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in Communication Disorders
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Permanent Childhood Hearing Loss
Audiologic Assessment

Tympanometry/Acoustic Reflex



External Scientific Evidence

Evidence-Based Practice Guidelines
New York State Department of Health, Early Intervention Program; U.S. Department of Education

Clinical Practice Guideline: Report of the Recommendations. Hearing Loss, Assessment and Intervention for Young Children (Age 0-3 Years)
New York State Department of Health, Early Intervention Program. (2007).
Albany (NY): NYS Department of Health, Publication No. 4967, 354 pages.
Added: July 2012

This evidence-based and consensus-based guideline provides recommendations for the assessment and intervention of hearing loss for young children ages birth to three. The guideline targets parents and professionals. Recommendations of interest to audiologists and speech-language pathologists include screening, assessment, and management of hearing and assessment of communication. Each recommendation is provided with a strength of evidence rating defined as Level A (strong evidence), Level B (moderate evidence), Level C (limited evidence), Level D1 (consensus panel opinion based on topics where a systematic review has been conducted), and Level D2 (consensus panel opinion not based on findings from a systematic review).

  • Tympanometry and measurements of middle ear reflexes should be used in conjunction to assess middle ear function (Level D2 Evidence).

  • Children with a flat tympanogram for over 3 months should receive a full audiologic evaluation (Level B Evidence).

» See full summary and quality ratings

Evidence-Based Systematic Reviews
No evidence-based systematic reviews were found.

Clinical Expertise/Expert Opinion

Consensus Guidelines
American Academy of Audiology

Audiologic Guidelines for the Assessment of Hearing in Infants and Young Children
Retrieved from
Added: May 2013

This guideline provides recommendations for the assessment of auditory function in infants and young children. The target audience of this guideline is audiologists. Select recommendations are provided below; for the full set of recommendations, please review the guideline document.


  • A pediatric audiologic assessment test battery includes a case history, otoscopy, behavioral observation, visual reinforcement audiometry, conditioned play audiometry, physiologic assessments (e.g., tympanometry, otoacoustic emission testing), and electrophysiologic audiometry (e.g., auditory brainstem response, auditory steady state response).

  • Tympanometry and acoustic reflex measurements assess middle ear function and the integrity of the auditory pathway and are used to evaluate for the presence of middle ear abnormalities including otitis media.

  • Immittance testing should be conducted as part of the hearing evaluation for infants and young children, "and more frequently for children at increase risk for middle ear disease or for those with known sensorineural hearing loss, or at risk for auditory neuropathy" (p. 23).

  • For infants below 6 months, a higher probe tone frequency, such as 1000 Hz, is preferred.

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Joint Committee on Infant Hearing

Year 2007 Position Statement: Principles and Guidelines for Early Hearing Detection and Intervention Programs
Joint Committee on Infant Hearing (2007).
Pediatrics, 120(4), 898-921.
Added: July 2012

This consensus-based guideline provides recommendations for screening infants for hearing loss, assessing infants identified as at-risk for hearing impairment, and providing appropriate early intervention for infants with hearing impairment. The intended audience of these guidelines is not specified, however they are relevant to all professionals involved in the screening, assessment or treatment of hearing in infants.


  • “There are insufficient data for routine use of acoustic middle ear muscle reflexes in the initial diagnostic assessment of infants younger than 4 months” (p. 14).

  • For infants birth through a developmental age of 6 months, the test battery should include:

    • Child and family history including an assessment of risk factors and parental reports of the infant’s response to sounds

    • Frequency-specific ABR with air-conduced bursts and bone-conducted bursts as needed

    • Click-evoked ABR

    • OAEs (transient evoked or distortion product)

    • 1000 Hz tympanometry

    • Clinical observations of the infant’s auditory behavior.

  • For children with a developmental age between 6 and 36 months, the test battery should include:

    • Child and family history including information on the child’s attainment of communication milestones and parental report of the child’s auditory and visual behaviors.

    • Behavioral audiometry (visual reinforcement or conditioned–play audiometry) consisting of pure tones across the frequency range as well as speech detection and speech recognition measures.

    • OAE

    • Tympanometry and acoustic reflex thresholds

    • If reliable responses cannot be obtained through behavioral audiometry, the child should receive an ABR.

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Commission for the Early Detection of Hypoacusis (CODEPEH), Spain

Early Hearing Detection and Intervention: 2010 CODEPEH Recommendation
Trinidad-Ramos, G., de Aguilar, V. A., et al. (2010).
Acta Otorrinolaringologica Espanola, 61(1), 69-77.
Added: July 2012

This guideline provides recommendations for early hearing detection and intervention (EHDI) programs. The target audience of this guideline is audiologists and speech-language pathologists. Recommendations are provided in the areas of screening, audiological evaluation, intervention and surveillance.

Diagnostic confirmation of hearing loss should be based on multiple tests and “should always include ABR, tympanometry, stapedial reflex (using 1000 Hz as a sound carrier), and TEOAE, repeated at least 2 times with a difference of one to 4 weeks” (p. 71).

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NHS Newborn Hearing Screening Programme Clinical Group (UK)

Newborn Hearing Screening and Assessment: Guidelines for the Early Audiological Assessment and Management of Babies Referred from the Newborn Hearing Screening Programme
Stevens, J., Sutton, G., et al. (2011).
England: NHS Newborn Hearing Screening Programme Clinical Group, 41 pages.
Added: July 2012

This consensus-based guideline provides recommendation for the early audiologic assessment of infants referred from the newborn hearing screening program.


  • An audiologic assessment should include the following:

    • OAEs

    • Air conduction tone pip ABR

    • Bone conduction ABR

    • ASSR

    • Tympanometry – A high frequency probe tone of 1 kHz should always be used for babies less than 6 months of age.

    • Reactions to stimuli

  • Some requirements for newborn audiologic assessment include:

    • “Equipment to carry out ABR threshold measurement using tone pips and clicks by both air and bone conduction” (p. 7)

    • Staff with expertise and the “ability to accurately interpret ABR waveforms, to accurately determine thresholds (including when and how to use masking) and to know how to deal with unusual or unexpected waveforms or results. Expertise should also include measurement of cochlear microphonics, otoacoustic emissions and tympanometry in babies” (p. 7).

    • A quiet environment, usually a sound-treated/proofed room

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Client/Patient/Caregiver Perspectives

No information was found pertaining to client/patient/caregiver perspectives.

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