Comparative Efficacy of Pure Tone Audiometry and Distortion Product Otoacoustic Emissions for Hearing Screening in Elderly Populations

Comparative Efficacy of Pure Tone Audiometry and Distortion Product Otoacoustic Emissions for Hearing Screening in Elderly Populations | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Comparative Efficacy of Pure Tone Audiometry and Distortion Product Otoacoustic Emissions for Hearing Screening in Elderly Populations Yuhan Wu, Jia Song, Kangfeng Zhang, Jingyi Song, Yinghui Zhang, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7972429/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective This study compares the efficacy of Pure Tone Audiometry and screening-type Distortion Product Otoacoustic Emissions in elderly hearing screening, aiming to establish a rapid and efficient method for detecting age-related hearing loss. Methods A total of 252 elderly participants aged 60 years and above were randomly selected from Wuyunshan Hospital in Hangzhou. Both Pure Tone Audiometry and screening-type Distortion Product Otoacoustic Emission were performed, and statistical methods were used to analyze the results. Results The air-conduction thresholds of Pure Tone Audiometry showed statistically significant differences across frequencies in hearing screening (P < 0.05), with 0.5 and 4 kHz being the most sensitive indicators of hearing abnormalities. The screening-type Distortion Product Otoacoustic Emission results also demonstrated statistical significance in hearing assessments (P < 0.05). Furthermore, a statistically significant difference was observed between the Pure Tone Audiometry and screening-type Distortion Product Otoacoustic Emission results (P < 0.05). Conclusions The Pure Tone Audiometry thresholds and screening-type Distortion Product Otoacoustic Emission tests across various frequencies both demonstrated good efficacy in hearing screening for elderly people. The hearing impairment detection rate was higher using Pure Tone Audiometry compared with screening-type Distortion Product Otoacoustic Emissions. These findings can guide the development of a rapid and effective screening method for age-related hearing loss in older adults. Health sciences/Diseases Health sciences/Health care Health sciences/Medical research Biological sciences/Neuroscience Age-related hearing loss Hearing screening Audiological evaluation Advance directives Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Hearing loss and deafness are serious global public health issues and among the most common sensory disorders that significantly contribute to the global disease burden [ 1 ]. Hearing loss is one among other “invisible disabilities” that often go unnoticed and are easily overlooked. Its prevalence is increasing due to population aging, unhealthy lifestyles, and other factors. Hearing loss not only negatively impacts the interpersonal interactions of elderly people with hearing impairments but can also lead to loneliness, isolation, and frustration. It is strongly associated with Alzheimer’s disease (though causal mechanisms remain under investigation) and has become a public health issue and has a significant societal burden [ 2 ]. Therefore, hearing loss prevention and treatment are important components of the World Health Organization (WHO) chronic disease prevention and treatment program, while hearing screening serves as an effective tool for the early detection and management of hearing loss [ 3 ]. China conducted its seventh national population census in 2020, and the data showed [ 4 ] that the population aged 60 years and above was 264.02 million, accounting for 18.7% of the total population. This result indicated that China is an aging society. Health problems among the elderly are becoming increasingly prevalent, and China has the highest number of individuals with hearing loss. Elderly individuals with hearing disabilities account for 30–50% of the total hearing-impaired population, according to data from the Second National Sample Survey on Disabled People [ 5 ]. Hearing loss has significantly impacted the quality of life and mental health of the elderly, raising widespread concern among families and society. In developed countries, elderly hearing loss has become a health issue that requires intervention from both the state and society. Significant efforts have been made to establish health strategies and provide testing equipment, acute care facilities, nursing equipment, and specialized screening methods [ 2 ]. The Chinese government and medical institutions attach great importance to hearing loss prevention and rehabilitation. In 2016, experts such as Yange Zhang and Xin Xi reached a consensus that hearing screenings should be included as a basic health-checkup component [ 6 ]. In addition, the performances of older adults with different hearing loss levels were analyzed by Xianting Hu and Mingfang Diao [ 7 ], and they produced a series of studies and development outcomes, including the Hearing Disability Screening Scale for Older Adults. However, elderly hearing screening in China remains in its infancy compared with newborn hearing screenings, which has been in development for more than 20 years and has been comprehensively deepened [ 8 ]. During the actual implementation of elderly hearing screening, it has been found that many of the audiological evaluations are difficult to operate and cannot effectively consider the accuracy, economic cost, and time cost. These are all factors that make it difficult for hearing screenings to be effectively conducted in primary community health centers. Therefore, accurate and effective early hearing loss screenings in the elderly can not only serve as a reference for clinical assessments and early interventions for hearing disability but also provide key measures to promote ongoing elderly health checkup program improvements [ 9 ]. This would facilitate the establishment of a robust system for elderly hearing health care services and the promotion of healthy aging [ 10 ]. Materials and methods Subjects The subjects were retired cadres aged 60 years and above [ 10 ] from the medical examination center of the Hangzhou Wuyunshan Sanatorium. A total of 252 subjects (mean age: 74.62 years, median: 75 years, interquartile range: 67–84 years) were included in this study. The inclusion criteria were as follows: subjects who could understand and communicate effectively in Mandarin, who were able to complete the audiological tests, and who were aware of their hearing status, including whether they had hearing loss and the degree of any such loss. Subjects were excluded if they were unable to complete the tests due to conditions such as cerumen impaction, outer ear-related lesions, or active/ recurrent ear discharges. Following application of these criteria, the final study comprised 245 participants (490 ears) with complete bilateral data meeting all study requirements. Instruments Hearing tests: The instruments used in this study consisted of the Italian Inventis audiometer BellPlusS with Maestro software, a transponder, TDH-39 headphones, 3A insert earphones, a visual electric otoscope, and a screening-type Distortion Product Otoacoustic Emission (DPOAE) device with the manufacturer’s standard probe assembly (ERO·SCAN by Maico Diagnostics GmbH). Test environment: The tests were performed in a soundproof room that complied with national standards (background noise < 30 dB (A)). Experimental methods Elderly people at the Medical Examination Center were informed about the method and purpose of the test, and they each signed an informed consent form. Audiological questionnaires that included participants’ medical histories and family histories were administered. Otoscope examination (used a digital otoscope): The auricle, external auditory canals, and tympanic membranes of all subjects were thoroughly examined to exclude cerumen impaction, outer ear pathologies, or active/ recurrent discharges. Pure Tone Audiometry Testing: The audiometer was calibrated and the test followed the standardized Hughson-Westlake procedure: 1. Start by providing the patient with clear instructions i.e., You will hear a series of tones. Press the response button whenever you hear a tone, no matter how loud or how quiet or which ear you hear the tones in. 2. Familiarise the patient - present a tone that is easily heard (approx. 50dB), and check that the patient responds. 3. If the patient does not respond, increase the tone by 20dB and continue until they do. 4. Begin the test at the intensity found during this familiarisation process. 5. Reduce the intensity in 10dB steps until the patient no longer responds. 6. When the patient fails to respond to a signal, increase the tone in 5dB steps until a response is received. 7. Repeat steps 5 and 6 to check for accuracy. A minimum of two out of three, or three out of five identical responses are required to accurately determine and record the patient’s threshold. 8. Repeat steps 5, 6 and 7 at frequencies of 1000Hz, 2000Hz, 4000Hz, 8000Hz, and 10000 Hz (with 1000 Hz retested if the threshold difference exceeded 10 dB HL), followed by 500Hz, 250Hz, and 125Hz. The test always begins at 1000Hz with a maximum sound output of 100 dB HL. 9. Test both ears following the above protocol."The subject was seated with their back to the tester, and the better ear was tested first followed by the worse ear. Air-conducted thresholds were recorded for each frequency in both ears. Cross-retesting using insert earphones was conducted in cases of a collapsed external auditory canal or other external ear defects. The degree of hearing loss was classified according to the new 2021 Hearing Loss Classification Criteria published by the WHO [ 11 ], where hearing is defined as the mean hearing threshold (the average of the air-conducted thresholds at frequencies of 500, 1000, 2000, and 4000 Hz). Screening-type Distortion Product Otoacoustic Emission: In a quiet environment, testing was performed at four frequencies (f2 = 500, 1000, 2000, and 4000 Hz) with primary tones f1 and f2 at frequency ratios (f2/f1 = 1.22), stimulus levels L1 = 65 dB SPL and L2 = 55 dB SPL. A response was considered valid when the Signal-to-Noise Ratio (SNR) ≥ 3 dB at a given frequency. An ear 'passed' screening if ≥ 3 of 4 frequencies met SNR criteria. Subjects used appropriate ear tips, and the test probes were kept clean. They remained seated during the test, with the better ear tested first, followed by the poorer ear. Subjects were instructed to avoid swallowing or gasping during the test. All test results were recorded and statistically analyzed. Statistical methods Continuous variables that fit the normal distribution were described by the mean ± standard deviation (X ± S), while those that did not fit the normal distribution were described by the median (interquartile range) [M (P25, P75)]. All statistical analyses, including normality testing (Kolmogorov-Smirnov test), chi-square tests, binomial logistic regression, and Receiver Operating Characteristic (ROC) curve analyses, were performed using SPSS Version 25.0. For binomial logistic regression analysis, we employed the Sigmoid (Logistic) function, which maps input values to probabilities between 0 and 1. For pure-tone audiometry (PTA), hearing thresholds at each frequency were dichotomized according to WHO 2021 hearing loss classification standards (> 20 dB HL = positive [ 1 ]; ≤20 dB HL = negative [0]). For DPOAE measurements, the internationally recognized screening criterion was applied (SNR < 3 dB = positive [ 1 ]; SNR ≥ 3 dB = negative [0]). The model transforms the linear combination of predictors through the sigmoid function to generate probability estimates. By applying a standard threshold of 0.5, these probabilities were converted into binary classifications (positive/negative for hearing loss). A two-sided P-value < 0.05 was considered statistically significant. Results Pure Tone Audiometry Pure tone air-conducted hearing threshold results at different frequencies in an elderly population The Pure Tone Audiometry results showed that, out of the 490 ears included, 28 (5.71%) had normal hearing (mean hearing threshold < 20 dB HL), and 462 (94.29%) had hearing loss (mean hearing threshold ≥ 20 dB HL). In the elderly population, air-conducted hearing thresholds [continuous variables that did not fit a normal distribution, denoted by M (P25, P75)] and the abnormality rate (hearing thresholds ≥ 20 dB HL indicated hearing loss) varied across different pure tone frequencies, as shown in Table 1 and Fig. 1 . Overall, the higher the pure tone frequency, the higher the measured air-conducted hearing thresholds (indicated more severe hearing loss). The abnormality rates at 2000 and 4000 Hz (medium and high frequencies) were 90% or higher, which was significantly greater than the abnormality rates at 125 and 250 Hz (low frequencies). Table 1 Air-conducted hearing thresholds (dB HL) and abnormality rates (%) at different frequencies of Pure Tone Audiometry in the elderly population Frequency Hz M (P25, P75) Abnormality rate% (abnormalities/total) 125 25 (15, 30) 69.18 (339/490) 250 25 (20, 35) 82.24 (403/490) 500 30 (20, 35) 85.71 (420/490) 1000 30 (20, 40) 85.31 (418/490) 2000 35 (25, 50) 90.00 (441/490) 4000 45 (30, 60) 95.92 (470/490) 8000 50 (30, 65) 86.33 (423/490) Note: M (P25, P75) represents the median (interquartile range). Application value of pure tone air-conducted hearing thresholds at different frequencies in an elderly population Using hearing loss (mean hearing threshold ≥ 20 dB HL) as the binary classification positive indicator, a binary logistic regression analysis was conducted to investigate whether pure-tone air conduction thresholds at different frequencies have an impact on screening for normal hearing.Table 2 shows the specific results, Fig. 2 is the forest plot of logistic regression analysis results. The likelihood ratio test for the binary logistic regression analysis showed a P-value < 0.001, indicating that the model was successfully constructed and the overall model is statistically significant. The − 2 log likelihood value was 49.76, and the H-L test showed P = 1.000. In addition, the Nagelkerke R² value was 0.806, suggesting a good model fit. Table 2 Logistic regression analysis of pure tone air-conducted hearing thresholds at different frequencies for normal hearing screening in an elderly population Variable Hz b value Standard error of b value Wald chi-square value P value OR value 95% CI of OR 125 -0.12 0.08 2.39 0.122 0.89 0.767, 1.032 250 0.25 0.11 5.19 0.023* 1.28 1.036, 1.593 500 0.30 0.12 6.56 0.010* 1.34 1.072, 1.683 1000 0.46 0.13 12.19 0.000*** 1.59 1.224, 2.052 2000 0.30 0.11 7.74 0.005** 1.35 1.092, 1.657 4000 0.34 0.11 10.25 0.001** 1.40 1.140, 1.724 8000 0.08 0.04 5.40 0.020 1.09 1.013, 1.168 Note: *P < 0.05, **P < 0.01, ***P < 0.001. It can be seen from the table that, except for 125 Hz, the effect of pure tone hearing thresholds on the outcome (normal hearing or not) was statistically significant. The odds ratio (OR) values for 250–8000 Hz were all greater than one. This result suggested that it was a facilitator of a positive event (hearing loss), i.e., the higher the threshold measured at this frequency, the higher the risk of hearing loss. The highest OR values were observed at 1 and 4 kHz. For each 1 dB HL increase in the hearing threshold, the hearing loss probability increased by 0.59 units at 1 kHz and 0.40 units at 4 kHz. The Receiver Operating Characteristic (ROC) curves of the pure tone hearing thresholds at different frequencies (250–8000 Hz) were constructed using hearing loss (average hearing threshold ≥ 20 dB HL) as a positive indicator for binary classification. Figure 3 shows the results. The ROC curves for all frequencies were above the diagonal (area under the curve (AUC) = 0.5), indicating that the pure tone air-conducted thresholds from 250 to 8000 Hz were valuable for screening for normal hearing. Furthermore, the closer a curve is to the upper left corner, the larger its AUC, indicating a higher application value. Table 3 shows the specific results of the ROC curves. The effect of the pure tone air-conducted thresholds from 250 to 8000 Hz on the positive events (hearing abnormalities) was statistically significant (P < 0.05), with AUC values greater than 0.7, indicating a medium-to-high application value. The highest AUC was observed for the 4 kHz pure tone air-conducted threshold, with an AUC of 0.937, a maximum Youden index of 0.75, a sensitivity of 85.30%, a specificity of 89.30%, and a cutoff value (optimal threshold) of 27.50 dB HL. The next highest AUC was for the 500 Hz pure tone air-conducted threshold, with an AUC of 0.922, a maximum Youden index of 0.72, a sensitivity of 89.80%, a specificity of 82.10%, and a cutoff value (optimal threshold) of 17.50 dB HL. Both frequencies demonstrated high application values (AUC > 0.9). Table 3 The values of the pure tone air-conduction hearing thresholds at different frequencies for normal hearing screenings in an elderly population: ROC curve analysis Frequency Hz Hearing threshold AUC Sensitivity% Specificity% Truncation value Yoden index Maximum P value 95%CI 250 0.745 48.50 100.00 27.50 0.49 0.000*** 0.686, 0.804 500 0.922 89.80 82.10 17.50 0.72 0.000*** 0.889, 0.954 1000 0.911 79.20 100.00 22.50 0.79 0.000*** 0.883, 0.939 2000 0.867 67.50 100.00 27.50 0.68 0.000*** 0.824, 0.910 4000 0.937 85.30 89.30 27.50 0.75 0.000*** 0.907, 0.967 8000 0.736 75.50 78.60 32.50 0.54 0.000*** 0.672, 0.799 Note: *P < 0.05, **P < 0.01, ***P < 0.001. An AUC between 0.5 and 0.7 indicates a low application value, an AUC between 0.7 and 0.9 indicates a medium application value, and an AUC above 0.9 indicates a high application value. Screening-type Distortion Product Otoacoustic Emission Results of the screening-type Distortion Product Otoacoustic Emission at different frequencies in an elderly population The criteria for passing the screening-type DPOAE were as follows: a Signal-to-Noise Ratio (SNR) ≥ 3 dB indicated that the frequency was passed, and the ear was considered to have passed the screening if three out of the four frequencies met this criterion. The results showed that, out of the 490 ears included in the study, 180 (36.73%) passed the screening, while 310 (63.27%) failed. The SNR values [continuous variables that do not fit a normal distribution, expressed as M (P25, P75)] and pass rates for the screening-type DPOAE at different frequencies (f2) in the elderly population are shown in Table 4 . Figure 4 shows the results of the DPOAE response for different frequencies in the elderly population. There was no significant difference in the SNR values of the screening DPOAE across different frequencies (f2). However, some differences were noted in the pass rates, with the pass rates at 1000 and 2000 Hz being higher than those at other frequencies. Table 4 SNR values and pass rates (%) for the screening-type DPOAE at different frequencies (f2) in an elderly population f2 M (P25, P75) Pass rate% (passes/total) 500 1 (-1, 3) 36.33 (178/490) 1000 1 (-1, 4) 44.49 (218/490) 2000 1 (-1, 4) 42.04 (206/490) 4000 0 (-1, 3) 34.49 (169/490) Note: M (P25, P75) represents the median (interquartile range). Application value of the screening-type Distortion Product Otoacoustic Emission in an elderly population Hearing loss (defined as a mean hearing threshold ≥ 20 dB HL) was used as a dichotomous positive indicator, and the SNR values and pass/fail outcomes of screening-type distortion product otoacoustic emissions (DPOAEs) at different frequencies (where SNR ≥ 3 dB indicated a pass for that frequency) were analyzed using binomial logistic regression. The results showed no statistically significant differences across frequencies (P > 0.05). This suggested that the SNR values and outcomes (pass/fail) of the screening-type DPOAE at a single frequency were not ideal for distinguishing between normal and abnormal hearing. Hearing loss (defined as a mean hearing threshold ≥ 20 dB HL) was again used as a positive dichotomous indicator. The elderly population was divided into pass and fail groups based on the pass/fail outcomes of the screening-type DPOAE, and a chi-square analysis was performed. The specific results are presented in Table 5 . The pass/fail outcome of the screening-type DPOAE was statistically significant in normal hearing screening (χ² = 22.37, P < 0.05), with a sensitivity of 65.8% and a specificity of 78.6%. This indicated that the combination of the four frequencies significantly improved the sensitivity and specificity of the screening-type DPOAE testing. Table 5 Usefulness of the screening-type DPOAE results for normal hearing screening in an elderly population Group Abnormal [Example (%)] Normal [Example (%)] Chi-square test Sensitivity Specificity Chi-square value P Fail group Pass group 304 (98.1) 158 (87.8) 6 (1.9) 22 (12.2) 22.366 0.000*** 0.658 0.786 Note: *P < 0.05, **P < 0.01, ***P < 0.001. Sensitivity (true positive rate) = true positive/(true positive + false negative); Specificity (true negative rate) = true negative/(true negative + false positive) Differential analysis of the Pure Tone Audiometry and screening-type Distortion Product Otoacoustic Emissions Participants were divided into two groups based on the hearing screening method: a screening-type distortion product otoacoustic emission (DPOAE) group and a Pure Tone Audiometry (PTA) group. Failure to pass a hearing screening was defined as follows: for Pure Tone Audiometry (PTA), an average hearing threshold ≥ 20 dB HL; for screening-type distortion product otoacoustic emissions (DPOAE), a Signal-to-Noise Ratio (SNR) ≥ 3 dB at fewer than three out of four frequencies. These criteria were used as dichotomous positive indicators, and a chi-square analysis was conducted. Table 6 shows the specific results. A comparison of the two methods showed a statistically significant difference (χ² = 141.004, P < 0.05). The prevalence rate detected using pure tone audiometry (PTA) was higher than that detected using screening-type distortion product otoacoustic emissions (DPOAE). Table 6 Comparison of the screening-type Distortion Product Otoacoustic Emission and Pure Tone Audiometry Group Fail [Example (%)] Pass [Example (%)] Chi-square test Chi-square value P DPOAE PTA 310 (63.27) 462 (94.29) 180 (36.73) 28 (5.71) 141.004 0.000*** Note: *P < 0.05, **P < 0.01, ***P < 0.001. Discussion The application value of pure tone air-conducted hearing thresholds at different frequencies in hearing screening Table 1 shows that the hearing threshold increased with frequency. This result indicated more severe hearing loss at higher frequencies. The progressive threshold elevation at higher frequencies with preserved low-frequency hearing demonstrates a characteristic high frequency sloping hearing loss, consistent with sensorineural hearing loss of presbycusis (age-related) type. The abnormality rates at 2 and 4 kHz were significantly higher than those at 0.125 and 0.250 kHz. This finding is consistent with the fact that 66.87% of hearing disabilities in elderly individuals are caused by presbycusis [ 12 ]. Age-related deafness is a type of sensorineural deafness characterized by progressive bilateral hearing loss due to aging and the degeneration of auditory organs. The primary pathological changes involve cochlear lesions, with damage initially occurring at the base of the cochlea. As a result, the audiological manifestations are most evident in high-frequency hearing decline [ 13 ]. A binomial logistic regression analysis revealed that pure tone air-conducted thresholds at frequencies excluding 125 Hz were statistically significant for screening normal hearing (P < 0.005), as shown in Table 2 . ROC curves were constructed and are presented in Fig. 3 and Table 3 . The analysis revealed that the AUC of the 4 kHz air-conducted threshold was the highest at 0.937, with a maximum Youden index of 0.75, a sensitivity of 85.30%, a specificity of 89.30%, and an optimal cutoff value of 27.50 dB HL. The AUC of the 0.5 kHz air-conducted threshold was the next highest at 0.922, with a maximum Youden index of 0.72, a sensitivity of 89.80%, a specificity of 82.10%, and a cutoff value (optimal threshold) of 17.50 dB HL. Both frequencies (4 and 0.5 kHz) demonstrated high application values (AUC > 0.9) and were considered the most important frequencies for screening normal hearing due to their high sensitivity and specificity. These findings were consistent with the results of a study by Min Zhang et al. [ 20 ] that identified 0.5 and 2 kHz as the most important frequencies for Pure Tone Audiometry. They also aligned with the 2016 consensus issued by Yange Zhang, Xin Xi, and other experts, which recommended including hearing screenings in basic health checkup programs [ 6 ] and highlighted 1 and 4 kHz as the most important frequencies for Pure Tone Audiometry. Future studies could employ other analytical methods and computer software to further analyze the data, expand the sample size, and simplify the Pure Tone Audiometry screening process while maintaining high accuracy, sensitivity, and specificity. This could lead to the development of a simple, practical, and time-saving high-precision screening tool, accessible in primary care units, thereby promoting nationwide hearing screening for the elderly. The application value of screening otoacoustic emissions in hearing screenings Table 4 shows no significant difference in the SNR values of the screening-type DPOAE at different frequencies. A binomial logistic regression analysis also showed no statistically significant differences (P > 0.05). This result indicated that the SNR value and the result (pass or fail) of the screening-type DPOAE at a single frequency were not reliable for screening normal hearing. By contrast, the combined diagnosis using all four frequencies significantly improved sensitivity and specificity (χ² = 22.37, P < 0.05), as shown in Table 5 . False negatives in the screening-type DPOAE (i.e., passing despite abnormal hearing) can occur. A study [ 14 ] demonstrated that DPOAE was not elicited or significantly decreased when hearing loss exceeded 40–50 dB HL. Therefore, the screening-type DPOAE may yield a pass result in cases of mild or moderate hearing loss. False positives in the screening-type DPOAE (i.e., failing despite normal hearing) can occur because the primary pathology of hearing loss in older adults involves cochlear damage, which includes widespread lesions of the stria vascularis and spiral ganglion cells, and this is often accompanied by outer hair cell damage. Cochlear function deteriorates further as the degree of hearing loss increases. The screening-type DPOAE is an objective test that assesses cochlear function. Even subtle cochlear lesions can reduce the pass rate [ 15 ]. In addition, hearing loss often first manifests as a decline in high-frequency hearing. Studies have shown that hearing abnormalities at frequencies above 10 kHz can be detected earlier than at other frequencies [ 16 ]. Therefore, screening-type DPOAE tests can identify hidden hearing loss before it is detectable using Pure Tone Audiometry [ 17 ]. While our DPOAE protocol focused on conventional frequencies (500–4000 Hz), we acknowledge that extending testing to higher frequencies could provide earlier detection of age-related cochlear changes. And it's an important direction in our future research. Pure Tone Audiometry: a more valuable screening method for hearing assessment in elderly populations A comparison of screening-type distortion product otoacoustic emissions and Pure Tone Audiometry revealed statistically significant differences between the two methods (P < 0.05). Pure tone air-conducted thresholds at 500 and 4000 Hz were more sensitive and specific than screening-type DPOAEs in screening for normal hearing. Specifically, Pure Tone Audiometry at 500 and 4000 Hz was more valuable than DPOAEs for this purpose. This may be because screening-type DPOAEs are objective tests that assess the function of outer cochlear hair cells and their surrounding structures, whereas Pure Tone Audiometry reflects the functional status of both inner and outer cochlear hair cells, as well as their associated auditory nerve conduction pathways at specific frequency sites [ 18 ]. Therefore, a pass or fail result in distortion product otoacoustic emissions screening should not be interpreted simply as an indicator of normal or abnormal hearing [ 15 ]. A comprehensive diagnostic hearing test is required to accurately assess the hearing status of individuals who fail the screening DPOAE. Conclusion Pure tone air-conducted hearing thresholds at different frequencies have good application in screening for normal hearing, with 500 and 4000 Hz being the most sensitive for detecting hearing abnormalities. The screening-type distortion product otoacoustic emission (pass/fail) results demonstrated good sensitivity and specificity in hearing screening. However, single-frequency DPOAE results were of limited value for hearing screening, and the results should not be interpreted simply as normal or abnormal hearing. The differences between the two hearing screening methods were statistically significant (P < 0.05). Pure Tone Audiometry detected a higher prevalence of hearing abnormalities than screening-type DPOAE [ 19 ]. In addition, pure tone air-conducted thresholds at 500 and 4000 Hz demonstrated higher sensitivity and specificity than screening-type DPOAE in detecting normal hearing. Therefore, Pure Tone Audiometry is the more valuable test for hearing screening in elderly populations. The results of this study could help simplify the procedure of routine Pure Tone Audiometry and contribute to the development of a rapid and efficient screening method for hearing loss in the elderly. However, due to the small sample size and limited inclusion of other influencing factors (e.g., gender, cognitive function, hypertension, and other diseases), the results may be biased to some extent. Future studies should include a larger sample size and utilize other analytical methods and computer software for in-depth data analysis. This could lead to the development of a simple, practical, and time-efficient high-precision screening tool [ 20 ] accessible in primary care units, thereby promoting the widespread implementation of nationwide hearing screening for the elderly. Abbreviations DPOAE Distortion product otoacoustic emission PTA Pure Tone Audiometry SNR Signal-to-Noise Ratio Declarations Acknowledgements We would like to thank Zhejiang University of Chinese Medicine,Hangzhou Wuyunshan Hospital and HuiTing (Hangzhou) International Hearing and Balance Center for providing us with resources and teachers for inspiration and support. Authors' contributions Y.W. and K.Z.wrote the main manuscript text; J.S. prepared figures; J.S. and Y.Z. collected data; D.W and C.T. supervised the manuscript. All authors reviewed the manuscript. Competing Interests The authors declare no competing financial or commercial interests. Availability of data and materials The data that support the findings of this study are available from the corresponding author upon reasonable request. Ethics approval and consent to participate This study was conducted in accordance with the ethical standards of the Declaration of Helsinki and approved by the Internal Review Board (IRB) of Hangzhou Wuyunshan Sanatorium (Approval No.: Ethics Approval [2023] No. 016). All participants were informed about the study’s purpose, procedures, and potential risks. Written informed consent was obtained from each participant prior to enrollment. Consent for publication Not applicable. 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Lough, M. & Plack, C. J. Extended high-frequency audiometry in research and clinical practice. J Acoust Soc Am. 151(3): 1944. (2022). Patterson, B. M. & Renaud, M. Routine hearing screening in primary care for adult populations using distortion product Otoacoustic Emissions testing. JAm Acad. Nurse Pract. 24 (7), 400–401 (2012). Chen, P. Distortion product otoacoustic emissions in the monitoring of senile deafness[D]. Zunyi Medical College, 2016(in Chinese). Xian, Y. et al. Meta-analysis of the prevalence of hearing loss in the elderly in China[J]. Mod. Prev. Med. 49 (13), 2451–2458 (2022). (in Chinese). Zhang, M. et al. A parsimonious approach for screening moderate-to-profound hearing loss in a community-dwelling geriatric population based on a decision tree analysis. BMC Geriatr. 9 (1), 214 (2019). Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7972429","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":551999358,"identity":"6c291c63-6990-49f5-8af8-1843072f9f90","order_by":0,"name":"Yuhan Wu","email":"","orcid":"","institution":"Zhejiang Chinese Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yuhan","middleName":"","lastName":"Wu","suffix":""},{"id":551999359,"identity":"c611d5bf-c5d7-4fd6-8bf3-d306b9e50cd5","order_by":1,"name":"Jia Song","email":"","orcid":"","institution":"Zhejiang Chinese Medical University","correspondingAuthor":false,"prefix":"","firstName":"Jia","middleName":"","lastName":"Song","suffix":""},{"id":551999360,"identity":"d09f0201-a5f4-4497-a01c-c3219a0b55c4","order_by":2,"name":"Kangfeng Zhang","email":"","orcid":"","institution":"Hangzhou Wuyunshan Hospital","correspondingAuthor":false,"prefix":"","firstName":"Kangfeng","middleName":"","lastName":"Zhang","suffix":""},{"id":551999361,"identity":"02b41da6-aabb-4cfe-9828-36522546d71b","order_by":3,"name":"Jingyi Song","email":"","orcid":"","institution":"HuiTing (Hangzhou) International Hearing and Balance Center","correspondingAuthor":false,"prefix":"","firstName":"Jingyi","middleName":"","lastName":"Song","suffix":""},{"id":551999362,"identity":"df469f21-42a8-45f1-a272-e334125ec6a7","order_by":4,"name":"Yinghui Zhang","email":"","orcid":"","institution":"HuiTing (Hangzhou) International Hearing and Balance Center","correspondingAuthor":false,"prefix":"","firstName":"Yinghui","middleName":"","lastName":"Zhang","suffix":""},{"id":551999363,"identity":"6e0c9829-40a5-45ad-9527-868f92bb0d51","order_by":5,"name":"Du Wu","email":"","orcid":"","institution":"Hangzhou Wuyunshan Hospital","correspondingAuthor":false,"prefix":"","firstName":"Du","middleName":"","lastName":"Wu","suffix":""},{"id":551999364,"identity":"c5dd1c4d-01f2-4949-a8d1-4405a8bc3535","order_by":6,"name":"Chenghua Tian","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA60lEQVRIie3RsWrDMBCAYQnBZRH1KlOSZ7hiUJfSvIqEIZMfwFsMBmUp7dpCH8KQF1ARKIuha0IWL/XUB8iWxKVTKXK6ddA/Hvctd4TEYv+whNHVQSGw5HtAqzGSrmoruvJqklaXEmy9Srt2lqC9lJBtgaiNvM7e3ceak7tpY1nfhQR9LlBps8ik9XLPySJrLNxiiDBRoNXG5/LtAc7E6cZyECECoriptDku1zUfyHGccO5zolpgCF/EjhMxqT1RJTDRgty9Yp69OJBBMnfU0MPwyifXbz/L++njpu6D5EfDqdgf9mOxWCz2eyfQAUjS4/Nb9QAAAABJRU5ErkJggg==","orcid":"","institution":"Zhejiang Chinese Medical University","correspondingAuthor":true,"prefix":"","firstName":"Chenghua","middleName":"","lastName":"Tian","suffix":""}],"badges":[],"createdAt":"2025-10-28 17:34:54","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7972429/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7972429/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":97262902,"identity":"5d7c603f-baf0-480c-90ac-29f31bca93a3","added_by":"auto","created_at":"2025-12-02 14:10:04","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":54776,"visible":true,"origin":"","legend":"","description":"","filename":"Manuscript.docx","url":"https://assets-eu.researchsquare.com/files/rs-7972429/v1/c3597ce52e445f158ba30d7a.docx"},{"id":97262904,"identity":"1cb3155f-38b8-48f2-b93e-70adc2498216","added_by":"auto","created_at":"2025-12-02 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14:10:04","extension":"xml","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":88369,"visible":true,"origin":"","legend":"","description":"","filename":"095eaa66c2fa4df997ea7bada7e17d5d1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7972429/v1/1dd92fe54557f8e6e495c227.xml"},{"id":97262913,"identity":"ee04c4aa-f911-4b0a-8574-25e19b660024","added_by":"auto","created_at":"2025-12-02 14:10:04","extension":"html","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":98660,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7972429/v1/6b02346e58717d304ea0211a.html"},{"id":97262903,"identity":"b01ece76-a6a3-46a2-81da-18b775b753c7","added_by":"auto","created_at":"2025-12-02 14:10:04","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":80672,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAir-conducted hearing thresholds (dB HL) at different frequencies of Pure Tone Audiometry in an elderly population. \u003c/strong\u003eThis box-and-whisker plot illustrates the variability of air-conducted hearing thresholds (in dB HL) across seven standard audiometric frequencies (125 Hz to 8000 Hz) in the elderly population.\u003c/p\u003e","description":"","filename":"figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-7972429/v1/d9392c941295d6a3edda4b39.png"},{"id":97366873,"identity":"d9bf758f-0000-46e1-922d-b69eb1f89488","added_by":"auto","created_at":"2025-12-03 16:11:44","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":299895,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eForest plot of logistic regression analysis results. \u003c/strong\u003eThis forest plot illustrates the odds ratios (OR) and 95% confidence intervals (CI) from the binomial logistic regression model.\u003c/p\u003e","description":"","filename":"figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-7972429/v1/b01e158fdb4c5dd2691d9aee.png"},{"id":97262912,"identity":"5c98d0f6-8e7e-42a3-9642-b2ce0d0232c6","added_by":"auto","created_at":"2025-12-02 14:10:04","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":187766,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eROC curves of pure tone air-conducted hearing thresholds at different frequencies for normal hearing screening. \u003c/strong\u003eThis figure presents receiver operating characteristic (ROC) curves evaluating the diagnostic performance of pure tone air-conducted hearing thresholds at six frequencies (250–8000 Hz) for normal hearing screening.\u003c/p\u003e","description":"","filename":"figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-7972429/v1/526467c8e101d6a3b5370c51.png"},{"id":97262906,"identity":"bc083e15-36e0-4a3a-93dc-bcc14f0a3c2a","added_by":"auto","created_at":"2025-12-02 14:10:04","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":75762,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe DPOAE response for different frequencies in an elderly population. \u003c/strong\u003eThis figure illustrates the frequency-specific distortion product otoacoustic emission (DPOAE) responses in an elderly cohort.\u003c/p\u003e","description":"","filename":"figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-7972429/v1/b83b5e5f7749c4d1edcbc644.png"},{"id":100421515,"identity":"1a1d3ab5-52f7-4d54-8b64-1df6d653d573","added_by":"auto","created_at":"2026-01-16 13:33:12","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1914733,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7972429/v1/9315cfd2-198b-4c2a-877c-31537ed66f5b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Comparative Efficacy of Pure Tone Audiometry and Distortion Product Otoacoustic Emissions for Hearing Screening in Elderly Populations","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHearing loss and deafness are serious global public health issues and among the most common sensory disorders that significantly contribute to the global disease burden [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Hearing loss is one among other \u0026ldquo;invisible disabilities\u0026rdquo; that often go unnoticed and are easily overlooked. Its prevalence is increasing due to population aging, unhealthy lifestyles, and other factors. Hearing loss not only negatively impacts the interpersonal interactions of elderly people with hearing impairments but can also lead to loneliness, isolation, and frustration. It is strongly associated with Alzheimer\u0026rsquo;s disease (though causal mechanisms remain under investigation) and has become a public health issue and has a significant societal burden [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Therefore, hearing loss prevention and treatment are important components of the World Health Organization (WHO) chronic disease prevention and treatment program, while hearing screening serves as an effective tool for the early detection and management of hearing loss [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eChina conducted its seventh national population census in 2020, and the data showed [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] that the population aged 60 years and above was 264.02\u0026nbsp;million, accounting for 18.7% of the total population. This result indicated that China is an aging society. Health problems among the elderly are becoming increasingly prevalent, and China has the highest number of individuals with hearing loss. Elderly individuals with hearing disabilities account for 30\u0026ndash;50% of the total hearing-impaired population, according to data from the Second National Sample Survey on Disabled People [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Hearing loss has significantly impacted the quality of life and mental health of the elderly, raising widespread concern among families and society.\u003c/p\u003e\u003cp\u003eIn developed countries, elderly hearing loss has become a health issue that requires intervention from both the state and society. Significant efforts have been made to establish health strategies and provide testing equipment, acute care facilities, nursing equipment, and specialized screening methods [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The Chinese government and medical institutions attach great importance to hearing loss prevention and rehabilitation. In 2016, experts such as Yange Zhang and Xin Xi reached a consensus that hearing screenings should be included as a basic health-checkup component [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In addition, the performances of older adults with different hearing loss levels were analyzed by Xianting Hu and Mingfang Diao [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], and they produced a series of studies and development outcomes, including the Hearing Disability Screening Scale for Older Adults. However, elderly hearing screening in China remains in its infancy compared with newborn hearing screenings, which has been in development for more than 20 years and has been comprehensively deepened [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. During the actual implementation of elderly hearing screening, it has been found that many of the audiological evaluations are difficult to operate and cannot effectively consider the accuracy, economic cost, and time cost. These are all factors that make it difficult for hearing screenings to be effectively conducted in primary community health centers. Therefore, accurate and effective early hearing loss screenings in the elderly can not only serve as a reference for clinical assessments and early interventions for hearing disability but also provide key measures to promote ongoing elderly health checkup program improvements [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. This would facilitate the establishment of a robust system for elderly hearing health care services and the promotion of healthy aging [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eSubjects\u003c/h2\u003e\u003cp\u003eThe subjects were retired cadres aged 60 years and above [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] from the medical examination center of the Hangzhou Wuyunshan Sanatorium. A total of 252 subjects (mean age: 74.62 years, median: 75 years, interquartile range: 67\u0026ndash;84 years) were included in this study. The inclusion criteria were as follows: subjects who could understand and communicate effectively in Mandarin, who were able to complete the audiological tests, and who were aware of their hearing status, including whether they had hearing loss and the degree of any such loss. Subjects were excluded if they were unable to complete the tests due to conditions such as cerumen impaction, outer ear-related lesions, or active/ recurrent ear discharges. Following application of these criteria, the final study comprised 245 participants (490 ears) with complete bilateral data meeting all study requirements.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eInstruments\u003c/h3\u003e\n\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eHearing tests: The instruments used in this study consisted of the Italian Inventis audiometer BellPlusS with Maestro software, a transponder, TDH-39 headphones, 3A insert earphones, a visual electric otoscope, and a screening-type Distortion Product Otoacoustic Emission (DPOAE) device with the manufacturer\u0026rsquo;s standard probe assembly (ERO\u0026middot;SCAN by Maico Diagnostics GmbH).\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eTest environment: The tests were performed in a soundproof room that complied with national standards (background noise\u0026thinsp;\u0026lt;\u0026thinsp;30 dB (A)).\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\n\u003ch3\u003eExperimental methods\u003c/h3\u003e\n\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eElderly people at the Medical Examination Center were informed about the method and purpose of the test, and they each signed an informed consent form.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eAudiological questionnaires that included participants\u0026rsquo; medical histories and family histories were administered.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eOtoscope examination (used a digital otoscope): The auricle, external auditory canals, and tympanic membranes of all subjects were thoroughly examined to exclude cerumen impaction, outer ear pathologies, or active/ recurrent discharges.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003ePure Tone Audiometry Testing: The audiometer was calibrated and the test followed the standardized Hughson-Westlake procedure: 1. Start by providing the patient with clear instructions i.e., You will hear a series of tones. Press the response button whenever you hear a tone, no matter how loud or how quiet or which ear you hear the tones in. 2. Familiarise the patient - present a tone that is easily heard (approx. 50dB), and check that the patient responds. 3. If the patient does not respond, increase the tone by 20dB and continue until they do. 4. Begin the test at the intensity found during this familiarisation process. 5. Reduce the intensity in 10dB steps until the patient no longer responds. 6. When the patient fails to respond to a signal, increase the tone in 5dB steps until a response is received. 7. Repeat steps 5 and 6 to check for accuracy. A minimum of two out of three, or three out of five identical responses are required to accurately determine and record the patient\u0026rsquo;s threshold. 8. Repeat steps 5, 6 and 7 at frequencies of 1000Hz, 2000Hz, 4000Hz, 8000Hz, and 10000 Hz (with 1000 Hz retested if the threshold difference exceeded 10 dB HL), followed by 500Hz, 250Hz, and 125Hz. The test always begins at 1000Hz with a maximum sound output of 100 dB HL. 9. Test both ears following the above protocol.\"The subject was seated with their back to the tester, and the better ear was tested first followed by the worse ear. Air-conducted thresholds were recorded for each frequency in both ears. Cross-retesting using insert earphones was conducted in cases of a collapsed external auditory canal or other external ear defects. The degree of hearing loss was classified according to the new 2021 Hearing Loss Classification Criteria published by the WHO [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], where hearing is defined as the mean hearing threshold (the average of the air-conducted thresholds at frequencies of 500, 1000, 2000, and 4000 Hz).\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eScreening-type Distortion Product Otoacoustic Emission: In a quiet environment, testing was performed at four frequencies (f2\u0026thinsp;=\u0026thinsp;500, 1000, 2000, and 4000 Hz) with primary tones f1 and f2 at frequency ratios (f2/f1\u0026thinsp;=\u0026thinsp;1.22), stimulus levels L1\u0026thinsp;=\u0026thinsp;65 dB SPL and L2\u0026thinsp;=\u0026thinsp;55 dB SPL. A response was considered valid when the Signal-to-Noise Ratio (SNR)\u0026thinsp;\u0026ge;\u0026thinsp;3 dB at a given frequency. An ear 'passed' screening if\u0026thinsp;\u0026ge;\u0026thinsp;3 of 4 frequencies met SNR criteria. Subjects used appropriate ear tips, and the test probes were kept clean. They remained seated during the test, with the better ear tested first, followed by the poorer ear. Subjects were instructed to avoid swallowing or gasping during the test.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eAll test results were recorded and statistically analyzed.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\n\u003ch3\u003eStatistical methods\u003c/h3\u003e\n\u003cp\u003eContinuous variables that fit the normal distribution were described by the mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (X\u0026thinsp;\u0026plusmn;\u0026thinsp;S), while those that did not fit the normal distribution were described by the median (interquartile range) [M (P25, P75)]. All statistical analyses, including normality testing (Kolmogorov-Smirnov test), chi-square tests, binomial logistic regression, and Receiver Operating Characteristic (ROC) curve analyses, were performed using SPSS Version 25.0. For binomial logistic regression analysis, we employed the Sigmoid (Logistic) function, which maps input values to probabilities between 0 and 1. For pure-tone audiometry (PTA), hearing thresholds at each frequency were dichotomized according to WHO 2021 hearing loss classification standards (\u0026gt;\u0026thinsp;20 dB HL\u0026thinsp;=\u0026thinsp;positive [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]; \u0026le;20 dB HL\u0026thinsp;=\u0026thinsp;negative [0]). For DPOAE measurements, the internationally recognized screening criterion was applied (SNR\u0026thinsp;\u0026lt;\u0026thinsp;3 dB\u0026thinsp;=\u0026thinsp;positive [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]; SNR\u0026thinsp;\u0026ge;\u0026thinsp;3 dB\u0026thinsp;=\u0026thinsp;negative [0]). The model transforms the linear combination of predictors through the sigmoid function to generate probability estimates. By applying a standard threshold of 0.5, these probabilities were converted into binary classifications (positive/negative for hearing loss). A two-sided P-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003ePure Tone Audiometry\u003c/h2\u003e\u003cdiv id=\"Sec9\" class=\"Section3\"\u003e\u003ch2\u003ePure tone air-conducted hearing threshold results at different frequencies in an elderly population\u003c/h2\u003e\u003cp\u003eThe Pure Tone Audiometry results showed that, out of the 490 ears included, 28 (5.71%) had normal hearing (mean hearing threshold\u0026thinsp;\u0026lt;\u0026thinsp;20 dB HL), and 462 (94.29%) had hearing loss (mean hearing threshold\u0026thinsp;\u0026ge;\u0026thinsp;20 dB HL). In the elderly population, air-conducted hearing thresholds [continuous variables that did not fit a normal distribution, denoted by M (P25, P75)] and the abnormality rate (hearing thresholds\u0026thinsp;\u0026ge;\u0026thinsp;20 dB HL indicated hearing loss) varied across different pure tone frequencies, as shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Overall, the higher the pure tone frequency, the higher the measured air-conducted hearing thresholds (indicated more severe hearing loss). The abnormality rates at 2000 and 4000 Hz (medium and high frequencies) were 90% or higher, which was significantly greater than the abnormality rates at 125 and 250 Hz (low frequencies).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eAir-conducted hearing thresholds (dB HL) and abnormality rates (%) at different frequencies of Pure Tone Audiometry in the elderly population\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFrequency Hz\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eM\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(P25, P75)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAbnormality rate% (abnormalities/total)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e125\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(15, 30)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e69.18 (339/490)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e250\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(20, 35)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e82.24 (403/490)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e500\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(20, 35)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e85.71 (420/490)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(20, 40)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e85.31 (418/490)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(25, 50)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e90.00 (441/490)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(30, 60)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e95.92 (470/490)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e8000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(30, 65)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e86.33 (423/490)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eNote: M (P25, P75) represents the median (interquartile range).\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\n\u003ch3\u003eApplication value of pure tone air-conducted hearing thresholds at different frequencies in an elderly population\u003c/h3\u003e\n\u003cp\u003eUsing hearing loss (mean hearing threshold\u0026thinsp;\u0026ge;\u0026thinsp;20 dB HL) as the binary classification positive indicator, a binary logistic regression analysis was conducted to investigate whether pure-tone air conduction thresholds at different frequencies have an impact on screening for normal hearing.Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the specific results, Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e is the forest plot of logistic regression analysis results. The likelihood ratio test for the binary logistic regression analysis showed a P-value\u0026thinsp;\u0026lt;\u0026thinsp;0.001, indicating that the model was successfully constructed and the overall model is statistically significant. The \u0026minus;\u0026thinsp;2 log likelihood value was 49.76, and the H-L test showed P\u0026thinsp;=\u0026thinsp;1.000. In addition, the Nagelkerke R\u0026sup2; value was 0.806, suggesting a good model fit.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eLogistic regression analysis of pure tone air-conducted hearing thresholds at different frequencies for normal hearing screening in an elderly population\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable Hz\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eb value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eStandard error of b value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eWald chi-square value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eOR value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003e95% CI of OR\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e125\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e-0.12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.122\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.767, 1.032\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e250\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e5.19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.023*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1.28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e1.036, 1.593\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e500\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e6.56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.010*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1.34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e1.072, 1.683\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e12.19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.000***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1.59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e1.224, 2.052\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e7.74\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.005**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1.35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e1.092, 1.657\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e10.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.001**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1.40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e1.140, 1.724\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e8000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e5.40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.020\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e1.013, 1.168\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"7\"\u003eNote: *P\u0026thinsp;\u0026lt;\u0026thinsp;0.05, **P\u0026thinsp;\u0026lt;\u0026thinsp;0.01, ***P\u0026thinsp;\u0026lt;\u0026thinsp;0.001.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eIt can be seen from the table that, except for 125 Hz, the effect of pure tone hearing thresholds on the outcome (normal hearing or not) was statistically significant. The odds ratio (OR) values for 250\u0026ndash;8000 Hz were all greater than one. This result suggested that it was a facilitator of a positive event (hearing loss), i.e., the higher the threshold measured at this frequency, the higher the risk of hearing loss. The highest OR values were observed at 1 and 4 kHz. For each 1 dB HL increase in the hearing threshold, the hearing loss probability increased by 0.59 units at 1 kHz and 0.40 units at 4 kHz.\u003c/p\u003e\u003cp\u003eThe Receiver Operating Characteristic (ROC) curves of the pure tone hearing thresholds at different frequencies (250\u0026ndash;8000 Hz) were constructed using hearing loss (average hearing threshold\u0026thinsp;\u0026ge;\u0026thinsp;20 dB HL) as a positive indicator for binary classification. Figure\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows the results. The ROC curves for all frequencies were above the diagonal (area under the curve (AUC)\u0026thinsp;=\u0026thinsp;0.5), indicating that the pure tone air-conducted thresholds from 250 to 8000 Hz were valuable for screening for normal hearing. Furthermore, the closer a curve is to the upper left corner, the larger its AUC, indicating a higher application value.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows the specific results of the ROC curves. The effect of the pure tone air-conducted thresholds from 250 to 8000 Hz on the positive events (hearing abnormalities) was statistically significant (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05), with AUC values greater than 0.7, indicating a medium-to-high application value. The highest AUC was observed for the 4 kHz pure tone air-conducted threshold, with an AUC of 0.937, a maximum Youden index of 0.75, a sensitivity of 85.30%, a specificity of 89.30%, and a cutoff value (optimal threshold) of 27.50 dB HL. The next highest AUC was for the 500 Hz pure tone air-conducted threshold, with an AUC of 0.922, a maximum Youden index of 0.72, a sensitivity of 89.80%, a specificity of 82.10%, and a cutoff value (optimal threshold) of 17.50 dB HL. Both frequencies demonstrated high application values (AUC\u0026thinsp;\u0026gt;\u0026thinsp;0.9).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eThe values of the pure tone air-conduction hearing thresholds at different frequencies for normal hearing screenings in an elderly population: ROC curve analysis\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"8\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eFrequency Hz\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"7\" nameend=\"c8\" namest=\"c2\"\u003e\u003cp\u003eHearing threshold\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAUC\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSensitivity%\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSpecificity%\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eTruncation value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eYoden index Maximum\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003e95%CI\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e250\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.745\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e48.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e100.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e27.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.000***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.686, 0.804\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e500\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.922\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e89.80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e82.10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e17.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.000***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.889, 0.954\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.911\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e79.20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e100.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e22.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.000***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.883, 0.939\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.867\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e67.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e100.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e27.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.68\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.000***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.824, 0.910\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.937\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e85.30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e89.30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e27.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.000***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.907, 0.967\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e8000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.736\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e75.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e78.60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e32.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.000***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.672, 0.799\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"8\"\u003eNote: *P\u0026thinsp;\u0026lt;\u0026thinsp;0.05, **P\u0026thinsp;\u0026lt;\u0026thinsp;0.01, ***P\u0026thinsp;\u0026lt;\u0026thinsp;0.001. An AUC between 0.5 and 0.7 indicates a low application value, an AUC between 0.7 and 0.9 indicates a medium application value, and an AUC above 0.9 indicates a high application value.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eScreening-type Distortion Product Otoacoustic Emission\u003c/h2\u003e\u003cdiv id=\"Sec12\" class=\"Section3\"\u003e\u003ch2\u003eResults of the screening-type Distortion Product Otoacoustic Emission at different frequencies in an elderly population\u003c/h2\u003e\u003cp\u003eThe criteria for passing the screening-type DPOAE were as follows: a Signal-to-Noise Ratio (SNR)\u0026thinsp;\u0026ge;\u0026thinsp;3 dB indicated that the frequency was passed, and the ear was considered to have passed the screening if three out of the four frequencies met this criterion. The results showed that, out of the 490 ears included in the study, 180 (36.73%) passed the screening, while 310 (63.27%) failed.\u003c/p\u003e\u003cp\u003eThe SNR values [continuous variables that do not fit a normal distribution, expressed as M (P25, P75)] and pass rates for the screening-type DPOAE at different frequencies (f2) in the elderly population are shown in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. Figure\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e shows the results of the DPOAE response for different frequencies in the elderly population. There was no significant difference in the SNR values of the screening DPOAE across different frequencies (f2). However, some differences were noted in the pass rates, with the pass rates at 1000 and 2000 Hz being higher than those at other frequencies.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSNR values and pass rates (%) for the screening-type DPOAE at different frequencies (f2) in an elderly population\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026minus;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ef2\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eM (P25, P75)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePass rate% (passes/total)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e500\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c2\"\u003e\u003cp\u003e1 (-1, 3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e36.33 (178/490)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c2\"\u003e\u003cp\u003e1 (-1, 4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e44.49 (218/490)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c2\"\u003e\u003cp\u003e1 (-1, 4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e42.04 (206/490)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c2\"\u003e\u003cp\u003e0 (-1, 3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e34.49 (169/490)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003eNote: M (P25, P75) represents the median (interquartile range).\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eApplication value of the screening-type Distortion Product Otoacoustic Emission in an elderly population\u003c/h2\u003e\u003cp\u003eHearing loss (defined as a mean hearing threshold\u0026thinsp;\u0026ge;\u0026thinsp;20 dB HL) was used as a dichotomous positive indicator, and the SNR values and pass/fail outcomes of screening-type distortion product otoacoustic emissions (DPOAEs) at different frequencies (where SNR\u0026thinsp;\u0026ge;\u0026thinsp;3 dB indicated a pass for that frequency) were analyzed using binomial logistic regression. The results showed no statistically significant differences across frequencies (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). This suggested that the SNR values and outcomes (pass/fail) of the screening-type DPOAE at a single frequency were not ideal for distinguishing between normal and abnormal hearing.\u003c/p\u003e\u003cp\u003eHearing loss (defined as a mean hearing threshold\u0026thinsp;\u0026ge;\u0026thinsp;20 dB HL) was again used as a positive dichotomous indicator. The elderly population was divided into pass and fail groups based on the pass/fail outcomes of the screening-type DPOAE, and a chi-square analysis was performed. The specific results are presented in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e. The pass/fail outcome of the screening-type DPOAE was statistically significant in normal hearing screening (χ\u0026sup2; = 22.37, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05), with a sensitivity of 65.8% and a specificity of 78.6%. This indicated that the combination of the four frequencies significantly improved the sensitivity and specificity of the screening-type DPOAE testing.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eUsefulness of the screening-type DPOAE results for normal hearing screening in an elderly population\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eGroup\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eAbnormal\u003c/p\u003e\u003cp\u003e[Example (%)]\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eNormal\u003c/p\u003e\u003cp\u003e[Example (%)]\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eChi-square test\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSensitivity\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSpecificity\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eChi-square value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFail group\u003c/p\u003e\u003cp\u003ePass group\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e304 (98.1)\u003c/p\u003e\u003cp\u003e158 (87.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (1.9)\u003c/p\u003e\u003cp\u003e22 (12.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e22.366\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.000***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.658\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.786\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"7\"\u003eNote: *P\u0026thinsp;\u0026lt;\u0026thinsp;0.05, **P\u0026thinsp;\u0026lt;\u0026thinsp;0.01, ***P\u0026thinsp;\u0026lt;\u0026thinsp;0.001. Sensitivity (true positive rate)\u0026thinsp;=\u0026thinsp;true positive/(true positive\u0026thinsp;+\u0026thinsp;false negative); Specificity (true negative rate)\u0026thinsp;=\u0026thinsp;true negative/(true negative\u0026thinsp;+\u0026thinsp;false positive)\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eDifferential analysis of the Pure Tone Audiometry and screening-type Distortion Product Otoacoustic Emissions\u003c/h2\u003e\u003cp\u003eParticipants were divided into two groups based on the hearing screening method: a screening-type distortion product otoacoustic emission (DPOAE) group and a Pure Tone Audiometry (PTA) group. Failure to pass a hearing screening was defined as follows: for Pure Tone Audiometry (PTA), an average hearing threshold\u0026thinsp;\u0026ge;\u0026thinsp;20 dB HL; for screening-type distortion product otoacoustic emissions (DPOAE), a Signal-to-Noise Ratio (SNR)\u0026thinsp;\u0026ge;\u0026thinsp;3 dB at fewer than three out of four frequencies. These criteria were used as dichotomous positive indicators, and a chi-square analysis was conducted. Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e shows the specific results. A comparison of the two methods showed a statistically significant difference (χ\u0026sup2; = 141.004, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The prevalence rate detected using pure tone audiometry (PTA) was higher than that detected using screening-type distortion product otoacoustic emissions (DPOAE).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of the screening-type Distortion Product Otoacoustic Emission and Pure Tone Audiometry\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eGroup\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eFail\u003c/p\u003e\u003cp\u003e[Example (%)]\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003ePass\u003c/p\u003e\u003cp\u003e[Example (%)]\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eChi-square test\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eChi-square value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDPOAE\u003c/p\u003e\u003cp\u003ePTA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e310 (63.27)\u003c/p\u003e\u003cp\u003e462 (94.29)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e180 (36.73)\u003c/p\u003e\u003cp\u003e28 (5.71)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e141.004\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.000***\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003eNote: *P\u0026thinsp;\u0026lt;\u0026thinsp;0.05, **P\u0026thinsp;\u0026lt;\u0026thinsp;0.01, ***P\u0026thinsp;\u0026lt;\u0026thinsp;0.001.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eThe application value of pure tone air-conducted hearing thresholds at different frequencies in hearing screening\u003c/h2\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows that the hearing threshold increased with frequency. This result indicated more severe hearing loss at higher frequencies. The progressive threshold elevation at higher frequencies with preserved low-frequency hearing demonstrates a characteristic high frequency sloping hearing loss, consistent with sensorineural hearing loss of presbycusis (age-related) type. The abnormality rates at 2 and 4 kHz were significantly higher than those at 0.125 and 0.250 kHz. This finding is consistent with the fact that 66.87% of hearing disabilities in elderly individuals are caused by presbycusis [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Age-related deafness is a type of sensorineural deafness characterized by progressive bilateral hearing loss due to aging and the degeneration of auditory organs. The primary pathological changes involve cochlear lesions, with damage initially occurring at the base of the cochlea. As a result, the audiological manifestations are most evident in high-frequency hearing decline [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eA binomial logistic regression analysis revealed that pure tone air-conducted thresholds at frequencies excluding 125 Hz were statistically significant for screening normal hearing (P\u0026thinsp;\u0026lt;\u0026thinsp;0.005), as shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. ROC curves were constructed and are presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. The analysis revealed that the AUC of the 4 kHz air-conducted threshold was the highest at 0.937, with a maximum Youden index of 0.75, a sensitivity of 85.30%, a specificity of 89.30%, and an optimal cutoff value of 27.50 dB HL. The AUC of the 0.5 kHz air-conducted threshold was the next highest at 0.922, with a maximum Youden index of 0.72, a sensitivity of 89.80%, a specificity of 82.10%, and a cutoff value (optimal threshold) of 17.50 dB HL. Both frequencies (4 and 0.5 kHz) demonstrated high application values (AUC\u0026thinsp;\u0026gt;\u0026thinsp;0.9) and were considered the most important frequencies for screening normal hearing due to their high sensitivity and specificity. These findings were consistent with the results of a study by Min Zhang et al. [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] that identified 0.5 and 2 kHz as the most important frequencies for Pure Tone Audiometry. They also aligned with the 2016 consensus issued by Yange Zhang, Xin Xi, and other experts, which recommended including hearing screenings in basic health checkup programs [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] and highlighted 1 and 4 kHz as the most important frequencies for Pure Tone Audiometry. Future studies could employ other analytical methods and computer software to further analyze the data, expand the sample size, and simplify the Pure Tone Audiometry screening process while maintaining high accuracy, sensitivity, and specificity. This could lead to the development of a simple, practical, and time-saving high-precision screening tool, accessible in primary care units, thereby promoting nationwide hearing screening for the elderly.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eThe application value of screening otoacoustic emissions in hearing screenings\u003c/h2\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e shows no significant difference in the SNR values of the screening-type DPOAE at different frequencies. A binomial logistic regression analysis also showed no statistically significant differences (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). This result indicated that the SNR value and the result (pass or fail) of the screening-type DPOAE at a single frequency were not reliable for screening normal hearing. By contrast, the combined diagnosis using all four frequencies significantly improved sensitivity and specificity (χ\u0026sup2; = 22.37, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05), as shown in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e.\u003c/p\u003e\u003cp\u003eFalse negatives in the screening-type DPOAE (i.e., passing despite abnormal hearing) can occur. A study [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] demonstrated that DPOAE was not elicited or significantly decreased when hearing loss exceeded 40\u0026ndash;50 dB HL. Therefore, the screening-type DPOAE may yield a pass result in cases of mild or moderate hearing loss. False positives in the screening-type DPOAE (i.e., failing despite normal hearing) can occur because the primary pathology of hearing loss in older adults involves cochlear damage, which includes widespread lesions of the stria vascularis and spiral ganglion cells, and this is often accompanied by outer hair cell damage. Cochlear function deteriorates further as the degree of hearing loss increases. The screening-type DPOAE is an objective test that assesses cochlear function. Even subtle cochlear lesions can reduce the pass rate [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In addition, hearing loss often first manifests as a decline in high-frequency hearing. Studies have shown that hearing abnormalities at frequencies above 10 kHz can be detected earlier than at other frequencies [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Therefore, screening-type DPOAE tests can identify hidden hearing loss before it is detectable using Pure Tone Audiometry [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. While our DPOAE protocol focused on conventional frequencies (500\u0026ndash;4000 Hz), we acknowledge that extending testing to higher frequencies could provide earlier detection of age-related cochlear changes. And it's an important direction in our future research.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003ePure Tone Audiometry: a more valuable screening method for hearing assessment in elderly populations\u003c/h2\u003e\u003cp\u003eA comparison of screening-type distortion product otoacoustic emissions and Pure Tone Audiometry revealed statistically significant differences between the two methods (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Pure tone air-conducted thresholds at 500 and 4000 Hz were more sensitive and specific than screening-type DPOAEs in screening for normal hearing. Specifically, Pure Tone Audiometry at 500 and 4000 Hz was more valuable than DPOAEs for this purpose. This may be because screening-type DPOAEs are objective tests that assess the function of outer cochlear hair cells and their surrounding structures, whereas Pure Tone Audiometry reflects the functional status of both inner and outer cochlear hair cells, as well as their associated auditory nerve conduction pathways at specific frequency sites [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Therefore, a pass or fail result in distortion product otoacoustic emissions screening should not be interpreted simply as an indicator of normal or abnormal hearing [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. A comprehensive diagnostic hearing test is required to accurately assess the hearing status of individuals who fail the screening DPOAE.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003ePure tone air-conducted hearing thresholds at different frequencies have good application in screening for normal hearing, with 500 and 4000 Hz being the most sensitive for detecting hearing abnormalities. The screening-type distortion product otoacoustic emission (pass/fail) results demonstrated good sensitivity and specificity in hearing screening. However, single-frequency DPOAE results were of limited value for hearing screening, and the results should not be interpreted simply as normal or abnormal hearing. The differences between the two hearing screening methods were statistically significant (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Pure Tone Audiometry detected a higher prevalence of hearing abnormalities than screening-type DPOAE [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In addition, pure tone air-conducted thresholds at 500 and 4000 Hz demonstrated higher sensitivity and specificity than screening-type DPOAE in detecting normal hearing. Therefore, Pure Tone Audiometry is the more valuable test for hearing screening in elderly populations.\u003c/p\u003e\u003cp\u003eThe results of this study could help simplify the procedure of routine Pure Tone Audiometry and contribute to the development of a rapid and efficient screening method for hearing loss in the elderly. However, due to the small sample size and limited inclusion of other influencing factors (e.g., gender, cognitive function, hypertension, and other diseases), the results may be biased to some extent. Future studies should include a larger sample size and utilize other analytical methods and computer software for in-depth data analysis. This could lead to the development of a simple, practical, and time-efficient high-precision screening tool [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] accessible in primary care units, thereby promoting the widespread implementation of nationwide hearing screening for the elderly.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eDPOAE\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eDistortion product otoacoustic emission\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePTA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePure Tone Audiometry\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSNR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSignal-to-Noise Ratio\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAcknowledgements\u003c/h2\u003e\n\u003cp\u003eWe would like to thank Zhejiang University of Chinese Medicine,Hangzhou Wuyunshan Hospital and HuiTing (Hangzhou) International Hearing and Balance Center for providing us with resources and teachers for inspiration and support.\u003c/p\u003e\n\u003ch2\u003eAuthors\u0026apos; contributions\u003c/h2\u003e\n\u003cp\u003eY.W. and K.Z.wrote the main manuscript text; J.S. prepared figures; J.S. and Y.Z. collected data; D.W and C.T. supervised \u0026nbsp;the manuscript. All authors reviewed the manuscript.\u003c/p\u003e\n\u003ch2\u003eCompeting Interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare no competing financial or commercial interests.\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n\u003cp\u003eThe data that support the findings of this study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eThis study was conducted in accordance with the ethical standards of the Declaration of Helsinki and approved by the Internal Review Board (IRB) of Hangzhou Wuyunshan Sanatorium (Approval No.: Ethics Approval [2023] No. 016). All participants were informed about the study\u0026rsquo;s purpose, procedures, and potential risks. Written informed consent was obtained from each participant prior to enrollment.\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis research was supported by Medical Science and Technology Project of Zhejiang Province (Item 2024KY1418) and the 2024 Zhejiang Provincial Association of Higher Education Laboratory Work Research Project (Item YB202475).\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. World report on hearing[EB/OL]. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/publications/i/item/world-report-on-hearin\u003c/span\u003e\u003cspan address=\"https://www.who.int/publications/i/item/world-report-on-hearin\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e, 2021-04-30.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBritish Society of Audiology, British Academy of Audiology, The British Society of Hearing Aid Audiologists. The link between adult-onset hearing loss and dementia. [Online]. Available from: insert web link. (2024).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSpeech understanding and aging. Working Group on Speech Understanding and Aging. Committee on Hearing, Bioacoustics, and Biomechanics, Commission on Behavioral and Social Sciences and Education, National Research Council. \u003cem\u003eJAcoust Soc. Am.\u003c/em\u003e \u003cb\u003e83\u003c/b\u003e (3), 859\u0026ndash;895 (1988).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eShi, P. China's Demographic Imbalance and Its Adjustment Strategies\u0026ndash;Analysis Based on the Seventh National Population Census Data[J]. \u003cem\u003eTaxation Econ.\u003c/em\u003e, (05): 1\u0026ndash;10 (2022). (in Chinese).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYu, L. et al. National survey on the current situation of the elderly population with hearing disabilities[J]. \u003cem\u003eChin. J. Hear. Speech Rehabilitation\u003c/em\u003e, (03): 63\u0026ndash;65 (2008). (in Chinese).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhang, Y. \u0026amp; Xi, X. Expert Consensus on Hearing Screening in Chinese Physical Examination Population[J]. \u003cem\u003eChin. J. Health Manage.\u003c/em\u003e \u003cb\u003e10\u003c/b\u003e (06), 420\u0026ndash;423 (2016).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWang, G. \u0026amp; Li, Z. Advances in Early Diagnosis and Intervention Research in Age-Related Deafness[J]. \u003cem\u003eChongqing Med.\u003c/em\u003e \u003cb\u003e43\u003c/b\u003e (15), 1946\u0026ndash;1948 (2014). (in Chinese).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFu, X., Duan, J. \u0026amp; Zhang, M. Analysis of the Current Situation of Hearing Screening in the Elderly and Its Research Progress[J]. \u003cem\u003eChin. J. Hear. Speech Rehabilitation\u003c/em\u003e. \u003cb\u003e16\u003c/b\u003e (03), 205\u0026ndash;208 (2018). (in Chinese).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRui Zhang. Analysis of the Current Situation of Hearing Screening in the Elderly and Its Research Progress[J]. \u003cem\u003eChina Geriatric Med.\u003c/em\u003e \u003cb\u003e20\u003c/b\u003e (04), 20\u0026ndash;22 (2022). (in Chinese).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRudnicka, E. et al. The World Health Organization (WHO) approach to healthy ageing[J]. \u003cem\u003eMaturitas:International J. Study Climacteric\u003c/em\u003e. \u003cb\u003e13\u003c/b\u003e (9), 6\u0026ndash;11 (2020).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJi, F. \u0026amp; He, Y. Application of Hearing Loss Classification and Mean Hearing Thresholds[J]. \u003cem\u003eChin. J. Hear. Speech Rehabilitation\u003c/em\u003e. \u003cb\u003e19\u003c/b\u003e (3), 227\u0026ndash;231 (2021). (in Chinese).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLu, Y. Early detection, diagnosis and prevention of senile deafness[J]. \u003cem\u003eChin. J. Otology\u003c/em\u003e. \u003cb\u003e16\u003c/b\u003e (03), 382\u0026ndash;388 (2018).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLihua Ren, Z. et al. Progress in the study of the etiology and pathogenesis of senile deafness[J]. \u003cem\u003eMod. J. Integr. Chin. Western Med.\u003c/em\u003e \u003cb\u003e27\u003c/b\u003e (07), 792\u0026ndash;795 (2018). (in Chinese).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLi, H. \u0026amp; Su, Z. A study of the relationship between otoacoustic emissions from hearing screening aberration products and hearing impairment[J]. \u003cem\u003eJ. Hebei Med. Univ.\u003c/em\u003e \u003cb\u003e39\u003c/b\u003e (04), 431\u0026ndash;433 (2018). (in Chinese).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLan, L. L. et al. Analysis of the results of otoacoustic emission hearing screening in 987 adults with aberrant product ears[J]. \u003cem\u003eJ. Audiol. Speech Disorders\u003c/em\u003e. \u003cb\u003e29\u003c/b\u003e (06), 647\u0026ndash;652 (2021). (in Chinese).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLough, M. \u0026amp; Plack, C. J. Extended high-frequency audiometry in research and clinical practice. J Acoust Soc Am. 151(3): 1944. (2022).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePatterson, B. M. \u0026amp; Renaud, M. Routine hearing screening in primary care for adult populations using distortion product Otoacoustic Emissions testing. \u003cem\u003eJAm Acad. Nurse Pract.\u003c/em\u003e \u003cb\u003e24\u003c/b\u003e (7), 400\u0026ndash;401 (2012).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChen, P. Distortion product otoacoustic emissions in the monitoring of senile deafness[D]. Zunyi Medical College, 2016(in Chinese).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eXian, Y. et al. Meta-analysis of the prevalence of hearing loss in the elderly in China[J]. \u003cem\u003eMod. Prev. Med.\u003c/em\u003e \u003cb\u003e49\u003c/b\u003e (13), 2451\u0026ndash;2458 (2022). (in Chinese).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhang, M. et al. A parsimonious approach for screening moderate-to-profound hearing loss in a community-dwelling geriatric population based on a decision tree analysis. \u003cem\u003eBMC Geriatr.\u003c/em\u003e \u003cb\u003e9\u003c/b\u003e (1), 214 (2019).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Age-related hearing loss, Hearing screening, Audiological evaluation, Advance directives","lastPublishedDoi":"10.21203/rs.3.rs-7972429/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7972429/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e\u003cp\u003eThis study compares the efficacy of Pure Tone Audiometry and screening-type Distortion Product Otoacoustic Emissions in elderly hearing screening, aiming to establish a rapid and efficient method for detecting age-related hearing loss.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA total of 252 elderly participants aged 60 years and above were randomly selected from Wuyunshan Hospital in Hangzhou. Both Pure Tone Audiometry and screening-type Distortion Product Otoacoustic Emission were performed, and statistical methods were used to analyze the results.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe air-conduction thresholds of Pure Tone Audiometry showed statistically significant differences across frequencies in hearing screening (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05), with 0.5 and 4 kHz being the most sensitive indicators of hearing abnormalities. The screening-type Distortion Product Otoacoustic Emission results also demonstrated statistical significance in hearing assessments (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Furthermore, a statistically significant difference was observed between the Pure Tone Audiometry and screening-type Distortion Product Otoacoustic Emission results (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eThe Pure Tone Audiometry thresholds and screening-type Distortion Product Otoacoustic Emission tests across various frequencies both demonstrated good efficacy in hearing screening for elderly people. The hearing impairment detection rate was higher using Pure Tone Audiometry compared with screening-type Distortion Product Otoacoustic Emissions. These findings can guide the development of a rapid and effective screening method for age-related hearing loss in older adults.\u003c/p\u003e","manuscriptTitle":"Comparative Efficacy of Pure Tone Audiometry and Distortion Product Otoacoustic Emissions for Hearing Screening in Elderly Populations","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-02 14:09:59","doi":"10.21203/rs.3.rs-7972429/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"169c8bbe-253f-442e-ba8a-0398e0ee7d0d","owner":[],"postedDate":"December 2nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":58740768,"name":"Health sciences/Diseases"},{"id":58740769,"name":"Health sciences/Health care"},{"id":58740770,"name":"Health sciences/Medical research"},{"id":58740771,"name":"Biological sciences/Neuroscience"}],"tags":[],"updatedAt":"2026-01-05T01:54:03+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-02 14:09:59","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7972429","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7972429","identity":"rs-7972429","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}