J Am Acad Audiol 2019; 30(06): 482-492
DOI: 10.3766/jaaa.17120
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Monitoring Hearing in an Infectious Disease Clinic with mHealth Technologies

Marize Brittz
*   Department of Speech-Language Pathology and Audiology, University of Pretoria, Pretoria, South Africa
Barbara Heinze
*   Department of Speech-Language Pathology and Audiology, University of Pretoria, Pretoria, South Africa
Faheema Mahomed-Asmail
*   Department of Speech-Language Pathology and Audiology, University of Pretoria, Pretoria, South Africa
De Wet Swanepoel
*   Department of Speech-Language Pathology and Audiology, University of Pretoria, Pretoria, South Africa
†   Ear Science Institute Australia, Subiaco, Australia
‡   Ear Sciences Centre, The University of Western Australia, Nedlands, Australia
Anton Stoltz
§   Department of Infectious Diseases, Steve Biko Academic Hospital, Pretoria, South Africa
› Author Affiliations
Further Information

Publication History

10 February 2018

22 March 2018

Publication Date:
25 May 2020 (online)



Decentralized detection and monitoring of hearing loss can be supported by new mobile health technologies using automated testing that can be facilitated by minimally trained persons. These may prove particularly useful in an infectious disease (ID) clinic setting where the risk of hearing loss is high.


To evaluate the clinical utility of mobile and automated audiometry hearing health technology in an ID clinic setting.

Research Design:

Smartphone-automated pure-tone audiometry (PTA) (hearTest™) and speech-in-noise testing (SA English digits-in-noise [DIN] test) were compared with manual audiometry (2, 4, and 8 kHz). Smartphone-automated PTA and the DIN test were repeated to determine the test–retest reliability.

Study Sample:

Two hundred subjects (73% female and 27% male) were enrolled. Fifty participants were retested with the smartphone applications. Participants ranged from an age of 18 to 55 years with a mean age of 44.4 (8.7 standard deviation).

Data Analysis:

Threshold comparisons were made between smartphone audiometry testing and manual audiometry. Smartphone-automated PTA, manual audiometry, and test–retest measures were compared (Wilcoxon signed ranked test). Spearman rank correlation test was used to determine the relationship between the smartphone applications and manual audiometry, as well as for test–retest reliability.


Within all participants, 88.2% of thresholds corresponded within 10 dB or less between smartphone audiometry and manual audiometry. There was a significant difference (p < 0.05) between the right ear at 4 and 8 kHz and in the left ear at 2 and 4 kHz between smartphone and manual audiometry, respectively. No significant difference was noted (p < 0.05) between test and retest measures of smartphone technology.


Smartphone audiometry with calibrated headphones provides reliable results in an ID clinic setting and can be used as a baseline and monitoring tool at ID clinics.

The hearTest™ application is intellectual property owned and trademarked by the University of Pretoria. The third author has a relationship with the hearX Group, who owns the right to the IP that includes equity, consulting, and potential royalties.


  • American Speech-Language-Hearing Association (ASHA) 2005. Guidelines for Manual Pure-tone Threshold Audiometry. Rockville, MD: ASHA;
  • Araújo EDS, Zucki F, Corteletti LCBJ, Lopes AC, Feniman MR, Alvarenga KDF. 2012; Hearing loss and acquired immune deficiency syndrome: systematic review. J Soc Bras Fonoaudio 24 (02) 188-192
  • Assuiti LF, Lanzoni GM, Santos FC, Erdmann AL, Meirelles BH. 2013; Hearing loss in people with HIV/AIDS and associated factors: An integrative review. Braz J Otorhinolaryngol 79 (02) 248-255
  • Bankaitis AE, Keith RW. 1995; Audiological changes associated with HIV infection. Ear Nose Throat J 74 (05) 353-359
  • Bankaitis A, Schountz T. 1998; HIV-related ototoxicity. Semin Hear 19 (02) 155-163
  • Bland JM, Altman DG. 1999; Measuring agreement in method comparison studies. Stat Methods Med Res 8 (02) 135-160
  • Branford W, Claughton JS. 2002. Mutual lexical borrowings among some languages of Southern Africa: Xhosa, Afrikaans and English. In: Mestherie R. Language in South Africa. New York, NY: Cambridge University Press; 199-215
  • Chandrasekhar SS, Connelly PE, Brahmbhatt SS, Shah CS, Kloser PC, Baredes S. 2000; Otologic and audiologic evaluation of human immunodeficiency virus-infected patients. Am J Otolaryngol 21 (01) 1-9
  • Chia EM, Wang JJ, Rochtchina E, Cumming RR, Newall P, Mitchel P. 2007; Hearing impairment and health-related quality of life: the blue mountains hearing study. Ear Hear 28: 187-195
  • Clark JL, Swanepoel DW. 2014; Technology for hearing loss—as we know it, and as we dream it. Disabil Rehabil Assist Technol 9 (05) 408-413
  • Cohen BE, Durstenfeld A, Roehm PC. 2014; Viral causes of hearing loss: a review for hearing health professionals. Trends Hear 18: 1-17
  • Eloff I. 2010. Psychosocial impact of HIV/AIDS in communication disorders. In: Swanepoel DW, Louw B. HIV Related Communication, Hearing, and Swallowing Disorders. San Diego, Oxford, Brisbane: Plural Publishing; 97-113
  • Fausti SA, Larson VD, Noffsinger D, Wilson RH, Phillips DS, Fowler CG. 1994; High-frequency audiometric monitoring strategies for early detection of ototoxicity. Ear Hear 15 (03) 232-239
  • Foulad A, Bui P, Djalilian H. 2013; Automated audiometry using Apple iOS-based application technology. Otolaryngol Head Neck Surg 149 (05) 700-6
  • Gopinath B, Schneider J, Hickson L, McMahon CM, Burlutsky G, Leeder SR, Mitchell P. 2012; Hearing handicap, rather than measured hearing impairment, predicts poorer quality of life over 10 years in older adults. Maturitas 72: 146-151
  • Internet World Stats 2014 Internet population statistics. www.internetworldstats.com/stats1.htm . Accessed September 6, 2017.
  • Jansen S, Luts H, Dejonckere P, van Wieringen A, Wouters J. 2013; Efficient Hearing Screening in Noise-Exposed Listeners Using the Digit Triplet Test. Ear Hear 34 (06) 773-778
  • Jolles S, Kinloch de LS, Johnsons MA, Janossy G. 1996; Primary HIV-1 infection: a new medicial emergency?. BMJ 312 (7041) 1243-1244
  • Keidser BG, Convery E. 2016; Preliminary observations of self-fitted hearing aid outcomes. Hear J 69 (11) 34-38
  • Khoza-Shangase K. 2010; HIV/AIDS and auditory function in adults: the need for intensified research in the developing world. Afr J AIDS Res 9 (01) 1-9
  • Khoza-Shangase K, Ross E. 2002; Auditory function in a group of adults infected with HIV/AIDS in Gauteng, South Africa. S Afr J Commun Disord 49: 17-27
  • Leensen MC, Dreschler WA. 2013; The applicability of a speech-in-noise screening test in occupational hearing conservation. Int J Audiol 52 (07) 455-465
  • Louw C, Swanepoel DW, Eikelboom RH, Myburgh HC. 2017; Smartphone-based hearing screening at primary health care clinics. Ear Hear 38 (02) e93-e100
  • Maclennan-Smith F, Swanepoel DW, Hall JW. 2013; Validity of diagnositc pure-tune audiometry without a sound-treated environment in older adults. Int J Audiol 52 (02) 66-73
  • Madsen BM, Margolis RH. 2014 Audiometric properties of three circumaural earphones. 41st Annual Scientific and Technology Conference of the American Auditory Society, Scottsdale, Arizona, March 6–8.
  • Mahomed-Asmail F, Swanepoel DW, Eikelboom RH. 2016; Diagnostic hearing assessment in schools: validity and time efficiency of automated audiometry. J Am Acad Audiol 27 (01) 42-8
  • Mahomed-Asmail F, Swanepoel DW, Eikelboom RH, Soer M. 2013; Validity of automated threshold audiometry: a systematic review and meta-analysis. Ear Hear 34 (06) 745-52
  • Margolis RH, Frisina R, Walton JP. 2011; AMTAS®: automated method for testing auditory sensitivity: II. Air conduction audiograms in children and adults. Int J Audiol 50 (07) 434-439
  • Margolis RH, Morgan DE. 2008; Automated pure-tone audiometry: an analysis of capacity, need, and benefit. Am J Audiol 17 (02) 109-113
  • Marin B, Thiébaut R, Bucher HC, Rondeau V, Costagliola D, Dorucci M, Hamouda O, Prins M, Walker S, Porter K, Sabin C, Chêne G. 2009; Non-AIDS defining deaths and immunodeficiency in the era of combination antiretroviral therapy. AIDS 23 (13) 1743-1753
  • Matas CG, Angrisani RG, Magliaro FC, Segurado AA. 2014; Audiological manifestations in HIV-positive adults. Clinics 69 (07) 469-75
  • McDaniel M, Chinn G, McCall K, Stewart A. 2013 Guidelines for audiometric baseline revision. http://c.ymcdn.com/sites/www.hearingconservation.org/resource/resmgr/Position_Statements/ Guidelines_for_Audiometric_B.pdf . Accessed August 2, 2017.
  • Mick P, Kawachi I, Lin FR. 2014; The association between hearing loss and social isolation in older adults. Otolaryngol Head Neck Surg 150 (03) 378-384
  • Modongo C, Sobota RS, Kesenogile B, Ncube R, Sirugo G, Williams SM, Zetola NM. 2014; Successful MDR-TB treatment regimens including amikacin are associated with high rates of hearing loss. BMC Infect Dis 14 (01) 542
  • Occupational Saftey and Health Administration (OSHA) 1983; Occupational noise exposure; hearing conservation amendment. Fed Regist 48: 9738-9785
  • Olusanya BO, Ruben RJ, Parving A. 2006; Reducing the burden of communication disorders in the developing world: an opportunity for the millennium development project. JAMA 296: 441-444
  • Peer S, Fagan JJ. 2015; Hearing loss in the developing world: evaluating the iPhone mobile device as a screening tool. S Afr Med J 105 (01) 35-39
  • Peters B, Post F, Wierzbicki AS, Phillips A, Power L, Das S, Johnson M, Moyle G, Highes L, Wilkins E, McCloskey E, Compston J, Di Angelantonio E. 2013; Screening for chronic comorbid diseases in people with HIV: the need for a strategic approach. HIV Med 14 (01) 1-11
  • Potgieter JM, Swanepoel DW, Myburgh HC, Hopper TC, Smits C. 2016; Development and validation of a smartphone-based digits-in-noise hearing test in South African english. Int J Audiol 55 (07) 405-411
  • Potgieter JM, Swanepoel DW, Myburgh HC, Smits C. 2018; The South African english smartphone digits-in-noise hearing test: effect of age, hearing loss and speaking competence. Ear Hear 39 (04) 656-663
  • Prasad HK, Bhojwani KM, Shenoy V, Prasad SC. 2006; HIV manifestations in otolaryngology. Am J Otolaryngol 27: 179-185
  • Rashid M, Leensen MCJ, de Laat JAPM, Dreschler WA. 2017; Laboratory evaluation of an optimised internet-based speech-in-noise test for occupational high-frequency hearing loss screening: occupational earcheck. Int J Audiol 56 (11) 844-853
  • Sandström J, Swanepoel DW, Carel Myburgh H, Laurent C. 2016; Smartphone threshold audiometry in underserved primary health-care contexts. Int J Audiol 55 (04) 232-238
  • Smits C, Houtgast T. 2005; Results from the dutch speech-in-noise screening test by telephone. Ear Hear 26 (01) 89-95
  • Smits C, Kapteyn TS, Houtgast T. 2004; Development and validation of an automatic speech-in-noise screening test by telephone. Int J Audiol 43: 15-28
  • Smits C, Theo Goverts S, Festen JM. 2013; The digits-in-noise test: assessing auditory speech recognition abilities in noise. J Acoust Soc Am 133 (03) 1693-706
  • Stearn N, Swanepoel DW. 2010. Sensory and neural auditory disorders associated with HIV/AIDS. In: Swanepoel DW, Louw B. HIV Related Communication, Hearing, and Swallowing Disorders. San Diego, Oxford, Brisbane: Plural Publishing; pp 243-287
  • Storey KK, Munoz K, Nelson L, Larsen J, White K. 2014; Ambient noise impact on accuracy of automated hearing assessment. Int J Audiol 53 (10) 730-736
  • Swanepoel DW, Biagio L. 2011; Validity of diagnostic computer-based air and forehead bone conduction audiometry. J Occup Environ Hyg 8 (04) 210-214
  • Swanepoel DW, Clark JL, Koekemoer D, Hall JW, Krumm M, Ferrari DV, Mcpherson B, Olusanya B, Mars M, Russo I, Barajas JJ. 2010; a Telehealth in audiology: the need and potential to reach underserved communities. Int J Audiol 49 (03) 195-202
  • Swanepoel DW, Hall JW. 2010; A systematic review of telehealth applications in audiology. Telemed J E Health 16: 181-201
  • Swanepoel DW, Mngemane S, Tutshini S. 2010; b Hearing assessment—reliability, accuracy, and efficiency of automated audiometry. Telemed J E-Health 16 (05) 6-8
  • Swanepoel DW, Myburgh HC, Howe DM, Mahomed F, Eikelboom RH. 2014; Smartphone hearing screening with integrated quality control and data management. Int J Audiol 53 (12) 841-849
  • Van Der Aerschot M, Swanepoel DW, Mahomed-Asmail F, Myburgh HC, Eikelboom RH, Swanepoel DW, Mahomed-Asmail F. 2016; Affordable headphones for accessible screening audiometry : an evaluation of the Sennheiser HD202 II supra-aural headphone. Int J Audiol 55 (11) 616-622
  • van der Westhuizen Y, Swanepoel DW, Heinze B, Hofmeyr LM. 2013; Auditory and otological manifestations in adults with HIV/AIDS. Int J Audiol 52 (01) 37-43
  • van Tonder J, Swanepoel DW, Mahomed-Asmail F, Myburgh H, Eikelboom RH. 2017; Automated smartphone threshold audiometry: validity and time efficiency. J Am Academy Audiol 28 (03) 200-208
  • World Health Organisation (WHO) 2013 Millions of people in the world have a hearing loss that can be treated or prevented. http://www.who.int/pbd/deafness/news/Millionslivewithhearingloss.pdf . Accessed October 13, 2016.
  • World Health Organisation (WHO) 2016 Global tuberculosis report 2016. http://apps.who.int/iris/bitstream/10665/250441/1/9789241565394-eng.pdf?ua=1 . Accessed September 15, 2017.
  • Yousuf Hussein S, Swanepoel DW, Biagio de Jager L, Myburgh HC, Eikelboom RH, Hugo J. 2015; Smartphone hearing screening in mHealth assisted community-based primary care. J Telemed Telecare 22 (07) 1-8