Hearing Testing Using At-Home Smartphone Apps
Over 20% of the world’s population has hearing loss, with 5% facing communication challenges. This disability causes psychosocial burdens, health issues, and economic losses due to decreased productivity. Early detection and remote monitoring can help reduce these negative effects and aid clinical diagnosis and research.
Pure Tone Audiometry has been the traditional gold standard for hearing assessment, requiring specialized equipment and personnel, limiting accessibility. Automated threshold audiometry enables self-assessment of hearing thresholds, showing comparable results to PTA for adults with mild to moderate hearing loss. Some methods require calibrated headphones or portable audiometers, while others only need earbuds and a smartphone, allowing for convenient home testing.
Smartphone audiometry apps have garnered increasing attention and adoption, particularly in contexts such as school screenings and resource-limited regions where traditional methods may be less accessible. Despite their growing popularity, the validation of these apps remains a significant concern, with most studies conducted in controlled environments such as clinics or offices.
While these controlled settings provide valuable insights into the performance of smartphone audiometry apps, they do not fully capture the complexities of real-world scenarios, particularly in home environments where ambient noise and other factors may significantly influence test results.
As such, there is a pressing need for validation studies specifically conducted in home settings to comprehensively evaluate the efficacy and accuracy of smartphone audiometry apps. These studies would provide critical data on the reliability and usability of these apps in everyday conditions, ensuring their suitability for broader clinical and research applications.
By conducting validation studies in home settings, researchers can better understand the real-world performance of smartphone audiometry apps and address any limitations or challenges that may arise. Ultimately, such efforts are essential for establishing the credibility and trustworthiness of these apps and facilitating their integration into routine healthcare practices.
Overview of the Study
This study seeks to investigate the potential of smartphone audiometry applications (apps) as a feasible and reliable alternative for self-assessment of hearing thresholds at home. Given that Pure Tone Audiometry (PTA) remains the gold standard for hearing assessment but necessitates access to specialized equipment, these smartphone apps offer a promising avenue for self-administered screening or monitoring.
The primary objectives include evaluating the validity of these apps for self-assessment of hearing thresholds in home environments and assessing the feasibility of patients utilizing them for such purposes. Additionally, the study aims to compare the results obtained from smartphone app-based self-assessment with those derived from traditional PTA conducted in clinical settings. Furthermore, the investigation seeks to determine the reliability of smartphone app-based automated threshold audiometry in both optimized and home environments, thus shedding light on their potential utility in broader healthcare contexts.
Methods
The study was designed as a multi-center, prospective randomized trial involving patients undergoing Pure Tone Audiometry (PTA) in clinical settings. Participants were randomly assigned to one of four publicly-available smartphone apps specifically designed for measuring pure tone thresholds.
Eligible participants, aged 18 and above, attending ENT or audiology clinics for ear or hearing assessments and owning a smartphone running iOS or Android, were included. Only those prescribed Pure Tone Audiometry (PTA) by an independent clinician were recruited. Analyses included participants who completed at least one smartphone app hearing test.
Exclusion criteria were: 1. Active ear infection or discharge; 2. Hearing loss exceeding 90 dB across three consecutive frequencies. Hearing loss severity was categorized per British Society of Audiology guidelines: normal (<20 dB), mild (21–40 dB), moderate (41–70 dB), severe (71–95 dB), profound (>95 dB).
Each participant used their assigned app once in optimal sound-treated conditions during their clinic visit and then three additional times at home. The study collected ear-specific frequency-specific thresholds and pure tone averages from both the smartphone apps and the traditional PTA method.
A priori power calculations were conducted using G-Power (v3.1) to assess correlation across repeats in various environments, compare Pure Tone Audiometry (PTA) with smartphone apps, and compare app-assisted hearing tests conducted at the hospital versus at home. The calculations determined a sample size of n = 34 per group (minimum n = 136 overall), with 80% power and an alpha of 0.05. Patients who did not submit any data were excluded from the overall sample size, while those who provided at least one smartphone result were included.
The comparison between these two sets of data was conducted using the Pearson correlation coefficient to assess the level of agreement. Furthermore, the study calculated the percentage of app-based hearing tests that produced results within ±10 dB of those obtained through PTA. To gauge patient acceptability and satisfaction with the smartphone apps, an online survey was administered to participants following their use of the apps. This comprehensive approach aimed to provide insights into the validity, feasibility, and patient acceptability of utilizing smartphone audiometry apps for self-assessment of hearing thresholds.
Results
156 UK participants gave written consent. 17 were excluded for not submitting data. Data from 139 participants (388 smartphone tests and 772 app-audiograms) were analyzed. 65 participants (47%) submitted a complete dataset.
The average age was 48 years (range: 19–78). 69 participants (50%) were female. Chronic otitis media was the most common reason for undergoing PTA. 58% of ears had normal hearing, while the remainder had mild, moderate, or severe hearing loss. The mean time to complete the app was 6 minutes (range: 2–15).
The findings revealed a strong correlation between the results obtained from two automated smartphone apps used at home and the average of Pure Tone Audiometry (PTA), with their frequency-specific median falling within an accuracy range of ±10 dB.
Additionally, smartphone audiometry conducted in both sound-treated rooms and home environments exhibited a very strong correlation. The ease of use of these apps was rated highly, with 90% of participants finding them easy or very easy to use. Moreover, 90% expressed satisfaction, indicating they would be happy or very happy to use an app for monitoring their hearing.
Final Thoughts
The trend toward remote care has underscored the increasing appeal of home-based, patient-conducted audiometry, potentially enhancing accessibility for certain patient demographics.
The implementation of home-based audiometry offers numerous advantages that contribute to its increasing appeal. Firstly, it eliminates the need for patients to travel to healthcare centers, reducing the associated inconveniences and minimizing the risk of exposure to infections. This aspect is particularly beneficial for individuals with limited mobility, such as the elderly or those residing in remote areas.
Furthermore, patient-conducted audiometry empowers individuals to take an active role in monitoring their hearing health. By conducting the tests in the comfort of their own homes, patients gain greater convenience and flexibility in scheduling and completing the assessments. This flexibility can be especially valuable for patients with busy schedules or those who face challenges in obtaining time off from work or other commitments.
Among the four apps assessed, two (iOS-1 and Android-2) demonstrated clinically reasonable accuracy, characterized by a strong correlation with traditional methods and a median falling within ±10 dB accuracy range.
Consequently, these apps may find suitability for clinical applications. Their high precision suggests they could be particularly valuable for monitoring fluctuations in hearing remotely, rather than solely relying on absolute hearing thresholds.
However, it’s crucial for both patients and clinicians to recognize their limitations; while these apps serve a purpose, they cannot fully substitute for Pure Tone Audiometry (PTA), often overestimating true hearing levels. Clinicians should exercise caution and refrain from endorsing unvalidated apps to ensure patient safety and accurate assessment.
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