APD/Tinnitus & Hyperacusis/TBI Flashcards
Define a TBI
An insult to the brain caused by an external physical force
What are the 2 major types of TBI?
- ) Open (penetrating) TBI
2. ) Closed TBI
What is an open (penetrating) TBI?
A TBI caused by a skull fracture or an object entering the skull (such as a bullet).
What is a closed TBI?
A TBI caused by a force on the skull not resulting in a broken, fractured, or penetrated skull.
How can TBIs be classified? What is the distinction between these classes?
Mild, moderate, severe
Alteration of consciousness, Loss of consciousness, post traumatic amnesia
What are the symptoms associated with a mild TBI?
- Normal imaging
- Tinnitus
- Dizziness
- Sound sensitivity
- Hearing loss
For a patient with sound sensitivity, intrusive tinnitus, and a history of a mild TBI (concussion), what tests besides an audiogram should be conducted?
- Tinnitus and hyperacusis evaluation
- APD evaluation–> trauma from accident may have resulted in injury to patient’s auditory cortex not present on imaging
- Speech-in-noise test such as QuickSIN (Duncan & Aarts, 2006)
- Acoustic reflex thresholds–> important to evaluate lower brainstem function
- ABR–> sensitive to central auditory legions of the brainstem
- MLR
- P300
What does the tinnitus and hyperacusis evaluation consist of?
- Audiogram including ultra-high frequency testing
- DPOAEs
- Tinnitus pitch matching
- Tinnitus loudness matching
- Loudness discomfort levels
- Minimal masking level
- Questionnaire such as the Tinnitus and Hearing Survey (THS)
What is the purpose of OAEs in the tinnitus and hyperacusis evaluation?
- Assesses OHC function
- Cochlear dysfunction present on DPOAE testing may indicate why patient is experiencing tinnitus
What is the tinnitus and hearing survey (THS)?
Measures how much of a problem on scale of 0-5 tinnitus, hearing, and sound sensitivity have been in last week
True or False: The THS is a reliable questionnaire to use
True
Henry et al., 2015
What results would be expected on tinnitus and hyperacusis evaluation?
- Would expect reduced loudness discomfort levels if the patient has hyperacusis
- Reduced DPOAE amplitude
Why is the central auditory nervous system important?
- Pitch identification
- Sound processing in noise
- Binaural processing including localization and auditory scene analysis
What is APD?
ASHA, 1996
A complex disorder with difficulties in processing information by the central nervous system.
What difficulties does someone with APD have?
- Sound localization and lateralization
- Auditory discrimination
- Auditory pattern recognition
- Temporal aspects of audition such as gap detection
- Auditory performance in competing signals
- Auditory performance with degraded signals
What are some common symptoms of APD?
- Difficulty understanding speech in background noise or in reverberation
- Localization difficulties
- Difficulty following rapid speech
- Difficulty following directions
- Difficulty with music perception
- A tendency to be easily distracted
- Academic difficulties including reading, spelling and/or learning problems
When designing an APD test battery, what considerations should be made?
1) Age-appropriate tests
2) individualized
3) inclusion of tests with variety of stimuli and test procedures
4) Should provide the most info in the shortest amount of time
For this patient, what tests should be included in the APD battery?
1) Dichotic digits test
2) Random gap detection test
3) Duration pattern sequence test
4) Low redundancy speech test
5) Masking level difference test (MLD)
What does the dichotic listening test evaluate?
Binaural integration and separation
What is the dichotic listening test sensitive to?
Lesions of the brainstem, cortex, and corpus callosum
Describe the dichotic digits test?
Patient hears a number pair in each ear and is asked to repeat everything heard (binaural integration) or direct their attention to one ear and repeat what is heard only in that ear (binaural separation).
Can also be completed using sentences instead of numbers, increasing the difficulty
What does the random gap detection test assess?
Temporal resolution
Describe the random gap detection test
Clicks and brief tones of octave frequencies from 250-4000 Hz are presented in pairs and the silent interval between each pair randomly increases and decreases in duration from 0-40 ms.
The patient is required to indicate whether they hear one stimulus or two and the gap detection threshold is defined as the smallest interval at which they consistently identify two stimuli.
What does the duration pattern sequence test assess?
Temporal sequencing
Describe the duration pattern sequence test.
Short (250 ms) and long (500 ms) tone bursts at 1000 Hz with a 300 ms intertone interval are presented in sequences of three tone patterns.
The patient is asked to repeat the pattern that they hear by stating whether the duration of the stones were long or short (i.e. long short short).
What does the low redundancy speech test assess?
Auditory closure or the ability to fill in the missing or distorted portions of the signal.
Describe the low-pass filtered NU-6 word test
Auditec has recordings of the NU-6 words that have been low-pass filtered at 4 different frequencies (500, 750, 1000, and 1500 Hz) available.
The 1000 Hz cutoff is recommended for clinical use (Wilson & Mueller, 1984).
Same as traditional word recognition testing, however the stimuli are filtered.
What does the masking level difference (MLD) test assess?
Auditory scene analysis and binaural interaction
Describe the masking level difference test
This test is completed using a 500 Hz tone and a narrow band masker centered around 500 Hz.
The target signal is presented with noise to both ears simultaneously and tests 2 conditions.
The first is when the signal and the noise are in phase with one another, and the second is when the signal and noise are out of phase with each other.
If the signal and noise are out of phase with each other, then there is a spatial release from masking and the patient is able to hear the signal better.
A threshold is obtained in a manner similar to that used for Bekesy audiometry in both conditions and the difference between the two thresholds is the MLD.
What is the MLR?
Auditory evoked potential using a click or tone burst that is sensitive to lesions of the auditory cortex and thalamocortical connections.
When there is damage to the auditory cortex, the MLR amplitude is reduced
When there are lesions elsewhere in the auditory cortex, the amplitude is preserved
What do the MLR and ABR together provide information about?
brainstem and thalamocortical regions
What is the P300?
An auditory late potential that is an index of:
1) Gross discrimination 2) Sequential informational processing 3) short-term memory
Oddball paradigm–> Patient asked to pick out stimulus that doesn’t belong in string of presented stimuli
What happens to the P300 with APD patients?
Increased P300 latency
What modifications should be made for this patient with testing?
- Tonal tests might be affected by patient’s tinnitus
- If patient has sound sensitivity, level at which testing is completed may need to be adjusted
- Provide breaks to avoid fatigue
- Complete testing in multiple sessions/days
What are the management options for APD?
1) manage tinnitus and sound sensitivity through TRT since it is his primary concern
2) auditory training to address deficit(s) as identified on APD testing
3) mild gain hearing aids may be beneficial for speech understanding improvements
4) assistive listening devices to reduce SNR
What are the 5 stages of TRT as described by Jasterboff & Jasterboff (2000)?
- Triage to determine appropriate referrals
- audiological evaluation to assess tinnitus and hyperacusis
- group education about causes and management options
- Interdisciplinary eval of tinnitus
- Individual management of tinnitus
