Original Article

International Journal of Audiology 2006; 45:417
427

Margaret Baldwin Choice of probe tone and classification of trace

Audiology Department, Whipps Cross
University NHS Trust, London, UK patterns in tympanometry undertaken in early
infancy
Key Words
Impedance audiometry
Middle ear Selección de la sonda de prueba y clasificación de la
Neonates curva de timpanometrı́a en la infancia temprana
Tympanometry

Abbreviations Abstract Sumario

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ABR: Auditory brainstem response
ECR: Ear canal volume
ETD: Eustachian tube dysfunction
LIF: Latency-intensity function
MEE: Middle ear effusion
NHSP: Neonatal hearing screeing
programme
PCHI: Permanent childhood
hearing impairment
TCHL: Temporary conductive
For personal use only.
Tympanometry using 226 Hz, 678 Hz, and 1000 Hz probe
tones was undertaken on two groups of babies, age 2 to 21
weeks. A group of 104 babies with normal ABR thresh-
olds or TEOAEs were compared with a second group of
107 babies who had evidence of temporary conductive
hearing loss based on the findings of a test battery, which
included air and bone conduction ABR. The tympano-
grams were classified by Method 1, a simple visual
classification system, and Method 2, adapted from a
system described by Marchant et al (1986). The majority
of tympanograms recorded in both groups using the 226
Hz probe tone were ‘normal’ Type A, with no significant
difference in middle ear pressure or static admittance.
However, both classification methods demonstrated sig-
Se efectuaron timpanometrı́as con sondas de 226, 678 y
1000 Hz a dos grupos de bebés de 2 a 21 semanas. Un
grupo de 104 bebés con ABR o TEOAE normales se
comparó con un segundo grupo de 107 bebés con
evidencia de hipoacusia conductiva temporal según los
hallazgos de la baterı́a de pruebas que incluyó ABR aéreo
y óseo. Se clasificaron los timpanogramas por el método
1: una clasificación visual simple y por el método 2: la
adaptación del sistema descrito por Marchant et al
(1986). Cuando se utilizó la sonda de 226Hz, la mayorı́a
de los timpanogramas obtenidos en ambos grupos fueron
tipo A ‘‘normales’’, sin diferencia significativa en la
presión del oı́do medio o la admitancia estática. Sin
embargo, ambos métodos de clasificación mostraron

nificant differences between the two groups using the diferencias significativas entre los dos grupos al utilizar
hearing loss higher frequency probe tones, with Method 2 being the la frecuencia más alta; el método 2 fue el sistema
TEOAEs: Transient otoacoustic preferred system of classification. Tympanometry using preferido de clasificación. La timpanometrı́a con 226Hz
emissions 226 Hz is invalid below 21 weeks and 1000 Hz is the es inválida en menores de 21 semanas y 1000Hz es la
frequency of choice. frecuencia de elección.
TM: Tympanic membrane

Newborn hearing screening programmes (NHSP) have been Otoscopy in neonates

implemented across the UK. Diagnostic audiological assessment
Otoscopy in neonates was described as ‘‘. . . an onerous task even
of screen positives is crucial to the process of early identification,
for the experienced physician’’ by Zarnoch and Balkany (1978).
and attention must be directed at improving diagnostic proce-
Tympanic membranes (TMs) are difficult to visualize and tiny
dures (Watkin & Baldwin, 1999). Assessment in the past has
external meati are often obscured by vernix caseosa and debris
involved threshold air conduction ABR, using click stimuli and
(Doyle et al, 1997). When viewed they are difficult to interpret
tympanometry using a 226 Hz probe tone. However tympano-
and familiar landmarks are less distinct (McLellan & Webb,
metry results were inconclusive and there was no reliable
1961). Inter-observer agreement about the presence of middle
measure of a conductive component to the hearing loss (Watkin
ear effusion (MEE) in neonates therefore varies from 85%
& Baldwin, 1999). Babies with moderately raised ABR thresh-
(Marchant et al, 1986) to 27% (LaRossa et al, 1993), and
olds were reviewed until behavioural hearing assessment and
Roberts et al (1995) concluded that otoscopy could not be relied
reliable tympanometry and otoscopy could be undertaken at
upon in this age group.
about seven months. Early habilitation was, therefore, limited to
severe or profound permanent childhood hearing impairment
(PCHI). Watkin and Baldwin (1999) reported that 4 to 5 babies
Maturational changes to the ear in early infancy
per 1000 screened had an ABR threshold of 50, 60, or 70 dB
nHL, and of these 77% had a temporary conductive hearing loss The TM and external auditory meatus of the neonate are
(TCHL) at the behavioural assessment. Only 0.65/1000 had a anatomically different (Jaffe et al, 1970; McLellan & Webb,
moderate PCHI that was targeted for early habilitation but a 1957). The bony floor of the ear canal is not fully formed until
reliable neonatal evaluation of the conductive component was about a year (Kenna, 1990) and the canal walls are therefore
necessary to enable this. more mobile. The ear canal diameter and length increase rapidly

ISSN 1499-2027 print/ISSN 1708-8186 online Accepted: Margaret Baldwin

DOI: 10.1080/14992020600690951 March 8, 2006 Audiology Department, Whipps Cross Hospital, Leytonstone, London E11 1NR,
# 2006 British Society of Audiology, International UK.
Society of Audiology, and Nordic Audiological Society E-mail: Margaret.Baldwin@WF-PCT.nhs.uk
 in early infancy (Keefe and Bulen, 1993), with the middle ear
cavity reaching adult size by about six months (Eby & Nadol,
1986). The acoustical properties of the external and middle ear
are therefore quite different, and significant developmental
changes occur over the first four months of life (Holte et al,
1991). Keefe and Bulen (1993) found that maturation of the
external and middle ear significantly affects the ear canal
impedance and reflection coefficient responses, and the power
transfer into the infant’s middle ear is much less than that of the
adult. Energy transmission into the middle ear was most efficient
in the 1000 Hz to 4000 Hz range, and 220 to 660 Hz was
considered ‘‘the worst possible range to use’’. In agreement with
Holte (1991) they showed significant differences in admittance
phase between adults and infants below four months but not
between six month old infants and adults. Himmelfarb (1979)
had warned that ‘‘fundamental differences in the acoustic
properties’’ of adult and neonatal ears would mean that
assumptions could not be made about neonatal ears from adult
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data at 220 Hz, but may be possible at 660 Hz. Reactance is
smaller than resistance at 220 Hz in the normal neonate, whereas
in the normal adult the opposite is the case. At 660 Hz reactance
and resistance are approximately equal, regardless of age. The
impedance of the neonatal middle ear is dominated more by
mass than stiffness, with increasing contribution of stiffness over
the first four months (Holte, 1991). The resonant frequency of
the neonatal tympanic membrane is also much lower than in
adults (Weatherby & Bennett, 1980; Holte, 1991). Meyer et al
(1997) measured the resonant frequency of the ear of one infant
from two weeks to six and a half months old and found that it
For personal use only.
remained below 550 Hz until she was 14 weeks old. Adult middle
ear resonant frequency of 800
1200 Hz (Silman & Silverman,
1991) was reached by three to four months. This supported the
theory that the infant middle ear changes from a mass- to
stiffness-dominated system, and that low frequency tympano-
metry was not appropriate below this age.
Using a ‘gold standard’ in neonatal tympanometry
Unfortunately the difficulties of an adequate neonatal ‘gold
standard’ to judge the presence of middle ear fluid has been a
confounding factor in developing tympanometry as a useful
neonatal test procedure. Confirming the presence of middle ear
fluid by myringotomy is reliable but usually not justifiable. An
alternative method of validating tympanometry is to see if there
is an association between the results of other reference tests
of auditory function. The presence of TEOAEs has been used
to indicate normal peripheral hearing without a conductive
hearing loss. However this has produced variable find-
ings (McKinley et al, 1997; Sutton et al, 1996; Thornton
et al, 1993; Kei et al, 2003). TEOAEs can be recorded in the
presence of middle ear dysfunction (Owens et al, 1992; Amadee,
1995; Driscoll et al, 2000; Taylor & Brooks, 2000). Conversely,
the absence of TEOAE is not an adequate method of estab-
lishing middle ear dysfunction and may be due to a variety of
reasons such as poor probe fit, poor test conditions, and SNHL.
Recognizing these limitations, combining diagnostic tests of
auditory function more reliably establishes the presence of a
conductive loss and improves the validity of the gold standard.
Exclusion of SNHL by follow up examination also increases
validation.
418
Neonatal tympanometry using the standard 226 Hz
probe tone
Tympanometry using 226 Hz probe tone is a well-established
technique used in adults and children (Brooks, 1968) and early
reports were optimistic about its use in neonatal tympanometry.
The test was feasible, traces seemed readily interpretable and
similar to those recorded from older children (Keith, 1973, 1975;
Groothius et al, 1979). However validity below the age of seven
months was called into question when normal Type A tympa-
nograms (Liden, 1969; Jerger, 1970) were reported in babies with
MEE confirmed by myringotomy (Paradise, Smith & Bluestone,
1976; Zarnoch & Balkany, 1978), and from a neonate when
otoscopic examination revealed bilateral tympanic membrane
perforations with draining pus (Zarnoch & Balkany, 1978).
However, use of the 226 Hz probe tone persisted because the
tympanograms seemed easier to interpret compared to those
recorded using higher frequency probe tones (Holte, 1991; El-
Refaie et al, 1996).
Neonatal tympanograms using high frequency probe
tones
The routine adoption of higher frequency probe tone tympano-
metry for neonates has been hindered by difficulties surrounding
trace interpretation. Tympanograms have been classified by
pattern in adults (Liden, 1969; Jerger, 1970; Beery, 1975;
Vanhuyse, 1975) but these systems have not been usefully applied
to the neonatal population. McKinley et al (1997) found no clear
relationship between the presence of TEOAEs and tympanome-
try using 226 Hz, 678 Hz and 1000 Hz probe tones classified
according to the Vanhuyse Model of Tympanometric Shapes
(Vanhuyse et al, 1975). The majority of 1000 Hz and half the 678
Hz recordings were classified as ‘other’, and consequently the
authors judged that neonatal high frequency tympanometry was
not useful. However, other measures have been used to classify
tympanometry in babies (Williams et al, 1995; Marchant et al,
1986; Sutton et al, 1996). Marchant et al (1986) devised a
classification system using a measure of peak susceptance of 5/0
mmho. Using the presence of middle ear fluid at myringotomy as
their reference they found a peak susceptance of 5/0 mmho in 33/
35 ears giving a sensitivity of 0.94. There were only three ears
with no evidence of fluid and they had peak susceptance /0
mmho. The technique was recommended as an objective
diagnosis of middle ear dysfunction below five months.
More recently, attempts have been made to describe the
characteristics of 1000 Hz tympanograms in neonates passing
an OAE screen (Kei et al, 2003; Margolis et al, 2003). These studies
have produced 5th to 95th percentile data for a variety of test
parameters which, the authors believe, may serve as pass/fail
criteria for 1000 Hz tympanometry. However, there are differences
between criteria, and uncertainty about transferring normative
data from one age to another. The sensitivity of the criterion
suggested by Margolis et al (2003) was low (0.5) when absence of
TEOAE was employed as the reference. The choice of pass/fail
criteria has therefore not been established and needs further
evaluation on babies with confirmed middle ear dysfunction. With
the exception of Marchant et al (1996) these studies have not
validated their findings on a cohort with reliable evidence of
middle ear dysfunction. The present study attempted to evaluate
International Journal of Audiology, Volume 45 Number 7
 tympanometry on a group of neonates with transient middle ear
dysfunction assessed by combining a battery of tests which
included air and bone conduction ABR, and where other
confounding conditions were excluded by follow-up of the group.
The study had two aims: firstly, to determine which probe tone
should be used in neonatal tympanometry; and secondly, to
propose a simple system of trace classification. With these aims in
mind, tympanograms recorded using 226 Hz, 678 Hz, and 1000 Hz
probe tones were compared between a group of babies with normal
tests of auditory function, and a group of babies with TCHL.
Methods
Subjects
Since 1996, neonates referred from the NHSP in Waltham Forest
and from the selective neonatal screen in Redbridge have been
audiologically assessed using a test battery approach. This
included measurement of TEOAEs, bilateral air conduction
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ABR threshold, bone conduction ABR threshold, and tympa-
nometry using three probe frequencies. Babies who were con-
sidered to have normal hearing on the basis of this test battery
were discharged but those with abnormal findings were recalled
for behavioural tests of hearing using either distraction testing or
visual reinforcement audiometry with ER3A ear inserts.
There were 211 infants recruited to the study over a three year
period from September 1996 to September 1999, and they were
assigned to either a ‘normal group’ (Group 1) or a ‘pathological
group’ (Group 2). There were 104 babies assigned to Group 1,
and 162 ears fulfilled the necessary criteria of having a TEOAE
For personal use only.
present or an ABR threshold 5/ 20 dB nHL. An assumption was
made that babies with no evidence of peripheral hearing loss were
less likely to have middle ear dysfunction. Their gestational ages
ranged from 24 to 42 weeks (mean /38.6, sd /3.5, mode/40
weeks). Their chronological age at the test ranged from two weeks
to 19 weeks (mean /10.2, s.d /4.1, mode /6 weeks). Their
corrected age at the test (relative to 40 weeks gestation), ranged
from /5 to 19 weeks (mean /8.8, s.d /5.0, mode /11 weeks).
In both groups the youngest babies tested were two weeks old.
This is because all the babies who were assessed were referred
into the Audiology Clinics where they were seen for a diagnostic
audiological assessment, and this process took at least two
weeks. None of the assessments took place in the maternity
wards immediately following the initial screen.
There were 107 babies recruited to the pathological Group 2,
and 156 ears were considered to have a TCHL on the basis of the
following criteria:
1. Absent TEOAE
2. 40 dB nHL 5/ air conduction ABR threshold B/80 dB nHL
3. Bone conduction ABR threshold 5/ 30 dB nHL.
4. Latency-intensity functions of wave V consistent with
conductive loss.
5. Follow-up behavioural assessment showing no evidence of
permanent sensori-neural hearing loss or permanent con-
ductive hearing loss.
Their gestational ages ranged from 26 to 42 weeks (mean /
39.2, sd /2.52, mode /40 weeks). Their chronological age at the
test ranged from two weeks to 21 weeks (mean /11.2, s.d /3.9,
mode/11 weeks). Their corrected age at the test (relative to 40
Choice of probe tone and classification of
trace patterns in tympanometry undertaken
in early infancy
weeks gestation), ranged from /5 to 19 weeks (mean /10.4,
s.d /4.3, mode/11 weeks).
Babies were recruited to this group following their behavioural
assessment in order to verify the neonatal test results. At this
assessment the baby could have normal hearing and middle ear
function, or evidence of MEE. If there was any doubt about the
confirmation of the type of hearing loss the baby was not
included in the cohort. Babies who were considered to have
sensori-neural hearing loss, or permanent conductive loss, were
always excluded. This was to ensure, as far as possible that those
babies assigned to this group had abnormally raised air
conduction ABR thresholds as a result of temporary conductive
loss attributable to middle ear dysfunction. A trained audiologist
undertook the follow-up assessment in 92% of the cases. The
remaining 8%, who did not attend this follow-up appointment
attended and passed the Infant Distraction Test undertaken by
their health visitor. From these assessments it can be assumed
that none of the children in this cohort had sensori-neural
hearing loss predisposing them to the raised ABR threshold in
the neonatal period.
Test procedures
TEOAEs were recorded using the Otodynamics ILO88. A signal-
to-noise ratio of 6 dB or greater, at third octave frequency bands
centred at 2400, 3200, and 4000 Hz, was judged to be a pass.
ABR thresholds were recorded using the Medelec Sapphire
system. Silver-silver chloride electrodes were positioned on the
ipsilateral mastoid (negative), high forehead (positive) and
contralateral mastoid (common). Inter-electrode impedances
were less than 5000 V. A click stimulus of 100 ms pulse duration
with alternating polarity was presented through a headphone
transducer at a repetition rate of 30/s. A 10 ms (or if necessary 20
ms) post stimulus recording window was used to average at least
1024 stimulus repetitions. Responses were filtered between the
negative and positive electrodes with a bandpass of 100 Hz to
2000 Hz. Bone conduction thresholds were measured with a
Radioear B-71 bone conductor placed on the mastoid of the test
ear (Webb & Stevens, 1991). Interaural attenuation of bone-
conducted stimuli in this age group is 25
35 dB (Yang, Allen &
Moushegian, 1987) and masking was therefore introduced at
stimulus levels above 30 dB nHL (Webb & Stevens, 1991).
The normal latency-intensity functions (LIF) of wave V for air
conduction ABR had been established for the equipment and
test set up described, in the appropriate age groups by testing a
minimum of 20 ears with ‘normal’ ABR thresholds and
TEOAEs present (Baldwin, 2004). The latencies of wave V
were plotted onto the LIF and comparisons made with the
normative data. These findings were used as part of the test
battery to support the diagnosis of a conductive hearing loss
when there was a horizontal shift in the LIF (van der Drift,
Brocaar & van Zanten, 1988a; Baldwin, 2004).
At the same clinic session admittance tympanograms at probe
tone frequencies of 226, 678, and 1000 Hz were recorded using
a Grason-Stadler GSI33 Version 2 Middle Ear Analyser with a
pressure change from /200 daPa to /400 or /600 daPa at a
speed varying from 600 daPa/s at the tails to 200 daPa/s at the
peak. The baby had to be still and quiet for the procedure. Traces
were repeated to check for consistency whenever possible. Traces
which were difficult to interpret, were always repeated. The
procedure was relatively straightforward once an acoustic seal
Baldwin 419
 had been achieved, but was more efficient if two testers were
present; one to check and hold the probe while the other
operated the machine.
Admittance tympanograms recorded from both groups were
examined in terms of their shape and middle ear pressure, and
were classified by 2 methods. The traces were classified by the
author who was not blind as to the hearing loss group to which
the infant belonged. To ensure that this did not bias the results, a
sample of 80 traces were also classified by two independent
testers who had no knowledge of the ABR findings. Tester 1 was
a trainee scientist with one year’s experience of classifying
tympanometry on both children and adults, using a 226 Hz
probe tone. Tester 2 was an audiologist with over 20 years’
experience.
Classification Method 1
A simple visual classification system based on the Liden/Jerger
classification (Liden, 1969; Jerger, 1970) in which traces were
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categorized into:
1. Normal: if there was a clear peak, and middle ear pressure
between /150 and /150 daPa (see Figure 1). In the case of
biphasic traces the measurement was taken from the negative
peak (Thornton et al 1993, Sutton et al 1996).
2. Eustachian tube dysfunction (ETD): if there was a clear peak
and a negative middle ear pressure of /150 and /400 daPa
(see Figure 2)
For personal use only.
Figure 1. Examples of tympanograms classified in Method 1 as ‘Normal’, recorded using 226 Hz, 678 Hz, and 1000 Hz probe tones
420
3. Flat or trough shaped: if there was no clear peak. Typically,
traces were trough-shaped or ‘monotonically decreasing’ (see
Figure 3).
4. Indeterminate: traces which the tester could not place into
the above categories were classified as indeterminate (see
Figure 4)
Classification Method 2
Marchant et al (1986) devised a classification system in which a
baseline was drawn between pressures of /300 and /400 mmho
and peak susceptance measured above the baseline. The absence of
a peak-, or a ‘trough’-shaped tympanogram was consistent with a
diagnosis of middle ear dysfunction, confirmed by myringotomy.
Adapted from Marchant’s methodology, using admittance
measurements rather than susceptance, a baseline was drawn
between /200 and /400 daPa. A vertical line was drawn from
the baseline to the peak of the trace either above (positive peak),
or below (negative peak) the baseline (see Figure 5). The traces
were classified as:
a. Positive peak: i.e. normal
b. Negative: i.e. abnormal
c. Indeterminate: traces which the tester could not classify as
‘Positive’ or ‘Negative’
NB: If there was a positive and a negative peak, the trace was
considered to be positive.
International Journal of Audiology, Volume 45 Number 7
 Figure 2. Two examples of tympanograms classified in Method 1 as ‘Eustachian Tube Dysfunction’ recorded using 678 Hz and 1000
Hz probe tones
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Results
Classification Method 1
Using the simple visual classification system described, tympano-
grams from both groups were analysed and classified. The results
are presented in Table 1 for both test groups, for the three probe
tone frequencies. Chi-square tests were used to test significance.
There were small numbers in some of the cells and in order for the
statistical test to be valid it was necessary to pool data. The data
from the ‘normal’ and ‘ETD’ categories were therefore combined
for the statistical analysis and the ‘flat-/trough- shaped’ traces
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were combined with the ‘indeterminate’ traces.
There were no significant differences between Group 1
(Normal) and Group 2 (TCHL) using the 226 Hz probe tone
(x2 /0.78, df /1, p/0.376). There were significant differences
between the 2 groups using the 678 Hz probe tone (x2 /143.13,
df/1, p/ B/0.0001) and the 1000 Hz probe tone (x2 /239.03,
df/1, p/ B/0.0001).
Tympanograms recorded using 226 Hz were compared
between the 2 groups. Mean static admittance and middle ear
pressure measurements are shown in Table 2. There was no
significant difference in static admittance between group 1 and 2
(t / 0.847, df /259, p /0.398) and no difference in middle ear
pressure (t / 0.593, df /259, P/0.553).
Figure 3. Two examples of tympanograms classified in Method 1 as ‘Trough Shaped’ recorded using 678 Hz and 1000 Hz probe
tones
Choice of probe tone and classification of
trace patterns in tympanometry undertaken
in early infancy
Classification Method 2
Tympanograms from both groups were reclassified using the
system described adapted from Marchant et al (1986). The
results are presented in Table 3. Once again it was necessary
to pool the data because of the low numbers in some of the
cells. The ‘indeterminate’ category was therefore pooled with
the ‘negative’ group. Chi-square tests were still invalid for the
226 Hz probe tone as the expected frequency count was less
than five in two of the cells. The Fisher exact test was
therefore used to test significance for this probe frequency and
this demonstrated no significant differences in the number of
positive and negative traces between Group 1 and 2 (Fisher
exact test, p/0.485, one tailed). Chi-square demonstrated
significant differences between the two test groups using 678
Hz (x2 /180.67, df /1, p/ B/0.0001) and 1000 Hz (x2 /
239.03, df /1, p/ B/0.0001).
Using this method of classification fewer traces were classified
as indeterminate. Figure 6 shows two traces which were classified
as ‘indeterminate’ using Method 1, reclassified using Method 2
as positive (i.e. normal). Table 4 shows the reclassification of
indeterminate traces for both groups using 678 Hz and 1000 Hz.
It was possible to reclassify the majority of indeterminate cases
into a positive or negative group.
Baldwin 421
 Figure 4. Two examples of tympanograms classified in Method 1 as ‘Indeterminate’ recorded using 678 Hz probe tones

Sensitivity and specificity of multifrequency tympanometry excluding the unclassified traces, and in order to include all the
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Table 5 shows the sensitivity and specificity of correctly
identifying TCHL for the three probe frequencies using this
method of classification. The results are shown excluding the
‘indeterminate’ traces, i.e. only for those traces which were
classified as normal or abnormal. The results clearly show that
226 Hz tympanometry is invalid in this age group with the best
results obtained for 1000 Hz. However, there are concerns about
For personal use only.
ears tested, the ‘indeterminate’ traces were grouped with the
‘negative’ traces and these results are also shown in parenthesis.
This is based on the assumption that the ‘indeterminate’ trace is
not considered to be normal although this assumption may be
incorrect. The specificity of the test for the high frequency probe
tones is slightly reduced but sensitivity remains high, and 1000
Hz remains the frequency of choice.

Figure 5. Tympanograms classified by Method 2 adapted from Marchant et al (1986)

422 International Journal of Audiology, Volume 45 Number 7

 Table 1. The classification of tympanograms recorded from Group1 and Group 2 using Method 1
Normal ETD Flat/Trough Indeterm. Total
226 Hz Group1 152(95.6%) 2(1.3%) 1(0.6%) 4(2.5%) 159
Group2 148(94.9%) 0 5(3.2%) 3(1.9%) 156
678 Hz Group1 86(53.1%) 22(13.6%) 18(11.1%) 36(22.2%) 162
Group2 2(1.3%) 2(1.3%) 128(82%) 24(15.4%) 156
1000 Hz Group1 115(71.4%) 25(15.5%) 13(8%) 8(5%) 161
Group2 0 1(0.6%) 154(98.7%) 1(0.6%) 156

The effect of age on trace classification at 226 Hz
In the current study the infants’ ages ranged from
5 to 19 weeks
corrected for prematurity. The use of the 226 Hz probe tone did
not differentiate between the ‘normal’ test group and those with
TCHL in this age group. There were only five flat traces recorded
from the pathological group using the 226 Hz probe tone, and
these were not from the older babies tested. The five abnormal
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repeatable. These tympanograms, in which the observer was
uncertain about the classification, were placed in the ‘indeter-
minate’ category. The ‘indeterminate’ category provides an
additional measure of the success of the classification system.
If there are too many in this group the system has failed, as the
question remains as to which group the traces belong.
Method 1 was a subjective methodology in which the observer

traces occurred in babies aged 0 (2 ears), 9, 10 and 13 weeks old.
These findings suggest that maturational changes, which enable
the valid use of the low frequency probe tone, must occur after
20 weeks.
Intra-tester reliability
Table 6 shows the author’s classification of a sample of 80 traces
compared to two blind observers using both methods of
classification. Using Method 1 both testers had a larger number
of indeterminate traces mainly in the group categorized as
‘Abnormal’ by the author. The percentage of indeterminate
For personal use only.
classified the traces based on their shape. There are obvious
limitations to this methodology, as the observer will exercise
their judgement based on their previous experience of a different
client group. One example may be the subjective interpretation
of a ‘clear peak’. A small peak may be classified as abnormal in
the absence of absolute measures for this subject group. The
results, however, demonstrate that traces could be readily
classified using the 226 Hz and 1000 Hz probe tones, but a
higher proportion of the traces recorded using 678 Hz were
placed in the ‘indeterminate’ category. There were 22% of traces
recorded using 678 Hz from the ‘normal’ test group which were

traces dropped when using Method 2, with greater agreement
with the author. There was substantial agreement between the
two testers using Method 2.
Discussion
Trace classification in neonatal tympanometry
One of the problems in the use of high frequency tympanometry
in neonates has been the high number of unclassifiable traces
when systems of classification designed for use with low
frequency tympanometry in adults and older children have
been applied. In some studies the excessive number of unclassi-
fied traces led the authors to dismiss the use of tympanometry in
this population (McKinley et al, 1997). In the current study the
traces were assessed using criteria that required subjective
interpretation, and using both methodologies some traces
remained difficult to classify. These traces tended to be:
undulating with several very small peaks; have peaks that
occurred below the baseline; or have a small positive peak
followed by a trough shape pattern i.e. an increasingly negative
admittance value as the pressure became more negative. Some
unclassifiable traces could be eradicated by repeating the test to
remove the effect of artefacts caused by poor fit and movements.
However, in this study, traces which were difficult to classify
were always repeated and the traces reported were genuine and
classified as difficult to interpret and some of the difficulties
related to the judgement of a ‘clear peak’.
Method 2 introduced a criterion which attempted to reduce
the subjectivity of the decision process. This classification system
categorized any positive peak as ‘normal’ irrespective of its size.
Hence small peaks which hitherto were indeterminate would be
reclassified as ‘normal’. Another group of traces, which were
notoriously difficult to classify, were those with more than one
peak. In Method 2 traces which were undulating in shape but
still fell below the baseline would be classified as ‘negative’. The
example in Figure 5 (c) shows an undulating trace recorded
using 678 Hz that is still difficult to classify as there is more than
one small peak crossing the baseline. Method 2 successfully
reduced the number of traces considered to be unclassifiable but
there were still some remaining, particularly when using 678 Hz.
The majority of these traces were reclassified appropriately,
using Method 2, according to their test group although three
traces were classified as normal in the pathological group (Table
4) using this methodology. The single unclassified trace, using
1000 Hz in the pathological group was reclassified correctly as
abnormal using Method 2.
Problems of subjective interpretation would be eradicated by
an objective pass/fail criterion by which to assess the tympano-
metry (Kei et al, 2003; Margolis et al, 2003). Kei et al (2003)
suggested using the 5th percentile for positive tail (/ 200 daPa)

Table 2. Comparison of tympanograms recorded from Group 1 and 2 using the 226 Hzprobe tone
Group 1 (Normal) Group 2 (TCHL) Significance
Static Compliance (ml) 0.68 (sd /0.32) 0.64 (sd /0.4) 0.398
Middle ear pressure (daPa) /8 (sd / 62) /12 (sd /48) 0.553

Choice of probe tone and classification of Baldwin 423

trace patterns in tympanometry undertaken
in early infancy
 Table 3. The classification of tympanograms recorded from groups 1 and 2 using Method 2 (Marchant et al, 1986)
Positive
226 Hz Group1 157(98.7%)
Group2 151(98.1%)
678 Hz Group1 128(79%)
Group2 7(4.5%)
1000 Hz Group1 140(87%)
Group2 1(0.6%)
peak
compensated static admittance as a pass/fail criterion
giving a value of B/0.39 mmho. However, the authors did not
evaluate this criterion on a group of babies with abnormal middle
ear function, and the sensitivity and specificity of the test are
unknown. Also this criterion applies to babies aged one to six
days and the possibility of extrapolating the findings to older
babies is also uncertain. Babies tested below four days are more
likely to have external-ear abnormality due to occluding vernix
Int J Audiol Downloaded from informahealthcare.com by University of Guelph on 09/09/12
(Doyle et al, 1997), which may produce different tympanometric
results to those with middle-ear abnormality. In establishing
normative data it is important to distinguish between the groups
of babies tested soon after birth and those aged two to four weeks
where any external-ear factors should be eliminated. It may be
necessary to establish norms for each group independently.
Margolis et al (2003) also produced normative data using 1000
Hz tympanometry from a group of older babies aged two to four
weeks who had passed OAE screening. They suggested the 5th
percentile for negative tail (/ 400 daPa) static admittance as a
For personal use only.
pass/fail criterion giving a value of B/0.6 mmho. They evaluated
the criterion on a group of babies less than four days old and
using this pass/fail criterion and the absence of OAE to indicate
a true positive, the sensitivity of their criterion was only 0.5 with
specificity of 0.91.
A comparative study using their normative data has not been
undertaken but a brief analysis shows that traces with small
peaks would be incorrectly placed in the pathological group. In
the current study, tympanograms with peaks, however small,
were more likely to be in the ‘normal’ test group, and using 1000
Hz there were no Type A tympanograms in Group 2. The results,
therefore, support the findings of Marchant et al (1986). Sutton
et al (1996) also found that tympanograms with small peaks
Figure 6. Tympanograms classified as in Method 1 as ‘Indeterminate’, reclassified as positive (i.e. normal) in Method 2
424
Negative Indeter-minate Total
2(1.3%) 0 159
3(1.9%) 0 154
27(16.7%) 7(4.3%) 162
142(91%) 7(4.5%) 156
18(11.2%) 3(1.9%) 161
155(99.4%) 0 156
( B/0.12 mmho) and those with a peak at positive middle ear
pressure ( //50 daPa) were more likely to be in the ‘normal’
hearing screening group.
The current study demonstrates that there is a typical shape,
which defines the traces from the pathological group, and 98.7%
were classified as flat or trough shaped using 1000 Hz.
Unfortunately, previous studies have been restricted by the small
number of ears with ‘abnormal’ tympanograms and conclusions
about their characteristics have therefore been limited (Sutton et
al, 1996; Rhodes et al, 1999). Rhodes et al (1999) reported only
three ears with flat 1000 Hz tympanograms, but these three ears
failed all the hearing screening tests. Sutton et al (1996)
demonstrated a significant association between the results of
TEOAE screening and 678 Hz tympanometry. However, the
majority of the cohort passed the hearing screen (135/169 ears)
and 87% of these had peaked tympanograms. Of the 33 ears that
failed the TEOAE screen only six ears had flat 678 Hz
tympanometry and 10 ears had MEPB/ /100 daPa. The
remaining ears had ‘normal’ tympanometry and this was
attributed to lesser degrees of MEE. However, failure at TEOAE
screening alone is an inadequate ‘gold standard’ and moreover
tympanometry was not always undertaken at the same test
session in this study. A time delay of two to eighteen days in 15%
of the cohort could influence the association between the two
tests. Kei et al (2003) described a trough shaped pattern in 5.7%
of newborn babies with TEOAEs present. They excluded these
traces from their cohort from which they derived normative
tympanometric data for the 1000 Hz probe tone. However, they
observed that TEOAEs were less robust in ears with these
tympanometric shapes and suggested this may be a result of
transient middle ear dysfunction.
International Journal of Audiology, Volume 45 Number 7
 Table 4. Traces classified as indeterminate using Method 1, reclassified using Method 2 (Marchant) at 678 Hz and 1000 Hz for
Group 1 and Group 2
Positive Negative
678 Hz Group1 21 9 6
Group2 3 17
1000 Hz Group1 2 5
Group2 0 1
The choice of probe tone in neonatal tympanometry
Using Method 1 to classify the traces, there was no significant
difference in the number of ‘normal’ tympanograms recorded
from the normal and pathological groups using the 226 Hz
probe tone, and Type A tympanograms were recorded in the
majority of ears (94.9%) regardless of the presence of TCHL.
Only five traces were classified as abnormal from the patholo-
gical group. The static admittance and middle ear pressure
measurements recorded using 226 Hz were compared between
Int J Audiol Downloaded from informahealthcare.com by University of Guelph on 09/09/12
the two groups and no significant differences were observed
(Table 2). Using Method 2 to classify the tympanograms
eradicated the unclassifiable traces but over 98% of traces were
classified as normal from both test groups. Hence, the sensitivity
of the test in identifying temporary middle ear dysfunction in
neonates was extremely low (0.02). This data supports the view
that tympanometry using low frequency probe tones is invalid in
babies within this age range. In contrast the use of high
frequency probe tones exposed significant differences between
the test groups using both systems of classification.
For personal use only.
The majority of traces recorded from the pathological group
using 678 Hz were classified as abnormal using both methods.
The main difficulty with this probe tone was the larger number
of unclassifiable traces. Method 2 reduced the number of
indeterminate traces in both test groups to less than 5%.
However seven traces were incorrectly classified as ‘normal’ in
the pathological group and the sensitivity and specificity of the
678 Hz probe tone was slightly less than for the 1000 Hz tone.
Using Method 1, there were no Type A traces recorded from
the pathological group using the 1000 Hz probe tone. The traces
were classified as flat or trough-shaped with one trace fulfilling
the criteria for ETD and only one unclassifiable trace. The
majority of traces recorded from the ‘normal’ test group (71.4%)
were categorized as normal with 15.5% falling within the
boundaries of ETD, and 8% flat/trough shaped. These findings
are to be expected when a proportion of cases with middle ear
dysfunction have been shown to retain their otoacoustic emis-
sions. The number of unclassifiable traces was much lower using
1000 Hz than 678 Hz and this number was reduced even further
Table 5. The sensitivity, specificity, and PPV of correctly
identifying temporary conductive hearing loss for the three
probe frequencies using Method 2. Results in parenthesis are
shown for the ‘Negative’ and ‘Indeterminate’ traces grouped
together.
Sensitivity Specificity PPV
226 Hz 0.02 0.99 0.6
678 Hz 0.95 (0.96) 0.83 (0.79) 0.84 (0.81)
1000 Hz 0.99 0.89 (0.87) 0.9 (0.88)
Choice of probe tone and classification of
trace patterns in tympanometry undertaken
in early infancy
Indeter-minate Total (Group 1,2)
60
4
1 9
0
using Method 2. The sensitivity, specificity and PPV of correctly
identifying middle ear dysfunction associated with TCHL was
highest for the 1000 Hz probe tone and this would therefore be
the frequency of choice for this age group.
In order to perform valid statistical tests the categories of
‘normal’ and ‘ETD’ were pooled and abnormal traces were
grouped with the unclassified traces. However it is useful to
examine the data for the individual categories. The indetermi-
nate traces were more likely to occur in Group 1 and, as
previously discussed, may have had small peaks or a small
positive peak followed by a trough. Further examination of the
types of traces in this category, in relation to the test group to
which they belong, may reduce the number of unclassified traces
in the future by providing information about unfamiliar trace
patterns and how they should be classified. Also, the classifica-
tion of ETD as MEP
150 to
400 daPa is extrapolated from
data measured from older children and adults. It is therefore an
assumption that this is an indicator of ETD in neonates and this
may be inappropriate. In addition ETD is harder to define in this
population when more than one peak can occur. It is therefore
useful to note that traces with negative middle ear pressure were
primarily found within the ‘normal’ test group using the high
frequency probe tones. This could suggest that the normal
population of neonates have more negative MEPs than older
children, and that MEPs within this range are not abnormal, or
that this milder form of middle ear dysfunction does not cause
any measurable TCHL in the majority of cases.
Intra-tester agreement in high frequency tympanometry
There are implications for training in classifying the tympano-
grams appropriately. Two independent testers who analysed a
sample of traces classified 26%
50% as indeterminate using
Method 1. Most difficulty was caused by tympanograms from
the pathological test group, and more difficulty was perceived
by the more experienced audiologist. Audiologists are familiar
with pattern classification of tympanograms in adults and
children into categories of ‘normal’ and ‘ETD’ and ‘flat’. The
trough shaped tympanogram, which is typical of the abnormal
ear using high frequency probe tones in this population, is an
unfamiliar pattern and is unobserved using low frequency probe
tones in an older age group. The shapes produced do not fit the
familiar classification systems to which we are accustomed.
Applying the criterion used in Method 2 reduced the number of
‘indeterminate’ traces to 9
10%. The Kappa statistic showed
substantial agreement between the two testers, and substantial
and almost perfect agreement between the author and the two
testers. These findings support the view that high frequency
tympanometry is difficult to interpret even by experienced
audiologists, but Method 2 can reduce the uncertainty in trace
classification.
Baldwin 425
 Table 6. The results of classification of 80 traces by the author and two independent observers, by both Method 1 and 2
Normal Abnormal Indeterminate
Author’s classification 21(26%) 55(69%) 4(5%)
Tester 1 Method 1 17(21%) 42(52%) 21(26%)
Tester 1 Method 2 18(22%) 54(68%) 8(10%)
Tester 2 Method 1 19(24%) 21(26%) 40(50%)
Tester 2 Method 2 29(36%) 44(55%) 7(9%)
*Agreement rating in parenthesis (Landis and Koch, 1977)
The use of a ‘gold standard’
An attempt has been made by this study to address the problem
of an adequate ‘gold standard’ for identifying the presence of
middle ear dysfunction in neonates. Babies with TEOAEs
present, or ‘normal’ hearing thresholds measured by AC ABR
Int J Audiol Downloaded from informahealthcare.com by University of Guelph on 09/09/12
were more likely to have normal middle ear function although it
had to be expected that a minority of this cohort would have
middle ear dysfunction. However a cohort of babies with
evidence of TCHL as assessed by air and bone conduction
ABR could be assumed to have middle ear dysfunction at the
time of the test. These findings were supported by follow-up
appointments to exclude permanent hearing impairment.
Maturational changes in the neonatal middle ear
Low frequency tympanometry produced erroneous results in
babies aged two to 21 weeks with TCHL. There were only five
For personal use only.
flat traces recorded from this group and there was no effect of
age. Previous studies had predicted that low frequency tympa-
nometry would be problematic below the age of four months
(Himmelfarb, 1979; Weatherby and Bennett, 1980; Holte, 1991;
Keefe and Bulen, 1993; Meyer, 1997). The neonatal middle ear
undergoes anatomical developmental changes in the first four
months of life that influence its acoustical properties. Energy
transmission into the neonatal middle ear is most efficient at
1000 to 4000 Hz (Keefe and Bulen, 1993). At frequencies below
500 Hz they found that less power was transferred into the
middle ear of babies below four months because of ear canal wall
vibration and resonance. These differences between the neonatal
and adult ear are no longer evident by the age of six months, and
Holte (1991) showed that the differences in admittance phase
measurements observed below four months had disappeared by
the age of six months. Meyer et al (1997) predicted that valid low
frequency tympanometry would only be possible when the adult
middle ear resonant frequency was reached and the infant
middle ear changed from a mass to stiffness dominated system.
This occurred at four months in their longitudinal study of one
baby. The current study supports the view that these matura-
tional changes, which invalidate the use of low frequency
tympanometry, must occur after 21 weeks of age. As tympano-
metry using 226 Hz probe tones is successfully used clinically to
differentiate pathological ears on babies over six months old,
further longitudinal studies would be necessary to establish the
variability in the age at which these changes occur.
The youngest baby tested in this study was two weeks old
because the cohort were all referred for diagnostic assessment
following the newborn hearing screening process. The cause of
TCHL in this group of babies is attributed to middle ear
426
Kappa statistic*
Measurement of agreement between:
Testers and author Tester1 and Tester2
0.58 (moderate) 0.43 (moderate)
0.89 (almost perfect) 0.61 (substantial)
0.28 (fair)
0.67 (substantial)
dysfunction and not to external ear factors. The influence of
vernix in the ear canal should have been negligible in this age
group (Doyle et al, 1997; Roberts et al, 1994). Doyle et al found
occluding vernix in 13% of neonates tested less than 48 hours.
The influence of external ear factors on the test performance is
not known and it may, therefore, not be possible to generalize
the findings of this study to a younger cohort tested soon after
birth.
Conclusions
1. The use of low frequency tympanometry in babies below the
age of five months is invalid. ‘Normal’ Type A tympano-
grams are recorded in the presence of middle ear dysfunc-
tion.
2. The sensitivity of high frequency tympanometry in correctly
identifying middle ear dysfunction in babies below the age of
five months is/0.9. It is highest for the probe frequency of
1000 Hz and this is the frequency of choice.
3. Trace classification of high frequency tympanometry has
been problematical. The proposed adaptation of Marchant’s
methodology reduces the number of unclassifiable traces
with substantial agreement between testers. There are fewest
unclassified traces using the probe frequency 1000 Hz, once
again making this the frequency of choice.
High frequency tympanometry is feasible and a useful addition
to the audiological test battery used to assess babies below the
age of five months. The difficulties of otoscopic examination at
this age increase its significance. The need to differentiate
between babies with moderate PCHI and those with TCHL,
identified by UNHS, is paramount if appropriate management is
to take place as soon as possible.
Acknowledgements
The author would like to gratefully acknowledge the assistance
of Dr Dave Parker, University of Manchester, Dr Graham
Sutton, and Dr Peter Watkin.
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