Article Text

Review: self report of hearing loss and the whispered voice test are useful for screening for hearing impairment
  1. Nancy Martin, RN, PhD
  1. Grand River Hospital
    Kitchener, Ontario, Canada

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Q Are simple screening tests useful for diagnosing hearing impairment?


Embedded ImageData sources:

Medline, EMBASE/Excerpta Medica (1966 to April 2005), bibliographies of relevant articles and a clinical skills textbook, and experts.

Embedded ImageStudy selection and assessment:

English language studies that evaluated the accuracy or precision of bedside screening questions or physical examination manoeuvres for hearing impairment in symptomatic and asymptomatic people ⩾16 years of age. 24 studies (n = 12 645) met the selection criteria. The tests evaluated included a self reported screening question (eg, “Do you feel you have a hearing loss?”); Hearing Handicap Inventory for the Elderly, screening version (HHIE-S), a 10 item self administered questionnaire measuring the social and emotional effects of hearing problems (range of scores 0–40); Weber and Rinne tuning fork tests; whispered voice test; and the audioscope. The reference standard was pure tone audiometry with thresholds ranging from 25 to 45 dB.

Embedded ImageOutcomes:

pooled positive and negative likelihood ratios (LRs).


Pooled LRs are shown in the table. The whispered voice test was the most accurate test for ruling out hearing impairment. A high cut point for the HHIE-S was not more useful than a lower cut point (table). The Weber tuning fork test (1 study, n = 122) was an inaccurate screening test, with LR confidence intervals including unity. The Rinne tuning fork test (5 studies, n = 1484) was an unreliable test and had limited accuracy, with +LRs ranging from 2.7 to 62 and −LRs ranging from 0.01 to 0.85.


The whispered voice test and the audioscope are accurate in ruling out hearing impairment.

A modified version of this abstract appears in Evidence-Based Medicine.

Accuracy of simple tests for hearing impairment*


Imagine how difficult it would be to communicate if you could not understand what was being said. This is the most common complaint in people with hearing loss.1 Hearing loss is one of the most common chronic conditions among elderly people, contributing to social isolation, depression, and loss of self esteem.1 Despite the high prevalence, associated morbidity, and ability to identify potentially reversible (treatable) hearing loss, evidence exists that hearing impairment is underdiagnosed.2

Many tests have been suggested for screening for hearing loss. Bagai et al assessed whether various screening methods can correctly distinguish between individuals who have hearing impairment and those who do not. The authors used an explicit search strategy, did a manual review of references from relevant articles, and contacted experts. 2 authors independently abstracted data from the individual studies, and study quality was assessed based on a standard grading scheme. These methods increase the confidence in the review findings and decrease the possibility of bias.

Bagai et al concluded that a simple single question about hearing impairment, followed up by the whispered voice test or examination with an audioscope, is the most useful screening method. Although the authors noted that the whispered test may be unreliable because of a lack of standardisation in methods, clear instructions for conducting the test were provided.

The importance of screening for hearing impairment in older adults is highlighted by its high prevalence (25–40% in those ⩾65 years of age according to Bagai et al) and associated conditions. Bagai et al outlined a clear process to identify people with hearing impairment who should be referred for formal assessment. As many healthcare professionals do not have access to an audioscope, use of a single question followed up by the whispered voice test provides clinicians with a simple, economical, and effective method to detect hearing impairment.


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  • For correspondence: Dr A S Detsky, Mount Sinai Hospital, Toronto, Ontario, Canada. allan.detsky{at}

  • Source of funding: no external funding.

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