Determining the Presence or Absence of Middle Ear Disorders: An Evidence-Based Systematic Review on the Diagnostic Accuracy of Selected Assessment Instruments Purpose To conduct an evidence-based systematic review on the state of the evidence and the diagnostic accuracy of multifrequency tympanometry (MFT), 1000 Hz tympanometry, and wideband acoustic transfer functions in determining the presence or absence of middle ear disorders. Method A systematic search of the literature published between ... Review Article
Free
Review Article  |   December 01, 2012
Determining the Presence or Absence of Middle Ear Disorders: An Evidence-Based Systematic Review on the Diagnostic Accuracy of Selected Assessment Instruments
 
Author Affiliations & Notes
  • Chris A. Sanford
    Idaho State University, Pocatello
  • Tracy Schooling
    American Speech-Language-Hearing Association, Rockville, MD
  • Tobi Frymark
    American Speech-Language-Hearing Association, Rockville, MD
  • Correspondence to Tracy Schooling: tschooling@asha.org
  • Editor: Sheila Pratt
    Editor: Sheila Pratt×
  • Associate Editor: Lisa Hunter
    Associate Editor: Lisa Hunter×
Article Information
Hearing Disorders / Review Articles
Review Article   |   December 01, 2012
Determining the Presence or Absence of Middle Ear Disorders: An Evidence-Based Systematic Review on the Diagnostic Accuracy of Selected Assessment Instruments
American Journal of Audiology, December 2012, Vol. 21, 251-268. doi:10.1044/1059-0889(2012/11-0029)
History: Received September 1, 2011 , Accepted May 2, 2012
 
American Journal of Audiology, December 2012, Vol. 21, 251-268. doi:10.1044/1059-0889(2012/11-0029)
History: Received September 1, 2011; Accepted May 2, 2012
Web of Science® Times Cited: 7

Purpose To conduct an evidence-based systematic review on the state of the evidence and the diagnostic accuracy of multifrequency tympanometry (MFT), 1000 Hz tympanometry, and wideband acoustic transfer functions in determining the presence or absence of middle ear disorders.

Method A systematic search of the literature published between 1975 and 2011 was conducted. Articles meeting the selection criteria were appraised by 2 reviewers and vetted by a 3rd for methodological quality.

Results Ten studies were included and focused on participants with otosclerosis or otitis media. Two studies investigated 1000 Hz tympanometry, 7 examined MFT, and 2 addressed wideband reflectance (WBR). Methodological quality varied. Positive likelihood ratios (LR+) were predominantly uninformative for MFT and were mixed for 1000 Hz tympanometry. LR+ values for WBR ranged from diagnostically suggestive to informative. Negative likelihood ratios (LR−) for 1000 Hz tympanometry and WBR were at least diagnostically suggestive. LR− values for MFT were mixed, with half considered clinically uninformative and half considered diagnostically suggestive.

Conclusions Although some of the results are promising, limited evidence and methodological considerations restrict the conclusions that can be drawn regarding the diagnostic accuracy of these technologies. Additional investigations are needed to determine which tools can most accurately predict middle ear status.

Single and multifrequency tympanometry (MFT) measurements have been in clinical use for over three decades. However, questions still remain regarding which tympanometric stimulus and response parameters provide the best diagnostic utility for identification of middle ear disorders. These questions, coupled with a growing body of research suggesting that wideband measures of middle ear function (e.g., wideband acoustic transfer functions, energy reflectance) may offer improved diagnostic capabilities, have sparked renewed interest in the assessment and monitoring of middle ear disorders. The aim of the present study was to undertake an evidence-based systematic review (EBSR) examining the diagnostic accuracy of middle ear assessment measures, including MFT, 1000 Hz tympanometry, and wideband acoustic transfer functions. The purpose of our review was twofold: first, to analyze and synthesize the existing evidence for the assessment of middle ear disorders across the age span; and second, to highlight the quantity and quality of the current state of the evidence to suggest areas as well as populations in need of further study.
Background
Early clinical application of immittance measurements (i.e., impedance and admittance) grew out of interest in developing an objective measure of middle ear dysfunction (Metz, 1953). Continued research, in particular that of Terkildsen and Thomson (1959), who pioneered the addition of ear-canal pressure variations to immittance measurements, led to clinical application of acoustic immittance measurements of the human middle ear (Margolis & Hunter, 1999). Since this time, tympanometry has been regarded as a safe and efficient method for assessing middle ear function.
Currently, conventional tympanometric measurement of acoustic admittance, using a 226 Hz probe stimulus, is a commonly used audiologic assessment tool. This low probe tone frequency has proven useful for the identification of various middle ear pathologies by providing valuable qualitative and quantitative information (Margolis & Hunter, 2000; Terkildsen & Thomson, 1959). Qualitatively, tympanograms are classified by type (e.g., A, B, C, and so forth) according to admittance morphology as a function of ear-canal pressure (Feldman, 1976; Jerger, 1970; Lidén, 1969). Other tympanometric characteristics have been quantified, including static acoustic admittance (Ytm), tympanometric peak pressure (TPP), equivalent ear-canal volume (Veq), and tympanometric width (TW) or gradient (GR). Variations of normal tympanometric characteristics are often indicative of middle ear disorders, including otitis media with effusion (OME), tympanic membrane perforations, and eustachian tube dysfunction (American Speech-Language-Hearing Association, 1988).
A number of studies have investigated the diagnostic test performance of tympanometric characteristics derived from 226 Hz tympanometry in children with OME (Nozza, Bluestone, Kardatze, & Bachman, 1992, 1994; Roush, Bryant, Mundy, Zeisel, & Roberts, 1995; Silman, Silverman, & Arick, 1992). Specifically, Nozza et al. (1992)  evaluated the diagnostic value of a variety of immittance characteristics in children receiving myringotomy and tympanostomy tube placement. Immittance measurements taken before and after surgery revealed the highest sensitivity (90%) and specificity (86%), with respect to differentiating ears with or without OME, for a combination of tympanometric GR and ipsilateral acoustic reflex data; the best performing individual tympanometric characteristic was GR (≤ 0.2 ml) with sensitivity and specificity of 78% and 90%, respectively. Nozza and colleagues (1994)  found that TW (< 275 daPa) had the best test performance for any single 226 Hz tympanometric characteristic, with sensitivity and specificity of 81% and 82%, respectively. Takata et al. (2003)  conducted a meta-analysis examining the accuracy of various assessment methods, including tympanometry, in diagnosing OME in children. Pooled tympanometry results varied considerably based on diagnostic specifications, with sensitivity values ranging from 33.9% to 93.8% and specificity estimates ranging from 48.6% to 94.1%.
Early research suggested that single-frequency (226 Hz), single-component (admittance) tympanometry was relatively insensitive to some pathologies, such as ossicular chain disorders, including otosclerosis and ossicular disruption, and not a good predictor of conductive hearing loss (Colletti, 1976; Lildholdt, Courtois, Kortholm, Schou, & Warrer, 1979; Lilly, 1984; Margolis, Hunter, & Giebink, 1994; Shahnaz & Polka, 1997). These factors limited the clinical utility of tympanometry. As such, the use of more complex tympanometric measurements, such as multifrequency and multicomponent tympanometry, were introduced as a means to improve the sensitivity of tympanometry to additional middle ear disorders (Lilly, 1984; Shahnaz & Polka, 2002).
Multifrequency–Multicomponent Tympanometry
Even though the value of expanding stimulus and measurement parameters beyond admittance at 226 Hz was recognized during the beginnings of clinical tympanometry (Margolis, 1978; Van Camp, Raman, & Creten, 1976; Vanhuyse, Creten, & Van Camp, 1975), it was not until advancements in measurement equipment technology occurred that more widespread interest in investigations of middle ear function using multicomponent (e.g., susceptance and conductance), higher frequency (e.g., 678 and 1000 Hz), and multifrequency tympanometry (e.g., 226–2000 Hz) began. Preliminary clinical studies using higher frequency probe tones revealed more complex tympanometric morphology (multiple peaks) than those obtained at 220 or 226 Hz (Alberti & Jerger, 1974; Colletti, 1976; Margolis & Popelka, 1977; Van Camp et al., 1976; Vanhuyse et al., 1975). Initial interpretations of the more complex patterns were attributed to pathological middle ears. However, further investigation revealed that the tympanometric complexities were present in measurements of normal middle ears as well (Margolis & Popelka, 1977).
Building on the work of Lidén (1969), Colletti (1975)  studied the relationship between changes in tympanometric shape as a function of changes in probe frequency. Colletti demonstrated that as probe frequency increased, tympanometric shape changed in a systematic way. Typically, the tympanometric shape progressed from a single-peaked tympanogram to a slightly notched peak, eventually progressing to a V-shaped tympanogram. Colletti examined multifrequency responses in individuals with normal ears and in ears with ossicular disarticulation and otosclerosis (confirmed at surgery) and identified the frequency at which a deep-notched tympanogram was obtained as the resonant frequency (RF) of the middle ear. Colletti suggested that the RF of the middle ear (where the contributions of middle ear mass and stiffness are equal) could be determined by identifying the frequency at which a deeply notched tympanogram was obtained. Using this shape classification method, Colletti suggested that the RF of a normal adult ear corresponded to a probe frequency near 1000 Hz. Additionally, otosclerotic ears had RFs near 1300 Hz, and ears with ossicular disarticulation had RFs near 400 Hz. These shifts in RF are consistent with the stiffening effect of otosclerosis and the decrease in stiffness associated with disarticulated ossicles, respectively. Vanhuyse and colleagues (1975)  provided a more detailed model of how changes in the complex components of impedance (resistance and reactance) contributed to the systematic changes in admittance patterns described by Colletti (1975) . The Vanhuyse model, as it has come to be known, predicts four patterns of admittance tympanograms as a function of changes in frequency. Deviations from model predictions in normal middle ears were considered signs of middle ear dysfunction. This model has had significant impact on the development of MFT.
Estimation of an ear’s RF has become one of the main focal points of MFT, with current technology allowing measurements in the range of 250 to 2000 Hz (Margolis & Goycoolea, 1993; Margolis & Shanks, 1994). Identification of an ear’s RF, as determined by an admittance phase angle of zero, helps to distinguish between pathologies that affect conductance and susceptance in different ways, shifting the normal RF either higher, such as with middle ear effusion or ossicular fixation, or lower, such as with ossicular discontinuities (Goycoolea, 1991). Other work suggests that closer examination of relationships between specific pathologies and an admittance phase angle of 45° (the point at which susceptance and conductance are equal contributors to middle ear transmission) provides useful diagnostic information (Lilly, 1984; Shahnaz & Polka, 1997; Shanks & Shelton, 1991). Most recently, Shahnaz et al. (2009)  found that a 45° admittance phase angle (F45) criterion outperformed both conventional and RF criteria in distinguishing otosclerotic from normal-functioning middle ears.
Notwithstanding promising results, there are still some challenges facing clinical application of tympanometry. Even with the expanded frequency range available with MFT, equipment constraints limit the upper frequency range to 2000 Hz, which could limit identification of RF in some individuals (Shanks, Wilson, & Cambron, 1993). In addition, the more complicated MFT response patterns are often difficult for untrained clinicians to interpret, and the broad range of RF results obtained in individuals with normal middle ear function limits its diagnostic usefulness (Holte & Margolis, 2002; Margolis & Goycoolea, 1993; Valvik, Johnsen, & Laukli, 1994). Similarly, single-frequency 226 Hz tympanograms, which are known to be a valid and reliable measure of middle ear function in older infants, often exhibit different characteristics in younger infants (i.e., < 6 months of age), children, and adults (Groothuis, Sell, Wright, Thompson, & Altemeier, 1979; Hunter & Margolis, 1992; Keith, 1973; Paradise, Smith, & Bluestone, 1976; Pestalozza & Cusmano, 1980; Poulsen & Tos, 1978; Shurin, Pelton, & Klein, 1976).
Tympanometry in Infants
Differences in infant and adult tympanometric characteristics were described in some of the first studies of immittance in neonates (Keith, 1973; Lidén, Peterson, & Björkman, 1970). One of the most striking differences noted in infants with normal middle ear function was multipeaked W-shaped tympanograms in response to 220 Hz probe tones. Specifically, Keith (1973)  reported that out of 40 infants with healthy middle ears, seven presented with multipeaked tympanograms. The variability in immittance characteristics with the use of low-frequency probe tones prompted the use of higher frequency probe tones. In addition, more studies began to report admittance components separately (e.g., susceptance and conductance) and in terms of actual admittance units (e.g., mmhos) instead of arbitrary compliance units. Researchers began using a higher frequency probe tone of 660 Hz and found, generally, less variable tympanometric patterns and better sensitivity to middle ear disorders when compared with conventional low-frequency tympanometry (Himelfarb, Popelka, & Shanon, 1979; Holte, Margolis, & Cavanaugh, 1991; Marchant et al., 1986; McKinley, Grose, & Roush, 1997; Sprague, Wiley, & Goldstein, 1985).
More recent studies using higher probe tone frequencies (up to and including 1000 Hz) have generally supported earlier work, suggesting that 1000 Hz tympanometry is more sensitive to changes in external middle ear status in infants compared with 226 Hz tympanometry (Alaerts, Luts, & Wouters, 2007; Calandruccio, Fitzgerald, & Prieve, 2006). Some studies have reported normative tympanometric data and test performance of specific 1000 Hz admittance criteria in predicting otoacoustic emission (OAE) screening results (Kei et al., 2003). Margolis and colleagues (2003)  assessed 1000 Hz tympanometric test performance in predicting whether a newborn infant passed or failed a distortion product otoacoustic emission (DPOAE) test. With the DPOAE test outcome serving as the reference standard, the tympanometric test had a specificity of 91% but a sensitivity of only 50%. Baldwin (2006)  compared admittance tympanometry results at 226, 678, and 1000 Hz between infants (mean age of 10 weeks) grouped as having either normal or disordered middle ear function, based on a combination of air- and bone-conduction auditory brainstem response (ABR) results and behavioral assessments. The tympanograms from these infants were organized using a traditional visual classification system (Jerger, 1970; Lidén, 1969) and an alternative method proposed by Marchant et al. (1986) . The Marchant et al. method for classifying 1000 Hz tympanograms provided the best results, with sensitivity of 0.99 and specificity of 0.89. Baldwin (2006)  cautioned that these findings might not apply to neonates, as the mean chronological ages for the “normal” and “pathological” groups were 10.2 and 11.2 weeks, respectively.
The reasons for differences in immittance characteristics between adults and infants are not fully known. However, evidence suggests that developmental changes in the infant external and middle ear contribute to differences in acoustic measures of middle ear function (Holte et al., 1991; Keefe, Bulen, Arehart, & Burns, 1993; Meyer, Jardine, & Deverson, 1997). On the basis of results from several studies, low-frequency tympanometry measurements are, for the most part, adultlike by about 7 months of age and are generally considered valid and reliable predictors of middle ear function (Cantekin et al., 1980; Hunter & Margolis, 1992; Keefe et al., 1993; Keefe & Levi, 1996; Roush et al., 1995).
The American Speech-Language-Hearing Association (ASHA) guidelines for audiologic screenings do not provide normative data for immittance measurements for infants less than 7 months of age (ASHA, 1997). Furthermore, it is not known whether a single frequency would be ideal for all infants in the neonatal to 7-month range in light of changes in acoustic ear-canal response properties as a function of age (Holte et al., 1991; Meyer et al., 1997).
Wideband Acoustic Transfer Functions
Wideband acoustic transfer functions, including reflectance, absorbance, and admittance, provide a broad spectral analysis of ear canal–based measurements of middle ear function (Keefe & Feeney, 2009). The middle ear, acting essentially as a bandpass filter, does not pass all sound energy presented to the ear canal into the cochlea, as some energy is lost in the middle ear space and some is reflected back along the ear canal. Quantitative description of this reflected energy in the ear canal formed the basis for wideband reflectance measurements. Wideband reflectance (WBR) is defined as the ratio of the energy reflected from the tympanic membrane to the incident energy presented in the ear canal and is scaled from 0.0 to 1.0, with 0 corresponding to all energy absorbed by the middle ear and 1 corresponding to all energy being reflected. WBR values obtained at ambient ear-canal pressure in normal-functioning adult ears are typically near 1.0 in the low frequencies, gradually decreasing to a minimum around 4000 Hz, then increasing at higher frequencies (Stinson, 1990).
WBR and other acoustic transfer functions have been reported for normal-hearing adults (Feeney & Sanford, 2004; Keefe et al., 1993; Shahnaz & Bork, 2006; Voss & Allen, 1994), children and infants (Hunter, Tubaugh, Jackson, & Propes, 2008; Keefe et al., 1993; Sanford & Feeney, 2008; Vander Werff, Prieve, & Georgantas, 2007), healthy newborns (Abdala, Keefe, & Oba, 2007; Hunter, Feeney, Lapsley Miller, Jeng, & Bohning, 2010; Keefe & Abdala, 2007; Keefe et al., 2000; Merchant, Horton, & Voss, 2010; Sanford et al., 2009), and newborns in an intensive care unit (Shahnaz, 2008). WBR measurements are sensitive to middle ear disorders, including OME (Piskorski, Keefe, Simmons, & Gorga, 1999) and otitis media in children with cleft palate (Hunter, Bagger-Sjoback, & Lundberg, 2008). Feeney, Grant, and Marryott (2003)  reported WBR results for otitis media, otosclerosis, ossicular discontinuity, and perforation of the tympanic membrane.
This growing body of literature suggests that WBR measurements appear to be good indicators of middle ear status across the age spectrum. Wideband measures are especially attractive because they extend the frequency region over which middle ear function can be measured, including the bandwidth of speech. The application of wideband middle ear measures provides additional information to supplement and perhaps exceed traditional tympanometry.
Summary and Clinical Questions
Over the past three decades, investigations of the usefulness of ear canal–based acoustic measurements of middle ear function have contributed to a large body of literature. Although not without contradiction, the overall results suggest improvements in the ability to identify middle ear disorders when expanded stimuli and analysis parameters are used (Baldwin, 2006; Holte & Margolis, 2002; Hunter & Margolis, 1992; Margolis, Bass-Ringdahl, Hanks, Holte, & Zapala, 2003; Shahnaz et al., 2009). Additional evidence suggests that emerging techniques utilizing acoustic transfer function measurements, including energy reflectance and absorbance, may offer improvements over conventional tympanometry or MFT when evaluating middle ear status across the age span (Keefe & Feeney, 2009). As an evidence assessment of conventional (226 Hz) tympanometry has already been completed (Takata et al., 2003), by conducting this EBSR, we sought to take a more comprehensive and in-depth look at the current state of evidence regarding the diagnostic accuracy of other assessment measures, namely, 1000 Hz tympanometry, MFT, and wideband measures of middle ear assessment in identifying middle ear disorders.
An essential first step in developing the clinical questions for this review was to identify the reference standard for comparison purposes. A reference standard is considered the best available method to establish the presence or absence of a disordered condition (ASHA, n.d.) and is used to compare how well the results from the diagnostic instrument being evaluated (index test) agree with the results of the reference standard.
We preidentified acceptable reference standards used to diagnose the most common middle ear disorders on the basis of a previous review by Takata et al. (2003) . These included myringotomy, tympanocentesis, and surgical confirmation. Because surgical confirmation is invasive and not a reasonable option for some populations (e.g., newborns and those without middle ear pathology), other nonsurgical reference standards used to identify middle ear disorders were also considered. These included MRI, pneumatic otoscopy, and CT scan. Therefore, the clinical questions developed for this EBSR were as follows:
  1. For children and adults, what is the diagnostic accuracy of 1000 Hz tympanometry in identifying the presence or absence of middle ear disorders?

  2. For children and adults, what is the diagnostic accuracy of MFT in identifying the presence or absence of middle ear disorders?

  3. For children and adults, what is the diagnostic accuracy of wideband acoustic transfer functions in identifying the presence or absence of middle ear disorders?

Method
A search of published literature in peer-reviewed journals was completed between July 2010 and March 2011 in 27 electronic databases (see Appendix A). To search these databases, we used a comprehensive strategy that included medical subject headings, key words, controlled vocabulary, and free-text words related to tympanometry, reflectance, screening accuracy, and middle ear pathology (see Appendix B). Additional studies were identified through reference mining of full-text articles, reviews, guidelines, and meta-analyses.
Studies were eligible for inclusion if they were written in English, published in a peer-reviewed journal between 1975 and March 2011, and provided original data pertaining to one or more of the identified clinical questions. Included studies had to confirm middle ear disorder using at least one of the preidentified reference standards (i.e., pneumatic otoscopy, surgery, myringotomy, tympanocentesis, magnetic resonance imaging, CT scan). Case studies, investigations involving animal models, and studies that did not specify the probe tone frequency used during tympanometry were excluded. Studies examining reflectometry or participants with Down syndrome or known craniofacial anomalies (including cleft palate) were also excluded. Finally, studies were excluded if they did not report or supply sufficient data to calculate at least one metric of screening accuracy (i.e., either sensitivity or specificity) of the screening tool.
We used an eight-item critical appraisal checklist (see Table 1) to evaluate studies for methodological quality. Key components of the diagnostic accuracy checklist were based on the Critical Appraisal of Diagnostic Evidence (Dollaghan, 2007) to identify sources of possible bias or methodological characteristics that could introduce bias into the results. Given that a principal aim of this EBSR was to determine the state and quality of the evidence, all studies were included regardless of methodological rigor. In addition to the quality appraisal information, key data were extracted and summarized to provide an overview of the participant and study variables (e.g., age, gender, screening technology, and screening parameters) for each study. When not indicated in the study, sensitivity, specificity, positive likelihood ratios (LR+), negative likelihood ratios (LR−), and 95% confidence intervals (CIs) were calculated from the findings if possible. Likelihood ratios (LR) are typical metrics used in reviews of diagnostic accuracy. LRs combine sensitivity and specificity values to determine the probability of having a disorder based on a positive or a negative test result. Positive likelihood ratios indicate the probability that a person with a disorder will obtain a test result in the affected range and are calculated by dividing the sensitivity of the test by 1 minus its specificity. Conversely, LR− values reflect the probability that a person without the disorder will achieve a test result in the unaffected range and are determined by dividing 1 minus the test’s sensitivity by the test’s specificity (ASHA, n.d.).
Table 1 Quality indicators.
Quality indicators.×
Indicator Quality marker
Study rationale Was there an adequate and plausible rationale for the study?
Measure and procedure description Were measures and procedures described clearly?
Independent measure administration Were the index measure and the reference standard administered independently?
Blinding Were assessors blinded when interpreting results of the index measure and reference?
Participant selection Were participants identified through a one-gate procedurea in which the participant’s diagnosis was unknown at the time of the administration of the index test and the reference test was used to confirm a diagnosis? One-gate designs help minimize spectrum bias and increase the likelihood that the study participants will represent the full range of attributes likely to be encountered in clinical settings.
Adequate participant representation Were participants recognizable and representative of the diagnostic task?
Avoidance of verification bias Were the index measure and reference standard administered to all participants?
Likelihood ratios and confidence intervals Were likelihood ratios and confidence intervals reported or calculable?
Table 1 Quality indicators.
Quality indicators.×
Indicator Quality marker
Study rationale Was there an adequate and plausible rationale for the study?
Measure and procedure description Were measures and procedures described clearly?
Independent measure administration Were the index measure and the reference standard administered independently?
Blinding Were assessors blinded when interpreting results of the index measure and reference?
Participant selection Were participants identified through a one-gate procedurea in which the participant’s diagnosis was unknown at the time of the administration of the index test and the reference test was used to confirm a diagnosis? One-gate designs help minimize spectrum bias and increase the likelihood that the study participants will represent the full range of attributes likely to be encountered in clinical settings.
Adequate participant representation Were participants recognizable and representative of the diagnostic task?
Avoidance of verification bias Were the index measure and reference standard administered to all participants?
Likelihood ratios and confidence intervals Were likelihood ratios and confidence intervals reported or calculable?
×
For this review, LR values were characterized as informative (LR+ ≥ 10 or LR− ≤ 0.1), suggestive (LR+ ≥ 3 and < 10 or LR− ≤ 0.3 and > 0.1), or uninformative (LR+ < 3 or LR− > 0.3) for ruling a disorder in or out (Dollaghan, 2007; Sackett, Haynes, Guyatt, & Tugwell, 1991; Sackett, Straus, Richardson, Rosenberg, & Haynes, 2000). However, CIs surrounding these LRs should be considered when interpreting the results.
Results
Search
Figure 1 displays the findings from the systematic search, which generated 547 unique and potentially relevant references. On the basis of title and/or abstract, two reviewers (the second and third authors) independently examined each citation and excluded those that were clearly irrelevant, leaving 275 publications preliminarily accepted into the EBSR. The same two reviewers independently completed a full-publication review of each citation to determine final study eligibility. This resulted in the elimination of 265 studies because they did not meet one or more of the inclusion criteria. Prior to final study inclusion, the first author reviewed the list of citations for completeness. Any disagreements were resolved through discussion and consensus. Study eligibility agreement between reviewers was 89%.
Figure 1

Flow of systematic literature search. EBSR = evidence-based systematic review.

 Flow of systematic literature search. EBSR = evidence-based systematic review.
Figure 1

Flow of systematic literature search. EBSR = evidence-based systematic review.

×
A total of 10 citations are reported in the final analysis: two investigating 1000 Hz tympanometry (clinical question number 1), seven examining the accuracy of MFT (clinical question number 2), and two examining acoustic transfer functions (clinical question number 3), specifically WBR. This total exceeds 10 because one study (Shahnaz et al., 2009) addressed more than one clinical question.
Participants
The 10 studies reported data on 1,000 ears (see Table 2 for participant variables). The participants ranged in age from 42 days to 73 years and presented with a variety of middle ear disorders, including acute otitis media, OME, otosclerosis, incudostapedial disconnection, stapes fixation, and malleus or incus fixation. Participant gender was reported by ear in six studies (n = 550 ears). Of these, 56% were female and 44% were male. Studies reporting race or ethnicity information classified 69% of the participants as Caucasian, 21% as Chinese, 8% as mixed or other, and 1% or fewer as East Indian, Hispanic, or Filipino.
Table 2 Participant variables.
Participant variables.×
Citation N (Ears) Age range (M) Gender Race-ethnicity (as reported)
Abou-Elhamd et al., 2006  71 OME NR NR NR
23 acute otitis media NR NR NR
50 healthy 2.5–45 years (19) NR NR
Beers et al., 2010  42 OME 3–12 years (6.34) NR Caucasian: 67%
Chinese: 14%
Other: 19%
144 healthy 5–11 years (6.15) 75 M Caucasian: 44%
69 F Chinese: 42%
Other: 14%
Funasaka & Kumakawa, 1988  12 incudostapedial dislocation NR NR NR
6 malleus and/or incus fixation NR NR NR
22 stapes fixation NR NR NR
Harris et al., 2005  35 1–10 years (NR) 13 M NR
8 F
N = participants
Lai et al., 2008  85 OME 18–73 years (47) 28 M NR
32 F
N = participants
36 healthy 19–62 years (36) 9 M
11 F
N = participants
Ogut et al., 2008  25 otosclerosis 24–57 years (39.6) 7 M NR
18 F
100 healthy 26–56 years (36.1) 34 M NR
66 F
Shahnaz & Bork, 2008  20 otosclerosis 22–56 years (42) 3 M Caucasian: 80%
Chinese: 15%
17 F East Indian: 5%
NR healthy (53 participants) 18–34 years (23) 27 M Caucasian: 49%
26 F Chinese: 51%
N = participants
Shahnaz et al., 2009  28 otosclerosis 24–56 years (41.6) 8 M Caucasian: 71%
20 F East Indian: 14%
Chinese: 7%
Hispanic: 4%
Filipino: 4%
115 healthy 20–32 years (25.7) 51 M Caucasian: 100%
64 F
Shahnaz & Polka, 1997  14 otosclerosis 29–69 years (48) 5 M NR
9 F
68 healthy 20–43 years (22) NR NR
Zhiqi et al., 2010  104 42 days–6 months (70 days) 60 M NR
44 F
Note. OME = otitis media with effusion; NR = not reported or calculable; M = male; F = female.
Note. OME = otitis media with effusion; NR = not reported or calculable; M = male; F = female.×
Table 2 Participant variables.
Participant variables.×
Citation N (Ears) Age range (M) Gender Race-ethnicity (as reported)
Abou-Elhamd et al., 2006  71 OME NR NR NR
23 acute otitis media NR NR NR
50 healthy 2.5–45 years (19) NR NR
Beers et al., 2010  42 OME 3–12 years (6.34) NR Caucasian: 67%
Chinese: 14%
Other: 19%
144 healthy 5–11 years (6.15) 75 M Caucasian: 44%
69 F Chinese: 42%
Other: 14%
Funasaka & Kumakawa, 1988  12 incudostapedial dislocation NR NR NR
6 malleus and/or incus fixation NR NR NR
22 stapes fixation NR NR NR
Harris et al., 2005  35 1–10 years (NR) 13 M NR
8 F
N = participants
Lai et al., 2008  85 OME 18–73 years (47) 28 M NR
32 F
N = participants
36 healthy 19–62 years (36) 9 M
11 F
N = participants
Ogut et al., 2008  25 otosclerosis 24–57 years (39.6) 7 M NR
18 F
100 healthy 26–56 years (36.1) 34 M NR
66 F
Shahnaz & Bork, 2008  20 otosclerosis 22–56 years (42) 3 M Caucasian: 80%
Chinese: 15%
17 F East Indian: 5%
NR healthy (53 participants) 18–34 years (23) 27 M Caucasian: 49%
26 F Chinese: 51%
N = participants
Shahnaz et al., 2009  28 otosclerosis 24–56 years (41.6) 8 M Caucasian: 71%
20 F East Indian: 14%
Chinese: 7%
Hispanic: 4%
Filipino: 4%
115 healthy 20–32 years (25.7) 51 M Caucasian: 100%
64 F
Shahnaz & Polka, 1997  14 otosclerosis 29–69 years (48) 5 M NR
9 F
68 healthy 20–43 years (22) NR NR
Zhiqi et al., 2010  104 42 days–6 months (70 days) 60 M NR
44 F
Note. OME = otitis media with effusion; NR = not reported or calculable; M = male; F = female.
Note. OME = otitis media with effusion; NR = not reported or calculable; M = male; F = female.×
×
1000 Hz Tympanometry
Two studies (Harris, Hutchinson, & Moravec, 2005; Zhiqi, Kun, & Zhiwu, 2010) addressing clinical question number one investigated the use of 1000 Hz tympanometry to determine the presence or absence of middle ear effusion in children or infants (Table 3). Harris et al. (2005)  validated the presence or absence of middle ear effusion by using myringotomy. The calculated LR+ value (2.17) was uninformative for diagnosing OME, but the LR− value (0) was considered informative for ruling out the disorder. In Zhiqi et al. (2010), 1000 Hz tympanometry findings were compared with spiral CT scan results. Computed LRs were considered clinically informative (LR+ of 46.18; LR− of .02). However, the CIs surrounding the LRs contained values in the diagnostically suggestive range.
Table 3 Study results.
Study results.×
Citation Technology Reference standard Disorder classification Sensitivity Specificity LR+ (95% CI) LR– (95% CI)
Type Controls Disordered
Abou-Elhamd et al., 2006  MFT: 250–2000 Hz sweep frequency in 1/6 octave increments Myringotomy X OME 100 NR NR NR
AOM NR NR NR NR
Beers et al., 2010  WBR Pneumatic otoscopy and video otomicroscopy X 50% OME 96% 95% 19.8 (9.6, 40.9) 0.04 (0.01, 0.18)
Funasaka & Kumakawa, 1988  MFT: 220–2000 Hz sweep frequency Surgical confirmation X ISD 83 NR NR NR
MIF 83 NR NR NR
Stapes fixation 55 NR NR NR
Overall 68 NR NR NR
Harris et al., 2005  1000 Hz tympanometry Myringotomy and pneumatic otoscopy X X OME 100 54 2.17 (1.2, 3.9) 0 (0, UND)
Lai et al., 2008  MFT: 250–2000 Hz sweep frequency in 50 Hz increments Tympanocentesis X OME on Day 1 100 NR NR NR
Ogut et al., 2008  MFT: 250–2000 Hz sweep frequency probe tone Surgical confirmation X RF at 1025 Hz 80 82 4.4 (2.8, 7.1) 0.2 (0.1, 0.5)
Shahnaz & Bork, 2008  MFT GSI and Virtual 310 Systems: 250-2000 Hz sweep frequency in 50 Hz (GSI) and 1/6 octave (Virtual) increments Surgical confirmation X RF GSI 65 NR NR NR
RF Virtual 70 NR NR NR
F45 GSI 70 NR NR NR
F45 Virtual 70 NR NR NR
Shahnaz et al., 2009  MFT: 250–2000 Hz sweep frequency in 1/6 octave increments Surgical confirmation X Reflectance (> 90th percentile, 211–6000 Hz) 82 83 4.7 (3.1, 7.3) 0.22 (0.1, 0.5)
WBR F45 > 600 Hz (+) 79 73 2.9 (2, 4.2) 0.3 (0.1, 0.6)
Shahnaz & Polka, 1997  MFT: 250–2000 Hz sweep frequency in 1/6 octave increments; 250–2000 Hz sweep pressure at 125 daPa/sec Surgical confirmation X RF/SF (+) 64 69 2.1 (1.2, 3.5) 0.5 (0.3, 1.1)
RF/SF (−) 57 66 1.7 (1, 3) 0.7 (0.4, 1.2)
RF/SP (+) 64 68 2 (1.2, 3.3) 0.5 (0.3, 1.1)
RF/SP (−) 57 63 1.6 (0.9, 2.7) 0.7 (0.4, 1.3)
F45/SF 79 71 2.7 (1.7, 4.2) 0.3 (0.1, 0.8)
F45/SP 57 57 1.3 (0.8, 2.3) 0.8 (0.4, 1.4)
Zhiqi et al., 2010  1000 Hz tympanometry CT scan X X MEE 98 98 46.18 (6.6, 321.1) 0.02 (0, 0.13)
Note. X = groups that received the reference standard in the study. LR = likelihood ratio; CI = confidence interval; MFT = multifrequency tympanometry; AOM = acute otitis media; WBR = wideband reflectance; ISD = incudostapedial dislocation; MIF = malleus and/or incus fixation; UND = unable to determine because sensitivity = 100%; RF = resonant frequency; GSI = Grason Stadler Instruments; F45 = 45° admittance phase angle; (+) = positive compensation; SF = sweep frequency; (−) = negative compensation; SP = sweep pressure; MEE = middle ear effusion.
Note. X = groups that received the reference standard in the study. LR = likelihood ratio; CI = confidence interval; MFT = multifrequency tympanometry; AOM = acute otitis media; WBR = wideband reflectance; ISD = incudostapedial dislocation; MIF = malleus and/or incus fixation; UND = unable to determine because sensitivity = 100%; RF = resonant frequency; GSI = Grason Stadler Instruments; F45 = 45° admittance phase angle; (+) = positive compensation; SF = sweep frequency; (−) = negative compensation; SP = sweep pressure; MEE = middle ear effusion.×
Table 3 Study results.
Study results.×
Citation Technology Reference standard Disorder classification Sensitivity Specificity LR+ (95% CI) LR– (95% CI)
Type Controls Disordered
Abou-Elhamd et al., 2006  MFT: 250–2000 Hz sweep frequency in 1/6 octave increments Myringotomy X OME 100 NR NR NR
AOM NR NR NR NR
Beers et al., 2010  WBR Pneumatic otoscopy and video otomicroscopy X 50% OME 96% 95% 19.8 (9.6, 40.9) 0.04 (0.01, 0.18)
Funasaka & Kumakawa, 1988  MFT: 220–2000 Hz sweep frequency Surgical confirmation X ISD 83 NR NR NR
MIF 83 NR NR NR
Stapes fixation 55 NR NR NR
Overall 68 NR NR NR
Harris et al., 2005  1000 Hz tympanometry Myringotomy and pneumatic otoscopy X X OME 100 54 2.17 (1.2, 3.9) 0 (0, UND)
Lai et al., 2008  MFT: 250–2000 Hz sweep frequency in 50 Hz increments Tympanocentesis X OME on Day 1 100 NR NR NR
Ogut et al., 2008  MFT: 250–2000 Hz sweep frequency probe tone Surgical confirmation X RF at 1025 Hz 80 82 4.4 (2.8, 7.1) 0.2 (0.1, 0.5)
Shahnaz & Bork, 2008  MFT GSI and Virtual 310 Systems: 250-2000 Hz sweep frequency in 50 Hz (GSI) and 1/6 octave (Virtual) increments Surgical confirmation X RF GSI 65 NR NR NR
RF Virtual 70 NR NR NR
F45 GSI 70 NR NR NR
F45 Virtual 70 NR NR NR
Shahnaz et al., 2009  MFT: 250–2000 Hz sweep frequency in 1/6 octave increments Surgical confirmation X Reflectance (> 90th percentile, 211–6000 Hz) 82 83 4.7 (3.1, 7.3) 0.22 (0.1, 0.5)
WBR F45 > 600 Hz (+) 79 73 2.9 (2, 4.2) 0.3 (0.1, 0.6)
Shahnaz & Polka, 1997  MFT: 250–2000 Hz sweep frequency in 1/6 octave increments; 250–2000 Hz sweep pressure at 125 daPa/sec Surgical confirmation X RF/SF (+) 64 69 2.1 (1.2, 3.5) 0.5 (0.3, 1.1)
RF/SF (−) 57 66 1.7 (1, 3) 0.7 (0.4, 1.2)
RF/SP (+) 64 68 2 (1.2, 3.3) 0.5 (0.3, 1.1)
RF/SP (−) 57 63 1.6 (0.9, 2.7) 0.7 (0.4, 1.3)
F45/SF 79 71 2.7 (1.7, 4.2) 0.3 (0.1, 0.8)
F45/SP 57 57 1.3 (0.8, 2.3) 0.8 (0.4, 1.4)
Zhiqi et al., 2010  1000 Hz tympanometry CT scan X X MEE 98 98 46.18 (6.6, 321.1) 0.02 (0, 0.13)
Note. X = groups that received the reference standard in the study. LR = likelihood ratio; CI = confidence interval; MFT = multifrequency tympanometry; AOM = acute otitis media; WBR = wideband reflectance; ISD = incudostapedial dislocation; MIF = malleus and/or incus fixation; UND = unable to determine because sensitivity = 100%; RF = resonant frequency; GSI = Grason Stadler Instruments; F45 = 45° admittance phase angle; (+) = positive compensation; SF = sweep frequency; (−) = negative compensation; SP = sweep pressure; MEE = middle ear effusion.
Note. X = groups that received the reference standard in the study. LR = likelihood ratio; CI = confidence interval; MFT = multifrequency tympanometry; AOM = acute otitis media; WBR = wideband reflectance; ISD = incudostapedial dislocation; MIF = malleus and/or incus fixation; UND = unable to determine because sensitivity = 100%; RF = resonant frequency; GSI = Grason Stadler Instruments; F45 = 45° admittance phase angle; (+) = positive compensation; SF = sweep frequency; (−) = negative compensation; SP = sweep pressure; MEE = middle ear effusion.×
×
Multifrequency Tympanometry
Of the seven studies addressing clinical question number two, five studies (Funasaka & Kumakawa, 1988; Ogut, Serbetcioglu, Kirazli, Kirkim, & Gode, 2008; Shahnaz & Bork, 2008; Shahnaz et al., 2009; Shahnaz & Polka, 1997) examined the use of MFT to distinguish ears with otosclerosis from healthy ears or to differentiate between different types of otosclerosis. The other two studies (Abou-Elhamd, Abd-Ellatif, & Sultan, 2006; Lai, Li, Xian, & Liu, 2008) assessed the accuracy of MFT in determining the presence or absence of acute otitis media or OME (see Table 3).
Within the five studies investigating otosclerosis, both sweep frequency and sweep pressure methods were used to derive a variety of tympanometric values, which were used to determine the diagnostic accuracy of MFT. These values included RF calculated with or without positive or negative compensation (with compensation denotes a tympanometric peak to tympanometric “tail” measure) and the frequency corresponding to admittance phase angle of 45° (F45) with or without positive tail compensation. Eight sets of LRs were calculable from three of the studies (Ogut et al., 2008; Shahnaz et al., 2009; Shahnaz & Polka, 1997). The LR+ results ranged from 1.3 to 4.4. Seven of the eight LR+ values were less than 3.0 and were considered clinically uninformative. The LR+ value (4.4) calculated for RF at 1025 Hz fell into the suggestive range (Ogut et al., 2008). Although the lower bounds of the CIs for all values fell in the diagnostically uninformative range, the upper 95% CI limits for five LR + results had values in the suggestive range.
The eight LR− results ranged from 0.2 to 0.8. Values for RF at 1025 Hz (LR− = 0.24), F45 > 600 Hz with positive compensation (LR− = 0.3), and F45 from sweep frequency MFT (LR− = 0.3) fell within the diagnostically suggestive range, and the others were considered diagnostically uninformative. The upper limit CI values all fell within the uninformative range, whereas five lower CI limit values were in the suggestive range.
Two other studies (Funasaka & Kumakawa, 1988; Shahnaz & Bork, 2008) evaluated MFT in diagnosing otosclerosis but did not report sufficient data to calculate LRs. Eight sensitivity values were reported for MFT ranging from 55% to 83%. LRs were not calculable from either of the two studies that examined the accuracy of MFT in determining the presence or absence of acute otitis media or OME (Abou-Elhamd et al., 2006; Lai et al., 2008). However, calculated and reported values of sensitivity ranged from 70% to 100%.
Wideband Acoustic Transfer Functions
Mixed findings were noted in the two studies (Beers, Shahnaz, Westerberg, & Kozak, 2010; Shahnaz et al., 2009) examining the ability of wideband acoustic transfer functions to identify the presence or absence of middle ear dysfunction (see Table 3). Beers et al. (2010)  used WBR to discriminate between school-age children with OME and participants with normal middle ear status. A WBR value at 1250 Hz produced the fewest false positive and false negative results and yielded an LR+ value of 19.8 and an LR− value of 0.04, indicating a measure that is clinically informative for distinguishing the OME and normal middle ear groups. Shahnaz et al. (2009)  compared WBR results in normal-hearing participants and those with surgically confirmed otosclerosis. Positive (4.7) and negative (0.2) LRs were considered diagnostically suggestive, signifying that further testing would be required to determine the presence or absence of middle ear disorders.
Study Quality
Table 4 displays the quality markers of the included studies. Agreement between the two reviewers on study quality was 83%, with all scoring discrepancies resolved through discussion. All 10 studies provided an adequate study rationale and a clear description of the assessment measures and procedures. Most studies (8 of 10) included participants who were representative of the diagnostic task and provided sufficient data to calculate LRs and CIs (6 of 10). However, studies were lacking in other areas. Few studies (2 of 10) reported independent administration of the index test and reference standard, selected participants through a one-gate procedure (see Table 1 for explanation), or administered the index and reference standard to all participants. In addition, the assessor blinding to middle ear status or other test results was indicated in only one study (Harris et al., 2005).
Table 4 Critical appraisal of diagnostic studies.
Critical appraisal of diagnostic studies.×
Citation Quality markers
Adequate study rationale Adequate description of measures and procedures Independent measure administration Blinding 1-gate procedure Adequate participant representation Reference and index standard LR/CI calculable
Abou-Elhamd et al., 2006  Yes Yes No No No No No No
Beers et al., 2010  Yes Yes +/− No No Yes No Yes
Funasaka & Kumakawa, 1988  Yes Yes No No No No No No
Harris et al., 2005  Yes Yes Yes Yes Yes Yes Yes Yes
Lai et al., 2008  Yes Yes No No No Yes No No
Ogut et al., 2008  Yes Yes No No No Yes No Yes
Shahnaz & Bork, 2008  Yes Yes No No No Yes No No
Shahnaz et al., 2009  Yes Yes No No No Yes No Yes
Shahnaz & Polka, 1997  Yes Yes Yes No No Yes No Yes
Zhiqi et al., 2010  Yes Yes No No Yes Yes Yes Yes
Note. +/− = partial administration.
Note. +/− = partial administration.×
Table 4 Critical appraisal of diagnostic studies.
Critical appraisal of diagnostic studies.×
Citation Quality markers
Adequate study rationale Adequate description of measures and procedures Independent measure administration Blinding 1-gate procedure Adequate participant representation Reference and index standard LR/CI calculable
Abou-Elhamd et al., 2006  Yes Yes No No No No No No
Beers et al., 2010  Yes Yes +/− No No Yes No Yes
Funasaka & Kumakawa, 1988  Yes Yes No No No No No No
Harris et al., 2005  Yes Yes Yes Yes Yes Yes Yes Yes
Lai et al., 2008  Yes Yes No No No Yes No No
Ogut et al., 2008  Yes Yes No No No Yes No Yes
Shahnaz & Bork, 2008  Yes Yes No No No Yes No No
Shahnaz et al., 2009  Yes Yes No No No Yes No Yes
Shahnaz & Polka, 1997  Yes Yes Yes No No Yes No Yes
Zhiqi et al., 2010  Yes Yes No No Yes Yes Yes Yes
Note. +/− = partial administration.
Note. +/− = partial administration.×
×
The results of the included studies were further analyzed to ascertain whether differences in individual quality markers were associated with differences in LRs. Of the two studies examining 1000 Hz tympanometry, Harris et al. (2005)  provided independent and blinded administration of the reference test and reported weaker LR+ values than did Zhiqi et al. (2010), who did not report blinded or independent assessment. However, LR− values were comparable. There was minimal variability on the quality indicators or LRs in the studies examining WBR or MFT; therefore, no analyses of these studies were possible.
Discussion
The main objectives of this systematic review were to (a) assess the current state of evidence regarding the diagnostic accuracy of 1000 Hz tympanometry, MFT, and wideband measures of middle ear assessment in identifying middle ear disorders; and (b) use the results to identify both clinically useful information and areas in need of additional exploration. Although strong conclusions regarding clinical implications are tempered by the low quantity of articles that qualified for detailed analysis, some useful information can be gleaned from this review. The following section provides a discussion of both clinical implications and areas for future research.
1000 Hz Tympanometry
Of the 10 studies that qualified for detailed analysis, only two addressed the issue of diagnostic accuracy of 1000 Hz tympanometry in identifying the presence or absence of middle ear effusion. Research and clinical work with 1000 Hz tympanometry has focused on pediatric populations, and thus it is not surprising that both studies investigated the use of this tool in young children or infants.
From this small pool of studies, evidence is mixed with regard to the accuracy of 1000 Hz tympanometry in identifying the presence or absence of middle ear effusion. LR data (both negative and positive) from Zhiqi et al. (2010)  suggested that 1000 Hz tympanometry was clinically informative for ruling middle ear effusion both in and out. Zhiqi et al. (2010)  used the traditional Jerger–Lidén visual classification system, categorizing ears with “flat” admittance tympanograms (Type B) in the effusion group and ears with single-peaked tympanograms (Type A) in the normal group (CT scan was the reference standard). The authors stated that a flat tympanogram was one that had “no distinct peak, admittance < 0.2 mmho, and/or tympanometric width > 200 daPa.” However, they did not specify how admittance (Y) was calculated (e.g., uncompensated peak Y or compensated peak-to-positive or peak-to-negative tail). Mean tympanometric data, including Veq, admittance, TW, and TPP, were reported for participants with Type A tympanograms, and the authors suggested that the data be used as clinical criteria to differentiate the presence and absence of OME. Nevertheless, because admittance calculation method is not stated and CIs were not reported, use of these specific data is problematic.
LRs data from Harris et al. (2005)  revealed that 1000 Hz tympanometry was useful only for ruling out middle ear effusion. Harris and colleagues (2005)  used myringotomy as a reference standard and categorized tympanometric data according to the Vanhuyse et al. (1975)  classification system (e.g., susceptance [B] and conductance [G] tympanograms). For example, 1000 Hz tympanometry data from ears that produced either a 1B1G, 3B1G, 3B3G, or 5B3G pattern (additional tympanometric width requirements were also included) were classified as a normal middle ear. Ears with deviations from these patterns were classified as abnormal.
Factors contributing to different LR outcomes for the Harris et al. (2005)  and Zhiqi et al. (2010)  studies could include use of different reference standards (myringotomy versus CT scan), varying participant age groups (1 to 10 years versus 42 days to 6 months), and varying tympanogram classification or quantification criteria (“B/G” shape classification system as per the Vanhuyse model versus Jerger–Lidén Type A, B, etc., classification system), respectively. LR values in the clinically informative range, produced from both studies, suggest that 1000 Hz tympanometry data provide clinically useful information with regard to ruling in or out the presence of middle ear effusion, based on the studies' use of tympanometric shape classification schemes and the specific populations that were sampled. From a clinical data interpretation standpoint, data generated from the method proposed by Zhiqi et al. (2010)  would be simpler to interpret and produce more accurate diagnostic outcomes relative to the method proposed by Harris et al. (2005) .
Multifrequency Tympanometry
Otosclerosis was the disorder of interest for five of the seven studies using MFT to assess middle ear function. From the five studies evaluated, eight sets of LRs were calculable from three of the studies (Ogut et al., 2008; Shahnaz et al., 2009; Shahnaz & Polka, 1997). Resonant frequency and a phase angle of 45° (F45) were the diagnostic variables evaluated in these studies. Although data analyses revealed that one LR+ value for RF fell into the diagnostically suggestive range and the upper 95% CI limits for five LR+ results had values in the diagnostically suggestive range, seven of the eight LR values were considered to be diagnostically uninformative. The high proportion of LR+ values in the 95% CI range for RF may suggest some potential clinical utility for RF in terms of ruling in otosclerosis, but overall, these results suggest that RF and F45 were weak predictors of the presence of otosclerosis. Only two LR− values fell in the diagnostically suggestive range, one each for F45 and RF, and five LR− values in the lower 5% CI were in the diagnostically suggestive range. Similar to LR+, LR− results suggest that RF and F45 were weak predictors of the absence of otosclerosis. These results are consistent with the overall test performance findings for conventional 226 Hz tympanometry, which is also a poor predictor of otosclerosis (Shahnaz & Polka, 1997, 2002).
Wideband Acoustic Transfer Functions
Data from Beers et al. (2010), which were used to examine the diagnostic accuracy of WBR in identifying the presence or absence of OME, revealed diagnostically informative LR values. Beers et al. (2010)  evaluated WBR data at 11 discrete frequencies ranging from 630 to 6300 Hz. LR data suggest that use of a WBR criterion of 0.7 at 1250 Hz would be clinically informative for distinguishing ears with or without OME. Therefore, considering data from Beers et al. (2010), an ear with a WBR value greater than 0.7 at 1250 Hz would be classified as having OME.
With regard to diagnosing the presence or absence of otosclerosis, data from Shahnaz et al. (2009)  showed that participants with otosclerosis had significantly higher WBR in the 400 to 1000 Hz range compared with participants in the control group. Shahnaz et al. (2009)  explored test performance results for a variety of WBR criteria (e.g., individual frequencies and a range of frequencies) and found the best test performance when using the criterion of WBR exceeding the 90th percentile of the control group at any frequency from 211 to 6000 Hz. On the basis of sensitivity and specificity data from this WBR criterion, positive and negative LRs fell in the diagnostically suggestive range. The authors noted that OME and perhaps other pathologies may also cause increased WBR and that additional research is needed to evaluate WBR patterns across a broad range of middle ear pathologies to assess the potential usefulness of WBR as a diagnostic tool.
Comparisons to Conventional Tympanometry
Takata et al. (2003)  conducted a meta-analysis examining the accuracy of various middle ear assessment methods, including 226 Hz tympanometry, in diagnosing OME in children. All studies evaluated in the Takata et al. (2003)  meta-analysis used myringotomy as the reference standard for determining the presence or absence of OME.
Diagnostic methods using 226 Hz tympanometry included “portable tympanometry” and “professional tympanometry” based on both quantitative (e.g., static acoustic admittance) and qualitative (e.g., Type B or C curves) criteria. Using sensitivity and specificity data from Table 2 of Takata et al. (2003), we calculated LR+ and LR− for six diagnostic methods using 226 Hz tympanometry. Professional tympanometry using a flat or Type B or Type C2 (i.e., tympanometric peak pressure between −200 and −400 daPa) curve criterion was the only method that fell into the diagnostically informative range (LR− of 0.09). Two additional methods were classified as diagnostically suggestive for distinguishing ears without OME, and the remaining three were classified as uninformative. Three methods were classified as diagnostically suggestive for distinguishing ears with OME, and three were classified as uninformative. On the basis of the Takata et al. (2003)  analysis, the qualitative criterion of a flat, Type B, or Type C2 tympanogram shape may be the most clinically useful 226 Hz tympanometry method for ruling out OME; all other methods were classified as either diagnostically suggestive or uninformative.
Takata et al. (2003)  noted that studies included in their meta-analysis used broad categories of diagnostic methods and that their analysis did not assess combinations of diagnostic methods or algorithms. Future evidence-based reviews should address these limitations and could potentially be expanded to include the diagnostic methods assessed in the present article.
Limitations and Future Directions
One of the purposes of this systematic review was to identify areas of research that warrant additional attention. As part of this evaluation, it is important to identify some limitations that should be considered when analyzing the results of this review. Given that only articles published in English in peer-reviewed journals were considered, it is possible that some studies addressing the clinical questions of this review were not located or that the included studies overrepresent positive findings (i.e., publication bias). Additionally, few studies were eligible for inclusion, and many of the studies that were included had considerable methodological shortcomings (e.g., index measure and reference standard not administered to all participants or not administered independently and lack of assessor blinding), thereby introducing bias and minimizing the clinical utility of the findings. In addition, this review targeted a limited number of assessment instruments, and the included studies primarily addressed only two middle ear pathologies: OME and otosclerosis. Future research could evaluate the accuracy of a wider variety of middle ear assessment technologies, including combinations of technologies (e.g., 226 Hz tympanometry plus acoustic reflex testing), with these and other pathologies and incorporate more rigorous research designs to address the methodological limitations of the current body of research.
As noted earlier, because a single, strict reference standard does not exist for diagnosing all middle ear disorders, several reference standards were used in the present review. Use of multiple reference standards introduces additional variables and highlights one of the challenges in identifying a single tool for effectively diagnosing a wide range of middle ear disorders. Notwithstanding this issue, perhaps the most important consideration for future studies is to aggressively use the strictest reference standard possible. More frequent use of a strict reference standard, combined with applications of clinical decision theory analysis and LR calculations, could help to further clarify the findings in this review and more effectively evaluate the performance of different tools used for assessment of middle ear function.
The strictest reference standard, in many cases, would be the use of surgical confirmation or a CT scan to diagnose middle ear disorders. Although ethical considerations prohibit surgical procedures and CT scans in participants with no indications of middle ear pathology (e.g., control groups), research studies involving individuals who would be receiving these treatments as part of their clinical care in hospitals and surgery centers could be more aggressively pursued. Though not always easily initiated, greater collaborative research efforts by physicians, clinicians, and scientists could yield studies with more clinically useful outcomes.
A less strict reference standard, pneumatic otoscopy, was included as an acceptable reference standard in the present review because surgical confirmation is not always practical, and clinical practice guidelines for assessing and treating OME rely heavily on pneumatic otoscopy (American Academy of Family Physicians, American Academy of Otolaryngology—Head and Neck Surgery, and American Academy of Pediatrics Subcommittee on Otitis Media with Effusion, 2004). Takata et al. (2003)  reported that out of eight different methods, pneumatic otoscopy was the best for diagnosing OME, with 94% sensitivity and 80% specificity. Although pneumatic otoscopy is relatively noninvasive and can be used in most populations, outcomes for predicting OME can have significant variability both within and across otoscopists (Finitzo, Friel-Patti, Chinn, & Brown, 1992; Rogers, Boseley, Adams, Makowski, & Hohman, 2010). Such factors may have influenced the results from some of the studies included in this review.
Practical considerations also limit use of surgical exploration, CT scans, and pneumatic otoscopy in young infants. Because ABR and OAE tests are dependent on and can be heavily influenced by middle ear function, these tests are often used as a reference standard when assessing the diagnostic and screening utility of middle ear assessment tools (e.g., 1000 Hz tympanometry and WBR) in infants (Baldwin, 2006; Hunter et al., 2010; Kei et al., 2003; Margolis et al., 2003; Sanford et al., 2009). Although these objective measures were not included as a reference standard in the present review and are less than ideal as a reference standard, until a better reference standard is established, OAE and ABR may be the best objective reference standards currently available for use in studies of the diagnostic and screening utility of middle ear assessment tools in young infants. Although beyond the scope of the current study, an evidence-based review of ABR and OAE reference standards would be a valuable addition to the growing body of literature in this area.
Data from studies using 1000 Hz tympanometry and WBR to predict the presence or absence of OME produced LR results considered to be diagnostically informative and are supportive of their use in clinical settings. It is important to remember that responsible implementation of the diagnostic criteria used in the reviewed studies is contingent on a clear understanding of the population and equipment characteristics under which the data were gathered. Clinicians must be careful to use similar equipment and stimulus parameters and not generalize the findings to populations outside of those used to generate test performance criteria.
A potentially useful outcome of acoustic middle ear measurements is the wide array of data obtained from such measurements. As discussed earlier, both qualitative and quantitative data can be generated and analyzed. A relatively simple measurement outcome, using a 1000 Hz tympanometry test, is compounded with the additional frequency information in MFT and WBR measurements. The variety of LR results obtained across studies using different test outcomes (e.g., tympanometric shape, RF, F45, WBR at individual and multiple frequencies) and different middle ear pathologies suggests that additional research is needed to investigate whether multiple middle ear tests are needed to accurately classify ears as normal or disordered or whether a single test criterion could be a valid predictor of middle ear status across a variety of disorders and ages.
The intent of the present review was to provide guidance for clinicians with regard to their efforts to accurately identify middle ear disorders and shed light on issues in need of further investigation. Some useful clinical information was obtained; however, it is clear that more evidence is needed to identify middle ear assessment tools that accurately predict the presence or absence of a wide variety of middle ear disorders.
Acknowledgments
This evidence-based systematic review was supported by the American Speech-Language-Hearing Association’s National Center for Evidence-Based Practice in Communication Disorders (N-CEP). The authors thank the following individuals, who contributed to the preparation of this article: Laura J. Cannon, N-CEP research assistant; and Rob Mullen, N-CEP director.
References

References marked with an asterisk indicate studies included in the evidence-based systematic review.

Abdala, C., Keefe, D. H., & Oba, S. (2007). Distortion product otoacoustic emission suppression tuning and acoustic admittance in human infants: Birth through 6 months. The Journal of the Acoustical Society of America, 121, 2617–2627. [Article]
Abdala, C., Keefe, D. H., & Oba, S. (2007). Distortion product otoacoustic emission suppression tuning and acoustic admittance in human infants: Birth through 6 months. The Journal of the Acoustical Society of America, 121, 2617–2627. [Article] ×
*Abou-Elhamd, K., Abd-Ellatif, A., & Sultan, M. A. (2006). The role of multifrequency tympanometry in otitis media. Saudi Medical Journal, 27, 357–360. [PubMed]
*Abou-Elhamd, K., Abd-Ellatif, A., & Sultan, M. A. (2006). The role of multifrequency tympanometry in otitis media. Saudi Medical Journal, 27, 357–360. [PubMed]×
Alaerts, J., Luts, H., & Wouters, J. (2007). Evaluation of middle ear function in young children: Clinical guidelines for the use of 226- and 1,000-Hz tympanometry. Otology & Neurotology, 28, 27–32. [Article]
Alaerts, J., Luts, H., & Wouters, J. (2007). Evaluation of middle ear function in young children: Clinical guidelines for the use of 226- and 1,000-Hz tympanometry. Otology & Neurotology, 28, 27–32. [Article] ×
Alberti, P. W., & Jerger, J. F. (1974). Probe-tone frequency and the diagnostic value of tympanometry. Archives of Otolaryngology, 99, 206–210. [Article] [PubMed]
Alberti, P. W., & Jerger, J. F. (1974). Probe-tone frequency and the diagnostic value of tympanometry. Archives of Otolaryngology, 99, 206–210. [Article] [PubMed]×
American Academy of Family Physicians, American Academy of Otolaryngology–Head and Neck Surgery, and American Academy of Pediatrics Subcommittee on Otitis Media With Effusion (2004). Otitis media with effusion: Clinical practice guideline. Pediatrics, 113, 1412–1429. [Article] [PubMed]
American Academy of Family Physicians, American Academy of Otolaryngology–Head and Neck Surgery, and American Academy of Pediatrics Subcommittee on Otitis Media With Effusion (2004). Otitis media with effusion: Clinical practice guideline. Pediatrics, 113, 1412–1429. [Article] [PubMed]×
American Speech-Language-Hearing Association (1988). Aural Acoustic-Immittance Measurements Committee on Audiologic Evaluation. Journal of Speech and Hearing Disorders, 53, 354–377. [PubMed]
American Speech-Language-Hearing Association (1988). Aural Acoustic-Immittance Measurements Committee on Audiologic Evaluation. Journal of Speech and Hearing Disorders, 53, 354–377. [PubMed]×
American Speech-Language-Hearing Association (1997). Guidelines for screening for hearing impairment—Preschool children 3 to 5 years. In Guidelines for audiologic screening: ASHA Panel on Audiologic Assessment (pp. 35–38). Rockville, MD: AuthorAvailable from www.asha.org/policy/GL1997-00199.htm
American Speech-Language-Hearing Association (1997). Guidelines for screening for hearing impairment—Preschool children 3 to 5 years. In Guidelines for audiologic screening: ASHA Panel on Audiologic Assessment (pp. 35–38). Rockville, MD: AuthorAvailable from www.asha.org/policy/GL1997-00199.htm×
American Speech-Language-Hearing Association. (n.d.). Evidence-based practice glossary. Available from www.asha.org/members/ebp/Glossary.htm
American Speech-Language-Hearing Association. (n.d.). Evidence-based practice glossary. Available from www.asha.org/members/ebp/Glossary.htm×
Baldwin, M. (2006). Choice of probe tone and classification of trace patterns in tympanometry undertaken in early infancy. International Journal of Audiology, 45, 417–427. [Article] [PubMed]
Baldwin, M. (2006). Choice of probe tone and classification of trace patterns in tympanometry undertaken in early infancy. International Journal of Audiology, 45, 417–427. [Article] [PubMed]×
*Beers, A. N., Shahnaz, N., Westerberg, B. D., & Kozak, F. K. (2010). Wideband reflectance in normal Caucasian and Chinese school-aged children and in children with otitis media with effusion. Ear and Hearing, 31, 221–233. [Article] [PubMed]
*Beers, A. N., Shahnaz, N., Westerberg, B. D., & Kozak, F. K. (2010). Wideband reflectance in normal Caucasian and Chinese school-aged children and in children with otitis media with effusion. Ear and Hearing, 31, 221–233. [Article] [PubMed]×
Calandruccio, L., Fitzgerald, T. S., & Prieve, B. A. (2006). Normative multifrequency tympanometry in infants and toddlers. Journal of the American Academy of Audiology, 17, 470–480. [Article] [PubMed]
Calandruccio, L., Fitzgerald, T. S., & Prieve, B. A. (2006). Normative multifrequency tympanometry in infants and toddlers. Journal of the American Academy of Audiology, 17, 470–480. [Article] [PubMed]×
Cantekin, E. L., Bluestone, C. D., Fria, T. J., Stool, S. E., Berry, Q. C., & Sabo, D. L. (1980). Identification of otitis media with effusion in children. Annals of Otology, Rhinology and Laryngology, 89, 190–196.
Cantekin, E. L., Bluestone, C. D., Fria, T. J., Stool, S. E., Berry, Q. C., & Sabo, D. L. (1980). Identification of otitis media with effusion in children. Annals of Otology, Rhinology and Laryngology, 89, 190–196.×
Centre for Reviews and Dissemination. (2009). Systematic reviews: CRD’s guidance for undertaking reviews in health care. Available from www.york.ac.uk/inst/crd/index_guidance.htm
Centre for Reviews and Dissemination. (2009). Systematic reviews: CRD’s guidance for undertaking reviews in health care. Available from www.york.ac.uk/inst/crd/index_guidance.htm×
Colletti, V. (1975). Methodologic observations on tympanometry with regard to the probe-tone frequency. Acta Otolaryngology, 80, 54–60. [Article]
Colletti, V. (1975). Methodologic observations on tympanometry with regard to the probe-tone frequency. Acta Otolaryngology, 80, 54–60. [Article] ×
Colletti, V. (1976). Tympanometry from 200 to 2000 Hz probe tone. Audiology, 15, 106–119. [Article] [PubMed]
Colletti, V. (1976). Tympanometry from 200 to 2000 Hz probe tone. Audiology, 15, 106–119. [Article] [PubMed]×
Dollaghan, C. A. (2007). Appraising diagnostic evidence: The handbook for evidence-based practice in communication disorders. Baltimore, MD: Brookes.
Dollaghan, C. A. (2007). Appraising diagnostic evidence: The handbook for evidence-based practice in communication disorders. Baltimore, MD: Brookes.×
Dollaghan, C., & Horner, E. (2011). Bilingual language assessment: A meta-analysis of diagnostic accuracy. Journal of Speech, Language, and Hearing Research, 54, 1077–1088. [Article]
Dollaghan, C., & Horner, E. (2011). Bilingual language assessment: A meta-analysis of diagnostic accuracy. Journal of Speech, Language, and Hearing Research, 54, 1077–1088. [Article] ×
Feeney, M. P., Grant, I. L., & Marryott, L. P. (2003). Wideband energy reflectance measurements in adults with middle-ear disorders. Journal of Speech, Language, and Hearing Research, 46, 901–911. [Article]
Feeney, M. P., Grant, I. L., & Marryott, L. P. (2003). Wideband energy reflectance measurements in adults with middle-ear disorders. Journal of Speech, Language, and Hearing Research, 46, 901–911. [Article] ×
Feeney, M. P., & Sanford, C. A. (2004). Age effects in the human middle ear: Wideband acoustical measures. The Journal of the Acoustical Society of America, 116, 3546–3558. [Article] [PubMed]
Feeney, M. P., & Sanford, C. A. (2004). Age effects in the human middle ear: Wideband acoustical measures. The Journal of the Acoustical Society of America, 116, 3546–3558. [Article] [PubMed]×
Feldman, A. S. (1976). Tympanometry—Procedures, interpretations and variables. In Feldman, A. S., & Wilber, L. A. (Eds.), Acoustic impedance and admittance: The measurement of middle ear function (pp. 103–155). Baltimore, MD: Williams & Wilkins.
Feldman, A. S. (1976). Tympanometry—Procedures, interpretations and variables. In Feldman, A. S., & Wilber, L. A. (Eds.), Acoustic impedance and admittance: The measurement of middle ear function (pp. 103–155). Baltimore, MD: Williams & Wilkins.×
Finitzo, T., Friel-Patti, S., Chinn, K., & Brown, O. (1992). Tympanometry and otoscopy prior to myringotomy: Issues in diagnosis of otitis media. International Journal of Pediatric Otrhinolaryngology, 24, 1001–1010.
Finitzo, T., Friel-Patti, S., Chinn, K., & Brown, O. (1992). Tympanometry and otoscopy prior to myringotomy: Issues in diagnosis of otitis media. International Journal of Pediatric Otrhinolaryngology, 24, 1001–1010.×
*Funasaka, S., & Kumakawa, K. (1988). Tympanometry using a sweep-frequency probe tone and its clinical evaluation. Audiology, 27(2)99–108. [Article] [PubMed]
*Funasaka, S., & Kumakawa, K. (1988). Tympanometry using a sweep-frequency probe tone and its clinical evaluation. Audiology, 27(2)99–108. [Article] [PubMed]×
Goycoolea, H. (1991). Multifrequency tympanometry in normal adults. (Unpublished master’s thesis). University of Minnesota, Minneapolis.
Goycoolea, H. (1991). Multifrequency tympanometry in normal adults. (Unpublished master’s thesis). University of Minnesota, Minneapolis.×
Groothuis, J. R., Sell, S. H., Wright, P. F., Thompson, J. M., & Altemeier, W. A. (1979). Otitis media in infancy: Tympanometric findings. Pediatrics, 63, 435–442. [PubMed]
Groothuis, J. R., Sell, S. H., Wright, P. F., Thompson, J. M., & Altemeier, W. A. (1979). Otitis media in infancy: Tympanometric findings. Pediatrics, 63, 435–442. [PubMed]×
*Harris, P. K., Hutchinson, K. M., & Moravec, J. (2005). The use of tympanometry and pneumatic otoscopy for predicting middle ear disease. American Journal of Audiology, 14, 3–13. [Article] [PubMed]
*Harris, P. K., Hutchinson, K. M., & Moravec, J. (2005). The use of tympanometry and pneumatic otoscopy for predicting middle ear disease. American Journal of Audiology, 14, 3–13. [Article] [PubMed]×
Himelfarb, M. Z., Popelka, G. R., & Shanon, E. (1979). Tympanometry in normal neonates. Journal of Speech and Hearing Research, 22, 179–191. [Article] [PubMed]
Himelfarb, M. Z., Popelka, G. R., & Shanon, E. (1979). Tympanometry in normal neonates. Journal of Speech and Hearing Research, 22, 179–191. [Article] [PubMed]×
Holte, L., & Margolis, R. H. (2002). Contemporary research in tympanometry. Current Opinion in Otolaryngology & Head and Neck Surgery, 10, 387–391. [Article]
Holte, L., & Margolis, R. H. (2002). Contemporary research in tympanometry. Current Opinion in Otolaryngology & Head and Neck Surgery, 10, 387–391. [Article] ×
Holte, L., Margolis, R. H., & Cavanaugh, R. (1991). Developmental changes in multifrequency tympanograms. Audiology, 30, 1–24. [Article] [PubMed]
Holte, L., Margolis, R. H., & Cavanaugh, R. (1991). Developmental changes in multifrequency tympanograms. Audiology, 30, 1–24. [Article] [PubMed]×
Hunter, L., Bagger-Sjoback, D., & Lundberg, M. (2008). Wideband reflectance associated with otitis media in infants and children with cleft palate. International Journal of Audiology, 47, 57–61. [Article]
Hunter, L., Bagger-Sjoback, D., & Lundberg, M. (2008). Wideband reflectance associated with otitis media in infants and children with cleft palate. International Journal of Audiology, 47, 57–61. [Article] ×
Hunter, L. L., Feeney, M. P., Lapsley Miller, J. A., Jeng, P. S., & Bohning, S. (2010). Wideband reflectance in newborns: Normative regions and relationship to hearing-screening results. Ear and Hearing, 31, 599–610. [PubMed]
Hunter, L. L., Feeney, M. P., Lapsley Miller, J. A., Jeng, P. S., & Bohning, S. (2010). Wideband reflectance in newborns: Normative regions and relationship to hearing-screening results. Ear and Hearing, 31, 599–610. [PubMed]×
Hunter, L., & Margolis, R. H. (1992). Multifrequency tympanometry: Current clinical application. American Journal of Audiology, 1, 33–43. [Article]
Hunter, L., & Margolis, R. H. (1992). Multifrequency tympanometry: Current clinical application. American Journal of Audiology, 1, 33–43. [Article] ×
Hunter, L., Tubaugh, L., Jackson, A., & Propes, S. (2008). Wideband middle ear power measurement in infants and children. Journal of the American Academy of Audiology, 19, 309–324. [Article] [PubMed]
Hunter, L., Tubaugh, L., Jackson, A., & Propes, S. (2008). Wideband middle ear power measurement in infants and children. Journal of the American Academy of Audiology, 19, 309–324. [Article] [PubMed]×
Jerger, J. (1970). Clinical experience with impedance audiometry. Archives of Otolaryngology, 92, 311–324. [Article] [PubMed]
Jerger, J. (1970). Clinical experience with impedance audiometry. Archives of Otolaryngology, 92, 311–324. [Article] [PubMed]×
Keefe, D. H., & Abdala, C. (2007). Theory of forward and reverse middle-ear transmission applied to otoacoustic emissions in infant and adult ears. The Journal of the Acoustical Society of America, 121, 978–993. [Article] [PubMed]
Keefe, D. H., & Abdala, C. (2007). Theory of forward and reverse middle-ear transmission applied to otoacoustic emissions in infant and adult ears. The Journal of the Acoustical Society of America, 121, 978–993. [Article] [PubMed]×
Keefe, D. H., Bulen, J. C., Arehart, K. H., & Burns, E. M. (1993). Ear-canal impedance and reflection coefficient inhuman infants and adults. The Journal of the Acoustical Society of America, 94, 2617–2638. [Article] [PubMed]
Keefe, D. H., Bulen, J. C., Arehart, K. H., & Burns, E. M. (1993). Ear-canal impedance and reflection coefficient inhuman infants and adults. The Journal of the Acoustical Society of America, 94, 2617–2638. [Article] [PubMed]×
Keefe, D. H., & Feeney, M. P. (2009). Principles of acoustic immittance and acoustic transfer functions. In Katz, J. (Ed.), Handbook of clinical audiology (6th ed., pp. 125–156). Baltimore, MD: Lippincott, Williams, & Wilkins.
Keefe, D. H., & Feeney, M. P. (2009). Principles of acoustic immittance and acoustic transfer functions. In Katz, J. (Ed.), Handbook of clinical audiology (6th ed., pp. 125–156). Baltimore, MD: Lippincott, Williams, & Wilkins.×
Keefe, D. H., Folsom, R. C., Gorga, M. P., Vohr, B. R., Bulen, J. C., & Norton, S. (2000). Identification of neonatal hearing impairment: Ear canal measurements of acoustic admittance and reflectance in neonates. Ear and Hearing, 21, 443–461. [Article] [PubMed]
Keefe, D. H., Folsom, R. C., Gorga, M. P., Vohr, B. R., Bulen, J. C., & Norton, S. (2000). Identification of neonatal hearing impairment: Ear canal measurements of acoustic admittance and reflectance in neonates. Ear and Hearing, 21, 443–461. [Article] [PubMed]×
Keefe, D. H., & Levi, E. (1996). Maturation of the middle and external ears: Acoustic power-based responses and reflectance tympanometry. Ear and Hearing, 17, 361–373. [Article] [PubMed]
Keefe, D. H., & Levi, E. (1996). Maturation of the middle and external ears: Acoustic power-based responses and reflectance tympanometry. Ear and Hearing, 17, 361–373. [Article] [PubMed]×
Kei, J., Allison-Levick, J., Dockray, J., Harrys, R., Kirkegard, C., Wong, J., & Tudehope, D. (2003). High-frequency (1000 Hz) tympanometry in normal neonates. Journal of the American Academy of Audiology, 14, 20–28. [Article] [PubMed]
Kei, J., Allison-Levick, J., Dockray, J., Harrys, R., Kirkegard, C., Wong, J., & Tudehope, D. (2003). High-frequency (1000 Hz) tympanometry in normal neonates. Journal of the American Academy of Audiology, 14, 20–28. [Article] [PubMed]×
Keith, R. (1973). Impedance audiometry with neonates. Archives of Otolaryngology, 97, 465–467. [Article] [PubMed]
Keith, R. (1973). Impedance audiometry with neonates. Archives of Otolaryngology, 97, 465–467. [Article] [PubMed]×
*Lai, D., Li, W., Xian, J., & Liu, S. (2008). Multifrequency tympanometry in adults with otitis media with effusion. European Archives of Otorhinolaryngology, 265, 1021–1025. [Article] [PubMed]
*Lai, D., Li, W., Xian, J., & Liu, S. (2008). Multifrequency tympanometry in adults with otitis media with effusion. European Archives of Otorhinolaryngology, 265, 1021–1025. [Article] [PubMed]×
Lidén, G. (1969). The scope and application of current audiometric tests. Journal of Laryngology and Otology, 83, 507–520. [Article] [PubMed]
Lidén, G. (1969). The scope and application of current audiometric tests. Journal of Laryngology and Otology, 83, 507–520. [Article] [PubMed]×
Lidén, G., Peterson, J. L., & Björkman, G. (1970). Tympanometry. Archives of Otolaryngology, 92, 248–257. [Article] [PubMed]
Lidén, G., Peterson, J. L., & Björkman, G. (1970). Tympanometry. Archives of Otolaryngology, 92, 248–257. [Article] [PubMed]×
Lildholdt, T., Courtois, J., Kortholm, B., Schou, J. W., & Warrer, H. (1979). The occurrence of negative middle ear pressure in children: An analysis of supposed associated factors. International Journal of Pediatric Otorhinolaryngology, 1, 211–219. [Article] [PubMed]
Lildholdt, T., Courtois, J., Kortholm, B., Schou, J. W., & Warrer, H. (1979). The occurrence of negative middle ear pressure in children: An analysis of supposed associated factors. International Journal of Pediatric Otorhinolaryngology, 1, 211–219. [Article] [PubMed]×
Lilly, D. (1984). Multiple frequency, multiple component tympanometry: New approaches to an old diagnostic problem. Ear and Hearing, 5, 300–308. [Article] [PubMed]
Lilly, D. (1984). Multiple frequency, multiple component tympanometry: New approaches to an old diagnostic problem. Ear and Hearing, 5, 300–308. [Article] [PubMed]×
Marchant, C. D., McMillan, P. M., Shurin, P. A., Johnson, C. E., Turczyk, V. A., Feinstein, J. C., & Murdell Panek, D. (1986). Objective diagnosis of otitis media by tympanometry and ipsilateral acoustic reflex thresholds. Journal of Pediatrics, 109, 590–595. [Article] [PubMed]
Marchant, C. D., McMillan, P. M., Shurin, P. A., Johnson, C. E., Turczyk, V. A., Feinstein, J. C., & Murdell Panek, D. (1986). Objective diagnosis of otitis media by tympanometry and ipsilateral acoustic reflex thresholds. Journal of Pediatrics, 109, 590–595. [Article] [PubMed]×
Margolis, R. H. (1978). Tympanometry in infants—State of the art. In Hanford, E. R., Bess, F. H., Bluestone, C. D., & Klein, J. O. (Eds.), Impedance screening for middle ear disease in children (pp. 11–16). New York, NY: Grune & Statton.
Margolis, R. H. (1978). Tympanometry in infants—State of the art. In Hanford, E. R., Bess, F. H., Bluestone, C. D., & Klein, J. O. (Eds.), Impedance screening for middle ear disease in children (pp. 11–16). New York, NY: Grune & Statton.×
Margolis, R. H., Bass-Ringdahl, S., Hanks, W., Holte, L., & Zapala, D. (2003). Tympanometry in newborn infants—1 kHz norms. Journal of the American Academy of Audiology, 14, 383–392. [PubMed]
Margolis, R. H., Bass-Ringdahl, S., Hanks, W., Holte, L., & Zapala, D. (2003). Tympanometry in newborn infants—1 kHz norms. Journal of the American Academy of Audiology, 14, 383–392. [PubMed]×
Margolis, R. H., & Goycoolea, H. G. (1993). Multifrequency tympanometry in normal adults. Ear and Hearing, 14, 408–413. [Article] [PubMed]
Margolis, R. H., & Goycoolea, H. G. (1993). Multifrequency tympanometry in normal adults. Ear and Hearing, 14, 408–413. [Article] [PubMed]×
Margolis, R., & Hunter, L. (1999). Tympanometry: Basic principles and clinical application. In Musiek, F., & Rintelmann, W. (Eds.), Contemporary perspectives in hearing assessment (pp. 89–130). Boston, MA: Allyn & Bacon.
Margolis, R., & Hunter, L. (1999). Tympanometry: Basic principles and clinical application. In Musiek, F., & Rintelmann, W. (Eds.), Contemporary perspectives in hearing assessment (pp. 89–130). Boston, MA: Allyn & Bacon.×
Margolis, R. H., & Hunter, L. L. (2000). Acoustic immittance measurements. In Roeser, R., Valente, M., & Hosford-Dunn, H. (Eds.), Audiology diagnosis (pp. 381–425). New York, NY: Thieme.
Margolis, R. H., & Hunter, L. L. (2000). Acoustic immittance measurements. In Roeser, R., Valente, M., & Hosford-Dunn, H. (Eds.), Audiology diagnosis (pp. 381–425). New York, NY: Thieme.×
Margolis, R. H., Hunter, L. L., & Giebink, G. S. (1994). Tympanometric evaluation of middle ear function in children with otitis media. Annals of Otology, Rhinology & Laryngology, 163(Suppl.), 34–38.
Margolis, R. H., Hunter, L. L., & Giebink, G. S. (1994). Tympanometric evaluation of middle ear function in children with otitis media. Annals of Otology, Rhinology & Laryngology, 163(Suppl.), 34–38.×
Margolis, R. H., & Popelka, G. R. (1977). Interactions among tympanometric variables. Journal of Speech and Hearing Research, 20, 447–462. [Article] [PubMed]
Margolis, R. H., & Popelka, G. R. (1977). Interactions among tympanometric variables. Journal of Speech and Hearing Research, 20, 447–462. [Article] [PubMed]×
Margolis, R. H., & Shanks, J. E. (1994). Tympanometry. In Katz, J. (Ed.), Handbook of clinical audiology (4th ed., pp. 438–475). Baltimore, MD: Williams & Wilkins.
Margolis, R. H., & Shanks, J. E. (1994). Tympanometry. In Katz, J. (Ed.), Handbook of clinical audiology (4th ed., pp. 438–475). Baltimore, MD: Williams & Wilkins.×
McKinley, A. M., Grose, J. H., & Roush, J. (1997). Multifrequency tympanometry and evoked otoacoustic emissions in neonates during the first 24 hours of life. Journal of the American Academy of Audiology, 8, 218–223. [PubMed]
McKinley, A. M., Grose, J. H., & Roush, J. (1997). Multifrequency tympanometry and evoked otoacoustic emissions in neonates during the first 24 hours of life. Journal of the American Academy of Audiology, 8, 218–223. [PubMed]×
Merchant, G. R., Horton, N. J., & Voss, S. E. (2010). Normative reflectance and transmittance measurements on healthy newborn and 1-month-old infants. Ear and Hearing, 31, 746–754. [Article] [PubMed]
Merchant, G. R., Horton, N. J., & Voss, S. E. (2010). Normative reflectance and transmittance measurements on healthy newborn and 1-month-old infants. Ear and Hearing, 31, 746–754. [Article] [PubMed]×
Metz, O. (1953). Influence of the patulous Eustachian tube on the acoustic impedance of the ear. Acta Otolaryngology, 109(Suppl.), 105. [Article]
Metz, O. (1953). Influence of the patulous Eustachian tube on the acoustic impedance of the ear. Acta Otolaryngology, 109(Suppl.), 105. [Article] ×
Meyer, S. E., Jardine, C. A., & Deverson, W. (1997). Developmental changes in tympanometry: A case study. British Journal of Audiology, 31, 189–195. [Article] [PubMed]
Meyer, S. E., Jardine, C. A., & Deverson, W. (1997). Developmental changes in tympanometry: A case study. British Journal of Audiology, 31, 189–195. [Article] [PubMed]×
Nozza, R., Bluestone, C., Kardatze, D., & Bachman, R. (1992). Towards the validation of aural acoustic immittance measures for diagnosis of middle ear effusion in children. Ear and Hearing, 13, 442–453. [Article] [PubMed]
Nozza, R., Bluestone, C., Kardatze, D., & Bachman, R. (1992). Towards the validation of aural acoustic immittance measures for diagnosis of middle ear effusion in children. Ear and Hearing, 13, 442–453. [Article] [PubMed]×
Nozza, R., Bluestone, C., Kardatze, D., & Bachman, R. (1994). Identification of middle ear effusion by aural acoustic immittance measures for diagnosis of middle ear effusion in children. Ear and Hearing, 15, 310–323. [Article] [PubMed]
Nozza, R., Bluestone, C., Kardatze, D., & Bachman, R. (1994). Identification of middle ear effusion by aural acoustic immittance measures for diagnosis of middle ear effusion in children. Ear and Hearing, 15, 310–323. [Article] [PubMed]×
*Ogut, F., Serbetcioglu, B., Kirazli, T., Kirkim, G., & Gode, S. (2008). Results of multiple-frequency tympanometry measures in normal and otosclerotic middle ears. International Journal of Audiology, 47, 615–620. [Article] [PubMed]
*Ogut, F., Serbetcioglu, B., Kirazli, T., Kirkim, G., & Gode, S. (2008). Results of multiple-frequency tympanometry measures in normal and otosclerotic middle ears. International Journal of Audiology, 47, 615–620. [Article] [PubMed]×
Paradise, J., Smith, C., & Bluestone, C. (1976). Tympanometric detection of middle ear effusion in infants and young children. Journal of Pediatrics, 587, 198–210.
Paradise, J., Smith, C., & Bluestone, C. (1976). Tympanometric detection of middle ear effusion in infants and young children. Journal of Pediatrics, 587, 198–210.×
Pestalozza, G., & Cusmano, G. (1980). Evaluation of tympanometry in diagnosis and treatment of otitis media of the newborn and of the infant. International Journal of Pediatric Otorhinolaryngology, 2, 73–82. [Article] [PubMed]
Pestalozza, G., & Cusmano, G. (1980). Evaluation of tympanometry in diagnosis and treatment of otitis media of the newborn and of the infant. International Journal of Pediatric Otorhinolaryngology, 2, 73–82. [Article] [PubMed]×
Piskorski, P., Keefe, D. H., Simmons, J. L., & Gorga, M. P. (1999). Prediction of conductive hearing loss based on acoustic ear-canal response using a multivariate clinical decision theory. The Journal of the Acoustical Society of America, 105, 1749–1764. [Article] [PubMed]
Piskorski, P., Keefe, D. H., Simmons, J. L., & Gorga, M. P. (1999). Prediction of conductive hearing loss based on acoustic ear-canal response using a multivariate clinical decision theory. The Journal of the Acoustical Society of America, 105, 1749–1764. [Article] [PubMed]×
Poulsen, G., & Tos, M. (1978). Screening tympanometry in newborn infants and during the first six months of life. Scandinavia Audiology, 7, 59–66.
Poulsen, G., & Tos, M. (1978). Screening tympanometry in newborn infants and during the first six months of life. Scandinavia Audiology, 7, 59–66.×
Rogers, D. J., Boseley, M. E., Adams, M. T., Makowski, R. L., & Hohman, M. H. (2010). Prospective comparison of handheld pneumatic otoscopy, binocular microscopy, and tympanometry in identifying middle ear effusions in children. International Journal of Pediatric Otrhinolaryngology, 74, 1140–1143. [Article]
Rogers, D. J., Boseley, M. E., Adams, M. T., Makowski, R. L., & Hohman, M. H. (2010). Prospective comparison of handheld pneumatic otoscopy, binocular microscopy, and tympanometry in identifying middle ear effusions in children. International Journal of Pediatric Otrhinolaryngology, 74, 1140–1143. [Article] ×
Roush, J., Bryant, K., Mundy, M., Zeisel, S., & Roberts, J. (1995). Developmental changes in static admittance and tympanometric width in infants and toddlers. Journal of the American Academy of Audiology, 6, 334–338. [PubMed]
Roush, J., Bryant, K., Mundy, M., Zeisel, S., & Roberts, J. (1995). Developmental changes in static admittance and tympanometric width in infants and toddlers. Journal of the American Academy of Audiology, 6, 334–338. [PubMed]×
Sackett, D. L., Haynes, R. B., Guyatt, G. H., & Tugwell, P. (1991). Clinical epidemiology: A basic science for clinical medicine (2nd ed.). Boston, MA: Little, Brown.
Sackett, D. L., Haynes, R. B., Guyatt, G. H., & Tugwell, P. (1991). Clinical epidemiology: A basic science for clinical medicine (2nd ed.). Boston, MA: Little, Brown.×
Sackett, D. L., Straus, S. E., Richardson, W. S., Rosenberg, W., & Haynes, R. B. (2000). Evidence-based medicine: How to practice and teach EBM. Edinburgh, Scotland: Churchill Livingstone.
Sackett, D. L., Straus, S. E., Richardson, W. S., Rosenberg, W., & Haynes, R. B. (2000). Evidence-based medicine: How to practice and teach EBM. Edinburgh, Scotland: Churchill Livingstone.×
Sanford, C. A., & Feeney, M. P. (2008). Effects of maturation on tympanometric wideband acoustic transfer functions in human infants. The Journal of the Acoustical Society of America, 124, 2106–2122. [Article] [PubMed]
Sanford, C. A., & Feeney, M. P. (2008). Effects of maturation on tympanometric wideband acoustic transfer functions in human infants. The Journal of the Acoustical Society of America, 124, 2106–2122. [Article] [PubMed]×
Sanford, C. A., Keefe, D. H., Liu, Y.-W., Fitzpatrick, D. F., McCreery, R., Lewis, D. E., & Gorga, M. P. (2009). Sound-conduction effects on DPOAE screening outcomes in newborn infants: Test performance of wideband acoustic transfer functions and 1.0-kHz tympanometry. Ear and Hearing, 30, 635–652. [Article] [PubMed]
Sanford, C. A., Keefe, D. H., Liu, Y.-W., Fitzpatrick, D. F., McCreery, R., Lewis, D. E., & Gorga, M. P. (2009). Sound-conduction effects on DPOAE screening outcomes in newborn infants: Test performance of wideband acoustic transfer functions and 1.0-kHz tympanometry. Ear and Hearing, 30, 635–652. [Article] [PubMed]×
Shahnaz, N. (2008). Wideband reflectance in neonatal intensive care units. Journal of the American Academy of Audiology, 19, 419–429. [Article] [PubMed]
Shahnaz, N. (2008). Wideband reflectance in neonatal intensive care units. Journal of the American Academy of Audiology, 19, 419–429. [Article] [PubMed]×
Shahnaz, N., & Bork, K. (2006). Wideband reflectance norms for Caucasian and Chinese young adults. Ear and Hearing, 27, 774–788. [Article] [PubMed]
Shahnaz, N., & Bork, K. (2006). Wideband reflectance norms for Caucasian and Chinese young adults. Ear and Hearing, 27, 774–788. [Article] [PubMed]×
*Shahnaz, N., & Bork, K. (2008). Comparison of standard and multi-frequency tympanometric measures obtained with the virtual 310 system and the Grason-Stadler Tympstar. Canadian Journal of Speech-Language Pathology and Audiology, 32, 146–157.
*Shahnaz, N., & Bork, K. (2008). Comparison of standard and multi-frequency tympanometric measures obtained with the virtual 310 system and the Grason-Stadler Tympstar. Canadian Journal of Speech-Language Pathology and Audiology, 32, 146–157.×
*Shahnaz, N., Bork, K., Polka, L., Longridge, N., Bell, D., & Westerberg, B. D. (2009). Energy reflectance and tympanometry in normal and otosclerotic ears. Ear and Hearing, 30, 219–233. [Article] [PubMed]
*Shahnaz, N., Bork, K., Polka, L., Longridge, N., Bell, D., & Westerberg, B. D. (2009). Energy reflectance and tympanometry in normal and otosclerotic ears. Ear and Hearing, 30, 219–233. [Article] [PubMed]×
*Shahnaz, N., & Polka, L. (1997). Standard and multifrequency tympanometry in normal and otosclerotic ears. Ear and Hearing, 18, 326–341. [Article] [PubMed]
*Shahnaz, N., & Polka, L. (1997). Standard and multifrequency tympanometry in normal and otosclerotic ears. Ear and Hearing, 18, 326–341. [Article] [PubMed]×
Shahnaz, N., & Polka, L. (2002). Distinguishing healthy from otosclerotic ears: Effect of probe-tone frequency on static admittance. Journal of the American Academy of Audiology, 13, 345–355. [PubMed]
Shahnaz, N., & Polka, L. (2002). Distinguishing healthy from otosclerotic ears: Effect of probe-tone frequency on static admittance. Journal of the American Academy of Audiology, 13, 345–355. [PubMed]×
Shanks, J. E., & Shelton, C. (1991). Basic principles and clinical applications of tympanometry. Otolaryngology Clinics of North America, 24, 299–328.
Shanks, J. E., & Shelton, C. (1991). Basic principles and clinical applications of tympanometry. Otolaryngology Clinics of North America, 24, 299–328.×
Shanks, J. E., Wilson, R., & Cambron, N. (1993). Multiple frequency tympanometry: Effects of ear canal volume compensation on static acoustic admittance and estimates of middle ear resonance. Journal of Speech and Hearing Research, 36, 178–185. [Article] [PubMed]
Shanks, J. E., Wilson, R., & Cambron, N. (1993). Multiple frequency tympanometry: Effects of ear canal volume compensation on static acoustic admittance and estimates of middle ear resonance. Journal of Speech and Hearing Research, 36, 178–185. [Article] [PubMed]×
Shurin, P. A., Pelton, S. I., & Klein, J. O. (1976). Otitis media in the newborn infant. Annals of Otology, Rhinology & Laryngology, 85, 216–222.
Shurin, P. A., Pelton, S. I., & Klein, J. O. (1976). Otitis media in the newborn infant. Annals of Otology, Rhinology & Laryngology, 85, 216–222.×
Silman, S., Silverman, C., & Arick, D. (1992). Acoustic-immittance screening for detection of middle-ear effusion in children. Journal of the American Academy of Audiology, 3, 262–268. [PubMed]
Silman, S., Silverman, C., & Arick, D. (1992). Acoustic-immittance screening for detection of middle-ear effusion in children. Journal of the American Academy of Audiology, 3, 262–268. [PubMed]×
Sprague, B., Wiley, T., & Goldstein, R. (1985). Tympanometric and acoustic-reflex studies in neonates. Journal of Speech and Hearing Research, 28, 265–272. [Article] [PubMed]
Sprague, B., Wiley, T., & Goldstein, R. (1985). Tympanometric and acoustic-reflex studies in neonates. Journal of Speech and Hearing Research, 28, 265–272. [Article] [PubMed]×
Stinson, M. R. (1990). Revision of estimates of acoustic energy reflectance at the human eardrum. The Journal of the Acoustical Society of America, 88, 1773–1778. [Article] [PubMed]
Stinson, M. R. (1990). Revision of estimates of acoustic energy reflectance at the human eardrum. The Journal of the Acoustical Society of America, 88, 1773–1778. [Article] [PubMed]×
Takata, G. S., Chan, L. S., Morphew, T., Mangione-Smith, R., Morton, S., & Shekelle, P. (2003). Evidence assessment of the accuracy of methods of diagnosing middle ear effusion in children with otitis media with effusion. Pediatrics, 112, 1379–1387. [Article] [PubMed]
Takata, G. S., Chan, L. S., Morphew, T., Mangione-Smith, R., Morton, S., & Shekelle, P. (2003). Evidence assessment of the accuracy of methods of diagnosing middle ear effusion in children with otitis media with effusion. Pediatrics, 112, 1379–1387. [Article] [PubMed]×
Terkildsen, K., & Thomson, K. (1959). The influence of pressure variations on the impedance of the human ear drum. Journal of Laryngology and Otology, 73, 409–418. [Article] [PubMed]
Terkildsen, K., & Thomson, K. (1959). The influence of pressure variations on the impedance of the human ear drum. Journal of Laryngology and Otology, 73, 409–418. [Article] [PubMed]×
Valvik, B. R., Johnsen, M., & Laukli, E. (1994). Multifrequency tympanometry. Preliminary experiences with a commercially available middle-ear analyzer. Audiology, 33, 245–253. [Article] [PubMed]
Valvik, B. R., Johnsen, M., & Laukli, E. (1994). Multifrequency tympanometry. Preliminary experiences with a commercially available middle-ear analyzer. Audiology, 33, 245–253. [Article] [PubMed]×
Van Camp, K. J., Raman, E., & Creten, W. (1976). Two-component versus admittance tympanometry. Audiology, 15, 120–127. [Article] [PubMed]
Van Camp, K. J., Raman, E., & Creten, W. (1976). Two-component versus admittance tympanometry. Audiology, 15, 120–127. [Article] [PubMed]×
Vander Werff, K. R., Prieve, B. A., & Georgantas, L. (2007). Test–retest reliability of wideband reflectance measures in infants under screening and diagnostic test conditions. Ear and Hearing, 28, 669–681. [Article] [PubMed]
Vander Werff, K. R., Prieve, B. A., & Georgantas, L. (2007). Test–retest reliability of wideband reflectance measures in infants under screening and diagnostic test conditions. Ear and Hearing, 28, 669–681. [Article] [PubMed]×
Vanhuyse, V. J., Creten, W., & Van Camp, K. J. (1975). On the W-notching of tympanograms. Scandinavian Audiology, 4, 45–50. [Article]
Vanhuyse, V. J., Creten, W., & Van Camp, K. J. (1975). On the W-notching of tympanograms. Scandinavian Audiology, 4, 45–50. [Article] ×
Voss, S. E., & Allen, J. B. (1994). Measurement of acoustic impedance and reflectance in the human ear canal. The Journal of the Acoustical Society of America, 95, 372–384. [Article] [PubMed]
Voss, S. E., & Allen, J. B. (1994). Measurement of acoustic impedance and reflectance in the human ear canal. The Journal of the Acoustical Society of America, 95, 372–384. [Article] [PubMed]×
*Zhiqi, L., Kun, Y., & Zhiwu, H. (2010). Tympanometry in infants with middle ear effusion having been identified using spiral computerized tomography. American Journal of Otolaryngology, 31, 96–103. [Article] [PubMed]
*Zhiqi, L., Kun, Y., & Zhiwu, H. (2010). Tympanometry in infants with middle ear effusion having been identified using spiral computerized tomography. American Journal of Otolaryngology, 31, 96–103. [Article] [PubMed]×
Appendix A
Electronic databases searched
Centre for Reviews and Dissemination Databases
CINAHL (EBSCO)
Cochrane Library (Wiley)
ComDisDome (CSA)
Communication & Mass Media Complete (EBSCO)
Early Hearing Detection and Intervention (EHDI)
Education Research Complete (EBSCO)
Education Resources Information Center (ERIC)
GoogleScholar
Health Source: Nursing/Academic Edition (EBSCO)
HighWire Press
Latin American and Caribbean Center on Health Sciences Information (LILACS)
Linguistics Language Behaviour Abstracts (CSA)
National Rehabilitation Information Center—REHABDATA Neuroscience Abstracts (CSA)
Otseeker
PEDro
PsycBITE
Psychology and Behavioral Sciences Collection (EBSCO)
PsycINFO (EBSCO)
PubMed (NLM)
Science Citation Index Expanded (ISI)
ScienceDirect (Elsevier)
Social Sciences Citation Index (ISI)
Social Services Abstracts (CSA)
SpeechBITE
TripDatabase
Appendix B
Key words and expanded search strategy
Database Last date searched Search words and limits Yield
PubMed 1/28/11 (“Ear, Middle/pathology”[Mesh]OR “Ear Diseases/pathology”[Mesh] OR “Ear Diseases/physiopathology”[Mesh] OR “Ear, Middle/physiopathology”[Mesh] OR “Ear Diseases/diagnosis”[Mesh]) AND (“Acoustic Impedance Tests”[Mesh] OR tympanomet* OR tympanogram OR reflectance OR transmittance OR “acoustic power” OR “acoustic transfer” OR immitance OR immittance OR impedance OR admittance OR compliance OR “power absorption” OR “power flow” OR “acoustic resistance” OR “acoustic reactance” OR wideband) 1,916
1975–2011, English, Human
PubMed 1/31/11 (reflectance OR wideband OR “acoustic transfer”) AND (“Ear, Middle/pathology”[Mesh]OR “Ear Diseases/pathology”[Mesh] OR “Ear Diseases/physiopathology”[Mesh] OR “Ear, Middle/physiopathology”[Mesh] OR “Ear Diseases/diagnosis”[Mesh] OR “Acoustic Impedance Tests”[Mesh] OR ear OR otosclero* OR otolog* OR audiolog* OR “otitis media” OR cholesteatoma OR ossicles OR eustachian OR tympanic) OR 428
(“sweep frequency” OR “multiple frequency” OR “multi frequency” OR multifrequency or “high frequency” OR “1000 hz” OR “1 kHz” OR “probe-tone frequencies” OR “660 hz”) AND (“impedance audiometry” OR tympanometry OR tympanometric OR tympanogram)
1975–2011, English, Human
All EBSCO databases 2/11/11 (“sweep frequency” OR “multiple frequency” OR “multi frequency” OR multifrequency OR “probe tone frequencies” OR “high frequency probe” OR “high frequency tympanometry” OR “1000 hz probe” OR “1000 hz tympanometry” OR “1 kHz probe” OR “1 kHz tympanometry” OR “660 hz probe” OR “660 hz tympanometry”) AND (ear OR tympan* OR “otitis media” OR cholesteatoma OR otosclero* OR Eustachian OR ossicles) 81
1975–2011
CINAHL 2/14/11 ((MM “Acoustic Impedance Tests”) OR tympanomet* OR tympanogram OR reflectance OR transmittance OR “acoustic power” OR “acoustic transfer” OR immitance OR immittance OR impedance OR admittance OR compliance OR “power absorption” OR “power flow” OR “acoustic resistance” OR “acoustic reactance” OR wideband) AND ((MM “Diagnosis, Ear+”) OR (MM “Ear, Middle+”) OR (MM “Ear Diseases+”)) 559
Through EBSCO MM = Major concept
1975–2011, peer reviewed, English, human
PsycINFO 2/17/11 (MM “Ear Disorders” OR MM “Labyrinth Disorders” OR MM “Tinnitus” OR MM “Middle Ear” OR otosclerosis OR “otitis media” OR cholesteatoma OR tympanic OR ossicles OR Eustachian OR ear) AND (tympanomet* OR tympanogram OR reflectance OR transmittance OR “acoustic power” OR “acoustic transfer” OR immitance OR immittance OR impedance OR admittance OR “power absorption” OR “power flow” OR “acoustic resistance” OR “acoustic reactance” OR wideband) 134
Through EBSCO MM = Major concept
1975–2011, peer reviewed, English, human
Health Source: Nursing/Academic Edition 2/18/11 (tympanomet* OR tympanogram OR reflectance OR transmittance OR “acoustic power” OR “acoustic transfer” OR immitance OR immittance OR impedance OR admittance OR “power absorption” OR “power flow” OR “acoustic resistance” OR “acoustic reactance” OR wideband) AND (ear OR otosclero* OR “otitis media” OR cholesteatoma OR ossicles OR eustachian OR tympanic) 225
Through EBSCO 1975–2011, peer reviewed
Psychology and Behavioral Sciences Collection 2/18/11 (tympanomet* OR tympanogram OR reflectance OR transmittance OR “acoustic power” OR “acoustic transfer” OR immitance OR immittance OR impedance OR admittance OR “power absorption” OR “power flow” OR “acoustic resistance” OR “acoustic reactance” OR wideband) AND (otosclero* OR “otitis media” OR cholesteatoma OR ossicles OR eustachian OR tympanic OR ear) 103
Through EBSCO 1975–2011, peer reviewed
Communication & Mass Media Complete 2/18/11 (tympanomet* OR tympanogram OR reflectance OR transmittance OR “acoustic power” OR “acoustic transfer” OR immitance OR immittance OR impedance OR admittance OR “power absorption” OR “power flow” OR “acoustic resistance” OR “acoustic reactance” OR wideband) AND (otosclero* OR “otitis media” OR cholesteatoma OR ossicles OR eustachian OR tympanic OR ear) 21
Through EBSCO 1975–2011, peer reviewed
Education Research Complete 2/18/11 (tympanomet* OR tympanogram OR reflectance OR transmittance OR “acoustic power” OR “acoustic transfer” OR immitance OR immittance OR impedance OR admittance OR “power absorption” OR “power flow” OR “acoustic resistance” OR “acoustic reactance” OR wideband) AND (otosclero* OR “otitis media” OR cholesteatoma OR ossicles OR eustachian OR tympanic OR ear) 85
Through EBSCO 1975–2011, peer reviewed
ERIC 11/16/10 ((Thesaurus Descriptors:“Diseases”) and (Keywords:ear)) 35
Publication Date: 1975–2010
ERIC 11/16/10 ((Keywords:tympanometry) or (Keywords:tympanogram)) 22
Publication Date: 1975–2010
CSA 11/27/10 ((reflectance OR immitance OR immittance OR impedance) AND (tympanic OR ossicles OR Eustachian OR ear)) OR (tympanogram OR tympanomet* OR “acoustic power” OR “acoustic transfer” OR “acoustic resistance” OR “acoustic reactance”) 1080
1975–2011, journal articles, English only
ISI Web of Knowledge 12/3/10 #1 TS = (reflectance OR immitance OR immittance OR impedance OR “acoustic power” OR “acoustic transfer” OR “acoustic resistance” OR “acoustic reactance”) 1,386
#2 TS = (ear OR tympanic OR ossicles OR eustachian)
#3 TS = tympanomet*
(#1 and #2) OR #3 Articles only, English
TS = Topic, Title, Abstract, Keywords
Science Direct 12/7/10 “sweep frequency tympanometry ” OR “multifrequency tympanometry ” OR “multiple frequency tympanometry ” OR “multi-frequency tympanometry” OR “1000 hz tympanometry” 38
Publication date > 1974
Science Direct 12/28/10 (“acoustic power” OR “acoustic transfer” OR “acoustic resistance” OR “acoustic reactance” OR “power absorption” OR “power flow” OR reflectance) AND (ear OR tympanic OR ossicles OR Eustachian) 339
Publication date > 1974
Science Direct 12/28/10 (“acoustic power” OR “acoustic transfer” OR “acoustic resistance” OR “acoustic reactance” OR “power absorption” OR “power flow” OR reflectance) AND (“middle ear” OR otosclero* OR otolog* OR audiolog* OR “otitis media” OR cholesteatoma) 7
Publication date > 1974
Science Direct 1/20/11 (TITLE-ABSTR-KEY(tympanometr*)) OR (TITLE-ABSTR-KEY(impedance) and ALL(“middle ear” OR otosclero* OR otolog* OR audiolog* OR “otitis media” OR cholesteatoma OR ossicles OR eustachian OR tympanic)) 417
Publication date > 1974
HighWire 1/25/11 Anywhere: reflectance OR “acoustic power” OR “acoustic transfer” OR “wideband power” 71
Title/abstract: ear OR tympanic OR “otitis media” OR “cholesteatoma” OR otolog* OR otosclero* OR audiolog*
HighWire 1/28/11 Anywhere: ear OR tympanic OR “otitis media” OR “cholesteatoma” OR otolog* OR otosclero* OR audiolog* 97
Title/abstract: reflectance OR “acoustic power” OR “acoustic transfer”
HighWire 1/28/11 Anywhere: tympanic OR “otitis media” OR “cholesteatoma” OR otosclero* 3
Title/abstract: “acoustic resistance” OR “acoustic reactance” OR “power absorption” OR “power flow”
HighWire 1/28/11 Anywhere: “acoustic resistance” OR “acoustic reactance” OR “power absorption” 4
Title/abstract: tympanic OR “otitis media” OR “cholesteatoma” OR otosclero*
HighWire 1/31/11 Anywhere: ear OR tympanic OR “otitis media” OR otolog* OR otosclero* OR audiolog* 280
Title/abstract: impedance
HighWire 2/2/11 Title/abstract: tympanometr* OR tympanogram 280
HighWire 2/2/11 Anywhere: ear OR tympanic OR “otitis media” OR otolog* OR otosclero* OR audiolog* 35
Title/abstract: immittance OR immitance
HighWire 2/2/11 Anywhere: cholesteatoma 6
Title/abstract: immittance OR immitance OR impedance
HighWire 2/7/11 Anywhere: ear OR tympanic OR “otitis media” OR otolog* OR otosclero* OR audiolog* 48
Title/abstract: admittance
HighWire 2/8/11 Anywhere: “sweep frequency” OR “multiple frequency” OR “multi frequency” OR multifrequency 95
Title/abstract: ear OR tympan* OR “otitis media” OR otolog* OR otosclero* OR audiolog* NOT bioelectric*
HighWire 2/8/11 Anywhere: “probe tone frequencies” 17
Title/abstract: ear OR tympan* OR “otitis media” OR otolog* OR otosclero* OR audiolog* NOT bioelectric*
HighWire 2/8/11 Anywhere: “probe frequencies” 34
Title/abstract: ear OR tympan* OR “otitis media” OR otolog* OR otosclero* OR audiolog* NOT bioelectric*
HighWire 2/8/11 “1000 hz tympanometry” OR “1 kHz tympanometry” 7
HighWire 2/8/11 “1000 hz tympanogram” OR “1 kHz tympanogram” 1
HighWire 2/8/11 “high frequency tympanogram” OR “high frequency tympanometry” 11
HighWire 2/8/11 “1000 hz probe” AND tympano* 13
HighWire 2/8/11 “1 kHz probe” AND tympano* 2
HighWire 2/10/11 “660 hz” AND tympano* 51
HighWire 2/10/11 “high frequency probe” AND tympano* 13
OT seeker 1/28/11 Tympanometry OR tympanometric OR tympanogram OR impedance OR reflectance 1
Evidence-Based Communication Assessment and Intervention 2/1/11 Tympanometr* OR impedance OR reflectance OR “acoustic transfer” OR tympanogram OR wideband 1
SpeechBITE 2/3/11 Key word: otitis media 4
SpeechBITE 2/3/11 Tympanometry OR reflectance 0
National Rehab 2/3/11 Tympanometry OR Tympanometric OR Tympanogram OR Reflectance 21
PEDRO 2/3/11 Tympanometry OR Tympanometric OR Tympanogram OR Reflectance 2
PsycBITE 2/3/11 Tympanometry OR Tympanometric OR Tympanogram OR Reflectance 0
EHDI 2/3/11 Tympanometry OR Tympanometric OR Tympanogram OR Reflectance (in title) 4
LILACS 2/16/11 tympanometr$ OR reflectance 181
DARE, NHS EED, HTA databases through the Centre for Reviews and Dissemination 2/18/11 Tympanometry OR reflectance 12
TRIP database 2/24/11 ((tympanometry OR tympanometric OR tympanogram OR reflectance OR immitance OR immittance OR impedance OR “acoustic power” OR “acoustic transfer” OR “acoustic resistance” OR “acoustic reactance” OR “power absorption” OR “power flow”) AND (ear OR otosclerosis OR “otitis media” OR cholesteatoma OR tympanic OR ossicles OR eustachian)) from:1975 to:2011, exclude textbooks 561
Cochrane 3/1/11 ((reflectance OR immitance OR immittance OR impedance OR “acoustic power”OR “acoustic transfer” OR “acoustic resistance” OR “acoustic reactance” OR compliance OR admittance OR “power absorption” OR “power flow” OR wideband OR “sweep frequency” OR “multifrequency” OR “multiple frequency” OR “multi-frequency” OR tympanomet* OR tympanogram) and (ear OR tympanic OR ossicles OR Eustachian)) 229
Clinical trials
Cochrane 3/11/11 “Ear, Middle/pathology”[Mesh] OR “Ear, Middle/physiopathology”[Mesh] 41
Clinical trials
Cochrane 3/11/11 (“Ear Diseases/pathology”[Mesh] OR “Ear Diseases/physiopathology”[Mesh] OR “Ear Diseases/diagnosis”[Mesh]) AND (“Acoustic Impedance Tests”[Mesh] OR ((reflectance OR immitance OR immittance OR impedance OR “acoustic power” OR “acoustic transfer” OR “acoustic resistance” OR “acoustic reactance” OR compliance OR admittance OR “power absorption” OR “power flow” OR wideband OR “sweep frequency” OR “multifrequency” OR “multiple frequency” OR “multi-frequency” OR tympanomet* OR tympanogram)) 107
Clinical trials, 1975–2011
Google Scholar 3/22/11 “sweep frequency tympanometry” OR “multiple frequency tympanometry” OR “multifrequency tympanometry” OR “multi frequency tympanometry” OR “high frequency tympanometry” OR “1000 hz tympanometry” OR “1 kHz tympanometry” 537
English
Google Scholar 3/22/11 “sweep frequency tympanogram” OR “multiple frequency tympanogram” OR “multifrequency tympanogram” OR “multi frequency tympanogram” OR “high frequency tympanogram” OR “1000 hz tympanogram” OR “1 kHz tympanogram” 46
English
Google Scholar 3/23/11 “sweep frequency tympanometric” OR “multiple frequency tympanometric” OR “multifrequency tympanometric” OR “multi frequency tympanometric” OR “high frequency tympanometric” OR “1000 hz tympanometric” OR “1 kHz tympanometric” 67
English
Google Scholar 3/23/11 “probe tone frequencies” AND tympanometry (NOT “multifrequency tympanometry”) 71
English
Google Scholar 3/23/11 “multifrequency impedance audiometry” OR “high frequency impedance audiometry” OR “multifrequency immittance” OR “high frequency immittance” (NOT “high frequency tympanometry”) 29
English
Google Scholar 3/28/11 “wideband reflectance” OR “middle ear power” OR “reflectance tympanometry” OR otoreflectance OR “wideband middle ear” OR “admittance reflectance” OR “wideband energy reflectance” OR “wideband acoustic transfer” 279
English
Google Scholar 3/28/11 “reflectance YR” 16
English
Google Scholar 3/30/11 (“energy reflectance” OR “pressure reflectance” OR “power reflectance”) AND “middle ear” x221
Database Last date searched Search words and limits Yield
PubMed 1/28/11 (“Ear, Middle/pathology”[Mesh]OR “Ear Diseases/pathology”[Mesh] OR “Ear Diseases/physiopathology”[Mesh] OR “Ear, Middle/physiopathology”[Mesh] OR “Ear Diseases/diagnosis”[Mesh]) AND (“Acoustic Impedance Tests”[Mesh] OR tympanomet* OR tympanogram OR reflectance OR transmittance OR “acoustic power” OR “acoustic transfer” OR immitance OR immittance OR impedance OR admittance OR compliance OR “power absorption” OR “power flow” OR “acoustic resistance” OR “acoustic reactance” OR wideband) 1,916
1975–2011, English, Human
PubMed 1/31/11 (reflectance OR wideband OR “acoustic transfer”) AND (“Ear, Middle/pathology”[Mesh]OR “Ear Diseases/pathology”[Mesh] OR “Ear Diseases/physiopathology”[Mesh] OR “Ear, Middle/physiopathology”[Mesh] OR “Ear Diseases/diagnosis”[Mesh] OR “Acoustic Impedance Tests”[Mesh] OR ear OR otosclero* OR otolog* OR audiolog* OR “otitis media” OR cholesteatoma OR ossicles OR eustachian OR tympanic) OR 428
(“sweep frequency” OR “multiple frequency” OR “multi frequency” OR multifrequency or “high frequency” OR “1000 hz” OR “1 kHz” OR “probe-tone frequencies” OR “660 hz”) AND (“impedance audiometry” OR tympanometry OR tympanometric OR tympanogram)
1975–2011, English, Human
All EBSCO databases 2/11/11 (“sweep frequency” OR “multiple frequency” OR “multi frequency” OR multifrequency OR “probe tone frequencies” OR “high frequency probe” OR “high frequency tympanometry” OR “1000 hz probe” OR “1000 hz tympanometry” OR “1 kHz probe” OR “1 kHz tympanometry” OR “660 hz probe” OR “660 hz tympanometry”) AND (ear OR tympan* OR “otitis media” OR cholesteatoma OR otosclero* OR Eustachian OR ossicles) 81
1975–2011
CINAHL 2/14/11 ((MM “Acoustic Impedance Tests”) OR tympanomet* OR tympanogram OR reflectance OR transmittance OR “acoustic power” OR “acoustic transfer” OR immitance OR immittance OR impedance OR admittance OR compliance OR “power absorption” OR “power flow” OR “acoustic resistance” OR “acoustic reactance” OR wideband) AND ((MM “Diagnosis, Ear+”) OR (MM “Ear, Middle+”) OR (MM “Ear Diseases+”)) 559
Through EBSCO MM = Major concept
1975–2011, peer reviewed, English, human
PsycINFO 2/17/11 (MM “Ear Disorders” OR MM “Labyrinth Disorders” OR MM “Tinnitus” OR MM “Middle Ear” OR otosclerosis OR “otitis media” OR cholesteatoma OR tympanic OR ossicles OR Eustachian OR ear) AND (tympanomet* OR tympanogram OR reflectance OR transmittance OR “acoustic power” OR “acoustic transfer” OR immitance OR immittance OR impedance OR admittance OR “power absorption” OR “power flow” OR “acoustic resistance” OR “acoustic reactance” OR wideband) 134
Through EBSCO MM = Major concept
1975–2011, peer reviewed, English, human
Health Source: Nursing/Academic Edition 2/18/11 (tympanomet* OR tympanogram OR reflectance OR transmittance OR “acoustic power” OR “acoustic transfer” OR immitance OR immittance OR impedance OR admittance OR “power absorption” OR “power flow” OR “acoustic resistance” OR “acoustic reactance” OR wideband) AND (ear OR otosclero* OR “otitis media” OR cholesteatoma OR ossicles OR eustachian OR tympanic) 225
Through EBSCO 1975–2011, peer reviewed
Psychology and Behavioral Sciences Collection 2/18/11 (tympanomet* OR tympanogram OR reflectance OR transmittance OR “acoustic power” OR “acoustic transfer” OR immitance OR immittance OR impedance OR admittance OR “power absorption” OR “power flow” OR “acoustic resistance” OR “acoustic reactance” OR wideband) AND (otosclero* OR “otitis media” OR cholesteatoma OR ossicles OR eustachian OR tympanic OR ear) 103
Through EBSCO 1975–2011, peer reviewed
Communication & Mass Media Complete 2/18/11 (tympanomet* OR tympanogram OR reflectance OR transmittance OR “acoustic power” OR “acoustic transfer” OR immitance OR immittance OR impedance OR admittance OR “power absorption” OR “power flow” OR “acoustic resistance” OR “acoustic reactance” OR wideband) AND (otosclero* OR “otitis media” OR cholesteatoma OR ossicles OR eustachian OR tympanic OR ear) 21
Through EBSCO 1975–2011, peer reviewed
Education Research Complete 2/18/11 (tympanomet* OR tympanogram OR reflectance OR transmittance OR “acoustic power” OR “acoustic transfer” OR immitance OR immittance OR impedance OR admittance OR “power absorption” OR “power flow” OR “acoustic resistance” OR “acoustic reactance” OR wideband) AND (otosclero* OR “otitis media” OR cholesteatoma OR ossicles OR eustachian OR tympanic OR ear) 85
Through EBSCO 1975–2011, peer reviewed
ERIC 11/16/10 ((Thesaurus Descriptors:“Diseases”) and (Keywords:ear)) 35
Publication Date: 1975–2010
ERIC 11/16/10 ((Keywords:tympanometry) or (Keywords:tympanogram)) 22
Publication Date: 1975–2010
CSA 11/27/10 ((reflectance OR immitance OR immittance OR impedance) AND (tympanic OR ossicles OR Eustachian OR ear)) OR (tympanogram OR tympanomet* OR “acoustic power” OR “acoustic transfer” OR “acoustic resistance” OR “acoustic reactance”) 1080
1975–2011, journal articles, English only
ISI Web of Knowledge 12/3/10 #1 TS = (reflectance OR immitance OR immittance OR impedance OR “acoustic power” OR “acoustic transfer” OR “acoustic resistance” OR “acoustic reactance”) 1,386
#2 TS = (ear OR tympanic OR ossicles OR eustachian)
#3 TS = tympanomet*
(#1 and #2) OR #3 Articles only, English
TS = Topic, Title, Abstract, Keywords
Science Direct 12/7/10 “sweep frequency tympanometry ” OR “multifrequency tympanometry ” OR “multiple frequency tympanometry ” OR “multi-frequency tympanometry” OR “1000 hz tympanometry” 38
Publication date > 1974
Science Direct 12/28/10 (“acoustic power” OR “acoustic transfer” OR “acoustic resistance” OR “acoustic reactance” OR “power absorption” OR “power flow” OR reflectance) AND (ear OR tympanic OR ossicles OR Eustachian) 339
Publication date > 1974
Science Direct 12/28/10 (“acoustic power” OR “acoustic transfer” OR “acoustic resistance” OR “acoustic reactance” OR “power absorption” OR “power flow” OR reflectance) AND (“middle ear” OR otosclero* OR otolog* OR audiolog* OR “otitis media” OR cholesteatoma) 7
Publication date > 1974
Science Direct 1/20/11 (TITLE-ABSTR-KEY(tympanometr*)) OR (TITLE-ABSTR-KEY(impedance) and ALL(“middle ear” OR otosclero* OR otolog* OR audiolog* OR “otitis media” OR cholesteatoma OR ossicles OR eustachian OR tympanic)) 417
Publication date > 1974
HighWire 1/25/11 Anywhere: reflectance OR “acoustic power” OR “acoustic transfer” OR “wideband power” 71
Title/abstract: ear OR tympanic OR “otitis media” OR “cholesteatoma” OR otolog* OR otosclero* OR audiolog*
HighWire 1/28/11 Anywhere: ear OR tympanic OR “otitis media” OR “cholesteatoma” OR otolog* OR otosclero* OR audiolog* 97
Title/abstract: reflectance OR “acoustic power” OR “acoustic transfer”
HighWire 1/28/11 Anywhere: tympanic OR “otitis media” OR “cholesteatoma” OR otosclero* 3
Title/abstract: “acoustic resistance” OR “acoustic reactance” OR “power absorption” OR “power flow”
HighWire 1/28/11 Anywhere: “acoustic resistance” OR “acoustic reactance” OR “power absorption” 4
Title/abstract: tympanic OR “otitis media” OR “cholesteatoma” OR otosclero*
HighWire 1/31/11 Anywhere: ear OR tympanic OR “otitis media” OR otolog* OR otosclero* OR audiolog* 280
Title/abstract: impedance
HighWire 2/2/11 Title/abstract: tympanometr* OR tympanogram 280
HighWire 2/2/11 Anywhere: ear OR tympanic OR “otitis media” OR otolog* OR otosclero* OR audiolog* 35
Title/abstract: immittance OR immitance
HighWire 2/2/11 Anywhere: cholesteatoma 6
Title/abstract: immittance OR immitance OR impedance
HighWire 2/7/11 Anywhere: ear OR tympanic OR “otitis media” OR otolog* OR otosclero* OR audiolog* 48
Title/abstract: admittance
HighWire 2/8/11 Anywhere: “sweep frequency” OR “multiple frequency” OR “multi frequency” OR multifrequency 95
Title/abstract: ear OR tympan* OR “otitis media” OR otolog* OR otosclero* OR audiolog* NOT bioelectric*
HighWire 2/8/11 Anywhere: “probe tone frequencies” 17
Title/abstract: ear OR tympan* OR “otitis media” OR otolog* OR otosclero* OR audiolog* NOT bioelectric*
HighWire 2/8/11 Anywhere: “probe frequencies” 34
Title/abstract: ear OR tympan* OR “otitis media” OR otolog* OR otosclero* OR audiolog* NOT bioelectric*
HighWire 2/8/11 “1000 hz tympanometry” OR “1 kHz tympanometry” 7
HighWire 2/8/11 “1000 hz tympanogram” OR “1 kHz tympanogram” 1
HighWire 2/8/11 “high frequency tympanogram” OR “high frequency tympanometry” 11
HighWire 2/8/11 “1000 hz probe” AND tympano* 13
HighWire 2/8/11 “1 kHz probe” AND tympano* 2
HighWire 2/10/11 “660 hz” AND tympano* 51
HighWire 2/10/11 “high frequency probe” AND tympano* 13
OT seeker 1/28/11 Tympanometry OR tympanometric OR tympanogram OR impedance OR reflectance 1
Evidence-Based Communication Assessment and Intervention 2/1/11 Tympanometr* OR impedance OR reflectance OR “acoustic transfer” OR tympanogram OR wideband 1
SpeechBITE 2/3/11 Key word: otitis media 4
SpeechBITE 2/3/11 Tympanometry OR reflectance 0
National Rehab 2/3/11 Tympanometry OR Tympanometric OR Tympanogram OR Reflectance 21
PEDRO 2/3/11 Tympanometry OR Tympanometric OR Tympanogram OR Reflectance 2
PsycBITE 2/3/11 Tympanometry OR Tympanometric OR Tympanogram OR Reflectance 0
EHDI 2/3/11 Tympanometry OR Tympanometric OR Tympanogram OR Reflectance (in title) 4
LILACS 2/16/11 tympanometr$ OR reflectance 181
DARE, NHS EED, HTA databases through the Centre for Reviews and Dissemination 2/18/11 Tympanometry OR reflectance 12
TRIP database 2/24/11 ((tympanometry OR tympanometric OR tympanogram OR reflectance OR immitance OR immittance OR impedance OR “acoustic power” OR “acoustic transfer” OR “acoustic resistance” OR “acoustic reactance” OR “power absorption” OR “power flow”) AND (ear OR otosclerosis OR “otitis media” OR cholesteatoma OR tympanic OR ossicles OR eustachian)) from:1975 to:2011, exclude textbooks 561
Cochrane 3/1/11 ((reflectance OR immitance OR immittance OR impedance OR “acoustic power”OR “acoustic transfer” OR “acoustic resistance” OR “acoustic reactance” OR compliance OR admittance OR “power absorption” OR “power flow” OR wideband OR “sweep frequency” OR “multifrequency” OR “multiple frequency” OR “multi-frequency” OR tympanomet* OR tympanogram) and (ear OR tympanic OR ossicles OR Eustachian)) 229
Clinical trials
Cochrane 3/11/11 “Ear, Middle/pathology”[Mesh] OR “Ear, Middle/physiopathology”[Mesh] 41
Clinical trials
Cochrane 3/11/11 (“Ear Diseases/pathology”[Mesh] OR “Ear Diseases/physiopathology”[Mesh] OR “Ear Diseases/diagnosis”[Mesh]) AND (“Acoustic Impedance Tests”[Mesh] OR ((reflectance OR immitance OR immittance OR impedance OR “acoustic power” OR “acoustic transfer” OR “acoustic resistance” OR “acoustic reactance” OR compliance OR admittance OR “power absorption” OR “power flow” OR wideband OR “sweep frequency” OR “multifrequency” OR “multiple frequency” OR “multi-frequency” OR tympanomet* OR tympanogram)) 107
Clinical trials, 1975–2011
Google Scholar 3/22/11 “sweep frequency tympanometry” OR “multiple frequency tympanometry” OR “multifrequency tympanometry” OR “multi frequency tympanometry” OR “high frequency tympanometry” OR “1000 hz tympanometry” OR “1 kHz tympanometry” 537
English
Google Scholar 3/22/11 “sweep frequency tympanogram” OR “multiple frequency tympanogram” OR “multifrequency tympanogram” OR “multi frequency tympanogram” OR “high frequency tympanogram” OR “1000 hz tympanogram” OR “1 kHz tympanogram” 46
English
Google Scholar 3/23/11 “sweep frequency tympanometric” OR “multiple frequency tympanometric” OR “multifrequency tympanometric” OR “multi frequency tympanometric” OR “high frequency tympanometric” OR “1000 hz tympanometric” OR “1 kHz tympanometric” 67
English
Google Scholar 3/23/11 “probe tone frequencies” AND tympanometry (NOT “multifrequency tympanometry”) 71
English
Google Scholar 3/23/11 “multifrequency impedance audiometry” OR “high frequency impedance audiometry” OR “multifrequency immittance” OR “high frequency immittance” (NOT “high frequency tympanometry”) 29
English
Google Scholar 3/28/11 “wideband reflectance” OR “middle ear power” OR “reflectance tympanometry” OR otoreflectance OR “wideband middle ear” OR “admittance reflectance” OR “wideband energy reflectance” OR “wideband acoustic transfer” 279
English
Google Scholar 3/28/11 “reflectance YR” 16
English
Google Scholar 3/30/11 (“energy reflectance” OR “pressure reflectance” OR “power reflectance”) AND “middle ear” x221
×
Figure 1

Flow of systematic literature search. EBSR = evidence-based systematic review.

 Flow of systematic literature search. EBSR = evidence-based systematic review.
Figure 1

Flow of systematic literature search. EBSR = evidence-based systematic review.

×
Table 1 Quality indicators.
Quality indicators.×
Indicator Quality marker
Study rationale Was there an adequate and plausible rationale for the study?
Measure and procedure description Were measures and procedures described clearly?
Independent measure administration Were the index measure and the reference standard administered independently?
Blinding Were assessors blinded when interpreting results of the index measure and reference?
Participant selection Were participants identified through a one-gate procedurea in which the participant’s diagnosis was unknown at the time of the administration of the index test and the reference test was used to confirm a diagnosis? One-gate designs help minimize spectrum bias and increase the likelihood that the study participants will represent the full range of attributes likely to be encountered in clinical settings.
Adequate participant representation Were participants recognizable and representative of the diagnostic task?
Avoidance of verification bias Were the index measure and reference standard administered to all participants?
Likelihood ratios and confidence intervals Were likelihood ratios and confidence intervals reported or calculable?
Table 1 Quality indicators.
Quality indicators.×
Indicator Quality marker
Study rationale Was there an adequate and plausible rationale for the study?
Measure and procedure description Were measures and procedures described clearly?
Independent measure administration Were the index measure and the reference standard administered independently?
Blinding Were assessors blinded when interpreting results of the index measure and reference?
Participant selection Were participants identified through a one-gate procedurea in which the participant’s diagnosis was unknown at the time of the administration of the index test and the reference test was used to confirm a diagnosis? One-gate designs help minimize spectrum bias and increase the likelihood that the study participants will represent the full range of attributes likely to be encountered in clinical settings.
Adequate participant representation Were participants recognizable and representative of the diagnostic task?
Avoidance of verification bias Were the index measure and reference standard administered to all participants?
Likelihood ratios and confidence intervals Were likelihood ratios and confidence intervals reported or calculable?
×
Table 2 Participant variables.
Participant variables.×
Citation N (Ears) Age range (M) Gender Race-ethnicity (as reported)
Abou-Elhamd et al., 2006  71 OME NR NR NR
23 acute otitis media NR NR NR
50 healthy 2.5–45 years (19) NR NR
Beers et al., 2010  42 OME 3–12 years (6.34) NR Caucasian: 67%
Chinese: 14%
Other: 19%
144 healthy 5–11 years (6.15) 75 M Caucasian: 44%
69 F Chinese: 42%
Other: 14%
Funasaka & Kumakawa, 1988  12 incudostapedial dislocation NR NR NR
6 malleus and/or incus fixation NR NR NR
22 stapes fixation NR NR NR
Harris et al., 2005  35 1–10 years (NR) 13 M NR
8 F
N = participants
Lai et al., 2008  85 OME 18–73 years (47) 28 M NR
32 F
N = participants
36 healthy 19–62 years (36) 9 M
11 F
N = participants
Ogut et al., 2008  25 otosclerosis 24–57 years (39.6) 7 M NR
18 F
100 healthy 26–56 years (36.1) 34 M NR
66 F
Shahnaz & Bork, 2008  20 otosclerosis 22–56 years (42) 3 M Caucasian: 80%
Chinese: 15%
17 F East Indian: 5%
NR healthy (53 participants) 18–34 years (23) 27 M Caucasian: 49%
26 F Chinese: 51%
N = participants
Shahnaz et al., 2009  28 otosclerosis 24–56 years (41.6) 8 M Caucasian: 71%
20 F East Indian: 14%
Chinese: 7%
Hispanic: 4%
Filipino: 4%
115 healthy 20–32 years (25.7) 51 M Caucasian: 100%
64 F
Shahnaz & Polka, 1997  14 otosclerosis 29–69 years (48) 5 M NR
9 F
68 healthy 20–43 years (22) NR NR
Zhiqi et al., 2010  104 42 days–6 months (70 days) 60 M NR
44 F
Note. OME = otitis media with effusion; NR = not reported or calculable; M = male; F = female.
Note. OME = otitis media with effusion; NR = not reported or calculable; M = male; F = female.×
Table 2 Participant variables.
Participant variables.×
Citation N (Ears) Age range (M) Gender Race-ethnicity (as reported)
Abou-Elhamd et al., 2006  71 OME NR NR NR
23 acute otitis media NR NR NR
50 healthy 2.5–45 years (19) NR NR
Beers et al., 2010  42 OME 3–12 years (6.34) NR Caucasian: 67%
Chinese: 14%
Other: 19%
144 healthy 5–11 years (6.15) 75 M Caucasian: 44%
69 F Chinese: 42%
Other: 14%
Funasaka & Kumakawa, 1988  12 incudostapedial dislocation NR NR NR
6 malleus and/or incus fixation NR NR NR
22 stapes fixation NR NR NR
Harris et al., 2005  35 1–10 years (NR) 13 M NR
8 F
N = participants
Lai et al., 2008  85 OME 18–73 years (47) 28 M NR
32 F
N = participants
36 healthy 19–62 years (36) 9 M
11 F
N = participants
Ogut et al., 2008  25 otosclerosis 24–57 years (39.6) 7 M NR
18 F
100 healthy 26–56 years (36.1) 34 M NR
66 F
Shahnaz & Bork, 2008  20 otosclerosis 22–56 years (42) 3 M Caucasian: 80%
Chinese: 15%
17 F East Indian: 5%
NR healthy (53 participants) 18–34 years (23) 27 M Caucasian: 49%
26 F Chinese: 51%
N = participants
Shahnaz et al., 2009  28 otosclerosis 24–56 years (41.6) 8 M Caucasian: 71%
20 F East Indian: 14%
Chinese: 7%
Hispanic: 4%
Filipino: 4%
115 healthy 20–32 years (25.7) 51 M Caucasian: 100%
64 F
Shahnaz & Polka, 1997  14 otosclerosis 29–69 years (48) 5 M NR
9 F
68 healthy 20–43 years (22) NR NR
Zhiqi et al., 2010  104 42 days–6 months (70 days) 60 M NR
44 F
Note. OME = otitis media with effusion; NR = not reported or calculable; M = male; F = female.
Note. OME = otitis media with effusion; NR = not reported or calculable; M = male; F = female.×
×
Table 3 Study results.
Study results.×
Citation Technology Reference standard Disorder classification Sensitivity Specificity LR+ (95% CI) LR– (95% CI)
Type Controls Disordered
Abou-Elhamd et al., 2006  MFT: 250–2000 Hz sweep frequency in 1/6 octave increments Myringotomy X OME 100 NR NR NR
AOM NR NR NR NR
Beers et al., 2010  WBR Pneumatic otoscopy and video otomicroscopy X 50% OME 96% 95% 19.8 (9.6, 40.9) 0.04 (0.01, 0.18)
Funasaka & Kumakawa, 1988  MFT: 220–2000 Hz sweep frequency Surgical confirmation X ISD 83 NR NR NR
MIF 83 NR NR NR
Stapes fixation 55 NR NR NR
Overall 68 NR NR NR
Harris et al., 2005  1000 Hz tympanometry Myringotomy and pneumatic otoscopy X X OME 100 54 2.17 (1.2, 3.9) 0 (0, UND)
Lai et al., 2008  MFT: 250–2000 Hz sweep frequency in 50 Hz increments Tympanocentesis X OME on Day 1 100 NR NR NR
Ogut et al., 2008  MFT: 250–2000 Hz sweep frequency probe tone Surgical confirmation X RF at 1025 Hz 80 82 4.4 (2.8, 7.1) 0.2 (0.1, 0.5)
Shahnaz & Bork, 2008  MFT GSI and Virtual 310 Systems: 250-2000 Hz sweep frequency in 50 Hz (GSI) and 1/6 octave (Virtual) increments Surgical confirmation X RF GSI 65 NR NR NR
RF Virtual 70 NR NR NR
F45 GSI 70 NR NR NR
F45 Virtual 70 NR NR NR
Shahnaz et al., 2009  MFT: 250–2000 Hz sweep frequency in 1/6 octave increments Surgical confirmation X Reflectance (> 90th percentile, 211–6000 Hz) 82 83 4.7 (3.1, 7.3) 0.22 (0.1, 0.5)
WBR F45 > 600 Hz (+) 79 73 2.9 (2, 4.2) 0.3 (0.1, 0.6)
Shahnaz & Polka, 1997  MFT: 250–2000 Hz sweep frequency in 1/6 octave increments; 250–2000 Hz sweep pressure at 125 daPa/sec Surgical confirmation X RF/SF (+) 64 69 2.1 (1.2, 3.5) 0.5 (0.3, 1.1)
RF/SF (−) 57 66 1.7 (1, 3) 0.7 (0.4, 1.2)
RF/SP (+) 64 68 2 (1.2, 3.3) 0.5 (0.3, 1.1)
RF/SP (−) 57 63 1.6 (0.9, 2.7) 0.7 (0.4, 1.3)
F45/SF 79 71 2.7 (1.7, 4.2) 0.3 (0.1, 0.8)
F45/SP 57 57 1.3 (0.8, 2.3) 0.8 (0.4, 1.4)
Zhiqi et al., 2010  1000 Hz tympanometry CT scan X X MEE 98 98 46.18 (6.6, 321.1) 0.02 (0, 0.13)
Note. X = groups that received the reference standard in the study. LR = likelihood ratio; CI = confidence interval; MFT = multifrequency tympanometry; AOM = acute otitis media; WBR = wideband reflectance; ISD = incudostapedial dislocation; MIF = malleus and/or incus fixation; UND = unable to determine because sensitivity = 100%; RF = resonant frequency; GSI = Grason Stadler Instruments; F45 = 45° admittance phase angle; (+) = positive compensation; SF = sweep frequency; (−) = negative compensation; SP = sweep pressure; MEE = middle ear effusion.
Note. X = groups that received the reference standard in the study. LR = likelihood ratio; CI = confidence interval; MFT = multifrequency tympanometry; AOM = acute otitis media; WBR = wideband reflectance; ISD = incudostapedial dislocation; MIF = malleus and/or incus fixation; UND = unable to determine because sensitivity = 100%; RF = resonant frequency; GSI = Grason Stadler Instruments; F45 = 45° admittance phase angle; (+) = positive compensation; SF = sweep frequency; (−) = negative compensation; SP = sweep pressure; MEE = middle ear effusion.×
Table 3 Study results.
Study results.×
Citation Technology Reference standard Disorder classification Sensitivity Specificity LR+ (95% CI) LR– (95% CI)
Type Controls Disordered
Abou-Elhamd et al., 2006  MFT: 250–2000 Hz sweep frequency in 1/6 octave increments Myringotomy X OME 100 NR NR NR
AOM NR NR NR NR
Beers et al., 2010  WBR Pneumatic otoscopy and video otomicroscopy X 50% OME 96% 95% 19.8 (9.6, 40.9) 0.04 (0.01, 0.18)
Funasaka & Kumakawa, 1988  MFT: 220–2000 Hz sweep frequency Surgical confirmation X ISD 83 NR NR NR
MIF 83 NR NR NR
Stapes fixation 55 NR NR NR
Overall 68 NR NR NR
Harris et al., 2005  1000 Hz tympanometry Myringotomy and pneumatic otoscopy X X OME 100 54 2.17 (1.2, 3.9) 0 (0, UND)
Lai et al., 2008  MFT: 250–2000 Hz sweep frequency in 50 Hz increments Tympanocentesis X OME on Day 1 100 NR NR NR
Ogut et al., 2008  MFT: 250–2000 Hz sweep frequency probe tone Surgical confirmation X RF at 1025 Hz 80 82 4.4 (2.8, 7.1) 0.2 (0.1, 0.5)
Shahnaz & Bork, 2008  MFT GSI and Virtual 310 Systems: 250-2000 Hz sweep frequency in 50 Hz (GSI) and 1/6 octave (Virtual) increments Surgical confirmation X RF GSI 65 NR NR NR
RF Virtual 70 NR NR NR
F45 GSI 70 NR NR NR
F45 Virtual 70 NR NR NR
Shahnaz et al., 2009  MFT: 250–2000 Hz sweep frequency in 1/6 octave increments Surgical confirmation X Reflectance (> 90th percentile, 211–6000 Hz) 82 83 4.7 (3.1, 7.3) 0.22 (0.1, 0.5)
WBR F45 > 600 Hz (+) 79 73 2.9 (2, 4.2) 0.3 (0.1, 0.6)
Shahnaz & Polka, 1997  MFT: 250–2000 Hz sweep frequency in 1/6 octave increments; 250–2000 Hz sweep pressure at 125 daPa/sec Surgical confirmation X RF/SF (+) 64 69 2.1 (1.2, 3.5) 0.5 (0.3, 1.1)
RF/SF (−) 57 66 1.7 (1, 3) 0.7 (0.4, 1.2)
RF/SP (+) 64 68 2 (1.2, 3.3) 0.5 (0.3, 1.1)
RF/SP (−) 57 63 1.6 (0.9, 2.7) 0.7 (0.4, 1.3)
F45/SF 79 71 2.7 (1.7, 4.2) 0.3 (0.1, 0.8)
F45/SP 57 57 1.3 (0.8, 2.3) 0.8 (0.4, 1.4)
Zhiqi et al., 2010  1000 Hz tympanometry CT scan X X MEE 98 98 46.18 (6.6, 321.1) 0.02 (0, 0.13)
Note. X = groups that received the reference standard in the study. LR = likelihood ratio; CI = confidence interval; MFT = multifrequency tympanometry; AOM = acute otitis media; WBR = wideband reflectance; ISD = incudostapedial dislocation; MIF = malleus and/or incus fixation; UND = unable to determine because sensitivity = 100%; RF = resonant frequency; GSI = Grason Stadler Instruments; F45 = 45° admittance phase angle; (+) = positive compensation; SF = sweep frequency; (−) = negative compensation; SP = sweep pressure; MEE = middle ear effusion.
Note. X = groups that received the reference standard in the study. LR = likelihood ratio; CI = confidence interval; MFT = multifrequency tympanometry; AOM = acute otitis media; WBR = wideband reflectance; ISD = incudostapedial dislocation; MIF = malleus and/or incus fixation; UND = unable to determine because sensitivity = 100%; RF = resonant frequency; GSI = Grason Stadler Instruments; F45 = 45° admittance phase angle; (+) = positive compensation; SF = sweep frequency; (−) = negative compensation; SP = sweep pressure; MEE = middle ear effusion.×
×
Table 4 Critical appraisal of diagnostic studies.
Critical appraisal of diagnostic studies.×
Citation Quality markers
Adequate study rationale Adequate description of measures and procedures Independent measure administration Blinding 1-gate procedure Adequate participant representation Reference and index standard LR/CI calculable
Abou-Elhamd et al., 2006  Yes Yes No No No No No No
Beers et al., 2010  Yes Yes +/− No No Yes No Yes
Funasaka & Kumakawa, 1988  Yes Yes No No No No No No
Harris et al., 2005  Yes Yes Yes Yes Yes Yes Yes Yes
Lai et al., 2008  Yes Yes No No No Yes No No
Ogut et al., 2008  Yes Yes No No No Yes No Yes
Shahnaz & Bork, 2008  Yes Yes No No No Yes No No
Shahnaz et al., 2009  Yes Yes No No No Yes No Yes
Shahnaz & Polka, 1997  Yes Yes Yes No No Yes No Yes
Zhiqi et al., 2010  Yes Yes No No Yes Yes Yes Yes
Note. +/− = partial administration.
Note. +/− = partial administration.×
Table 4 Critical appraisal of diagnostic studies.
Critical appraisal of diagnostic studies.×
Citation Quality markers
Adequate study rationale Adequate description of measures and procedures Independent measure administration Blinding 1-gate procedure Adequate participant representation Reference and index standard LR/CI calculable
Abou-Elhamd et al., 2006  Yes Yes No No No No No No
Beers et al., 2010  Yes Yes +/− No No Yes No Yes
Funasaka & Kumakawa, 1988  Yes Yes No No No No No No
Harris et al., 2005  Yes Yes Yes Yes Yes Yes Yes Yes
Lai et al., 2008  Yes Yes No No No Yes No No
Ogut et al., 2008  Yes Yes No No No Yes No Yes
Shahnaz & Bork, 2008  Yes Yes No No No Yes No No
Shahnaz et al., 2009  Yes Yes No No No Yes No Yes
Shahnaz & Polka, 1997  Yes Yes Yes No No Yes No Yes
Zhiqi et al., 2010  Yes Yes No No Yes Yes Yes Yes
Note. +/− = partial administration.
Note. +/− = partial administration.×
×
Database Last date searched Search words and limits Yield
PubMed 1/28/11 (“Ear, Middle/pathology”[Mesh]OR “Ear Diseases/pathology”[Mesh] OR “Ear Diseases/physiopathology”[Mesh] OR “Ear, Middle/physiopathology”[Mesh] OR “Ear Diseases/diagnosis”[Mesh]) AND (“Acoustic Impedance Tests”[Mesh] OR tympanomet* OR tympanogram OR reflectance OR transmittance OR “acoustic power” OR “acoustic transfer” OR immitance OR immittance OR impedance OR admittance OR compliance OR “power absorption” OR “power flow” OR “acoustic resistance” OR “acoustic reactance” OR wideband) 1,916
1975–2011, English, Human
PubMed 1/31/11 (reflectance OR wideband OR “acoustic transfer”) AND (“Ear, Middle/pathology”[Mesh]OR “Ear Diseases/pathology”[Mesh] OR “Ear Diseases/physiopathology”[Mesh] OR “Ear, Middle/physiopathology”[Mesh] OR “Ear Diseases/diagnosis”[Mesh] OR “Acoustic Impedance Tests”[Mesh] OR ear OR otosclero* OR otolog* OR audiolog* OR “otitis media” OR cholesteatoma OR ossicles OR eustachian OR tympanic) OR 428
(“sweep frequency” OR “multiple frequency” OR “multi frequency” OR multifrequency or “high frequency” OR “1000 hz” OR “1 kHz” OR “probe-tone frequencies” OR “660 hz”) AND (“impedance audiometry” OR tympanometry OR tympanometric OR tympanogram)
1975–2011, English, Human
All EBSCO databases 2/11/11 (“sweep frequency” OR “multiple frequency” OR “multi frequency” OR multifrequency OR “probe tone frequencies” OR “high frequency probe” OR “high frequency tympanometry” OR “1000 hz probe” OR “1000 hz tympanometry” OR “1 kHz probe” OR “1 kHz tympanometry” OR “660 hz probe” OR “660 hz tympanometry”) AND (ear OR tympan* OR “otitis media” OR cholesteatoma OR otosclero* OR Eustachian OR ossicles) 81
1975–2011
CINAHL 2/14/11 ((MM “Acoustic Impedance Tests”) OR tympanomet* OR tympanogram OR reflectance OR transmittance OR “acoustic power” OR “acoustic transfer” OR immitance OR immittance OR impedance OR admittance OR compliance OR “power absorption” OR “power flow” OR “acoustic resistance” OR “acoustic reactance” OR wideband) AND ((MM “Diagnosis, Ear+”) OR (MM “Ear, Middle+”) OR (MM “Ear Diseases+”)) 559
Through EBSCO MM = Major concept
1975–2011, peer reviewed, English, human
PsycINFO 2/17/11 (MM “Ear Disorders” OR MM “Labyrinth Disorders” OR MM “Tinnitus” OR MM “Middle Ear” OR otosclerosis OR “otitis media” OR cholesteatoma OR tympanic OR ossicles OR Eustachian OR ear) AND (tympanomet* OR tympanogram OR reflectance OR transmittance OR “acoustic power” OR “acoustic transfer” OR immitance OR immittance OR impedance OR admittance OR “power absorption” OR “power flow” OR “acoustic resistance” OR “acoustic reactance” OR wideband) 134
Through EBSCO MM = Major concept
1975–2011, peer reviewed, English, human
Health Source: Nursing/Academic Edition 2/18/11 (tympanomet* OR tympanogram OR reflectance OR transmittance OR “acoustic power” OR “acoustic transfer” OR immitance OR immittance OR impedance OR admittance OR “power absorption” OR “power flow” OR “acoustic resistance” OR “acoustic reactance” OR wideband) AND (ear OR otosclero* OR “otitis media” OR cholesteatoma OR ossicles OR eustachian OR tympanic) 225
Through EBSCO 1975–2011, peer reviewed
Psychology and Behavioral Sciences Collection 2/18/11 (tympanomet* OR tympanogram OR reflectance OR transmittance OR “acoustic power” OR “acoustic transfer” OR immitance OR immittance OR impedance OR admittance OR “power absorption” OR “power flow” OR “acoustic resistance” OR “acoustic reactance” OR wideband) AND (otosclero* OR “otitis media” OR cholesteatoma OR ossicles OR eustachian OR tympanic OR ear) 103
Through EBSCO 1975–2011, peer reviewed
Communication & Mass Media Complete 2/18/11 (tympanomet* OR tympanogram OR reflectance OR transmittance OR “acoustic power” OR “acoustic transfer” OR immitance OR immittance OR impedance OR admittance OR “power absorption” OR “power flow” OR “acoustic resistance” OR “acoustic reactance” OR wideband) AND (otosclero* OR “otitis media” OR cholesteatoma OR ossicles OR eustachian OR tympanic OR ear) 21
Through EBSCO 1975–2011, peer reviewed
Education Research Complete 2/18/11 (tympanomet* OR tympanogram OR reflectance OR transmittance OR “acoustic power” OR “acoustic transfer” OR immitance OR immittance OR impedance OR admittance OR “power absorption” OR “power flow” OR “acoustic resistance” OR “acoustic reactance” OR wideband) AND (otosclero* OR “otitis media” OR cholesteatoma OR ossicles OR eustachian OR tympanic OR ear) 85
Through EBSCO 1975–2011, peer reviewed
ERIC 11/16/10 ((Thesaurus Descriptors:“Diseases”) and (Keywords:ear)) 35
Publication Date: 1975–2010
ERIC 11/16/10 ((Keywords:tympanometry) or (Keywords:tympanogram)) 22
Publication Date: 1975–2010
CSA 11/27/10 ((reflectance OR immitance OR immittance OR impedance) AND (tympanic OR ossicles OR Eustachian OR ear)) OR (tympanogram OR tympanomet* OR “acoustic power” OR “acoustic transfer” OR “acoustic resistance” OR “acoustic reactance”) 1080
1975–2011, journal articles, English only
ISI Web of Knowledge 12/3/10 #1 TS = (reflectance OR immitance OR immittance OR impedance OR “acoustic power” OR “acoustic transfer” OR “acoustic resistance” OR “acoustic reactance”) 1,386
#2 TS = (ear OR tympanic OR ossicles OR eustachian)
#3 TS = tympanomet*
(#1 and #2) OR #3 Articles only, English
TS = Topic, Title, Abstract, Keywords
Science Direct 12/7/10 “sweep frequency tympanometry ” OR “multifrequency tympanometry ” OR “multiple frequency tympanometry ” OR “multi-frequency tympanometry” OR “1000 hz tympanometry” 38
Publication date > 1974
Science Direct 12/28/10 (“acoustic power” OR “acoustic transfer” OR “acoustic resistance” OR “acoustic reactance” OR “power absorption” OR “power flow” OR reflectance) AND (ear OR tympanic OR ossicles OR Eustachian) 339
Publication date > 1974
Science Direct 12/28/10 (“acoustic power” OR “acoustic transfer” OR “acoustic resistance” OR “acoustic reactance” OR “power absorption” OR “power flow” OR reflectance) AND (“middle ear” OR otosclero* OR otolog* OR audiolog* OR “otitis media” OR cholesteatoma) 7
Publication date > 1974
Science Direct 1/20/11 (TITLE-ABSTR-KEY(tympanometr*)) OR (TITLE-ABSTR-KEY(impedance) and ALL(“middle ear” OR otosclero* OR otolog* OR audiolog* OR “otitis media” OR cholesteatoma OR ossicles OR eustachian OR tympanic)) 417
Publication date > 1974
HighWire 1/25/11 Anywhere: reflectance OR “acoustic power” OR “acoustic transfer” OR “wideband power” 71
Title/abstract: ear OR tympanic OR “otitis media” OR “cholesteatoma” OR otolog* OR otosclero* OR audiolog*
HighWire 1/28/11 Anywhere: ear OR tympanic OR “otitis media” OR “cholesteatoma” OR otolog* OR otosclero* OR audiolog* 97
Title/abstract: reflectance OR “acoustic power” OR “acoustic transfer”
HighWire 1/28/11 Anywhere: tympanic OR “otitis media” OR “cholesteatoma” OR otosclero* 3
Title/abstract: “acoustic resistance” OR “acoustic reactance” OR “power absorption” OR “power flow”
HighWire 1/28/11 Anywhere: “acoustic resistance” OR “acoustic reactance” OR “power absorption” 4
Title/abstract: tympanic OR “otitis media” OR “cholesteatoma” OR otosclero*
HighWire 1/31/11 Anywhere: ear OR tympanic OR “otitis media” OR otolog* OR otosclero* OR audiolog* 280
Title/abstract: impedance
HighWire 2/2/11 Title/abstract: tympanometr* OR tympanogram 280
HighWire 2/2/11 Anywhere: ear OR tympanic OR “otitis media” OR otolog* OR otosclero* OR audiolog* 35
Title/abstract: immittance OR immitance
HighWire 2/2/11 Anywhere: cholesteatoma 6
Title/abstract: immittance OR immitance OR impedance
HighWire 2/7/11 Anywhere: ear OR tympanic OR “otitis media” OR otolog* OR otosclero* OR audiolog* 48
Title/abstract: admittance
HighWire 2/8/11 Anywhere: “sweep frequency” OR “multiple frequency” OR “multi frequency” OR multifrequency 95
Title/abstract: ear OR tympan* OR “otitis media” OR otolog* OR otosclero* OR audiolog* NOT bioelectric*
HighWire 2/8/11 Anywhere: “probe tone frequencies” 17
Title/abstract: ear OR tympan* OR “otitis media” OR otolog* OR otosclero* OR audiolog* NOT bioelectric*
HighWire 2/8/11 Anywhere: “probe frequencies” 34
Title/abstract: ear OR tympan* OR “otitis media” OR otolog* OR otosclero* OR audiolog* NOT bioelectric*
HighWire 2/8/11 “1000 hz tympanometry” OR “1 kHz tympanometry” 7
HighWire 2/8/11 “1000 hz tympanogram” OR “1 kHz tympanogram” 1
HighWire 2/8/11 “high frequency tympanogram” OR “high frequency tympanometry” 11
HighWire 2/8/11 “1000 hz probe” AND tympano* 13
HighWire 2/8/11 “1 kHz probe” AND tympano* 2
HighWire 2/10/11 “660 hz” AND tympano* 51
HighWire 2/10/11 “high frequency probe” AND tympano* 13
OT seeker 1/28/11 Tympanometry OR tympanometric OR tympanogram OR impedance OR reflectance 1
Evidence-Based Communication Assessment and Intervention 2/1/11 Tympanometr* OR impedance OR reflectance OR “acoustic transfer” OR tympanogram OR wideband 1
SpeechBITE 2/3/11 Key word: otitis media 4
SpeechBITE 2/3/11 Tympanometry OR reflectance 0
National Rehab 2/3/11 Tympanometry OR Tympanometric OR Tympanogram OR Reflectance 21
PEDRO 2/3/11 Tympanometry OR Tympanometric OR Tympanogram OR Reflectance 2
PsycBITE 2/3/11 Tympanometry OR Tympanometric OR Tympanogram OR Reflectance 0
EHDI 2/3/11 Tympanometry OR Tympanometric OR Tympanogram OR Reflectance (in title) 4
LILACS 2/16/11 tympanometr$ OR reflectance 181
DARE, NHS EED, HTA databases through the Centre for Reviews and Dissemination 2/18/11 Tympanometry OR reflectance 12
TRIP database 2/24/11 ((tympanometry OR tympanometric OR tympanogram OR reflectance OR immitance OR immittance OR impedance OR “acoustic power” OR “acoustic transfer” OR “acoustic resistance” OR “acoustic reactance” OR “power absorption” OR “power flow”) AND (ear OR otosclerosis OR “otitis media” OR cholesteatoma OR tympanic OR ossicles OR eustachian)) from:1975 to:2011, exclude textbooks 561
Cochrane 3/1/11 ((reflectance OR immitance OR immittance OR impedance OR “acoustic power”OR “acoustic transfer” OR “acoustic resistance” OR “acoustic reactance” OR compliance OR admittance OR “power absorption” OR “power flow” OR wideband OR “sweep frequency” OR “multifrequency” OR “multiple frequency” OR “multi-frequency” OR tympanomet* OR tympanogram) and (ear OR tympanic OR ossicles OR Eustachian)) 229
Clinical trials
Cochrane 3/11/11 “Ear, Middle/pathology”[Mesh] OR “Ear, Middle/physiopathology”[Mesh] 41
Clinical trials
Cochrane 3/11/11 (“Ear Diseases/pathology”[Mesh] OR “Ear Diseases/physiopathology”[Mesh] OR “Ear Diseases/diagnosis”[Mesh]) AND (“Acoustic Impedance Tests”[Mesh] OR ((reflectance OR immitance OR immittance OR impedance OR “acoustic power” OR “acoustic transfer” OR “acoustic resistance” OR “acoustic reactance” OR compliance OR admittance OR “power absorption” OR “power flow” OR wideband OR “sweep frequency” OR “multifrequency” OR “multiple frequency” OR “multi-frequency” OR tympanomet* OR tympanogram)) 107
Clinical trials, 1975–2011
Google Scholar 3/22/11 “sweep frequency tympanometry” OR “multiple frequency tympanometry” OR “multifrequency tympanometry” OR “multi frequency tympanometry” OR “high frequency tympanometry” OR “1000 hz tympanometry” OR “1 kHz tympanometry” 537
English
Google Scholar 3/22/11 “sweep frequency tympanogram” OR “multiple frequency tympanogram” OR “multifrequency tympanogram” OR “multi frequency tympanogram” OR “high frequency tympanogram” OR “1000 hz tympanogram” OR “1 kHz tympanogram” 46
English
Google Scholar 3/23/11 “sweep frequency tympanometric” OR “multiple frequency tympanometric” OR “multifrequency tympanometric” OR “multi frequency tympanometric” OR “high frequency tympanometric” OR “1000 hz tympanometric” OR “1 kHz tympanometric” 67
English
Google Scholar 3/23/11 “probe tone frequencies” AND tympanometry (NOT “multifrequency tympanometry”) 71
English
Google Scholar 3/23/11 “multifrequency impedance audiometry” OR “high frequency impedance audiometry” OR “multifrequency immittance” OR “high frequency immittance” (NOT “high frequency tympanometry”) 29
English
Google Scholar 3/28/11 “wideband reflectance” OR “middle ear power” OR “reflectance tympanometry” OR otoreflectance OR “wideband middle ear” OR “admittance reflectance” OR “wideband energy reflectance” OR “wideband acoustic transfer” 279
English
Google Scholar 3/28/11 “reflectance YR” 16
English
Google Scholar 3/30/11 (“energy reflectance” OR “pressure reflectance” OR “power reflectance”) AND “middle ear” x221
Database Last date searched Search words and limits Yield
PubMed 1/28/11 (“Ear, Middle/pathology”[Mesh]OR “Ear Diseases/pathology”[Mesh] OR “Ear Diseases/physiopathology”[Mesh] OR “Ear, Middle/physiopathology”[Mesh] OR “Ear Diseases/diagnosis”[Mesh]) AND (“Acoustic Impedance Tests”[Mesh] OR tympanomet* OR tympanogram OR reflectance OR transmittance OR “acoustic power” OR “acoustic transfer” OR immitance OR immittance OR impedance OR admittance OR compliance OR “power absorption” OR “power flow” OR “acoustic resistance” OR “acoustic reactance” OR wideband) 1,916
1975–2011, English, Human
PubMed 1/31/11 (reflectance OR wideband OR “acoustic transfer”) AND (“Ear, Middle/pathology”[Mesh]OR “Ear Diseases/pathology”[Mesh] OR “Ear Diseases/physiopathology”[Mesh] OR “Ear, Middle/physiopathology”[Mesh] OR “Ear Diseases/diagnosis”[Mesh] OR “Acoustic Impedance Tests”[Mesh] OR ear OR otosclero* OR otolog* OR audiolog* OR “otitis media” OR cholesteatoma OR ossicles OR eustachian OR tympanic) OR 428
(“sweep frequency” OR “multiple frequency” OR “multi frequency” OR multifrequency or “high frequency” OR “1000 hz” OR “1 kHz” OR “probe-tone frequencies” OR “660 hz”) AND (“impedance audiometry” OR tympanometry OR tympanometric OR tympanogram)
1975–2011, English, Human
All EBSCO databases 2/11/11 (“sweep frequency” OR “multiple frequency” OR “multi frequency” OR multifrequency OR “probe tone frequencies” OR “high frequency probe” OR “high frequency tympanometry” OR “1000 hz probe” OR “1000 hz tympanometry” OR “1 kHz probe” OR “1 kHz tympanometry” OR “660 hz probe” OR “660 hz tympanometry”) AND (ear OR tympan* OR “otitis media” OR cholesteatoma OR otosclero* OR Eustachian OR ossicles) 81
1975–2011
CINAHL 2/14/11 ((MM “Acoustic Impedance Tests”) OR tympanomet* OR tympanogram OR reflectance OR transmittance OR “acoustic power” OR “acoustic transfer” OR immitance OR immittance OR impedance OR admittance OR compliance OR “power absorption” OR “power flow” OR “acoustic resistance” OR “acoustic reactance” OR wideband) AND ((MM “Diagnosis, Ear+”) OR (MM “Ear, Middle+”) OR (MM “Ear Diseases+”)) 559
Through EBSCO MM = Major concept
1975–2011, peer reviewed, English, human
PsycINFO 2/17/11 (MM “Ear Disorders” OR MM “Labyrinth Disorders” OR MM “Tinnitus” OR MM “Middle Ear” OR otosclerosis OR “otitis media” OR cholesteatoma OR tympanic OR ossicles OR Eustachian OR ear) AND (tympanomet* OR tympanogram OR reflectance OR transmittance OR “acoustic power” OR “acoustic transfer” OR immitance OR immittance OR impedance OR admittance OR “power absorption” OR “power flow” OR “acoustic resistance” OR “acoustic reactance” OR wideband) 134
Through EBSCO MM = Major concept
1975–2011, peer reviewed, English, human
Health Source: Nursing/Academic Edition 2/18/11 (tympanomet* OR tympanogram OR reflectance OR transmittance OR “acoustic power” OR “acoustic transfer” OR immitance OR immittance OR impedance OR admittance OR “power absorption” OR “power flow” OR “acoustic resistance” OR “acoustic reactance” OR wideband) AND (ear OR otosclero* OR “otitis media” OR cholesteatoma OR ossicles OR eustachian OR tympanic) 225
Through EBSCO 1975–2011, peer reviewed
Psychology and Behavioral Sciences Collection 2/18/11 (tympanomet* OR tympanogram OR reflectance OR transmittance OR “acoustic power” OR “acoustic transfer” OR immitance OR immittance OR impedance OR admittance OR “power absorption” OR “power flow” OR “acoustic resistance” OR “acoustic reactance” OR wideband) AND (otosclero* OR “otitis media” OR cholesteatoma OR ossicles OR eustachian OR tympanic OR ear) 103
Through EBSCO 1975–2011, peer reviewed
Communication & Mass Media Complete 2/18/11 (tympanomet* OR tympanogram OR reflectance OR transmittance OR “acoustic power” OR “acoustic transfer” OR immitance OR immittance OR impedance OR admittance OR “power absorption” OR “power flow” OR “acoustic resistance” OR “acoustic reactance” OR wideband) AND (otosclero* OR “otitis media” OR cholesteatoma OR ossicles OR eustachian OR tympanic OR ear) 21
Through EBSCO 1975–2011, peer reviewed
Education Research Complete 2/18/11 (tympanomet* OR tympanogram OR reflectance OR transmittance OR “acoustic power” OR “acoustic transfer” OR immitance OR immittance OR impedance OR admittance OR “power absorption” OR “power flow” OR “acoustic resistance” OR “acoustic reactance” OR wideband) AND (otosclero* OR “otitis media” OR cholesteatoma OR ossicles OR eustachian OR tympanic OR ear) 85
Through EBSCO 1975–2011, peer reviewed
ERIC 11/16/10 ((Thesaurus Descriptors:“Diseases”) and (Keywords:ear)) 35
Publication Date: 1975–2010
ERIC 11/16/10 ((Keywords:tympanometry) or (Keywords:tympanogram)) 22
Publication Date: 1975–2010
CSA 11/27/10 ((reflectance OR immitance OR immittance OR impedance) AND (tympanic OR ossicles OR Eustachian OR ear)) OR (tympanogram OR tympanomet* OR “acoustic power” OR “acoustic transfer” OR “acoustic resistance” OR “acoustic reactance”) 1080
1975–2011, journal articles, English only
ISI Web of Knowledge 12/3/10 #1 TS = (reflectance OR immitance OR immittance OR impedance OR “acoustic power” OR “acoustic transfer” OR “acoustic resistance” OR “acoustic reactance”) 1,386
#2 TS = (ear OR tympanic OR ossicles OR eustachian)
#3 TS = tympanomet*
(#1 and #2) OR #3 Articles only, English
TS = Topic, Title, Abstract, Keywords
Science Direct 12/7/10 “sweep frequency tympanometry ” OR “multifrequency tympanometry ” OR “multiple frequency tympanometry ” OR “multi-frequency tympanometry” OR “1000 hz tympanometry” 38
Publication date > 1974
Science Direct 12/28/10 (“acoustic power” OR “acoustic transfer” OR “acoustic resistance” OR “acoustic reactance” OR “power absorption” OR “power flow” OR reflectance) AND (ear OR tympanic OR ossicles OR Eustachian) 339
Publication date > 1974
Science Direct 12/28/10 (“acoustic power” OR “acoustic transfer” OR “acoustic resistance” OR “acoustic reactance” OR “power absorption” OR “power flow” OR reflectance) AND (“middle ear” OR otosclero* OR otolog* OR audiolog* OR “otitis media” OR cholesteatoma) 7
Publication date > 1974
Science Direct 1/20/11 (TITLE-ABSTR-KEY(tympanometr*)) OR (TITLE-ABSTR-KEY(impedance) and ALL(“middle ear” OR otosclero* OR otolog* OR audiolog* OR “otitis media” OR cholesteatoma OR ossicles OR eustachian OR tympanic)) 417
Publication date > 1974
HighWire 1/25/11 Anywhere: reflectance OR “acoustic power” OR “acoustic transfer” OR “wideband power” 71
Title/abstract: ear OR tympanic OR “otitis media” OR “cholesteatoma” OR otolog* OR otosclero* OR audiolog*
HighWire 1/28/11 Anywhere: ear OR tympanic OR “otitis media” OR “cholesteatoma” OR otolog* OR otosclero* OR audiolog* 97
Title/abstract: reflectance OR “acoustic power” OR “acoustic transfer”
HighWire 1/28/11 Anywhere: tympanic OR “otitis media” OR “cholesteatoma” OR otosclero* 3
Title/abstract: “acoustic resistance” OR “acoustic reactance” OR “power absorption” OR “power flow”
HighWire 1/28/11 Anywhere: “acoustic resistance” OR “acoustic reactance” OR “power absorption” 4
Title/abstract: tympanic OR “otitis media” OR “cholesteatoma” OR otosclero*
HighWire 1/31/11 Anywhere: ear OR tympanic OR “otitis media” OR otolog* OR otosclero* OR audiolog* 280
Title/abstract: impedance
HighWire 2/2/11 Title/abstract: tympanometr* OR tympanogram 280
HighWire 2/2/11 Anywhere: ear OR tympanic OR “otitis media” OR otolog* OR otosclero* OR audiolog* 35
Title/abstract: immittance OR immitance
HighWire 2/2/11 Anywhere: cholesteatoma 6
Title/abstract: immittance OR immitance OR impedance
HighWire 2/7/11 Anywhere: ear OR tympanic OR “otitis media” OR otolog* OR otosclero* OR audiolog* 48
Title/abstract: admittance
HighWire 2/8/11 Anywhere: “sweep frequency” OR “multiple frequency” OR “multi frequency” OR multifrequency 95
Title/abstract: ear OR tympan* OR “otitis media” OR otolog* OR otosclero* OR audiolog* NOT bioelectric*
HighWire 2/8/11 Anywhere: “probe tone frequencies” 17
Title/abstract: ear OR tympan* OR “otitis media” OR otolog* OR otosclero* OR audiolog* NOT bioelectric*
HighWire 2/8/11 Anywhere: “probe frequencies” 34
Title/abstract: ear OR tympan* OR “otitis media” OR otolog* OR otosclero* OR audiolog* NOT bioelectric*
HighWire 2/8/11 “1000 hz tympanometry” OR “1 kHz tympanometry” 7
HighWire 2/8/11 “1000 hz tympanogram” OR “1 kHz tympanogram” 1
HighWire 2/8/11 “high frequency tympanogram” OR “high frequency tympanometry” 11
HighWire 2/8/11 “1000 hz probe” AND tympano* 13
HighWire 2/8/11 “1 kHz probe” AND tympano* 2
HighWire 2/10/11 “660 hz” AND tympano* 51
HighWire 2/10/11 “high frequency probe” AND tympano* 13
OT seeker 1/28/11 Tympanometry OR tympanometric OR tympanogram OR impedance OR reflectance 1
Evidence-Based Communication Assessment and Intervention 2/1/11 Tympanometr* OR impedance OR reflectance OR “acoustic transfer” OR tympanogram OR wideband 1
SpeechBITE 2/3/11 Key word: otitis media 4
SpeechBITE 2/3/11 Tympanometry OR reflectance 0
National Rehab 2/3/11 Tympanometry OR Tympanometric OR Tympanogram OR Reflectance 21
PEDRO 2/3/11 Tympanometry OR Tympanometric OR Tympanogram OR Reflectance 2
PsycBITE 2/3/11 Tympanometry OR Tympanometric OR Tympanogram OR Reflectance 0
EHDI 2/3/11 Tympanometry OR Tympanometric OR Tympanogram OR Reflectance (in title) 4
LILACS 2/16/11 tympanometr$ OR reflectance 181
DARE, NHS EED, HTA databases through the Centre for Reviews and Dissemination 2/18/11 Tympanometry OR reflectance 12
TRIP database 2/24/11 ((tympanometry OR tympanometric OR tympanogram OR reflectance OR immitance OR immittance OR impedance OR “acoustic power” OR “acoustic transfer” OR “acoustic resistance” OR “acoustic reactance” OR “power absorption” OR “power flow”) AND (ear OR otosclerosis OR “otitis media” OR cholesteatoma OR tympanic OR ossicles OR eustachian)) from:1975 to:2011, exclude textbooks 561
Cochrane 3/1/11 ((reflectance OR immitance OR immittance OR impedance OR “acoustic power”OR “acoustic transfer” OR “acoustic resistance” OR “acoustic reactance” OR compliance OR admittance OR “power absorption” OR “power flow” OR wideband OR “sweep frequency” OR “multifrequency” OR “multiple frequency” OR “multi-frequency” OR tympanomet* OR tympanogram) and (ear OR tympanic OR ossicles OR Eustachian)) 229
Clinical trials
Cochrane 3/11/11 “Ear, Middle/pathology”[Mesh] OR “Ear, Middle/physiopathology”[Mesh] 41
Clinical trials
Cochrane 3/11/11 (“Ear Diseases/pathology”[Mesh] OR “Ear Diseases/physiopathology”[Mesh] OR “Ear Diseases/diagnosis”[Mesh]) AND (“Acoustic Impedance Tests”[Mesh] OR ((reflectance OR immitance OR immittance OR impedance OR “acoustic power” OR “acoustic transfer” OR “acoustic resistance” OR “acoustic reactance” OR compliance OR admittance OR “power absorption” OR “power flow” OR wideband OR “sweep frequency” OR “multifrequency” OR “multiple frequency” OR “multi-frequency” OR tympanomet* OR tympanogram)) 107
Clinical trials, 1975–2011
Google Scholar 3/22/11 “sweep frequency tympanometry” OR “multiple frequency tympanometry” OR “multifrequency tympanometry” OR “multi frequency tympanometry” OR “high frequency tympanometry” OR “1000 hz tympanometry” OR “1 kHz tympanometry” 537
English
Google Scholar 3/22/11 “sweep frequency tympanogram” OR “multiple frequency tympanogram” OR “multifrequency tympanogram” OR “multi frequency tympanogram” OR “high frequency tympanogram” OR “1000 hz tympanogram” OR “1 kHz tympanogram” 46
English
Google Scholar 3/23/11 “sweep frequency tympanometric” OR “multiple frequency tympanometric” OR “multifrequency tympanometric” OR “multi frequency tympanometric” OR “high frequency tympanometric” OR “1000 hz tympanometric” OR “1 kHz tympanometric” 67
English
Google Scholar 3/23/11 “probe tone frequencies” AND tympanometry (NOT “multifrequency tympanometry”) 71
English
Google Scholar 3/23/11 “multifrequency impedance audiometry” OR “high frequency impedance audiometry” OR “multifrequency immittance” OR “high frequency immittance” (NOT “high frequency tympanometry”) 29
English
Google Scholar 3/28/11 “wideband reflectance” OR “middle ear power” OR “reflectance tympanometry” OR otoreflectance OR “wideband middle ear” OR “admittance reflectance” OR “wideband energy reflectance” OR “wideband acoustic transfer” 279
English
Google Scholar 3/28/11 “reflectance YR” 16
English
Google Scholar 3/30/11 (“energy reflectance” OR “pressure reflectance” OR “power reflectance”) AND “middle ear” x221
×