International Journal of Audiology

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Applied tele-audiology research in clinical practice

during the past decade: a scoping review

Karen Muñoz , Naveen K. Nagaraj & Natalie Nichols

To cite this article: Karen Muñoz , Naveen K. Nagaraj & Natalie Nichols (2020): Applied tele-
audiology research in clinical practice during the past decade: a scoping review, International
Journal of Audiology, DOI: 10.1080/14992027.2020.1817994

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Published online: 10 Sep 2020.

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INTERNATIONAL JOURNAL OF AUDIOLOGY
https://doi.org/10.1080/14992027.2020.1817994

RESEARCH ARTICLE

Applied tele-audiology research in clinical practice during the past decade:

a scoping review
~oz, Naveen K. Nagaraj and Natalie Nichols
Karen Mun
Communication Disorders & Deaf Education, Utah State University, Logan, UT, USA

ABSTRACT ARTICLE HISTORY

Objective: The purpose of this scoping review was two-fold, (1) to provide information about the charac- Received 11 March 2020
teristics, type of service delivery, participant information and outcomes related to tele-audiology in clinical Revised 13 August 2020
popluations, and (2) to describe documented facilitators and barriers to tele-audiology delivery from the Accepted 28 August 2020
perspectives of practitioners and service recipients. Knowledge of these findings can assist audiologists in
KEYWORDS
considering remote service delivery options for their practices. Telehealth; telemedicine;
Design: A scoping review was conducted in November 2019 to identify English-language peer-reviewed ehealth; audiology; hearing
journal articles published from 1 January 2010 to 30 October 2019 related to remote clinical service deliv-
ery in audiology.
Results: Thirty-six published research articles were included. Research studies were classified into four
broad areas with some articles including more than one area within the scope of their article: Screening
(n ¼ 5), Diagnostic (n ¼ 5), Intervention (n ¼ 18), and Perspectives (n ¼ 22).
Conclusion: Hearing healthcare service delivery is expanding with the changing technological landscape,
providing greater opportunities and flexibility for audiologists and patients. There are clear opportunities
for interdisciplinary collaboration and for collaboration with on-site local facilitators. Local facilitators, with
training, can assist in connecting individuals to follow-up care, provide educational support, and needed
hands-on assistance for specialised testing.

The World Health Organisation (WHO) estimates that one in
ten, approximately 466 million people, experience the consequen-
ces of disabling hearing loss and that the number is expected to
increase to 900 million by the year 2050 (WHO 2019).
Furthermore, WHO estimates significant costs to society when
hearing loss is unaddressed, with annual global costs as much as
US$750 billion. Many in need of services face barriers accessing
hearing care. Tele-audiology opportunities continue to expand
with advances in technology and global connectivity through the
internet. Audiologists have an opportunity to embrace the flexi-
bility that remote service delivery offers to improve service acces-
sibility and further individualise services for patients and
their families.
Traditional in-person appointments with health-care pro-
viders can represent an array of barriers to patients, limiting
their ability to obtain needed hearing care and engage in ongoing
care. For example, a lack of providers was found as a barrier for
adults with hearing loss living in rural areas in the US state of
Kentucky (Powell et al. 2019). Similarly, a scoping review found
that children with hearing loss living in rural areas of the US
and Canada experienced barriers accessing specialised services
compared to peers in urban areas (Barr, Dally, and Duncan
2019). It is also likely that individual factors play a role even for
patients living in urban areas, such as accessing transportation,
mobility challenges, and poor health, making travel to a facility
for services difficult (e.g. Coco, Champlin, and Eikelboom 2016).
Furthermore, recent developments with the 2020 COVID-19
pandemic and need for physical distancing also support the
importance of remote service options. By strategically consider-
ing inclusion of delivering services remotely, audiologists can
increase patient access to care and support patients in effectively
managing their daily hearing needs, ultimately increasing patient
engagement and satisfaction.
Scoping reviews can assist audiologists in understanding the
extent of tele-audiology, additional research needs, and services
they can consider embracing to meet the needs of patients within
their practice, as well as reaching those who currently are not
able to access services. An earlier literature review of tele-audi-
ology applications found 26 peer-reviewed articles addressing
screening, diagnosis, intervention and patient perceptions, pub-
lished up to May 2009 (Swanepoel and Hall 2010). The authors
concluded that while the studies spanned various service types,
there were limited peer-reviewed empirical studies and further
research was needed; for example, no reports addressed perspec-
tives of audiologists related to remote service provision.
Given mounting interest in tele-audiology solutions for access to
care problems, subsequent literature reviews have investigated
rehabilitation applications for adults with hearing aids (Tao et al.
2018), the adult hearing aid journey (Paglialonga et al. 2018), and
audiologists’ perceptions of tele-audiology (Ravi et al. 2018). These
reviews clearly support the growth in attention that tele-audiology
has received in recent years. The landscape continues to change for
remote hearing care delivery. Therefore, the purpose of this scoping
review was two-fold: (1) to provide information about the

CONTACT Karen Mun ~oz karen.munoz@usu.edu Department of Communicative Disorders and Deaf Education, Utah State University, 1000 Old Main Hill,
Logan, UT 84322, USA
Supplemental data for this article is available online at publisher’s website
ß 2020 British Society of Audiology, International Society of Audiology, and Nordic Audiological Society
2 K. N. K. NAGARAJ AND N. NICHOLS

characteristics, type of service delivery, participant information and
outcomes related to tele-audiology in clinical popluations, and (2)
to describe documented facilitators and barriers to tele-audiology
delivery from the perspectives of practitioners and service recipients.
Method
Procedure
A scoping literature review was completed in November 2019
(Tricco et al. 2018). Scoping reviews follow a systematic process
to examine a broad area and can be used to identify main con-
cepts and gaps in research. The purpose of a scoping review is to
identify what kind of evidence is available, not necessarily to
provide a critical appraisal of the evidence. The Joanna Briggs
Institute (Aromataris and Munn 2015) provides a detailed
description of the purpose and process for conducting scop-
ing reviews.
For inclusion in the review, the articles needed to address (1)
audiological services delivered using tele-audiology to a clinical
population (e.g. those with hearing loss) or to individuals sus-
pected or at risk of hearing loss, or (2) clinician, patient, and/or
facilitator perspectives on tele-audiology. Peer-reviewed journal
articles were included if they were in English and published
between 1 January 2010 and 30 October 2019. Research articles
were excluded if a clinical population was not used (e.g. lab
Idenficaon
simulation, associated factors) or if an audiologist was not dir-
ectly involved in the tele-audiology delivery.
To identify potentially relevant articles, four databases were
searched (MEDLINE, CINHAL Complete, PsycINFO via
EBSCOhost, Scopus) using the following key words (telemedicine
or telerehabilitation or telehealth or telepractice or teleinterven-
tion or teleaudiology or ehealth) and (audiology or hearing). For
the search in Scopus, mhealth (mobile health) was included as
an additional key word; it was not used in the other dabase
searches after initial testing with the term did not identify rele-
vant studies.
The database search was performed by two authors (KM;
NN). The two reviewers jointly developed a data charting form
prior to completing the search, and calibrated the search by
working together before continuing the search independently.
First, article titles and abstracts were reviewed independently and
then the reviewers came together to discuss and resolve any dis-
crepancies in selected articles, updating the charting form in an
iterative process. Second, a full text review was completed (NN)
followed by discussion to finalise article selection. Finally, refer-
ence lists of included articles were reviewed (NN) to identify fur-
ther articles for consideration. See Figure 1 for article
inclusion flowchart.
Included articles were analysed to identify characteristics (i.e.
publication year, country of origin), type of service delivery (e.g.
diagnosis, intervention), participant information, and outcomes.
We aimed to describe the characteristics of clinically-focussed

Records idenfied through Addional records idenfied

database searching through other sources
(n = 740) (n = 43)

Records aer duplicates removed

(n = 684)
Screening

Records screened Records excluded aer tle

(n = 684) and abstract review
(n = 563)

Full-text arcles assessed Full-text arcles excluded

for eligibility (n = 85)
Eligibility

(n = 121) • Lab Seng (n=31)

• Lack of audiologist
parcipaon (n=23)
• No actual service
Studies included in delivery (n=29)
qualitave synthesis • Not a peer reviewed
(n = 36) arcle (n=1)
• Results not reported
(n=1)
Included

Figure 1. Article Inclusion Flowchart.


Table 1. Summary of included research articles by category.
Categories No. of studies Populations
Screening 5 Infants, children, and adults
Diagnosis 5 Infants and adults
Intervention 18 Children and adults
Perceptions 22 Audiologists, support personnel,
parents, adult patients
OAE: otoacoustic emissions; ABR: auditory brainstem response; CI: cochlear implant; HA: hearing aid. Note. Total number is higher for stud-
ies than for articles as some articles included more than one aspect of connected health.
tele-audiology research and narratively synthesise the outcomes,
to provide an overview of current research.
Results
This scoping review identified 36 tele-audiology articles pub-
lished from 1 January 2010 to October 2019 conducted with clin-
ical populations or to screen those at risk for hearing loss.
Research studies were conducted in four broad areas of service
delivery in audiology (see Table 1), with some articles including
more than one area within the scope of their article: Screening
(n ¼ 5), Diagnostic (n ¼ 5), Intervention (n ¼ 18), and
Perceptions (n ¼ 22). The study components included in each
category are discussed below and a summary table of the articles
is available (see Supplemental Information, Appendix A).
Screening studies
Our scoping review identified five tele-audiology community-
based hearing screening studies in children and infants (Ciccia
et al. 2011; Monica et al. 2017; Govender and Mars 2018;
Eksteen et al. 2019; Ameyaw, Anim-Sampong, and Ribera 2019).
These studies described results of audiologists along with trained
facilitators at remote sites that provided hearing screening serv-
ices for infants and children.
Eksteen et al. (2019) reported that use of minimally trained
community care workers (CCW) to screen for both hearing and
vision was affordable (estimated cost $5.63 USD per child) and
provided a scalable service delivery model. Monica et al. (2017)
assessed the feasibility of synchronous remote tele-hearing
screening using audiometry and distortion product otoacoustic
emissions (DPOAE) on a small group of school children (n ¼ 31)
in India. They reported that using tele-screening was feasible
with the help of teachers as facilitators and results were compar-
able to in-person screening. The authors noted some of the tech-
nical challenges in implementing tele-screening which were
related to slow internet bandwidth in remote villages and the
high noise levels in schools. In a similarly motivated study,
Govender and Mars (2018) evaluated the efficacy of asynchron-
ous screening and diagnostic hearing tests using automated audi-
ometry (KUDUwave 5000) in South Africa. KUDUwave 5000
(eMoyoDotNet, Johannesburg, South Africa) has built-in tech-
nology to attenuate ambient noise and monitor noise levels dur-
ing testing, which is reported to significantly improve the
reliability of screening results. Their findings based on testing 73
children (6–12 years) suggested a concerning level of false nega-
tives (i.e. low sensitivity of automated screening test results).
Low sensitivity of the screening test (65%) was attributed poten-
tially to test accuracy, possibly related to inadequate probe tip
insertion, and low frequency hearing loss.
INTERNATIONAL JOURNAL OF AUDIOLOGY 3
Test procedures
Audiometry; OAE; Tympanometry
ABR, video-otoscopy,
tympanometry, audiometry
CI mapping, tinnitus management,
education, counselling, HA
programming, Digits in Noise
N/A
In Ghana, Ameyaw, Anim-Sampong, and Ribera (2019)
explored the feasibility of remote DPOAE screening to expand
newborn hearing screening access. Fifty infants were enrolled,
and their hearing was screened onsite in addition to using
remotely controlled DPOAE system over the internet by an audi-
ologist. Specialised software (Team Viewer 8.0) provided real-
time video, audio, and text communication between the audiolo-
gist and the test site facilitator. Results showed that remote
screening was as effective as the onsite screening and can be an
efficient way of providing hearing screening services to remote
patients in the Greater Accra Region. To improve screening
access to children in an urban area of the United States, Ciccia
and colleagues (2011) explored remote synchronous screening
for speech, language, and hearing. They screened 411 children
up to 6 years of age, and during the 2 years of the study the reli-
ability of pure-tone screening and DPOAE screening were 100%,
they had around 84% reliability for tympanometry results done
remotely compared to in-person.
Diagnostic testing
Five studies were identified that evaluated remote diagnostic test-
ing procedures (Hayes et al. 2012; Dharmar et al. 2016;
Ramkumar, Rajendran, et al. 2018; Ramkumar et al. 2019;
Hatton et al. 2019). Three of the studies assessed the feasibility
of remote testing to reduce loss to follow-up from newborn hear-
ing screening (Hayes et al. 2012; Dharmar et al. 2016; Hatton
et al. 2019). Findings from these remote testing studies provide
strong clinical evidence that tele-audiology diagnostic hearing
services can be successfully implemented for infant hearing test-
ing. In addition, results also suggest that remote diagnostic test-
ing reduces costs and also reduces loss to follow-up of infants
due to easy access to hearing health care for patients who live in
remote areas.
The Children’s Hospital at Colorado and the University of
Guam successfully conducted a pilot study with nine infants and
demonstrated the advantages of tele-audiology diagnostic testing
(Hayes et al. 2012). An experienced audiologist from the
Children’s Hospital remotely operated the diagnostic equipment
in Guam and performed hearing testing with a trained facilitator
to set up the equipment. The audiologist conducted auditory
evoked potential and OAE testing and also provided counselling
and feedback to families. Two infants were identified with hear-
ing loss and were referred to a primary health care provider.
Dharmar et al. (2016) evaluated the California tele-audiology
program, which provides a remote tele-audiology diagnostic
audiological evaluation for children who do not pass their new-
born hearing screening. Twenty-two infants who underwent a
comprehensive tele-audiology test battery, including case history,
video otoscopy, immittance, DPOAE and ABR testing. A paedi-
atric audiologist remotely conducted all the testing with the aid
4 K. N. K. NAGARAJ AND N. NICHOLS
of a facilitator who prepared the infant’s skin, placed electrodes,
tympanometry probe and also positioned the otoscope. The team
successfully evaluated all the infants and identified 13 children
with hearing loss and 60% of those children were identified
within the first tele-audiology visit.
In a large-scale study of 102 infants who failed their newborn
hearing screening and/or had risk factors for hearing loss, the
British Columbia Early Hearing Program (BCEHP) conducted a
tele-audiology diagnostic test battery with the help of trained
audiometric technicians located at the patient site (Hatton et al.
2019). Overall, the authors found that the tele-audiology diag-
nostic testing substantially reduced costs for British Columbia’s
EHDI program, averting $91,250 in travel cost for 102 infants.
In addition, the efficiency for tele-audiology was comparable to
in-person testing. Twenty children were identified with perman-
ent hearing loss. Some limitations highlighted in these studies
are related to lack of common policies and underdeveloped sup-
port infrastructure (e.g. lack of common approach to incident
management, and lack of reliable access to IT support and
resources) across health facilities. Ramkumar and colleagues
(2018) explored remote diagnostic testing for children and adults
with cleft lip/palate (n ¼ 160). They identified 22 ears with hear-
ing loss, and the individuals received the diagnosis and recom-
mendations via tele-conference. More coverage for people in
need of services was achieved with this approach and internet
connectivity was a barrier for only a few. Ramkumar and col-
leagues (2019) included diagnostic testing for children 0–5 years
that failed the remote hearing screening by village health work-
ers. They found that having access to remote ABR testing
improved the follow-up rate after a failed screening.
Intervention
There were 18 studies in the intervention category that addressed
hearing aid adjustments, cochlear implant testing, tinnitus man-
agement, and rehabilitation. There were two hearing aid studies
(Novak et al. 2016; Pross, Bourne, and Cheung 2016); six coch-
lear implant studies (Rodrıguez et al. 2010; McElveen et al. 2010;
Wasowski et al. 2012; Hughes et al. 2012; Cullington and
Agyemang-Prempeh 2017; Slager et al. 2019), four tinnitus stud-
ies (Henry et al. 2012; Beukes et al. 2017; Beukes et al. 2018;
Henry et al. 2019), and six rehabilitation studies (Thoren et al.
2011; Thoren et al. 2014; Abrams, Bock, and Irey 2015;
Br€annstr€
om et al. 2016; Mu~ noz et al. 2017; Gomez and
Ferguson 2020).
The two hearing aid studies were based on large number of
adults (total of 1190 patients) suggest that quality HA fitting
including probe-mic verification and adjustment services can be
provided remotely using facilitators such as nurses or trained
audiology technicians. The five CI mapping studies were mainly
for adults and older children, and found remote CI mapping to
be feasible and provide identical outcomes to in-person mapping
visits. Researchers also highlight that it is important to have
alternative communication strategies (video communication for
speech reading and sign language or text messaging) during
remote mapping sessions. The four tinnitus studies, including
two RCT studies, provide strong evidence for tele-intervention
options for adult patients with tinnitus. Moreover, all studies
clearly support an increased quality of life and reduced tinnitus
distress following tele-tinnitus services. However, it is possible
that online administration of the survey in studies might have
excluded some of the participants.
Hearing aid adjustments
Novak and colleagues (2016) implemented an interprofessional
education project using faculty and students in the nursing and
Doctor of Audiology programs to provide hearing aid service
using a tele-audiology approach. Using remote desktop access
and video conferencing, nursing faculty and students facilitated
hearing aid (HA) fitting performed remotely by the audiology
faculty and students at the remote site. A total of 205 individuals
were referred to the tele-audiology clinic and 181 patients were
successfully fitted with hearing aids that included probe micro-
phone measures, with nursing conducting probe placement and
providing patient education components. The majority of the
patients reported significant improvement in their communica-
tion and quality of life following hearing aid use.
In a population-based study at the Veterans Health
Administration, Pross, Bourne, and Cheung (2016) assessed the
effectiveness of tele-audiology for hearing aid services. Among
42,697 veterans who received hearing aids and completed hear-
ing outcome measures 1,009 received remote services and 41,688
received conventional in-person care. Tele-audiology HA fitting
and follow-up services included real-time video conferencing
between an audiologist and patient which was facilitated by an
audiology technician. The audiologist conducted the hearing
evaluation, probe mic measurement, HA fitting and adjustment.
The authors reported that the tele-audiology model provided
cost effective services with HA satisfaction comparable to an in-
person service delivery model.
Cochlear implant programing
Two studies, one retrospective (McElveen et al. 2010) and one
prospective (Rodrıguez et al. 2010) demonstrated the feasibility
of remote CI mapping on a small group of adult patients.
Rodrıguez and colleagues used a program to remotely control
the CI mapping system and sucessfully performed 1, 3, 6 and
12 months post-implantation mapping for 7 CI patients. A separ-
ate audio-video linkage program was used to facilitate communi-
cation between the patient and the audiologist. Both studies
reported that tele-audiology is a viable cost-effective option that
can be successfully implemented for CI mapping. More import-
antly, results from both studies confirmed that the post CI map-
ping outcome (audiological measure) of cHealth and in-clinic
patients were comparable.
In a similar study conducted using 23 adults and 6 children,
Hughes et al. (2012) showed that CI mapping and audiological
measures can be obtained using a tele-audiology platform with a
minimally trained assistant without specialised knowledge of
audiology and/or CI; however, speech perception measures were
poorer in the remote condition as they were not done in a sound
booth. One main limitation noted by the authors was related to
communication with patients when the CI was connected to the
programming interface which makes the CI microphone inactive.
They recommended using sign-language or speech reading to
communicate in those situations.
A large-scale nationwide study (Wasowski et al. 2012) that
included 94 adult CI patients in 8 centres in Poland investigated
remote CI mapping using a facilitator. The authors reported that
remote mapping improved post-operative care. In another multi-
site tele-audiology, Slager and colleagues (2019) evaluated 40 CI
subjects (12 years and older) and found tele-audiology mapping
to be safe and that it provided similar outcomes in patients’
speech perception ability compared to in-person mapping.

Tinnitus management
Four studies evaluated the effectiveness of remote services for
tinnitus management using educational resources and counsel-
ling to help manage tinnitus distress. Henry et al. (2012) assessed
the feasibility of providing remote tinnitus management for 36
patients with traumatic brain injury. Patients were provided 6
sessions of telephone-based counselling to facilitate therapeutic
use of sound and cognitive behaviour training by an audiologist
and a psychologist. Results based on the pre- and post- Tinnitus
Handicap Inventory outcomes showed positive benefits. In a
recent randomised control trial (RCT), Henry et al. (2019) repli-
cated their 2012 study on a large group of patients (n ¼ 205)
with special emphasis on patients with traumatic brain injury
(TBI). They randomised patients into 6-month remote tele-pro-
gressive tinnitus management intervention group or wait list
control. Tele-progressive tinnitus management program, involved
two telephone appointments with an audiologist who taught how
to use the therapeutic sounds and three telephone appointments
with a psychologist who taught tinnitus coping skills based on
cognitive-behavioural therapy (CBT). Results strongly supported
the use of tele-progressive tinnitus management services to
patients with bothersome tinnitus.
Two similar studies (Beukes et al. 2017; Beukes et al. 2018)
were conducted to explore a remote tinnitus treatment. In their
2017 study, Beukes and colleagues demonstrated the feasibility
and cost-effectiveness of remote delivery using a single group
study design with 37 adults with tinnitus. Participants reported
significant improvements in their quality of life following an 8-
week intervention that included continuously guided CBT with
audiologist support. Beukes et al. (2018) then conducted an effi-
cacy study with 73 experimental and 73 control group partici-
pants. Results showed a significant reduction in tinnitus distress
and increased quality of life effect for individuals in the interven-
tion group. The investigators documented a moderate effect size
(Cohen’s d ¼ 0.7) for the remote CBT intervention results.
Rehabilitation
Thoren et al. (2011, 2014) evaluated the benefit of tele-audiology
rehabilitative intervention for adult hearing aid users. In 2011,
Thoren and colleagues compared outcomes of online peer-group
discussion, rehabilitative education, and interaction with an audi-
ologist to an active control group. Results indicated positive
gains in both groups. Authors developed an intervention that
incorporated aspects of both the control and intervention condi-
tions to foster positive behavioural changes in hearing aid users
and in their 2014 study, the authors determined the 5-week
intervention improved patient outcomes compared to the control
group. Recently, Gomez and Ferguson (2020) conducted a rand-
omised intervention trial to study the effectiveness of publicly
funded multimedia educational program (C2hearonline.com) for
first-time hearing aid users. Significant improvement for the
intervention group (n ¼ 24) in self-efficacy and knowledge of
hearing aids was observed compared to a control group (n ¼ 23).
Abrams, Bock, and Irey (2015) examined the effectiveness of a
computer-based auditory training program in improving first
time hearing users’ speech perception in noise ability. Results
based on comparing scores of clinical speech-in-noise test scores
indicated that there were no significant differences between the
intervention and control groups.
Finally, one study documented the benefit of virtual visits by
an audiologist to monitor children’s hearing aid use with
INTERNATIONAL JOURNAL OF AUDIOLOGY 5
datalogging and to help parents manage their child’s hearing aids
(Mu~ noz et al. 2017). Result based on 6 months of longitudinal
data collected on four families showed that the average hearing
aid wear time increased from 7 to 10.5 h by the end of the study.
Another study explored use of an Internet-based support system
for 23 adult hearing aid users to improve self-efficacy and conse-
quences of hearing loss (Br€annstr€ om et al. 2016). The authors
found significant improvement in perceived consequences but no
differences for self-efficacy.
Perspective studies
Perspectives of providers, adult patients, parents of paediatric
patients, and test facilitators related to tele-audiology services
were explored in 22 studies. Two studies sought perspectives
related to screening (Ciccia et al. 2011; van Wyk et al. 2019),
four related to diagnostics (Hayes et al. 2012; Dharmar et al.
2016; Ramkumar et al. 2016; Hatton et al. 2019), six related to
cochlear implants (Rodrıguez et al. 2010; Wasowski et al. 2012;
Hughes et al. 2012; Kuzovkov et al. 2014; Cullington and
Agyemang-Prempeh 2017; Slager et al. 2019), four related to
hearing aids (Penteado et al. 2014; Novak et al. 2016; Mu~ noz
et al. 2017; Thrum, Driscoll, and Keogh 2018), and three related
to rehabilitation (Br€annstr€om et al., 2016; Beukes et al. 2017;
Thrum, Driscoll, and Keogh 2018). Three studies sought perspec-
tives of audiologists broadly related to tele-audiology services
(Singh et al. 2014; Eikelboom and Swanepoel 2016; Rashid
et al. 2019).
Parents of children who underwent tele-audiology screening
or diagnostic services expressed a positive experience and advan-
tages of remote testing, especially easy and early access to testing.
Patient who participated in remote CI reported an overall posi-
tive experience with a high level of satisfaction with the service.
However, participants in two studies also reported that they
would prefer in-person appointments over remote programming.
Patient perspectives for remote hearing aid programming and
adjustment revealed that patients were overall satisfied. Studies
related to audiologists’ perspectives towards tele-audiology serv-
ices found that most audiologists had positive attitudes towards
tele-practice. However, not all audiologists are currently provid-
ing tele-audiology services.
Screening perspectives
van Wyk et al. (2019) evaluated the knowledge and experience of
CCWs (n ¼ 15) who performed the hearing screening. Overall
CCWs reported a positive experience with community tele-audi-
ology service. The majority of the workers agreed that it was
easy to perform hearing screening on adults and children using
the mobile technology. Perspectives of parents of children under
six years (n ¼ 411; Ciccia et al. 2011) were similarly positive.
Parents indicated that they were satisfied and would seek remote
screening in the future for their children if it is available.
Diagnostic perspectives
Parent satisfaction following tele-audiology ABR diagnostic test-
ing was high (Hayes et al. 2012; Dharmar et al. 2016; Ramkumar
et al. 2016; Hatton et al. 2019) and the majority of the caregivers
thought that they could access service providers sooner with tele-
audiology (Hatton et al. 2019). Dharmar and colleagues (2016)
reported that almost all parents were engaged and comfortable
6 K. N. K. NAGARAJ AND N. NICHOLS
talking about the testing through teleconferencing and providers
also reported positive perceptions with the experience. For both
parents and providers, however, the response rate was low, 50%
and 54% respectively, limiting understanding of the experience
for both groups.
Intervention perspectives
Perspectives about remote cochlear implant mapping were posi-
tive overall. Wasowski and colleagues (2012) found high patient
satisfaction and the overwhelming majority of patients reported
that tele-audiology is a good alternative for in-person follow up
(86 patients) and that they are willing to use remote mapping in
the future (88 patients); however, only 33 patients agreed that
tele-audiology is a good alternative for first time CI mapping.
Kuzovkov and colleagues (2014) sought perspectives of patients,
facilitators and audiologists from 33 remote programming ses-
sions in Italy, Sweden and Russia from 26 CI patients. The
authors obtained a positive response for all aspects of CI map-
ping. Rodrıguez and colleagues (2010) obtained positive
responses from patients and providers regarding remote map-
ping. Furthermore, Slager and colleagues (2019) found that
patients reported a high level of satisfaction with remote pro-
gramming of their CI devices and 80% (n ¼ 39) of them also
reported that they would recommend remote CI mapping. In the
Cullington and Agyemang-Prempeh (2017) study, most patients
felt that the remote services were convenient and cost effective;
however, 9 out of 17 patients reported that their hearing could
be better assessed in the clinic and that it was easier to discuss
their difficulties during a clinical visit in person. Similarly, par-
ticipants in the Hughes et al. (2012) reported that while they
would use remote CI services again, they felt they were poorer
than in person appointments.
Perspectives related to remote hearing aid services were also
positive. Angley, Schnittker, and Tharpe (2017) evaluated per-
ceived benefit of providing tele-audiology HA follow-up appoint-
ments with 50 adult HA users. Participants were provided with
proprietary distance support hardware and software for remote
visits. Results revealed that 80% of distance support appoint-
ments were perceived to be as effective as in-person appoint-
ments. Overall participants had a positive reaction to remote
care, and their satisfaction was greatly increased with the use of
a web camera during the in-house appointment. A high-level of
patient satisfaction was reported in other studies that employed
remote hearing aid fitting, adjustment, and support (Penteado
et al. 2014; Novak et al. 2016; Mu~ noz et al. 2017).
Similarly, perceptions were positive for studies related to
rehabilitation. Br€annstr€
om et al. (2016) evaluated audiologists’
and patients’ perception towards tele-audiology internet support
for first time hearing aid users to understand the quality of con-
tent, ease of navigation and benefit from the program. Patients
in general expressed satisfaction and a positive view towards the
support system. Some patients felt that navigating the support
system required an advanced level of technological experience.
Audiologists however reported that the support system did not
address all their patients’ needs. Beukes et al. (2017) assessed
patient satisfaction following tinnitus intervention and found
that overall rating was high with a mean rating of 4.29 on a 5-
point Likert scale. Both patients and audiologists reported high
levels of satisfaction with a remote rehabilitation study in
Australia (Thrum, Driscoll, and Keogh 2018).
Audiologist perspectives broadly
Three studies surveyed audiologists about their perspectives
towards tele-audiology services (Singh et al. 2014; Eikelboom and
Swanepoel 2016; Rashid et al. 2019). Singh and colleagues (2014)
surveyed 152 audiologists and 49 hearing instrument specialists
in Canada using an attitude towards tele-audiology scale for
practitioners. Most thought tele-audiology would have a minimal
effect on quality and on client-practitioner interactions and a
positive effect on accessibility; however, some thought it would
have a negative impact on quality. Respondents’ willingness to
use remote service delivery was based on type of service, express-
ing more positive reactions to services that do not require a need
to touch the patient (e.g. counselling, minor adjustments).
Based on an online survey, Eikelboom and Swanepoel (2016)
found that overall audiologists (n ¼ 269) had positive attitudes
towards using tele-audiology to deliver services. However, less
than one-quarter of audiologists who responded to the survey
reported having used tele-audiology services. A recent survey of
audiologists (n ¼ 43) in Malaysia (Rashid et al. 2019) found that
about 50% felt that tele-audiology could have an overall positive
effect on quality of care, accessibility and their clinical practice.
Results also indicated a greater willingness of audiologists to
implement tele-audiology if it would improve quality of care, not
just accessibility.
Discussion
Access to hearing-health care continues to be a global challenge
for large populations that live in remote locations, are not in
good health to travel, or those with other factors that interfere
with their ability to travel to receive in-person services. With
availability of affordable broadband internet, computers, and
mobile phones with built in communication accessories (such as
a webcam and microphone), tele-audiology is not only feasible,
but is becoming more common across the globe. The purpose of
this literature review was to (1) to provide information about the
characteristics, type of service delivery, participant information
and outcomes related to tele-audiology in clinical popluations,
and (2) to describe documented facilitators and barriers to tele-
audiology delivery from the perspectives of practitioners and ser-
vice recipients. This information can assist hearing care profes-
sionals in considering opportunities to expand tele-audiology
services within their practice.
Based on our review, several research groups have successfully
implemented tele-audiology screening using community health
workers in remote places that have limited healthcare resources.
The key advantage of any community- based health-care pro-
gram that utilises locally existing resources is the sustainability
and cost effectiveness of the program. Minimally trained health
workers and school teachers can be employed to successfully
screen large populations of adults and school children using
smart-phone based hearing screeners. Screening devices with
built-in quality control measures such as monitoring ambient
noise levels and detecting false alarm rates have shown to
improve the sensitivity of screening results. Community health
workers can also be trained to perform OAE screening for
infants and assist in preparing babies for cHealth ABR testing
(Ramkumar et al. 2019). Global implementation of tele-audiology
community screening programs are crucial for early identifica-
tion and management of hearing disorders, particularly for those
living in remote rural and underserved areas.

No recent studies were identified in our review on tele-audi-
ology diagnostic hearing assessment for older children and
adults. Studies on clinical populations are clearly warranted
before recommending tele-audiology diagnostic hearing threshold
estimation without audiometric sound treated rooms. However,
several included studies have successfully implemented cHearing
diagnostic evaluation for infants to address the loss to follow-up
after a failed newborn hearing screening. CDC (2017) summary
of Early Hearing Detection and Intervention (EHDI) hearing
screening and follow-up survey data suggest that 34.8% of infants
(n ¼ 21,872) who did not pass hearing screening in the United
States did not have a diagnostic evaluation documented with
their state EHDI program. Remote infant diagnostic testing is an
opportunity to reach more children within the timeframe bench-
marks described in the Joint Committee on Infant Hearing
Position Statement (JCIH 2020). The feasibility study by
Canada’s British Columbia Early Hearing Program can serve as a
model for implementing tele-audiology diagnostic services for
infants (Hatton et al. 2019). Recent advances in automated CE-
Chirp ABR/ASSR show promise in providing objective interpret-
ation of results to obtain faster and accurate estimates of hearing
threshold in infants (Sininger et al. 2018), and are an area in
need of further research for tele-audiology opportunities, includ-
ing comparing traditional click and toneburst ABR with novel
stimuli (e.g. chirp).
An area in rehabilitative audiology with significant potential
for tele-audiology is remote fitting and programming of hearing
aids and cochlear implants. Remote hearing aid adjustment has
been increasingly popular with major HA manufacturers who
have a built-in capability for tele-audiology within their fitting
software to remotely adjust hearing aid settings. Several clinical
validation studies related to this topic were included in this sys-
tematic review. Large-scale validation studies found that tele-
audiology aid fitting and follow-up services were as effective as
in-person appointments (Pross, Bourne, and Cheung 2016;
Novak et al. 2016). After initial CI mapping or HA verification
appointment with an audiologist, much of the fine-tuning and
programming of these devices can be done remotely with the aid
of a smartphone/computer. Remote programming of the Nucleus
cochlear implant is currently approved by the FDA in the
United Stated for patients 12 years or older. Based on current
research evidence, remote mapping of CI and programming of
HAs can be a safe and efficient option for adult patients. The
number of tele-audiology HA and CI programing studies that
have included children under the age of 18 years are limited and
further research is needed before considering remote paediatric
applications for tele-audiology.
Tinnitus is the most common service-related disability in the
United States veterans and the incidence of tinnitus associated
with mild TBI is up to 75.7% (Oleksiak et al. 2012). Tinnitus is
not only widespread in veterans, but also in the general public.
Randomised control studies focussed on tinnitus intervention
strongly support the use of tele-audiology intervention. tele-audi-
ology guided cognitive behaviour therapy (CBT)/progressive tin-
nitus management (PTM) was found to be an easily accessible
and clinically effective tinnitus intervention for large number of
adults suffering from tinnitus. cHealth CBT intervention has
been incorporated by psychologists in regular clinics in Sweden
for quite some time now (Kaldo et al. 2013). Recent studies in
this review; however, demonstrated feasible and effective collab-
oration opportunities for audiologists and psychologists in pro-
viding comprehensive tinnitus management.
INTERNATIONAL JOURNAL OF AUDIOLOGY 7
Aural rehabilitation to individuals with hearing loss and
assistance to parents of children who are deaf or hard of hearing
(DHH) is another area where tele-audiology services can play a
significant role in improving the quality of life for individuals.
Many older hearing-aid users need training and counselling to
maximise the benefits from hearing devices. Tele-audiology
rehabilitative studies designed for hearing aid users have consist-
ently shown positive consequences, including improved hearing
aid satisfaction and improved quality of life for patients (e.g.
Gomez and Ferguson 2020; Thoren et al. 2014). Clinicians
implementing remote rehabilitation services may consider
including the following elements; (a) providing engaging educa-
tion materials related to hearing loss and self-management of
hearing aids/assistive listening devices, (b) strategies to help
adjust to new hearing-aids and (c) online support groups for first
time hearing aid users. Even though most studies included in
our review were focussed on adult hearing-aid users, similar tele-
audiology services can be easily adopted to benefit CI users, and
parents of children who are DHH. One study showed that using
a virtual audiologist significantly improved the hearing aid wear
time with children (Mu~ noz et al. 2017).
Further research is needed to investigate the benefits of indi-
vidual elements of tele-audiology rehabilitative services, especially
in the paediatric population. Furthermore, there is increasing
evidence showing the link between hearing loss and cognitive
decline in older adults (e.g. Lin et al. 2013), underscoring the
importance of implementing accessible rehabilitation options for
this population. Additionally, studies are needed that evaluate
the benefits of tele-audiology audiological rehabilitation services
on addressing the social and psychological consequences of hear-
ing loss.
A limitation to the expansion and widespread use of tele-
audiology services, at least in the United States, has been reim-
bursement for services as most insurance agencies and Medicare/
Medicaid have not considered Audiologists as eligible providers
of tele-audiology services (American Speech-Language-Hearing
Association 2020). Furthermore, the lack of reciprocity between
states for licensure makes it difficult to provide tele-audiology
services to patients who live in other states without dual licen-
sure. Rapid changes in healthcare accessibility and increased
demands for tele-audiology services require changes in current
policies and procedures at state and federal levels. With the cur-
rent COVID-19 emergency, policies that impact tele-audiology
are rapidly evolving along with innovative telepractice solutions
for providing hearing health care for vulnerable populations. For
example, in the United States health plans such as Medicare and
Medicaid services have significantly broadened their coverage for
telepractice services including reimbursement (Center for
Medicare and Medicaid Services 2020, Centers for Disease
Control and Prevention 2020). Similarly, the Australian govern-
ment has added teleaudiology services to their Medicare system
to provide person centred care (Audiology Australia 2020).
Widespread adoption of teleaudiology services due to COVID-19
has provided hearing health care professionals with an opportun-
ity to reimagine service delivery models to incorporate synchron-
ous and asynchronous hearing services.
Conclusion
Hearing healthcare service delivery is expanding with the chang-
ing technological landscape, providing greater opportunities and
flexibility for providers and patients. Remote service delivery can
increase access to lifechanging services for individuals living in
8 K. N. K. NAGARAJ AND N. NICHOLS
underserved areas and those who experience other barriers to
attending clinic appointments. Opportunities for interdisciplinary
collaboration abound, improving continuity of care, as demon-
strated in recent tinnitus studies. Additionally, there are opportu-
nities for collaboration with on-site local facilitators. Local
facilitators, with training, can assist in connecting individuals to
follow-up care, provide educational support, and needed hands-
on assistance for specialised testing.
Disclosure statement
No potential conflict of interest was reported by the author(s).
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