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Occupational Hearing Screenings

Lee D. Hager

June 22, 2001

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Question

For persons conducting occupational hearing screenings, what are the recommended criteria for initiating audiologic referral?

Answer

The National Hearing Conservation Association has been working on this issue for some time. Their ad-hoc committee on referral criteria issued draft guidelines earlier this year, which are offered here. Please keep in mind that these are draft criteria, and have not been officially sanctioned by NHCA;any questions or comments should be addressed to nhca@gwami.com, care of Referral Criteria Committee. Please note there are two levels of referral indicated - first, audiograms identified by the occupational hearing conservationist/technician during the hearing testing screening phase of a hearing conservation program as requiring professional review, and second, suggestions for the reviewing professional who may need to refer specific cases to an otolaryngologist for review.

PLEASE NOTE: If you would like to comment on the information below, or if you would like a complete copy of the draft, the email address and other contact information is listed at the end (below).

CRITERIA FOR PROFESSIONAL REVIEW OF AUDIOMETRIC RECORDS: Technician Referral

These guidelines are intended for the occupational hearing conservationist who conducts hearing conservation audiograms. The goal of these guidelines is to provide information to identify problem audiograms, which would require a mandatory or ''best practice'' review by an audiologist or physician. The audiologist or physician is responsible to determine if further evaluation is required.

Mandatory review criteria were developed to ensure compliance with OSHA CFR 1910.95 and consistency with the NHCA Guidelines for Audiometric Baseline Revision (1996).

1. MANDATORY REVIEW OF RECORDS BY AUDIOLOGIST OR PHYSICIAN

A. OSHA-defined STS (DOD-defined STS for military facilities) on annual audiogram
B. Change of 15 dB (improvement or degradation) or more at any frequency, on either ear, on annual audiogram, compared to the baseline audiogram.
C. Asymmetry
1. Difference of 40 dB or more between ears at any frequency on baseline
2. Difference of 25 dB or more between ears at two consecutive frequencies on annual audiogram
D. Unreliable audiograms: inconsistent/unreliable thresholds-differences of 10 dB or more between annual and follow-up audiograms, or compared to the previous year's test(s), at the same frequency(ies) in the same ear
E. Low frequency hearing loss
1. Average hearing level greater than 25 dB at 500, 1000 AND 2000 Hz on the baseline audiogram
2. Shift of 10 dB average at 500, 1000 and 2000 Hz on annual audiogram
F.Technician unable to obtain audiogram using standard procedures

2. ''BEST PRACTICE'' REVIEW BY AUDIOLOGIST OR PHYSICIAN

A. Pre-existing hearing loss on baseline audiogram
1. Average of 25 dB or more at 500, 1000 and 2000 Hz either ear
2. Any threshold of 55 dB or more at 3000, 4000, or 6000 Hz either ear
B. Potentially compensable hearing loss on baseline audiogram, based on formula applicable in state of employment. Purpose is to document loss and provide employee feedback.
C. Significant hearing shift less than OSHA STS on annual audiogram, in order to warn employee of hearing changes before an STS occurs.
1. Persistent 15 dB shift at 3000, 4000 or 6000 Hz.
2. Persistent 10 dB shift at 2 consecutive frequencies, 3000 through 6000 Hz.
3. 20 dB shift at any frequency.
4. Progressive loss in the critical speech communication range (500, 1000 or 2000 Hz) of 10 dB.
D. Significant hearing improvement of 15 dB at any frequency, which may require revision of baseline for medical reasons, such as after a middle ear problem is treated.
E. Persistent hearing improvement of 5 dB of the threshold average for 2000, 3000 and 4000 Hz, as compared to the baseline.
F. Patient report/history of medical problems, such as cerumen.
G. Patient complaint about ear problems or problems understanding speech.

CRITERIA FOR AUDIOLOGICAL AND MEDICAL REFERRALS: Otologic referral by reviewing professional

These guidelines are intended for the audiologist or physician who reviews hearing conservation audiograms. An audiologist or physician is responsible to determine if further evaluation is required for ''problem audiograms.'' The audiologist or physician must use their professional judgment when deciding the need for further evaluation. ''An audiogram is not the sole indicator of a need for a referral.'' (www.osha-slc.gov/OshDoc/Interp_data/I19980602.html).

1. MANDATORY REFERRAL FOR AUDIOLOGICAL EVALUATION AT EMPLOYER'S EXPENSE (Clinical audiogram;may require medical/ENT exam, depending on results)

A. Asymmetric hearing loss of 40 dB or more between ears at any frequency, which requires masking. This is required on the baseline audiogram, but is only required on the annual audiogram if there is an OSHA-defined STS or shift in hearing of 15 dB or more.
B. Unreliable audiograms: inconsistent/unreliable thresholds-differences of 10 dB or more between annual and follow-up audiograms, or compared to the previous year's test(s), at the same frequency(ies) in the same ear
C. Technician unable to obtain audiogram using standard procedures.

2. MANDATORY REFERRAL FOR OTOLOGICAL EXAM AND AUDIOLOGICAL EVALUATION AT EMPLOYER'S EXPENSE

A. OSHA-defined STS AND an indication a medical ear problem may have been caused or aggravated by wearing hearing protection, or an employee may not be able to wear earplugs due to a medical ear problem
B. OSHA-defined STS AND need to document a problem is not work-related. For example, an employee sticks a Q-tip through the eardrum or experiences acoustic trauma from an exploding firecracker/bicycle tire
C. Employer questions employee's ability to perform his/her job safely due to employee's hearing loss or problems understanding speech in noise at work

3. MANDATORY RECOMMENDATION FOR EMPLOYEE TO SEEK AUDIOLOGICAL AND/OR MEDICAL EVALUATION AT HIS/HER OWN EXPENSE

A. Shifts on annual audiograms suggesting potential medical problems
1. Rapid change in hearing in one ear within one year
2. Change of 15 dB at 500, 1000 or 2000 Hz or average change of 10 dB
3. Asymmetry of 25 dB between ears at any frequency
B. Patient complains about dizziness, severe persistent tinnitus, discomfort in ear(s), fluctuating hearing, drainage, ear pain or ear fullness
C. Patient reports problems understanding speech in noise at work
D. History of chronic ear problems/symptoms not resolved, such as serous otitis media



Please provide comments to
NHCA
9101 E Kenyon Ave., Ste. 3000
Denver, CO 80237
Voice: 303/224-9022
Fax: 303/770-1812
nhca@gwami.com

BIO:
Lee D. Hager is Executive Vice President for James, Anderson & Associates, Inc. (JAA), a leading hearing loss prevention management and noise control consulting firm. He has been active in the field of hearing loss prevention since 1986, participating in the development and documentation of the Sound Exposure Profiling survey technique. Lee manages the Technical Services Division of JAA, which is responsible for conducting sound exposure monitoring studies and related hearing loss prevention activity for over 300,000 workers annually. Lee is also active in professional associations related to hearing loss prevention, serving currently as Past-President of the National Hearing Conservation Association;Vice-chair of the American Industrial Hygiene Association Noise Committee;a member of the Acoustical Society of America Technical Committee on Noise;and a voting member of American National Standards Institute Accredited Standards Committee S12, Noise.


Lee D. Hager

Hearing Loss Prevention Consultant for Sonomax Hearing Healthcare, Inc.

Lee brings nearly 20 years of experience to his position as Hearing Loss Prevention Consultant for Sonomax Hearing Healthcare, Inc.  Sonomax is a leading provider of new technology in hearing protection devices.  Previously, his tenure with James, Anderson & Associates, Inc. provided him the opportunity to consult with Fortune 5 companies regarding the quality and integrity of their hearing conservation programs, including noise exposure monitoring and hearing test data management. He has served as President of the National Hearing Conservation Association (NHCA);chair of the Noise Committee of the American Industrial Hygiene Association (AIHA);as NIOSH National Occupational Research Agenda (NORA) Noise Team member;and with ANSI Working Group S12/WG11 on hearing protector evaluation and labeling issues.  He has presented at major conferences on noise and hearing topics, having received the AIHA Noise Committee Outstanding Lecture Award in 2003.  He publishes regularly in occupational health and safety publications, and he cares about your ears. I am employed by Sonomax Hearing Healthcare, Inc., a hearing protection manufacturer. While Sonomax technology may be part of an overall best practices hearing loss prevention program, the company and technology will not be discussed in this presentation


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