How Does Long Term Use of Surgical Face Mask Affect the Voice in Normophonic Subjects?

OBJECTIVES: To assess the effects of the longterm-use of surgical face mask (SFM) on acoustic and auditory-perceptual voice parameters in normophonic subjects without any known risk factor related to voice disorders. MATERIALS AND METHODS: Of 73 normophonic subjects who were previously included in a couple of studies before the COVID-19 outbreak, 25 people (18 female and 7 male) who were free of any known risk factor related to voice disorders during the outbreak were re-evaluated to assess the long-term effect of SFM on voice by using acoustic (mean F0, Jitter-local, Shimmer-local, Cepstral Peak Prominence (CPP), Noise to Harmonic Ratio (NHR), maximum phonation time (MPT)) and auditory-perceptual (Consensus Auditory-Perceptual Evaluation of Voice, CAPE-V) parameters and those data found in SFM period were compared with the previous (preSFM) data. MPT and acoustic data were analyzed by PRAAT software. RESULTS: It was seen that the mean F0 value presented a significant increase, while Jitter-local and Intensity values revealed a significant decrease in females after 2 years pass with SFM use (average 22.52 ± 0.18 months).In males, only a significant decrease in Jitter-local was detected. CONCLUSIONS: This study is the first longitudinal investigation on the effects of SFM use on acoustic and auditory-perceptual measures of voice. The data in this study, revealed that long-term use of SFM would not appear to be negatively affecting the acoustic parameters of the voice in normophonic subjects (particularly females) without any related risk factors such as tobacco use, reflux, and etc.

Acoustic and Auditory-Perceptual Analysis of Voice in the Female Smokers Who Do Not Have Self-Reported Voice Complaint.

OBJECTIVES: Smoking affects the voice quality and the previous studies presented higher Voice Handicap Index (VHI) scores, and abnormal acoustic data in smokers. However, there is no study revealing any voice parameter indicating incipient damage in voice functionality. The studies documented that the adverse effects of smoking on phonatory function were higher in females than males and further the prevalence of smoking among females tends to increase. The purpose of this study was to investigate the effect of smoking on the acoustic and auditory-perceptual analysis of the speaking voice in female smokers who scored the VHI-10 scale as grade 0 (absent), and thus to look for a criterion for incipient vocal damage of smoking. METHODS: The study group composed of 22 female smokers and 22 female nonsmokers between the ages of 18 and 55 years. The acoustic parameters (mean F0, jitter local [%], jitter local abs, jitter rap, jitter ppq, shimmer local [%], shimmer local [dB], shimmer apq3, shimmer apq5, shimmer apq11, and mean HNR) and the GRBAS scale were analyzed in all subjects. RESULTS: No significant difference observed between the smoker and nonsmokers groups in acoustic voice analysis. It was seen that the smokers presented a small but significant increase in the Strain parameter of the GRBAS scale while there was no significant difference in the Grade, Roughness, Breathiness, and Asthenia parameters between the study groups. CONCLUSION: The results of this study indicate that increase in Strain could be considered as an early data in the smokers without voice complaints. However, our data declared that conventional acoustic perturbation analysis did not reveal incipient Strain in voice.

Reflux, dysphonia, and dysphagia symptoms in patients with diabetes and their association with diabetic complications.

BACKGROUND: Diabetes mellitus (DM) could influence various organs, especially the eyes, kidneys, nerves, heart, and blood vessels, and finally results in many irreversible disease-related complications. In this paper, the association between reflux, swallowing, and voice symptoms in patients with DM and the possible effect of diabetic complications on these symptoms were investigated. METHODS: A total of 179 patients with diabetes were included to the study. Three self-reported questionnaires; Reflux Symptom Index (RSI), Eating Assessment Tool-10 (EAT-10), and Voice Handicap Index-10 (VHI-10) were administrated to the patients and, their association with DM-related neuropathy and nephropathy were examined. RESULTS: The scores of each questionnaire were significantly correlated with each other (p < 0.001). There was not any statistically significant association between the score of T-RSI and the diabetic complications (p = 0.077), while a statistically significant association was found between the T-EAT-10 score and neuropathy (p < 0.001). Neither neuropathy nor nephropathy alone had an association with the T-VHI-10 score. However, the presence of nephropathy and neuropathy together was found to be associated with the T-VHI-10 score (p = 0.027). DISCUSSION: It is possible to conclude that gastrointestinal symptoms such as reflux, dysphonia, and dysphagia are associated with each other and they may possibly be related to the microvascular complications of DM. The clinicians should be aware of the possible reflux, voice, and swallowing complaints and also inquire about the presence of neuropathy and nephropathy in the diabetic population.

Vocal outcomes after COVID-19 infection: acoustic voice analyses, durational measurements, self-reported findings, and auditory-perceptual evaluations.

PURPOSE: The ongoing literature suggests that COVID-19 may have a potential impact on voice characteristics during the infection period. In the current study, we explored how the disease deteriorates different vocal parameters in patients who recovered from COVID-19. METHODS: A total of 80 participants, 40 patients with a prior history of COVID-19 (20 male, 20 female) with a mean age of 39.9 ± 8.8 (range, 21-53) and 40 gender and age-matched healthy individuals (mean age, 37.3 ± 8.8; range, 21-54) were included to this study. The data of acoustic voice analyses, durational measurements, patient-reported outcomes, and auditory-perceptual evaluations were compared between the study group and the control group. Correlation analyses were conducted to examine the association between the clinical characteristics of the recovering patients and measured outcomes. RESULTS: Maximum phonation time (MPT) and the scores of both Voice Handicap Index-10 (VHI-10) and Voice-Related Quality of Life (V-RQOL) questionnaires significantly differed between the groups, which was more evident in female participants. The overall severity score of dysphonia was found to be higher in the study group than the control group (p = 0.023), but gender-based comparisons reached significance only in males (p = 0.032). VHI-10 and V-RQOL revealed significant correlations with the symptom scores of the disease. CONCLUSIONS: Patients with a prior history of COVID-19 had significantly lower MPT, increased VHI-10 scores, decreased voice-related quality of life based on the V-RQOL questionnaire, and higher overall severity scores in the auditory-perceptual evaluation. Self-reported voice complaints disclosed close relationships with the symptom scores of COVID-19 disease.

Negative Effects of Noise on NICU Graduates' Cochlear Functions.

AIM: To evaluate the adverse effects of noise on hearing. Methods: Thirty-two infants that had been admitted to neonatal intensive care unit (NICU) and 25 healthy controls were included in this study. Noise levels were recorded continously during the hospitalization period. Results: All healthy controls passed the hearing screening tests before discharge and on the sixth-month follow up. Hospitalized infants had lower "Distortion Product Auto Acoustic Emission Signal Noise Ratio" (DPOAE SNR) amplitudes (dB) at five frequencies (1001, 1501, 3003, 4004, 6006 Hz in both ears). DPOAE fail rates at 1001 Hz and 1501 Hz were higher than in hospitalized infants (81.8% and 50.0% vs 20.0% and 4.0%). Infants who failed the test at 1001 and 1501 Hz were exposed to noise above the recommended maximum level for longer periods of time. Conclusion: Hearing tests performed at sixth-months of life were adversely affected in NICU graduates.

Validating the Turkish version of the Weinstein noise sensitivity scale: effects of age, sex, and education level

Background/aim: Subjective noise sensitivity (SNS) is not only one of the most important predictors of perceived noise annoyance for the subjects exposed to the noise, but also strongly related with some psychological conditions and poor health perception of the subjects. Weinstein's Noise Sensitivity Scale (WNSS) is widely used for measuring of SNS. Materials and methods: In this study we adapted WNSS to Turkish (Tr-WNSS) and evaluated its psychometric properties and effect of age, sex and education level on SNS. Results: The study included 105 males and 105 female subjects between 18 and 55 years of age. Conclusion: Our data demonstrated that Tr-WNSS was a reliable, valid, and invariant scale for the Turkish population, and not affected by sex, age and education level.

Impact of the demographic and aetiological factors and intraoperative findings on postoperative outcomes in chronic otitis media surgery

Background/aim: Surgical success is related with many factors belonging to both the patient and the disease. This study aims to analyse the preoperative and intraoperative characteristics, the postoperative results, and the factors affecting the surgical success in different types of chronic otitis media (COM). Materials and methods: A total of 1510 ears of 1398 patients who underwent COM surgery were included in the study. Postoperative results were obtained from 376 ears of 356 patients who had been followed after surgery. The demographic characteristics of the patients, such as age and sex, operative findings, preoperative audiological examination results, and final audiometric and otoscopic examination findings, were retrospectively obtained from the archives of the department. Results: The most frequent diagnosis was simple COM (39.9%), and the most frequently performed surgery was tympanoplasty without mastoidectomy (46.6%). The overall hearing success rate was found to be 75.8%. Postoperative hearing success was significantly associated with the chronic otitis subgroup, ossicular pathologies, and the condition of the middle ear mucosa. Postoperative graft take rate was found to be 78.6%. Graft success was statistically significantly higher in patients with normal middle ear mucosa. Performing mastoidectomy, the presence of patency in aditus ad antrum, and being a paediatric case had no impact on graft success. Conclusion: Factors affecting the success of COM surgery include age, chronic otitis subgroup, location and size of perforation, the condition of the middle ear mucosa, and the level of the ossicular disease. These factors should be known and an appropriate treatment plan should be prepared.

Is intensity-modulated radiotherapy superior to conventional techniques to prevent late ear complications of nasopharyngeal cancer?

PURPOSE: This study analyzed the late ear complications of radiotherapy for nasopharyngeal cancer (NPC) and compared the conventional and intensity-modulated radiotherapy (2D-RT and IMRT, respectively). METHODS: At 2-21 years after the end of NPC treatment, 104 ears of 52 patients were evaluated with the otoscopic examination, pure tone audiometry test, tympanometry, and subjective complaints by being blinded to the radiotherapy technique. RESULTS: There were no differences in terms of the pathology of the external, middle or inner ear, air and bone-conduction hearing thresholds, and the air-bone (A-B) gap at 500, 1000, 2000, and 4000 Hz, and tympanometry types between 2D-RT and IMRT groups (p > 0.05). There were positive correlations between the values of A500 and A1000 thresholds; gap 500, 4000, and mean cochlear RT dose (p < 0.05). There were positive correlations between the values of A500, A1000, and A4000 thresholds; gap 500, 1000, 2000, 4000, and maximum cochlear RT dose (p < 0.05). CONCLUSION: IMRT was not found to be superior to 2D-RT to prevent RT-induced ear complications. The solution of the middle ear problems must be the goal of the strategies for complications treatment.

Turkish Adaptation of the Pediatric Voice Related Quality of Life Survey: A validity and reliability study.

OBJECTIVES: Childhood voice disorders have increased in recent years reduce not only communication of the child, but also; the quality of life by affecting the socio-emotional state. METHODS: In the study, it is aimed to test validity and reliability of Pediatric Voice Related Quality of Life Survey (PVRQOL)'s Turkish adaptation. A total of 223 individuals aged between 2 years and 18 years, with and without voice problems were involved in this study. RESULTS: Statistically significant differences were found between study and control groups for total score and sub domain scores for PVRQOL (p < 0,001). Total score of quality of life was higher in the control group. Cronbach alpha coefficient for overall PVRQOL was 0,922; dimension of physical function was 0,894 and socio-emotional domain was 0,804. In the test-retest reliability test, overall PVRQOL was found to be 0,732; physical functional sub domain was 0,734; socio-emotional sub domain was 0,721. The validity of the questionnaire was determined by factor analysis. CONCLUSION: The results suggest that the Turkish version of the PVRQOL has reliability and validity, and may play a crucial role in evaluating children with voice disorders.

The effect of obstructive sleep apnea syndrome on the central auditory system

Background/aim: Obstructive sleep apnea syndrome (OSAS) is a disease characterized by repeated hypoxia attacks during sleep. The effect of hypoxia on the central nervous system is a well-known entity. In this study we aimed to investigate the effect of OSAS on the central auditory system. Materials and methods: Twenty-one OSAS patients diagnosed by polysomnography (PSG) and 10 control subjects were included in the study. After a thorough otorhinolaryngology examination, all subjects underwent pure tone audiometry (250 to 8000 Hz frequency). The subjects with normal otoscopic examination and hearing threshold were included in the study. All participants underwent speech discrimination analyses and auditory time processing and sequencing tests, i.e. frequency pattern test (FPT) and duration pattern test (DPT). Results: Although hearing was normal in the OSAS patients, significant loss was observed in the speech discrimination rates compared to the control group (P < 0.05). Significant disruption was also detected in the FPT and SPT in the OSAS patients (P < 0.05). Conclusion: Repeated hypoxic episodes in OSAS resulted in statistically significant impairments in the central auditory pathways, even if the hearing threshold was within normal limits.

Does nasal congestion have a role in decreased resistance to regular CPAP usage?

Nasal obstruction is known to cause resistance to continuous positive airway pressure (CPAP) therapy in obstructive sleep apnea syndrome (OSAS). In this paper, short- and long-term nasal congestion in OSAS patients receiving CPAP treatment were evaluated with acoustic rhinometry (AR). A total of 36 patients with moderate-to-severe OSAS, diagnosed with polysomnography were included in the study. Ten healthy subjects without OSAS constituted the control group. Pre-treatment nasal patency were measured with AR in all participants. 26 patients used the recommended CPAP treatment. Ten patients did not accept CPAP treatment. The AR test was repeated for all the subjects after 1 and 3 months except the 3rd month's measurements of the control group. There was no statistically significant difference between the initial minimum cross-sectional area (MCA) measurements of OSAS patients, using or not using CPAP, and the control group (P > 0.05). However, the first month MCA measurements of patients receiving CPAP were found to be significantly decreased compared with the initial values (P < 0.001). There was no significant change in the first and third months MCA values in the control group and patients who did not use CPAP (P > 0.05). No significant difference revealed in the 3rd month MCA measurements of the patients using CPAP compared with the initial values (P > 0.05). In this study, the increased nasal congestion, which is thought to be the cause of CPAP resistance, was objectively demonstrated in OSAS patients using CPAP. In addition, the nasal congestion developing at the first month was shown to disappear over time, supporting the opinion that patient compliance in CPAP treatment is expected to increase after regular device usage.

Craniofacial Deviations in the Children With Nasal Obstruction.

Nasal obstruction mainly caused by adenoid hypertrophy in children affects the craniofacial growth and development process, and the craniofacial deviations and/or differences reported in the children are very similar to those in the adults with obstructive sleep apnea syndrome (OSAS). The authors aimed to look for relationships of the linear craniofacial dimensions in the children suffering from nasal obstruction with age, degree of clinical nasal obstruction score (CNOS), and relative size of the adenoid mass within the nasopharynx in their study.Fifty-five children suffering from nasal obstruction were retrospectively enrolled, and clinical data was used to calculate CNOS. On the lateral cephalometric radiographies, 9 linear variables were measured and adenoidal-nasopharyngeal ratio (ANR) was calculated.The data presented that, not CNOS, but ANR shown decrease by age, while many skeletal variables with exception of the nasopharyngeal and adenoidal postero-anterior dimensions were increased by age. Further, it was found that while CNOS were negatively correlated with the anterior cranial base length, anterior-superior facial height, and maxillary depth, ANR disclosed significant correlation only with the anteriorsuperior facial height. The authors' results support that nasal obstruction in the children was related not only to the adenoidal hypertrophy. Although relative size of the adenoidal mass in relation to the nasopharynx decreased by age, nasal obstruction was still present. Further, these results support that craniofacial deviations and/or differences in the children with nasal obstruction is similar to the adult OSAS patients. Smaller dimensions related to the naso-maxillary complex in the children with more severe nasal obstruction appear to be continuous by age. Hence, it could be said that narrow naso-maxillary complex could contribute to proceed nasal obstruction by age, which may contribute to OSAS in the adults.

Acoustic Analysis of Used Tuning Forks.

OBJECTIVE: In this study, we evaluated used aluminum tuning forks (TFs) for fundamental frequencies (FF), overtones, and decay times. MATERIALS AND METHODS: In total, 15 used (1 C1, 11 C2, and 3 C3) and 1 unused (C2) TFs were tuned, and the recorded sound data were analyzed using the Praat sound analysis program. RESULTS: It was found that FFs of the recorded sounds produced by the used C2-TFs presented a high variability from 0.19% to 74.15% from the assumed FFs, whereas this rate was smaller (1.49%) in the used C3-TFs. Further, decay times of the used C2-TFs varied from 5.41 to 40.97 s. CONCLUSION: This study, as the first of its kind in the literature, reported that some of the used aluminum TFs lost their physical properties that are important for clinical TF tests. It could be said that this is a phenomenon related to metal fatigue, which is common in aluminum products due to the cyclic load.

Management of children with auditory neuropathy spectrum disorder (ANSD) / Tratamento de crianças com espectro da neuropatia auditiva (ENA)

ABSTRACT INTRODUCTION: ANSD is a challenging problem. OBJECTIVE: To present our experience on management of the children with ANSD with respect to clinical data. METHODS: This retrospective study included all children younger than 16 years of age who applied to the department between 2005 and 2013 (with the exception of newborn hearing screening NHS referrals). The data were derived from pure tone, OAEs and ABR tests, and further medical risk factors of the subjects were evaluated. RESULTS: ANSD was recognized in 74 ears of 40 children (B/U: 34/6) among 1952 children with SNHL (2.04%) detected among 9520 applicants to the department (0.42%). The clinical tests revealed that hearing loss greater than 15 dB was present in both ears of 38 cases. The degree of hearing loss was profound in 48% children, severe in 12% children, moderate in 28% children, mild in 10% children and normal in 5% children. ABRs were absent/abnormal in 37/3 ears and CMs were detected in all. Acoustic reflexes were absent in all ears. Rehabilitation was managed by CI and hearing aids in 15 and 23 cases, respectively. FM system was given to two cases displaying normal hearing but poor speech discrimination in noisy environments. CONCLUSION: ANSD is a relatively challenging problem for the audiology departments because of its various clinical features and difficulties in management. Our patients with ANSD most commonly displayed profound hearing loss. The number of overlooked cases may be minimized by performing ABR and OAE in every case referred with the suspicion of hearing loss.

Resumo Introdução: Espectro da neuropatia auditiva ainda é uma condição clínica desafiadora. Objetivo: Apresentar nossa experiência no tratamento de crianças com espectro da neuropatia auditiva em relação aos dados clínicos. Método: Este estudo retrospectivo incluiu crianças menores de 16 anos de idade que deram entrada no departamento entre 2005 e 2013 (com exceção de encaminhamentos para triagem auditiva neonatal). Foram avaliados os dados obtidos a partir dos exames de audiometria tonal, emissões otoacústicas (EOA), potencial evocado auditivo de tronco encefálico (ABR) e outros fatores de risco. Resultados: Das 1.952 crianças com perda auditiva neurossensorial (2,04%) detectadas dentre os 9.520 candidatos que deram entrada no departamento (0,42%), espectro da neuropatia auditiva foi reconhecida em 74 orelhas de 40 crianças (B/U: 34/6). Os testes clínicos revelaram que uma perda auditiva superior a 15 dB estava presente em ambas as orelhas em 38 casos. O grau de perda auditiva das crianças era profundo em 48%, grave em 12%, moderado em 28%, leve em 10%, e normal em 5%. ABR estava ausente/anormal em 37/3 orelhas e microfonia coclear foi detectado em todas as crianças. Reflexos acústicos estavam ausentes em todas as orelhas. A reabilitação foi tratada com implante coclear e aparelhos auditivos em 15 e 23 casos, respectivamente. Um sistema FM foi utilizado em dois casos que apresentavam audição normal, mas discriminação deficiente da fala em ambientes ruidosos. Conclusão: Espectro da neuropatia auditiva é um problema desafiador para os departamentos de audiologia, devido às suas várias características clínicas e dificuldades no tratamento. Em nossos pacientes a perda auditiva profunda foi a mais frequente. O número de casos negligenciados pode ser diminuído com a realização dos exames ABR e EOA em todos os casos encaminhados com suspeita de perda auditiva.

Role of nasal problems on positional and nonpositional obstructive sleep apnea.

OBJECTIVES: This study aims to examine the relationship between nasal pathologies and positional (PP) obstructive sleep apnea (OSA) or nonpositional (NPP) OSA. PATIENTS AND METHODS: A total of 44 male OSA patients (mean age 48.0±6.8 years; range 31 to 60 years) suffering from nasal obstruction were retrospectively evaluated for nasal obstruction scores, overall apnea hypopnea index (AHI) and AHI in supine and nonsupine positions, daytime sleepiness scores, and body mass index (BMI). Patients were divided into two equal groups as PP group and NPP group. Output parameters were snoring severity index, clinical nasal obstruction score, septal deviation score, conchal hypertrophy score, and allergic rhinitis (AR) score. These parameters were correlated with the type of OSA. RESULTS: Apnea hypopnea index was significantly lower in PP group than in NPP group (p<0.03). Spearman correlation analysis revealed significant negative correlation between AR score and PP (r=-0.40, p<0.0001). Pearson correlation test revealed significant correlation between AHI and BMI (r=0.32, p<0.05). CONCLUSION: We suggest that AR is not only an important risk factor for OSA, but also patients with AR tend to be NPP OSA patients because of the serious nasal obstruction which already causes an increase in nasal resistance or pharyngeal collapsibility.

Management of children with auditory neuropathy spectrum disorder (ANSD).

INTRODUCTION: ANSD is a challenging problem. OBJECTIVE: To present our experience on management of the children with ANSD with respect to clinical data. METHODS: This retrospective study included all children younger than 16 years of age who applied to the department between 2005 and 2013 (with the exception of newborn hearing screening NHS referrals). The data were derived from pure tone, OAEs and ABR tests, and further medical risk factors of the subjects were evaluated. RESULTS: ANSD was recognized in 74 ears of 40 children (B/U: 34/6) among 1952 children with SNHL (2.04%) detected among 9520 applicants to the department (0.42%). The clinical tests revealed that hearing loss greater than 15dB was present in both ears of 38 cases. The degree of hearing loss was profound in 48% children, severe in 12% children, moderate in 28% children, mild in 10% children and normal in 5% children. ABRs were absent/abnormal in 37/3 ears and CMs were detected in all. Acoustic reflexes were absent in all ears. Rehabilitation was managed by CI and hearing aids in 15 and 23 cases, respectively. FM system was given to two cases displaying normal hearing but poor speech discrimination in noisy environments. CONCLUSION: ANSD is a relatively challenging problem for the audiology departments because of its various clinical features and difficulties in management. Our patients with ANSD most commonly displayed profound hearing loss. The number of overlooked cases may be minimized by performing ABR and OAE in every case referred with the suspicion of hearing loss.

Audiologic evaluations of children with mucopolysaccharidosis.

INTRODUCTION: Mucopolysaccharidosis is a hereditary lysosomal storage disease, which develops due to a deficiency in the enzymes that play a role in the metabolism of glycosaminoglycans (GAG). The incidence of mucopolysaccharidosis is 1/25,000, with autosomal recessive inheritance (except for MPS II). Mucopolysaccharidosis occurs in seven different types, each with a different congenital deficiency of lysosomal enzymes. In mucopolysaccharidosis patients, even though progression of clinical findings is not prominent, the disease advances and causes death at early ages. Facial dysmorphism, growth retardation, mental retardation, and skeletal or joint dysplasia are the most frequently found symptoms in these patients. OBJECTIVE: The purpose of our study is to present the types of hearing loss types and tympanometric findings of patients with mucopolysaccharidosis referred to our clinic with suspicion of hearing loss. METHODS: After otorhinolaryngological examination, 9 patients with different types of mucopolysaccharidosis, underwent to immittance and audiometric evaluations, performed according to their physical and mental abilities, and ages, in order to determine their hearing thresholds. RESULTS: The audiometric findings of the 9 patients followed with mucopolysaccharidosis were reported separately for each case. CONCLUSION: Based on the high frequency of hearing loss in mucopolysaccharidosis patients, early and detailed audiological evaluations are highly desirable. Therefore, regular and systematic multidisciplinary evaluations are very important.

Newborn hearing screening outcomes during the first decade of the program in a reference hospital from Turkey.

In this study, the authors report the results of a three-stage newborn hearing screening (NHS) program for well babies at the Gazi University Hospital (GUH) in Ankara between 2003 and 2013. GUH-NHS was performed by automated transient evoked otoacoustic emission (a-TEOAE) at the first and second steps and by automated brainstem audiometry (a-ABR) at the third step. The data were analysed to assess not only rate of congenital permanent hearing loss (CPHL), but also the effectiveness of the program during the years. A total of 18,470 well babies were tested. The data showed that coverage ratio for the GUH-born babies was increased and more outside-born babies (OBB) were admitted by time (means 84.31 and 11.28 %, respectively). Mean CPHL was found to be 0.26 %. Mean referral rate was decreased to 0.81 % by a-ABR from 2.16 % by a-TEOAE. Mean of missed cases in any stage of GUH-NHS was 4.88 %. It was seen that neither CPHL nor referral rate, but only ratio of missed ones presented increase in parallel to increment in OBB. This paper first presents that clinically acceptable screening procedures developed in GUH by time, and secondly higher rate of CPHL in Turkey than in the Western countries, and benefits of third stage screening by a-ABR because it prevented referral of 251 children (1.29 %) to the clinical tests. We think that this number is reasonably important regarding not only economical point of view, but also waiting lists in the audiology departments in a developing country, in which audiological service is still limited.