Optimizing the Chinese Zodiac-in-Noise Test With Antiphasic Stimuli for Better Hearing Loss Detection

Objectives: The antiphasic digit-in-noise test has demonstrated the advantages of antiphasic presentation in hearing screening. Inspired by this, this study explores whether incorporating antiphasic stimuli in the Chinese zodiac-in-noise (ZIN) test can enhance its sensitivity to detect hearing loss. Furthermore, this study investigates the relation between the binaural intelligibility level difference (BILD), calculated as the difference between antiphasic and diotic results, and hearing thresholds, and evaluates the potential of BILD as an indicator for hearing loss. Design: Normative data for the antiphasic ZIN test were established based on data from 117 normal-hearing listeners. Subsequently, the performance of the antiphasic ZIN test was evaluated in 195 listeners with varying degrees and types of hearing loss. Participants were classified into four groups based on their audiograms: normal hearing (n = 115), symmetric hearing loss (n = 37), asymmetric hearing loss (n = 14), and unilateral hearing loss (n = 29). BILD was further analyzed to assess its relation with high- and low-frequency hearing thresholds. Results: The antiphasic ZIN test has a cutoff value of −13.7 dB and a reference speech reception threshold of −19.0 ± 3.2 dB. The measurement error, as estimated from the test-retest reliability, was 1.2 dB. Partial correlation analysis controlling for age revealed comparable associations of hearing thresholds across ears with BILD ( ρ poorer-antiphasic = 0.65, 95% confidence interval [CI]: 0.54 to 0.74 versus ρ poorer-diotic = 0.43, 95% CI: 0.29 to 0.55). Compared with the diotic ZIN test, the antiphasic ZIN demonstrates higher sensitivity (0.88, 95% CI: 0.78 to 0.93 versus 0.49, 95% CI: 0.38 to 0.60) in detecting hearing loss of >25 dB HL in the poorer ear, with comparable specificity (0.86, 95% CI: 0.79 to 0.91 versus 0.97, 95% CI: 0.93 to 0.99). Compared with high-frequency hearing loss, BILD showed a stronger association with low-frequency hearing loss, with a more pronounced decrease as hearing impairment in the poorer ear worsened. Conclusions: The antiphasic ZIN test demonstrates higher screening sensitivity compared with the diotic ZIN, particularly in detecting asymmetric and unilateral hearing loss. BILD is more sensitive to low-frequency hearing impairments and shows substantial promise as an indicator for hearing loss.