PRIMARY EAR AND HEARING CARE TRAINING MANUAL



WEB ANNEX. DEVELOPMENT OF


THE PRIMARY EAR AND HEARING
  

   

CARE TRAINING MANUAL,
  

INFORMATION SOURCES AND

  
DECLARATION OF INTERESTS
 Web Annex:

DEVELOPMENT OF THE PRIMARY EAR

AND HEARING CARE TRAINING MANUAL,
INFORMATION SOURCES AND DECLARATION OF
INTERESTS
The manual was developed through an evidence-based consultative process. The clinical processes,
diagnostic steps and management/referral criteria described in the manual are based on high-quality
information sources. The hierarchy of evidence that informs this manual is as follows:

• WHO guidelines and evidence-based technical products

• Published, high-quality clinical guidelines (quality assessed through application of AGREE-II tool for
rating) including systematic reviews of clinical guidelines.
• Systematic reviews including those published by Cochrane ENT that relate to ear and hearing
examination and clinical interventions.
• Textbooks on ENT and audiology, that are based on evidence synthesis and document the evidence
sources.
• Peer-reviewed publications: these were used to inform the introduction and some narrative
components of the manual.
• Discussions with experts guided the:
•  Selection of conditions to be included within the manual;
•  Inclusion of guidelines and their application within the manual;
•  Validation of clinical approaches including red flags for common ear diseases;
•  Choice of methodology of ear examination and hearing assessment, in cases where conflicting
methodologies were identified in the textbooks and clinical guidelines.
• Stakeholder consultations: a stakeholder group that included academia, NGOs, clinical service
providers, professional associations, and representatives of deaf and hard of hearing persons were
involved in:
•  Validation of conditions selected;
•  Agreement on language and overall direction of the manual.
• Delphi surveys: two surveys were conducted to inform the:
•  Selection of conditions to be included;
•  Approaches to hearing screening in adults.
The outcomes were used by the expert group to make the final selection.

Process:

WHO guidelines and sources were first sought and used to inform all aspects of this training manual. For
clinical processes where WHO guidelines are not available, clinical guidelines were identified through
scoping the literature. These were assessed for quality using the AGREEII tool applied by two reviewers.
Those with an average sum above 50 were included. In parallel, Cochrane reviews published by the Cochrane
ENT group relevant for this training manual were identified. Where neither of the above two were applicable
or all required information not available, other systematic reviews were sought.
All information extracted from these sources was shared with the expert group during technical working
group meetings, and their applicability in low- and middle-income settings discussed prior to their inclusion.

Due to a paucity of guidelines for hearing screening in adults, a Delphi survey was conducted to inform the
selection of tests. Textbooks were referred to for description of clinical procedures that are widely known and
accepted as the gold-standard, such as examination of ear and audiometry. The textbooks were identified
based on expert recommendations. Only those textbooks that provided the sources of information were
included.

The information sources used are listed in table 1 and summary of experts and their declaration interest are
summarized in table 2.

Table 1: List of information sources

Type of source References

WHO evidence- 1.  World Health Organization. WHO recommendations on maternal and newborn
based guidelines care for a positive postnatal experience. Available at https://www.who.int/
and technical publications/i/item/9789240045989, accessed 19 February 2023.
products 2.  World Health Organization. Integrated care for older people: guidelines on
community-level interventions to manage declines in intrinsic capacity.
Available at https://www.who.int/publications/i/item/9789241550109, accessed
19 February 2023.
3.  World Health Organization; Geneva: 2014. Childhood hearing loss Integrated
Management of Childhood Illness: distance learning course. https://apps.who.
int/iris/handle/10665/104772.
4.  World Health Organization; Geneva: 2012. Recommendations for Management
of Common Childhood Conditions: Evidence for Technical Update of Pocket
Book Recommendations. https://apps.who.int/iris/handle/10665/44774.
5.  World Health Organization. Integrated care for older people (ICOPE): guidance
for person-centred assessment and pathways in primary care. Available
at https://www.who.int/publications/i/item/WHO-FWC-ALC-19.1, accessed 19
February 2023.
6.  World Health Organization. Hearing screening: considerations for
implementation. Available at https://www.who.int/publications/i/
item/9789240032767, 19 February 2023.
7.  World Health Organization 2023. Package of Interventions for Rehabilitation:
sensory conditions (approved, in publication)
8.  World Health Organization; Geneva: 2021. World Report on Hearing. https://
www.who.int/publications/i/item/world-report-on-hearing
9.  World Health Organization; Geneva: 2021. World Report on Ageing. https://apps.
who.int/iris/handle/10665/186463.  

Web Annex  |  Development of the training manual, information sources and declaration of interests  3
 Evidence-based 1.  Aural Rehabilitation Clinical Practice Guideline Development Panel, Basura G,
guidelines (with Cienkowski K, Hamlin L, Ray C, Rutherford C, Stamper G, Schooling T, Ambrose J.
AGREE II average American Speech-Language-Hearing Association Clinical Practice Guideline on
sum score >50) Aural Rehabilitation for Adults with Hearing Loss. Am J Audiol. 2022 Nov 14:1-51.
doi: 10.1044/2022_AJA-21-00252. Epub ahead of print. PMID: 36374028.
2.  Grine K, Stephens M. A guideline for managing disorders of the ear: pinna and
canal. J Fam Pract. 2020 Jul/Aug;69(6): E1-E6. PMID: 32724914.
3.  The Rotherham NHS Foundation Trust: Otoscopy Guidelines. Available at http://
www.earcarecentre.com/uploadedFiles/Pages/Health_Professionals/Protocols/
Otoscopy%20Guideline.pdf, accessed on 19 February 2023.
4.  Chang P, Pedler K. Ear examination--a practical guide. Aust Fam Physician. 2005
Oct;34(10):857-62. PMID: 16217573.
5.  Rosenfeld RM, Shin JJ, Schwartz SR, et al. Clinical Practice Guideline: Otitis
Media with Effusion (Update). Otolaryngology–Head and Neck Surgery.
2016;154(1_suppl): S1-S41. doi:10.1177/0194599815623467.
6.  British Society of Audiology. Practice Guidance: Behavioural Observational
Audiometry. Available at https://www.hincyp.scot.nhs.uk/wp-content/
uploads/2020/07/7.-Audiology-OD104-78BSA-Practice-Guidance-Behavioural-
Observation-Audiometry-FINAL-Review-2024.pdf, accessed on 19 February 2023.
7.  British Society of Audiology Assessment Guidelines for the Distraction Test of
Hearing. Available https://www.thebsa.org.uk/resources/protocol-distraction-
test-hearing/, accessed on 19 February 2023.
8.  University Hospitals Sussex NHS Foundation Trust. Instillation of ear drops.
Available at https://www.uhsussex.nhs.uk/content/uploads/2021/05/Instillation-
of-ear-drops-1.pdf, accessed on 19 February 2023.
9.  The Joint Committee on Infant Hearing. Year 2019 Position Statement: Principles
and Guidelines for Early Hearing Detection and Intervention Programs. DOAJ.
2019; 4(2): 1–44.
10.  Suzuki HG, Dewez JE, Nijman RG, Yeung S. Clinical practice guidelines for acute
otitis media in children: a systematic review and appraisal of European national
guidelines. BMJ Open. 2020;10(5): e035343. Published 2020 May 5. doi:10.1136/
bmjopen-2019-035343
11.  Wen C, Zhao X, Li Y, Yu Y, Cheng X, Li X, Deng K, Yuan X, Huang L. A systematic
review of newborn and childhood hearing screening around the world:
comparison and quality assessment of guidelines. BMC Pediatr. 2022
Mar 29;22(1):160. doi: 10.1186/s12887-022-03234-0. PMID: 35351033; PMCID:
PMC8962144
12.  Kamenov K, Chadha S. Methodological quality of clinical guidelines for
universal newborn hearing screening. Dev Med Child Neurol. 2021;63(1):16-21.
doi:10.1111/dmcn.14694

4  Primary Ear & Hearing Care Training Manual

Cochrane 1.  Lieu JEC, Kenna M, Anne S, Davidson L. Hearing Loss in Children: A Review.
reviews and JAMA. 2020;324(21):2195-2205. doi:10.1001/jama.2020.17647.
articles based 2.  Jones SEM, Mahendran S. Interventions for acute auricular haematoma.
on systematic Cochrane Database of Systematic Reviews 2004, Issue 2. Art. No.: CD004166.
reviews DOI: 10.1002/14651858.CD004166.pub2.
3.  Kaushik V, Malik T, Saeed SR. Interventions for acute otitis externa. Cochrane
Database of Systematic Reviews 2010, Issue 1. Art. No.: CD004740. DOI:
10.1002/14651858.CD004740.pub2.
4.  Venekamp RP, Burton MJ, van Dongen TMA, van der Heijden GJ, van Zon A,
Schilder AGM. Antibiotics for otitis media with effusion in children. Cochrane
Database of Systematic Reviews 2016, Issue 6. Art. No.: CD009163. DOI:
10.1002/14651858.CD009163.pub3.
5.  Perera R, Glasziou PP, Heneghan CJ, McLellan J, Williamson I. Autoinflation for
hearing loss associated with otitis media with effusion. Cochrane Database
of Systematic Reviews 2013, Issue 5. Art. No.: CD006285. DOI: 10.1002/14651858.
CD006285.pub2.
6.  Ferguson MA, Kitterick PT, Chong LY, Edmondson-Jones M, Barker F, Hoare DJ.
Hearing aids for mild to moderate hearing loss in adults. Cochrane Database
Syst Rev. 2017 Sep 25;9(9):CD012023. doi: 10.1002/14651858.CD012023.pub2.
PMID: 28944461; PMCID: PMC6483809.
7.  Campbell R, MacSweeney M, Waters D. Sign language and the brain: a review. J
Deaf Stud Deaf Educ. 2008 Winter;13(1):3-20. doi: 10.1093/deafed/enm035. Epub
2007 Jun 29. PMID: 17602162.
8.  Barker F, Mackenzie E, Elliott L, Jones S, de Lusignan S. Interventions to improve
hearing aid use in adult auditory rehabilitation. Cochrane Database Syst Rev.
2016 Aug 18;2016(8):CD010342. doi: 10.1002/14651858.CD010342.pub3. PMID:
27537242; PMCID: PMC6463949.
9.  Aaron K, Cooper TE, Warner L, Burton MJ. Ear drops for the removal of ear wax.
Cochrane Database of Systematic Reviews 2018, Issue 7. Art. No.: CD012171.
DOI: 10.1002/14651858.CD012171.pub2
Textbooks 1.  Watkinson J., Clarke R. (Ed.). (2018). Scott-Brown’s Otorhinolaryngology and
Head and Neck Surgery, Eighth Edition 3 volume set. Routledge.
2.  Katz, J. (2014). Handbook of clinical audiology (7th ed.). Lippincott Williams and
Wilkins.
3.  Hogan C.J., Tadi P. (2022). Ear Examination. StatPearls.
4.  Lotterman S., Sohal M. (2022). Ear Foreign Body Removal. StatPearls.
5.  Sommerfeldt J., Kolb C. M. (2022). Hearing Loss Assessment in Children.
StatPearls.

Web Annex  |  Development of the training manual, information sources and declaration of interests  5
 Other peer- 1.  GBD 2019 Hearing Loss Collaborators. Hearing loss prevalence and years lived with
reviewed disability, 1990–2019: findings from the Global Burden of Disease Study 2019. The
articles (not Lancet. (2021). doi: 10.1016/S0140-6736(21)00516-X.
based on 2.  Wilson BS, Tucci DL, Merson MH, O’Donoghue GM. Global hearing health care: new
systematic findings and perspectives. Lancet. 2017 Dec 2;390(10111):2503-2515. doi: 10.1016/
reviews) S0140-6736(17)31073-5. Epub 2017 Jul 10. PMID: 28705460.
3.  What is primary care? J Public Health Policy. 1983 Jun;4(2):129-34. PMID: 6885995.
4.  American Speech-Language-Hearing Association. How Does Your Child Hear and
Talk? Available at https://www.asha.org/public/speech/development/chart/,
accessed 15 February 2023.
5.  Kamenov K, Martinez R, Kunjumen T, Chadha S. Ear and Hearing Care Workforce:
Current Status and its Implications. Ear Hear. 2021 Mar/Apr;42(2):249-257. doi:
10.1097/AUD.0000000000001007. Erratum in: Ear Hear. 2021 Jun 18;42(5):1445.
PMID: 33480624.
6.  O’Donovan J, Verkerk M, Winters N, Chadha S, Bhutta MF. The role of community
health workers in addressing the global burden of ear disease and hearing loss:
a systematic scoping review of the literature. BMJ Glob Health. 2019 Mar 1;4(2):
e001141. doi: 10.1136/bmjgh-2018-001141. PMID: 30899572; PMCID: PMC6407559.
7.  Davis A, McMahon CM, Pichora-Fuller KM, et al. Aging and Hearing Health: The
Life-course Approach. Gerontologist. 2016;56 Suppl 2(Suppl 2): S256-S267.
doi:10.1093/geront/gnw033.
8.  Bhutta MF. Models of service delivery for ear and hearing care in remote or
resource-constrained environments. J Laryngol Otol. 2019 Jan;133(1):39-48. doi:
10.1017/S0022215118002116. Epub 2018 Dec 18. PMID: 30558687.
9.  Bhutta MF, Bu X, de Muñoz PC, Garg S, Kong K. Training for hearing care providers.
Bull World Health Organ. 2019 Oct 1;97(10):691-698. doi: 10.2471/BLT.18.224659.
Epub 2019 Aug 20. PMID: 31656334; PMCID: PMC6796672.
10.  Humes LE. The World Health Organization’s hearing-impairment grading system:
an evaluation for unaided communication in age-related hearing loss. Int J Audiol.
2019;58(1):12-20. doi:10.1080/14992027.2018.1518598.
11.  Sánchez D, Adamovich S, Ingram M, Harris FP, de Zapien J, Sánchez A, Colina
S, Marrone N. The Potential in Preparing Community Health Workers to Address
Hearing Loss. J Am Acad Audiol. 2017 Jun;28(6):562-574. doi: 10.3766/jaaa.16045.
PMID: 28590899; PMCID: PMC6800024.
WHO webpages 1.  World Health Organisation. Primary Care. Available at https://www.who.int/
teams/integrated-health-services/clinical-services-and-systems/primary-care,
accessed 19 February 2023.
2.  World Health Organisation. Deafness and hearing loss. Available at https://www.
who.int/news-room/fact-sheets/detail/deafness-and-hearing-loss, accessed 19
February 2023.
3.  Health Organization; Geneva: 2016. Childhood hearing loss: strategies for
prevention and care. https://apps.who.int/iris/handle/10665/204632.

6  Primary Ear & Hearing Care Training Manual

Primary ear and hearing care training manual: management of conflict of interest

All members of the technical working group (TWG) and peer reviewers completed and submitted a WHO
Declaration of Interests form and signed confidentiality undertakings prior to attending any TWG meetings
and review. The WHO department for Noncommunicable diseases reviewed and assessed the submitted
declarations of interest and performed an internet search to identify any obvious public controversies
or interests that may lead to compromising situations. If additional guidance on management of any
declaration or conflicts of interest had been required, the department would have consulted with colleagues
in Office of Compliance, Risk Management and Ethics. If deemed necessary, individuals found to have
conflicts of interest, financial or non-financial, would have been excluded from participation on any topics
where interests were conflicting. The management of conflicts of interest was reviewed throughout the
process. TWG members were required to update their Declaration of Interest, if necessary, before each
meeting. Declared interests of the TWG members and reviewers are summarized below. No conflict of interest
was identified.

Table 2: Declaration of interests

Management of conflict
Name Expertise Disclosure of interest
of interest
Arun Agarwal Community ENT None declared None identified
Mazin Al-Khabori ENT None declared None identified
Mahmooh Bhutta Employed by University of
ENT None identified
Sussex. Research funds
Xingkuan Bu ENT, hearing screening None declared None identified
Priya Carling Audiology None declared None identified
Patricia Castellanos
Community audiology None declared None identified
de Muñoz
Oh Chunghyeon ENT None declared None identified

Chitra Chander Public health Paid consultancy (WHO) None identified

Jackie Clark Audiology None declared None identified

Victor De Andrade Audiology None declared None identified
Carolina Der ENT None declared None identified
Uta Fröschl CBM directly supported
field testing of the manual
through technical and
financial contributions.
ENT Employed by CBM
This did not pose a
conflict as the content and
structure of the manual
was agreed prior to this.
Suneela Garg Public health Research funds None identified
Rachael Hapunda Primary care, ENT Paid consultancy (WHO) None identified

Web Annex  |  Development of the training manual, information sources and declaration of interests  7
 Lived experience of
Sally Harvest Research funds None identified
hearing loss
Linda Hood Audiology None declared None identified
Isaac Macharia Community ENT None declared None identified
Amarilis Meléndez ENT None declared None identified
Norberto Martinez ENT and audiology None declared None identified
Pallavi Mishra Health systems Paid consultancy (WHO) None identified
Serah Ndwega Community audiology None declared None identified
James O’Donovan Primary care None declared None identified
Hubert Ramos Audiology None declared None identified
Diego Santana- CBM directly supported
Hernández field testing of the manual
through technical and
financial contributions.
Community ENT Employed by CBM
This did not pose a
conflict as the content and
structure of the manual
was agreed prior to this.
Paige Stringer Lived experience of
None declared None identified
hearing loss
Audiology, digital Co-founder hearX digital
De Wet Swanepoel None identified
health hearing technologies
George Tavartkilaze Audiology None declared None identified

8  Primary Ear & Hearing Care Training Manual

 WHO/UCN/NCD/SDR/23.8 – © World Health Organization 2023.

Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO licence.
https://www.who.int/health-topics/hearing