final exam new info Flashcards
what is the clinical value of acoustic immittance
objective measure of TM mobility, measures middle ear pressure, identifies TM perforations, differentiates ME fixation from ossicular disarticulation, aids in the differential diagnosis of conductive HL, validates functional HL and provides objective inference of hearing sensitivity/pathology
process of acoustic immittance
muscle contracts, stiffens bones, pulls TM and some of the energy coming in will bounce back and won’t go in
what are some ways to promote the child’s cooperation during immittance testing
animated toys, hand puppets, pendulum, mirror, sticky tape, cotton ball or tissues
-children that are older than 3, generally will not need special distractions
compensated vs. not compensated tympanograms
compensated: the tymp begins at 0 admittance on the y ; removes the volume and the effect of the ear canal from the whole value
non compensated: the tymp begins above the 0 admittance on the y
how can we make a tymp compensated
we need to get the tails at the 0 line, so we can subtract the difference to ensure all correct values are mesaured
tymapnometric peak pressure (TPP)
provides indirect estimate of the air pressure in the ME space at which energy flows best into the conductive mechanism
-pay attention to if this is compensated or not
tympanometric width (TW)
halfway up the graph and then the distance between the peaks
-the wider it is, the more correlated it becomes with the potential of a ME pathology
ear canal volume
estimation of the volume that exists between the probe tip and the TM
-can be used to monitor the courser of ME disease after the placement of tubes
usage of 226 Hz tymp and how it correlates to infants
226 Hz is because it is sensitive to the stiffness dominated middle ear however with infants, their middle ear system is mass dominated
-therefore it is not suggested to infants
limitations of 226 Hz tymp in infants
low sensitivity to the presence of MEE, flat tymps are observed in some neonates with normal MEE, normal tymps were obtained in infants with diagnosed MEE and a notched 226 tymps in infants with confirmed OME
-low sensitivity to middle ear pathologies
226 Hz tymps are poor for infants under ___ months
6
anatomical differences between infants and adults
compliant EAC, small ear canal, horizontal orientation of the tympanic membrane, underosssified ossicular chain, small ME space, ET is more horizontal and shorter
how are immittance measurements altered within infants
the 226 Hz tymp may not provide accurate immittance results for children less than 6 to 9 months as this will result in lower static admittance, broader tympanometric width and appearance of notching at low frequencies
infant middle ear is a ____ dominated system with a ________ resonant frequency
mass ; higher
adult middle ear is a ______ dominated system with a ________ resonant frequency
stiffness ; lower
advantages of using 1000 Hz tymps in infants
is a more sensitive measure to changes within the ME status
-tend to be either a single peak or flat
-we are mainly looking to see if there is that single peak which means it is normal and without a peak it is abnormal
a _______________ during the first week after birth and is indicated when acoustic admittance decreased towards 0 mmho
collapsed canal
for infants (birth to around 6-9 months), explain the overview of the tymps
226 Hz is good for ear canal volume, 1000 Hz is good for the shape of the tymp BUT with wideband it is efficient to get both at the same time
why is there needing to be used caution when assessing ARTs at a higher level in infants
threshold shift is at a higher risk in infants due to smaller canal volumes than in adults and there is at least a 10 dB increase than what is delivered into an adult ear
-would not want to exceed 100 dB for infants
advantages of using WB tympanometry in pediatric populations
gives a broad frequency range, more sensitive/specific, less affected by ear canal volume/probe position, measured at ambient pressure, the air tight seal in not required
list some factors that affect OAE recording success
probe fit, conductive elements, restlessness and loud environment
what are OAEs used for within a pediatric assessment
NBHS, school screening, site of lesion testing, monitoring ototixc drugs on cochlear functions, estimates hearing sensitivity within a limited range and can be used as a cross check principal
benefits of recording both TEOAEs and DPOAEs
they do not provide the same information and therefore they may target different cochlear mechanisms
-by including both types it can provide a more comprehensive assessment of cochlear health and HL
how can a middle ear pathology effect OAEs
-OM or negative pressure can disrupt sound transmission to/from the cochlea, altering the OAE measurement
-severe OM can affect mobility of the TM and OAEs are likely to be absent
-negative pressure reduced OAE levels but does not eliminate them always unless there is a mild SNHL
advantages of OAEs
evaluate OHC function, quick/objective, ear specific, frequency specific, can predict future HL and not booth is required
limitations of OAEs
susceptible to noise, site specific, cannot quantify the degree of HL and cannot rule out minimal/mild HL
explain the challenges of conducting audiological evaluations in children with special needs
children may have problems with speech, responding to sound or understanding the task, may have a longer time to focus, longer latency time, may need to consider other responses, may fatigue quicker and there may be unexpected reactions
modifications needed for children with severe to profound loss
may take longer to respond to conditioning
-since they are visually alert, make sure there are no visual cues
-begin with low frequency stimuli
-if not responding to auditory stimulus, use a tactile stimulus
modifications needed for developmental delayed children
positioning, timing of test stimulus presentations and response reliability and interpretation
modifications needed for intellectual delayed children
the important factor is that we need to use a technique that will bridge the difference between the chronologic and developmental age of individuals
-VRA is an effective test!
-can use tactile conditioning procedure
-demonstrate the task
-include control trials
-monitor ME status
modifications needed for physical disabilitied children
child should be positioned to keep upper body steady and allowing for a head turn or the use of arms
-CPA can be used is toy that is selected is easy to manipulate
-hand raising or nod for older children can be accepted
-limit the speech to closed set
modifications needed for children with autism spectrum disorder
seat the child in a position that does not permit walking away, minimize physical contact, identify cognitive age prior to test protocol, avoid speech stimuli, presented stimuli at low levels and increase gradually, use loud stimulus for children who ignore the sound, behavioral testing that is appropriate for cognitive level, weighted blanket
modifications needed for children with ADHD
may take longer than expected, seat child in a high chair or at a table, reinstruct more often, change toys frequently, take small breaks, weighted blanket, visual schedule
modifications needed for children with a visual impairment
let the patient explore the test environment, allow the patient to examine the equipment, move reinforcer closer to the patient, if the child does not have sufficient vision to see bright light you can pair the stimulus with vibrotactile
modifications needed for pediatric nonorganic HL
reinstruct the child and if still not successful, use a portable audiometer and have the child seated next to you so that you can make eye contact
-if still not successful, have the child count the beeps or use a yes/no response
what is the purpose of a screening
identifying individuals at risk for specific disorders
-separating those with a high or low probability of a disease or disorder
prevalence
total number of cases within a time period
-proportion of the population that has the condition at a point in time
incidence
total number of new cases
-fraction of the population at risk of developing the disease or condition
equation for sensitivity
(true positive / true positives + false negatives) x 100
equation for specificity
(true negative / true negative + false positive) x 100
1-3-6 principle
1 month : children should be screened
3 month : receive comprehensive evaluation
6 month : receive appropriate intervention
why is there a push to move to a 1-2-3 principle
earliest age of identification is encouraged because the infant can then receive earlier intervention for auditory and/or verbal access to langue and objective audiologic testing can be completed without sedation
early hearing detection and intervention (EHDI)
programs ensure that infants and children with hearing loss are detect and receive intervention as early as possible
-they offer comprehensive hearing evaluations !
medical home
provides health care that is acceptable, family centered, continuous, comprehensive, coordinated, compassionate and culturally competence
what is the difference when it comes to when an ABR is needed in the JCIH 2007 and 2019
2007 : ABR is required by the age of 3 if you are trying to confirm HL or if you have found a child with HL, even if ear specific information is needed
2019: ABR is only required when ear specific information cannot be obtained
explain what need to occur for a full pass
both ears must have a pass result in the same screening session to be considered an overall pass
-rescreening should comprise of a single valid rescreen of both ears in the SAME session
loss to follow up (LTF)
not returning for necessary outpatient testing and therefore they do not receive a recommended follow up appointment service after a failed NBHS
-can be caused by inconsistent screening, parental refusal to follow up, lack of access, inconsistent quality, lack of communication, false negatives
how can we reduce LTF
use an interpreter, provide written materials in parents language, verify contact information and verify the PCP
loss to documentation (LTD)
those who have received services but results have not been reported to the EHDI program and therefore cannot be documented
-can be caused by name changes, data mismatched, incomplete data, unknown PCP
common behaviors in school age children due to hearing impairment
difficulty attending to spoken or other auditory information, frequently requests repetition, fatigues easily when listening, gives inappropriate answers to simple questions and appears isolated from peers
importance of screening beyond the newborn period
HL can go undetected after the NBHS
-HL can be late onset or progressive
kids tend to become sicker in the wintertime which can impact the ME with fluid, therefore it is important that screenings occurs in the __________
fall
-less risk for URT infections so we are able to identify those people who truly have some abnormality in their hearing
what is the pure tone screening protocol
pure tone sweep at 1000, 2000 and 4000 Hz at 20 dB HL
-lack of response at any requires a rescreen immediately
neural development within infants
they are borns with billions of connections that are awaiting stimulation to become strengthened
-the developing brain depends on external stimulation to form meaningful neural connections and a functional network
in order for connections to form, __________ behavior needs to occur
repetitive
what is a consequence if there is no stimulation
cross modal reorganization
cross modal reorganization
new tasks are given to an area of the brain when there is so stimulation
-somatosensory and visual processing may take place within the auditory cortical areas in long term deafened adults
bottom up maturation process
matures in stages from the bottom up to the top
-the previous stage needs to occur as all stages depend on the completion of stage 1
neuroplasticity
the brain organizes itself and develops neural connections with repeated stimulation
-the brains ability to create new connections/pathways or to modify existing ones
what are three means by which plasticity occurs
synaptic plasticity (create new connections through learning and practice), neurogenesis (birth of new neurons) and functional compensatory plasticity (sensory reassignment)
pruning
recognizing some areas are not being used and will get rid of those areas
-monitoring to see which parts of the brain get stimulated and those that do not
sensitive period
how long a child can go without stimulation but will still be treated effectively
critical period
a rigid age, once you pass this it will not happen
how do critical and sensitive periods play a role in amplification in infants
the earlier a child can be amplified the better the outcomes
-with CI’s the critical period is 7 years of age so their positive outcomes will decrease
-3.5 is the sensitive period so positive outcomes can still occur however it may take more effort and more sessions to gain those
three overarching reasons for why special considerations need to occur for children with amplification
rapidly changing ear canal acoustics, limited ability to provide reliable behavioral/verbal responses and the need for better SNR/sound access for speech and learning
ASSR
measuring electric activity from the scalp
-not as reliable as ABR however they still can test multiple frequencies
-both ears can be tested, faster than an ABR
-artifacts can be present more often
-ANSD cannot be detected
ABR assessment protocol
AC ABR thresholds using toneburst at 500, 2000 and 4000 (including 1000 when indicated) with BC ABR thresholds using toneburst at 500 and 2000
explain ABR and how it is needing conversion factors
results are reported in dB nHL which does not equal dB HL so in order to use for fittings, we need to make the conversion
-we convert nHL into a eHL (behaviorally equivalent measure)
what can happen if we do not indicate the proper results
-if we indicate in the software that it is nHL but it has already been converted then there can be under amplification as there will be an additional conversion
RECD
objective verification that is essential for preverbal children
-measuring the difference between a child’s ear canal size and the standard coupler
how does the RECD vary in children from adults
it is greatest with younger children as the residual volume is smaller for infants
-meaning there is more change between the coupler and the ear canal
RECD’s should be measured …..
each time there is a new earmold
what are the 2 considerations needed when selecting HA’s for children
non-electroacoustic considerations and electroacoustic considerations
3 important components for HA selection and fitting process
be attentive to the auditory input that is received by the child so that the speech and language development can occur in a natural way, basic premise of the initial HA selection is that all initial electroacoustic characteristics are tentative and HA selection must be viewed as an ongoing process
non-electroacoustic characteristics that are important
hearing aid style, ear mold impressions, ear molds, ear hook, retention options, tamper resistant battery doors, volume control lock, appearance of them (such as color) and is using two or one
what style is recommended for children and why
BTE
-can grow with them as the ears grow, will just require new molds
-more durable and less risk for injury
-addressed feedback issues by creating a bigger distance between microphone and where sound is coming out of
-good for a wide range of hearing losses
-direct audio input capabilities
what is the recommended earmold material and why
vinyl because it is soft but rigid enough to keep the sound bore open when inserted
-can be modified easily
-addresses safety concerns
for very young children, what is the concern with using the standard #13 tube
the ear canal may not be large enough to accommodate the length so it may not go all the way to the sound bore leading to it impacting the acoustic dimensions
how often do earmolds need to be replaced
every 3 months for children under 1 year of age
-every 6 to 12 months for children one year and older (up to around 5 years)
why is having feedback a sign that an earmold needs to be replaced
the ear mold is loose within the canal allowing for amplified signal to leak out
explain how binaural summation is essential for neural development
helps with localization and can impact the SNR through the usage of the head shadow, binaural summation will allow the sound to be perceived as louder, and an improved SNR when both ears are used due to binaural squelch
when compared to adults, what are the different characteristics based on
having a higher resonance, by needing a higher SNR and because children need amplification to develop speech and language skills
at what levels can higher gain be beneficial for children
-medium sounds because it may provide more speech intelligibility as well as it may reduce listening effort
-low sounds because it appears that child will be able to hear from a distance better as well as since this level is soft they will have a benefit from additional gain
why do children not benefit from more gain within the high level sounds
from research we know that children can have the same LDL as adults so by increasing this, the level can then become uncomfortable
what is the only feature that improves SNR
directional microphone
selection of directional microphones in infants/children
benefit is only reliant based on the child’s ability to turn towards the talker
-full time usage is not recommended due to them not being likely to turn to the target
-can be activated for school aged children with certain situations
selection of feedback cancellation in infants an children
this allows for the gain that is needed to be provided without the concern of feedback occurring
-however, with younger children as they grow the ear molds will create feedback so it could be altering the signals that they are getting that are important for speech
-we should not use FC as a way to prolong the life of an earmold
given what we know about earmolds and feedback, when there is any feedback within children that is typically a sign of what
the child needs a new ear mold
-with the feedback they are losing the higher frequencies
selection of digital noise reduction in infants and children
anything that has noise associated with it will be reduced so this does not improve the SNR but it is expected to reduce the cognitive load of the patient
-should increase listening comfort, listening effort and speech intelligibility should left unchanged
selection of frequency lowering in infants and children
sending the HF signals into an area where there is no HL to become audible and to be perceived
-if children have HF loss we need to think about this to help with speech recognition and phonological development
what are some candidacy factors for frequency lowering
hearing instrument details, does the child have access to the female /s/, depending on the developmental status do they response to the /s/
-FL is more likely with a HF or severe to profound loss
what are some topics that need to be covered during counseling with parents
hearing milestones, care/use of HAs, troubleshooting, safety issues, help parents understand that the more consistent they are the better outcomes there are and ensure that parents are aware of the milestones that they can expect from their child
what are some care and use of the HA that needs to be covered
cleaning the earmold/HA, changing batteries or charging schedule’s, performing listening checks, putting the HAs on, setting controls and avoiding hazards such as moistures
hearing should be re-evaluated ….
-1 month following the fitting
-2 to 3 month intervals for the first year of amplification
-every 4 to 6 months until age 5
-yearly for children over the age of 5
what is the importance of early intervention
early diagnosis of a HL is vital to help promote brain development
-the failure to detect congenital or acquired HL in children may result in lifelong deficits
cross check principle
achieved through a test battery approach, where multiple tests can check each other to ensure accuracy
-behavioral and electrophysiological tests must be used to determine the extent of a child’s auditory function
3 stages for selecting a test protocol
determine the child’s cognitive age, evaluate the child’s physical status and then choose the test room setup
closed vs. open set
want to attempt an open set by the age of 5 years old
-if child is developmentally delayed, you may want to use closed set
-if child has a speech or language delay would not want to attempt an open list
how does a tymp become compensated
the volume and the effect of the ear canal from the whole value
typically we will want to accomplish a full audio by the age of _______
5
-at this time they should be able to be tested through conventional audiometry
what testing requires cooperation? what testing does not require cooperation?
behavioral testing ; electrophysiological testing
between 6 months and 5 years, what is important to do for testing?
needing to select a developmentally appropriate assessment
-selecting between VRA and CPA based on the child’s cognitive age
ABR testing is indicated when ______________
behavioral responses are not reliable enough to provide ear specific information and if there is any evidence of HL
6 months to 24 months with speech testing
can so SDT/SAT with MLV including their name or other phrases to get them to turn OR if the older children do know some body parts you can do body part pointing for SRT
2 to 5 years with speech testing
should do SRT based on age accordance, is younger children known body parts do this, otherwise you can do SAT/SDT
