6 ± 5.6 (dB HL) 11.9 ± 4.0 (dB HL)
B: 293 children B: 19.2 ± 8.4 (dB HL)
NA (27–65 month) U: 36 children SRT U: 15.7 ± 10.4 (dB HL) 8.2b (dB HL)
B: 48 children B: 22.1b (dB HL)
NA (39–71 month) U: 19 children SRT U: 18.2 ± 10.4 (dB HL) 6.2b (dB HL)
B: 9 children B: 18.7b (dB HL)
Haggard et al (2004) Clinic patients PTA, TYM 61 month Word recognition in 56.5 (dB SPL)
noise by
(IHR)-McCormick
automated toy test
Hall et al (2007) General population TYM 31 month U: 98 children Word recognition threshold U: 34.2 ± 6.0 (dB A) 28.5 ± 5.0 (dB A)
B: 96 children in quiet by B: 46.0 ± 8.7 (dB A)
(IHR)-McCormick
automated toy test
43 month U: 110 children U: 28.1 ± 4.8 (dB A) 23.1 ± 3.6 (dB A)
B: 117 children B: 39.2 ± 10.1 (dB A)
61 month U: 59 children U: 28.8 ± 4.3 (dB A) 23.2 ± 3.7 (dB A)
B: 68 children B: 38.5 ± 8.9 (dB A)
Keogh et al (2010) Primary school students Otoscopy, TYM, PTA 7.7 year (5.4–10.9 year) UH: 38 children Speech comprehension UH: 76.5 ± 19.8 80.8 ± 17.8
BH: 63 children score in noise BH: 69.3 ± 22.5
I: 82 children (5 dB SNR) by UQUEST I: 75.3 ± 20.0
Speech comprehension score UH: 70.5 ± 17.5 72.0 ± 18.0
in noise (0 dB SNR) by BH: 60.8 ± 23.5
UQUEST I: 69.3 ± 18.8

SAT: speech awareness threshold; SRT: speech recognition threshold; PTA: pure tone audiometry; TYM: tympanometry; U: unilateral OME; B: bilateral OME; UQUEST: the University
of Queensland Understanding Everyday Speech Test; UH: unilateral OME and unilateral hearing loss; BH: bilateral OME and bilateral hearing loss; I: unilateral or bilateral OME with
bilateral normal hearing.
a
Testing outcomes in the normal control group of children without OME.
b
Right ear and left ear averaged.
c
Range of SRT.
Hearing loss in children
7
8 T. Cai & B. McPherson
Speech audiometry assessment
Speech audiometry was reported in seven studies, including
evaluation of speech awareness thresholds (SAT), speech recogni-
tion thresholds (SRT), speech recognition in quiet, and speech
recognition in noise (Fria et al, 1985; Mandel et al, 1989; Silman et
al, 1994; Sabo et al, 2003; Haggard et al, 2004; Hall et al, 2007;
Keogh et al, 2010). Table 2 summarises the characteristics and
speech audiometric outcomes of participants of these studies. Non-
standardised speech audiometry was used in four studies for SAT in
infants below two years of age and SRT in children aged above two
years (Fria et al, 1985; Mandel et al, 1989; Silman et al, 1994; Sabo
et al, 2003). There was no ear-specific SAT for children under two
years of age since test stimuli were presented through loudspeakers.
Therefore, SAT in infants with unilateral OME represents the
speech hearing sensitivity in the better hearing ear. A standardised
speech audiometry material, the IHR-McCormick automated toy
test (Ousey et al, 1989), was used in two studies for word
recognition thresholds in quiet (Hall et al, 2007) and in noise
(Haggard et al, 2004). Children with unilateral or bilateral OME had
a mean increase of 5 dB or 15 dB, respectively, for word recognition
thresholds in quiet (Hall et al, 2007). Another utilised standard
speech test was the University of Queensland Understanding
Everyday Speech Test (UQUEST), which evaluates comprehension
performance for conversational speech under a series of signal-to-
noise ratios (Kei et al, 2003).
Discussion
Healthcare providers are recommended to evaluate hearing ability
by age-apropriate techniques for children with persistent OME of
more than three months duration or children at risk of speech
development disorders (Rosenfeld et al, 2016). However, fre-
quency-specific hearing thresholds or SRT have not been compre-
hensively explored in most studies. In the majority of reviewed
studies, pure tone hearing loss or speech perception were reported
as indictors or baseline measurements for different interventional
modalities rather than for assessment of the hearing impairment
itself. In addition, pure tone thresholds were reported most often at
speech frequencies and they were available for a full 125 Hz to
8000 Hz range in only one study which was published nearly half a
century ago with a different reference zero standard from the
current specification (Kokko, 1974). The lack of data across the full
range of frequencies makes audiometric configuration analysis
difficult and imprecise. For example, if only speech frequencies are
considered, hearing thresholds at 500 Hz are worst in ten out of 13
study populations. When 250 Hz and 8000 Hz are both involved, the
maximum hearing loss is at 250 Hz (Yamamah et al, 2012) or
8000 Hz (Aithal et al, 1995). The most prominent hearing loss
occurred at the extremities of the range of frequencies in 12 out 13
study populations reviewed. Hearing thresholds at key speech
frequencies from 500 Hz to 4000 Hz are of great importance and
have clinical implications for children with OME while full range
pure tone audiometry would provide a comprehensive picture of the
audiometric configurations associated with OME for research
purposes.
Types of hearing loss associated with OME
Conductive hearing loss was confirmed for study participants in all
reviewed articles. Mixed hearing loss associated with OME has also
been discussed in case reports or described in retrospective studies
but all with relatively small sample size (Harada et al, 1992; Mutlu
et al, 1998; Zhou et al, 2012; Aviel & Ostfeld, 1982) and therefore
not included in this review. Two mechanisms have been proposed to
explain the sensorineural component of this hearing impairment.
One is temporary inhibition in the vibratory movement of the oval
and/or round window membrane caused by middle ear problems or
reversible cochlear dysfunction caused by changes in the ionic
composition of the inner ear fluids (Mutlu et al, 1998), which
usually appears as a depressed threshold region around 2000 Hz.
The other is a true disturbance of inner ear function which does not
resolve after an episode of OME (Harada et al, 1992; Mutlu et al,
1998). In the reviewed articles, the average pure tone audiogram of
Aithal et al’s study (1995) showed a bone conduction depression at
2000 Hz, with a mean of 11.6 dB HL. Since bone conduction
thresholds were reported in only three studies from all the reviewed
articles, there was inadequate data to derive a definitive conclusion
regarding a sensorineural component in OME related hearing loss.
Pure tone hearing profiles of OME
The average hearing thresholds calculated based on 500 Hz,
1000 Hz and 2000 Hz in the study groups are in the range of
18–35 dB HL, which is the range of mild or moderate hearing loss
in adults according to conventional classifications (Olusanya et al,
2008). This categorisation of ‘‘mild or moderate hearing loss’’ is
based on the averaged hearing thresholds within a group and not the
whole range of pure tone thresholds of all children in that study
group. As stated by Fria, the range of hearing loss can be as high as
50 dB HL (1985). It would be misleading if the hearing loss
associated with OME was solely discussed on a group mean basis,
especially when developmental sequelae are considered. Hasenstab
(1987) provided eleven detailed, successive audiograms of a four-
year-old who intermittently suffered from OME. The audiograms
show a hearing loss markedly fluctuating both in terms of severity
and audiometric configuration. The individual differences and
variations from episode to episode make the situation complex and
require a more patient-centred perspective. Too much attention on
the average level of hearing loss and an absence of consideration of
children with poorer thresholds, and/or longer durations of hearing
loss, may compromise the identification of specific children at risk
of possible developmental delays (Matkin, 1988).
There are a range of factors that may influence the results of
audiological assessment in children with OME: subject recruitment
settings; test environment; test procedures; diagnostic strategies;
duration of OME; laterality and whether analysis is based on ear or
child. Subjects recruited from surgical candidates typically have
more obvious hearing loss or longer duration of middle ear effusion.
Children who attend hearing clinics or hospital outpatient depart-
ments are generally less markedly affected compared to surgical
candidates. Children detected by screening programmes from
schools are usually asymptomatic and with normal hearing or
very slight hearing loss. As shown in Table 1, hearing levels
reported from surgical candidates are more elevated than from
clinic or outpatient department based studies, which in turn are
higher than those from community or school based studies.
In order to obtain accurate and comparable pure tone audiomet-
ric results, the permissible ambient noise in the test room should be
within the criteria provided by standards organisations. Audiometric
rooms were used in most clinic or hospital based studies and a quiet
room was, in most cases, a preferred choice for school or

community based studies. For slight or mild hearing loss, a quiet
room in a school may be adequate to provide reliable hearing
screening pass or fail results that are comparable to those obtained
in a sound-treated audiometric room. However, a quiet room may
not be a valid environment to determine frequency-specific
thresholds, especially at low frequencies (Schlauch & Nelson,
2015).
Choice of testing techniques is determined by the age of children
and their cooperativeness. Young infants without OME tested by
visual reinforcement audiometry have significantly higher thresh-
olds than those tested by play audiometry. Similarly, pure tone
thresholds in children tested by play audiometry without OME were
higher than those tested by conventional audiometry (Sabo et al,
2003). Therefore, it may be somewhat arbitrary to compare or
combine hearing loss data from children of different ages and those
tested by different techniques. The degree of hearing loss may also
affected by the laterality of OME. Hearing impairment in the
affected ear of unilateral OME tends to be milder than that in
bilateral OME (Fria et al, 1985; Sabo et al, 2003). Studies that
analysed hearing thresholds on the basis of ears and combine
unilateral and bilateral affected ears together may overestimate the
hearing impairment of children with unilateral disease and under-
estimate that of children with bilateral affected ears. Among
reviewed study groups, the most severe hearing loss was reported by
Aithal et al. (1995) in whose study only bilateral OME was
investigated. Hearing acuity in children with unilateral OME is
asymmetric from affected ear to unaffected ear. Bilateral OME may
also induce symmetric or asymmetric hearing loss (Keogh et al,
2010). Asymmetric or unilateral hearing loss may generate a series
of challenges such as sound localisation difficulties, problems
distinguishing speech in background noise, and speech and
educational problems (Wilmington et al, 1994; Lieu, 2004;
Mondelli et al, 2016; Winiger et al, 2016). Management of
unilateral OME varies according to different clinical guidelines.
AAO-HNSF clinical guidelines indicate unilateral OME with
prolonged hearing loss and other symptoms which are likely to be
attributable to OME warrants treatment similar to that for bilateral
OME (Rosenfeld et al, 2016). However, in NICE and Danish
guidelines, only persistent bilateral OME with hearing loss is
considered as indicative for surgical intervention and unilateral
OME is not specifically mentioned (National Collaborating Centre
for Women’s and Children’s Health (UK), 2008; Heidemann et al,
2016). Future studies on unilateral OME are needed to provide
high-quality evidence to support management decisions.
Based on the limited information reported by reviewed studies,
the relationship between duration of OME and degree of hearing
loss is not clear. Longitudinal research is desirable to evaluate the
natural history of hearing loss at different frequencies in children
with OME.
Speech perception related to OME
SRT or SAT is convenient and provides an estimation of speech
perception ability but is not routinely performed as a standardised
test and thus results cannot be compared across different audiology
clinics or studies. The test stimuli, typically spondaic words, may
not represent children’s vocabulary or everyday listening experi-
ence. SRT or SAT tested in a quiet environment may not reflect
communication disabilities in noisy listening settings. Both the
IHR-McCormick automated toy test and UQUEST were developed
to assess communication performance of children in real life
Hearing loss in children 9
listening environments. Adding background noise to speech recog-
nition tests greatly enhances the sensitivity of the assessment,
especially for children with mild hearing impairment – which is
often the case in OME related hearing loss. Word recognition
thresholds in noise were reported to be better than baseline pure
tone hearing loss in predicting children who will benefit from
tympanostomy tube insertion (Haggard et al, 2004). Unilateral
OME is relatively less common than bilateral OME. There was no
clear indication in any reviewed articles whether the binaural
speech perception ability in children with unilateral OME was
statistically significantly reduced compared to children with normal
hearing.
Pink noise is used in the IHR-McCormick automated toy test and
wideband noise or white noise in UQUEST. It may be worthwhile to
incorporate informational or perceptual masking which provides
greater masking than energetic noise (Carhart et al, 1969; Brungart,
2001; Brungart et al, 2006). Adoption of informational masking,
such as multitalker babble or a single speech masker, may increase
the sensitivity and validity of speech tests (Schafer, 2010; McArdle
& Hnath-Chisolm, 2015). In addition, error patterns linked to OME
related hearing loss in speech discrimination or recognition have
only been analysed in case studies. Post vocalic consonant
discrimination was reported to be impaired in children with OME
associated hearing loss in a quiet environment (Dobie & Berlin,
1979; DeMarco & Givens, 1989). Further research on error pattern
analysis in noisy backgrounds may be beneficial for developing
more effcient intervention and to optimise rehabiliation strategies
for specific listening problems.
Implications for clinical practice
The observed range of hearing loss and degree of hearing loss were
found to be influenced by methodological factors. These factors
should be noted when healthcare professionals use study findings in
the management of children with OME. Speech perception in noise
is considered as a good indicator of hearing benefit from surgical
intervention (Haggard et al, 2004). Active listening is the primary
channel for knowledge acquisition in children. Hearing loss and
impaired speech perception in noise have been reported to be
related with poor quality of life, poor academic performance and
increased listening effort (Rosenfeld et al, 1997; Hicks & Tharpe,
2002; Khairi Md Daud et al, 2010). Incorporating pure tone
audiometry and speech audiometry into the assessment for children
with OME who report hearing or learning difficulites and for
parents/caregivers who are concerned their children’s behaviours
(e.g. needs for higher sound levels when watching TV than their
siblings), may be valuable for identifying the specific auditory
difficulites concerned and tracking changes along the course of
treatment. Use of standardised and sensitive speech tests with
satisfactory validity and reliability may provide readily comparable
measures of speech perception impairment in realistic listening
environments.
Implications for future research
From the above review it can be seen that there are limited numbers
of studies that discuss the actual effects of OME on children’s
hearing status, i.e. their ‘‘real time’’ hearing performance when
OME is present. Perhaps surprisingly, this question is under-
investigated compared to the numerous studies of the potential long
term auditory sequelae of repeated OME. However, the former
10 T. Cai & B. McPherson
aspect is important because the immediate effects of OME on
hearing ability are the basis of any long term complications and
indicate the degree to which peripheral hearing impairment may
influence higher level auditory processing and speech processing. In
addition, synchronous hearing status associated with OME, e.g.
degree and duration of hearing loss, persistency or fluctuations in
the magnitude of hearing impairment, may be helpful in clinical
decision making on management and surveillance. Stratification of
OME related hearing loss may flag children with increased risk of
speech and language disorders (who would benefit from interven-
tions focussing on hearing improvement) and avoid over-referral of
children at lower risk of such disorders (Rosenfeld et al, 2016). The
only study which assessed a full range of frequency-specific pure
tone thresholds in children with OME was conducted in 1974
(Kokko, 1974). Since treatment procedures have changed, general
standards of healthcare have risen and people have better hearing in
many regions over the past half century (Hoffman et al, 2010; Zhan
et al, 2010), updated data are necessary to establish whether
children with OME suffer the same level of hearing loss as they did
in the past.
OME and hearing loss in developing countries has received very
little research attention. Nearly all studies investigating OME and
related hearing loss have been carried out in developed regions,
with one study in Papua New Guinea a notable reviewed exception
(Aithal et al, 1995) – and which indicated the most severe OME
related hearing loss of any study. It is possible that differences in
OME severity and associated hearing level may exist across
socioeconomic communities. Genetic sensitivity, environmental
factors and traditional practice also influence prevalence, presen-
tations, and prognosis of health disorders and should be considered
when evaluating audiological findings.
Speech perception in noise evaluated by standardised tests is
needed for assessment of hearing performance of children with
OME in a realistic listening environment. The strategy of ‘‘watchful
waiting’’ is now widely recommended and implemented for OME
management (Rosenfeld et al, 2016). During the period of
observation, children may have mild to moderate hearing loss for
several weeks or months, before and possibly for some time after
middle ear effusion resolves. Such children may experience
considerable difficulties perceiving teacher and peer speech in
noisy classrooms which may lead to increased listening effort,
fatigue, and suboptimal quality of life (Rosenfeld et al, 1997; Hicks
& Tharpe, 2002). This kind of unfavourable classroom environment
is widely found in both developed and developing countries
(Crandell & Smaldino, 2000; Choi & McPherson, 2005; Li et al,
2008; Chan et al, 2015). Speech-in-noise perception and other high-
order auditory processing of children with OME related hearing loss
may be impaired in an adverse acoustic environment. It is important
to gauge this kind of difficulty, to improve OME related hearing
loss management and advise educators on ways to ameliorate
disadvantageous classroom acoustical conditions and to optimise
listening and learning environment for children with OME related
hearing loss.
From the above discussion, future research on hearing assess-
ment of OME may be better advanced if the following suggestions
are considered. Firstly, duration of OME, laterality, test environ-
ment, past history of acute otitis media and risk factors which may
increase possibility of speech, language and learning problems
should be clearly reported. Secondly, pure tone audiometry with
bone conduction hearing thresholds to rule out sensorineural
hearing loss and preferably full-range air conduction hearing
should be performed with age-appropriate, ear-specific testing
protocols. Thirdly, standardised speech perception assessments
should be employed for children with a prolonged history of OME
or elevated hearing thresholds.
Limitations
Only English language literature and published journal articles were
included in the search attempt and language and publication biases
were inevitable. Owing to the limited studies reporting frequency-
specific pure tone thresholds or speech perception in children with
OME and the heterogeneity of populations and testing methods in
reviewed articles, findings in this review need to be applied with
caution.
Conclusions
Pure tone audiometric thresholds and speech perception in noise are
important measures to evaluate the severity and effects of OME.
OME related hearing loss averages 18–35 dB HL. The audiometric
configuration of typical OME related hearing loss is typically flat
with a slight peak at 2000 Hz and a fall at 8000 Hz. Speech
perception in quiet and in noise is impaired in children with OME
associated hearing loss. Owing to factors which affect patterns and
severities of hearing loss and individual variations within and
among groups, categorising OME related hearing loss on the basis
of a group average may be misleading. Large-scale studies with
pure tone thresholds at full range of frequencies are warranted for an
updated audiometric profile of this disorder. Studies investigating
speech perception in noise as well as in quiet using standardised test
procedures are also needed to give improved ‘‘real world’’
understanding of the effects of OME on hearing abilities.
Declaration of interest: The authors report no declarations of
interest.
ORCID
Ting Cai http://orcid.org/0000-0002-9606-9752
Bradley McPherson http://orcid.org/0000-0002-7982-1033
References
Aithal, V., Aithal, S. & Pulotu, L. 1995. Otitis media with effusion in
children: An audiological case series study. P N G Med J, 38, 79–94.
American National Standard Institute. 1969. Specification for Audiometers.
ANSI S3.6-1969. New York: American National Standards Institute.
American National Standard Institute. 1996. Specification for Audiometers.
ANSI S3.6-1996. New York: American National Standards Institute.
American Standards Association. 1951. Specification for Audiometers for
General Diagnostic Purposes. ASA-Z24.5-1951, New York: American
Standards Association.
Arick, D.S. & Silman, S. 2005. Nonsurgical home treatment of middle ear
effusion and associated hearing loss in children. Part I: Clinical trial. Ear
Nose Throat J, 84, 567–568. 570–574, 576 passim.
Atkinson, H., Wallis, S. & Coatesworth, A.P. 2015. Otitis media with
effusion. Postgrad Med, 127, 381–385.
Aviel, A. & Ostfeld, E. 1982. Acquired irreversible sensorineural hearing
loss associated with otitis media with effusion. Am J Otolaryngol, 3,
217–222.

Bondy, J., Berman, S., Glazner, J. & Lezotte, D. 2000. Direct expenditures
related to otitis media diagnoses: Extrapolations from a pediatric
Medicaid cohort. Pediatrics, 105, e72.
British Standards Institution. 1954. The Normal Threshold of Hearing for
Pure Tones by Earphone Listening. 2497. London: British Standards
Institution.
Brungart, D.S. 2001. Informational and energetic masking effects in
the perception of two simultaneous talkers. J Acoust Soc Am, 109,
1101–1109.
Brungart, D.S., Chang, P.S., Simpson, B.D. & Wang, D. 2006. Isolating the
energetic component of speech-on-speech masking with ideal time-
frequency segregation. J Acoust Soc Am, 120, 4007–4018.
Carhart, R., Tillman, T.W. & Greetis, E.S. 1969. Perceptual masking in
multiple sound backgrounds. J Acoust Soc Am, 45, 694–703.
Carney, A.E. & Moeller, M.P. 1998. Treatment efficacy: Hearing loss in
children. J Speech Lang Hear Res, 41, S61–S84.
Chan, K.M., Li, C.M., Ma, E.P., Yiu, E.M. & McPherson, B. 2015. Noise
levels in an urban Asian school environment. Noise Health, 17, 48–55.
Chen, C.H., Lin, C.J., Hwang, Y.H. & Ku, C.J. 2003. Epidemiology of otitis
media in Chinese children. Clin Otolaryngol Allied Sci, 28, 442–445.
Choi, C.Y. & McPherson, B. 2005. Noise levels in Hong Kong primary
schools: Implications for classroom listening. Intl J Disabil Dev Educ,
52, 345–360.
Coyte, P.C., Asche, C.V. & Elden, L.M. 1999. The economic cost of otitis
media in Canada. Int J Pediatr Otorhinolaryngol, 49, 27–36.
Crandell, C.C. & Smaldino, J.J. 2000. Classroom acoustics for children with
normal hearing and with hearing impairment. Lang Speech Hear Serv
Sch, 31, 362–370.
DeMarco, S. & Givens, G.D. 1989. Speech sound discrimination pre- and
posttympanostomy: A clinical case report. Ear Hear, 10, 64–67.
Dobie, R.A. & Berlin, C.I. 1979. Influence of otitis media on hearing and
development. Ann Otol Rhinol Laryngol Suppl, 88, 48–53.
Engel, J., Anteunis, L., Volovics, A., Hendriks, J. & Marres, E. 1999.
Prevalence rates of otitis media with effusion from 0 to 2 years of age:
Healthy-born versus high-risk-born infants. Int J Pediatr
Otorhinolaryngol, 47, 243–251.
Fria, T.J., Cantekin, E.I. & Eichler, J.A. 1985. Hearing acuity of children
with otitis media with effusion. Arch Otolaryngol Head Neck Surg, 111,
10–16.
Giebink, G.S. 1992. Otitis media update: pathogenesis and treatment. Ann
Otol Rhinol Laryngol Suppl, 155, 21–23.
Haggard, M., Gannon, M., Birkin, J., Bennett, K., Nicholls, E., et al. 2004.
Speech reception in noise: An indicator of benefit from otitis media with
effusion surgery. Clin Otolaryngol, 29, 497–504.
Hall, A.J., Munro, K.J. & Heron, J. 2007. Developmental changes in word
recognition threshold from two to five years of age in children with
different middle ear status. Int J Audiol, 46, 355–361.
Harada, T., Yamasoba, T. & Yagi, M. 1992. Sensorineural hearing loss
associated with otitis media with effusion. ORL, 54, 61–65.
Hasenstab, M.S. 1987. Language Learning and Otitis Media. London:
Taylor & Francis.
Heidemann, C.H., Lauridsen, H.H., Kjeldsen, A.D., Faber, C.E., Johansen,
E.C.J., et al. 2015. Quality-of-life differences among diagnostic
subgroups of children receiving ventilating tubes for otitis media.
Otolaryngol Head Neck Surg, 153, 636–643.
Heidemann, C.H., Lous, J., Berg, J., Christensen, J.J., Hakonsen, S.J., et al.
2016. Danish guidelines on management of otitis media in preschool
children. Int J Pediatr Otorhinolaryngol, 87, 154–163.
Hicks, C.B. & Tharpe, A.M. 2002. Listening effort and fatigue in school-age
children with and without hearing loss. J Speech Lang Hear Res, 45,
573–584.
Hoffman, H.J., Dobie, R.A., Ko, C.W., Themann, C.L. & Murphy, W.J.
2010. Americans hear as well or better today compared with 40 years
ago: Hearing threshold levels in the unscreened adult population of the
United States, 1959–1962 and 1999–2004. Ear Hear, 31, 725–734.
International Organization for Standardization. 2004. Acoustics: Reference
Zero for the Calibration of Audiometric Equipment. Part 1, Reference
Hearing loss in children 11
Equivalent Threshold Sound Pressure Levels for Pure Tones and Supra-
Aural Earphones. ISO 389-1 2004. Geneva: International Organization
Standardization.
International Standards Organization. 1998. Acoustics: Reference Zero for
the Calibration of Audiometric Equipment. Part 1, Reference Equivalent
Threshold Sound Pressure Levels for Pure Tones and Supra-Aural
Earphones. ISO 389-1 1998. Geneva: International Organization
Standardization.
Johansen, H. 1948. Relation of audiograms to the impedance formula. Acta
Otolaryngol, 36, 65–75.
Kei, J., Smyth, V., Burge, E., Fernando, S., Fiteni, R., et al. 2003. Measuring
the ability of children to understand everyday speech using com-
puter technology: A normative study. Asia Pac J Speech Lang Hear, 8,
235–242.
Kemaloğlu, Y.K., Şener, T., Beder, L., Bayazit, Y. & Göksu, N. 1999.
Predictive value of acoustic reflectometry (angle and reflectivity) and
tympanometry. Int J Pediatr Otorhinolaryngol, 48, 137–142.
Keogh, T., Kei, J., Driscoll, C. & Khan, A. 2010. Children with minimal
conductive hearing impairment: Speech comprehension in noise. Audiol
Neurootol, 15, 27–35.
Khairi Md Daud, M., Noor, R.M., Rahman, N.A., Sidek, D.S. & Mohamad,
A. 2010. The effect of mild hearing loss on academic performance in
primary school children. Int J Pediatr Otorhinolaryngol, 74, 67–70.
Kokko, E. 1974. Chronic secretory otitis media in children. A clinical study.
Acta Otolaryngol Suppl, 327, 1–44.
Kramer, A.H. & McCullough, D.W. 1998. The prevalence of otitis
media with effusion among Inuit children. Int J Circumpolar Health,
57, 265–267.
Kubba, H., Pearson, J.P. & Birchall, J.P. 2000. The aetiology of otitis media
with effusion: A review. Clin Otolaryngol Allied Sci, 25, 181–194.
Lannon, C., Peterson, L.E. & Goudie, A. 2011. Quality measures for the care
of children with otitis media with effusion. Pediatrics, 127, 1490–1497.
Li, J., Preston, G., Wang, L. & Long, J. 2008. An investigation on the
classroom noise and reverberation time in a rehabilitation center for
hearing-impaired children. Zhong Guo Ting Li Yan Yu Ke Xue Za Zhi,
22–23.
Lieberthal, A.S., Carroll, A.E., Chonmaitree, T., Ganiats, T.G., Hoberman,
A., et al. 2013. The diagnosis and management of acute otitis media.
Pediatrics, 131, e964–e999.
Lieu, J. 2004. Speech-language and educational consequences of unilat-
eral hearing loss in children. Arch Otolaryngol Head Neck Surg, 130,
524–530.
Lous, J., Burton, M.J., Felding, J.U., Ovesen, T., Rovers, M.M., et al. 2005.
Grommets (ventilation tubes) for hearing loss associated with otitis
media with effusion in children. Cochrane Database Syst Rev,
CD001801.
Mandel, E.M., Rockette, H.E., Bluestone, C.D., Paradise, J.L. & Nozza, R.J.
1989. Myringotomy with and without tympanostomy tubes for chronic
otitis media with effusion. Arch Otolaryngol Head Neck Surg, 115,
1217–1224.
Martines, F., Bentivegna, D., Maira, E., Sciacca, V. & Martines, E. 2011.
Risk factors for otitis media with effusion: Case-control study in Sicilian
schoolchildren. Int J Pediatr Otorhinolaryngol, 75, 754–759.
Matkin, N.D. 1988. Re-evaluating our approach to evaluation:
Demographics are changing—are we? In: Bess, F.H. (ed.) Hearing
Impairment in Children. Parkton, MD: York Press, pp. 101–111.
McArdle, R. & Hnath-Chisolm, T. 2015. Speech audiometry. In: Katz, J.
(ed.) Handbook of Clinical Audiology: Seventh Edition. Philadelphia:
Wolters Kluwer Health/Lippincott Williams & Wilkins, pp. 61–75.
Menyuk, P. 1986. Predicting speech and language problems with persistent
otitis media. In: Kavanagh, J.F. (ed.) Otitis Media and Child
Development. Parkton, MD: York Press, pp. 83–96.
Mondelli, M.F., Dos Santos Mde, M. & Jose, M.R. 2016. Speech
perception in noise in unilateral hearing loss. Braz J Otorhinolaryngol,
82, 427–432.
Morris, P.S., Leach, A.J., Silberberg, P., Mellon, G., Wilson, C., et al. 2005.
Otitis media in young Aboriginal children from remote communities in
12 T. Cai & B. McPherson
Northern and Central Australia: A cross-sectional survey. BMC Pediatr,
5, 27.
Mutlu, C., Odabasi, A.O., Metin, K., Basak, S. & Gökhan, E. 1998.
Sensorineural hearing loss associated with otitis media with effusion in
children. Int J Pediatr Otorhinolaryngol, 46, 179–184.
National Collaborating Centre for Women’s and Children’s Health (UK),
2008. Surgical Management of Otitis Media with Effusion in Children.
London: RCOG Press.
Nozza, R.J., Bluestone, C.D., Kardatzke, D. & Bachman, R. 1994.
Identification of middle ear effusion by aural acoustic admittance and
otoscopy. Ear Hear, 15, 310–323.
Olusanya, B.O., Somefun, A.O. & Swanepoel, D.W. 2008. The need for
standardization of methods for worldwide infant hearing screening: A
systematic review. Laryngoscope, 118, 1830–1836.
Ousey, J., Sheppard, S., Twomey, T. & Palmer, A.R. 1989. The IHR-
McCormick automated toy discrimination test—description and initial
evaluation. Br J Audiol, 23, 245–249.
Paradise, J.L. 1987. On classifying otitis media as suppurative or nonsup-
purative, with a suggested clinical schema. J Pediatr, 111, 948–951.
Pearl, G.W. 1968. International standard reference zero for audiometers. J
Acoust Soc Am, 44, 264–275.
Rosenfeld, R.M., Goldsmith, A.J., Tetlus, L. & Balzano, A. 1997. Quality of
life for children with otitis media. Arch Otolaryngol Head Neck Surg,
123, 1049–1054.
Rosenfeld, R.M., Schwartz, S.R., Pynnonen, M.A., Tunkel, D.E., Hussey,
H.M., et al. 2013. Clinical practice guideline: Tympanostomy tubes in
children. Otolaryngol Head Neck Surg, 149, s1–s35.
Rosenfeld, R.M., Shin, J.J., Schwartz, S.R., Coggins, R., Gagnon, L., et al.
2016. Clinical practice guideline: Otitis media with effusion (update).
Otolaryngol Head Neck Surg, 154, s1–s41.
Sabo, D.L., Paradise, J.L., Kurs-Lasky, M. & Smith, C.G. 2003. Hearing levels
in infants and young children in relation to testing technique, age group,
and the presence or absence of middle-ear effusion. Ear Hear, 24, 38–47.
Sadé, J., Fuchs, C., Russo, E. & Cohen, D. 2003. Is secretary otitis media a
single disease entity?. Ann Otol Rhinol Laryngol, 112, 342–347.
Schafer, E. 2010. Speech perception in noise measures for children: A
critical review and case studies. J Educ Audiol, 16, 4–15.
Schlauch, R.S. & Nelson, P. 2015. Puretone evaluation. In: Katz, J. (ed.)
Handbook of Clinical Audiology: Seventh Edition. Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, pp. 29–47.
Silman, S., Silverman, C.A. & Arick, D.S. 1994. Pure-tone assessment and
screening of children with middle-ear effusion. J Am Acad Audiol, 5,
173–182.
Son, D.H., Tri, L., Tien, V.M., Phuong, T. k., Balle, V., et al. 1998. Point
prevalence of secretary otitis media in children in southern Vietnam.
Ann Otol Rhinol Laryngol, 107, 406–410.
View publication stats
Takata, G.S., Chan, L.S., Morphew, T., Mangione-Smith, R., Morton, S.C.,
et al. 2003. Evidence assessment of the accuracy of methods of
diagnosing middle ear effusion in children with otitis media with
effusion. Pediatrics, 112, 1379–1387.
Taylor, P.S., Faeth, I., Marks, M.K., Del Mar, C.B., Skull, S.A., et al. 2009.
Cost of treating otitis media in Australia. Expert Rev Pharmacoecon
Outcomes Res, 9, 133–141.
Tos, M. 1983. Epidemiology and spontaneous improvement of secretory
otitis. Acta Otorhinolaryngol Belg, 37, 31–43.
Velepic, M., Starcevic, R., Bonifacic, M., Ticac, R., Kujundzic, M., et al.
2011. The clinical status of the eardrum: An inclusion criterion for the
treatment of chronic secretory otitis media in children. Int J Pediatr
Otorhinolaryngol, 75, 686–690.
Watters, G.W.R., Jones, J.E. & Freeland, A.P. 1997. The predictive value of
tympanometry in the diagnosis of middle ear effusion. Clin Otolaryngol
Allied Sci, 22, 343–345.
Williams, C.J., Coates, H.L., Pascoe, E.M., Axford, Y. & Nannup, I. 2009.
Middle ear disease in Aboriginal children in Perth: Analysis of hearing
screening data, 1998-2004. Med J Aust, 190, 598–600.
Wilmington, D., Gray, L. & Jahrsdoerfer, R. 1994. Binaural processing after
corrected congenital unilateral conductive hearing loss. Hear Res, 74,
99–114.
Winiger, A.M., Alexander, J.M. & Diefendorf, A.O. 2016. Minimal hearing
loss: From a failure-based approach to evidence-based practice. Am J
Audiol, 25, 232–245.
Yamamah, G., Mabrouk, A., Ghorab, E., Ahmady, M. & Abdulsalam,
H. 2012. Middle ear and hearing disorders of schoolchildren aged
7–10 years in South Sinai, Egypt. East Mediterr Health J, 18,
255–260.
Zhan, W., Cruickshanks, K.J., Klein, B.E.K., Klein, R., Huang, G.H., et al.
2010. Generational differences in the prevalence of hearing impairment
in older adults. Am J Epidemiol, 171, 260–266.
Zhang, Q., Wei, J., Xu, M., Zhang, Q., Zhang, X., et al. 2011. Prevalence of
otitis media with effusion among children in Xi’an, China: A
randomized survey in China’s mainland. Ann Otol Rhinol Laryngol,
120, 617–621.
Zhou, H., Chen, Z.B., Tian, H.Q., Xu, X., Wang, Y.Q., et al. 2012. Effects of
hypoxia-inducible factor 1alpha on bone conduction impairment in otitis
media with effusion. Acta Otolaryngol, 132, 938–943.
Zielhuis, G.A., Rach, G.H., Van Den Bosch, A. & Van Den Broek, P. 1990a.
The prevalence of otitis media with effusion: A critical review of the
literature. Clin Otolaryngol Allied Sci, 15, 283–288.
Zielhuis, G.A., Rach, G.H. & Van Den Broek, P. 1990b. The occurrence of
otitis media with effusion in Dutch pre-school children. Clin
Otolaryngol Allied Sci, 15, 147–153.