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Presented by: Candice “Evie” Ortiz, AuD Conduction of Stimuli Air Conduction Signals are delivered through the outer, middle and inner ears Further processing in the CANS Bone Conduction Signal delivered to the mastoid bone ○ Bypasses the conductive mechanism Stimulates both cochlea simultaneously Masking Used to obtain accurate thresholds when cross-hearing is likely Asymmetrical hearing losses of ≥ 40dB or ≥60dB ○ Dependent on transducers Gaps of ≥ 15dB during BC Non-test ear is kept “busy” by the introduction of a masking noise Basics of the Audiogram Classification of Hearing Loss Picture Adapted from: Bess, F.H., Humes, L.E., Audiology: The fundamentals, 2003. Normal: -10 to 25 dB Mild: 26 to 40 dB Moderate: 41 to 55 dB Moderately-Severe: 56 to 70 dB Severe: 71 to 90 dB Profound: > 90 dB Common Audiometric Configurations Type of Hearing Loss Sensorineural (SNHL) No air-bone gaps ○ ≥15 dB gap between AC and BC thresholds Conductive (CHL) ≥15dB air-bone gap Consistent with middle ear pathology Maximum conductive component is 60dB Describing a Hearing Loss Degree, Configuration, Location, Type Examples ○ Mild to severe sloping SNHL No location implies that loss affects all frequecies ○ Severe high frequency SNHL ○ Moderate to mild rising low frequency CHL Describing Hearing Loss Essentially Mild Profound Normal Normal Mild to Moderate Describing Hearing Loss Turn to Handouts Familiar Sounds Audiogram Not Audible SAT, SRT, and WRS Speech Audiometry Speech Recognition Threshold (SRT) Adults Speech Awareness Threshold (SAT) Infants and Non-Verbal patients Useful in determining test reliability Malingering Does not understand task Reliability Determination PTA = 3 PTA = 35 Good SRT-PTA agreement Good SRT-PTA agreement PTA = 10 PTA = 35 Good SRT-PTA agreement Poor SRT-PTA agreement Clinical Application of Word Recognition Tests Determine site of lesion PB Rollover Surgery candidacy Hearing aid candidacy If poor WRS, may not be a good candidate Word Recognition Consideration Dx: Otosclerosis Tx: Stapedectomy Q: Which side? + Rollover Rollover Very Poor WRS May not be a good hearing aid candidate Consider CROS style or additional testing Tympanometry Graphic representation of ear compliance in relation to static pressure changes Normative Tympanometry Values Children Ages 3-5 years EAR CANAL VOLUME (cm3) COMPLIANCE (ml) MEAN 0.5 0.7 90% RANGE 0.4 to 1.0 0.2 to 0.9 Adults EAR CANAL VOLUME (cm3) COMPLIANCE (ml) MEAN 1.1 0.8 90% RANGE 0.6 to 1.5 0.3 to 1.4 Peak Pressure is typically WNL in the range of -150 to +25 daPA Compliance refers to mobility of tympanic membrane Margolis and Heller (1987) Tympanometric Configurations: Middle Ear Pathology Tympanometric Configurations: Middle Ear Pathology Type A Type As Normal or Hypomobility Otosclerosis Tympanometric Configurations: Middle Ear Pathology Type C Negative pressure Eustachian Tube dysfunction Developing otitis media TM retraction Tympanometric Configurations: Middle Ear Pathology Type Ad Hypermobile Aging Atrophic scars Healed perforation Ossicular discontinuity Tympanometric Configurations: Middle Ear Pathology Type B Flat Perforated TM ECV = 7.0 Patent PE tube Tympanometric Configurations: Middle Ear Pathology Type B Flat Middle ear fluid ECV = 1.0 Serous Otitis Blocked PE tube Tympanometric Configurations: Middle Ear Pathology Type B ECV = 0.2 Flat Impacted cerumen Tympanometric Configurations: Middle Ear Pathology Type B? Type As? Middle ear fluid ART and AR Decay Acoustic Reflexes Acoustic reflex threshold (ART): Lowest level at which an AR can be obtained Most sensitive to middle ear pathology Normative Values ○ Present for SNHL up to 50 dB ○ WNL from 70 to 100 dB ○ Elevated responses (≥100 dB) for thresholds < 50 dB Stapedial Reflex Arc Presentation of an intense sound elicits a contraction of the stapedius muscle Changes the ear’s immittance “Probe Right” Acoustic Reflexes Probe Stimulus (ipsi) Stimulus (contra) Common Acoustic Reflex Patterns ART Patterns: Unilateral CHL CHL, AD WNL, AS ART Patterns: VIII CN or CPA outside of brainstem Mild high frequency SNHL, AD WNL, AS ART Patterns: Lesions within brainstem which involve reflex pathways Mild high frequency SNHL, AU ART Patterns: Facial Nerve Lesion WNL, AU Absent probe right Lesion proximal to stapedius nerve Verticle segment of facial nerve ART Patterns: Cochlear Impairment Acoustic Reflex Decay Retrocochlear Test Measure of ability to maintain reflex contraction during a continuous stimulation Positive Result Response decays to ≥ ½ its original magnitude Techniques, Age-Appropriate Results, Management Testing Techniques: Newborns and Infants Otoacoustic Emissions (OAE) Measures pre-neural signals produced by outer hair cells Objective measure Quick and easy Non-invasive Sensitive to: ○ Presence of hearing loss ○ Problems affecting integrity of cochlea Auditory Brainstem Response (ABR) If baby does not pass OAE Testing Techniques: Behavioral Observation Audiometry (BOA) 3 months through 6 months Parents hold infant Observe natural response to sounds ○ e.g., eye widening or eye shifts No reinforcement needed (Developmental) Age Appropriate Response Levels TONES (dB) SPEECH (dB) 0 TO 6 WKS 75 50 6 WKS TO 4 MOS 70 45 4 TO 7 MOS 50 20 7 TO 9 MOS 45 15 9 TO 13 MOS 35 10 As age increases, responses to softer sounds increase Generally more responsive to speech than tones and narrow band noise Testing Techniques: Visual Reinforcement Audiometry (VRA) Age: 6 mos – 3 yrs (developmental) Teach a child to turn their heads in response to sound, by reinforcing the act with visual stimuli Requires head control and good vision Can be performed with all transducers Testing Techniques: Visual Reinforcement Audiometry Patient on lap Focus held ahead by a distracting assistant When sound is heard, child turns toward speaker Action rewarded by an animated, visual reinforcer VRA Video VRA In Action Testing Techniques: Conditioned Play Audiometry Age: 3 – 4 yrs Child reacts in “game” fashion when a sound is heard Requires active listening Longitudinal Case Study Child diagnosed with Trisomy 21 Failed Newborn Infant Hearing Screen No show at 1 month ABR appointment Audiogram: 3 Months Old Impacted cerumen removed prior Tymps were WNL Tolerated headphones but not BC Hearing Loss?? Age Appropriate Response Levels TONES (dB) 0 TO 6 WKS SPEECH (dB) 75 50 6 WKS TO 4 MOS 70 45 4 TO 7 MOS 50 20 7 TO 9 MOS 45 15 9 TO 13 MOS 35 10 Probably not Monitor closely due to risk factors Every 3 months ME pathologies Impacted cerumen due to ear canal size Audiogram: 10 Months Old Developmental Age: 6 mos More difficult to test More active Won’t tolerate headphones Responding with eye shifts only Audiogram: 18 Months Old Will not tolerate headphones Audiogram: 6 Years Old Play is usually used at 3-4 yr of age Cerumenectomy 1 wk prior Every 6 months, prior to audio evaluation. Necessary maintenance for managing his chronic ME pathology. And for maintaining good hearing. Audiogram: 9 Years Old Audiogram: 10 Years Old No cerumenectomy prior Impaction AD Unable to rule out ME pathology Pediatric Goals Verify and/or enable access to speech sounds in order to promote speech and language development