Midterm Flashcards
Common Types of Studies
Empirical Studies
Literature Review
Case Study
Empirical Studies
Contain original research Sequence: - Introduction - Method - Results - Discussion
Literature Review
- Investigates research studies that have already been published
- Important in discovering if your topic is a good one, and if the answer has already been found
Sequence:
> Define and clarify topic/question
> Summarize previous studies
> Identify any holes or inconsistencies in the studies
> suggest next steps in filling the hole/inconsistencies
Case Study
- Studies of actual patients
- Studies that use case information from an individual or group
Sequence:
> Introduction
> Method
> Results
> Discussion
Overall Purpose of Studies
- Provide new information and views on topics related to our profession
- support ethical practice of our profession as well as clinical procedures
Ethics in Research
need to ensure:
- rights of the participants are protected
- results of any study are accurate
- author’s results are protected (called intellectual property)
(where plagiarism comes into play. the info is now their property)
Plagiarism
- claiming the ideas and words of others as your own
- not giving credit where credit is due
Avoiding Plagiarism
Quotation Marks: used when you copy the exact words
Paraphrasing: summarizing and idea or passage, use synonyms, rearrange the order of the content (use all three). credit the source
Body of the Paper
- Abstract
- Introduction
- Labeled sections (subheadings)
- Conclusion
- References
- Appendices
Additional : page header (running head and title page)
Initial Patient Encounter
First Impressions
Family Involvement
Case History (written and verbal)
First Impressions
Begins with a friendly greeting and a clear expectation of the purpose of the clinical visit
- tell them what to expect
- alleviate tension/anxiety
- meet the fam, but address patient primarily
Family Involvement
Clinical services are family centered most important for: - explanation of test findings - counseling regarding the findings - explanation of recommendations for management (can help pt retain info)
Case Hx
Information about the patient’s past and present health status
Goals
Chief complaint
Written Case Hx
- each clinic has their own form
- questions are developed by management or the clinician
Types of forms:
adult and pediatric
Written case Hz pros/cons
Pros:
- allows pt to provide written record of hx
- gives audiologist a base hx to work from
- pt can complete paperwork before appointment
Cons:
- pt can complain if too long
- not exhaustive
- pt may omit info
Verbal Case Hx purpose
filling in the gaps
verifies/clarifies info
opportunity to ask family questions
Case Hx and Diagnostic Process
- importance of accurate diagnosis (timing, accuracy)
- case hx makes it easier to make appropriate recommendations…need to see the big picture
Why are audiological reports important?
documentation
billing
progress
treatment
provide documentation of what took place
important for audiologist, referral source, and pt
reports need to be:
accurate
concise
to the point
Authorship of audiological reports
the person who evaluated the pt typically writes the report
- must hold a license and be credentialed
- supervisor is responsible even if student writes and signs the report
HIPAA
privacy rule establishes national standards
protects medical records and protected health information
Formatting options for reports
Freeform
Template
Combination
Formatting: Narrative Report
Completed after audiological report Contains: 1. Identifying info 2. Case hx info 3. Test Performed and Results 4. Summary 5. Recommendations 6. Signatures 7. CCs
Identifying Info
date, name address, DOB, age, AuD, ICD-10, CPD, parent/spoud, phone, referred by, modifier
CPT Diagnostic Hearing Eval
92557
CPT Tympanometry
92567
G codes and C modifiers
used primarily for medicare and medicaid
CCs
stands for carbon copy
used to designate where copies of the report need to be sent
Chart note
common form of reporting used as a brief summary of the appointment
typically used for follow up appointment
Summary Report
contains similar information but is written on the audiogram from notes section
Most often used in an ENT clinic where a summary of results is needed immediately
SOAP notes
subjective, objective, assessment, plan
Electroacoustic Tests
- Involve the measurement of sounds within the external ear canal and can provide information about how well the middle ear system transmits energy from the outer ear to the inner ear.
Others detect sounds in the ear canal that actually reflect energy associated with movement of outer hair cells within the cochlea
not dependent on the patient’s attention to stimulation
Clinical Uses of Electroacoustic Tests
permit assessment of auditory function in patients who cannot participate in behavior hearing testing:
- infants
- young children
- newborn babies
- older children who are difficult to test
- documenting abnormal function of the auditory system
Acoustic Immittance
combination of the terms impedance and admittance
abnormal middle ear function is characterized by high impedance or resistance, like fluid within the middle ear cavity, is associated with low admittance.
Allow audiologists to objectively describe and quantify how well the middl ear is working
Acoustic Impedance
defines the total amount of opposition to the flow of energy through the middl ear system from the eardrum to the inner ear.
Acoustic Admittance
refers to the ease with which energy flows through the middle ear
Things that can affect acoustic immittance
Ear wax, collapsing canal, middle ear fluid, ossicular disarticulation, abnormal growths/tumors
Instrumentation Components on acoustic immittance test
- miniature speaker (pure tone: 226 Hz, sometimes 1000 Hz)
- small microphone
- airpump for changing air pressure within the sealed external ear canal (described in mm H20 or deccaPascals (daPa))
- Controls/buttons
- Probe tip
Tympanometry
the measurement of acoustic admittance of the middle ear as a function of changes in air pressure in the ear canal
Tympanometry measurement process
- probe tone delivered to EAC, vibrates TM
- some energy flows through TM, and some is bounced back and is picked up by the microphone
- sound pressure level measured at the probe tip is directly proportional to acoustic immittance
(measurement made at tip of probe, not TM)
Immittance Components
Mass: TM and ossicles
Stiffness: TM, middle ear space, muscles/ligaments, round window
Friction: known as resistance
middle ear structures, air within spaces, cochlear fluids
Two units of measurement to record acoustic immittance
impedance: ohms
admittance: mhos
Clinical Procedure of Tympanometry
- Otoscopy
- Select probe size and put on tympanometer
- Instruct patient
- obtain airtight seal
- test automatically runs
- Tell patient you will complete test on other ear (repeat 4/5)
- Interpret results
Estimation of Ear Canal Volume
estimated for the space enclosed between the medial edge of the probe tip and the tympanic membrane
At high ear canal presures (+200 daPa) or low pressures (-200, -400 daPa), the middle ear is essentially eliminated from immittance measurement
Ear canal volumes are directly related to:
Age
Body size
Gender
Static Acoustic Compliance (Admittance)
- the value measured at maximum compliance
- for a normal middle ear system, maximum compliance or is found near 0 daPa, corresponding to atmospheric pressure
- @0 daPa, there is little to no difference in air pressure from one side of the TM to the other.
- the middle ear system is most flexible at this neutral pressure
Type A
- normal middle ear pressure and admittance
- consistent with normal ear function
- peak compliance between .30 and 1.50 ml
- peak pressure falls somewhere between the pressure region of +50 daPa to -150 daPa
- could have normal tymps and sensorineural hearing loss
(normal)
Type As
- normal middle ear pressure with reduced admittance
- consistent with a stiffness dominated system
- shallow
(fixation of the ossicles)
Type Ad
- normal middle ear pressure with increased admittance
- consistent with a hypermobile system
- deep
(TM recently healed preforation: norm PTAs)
(disontinuity/break in ossicular chain: ab PTAs)
Type B
- no identifiable point of maximum admittance.
- consistent with extreme stiffness of the outer/middle ear systems
- check for technical problems
(excessive cerumen, severe restricted mobility of middle ear system, fluid in middle ear, other disorders that need immediate attention)
Technical problems in Tympanometry
- debris occluding the probe assembly
- cerumen occluding the probe assembly
- excessive cerumen in the eac
Type C
- abnormally negative ear pressure with normal admittance
- consistent with eustachian tube dysfunction
How is tympanogram type determined?
- using components of a tympanogram
- tympanic peak pressure
- acoustic admittance
- ear canal volume
tympanic peak pressure
- the estimated pressure in the middle ear.
- determined by finding the peak and following it down to the pressure measurements on the x axis
Normative data: +/- 200 daPa
Abnormal Pos pressure: noise, blowing, crying
Abnormal Neg Pressure: eustachian tube dysfunction
Acoustic Admittance
- the estimated admittance of the middle ear
- determined by finding the height of the peak and following it over to the admittance
- Normative Data: .25 to 1.5 mhos for children
.3 to 1.7 mhos for adults - Abnormal High Values: decreased stiffness of the middle ear
- Abnormal Low Values: increased stiffness of the middle ear
Ear canal volume normative data
.3 to .9 cc for infants
.3 to 1.5 cc for children
.6 to 2.0 cc for adults
Ear canal volume
- estimated volume of the EAC
- determined by reading the measurement marked V on tympanogram
- measured in cubic centemeters
Ear canal volume values/meaning
Abnormally high - preforation or PE tubes
Abnormally low: wax or probe misplacement
Clinical Applications of tympanometry
- sensitive indicator of middle ear functioning
- highly sensitive to middle ear dysfunction.
- quick objective test which is feasible for patients any age
- does not permit diagnosis of ear pathology
- is not a valid measure of hearing
Otoacoustic Emissions
- sounds measured in the EAC that are associated with activity of the outer hair cells
- outer hair cell motility (lengthening/shortening)
- some energy from outer hair cell motility returns to the EAC
- permits early detection of inner ear abnormalities associated with various causes
OAE’s discovered
1970’s David Kemp
TEOAEs 1978 to mid-1990’s
use increased due to:
manufacturer development/marketing
new billing codes approved
clinical value discovred
OAE equipment
OAE Machine
computer and printer
Probe (sound generator, amplifier, speaker, microphone
OAE process
- insert probe into EAC
- probe is used to present stimulus sounds to the ear to detect sounds produced by outer hair cell movement
- amplitude of OAEs are recorded
Normal range: 0-15 dB
4 regions of auditory system anatomy involved in OAE measurement:
- External Auditory Canal
- Middle Ear
- Inner Ear
- Efferent Auditory System
EAC effects on OAEs
effectiveness of stimulation may be reduced by debris or cerumen
Middle ear effects on OAEs
OAEs reduced in amplitude and often not detected in pts with middle ear abnormalities
Inner Ear effects on OAEs
- functional integrity of outer hair cells is essential for generation of OAEs
- Increased basilar membrane movement associated with outer hair cell motility
- stria vascularis plays a critical role in generating energy needed for hair cell movement
Efferent auditory systems effects on OAEs
not essential
influenced by efferent auditory activity
stimulation of efferent pathways that course from the lower brainstem to the outer hair cell, suppresses outer hair cell activity, reduced OAE amplitude
Types of OAEs
Spontaneous (SOAEs)
Transient (TEOAEs)
Distortion product (DPOAEs)
Spontaneous OAEs
- not evoked with a stimulus
- may or may not be present in normal hearing persons
- can be recorded more often in females than males
- not useful clinically
TEOAEs
transient evoked
- elicited with very transient/brief sounds
- stimuli: complex sounds (clicks, tone bursts)
- stimuli usually presented at 80 dB SPL
- energy recorded within a frequency range of 1000-4000Hz
DPOAEs
distortion product
- elicited with pairs of two pure tones
- tones labeled f1 and f2 (closely spaced)
- presented at 55-65 dB
- recorded at 500-8000 Hz
Clinical Procedure of OAEs
- Instruct Patient
- Probe Insertion (seal not needed)
- Stimulus Calibration (done each day, calibrates intensity automatically, audiologist verifies level)
- Detection of OAEs (microphone, distinguish from other noise)
- Display of OAE findings (on comp screen)
- Analysis of OAE findings
Other types of noise in OAEs
physiological from the patient
ambient from the environment
OAE automated analysis includes:
- calculation of amplitude values
- calculation of noise floor levels
- statistical confirmation of presence/absence of OAEs
Analysis of OAE findings
- noise levels need to be low to detect OAEs (lower than -10 dB is desirable)
- presence of OAEs are verified when reliable OAEs at any stimulus test frequency exceed the noise level by 6 dB or more.
OAE’s 3 general categories
Normal: amplitudes within normal limits
Present but Abnormal: amplitudes exceed the noise floor by greater than 6 dB but fall outside the normal region.
Absent: OAE activity is less than 6 dB above the noise floor
What do OAEs tell us?
- normal amplitudes: outer hair cells for that portion of the cochlea are intact
- normal amplitudes: indirect..middle ear is functioning normally
- decreased/absent amplitudes: cochlear dysfunction involving outer hair cells
OAEs and audiogram don’t match?
middle ear dysfunction
hearing loss that doesn’t involve outer hair cell dysfunction
Most common clinical applications of OAEs
- hearing screening (infants, preschool, school-aged)
- dx auditory dysfunction
- monitoring cochlear auditory function in patients taking ototoxic meds
- false, exaggerated HL
- early detection of noise exposure damage
reflex
an action or movement of the body that happens automatically as a reaction to something
- typically involves a tendon and muscle movements that provide info regarding the neurological system
ex: pupillary light reflex, gag reflex, knee jerk reflex, moro reflex
acoustic reflexes
- physiologic response - not behavioral
- sonomotor response
- involuntary muscle contraction that occurs in the middle ear in response to high intensity sounds
- involves stepedius tendon and muslce
bilateral phenomenon
when what ear is stimulated, a reflex will occur in both ears
tensor tympani muscle
connected to the malleus and innervated by the fifth (trigemical) cranial nerve
stapedius muscle
connected to the neck of the stapes and innervated by the seventh (facial) cranial nerve
normally contracts in response to a high intensity sound exceeding about 70 dB HL
Ipsilateral condition
sound stimulus for acoustic reflexes is presented on one ear and the change in middle ear compliance is recorded in the same ear
Contralateral condition
sound stimulus is presented in the ear opposite the ear with the probe assembly recording changes in middle ear compliance
Acoustic reflex afferent pathways
- carry info from ear to brain
- (cochlea, auditory portion of the eight cranial nerve)
- cochlear nucleus (nuclei) in brainstem contributes to the acoustic reflex arc in both ipsilateral and contralateral measurement conditions
- additional neurons in the trapezoid body and medial superior olivary complex contribute to the acoustic reflex pathways in the contralateral measurement condition
Acoustic reflex efferent pathways
- brainstem to ear
- includes motor fibers in the 7th (facial) cranial nerve, particularly a branch that innervates the stapedius muscle
Required equipment for acoustic reflexes
Tympanometer air/pressure pump manometer probe tone loudspeaker microphone/recorder
Why measure acoustic reflexes?
- determine status of middle ear and possible site of lesion
- reflexes typically reflect the functionality of the middle ear and nervous system
acoustic reflexes are recorded at:
- the external ear canal air pressure where there is a tympanogram peak
- where compliance reaches its maximum value
Stimulus options for acoustic reflexes:
Pure tones (500, 1000, 2000, and 4000 Hz) Noise signals like BBN
Clinical Procedure of acoustic reflexes
- select probe size and place on tympanometer
- instruct patient
- obtain airtight seal
- test automatically runs
- let patient know you will be completing the same thing in other ear (repeat 3 and 4)
Acoustic reflex factors
- highly dependent on status of ear
- usually indicates normal middle ear function
- most middle ear abnormalities obscure confident detection of acoustic reflexes
