OPEN ACCESS GUIDE TO AUDIOLOGY AND HEARING
AIDS FOR OTOLARYNGOLOGISTS
MOBILE PHONE AUDIOMETRY Faheema Mahomed-Asmail, De Wet Swanepoel
Recent estimates by the World Health moral obligation to pursue ways of penetra-
Organization (2013) indicate that 360 ting underserved communities with audio-
million persons, comprising 5.3% of the logical services. Tele-audiology holds the
global population, suffer from permanent promise of bridging this gap by delivering
disabling hearing loss. The high prevalence services through an expanding reach of
of hearing loss has resulted in hearing loss global connectivity.
becoming a significant global healthcare
burden due its long-term consequences on This chapter reviews applications available
affected individuals, communities and for hearing screening that have published
societies. Furthermore, the vast majority of validation data. A summarized description
individuals affected by a hearing loss may of the current available applications is
not have access to early detection services provided below according to the hardware
(WHO, 2010, 2013). However, with the and software utilized, the accuracy, advan-
widespread usage of mobile phones and tages and limitations, as well as from where
penetration of cellular network reception they can be downloaded.
globally, even in underserved regions such
as sub-Saharan Africa (Kelly & Minges, uHear™
2012), the use of mobile health (mHealth)
has emerged as a possible means of hearing Unitron developed uHear™ - a mobile
assessment. application which uses a mobile iOS Apple
operated device.
The trademark catch phrase, “There’s an
app for that” now has gained a place in
hearing health care. Utilization of tele-
health approaches for hearing assessment
has steadily gained acceptance in recent
years (Swanepoel & Hall, 2010; Swane-
poel et al, 2010). A recent study by
Paglialongaa, Tognola and Pinciroli
(2015) indicated that, in hearing health care,
there is a distribution of available apps in
five major categories: i) education &
information (23%), ii) hearing testing
(18%), iii) rehabilitation (24%), iv) sound
enhancement (28%), and v) assistive tools
(7%) (Paglialongaa, Tognola & Pinciroli,
2015).
Mobile applications for screening have
gained much interest of the past few years.
However, as a field in its infancy much
work remains to be done to develop and
validate the technology available as a means
of delivering services. The absence of
hearing healthcare for the vast majority of
people with hearing loss globally raises a Figure 1. Initial screen view of uHear™
Hardware and software Although it has many advantages the
following limitations exist
uHear™ is suitable for the following Apple
mobile devices: iPhone, iPod Touch and It is inaccurate for low frequencies
iPad. The application requires use of Apple- It must be performed in a quiet room or
endorsed insert headphones (ear-buds) a soundproof room
which are provided with the device. Any It does not distinguish between con-
compatible headphones with built-in back- ductive and sensorineural hearing loss
ground noise eliminators can also be used. Because it uses ear buds it may not be
The application can be download for free suited to patients with otorrhoea
from the iTunes website, or from Apple App Instructions are in English so non-
Store. English speakers need a translator to
explain the steps of the test
Accuracy and evidence
uHear™ can be download from iTunes at
Studies on uHear™ have indicated that it is http://itunes.apple.com/us/app/uhear/id309
sensitive only for high frequency hearing 811822?mt=8
loss in a quiet room (p<0.05) with mode-
rate sensitivity for detecting low frequency
hearing loss. It has been recommended that EarTrumpet
uHear™ should be used to screen those at
risk of developing or having a high fre- EarTrumpet (Praxis Biosciences, Irvine,
quency sensorineural hearing loss such as California) is a self-administered Apple iOS
smartphone application downloaded from
Patients on ototoxic drugs e.g. MDR- iTunes and can be installed on an iPhone
TB (Multi-Drug Resistant Tuberculo- and IPod Touch. It was originally created by
sis) therapy, chemotherapy, and Dr. Allen Foulad with the support of the
HAART (Highly Active Anti-Retro- Otolaryngology Department at the Univer-
viral) therapy sity of California, Irvine, USA.
Patients with presbyacusis
Children to be screened in a classroom, Hardware and software
if no other audiology services are
available EarTrumpet is an iOS-based hearing appli-
cation suite that provides a user-adminis-
Advantages and limitations tered hearing test and a customizable per-
sonal sound amplification tool. It is com-
uHear™ has the following advantages patible with the iPhone, iPod Touch (2nd
generation and later), and the iPad. A
It can be self-administered as it is easy headset that has both an earpiece and a
and simple to use microphone is recommended. An Apple
It takes only 6 minutes to administer the headset is required to provide the most
full test accurate hearing test results. EarTrumpet
Information is recorded on the mobile also allows selection of a headphone trans-
device and displayed immediately for ducer, with the application pre-calibrated
assessment for the accompanying Apple in-ear head-
It can be used on multiple Apple devi- phones (Foulad et al, 2013).
ces (iPhone, iPad or iPod Touch)
2
The hearing suite consists of two modules: Advantages and limitations
a hearing enhancer (i.e. sound amplifier)
and hearing test. The self-administered It has been reported that the EarTrumpet
hearing test module allows for three test screening tool yields an increase in self-
types and has an option to select a head- efficacy in individuals compared to indivi-
phone transducer (Foulad et al, 2013). Test duals who experienced a traditional hear-
types include “Basic” (i.e. thresholds ing screening model. This increase in self-
obtained at 500, 1000, 4000, 8000 Hz), efficacy improved the likelihood of impair-
“Comprehensive” (i.e. thresholds obtained ed listeners seeking the services and techno-
at audiometric octave frequencies between logies offered by hearing healthcare provi-
125 Hz and 8000 Hz), and “Custom” (i.e. ders (Amlani, 2014). Furthermore, it was
thresholds to be selected for testing). found that EarTrumpet could be used as part
of a hearing wellness program which would
Before the test, the tester needs to couple make healthcare available even with the
the headphone transducer to the respective limited supply of professionals entering the
ear, then calibrate the volume level of the profession (Swanepoel et al., 2010;
headphone’s output to a predetermined Windmill & Freeman, 2013). A limitation
level as depicted on the iPad screen by of this device is that it cannot be used on
means of a sliding bar and a green check Android applications and that the head-
mark. Then the tester initiates the hearing phones cannot be calibrated according to
test by pressing a button box labeled “start” current ISO standards.
which then defaults to the application
running a 5-second analysis of the levels in EarTrumpet can be downloaded from
the environment. Once the environment is iTunes at
considered satisfactory for testing, the https://itunes.apple.com/us/app/eartrumpet/
application screen defaults to a new screen id385494796
that displays a button box instructing the
tester to press the button when they hear a
series of three pulsed pure-tones. Thres- hearScreen™
holds at each frequency are determined in
5dB intervals and after the third ascending hearScreen™ was developed for hearing
reversal (Foulad et al, 2013). screening with automated test sequences
employing real-time monitoring of envi-
Accuracy and evidence ronmental noise and data management
facilities. It is being developed at the Uni-
The EarTrumpet and Apple iOS-based versity of Pretoria, and is a mobile pure tone
devices provide a platform for automated screening application that utilizes an inex-
air conduction audiometry without requir- pensive smartphone (Android OS) and
ing extra equipment and yield hearing test headphone hearScreen™. It is currently in a
results that approach those of conventional beta launch phase, and because the product
audiometry (Foulad et al, 2013). However has not been officially launched, its com-
it is indicated that EarTrumpet is intended mercial availability is currently limited.
for novelty purposes only and is not meant
to replace clinical hearing tests. The infor- Hardware and software
mation obtained from this application
should not be used in the diagnosis of any The hearScreen™ application uses an
medical condition, including but not limited Android SDK (software development kit)
to hearing loss. version 21.0.1 via the Eclipse IDE
3
(integrated development environment) ver- No significant difference for screening out-
sion 4.2.1 is developed for Android phones. comes using smartphone hearScreen™ and
The hearScreen™ software can link with a conventional audiometry was evident when
calibrated headphone to allow for accurate tested on school-aged children (Mahomed-
hearing testing and screening. The screen- Asmail et al., 2016). In addition, hear-
ing version makes use of a force-choice Screen™ has been validated in a primary
paradigm that requires the test operator to health care setting (Louw et al., in press)
present the test signal. Once the patient and can be administered by a lay person
indicates the tone has been heard the tester (Yousuf Hussein et al., in press).
is required to indicate whether the patient
has responded to the sound in a YES/NO Advantages and limitations
response provided on the application
(Figure 2). Based on the response, the hearScreen™ is a unique, patented solution
intensity and frequency change automatic- for school-based hearing screening, which
ally according to the programmed test pro- utilizes a commercial smartphone and head-
tocol. There is also a threshold version phones with a software module allowing for
(hearTest) that uses automated testing with calibration of signals according to current
a response button on the phone. standards (SANS 10154-1:2004). It makes
use of recommended screening protocols
preprogrammed for consistent, reliable and
user-friendly screening and has integrated
noise monitoring which provides real-time
feedback on compliance of environmental
noise to prescribed Maximum Permissible
Ambient Noise Levels (MPANLs).
It is intended for use by minimally trained
test facilitators and has been used by com-
munity health workers (Yousuf Hussein et
al., in press). It also has an electronic data
capturing feature, hearData, which allows
for data sharing with cellular or Wi-Fi
networks, ensuring data management which
permits monitoring outcomes and efficacy
of screening programs. A limitation of the
screening application is that it is only
compatible with Android OS software and
Figure 2. User-friendly force-choice para- requires calibrated headphones; however
digm with noise monitoring function this allows for validated and accurate
results and monitoring of MPANLs while
Accuracy and evidence testing.
hearScreen™ is calibrated according to cur- hearScreen™ is currently in a beta launch
rent standards (ANSI/ASA S3.6-2010 ; ISO phase. For more information visit
389-1,1998) and has shown that valid moni- https://www.hearscreen.com
toring of environmental noise can be
achieved according to maximum permissi-
ble ambient noise levels (MPANLs).
4
hearZA™ screen which prompts the user to put on the
smartphone headset and listen to digits
hearZA™, South Africa’s National Hearing being repeated. The user uses a scrollbar to
Test, is a self-test which serves as a speech- adjust the intensity of the digits to a
in-noise screening tool that was recently comfortable listening intensity. A “Start
developed by a group of researchers at the Test” button allows the subject to begin
University of Pretoria. Currently it is only testing. When the test starts digits are
available for download in South Africa and presented diotically. A popup keypad
offers 3 free hearing screenings. The appears after the subject listened to the
screening results are provided immediately digits to allow the subject to enter the
and are reported to the user on the response.
smartphone.
Accuracy and evidence
Hardware and software
HearZa has been successfully developed
hearZA™, is a smartphone application that and validated as a self-test on a smartphone
was designed using Android studio (version via a smartphone application using any
0.6.0, created by Google) written in Java available headphone type (Potgieter et al.,
(Java development kit version 8.0, created 2016). The mean SRT and speech recog-
by Oracle). The smartphone application nition functions for the smartphone-based
was designed to be used on any Android hearing test corresponds well to previous
smartphone with any headphone or ear- developed telephone-based digits-in-noise
phone and results can be obtained within a tests (Smits et al, 2004; Jansen et al, 2010).
few minutes. A list of triplets is stored in the The application can be used on any Android
Android application containing 120 unique smartphone and with any headphone type.
digit triplets (Smits, Goverts & Festern,
2013). Sound-files of the digits 0 to 9 were Advantages and limitations
stored separately in OGG format on the
application. When the test starts a digit The South African smartphone digits-in-
triplet is randomly selected from the list of noise hearing test could increase access to
120 different digit triplets. After the triplet hearing services if made available via
has been identified, the program assembles online App-stores. The issue of English
the triplet by selecting and presenting the additional language speakers’ performance
appropriate digits with silent intervals of needs to be investigated in the context of the
500ms in between. The test operates with a multilingualism (Potgieter et al., 2016).
fixed noise level and a varying speech level Furthermore, currently hearZa is only
when triplets with negative SNRs are available for download in South Africa and
presented. When triplets with positive provides 3 free hearing screenings.
SNRs are presented the speech level
becomes fixed and the noise level varies. More information on hearZa:
This procedure ensures a constant overall http://www.hearza.co.za
level of the stimulus (i.e., triplet and noise).
When the application is opened a tutorial Current recommended clinical applica-
screen appears to instruct the subject how to tions of mobile phone audiometry
use the application. The next screen in-
structs the user to enter their biographic Based on current data about reliability of
details and then moves on to an instruction the above mobile phone audiometry apps,
5
the authors recommend the following clini- 5. Kelly T. & Minges M. Exclusive Sum-
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AUDIOLOGY & HEARING AIDS
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Operative Surgery by Johan Fagan (Editor)
[email protected] is licensed under a Creative
Commons Attribution - Non-Commercial 3.0 Unported
Authors License
Faheema Mahomed-Asmail, PhD
Lecturer: Audiology
Department of Speech-Language Patholo-
gy & Audiology
University of Pretoria, South Africa
[email protected]Author and Editor
De Wet Swanepoel PhD
Professor
Department of Speech-Language Patholo-
gy & Audiology
University of Pretoria
Pretoria, South Africa
[email protected]Editors
Claude Laurent, MD, PhD
Professor in ENT
ENT Unit
Department of Clinical Science
University of Umeå
Umeå, Sweden
[email protected]Johan Fagan MBChB, FCORL, MMed
Professor and Chairman
Division of Otolaryngology
