New Perspectives in Hearing Assessment: Part 2. Application of Distortion Product Otoacoustic Emissions in the Diagnosis of Hearing Loss - Step A

2MEDINCUS - DOI: 10.5281/ZENODO.16905033 - VOL.31, OCTOBER/2025
This is he second in a se ies o newsle e s ha ocus on he impo ance o
e idence-based hea ing assessmen in making an accu a e audiologic diagnosis.
Anaccu a ediagnosiso hea ingdys unc ionis he i s s epinde elopingan
e ec i e plan o managing hea ing loss. The se ies, i led “New Pe spec i es in
Hea ing Assessmen ,” includes newsle e s ha e iew he main es ing p oce-
du es o diagnos ic e alua ion o hea ing unc ion in child en and adul s.
A ecu ing heme in he se ies is he applica ion o he c osscheck p in-
ciple. We highligh he unique cha ac e is ics and p ac ical ad an ages o each
audi o y p ocedu e, as well as he pa e n o es esul s ha guide us o a clea
and eliable audiologic diagnosis.
MilaineDominiciSan ins,Pio Hen ykSka zynskiandJamesWHallIII
NEW PERSPECTIVES
IN HEARING ASSESSMENT:
PART 2.APPLICATION OF DISTORTION PRODUCT
OTOACOUSTIC EMISSIONS IN THE DIAGNOSIS OF
HEARING LOSS - STEP A (ANATOMICAL REVIEW AND
CLINICAL ADVANTAGES)
3
MEDINCUS - DOI: 10.5281/ZENODO.16905033 - VOL.31, OCTOBER/2025
INTRODUCTION
Since Da id Kemp desc ibed “s imula ed acous ic emissions om wi hin
he human audi o y sys em” in 1978 (Kemp, 1978), o oacous ic emissions (OAEs)
ha e e ol ed in o a aluable clinical echnique o hea ing sc eening and diagno-
sis o audi o y dys unc ion.
OAEs o e a ela i ely simple, quick, and inexpensi e app oach o ea ly
de ec ion o hea ing loss in a ied popula ions, including:
newbo n in an s,
 p eschoolandschoolchild en,
 adul sa  isk o noise-and/o music-inducedhea ingimpai men 
(Dha & Hall, 2018; Hall & Kleindiens Roble , 2024; Join Commi ee on In an Hea ing, 2019).
OAEs also play an impo an and a he unique ole in he es ba e y o
diagnosis o hea ing loss and ela ed hea ing diso de s in pa ien s ac oss he li-
espan (Hall, 2021)., e.g.:
 inni us,
 diso de so dec easedsound ole ance,
 audi o yp ocessingdiso de s
E idence-based clinical p ac ice guidelines p o ide de ailed ecommenda-
ions o OAE measu emen , analysis, and clinical applica ion (B i ish Socie y o
Audiology, 2023).
4MEDINCUS - DOI: 10.5281/ZENODO.16905033 - VOL.31, OCTOBER/2025
 In e es ed eade swillha enop oblem inding esou cesand e e enceon
OAEs, including de ailed discussions o ele an audi o y ana omy and physiology,
mechanisms, dis inc ions be ween ansien e oked OAEs (TEOAEs) s. dis o ion
p oduc OAEs (DPOAEs), and esea ch-based e iews o clinical applica ions o
OAEs in a wide ange o audi o y diso de s and o ologic diseases (e.g., Dha &
Hall,2018;Hall&Swanepoel,2010).Inaddi ion. hescien i icli e a u econ ains
o e 6500 pee e iewed publica ions on OAEs (e.g.,
h ps://pubmed.ncbi.nlm.
nih.go /? e m=o oacous ic+emissions.
This b ie pape p esen s p ac ical in o ma ion
on clinical measu emen and analysis o DPOAEs in
he diagnosis o audi o y dys unc ion. The discussion
ocuses on DPOAEs, no TEOAEs. Also, we don’ add ess
he well-documen ed applica ion o OAEs in hea ing
sc eening no he a ied con ibu ions o in o ma ion
om OAE measu e in basic in es iga ions o cochlea
physiology and pa hophysiology. Ou o e all goal is
o encou age audiologis s o ake ull ad an age o
DPOAEs as a clinical ool, and o p o ide some p ac ical
ips o he mos e ec i e clinical applica ion o DPOAEs
in pedia ic and adul pa ien popula ions.
5
MEDINCUS - DOI: 10.5281/ZENODO.16905033 - VOL.31, OCTOBER/2025
BRIEF REVIEW OF
ANATOMIC STRUCTURES
INVOLVED IN DPOAE
MEASUREMENT
 Agoodunde s andingo  heana omicand
physiologicunde pinningso OAEgene a ionand
measu emen isessen ial o  eco ding,analyzing,and
in e p e ing indingsin heclinicalse ing.Asillus a ed
schema icallyinFigu e1, ou gene al egionso 
audi o ysys emana omya ein ol edin hegene a ion
andmeasu emen o OAEs.
Figu e1. Schema ic diag am o he ou audi o y s uc u es o egions in ol ed
in he measu emen o DPOAEs. Sou ce: Dha S & Hall JW III (2018). O oacous ic
Emissions: P inciples, P ocedu es, and P o ocols. San Diego: Plu al Publishing
San ins,Ska zynskiandHall,2025

6MEDINCUS - DOI: 10.5281/ZENODO.16905033 - VOL.31, OCTOBER/2025
TheEXTERNALEARCANAL
plays a c ucial ole in s imulus deli e y and OAE eco ding. a ie y o
pa hologic and non-pa hologic condi ions o he ex e nal ea ha e se ious
ami ica ionsonOAEmeasu emen s.
TheMIDDLEEAR
( ympanic memb ane and ossicles) is a i al link in OAE measu emen .
S imuli used o elici OAEs a e ansmi ed o he cochlea ia he middle
ea . In addi ion, OAEs gene a ed in he cochlea a el ou wa d h ough he
middle ea on he way o he ex e nal ea canal.
The sou ce o OAE ac i i y is ound wi hin he COCHLEA.Speci ically,OAEs
e lec ou e hai cellac i i yand unc ionalin eg i yo allcomponen so 
ou e hai cells is essen ial o gene a ion o OAEs. O he s uc u es in and
ela ed o he cochlea also play a c ucial ole in he gene a ion o no mal
OAEs, including he blood essels se ing he o gan o Co i, he s ia
ascula is, and he e icula o ma ion.
Finally, ac i a ion o he EFFERENT AUDITORY SYSTEM, pa icula ly he
oli ocochlea bundle,mayalsoin luenceOAE eco dings.
Reade s a e e e ed o Chap e 2 o Dha & Hall (2018) o a mo e de ailed e iew
o he ana omy and physiology unde lying OAE measu emen .
1
2
3
4
7
Clinical epo s desc ibing he diagnos ic alue o DPOAEs in e-
quency-speci ic assessmen  o  hea ing loss da e back o he mid-1990s
(e.g., Go ga e al, 1993; Hall, 2000; Ho nsby, Kelly & Hall, 1996; Lonsbu-
y-Ma in, Ma in, McCoy & Whi ehead, 1994).
Du ing his exci ing e a in he e olu ion o OAEs, mos manu ac u-
e s o  audiology ins umen a ion in oduced he i s  gene a ion o  cli-
nical DPOAE de ices. Resea ch since hen has clea ly demons a ed he
diagnos icsensi i i yandspeci ici yo DPOAEs o adi e secollec iono 
e iologies a ec ing ou e hai cell unc ion, such as:
( o e iews see Dha & Hall, 2018; Hall, 2021).
pe ina aldiseases,
exposu e o damaging le-
els o  noise o  music o 
o o oxicd ugs,
o ologicdiseases(e.g.,Me-
nie e’s disease, au oim-
munedisease),
age- ela ed hea ing loss
seconda y o como bid
condi ions like diabe es
andca dio ascula disease
DISTINCTIONS IN APPLICATION OF
DPOAES FOR DETECTION VERSUS
DIAGNOSIS OF HEARING LOSS
MEDINCUS - DOI: 10.5281/ZENODO.16905033 - VOL.31, OCTOBER/2025
8
 Longs anding basic and clinical esea ch indings con i m ha 
DPOAEs a e a highly sensi i e and equency speci ic measu e o  ou e 
hai cell unc ion, wi h diagnos ic quali ies unma ched by any o he clinical
p ocedu e.
As a diagnos ic measu e, DPOAEsp o ide i alin o ma ionon he
s a uso ou e hai cells.Abno mali ies in ou e hai cell unc ion may also
occu seconda y o pa hophysiology a ec ing o he cochlea s uc u es,
pa icula ly he s ia ascula is.
OAEsdono shedanyligh oninne hai cell unc ion. This limi a ion
has minimal impac on he clinical use ulness o OAEs because ou e hai cell
dys unc ion o damage is an in a iable ea u e o many o ologic diso de s
o diseases associa ed wi h a wide asso men o cochlea abno mali ies. As
a esul , he diagnos ic alue o DPOAEs ex ends o essen ially all e iologies
o senso y hea ing loss.
The e is compelling longs anding esea ch e idence in suppo o he
alue o DPOAEs in diagnosis o audi o y unc ion. None heless, audiologis s
o en eco dandanalyzeDPOAEsindiagnos icassessmen s wi h he
same simple dicho omous “pass” s. “ ail” o “p esen ” e sus “absen ”
app oach ha is used in hea ing sc eening.
MEDINCUS - DOI: 10.5281/ZENODO.16905033 - VOL.31, OCTOBER/2025
 Table 1. Dis inc ions in measu emen and analysis o dis o ion p oduc
o oacous ic emissions (DPOAEs) in de ec ion o hea ing loss (hea ing sc eening)
e sus he diagnosis o hea ing loss (comp ehensi e audiologic assessmen ).
Re e also o Figu es 1.
HEARINGSCREENING DIAGNOSISOFHEARINGLOSS
DPOAE
Measu emen
S imulus
F equency
Range
Tes s imuli wi hin a limi ed
equency ange,e.g.,2000Hz
o5000Hz
Tes s imuli o a wide equency
ange,e.g.500Hz o>8000Hz
Numbe 
o S imulus
F equencies
•S imuli o a limi ed numbe
o equencies, e.g., wo o
h ee o equencies
•Few equencies pe oc a e,
e.g., 1 o 2
•Rela i ely la ge numbe o s imulus
equencies,e.g.,>20 equencies
•Nume ous equencies pe oc a e,
e.g.,>4
Replica ion
o Reco dings
DPOAEs a e no eplica ed
(plo ed as a single DPg am)
DPOAEs a e eplica ed and plo ed as
wo supe imposed DPg ams
S imulus
In ensi y
S imuli a e p esen ed a a
single ixedin ensi yle el(e.g.,
L1 = 65 dB SPL; L2 = 55 dB SPL)
S imuli may be p esen ed a mul iple
highe and lowe in ensi y le els
DPOAEAnalysis
9
MEDINCUS - DOI: 10.5281/ZENODO.16905033 - VOL.31, OCTOBER/2025
Table 1. delinea es dis inc ions be ween he applica ion o DPOAEs
in hea ing sc eening e sus diagnos ic assessmen . We’ll o e a his poin
se e al hypo he ical clinical scena ios o cla i y he ob ious limi a ions esul ing
om eliance on a simple DPOAE sc eening p o ocol when he clinical goal is
comp ehensi e diagnos ic assessmen .
16
e e ences consul ed:
B i ish Socie y o Audiology (2023). Recommended P ocedu e:
Clinical Applica ion o O oacous ic Emissions (OAEs) in
Child en and Adul s. h ps://www. hebsa.o g.uk/wp-con en /
uploads/2023/10/OD104-120-Recommended-P ocedu e-Clinical-
Applica ion-o -O oacous ic-Emissions-OAEs.docx.pd
San ins Dominici M, Ska zynski P & Hall JW III (2024). New
Pe spec i es in Hea ing Assessmen : Pa 1. Applica ion o
alue-added es s in he diagnosis o hea ing loss. Medincus, 13
(Feb ua y), 1-18.
Cane e OM, El-Haj-Ali M, Fe eczkowski M (2024). Compa ison o
wo de ices o measu emen o dis o ion p oduc o oacous ic
emissions in no mal hea ing adul s. Jou nal o Audiology and
O ology, 28, 146-152
Dha S & Hall JW III (2018). O oacous ic emissions: P inciples,
P ocedu es, and P o ocols. San Diego: Plu al Publishing.
San ins MD, Be azolli LF, Ska zynski PH, Ska zynska MB,
Donadon C & Colella-San os MF (2020). O oacous ic Emissions
in Child en wi h Long-Te m Middle Ea Disease. Li e (Basel,
Swi ze land), 10(11), 287. h ps://doi.o g/10.3390/li e10110287
Gell ick D, G oge M, Ech e nach M, Ede K & Hube P (2024).
Neona al hea ing sc eening – does ailu e in TEOAE sc eening
ma e when AABR es is passed? Eu opean A chi es o O o-
Rhino-La yngology. 281, 1273-1283
Go ga MP, Neely ST, Be gman B, Beauchaine KL, Kaminski
JR, Pe e s J & Jes ead W.J (1993). O oacous ic emissions om
no mal-hea ing and hea ing-impai ed subjec s: dis o ion
p oduce esponses. Jou nal o he Acous ical Socie y o Ame ica,
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Hall JW III, Chase PA, Bae JE & Schwabe MK (1994). Clinical
applica ion o o oacous ic emissions: Wha do we know abou
ac o s in luencing measu emen and analysis? O ola yngology
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Diego: Singula Publishing G oup
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Pena i HC, Donadon C, Souza IP, Sil a IVD & Colella-San os MF
(2024). Wideband Tympanome y and P essu ized O oacous ic
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sc eening wi h combined o oacous ic emissions and audi o y
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Audiology, 15, 414-425
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Hea ing Loss. San Diego: Plu al Publishing
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Essen ial o ea ly in e en ion. Jou nal o Hea ing Science, 6
(2), 1-17
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audiology: A 40-yea pe spec i e. Jou nal o Audiology and
O ology, 20 (2), 1-9
Hall JW III (2021). P omo ing heal hy hea ing o e he li espan.
Audi o y & Ves ibula Resea ch, 30, 74-94
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o hea ing sc eening o p eschool and school-age
child en. AudiologyOnline, A icle 29069. A ailable a www.
audiologyonline.com
Ho nsby B, Kelly T, Hall JW III (1996). No ma i e da a o i e
FDA-app o ed comme cially a ailable dis o ion p oduc
sys ems. The Hea ing Jou nal 49, 39- 46
Je ge JF & Hayes D (1976). The c oss-check p inciple in
pedia ic audiome y. A chi es o O ola yngology, 102, 614-620
Join Commi ee on In an Hea ing (2019). Yea 2019 Posi ion
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Hea ing De ec ion and In e en ion, 4 (9), 1-44
Kemp DT (1978). S imula ed acous ic emissions om wi hin
he human audi o y sys em. The Jou nal o he Acous ical
Socie y o Ame ica, 64, 1386-1391
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M. (1994). O oacous ic emissions es ing in young child en:
middle ea in luences. Ame ican Jou nal o O ology, 15
(supplemen 1), 13-20
Me es IB & Ma quess A (2023). A su ey o U.S. audiologis s’
usage and a i udes owa d o oacous ic emissions. Ame ican
Jou nal o Audiology, 32, 417-431.
San ins Dominici M, Ska zynski P & Hall JW III (2024). New
Pe spec i es in Hea ing Assessmen : Pa 1. Applica ion o
alue-added es s in he diagnosis o hea ing loss. Medincus,
13 (Feb ua y), 1-18.
Windmill IM & F eeman BA (2019). Medica e, hea ing ca e and
audiology. Audiology Today, 31 (Ma ch), 17 – 26.
No elli CVL, San ins MD, Ska żyński PH, Ska żyńska MB,
Diniz-Hein TA & Colella-San os MF (2024). Neona al Hea ing
Sc eening Using Wideband Abso bance and O oacous ic
Emissions Measu ed Unde Ambien and P essu ized
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child en11111290
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02.
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MEDINCUS - DOI: 10.5281/ZENODO.16905033 - VOL.31, OCTOBER/2025

17
MEDINCUS - DOI: 10.5281/ZENODO.16905033 - VOL.31, OCTOBER/2025
Au ho s
- P o esso , ENT, Mas e and Doc o a e by Medical
Uni e si y o Wa saw;
- Resea ch, didac ic, clinical, and o ganiza ional wo k
in Wo ld Hea ing Cen e o Ins i u e o Physiology and
Pa hology o Hea ing, Ins i u e o Senso y O gans and
Medical Uni e si y o Wa saw;
- Specialis in ENT, pedia ic ENT, audiology and
phonia ics, and public heal h. Pa icipa ed in he 3 d
S akeholde s Consul a ion mee ing du ing which he
Wo ld Hea ing Fo um o WHO was announced;
- Membe o he Ros e o Expe s on Digi al Heal h o
WHO, Vice-P esiden and Ins i u ional Rep esen a i e o
IS TeH;
- P esiden -elec o In e na ional Ad iso y Boa d o
AAOHNS, membe o Cong ess and Mee ing Depa men
o EAONO, Regional Rep esen a i e o Eu ope o ISA,
ViceP esiden o Hea Ring G oup, Audi o o EFAS,
membe o he Facial Ne e S imula ion S ee ing
PROF.DR.PIOTRHENRYKSKARZYNSKI
Commi ee;
- Boa d Sec e a y o he Polish Socie y o
O o hinola yngologis s, Phonia is s and Audiologis s.
Membe o Hea ing Commi ee (2018–19);
- Goodwill Ambassado ep esen ing Poland a he
AAOHNSF 2021 Annual Mee ing & OTO Expe ience, and
since 2021 a membe o Implan able Hea ing De ices
Commi ee and O ology & Neu o ology Educa ion
Commi ee o AAOHNS;
- Consul an Commi ee o In e na ional Expe s o
CPAM-VBMS (by special in i a ion), hono a y membe o
ORL Danube Socie y, and hono a y membe o Socié é
F ançaise d’O o-Rhino-La yngologie;
- Membe o he Council o Na ional Science Cen e ;
- Expe and membe o nume ous na ional o ganiza ions.
- P o esso o he Audiology da Uni e sidade Fede al de
São Paulo (UNIFESP);
- Resea ch g oup membe , Ins i u e o Physiology and
Pa hology o Hea ing, Kaje any, Poland.
- P o esso o he pos -g adua e p og am in Clinical
Audiology a he Albe Eins ein Is aeli e Ins i u e o
esea ch and eaching;
- Pos doc a he Wo ld Hea ing Cen e , Wa saw, Poland;
- Sandwich Doc o a e by School o Medical Sciences,
Uni e sidade Es adual de Campinas (FCM-UNICAMP) and
by Uni e si à degli S udi di Fe a a/I aly;
- Specialis in Audiology by Fede al Council o Speech
The apy and Audiology;
PROF.DR.MILAINEDOMINICISANFINS
- Speech The apis and Audiologis , Mas e by Medical
School o Uni e si y o São Paulo (FMUSP);
- Membe o he Teaching and Resea ch Commission o
he B azilian Academy o Audiology (2024-2026);
- Rappo eu o he Resea ch E hics Commi ee o he
Fede al Uni e si y o São Paulo;
- Re iewe o scien i i c a icles in he a ea o
Neu oaudiology, Neu oscience, Elec ophysiology and
Audiology;
- Ins ag am @misan i ns / email: msan i [email p o ec ed]om.b and
msan i ns@uni esp.b
18 MEDINCUS - DOI: 10.5281/ZENODO.16905033 - VOL.31, OCTOBER/2025
Is an in e na ionally ecognized audiologis wi h
mo e han 40-yea s o clinical, eaching, esea ch, and
adminis a i e expe ience. He ecei ed his bachelo ’s
deg ee in biology om Ame ican In e na ional College, his
mas e 's deg ee in Speech Pa hology om No hwes e n
Uni e si y, and his Ph.D. in Audiology om Baylo
College o Medicine unde he di ec ion o James Je ge .
Du ing his ca ee , D . Hall has held clinical and academic
audiology posi ions a majo medical cen e s. A ounde
PROF.DR.JAMESHALLIII
o he Ame ican Academy o Audiology, D . Hall has held
nume ous leade ship oles in he o ganiza ion. D . Hall is
he au ho o o e 200 pee - e iewed publica ions, in i ed
a icles, and book chap e s, plus 12 ex books. D . Hall now
holds academic appoin men s as P o esso (pa - ime) a
Salus Uni e si y and he Uni e si y o Hawaii, a posi ion as
Ex ao dina y P o esso a he Uni e si y o P e o ia Sou h
A ica, along wi h o he adjunc and isi ing p o esso
posi ions in he USA and ab oad.
19
Quiz
1.Acco ding o heana omical e iewo  he
ex ,whicho  he ollowings uc u esis he
sou ceo Dis o ionP oduc O oacous ic
Emissions(DPOAE)ac i i y?
A. The middle ea ( ympanic memb ane and ossicles).
B. The cochlea. The cochlea.
C. The e e en audi o y sys em.
D. The ex e nal audi o y canal.
2.Acco ding o'Table1'o  he ex ,which
o  he ollowings a emen sco ec ly
desc ibes hecollec iono OAEsin he
con ex o anaudiologicaldiagnosis,
compa ed ohea ingsc eening?
A. Use o s imuli a a single ixed in ensi y le el.
B. Dicho omous analysis o he esul s, such as 'App o ed'
e sus 'Failed'.
C. Tes s imuli o a wide ange o equencies (e.g., 500 Hz
o > 8000 Hz).
D. Tes s imuli in a limi ed equency ange (e.g., 2000 Hz o
5000 Hz).
3.Acco ding o he ex ,wha isaclinical
limi a iono O oacous icEmissions(OAE)?
Acco ding o he ex ,wha isaclinical
limi a iono O oacous icEmissions(OAE)?
A. They do no cla i y he unc ion o he inne hai cells.
B. The measu emen o OAEs equi es a sound- ea ed
oom.
C. They do no p o ide in o ma ion abou he unc ion o
he ou e hai cells.
D. They depend on he pa ien 's mo i a ion o p o ide a
beha io al esponse.
4.Whicho  he ollowingop ionsis
p esen edin he ex asasigni ican 
clinicalad an ageo OAEsinaudiological
diagnosis?Whicho  he ollowingop ions
isp esen edin he ex asasigni ican 
clinicalad an ageo OAEsinaudiological
diagnosis?
A. The analysis o he esul s is a manual and ime-
consuming p ocess.
B. They depend on he pa ien 's cogni i e s a e, such as
a en ion and memo y. They depend on he pa ien 's
cogni i e s a e, such as a en ion and memo y.
C. They equi e a long es ing ime (o en mo e han 5
minu es pe ea ).
D. They a e a comple ely objec i e measu e, no
depending on a beha io al esponse om he pa ien .
5.Thecombina iono ano malaudiog am
wi habno malOAEsisa ele an clinical
inding.Thecombina iono ano mal
audiog amwi habno malOAEsisa
ele an clinical inding.Acco ding o he
ex ,wha is hemos likelyimplica iono 
hiscombina iono  esul s?
A. In eg i y o he ou e hai cells and no mal cochlea
in eg i y.
B. The p esence o neu al hea ing loss, such as in audi o y
neu opa hy spec um diso de (ANSD).
C. Cochlea dys unc ion associa ed wi h isk ac o s such
as noise exposu e o o o oxic medica ions.
D. The p esence o a alse hea ing loss (simula ion).
Answe s:
1- B
2- D
3- A
4- D
5- C
MEDINCUS - DOI: 10.5281/ZENODO.16905033 - VOL.31, OCTOBER/2025