International Journal of Otorhinolaryngology and Head and Neck Surgery

Kumari R et al. Int J Otorhinolaryngol Head Neck Surg. 2019 May;5(3):678-682

http://www.ijorl.com pISSN 2454-5929 | eISSN 2454-5937

DOI: http://dx.doi.org/10.18203/issn.2454-5929.ijohns20191729
Original Research Article

A study of brainstem evoked response audiometry in children

with severe hearing loss
Rakhi Kumari1, Rajiv Kumar Jain2, Dhananjay Kumar3*
1
Department of ENT, Sri Krishna Medical College, Muzaffarpur, Bihar, India
2
Department of Otorhinolaryngology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar
Pradesh, India
3
Department of Community Medicine, Patna Medical College, Patna, Bihar, India

Received: 22 December 2018

Accepted: 18 March 2019

*Correspondence:
Dr. Dhananjay Kumar,
E-mail: djkum2k4@gmail.com

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Brainstem evoked response audiometry (BERA) is a non-invasive diagnostic tool which can be used to
assess the early hearing loss. The objectives of the study were to find out the risk factors for severe hearing loss in
children and to evaluate the role of BERA in early diagnosis of severe hearing loss in children.
Methods: The present hospital based cross sectional study was conducted on 105 children suffering from severe
hearing loss. Risk factors of hearing loss was assessed in these children and brainstem evoked response audiometry
was performed.
Results: Out of 105 children studied risk factors for hearing loss were present in 69 cases (65.71%) in which several
cases had multiple risk factors. History of prolonged stay at NICU was present in 23 cases (21.9%). 11 (10.5%) cases
had suffered from meningitis while history of cerebral malaria was present in 2 cases (1.9%). History of cerebral
palsy was present in 5.7% cases. The family history of hearing loss was present in 15 patients (14.3%). Bilateral
severe hearing loss was present in 76 cases (72.4%) while in 13 cases (12.4%) there was bilateral severe to profound
hearing loss assessed using BERA test.
Conclusions: Early detection and timely intervention can not only help prevent this silent handicap of deafness but
also contribute to social and economic productivity of a community.

Keywords: Severe hearing loss, Brainstem evoked response audiometry, Children

INTRODUCTION Hearing loss is one of the commonest childhood handicap

and with a large quantum of its burden in developing
Hearing is the deepest, most humanizing philosophical countries like India; there is a need to address this issue.
sense man possesses. The sense of hearing is important
during the early years of life for the development of Hearing loss in infants should be recognized in time and
speech, language, and cognition. Losses in either partial appropriate otological and audiological interventions and
or total hearing may lead to poor language and speech rehabilitation should be instituted early, to take advantage
development and thereby affects the comprehensive of the plasticity of developing sensory system. So, early
development of the individual and his productivity. detection of hearing loss in children and providing
Hearing loss and deafness are global issues that affect at hearing devices helps to develop speech, language, and
least 278 million people worldwide. Two-thirds of these listening skills needed for oral communication. Because
people live in developing countries.1

International Journal of Otorhinolaryngology and Head and Neck Surgery | May-June 2019 | Vol 5 | Issue 3 Page 678
 Kumari R et al. Int J Otorhinolaryngol Head Neck Surg. 2019 May;5(3):678-682

of this reason, early detection of a possible hearing loss in birth trauma, asphyxia, weight of child, cry at birth,
children is crucial.2 neonatal intensive care unit admission, Neonatal
jaundice, seizure, congenital anomaly, immunisation
With the advent of brainstem evoked response history were asked. Postnatal history regarding any
audiometry (BERA), detection and quantification of relevant findings was also assessed. History of deafness
hearing impairment has been easier in pediatric patients in family members and relatives were asked.
who are unable to cooperate with routine testing. The best
predictor of permanent hearing loss is bilateral failure in Brainstem evoked response audiometry
auditory brainstem response (ABR) possibly because of
its ability to detect both cochlear and brainstem lesions. Before the test all patients underwent through ENT
Hearing loss of 40 dB or more at any frequency in the examination. If any wax or any foreign body found it was
range of 0.5–4 kHz in the better ear is defined as removed. Any ear discharge was treated. This test was
sensorineural deafness with or without associated performed in the department of ENT, Institute of medical
conductive loss. An infant is considered to have passed sciences, BHU in a dust free, sound free and air
the ABR test if a replicable wave V response is present at conditioned room free from electromagnetic disturbances.
30 dB hearing level in both ears or in one ear at 30 dB Syrup Trichlofos (25 mg/kg body wt.) was given to
hearing level and the other ear at 45 dB hearing level. 3 sedate the baby half an hour before procedure. The
patients laid on a flat couch and were allowed to relax
With taking all these considerations the present study was before testing. After cleaning the forehead, vertex and
undertaken with following objectives: both mastoid regions with spirit, surface electrodes were
applied and subject tested in sleeping state with neck
 To find out the risk factors for severe hearing loss in slightly flexed to minimise any myogenic activity.
children. External auditory canals were cleaned and head phones
 To evaluate the role of BERA in early diagnosis of were held against the ear of baby taking care that external
severe hearing loss in children. auditory canal did not collapse. The BERA test was
performed using a portable computerised system EP15-25
METHODS (ABR neuroscreening) interacoustics and graph was
obtained. The software used was Ia base 2000 software.
The present study was conducted in the department of The electrodes used were pre gelled kendall (Tyco health
otorhinolaryngology, institute of medical sciences, care, H92SG, 48×34 mm). The transducer used was
Banaras Hindu University from January 2014 to July TDS39. Filter setting was 3000 Hz (low pass). Electrode
2015. impedance was checked for each individual and was
maintained at <5 for all electrodes. Auditory click stimuli
Selection of cases delivered monoaurally at the rate of 19.1/sec varying
from 105 dBL-40 dBL using 2000 clicks failing which
The study population comprised of children below twelve 4000 clicks were given. The test takes between 30-45
years of age with severe hearing loss who came to the minutes with optimal testing conditions.
department of otorhinolaryngology, institute of medical
sciences, Banaras Hindu University and whose parents This procedure was performed for both ears separately.
have given consent regarding participation in this study. Hearing threshold was taken as normal if wave V was
present at 40dB intensity of stimulus in BERA graph. If
One hundred and five subjects were registered in the no wave V was found in BERA graph patient was
study who fullfilled the eligibility criteria. All these diagnosed as hearing impaired. The morphology of the
children had complaint of difficulty in hearing and/or graph was noted until wave V is no longer identifiable.
speech. The minimum intensity at which wave V is identifiable is
taken as the hearing threshold for that individual.
A careful history was taken and full clinical examination
was carried out and points were noted in performa. After Data analysis
proper history and clinical examination patients were
subjected to brainstem evoked response audiometry test The data thus collected was coded and entered into
(BERA). Microsoft office excel worksheet. Frequency table and
percentage of required variables were made.
Past history of prolonged medical illness, ototoxic drug
intake, seizure, meningitis, head trauma, fever with Ethical consideration
rashes, noise exposure were taken. Antenatal history like
maternal health during pregnancy, previous history of The study was approved by the ethical committee of the
abortion, maternal age, drug intake during pregnancy, Institute of Medical Sciences, Banaras Hindu University.
radiation on exposure, any illness were asked. Perinatal Informed consent was taken from the parents.
history regarding term or preterm birth, mode of delivery,

International Journal of Otorhinolaryngology and Head and Neck Surgery | May-June 2019 | Vol 5 | Issue 3 Page 679
 Kumari R et al. Int J Otorhinolaryngol Head Neck Surg. 2019 May;5(3):678-682

RESULTS (10.5%) while history of recurrent pneumonia was

present in 17 cases (16.2%). The family history of
Out of 105 children studied most of them (80.9%) hearing loss was present in 15 patients (14.3%).9 children
belonged to 1-5 years age group. Among infants 5 cases (8.6%) had preterm birth (less than 36 weeks of
(83.3%) were male while 1 case (16.7%) was female. In gestation) while 10 children (9.5) had very low birth
1-5 years age group 51 cases (60.0%) were male and 34 weight (less than 1.5 Kg).
cases were female (40.0%). In 6-12 years age group 6
cases (42.9%) were male while 8 cases were female Table 3: Frequency of hearing impairment in both ear
(57.1%) (Table 1). in study group based on BERA threshold.

Table 1: Distribution of patients according to sex and No of No of

Threshold % %
their age group. right ear left ear
≥105 dB 43 40.9 41 39.1
Male Female 95 dB 58 55.2 58 55.2
Age group Total
No. of No. of 85 dB 4 3.8 6 5.7
(in years) % % (n=105)
cases cases
Less than 1 05 83.3 01 16.7 06 (5.7) Table 3 shows hearing threshold of both the ear
1-5 51 60.0 34 40.0 85 (80.9) separately. In right ear the maximum hearing threshold
6-12 6 42.9 8 57.1 14 (13.4) was obtained at 95 dB for 58 ears (55.2%) followed by at
or above 105 dB and 85 dB which was 40.9% and 3.8%
Table 2: Frequency of various risk factors for hearing respectively. In left ear the maximum hearing threshold
loss present in study group. was obtained at 95 dB for 58 ears (55.2%) followed by at
or above 105 dB and 85 dB which was 39.1% and 5.7%
No. of respectively.
Risk factors %
cases
Pre-term birth (<36 weeks of Table 4: Distribution of cases according to interaural
9 8.6 difference of wave V latency in BERA test.
gestation)
Very low birth weight 10 9.5
Hyperbilirubinemia at birth No. of
10 9.5 Increased interaural difference of %
requiring phototherapy cases
wave V latency >0.3 ms
Meningitis 11 10.5 66 62.9
Cerebral palsy 6 5.7 Increased interaural difference of
39 37.1
Cerebral malaria 2 1.9 wave V latency < 0.3 ms
History of seizures 7 6.7
An increased inter aural difference of wave V latency of
Ototoxic drugs 3 2.9
more than 0.3 ms was present in 66 cases (62.9%) while
Recurrent diarrhoea 11 10.5 an increased inter aural difference of wave V latency of
Recurrent Pneumonia 17 16.2 less than 0.3 ms was present in 39 cases (37.1%) (Table
Delayed crying at birth 37 35.2 4).
History of NICU administration
23 21.9
for more than 48 hours Table 5: Interpretation of BERA finding in study
Family history of hearing loss in subjects.
15 14.3
siblings
No. of
BERA interpretation %
Table 2 shows presence of various risk factors related to cases
hearing loss in study subjects. In present study risk Bilateral moderately severe
2 1.9
factors for hearing loss were present in 69 cases (65.7%) hearing loss
in which several cases had multiple risk factors. In 9 Bilateral moderately severe to
cases there was history of preterm birth. 3 2.9
severe hearing loss
Hyperbilirubinemia at birth leading to phototherapy was Bilateral severe hearing loss 76 72.4
present in 10 cases (9.5%). History of prolonged stay at Bilateral severe to profound
NICU was present in 23 cases (21.9%). 11 (10.5%) cases 13 12.4
hearing loss
had suffered from meningitis while history of cerebral Rt severe lt moderately severe to
malaria was present in 2 cases (1.9%). History of cerebral 4 3.8
severe hearing loss
palsy was present in 5.7% cases.
Lt severe Rt moderately severe to
7 6.7
severe hearing loss
History of seizures was present in 7 cases (6.7%). In 3
cases (2.9%) there was history of ototoxic drug intake.
Bilateral severe hearing loss was present in 76 cases
History of recurrent diarrhoea was present in 11 cases
(72.4%). In 13 cases (12.4%) there was bilateral severe to

International Journal of Otorhinolaryngology and Head and Neck Surgery | May-June 2019 | Vol 5 | Issue 3 Page 680
 Kumari R et al. Int J Otorhinolaryngol Head Neck Surg. 2019 May;5(3):678-682

profound hearing loss. In 4 cases (3.8%) there was right In a study by Lachowaska et al (2014), among the infants
sided severe and left sided moderately severe to severe with particular risk factors of having hearing loss, the
hearing loss. In 7 (6.7%) cases there was left sided severe ones with hyperbilirubinemia, low birth weight, intensive
hearing loss and right sided moderately severe to severe therapy for at least 7 days, low Apgar scores, and
hearing loss (Table 5). craniofacial abnormalities proved to correlate with
confirmation of hearing loss.9
DISCUSSION
Bhagya et al in their study found similar risk factors like
In this study, majority of children with hearing loss present study. In their study out of 18 patients with severe
belong to age group 1–5 years (81%). Similar findings of hearing impairment 3 had hyperbilirubinemia, 8 had
delayed reporting were also found in different studies neonatal convulsions and 7 had birth asphyxia. Out of 50
across India.4,5 Much of the speech and language patients with profound hearing loss, 10 patients were
development occurs during this period. Hence, hearing preterm, 18 had hyperbilirubinemia, 6 had neonatal
loss is identified when the child presents with delayed convulsions, 12 birth asphyxia, 4 LBW.10
speech.
Bansal et al in their study also reported meningitis, birth
Only 6% of children belonged to infant category in asphyxia, ototoxicity, respiratory distress and
present study. This shows that the early referral was poor. hyperbilirubinemia as risk factors for hearing loss.7
Neonatal screening can identify such children at an
earlier stage which helps in early rehabilitation. Early Hearing assessment in children is one of the dark areas in
identification of hearing loss offers children the spite of the fact that two out of every 1,000 children have
opportunity to develop significantly improved language permanent bilateral hearing loss above 60 dB. Four to six
skills compared with those children who are diagnosed out of every 1,000 children born in India are found to
later. Therefore, internationally recommended age for the have severe to profound hearing loss.3,11
diagnosis of hearing loss in children is 3 months of age. If
hearing loss is confirmed, intervention should start as BERA is the only tool which can confirm the normal
soon as possible, preferably before 6 months of age. 6 sensitivity of hearing whenever required & is very useful
in early detection of hearing loss and planning
Severe deafness in children is usually due to rehabilitative procedures. In case of multiple handicaps,
sensorineural hearing loss rather than conductive loss or BERA is the only test which can give accurate picture of
auditory processing disorders. Sensorineural deafness can hearing sensitivity.12 In case of high risk babies who are
be due to causes such as: (1) Hereditary (genetic), (2) exposed to multiple risk factors like preterm babies,
prenatal (rubella), (3) perinatal (kernicterus, birth neonatal jaundice, neonatal convulsions, birth asphyxia &
asphyxia, etc.) and (4) childhood acquired deafness LBW & even other multiple risk factors which have
(following meningitis, trauma).3 chances of impairing hearing ability, BERA should be
carried out as a routine procedure to detect the hearing
In present study the family history of hearing loss was loss in such babies. In present study bilateral severe
present in 15 patients (14.29%). Bansal et al in their study hearing loss was present in 76 cases (72.4%). In 13 cases
on severe hearing loss found that family history of (12.4%) there was bilateral severe to profound hearing
hearing loss was present in 15.6% and 16.6% cases loss. In 4 cases (3.8%) there was right sided severe and
respectively.7 left sided moderately severe to severe hearing loss. In 7
(6.7%) cases there was left sided severe hearing loss and
In present study multiple risk factors for hearing loss right sided moderately severe to severe hearing loss. So,
were present in 69 cases (65.7%) in which several cases BERA test not only able to assess the threshold of
had multiple risk factors. Gupta in his study found that hearing but also helped in planning of management in
risk factors for hearing loss were present in 54.3% cases. 8 these cases.

In present study there were 9 cases with history of BERA test although a more time consuming process is an
preterm birth. Hyperbilirubinemia at birth leading to accurate test for early detection of neural conduction
phototherapy was present in 10 cases (9.5%), history of irregularities in the auditory pathway. It can be reliably
prolonged stay at NICU was present in 23 cases (21.9%), recorded even in premature infants of 30 weeks
11 (10.5%) cases had suffered from meningitis while gestational age. It gives an estimate of degree and type of
history of cerebral malaria was present in 2 cases (1.9%), hearing impairment. It is used to localize the site of lesion
history of cerebral palsy was present in 5.7% cases, in patients with hearing loss and vertigo. Threshold
history of seizures was present in 7 cases (6.7%) and in 3 estimation by BERA is used to identify hearing
cases (2.9%) there was history of ototoxic drug intake. impairment in neonates thus facilitating early
Several other risk factors in the history during antenatal, rehabilitation. The existence of peak V is considered as
perinatal and postnatal period were also studied. sound stimulus perceived by the ear.4

International Journal of Otorhinolaryngology and Head and Neck Surgery | May-June 2019 | Vol 5 | Issue 3 Page 681
 Kumari R et al. Int J Otorhinolaryngol Head Neck Surg. 2019 May;5(3):678-682

CONCLUSION 5. Chalak SS, Kale AB, Deshpande VK, Patil CY,

Biswas DA, Sawane MV, et al. BERA in Detection
Hearing loss commonly goes undetected until it affects of Hearing Loss in Children A Retrospective Study
the child’s communication in the form of speech and of its use in Acharya Vinoba Bhave Rural Hospital.
language. This emphasizes the need for newborn JDMIMSU. 2010;5(1):45-8.
screening. Screening programs should not only include 6. Mehl AL, Thomson V. Newborn hearing screening:
newborn screening but screening in later periods also The great omission. Pediatrics. 1998;101:e4.
based on the risk factors. BERA gives an accurate picture 7. Bansal R, Agarwal AK. BERA in high risk children
of hearing sensitivity. Hence, in all high risk babies, a 5 year hearing evaluation. IJO & HNS. 1997: 73-
BERA should be carried out as a routine procedure to 80.
detect hearing impairment. 8. Gupta N. Brain stem evoked response audiometry
(BERA) in patients with severe hearing
Funding: No funding sources impairement. 2008.
Conflict of interest: None declared 9. Lachowska M, Surowiec P, Morawski K, Pierchała
Ethical approval: The study was approved by the K, Niemczyk K. Second stage of universal neonatal
Institutional Ethics Committee hearing screening: a way for diagnosis and
beginning of proper treatment for infants with
REFERENCES hearing loss. Advances Med Sci. 2014;59:90-4.
10. Bhagya V, Brid SV, Doddamani M. Incidence of
1. Tucci DL, Merson MH, Wilson BS. A summary of hearing loss in infants at risk. Int J Biol Med Res.
the literature on global hearing impairment: current 2011;2(4):1102-5.
status and priorities for action. Otol Neurotol. 11. Harvey C. New born hearing screening. Aust Prescr.
2010;31(1):31–41. 2003;26(4):82.
2. Alberti PW, Hyde ML, Riko K, Corbin H, 12. Kumari R, Chakraborty P, Jain RK, Kumar D.
Abramovich S. An evaluation of BERA for hearing Auditory assessment of children with severe hearing
screening in high-risk neonates. Laryngoscope. loss using Behavioural Observation Audiometry
1983;93:1115-21. (BOA) and Brainstem Evoked Response
3. Biswas A. Assessing the deaf child. Clinical Audio‑ Audiometry (BERA). Int J Res Med Sci.
Vestibulometry for Otologists and Neurologists. 3rd 2016;4:2870-3.
ed. Mumbai: Bhalani Publishing House; 2002: 96‑
100.
Cite this article as: Kumari R, Jain RK, Kumar D. A
4. Thirunavukarasu R, Balasubramaniam GK,
study of brainstem evoked response audiometry in
Kalyanasundaram RB, Narendran G, Sridhar S. A
children with severe hearing loss. Int J
study of brainstem evoked response audiometry in
Otorhinolaryngol Head Neck Surg 2019;5:678-82.
high-risk infants and children under 10 years of age.
Indian J Otol. 2015;21:134-7.

International Journal of Otorhinolaryngology and Head and Neck Surgery | May-June 2019 | Vol 5 | Issue 3 Page 682