CAUD8108 VIVA GUIDE - SAL PDF

The ICF model: ➔ Body Functions: Physiological aspects of hearing: hearing sensitivity and speech understanding ➔ Body Structures: The anatomical components involved in hearing: ear structures e.g., cochlea, auditory nerve ➔ Activities: Daily tasks affected by hearing loss, ➔ Par...

The ICF model: ➔ Body Functions: Physiological aspects of hearing: hearing sensitivity and speech understanding ➔ Body Structures: The anatomical components involved in hearing: ear structures e.g., cochlea, auditory nerve ➔ Activities: Daily tasks affected by hearing loss, ➔ Participation: impact on social and work participation Contextual factors: ➔ Environmental factors: availability of hearing aids or support services ➔ Personal factors: coping skills, social support that influence how hearing loss affects the individual’s life. Holistic assessment and treatment plan, emphasising both functional and participatory aspects of hearing loss, to improve quality of life. TUNING FORKS Tuning fork tests - Weber: ➔ Sensorineural HL = lateralized to better ear ➔ Conductive HL = lateralized to the poorer ear ➔ No significance between ear = midline ➔ Mixed hearing loss = results aren't as accurate - Rinne: ➔ Positive = AC>BC, normal and SNHL ➔ Negative = BC>AC, CHL (True), severe unilateral SNHL/bilateral CHL (false negative) PTA Interaural attenuation is the reduction of sound energy as it crosses from one ear to the other as sound energy leaks from the test ear to the non-test ear. - Headphones (40dB IA) because more sound can cross over to NTE, sounds over 40dB can be heard in the NTE 1  - Inserts (60dB IA) is deeper into the ear canal resulting in less sound leak to NTE - Beneficial for asymmetrical HL as it reduces the need for masking Overmasking occurs when you have a difference of the IA between the presentation sound and masking sound Cross-hearing occurs when the TE is benefiting from the NTE Central Masking - This is when the thresholds increase by 5db after masking - This is more common in AC because in BC masking when stimulating the cochlea by BC it reduces the interaction between the stimulus between both ears hence the threshold shift is smaller and more noticeable when compared to AC masking Occlusion effect may occur when masking for BC - This means we should re-establish BC threshold before we begin masking as the headphones may cause sound perception to change Nauntons Masking Dilemma - This is when it is impossible to mask - Usually occurs when there is a bilateral conductive moderate loss - All or many threshold move towards ‘no response’ Getting unmasked threshold may help to clarify the situation along with the case history and IA - Using inserts may allow for greater IA - Best to always note on the audiogram what is happening for clarity ➔ Ie; nauton’s masking dilemma or masked threshold could not be obtained Why would you not present a stimulus for too long or too short: ➔ Too long of a stimulus may lead to fatigue, habituation, or expectation bias ➔ Too short of a stimulus may cause the client to miss the stimulus or fail to respond accurately Descriptors - Sharply falling: 15-20dB increase per octave - Notched: 20dB or greater loss at one frequency with complete or near-complete recovery at adjacent octave frequencies Tympanometry 2  - Ya: uncompensated tympanogram (includes ECV) Ytm: compensated tympanogram starting at 0 (no ECV) Purpose/ Analysing Acoustic Immittance Results - Provides objective information on middle ear function and how well sound is able to pass through the middle ear by playing a stimulus identifying ECV, TPP and TP - Cross-check with other audiometric assessments - 226Hz is used to determine ECV as they are stiffness dominated the ME system at lower frequencies from 6 months+ of age - 1000Hz is used for children (0-6 months) as they are mass dominated at lower frequencies, hence a higher frequency probe tone of 1000Hz is used to assess ME system - No ECV is detected Adult Tympanometry Guideline (6 months +) Type A Type As Type Ad Type B Type C Normal Reduced Peak Increased Peak Flat Neg. Shifted ECV 0.6 - 2.5 cc 0.6 - 2.5 cc 0.6 - 2.5 cc Low: 0 - 0.5 0.6 - 2.5 cc High: > 2.5 Compliance 0.3 ml - 1.6 mmho < 0.2 mmho > 1.7 mmho N/A Classified as (admittance) shallow or deep TPP Between ± 100 Between ± 100 Between ± 100 N/A < - 100 daPa daPa daPa daPa Resonance 800-1200 Hz >1200Hz 2.5 Compliance 0.3 ml - 1.4 mmho < 0.2 mmho > 1.5 mmho N/A Classified as (admittance) shallow or deep TPP -150 - +100 daPa -150 - +100 daPa -150 - +100 daPa N/A > -150 daPa Multifrequency Tympanometry 1B1G Means a stiffness dominated middle ear system At 226Hz, the normal middle ear is stiffness dominated and will show a 1B1G pattern ➔ At higher frequencies, more complex patterns emerge (3B1G, 3B3G, 5B3G) ➔ Can be recorded at low probe frequencies in pathological middle ears such as those with otosclerosis 3B1G Obtained when probe tip is close to the middle ear common in eardrum pathologies such as monomeres and tympanosclerotic plaques 3B3G Probe tone frequency is above middle ear resonance 8% of normal men at high probe frequencies and in patients with eardrum pathology or ossicular discontinuity 4 5B3G Obtained with a mass dominated middle ear 5% of normal ears and in eardrum pathology and ossicular chain discontinuity Normative Results At low probe tone frequencies most common result would be 1B1G ➔ At higher frequencies, most common result would be 3B1G Normal ear progress through 1B1G-5B3G with increasing probe tone frequency ➔ Broad or laterally located notches may indicate a middle ear disorder Acoustic Reflexes Acoustic Reflex Pathway External ear → middle ear → inner ear → ventral cochlear nucleus (via vestibulocochlear nerve) → 3 pathways 1. Ipsilateral medial superior olive → contralateral facial motor neuron → contralateral stapes (via facial nerve) 2. Contralateral medial superior olive → contralateral facial motor neuron → contralateral stapes (via facial nerve) 3. Ipsilateral facial motor neuron → ipsilateral stapes (via facial nerve) - Test 500, 1 kHz, 2 kHz, 4 kHz ipsilateral and contralateral - Response - Normal= 75-100 dB - Normal hearing - SNHL up to 50 dB - Elevated = 100-120 dB - Mild Conductive Hearing Loss likely to result in elevated reflexes - SNHL from 50 dB up to 70-80 dB in the stimulated ear - Absent - Moderate and worse conductive hearing losses - Profound SNHL over 70-80 dB in the stimulated ear - Retrocochlear pathology - No Response 5  - VII Nerve (facial nerve - Bell's Palsy) involvement on the affected side - Type A tymps Contralateral Right: Sound in right ear, probe in left ear Contralateral Left: Sound in left ear, probe in right ear Ipsilateral: Sound and probe in same ear Probe ear effect - The presence of conductive pathology in the probe ear causing the acoustic reflex to be absent - The stapedius muscle may actually be contracting but the presence of middle ear pathology prevent us from registering any change in admittance - The presence of a reflex rules out otitis media or a perforation in the probe ear Stimulus ear effect - A conductive hearing loss in the stimulus ear causes the acoustic reflex threshold to be elevated by the amount of conductive hearing loss Reflex Decay: Normal results: - Nil/negative - No decay - No significance Abnormal results: - Positive - Decay - Significant Otoacoustic Emissions DPOAEs TEOAEs - Frequency-specific - Broad overview of cochlear function across a wide freq. range - Uses two continuous pure tones - Uses click, broadband stimuli - Used for detailed frequency-specific information - Used for general screening 6 - No OAEs can indicate a conductive pathology with OAEs - If TEOAEs are present, can infer hearing better only being present for SNHL up to 50dB than 30dB - DPOAEs are always present for neural & retrocochlear losses Purpose: To determine the integrity of OHC of the cochlear - NOT a hearing test and cannot estimate the type or degree of loss Used as a cross-check with PTA Present emissions at or above 6dB signal-to-noise ratio Report on - Noise levels - Stimulus levels and stability - Probe fit - Reproducibility - Response (SNR in dB) Present and normal - Emissions ≥6dB above noise floor - Wave reproducibility above 80% - SNR high at 75-80% of frequencies (or frequency bands) - Emission value > 0 (when norms are not available) - Emissions ≥6dB above noise floor - Present across 75-80% of frequencies Speech Audiometry Speech testing is used as a cross-check reference with PTA results to confirm diagnosis - Helps determine which ear to fit - Helps gauge an understanding if surgery is needed & effectiveness of surgical intervention Score interpretation: Speech Masking: PL: 3FA + 30/20/10 (FA = 500 + 1kHz + 2kHz / 3) Speech Masking Criteria: PL (NTE) - IA > AVG BC (NTE) Speech Masking Level: PL (TE) - IA + AVG ABG (NTE) + ESML * The ear needs a …dB minimum speech lvl Masking for the other ear 7  Overmasking: ML - IA ≥ AVG BC (TE) Rollover (retrocochlear): RI index (RI) - RI (PBmax - PBmin)/ PB max - Significant if > 0.45 Predicted scores - NH: 100% at 3FA + 30 and 50% at 3FA - CHL: 100% when made loud enough to overcome conductive loss ABR Fig 1: Norm ABR for Adults ABR waveform ABR is not a hearing test, rather a diagnostic tool useful for site of lesion testing the neural synchrony of the neurons and its ability to maintain precise reaction timing and responding synchronously to external stimuli. - This is used to determine if the auditory system is functioning adequately - ABR testing using insert earphones produces a known increase in latencies of 0.9ms How to read ABR - In adults, Wave I is smaller than Wave V. - Children have bigger Wave I and smaller Wave V - Only 1, 3 and 5 are visible in neonates Latency Norms for Adults Wave I (auditory nerve response): ~ 1.5ms Wave III (activity in the cochlear nucleus): ~ 3.5ms Wave V (activity in the lateral lemniscus and inferior colliculus): ~ 5.5ms Conductive Loss ABR Sensorineural Loss ABR Retrocochlear Loss ABR 8  - Changed in latency - Latency slightly shifted - Range of abnormal ABR Wave I: 2ms Wave I: ~1.7ms All Waves can be prolonged Wave V: 6ms Wave V: ~ 5.7ms Abnormal latency/morphology Interpeak latencies for Wave I-V: ~ 4ms Only early Waves (I & II) present conductive are normal and absent V/response - For retrocochlear pathology, expect that when hearing is symmetric, Wave V latency will be symmetric, otherwise this is a red flag for retrocochlear pathology and is considered suspicious (0.2ms - 0.3ms) /abnormal (> 0.4ms) Latency Norms for Paediatrics Wave I (auditory nerve response): ~ 1.7ms Wave III (activity in the cochlear nucleus): ~ 4ms Wave V: (activity in the cochlear nucleus): ~ 6.5ms Examples of interpreting ABR waveforms: With a further decrease in intensity, we can see that the latency of wave V has shifted even further to the right, presenting at 10 milliseconds. This demonstrates the expected latency shift as a function of decreasing intensity The latency of wave V shifts to the right (longer latency) for the 40 dB nHL intensity level at 8.5ms when compared to a higher intensity level of 60 dB nHL just before 8ms Middle-latency response (MLR) Middle-latency response (MLR) The response occurs later after the sound has been played than in ABR Controversial and difficult to record due to possible contamination by the post-auricular muscle response (overlapping response between the muscles response and neural response) - This is because the muscle can respond to the sound which overlaps with the neural response of the MLR 9  Not used very much clinically - If you see MLR you know the stimulus has travelled through the brainstem to the Inferior Colliculus and to the cortex (confirms sound transmission to higher brain centres) The Na peak (negative deflection) appears around 18 milliseconds. The Pa peak (positive deflection) follows around 25 milliseconds. Electrocochleography (ECochG) Measure electrical potentials (EP) generated within the cochlea in response to a sound. To diagnose site of lesion, threshold testing and to monitor cochlear/auditory nerve. Last resort is very uncomfortable. ➔ ANSD: Normal cochlear function but abnormal auditory nerve activity, present CM/SP with absent or abnormal CAP ➔ Meniere’s Disease: Abnormal Summating Potential (SP) to Action Potential (AP) ratios indicate fluid imbalance (endolymphatic fluid buildup) in the cochlea. ➔ Monitor the integrity of the auditory nerve and cochlear function during surgeries, such as vestibular schwannoma removal or cochlear implantation. ➔ Evaluate the function of the auditory nerve in patients with auditory neuropathy. Absent or Abnormal CAP: May indicate ANSD or damage to the auditory nerve. Enlarged SP: Can be a sign of Ménière's disease, or large SP/CAP ratio is Endolymphatic Hydrops Abnormal CM: May indicate OHC dysfunction Auditory Steady State Response (ASSR) - ASSR measures the brain's electrical responses to steady, modulated sounds to create an estimated audiogram. - This objective test is valuable for difficult to test populations for: Threshold estimation: fitting HA/CI Hl detection: CHL, SNHL or ANSD Referrals Middle Ear Pathology - 1st time: GP, retest 3 months - 2nd time: GP, retest 3 months 10  - 3rd time: ENT referral, retest after treatment - 1st time: but the child has a pre-existing SNHL - 1st time: but the HL is at the moderate range and the child has speech delays Other - Unilateral tinnitus may indicate vestibular schwannoma (tumour) - Client reports tinnitus has gone significantly worse. May indicate a tumour - Inconsistent results e.g., poorer speech than expected or unexpected absent reflexes. May indicate a tumour or retrocochlear - When you suspect pathologies for instance, cholesteatoma and otosclerosis for an appropriate diagnosis. SNHL - Infant with absent ABR and OAEs: ENT referral, Hearing Australia - 1st audiometry/behavioural test indicating SNHL: retest within 1-2 weeks - Test frequencies that you may have missed and conduct objective tests - If SNHL is still result, refer to ENT, Hearing Australia - Sudden SNHL, send to an ENT immediately AS PART OF MANAGEMENT, ALL CASES MUST mention listening and communication strategies, letter to GP/referral and letter to anyone else (themselves, school/daycare etc.) If asymmetry is present of 15dB or more between AC thresholds bilaterally, refer to ENT Hearing Aids When to use the aids and its features BTE RITE 1. Directional / Adaptive microphones 1. Directional / Adaptive microphones 2. Bluetooth 2. Bluetooth 3. Telecoil 3. Telecoil 4. Vent sizes 4. Vent size 5. Filter 5. Filter 11  6. Slim/Standard tubing 6. Wire 7. Power of the aid 7. Power of the aid Smaller receiver (RITE60) - for losses up to 70dB Medium receiver (RITE85) - ‘’ 90 dB Power receiver (RITE100) - ‘’ 110dB 8. Remote control 8. Remote control 9. Roger pen 9. Roger pen 10. Rechargeable option 10. Rechargeable option 11. FM/DM system reducing BGN 11. FM/DM system reducing BGN 12. Phone/TV streaming 12. Phone/TV streaming 13. Music feature 13. Music feature 14. Background noise reduction feature 14. Background noise reduction feature 15. Domes can only be fitted with slim tubing 15. Cosmetic 16. Moulds can be fitted with standard or 16. Open/close domes and moulds slim tubing It is best fitted on Paediatrics at all times due to It is best fitted on adults when they present with their constant ear canal changing & are more a mild to severe HL with a more discrete fit than a durable/secure and adults with any type of HL, BTE. HOWEVER, someone who has a lot of wax especially severe to profound HL and plays sports and sweats, a BTE is needed - Delivers higher amplification than RITE - High gain can be provided without - Is active/plays sports, BTE with a custom excessive feedback mould/sports lock can benefit from the - Reducing occlusion effect stability of BTE - Compare monaural and binaural hearing 1. Binaural summation (6dB) - the signal will match between the ears (boosts) 2. Sound localisation in the horizontal (azimuth plane) - ITD and LTD domains 3. Sounds segregation and separation - separate sources to make it easier to understand in background noise 12  4. Spatial release from masking - background noise becomes lowered (competing noise) 5. Binaural squelch - matching information, signal to noise ratio separates the target from the noise 6. Head shadow effect 7. Speech perception in noise - overall TROUBLESHOOTING No sound or sound is weak 1. Check the batteries 2. Ensure the sound outlet is wax free 3. Ensure the volume isn't all the way down 4. Check its not accidentally switched to telecoil program Feedback 1. Occlude the ear more 2. Run feedback manager (can show problematic frequencies)- Make sure feedback manager is on 3. Reduce gain 4. Adjust venting/ dome 5. Check canal for wax 6. Ensure device inserted properly My hearing aid sounds sharp and tinny 1. High frequencies uncomfortably loud 2. Reduce HF gain 3. Counsel - Client has spent a long time not hearing these sounds, needs time to readjust to hearing these sounds again 4. Hearing loss more severe at HFs Output graph - Loudest sound on the top (output is larger than when we and inputting a softer stimuli) 13  Real ear - insertion gain graph (response) Outer/Middle Ear Pathologies Pinna Malformations Occurs during embryological development 1. Grade 1: Microtia: ○ malformation of the pinna ○ Presence of ear canal 14  1. Grade 2: Atresia ○ Malformation of the pinna ○ Absence of ear canal 2. Grade 3: Anotia ○ Absence of pinna ○ Absence of ear canal * causes a conductive hearing loss Perichondritis - Perichondriths = inflammation of the pinna causing swelling and redness of the pinna due to low blood supply in the area Trauma can cause loss of blood supply and necrosis (cell tissue death) Common in immunocompromised, diabetes patients, untreated OE/ME infections spreading to the pinna, trauma to the pinna * causes a conductive hearing loss Cauliflower Ear Happens as blood accumulates in the pinna that can disrupt the blood supply due to trauma ○ May report difficulty hearing, tinnitus, vision changes, pain, and/or headache. ○ In Case Hx ask if trauma led to any severe pathologies (lost consciousness or neurologic symptoms) - should be treated ASAP by ED visit * causes a conductive hearing loss Otitis Externa: swimmer's ear Otitis Externa is the inflammation caused by a bacterial INFECTION in the external auditory meatus (EAM), although can extend to pinna or tragus - Occurs due to excessive moisture (surfers etc.) ○ When chronic, malignant otitis externa (MOE) which is a life threatening condition where the infection can spread to the temporal bone. * causes a conductive hearing loss Otitis Media (ME infection) 1. Acute Otitis Media (AOM) - inflammation of the mucous membrane of the ME Rapid onset associated with: ○ Redness of the TM ○ Pain ○ Fever ○ Potential bulging of the TM 15  2. Otitis Media with Effusion (OME) Serous fluid accumulation in the middle ear without signs of pain, redness, fever ○ Dull/opaque TM 3. Chronic Suppurative Otitis Media (CSOM) Chronic inflammation of the ME with a non-intact TM and persistent ear discharge ○ Typically lasting ≥ 6-12 weeks Increases risk for permanent hearing loss * causes a conductive hearing loss Exostoses: surfers ear Exostoses are bony growths in the canal due to either repeated exposure to cold water or cold wind Can cause ear infections as fluid is trapped between exostoses and TM and is often bilateral * causes a conductive hearing loss Mastoiditis Inflammation of mastoid ○ If left untreated can lead to meningitis (SNHL) ○ More common in children with symptoms of irritability, fussiness, fever, ear pulling/ear pain ○ Adults present with fever, headaches and ear pain * causes a conductive hearing loss if treated Tumours: benign (does not spread)/ malignant (spreads - serious) Osteoma is a benign growth Basal/squamous cells are cancerous (malignant) Perforation Perforation of TM due to trauma, infection (OM) or pressure changes Will usually heal within 4-12 weeks * causes a mild to moderate conductive hearing loss Tympanosclerosis Is the scarring that appears after a perforation heals with the TM appearing to have a bright white look * causes a mild to moderate conductive hearing loss 16 Otosclerosis Stiffening of the ossicles which is more common in pregnant women than men - genetic/hereditary Will likely present with tinnitus, dizziness, Schwartze’s Sign (TM red) and more unilateral ○ BC drops at 2kHz of up to 30dB, not present in all otosclerosis cases. ○ Management: Stapedectomy (after may appear with a type C) * causes conductive hearing loss Ossicular Chain Discontinuity Ossicles separated due to trauma and is typically managed by surgical intervention to resolve A-B gap. Tinnitus, vertigo, intact eardrum, CT scan will help confirm. * causes conductive hearing loss Cholesteatoma Abnormal skin growth trapped behind the ME space (TM, ossicles) Typically unilateral and has discharge with recurrent ME infections, dizziness/vertigo * causes conductive hearing loss Neoplastic Neoplasm = abnormal growth of cells (tumor) * causes both sensorineural and conductive hearing loss Pierre Robin Sequence Congenital, ME fluid due to cleft palate impairing the function of the eustachian tube ○ Recurrent ME infections and potential need for grommets * causes conductive hearing loss Stickler syndrome/connective dysplasia Genetic mutation disorder affecting the connective tissues impacting the inner ear ○ ME infections can occur due to conductive component - grommets needed ○ Hearing aids may be required * causes both sensorineural and conductive hearing loss or mixed hearing loss 17 Klippel-Feil Syndrome Congenital and can cause structural abnormalities in the ossicles of the middle ear and more ME infections Malformations can occur in inner ear such as the cochlea * causes both sensorineural and conductive hearing loss or mixed hearing loss Branchio-Oto-Renal Syndrome Genetic disorder affecting the formation of neck and ears ○ Ear canal abnormalities such as atresia can occur or ossicles and ET dysfunction ○ Cochlea or auditory nerve can be impacted * causes both sensorineural and conductive hearing loss or mixed hearing loss Hemifacial Microsomia/Goldenhar Syndrome/Oculo-Auricular-Vertebral Dysplasia (OAVs) Malformation of the ears and jaw ○ Associated with CHL but sometimes SNHL ○ Audiological management - surgery for ear malformations, hearing aid, CIs Cornelia de Lange Syndrome, Trimosies (down syndrome) and Kabuki Malformations in the structure of the ear * causes both sensorineural and conductive hearing loss or mixed hearing loss Crouzon’s Syndrome Is a genetic disorder that can affect both ME and Inner ear ○ Otitis media or ossicular and auditory nerve malformation can occur * causes both sensorineural and conductive hearing loss or mixed hearing loss Charge syndrome Many ear anomalies are associated with Charge Inner, middle and outer ear 85% of Charge have hearing loss Associated with chronic otitis media Inner Ear Pathologies Sensorineural hearing loss: - Sudden sensorineural hearing loss - Noise-induced hearing loss - Hearing loss related to ototoxicity 18  - Presbycusis Meniere’s disease Abnormality in the labyrinth causing fluid buildup ○ This causes vertigo, tinnitus, hearing loss and aural fullness in the ear * causes sensorineural hearing loss Acoustic Neuroma Non-cancerous tumours on the 8th nerve which impacts hearing and balance and causes headaches, swallowing difficulties and dizziness * causes sensorineural hearing loss Pendred Syndrome Occurs bilaterally, often progressive and begins in early childhood, can occur congenital ○ Vestibular dysfunction can occur * causes sensorineural hearing loss, hearing aids must be fitted (CI may be fitted if worsened HL) Mondini Malformation The cochlea fails to develop (less turns