SHOEBOX Audiometry VALIDATION 2017-04-28T20:12:03+00:00







SHOEBOX is listed as a Class II device by the FDA and Health Canada. SHOEBOX conforms to current ANSI, OSHA and CSA standards. SHOEBOX is both HIPAA & ISO 13485 compliant.

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Accuracy of Mobile-Based Audiometry in the Evaluation of Hearing Loss in Quiet and Noisy Environments

Saliba, J., Al-Reefi, M., Carriere, J.S., Verma, N., Provencal, C., Rappaport, J.M.

Journal of Otolaryngology – Head and Neck Surgery


Objectives: (1) To compare the accuracy of 2 previously validated mobile-based hearing tests in determining pure tone thresholds and screening for hearing loss. (2) To determine the accuracy of mobile audiometry in noisy environments through noise reduction strategies.

Study Design: Prospective clinical study.

Setting: Tertiary hospital.

Subjects and Methods: Thirty-three adults with or without hearing loss were tested (mean age, 49.7 years; women, 42.4%). Air conduction thresholds measured as pure tone average and at individual frequencies were assessed by conventional audiogram and by 2 audiometric applications (consumer and professional) on a tablet device. Mobile audiometry was performed in a quiet sound booth and in a noisy sound booth (50 dB of background noise) through active and passive noise reduction strategies.

Results: On average, 91.1% (95% confidence interval [95% CI], 89.1%-93.2%) and 95.8% (95% CI, 93.5%-97.1%) of the threshold values obtained in a quiet sound booth with the consumer and professional applications, respectively, were within 10 dB of the corresponding audiogram thresholds, as compared with 86.5% (95% CI, 82.6%-88.5%) and 91.3% (95% CI, 88.5%-92.8%) in a noisy sound booth through noise cancellation. When screening for at least moderate hearing loss (pure tone average >40 dB HL), the consumer application showed a sensitivity and specificity of 87.5% and 95.9%, respectively, and the professional application, 100% and 95.9%. Overall, patients preferred mobile audiometry over conventional audiograms.

Conclusion: Mobile audiometry can correctly estimate pure tone thresholds and screen for moderate hearing loss. Noise reduction strategies in mobile audiometry provide a portable effective solution for hearing assessments outside clinical settings.



Accuracy of a Tablet Audiometer for Measuring Behavioral Hearing Thresholds in a Clinical Population

Thompson, G.P., Sladen, D.P., Hughes Borst, B.J., Still, O.L.

Journal of Otolaryngology – Head and Neck Surgery


Objective: To examine the validity of a tablet computer–based audiometer for measuring hearing thresholds in a moderately noisy environment.

Study Design: A prospective single-cohort repeated measures study.

Setting: Tertiary care institution providing hearing health care to a diverse population.

Subjects and Methods: Subjects included 49 participants (44 adults, 5 children) with all degrees of hearing sensitivity. Potential participants were excluded if they were <4 years old or had cognitive deficits or ear drainage. Participants were tested with established audiometric tests and a tablet audiometer. Threshold values were measured for both ears using various stimuli (500, 1000, 2000, and 4000 Hz). Testing with the tablet audiometer was conducted in a non-sound-treated room; room properties were characterized by ambient noise level and reverberation testing. Calibration assessment of the tablet audiometer was performed on 3 occasions.

Results: Within the test thresholds for hearing level, results from the tablet device were within 10 dB of those determined by conventional audiometry for 164 of 172 hearing levels and did not show proportional bias over the testing range. Calibration assessment showed accurate proximity between output and target values, though crosstalk and linearity failed initial assessments.

Conclusion: The tablet-based automated audiometer presents a new method for threshold hearing assessment outside conventional sound booths.



Mobile tablet audiometry in fluctuating autoimmune ear disease

Kohlert, S., Bromwich, M.

Journal of Otolaryngology – Head and Neck Surgery


Background: Autoimmune inner ear disease (AIED) is a rare condition characterized by bilateral fluctuating sensorineural hearing loss (SNHL). The labile nature of this hearing loss makes it difficult to accurately quantify with conventional methods, and therefore it is challenging to rehabilitate.

Methods: Over a 9-month period one pediatric patient with severe AIED was monitored and conducted home audiograms using a previously validated testing system (Shoebox Audiometry). During this period he also underwent several clinical audiograms. The correlation between clinical and home audiograms was analyzed with a Pearson coefficient, and the range and frequency of fluctuations was recorded.

Results: Sixty-four automated home audiograms and nine clinical audiograms were conducted. When tested at home using a calibrated system the pure tone average (PTA) fluctuated between 12 dB and 72 dB indicating large variability in hearing. Fluctuations were frequent: on 28 occasions the PTA varied by at least 5 dB when retested within 4 days. The mean PTA was 50 dB and 95% of the thresholds were within 36 dB of the mean. Clinical audiograms obtained on the same day or within 1 day of home testing were highly concordant (with a Pearson coefficient of 0.93).

Conclusion: AIED can result in significant fluctuations in hearing over short periods of time. Home testing enables a more granular look at variations over time and correlates well with clinical testing, and thus facilitates rapid action and informed rehabilitation.



Tablet Audiometry in Canada’s North: A Portable and Efficient Method for Hearing Screening

Rourke, R., Chan Chun Kong, D., Bromwich, M.

Journal of Otolaryngology – Head and Neck Surgery


Background: Access to hearing health care is limited in many parts of the world, creating a lack of prompt diagnosis, which further complicates treatment. The use of portable audiometry for hearing loss testing can improve access to diagnostics in marginalized populations. Our study objectives were twofold: (1) to determine the prevalence of hearing loss in children aged 4 to 11 years in Iqaluit, Nunavut, and (2) to test and demonstrate the use of our tablet audiometer as a portable hearing testing device in a remote location.

Study Design: Prospective cross-sectional observational.

Setting: Remote elementary schools in 3 Canadian Northern communities.

Subjects and Methods: Tablet audiometers were used to test hearing in 218 children. Air conduction pure tones thresholds were obtained at 500, 1000, 2000, and 4000 Hz. Children with hearing loss ≥30 dB in either ear were referred for audiology services.

Results: Tablet audiometry screening testing revealed abnormal results in 14.8% of the study participants. No significant difference in the rate of hearing loss was seen by sex; however, the rate of hearing loss decreased significantly with increasing age. The median duration of the hearing test was 5 minutes 30 seconds.

Conclusions: Of the study population, 14.8% tested positive for hearing loss based on our interactive tablet audiometer. In this setting, the tablet audiometer was both time efficient and largely language independent. This type of testing is valuable for providing much-needed hearing health care for high-risk populations in rural and remote areas where audiology services are often unavailable.


The new age of play audiometry: prospective validation testing of an iPad-based play audiometer

Yeung, J., Javidnia, H., Heley, S., Beauregard, Y., Champagne, S., Bromwich, M.

Journal of Otolaryngology – Head and Neck Surgery


Objective: The timely diagnosis of hearing loss in the pediatric population has significant implications for a child’s development. However, audiological evaluation in this population poses unique challenges due to difficulties with patient cooperation. Though specialized adaptations exist (such as conditioned play audiometry), these methods can be time-consuming and costly. The objective of this study was to validate an iPad-based play audiometer that addresses the shortcomings of existing audiometry.

Methods: We designed a novel, interactive game for the Apple® iPad® that tests pure tone thresholds. In a prospective, randomized study, the efficacy of this tool was compared to standard play audiometry. 85 consecutive patients presenting to the Audiology Clinic at the Children’s Hospital of Eastern Ontario (ages 3 and older) were recruited into this study. Their hearing was evaluated using both tablet and traditional play audiometry.

Outcome measure: Warble-tone thresholds obtained by both tablet and traditional audiometry.

Results: The majority of children in this age group were capable of completing an audiologic assessment using the tablet computer. The data demonstrate no statistically significant difference between warble-tone thresholds obtained by tablet and traditional audiometry (p=0.29). Moreover, the tablet audiometer demonstrates strong sensitivity (93.3%), specificity (94.5%) and negative predictive value (98.1%).

Conclusion: The tablet audiometer is a valid and sensitive instrument for screening and assessment of warble-tone thresholds in children.



Prevalence of Hearing Loss in Teachers of Singing and Voice Students

Isaac, M.J., McBroom, D.H., Nguyen, S.A., Halstead, L.A.

Journal of Voice


Objectives: Singers and voice teachers are exposed to a range of noise levels during a normal working day. This study aimed to assess the hearing thresholds in a large sample of generally healthy professional voice teachers and voice students to determine the prevalence of hearing loss in this population.

Study Design: A cross-sectional study was carried out.

Methods: Voice teachers and vocal students had the option to volunteer for a hearing screening of six standard frequencies in a quiet room with the Shoebox audiometer (Clearwater Clinical Limited) and to fill out a brief survey. Data were analyzed for the prevalence and severity of hearing loss in teachers and students based on several parameters assessed in the surveys. All data were analyzed using Microsoft Excel (Microsoft Corp.) and SPSS Statistics Software (IBM Corp.).

Results: A total of 158 participants were included: 58 self-identified as voice teachers, 106 as voice students, and 6 as both. The 6 participants who identified as both, were included in both categories for statistical purposes. Of the 158 participants, 36 had some level of hearing loss: 51.7% of voice teachers had hearing loss, and 7.5% of voice students had hearing loss. Several parameters of noise exposure were found to positively correlate with hearing loss and tinnitus (P < 0.05). Years as a voice teacher and age were both predictors of hearing loss (P < 0.05).

Conclusions: Hearing loss in a cohort of voice teachers appears to be more prevalent and severe than previously thought. There is a significant association between years teaching and hearing loss. Raising awareness in this population may prompt teachers and students to adopt strategies to protect their hearing.



Ellaham, N., Yilma, Y., Jourdan, G.V.,  Bromwich, M.

Canadian Acoustics


This paper presented a new app developed for the iPad platform to perform CPA tests for screening pre-school children for potential hearing loss. The app is intended for use in free-field environments where access to sound booths and elaborate equipment is not available. Equipment and environment limitations were discussed along with elegant solutions. A means of calibrating the system in two stages is also provided. A prototype of the app has been developed and is presently being tested in trials at the Division of Pediatric Otolaryngology, Head and Neck Surgery at the Children’s Hospital of Eastern Ontario.


Evolution of audiometry: Clinical testing of a new tablet audiometer

NEllaham, N., Jourdan, G.V., Champagne, S., Yeung, J., Bromwich, M.

Canadian Acoustics


A clinical study was conducted to determine the accuracy of audiometric thresholds measured using tablet audiometry. The results were compared to those obtained with accepted conventional conditioned play audiometry (CPA). The study was conducted on a population of 85 patients with normal or abnormal hearing, aged 3-16, at the Audiology Clinic at the Children’s Hospital of Eastern Ontario. All participants completed two audiometric evaluations, one with the tablet audiometer and one with conventional CPA and the order of the test was determined at random. 55 subjects were identified by the conventional CPA test to have normal hearing. Of these, 52 were correctly identified with tablet audiometry, the remaining 3 children scoring slightly outside the parameters defined for normal hearing. For patients who had separate left-right ear assessments, a repeated measures model for the threshold in each ear at each frequency was fitted using linear mixed effects modeling.

Administering the automated tablet-based system is a skill that can be taught to an allied health professional (eg, a nurse or teacher). The compact size increases portability, thereby adding to its ease of use. The tablet audiometer presents a potentially cost-effective method for assessing hearing in various settings.
Gregory P. Thompson, Department of Otolaryngology–Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
Standard audiometers are much too costly for healthcare systems in developing countries. In addition, the resources for annual calibration and maintenance are essentially non-existent. Therefore, many units are left without equipment to properly assess hearing status in their patients. The ShoeBOX audiometer is a cost effective, portable and low maintenance option for these healthcare settings.The screening program was easy to use and when cross referenced to audiograms completed on a standard audiometer, accurate results were yielded.
Katie de Champlain, MSc., R.Au Registered Audiologist, Alberta Health Services
Having used the ShoeBOX audiometer system in Leveque, Haiti this past January, I can vouch for the effectiveness of the equipment, its robustness in field conditions and the value of the information i provided on the children we tested.
Dr. Daniel Choo, MD, FACS, FAAP, Professor & Director, Division of Pediatric Otolaryngology Department of Otolaryngology Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center
As an Otolaryngology resident at the University of Ottawa I used ShoeBOX to test children ages 4-10 years old at three elementary schools in Iqaluit, Nunavut. I screened 218 children for hearing loss in four days. With three devices, I was able to test three children at once, so three children were tested in 5 minutes and 30 seconds by one test administrator.

The children found the device and hearing screening game to be extremely fun! Word spread around the school about the testing and the kids all wanted to have a turn playing the ‘hearing game’ (there were even high-fives exchanged!). This made for a positive hearing testing experience for all involved.

ShoeBOX is also very portable. I easily traveled to Iqaluit with three devices. They were light to carry from school to school. Transportation of data was safe and secure.

Dr. Ryan Rourke, Otolaryngology, University of Ottawa
  • Validation of a new tablet audiometer – Best Project, Canadian Society of Otolaryngology

  • ShoeBOX Audiometery – Best Research Paper – Medicine 2.0 International Medical Informatics Association

  • ShoeBOX Audiometery – Best Technological Innovation for Care Delivery Children’s Hospital Academic Medical Organization of ONTARIO

  • 2014 Telus Award for Mhealth Innovation

  • 2016 Interface Health ChallengeX, First Place

  • 2016 Global Digital Health 100 – Journal of mHealth