Key points
1.To overcome the disadvantages of the current hearing screening methods
2. To eliminate the disadvantages of the conventional FFVT
3.To invent a digital option to screen hearing loss
3. To test the accuracy and sensitivity of the mobile-app and FFVT compared to PTA
4. To have more accessibility to screen hearing loss nationwide
Level of evidence : Level 2
Keywords : mobile apps; smartphone; audiometry; hearing loss; hearing tests
INTRODUCTION
Hearing loss is a prevalent disease in the population. This disorder does not only affect aging population but, also younger adults and children. In children, this condition can implicate their normal speech and language development. According to World Health Organization, about 466 million people have disabling hearing loss globally, which is about 5% of the world’s overall population. Among these vast numbers, 34 million are children. It is predicted that the number will escalate to over 900 million people by 2050, in which one in ten people will have the hearing loss disability.
There are various tests available to detect hearing loss in the clinical settings, which can be either objective or subjective tests.. Tuning fork, pure tone audiometry (PTA) and Barany box are the examples. The commonest subjective test used is PTA. Hearing loss is tested with audiometry by average of hearing thresholds at frequencies of 0·5 kHz, 1 kHz, 2 kHz, and 4 kHz while hearing loss of 35 dB and more are viewed as disabling hearing losses.2 However, PTA is not a practical solution for hearing screening in a large population as it requires trained audiologists to conduct the test.3Moreover, not every healthcare facility own an audiology service as a soundproof room with an audiometry are required.4,5
Free Field Voice Test (FFVT) or also known as whispered voice test is another screening tool to detect hearing loss. This test can be used for both children and adults as it uses a combination of numbers and letters. In children, bi-syllabic words like cowboy and football are often used.6 A study on FFVT reported that the test had 90% test sensitivity in detecting hearing thresholds above 30 dB HL, making it a suitable hearing screening tool.7General practitioners are often recommended to use FFVT to screen hearing among the elderly. Clinical guidelines are also formulated by various national health board to make hearing impairment as part of the health screening.8 However, FFVT have been criticized as there is no standardization of sound levels of speech among the examiners. There is also a significant difference in the sound levels of the examiners tested in different occasions, especially during a whisper.6
With usage of mobile phones being an integral part of our daily lives, many health-related apps are easily accessible now. Hearing assessments can also be conducted via mobile phones which are portable, cost-effective and accessible especially in resource-limited settings.5 There is a growing interest in establishing more of such digital services such as smartphone-enabled otoscope and noise level detectors.9 In a recent systematic review published, the validation of smartphone apps in supporting and controlling tinnitus symptoms was reported. One of the relief therapies analyzed is the mobile phone-based Cognitive Behavioural Therapy (CBT) which proved to be beneficial to patients with tinnitus, which frequently accompanies hearing loss.10
Our aim is to create a cost-effective, digital tool to screen hearing. Thus, we have designed an app using Flutter-Dart language, which is a programming tool used to create cross- platform mobile applications. Mobile apps can be used to mimic the findings of FFVT and is dubbed by the authors as the free field click test (FFCT). It is named as such as it employs broad-band clicks to elicit a clinical response. There is very little information in the literature about the validity of digital hand-held devices on the detection of hearing loss. This study will demonstrate on how a low-cost software can be developed and used to detect hearing loss in the general population in the future.
MATERIALS & METHODS
Study Population
This study was conducted at a sound-proof room in ORL clinic in[removed for blind peer review] from December till March 2020. A total of 50 patients from the age of 18 until 80 years old with primary complaint of hearing loss were recruited. These patients were then randomly assigned into two groups; FFVT and FFCT which were then compared with the gold standard of PTA. Patients whom were less than 18 and more than 80 years old with hearing loss and pregnant ladies were excluded from this study. Patients with less than one year duration of post-traumatic and post-operative hearing loss were also excluded.
Study design