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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 27  |  Issue : 3  |  Page : 124-130

Audiology lab tertiary center: Audit report 5 years


Department of Otorhinolaryngology (ENT), All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

Date of Submission24-May-2020
Date of Decision10-Jun-2020
Date of Acceptance20-Jun-2020
Date of Web Publication16-Dec-2021

Correspondence Address:
Dr. Saurabh Varshney
Department of Otorhinolaryngology (ENT), All India Institute of Medical Sciences, Rishikesh - 249 203, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/indianjotol.INDIANJOTOL_101_20

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  Abstract 


Background: The role of audiology lab and field of audiology in India has expanded exponentially in recent years. However, little is known about the practice trends. The audits allow for changes in service quality to be charted over time both locally and nationally. Audit covers how audiology services should gather information about their service and use that information to improve things for service users. However, such information is currently lacking in India. For this reason, the current audit study is aimed at understanding current audiological practices in India with an intention of identifying areas warranting change. It is important to evaluate our practice trends to identify gaps in services to track quality of practices and possibly in the planning of future services. The current study provides some understanding about the status of current audiological practices in India. This study reports the results of a retrospective audit, which, to our knowledge, is the first of its kind to be conducted in India in the field of audiology. Aims and Objectives: An audit of audiology services at Department of Otorhinolaryngology, AIIMS, Rishikesh. for a period of 5 years (January 2015–December 2019) was conducted to – know number of various types of audiological tests done and to analyse various audiological tests in relation to time spent in minutes/hours per year on individual tests and percentage of average working audiology lab time spent on that particular tests per year to know the ratio of time spent on various audiological tests. Materials and Methods: An observational, retrospective study was conducted as audit of audiology services at Department of Otorhinolaryngology, AIIMS, Rishikesh. for a period of 5 years (January 2015–December 2019). Results: A total of 41,299 audiological investigations were performed during the period of study, i.e., 5 years and it was observed that the most common investigation performed was PTA (20,361; 49.38%), followed by immittance audiometry (10,900; 26.39%), OAE (4306; 10.44%), speech audiometry (2824; 6.84%), special tests (tone decay, SISI, etc.) (1693; 5.0%), and ABR/ASSR (1145; 2.77%). The most commonly performed audiological test was PTA (49.38%), and an average time spent on PTA (at 20 min per test) was 81,440 min/1357.33 h, i.e., 73.44% of total working time of audiology lab per year. (1,10,880 min/1848 h) followed by Immittance audiometry (26.39%), and an average time spent on immittance audiometry (at 10 min per test) was 21,800 min/363.33 h, i.e., 19.66% of total working time of audiology lab per year. (110,880 min/1848 h). Conclusion: The current study provides useful information about the diversity in current audiological practices in India. This study identifies the need for improving clinical practice, as inconsistencies were observed even in performing basic procedures such as PTA. This could greatly improve audiological practice and, thereby, patient outcomes. As per advances in audiology, this study can contribute in planning Telepractice in Audiology: Future Prospects and Challenges.

Keywords: Audiology, audit, hearing, pure-tone average


How to cite this article:
Varshney S, Yadav MC, Kumar A, Tyagi AK, Kumar N, Malhotra M, Priya M, Bhardwaj A. Audiology lab tertiary center: Audit report 5 years. Indian J Otol 2021;27:124-30

How to cite this URL:
Varshney S, Yadav MC, Kumar A, Tyagi AK, Kumar N, Malhotra M, Priya M, Bhardwaj A. Audiology lab tertiary center: Audit report 5 years. Indian J Otol [serial online] 2021 [cited 2022 May 24];27:124-30. Available from: https://www.indianjotol.org/text.asp?2021/27/3/124/332645




  Introduction Top


Deafness means loss of hearing and it may be partial or total. Hearing impairment cannot be seen and hence its effects are not visible to others, so deaf suffers in silence. Unlike blindness, deafness often provokes ridicules rather than sympathy. A deaf person is so isolated from family and friends and greeted by unsympathetic attitude he/she is often depressed and needs psychological counseling. The statistics are staggering – 360 million people in the world suffer from disabling hearing loss. This constitutes a substantial 5.3% of the world's population. The prevalence and incidence of hearing impairment in India also are substantially high. The high burden of deafness globally and in India is largely preventable and avoidable. The prevalence of deafness in South-East Asia ranges from 4.6% to 8.8%.[1] India is the fastest developing country in the world. According to the WHO (2006), 80% of the hearing-impaired population lives in low- and middle-income countries.

The treatment of ear diseases in India dates back to early fourth century BC,[2],[3] which is now known as ayurvedic medicine. However, the profession of audiology is relatively new and dates back to only half a century.[4] Within this short period of time, the profession of audiology has grown exponentially. It has made significant progress in human resource development, service delivery, and public awareness. While audiology in India has grown exponentially in terms of human resource development, audiological service delivery, and public awareness, there is a dearth of audiologists who serve a population of 1.28 billion. There is still a need for improvement in services, considering the prevalence of hearing loss, in addition to the diversity in access to ear and hearing health-care services. The key to planned progress in a profession involves evaluation of current trends of practice. However, little is known about the trends in service delivery and professional practice of audiologists in India.[5] The audits allow for changes in service quality to be charted over time both locally and nationally. Audit covers how audiology services should gather information about their service and use that information to improve things for service users. There have been surveys from Western countries that probe into trends in professional practice, service delivery, and consumer satisfaction in audiology. These surveys have led to a better understanding of practices influencing patient outcomes and best utilization of resources. However, such information is currently lacking in India.

Normal hearing sensitivity is usually inferred when hearing sensitivity as determined by the acquisition of absolute threshold response is “excellent” and is observed to be within normal and acceptable auditory limit. When hearing sensitivity is excellent, the first assumption is that an auditory system under scrutiny is free of disease,[6] from the outer ear to cerebral cortex and the assumption is that listener is said to have auditory system that is functioning optimally. Hearing is a sensory activity which enables us to communicate with the other individuals, share the feeling and thoughts, warns from danger.

Thresholds obtained using pure tones have long been used by audiologists as the gold standard for measuring hearing sensitivity.[7] These tests are important in determining hearing sensitivity at specific frequencies, but they are often inadequate when it comes to predicting speech understanding, especially in noise. Pure-tone thresholds primarily reflect the mechanical amplification of quiet sounds provided by the outer hair cells.[8] Thus, the audiogram is primarily a reflection of pure hearing sensitivity.[9] In contrast, it is the inner hair cells that are responsible for sending most of the auditory signals to the brain, and if there is inner hair cell damage, individuals typically suffer more from a loss of clarity than a loss of sensitivity.[8]

Speech perception is vital to the communication process and hence its assessment in the audiometric testing is indispensable for successful audiologic rehabilitation.[10] Tests of speech perception employ a variety of stimuli such as nonsense syllables, monosyllabic words, bisyllabic words, and sentences.[11] The advantages of speech audiometry test are (i) they can provide insight regarding an individual's performance in more realistic communication scenarios; (ii) they are considered to be valid indicators of intelligibility and give better representation of verbal communication.[12] (iii) they provide better accuracy and effectiveness in measuring speech reception thresholds due to steeper intelligibility functions of sentence level or single words;[13] (iv) they contain contextual cues and are expected to have better predictivity; (v) they assesses co-articulation as well as temporal aspects of speech; and (iv) they have face validity as 'natural' and 'meaningful' stimuli for assessing auditory function.[12]

Immittance evaluation with acoustic reflex assessment provides reliable hearing information associated with middle ear and  Eustachian tube More Details dysfunctioning in children , adults and geriatric population. Acoustic reflex assessment gives a much clear picture of functioning of VIII cranial nerve and helps in finding growth at the intracanalicular and extracanalicular level and facial nerve palsy.

Otoacoustic emission (OAE) is a test which directly provides the information at functioning of outer hair cell in inner ear. It helps in the diagnosis of early infant hearing disorders, noise-induced hearing loss, ototoxicity, and sensory neural hearing loss.

The auditory brainstem response (ABR) test tells us how the inner ear, called the cochlea, and the brain pathways for hearing are working. ABR audiometry is a neurologic test of auditory brainstem function in response to auditory (click) stimuli. It refers to an evoked potential generated by a brief click or tone pip transmitted from an acoustic transducer in the form of an insert earphone or headphone. The elicited waveform response is measured by surface electrodes typically placed at the vertex of the scalp and ear lobes. The test is used with children or others who cannot complete a typical hearing screening.

Loss of hearing isolates the individual from the society and gives rise to frustration. Extraction of speech from the background noise or any other competing voice is essential for understanding the communication. Hearing loss makes this process more difficult, which, in turn, hampers the effective communication. Speech communication in daily life does not use single words and one ear, but occurs at semantic level of the sentence involving both ears, and not in a surrounding free from interference but practically always in ambient noise. The listener receives constantly a mixture of interference and signal, the latter in the form of sentences.

Test battery approach

A making of good diagnosis provides the better direction in the management of disorders. Hearing evaluation requires the multiple test, i.e., pure-tone audiometry, speech evaluation, immittance assessment, OAEs, and ABR/auditory steady state response (ASSR).[14] Each test or combination of tests should be carried out when performing the test procedure to avoidance of misdiagnosis.


  Methodology Top


Study

Observational, retrospective.

Duration

Five years (January 2015–December 2019).

Total working of audiology lab/year

  • Total number of days in a year 365.
  • Nonworking days: 74 days (54 days of Sundays + 27 days [Saturday half day] +20 days of Gazetted holidays) per year = 101 days
  • Total no working days per year: 365 days–101 days = 264 days
  • Total working hours per day: 7 h/day


    • Hence, working hours per year: 264 × 7 h = 1848 h
    • Hence, working hours per year: 1848 × 60 min = 110,880 min.


All the data were collected retrospectively present in hospital database for the last 5 years from January 2015 to December 2019. All the data were categorized in different tests such as pure-tone average (PTA) (20,361), speech audiometry (2824), immittance (10,900), OAE (4306), special tests (tone decay, SISI, etc.) (1693), ABR, and ASSR (1145).


  Results and Discussion Top


This audit of audiology services at our institute was conducted by retrospective evaluation of audiology records for a period of 5 years (January 2015–December 2019).

The key to planned progress in a profession involves evaluation of current trends of practice. However, little is known about the trends in service delivery and professional practice of audiologists' in India. The audits allow for changes in service quality to be charted over time both locally and nationally. Audit covers how audiology services should gather information about their service and use that information to improve things for service users. Hence, a retrospective audit of audiology lab for various audiological investigations for a period of 5 years (January 2015–December 2019) was done. As per our information, this is the first audit of its kind in the country.

A calculation was done for total working days of audiological lab per year, considering all holidays. It was observed that audiology lab was functional for 264 days out of 365 days per year. With working hours of 7 h/day, total working of lab was calculated as 1848 h (110,880 min) per year.

A total of 41,299 audiological investigations were performed during the period of study, i.e., 5 years and it was observed that the most common investigation performed was PTA (20,361; 49.38%), followed by immittance audiometry (10,900; 26.39%), OAE (4306; 10.44%), speech audiometry (2824; 6.84%), special tests (tone decay, SISI, etc.) (1693; 5.0%), and ABR/ASSR (1145; 2.77%) [Table 1] and [Figure 1], [Figure 2], [Figure 3].
Table 1: Various audiological tests (5 years)

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Figure 1: Audiological tests year wise

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Figure 2: Audiological tests (per year)

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Figure 3: Audiological tests (per day)

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Next, an average evaluation of time taken to perform various audiological tests based on an average timing of three audiologists was calculated [Table 2].
Table 2: Average time spent for different audiological test per case (based on average timing of 3 audiologists)

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Further, analysis was done for various audiological tests in relation to time spent in minutes/hours per year on individual tests and percentage of average working audiology lab time spent on that particular tests per year [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9].


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Table 4: Immittance audiometry: Time spent in minutes/hours per year

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Table 5: Speech audiometry: Time spent in minutes/hours per year

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Table 6: Special tests (tone decay, SISI etc.): Time spent in minutes/hours per year

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Table 7: Otoacoustic emission: Time spent in minutes/hours per year

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Table 8: Auditory brainstem response/auditory steady state response: Time spent in minutes/hours per year

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Table 9: Average number of audiological tests and time spent (mins/h) per year

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The most commonly performed audiological test was PTA (49.38%), and an average time spent on PTA (at 20 min per test) was 81,440 min/1357.33 h, i.e., 73.44% of total working time of audiology lab per year. (1, 10, 880 min/1848 h) [Table 3]a.

This study shows that many of normal-hearing individuals had been referred to audiology lab for hearing test, i.e., PTA. Further analysis of PTA at various stages (1800 PTA performed, 5000 PTA performed, and 10000 PTA performed) showed normal PTA in 10.77%, 14.9%, and 17.2% of PTA with an average of 14.30% PTA being normal [Table 3]b. Such a high number of normal PTA raises a concern of referral by clinicians to audiology lab. without assessing the hearing by Tuning fork tests (TFTs) which is a very sensitive tool. The study indicates emphasis on screening by TFT, which can reduce time spent by audiology labs in performing these PTAs. As per the data analyzed, an average 582 out of 4072 (14.3%) PTA performed per year were normal, which indicates that time spent on these 582 PTAs was 11,640 min/194 h, i.e., 10.50% of total audiology lab time. These cases can screen at the otolaryngologist level by doing different screening tests, thus saving time of audiology lab for other tests.

Other audiological tests performed were:

  • Immittance audiometry (26.39%), and an average time spent on immittance audiometry (at 10 min per test) was 21,800 min/363.33 h, i.e., 19.66% of total working time of audiology lab per year. (110,880 min/1848 h) [Table 4]
  • Speech audiometry (6.84%), and an average time spent on speech audiometry (at 10 min per test) was 5650 min/94.17 h, i.e., 5.10% of total working time of audiology lab per year. (110,880 min/1848 h) [Table 5]
  • Special tests (tone decay, SISI etc.) (5.0%), and an average time spent on special tests (at 15 min per test) was 5085 min/84.75 h, i.e., 4.58% of total working time of audiology lab per year (110,880 min/1848 h) [Table 6]
  • OAE (10.44. %), and an average time spent on OAE [at 5 min per test] was 4305 min/71.75 h, i.e., 3.88% of total working time of audiology lab per year. (110,880 min/1848 h) [Table 7]
  • ABR/ASSR (2.77%), and an average time spent on OAE (at 120 min per test) was 27480 min/458 h, i.e., 24.78% of total working time of audiology lab per year. (110,880 min/1848 h) [Table 8].


On further analysis for number of audiological tests done per day [Table 10], it was observed that on an average, 30 audiological tests were performed per day in audiology lab: PTA (15–16/day), speech audiometry (2–3/day), special tests (1–2/day), impedance audiometry (8–9/day), OAE (3–4/day), and ABR/ASSR (1/day). [Table 10] indicates that more than half of the tests done and more than half of the audiology time is spent on PTA. As per the number of tests performed per day, the audiology lab has to function more than routine 7 h/day, i.e., 550 min/9.16 h, against scheduled time; this creates a waiting list for other audiological tests as maximum time is utilized for PTA.
Table 10: Average number of audiological tests and time spent (min/h) per day (264 working days in a year)

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The study also shows that the appropriate test battery for audiologist at ENT setup for diagnostic evaluation is with PTA and with immittance. Pure-tone audiometry alone is mostly done for the individual who does not have any otological symptoms or minimal symptoms with presence of hearing loss. These individuals are having sensorineural hearing loss, whereas individuals on whom pure-tone audiometry with immittance audiometry is done are having conductive haring loss. Speech audiometry is needed in those individuals who have a complaint of difficulty in understanding speech. Pure-tone audiometry with speech audiometry also helps in identifying the retrocochlear pathologies.

The audiologists spend much of their time performing the tests which do not add any specific diagnostic information, such as , PTA, in normal-hearing individuals (if already assessed, by TFT) immittance in sensory neural hearing loss cases etc. If proper screening is done by clinician with proper referral for audiological tests, the time can be saved of audiology lab and can be utilized for special tests such as reflexometry, reflex decays test, tone decay, SISI, and ABR for identification of cochlear pathology (CP) and retrocochlear pathology (RCP). Thus, sensitivity to identify the cochlear pathologies and retrocochlear pathologies can be increased and more time can be given for management of these populations.

Implications of this study

It is important to evaluate our practice trends to identify gaps in services to track quality of practices and possibly in the planning of future services. The current study provides some understanding about the status of current audiological practices in India. The results of this study also indicate the need to evaluate more focused areas rather than the more generic approach adopted in the current study. Considering the likelihood that this study is the first of its kind in India, these results may be used for monitoring practice trends. We believe that these results may be helpful in developing guidelines to suit the Indian context. We suggest that educational institutes address these identified gaps in their training programs. As well, professional and regulatory bodies in the field of audiology may take directed steps to improve and monitor audiological practice across the country.

Recommendation

  1. The audiology test battery chosen for any patients should be based on their clinical symptoms not as a routine test. This can save the audiologist time and also reduces the patients load on audiologist. If the audiologist has time, it can be utilized to increase the identification CP and RCPs
  2. There should be mandatory protocol for TFT for patients who come to ENT outpatient department before referral to audiology lab, as it is being observed that many times audiological testing (particularly PTA) is ordered without evaluation in ENT clinic. This practice and training will avoid undue testing and save time for special and sensitive audiological tests and reduce the waiting list of such patients
  3. By saving audiology lab time, more physiological tests such as ABR and ASSR and more advanced tests and neonatal/universal hearing screening can be done
  4. A proper management and rehabilitation for hearing- impaired and hearing aid users as well as cochlear implant habitation can be done
  5. In times of competency-based medical education, data can be used for making curriculum for various audiological courses (Diploma/Degree).


Study limitation and need for further research

Since this study is first of its kind and has been conducted in a tertiary care center, care must be taken when generalizing these findings to other parts of the country. This study may have limited representation of those audiologists' practices that followed at secondary level/nonteaching tertiary level. Future surveys could be designed to cater to fewer domains when providing better resolution in data distribution (e.g., urban vs. rural or public vs. private practice). Other areas that need to be explored are procedural variations as opposed to types of procedures used, like in the current survey.


  Conclusions Top


The current study provides useful information about the diversity in current audiological practices in India. This study identifies the need for improving clinical practice, as inconsistencies were observed even in performing basic procedures such as PTA. We suggest that collaborative efforts from educational institutes, professional and regulatory bodies, nongovernment organizations, and the government are necessary in developing, implementing, and monitoring clinical guidelines. This could greatly improve audiological practice and, thereby, patient outcomes. As per advances in audiology, this study can contribute in planning Telepractice in Audiology: Future Prospects and Challenges.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Varshney S. Deafness in India. Indian J Otol 2016;22:73-6.  Back to cited text no. 1
  [Full text]  
2.
Savithri SR. Speech and hearing science in ancient India – A review of Sanskrit literature. J Commun Dis 1988;21:271-317.  Back to cited text no. 2
    
3.
Stephens D. Deafness and its treatment in ancient civilizations. Audiol Med 2006;4:85-93.  Back to cited text no. 3
    
4.
Manchaiah VK, Reddy S, Chundu S. Audiology in India. Audiol Today 2009;21:38-44.  Back to cited text no. 4
    
5.
Easwar V, Boothalingam S, Chundu S, Vinaya KC, Manchaiah C, Ismail SM. Audiological practice in India: An internet-based survey of audiologists. Indian J Otolaryngol Head Neck Surg 2013;65 Suppl 3:S636-44.  Back to cited text no. 5
    
6.
Sahley TL, Musiek FE. Basic Fundamentals in Hearing Science. Available from: https://books.google.co.in/books. [Last accessed on 2020 May 20].  Back to cited text no. 6
    
7.
Lins OG, Picton TW, Boucher BL, Durieux-Smith A, Champagne SC, Moran LM, et al. Frequency-specific audiometry using steady-state responses. Ear Hearing 1996;17:81-96.  Back to cited text no. 7
    
8.
Moore BC. Cochlear Hearing Loss: Physiological, Psychological and Technical Issues. United States: John Wiley & Sons; 2007.  Back to cited text no. 8
    
9.
Killion MC, Niquette PA, Gudmundsen GI, Revit LJ, Banerjee S. Development of a quick speech-in-noise test for measuring signal-to-noise ratio loss in normal-hearing and hearing-impaired listeners. J Acoust Soc Am 2004;116:2395-405.  Back to cited text no. 9
    
10.
McArdle R, Wilson RH. Predicting Word-Recognition performance in noise by young listeners with normal hearing using acoustic, phonetic, and lexical variables. J Am Acad Audiol 2008;19:507-18.  Back to cited text no. 10
    
11.
Tyler A. The role of repetition in perceptions of discourse coherence. J Pragmat 1994;21:671-88.  Back to cited text no. 11
    
12.
Miller GA, Heise GA, Lichten W. The intelligibility of speech as a function of the context of the test materials. J Exp Psychol 1951;41:329-35.  Back to cited text no. 12
    
13.
Zokoll MA, Hochmuth S, Warzybok A, Wagener KC, Buschermöhle M, Kollmeier B. Speech-in-noise tests for multilingual hearing screening and diagnostics1. Am J Audiol 2013;22:175-8.  Back to cited text no. 13
    
14.
Jerger JF, Hayes D. The cross-check principle in pediatric audiometry. Arch Otolaryngol 1976;102:614-20.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10]



 

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