Prevalência de deficiência auditiva e fatores associados em adolescentes e crianças em idade escolar: uma revisão sistemática

www.bjorl.org

Brazilian

Journal

of

OTORHINOLARYNGOLOGY

REVIEW

ARTICLE

Prevalence

of

hearing

impairment

and

associated

factors

in

school-aged

children

and

adolescents:

a

systematic

review

夽

Aryelly

Dayane

da

Silva

Nunes

_,

_Carla

_Rodrigues

_de

_Lima

_Silva

_,

Sheila

Andreoli

Balen

_,

_Dyego

_Leandro

_Bezerra

_de

_Souza

_,

Isabelle

Ribeiro

Barbosa

a_{UniversidadeFederaldoRioGrandedoNorte(UFRN),ProgramadePós-Graduac¸ãoemSaúdeColetiva,Natal,RN,Brazil} b_{UniversidadeFederaldoRioGrandedoNorte(UFRN),DepartamentodeFonoaudiologia,Natal,RN,Brazil}

c_{UniversidadeFederaldoRioGrandedoNorte(UFRN),DepartamentodeSaúdeColetiva,Natal,RN,Brazil}

d_{UniversidadeFederaldoRioGrandedoNorte(UFRN),FaculdadedeCiênciasdaSaúdedeTrairi(FACISA),SantaCruz,RN,Brazil}

Received3June2018;accepted23October2018 Availableonline1December2018

KEYWORDS Hearingloss; Child; Adolescent; Prevalence; Epidemiologicfactors Abstract

Introduction:Hearingimpairmentisoneofthecommunicationdisordersofthe21stcentury, constitutingapublichealthissueasitaffectscommunication,academicsuccess,andlifequality ofstudents.Mostcasesofhearinglossbefore15yearsofageareavoidable,andearlydetection canhelppreventacademicdelaysandminimizeotherconsequences.

Objective:Thisstudyresearchedscientificliteraturefortheprevalenceofhearingimpairment inschool-agedchildrenandadolescents,withitsassociatedfactors.Thiswasaccomplishedby askingthedefiningquestion:‘‘Whatistheprevalenceofhearingimpairmentanditsassociated factorsinschool-agedchildrenandadolescents?’’

Methods:ResearchincludedthedatabasesPubMed/MEDLINE,LILACS,WebofScience,Scopus andSciELO,andwascarriedoutbytworesearchers,independently.Theselectedpaperswere analyzedonthebasisofthechecklistprovidedbythereportStrengtheningtheReportingof ObservationalStudiesinEpidemiology.

Results:Fromthe463papersanalyzed,26fulfilledthecriteriaandwereincludedinthereview presentedherein.Thedetectionmethods,aswellasprevalenceandassociatedfactors,varied acrossstudies.Theprevalencereportedbythestudiesvariedbetween0.88%and46.70%. Oto-logicandnon-otologicfactorswereassociatedwithhearingimpairment,suchasmiddleearand airpassageinfections,neo-andpost-natalicterus,accumulationofcerumen,familyhistory, suspicionofparents,useofearphones,ageandincome.

夽 _{Pleasecitethisarticleas:NunesAD,SilvaCR,BalenSA,SouzaDL,BarbosaIR.Prevalenceofhearingimpairmentandassociatedfactors}

inschool-agedchildrenandadolescents:asystematicreview.BrazJOtorhinolaryngol.2019;85:244---53.

∗_{Correspondingauthor.}

E-mail:aryellydayane@gmail.com(A.D.Nunes).

https://doi.org/10.1016/j.bjorl.2018.10.009

1808-8694/©2018Associac¸˜aoBrasileiradeOtorrinolaringologiaeCirurgiaC´ervico-Facial.PublishedbyElsevierEditoraLtda.Thisisanopen

Prevalenceofhearingimpairmentandassociatedfactorsinchildrenandadolescents 245

Conclusion: Thereisheterogeneityregardingmethodology,normalitycriteria,andprevalence andriskfactorsofstudiesabouthearinglossinadolescentsandschool-agedchildren. Never-theless,therelevanceofthesubjectandthenecessityofearlyinterventionsareunanimous acrossstudies.

© 2018 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Published by Elsevier Editora Ltda. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/). PALAVRAS-CHAVE Perdaauditiva; Crianc¸a; Adolescente; Prevalência; Fatores epidemiológicos

Prevalênciadedeficiênciaauditivaefatoresassociadosemadolescentesecrianc¸as emidadeescolar:umarevisãosistemática

Resumo

Introduc¸ão: Adeficiênciaauditivaéumdosdistúrbiosdecomunicac¸ãodoséculoXXI,constitui umproblemadesaúdepública,poisafetaacomunicac¸ão,osucessoacadêmicoeaqualidade devidadosestudantes.Amaioriadoscasosdeperdaauditivaantesdos15anoséevitávelea detecc¸ãoprecocepodeajudaraevitaratrasosacadêmicoseminimizaroutrasconsequências.

Objetivo: Esteestudoinvestigoualiteraturacientíficasobreaprevalênciadadeficiência audi-tivaemcrianc¸aseadolescentesemidadeescolar,comseusfatoresassociados.Issofoifeito através daquestão norteadora: ‘‘Qual a prevalência dadeficiência auditivae seus fatores associadosemcrianc¸aseadolescentesemidadeescolar?’’

Método: ApesquisacompreendeuasbasesdedadosPubMed/MEDLINE,LILACS,WebofScience, ScopuseSciELOefoifeitadeformaindependentepordoispesquisadores.Osartigos seleciona-dosforamanalisadoscombasenalistadeverificac¸ãofornecidapelorelatórioStrengthening theReportingofObservationalStudiesinEpidemiology.

Resultados: Dos463artigosanalisados,26preencheramoscritérioseforamincluídosnarevisão aquiapresentada.Osmétodosdedetecc¸ão,assimcomoaprevalênciaeosfatoresassociados, variaramentreosestudos.Aprevalênciarelatadapelosestudosvariouentre0,88%e46,70%. Fatoresotológicosenãootológicosforamassociadosàdeficiênciaauditiva,comoinfecc¸õesda orelhamédiaedasviasaéreas,icterícianeonatalepós-natal,acúmulodecerúmen,histórico familiar,suspeitadospais,usodefonesdeouvido,idadeerenda.

Conclusão:Háheterogeneidadequantoàmetodologia,aoscritériosdenormalidadee, conse-quentemente,àprevalênciaeaosfatoresassociadosnosestudossobredaperdaauditivaem adolescentesecrianc¸asemidadeescolar.Noentanto,arelevânciadoassuntoeanecessidade deintervenc¸õesprecocessãounânimesentreosestudos.

© 2018 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Publicado por Elsevier Editora Ltda. Este ´e um artigo Open Access sob uma licenc¸a CC BY (http:// creativecommons.org/licenses/by/4.0/).

Introduction

Inthe21stcentury,communicationdisorders(whichinclude hearingimpairment,HI)constituteaseriousconcernwithin public health; if not treated, there are negative effects on the economic well-being of a society in the era of communication.1 _{The problemdeservestobehighlighted,}

asthesenseofhearingisessentialforthedevelopmentof speech,languageandlearning,2_{andthehigherthedegreeof}

hearingimpairment,thegreaterthedifficultiesin perceiv-inganddistinguishingspeech,includinglanguagedeficits.3

In children under the age of 15, 60% of hearing loss occur due to avoidable causes,4 _{and estimates indicate}

that 1.1 billionpeople around the world couldbe at risk for hearing impairment due to unsafe hearing practices, such asthe use of individual audio devices.5 _Adolescents

deservecloseattention,astheyareexposedtohighlevelsof non-occupational noise.5,6 _{Some factors associated with}

hearing impairment include infections of the superior air passages7 _{and middle ear,}8---10 _{in addition tothe presence}

ofcerumenobstructingtheexternalacousticmeatus,9---11_as

thesecaninterfereinthetransmissionofthehearing stim-ulus.However,despite the factthat thecauses of HIcan beidentifiedinchildrenandadolescents,dataarelimited regardingpossibleriskfactorsforacquiredHI.8

EarlydetectionofHIcanhelppreventacademicdelays,10

besidesbeingadeterminantforproductivityandlifequality ofthepotentialbearerofHI.12_{Auditorytestsareindicated}

fortheearlydetectionofhearingdisorders.7_Thereforethe

needordeeperknowledgeontheprevalenceandassociated factorsforhearingimpairmentinschool-agedindividualsis evident.Preventionandinterventionactionscouldthenbe carriedouttominimizethenegativeconsequencesofHIin thelifeofindividuals.Theobjectiveofthisstudyistocarry outasystematic review in thescientific literatureonthe

prevalenceofhearingimpairmentanditsassociatedfactors inschool-agedindividuals.

Methods

Asystematicliteraturereviewwascarriedout,guidedbythe question:‘‘What is theprevalence of hearingimpairment anditsassociatedfactorsinschool-agedchildrenand ado-lescents?’’ThedatabasesconsultedwerePubMed/MEDLINE, LILACS, Web of Science, Scopus and SciELO. The main descriptors related to the investigated subject were crossed:‘‘prevalence’’,‘‘epidemiology’’,‘‘cross-sectional studies ‘‘hearing’’, ‘‘hearing loss’’, ‘‘hearing disorders’’, ‘‘schoolhealth services’’,‘‘schoolhealth’’, ‘‘child’’,and ‘‘adolescent’’, as shown by the strategies depicted in

Table1.

The review included only the studies that were cross-sectional and presented the prevalence of hearing impairmentinchildrenand/oradolescents.Othertypesof studiesorformatswereexcludedaswellascross-sectional studiesthat included children and/or adolescents butdid notpresentaspecificprevalenceforthispopulation. Biblio-graphicdatacompilationoccurredonApril10,2018,based on the aforementioned inclusion criteria. The first phase of theselection of papers wasthe exclusion of duplicate studies,followedbythe readingandanalysisoftitlesand abstracts of all identified papers. The next stepwas the completereadingoftheselectedstudies,whichledtothe exclusionof papersthatwerenotalignedwiththereview proposal.Thebibliographies ofthepapersidentifiedwere analyzedtoidentifypossible additionalstudiesthat could beaddedtothereviewpresentedherein.

The selected papersunderwent methodological assess-ment in accordance with the checklist provided by Strengthening the Reporting of Observational Studies in Epidemiology(STROBE)13_{forcross-sectionalstudies,}

receiv-ing the value 1 when the item was contemplated, 0 when not contemplated and 0.5 when partially contem-plated. All phases were carried out by the two first authors/researchers, independently. The study presented hereinonlyincluded thepapersthat reachedat least60% of the scoredetermined by the STROBE checklist, witha cutoffpointestablishedtoensuregoodmethodological qual-ity. Papers that did not meet the cutoff threshold were excluded. All procedures of the review presented herein were conducted in accordance with the checklist of the ReportingItemsfor SystematicReviewsandMeta-Analyses (PRISMA).

Results

A total of 463 papers were identified, which approached theprevalenceof hearingimpairmentinschool-aged chil-drenand/oradolescents.Afterallthemethodologicalsteps, 26paperswereincluded(Fig.1),withadescriptionofthe methodologicalqualityshowninTable2.Thepapers investi-gateddifferentpopulations,agegroups,hearingimpairment diagnosiscriteriaandmethods,revealing heterogeneityin theresults.

The studies evaluated different age groups, and eight papers included age groups beyond children and

adolescents.11,12,14---19 _{There was variation in the}

diagnos-tic methods and normality criteria across the selected studies. Some studies utilized the auditory threshold as screening procedure,9,11,12,15,16,18,19---28 _{automated auditory}

threshold,8,17,29,30 _{audiometric screening,}14,31 _and

audio-metricdiagnosis at somepoint.10,32,33 _{Regardingnormality}

criteria, there were differences even among those that utilized the sametechnique, either auditory thresholdor scanning,andsomestudiespresentedasetofproceduresto indicatetestnormality.Duetothesedifferences,therewas variationintheprevalencevaluesencountered.Most stud-iesdidnotprovidetherespectiveconfidenceintervals(CI) (Table3),andsomestudiesanalyzedprevalencethrough dif-ferentcriteriaand/orassessedawideragegroupthatwhat wasincludedherein,presentingCIforsomecriteria.

Similarly, the study of associated factors was not homogeneous. Seven studies did not include analy-sis of associated factors besides prevalence of hearing impairment,16,22,24,26,27,29,33_{andsevenstudiesincluded}

anal-ysis, but it wasnotspecific for theage group of children and/oradolescents.11,12,14,15,17---19_{Duetothelownumberof}

studiesthatevaluatedassociatedfactors,thecauses estab-lishedbythestudieswereindicatedasassociatedfactorsin

Table3.

Discussion

Twenty-sixpaperswereselectedforsystematicreview,but therewassignificantvariationintheidentificationmethod forhearingimpairment,normalitycriteriaandinvestigated age groups, which consequently led to variability in the prevalenceanditsassociatedfactors.

Thelowestprevalenceencounteredwas0.88%21_andthe

highestwas46.7%.33_{Whilesomestudiesincludeddiagnosis}

assessment,7,10,32 _{othersconsidered incapacitatinghearing}

loss.11,12,15,16,18_{Somestudiesappliedquestionnaires,}9,26,32,33

butwithdifferentobjectives.Questionnaireswereapplied with parents9,26,32 _{and school-aged individuals, to}

investi-gatepotentialcausesofhearingchanges26 _{andriskfactors}

forHI32_{suchashealthhistory,}9_{possiblepresenceofbuzzing}

andlearningdifficulties.26_{However,oneofthestudieshad}

the objectiveof developing a questionnaireasa low-cost toolforauditoryscreening.33

The prevalences found in the studies varied according tomethod, age group andnormality criterion established by the authors and population under study; there was also variability in the study of risk factors associated with HI. Considering the studies that focused on eval-uating children and/or adolescents, and considering the age group ‘‘children’’ limited to 12 years of age, it was verifiedthat the same number of studies considered children,21,25,26,28,29,32,33 _{andboth age groups(children and}

adolescents),7,9,10,20,22,27,31_{withlimitedspecificresearchon}

adolescents.8,23,24,30 _{It must be highlighted that the age}

rangeswithintheagegroups werenotthesame,norwere thesamplingcriteriaforeachstudy.

Some studies mixed preschoolers with school-aged individuals,10,12,15,19,22,31,33_{andwithinthesestudiesthemost}

common causes for hearing impairment were impacted cerumen10,31 _{and infections}31 _{such as otitis media.}10,31 _In

Prevalenceofhearingimpairmentandassociatedfactorsinchildrenandadolescents 247

Table1 Searchstrategyfortheselecteddatabases.

Pubmed ((((prevalenceandepidemiology))ANDcross-sectionalstudies)AND(hearing lossorhearing))AND(childoradolescent)(schoolhealthservicesorschool health)

Webofscience (TS=(prevalence)ANDTS=(Hearinglossorhearing)ANDTS=(cross-sectional studies)ANDTS=(childoradolescent))

Scopus ALL(prevalence)ANDALL(‘‘cross-sectionalstudies’’)ANDALL(‘‘hearingloss’’ OR‘‘hearingdisorders’’)ANDALL(‘‘schoolhealthservices’’OR‘‘school health’’)ANDALL(childORadolescent)

Lilacs ‘‘PérdidaAuditiva’’OR‘‘hearingloss’’OR‘‘perdaauditiva’’[Words]and PrevalênciaORPrevalenciaORPrevalence[Words]andCrianc¸aORNi˜noOR child[Words]

Scielo ((prevalenceAND(‘‘hearingloss’’ORhearing)))AND(childORadolescent)

503 reports identified in the searched

databases 03 reports identified in other sources

463 reports after elimination of duplicates

Selection

Identification

Elegibility

Inclusion

463 tracked reports 417 reports excluded

46 full-text papers evaluated

26 studies included

20 full-text papers excluded: other designs (2) self-reported HI (1)

pre-school population (3) no data on the studied age

group (1) fulfils up to 60% of the

STROBE criteria (13)

Figure1 Flowchartofpaperselection.

46.7%.33 _{These higher values could be explained by the}

diagnosiscriterionutilized,whichbesidesaudiometry,also consideredTypeAtympanogramandthepresenceof acous-ticreflexes.Also,thereweregroupsofchildrenwithhigher prevalence ofconductive alterations,such asdiagnosisof conductivelossin84.4%10_{ofthechildrenwithHI.However,}

thestudy that comparedtwoage groups withinthe same populationfoundsimilarprevalence:1.3%fortheagegroup 4---9yearsold,and1.4%fortheagegroup10---19yearsold, fromtheanalysisofthebestear.16

Thenormalitycriterionemployed,thenumberof school-aged individuals included and/or the selected population couldhave causedsuchdiscrepancies, asthe maincauses ofHIfor youngerindividuals areconductivefactors--- oti-tismediawitheffusion (agegroup 4---8years old),10 _otitis

mediawitheffusion,associatedwithauditorytube dysfunc-tionandadenoiddysplasia(agegroup4---10yearsold).11_The

studythatencounteredthelowestprevalenceevaluateda specific group of school-aged individuals, withthe objec-tiveofestablishingHIprevalencein thosewhounderwent neonatalauditoryscreening.Forthisreason,thosethatdid

notundergoscreening or thosealreadydiagnosed withHI wereexcluded.23_{Thestudiesdidnotpresentdeep}

discuss-ionsontheetiology,possiblybecausetheresultsoriginate fromprevalencestudiesandnotfromdiagnostic investiga-tion.Itisimportanttostudynotonlythefactorsthatlead tohearingimpairment,butalsothegeneticcauses.

TheriskfactorsforHIinchildrenandadolescentscanbe otologic or non-otologic.9 _{The consulted studies revealed}

different factors associated with HI such as suspicion of parents,32 _{poorer shortterm phonologicmemory,}21 _{use of}

personalelectronicdevices,23_{middleearinfections,}8---11,18,31

infectionssuchasmeasles,meningitis,mumpsandmaternal Germanmeasles,31_{tubedysfunction,}7,9_cerumen,9---11,14,18,20

tympanicmembraneabnormalities,9,10_neonatal9_and

post-natal32_{icterus,convulsions,andhospitalization.}9_Ontheday

oftheevaluation,self-reportedassociatedsignswerealso included, suchassinusitis, cold, earache anduse of ven-tilationtube.20 _{Low socioeconomic level,}18,32 _income,8,9,15

educationlevel12,15_{andlowmaternaleducationlevel}28_were

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Table2 Methodologicalqualityofthestudiesincluded,inaccordancewiththeSTROBEchecklist.

Reference TA SJ O SD S P V DM B SS QV SM P DD O MR OA MR L I G F Total Al-Rowailyetal.(2012) 1 0.5 1 1 1 1 1 1 0 1 1 0.5 1 0.5 1 1 0 1 1 0.5 1 0 17 Al-Khaborietal.(2004) 1 1 1 1 0.5 1 0.5 0.5 0 1 0 0 1 1 1 1 0 1 0.5 0.5 0 1 14.5 Balenetal.(2009) 1 1 1 0.5 1 1 1 0.5 0 1 1 0.5 1 1 1 0.5 0 1 0 0.5 0 1 15.5 Barakyetal.(2012) 1 1 1 1 1 1 1 1 0.5 1 1 1 1 1 1 1 0 1 0 1 1 1 19.5 Bériaetal.(2007) 1 1 1 1 1 1 1 1 0 1 1 1 1 1 1 1 1 1 1 1 0.5 1 20.5 Bevilacquaetal.(2013) 1 0.5 1 1 1 1 1 1 0 1 0.5 0 1 1 1 0.5 0 1 0 0.5 0.5 1 15.5 Chenetal.(2011) 0.5 0.5 1 1 1 0.5 1 1 0 0.5 1 1 1 1 0.5 0.5 0 1 1 1 1 1 17 Czechowiczetal.(2010) 1 1 1 1 0.5 1 1 1 0 0.5 1 1 1 1 1 1 0 1 0 1 0.5 1 17.5 Federetal.(2017) 1 0.5 1 0.5 0.5 1 1 1 0 1 1 0.5 0.5 1 0.5 0.5 0 1 1 1 1 1 16.5 Giereketal.(2009) 0.5 1 1 0 1 1 1 1 0 0 1 1 0.5 1 1 1 1 1 0 0.5 0.5 1 16 Gondimetal.(2012) 1 1 1 1 1 1 1 1 0.5 1 1 0.5 1 1 1 1 0 1 0 0.5 0 0 16.5 Govenderetal.(2015) 1 1 1 1 1 1 0.5 1 0 1 0.5 1 0.5 1 1 1 0 1 0 1 0.5 0 16 Hongetal.(2016) 1 1 1 1 1 1 1 1 0 0.5 1 1 1 1 1 1 0 1 1 1 0.5 0 18 Junetal.(2015) 1 1 1 1 1 0.5 1 1 0 0.5 0.5 1 1 1 1 1 0 1 1 1 1 1 18.5 Kametal.(2013) 1 1 1 1 0.5 0.5 0.5 1 0 0 0 1 1 1 1 1 0 1 1 0 0 1 14.5 leClercqetal.(2017) 1 1 1 0.5 1 1 1 1 0 1 1 1 1 1 1 1 0 1 1 1 1 1 19.5 Niskaretal.(1998) 0.5 1 0.5 1 0.5 1 0.5 1 0 0.5 1 1 1 1 1 1 0 1 1 1 1 1 17 Rammaetal.(2016) 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 21 Samellietal.(2011) 0.5 1 1 0.5 0.5 0.5 1 1 0 0 1 1 1 1 1 1 1 1 1 1 1 1 18 Serraetal.(2014) 0.5 1 1 0 0.5 0.5 1 0.5 0 0 0.5 1 1 1 1 1 0 1 0.5 1 0.5 1 14.5 Shargorodskyetal.(2010) 1 1 1 1 1 0.5 1 1 0 0 1 1 1 1 1 1 0 1 1 1 0.5 1 17

Skarzy´nskietal.(2016) 0.5 1 1 0 0 0.5 0.5 1 0 0 0.5 1 1 1 0.5 1 0 1 0 1 1 1 13.5

Tahaetal.(2010) 0.5 1 0 0 1 0.5 1 1 0 0 1 1 1 1 1 1 0 1 0.5 1 1 0 14.5

Tarafderetal.(2015) 1 1 1 1 0.5 1 1 1 0 1 1 1 1 1 1 1 0 1 1 0.5 0.5 1 18.5

Wakeetal.(2006) 1 1 1 1 1 1 1 1 0 1 0.5 1 1 1 1 1 0 1 1 1 1 1 19.5

Westerbergetal.(2005) 1 1 1 1 0.5 1 1 1 0 1 0.5 0 1 1 1 1 0 1 1 1 0.5 1 17.5

TA,titleandabstract;SJ,setting/motivation;O,objectives;SD,studydesign;S,settings;P,participants;V,variables;DM,datasource/measurement;B,bias;SS,sizeofsample;QV, quantitativevariables;SM,statisticmethods;P,participants;DD,descriptivedata;O,outcome;MR,mainresults;OA,otheranalyses;MR,mainresults;L,limitations;I,interpretation; G,generalization;F,funding.

P revalence of hearing impairment and associated factors in children and adolescents 249

Table3 Characteristicsoftheincludedstudies,withmethodologicalqualityevaluatedinaccordancewiththeSTROBEchecklistcriteria.

Reference City/country Sample/population Diagnosismethod Normalitycriterion PrevalenceofHI FactorsassociatedwithHI Al-Rowaily etal.(2012) KingAbdulaziz MedicalCity, SaudiArabia 2574(4---8 years)

Auditorythreshold1,2and 4kHza

20dB 1.75%(1.25---2.25) otitismedia,cerumen,

chronicotitismedia, sensorineuralhearingloss, tympanicperforationb Al-Khabori etal.(2004) Oman 11,400 individualsc Screeningat1,2and4kHz >25dB Immediatere-testat35dB 0---9years,16.7% (12.71---20.76) Cerumen,presbycusis, infectionsb,d 10---19years,33.3% (27.63---38.91) Balenetal. (2009) Itajaí,Brazil 419(0---14 years) 4---14years:Auditory thresholdat1,2and4kHz, acousticreflexesand tympanometry

>15dBforbestear 16.84% Associatedfactorsnot includedinthestudy.

Barakyetal. (2012) JuizdeFora, Brazil 267(4---19 years) Otoscopy Auditorythresholdat1,2 and4kHz Questionnaire

Incapacitatinghearingloss (WHO)

3.03%(8---267) Buzz,>60years,low educationleveld Bériaetal. (2007) Canoas,Brazil 776(4---19 years) Auditorythresholdat1,2 and4kHz

Incapacitatinghearingloss (WHO)

4---9years:12%;10---19 years:7.1%

Incomeandeducationleveld Incapacitating: 4---9years:5.3%;10---19 years:2.2% Bevilacqua etal.(2013) MonteNegro, Brazil 577individualsc _Otoscopy Auditorythresholdat1,2at 4kHz 0---29dBnocompromise; 30---40dBslight;41---60dB moderate;61---80dBsevere; >80dBprofound 3.8%(2.17---5.45) incapacitating

Associatedfactorsnot includedinstudy. Chenetal. (2011) Xi’na,China 1567(12---19 years) Otoscopy Auditorythreshold0.25kHz to8kHz Tympanometry Auditorythreshold (500---4000Hz)>25dB

3.32%eardisease(30---1567) Gender,useofportable audiodevices,ototoxic drugs,HIFamilyhistory Czechowicz etal.(2010) Limadistrict, Peru 355(6---19 years) Pneumaticotoscopy Auditorythreshold0.25, 0.5,1,2,4,8kHz Tympanometry

Academicperformanceand questionnaireappliedwith responsibleadult

>25dB 6.9%(4.2%---9.6%) Income,poverty.

Neonatalicterus, hospitalization,recurrent middleearinfections,HI Familyhistory<35years, tympanicmembrane abnormality,impacted cerumen,tubedysfunction Federetal. (2017) Canada 1879(6---19 years) Auditorythresholdat 0.5kHzto8kHz

>20dB 4.7% Associatedfactorsnot

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Table3(Continued)

Reference City/country Sample/population Diagnosismethod Normalitycriterion PrevalenceofHI FactorsassociatedwithHI EOAPD >26dBand‘‘passing’’in

threeoutoffourtest frequencies(2,3,4and 5kHz)withSR6dB Giereketal. (2009) UpperSilesia, Poland 8885(6---14 years) Screeningat1,2and4kHz Speechinnoise

Testwithfiguresandtest withwordsa

25dBNA 10.3%failed Dysfunctionofauditory

tubesduetoupperairway infection

90%correct;75%correct 6%confirmedHI Gondimetal.

(2012)

Itajaí,Brazil 35(4---9years) Questionnaire Otoscopy

Auditorythresholdat1,2 and4kHz

Tympanometry Acousticreflexes

Incapacitatinghearingloss (WHO)

2.86% Presbycusis,idiopathy,

cerumen,chronicotitis media,otosclerosis,noise inducedhearingloss, labyrinthopathy.b,d Govenderetal. (2015) Durban,South Africa 241(1styear students) Otoscopy Tympanometry Auditorythresholdat0.5, 1,2and4kHz

20dBNA 24% Thestudiedfactorsdidnot

presentstatistical significance Hongetal. (2016) Korea 1534(13---18 years) Automatedauditory thresholdat0.5kHzto6kHz

>25dB0.5,1,2and3kHz 2.2%(1.3---3.7)unilateral Age,tympanometry, income,useofearphones withthresholds>20dBin highfrequencies 0.4%(0.2---0.9)bilateral Junetal. (2015) SouthKorea 2033(12---19 years) Automatedauditory threshold0.5to6kHz HIspeechfrequency: thresholdsat0.5,1,2,3, 4kHz_≥25dBNA

Unilateral:2.18%(_±0.48) Age,sex

Bilateral:0.34%(±0.13) HIhighfrequency: thresholdsat3,4,6kHz≥ 25dBNA Unilateral:2.81%(±0.55) Bilateral:0.83%(_±0.25) Kametal. (2013) Shenzhen, China 325(6---10 years) Automatedauditory thresholdat1,2and4kHz

>25dB 4.92% Associatedfactorsnot

includedinstudy. leClercqetal. (2017) Rotterdam, Netherland 5368(9---11 years) Auditorythresholdat 0.5kHzto8kHz Tympanometry

>15dB 17.50% OMandlowmaternal

educationlevels Niskaretal. (1998) EUA 6166(6---19 years) Auditorythresholdat 0.5kHzto8kHz

>15dB 14.9% Cold,sinusitis,earache,

ventilationtube, self-reportedonthe evaluationday

P revalence of hearing impairment and associated factors in children and adolescents 251 Table3(Continued)

Reference City/country Sample/population Diagnosismethod Normalitycriterion PrevalenceofHI FactorsassociatedwithHI Rammaetal. (2016) CapeTown, SouthAfrica 1000(4---19 years) Auditorythresholdat 0.25kHzto8kHz

>25dB 4---9(4.3%);10---19(2.6) Malesex,age,

hypertension,historyof cranioencephalictrauma, andHIfamilyhistory.b Samellietal.

(2011)

Butantã,Brazil 214(2---10 years)

Auditoryassessmenta _{>15dB,tympanogram,} presenceofacoustic reflexes

46.7% Associatedfactorsnot

includedinthestudy. Serraetal. (2014) Córdoba, Argentina 172(14---15 years) Auditorythreshold 0.25---8kHz;8---16kHzTOAE 18dB;reproductivity:>70% SNR;>6dBin3frequencies

34.88% Associatedfactorsnot

includedinstudy. Shargorodsky etal.(2010) USA Cycle 1988---1994: 1771(12---19 years) Automatedhearing thresholdat0.5---8kHz. Noise-inducedthreshold shift

Worstear:discretebetween 15and25dBNA,slightor higher>25dBNA

Cycle1988---1994:14.9% (13.0---16.9)

Race/Ethnicity Povertyrate/income 3+middleearinfections Cycle 2005---2006: 2288(12---19 years) Cycle2005---2006:19.5% (15.2---23.8) Skarzy´nski etal.(2016) Tajikistan, Poland

143(7---8years) Auditorythreshold, questionnaires(parentsand children)

25dB 23.7% Associatedfactorsnot

includedinstudy. Tahaetal. (2010) ShebinEl-Kom District,Egypt 555(6---12 years) Audiometricscreening, questionnairea

20dB 20.9% Suspicionofparents,otitis

media,consumptionof tobaccoathome,low socio-economiclevel,and post-natalicterus. Tarafderetal. (2015) Bangladesh 899(5---14 years) Auditorythreshold0.5,1,2, 4kHz;EOAT 30dB 13% Age,socioeconomic

deprivation,familyhistory, impactedearwax,chronic suppurativeotitismedia, otitismediawitheffusion, andexternalotitis Wakeetal. (2006) Melbourne, Australia 6581(=∼7---12 years) Auditorythreshold0.5,1 and2kHzor3,4and6kHz >40dB bestear

0.88%(0.66---1.15) Poorershortterm phonologicalmemory Westerberg etal.(2005) Manicaland, Zimbabwe 5528(4---20 years) Auditoryscreeningat1,2 and4kHz >30dB 2.4%(2.0---2.8) Impactedcerumen, infectionsb

a _{Thisstudyincludesdiagnosticauditoryassessment.}

b _{Thesestudiesdidnotincludeanalysisofassociatedfactors,onlyanalysisofthecauses.} c _{Thesestudiesdidnotincludespecificagegroupsforchildren/adolescents.}

caseoflimitedaccesstopediatriccare,constitutean impor-tantriskfactorforHI.

Variationintheprevalenceamongadolescentswas veri-fiedherein,dependingonthenormalitycriterionutilized,as somestudiesanalyzedincapacitatinghearingloss,11,12,15,16,18

whileothersincludedfrequenciesover4kHzinthenormal hearing criterion,7---9,17,19,24,27,30 _{evidencingthe importance}

ofevaluatinghighfrequenciesinthisgroup.Thefourstudies thatfocused onadolescentsasmaininvestigatedsubjects were carried out within the last decade, and the preva-lencefoundvariedbetween2.2%30_and34.88%.24_Thehighest

prevalencecanbeexplainedbytheinclusionoffrequencies over8kHzandevokedoptoacousticemissions.Itispossible thatthisoccurredduetonoiseexposurewhenusingpersonal devices,17,23_{astheuseofear-andhead-phonesiscommon,}

withoutconcernsregardingtheexposurelevelsorduration.6

The use ofmedia technologiesmust behighlighted, as wellasthehabitoflisteningtomusicwithear-and head-phones, which occurs progressively earlier in life,34 _and

thereforeitiscommontobeprecociouslyexposedtohigh levelsof noise. A study involving school-aged individuals, agedbetween 6 and 14 years oldin Poland, investigated loweredthresholdsin high frequencies--- 6---8kHz, altered in 17.8% of the sample, being the influence of noise the most probable factor for suchchange.7 _{It is important to}

mentionthattheclassificationsforhearinglossgenerallydo notincludehighfrequencies,suchastheclassification pro-posedbythe WHO andemployedinsome ofthe included studies.9,12,15 _{Some of the screenings carried out did not}

includehighfrequencies,andthereforemightnothave evi-dence the beginning of noise-inducedhearing loss, which surelypresents high incidence in this specific population, asrevealedbytheincreaseinHIprevalenceinadolescents over a time interval of almost ten years.8 _{There was an}

associationbetweentheuseofear-andhead-phonesand academic issues,9 _{highlighting the importanceof auditory}

healthinterventions.

Overall,itisdifficulttocomparetheprevalences encoun-teredindifferentstudies,19 _{asdemonstratedintheresults}

presentedherein.Besidestheheterogeneityofthemethods employed to detect and classify HI in school-aged chil-dren and adolescents, the life context and the health of thispopulationisdiverse,andsoaretheauditorychanges experienced by younger and older children.15 _These

fac-tors interfere with HI prevalence, constituting the main limitationofthestudypresentedherein.Despitethe hetero-geneityofmethods,prevalenceanditsassociatedfactors, HIis an important factor thatcompromises the academic developmentandperformanceofchildrenandadolescents.

Conclusion

There is heterogeneity regarding methodology, normal-ity criteria, and consequently, regarding prevalence and itsassociated factors. Nevertheless, therelevance of the subjectandthenecessityofearlyinterventionsare unani-mousacrossstudies.Morestudiesarerequired,locallyand globally,toinvestigatethecorrelationbetweenthe associ-atedfactorsandhearingimpairmentinthispopulation,so that auditory health interventionsand public policies are

progressivelymoreassertiveanddirectedtothenew neces-sitiesofthisgeneration.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

References

1.RubenRJ.Redefiningthesurvivalofthefittest:communication disordersinthe21st_{century.Laryngoscope.2000;110:241---5.}

2.Regac¸oneSF,Guc¸ãoACB,FrizzoACF.Eletrofisiologia: perspec-tivasatuaisdesuaaplicac¸ãoclínicaemfonoaudiologia.Verba Volant.2003:1---20.

3.Oliveira PS, Penna LM, Lemos SMA. Language develop-mentandhearing impairment:literaturereview.Rev CEFAC. 2015;6:2044---55.

4.World and Health Organization [WHO Web site]. Deafness

and hearing loss; 2013. Available at: http://www.who.int/

mediacentre/factsheets/fs300/en/[accessed23.02.17].

5.World and Health Organization [WHO Web site]. Hearing

lossdue to recreational exposure to loud sounds:a review;

2015. Available from: http://apps.who.int/iris/bitstream/

10665/154589/1/9789241508513eng.pdf[accessed22.09.17]. 6.MarquesAPC,FilhoALM,MonteiroGTR.Prevalenceofhearing lossinadolescentsandyoungadultsasaresultofsocialnoise exposure:meta-analysis.RevCEFAC.2015;6:2056---64.

7.Gierek T, Gwó´zd´z-Jezierska M, Markowski J, Witkowska M.

Theassessmentofhearingorganofschoolchildrenin Upper

Silesiaregion.IntJPediatrOtorhinolaryngol.2009;73:1644---9,

http://dx.doi.org/10.1016/j.ijporl.2009.08.009.

8.Shargorodsky J, Curhan SG, Curhan GC, Eavey R. Change in prevalence of hearing loss in US adolescents. JAMA. 2010;18:772---8.

9.Czechowicz JA, Messner AH, Alarcon-Matutti E, Alarcon J, Quinones-CalderonG,MontanoS,etal.Hearingimpairmentand poverty:theepidemiologyofeardiseaseinPeruvian schoolchil-dren.OtolaryngolHeadNeckSurg.2010;142:272---7.

10.Al-RowailyMA,AlFayezAI,AlJomieyMS,AlBadrAM,Abolfotouh MA.HearingimpairmentsamongSaudipreschoolchildren.IntJ PediatrOtorhinolaryngol.2012;76:1674---7.

11.GondimLM, BalenSA,Zimmermann KJ, PagnossinDF,Fialho IdeM,RoggiaSM.Studyoftheprevalenceofimpairedhearing anditsdeterminantsinthecityofItajaí,SantaCatarinaState, Brazil.BrazJOtorhinolaryngol.2012;78:27---34.

12.BarakyLR,BentoRF,RaposoNR,Tibiric¸áSH,RibeiroLC,Barone MM,et al.DisablinghearinglossprevalenceinJuizde Fora, Brazil.BrazJOtorhinolaryngol.2012;78:52---8.

13.VandenbrouckeJP,vonElmE,AltmanDG,GøtzschePC,Mulrow CD,Pocock SJ,et al. Strengthening theReporting of Obser-vational Studies in Epidemiology (STROBE): explanation and elaboration.PLoSMed.2007;16:e297.

14.AlKhaboriM,KhandekarR.Theprevalenceandcausesof hear-ingimpairment in Oman:a community-based cross-sectional study.IntJAudiol.2004;43:486---92.

15.BériaJU,RaymannBC,GiganteLP,FigueiredoAC,JotzG, Roith-manR,etal.Hearingimpairmentandsocioeconomicfactors:a population-basedsurveyofanurbanlocalityinsouthernBrazil. RevPanamSaludPublica.2007;21:381---7.

16.BevilacquaMC,BanharaMR,OliveiraAN,MoretALMN,Alvarenga KF,CaldanaML,etal.Surveyofhearingdisordersinanurban population inRondonia, Northern Brazil.Rev SaúdePública. 2013;47:309---15.

17.Jun HJ, Hwang SY, Lee SH, Lee JE, Song JJ, Chae S. The prevalence of hearing loss in South Korea: data from a population-basedstudy.Laryngoscope.2015;125:690---4.

Prevalenceofhearingimpairmentandassociatedfactorsinchildrenandadolescents 253

18.TarafderKH,AkhtarN,ZamanMM,RaselMA,BhuiyanMR,Datta PG.Disablinghearingimpairmentin theBangladeshi popula-tion.JLaryngolOtol.2015;129:126---35.

19.RammaL,SebothomaB.Theprevalenceofhearingimpairment withintheCapeTownMetropolitanarea.SAfrJCommunDisord. 2016;8:63.

20.NiskarAS,KieszakSM,HolmesA,EstebanE,RubinC,BrodyDJ. Prevalenceofhearinglossamongchildren6---19yearsofage:the ThirdNationalHealthandNutritionExaminationSurvey.JAMA. 1998;8:1071---5.

21.WakeM,TobinS,Cone-WessonB,DahlHH,GillamL,McCormick L,etal.Slight/mildsensorineuralhearinglossinchildren. Pedi-atrics.2006;118:1842---51.

22.BalenSA,DebiasiTF,PagnossimDF,BrocaVS,RoggiaSM,Gondim LM.Caracterizac¸ãodaaudic¸ãodecrianc¸asemum estudode basepopulacionalnomunicípiodeItajaí/SC.ArqInt Otorrino-laringolIntlArchOtorhinolaryngol.2009;4:372---80.

23.ChenY,LiX,XuZ,LiZ,ZhangP,HeY,etal.Eardiseasesamong secondaryschoolstudentsinXi’an,China:theroleofportable audiodeviceuse, insomnia and academicstress.BMC Public Health.2011:8.

24.SerraMR,BiassoniEC,HinalafM,AbrahamM,PavlikM,Villalobo JP,etal.Hearingandloudmusicexposurein14---15yearsold adolescents.NoiseHealth.2014;16:320---30.

25.GovenderS,LatiffN,AsmalN,RamsaroopS,MbeleT. Evaluat-ingtheoutcomesofahearingscreeningserviceforgradeone learnersinurbanareasatDurban,SouthAfrica.JPublicHealth Afr.2015;13:52---6.

26.Skarzy´nskiPH, ´SwierniakW,PiłkaA,Skar˙zynskaMB,Włodarczyk AW,KholmatovD,etal.Ahearingscreeningprogramfor chil-dreninprimaryschoolsinTajikistan:atelemedicinemodel.Med SciMonit.2016;12:2424---30.

27.FederKP,MichaudD,McNameeJ,FitzpatrickE,Ramage-MorinP, BeauregardY.Prevalenceofhearinglossamongarepresentative sampleofCanadianchildrenandadolescents,3to19yearsof age.EarHear.2017;38:7---20.

28.leClercqCMP,vanIngenG,RuytjensL,GoedegebureA,Moll HA,RaatH,etal.Prevalenceofhearinglossamongchildren9 to11yearsold:thegenerationRstudy.JAMAOtolaryngolHead NeckSurg.2017;143:928---34.

29.KamAC,GaoH,LiLK,ZhaoH,QiuS,TongMC.Automated hear-ingscreeningforchildren:apilotstudyinChina.IntJAudiol. 2013;52:855---60.

30.Hong SM, Park I-S, Kim YB, Hong SJ, Lee B. Analysis

of the prevalence of and factors associated with hearing

loss in Korean adolescents. PLoS ONE. 2016;11:e0159981,

http://dx.doi.org/10.1371/journal.pone.0159981.

31.WesterbergBD,SkowronskiDM,StewartIF,StewartL,Bernauer M, Mudarikwa L. Prevalence of hearing loss in primary schoolchildrenin Zimbabwe.IntJPediatr Otorhinolaryngol. 2005;69:e517---25.

32.TahaAA, PrattSR, FarahatTM, Abdel-Rasoul GM, Albtanony MA,ElrashiedyAL,etal.Prevalenceandriskfactorsof hear-ingimpairmentamongprimary-schoolchildreninShebinEl-kom District,Egypt.AmJAudiol.2010;19:46---60.

33.SamelliAG,RabeloCM,VespasianoAP.Developmentand anal-ysisofalow-costscreeningtooltoidentifyandclassifyhearing lossinchildren:aproposalfordevelopingcountries.Clinics(Sao Paulo).2011;66:1943---8.

34.DiasAC,Siqueira LP,Viganó C.Análise dasac¸õeseducativas sobre asaúdeauditiva em crianc¸as escolares.RevBrasPesq Saúde.2016;18:91---9.