Screen-H Website Audiometry as a Diagnostic Tool for Hearing Screening in Patients with Hearing Loss

Melati Sudiro; Wijana Hasansulama; Rano Digdayan Makerto; Raden Ayu Hardianti Saputri

doi:10.12688/f1000research.146735.1

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Research Article

Screen-H Website Audiometry as a Diagnostic Tool for Hearing Screening in Patients with Hearing Loss

[version 1; peer review: 1 approved with reservations]

Melati Sudiro¹, Wijana Hasansulama¹, Rano Digdayan Makerto¹, Raden Ayu Hardianti Saputri¹

PUBLISHED 29 Apr 2024

Author details Author details

¹ Otorhinolaryngology-Head and Neck Surgery, Universitas Padjadjaran, Bandung, West Java, Indonesia

Melati Sudiro
Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Supervision, Validation, Visualization, Writing – Review & Editing

Wijana Hasansulama
Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Resources, Software, Supervision, Writing – Review & Editing

Rano Digdayan Makerto
Roles: Data Curation, Formal Analysis, Investigation, Methodology, Writing – Original Draft Preparation

Raden Ayu Hardianti Saputri
Roles: Conceptualization, Data Curation, Formal Analysis, Supervision, Writing – Review & Editing

OPEN PEER REVIEW

REVIEWER STATUS

Abstract

Background

Hearing loss, affecting 16.8% of Indonesians, impacts quality of life and daily activities. Limited access to hearing loss evaluation and treatment, due to demographic and socioeconomic conditions, particularly in remote areas, hinders early detection and intervention. Website audiometry Screen-H, accessible on mobile phones, tablets, and computers, offers a fast, painless, and non-invasive solution.

Purpose

This study aimed to assess the agreement between Screen-H and gold standard pure-tone audiometry.

Methods

In this analytical observational study with a cross-sectional design, participants over 10 years old with hearing loss were consecutively sampled at the Audiology Clinic of Otorhinolaryngology-Head and Neck Surgery, Dr. Hasan Sadikin General Hospital, Bandung. The sensitivity and specificity of Screen-H® were evaluated, and the Kappa score measured agreement with pure-tone audiometry.

Results

We included 321 patients, comprising 150 women (47%) and 171 men (53%). Screen-H® showed 82.8% sensitivity and 94.1% specificity in the right ear, and 80.8% sensitivity and 93.1% specificity in the left ear.

Conclusion

The high specificity and sensitivity of Screen-H, combined with its speed, ease of use, non-invasiveness, and cost-effectiveness, make it an effective screening tool for hearing loss in environments with noise levels ≤ 40 dB HL, starting from 35 dB HL stimuli.

Keywords

diagnostic test, hearing loss, pure-tone audiometry, website audiometry

Corresponding author: Melati Sudiro

Competing interests: Hopefully this research can be published on f1000research so that the Screen-H audiometry website software has a basis in international journals and can be recognized for its use on a national and international scale.

Grant information: Financial support was received from the Universitas Padjadjaran no.537/UN6.WR3/TU.00/2023
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Copyright: © 2024 Sudiro M et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Sudiro M, Hasansulama W, Digdayan Makerto R and Ayu Hardianti Saputri R. Screen-H Website Audiometry as a Diagnostic Tool for Hearing Screening in Patients with Hearing Loss [version 1; peer review: 1 approved with reservations]. F1000Research 2024, 13:416 (https://doi.org/10.12688/f1000research.146735.1) First published: 29 Apr 2024, 13:416 (https://doi.org/10.12688/f1000research.146735.1) Latest published: 29 Apr 2024, 13:416 (https://doi.org/10.12688/f1000research.146735.1)

Introduction

Hearing loss occurs when the sound transmission from the outer ear to the brain, is impaired.¹ In children, it is associated with impairments in expressive and receptive language skills, challenges in social interactions, stress management issues, increased frustration, and lowered self-esteem.²^–⁶ In adults, hearing loss affects communication, daily activities, work, social life, and self-confidence. Furthermore, it is linked to occupational restrictions, leading to economic issues.²^–⁶

Early detection of hearing loss is essential for timely and accurate intervention.⁵^,⁷ Pure-tone audiometry is considered the gold standard for diagnosing hearing loss; however, limitations in infrastructure, availability of trained personnel, and the requirement for soundproofed environments can delay hearing loss evaluations, causing gaps in hearing screening in rural or remote areas.⁵^,⁷ An alternative approach is hearing screening using Screen-H^, which offers a rapid, painless, non-invasive solution that is accessible through mobile phones, tablets, and computers, provided there is a signal and headphones for sound stimulation.⁷^–¹¹

This study aimed to evaluate the agreement between Screen-H and pure-tone audiometry.

Methods

The study population comprised patients with hearing loss seeking treatment at the Audiology Clinic of Otorhinolaryngology, Head and Neck Surgery, at Dr. Hasan Sadikin General Hospital, Bandung. This analytical observational research employed a cross-sectional design and a diagnostic test to evaluate the performance of Screen-H. The diagnostic test assessed multiple measures, including sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (PLR), negative likelihood ratio (NLR), and accuracy. The reliability of the study was assessed using the Kappa Index. Data processing and analysis were conducted using Microsoft Excel 365 https://www.microsoft.com/id-id/microsoft-365/free-office-online-for-the-web. The inclusion criteria for this study were individuals aged over 10 years who demonstrated a cooperative demeanor and havDatae agreed to research consent. The exclusion criteria included the inability to undergo pure tone audiometry, craniofacial anomalies, and congenital abnormalities. This study received approval from the ethics committee of Padjadjaran University, under reference number 255/UN6.KEP/EC/2023 which was published on 28 February2023, and was conducted from May to July 2023.

Pure tone audiometry was performed in a soundproof room. Screen-H hearing tests were administered in a room with a noise level ≤ 40 dB using Sennheiser HD 201 headphones, chosen for their noise reduction capability of 15-20 dB HL, a stimulus output of up to 108 dB HL, and a frequency range of 21-18000 Hz. The calibration process for Screen-H relied on a sound reference approach, measuring sound intensity and subsequently record it to establish a reference point. Post-calibration, it was determined that the sound intensity emitted by Screen-H aligned with that of pure tone audiometry. The typical ambient sound level in the test room was measured at 40 dB SPL.¹² During the hearing screening, the initial stimulus intensity commonly ranged from 30-40 dB HL, with the recommended initial intensity for Screen-H set at 35 dB HL.¹²

Hearing tests were performed using Screen-H and pure tone audiometry (Resonance, EN60645-1/-2, New Holland) as the gold standard. Screen-H has been patented and we as researchers have permission to use the application and Software available from: screenout.id. We use pure tone audiometry (Resonance, EN60645-1/-2, New Holland) which has permission to use from the local health department. All subjects underwent examinations first with Screen-H and then with pure tone audiometry. During the Screen-H test, subjects were exposed to auditory stimuli through headphones at specific frequencies of 500, 1,000, 2,000, 4,000, and 8,000 Hz, with intensity levels set at 35, 55, and 75 dB.¹³

Results

A total of 321 participants met the inclusion and exclusion criteria, comprising 280 individuals with hearing impairment and 41 with normal hearing.

The most prevalent age range for hearing loss complaints was between 26 and 35 years. Table 1 presents the prevalence rates of hearing loss among males and females, showing a rate of 53% for males and 47% for females. Sensorineural hearing loss was identified as the most common type, with chronic suppurative otitis media being the leading cause.

Table 1. Characteristics of eesearch subjects.

Variable		N=321	%
Age	10-11	8	2.4
	12-16	24	7.4
	17-25	50	15.5
	26-35	68	21
	36-45	59	18.3
	46-55	54	16.8
	56-65	44	13.7
	> 65	14	4.3
Gender	Man	171	53.3
	Woman	150	46.7
Type	Normal	41	12.8
Type	Sensorineural hearing loss	130	40.5
	Conductive	84	26.2
	Mixed	66	20.6
Diagnosis	Chronic suppurative otitis media	127	39.6
	Cerumen	50	15.6
	Presbycusis	34	10.6
	Acute otitis media	34	10.6
	Ototoxic	33	10.3
	Noise induces	14	4.4
	Sudden deafness	10	3.1
	Congenital	6	1.9
	Meniere's disease	3	0.9
	Stenosis	3	0.9
	Tumor	2	0.6
	Otosclerosis	1	0.3

Tables 2 and 3 present results indicating that Screen-H closely adheres to pure tone audiometry in both the right and left ears, as evidenced by high Kappa values.

Table 2. Right ear hearing threshold.

Variable	Pure Tone Audiometry		Kappa
	>25 dB HL	≤25 dB HL
	N=169	N=152
Screen-H®
>35 dB HL	140 (83%)	9 (6%)	0.764
≤35 dB HL	29 (17%)	143 (94%)

Table 3. Left ear hearing threshold.

Variable	Pure Tone Audiometry		Kappa
	>25 dB HL	≤25 dB HL
	N=188	N=133
Screen-H®
>35 dB HL	152 (81%)	8 (6%)	0.726
≤35dB HL	36 (19%)	125 (94%)

Table 4 shows that Screen-H exhibits strong sensitivity, very high specificity, very high PPV and NPV in the right ear, with sufficient NPV, high accuracy, high PLR, high NLR in the left ear. The Kappa value suggests greater suitability for the right ear compared to the left.

Table 4. Screen-H® diagnostic test.

	Right Ear	Left Ear
Sensitivity	82.8%	80.8%
Specificity	94.1%	93.9%
PPV	94%	95%
NPV	83.1%	77.6%
Accuracy	88.2%	86.2%
PLR	13.99	13.44
NLR	0.182	0.20
Kappa	0.764	0.726

Discussion

Hearing loss affects individuals across all ages.⁴^,¹⁴ Our study included patients ranging from 11 to 83 years, with the most prevalent age group being 26 to 35 years. There is higher prevalence of hearing loss in men compared to women, which can be attributed to several risk factors and comorbidities.¹⁵

The current study revealed that sensorineural hearing loss was the most common type, accounting for 40.5% of cases, followed by conductive hearing loss at 26%. Various factors contributed to these types of hearing loss, including chronic suppurative otitis media, presbycusis, ototoxicity, noise-induced hearing loss, sudden sensorineural deafness, congenital hearing loss, and Meniere's disease. Additionally, cerumen presence was a contributor to conductive hearing loss.

Chronic suppurative otitis media has been linked with various types of hearing loss, including conductive, sensorineural, and mixed types.¹⁶ Particularly, sensorineural hearing loss can develop when chronic otitis media persists for more than 14 days, leading to increased levels of CD45+ macrophages, which act as inflammatory mediators in the cochlea. These macrophages are closely associated with the damage to the external hair cells.¹⁶ Prolonged infection and inflammation beyond 14 days can lead to irreversible auditory function impairment. primarily affecting Based on Xia’s research, the damage primarily affects the outer hair cells while sparing the inner hair cells.¹¹^,¹⁶^,¹⁷ Conductive hearing loss, on the other hand, results from impaired sound transmission from the outer to the inner ear. In this study, factors such as chronic otitis media, cerumen prop, acute otitis media, external acoustic canal stenosis, tumors, and otosclerosis accounted for the 26% incidence of conductive hearing loss.¹⁸

Screen-H has greater specificity compared to sensitivity, as the test is more effective at accurately identifying individuals without hearing loss than those with hearing loss. The accuracy of the test in both the right and left ears demonstrated robust values, indicating that the audiometry testing conducted on the Screen-H possesses statistically significant accuracy. The Kappa value is strong for the right ear and satisfactory for the left ear.

Other studies have reported sensitivity and specificity rates of 82% and 95%, respectively, which are comparable to the findings of our current study.¹⁹ Another study revealed a sensitivity of 93%, specificity of 88%, a positive predictive value of 87%, and a negative predictive value of 94%.²⁰ These findings align with our investigation, indicating that the Screen-H assessment has adequate statistical significance in accurately identifying individuals with either hearing loss or normal hearing. The impact of environmental noise on website audiometry examinations is major, especially when tests are carried out at intensities >40 dB HL.²¹^,²² In this study, Screen-H examinations were performed in areas where the environmental noise was ≤40 dB HL, and headphones with a noise-canceling capability of around 15-20 dB HL were used. This setup ensured that the 35 dB stimulus was effectively received.

In addition, the earphones can affect the results of audiological assessments and whether the earphones are positioned by trained examiners or by examinees can affect audiological judgments.¹¹ The negative effects of background noise may further support that examinations performed in soundproof booths have better diagnostic accuracy.¹⁹ The influence of ambient noise, which results in incorrect smartphone audiometry test results, leading to the use of soundproof booths can improve the diagnostic accuracy of smartphone-based hearing tests.¹¹

Pure tone audiometry, known for its high cost and limited accessibility, is typically available only in larger healthcare facilities. This presents a challenge for many individuals in Indonesia, especially considering the country’s archipelagic geography, which further complicates access to hearing examination services. Therefore, there is an urgent need for a hearing loss detection method that is accessible to all Indonesians, cost-effective, available in the Indonesian language, and does not require the assistance of professional personnel.

This study has limitations, notably the use of Sennheiser HD 201 headphones, which are not standard audiometry equipment. This factor could potentially influence the study results.

Conclusion

Screen-H demonstrated excellent capabilities in hearing loss screening due to its speed, ease of use, non-invasive nature, high sensitivity (80.8%-82.8%) and specificity (93.9%-(94.1%), and cost-effectiveness. It can effectively be used as a screening tool for hearing loss in environments with noise levels ≤ 40 dB, starting with a stimulus of 35 dB.

Ethics and Consent

This research has been approved by the Ethics Committee of Padjadjaran University with number 255/UN6.KEP/EC/2023 which was published on February 28, 2023 and was conducted from May to July 2023. All participants were informed about subject of the study and signed written consent.

Author contributions

MS performed examination to the subject, analysis, and interpretation of the patient’s data, also was a major contributor in writing the manuscript. All authors had full access to all data in the study ad had final responsibility for the decision on submit for publication.

Data availability statement

Figshare: Screen-H Website Audiometry as a Diagnostic Tool for Hearing Screening in Patients with Hearing Loss, https://doi.org/10.6084/m9.figshare.25416769.v1

The project contains the following underlying data:

• Data file 1. Datasets.xlsx

Data are available under the terms of the CC by 4.0

Acknowledgments

We gratefully acknowledge all the study participants for their time and commitment to this study. Our thanks also go to the Faculty of Medicine, Universitas Padjadjaran, and Dr. Hasan Sadikin General Hospital, Bandung, for their indispensable support, which made this study possible. Parts of this study were presented at ORLIAC 2023, International symposium on October 25–27, 2023, Bali, Indonesia.

Reference

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3. Joint Committee on Infant Hearing: Year 2019 position statement: principles and guidelines for early hearing detection and intervention programs. Utah: J Early Hear Detect Interv; 2019; vol. 4. ; 1–44.
4. World Health Organization: Addressing the rising prevalence of hearing loss. Geneva: World Health Organization; 2018; 1–40.
5. Joyce Li LY, Wang SY, Wu CJ, et al.: Screening for hearing impairment in older adults by smartphone-based audiometry, self-perception, HHIE screening questionnaire, and free-field voice test: Comparative evaluation of the screening accuracy with standard pure-tone audiometry. JMIR Mhealth Uhealth. 2020; 8(10): 1–10.
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8. Rizqi Septiana N: Widowati Kesehatan dan Keselamatan Kerja E, Ilmu Kesehatan Masyarakat J, Ilmu Keolahragaan Universitas Negeri Semarang F. Gangguan Pendengaran Akibat Bising. 2017; 1(1): 73–82.
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12. Colsman A, Supp GG, Neumann J, et al.: Evaluation of Accuracy and Reliability of a Mobile Screening Audiometer in Normal Hearing Adults. Front. Psychol. 2020; 11(April): 1–12. Publisher Full Text
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16. Xia A, Thai A, Cao Z, et al.: Chronic suppurative otitis media causes macrophage-associated sensorineural hearing loss. J. Neuroinflammation. 2022; 19(1): 1–15.
17. Haile LM, Kamenov K, Briant PS, et al.: Hearing loss prevalence and years lived with disability, 1990-2019: Findings from the Global Burden of Disease Study 2019. Lancet. 2021; 397(10278): 996–1009. PubMed Abstract | Publisher Full Text | Free Full Text
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Version 1

VERSION 1 PUBLISHED 29 Apr 2024

Author details Author details

¹ Otorhinolaryngology-Head and Neck Surgery, Universitas Padjadjaran, Bandung, West Java, Indonesia

Melati Sudiro
Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Supervision, Validation, Visualization, Writing – Review & Editing

Wijana Hasansulama
Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Resources, Software, Supervision, Writing – Review & Editing

Rano Digdayan Makerto
Roles: Data Curation, Formal Analysis, Investigation, Methodology, Writing – Original Draft Preparation

Raden Ayu Hardianti Saputri
Roles: Conceptualization, Data Curation, Formal Analysis, Supervision, Writing – Review & Editing

Competing interests

Hopefully this research can be published on f1000research so that the Screen-H audiometry website software has a basis in international journals and can be recognized for its use on a national and international scale.

Grant information

Financial support was received from the Universitas Padjadjaran no.537/UN6.WR3/TU.00/2023
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Published: 29 Apr 2024, 13:416

https://doi.org/10.12688/f1000research.146735.1

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© 2024 Sudiro M et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Sudiro M, Hasansulama W, Digdayan Makerto R and Ayu Hardianti Saputri R. Screen-H Website Audiometry as a Diagnostic Tool for Hearing Screening in Patients with Hearing Loss [version 1; peer review: 1 approved with reservations]. F1000Research 2024, 13:416 (https://doi.org/10.12688/f1000research.146735.1)

NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.

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PUBLISHED 29 Apr 2024

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Reviewer Report 05 Sep 2025

Małgorzata Pastucha, World Hearing Center, Institute of Physiology and Pathology of Hearing, Warsaw, Poland

Approved with Reservations

https://doi.org/10.5256/f1000research.160851.r404394

Title: Although the authors compared their results with a diagnostic gold standard and were therefore able to report the type of hearing loss, the tool under evaluation based only on air-conduction thresholds doesn’t allow for a full diagnostic work-up. Its function ... Continue reading

Title: Although the authors compared their results with a diagnostic gold standard and were therefore able to report the type of hearing loss, the tool under evaluation based only on air-conduction thresholds doesn’t allow for a full diagnostic work-up. Its function is more consistent with a screening tool rather than a diagnostic one. I would suggest adjusting the title accordingly, e.g., by removing the term “diagnostic tool” to avoid overstating its capabilities.

Abstract: In the Methods section, the specific name of the clinic where the study was conducted is given. This is unnecessary in the abstract, where the focus should be on the study design, population and main procedures. Details of the institution are more appropriate for the full text of the Methods section.

Keywords: I would recommend replacing “diagnostic test” with “screening tool”, as this more accurately reflects the scope and purpose of the study.

Introduction: First sentence (“Hearing loss occurs when the sound transmission from the outer ear to the brain is impaired”) is too simplistic and may be misleading. Hearing loss results from impairments across the auditory system, affecting detection and/or processing, and not only sound transmission. I suggest expanding this statement to more accurately reflect the underlying mechanisms.
In the second paragraph, the transition to “An alternative approach is hearing screening using Screen-H” is too abrupt. Before introducing Screen-H, it would be useful to briefly present other existing mobile or web-based hearing screening tools. This would provide a broader context, supported by recent literature, and then naturally lead to the rationale for evaluating Screen-H as one of these solutions.
The overall structure of the Introduction could be made clearer by organizing it into:
(a) the importance and consequences of hearing loss,
(b) current diagnostic standards and their limitations,
(c) a broader overview of mobile and web-based hearing screening methods, and
(d) the rationale for evaluating Screen-H.
This structure would guide the reader step by step and provide a stronger rationale for the study.

Methods: Descriptions of diagnostic accuracy measures (sensitivity, specificity, PPV, NPV, PLR, NLR, accuracy, Kappa) should be moved to the end of the Methods section, under “Statistical analysis,” rather than appearing at the beginning.
The sentence “Data processing and analysis were conducted using Microsoft Excel 365 https://www.microsoft.com/...” should be revised by removing the web link, as it is unnecessary and does not add value to the text.
The last paragraph contains repeated information about the audiometer (Resonance, EN60645-1/-2, New Holland). Please remove the duplication.
I recommend dividing the methods section into subsections such as Participants, Tonal audiometry, Screen-H, Test procedure, Statistical analysis. This would make the whole section more clearly organised.
In the subsection on Screen-H, please provide a more detailed description of the tool. Since the aim of the study is to evaluate its agreement with the gold standard, the device and its functioning should be described in sufficient detail.
The study procedure should be described with enough detail to allow replication. Currently, essential information is missing, for example: who performed the tests, whether both tests were conducted on the same day, and in what order.

Results: I am not convinced by the way the results compare between tonal audiometry and Screen-H. Pure-tone audiometry applies the conventional threshold of ≤25 dB HL as normal hearing, while Screen-H uses 35 dB HL. This creates a mismatch: individuals with mild hearing loss (26–35 dB HL) are considered normal by Screen-H but impaired by pure-tone audiometry. Directly comparing these cut-offs (Tables 2 and 3) may lead to biased estimates of agreement. Please reconsider this approach or provide a clear justification for using different threshold values.
The Results section focuses extensively on general characteristics of hearing loss in the sample (age, sex distribution, type and cause of hearing loss). While these data are important, they are not directly related to the main study objective, which is the agreement between Screen-H and pure-tone audiometry. The emphasis should be placed on agreement measures.
Table 1 presents the most common type and cause of hearing loss, but these findings are not linked in any way to the performance of Screen-H. If these variables are not analyzed in relation to Screen-H results, they may be better placed in a descriptive section or omitted altogether.
The discussion of results is very limited. The results should be interpreted in more depth, focusing on the actual level of agreement, strengths, and weaknesses of Screen-H compared to the reference standard. Currently, the interpretation is superficial and does not explain the relevance of the findings.

Discussion: The paragraph on “Chronic suppurative otitis media…” is too extensive and shifts the focus away from the main aim of the paper. While it is acceptable to briefly mention possible causes of hearing loss, the article is primarily about evaluating a screening tool. Moreover, the Results section did not present sensitivity or specificity by type of hearing loss, so the detailed discussion of etiologies is not supported by the study findings and could be shortened considerably.
The Discussion includes sections (e.g., comparison of testing inside vs. outside a soundproof) that were not directly studied in this paper. These digressions weaken the connection between the Discussion and the actual results. The authors should focus more closely on the aspects that were directly analyzed — namely, the agreement between Screen-H and pure-tone audiometry, and the interpretation of the diagnostic accuracy values obtained.
Overall, the Discussion is too general and does not sufficiently interpret the specific findings of this study. It would benefit from a more focused analysis of the presented results, highlighting the strengths and limitations of Screen-H in the studied population, rather than broad background information or findings from unrelated studies.

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

No
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: audiologist

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

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Małgorzata Pastucha, Institute of Physiology and Pathology of Hearing, Warsaw, Poland

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Reviewer Report

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05 Sep 2025 | for Version 1

Małgorzata Pastucha, World Hearing Center, Institute of Physiology and Pathology of Hearing, Warsaw, Poland

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Approved With Reservations

Title: Although the authors compared their results with a diagnostic gold standard and were therefore able to report the type of hearing loss, the tool under evaluation based only on air-conduction thresholds doesn’t allow for a full diagnostic work-up. Its function is more consistent with a screening tool rather than a diagnostic one. I would suggest adjusting the title accordingly, e.g., by removing the term “diagnostic tool” to avoid overstating its capabilities.

Abstract: In the Methods section, the specific name of the clinic where the study was conducted is given. This is unnecessary in the abstract, where the focus should be on the study design, population and main procedures. Details of the institution are more appropriate for the full text of the Methods section.

Keywords: I would recommend replacing “diagnostic test” with “screening tool”, as this more accurately reflects the scope and purpose of the study.

Introduction: First sentence (“Hearing loss occurs when the sound transmission from the outer ear to the brain is impaired”) is too simplistic and may be misleading. Hearing loss results from impairments across the auditory system, affecting detection and/or processing, and not only sound transmission. I suggest expanding this statement to more accurately reflect the underlying mechanisms.
In the second paragraph, the transition to “An alternative approach is hearing screening using Screen-H” is too abrupt. Before introducing Screen-H, it would be useful to briefly present other existing mobile or web-based hearing screening tools. This would provide a broader context, supported by recent literature, and then naturally lead to the rationale for evaluating Screen-H as one of these solutions.
The overall structure of the Introduction could be made clearer by organizing it into:
(a) the importance and consequences of hearing loss,
(b) current diagnostic standards and their limitations,
(c) a broader overview of mobile and web-based hearing screening methods, and
(d) the rationale for evaluating Screen-H.
This structure would guide the reader step by step and provide a stronger rationale for the study.

Methods: Descriptions of diagnostic accuracy measures (sensitivity, specificity, PPV, NPV, PLR, NLR, accuracy, Kappa) should be moved to the end of the Methods section, under “Statistical analysis,” rather than appearing at the beginning.
The sentence “Data processing and analysis were conducted using Microsoft Excel 365 https://www.microsoft.com/...” should be revised by removing the web link, as it is unnecessary and does not add value to the text.
The last paragraph contains repeated information about the audiometer (Resonance, EN60645-1/-2, New Holland). Please remove the duplication.
I recommend dividing the methods section into subsections such as Participants, Tonal audiometry, Screen-H, Test procedure, Statistical analysis. This would make the whole section more clearly organised.
In the subsection on Screen-H, please provide a more detailed description of the tool. Since the aim of the study is to evaluate its agreement with the gold standard, the device and its functioning should be described in sufficient detail.
The study procedure should be described with enough detail to allow replication. Currently, essential information is missing, for example: who performed the tests, whether both tests were conducted on the same day, and in what order.

Results: I am not convinced by the way the results compare between tonal audiometry and Screen-H. Pure-tone audiometry applies the conventional threshold of ≤25 dB HL as normal hearing, while Screen-H uses 35 dB HL. This creates a mismatch: individuals with mild hearing loss (26–35 dB HL) are considered normal by Screen-H but impaired by pure-tone audiometry. Directly comparing these cut-offs (Tables 2 and 3) may lead to biased estimates of agreement. Please reconsider this approach or provide a clear justification for using different threshold values.
The Results section focuses extensively on general characteristics of hearing loss in the sample (age, sex distribution, type and cause of hearing loss). While these data are important, they are not directly related to the main study objective, which is the agreement between Screen-H and pure-tone audiometry. The emphasis should be placed on agreement measures.
Table 1 presents the most common type and cause of hearing loss, but these findings are not linked in any way to the performance of Screen-H. If these variables are not analyzed in relation to Screen-H results, they may be better placed in a descriptive section or omitted altogether.
The discussion of results is very limited. The results should be interpreted in more depth, focusing on the actual level of agreement, strengths, and weaknesses of Screen-H compared to the reference standard. Currently, the interpretation is superficial and does not explain the relevance of the findings.

Discussion: The paragraph on “Chronic suppurative otitis media…” is too extensive and shifts the focus away from the main aim of the paper. While it is acceptable to briefly mention possible causes of hearing loss, the article is primarily about evaluating a screening tool. Moreover, the Results section did not present sensitivity or specificity by type of hearing loss, so the detailed discussion of etiologies is not supported by the study findings and could be shortened considerably.
The Discussion includes sections (e.g., comparison of testing inside vs. outside a soundproof) that were not directly studied in this paper. These digressions weaken the connection between the Discussion and the actual results. The authors should focus more closely on the aspects that were directly analyzed — namely, the agreement between Screen-H and pure-tone audiometry, and the interpretation of the diagnostic accuracy values obtained.
Overall, the Discussion is too general and does not sufficiently interpret the specific findings of this study. It would benefit from a more focused analysis of the presented results, highlighting the strengths and limitations of Screen-H in the studied population, rather than broad background information or findings from unrelated studies.

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

No
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

audiologist

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

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Screen-H Website Audiometry as a Diagnostic Tool for Hearing Screening in Patients with Hearing Loss

Abstract

Background

Purpose

Methods

Results

Conclusion

Keywords

Introduction

Methods

Results

Table 1. Characteristics of eesearch subjects.

Table 2. Right ear hearing threshold.

Table 3. Left ear hearing threshold.

Table 4. Screen-H® diagnostic test.

Discussion

Conclusion

Ethics and Consent

Author contributions

Data availability statement

Acknowledgments

Reference

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