Final (Weeks 1-5) Flashcards
birth to 6 wks
crying
7wks to 3 mos
cooing
after 4 mos (up to 7)
babbling
8-10 mos
first understanding of language
around 12 mos
first words
18 mos
50 words
18-20 mos
vocab spurt
24 mos
two word sentences
after 30 mos
grammar dev
extended repetition of certain single syllables around 6-7 mos
babbling
risk factor of HL with apgar
Apgar scores below 5 at 1 min or less than 6 at 5 min
Human cochlea shows response to sounds after _____ week of gestation
20th
auditory system becomes functional around
25 weeks’ gestation
chronological age
age of actual day child was born
corrected ag
Only used with premature babies (born before 37 wks)
Baby’s actual age in weeks minus the number of weeks the baby was preterm
Corrected age (CA) = chronological age - # weeks or months premature
Baby J was born at 28 weeks gestation and is 6 mos chronological what is is corrected age
3 mos
Moro reflex, eye blinking or widening, sucking. Startle when there is a very loud noise.
0-4 mos
Lateral head turn towards sound source
4-7 mos
Good lateral localization skills & downwards
7-9 mos
Sound localization in all directions
9-13 mos
Excellent localization. Easily distracted
13+ mos
Identify the red flags indicating potential issues in speech and auditory development.
No babbling at 12 months
No gesturing (pointing, waving bye-bye) by 12 months
No single words by 16 months
No 2 words combination spontaneous phrases by 24 months
No 3 words combination by 3 years of age
Unintelligible speech at 3 years
Limited number of consonants at 2 years
Simplified grammar at 3 ½ years
Difficulty formulating ideas and using vocab at 4 years
Language not used communicatively
kid misses 10% of speech with distance
kid misses 10% of speech with distance
inaudible (voiceless stops & fricatives)
inattention
mild hl
miss most conversational speech
vowels heard better than consonants
(-s, -ed) are difficult
inattention
learning difficulties
moderate HL
Language and speech do not develop spontaneously without intervention.
can hear distorted self-vocalization, very loud environmental sounds, and only the most intense speech at close range.
severe hl
rely on vision than hearing, aware of vibrations than tonal patters, S/L will not develop spontaneously, severe language delays, speech problems, and potential learning dysfunction without intervention
Speech often includes issues with voice, articulation, resonance, and prosody. Vocal pitch may be higher, with a monotone quality due to lack of intonation and stress
profound hl
not direct tests of hearing & not always able to provide complete & accurate assessments of hearing in early infancy
physiological tests
objective, reliable, provide info about the status of the auditory status
physiological (ABR, ASSR, & DPOAEs)
goal of behavioral testing
determine if the child has sufficient hearing to develop S/L
provides direct measure of hearing
behavioral audio
Purposes of audiological assessments in infants and children
To determine the type, degree, and configuration of hearing loss in each ear.
To assess the impact of hearing loss on speech, language, communication, and education.
To identify risk factors for progressive or delayed-onset hearing loss for ongoing monitoring.
To evaluate candidacy for sensory devices (hearing aids, assistive devices, cochlear implants).
To refer for medical evaluation and early intervention services when appropriate
Indications for Comprehensive Audiological Evaluation
Referral from newborn hearing screens or risk factors for hearing loss.
Behaviors indicating hearing loss vary by age
Parental concerns about hearing or speech/language delays.
Advantages of test battery approach
Provides detailed information
Avoids drawing conclusions from a single test
Allows for the identification of multiple pathologies
Provides a comprehensive foundation for observing a child’s auditory behaviors
Appropriate behavioral procedures depends on their developmental, cognitive and linguistic level, visual and motor development, and ability to respond appropriately
true
how do you pick the appropriate testing protocol
determine cognitive age
evaluate physical status
test stimuli for behavioral audiology
Frequency specific
Warble tones (pure tones?)
Narrow band noise
Non-frequency specific
Music
Noise
speech (capture attention & determine SAT)
presentation of stimuli in behavioral audios
Begin at HFs because many infants respond better to these (usually 2000 Hz) (obtain one HF & one LF)
If SNHL suspected start at 500 Hz
If middle ear pathology/CHL , start at 2000 Hz because CHL affects LFs more
Significant difference between 5 and 2: test 1 next & if flat loss test 4 next
test 250, 500, & 2,000
chl
test 500, 2,000 & 4,000
snhl
Suprathreshold stimuli presented at a level at which the infant previously responded
Used to demonstrate understanding of the task before descending in level to determine threshold and through the test to determine if the infant is still on task
probe trials
Observation trials in which the examiner judges whether a head turn occurs in teh absence of sound stimulation
Primarily used to determine if the responses “head turn” being judged are truly responses to the test stimuli and not just random head turns
control trials
reasons for a follow up visit
Inconsistent responses
Inadequate cooperation: might be fussy, sleepy, uncooperative
If infant is unwell (cold, flu, ear infections)
Ototoxicity monitoring
Ear canal/tympanic membrane abnormalities
what does acoustic immittance test
middle ear (ME) function, the cochlea, auditory nerves, and the brainstem
In the middle ear, sound vibrations are transferred from the TM to the cochlea via the ossicles, specifically the stapes, contributing to about ______ of amplification. Loss of ME results in _____ HL loss
30 dB
60 dB
two mechanisms that aid in amplification in the ME (MEIM)
The area difference between the TM and the oval window increases the pressure on the stapes footplate.
The lever action of the malleus and incus boosts sound energy at the footplate.
Highest incidence of middle ear problems occurs in the first few years of life.
RRUE
strategies to increase a child’s cooperation during immittance testing.
Seat young children and infants on the parent’s lap; parents can help prevent them from grabbing their ears.
Comfort children with otoscopy by showing the flashlight or looking into the parent’s ears; distract them with a toy.
Ensure children are quiet and still during the test.
Greet the child with an enticing toy to distract from the unfamiliar room.
Have an experienced assistant, and sometimes involve the parent.
Children over 3 typically don’t need special distractions.
Children aged 1-3 years can have unpredictable behavior and often fear pain.
Let them place the piece to their ear or watch the process.
WHAT SHOULD YOU NOT DO DURING TSTING
Don’t ask for permission, as this may encourage them to say no.
Like can I look in your ears? Can I put this in your ears?
Avoid mentioning pain unless they bring it up.
don’t use this as encouragement to do the test unless they mention it first or ask
Don’t over-explain the procedure; keep instructions simple or say nothing.
It is sufficient to say something like, “Here, listen to this,” or “Hold still for me,” and then proceed with the test. Better yet, say nothing!
This is what will happen and this is what i am going to do
how are ARTs measured
During ART testing, the probe monitors changes in middle ear compliance. When a loud sound is perceived by the brain, it triggers the stapedius reflex, causing the ossicles to stiffen and the tympanic membrane (TM) to pull inward. This stiffening reduces the amount of sound energy that can enter the middle ear, and the probe detects this as a decrease in admittance (e.g., a .02 drop).
when should you use 226 hz probe tone
ages 7 mos to adulthood (226 becomes adultlike by around 6-8mos)
when should you use 1000 Hz probe tone
<7mos
infant ears are ____ dominant
mass
limitations of 226 Hz tone
ears are structurally and functionally different so it doesnt work
can cause collapsing
results in lower static admittance, broader tymp width, & appearance of notching at LF due to the tone not matching the property of the system we are testing
Key factors in immittance include:
Stiffness (fluid pressure from the inner ear)
Mass (weight of the ossicles & TM)
Friction (ligaments supporting the ossicles)
In infants, the ME is mass-dominated with a higher resonant frequency, whereas in adults, it is stiffness-dominated with a lower resonant frequency.
true
Changes in the first postnatal months of life (bw 6-8 mos) includes
Growth of bony portion of the ear canal wall resulting in decrease in the length of the cartilaginous portion of the canal
Increase in overall size of the ear canal
Decrease in density of ossicles over first 6 months of life due to ossification and absorption of residual mesenchyme
Changes in orientation of the ™ to be more vertical
Progressive stiffening of the ossicular joints
Infant ear canal is small, compliant, and flaccid, gradually increasing in size and rigidity within 2 years.
true
anatomical differences in infants
it is small, compliant and flaccid
higher resonance frequency
TM is horizontal and thick but thins and becomes perpendicular (due to loss of mesenchymal tissues)
ME space increases w/ aeration, ossicular joint tightening and pneumatization of air cells
ET is more horizontal and less rigid (higher ME infections)
anatomical differences
Acoustic properties of the infant ear changes drastically over the first 6 mos of life
Excessively compliant EAC
Small ear canal
Horizontal orientation of ™
Underossified ossicular chain
Small ME space
what is static acoustic admittance (Ytm)
measures max mobility of the ME system
what is middle ear pressure (TPP)
pressure at which peak admittance occurs
shows where air pressure in ME matches atmospheric pressure
what is width/gradient
measures sharpness or broadness of the tymp peak
what is a rounded wide peak indicative of
fluid in ME
what are sharp peaks indiciative of
normal function
flatter and wider peaks
OM
Peak becomes smaller as admittance becomes lower
OM & cholesteatoma
Gradient <.02 is considered abnormally low
ture
Assesses if the volume between the probe and TM is normal.
ECV (Veq)
TPP norm for adult
+50 - -200
Vea norm for adult
.9-2.0
Y (mmho or cc) norm for adult
.3 - 1.7
TW (daPa or mmh20) norm for adult
51 to 114
tpp norm for child (3-10 yrs)
+50 - -150
Vea norm for child
.3 to .9
Y norm for child
.25 to 1.05
acoustic admittance
TW for child
80-159
what are the norms for less than 3 yrs old
6-12 mos: Ytm: .20 to .50, wideth: 102-234
12-18 mos: Ytm: .20-.60, width: 102-204
18-24 mos: Ytm: .30 to .70, width: 102-204
24-30 mos: .30 to .80, width 96-192
Describe the advantages of using 1000 Hz tympanometry in infants and be able to interpret the results.
more sensitive for detecting middle ear changes in infants than the 226 Hz test.
helps differentiate normal from abnormal ears and is a good predictor of otoacoustic emissions (OAEs).
what are the 1000 Hz norm for birth - 4 kws
negative tail (-400 daPa)
.6-4.3
what are the 1000 Hz norm for birth
positive tail (+200)
.31-.96
what are the 1000 Hz norm for 1-6 days
positive tail
.39-2.28
what are the 1000 Hz norm for 6 wks
positive tail
.34-1.12
______ is the cutoff of what is considered normal for newborns & 1000 Hz
0.35
what is meant by a compensated tymp
it evalues the ME fxn by isolating admittance of just the ME exclusind the ECV measurements
how does a compensated tymp work
first tymp measure admittance of ear canal alone by pushing positive pressure in to stiffen the eardrum and elimate the ME measurement
then the pressure varies and this is taken at the point where the ME system is most efficient (around 0 when pressure on both sides of the eardrum are equal)
then the ear canal (baseline) is subtracted from the test measurement (second measure) to get the static compensated acoustic admittance
Subtracts the whole system from the fixed ™ giving compliance (mobility) and gives us the admittance
static compensated acoustic admittance
how do you know if you look at a tymp if it is compensated or not?
if it starts at 0 at the bottom left = compensated
if it starts anywhere else - not compensated
increases admittance, makes it easier to distinguish between normal and abnormal but can be problematic in infants
negative tail
prevents ear canal collapse at negative pressures, has greater test-retest reliability but overestimates ECV
positive tail
3 methods to compensate a tymp
neg tail
pos tail
two tail
pros and cons of neg tail
gives you larger results; what is normal (larger value) vs not normal (lower value); gives more sensitivity if there is fluid and mobility of the system; can cause collapse ear canal
pros and cons of pos tail
better for test-retest reliability but it can overestimate ECV because the positive pressure pushes the eardrum in so with the measurement it makes it larger because it isn’t at its normal position
what is two tail
looks at both and averages them to give ECV and admittance value
Often results in absent reflexes in neonates, and flat tympanograms can appear in both normal and abnormal middle ears (MEE).
226 tone
Provides measurable reflexes in nearly all neonates and is more effective for evaluating middle ear status.
1000 Hz
Not useful for assessing the middle ear system in infants due to low sensitivity and variable results.
LF tone
Result in 100% present reflexes with broadband noise (BBN) activator.
High-Frequency Tones (≥800 Hz)
what are we worried about with ARTs in infants
Permanent threshold shift is higher in infants because they have smaller ear canals resulting in a higher SPL (at least 10dB higher than adults)
110 dB in infants can reach
126 to 130 dB
what does the testing look like in infants with ARTs
pure tone activator frequencies are used for infants and children from birth to 5 years, with contralateral testing for potential neural issues. Absent reflexes can help diagnose MEE, while present reflexes indicate non-severe hearing loss.
what can you do with active children with ARTs
Use BBN stimulus for reflexes in wiggly or uncooperative children to assess middle ear function and system integrity.
what is the adv of using WB tymps in peds
ME fxn is evaluated w/ a wide range of frequencies
Broad frequency range, more sensitive & specific, less affected by ECV & probe position
measured at ambient pressure, airtight seal, wide frequency ranges to assess ME fxn, & distinticve wb reflectance patterns are associated with normal or different types of mE dysfunction
a way to measure sound energy transferred in the ME across a broad frequency range
reflection
increases the potential benefits of improved pediatric-driven ME disorders & is sensitive to developmental changes in the ear canal & ME
WB tymps
overall pronounced effects on WAI in the mid frequency range (1-3kHz) suggesting these can be diagnostically useful in helping to distinguish normal from abnormal ME fxn
wb tymps
Mass dominated
flaccid/hypermobile ™
ME effusion & ossicular change discontinuity
Stiffness dominated
Ossicular chain fixation & OTSC
ASHA guidance for tymps
Use of 1000 Hz in infants is recommended when attempting to identify MEE to avoid false negative tymps
LF (226) probe tone is appropriate for older infants and children
asha guidelines for ARTs
For children from birth to 5 yrs, ARTs should be obtained for pure-tone activator frequencies 500, 1000, & 2000 ipsi
Neural pathology - contra should be completed @ same frequencies
Unilateral retro of FN issues are rare in infants & children
Absence of ART can be helpful to diagnose MEE when tymp shape is ambiguous
Neural path in ARTs according to ASHA
contra should be completed at 5, 1, &2
JCIH acoustic immitance guidelines
ME fxn should be included as diagnostic audiologic process for infants & young children
under 9 mos, use 1000 Hz for tymps & ARTs
Up to age 9 mos use 1000 Hz probe tone
ARTs are important for testing ME fxn & integrity of auditory bs pathways
Completed using 1000 Hz probe tone in newborns & infants under 9 mos of age
External and ME development over the first _____months of life results in tympanometric data that might not accurately reflect ME fxn when using a ______ probe tone
6-8
226
___________ assessment techniques provide greater sensitivity to ME disorders in neonates & young infants than ______ does
1000 Hz tympanometry & wideband
226
what factors affect OAE recordings
proper probe fit
cable position
restless baby
constant environmental background noise (AC/parents talking)
fluid/debris
Although OAEs reflect cochlear health, they are significantly influenced by the acoustics of the ear canal and the forward and reverse transmission through the middle ear
true
OAEs are a good indicator of HL and is a hearing test; it is a test of cochlear function
false
not a hearing test
what is clinically important of a detectable OAE response
The PRESENCE of a detectable OAE response to a particular stimulus is clinically important not the strength or intensity of the OAE
what should be examined to ensure valid OAE recordings
stim graph, probe graph, noise floor, OAE level
describe the analysis of OAEs`
verify noise levels (if elevated, reduce noise if not…)
repliate recording
inspect amps (NF >/= 6 they are present; NF </= 6 they are absent)
present: oae amp is normal or oae amp is present but abnormal
absent: rule out or confirm ME dysfunction; performal WB reflectance measures
repeat oae measures in other ear
analyze findings
what are the applications of OAEs in peds asssessments
Newborn hearing screening, school screenings, site of lesion testing (cochlear vs retrocochlear basis), monitoring of effect of ototoxic drugs on cochlear function, partially estimate hearing sensitivity within a limited range, cross check principle.
what must be met for OAEs to be recorded
no obstruction in EAC
ME can transfer energy forward and backward
passive BM & active OHC mechanics are operational
how are OAEs a sensitive indicator of general cochlear health
becuae they are a byproduct of cochlear amp processes
Otoacoustic emissions play a critical role in both screening (e.g., newborn, school age) and diagnostic (e.g., ototoxicity) protocols
true
are OAEs a test of hearing
no
why is the clinical value of OAEs high
because HL is commonly related to OHC dysfunction
Detecting normal cochlear function improves when they are screened 24-48 hrs postpartum or when
the vernix is cleared
Why do OAE levels fluctuate significantly in the first few months or years of life?
Primarily due to the dramatic developmental changes in the outer and middle ear
Explain the use of OAEs in cross-check evaluations and provide examples.
They are a simple noninvasive test that can determine cochlear status (hair cell fxn)
W/ difficult to test kids, oAEs are a quick test for further assessment or not
Normal OAEs, tymps & ARTs generally rules out peripheral HL
Abs OAEs or abnormal OAEs & normal tymps indicates further eval is needed
Abs OAEs or abnormal OAEs & normal tymps indicates
further eval is needed
Normal OAEs, tymps & ARTs generally
rules out peripheral HL
what makes a present TEOAE
SNR (relative value)(TE-NF) >/= 3-6 dB (varies)
reproducibility of 70% or greater (some say 50%, which is not good)
Absolute emission > -10 dB SPL
what can be said about a present TEOAE
normal or near-normal cochlear function and hearing better or equal to approximately 25-30 dB at frequencies where emissions are present
what makes a present DPOAE
Absolute emission > -10 dB SPL
SNR (relative value) >6 dB (3-5 dB some)
Replicates
when looking at TEOAEs, what are the steps to determine if it is pass or fail
Is the stimulus the right amplitude (presenting around 83dB)
Needs to be + or - 3 dB
Has to end by 4s
Response waveform
Starts around 4s and if click continues it will create noise
real response has two waves almost identical and if it isn’t the waves do not overlap
look at amplitude
noise needs to be less than -10
of rejected
want a low number
high = too much noise
why should you record both TE and DPOAEs
TE - used for screenings, validate behavioral/electrophysiological thresholds & assess cochlear fxn relative to site of lesion
DP - used for diagnostics, gives more frequencies,
they both target different cochlear mechanisms, provide more comprehensive assessments of cochlear health & HL with both
how does ME pathology affect OAEs
They are produced in the cochlea but they have to pass through the ME into the ear canal
OM or negative pressure can disrupt sound transmission to and from the cochlea that in turn affects OAE measures
Severe OM can affect ™ mobility = likely _____ OAEs
absent
Negative ME pressure reduces OAE levels but doesn’t always produce absent (unless they have mild SNHL)
TRUE
Patent PE tubes or ™ perfs can result in what type of OAE response
variable OAE responses but can still be measured in some
limitations of OAES
Susceptible to noise
Site specificity
Cannot quantify degree of HL
Cannot rule out minimal or mild hL
ADV of OAEs
Evaluates OHC fxn
Quick and objective
Ear specific
Frequency specific
Can predictu future HL to allow for early intervention & preventive counseling
Do not need a booth to perform
JCIH Rec (2019) for OAEs
OAEs provide important info about the integrity of the OHCs of the cochlea & about differential diagnosis of ANSD and SNHL
Explain to parents the effects of Hearing loss:
Hearing loss affects their vocabulary, sentence structure and speech. They will have difficult academically especially in reading and mathematical concepts. Without the appropriate management they will achieve one to four grade levels lower than their peers. Appropriate educational intervention is needed to occur early. Children with hearing losses may feel isolates, without friends, unhappy in school, socialization is limited. Social affects happen more in children with mild or moderate hearing losses than those with a severe to profound hearing loss.
explain to parents minimal HL
A child with minimal hearing loss is likely to have increased behavioral and linguistic problems compared to hearing children. Studies show they have either repeated a grade or need additional resources in school for educational support. They may miss out on understanding speech and miss speech sounds spoken.
Difference between pediatric and adult case history:
Pediatric: Patient information, prenatal and birth history, medical history, growth and development, educational progress, behavior, milestones…
Adult: Patient information, general information, medical history, concerns, amplification, dizziness
Importance of a thorough case history:
Understand the child (development, health, cognitive, auditory skills), Understand the family (concerns, needs, expectations, rapport, counseling), Observational opportunities (observe behavior and interactions with family members), Guidance for assessment (helps formulate complaints, testing, strategies, and contributing factors)
what protocol for complete audiologic exam would you perform for ages birth to 6 mos
stim: Frequency specific (Warble tones, NBN), Non-frequency (Music, noise, speech)
SF, inserts, supras, BC, CI, HA
perform BOA as a supplement to electrophysiologic measures
functional assessments
functional auditory assessments
Case history, parent/caregiver report, behavioral observation of the infant’s responses to a variety of sounds, developmental screening, and functional auditory assessments should also be performed.
what protocol for complete audiologic exam would you perform for ages 6 mos to 24 mos
behavioral: VRA
OAEs
developmental screening and functional auditory assessments
ABR when behavioral test are unreliable, ear specifics cannot be obtained, behavioral results are inconclusive, ANSD suspected
perform SDT - watch for a reaction for younger ages
perform SRT - closer to older end of this age group as long as they have the languae skills to do so
what protocol for complete audiologic exam would you perform for ages 25 mos through 60 mos
younger ones - maybe VRA
older ones - CPA
around 5 yrs try conventional
speech - depends on ability, can be anything; younger might do SRT if they can point (around 25 mos) and older can do srt and wrs
younger than 5 do closed lists
5 and older attempt open
what should you do with a false responder
Reinstruct the child, place an open hand just in front or rest against the child’s hand holding the response peg or block. The child then will have to go around or through the audiologist’s hand to complete the task once the sound is heard.
what should you do with a reluctant responder
Child frequently waits until they are visually prompted to complete the task despite numerous training trials and reinforcement.
Audiologist may want to identify if there is a definite facial response or reaction when the tone is presented and can then assist the child in completing the play task and watch for the child’s reaction to the next stimulus.
what should you do with an off responder
Child prefers to wait until the stimulus has stopped prior to completing the task
Use a continuous tone can often assist them in feeling more confident in responding because there is a definite “off” to the signal
internal factors that affect WRS
Vocabulary and language competency, chronological age, cognitive abilities, alertness, motivation, fatigue.
External factors affecting WRS
Designation of an appropriate response task, effective utilization of reinforcement, controlling the memory load inherent in the task that can influence test performance.
should degree of loss be a factor when selecting testing protocol
NO
based on individuals language abilities
should you do a half word list
Use only when the word list is valid to be used with less words, 10 words are not enough unless you are using the isophonemic word list.
full list Reduces chance of scoring errors, increases reliability, time consuming, 25 words allow for good evaluation of auditory function.
