Final Exam (New Material) Flashcards
1
Q
what is SII
A
Calculates % of speech info that is audible and usable to the listener
2
Q
SII of 50%
A
50% of speech cues supporting intelligibility are audible in a quiet setting
3
Q
Increase in # of dots
A
frequency region with higher contribution to intelligibility (HF)
4
Q
Decrease in # of dots
A
frequency region with reduced contribution to intelligibility (LF)
5
Q
purpose of measuring LDL
A
needed to ensure amplified output doesn’t exceed the individual’s loudness tolerance
6
Q
interpretation of LDL
A
normal is between 100-105
7
Q
purpose for ANL
A
Quantifies a listener’s willingness to listen to speech in the presence of background noise.
Identifies those who will have more difficulty adapting to amplification
8
Q
how to score ANL
A
MCL value – BNL value = ANL score
9
Q
low anl score
A
difference <7
Indicates the patient ACCEPTS a lot of noise background noise w/o issues
This patient is likely to wear hearing aids on a regular basis
10
Q
high anl score
A
difference > 13 dB
Indicates the patient LACKS TOLERANCE for background noise
This patient is less likely to wear hearing aids regularly
Premium technology
11
Q
ANL scores b/w 8-12 dB
A
equivocal
May require extra post-fitting counselling or adjustment period
12
Q
purpose of SNL
A
Speech intelligibility in noise remains the #1 improvement patients seek with hearing aids
Each patient will need tailored technological recommendations based on their individual “signal-to-noise loss.”
13
Q
0-2 snr
A
normal
omni or may benefit with directional mic
14
Q
2-7 snr
A
mild loss
recommend standard directional mics
15
Q
7-15 snr
A
moderate
beamforming as well as standard directional mics
16
Q
> 15 snr
A
severe
requires remote mic in addition to beamforming and directional mics
17
Q
rem ref mic
A
monitor and calibrate the soundfield speaker output, maintaining the desired signal intensity at the measurement point
18
Q
retention cord
A
to stabilize and maintain the reference microphone’s position
Blue stretchy coard
19
Q
probe tube
A
measure the intensity of the signal arriving to the TM
20
Q
prob mic
A
collects and measures sound from the probe tube attached to it
Stem
21
Q
Aided output of 15dB in needed to achieve binaural benefit
A
true
22
Q
type I signal
A
brief puretone signal swept over variety of frequencies
verifies MPO
DFS can attenuate this signal
doesn’t show the affect of compression or channel interactions on output signal
23
Q
type II signal
A
complex speech like signals
BB signal over different intensities
mimics speech
might not show all spectral issues because we cannot capture every little detail
24
Q
types of type II signal
A
standardized
nonstandardized
25
standardized speech signal
calibrated
repeatable
verifies device can reach prescriptive targets
ex: speech map, ISTS, ICRA
26
nonstandardized signal
not used for programming
good for counseling
less repeatable
27
speech envelope
Visual representation of modulated speech sounds
28
LTASS
long term average speech spectrum
Measured by averaging a measured signal for 10 seconds
29
what are factors that impact its average value
will change with varying vocal effort, mic position, and language
30
vocal effort influences
mid frequency LTASS avg
31
mic position influences
HF LTASS avg
32
tonal languages influence
LF LTASS avg
33
Speech envelope has a crest factor of +____dB (louder speech signals) & valleys of - ______ dB (soft speech signals)
12 18
34
crest factor and valleys define the representative ______ of normal convo speech over time
dynamic range
35
The difference between the valleys (softest signal) and peaks (loudest signal) of speech is
~30dB SPL
36
Difference bw threshold & LDL represents
dynamic range
37
what is room mean squared error
how close the measured output is to the prescribed target
38
what is RMSE criterian
5dB
39
what are the calibration methods
substitutioin method of soundfield equalization
modified pressure methdos
40
substitution method equalization
Done before the PT arrives, placed at where subject’s head would be, stored as a reference point, used to calibrate the reference mic and probe
Impacts results if the subject changes location or moves
41
modified pressure concurrent equalization
reference mic monitors test signal throughout test to equalize and adjust, calibration signal replays every 10 seconds (pink noise segment)
42
modified pressure stored equalization
probe is calibrated one time on PT’s ear & stored for fitting process
Used to avoid ref mic contamination (stops it)
43
what is ref mic contamination? what is used to stop it?
happens when amp output escapes ear canal through open dome
Modified pressure “stored equalization”
44
Probe tube Calibration & Acoustic Transparency
probe microphone module cannot be physically located in the ear canal; the probe tube serves as an extension to the probe microphone
Probe tube tip is placed directly over the reference microphone during calibration. This protocol accounts for the different intensities arriving to the probe microphone module’s reference mic and through the probe tube.
The unit mathematically adjusts the intensity differences removing the tube’s resonance effects.
This procedure makes the probe tube “acoustically invisible”
45
ANSI Recommendations & Working Distance
Distance allowed bw PT and speaker (18”-36”)
Reflective surfaces & tester: 2 x WD (about 34-36 in away)
Ambient noise in the room must be 10dB lower than REM signal
Horizontal plane: 0º azimuth: greatest reliability
Vertical plane: speakr should be level to the PT’s ear in order to accurately measure HF output
46
RE
real ear
47
r
response
48
g
gain
49
what is R
absolute measure of SPL output arriving to the TM
50
what is gain
diff bw output intensity and input intensity
output - input = gain
51
REUR
measurement of the absolute SPL level of an open ear canal response, across all frequencies, at the tympanic membrane (input + gain + resonance = output)
52
REUG
the measurement of gain increase resulting from pinna, ear canal, and head diffraction effects, as measured from an open ear canal
REUR - input = REUG
53
REOR
A measurement of insertion loss occurring because of the presence of a mold/dome in the ear canal
54
why do we do REUR
Knowing a patients ear canal resonance improve accuracy of prescriptive fitting
55
REUR changes due to
ear canal differences
Size, texture, shape, or presence of abnormal anatomy
Age: pediatric, adult, elderly
One person can have 2 different REUR’s
56
REOR
A measurement of insertion loss occurring because of the presence of a mold/dome in the ear canal
57
why do we do REOR
Lets us see if the vent effect is performing as expected
To identify which low frequencies are released due to the vent effect
To determine if the vent introduced undesired standing waves
58
REAR
absolute aided output and frequency response when a hearing aid is turned on
59
why do we do REAR
To view devices absolute aided output in a unique ear canal (if you don’t measure it, you don’t know if you’ve met your objective)
60
Measures intensity of the output signal arriving at the TM, when the input signal is sufficiently intense to drive the device to its maximum power output level
REAR 85/90
61
REIG
The difference between the AIDED response and the UNAIDED response of the ear canal
REAR- REUR = REIG
62
RECD
difference between the SPL resonance of a 2cc coupler and the SPL resonance of the real ear
63
why do we measure RECD
accurately converts HL thresholds using inserts to SPL values creating a personalized conversio factor for precise conversions
predicts the real ear output when HA measurements are made in the test box
64
the natural resonance resulting from the pinna and ear canal effect that the patient walked in the door with
REUR
65
the insertion loss that results from the mold/dome
REOR
66
the output arriving to the TM when aid is turned on
REAR
67
the amount of gain added to the input signal when the aid is turned on
REIG
68
the MPO that’s arriving to the TM
MPO/RESR/REAR85/90-
69
difference between the SPL resonance of a 2cc coupler and the SPL resonance of the real ear
RECD
70
How does an SPL-ogram differ from an audiogram. Why will measurement of the RECD improve the accuracy of the conversion?
SPL-o-gram is in dB SPL (physical sound level), while an audiogram is in dB HL (normalized against normal hearing thresholds).
Audiograms are used for diagnosing hearing loss, whereas SPL-o-grams are more common in hearing aid fitting because they show the actual sound level being delivered to the ear.
It creates a customized conversation to create accurate fitting targets for the patient.
71
RECD ANSI standards
Can be made with a custom earmold or foam insert
The same coupler must be used for both measurements - ANSI requires the use of HA-1 coupler
72
pink line in RECD
real ear measurement
73
green line in RECD
green
74
dots in recd
HA-1 RECD avg
75
blue line in recd
actual ha-1 recd measurement
76
if RECD is above avg
smaller ear canal than avg
77
if RECD is below avg
larger ear canal than avg
78
If RECD is negative in LFs below 1000
slit leak
79
if RECD is negative in LFs below 1500
pe tube or perf
80
Negative RECD >10dB in the 4-6 kHz region
blocked probe tube
81
increase in the mid frequencies in RECD
fluid
82
open mastoid cavity in RECD
decreases in mid to highs
83
MEE in RECD
increases REC in mids
84
proprietary formula
developed by manufacturers
85
NAL-NL2
loudness equalization formula
balances perception of loudness over a range of frequencies (LF has more energy so it increases mid and highs until it equals)
uses REIG
provides tonal language targets
adults
if PT wants increased intelligibility
86
NAL-NL2 formula
Early formulas used Lybarger ½ gain rule
Calculates gain targets as 50% of the threshold loss.
Revised formula calculates gain targets as 46% of threshold loss
CURRENT: bases gain recommendations on the Speech intelligibility Index % (SII)
More gain is prescribed to those sounds that contribute the most to speech intelligibility
87
NAL-RP
profound losses
Gain is calculated as 66% of the threshold loss rather than 46% of loss
88
NAL-NL2 calculation for A-B gaps
25% of the air-bone gap is added to the NAL-NL2 formula
89
DSL 5.0
loudness normalization formula
maxes audibility to assist lnaguage development
uses REAR
provides MPO targets
adults & kids
PT desires increased comfort or REUR is not avg
90
Maximized audibility formula
Speech Intelligibility Index (SII) Audibility targets
91
Is it acceptable for an audiologist to change the prescription, applying gain that does not meet the "+/- 5 dB for target" criteria?
Begin by following +/- 5dB match target rule as a good general guideline
However, make further adjustments based on PT complaints
The line must match the shape (contour) of the targets that are present
92
When you adjust a band, you adjust the entire speech envelope up and down
TRUE
93
When you adjust a channel, you either adjust bottom or the top of the speech envelope
true
94
move bands, raise soft sounds, then raise loud sounds - maintain balance bw
all the CR TKs
95
Frequency lowering verification and modification
Verify audibility of HFs /s/ sound
Adjust FL to MOAF as needed
Use the /s/ stimulus on audioscan to assess HF audibility
96
goal of FL
add the least amount of FL required to put the upper shoulder of /s/ response into the MAOF
97
too much audibility fr FL
poor sound quality
98
what is aided functional gain measures
Compares aided thresholds to unaided thresholds using puretone signals in the sound field
The purpose of hearing aids is to get the persons aided thresholds as close to normal conversation levels as possible
99
why do functional aided testing
REM equipment is not available
Gooey cerumen clogs probe mic
Pediatric fittings or uncooperative patients
CI, BAHA, or Lyric fittings
Some federal government agencies require the test
100
limitations to aided testing
Test retest reliability is poor
Varies by 10-15dB
Only verifies threshold of audibility
Aided thresholds are invalid for near-normal hearing (usually in the low frequencies)
The reason for this is because ambient noise masks the test signal resulting in a poorer aided functional gain response
Hearing aid features could suppress audibility of tones
limited frequencies - can miss ranges critical for speech understanding
Doesn’t reflect real world listening
Lack of speech information
101
conformity protocols
Used to ensure HAs are providing the appropriate amplification based on the PTs hearing needs
On-Ear Real Ear Verification
RECD measurement and Test Box Programming
Aided functional gain
Aided speech intelligibility measures
Aided subjective ratings
Subjective speech intelligibility judgments
Speech quality judgments
Loudness rating
102
Closer the lines are the higher the
CR is
103
Further lines go apart
more linear
104
The closer they are the more compression that is added
true
105
If we shift tk up and down it impacts signal at kneepoint but not the rest of the signal
true
106
107
Aided output needs to be ______ bw ears to support binaural advantage
15 SPL
108
ILD -
HF > 3
109
ITD
LF <850
110
Strategies for binaural advantage
Fit better ear first
Relies on this for communication
Fit poorer ear second after good ear is optimized
111
Asymmetric HL
Asymmetric threshold loss: 3 adjacent frequencies >20dB or 1 frequency >25 dB
SII: if the speech signal audible frequencies arecritical to understanding
SNR loss: 20% difference
discomfort levels: are tolerance levels significantly different
112
fitting asymmetric HL
may need to try one or more formulas (create multiple memories for different ones)
use formula for severe losses when needed
provide useful info to aid localization to help the PT
113
considerations to fitting unilateral vs bilateral devices
how does each ear contribute to SI in isolation
amoutn of useful audibility in each ear
will bilateral help binaural benefit
114
when do you need special fitting considerations for NIHL
type III
115
how to fit type I and II NIHL
disable FL
add audibility to residual hearing (threshold x .2 = 65dB of gain)
add 5-8dB to normal range before the precipitous drop
enable expansion when hearing is near normal below 2 (reduces mic noise)
verify audibility of s
enable & adjust FL 4-6 wks after first fit
116
Type III NIHL fitting
add gain to thresholds below 85 dB
balance audibility from 5-3 below 85 dB
add 5-8dB to normal before precipitous drop
enable expansion when eharing is near normal below 2
if threshold is near LDL do not add gain or add 2% of threshold vs normal 46%)
117
receiver considerations
add gain to the healthier areas of the cochlea in lows and mmids
no need for receiver with wider frequency responses with extenced HFs
118
fitting for reverse slope HL
add only 15-20dB in low and mids
add 10-15 at 2kHz and above even if they are WNL
allow habituation time
add additional MF gain in 5dB periods of habituation (be cautious of LF adding)
once LF and mids are adjusted, modify HF based on PT perceptions & increase by 5-10dB
119
dead regions fitting
1-2 no special
>3: benefit from HF gain bw 1-4 kHz
120
which Rx doesn't account for ab gaps
DSL
121
how do you account for additonal gain for ab gaps
Calculate prescriptive gain recommendation for AC threshold
Calculate 25% of A-B gap. This additional gain is added to the AC prescriptive targets
Increase MPO by the same percentage used for A-B gap calculation allowing headroom for the extra gain
122
perf fittings
decrease in LFs by 8dB so adding gain here is not beneficial
options: bc/bone anchored device, will path effect ear level device
123
sev to profound fittings
Reduced reliance on audibility and they rely on other communictive strategies
use NAL-RP, low CRs and slow acting compression
freuency lowering might help
124
Raising or lowering TK modifies output for
soft sounds
125
Improving sound quality
increase/decrease loud signals (channels)
increase/decrease LF bands
126
Increasing or decreasing MPO manages
very loud signals (90+)
127
Improving clarity or comfort
increase/decrease HF bands
increase/decrease soft signals (channels)
increase/decrease loud input signals (channels)
128
how to determine if own voice complaints are from amp or shell origin
check the physical device (push in or pull out mold)
ask if it changes when they speak at different intensities
129
voice improves when pushed in
increase canal length of device or improve aperture seal
130
Sound improves with it pulled out slightly
increase vent size or shorten canal length
131
no difference when checking physical fit
amp origin and change gain/output
132
Worse when they are louder
Indicates saturation or excessive gain
Adjust mpo or loud input
133
Worse when they speak softer
Insufficient gain
Increase LF band or soft inputs
134
No difference when they speak
OE
135
if sounds better when device is on
shell origin
modify shell
136
if there is no differences when it if off vs on
probably shell
137
if it sounds better with device off
amplifier origin
modify device gain/output
138
how to manage hf amp origin
increaswe gain in mids
139
Describes own voice as sounding like an echo, lispy, raspy or muffled
Report an unnatural perception of their voice coming from somewhere else
hf amp origin
140
own voice complaints from shell origin
Prevalent when LF thresholds are <40 dB HL
continues when device is off
manage: open vent or increase length
141
own voice complaints from LF amp origin
complaint stops when HA is off
manage: lower LF band 4-6dB (if it doesn't work incrase LF band 4-6)
change loud LF channel first
142
HF amp origin
Describes own voice as sounding like an echo, lispy, raspy or muffled
Report an unnatural perception of their voice coming from somewhere else
manage: increase mid gain
143
how to fix paper complaints
reduce loud channel at all frequecies first
144
PT will say Having trouble listening in noisy environments when at shopping mall with family and they are talking to me
Background noise is pretty constant in this scenario
Traffic
Museum or Shopping center
Multi-talker babble
Heavy machinery
improve speech intelligibility
Decrease the LF bands & increase th HF bands
can raise the TK to attenuate soft LF interference
145
what can you do to improve sound quality
increase/decrease loud channels
increase/decrease LF bands
146
what can you do to improve clarity or comfort
increase/decrease HF bands
increase/decrease soft signals (channels)
increase/decrease loud input signals (channels)
147
crockery, clattering
Household electrical appliances
Water running
Paper rustling
Vacuum
HF weighted noise
tolerance of noise
increase LF band under 1500 Hz
decrease HF band above 1500 Hz
148
increasing CR in loud
decreasing loud input
this makes loud sounds less audible & more comfy
149
decreasing CR for loud
increase loud input
this makes the loud sounds more crisp and clear
150
increase CR soft
increase soft sounds to make it more audible (louder)
151
decrease CR soft
decrease soft sounds to make it less audible (quieter)
152
ex of LF weighted background noise
shopping mall
traffic
museum or shopping center
multi talker babble
heavy machinery
153
ex of HF weighted background noise
Crockery (dishes, plates, cups, etc.), clattering
Household electrical appliances
Water running
Paper rustling
Vacuum
154
what to do for HF weighted noise
increase LF & decrease HF bands
155
what to do for LF weighted noise
decrease LF & increase HF bands
156
how to increase comfort in LF noise
increase CR (decreasing loud input) in LF channel by 1-2 dB
raisae LF tK 50dB below 1500 Hz
157
what to do for party noise/wedding
raise HF tk to 60dB (decreases soft HF sounds)
158
dishes clattering
decrease loud HF gain (increase CR)
decrease MPO
159
utensils
lower loud channel at all frequencies
159
water running
decrease MPO
160
what to do in bars/parties/weddings
increase HF TK to 60dB
increase HF compression ratio to lower loud HF sounds
161
what should you do for a music program
disable directional mic, DFS, DNR, make it more linear and raise MPO
162
grocery bag complaint
change moderate HF sounds
163
how to reduce toilet flushing
decrease LF loud channel
164
if HA sounds boomy
decrease LF bands
decrease overall gain
decrease MPO
165
HVAC complaint
raise TK
lower soft LFs
add more expansion??
166
what to program for music
Disable LFdirectional mic, DFS, DNR, make it more linear & raise MPO (higher crest factor so gives it more room)
167
There is no ‘long-term average” for instrumental music and therefore targets prescriptive fitting formulas are unavailable
true
168
Crest factor of +16 to +18 dB whereas speech is assumed to be +12 dB
true
169
The output waveform of music is “peakier” relative to speech
true
170
Describe the 3 considerations made to determine if manual memories are warranted
are they in challenging environments a lot
can they cognitively and physically understand and manage additional manual programs
can the program make a noticeable difference
171
when is noticeable difference achieved most
Threshold loss at 500 Hz is is >40 dB
HF loss is not too severe (70dB HL or better)
172
other factors for determining if manual programs are useful
Individuals with wider dynamic ranges may benefit from additional manual memories
Milder losses with poor than expected SNR loss require manual programs to control noise in their environment.
173
when will Medicare cover
Only covers diagnostic procedures needed to diagnose an auditory disorder
Tests of auditory and vestibular systems, tinnitus, auditory processing and osseointegrated devices
Does cover treatment for auditory disorders as speeh-language pathology services
174
what does medicare not cover
HA
Vestibular treatment/rehab
Aural rehab
Cerumen management
175
qualified audiologist
licensed as an audiologist by the State in which the individual furnishes such services
176
who can be paid for an audio
Just an audiologist
177
Medicare will not pay for services done by
4th year AuD students, audiological aides, assistants, technicians, hearing instrument specialists or others who do not meet the qualifications
178
100% supervision
Procedures can only be billed to Medicare with the Preceptor’s NPI only if they interact with you and the PT 100% of the time of the procedure
179
when can we provide non acute hearing tests every year without an order
when it isn't related ot
isequilibrium or HAs
Exams for prescribing, fittings or changing HAs
Only relates to Medicare (Part B) beneficiaries only
Medicare advantage plans usually do not require a physician order (unless specified in your agreement)
180
If the audiologist performs a test without an order they are not covered even if they discover a pathological condition
true
181
non acute
still need medical necessity but they do not need to see a physician first
182
who can write orders
Certified Nurse Midwives
Clinical Nurse Specialists
Clinical Psychologists
Clinical Social Workers
Interns, Residents and Fellows
Nurse Practitioners
Physicians Assistants
Physicians (MDs or DOs, Dentists, Podiatrists, or Doctors of Optometry)
183
a physician writes an order for a PT to get a VNG. What can the audiologist perform?
Only the CPT descriptor the order specifies
184
If the physician order diagnostic audiological tests without naming specific tests, the audiologist can select the appropriate test battery
true
185
Despite med necessity, you can only perform the test code that the physician sends
ture
186
recomendation from a DR for a PT to see another provider like a specialist; directs the PT to another medical provider for specialized care
f
referral
187
more broad; directive order to perform tests, procedures or treatment results in service being provided
order
188
what constitutes medical necessity
Services must be necessary based on the PTs diagnosis or symptoms
Re-evaluation is needed due to suspected change in hearing, tinnitus, or balance
Eval is needed to determine cause of a disorder
Eval is needed to determine effect of medications, surgeries or other treatments
Re-eval is needed to follow-up on changes in hearing, tinnitus, or balance caused by an established diagnosis (comorbidity) that puts a PT at risk for change including
otosclerosis, atelectatic tympanic membrane, tympanosclerosis, cholesteatoma, resolving middle ear infection, Meniére’s disease, sudden idiopathic sensorineural hearing loss, autoimmune inner ear disease, acoustic neuroma, demyelinating diseases, ototoxicity secondary to medications, or genetic vascular and viral conditions;
Failure of a screening test
Diagnostic eval of cochlear or BS implant and programming
Audiological diagnostic tests before and periodically after implantation of auditory prosthetic devices
Physician refers related to signs associated with HL, balance disorder, tinnitus, ear disease, or ear injury
189
bundled pricing model
Consumer prepays for all current and future services at the time of purchase
Bundled pricing includes the cost of devices and all associated services
Or, all fees associated with product are combined into the initial cost for a predetermined length of time during which office visits are provided at no charge
190
benefits of bundled
Practice can easily estimate revenue generation based on number of amplification units dispensed each month
Billing protocols are less complicated
191
what are disadvantages to bundled
giving away:
Cost of time spent completing a formal Communication Needs Assessment
Cost of time spent on quality control checks and preprogramming
Cost of time spent verifying, programming, finetuning, and finetuning, and finetuning
Cost of time spent completing paperwork for warrantied services
Cost of time spent cleaning the device
Cost of time spent on annual HAC; In-office repairs, reprogramming when thresholds change
Cost of time spent visiting with patients who just “really like visiting you!”
192
A PT who comes in once every month compared to one that comes once every year gets a better deal because they are geting more for what the paid for
bundled
193
unbundled pricing
Separates cost of technology from all other associated services
Pay as you go:
Allows the consumer to readily differentiate the cost of the device, accessories from YOUR services
Provides the consumer with the opportunity to be selective in choosing the level of services
Reduces the price differential between low, mid-range and high-level technologies as the cost of your services is fixed, regardless of the technology level
Allows consumers to purchase devices through other platforms and then receive only the service components from the audiologist
194
challenges of unbundled
3rd party payers expect providers to unbundle billed services
Durable medical goods (devices) are reimbursed separately from services
Submission of a single bundled fee reduces reimbursement
Knowledge of reimbursement fee schedules to determine the combination of codes needed to optimize payments received is challenging & time consuming.
Insurance reimbursement polices varies from company to company and within plans.
Requires you to know your hourly costs to calculate cost of services
195
Requires you to know your hourly costs to calculate cost of services
unbundled
