Download Hearing Assessment

Introduction to Audiological
Assessment
Lecture
2009
Topics
• Introduction to hearing assessment
• Referral source
• Case history
• Otoscopic examination
• Types of audiological assessments
What is the main purpose of Hearing Evaluation ?
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Define the nature & extent of a hearing problem
• First step of the process:
 To start the medical intervention
 To find out the communication difficulties
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Why the patient is here today for an assessment?
 Two important sources of information:
 Referral source
 Case history
Referral Source
• Sources:
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Self
Physicians
Teachers
Spouse
Children
Other medical specialists (i.e. SLP)
Lawyers
Nurses
How to obtain information about your client ?
1)
Referral source information
2)
Case History
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A guide
Helps to formulate a plan for testing
Provides clues to factors that contribute to hearing impairment
Differs depending on cases load
(infants/pediatrics/adults/geriatrics, or by specialty such as
cochlear implant, auditory processing disorders (APD), etc.)
1. Referral Source Information
• Family physician
• Medical specialist (i.e. ENT)
• Other health care providers
• Educational sources
• Self-referrals
Components of Referral information
• Identifying information (name, address, DOB, phone/email)
• Diagnosis (if available)
• Client’s compliant
How do you collect info for your case history?
A.
Hospital chart
B.
Observation
C.
Pre-assessment questionnaire
D.
Interview
Case History
A. Hospital Chart
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Includes:
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History
Doctor’s order
Nurse’s notes
Doctor’s progress notes
X-ray
Lab pathology
Consults
Allied health professionals
B. Observation
• Verbal information “The most important thing in communication is to
hear what is being said !”
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Non-verbal information
Eye contact
Facial expression
Intonation
Body posture
Gesture
C. Pre-assessment Questionnaire
• Usually sent out to the client when referral is received
• In most places, the first thing the client will be asked to do when
he/she arrives for his/her appointment
• Audiologist should review the information before he/she see the
client
• Double check the info with the client
• Advantage: saves time
D. The Interview
• Could be carried out with the pre-assessment questionnaire
• Sometimes only the interview will be done without the preassessment
• i.e. (acute care hospital sites, sites where support staff is not
available)
• Medical Model (direct, highly specific and briefly stated questions);
Provides the maximum amount of info in he minimum amount of
time
Interview Format
1. Reason for referral/ reason for visit
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Sometimes major compliant is known from the referral source
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Ask a preliminary questions to discover the client’s “chief compliant”
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Remember to record it exactly as stated by the client
Interview Format
2. History of the problem:
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Onset of problem / How long?
Who first noted?
Problem in one ear or both? If both, which is the better ear?
Associated pain?
Tinnitus, one ear? Both ears?
Previous diagnosis and treatment, when and where?
Family history of problem
Dizziness and vertigo
Course of problem
History of occupational or environmental noise exposure
Estimate of severity “how much of a problem”
Results of previous audiological evaluation (when and where ?)
Interview Format
3. Medical history:
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Current major illnesses
Childhood illnesses
Head injuries
Exposure to ototoxic drugs
Current medications
Allergies
Ear infections
Operations
Interview Format
4. Social history
 Work environment
 Leisure environment
5. If your client is a child, include the following
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Birth history
Developmental history (developmental milestones)
Speech and language development history
Previous speech and language assessment (When and results)
Educational history (regular or special school, learning environment,
learning difficulties)
The Interview Skills
 Set the tone (introduction – comfort check)
 Privacy
 What you are about to do
 What the client will be expected to do
 Emphasis on confidentiality
 Must establish an atmosphere of mutual RESPECT
Interview Skills
Learn To Listen
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Become familiar with questions
Understand the sequence of questions
Watch how questions relate to other questions
Frame Questions Clearly
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State questions briefly and simply
Medical model (direct, highly specific and briefly stated questions)
Don’t forget to use common terminology
Interview Skills
Avoid Yes/No Questions
• Open-ended questions provide more information
• (i.e. Does Ahmad has allergy? Tell me about Ahmad General
Health?)
Interview Skills
AVOID LEADING QUESTIONS
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Leading questions inhabit freedom of responses (i.e. “ You never use Q-tips
in your ears, do you?”)
Avoid putting answers in client’s mouth
Provide a rating scale
PROVIDE TRANSITIONS IN QUESTIONS
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Avoid abrupt changes in questions
Return to topic if the client goes off track
Follow lines of questionings that produce relevant info
Interview Skills
AVOID TALKING TOO MUCH
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Helps the client feel free to talk
It is not necessary to “fill-up” silences
The client should usually be doing more talking than you
Give the client time to answer
Use verbal encourages (i.e. “I see”, “OK”)
ATTEMPT TO PROBE BENEATH ANSWERS
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Client may need assistance
Summarize; rephrase
Interview Skills
HANDEL EMOTIONAL SCENES TACTFULLY
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Be prepared, you never know how someone may react (anger, guilt, fear)
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Emphasize
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Don’t say “ I know how you feel” unless you explain that your self or your
relative has the same problem
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Don’t make client fell uncomfortable or embarrassed if he/she cries
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One of the aims of the interview is to establish rapport with the patient
before examination started
Interview Skills
Record Your Information
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If the interview is long, you may wish to record/video
Obtain permission for taping
Be Prepared For Questions
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Know why you are asking each question
Don’t say “ I am just asking !” or “ I am just a student, and I should ask this
question” or “I don’t know why I am asking this question !!”
If you are unsure about something, admit it.
Interview Skills
Bring The Interview To A Close
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Explain what will happen next
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Ask if client has any questions
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Express appreciation for the info provided
Otoscopy
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The evaluation of the external auditory canal and tympanic membrane with
a device called an “Otoscope”
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Purpose of Otoscopy: to inspect the Outer ear (OE), external auditory canal
and (EAC) & Tympanic Membrane (TM)
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An important prerequisite to the hearing evaluation
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Types:
Hand-held otoscopy
Pneumatic otoscopy
Video otoscopy
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Hand-held Otoscopy
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Traditional otoscope
Components:
Head
Power handle (battery
compartment)
 Ear specula
 Fiber optic producing light
 The TM & EAC are only
viewed by the examiner
Pneumatic Otoscopy
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A regular hand-held otoscope
with a rubber bulb attached to
it
It allows the examiner to send
a small puff of air into the ear.
This changes the pressure
inside then the examiner can
watch how the eardrum
responds to pressure
The TM & EAC are only
viewed by the examiner
Video Otoscopy
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Otoscope
Separate light source
Fiberoptic cable
Video camera
Color mointor
 TM is viewed through the video
monitor
 Pt. and other interested people
can watch as well
 Possibility of videotaping and
photography for documentation
The Interview Skills
 Set the tone (introduction – comfort check)
 Privacy
 What you are about to do
 What the client will be expected to do
 Emphasis on confidentiality
 Must establish an atmosphere of mutual RESPECT
Interview Skills
Learn To Listen
•
•
•
Become familiar with questions
Understand the sequence of questions
Watch how questions relate to other questions
Frame Questions Clearly
•
•
•
State questions briefly and simply
Medical model (direct, highly specific and briefly stated questions)
Don’t forget to use common terminology
Interview Skills
Avoid Yes/No Questions
• Open-ended questions provide more information
• (i.e. Does Ahmad has allergy? Tell me about Ahmad General
Health?)
Interview Skills
AVOID LEADING QUESTIONS
•
•
•
Leading questions inhabit freedom of responses (i.e. “ You never use Q-tips
in your ears, do you?”)
Avoid putting answers in client’s mouth
Provide a rating scale
PROVIDE TRANSITIONS IN QUESTIONS
•
•
•
Avoid abrupt changes in questions
Return to topic if the client goes off track
Follow lines of questionings that produce relevant info
Interview Skills
AVOID TALKING TOO MUCH
•
•
•
•
•
Helps the client feel free to talk
It is not necessary to “fill-up” silences
The client should usually be doing more talking than you
Give the client time to answer
Use verbal encourages (i.e. “I see”, “OK”)
ATTEMPT TO PROBE BENEATH ANSWERS
•
•
Client may need assistance
Summarize; rephrase
Interview Skills
HANDEL EMOTIONAL SCENES TACTFULLY
•
Be prepared, you never know how someone may react (anger, guilt, fear)
•
Emphasize
•
Don’t say “ I know how you feel” unless you explain that your self or your
relative has the same problem
•
Don’t make client fell uncomfortable or embarrassed if he/she cries
•
One of the aims of the interview is to establish rapport with the patient
before examination started
Interview Skills
Record Your Information
•
•
If the interview is long, you may wish to record/video
Obtain permission for taping
Be Prepared For Questions
•
•
•
Know why you are asking each question
Don’t say “ I am just asking !” or “ I am just a student, and I should ask this
question” or “I don’t know why I am asking this question !!”
If you are unsure about something, admit it.
Interview Skills
Bring The Interview To A Close
•
Explain what will happen next
•
Ask if client has any questions
•
Express appreciation for the info provided
Hand-held Otoscopy
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Procedure:
 We need to direct the light into the TM
 Adults are examined from below the head - pinna is pulled up and back to
better straighten the canal for a more direct view of the TM
 Infants and young children are examined from above the head - pinna is
pulled down and back for, why? (canal is angled downward rather than
upward and is at a more acute angle)
 The examiner fingers should brace the head to prevent injury to the ear
canal if the pt. should suddenly move
 Pressing the pinna against the head while looking into the ear canal will
reveal any potential for ear canal collapse during testing with supra-aural
earphones
What do we see from an Otoscope ?
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Landmarks:
 The EAC
 Tympanic Membrane (Pars Tensa & Pars Flaccida)
 Cone of light (result of light reflection from the TM directed inferiorly and
anteriorly)
 Umbo (the point of greatest retraction (inward pulling of the TME to the ME)
caused by the tip of the handle of Malleus
 Some of ME structures (i.e. Incus, manubrium)
What can we detect from Otoscopy ?
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Get an idea of the size and shape of the EAC (important to select the appropriate ear
tip required for testing)
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Abnormalities detected:
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Small, missing or malformed auricle
Atresia (absence of EAC)
Stenosis (narrowing of EAC)
Collapsed EAC (blocking of EAC opening due to the pressure of supra-aural
earphone cushions on the auricle)
Inflammation (otitis extena, otitis media)
Ear discharge / runny ears
Growths
Foreign bodies (cotton pieces, insects, food…etc.)
Excessive cerumen
TM abnormality (perforation, thickening “ Tympanosclerosis”
Ventilation tubes/Grommets in TM or falling in the ear canal
Trauma
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Results of Otoscopy
• If any abnormality is found, the pt. should be referred for medical
evaluation & management:
 Excessive cerumen ……… referred for GP or ENT for cerumen
removal (unless the audiologist is trained for cerumen management)
 Ear discharge, TM perforation, Otitis media, Otitis Externa,
growths…etc. ………..referred for medical evaluation and treatment
 Grommets………..referred for ENT for follow-up
Medical management should precede audiological
assessment in the following cases
 if wax is blocking the EAC (usually if we can’t view the TM, the wax should
be removed before testing, otherwise wax accumulation can affect test
results)
 If the ear has discharge or its inflamed, the ear should be treated and get
dry before the hearing test
 Foreign bodies should be taken out before assessment
 If the patient is experiencing ear ache, the audiological assessment should
not be performed
BUT…we can still perform audiological assessment with
the existence of the following abnormalities
 Dry TM perforation
 Outer ear OR Middle ear abnormal growth
 Grommets in TM or EAC
 Trauma
 Collapsing EAC (Canal can be opened by replacing the supra-aural
earphones with insert earphones)
Audiological Assessment
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Types of Audiological Assessments:
1)
Screening
2)
Basic/Routine/Regular
3)
Diagnostic
Audiological Screening
• Usually Known As (UKA): Hearing Screening
• For who?
 Neonates after birth in the hospital before or shortly after they get
discharged to rule out the presence of hearing loss (Neonatal
Hearing Screening “NHS”) – ideally for all the newborns (universal
hearing screening) – but still done in many hospitals only for babies
who fulfill the criteria for HRR “High Risk Register”
 Adults as part of pre-employment medical check-up to assure the
candidacy for getting a job
 School-age children before their admission to school as part of the
pre-school admission medical check-up
Audiological Screening
• The available Audiological Screening tests:
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Air conduction pure tone audiometry (adults & school-age children)
Air conduction pure tone play audiometry (pre-school children)
Automated Auditory Brainstem Response (ABR) – (neonates)
Evoked Oto-acoustic Emissions (EOAEs) – (all age groups)
Middle ear immittance (Tympanometry and Acoustic Reflexes) – (All
age groups)
Audiological Screening
• Results are interpreted on the basis of Pass/Fail criteria:
 Pass: means no audiological follow-up required
 Fail: means audiolgical follow-up required
• Fast and quick procedure
• We don’t diagnose hearing loss type or degree from screening
results
Basic Audiological Assessment
• UKA: routine or regular
• Used to asses or monitor the status of the peripheral auditory
system (Outer ear (OE), middle ear (ME) and inner ear (IE))
• Done for both adults and pediatric patients
• Takes more time than screening procedures
• We can diagnose hearing loss (type & degree)
Basic Audiological Assessment
• Available procedures:
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Audiological case history
Pure Tone Audiometry PTA (Air conduction and Bone conduction):
foundation of basic audiological assessment
Speech Audiometry (Speech Recognition Score (SRT))
Middle ear Immittance measures (Tympanometry & acoustic
reflexes)
EOAEs
Threshold Estimation ABR (Auditory Brainstem Response)
• Case history and basic audiological assessment results will either:
 recommend further testing (refer for diagnostic assessment)
 Or offer management options (i.e. HA use)
Diagnostic Audiological Assessment
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UKA: site of lesion testing because it helps sometimes to locate the site of
impairment (i.e. peripheral, central, cochlear, retrocochlear)
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Results leads to more specified diagnosis
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Done for both adults and pediatric patients
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Advanced & sophisticated assessment procedures
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Usually will be recommended based on the results of basic assessments
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Usually includes basic audiological assessment procedures plus other
procedures
Diagnostic Audiological Assessment
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Components:
 Pure Tone Audiometry PTA (Air conduction and Bone conduction)
 Speech Audiometry (Word Discrimination Score (WDS))
 Behavioral site of lesion tests (SISI, ABLB, Tone Decay)
 Objective site of lesion tests (Acoustic Reflex Threshold (ART), Reflex
Decay, EOAEs, Diagnostic ABR)
 CAPD (central auditory processing disorder) tests
Audiology I – (RHS 371)
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Introduction to hearing assessment
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Referral source
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Case history
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Otoscopic examination
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Tuning Fork Tests
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Pure Tone Audiometry (Air conduction)
Pure Tone Audiometry (Bone conduction)
Clinical Masking
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Introduction to Speech Audiometry
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Audiology I
• Theoretical information:
 Basic Physics of Sound & the Decibel Scale
 Types of Hearing Loss
 Basic Pathologies of The Auditory System