Fig. 1

Selection procedure for study participants. This figure illustrates the participant selection process from the National Health and Nutrition Examination Survey (NHANES) data spanning 2005–2010 and 2017–2018. Adolescents aged 6–19 years were initially considered. Exclusions were applied for incomplete data on hearing assessments, otoscopic examinations, tympanograms, or NHHR. Additional exclusions were made for abnormal otoscopic findings, poor-quality tympanogram results, or tympanograms showing a compliance of ≤ 0.3 mL. The final study cohort comprised 4,296 adolescents