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Tympanometry in Infants: A Study of the Sensitivity and Specificity of 226-Hz and 1,000-Hz Probe Tones

Abstract

Introduction

 For infants under 6 months, the literature recommends 1,000-Hz tympanometry, which has a greater sensitivity for the correct identification of middle ear disorders in this population.

Objective

 To systematically analyze national and international publications found in electronic databases that used tympanometry with 226-Hz and 1,000-Hz probe tones.

Data Synthesis

 Initially, we identified 36 articles in the SciELO database, 11 in the Latin American and Caribbean Literature on the Health Sciences (LILACS) database, 199 in MEDLINE, 0 in the Cochrane database, 16 in ISI Web of Knowledge, and 185 in the Scopus database. We excluded 433 articles because they did not fit the selection criteria, leaving 14 publications that were analyzed in their entirety.

Conclusions

 The 1,000-Hz tone test has greater sensitivity and specificity for the correct identification of tympanometric curve changes. However, it is necessary to clarify the doubts that still exist regarding the use of this test frequency. Improved methods for rating curves, standardization of normality criteria, and the types of curves found in infants should be addressed.

Keywords
speech language and hearing sciences; hearing; acoustic impedance tests; otitis media with effusion; spontaneous otoacoustic emissions


Introduction

Tympanometry is effective in the early identification of changes in the external ear (EE) and middle ear (ME), and its use is well established for children and adults. However, its use for newborns and infants is still controversial. The literature recommends 1,000-Hz tympanometry for infants under 6 months, which has a greater sensitivity for the correct identification of ME dysfunction in this population.11 Kei J, Allison-Levick J, Dockray J, et al. High-frequency (1000 Hz) tympanometry in normal neonates. J Am Acad Audiol 2003; 14(1):20-28 , 22 Margolis RH, Bass-Ringdahl S, Hanks WD, Holte L, Zapala DA. Tympanometry in newborn infants-1 kHz norms. J Am Acad Audiol 2003;14(7):383-392

Literature Review

ME alterations have a high incidence in children. The presence of otitis media with effusion, cerumen, vernix, or other causes of conductive hearing loss contribute to a large number of false-positive results in neonatal hearing screening and may also delay the completion of diagnostic audiology. Therefore, it is important to identify hearing screening failures caused by transient changes in the ME and EE through an instrument that allows quick, accurate, and noninvasive assessment.11 Kei J, Allison-Levick J, Dockray J, et al. High-frequency (1000 Hz) tympanometry in normal neonates. J Am Acad Audiol 2003; 14(1):20-28 , 22 Margolis RH, Bass-Ringdahl S, Hanks WD, Holte L, Zapala DA. Tympanometry in newborn infants-1 kHz norms. J Am Acad Audiol 2003;14(7):383-392

One of the assessment tools used in routine audiology of the ME is the measurement of acoustic impedance, which is a general term related to the transfer of acoustic energy, either by facilitation (admittance) of or opposition (impedance) to the passage of sound energy. This is influenced by the amount of sound energy that is absorbed and reflected by the tympanic membrane (TM). When it is more compliant, the TM absorbs more energy and therefore allows greater admittance of the system. On the other hand, the more rigid the TM, the more energy will be reflected, creating greater system impedance.33 Carvallo RM. Medidas eletroacústicas imitância acústica. In: Carvallo RM, ed. Fonoaudiologia Informação para a Formação. Procedimentos em Audiologia. Rio de Janeiro, Brazil: Guanabara Koogan; 2003:1-22 , 44 Margolis RH, Hunter LL. Timpanometria: princípios básicos e aplicações clínicas. In: Musiek FR, RintelmanWF eds. Perspectivas Atuais em Avaliação Auditiva. São Paulo, Brazil: Manole; 2001: 85-126

Tympanometry is a measure of the variation of the acoustic impedance of the tympanic ossicular system caused by pressure variations introduced into the external auditory canal and indicates the condition of the ME and auditory pathways.44 Margolis RH, Hunter LL. Timpanometria: princípios básicos e aplicações clínicas. In: Musiek FR, RintelmanWF eds. Perspectivas Atuais em Avaliação Auditiva. São Paulo, Brazil: Manole; 2001: 85-126 In audiology, the most commonly used probe tone has a low frequency of 226 Hz; however, more modern equipment includes additional probe tones such as 660, 678, and 1,000 Hz.

Tympanometry is a common practice in children and adults, and its specifications are very well established. However, there are many uncertainties regarding the specificity and sensitivity of the probe tones used in the evaluation of neonates and infants. The literature has shown that in neonates and infants, tympanograms obtained with a low-frequency probe tone can be recorded as normal, even in the presence of altered ME function.22 Margolis RH, Bass-Ringdahl S, Hanks WD, Holte L, Zapala DA. Tympanometry in newborn infants-1 kHz norms. J Am Acad Audiol 2003;14(7):383-392

3 Carvallo RM. Medidas eletroacústicas imitância acústica. In: Carvallo RM, ed. Fonoaudiologia Informação para a Formação. Procedimentos em Audiologia. Rio de Janeiro, Brazil: Guanabara Koogan; 2003:1-22

4 Margolis RH, Hunter LL. Timpanometria: princípios básicos e aplicações clínicas. In: Musiek FR, RintelmanWF eds. Perspectivas Atuais em Avaliação Auditiva. São Paulo, Brazil: Manole; 2001: 85-126

5 Sininger YS. Audiologic assessment in infants. Curr Opin Otolaryngol Head Neck Surg 2003;11(5):378-382
- 66 Shahnaz N, Miranda T, Polka L. Multifrequency tympanometry in neonatal intensive care unit and well babies. J Am Acad Audiol 2008;19(5):392-418 High-frequency probe tones, in particular 1,000 Hz, have a higher sensitivity for the identification of ME changes and therefore should be used in neonates and infants under 6 or 7 months of age if possible.22 Margolis RH, Bass-Ringdahl S, Hanks WD, Holte L, Zapala DA. Tympanometry in newborn infants-1 kHz norms. J Am Acad Audiol 2003;14(7):383-392 , 44 Margolis RH, Hunter LL. Timpanometria: princípios básicos e aplicações clínicas. In: Musiek FR, RintelmanWF eds. Perspectivas Atuais em Avaliação Auditiva. São Paulo, Brazil: Manole; 2001: 85-126

5 Sininger YS. Audiologic assessment in infants. Curr Opin Otolaryngol Head Neck Surg 2003;11(5):378-382

6 Shahnaz N, Miranda T, Polka L. Multifrequency tympanometry in neonatal intensive care unit and well babies. J Am Acad Audiol 2008;19(5):392-418

7 Baldwin M. Choice of probe tone and classification of trace patterns in tympanometry undertaken in early infancy. Int J Audiol 2006;45(7):417-427
- 88 Swanepoel W, Werner S, Hugo R, Louw B, Owen R, Swanepoel A. High frequency immittance for neonates: a normative study. Acta Otolaryngol 2007;127(1):49-56

The objectives of this study were to systematically analyze national and international scientific publications on the application of tympanometry in infants using 226-Hz and 1,000-Hz test tones and to compare sensitivity and specificity between these two test tones.

To investigate the number of publications on this topic, two researchers independently conducted a bibliographic survey in the SciELO, Latin American and Caribbean Literature on the Health Sciences (LILACS), MEDLINE, Cochrane, Scopus, and ISI Web of Knowledge electronic databases. For the search strategy, the Descriptors in Health Sciences (MeSH, created by the National Library of Medicine) term acoustic impedance tests was combined with the words neonate and infant. National and international articles published in the past 10 years were examined, delimiting the period between January 2001 and December 2011.

The inclusion criteria for the full analysis of texts were as follows: original article or case report; infants up to 7 months old as the research subjects; use of 1,000-Hz probe tone as tone test during tympanometry; description of tympanometric curves obtained; and published in Portuguese, English, or Spanish.

The articles that met the inclusion criteria were selected for review in full, analyzed, and organized in a database with the following parameters: author(s), title, source, year, research type, sample characteristics, test tones used, main findings, and classification of tympanometric curves.

Discussion

Initially, 447 articles were identified. Thirty-six articles were found in the SciELO database, 11 in the LILACS database, 199 in MEDLINE, 0 in the Cochrane database, 16 in ISI Web of Knowledge, and 185 in the Scopus database. We excluded 433 publications because they did not fit the selection criteria, leaving 14 publications that were analyzed in their entirety. The route taken for selection and analysis of text is shown in Fig. 1.

Fig. 1
Route taken for selection and analysis of text.

The 14 selected publications were analyzed considering the source and year of publication. It was found that in the 10-year period investigated (2001 to 2011), the number of studies performed on tympanometry with high-frequency probe tones was not significant, but the number of publications increased from the year 2006 (Table 1).

Table 1
List of studies on tympanometry with high- and low-frequency probe tones from 2001 to 2011

A thorough analysis of the publications was performed considering the characteristics of the sample, the test tone frequencies used in tympanometry, the main findings identified, and the classification of tympanometric curves (Table 2). This information is presented and discussed hereafter, with the assistance of other theoretical publications considered relevant for the purpose of better understanding the topic in question.

Table 2
Main characteristics of studies with test tones of 226- and 1,000-Hz

Test Frequency and Age

In neonates and infants, growth entails changes in the ear that generate mechanical alterations, which can influence tympanogram recordings. These changes include increased EE, mastoid, and ME cavity; mass reduction of the ME due to changes in bone density; and bone formation in the wall of the external auditory canal.44 Margolis RH, Hunter LL. Timpanometria: princípios básicos e aplicações clínicas. In: Musiek FR, RintelmanWF eds. Perspectivas Atuais em Avaliação Auditiva. São Paulo, Brazil: Manole; 2001: 85-126 In addition, the resonance of the ME is modified according to age; the resonance frequency of the ME is lower in babies when compared with the values of an adult.99 Weatherby LA, Bennett MJ. The neonatal acoustic reflex. Scand Audiol 1980;9(2):103-110 Sagging of the ear canal can also cause movement of the wall of the ear canal.1010 Keefe DH, Bulen JC, Arehart KH, Burns EM. Ear-canal impedance and reflection coefficient in human infants and adults. J Acoust Soc Am 1993;94(5):2617-2638 , 1111 Gravel JS, Hood LJ. Avaliação audiológica infantil. In: Musiek FE, Rintelmann WF, eds. Perspectivas Atuais em Avaliação Auditiva. São Paulo, Brazil: Manole; 2001:301-322

In the literature, there are notable divergences in the age at which the high-frequency probe test is recommended. There are indications for its use in children under 7 months of age,22 Margolis RH, Bass-Ringdahl S, Hanks WD, Holte L, Zapala DA. Tympanometry in newborn infants-1 kHz norms. J Am Acad Audiol 2003;14(7):383-392 , 44 Margolis RH, Hunter LL. Timpanometria: princípios básicos e aplicações clínicas. In: Musiek FR, RintelmanWF eds. Perspectivas Atuais em Avaliação Auditiva. São Paulo, Brazil: Manole; 2001: 85-126

5 Sininger YS. Audiologic assessment in infants. Curr Opin Otolaryngol Head Neck Surg 2003;11(5):378-382

6 Shahnaz N, Miranda T, Polka L. Multifrequency tympanometry in neonatal intensive care unit and well babies. J Am Acad Audiol 2008;19(5):392-418

7 Baldwin M. Choice of probe tone and classification of trace patterns in tympanometry undertaken in early infancy. Int J Audiol 2006;45(7):417-427
- 88 Swanepoel W, Werner S, Hugo R, Louw B, Owen R, Swanepoel A. High frequency immittance for neonates: a normative study. Acta Otolaryngol 2007;127(1):49-56 less than 6 months old,1212 Joint Committee on Infant Hearing. Year 2007 Position Statement: Principles and Guidelines for Early Hearing Detection and Intervention Programs. Pediatrics 2007;120(4):898-921 , 1313 Newborn Hearing Screening and Assessment. Tympanometry in babies under 6 months. A Recommended Test Protocol [cited November 20, 2012]. Available at: http://hearing.screening.nhs.uk/audiologyprotocols#fileid10753
Available at: http:...
less than 4 months old,1414 Holte L, Margolis RH, Cavanaugh RMJr. Developmental changes in multifrequency tympanograms. Audiology 1991;30(1):1-24 and under 5 months of age.77 Baldwin M. Choice of probe tone and classification of trace patterns in tympanometry undertaken in early infancy. Int J Audiol 2006;45(7):417-427 Other authors claim that for use of 1,000-Hz test tones in infants up to 3 months old and between 3 and 9 months of age, ME evaluation must be performed in two stages. Initially, the 1,000-Hz test tone should be used and in cases of failure with this tone, testing should then be performed with a 226-Hz probe tone. The use of a low test frequency of 226 Hz has also been indicated for the assessment of infants over 9 months.1515 Alaerts J, Luts H, Wouters J. Evaluation of middle ear function in young children: clinical guidelines for the use of 226- and 1,000- Hz tympanometry. Otol Neurotol 2007;28(6):727-732

Classification of Tympanometric Curves

According to the literature, tympanometric curves are usually classified as follows: type A (normal curve having a single peak of admittance between −150 and 100 daPa and a volume of 0.2 to 1.8 mL); flat or type B (flat curve with no admittance peak); type C (admittance peak shifted to negative pressures); As (curve with low admittance); Ad (interval between the two branches of the curve equal to or greater than 100 daPa)1616 Jerger J. Clinical experience with impedance audiometry. Arch Otolaryngol 1970;92(4):311-324; DP (double peak curve)1717 Lidén G. The scope and application of current audiometric tests. J Laryngol Otol 1969;83(6):507-520; ASS (asymmetrical curve with peak at high positive pressure); and I (inverted curve with an inverted configuration compared with the normal curve).1818 Margolis RH, Smith P. Tympanometry in infants: state of art. In: Harford E, Klein J eds. Impedance Screening of Middle Ear Disease in Children. New York, NY: Grune and Stratton; 1978 However, there are also other less common types of tympanometric curves.1919 Sutton G, Baldwin M, Brooks D, Gravel J, Thornton R. Tympanometry in neonates and infants under 4months: a recommended test protocol. Manchester, England 2002 [cited November 20, 2012]. Available at: http://hearing.screening.nhs.uk/
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, 2020 Marchant CD,McMillan PM, Shurin PA, et al. Objective diagnosis of otitis media in early infancy by tympanometry and ipsilateral acoustic reflex thresholds. J Pediatr 1986;109:590-595 , 2121 Vanhuyse VJ, Creten WL, Van Camp KJ. On the W-notching of tympanograms. Scand Audiol 1975;4(1):45-50

Among the studies analyzed in the current review, it was observed that there was a consensus that the type A curve indicated a normal ME,11 Kei J, Allison-Levick J, Dockray J, et al. High-frequency (1000 Hz) tympanometry in normal neonates. J Am Acad Audiol 2003; 14(1):20-28 , 1515 Alaerts J, Luts H, Wouters J. Evaluation of middle ear function in young children: clinical guidelines for the use of 226- and 1,000- Hz tympanometry. Otol Neurotol 2007;28(6):727-732 , 1717 Lidén G. The scope and application of current audiometric tests. J Laryngol Otol 1969;83(6):507-520 , 1818 Margolis RH, Smith P. Tympanometry in infants: state of art. In: Harford E, Klein J eds. Impedance Screening of Middle Ear Disease in Children. New York, NY: Grune and Stratton; 1978 , 1919 Sutton G, Baldwin M, Brooks D, Gravel J, Thornton R. Tympanometry in neonates and infants under 4months: a recommended test protocol. Manchester, England 2002 [cited November 20, 2012]. Available at: http://hearing.screening.nhs.uk/
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and B, C, As, and Ad curves implied an altered ME.1515 Alaerts J, Luts H, Wouters J. Evaluation of middle ear function in young children: clinical guidelines for the use of 226- and 1,000- Hz tympanometry. Otol Neurotol 2007;28(6):727-732 , 2222 GarciaMV, AzevedoMF, Testa JR. Accoustic immitancemeasures in infantswith 226 and 1000 hz probes: correlationwith otoacoustic emissions and otoscopy examination. Braz J Otorhinolaryngol 2009;75(1):80-89 , 2323 Camboim ED, Correia AMN, Vasconcelos D, Torres R, Scharlach RC, Azevedo MF. Comparative analysis of otoacoustic emissions with tympanometry in 0-6 month infants. Rev CEFAC-Speech, Language, Hearing Sciences and Education Journal [online] 2012; 14(3):403-412 [cited November 20, 2012]. Available at: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-8462012000300004&lng=en&nrm=iso
Available at: http:...
, 2424 Tazinazzio TG, Diniz TA, Marba STM, Colella-Santos MF. Otoacoustic emissions and acoustic immitance measurements using 226 Hz and 1000 Hz probe tones in neonates. Rev CEFAC-Speech, Language, Hearing Sciences and Education Journal [online] 2011; 13 (3):479-488 [cited November 20, 2012]. Available at: http://www. scielo.br/scielo.php?script=sci_arttext&pid=S1516-8462011000300011&lng=pt&nrm=iso
Available at: http://www. ...
, 2525 Zhiqi L, Kun Y, Zhiwu H. Tympanometry in infants withmiddle ear effusion having been identified using spiral computerized tomography. Am J Otolaryngol 2010;31(2):96-103

Regarding the DP curve, also called a type D curve, five studies showed that this curve indicates normality of the ME in the case of neonates.1515 Alaerts J, Luts H, Wouters J. Evaluation of middle ear function in young children: clinical guidelines for the use of 226- and 1,000- Hz tympanometry. Otol Neurotol 2007;28(6):727-732 , 2222 GarciaMV, AzevedoMF, Testa JR. Accoustic immitancemeasures in infantswith 226 and 1000 hz probes: correlationwith otoacoustic emissions and otoscopy examination. Braz J Otorhinolaryngol 2009;75(1):80-89 , 2323 Camboim ED, Correia AMN, Vasconcelos D, Torres R, Scharlach RC, Azevedo MF. Comparative analysis of otoacoustic emissions with tympanometry in 0-6 month infants. Rev CEFAC-Speech, Language, Hearing Sciences and Education Journal [online] 2012; 14(3):403-412 [cited November 20, 2012]. Available at: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-8462012000300004&lng=en&nrm=iso
Available at: http:...
, 2424 Tazinazzio TG, Diniz TA, Marba STM, Colella-Santos MF. Otoacoustic emissions and acoustic immitance measurements using 226 Hz and 1000 Hz probe tones in neonates. Rev CEFAC-Speech, Language, Hearing Sciences and Education Journal [online] 2011; 13 (3):479-488 [cited November 20, 2012]. Available at: http://www. scielo.br/scielo.php?script=sci_arttext&pid=S1516-8462011000300011&lng=pt&nrm=iso
Available at: http://www. ...
, 2626 Meyer SE, Jardine CA, Deverson W. Developmental changes in tympanometry: a case study. Br J Audiol 1997;31(3):189-195 According to one author,33 Carvallo RM. Medidas eletroacústicas imitância acústica. In: Carvallo RM, ed. Fonoaudiologia Informação para a Formação. Procedimentos em Audiologia. Rio de Janeiro, Brazil: Guanabara Koogan; 2003:1-22 this type of tympanogram is most often identified in the neonate population when tympanometry testing is performed with a 226-Hz probe tone. This is because such registration occurs when measurement is performed at the resonant frequency of the ME and in the case of this population, this frequency is shifted to lower values.

Regarding the I and ASS curves, it was found that there are disagreements with regards to their normal standards and which parameters should be used for classification of a normal or altered curve. The ASS curve and the I curve can be identified in subjects with and without alteration of the ME and can be regarded as normal or altered.2222 GarciaMV, AzevedoMF, Testa JR. Accoustic immitancemeasures in infantswith 226 and 1000 hz probes: correlationwith otoacoustic emissions and otoscopy examination. Braz J Otorhinolaryngol 2009;75(1):80-89 , 2727 Silva KA, Novaes BA, Lewis DR, Carvallo RM. Tympanometry in neonates with normal otoacoustic emissions: measurements and interpretation. Braz J Otorhinolaryngol 2007;73(5):633-639 One publication stated that the I curve should be classified as normal in infants.2222 GarciaMV, AzevedoMF, Testa JR. Accoustic immitancemeasures in infantswith 226 and 1000 hz probes: correlationwith otoacoustic emissions and otoscopy examination. Braz J Otorhinolaryngol 2009;75(1):80-89

Besides the ambiguity that exists in the classification of curves with a 1,000-Hz probe tone, another issue regarding high-frequency tympanometry in neonates is the high number of unclassified or indeterminate curves obtained by the use of classification systems designated for the low-frequency tone test in adults and older children.77 Baldwin M. Choice of probe tone and classification of trace patterns in tympanometry undertaken in early infancy. Int J Audiol 2006;45(7):417-427 This has created more doubt and questions regarding curve classification and the parameters that define categorization as normal or abnormal.

In a study using 1,000-Hz testing, the authors classified curves as follows: type 1 (similar to type A), type 2 (similar to type B), type 3 (similar to DP), and atypical forms. With a 226-Hz tone test, in addition to using the classification of DP, the authors also used the nomenclature single-peak tympanogram, multiple-peak tympanogram, and invalid tympanogram. From this perspective, the authors concluded that there is no direct correspondence between ME condition and tympanometry curve type. However, the type 1 curve, which was obtained in 92.3% of neonates, indicated an ME without alterations.11 Kei J, Allison-Levick J, Dockray J, et al. High-frequency (1000 Hz) tympanometry in normal neonates. J Am Acad Audiol 2003; 14(1):20-28

It has been hypothesized that changes in the patterns of tympanometry may also vary according to the age of the individuals assessed. In one study using a 226-Hz probe tone, the percentage of type A curves increased with increasing age, and the percentage of DP curves decreased.1515 Alaerts J, Luts H, Wouters J. Evaluation of middle ear function in young children: clinical guidelines for the use of 226- and 1,000- Hz tympanometry. Otol Neurotol 2007;28(6):727-732 Furthermore, the use of the 1,000-Hz tone decreased the prevalence of flat tympanograms and increased DP curves in a group of children. However, it should be mentioned that the sample surveyed included no children with ME alterations.

Changes in the quantitative values of tympanometry can be justified by the rapid anatomical growth of the ear in neonates during the first 6 weeks of life.2828 Mazlan R, Kei J, Hickson L, et al. High frequency immittance findings: newborn versus six-week-old infants. Int J Audiol 2007;46:711-717 An increase in resonance frequency occurs in the ear of neonates, and this shifts the type of tympanometric curve from DP to single peak. This alteration can be explained by anatomical evidence showing that the physical structure of the ear changes from a state allowing positive reactance (dominated by mass) to one allowing negative reactance (dominated by stiffness). When the ME reaches negative reactance, the low-frequency tone test becomes an appropriate tool to evaluate the peripheral auditory system. That is, with the evaluation of ear reactance, it is possible to identify the resonance frequency, and if this is low, the use of a high-frequency tone is sufficiently sensitive. However, if this frequency approaches the frequency of the adult, the conventional 226-Hz tone should be used. Such changes in resonance frequency may be due to intrasubject variability or true evolution of ME function with age.2626 Meyer SE, Jardine CA, Deverson W. Developmental changes in tympanometry: a case study. Br J Audiol 1997;31(3):189-195

Relationship between Tympanometry and Other Audiological Evaluations

Other procedures used to identify hearing loss in infants include measurement of otoacoustic emissions (OAEs) and brainstem auditory evoked potentials. It is possible to correlate the results of these procedures and tympanometry traces to better assess hearing condition.

The literature indicates that the 1,000-Hz probe tone has a higher correlation with the responses of transient otoacoustic emissions (TOAEs) and distortion product otoacoustic emissions.2323 Camboim ED, Correia AMN, Vasconcelos D, Torres R, Scharlach RC, Azevedo MF. Comparative analysis of otoacoustic emissions with tympanometry in 0-6 month infants. Rev CEFAC-Speech, Language, Hearing Sciences and Education Journal [online] 2012; 14(3):403-412 [cited November 20, 2012]. Available at: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-8462012000300004&lng=en&nrm=iso
Available at: http:...
, 2424 Tazinazzio TG, Diniz TA, Marba STM, Colella-Santos MF. Otoacoustic emissions and acoustic immitance measurements using 226 Hz and 1000 Hz probe tones in neonates. Rev CEFAC-Speech, Language, Hearing Sciences and Education Journal [online] 2011; 13 (3):479-488 [cited November 20, 2012]. Available at: http://www. scielo.br/scielo.php?script=sci_arttext&pid=S1516-8462011000300011&lng=pt&nrm=iso
Available at: http://www. ...
, 2929 Swanepoel W, Hugo R, Louw B. Infant hearing screening at immunization clinics in South Africa. Int J Pediatr Otorhinolaryngol 2006;70(7):1241-1249 The 1,000-Hz tone displays this correlation in both the evaluation of normal ears and ears with ME alterations. Tympanometry with a 226-Hz tone provides results consistent with assessment of OAEs in the presence of a normal ME only.2323 Camboim ED, Correia AMN, Vasconcelos D, Torres R, Scharlach RC, Azevedo MF. Comparative analysis of otoacoustic emissions with tympanometry in 0-6 month infants. Rev CEFAC-Speech, Language, Hearing Sciences and Education Journal [online] 2012; 14(3):403-412 [cited November 20, 2012]. Available at: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-8462012000300004&lng=en&nrm=iso
Available at: http:...

For infants with TOAEs present, both probe tones have good specificity but, for infants with TOAEs absent, the 1,000-Hz tone is more sensitive for the identification of possible alterations in the ME.2222 GarciaMV, AzevedoMF, Testa JR. Accoustic immitancemeasures in infantswith 226 and 1000 hz probes: correlationwith otoacoustic emissions and otoscopy examination. Braz J Otorhinolaryngol 2009;75(1):80-89 From this perspective, the use of tympanometry with a 1,000-Hz tone in infants is the most appropriate procedure for detecting changes in the ME, especially when TOAEs are absent.2424 Tazinazzio TG, Diniz TA, Marba STM, Colella-Santos MF. Otoacoustic emissions and acoustic immitance measurements using 226 Hz and 1000 Hz probe tones in neonates. Rev CEFAC-Speech, Language, Hearing Sciences and Education Journal [online] 2011; 13 (3):479-488 [cited November 20, 2012]. Available at: http://www. scielo.br/scielo.php?script=sci_arttext&pid=S1516-8462011000300011&lng=pt&nrm=iso
Available at: http://www. ...

On the other hand, different tympanometry curve types can be identified even in the presence of different OAE recordings. The reason for the detection of heterogeneous curves even with the presence of OAEs, which suggest normal ME function, is unclear. It may be due to the fact that light dysfunction of the ME is not able to prevent OAE recording or may even be caused by inadequate sealing of the probe, resulting in movement-generated artifacts.11 Kei J, Allison-Levick J, Dockray J, et al. High-frequency (1000 Hz) tympanometry in normal neonates. J Am Acad Audiol 2003; 14(1):20-28

The relationship between responses to 226- and 1,000-Hz probe tones and OAE recordings was also analyzed in a study of children with Down syndrome, showing a strong correlation between 1,000-Hz tympanometry and OAE results.3030 Lewis MP, Bradford Bell E, Evans AK. A comparison of tympanometry with 226 Hz and 1000 Hz probe tones in children with Down syndrome. Int J Pediatr Otorhinolaryngol 2011;75(12): 1492-1495

Test Frequency Most Suitable for Evaluation of Infants

Despite the fact that it has been used for decades, the 226-Hz tone test is not the most appropriate for assessing infants,11 Kei J, Allison-Levick J, Dockray J, et al. High-frequency (1000 Hz) tympanometry in normal neonates. J Am Acad Audiol 2003; 14(1):20-28 , 22 Margolis RH, Bass-Ringdahl S, Hanks WD, Holte L, Zapala DA. Tympanometry in newborn infants-1 kHz norms. J Am Acad Audiol 2003;14(7):383-392 , 55 Sininger YS. Audiologic assessment in infants. Curr Opin Otolaryngol Head Neck Surg 2003;11(5):378-382

6 Shahnaz N, Miranda T, Polka L. Multifrequency tympanometry in neonatal intensive care unit and well babies. J Am Acad Audiol 2008;19(5):392-418

7 Baldwin M. Choice of probe tone and classification of trace patterns in tympanometry undertaken in early infancy. Int J Audiol 2006;45(7):417-427
- 88 Swanepoel W, Werner S, Hugo R, Louw B, Owen R, Swanepoel A. High frequency immittance for neonates: a normative study. Acta Otolaryngol 2007;127(1):49-56 , 2222 GarciaMV, AzevedoMF, Testa JR. Accoustic immitancemeasures in infantswith 226 and 1000 hz probes: correlationwith otoacoustic emissions and otoscopy examination. Braz J Otorhinolaryngol 2009;75(1):80-89

23 Camboim ED, Correia AMN, Vasconcelos D, Torres R, Scharlach RC, Azevedo MF. Comparative analysis of otoacoustic emissions with tympanometry in 0-6 month infants. Rev CEFAC-Speech, Language, Hearing Sciences and Education Journal [online] 2012; 14(3):403-412 [cited November 20, 2012]. Available at: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-8462012000300004&lng=en&nrm=iso
Available at: http:...
- 2424 Tazinazzio TG, Diniz TA, Marba STM, Colella-Santos MF. Otoacoustic emissions and acoustic immitance measurements using 226 Hz and 1000 Hz probe tones in neonates. Rev CEFAC-Speech, Language, Hearing Sciences and Education Journal [online] 2011; 13 (3):479-488 [cited November 20, 2012]. Available at: http://www. scielo.br/scielo.php?script=sci_arttext&pid=S1516-8462011000300011&lng=pt&nrm=iso
Available at: http://www. ...
, 2727 Silva KA, Novaes BA, Lewis DR, Carvallo RM. Tympanometry in neonates with normal otoacoustic emissions: measurements and interpretation. Braz J Otorhinolaryngol 2007;73(5):633-639 mainly because, as already mentioned, this population has maturational characteristics that are distinct from children older than 6 months of age and adults.

Among the sources analyzed, were identified three studies that used testing tones of 678 and 630 Hz in addition to 226 and 1,000 Hz. In all three studies, the authors observed that the 1,000-Hz tone test showed better results for the characterization of tympanograms when compared with other frequencies.77 Baldwin M. Choice of probe tone and classification of trace patterns in tympanometry undertaken in early infancy. Int J Audiol 2006;45(7):417-427 , 2727 Silva KA, Novaes BA, Lewis DR, Carvallo RM. Tympanometry in neonates with normal otoacoustic emissions: measurements and interpretation. Braz J Otorhinolaryngol 2007;73(5):633-639 , 3131 Calandruccio L, Fitzgerald TS, Prieve BA. Normative multifrequency tympanometry in infants and toddlers. J Am Acad Audiol 2006;17(7):470-480

Studies have shown that the efficacy of the 1,000-Hz tone in relation to the 226-Hz and 678-Hz probe tones is justified by the fact that mass components are larger at high-frequency probe tones and lower at low-frequency probe tones, which modifies the resonance characteristics of the ME.11 Kei J, Allison-Levick J, Dockray J, et al. High-frequency (1000 Hz) tympanometry in normal neonates. J Am Acad Audiol 2003; 14(1):20-28 , 22 Margolis RH, Bass-Ringdahl S, Hanks WD, Holte L, Zapala DA. Tympanometry in newborn infants-1 kHz norms. J Am Acad Audiol 2003;14(7):383-392 Changes in the wall of the external auditory canal, ME mobility, and tympanometric characteristics are observed in the first months of life. This is because the ME of children is dominated by the component of mass, and the resonance frequency tends to be lower when compared with normal adults, in whom the system is controlled by stiffness.1414 Holte L, Margolis RH, Cavanaugh RMJr. Developmental changes in multifrequency tympanograms. Audiology 1991;30(1):1-24 A Brazilian study investigating resonance frequency reported a value of 250 Hz in children between 2 and 12 days and a value of 385 Hz in children between 72 and 84 days.3232 André KD, Sanches SGG, Carvallo RMM. Middle ear resonance in infants: age effects. Int Arch Otorhinolaryngol 2012;16(3): 353-357

Conclusion

After the analysis of several publications, it was found that both the test tones of 226 and 1,000 Hz show false-positive results (indicating the presence of alterations in the ME when they do not exist) and false-negative results (when changes are not detected even in their presence). However, both false-positives and false-negatives are less frequent with the 1,000-Hz probe tone. For this reason, the test frequency of 1,000 Hz is more sensitive and specific than the frequency of 226 Hz for the assessment of ME alterations in neonates. Therefore, it is concluded that this probe tone is most appropriate for evaluating infants less than 6 months of age. Although the literature confirms that the 1,000-Hz tone test is the most appropriate for assessment in this population, further studies are needed to clarify the doubts that still exist regarding the use of tympanometry with a high-frequency tone. In addition, better systems for the classification of curves and normality criteria should be investigated.

References

  • 1
    Kei J, Allison-Levick J, Dockray J, et al. High-frequency (1000 Hz) tympanometry in normal neonates. J Am Acad Audiol 2003; 14(1):20-28
  • 2
    Margolis RH, Bass-Ringdahl S, Hanks WD, Holte L, Zapala DA. Tympanometry in newborn infants-1 kHz norms. J Am Acad Audiol 2003;14(7):383-392
  • 3
    Carvallo RM. Medidas eletroacústicas imitância acústica. In: Carvallo RM, ed. Fonoaudiologia Informação para a Formação. Procedimentos em Audiologia. Rio de Janeiro, Brazil: Guanabara Koogan; 2003:1-22
  • 4
    Margolis RH, Hunter LL. Timpanometria: princípios básicos e aplicações clínicas. In: Musiek FR, RintelmanWF eds. Perspectivas Atuais em Avaliação Auditiva. São Paulo, Brazil: Manole; 2001: 85-126
  • 5
    Sininger YS. Audiologic assessment in infants. Curr Opin Otolaryngol Head Neck Surg 2003;11(5):378-382
  • 6
    Shahnaz N, Miranda T, Polka L. Multifrequency tympanometry in neonatal intensive care unit and well babies. J Am Acad Audiol 2008;19(5):392-418
  • 7
    Baldwin M. Choice of probe tone and classification of trace patterns in tympanometry undertaken in early infancy. Int J Audiol 2006;45(7):417-427
  • 8
    Swanepoel W, Werner S, Hugo R, Louw B, Owen R, Swanepoel A. High frequency immittance for neonates: a normative study. Acta Otolaryngol 2007;127(1):49-56
  • 9
    Weatherby LA, Bennett MJ. The neonatal acoustic reflex. Scand Audiol 1980;9(2):103-110
  • 10
    Keefe DH, Bulen JC, Arehart KH, Burns EM. Ear-canal impedance and reflection coefficient in human infants and adults. J Acoust Soc Am 1993;94(5):2617-2638
  • 11
    Gravel JS, Hood LJ. Avaliação audiológica infantil. In: Musiek FE, Rintelmann WF, eds. Perspectivas Atuais em Avaliação Auditiva. São Paulo, Brazil: Manole; 2001:301-322
  • 12
    Joint Committee on Infant Hearing. Year 2007 Position Statement: Principles and Guidelines for Early Hearing Detection and Intervention Programs. Pediatrics 2007;120(4):898-921
  • 13
    Newborn Hearing Screening and Assessment. Tympanometry in babies under 6 months. A Recommended Test Protocol [cited November 20, 2012]. Available at: http://hearing.screening.nhs.uk/audiologyprotocols#fileid10753
    » Available at: http://hearing.screening.nhs.uk/audiologyprotocols#fileid10753
  • 14
    Holte L, Margolis RH, Cavanaugh RMJr. Developmental changes in multifrequency tympanograms. Audiology 1991;30(1):1-24
  • 15
    Alaerts J, Luts H, Wouters J. Evaluation of middle ear function in young children: clinical guidelines for the use of 226- and 1,000- Hz tympanometry. Otol Neurotol 2007;28(6):727-732
  • 16
    Jerger J. Clinical experience with impedance audiometry. Arch Otolaryngol 1970;92(4):311-324
  • 17
    Lidén G. The scope and application of current audiometric tests. J Laryngol Otol 1969;83(6):507-520
  • 18
    Margolis RH, Smith P. Tympanometry in infants: state of art. In: Harford E, Klein J eds. Impedance Screening of Middle Ear Disease in Children. New York, NY: Grune and Stratton; 1978
  • 19
    Sutton G, Baldwin M, Brooks D, Gravel J, Thornton R. Tympanometry in neonates and infants under 4months: a recommended test protocol. Manchester, England 2002 [cited November 20, 2012]. Available at: http://hearing.screening.nhs.uk/
    » Available at: http://hearing.screening.nhs.uk/
  • 20
    Marchant CD,McMillan PM, Shurin PA, et al. Objective diagnosis of otitis media in early infancy by tympanometry and ipsilateral acoustic reflex thresholds. J Pediatr 1986;109:590-595
  • 21
    Vanhuyse VJ, Creten WL, Van Camp KJ. On the W-notching of tympanograms. Scand Audiol 1975;4(1):45-50
  • 22
    GarciaMV, AzevedoMF, Testa JR. Accoustic immitancemeasures in infantswith 226 and 1000 hz probes: correlationwith otoacoustic emissions and otoscopy examination. Braz J Otorhinolaryngol 2009;75(1):80-89
  • 23
    Camboim ED, Correia AMN, Vasconcelos D, Torres R, Scharlach RC, Azevedo MF. Comparative analysis of otoacoustic emissions with tympanometry in 0-6 month infants. Rev CEFAC-Speech, Language, Hearing Sciences and Education Journal [online] 2012; 14(3):403-412 [cited November 20, 2012]. Available at: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-8462012000300004&lng=en&nrm=iso
    » Available at: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-8462012000300004&lng=en&nrm=iso
  • 24
    Tazinazzio TG, Diniz TA, Marba STM, Colella-Santos MF. Otoacoustic emissions and acoustic immitance measurements using 226 Hz and 1000 Hz probe tones in neonates. Rev CEFAC-Speech, Language, Hearing Sciences and Education Journal [online] 2011; 13 (3):479-488 [cited November 20, 2012]. Available at: http://www. scielo.br/scielo.php?script=sci_arttext&pid=S1516-8462011000300011&lng=pt&nrm=iso
    » Available at: http://www. scielo.br/scielo.php?script=sci_arttext&pid=S1516-8462011000300011&lng=pt&nrm=iso
  • 25
    Zhiqi L, Kun Y, Zhiwu H. Tympanometry in infants withmiddle ear effusion having been identified using spiral computerized tomography. Am J Otolaryngol 2010;31(2):96-103
  • 26
    Meyer SE, Jardine CA, Deverson W. Developmental changes in tympanometry: a case study. Br J Audiol 1997;31(3):189-195
  • 27
    Silva KA, Novaes BA, Lewis DR, Carvallo RM. Tympanometry in neonates with normal otoacoustic emissions: measurements and interpretation. Braz J Otorhinolaryngol 2007;73(5):633-639
  • 28
    Mazlan R, Kei J, Hickson L, et al. High frequency immittance findings: newborn versus six-week-old infants. Int J Audiol 2007;46:711-717
  • 29
    Swanepoel W, Hugo R, Louw B. Infant hearing screening at immunization clinics in South Africa. Int J Pediatr Otorhinolaryngol 2006;70(7):1241-1249
  • 30
    Lewis MP, Bradford Bell E, Evans AK. A comparison of tympanometry with 226 Hz and 1000 Hz probe tones in children with Down syndrome. Int J Pediatr Otorhinolaryngol 2011;75(12): 1492-1495
  • 31
    Calandruccio L, Fitzgerald TS, Prieve BA. Normative multifrequency tympanometry in infants and toddlers. J Am Acad Audiol 2006;17(7):470-480
  • 32
    André KD, Sanches SGG, Carvallo RMM. Middle ear resonance in infants: age effects. Int Arch Otorhinolaryngol 2012;16(3): 353-357

Publication Dates

  • Publication in this collection
    2013

History

  • Received
    20 Nov 2012
  • Accepted
    12 Feb 2013
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