|Year : 2022 | Volume
| Issue : 2 | Page : 103-106
Whisper test – Mass hearing screening programme
MK Taneja1, Megha Jain2, Vivek Taneja3, Sandip M Parmar4
1 Department of ENT, Indian Institute of Ear Diseases, Muzaffarnagar, Uttar Pradesh, India
2 Department of ENT, Muzaffarnagar Medical College, Muzaffarnagar, Uttar Pradesh, India
3 Department of ENT, World College of Medical Sciences, Jhajjar, Haryana, India
4 Muzaffarnagar Medical College and Hospital, Bahadarpur, Uttar Pradesh, India
|Date of Submission||30-Jun-2022|
|Date of Decision||08-Jul-2022|
|Date of Acceptance||21-Jul-2022|
|Date of Web Publication||21-Sep-2022|
Dr. M K Taneja
281, North Civil Line, Railway Road, Muzaffarnagar, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Aims and Objectives: To screen the school going mass for hearing loss and study its relationship with their academic performance and aptitude and compare it with pure tone audiometry and validate whisper test. Material and Methods: Procedure- Examiner stands arm distance (60cm) behind the patient. Mask the non-test ear by occluding the external auditory canal by continuously generating rubbing sound. The patient is explained to repeat the words. Test always started with consonants followed by vowels. If more than 80% were correct it was treated as passed. Results: In our study out of 86 students, 8 children failed in whisper test, but all passed in conversation test. In the present study performance was poor in failed students. The incidence of day dream, learning difficulty, inattentiveness was high with hearing impaired children. Conclusion: The whisper test is a simple effective diagnostic and mass hearing screening test which can predict an early hearing loss and if performed by a trained paramedical or social worker can differentiate in conductive, sensorineural, cochlear, and retrocochlear lesion. Since the whisper test does not require a qualified audiologist or otolaryngologist, it should be be a part of annual health check-up and national programme of prevention and control of deafness specifically hearing care in the elderly.
Keywords: Cochlear, conductive, conversation, deafness, hearing loss, retrocochlear, sensorineural, whisper test
|How to cite this article:|
Taneja M K, Jain M, Taneja V, Parmar SM. Whisper test – Mass hearing screening programme. Indian J Otol 2022;28:103-6
| Introduction|| |
Before 1940, when pure tone audiometry (PTA) became available, voice testing as whisper and conversation was the main tool. Even at the end of the 1970s during medical school training, it was routine to perform whisper/conversation test as a standard protocol of ear examination. It is perhaps the easiest and most relevant to use free-field voice testing.
The importance of free-field voice testing has been highlighted in past. Older studies suggest it as a reliable screening technique which can be performed by nonspecialists including class teachers and paramedical workers even a social worker can learn it online. It can be of great help for routine hearing screening of the elderly population.
Hearing impairment is an extremely common, unattended, noncommunicable disease affecting 30% population at the age of 60 and more than 40% at and above the age of 70 years., If not attended it can lead to isolation depression and dementia. Most of the government schemes and social organizations are working and promoting neonatal screening while the incidence in them is negligible. Self-reporting of hearing disability is ignored and scarcely reported hence data of the actual prevalence of disability is either not available or consistently underestimated.
Of course, we cannot neglect even a single person or child but as a whole, we have to assess our resources and target the total population. Literature and clinical studies on free-field voice test are lacking hence this study was conducted on school children to compare the free-field voice test along with PTA. The tuning fork test evaluates the single low frequency (512 Hz) which is not appropriate in presbycusis where hearing loss is usually in high frequency above 4000 Hz. Tuning fork test was a modality in past using multiple tuning forks of various frequencies which were time-consuming and hence have been neglected and replaced by PTA, putting the legal responsibility on audiologist.
| Methods|| |
To examine the patient/child, the examiner stands at an arm distance (60 cm) behind the patient to avoid the chance of lip or face reading. Since the sound can be perceived by both ears simultaneously hence it is mandatory to mask the nontest ear. It was done by occluding the external auditory canal by the index finger of the nontest side hand and continuously rotating in pendular motion and generating a rubbing sound. The patient is explained to repeat the words loudly. It was necessary to give a demo/trial to every child. In trial, initially at the place of whisper, conversation was used followed by whisper test. Test always started with consonants as they are of high frequency followed by vowels. Whisper is done after full quiet expiration to ensure a quiet voice. At least three sets of either numerals/letter or spondee words were used. If more than 80% were correct it was treated as passed. Every time different combinations of numerals/letters or spondee words were used.
If failed to identify whisper/conversation test, the test was repeated at a distance of 30 cm (1 feet). Again if failed then repeated at a distance of 15 cm (6 inches). All these children were evaluated by audiometry and a comparative chart was made for future assessment of hearing loss in decibels. The same way test is repeated by consonants/vowels to assess the frequency-specific loss.
Hundred percent identification by whisper suggest that there is no hearing loss, unable to hear suggest a hearing loss above 30 dB to be confirmed by PTA. The speech discrimination score (Pass rate) drops means there is sensorineural deafness. The higher failure rate with vowel is directed toward low frequency and consonants for higher frequency. The consonants are more sensitive to distortion than vowels. If the hearing deteriorates in noisy surrounding and at a higher volume it directs toward cochlear and retrocochlear pathology.
| Results|| |
In our study of 86 school-going class 12th female gender students aged from 14th to 18th were examined. A general questionnaire of aptitude related to hearing and performance was filled up by the class teacher who was looking after them for a year [Figure 1]. Whisper test was conducted, eight children failed but all passed in conversation test. Among those failed, two were having tympanosclerosis one in the right posterosuperior quadrant, another in the left anteromedial quadrant. Wax was observed in six children, four in both sides and two in single side. Out of six having wax, only two failed in whisper test. There was a significant difference in passed versus failed. In failed group, average academic skill/marks was maximum 76%, minimum 41% average 60.6% while in passed maximum 87%, minimum 48% and average 63.55%. In passed easily distracted score was 62.3%, in failed it was 77.7%. Learning difficulty was observed on average in 38.9%, passed 32.4%, and failed 55.5%. Daydream/inattentiveness average is 36.3%, in passed 28.5% and failed 66.6% [Table 1]. Fortunately, the failed students were marked organized 100% as compared to 6.4% of passed. It may be a better school training. The PTA average of failed student was 24 dB (15dB–30dB) and passed students was 17dB (10dB–20dB). The common alphabet missed were N (15.11%) B (13.95%) L (10.46%) followed by T, P, O, and H.
| Discussion|| |
The whisper/conversation test which was a routine test in the late 70s and early 80s lost its significance and physician switched on to PTA. Voice test is easy to perform and could be done by any trained paramedical or social worker. There is a 100% pass in speech recognition if hearing loss is <30 dB. If we go from whisper to conversation and on raised voice level if speech recognition is 100%, then it is suggesting conductive hearing loss. Poor word recognition is suggestive of cochlear pathology and if on further raising the voice word recognition level deteriorates, it is suggestive of retrocochlear sensorineural hearing loss. Unilateral hearing loss is more specific and invites proper investigation. Neonatal hearing care program is one of the requirements. Although it is a need, less importance is given to neonatal screening program which is diagnosed by sophisticated instruments, otoacoustic emissions, and evoked potential (brainstem evoked response audiometry) and requiring expert.
Microangiopathy in diabetic and hypertensive or metabolic syndrome is one of the basic causes of aging deafness apart from noise pollution. It affects the majority of obese patients with metabolic syndrome which can be cured by timely early intervention. Increased use of mobile phone/roadside noise may be a factor for silent, progressive hearing loss. The hearing loss of microangiopathy is either of low frequency or has a flat curve in audiogram. It is a sign that with timely intervention, recovery, or rehabilitation results will be good.
Online teaching increased mobile phone and laptop usage in school children along with curtailment of physical or sports activity which may be one of the precipitating factors for this psychosocial problem. Which can be recovered by yoga and sports activity. Only a few studies have been conducted on school children. One study by Dempster and Mackenzie observed that those who passed had average of 14 dB on PTA, while in our study average was 17 dB in passed and 25 dB average in failed with maximum of 40 dB in one child. Most of the studies of whisper test has been conducted in the middle-aged and older population and revealed a significant incidence of 58.87% of hearing loss which is more than 30 dB and almost the same as 70.96% in PTA. The uniformity of conducting the test and variation in loudness by different examinees may change the results in sensitivity and specificity. To maintain uniformity whisper test has to be performed after slow complete silent exhalation. In our study, 88.37% passed in whisper test by 80% or more correct answer with air conduction threshold (PTA) of 17 dB, while a school survey by purmani pass rate was 92.5% and air conduction was 14.8–20.5 dB. In our study, the incidence of failure was 10.46% with air conduction loss of an average of 24 dB (15dB–30 dB) which was quite high 26–31 dB, with purmani. In his study, there was a 4% incidence of sensory deafness of 30dB–50 dB. It might be due to the high incidence of retracted tympanic membrane 32%, tympanic membrane perforation 1.5% and 1.5% with cicatrix, while the incidence was quite low in our series. No case of perforation or cicatrix seen only retracted tympanic membrane at 3.5%, tympanosclerosis at 5.35%, and wax at 12.79%. The failure rate in our study was 10.46%, while purmani reported 7.5% failure rate in spite of the high incidence of ear pathology. The noise level of school was 50dB–80 dB which was 45 dB–60 dB in our study.
| Conclusion|| |
The whisper test is a simple effective diagnostic and mass hearing screening test which can predict an early hearing loss and if performed by a trained paramedical or social worker can differentiate in conductive, sensorineural, cochlear, and retrocochlear lesions.
A routine check-up by whisper hearing test of all school children must be done who are having poor academic scores, learning difficulties, or easily distracted. In these children/adults wax or forgotten cotton bud should be looked for and removed. Other causes may be deficiency of Vitamin D which should also be checked and corrected.,
Since the whisper test does not require a qualified audiologist or otolaryngologist, it should be added in general examination and be a part of fitness in health insurance or annual health check-up. Since mass hearing screening is possible by whisper test it should be a tool in the national programme of prevention and control of deafness specifically hearing care in the elderly. Early investigation if hearing loss is in low frequency/flat curve or with vowel, which is usually in diabetic or metabolic syndrome leads to promising recovery by multi-model management.
Preliminary screening can find out discharging ear, cholesteatoma, and otitis media with effusion hence a school health survey, tympanometry in school children should be a part of mass screening program., Surgery if required a minimum access mastoidectomy with tympanoplasty may restore hearing at an early stage leading to the adequate social and educational development of the child. In smaller children, behavioral observation audiometry may be good for social workers as a tool for preliminary screening. Whispers test can help in eradication of the social stigma of deafness.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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