- 學位論文
自動聽性腦幹反應新生兒聽力篩檢 –特別提及篩檢工具
Automated Auditory Brainstem Response Newborn Hearing Screen-with Special Reference to Screening Tools
摘要
研究背景 新生兒聽力篩檢在國內已施行約10年，新生兒出生1個月內接受篩檢、3個月內確立診斷及6個月內開始介入治療的觀念也廣為人知。選擇篩檢的工具是建立一個成功的篩檢模式十分重要的課題，過去以耳聲傳射最為普遍，但耳聲傳射的轉介率較高及可能有偽陰性，另一種篩檢工具自動聽覺腦幹反應則轉介率低且無偽陰性，但有成本高與操作時間長等缺點。聽覺穩定狀態反應則是用於嬰幼兒聽力診斷的工具，理論上或可用於篩檢但缺乏臨床驗證。因此提出我們的自動聽覺腦幹反應新生兒聽力篩檢模式與其他國內耳聲傳射模式比較，同時也測試聽覺穩定狀態反應新生兒聽力篩檢的可行性。 研究材料與方法 本次研究材料為彰化基督教醫院嬰兒室健康新生兒，研究時間為2005年7月至2008年3月，經家長同意後接受自費新生兒聽力篩檢者。 選用的篩檢儀器為Algo-3i自動聽性腦幹儀，與國內其他耳聲傳射篩檢模式，就受檢率、篩檢時機、與轉介率等項目分析比較。另選用IHS聽覺穩定狀態反應儀，檢驗其轉介率與偽陰性。 結果 彰化基督教醫院自動聽性腦幹新生兒聽力篩檢受檢率為55.4%(2504/4537)；出院轉介率為2.1%(52/2504)，滿月複檢後轉介率為0.7%(18/2504)；回診率為90.4%(47/52)；確診10位聽障新生兒，其中3位為單側聽障(0.12%)，7位為兩側聽障(0.28%)，兩側聽障包括中度聽障(40-69 dBHL)4位，重度聽障(70-90 dBHL)1位，極重度聽障(>90 dBHL)2位；篩檢時機於出生24小時內並不會提高轉介率(卡方檢定，p>0.1,CI:-1.49%—1.23%)。 聽覺穩定狀態反應有88位受檢，79位通過兩耳，轉介率為10.2%(9/88)，7位只通過一耳，2位兩耳皆未通過，未通過聽覺穩定狀態新生兒聽力篩檢者後續追蹤結果皆正常。若以自動聽覺腦幹反應為標準，則聽覺穩定狀態的篩檢偽陽性為8.9%(7/79)，篩檢偽陰性為0(0/2)，正確率為92.0%(81/88)。 討論與建議 彰化基督教醫院自動聽性反應新生兒聽力篩檢符合美國嬰幼兒聽力聯合委員會對聽力篩檢的品質要求，即轉介率<4%、回診率>70%，同時受檢率也不會低於國內耳聲傳射新生兒聽力篩檢，可以作為選擇篩檢工具的考量。聽覺穩定狀態反應是可用的，雖然正確率高但轉介率並不理想，選擇耳罩與使用連續變頻是可能改善的方法，還需要更大規模的臨床測試。
並列摘要
Background Newborn hearing screen has been implemented in Taiwan for 10 years. The idea of screening infants before one month old, identifying hearing loss before 3 months old and beginning their intervention as early as 6 months of age has also well been known. To choose the appropriate screening tool is a very important step in building a successful screening program. Otoacoustic emission(OAE) was used a lot yet with a flaw of higher referral rate and the possibility of missing babies with permanent hearing loss. Automated auditory brainstem response(AABR) is the other choice with a lower referral rate and no known false-negatives. However ,it is more expensive and time-consuming to use. Auditory steay state response(ASSR) is a new diagnostic test of infant hearing thresholds without actual application of newborn hearing screening in daily practice. We bring out our experience in conducting an AABR newborn hearing screening in comparison with others using OAE in Taiwan. We also test the possibility of ASSR newborn hearing screen. Materials and Methods Healthy babies from the nursery of Changhua Christian Hospital were recruited between July 2005 and March 2008 at the consent of parents who paid the Algo-3i AABR newborn hearing screen. The results of screening rate, screening timing and referral rate were collected and were compared with the results of other OAE screen programs in Taiwan. We also used the IHS ASSR machine to test the referral rate and false-negative in newborn hearing screen. Results The screening rate of our program was 55.4%(2504/4537),the referral rates were 2.1%(52/2504) at discharge and 0.7%(18/2504) after follow-up screen at one month ,the follow up rate is 90.4%(47/52). 10(0.4%) infants were identified with permanent hearing loss including 3(0.12%) with unilateral hearing loss and 7(0.28%) with bilateral hearing loss. Of the babies with bilateral hearing loss,the hearing loss was moderate (40-69 dBHL) in 4,severe (70-90 dBHL) in 1 and profound (>90 dBHL) in 2. The timing of screening in 24 hours post-partum did not elevate the referral rate (Chi-square test，p>0.1,CI:-1.49%—1.23%)。 88 infants were also tested with ASSR, of which 79 passed the test,7 failed only one ear and 2 failed both sides .The referral rate was 10.2%(9/88). Of the 7 infants,2 failed the same ear with AABR test .Those who fail ASSR test were later proved to be of normal hearing. Using the AABR as the gold standard ,the false positive rate ,false negative rate and accurate rate of ASSR test were 8.9%(7/79) ,0%(0/2) and 92.0%(81/88) respectively. Discussion and Suggestion The results of newborn hearing screen with AABR of Changhua Christian Hospital meet the requirements of Joint Committee of Infant Hearing of America(JCIH),with the referral rate < 4% and follow up rate > 70 % and meanwhile the screening rate were not different from other programs using OAE in Taiwan. We therefore suggest that AABR is an appropriate tool of screening in the pay-for-test model in Taiwan. Besides ,ASSR is applicable in newborn hearing screening though with a unsatisfactory high referral rate. By using the ear muff instead of insert earphone , chirp instead of click might improve the referral rate. However, more clinical trial is needed.