Hearing Screening Training Manual - Minnesota Department of Health

Hearing Screening
Training Manual
Hearing Screening Procedures:
Infants to 3 years
Age 3 years through 20 years
Community and Family Health Division
Guidelines 1996, reprinted August, 2010

For more information, contact:
Minnesota Department of Health
Maternal Child Health Section
Child and Adolescent Health Unit
85 East Seventh Place, Suite 220
St. Paul, MN 55164-0882
Phone (651) 201-3760
Fax: (651) 201-3590
http://www.health.state.mn.us/divs/fh/mch/ctc/
The materials in this publication are also available on the MDH website:
www.health.state.mn.us/divs/fh/mch/hlth-vis/materials.html
Online Hearing Screening Training:
www.health.state.mn.us/divs/fh/mch/webcourse/hearing/index.cfm
Printed on paper that contains a minimum of 10 percent post consumer waste.
Please recycle. Upon request, this publication can be made available in
alternative formats such as large prints, Braille or cassette tape.

TABLE OF CONTENTS
BACKGROUND AND OVERVIEW..........................................................................1
HEARING SCREENING PROCEDURES: INFANTS TO 36 MONTHS...................................3
Hearing Screening Programs .......................................................................................4
Screening Procedures: Hearing History.......................................................................7
Visual Inspection .........................................................................................................8
Parent/Teacher/Child Observation .............................................................................9
Joint Commission on Infant Hearing (JCIH) Position Statement (2007) ....................10
Explanation of Risk Indicators ...................................................................................11
HEARING SCREENING PROCEDURES: AGE 3 THROUGH 20 YEARS..............................15
Frequency of Screening.............................................................................................16
Hearing History..........................................................................................................17
Parent/Teacher/Child Observation ...........................................................................18
Visual Inspection .......................................................................................................19
Pure Tone Screening .................................................................................................20
Play Audiometry........................................................................................................21
Pure Tone Threshold Screening (Optional for C&TC)................................................22
HEARING SCREENING FORMS..........................................................................23
C&TC Documentation Forms for Providers and Clinics…………………………………………..24
Early Childhood Hearing Screening Worksheet……….…………………………………………….26
School Hearing Screening Worksheet……….…………………………………………………………..27
Hearing Referral Letter………………………………………………………………………………………….28
*Referral letter is available in Hmong, Laotian, Russian, Spanish and Vietnamese
AUDIOMETER FORMS AND RESOURCES..............................................................29
The Audiometer ........................................................................................................30
Care of the Audiometer.............................................................................................31
Environmental Noise Level Check .............................................................................32
Mechanical Function Check.......................................................................................33
Mechanical Function Check Sheet…………………………………………………………………………34
Biologic Calibration Check.........................................................................................35
Biologic Calibration Check Sheet...............................................................................36
Audiometer Supplies, Repair and/or Purchase .........................................................37
RESOURCES FOR HEARING SCREENING...............................................................38
MDH Vision/Hearing Screening Clinic Self-­‐Assessment ............................................39
Hearing Screening Facility .........................................................................................40
Degree and Effects of Hearing Loss……………………………………………………………………….41
Noise Induced Hearing Loss (NIHL) ...........................................................................42
The Nature of Sound and How We Use It .................................................................44
Hearing Resources on the Web.................................................................................45
Hearing Glossary .......................................................................................................46
REFERENCES ...............................................................................................50

Introduction
BACKGROUND AND OVERVIEW
Hearing screening with a pure tone audiometer conducted by properly trained personnel will lead
to early identification of children with hearing loss. The hearing screening process can identify
children with outer and middle ear problems as well as hearing loss caused by damage to the
inner ear. The screening program described here is intended to identify children in need of
further diagnosis and treatment.
Audience
This manual is intended for use in Child and Teen Checkups clinics, Early Childhood Screening
programs, Head Start agencies and School based programs. Pure tone audiometry is considered
the ‘gold standard’ method for screening children age 3 years and older. For screening younger
children or developmentally disabled children, play audiometry is recommended as a more
appropriate screening method. 1
Purpose
The purpose of this hearing training manual is to provide the screener with instructional
information to conduct pure tone hearing screening in the school or clinic setting. This manual is
not a substitute for training, but should be used as a post-training reference. Detailed description
of each procedure will be presented at the training workshop.
These guidelines were developed by a professional review committee made up from experts in
their field. The committee had representatives from ENT, audiology, family practice, pediatrics,
school and public health nursing, Minnesota Department of Human Services, Deaf and Hard of
Hearing Services Division and the Department of Education, Minnesota Academy for the Deaf.
Statistics of Hearing Problems
In the United States, approximately 1 of every 1,000 babies is born deaf and 3 to 5 babies are
born hard of hearing. 2 In Minnesota (MN), that may mean 4 babies are born each week with
hearing loss, or about 200 a year.
About 98% of MN newborns receive screening using electrophysiologic methods such as
Otoacoustic Emissions (OAE) and/or Automated Auditory Brainstem Response (AABR). 3
However, some newborn screening may miss hearing loss, which may be detected later due to
other reasons (see Risk Factors in this document).
How is a child affected by hearing loss?
Hearing loss can impact language acquisition, speech, psycho-social well-being and learning.
The critical time to learn and stimulate the auditory and brain pathways is during the first 6
months of age. Children with all degrees of hearing loss, who receive appropriate intervention
prior to 6 months of age, can obtain speech and language skills comparable to their hearing peers
at age 3 years. 4 Therefore, ongoing review of hearing and speech age-appropriate milestones,
risk factors and routine hearing screening is critical.
1

Unidentified hearing impairments in the school population are associated with speech and
language delays, decreased attention span, and academic deficits. 5 Even mild hearing loss can
significantly interfere with the reception of spoken language and education performance.
Research indicates that children with unilateral hearing loss (in one ear) are ten times as likely to
be held back at least one grade compared to children with normal hearing. 6 Chronic otitis media
(OME), affects 5-30% of children aged 6 months to 11 years, and can persist for 4 to 5 months
with or without medical intervention. 7 During this period, the child is at risk for a fluctuating
hearing loss that can affect speech and language acquisition and auditory processing. 5 In school,
students must be able to listen in a noisy environment, pay attention, concentrate, and interpret
information.
Reading success is particularly affected by the linguistic skill of interpreting information.
Therefore, a child with a hearing loss is at a greater risk for academic deficits. Since hearing has
such an impact on the ability to learn how to read, half of children with hearing loss graduate
from high school with a 4th grade reading level or less unless appropriate early educational
intervention occurs. 8
Hearing Loss due to Excessive Noise Exposure:
Hearing loss can also be caused by an overexposure to noise. There is a growing occurrence of
hearing loss in children and adolescents due to overexposure to noise; this is called noiseinduced
hearing loss (NIHL). 9 Approximately 17 million Americans have NIHL even though it’s
completely preventable. 10 Children are often exposed to excessive levels of sound; one study
shows 97% of 3rd graders had been exposed to hazardous sound levels. 11 Sources of excessive
noise for children include loud music, real or toy firearms, power tools, fireworks, loud toys,
snowmobiles, and other loud engines such as jet skis, motorcycles or farm equipment. 11 A tenyear
school district study showed the incidence of hearing loss increased 400% in eighth
graders. 12 The significance of the problem lies in the insidious nature of noise-induced hearing
loss as well as the cumulative interaction between this type of loss and the natural aging process
that affects hearing.
Addressing hearing loss early and taking steps to prevent it is vital. Depending on the amount of
exposure to noise, the effects of hearing loss may come on very gradually, and hearing loss as a
result of damage to hair cells is permanent. 13
2

Hearing Screening
Procedures
Infants to 36 months
3

MINNESOTA DEPARTMENT OF HEALTH
HEARING SCREENING PROGRAMS
Newborn Hearing Screening became mandatory in Minnesota in September 2007 under
Minnesota Statute 144.966. This legislation has greatly enhanced the comprehensive system of
hearing screening for all newborns. The Newborn Screening Program now oversees hearing
screening for all infants born in Minnesota. Newborn screening staff at the Minnesota
Department of Health work to ensure that all infants are being screened and test results promptly
reported. Staff also work to confirm that all infants who do not pass their hearing screening are
referred to an audiologist or other professional for diagnostic evaluations.
Step-­‐by-­‐Step Guide to Newborn Hearing Screening*
• Before your baby leaves the hospital, simple tests will be done to check your baby's
hearing.
• While your baby is asleep, a nurse or other health staff member will use special
computerized equipment to check your baby's hearing.
• If your baby does not pass the hearing test, another hearing test needs to be done. The
nurse or hospital will help you set-up an appointment to have your baby's hearing
rechecked.
• If your baby's next hearing test also has a refer result, your baby will need to see an
audiologist. The audiologist specializes in testing for hearing loss and has more sensitive
equipment to tell whether your baby is hearing or if the baby has a confirmed hearing
loss.
• If your baby gets a pass result, it is unlikely that your baby has hearing loss, but you
should continue to monitor your baby's hearing and language. Some forms of hearing loss
do not show up until after your baby is older.
• The results of all your baby's hearing tests are sent to MDH where they are kept in a
secure database.
*Note: This step-by-step guide is intended to be shared with parents of newborns.
For more information regarding the MDH Newborn Hearing Screening Program, visit the MDH
website at http://www.health.state.mn.us/newbornscreening/hear_universal.html.
HEARING SCREENING AFTER THE NEWBORN TIME FRAME
In Minnesota, all 109 birthing hospitals are providing newborn hearing screening. Some children
who pass newborn hearing screening may still have risk factors that put them at risk for
progressive or late onset hearing loss. It is the goal of the Early Hearing Detection and
Intervention Program to identify children with hearing loss and connect them with intervention
services as soon as possible.
Although 90% of newborns in the U.S. are being screened at birth for congenital hearing loss,
unfortunately, up to 50% of infants not passing the newborn hearing screening are lost to followup
before diagnostic and intervention services can be provided. In addition, it is estimated that
the incidence of permanent hearing loss triples between birth and the school-age years, from 1 in
4

300 to 3 in 300. Children may also acquire hearing loss from environmental factors such as ear
infections, infectious disease or excessive noise exposure too. For these reasons, periodic
hearing screening throughout early childhood is an essential safety net for identifying
children who experience a delayed-onset or progressive hearing loss or become lost to
follow-up after newborn screening.
Follow-­‐up after Diagnosis of Hearing Loss
MDH Minnesota Children and Youth with Special Health Needs (MCYSHN) staff are
responsible for ongoing follow-up services to children and their families once a diagnosis of
hearing loss is confirmed. MCYSHN will ensure appropriate and timely intervention and
connections for families with statewide services and resources until the child transitions into
adulthood. Program and outcome evaluation allows EHDI to engage in continuous quality
improvement so children and families are well-served through this enhanced system.
THE CHILD AND TEEN CHECKUPS (C&TC) PERIODICITY SCHEDULE
Children who are income eligible may qualify for screening via the C&TC program (called Early
Periodic Screening, Diagnosis and Treatment in some states). For children age 1 month through
24 months, the C&TC program recommends certain hearing screening procedures to be
performed at the following intervals: 0-1, 2, 4, 6, 9, 12, 15, 18 and 24 months.
The periodicity schedule lists the screening components to be done for each time frame. Under
each age, an “O” or “S” is listed. An “O” indicates Objective screening procedures, by
appropriate standard testing method, and “S” indicates Subjective screening procedures, by the
child’s health or family history.
For the 0–1 month time frame:
The periodicity schedule indicates O/S. At this visit (or the first C&TC visit if this one is not
scheduled), the parent should be asked if the child had newborn hearing screening in the nursery
and if so, did the child pass or not pass newborn screening.
If the child passed newborn hearing screening, proceed with subjective screening as indicated
below (see the 2 to 24 month paragraph).
If the child did not have newborn hearing screening or did not pass newborn hearing screening
and did not have a follow up with a repeat screen, then the child should be referred for
appropriate screening.
For the 2–24 month time frame:
Hearing is all subjective (S), meaning that the health history should be updated by following the
procedures in this manual. The parent or guardian is asked the questions from the health history
form, the Mommy Can you Hear Me check list and the JCIH risk factors should be reviewed. If
the parent has concerns about any of these questions, or the answer is ‘yes’ to any of the
questions, then the child should be referred for further evaluation, which would include an
objective hearing evaluation by an appropriate standard testing method.
5

In addition, the provider will perform otoscopic screening as part of the physical exam.
Tympanometry is also an optional tool.
Otoacoustic Emissions (OAE) Technology
Otoacoustic emissions (OAE) screening is a hearing test that uses a small probe inserted into the
external ear canal to introduce a sound stimulus (series of beeps) and measures the response
sound, like an echo, emitted by the inner ear (cochlea) of a normal hearing person. The cochlea
of a person with hearing loss greater than 25-30 dB does not emit a sound in response to a sound
stimulus.
As of July 2010, OAEs are not part of the Minnesota Department of Health’s (MDH) hearing
screening procedures. However, many studies have shown that screening children 0-3 years of
age may be beneficial with OAEs. 14
The OAE technology is very good for children who are unable to respond to a sound by raising
their hand or dropping a toy into a bucket to indicate response to the stimulus. It is not
recommended for children over age 3 years who are developmentally able to perform pure tone
audiometry, either by the play or hand raising method. However, OAE technology may not be
able to detect a mild hearing loss (defined as a 20dB to a 40dB loss), which can impact a child’s
performance in school. One study shows that 37% of children with mild hearing loss fail at least
one grade. 6
6

Ages/Grades: 1 month* to 3 years
SCREENING PROCEDURES
HEARING HISTORY
Purpose: To determine if medical factors exist to put the child at risk for hearing
loss
Description: A review of the history questions with the parent or caregiver
Equipment: Forms: See JCIH Risk Factors and Mommy Can You Hear me?
http://www.health.state.mn.us/divs/fh/mch/unhs/resources/brochures/chec
klist-english.html
Facilities: Comfortable, private interview area
Procedure: Question the parent/caregiver about the child's hearing history.
Pass: No positive response to hearing history
Rescreen/
Refer: Refer to the Joint Committee on Infant Hearing Position Statement (2007)
for a list of hearing loss risk indicators (page 13). Children with one or
more risk factors should have ongoing hearing screening and at least one
diagnostic audiology assessment by 24 to 30 months of age. 1516
*For the 0-1 month time frame: The C&TC periodicity schedule indicates O/S. At this visit
(or the first C&TC visit if this one is not scheduled), the parent should be asked if the infant had
newborn screening in the nursery and if so, did the infant pass newborn screening. If the answer
is no to either of these questions, the infant should be referred for OAE and/or ABR screening.
7

Ages/Grades: Infant through 36 months
VISUAL INSPECTION
Purpose: To check for signs of ear disease and/or abnormal development
Description: A systematic inspection of the external ear canal, surrounding tissue, ear canal,
and tympanic membrane
Equipment: External inspection – None
Internal inspection – Otoscope
Facilities: A well-lighted area
Procedure: External: Inspect the pinna and the area around it for set (position) of the
ears, skin tags or pits, tenderness, redness or edema, signs of drainage or wax
build-up in the outer 1/3 of the canal.
Internal: With the otoscope, inspect the ear canal and tympanic membrane
for: signs of drainage, wax build-up, foreign bodies, redness of the skin or to
the ear canal. Also note whether normal landmarks on the tympanic membrane
can be seen. If the screener lacks training and experience in using the otoscope,
the visual inspection should be limited to the external visual inspection.
Pass: Normal appearance of all structures and no complaints of pain when the pinna
or the tissue around the ear is being manipulated
Rescreen/
Refer: Refer any abnormality for medical examination. If tenderness, sign of drainage
or foul smell are present, DO NOT proceed with audiometer screening; this
would be an automatic referral.
8

Ages/Grades: All ages
PARENT/TEACHER/CHILD OBSERVATION
Purpose: To extend the identification of suspected ear problems or hearing losses
throughout the year
Description: Reporting complaints or observed abnormal listening behaviors
Equipment: None
Facilities: None
Procedure: Child is asked to report any complaint about his/her ears. Parents and/or
teachers are asked to report any abnormal listening behaviors.
Complaints:
• pain in ear
• fullness in ear
• noise in ears
• drainage
• cannot hear
Behaviors:
• tugging at ear
• asks to have things repeated
• turns side of head toward speaker
• inattentive in class discussion
• watches teachers' lips
• shows strain when listening
• difficulty with phonics
• frequent mistakes in following directions
• day dreaming
• tends to isolate
• tires easily
• talks too loudly or softly
• has a speech problem
• not working to capacity
• tends to be passive
Any child with complaints or observed abnormal listening behaviors should
be seen by the referral/follow-up professional to determine the appropriate
course of evaluation.
Note: This list of potential indicators of hearing loss should be given to teachers in the
beginning of the school year so they can be alerted to children who should have their
hearing checked.
9

JOINT COMMISSION ON INFANT HEARING (JCIH)
POSITION STATEMENT (2007):
Principles and Guidelines for Early Hearing Detection and Intervention Programs 16
The JCIH Year 2007 Position Statement identified eleven indicators associated with hearing loss.
It is vital to obtain complete and accurate information about the child’s prenatal and birth history,
results of the newborn hearing screening, and the presence of specific early childhood conditions
in order to determine if factors associated with hearing loss are present. The identification of risk
indicators is an essential component of a comprehensive hearing screening program for children
ages birth through 2 years and also for those babies who have not received Newborn Hearing
Screening. However, use of risk indicators alone will identify only 40-50% of infants with
hearing loss.
The JCIH recommends that all infants with and without risk indicators be monitored during
routine medical care consistent with the AAP periodicity schedule. All infants with a risk
indicator for hearing loss should be referred to an audiologist at least once by 24 to 30 months of
age. Children with risk indicators that are highly associated with delayed-onset hearing loss, such
as having received ECMO or having CMV infection, should have more frequent audiological
assessments.
Risk indicators associated with permanent congenital, delayed-­‐onset, or progressive hearing
loss in childhood:
1. Caregiver concern regarding hearing, speech, language, or developmental delay.
2. Family history of permanent childhood hearing loss.
3. All infants with or without risk factors requiring neonatal intensive care for greater than 5
days, including any of the following: ECMO,* assisted ventilation, exposure to ototoxic
medications (gentamycin and tobramycin) or loop diuretics (furosemide/lasix). In addition,
regardless of length of stay: hyperbilirubinemia requiring exchange transfusion.
4. In utero infections, such as CMV, herpes, rubella, syphilis, and toxoplamosis.
5. Craniofacial anomalies, including those that involve the pinna, ear canal, ear tags, ear
pits, and temporal bone anomalies.
6. Physical findings, such as white forelock, that are associated with a syndrome known to
include a sensorineural or permanent conductive hearing loss.
7. Syndromes associated with hearing loss or progressive or late-onset hearing loss, such as
neurofibromatosis, osteopetrosis, and Usher syndrome; other frequently identified
syndromes include Waardenburg, Alport, Pendred, and Jervell and Lange-Nielson.
8. Neurodegenerative disorders, such as Hunter syndrome, or sensory motor neuropathies,
such as Friedreich ataxia and Charcot-Marie-Tooth syndrome.
9. Culture-positive postnatal infections associated with sensorineural hearing loss, including
confirmed bacterial and viral (especially herpes viruses and varicella) meningitis.
10. Head trauma, especially basal skull/temporal bone fractures that requires hospitalization.
11. Chemotherapy.
10

EXPLANATION OF RISK INDICATORS
All of the risk indicators have been shown to have a potential impact on hearing in young children.
A brief explanation of each indicator is provided below in order to ensure that accurate and
pertinent information is obtained from each parent or caregiver.
1. Caregiver concern regarding hearing, speech, language, or developmental delay.
It is important that hearing loss be identified as early as possible to prevent speech, language and
other developmental delays. Most parents are reliable reporters of their child’s development. The
National Institute of Health Consensus Statement on Early Identification of Hearing Loss in
Infants and Young Children (1993) stated that as many as 70% of deaf and hard of hearing
children are identified because of parental concern.
2. Family history of permanent childhood hearing loss.
This question is aimed at identification of hereditary (genetic) hearing loss from both maternal
and paternal family members, living or deceased, when known. However, a family history of
hearing loss is not necessary for the cause of a child’s hearing loss to be genetic. Hearing loss
that is genetic is most often sensorineural. It is important to ensure that the relative’s hearing loss
was not acquired (such as those resulting from meningitis, noise exposure, chemotherapy, or the
aging process). Acquired hearing losses are not inherited. The type of loss which is inherited is
typically present at a very young age. Semi-annual hearing screening is recommended because
hereditary hearing loss may have delayed onset.
3. Neonatal intensive care of more than 5 days or any of the following regardless of length of
stay: ECMO, assisted ventilation, exposure to ototoxic medication (gentimycin and
tobramycin) or loop diuretics (furosemide/Lasix), and hyperbilirubinemia that requires
exchange transfusion.
Infants admitted to NICU are at greater risk for hearing loss. For example, infants with very low
birth weight are at increased risk for both sensorineural and conductive hearing loss.
Additionally, jaundice is a condition which occurs when there is too much by-product from the
liver in the blood, eventually resulting in high bilirubin levels. Too much bilirubin
(hyperbilirubinemia) is ototoxic and may cause hearing loss. Premature infants and infants with
low birth weight are at greater risk for high bilirubin levels. Low bilirubin levels (slight jaundice)
typically do not affect hearing. Also, infants who require prolonged use of mechanical
ventilation are at risk for hearing loss (e.g., persistent pulmonary hypertension, conditions
requiring the use of extracorporeal membrane oxygenation (ECMO)).
4. In utero infections, such as CMV, herpes, rubella, syphilis, and toxoplamosis.
The presence of these infectious agents has been linked to hearing loss in children. The majority
of infections in pregnant women involve the upper respiratory and gastrointestinal tract and are
not known to cause hearing loss. However, some infectious agents, contracted by the mother
during pregnancy, may cross the placental barrier and invade fetal tissue. Severe infections,
especially those occurring in the first trimester, can be related to hearing loss since this is when
11

the auditory system develops. Many infections go unrecognized due to the lack of clinical
symptoms in the mother. Semi-annual hearing screening is recommended due to the potential of
delayed onset sensorineural hearing loss.
Cytomegalovirus (CMV): A virus in the herpes group and the leading cause of fetal viral
infection in the U.S, the infection is most often asymptomatic in the mother. CMV can
cause sensorineural hearing loss, which varies in severity, may have a delayed onset, may
be unilateral, and is often progressive.
Herpes: Either systemic or simplex 1 or 2 and in the same family as the CMV virus,
herpes may cause severe to profound sensorineural hearing loss.
Toxoplasmosis: Caused by a protozoan parasite, the infection is usually asymptomatic in
the mother. The incidence of intrauterine toxoplasmosis averages one case per 750
deliveries in the U.S. Infection during the first trimester appears most likely to adversely
affect the fetus. Central nervous system involvement, as well as mental retardation,
seizures, and ocular disease are frequently seen.
Rubella (German Measles): Occurring within the first trimester of pregnancy, rubella
poses a serious risk to the developing fetus. In addition to hearing loss, other anomalies
which may occur include heart disorder, low birth weight, mental retardation, and vision
loss. When hearing loss occurs, 50% have bilateral severe to profound loss. Hearing loss
may be progressive.
Syphilis: Congenital syphilis may become apparent in the first 2 years of life, or between
the ages of 8 to 20 years. Hearing loss is sensorineural and may be sudden, progressive,
or fluctuating. Early onset hearing loss caused by syphilis may be reversible with early
detection and prompt treatment.
5. Craniofacial anomalies, including those that involve the pinna, ear canal, ear tags, ear pits,
and temporal bone anomalies.
Craniofacial abnormalities (e.g., cleft lip/palate, shortened neck, webbed neck, abnormal head
circumference) may be indications of the presence of a hearing loss. Malformation of the ears
may include atresia, low set ears, skin tags, and preauricular pits. These abnormalities may be
indicative of a syndrome.
12

6. Physical findings, such as white forelock, that are associated with a syndrome known to
include a sensorineural or permanent conductive hearing loss.
7. Syndromes associated with hearing loss or progressive or late-onset hearing loss, such as
neurofibromatosis, osteopetrosis, and Usher syndrome; other frequently identified syndromes
include Waardenburg, Alport, Pendred, and Jervell and Lange-Nielson.
8. Neurodegenerative disorders, such as Hunter syndrome, or sensory motor neuropathies,
such as Friedreich ataxia and Charcot-Marie-Tooth syndrome.
There are many syndromes associated with hearing loss that include observable physical anomalies of
the head, neck, and ears which frequently result in hearing loss (e.g., Down syndrome). Another
example is Neurofibromatosis Type II (NF2), an inherited tumor syndrome. Some syndromes are not
evident at birth.
9. Culture-positive postnatal infections associated with sensorineural hearing loss, including
confirmed bacterial and viral (especially herpes viruses and varicella) meningitis.
Type B, Hemophilus Influenza, carries the greatest incidence of hearing loss. Bacterial
meningitis is the leading cause of acquired deafness in infants and childhood, ranging in
incidence from 5-30%. Most occurrences result in severe, bilateral, symmetrical, sensorineural
hearing loss; 30% have profound loss. The age at which meningitis occurs significantly affects
rehabilitative needs; the younger the child, the greater the impact on speech and language
acquisition.
10. Head trauma, especially basal skull/temporal bone fractures that requires hospitalization.
Head trauma (e.g., a skull fracture) may affect hearing due to potential damage to either the
cochlea or middle ear, resulting in sensorineural or conductive hearing loss. Sensorineural loss
may occur due to damage or obliteration of the temporal bone housing the inner ear. Conductive
hearing loss occurs as a result of perforation of the tympanic membrane, bleeding, or disruption of
the ossicular chain.
11. Chemotherapy.
“Chemotherapy” refers to a number of drugs which can be “ototoxic”
Ototoxicity is damage to the ear (oto-), specifically the cochlea or auditory nerve and sometimes
the vestibular system, by a toxin. It is commonly medication-induced; ototoxic drugs include
antibiotics such as the aminoglycoside gentamicin, loop diuretics such as furosemide, and
platinum-based chemotherapy agents such as cisplatin. It can result in sensorineural hearing loss,
dysequilibrium, or both. Either may be reversible and temporary, or irreversible and permanent.
13

Note: The 2007 JCIH Position Statement no longer includes in its list of risk indicators
recurrent or persistent otitis media with effusion for at least 3 months. However, the JCIH
recommends careful assessment of middle-ear status at all well-child visits, and children with
persistent middle-ear effusion lasting 3 months or longer should be referred for otologic
evaluation.
Middle ear infection is a frequently occurring illness in very young children, second only to the
common cold. “Recurrent” is defined as three or more bouts of otitis media within a twelvemonth
period; “persistent” is defined as lasting three months or longer. PE tubes may have been
inserted to address the otitis media with effusion (OME). Frequent episodes of OME may result
in fluctuating conductive hearing loss, in turn influencing speech and language development.
OME compounds hearing loss due to other conditions (e.g., sensorineural hearing loss) and
should be monitored vigilantly.
14

Hearing Screening
Procedures
Children age 3 years through 20 years
15

FREQUENCY OF SCREENING
In the school setting, children in kindergarten and grades 1, 2, 3, 5, 8 and 11 should be screened
each year. In addition, parent, teacher and child referrals, new students, children with known
losses, special education classes, and high-risk children should also be included in the yearly
screening. High-risk students are those children who have:
1. Chronic or recurrent otitis media
2. Cleft palate or other cranio-facial anomalies
3. Family history of developing hearing problems
4. Exposure to potentially harmful levels of noise
The Early Childhood Screening law (M§ 123.701-123.702) requires that children be screened
once before school entry. This usually occurs in the 3-5 year age range.
The Child and Teen Checkups (M§ 256B.04-256B.0625) program recommends hearing be
screened as follows:
Infancy: 0-1 month (O/S)*, 2 months (S), 4 months (S), 6 months (S),
9 months (S), 12 months (S)
Early Childhood: 15 months (S), 18 months (S), 24 months (S), 3 years (O/S)*, 4 years (O)
Late Childhood: 5 years (O), 6 years (O), 8 years (O), 10 years (O), 12 years (O)
Adolescence: 14 years (O), 16 years (S), 18 years (O), 20 years (S)
S = subjective, by history
O = objective, by appropriate standard testing
*O/S = either at this age
The Child and Teen Chekups periodicity schedule can be found at:
http://edocs.dhs.state.mn.us/lfserver/Legacy/DHS-3379-ENG
16

HEARING HISTORY
Ages/Grades: Age 3 years through 20 years
Purpose: To determine if medical factors exist to put the child at risk for hearing
loss
Description: A review of the history questions with the parent or caregiver
Equipment: None
Facilities: Comfortable, private interview area
Procedure: Question the parent/caregiver about the child's hearing history
Pass: No positive response to hearing history
Rescreen/
Refer: A positive response to one or more of the history questions should be used
as a reason for referral only if the child cannot be screened.
1. Do you have a problem hearing over the telephone?
2. Do you have trouble following the conversation when two or more
people are talking at the same time?
3. Do people complain that you turn the TV volume up too high?
4. Do you have to strain to understand conversation?
5. Do you have trouble hearing in a noise background?
6. Do you find yourself asking people to repeat themselves?
7. Do many people you talk to seem to mumble (or not speak clearly)?
8. Do you misunderstand what others are saying and respond
inappropriately?
9. Do you have trouble understanding the speech of women and children?
10. Do people get annoyed because you misunderstand what they say?
Note: These history questions extracted from the American Academy
of Pediatrics publication, Bright Futures (2008). 17
17

Ages/Grades: All ages
PARENT/TEACHER/CHILD OBSERVATION
Purpose: To extend the identification of suspected ear problems or hearing losses
throughout the year
Description: Reporting complaints or observed abnormal listening behaviors
Equipment: None
Facilities: None
Procedure: Child is asked to report any complaint about his/her ears. Parents and/or
teachers are asked to report any abnormal listening behaviors.
Complaints:
• pain in ear
• fullness in ear
• noise in ears
• drainage
• cannot hear
Behaviors:
• tugging at ear
• asks to have things repeated
• turns side of head toward speaker
• inattentive in class discussion
• watches teachers' lips
• shows strain when listening
• difficulty with phonics
• frequent mistakes in following directions
• day dreaming
• tends to isolate
• tires easily
• talks too loudly or softly
• has a speech problem
• not working to capacity
• tends to be passive
Any child with complaints or observed abnormal listening behaviors should
be seen by the referral/follow-up professional to determine the appropriate
course of evaluation.
Note: This list of potential indicators of hearing loss should be given to teachers in
the beginning of the school year so they can be alerted to children who should have
their hearing checked.
18

Ages/Grades: Age 3 years through 20 years
VISUAL INSPECTION
Purpose: To check for signs of ear disease and/or abnormal development
Description: A systematic inspection of the external ear canal, surrounding tissue, ear canal,
and tympanic membrane
Equipment: External inspection – None
Internal inspection – Otoscope
Facilities: A well-lighted area
Procedure: External: Inspect the pinna and the area around it for set (position) of the
ears, skin tags or pits, tenderness, redness or edema, signs of drainage or wax
build-up in the outer 1/3 of the canal.
Internal: With the otoscope, inspect the ear canal and tympanic membrane
for: signs of drainage, wax build-up, foreign bodies, redness of the skin or to
the ear canal. Also note whether normal landmarks on the tympanic membrane
can be seen. If the screener lacks training and experience in using the otoscope,
the visual inspection should be limited to the external visual inspection.
Pass: Normal appearance of all structures and no complaints of pain when the pinna
or the tissue around the ear is being manipulated.
Rescreen/
Refer: Refer any abnormality for medical examination. If tenderness, sign of drainage
or foul odor are present, DO NOT proceed with audiometer screening; this
would be an automatic referral.
19

PURE TONE SCREENING
Ages/Grades: Age 3 years through 20 years
Purpose: To identify children with suspected hearing loss
Description: Having the child listen to a series of pure tones and note whether or not
there was a response to each one, using only “time Locked” not “random”
responses
Equipment: Pure tone audiometer/headphones
Facilities: Quiet room/area, free from visual distractions
Procedure: Set Up:
• Seat the child so they cannot see the front of the audiometer
• Remove glasses, hair bands, large earrings, etc.
• Place hair behind the ears
• Instruct the child to raise either hand when a tone is heard
• Set selector switch to “Right”
• Set HL dial to 40 dB
• Set frequency dial to 1000 Hz
• Place the earphones on child's head with the red phone on the right ear
and the headband flush to the head
Screening:
• Present the 1000 Hz 40 dB conditioning tone for 1-2 seconds
• Turn HL dial to 20 dB
• Present tones at 1000, 2000 and 4000 Hz
• Turn selector switch to Left
• Present tones at 4000, 2000 and 1000 Hz
• Set HL dial at 25 dB
• Turn frequency dial to 500 Hz**
• Present the tone
• Turn selector switch to Right
• Present the tone
• Recheck if the child did not hear one or more tones
• Place a checkmark in the proper boxes on the screening form if a child
does not respond to the tone(s)
Pass: Child hears all eight tones (20dB at 1000, 2000, 4000 Hz; 25dB at 500 Hz)
Rescreen: Child who does not hear one or more tones after immediate recheck; child
should be scheduled for rescreening in 14-21 days.
**NOTE: The 500 Hz tone may be eliminated when tympanometry is included or
when the ambient noise level is too high.
20

PLAY AUDIOMETRY
Ages/Grades: Children who are difficult to screen
Purpose: To obtain valid results with children when a hand-raising response to the
stimulus is not effective
Description: A modification of the standard pure tone screening procedure in which the
child is conditioned to respond to the sound by placing a toy in a container
(this replaces the hand-raising technique normally used)
Equipment: Pure tone audiometer, stickers, and interesting, child-safe toys, i.e., animals,
airplanes, cars, beads, clothes pins, pegs and pegboard or nested boxes
Facilities: Appropriate size table and chairs in a quiet, comfortable setting with some
degree of privacy
Procedure: Place the headphones on the table facing the child with the audiometer set at
2000 Hz and the maximum level to insure the tone is audible.
Screener holds the toy near their own ear, assumes a “listening” attitude and
presents the tone. Indicate through facial expression that the sound was heard
and then drops the toy in a pail. This may be repeated as often as necessary
until the child shows interest.
Screener offers the toy to the child and places their hand on the child’s to guide
the first responses. Encourage the child to wait until the sound is heard. When
the child appears ready, present the sound and guide the child’s hand to put the
toy in the container. Child may give consistent responses after only one
demonstration or may need several to respond on their own. Demonstrate first
without and then with the headset on.
Reward the child with praise after the initial responses. If this is not effective, a
tangible reward, like a sticker or food, may be given.
Other
Information: The response interval (tone to response time) varies between children. Some
children will drop the toy as soon as the tone is heard, others will wait until the
sound goes off before dropping the toy.
If the child does not accept the headset, the screener should try putting it on for
only one or two seconds, remove and reward the child. The time with the
headset on should be slowly increased.
A timid child will often benefit from watching one or two other children
successfully complete the screening.
21

PURE TONE THRESHOLD SCREENING (OPTIONAL FOR C&TC)
Ages/Grades: Age 3 years through 20 years (as indicated by C&TC schedule)
Purpose: To obtain record of the child's level of hearing prior to initial referral
Description: Having the child listen to a series of pure tones and record the softest dB
level that the child responds to at each frequency, using only “time locked”
not “random” responses
Equipment: Pure tone audiometer
Facilities: Quiet room, free from visual distractions
Procedure: Set Up:
• Seat the child so they cannot see the front of the audiometer
• Remove glasses, hair bands, large earrings, etc.
• Place hair behind the ears
• Instruct the child to raise either hand when a tone is heard
• Set selector switch to “Right”
• Set HL dial to 40 dB
• Set frequency dial to 1000 Hz
• Place the earphones on child's head with the red phone on the right ear
and the headband flush to the head
Threshold Determination:
• Screen right or better ear
• Present the 1000 Hz tone at 40, 20, 0 dB until there is no response
• At the level there is no response, increase in 5 dB increments until there
is response
• Drop 10 dB
• Increase in 5 dB increments until there is a response
• Repeat until there are 2 responses at the same level
• Record threshold level
• Repeat the process for 2000, 4000, 8000, recheck 1000 Hz and 500 Hz
in the right or better ear
• Repeat for the other ear
Pass: Child's threshold is above the bold line on the audiogram (20dB at 500 Hz;
15dB at 1000, 2000, 4000 Hz)
Referral: Any threshold level on or below the bold line on the audiogram (25dB at
500 Hz; 20dB at 1000, 2000, 4000 Hz)
Exceptions: When a child has a known hearing loss that has been diagnosed as nontreatable,
referral to the school audiologist should be made if there is a
change of 10dB poorer at any frequency.
NOTE: For children who are difficult to screen, use play audiometry procedures.
22

Hearing
Screening Forms
23

EARLY CHILDHOOD HEARING SCREENING WORKSHEET
(Also used for Child and Teen Checkups)
SCREEN RESCREEN
Name Age | Dates | | | |
Yrs Mos
Problem Noted: NO YES NO YES
A. Risk Factors (29 days to 2 years) . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . .
B. Hearing History (all ages) . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . .
C. Auditory Checklist (birth to 24 mos.) . . . . . . . . . . . . . . . .. . . . . . . . . . . . .
D. Visual Inspection/Otoscopy (all ages) . . . . . . . . . . . . . . . .. . . . . . . . . . . .
E. Tympanometry (6 mos. +) If problems noted attach tympanogram. . . . . .
F. Pure tone (3 years +). . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . .
Pure Tone:
Screen: □ Head cold □ Pass □ Rescreen
Level (dB) 25 20 20 20
Frequency (Hz) 500 1000 2000 4000
Right Ear
Left Ear
Rescreen: □ Head cold □ Pass □ Rescreen □ Refer
Level (dB) 25 20 20 20
Frequency (Hz) 500 1000 2000 4000
Right Ear
Left Ear
Threshold in HL: □ Head cold Date _____/_____/_____
Frequency (Hz) 500
Right Ear
1000 2000 4000 8000
(dB)
Left Ear
(dB) (dB) (dB) (dB)
(dB) (dB) (dB) (dB) (dB)
Reliability: □ Good □ Fair □ Poor
Hearing History (all ages):
1. Is there concern that this child has a hearing, speech or language problem?
2. Are there any childhood hearing problems in the family of either the child's mother or
father?
3. Does child have history of middle ear disease and/or tubes?
4. Has child had head trauma with concussion, skull fracture or loss of consciousness?
5. Has child been hospitalized with a serious illness (i.e. kidney, meningitis) or diagnosed
with amblyopia?
26

27
School Hearing Screening Worksheet
Child’s Name______________________________________________________
Teacher______________________________ Grade_____ Date_____________
Parent/Teacher/Child Concerns about hearing:
Visual Inspection:
External
Otoscopy
Tympanometry Results Pass � RESCREEN �
Pass Rescreen
Pure Tone:
Screen: � Head cold � Pass � Rescreen
Level (dB) 25 20 20 20
Frequency (Hz) 500 1000 2000 4000
Right Ear
Left Ear
Rescreen: � Head cold � Pass � Rescreen
Level 25 20 20 20
Frequency 500 1000 2000 4000
Right Ear
Left Ear
Threshold in HL: � Head cold Date__________________
Frequency 500 1000 2000 4000 8000
Right Ear
Left Ear
Reliability: � Good � Fair � Poor
Form Completion (Marking):
✔ ✔ ✔
✔
Response No Response Response No Response
(leave blank) on ImRe on ImRe
School Hearing Screening Worksheet
Child’s Name______________________________________________________
Teacher______________________________ Grade_____Date______________
Parent/Teacher/Child Concerns about hearing:
Visual Inspection:
External
Otoscopy
Tympanometry Results Pass � RESCREEN �
Pass Rescreen
Pure Tone:
Screen: � Head cold � Pass � Rescreen
Level (dB) 25 20 20 20
Frequency (Hz) 500 1000 2000 4000
Right Ear
Left Ear
Rescreen: � Head cold � Pass � Rescreen
Level 25 20 20 20
Frequency 500 1000 2000 4000
Right Ear
Left Ear
Threshold in HL: � Head cold Date__________________
Frequency 500 1000 2000 4000 8000
Right Ear
Left Ear
Reliability: � Good � Fair � Poor
Form Completion (Marking):
✔ ✔ ✔
✔
Response No Response Response No Response
(leave blank) on ImRe on ImRe

HEARING REFERRAL LETTER
Name___________________________________
Dear Parent/Guardian:
In keeping with the recommendations of the Minnesota Department of Health, your
child's school class was screened for hearing on ___/___/___ and rescreened on
___/___/___.
Your child was unable to hear all of the screening sounds. Although the results do not
definitely mean your child has a hearing problem, you are urged to take him/her to your
physician and/or audiologist for further hearing evaluation.
Please take this letter with you when your child is examined and ask the examiner to
complete the bottom half.
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
See the attached screening audiogram or tympanogram.
Please complete this portion of the form and send it at your earliest convenience to:
I have examined and find the following:
MEDICAL:
□ Normal hearing
□ Medically treatable
□ Not medically treatable
□ Outer ear
□ Middle ear
□ Inner ear
□ Refer to audiology
□ Further comments
____________________________
____________________________
____________________________
Signed: _________________________
Date: ___________________________
28
AUDIOLOGICAL:
□ Normal hearing
□ Conductive hearing loss
□ Mixed hearing loss
□ Sensorineural hearing loss
□ Refer to physician
□ Amplification evaluation
□ Further comments
_____________________________
_____________________________
_____________________________
Signed: _______________________
Date: ________________________

Audiometer Forms
and Resources
29

THE AUDIOMETER
An audiometer is a device that produces tones at set frequencies and known amplitudes through
headphones worn by the patient. The patient is required to indicate what tones s/he can hear. The
pure tone audiometer is the preferred instrument used in school and clinic hearing screening
programs.
The audiometer has test tones ranging from 250 to 8,000 Hz (Hz refers to frequency, or cycles
per second). This is the pitch of the tones that range from very low pitch to high pitch. The tones
most often used in audiometric screenings are 500, 1,000, 2,000, and 4,000 Hz. The intensity
(loudness) is expressed in decibels (dB). Thirty (30dB) is considered the level of a soft whisper
at a distance of three feet. Sixty-five (65dB) is the average intensity for a normal conversation,
and eighty-five (85db) is so loud that individuals must be protected when working under such
exposure for a prolonged period. Most screening is done at 20dB.
Audiometric tests record the softest level at which an individual can hear a tone. The responses
are recorded on a graph, called an audiogram. Audiometers come with headphones; these
headphones have been calibrated to a specific audiometer and should not be exchanged with
other audiometers.
There are several different brands of audiometers, though most have the following dials.
Power or On/Off Switch: This switch needs to be on when testing.
Frequency Dial: This dial rotates from 250 to 8000 Hz. This dial controls the test
frequency, or the pitch of the tone.
Hearing Level Dial or Decibel (dB) Dial: This controls the test intensity, or loudness of
the tone. Normally this is a rotary dial, which allows you to vary the tones presented in 5
dB steps.
Tone Presentation Bar or Stimulus Switch: Pressing this bar (or switch) presents the
tone to the person being tested.
30

General Care:
CARE OF THE AUDIOMETER
Handle gently and avoid dropping or rough treatment. When transporting the audiometer, place it
on the seat and secure it so it can’t fall during a sudden stop.
Avoid extreme temperatures (below freezing and above 90° F). Keep all cords free of tangles and
twists. Check all electrical connections, dials and switches for signs of problems, the earphone
jacks should be occasionally removed from their plugs and wiped with an alcohol pad to improve
the connection. Proper care must be taken to prevent moisture from getting inside the
audiometer.
The case should be kept closed to prevent dust build-up. If that case or exposed surfaces should
become dirty, soap and water is usually sufficient to clean them.
Mechanical and biological function checks must be done each day, on each audiometer, before
use (copies of instructions and documentation regarding this are enclosed).
Earphones:
Clean routinely with cleaning agent, alcohol free wipes. (Do not use alcohol because it may dry
out the rubber cushions on earphones.) When the earphone cushions need cleaning, remove
them from the headset, clean and dry thoroughly before replacing. Keep all moisture away from
the diaphragm (hole in the center of the earphones).
Calibration:
An electric calibration check should be done yearly. An extensive calibration, which includes
internal cleaning and lubrication should be done at a repair facility or the factory about every
fifth year.
The audiometer is in need of repair if:
• Tone does not sound normal or sound is not produced when tone lever or button is
pressed or static is heard
• Earphones do not remain in proper position over ears
• A dial or switch does not function or indicator lights do not glow
31

ENVIRONMENTAL NOISE LEVEL CHECK
Most local agencies and schools do not have the equipment to take ambient noise level
measurements in the areas to be used for screening. A biologic noise level check may be
substituted. This is defined as the ability to establish thresholds at 10dB below the screening
level at all frequencies on a person with known normal hearing. If these thresholds cannot be
established, the area must not be used for screening. However, if 500 Hz is the only frequency
affected, then it may be deleted from the screening protocol.
32

MECHANICAL FUNCTION CHECK
Before using the audiometer, plug it in for ten minutes and then check the mechanical function.
(Form on next page.)
1. Power On – Make sure there is power to the audiometer.
2. Jacks Seated – Make sure the jacks are in the proper receptacle and are pushed in all the
way. (Occasionally, moisten the receptacle with an alcohol wipe and push into the jack and
rotate it; this breaks up dust).
3. Earphone Cushions – The cushions should be clean, pliable and free from breaks or tears.
(NEVER use alcohol wipes on the cushions).
4. Dials Tight – Turn the frequency and attenuator dials to check for slippage. Loose dials
should be tightened before the audiometer is used.
5. Headband Tension – Put on the earphones. There should be enough tension so that when
positioned on the head, the earphones rest snugly on the ears.
6. Tone ON/OFF (NORM/REV) – Turn the switch to ON (NORM) position and the sound
should be on. The sound should be off in OFF (REV) position.
7. Cords OK – With the selector switch on "right," turn the tone interrupter switch to the ON
(NORM) position. Gently twist the cord by the right earphone and at the jack position; turn
the sound to "left" and check the left cord. If the sound cuts out or becomes scratchy, the
connections must be tightened or cords must be replaced.
8. Volume Increase/Decrease – Turn the Hearing Level (HTL) dial and listen for loudness
changes.
9. Pitch Change – Change the frequency dial and listen for changes in pitch.
10. Tone Presenter Switch(es) – Press the switch and the sound should come on if the tone is
in the OFF (REV) position. If the tone is in the ON (NORM) position, the tone should go
off “when the switch is pushed.” Check both switches if the audiometer is so equipped.
11. Static – No static should be heard. Static may indicate dirty contacts and they can be
"cleaned" by rotating the dials quickly.
12. Cross Talk – As you listen to the left phone, no sound should be present in the right phone
and vice versa.
33

34
DATE
Power
On Jacks Seated
Earphone
Cushions
MECHANICAL FUNCTION CHECK SHEET
Dials
Tight
Head Band
Tension
Tone
On/Off
Cords
OK
Volume
Inc/Dec
Pitch
Change
Tone
Presenter
No
Static
No
Cross Talk

BIOLOGIC CALIBRATION CHECK
(Optional if Threshold Audiometry is not performed)
To insure that the audiometer is in calibration, the person with primary responsibility for the
hearing screening program should do biologic calibration checks. These calibration checks
should be done each day prior to use or anytime during use when there is reason to suspect the
audiometer may not be working properly. Use the “Same Ear HL” procedure described below.
(Form on next page.)
Same Ear HL Procedure:
1. Obtain a threshold (500–8000 Hz) on the better ear with right (red) earphone and record
the results.
2. Obtain a threshold (500–8000 Hz) on the same ear with the left (blue) earphone and
record the results.
3. Check the thresholds at each frequency to see that they differ by no more that ±5 dB. If
they do vary more than this, the audiometer should not be used and the audiometer should
be checked.
35

Audiometer I.D._______________
Date
Red
Blue
Red
Blue
Red
Blue
Red
Blue
Red
Blue
Red
Blue
Red
Blue
Red
Blue
Red
Blue
Red
Blue
Red
Blue
Red
Blue
Red
Blue
Red
Blue
Red
Blue
Phone
BIOLOGIC CALIBRATION CHECK SHEET
500
SAME EAR HTL
1000
36
2000
4000
8000
Screener

AUDIOMETER SUPPLIES
ITEM AVAILABLE THROUGH
Audiogram WIB Self Carbon
ACS
526 West 7 th Street
St. Paul, MN 55102
Phone: (651) 224-3547
Branson Electronics
17039 Kettle River
Boulevard
Forest Lake, MN 55025
Phone: (651) 464-6915
Medical Technologies,
Inc.
412 Gateway Boulevard
Burnsville, MN 55337
Phone: (800) 328-6709
or (952) 808-0320
www.medtechnologies.com
MacGill Discount
Nurse Supplies
1000 N. Lombard Rd.
Lombard, Illinois 60148
Phone: (800) 323-2841
Fax: (800) 727-3433
www.macgill.com
Booth Documents & Publishers
155 North Lake Street
Forest Lake, MN 55025
(651) 464-2776 or 1-866-245-1695
Fax (651) 464-5011
boothpublishers@aol.com
AUDIOMETER REPAIR AND/OR PURCHASE
MSI Midwest Special
Instruments Corp.
16204 Lakeside Ave. SE
Prior Lake, MN 55372
Phone: (612) 548-4858
Fax: (888) 795-9592
www.midwestsi.com
Medical Calibration
Services, Inc.
22287 169 th Street NW
Big Lake, MN 55309
Phone: (763) 263-8420
School Health Corp.
865 Muirfield Drive
Hanover Park, IL 60103
Phone: (866) 323-5465
Fax: (800) 323-1305
www.schoolhealth.com
School Nurse Supply,
Inc.
P.O. Box 68968
Schaumburg, IL 60168
Phone: (800) 485-2737
Fax: (800) 485-2738
www.schoolnursesupplyinc.com
Specialty Instruments
2500 Mendelssohn N.
Golden Valley, MN 55427
Phone: (866) 559-7407
Or (763) 559-7407
Fax: (763) 504-3193
www.specialtyinstruments.com
Starkey Labs
6700 Washington Ave S
Eden Prairie, MN 55344
Phone: (800) 328-3897
or (952) 941-6401
www.starkey.com
Note: The Minnesota Department of Health (MDH) does not endorse any particular
product; this resource list is provided for informational purposes only. In addition, MDH
is not responsible for the content of websites listed here. Any person or entity that relies
on any information obtained from this resource list does so at his or her own risk.
37

Resources for Hearing
Screening
38

MINNESOTA DEPARTMENT OF HEALTH
VISION/HEARING SCREENING CLINIC SELF-­‐ASSESSMENT
� Vision History (Usually completed by
Primary Care Provider)
Parental concern, family hx, observed
problems, sensitivity to lights,
headaches, squinting, hearing problems
� Muscle Balance (Usually completed by
Primary Care Provider)
� Observation
� Corneal Light
� Cross Cover
� Visual Acuity (Usually completed by
Medical Assistant)
Age 3-5 Years
� HOTV/Lea chart @10ft.
� Pass 10/20 – 10/15 or better
without 2 line difference
Age 6 – older years
� Snellen@20ft
� Pass 20/30 or better
� Memorization avoidance
E.g., to avoid memorization, hang chart
string and turn it over when ready to test
or vary letters on each line
� Documentation
Document results such as distance from
vision chart, behaviors, (i.e., head tilt,
squint) and history
1/05
CHILD AND TEEN CHECKUPS CHECKLIST
� Hearing History
Family Hx or concern: speech delays, risk factors for
progressive and late onset hearing loss, congenital eye
or kidney problems, vision problems, head trauma,
meningitis, rubella, etc.
� Pure tone Audiometer
Calibrate yearly; headphones calibrated specifically to
audiometer. (C&TC does not recommend hand-held or
Pilot audiometers.)
� Quiet Room
Not high traffic area, room intercom off, pass
environmental noise level check
� Screening Levels
500 Hz @ 25 dB; 1000, 2000 and 4000 Hz @ 20 dB
*Document results and screen levels
� Infection Control
Clean headphones. Use an alcohol free, 100%
tuberculocidal, bactericidal, fungicidal, and virucidal
agent.
39
For more information:
MDH Community and Family Health Division
http://www.health.state.mn.us/divs/fh/mch/hlthvis/materials/clinicselfassess.html

Screening site general considerations:
Very quiet room
HEARING SCREENING FACILITY
• Maintain as silent a screening site as possible
• Avoid areas near:
o Fans or air conditioners
o Hall traffic (reroute if possible)
o Playground or street traffic
o Group activities (i.e. music, free play)
o Bathrooms
o Lunchrooms
o Office equipment (i.e. copy machines)
o Soft drink machines
o Refrigerators, etc.
• Avoid excess noise within screening area, such as:
o Talking
o Paper shuffling
o Open windows
o Movement of desks, furniture
• Cease screening momentarily if any distracting noise occurs.
Room should be uncluttered and free of visual distraction
• Avoid mirrors or reflecting surfaces
• Avoid child facing a window
40

DEGREE AND EFFECTS OF HEARING LOSS
Decibels (dB) Degree Effect on language and speech development 18
0-15 dB None No hearing loss.
16-20 dB Slight
21-40 dB Mild
41-55 dB Moderate
56-70 dB
Moderate to
Severe
71-90 dB Severe
91 + dB Profound
May have difficulty hearing faint or distant speech, especially
in noisy areas. Speech/language not likely to be affected. May
need assistive listening technology in classroom situations.
May miss a considerable amount of speech depending on noise
levels, distance from speaker, and configuration of hearing
loss, not hear consonants sounds (all letters except a, e, i, o, u)
especially if loss in higher frequency range, have difficulty
understanding speech if not in line of vision of speaker and
speech is quiet.
Will miss between 50-100% of speech without use of
appropriate amplification. Delayed speech-language
development and vocal quality deviation likely.
Without amplification, almost 100% of speech information will
be missed. School situations requiring vocal information will
require assisted listening devices. Delays in language and
speech common and the voice may be monotone.
Amplification is required to hear spoken language, identify
environmental sounds, and detect all speech sounds. If hearing
loss occurs before the child has learned to speak, oral speech
and language will not develop spontaneously, or will be
severely delayed. If the loss is after the development of speech,
then speech is likely to deteriorate in production and vocal
quality.
May be able to feel loud auditory vibrations without
amplification. With amplification, may be able to detect
sounds. May rely on vision for communication and learning,
rather than audition. Speech and language will not develop
spontaneously. Cochlear implant is possible option.
41

NOISE INDUCED HEARING LOSS (NIHL)
What Teenagers need to know!
Excessive noise is a leading cause of hearing loss, especially among young
people. 10
Why does excessive noise cause hearing loss?
The noise causes damage to the hair cells of the inner ear and is the largest single form of
hearing loss. 10 NIHL is totally preventable, but once you have hearing loss, you’ll have it
for life.
NIHL can be caused by a one-time exposure to loud sound as well as by repeated
exposure to sounds at various loudness levels over an extended period of time.
We hear over various frequencies, and NIHL will impact the higher frequencies first,
resulting in difficulty with background noise. However, the loss will gradually progress
into the lower speech frequencies. Once it has affected those, you will have problems
understanding speech, and it will progress to a severe level in the high frequencies.
What kind of noise is too loud? 9,10,13 *
If you have to raise your voice to talk to someone who is only an arms length away,
chances are it is too loud. Sound is measured in decibels (dB), and prolonged exposure to
noise over 85dB can cause hearing loss. Regular exposure to noise over 110dB or more
for more than 1 minute can cause permanent hearing loss. Immediate ear damage will be
caused by exposure to 150dB plus. For every 5dB increase in noise, the maximum
exposure time is cut in half.
Can NIHL be prevented?
NIHL is preventable. You need to understand the hazards of noise and how to avoid it
and protect your ears.
• Know which noises can cause damage (those above 85 decibels)
• Wear earplugs or other hearing protective devices when involved in a loud
activity (special earplugs and earmuffs are available at hardware stores and
sporting good stores).
• Be alert to hazardous noise in the environment
• Tell your friends and family about this!
*Note: Decibel levels vary between sources, though the levels noted here are generally
agreed upon in the field.
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THE NATURE OF SOUND AND HOW WE USE IT
The sound that we hear can be described by two characteristics:
Pitch (Frequency):
This refers to the position of sound on the musical scale, from low to high. It is measured
in Hertz (Hz). Although we can hear from 20 Hz (an extremely low pitch), we only use a
very limited range for our daily listening needs (250 Hz through 8000 Hz). Specifically,
500, 1000, 2000 and 40000 Hz are critical for hearing and understanding speech sounds.
Loudness (Intensity):
This refers to the volume of the sound, from quiet to loud. It is measured in decibels
(dB). The abbreviation “dB” is written after a number to define how loud a sound is.
With the dB scale, zero dB does not indicate the absence of sound; rather, it indicates a
minimal level for normal hearing. The greater the decibel number the louder the sound. A
130dB sound causes pain in most people’s ears; there are people who will experience
pain from hearing a sound at 100-110dB. People usually speak at an intensity of 50-
60dB. A person with normal hearing should be able to hear at intensities al low as 0-
20dB from 250 through 8000 Hz.
44

HEARING RESOURCES ON THE WEB
Hearing Resources Websites
American Academy of Audiology www.audiology.org
American Academy of Pediatrics
(AAP) Hearing health topic resources
www.aap.org/healthtopics/visionhearing.cfm
American Speech-Language-Hearing
Association
www.asha.org/
CDC Early Hearing Detection and
Intervention (EHDI) Program
www.cdc.gov/ncbddd/ehdi/
CDC, Noise-Induced Hearing Loss www.cdc.gov/HealthyYouth/noise/index.htm
C&TC Provider Guide
http://edocs.dhs.state.mn.us/lfserver/Legacy/D
HS-4212-ENG
Center for Hearing and Communication www.chchearing.org/
Dangerous Decibels www.dangerousdecibels.org/
Ear and hearing games faculty.washington.edu/chudler/chhearing.html
Name that sound – What does hearing
loss sound like?
www.hearingcenteronline.com/sound.shtml
National Center for Hearing
Assessment and Management
www.infanthearing.org/
National Hearing Conservation
Association
National Institute on Deafness and
www.hearingconservation.org/
Other Communication Disorders
(NIDCD)
www.nidcd.nih.gov/
NIDCD “Wise Ears!”
National Institute for Occupational
www.nidcd.nih.gov/health/wise/
Safety and Health (NIOSH): A
Practical Guide to Preventing Hearing
Loss (publication no. 96-110)
www.cdc.gov/niosh/docs/96-110/
Minnesota Department of Health www.health.state.mn.us/divs/fh/mch/hlth-
(MDH) Hearing and Vision website vis/index.html
MDH Online C&TC Hearing Training
www.health.state.mn.us/divs/fh/mch/webcours
e/hearing/index.cfm
Minnesota Early Childhood Screening
Statutes
www.revisor.mn.gov/statutes/?id=121A.17
Sight and Hearing Association www.sightandhearing.org/
45

HEARING GLOSSARY
Acoustic Trauma – Hearing loss resulting from a single exposure to very intense noise,
such as a blast or explosion.
Air Conduction Audiometry – Pure tone sounds are transmitted from an earphone to the
inner ear through the outer and middle ear.
Ambient Noise – Background noise present in the screening area.
Amplification – The use of hearing aids and other electronic devices to increase the
loudness of a sound so that it may be more easily received and understood.
ANSI – American National Standards Institute.
ASHA – American Speech-Language-Hearing Association.
Assistive Communication Devices – Devices and systems, which are available to help
deaf and hard of hearing people improve communication, adapt to their environment, and
function in society more effectively.
Audiogram – A graph on which a person’s ability to hear the safest sound at different
frequencies is recorded.
Audiologist – A professional who specializes in preventing, identifying and assessing
hearing impairments as well as managing any non medical rehabilitation of individuals
with hearing loss.
Audiometer – An instrument used to measure hearing.
External Auditory Canal – Includes auricle and external meatus up to the Tympanic
Membrane or ear canal.
Auditory Nerve – The eighth cranial nerve in the human body. The auditory nerve is the
nerve of hearing that sends signals from the cochlea to the brain.
Automated ABR/Auditory Brainstem Response – A non-invasive test that measures
responses in the brain waves to auditory stimulus. This test can indicate whether or not
sound is being detected, even in an infant. This test may also be referred to as Brainstem
Auditory Evoked Response (BAER), Brainstem Evoked Potential (BSEP), and Brainstem
Evoked Response (BSER).
Binaural – Pertaining to both ears.
46

Biologic Check – Doing an audiogram on a person serving as a control (no hearing loss or
stable hearing loss) and finding no variation greater than ± 5 dB from previous
audiograms.
Calibration Checks – Methods to determine the accuracy of an audiometer. The two
primary methods are:
Biological – Checking the audiometer against a known hearing level.
Electronic – Measurement of the absolute sound pressure levels of each frequency
and other characteristics, e.g., harmonic distortion, frequency count, rise-fall time.
Cerumen – The wax like secretion found within the external auditory canal; ear wax.
Cochlea – Snail shaped, fluid-filled capsule, which contains the organ of hearing.
Cochlear Implant – An electronic device surgically implanted in the inner ear to
stimulate nerve endings (cochlea) in order to receive and process sound and speech.
Compliance – A measurement taken during tympanometry showing the excursion of the
eardrum as a function of sound reflected back to the tympanometer under varying
pressures.
Conductive Hearing Loss – A hearing impairment due to “problems” in the outer and/or
middle ear, which prevents air-borne sound from being conducted to the cochlea.
Congenital Hearing Loss – Hearing loss present at birth or associated with the birth
process, or which develops in the first few days of life.
deca Pascals (daPa) – The unit of measurement of the pressure used in tympanometry.
The usual measured range is from +200 daPa to –400 daPa.
Decibel (dB) – Logarithmic unit that expresses the intensity of a sound.
ENT – A medical doctor who specializes in the ears, nose and throat. Sometimes referred
to as an otolaryngologist, or otologist.
Frequency – The number of vibrations per second of a sound. Frequency, expressed in
Hertz (Hz), determines the pitch of the sound.
Hearing Aid – An electronic device that conducts and amplifies sound to the ear.
Hearing Level – The amount of hearing loss indicated by audiometry and measured in
terms of decibels for any given frequency; may be used synonymously with “hearing
threshold level” (HTL).
47

Hearing Loss – Varies greatly from person to person. The American Speech-Language
and Hearing Association (ASHA) classifies hearing loss as follows:
0-20 dB – normal
21-25 dB – slight
26-40 dB – mild
41-55 dB – moderate
56-70 dB – moderately severe
71-90 dB – severe
91+ dB – profound
Hertz (Hz) – The unit of measurement which specifies the frequency of a sound wave.
High Risk – Children who have one or more of the risk factors known to impact hearing.
Incus (anvil) – The middle bone of the ossicular chain.
Inner Ear – Made up of the cochlea, semi circular canals and vestibules.
Intensity – The loudness of a sound, measured in decibels (dB).
Loudness – The psychological correlate of intensity.
Malleus (hammer) – The first bone of the ossicular chain; it is attached to the eardrum.
Mastoid – The hard bony area of the temporal bone just behind the auricle.
Middle Ear – The portion of the ear from the eardrum (tympanic membrane) to the inner
ear.
Mixed Hearing Loss – A combination of conductive and sensorineural hearing loss.
Myringotomy – Surgical opening of the ear drum with or without insertion of a
ventilating tube.
Noise – Any sound that is unwanted, undesired, or interferes with one’s hearing.
Ossicles – Three small bones in the middle ear cavity; malleus, incus, and stapes.
Otitis Media – Inflammation of the middle ear or eardrum.
Otoacoustic Emissions (OAE) – This test evaluates hearing in infants and young children
who cannot be tested using common methods. The test measures sound which is reflected
back into the ear canal. It uses a computer to analyze responses.
Otoscope – Instrument to examine the ear canal and eardrum.
48

Outer Ear – The part of the ear from the Pinna to the eardrum (tympanic membrane)
consisting of the auricle and external auditory canal.
Pinna – Outer ear, sometimes called the auricle.
Pitch – The psychological correlate of frequency.
Play Audiometry – Special technique used to screen hearing of young children and/or
developmentally delayed individuals.
Pure Tone – A tone of a single frequency produced by an audiometer. A pure tone
contains no harmonics or overtones.
Screening Audiometry – Hearing test procedures used to identify individuals in need of
further hearing evaluation. Also called Sweep Screening.
Sensorineural Hearing Loss – A type of hearing loss due to pathology of the inner ear
(cochlea) or the nerve pathway from the inner ear (cochlea) and/or nerve of hearing to the
brain stem. Sensorineural damage is usually irreversible.
Stapes (stirrup) – The third and smallest bone of the ossicular chain.
Threshold – The softest (minimum) hearing level at which an individual is able to
respond to a tone at least 50% of the time.
Tubes – See Ventilation Tubes.
Tympanic Membrane – A thin membrane between the external auditory canal and the
middle ear cavity, it moves in response to sound waves and sets the ossicular chain into
motion.
Tinnitis – Inner ear sounds (ringing, buzzing, or roaring) perceived from possible damage
to nerve cells.
Tympanogram – The visual representation (results) of tympanometry.
Tympanometry – An instrument that measures the movement of the tympanic membrane
and middle ear system under varying air pressures.
Unilateral Hearing Loss – A mild to profound hearing loss in one ear.
Ventilation Tubes – Small plastic or metal tubes inserted through the eardrum to drain
fluid from the middle ear cavity and to equalize air pressure in the middle ear.
49

REFERENCES
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2 Keren, R., Helfand, M., Homer, C., McPhillips, H., & Lieu, T. A. (2002). Projected cost effectiveness of
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3 Minnesota Department of Health, Newborn Screening Program (2010).
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6 Bess, F., Dodd-Murphy, J. & Parker, R. (1998). Children with minimal sensorineural hearing loss:
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14 National Center for Hearing Assessment and Management. (2008). Issues and Evidence: Accuracy of
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