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The Rational Clinical Examination
Clinician's Corner
January 25, 2006

Does This Patient Have Hearing Impairment?

Author Affiliations

The Rational Clinical Examination Section Editors: David L. Simel, MD, MHS, Durham Veterans Affairs Medical Center and Duke University Medical Center, Durham, NC; Drummond Rennie, MD, Deputy Editor, JAMA.


Author Affiliations: Departments of Health Policy, Management and Evaluation (Dr Detsky) and Medicine (Drs Bagai, Thavendiranathan, and Detsky), University of Toronto, Toronto, Ontario; and Department of Medicine, Mount Sinai Hospital and University Health Network, Toronto (Dr Detsky).

JAMA. 2006;295(4):416-428. doi:10.1001/jama.295.4.416

Context Hearing impairment is prevalent among the elderly population but commonly underdiagnosed.

Objective To review the accuracy and precision of bedside clinical maneuvers for diagnosing hearing impairment.

Data Sources MEDLINE and EMBASE databases (1966 to April 2005) were searched for English-language articles related to screening for hearing impairment.

Study Selection Original studies on the accuracy or precision of screening questions and tests were included. Articles that used unaccepted reference standards or contained insufficient data were excluded. Medical Subject Headings or keywords used in the search included hearing loss, hearing handicap, hearing tests, tuning fork, deafness, physical examination, sensitivity, specificity, audiometry, tuning fork tests, Rinne, Weber, audioscope, Hearing Handicap Inventory for the Elderly–Screening version, whispered voice test, sensorineural, and conductive.

Data Extraction One author screened all potential articles and 2 authors independently abstracted data. Differences were resolved by consensus. Each included study (n = 24) was assigned a methodological grade.

Data Synthesis A yes response when asking individuals whether they have hearing impairment has a summary likelihood ratio (LR) of 2.5 (95% confidence interval [CI], 1.7-3.6); a no response has an LR of 0.13 (95% CI, 0.09-0.19). A score of 8 or greater on the screening version of the Hearing Handicap Inventory for the Elderly (HHIE-S) has an LR of 3.8 (95% CI, 3.0-4.8); a score less than 8 has an LR of 0.38 (95% CI, 0.29-0.51). An abnormal Weber tuning fork test response has an LR of 1.6 (95% CI, 1.0-2.3); a normal response has an LR of 0.70 (95% CI, 0.48-1.0). An abnormal Rinne tuning fork test response has LRs ranging from 2.7 to 62; a normal response has LRs from 0.01 to 0.85. Inability to perceive a whispered voice has an LR of 6.1 (95% CI, 4.5-8.4); normal perception has an LR of 0.03 (95% CI, 0-0.24). Not passing the audioscope test has an LR of 2.4 (95% CI, 1.4-4.1); passing has an LR of 0.07 (95% CI, 0.03-0.17).

Conclusions Elderly individuals who acknowledge they have hearing impairment require audiometry, while those who reply no should be screened with the whispered-voice test. Individuals who perceive the whispered voice require no further testing, while those unable to perceive the voice require audiometry. The Weber and Rinne tests should not be used for general screening.