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\begin{document}

\title{The Decision Making Role of Audiological Tests in ENT Practise}



\author[1]{Ateş Mehmet Akşit}%
\author[1]{Ebru Kösemihal}%
\affil[1]{Near East University}%


\vspace{-1em}



  
  \date{May 27, 2024}


\begingroup
\let\center\flushleft
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\maketitle
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\selectlanguage{english}
\begin{abstract}
Objective This study aims to determine to what extent audiological test
data effected on decision-making in the diagnosis process of patients
who have hearing loss. Design Survey study Setting and Participants The
audiological test results of six pathologies (auditory neuropathy
spectrum disorder-ANSD, Menier\selectlanguage{ngerman}é's Disease-MD, superior semicircular
canal dehiscence-SSCD, large vestibular aquaduct syndrome-LVA, chronic
otitis media-COM, and secretory otitis media-SOM) belonging to five
different patients with a definite diagnosis were presented to 87
otolaryngology (ENT) physicians. The physicians were not informed about
patient histories and otoscopic findings. The breakdown of the
physicians according to their specialization was as follows: 19 were
residents, 53 were ENT specialists, 6 were associate professors, and 9
were professors. The participant physicians were asked to indicate
possible pathologies (one or more) for each audiological outcome. The
answers given were classified as ``correct,'' ``undefined'' and
``incorrect.'' Main outcome measures To determine how effective only
audiological reports are for the diagnostic decision-making role was
evaluated by analysing the percent of ``correct'' answers according to
their work place and title. Results The mean ``correct'' response rate
for all pathologies was 19.2\%, and the '' incorrect'' response rate was
38\%. The ratio of ``undefined'' answers was 41.8. The ``correct''
prediction rates for each pathology, were 26\% for ANSD, 32\% for SOM,
19\% for MD, 16\% for COM and 14\% for SSCD. There was no ``correct''
prediction for LVA. Conclusion Audiological tests are likely to support
the decision-making process for the ENT physician when they are
accompanied by other (case history, otoscopic examination, radiological
findings etc.) The audiological report content may increase the
diagnostic value of audiological tests.%
\end{abstract}\selectlanguage{ngerman}%



\sloppy


\textbf{THE DECISION-MAKING ROLE OF AUDIOLOGICAL TESTS IN ENT PRACTISE}

\textbf{ABSTRACT}

\textbf{Objective}

This study aims to determine to what extent audiological test data
effected on decision-making in the diagnosis process of patients who
have hearing loss.

\textbf{Design}

Survey study

\textbf{Setting and Participants}

The audiological test results of six pathologies (auditory neuropathy
spectrum disorder-ANSD, Menier\selectlanguage{ngerman}é's Disease-MD, superior semicircular
canal dehiscence-SSCD, large vestibular aquaduct syndrome-LVA, chronic
otitis media-COM, and secretory otitis media-SOM) belonging to five
different patients with a definite diagnosis were presented to 87
otolaryngology (ENT) physicians. The physicians were not informed about
patient histories and otoscopic findings. The breakdown of the
physicians according to their specialization was as follows: 19 were
residents, 53 were ENT specialists, 6 were associate professors, and 9
were professors. The participant physicians were asked to indicate
possible pathologies (one or more) for each audiological outcome. The
answers given were classified as ``correct,'' ``undefined'' and
``incorrect.''

\textbf{Main outcome measures}

To determine how effective only audiological reports are for the
diagnostic decision-making role was evaluated by analysing the percent
of ``correct'' answers according to their work place and title.

\textbf{Results}

The mean ''correct'' response rate for all pathologies was 19.2\%, and
the '' incorrect'' response rate was 38\%. The ratio of ``undefined''
answers was 41.8. The ''correct'' prediction rates for each pathology,
were 26\% for ANSD, 32\% for SOM, 19\% for MD, 16\% for COM and 14\% for
SSCD. There was no ''correct'' prediction for LVA.

\textbf{Conclusion}

Audiological tests are likely to support the decision-making process for
the ENT physician when they are accompanied by other (case history,
otoscopic examination, radiological findings etc.) The audiological
report content may increase the diagnostic value of audiological tests.

\textbf{KEY POINTS}

1. The participants were asked to identify the pathology that caused
hearing loss in patients by referring to their audiological tests. The
results showed that 19\% of the participants' predictions were correct,
38\% of them were wrong, 36\% of the participants named the type of
hearing loss rather than the pathology, and 7\% did not respond.

2. The group of participants with the highest number of incorrect
(42.6\%) but also the highest number of correct predictions (31.2\%)
were physicians working in university hospitals.

3. It was found that audiological tests were the least helpful in
diagnosing SSCD, LVA and ANSB.

4. If the audiological reports only mention the type of hearing loss,
pathologies such as SSCD and LVA can go unnoticed.

5. All audiological tests should be considered in the decision-making
process to increase the reliability of the diagnosis.

\textbf{INTRODUCTION}

Patient history, physical examination, audiological, radiological, and
other laboratuary tests have an important place in ENT diagnosis. The
diagnostic value of these tests varies according to the pathology. For
example, otoscopic examination and tympanometric findings in middle ear
infections {[}1,2{]}, patient history in Menieré's disease (MD) {[}3{]},
auditory brainstem response (ABR) test in auditory neuropathy spectrum
disorder (ANSD) {[}4), and radiological findings in cerebellopontine
angle tumors For example, otoscopic examination and tympanometric
findings in middle ear infections {[}1,2{]}, patient history in
Menieré's disease (MD) {[}3{]}, auditory brainstem response (ABR) test
in auditory neuropathy spectrum disorder (ANSD) {[}4{]}, and
radiological findings in cerebellopontine angle tumors play an important
role in diagnosis. For this reason, ENT physicians are expected to have
knowledge and experience in evaluating different tests and interpreting
them together to decide on a patient's diagnosis.

The diversity of testing methods prompts ENT physicians to cooperate
with healthcare professionals in different disciplines, such as
audiology, radiology, hematology, neurology, and oncology. Drawing up
information from these various fields for one patient is crucial to
diagnose the problem correctly. Detection of the pathology is the
responsibility of the ENT doctor. However, the test results obtained
from the disciplines for which consultation is requested draw attention
to possible pathologies, which will help the diagnosis to be fast and
reliable.

Hearing tests are among the tools most commonly used by ENT physicians
in the diagnosis process. Hearing test batteries play an essential role
in distinguishing diseases with similar auditory configurations (e.g.,
MD, Superior Semisircular Canal Dehiscence (SSCD), and otosclerosis) and
in the diagnosis of diseases that do not provide overt symptoms on
otoscopic examination (e.g., third window syndromes (SSCD) and ANSD).
Audiological tests are also indispensable in hearing aid and auditory
implant decisions.

The type of hearing loss (sensory-neural, mixed or conductive) is
usually emphasized in the reporting of the audiological tests. Although
the type of hearing loss is an important finding, it is not sufficient
to understand the pathology. For example, the expression ``sensory
neural hearing loss'' indicates that the pathology is in the cochlea or
the auditory nerve {[}5{]}. However, this expression may indicate many
pathologies such as MD, acoustic trauma, presbycusis, or vestibular
schwannoma. The scope of the definition of ``mixed hearing loss'' is
much broader: it includes multiple pathologies starting from the outer
ear and extending to the brain stem {[}5{]}. Therefore, audiological
reports limited to specifying the type of hearing loss may cause
inadequacy in diagnosing the pathology.

Mortality and morbidity rates seen in ENT clinics due to human factor
errors have been demonstrated in various studies after 2004 {[}6,7,8{]}.
The source of errors has been determined as diagnostic, treatment,
surgical, communication, and administrative components {[}6{]}. In the
same study, the ratio of errors resulting from the execution and
evaluation of diagnostic tests to total errors was 10.4\%. However,
those studies did not specify the role of audiological tests in
diagnostic illusion.

Our study aims to investigate to what extent audiological findings
solely guide ENT physicians in determining pathology when other
essential diagnostic tools (history, physical examination, radiologic
test, etc.) are absent.

\textbf{MATERIAL AND METHOD}

This study used audiological findings of six different pathologies
belonging to five patients with a definitive diagnosis. Pathologies were
selected according to their incidence rates. Chronic otitis media (COM),
secretory otitis media (SOM) and Menieré's disease (MD) were classified
as common pathologies, while SSCD, large vestibular aqueduct syndrome
(LVA) and auditory neuropathy spectrum disorder (ANSD) were classified
as rare pathologies. Pure tone threshold, speech, and tympanometric test
results in all pathologies were marked on the audiogram form. The ANSD
patient also had otoacoustic emission and auditory brainstem response
(ABR) test results (Table 1). Audiograms were prepared in the form of a
questionnaire. Apart from audiological findings, no additional
information such as audiology report, patient history, otoscopic or
radiological findings was included in the questionnaire. The answers
accepted as correct according to the pathologies are given in Table 2.

Questionnaires were filled with the face-to-face interview technique.
The interviewers were selected from among the final year students of the
received training on survey interviews. Ethical approval
(02.05.2019-710) was obtained from Ethics Committee of the
\ldots{}\ldots{}\ldots{}. University \ldots{}\ldots{}\ldots{}..

\textbf{Participants}

The survey was conducted with 87 ENT physicians during the three
separate national ENT meetings held in 2019. The participants were
randomly selected among physicians attending the meeting. Age, gender,
institution, and titles of the participants were recorded as demographic
information. The question ''which pathology do the audiological findings
suggest?'' was asked to physicians. Questions were open ended. It was
stated that they could write possible pathologies without any number
restriction.

\textbf{Grouping of answers}

If the participants' answer included the corect pathology the answer was
defined as ``correct.'' If more than one pathology was listed next to
the correct answer, the others were ignored.

If the type of hearing loss was specified instead of the pathology
causing the hearing loss, the response was classified as ``undefined.''
Responses that did not include the correct pathology and type of hearing
loss were classified as ''incorrect''. The audiological findings of the
pathologies are given in Table 1.

\textbf{Data analysis}

The ''correct,'' ''undefined'' and ''incorrect'' answers given by the
participants were evaluated depending on the type of pathology presented
in the audiogram, the professional titles of the participants and the
institutions they work for.

\textbf{RESULTS}

The questionnaire was given to 87 ENT physicians (female: 21, male: 66).
The mean age was 42.7 (the range was 27 - 68).

When classified according to their professional titles, 19 of the
participants were residents, 53 were specialists, 6 were associate
professors, and 9 were professors. Associate professors and professors
were gathered in a single group under the name of faculty members. Of
the participants, 28 were working in a state hospital (SH), 31 at a
state university (SU), 14 at a private hospital (PH), and 5 at a private
university (PU). Nine participants did not specify the institution where
they worked.

The response rates of participants to pathologies according to their
professional titles are given in Table 3. The highest number of
``correct'' responses was given to the SOM audiogram with 41\%, and the
lowest was given to the LVA audiogram with 0\%. The highest number of
``incorrect'' responses were seen in the SSCD audiogram (82\%) and the
lowest in the SOM and MD audiogram (13\%). Only the answers indicating
the type of hearing loss (``undefined'' answers) were seen the most in
the MD audiogram (61\%) and the least in the SSCD audiogram (2\%).
Approximately one-third (35.7\%) of the participants expressed the type
of hearing loss, not the pathology name. This ratio was almost the same
in all groups.

The rate of the correct association of audiological findings with the
pathology (``correct'') was 19.2\% on average. Faculty members gave the
highest number of ``correct'' answers with 26.7\%, and experts gave the
lowest (16.5\%).

The mean of ''incorrect'' response was found to be 38\%. The highest
''incorrect'' response rate was seen in faculty members (40.2\%). This
rate was 37.3\% for specialists and 29.3\% for residents. The rate of
unanswered (NR) questions was 7.2\%. This rate was 10.4\% for
specialists and 8\% for residents. The only group that answered all the
questions was the faculty members.

When the answers were evaluated according to the hospitals, the highest
number of ''correct'' answers came from SU (27.8\%) and the lowest from
SH (16.2\%). The highest rate of ``incorrect'' answers came from those
working in PU (60\%), and the lowest among those working in PH and SH
(36.8\% and 37\%, respectively). ``Undefined'' response rates were the
lowest in PU (20\%), and the highest in SH (38.2\%) (Table 4).

When we grouped pathologies according to their frequency of occurrence
(frequent: COM, SOM, MD; rare: ANSD, SSCD, LVA), the rate of ``correct''
response was found to be approximately 2.5 times higher in common
pathologies than in rare pathologies (27.3\% vs. 11\%). On the other
hand, the rate of ``incorrect'' response in rare pathologies was three
times higher than in common pathologies (57\% vs. 18.7\%) (Table 5).

\textbf{DISCUSSION}

Although the diagnostic importance of audiological tests is well known,
the extent to which they guide ENT physicians correctly has not been
studied much. In our study, the effect of audiological findings was
investigated in isolation from all other tools commonly used by ENT
physicians (otoscopic examination, patient history, radiological tests,
etc.). Therefore, ``incorrect'' or ``undefined'' answers by physicians
should not mean that audiological tests that are not interpreted
correctly will lead to the misdiagnosis of patients. When evaluated
together with other diagnostic tests, audiological findings are more
likely to guide physicians more accurately.

One of the difficulties in making a diagnostic evaluation with
audiological findings is that the same pathology can yield distinct
findings in patients. In addition, similar audiological findings may
suggest different pathologies. Therefore, the expectation in our study
was that the physicians examining the audiogram would state the
``correct'' pathology among the possible pathologies. Hence, if there is
a ''correct'' pathology among all the pathologies that come to mind, the
answers were accepted as ''correct''. However, the average of the
''incorrect'' answers was higher than the ''correct'' answers.
Especially in rare pathologies (ANSD, SSCD, and LVA), ``incorrect''
response rates were approximately five times higher than ``correct''
responses. This result shows that in rare pathologies, most of the
participants did not associate the features of the pathology with the
audiological findings well enough. In pathologies such as COM, SOM and
MD, since the otoscopic examination and patient history play an
important role in the physician's determination of the pathology, the
relationship between these pathologies and audiological findings may be
easier to establish.

The fact that ``incorrect'' answers were more than ``correct'' answers
was valid for all participant groups (faculty members, ENT specialists
and residents). Interestingly, the faculty members gave the highest
ratio of both ''correct'' and ''incorrect'' answers. Whereas, it was
expected that faculty members gave the highest ''correct'' answer. The
high rate of ``incorrect'' answers can be interpreted as the
audiological test battery not being evaluated holistically.

One of the difficulties in interpreting audiological tests is that
different pathologies may yield similar audiological configurations. For
example, hearing loss, which is more occurs at low frequencies, may
resemble MD, SSCD and otosclerosis at first glance. In such a case, the
relationship of air/bone conduction thresholds, acoustic reflex test and
speech comprehension score gain importance in determining the diagnosis
from an audiological point of view. Therefore, it is important to
evaluate audiological tests holistically. The lack of holistic
assessment was evident in the COM/SOM distinction. Of the 26
participants, 18 (69\%) who responded ''incorrect'' on the COM audiogram
evaluated the pathology as OME. Interpretation of COM findings as SOM is
most likely related to missing the ear canal volume indicated in the
tympanometric test.

Another common mistake is defining LVA and SSCD audiograms as conductive
or mixed hearing loss. The audiogram configuration and the air/bone gap
seen at low frequencies may suggest a conduction component in these
patients. However, obtaining acoustic reflexes should have brought the
inner ear anomaly to the physician's mind.

The audiogram configuration of third window syndromes such as SSCD and
LVA appears to be conductive or mixed hearing loss. However, in these
pathologies, hearing loss occurs due to inner ear anomalies.
Classification of these pathologies according to the type of hearing
loss is another matter of debate. It is generally accepted that the
terms ''conductive'' or ''mixed type'' indicate that outer or middle ear
diseases are effective in hearing loss. Because the middle ear does not
show a pathological effect in the third window syndrome, the definition
of ''third window syndrome'' as ''conductive'' or ''mixed hearing loss''
according to the audiological configuration was accepted as an
''incorrect'' answer in our study.

Responses that correctly stated the type of hearing loss, but not the
pathology causing the hearing loss, were classified as ``undefined''.
About one-third of the subjects preferred to specify the type of hearing
loss, even though the questionnaire was asking ``name of possible
pathology.'' These responses were not unexpected, as the classification
most frequently encountered by ENT physicians in audiological reports is
for the type of hearing loss. However, it did not help us much to answer
our research question about the importance of audiological findings in
diagnosis.

When the results were evaluated according to the institutions where the
physicians worked, it was seen that there were more ''incorrect''
answers in private and state universities. The results are instrumental
in that they show the decision-making augmentation of ENT tests for
clinical practice

\textbf{CONCLUSION}

When ENT physicians evaluate the results of the audiological findings
independent from all other diagnostic tools (autoscopic examination,
patient history, radiological tests, etc.), they can predict the actual
pathology, but it turns out that error rates are higher than hit rates.
The incomplete interpretation of audiological tests, emphasizing the
type of hearing loss rather than possible pathology in audiological
reports, and the incidence of pathologies can be considered as potential
factors in increasing the error rate.

One of the critical results of the study is that more emphasis should be
placed on audiological evaluation in the training of ENT residents.
Another significant result is that audiological reports should be
designed to remind the ENT physician of possible pathologies. The format
and the content of the audiological report may be the subject of another
study. However, the indication of only the type of hearing loss in the
reports does not have a crucial role in detecting the pathology.

Although not a focal point in this study, another important point to be
considered is the risk created by the fact that audiological reporting
is limited to the tests requested by the ENT physician. For the
audiologists to clarify the possible pathology, applying additional
tests on their initiative or clearly stating in their report that
further tests are required will increase the reliability of the
diagnosis.

Responsibilities of audiologists and otologists and reporting of
audiological tests may vary from country to country. Therefore, the
instrumental value of audiological reports may differ. For example, in
countries such as the USA, audiology is considered as an independent
science, and in Germany, ENT physicians are more dominant in the
audiological field {[}8{]}. Examining these different schools in terms
of the instrumental value of audiological tests may provide effective
results in the field, enhancing the critical decision making process.

\textbf{REFERENCES}

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\end{enumerate}

\textbf{Appendix 1: Audiometric results for six pathologies}

\emph{Auditory Neuropathy Spectrum Disorder:}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

\emph{Meniere Disease:}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

\end{center}
\end{figure}

\emph{Semicircular Canal Dehiscense}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image3/image3}

\end{center}
\end{figure}

\emph{Chronic Otitis Media (left)}

\emph{Secretory Otitis Media (right)}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image4/image4}

\end{center}
\end{figure}

\emph{Large Vestibular Aqueduct~Syndrome}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image5/image5}

\end{center}
\end{figure}

\textbf{Hosted file}

\verb`Tables.docx`  available at \url{https://authorea.com/users/738085/articles/712595-the-decision-making-role-of-audiological-tests-in-ent-practise}

\selectlanguage{english}
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